Retail pharmacy

Medications covered under the pharmacy benefit are typically those that can be self-administered by the patient, such as oral tablets and capsules, topical creams and lotions.

Depending on the prescription, the member may need prior authorization. When a Prior Authorization is needed for a prescription, the health care provider will need to contact the CVS Caremark® Prior Authorization Department to answer criteria questions to determine coverage.

Prior Authorization

• To complete a prior authorization, please complete the Prior Authorization Form for Prescription Drugs and submit it by fax as indicated on the form.
• To understand which medications require approval please see the Metallic Prior Authorization Medication List (machine readable)
• To view clinical criteria please see Prior Authorization and Step Therapy Criteria

Please note: Not all medications require prior authorization. You may contact customer service to determine what medications require prior authorization.

Pharmacy exception requests

Healthcare providers may file a pharmacy exception request when both of the following criteria are met:

• A member is taking an excluded or nonformulary medication
• The provider determines that no other medication listed in the formulary is effective for that member

Exception requests are reviewed based on medical necessity. Factors considered in the review of a pharmacy exception request may include:

• Clinical guidelines
• Formulary alternatives
• Brand/generic availability
• Step therapy
• Quantity limits

Clinical documentation should be provided with each request.

The requesting provider and member will be notified of the determination. If the member’s request is denied, the member has the right to request an appeal. 

To complete an exception request, please complete the Exception request form and submit it by fax as indicated on the form.