Affinity Health Plan

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  • Affinity Qualified Health Plan (QHP) Pharmacy Information

    Two Convenient Ways 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
    Through the Caremark Mail Order Pharmacy - If your doctor has prescribed a drug for you to take for a long time (also called a Maintenance Medication), you may be able to have up to a 90-day supply delivered directly to your home or location of choice from our mail order pharmacy by using the following form: English / Spanish
    When it’s time to get a refill you can order online or by phone anytime, day or night. You can also choose automatic refills. Click here for more information on ordering your prescriptions through the mail.
    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 1-855-722-6228.
    Medication Claim Form

    Summary of Benefits and Coverage by Plans
    Formulary (Drug) Information

    To find information regarding your prescription drugs and how we cover them click below.They are the same for all plans.

    AffinityAccess and AffinityAccess Direct Plans
    Covered Drug list(Formulary)
    Abridged Covered Drug list
    For medications not listed on the formulary Providers may follow the same course of action as you would for a Coverage Determination, also called a Prior Authorization. This can be initiated by the provider calling 855-582-2022 and requesting a Coverage Determination for the Medication(s) regardless of if it is listed on the Formulary. Should this coverage be denied you can appeal within 60 days of the initial denial by calling 888-543-9069 (option 1 for Pharmacy appeals) or having the Provider fax clinical chart notes or a letter of medical necessity to 718-536-3383.
    Generic Drug Information: English | Spanish

    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 1-800-237-2767 to enroll patients in the Specialty plan design.