CVS/Caremark Plan Begins Jan. 1, 2016! Prescription Drug Benefits (Full-Time Actives)

You must be enrolled in basic health insurance through the NYC Employee Health Benefits Program (NYC HBP) to be eligible for prescription drug benefits under supplemental health insurance. Prescription drug benefits are available through CVS/Caremark for yourself and your eligible dependents. The program covers most FDA-approved drugs that require a prescription. Over-the-counter medications are not covered. The amount you pay for a prescription depends on a number of factors:

  • whether your prescription is filled with a generic drug when one is available
  • whether your prescription is filled with a drug that is included on the CVS/Caremark formulary
How Much You Pay for a
Covered Prescription Drug* 
 Retail Pharmacy
(up to a 30-day supply)
CVS/Caremark Mail
or CVS Pharmacy
(90-day supply)
 First Three FillsEach Subsequent Refill 
Generic 20% ($5 minimum) 35% ($5 minimum) 20% ($10 minimum)
Preferred Formulary 20% ($15 minimum) 35% ($15 minimum) 20% ($30 minimum)
Non-Preferred formulary 20% ($30 minimum) 35% ($30 minimum) 20% ($60 minimum)

*When the Welfare Fund’s annual drug expenditure for an individual member reaches $10,000, the member’s drug co-pay (for the first three fills) will increase from 20% to 50%. At the $15,000 level, the member co-pay increases to 80%. Please See the Details Tab for the complete description of co-pay rates above the $10,000 level.

If you fill a prescription at a participating pharmacy and show your ID card, you will pay only a co-pay at the time of purchase. If you use a non-participating pharmacy or do not show your CVS/Caremark ID card, you may have to pay the full retail amount and submit a CVS/Caremark claim form for reimbursement. For mail order go to the CVS/Caremark website or use the Mail Service Order Form.

If you do not want to participate in the Welfare Fund CVS/Caremark drug plan and you are enrolled in CIGNA, HIP Prime POS or GHI HMO under the basic health insurance program, you may choose instead to purchase prescription drug coverage from your basic health insurance carrier. If you elect this option, you will receive a stipend from the Welfare Fund to help cover the cost of your prescription drug coverage.

This page includes only highlights of your drug benefits. See the Details Tab for more information.

Create a PDF of:

Plan participants must be enrolled in a basic health plan to be eligible for the CVS/Caremark Prescription Drug Program.  

Participating members will receive a CVS/Caremark prescription drug card unless they elect to purchase an optional drug rider through certain basic health programs. Those who elect a rider over the card should refer to the stipend section below. Please note that the CVS/Caremark Prescription Drug Program restricts coordination of benefits with other drug coverage.

CVS/Caremark Prescription Drug Program

Scope of Benefit

The plan covers most drugs that legally require a prescription and have FDA approval for treatment of the specified condition. Drugs available without a prescription, classified as "over the counter" (OTC), are not covered regardless of the existence of a physician's prescription.The Welfare Fund program through CVS/Caremark encourages utilization of (a) generic equivalent medications, (b) selected drugs among clinical equivalents.

  • If a generic equivalent medication is available and you or your physician chose it, you pay the standard co-payment for a generic drug. If you choose a brand name drug (either preferred or non-preferred) when a generic is available, you will pay the brand name drug's co-paymentplusthe difference in cost between the generic drug and the brand name drug.
  • CVS/Caremark has determined a list of drugs that treat medical conditions in the most cost-efficient manner. This list, or formulary, is regularly reviewed and updated by physicians, pharmacists and cost analysts. In order to encourage formulary compliance, the program assesses a higher co-payment on prescriptions filled with non-formulary drugs.
  • Home delivery (mail-order) or use of a CVS pharmacy is encouraged as a less costly way to fill prescriptions for long-term (maintenance) drugs. After an initial fill and a two re-fills of any prescription at a local pharmacy, higher levels of co-payment are assessed for continued use of the retail pharmacy.

Co-payment

A co-payment is the part of the drug cost that is paid by the plan participant. Co-payments are based on the category (generic, formulary and non-formulary) and place of purchase(retail pharmacy or mail-order pharmacy).

How Much You Pay for a
Covered Prescription Drug* 
 Retail Pharmacy
(up to a 30-day supply)
CVS/Caremark Mail 
or CVS Pharmacy
(90-day supply)
 First Three FillsEach Subsequent Refill 
Generic 20% ($5 minimum) 35% ($5 minimum) 20% ($10 minimum)
Preferred Formulary 20% ($15 minimum) 35% ($15 minimum) 20% ($30 minimum)
Non-Preferred Formulary 20% ($30 minimum) 35% ($30 minimum) 20% ($60 minimum)

* On July 1, 2014, the maximum benefit limit was lifted in compliance with the Affordable Care Act. Under the new benefit, the member will continue to pay a 20% co-pay until the cost to the Fund reaches $10,000. If the annual plan expenses are between $10,000 and $15,000, the member's co-pay will be 50%.

