Frequently asked general pharmacy questions.


What is the formulary list?

The formulary is comprised of generic, brand name and specialty drugs, including Preferred drugs, that when selected will lower your out-of-pocket costs. Drugs on the formulary are assigned to a tier. Your cost share will depend on the tier in which your drug resides. Formulary placement decisions are based on recommendations by the Pharmacy and Medical Policy Committee (PMPC) – an independent group of practicing physicians and pharmacists. You can view a list on our Formulary page.

How does the formulary work with my pharmacy benefit?

Your cost share is determined by the formulary tier to which your drug is assigned. The following tier structure applies to both Standard Option and Basic Option. Choosing generic, Preferred brand name drugs and Preferred specialty drugs will provide you with a high quality, cost-effective pharmacy benefit.

  • Tier 1 - Generic drugs
  • Tier 2 - Preferred brand name drugs
  • Tier 3 - Non-preferred brand name drugs
  • Tier 4 - Preferred specialty drugs
  • Tier 5 - Non-preferred specialty drugs 

The following tier structure applies to FEP Blue Focus.

  • Tier 1 - Preferred generics
  • Tier 2 - Preferred brand name drugs, Preferred generic specialty drugs, and Preferred brand name specialty drugs

What is a managed formulary?

Certain drugs are no longer covered under Basic Option. These drugs, known as “Managed Not Covered” drugs, have available covered options in the same therapeutic class. Click here for a full listing of “Managed Not Covered” drugs and available covered options. Basic Option members taking a “Managed Not Covered” drug should expect to pay the full cost of the prescription.

What is the difference between the Standard Option, Basic Option and FEP Blue Focus formularies?

Standard Option has a comprehensive formulary. This means we cover almost all U.S. FDA approved drugs. There is a small list of excluded drugs that are not covered. See the Standard Option Formulary for the exclusions list.

Basic Option has a managed formulary. This means that we cover most U.S. FDA approved drugs. See the Managed Not Covered list with Preferred alternatives that you may use.

FEP Blue Focus has a limited (or closed) formulary. This means that we only cover some U.S. FDA approved drugs. Any drug not on the FEP Blue Focus formulary is not covered.

What is a generic drug?

A generic drug has the same active ingredient and dosage form (e.g. tablet or capsule), and works in exactly the same way as its brand name counterpart. When the patent on a brand name drug expires, other drug manufacturers can apply to the U.S. Food and Drug Administration (FDA) to make a generic version of the drug. The FDA approves generic drugs when manufacturers have proven that the generic version is as safe and effective as the brand name counterpart. Generic drugs usually cost less than the brand name equivalent. Therefore, using generic drugs instead of brand name drugs is one of the easiest ways to reduce your prescription costs. 

How can I find out if there is a generic drug for the brand name drug that I am taking?

There are two ways to find out if the brand name drug you are taking is available in generic form. You can use the check drug cost tool accessible on our Pharmacy page to search for a brand name drug and see if it has any generic equivalents. You can also contact the retail, mail service or specialty drug programs at the following toll-free numbers and a customer service representative will help you. 

  • Retail 1-800-624-5060
  • Mail Service 1-800-262-7890
  • Specialty 1-888-346-3731

What is an excluded drug?

A few drugs are no longer covered on the Standard Option formulary. These excluded drugs have other drugs available that treat the same condition - either generic drugs, brand name drugs or both. These options are effective and safe, and they may help you save money on your prescriptions. Click here for a full listing of excluded drugs and available covered options. Standard Option members taking an excluded drug should expect to pay the full cost of the prescription.

What are specialty drugs?

Specialty drugs are pharmaceutical products that are typically high in cost and include one or more of the following characteristics: 

  • Injectable, infused, inhaled 
  • Products of biotechnology
  • Require special handling, shipping and storage
  • Involve specialized patient training and coordination of care

You can download the specialty drug list here. This list is reviewed and updated regularly. 

What is prior approval?

Drug prior approval is a process to obtain advanced approval of coverage for a prescription drug. Most drugs are covered without requiring prior approval. However, some select drugs require your doctor to provide information about your prescription to determine coverage. Your doctor may provide information for a prior approval review by calling or faxing a form to CVS Caremark. Your doctor will be notified whether your prescription is approved for coverage. You can view the current prior approval list here. This list is reviewed and updated regularly.

What does Preferred pharmacy mean?

Preferred pharmacy means a pharmacy has an agreement with CVS Caremark to provide covered services to our members. You can choose from more than 65,000 network pharmacies nationwide when filling your prescriptions.  

To locate a Preferred retail pharmacy, click on Find a Pharmacy or call toll-free 1-800-624-5060.

What happens if I use a Non-preferred pharmacy?

Pharmacy benefits under Basic Option and FEP Blue Focus are available only if you use one of our Preferred retail pharmacies or the Specialty Drug Pharmacy Program. Standard Option members can purchase prescription drugs and supplies from a Non-preferred pharmacy, but will have to pay the full amount for these items when they are filled. Then, you will have to file a Retail Prescription Drug claim form for reimbursement. 

How do I know I am getting the best value when filling my prescription?

To make sure you are getting the best value check the cost of your prescription drugs by using the check drug cost tool accessible on our Pharmacy page.  

You can also contact Customer Care at the following toll-free numbers and a customer service representative will help you. 
  • Retail 1-800-624-5060
  • Mail Service 1-800-262-7890
  • Specialty 1-888-346-3731

I live in Germany, so how does that affect delivery of my drugs through Mail Order Pharmacy?

CVS Caremark cannot accept orders through their mail order or specialty pharmacy for members with APO and FPO shipping addresses in Germany, due to current German law. Members must obtain their prescriptions at a local German pharmacy and submit the claim for reimbursement. Basic Option members must have Medicare Part B primary to be reimbursed for drugs ordered through the mail service, otherwise, they should use a retail pharmacy to receive benefits. Members will be charged the lesser of their mail order or retail cost share when submitting paper claims for covered drugs obtained at a local retail pharmacy in Germany on or after December 4, 2012. Claims should be submitted by fax to 001-480-614-7674 or online for reimbursement. Members residing in Germany with DPO military addresses may continue to receive non-cold pack medications delivery of mail order medications through CVS Caremark.

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