|Medical Plan (In-Network Benefits Only): What You Pay|
|Total Deductible||$3,000 (Single); $9,000 (Family)|
|HRA Allocation (City Contribution)||N/A|
|Out-of-Pocket Max (Combined with Pharmacy)||$6,350 (Single); $12,700 (Family)|
|Office Visits||30% after Deductible|
|X-ray and Lab Work||30% after Deductible|
|Preventive Services||Covered at 100%|
|Emergency Room||You pay $100 copay plus 30% after Deductible|
|Urgent Care Facility Only||30% after Deductible|
|Outpatient Services||30% after Deductible|
|Inpatient Services||30% after Deductible|
|Enhanced Facility Benefit||10% after Deductible|
|Prescription Drug Benefit (CVS Caremark)||See Pharmacy section for more details|
|Prescription Drug Deductible||$750 Individual|
EPO 75/25 HRA Plan
|Medical Plan (In-Network Only): What You Pay|
|Wellness Incentive Earned||Wellness Incentive NOT Earned|
|Total Deductible||$2,500 (Single); $5,000 (Family)||$2,500 (Single); $5,000 (Family)|
|HRA Allocation (City $$$)||$1,000 (Single); $2,000 (Family)||$700 (Single); $1,700 (Family)|
|Out-of-Pocket Maximum (includes pharmacy)||$6,350 (Single); $12,700 (Family)||$6,350 (Single); $12,700 (Family)|
|Office Visits||25% after Deductible||25% after Deductible|
|X-ray and Lab Work||25% after Deductible|
|Preventive Care||Covered at 100%|
|Emergency Room||25% after Deductible|
|Urgent Care Facility only||25% after Deductible|
|Inpatient Services||25% after Deductible|
|Outpatient Services||25% after Deductible|
|Enhanced Facility Benefit||10% after Deductible|
|Prescription Drug Coverage (CVS Caremark)||See Pharmacy section for more details|
|Prescription Drug Deductible||NA|
See the Medical Video for more information on the medical plans.
|EPO 70/30 Plan||EPO 75/25 with HRA|
|Ask your doctor or other prescriber if there is a generic available, as these generally cost less.||10% ($10 minimum)||10%|
|Preferred Brand-Name Medications|
|If a generic is not available or appropriate, ask your doctor or healthcare provider to prescribe from your plan's preferred drug list.||25% ($25 minimum)||25%|
|Non-Preferred Brand-Name Medications|
|You will pay the most for medications not on your plan's preferred drug list.||40% ($40 minimum)||40%|
|Annual Deductible||$750 Individual||NA|
|Mail Order (90-Day Supply)|
|Generic||10% ($10 minimum)||10%|
|Preferred Brand-Name||25% ($25 minimum)||25%|
|Non-Preferred Brand-Name||40% ($40 minimum)||40%|
|CVS Caremark Retail Pharmacy Network
For short-term medications
(Up to a 31-day supply)
|The CVS Caremark Retail Network includes more than 67,000 participating pharmacies nationwide, including independent pharmacies, chain pharmacies and 7,400 CVS Pharmacy locations. To locate a CVS Caremark participating retail network pharmacy in your area, simply click on "Find a Pharmacy" at www.caremark.com or call a Customer Care representative toll-free at (855) 465-0023.|
|CVS Caremark Mail Service Pharmacy or CVS Caremark Retail-90 Pharmacy
For long-term medications
(Up to a 90-day supply)
|You have the convenience of getting your long-term medications at one of our 51,000 Retail-90 Pharmacy locations for your mail service copay. Or simply mail your original prescription and the mail service order form to CVS Caremark. Your medications will be sent directly to your home, office or a location of your choice.|
|Web Services||Register at www.caremark.com to access tools that can help you save money and manage your prescription benefit. To register, have your Prescription Card ready.|
|Customer Care||Visit www.caremark.com or call (855) 465-0023|
Copay or coinsurance means the amount a plan participant is required to pay for a prescription in accordance with a plan, which may be a deductible, a percentage of the prescription price, a fixed amount or other charge, with the balance, if any, paid by a plan.
Prescription Benefit Overview
This plan offers you choice and savings when it comes to filling prescriptions. When you need short term medications, you can purchase them through a local retail pharmacy or, for medications you take on an ongoing basis, through the mail order program. Plus, you can easily order refills and manage your prescriptions anytime at www.caremark.com.
Retail Prescription Program
- Pick up your medication at a time that is convenient for you
- Up to 31-day supply of medication
- Talk with a pharmacist face-to-face
CVS/Caremark Mail Service Program
- A convenient and cost-effective way to fill prescriptions for medications taken on a regular basis
- Receive a 3-month supply of medications
- Mailed to your home
Generic Step Therapy
- For certain high-cost prescription drugs, you may need to try two alternative, generic medications before "stepping up" to a more costly treatment.
- Pharmacist will let you know at the time of purchase if your prescription requires step therapy.
Dispense As Written Penalty
- If you elect to fill a brand-name medication when a generic is available, you will pay your generic copay AND the cost difference between the brand-name and the generic medication.
- Generic drugs can save you money!
Specialty Drug Formulary Prescriptions
- Certain specialty drug formulary prescriptions, like medications for complex conditions such as cancer and autoimmune disorders, must be filled with a drug on CVS/Caremark's approved list.
- If you choose to fill your prescription with a drug on the "excluded" list, you must pay the full cost of that drug.