The retail copayment for prescription drugs filled at a Network pharmacy for each 30 day supply is:
- Generics – $10 copay
- Brand with no generic available – 20% of cost, with minimum copay of $30 and maximum copay of $125 per prescription
- Brand with generic available – 50% of cost, with minimum copay of $50 and no maximum copay
- Specialty drugs – $200 copay (see 2017 Specialty Drug List)
Mandatory step-therapy: For Proton Pump Inhibitors (PPI), antihistamines and nasal corticosteroids, you must first fill a generic or over the counter (OTC) medication at a zero copay before a brand name prescription will be covered. The following are the generic or OTC medications covered at a zero copay with a written prescription from your physician:
- PPIs – omeprazole, omeprazole OTC, omeprazole-sodium bicarbonate, pantoprazole, lansoprazole, lansoprazole ODT, Nexium OTC, Prevacid OTC, Prilosec OTC, Zegerid OTC
- Antihistamines – cetirizine, cetirizine OTC, fexofenadine-pseudoephedrine, levocetirizine, loratadine OTC, Alavert, Alavert-D, Allegra OTC, Allegra-D OTC, Claritin OTC, Claritin-D 12 HR, Zyrtec OTC
- Nasal corticosteroid – Flonase OTC and Nasacort OTC
Multiple copays will be charged for maintenance medications dispensed in excess of one month’s supply through a retail pharmacy or mail order. If your physician has written a prescription for a 90 day supply of a medication under the “maintenance medication” list, multiple copayments will apply. For information about mail service, see the CVS Caremark site or call (877) 889-3402.
Some of the Plan’s Network pharmacies include:
- USC Pharmacy
- USC Medical Plaza Pharmacy
- USC Verdugo Hills Professional Pharmacy
- Rite Aid
- Payless Drugs
Some small independent pharmacies are also in-Network. Call (877) 807-7341 to verify pharmacy participation.
For prescriptions filled at non-Network pharmacies, the Plan will reimburse a member for 50% of the Plan’s CVS Caremark contracted rate (not 50% of the cost). You must pay in full for the prescription at the pharmacy, and then submit a reimbursement claim to CVS Caremark within 60 days of your fill to:
Commercial Paper Claims
PO Box 53992
Phoenix, AZ 85072-3992
For questions regarding pharmacies or claims, call CVS Caremark at (877) 807-7341.
Annual prescription out-of-pocket copay maximums
The following calendar year prescription out-of-pocket copay maximums are separate from the Network Plan’s calendar year medical out-of-pocket maximum:
- $4350 maximum – individual
- $6200 maximum – family (two or more people)
Maximum excludes out-of-network pharmacy prescription copays.
This means that after a single person meets the out-of-pocket maximum of $4350 in a calendar year, or after a family cumulatively meets the $6200 maximum, all covered individuals will be covered at 100% for prescriptions filled at in-network pharmacies for the remainder of the calendar year.