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Prescription Drug Program Frequently Asked Questions

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Prescription Drug Program

What is the Prescription Drug Program?

Answer: All covered prescription drugs are ranked into categories (tiers) depending on your plan. Plans may include 3, 4 or 5 categories (tiers). The price you pay will depend on which category a drug falls into.

  • Generic drugs ($) - Some plans divide generic drugs into preferred generics and non-preferred generics
  • Preferred Brand drugs ($$)
  • Non-preferred Brand drugs ($$$)
  • Self-Administered  Injectable/ Specialty drugs (excluding insulin) ($$$$)

Your coverage may also contain any of the following components:

  • Mandatory Generic Substitution
  • Prior Authorization
  • Quantity Limits

Do I have to use a generic drug if it is available?

Answer: No, but you will have the lowest out-of-pocket cost for the generic drug. For plans that have preferred and
non-preferred generic categories, preferred generics have the lowest out-of-pocket cost.

Are all available generic drugs included on the Preferred Drug List?

Answer: Most generic drugs that have Food & Drug Administration (FDA) approval are included on the Preferred Drug List.

Exceptions:

  • Those not approved by the FDA
  • Those used for cosmetic purposes
  • DESI drugs (drugs designated not effective by the FDA)
  • Over The Counter (OTC) drugs
  • Those excluded by your employer's benefit plan

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General Information

Do I have a choice of pharmacies?

Answer: Yes. You can choose from more than 60,000 participating pharmacies nationwide that accept CareFirst or CareFirst BlueChoice insurance plans. You can find out if a pharmacy participates by clicking Prescription Drug Tools in the Resource section of the CareFirst website or, you can call CareFirst Pharmacy Services at (800) 241-3371. You can also use nonparticipating pharmacies, but you will have to pay for the full cost of the drug at the time of purchase and submit a claim for reimbursement. Your benefits may not reimburse you for the full cost of the prescription.

Do I have an annual maximum as part of my drug plan?

Answer: There are several prescription drug programs that include an annual maximum. Please refer to your benefit contract to see if your plan has such a maximum or call CareFirst Pharmacy Services at (800) 241-3371.

How do I use my retail prescription drug card benefits?

Answer: To have your prescription filled:

  • Present your pharmacy ID card to your pharmacist
  • Pay the appropriate copay or coinsurance for your medication

Who do I contact if I have questions about my medication?

Answer: Call your physician or pharmacist for questions about:

  • The drug you have been prescribed
  • Side effects
  • Drug interactions
  • Storage

How do I obtain a copy of my Certificate of Coverage?

Answer: You can:

a) Contact the plan administrator if you are in a group plan; or

b) Call Member Services if you have individual coverage.

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Mandatory Generic Substitution

What is mandatory generic substitution and how does it work?

Answer: Mandatory generic substitution means that you will automatically be given a generic drug when available, even if the prescription is for the brand-name. If a generic drug is available and you choose to purchase a non-preferred brand drug, you will pay the Plan copay or coinsurance amount PLUS the difference between the generic and the non-preferred brand drug cost up to the cost of the prescription.

Note: Not all the brand-name drugs have generic equivalents.

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Mail Order Prescriptions

How do I get prescriptions filled through a mail order pharmacy?

Answer: You can learn more by clicking on the "Prescription Drug Tools" in the Resource section of the CareFirst website.

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Maintenance Medications

What is a maintenance drug?

Answer: A maintenance drug is taken regularly for an ongoing condition, like diabetes or asthma. For most plans, you can get a 90-day supply of maintenance drugs and pay only a two month copay for categories (tiers) that are copay-based. If you take a drug regularly for more than six months and it is not on CareFirst's Maintenance Drug List, you can call CareFirst Pharmacy Services at (800) 241-3371 to ask that the drug be deemed a maintenance drug for you or submit a maintenance medication request form.

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Preferred Drug List

What is a Preferred Drug List?

Answer: The Prescription Drug Program uses a list of preferred drugs. Selected for their effectiveness and affordability, the preferred drugs include both generic (including preferred and non-preferred generics) and preferred brand drugs.

