Prescription Drug Coverage
If you enroll in any of Penn’s medical plans, prescription drug coverage is provided for you and your enrolled dependents. The prescription drug plan is administered by CVS/caremark for all medical plans. Coverage differs, however, depending on which medical plan you select.
You will need to work with your provider to ensure that the medication being prescribed is on the approved formulary list. Please note: the charts below for the 2025-2026 plan year only apply to medications on the approved formulary list. If the medication does not appear on the approved formulary list, and a participant does not select an alternative, the drug will not be covered.
You can fill your prescriptions at CVS pharmacies as well as a wide network of non-CVS pharmacies. The online Pharmacy Locator Tool can help you find a network pharmacy in your area.
Maintenance medication and the 90-day retail pick-up option are only available at CVS pharmacies. You may also use the CVS/caremark Mail Service pharmacy to receive your maintenance medications at your address of choice.
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Coverage and Cost
The way your prescription drug coverage works is based on which medical plan you select. If you enroll in the Aetna High Deductible Health Plan (HDHP), your coverage will be structured differently than Penn’s other medical plans.
No matter which medical plan you select, the cost for prescription drug coverage is built into your medical coverage rate.
Use the drug cost estimators listed below to check the costs of your prescription under various Penn medical plans.
- Non-HDHP
- Aetna HDHP Individual Plan before deductible is met
- Aetna HDHP Family Plan before deductible is met
- All Aetna HDHP Plans after deductible is met
No-Cost Preventative Services
Penn’s health plans now offer certain preventive service benefits— such as medicines, supplements, health-related products or vaccines— at no cost to you. This means you don’t have to pay a copay* or coinsurance, even if you
haven’t met your deductible. These no-cost benefits are part of the Affordable Care Act (ACA).
Click here to download a list of no-cost preventative services.
Other rules and limits may apply. Please contact your health plan provider for a complete coverage and list details.
PennCare/Personal Choice PPO, Aetna Choice POS II, and Keystone/AmeriHealth HMO Plans
When you’re enrolled in any of these plans, the amount you pay for prescriptions depends on the type of medication and how you buy it:
- When you go to a retail pharmacy, you pay less if you use a participating in-network pharmacy.
You can use the CVS/caremark Mail Service for long-term maintenance medications. The mail order program offers several advantages including home delivery, three-month supplies, and lower minimum and maximum coinsurance amounts.
- If you can use a generic drug, you save money: not only do you pay a lower coinsurance, but that lower coinsurance is a percentage of a lower base price.
The table below shows how you can save significantly in two areas by making wise purchasing decisions:
- Get 90-day supplies of maintenance drugs If you use a retail pharmacy for more than three 30-day fills of a maintenance medication, you’ll pay double the normal coinsurance amount as well as double the minimum and maximum copays. If, however, you get 90-day supplies, your coinsurance and copays remain the same no matter how many refills you get.
- Use generic drugs if possible If you choose to get a brand-name drug instead of an available generic equivalent, you pay a percentage of the cost of the brand-name version PLUS the cost difference between the brand name and the generic—and this difference doesn’t count toward the minimums and maximums.
Plan Year (2025-2026)
PennCare/PersonalChoice PPO • Aetna Choice POS II • Keystone/AmeriHealth HMO
Coinsurance, Minimum and Maximum Payment
| Generics**** | Preferred Brand**** | Non-Preferred Brand**** | |
|---|---|---|---|
| 30-day supply (any network retail pharmacy) | 10% ($7.50 min, $20 max) | 15% ($15 min, $75 max) | 30% ($25 min, $100 max) |
| Generics**** | Preferred Brand**** | Non-Preferred Brand**** | |
|---|---|---|---|
| 30-day supply (any network retail pharmacy, up to 3 fills)** | 10% ($7.50 min, $20 max) | 15% ($15 min, $75 max) | 30% ($25 min, $100 max) |
| 30-day supply (any network retail pharmacy, after 3 fills)** | 20% ($15 min, $40 max) | 30% ($30 min, $150 max) | 60% ($50 min, $200 max) |
| 90-day supply (Select Participating Pharmacies* or CVS Mail Service) To find a participating pharmacy, visit Caremark.com/PharmacyLocator | 10% ($15 min, $40 max) | 15% ($30 min, $150 max) | 30% ($50 min, $200 max) |
| Specialty | |
|---|---|
| Non-Prudent Rx Drugs | Applicable Cost Share based on above drug tier |
| Prudent Rx Drugs | 30% coinsurance if not enrolled in Prudent Rx $0 member cost share if enrolled in Prudent Rx |
| Specialty Medication must be filled at CVS Specialty or a Penn Pharmacy |
| Annual Out-of-Pocket Maximum |
|---|
| $2,000 individual / $6,000 family* |
*When a generic is available but the pharmacy dispenses the brand per your request or your physician’s, you will pay the cost difference between the brand and generic plus the brand copay. The cost difference between the brand and generic will not apply towards the Maximum Out of Pocket.
