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To: Subject: Date: Employees enrolled in Blue Cross Blue Shield Plan 3900 Prescription Reimbursement Card (PRC) June 1,...

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To: Subject: Date:

Employees enrolled in Blue Cross Blue Shield Plan 3900 Prescription Reimbursement Card (PRC) June 1, 2014

Employees enrolled in the Blue Cross Blue Shield Medical Plan 3900 are issued a “My Source” debit card with a $500 Plan Year allowance, which may be used toward prescription expenses incurred during the Plan Year, June 1, 2014 to May 31, 2015. Details regarding the use of the debit card are as follows: ∗

The debit card will be issued in the employee’s name. If you have spouse or family coverage you may request a card for your spouse on the attached Enrollment Agreement.



If you request a replacement card, a $5.00 charge will be deducted from your payroll check.

The card may ONLY be used for PRESCRIPTION DRUGS as follows: ∗

You must present your Blue Cross medical plan ID card to the pharmacy counter.



All pharmacy approved prescriptions, including the $10.00 generic drug co-pay, up to the $500 maximum allowance. You may continue to use your Blue Cross card after the $500 allowance has been depleted and pay your $10.00 generic co-pay if applicable.

To minimize the plan cost and your out of pocket dollars, please follow these steps: 1. Take your prescription to a Blue Cross In- Network Pharmacy

2. Give the pharmacy your Blue Cross ID card and they will process your prescription

3. Give the pharmacy your “My Source” card to pay for: the cost of the drug or the $10.00 Generic Co-pay

Any questions regarding this policy and the reimbursement allowance should be directed to Alice Adams, Benefits Administrator. She can be reached at 239-642-2812 or at [email protected] You agree to save all invoices and receipts related to any expense paid with the Card; upon request you must submit these documents for review by the Plan Service Provider, Diversified Administrators.