Benefits Handbook

Prescription drugs are covered as follows:

Lower cost drugs may be available outside the prescription drug plan, including through coupon programs, manufacturer assistance programs, charities, or otherwise. Keep in mind that processing prescription drug claims outside the CVS Caremark benefit will bypass built-in safety edits for drug-drug and drug-disease interaction checks.

The Plan covers formulary and non-formulary prescription drugs purchased via the Plan's mail order service or a participating retail pharmacy. The prescription drugs in the formulary may change. Select medications may be excluded from coverage (this list may be updated periodically).

To price medications and check formulary, visit www.caremark.com.

Unless your physician specifically prescribes a brand-name medication without substitution, prescriptions will be filled with the generic equivalent when allowed by state law.

The Plan covers generic prescription drugs purchased via the Plan's mail order service or at a retail pharmacy.

Unless your physician specifically prescribes a brand name medicine without substitution, prescriptions will be filled with the generic equivalent when allowed by state law.

If you or your physician requests the brand-name prescription drug when a generic prescription drug is available and there is no medical reason for the brand-name prescription drug, you pay your share of the cost for the generic drug in addition to the difference between the brand-name prescription drug and generic prescription drug gross cost. The difference in cost between the brand-name prescription drug and generic prescription drug does not accumulate towards your deductible and out-of-pocket maximum. If you meet your out-of-pocket maximum, you will continue to pay the difference in cost between the brand-name prescription drug and generic prescription drug.

The Plan will cover certain generic and brand-name contraceptive medications with no generic equivalent at 100% in-network with no cost sharing as long as a valid prescription is submitted.

Preventive drugs as defined by the Patient Protection Affordable Care Act for the $1,600 Deductible Plan and $3,200 Deductible Plan are covered with no cost sharing (i.e. deductible, coinsurance). Certain examples include: aspirin products (except low dose aspirin), fluoride products, folic acid products, immunizations, contraceptive methods, smoking cessation products, bowel preps, primary prevention of breast cancer and statins. The list of preventive medications covered with no cost sharing, called the CVS Caremark ACA Drug List, is subject to periodic review and may change.

If you enrolled in the $1,600 Deductible Plan or the $3,200 Deductible Plan, there are certain preventive medications that are not subject to the deductible. Certain examples include: hypertension, diabetes, asthma, and cholesterol lowering drugs. This list of preventive medications, called the CVS Caremark Preventive Drug List, is covered at the standard coinsurance and the list of medications is subject to periodic review and change.

Call CVS Caremark® at +1 844 449 0362 for more information about preventive drugs. You can access the preventive drug listing at www.caremark.com. To obtain information on the cost of preventive drugs, log on to the Drug Cost Tool at www.caremark.com. Follow the provided steps to access the Drug Cost Tool.

The Prescription Drug Benefits Manager provides an online directory of network pharmacies available at www.caremark.com. You may also call the Prescription Drug Benefits Manager.

The Plan's mail order service allows participants to order up to a 90-day supply of prescription medication by mail for certain maintenance medications. You may also obtain a 90-day supply of maintenance medications at CVS Caremark® retail pharmacies.

Effective April 1, 2024, the Maintenance Choice® program has been expanded to include Kroger affiliated pharmacies, Costco and its mail pharmacies, and several independent pharmacies. You can log into www.caremark.com to identify and locate select participating pharmacies by using the pharmacy locator tool.

Using the CVS Caremark® Maintenance Choice Program mail order service or obtaining a 90 day supply of maintenance medications will generally cost you less than using a non-CVS Caremark® retail pharmacy.

For those prescriptions filled in Oklahoma, effective November 1, 2023, members will be able to fill a 90-day supply of their maintenance medications at any pharmacy in Oklahoma that participates in the CVS Caremark Retail 90 network or through the CVS Caremark Mail Order Pharmacy. To locate an in network pharmacy in the CVS Caremark Retail 90 network, go to www.caremark.com, Select Plan & Benefits, then select Pharmacy locator. For more information, refer to "Is there a network of pharmacies?."

