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Prescription Drug Plan Summary Chart

See a list of prescription medications, including diabetic supplies, in the Prescription Drug Plan Summary Chart below. Review Understanding Your Prescription Costs and Options Tip Sheet for information on medication costs under the different medical plan options.

Medication or Supply
HSA Copay
Network Copay and Traditional Coinsurance
Annual Deductible
$1,600/$3,200
(Combined with medical)
No Deductible
Most Pfizer Medications
(when no generic is available)
No cost, after deductible; deductible doesn't apply if medication is on the HSA Copay Preventive Drug List
No cost
Retail Medications — Per 30-day Supply
Retail Medications — Per 30-day Supply
Retail Medications — Per 30-day Supply
Non-Pfizer Generic Medication
$15 copay, after deductible; deductible doesn't apply if medication is on the HSA Copay Preventive Drug List
$15 copay
Non-Pfizer Brand Medications and Pfizer Medications (when a generic is available)
20% coinsurance after deductible (Min $15, Max $80); deductible doesn’t apply if medication is on HSA Copay Preventive Drug List
20% coinsurance (Min $15, Max $80)
Maintenance Choice Program Medications (Up to a 90-day supply of non-specialty maintenance medications when filled at a CVS Pharmacy or through CVS Caremark Mail Service Pharmacy.)
Maintenance Choice Program Medications (Up to a 90-day supply of non-specialty maintenance medications when filled at a CVS Pharmacy or through CVS Caremark Mail Service Pharmacy.)
Maintenance Choice Program Medications (Up to a 90-day supply of non-specialty maintenance medications when filled at a CVS Pharmacy or through CVS Caremark Mail Service Pharmacy.)
Non-Pfizer Generic Medication
$30 copay, after deductible; deductible doesn’t apply if medication is on the HSA Copay Preventive Drug List
$30 copay
Non-Pfizer Brand Medications and Pfizer Medications (when a generic is available)
20% coinsurance, after deductible (Min $30, Max $160); deductible doesn’t apply if medication is on the HSA Copay Preventive Drug List
20% coinsurance
(Min $30, Max $160)
Plan Pays 100% Coverage for Other Medications
Plan Pays 100% Coverage for Other Medications
Plan Pays 100% Coverage for Other Medications
Medications on the ACA Drug List including preventive vaccines
100%
(Deductible doesn’t apply)
100%
Blood Glucose Testing Meters
100%
(Deductible doesn’t apply)
100%
Eligible Diabetic Supplies
100%
(Deductible doesn’t apply)
100%
Out-of-Pocket Maximum
$3,600/$7,200
(Combined with medical)
$1,600/$2,400
(Separate from medical)

Note: If actual cost of medication is less than the copay or coinsurance minimum, you will pay the actual cost.

Reminder: If you use an out-of-network pharmacy, you will be required to pay the full cost of the prescription (even for Pfizer medications) at the time of your purchase and then submit a claim to CVS Caremark for reimbursement. Your reimbursement, less any applicable cost share, may be less than the full cost of the prescription if the cost is over the contracted rate.

Non-Specialty Maintenance Medications

Non-specialty maintenance medications are typically taken on a regular or daily basis to treat long-term or chronic conditions.

Medications on the ACA Drug List

Includes certain medications considered preventive by the Affordable Care Act (ACA). These include medications such as fluoride treatments, smoking-cessation treatments, oral contraceptives, colonoscopy prep medications, and low-dose generic statins, as well as certain over-the-counter products indicated for specific age and risk factors. Medications on the ACA Drug List (which includes preventive vaccines) are covered at 100 percent; the deductible does not apply if you enrolled in the HSA Copay plan. View the Affordable Care Act (ACA) Drug List or, for more information, contact CVS Caremark.

HSA Copay Preventive Drug List

If you’re enrolled in the HSA Copay option and you are taking a medication on the HSA Copay Preventive Drug List (e.g., for diabetes or hypertension), the deductible won’t apply; you will pay either your cost share, or no cost if the medication is on the Pfizer Zero Cost Prescription Drug List. View the HSA Copay Preventive Drug List or call CVS Caremark for more information.

Blood Glucose Testing Meters

Blood glucose testing meters must be purchased through the Diabetic Meter Program. Contact 1-800-588-4456 for program information and to receive a meter. Choice of meter is subject to change.

Eligible Diabetic Supplies

Eligible diabetic supplies dispensed at a pharmacy if you participate in a coaching program administered by TrestleTree. (See the Medical Support Programs section for program information.) These include insulin needles and syringes, lancets and devices, and test strips.

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