Prescription Plan with the PPO Medical Plan

When you enroll in the GW PPO, you are automatically provided with prescription drug coverage through CVS Caremark. You have access to prescription medications through both retail pharmacies and a mail-order program.

Plan Highlights

Under the prescription plan, generic, brand formulary and brand non-formulary drugs will be paid by fixed percentage of the total cost each time you fill a prescription. Please review the list of medications currently considered “Brand, Formulary”, as well as generic equivalents or alternative drugs on the formulary. For more information about the plan, see the Benefits Guide for Faculty & Staff (PDF). 

• Under the prescription plan medications will be paid by fixed percentage of the total cost each time you fill a prescription, with caps in place to limit the amount you will spend on a prescription (referred to as a maximum). For more information, see the 2025 Benefits Guide for Faculty & Staff (PDF).
• Any time you receive a prescription, ask your doctor if a generic option of the drug is available, and whether it’s right for your condition. Doing so can save you hundreds of dollars.
• You may use your Health Care Flexible Spending Account (HCFSA) to pay for your prescriptions.
• To compare medication costs at participating pharmacies, please use the "Check Drug Cost & Coverage" tool by logging into your account at www.caremark.com.

Please review the list of medications currently considered “Brand, Formulary”, as well as generic equivalents or alternative drugs on the formulary.

Prescription Plan Features/Programs

Understanding Prescription Drug Tiers

A drug formulary is a list of medications published by CVS Caremark. Medications on the list fall into one of the following three categories:

1. Generic Drugs: A generic medication is an FDA-approved drug, composed of virtually the same chemical formula as a brand-name drug. Generics are the least expensive category of medications.

2. Brand, Formulary Drugs: If a generic medication is not available for your condition, your doctor may prescribe a brand-name medication. Brand, Formulary Drugs have been evaluated by physicians and pharmacists at CVS Caremark and are deemed the most cost-effective means of treating a specific condition. Brand, Formulary Drugs covered at a slightly higher cost to you than generic drugs, but at a lesser cost than Brand, Non-Formulary Drugs.

3. Brand, Non-Formulary Drugs: In the event that you require a prescription medication that is neither Generic nor on the Brand, Formulary Drug list, you will pay the highest out-of-pocket cost for a Brand, Non-Formulary Drug.

4. Specialty Drugs: These are prescription medications that require special handling, administration or monitoring. These drugs are used to treat complex, chronic and often costly conditions. All specialty medications must be filled through CVS Specialty. The PPO prescription benefit also includes PrudentRx for specialty medications. This program is designed to lower your out-of-pocket costs. Members must enroll in the PrudentRx program to access $0 copay benefits. Formulary exclusions will supersede this list. If a participant’s specialty medication is not on the PrudentRx list, then the brand formulary or brand non-formulary plan design will apply.

CVS Caremark Maintenance Choice Program

If you have a condition that requires ongoing prescription medication, you will receive the lowest total copay possible by requesting that your doctor provide a prescription for a 90-day supply of your medication. Below are the options available to you under the Maintenance Choice Program:

1. Fill your prescription via mail order (90-day supply mailed to them)
2. Fill your prescription via retail store that participates in the program (pick up 90-day supply at participating pharmacies)
3. Opt-out* and continue to pick up 30-day supply at in-network pharmacy

If choosing Option 1 or 2, to fill your 90-day prescription:

• Mail Order Service - Learn more about this option by clicking here.
• Select Retail Pharmacies - Login at Caremark.com/pharmacylocator, enter your zip code and filter by "90-day supply" to find a participating pharmacy near you (e.g., CVS, Kroger, Costco).

*To opt-out of maintenance choice and continue filling a 30-day supply at your local in-network pharmacy or for other questions about this program, please call 1-877-357-4032. If you do not opt out, and you continue filling your medications at a retail pharmacy after the initial three 30-day fills, you will be responsible for 100% of the medication's cost.

Diabetes Management Program

Many condition management programs take a one-size-fits-all approach based on principles of population health. CVS’s Transform Diabetes Care focuses on a highly personalized approach, customizing support based on a participant's risk profile.

Transform Diabetes Care is a free program that helps manage diabetes and overall health. It offers personalized health coaching, guidance on healthy lifestyle plans, and reminders for screenings. The program can assist with lifestyle choices, medication management, and preventive screenings. The CVS Medication-Nutrition Management program, a part of TDC, provides support from a team of clinicians, including a registered dietitian, to help develop a personalized nutrition plan. Program features include:

• Highly personalized support from Certified Diabetes Care Nurses.
• Two vouchers that can be used for comprehensive diabetes visits at MinuteClinic locations, or virtually, at no out- of-pocket cost, including A1C checks. These can be downloaded from the Health Optimizer app.
• A meter that best suits your condition. Test strips and lancets will be available at $0 out-of-pocket cost.
• Access to digital tools within the health optimizer, including coaching on nutrition planning, blood glucose testing, and medication management, as well as reminders and alerts tailored to the individual.