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Pharmacy benefits

We cover a wide range of prescription and over-the-counter (OTC) medications to help keep our members as healthy as they can be.

 

Questions?

Just contact us. We’re here to help.

Covered medications

Covered medications

Prescription medications

 

Each plan has its own list of prescription medications we cover, known as the preferred drug list (PDL). You can download the PDL or check it online.

 

If a medication isn’t on the PDL, you can:  

 

  • Prescribe a similar medication on the PDL  
  • Get prior authorization (PA) for coverage

 

Diabetes prescriptions

 

If you’re prescribing a glucose meter and test strips, Johnson & Johnson OneTouch® products are preferred.

 

Copays

 

Note that Medicaid Managed Medical Assistance (MMA) members never have a copay for prescription medications. Their prescriptions are always free. Florida Healthy Kids (FHK) members may have a $5 copay. 

OTC medications

Members under age 20 can get coverage for OTC medications on the PDL when they:

  • Meet any added requirements (for some medications)
  • Get a prescription from their provider
  • Fill their OTC prescription at a pharmacy in our network

Not sure what’s covered? Just contact us. Be sure to have the member’s list of medications ready. We can check to see if they’re on the list.

 

$25 OTC benefit

 

Medicaid members can get $25 per month (per household) toward certain OTC medications and supplies. We’ll mail those supplies or medications directly to the member. They just need to have their member ID number ready when they place the order. They can place an order if they:

 

  • Sign in with their member ID and password. Or create a new account if they’re a first-time visitor.
  • Call OTC Health Solutions at 1-888-628-2770, Monday through Friday, 9 AM to 8 PM.

 

You can see which items are eligible for this benefit in our OTC catalog (PDF).

 

More about member pharmacy benefits 

Specialty medications

Specialty medications

If you prescribe a specialty medication, members must fill it at a CVS Specialty pharmacy (unless they formally request an exemption). Some conditions that need specialty medications include:

 

  • Cancer
  • Hemophilia
  • Immune deficiency
  • Multiple sclerosis
  • Rheumatoid arthritis

You’ll want to get prior authorization for these medications. Fax the PA form to 1-844-235-1340. Or you can call Member Services to ask for PA. Be sure to submit all required clinical information on the form. 

 

Member Services:

 

 

Filling a specialty medication prescription

 

If you’re treating a member with a prescription for a specialty medication, they’ll need to fill it at a CVS Specialty® pharmacy. Specialty drugs can be delivered to either your office or your patient’s home in temperature-controlled packaging with the necessary supplies (ex: needles, syringes, and alcohol wipes). Or, you can have your patient drop off and pick up most of their prescriptions at any CVS Pharmacy® location, including those inside Target stores.

 

You or the member can call CVS Specialty pharmacy at 1-800-237-2767 (TTY/TDD: 1-800-863-5488), Monday through Friday, 7:30 AM to 9:00 PM. They will help you fill the prescription.

 

Here’s a list of specialty medications (PDF). You may need to get prior authorization for some of the medications on this list. You can find and submit PA forms online or fax a completed form to us at 1-844-235-1340.

 

More about CVS Specialty pharmacies (PDF)

 

 

Informed consent

 

Are you prescribing a psychotropic medication for a member under age 13? If so, the pharmacy will need their guardian or parent’s approval before it can dispense that medication. Just have the member’s parent or guardian fill out a consent form to sign. Then they can take the signed form to the pharmacy for each new prescription.

More pharmacy information

If a member needs prior authorization (PA) for a medication, you can fill out a pharmacy PA form on their behalf. You can find PA guidelines, instructions for submission and forms for individual medications on our pharmacy PA page.

 

Pharmacy PA

When members need medication, they’ll:

 

  • Ask you to make sure the medication is on the PDL for their plan
  • Take their prescription to a pharmacy in our network
  • Show their plan member ID card at the pharmacy

Remind members to check with you at least five days before running out of medication. They understand that you may want to see them before prescribing refills.

Members can fill prescriptions at any pharmacy in our network. We can’t cover medications they fill at other pharmacies.

 

Find a pharmacy nearby

When members take maintenance medication for an ongoing health condition, they can get it by mail. We work with CVS Caremark® to provide this service at no extra cost. Each order is checked for safety. And members can speak with a pharmacist anytime on the phone. 

 

To get started, members will need their:

 

  • Plan member ID card
  • Mailing address, including ZIP code
  • Provider’s first and last name and phone number
  • List of allergies and other health conditions
  • Original prescription from their provider (if they have it)

 

Mail service makes it easy

Members and providers can call CVS Caremark at 1-855-271-6603 (TTY: 711), 24 hours a day, 7 days a week. They’ll explain which medications can be filled with CVS Caremark Mail Service Pharmacy. CVS Caremark will also contact you for a prescription and mail the member’s medication. Members can sign up for mail service:

 

Online

Members can go to the Member Portal and sign in or register (for new users). Then, they’ll choose: Tasks, Pharmacy services, CVS and Start mail service.

 

With an order form

Members will ask you to write a prescription for a 90-day supply with up to one year of refills. Then, they can fill out a mail service order form English (PDF) | Spanish (PDF). Or we can mail them a form. They just need to contact us

 

Members can send the form along with their prescription to:

CVS Caremark

PO Box 2110

Pittsburgh, PA 15230-2110 

 

By phone

Members can also call CVS Caremark at 1-855-271-6603 (TTY: 711). They can call 24 hours a day, 7 days a week. If they agree, CVS Caremark will call you to get a prescription.

 

Each plan’s PDL is up to date with the medications we cover. Remember that some medications need PA before they can be dispensed. 

What is the Pharmacy Lock-in program?   

 

This program helps to prevent potential abuse or misuse of benefits. Members choose one in-network pharmacy to fill their prescriptions. Then they stick with it for 12 months.   

   

What happens if that pharmacy doesn’t have the medicine my patient needs? 

  

Either you or your patient’s pharmacy can call the CVS Pharmacy help desk at 1-866-693-4445. They can approve the order at a new pharmacy. Note that only providers and pharmacies can call to override the member’s pharmacy lock-in, since a national provider identifier (NPI) number is required. 

 

What if my patient doesn’t want to use only one pharmacy?    

 

They can contact Member Services to file an appeal. Or they can visit our grievances and appeals page.

 

Need information about medication recalls? Just call the U.S. Food and Drug Administration (FDA) at 1-888-463-6332. Or visit the drug recalls page on the FDA website.

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