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 descriptions.

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.

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 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 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 is a safety issue with how the medication is prescribed, for example there is too much acetaminophen prescribed (calculated as greater than 4 grams per day), the claim will reject and not allow the transition supply.
• 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 (OTC, fertility, etc.), it will not be eligible for a transition fill.

Coverage Determination, Appeals, Exceptions and Redetermination

Coverage Determination: A decision CareFirst makes about your benefits 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

Exceptions are granted when CareFirst BlueCross BlueShield Medicare 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 a request is approved, a notice is sent to the provider and member. If a 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:

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 65 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: