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Medicare Basics FAQ

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Original Medicare does not cover 100% of the costs of your health services. It covers about 80%. Some of the services NOT covered by Original Medicare include:
  • Prescription drugs
  • Dental exams, most dental care or dentures
  • Routine eye exams, eyeglasses or contacts
  • Hearing aids or related exams or services
  • Most care while traveling outside the United States
  • Help with bathing, dressing, eating, etc. (custodial care)
  • Comfort items such as a hospital phone, TV or private room
  • Long-term care
  • Cosmetic surgery
  • Most chiropractic services
  • Acupuncture or other alternative treatments
  • Routine foot care

If you’ve had Medicare Part B for at least 12 months, your annual wellness visit (AWV) is 100% covered. It’s not a physical, but your doctor will work with you to make a personalized plan for managing your health during your AWV. Many Medicare Advantage (Part C) plans may also cover an annual physical.

Yes. It’s called dual eligibility. Medicare pays your doctors first. Then, Medicaid pays the remaining expenses. This often covers most of your total healthcare costs. Dual coverage often offers benefits not covered by Parts A and B, including dental, hearing and vision. For more information, contact your state’s Medicaid office. Or, call Social Security toll-free at 800-772-1213, TYY 800-325-0078.

There are programs available that can help you cover the costs of your medical expenses. Programs include:

Medicare Advantage is also known as Medicare Part C and it combines your hospital (Part A), doctor (Part B), and sometimes drug coverage (Part D) all in one plan. These plans follow all of the rules and cover all the benefits covered by Original Medicare and are offered by private insurance companies like CareFirst. Under a Medicare Advantage plan, CareFirst can offer additional supplemental benefits like a nurse line, fitness program, telehealth benefits, and in-home assessments that are not covered by Medicare Part A or Part B. 

No, you can only be enrolled in one Medicare Advantage plan at a time. Medicare will automatically terminate you from this plan if you enroll in any other Medicare Advantage plan or standalone Part D prescription drug plan.

General CareFirst Group Advantage FAQ

CareFirst ID Cards and Welcome Kits will be received prior to your effective date. Retirees and Medicare-eligible dependents will each receive their own card. Please note that each enrollee may not receive their plan information on the same day—this is normal. 

You will receive a welcome kit and a CareFirst ID card for your Medicare Advantage plan. Your new Medicare Advantage ID card will be needed to ensure that claims will be filed correctly by your providers and they can access your benefits accurately. Make sure you keep your Original Medicare card somewhere safe, but you will not need to show it to your doctors. 

Yes. To be enrolled in a Medicare Advantage Group PPO plan, Medicare beneficiaries must be enrolled in Medicare Part A and Part B and continue to pay their Part B premium. For higher income retirees assessed with Part B and Part D Income Related Monthly Adjustment Amounts (IRMAA), you will need to continue to pay your Part B and Part D IRMAA premiums. 

Unfortunately, the Centers for Medicare and Medicaid Services (CMS) will ask CareFirst to dis-enroll you from the CareFirst Medicare Advantage plan. You would need to work with Social Security to determine how you can be reinstated with Medicare and will not have drug or medical coverage through CareFirst during that time. 

Because employers can customize Group Medicare Advantage plans, no two Group Medicare Advantage plans are alike. Once enrolled in the Group Medicare Advantage plan offered by your former employer or union, you can access your plan-specific information by registering for My Account, your secure and personalized member portal. There you will locate your Evidence of Coverage, which details all the benefits covered by your plan and how much you’ll be responsible for paying in Chapter 4 – Medical Benefits Chart. There are copays associated with most covered services, but some benefits may have coinsurance depending on your plan. If you still have questions, you can call the Member Services number on the back of your ID card for support. 

Prior authorization is a health plan’s approval to provide a service or fill a prescription. It helps ensure that the care is medically necessary and that the plan doesn’t pay for unnecessary services. Prior authorization focuses on services that are more complex, dependent on clinical judgment, harmful if misused, and subject to patterns of fraud or abuse.

Coverage of a service is based on the medical documentation that your physician provides. The medical documentation is then reviewed against medical criteria by clinical staff who make a coverage determination. This process is done before the member has the service and before a claim is submitted. If the determination is the service will not be covered, the member has the right to appeal the decision. A medical provider is the only person who is able to complete the medical documentation necessary for prior authorization. The member is not responsible for submitting prior authorization requests.

