Participants may purchase medically necessary prescription drugs at participating retail pharmacies or by mail through the Plan's pharmacy benefit manager (PBM), CVS Caremark. (See Diabetic Management Program and Pharmacy Mail Order Program sections for more detail.) Specialty medications must be purchased through participating specialty drug providers. Coverage for prescription drugs purchased at a retail pharmacy is limited to a 90-day supply. Coverage for prescription drugs purchased through the pharmacy mail order program is limited to a minimum 60-day supply and a maximum 90-day supply. Coverage for prescription drugs purchased through the specialty pharmacy program is limited to a 30-day supply.
When a covered prescription drug is purchased at a network retail pharmacy, the participant is only required to pay the appropriate copayment amount (after the applicable deductible is met) or the cost of the drug, whichever is less. There is no claim form to file. When a prescription drug is purchased at an out-of-network pharmacy, the participant must file a claim with CVS Caremark. The prescription drug claim form is available to be downloaded and submitted online at http://www.caremark.com or the paper claim can be returned to CVS Caremark. Payment of the claim will be made based upon the Plan's allowable charge. The participant is responsible for any amount in excess of the allowable charge, plus the applicable deductible and/or copayment.
In most instances, when a generic drug is available and the participant purchases the brand name drug instead, the participant will pay the difference in the cost of the brand name drug and the generic drug, plus the brand copayment amount.