There are important features you should be aware of. These include:
- Who can write your prescription. A licensed physician or dentist, and in the states allowing it, licensed or certified authority prescribing within their scope of practice must prescribe your medication.
- Where you can obtain them. You may fill the prescription at a network pharmacy, a non-network pharmacy, or by mail for certain drugs. We pay a higher level of benefits when you use a network pharmacy.
- Network pharmacy – Present your Plan identification card at a network pharmacy to purchase your prescriptions and have the claim be filed electronically for you. Call 800-410-7778 or check the electronic directory via www.MHBP.com to locate the nearest network pharmacy.
- Non-Network pharmacy – Standard Option members may purchase prescriptions at pharmacies that are not part of our network. You pay the full cost and manually file a claim for reimbursement. See Section 7, Filing a claim for covered services. Prescription drugs obtained from a non-network pharmacy are not covered under Value Plan.
- Mail order – To obtain more information about the mail order drug program, order refills, check order status and request additional mail service envelopes and claim forms, or to ask questions about eligibility, copayments or other issues, call CVS Caremark at 866-623-1441 or visit our website, www.MHBP.com.
Remember to use a Network pharmacy whenever possible and show your MHBP ID card to receive the maximum benefits and the convenience of having your claims filed for you.
We use a formulary. A formulary is a list of generic and preferred drugs (see below) that are available through this plan. It places all FDA approved drugs into categories based on their clinical effectiveness, safety and cost and is designed to control costs for you and the Plan. The categories include:
- Generic drug category includes primarily generic drugs;
- Preferred drug category (also called "formulary") includes preferred brand name drugs;
- Non-Preferred drug category (also called "non-formulary") includes non-preferred brand name drugs;
- Specialty drug category (see description of Specialty drugs below).
Occasionally, drugs may change from one category to another category, which can affect your cost-share amount. We will attempt to notify you when this occurs.
When you need a prescription, share the formulary with your physician and request a Generic or Preferred category drug if possible. By choosing Generic or Preferred category drugs, you may decrease your out-of-pocket expenses. While all FDA-approved drugs are available to you, we may have formulary restrictions on certain drugs, including but not limited to, quantity limits, age limits, dosage limits, brand exception and preauthorization. To request a copy of our current formulary, call us at 800-410-7778 or visit our website, www.MHBP.com.
A generic equivalent will be dispensed if it is available when you obtain your prescription from a network pharmacy or through our mail order drug program. If you choose a brand name medication for which a generic medication exists, you will pay your cost-share plus the difference in cost between the brand name and generic medication. If you have a medical condition that requires a brand name drug your prescribing physician must obtain a brand exception. For information on how to obtain a brand exception, you or your physician should call us at 800-410-7778 or visit our website, www.MHBP.com. If the exception is not approved, your cost-sharing will be greater.
Why use generic drugs? A generic drug is the chemical equivalent to a brand name drug, yet it costs much less. Choosing generic drugs rather than brand name drugs can reduce your out-of-pocket expenses. The U.S. Food and Drug Administration sets quality standards for generic drugs to ensure that these drugs meet the same standards of quality and strength as brand name drugs. They must contain the same active ingredients, be equivalent in strength and dosage, and meet the same standards for safety, purity and effectiveness as the original brand name product.
Maintenance and long-term medications. A long-term maintenance medication is one that is taken regularly for chronic conditions or long-term therapy. A few examples include medications for managing high blood pressure, asthma, diabetes or high cholesterol. MHBP offers a Maintenance Choice Program that allows members to get up to 90-day fills at a CVS retail pharmacy or through our mail order drug program for the same cost-share as mail order.
There are dispensing limitations. All prescriptions will be limited to a 30-day supply for retail and a 90-day supply for mail order. Also, in most cases, refills cannot be obtained until 75% of the drug has been used. Occasionally, as part of regular review, we may recommend that the use of a drug is appropriate only with limits on its quantity, total dose, duration of therapy, age, gender or specific diagnoses. Since the prescription does not usually explain the reason your provider prescribed a medication, we may implement any of these limits and/or require preauthorization to confirm the intent of the prescriber.
Preauthorization. We require preauthorization (PA) for certain drugs to ensure safety, clinical appropriateness and cost effectiveness. PA criteria are designed to determine coverage and help to promote safe and appropriate use of medications. Drugs subject to PA are screened at the point of service and the dispensing pharmacy is advised to have the prescriber contact the CVS Caremark PA department. CVS Caremark will obtain the relevant information from the prescriber to determine whether the drug use meets the established criteria for the requested drug. In certain circumstances, a preauthorization may require the trial or step of a more appropriate first line agent before the drug being requested is approved.
