Medicare Advantage Plan > Prescription Drug Coverage > Pharmacy Frequently Asked Questions
Pharmacy Frequently Asked Questions
Answers to your pharmacy benefit questions.
Below are some helpful links, documents and searchable tools to help you understand your pharmacy benefit.
Yes, as of January 1, 2024, 100- day supply is available for drugs on Tier 1, Tier 2 and Tier 3. Members are eligible to receive 100-day supplies of their tier 1 and tier 2 medications for the same copay as a 30-day supply. Additionally, members are eligible to receive 100-day supplies of their tier 3 medications for the same copay as a 90-day supply.
CareFirst BlueCross BlueShield Medicare Advantage has a nationwide network of pharmacies, so you can fill your prescriptions whether you’re close to home or traveling. We want you to feel safe knowing you can always find a network pharmacy. It’s important to use a network pharmacy in order to receive the best cost and coverage of your medication. If you use an out-of-network pharmacy, you may be able to obtain coverage and you may need to use the form below for reimbursement.
Yes. In fact, you can even save money using mail order for 90-day supplies of chronic medications.
Mail Order Pharmacy Form (PDF)Drugs administered by a provider are covered. There are certain limitations on these medications. Review the forms below for more information. You may have a 20% coinsurance on these medications.
Part B Step Therapy and Part B Prior Authorization criteria can be found here.
If you pay for a prescription out of pocket, you may be able to obtain coverage. Please use the form below for reimbursement.
A Coverage Determination is 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. A standard review will be completed in 72 hours or less, and an expedited review will be completed in 24 hours or less.
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.
- Fax: 855-633-7673
- Online:Coverage Determination Form English | Spanish
- Mail: CVS Caremark Coverage Determinations/Exceptions
P.O. Box 52000
MC109
Phoenix, AZ 85072-2000
Yes, and members can enjoy several products at $0 copay such as:
- Dexcom G5 Continuous Glucose Monitor
- Dexcom G6 Continuous Glucose Monitor
- Dexcom G7 Continuous Glucose Monitor
- FreeStyle Libre Continuous Glucose Monitor
The CareFirst BlueCross BlueShield Medicare Advantage MTM Program is dedicated to providing you with information about safe medication disposal. Medications that are safe for you may not be safe for someone else. Unneeded medications should be disposed of as soon as possible. You can discard your unneeded medications through a local safe disposal program or at home for some medications.
- Locating a community safe drug disposal site
A drug take back site is the best way to safely dispose of medications. To find drug take back sites near you, visit the website below and enter your location: http://www.carefirst.com/safe-disposal-sites
Some pharmacies and police stations offer on-site drop-off boxes, mail-back programs, and other ways for safe disposal. Call your pharmacy or local police department (non-emergency number) for disposal options near you. - Mailing medications to accepting drug disposal sites
Medications may be mailed to authorized sites using approved packages. Information on mail-back sites can be found at www.deatakeback.com. - Safe at-home medication disposal
You can safely dispose of many medications through the trash or by flushing them down the toilet. Visit the following website first to learn what medications are safe to dispose of at home: https://www.hhs.gov/opioids/prevention/safely-dispose-drugs/index.html. - Steps for medication disposal in the trash:
- Remove medication labels to protect your personal information
- Mix medications with undesirable substances, such as dirt or used coffee grounds
- Place mixture in a sealed container, such as an empty margarine tub
CVS Caremark Mail Service Pharmacy can deliver 90-day supplies of medications you take regularly to your door. It’s a safe and secure way to get your Rx – you’ll probably save money too.
There are three ways to get started:
- Ask your doctor to send an electronic prescription to CVS Caremark Mail Service Pharmacy. This is the easiest way to get started – we will process and ship your order in 10 business days.
- Fill out a mail service request form and mail it with your 90-day prescription.
- Call the pharmacy number on your member ID card for live help getting set up.
Yes, mail order prescriptions will generally transfer over to the new plan. We recommend you call the pharmacy number on your member ID card to confirm your mail order transferred to the new plan. CVS Caremark mail order will have the ID information when we receive eligibility, and if any mail order has open refills, they will be transferred to the new ID profile. However, the formulary coverage may change, and the prescription may no longer have refills, therefore, you should call pharmacy number on your member ID card regarding the new coverage to get a better understanding on the impact.
