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Effective July 15th, Health Services for Children with Special Needs (HSCSN) will implement Optum Financial/Optum Pay as the check payment vendor for provider electronic funds transfer (EFT). The details to the provider letter can be found in this document.

Pharmacy Benefits

CVS Caremark

CVS/Caremark manages the Pharmacy Benefit for HSCSN. You can sign-up on the Caremark website to get additional information about Caremark services.

List of Covered Drugs (Drug Formulary)

All drugs covered through HSCSN are on the Drug Formulary. The formulary is another name for a list of prescription drugs. We update the list once every quarter. To get a copy of the Drug Formulary, call HSCSN Customer Care at (202) 467-2737 or 1 (866) 937-4549.

 

Find a medication or pharmacy

Your HSCSN pharmacy benefits are through CVS Health. To learn how to find a medication and a pharmacy, call:

Also, check the list of frequently asked questions below.

Pharmacy Locations 

 Pharmacy Network

Our pharmacy network is managed by CVS Health Pharmacy Network, for local and national pharmacies in the United States. If you wish to find out if your pharmacy is a part of the CVS Health Pharmacy Network, please call CVS Customer Care at (866) 885-4944 or click the link below.

Click here for more pharmacy locations.

Retail chains include:

  • CVS Pharmacy
  • Walgreens
  • Rite Aid
  • Costco
  • Safeway 
  • Giant 
  • Harris Teeter
  • Walmart 
  • Target

DC Pharmacies in the CVS Network 

Download the list of all in-network pharmacies [PDF]. HSCSN updates this list regularly.

To Get a Prescription Filled

If you have an HSCSN Enrollee ID card:

  • Pick a pharmacy in the CVS Health network and close to home or work.
  • Take your HSCSN ID Card with you to the pharmacy. The pharmacy will contact HSCSN for other information needed to fill your prescription.
  • Do not pay for any medications.
  • If the pharmacy asks you to pay or if you have other questions, call HSCSN Customer Care at (202) 467-2737 or 1 (866) 937-4549.

If you do not have an HSCSN ID card:

To get a prescription filled:

Pick a pharmacy that is part of the HSCSN network and is close to your work or home. When you have a prescription, go to the pharmacy, and give the pharmacist your prescription and your HSCSN Enrollee ID Card. If you need help, please call Customer Care Services at (202) 467-2737, 1 (866) 937-4549, or TTY/TTD (202) 467-2709.  

Things to remember:

You should not be asked to pay for your medicines. Call HSCSN Customer Care Services if the pharmacy or drug store asks you to pay. y Sometimes, your doctor may need to get prior authorization (PA) from HSCSN for a drug. While your doctor is waiting for the prior authorization, you have a right to get the medication:

  • For up to 72 hours or
  • For one full round of the medicine if you take it less than once a day

If you need help or have questions:

 CVS Caremark Mail Order Service

Enrollees now have the ability to obtain a 90 day supply of medication. If you wish to switch to Mail Order:

Download the Mail Service Fax Form 
Specialty Medications

For specialty medications, HSCSN uses CVS Specialty Pharmacy. For more information on specialty medications please call CVS Health (800) 237-2767. Forms can be faxed to (800) 323-2445, or visit www.CVSspecialty.com.

Prior Authorizations

In some cases, CVS Health will need to approve the use of medications based on medical reasons. This is called a prior authorization (PA). To submit a PA request, have your doctor complete the PA form below and fax it to CVS Health at 1-888-836-0730. Your doctor can also call CVS Utilization Management Department at (877) 433-7643. 

While you wait for PA approval, your pharmacist may provide your medication:

  • For up to 7 days or
  • For one full round of the medication if you take it less than once a day

Download the PA Form

Formulary Exceptions

If you are currently taking a medication that is not on the Preferred Drug List, your doctor can request an exception by faxing the exception request form below to CVS Health at 1-888-836-0730. If your doctor has any questions about the PA form, call 1-800-294-5979. Your doctor can also call CVS Utilization Management Department at (877) 433-7643. 

Download the Exception Form

Medication Therapy Management (MTM) 

Medication Therapy Management (MTM) under Clinical Pharmacy Associates (CPA) includes a review of your current medications and provide education about them. The purpose is to help you identify medications, side effects, and dosage. Enrollees referred to the MTM program will be assigned a pharmacist who will provide you with medication counseling and a review of your current medication list.

Online Medication Management with a Personal Clinical Pharmacist

  • Do you or your child take several medications?
  • Do you or your child’s medications change often?
  • Do you or your child have to see more than one doctor or specialist?
  • Is it hard to order or to remember when to give your child medications?

If you answered, YES to the above questions, you or your child are likely to be eligible for the MTM (Medication Therapy Management) program sponsored by HSCSN.

  • Our MTM Medication Therapy Management Program connects you to a dedicated Clinical Pharmacist to help you or your child take medications easily, and safely.
  • You will also receive free access to a medication management app, which can remind you of medications, appointments, and provide you with direct chat access to a licensed clinical pharmacist.

Learn about your medication and how to use the MTM app.

Read the MTM FAQs 

Frequently Asked Questions

Q: What should I ask my pharmacist?
A: Here are things you should ask:

  • What is my medicine used for?
  • What should my doctor know before I take my medicine?
  • How do I take my medicine(s)?
  • What if I miss a dose of my medicine?
  • Will other medicines or foods affect this medicine?
  • Why does my medicine look different than it did before?
  • Is my medicine a generic?

Q: How do I get a medication that requires Prior Authorization (PA)?
A: Talk to your doctor. They must request PA for the drug.

Q: What is a generic drug?
A: A generic drug is the same as a brand-name drug in:

  • dosage, strength, safety, quality
  • the way it works
  • the way it is taken
  • the way it should be used.

Q: Are generic drugs as strong as brand name drugs?
A: Yes. The government requires generic drugs to be equal to brand name drugs. That means they have the same quality, strength, purity, and stability.

Q: Why would my doctor choose a generic over a brand name?
A:  Generic drugs are as safe and effective as a brand name. They usually cost much less than brand name drugs.

We Want to Hear From You

Enrollees - If you have any questions about your pharmacy benefits or the formulary contact: