A process that can be initiated by a patient and/or provider to review a previous benefit determination. There are three levels to appeals:
- First Level (Coverage Determination): Ensures the claim adjudicated according to plan setup.
- Second Level: For an approval previously deemed not covered. Coordinated by CVS/caremark when an external provider and the participant’s current provider determine coverage together. This level can only be initiated by a provider.
- Third Level: Review of claim of approval that was previously denied by plan setup and through second level appeals. This appeal is coordinated by CVS/caremark and occurs between a different external provider and the patient’s current provider. This level can only be initiated by a provider.
Dispense as Written (DAW)
A prescription notation that states the brand name drug should be dispensed despite the availability of a generic equivalent.
- DAW 1: A prescription order from a prescriber that states the brand name drug is medically necessary and no substitution is allowed.
- DAW 2: A prescription order from a prescriber that allows for a generic substitution, but the patient requests the brand name drug to be dispensed.
A list of preferred medications that are covered under a drug benefit plan, based on specific plan setup. The trademarked formularies specific to CVS/caremark exist on a continuum:
- Opt-out: An open formulary that offers no exclusions.
- Standard Control: Exclusions are introduced in this formulary.
- Advanced Control Formulary: This formulary offers the third highest number of exclusions.
- Value Formulary: Built-in utilization management is introduced in this formulary and offers the highest number of exclusions.