Rx coverage and plan requirements.
Find out what terms like formulary and prior authorization mean and how these requirements can affect your medication options.
Your plan’s formulary.
A formulary is your plan’s list of covered medications. The formulary is designed to help you get the medication you need at the lowest possible cost. While it doesn’t include every available medication, it includes options to treat most health conditions. When your doctor prescribes a formulary medication, you’ll pay your plan’s required copay or coinsurance at the pharmacy.
Frequently Asked Questions.
Your plan asks CVS Caremark® to monitor your list of covered medications and make changes when lower-cost, clinically appropriate options become available. There are often several medications, brand name and generic in some instances, available to treat the same condition. This could help save money for both you and your plan throughout the year. We’re committed to helping you get the medication you need at the lowest possible cost.
No. You always have the choice of continuing with your current medication, and your doctor always has the final decision on what medication is right for your condition. However, if you choose to continue taking your current medication, you should expect to pay the full cost. We encourage you to talk to your doctor about whether a covered medication will work for you. If your doctor thinks there is a clinical reason why one of these covered options won’t work for you, your doctor may be able to request prior authorization for coverage, depending on your plan. Refer to the Prior Authorization tab for more information.
To view the exact price you will pay for your medication, sign in or register at Caremark.com and use the Check Drug Cost tool. The CDC tool shows what the price would be at the time you check, and will not show future dated pricing. Remember—the savings really add up if you are taking a long-term medication for months or years at a time.
Not necessarily – the cost may vary by retail or mail service. To find out how much you’ll pay, and to see your lowest cost option for filling prescriptions, sign in or register at Caremark.com and use the Check Drug Cost tool.
The formulary for your plan applies to any prescriber, including those that work in a hospital. In many cases, there are several medications used to treat specific conditions and they may not all be covered depending on your plan design. Depending on your plan, your doctor may be able to request prior authorization. Refer to the Prior Authorization tab for more information.
Talk to your doctor and let them know that you’ll have to pay the entire cost. Ask if there is a covered medication that will work for you – if so, ask for a new prescription. Depending on your plan, your doctor may be able to request prior authorization for coverage. Refer to the Prior Authorization tab for more information.
Some plans share the cost between what is paid by insurance and what you are responsible for.
You may be able to save money by using an alternative or generic medication or by filling your prescription at a pharmacy in your plan’s network.
To see your lowest cost option for filling prescriptions, sign in or register at Caremark.com and use the Check Drug Cost tool. To find a pharmacy in your network, sign in or register at Caremark.com and use the Pharmacy Locator tool.
Usually, yes. Generics are typically the lowest cost option. The research, development and marketing of new medicines cost a lot of money. Companies that make generic medicines do not have to develop them from scratch, so it usually costs much less to make. Generic medicine manufacturers then pass the savings on to consumers. Lower cost does not mean lower quality. Companies that make generic medicine must show that their product performs the same as the brand-name.
There are some cases where the brand medication is covered and not the generic. Check your plan’s formulary or use the Check Drug Cost Tool to determine coverage.
To see how much you can save with generics, sign in or register at Caremark.com and use the Check Drug Cost tool.
We have a panel of independent experts (our Pharmacy & Therapeutics committee-P&T) who help us ensure that the drugs we cover will provide options for patients that are clinically appropriate and cost-effective. You always have the choice of continuing with your current medication, and your doctor always has the final decision on what medication is right for your condition. If your doctor thinks there is a clinical reason why one of these covered options won’t work for you, your doctor may be able to request prior authorization for coverage, depending on your plan. Refer to the Prior Authorization tab for more information.
Prior Authorization.
Prior Authorization.
Prior authorization (PA) is an extra layer of review that’s needed for some medications. If PA is required, your doctor will need to provide information on why they are prescribing this medication for you. Depending on the medication, your doctor may need to provide your diagnosis, results of lab tests, or other information from your medical record. Watch the video to learn more about PA, how the review process works, and what you can expect.
