Coverage for prescription drugs for all four health plans are administered by CVS Caremark, one of the largest providers of pharmacy benefits with more than 64,000 participating retail pharmacies nationwide (including Target/CVS locations). Most major drug chains and many small, independent pharmacies are part of the CVS Caremark network. Mail-order services are also available for maintenance medications. If you choose to use a nonparticipating pharmacy, you will be responsible for your regular coinsurance plus any difference between the amount charged by the pharmacy and CVS Caremark's discounted price. Certain drugs, including compound prescription medications, may require prior authorization from CVS Caremark to confirm medical necessity and this list may be updated throughout the year. To obtain information on a particular medication(s), log on to caremark.com.
Preventive Drugs
Preventive drugs can help keep you healthy and prevent serious complications down the road. The plan covers generic preventive drugs at 100%. If you take a preferred brand name preventive drug, you will pay 50% of the cost up to a maximum of $100 per prescription for a 30-day supply. If you take a non-preferred brand name preventive drug, you will pay 50% of the cost up to a maximum of $150 per prescription for a 30-day supply. Certain over-the-counter preventive drugs prescribed by your doctor (based on age and gender eligibility requirements) are covered at no cost, such as vitamin D, aspirin, folic acid and iron supplements. Coverage for preventive drugs is not subject to the deductible, which means that you don’t need to satisfy your deductible before these benefits begin.
Non-Preventive Drugs
Under the Purple plan, prescriptions are not subject to the deductible.
Under the Blue, Green, and Orange plans, you will pay the full discounted cost of any eligible non-preventive drug until your deductible is met. The cost of these drugs will apply to your health plan deductible.
After you meet your deductible, you will pay 50% of the cost of your prescription drugs up to a certain maximum per prescription. The maximum will depend on the type of drug you take, and whether it’s for a 30-day supply or a 90-day supply. See the chart below for details. Even before your deductible is met, you will get the benefit of the discounted rates CVS Caremark negotiates with participating pharmacies.
Maintenance Medications
If you take medications on a regular basis to treat a chronic condition (such as high cholesterol or high blood pressure), you must fill them through a 90-day supply instead of a 30-day supply. You can fill 90-day maintenance medication prescriptions through a CVS Caremark pharmacy only (including Target/CVS locations) or you can order them via CVS Caremark’s mail order service. This will save you time and money.
The plan allows for two 30-day fills of maintenance medications at any pharmacy in the CVS Caremark network. After that, the plan will cover maintenance medications only if you have 90-day supplies filled through mail-order or at a CVS Caremark pharmacy. Specialty medications are limited to a 30-day supply. You can call CVS Caremark to discuss payment options. If, after your first two fills, you continue to have 30-day supplies of maintenance medications filled (regardless of whether the pharmacy is in the CVS Caremark network), you will be responsible for the entire cost of the medication.
CVS Caremark’s Mail-Order Service
CVS Caremark’s mail-order service can save you money and time. When you order maintenance medications via CVS Caremark’s mail-order service, you’ll get a 90-day supply for 50% of the cost up to a certain maximum per prescription, depending on the type of drug you take. See the chart below for details. It’s easy and convenient to participate - you can order refills online and standard shipping is always free. Visit caremark.com or call CVS Caremark at 1-866-587-4799 for more information.
Dispense as Written Guidelines
To encourage the use of cost-effective FDA-approved generic equivalents, when a prescribed brand name drug has a generic equivalent, you'll receive the generic equivalent unless your physician specifies Dispense as Written, or DAW, on the prescription. If your physician does not specify DAW and you select the brand name drug, you'll pay your share of the cost plus the difference in price between the brand name drug and the generic drug. You will never pay more than the actual cost of the drug, but you may pay more than the plan’s per-prescription maximum.
CVS Caremark’s Formulary
Coverage for prescription drugs under all four health plans is administered by CVS Caremark. The prescription plan has a wide variety of safe and effective generic and brand medications, covering treatments for all types of injuries and illnesses.
Caremark periodically reviews their formulary or covered drug list. Certain formulary medications may be excluded from coverage from time to time and impacted members will be notified directly by CVS Caremark. The health plans include three tiers of prescription coverage: generic, preferred brand and non-preferred brand. The cost you pay per prescription is based on the tier your medication is in.
By using generic or preferred brand medicines, you can help make sure you get better value based on your plan and individual needs. Click here to view the specialty formulary and click here to view the non-specialty formulary. You can also visit caremark.com to review the formulary lists, updated quarterly, to find out which therapeutic medicines provide you with greater savings. Here are definitions of each of the three tiers:
Tier 1: Generic - generic drugs must have the same active ingredients as the original brand name drug.
Tier 2: Preferred brand - brand name drugs listed on the CVS formulary/covered drug list.
Tier 3: Non-preferred brand - brand name drugs not listed on the CVS formulary/covered drug list.
See the chart below for coverage by each tier.
| Retail (30-day supply) | Mail order prescriptions or retail maintenance prescriptions at a CVS pharmacy (90-day supply) | |||||
| Type of Medication | Coinsurance | Minimum per prescription | Maximum per prescription | Coinsurance | Minimum per prescription | Maximum per prescription |
| Generic* | 50% | $0 | $50 | 50% | $0 | $125 |
| Preferred brand | 50% | $15 | $100 | 50% | $30 | $200 |
| Non-preferred brand | 50% | $40 | $150 | 50% | $80 | $300 |
| Fill Limit for Long-Term Medications | Two fills on long-term maintenance medicines only | None | ||||
*Please note that generic preventive drugs are 100% covered.
Note: What you pay will never exceed the total cost of the medication.
Here is a chart explaining what you might expect to pay based on the below illustrative medication costs:
| Type of medication | Member cost-share after deductible, before out-of-pocket maximum | Drug costs | You pay |
| Retail Generic (30-day supply) | 50% max $50 | $25 | $12.50 |
| Retail Non-Preferred (30-day supply) | 50% min $40 max $150 | $200 | $100 |
| Preferred Mail order (90-day supply) | 50% min $30 max $200 | $30 | $30 |
Filling Your Prescription at a Non-Participating Pharmacy
If you choose to go to a non-participating (out-of-network) pharmacy, you'll pay the full prescription price at the point of sale and will need to send CVS Caremark a paper claim. You should submit a paper claim form along with the original prescription receipt(s) to CVS Caremark for reimbursement of covered expenses. You can download and print a claim form when you log in to caremark.com. If you fill your prescription at a non-participating pharmacy, you will be responsible for your regular coinsurance plus any difference between the amount charged by the pharmacy and CVS Caremark’s discounted price.
