Prescription Drug Policies and Programs
Managing your prescription medications isn’t always easy, especially when you change coverage plans or your medications are difficult for pharmacies to stock. We’ve created several policies and programs to help you manage your prescriptions.
Prescription Drug Utilization Review
To help ensure that the quantity and dosage of your medications remain consistent with manufacturer, clinical, and Food & Drug Administration (FDA) recommendations, we maintain a list of medications subject to Quantity Limits (QL).
When you fill a prescription for a medication subject to QL, your prescription is reviewed for:
- Dose Consolidation – Dose Consolidation checks to see whether you're taking two or more daily doses of medicine that could be replaced with one daily dose providing the same total amount of medication. Dose Consolidation advantages include:
- Making it more convenient for you to take your medication (you take fewer pills, instead of several doses or pills daily).
- Helping to control overall pharmacy costs.
- Recommended Monthly Dosing Level – This process checks to see that your monthly dosage of medication is consistent with both the manufacturer's and the FDA's monthly dosing recommendations and clinical information. Your doctor can also apply for an exception to QL guidelines when medically necessary.
- Safety: CVS Caremark®´ is the prescription mail-order service provider for our Medicare Advantage and Medex®´ plans with prescription coverage. When you fill a mail-order prescription, CVS will electronically review it against your previous or current prescriptions. If safety issues are detected, CVS will send an alert to the retail or mail-order pharmacy filling your prescriptions.
Medicare Plan Drug Transition Policy
As a new or continuing member in our plan, you may be taking medications that are not on our formulary. Or, you may be taking a medication that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription.
Talk to your doctor to decide if you should switch to an appropriate covered medication, or request a formulary exception so that we'll cover the medication you take. While you talk to your doctor to determine the right course of action for you, we may cover your medication in certain cases during the first 90 days you're a member of our plan.
Temporary Supply
For each of your medications that isn’t on our formulary or if your ability to get your medications is limited, we’ll cover a temporary 30-day supply. If your prescription is written for fewer days, we’ll allow refills to provide up to a maximum 30-day supply of medication. After your first 30-day supply, we won’t pay for these medications, even if you’ve been a member of the plan for less than 90 days.
For Long-Term Care Facility Residents
If you're a resident of a long-term care facility, we'll allow you to refill a prescription until we've provided you with at least a 31-day supply. We'll cover more than one refill of these drugs for the first 90-days if you're a member of our plan.
Emergency Supply
If you're a resident of a long-term care facility and you need a medication that isn't on our formulary, or if your ability to get your medication is limited, but you're past the first 90 days of membership in our plan, we'll cover a 31-day emergency supply of that medication while you pursue a formulary exception.
Level of Care Changes
If you change your level of care, such as a move from a hospital to a home setting, and you need a medication that isn't on our formulary or if your ability to get your medications is limited, but you're past the first 90 days of membership in our plan, we'll cover up to a temporary 30-day supply (or 31-day supply if you're a long-term care resident) when you go to a network pharmacy. After your first 30-day supply, you're required to use the plan’s exception process. Our transition supply won't cover medications that Medicare doesn't allow Part D plans to cover or medications that might be covered under Medicare Part B.
