| |
|
The health
insurance ID card has a series of ID numbers at
the bottom. Please present your card to the pharmacist
so that they may process your prescription and
apply the proper discounts. |
|
Claims
will be automatically processed at the point of
service and there are no forms or receipts to
submit. |
| |
The
Tiers described below help to classify prescription
drugs. The Formulary PDF can be a helpful guide
to locating your Drug name and classification.
Generic drugs are not listed, as there are many.
If you would like to know what tier your drug
classifies as, or what alternatives may be available,
you may also contact your pharmacy or the Caremark
number located on your membership card. |
| |
| |
|
| |
Tier
1 (Most preferred)- All Generic Drugs |
| |
|
| |
Tier
2 (Preferred Drugs)- Drugs that are cost
effective alternatives to higher priced
drugs of the same category and clinical
effectiveness. A generic drug may also be
available in some cases |
| |
|
| |
Tier
3(Non-Preferred Drugs)- Higher cost drugs
for which other alternative drugs, and/or
generics with the same clinical effectiveness
are available |
| |
|
|
| |
| Note:
Generic brand drugs are mandatory when available. |
| |
| |
| Days
Supply:
|
30-60 |
90 |
120 |
150 |
180 |
| Tier 1 |
$10 |
$10 |
$10 |
$10 |
$10 |
| Tier
2 |
$20 |
$25 |
$30 |
$35 |
$40 |
| Tier 3 |
$40 |
$50 |
$60 |
$70 |
$80 |
|
|
| |
All prescriptions
purchased outside of the U.S. network are subject
to a 20% co-pay in addition to the co-pays applicable
to the formulary plan. For more information on
your pharmacy benefit, please refer to your policy. |
| |
| |
