Prescription Drug Coverage
Pharmacy FAQs
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Medicare Advantage (PPO)
Getting Your Prescriptions
CareFirst BlueCross BlueShield Medicare Advantage has a nationwide network of pharmacies, so you can fill your prescriptions whether you’re close to home or traveling. We want you to feel safe knowing you can always find a network pharmacy. It’s important to use a network pharmacy in order 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 form below for reimbursement.
Yes, except for DualPrime, a 100-day supply is available for drugs on Tier 1, Tier 2 and Tier 3. Please refer to Chapters 5 and 6 of the Evidence of Coverage - Essential or Evidence of Coverage - Complete for more information on prescription drug costs.
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.
Drugs administered by a provider are covered. There are certain limitations on these medications. Review the forms below for more information. You may have a cost-share on these medications.
Part B Step Therapy and Part B Prior Authorization criteria can be found here.
Mail Order
Yes. You may be able to save money by using mail order for a 90- to 100-day supply of your maintenance medications. In addition, Individual MAPD members may be eligible to receive up to a 100-day supply of Tier 1, Tier 2 and Tier 3 medications through mail order. Please refer to your Evidence of Coverage (EOC) for more information about prescription drug costs and coverage.
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:
- 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.
- 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.
- Fill out a mail service request form and mail it with your 90- or 100-day prescription: Mail Order Pharmacy Form (PDF) - English | Spanish.
- Call the pharmacy number on your member ID card for live help getting set up.
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.
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 90- or 100-day supply.
You can obtain controlled substances through the mail order; however, some do require 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 vs. a 90-day supply. Check with your doctor if you are taking a controlled substance to determine if there are restrictions.
Just like your local retail pharmacy, registered pharmacists are available for consultation by calling the pharmacy number on your member ID card.
Shipping and Delivery
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.
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.
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.
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.
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.
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.
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 (to protect the item from freezing) in a foam cooler. CVS Caremark uses an “Electronic Packing and Shipping System” (EPSS), which develops a cold chain solution for each order based on the individual order characteristics such as 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.
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 90- or 100-day supply. 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.
Coverage, Claims, and Reimbursement
Yes, please see below for products that are covered at network pharmacies with valid prescription. Please refer to your evidence of coverage for more information on the cost of the products:
- 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.
Yes, CareFirst has preferred test strip and blood glucose monitor. True Metrix and Accu-Chek are the preferred test strips and blood glucose monitors covered at network pharmacies with valid prescription. We may apply quantity limits for certain Part B diabetic supplies. If the request exceeds the quantity limits, a review may be required.
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.
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 hours a day, 7 days a week, 365 days a year. Medicare Advantage members can call 1-888-970-0917 (TTY: 711). DualPrime (D-SNP) members with questions about Part D prescription drug coverage can call 1-844-386-6762 (TTY: 711).
- Fax: 855-633-7673
- Online: Coverage Determination Form - 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 (PDF)
Prescription Management
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. If you have questions about prescription eligibility, call or visit your pharmacy.
You can enroll online via 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 on the program, 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, 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
- How does CareFirst respond to drug shortages?
- 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 for assistance.
For additional resources on drug shortage, please refer to the links below:
The CareFirst BlueCross BlueShield Medicare Advantage MTM Program is dedicated to providing you with information about safe medication disposal. Medications that are safe for you may not be safe for 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 website below and enter your location: CareFirst safe disposal sites. Some 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 disposal guidance.
- Steps for medication disposal in the trash:
- Remove medication labels to protect your personal information
- Mix medications with undesirable substances, such as dirt or used coffee grounds
- Place the mixture in a sealed container, such as an empty margarine tub
RxSavingsPlus for Medicare
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 Pharmacy Services at 888-970-0917 for more information on this program including participating pharmacies.
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 or Tylenol) | Laxatives (e.g., psyllium fiber or Metamucil) |
| Antihistamine (e.g., cetirizine hydrochloride or Zyrtec) | nutrients (e.g., melatonin); |
| Cough/cold/allergy (e.g., guaifenesin or Robitussin) | OTC eye and ear agents (e.g., polyethylene glycol 400 (0.4%) or Systane) |
| Impotence agents (e.g., sildenafil citrate or Viagra) | Multivitamins/minerals/electrolytes (e.g., multi-vitamin or Centrum Silver) |
Please reach out to Pharmacy Services at 888-970-0917 for more information.
