Prescription Drugs

What you need to know

You automatically have prescription drug coverage through CVS Caremark when you enroll in either of the High-Deductible Health Plans. You can use your HSA or HRA to pay for your share of the cost. You can fill covered prescriptions at participating CVS retail pharmacies or through the CVS Caremark mail service.

Until the deductible is met, all covered medical and prescription costs are applied against the deductible. You will pay the actual cost of your prescription, as negotiated between CVS Caremark and the pharmacy.

Filling Your Prescription

What You Pay for Fills

Preauthorization and Other Special Circumstances

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Filling Your Prescription

Short-Term Medications

You can fill up to a 30-day supply of a prescription at more than 5,000 participating pharmacies in the Connecticut, New York, and New Jersey area (64,000 nationwide), including major pharmacy and supermarket chains and most independent drug stores. Simply present the prescription and your CVS Caremark prescription drug card.

In an emergency or if you’re out of state and can’t get to a participating pharmacy, you’ll pay out of pocket and then file a claim for reimbursement from CVS Caremark.

Pay nothing for certain preventive drugs
The Affordable Care Act (ACA) makes many prescription medications, vaccines, and supplements—including contraceptives and statins—available to you at no cost.
No-Cost Preventive Drug List
When a generic is available and you or your doctor chooses a brand-name drug instead, you’ll pay the brand-name copay—plus the difference in cost between the two medications.

What You Pay for Fills

The High-Deductible Health Plans have a combined annual deductible for medical and prescription drug services. You’ll pay the full cost of services until you meet your deductible; for prescription drugs, you’ll pay the actual cost of your medication, as negotiated between CVS Caremark and the pharmacy.

Under these plans, the most you’ll pay out of pocket for medical care and prescription drugs in any calendar year is $3,000 per individual or $6,000 per family.

How much you’ll pay for your prescription depends on the type of medication and the amount prescribed. When the cost of a drug is less than the minimum copay, you’ll pay the lower amount.

Tier 1: Generic

30-day supply: $10 copay after deductible

31- to 90-day supply: $10 copay after deductible through CVS Caremark mail service

Tier 2: Brand Name
30-day supply: $25 copay after deductible, if the drug is on the list of preferred brand drugs (the formulary)

31- to 90-day supply: $50 copay after deductible through CVS Caremark mail service

Tier 3: Non-Preferred Brand
30-day supply: $40 copay after deductible, if the drug isn’t on the list of preferred brand drugs (the formulary)

31- to 90-day supply: $80 copay after deductible through CVS Caremark mail service

A Word About Specialty Drugs
Certain high-cost specialty drugs are subject to the Advance Control Specialty Formulary. This formulary includes specialty generics and clinically effective brand therapies, and combines other specialty programs, such as Specialty Guideline Management to ensure proper utilization. For the most current formulary listing, visit the Caremark website or call CVS Caremark customer service at 877-636-0406.

Preauthorization and Other Special Circumstances

Compounded Medications
Some prescriptions, including compounded drugs, require preauthorization from CVS Caremark before they can be filled. Your pharmacist will let you know if your doctor needs to make that call. Compounded drugs are covered as Tier 3 medications.
Breast Cancer Drugs
If you’re taking raloxifene (brand name: Evista) or tamoxifen (brand name: Nolvadex) for primary prevention of breast cancer, these generics may be available at no cost to you through the preventive provisions of the Affordable Care Act. To learn if you qualify, your doctor will need to complete the Preventive Services Zero Cost Sharing Form and fax it to CVS Caremark.
Drugs and Supplies Not Covered

The following drugs and medical supplies are not covered by the plan:

  • Medical devices and appliances
  • Experimental drugs
  • Drugs whose sole purpose is to promote or stimulate hair growth
  • Retin A (for those over age 28)
  • Weight-loss drugs
  • Immunization agents, biological sera, blood or blood plasma
  • Infertility medications
  • Most over-the-counter drugs, vitamins, and nutritional supplements
  • Ostomy supplies

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Connect with…

HRConnect
Monday–Friday,
7:30 a.m. to 5 p.m. ET
844-543-2147
203-200-3838 (fax)
Website

CVS Caremark
800-776-1355
800-294-5979 (Preauthorization)
800-237-2767 (Specialty Pharmacy)
Website

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