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Prescription Drug Benefits

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All four Northwestern-sponsored medical plans provide benefits toward the cost of prescription drugs. CVS Caremark is the Pharmacy Benefit Manager for all four plans.  If you have questions about a covered medication, contact CVS Caremark directly at 833-844-5348. You can find participating pharmacies on the CVS Caremark website.

Use links below to learn more about the plan:

Copays and Coinsurance

30-day retail and 90-day mail order supply

Plan Feature PPO HSA Plus HSA Essential HMO
Out-of-Pocket
Maximum
(Individual/Family)		 $1,500/
$3,000		 $4,000/
$8,000		 $7,000/
$14,000		 $1,500/
$10,200

Prescription Drugs
(Retail/Mail Order)

Generic
Formulary
Non-Formulary
Specialty

Copay:

$10/20
$50/100
$75/150
$100/$200

Coinsurance after deductible:

20%/20%
20%/20%
20%/20%
20%/20%

Copay:

$10/$20
$30/$60
$60/$120
$90/$180

Certain drugs have per month or benefit period limits or prior authorization. Contact CVS Caremark or check with your pharmacist or physician for a list of drugs subject to limitations.

 

Coverage Considerations

Not all prescriptions can be filled at a retail pharmacy.  Review the chart below to better understand how certain types of medications will be covered under the plan.

PPO and HMO HSA Plus and Essential
  • Some prescriptions are not eligible for a one-month supply and may only be filled at select pharmacies. See the CVS Retail 90 Network section of this webpage for more information and a drug list.
  • Specialty drugs are filled using CVS Speciality Pharmacy, a wholly owned subsidiary of CVS Caremark.
  • Certain specialty medications are assigned a different copay than listed above. See the PrudentRx section of this website for a list of copays and drugs as well as information on how to receive your medications free of charge ($0). These medications will not count towards your deductible or out-of-pocket maximums.
  • Some prescriptions are not eligible for a one-month supply and may only be filled at select pharmacies. See the CVS Retail 90 Network section of this webpage for more information and a drug list.
  • Specialty drugs are filled using CVS Speciality Pharmacy, a wholly owned subsidiary of CVS Caremark.
  • The HSA Plus and HSA Essential plans are not subject to the PrudentRx program.

Generics preferred

Under this program, if a brand-name drug is dispensed rather than an available chemically equivalent generic drug, an ancillary charge is applied in addition to the member’s generic coinsurance. Ancillary charges are the responsibility of the employee, regardless of whether the “dispense as written” box is checked by your doctor. The ancillary charge is 50 percent of the difference in cost between the brand and generic product. Ancillary charges do not apply toward the maximum cost per prescription or the out-of-pocket maximum. It is important to remember that this program still allows you the choice between treatment options, but not at an increased cost to the plan and its participants.

If you are prescribed a specialty drug

Prescriptions for all Specialty Drugs must be filled through CVS Specialty; these prescriptions cannot be filled at a retail pharmacy, at your providers office, or at an infusion center. CVS Specialty fills prescriptions for Specialty Drugs for oral, injectable, and infused medications and provides nurse and pharmacist support for patients on these complex, expensive drugs. Once you enroll in CVS Specialty, you can have your medication delivered anywhere nationwide, even if you’re on vacation. Or you can pick it up at any CVS Pharmacy location. Because many Specialty Drugs require refrigeration, CVS Specialty takes precautions to ensure product preservation, including using temperature-controlled packaging and working with patients to arrange for safe and secure package delivery.

To fill or transfer your prescription with CVS Specialty, call 800-237-2767.

CVS Retail 90 Network: Required 90-Day Supply

This program will apply to select long-term medications, which will now require a 90-day supply. With CVS Retail 90 Network, you can conveniently fill these prescriptions with a 90-day supply either through home delivery from the CVS Caremark or from any CVS, Walgreens or Duane Reade pharmacies.

If you keep filling a 1-month supply of the listed long-term medications at a nonparticipating pharmacy, you could pay more. For example, if a drug costs $75, even if your copay or coinsurance is only $20, you could pay up to the full $75. Additionally, when you pay the full cost on retail maintenance medications, your cost share will not count towards you deductible and or maximum out of pocket costs.

PrudentRx

If you elect coverage under the PPO or HMO medical plan, CVS’s PrudentRx program can help you save money on certain Specialty Drugs s prescribed by your provider. If you elect coverage under the HSA Plus or HSA Essential medical plan, you are not eligible to use the PrudentRx program.

If you are eligible for the PrudentRx program and a specialty medication you’ve been prescribed is included on the PrudentRx Drug list, you can receive your medications free of charge ($0) when you fill your prescription through the PrudentRx program. Otherwise, you will be responsible for 30 percent of the cost of your specialty medications, which will count toward your deductible and out-of-pocket maximums.

If you have any questions about the PrudentRx program and how to enroll, call 800-578-4403.

Price A Medication

You can verify how a medication is covered by medical plan using the links below:

Claim forms