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 statement in the mail. The statement will include:
- A list of your prescription drugs covered by CCA
- The amount of money that CCA pays to cover your prescriptions
- Instructions for how to request an exception and appeal our coverage decisions
- A list of upcoming changes to the list of drugs that CCA covers
Search for Covered Drugs
CCA covers a wide range of both brand-name and generic prescription drugs. Find out if a medication is covered under your plan and what to do when it’s not.
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.
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.
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 833-346-9222 (TTY: 711) to find out if there is an in-network pharmacy where you are.
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.
Prescription (Part D) Reimbursement:
CCA works in partnership with its Pharmacy Benefit Manager (PBM), Navitus Health Solutions, to provide Med D prescription reimbursements.
To submit a claim for reimbursement of medications, please fill out the Navitus form. Forms can be mailed OR faxed to Navitus Health Solutions, using the contact information below:
Navitus Health Solutions, LLC
P.O. Box 999
Appleton, WI 54912-0999
Toll Free: 855-668-8550
You must submit your claim to Navitus Health Solutions within 12 months of the date you got the service, item, or drug.
CCA offers support with your medications through a range of free services and programs.
You can have your prescriptions mailed to your home for free. The medications available for mail-order service are generally medications that you take on a regular basis for a chronic or long-term medical condition, such as those for high blood pressure, high cholesterol, or diabetes.
CCA partners with Costco Mail Order Pharmacy to provide this service. There are four ways to order your prescriptions:
- Online: pharmacy.costco.com*
- Phone: 800-607-6861, 8:00 am to 10:00 pm Monday to Friday, and 12:30 pm to 5:00 pm Saturday
- Mail: You will be sent a pre-addressed, postage-paid envelope with each order, and it can be used to refill or order a new prescription.
- Fax: Your doctor can fax in orders to 800-633-0334.
Costco Mail Order Pharmacy Form
Visit pharmacy.costco.com* or mail this form to register for a Costco Pharmacy account.
CCA covers the cost of the mail order service. A credit card is required for processing by Costco, but it will not be charged for this service. Your prescription drug copays remain the same. If you have a copay, you will be charged; if you do not have copays, you will not be charged. For detailed information about your plan’s coverage of prescription drugs, read your Evidence of Coverage/Member Handbook.
Your prescriptions will be delivered within 10 to 14 days of when Costco Pharmacy receives your prescription or refill request.
CCA partners with Lumicera Health Services* to provide speciality 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 speciality 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.
We partner with Clinical Support Services (CSS Healthcare)* to provide MTM services. A pharmacist or specially trained clinician will call you to review all your medications. They will work with you and your doctor to make sure all the medications you take are necessary, safe, and effective. The MTM program is offered only to members who meet all of these criteria:
- Have at least three of the following chronic diseases: Alzheimer’s disease, asthma, chronic alcohol or other drug dependence, chronic obstructive pulmonary disease (COPD), diabetes, end-stage renal disease, HIV/AIDS, osteoarthritis, osteoporosis, and rheumatoid arthritis
- Take at least 8 drugs covered by Medicare Part D
- Are likely to incur annual Medicare Part D costs greater than or equal to $4,376
If you qualify for the MTM program, you will receive a letter or phone call to explain the program. Members will also receive a summary of the program.
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
1When you click this link, you will leave the Commonwealth Care Alliance website.