Benefits Handbook

Prescription drugs are covered as follows:

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 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 are covered with no cost sharing (i.e. copay). 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 share, called the CVS Caremark ACA Drug List, is subject to periodic review and may 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 Pricing Tool.

The Pharmacy 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 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 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 non-covered 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 will only be covered through CVS Caremark's Specialty Pharmacy. If these medications are obtained from an outpatient clinic, a home infusion company, a doctor's office or from another pharmacy, they will not be covered and you will be responsible for the full cost of the medication. This does not apply to medications supplied by an emergency room or during an inpatient hospital stay.

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

PrudentRx is a program that can help you receive eligible specialty medications at no cost for the treatment of complex chronic conditions, including, but not limited to, multiple sclerosis, cancer and rheumatoid arthritis.

Your specialty medication will be filled through CVS Specialty Pharmacy. You can see the prescription drugs in the PrudentRx Program at www.caremark.com. This list is subject to periodic review and change.

You are eligible for the PrudentRx Program if you are currently taking a specialty medication covered under the prescription drug benefit that is on the PrudentRx Drug List (available at www.caremark.com), you receive your prescription drugs benefits through CVS Specialty Pharmacy, and you are enrolled in the Surest Copay Plan.

If you are eligible for the PrudentRx Program and your specialty medication is on the PrudentRx Drug List (available at www.caremark.com), you must participate and enroll in the PrudentRx Program to receive your specialty medication free of charge. If eligible, you'll be enrolled in the PrudentRx program. PrudentRx will reach out to you or your enrolled family members to gather information upon filling a prescription through CVS Specialty Pharmacy. PrudentRx will send a letter followed up by a phone call to provide specific information about the program and gather required information as it relates to your specialty medication, which will be filled through CVS Specialty Pharmacy. To secure your enrollment and participation in the PrudentRx program, you must speak with PrudentRx.

You can see the eligible specialty medications included in the PrudentRx Program, (i.e., on the PrudentRx Drug List) at www.caremark.com. The PrudentRx Drug List may be updated periodically.

These specialty medications are considered non-essential health benefits under the program and the cost of such medications will not be applied towards your out-of-pocket maximum as there will be no cost to you.

Participating in the PrudentRx program means that you must speak with PrudentRx to verify your enrollment and properly complete any steps required by a manufacturer to obtain copay assistance. If you do not speak with PrudentRx, you'll be responsible for paying the 30% coinsurance cost for each eligible specialty prescription medication, and the costs will NOT count towards either out-of-pocket maximum.

If your specialty medication is not on the PrudentRx drug list, your medication cost share follows 90-day supply copays outlined in "How does the Plan cover prescription drugs?." If you receive less than a 90-day supply, your copay is prorated based on the day supply of medication you receive.

If You're Currently Enrolled in a Manufacturer Copay Assistance Program:

If you're currently enrolled in a manufacturer copay assistance for a specialty medication and this medication is on the PrudentRx Drug list, you'll need to provide the manufacturer copay enrollment information to PrudentRx in order to pay $0 for this medication. If you do not speak with PrudentRx and provide the manufacturer copay enrollment information to PrudentRx, you'll be responsible for paying the 30% coinsurance cost for each eligible specialty prescription medication, and the costs will NOT count towards either out-of-pocket maximum.

If You're Not Currently Enrolled in a Manufacturer Copay Assistance Program:

If you're not currently enrolled in manufacturer copay assistance for a medication on the PrudentRx Drug list and the manufacturer requires enrollment in copay assistance, you'll need to speak with PrudentRx so that PrudentRx can assist with getting you enrolled with the manufacturer copay assistance in order to pay $0 for this medication. PrudentRx will contact you if you're required to enroll in the copay assistance for any medication that you take. PrudentRx will work with you and the drug manufacturer to get copay assistance and will manage enrollment and renewals on your behalf. If you do not enroll in any copay assistance as required by the manufacturer, you'll be responsible for paying the 30% coinsurance cost for each eligible specialty prescription medication, and the costs will NOT count towards either out-of-pocket maximum.

If you do not speak with PrudentRx, do not enroll in any copay assistance as required by a manufacturer, or do not choose to participate in the PrudentRx program, i.e. opt out, you'll be responsible for paying the 30% coinsurance cost for each eligible specialty prescription medication, and the costs will NOT count towards either out-of-pocket maximum.

If you have any questions, contact PrudentRx at +1 800 578 4403, Monday to Friday, from 9:00 am to 9:30 pm, and Saturday, 9:00 am to 6:00 pm, Eastern Time.

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.

The PrudentRx Program does not apply to prescription drugs dispensed through the medical benefit.

Prior authorization 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.

For a list of Medically Administered Specialty Drugs that need prior authorization, please contact your Claims Administrator. Drugs requiring prior authorization may be updated from time to time. 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 prior authorization 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 Pharmacy 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 copay. 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 responsible for the contracted rate less copay. You have 12 months from the date the expense was incurred to submit a claim.

If you are eligible for the PrudentRx Program and your specialty medication is on the PrudentRx Drug List, refer to "Prescription Drug Programs" for information on how the PrudentRx Program works.

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.