Prescriptions that are included in the Part D formulary must be filled at a “network pharmacy,” because we have made arrangements with them to provide prescription drugs to plan members. A network pharmacy is a pharmacy where beneficiaries obtain prescription drug benefits provided by CDPHP Medicare Choices. In most cases, your prescriptions are covered under CDPHP Medicare Choices only if they are filled at a network pharmacy or through our mail-order pharmacy service. We offer flexibility within our network. You are not required to continue going to the same pharmacy to fill your prescriptions; you can try any of our network pharmacies. We will fill prescriptions at non-network pharmacies under certain circumstances as described in the Evidence of Coverage for HMO.
Out-of-network pharmacies are those pharmacies not in the plan's network. If you use an out-of-network pharmacy, you may have to pay the full cost (rather than paying just your copayment) when you fill your prescription. You can ask us to reimburse you for our share of the cost by submitting a claim form. You may be responsible for paying the difference between what we would pay for a prescription filled at an in-network pharmacy and what the out-of-network pharmacy charged.
When to Use an Out-Of-Network Pharmacy
- When you are traveling outside your plan’s service area.
- If you lose or run out of your covered drugs or you become ill and need a covered drug immediately and cannot access a network pharmacy.
- If you cannot obtain a covered drug within your service area in a timely manner due to lack of availability of a participating network pharmacy.
- If your covered drug is provided by an out-of-network institution-based pharmacy while you are in an emergency department, provider-based clinic, outpatient surgery, or other outpatient setting.
- If you are administered a vaccine covered by your plan in a physician’s office.
- If you must fill a covered drug prescription and the drug is not regularly stocked at accessible network retail or mail-order pharmacies.
How to Submit a Paper Claim for an Out-of-Network Prescription
If you go to an out-of-network pharmacy for any of the reasons listed above, the pharmacy may not be able to submit the claim directly to us. When that happens, you will have to pay the full cost of your prescription and mail the completed claim form along with the receipt to:
CVS Caremark Part D Service, LLC
Medicare Part D Paper Claims
P.O. Box 52066
Phoenix, AZ 85072-2066
Upon receipt, an initial coverage determination will be made on the claim. For more information on initial coverage determinations, limits, and financial responsibilities, please refer to your Evidence of Coverage for HMO, or call customer care.
Is Your Drug Covered By Our Plan?
If your medication is not on our Medicare Formulary (list of covered Part D drugs) or if the drug is restricted in some way, you have options.
You may be able to get a temporary supply of the drug (only members in certain situations can get a temporary supply). If you are approved for a temporary supply, you should talk with your prescriber during that time to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug.
How to Request a Formulary Exception
If you can’t switch to another drug, you and your prescriber can ask the plan to make an exception for you and cover the drug in the way you would like it to be covered. If your prescriber says that you have medical reasons that justify asking us for an exception, your prescriber can help you request an exception to the rule. This is called a “coverage determination.”
You and your prescriber can complete the Coverage Determination Request Form and submit it to the CDPHP pharmacy department for consideration.
If we approve your request for a Formulary exception, our approval usually is valid until the end of the plan year. This is true as long as your doctor continues to prescribe the drug for you and that drug continues to be safe and effective for treating your condition.
How to Request a Formulary Redetermination
If we deny your request for a Formulary exception, you can ask for a review of our decision by making an appeal. This is called a “redetermination.”
You and your prescriber can complete the Redetermination Request Form and submit it to the CDPHP appeals department for consideration.
NOTE: These forms should be completed by you (or someone acting on your behalf) and your prescriber.
Medicare Pharmacy Exception and Appeals Forms
Coverage Determination Request Form
Y0019_12-3001A File & Use 12132011
This form may be used to request an exception to our Medicare Formulary (list of covered Part D drugs).
You may also ask us for a coverage determination by phone at (518) 641-3950 or 1-888-248-6522 (TTY/TDD (518) 641-4000 or 1-877-261-1164).
Who May Make a Request:
Your prescriber may ask us for a coverage determination on your behalf. If you want another individual (such as a family member or friend) to make a request for you, that individual must be your representative. Contact us to learn how to name a representative.
Redetermination Request Form
Y0019_12-3001B File & Use 12132011
This form may be used if we have denied your request for an exception to our Medicare Formulary (list of covered Part D drugs).
CDPHP refers to both the Capital District Physicians’ Health Plan, Inc., a Medicare-approved HMO plan, and CDPHP Universal Benefits®, Inc., a Medicare-approved PPO plan. CDPHP is a health plan with a Medicare contract. Enrollment in CDPHP Medicare Choices depends on contract renewal. To join, you must have Medicare Parts A and B and live in the service area.