You can get Preferred Brand Insulin for $0 with no deductible requirement—no matter which CareFirst plan you choose.
Prescription drug benefits
Click on one of the categories below for more information about drug coverage.
Drug Tiers
The prescription drugs covered on the CareFirst formulary (drug list) are reviewed and approved by an independent national committee comprised of physicians, pharmacists and other healthcare professionals who make sure they are safe and clinically effective. The drugs are categorized into one of the following tiers and your cost-share is determined by that tier. For information on a particular drug, use the Drug Search tool.
Zero cost-share drugs include preventive drugs, oral chemotherapy drugs, medication assisted treatment drugs and diabetic supplies.
Generic drugs are equally safe and effective as brand-name drugs, but generics typically cost significantly less.
Preferred brand drugs are brand-name drugs that may not be available in generic form, but are chosen for their cost effectiveness compared to alternatives. Your cost-share will be more than generics but less than non-preferred brand drugs. If a generic drug becomes available, the preferred brand drug may be moved to the non-preferred brand category.
Non-preferred brand drugs often have a generic or preferred brand drug option where your cost-share will be lower.
Preferred specialty drugs are medications that are used to treat complex and/or rare health conditions. These drugs may have a lower cost-share than non-preferred specialty drugs.
Non-preferred specialty drugs often have a specialty drug option where your cost-share will be lower.
Care Support Programs
Together with our pharmacy benefit manager, we offer care support programs and tools designed to improve your health while lowering your overall health costs.
This program addresses the unique clinical needs of those taking high-cost specialty drugs for certain diseases like multiple sclerosis and hemophilia. This program provides enhanced one-on-one support with a registered nurse, 24-hour pharmacist assistance, condition-specific education and counseling and a dedicated clinical team to work with your doctor to help manage specialty drugs.
When you are taking multiple drugs to treat a medical condition, it can be overwhelming. The Comprehensive Medication Review program can connect you with a pharmacist who will review your medications and talk to your doctor about dosages, duration and any other pertinent issues. The pharmacist will work with your doctor to determine which medications best fit your situation.
Medications do not work if they are not taken as prescribed. Through our Pharmacy Advisor program, CareFirst partners with our pharmacy benefit manager to engage members with at least one of 11 chronic conditions. Pharmacists are alerted to gaps in care and non-adherence and provide in-person one-on-one counseling when the prescription is filled at an in-network pharmacy. If the prescription is filled through mail order or at other network pharmacies, one-on-one telephonic counseling is offered to help you stay on track. The pharmacist will provide personalized tips and support to help you stay adherent to your medications and identify potential opportunities for you to save money on your prescriptions.
Prescription Guidelines
To ensure you are receiving the most appropriate medication for your condition(s), certain medications have prescription guidelines. To see whether your drug requires prior authorization, step therapy or quantity limits, use our Drug Search.
If you fill a non-preferred brand drug when a generic alternative is available, you will pay the non-preferred brand copay or coinsurance plus the cost difference between the generic and non-preferred brand drug, even if your doctor states Dispense as Written (DAW) on the prescription.
There is an exception process if you need the brand-name drug to be covered for medical necessity reasons. Your doctor may submit a brand exception request. To view this form, check our Drug Forms.
Prior authorization is required before you fill prescriptions for certain drugs. Your doctor must obtain prior authorization before they can be filled. Without prior authorization approval, your drugs may not be covered.
Step therapy ensures you receive a lower-cost drug option as the first step in treating certain health conditions. When similar drugs are available, step therapy guides your doctor to prescribe the lower-cost option first. You may then move up the cost levels until you find the drug that works best for you. Higher step drugs may require prior authorization by your doctor before they can be covered.
Quantity limits are placed on selected drugs for safety, quality or utilization reasons. Limits may be placed on the amount of the drug covered per prescription or for a defined period of time. If your doctor decides that a different quantity of medication is right for you, your doctor can request prior authorization for coverage.
Some drugs may not be covered on your formulary, or may have quantity limits. There is an exception process if you need an excluded drug, or an additional quantity, to be covered for medical necessity reasons. Your provider can submit a request on your behalf by contacting 855-582-2022.
Ways To Fill
Here are two ways to help you save on your prescription drug costs.
With access to 66,000 pharmacies across the country, you can use our Find a Pharmacy tool to locate a convenient participating pharmacy. Be sure to take your prescription and member ID card when filling prescriptions.
Mail order is a convenient way to fill your prescriptions, especially for refilling drugs taken frequently. You can register online through My Account. Once you register, you’ll be able to:
- Refill prescriptions online, by phone or by email
- Choose your delivery location
- Consult with pharmacists by phone 24/7
- Schedule automatic refills
- Receive email notification of order status
- Choose from multiple payment options