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Just call us as 1-800-279-1878 (TTY: 711). We’re here for you Monday through Friday, 8 AM to 6 PM.
We cover the prescription medications on the formulary (or drug list). FAMIS members may have small copays. You can download the list or search the formulary online to see updates.
If a medication isn’t 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 us. We can check it for you.
Some members have both Medicare (Part A and/or Part B) and Medicaid coverage. This means they’re dual eligible. In this case, we have a separate formulary for dual-eligible members.
Does your patient take medication for a chronic (long-term) condition? If so, they’re covered for up to a 90-day supply. To become eligible, they must’ve received two 30- to 34-day medication fills in the past 120 days. If they received more than a 34-day supply with Aetna Better Health® of Virginia, they don’t need to meet the two-fill requirement. If a medication isn’t on the formulary, they can get coverage for up to a 34-day supply.
You can see a preview of the list of the medications for January 2023 (subject to change).
Members can get coverage for OTC medications on the formulary (PDF) | 2023 formulary (PDF) or dual-eligible formulary (PDF) 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
Not sure what’s covered? Just call us. Be sure to have the member’s list of medications ready. We can check to see if they’re on the list.
If you prescribe a specialty medication, members can fill it at any pharmacy in our network. Not all pharmacies carry these medications, so members may need to find a specialty pharmacy. They can also fill their specialty medication through CVS Specialty® pharmacy. Members can call 1-800-237-2767 (TTY: 711) with questions.
Some conditions that need specialty medications include:
- Immune deficiency
- Multiple sclerosis
- Rheumatoid arthritis
You’ll want to get PA for these medications. Fax the PA form to 1-855-799-2553 Or you can call us to ask for PA. You can also include any medical records that may help with the review of your request.
More pharmacy info
Learn about everything from step therapy to prior authorization (PA).
If a member needs prior authorization (PA) for a medication, you can fill out a pharmacy PA form. You can find the PA form and guidelines on our pharmacy PA page.
When members need medication, they’ll:
- Ask you to make sure the medication is on the 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.
Members can fill prescriptions at any pharmacy in our network. We can’t cover medications they fill at other pharmacies.
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:
Members can go to the Member Portal and sign in or register (for new users). Then, they’ll choose: Tasks, Pharmacy services, CVS and Start 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 contact us.
Members can send the form, along with their prescription, to:
PO Box 2110
Pittsburgh, PA 15230-2110
Members can also call CVS Caremark at 1-855-271-6603 (TTY: 711). They can call 24 hours a day, 7 days a week. If they agree, CVS Caremark will call you to get a prescription.
The step therapy program requires certain first-line drugs, such as generic drugs or brand-name drugs, to be prescribed before approval of specific, second-line drugs. The formulary identifies these drugs as “Step Therapy (ST).”
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 PA form to 1-855-799-2553. Or you can call us to ask for PA. You can also include any supporting medical records that may help with the review of your request.
Need info about medication recalls? Just call the U.S. Food and Drug Administration (FDA) at 1-888-463-6332. Or visit the drug recalls page on the FDA website.
What is the Patient Utilization Management and Safety (PUMS) Program?
It’s a care coordination program that helps ensure members are getting and using services in a safe way. Members choose one in-network pharmacy to fill their prescriptions and stick with it. If members are having trouble choosing a pharmacy, case management can help them.
What happens if the member’s pharmacy is closed?
A different pharmacy can call the pharmacy help desk and get the member a one-time override for emergency prescriptions. Members may want to choose a pharmacy that has extended hours or is open 24 hours a day, 7 days a week.
What happens if the member no longer wants to use the pharmacy?
The member can contact their care coordinator to talk about other options to meet their needs.