Value Formulary Plan Member FAQs

  • Value Formulary Plan Member FAQs

    Q1: Does this plan cover medicines to treat all health conditions?
    A1: Yes. This plan includes medicines to treat all health conditions.* CVS/caremark helps to make sure you have access to medicines that treat all short-term or long-term health conditions.

    Q2: The Quick Reference List and Complete Drug List refer to my plan as “Value Formulary.” What is Value Formulary?
    A2: A formulary is a list of the medicines that are included on your prescription benefit plan. A formulary is also called a drug list. These lists refer to Value Formulary because the medicines on the plan’s formulary are high-value. That is, they provide quality health benefits and could help you save money.

    Q3: Why is there more coverage on this plan different for certain medicines and not others?
    A3: CVS/caremark pharmacists and doctors created Value Formulary as a high-value plan based on medical treatment guidelines first, and then cost. The plan includes medicines that provide quality health benefits and could help you save money.* Medicines that cost more but may not work better may be offered to members at up to the full cost, depending on your specific plan.

    Q4: Does this plan cover medicines for “lifestyle” conditions?
    A4: Not always – it may not cover medicines used to treat lifestyle conditions. You may have to pay the full cost to use these medicines. These include medicines for erectile dysfunction, infertility, anti-obesity and cosmetic conditions. If you have questions about whether your plan covers lifestyle conditions, call the toll-free number on the back of your prescription (or “member”) ID card.

    Q5: What are my out-of-pocket costs for the different medicines under the Value Formulary plan?
    A5: Typically, you will pay less out-of-pocket costs for generic medicines than for brand-name medicines.† You may already pay more for brand-name medicines under your current plan. If so, you may not pay more than your current out-of-pocket costs for a brand-name medicine if it is included in the Value Formulary plan.

    Q6: How do I know if my current medicine is a lower-cost option on the Value Formulary plan?
    A6: Try one of the methods below to see if Value Formulary covers your current medicine as a lower-cost option:

    • Check to see if your current medicine is listed on the Quick Reference List , which includes plan medicines to treat some common health conditions. For a full list of plan medicines, please review the Complete Drug List.
    • Call the toll-free number on the back of your prescription (or “member”) ID card to learn about all your options.

    Also, if your plan sponsor will soon change to the Value Formulary plan within the next few months, watch for a letter from CVS/caremark. You will receive a letter from CVS/caremark if your new Value Formulary plan does not cover your current medicine, or covers it with clinical requirements

    Q7: Can I keep filling my current prescription on the Value Formulary plan?
    A7: Yes. However, you may have to pay up to the full cost to keep using this medicine if your current prescription is not a lower-cost option. Once the coverage changes of your new plan become effective, medicines not included on your plan may be covered at a very high cost to you or may not be covered at all, depending on your specific plan.

    Q8: Why does it make sense to change to a lower-cost option on the Value Formulary plan?
    A8: Because for many health conditions, many medicines on this plan work just as well but may cost up to 80% less.** When and your doctor choose a lower-cost medicine from your Value Formulary plan, it also helps keep the cost of health care down for your plan sponsor. In turn, this change helps keep health care costs down for you and your family.

    Q9: How do I change from my current medicine to a lower-cost option included on this plan?
    A9: Before the coverage changes on your new plan become effective, follow these simple steps:

    1. Ask your doctor which lower-cost option on the Value Formulary plan will work for you. Your doctor can visit Caremark.com/highvalueplan to view options.

    2. Fill your new prescription(s) at retail or mail service:

    • Retail Pharmacy: Ask your doctor to call in the new prescription(s) to a CVS/caremark network pharmacy (find one at Caremark.com). Out-of-network pharmacies may cost you more.
    • CVS Caremark Mail Service Pharmacy: Your doctor can call in the new prescription to us toll-free at 1-800-378-5697. Or call us toll-free at 1-866-251-9383, and we will contact your doctor for you!

    3. Let your doctor or other health care provider know you prefer to use generic medicines whenever possible.

    Q10: What if my doctor thinks I should continue my current, higher-cost medicine?
    A10: Ask your doctor to visit caremark.com/highvalueplan to consider the lower-cost options that may work for you instead. If your doctor still does not think the options on the high-value plan are right for you because of a special medical situation, he/she can contact us.

    Q11: I’ve asked my doctor for a coverage exception for a medicine that is not included on the Value Formulary plan. How long does it take CVS/caremark to process my request?
    A11: A coverage exception request can take up to 15 business days to process, depending on your plan. Here are a couple of suggestions:

    • If your doctor submitted the request in the last 15 business days, please continue to wait and look for a notification of the coverage decision in the mail. Your doctor should also receive a notification in the mail.
    • If you haven't heard from CVS/caremark about your request and it has been more than 15 business days, call your doctor to confirm that the request for a coverage exception was sent to CVS/caremark.

    Q12: My request for a coverage exception was denied, but my doctor and I are appealing the CVS/caremark decision. How long does it take CVS/caremark to process my appeal request?
    A12: 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 receive a notification in the mail for an appeal request and a second level appeal.

*Plan’s medicine 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 medicines and some brand-names when a generic is not available in the class. Medicines 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.

 

**Savings will vary based on your plan limitation and/or drug prescribed. Source: Generic Pharmaceutical Association Website: http://www.gphaonline.org/about/generic-medicines. CVS/caremark does not operate the websites/organization listed here, nor is it responsible for the availability or reliability of its content. This listing does not imply or constitute an endorsement, sponsorship or recommendation by CVS/caremark.

†Out-of-pocket costs are copayment, copay or coinsurance which means the amount a plan member is required to pay for a prescription in accordance with a plan, which may be a deductible, a percentage of the prescription price, a fixed amount or other charge, with the balance, if any, paid by a plan.

 

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