• Essential Plan

  • 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 800.894.5979 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.

    Covered Drug List (Formulary): 2021
    Over-The-Counter Drug list for Essential Plans 3 & 4
    Supplemental Over-The-Counter Drug list for Essential Plans 3 only  

  • Two Convenient Ways to Fill Prescriptions

    • 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:

      Pharmacy Mail Order Forms: 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.

    If you paid out of pocket for a covered medication and you were active on the date filled please utilize the following form with instructions for a reimbursement.

    The reimbursement is issued through our Pharmacy Benefits Manager CVS. Should you have any questions about a claim reimbursement or the status of an already filed claim please call 855.722.6228.

    Claim Form

    Specialty Medications
    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 866.814.5506 to enroll patients in the Specialty plan design.

  • Comprehensive Contraception Coverage Act (CCCA)

    You are covered for all forms of contraceptive drugs, devices and products approved by the U.S. Food and Drug Administration (FDA). This includes all FDA-approved over-the-counter contraceptive products as prescribed or as otherwise authorized under state or federal law. You are also permitted to receive an entire 12-month supply of a contraceptive at once.

    Where the FDA has approved one or more therapeutic and pharmaceutical equivalent versions of a contraceptive drug, device or product, Affinity Health Plan is not required to include all of the therapeutic and pharmaceutical equivalent versions in its formulary, so long as at least one is included and covered without cost-sharing.

    Your contraceptive coverage is provided without any cost-sharing, including any deductible, coinsurance or copayment. Prior authorization, step therapy protocols, or quantity limits on a 12-month supply are not permitted for your contraceptive coverage.