Services requiring prior authorization can be found in your Evidence of Coverage. They include services such as inpatient hospital care, durable medical equipment (DME), outpatient rehabilitation services (e.g., physical therapy), outpatient surgery and skilled nursing facility (SNF) care.

Yes. Retirees enrolled in a CareFirst Group Medicare Advantage plan are required to reside in the 50 United States, D.C. or a U.S. territory in order to stay enrolled in the plan. CareFirst partners with other Blue Cross Blue Shield Medicare Advantage networks across the nation to ensure members have in-network coverage anywhere in the U.S.

Yes. Retirees enrolled in a CareFirst Group Medicare Advantage plan are required to reside in the 50 United States, D.C., or a U.S. territory in order to stay enrolled in the plan. However, the plan does provide limited coverage for worldwide emergency and urgent care services outside the U.S. for retirees traveling abroad. This coverage includes a $50,000 combined maximum benefit for care received in an emergency or urgent care setting only. If admitted, inpatient benefits are not covered. Retirees are responsible for payment at the time services are rendered and then may submit the claims and proof of payment to CareFirst for reimbursement consideration (minus any applicable member cost sharing). Because this coverage is limited to care provided in emergency and urgent care settings only, obtaining additional travel insurance is recommended if traveling outside of the country for extended periods of time.

Yes. You will have to complete and submit a Designation of Personal Representative Form Designation of Personal Representative Form to CareFirst. CareFirst requires this for each individual who you permit to act on your behalf in making decisions related to your healthcare coverage. Please note if you and your spouse both have a CareFirst Group Medicare Advantage plan and both allow your child to act on your behalf, a form will need to be submitted for each of you (2 forms total).

The only people who may be enrolled in the same Medicare Advantage plan as you are the Medicare-eligible individuals who retired from the same employer or union. The Medicare Advantage plan you’re enrolled in is a Group Medicare Advantage plan that has been customized by your previous employer or union. It is available exclusively to the retirees of your former employer or union. This is different than all the Individual Medicare Advantage plans on the market that other Medicare-eligible individuals may choose to buy when they don’t have retiree coverage available to them from their former employer or union.

RetireeFirst is a retiree advocacy service provider that some employers work with to offer their retirees additional support with their health plan. RetireeFirst advocates are US-based and available to help members with questions about their plan. They can also assist with things like prior authorization and perform outreach to your providers on your behalf. RetireeFirst is not part of CareFirst, but the two companies work closely together to support retirees. Please contact your retiree benefits team at your former employer or union to learn if RetireeFirst’s services are available to you.

Provider Network FAQ

Yes, and while we encourage you to visit network providers, you can go to any provider, hospital, or facility that accepts Medicare and is willing to bill CareFirst or their local Blues plan if the provider is outside of Maryland or Washington, D.C. In-network and out-of-network medical cost-sharing are the same under this plan.

If your provider is in the CareFirst Medicare Advantage PPO network (visit carefirst.com/findadocmappo), you can continue to see them. If they are not in the network, if they accept Medicare and are willing to bill CareFirst or their local Blues plan, you can continue to see them. If you do not see your provider in our directory, please contact them directly and ensure they are willing to bill CareFirst before your visit. 

With a Medicare Advantage PPO plan, you will have access to a national provider network through the Blue Cross and Blue Shield Association. However, if your doctor is not in the network, if they accept Medicare and are willing to bill CareFirst or their local Blues plan for the services they provide to you, your medically necessary services will be covered. The good news is that your out-of-pocket expense or medical cost-sharing will be the same for doctors who are in and out of network.

No, this plan does not require referrals but may require prior authorization for some services.

You pay your copay or coinsurance according to your plan benefits. Your doctor or healthcare provider will bill CareFirst for the rest of the cost of your service(s).

Visit carefirst.com/findadocmappo and select the Medicare Advantage (PPO) network to locate in-network medical providers. You can also find in-network dental, hearing and vision providers at carefirst.com/findadocmappo. Click on Network and select either Medicare Advantage Dental (PPO), Medicare Advantage Hearing (PPO), or Medicare Advantage Vision (PPO) from the dropdown before beginning your search. Not all Group Medicare Advantage plans include dental, hearing and/or vision coverage so be sure to check your plan documents to see what is covered under your plan from your former employer or union.

