Prescription Drug Benefits
All four faculty and staff Northwestern-sponsored medical plans provide benefits toward the cost of prescription drugs. Postdoctoral Scholars and employees on the Cigna International plans should review their respective plans for coverage.
Enrollment in the prescription drug plan is automatic with enrollment in a medical plan. Though some programs associated with the plan, such as PrudentRx, may require separate enrollment (see below for more information). The formulary, or list of covered drugs, is the same regardless of which medical plan you elect; but how the drugs are covered under the plan may be different. Review the information on this website to better understand how your coverage works.
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.
There are over 60,000 in-network pharmacies in which you may fill many 30-day scripts. You may use the online pharmacy locator or call 833-844-5348 to find an in-network pharmacy near you. National providers include: Costco Pharmacies, CVS, Jewel-Osco / Albertsons / Safeway, Kroger, Meijer Pharmacy, Rite Aid, Sam's Club, Walgreens, Walmart, and more. You can find participating pharmacies on the CVS Caremark website.
Use links below to learn more about the plan:
- Copays and Coinsurance
- Coverage Considerations
- Generics preferred
- Specialty drugs
- CVS Retail 90 Network: Required 90-Day Supply
- PrudentRx (For Select Specialty Drugs)
- CVS Formulary
- Claim forms
Copays and Coinsurance
30-day retail and 90-day mail order supply
The formulary, or list of covered drugs, is the same regardless of which medical plan you elect; but how the drugs are covered under the plan may be different. Those enrolled in the PPO or HMO will have a set co-pay & until the annual Out-of-Pocket Maximum is met. Those enrolled in the HSA Plus and HSA Essential will pay 100% for covered drugs until the deductible is met, at which point the plan will pay 80% of covered drugs, until the annual Out-of-Pocket Maximum is met. See the chart below to understand how your drugs will be covered under the plan.
| 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 |
| Medical + Rx Deductible (Individual/Family) |
n/a |
$2,000/$4,000 |
$4,000/$8,000 |
n/a |
|
Prescription Drugs Generic |
Copay: $10/20 |
Coinsurance after deductible: 20%/20% |
Copay: $10/$20 |
|
If you select coverage under the PPO or HMO medical plans, the amount you pay toward the cost of your prescription drugs under the prescription drug plan is a flat dollar copay. The out-of-pocket costs for prescription drugs each year is subject to the annual $1,500 out-of-pocket maximum, which is tracked separately for you and each covered family member. If the amount you pay in copays reaches $1,500 for you or a covered family member in a calendar year, the prescription drug copays will no longer apply to prescriptions filled through the plan for you or that family member for the balance of the year.
If you select coverage under the HSA Plus or HSA Essential medical plans, you pay the full cost of prescription drugs for you and your covered family members until you meet the plan’s annual deductible, which is a combined limit for both medical and prescription. Once you do, you pay coinsurance toward the cost of each prescription until your share of covered expenses for the year reaches the plan’s out-of-pocket maximum, which is a combined limit for both medical and prescription. Once you do, the plan pays the full cost of prescription drugs for you and your family for the rest of the year.
Prescription drug costs that exceed the approved dispensing limit in any given month—or that are for medications not covered by the plan—will not count toward your annual out-of-pocket expenses.
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.
For information on how compound drugs may be covered under the plan, see FAQs.
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 |
|---|---|
|
|
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
Prescriptions for select long-term medications must now be filled in a 90-day supply. This program – CVS Retail 90 Network – makes it convenient to order 90-day refills either through home delivery from CVS Pharmacy Mail Order or in-person from any CVS, Walgreens or Duane Reade pharmacies. See list of medications below that can be filled through the CVS Retail 90 Network program. Using the CVS Retail 90 Network program to order 90-day refills of your long-term medications can help you save time, money and trips to the pharmacy. If you continue to refill these prescriptions in 30-day supplies at a nonparticipating pharmacy, you could pay more for your medications than you need to.
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 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 covered by the formulary and 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 out-of-pocket maximums. The PrudentRx benefit only applies to drugs that are also covered by the formulary. Inclusion on the PrudentRx drug list does not imply formulary coverage.
If you have any questions about the PrudentRx program and how to enroll, call 800-578-4403.
CVS Formulary
For the most up‑to‑date information on your prescriptions, use the online formulary tool in the CVS online portal or the mobile app. Below are additional search tools to research covered drugs. You can also review the specialty formulary here and non-specialty formulary here in addition please review the medications that are excluded from the plan here.