Prescription Drug Coverage

You have prescription drug coverage automatically when choosing coverage under either the Advantage Plus Plan or Advantage Plan. The prescription drug program is administered by CVS Caremark, one of the country’s largest prescription drug administrators. This program offers three cost-effective ways to fill prescriptions for covered drugs and medications: at participating retail pharmacies, through the CVS Caremark “Maintenance Choice” program when you need maintenance drugs, and specialty pharmacy services offered as walk-in or via mail through Outpatient Pharmacy Services at YNHHS in Hamden or the Apothecary and Wellness Center at the Saint Raphael Campus of YNHH.

Short Term Medications

You may fill up to a 30-day supply of a prescription at over 5,000 participating pharmacies in the Connecticut, New York, and New Jersey area (64,000 nationwide), including most independent drug stores and at major pharmacy and supermarket chains. To determine if a pharmacy is a part of the CVS Caremark network, visit the online pharmacy provider directory at www.caremark.com.

When you fill a short-term prescription such as a 30 day supply at a participating pharmacy, simply present the prescription and your CVS Caremark prescription drug card. You’ll pay:

TIER 1 – $8 copay* per prescription if it’s filled with a generic drug

TIER 2 – 20% coinsurance per prescription ($30 minimum*; $75 maximum) if it’s filled with a brand name drug that’s on the list of preferred brand drugs, called the “formulary”

TIER 3 – 40% coinsurance per prescription ($50 minimum*; $115 maximum) if the brand name drug isn’t on the list of preferred brand drugs

* Minimum Copay - If the actual cost of a drug is less than the minimum copay, you will pay the lower amount.

Specialty Rx Program

Specialty Rx Program exists for certain high cost specialty drugs, including select injectables and oral medications. Employees and dependents using such specialty drugs will be able to obtain them through Caremark Specialty Pharmacy Services at 1-800-237-2767. Employees and dependents also have the convenience of dropping and/or picking up their specialty medication at a CVS/pharmacy. Expedited mail service and other services are available to the participants in the program.

Additionally, we offer a benefit that will provide substantial “out of pocket” savings for Yale New Haven Health System employees and their covered dependents who take high-cost specialty (Tier 4) medications, including select injectables and oral medications for the following disease states: oncology, hepatitis C, HIV, multiple sclerosis, rheumatoid arthritis, and inflammatory conditions.

Details about this benefit

• Employees/covered dependents who take certain specialty drugs will be able to purchase them at a significant savings-the cost for both generic and brand specialty medications will be a flat $20 co-pay for up to a 30-day supply. To obtain this pricing, the specialty medications must be purchased through Outpatient Pharmacy Services at YNHHS in Hamden or the Apothecary and Wellness Center at YNHH, a retail pharmacy located on the YNHH Saint Raphael Campus that offers pick-up, mail order, and delivery service for Tier 4 medications. Call 1-844-881-0043 for more information.
• Employees enrolled in a YNHHS medical plan can choose to continue to use the Caremark Connect Specialty Pharmacy Services program for Tier 4 specialty medications. However, they will continue to pay 40% of the cost for each prescription, up to a $100 maximum for a generic medication or a $130 maximum for a brand-name medication.

Two options available:

TIER 4 – Specialty Drugs

YNHHS Outpatient Pharmacy Services, Specialty Pharmacy Program

1. Generic – $20
2. Brand – $20

TIER 4 – Specialty Drugs

CVS Caremark Program—40% coinsurance per prescription (up to 30-day supply)

1. Generic - $100 maximum
2. Brand - $130 maximum

If you take Specialty drugs for any of these conditions – Human Growth, Rheumatoid Arthritis and Multiple Sclerosis – you will be required to use preferred drug prior to utilization of non-preferred drug.

Important! Prescriptions filled at non-participating pharmacies will not be covered unless you need to fill a prescription in an emergency that occurs while out-of-state. In this case, you’ll pay the full cost of the prescription at the time it’s filled and later file a claim for reimbursement with CVS Caremark.

Maintenance Drugs

If you take medications regularly for chronic conditions or long-term therapy, known as “maintenance drugs,” you must use the CVS Caremark “Maintenance Choice” program. This program allows you to get up to a 90-day supply of a maintenance drug through the CVS Caremark Mail Service Program or at any CVS Pharmacy. Examples include drugs for high blood pressure, diabetes, asthma, arthritis, or high cholesterol. For maintenance drugs, you can only receive two 30-day fills at a retail Pharmacy, after which you must use the “Maintenance Choice” program.

Using the “Maintenance Choice” program saves you money in lower copays for a larger supply (as shown below) and also saves our self-insured medical plan money.

When you fill a prescription under the “Maintenance Choice” program, you’ll pay:

TIER 1 – $20 copay** per prescription if it’s filled with a generic drug.

