Employees new to coverage, or who change or transfer health plans, will receive new pharmacy benefit ID cards. Members can request additional ID cards by contacting the carrier or by using the carrier’s mobile app.
All of our health plans include full prescription drug benefits.
The health plan you choose determines your out-of-pocket prescription costs, which include your 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, nonpreferred brand or specialty drug (two different cost tiers in the PPOs);
- the day supply you receive – 30-day (or <30) or a 90-day (>31) supply; and
- where you fill your prescription – at a retail, Retail-90 or mail order pharmacy.
Click here for the CVS Caremark Performance Drug List. (This list is updated each January, April, July and October.)
Prescription Drug Tiers
Tier One - Generic drugs: You’ll pay the lowest amount. A generic medicine is approved by the Food and Drug Administration and equal to the brand name product in safety, effectiveness, quality and performance.
Tier Two - Preferred brand drugs: You’ll pay a higher amount. Many popular and highly used preferred brands are included on the preferred drug list.
Tier Three - Non-preferred brand drugs: You’ll pay the highest amount. These belong to the most expensive group of drugs. These drugs are not included on the preferred drug list.
Specialty drug tiers: In the Standard, Premier and Limited PPOs, there are two drug tiers. For generics in a 30-day supply, 20% coinsurance applies with a $100 member minimum and a $200 maximum out-of-pocket. In the PPOs for all other brands, a 30-day supply, 30% coinsurance applies with a $200 member minimum and a $400 maximum out-of-pocket. Members enrolled in a consumer-driven health plan pay coinsurance for specialty drugs and are responsible for the full insurance-negotiated cost of the drug until you reach your plan’s deductible.
CVS Caremark 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, also called a formulary, a member handbook and answers to frequently asked questions.
- Register on the CVS Caremark website and get details about your drug costs, download the mobile app and more!
- Taking your medication as directed helps you stay healthier. Check out some tips to keep you on track.
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 through 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 Retail-90 pharmacies by going to info.caremark.com/stateoftn.
- Maintenance drugs
- There are lower out-of-pocket costs on a large group of maintenance medications. Under the maintenance medication benefit, you can get a 90-day supply of certain drugs from a Retail-90 or mail-order pharmacy at a reduced cost. If you fill a 30-day supply, your regular copayment or coinsurance applies and for Consumer-driven Health Plan members, the deductible is not bypassed.
- The maintenance medication benefit applies to drugs in the following classes: coronary artery disease, congestive heart failure, hypertension, diabetes, asthma/COPD, depression, statins used for high cholesterol, and osteoporosis.
- Please note that any drug classified as a specialty drug (regardless of whether it is in one of these classes) does not qualify for lower cost share or deductible bypass.
- 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 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.
Eli Lilly $35 insulin
- Eli Lilly offers the Lilly Insulin Value Program. Through this program all Lilly insulins are available for $35 a month whether you have commercial insurance or no insurance.
- Currently, the only Eli Lilly insulins covered on the Partners for Health drug list (formulary) are Basaglar and Humulin R U-500. To review the drug list, visit https://www.caremark.com/portal/asset/state_tn_formulary.pdf and look for the section labeled Endocrine and Metabolic, then Insulins.
- To receive any Eli Lilly insulin other than Basaglar and Humulin R U-500 through your Partners for Health insurance you must first receive a prior authorization approval for medical necessity from CVS Caremark. Your prescriber must request a prior authorization for medical necessity from CVS Caremark and provide clinical records for review. Your provider may contact CVS Caremark at 1.855.240.0536. The prior authorization line is for your doctor’s use only.
- Members may go to Eli Lilly’s site https://www.insulinaffordability.com/ and choose one of two options to download a $35 copay assistance card from Eli Lilly:
- I have commercial insurance will provide you with a $35 savings card that you can use at your pharmacy, subject to the Lilly terms and conditions. This option will utilize your Partners for Health insurance and cap your cost at $35 (or less if your plan’s copay is lower than $35).
- I pay cash will provide you with a $35 savings card that you can use at your pharmacy, subject to the Lilly terms and conditions. Choosing this option will not utilize your Partners for Health insurance, will not count toward your deductible or maximum out of pocket amounts, and you will not be subject to any applicable insurance prior authorization requirements.
Additional Pharmacy Benefits and Savings
The only covered meters, test strips and supplies are those from OneTouch and Accu-Chek. The only covered needles and syringes are BD brand products. Members will have lower copays using supplies from these preferred brands. Enrolled members with diabetes may be eligible for a new OneTouch or Accu-Chek blood glucose meter at no charge from the manufacturer. For more information on how to obtain a free blood glucose meter, call 877.418.4746.
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 members ages 40 through 75 years old.
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:
- Varenicline (generic 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 to fill at $0 copay. The plan only covers generic over-the-counter tobacco cessation products.
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 CVS 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 determine 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.
- External Review — If the member's second level internal appeal is denied, the member or their authorized representative may choose to request that an independent review organization review the case and make a final determination. The independent review organization will communicate their decision to the member. This decision will be final and binding on the member, the plan and CVS Caremark.