Pharmacy Benefits for Active and Pre-Medicare

HealthChoice Pharmacy Copay Structure

Active and Pre-Medicare Members

Prescription Medications	30-Day Supply	90-Day Supply
Generic	Up to $10.	Up to $25.
Preferred	Up to $45.	Up to $90.
Non-Preferred	Up to $75.	Up to $150.
Specialty	Generic – $10 copay. Preferred – $100 copay. Non-Preferred – $200 copay.	30-day copays apply to each additional 30-day supply.
Insulin Effective Nov. 1, 2021, for ALL health insurance plans.	No more than $30.	No more than $90.
HealthChoice High, High Alternative, Basic, Basic Alternative and HDHP** Plans The applicable pharmacy deductible must be met before pharmacy copays apply. Refer to the bottom of the page for more details. Note: Only FDA approved drugs and drugs with FDA Emergency Use Authorizations are covered. Experimental treatments and unapproved drugs and drugs not approved or not authorized for emergency use by the FDA are not covered under this plan.

Pharmacy deductible

*HealthChoice High, High Alternative, Basic and Basic Alternative plan members must meet the pharmacy deductible of $100 per individual/$300 maximum per family before benefits are available.

**HDHP members must meet the combined medical and pharmacy deductible ($1,750 individual/$3,500 family) before benefits are available.

Medications on the HealthChoice Preventive Medication List are not subject to the deductible. Copays apply to the pharmacy out-of-pocket maximum, but not the deductible.

For questions regarding the benefits under the pharmacy plan, please contact the pharmacy benefit manager toll-free at 877-720-9375, 24 hours seven days a week. TTY users call 711.

Pharmacy prior authorizations, quantity limits, specialty drugs and step therapy for HealthChoice High, High Alternative, Basic and Basic Alternative Plans and High Deductible Health Plan (HDHP).

Pharmacy prior authorization

Pharmacy prior authorization is a medical review that is required for coverage of certain drugs such as those that:

Are high cost.
Have specific prescribing guidelines.
Are generally used for cosmetic purposes.
Have quantity limitations.

Follow the steps below to request a prior authorization:

Have your physician’s office call the pharmacy benefit manager toll-free at 800-294-5979.
The pharmacy benefit manager will assist your physician’s office with completing a prior authorization form.
If your prior authorization is approved, your physician’s office is notified of the approval within 24 to 48 hours. You are also notified in writing.
If your prior authorization is denied, your physician’s office is notified of the denial within 24 to 48 hours. You are also notified in writing.

Types of prior authorizations

Traditional prior authorization drugs
Traditional prior authorization reviews typically require that specific medical criteria be met before access to the drug is allowed.

Step therapy drugs
Step Therapy prior authorizations require you to first try a designated Preferred drug to treat your medical condition before the plan covers another drug for that same condition. Some step therapy drugs may also be limited in quantity. If you require a step therapy exception, contact CVS Caremark Pharmacy Prior Authorization Department at 800-294-5979 or TTY 711.

Brand-name exception and non-preferred drugs review
A prior authorization for a brand-name or non-preferred drug may be approved when you are unable to tolerate the generic or preferred drug. All of these reviews follow the same process as described in the Pharmacy prior authorization section above.

Drugs limited in quantity
Certain drugs are limited in the quantity you can receive per copay based on their recommended duration of therapy and/or routine use.

If generics are available or become available for brand-name drugs that are limited in quantity, the generics are also limited in quantity. When new drugs become available in drug categories that have quantity limits, they will automatically have quantity limits per copay. New drug categories also can become subject to quantity limits throughout the year.

Specialty drugs
Specialty drugs are usually high-cost drugs that require special handling and extensive monitoring. You must pay a copay for each 30-day fill of a specialty drug. Copays are $100 for preferred drugs and $200 for non-preferred drugs.