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.rcbphealth.com. 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 Caremark mail service pharmacy: You may fill your long-term prescription through the CVS Caremark mail service pharmacy. You will receive order forms and information on how to use the mail service prescription program from CVS Caremark . To order your prescription by mail: 1) complete the CVS Caremark order form; 2) enclose your prescription(s) and copayment(s); 3) mail your order to CVS Caremark, 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.
We use a formulary. A formulary is a list of generic and preferred drugs (see below) that are available through this plan. It places all U.S. Food and Drug Administration (FDA) approved drugs into categories based on their clinical effectiveness, safety and cost. The formulary is designed to control costs for you and the Plan. The categories include:
- Tier I category (also called “generic”) includes primarily generic drugs
- Tier II category (also called "formulary brands") includes preferred brand name drugs
- Tier III category (also called "non-formulary brands") includes non-preferred brand name drugs
- Tier IV category (also called “Specialty drugs,”) see description of Specialty drugs below
CVS Caremark's Primary/Preferred Drug list
The CVS Caremark 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.rcbphealth.com 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 www.caremark.com for a list of the specialty medications formulary.
- Prior Authorization: We require prior authorization for certain drugs, such as specialty, weight management and non-preferred (non-formulary) 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 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 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 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 Specialty Pharmacy's clinical team.
Certain specialty self-administered medications will be covered only when purchased through a CVS 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 at 800-237-2767 for the current list of specialty medications covered under the prescription drug benefit when purchased through a CVS Specialty Pharmacy.
Site of Care Management for Specialty Medications
Select clinician-administered specialty medications must be obtained through CVS Specialty Pharmacy and will be covered only under the pharmacy benefit. The CVS Specialty Care Team will work with your providers to determine site of care options, as clinically appropriate. Options may include homecare, ambulatory infusion center or physician’s office. Please call CVS Specialty Customer Care at 888-265-7790 for assistance with setting up your prescription.
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 Caremark 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 Caremark for reimbursement after you satisfy the annual $200 prescription drug deductible, if applicable (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 FDA 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 generic (Tier 1) copayment.
- You may purchase up to a 90-day supply of a medication through the CVS Caremark mail service prescription program. If you request a refill before you use 75% of the medication or 80% for controlled medications, CVS Caremark will return the refill request to you. CVS Caremark 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. FDA. If a FDA approved generic drug is available, CVS Caremark 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 generic (Tier 1) 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 generic (Tier I) copayment.
CVS Caremark 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.
Medicare Part B coverage: When Medicare Part B is primary, have the pharmacy submit Medicare covered medications and supplies to Medicare first. Prescriptions typically covered by Medicare Part B include diabetes supplies (such as test strips and meters), specific medications used to aid tissue acceptance from organ transplants, and certain oral medications used to treat cancer.
Retail pharmacy: Present your Medicare ID card and ask the pharmacy to bill Medicare as primary. Most independent pharmacies and national chains participate with Medicare. To locate a retail pharmacy that participates with Medicare Part B, visit the Medicare website at www.medicare.gov/supplier/home.asp, or call Medicare Customer Service at 800-633-4227. To maximize your benefits, use a pharmacy that participates with Medicare Part B and is also in our network. When the claim is submitted through coordination of benefits process as a secondary claim through RCBP (this may require submitting a paper claim).
- If you have Medicare Part B as primary, we waive your deductible for prescription drugs and supplies that you buy at a CVS retail participating pharmacy or at a non-participating pharmacy. Additionally, your copayment is reduced for all Caremark mail service prescriptions or for 90-day prescriptions filled at a CVS retail pharmacy.
Note: If Medicare Part B is the primary payor and covers your prescription drugs or diabetic supplies, we waive your deductible and coinsurance for these prescriptions at a network retail pharmacy and waive your copayment at CVS Caremark mail service. 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. 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 Caremark 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 Caremark. Use the CVS Caremark prescription claim form and either file your claim via the Caremark app, www.caremark.com or send your claim to:
CVS Caremark, PO Box 52136, Phoenix, AZ 85072-2136
Claims for prescription drugs and supplies that are not ordered through the CVS Caremark mail service prescription program or a CVS Caremark 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 National Provider Identifiers (NPI), 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.rcbphealth.com.