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Pharmacy Benefits

Your health insurance benefits include pharmacy benefits. This benefit is included for you and all enrolled dependents when you enroll in health insurance. Pharmacy benefits are administered by Caremark.

A Summary of Your Prescription Drug Benefits

The state’s prescription drug plan requires either a copay or coinsurance, depending on your health insurance option. How much you pay depends on how the prescription is filled.

You’ll pay the lowest amount for a generic (tier one) drug. A generic medicine is FDA approved and equal to the brand name product in safety, effectiveness, quality and performance.

You’ll pay a higher amount for a preferred brand (tier two) drug. Many popular and highly used preferred brands are included on the drug list.

You’ll pay the highest amount for a non-preferred brand (tier three) drug. These belong to the most expensive group of drugs. These drugs are not included on the drug list.

In 2017, there will be a new specialty drug tier. For specialty drugs in the PPOs, 10% coinsurance will apply with a member minimum ($50, unless the drug cost is under $50, then you would pay the full cost of the drug) and a maximum ($150) out-of-pocket. Members enrolled in a CDHP will pay coinsurance for specialty drugs.

Did you know?

CVS/caremark has website tools to help you compare costs for your prescriptions. You can also find out what you have spent in the past. Learn more by calling 877.522.8679 or go to info.caremark.com/stateoftn. You must register to view your prescription history and costs.

Finding a Caremark Network Pharmacy

More than 67,000 independent and chain pharmacies are available throughout this U.S. All offer 30-day prescriptions. If you take a longer term medication, more than 916 Tennessee "mail at retail" pharmacies also fill 90-day prescriptions. Mail service is also available.

You can find a 30-day or 90-day network pharmacy through the Caremark website at info.caremark.com/stateoftn. You can also call Caremark customer service at 877.522.TNRX (8679) to find a network pharmacy near you.

Coordination of Benefits — Other Coverage

Click here to find out how to request reimbursement for prescriptions if you have secondary coverage with the state group insurance program.

Flu and Pneumococcal Vaccine Coverage

View the 2016-2017 flu and pneumococcal vaccine coverage information sheet on how to access this free benefit.

Tobacco Quit Aids

The state's prescription drug coverage provides free tobacco quit aids to members who want to stop using tobacco products.

The following quit aids are FREE under the pharmacy benefit:

  • Chantix
  • Bupropion (Generic Zyban)
  • Over-the-counter generic nicotine replacement products, including gum, patches and lozenges
  • Nicotrol oral and nasal inhalers

Members may receive up to two, 12-week courses of treatment per calendar year (up to 168 days of treatment) with no lifetime maximum.

A written prescription by a licensed clinician is required to receive any tobacco cessation products at no cost, including over-the-counter aids. Simply present your prescription and your Caremark card at the pharmacy counter (not at the front check out registers) to have those filled at $0 copay.

Smoking cessation counseling is also available from health coaches through our ParTNers for Health wellness program. To speak to a coach, call 888.741.3390.

Maintenance Drugs

Copays are lower for certain medications from the special, less costly 90-day network. As an incentive to use pharmacies that cost the plan less, there are lower copays on a large group of maintenance drugs. The maintenance tier medication list includes certain anti-hypertensives (used to treat high blood pressure), statins (certain medications used to treat high cholesterol), coronary artery disease, congestive heart failure, depression, asthma/chronic obstructive pulmonary disease (COPD), and diabetes (oral medications, insulins, needles, test strips, and lancets).

New in 2017 — Copay Installment Program for Maintenance Medications
Members can spread the cost of 90-day mail order prescriptions over a three-month period — at no additional cost. You would enroll online at info.caremark.com/stateoftn > register and log in, or by calling CVS/caremark customer care at 877.522.8679. This benefit only applies to 90-day mail order prescriptions provided by CVS/Caremark mail order, and not to specialty medications.

Anti-Obesity Medications

Some obesity medications will be available for members who meet certain prior authorization requirements. This gives members a less costly, non-surgical option for losing weight.

Appeals

Members have the right to appeal a denial made by Caremark. There are three levels of appeal available:

  • First Level Appeal — if the member's prescription requires prior authorization, and the request is denied because it does not meet their plan's approved criteria for use of the medication, the member may choose to appeal the denial. The member or their authorized representative may request that Caremark re-review the request along with any additional clinical information that the member's physician provides. If this appeal request is not approved the member will receive a letter explaining the decision and providing information about how to request a second level internal appeal from Caremark.
  • Second Level Appeal — if the member's first level appeal is denied, the member or their authorized representative may choose to request that Caremark review the case and make a determination as to whether the drug is medically necessary for the member's treatment. Caremark will review the case and any additional clinical information provided by the member's physician to make this determination. If this appeal is not approved, the member will receive a letter explaining the decision and providing information about how to request an external review of their case from an independent review organization (IRO).
  • External Review — if the member's second level internal appeal is denied, the member or their authorized representative may choose to request that an IRO review the case and make a final determination. The IRO will communicate their decision to the member. This decision will be final and binding on the member, the plan and Caremark.