Explore your plan and benefits
Find out what terms like formulary and prior authorization mean and how these requirements can affect your medication options.
Your one stop for all things related to your plan
-
Plan summary
Understand the details of your prescription coverage and your share of costs. Plus, keep track of where you are with your deductible.
-
Covered medications
Our Check Drug Cost tool will show you whether or not your prescription is covered under your plan.
-
High deductible health plans
A high deductible health plan (HDHP) requires you or your family to pay the full cost of your health care, including your medications, until you meet your plan’s annual deductible.
Take a closer look at your plan's formulary
00:00:01:23 - 00:00:30:18
Unknown
Helping you access the medications you need at the lowest possible cost is our priority. To help keep costs low, your prescription plan provides a list of covered medications used to treat most health conditions. This list is known as your covered drug list or drug formulary. It's important to review this list with your doctor, so they can try to prescribe an effective medication that's also covered by your plan.
00:00:30:20 - 00:00:52:24
Unknown
You may have been notified recently about a change in the medication covered under your plan.
Throughout the year, your covered drug list is reviewed and sometimes changes are made.
If you're affected by a formulary change, we'll let you know in advance, so you'll have time to discuss your options with your doctor and get a new prescription if you need one.
00:00:53:01 - 00:01:23:00
Unknown
There are often several listed medications, both brand name and generic, available to treat the same condition. These are clinically-appropriate for the condition and may cost you less. Once the updates to your covered drug list take effect, you can use our Check Drug Cost tool to see how the cost of your medication may have changed. There may be some instances where the drug you have been prescribed is not on your plans’s formulary and therefore not covered by your insurance.
00:01:23:02 - 00:01:44:17
Unknown
If no covered option is medically appropriate for you, your doctor may be able to request prior authorization. Remember, you should always consult with your doctor about which medication is right for your condition. However, if you wish to continue with a medication that is no longer on your plan’s covered drug list, you will need to pay the full cost.
00:01:44:19 - 00:01:46:12
Unknown
To learn more, visit Caremark.com
Your plan’s formulary
A formulary is your plan’s list of covered medications. The formulary is designed to help you get the medication you need at the lowest possible cost. When your doctor prescribes a formulary medication, you’ll pay your plan’s required copay or coinsurance at the pharmacy.
Formulary questions
Your plan asks CVS Caremark® to monitor your list of covered medications and make changes when lower-cost, clinically appropriate options become available. There are often several medications, brand name and generic in some instances, available to treat the same condition. This could help save money for both you and your plan throughout the year. We’re committed to helping you get the medication you need at the lowest possible cost.
No. You always have the choice of continuing with your current medication, and your doctor always has the final decision on what medication is right for your condition. However, if you choose to continue taking your current medication, you should expect to pay the full cost. We encourage you to talk to your doctor about whether a covered medication will work for you. If your doctor thinks there is a clinical reason why one of these covered options won’t work for you, your doctor may be able to submit a request for coverage, depending on your plan.
To view the exact price you will pay for your medication, sign in or register at Caremark.com and use the Check Drug Cost tool. The tool shows what the price would be at the time you check, and will not show future dated pricing. Remember — the savings really add up if you are taking a long-term medication for months or years at a time.
Not necessarily – the cost may vary by retail or mail service. To find out how much you’ll pay, and to see your lowest cost option for filling prescriptions, sign in or register at Caremark.com and use the Check Drug Cost tool.
The formulary for your plan applies to any prescriber, including those who work in a hospital. In many cases, there are several medications used to treat specific conditions and they may not all be covered depending on your plan design. Your doctor may be able to submit a request for coverage, depending on your plan.
Talk to your doctor and let them know that you’ll have to pay the entire cost. Ask if there is a covered medication that will work for you — if so, ask for a new prescription. Your doctor may be able to submit a request for coverage, depending on your plan.
Some plans share the cost between what is paid by insurance and what you are responsible for.
