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Prescription Drug Copays
There is no deductible for prescription drug coverage.
Note: The copay amounts shown in the following table are the maximum amounts. If your prescription costs less, you will pay less.
Prescription Drug Copays
Simplified Option 1
Simplified Option 2
 
Traditional
Specialty
Traditional
Specialty
Preventive Generic Drugs*
Free
Free
Retail Pharmacy (up to a 30-day supply)
 
Non-preventive Generic*
$10
$100
$15
$125
Preferred Brand name*
$75
$150
$125
$200
Non-preferred brand name*
$150
$200
$250
$250
Mail Order Pharmacy or CVS Retail Pharmacy/ 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
Out-of-Pocket Maximum
(combined with Medical Out-of-Pocket Maximum)
See "The Annual Out-of-Pocket Maximum"
See "The Annual Out-of-Pocket Maximum"
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 any CVS retail pharmacy. If you "opt out" out of Maintenance Choice®, your prescription costs will generally be higher. Please see "Details About Maintenance Choice®."