CVS Caremark Prescription Coverage

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Video Orientation

Benefits Flex PD 10/20/30 (CVS Caremark)
Generic Prescriptions10% co-pay for generics; must be filled at an In-Network Pharmacy. *This plan is a mandatory generic plan and will fill automatically with a generic prescription if a generic is available.

Brand name drug on Formulary/Drug List.

 

20% co-pay using an In-Network Pharmacy if there is no generic equivalent drug available.  *If a brand drug is used and the brand drug has a generic equivalent, the cost to the employee will be the difference between the brand cost and the generic cost plus the applicable brand co-pay (20%) of the full cost of the brand drug.

Brand name prescription not on the Formulary  Drug List.

 

30% co-pay; must be filled at an In-Network Pharmacy if there is no generic equivalent drug available. *If a brand drug is used and the brand drug has a generic equivalent, the cost to the employee will be the difference between the brand cost and the generic cost plus the applicable brand co-pay (30%) of the full cost of the brand drug.
Step Therapy Program
Certain maintenance medications require step therapy. Step Program Drug List
Out-of-Network Pharmacy50% co-pay.
Member Out-of- Pocket Maximum (7/1-6/30)Plan year annual member out-of-pocket cost maximum in prescription co-pays, $2,000 per person/$4,000 per family.  This maximum does apply to any penalty cost members pay.
Mail Order AvailableToll free access to mail service pharmacy is available at 1-888-796-8687.
Drug ExclusionsExperimental drugs, appetite suppressants, anorexiants (weight control), Rogaine, over-the-counter products, devices and implants, any drug not FDA approved, drugs used for cosmetic purposes, fertility agents, legend multivitamins and supplemental agents.
Oral Contraceptives (birth control pills)Yes
Specialty medicationsSpecialty medications such as infusion, injection or orally taken to treat chronic or rare conditions and must be prior authorized and can be filled only by the CVS Caremark Specialty pharmacy.

Preventative Drugs

 

100% covered when prescribed by physician, no deductible.

  • Aspirin for adults age 45 or older
  • Iron supplements for children age 1 or younger
  • Fluoride supplements for children age 6 or younger
  • Folic acid for women age 55 or younger (child-bearing age)
Smoking Cessation
Cessation Support Resources
100% covered, no age restrictions.
 RestrictionsGrowth hormones, Biotech, and genetically engineered drugs are restricted.  If medically necessary, subject to pre-authorization process.
Drug Utilization Review

On-line electronic Point of Sale Claims Management system to check for the following:

  • duplicate prescriptions
  • therapeutic duplication
  • incorrect dosage
  • too early refill
  • drug interactions/allergies
  • drug to age conflict
  • compliance check