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.
NEW – In 2021, the covered drug list (formulary) will change. 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 will receive a letter from CVS Caremark in November. The letter will explain which drug(s) will be no longer covered under the plan, provide your covered drug options, and the appeal process for possible continued coverage.
NEW – In 2021, some osteoporosis medications will be added to the maintenance tier drug list (see Maintenance tier drugs below).
Click here for the CVS/caremark preferred drug list. (This list is updated each January, April, July and October.)
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 will make fewer trips to the pharmacy, and you’ll only need to make one payment every three months. If you choose to use the Retail-90 option, you have 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. You can find a list of the nationwide Retail-90 pharmacies by going to info.caremark.com.stateoftn for details.
- Maintenance drugs
- 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) and diabetes (oral medications, insulins, needles, test strips and lancets). New in 2021 – some osteoporosis medications will be added to the list.
- Members may work with their pharmacists to coordinate refills for maintenance drugs so that multiple medications are filled on the same day. For PPO members, the drugs being filled to get you “synced” will have pro-rated copays. This applies to statins for high cholesterol, high blood pressure, coronary artery disease, congestive heart failure, diabetes, depression and asthma/COPD medications. In 2021, will include some osteoporosis medications. Talk to your pharmacist about how this may work for you.
Most (not all) medications in the following drug classes are part of the maintenance tier that offers a lower cost share when filled in a 90-day supply through Caremark mail order or at a participating Retail-90 pharmacy: diabetes, depression, asthma/COPD, anti-hypertensives, coronary artery disease, congestive heart failure, statins used to treat high cholesterol, and starting in 2021 some medicines used to treat osteoporosis.
- 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
Additional pharmacy benefits and savings
OneTouch and Accu-Chek diabetic testing supplies are the only diabetic testing supplies covered at the preferred brand pricing in 2020. Members have lower copays by using OneTouch and Accu-Chek supplies. Diabetics may be eligible for a new Accu-Chek or OneTouch glucose meter at no charge from the manufacturer. For more information on how to obtain a free blood glucose meter, call 877.418.4746.
In 2021, the only preferred brand of diabetes testing supplies will be Accu-Chek brand. Also, only BD Ultafine Needles and Insulin Syringes will be the only preferred brands covered by the insurance plans for diabetes management.
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.
There are some obesity medications 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
The following quit aids are FREE under the pharmacy benefit:
- 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).
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.