As our pharmacy benefits manager, CVS Caremark reviews and processes your claims when you purchase prescription medications. Members covered by our pharmacy benefit may fill prescriptions at any of the more than 63,000 CVS Caremark–participating pharmacies, which include retail chain stores, independent pharmacies, and designated specialty pharmacies, in addition to CVS/pharmacy locations. The CVS Caremark mail service is available for members who take maintenance medications. Maintenance medications are those you refill each month for conditions such as diabetes, high blood pressure, and asthma.
If you are currently on a medication, be sure you have enough on hand to last until your new coverage takes effect.
When You’re Ready to Fill a New Prescription, Follow These 3 Easy Steps:
1. Confirm that your medication is on our formulary, a list of covered drugs. If your medication is not listed, speak to your provider about alternatives that are covered.
View Pharmacy Formularies
2. Check whether any of the following pharmacy management programs apply to your medication:
- PA: Prior authorization
- NC: Non-covered
- STPA: Step therapy
- QL: Quantity limitation
- SP: Designated specialty pharmacy
If any of these programs apply, follow the applicable recommendations outlined in step 3, below.
3. Follow these appropriate steps for any applicable pharmacy management programs:
- Prior authorization (PA): Contact the provider who has written your prescription. If your provider believes a drug with a PA is necessary for your treatment, he or she may submit a request for coverage by faxing the appropriate form to Tufts Health Plan. We will cover the medication if it meets our medical necessity coverage guidelines. If the request is approved, you will be covered for your prescription. If it is not approved, you can appeal the decision.
- Step therapy prior authorization (STPA): Check our step therapy drug list to confirm the step your drug is on. If you have not previously taken the steps required by our pharmacy coverage guidelines, and your provider believes the drug prescribed for you is medically necessary, he or she may request coverage.
- Quantity limitation (QL): You are covered for up to the quantity posted in our list of covered drugs. If your provider believes it is necessary for you to take more than the QL quantity posted on the list, he or she may submit a request for coverage.
- Non-covered (NC): Contact the provider who has written your prescription. If your provider believes a drug with an NC is necessary for your treatment, he or she she may submit a request for coverage to Tufts Health Plan. We will cover the medication if it meets our medical necessity coverage guidelines. If the request is approved, you will be covered for your prescription. If it is not approved, you can appeal the decision.
- Designated specialty pharmacy (SP): Call the designated specialty pharmacy provider indicated in your online search in Step 1 or contact our Member Services Department to help ensure you receive your medication without interruption.