2017 Covered Drug list (Formulary)*Not Effective until 01/01/20172016 Covered Drug list (Formulary)Over-The-Counter Drug list for Essential Plans 3 & 4 members only
For medications not listed on the Formulary, Providers may follow the same course of action as with a Coverage Determination, also called a Prior Authorization. This can be initiated by having your Provider call 855-294-5979 and request a Coverage Determination for the Medication(s) whether or not it is listed on the Formulary. Should this coverage be denied, an appeal can be made within 60 days of the initial denial by calling 888-543-9069 (choose option 1 for pharmacy appeals) or by having the Provider fax clinical chart notes or a letter of medical necessity to 718-536-3383.
At your local pharmacy
You can use your prescription benefit ID card at most chain and independent pharmacies across the country. Find a participating pharmacy near you using the Pharmacy Locator
Through the Caremark Mail Order Pharmacy
If your doctor has prescribed a drug for you to take for a long time (also called a Maintenance Medication), you may be able to have up to a 90-day supply delivered directly to your home or location of choice from our mail order pharmacy by using the following form: English | Spanish
When it’s time to get a refill you can order online or by phone anytime, day or night. You can also choose automatic refills. Click here for more information on ordering your prescriptions through the mail.
These are high-cost, injectable, oral, infused or inhaled medications that are typically self-administered.
Specialty Guideline Management (SGM)
SGM is our utilization management program; administered by CVS Caremark, that helps ensure appropriate utilization for specialty medication based on currently accepted evidence-based medicine guidelines. SGM is designed to ensure safety and efficacy while preventing off-guideline utilization. Prescribers may call (800) 237-2767 to enroll patients in the Specialty plan design.