Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:
Prior Authorization: The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Care N’ Care before you fill your prescriptions. If you don’t get approval, we may not cover the drug. These drugs are listed in the drug formulary with the symbol “PA”.
Download the Prior Authorization Criteria document: Download PDF
Download the blank Prior Authorization request form document: Download PDF
Step Therapy: In some cases, Care N’ Care requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, the Plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. These drugs are listed in the drug formulary with the symbol “ST”.
Download the blank Step Therapy request form document: Download PDF
Quantity Limits: For certain drugs, the Plan limits the amount of the drug that we will cover. For example, Care N’ Care provides 30 tablets per prescription for Januvia 100mg tablets. This may be in addition to a standard one-month or three-month supply. These drugs are listed in the drug formulary with the symbol “QL” followed by the quantity and day supply limitation. To find out if your medication has a Quantity Limit, please search for the medication on the Medication Look Up page or download the Comprehensive Formulary under the 2019 Plan Documents.
Download the blank Quantity Limit Exception request form: Download PDF
Nonformulary Exception Request: You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. For more information, please see your Evidence of Coverage document located on the 2019 Plan Documents
Download the blank Nonformulary Exception request form: Download PDF
Tier Exception Request: You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. For more details on which drugs you can request this type of exception, please see your Evidence of Coverage document located on the 2019 Plan Documents
Download the blank Tier Exception request form: Download PDF