Pharmacy Information and Programs
Your Pharmacy Benefits
Below you’ll find important information about your pharmacy and drug coverage.
Explanation of Benefits
When you use your prescription drug benefits, we will send you an Explanation of Benefits (EOB) statement in the mail. This is for your Medicare prescription drug coverage (Part D). Your EOB shows:
- The prescriptions you filled
- What we paid
- What you and others have paid
- What counts towards your Out-of-Pocket Costs and your Total Drug Costs
Your EOB is not a bill.
If you paid a co-pay or coinsurance for your drug, the EOB should show the amount you paid.
You may not get an EOB every month
When we get a claim (bill) from your pharmacy, you’ll get an EOB the next month. For example, if we get a claim in March, you’ll get an EOB in April.
Take a minute to look over your EOB
Check your EOB to make sure everything is correct. If you have questions, find mistakes, or suspect fraud, we’re happy to help. Call us at the number below.
Search for Covered Drugs
CCA covers a wide range of both over-the-counter, brand-name and generic prescription drugs at no cost to you. Find out if a medication is covered under your plan and what to do when it’s not.
CCA MassHealth Plans Coverage
CCA Medicare Advantage Plan Coverage
Real-time Benefit Tool
What’s my out-of-pocket expense? Click below to check up-to-date medication costs at your pharmacy of choice.
Coverage Determinations and Redeterminations
For some drugs, you will need to get approval (“prior authorization”) from Commonwealth Care Alliance before we can agree to cover a drug for you. The requirement for getting approval in advance may also help to guide appropriate use of certain drugs. If you do not get this approval, your drug might not be covered by the plan.
Coverage Determination Request Form Vaccines (Medicare B vs D)
CCA Massachusetts – Prescription Drug Coverage Determination Request Form
CCA Redetermination Form
If your request for coverage for a prescription drug was denied, you have the right to ask for an appeal of our decision within 60 days of the Notice of Denial.
Drug Coverage Redetermination Form
If you’ve been prescribed a drug that’s not on the formulary (or “drug list”) you may still be able to get a temporary supply of the drug; request a similar drug that’s on the formulary; or ask the plan to grant an exception or otherwise remove restrictions. Refer to the transition process document based on the plan you’re enrolled in below.
Transition Process for CCA Medicare Preferred (PPO) and CCA Medicare Value (PPO), MA
Transition Process for CCA Senior Care Options (HMO D-SNP), MA
Transition Process for CCA One Care (Medicare-Medicaid Plan), MA
Prescription Fills
Show your CCA member ID card to get your prescription filled at your pharmacy. Make sure your pharmacy is in our network first. There are some cases when we will cover prescriptions filled at an out-of-network pharmacy: when you travel, if you need urgent or emergency care, or if a network pharmacy or drug is not available. Prior to filling your prescription at an out-of-network pharmacy, get in touch with our Member Services team at 866-610-2273 (TTY: 711) to find out if there is an in-network pharmacy where you are.
Drug Recalls
CCA is committed to protecting the health and safety of our members. We monitor alerts from the U.S. Food and Drug Administration (FDA) about drug recalls and withdrawals. We will notify you and your prescriber if we learn of potential problems with a medication.
A drug recall is when a medication or an over-the-counter product is removed from the market. A drug can be voluntarily recalled by the drug company and the FDA, or the FDA can require a recall. The FDA makes sure that recalls are handled correctly to safely stop the drug from being sold.
A drug may be recalled for many reasons, like safety concerns, mislabeling, or because it was poorly produced by the company.
Do not stop taking your medication until you speak to your doctor. In some cases, stopping a medication suddenly can cause a return of your symptoms that can be worse than before. In other cases, stopping a medication suddenly can be life-threatening. Follow these steps:
- Contact your doctor to discuss your options.
- Contact your pharmacy to discuss possible substitutes. For example, the pharmacist may be able to get the same medication from a different drug company. If not, they can contact your doctor to switch to another drug.
Visit the FDA website1 to learn more and to sign up to receive alerts on drug recalls.
Find a Pharmacy
You can fill your prescriptions at any pharmacy in our large network. Ask your pharmacist if they’re in the Commonwealth Care Alliance network. You can also check the CCA directory by selecting “Pharmacy” from the “Specialty” drop-down.
Reimbursement
CCA works in partnership with its Pharmacy Benefit Manager (PBM), Navitus Health Solutions, to provide Medicare Part D prescription reimbursements.
To submit a claim for reimbursement of medications, please fill out a prescription reimbursement form. Forms can be mailed OR faxed to Navitus Health Solutions, using the contact information provided on the form.
You must submit your claim to Navitus Health Solutions within 12 months of the date you got the service, item, or drug.