You may be able to save money by using an alternative or generic medication or by filling your prescription at a pharmacy in your plan’s network.
To see your lowest cost option for filling prescriptions, sign in or register at Caremark.com and use the Check Drug Cost tool. To find a pharmacy in your network, sign in or register at Caremark.com and use the Pharmacy Locator tool.
Usually, yes. Generics are typically the lowest cost option. The research, development and marketing of new medicines cost a lot of money. Companies that make generic medicines do not have to develop them from scratch, so it usually costs much less to make. Generic medicine manufacturers then pass the savings on to consumers. Lower cost does not mean lower quality. Companies that make generic medicine must show that their product performs the same as the brand-name.
There are some cases where the brand medication is covered and not the generic. Check your plan’s formulary or use the Check Drug Cost Tool to determine coverage.
To see how much you could save with generics, sign in or register at Caremark.com and use the Check Drug Cost tool.
We have a panel of independent experts (our Pharmacy & Therapeutics committee-P&T) who help us ensure that the drugs we cover will provide options for patients that are clinically appropriate and cost-effective. You always have the choice of continuing with your current medication, and your doctor always has the final decision on what medication is right for your condition. If your doctor thinks there is a clinical reason why one of these covered options won’t work for you, your doctor may be able to submit a request for coverage, depending on your plan.
Check if your prescriptions require prior authorization
00:00:00:06 - 00:00:23:17
If you've ever wondered why a medication costs what it does or why it needs extra approval. You're not alone. Understanding your prescription coverage isn't always simple, but we're here to help make it easier. Your plan covers a list of medications, also called a drug list or formulary. Before you fill a prescription, you can check if it's covered and see what it may cost.
00:00:23:18 - 00:00:50:18
Just use the drug cost and coverage tool on your Caremark.com account to look up your medication, compare options, and find lower cost alternatives. Some medications may require a process called prior authorization. PA, that means your doctor needs to share a little more information with us before your plan can cover the medication. This helps make sure the medicine is safe, appropriate, and covered under your plan.
00:00:50:19 - 00:01:15:23
If a PA is needed, your doctor will submit the request. You can track the status anytime in your dashboard. Simply go to prior authorizations to see updates in one place. You can also choose how you'd like to receive notifications by email, text, or mail so you stay informed every step of the way to check your prescription coverage and see if a prior authorization is required.
00:01:15:24 - 00:01:18:14
Sign in to Caremark.com today.
Prior authorization
Prior authorization (PA) is a review process that a member’s plan uses to make sure the medications, tests and treatments they receive are clinically appropriate, safe and affordable.
Prior authorization questions
Some prescription plans may require prior authorization for certain medications. This means that your doctor will have to provide additional information on why they are prescribing this medication for you. CVS Caremark® reviews this information and, based on your plan, determines whether or not the medication will be covered.
You or your pharmacy can ask your doctor to start a PA. Then, your doctor can submit an electronic prior authorization (ePA) request to Caremark. Information for providers about this process is available here.
Yes, but you may pay more if you choose to pay the retail price for your prescription without using insurance.
Talk to your doctor about your treatment. If your doctor decides you should continue with your current medication, they may need to submit a new request for coverage.
CVS Caremark proactively starts the renewal process before PAs expire in select cases. This helps make it easier for prescribers to respond electronically and for members to continue their therapy.
Not yet. Once your doctor submits the request, it will be reviewed by CVS Caremark and a decision will be made. If the PA is approved, the medication will be covered. If the PA is denied, your medication will not be covered, and you may have to pay the entire cost if you continue to take that medication. You will be notified of the decision by mail. You can also check the status of your prior authorization request by signing in or registering at Caremark.com, on mobile apps, by Secure Message or SMS.
Yes. You and your doctor will be notified by letter of approval or denial. You can check the status of your PA by signing in to your Caremark.com account and visiting Prescriptions > Prior Authorizations. You may also check PA status on mobile apps, by Secure Message or SMS.