For those prescriptions filled in Minnesota, effective July 1, 2023, members will be able to fill a 90-day supply of their maintenance medications at any pharmacy in Minnesota that participates in the CVS Caremark Maintenance Choice network (includes CVS Retail stores and the CVS Caremark Mail Order Pharmacy). To locate an in-network pharmacy, go to www.caremark.com, Select Plan & Benefits, then select Pharmacy locator. For more information, refer to "Is there a network of pharmacies?."

For specialty medications in Minnesota, effective January 1, 2024, members will be able to fill their specialty medications at any pharmacy that is able to dispense specialty medications in the state of Minnesota in addition to CVS specialty.

For those prescriptions filled in Tennessee, effective October 1, 2023, members will be able to fill a 90-day supply of their maintenance medications at any pharmacy in Tennessee that participates in the CVS Caremark Maintenance Choice network (includes CVS Retail stores and the CVS Caremark Mail Order Pharmacy). To locate an in-network pharmacy, go to www.caremark.com, Select Plan & Benefits, then select Pharmacy locator. For more information, refer to "Is there a network of pharmacies?."

For those prescriptions filled in Florida, effective January 1, 2024, members will be able to fill a 90-day supply of their maintenance medications at any pharmacy in Florida that participates in the CVS Caremark Retail 90 network or through the CVS Caremark Mail Order Pharmacy. To locate an in network pharmacy in the CVS Caremark Retail 90 network, go to www.caremark.com, Select Plan & Benefits, then select Pharmacy locator. For more information, refer to "Is there a network of pharmacies?."

For specialty medications in Florida, effective January 1, 2024, members will be able to fill their specialty medications through an expanded network that includes CVS specialty and Publix pharmacies.

For those prescriptions filled in West Virginia, effective January 1, 2024, members will be able to fill a 90-day supply of their maintenance medications at any pharmacy in West Virginia that participates in the CVS Caremark Retail 90 network or through the CVS Caremark Mail Order Pharmacy. To locate an in network pharmacy in the CVS Caremark Retail 90 network, go to www.caremark.com, Select Plan & Benefits, then select Pharmacy locator. For more information, refer to "Is there a network of pharmacies?."

For specialty medications in West Virginia, effective January 1, 2024, members will be able to fill their specialty medications at any pharmacy that is able to dispense specialty medications in the state of West Virginia in addition to CVS specialty.

In addition to mail order, you will be able to fill a 90-day supply of your maintenance medications at a CVS Caremark® retail pharmacy, at the same cost as you would through the CVS Caremark® Maintenance Choice mail order program. For all maintenance medications, after the first three fills, you must fill a 90-day supply either at CVS Caremark® Retail or through CVS Caremark® Maintenance Choice Mail Order service. After three fills, the next fill for a 30 day supply or filled at a non-CVS Caremark® Retail pharmacy or not through CVS Caremark® Maintenance Choice Mail Order will be rejected. You will pay 100% of the full cost for all subsequent fills. Amounts you pay for rejected claims will not accumulate towards the deductible and out-of-pocket maximum.

If a specialty medication is filled at non-CVS Caremark® retail pharmacy, the prescription will not be covered and amounts you pay for the noncovered prescription will not accumulate to the out-of-pocket maximum.

You may be subject to several different types of drug management programs. These include quantity management, prior authorization and qualification by history or step therapy.

Quantity Management

To ensure safe and effective drug therapy, certain covered medications may have quantity restrictions. These quantity restrictions are based on manufacturer and/or clinically approved guidelines and are subject to periodic review and change.

Select examples of drug categories include:

Prior Authorization

Certain medical treatments and prescription medicines need prior approval (which may include the submission of clinical information by your prescriber) before the Plan will cover them. This requirement is to ensure the treatment or medication is appropriate and effective. If you do not receive approval, you will be responsible for paying the full cost.