TIER 2 – 20% coinsurance per prescription ($60 minimum**; $140 maximum) if it’s filled with a brand name drug that’s on the list of preferred brand drugs, called the “formulary”

TIER 3 – 40% coinsurance per prescription ($100 minimum**; $220 maximum) if the brand name drug isn’t on the list of preferred brand drugs

** Minimum Copay - If the actual cost of a drug is less than the minimum copay, you will pay the lower amount.

The drugs covered under the prescription drug program include:

• legend drugs (drugs that require a prescription)
• compounded drugs***
• insulin
• diabetic supplies (such as syringes, test strips, lancets, glucometers, etc. )
• prenatal vitamins requiring a prescription

*** What are compounded medications?

• Compounded medications are customized medications developed for an individual patient in response to a licensed practitioner’s prescription. The medication, which is otherwise not commercially available, is created by combining, mixing or altering pharmaceutical ingredients. Compounds are often used to provide medication in an oral suspension form for children, in instances of medication shortages, or for conditions that require personalized medicine, such as hormone replacement therapy.
• Prescriptions for compounded drugs will require prior authorization from CVS Caremark
• Compounded drugs will be covered as Tier 3 medications in our plan design. A 30-day supply can be obtained at a retail pharmacy in the CVS Caremark network. Compounded medications can also be ordered through the CVS Caremark “Maintenance Choice” program.

Some prescriptions require prior authorization before they can be filled. Your pharmacist will notify you if that is the case. If it is, your doctor will need to contact CVS Caremark at 1-800-294-5979 for approval.

Drugs and supplies not covered by the program include:

• medical devices and appliances
• experimental drugs
• drugs whose sole purpose is to promote or stimulate hair growth
• Retin A (for those over age 28)
• anorexiants (drugs for weight reduction)
• immunization agents, biological sera, blood or blood plasma
• infertility medications
• most over-the-counter drugs, vitamins and nutritional supplements
• ostomy supplies

The following drugs are covered at 100% as a result of the Affordable Care Act but do require a prescription:

• Vitamin D – covered for adults age 65 years or older who are at increased risk for falls. This vitamin is obtained Over-the-Counter (OTC) but must be accompanied by a prescription.
• Aspirin – to prevent cardiovascular disease – men age 45–79, women age 55–79. Generic only, OTC, <=325 mg, prescription required
• Iron Supplements – children aged 6 to 12 months who are at increased risk for iron deficiency anemia. Brand or generic, prescription or OTD, prescription required
• Oral Fluorides – age limit <= 6 yrs., Brand or generic, prescription products only
• Folic Acid – Women only, age limit <=55, generic only, OTC, prescription required
• Tobacco Cessation Products – 168 day supply limit in one year for generic nicotine replacement products (patch, gum, lozenges) or Chantix or generic Zyban. Rx or OTC (prescription required)
• Oral Contraceptives and Devices and FDA-approved female OTC methods with prescription (multi-source brand medications are covered at brand copays)
• Breast Cancer Drugs (for primary prevention of breast cancer). These medications are available at no cost to women age 35 and older if your doctor has prescribed these drugs for the primary prevention of breast cancer. As required under the Affordable Care Act, these drugs are covered at no cost if you have not had breast cancer and your doctor has prescribed one of them to reduce your risk of developing breast cancer in the future.
• Low to moderate dose statins – men and women ages 40 through 75, no quantity limit and no prior authorization. See list of drugs on page 9.

How to find out if you qualify for these drugs at no cost to you:

1. If you are taking raloxifene (brand name Evista) or tamoxifen (brand name Nolvadex) for primary prevention of breast cancer, take the Preventive Services Zero Cost Sharing Form to your doctor who will complete and fax the form to CVS/Caremark. If you are not sure whether you qualify, talk to your doctor.
2. CVS/Caremark will review your diagnosis to determine if you qualify to receive these drugs at no cost. Please note that only the generic drugs are available at no cost to you.

You may access the Preventive Services Zero Copay Exception form from HRConnect at www.ynhhs.org/hrconnect. Please call the number on the back of your prescription benefit ID card with questions.

Step Therapy Program

The step therapy program offered by CVS Caremark includes several classes of drugs, including medications that treat high cholesterol, high blood pressure, gastrointestinal disorders (e.g., GERD), sleep aids, depression and others. If you are currently taking, or are newly prescribed, a brand name drug in any of these classes, you will be required to use one or two generic drugs first before receiving coverage of the brand name drug.

Out-of-Pocket Maximum

You and your dependents who use the prescription drug benefit have an annual maximum out of pocket dollar amount. For both individuals and families the dollar amount is $3,300. Once the out of pocket maximum is met, the plan pays 100% of covered expenses for the covered individual or family for the remainder of the year.