Rx coverage & prior authorizations
Making sure you have access to medications at the lowest possible cost is our priority. To help keep costs low, your plan covers a list of medications used to treat most conditions. This list is sometimes called your drug formulary. It's important to review this list with your doctor so they can try to prescribe an effective medication that's also covered by your plan. The easiest way to see which medications are covered is to sign into your Caremark.com account and review your plan info. You can also use our drug cost and coverage tool with your doctor to compare your options before you fill a prescription. If your doctor still prescribes a medication that isn't covered by your plan, then you may need prior authorization. This process ensures certain criteria is met before your plan will cover your prescription. There are a few reasons why a prior authorization might be required. The medication may be unsafe when combined with other medications you're taking, used only for certain health conditions, have the potential for misuse or abuse, or an effective alternative might be available. If your medication does require a prior authorization, you should speak with your doctor to see if an alternative is available. If not, then you or your pharmacist can ask your doctor to start a prior authorization. We’ll then work with your doctor to get additional information that will help us determine if the medication should be covered. The process can take several days and depends on how complete and quickly information is provided and reviewed. If approved, you can fill your prescription. If denied, you'll receive a letter and then you can, ask your doctor if there's another medication covered by your plan that may also work for you if you haven't already. Choose to pay for the medication yourself at a retail pharmacy, or you or your doctor can submit an appeal by following the steps in your letter. To learn more, visit our help center at Caremark.com
Prior Authorization.
Rx coverage & prior authorizations
Making sure you have access to medications at the lowest possible cost is our priority. To help keep costs low, your plan covers a list of medications used to treat most conditions. This list is sometimes called your drug formulary. It's important to review this list with your doctor so they can try to prescribe an effective medication that's also covered by your plan. The easiest way to see which medications are covered is to sign into your Caremark.com account and review your plan info. You can also use our drug cost and coverage tool with your doctor to compare your options before you fill a prescription. If your doctor still prescribes a medication that isn't covered by your plan, then you may need prior authorization. This process ensures certain criteria is met before your plan will cover your prescription. There are a few reasons why a prior authorization might be required. The medication may be unsafe when combined with other medications you're taking, used only for certain health conditions, have the potential for misuse or abuse, or an effective alternative might be available. If your medication does require a prior authorization, you should speak with your doctor to see if an alternative is available. If not, then you or your pharmacist can ask your doctor to start a prior authorization. We’ll then work with your doctor to get additional information that will help us determine if the medication should be covered. The process can take several days and depends on how complete and quickly information is provided and reviewed. If approved, you can fill your prescription. If denied, you'll receive a letter and then you can, ask your doctor if there's another medication covered by your plan that may also work for you if you haven't already. Choose to pay for the medication yourself at a retail pharmacy, or you or your doctor can submit an appeal by following the steps in your letter. To learn more, visit our help center at Caremark.com
Prior Authorization.
Prior authorization (PA) is an extra layer of review that’s needed for some medications. If PA is required, your doctor will need to provide information on why they are prescribing this medication for you. Depending on the medication, your doctor may need to provide your diagnosis, results of lab tests, or other information from your medical record. Watch the video to learn more about PA, how the review process works, and what you can expect.
Frequently Asked Questions.
Some prescription plans may require an extra level of approval for certain medications. This is called prior authorization, or PA, and it means that your doctor will have to provide additional information on why they are prescribing this medication for you. CVS Caremark reviews this information and, based on your plan, determines whether or not the medication will be covered. Watch the video to learn more.
Rx coverage & prior authorizations
Making sure you have access to medications at the lowest possible cost is our priority. To help keep costs low, your plan covers a list of medications used to treat most conditions. This list is sometimes called your drug formulary. It's important to review this list with your doctor so they can try to prescribe an effective medication that's also covered by your plan. The easiest way to see which medications are covered is to sign into your Caremark.com account and review your plan info. You can also use our drug cost and coverage tool with your doctor to compare your options before you fill a prescription. If your doctor still prescribes a medication that isn't covered by your plan, then you may need prior authorization. This process ensures certain criteria is met before your plan will cover your prescription. There are a few reasons why a prior authorization might be required. The medication may be unsafe when combined with other medications you're taking, used only for certain health conditions, have the potential for misuse or abuse, or an effective alternative might be available. If your medication does require a prior authorization, you should speak with your doctor to see if an alternative is available. If not, then you or your pharmacist can ask your doctor to start a prior authorization. We’ll then work with your doctor to get additional information that will help us determine if the medication should be covered. The process can take several days and depends on how complete and quickly information is provided and reviewed. If approved, you can fill your prescription. If denied, you'll receive a letter and then you can, ask your doctor if there's another medication covered by your plan that may also work for you if you haven't already. Choose to pay for the medication yourself at a retail pharmacy, or you or your doctor can submit an appeal by following the steps in your letter. To learn more, visit our help center at Caremark.com
You or your pharmacy can ask your doctor to start a PA. Then, your doctor can submit an electronic prior authorization request to Caremark. Information for providers about this process is available at www.caremark.com/epa.
