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Using Your Prescriptions Benefits
- Using your Prescription Drug Benefits
- Member Prescription Transition Plan
- Low-Income Subsidy Program
- Consumer Pharmacy Programs
- Quality Management Programs
- Drug Utilization Management
- Medication Therapy Management Program
- Part D Exceptions and Appeals
Where can I find the Formulary or drugs covered, and where do I go to get my prescription drugs?
To find out more information on the official Formulary and Notice of Negative Formulary Changes plan documents. visit our home page and please choose your state and your county. Then visit our Explore your Plan section. Select the name of your plan in the left-hand column to view the plan description page.
You can get your prescription drugs by mail order, or by visiting a local network pharmacy.
What if my prescription drug is not on the list in the Formulary?
Please contact your prescribing physician so that he or she may submit a prior authorization request. This is also called an "exception". For more information, see the Part D Appeals and Grievances page.
How do I fill a prescription through the network mail order pharmacy service?
You can use our network mail order pharmacy service to fill prescriptions for drugs that you take on a regular basis for chronic or long-term medical conditions. It generally takes us 14 days to process your order and ship it to you, but always order your mail order prescriptions at least 2 weeks prior to your need. If your prescription is delayed, you can contact your doctor to have a short-term prescription filled for immediate use. You are not required to use our mail order services to get an extended supply of maintenance medications. You can also get an extended supply through some retail network pharmacies.
Caremark Mail Order Process
- Register with Caremark by phone or online. Caremark will require a payment type for prescriptions; you can provide debit or credit card information when registering.
- Each member needs a written prescription from physician for the drug(s) for a 90 day supply - the prescription needs to indicate refills should be included for a year.
- Complete the “Caremark mail order” form- click the link below to open and print the form. This form must be completed and sent in with your prescription(s).
- Your physician can fax the form directly to Caremark at 1-800-378-0323 or you can mail in the prescription to Caremark. Please include your name, date of birth, and Health Plan Member ID number from your Member card.
- Typical processing time is about 2 weeks for you to receive your 90 day supply of medication in the mail.
What is a network pharmacy?
A network pharmacy has a contract with us to provide your covered prescriptions. In most cases, your prescriptions are covered only if they are filled at one of our network pharmacies. You may switch between network pharmacies as often as you'd like, but keep in mind that you must either have a new prescription written by a doctor or have the previous pharmacy transfer the existing prescription if any refills remain.
How do I fill a prescription outside the network?
We have network pharmacies outside of the service area where you can get your drugs covered as a member of our plan. Generally, we only cover drugs filled at an out-of-network pharmacy in limited circumstances when a network pharmacy is not available. We will cover your prescription at an out-of-network pharmacy if at least one of the following applies:
- If you are unable to get a covered prescription drug in a timely manner within our service area because there are no network pharmacies within a reasonable driving distance that provide 24-hour service.
- If you are trying to fill a covered prescription drug that is not regularly stocked at an eligible network retail or mail order pharmacy (these drugs include orphan drugs or other specialty pharmaceuticals).
Before you fill your prescription in these situations, call Member Services to see if there is a network pharmacy in your area where you can fill your prescription. If you go to an out-of-network pharmacy for the reasons listed above, you may have to pay the full cost (rather than paying just your co-payment). You can ask us to reimburse you for our share of the cost by submitting a claim form. You should submit a claim to us if you fill a prescription at an out-of-network pharmacy as any amount you pay will help you qualify for catastrophic coverage (please refer to the Catastrophic Coverage section under Outpatient Prescription Drugs in the Summary of Benefits). If we do pay for the drugs you get at an out-of-network pharmacy, you may still pay more for your drugs than what you would have paid if you went to a network pharmacy.
We cannot pay for any prescriptions that are filled by pharmacies outside the United States, even for a medical emergency. You can ask us to reimburse you for our share of the cost by submitting a claim form. To learn how to submit a paper claim, please refer to the paper claims process described in the next link.
How do I submit a paper claim for a prescription?
When you go to a network pharmacy, your claim is automatically submitted to us by the pharmacy. However, if you go to an out-of-network pharmacy, 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. When you return home, simply submit your claim and your receipt to the following address:
Caremark Claims Department
P.O. Box 52193
Phoenix, Arizona 85072-2193
What do I present as coverage when I am seeking medical and prescription services?
You should always carry your Desert Canyon Community Care ID card and state Medicaid card or letter, if applicable, to present as coverage. Contact us if you need to order a new ID card.
What is a specialty pharmacy?
A specialty pharmacy usually fills prescriptions for high-cost oral and self-injectable medications listed on your formulary as a Specialty Drug in a tier. There are two preferred specialty pharmacies that are recommended for your use, Axium Healthcare and Caremark Specialty. To fill a prescription from the pharmacy of your choice, simply complete the corresponding form below and send together with your prescription. For more information, please contact the specialty pharmacy of your choice:
Axium Healthcare: 1-888-315-3395
Caremark Specialty: 1-800-237-2767
How do I go about obtaining Durable Medical Equipment (DME) supplies?
Your Primary Care Physician (PCP) needs to submit an authorization for those supplies and if approved, you will be directed to a DME provider. An approved authorization will allow each member to utilize their Durable Medical Equipment supplies.
Y0007_MKT602 (H0320) CMS Approved (10/07/2011)