For Annual Plan Expenditures
Between $10K and $15K
 Retail Pharmacy
(up to a 30-day supply)

CVS/Caremark Mail 
or CVS Pharmacy
(90-day supply)

 First Three FillsEach Subsequent Refill 
Generic 50% ($5 minimum) 60% ($5 minimum) 50% ($10 minimum)
Preferred Formulary 50% ($15 minimum) 60% ($15 minimum) 50% ($30 minimum)
Non-Preferred Formulary 50% ($30 minimum) 60% ($30 minimum) 50% ($60 minimum)

If the annual plan expenses exceed $15,000, the member's co-pay will become 80%.

For Annual Plan Expenditures Over $15K
 Retail Pharmacy
(up to a 30-day supply)
CVS/Caremark Mail 
or CVS Pharmacy
(90-day supply)
 First Three FillsEach Subsequent Refill 
Generic 80% ($5 minimum) 90% ($5 minimum) 80% ($10 minimum)
Preferred Formulary 80% ($15 minimum) 90% ($15 minimum) 80% ($30 minimum)
Non-Preferred Formulary 80% ($30 minimum) 90% ($30 minimum) 80% ($60 minimum)

Non-Covered or Restricted Drugs

The program does not cover the following:

  • Fertility drugs
  • Growth hormones
  • Needles and syringes
  • Experimental and investigational drugs
  • PICA drugs
  • Over the counter drugs (i.e., not requiring a prescription)
  • Diabetic medications (refer to your NYC Health Benefits Plan carrier, ie., GHI, HIP, etc.)
  • Cosmetic medications
  • Therapeutic devices or applications
  • Charges covered under Workers' Compensation
  • Medication taken or administered while a patient in a hospital, rest home, sanitarium, extended care facility, convalescent hospital, nursing home or similar institution.
  • Shingles vaccine
  • Weight Management drugs

The following drugs are covered with limitations:

  • Drugs for erectile dysfunction up to an annual maximum reimbursement of $500, with a maximum of 18 tablets every 90 days.
  • Smoking cessation drugs up to an 84-day supply

Reimbursement Practices

Prescriptions filled at participating pharmacies will require presentation of a valid drug card. The co-payment must be met in order to acquire medication.

Prescriptions filled at non-participating pharmacies or without presenting a drug card may require payment in full. In such cases, CVS/Caremark will honor a Direct Reimbursement Claim for payment, but only to the extent of the amount that would have been paid to a participating pharmacy, adjusted for co-payment and deductible.

Using Mail Order

To use mail order, participants may register on the CVS/Caremark website or use the Mail Service Order Form. Physicians may call 1-866-209-6177 for instructions on how to FAX a prescription.

Standard shipping and handling is free; express delivery is available for an added charge.Temperature-sensitive items are packaged appropriately, but special measures may be necessary if there are delivery and receipt issues at an additional cost to the member.

Special Accommodations

Travel or Vacation

If a larger-than-normal supply of medication is required, a participant may contact CVS at least three weeks in advance so that appropriate arrangements can be made with the prescription drug plan.

Eligible dependent children away at school

If an eligible dependent child is away at school, a separate card may be made available for that child by contacting the Fund. The initial card is issued at no cost but a payment of $10.00 is required each time a card is re-issued. Prescriptions filled in other manners will require the student to pay the full cost of the prescription and submit a claim for direct (partial) reimbursement.

How to Contact CVS/Caremark

Call Customer Service at 1-866-209-6177 for

  • Location of Pharmacies
  • Direct Reimbursement
  • Eligibility issues
  • Mail Order Forms

Visit the CVS/Caremark website for:

  • Interactive Pharmacy Locator
  • Claim Form Download 
  • Mail-order tracking
  • Formulary Drug Listing

Non-CVS/Caremark Drug Coverage

PICA for Express Scripts members

There are some drugs for which participants do not use the CVS/Caremark card, but instead use another card, not issued by the Welfare Fund. For eligible full-time active participants, Injectable and Chemotherapy medications are available only through the PICA program, which is sponsored by the N.Y. City Employee Health Benefits Program, and-at the time of this writing-administered by Express Scripts. The N.Y. City Employee Health Benefits Program (212-306-7200) should be consulted for further detail and updates. Eligible individuals will be issued a drug card for PICA coverage.

Stipend for Rx coverage in lieu of CVS/Caremark

Eligible full-time active participants who wish to opt out of the Welfare Fund drug plan may purchase a drug rider through their basic health carrier if their carrier is CIGNA, HIP Prime POS, or GHI HMO. This may be elected at the time of employment or during any open enrollment period through the city of New York. The plan participant will receive a stipend to offset cost.The current stipend is:

  • Individual: $300 per year
  • Family: $700 per year

Payment is made within 45 days of the end of a calendar year. If rider coverage was only in effect part of the year reimbursement will be pro-rated. The Fund office will provide claim forms on request.

Members who participate in a drug rider plan through a basic health carrier will automatically be dropped from the Welfare Fund drug plan.