Yes. You may pay more if you choose to pay the retail price for your prescription without using insurance.
Talk to your doctor about your treatment. If your doctor determines you should continue with your current medication, they may need to submit a new request for coverage.
Not yet. Once your doctor submits the request, it will be reviewed by CVS Caremark and a decision will be made. If the PA is approved, the medication will be covered. If the PA is denied, your medication will not be covered, and you will have to pay the entire cost if you continue to take that medication. To check the status of your prior authorization request, sign in or register at Caremark.com. You will then receive a letter of determination in the mail.
Yes. You and your doctor will be notified by letter of the approval or denial. You can check the status of your PA by signing in to your Caremark.com account and visiting Plan Benefits > Prior Authorization.
You have several options. You can ask your doctor if an alternative medication might work for you. You can choose to continue taking the medication and pay for it yourself. Or, you can submit an appeal by following the steps outlined in your denial letter.
An appeal request can take up to 15 business days to process. If your exception request is still denied after the appeal, a second level appeal could also take up to 15 business days to process. You and your doctor will each receive a notification in the mail for an appeal request and a second level appeal.
Quantity limits.
A quantity limit is the highest amount of medication covered by your plan for a period of time (for example, 30 tablets per month). Your plan will cover your medication up to the limit. Once the quantity limit is reached, you’ll have to pay the full cost of the medication. Quantity limits are sometimes used to help make sure a medication isn’t overused or to help save money for you and your plan.
Frequently Asked Questions.
Some medications are intended to be taken in limited amounts for a specific period of time. Your prescription plan may put a limit on the amount that will be covered. This is called a quantity limit. Once you reach the limit, you can continue to fill prescriptions, but your medication will not be covered and you will have to pay the entire cost. For certain medications, your plan may cover an additional amount after the limit is reached. If it is medically necessary for you to continue taking this medication after the limit is reached, your doctor can request prior authorization. If the request is approved, a greater amount of the medication will be covered.
Quantity limits are typically managed per fill however there may be times when products are limited for a period of time.
The limit only applies to the amount of medication your plan will cover. If you need more medication, you can choose to continue filling your prescription after the limit is reached, but you will have to pay the entire cost.
First, talk to your doctor about whether there’s an alternative medication without quantity limits that might work for you. For certain medications, your plan may cover an additional amount after the limit is reached. If it is medically necessary for you to continue taking this medication after the limit is reached, your doctor can request prior authorization. If the request is approved, a greater amount of the medication will be covered.
Yes, the limit only applies to the amount of medication your plan will cover. You can choose to continue filling your prescription after the limit is reached, but you will have to pay the entire cost.
Step therapy.
Step therapy is when your plan requires you to try an alternative medication (often lower cost) before “stepping up” to a medication that works to treat your condition in a similar way but may cost more. Once you try the alternative medication, you can choose to keep taking (if it works for you) or change back to your original medication.
Frequently Asked Questions.
Talk to your doctor about your treatment. If your doctor determines you should continue with your current medication, they can contact us to submit a prior authorization (PA) request for coverage. Refer to the Prior Authorization tab for more information.
Talk to your doctor. Ask them to prescribe the preferred option and take it for the required trial period. If it works, keep taking it. If not, you may be able to go back to the non-preferred medication. Note that both preferred and non-preferred medications may require a prior authorization.
Depending on your plan, your doctor may be able to request a prior authorization. It’s important to remember that medications considered formulary or preferred on your plan can sometimes require a PA. If the request is approved, the non-preferred medication will be covered.
No. Keep taking the preferred medication. Make sure you ask your doctor to write your prescriptions for the preferred medication when it’s time to renew.