CCA Senior Care Options – Prescription Reimbursement Form
CCA One Care – Prescription Reimbursement Form
CCA Medicare Plans (MA) – Prescription Reimbursement Form
Pharmacy Programs
CCA offers support with your medications through a range of free services and programs.
You can get prescription drugs shipped to your home through our network mail-order delivery program which is called CVS Caremark Mail Service Pharmacy Program. The pharmacy will contact you, by phone, to get your approval before shipping any prescriptions. If we are unable to reach you for approval, your prescription will not be sent to you. Typically, you should expect to get your prescription drugs within 14 days. If you do not get your prescription drug(s) within this time, or if you need to ask for a refund for prescriptions you got that you did not want or need, please contact us at 866-610-2273 (TTY 711), 8 am to 8 pm, 7 days a week. To learn more about mail-order pharmacies, refer to Chapter 5 of the Evidence of Coverage/Member Handbook.
CCA partners with Lumicera Health Services1 to provide specialty medications. They offer CCA members personalized support and refill reminders too. Contact Lumicera 24/7 at 855-847-3553 with any questions about filling your specialty medications.
You can get a 90-day supply for medications you take regularly for chronic conditions. A 90-day supply can help you reduce trips to the pharmacy. Some pharmacies will only provide a 30-day supply of medications, so ask your pharmacy about their policy.
CCA allows members to have all their medications filled on the same day. This is called medication synchronization, or “med sync.” This will help reduce trips to the pharmacy.
Medication Therapy Management (MTM) Program
Our Medication Therapy Management Program is focused on improving therapeutic outcomes for Medicare Part D members.
Better therapeutic outcomes for members with multiple conditions.
Our Medication Therapy Management (MTM) program is focused on improving therapeutic outcomes for Medicare Part D members. To qualify for the MTM program, a member must meet all the following criteria:
Members must have filled eight or more chronic Part D medications; and Members must have at least three of the following ten chronic conditions:
- Asthma
- Chronic Obstructive Pulmonary Disease (COPD)
- Congestive Heart Failure (CHF)
- Depression
- Diabetes
- High Blood Pressure
- High Cholesterol
- Osteoporosis
- Rheumatoid Arthritis
- HIV
In addition, members must be likely to incur 2024 annual costs of $5,330 for all covered chronic Part D medications.
If you meet all the criteria above, our MTM program will help you learn about how to manage the various medications you need to stay healthy free of charge.2
Our MTM program offers a wide range of services to help members with multiple conditions by:
- Ensuring they take their medications correctly
- Improving medication adherence
- Detecting potentially harmful medication uses or combinations of medications
- Educating members and health care providers
Comprehensive medication review (CMR)
You’ll have a one-on-one consultation with a clinician to ensure you’re taking your medications as prescribed by your health care provider(s).
The Centers for Medicare & Medicaid Services (CMS) requires all Part D sponsors to offer an interactive, person-to-person comprehensive medication review (CMR) to all MTM-eligible members as part of the MTM program.
If you meet the criteria outlined above, you’ll receive an MTM program enrollment mailer or phone call offering our CMR services. A CMR is a review of a member’s medications (including prescription, over the counter, herbal therapies, and dietary supplements) intended to assess your medication therapy and to optimize your outcomes.
Also, you’ll be included in quarterly targeted medication review (TMR) programs that assess medication profiles for duplicate therapy or drug-disease interaction in which your prescribers may receive a member-specific report.
The CMR includes three components:
1. Review of medications to assess medication use and identify medication-related problems. This may be conducted person-to-person or “behind the scenes” by a qualified provider and/or using computerized, clinical algorithms.
2. An interactive, person-to-person consultation performed by a qualified provider at least annually. This is typically conducted over the phone and will take about an hour to complete.
3. An individualized, written summary of the consultation for you which will include (but not be limited to) a medication list, reconciled medication list, and recommended to-do list for monitoring, education, or self-management. This will be delivered within two weeks of completing your CMR.
How to get started
You don’t need to do anything to access the program. A CCA representative will reach out to you if you meet the criteria to complete your CMR with you. To prepare for the CMR, you can download and complete the Personal Medication List below.
Medication List
Best Available Evidence Policy
This is a policy from the Centers for Medicare & Medicaid Services (CMS). It requires CCA to inform CMS when presented with evidence that a CCA member’s low-income subsidy (LIS) status is incorrect in CMS systems. For more information, visit the CMS website.1
1 When you click this link, you will leave the Commonwealth Care Alliance website.
2 This program is not a benefit; therefore, if you qualify for our program based on our criteria, we will automatically enroll you in the program and offer you program services over the phone or send you information by mail. The MTM program is free of charge to eligible members. Program participation is voluntary.
Your Pharmacy Benefits
Below you’ll find important information about your pharmacy and drug coverage.