An out-of-network doctor or healthcare provider does not have a contract with CareFirst.

You can see any out-of-network doctor or healthcare provider that participates in Medicare and accepts the plan. Accepting the plan means the doctor is willing to treat you and bill your health insurance plan.

We’ll be happy to talk to your doctor to explain how the plan works. Usually, that’s all that’s needed. You may also share this flier with your provider.

Prescription Drug FAQ

CareFirst BlueCross BlueShield Group Advantage has a nationwide network of pharmacies, so you can fill your prescriptions whether you're close to home or traveling. It's important to use a network pharmacy 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 reimbursement form for reimbursement.
2026 Pharmacy Network Search Tool
2026 Pharmacy Directory (PDF) English | Spanish
OON Pharmacy Claim Reimbursement (PDF)

Yes, as of January 1, 2026, a 100-day supply is available for drugs on Tier 1.

Yes. In fact, you may even save money using mail order for 90-day supplies of chronic medications. Additionally, a 100-day supply is available for drugs on Tier 1.  
Mail Order Pharmacy Form (PDF) English | Spanish

CVS Caremark Mail Service Pharmacy can deliver 90- or 100-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 four ways to get started:
  1. 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.
  2. Fill out a mail service request form  (English | Spanish) and mail it with your 90- or 100-day prescription.
  3. Call the pharmacy number on your member ID card for live help getting set up.
  4. Sign in at carefirst.com/myaccount. Under the Benefits tab, select What's Covered. Click on the Pharmacy header and scroll down to the Mail Order section. Click on Request a New Mail Order Prescription. 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.
Please note: A 100-day supply is available for drugs on Tier 1.

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.
Coverage Determination Request Form (PDF)

You, your prescriber, or your appointed representative may request a coverage decision and/or exception in the following ways:

Phone: Contact Pharmacy Member Services for any requests, including oral requests related to Coverage Determination and Appeals. Our team is available 24 hours a day, 7 days a week, 365 days a year at 888-970-0917.

Fax: 855-633-7673

Online: Coverage Determination Form available in English | Spanish

Mail:

CVS Caremark Coverage Determinations/Exceptions
P.O. Box 52000
MC109
Phoenix, AZ 85072-2000

If you pay for a prescription out of pocket, you may be able to obtain coverage. Please use the form below for reimbursement.
Prescription Claim Form

In many cases, existing CVS Caremark mail service prescriptions can transfer to your new plan. Once your new coverage begins, call CVS Caremark Mail Service Pharmacy or the pharmacy number on your member ID card to confirm that your new coverage information has been updated and that your prescriptions and refills are available under your new plan. CVS Caremark can also review any formulary or coverage changes that may affect your medications. If you do not currently use CVS Caremark Mail Service Pharmacy, you may need a new prescription from your provider to start mail service.

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 affect 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.
Please note: to decrease medication waste and ensure medication safety, we may delay when you can refill your medications if you have extra medication on hand.

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 100-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 in a foam cooler. CVS Caremark uses an Electronic Packing and Shipping System (EPSS) that develops a cold chain solution for each order based on 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 FedEx 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 100 days' supply depending on the formulary tier. 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.
Please check your Evidence of Coverage to verify whether your drug can be filled for an extended day supply.

You can obtain controlled substances through the mail order; however, some do require a 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. 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.

Yes. If your email address is on file with CVS Caremark, you'll receive notifications when your order is received and when it ships. If your order requires expedited shipping or a signature, CVS Caremark will also call you with delivery information. To receive important updates about your prescriptions, make sure your communication preferences and contact information are current so CVS Caremark can reach you using your preferred method.

Yes. The following products are covered at network pharmacies with a valid prescription:
  • Dexcom G5 Continuous Glucose Monitor
  • Dexcom G6 Continuous Glucose Monitor
  • Dexcom G7 Continuous Glucose Monitor
  • FreeStyle Libre Continuous Glucose Monitor
Prior authorization may be required for certain Medicare-covered diabetic supplies. If prior authorization is needed, your provider must submit the request to obtain coverage. Please refer to your Evidence of Coverage for more information on cost and coverage.

