Prescription Coverage Overview
Formulary Information (also known as the Drug List)
A formulary is a list of covered drugs selected by CareFirst BlueCross BlueShield Medicare 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.
Limited Access (LA)
This prescription may be available only at certain pharmacies. For more information, consult your Pharmacy Directory (PDF) English | Spanish or call CVS Member Services at 844-786-6762, 24 hours a day/7 day a week, Monday through Friday. TTY users should call toll-free TTY 711.
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 Medicare Advantage that describes the use and the place where you receive and take the drug so a determination can be made.
Your Prescriptions, Your Way
Did you know you can get your prescriptions delivered directly to your door at no extra cost? In some cases, getting your prescriptions sent to you can actually save you money and for certain medications, you can get extended refills for as many as 90 days. There are four ways to sign up:
- Ask your doctor to send an electronic prescription for a 3-month supply of your medication to our mail service pharmacy partner, CVS Caremark® Mail Service Pharmacy.
- Sign in to www.caremark.com Select Prescriptions, then select Start Rx Delivery by Mail. Enter your drug information to confirm your drug is covered and follow the prompts to submit your request. The mail service pharmacy will contact your doctor and get the process started for you. (Note: You cannot access this option from the Caremark app.)
- Call Customer Care at 1-844-786-6762, 24 hours a day, 7 days a week (TTY: 711).
- Submit a claim form directly.
How to Find a Network Pharmacy
DualPrime has a nationwide network of pharmacies, so chances are there's one near you! To find a participating pharmacy near you, use the Pharmacy Locator Tool or search our downloadable Pharmacy Directory below.
To determine if your pharmacy is in the network, you can call our Medicare Part D Member Services line at 844-786-6762, 24 hours a day, 7 days a week. TTY users, please call 711.
If you would like to be mailed a hard copy of the pharmacy directory or need help finding a network pharmacy, please call member services at: 844-331-6334 (TTY: 711)
Search for Your Medications
Use the 2024 Formulary Search Tool to find out if your prescription is covered.
Search Covered MedicationsMail Order Pharmacy
You can get certain prescription drugs shipped to your home through the network mail-order delivery program. Your prescription will arrive with 10 days. Refer to your Evidence of Coverage (EOC) for more information.
Mail Order Form
What If My Drug Isn’t Covered?
If you don’t find your prescription listed on our formulary, please call Member Services at 844-786-6762 (TTY: 711). They’re available 24 hours a day, seven days a week.