CVS Caremark FAQs

• What are the prescription drug co-pays?
• Are the formulary drugs the same at mail service and retail network pharmacies?
• My medication was removed from the formulary list. How will my medication be filled in the future?
• My medication was removed from the formulary list. How will my physician(s) know about this change?

Prescription Drug Co-pays

• I understand there is an annual maximum out-of-pocket (MOOP) of $1,000 per individual or $2,000 per family. How is this applied and tracked? Does this maximum include co-pays for physician office visits and prescriptions?
• Do I need to save my receipts in order to be sure I don't go beyond the $1,000/$2,000 MOOP?

Generic Prescribing Program

• Why is MSU changing our prescription coverage to more strongly encourage use of generic medications whenever possible?
• What is the savings to MSU by making this change?
• What if I am currently taking a brand name maintenance medication that has a generic available and would be covered by the Generic Prescribing Program?
• What if I choose to keep taking the brand name medication?
• What if my physician wants me to continue taking a brand medication?
• Who pays for the exception request?
• What happens if the exception request is approved?
• Will I be required to change from the pharmacy I currently use?
• What happens if there is not a generic equivalent for my medication in medication classes other than the ones listed?
• Is it up to me to remind my physician every visit that I need a generic medication?
• What happens if I go to fill my prescription at the pharmacy and they charge me a higher fee because there is a generic available?
• Is it really true that all medicines in a drug class work the same?
• If my physician files an Exception Request and it is approved by CVS Caremark for a Level I or Level II drug, how long is the exception valid?
• What happens when a drug moves from Level II to Level I?
   

• I understand changes in Michigan State University's prescription drug program administered through CVS Caremark includes a drug formulary or drug list. What is that?
• What is a "4-Tier Drug Program"?
• Does the CVS Caremark Custom Drug List include the same drugs for both CVS Caremark mail service and retail network pharmacies?
• Can I continue to purchase a brand drug even though it is not on the CVS Caremark Custom Drug List?
• Are drugs not on the CVS Caremark Custom Drug List still covered?
• Are there drugs not covered at all under MSU's prescription drug plan?
• My medication was removed from the CVS Caremark Custom Drug List. How will my medication be filled in the future?
• My medication was removed from the CVS Caremark Custom Drug List. How will my physician(s) know about this change?
• Why do drugs on the CVS Caremark Custom Drug List change?
• How can my physician or I find out what drugs are on the CVS Caremark Custom Drug List?

• Are diabetic supplies covered under the MSU prescription drug program?
• Are glucose monitors covered under the MSU prescription drug program?

• Do I need to enroll in the prescription drug plan if I change health plans?
• Can I receive additional I.D. cards?

• What is the difference between brand drugs and generics?
• How long does it take for my prescription to arrive by mail?
• What if I need to take my maintenance medication right away?
• Can I purchase long-term maintenance medications at a retail pharmacy?
• How many refills can I get at a retail pharmacy?
• How do I get my mail service medication if I live somewhere else during the winter?
• How do I switch my prescription from a non-participating pharmacy to a CVS Caremark participating pharmacy?
• What if I show my card and the pharmacist indicates I am not and/or my dependents are not eligible for the prescription drug plan?
• How does my child, who is a student away at college, obtain prescription drugs?

*Generic Prescribing Program

Brand-name drugs available under the plan may be affected by the Generic Prescribing Program. This program includes the following provisions:

Level I of the Program: If you or your dependent selects a brand-name prescription drug for which a direct generic equivalent is available, in addition to the generic copay, you will also need to pay the difference in cost between the brand-name drug and the direct generic equivalent that could have been chosen.

Level II of the Program: For certain therapeutic classes of drugs, if you or your dependent choose a brand-name drug for which generic options exist within the same therapeutic class of drugs, in addition to the generic copay, you will also need to pay the difference in cost between the brand-name drug and the average cost of the generic alternatives available in the therapeutic class. The therapeutic classes of drugs impacted by Level II of the program include osteoporosis, nasal steroids, high cholesterol, allergies, sleep problems and GERD/acid reflux.  (Effective 7/1/11, migraine medications, blood pressure drugs (ARBs and ACEs) and acne antibiotics will be part of this class of drugs.)

Excluded-Drugs: Under Level I and Level II of the program include: Premarin, Lanoxin, Dilantin, Coumadin and Synthroid.

Exception-Process: In rare cases, some people are unable to use a certain generic drug for documented medical reasons. There is an exception process through CVS Caremark that physicians can use to request an exception if there is a documented medically necessary reason that a patient needs to take a brand medication instead of a generic. There will be no additional charge to you or your physician to file an exception (however, your physician may charge you a fee or copay for their time). 

• Exception Request Form

** “Bio-Tech/Specialty Drugs” will be limited to 34-day supplies (90-day supplies will no longer be available for these drugs). In addition, effective 7/1/11 these types of drug prescriptions can only be filled by the CVS/Caremark Specialty Pharmacy. Rheumatoid arthritis prescriptions are an exception and can continue to be filled in 90-day supplies.

My medication was removed from the formulary list. How will my medication be filled in the future?
You can still receive a non-formulary drug, however, you will be required to pay the higher co-pay for the drug.

