Page 5 - 2020FCSBenefitsGuide
P. 5
Pharmacy Benefits
Medical/Rx Combined Out-of-Pocket Maximum
Core and Prime Plan High Deductible Health Plan
with HSA
In-Network Out-of-Network In-Network Out-of-Network
Retail (Non-Maintenance) (30-Day Supply)
Deductible $100 Rx deductible—applied per Generic maintenance medication
member capped at $400 per family covered 100%—no deductible
Generic $10 copay Not covered 10% after Not covered
deductible
Preferred Brand $40 copay Not covered 10% after Not covered
deductible
Non-Preferred 20% to a Not covered 10% after Not covered
Brand maximum of deductible
$200
Specialty 10% to a max of Not covered 10% after Not covered
Medications $400 deductible
Mail Order (90-Day Supply)
Generic $25 copay Not covered 10% after Not covered
deductible
Preferred Brand $100 Copay Not covered 10% after Not covered
deductible
Non-Preferred 20% to a Not covered 10% after Not covered
Brand maximum of deductible
$400
The medical and RX out-of-pocket maximums are now combined. See
medical grid for total out-of-pocket max.
Your pharmacy beneit is through CVS Caremark and is administered
by Rx Beneits. CVS Caremark includes all CVS Pharmacies, Walmart,
Publix, Walgreens, and Target locations, plus various grocers and
independent pharmacies. Visit www.caremark.com to get a list of in-
network pharmacies. You will receive a separate ID card for the Rx
Beneits. On or after your effective date, you can register online at
Caremark.com. It is designed to help you explore ways to save, track your
prescription beneits, and manage your own alerts. You can even give
family members permission to manage prescriptions online, if they are on
your beneit plan. We put the power in your hands so you can maximize
your prescription beneits. Dispense As Written
Members can utilize any of the more than 60,000 pharmacies in the (Generics Policy)
network for all prescriptions except those considered maintenance If you choose to buy the brand
name drug when a generic
medications. Maintenance medications must be illed at CVS or mail equivalent is available, you will be
order with CVS/Caremark. After the irst 2 ills, you will be required to required to pay the brand copay
either set-up the prescription for a 90-day ill via the Rx Beneits—CVS/ plus the diference in cost between
Caremark system or ill these medications at a CVS retail pharmacy in the generic and brand name drug.
accordance with the directions on the following page.
Florida Cancer Specialists and Research Institute 5
Medical/Rx Combined Out-of-Pocket Maximum
Core and Prime Plan High Deductible Health Plan
with HSA
In-Network Out-of-Network In-Network Out-of-Network
Retail (Non-Maintenance) (30-Day Supply)
Deductible $100 Rx deductible—applied per Generic maintenance medication
member capped at $400 per family covered 100%—no deductible
Generic $10 copay Not covered 10% after Not covered
deductible
Preferred Brand $40 copay Not covered 10% after Not covered
deductible
Non-Preferred 20% to a Not covered 10% after Not covered
Brand maximum of deductible
$200
Specialty 10% to a max of Not covered 10% after Not covered
Medications $400 deductible
Mail Order (90-Day Supply)
Generic $25 copay Not covered 10% after Not covered
deductible
Preferred Brand $100 Copay Not covered 10% after Not covered
deductible
Non-Preferred 20% to a Not covered 10% after Not covered
Brand maximum of deductible
$400
The medical and RX out-of-pocket maximums are now combined. See
medical grid for total out-of-pocket max.
Your pharmacy beneit is through CVS Caremark and is administered
by Rx Beneits. CVS Caremark includes all CVS Pharmacies, Walmart,
Publix, Walgreens, and Target locations, plus various grocers and
independent pharmacies. Visit www.caremark.com to get a list of in-
network pharmacies. You will receive a separate ID card for the Rx
Beneits. On or after your effective date, you can register online at
Caremark.com. It is designed to help you explore ways to save, track your
prescription beneits, and manage your own alerts. You can even give
family members permission to manage prescriptions online, if they are on
your beneit plan. We put the power in your hands so you can maximize
your prescription beneits. Dispense As Written
Members can utilize any of the more than 60,000 pharmacies in the (Generics Policy)
network for all prescriptions except those considered maintenance If you choose to buy the brand
name drug when a generic
medications. Maintenance medications must be illed at CVS or mail equivalent is available, you will be
order with CVS/Caremark. After the irst 2 ills, you will be required to required to pay the brand copay
either set-up the prescription for a 90-day ill via the Rx Beneits—CVS/ plus the diference in cost between
Caremark system or ill these medications at a CVS retail pharmacy in the generic and brand name drug.
accordance with the directions on the following page.
Florida Cancer Specialists and Research Institute 5