To obtain a list of drugs that require preauthorization, please visit our website, www.MHBP.com or call 866-623-1441. We periodically review and update the preauthorization drug list in accordance with guidelines set by the US Food and Drug Administration, as a result of new drugs, new generic drugs, new therapies and other factors. To request preauthorization, your physician should contact the CVS Caremark Preauthorization Department at 800-294-5979. CVS Caremark will work with your physician to obtain the information needed to evaluate the request. You may contact CVS Caremark at 866-623-1441 for the status of your request and any questions you have regarding preauthorization.
Specialty drugs, including biotech drugs, require special handling and close monitoring, and are used to treat chronic complex conditions including, but not limited to: hemophilia, immune deficiency, growth hormone deficiencies, multiple sclerosis, Crohn's disease, hepatitis C, HIV, hormonal disorders, rheumatoid arthritis and pulmonary disorders.
- Certain specialty drugs require preauthorization (also referred to as Specialty Guideline Management (SGM)) to determine medical necessity and appropriate utilization.
- A specialty preferred drug trial must be completed before certain non-preferred specialty drug will be authorized.
- Certain specialty drugs must be obtained from CVS Caremark Specialty Pharmacy.
To obtain a list of drugs that require preauthorization, a specialty preferred drug trial, or that must be obtained from CVS Caremark Specialty Pharmacy, please review the Specialty Prescription Drug List on our website, www.MHBP.com or call 866-623-1441.
Advanced Control Specialty Formulary – We use a formulary for specialty drugs that includes generic and preferred brand name drugs that are therapeutically equivalent to non-preferred brand drugs for certain drug classes. An exception process is available. The formulary is subject to change on a quarterly basis.
CVS Weight Management™ Program combined with weight loss medications provides personalized support that helps participants achieve lasting weight loss results. Participation is voluntary. The program will help you reach your weight loss goals through:
- One-on one support from a team of clinicians, including providers and registered dieticians
- A nutrition plan tailored just for you
- Health Optimizer™ app with helpful, guides, recipes, goal setting and much more
- Connected body weight scale and other devices, as applicable, to support and track your progress
There is no cost to you to participate in this program. For additional questions or to enroll in the CVS Weight Management Program please call 1-800-207-2208.
Compound medications. A compound medication is made by combining, mixing or altering one or more ingredients of a drug (or drugs) to create a customized medication that is not otherwise commercially available. Preauthorization may be required for some compound medications. Certain ingredients contained in some compound medications are excluded from coverage under this Plan. They are certain proprietary bases, drug specific bulk powders, hormone and adrenal bulk powders, bulk nutrients, bulk compounding agents, and miscellaneous bulk ingredients. Dispensing and refill limits may apply.
Pharmacies must submit all ingredients in a compound medication as part of the claim. At least one of the ingredients in the compound medication must require a physician’s prescription in order to be covered by the Plan. CVS Caremark can compound some medications. If the mail order pharmacy cannot accommodate your prescription, please consult your Network retail pharmacy. Ask your pharmacist to submit your claim electronically. If the retail pharmacy is unable to submit the compound medication claim electronically to CVS Caremark, you will pay the full cost of the medication and submit the claim for reimbursement. Make sure that your pharmacist provides the NDC number and quantity for every ingredient in the compound medication, and include this information on your claim. You are responsible for the appropriate copayment or coinsurance based on the compound ingredients. Claim calculations and your cost sharing is performed using an industry standard reimbursement method for compounds.
Investigational drugs are not FDA approved. If the compound includes an investigational drug, the compound will not be covered.
We can accommodate your drug refill requests when you are called to active military duty or in the case of a declared emergency. Call 866-623-1441 in advance to request the accommodation. You will be required to provide a copy of your work order.
The Plan conducts Drug Utilization Review (DUR). When you fill your prescription at a network pharmacy or through the mail-order program, we and/or the pharmacist may electronically access information about prior prescriptions, checking for harmful drug interactions, drug duplication, excessive use and the frequency of refills. DUR helps protect against potentially dangerous drug interactions or inappropriate use. When appropriate, your pharmacist(s) and/or CVS Caremark may contact your physician(s) to discuss an alternative drug or treatment option, prescription drug compliance, and the best and most cost-effective use of services. In addition, we may perform a periodic review of prescriptions to help ensure your safety and to provide health education and support. Upon review, we may contact you or your provider(s) to discuss your current medical situation and may offer assistance in coordinating care and treatment. For more information about this program, call us at 866-623-1441.
