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Contact us
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.
Want more information about the formulary, including updates and our search tool? Just visit our formulary and updates page.
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.
Members can get $30 per month (per member) toward some OTC medications and supplies.
Specialty medications
Specialty medications
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:
- Cancer
- Hemophilia
- Immune deficiency
- Multiple sclerosis
- Rheumatoid arthritis
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.
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
By phone: Call 1-724-978-0110
By fax: 877-526-8823
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:
E-prescribe
By phone: Call 1-877-408-9742 or 1-800-237-2767
By fax: 1-800-323-2445
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
By phone: Call 1-877-218-4499
By fax: 215-827-1934
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:
E-prescribe
By phone: Call 1-215-471-4000
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:
E-prescribe
By phone: Call 1-855-265-8008
By fax: 844-812-6227
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).
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 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.
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.
Medical directors are available to discuss denials based on medical necessity. Providers can reach the Pharmacy Services Department by calling 1-866-638-1232 and following the prompts. Medical directors are available during and after normal business hours (subject to reasonable limitations of availability). Adverse benefit determinations can be discussed from the time of denial until the internal grievance process or internal adverse benefit determination process commences.