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Prescription Drug Copays and Out-of-Pocket Maximums
There is no deductible for prescription drug coverage.
Note: The copay amounts shown in the following table are maximum amounts. If your prescription costs less, you will pay less.
Prescription Drug Copays
Plan Option 1
Plan Option 2
Preventive Drugs*(generic and brand)
100% coverage ($0 copay)
100% coverage ($0 copay)
Retail Pharmacy (up to a 30-day supply)
Generic*
$5
$5
Preferred Brand name*
$50
$100
Non-preferred brand name*
$150
$250
Specialty*
$200
$250
Mail Order Pharmacy or Maintenance Choice® (up to a 90-day supply; opt-out available)**
2 times Retail copay amount shown above
2 times Retail copay amount shown above
Annual Out-of-Pocket Maximum
Employee-Only***
$1,250
Employee + Spouse/DP or Child(ren)
$2,000
Employee + Spouse/DP + Child(ren)
$2,600
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 take a non-covered 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.
** The Maintenance Choice® program covers 90-day supplies of maintenance medication. 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 a participating pharmacy (including any CVS retail pharmacy). To find a participating pharmacy, please visit www.caremark.com If you "opt out" out of Maintenance Choice®, your prescription costs will generally be higher. Please see "Details About Maintenance Choice®."
*** Also functions as a "per person" out-of-pocket maximum under the other coverage levels.