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Prescription Drugs

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Last updated date: 7/18/2024

You will automatically receive prescription drug coverage through CVS Caremark when you enroll in the In-network Only Plan, Choice Plan or High Deductible Plan with HSA.

Benefits-at-a-glance

  In-network Only Plan and
Choice Plan
High Deductible Plan with HSA*
Deductible
$100 per person/$200 family maximum
  • $1,800 individual/$3,600 family for in-network
  • $2,800 individual/$5,600 for out-of-network
 
Note: You must meet your combined medical/prescription drug deductible before the plan pays benefits.
Out-of-pocket Maximum
$1,500 individual/$3,000 family
  • $5,000 individual / $10,000 family ($6,850 per individual) for in-network
  • $7,500 out-of-network / $15,000 ($15,000 per individual) for out-of-network
Copay/coinsurance — In-network retail pharmacy
Generic drug** $10
Preferred brand-name drug*** $30
Non-preferred brand-name drug 50% of the cost of the drug, with a minimum payment of $50, to a maximum of $150
Copay/coinsurance — Maintenance Choice program
Generic drug** $20
Preferred brand-name drug*** $75
Non-preferred brand-name drug 50% of the cost of the drug, with a minimum payment of $125, to a maximum of $375
Copay/coinsurance — Specialty
Generic drug** $0 with PrudentRx (see below) $20
Preferred brand-name drug*** $0 with PrudentRx (see below) 25% of the cost of the drug, with a minimum payment of $50, to a maximum of $150
Non-preferred brand-name drug $0 with PrudentRx (see below) 50% of the cost of the drug, with a minimum payment of $100, to a maximum of $250

*In the High Deductible Plan with HSA, you must meet your combined medical/prescription drug deductible before the Program will pay benefits, except for certain preventive drugs.

**The use of generic prescription drug equivalents whenever possible (through both the retail and CVS Caremark Mail Service programs) is more cost-effective. Ask your medical professional about this distinction. If you or your doctor requests a brand-name drug and a generic alternative is available, you will pay the difference between the cost of the brand-name drug and the generic drug in addition to the copay for the generic drug.

***Citi does not determine preferred brand-name drugs. Rather, CVS Caremark brings together an independent group of practicing physicians and pharmacists who meet quarterly to review the preferred brand-name formulary list and make determinations based on current clinical information. Call CVS Caremark Customer Care at 1 (844) 214-6601 or visit www.caremark.com for a copy of its Preferred Formulary (updated at least quarterly). Note: Preferred brand-name prescription drugs count toward the out-of-pocket maximum.

PrudentRx

You can take advantage of coupons that are available through PrudentRx for certain specialty medications. With these coupons, your medication will be free. If you don't use the PrudentRx program, you'll pay 30% coinsurance. PrudentRx will contact you if your medication is eligible, or you can call PrudentRx at 1 (800) 578-4403 for more information.

Save Money on Generic Prescription Drugs

Through the Caremark Cost Saver program, you will automatically receive discounted prices on generic prescription drugs through GoodRx. When you submit a prescription to be filled at a retail pharmacy, your Caremark benefits and any available GoodRx discounts will be applied to ensure you pay the lowest available price. The amount you pay will automatically be applied to your plan's prescription deductible and out-of-pocket maximum. This program applies to generic medications only and is part of the prescription drug coverage you receive with the In-network Only Plan, Choice Plan, and High Deductible Plan with HSA.

Note: The Caremark Cost Saver program is not available in Florida.

Getting the Medication You Need

Your prescription drug benefits are designed to help ensure your safety and make sure you receive the most clinically appropriate and cost-effective medication for your needs.

Here is some information about your prescription drug coverage that may help you understand the process involved in getting medication to support your care:

  • Prior authorization: Certain prescription drugs may require prior authorization — a process in which the prescription drug administrator will review the medical need for the prescribed medication — in order for your prescription to be approved.
  • Dosage and quantity limits: In some instances, certain medications may be subject to dosage and quantity limits per prescription that is filled. Examples of prescription drugs where this may apply are controlled substances, such as those that treat attention deficit disorder and chronic pain.
  • In-network pharmacies: To pay the lowest cost for your prescriptions, be sure to go to one of the thousands of pharmacies nationwide that participate in the CVS Caremark network. To find a network pharmacy, log in to your www.caremark.com account and select “Find a Pharmacy." If you go to an out-of-network pharmacy, you will pay the full cost yourself. Use the CVS Prescription Reimbursement Claim Form on the Forms & Documents page to request reimbursement.

If you have any questions about your prescription coverage or want to learn about any additional procedures that must be taken before you can fill a prescription, contact Caremark at 1 (844) 214-6601 or log in to your www.caremark.com account.

Should you ever face a supply shortage of a needed medication, Caremark can help you locate a pharmacy with in-stock supply when available. Contact Caremark at 1 (844) 214-6601 for assistance. You can also work with your doctor to identify where to find a prescription drug.

