Prescription Coverage Overview 

What are Medicare Part D Covered Drugs?

A Part D covered drug is available only by prescription, approved by the Food and Drug Administration (FDA) and used and sold in the United States. These medications are listed on the plan’s formulary.

Medicare covered Part D drugs include:

• Prescription drugs
• Biological products
• Insulin as defined by the Centers for Medicare & Medicaid Services (CMS)
• Certain vaccines
• Medical supplies associated with the injection of insulin (syringes, needles, alcohol swabs, and gauze)

Formulary (also known as the Drug List)

What is a Formulary?

The CareFirst BlueCross BlueShield Advantage DualPrime Formulary is a list of drugs covered by a plan. Formularies are developed to meet the needs of most members based on the most commonly prescribed drugs, including certain prescription drugs that Medicare requires that we cover. CareFirst BlueCross BlueShield Advantage DualPrime covers both brand name drugs and generic drugs.

The CareFirst BlueCross BlueShield Advantage DualPrime Medicare Part D formulary is approved by Medicare and updated throughout the plan year and may change if:

• The plan no longer covers a drug.
• A new drug is added.
• A Prior Authorization, Step Therapy restriction or Quantity Limit has been added or changed for a drug 
• A drug is removed from the market.

If the change affects a drug you take, we will notify you before the change is effective. However, if the U.S. Food and Drug Administration (FDA) deems a drug on our formulary to be unsafe, or if the drug's manufacturer removes the drug from the market, we may immediately remove the drug from the CareFirst BlueCross BlueShield Advantage DualPrime Part D formulary and notify all affected members as soon as possible.

You may download the CareFirst BlueCross BlueShield Advantage DualPrime Formulary documents located within the table below or use our Formulary Search Tool to find medications covered under your plan. If you have questions using this Formulary Search Tool or if you would like to be mailed a hard copy of the Formulary, please call Member Services at 1-844-786-6762, 24 hours a day, 7 days a week.  TTY users please call 711.

How to get Mail Order Prescriptions

For certain kinds of drugs, you can use CareFirst Medicare Advantage’s network mail-order which is called CVS Caremark Mail Service Pharmacy®. Most times, the drugs provided through mail order are drugs that you take on a regular basis, for a chronic or long-term medical condition. 

For mail-order, you can get prescription drugs shipped to your home through the network mail-order delivery program. Click here to access the mail service order form.

Mail-order drugs usually arrive within 10 days. Please call Part D Member Services at 1-844-786-6762 (TTY users please call 711), 24-hours a day, 7 days a week. If you do not receive your mail-order drugs within this timeframe, please call the phone number listed on the back of your member ID card.

Please refer to your Evidence of Coverage (EOC) for more information.

Transition Policy

What is transition?

A transition refill, also known as a transition fill, is typically a one-time, one-month supply of a drug that you’re taking. Transition refills let you get temporary coverage for drugs that are not on your plan’s formulary or that have certain coverage restrictions (such as prior authorization or step therapy). 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 30-day supply. If your prescription is written for fewer days, we’ll allow refills to provide up to a maximum 30-day supply of medication. After your first 30-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 31-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 31-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. Please refer to your Evidence of Coverage for more information on the CareFirst BlueCross BlueShield Advantage DualPrime transition process.

Pharmacy Frequently Asked Questions

What If My Drug Is Not on The Formulary?

If your prescription is not listed on our formulary, i.e. non-formulary, you should: first contact Member Services (1-844-786-6762, 24 hours a day, 7 days a week.  TTY users please call 711) to be sure it is not covered. See  How to Request a Coverage Determination for more information.

Are my Blood Glucose Meter Test Strips and Lancets Covered?

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

One Touch by Lifescan is the preferred covered blood glucose meter and test strips for CareFirst BlueCross BlueShield Advantage DualPrime members. This means this is the only brand accessible at a network pharmacy. We allow coverage for up to 100 test strips for members with Diabetes who are not using insulin or up to 300 test strips for members with Diabetes who are using insulin every 90 days. 

