For medications not listed on the Formulary, providers may follow the same course of action as with a Coverage Determination, also called a Prior Authorization. This can be initiated by having your Provider call 855.294.5979 and request a Coverage Determination for the Medication(s) whether or not it is listed on the Formulary. Should this coverage be denied, an appeal can be made within 60 days of the initial denial by calling 888.543.9069 (choose option 1 for pharmacy appeals) or by having the Provider fax clinical chart notes or a letter of medical necessity to 718.536.3383.

Covered Drug List (Formulary)
 

A Convenient Way to Fill Prescriptions

• At your local pharmacy
  You can use your prescription benefit ID card at most chain and independent pharmacies across the country. Find a participating pharmacy near you using the Pharmacy Locator.

If you paid out of pocket for a covered medication and you were active on the date filled please utilize the following form with instructions for a reimbursement.

The reimbursement is issued through our Pharmacy Benefits Manager CVS. Should you have any questions about a claim reimbursement or the status of an already filed claim please call 855.722.6228.

Claim Form

Specialty Medications
These are high-cost, injectable, oral, infused or inhaled medications that are typically self-administered.

Specialty Guideline Management (SGM)
SGM is our utilization management program; administered by CVS Caremark, that helps ensure appropriate utilization for specialty medication based on currently accepted evidence-based medicine guidelines. SGM is designed to ensure safety and efficacy while preventing off-guideline utilization. Prescribers may call 800.237.2767 to enroll patients in the Specialty plan design.

Comprehensive Contraception Coverage Act (CCCA)

You are covered for all forms of contraceptive drugs, devices and products approved by the U.S. Food and Drug Administration (FDA). This includes all FDA-approved over-the-counter contraceptive products as prescribed or as otherwise authorized under state or federal law. You are also permitted to receive an entire 12-month supply of a contraceptive at once.

Where the FDA has approved one or more therapeutic and pharmaceutical equivalent versions of a contraceptive drug, device or product, Affinity Health Plan is not required to include all of the therapeutic and pharmaceutical equivalent versions in its formulary, so long as at least one is included and covered without cost-sharing.

Your contraceptive coverage is provided without any cost-sharing, including any deductible, coinsurance or copayment. Prior authorization, step therapy protocols, or quantity limits on a 12-month supply are not permitted for your contraceptive coverage.