Page 7 - Benefits Guide

Health Care
Prescription Drug Coverage
Each medical option includes coverage for prescription drugs, outlined in the following table.
Prescription drug benefits are provided through CVS Caremark, with a pharmacy network that includes more than 74,000 pharmacies nationwide.
These include not only participating CVS pharmacies but also Walgreens, Walmart and many other pharmacy chains, as well as more than 20,000 independent pharmacies. For a list of covered drugs, you can either call CVS Caremark at 1-866-243-5105 or go to their website at www.caremark.com/druglist.
Provider:
CVS Caremark
SMART Value HDHP with HSA
SMART Choice HDHP with HSA
SMART Premium PPO Plan
Preventive Drugs (per Affordable Care Act)
You pay $0
Must have a doctor’s prescription for the medication (even if sold over the counter)
In-Network
Out-of-Network
In-Network
Out-of-Network
In-Network
Out-of-Network
Deductible
Combined Medical and Rx Deductible
Combined Medical and Rx Deductible
$100 Individual/$300 Family Separate Rx Deductible
Out-of-Pocket Maximum
Combined Medical and Rx Out-of-Pocket Maximum
Combined Medical and Rx Out-of-Pocket Maximum
Combined Medical and Rx Out-of-Pocket Maximum
Retail (30-Day Supply)
Tier 1: Generic
70%*
Not covered
$10 copay*
Not covered
$10 copay
Not covered
Tier 2:
Brand Formulary
70%*
Not covered
$35 copay*
Not covered
$35 copay
Not covered
Tier 3:
Non-Brand Formulary
70%*
Not covered
$60 copay*
Not covered
$60 copay
Not covered
Tier 4: Specialty
70%*
Not covered
$200 copay*
Not covered
$200 copay
Not covered
*After deductible is met
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