Prescription Guidelines

To ensure you are receiving the most appropriate medication for your condition(s), additional information may be required from your doctor before filling certain prescriptions. In those instances, we will work with you and your doctor to manage the following processes:

  • Generics are dispensed when available unless your provider determines that a brand-name drug is necessary for your overall health. You should always check with your doctor to make sure a generic alternative is right for you.
    • Please note: there may be cost-sharing implications for choosing non-preferred brand medications when generics are available. Your cost share depends on which of the three generic substitution coverage levels you have –voluntary, mandatory or restrictive. Refer to your benefit summary or enrollment materials for more information.
  • Prior authorization from CareFirst is required before you fill prescriptions for certain drugs. Your doctor may need to provide some of your medical history or laboratory tests to determine if these medications are appropriate. Without prior authorization from CareFirst, your drugs may not be covered.
  • Step therapy asks that you try lower-cost, equally effective drugs that treat the same medical condition before trying a higher-cost alternative. Your doctor will need to provide information to CareFirst about your experience with these alternatives prior to dispensing a more expensive drug.
  • Quantity Limits are guidelines that set limits on the amount of drugs your prescription drug benefit program will cover. These quality and cost-savings initiatives aimed at safe and appropriate use of drugs are based on clinical guidelines and direction from the U.S. Food and Drug Administration. Remember, the final decision regarding the amount prescribed remains with your doctor.

Exception Requests

If the formulary does not meet the needs of your particular condition, your doctor can request an exception with an Exception Request Form. To see whether your drug requires prior authorization, step therapy and quantity limits, check the Drug Search tool.

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