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: 711) to be sure it is not covered. 

If Member Services confirms that we do not cover your drug, you have three (3) options:

• You can talk to your doctor(s) to decide if you should switch to a similar drug on our formulary that is used to treat the same medical conditions. For a list of drugs covered under your formulary, refer to Find a Medication and/or Pharmacy 
• You can ask us to make an exception and cover your drug. See “How Can I Request An Exception to the Formulary". 
• You can pay out-of-pocket for the drug and request that the plan reimburse you. Unless it is an emergency, if you did not follow our exception process or the exception was not approved, your request for reimbursement may be denied.  If we deny your request for reimbursement, you have the right to file an appeal. 

How Can I Request An Exception to the Formulary?

You can ask us to make an exception to our coverage rules. Exceptions are a type of coverage determination. Providers and members can submit an exception request for drug coverage determination. These exceptions include:

• Non-Formulary Drug Exception: A request to cover a non-formulary drug
• Quantity Limit Exception: A request for a drug to bypass quantity limit guidelines
• Prior Authorization Exception: A request for a drug to bypass prior authorization guideline
• Step Therapy Exception: A request for a drug to bypass step therapy guidelines

Coverage Determination, Appeals and Grievances

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.

Exceptions requests are granted when CareFirst BlueCross BlueShield Advantage determines that a requested drug is medically necessary for you. Generally, we will only approve your request for an exception if the alternative drugs included on the plan’s formulary, would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

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

Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. 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).

How to Request a Coverage Determination

A member, prescriber, or a member's appointed representative may request a standard or expedited coverage determination. You, your prescriber or your appointed representative may request a coverage decision and/or exception any of the following ways:

Phone:

Contact customer service for any requests including making an oral request related to Coverage Determination and Appeals. Our customer service team is available at 1-844-786-6762, 24 hours a day, 7 days a week (TTY users please call 711). Appeals calls are then redirected to the correct department for further action. 

Fax: 855-633-7673

Online: Coverage Determination Form

Mail:

CVS Caremark Coverage Determinations/Exceptions
P.O. Box 52000
Phoenix, AZ 85072-2000

You can also contact Medicare directly at 1-800-MEDICARE or file a complaint online at:
www.Medicare.gov/MedicareComplaintForm/home.aspx

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.

To check the status of an appeal, call our customer service team at 1-844-786-6762, 24 hours a day, 7 days a week.  TTY users please call 711.

How to Request a Redetermination (Appeal)

An initial coverage determination decision can be appealed. To start your appeal, a member, prescriber, or a member's appointed representative must contact us within 60 calendar days of the date of the denial notice they received (unless the filing window is extended). You, your prescriber, or your appointed representative may ask for an expedited (fast) or standard appeal via any of the following ways:

Phone:

Contact customer service for any requests related including making an oral request to Coverage Determination and Appeals. Our customer service team is available 1-844-786-6762, 24 hours a day, 7 days a week (TTY users please call 711). 

Fax: 855-633-7673

Online: Redetermination Form

Mail:

CVS Caremark Coverage Determinations/Exceptions
P.O. Box 52000
Phoenix, AZ 85072-2000

You can also contact Medicare directly at 1-800-MEDICARE or file a complaint online at: www.Medicare.gov/MedicareComplaintForm/home.aspx

Grievance

A “grievance” is a complaint that does not involve a coverage determination. The grievance process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive. 

How to Request a Grievance

Phone:

Contact our customer service team at 1-844-786-6762, 24 hours a day, 7 days a week (TTY users please call 711). 

Fax: 1-866-217-3353

Mail:

Grievance Department
P.O. Box 30016
Pittsburgh, PA 15222-0330

You can also contact Medicare directly at 1-800-MEDICARE or file a complaint online at: www.Medicare.gov/MedicareComplaintForm/home.aspx

Opioid Safety

• CareFirst BlueCross BlueShield Advantage DualPrime is dedicated to helping you use opioid pain medications more safely.
• To help prevent and combat prescription opioid overuse through improved concurrent Drug utilization review (DUR), CareFirst BlueCross BlueShield Advantage DualPrime will implement opioid safety review at the point of sale (POS), including a care coordination review based on a cumulative morphine milligram equivalent (MME) threshold of 90 MME per day.
  • This review is triggered when the member receives opioid prescriptions from three or more prescribers and the cumulative opioid daily dose is greater than or equal to 90 Morphine Milligram Equivalents (MME).
  • The pharmacist can override this review by consulting with the prescriber to determine the medical necessity of the opioid prescription(s). If the pharmacist is unable or unwilling to override this review, the member, member’s representative and/or prescriber have the option of submitting a coverage determination.
• A hard safety review to limit initial opioid prescription fills for the treatment of acute pain to no more than a 7-day supply.
  • This review is triggered when an opioid-naïve member fills an opioid prescription for a greater than 7-day supply. Pharmacists can dispense a seven-day supply. The member, member’s representative and/or prescriber have the option of submitting a coverage determination to obtain quantity greater than 7-day supply.
• A hard 200 MME review
  • This review is triggered when the member receives opioid prescriptions from three or more prescribers and the cumulative opioid daily dose is greater than or equal to 200 Morphine Milligram Equivalents (MME).
• Prescription may not be filled by the pharmacist without a prior authorization from the plan. The member, member’s representative and/or prescriber will need to submit coverage determination.

How to Appoint Someone to Act on your Behalf

Appointed Representative/ Appointed of Representative (AOR)
 
You or your physician may request an initial determination or file a grievance or appeal. You may name a relative, friend, advocate, doctor, or anyone else as your “appointed representative” to act for you. You may already have a representative authorized under State law to act for you; however, if you want someone to act for you, you and your representative must sign and date a statement giving the person legal permission to be your appointed representative. The form is available below. Please contact your plan for more information.

Appointment of Representative Form