Explanation of Benefits
When you use your prescription drug benefits, we will send you an Explanation of Benefits (EOB) statement in the mail. This is for your Medicare prescription drug coverage (Part D). Your EOB shows:
- The prescriptions you filled
- What we paid
- What you and others have paid
- What counts towards your Out-of-Pocket Costs and your Total Drug Costs
Your EOB is not a bill.
If you paid a co-pay or coinsurance for your drug, the EOB should show the amount you paid.
You may not get an EOB every month
When we get a claim (bill) from your pharmacy, you’ll get an EOB the next month. For example, if we get a claim in March, you’ll get an EOB in April.
Take a minute to look over your EOB
Check your EOB to make sure everything is correct. If you have questions, find mistakes, or suspect fraud, we’re happy to help. Call us at the number below.
Search for Covered Drugs
CCA covers a wide range of both over-the-counter, brand-name and generic prescription drugs at no cost to you. Find out if a medication is covered under your plan and what to do when it’s not.
CCA MassHealth Plans Coverage
Coverage Determinations and Redeterminations
For some drugs, you will need to get approval (“prior authorization”) from Commonwealth Care Alliance before we can agree to cover a drug for you. The requirement for getting approval in advance may also help to guide appropriate use of certain drugs. If you do not get this approval, your drug might not be covered by the plan.
Coverage Determination Request Form Vaccines (Medicare B vs D) (2025)
CCA Massachusetts – Prescription Drug Coverage Determination Request Form (2025)
CCA Redetermination Form
If your request for coverage for a prescription drug was denied, you have the right to ask for an appeal of our decision within 60 days of the Notice of Denial.
Drug Coverage Redetermination Form (2025)
If you’ve been prescribed a drug that’s not on the formulary (or “drug list”) you may still be able to get a temporary supply of the drug; request a similar drug that’s on the formulary; or ask the plan to grant an exception or otherwise remove restrictions. Refer to the transition process document based on the plan you’re enrolled in below.
Transition Process for CCA Senior Care Options (HMO D-SNP), MA (2025)
Transition Process for CCA One Care (Medicare-Medicaid Plan), MA (2025)
Prescription Fills
Show your CCA member ID card to get your prescription filled at your pharmacy. Make sure your pharmacy is in our network first. There are some cases when we will cover prescriptions filled at an out-of-network pharmacy: when you travel, if you need urgent or emergency care, or if a network pharmacy or drug is not available. Prior to filling your prescription at an out-of-network pharmacy, get in touch with our Member Services team at 866-610-2273 (TTY: 711) to find out if there is an in-network pharmacy where you are.
Drug Recalls
CCA is committed to protecting the health and safety of our members. We monitor alerts from the U.S. Food and Drug Administration (FDA) about drug recalls and withdrawals. We will notify you and your prescriber if we learn of potential problems with a medication.
A drug recall is when a medication or an over-the-counter product is removed from the market. A drug can be voluntarily recalled by the drug company and the FDA, or the FDA can require a recall. The FDA makes sure that recalls are handled correctly to safely stop the drug from being sold.
A drug may be recalled for many reasons, like safety concerns, mislabeling, or because it was poorly produced by the company.
Do not stop taking your medication until you speak to your doctor. In some cases, stopping a medication suddenly can cause a return of your symptoms that can be worse than before. In other cases, stopping a medication suddenly can be life-threatening. Follow these steps:
- Contact your doctor to discuss your options.
- Contact your pharmacy to discuss possible substitutes. For example, the pharmacist may be able to get the same medication from a different drug company. If not, they can contact your doctor to switch to another drug.
Visit the FDA website1 to learn more and to sign up to receive alerts on drug recalls.
Find a Pharmacy
You can fill your prescriptions at any pharmacy in our large network. Ask your pharmacist if they’re in the Commonwealth Care Alliance network. You can also check the CCA directory by selecting “Pharmacy” from the “Specialty” drop-down.
CCA Senior Care Options – Prescription Reimbursement Form (2025)
CCA One Care – Prescription Reimbursement Form (2025)
Pharmacy Programs
CCA offers support with your medications through a range of free services and programs.
You can get prescription drugs shipped to your home through our network mail-order delivery program which is called CVS Caremark Mail Service Pharmacy Program. The pharmacy will contact you, by phone, to get your approval before shipping any prescriptions. If we are unable to reach you for approval, your prescription will not be sent to you. Typically, you should expect to get your prescription drugs within 14 days. If you do not get your prescription drug(s) within this time, or if you need to ask for a refund for prescriptions you got that you did not want or need, please contact us at 866-610-2273 (TTY 711), 8 am to 8 pm, 7 days a week. To learn more about mail-order pharmacies, refer to Chapter 5 of the Evidence of Coverage/Member Handbook.
