Understanding the difference between your medical benefits and your pharmacy benefit through your Group Insurance Commission coverage

July 22, 2025

 

When it comes to how your medications are covered, it's important to know whether your prescription is handled through your medical benefit or your pharmacy benefit.

 

All Group insurance Commission (GIC) non-Medicare health insurance plans provide you with prescription drug coverage that is administered by CVS Caremark. Wellpoint is not responsible for CVS Caremark’s benefits or policies.

 

If you have any questions about your prescription drug benefits, contact CVS Customer Care number for GIC members at 877-876-7214.

 

To learn more about how your medical and pharmacy benefits differ, please continue reading below:

 

MEDICAL BENEFIT COVERAGE

 

Medications covered under your medical benefit are typically administered in a healthcare setting, such as a doctor's office, hospital, or outpatient clinic. Examples include:

  • IV infusions (like chemotherapy or biologics).
  • Injectable medications given during a provider visit.
  • Medications that require special handling or supervision.

 

How it works:

  • Billed as part of your medical insurance claim.
  • You may have co-pays, coinsurance, or meet a deductible under your medical plan.
  • Prior authorization may be required from Wellpoint.

 

PHARMACY BENEFIT COVERAGE

 

Medications covered through a pharmacy benefit are usually self-administered and picked up at or delivered by a retail, specialty, or mail-order pharmacy. Examples include:

  • Tablets or pills taken at home.
  • Self-injected medications (like insulin or GLP-1s for weight management).
  • Maintenance medications for chronic conditions.

 

How it works:

  • Managed by a Pharmacy Benefit Manager (PBM) like CVS Caremark.
  • You use your pharmacy insurance card to fill prescriptions.
  • Costs may include a copay, tiered pricing, or coinsurance.
  • Formularies (approved drug lists) may change, and prior authorization may be needed from CVS Caremark.

 

COVERAGE CHANGE FOR ZEPBOUND & GLP-1 MEDICATIONS

 

You may have heard about CVS Caremark’s decision to remove Zepbound from the CVS Caremark formulary, effective July 1, 2025.

 

For more information on the removal of zepbound from CVS Caremark’s formulary please visit the Group Insurance Commission’s FAQ page for impacted members.