Prior Authorization Frequently Asked Questions

Frequently Asked Questions

  • Why are the medications covered under my plan changing?

    Your plan asks CVS Caremark® to monitor your list of covered medications and make changes when lower-cost options become available. This helps save money for both you and your plan throughout the year. CVS Caremark is committed to helping you get the most effective medications at the best price and keeping access to prescription medications affordable.

  • How are decisions made about what medications are covered under my plan?

    There are often several medications, both generic and brand name, available to treat the same condition. If your medication requires prior authorization, it may be because there are other, less expensive options available to treat your condition. However, determining the best covered option for you is up to you and your doctor.

  • Why is prior authorization now required for my current medication?

    CVS Caremark is committed to helping you get the most effective medication to treat your condition at the lowest possible cost. Our team continually reviews medications, products and prices for your plan sponsor. As part of this effort, some medications covered by your plan require prior approval by our clinical staff.

  • What happens if I do not receive prior authorization for my current medication?

    If you fill your prescription without prior authorization, you will pay 100 percent of the cost of your medication. Because approvals are only given in select situations, we recommend talking to your doctor soon about choosing a covered medication that does not require prior authorization to keep your costs down.

  • If I have more than one option, how do I decide?

    Talk to your doctor about which of your options might be best for you. Have this conversation soon, before your current medication is no longer covered.

  • Do I have to change to a different medication?

    No. You always have the choice of continuing with your current medication. However, if you choose to continue taking your current medication, you will have to pay 100 percent of the cost.

  • How much will I pay when I change to another medication?

    You can use the Check Drug Cost & Coverage tool at Caremark.com to see how much your medication will cost according to your plan.

  • My other medications are not listed here. Will they still be covered?

    Yes, formulary changes only affect a small number of medications. Review your benefit plan to make sure there are no other specific coverage rules for your other medications.

  • What can I do to help keep my out-of-pocket costs low?

    Typically, you will pay less for generic medications than for brand-name medications. Generics work just as well as brands, but cost up to 80 percent less.   * Ask your doctor to prescribe generics (if available) or lower-cost brands to help save money for you and for your plan. It may be helpful to print out your list of covered medications and bring it with you to your next doctor’s appointment.   *Plan’s medication list covers all disease states. Lifestyle-related treatments (i.e., anti-obesity, cosmetic, erectile dysfunction and fertility agents) may not be included or may be included at a much higher cost. Plan is limited to generic medications and some brand-names when a*Research shows that individuals on average can save 30 to 80 percent by using generics. Your savings will vary based on your plan and/or drug prescribed. Source: Generic Pharmaceutical Association website, http://www.gphaonline.org/about-gpha/about-generics/case. generic is not available in the class. Medications that cost more but may not work better may be offered to members at up to the full cost, depending on their plan. Coverage may vary. Please consult your plan for further information.

  • What if my doctor wants me to stay on my current medication?

    If your doctor determines that none of the covered medications will work for your condition, your doctor can call us at 1-855-240-0536 to request prior authorization for your current medication. Please remember that prior authorization approvals are not guaranteed, so we recommend talking to your doctor about changing to a covered medication.