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 Meritain Health plans.
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.
What you pay under the Meritain Health 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.
Meritain Health 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.
| Meritain Copay Plan | Meritain 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 Meritain 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 Meritain Health 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:
- Visit caremark.com, or call CVS Caremark customer care at 844-287-1297.
- Use the Check Drug Cost tool to 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 is prior authorization and why is it needed?
Prior authorization is an extra level of approval that benefit plans require for certain medications. It helps ensure the safe, effective, and appropriate use of selected medication, making sure you’re receiving the right medication for your condition. It may also help keep costs down, so you don’t overpay.
Prior authorization may be needed if:
- There is a lower cost option that’s just as effective
- The medication has potential for misuse or abuse
- The medication is for certain conditions or diagnoses
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
Prescription drugs
Plan / Group number: 1166
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.
Provider contact information
Medical
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 Meritain Health 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.
All Meritain Health 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 Meritain Health members
Meritain Health 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.
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 and 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 and 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 and get your Rx online
Fill or refill your prescription online in a few simple steps with CVS Caremark's easy-to-use tools.