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FAQs: Frequently Asked Questions
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Below are a few questions that are often asked by members.
What is a Specialty Pharmacy?
Specialty pharmacy is a unique service model designed to help people manage complex conditions and their associated treatments. Medicines handled by a specialty pharmacy may be:
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Specialty medications can help you stay healthier, but getting the most from them requires extra care. That’s why choosing the right specialty pharmacy is so important.
How will the insurance process work now that I am with CVS Caremark Specialty Pharmacy?
CVS Caremark will file all claims for your therapy with your insurance carrier. CVS Caremark will contact your insurance carrier to determine coverage and documentation requirements. If a claim is ever denied, CVS Caremark will work with you and your doctor to appeal the decision.
What can I do to help the reimbursement process along?
- If CVS Caremark requests information regarding your insurance, be sure to respond promptly.
- If your insurer contacts you for information on a claim, let your CareTeam know.
- Occasionally, CVS Caremark might request that you contact your insurer to assist with an appeal or to expedite the processing of your claim.
- Most of all, read your benefits booklet and become as familiar as you can with your insurance policy.
How will I know when payments have been made to CVS Caremark and if there is a balance due?
All insurers (payors) provide their subscribers with an Explanation of Benefits (EOB) report that describes which services were covered and how much was paid. You should review these reports carefully. If you have any questions, contact your CareTeam Representative. If a balance remains that you are responsible for, it will be noted on the EOB. You will also receive a statement from CVS Caremark if there is activity on your account, including any balance for which you are responsible.
My insurance has changed. What should I do?
Contact your CareTeam Representative as soon as you are aware of any changes to your insurance. This is very important. Your CareTeam will verify your new benefits to determine the degree to which your treatment will be covered. In addition, many insurance companies require prior authorization for certain therapies. This process can take as long as 30 days, so your CareTeam Representative must begin working on this as soon as possible.
I have the opportunity to change my health plan. What should I be aware of?
It is important to make sure that the new plan does not have a “pre-existing condition” clause or if it does, that it is waived. This clause could mean that coverage for your therapy could be delayed six months or longer, depending on what the clause stipulates. It is also critical that you complete all policy applications thoroughly and accurately, since failure to disclose a pre-existing condition could result in cancellation of your policy or temporary loss of benefits. Generally, the pre-existing condition clause would not be a factor because the employer has negotiated up front for all employees to be covered. Your Human Resources Department will know the details of your benefit plans. Before you change plans, give us a call if you have any questions.
What do I do about health benefits if I lose my job?
If you lose your job, you can usually extend your policy with your employer for up to 18 months under their group plan; you will generally be required to pay the company the premiums to continue your coverage. (There are some exceptions. Please ask your employer for details.) You must apply for this benefit, commonly known as COBRA (Consolidated Omnibus Budget Reconciliation Act), within 60 days after you terminate employment. You may also want to apply for coverage under a state program or short-term medical insurance policy to cover you between jobs.
It is extremely important to stay in contact with your CareTeam Representative throughout this process, even if you are only anticipating a change in your policy or job status.
Can medications be returned?
Pharmacy policy prohibits the restocking of medicines. More specifically, such products will not be accepted for return or exchange by a pharmacist or pharmacy after they have been sold, distributed or dispensed.
CVS Caremark delivers products according to the prescription from your doctor. We cannot issue credit for excess stock or for unused products resulting from a prescription change after delivery. Therefore, it is very important that you adhere to the medication instructions as prescribed by your doctor. We also ask that you provide accurate information regarding your inventories of supplies and medication at the time deliveries are scheduled.
What is your complaint procedure?
If you have a complaint or concern about the care you are receiving, please contact the manager at your designated CVS Caremark Specialty Pharmacy. If the designated CVS Caremark Pharmacy does not handle your issue to your satisfaction, you can call toll-free 1-800-237-2767 and ask for the Department of Performance Improvement.
CVS Caremark is committed to providing the highest quality of care available to our plan members. In a continuing effort to improve our services, you may be contacted by a third party for the purpose of assessing your satisfaction with our services. If you believe that you have pertinent and valid information regarding the services provided by CVS Caremark Specialty Pharmacy, you may call The Joint Commission toll-free at 1-800-994-6610, or write to The Office of Quality Monitoring, The Joint Commission, One Renaissance Boulevard, Oakbrook Terrace, IL 60181.
