Citi Benefits Handbook
Specialty Medication Copayment Assistance
High Deductible Plan with HSA
Specialty medications may qualify for third-party copayment assistance programs that could lower your out of-pocket costs for those products. In many of these programs, your copay/coinsurance may be reduced for a 31-day supply of your specialty medication. Please note that any assistance received will not count towards your annual deductible or total out-of-pocket maximum you are required to pay related to Plan coverage.
CVS Specialty® will help you receive third-party copayment assistance for these particular prescribed drugs. Enrollment in the program is voluntary. If you choose not to participate in the copayment assistance programs, you will be required to pay the full prescription drug copay/coinsurance amount, which will count towards your annual deductible or total out-of-pocket cost where applicable.
Eligibility for third-party copay assistance programs is dependent on the applicable terms and conditions of a particular program. The terms and conditions of such programs are subject to change. This program is offered as part of your Plan's exclusive specialty pharmacy network with CVS Specialty. Please note that the specialty drugs eligible for specialty copayment assistance programs is subject to change.
To enroll, call CVS Caremark Customer Care at 1 (844) 214-6601. The CVS Specialty Care Team will coordinate the filling of your specialty medication prescription and enroll you in the available manufacturer's copay assistance program. Once enrolled in the program, your medication will continue to be filled through CVS Specialty Pharmacy, your specialty mail service provider.
Additionally, the designated pharmacy will enter the copay assistance details when submitting the initial and subsequent claims and the copay assistance benefit will be applied by CVS Specialty to all related prescriptions.
You may continue to use copay cards to help reduce your copay/coinsurance. However, any resultant reduction in your copay/coinsurance amount from the use of the card will not apply towards your annual deductible or out-of-pocket maximum that you are required to pay related to plan coverage.
Choice Plan and In-Network Only Plan – PrudentRx Copay Program
If you are enrolled in the Choice Plan or the In-Network Only Plan, you and your family will be eligible to participate in the PrudentRx Copay Program for certain specialty medications from drug manufacturers. PrudentRx reduces your cost share for eligible medications thereby reducing your out-of-pocket expenses. The PrudentRx Copay Program assists members by helping them enroll in manufacturer's copay assistance programs.
If you are not enrolled in the PrudentRx program, medications in the specialty tier will be subject to a 30% coinsurance on specialty medications that are eligible for the Prudent Rx program, and the amount may not count towards the deductible or out-of-pocket maximum. However, enrolled members who get a copay card for their specialty medication (if applicable) will have a $0 out-of-pocket coinsurance for their prescriptions covered under the PrudentRx Copay Program.
If you currently take one or more medications included in the PrudentRx Program Drug List available at https://www.prudentrx.com/SpecialtyDrugList/ (this list is subject to change), you will receive a welcome letter and phone call from PrudentRx that provides specific information about the program as it pertains to your medication, including how to enroll. If you take one or more eligible specialty medications, you must speak with a representative from PrudentRx to register for the specialty medication copay assistance program.
If you or a covered family member are not currently taking, but will start a new medication covered under the PrudentRx Copay Program, you can reach out to PrudentRx directly or they will contact you the day after your applicable prescription is filled through CVS Specialty Pharmacy, so you can take full advantage of the PrudentRx program. PrudentRx can be reached at 1 (800) 578-4403 to address any questions regarding the PrudentRx Copay Program. The CVS Specialty pharmacy may also transfer you to PrudentRx when filling your prescription.
The amount that a participant is required to pay for certain specialty medications that are not subject to special treatment under the Affordable Care Act (not determined to be "essential health benefits" related to prescription drugs) will not count towards the Plan's out-of-pocket maximum, regardless of the payment source (the participant or the manufacturer copayment assistance program). A list of specialty medications that are not considered to be "essential health benefits" is available at https://www.prudentrx.com/SpecialtyDrugList/.
For questions about the PrudentRx Copay Program, please call 1 (800) 578-4403.