• Print:
  • Text Size:

Drug Coverage

PDF

Viewing and printing this document requires Adobe Acrobat Reader, which can be downloaded free from the Adobe site.

Control Your Drug Costs

Controlling drug costs is one of the major challenges of our health care system. CareFirst helps to manage these expenses through the formulary system, which gives preference to the most effective medications that are also the most cost-efficient.

Expand All | Collapse All

The Formulary System

Drugs are ranked into categories (tiers) depending on your plan, and the price you pay will depend on which category a drug falls into. For ACA Drug Tier information, refer to the drug list for your plan

  • Generic drugs work the same as brand-name drugs, but cost much less. So you’ll pay less to use them. Some plans also divide generics into Preferred Generics and Non-preferred Generics based on cost.
  • Preferred Brand drugs are brand-name medications that are not yet available in generic form, but are chosen for their effectiveness and affordability compared to alternatives. They cost more than Generics, but less than Non-preferred Brand drugs. If a Generic drug becomes available, the Preferred Brand drug will be moved to the Non-preferred brand category.
  • Non-preferred Brand drugs are often available in less-expensive forms, either as Generics or Preferred Brand drugs. You will pay more for this category of drugs.
  • Self-Administered Injectable/ Specialty drugs (excluding insulin) often have the highest out-of-pocket cost. In most cases, these are high-cost prescription drugs that may require special handling, administration or monitoring and may be oral or injectable medications used to treat serious or chronic medical conditions.

When you call, ask your provider to prescribe a generic drug, or choose a generic version of the prescribed brand-name drug if one is available.

Generic Drugs

Generic drugs account for 80% of US prescriptions and can cost up to 80% less than their brand-name counterparts. Fully approved by the FDA, generics contain the same active ingredients as brand-name drugs that have been in the system for years— but are not saddled with the high marketing expenses that inflate the price of brand-name drugs.

Here is a sample of brand-name vs. generic drug costs. If your medication doesn’t have a generic equivalent, ask your doctor if there’s a generic drug that will work for you.

Brand Name
Generic Name
Average Monthly Cost* of Brand
Average Monthly Cost* of Generic
Monthly Savings if using Generic
AMBIEN ZOLPIDEM TARTRATE $263 $3 $260
COUMADIN WARFARIN SODIUM $40 $9 $31
LIPITOR ATORVASTATIN CALCIUM $140 $11 $129
PROZAC FLUOXETINE HCL $206 $5 $201
SINGULAIR MONTELUKAST SODIUM $166 $25 $141
Step Therapy Ensures Lower Costs

When similar medications are available in multiple forms, Step Therapy guides your doctor to prescribe the lower-cost version first. You may then move up the cost levels until you find the drug that works best for you.

Higher-step drugs will require prior authorization. For more information, call CareFirst Pharmacy Services at 800-241-3371.

Preventive Drugs, Available at no Cost

The Affordable Care Act (ACA) classifies certain therapies as “preventive” if they reduce the risk of some serious health problems. If you meet the eligibility requirements, preventive drugs will be fully covered by your prescription drug plan—available at no cost to you. You will not have to pay deductibles or copays.

The Preventive Drugs List includes a brief description of the eligibility requirements.

Save on Maintenance Medications through Mail Order

Drugs you take regularly for ongoing conditions such as diabetes, high blood pressure, or asthma are called maintenance medications. You may save money on your maintenance medications by ordering them at a discount through our mail order pharmacy.

For more information on maintenance mediations, call CareFirst Pharmacy Services at 800-241-3371.

Expand All | Collapse All