MAVYRET is a registered trademark of AbbVie Inc.
ZEPATIER is a registered trademark of Merck Sharp & Dohme Corp.
EPCLUSA is a registered trademark of Gilead Sciences, Inc.
Contact us
Questions? Call 1-866-316-3784
(TTY: 711). We’re here for you Monday through Friday, 8 AM to 5 PM.
Covered medications
Prescription medications
We cover the prescription medications on the preferred drug list (PDL) at no extra cost to members. If your patient needs medication, you’ll want to check the list for covered medications, step therapy requirements, quantity limits and updates. You can download the list.
If a medication isn’t on the PDL, you can:
Prescribe a similar one that’s on the list
Get prior authorization (PA) for coverage
Still not sure if we cover a specific medication? Just call 1-866-316-3784 (TTY: 711). We can check it for you.
Other drug lists
Not all covered drugs are listed on the PDL. You may also check the Common Formulary (PDF). Or refer to these other resources:
Diabetes supplies
Here’s a list of preferred diabetes supplies:
- Preferred glucose meter and test strips: Lifescan OneTouch® products
- Preferred lancets and lancing devices: Lifescan OneTouch Delica® and Delica® Plus
- Preferred pen needles: Becton Dickinson (BD) products
- Preferred continuous glucose monitors (CGMs): Dexcom G6 and Freestyle Libre (both require prior authorization)
Non-preferred diabetic supplies require prior authorization (PA).
OTC medications
Members can get coverage for OTC medications on the PDL when they:
- Meet any added requirements (for some medications)
- Get a prescription from their provider
- Fill their OTC prescription at a pharmacy in our network
Not sure what’s covered? Just call us at 1-866-316-3784 (TTY: 711). Be sure to have the member’s list of medications ready. We can check to see if they’re on the list.
More pharmacy information
Learn about everything from step therapy to prior authorization.
If a member needs prior authorization (PA) for a medication, you can fill out a pharmacy PA form on their behalf. Or you can call us at 1-866-316-3784 (TTY: 711).
When members need medication, they’ll:
- Ask you to make sure the medication is on the PDL
- Take their prescription to a pharmacy in our network
- Show their plan member ID card at the pharmacy
Remind members to check with you at least five days before running out of medication. They understand that you may want to see them before prescribing refills.
When members take their prescription to an in-network pharmacy, they can show their member ID card along with this information:
- BIN: 610591
- PCN: ADV
- GROUP: RX8826
For payer sheets and other network or processing information, just visit the CVS Caremark® website.
Members can fill prescriptions at any pharmacy in our network. We can’t cover medications they fill at other pharmacies.
When members take maintenance medication for an ongoing health condition, they can get it by mail. We work with CVS Caremark® to provide this service at no extra cost. Each order is checked for safety. And members can speak with a pharmacist anytime on the phone.
To get started, members will need their:
- Plan member ID card
- Mailing address, including ZIP code
- Provider’s first and last name and phone number
- List of allergies and other health conditions
- Original prescription from their provider (if they have it)
Mail service makes it easy
Members and providers can call CVS Caremark at 1-855-271-6603 (TTY: 711), 24 hours a day, 7 days a week. They’ll explain which medications can be filled with CVS Caremark Mail Service Pharmacy. CVS Caremark will also contact you for a prescription and mail the member’s medication. Members can sign up for mail service:
Online
Members can go to the Member Portal and sign in or register (for new users). Then, they’ll choose: Tasks, Pharmacy services, CVS and Start mail service.
With an order form
Members will ask you to write a prescription for a 90-day supply with up to one year of refills. We’ll send them a mail service order form. They just need to fill out the form.
Members can send the form, along with their prescription, to:
CVS Caremark
PO Box 2110
Pittsburgh, PA 15230-2110
By phone
Members can also call CVS Caremark at 1-855-271-6603 (TTY: 711). They can call 24 hours a day, 7 days a week. CVS Caremark will call you to get a prescription.
The step therapy program requires certain first-line drugs, such as generic drugs or brand-name drugs, to be prescribed before approval of specific, second-line drugs.
You can review the step therapy criteria (PDF) for drugs on the Medicaid PDL.
Certain drugs on the PDL have quantity limits. Quantity limits are based on:
- FDA-approved dosing levels
- Nationally established, recognized guidelines related to each condition
Need to ask for an override for step therapy or a quantity limit? Just fax the pharmacy PA form to: 1-855-799-2551.
