Frequently Asked Questions (FAQs) - Part D

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How to Use the FAQs

Below are some commonly asked questions regarding Medicare and Medi-CareFirst Part D plans. These questions have been divided into several categories to help you find what you need more quickly.

General Information

When can I join a Medicare Drug Plan?

There are three opportunities to join:

1. Initial Enrollment Period — Newly eligible to Medicare

You will ensure that you receive the best rates by enrolling as soon as you are eligible.

  • If you are turning age 65, your seven-month Initial Enrollment Period begins three months before and ends three months after the month of your birthday.
  • If you have become eligible for Medicare based on disability, you can join three months before and three months after your twenty-fourth month of cash disability benefits.

2. Annual Coordinated Election Period

If you did not join when you were first eligible or if you wish to change plans, you can join from November 15 through December 31, annually.

  • If you apply during this period, your coverage will be effective January 1 of the following year.
  • Remember, if you missed your Initial Enrollment Period you will likely pay a higher premium every month, for as long as you have a Medicare Prescription Drug Plan.

3. Special Enrollment Periods (SEP)

Under unique circumstances, you are eligible to enroll or change plans throughout the year. If you meet any of the following criteria, you may be eligible to enroll in BlueRx:

  • Involuntarily lose your coverage that is creditable prescription drug coverage "as good as Medicare's."
  • Have both Medicare and Medicaid or your state helps pay for your Medicare premiums.
  • Receive extra help paying for your Medicare Prescription Drug coverage or are no longer eligible for extra help in paying for your Medicare prescription drugs.
  • Have recently moved to Maryland, Delaware or the District of Columbia as your permanent residence and your new home is outside of the service area of your current prescription drug plan.
  • Receive help from a State Pharmacy Assistance Program (SPAP).

Note: You can only be enrolled in one Medicare Prescription Drug Plan at a time. If you are enrolled in a Medicare Advantage Plan, you cannot enroll in a Medicare Prescription Drug Plan unless you are a member of a Medicare Advantage Private Fee-For-Service (PFFS) Plan, a Medicare Advantage Medical Savings Account Plan (MSA) or a 1876 Cost Plan.

How do I know that Medi-CareFirst will stay in Medicare's Prescription Drug Plan?

Like all prescription drug plans, Medi-CareFirst is authorized by law to refuse to renew its contract with Medicare, and Medicare may also refuse to renew the contract with Medi-CareFirst. However, all Medicare Prescription Drug Plans agree to stay in the program for a full year at a time.

  • Each year, the plans decide whether to continue for another year.
  • Even if a Medicare Prescription Drug Plan leaves the program, you will not lose Medicare Prescription Drug coverage.
  • If we decide not to continue, we must send you a letter at least 60 days before your coverage will end. The letter will explain your options for Medicare Prescription Drug coverage in your area.

I have a discount drug card. Can I use my discount drug card with this plan?

If you have a discount drug card, you will probably find that the benefits under BlueRx (PDP) plans are better. However, if you have a BlueRx (PDP) plan and keep your discount drug card, you can use that card for any drugs not covered by your Medicare Prescription Drug plan.

What do I need to know if I have drug coverage from TRICARE, the Department of Veteran's Affairs (VA), or the Federal Employee Health Benefits Program (FEHB)?

As long as you still qualify, your TRICARE, VA, or FEHB prescription drug coverage is not changing. You should contact your benefits administrator or FEHB insurer for information about your TRICARE, VA, or FEHB coverage before making any changes. It will almost always be to your advantage to keep your current coverage without any changes.

If you lose your TRICARE, VA, or FEHB coverage and you join a Medicare drug plan, in most cases, you won't have to pay a penalty, as long as you join within 60 days of losing TRICARE, VA, or FEHB coverage. Click here for more information on TRICARE.

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How Do I Use My Plan?

How does BlueRx (PDP) work?

Step 1: Deductible
There is a $150 deductible for our BlueRx Standard (PDP) plan. There is no deductible for our BlueRx Enhanced (PDP) plan.

Step 2: Initial Coverage Period
After the deductible (if there is one), members pay a mix of copayments or co-insurance and Medi-CareFirst BlueCross BlueShield pays the rest. Members move to step three after the member and Medi-CareFirst have together paid $2,840 in total prescription drug costs. This limit is called the Initial Coverage Limit.

Step 3: Coverage Gap
BlueRx Standard (PDP): Members pay 93% for Generic drugs and the discounted drug cost for Brand drugs up to $4,550 (excluding premium).

BlueRx Enhanced: Members pay $5 for Generic drugs and discounted Brand drug costs up to $4,550 (excluding premium).

