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Generic Substitution
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.
- 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.
- 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
- 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
- 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.
- 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
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.
- 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 $300 must receive prior authorization from CareFirst before being filled.
- No cost drugs
- Generic drugs ($)
- 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
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.
- Present your pharmacy ID card to your pharmacist
- Pay the appropriate copay or coinsurance for your medication
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
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Technical Help
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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?
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- What’s the status of my prior authorization request?
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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?
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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.