BNY Mellon Benefits Guide
Prescription Drug Benefits
If you elect medical coverage through Plan HRA (including Health Reimbursement Account) or Plan HSA (including Health Savings Account) with Aetna or UnitedHealthcare, you will automatically be enrolled for prescription drug coverage through CVS Caremark. (Those enrolled in the Kaiser Permanente, HMSA or Aetna International plans will receive prescription coverage through their medical carrier.) The CVS Caremark prescription plan offers lower prices for generic drugs, a mail order option for maintenance medications and coverage for specialty drugs. This prescription plan also requires mandatory generic substitution.
For maintenance drugs, you have the choice of CVS pharmacy or CVS Caremark Mail Service. If you use maintenance drugs, you may fill a 30-day prescription twice at the retail level, then future fills must be completed through the mail order service in 90-day quantities. You also may pick up a 90-day supply through the Maintenance Choice program at any CVS pharmacy location.
Under Plan HRA, all covered prescription drugs are subject to the traditional four-tier prescription drug schedule (generic and specialty copayments, formulary and non-formulary coinsurance).
Under Plan HSA, non-preventive prescription drugs are subject to the deductible/coinsurance provisions, but preventive prescription drugs are covered under the traditional four-tier prescription drug schedule, offering low copayments for generic drugs and coinsurance for formulary, non-formulary and specialty drugs.
As required by the Affordable Care Act, prescription drug expenses under both health plans now count toward the out-of-pocket maximum.
PRESCRIPTION DRUGS
 
PLAN HRA1
Drugs are not subject to the overall plan deductible and follow the traditional 4-tier prescription drug schedule
PLAN HSA1
Non-preventive drugs are subject to the overall plan deductible. Preventive drugs are not subject to the overall plan deductible and are covered under the same traditional 4-tier prescription drug schedule as Plan HRA.
Preventive2
Same as Retail/Mail Order below
Same as Retail/Mail Order under Plan HRA (deductible does not apply)
Retail3
Non-Preventive Drugs
  • Generic: Lesser of $10 or retailer's regular cost
  • Formulary (Preferred) Brand: 25% coinsurance ($50 minimum; $75 maximum)
  • Non-Formulary (or Non-Preferred) Brand: 40% coinsurance ($75 minimum; $100 maximum)
Non-Preventive Drugs
  • Generic: 20% coinsurance after deductible
  • Formulary (Preferred) Brand: 20% coinsurance after deductible
  • Non-Formulary (or Non-Preferred) Brand: 40% coinsurance after deductible5
Mail Order3
Non-Preventive Drugs
  • Generic: Lesser of $25 or regular discount cost
  • Formulary (Preferred) Brand: 25% coinsurance ($125 minimum; $187.50 maximum)
  • Non-Formulary (or Non-Preferred) Brand: 40% coinsurance ($187.50 minimum; $250 maximum)
Non-Preventive Drugs
  • Generic: 20% coinsurance after deductible
  • Formulary (Preferred) Brand: 20% coinsurance after deductible
  • Non-Formulary (or Non-Preferred) Brand: 40% coinsurance after deductible5
Specialty4
  • Generic: $10
  • Formulary (Preferred) Brand: $75
  • Non-Formulary (or Non-Preferred) Brand: $100
  • Generic: 20% coinsurance after deductible
  • Formulary (Preferred) Brand: 20% coinsurance after deductible
  • Non-Formulary (or Non-Preferred) Brand: 40% coinsurance after deductible5
1 Your costs for preventive and non-preventive drugs count toward the out-of-pocket maximum; mandatory generic and step therapy programs apply.
2 Examples of preventive drugs include, but are not limited to, diabetes medications, cholesterol medications, and high blood pressure medications.
3 Maintenance/preventive medication must be filled through mail order or at a CVS (or Target) retial pharmacy after the prescription is filled twice at a retail location.
4 30-days' supply maximum at Retail and Mail Order.
5 Minimums and maximums do not apply.
Note: CVS Caremark requires prior authorization, quantity limits and/or specialty guideline management for select medications, and these requirements may change from time to time. Current medications subject to these special guidelines are listed in the "Value Formulary Quick Reference List."
CVS Caremark Value Formulary
The Prescription Drug Formulary is updated regularly and can be accessed at http://info.caremark.com/highvalueplan. If you currently take prescription drugs or need prescription drugs during 2018, it is important that you review this formulary list with your doctor. If your prescribed drug is not on the list, discuss with your doctor whether your treatment plan can include a generic alternative or, if not available or tolerated, a high-quality, preferred name-brand drug included in the new Value Formulary.