Simply present your CareFirst BlueCross BlueShield 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.
Low-Income Subsidy (LIS)
Low income subsidy (LIS), also known as Extra Help, is a program that helps individuals who have a limited income pay for their Medicare prescription drug costs. If you get extra help from Medicare to pay for your prescription drug plan costs, your monthly plan premium will be lower than what it would be if you did not get extra help from Medicare. The amount of extra help you get will determine your total monthly plan premium as a member of our plan.
If you receive extra help, download and refer to the LIS Premium Summary Chart to show you what you’ll pay each month depending on the plan you have and the level of extra help you get.
LIS Summary Chart (PDF) - English
LIS Summary Chart (PDF) - Spanish
There are several ways a member can apply for Extra Help assistance: visiting a local Social Security Administration (SSA) office, applying online at www.ssa.gov, calling SSA at 1-800-772-1213, or requesting an application from the state Medicaid agency.
Best Available Evidence (BAE)
Process for Urgent Need of Medication
When Low-Income Subsidy (LIS) information is incorrect or absent from our internal and CMS systems, we use a process called Best Available Evidence (BAE) to assist the member.
- This may occur, for example, because a state has been unable to successfully report the member as Medicaid-eligible or is not reporting him/her as institutionalized.
Note: Members may or may not have documentation that they have subsidy.
The Customer Care Representative (CCR) must immediately determine the days’ supply of medication the member has on hand:
- Urgent: 3-day supply or less of medication
- Non-urgent: more than a 3-day supply of medication
CareFirst BlueCross BlueShield Medicare Advantage will request a CMS review if the member is eligible for subsidy, either based on the documentation provided or if the member does not have acceptable documentation.
- Confirm with member, Power of Attorney and/or Senior Health Insurance Program Counselor if member has urgent need for lifesaving medication(s)
Reminder: If the CMS-approved document does not provide the actual low-income cost-sharing level, a Temporary LIS Level 1 adjustment will be offered to members as a courtesy for one month.
When a Temporary LIS level adjustment is offered and the member does not qualify for a subsidy, the member will be responsible to repay all copays or cost-sharing back to CareFirst BlueCross BlueShield Medicare Advantage.
For members residing in a long-term care facility, temporary LIS is not necessary, as they have access to care.
Medicare Advantage Quality Assurance Program
Ensuring Appropriate Utilization of Resources
CareFirst BlueCross BlueShield Medicare Advantage is committed to providing a Quality Assurance Program and improving the quality of care surrounding utilization management of medical, behavioral and substance use authorizations. We rely on individual clinical contributors to enhance the quality of care and prevent over- and under-utilization of services requested and provided for our enrollees. Results of these activities are analyzed for trends and patterns by examining trends based on:
- Hospital Admissions
- Hospital days vs benchmarks
- ER visits vs benchmarks
CareFirst BlueCross BlueShield Medicare Advantage plans work to promote fair and consistent care management decision making and to promote the quality, safety, effectiveness, and efficiency of medical and behavioral health care provided to enrollees.
Care Management decision making is based only on appropriateness of care and services. The plan does not compensate practitioners or other individuals conducting utilization review for adverse decisions and does not offer incentives to encourage adverse decisions. CareFirst BlueCross BlueShield Medicare Advantage plans follow peer reviewed and industry recognized clinical resources when performing utilization management reviews.
- Care Management clinical staff carefully evaluate available clinical information on a case by case basis.
- In making utilization management decisions, clinical staff apply industry recognized criteria when making substance use disorder, medical necessity and utilization review determinations.
- Medical necessity/appropriateness denial decisions are made by Medical Directors/Physician Reviewers.
