Affinity Health Plan

  • 2016 QHP Banner - Couple
  • 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.

    2016 AffinityAccess, AffinityAccess direct, and AffinityAccess 2.0 Plans
    Covered Drug List(Formulary)
    Abridged Covered Drug list(Pending)

    2015 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 with a Coverage Determination, also called a Prior Authorization. This can be initiated by having your Provider call (855) 582-2022 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.

    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.