Yes. True Metrix and Accu-Chek are the preferred test strips and blood glucose monitors covered at network pharmacies with a valid prescription.

The CareFirst BlueCross BlueShield Group Advantage (PPO) MTM Program is dedicated to providing you with information about safe medication disposal. Medications that are safe for you can harm 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 CareFirst safe disposal sites page and enter your location. 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: HHS safe drug disposal information.

    Steps for medication disposal in the trash:

    • Remove medication labels to protect your information
    • Mix medications with undesirable substances such as dirt or used coffee grounds
    • Place mixture in a sealed container like an empty margarine tub

The late enrollment penalty is an amount that's permanently added to your Medicare drug coverage (Part D) premium. You may owe a late enrollment penalty if at any time after your Initial Enrollment Period is over, there's a period of 63 or more days in a row when you don't have Medicare drug coverage or other creditable coverage.
Visit Medicare.gov or Part D late enrollment penalty

The Medicare Income-Related Monthly Adjustment Amount (IRMAA) is an amount you may pay in addition to your Part B or Part D premium if your income is above a certain level. The Social Security Administration (SSA) sets four income brackets that determine your (or you and your spouse's) IRMAA.
Learn more by visiting Medicare.gov or Initial IRMAA Determination

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 are eligible. If you have questions about prescription eligibility, call or visit your pharmacy.

You can enroll online via carefirst.com/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, 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.

Below are some common issues that can affect drug supplies:
  • Shortage of ingredients used to make a drug
  • Supply chain distribution issues, such as closed airports or workers' strikes
  • Drugs being recalled due to harmful defects or potential risks
  • Drugs being removed from the market by either the FDA or the drug manufacturer
For additional resources and Frequently Asked Questions (FAQs) about drug shortage, please visit the Federal Drug Administration (FDA)  or the American Society of Health-System Pharmacists (ASHP).

CareFirst responds to drug shortages in the following ways:
  • We work closely with clinical experts to include various covered medication options to help ensure continuity of therapy.
  • We recommend you also talk with your doctor to explore alternatives until the shortage resolves. If there are any questions on alternatives, you can call our customer service team at the phone number on the back of your Member ID card for assistance.

RxSavingsPlus for Medicare is a program that allows you to purchase select medications not covered by your prescription plan at a discount. You will be able to fill these medications at the pharmacy counter where you may also receive important pharmacist guidance regarding drug safety and potential drug interactions. Please reach out to CVS at 888-970-0917 for more information on this program including participating pharmacies.

Simply present your CareFirst Medicare Advantage ID card and your prescription at a participating network pharmacy. Most pharmacy chains are participating (around 65,000 nationwide), with some exceptions including Walmart. When the participating pharmacy processes a claim for your non-covered drug, they receive instructions to reprocess the claim to provide you with a discounted price.

RxSavingsPlus for Medicare allows you, as a member with prescription benefit coverage, to purchase select medications that may not be covered by your prescription plan at a discount. Please note that some medications used for weight loss, such as Wegovy and Zepbound, are excluded from this program. Below are examples of drug classes that are included in this program:  
  • Analgesics (e.g., acetaminophen/Tylenol)
  • Antihistamines (e.g., cetirizine hydrochloride/Zyrtec)
  • Cough/Cold/Allergy (e.g., guaifenesin/Robitussin)
  • Impotence Agents (e.g., sildenafil citrate/Viagra)
  • Laxatives (e.g., psyllium fiber/Metamucil)
  • Nutrients (e.g., melatonin)
  • OTC Eye and Ear Agents (e.g., polyethylene glycol 400/Systane)
  • Multivitamins/Minerals/Electrolytes (e.g., multi-vitamin/Centrum Silver)
Please reach out to CVS at 888-970-0917 for more information.

Yes. If you obtain some prescriptions from the VA, you may continue to do so. This is a separate benefit and may have separate formularies, copays, and restrictions in place.

People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If eligible, Medicare could pay for 75% or more of your drug costs. For more information about Extra Help, contact your local Social Security office or call Social Security at 800-772-1213 (TTY: 800-325-0778). You can also apply for Extra Help online at cms.gov.