CVS Caremark: Pharmacy Benefits

CVS Caremark’s retail pharmacy network is national in scope and is comprised of over 64,000 pharmacies, including major chains, regional pharmacies, and independents. While rare, there could be some changes to your retail pharmacy (e.g. due to pharmacy closures). In the coming months, members will receive a letter notifying them if they will experience any pharmacy network changes. Additionally, members will also have access to CVS Caremark’s website that will allow you to search whether a specific pharmacy will be in network using their pharmacy locator.

Most retail pharmacies will remain accessible through CVS Caremark. If your pharmacy is impacted, you will receive a letter notifying you of the change approximately 90 days prior to the effective date of January 1, 2026.  In addition, members can utilize CVS Caremark’s digital portal during Open Enrollment to confirm network pharmacy status.

In most cases, you will continue to fill prescriptions at your preferred retail pharmacy (e.g. CVS, Walgreens, Safeway, VONS, etc.) as you do today. However, there may be some changes to the list of covered drugs or changes to in-network pharmacies. Additionally, mail order prescriptions and specialty pharmacy prescriptions will be dispensed through CVS Caremark pharmacies, instead of OptumRx pharmacies.

Non-controlled prescriptions with refills remaining that are currently filled at OptumRx mail and specialty pharmacies will automatically transfer to CVS Caremark. Some prescriptions may require a new prescription from your doctor, such as controlled substances or expired refills. CVS will notify you prior to the effective date if action is needed.

Some medications may have different approval requirements under the new PBM. If you currently have an active approved prior authorization, it will transfer automatically to CVS.

Yes. The mail order pharmacy will change, but mail order delivery will continue to be an option. Most mail order prescriptions will transfer automatically, and you will receive instructions on how to place your first fill.

Many prescriptions will be transferred automatically to the new mail order pharmacy (CVS Caremark). Some medications may require a new prescription from your doctor, such as controlled substances or expired refills. CVS will notify you prior to the effective date if action is needed.

For prescriptions that can’t be transferred, such as controlled substances or prescriptions with no remaining refills, please contact your prescriber or CVS Caremark.

Yes. You will need to provide your new member ID card to the pharmacy.

Your physician can request a medical necessity exception for your medication if it is no longer covered but they believe it is the most effective medication for your condition. Additionally, for Basic plans, if you need more time to make a change from your excluded drug to a preferred medication, members can call into CVS's dedicated team and request a 90-day transition fill. For Medicare plan members impacted by the formulary change, there will be a 90-day transition period for filling prescriptions, prior to being switched to an equally safe and effective alternative medication.

Yes. Specialty medications will now be filled through CVS specialty pharmacies.

CVS will notify members who may experience changes to their coverage. If impacted, you will receive detailed information approximately 90 days prior to the effective date of January 1, 2026.

There may be updates to the formulary, including changes to covered medications. If your medication is impacted, CVS will notify you by mail and provide additional information, including alternative options, to discuss with your doctor.

Yes. All medications that may be excluded will have an equally safe and effective alternative medication on the new formulary.

It is possible that some medications may change tiers in the new formulary which would result in changes to copayments.

A formulary change refers to modifications made to the list of covered prescription drugs, known as the formulary. These changes can involve adding, removing, or reclassifying drugs, as well as adjusting prior authorization or step therapy requirements.

If your medication is affected by a formulary change – for example, no longer covered or moved to a higher tier, you will receive a personalized letter approximately 90 days before the effective date of January 1, 2026. This letter will include:

• Covered alternatives
• Next steps if you need to request a formulary exception
• How to speak with your doctor about switching medications