Members cannot get Lifescan Test Strips higher than the quantity limit listed above and Non-Lifescan test strips/glucose meters at network pharmacies. An Organization Determination through CareFirst BlueCross BlueShield Advantage DualPrime’s Utilization Management (UM) department is required. Your provider may contact our Part C Member Services and Prior Authorizations department and our UM staff will make arrangements with a network Durable Medical Equipment (DME) provider to mail you the additional test strips and/or lancets approved.

Lancets

CareFirst BlueCross BlueShield Advantage DualPrime does not have preferred lancet brand products available at network pharmacies. However, coverage at network pharmacies depends on the quantity and whether you are using insulin. We only allow coverage for up to 100 lancets for members with Diabetes who are not using insulin or up to 300 lancets for members with Diabetes who are using insulin every 90 days.

Members cannot get lancets higher than the quantity limit listed above at network pharmacies. An Organization Determination through CareFirst BlueCross BlueShield Advantage DualPrime’s Utilization Management (UM) department is required. Your provider may contact our Part C Member Services and Prior Authorizations department and our UM staff will make arrangements with a network Durable Medical Equipment (DME) provider to mail you the additional test strips and/or lancets approved.

Please speak with your provider to see if test strips and/or lancets over these quantities are needed to manage your Diabetes. Your provider will contact us directly to request an Organization Determination. 

Does the CareFirst BlueCross BlueShield Advantage DualPrime plan cover Continuous Glucose Monitors (CGM) and their supplies?

Yes, and members can enjoy 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

If you use another brand of test strips and meter, you may work with your PCP to submit an order to a network DME provider.

What scenarios could exist to prevent me from receiving a transition fill?

• Refill Too Soon (RTS) If it is too soon to refill your medication based on your previous fill, you will not receive transition. You may be able to receive a transition fill once this time period has expired.
• DUR Safety Checks If there is a safety issue with how the medication is prescribed, for example there is too much acetaminophen prescribed (calculated at greater than 4 grams per day), the claim will reject and not allow transition.
• Part A or B Only Drugs These medications pay pursuant to a different benefit. Only part D drugs will qualify for this type of fill.
• Part A or B vs. Part D (A or B vs. D) These medications may pay pursuant to a different benefit and until it can be determined how they should pay, there cannot be a transition fill.
• Excluded Drugs If a drug is not considered a part D drug (OTC, weight loss, fertility, etc.) it will not be eligible for a transition fill.

What is ScriptSync?

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 MyHealth Portal 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.
• 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.

How to Find a Network Pharmacy

CareFirst BlueCross BlueShield Advantage DualPrime has a nationwide network of pharmacies, so chances are there's one near you! CareFirst BlueCross BlueShield Advantage DualPrime in partnership with CVS Health, our Pharmacy Benefits Manager, contracts with pharmacies that equal or exceed the Center for Medicare & Medicaid Services (CMS) requirements for pharmacy access in your area. Use the Pharmacy Locator Tool or search our downloadable Pharmacy Directory below to help locate participating pharmacies for you that are convenient and accessible to you.

Since the network can change year-to-year, accessing the Pharmacy Locator tool is a great way to keep current on all the in-network pharmacies.  You can use this Pharmacy Locator tool to locate a network pharmacy or to determine if your pharmacy is in the network, or you can call our Medicare Part D Member Services at 1-844-786-6762, 24 hours a day, 7 days a week.  TTY users, please call 711.

 If you would like to be mailed a hard copy of the pharmacy directory or if you need help finding a network pharmacy, please call toll free:

Prospective Members: 1-844-331-6334 (TTY: 711)
8 AM to 8 PM EST, 7 days a week from October 1 - March 31
8 AM to 8 PM EST, Monday through Friday from April 1 - September 30

Current Members: 844-786-6762 (TTY: 711); 24 hours a day, 7 days a week.