Expand All Collapse All

If there is a generic drug available for the drug your provider prescribed, it will be dispensed at your pharmacy. If you or your provider wishes to have a brand-name drug, it will cost you more at the pharmacy. When there is a generic equivalent available, brand-name drugs are placed in the non-preferred brand tier on our formulary. If you or your provider requests the brand, you will be required to pay the non-preferred brand copay or coinsurance plus the difference between the generic cost and non-preferred brand-name drug cost.

If there is a generic drug available for the drug your provider prescribed, it will be dispensed at your pharmacy. If you wish to have a brand name, it will cost you more at the pharmacy. When there is a generic equivalent available, brand-name drugs are placed in the non-preferred brand tier on our formulary. If you request the brand, you will be required to pay the non-preferred brand copay or coinsurance plus the difference between the generic cost and non-preferred brand drug cost.

If your provider specifies you are required to receive the brand-name drug on your prescription, you will pay a non-preferred brand copayment to receive that brand-name drug when the generic is available.

NOTE: Please refer to your Evidence of Coverage for details to determine if mandatory or generic substitution apply to your plan.

Expand All Collapse All

You can register three ways:
  • Online through My Account
  • By phone
  • My mail - On the mail order form, the address provided is:
    CVS Caremark
    PO Box 94467
    Palatine, IL 60094-4467

Log in to My Account to learn more. Click on Drug and Pharmacy Resources under Quick Links and go to the Mail Order Prescriptions tab.

Expand All Collapse All

A maintenance drug is taken regularly for an ongoing condition, like diabetes or asthma. For most plans, you can get a 90-day supply of maintenance drugs and pay only a two-month copay for tiers that are copay-based. If you take a drug regularly for more than six months and it is not on CareFirst’s Maintenance Drug List , you can call CareFirst Pharmacy Services at 800-241-3371 for assistance on the exception process or have your physician submit a Maintenance Medication Request Form .
A generic drug:
  • Has the same active ingredients, strength and dosage as the brand-name drug
  • Must be absorbed into the bloodstream in the same timeframe
  • Has satisfied Food & Drug Administration (FDA) quality and safety reviews in the same way as a brand-name drug
  • Saves you money, yet provides the same quality as the brand-name drug
  • Falls within the generic tier of the CareFirst Prescription Drug Program
A brand-name drug:
  • Has been approved by the Food and Drug Administration (FDA) after trials show it is safe and effective for humans
  • Is protected by patents—once the patent expires for the brand-name drug, pharmaceutical companies typically manufacture and sell the drug’s generic equivalent
  • Is more costly than its generic equivalent
  • Can fall within the non-preferred or preferred brand-name drug tier or the self-administered injectable or specialty tier of the CareFirst Prescription Drug Program
An OTC drug is:
  • Available without a prescription
  • Approved by the Food & Drug Administration (FDA)
  • Not covered by your pharmacy benefits

NOTE: Many OTC medications were once prescription drugs.

Under the Affordable Care Act (ACA), certain drugs were identified to potentially reduce serious health problems in individuals with certain medical conditions. These drugs are called “preventive drugs,” and are available to members at a $0 copayment. These drugs are also not subject to the deductible when a prescription is written by a provider for members meeting certain medical criteria.
Certain prescription drugs may be prescribed only in limited quantities. Quantity limit guidelines are set by the Food and Drug Administration (FDA).
  • The Prescription Guidelines include dosage limits for some drugs. These limits are based on current medical literature and input from an independent CVS Caremark national committee of doctors and pharmacists.
  • Review the full list of drugs that have quantity limits. The list is subject to change.
  • When medically necessary, an exception to quantity limits can be requested.

NOTE: Physicians who write prescriptions that exceed the quantity limit must call CareFirst Pharmacy Services at 800-241-3371 for assistance on the exception process or have your physician submit a

Step therapy helps ensure you receive a lower-cost drug option, such as a generic or lower cost brand-name, as the first step in treating your health condition. Step therapy means trying less expensive options before "stepping up" to drugs that cost more.

Scenario

Jen is having allergy issues. She starts using an over-the-counter medication. That doesn’t help so she talks to her doctor who prescribes a brand-name medication which is on a higher drug tier. The pharmacist advises Jen that there’s a generic option which must be used as the first step in treating her allergies. Jen can choose to fill the brand-name drug, but she would have to pay full cost. She discusses it with her doctor and decides to try the generic drug which works well for her. To see if a drug requires step therapy, log in to My Account, select Tools then Drug Pricing Tool to search for a specific drug.

NOTE: If there is some medically necessary reason that you cannot take the preferred drug, your physician must call CareFirst Pharmacy Services at 800-241-3371 for assistance on the exception process or have your physician submit a

Expand All Collapse All

To get a preferred list of drugs, log in to My Account. On the My Coverage tab, select Drug and Pharmacy Resources, then click the "View My Plan Summary" link. In the new window that opens, select "Covered Drug List."

The Prescription Drug Program uses a list of preferred drugs. Selected for their effectiveness and affordability, the preferred drugs include both generic and preferred brand-name drugs.

Preferred drugs are brand-name drugs which are:

  • Chosen for their quality, effectiveness and affordability
  • Not available as a generic drug
  • Indicated through research to be as effective as non-preferred brand drugs

Review the Preferred Drug List to find out if a drug is on it or you can call CareFirst Pharmacy Services at 800-241-3371 for assistance on the exception process or have your physician submit a

Non-preferred drugs are brand-name drugs which are:

  • Not part of the Preferred Drug List but are covered by your pharmacy benefits
  • Typically more expensive
  • The member pays the highest out-of-pocket expense
  • May have a generic drug available
  • Examples of some non-preferred drugs are:
    • Drugs lacking Food & Drug Administration (FDA) approval
    • DESI drugs (drugs designated not effective by the FDA)
    • Over-the-counter (OTC) drugs
    • Those used for cosmetic purposes
    • Those excluded from your employer’s benefit plan
    • Non-preferred brand-name drugs (these drugs are covered by your pharmacy benefits, just at the higher cost share)
    • Other brand-name drugs for which a therapeutically equivalent drug is available

The Preferred Drug List is based on current medical research and input from an independent CVS Caremark national committee of doctors and pharmacists.

  • Drugs are selected for their quality, effectiveness and cost.
  • The Preferred Drug List can change within 24 hours in response to Food and Drug Administration (FDA) requirements
  • The list is also adjusted when a generic drug is introduced for a brand-name drug. When that happens, the generic drug will be added to the Preferred Drug List and the brand-name drug will automatically move from the preferred brand category to the non-preferred brand category.

No. Your benefits also provide coverage for non-preferred drugs (those drugs not on the Preferred Drug List). However, you are responsible for paying a higher out-of-pocket cost for these drugs.

The Preferred Drug List changes when:

  • New drugs become available
  • Generic equivalents of brand-name drugs become available
  • A prescription drug becomes available as an over-the-counter (OTC) drug

NOTE: The Preferred Drug List can change frequently in response to Food and Drug Administration (FDA) requirements.

Expand All Collapse All

Non-covered drugs include:
  • Drugs not approved by the Food & Drug Administration (FDA)
  • Generic or brand-name drugs used for cosmetic purposes
  • Medications available as over-the-counter (OTC) drugs
  • Drugs excluded by your employer’s benefit plan

If you are taking a specialty medication, you may want to call the specialty pharmacy coordination team at CVS at 800-237-2767 for assistance on the exception process or have your physician submit a

A compound drug is a medication made by combining, mixing or altering ingredients (some of which may not be subject to approval by the FDA), in response to a prescription to create a customized drug that is not otherwise commercially available.

Compound medications are covered under your prescription drug benefit if at least one of the drugs in the compound is a covered prescription drug. You will be charged a non-preferred brand-name drug copay or coinsurance for the compound prescription. All compounds over $300 must receive prior authorization from CareFirst before being filled.

Allergy serums are generally covered under your medical benefit. Please check your Evidence of Coverage to determine how they are covered.
All covered prescription drugs are ranked into tiers depending on your plan. The price you pay will depend in which tier a drug is placed.
  • No cost drugs
  • Generic drugs ($)
  • Preferred brand-name drugs ($$)
  • Non-preferred brand-name drugs ($$$)
  • Self-administered Injectable drugs or specialty drugs (excluding insulin) ($$$$)

NOTE: Some plans have a separate tier that either contains self-administered injectables (excluding insulin) or specialty drugs. If your plan does not have a separate tier for these drugs, the self-injectables or specialty drugs are covered under the generic, preferred brand or non-preferred brand tier.

Your coverage may also contain any of the following components:

  • Restrictive or mandatory generic substitution
  • Prior authorization
  • Quantity limits
  • Step therapy
No, but you will have the lowest out-of-pocket cost for the generic drug. Some plans may require you to pay additional cost if you choose a brand-name drug when a generic drug is available.
You pay the cost of the medication.
Most generic drugs that have Food & Drug Administration (FDA) approval are included on the Preferred Drug List .

Exceptions:

  • Those not approved by the FDA
  • Those used for cosmetic purposes
  • DESI drugs (drugs designated not effective by the FDA)
  • Over-the-counter (OTC) drugs
  • Those excluded by your employer’s benefit plan

Yes. All CareFirst plans include prescription drug coverage.

Want to see if your prescriptions are covered? Visit the Drug Search page.

Yes. You can choose from over 68,000 participating pharmacies nationwide that accept CareFirst or CareFirst BlueChoice insurance plans. Use the Pharmacy Locator to find out if a pharmacy participates in our network or you can call CareFirst Pharmacy Services at 800-241-3371. You can also use non-participating pharmacies, but you will have to pay the full cost of the drug at the time of purchase and submit a claim for reimbursement. It is unlikely that your benefits will reimburse you for the full cost of the prescription. Some plans only will reimburse for drugs at a non-participating pharmacy in an emergency situation or out-of-area urgent care. Refer to your Evidence of Coverage.
As a part of the Affordable Care Act, all plans are required to have an annual out-of-pocket maximum. Once that maximum has been met, you pay no additional costs for covered benefits. Please refer to your benefit contract to determine the out-of-pocket maximum for your plan or call CareFirst Pharmacy Services at 800-241-3371.
To have your prescription filled:
  • Present your pharmacy ID card to your pharmacist
  • Pay the appropriate copay or coinsurance for your medication
If you are in an Affordable Care Act (ACA) compliant health plan, then you may be eligible for this benefit. Please refer to your Evidence of Coverage for details on your coverage eligibility.

Review the list of preventive drugs .

Questions that Require Phone Support

The following questions are best answered by one of our Member Services experts.

  • How do I get immediate help with a change in my membership?
  • When will I get my new member ID cards?
  • How do I get proof of coverage or a letter of credible coverage?
  • How do I get help if I’m having technical issues with the website?

Support & Service

Need help with your plan?

Have a question about your benefits? Not finding your answer online? Something else? We’re here for you.

Member Services

If you have additional questions, call Member Services using the phone number on the back of your ID card

Having technical problems?

Can’t log in? Page not loading? Things not working the way they should? We can help.

Technical Help

Phone: 877-526-8390
Hours: Monday–Friday, 8 a.m.–6 p.m. ET

Questions that Require Phone Support

The following questions are best answered by one of our Member Services experts.

  • Can you help me understand how my insurance plan works?
  • How do I get assistance with complex benefits or specific benefit issues?
  • How do I get more information about a particular treatment/service I’m considering?
  • How do I find out if I need prior authorization for a procedure?
  • What’s the status of my prior authorization request?
  • How do I know how many visits I have remaining for a specific service (e.g., physical therapy)?
  • How do I know how much money I have remaining in my allowance for a specific service (e.g., infertility treatments)?

Support & Service

Need help with your plan?

Have a question about your benefits? Not finding your answer online? Something else? We’re here for you.

Member Services

If you have additional questions, call Member Services using the phone number on the back of your ID card

Having technical problems?

Can’t log in? Page not loading? Things not working the way they should? We can help.

Technical Help

Phone: 877-526-8390
Hours: Monday–Friday, 8 a.m.–6 p.m. ET

Questions that Require Phone Support

The following questions are best answered by one of our Member Services experts.

  • What’s the status of my claim appeal?
  • Can you explain the denial code on my benefits claim?
  • Can you help me with a claim I think has been processed incorrectly?
  • Why is my claim being adjusted?
  • Why was my claim with my in-network doctor processed as out-of-network ?
  • Can you help me figure out how much I owe and to whom?
  • Can you help me update my Coordination of Benefits (COB)?
  • Can you help me with a routine visit that requires applied a cost share/patient liability?
  • What’s the status of my over-accumulation review?

Support & Service

Need help with your plan?

Have a question about your benefits? Not finding your answer online? Something else? We’re here for you.

Member Services

If you have additional questions, call Member Services using the phone number on the back of your ID card

Having technical problems?

Can’t log in? Page not loading? Things not working the way they should? We can help.

Technical Help

Phone: 877-526-8390
Hours: Monday–Friday, 8 a.m.–6 p.m. ET

Questions that Require Phone Support

The following questions are best answered by one of our Member Services experts.

  • I can’t find a medical specialist for a specific issue. Can you help me?
  • I can’t find a mental health specialist for a specific issue. Can you help me?
  • Can you help me find an in-network doctor who doesn’t appear when using the Find a Doctor tool?
  • Do I need prior authorization for a procedure I’m considering?
  • Do I need a referral to see a specialist?
  • Can you tell me if a doctor who’s not listed as a pediatrician works with children?

Support & Service

Need help with your plan?

Have a question about your benefits? Not finding your answer online? Something else? We’re here for you.

Member Services

If you have additional questions, call Member Services using the phone number on the back of your ID card

Having technical problems?

Can’t log in? Page not loading? Things not working the way they should? We can help.

Technical Help

Phone: 877-526-8390
Hours: Monday–Friday, 8 a.m.–6 p.m. ET

Questions that Require Phone Support

The following questions are best answered by one of our Member Services experts.

  • How can my healthcare plan help me save money?
  • Am I eligible for any non-medical discounts through CareFirst?

Support & Service

Need help with your plan?

Have a question about your benefits? Not finding your answer online? Something else? We’re here for you.

Member Services

If you have additional questions, call Member Services using the phone number on the back of your ID card

Having technical problems?

Can’t log in? Page not loading? Things not working the way they should? We can help.

Technical Help

Phone: 877-526-8390
Hours: Monday–Friday, 8 a.m.–6 p.m. ET

Related Resources for "Plans & Coverage"

Wellness Programs Overview

Learn about the health and wellbeing programs and resources that may be available to you as a part of your CareFirst plan.

Prescription Drug Forms

Find forms for prescription drug-related requests, exceptions and orders here.