Pharmacy

UnitedHealthcare (HSA PPO or Traditional PPO)

If you are enrolled in the HSA PPO or the Traditional PPO medical plans, your pharmacy benefits are covered under CVS Caremark. Coverage for prescription drugs is included when you enroll in a UnitedHealthcare medical plan. Both the HSA PPO and the Traditional PPO plans have a combined deductible which means that you must meet the annual deductible before the plan pays benefits for prescription drugs. However, if you are enrolled in the HSA PPO plan you may use your HSA to cover the cost of prescription drugs. If you are enrolled in the Traditional PPO plan you may use your GPFSA to cover the cost of prescription drugs.

Generic and brand name prescriptions filled by a retail pharmacy are limited to, up to a 90-day supply. Prescriptions filled through the mail-order program may be up to a 90-day supply. Specialty prescriptions are limited to a 30-day supply through CVS Specialty Pharmacy only.

Pharmacy Plan Details

In-Network Pharmacy1 Out-of-Network Pharmacy1
Retail (30-day supply)2
Generic3/Brand4/Non-Preferred Brand Name5
HSA PPO: 10%/15%/20% after deductible

Traditional PPO: 10%/25%/40% after deductible

HSA PPO & Traditional PPO: 50% after deductible
Mail Order (90-day supply)2
Generic3/Brand4/Non-Preferred Brand Name5
HSA PPO: 10%/15%/20% after deductible

Traditional PPO: 10%/25%/40% after deductible

HSA PPO & Traditional PPO: Not Covered

1 Individual deductible and OOP maximum only apply to employees enrolled in Individual tier. Members in dependent tiers must satisfy an aggregate deductible – the health plan doesn’t begin paying benefits until the entire family deductible has been met. Once the entirety of the family deductible has been met, by one family member or a combination of family members, then the cost sharing begins.
2 Deductible waived for preventive medications.
3 Generic Medicines: Always ask your doctor if there’s a generic option available. It could save you money.
4 Preferred Brand Name Medicines: If a generic is not available or appropriate, ask your doctor to prescribe from the preferred options drug list (pgs. 7-10).
5 Non-Preferred Brand Name Medicines: Drugs that are not on the plan’s preferred list will cost more. If a Non-Preferred Brand Name is part of the CVS Caremark Formulary Drug Exclusions, you will be required to pay the full cost, which does not count towards your annual deductible or annual out-of-pocket maximum.

Preventive Drugs

Your pharmacy plan includes Preventive Drugs. Medications on this list are not subject to your deductible. You will only pay the applicable copay/coinsurance for medications on this list.

Non-Specialty Drugs

Review the CVS Caremark Performance Drug List for Non Specialty Drugs. This includes a listing of commonly prescribed generics and preferred brands by category (pgs. 1-4), an alphabetic listing of the commonly prescribed generics and preferred brands (pgs. 5-6) and formulary excluded medications (not covered under the prescription benefit and do not contribute towards your deductible or out of pocket maximum) and their preferred alternative (pgs. 7-10).

Specialty Drugs

Specialty drugs are high-cost prescription medicines used to treat complex, chronic conditions. (Ex: rheumatoid arthritis, multiple sclerosis, cancer, etc.) Just like non-specialty drugs, specialty drugs offer generics and preferred brand medicines. For more information review the CVS Caremark Advanced Control Specialty Formulary Drug list. This includes listings of generics and preferred brands (pgs. 1-3), and formulary excluded medications (not covered under the prescription benefit and do not contribute towards your deductible or out of pocket maximum) and their preferred alternative (pg. 3) and outlines the indication based formulary for autoimmune products (pg. 4).

Some specialty drugs may qualify for third-party co-payment assistance programs that could lower your out-of-pocket costs. For any such specialty drug where third-party co-payment assistance is used, you will not receive credit toward your out-of-pocket maximum (OOP) or deductible for any co-payment or coinsurance amounts that are applied to a manufacturer coupon or rebate. Visit the HSA PPO or Traditional PPO pages for more information on OOP maximums and annual deductibles.

Formulary Exclusions

Review the CVS Caremark Formulary Drug Exclusions to see if your current medicine is not included in your plan’s formulary. If you continue taking a drug listed on the CVS Caremark Formulary Drug Exclusions you will be required to pay the full cost, which does not contribute towards your annual deductible or annual out-of-pocket maximum. Ask your doctor to review the generic or preferred brand name alternatives. To check on drug coverage and costs visit the CVS Caremark website or contact your CVS Customer Care team at 1-844-257-4616.

Kaiser HMO N. CA

Coverage for prescription drugs is included when you enroll in the Kaiser HMO N. CA plan. In general, generic and brand name prescriptions filled at a retail pharmacy are limited to a 30-day supply. Prescriptions filled through the mail order program may be up to a 100-day supply. However, mail order may be reduced to a 30-day supply for specific drugs. If you are enrolled in the GPFSA, you may use it to cover the cost of prescription drugs.

Prescription Plan Details

In-Network Pharmacy Out-of-Network Pharmacy
Retail (30-day supply)
Generic/Brand/Non-Formulary
$10/$20/$20 co-pay Not Covered
Mail Order (100-day supply)
Generic/Brand/Non-Formulary
$20/$40/$40 co-pay Not Covered

Kaiser HMO HI

Coverage for prescription drugs is included when you enroll in the Kaiser HMO HI plan. In general, generic and brand name prescriptions filled at a retail pharmacy are limited to a 30-day supply. Prescriptions filled through the mail order program may be up to a 100-day supply. However, mail order may be reduced to a 30-day supply for specific drugs. If you are enrolled in the GPFSA, you may use it to cover the cost of prescription drugs.

Prescription Plan Details

In-Network Pharmacy Out-of-Network Pharmacy
Retail (30-day supply)
Generic/Brand/Non-Formulary
$10/$35/$35 co-pay
$200 co-pay Specialty
Not Covered
Mail Order (100-day supply)
Generic/Brand/Non-Formulary
$20/$70/$70 co-pay
Specialty Not Covered
Not Covered

Contact Us

HR Source
ASK HR [VMware network access required]
Phone: 1-888-VMWARE8, option ‘US Benefits’
Internal Phone: ext. 29200


CVS Caremark
Phone: 1-844-257-4616
Visit website

Resources

Benefits Contact Quick Reference Guide


CVS Caremark Accessing Dependents Online


CVS Caremark Benefits at a Glance HSA PPO


CVS Caremark Benefits at a Glance Traditional PPO


CVS Caremark Digital Benefits


CVS Caremark Managing Your Family’s Prescriptions Online


CVS Caremark Registering
Online


CVS Caremark Rx Advanced Control Specialty Formulary
Drugs


CVS Caremark Rx Formulary Drug Exclusions


CVS Caremark Rx Performance Drug List for Non Specialty
Drugs


CVS Caremark Rx Standard Preventive Drug List


CVS Caremark Sample Welcome Kit & ID Card


CVS Caremark Temp ID Card


Kaiser HMO Pharmacy Refill
Form


Key Benefit Terms