Drug Management Programs
Utilization Management
CareFirst BlueCross BlueShield uses certain strategies (“utilization management”) to ensure that medications are properly prescribed, dispensed and used. Below are some helpful explanations.
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 based on certain criteria before you fill certain prescriptions. If you don’t get approval, the drug may not be covered.
Quantity Limit (QL)
For certain drugs, our plan limits the amount of the drug that we will cover. For example, our plan provides 30 tablets per 30 days per prescription for simvastatin 80 mg tablets.
Step Therapy (ST)
In some cases, we require you to try certain drugs first to treat your medical condition before we'll 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.
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 Group Advantage that describes the use and the place where you receive and take the drug so a determination can be made.
Transition Policy
What is a transition fill?
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 give you 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.
| Description | Transition Fill Supply |
|---|---|
| New and renewing members | |
| Not in long-term care | 30-day supply within first 90 days in the plan; multiple fills up to a cumulative month’s supply are allowed to accommodate fills for amounts less than prescribed. |
| In long-term care | Emergency supply transition fills are allowed up to a cumulative 31-day supply within first 90 days in the plan, except for oral brand solids which are limited to a 14-day supply with exceptions as required by CMS guidance. Multiple fills for a cumulative month’s supply are allowed to accommodate fills for amounts less than prescribed on 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 month’s supply are allowed to accommodate fills for amounts less than prescribed. |
The transition supply gives you time to talk with your doctor or other prescriber about alternative medications that are covered by your plan. Transition coverage is temporary and cannot continue beyond the transition period, even if you have been a member for less than 90 days and received a one-time transition supply.
If you receive a transition supply, you'll receive a letter from your plan notifying you that you've received a temporary supply of your prescription drug. Please refer to your Evidence of Coverage for more information on the CareFirst BlueCross BlueShield Group 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 be eligible for a transition supply at that time. You may become eligible for a transition supply once the refill-too-soon period has ended.
- DUR Safety Checks:If there's 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 be rejected.
- Part A or B Only Drugs:These medications are covered under a different part of Medicare. Because they are not covered under Medicare Part D, they are not eligible for a transition supply.
- Part A or B vs. Part D (A or B vs. D):These medications may be covered under a different Medicare benefit. Until it is determined whether the medication should be covered under Medicare Part A, Part B or Part D, a transition supply cannot be provided.
- Excluded Drugs:If a drug is not considered a Part D drug (e.g., OTC, fertility, etc.), it will not be eligible for a transition fill.
Coverage Determination, Appeals, Exceptions and Redetermination
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
Exceptions requests are granted when CareFirst BlueCross BlueShield Group Advantage determines that a requested drug is medically necessary for you. Generally, we will only approve your request for an exception if the alternative drugs included on the plan’s formulary, would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
To request a formulary, tiering or utilization management exception, please contact us for a coverage determination. Your prescriber must provide a statement supporting the request and explaining why the exception is medically necessary.
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 your 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 Pharmacy Member Services 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 Pharmacy Member Services for assistance with coverage determinations, appeals, and related requests, including submitting an oral request. Representatives are available 24 hours a day, 7 days a week, 365 days a year at 888-970-0917. If your request is an appeal, your call will be directed to the appropriate department for further review and processing.
Fax
CVS Caremark
P.O. Box 52000,
MC109M
Phoenix, AZ 85072-2000
You can also contact Medicare directly at 1-800-MEDICARE or file a complaint online at:
File a Medicare complaint
When does the coverage determination process start?
You can request a coverage determination review as early as 12/1/2026 for your 1/1/2027 benefit as along as your eligibility is on file.
Can my previous prior authorization transfer over?
Your previous prior authorization cannot transfer to your new Group Medicare Advantage plan. A new prior authorization will be required. To streamline your care, we allow for early coverage determination starting the first day of the month prior to your coverage effective date (e.g., 1/1/2027) as long as your eligibility is on file. Additionally, the transition period will generally allow you a one-time, one-month supply of a drug that you’re taking within your first 90 days of enrollment in the plan.
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:
Phone
Contact Pharmacy Member Services for assistance with coverage determinations, appeals, and related requests, including submitting an oral request. Representatives are available 24 hours a day, 7 days a week, 365 days a year at 888-970-0917. If you are requesting an appeal, your call will be routed to the appropriate department for review and processing. Additional contact options are listed below.
Fax
CVS Caremark
P.O. Box 52000,
MC109M
Phoenix, AZ 85072-2000
You can also contact Medicare directly at 1-800-MEDICARE or file a complaint online at:
Medicare.gov/MedicareComplaintForm/home.aspx
Opioid Safety
CareFirst BlueCross BlueShield Group Advantage is dedicated to helping you use opioid pain medications more safely.
To help prevent and combat prescription opioid overuse through improved concurrent Drug Utilization Review (DUR), CareFirst BlueCross BlueShield Group Advantage will implement an opioid safety review at the point of sale (POS), including:
- A care coordination review based on a cumulative morphine milligram equivalent (MME)
threshold of 90 MME per
day
- This review is triggered when the member receives opioid prescriptions from three or more prescribers and the cumulative opioid daily dose is greater than or equal to 90 morphine milligram equivalent (MME).
- The pharmacist can override this review by consulting with the prescriber to determine the medical necessity of the` opioid prescription(s). If the pharmacist is unable or unwilling to override this review, the member, member’s representative and/or prescriber have the option of submitting a coverage determination.
- A safety review limits initial opioid prescriptions for the treatment of acute pain to a maximum seven-day supply.
- This review is triggered when an opioid-naïve member receives a prescription for a greater than seven-day supply.
- A pharmacy may dispense up to a seven-day supply. If additional medication is needed, the member, the member's representative, or the prescriber may request a coverage determination for a quantity greater than a seven-day supply.
- High-Dose Opioid Safety Review.
- This review is triggered when the member receives opioid prescriptions from three or more prescribers and the cumulative opioid daily dose is greater than or equal to 200 morphine milligram equivalent (MME).
- Prescription may not be filled by the pharmacist without a prior authorization from the plan. The member, member’s representative and/or prescriber will need to submit a coverage determination.