The Fund offers you the opportunity to purchase prescription drugs at a greatly reduced cost through Caremark (the Contract Pharmacy Network). Mail order is required for maintenance medications after TWO fills (one original fill followed by one subsequent refill) at a retail pharmacy. Certain prescriptions are not covered, including prescriptions that are not on the pharmacy network formulary list. Certain drugs require prior authorization. Clinical management programs apply to certain prescription drugs, including specialty medications. Specialty drugs must be dispensed by the Caremark specialty pharmacy (1-866-387-2573). ALWAYS PRESENT YOUR CAREMARK PRESCRIPTION DRUG CARD TO THE PARTICIPATING RETAIL PHARMACY. To locate a participating pharmacy go to www.caremark.com or call 1-800-824-6349.
The prescription drug vendor (CVS/Caremark) provides certain programs to help determine the appropriateness of the prescribed drug therapy, including specialty medications. Examples of these programs that are currently already in place include Prior Authorization and Specialty Guideline Management. These programs evaluate the appropriateness of certain therapies according to evidence-based guidelines both before the initiation of the therapy and on an ongoing basis. These types of clinical programs help ensure patient safety, efficacy and optimal therapeutic benefit. These programs are periodically reviewed and adjusted.
A compound drug is one that is made by combining, mixing or altering ingredients, in response to a prescription, to create a customized drug that is not otherwise commercially available. Compound drugs generally require prior authorization. If you or your eligible dependent are prescribed a drug that requires compounding by the pharmacy, CVS/Caremark will conduct a prior authorization review and provide authorization to your doctor before the drug is covered by the Plan. Coverage will be denied for any compound drug, including patches or creams, that includes a component that is not FDA approved for that use, such as certain bulk powders.
Generic Step Therapy is required for certain brand name drugs. Two generic drugs must be tried before the brand name drug is covered. Examples of conditions subject to generic step therapy are high cholesterol, acne, high blood pressure. If you or your eligible dependent is currently taking a brand name drug that is included in the Generic Step Therapy program, you will receive a letter from CVS/Caremark explaining the generic alternatives for that specific brand name drug. If you need to take a new prescription that is part of this program, please ask your doctor to prescribe the generic first. If you are prescribed a brand drug and the prescription rejects at the pharmacy, please contact your doctor and ask the office to send a prescription for the generic to the pharmacy. If you or your dependent has a unique medical situation that requires you to keep taking the brand name drug, your doctor can contact CVS/Caremark to request a prior authorization for the brand name drug. If you or your dependent requests a brand name drug when a generic substitution is required, you will pay the copayment for the brand name drug and the difference between the contracted price of the brand name drug less the remaining contracted price of the generic substituted drug.
All specialty drugs prescribed by your physician must be dispensed by CVS/Caremark’s specialty pharmacy. In addition to dispensing the drugs, the specialty pharmacy provides you with personalized pharmacy care management services, convenient delivery to you, your doctor’s office or a local CVS pharmacy, medicine and disease-specific education and information, and ongoing support. Contact CVS/Caremark at 1-866-387-2573 for more information.