- Online: Caremark.com
- Phone: 866-610-2273 (TTY 711), 8 am to 8 pm, 7 days a week
- Mail: Download and complete the mail-order form and send via mail to:
CVS Caremark
PO BOX 659541
SAN ANTONIO, TX 78265-9541
Mail Order Pharmacy Form
Mail this form to register for a CVS Caremark Mail Service Pharmacy account.
You can get your specialty medications shipped to your home through our specialty pharmacies. We utilize a network of specialty pharmacies to help our members with complex conditions get their specialty medicine.
You can contact our member services to receive a list of specialty pharmacies that are in-network at 866-610-2273 (TTY 711), 8 am to 8 pm, 7 days a week.
You can get a 90-day supply for medications you take regularly for chronic conditions. A 90-day supply can help you reduce trips to the pharmacy. Some pharmacies will only provide a 30-day supply of medications, so ask your pharmacy about their policy.
CCA allows members to have all their medications filled on the same day. This is called medication synchronization, or “med sync.” This will help reduce trips to the pharmacy.
Medication Therapy Management (MTM) Program
Our Medication Therapy Management Program is focused on improving therapeutic outcomes for Medicare Part D members.
Better therapeutic outcomes for members with multiple conditions.
Our Medication Therapy Management (MTM) program is focused on improving therapeutic outcomes for Medicare Part D members. To qualify for the MTM program, a member must meet all the following criteria:
Members must have filled at least eight Part D medications.
Members must have a minimum of three of the following ten chronic conditions:
- Alzheimer’s Disease
- Bone Disease-arthritis (including Osteoporosis, Osteoarthritis, and Rheumatoid Arthritis)
- Chronic Congestive Heart Failure (CHF)
- Diabetes
- Dyslipidemia
- End-stage Renal Disease (ESRD)
- Human Immunodeficiency Virus / Acquired Immunodeficiency Syndrome (HIV / AIDS)
- Hypertension
- Mental Health (including Depression, Schizophrenia, Bipolar Disorder, and Chronic / Disabling Mental Health Conditions)
- Respiratory Disease (including Asthma, Chronic Obstructive Pulmonary Disease (COPD), and Chronic Lung Disorder)
In addition, members must be likely to incur $1,623 for covered Part D medications in total cost in 2025.
If you meet all the criteria above, our MTM program will help you learn about how to manage the various medications you need to stay healthy free of charge.2
Our MTM program offers a wide range of services to help members with multiple conditions by:
- Ensuring they take their medications correctly
- Improving medication adherence
- Detecting potentially harmful medication uses or combinations of medications
- Educating members and health care providers
Comprehensive medication review (CMR)
You’ll have a one-on-one consultation with a clinician to ensure you’re taking your medications as prescribed by your health care provider(s).
The Centers for Medicare & Medicaid Services (CMS) requires all Part D sponsors to offer an interactive, person-to-person comprehensive medication review (CMR) to all MTM-eligible members as part of the MTM program.
If you meet the criteria outlined above, you’ll receive an MTM program enrollment mailer or phone call offering our CMR services. A CMR is a review of a member’s medications (including prescription, over the counter, herbal therapies, and dietary supplements) intended to assess your medication therapy and to optimize your outcomes.
Also, you’ll be included in quarterly targeted medication review (TMR) programs that assess medication profiles for duplicate therapy or drug-disease interaction in which your prescribers may receive a member-specific report.
The CMR includes three components:
1. Review of medications to assess medication use and identify medication-related problems. This may be conducted person-to-person or “behind the scenes” by a qualified provider and/or using computerized, clinical algorithms.
2. An interactive, person-to-person consultation performed by a qualified provider at least annually. This is typically conducted over the phone and will take about an hour to complete and is designed to improve your knowledge of their prescriptions, over-the-counter (OTC) medications, herbal therapies and dietary supplements, identify and address problems or concerns that you may have, and empower patients to self-manage their medications and their health condition(s).
3. An individualized, written summary of the consultation for you which will include (but not be limited to) who performed the CMR, who received the CMR, and when the CMR was delivered, as well as a copy of the summary including a medication list, reconciled medication list, and recommended to-do list for monitoring, education, or self-management and its delivery date. This will be delivered within two weeks of completing your CMR.
How to get started
You don’t need to do anything to access the program. A CCA representative will reach out to you if you meet the criteria to complete your CMR with you. To prepare for the CMR, you can download and complete the Personal Medication List below.
Medication List (2025)
Best Available Evidence Policy
This is a policy from the Centers for Medicare & Medicaid Services (CMS). It requires CCA to inform CMS when presented with evidence that a CCA member’s low-income subsidy (LIS) status is incorrect in CMS systems. For more information, visit the CMS website.1
1 When you click this link, you will leave the Commonwealth Care Alliance website.
2 This program is not a benefit; therefore, if you qualify for our program based on our criteria, we will automatically enroll you in the program and offer you program services over the phone or send you information by mail. The MTM program is free of charge to eligible members. Program participation is voluntary.