Drug Management Programs
Formulary Information (also known as the Drug List)
A formulary is a list of covered drugs selected by CareFirst BlueCross BlueShield Group Advantage in consultation with a team of healthcare providers. This list represents the prescription therapies believed to be a necessary part of a quality treatment program. CareFirst will generally cover the drugs listed in our formulary if the drug is medically necessary, the prescription is filled at a network pharmacy and other plan rules are followed.
CareFirst BlueCross BlueShield uses certain strategies (“utilization management”) to ensure that medications are properly prescribed, dispensed and used. Below are some descriptions.
Prior authorization (PA)
We require you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from CareFirst before you fill certain prescriptions. If you don’t get approval, the drug may not be covered.
Quantity Limit (QL)
For certain drugs, we limit the amount that you can have each time you fill your prescription.
Step Therapy (ST)
In some cases, we require you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.
Not Available via Mail-Order (NM)
This drug is not available through mail order pharmacy.
Drug may be covered under Medicare Part B or D (B/D)
Some drugs may be covered under Medicare Part B or Part D depending on your circumstances. Information may need to be submitted to CareFirst BlueCross BlueShield Group Advantage that describes the use and the place where you receive and take the drug so a determination can be made.
Here are some helpful formulary documents for CareFirst BlueCross BlueShield Group Advantage plans.
2024 Documents
Comprehensive Formulary
English
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Spanish
Formulary Changes (PDF)
English
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Spanish
Prior Authorization Criteria (PDF)
English
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Spanish
Step Therapy Criteria (PDF)
English
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Spanish
*Your employer may offer additional coverage. Please refer to Chapter 5 of your Evidence of Coverage for more information.
Transition Policy
What is transition?
A transition refill, also known as a transition fill, is typically a one-time, one-month supply of a drug that you’re taking. Transition refills let you get temporary coverage for drugs that are not on your plan’s formulary or that have certain coverage restrictions (such as prior authorization or step therapy). You can only get transition fills for drugs you were already taking before switching plans or before your existing plan changed its coverage.
As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.
For each drug that is not on our formulary, or if your ability to get your drugs is limited, we will cover a temporary 30-day supply. If your prescription is written for fewer days, we’ll allow refills to provide up to a maximum 30-day supply of medication. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.
If you are a resident of a long-term care facility and you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug while you pursue a formulary exception.
If you experience a level of care change (such as being discharged or admitted to a long-term care facility), your physician or pharmacy can request a one-time prescription override. This one-time override will provide you with temporary coverage (up to a 31-day supply) for the applicable drug(s).
Below are the timeframes and allotments of medication that you can receive as you change living situations.
| Description | Transition Fill Supply |
|---|---|
| New & Renewing Members | |
| Not in long-term care | 30-day supply within first 90 days in the plan; multiple fills up to a cumulative applicable month’s supply are allowed to accommodate fills for amounts less than prescribed. |
| In long-term care | Emergency Supply Transition Fills are allowed up to a cumulative 31-day supply within first 90 days in the plan, except for oral brand solids which are limited to a 14-day supply with exceptions as required by CMS guidance. Multiple fills for a cumulative applicable month’s supply are allowed to accommodate fills for amounts less than prescribed on the first 90 days. |
| Non-Long-term Care Resident Level of Care Change | |
| Member released from long-term care facility within past 30 days | 30-day supply; multiple fills up to a cumulative applicable month’s supply are allowed to accommodate fills for amounts less than prescribed. |
The transition supply allows you time to talk to your doctor or other prescriber about pursuing other options available to you within our formulary. Your plan cannot continue to pay for these medications under the transition policy, even if you have been a member for less than 90 days following your one-month transition supply.
If you receive a transition supply, you will receive a letter from your plan notifying you that you have received a temporary supply of your prescription drug. Please refer to your Evidence of Coverage for more information on the CareFirst BlueCross BlueShield Group Advantage transition process.
What scenarios could exist to prevent me from receiving a transition fill?
- Refill Too Soon (RTS) If it is too soon to refill your medication based on your previous fill, you will not receive transition. You may be able to receive a transition fill once this time period has expired.
- DUR Safety Checks If there is a safety issue with how the medication is prescribed, for example there is too much acetaminophen prescribed (calculated at greater than 4 grams per day), the claim will reject and not allow transition.
- Part A or B Only Drugs These medications pay pursuant to a different benefit. Only Part D drugs will qualify for this type of fill.
- Part A or B vs. Part D (A or B vs. D) These medications may pay pursuant to a different benefit and until it can be determined how they should pay, there cannot be a transition fill.
- Excluded Drugs If a drug is not considered a Part D drug (OTC, fertility, etc.) it will not be eligible for a transition fill.
Coverage Determination, Appeals, Exceptions and Redetermination
Coverage Determination: A decision CareFirst makes about your benefit and coverage and the amount you will pay. If a drug is not covered or there are restrictions or limits on a drug, you may request a coverage determination.
