Additional Plan Provisions
The Plan contains a mandatory generic drug program, in which generic drugs are substituted for certain brand-name* prescription drugs. If you fill your prescription with a brand-name drug when a generic equivalent is available, you pay the entire cost difference plus the generic drug copay. Please Note: These cost differences will not be limited by per-prescription maximums or annual out-of-pocket maximum limits. Your physician can contact CVS Caremark to seek a medical exception review for possible approval for specific clinical reasons.
*For this purpose, brand drugs refer to those brand drugs with a direct generic equivalent produced by at least two manufactures.
Step Therapy is a program that lets members get the treatment they need affordably. It also helps the Plan maintain affordable prescription drug coverage. In step therapy, medicines are grouped in categories based on treatment and cost.
- First-line medicines are the first step. First-line medicines are typically generic and lower-cost brand-name medicines approved by the U.S. Food & Drug Administration (FDA). They are proven to be safe, effective and affordable. Step therapy suggests that a patient try these medicines first because, in most cases, they provide the same health benefit as more expensive drugs, but at a lower cost.
- Second-line drugs are the second and third steps. Second-line drugs typically are brand-name drugs. They are best suited for the few patients who don't respond to first-line medicines. Second-line drugs are the most expensive options.
Certain medications may only be covered by the Plan under certain conditions with a prior authorization (PA) from CVS Caremark prior to purchasing the medicine. To find out if a drug requires a PA, log in to www.caremark.com and click on "Check Drug Cost & Coverage" on the "Plan & Benefits" tab, or call CVS Caremark.
There may be quantity limits on certain medicines. Quantity limits are based on the Food and Drug Administration's (FDA) recommended dosing guidelines for each medication and are reviewed regularly by CVS Caremark to ensure clinical appropriateness. Limits are set to ensure safety and efficacy in the treatment of various health conditions.
Certain prescriptions may also be limited to less than the standard days supply, which is a thirty (30) day supply. For specific medicine limitations, please log in to www.caremark.com or call CVS Caremark at (866) 209-6093. Quantity limits may change periodically based on updates from the FDA's recommended dosing guidelines.
To determine whether your medication is subject to CVS Caremark's utilization management program such as Step Therapy, Prior Authorization or Quantity limit, etc., please contact CVS Caremark.
The Plan also offers Pharmacy Advisor, a voluntary counseling program offered through CVS Caremark to help employees (and covered spouses/domestic partners) with certain conditions — such as diabetes or heart disease — adhere to their prescription regimen, manage their medications and make sure their medications don't conflict with each other. When you pick up your prescription at a CVS retail pharmacy, the pharmacist will automatically offer to provide onsite counseling.
Certain conditions such as asthma, growth hormone deficiency, hepatitis C, immune disorders, infertility, multiple sclerosis, and rheumatoid arthritis may be treated with specialty drugs. These drugs may be oral or self-injectable, include biological drugs, often require special handling, such as refrigeration, and are generally not available at the majority of pharmacies. CVS Caremark Specialty Pharmacy is a comprehensive pharmacy program that provides specialty drugs directly to covered individuals along with supplies, equipment, and care coordination.
Certain specialty drugs require further clinical review and prior authorization before coverage will be approved. The "CVS Specialty Drug List" can be found on CVS Caremark's website. The CVS Caremark Specialty Guideline Management Program evaluates the appropriateness of drug therapy with specialty medications according to evidence-based guidelines both before the initiation of therapy and on an ongoing basis. This clinical program helps ensure patient safety, efficacy, and optimal therapeutic benefit.
If you submit a prescription for a specialty drug that requires preauthorization, CVS Caremark will undertake a review. The provider who prescribed the medication will be required to call (866) 814-5506 as part of the review process. After the review is complete, you and your physician will receive a letter confirming whether coverage has been approved or denied (usually within 48 hours after CVS Caremark receives the information it needs).
In certain cases, a first-line specialty drug may be required. This is a step therapy program that encourages the use of a preferred drug before using a non-preferred drug. Preferred drugs under this program are well-supported treatment options and represent the most cost-effective drug for a given condition. Before a non-preferred specialty drug is covered, an established evidence-based protocol must be met.
If coverage is approved, you'll pay your normal copay or coinsurance amount for your prescription. If coverage is not approved, you have the right to appeal (please see the Plan Administration section).
You may contact CVS Caremark Specialty Customer Care at (800) 237-2767 from 7 a.m. to 7 p.m. Central time, Monday – Friday, to arrange for expedited, confidential delivery of your specialty drug to the location of your choice. You will also have access to a pharmacist-led or nurse-led Care Team that can provide customized care, counseling on how to best manage your condition(s), patient education, and evaluation to assess your progress and to discuss your concerns.