Non-preferred brand drugs, are not part of the Preferred Drug List, but are covered by your pharmacy benefits.

How do drugs get on the Preferred Drug List?

Answer: The Preferred Drug List is based on current medical research and input from a committee of doctors and pharmacists who serve the CareFirst region.

  • Drugs are selected for their quality, effectiveness and cost.
  • The Preferred Drug List can change in 24 hours in response to Food and Drug Administration (FDA) requirements
  • The list is also adjusted when a generic drug is introduced for a brand-name drug. When that happens, the generic drug will be added to the Preferred Drug List and the brand-name drug will automatically move from the preferred brand category to the non-preferred brand category

How can I find out if my drug is on the Preferred Drug List?

Answer: You can use the online "Drug Coverage & Cost" in the Prescription Drugs Tools section of the CareFirst website to find out if a drug is on the Preferred Drug List or you can call CareFirst Pharmacy Services at (800) 241-3371.

Which brand-name drugs are not on the Preferred Drug List?

Answer: Those lacking Food & Drug Administration (FDA) approval

  • DESI drugs (drugs designated not effective by the FDA)
  • Over The Counter (OTC) Drugs
  • Those used for cosmetic purposes
  • Those excluded from your employer’s benefit plan
  • Non-preferred brand drugs. (These drugs are covered by your pharmacy benefits, just at the higher cost share)
  • Other brand-name drugs for which a therapeutically equivalent drug is available

How does the Preferred Drug List help me?

Answer: The Preferred Drug List was designed to help you and your doctors determine if you can reduce your drug costs.

Do my benefits provide coverage for Preferred Drugs only?

Answer: No. Your benefits provide coverage for non-preferred drugs as well -- that is, those that are not on the Preferred Drug List. However, you are responsible for paying a higher out-of-pocket cost for these drugs.

Why does the Preferred Drug List change?

Answer: It changes when:

  • New drugs become available.
  • Generic equivalents of brand-name drugs become available.
  • A prescription drug becomes available as an Over the Counter (OTC) drug.

Note: The Preferred Drug List can change frequently in response to Food and Drug Administration (FDA) requirements.

What is the difference between a preferred brand drug and a non-preferred brand drug?

Answer:  Preferred drugs are brand-name drugs which are:

  • Chosen for their quality, effectiveness and affordability
  • Not available as a generic drug
  • Indicated through research to be as effective as non-preferred brand drugs

Non-preferred drugs are brand-name drugs which are:

  • Typically more expensive
  • The member pays the highest out-of-pocket expense
  • May have a generic drug available

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Preventive Drugs

What are preventive drugs?

Answer: Under the Affordable Care Act (ACA), certain drugs were identified to potentially reduce more serious health problems in individuals with certain medical conditions. These drugs, Preventive Drugs, are available to members at a $0 copay and are not subject to the deductible when a prescription is written by a provider for members meeting certain medical criteria. 

Am I eligible for the preventive drug benefit?

Answer: If you are in an Affordable Care Act (ACA) compliant health plan, then you may be eligible for this benefit. Please refer to your Evidence of Coverage for details on your coverage eligibility.

Also, members with certain medical criteria prescription who have a written prescription by a provider are eligible for this benefit.

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Prescription Drug Coverage

What is a generic drug?

Answer: A drug that:

  • Has the same active ingredients, strength and dosage as the brand-name drug 
  • Must be absorbed into the bloodstream in the same timeframe
  • Has satisfied Food & Drug Administration (FDA) quality and safety reviews in the same way as a brand-name drug 
  • Saves you money, yet provides the same quality as the brand-name drug 
  • Falls within the generic category (tier) of the CareFirst Prescription Drug Program. Some plans have preferred generic and non-preferred generic categories (tiers)

What is a brand-name drug?