Appeal: A request to reconsider and change a decision or determination made about the plan services or benefits or the amount the plan will pay for a service or benefit.
Exception: Exceptions are a type of coverage determination. Providers and members can submit an exception request for drug coverage determination.
These exceptions include:
- Non-Formulary Drug Exception: A request to cover a non-formulary drug
- Tier Exception: A request to cover a non-preferred drug at a lower tier cost-share
- Quantity Limit Exception: A request for a drug to bypass quantity limit guidelines
- Prior Authorization Exception: A request for a drug to bypass prior authorization guidelines
- Step Therapy Exception: A request for a drug to bypass step therapy guidelines
Exceptions requests are granted when CareFirst BlueCross BlueShield Group Advantage determines that a requested drug is medically necessary for you. Generally, we will only approve your request for an exception if the alternative drugs included on the plan’s formulary, would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request.
Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. If request is approved, a notice is sent to the provider and member. If request is denied, a notice is sent to the provider and member explaining the reason why the request was denied and information on how to submit a redetermination (Appeal).
To check the status of an appeal, call our customer service team at 888-970-0917.
How to Request a Coverage Determination
A member, prescriber, or a member's appointed representative may request a standard or expedited coverage determination. You, your prescriber or your appointed representative may request a coverage decision and/or exception any of the following ways:
Phone:
Contact customer service for any requests including making an oral request related to Coverage Determination and Appeals. Our customer service team is available 24/7/365 at 888-970-0917. Appeals calls are then redirected to the correct department for further action. Other means of contact are provided below.
Fax: 855-633-7673
Online: Coverage Determination Form (PDF) English | Spanish
Mail: CVS Caremark
P.O. Box 52000
MC109
Phoenix, AZ 85072-2000
You can also contact Medicare directly at 1-800-MEDICARE or file a complaint online at:
Medicare.gov/MedicareComplaintForm/home.aspx
When does the coverage determination process start?
You can request a coverage determination review as early as 12/1/2024 for your 1/1/2025 benefit as along as your eligibility is on file.
Can my previous prior authorization transfer over?
No, due to CMS regulation, your previous prior authorization cannot transfer to your new Medicare Plan. To streamline your care, we allow for early coverage determination starting 12/1/2024 as along as your eligibility is on file. Additionally, the transition period will generally allow you a one-time, one-month supply of a drug that you’re taking within your first 90 days of enrollment.
How to Request a Redetermination (Appeal)
An initial coverage determination decision can be appealed. To start your appeal, a member, prescriber, or a member's appointed representative must contact us within 60 calendar days of the date of the denial notice they received (unless the filing window is extended). You, your prescriber, or your appointed representative may ask for an expedited (fast) or standard appeal via any of the following ways:
Phone:
Contact customer service for any requests related including making an oral request to Coverage Determination and Appeals. Our customer service team is available 24/7/365 at 888-970-0917. Appeals calls are then redirected to the correct department for further action. Other means of contact are provided below.
Fax: 855-633-7673
Online: Redetermination Form (PDF) English | Spanish
Mail:
CVS Caremark
P.O. Box 52000
MC109
Phoenix, AZ 85072-2000
You can also contact Medicare directly at 1-800-MEDICARE or file a complaint online at:
Medicare.gov/MedicareComplaintForm/home.aspx
Opioid Safety
- CareFirst BlueCross BlueShield Group Advantage is dedicated to helping you use opioid pain medications more safely.
- To help prevent and combat prescription opioid overuse through improved concurrent Drug Utilization Review (DUR), CareFirst BlueCross BlueShield Group Advantage will implement opioid safety review at the point of sale (POS), including:
- A care coordination review based on a cumulative Morphine Milligram Equivalent (MME) threshold of 90 MME per day.
- This review is triggered when the member receives opioid prescriptions from three or more prescribers and the cumulative opioid daily dose is greater than or equal to 90 Morphine Milligram Equivalents (MME).
- The pharmacist can override this review by consulting with the prescriber to determine the medical necessity of the opioid prescription(s). If the pharmacist is unable or unwilling to override this review, the member, member’s representative and/or prescriber have the option of submitting a coverage determination.
- A hard safety review to limit initial opioid prescription fills for the treatment of acute pain to no more than a 7-day supply.
- This review is triggered when an opioid-naïve member fills an opioid prescription for a greater than 7-day supply. Pharmacists can dispense a seven-day supply. The member, member’s representative and/or prescriber have the option of submitting a coverage determination to obtain quantity greater than 7-day supply.
- A hard 200 Morphine Milligram Equivalents (MME) review
- This review is triggered when the member receives opioid prescriptions from three or more prescribers and the cumulative opioid daily dose is greater than or equal to 200 Morphine Milligram Equivalents (MME).
- Prescription may not be filled by the pharmacist without a prior authorization from the plan. The member, member’s representative and/or prescriber will need to submit a coverage determination.