This plan requires you to pay the full cost of your prescriptions until you meet your deductible.
2025 prescription cost shares| Prescription type | In-network | Out-of-network |
|---|
| Retail (up to 90-day supply) | 20% after deductible | Members can submit a claim form for potential reimbursement, up to the lower of the CVS price or purchase price. Approved claims apply to the in-network deductible and out-of-pocket maximum. |
| Mail order (up to 90-day supply) | 20% after deductible | Not covered |
| Specialty (up to 30-day supply) | 20% after deductible | Not covered |
Estimate drug costs for the HDHP
Note: Actual costs may differ from the estimates provided by this tool due to pharmacy location and prescription quantity. Always check with your pharmacy to confirm. Current members should log in to their CVS Caremark account for customized pricing.
Preventive medications
Preventive medications listed on the no-cost share medication list are covered at 100% by the plan. These include items such as generic contraceptives, bowel preps, statins, and tobacco cessation products.
Medications on the HDHP preventive Rx list are covered with a 20% coinsurance and no deductible.
This plan has flat dollar copays and an out-of-pocket maximum for in-network prescriptions separate from the medical plan. For 2025, it is $7,050 per member/$11,700 family maximum. If you request a brand drug with a generic version, you must pay the generic copay plus the cost difference between the brand and generic.
2025 retail and mail order copays
In-network:| Service | Retail (up to 30-day supply) | Retail (31–90-day supply) | Mail order (up to 90-day supply) |
|---|
| Tier 1 (Generic) | $8 | $20 | $20 |
| Tier 2 (Preferred Brand) | $25 | $62 | $62 |
| Tier 3 (Non-Preferred Brand) | $45 | $112 | $112 |
Out-of-network:
- Retail: 50% coinsurance (plus amounts above the network’s discounted price)
- Mail order: Not covered.
Estimate drug costs for the PPO $500 plan
Note: The prices shown in this tool are estimates and may vary based on your pharmacy and prescription quantity. Always confirm the final cost with your pharmacy. Current members can log in to their CVS Caremark account for personalized pricing
Preventive medications on the No Cost Share Medication List are covered by the plan 100%.
2025 specialty drug copays
Up to 30-day supply through Archimedes. When using copay assistance, only the actual amount you pay counts towards your prescription out-of-pocket maximum.
In-network:
- Tier 1 (generic): $20
- Tier 2 (Preferred Brand): $62
- Tier 3 (Non-Preferred Brand): $112
Out-of-network: Not covered.
This plan has flat dollar copays and an out-of-pocket maximum for in-network prescriptions separate from the medical plan. For 2025 it is $7,400 per member/$13,000 family maximum.
2025 retail and mail order copays
In-network:| Service | Retail (up to 30-day supply) | Retail or mail order (31–90-day supply) |
|---|
| Tier 1 (Generic) | $10 | $25 |
| Tier 2 (Preferred Brand) | $25 | $60 |
| Tier 3 (Non-Preferred Brand) | $75 | $180 |
Out-of-network:
- Retail: 50% coinsurance (plus amounts above the network’s discounted price
- Mail Order: Not Covered
Estimate drug costs for the resident plan
Note: Prices in this tool are estimates only and may differ depending on the pharmacy and quantity of medication. Always check with the pharmacy for your actual cost. Current members can view personalized cost estimates by logging in to their CVS Caremark account.
Preventive medications on the No Cost Share Medication List are covered by the plan 100%.
2025 specialty drug copay
Up to 30-day supply through Archimedes. If you use copay assistance, only the actual amount you pay counts towards your prescription out-of-pocket maximum.
