Prescription Drug Coverage

 

This chart shows coverage for prescription drugs under both Consumer Choice 1 and Consumer Choice 2.

*Certain generic only preventive care prescriptions may be covered at $0 copayment.

**If you choose to get a Brand Name Drug when a Generic Equivalent is available, you will pay a penalty between the cost of the generic and brand name drug. That penalty does not apply toward your deductible or out-of-pocket maximum.

Free Preventive Generic Prescriptions

We have partnered with CVS Caremark on a program that will cover certain drugs classified as "preventive care prescriptions" at no cost to you, regardless of whether the deductible has been met. These include drugs that treat chronic conditions such as high blood pressure, high cholesterol, diabetes etc.

The drugs listed on this document must still fall within our formulary plan rules. It is recommend you log into your CVS Caremark account or utilize the Prescription Cost Estimator Tool to verify plan coverage.

• View preventive drug list (subject to change)

• Generic Drugs: A generic drug is identical, or bioequivalent, to a brand name drug in dosage, safety, strength, quality, performance characteristics and intended use. You will pay the lowest copayment for generic drugs. Generics are equivalent to their brand-name counterparts, and are ensured by the Food and Drug Administration to be as safe and effective. However, generics are significantly less expensive than the brand name. To be sure you pay the lowest co-payment, ask your doctor to prescribe generic medications, when appropriate.
  
  

• Preferred Drugs: These are prescription drugs that have been placed on a list of preferred drugs for a medical plan. Preferred Drugs are brand name drugs that are effective for treating specific condition and are more cost-effective than equivalent non-preferred drugs. Often there is a choice of medications you can take for the same condition. One or more of these medications may be a preferred drug under this plan. They cost generally more than generics, but less than non-preferred brand name drugs.
  
  

• Non-Preferred Brand Drugs: These are medications that have been patented for name and chemical content. Once the patent expires, generic drugs with a different name but the same chemical make-up typically become available. Non-preferred drugs are prescription drugs that are not generic or on the list of preferred drugs. Typically, non-preferred named drugs are the most expensive and/or have a comparable drug that is either generic or on the preferred list. Generally, these are higher-cost medications that have recently come on the market. These drugs have the highest copayment. In most cases, an alternative preferred medication is available. Depending on your personal health care needs, there may be times when non-preferred drugs are right for you. In these situations, you will need to pay the non-preferred co-payment.
  
  

• Affordable Care Act (ACA) Preventive: Under the ACA there are certain drugs that are considered preventative. Examples of these medications include doctor-written prescriptions for women’s health preventive care, including Food and Drug Administration-approved contraceptive methods, preventive aspirin for men and women, iron supplements for children, folic acid for childbearing age or pregnant women, Vitamin D for at-risk adults over age 65, prescribed fluoride supplements for children under age six and tobacco cessation products. All preventive drugs and treatments require a doctor’s prescription under the preventive tier.
  
  

• Lifestyle Drugs: These are prescription drugs that are not generally considered medically necessary. You will pay the full cost of the prescription after a discount has been applied. Lifestyle drugs are typically drugs that are prescribed for non-medically necessary uses such as cosmetic Botox® and Propecia® for hair loss.
  
  

• Dispense As Written (DAW) Penalty: If you purchase a preferred or non-preferred drug at retail or mail when a generic is available, you will pay the brand copay plus the difference between the cost of the generic drug and the drug dispensed.

Diabetic Supplies

Your diabetic supply kit (swabs, lancets, syringes, and strips) are free when ordered with your insulin prescription/refill (mail order and retail). In addition, CVS Caremark has a disease management program available to help you manage your diabetes. Contact CVS Caremark for more information about this program.

CVS Caremark’s Specialty Pharmacy

Certain medications may need to be filled through CVS Caremark’s Specialty Pharmacy.

Specialty pharmaceuticals are drug therapies developed to treat a wide range of complex chronic conditions. They are generally developed to serve a relatively small population of patients, most of whom have progressively severe diseases. Patients tend to be on these medications long-term, most for life (some exceptions include RSV, infertility and Hepatitis C). These drugs may be biologically derived; many require special handling and specialized training for mixing and administration, and are often very expensive—from several thousand to hundreds of thousand per year. Specialty medications must be dispensed by CVS Caremark specialty pharmacies and cannot be obtained through regular CVS Network pharmacies.

Specialty Guideline Management (SGM) is a program that helps to ensure appropriate utilization for specialty medications based on evidence-based medicine guidelines and consensus statements. Patient progress is continually assessed to determine whether appropriate therapeutic results are achieved.

CVS Caremark Specialty Guideline Management extends beyond prior authorization ensuring:

• The specialty drug is safe and effective for the patient

• The specialty drug is used properly

• Inappropriate utilization is avoided

• Unsafe or ineffective therapies are discontinued in a timely manner

Specialty drugs may be prescribed for the following therapies:

• Asthma

• Crohn’s disease

• Cystic fibrosis

• Growth hormone and related disorders

• Hematopoietics

• Hemophilia, von Willebrand disease and related bleeding disorders

• Hepatitis C

• HIV

• Hormonal therapies

• Immune disorders

• Infertility

• Lysosmal storage disorders

• Macular degeneration

• Multiple sclerosis

• Oncology

• Osteoarthritis

• Osteoporosis

• Psoriasis

• Pulmonary arterial hypertension

• Pulmonary disorders

• Renal disorder

• Rheumatoid arthritis

• RSV prevention

• Transplant