Prescription Drug Benefits
Prescription coverage is provided through CVS/Caremark for all medical plans, except the Highmark HMO (which has prescription coverage provided through Merck-Medco.)
- If you elect medical coverage through Carnegie Mellon, you must select a pharmacy plan to cover the same individuals. If you opt out of our medical coverage, you cannot enroll in prescription coverage.
- The Highmark HMO coverage must be selected by participants in that health plan. Those not enrolled in the Highmark HMO cannot select the Highmark HMO prescription coverage.
There are two prescription coverage options through Caremark, with different monthly rates. The plan that is right for you depends on your level of prescription drug usage. Both plans come with the ExtraCare Health program, which provides a 20% discount on over-the-counter CVS-brand FSA-eligible products. (You need not be enrolled in the HCFSA to receive this discount.)
Prescription Drug Participant Copays/Coinsurance
| |
Caremark Option A
|
Caremark Option B
|
Highmark HMO
Prescription
|
| In-Network Retail |
(Up to 30-day supply)
|
(Up to 34-day supply)
|
| Generic (automatic substitution) |
$10
|
$5
|
$10
|
| Brand Name - on the Formulary |
- No generic available
- Generic available |
$15 in 2009
$20 in 2010
$25
|
35%
($100 maximum)
|
$15 in 2009
$20 in 2010
$25
|
| Brand Name - Non-formulary |
$40*
|
Not Covered*
|
$40
|
| Mail Order or Maintenance Choice (Up to 90-day supply) |
| Generic (automatic substitution) |
$20
|
$10
|
$20
|
| Brand Name - on the Formulary |
- No generic available
- Generic available |
$30 in 2009
$40 in 2010
$50
|
35%
($200 maximum)
|
$30 in 2009
$40 in 2010
$50
|
| Brand Name - Non-formulary |
$80*
|
Not Covered*
|
$80
|
| Annual Out-of-Pocket Max (separate from medical out-of-pocket max) |
| |
None
|
$1,500 indiv /
$3,000 family
|
None
|
* - Prior Authorization - Medical Necessity Waivers: Non-formulary medications will be covered at the "formulary - no generic available" level if they are deemed medically necessary. Your doctor must submit a Prior Authorization request in advance by calling 1-888-414-3125 to demonstrate why the formulary medicine can not be used (and/or why a non-formulary medication must be used).
See the Caremark Copayment/Coinsurance Calculator to determine the copayment or coinsurance responsibility for a particular medication under either Caremark option.
