Value Formulary Plan Prescriber FAQs

  • Value Formulary Plan Prescriber FAQs

    Q1: How do I know if there is a coverage change for my patient’s medication on the Value Formulary plan?
    There are several ways to determine whether there is a coverage change for your patient’s medication:

    • Check the Value Formulary plan’s Quick Reference List, that includes lower-cost plan medications to treat some common health conditions. For a more detailed list of lower-cost plan medications, please review the Complete Drug List .
    • Look for communications from CVS/caremark. If your patient’s plan sponsor will soon change to the Value Formulary plan for its ensuing plan year, you will receive a letter from CVS/caremark within the next few weeks or months. This letter will provide details as to your patient’s coverage.

    Q2: Can my patient continue to fill his or her current medications if the patient is not included on the Value Formulary plan?
    A2: Yes. However, to continue using these medications your patient may have to pay up to the full cost.

    Q3: How do I change my patient’s current medications to lower-cost options included on the Value Formulary plan?
    A3: Here’s how:

    1. Review the Quick Reference List or the Complete Drug List and select medications that are appropriate for your patient.

    2. Order the new prescription(s) for your patient:

    • Retail Pharmacy: Call, fax or e-prescribe the new prescription(s) to your patient’s pharmacy.
    • CVS Caremark Mail Service Pharmacy: Call the prescriber line toll-free at 1 800 378 5697 if your patient wishes to start a 90-day prescription.

    Q4: What if my patient needs to continue his or her current, higher-cost medication(s)?
    A4: If your patient has a unique or atypical medical situation that is better treated with a higher-cost medication, then you may request an exception. You may do this in one of two ways, depending on your patient’s plan:

    • If your patient has paid or will have to pay a very high amount for the medication, you may download and complete a Tiering Exceptions Request Form and fax it to our Exceptions team at 1-888-487-9257.
    • If your patient’s medication has been or will be denied, you may call our Prior Authorization team toll-free at 1-877-203-1681 to initiate a Formulary Exceptions request. For both requests, please provide detailed notes and additional documentation that demonstrates your patient’s medical necessity for the current, higher-cost medication.

    Q5: Does this plan cover medications to treat all health conditions?
    A5: Yes. The CVS/caremark Value Formulary plan includes medications to treat all acute or chronic health conditions.*

    Q6: Why is the coverage different for certain medications on the Value Formulary plan?
    A6: CVS/caremark pharmacists and doctors created Value Formulary based on medical treatment guidelines first, and cost second. The Value Formulary plan includes medications and utilization management tools to provide high quality, cost-effective pharmacy care.

    Q7: Does the Value Formulary plan cover medications for “lifestyle” conditions?
    A7: Not always – it may not cover medicines used to treat lifestyle conditions. Your patient may have to pay the full cost to use these medicines. These include medicines for erectile dysfunction, infertility, anti-obesity and cosmetic conditions. If your patient has questions about whether the plan covers lifestyle conditions, the patient should call the toll-free number on the back of the prescription (or “member”) ID card to find out what the cost share will be for these medicines.

*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 some members at up to the full cost, depending on their plan. Coverage may vary. Please consult your plan for further information.

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