You have several options. You may ask your doctor if an alternative medication might work for you. You may choose to continue taking the medication and pay for it yourself. Or, you can submit an appeal by following the steps outlined in your denial letter.
An appeal request can take up to 15 business days to process. If your exception request is still denied after the appeal, a second-level appeal could also take up to 15 business days to process. You and your doctor will each be sent a notice in the mail for an appeal request and a second-level appeal.
Learn about quantity limits
00:00:00:22 - 00:00:10:01
Unknown
We prioritize making sure you can get the medication you need at the lowest possible cost.
00:00:10:03 - 00:00:41:23
Unknown
A quantity limit is the maximum amount of medication your prescription plan covers over a set period. For example, your plan may cover up to 30 doses of a medication per month. Once you reach that limit, you can keep filling your prescription, but you'll pay the full cost. These limits help ensure medications are not overused. If you think you have a medical reason to keep taking your medication after reaching the limit, talk to your doctor about your options.
00:00:42:00 - 00:00:52:10
Unknown
If your doctor determines it's medically necessary for you to stay on the same drug after the limit is reached, they can request prior authorization.
00:00:52:12 - 00:00:59:21
Unknown
It's always a good idea to consult your doctor about any changes in your prescription plan.
00:00:59:23 - 00:01:02:04
Unknown
To learn more, visit Caremark.com
Quantity limits
A quantity limit is the highest amount of medication covered by your plan for a period of time (for example, 30 tablets per month). Your plan will cover your medication up to the limit. Once the quantity limit is reached, you’ll have to pay the full cost of the medication.
Quantity limits questions
Some medications are intended to be taken in limited amounts for a specific period of time. Your prescription plan may put a limit on the amount that will be covered. This is called a quantity limit. Once you reach the limit, you can continue to fill prescriptions, but your medication will not be covered and you will have to pay the entire cost. For certain medications, your plan may cover an additional amount after the limit is reached. If it is medically necessary for you to continue taking this medication after the limit is reached, your doctor can request prior authorization. If the request is approved, a greater amount of the medication will be covered.
Quantity limits are typically managed per fill. However, there may be times when products are limited for a period of time.
The limit only applies to the amount of medication your plan will cover. If you need more medication, you can choose to continue filling your prescription after the limit is reached, but you will have to pay the entire cost.
First, talk to your doctor about whether there’s an alternative medication without quantity limits that might work for you. For certain medications, your plan may cover an additional amount after the limit is reached. If it is medically necessary for you to continue taking this medication after the limit is reached, your doctor can request prior authorization. If the request is approved, a greater amount of the medication will be covered.
Yes, the limit only applies to the amount of medication your plan will cover. You can choose to continue filling your prescription after the limit is reached, but you will have to pay the entire cost.
Understand what step therapy means for your plan
Step therapy
Step therapy occurs when your plan requires you to try an alternative medication (often lower cost) before “stepping up” to a medication that works to treat your condition in a similar way but may cost more. Once you try the alternative medication, you can choose to keep taking it (if it works for you) or change back to your original medication.
Step therapy questions
Talk to your doctor about your treatment. If your doctor determines you should continue with your current medication, they can contact us to submit a prior authorization (PA) request for coverage. Refer to the Prior Authorization section for more information.
Talk to your doctor. Ask them to prescribe the preferred option and take it for the required trial period. If it works, keep taking it. If not, you may be able to go back to the non-preferred medication. Note that both preferred and non-preferred medications may require a prior authorization.
Depending on your plan, your doctor may be able to request a prior authorization. It’s important to remember that medications considered formulary or preferred on your plan can sometimes require a PA. If the request is approved, the non-preferred medication will be covered.
No. Keep taking the preferred medication. Make sure you ask your doctor to write your prescriptions for the preferred medication when it’s time to renew.
Your questions, answered
We're here for you, every step of the way. Find answers to frequently asked questions in our help center.