- In addition to recognizing that criteria may not always be appropriate for the complicated patient, CareFirst BlueCross BlueShield Medicare Advantage plans also evaluate the individual enrollee’s needs and local health care delivery system. Therefore, clinical staff must consider the following factors when applying criteria to a given individual:
- Age
- Comorbidities
- Complications
- Progress of treatment
- Psychological situation
- Home environment when appropriate
- Availability of alternative facilities/settings
- Availability of home care services
- Coverage of benefits for alternative facilities/settings
- Ability of hospitals to provide all recommended services
- Extension of benefit coverage for additional services of hours per week or weeks per duration of treatment
When the factors listed above indicate that the industry recognized clinical resources are not appropriate for an individual, the case should be reviewed with a Medical Director/Physician Reviewer or board-certified consultants’ panel, as appropriate.
Ensuring Appropriate Utilization of Resources
CareFirst BlueCross BlueShield Medicare Advantage is committed to providing a Quality Assurance Program and improving the quality of care surrounding prescription drugs. We use system reviews to enhance the quality of care, prevent overutilization and manage potential drug therapy problems. Results of these activities are analyzed for trends and patterns. CareFirst BlueCross BlueShield Medicare Advantage works proactively and in collaboration with our Pharmacy Benefits Manager and Care Management to assess trends and outliers for further intervention.
Promoting Member Safety
The focus of CareFirst BlueCross BlueShield Medicare Advantage’s safety program is to promote knowledge around medication use and overall member safety. CareFirst BlueCross BlueShield Medicare Advantage provides notification to members, providers, and pharmacies for those who have claims for medications with new market withdrawals or recalled medications.
Concurrent Drug Utilization Review (DUR)
CareFirst BlueCross BlueShield Medicare Advantage, in conjunction with the Pharmacy Benefit Manager, conducts a Concurrent Drug Utilization Review Program to assess appropriateness, medical necessity and adverse effects. Concurrent DURs assist in the promotion and improvement of member safety. CareFirst BlueCross BlueShield Medicare Advantage adheres to all CMS and state regulations regarding Concurrent Drug Utilization Review.
CareFirst BlueCross BlueShield Medicare Advantage concurrent DUR program includes, but is not limited to, the following checks each time a prescription is dispensed:
- Screening for potential drug therapy problems due to therapeutic duplication
- Age/gender-related caution screening
- Over-utilization and under-utilization
- Drug regimen compliance screening
- Drug-drug interactions
- Incorrect drug dosage or duration of drug therapy
- Refill Too Soon
- Multiple prescribers
- Multiple pharmacies
- Cumulative Acetaminophen Dose
- Maximum dose multiplier
- Cumulative Morphine Milligram Equivalent
- Buprenorphine with Subsequent Opioids
CareFirst BlueCross BlueShield Medicare Advantage concurrent DUR checks are applied at the level of the dispensing pharmacy (mail or retail).
Retrospective Drug Utilization Review (DUR)
CareFirst BlueCross BlueShield Medicare Advantage, in conjunction with the Pharmacy Benefit Manager, conducts a retrospective Drug Utilization Review (DUR) Program as a mechanism for the ongoing periodic and systematic review of drug utilization and prescribing patterns. The DUR Program compares prescriptions for outpatient medications against standards relating to appropriateness, medical necessity and likelihood of resulting in adverse medical effects. The Retrospective Drug Utilization Review programs (RetroDUR) are designed to ensure ongoing periodic examination of claims data and other records, through computerized drug claims processing and information retrieval systems, in order to identify patterns of inappropriate or medically unnecessary care.
The Program will help:
- Identify potential over-utilization and misuse resulting from poorly coordinated care, drug abuse and prescription fraud
- Educate those involved with members’ medical care, including physicians, physician assistants, nurse practitioners and network pharmacists on how to identify and reduce the frequency and patterns of fraud, abuse, gross overuse or inappropriate/medically unnecessary care
- Enhance or improve the quality of pharmaceutical care
- Improve member outcomes
DualPrime (HMO-SNP)
Getting Your Prescriptions
If your prescription is not listed on our formulary, contact Pharmacy Member Services at 1-844-786-6762, 24 hours a day, 7 days a week (TTY: 711), to be sure it is not covered. See How to Request a Coverage Determination for more information.
