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Contact us
Questions? Just call 1-855-676-5772
(TTY: 711). We’re here for you Monday through Friday, 8 AM to 5 PM.
Covered medications
Prescription medications
We cover the prescription medications on the 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 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 1-855-676-5772 (TTY: 711). We can check it for you.
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 1-855-676-5772 (TTY: 711). Be sure to have the member’s list of medications ready. We can check to see if they’re on the list.
More pharmacy information
Learn about everything from step therapy to prior authorization.
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 1-855-676-5772 (TTY: 711).
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:
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. Or we can mail them a form. They just need to call Member Services.
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. 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.
You can review the step therapy criteria (PDF) for drugs on the Medicare-Medicaid plan formulary.
Certain drugs on the formulary have quantity limits. 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: 844-242-0914.
Or you can call us to ask for PA. Just call 1-855-676-5772 (TTY: 711). You can also include any supporting medical records that may help with the review of your request.
More about PA
Some medically administered Part B drugs, like injectables or biologics, may have other requirements or coverage limits. That may include step therapy, where we require a trial of a preferred drug to treat a medical condition before covering another non-preferred drug.
Example:
If drug A and drug B both treat a medical condition, we may prefer drug A and require a trial of it first. If drug A does not work, we’ll then cover drug B. The listed preferred products should be used first.
Note: The step therapy requirement does not apply to patients who’ve already received treatment with the non-preferred drug within the past 365 days.
Find preferred drugs
You can check the list of preferred drugs for Medicare Part B.
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.