There are important features you should be aware of. These include:
Who can write your prescription? A licensed physician or dentist, and in states allowing it, licensed/certified providers with prescriptive authority prescribing within their scope of practice must prescribe your medication.
Where you can obtain your prescription? You may fill the prescription at a CVS Health participating pharmacy, a non-network pharmacy, or through the CVS Health mail service prescription program for a maintenance medication.
- CVS Health participating (In-network) pharmacy: You may fill your prescription at any CVS Health participating pharmacy. To find a participating pharmacy near where you live, call CVS Health toll-free at 800-292-4182 or on the Internet at www.Caremark.com or through a link on our website at www.nrlca.org. You must show the pharmacy your Plan ID card (that includes the CVS Health logo) to receive the negotiated discount price. You pay the coinsurance and any deductible, if applicable, for your prescription. You do not need to file a claim when you use a CVS Health participating pharmacy and show your Plan ID card. The participating pharmacy will file the claim with CVS Health for you. Prescriptions you purchase at a CVS Health network pharmacy without using your ID card are at the full regular price charged by the pharmacy. If you do not show your ID card at a participating pharmacy, you will need to file a claim with CVS Health.
- Non-participating (Out-of-network) pharmacy: You may fill your prescription at any out-of-network pharmacy. You pay the full regular price for your prescription and then file a claim with CVS Health.
- CVS Health mail service pharmacy: You may fill your long-term prescription through the CVS Health mail service pharmacy. You will receive order forms and information on how to use the mail service prescription program from CVS Health. To order your prescription by mail: 1) complete the CVS Health order form; 2) enclose your prescription(s) and copayment(s); 3) mail your order to CVS Health, P O Box 659572, San Antonio, TX 78256-9572; and 4) allow approximately two weeks for delivery. You will receive order forms for refills and future prescription orders each time you use the mail service program. You can also order refills from the mail service program by phone toll-free at 800-292-4182 or on the Internet at www.Caremark.com
CVS Health's Primary/Preferred Drug list
The CVS Health Primary/Preferred Drug list is a list of “preferred” prescription drugs that are identified by the CVS Health team of physicians and pharmacists (Pharmacy and Therapeutics Committee) to be the best overall value based on quality, safety, effectiveness, and cost. The Primary/Preferred Drug list includes nearly all covered generic drugs, and specific brand-name drugs. We list the most commonly requested formulary drugs on the Primary/Preferred Drug list. To order a Primary/Preferred Drug list, call the CVS Health Customer Service Department at 800-292-4182 or visit our website at www.nrlca.org and click on Departments, then Insurance.
We also cover certain non-preferred (non-formulary) drugs prescribed by your Plan physician. However, we encourage you to use preferred drugs, especially preferred generic drugs, whenever possible because they will cost you less. Refer to the Primary/Preferred Drug list and check with your physician or pharmacist to find out if a preferred generic drug is available, or if a lower-cost alternative might work for you.
Specialty medications are typically high-cost, biologic drugs with complex dosing regimens, significant side effects, or alternate routes of administration such as injections and infusions. The Advanced Control Specialty Formulary ensures the safety and effectiveness of specialty medications and promotes the use of specialty generics in applicable situations Visit info.caremark.com/acsdruglist for a list of the specialty medications formulary.
- Prior Authorization: We require prior authorization for certain drugs, including specialty and weight management medications. To obtain a list of drugs that require prior authorization, please call the CVS Health Customer Service Department at 800-292-4182. The prior authorization drug list is reviewed by the CVS Health Pharmacy and Therapeutics Committee and may change from time to time due to new drugs, new generic drugs, new therapies, new guidelines from the Food and Drug Administration (FDA), or other factors. For those drugs that require prior authorization, you should discuss with your physician or pharmacist about available options that do not require prior authorization. To request prior authorization, your physician may contact the CVS Health Prior Authorization Department at 855-240-0536. CVS Health will work with your physician to obtain the information we need to process the request. You may contact the CVS Health Customer Service Department for the status of your request at 800-292-4182.