Or you can call us to ask for PA. Just call 1-866-316-3784 (TTY: 711). You can also include any supporting medical records that may help with the review of your request.
MDHSS carves out certain classes of drugs. These drugs are covered by MDHSS Fee-For-Service (FFS) through the Magellan Pharmacy Benefit Manager.
For up-to-date information on carved-out agents, you can use the MDHSS FFS drug search tool.
We partner with MDHSS in the We Treat HEP C initiative to provide treatment for members who have hepatitis C.
Hepatitis C treatment no longer requires prior authorization if using the state-preferred PDL agent, MAVYRET®. Hep C treatment is carved out to MDHHS FFS (MagellanRx) and the system is set up to approve MAVYRET for up to a 12-week supply.
Commonly asked questions
Which type of provider may prescribe MAVYRET?
All MDHHS registered prescribers, including non-specialists, will be able to prescribe MAVYRET.
What must be submitted with a MAVYRET claim if PA isn’t required?
The claim will be paid if submitted in accordance with our Pharmacy Claims Processing Manual. Diagnosis codes are not required on these claims.
Will MAVYRET be covered without a PA in the rare case a patient requires 12 weeks of therapy?
Yes.
For patients currently taking another Direct-Acting Antiviral (DAA) therapy (ZEPATIER®, EPCLUSA®, etc.), will they be able to complete their course of therapy (ex: refills)?
Yes.
Will there be specific PA criteria listed in the PDL for the non-preferred DAAs?
Non-preferred DAAs will require a PA explaining why MAVYRET is not clinically appropriate.
Are prisoners covered by Medicaid upon release and therefore able to get MAVYRET without a PA?
We are working on a Targeted Case Management benefit that provides support and resources for individuals recently released from a correctional facility. Stay tuned for more information.
Can patients fill their MAVYRET prescription at any specialty or retail pharmacy?
Yes.
What is the copay for MAVYRET under this agreement? What is the copay for a non-preferred DAA?
For Medicaid, copay for MAVYRET is $1, and copay for non-preferred DAAs are $3. There are no copays for viral hepatitis treatments for Medicare-Medicaid plan.
Can more than 4 weeks of therapy be prescribed at a single time (ex: 8 weeks of therapy, or less frequently 12 weeks of therapy, as opposed to 4 weeks with refill(s))?
Pharmacies are authorized to dispense up to 102 days of therapy at a single time. However, many pharmacies may default to dispensing in 4-week increments, unless the script specifies an 8- or 12-week supply.
Is MAVYRET covered for patients on Emergency Services Only (ESO) Medicaid?
Yes. MAVYRET is covered for beneficiaries on ESO Medicaid. The pharmacy should indicate level of service 3 (emergency) on the claim.
Under the Common Formulary, the Medicaid formulary coverage is limited to products with national drug codes (NDC) from manufacturers who participate in the Medicaid Drug Rebate Program (MDRP).
This MDRP reference is reproduced from the Drug Manufacturer Contacts reference.
A manufacturer’s labeler code is represented in the first five digits of a product’s NDC. Formulary NDCs included under a manufacturer’s labeler code are covered according to formulary coding established under the Common Formulary.
If an NDC for a non-MDRP participating labeler is adjudicated on a pharmacy claim, NCPDP error AC (product not covered non-participating manufacturer) will be included in the reject messaging.
We may consider making medical necessity accommodations for members who need a non-MDRP participating NDC when all formulary NDCs are unavailable. Prescribers must submit a prior authorization request through the CoverMyMeds® website.
To learn more about pharmacy prior authorization, just visit our pharmacy prior authorization page. For urgent needs, pharmacies can call the CVS Caremark Pharmacy Help Desk for help. Just call 1-855-432-6843.
Note: Updates to the MDRP may occur multiple times each week. For a current list of additional updates, visit the New/Reinstated & Terminated Labeler Information. Medicaid health plans apply the optional effective date for new/reinstated labelers. Labelers listed for termination are removed from coverage according to the effective date presented on the Terminated Labelers table.
Need information about medication recalls? Just call the U.S. Food and Drug Administration (FDA) at 1-888-463-6332. Or visit the drug recalls page on the FDA website.