For refills of your drugs, please contact your pharmacy 10- 15 days before your current prescription will run out to make sure your next order is shipped to you in time.
Below are some reasons why your order may be delayed:
- Severe weather may affects mail delivery
- Your medication has special restrictions, such as prior authorization
- We don’t have your payment information
- We don’t have your consent to ship the order
Please call us at the number on your member ID card to learn about options and how we can help.
No. You cannot order a refill until you have used up 75% for most drugs, 80% for opioid drugs, or 70% for topical ophthalmic drugs of your current shipment. For a 90-day supply, this means for most drugs you can order a refill when you have three weeks left of your current shipment.
Only certain medications are available through mail order. On your formulary drug list, the last column will be marked with NM if the medication is not available through mail order. Please check your Evidence of Coverage to verify whether your drug can be filled for a 90-day supply.
When an order contains drugs that are sensitive to cold, we look at the destination temperature. If the destination temperature is below 33 degrees Fahrenheit, we ship it via a standard shipping method, with a signature required. When an order contains drugs that require refrigeration (including insulin) the order is packaged with the appropriate mix of frozen and ambient temperature gel packs (to protect the item from freezing) in a foam cooler. CVS Caremark uses an “Electronic Packing and Shipping System” (EPSS), which develops a cold chain solution for each order based on the individual order characteristics such as destination temperatures, medication type and time in transit. It is shipped via time committed delivery services with carriers such as FedEx, UPS, or Express Mail.
Just like your local retail pharmacy, registered pharmacists are available for consultation by calling the pharmacy number on your member ID card.
Yes. You can select a different shipping address to mail your prescription order to at any time. You can call the pharmacy number on your member ID card for extra help on this.
Your mail order prescription can be shipped to a PO Box if delivery is being made by your local mail service carrier. If your package is coming through another service carrier, such as Fed Ex or UPS, your order cannot be shipped to a PO Box.
Delivery will always be free—even if there are special shipping requirements (for example, overnight or next day). If, however, you request expedited shipping due to a particular reason (for example, you forgot to place your order in time), you will be responsible for these shipping costs.
There are specific procedures to follow in the rare event your medication is lost, stolen or damaged. In these cases, we will issue another supply to you. Call the pharmacy number on your member ID card immediately if your medication is lost, stolen or damaged. Please note, there may be additional restrictions for controlled substances. Check with your doctor if you are taking a controlled substance to determine if there are restrictions.
You can request an additional supply of medication by mail order or retail by calling the pharmacy number on your member ID card for up to a 90 days’ supply. They will make certain you have the necessary supply of medication while you’re away. Please note, there may be additional restrictions for controlled substances. Check with your doctor if you are taking a controlled substance to determine if there are restrictions.
You can obtain controlled substances through the mail order; however, some do require signature upon delivery. Some controlled substances require a new prescription for each fill and have dispensing restrictions that would only allow a certain day supply vs. a 90-day supply. Check with your doctor if you are taking a controlled substance to determine if there are restrictions.
You can continue to use a retail pharmacy for your short-term prescription needs and for other non-maintenance type medications, such as antibiotics, pain relief and sleep agents. Please note: You can go to any retail pharmacy in your network to fill your prescriptions and are not required to use a CVS pharmacy.
If your e-mail address is on file with CVS Caremark, you will be notified both when your order has been received and when it’s shipped. If your order requires expedited shipping or a signature, CVS Caremark will also call you to advise when delivery is expected.
ScriptSync is a service that coordinates your refill prescriptions so you can pick them up together at your CVS Pharmacy.
Your regular prescriptions (not including controlled substances) that are filled at the same CVS Pharmacy. If you have questions about prescription eligibility, call or visit your pharmacy.
You can enroll online via myaccount or work with your CVS pharmacy team to find a convenient pickup date. We'll refill your prescriptions on a 30- or 90-day schedule and let you know when they're ready. You can add or remove prescriptions from ScriptSync online or at the pharmacy. For more information on the program, please call us at the number on your member ID card.
Your CVS Pharmacy team will suggest your first pickup date. Based on the date you pick up your ScriptSync order, your prescriptions will be refilled on a recurring 30- or 90-day schedule. After you've picked up your first ScriptSync order, you can change the date online or with help from your pharmacy team.
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 (PDF)
LIS Summary Chart (PDF) - Spanish
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