FAQs Prescription Drugs
CVS Caremark administers prescription drug benefit for all Anthem Blue Cross plan participants. CVS Caremark provides CVS Caremark Mail Order program as well as a network of retail pharmacies.
What’s the difference between formulary and non-formulary drugs?
CVS Caremark's formulary is a list of generic and preferred brand name drugs. This list includes a wide selection of medications and offers you a choice while helping keep the cost of your prescription drug benefit affordable. Every drug on the formulary is Food and Drug Administration approved, and reviewed by an independent group of doctors and pharmacist for safety and efficacy.
Does our prescription drug program cover both formulary and non-formulary prescriptions?
Yes, as long as it is a covered medication under the LAUSD benefit plan, you can obtain formulary and non-formulary medications through CVS Caremark. See CVS Caremark's website at www.caremark.com to view more information.
Is prior authorization ever required?
Yes, some medications are covered by your plan only for certain uses or in certain quantities. For example, a drug may not be covered when it is used for cosmetic purposes. Also, the quantity covered may be limited to certain amounts over certain time periods. In these cases, your doctor may need to provide more information.
The pharmacy will let you know if additional information is required. You or the pharmacy can then ask your doctor to call a special toll-free number. This call will initiate a review that typically takes 1 business day. Once the review is completed you and your doctor will be notified of the decision. If coverage is approved, you will be sent a letter, which includes the length of the coverage approval. If the coverage is denied, you will be sent a letter, which includes the reason for coverage denial and instruction on how to submit an appeal.
What drugs are not covered under our prescription drug program?
- Infertility medications when used for assisted reproduction.
- Drugs prescribed, dispensed, or intended for use while in a hospital, skilled nursing facility or alternate facility.
- Drug products for any condition, injury, sickness or mental illness arising out of, or in the course of, employment for which benefits are available under any workers' compensation or other similar laws.
- Drugs administered at a doctor's office or hospital, including allergy serum, immunizations, biological sera, blood, or blood plasma. However, these may be covered under the medical plan.
- OTC products that do not require a prescription or any prescription medication that is available as an OTC medication. Exceptions are insulin and niacin.
- Drugs used for investigational purposes or experimental indications, drugs with no approved FDA indications.
- Implantable or injectable contraceptives.
- Injectable drugs, except when the drug can be self-administered, as defined by the plan. Other injectables may be covered under the medical plan.
- Unit dose or convenience packaging of prescription drug products.
- Durable medical equipment, prescribed and non-prescribed outpatient supplies, other than selected diabetic supplies.
- Anabolic steroids except testosterone
- Drugs used for cosmetic purposes or aesthetic enhancement
What if I fill a prescription at a non-participating refill pharmacy?
First, you will pay the full cash price of the prescription. Then, in order to request reimbursement, you may obtain a direct claim reimbursement form at www.caremark.com or you may call CVS Caremark Customer Service. Complete the form and submit to the address provided. The reimbursement will be 70% of the approved amount.
Remember: To pay your usual co-payment amounts, always go to a participating retail pharmacy and present your prescription drug card or use CVS Caremark's Maintenance Choice by Mail program.
