Transition Policy and Exceptions
Prescription Drug Transition Fills for New Members
The following applies to new members who are taking a Part D drug that is either:
- Not on the CareFirst Medicare Advantage formulary; or
- Subject to a utilization management requirement or limitation (such as step therapy, prior authorization, or a quantity limit).
You are entitled to receive up to a 30-day supply of a Part D drug within the first 90 days of your enrollment. (The period of time in which you are entitled to receive the transition supply is called your “transition period.”)
You can get multiple fills up to the 30-day supply within your transition period if your first fill is less than a 30-day supply. In general, we will determine your right to a 30-day supply at the network pharmacy when you go to fill your prescription. However, in some situations, we will need to get additional information before we can determine if you are entitled to a transition 30-day transition fill.
Prescription Drug Transition Fills for Renewing Members
The following applies to existing members who renew their CareFirst Medicare Advantage coverage and are taking a Part D drug that is either:
- Removed from the formulary
- Subject to a new utilization requirement or limitation at the beginning of the new plan year
You are entitled to receive up to a 30-day supply during your transition period. For existing members who renew their CareFirst Medicare Advantage coverage from one year to the next, your transition period is the first 90 days of the new plan year.
The 90-day transition period is also available to members throughout the plan year if a drug is removed from the formulary.
You can get multiple fills up to the 30-day supply within your transition period if your first fill is less than a 30-day supply. In general, we will determine your right to a 30-day supply at the pharmacy when you go to fill your prescription. However, in some situations, we will need to get additional information before we can determine if you are entitled to a transition 30-day transition fill.
Members who received a transition fill of a non-formulary drug in 2020 will not be able to receive an additional transition fill of the same non-formulary drug in 2021.
Prescription Drug Transition Fills for Members in a Long-Term Care Facility
If you are a resident of a long-term care facility, you can receive a maximum 31-day single fill of a Part D drug during your transition period. We will allow you to refill your prescription until we have provided you with up to a 90-day transition supply, consistent with the dispensing increment (unless you have a prescription written for fewer days).
Prescription Drug Transition Fills for “Level of Care Changes”
You may also be eligible to receive a transition fill outside of your 90-day transition period. For example, you may be eligible to receive a temporary supply of a drug if you experience a change in your “level of care.” (An instance of this would be if you returned home from a stay in the hospital with a prescription for a drug that isn’t on the formulary).
There are other situations where you may be entitled to receive a temporary supply of a prescription drug. If you have questions about whether you are entitled to a temporary supply of a drug in a particular situation, please call Member Services.
After you get your Transition Fill
After you get a transition fill, you will receive a letter from CareFirst Medicare Advantage telling you what to do next. These are the steps you should follow to ensure you are able to continue to get coverage for the prescription drug(s) you need:
If your drug is not on the formulary, you should either:
- Speak to your doctor about whether you should change the drug you are currently taking.
- Request an exception before you run out of your transition drug supply.
Your doctor can help you determine if there’s a different drug on the formulary that would be equally effective for your condition. Or, your doctor may believe it’s medically necessary for you to continue taking your current medication. In that case, you will need to ask us for an exception to receive coverage for the drug.
You can make the request for a formulary exception or your doctor can make the request on your behalf. However, it may be easier to have your doctor submit the request for you. We will need the doctor to give us a written statement with the medical reasons for the formulary exception you are requesting. (We call this the “doctor’s statement.”) Your doctor can fax or mail the statement to us. Or your doctor can call us and follow up by faxing or mailing the signed statement.
To start the formulary exception process, you, your authorized representative, or your doctor must call, fax or write to our Precertification Unit.
Your doctor can help you if your prescription drug is subject to quantity limits, step therapy or prior authorization. These special requirements are developed by a team of doctors and pharmacists to help our members use drugs safely and in a cost effective manner.
Prior authorization refers to a requirement that applies to certain medications. It means you or your doctor has to provide us information regarding the reason your doctor prescribed the drug. This lets us confirm that it’s medically necessary. Your doctor can help you by providing clinical information needed for the prior authorization process.
You might be required to try a different drug first, to see if it will work, before the drug you want to take will be covered for you. This is called “step therapy". Or there might be limits on what amount of the drug (number of pills, etc.) is covered during a particular time period. This is called a “quantity limit.”
If you and your doctor believe these restrictions should not apply, you or your doctor can request an exception. It may be easier for your doctor to contact us and request prior authorization or removal of a restriction. You or your doctor can get in touch with us using the contact information below.
How to contact us for an exception
By Mail:
CareFirst BlueCross BlueShield Medicare Advantage
c/o CVS Caremark
P.O. Box 52000, MC109
Phoenix, AZ 85072-2000
- By Fax: 1-855-633-7673
- By Telephone: 1-844-786-6762 (TTY users please call 711), 24 hours a day, 7 days a week
Once we receive the provider statement, we must notify you of our decision no later than:
- 24 hours for an expedited request
- 72 hours for a standard request
Your request will be expedited if we determine, or your doctor informs us, that your life, health, or ability to regain maximum function may be seriously jeopardized by waiting for a standard request.
What if your request is denied?
If your request is denied, you have the right to appeal. You can ask for a review of our decision. You must request this appeal within 60 calendar days from the date of our decision.
CareFirst BlueCross BlueShield Medicare Advantage
Attention: Appeals & Grievances
PO Box 915
Owings Mills, MD 21117
Telephone: 410-779-9932 or toll-free at 1-844-386-6762 (TTY: 711)
October 1 - March 31 | 8 am - 8 pm EST | 7 days a week
April 1 - September 30 | 8 am - 8 pm EST | Monday – Friday
Fax: 1-844-329-0831
If you need help requesting an exception, or would like more information about our transition policy (including alternate format or languages), please call Member Services at 1-844-786-6762, 24 hours a day, 7 days a week. TTY users please call 711.