Non-Medicare Retirees: Prescription Drug Coverage

Prescription Drug Coverage

No matter which medical plan you choose, your non-Medicare prescription drug coverage is provided through CVS Caremark. The plan has a four-tier copay structure. The amount you pay for prescription drugs depends on whether your prescription is for a preferred generic drug, a generic drug, a brand name drug listed on CVS Caremark’s preferred drug list (the formulary), or a non-preferred brand name drug. The amount you pay also depends on where you fill your medication and when you retired, as shown in the following tables.

In-Network Prescription Drug Coverage

Tier Groups 1 and 2 Groups 3
Acute and Maintenance Drugs (up to a 90-day supply) Caremark Mail Order/Maintenance Drug Network* (90-day supply) Acute and Maintenance Drugs (up to a 90-day supply) Caremark Mail Order/Maintenance Drug Network* (90-day supply)
Tier 1: Preferred generic $3 copay $0 copay $5 copay $0 copay
Tier 2: Generic $3 copay $0 copay $5 copay $0 copay
Tier 3: Preferred brand $6 copay $0 copay $10 copay $0 copay
Tier 4: Non-preferred brand $6 copay $0 copay $25 copay $0 copay

* You are not required to fill your maintenance drug prescription using the maintenance drug network or CVS Caremark Mail Order. However, if you do, you will get a 90-day supply of maintenance medication for a $0 copay.

Out-of-Network Prescription Drug Coverage

Tier All Retirement Groups
Tier 1: Preferred generic 20% of prescription cost
Tier 2: Generic 20% of prescription cost
Tier 3: Preferred brand 20% of prescription cost
Tier 4: Non-preferred brand 20% of prescription cost

Prescription Drug Tiers

A drug’s tier placement is determined by CVS Caremark and is reviewed quarterly. If new generics have become available, new clinical studies have been released, or new brand name drugs have become available, the Pharmacy and Therapeutics Committee may change the tier placement of a drug.

Group 4 Group 5*
Acute Drugs (up to a 90-day supply) Maintenance Drugs (90-day supply)‡ HEP Enrolled ◊ Acute Drugs (up to a 90-day supply) Maintenance Drugs (90-day supply)‡ HEP Enrolled ◊
$5 copay $5 copay $0 copay $5 copay $5 copay $0 copay
$5 copay $5 copay $0 copay $10 copay $10 copay $0 copay
$20 copay $10 copay $5 copay $25 copay $25 copay $5 copay
$35 copay $25 copay $12.50 copay $40 copay $40 copay $12.50 copay

** Retirees in Group 5 have a different CVS Caremark formulary (that is, the covered drug list), than retirees in the other groups. The CVS Caremark Standard Formulary is focused on clinically effective lower-cost alternatives to high-cost drugs.

You are required to fill your maintenance drugs using the maintenance drug network or CVS Caremark Mail Order.

Maintenance drugs to treat 1) asthma or COPD; 2) diabetes (type 1 or 2); 3) heart failure/heart disease; 4) hyperlipidemia (high cholesterol); or 5) hypertension (high blood pressure): You are required to fill your maintenance drugs using the maintenance drug network or CVS Caremark Mail Order.

Prescription Drug Programs

Your prescription drug coverage has the following programs to encourage the use of safe, effective and less costly prescription drugs.

Mandatory Generics. Your prescription will be filled automatically with a generic drug if one is available, unless your doctor completes CVS Caremark’s Coverage Exception Request Form and the form is approved by CVS Caremark. (It is not enough for your doctor to note “dispense as written” on your prescription; completion of the Coverage Exception Request Form is required.)

If you request a brand name drug instead of a generic alternative without obtaining a coverage exception, you will pay the generic drug copay PLUS the difference in cost between the brand and generic drug.

CVS Specialty Pharmacy. Treatment of certain chronic and/or genetic conditions requires special pharmacy products, which are often injected or infused. The Specialty Pharmacy program provides these prescriptions along with the supplies, equipment and care coordination needed. Call 800-237-2767 for information.

Tips for Reducing Your Prescription Drug Costs

Compare and contrast prescription drug costs. Contact CVS Caremark to find the tier of the prescription drugs you and your family members use. If you have any Tier 3 or Tier 4 drugs, consider speaking with your doctor about switching to a generic equivalent.

Use the Maintenance Drug Network or the Mail Service Pharmacy. If you are taking a maintenance medication for a long-term condition, such as asthma, high blood pressure or high cholesterol, switch your prescription from a retail pharmacy to the Maintenance Drug Network or the Mail Service Pharmacy. Once you begin using the Mail Service Pharmacy, you can conveniently order refills by phone or online. Contact CVS Caremark for more information.