People’s bank

St. Mary Medical Center

Caremark consistently strives to provide you with the highest quality prescription benefits program available. Caremark offers
a network of over 54,000 pharmacies in the United States for your retail prescriptions, including CVS, Eckerd, Kinney, Kroger,
Publix, Revco, Rite Aid, Stop and Shop, Walgreen’s, Wal-Mart, and Winn-Dixie.
Retail Pharmacy / Specialty Drug Program*
CVS / Home Delivery**
Prescriptions limited to a 30 day supply Prescriptions limited to a 90 day supply

Specialty Home Delivery is recommended for all Specialty Drugs; prescriptions limited to a 30 day supply.
Home Delivery is required for each medication after an initial retail prescription and two refills.
Maximum Allowable Cost:
If a brand medication is dispensed when a generic is available, you will pay the generic copay plus the difference in
cost between the brand and the generic.
Covered Medications:
Rx Required - no copay - Iron supplements ( Ages 1 and younger), Fluoride supplements (Ages 6 and younger), Aspirin (ages 45 and older) & Folic Acid (Women ages 55 and younger) -100 units per fill, generic only Insulin, Disposable blood/urine glucose/acetone testing agents, Needles/Syringes, Lancets, Alcohol swabs Tobacco Cessation-Rx required - No copay for generic Nicotine replacement products, including Nicotine patch, gum & lozenges. Also covers generic Zyban or Chantix – no copay Annual limit of 2 “cycles of treatment”- total 168 day supply Exclusions:
Cosmetic medication – (Anti-wrinkle agents, Hair growth / removal, etc., ) – Retail discount only Infertility medications – Retail discount only Contraceptives Pharmacy Management Programs:

Specialty Guideline Management - Program enables Caremark to coordinates with prescribers and members
throughout treatment to help ensure medication is appropriate, safe and is being used effectively. High Performance Generic Step Therapy - Steers members to more cost effective first-line generics and
provides coverage for one preferred select brand in most classes. The preferred select brand is determined by clinical effectiveness based on FDA approved indications, lowest net cost and/or shortest remaining patent life. For some classes, such as the PPI class where sufficient generics are available, a generic trial is required before any single source brand is covered. Prior Authorizations (PA) - Some drugs require Prior Authorization in order to be covered. Your physician
must call 1-888-413-2723 to obtain approval for a period of up to one year. Below is a list of some of those drugs requiring PA to be covered:  Anabolic steroids More information is available through to help you manage your prescription drug program. You
will be able to locate a pharmacy, order mail service refills, track mail service orders, and ask questions. For
additional information contact Caremark at 800-966-5772.
Carrier: CHE1 Group: 0023 & 0223 – 500M


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