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2021 CarePlus Prescription Drug Coverage Information

CarePlus offers prescription drug coverage in all of our plans. This coverage may vary depending on the plan you select. To find out if your prescription drugs are covered, please refer to the comprehensive Prescription Drug Guides (also known as “formularies”) below, which are updated and posted on the website monthly. Only the current formulary for each plan will display.

The comprehensive formularies include a list of covered drugs selected by CarePlus. We worked with a team of doctors and pharmacists to make a formulary that represents the prescription drugs we think you need for a quality treatment program. CarePlus will generally cover the drugs listed in our formularies as long as the drug is medically necessary, the prescription is filled at a CarePlus network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

You may also request that a printed Prescription Drug Guide be mailed to you. Please fill out and submit this form or call Member Services at 1-800-794-5907 (TTY: 711). From October 1 - March 31, we are open 7 days a week, 8 a.m. to 8 p.m. From April 1 - September 30, we are open Monday - Friday, 8 a.m. to 8 p.m. You may always leave a voicemail after hours, Saturdays, Sundays, and holidays and we will return your call within one business day.

If you are not a CarePlus member, please fill out this form to request a Prescription Drug Guide be mailed to you.

Viewable Documents

Note: Our documents below are in Portable Document Format (PDF) and require Adobe Reader for viewing and printing. To get the plug-in, visit Adobe's Website to
Download Adobe Reader (link opens in new window).

South Florida:

North Florida:

Part D Utilization Management Requirements: Prior Authorization (PA), Step Therapy (ST), Quantity Limit (QL), and Exceptions

Part D Prior Authorization and Step Therapy Criteria

  • Miami-Dade: All plans
  • Broward: All plans, excluding CareFree (HMO)
  • Palm Beach: All plans, excluding CareFree (HMO)
  • Tampa area: All plans
  • Orlando area: All plans
  • Daytona area: All plans
  • Broward, Palm Beach: CareFree (HMO)
  • Space Coast area: All plans
  • North Florida area: All plans

Prescription Drug Transition Policy

We know that changing plans can be confusing. CarePlus wants to make sure that you, as a new or existing member, safely transition into the new plan year. If you are not able to get your prescription drug because it is not in the current Prescription Drug Guide or it requires prior authorization because of quantity limits, step therapy requirements, or confirmation of your clinical history, we can help. To learn more about the transition process, please review our Transition Policy.

PDF2021 Transition Policy – English (opens in new window) 

PDF2021 Transition Policy – Spanish (opens in new window) 

How and Where to Send Your Request for Prescription Drug Payment

  • You can mail your request for prescription drug payment reimbursement along with any bills, receipts, and/or medical record documentation directly to us. To make sure you are giving us all the information we need to make a decision on your request for payment, please fill out our Prescription Drug Claim Form provided below or call Member Services and ask for a form to be mailed to you. Call 1-800-794-5907 (TTY: 711). From October 1 - March 31, we are open 7 days a week, 8 a.m. to 8 p.m. From April 1 - September 30, we are open Monday - Friday, 8 a.m. to 8 p.m. You may always leave a voicemail after-hours, Saturdays, Sundays, and holidays and we will return your call within one business day. Using this form will help us process your request faster.

    PDFPrescription Drug Claim Form – English (opens in new window) 

    PDFPrescription Drug Claim Form – Spanish (opens in new window) 

  • The Prescription Drug Claim Form or signed reimbursement request must be sent in writing.

  • Send the completed Prescription Drug Claim Form or signed reimbursement request to:

    CarePlus Health Plans, Inc.

    Attention: Member Services department

    11430 NW 20th Street, Suite 300

    Miami, FL 33172

  • Fax us at our toll-free fax number: 1-800-956-4288

  • You also can find detailed information about requesting a prescription drug payment reimbursement in our Evidence of Coverage, under Chapter 7, Section 2.1, or by reviewing our Prescription Drug Direct Member Reimbursement Policy below:

    PDFPart D Direct Member Reimbursement Policy – English (opens in new window) 

    PDFPart D Direct Member Reimbursement Policy – Spanish (opens in new window) 

*CareNeeds PLUS (HMO D-SNP): This plan is available to anyone receiving both Medicare and Medicaid: Qualified Medicare Beneficiaries (QMB/QMB+), Specified Low-Income Medicare Beneficiaries (SLMB/SLMB+), Qualifying Individuals (QI), Qualified Disabled and Working Individuals (QDWI) and other Full Benefit Dual Eligibles (FBDE). CareNeeds PLUS (HMO D-SNP) is sponsored by CarePlus Health Plans, Inc. and the State of Florida, Agency for Health Care Administration.

**CareComplete (HMO C-SNP): This plan is available to anyone with Medicare who has been diagnosed with diabetes, cardiovascular disorders or chronic heart failure.

***(057-CareOne PLUS (HMO-POS) Orlando): This plan covers certain out-of-network services for members while visiting Puerto Rico. Except in emergency or urgent situations, non-contracted providers may deny care.

****(110-CareOne PLATINUM (HMO-POS) Space Coast): This plan covers certain services received from out-of-network providers in Brevard and Indian River counties in Florida. Except in emergency or urgent situations, non-contracted providers may deny care. You will pay a higher copay for services received by non-contracted providers.

Out-of-network/non-contracted providers are under no obligation to treat CarePlus members, except in emergency situations. Please call our Member Services number or see your Evidence of Coverage for more information, including the cost- sharing that applies to out-of-network services.