CVS Opioid Management Program
Beginning January 1, 2018, CVS will align their opioid management with the Guideline for Prescribing Opioids for Chronic Pain issued by the Centers for Disease Control and Prevention (CDC) to positively influence the prescribing and use of opioids to treat pain. The enhanced program will limit days' supply, limit quantity of opioids and require step therapy. For more information, please contact CVS Caremark at 1-800-685-4130.
Compound Prescriptions
Due to the lack of U.S. Food and Drug Administration (FDA) approval for many ingredients included in compounds and the high cost of these compounded medications, they may not be covered by your prescription plan or may require a prior authorization. If the compound ingredients are not covered, you will be responsible for the full cost of those ingredients. In situations where the compound ingredients are covered through prior authorization, you will pay the share of the cost specified by your prescription benefits.
Over-the-Counter Equivalents
Prescription drugs that have an over-the-counter (OTC) equivalent are not covered by either of the BNY Mellon health plans.
Preventive Therapy Drugs
Preventive drugs are medications that can help prevent a health condition from developing. Examples include blood pressure and cholesterol-lowering medications that may prevent heart attacks and strokes. Please call CVS Caremark at 1-800-685-4130 for more information.
Diabetes Discount Program (Only for Participants in Plan HRA)
The Diabetes Discount Program provides a 50 percent discount on diabetes prescriptions and supplies. The discount is provided to all benefits-eligible participants enrolled in Plan HRA who have completed an A1C test in the prior 12 months. You will be contacted if this program applies to you.
The discount does not apply to any medications on the CVS Caremark Value Formulary.
Not all diabetic medications and supplies are eligible for the program discount.
If you have questions regarding this program, the specific coverages for diabetic medications and supplies, or the testing requirements, please call CVS Caremark at 1-800-685-4130.
Specialty Drug Services
Specialty drugs are prescriptions that are used for the treatment of complex, chronic conditions such as hepatitis, hemophilia, and cancer.
CVS Caremark offers a program for specialty injectable and oral drugs that can provide you with greater convenience, including express delivery, follow-up care calls, expert counseling and superior service. Specialty medications (excluding HIV and transplant therapies) are no longer eligible for a grace fill at non-CVS retail pharmacies or other non-CVS specialty pharmacies. However, a one-time annual grace fill is available for HIV and transplant therapies. All other specialty prescriptions must be filled through CVS Specialty, and will be accepted at all CVS retail pharmacies. Also, CVS pharmacy locations with a MinuteClinic® have a service that provides education regarding the medication or the injectables you are taking.
Step Therapy Program
The prescription drug Step Therapy program helps ensure that you receive appropriate, safe and cost-effective drug therapy. Step Therapy encourages the use of therapies that should be tried first, before other treatments are covered, based on clinical practice guidelines and cost-effectiveness.
If your doctor prescribes a brand-name drug for the treatment of an ongoing condition, you will be required to try a medically equivalent but lower-cost alternative to the drug first. You will be contacted before implementation of Step Therapy with a list of the alternative drugs available. After you review the list, you or your pharmacist may contact your doctor to approve the change. If your doctor does not authorize the switch to the preferred drug, the request will be clinically reviewed and you will be informed of the outcome.
Review the CVS Caremark Value Formulary with your doctor if you are being treated for an ongoing condition. Your doctor will help you determine whether your treatment plan can include a generic alternative or, if not available or tolerated, a high-quality preferred brand-name drug included in the Formulary.
Dispense as Written (DAW) Provision
Sometimes, your doctor may determine that it is medically necessary for you to take the brand-name version of a drug, even if a generic version is available. If so, your doctor would write "DAW" at the bottom of the prescription. This means that your prescription must be filled with the brand-name version of the medication.
If you use a DAW prescription and receive a drug's brand-name version, you will be required to pay the brand copayment plus the cost difference between the brand and generic drug. If you are unable to take a generic equivalent drug for clinical reasons (e.g., you are allergic to the generic filler), your physician can appeal. If your appeal is approved, you can take the brand-name drug without paying the differential.
CVS Caremark Resources and Savings
CVS Caremark offers innovative online solutions at www.caremark.com, using a secure, encrypted web environment for transactions and information to empower you to make cost-effective and informed health care decisions. Online features include:
  • fast and convenient mail service for new prescriptions and online refills;
  • expedited new prescription mail service orders with Fast Start;
  • your prescription history;
  • tools that allow you to check for lowest-price options;
  • Ask-a-Pharmacist and Customer Care to answer your questions;
  • information about drug interactions with other drugs, vitamins and foods; and
  • health information about specific conditions through Self-Care Centers.
Go to www.caremark.com/register to get started. It's a fast, free and easy way to make the most of your prescription drug coverage.