Prescription drugs
Prescription drug coverage overview
Prescription drug coverage overview
Prescription drug coverage is automatically provided under both Core and Core Plus.
The annual deductible under the medical plan applies to prescription drugs.
In other words, you have just one deductible for both medical and prescription drugs. Prescription drug expenses also apply to the medical plan’s out-of-pocket maximum.
1. What tier the medication falls into
Tiers are the different cost levels you pay for any medication.
Generic drugs generally cost the least, so are your least expensive option. Higher-cost brand-name drugs, on the other hand, are the most expensive option. See Table 1 below.
2. Whether the drug qualifies as preventive
Preventive drugs are deliberately set up to be less expensive because adhering to medication requirements for preventive care is important to getting and staying healthy.
As a result, for certain preventive drugs, the annual deductible does not apply. CVS Caremark maintains lists of these drugs, which include commonly used medications such as beta blockers, cholesterol drugs, thyroid supplements and anti-depressants. See Table 2 below for details.
Other preventive drugs are covered at 100% because of the Affordable Care Act (ACA). See Preventive Drugs (ACA) section in Table 2 below.
* Assuming the prescriptions are covered by the plan.
1. Use generics, where applicable
A generic drug is intended to be a copy of, or chemically equivalent to, a brand-name drug in dosage form, safety, strength, route of administration, quality, performance characteristics and intended use. Although chemically equivalent, generics are typically sold at substantial discounts to their branded counterparts. They save consumers an estimated $8 to $10 billion a year at retail pharmacies, according to the Congressional Budget Office.
If you choose to fill a prescription with a brand-name medication when a chemically equivalent generic alternative is available, your cost will be higher. See Tables 1 and 2 for details.
2. Use the mail-order program, when you can
The mail-order program is designed to provide a convenient, cost-effective way to fill long-term or maintenance medications (90-day supply).
You will continue to be required to use the mail-order program if you refill a 30-day supply more than two times at a retail pharmacy, or pay more. See the Prescription Drug Coverage for additional details.
Your cost for a 30-day supply from a network pharmacy, and for a 90-day supply through the mail order program
Tier of drug | Tier of drug | Supply amount | Supply amount | Preventive drugs | Preventive drugs | All other (non-preventive) drugs | All other (non-preventive) drugs |
|---|---|---|---|---|---|---|---|
Tier of drug | Tier 1: Generic | Supply amount | 30-day supply 90-day supply from mail order program | Preventive drugs | You pay a $5 copay*
| All other (non-preventive) drugs | You pay a $5 copay after you've met your deductible You pay a $12.50 copay after you've met your deductible |
Tier of drug | Tier 2: Preferred Brand Name | Supply amount | 30-day supply
90-day supply | Preventive drugs | You pay 25%*of the cost of the drug up to $100.00 per fill
You pay 25%* of the cost of the drug up to $250.00 per fill | All other (non-preventive) drugs | You pay 25% of the cost of the drug, up to $100 per fill after you've met your deductible
You pay 25% of the cost of the drug, up to $250 per fill after you've met your deductible |
Tier of drug | Tier 3: Non-Preferred Brand Name | Supply amount | 30-day supply
90-day supply | Preventive drugs | You pay 45%* of the cost of the drug up to $200.00 per fill
You pay 45%* of the cost of the drug up to $500.00 per fill | All other (non-preventive) drugs | You pay 45% of the cost of the drug, up to $200 per fill after you've met your deductible
You pay 45% of the cost of the drug, up to $500 per fill after you've met your deductible |
Note regarding Tier 3: In most cases, a lower-cost alternative is available for medications in Tier 3. Check with your doctor or pharmacist and refer to the Preventive and Preferred Drug lists from CVS Caremark.
Preventive and Preferred Drug Lists
For Aetna, Cigna or Anthem enrollees.
If you have Kaiser, refer to their website, https://my.kp.org/ubs/
Preventive and Preferred Drug Lists | Preventive and Preferred Drug Lists | Description | Description |
|---|---|---|---|
Preventive and Preferred Drug Lists | Preventive Drugs (ACA) | Description | The Affordable Care Act (ACA) has created a listing of preventive drugs which are covered at 100% without deductible or coinsurance. |
Preventive and Preferred Drug Lists | Preventive Drug List (All others) | Description |
|
Preventive and Preferred Drug Lists | Preferred Brand Name List | Description |
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If you or a covered dependent require specialty drugs to treat certain serious or complex conditions, the CVS Caremark Advanced Control Specialty Formulary and Quantity Limits Program (ACSF) can help you manage your prescription--and your costs. It also ensures all dispensing limits adhere to the FDA and manufacturer dosing guidelines.
How it works
- If there is no generic specialty drug available for your condition, the Advanced Control Specialty Formulary® can help you and your doctor identify preferred brand-name medicines that are clinically appropriate and cost-effective.
- If you currently take a name-brand specialty drug, check to see if it is listed as preferred brand-name medication. If not, ask your doctor to consider switching you to a generic or preferred brand name before the end of the plan year so you can be sure there is no disruption when we start the new year.
