Carefirst formulary 2017

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Espanol PDF. You can only get transition fills for drugs you were already taking before switching plans or before your existing plan changed its coverage. 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 day supply. After your first 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 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 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 allows you time to talk to your doctor or other prescriber about pursuing other options available to you within our formulary.

Your plan cannot continue to pay for these medications under the transition policy, even if you have been a member for less than 90 days following your one-month 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. No, due to CMS regulation, your previous prior authorization cannot transfer to your new Medicare Plan.

Coverage Determination: 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. 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. Exceptions requests are granted when CareFirst BlueCross BlueShield Advantage determines that a requested drug is medically necessary for you.

You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request.

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 request is approved, a notice is sent to the provider and member.

If 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. Learn More. We're on a mission to make quality care affordable, easy to use and available to everyone in Maryland, Washington, D.

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