Prescription Drugs

What you need to know

You automatically have prescription drug coverage when you enroll in the YNHHS Medical Plan. You can fill covered prescriptions at participating CVS retail pharmacies, through mail order, or through YNHHS Outpatient Pharmacy Services.

Need to fill a prescription?

Find a participating pharmacy near you.

Filling Your Prescription

Your prescription will be covered only if it’s filled at a participating pharmacy. To fill 30-day supply prescriptions, just present your prescription and CVS Caremark prescription drug card at a pharmacy in the CVS Caremark network. To fill a maintenance medication, you must use a CVS retail pharmacy, mail order, or visit a YNHHS Outpatient Pharmacy. For specialty medications, you’ll need to use mail order or specialty pharmacy services, as described below.

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.

When you’re covered by the YNHHS Medical Plan, the out-of-pocket maximum is the most you’ll pay out of pocket for medical care and prescription drugs.

When a generic is available and you or your doctor chooses a brand-name drug, you’ll pay the brand-name coinsurance—plus the difference in cost between the two medications.

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.

Save on Maintenance Drugs

For medications you take on an ongoing basis, you’ll use the CVS Caremark Maintenance Choice program to get refills at a lower copay for a larger supply. With CVS Maintenance Choice, you get up to two 30-day fills at a retail pharmacy before you’ll need to use CVS Caremark mail service or a CVS Pharmacy for 90-day fills.

No-cost vaccines when you use the right ID card

You and your covered dependents can get no-cost vaccines for shingles, pneumonia, flu (ages 18 and older only), COVID-19, tetanus/diphtheria, and hepatitis A and B. To ensure 100% coverage, show the right ID card. If you are in a CVS Minute Clinic or Health Hub, use your medical plan ID card. Any other network pharmacy, use your CVS Caremark ID card.

What You Pay for Fills

What you’ll pay 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.

As a reminder, you only need to meet one combined annual out-of-pocket maximum for medical and prescription drugs. All your copays and coinsurance for covered services are applied toward this maximum. Once the out-of-pocket maximum is met, the plan pays 100% of eligible expenses for the remainder of the calendar year for each enrolled person.

Tier 1: Generic

30-day supply: $10 copay

90-day supply through CVS Maintenance Choice: $20 copay

Tier 2: Brand name
30-day supply: 20% coinsurance ($35 minimum, $80 maximum) if the drug is on the list of preferred brand drugs (the formulary)

90-day supply through CVS Maintenance Choice: 20% coinsurance ($70 minimum, $150 maximum) if the drug is on the list of preferred brand drugs (the formulary)

Tier 3: Non-preferred brand
30-day supply: 40% coinsurance ($55 minimum, $120 maximum) if the drug isn’t on the list of preferred brand drugs (the formulary)

90-day supply through CVS Maintenance Choice: 40% coinsurance ($110 minimum, $230 maximum) if the drug isn’t on the list of preferred brand drugs (the formulary)

Tier 4: Specialty

Up to a 30-day supply only through YNHHS Outpatient Pharmacy Services Generic and brand name: $20 copay

For certain high-cost specialty drugs not available through Outpatient Pharmacy Services or the Apothecary & Wellness Center, you’ll use CVS Specialty Pharmacy. These medications are subject to 40% coinsurance (up to $150 generic, $200 brand name).

Employees and/or their covered dependents who are enrolled in the YNHHS Medical Plan and take specialty medications can access a free program that will save them money by reducing out-of-pocket costs for eligible specialty medications.

CVS Caremark, YNHHS’ prescription plan administrator, has partnered with PrudentRx to offer this program for eligible specialty medications. If your specialty medication is on the PrudentRx Exclusive Specialty Drug List, you will have a $0 copay for your medication(s). If your medication is on the Prudent Rx Specialty Drug List, and you do not enroll in their program, you will pay 30% of the medication cost. To receive this benefit, specialty medications must be filled at the YNHHS Outpatient Pharmacy Services 844-881-0043 or the Apothecary & Wellness Center 203-789-4076.

To take advantage of this program or to see if your specialty medication is on the PrudentRx drug list, call PrudentRx at 800-578-4403, Monday through Friday, 8 a.m. – 8 p.m. Eligible employees must register first with PrudentRx before filling a prescription.

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.
Breast Cancer Drugs
If you’re taking raloxifene (brand name: Evista) or tamoxifen (brand name: Noladex) 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.
Step Therapy Program
The step therapy program requires you to try one or two generic equivalents before the brand-name drug will be covered.

Drug classes included in this program include medications that treat high cholesterol, high blood pressure, gastrointestinal disorders (GERD, for instance), sleep disorders, depression, and other conditions.

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
  • Most over-the-counter drugs, vitamins, and nutritional supplements
  • Ostomy supplies
  • Prescription ophthalmic products used to improve the field of vision (e.g., presbyopia, blepharoptosis, drug-eluting contact lenses, etc.)
  • Certain drugs that have limited clinical value and which have clinically-appropriate, lower-cost alternatives (e.g., brand name or generic drugs that are combinations of existing generic or over-the counter drugs, new formulations of existing drugs)

Connect with…

7:30 a.m. to 5 p.m. ET
203-200-3838 (fax)
Choose the YNHH_PRD option

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

YNHHS Outpatient Pharmacy Services
203-230-0679 (fax)

Apothecary and Wellness Center at Yale New Haven Hospital
Saint Raphael Campus, 1450 Chapel Street, New Haven, CT 06511

Yale New Haven Health Pharmacy at North Haven Medical Center
6 Devine Street
North Haven, CT 06473

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