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Active Members Information: Prescription Drug Coverage

Summary

  • Three-Tier Copayment Plan - Generic, Preferred Drugs and Non-Preferred Drugs
  • Retail Prescriptions (up to 30-day supply) - Generic drug: $15; Preferred brand-name drug: $40, plus the cost difference between the brand and the generic, if one exists.; Non-preferred brand-name drug: $80, plus the cost difference between the brand and the generic, if one exists.
  • Retail Maintainence at CVS Pharmacy and Mail Order - Generic drug: $22.50; Preferred brand-name drug: $60, plus the cost difference between the brand and the generic, if one exists.; Non-preferred brand-name drug: $120, plus the cost difference between the brand and the generic, if one exists.
  • Retail Maintenance at a Rite Aid Pharmacy (up to 90-day supply) - Generic drug: $30; Preferred brand-name drug: $80, plus the cost difference between the brand and the generic, if one exists.; Non-preferred brand-name drug: $160, plus the cost difference between the brand and the generic, if one exists.

Preventive Care Covered Medications – No Copayment

For Members Enrolled in Medical Only: If you and your eligible Dependents are enrolled for coverage in a Medical Plan Option but not in the prescription drug Supplemental Benefits Option, your Medical Plan Option shall be supplemented to provide you and your eligible dependents with coverage, without cost-sharing, for the preventive prescription drugs listed below. You will receive a CVS Caremark Preventive Drug Plan ID card which you should use at a CVS Pharmacy to obtain preventive prescription drugs without any deductible, copayments or coinsurance. Please refer to the list of covered medications below.

For Members Enrolled in the PEBTF Prescription Drug Plan: If you are enrolled in the prescription drug Supplemental Benefits Option, the plan offers coverage for preventive care prescription drugs.

The following medications are covered at no cost with a prescription from your doctor:

  • Aspirin to help prevent illness and death from preeclampsia in women age 12 and older after 12 weeks of pregnancy who are at high risk for the condition
  • Bowel preparation medications for screening colorectal cancer for adults age 45 through 74
  • Contraceptives (for females) including emergency contraceptives and over-the-counter contraceptive products (condoms, sponges, spermicides)
  • Folic acid daily supplement for women only age 55 or younger who are planning to become pregnant or are able to become pregnant
  • Medications for risk reduction of primary breast cancer in women age 35 and older who are at risk
  • Oral fluoride for preschool children older than six months to five years of age without fluoride in their water
  • Tobacco cessation and nicotine replacement products – prescription drug coverage is for the generic form of Zyban or brand-name Chantix and nicotine replacemnt products (limited to a maximum of 168-day supply)
  • Statins to help prevent serious heart and blood vessel problems(cardiovascular disease) in adults age 40-75 who are at risk. This covers generic low to moderate intensity statins only.
  • Antiretroviral therapy for pre-exposure prevention of Human Immunodeficiency Virus (HIV) infection in people who are at an increased risk

Remember that a prescription is required for you to obtain reimbursement for any of these preventive prescription drugs, even those that are available over the counter.

NOTE: These guidelines are subject to change.

If you use a pharmacy that does not participate in the CVS Caremark network, you pay the full cost of your prescription. You must then file a claim with CVS Caremark in order to receive reimbursement.

To find out if your pharmacy participates with CVS Caremark, call your pharmacy or contact CVS Caremark at
1-888-321-3261.

For Copayment Information, log on to the CVS Caremark Web Site: www.caremark.com. More information on the Prescription Drug Plan appears under the Publications/Forms section of this web site.

To review the Prescription Drug Formulary and other prescription drug related forms and publications, click here.

For more information, refer to your Summary Plan Description or contact the PEBTF.