Prescription Drug Coverage & Management
Starting January 1, 2016 CVS Caremark’s Advanced Control Formulary will be implemented for specialty pharmacy drugs. If you are prescribed a non-preferred specialty product under certain specialty classes, CVS Caremark will contact your doctor to request consideration of a drug list product or generic equivalent. An established evidence-based protocol must be met before a non-preferred specialty drug will be covered. Examples of some specialty classes include Autoimmune, CML, Hematology, Hepatitis C, Growth Hormone, Multiple Sclerosis, Osteoarthritis, Osteoporosis, Prostate Cancer, Pulmonary Arterial Hypertension, and Transplant.
Generic Step Therapy Program
The medicines you and your family need to stay healthy can be costly. The good news is there are over 10,000 lower-cost, generic medicine options available. Trying a generic medicine makes sense because for almost everyone, they work as well as brand-name medicine-and usually cost much less. Generic medicine can help you stay healthy and save money.
Many health conditions have treatment options that vary in cost. Generic step therapy is a program that helps make sure the generic medicines that work well and cost less are used first. For certain conditions, your plan will require you try these lower-cost, generic options before some brand-name medicines will be covered. Generic step therapy helps lower costs for you and your plan while providing quality treatment.
Contact CVS Caremark at (888) 202-1654 with questions regarding the Generic Step Therapy Program.Insert Copy Here
Specialty Drug Step Therapy Program
The step therapy program for specialty drugs is similar to the Generic Step Therapy Program noted above however, it requires insured’s to try a preferred brand drug before the non-preferred brand drug can be dispensed. This program impacts users of prescription drugs in the Auto- Immune and Multiple Sclerosis drug class. An established evidence-based protocol must be met before a non-preferred specialty drug will be covered.
Contact CVS Caremark at (800) 237-2767 with questions regarding the Specialty Drug Step Therapy Program.
Formulary Drug Exclusion Program
A formulary is a list of medicines that are covered by your prescription benefit plan. A formulary is also called a drug list. A team of doctors and pharmacists evaluate formulary medicines based on medical guidelines first, then cost. Certain non-preferred brand-name medicines may not be covered by your plan or may only be covered after you and your doctor meet certain medical requirements. The good news is there are alternative “preferred”, covered options available. These options are “preferred” because they provide quality treatment and are cost effective.
If according to (your) physician you need to receive any of these brand name drugs, they will need to submit request for a prior approval. Without a request for prior approval, the drug will not be covered by the University’s prescription drug plan and you would be responsible for the full cost of the drug. If medical necessity is approved thru the prior approval process, the drug will be covered under the University’s plan and you would pay the brand non-formulary copay (third tier).
If you are currently using one of the drugs, ask your doctor to choose one of the generic or brand formulary considerations.
Contact CVS Caremark at (888) 202-1654 with questions regarding the Formulary Drug Exclusion Program.
HRA Completion and Caremark
Employees who completed the Wellstream Health Risk Assessment (HRA) during the NUFlex Benefits enrollment period have the following additional pharmacy benefits: