Prescription Drug Coverage
Retail and mail order prescription drug coverage is included when enrolled in a medical plan. The University prescription plan is administered by CVS Caremark. CVS Caremark utilizes a formulary drug listing. These lists are not all-inclusive and do not guarantee coverage. In addition to using this list, you are encouraged to ask your doctor to prescribe generic drugs whenever appropriate. For more information on the formulary visit: https://www.caremark.com/portal/asset/caremark_recaprxclaimsdruglist.pdf. Employees can also access the formulary listing from their caremark.com account. Formulary listings are maintained and controlled by a prescription benefits management company (PBM) and is subject to changes as directed by PBM.
ID Cards and Caremark.com
CVS Caremark will send ID cards to employees' homes upon enrollment. Cards are in the employee's name, covered dependents will not receive cards in their name(s). Electronic cards are available through the caremark.com account or the CVS Caremark app.
Visit https://www.caremark.com and create an account to manage prescriptions, comparison shop, view claims and balances, locate a pharmacy, price a medication and more. Due to HIPAA guidelines the cardholder can only see those dependents on their account that are under the age of 18. Dependents 18 years and older will need to register separately. Dependents may grant family access to their account (top of the page – right corner, then under update my profile click on family access).
Elements of the CVS Caremark prescription drug plan include the Advanced Utilization Management, Generics Preferred and Exclusive Home Delivery Programs. Effective 7/1/21 the PrudentRx Specialty Drug Copay Program was applied to faculty and staff; members of the AFSCME bargaining unit are not eligible to participate.
PrudentRx Specialty Drug Copay Program
The PrudentRx Specialty Drug Copay Program offered through CVS Caremark allows faculty and staff who enroll to have a $0 copay for their specialty drug prescriptions. Individuals who do not enroll in the program will be subject to a 30% co-insurance for specialty medications. There is no cost associated with joining the program. This program does not apply to members of the AFSCME 1699 bargaining unit.
The PrudentRx specialty drug listing [PDF] is updated periodically. CVS Specialty Pharmacy may be reached at 1-866-387-2573 and PrudentRx at 1-800-578-4403.
Advanced Utilization Management Program
These programs may require additional information from a prescribing physician in order for a prescription to be covered and paid for by the University’s health plan. Failure to provide additional information may result in a prescription not being covered by the health plan.
Drug Quantity Management
Under Drug Quantity Management, CVS Caremark monitors the amount of medication prescribed compared to the recommended level for a medication. For example, if medical guidelines state a medication should be taken no more than once per day and a physician prescribes it for two times per day, CVS Caremark will reach out to the physician for justification regarding the higher amount prescribed. Sufficient justification will be required in order for the additional medication to be approved.
These programs may require additional information from a prescribing physician in order for a prescription to be covered and paid for by the university’s health plan.
Under Step Therapy, an individual may be required to use a therapeutically equivalent and less costly drug where available and appropriate (such as a generic prescription) prior to being able to a more costly medication.
Under Prior Authorization, CVS Caremark will require pre-approval be obtained for certain medications in order for the drug to be covered by the health plan. For mediations requiring prior authorization, a physician will be required to provide documentation that the patient meets the established medical guidelines for the medication. This may include prescriptions individuals are currently receiving.
Please contact HR-Benefits at firstname.lastname@example.org if you have any questions regarding these programs.
Generics Preferred Program
The University's prescription drug plan includes a "generics preferred" program. When employees or family members need a new prescription or a refill for a brand-name drug, the pharmacist will check whether a generic drug is available instead. If a generic is available, employees are encouraged to utilize the generic option. If the employee chooses to use the brand-name instead of the generic, the employee will be charged the full cost difference between the generic and the brand-name drug. If there is no generic available, the employee will be charged the normal brand name copay.
Maintenance Choice - Home Delivery Program
Under Maintenance Choice – Home Delivery the medications you take regularly (for health issues such as diabetes, asthma or high blood pressure) must be filled at CVS pharmacies or through the CVS Caremark Mail Order Pharmacy.
Employees can fill a prescription of a maintenance medication up to two times at any retail pharmacy such as CVS, Wal-Mart, or Kroger. After that, the University's health plan will cover the medication only if it is obtained through CVS retail or Mail Order Pharmacies.
Certain medications such as schedule II drugs or drugs with manufacturer or FDA supply limits may be exempted from the Maintenance Choice -Home Delivery Program. Members may contact CVS Caremark directly at 1-888-964-0089 about specific medications.