Drug Management Programs

Formulary Information (also known as the Drug List)

A formulary is a list of covered drugs selected by CareFirst BlueCross Blue Shield 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 Member Services at 855-290-5744 (TTY: 711) 8 a.m.-8 p.m. ET, 7 days a week from October 1 through December 7. From April 1 through September 30, you will need to leave a message on weekends and holidays.

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.

Here are some helpful formulary documents for the 2021 CareFirst BlueCross BlueShield Medicare Advantage plans.

Searchable Core Formulary

Searchable Enhanced Formulary

Comprehensive Core Formulary (PDF) English | Spanish

Comprehensive Enhanced Formulary (PDF) English | Spanish

Formulary Changes Core (PDF) English | Spanish

Formulary Changes Enhanced (PDF) English | Spanish

Prior Authorization Criteria - Core (PDF) English | Spanish

Prior Authorization Criteria - Enhanced (PDF) English | Spanish

Step Therapy Criteria - Core (PDF) English | Spanish

Step Therapy Criteria - Enhanced (PDF) English | Spanish

Medicare Advantage Pharmacy Resources

Medication Therapy Management Program

The CareFirst BlueCross BlueShield Medicare Advantage medication therapy management program helps you get the greatest health benefit from your medications by:

Preventing or reducing drug-related risks
Increasing your awareness
Supporting good habits

You’ll be enrolled in the program automatically at no cost to you if these three conditions apply:

You take eight or more Medicare Part D covered maintenance drugs
You have three or more of these long-term health conditions:

Asthma
Chronic obstructive pulmonary disease (COPD)
Diabetes
Depression
Osteoporosis
Chronic heart failure
HIV
Cardiovascular disorders, such as high blood pressure, high cholesterol or coronary artery disease

You reach $4,376 in yearly prescription drug costs paid by you and the plan

This program is not a benefit for all plan members. It’s provided only to those who are invited. Your participation is voluntary and does not affect your coverage.

The program provides you with two medication reviews: a comprehensive medication review and a targeted medication review.

Comprehensive Medication Review

The review is a one-on-one discussion with a pharmacist, to answer questions and address concerns you have about the medications you take, including:

Prescription drugs
Over-the-counter (OTC) medicines
Herbal therapies
Dietary supplements and vitamins

The pharmacist will offer ways to manage your conditions with the medications you take. If more information is needed, the pharmacist may contact your prescribing doctor. The review takes about 30 minutes and is usually offered once each year—if you qualify. At the end of your discussion, the pharmacist will provide you a Personal Medication List with the medications you discussed during your review.

You will also receive a Medication Action Plan. Your plan may include suggestions from the pharmacist for you to discuss with your doctor.

Use this blank copy of the Personal Medication List to track your prescriptions.

Targeted Medication Review

With this review, we mail, fax or call your doctor with suggestions about prescription drugs that may be safer, or work better than your current drugs. As always, your prescribing doctor will decide whether to consider our suggestions. Your prescription drugs will not change unless you and your doctor decide to change them. We may also contact you, by mail or phone, with suggestions about your medications.

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If you qualify, we will mail you a letter. Also, you may receive a call, inviting you to participate in this one-on-one medication review.

You may receive a call from a pharmacy where you recently filled one or more of your prescriptions. You will be given the option to choose an in-person review or a phone review.

You may be contacted by a call center pharmacist to provide your review and ensure that you have access to the service if you wish to participate. These reviews are conducted by phone.

Different doctors may write prescriptions for you without knowing all the prescription drugs and/or OTC medications you take. For that reason, a pharmacist will:

Discuss how your prescription drugs and OTC medications may affect each other
Identify any prescription drugs and OTC medications that may cause side effects and offer suggestions to help
Help you get the greatest health benefit from all your prescription drugs and OTC medications
Review opportunities to help you reduce your prescription drug costs

Discussing your medications can result in real peace of mind, knowing that you are taking your prescription drugs and OTC medications safely
The pharmacy can look for ways to help you save money on your out-of-pocket prescription drug costs
You benefit by having a Personal Medication List and a Medication Action Plan to keep and share with your doctors and other healthcare providers

For more information, or if you do not want to participate after being enrolled in the program, contact CVS Member Services at 844-635-3406, 24 hours a day, 7 days a week. (TTY: 711)

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Transition Policy

What is transition?

Espanol (PDF)

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.

30-day supply cost tier
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	31-day supply within first 90 days in the plan, oral brand solids 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 or 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 Medicare 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, weight loss, fertility, etc.) it will not be eligible for a transition fill.

Coverage Determination, Appeals, Exceptions and Redetermination

Coverage Determination: A decision CareFirst make 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

Generally, CareFirst BlueCross BlueShield Advantage will only approve your request for an exception if the alternative drugs included on the plan’s formulary, [the lower cost-sharing drug] or additional utilization restrictions 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 English | Spanish

Mail: CVS Caremark Coverage Determinations/Exceptions
P.O. Box 52000
Phoenix, AZ 85072-2000

You can also contact Medicare directly at 1-800-MEDICARE or file a complaint online at:
www.Medicare.gov/MedicareComplaintForm/home.aspx

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: