Prescription Drugs

Prescription Drug Benefits (Not applicable to members of Kaiser Northern CA and Kaiser Southern CA)

Prescription drug coverage for both of the PPOs is administered by CVS/caremark. Three types of medications are covered:

Generic Drugs — These drugs are medically equivalent to brand name drugs. They contain the same active ingredients and have the same effect as their brand name counterparts, as required by the Food & Drug Administration (FDA). They are less expensive due to the absence of marketing and advertising costs, and competition among different drug manufactures.

Preferred Brand Name Drugs (Formulary) — Preferred brand name drugs that have been selected by CVS/caremark pharmacists based on a variety of factors, including safety of the medication compared to available alternatives, efficacy (how well the medication works) compared to available alternatives, unique qualities of the medication compared to available alternatives, and cost of the medication.

Non-preferred Brand Name Drugs (Non-Formulary) — These drugs are more costly due to associated research and development, and marketing and advertising costs.

Filling Prescriptions

You can purchase prescription drugs at a retail pharmacy or through the mail order service:

Retail Pharmacies — You can obtain up to a 31-day supply of medication at a participating retail pharmacy. In addition to over 7,400 CVS pharmacies (including those in Target stores), CVS’ retail network includes more than 67,000 pharmacies nationwide, including chain pharmacies such as Wal-Mart, Safeway & Duane Reade and 20,000 independent pharmacies. Simply show your CVS Caremark I.D. card and you will be charged the applicable copayment.

You can obtain a list of participating pharmacies by calling Member Services at 1-844-432-0696.

If you fill your prescriptions at a non-participating pharmacy, you will pay the full retail price of your prescription. You will not be reimbursed for your prescription drugs unless you use a participating pharmacy.

Mail Order — If you use the mail order service, you can save by obtaining up to a 90-day supply at the cost of two and a half times the retail copay.

Maintenance Choice® requires that members taking long-term medications AND live within 5 (FIVE) miles of a CVS pharmacy (including those in Targets stores) MUST fill their prescriptions through mail order service or at a CVS pharmacy. Regardless of which method is used to fill a prescription, members pay the lower mail copay. Employees can call CVSC at (844) 432 – 0696 for more info.

Using the mail order service is easy — obtain an order form from CVS/caremark or the Benefits Website, and send it to the address on the form along with your prescription and payment.

NOTE: Specialty medications must be filled through CVS Specialty. Members will only receive up to a 31—day supply limit. Please note that specialty medications filled by other pharmacies will not be covered. You can contact CVS Care Team at 1-800-237-2727 or at CVSspecialty.com with any questions.

Beginning January 1, 2017, flu shots are covered through participating pharmacies at no cost. In addition, the following non-seasonal vaccines are covered through participating pharmacies at no cost to the member: Shingles, Pneumonia and preventive care vaccines for children & adults such as Measles, Tetanus & Diphtheria.

The copays for prescription drugs are listed below.

Participating Retail Pharmacy (up to a 31-day supply) Mail Order (up to a 90-day supply)
Out-of-Pocket Maximum: $1,500 single / $3,000 family  
Generic drugs $10 copay $25 copay
Preferred brand name drugs (formulary) $35 copay $87.50 copay
Non-preferred brand name drugs (non formulary) $60 copay $150 copay

There is a separate out-of-pocket maximum for prescription drugs. If you reach the out-of-pocket maximum in a calendar year, the Plan will pay 100% of eligible prescriptions for the remainder of the year. The prescription out-of-pocket limit is $1,500 per person and $3,000 for a family.