Answer: A drug that:

  • Has been approved by the Food and Drug Administration (FDA) after trials show it is safe and effective for humans
  • Is protected by patents. Once the patent expires for the brand-name drug, pharmaceutical companies typically manufacture and sell the drug’s generic equivalent
  • Is more costly than its generic equivalent
  • Falls within the non-preferred or preferred brand drug categories of the CareFirst Prescription Drug Program

What is an Over the Counter (OTC) drug?

Answer: A drug that is:

  • Available without a prescription, and
  • Approved by the Food & Drug Administration (FDA), and
  • Not covered by your pharmacy benefits

Note: Many OTC medications were once prescription drugs.

What types of drugs are not covered by my benefits?

Answer: Non-covered drugs include:

  • Drugs not approved by the Food & Drug Administration (FDA)
  • Generic or brand-name drugs used for cosmetic purposes
  • Medications available as Over The Counter (OTC) drugs
  • Drugs excluded by your employer's benefit plan

Does my prescription drug benefit cover compound medications?

Answer: Compound medications are covered under your prescription drug benefit if at least one of the drugs in the compound is a covered prescription drug. You will be charged a non-preferred brand drug copay or coinsurance for the compound prescription.

How are Allergy Serums covered?

Answer: Allergy serums may be covered under your prescription or major medical benefit. Please check your benefits guide to determine how it is covered. If your allergy serum is covered under the prescription benefit, you are responsible for initial payment and must submit a request for reimbursement. Please have your provider complete a HICFA 1500 form or an itemized bill. Either must be submitted along with a direct member reimbursement form. Please mail completed forms to:

CareFirst Pharmacy Services

P.O. Box 94467

Palatine, IL 60094-4467

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Prior Authorization

What is Prior Authorization (PA)?

Answer: Prior authorization is advance approval to ensure that your drug is covered by the Plan. The list of drugs which require prior authorization is available online. The list is subject to change. The prior authorization forms can be downloaded from CareFirst.com.

How does Prior Authorization (PA) work?

Answer: Your doctor should call CareFirst Pharmacy Services at (800) 241-3371 before writing a prescription for any drug on the PA list. Without proper authorization, you will pay the full price of the prescription rather than only your copay or coinsurance amount.

How do I know if my drug requires a Prior Authorization (PA)?

Answer: There are two ways:

  • Look it up online in the Prior Authorization list
  • Call CareFirst Pharmacy Services at (800) 241-3371

The PA list is subject to change and is subject to your benefit plan. Please note your employer may have excluded drugs that are on the Preferred Drug List from your plan.

Does my doctor need to get a Prior Authorization (PA) each time my prescription is filled?

Answer: No. Once a PA is given, it is typically valid for four (4) months to a year.

What can I do if I am at the pharmacy and discover my medication requires a Prior Authorization (PA) but none was requested in advance?

Answer: Have your pharmacist call your doctor to start the PA process. The request will be approved or denied within 48 hours after the physician provides all of the requested information.

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Quantity Limitations

What is a Quantity Limit?

Answer: Certain prescription drugs may be prescribed only in limited quantities. Quantity limit quidelines are set by the Food and Drug Administration (FDA).

  • The Quantity Limit List includes dosage limits for some drugs and is based on current medical literature and input from a committee of doctors and pharmacists who serve our region in the Drug Search section. 
  • The full list of drugs which have Quantity Limits is available online. The list is subject to change.
  • When medically necessary, an exception to quantity limits can be requested.

How can I get an exception to a quantity limit?

Answer: Physicians who write prescriptions that exceed the quantity limit must call CareFirst Pharmacy Services at (800) 241-3371 to request a Prior Authorization before the prescription can be filled at the levels that exceed the drug's quantity limit.

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Travel Coverage

If I am going out of the country for an extended period of time, how do I request the extra supply of drugs I will need?

Answer: If you are traveling out of the country for less than one month, call CareFirst Pharmacy Services at
(800) 241-3371 to receive authorization for an additional short-term supply. If you need to request additional quantities (greater than one month), please contact CareFirst Member Services using the number listed on your ID card.

Please call 10 days in advance of your departure date to request the additional supply.

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