High-Value Plan (Value Formulary) Member FAQs

Q:  Does the high-value plan cover medicines to treat all health conditions?
A:  Yes. Your new high-value prescription benefit plan includes medicine to treat all health conditions.* CVS Caremark helps make sure you have access to medicines that treat all short-term or long-term health conditions.

Q:  Why is coverage different for certain medicines and not others?

A:  CVS Caremark pharmacists and doctors created the high-value plan based on medical treatment guidelines first, and then cost. The high-value plan includes medicines that provide health benefits and are priced right.* Medicines that cost more, but may not work better, may be offered to members at up to the full cost, depending on their plan. Choosing a lower-cost, high-value plan medicine, you can help you stay healthy and may save money, too!**

Q:  Does the high-value plan cover medicines for “lifestyle” conditions?
A:  Not always. The plan may not cover any medicines used to treat lifestyle conditions. You may have to pay the full cost to use these medicines. Examples of lifestyle condition medicines include cosmetic medicines. Depending on your plan sponsor, medicines used to treat erectile dysfunction, obesity, and infertility may be considered lifestyle condition medicines.

Questions? Call the toll-free number on the back of your benefit (or “member”) ID card to find out whether you will have to pay the full cost for these medicines.

Q:  The Quick Reference List and Complete Drug List refer to my plan as “Value Formulary.” What is the Value Formulary?
A:  A formulary is a list of the medicines that are included on your prescription benefit plan. A formulary is also called a drug list. These lists refer to the Value Formulary because the medicines on the plan’s formulary are high value. That is, they provide great health benefits and are priced right.

Q:  Why should I choose the high-value plan for my prescription benefits instead of keeping my current plan?
A:  In many cases, choosing the high-value plan for your prescription benefits means you will typically pay less out-of-pocket costs for your medicines than staying with the plan you have had in the past.  With the high-value plan, you will continue to have access to medicines to treat your health conditions while saving money.

Q:  What are my out-of-pocket costs for the different medicines under the high-value plan?
A:  Typically, you will pay less out-of-pocket costs for generic medicines than for brand-name medicines.  You may already pay more for brand-name medicines under your current plan. If so, you may not pay more than your current out-of-pocket costs for a brand-name medicine if it is covered by the high-value plan.

Q:  How do I know if my current medicine is a lower-cost option on the high-value plan?
A:  Try one of the methods below to see if the high-value plan covers your current medicines:

  • Check to see if your current medicine is included on the high-value plan by reviewing the Quick Reference List which includes plan medicines to treat some common health conditions. For a full list of plan medicines, please review the Complete Drug List.
  • Call the toll-free number on the back of your benefit (or “member”) ID card to learn about all your options.
  • Watch for a letter from CVS Caremark. If your plan sponsor has decided to change to the high-value plan within the next few months, you will receive a letter from CVS Caremark, This letter will let you know if the high-value plan does not cover your current medicine(s), or covers it with restrictions.

Q:  Can I keep filling my current prescription on the high-value plan?
A:  Yes. However, you may have to pay up to the full cost to keep using this medicine if your current prescription is not a lower-cost option. Once your new plan becomes effective, medicines not included on your plan will not be covered.

Q:  Why does it make sense to change to medicine on the high-value plan?
A:   Because for a lot of health conditions, many medicines on the high-value plan work just as well but may cost up to 80 percent less.**

When you and your doctor choose a lower-cost medicine from your high-value plan, it also helps keep the cost of health care down for your plan sponsor. In turn, this change helps keep health care costs down for you and your family.

Q:  How do I change from my current medicine to a lower-cost option on the high-value plan?
A:  Once your new plan is effective, follow these simple steps:

  1.  Ask your doctor to visit caremark.com/highvalueplan to consider the covered, lower cost options that may work for you instead. If your doctor still does not think the options on the high-value plan are right for you because of a special medical situation, he or she can contact us.
  2. Fill your new prescription:
  • Retail Pharmacy: Have your doctor call in the new prescription(s) to a CVS Caremark network pharmacy (find one at www.caremark.com). Out-of-network pharmacies may cost you more.
  • CVS Caremark Mail Service Pharmacy: Your doctor can call in the new prescription to us toll-free at 1-800-378-5697. Or call us toll-free at 1-866-251-9383, and we will contact your doctor for you!

Q:  What if my doctor thinks I should continue my current, higher-cost medicine?
A:  Ask your doctor to visit www.caremark.com/highvalueplan to consider the covered, lower-cost options that may work for you instead. If your doctor still does not think the options on the high-value plan are right for you because of a special medical situation, he or she can contact us.

Please note: Your doctor may be able to request a prior authorization if you have a special medical situation that requires you to keep taking a higher-cost, non-covered medicine.

*Plan’s medicine list covers all disease states. Lifestyle-related treatments (i.e., anti-obesity, cosmetic, erectile dysfunction, and fertility agents) may not be included. Plan is limited to generic medicines and some brand-names when a generic is not available in the class. Coverage may vary, please consult your plan for further information.

**Savings will vary based on your plan limitation and/or drug prescribed.
Source: Generic Pharmaceutical Association Website: http://www.gphaonline.org/about/generic-medicines

†Out-of-pocket costs are copayment, copay or coinsurance which means the amount a plan member is required to pay for a prescription in accordance with a plan, which may be a deductible, a percentage of the prescription price, a fixed amount or other charge, with the balance, if any, paid by a plan.

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