Prescription Drug Coverage

Your prescription drug coverage is administered by CVS Caremark. Prescription benefits are the same no matter which medical plan you choose.

There is a 4-tier copay structure. The amount you pay depends on whether your prescription is for a generic drug, a brand-name drug listed on CVS Caremark’s preferred drug list (the formulary), or a non-preferred brand-name drug.

Here’s what you’ll pay for covered prescription drugs, depending on the tier and where you choose to fill your prescription.

If you are enrolled in the Health Enhancement Program, you’ll pay lower copays for medications used to treat chronic conditions covered by HEP’s disease education and counseling programs:

• Tier 1: $0 copay
• Tier 2: $5 copay
• Tier 3: $12.50 copay

You’ll pay nothing for medications and supplies used to treat diabetes (Type 1 and Type 2).

To check which copay amount applies to your prescriptions, visit www.Caremark.com. Once you register, click Look up Copay and Formulary Status. Type the name of the drug you want to look up and you will see the cost and copay amounts for that drug as well as alternatives.

Brand-Name Drugs

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

If your doctor believes a non-preferred brand-name drug is medically necessary for you, they will need to complete the Coverage Exception Request form and fax it to CVS Caremark. If approved, you will pay the preferred brand copay amount.

Mandatory Generics

Prescriptions will be filled automatically with a generic drug if one is available, unless your doctor completes CVS Caremark’s Coverage Exception Request form and it is approved. Note: It is not enough for your doctor to note “dispense as written” on your prescription; a separate 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.

90-day Supply for Maintenance Medications

If you or your family member takes a maintenance medication, you are required to get your maintenance prescriptions as 90-day fills. You can get your first 30-day fill of a new medication at any participating pharmacy. After that, your two choices are:

• Receive your medication through the CVS Caremark mail-order pharmacy, or
• Fill your medication at a pharmacy that participates in the State’s Maintenance Drug Network (see the list of participating pharmacies).

A list of maintenance medications is available here.

CVS Caremark Specialty Pharmacy

Certain chronic and/or genetic conditions require special pharmacy products (often injected or infused). The specialty pharmacy program provides these prescriptions along with the supplies, equipment, and care coordination needed to take the medication. Call (800) 237-2767 for information.

New! When you fill a prescription for a specialty drug, you will automatically be enrolled in a PrudentRx program that reduces your out of pocket cost to $0. You can choose to opt out of this program.