More Ways to Pay Less for Prescriptions

In addition to choosing generic and using the Caremark Cost Saver program, here are some additional ways to save money on the medications you take.

  1. Check if your preventive drugs are covered. The High Deductible Plan with HSA covers the cost of certain preventive drugs without having to meet a deductible. You will pay the applicable copay or coinsurance, which will count toward your combined medical and prescription drug out-of-pocket maximum. For a list of these preventive drugs, call CVS Caremark at 1 (844) 214-6601. You can also visit www.caremark.com.
  2. Go to a network pharmacy. You can go to one of the thousands of pharmacies nationwide that participate in the CVS Caremark network. If you go to an out-of-network pharmacy, you will pay the full cost yourself, and then you can file a claim to be reimbursed at the contracted rate after you meet your deductible and pay the applicable copay.
  3. Use PrudentRx for specialty medication. If you take specialty medication, you can save money with PrudentRx (offered through CVS Caremark). This program will optimize coupons that are available for certain specialty medications. If you use the program, these medications will be free; otherwise, you'll pay 30% coinsurance. You'll receive more information from CVS if this applies to you. You can also visit www.caremark.com or call 1 (844) 214-6601 for more information.

CVS Caremark offers three ways to purchase prescription drugs:

Pickup at a CVS Pharmacy

You can pick up your short-term prescriptions or a 90-day supply at CVS retail stores, including those within a Target retail store. If you choose to pick up your prescription at a CVS Pharmacy or retail store, it will not cost more than using the CVS Caremark Mail Service or Maintenance Choice program. Note: If you go to an out-of-network pharmacy, you will pay the full cost yourself, and then you can file a claim to be reimbursed at the contracted rate, after you meet your deductible and pay the applicable copay.

Maintenance Choice Program

You may save money by having your maintenance and preventive drugs (up to a 90-day supply, plus refills if appropriate) either delivered by mail or picked up at a CVS or Costco pharmacy through the CVS Caremark Maintenance Choice® program.*

Start filling your 90-day prescriptions through CVS Caremark:

  1. By phone – Call CVS Caremark Customer Care at 1 (844) 214-6601.
  2. By mail – Fill out and return a Mail Service order form. You can download one from CVS Caremark, or request one from CVS Caremark Customer Care.
  3. Online – Visit www.caremark.com and log in. You may then request a new Mail Service prescription from your doctor using “Request a Prescription with Fast Start." You may also order and track your refills via the CVS Caremark mobile app.
  4. In person – Take your 90-day prescription to a CVS or Costco pharmacy.

*Please note that the Maintenance Choice Program may not apply within specific states such as Oklahoma and West Virginia due to state-specific regulations.

Specialty Pharmacy

The CVS Caremark Specialty Pharmacy dispenses oral and injectable specialty medications for the treatment of complex chronic diseases, including, but not limited to, multiple sclerosis, hemophilia, cancer and rheumatoid arthritis. Specialty medications purchased through the CVS Specialty Pharmacy are limited to a 31-day supply or less. It's important to know that prescriptions for specialty medications take longer to fill than traditional medications due to added steps and approvals.

You must use the CVS Specialty Pharmacy to fill specialty drug prescriptions, with the exception of HIV and transplant drugs, which can be filled at a retail pharmacy. Once you are using the program, the CVS Specialty Pharmacy will call your physician to obtain a prescription and then call you to schedule delivery.

In the Choice Plan and In-network Only Plan, members filling certain specialty medications are eligible for the PrudentRx program (offered through CVS Caremark). PrudentRx will assist you in enrolling in manufacturer assistances available to you. The good news is, these medications will be free to you if you remain enrolled in the program; otherwise, you'll pay 30% coinsurance. Because certain specialty medications do not qualify as "essential health benefits" under the Affordable Care Act, member cost share payments for these medications, whether made by you or a manufacturer copayment assistance, do not count toward the Plan's out-of-pocket maximums. You will be contacted by PrudentRx if you are eligible.

To learn more about CVS Caremark’s Specialty Pharmacy services, including the cost of your prescription drugs, call 1 (844) 214-6601.

Find a Network Pharmacy

To find out whether a pharmacy participates in the CVS Caremark network, use one of the following methods:

  • Ask your pharmacist.
  • Visit www.caremark.com.
  • Download the CVS Caremark free mobile app from your device’s app store (search for “CVS Caremark”).
  • Call CVS Caremark Customer Care at 1 (844) 214-6601.

Location Options for Drug Infusions

If you’re enrolled in a Citi medical coverage and you receive certain specialty drugs at an outpatient hospital facility, you may receive a letter from Citi about utilizing a different site of care for infusions. This would include receiving infusions for those drugs in an office setting, an infusion center or in the comfort of your own home.