Pharmacy Part D

Continue to use your current pharmacy through the end of the year. Use the Pharmacy Locator tool above to find the most convenient pharmacy near you. After January 1st, you’ll be able to set up your online CVS Caremark account via your CHRISTUS Health Plan member portal to easily move any current prescriptions to your new pharmacy, and set up any recurring home deliveries via the website, over the phone, or by mailing in the home delivery order form. You will also be able to call CVS Customer Care for assistance in moving your medications or you can visit your new pharmacy in-person and ask them to transfer your current prescriptions. Don’t forget to mention your new pharmacy to any providers at your next visit in the new year!

Utilization management is a practice where some medical services and drugs are evaluated for need before they can be used. This means that for certain prescription drugs, special rules restrict how and when the plan covers them. A team of doctors and pharmacists developed these rules to help members use drugs effectively and keep coverage affordable.

Examples of utilization management include:

Prior Authorization

We may require you to get approval from us before you fill certain prescriptions. If you don’t get approval, we may not provide coverage for the drug.

Downloadable List of Prescriptions that require a Prior Authorization per plan coverage year.

• 2025 Premier Performance Standard Prior Authorization (PDF) Last Updated 09/01/2025

Quantity Limits

We may limit or only cover a certain amount of a drug per prescription or for a period of time.

Step Therapy

In some cases, members may need to try one drug to treat their condition before we will provide coverage for another drug.

Downloadable List of Prescriptions that are part of Step Therapy utilization per plan year.

• 2025 Premier Performance Standard Step Therapy (PDF) Last Updated 09/01/2025

Generic Substitution

When a generic version of a drug is available, our pharmacies will automatically give members that version unless your doctor has told us that you must take the brand name drug.

You can find out if your drug is subject to these additional requirements or limits by looking in our formulary. If your drug does have additional restrictions or limits, you can ask us to make an exception to our coverage rules.

During a drug utilization review, we check your prescriptions and look for problems like:

• Possible medication errors
• Duplicate drugs that are unnecessary
• Drugs that are inappropriate because of your age or gender
• Possible harmful interactions between drugs you are taking
• Drug allergies or dosage errors

These reviews are especially important if you have multiple doctors who prescribe medications.

We conduct reviews each time you fill a prescription and on a regular basis. If we see a problem during our review, we will work with your doctor to correct it.

A coverage determination is a decision made by CHRISTUS Health Plan regarding payment, dosage limits prior authorization and other matters with prescription drugs. Coverage determinations can be requested if a member disagrees with:

• Receipt or payment for a prescription drug that a member believes may be covered
• A tiering or formulary exception
• The amount that CHRISTUS Health Plan requires a member to pay for a Part D prescription drug
• The limit on the quantity or dose of a requested drug
• A requirement that a member try another drug before CHRISTUS Health Plan will pay for the requested drug
• A decision on whether the member has or has not satisfied a prior authorization or other utilization management requirement

How to Request a Part D Coverage Determination or Exception

A member, their representative, or a prescribing physician may request a coverage determination by filling out the Part D Coverage Determination Request Form. Complete the form and fax it to 1-877-251-5896 or mail it to:

Express Script
ATTN: Medicare Reviews
P.O. Box 66571
St. Louis, MO 63166-6571

This form is also available in Spanish. Solicitud de determinación de cobertura de medicamentos recetados de Medicare.

A member, their representative, or a prescribing physician may also request a coverage determination by selecting the link below and completing the information.

• Coverage Determination for Part D Medication

Part D Coverage Determination & Exception Decisions

For requests for benefits that do not involve exceptions, the Plan will provide notice of its decision within 72 hours after receiving an expedited request or 7 days after receiving a standard request.

For requests for benefits that involve exceptions, the adjudication timeframes do not begin until the member’s prescriber submits his or her supporting statement to the Plan for review.

For payment requests, including payment requests that involve exceptions, CHRISTUS Health Plan Generation will provide written notice of its decision (and make payment when appropriate) within 14 calendar days after receiving a request.

If CHRISTUS Health Plan Generation coverage determination is unfavorable, the decision will contain the information needed to file a request for appeal / redetermination with the Plan.