PrudentRx Copay Program FAQs

The PrudentRx Copay Program combines an innovative specialty copay plan design strategy and improved member experience to help optimize savings from non-needs based manufacturer copay cards and reduce member costs. The program allows members to pay $0 OOP for all specialty medications on the plan’s Exclusive Specialty Drug List dispensed by CVS Specialty, as well as select high-cost specialty LDDs, regardless if a copay card is available.

A third-party sponsored copay card is a direct-to-consumer incentive manufacturers offer to promote brand loyalty and the use of brand-name pharmaceutical products. The copay card can also be used to lower OOP costs for eligible patients.

Yes. There are two types of copay card programs offered:

 1. Non-Needs Based: This type is offered to commercially insured population. These copay cards may be used regardless of a patient’s financial status and do not require any form of eligibility or qualification to get assistance. 

2. Needs-Based/Patient Assistance Program (PAP): This type is offered by a manufacturer sponsor or independent non-profit to help patients who meet specific financial eligibility criteria. These patients may be uninsured, underinsured or may have been denied coverage by commercial plans. This type of assistance is not part of The PrudentRx Copay Program, but your specialty pharmacy may be able to help you if needed in connecting with these types of programs.

No. Federal law prohibits Medicare Part D, Medicaid beneficiaries and other federally funded plans from using these incentives.

You will continue to fill prescriptions as usual. The pharmacy or PrudentRx enters the copay assistance details when submitting the claim, and the copay assistance is applied toward the member cost share by the pharmacy.

Most copay cards are designed for more expensive specialty prescription drugs. PrudentRx will be able to tell you if your medication has a copay card program.

Deductibles are established as a means of cost sharing with your plan sponsor while a Maximum Out Of Pocket (MOOP) is the most you will pay during a policy period. The help you get from a copay card is provided by the copay card sponsor and does not reflect any actual OOP cost the member pays. Given that deductibles and Maximum Out Of Pockets are intended to capture true member costs only and not third-party assistance through a copay card (not including monthly premium payments), the update to accumulators are made to reflect only the amount a member actually pays.

No. Members do not need to participate in a copay card program. However, it is strongly encouraged to help reduce a member’s final OOP cost. If you opt out of using assistance or enrolling in The PrudentRx Copay Program, you are responsible for the 30% copay.

While most employers will implement the program across all plans, some may only do so for individual plans offered. To see if the plan you are currently enrolled in is participating in the program, please contact your Pharmacy Benefit Manager (PBM), CVS Caremark®, at the Customer Care number on the back of your member identification card or work with your human resource representative.

If you or an existing member have filled specialty medications, PrudentRx will send out a letter on behalf of the client and follow up with the member with a phone call. When a new prescription is received and processed by CVS Specialty, there is an administrative process to capture the claim and reach out to the member. From there, CVS Specialty will offer to transfer the member to PrudentRx or will provide the member with the PrudentRx contact information to enroll.

PrudentRx will help the member enroll in the manufacturer copay card program and get the necessary manufacturer copay (where applicable). This process usually takes less than ten minutes but may take up to five to seven days depending on the manufacturer process. The member will be informed throughout the process. PrudentRx will provide CVS Specialty confirmation that the member has completed enrollment and will contact CVS Specialty to schedule delivery.

Specialty copay cards are monitored on a regular basis to quickly respond to any changes. If a specialty copay card is no longer being offered and you are enrolled in the program, your final OOP cost will remain $0.

If you are enrolled in The PrudentRx Copay Program, your final OOP cost is $0.

If you do not want to be enrolled in the program, or if you do not confirm that you are enrolled in any copay assistance as required by a manufacturer, you will need to pay the full 30% copay for specialty medications that are eligible for The PrudentRx Copay Program. You may still use available copay cards or manufacturer assistance for these medications; however, those dollars will not be applied toward your annual deductible or Maximum Out Of Pocket.

Drug classes like HIV: these drugs will be included in the program if the Plan includes them as Exclusive Specialty. If they are open network or excluded as specialty products, they will be excluded from the PrudentRx program.

LDDs not available at CVS Specialty: select high-cost specialty LDDs have been incorporated into the program to expand program capabilities and meet client needs. These LDDs will continue to be dispensed via the established authorized pharmacies; however, we’ve coordinated with PrudentRx to confirm appropriate communication with those pharmacies to ensure members enrolled in the program receive these medications for a final $0 OOP. These LDDs are included on the PrudentRx Drug List. LDDs not included on the PrudentRx Drug List will remain excluded from the PrudentRx program until further notice. They may still be covered under the Plan as they are today with the appropriate member cost share.

Under the ACA, non-grandfathered, self-funded plans are not required to cover EHB; however, they are subject to annual Maximum Out Of Pocket limits. Covered benefits that fall outside the authorized definition are deemed non-EHB and need not be counted toward a member’s Maximum Out Of Pocket limit. In The PrudentRx Copay Program, non-EHB medications may still be covered by the plan; however, the 30% copay will not apply toward the Maximum Out Of Pocket. Please note: If you participate in The PrudentRx Copay Program, you will have a $0 OOP for drugs that are deemed non-EHB.

You need to go through the usual PA and appeals process before the medication is processed by CVS Specialty. While your PA is being reviewed, you can still confirm enrollment or opting out of The PrudentRx Copay Program. If your medication is not approved, your doctor may be able to prescribe a different medication for you. If you’re enrolled in the program, your OOP cost for an eligible specialty medication prescribed by your doctor and dispensed by CVS Specialty will be $0.

No. Even if you originally opted out of the program, you can contact PrudentRx to confirm you’d like to enroll in the program at any time. However, only those prescriptions filled after you have enrolled in The PrudentRx Copay Program will have a $0 OOP cost.

Yes. A member can enroll a minor dependent on their behalf.

No. Only specialty medications on your plan’s PrudentRx Drug List are eligible for the program and will have a $0 OOP cost. Please note: PrudentRx does not decide what medications are covered (on the client’s formulary) by the plan. Please call CVS Caremark Customer Care at the number on the back of your member ID card if you have questions about coverage.

Your plan has chosen CVS Specialty as the exclusive provider to dispense most specialty medications. If you fill an exclusive specialty medication outside of CVS Specialty, it will not be covered. Please call CVS Caremark Customer Care at the number on the back of your member ID card for help. Please note: should you be allowed an override to process the medication outside of CVS Specialty, you will be responsible for the 30% copay.

Once you are enrolled, PrudentRx will only call you to help enroll you in new copay card programs for your medications. You won’t receive another call from PrudentRx until it is time to renew. If you have any questions, you can always call PrudentRx at 1-800-578-4403.

If you start a new specialty medication, PrudentRx will contact you to start any copay assistance available for the new medication or you can call PrudentRx at 1-800-578-4403.

PrudentRx offers direct member support. Specially trained customer care advocates are available Monday through Friday from 8 AM to 8 PM ET. Spanish-speaking advocates and language services are available.