Prescription Drug Coverage

PRESCRIPTION DRUG COVERAGE

Choose Your Prescription Drug Coverage

You have two choices for prescription drug coverage. Both options cover the same medicines and have the same copay for generic drugs. They both have the same formulary — which is the list of covered preferred medications. The difference in the plans is the amount you pay out of each paycheck, and the coinsurance (the amount you pay when you get your prescription) for preferred and non-preferred* medications. rx

How It Works

The pharmacy benefits work different depending on which medical plan option you have selected: 

  • UHC Choice 2500:
    • You pay the FULL COST of your prescription drugs until you reach your deductible. 
    • After you pay your deductible, your insurance benefits kick in, and you pay the copay or coinsurance amount shown in the charts below. 
  • Quantum Care 750 and UHC Choice 1000: 
    • You pay the copay and coinsurance amounts shown below. 

 

Type of Prescription

Low Rx

High Rx

Retail: 30-day supply

Mail Order1: 90-day supply

Retail: 30-day supply

Mail Order1: 90-day supply
Generic3 $10 copay $20 copay $10 copay $20 copay
Preferred 40% ($20 minimum and $150 maximum per prescription) 40% ($40 minimum and $300 maximum per prescription) 25% ($20 minimum and $100 maximum per prescription) 25% ($40 minimum and $200 maximum per prescription)
Non-Preferred* (Drugs Not on the Value Formulary) 50% ($40 minimum and $300 maximum per prescription) 50% ($80 minimum and $600 maximum per prescription) 40% ($40 minimum and $300 maximum per prescription) 40% ($80 minimum and $400 maximum per prescription)

Quantum Care 750 and UHC 1000 Medical and Rx Out-of-Pocket Maximum2

$6,850 individual / $13,700 family

UHC Choice 2500 
Medical and Rx Out-of-Pocket Maximum

$6,750 individual / $13, 500 family (you pay the full cost of your prescription drugs until you reach your deductible)

*Applies only when an exception approval has occurred.

1 Up to a 90-day supply. Mail order is required for maintenance medications on the third time you fill it. Or you may purchase a 90-day supply at the retail pharmacy at Texas Health Dallas, Texas Health Plano, Texas Health Infusion Pharmacy, or any CVS pharmacy. Otherwise you pay double the retail charge.

2 Maximum combined for retail and mail-order prescriptions. Prescription drug annual out-of-pocket maximum is combined with medical annual out-of-pocket maximum. Co-pays for generic drugs, as well as coinsurance for drugs, apply toward the out-of-pocket maximum.

3 In order to have coverage for prescription drugs in certain drug classes, you must try a generic drug first (see Benefits Handbook for additional information).

Download the CVS/Caremark app to scan prescriptions for refills, check and compare prescription drug prices, find a pharmacy in network, and more! Caremark

Maintenance Medications

A mail order is required for maintenance medications on the third time you fill the prescription. You are required to refill maintenance medications with a 90-day supply through Caremark’s mail order program, at the Texas Health Dallas, Plano or Arlington Cancer Center retail pharmacies, or at your local CVS or Target pharmacy. Otherwise, you will pay double the retail charge after the second time you fill the prescription.

Medical with Clinical Requirements

Certain medications have requirements that must be met before the plan provides coverage.

  • Prior Authorization: This means that your doctor must contact CVS/Caremark and confirm that a specific medication meets plan guidelines for covering your condition
  • Step Therapy with Post-Step Prior Authorization: You must try a lower-cost alternative before a higher-cost medication will be covered. If you have a unique medical situation where the lower-cost alternative doesn’t work well for you, your doctor must contact CVS/Caremark and confirm that a specific medication is clinically necessary for your condition.
  • Quantity Limit: The plan limits the amount of a specific medication that you can fill in a 30-day or 90-day period. If you have a unique medical situation that requires you to exceed the limit, your doctor can contact CVS/Caremark and confirm that a higher quantity is clinically necessary for your condition.

You can find a full list of covered drugs along with any specific criteria at caremark.com.

Online Tools

  • Formulary List: Each calendar quarter, Caremark updates the formulary list. Before you fill a prescription, check to be sure the medication is on the formulary list.
    • Texas Health uses Caremark’s Value Formulary, but our specific pharmacy plan does exclude some drugs shown on this formulary list, such as obesity drugs like Wegovy. For a full list of excluded drugs, please review Texas Health’s benefit handbook.
  • Other Features: Using caremark.com, you can order prescription refills, set refill reminders, check drug costs, check the status of your prescription order, check your pharmacy coverage, research drug information, view your prescription history, locate a pharmacy near you, view valuable health information, and send an email message to Caremark Customer Care if you have questions.

Transform Diabetes Care

The Transform Diabetes Care (TDC) program can assist with lifestyle choices, overall health, your medications, and preventive screenings. Support in this program is ongoing and includes:

  • Information about ordering and using your new connected devices
  • Coaching and support calls when needed from a nurse to help you stay on track
  • Communication with your doctor (only with your permission) to share results

If you take diabetes medications or are already enrolled in a diabetes program, you’ll automatically be enrolled in TDC.

Helpful Information