Pharmacies and Out-of-Network Coverage 2023

Network Pharmacies

"Network pharmacies" are pharmacies we have made arrangements with to provide prescription drugs to plan members. A network pharmacy is a pharmacy where beneficiaries obtain prescription drug benefits provided by Martin's Point Generations Advantage. In most cases, your prescriptions are covered under Martin's Point Generations Advantage only if they are filled at a network pharmacy or through our mail-order pharmacy service. Once you go to one, you are not required to continue going to the same pharmacy to fill your prescription; you can go to any of our network pharmacies. We will cover prescriptions filled at out-of-network pharmacies under certain circumstances as described later. Through Caremark, we currently have over 67,000 pharmacies in our nationwide network. 

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Access Requirements

The Caremark Medicare Part D Network meets access requirements in all regions and in all states. In addition, Caremark has not received any deficiency notices from CMS regarding the Caremark Medicare Part D Network.

Pharmacies with Preferred Cost Sharing

Martin's Point Generations Advantage is happy to offer a network of pharmacies with preferred cost sharing. The Martin's Point Generations Advantage network of pharmacies with preferred cost sharing includes Hannaford Pharmacies, CVS Pharmacies and Martin's Point Health Care Center Pharmacies in Portland, ME and Portsmouth, NH.

We also have a network of local pharmacies with preferred cost sharing. These include:

Maine

• Community Pharmacies
• Herbert Rexall Pharmacy, Van Buren
• Miller Drug, State Street, Riverside, and Westgate, Bangor, Brewer
• St. John Valley Pharmacy, Fort Kent
• Unity Pharmacy
• Western Maine Pharmacy, Kingfield
• Wilson’s Drug Store, Bath

New Hampshire

• The Medicine Store, Concord
• Roberts Scarlett Pharmacy, New London

In the network of pharmacies with preferred cost sharing, Generations Advantage members receive medications in Tier 1, Tier 2, Tier 3, and Tier 4 of the Generations Advantage formulary (or drug list) at lower copays than at pharmacies with standard cost sharing.

How do I fill a prescription through the Martin's Point Generations Advantage mail-order pharmacy service?

Click here to download a Prescription Mail Order Form.

To get order forms and information about filling your prescriptions by mail, please contact the Martin's Point Generations Advantage mail-order service at 1-888-296-6961 or contact Member Services at 1-866-544-7504 (TTY:711). Please note that you must use the Martin's Point Generations Advantage mail-order service, operated by CVS Caremark. Prescription drugs that you get through any other mail-order service are not covered.

You can use the mail-order service to fill prescriptions for what we call "maintenance drugs." These are drugs that you take on a regular basis, for a chronic or long-term medical condition. The formulary list tells you which drugs we consider to be maintenance drugs. These are the only drugs available through our mail-order service. When you order prescription drugs by mail, you must order at least a one-day supply and no more than a 90-day supply.

You are not required to use mail-order prescription drug services to obtain an extended supply of maintenance medications. You also have the option of using a retail pharmacy in our network to obtain a supply of maintenance medications. Some retail pharmacies may agree to accept the mail-order reimbursement rate for an extended supply of medications for up to 90 days per dispensing, which may result in no out-of-pocket payment difference to you. Other retail pharmacies may not agree to accept the mail-order reimbursement rate for an extended supply of medication. In this case, you will be responsible for the difference in price.

Please read the Evidence of Coverage for your plan call our Member Services for more information.

Generally, it takes us 10-14 days to process your order and ship it to you. However, sometimes your mail-order may be delayed. If your mail-order shipment is delayed and you need your prescription immediately, the mail-order service will work with you to ensure that you receive your prescription. The mail-order prescription service will either expedite your order or have it filled locally. If your medication must be taken immediately, ask your physician to issue two prescriptions—one for a short supply to be filled at our in-network local pharmacy, and a second for an extended supply to be mailed to the mail-order prescription drug service.

Automatic Refill Service

For refills of your drugs, you have the option to sign up for an automatic refill program called ReadyFill at Mail^®. Under this program we will start to process your next refill automatically when our records show you should be close to running out of your drug. The pharmacy will contact you prior to shipping each refill to make sure you are in need of more medication, and you can cancel scheduled refills if you have enough of your medication or if your medication has changed. If you choose not to use our auto-refill program, please contact your pharmacy 15 days before you think the drugs you have on hand will run out to make sure your next order is shipped to you in time.

So the pharmacy can reach you to confirm your order before shipping, please make sure to let the pharmacy know the best ways to contact you. Please contact CVS Mail Order Customer Care at 1-888-296-6961 for options regarding automatic refill preferences.

To opt out of our program that automatically prepares mail order refills, please contact CVS Customer Care at 1-888-296-6961. 

Filling prescriptions outside the network

Generally, we only cover drugs filled at an out-of-network pharmacy in limited, non-routine circumstances when a network pharmacy is not available. Below are some circumstances when we would cover prescriptions filled at an out-of-network pharmacy. Before you fill your prescription in these situations, call Member Services to see if there is a network pharmacy in your area where you can fill your prescription. If you do go to an out-of-network pharmacy for the reasons listed below, you may have to pay the full cost (rather than paying just your copayment) when you fill your prescription.

You can ask us to reimburse you for our share of the cost by submitting a claim form. However, even after we reimburse you for our share of the cost, you may pay more for a drug purchased at an out-of-network pharmacy because the out-of-network pharmacy's price is higher than what a network pharmacy would have charged. You should submit a claim to us if you fill a prescription at an out-of-network pharmacy as any amount you pay, consistent with the circumstances listed above, will help you qualify for catastrophic coverage.

We will cover your prescription at an out-of-network pharmacy if at least one of the following applies:

• If you are unable to get a covered drug in a timely manner within our service area because there are no network pharmacies within a reasonable driving distance that provide 24-hour service.
• If you are trying to fill a covered prescription drug that is not regularly stocked at an eligible network retail or mail-order pharmacy (these drugs include "orphan drugs," which are pharmaceutical products that have been developed specifically to treat a rare medical condition, or other specialty pharmaceuticals).
• If you are traveling outside of the U.S. and your prescription is associated with an emergency or urgent care visit. As with traveling within the U.S., you may ask us to reimburse you for our share of the cost by submitting a claim form.

Please note: Out-of-network prescriptions are limited to a 30-day supply.

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