Pharmacy Benefits

Pharmacy benefits are included when you and your dependents enroll in a health plan.

  • The plan you choose determines the out-of-pocket prescription costs.
  • How much you pay for your drug depends on if it is a generic, brand, non-preferred brand or specialty drug and the day-supply.

A Summary of Your Prescription Drug Benefits

Generic (tier one) drug:  You’ll pay the lowest amount. A generic medicine is FDA approved and equal to the brand name product in safety, effectiveness, quality and performance.

Preferred brand (tier two) drug: You’ll pay a higher amount. Many popular and highly used preferred brands are included on the preferred drug list (PDL).

Non-preferred brand (tier three) drug:  You’ll pay the highest amount. These belong to the most expensive group of drugs. These drugs are not included on the PDL.

Specialty drug tier: In the PPOs, 10% coinsurance applies with a member minimum ($50, unless the drug cost is under $50, then you would pay the full cost of the drug) and a maximum ($150) out-of-pocket. Members enrolled in a CDHP pay coinsurance for specialty drugs.

Did you know?

CVS/caremark has website tools to help you compare costs for your prescriptions. You can also find out what you have spent in the past. Learn more by calling 877.522.8679 or go to info.caremark.com/stateoftn. You must register to view your prescription history and costs.

Finding a Caremark Network Pharmacy

You can find a 30-day or 90-day network pharmacy through the Caremark website at info.caremark.com/stateoftn. You can also call Caremark customer service at 877.522.TNRX (8679) to find a network pharmacy near you.

Maintenance Drugs

There are lower out-of-pocket costs on a large group of maintenance drugs. To pay the lower price for these certain medications, you must use the special, less costly Retail-90 network (pharmacy or mail order) and fill a 90-day supply of your medication. The maintenance tier list includes certain medications for high blood pressure, high cholesterol, coronary artery disease, congestive heart failure, depression, asthma/chronic obstructive pulmonary disease (COPD), and diabetes (oral medications, insulins, needles, test strips and lancets).

Certain Low-Dose Statins

There are lower out-of-pocket costs on a large group of maintenance drugs. To pay the lower price for these certain medications, you must use the special, less costly Retail-90 network (pharmacy or mail order) and fill a 90-day supply of your medication. The maintenance tier list includes certain medications for high blood pressure, high cholesterol, coronary artery disease, congestive heart failure, depression, asthma/chronic obstructive pulmonary disease (COPD), and diabetes (oral medications, insulins, needles, test strips and lancets).

Copay Installment Program

Members can spread the cost of 90-day mail order prescriptions over a three-month period — at no additional cost. You may enroll online at info.caremark.com/stateoftn, register and log in, or by calling CVS/caremark customer care at 877.522.8679. This benefit is only for 90-day mail order prescriptions provided by CVS/Caremark mail order. This does not apply to specialty medications.

Weight Management

There are some obesity medications available for members who meet certain requirements. This gives members a less costly, non-surgical option for losing weight. Go to info.caremark.com/stateoftn to look for covered medications. They are found under “Antiobesity” on the preferred drug list (PDL).

Diabetic Supplies

OneTouch diabetic testing supplies are the only diabetic testing supplies covered at the preferred brand copay. Members will have lower copays by using OneTouch supplies. Diabetics may be eligible for a new OneTouch glucose meter at no charge from the manufacturer. Click here for more information or call 800.588.4456.

Flu and Pneumococcal Vaccine Coverage

View the 2017-2018 flu and pneumococcal vaccine coverage information sheet on how to access this free benefit.

Tobacco Cessation Products

Members who want to stop using tobacco products can get free tobacco quit aids.

The following quit aids are FREE under the pharmacy benefit:

  • Chantix
  • Bupropion (Generic Zyban)
  • Over-the-counter generic nicotine replacement products, including gum, patches and lozenges
  • Nicotrol oral and nasal inhalers

Members may receive up to two, 12-week courses of treatment per calendar year (up to 168 days of treatment) with no lifetime maximum. A licensed clinician is required to write a prescription to get any tobacco cessation products at no cost, including over-the-counter aids. Simply present your prescription and your Caremark card at the pharmacy counter (not at the check-out registers) to fill at $0 copay. The plan only covers generic over-the-counter tobacco cessation products (not brand names).

Appeals

Members have the right to appeal a denial made by Caremark. There are three levels of appeal available:

  • First Level Appeal — if the member's prescription requires prior authorization, and the request is denied because it does not meet their plan's approved criteria for use of the medication, the member may choose to appeal the denial. The member or their authorized representative may request that Caremark re-review the request along with any additional clinical information that the member's physician provides. If this appeal request is not approved the member will receive a letter explaining the decision and providing information about how to request a second level internal appeal from Caremark.
  • Second Level Appeal — if the member's first level appeal is denied, the member or their authorized representative may choose to request that Caremark review the case and make a determination as to whether the drug is medically necessary for the member's treatment. Caremark will review the case and any additional clinical information provided by the member's physician to make this determination. If this appeal is not approved, the member will receive a letter explaining the decision and providing information about how to request an external review of their case from an independent review organization (IRO).
  • External Review — if the member's second level internal appeal is denied, the member or their authorized representative may choose to request that an IRO review the case and make a final determination. The IRO will communicate their decision to the member. This decision will be final and binding on the member, the plan and Caremark.