Compound Medication: A compound drug is a medication made by combining, mixing or altering ingredients in response to a prescription, to create a customized drug that is not otherwise commercially available.
Coverage for certain compounding chemicals (over-the-counter (OTC) products, bulk powders, bulk nutrients, bulk compounding agents, bulk chemicals, hormone and adrenal bulk powders, miscellaneous bulk ingredients, and proprietary bases are not covered through the prescription benefit and coverage for other ingredients commonly found in compound prescriptions will be determined through preauthorization. Refill limits may apply. When a claim is submitted for online processing or direct reimbursement of a compound medication, the pricing is based on the contractual discounts plus a professional fee and any applicable sales tax. Pharmacies must submit all ingredients in a compound prescription as part of the claim for both online claims and paper claim submissions. At least one of the ingredients submitted with the compound Rx claim must require a physician’s prescription in order to be covered by the plan. You are responsible for the appropriate brand name or generic copay or coinsurance based on the compound ingredients. Prior authorization may be required. Investigational drugs are not FDA approved. If the compound includes an investigational drug, the compound will not be covered.
Topical Analgesics: Certain topical analgesics for the temporary relief of minor aches and muscle pains may be marketed contrary to the Federal Food, Drug and Cosmetic Act (the FD&C Act) and are excluded by the Plan. Your prescription drug benefit includes other medications that are approved by the U.S. Food and Drug Administration (FDA) for the temporary relief of minor aches and muscle pains by means of the prescribed route of administration.
Specialty drugs are unique prescription medicines that are often high-cost injectable, infused, oral or inhaled drugs that require close supervision and monitoring by your physician. You must purchase certain specialty drugs, including biotech, biological, biopharmaceutical, and oral chemotherapy drugs through a CVS Health Specialty Pharmacy.
All specialty drugs require prior authorization to ensure appropriate treatment therapies for chronic complex conditions. Call CVS Health Specialty Pharmacy Services at 866-814-5506 to obtain prior authorization. Decisions about prior authorization are based on guidelines developed by physicians at the FDA or independent expert panels and are administered by the CVS Health Specialty Pharmacy's clinical team.
Certain specialty self-administered medications will be covered only when purchased through a CVS Health Specialty Pharmacy and will not be covered under any other Plan benefit. A list of these specialty self-administered medications is available at www.caremark.com. This list is subject to periodic change. Please call CVS Health at 800-237-2767 for the current list of specialty medications covered under the prescription drug benefit when purchased through a CVS Health Specialty Pharmacy.
Infusion Nursing and Site of Care Management for Specialty Medications
Infusion nursing services for certain specialty medications that are administered in the home and/or in an ambulatory infusion center are covered, coordinated through, and must be purchased from a CVS Health Specialty Pharmacy. For infused specialty medications, except for oncology (cancer) medications, that require administration by a medical professional, a CVS Health Care Team nurse will work with you and your physician to assess your clinical history and determine clinically appropriate options (location for your infusion) for clinician-infused specialty medications. Options may include homecare, an ambulatory infusion center, or physician's office. Care Team nurses will contact all impacted Plan members to provide assistance and guidance. Please call 800-237-2767 for complete information.
These are the dispensing limitations.
- You may purchase up to a 34-day supply of medication at any network retail pharmacy. There is a limit of the number of refills that you can buy at a network retail pharmacy for long-term maintenance medications (prescription medications that you take every day). You can buy an initial 34-day supply and two refills for long-term medications at a network retail pharmacy during any twelve month period. After the third fill at a network retail pharmacy, you must purchase your long-term medications through the CVS Health Mail Service pharmacy or a CVS Pharmacy to have the prescriptions covered by the Plan.
- There is also a 34-day supply limit for prescriptions that you buy at a non-participating pharmacy. In addition, you are limited to an initial 34 day supply plus two refills for long-term maintenance medications that you buy at a non-participating pharmacy. You pay the full regular price for any prescription that you buy at a non-participating pharmacy and then file a claim with CVS Health for reimbursement after you satisfy the annual $200 prescription drug deductible (see page 59).
