Prescription drugs

What you need to know

Your prescription drug benefits depend on the medical plan you choose. The Kaiser HMO plan manages its own prescription drug benefits, while CVS Caremark provides prescription drug benefits for participants in the UnitedHealthcare (UHC) plans.

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What's a formulary?

Prescription drug coverage includes a formulary, which is a list of generic and brand-name prescription drugs covered by your pharmacy plan.

A formulary includes:

  • Commonly prescribed medications covered by your plan’s pharmacy benefit
  • The medications available for certain conditions, organized into cost levels or tiers
  • Medication exclusions or other requirements, such as prior authorization and step therapy, that may affect how medications are covered

If your doctor prescribes a drug that is not on the standard formulary but is clinically necessary, your provider can request an authorization.

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What you pay under the UHC medical plans

Retail versus mail order

You can get a 30-day supply of medication from retail pharmacies.

If you're on a maintenance medication, such as high blood pressure medication, for an extended period of time, consider the mail-order option, which provides a larger quantity for a reduced copay. 

UHC participants can pick up to a 90-day supply of maintenance prescriptions at their local CVS or Target pharmacy, in addition to using the mail-order drug program.

Dispense-as-written requirement

If you fill a prescription for a brand drug when a generic is available, you’ll pay the difference between the brand and generic prescription drug cost (including copay), unless the brand drug is clinically necessary. In this case, your provider can send a request for authorization to CVS.

  UHC $300 Deductible UHC CDHP with HSA*
Generic In-network: $10
Out-of-network: $10 + 50%
In-network: 10% after deductible
Out-of-network: 30% after deductible
Brand formulary In-network: $25
Out-of-network: $25 + 50%
In-network: 10% after deductible
Out-of-network: 30% after deductible
Brand non-formulary In-network: $40
Out-of-network: $40 + 50%
In-network: 10% after deductible
Out-of-network: 30% after deductible
Maintenance medications Mail order or at CVS or Target pharmacies: Up to a 90-day supply for just 2 times the retail copay amount. Check with the plan for details about mail order. Mail order or at CVS or Target pharmacies: Up to a 90-day supply for just 2 times the retail copay amount. Check with the plan for details about mail order.

*Under the UHC CDHP with HSA , deductibles and coinsurance apply. You are responsible for full prescription costs until you reach combined deductible.

Note: Manufacturers often provide copay cards to patients to help cover the very high cost of specialty drugs. If you’re prescribed a specialty drug and use a manufacturer copay card to help offset the cost, the dollar value of the manufacturer copay card does not count toward your medical plan deductible.

Prescription Drug Out-of-Pocket Maximum

After you reach your out-of-pocket maximum, the plan pays 100% of eligible expenses for the remainder of the plan year. Under both UHC plans, prescription out-of-pocket maximums are included in the medical out-of-pocket maximum.

What prescriptions are covered?

To find out whether your medication is covered:

  1. Visit caremark.com, or call CVS Caremark customer care at 844-287-1297.
  2. Download the formulary, or view on the CVS Caremark app.
  3. Use the Check Drug Cost tool. You’ll instantly see if a specific prescription is covered under your plan. And if it is no longer covered, you’ll see how much the prescription will cost.

What to do if your prescription requires prior authorization

Check the Medications Requiring Prior Authorization list, and if you are currently using one of the drugs requiring prior authorization for medical necessity, ask your doctor to choose one of the generic or brand formulary options listed.

How to submit a request for prior authorization

How to appeal a prior authorization denial

Where to send your appeals

Provider contact information

What you pay under the Kaiser HMO medical plan

You can get a 30-day supply of medication from retail pharmacies.
If you're on a maintenance medication, such as high blood pressure medication, for an extended period of time, consider the mail-order option, which provides a larger quantity for a reduced copay.

  Kaiser HMO (CA)
Generic $10
Brand formulary $25
Brand non-formulary $25
Maintenance medications Mail order: Up to a 90-day supply for just 2 times the retail copay amount. Check with the plan for details about mail order

Prescription Drug Out-of-Pocket Maximum

After you reach your out-of-pocket maximum, the plan pays 100% of eligible expenses for the remainder of the plan year. Prescription out-of-pocket maximums are included in the medical out-of-pocket maximum.

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Provider contact information

Save money with these tips

Whenever possible, ask for a generic equivalent to save money, and use in-network pharmacies to avoid paying more.

Compare costs. Save money.

If you're a UHC member, you can use the CVS Check Drug Cost tool to see what you’ll pay and whether there’s a lower-cost alternative available.

Use the tool

UHC and Kaiser Permanente (CA) medical plan members receive in-network maintenance drugs at no cost to help manage ongoing or chronic medical conditions, such as:

  • Diabetes
  • High blood pressure
  • High cholesterol

All of our medical plans cover certain preventive anti-cancer medications at no extra cost for women over age 35 with increased risk of breast cancer and annual screenings for certain individuals at risk for lung cancer, including CT scans of the thorax.

Need some help understanding features of the prescription drug plan? See the Terms to know page.

Additional savings for UHC members

UHC members can save 20% on thousands of CVS® brand health-related items, like pain medicine, cough and cold remedies, vitamins, and more, with the CVS ExtraCare Health Card Program, available at retail stores.

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Learn more about your prescription drug benefits

Getting to know CVS Caremark's digital tools
A basic overview of the features available on caremark.com and the mobile app, ways to save, how to save time with your order, and understanding your plan.

Compare Rx costs & coverage
Learn more about the full costs of prescription drugs, how to compare drug costs at different pharmacies, and personalized drug savings opportunities. 
 
Rx coverage & prior authorizations
Explains what a drug formulary is, why and how prior authorizations work, and what to expect with prior authorization. 

Prescription benefits 101
New to prescription drugs? Not sure how your benefits work? This video provides a basic overview of your benefits and CVS Caremark's digital tools. 

Save time & get your Rx online
Fill or refill your prescription online in a few simple steps with CVS Caremark's easy-to-use tools.

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