1. Prescription Drug Plan
Plan Benefits Under Caremark
With CVS Caremark, you can purchase covered prescription drugs through a nationwide network of
participating pharmacies and/or a mail service program. The Caremark retail network includes over
62,000 participating pharmacies nationwide, including more than 20,000 independent community
pharmacies. For a complete listing of Caremark participating pharmacies, visit their website at
. Retail Network Pharmacies
When filling prescriptions for short-term medications, such as antibiotics, it is important that you use a
CVS Caremark participating retail pharmacy. When you need a prescription filled immediately, present
your Caremark ID card at a participating retail pharmacy. Verify that the pharmacist has accurate
information about you and your covered dependents, including date of birth and gender. Pay the
applicable co-payment or coinsurance (see chart below) to receive up to a 30-day supply of medication.
You can search for a participating pharmacy by logging onto Caremark.com (you must be a registered
user) and clicking Find a Local Pharmacy
under the Member Quick Links section on the left side of the
screen. You can also call the Caremark Customer Care Center at 866-559-6903.
The CVS Caremark plan will allow three 30-day fills (the initial fill plus two refills) of a long-term
maintenance medication at a retail pharmacy. No plan coverage will be provided at participating retail
pharmacies after the third fill of a long-term maintenance medication. After you have met the three fills,
you are required to use either of the following options – both of which have the same copay.
Use the mail service program to have a 90-day supply of medication delivered to your home.
Have the 90-day prescription filled at CVS/pharmacy through the Maintenance Choice program.
Mail Service Program
The CVS Caremark Mail Service Program can be used to obtain your long-term maintenance
medications. You can receive up to a 90-day supply of maintenance medications for the applicable co-
payment or coinsurance (see chart below) for direct delivery to your home.
For new maintenance medications, complete a Mail Service Order Form and send it to CVS Caremark,
along with your original prescription(s) and the applicable co-payment for each prescription. Be sure to
include your original prescription, not a photocopy. You can expect to receive your prescription
approximately 14 calendar days after CVS Caremark receives your order. The CVS Caremark mail order
forms can be found on CrewNet or .
In addition, you can contact CVS Caremark FastStart at 1-800-875-0867
(For TDD assistance, please dial
toll-free 1-800-231-4403) for assistance with transitioning your prescription to mail order. Hours of
operation are Monday through Friday 7 a.m. to 7 p.m. (CT). Be prepared to provide your ID number,
prescription name, doctor’s name and phone number, mailing address, and payment information. The
representative will contact your doctor and even fill out the order form for you.
Once you have processed a prescription through the Caremark Mail Service Program, you can obtain
refills using the internet ( phone (866/559-6903), or mail. Order your prescriptions
three weeks in advance of your current prescription running out. Suggested refill dates will be included
on the prescription label you receive from CVS Caremark. To make managing your mail service
prescriptions even easier, enroll in CVS Caremark’s automatic refill and renewal program. Once enrolled
in this program, CVS Caremark will automatically mail your prescription to you when you are due for a
refill and when your prescription is about to expire, they will reach out to your physician to request a new
prescription. To learn more about the refill and renewal program, log onto nd click
Refill a Prescription. Note:
By law, CVS Caremark must fill your prescription for the exact quantity of medication prescribed
by your doctor, up to the 90-day plan limit – “30 days plus two refills” does not equal one prescription
written for “90 days”. CVS/pharmacy Maintenance Choice
As an alternative to the mail service program, you may fill a 90-day supply of long-term maintenance
medications at your local CVS/pharmacy. Just have your physician write a 90-day prescription (with
refills, if applicable) and take it to your neighborhood CVS pharmacist. You will be charged the same
copay or coinsurance as the mail service program. CVS Caremark Specialty Pharmacy
Certain chronic or genetic conditions require special pharmacy products, often in the form of injected or
infused medicines. CVS Caremark Specialty Pharmacy Services is a comprehensive pharmacy program
that provided these products directly to covered individuals, along with the supplies, equipment, and care
Common conditions managed by the CVS Caremark specialty pharmacy include:
• Crohn’s disease
• Growth hormone and related disorders
• Hemophilia, von Willebrand disease and
Select specialty medications require an additional level of approval through the Caremark Specialty
Guideline management program. CVS Caremark may request information from your physician to determine
if clinical use and safety guidelines are met prior to dispensing the specialty medication. For more
information on CVS Caremark Specialty Pharmacy, please call CaremarkConnect toll-free at 1-800-237-
2767. Non-Participating Retail Pharmacy
In most cases, you will not need to use a pharmacy outside the CVS Caremark network because there are
over 62,000 participating pharmacies in the CVS Caremark Retail Network. However, if you choose to go to
a non-participating pharmacy, you will pay 100% of the prescription price. You will then need to submit a
paper claim form along with the original prescription receipt(s) to CVS Caremark for 50% reimbursement of
covered expenses. In most cases this option will cost you more.
