CVS CAREMARK CRITERIA
Starting January 1, 2018, these patients may not be able to fill their current medication at the pharmacy, based on the plan’s coverage changes.
Please visit caremark.com/highvalueplan to review the coverage details of this pharmacy benefit plan.
PA = Prior Authorization There must be a satisfied PA on file or a PA must be requested.
Please call 1-877-203-1681
ST = Step Therapy The patient must have already satisfied the step therapy
requirements through previous medication use.
QL = Quantity Limits The medication to be dispensed must be for less than the quantity
limits restriction. No further action is necessary if the quantity dispensed for this prescription is below the limit.
QLWPA = Quantity Limits With The medication to be dispensed must be for less than the quantity
Prior Authorization limits restriction. A PA must be requested for quantities greater than the limit restriction. Please call 1-877-203-1681. No further action is necessary if the quantity dispensed for this prescription is below the limit.
FE = Formulary Exclusion Patient’s formulary does not cover the medication. You may request
A formulary exception based on medical necessity. Please call
BE = Benefit Exclusion Patient’s pharmacy benefit design does not cover this medication.