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We cover the prescription medications listed in our preferred drug list (formulary) at no extra cost to members. If your patient needs medication, you’ll want to check the list for covered medications, step therapy requirements, quantity limits and updates. You can download the list or check it online.
If a medication isn’t listed on the formulary, you can:
Prescribe a similar one that’s on the list
Get prior authorization (PA) for coverage
Still not sure if we cover a specific medication? Just call 1-855-232-3596 (TTY: 711). We can check it for you.
Members can get coverage for OTC medications on the preferred drug list (formulary) when they:
- Meet any added requirements (for some medications)
- Get a prescription from their provider
- Fill their OTC prescription at a pharmacy in our network
If members have both Medicare and Medicaid coverage, they’re dual eligible. In this case, they can check the OTC wrap formulary for dual-eligible members (PDF).
Not sure what’s covered? Just call us at 1-855-232-3596 (TTY: 711). Be sure to have the member’s list of medications ready. We can check to see if they’re on the list.
Medications and refills
Medications and refills
When members need medication, they’ll:
- Ask you to make sure the medication is on our preferred drug list (formulary)
- Take their prescription to a pharmacy in our network
- Show their plan member ID card at the pharmacy
Remind members to check with you at least five days before running out of medication. They understand that you may want to see them before prescribing refills.
When members take maintenance medication for an ongoing health condition, they can get it by mail. We work with CVS Caremark® to provide this service at no extra cost. Each order is checked for safety. And members can speak with a pharmacist anytime on the phone.
To get started, members will need their:
- Plan member ID card
- Mailing address, including ZIP code
- Provider’s first and last name and phone number
- List of allergies and other health conditions
- Original prescription from their provider (if they have it)
Mail service makes it easy
Members and providers can call CVS Caremark at 1-855-271-6603 (TTY: 711), 24 hours a day, 7 days a week. They’ll explain which medications can be filled with CVS Caremark Mail Service Pharmacy. CVS Caremark will also contact you for a prescription and mail the member’s medication. Members can sign up for mail service:
With an order form
Members will ask you to write a prescription for a 90-day supply with up to one year of refills. Then, they can fill out a mail service order form (English PDF) | (Spanish PDF). Or we can mail them a form. They just need to call us at 1-855-232-3596 (TTY: 711).
Members can send the form, along with their prescription, to:
PO Box 2110
Pittsburgh, PA 15230-2110
CVS Specialty® pharmacy offers medications for conditions like:
- Immune deficiency
- Multiple sclerosis
- Rheumatoid arthritis
Local pharmacies may not carry these medications, which need PA. You can call 1-855-232-3596 (TTY: 711) to ask for PA. Or you can fill out a pharmacy prior authorization form. Then, fax it to 1-855-296-0323.
CVS Specialty pharmacy provides many services, such as:
- Delivery of specialty medications to the member’s home or provider’s office
- Counseling on medications and conditions
- Coordination of care with the member and their provider
- The option for members to drop off their prescription and pick up their medication at any CVS Pharmacy® location
- The ability to talk to a pharmacist 24 hours a day, 7 days a week
Members can call CVS Specialty pharmacy at 1-800-237-2767 (TTY: 711) with questions. They can also find answers to questions about CVS Specialty pharmacy (PDF).
Step therapy and quantity limits
The step therapy program requires certain first-line drugs, such as generic drugs or formulary brand drugs, to be prescribed before approval of specific, second-line drugs. The formulary identifies these drugs as “STEP.”
Certain drugs on the formulary have quantity limits. The formulary identifies these drugs with the letters “QLL.” Quantity limits are based on:
- FDA-approved dosing levels
- Nationally established, recognized guidelines related to each condition
Need to ask for an override for step therapy or a quantity limit? Just fax the pharmacy prior authorization form to 1-855-296-0323. You can also include any supporting medical records that may help with the review of your request.