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Covered medications formulary
Covered medications formulary
We cover the prescription medications on the formulary without copays. If your patient needs medication, you’ll want to check the list for covered medications, step therapy requirements, quantity limits and updates. You can download the list or check it using our online search tool.
The state updates the formulary regularly. Updates may include info about the addition and/or removal of:
- A medicine from the PDL
- Prior authorization (PA) requirements
You can find the most up-to-date PDL using our online search tool.
If you need a prescription for glucose meter and test strips, Johnson & Johnson OneTouch® products are preferred. The preferred pen needles and insulin syringes are BD products.
Members can get coverage for OTC medications on the formulary 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
Members can get $25 per month per household toward some OTC medications and supplies.
If you prescribe a specialty medication, members can fill it at any pharmacy in our network. Not all pharmacies carry these medications, so members may need to find a specialty pharmacy. Some conditions that need specialty medications include:
- Immune deficiency
- Multiple sclerosis
- Rheumatoid arthritis
You’ll want to get PA for these medications. Fax the PA form to 844-807-8453. Or you can call 1-855-221-5656 (TTY: 711) to ask for PA. You can also include any medical records that may help with the review of your request.
More pharmacy information
Learn about everything from step therapy to prior authorization (PA).
When members need medication, they’ll:
- Ask you to make sure the medication is on the formulary
- 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.
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:
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 up to 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 call us at 1-855-221-5656 (TTY: 711).
Members can send the form, along with their prescription, to:
PO Box 2110
Pittsburgh, PA 15230-2110
The step therapy program requires certain first-line drugs, before approval of specific, second-line drugs.
Certain drugs on the formulary have quantity limits. The formulary identifies these drugs with the letters “QLL.” Quantity limits are based on:
- FDA-approved dosing levels
- Nationally established, recognized guidelines related to each condition
Need to ask for prior authorization for step therapy or a quantity limit? Just fax the pharmacy PA form to 844-807-8453. Or you can call 1-855-221-5656 (TTY: 711) to ask for PA. You can also include any supporting medical records that may help with the review of your request.
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