Your out of Pocket Costs
Your prescription plan coverage can vary based on the medical plan that you choose. The coverage will be
the same under both the preferred provider organization (PPO) plan and the Aetna HealthFund. Under the
High-Deductible Health Plan (HDHP), the coverage will be based on whether a drug is considered to be
supporting preventive care or not. Reference the Preventative Drug List section of this document for more
information. PPO and Aetna HealthFund
(Mail service or CVS/pharmacy)
$9.99, if listed on the Value Generic Drug List $16 copay, if not listed on the Value Generic Drug List
(mail service or CVS/pharmacy)
Nonpreventive care drugs count toward the HDHP annual deductible:
$3,000 family Preventive-care drugs do not count toward the annual deductible.
$8, no deductible
$9.99, no deductible,
$16, no deductible, if not listed
on the Value Generic Drug List Nonpreventive:
Out of pocket cost considerations:
If the actual cost of a drug is less than the minimum, you will pay only the actual cost. If your
prescription drug costs more than the minimum, you will pay the coinsurance amount. You will never pay more than the maximum coinsurance amount for a prescription.
When a generic is available, but the pharmacy dispenses the brand name drug for any reason other
than a doctor indicating, “dispense as written” or equivalent instructions, you are required to pay the
difference between the cost of the brand name drug and the generic drug in addition to the applicable nonprimary copay or coinsurance listed above. This rule does not apply to schedule II controlled substance, Lanoxin, Premarin, Coumadin, Dilatin, or Synthroid. Prescriptions for thyroid replacement medication, Synthroid, will process at the generic coinsurance or copay.
Medications used to promote smoking cessation process at the non-primary coinsurance or copay.
All brand name nonsedating antihistamines (NSA) and proton pump inhibitors (PPIs) will be
considered nonprimary drugs. The patient will be charged the applicable nonprimary coinsurance or copay based on the prescription plan for which they are enrolled.
Singulair may be subject to varying copayment or coinsurance payment based upon the member’s
medication history. CVS Caremark will review the member’s prescription history for the 365 days prior to the processing of the Singulair claim to determine whether the copay or coinsurance will be subject to the primary or non-primary level. If, during that time, the member has filled a prescription that is commonly use to treat asthma, the Singulair claim will process at the primary copayment level. If no such medication is filled during the 365 day review period, the claim will process at the nonprimary copayment level.
A list of the commonly prescribed drugs which allow processing of Singulair at the primary tier follows: ATROVENT MDI/INH SOLN
Value Generic Drug List
To assist in reducing your out-of-pocket prescription costs, the Vanguard prescription plan offers lower
copay for certain generic medications through the Value Generic program. The Value Generics program
allows you to fill a 90-day supply of over 400 generic medications for a copay of $9.99. Most of the
medications included on the Value Generic Drug List are used to treat common conditions, such as blood
pressure, cholesterol, and diabetes. In order to receive the reduced the generics for the $9.99 copay, you
must fill the medication at either a local CVS/pharmacy or the CVS Caremark Mail Service Program. A
copy of the Value Generic Drug List can be found on CrewNet or on
If the generic medication that you are currently taking is not listed on the Value Generics Drug List, the
regular prescription copay or coinsurance (as indicated in the Your out of Pocket Costs
chart above) will
apply. If you are enrolled in the HDHP, the $9.99 copay will apply to only generic preventive medications.
Primary Drug List
The goal of the plan is to provide the highest quality pharmaceutical care that is economical for Vanguard
and for you. The Primary Drug List is one way to help control costs while maintaining quality care. The
brand name drugs listed on the Primary Drug List are a preferred list of drugs that are selected based on their
ability to meet patient needs at a reasonable cost.
Ask your doctor to consider prescribing a brand name on the Primary Drug List when there is not generic
available or more than one brand name drug available. You may want to bring the list with you when you or
a family member sees a doctor. Medications which are not on the Primary Drug List but do not have a
generic or formulary alternative are available to members at the primary brand coinsurance or copay.
A copy of the Primary Drug List is mailed to each crew member who enrolls in the plan along with their
CVS Caremark I.D. card and a list of the six closest network pharmacies. The Primary Drug list is also
available on the CVS Caremark website (and CrewNet
Note: CVS Caremark may contact your doctor after receiving your prescription to request consideration of an
alternative therapy, a preferred drug list product or generic equivalent. This may result in your doctor
prescribing a different therapy, brand name product or generic in place of your original prescription.
