Pharmacy Frequently Asked Questions

Low-Income Subsidy (LIS)

Low income subsidy (LIS), also known as Extra Help, is a program that helps individuals who have a limited income pay for their Medicare prescription drug costs. If you get extra help from Medicare to pay for your prescription drug plan costs, your monthly plan premium will be lower than what it would be if you did not get extra help from Medicare. The amount of extra help you get will determine your total monthly plan premium as a member of our plan.

If you receive extra help, download and refer to the LIS Premium Summary Chart to show you what you’ll pay each month depending on the plan you have and the level of extra help you get.

LIS Summary Chart
LIS Summary Chart (Espanol)

There are several ways a member can apply for Extra Help assistance: visiting local Social Security Administration (SSA) office, applying online at www.ssa.gov, calling SSA at 1-800-772-1213 or requesting an application from the state Medicaid agency.

Best Available Evidence (BAE)

Process for Urgent Need of Medication

When Low-Income Subsidy (LIS) information is incorrect or absent from our internal and CMS systems, we use a process called Best Available Evidence (BAE) to assist the member.

• This may occur, for example, because a state has been unable to successfully report the member as Medicaid-eligible or is not reporting him/her as institutionalized.
  Note: Members may or may not have documentation that they have subsidy.

The Customer Care Representative (CCR) must immediately determine the days’ supply of medication the member has on hand:

• Urgent = 3-day supply or less of medication
• Non-Urgent = More than a 3-day supply of medication

CareFirst BlueCross BlueShield Medicare Advantage will request a CMS review if the member is eligible for subsidy, either based on the documentation provided or if the member does not have the acceptable documentation.

• Confirm with member, Power of Attorney and or Senior Health Insurance Program Counselor if member has urgent need for lifesaving medication(s)

Reminder: If the CMS-approved document does not provide the actual low-income cost-sharing level, a Temporary LIS Level 1 adjustment will be offered to members as a courtesy for one month.

When a Temporary LIS level adjustment is offered and the member does not qualify for a subsidy, the member will be responsible to repay all copays or cost-sharing back to CareFirst BlueCross BlueShield Medicare Advantage.

For members residing in a long-term care facility, temporary LIS is not necessary, as they have access to care.

Medicare Advantage Quality Assurance Program

Ensuring Appropriate Utilization of Resources

CareFirst BlueCross BlueShield Medicare Advantage is committed to providing a Quality Assurance Program and improving the quality of care surrounding utilization management of medical, behavioral and substance use authorizations. We rely on individual clinical contributors to enhance the quality of care and prevent over- and under-utilization of services requested and provided for our enrollees. Results of these activities are analyzed for trends and patterns by examining trends based on:

• Hospital Admissions
• Hospital days vs benchmarks
• ER visits vs benchmarks

CareFirst BlueCross BlueShield Medicare Advantage plans work to promote fair and consistent care management decision making and to promote the quality, safety, effectiveness, and efficiency of medical and behavioral health care provided to enrollees.

Care Management decision making is based only on appropriateness of care and services. The plan does not compensate practitioners or other individuals conducting utilization review for adverse decisions and does not offer incentives to encourage adverse decisions. CareFirst BlueCross BlueShield Medicare Advantage plans follow peer reviewed and industry recognized clinical resources when performing utilization management reviews.

1) Care Management clinical staff carefully evaluate available clinical information on a case by case basis.

2) In making utilization management decisions, clinical staff apply industry recognized criteria when making substance use disorder medical necessity and utilization review determinations.

3) Medical necessity/appropriateness denial decisions are made by Medical Directors/Physician Reviewers.

4) In addition to recognizing that criteria may not always be appropriate for the complicated patient, CareFirst BlueCross BlueShield Medicare Advantage plans also evaluate the individual enrollee’s needs and local health care delivery system. Therefore, clinical staff must consider the following factors when applying criteria to a given individual:

• Age
• Comorbidities
• Complications
• Progress of treatment
• Psychological situation
• Home environment, when appropriate
• Availability of alternative facilities/settings
• Availability of home care services
• Coverage of benefits for alternative facilities/settings
• Ability of hospitals to provide all recommended services
• Extension of benefit coverage for additional services of hours per week or weeks per duration of treatment.

When the factors listed above indicate that the industry recognized clinical resources are not appropriate for an individual the case should be reviewed with a Medical Director/Physician Reviewer or board-certified consultants’ panel, as appropriate.

Ensuring Appropriate Utilization of Resources

CareFirst BlueCross BlueShield Medicare Advantage is committed to providing a Quality Assurance Program and improving the quality of care surrounding prescription drugs. We use system reviews to enhance the quality of care, prevent overutilization and manage potential drug therapy problems. Results of these activities are analyzed for trends and patterns. CareFirst BlueCross BlueShield Medicare Advantage works proactively and in collaboration with our Pharmacy Benefits Manager and Care Management to assess trends and outliers for further intervention.

Promoting Member Safety

The focus of CareFirst BlueCross BlueShield Medicare Advantage’s safety program is to promote knowledge around medication use and overall member safety. CareFirst BlueCross BlueShield Medicare Advantage provides notification to members, providers, and pharmacies for those who have claims for medications with new market withdrawals or recalled medications.

Concurrent Drug Utilization Review (DUR)

CareFirst BlueCross BlueShield Medicare Advantage, in conjunction with the Pharmacy Benefit Manager, conducts a Concurrent Drug Utilization Review Program to assess appropriateness, medical necessity and adverse effects. Concurrent DURs assist in the promotion and improvement of member safety. CareFirst BlueCross BlueShield Medicare Advantage adheres to all CMS and state regulations regarding Concurrent Drug Utilization Review.

CareFirst BlueCross BlueShield Medicare Advantage concurrent DUR program includes, but is not limited to, the following checks each time a prescription is dispensed:

• Screening for potential drug therapy problems due to therapeutic duplication
• Age/gender-related caution screening
• Over-utilization and under-utilization
• Drug regimen compliance screening
• Drug-drug interactions
• Incorrect drug dosage or duration of drug therapy
• Refill Too Soon
• Multiple prescribers
• Multiple pharmacies
• Cumulative Acetaminophen Dose
• Maximum dose multiplier
• Cumulative Morphine Milligram Equivalent
• Buprenorphine with Subsequent Opioids

CareFirst BlueCross BlueShield Medicare Advantage concurrent DUR checks are applied at the level of the dispensing pharmacy (mail or retail).

Retrospective Drug Utilization Review (DUR)

CareFirst BlueCross BlueShield Medicare Advantage, in conjunction with the Pharmacy Benefit Manager, conducts a retrospective Drug Utilization Review (DUR) Program as a mechanism for the ongoing periodic and systematic review of drug utilization and prescribing patterns. The DUR Program compares prescriptions for outpatient medications against standards relating to appropriateness, medical necessity and likelihood of resulting in adverse medical effects. The Retrospective Drug Utilization Review programs (RetroDUR) is designed to ensure ongoing periodic examination of claims data and other records, through computerized drug claims processing and information retrieval systems, in order to identify patterns of inappropriate or medically unnecessary care.

The Program will help:

• Identify potential over-utilization and misuse resulting from poorly coordinated care, drug abuse and prescription fraud
• Educate those involved with members’ medical care, including physicians, physician assistants, nurse practitioners and network pharmacists on how to identify and reduce the frequency of and patterns of fraud, abuse, gross overuse or inappropriate/medically unnecessary care
• Enhance or improve the quality of pharmaceutical care
• Improve member outcomes