• Pharmacy

  • Please click on the appropriate section to learn more about drug coverage, prior authorization/coverage determinations, medical benefit drug coverage and other important pharmacy information to help you provide the care needed for Affinity members.

  • Pharmacy Resources

    Pharmacy Prior Authorization (ePa) and Prior Authorization Information

    What are the Benefits of using Cover My Meds?

    Cover My Meds (ePA) allows a provider to:

    • Electronically request prior authorization criteria for a member and a medication
    • Receive the member-specific criteria
    • Submit answers to the criteria
    • Receive a determination often times in less than an hour

    ePA is intended to extend prior authorization process access to a provider’s electronic health record through a real-time request for criteria and delivery of that criteria to your Electronic Health Records system( such as Allscripts, NextGen, etc) for completion. For Medications not found on some of our Formularies, often times an alternative drug will be suggested.

    Cover My Meds Portal

    Available to use for all Affinity Plans. To register for a free CoverMyMeds account, create an account. Setting up an account only takes a few minutes. Furthur step-by-step instructions can be found in the Reference Guide. Instructions also include adding a group, for offices with multiple providers for greater ease.

    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.

    Medicaid and Child Health Plus
    (For prompter service please contact CVS/ Caremark For Prior Authorizations)
    Monday - Friday, 9:00 am - 7:00 pm
    Fax: 866.255.7569

    Medical and Pharmacy Prior Authorization Criteria

    Enriched Health Plan (HARP)
    (For prompter service please contact CVS/ Caremark For Prior Authorizations)
    Monday - Friday, 9:00 am - 7:00 pm
    Fax: 866.255.7569

    Essential Plan
    (For prompter service please use the Cover My Meds Portal or you can call CVS)
    Monday - Friday, 9:00 am - 7:00 pm
    Fax: 855.245.2134

    Specialty Drugs for Essential Plan

    Specialty Medication Information
    Specialty medications 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.