Select examples of drug categories include but are not limited to:

The drugs that require prior authorization may be modified. To obtain prior authorization for coverage ask your doctor to call CVS Caremark® at +1 800 237 2767. After they receive the necessary information, you and your doctor will be notified confirming whether or not coverage has been approved.

Qualification by History (Step Therapy)

Some medications require the trial of another drug and/or require certain criteria such as age, or condition (determined by previous claims history) to receive coverage. In these cases, a coverage review will be required if certain criteria cannot be determined from past history.

Select examples of drug categories include:

The drugs that may become subject to qualification by history rules may be modified.

Contact the Prescription Drug Benefits Manager at +1 844 449 0362 for more information about any of these programs.

Specialty medications may require prior authorization under the Plan and may be subject to quantity limitations and cost caps. These limits are subject to change and are discussed above.

Certain specialty drugs which you can administer to yourself (or a caregiver may administer to you) may not be covered under the medical benefit. These drugs must be obtained at CVS Caremark® Specialty Pharmacy.

Contact the Pharmacy Benefits Manager at +1 844 449 0362 for more information about any of these programs.

Your Plan covers certain Specialty Drugs that must be administered to you as part of a doctor's visit, home care visit, or at an outpatient Facility when they are Covered Services. This section applies when a Provider orders the Drug and a medical Provider administers it to you in a medical setting or in your home by a home infusion provider.

Specialty Drugs you obtain from a Retail or Mail Order Pharmacy are also not covered under your medical benefit.

Precertification is required for certain Medically Administered Specialty Drugs to help make sure proper use and guidelines for these drugs are followed. Your Provider will submit clinical information which will be reviewed for decision. The Claims Administrator will give the results of their decision to both you and your Provider by letter.

For a list of Medically Administered Specialty Drugs that need precertification, please contact your Claims Administrator. The precertification list is reviewed and updated from time to time. Including a Specialty Drug on the list does not guarantee coverage under your Plan. Your Provider may check with the Claims Administrator to verify Specialty Drug coverage, to find out which drugs are covered under this section and if precertification is required.

If you are receiving an infused medication, certain medications may require use of the lowest cost site of care.

The following drugs and drug supplies are excluded from prescription drug coverage:

There is a pharmacy network associated with this Plan administered by CVS Caremark®. You may use a pharmacy in the network as well as out-of-network to receive coverage under this Plan.

Note that when you go to a pharmacy that's out-of-network, you need to submit a claim form for reimbursement. Refer to "How do I file a prescription drug claim form?" for more information.

The Prescription Drug Benefits Manager provides an online directory of network pharmacies available at www.caremark.com.

To locate an in-network retail pharmacy:

Or call CVS Caremark® at +1 844 449 0362 for more information.

All prescriptions filled at a participating retail pharmacy require you to provide an ID card for coverage under the Plan. You are responsible for the applicable deductible, or coinsurance. Rarely will you need to file a claim with the Prescription Drug Benefits Manager (one example may be a prescription filled at retail before you have received your ID card). To file a claim, contact the Prescription Drug Benefits Manager.

Claim forms are available on the Prescription Drug Benefits Manager's website. Should you need to file a claim, you are reimbursed for the contracted rate less coinsurance. You have 12 months from the date the expense was incurred to submit a claim.

Yes, there is a separate ID card for the prescription drug program. If you are enrolled in medical coverage, you will automatically be sent a prescription drug ID card in addition to your medical plan ID card. You will be sent two prescription ID cards. If you enroll one or more family members, each prescription ID card will list the names of all covered family members.

You may request additional ID cards directly from the Prescription Drug Benefits Manager or by printing online at www.caremark.com.

There is a separate ID card for medical coverage. For information on medical plan ID cards, refer to the ID cards section.