CareFirst RX Prescription Benefits and Coverage

CareFirst RX offers a range of prescription benefits and coverage options to suit different needs and budgets.

CareFirst RX has a network of over 60,000 pharmacies, including major chain stores and independent pharmacies. This makes it easy for members to find a convenient location to fill their prescriptions.

With CareFirst RX, you can choose from various plan options that include different copayment amounts and coinsurance rates. Some plans also offer discounts on generic medications.

CareFirst RX also offers a 90-day supply option for many medications, which can help reduce copays and make it easier to manage prescriptions.

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CareFirst RX is a prescription medication program offered by CareFirst BlueCross BlueShield, a health insurance company serving Maryland, Washington D.C., and parts of Virginia.

CareFirst RX covers a wide range of prescription medications, including brand-name and generic options, to help members manage chronic conditions and stay healthy.

CareFirst RX has a network of over 63,000 pharmacies nationwide, making it easy for members to fill their prescriptions at a convenient location.

Members can access their prescription information, including medication lists and refill history, through the CareFirst member portal.

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CareFirst BlueCross BlueShield has implemented a program based on U.S. Centers for Disease Control and Prevention guidelines to help fight the opioid crisis. This program includes daily quantity limits specific to each covered opioid drug and prior authorization requirements for certain prescribing situations.

The formulary, or list of covered drugs, is selected by CareFirst in consultation with healthcare providers and represents the prescription therapies believed to be necessary for a quality treatment program. This list is available for reference on the CareFirst website.

CareFirst offers care support programs and tools to improve health while lowering overall health costs. The Comprehensive Medication Review program connects members with a pharmacist who reviews medications and talks to the doctor about dosages, duration, and other pertinent issues.

A formulary is a list of covered drugs selected by your health insurance provider, in this case, CareFirst. It's a list of prescription therapies believed to be necessary for a quality treatment program.

CareFirst will generally cover the drugs listed in their formulary if the drug is medically necessary and other plan rules are followed. This means that if your doctor prescribes a drug that's not on the formulary, it may not be covered by your insurance.

To find out which drugs are covered under your plan, you can use the Drug Search tool on the CareFirst website. This tool will help you determine the cost share for a particular drug based on its tier.

Here's a quick rundown of the different tiers:

Your prescription drug benefit is based on a list of covered drugs called a formulary, which is chosen by a group of independent doctors and pharmacists. They select drugs based on their effectiveness, safety, and value.

Drug management programs are in place to ensure you receive the most appropriate medication for your condition(s). These programs help control costs and prevent misuse of medications.

Prior authorization is required for certain drugs, which means your doctor must obtain approval before you can fill the prescription. Without prior authorization approval, your drugs may not be covered.

Quantity limits are placed on selected drugs for safety, quality, or utilization reasons. Limits may be placed on the amount of the drug covered per prescription or for a defined period of time.

Step therapy ensures you receive a lower-cost drug option as the first step in treating certain health conditions. When similar drugs are available, step therapy guides your doctor to prescribe the lower-cost option first.

Some drugs may not be covered on your formulary, or may have quantity limits. There is an exception process if you need an excluded drug, or an additional quantity, to be covered for medical necessity reasons.

Here are some common drug management programs:

These programs are in place to ensure you receive the most appropriate medication for your condition(s) and to control costs.

Care Support Programs offer one-on-one support with a registered nurse for those taking high-cost specialty drugs for diseases like multiple sclerosis and hemophilia.

This program provides 24-hour pharmacist assistance, condition-specific education and counseling, and a dedicated clinical team to work with your doctor.

A Comprehensive Medication Review can connect you with a pharmacist who will review your medications and talk to your doctor about dosages, duration, and other pertinent issues.

The pharmacist will work with your doctor to determine which medications best fit your situation, helping you navigate the complexity of taking multiple medications.

Medications don't work if they're not taken as prescribed, so the Pharmacy Advisor program engages members with chronic conditions through in-person or telephonic counseling with a pharmacist.

CareFirst members now have a new option for mail-order and prescription services - Johns Hopkins Outpatient Pharmacy (JHOP). This alternative to Optum Home Delivery offers a full inventory of standard, specialty, and over-the-counter medications.

You can fill your 90-day supply maintenance medications through one of JHOP's outpatient pharmacies or use their mail-order services. JHOP locations are available for your convenience.

To transfer your prescriptions to JHOP, simply call their service center at 888-264-0393. This will get you started with their mail-order and prescription services.

If you're enrolled in a CareFirst medical plan, your prescription drugs and prescription drug claims are managed by Capital Rx. This is important to know when searching for approved pharmacies.

Here are the JHOP locations, as well as other useful information:

Care Support Programs can be a game-changer for those taking high-cost specialty drugs for diseases like multiple sclerosis and hemophilia.

This program provides one-on-one support with a registered nurse, 24-hour pharmacist assistance, condition-specific education and counseling, and a dedicated clinical team to work with your doctor.

Taking multiple medications to treat a condition can be overwhelming, but the Comprehensive Medication Review program can connect you with a pharmacist who will review your medications and talk to your doctor about dosages and duration.

The pharmacist will work with your doctor to determine which medications best fit your situation.

Medications don't work if they're not taken as prescribed, which is why the Pharmacy Advisor program is so important.

CareFirst BlueCross BlueShield Group Advantage prioritizes opioid safety to help prevent and combat prescription opioid overuse through improved concurrent Drug Utilization Review (DUR).

The plan will implement opioid safety review at the point of sale (POS), which includes monitoring and evaluating opioid prescriptions to ensure safe and responsible use.

CareFirst BlueCross BlueShield has implemented a program to help combat the national opioid crisis. This program is based on guidelines from the U.S. Centers for Disease Control and Prevention.

Daily quantity limits are in place for each covered opioid drug. These limits ensure that members are not prescribed excessive amounts of opioid medication.

Prior authorization requirements are also in place for certain prescribing situations. This means that members may need to get approval from their doctor or CareFirst BlueCross BlueShield before receiving a prescription for an opioid.

First-time prescriptions for opioid medication are limited in terms of the amount of medication that will be covered. Members can check their specific plan coverage by logging into My Health Toolkit.

CareFirst BlueCross BlueShield Group Advantage is dedicated to helping members use opioid pain medications more safely.

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Specialty drugs are prescription medications that treat complex or chronic medical conditions like cancer, rheumatoid arthritis, multiple sclerosis, and hepatitis. They often require special management programs.

Depending on your plan, you may pay a different copayment or coinsurance for specialty drugs under the pharmacy benefit. Some members are subject to separate management programs for specialty drugs covered under their medical benefit.

Some medical specialty drugs require prior authorization, and infused specialty drugs must be administered at a specific site of care, such as at home or an infusion suite. Certain self-administered specialty drugs are only covered under the pharmacy benefit.

Here are some resources to help you navigate specialty drugs:

Specialty drugs are categorized into tiers, which determine your cost share. Zero cost-share drugs include preventive drugs, oral chemotherapy drugs, medication-assisted treatment drugs, and diabetic supplies.

Generic drugs are equally safe and effective as brand-name drugs, but they typically cost less.

Prior authorization is required for certain drugs, which means you'll need to get approval from CareFirst before filling a prescription. If you don't get approval, the drug may not be covered.

CareFirst makes decisions about benefit and coverage, and the amount you'll pay, known as a Coverage Determination. If a drug is not covered or has restrictions or limits, you can request a Coverage Determination.

You can request an exception to coverage for certain drugs, including non-formulary drugs, tier exceptions, quantity limit exceptions, prior authorization exceptions, and step therapy exceptions. These exceptions are granted when CareFirst determines that a requested drug is medically necessary for you.

To request an exception, you should contact CareFirst and submit a statement from your prescriber or physician supporting your request. CareFirst must make a decision within 72 hours of receiving the statement.

If you believe waiting 72 hours could seriously harm your health, you can request an expedited exception. If your request is approved, CareFirst must give you a decision within 24 hours of receiving a supporting statement from your doctor or other prescriber.

If your 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).

Here are the types of exceptions you can request:

Requesting a coverage determination with CareFirst BlueCross BlueShield Group Advantage is a straightforward process. You can request a standard or expedited coverage determination by contacting customer service at 888-970-0917, available 24/7/365.

To request a coverage determination, you can also submit a form, such as the Coverage Determination Form (PDF) available online in English and Spanish. This form can be found on the CareFirst website.

You can request a coverage determination as early as 12/1/2024 for your 1/1/2025 benefit, as long as your eligibility is on file. If you're concerned about waiting for a decision, 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.

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To request an exception, you'll need to submit a statement from your prescriber or physician supporting your request. This statement should explain why the requested drug is medically necessary for you.

If your request to expedite is granted, you'll receive a decision no later than 24 hours after CareFirst receives your prescriber's supporting statement. If your request is approved, you'll receive a notice sent to the provider and member. If your request is denied, you'll also receive a notice explaining the reason for the denial and information on how to submit a redetermination (Appeal).

Here are the ways to request a coverage determination:

• Phone: Call 888-970-0917, available 24/7/365

• Online: Submit a Coverage Determination Form (PDF) available on the CareFirst website

• In person: Contact customer service for assistance

Remember to have your prescriber's supporting statement ready to submit with your request.