**After three 30-day fills, you will pay double the normal coinsurance amount, as well as double the minimum and maximum coinsurance payments. You can save money by filling a 90-day supply at select participating pharmacies or CVS/Caremark Mail Service. To find a participating pharmacy, visit www.Caremark.com/PharmacyLocator.
***Specialty drugs must be filled at CVS/Specialty Pharmacy or one of the following PENN pharmacies: HUP Pharmacy, PENN Presbyterian Medical Center, PENN Outpatient, PENN Medicine at Radnor, PENN Presbyterian Apothecary, PENN Med University City Apothecary, PENN Home Infusion Therapy, and PCAM Pharmacy.
****The rates only apply if your drug is on the approved formulary list.
Plan Year (2024-2025)
PennCare/PersonalChoice PPO • Aetna Choice POS II • Keystone/AmeriHealth HMO
Coinsurance, Minimum and Maximum Payment
| Generics | Brand Name without Generic Equivalent | Brand Name with Generic Equivalent* | Speciality | |
|---|---|---|---|---|
| 30-day supply (any network retail pharmacy) | Coinsurance 10% /$20 max |
Coinsurance 30% /$100 max |
Coinsurance 10%+ $15 min/$100 max |
N/A |
| Generics | Brand Name without Generic Equivalent | Brand Name with Generic Equivalent* | Speciality | |
|---|---|---|---|---|
| 30-day supply (any network retail pharmacy, up to 3 fills)** | Coinsurance 10% /$20 max |
Coinsurance 30% /$75 max |
Coinsurance 10%+ $15 min/$100 max |
20% $20 min/$100 max |
| 30-day supply (any network retail pharmacy, after 3 fills)** | Coinsurance 20% /$40 max |
Coinsurance 60% /$150 max |
Coinsurance 20%+ $30 min/$200 max |
N/A |
| 90-day supply (any network retail pharmacy or mail order) | Coinsurance 10% /$40 max |
Coinsurance 20% /$100 max |
Coinsurance 10%+ $30 min/$200 max |
20%; $20 min/$100 max |
| Annual Out-of-Pocket Maximum |
|---|
| $2,000 individual / $6,000 family* |
* For brand names with a generic equivalent, you pay a percentage of the brand name cost PLUS the cost difference between brand name and generic. The cost difference between brand name and generic does not count toward the minimums and maximums.
** After three 30-day fills, you will pay double the normal coinsurance amount, as well as double the minimum and maximum coinsurance payments. You can save money by ordering 90-day supplies through the CVS/caremark Mail Service program or at CVS pharmacies.
*** Specialty drugs can be dispensed at CVS Pharmacies, CVS Specialty Mail Service, pharmacies at the Hospital of University of Pennsylvania, Penn Presbyterian Medical Center, Pennsylvania Hospital and Penn Medicine Radnor.
Aetna High Deductible Health Plan (HDHP) with Health Savings Account (HSA)
When you’re enrolled in this plan, the amount you pay for prescriptions depends on whether your prescription is a preventive generic drug or something else. Generic preventive drugs are not subject to the deductible; for all other drugs, you must reach your deductible before the plan covers any costs. Please note: 90-day prescription fills are only allowed at CVS retail pharmacies or by CVS mail order.
Plan Year (2025-2026)
| Annual Deductible* | $1,650 individual/$3,300 family |
| Annual Out-of-Pocket Maximum* | $3,300 individual/$6,600 family |
| Generic Drugs (any retail or mail order, maintenance or non-maintenance) 90-day supply can be filled at Select Participating Pharmacies* or CVS mail service | 10%, coinsurance after deductible |
| Preferred Brand Name Drugs (with or without generic equivalent, any retail or mail order, maintenance, or non-maintenance) 90-day supply can be filled at Select Participating Pharmacies* or CVS mail service | 10% coinsurance after deductible |
| Non-Preferred Brand Drugs (generic or brand, with or without generic equivalent, any retail or mail order, maintenance, or non-maintenance) 90-day supply can be filled at Select Participating Pharmacies* or CVS mail service | 15% coinsurance after deductible |
| Generic Preventative Drugs | 10% coinsurance; deductible waived |
| Specialty*** |
|---|
| 10% coinsurance; Prudent Rx program does not apply |
Plan Year (2024-2025)
| Annual Deductible* | $1,600 individual/$3,200 family |
| Annual Out-of-Pocket Maximum* | $3,200 individual/$6,400 family |
| Preventive Generic Drugs (any retail or mail order, maintenance or non-maintenance) | 10%, no deductible |
| Preventive Brand Name Drugs (with or without generic equivalent, any retail or mail order, maintenance or non-maintenance) | 10% after deductible |
| Non-Preventive Drugs (generic or brand, with or without generic equivalent, any retail or mail order, maintenance or non-maintenance) | 10% after deductible |
* Amounts you pay toward medical and behavioral health/substance abuse also count toward the deductible and out-of-pocket maximum. After the out-of-pocket maximum is reached, all covered prescription drugs are paid at 100%.
Creditable Coverage Notice
Read the Creditable Coverage Notice, which describes Penn’s prescription drug coverage and your options under Medicare’s prescription drug coverage. It will help you decide whether you want to join a Medicare drug plan.