About Your Medications
If you are a Medicare member, please check our Medicare section for information on your benefits.
Capital Health Plan utilizes Caremark to administer our pharmacy benefits. You can register at the Caremark web-site (www.caremark.com) to find out more information about your specific medications (including refill history and cost), general information on medications (side effects, storage concerns, and drug interactions), and the benefit of using generics over brand name medications. If you have trouble logging in to Caremark's website, or you do not have access to a computer, you can contact their customer service department at 1-800-966-5772.
Prescription Drug Benefit
Each covered prescription drug, when purchased from a participating pharmacy, is subject to a copayment amount. The copayment amount is determined by the type of prescription drug dispensed (generic, preferred brand, non-preferred brand, self-injectable or specialty drug).
- Tier 1 Generic Drugs $
- Tier 2 Preferred Brand Drugs $$
- Tier 3 Non-Preferred Brand Drugs $$$
- Tier 4 Self-Injectable or Specialty Drugs $$$$ (if applicable)
Capital Health Plan encourages the use of generics as the first-line of treatment. Generic medications are the lowest-cost options to our members and are available at a Tier 1 copay. Talk with your doctor to see if a generic is available to treat your condition.
If a generic is not available, the use of a brand name medication designated as preferred (P) on our 2013 Commercial Formulary (pdf 768.18 kB) is desired. Any brand name not designated as preferred (P) is considered non-preferred and will result in a Tier 3 copay. A 4-tier Prescription Benefit Plan is available, with Tier 4 including drugs that are usually self-injectable or specialty.
Commercial Utilization Management Criteria
Your Prescription Drug Benefit may be subject to limitations and exclusions such as those listed below. For a complete list, refer to your Pharmacy Program Prescription Drug Endorsement.
- A prescription unit or refill is covered for up to a 30-day supply (or a 90-day supply of a generic drug at any participating retail pharmacy). Refills on prescriptions are not covered until at least 75% of the previous prescription is used based on the dosage schedule prescribed by the physician.
- Certain prescription drugs require prior authorization for coverage. For instructions on how to obtain prior authorization, please contact Member Services at (850) 383-3311 Monday through Friday, 8:00 a.m. to 5:00 p.m. Also, Commerical Criteria for those selected medications are available for download.
- If a generic drug is available and a more expensive brand name prescription drug is dispensed at the request of the member or the prescriber, the member must pay the copayment amount for the brand name drug plus pay the pharmacist 100% of the additional cost for the more expensive brand name prescription drug.
- CHP may limit quantities for medications prescribed to be taken on a p.r.n. (as needed) basis.
Please note: Medicare members have a different drug list, called the Medicare Advantage Formulary. If you are a Medicare member, please check our Medicare section for information on your prescription drug benefits.
Our Pharmacy Network
Capital Health Plan contracts with over 64,000 pharmacies nationwide. To locate a pharmacy in our network, use our pharmacy locator. Always present your CHP identification card when utilizing these pharmacies for your medication needs.
How to Request an Exception to our Prescription Drug Coverage Rules
You, your authorized representative, or your prescribing physician can request an exception to prescription drug coverage restrictions or quantity limits. For example, certain drugs on CHP's formulary have quantity limits. If your drug has a quantity limit, you can ask CHP to cover a quantity over the stated limit. You may need to meet certain clinical criteria to receive an approval for the higher quantity. The exception request can be initiated by calling our Member Services department at (850) 383-3311 or toll-free at 1-877-247-6512, Monday through Friday from 8:00 am through 5:00 pm. The TDD number for the hearing impaired is (850) 383-3534. If you call after hours or on a weekend, you can call (850) 383-3333 or toll-free (800) 390-1434. The after-hours number for the Florida State Relay, for the hearing impaired is (800) 955-8771.
You can also submit a drug exception request via e-mail to the Member Services department.
A Member Services representative will contact you within one business day to let you know that the request has been submitted to our Pharmacy Services department for a decision by a Capital Health Plan Medical Director. Staff from the Pharmacy Services department may need to request additional information from you or your prescribing doctor. A request for an exception will be approved only when there is a medical reason for it. If the exception is denied, you will be notified of the decision and given information about your appeal rights. For additional information about the decision-making procedures for an exception request, review the Utilization Management section of the web-site.
For up-to-date information on drug recalls, market withdrawals, and safety alerts, visit the U.S. Food and Drug Administration’s (FDA) website at http://www.fda.gov/opacom/7alerts.html.