Prescription Drug Benefits

Coverage for GW PPO Participants

When you enroll in the GW PPO, you are automatically enrolled in prescription drug coverage through CVS Caremark. You have access to prescription medications through both retail pharmacies and a mail-order program. Under the prescription plan, generic, brand formulary and brand non-formulary drugs are 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).

Coverage for GW HSP Participants

When you enroll in the GW HSP, you are automatically enrolled in prescription drug coverage through CVS Caremark. You have access to prescription medications through both retail pharmacies and a mail-order program. You must pay all out-of-pocket costs for prescription drugs until you meet your annual deductible. After you meet the deductible, you will be responsible for 20 percent in-network coinsurance until you reach the out-of-pocket maximum. You can use your HSA to pay for your prescriptions.

Under the GW HSP, preventive medications are covered at 100 percent (deductible and coinsurance do not apply). To review a list of preventive drugs, visit hr.gwu.edu/prescription-plan-health-savings-plan-hsp.

Note: Maintenance Choice provisions apply. After three 30-day retail fills, you will need to fill a 90-day prescription via CVS Retail or CVS Mail Order or contact customer service to opt-out and continue filling at your local pharmacy, in order to continue receiving the preventive medication at no cost.

PrudentRx for PPO and HSP Participants

PrudentRx for specialty medications is included in the GW PPO and HSP Pharmacy Benefit. This program is designed to lower your out of pocket costs by assisting you with enrollment in drug manufacturers discount copay cards/assistance programs. When enrolled in PrudentRx, your out of pocket cost will be $0* for medications included on the PrudentRx exclusive specialty drug list, which is updated monthly and posted on the Benefits website.

PPO participants: If you opt out, you will be responsible for the 30% coinsurance. Only the amount you pay out of pocket will apply toward your deductible/out of pocket maximums for essential health benefit medications.
HSP participants: If you opt out, you will be responsible for the 30% coinsurance. Only the amount you pay out of pocket will apply toward your out-of-pocket maximums for essential health benefit medications.

*HSP participants must meet their combined medical/prescription deductible before the out of pocket cost will be $0.

How to Enroll in PrudentRx

After enrolling in the GW PPO or HSP, you will be contacted via phone to enroll in PrudentRx at the time of your first specialty fill. You must complete any additional enrollment steps with PrudentRx to receive the $0 benefit.

IMPORTANT: 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.

For additional information, visit hr.gwu.edu/prudent.

Maintenance Choice Prescription Program for PPO and HSP Plans

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. You will have the option to fill this 90-day prescription at any CVS retail pharmacy or through CVS Caremark mail order. The number of 30-day fills for maintenance prescriptions at a retail pharmacy (including CVS) is limited to three.

After your third 30-day fill of a maintenance prescription, your medication will not be covered until you take one of two actions:

Move to a 90 day prescription filled at a CVS retail store OR via CVS Caremark mail order.
Or, opt out of the program. If you opt out, you can continue filling monthly at your local pharmacy but will forgo the savings and convenience opportunities associated with the program. Deductible/coinsurance applies.
To opt-out of maintenance choice and continue filling a 30-day supply at your local in-network pharmacy, please call 1-877-357-4032.

Next-Generation Transform Diabetes Care Program for the HSP and PPO Plans

GW will continue to offer CVS’s Next-Generation Transform Diabetes Care Program for 2024.

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

This program is designed to improve health outcomes and lower pharmacy costs through three key components: medication adherence, A1C control and lifestyle management. Program features include:

Highly personalized support from Certified Diabetes Care Nurses.
Two comprehensive diabetes visits at MinuteClinic locations, or virtually, at no out-of-pocket cost, including A1C checks. These can be downloaded from the CVS 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 CVS Pharmacy mobile app, including medication refill reminders, nutritional assessments, as well as the ability to refill prescriptions via two-way text messaging with your diabetes care nurse.

Note: Diabetic medications and supplies must be filled through CVS Retail or CVS Mail Order.

Tip: Check Drug Coverage Tiers

It’s a good idea to occasionally check up on your medications’ coverage tier (generic, brand formulary, brand non-formulary), as drugs can sometimes change tiers. To check a medication's coverage tier, call CVS Caremark at (877) 357-4032, visit caremark.com or download the CVS Caremark Mobile App.