When you have to file a claim. Standard Option members who purchase prescriptions at a non-network pharmacy, mail your CVS Caremark claim form and prescription receipts to: CVS Caremark, Attn: Claims Department, P.O. Box 52136, Phoenix, AZ 85072-2136. Receipts must include the prescription number, name of drug, date, prescribing doctor’s name, charge, name and address of pharmacy and NDC number (included on the bill). See Section 7, How to claim benefits for additional information.
Benefits for all prescription drugs will be determined based on the fill date for the prescription.
Note: Some drugs may not be available through the mail order program. Some of the drug classes that may not be available are: narcotics, hospital solutions and certain drugs such as antipsychotic agents and AIDS therapies and other drugs for which state or federal laws or medical judgment limit the dispensing amount to less than 90 days. In addition, some injectables may not be available through the mail order drug program. Covered drugs and supplies that are not available through the mail order drug program may be purchased at a retail pharmacy. For questions about the mail order drug program or to inquire about specific drugs or medications, please call 866-623-1441.
When you have other prescription drug coverage
When we are the primary payor for prescription drug claims, we will pay the benefits described in this brochure.
When we are the secondary payor for prescription drug claims, we will determine our allowance. After the primary plan pays, we will pay what is left of our allowance, up to our regular benefit, or up to the member’s responsibility as determined by the primary plan if there is no adverse effect on you (that is, you do not pay any more), whichever is less. We will not pay more than our allowance. The combined payment from both plans may be less than (but will not exceed) the entire amount billed by the pharmacy or healthcare provider.
The provision applies whether or not a claim is filed under the other coverage. When applicable, authorization must be given to this Plan to obtain information about benefits or services available from the other coverage, or to recover overpayments from other coverages.
Other commercial coverage: When you have drug coverage through another group health insurance plan and that coverage is primary, follow these procedures:
Retail pharmacy:
1. Present the ID cards from both your primary insurance plan and MHBP at the pharmacy. Instruct the pharmacy to submit to your primary plan first.
2. If able, the pharmacy will electronically submit claims to both your primary and secondary plans, and the pharmacist will tell you if you have any remaining balance to pay.
3. If the pharmacy cannot electronically submit the secondary (MHBP) claim, pay any copay/coinsurance required by the primary insurance, then manually submit your claim for MHBP benefits. Mail your pharmacy receipt to CVS Caremark for any secondary benefit that may be payable. Submit claims to CVS Caremark, PO Box 52136, Phoenix, AZ 85072-2136.
In order to receive MHBP’s Network pharmacy benefit, you must use a Network pharmacy. Otherwise, Non-network pharmacy benefits will apply.
If your primary plan does not provide for electronic claims handling, purchase your prescription from the pharmacy and submit a claim to your primary plan. When the primary plan has made payment, submit the claim and the primary plan’s Explanation of Benefit (EOB) to CVS Caremark for any secondary benefit that may be payable. Submit claims to CVS Caremark, PO Box 52136, Phoenix, AZ 85072-2136.
Mail service pharmacy:
1. Purchase the prescription through your primary plan’s mail service pharmacy and pay any copay/coinsurance required by the primary plan.
2. Then manually submit your claim for MHBP benefits. Mail your pharmacy receipt to CVS Caremark for any secondary benefit that may be payable. Submit claims to CVS Caremark, PO Box 52136, Phoenix, AZ 85072-2136.
Medicare Part B coverage: When Medicare Part B is your primary payor, have the pharmacy submit Medicare covered medications and supplies to Medicare first. Prescriptions typically covered by Medicare Part B include diabetes supplies (test strips, meters), specific medications used to aid tissue acceptance from organ transplants, and certain oral medications used to treat cancer. MHBP’s prescription drug benefits exclude coverage for Part B drugs and supplies, your prescriptions will be coordinated with Medicare and our medical benefits.
Retail pharmacy: Present your Medicare ID card and ask the pharmacy to bill Medicare as primary. Most independent pharmacies and national chains participate with Medicare. To locate a retail pharmacy that participates with Medicare Part B, visit the Medicare website at www.medicare.gov/supplier/home.asp, or call Medicare Customer Service at 800-633-4227. To maximize your benefits, use a pharmacy that participates with Medicare Part B and is also in our network. We will automatically retrieve your claim from Medicare and coordinate benefits for you.
