Prescription Drug Frequently Asked Questions

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General Information

Answer: Yes. You can choose from over 68,000 participating pharmacies nationwide that accept CareFirst or CareFirst BlueChoice insurance plans. Use the Pharmacy Locator to find out if a pharmacy participates in our network or you can call CareFirst Pharmacy Services at 800-241-3371. You can also use non-participating pharmacies, but you will have to pay the full cost of the drug at the time of purchase and submit a claim for reimbursement. It is unlikely that your benefits will reimburse you for the full cost of the prescription. Some plans only will reimburse for drugs at a non-participating pharmacy in an emergency situation or out-of-area urgent care. Refer to your Evidence of Coverage.

Answer: As a part of the Affordable Care Act, all plans are required to have an annual out-of-pocket maximum. Once that maximum has been met, you pay no additional costs for covered benefits. Please refer to your benefit contract to determine the out-of-pocket maximum for your plan or call CareFirst Pharmacy Services at 800-241-3371.

Answer: To have your prescription filled:

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

Answer: Call your physician or pharmacist for questions about:

  • Your prescribed drug
  • Side effects
  • Drug interactions
  • Storage

If you are taking a specialty medication, you may want to call the specialty pharmacy coordination team at CVS at 800-237-2767.

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Prescription Drug Coverage

Answer: A generic drug:

  • 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 tier of the CareFirst Prescription Drug Program

Answer: A brand-name drug:

  • 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
  • Can fall within the non-preferred or preferred brand-name drug tier or the self-administered injectable or specialty tier of the CareFirst Prescription Drug Program

Answer: An OTC drug is:

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

NOTE: Many OTC medications were once prescription drugs.

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

If you are taking a specialty medication, you may want to call the specialty pharmacy coordination team at CVS at 800-237-2767.

Answer: A compound drug is a medication made by combining, mixing or altering ingredients (some of which may not be subject to approval by the FDA), in response to a prescription, to create a customized drug that is not otherwise commercially available.

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-name drug copay or coinsurance for the compound prescription. All compounds over $300 must receive prior authorization from CareFirst before being filled.

Answer: Allergy serums are generally covered under your medical benefit. Please check your Evidence of Coverage to determine how they are covered.

Answer: All covered prescription drugs are ranked into tiers depending on your plan. The price you pay will depend in which tier a drug is placed.

  • No cost drugs
  • Generic drugs ($)
  • Preferred brand-name drugs ($$)
  • Non-preferred brand-name drugs ($$$)
  • Self-administered Injectable drugs or specialty drugs (excluding insulin) ($$$$).

NOTE: Some plans have a separate tier that either contains self-administered injectables (excluding insulin) or specialty drugs. If your plan does not have a separate tier for these drugs, the self-injectables or specialty drugs are covered under the generic, preferred brand or non-preferred brand tier.

Your coverage may also contain any of the following components:

  • Restrictive or mandatory generic substitution
  • Prior authorization
  • Quantity limits
  • Step therapy

Answer: No, but you will have the lowest out-of-pocket cost for the generic drug. Some plans may require you to pay additional cost if you choose a brand-name drug when a generic drug is available.

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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Mail Order Prescriptions

Answer: You can register three ways:

  • Online through My Account
  • By phone
  • By mail

Log in to My Account to learn more. Click on "Drug and Pharmacy Resources" under Quick Links and go to the Mail Order Prescriptions tab.

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Maintenance Medications

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 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 for assistance on the exception process or have your physician submit a Maintenance Medication Request Form .

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Prior Authorization

Answer: Prior authorization is advance approval to ensure your drug is covered by the plan. Your provider can submit a prior authorization form for a specific drug, if needed. The list of drugs requiring prior authorization is subject to change.

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

Answer: There are two ways:

  • Search the formulary
  • Call CareFirst Pharmacy Services at 800-241-3371

Drugs that require a prior authorization are subject to change and are subject to your benefit plan.

NOTE: Your employer may have excluded some drugs from your plan.

Answer: No. Once a prior authorization is given, it is typically valid for four (4) months to one (1) year.

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

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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 and preferred brand-name drugs.

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

Review the Preferred Drug List to find out if a drug is on it or you can call CareFirst Pharmacy Services at 800-241-3371.

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

  • Not part of the Preferred Drug List but are covered by your pharmacy benefits
  • Typically more expensive
  • The member pays the highest out-of-pocket expense
  • May have a generic drug available
  • Examples of some non-preferred drugs are:
    • Drugs 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-name 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

Answer: The Preferred Drug List is based on current medical research and input from an independent CVS Caremark national committee of doctors and pharmacists.

  • Drugs are selected for their quality, effectiveness and cost
  • The Preferred Drug List can change within 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

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

Answer: The Preferred Drug List 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.

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Quantity Limits

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

  • The Prescription Guidelines include dosage limits for some drugs. These limits are based on current medical literature and input from an independent CVS Caremark national committee of doctors and pharmacists.
  • Review the full list of drugs which have quantity limits. The list is subject to change.
  • When medically necessary, an exception to quantity limits can be requested.

NOTE: Physicians who write prescriptions that exceed the quantity limit must call CareFirst Pharmacy Services at 800-241-3371 to request a prior authorization. The prior authorization must be approved by CareFirst before the prescription can be filled at levels exceeding the drug’s quantity limit.

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Step Therapy

Answer:

  • Step therapy requires you try lower-cost, equally effective drugs that treat the same medical condition before trying a higher cost alternative. Your doctor may prescribe you alternative drugs to try prior to dispensing a more expensive drug.
  • Review the full list of drugs requiring step therapy. The list is subject to change.
  • When medically necessary, an exception to step therapy can be requested:

NOTE: If there is some medically necessary reason that you cannot take the preferred drug, your physician must call CareFirst Pharmacy Services at 800-241-3371 to request an exception and be approved before the prescription can be filled.

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Generic Substitution

Answer: If there is a generic drug available for the drug your provider prescribed, it will be dispensed at your pharmacy. If you or your provider wishes to have a brand-name drug, it will cost you more at the pharmacy. When there is a generic equivalent available, brand-name drugs are placed in the non-preferred brand tier on our formulary. If you or your provider requests the brand, you will be required to pay the non-preferred brand copay or coinsurance plus the difference between the generic cost and non-preferred brand-name drug cost.

Answer: If there is a generic drug available for the drug your provider prescribed, it will be dispensed at your pharmacy. If you wish to have a brand name, it will cost you more at the pharmacy. When there is a generic equivalent available, brand-name drugs are placed in the non-preferred brand tier on our formulary. If you request the brand, you will be required to pay the non-preferred brand copay or coinsurance plus the difference between the generic cost and non-preferred brand drug cost.

If your provider specifies you are required to receive the brand-name drug on your prescription, you will pay a non-preferred brand copayment to receive that brand-name drug when the generic is available.

NOTE: Please refer to your Evidence of Coverage for details to determine if mandatory or generic substitution apply to your plan.

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Preventive Drugs

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

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.

Review the list of preventive drugs .

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Travel Coverage

Answer: If you are traveling out of the country, please contact CareFirst Member Services using the pharmacy number listed on your ID card. Please call at least ten (10) days in advance of your departure date to request the additional supply.

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