DualPrime has a nationwide network of pharmacies, so chances are there’s one near you. CareFirst partners with CVS Health, our pharmacy benefits manager, to find pharmacies that meet or exceed the Center for Medicare & Medicaid Services (CMS) requirements for pharmacy access in your area. To find a participating pharmacy near you, use the Pharmacy Locator Tool or search our downloadable Pharmacy Directory below. Since the network can change from year to year, accessing the Pharmacy Locator Tool is a great way to keep current on all the network pharmacies. You can use the Pharmacy Locator Tool to locate a network pharmacy or determine if your pharmacy is in the network, or call our Medicare Part D Member Services at 1-844-786-6762 (TTY: 711).
If you would like to be mailed a hard copy of the pharmacy directory or need help finding a network pharmacy, please call Member Services at 1-844-786-6762 (TTY: 711).
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.
In some cases, we require you to first try certain drugs 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.
For certain drugs, we limit the amount that you can have each time you fill your prescription.
Mail Order
CVS Caremark Mail Service Pharmacy can deliver 90-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 three ways to get started:
- 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.
- Fill out a mail service request form and mail it with your 90-day prescription.
- Call the pharmacy number on your member ID card for live help getting set up.
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.
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 90-day supply.
Just like your local retail pharmacy, registered pharmacists are available for consultation by calling the pharmacy number on your member ID card.
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 instead of a 90-day supply. Check with your doctor if you are taking a controlled substance to determine if there are restrictions.
Shipping and Delivery
For refills of your drugs, please contact your pharmacy 10 to 15 days before your current prescription will run out to make sure your next order is shipped to you in time.
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.
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 with 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.
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.
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.
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 to protect the item from freezing in a foam cooler. CVS Caremark uses an Electronic Packing and Shipping System (EPSS), which 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.
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 90 days’ supply. 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.
Coverage, Claims, and Reimbursement
Part B covers home blood sugar (glucose) monitors and supplies you use with the equipment, including blood sugar test strips, lancet devices and lancets.
Blood Glucose Meter and Test Strips
The preferred covered blood glucose meters and test strips are True Metrix by Trividia Health and Accu-Chek by Roche for CareFirst BlueCross BlueShield Medicare Advantage DualPrime (HMO-SNP) members. This means these are the only brands accessible at a network pharmacy. There are no preferred lancet products. However, coverage for test strips and lancets in network pharmacies depends on the quantity and whether you are using insulin (see below).
| Product | Coverage Information | Getting your medication |
|---|---|---|
| Test Strips | ||
| True Metrix and Accu-Chek Test Strips within coverage limit | Allowed Test Strip Coverage
| Accessible at a network pharmacy |
| True Metrix and Accu-Chek Test Strips over the “Allowed Coverage” | Over “Allowed Coverage” |
|
| Other test strip brands (e.g., Contour Next Test Strips) | Other test strip brands are not covered (regardless of quantity) |
|
| Lancets | ||
| All lancet brands within coverage limit | Allowed Lancet Coverage
| Accessible at a network pharmacy |
| All lancet brands over the “Allowed Coverage” | Over “Allowed Coverage” |
|
Yes. Members can get several products at $0 copay, such as:
- Dexcom G5 Continuous Glucose Monitor
- Dexcom G6 Continuous Glucose Monitor
- Dexcom G7 Continuous Glucose Monitor
- FreeStyle Libre Continuous Glucose Monitor
We may apply quantity limits for certain Part B diabetic supplies. If the request exceeds the quantity limits, a review may be required.
Prescription Management
ScriptSync is a service that coordinates your refill prescriptions so you can pick them up together at your CVS Pharmacy.
- Which of my prescriptions are eligible for ScriptSync?
- Your regular prescriptions (not including controlled substances) that are filled at the same CVS Pharmacy. If you have questions about prescription eligibility, call or visit your pharmacy.
- How can I set up for ScriptSync?
- You can enroll online via My Account 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 on the program, please call the number on your member ID card.
- Can I change my ScriptSync pickup date?
- 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, 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).
Below are ways CareFirst responds to drug shortages:
- 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 1-844-386-6762 for assistance.
RxSavingsPlus for Medicare
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 Pharmacy Services at 1-844-786-6762 for more information on this program, including participating pharmacies.
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:
Please reach out to Pharmacy Services at 1-844-786-6762 for more information.
Simply present your CareFirst BlueCross BlueShield 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, it receives instructions to reprocess the claim to provide you with a discounted price.