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How Prescription Drug Benefits Are Paid Under the Medical Plan
Prescription drug coverage has a separate plan design from the other Medical Plan features, with a separate deductible, copayments, and coinsurance, and a separate "safety net" in the form of per-prescription maximums and an annual prescription drug out-of-pocket maximum.
Category
Provisions
Preventive Generic Drugs*
100% coverage (deductible does not apply)
Non-preventive Generic Drugs (non-specialty)*
30-day supply: $10 or the actual cost of the drug if less than $10; not subject to the deductible
90-day supply: You pay $20 or actual cost of the drug if less than $20; not subject to the deductible
Annual Retail Deductible
(retail pharmacy only; waived for non-specialty generic drugs)
Employee only (also serves as a per-person maximum**)
$100
Employee + spouse/domestic partner or Employee + child(ren)
$200
Family (employee + spouse/domestic partner + child(ren))
$300
Retail Pharmacy Benefit (up to a 30-day supply)
The Retail Pharmacy benefit covers up to a 30-day supply of medication purchased from a network pharmacy.
  • Preferred brand-name and specialty generic coinsurance/per-prescription maximum*
You pay 30% after the deductible, up to a $200 maximum per-prescription payment (the Plan pays 70% coinsurance plus costs above the $200 maximum)
  • Non-preferred brand-name coinsurance/per-prescription maximum*
You pay 45% after the deductible, up to a $250 maximum per-prescription payment (the Plan pays 55% coinsurance plus costs above the $250 maximum)
Mail Order Pharmacy or CVS Retail Pharmacy/ Maintenance Choice® (up to a 90-day supply; opt-out available)***
The deductible does not apply if you fill maintenance medications through Maintenance Choice®. Please see "Details about Maintenance Choice®" for more information.
  • Preferred brand-name and specialty generic coinsurance/per-prescription maximum*
You pay 30% up to a $500 maximum per-prescription payment (the Plan pays 70% coinsurance plus costs above the $500 maximum)
  • Non-preferred brand-name coinsurance/per-prescription maximum*
You pay 45% up to a $625 maximum per-prescription payment (the Plan pays 55%coinsurance plus costs above the $625 maximum)
Annual Out-of-Pocket Maximum
(covers copayment/coinsurance expenses for covered eligible prescription drugs; does not include the deductible)
Employee only (also serves as a per-person maximum**)
$1,150
Employee + spouse/domestic partner or Employee + child(ren)
$1,750
Family (employee + spouse/domestic partner + child(ren))
$2,300
  • CVS Caremark Excluded Drugs
(Traditional and Specialty)
Not covered; you will pay the full cost for these drugs.
  • Non-Sedating Antihistamines
(also known as NSAs)
Not covered; you will pay the full cost for these drugs.
* CVS Caremark determines which drugs are considered "generic," "brand," "preventive generic," "preferred," "non-preferred," "maintenance," and "specialty," etc. We use CVS Caremark's lists of covered and excluded drugs. An independent committee made up of pharmacists, physicians and medical ethicists reviews and approves the drug lists (also known as formularies).

These lists are subject to change quarterly by CVS Caremark. If you continue to take a noncovered drug, you will pay the full cost of the drug. To see a list of drugs in these categories, visit CVS Caremark's website at My Health.
** For both the retail deductible and the annual out-of-pocket maximum, the "per person" rule allows the employee or any covered dependent(s) [for example, spouse/domestic partner or child(ren)] to reach an individual deductible or out-of-pocket maximum, after which the deductible or out-of-pocket maximum is satisfied for the year for that person. Covered individuals who have not met the deductible or out-of-pocket maximum may combine to meet the remainder of the deductible or out-of-pocket maximum for that particular coverage level. If no one person has met the individual deductible or out-of-pocket maximum, the expenses of all covered individuals can combine to meet the deductible or out-of-pocket maximum for that coverage level.
*** The Maintenance Choice® program covers 90-day supplies of maintenance medication. There is no deductible for maintenance medications. Maintenance Choice® allows you to: 1) send your 90-day prescription to CVS Caremark and have your medicine delivered by mail to your home; or 2) fill your 90-day prescription at any CVS retail pharmacy. If you "opt out" out of Maintenance Choice®, your prescription will be subject to the deductible and your costs will generally be higher. Please see "Details about Maintenance Choice®."