My medication was removed from the formulary list. How will my physician(s) know about this change?
Physicians are notified of these changes by CVS Caremark with an updated personalized patient profile for their patient files. You should also talk with your physician at your next appointment about options that may be more cost effective.

I understand there is an annual maximum out-of-pocket (MOOP) of $1,000 per individual or $2,000 per family. How is this applied and tracked? Does this maximum include co-pays for physician office visits and prescriptions?
The annual maximum out-of-pocket (MOOP) limits of $1,000 per individual and $2,000 per family only apply to the prescription drug program. This MOOP does not apply to physician office visits or other co-pays under the health plans. CVS Caremark will track this. When an individual or family MOOP limit is reached, CVS Caremark notifies the pharmacist that no further co-pays are required for that calendar year. We recommend keeping personal records for verification.

Do I need to save my receipts in order to be sure I don't go beyond the $1,000/$2,000 MOOP?

CVS Caremark's administration system will track all co-pays for you and any family members and apply them toward the MOOP. You may wish to keep the receipts for your records particularly if you participate in the Health Care Spending Account program.

Why is MSU changing our prescription coverage to more strongly encourage use of generic medications whenever possible?
Generic medications usually cost substantially less than the brand name counterpart. A generic medication is the same as its corresponding brand name medication in dosage, safety, strength, how it is taken, quality, performance, and intended use. Before approving a generic medication, the U.S. Food and Drug Administration (FDA) requires many rigorous tests and procedures to assure that the generic medication can be substituted for the corresponding brand name medication. By law, a generic medication must contain the identical amounts of the same active ingredient(s) as the brand name product. For medication classes included in the Generic Prescribing Program, generic medications that are in the same class but are not identical to the brand name medication have not been shown to be any less effective than their brand name counterparts.

What is the savings to MSU by making this change?
The estimated annual savings to the MSU prescription plan is over $3.5 million. Saving money on the health plan allows the University to spend that money on other priorities while continuing to provide a health care plan.

What if I am currently taking a brand name maintenance medication that has a generic available and would be covered by the Generic Prescribing Program?
To pay the lowest cost, you need to switch to a less expensive generic medication.

What if I choose to keep taking the brand name medication?
You may choose to continue to take a brand name medication if desired. However, you will have higher (and potentially much higher) out-of-pocket costs, including:

• The usual co-pay ; as well as
• A “surcharge” representing the full difference in cost between the generic medication and the brand name medication, which can be tens or even hundreds of dollars per month.

What if my physician wants me to continue taking a brand medication?
Your physician may file for an exception request and must demonstrate that it is a medical necessity. If the exception request is denied, you can still choose the brand name medication but you will have to pay more for it.

Who pays for the exception request?
The cost of the exception request will be charged to the MSU prescription plan, not the member or physician. However, your physician may charge for an office visit for completion of necessary documentation to file the exception request.

What happens if the exception request is approved?
If the exception request is approved, your pharmacy coverage for that medication will be covered exactly as it is today.

Will I be required to change from the pharmacy I currently use?
No.

What happens if there is not a generic equivalent for my medication in medication classes other than the ones listed?
Your co-pay for that medication will be covered exactly as it is today.

Is it up to me to remind my physician every visit that I need a generic medication?
To ensure that you pay the lowest cost for your medications, you should always ask your physician if a generic alternative is available for the class of medication being prescribed and indicate that you want the generic medication. If the physician indicates that you need to take the brand name medication, you should inform the physician that his or her office will need to file an exception request. Also remember that your patented brand name drug today may be available as a generic tomorrow.

What happens if I go to fill my prescription at the pharmacy and they charge me a higher fee because there is a generic available?
You can ask your pharmacist to call your physician’s office and ask if a generic medication can be substituted. If not, you can choose to purchase the brand name prescription, or refuse the prescription and call your physician to ask if they can send a prescription to your pharmacy for a generic alternative.

Is it really true that all medicines in a drug class work the same?
A generic medication in the same drug class produces virtually identical benefits as a brand name medication in the same class. In the rare instance when your physician or you feel this is not the case, there is process available to request an exception.

If my physician files an Exception Request and it is approved by CVS Caremark for a Level I or Level II drug, how long is the exception valid?
All Level I and Level II exception requests that are approved by CVS Caremark are valid for ONE year from the date of approval.  Your physician must file a NEW exception request each year if it is medically necessary for you to continue taking the brand medication. 

What happens when a drug moves from Level II to Level I?
When a Level II drug becomes available in a direct generic equivalent, it will move to a Level I drug.  The Level II exception approval for that drug will EXPIRE on the date the Level II drug becomes available in a direct generic (Level I).  For example, we currently anticipate Lipitor will have a direct generic equivalent available late 2011.  On the date the direct generic equivalent becomes available; all Level II exception approvals will be voided.  Should you wish to continue taking the therapy, a new Level I exception will need to be filed on your behalf by your doctor with CVS Caremark.  Again this will apply whenever a Level II drug moves to a Level I drug.

Other Questions
The MSU Benefits office can answer general questions about the program, but cannot answer questions about specific drugs you take and what those drugs will cost under the program. If you have questions about your specific prescription drugs, contact CVS Caremark at 1-800-565-7105.