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Pharmacy benefits

We cover a wide range of prescription and over-the-counter (OTC) medications to help keep our members as healthy as they can be

 

Pharmacy benefits (PDF)

 

Contáctenos

Questions? Just call Provider Relations at 1-866-638-1232 (TTY: 711). We're here for you Monday through Friday, 8 AM to 5 PM.

Covered medications

Covered medications

Prescription medications

 

We cover the prescription medications on the formulary with or without small copays. 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 using our online search tool

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? We can check it for you. Just call 1-866-638-1232 (TTY: 711). We're here for you Monday through Friday, 8 AM to 5 PM. 

 

Formulary (PDF)

 

Want more information about the formulary, including updates and our search tool? Just visit our formulary and updates page.  

Formulary and updates

OTC medications

 

Members can get coverage for OTC medications on the 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

 

Not sure what’s covered? Just call us at 1-866-638-1232 (TTY: 711). Be sure to have the member’s list of medications ready. We can check to see if they’re on the list.

 

$30 OTC benefit

 

Members can get $30 per month (per member) toward some OTC medications and supplies. 

 

More about member pharmacy benefits

Medicamentos especializados

Medicamentos especializados

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. Some conditions that need specialty medications include:

 

  • Cáncer
  • Hemofilia
  • Immune deficiency
  • Esclerosis múltiple
  • Artritis reumatoide

You’ll want to get PA for these medications. Fax the PA form to 1-877-309-8077. Or you can call 1-866-638-1232 (TTY: 711) to ask for PA. You can also include any medical records that may help with the review of your request.

 

Members can call one of our preferred specialty pharmacies with questions.

 

Specialty drug list (PDF)

 

You can choose from a few ways to send specialty prescriptions to any of our preferred specialty pharmacies:  

 

AccuServ Pharmacy

 

Visit the AccuServ Pharmacy website for an enrollment form and other prescriber information. 

How to send specialty prescriptions:

 

  • E-prescribe   

 

Banks Apothecary 

 

Visit the Banks Apothecary website for an enrollment form and other prescriber information.

How to send specialty prescriptions:

 

  • E-prescribe   

  • By phone: Call 1-800-927-6703

  • By fax: 215-357-2129

 

CVS Specialty® Pharmacy 

 

Visit the CVS Specialty Pharmacy website for an enrollment form and other prescriber information.

How to send specialty prescriptions:

 

 

Einstein at Center One Pharmacy
 

Visit the Einstein at Center One Pharmacy website for an enrollment form and other prescriber information.

How to send specialty prescriptions:

 

  • E-prescribe   

 

Giant Eagle Pharmacy

 

Visit the Giant Eagle Pharmacy website for an enrollment form and other prescriber information. 

 

How to send specialty prescriptions:

  • E-prescribe   

  • By phone: Call 1-888-792-1552 or 1-440-356-3287  

  • By fax: 1-877-645-4142   

 

Sunray Drugs Specialty 

 

Visit the Sunray Drugs Specialty website for an enrollment form and other prescriber information. 

How to send specialty prescriptions:

 

  • By fax: 215-471-4001 

  

Value Specialty Pharmacy 

 

Visit the Value Specialty Pharmacy website for an enrollment form and other prescriber information.

How to send specialty prescriptions:

 

Are you a pharmacy interested in joining our preferred specialty pharmacy network? You can get the application process started today. Just email CVS Caremark®.

More pharmacy information

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 on their behalf. Or you can call us at 1-866-638-1232 (TTY: 711).

 

Pharmacy PA

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.

 

Find a pharmacy nearby

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:

 

Online

 

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 call us at 1-800-822-2447 (TTY: 711). We’re here for members Monday through Friday, 8 AM to 5 PM.

Members can send the form, along with their prescription, to:

CVS Caremark

PO Box 2110

Pittsburgh, PA 15230-2110 

 

By phone

 

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.”

 

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 1-877-309-8077. Or you can call 1-866-638-1232 (TTY: 711) to ask for PA. You can also include any supporting medical records that may help with the review of your request.

 

Step therapy guidelines (PDF)

 

More about PA

 

Need information 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.

Coming soon.

Our P & T Committee develops and reviews the formulary. The committee also reviews all clinical criteria for utilization management. All P & T changes are submitted to the Pennsylvania Department of Human Services (DHS) for review and approval prior to implementation. 

 

February 2020 (PDF)

 

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