Preventive Drug List
Those enrolled in the HDHP can benefit from lower out-of-pocket costs for preventive drugs that help
specific chronic conditions. Preventive care drugs are defined by the government as drugs taken by a person
who has developed risk factors for a disease that has not yet become a health issue, those taken to prevent the
reoccurrence of a disease from which a person has recovered, and those used as part of preventive care
procedures such as obesity and tobacco cessation. The complete preventive drug list can be found on CrewNet. Covered Drugs
The following drugs are covered under the prescription drug plan:
- Drugs requiring a prescription under the applicable state law
- Diabetic supplies including insulin, insulin syringes, needles, test strips and lancets
- Emergency Allergy Kits – one co-payment per kit.
- AccuCheck Glucose Meter (1 meter per lifetime at no cost to you). Crew member may obtain a blood
glucose meter and diabetes test strips and lancets by calling CVS Caremark Diabetic Blood Glucose Monitor Customer Care team at 800-588-4456. Representatives can request and process prescriptions from their physician for these items. The number is for ordering blood glucose meters, test strips and lancets only; crew members must order other diabetic testing supplies by calling their usual Customer Care number (866-559-6903).
- Insulin lancet device (1 device per year).
- Fertility drugs per individual up to the lifetime maximum benefit of $10,000. Once $10,000 is reached,
the member is responsible for 100% of the infertility costs.
- Oral Erectile Dysfunction Drugs – 6 pill limit per 30-day supply; 18 pills per 90-day supply. (Excluding
Cialis 2.5 mg which is not subject to a monthly limit.)
- Growth hormones covered through age 18, over age 18 for appropriate diagnoses only
- Acne Medications (Retin-A, Differin) covered through age 36, over age 36 for appropriate diagnoses
- There is a one fill limit on extended cycle oral contraceptive medications at participating retail
pharmacies before you are required to use either the Mail Service or Maintenance Choice Program. No plan coverage will be provided at participating retail pharmacies after the initial fill of an on extended cycle oral contraceptive medication.
The following drugs are not covered under the prescription drug plan:
- Therapeutic devices or appliances, support garments, and other non-medical substances
- Respiratory therapy supplies (e.g. spacers)
- Prescriptions that an eligible person is entitled to receive without charge under any Workers’
Compensation law, or any municipal, state, or federal program
- Anorexiants – covered for appropriate diagnoses only
- Cosmetic drugs not including acne medications
- Over the counter Schedule V controlled substances
- Vaccines Note: coverage for new drugs will be determined by the Plan Administrator based on FDA guidance and information. Prescribed medications may be reviewed by CVS Caremark pharmacists and discussed with the prescriber to ensure proper use based on FDA approved indications and dosing recommendations.
ExtraCare Health Care Card
Vanguard has partnered with CVS/Caremark to provide medical plan enrollees with a discount option on
certain health care expenses through the CVS ExtraCare Health card. The ExtraCare Health Care Card
provides a 20% discount on over-the-counter, CVS-exclusive products that are eligible under the flexible
spending account (FSA). You may use the card online or at any local CVS/pharmacy. Please note that sale
items do not qualify for the discount. To order a new or replacement card, call 1-888-543-5938. Payment of Claims
If prescriptions are purchased at a participating retail network pharmacy or CVS Caremark Mail Service
Pharmacy, the crew member pays a copay or coinsurance. If prescriptions are purchased at non-
participating pharmacies, the crew member must pay the full cost of the drug at the pharmacy and submit a
reimbursement form to CVS Caremark. Reimbursement will be at 50% of the cost of the drug.
The participant or their physician should submit their appeal in writing either by fax or mail to the
CVS Caremark Appeals department. Please contact CVS Caremark customer care to obtain an
CVS Caremark, Inc.
P.O. Box 52084
Phoenix, AZ 85072-2084
Fax number: 866-689-3092
Urgent appeals requests by physicians may also be submitted by calling the physician only toll-free
number at 866-443-1183.
The appeals process can take up to 60 days to complete. CVS Caremark will send a letter of
approval/denial once a determination has been made.
Coordination of Benefits
The CVS Caremark prescription plan does not coordinate benefits with other prescription plans.
Termination of Coverage
Termination of your coverage (and that of a spouse, domestic partner or dependent) terminates under this
plan at the earliest of the following events:
The date on which the crew member’s employment terminates;
The plan or the offered benefits terminates;
The date the crew member is no longer eligible for the benefit, or
The date the crew member fails to provide any required contribution at the end of the period for
However, those covered may be eligible for COBRA coverage as described on CrewNet
and in Summary
Plan Description in Section II.B.7.
For More Information
You may call CVS Caremark Customer Care at 1-866-559-6903 24 hours a day, 7 days a week or e-mail
them at . You may also call Benefits at 1-800-407-8576 or internally, at
34BEN, if you have any questions about your prescription drug benefits, or to get a complete list of what is
covered and what is not covered under the program.
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