- A generic equivalent will be dispensed if it is available. If you receive a prescription for a name brand drug when a Federally-approved generic drug is available, even if your physician requests "Dispense as Written" (DAW) on the prescription, you have to pay the difference in cost between the name brand drug and its generic equivalent plus the brand name (Tier III) copayment.
- You may purchase up to a 90-day supply of a medication through the CVS Health mail service prescription program. If you request a refill before you use 75% of the medication (based on your physician’s written directions for taking the medication), CVS Health will return the refill request to you. CVS Health follows generally accepted pharmacy standards when filling your prescriptions. These include Federal and state pharmacy regulations, the professional judgment of the pharmacist, and the usage recommendations of the drug manufacturer as approved by the U.S. Food and Drug Administration (FDA). If a Federally approved generic drug is available, CVS Health will substitute for a brand name drug. Certain types of prescription medications are not available through the mail service program such as:
- Specially mixed (compounded) capsules and suppositories
- Frozen medications
- Dental products
- Most medical devices
- Infertility drugs
- Medications specially wrapped in unit dose packaging
Note: Always request a generic drug from your physician or other prescriber when a generic is available. If a generic equivalent is available, but the pharmacy dispenses the brand name medication, you will pay the difference in cost between the brand name medication and the generic medication plus the brand name (Tier III) copayment. Similarly if your physician or other prescriber indicates "dispense as written" on the prescription, you will pay the difference in cost between the brand name medication and the generic medication plus the brand name (Tier III) copayment.
CVS Health will fill prescriptions for medications designated as Class II, III, IV, and V controlled substances by the FDA. However, Federal or state law may limit the supply of these medications to less than 90 days.
- If you have Medicare Part B, we do not waive your deductible or coinsurance for prescription drugs and supplies that you buy at a CVS Health participating pharmacy or at a non-participating pharmacy. However, your copayment is reduced for 90-day prescriptions that you order through the CVS Health mail service prescription program or at a CVS retail pharmacy.
Note: We waive your deductible and coinsurance at a network retail pharmacy and the copayment at the CVS Health mail service pharmacy if Medicare Part B covers your prescription drugs or diabetic supplies and is the primary payor. See Section 9 for further information.
Why use generic drugs? Generic drugs offer a safe and economic way to meet your prescription drug needs. The generic name of a drug is its chemical name; the name brand is the name under which the manufacturer advertises and sells a drug. Under Federal law, generic and name brand drugs must meet the same standards for safety, purity, strength, and effectiveness. Generic drugs contain the same active ingredients and are equivalent in strength and dosage to the original brand name product. All manufacturing and marketing of a generic drug is conducted following strict guidelines established by the U.S. Food and Drug Administration (FDA). No prescription drug can be sold in the U.S. without FDA approval. The manufacturing facilities of all drug companies, whether they make generic or brand name drugs, must pass stringent, regular inspections by the FDA. There is no difference between the standards set for drug companies that make brand name or generic medications. Many drug companies that make brand name drugs also make generic drugs. A generic prescription costs you -- and us -- less than a name brand prescription.
When you do have to file a claim. If you use a CVS Health participating pharmacy, the pharmacy will file the claim for you electronically. If you use a non-participating pharmacy, you will need to file a claim with CVS Health. Use the CVS Health prescription claim form and send your claim to:
CVS Health, PO Box 52136, Phoenix, AZ 85072-2136
Claims for prescription drugs and supplies that are not ordered through the CVS Health mail service prescription program or a CVS Health In-network pharmacy must include receipts that have the patient’s name, the prescription number, name of the drug, day supply, the medication's National Drug Code (NDC), prescribing physician’s name, date, charge, and pharmacy name. The pharmacist must sign any computer printout or pharmacy ledger. Prescription claim forms are available by calling toll-free 800-292-4182 or at our website at www.nrlca.org