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CORONAVIRUS BENEFITS AND VACCINE INFORMATION FROM PARTNERS FOR HEALTH

Pharmacy Benefits

Important 2021 Pharmacy Formulary Changes

NEW – In January 2021, the covered drug list (formulary) changed. In some cases, if there are other drugs that offer the same or similar clinical benefits at a lower cost, the plan will no longer cover certain drugs and other products on the current drug list. If you are taking one of these drugs, you and your prescribing physician received a letter from CVS Caremark. The letter explained the drug(s) no longer covered under the plan and provided your covered drug options, along with the appeal process for possible continued coverage.

Click here for the CVS Caremark preferred drug list. (This list is updated each January, April, July and October.)

Click here for a list of medications that require prior authorization.

Pharmacy Button_Blue

All of our health plans include full prescription drug benefits. 

  • The health plan you choose determines your out-of-pocket prescription costs (copay, coinsurance, deductible and out-of-pocket maximum).
  • How much you pay will depend on three things:
    • the drug tier - if you choose a generic, preferred brand, non-preferred brand or specialty drug (called tiers) drug;
    • the day supply you receive - 30-day (or <30) supply or a 90-day (>31) supply; and
    • where you fill your prescription – at a retail, Retail-90 or mail order pharmacy.

Click here for a benefit comparison, including pharmacy, for state and higher education.

Click here for a benefit comparison, including pharmacy, for local education and local government.

Click here for the CVS Caremark preferred drug list. (This list is updated each January, April, July and October.)

Click here for a list of medications that require prior authorization.

CVS Caremark
877.522.TNRX (8679)
24/7
info.caremark.com/stateoftn

Members can request additional ID cards by contacting the carrier or by using the carrier’s mobile app. Employees new to coverage, or who change or transfer plans, will receive new ID cards.

Prescription drug tiers

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

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

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

Specialty drug tier: In the PPOs, 10% coinsurance applies 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 pay coinsurance for specialty drugs and are responsible for the full insurance-negotiated cost of the drug until you reach your plan’s deductible. 

Did you know?

CVS Caremark has information to help you with your prescriptions.

  • Learn more by calling 877.522.8679 or go to info.caremark.com/stateoftn to find a pharmacy and compare drug costs by plan. You’ll also find the Preferred Drug List (formulary), member handbook, and FAQs.
  • Register on the CVS Caremark site at info.caremark.com/stateoftn and get details about your drug costs, download the mobile app and more!

Find a CVS Caremark network pharmacy

You can find a 30-day or 90-day network pharmacy through the CVS Caremark website at info.caremark.com/stateoftn. You can also call CVS Caremark customer service at 877.522.8679 to find a network pharmacy near you.

How to save on your prescriptions

Medications you fill on an ongoing basis could cost you less by filling them at a participating Retail-90 pharmacy or CVS Caremark Mail Service. You make fewer trips to the pharmacy and only need to make one payment every three months. There are several ways to get a 90-day supply of the drugs you take regularly for ongoing conditions. You can conveniently fill those prescriptions either through CVS mail order or at any participating Retail-90 pharmacy nationwide. Find a list of the nationwide Retail-90 pharmacies by going to info.caremark.com.stateoftn for details.

  • Maintenance drugs
    • New in 2021 – Some osteoporosis medications have been added to the maintenance drug tier list. Does not apply to any osteoporosis medications considered as a specialty medication (some examples include: Forteo, Prolia, Reclast and Evenity) 
    • There are lower out-of-pocket costs on a large group of maintenance drugs. The maintenance tier allows you to get a 90-day supply of these drugs from a Retail-90 or mail order pharmacy at a reduced cost. The maintenance drug list includes certain medications for high blood pressure, high cholesterol, coronary artery disease, congestive heart failure, depression, asthma/chronic obstructive pulmonary disease (COPD), statins for high cholesterol, depression and diabetes (oral medications, insulins, needles, test strips and lancets). 
  • Copay installment program
    • Members can spread the cost of 90-day mail order prescriptions that are filled through the CVS Caremark mail order pharmacy over a three-month period — at no additional cost. You may enroll online at info.caremark.com/stateoftn, register and log in, or by calling CVS Caremark customer care at (877) 522-8679. This benefit is only for 90-day mail order prescriptions provided by CVS Caremark mail order. This does not apply to specialty medications.

Flu and pneumococcal vaccine coverage

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

Additional pharmacy benefits and savings

Diabetic supplies

In 2021, the only covered meters, test strips and supplies are those from OneTouch Ultra and OneTouch Verio. The only covered needles and syringes are BD brand products. Members will have lower copays using supplies from these preferred brands. Enrolled diabetic members may be eligible for a new OneTouch blood glucose meter at no charge from the manufacturer. For more information on how to obtain a free blood glucose meter, call (800) 588-4456.

Certain low-dose statins

Eligible members can receive these medications in-network at zero cost share. These medications are primarily used to treat high cholesterol. No high-dose or brand statins are included. Applies to men and women ages 40 through 75 years old.

Weight management

Anti-obesity medication is available for members who meet prior authorization requirements as determined by the pharmacy benefits manager. This gives members a less costly, non-surgical option for losing weight. Go to info.caremark.com/stateoftn to look for covered medications. They are found under “Antiobesity” on the preferred drug list (PDL).

Certain medications used to treat opioid dependency

Members won’t have to pay for some of these medications.  

Tobacco cessation products

Members who want to stop using tobacco can get free tobacco quit aids.

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 licensed clinician is required to write a prescription to get any tobacco cessation products at no cost, including over-the-counter aids. Simply present your prescription and your CVS Caremark card at the pharmacy counter (not at the check-out registers) to fill at $0 copay. The plan only covers generic over-the-counter tobacco cessation products (not brand names).

Click here for the Member Handbook.

Click here for Frequently Asked Questions (FAQs)

Members have the right to appeal a denial made by CVS 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 CVS Caremark.
  • Second Level Appeal — if the member's first level appeal is denied, the member or their authorized representative may choose to request that CVS Caremark review the case and make a determination as to whether the drug is medically necessary for the member's treatment. CVS 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 CVS Caremark.