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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: $10; Preferred brand-name drug: $18, plus the cost difference between the brand and the generic, if one exists.; Non-preferred brand-name drug: $36, plus the cost difference between the brand and the generic, if one exists.
  • Mail Order through CVS Caremark Mail Service (up to 90-day supply) - Generic drug: $15; Preferred brand-name drug: $27, plus the cost difference between the brand and the generic, if one exists.; Non-preferred brand-name drug: $54, plus the cost difference between the brand and the generic, if one exists.
  • Maintenance Choice at a CVS pharmacy (up to 90-day supply) - Generic drug: $15; Preferred brand-name drug: $27, plus the cost difference between the brand and the generic, if one exists.; Non-preferred brand-name drug: $54, 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: $20; Preferred brand-name drug: $36, plus the cost difference between the brand and the generic, if one exists.; Non-preferred brand-name drug: $72, 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 for the prevention of cardiovascular disease – adults age 45 and older
  • 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 50 through 74
  • Contraceptives (for females) including emergency contraceptives and over-the-counter contraceptive products (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
  • Iron supplements for children who are at increased risk for iron deficiency anemia – children age 6 through 11 months
  • Medications for risk reduction of primary breast cancer in women age 35 and older
  • Oral fluoride for preschool children older than six months to five years of age without fluoride in their water
  • Vitamin D supplements to help prevent falls in adults age 65 years or older who are at increased risk for falls
  • Tobacco cessation and nicotine replacement products – prescription drug coverage is for the generic form of Zyban or brand-name Chantix (limited to a maximum of 168-day supply)
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.

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