NOTE: Members (those not already receiving "Extra Help") get discounts on most covered Part D brand-name drugs in the coverage gap. Discounts are based on agreements between the federal government and certain drug manufacturers. For this reason, most, but not all, brand-name drugs are discounted.

Step 4: Catastrophic Coverage
If $4,550 in out-of-pocket costs is reached, members pay the greater of 5% or $2.50 for Generic/Brands treated as Generics and $6.30 for all other drugs.

Can I get prescriptions filled through mail order?

Mail order service is not available. Members can get their 90-day prescription maintenance medications filled at a participating retail pharmacy at twice the monthly copay.

How do I fill a prescription at a network pharmacy?

To fill your prescription at a network pharmacy, you must show your Medi-CareFirst Member ID card. If you do not have your Member ID card with you when you fill a prescription, you may also use the letter that you received to confirm your enrollment.

If you do not have the confirmation letter or your ID card, you may have to pay the full cost of the prescription (rather than paying just your copay). If this happens, you would then fill out a claim form when you get home and send it to the address on the form.

*Viewing & printing this form requires Adobe Acrobat Reader, which can be downloaded free from the Adobe site.

What if I am traveling and become ill?

In the US -- Generally, we only cover drugs filled at an out-of-network pharmacy in limited, non-routine circumstances when a network pharmacy is not available. If you are traveling within the United States and territories and become ill, lose or run out of your prescription drugs, we will cover prescriptions that are filled at an out-of-network pharmacy. In this situation, you will have to pay the full cost (rather than paying just your copay) when your prescription is filled. When you return home, submit a claim form.*

You may be responsible for paying the difference between what we would pay for a prescription filled at an in-network pharmacy and what the out-of-network pharmacy charged for your prescription.

Call Claims Customer Service at 1-800-693-1434 (TTY: 1-800-693-0765), 24 hours a day/7 days a week to find out if there is a network pharmacy in the area where you are traveling. If there are no network pharmacies in that area, Customer Service may be able to make arrangements for you to get your prescriptions from an out-of-network pharmacy.

Outside the US -- We cannot pay for any prescriptions that are filled by pharmacies outside of the United States and territories, even for a medical emergency.

If you take a prescription drug on a regular basis and you are going on a trip, be sure to check your supply of the drug before you leave. When possible, take along all the medication you will need.

*Viewing & printing this form requires Adobe Acrobat Reader, which can be downloaded free from the Adobe site.

What if my claim is denied?

If Medi-CareFirst denies coverage for your prescription drugs, we will explain our decision to you. You always have the right to ask us to review the claim that was denied.

You may ask us to make an exception by calling Claims Customer Service at 1-800-693-1434 (TTY: 1-800-693-0765), 24 hours a day/7 days a week.

How do I submit a paper claim?

When you go to a network pharmacy, your claim is automatically submitted to us by the pharmacy. However, if you go to an out-of-network pharmacy, the pharmacy may not be able to submit the claim directly to us, and you will have to pay the full cost of your prescription.

You can print the claim form,* then mail it to the address noted on the form. If the claim is accepted, you should receive payment within 30 days. Your Evidence of Coverage explains this process in detail.

If you need to have a claim form sent to you by mail or fax, please call Claims Customer Service at 1-800-693-1434 (TTY: 1-800-693-0765), 24 hours a day/7 days a week.

*Viewing & printing this form requires Adobe Acrobat Reader, which can be downloaded free from the Adobe site.

How do I file a complaint about my plan?

You can file a complaint about any aspect of your plan by calling Customer Service at 1-800-693-1434 (TTY: 1-800-693-0765), 24 hours a day/7 days a week.

How do I get a new Member ID card if my card is lost?

To request a new ID card, call Membership Customer Service from 8 a.m. - 8 p.m., seven days a week at 1-888-857-6118 (TTY: 1-800-855-2880).

How do I appeal, if my exception request is denied?

If you do not agree with a decision, you have the right to appeal. To begin the appeals process, or to follow up on an appeal, call Claims Customer Service for assistance at 1-800-693-1434 (TTY: 1-800-693-0765), 24 hours a day/7 days a week.

For more information, please visit our Appeals & Exceptions page.

How do I report a grievance?

If you have any kind of problem with your plan, please call us at:

Claims Customer Service
1-800-693-1434
1-800-693-0765 (TTY)
24 hours a day, 7 days a week

We will try to resolve any problem during that call.

If we cannot solve your problem during that call, we will send your problem to someone in our company who can help you. They will then contact you.

If you want a written response to your phone call, we will respond in writing to you.

If you prefer to write or fax us about your problem:

Mail to:
Medicare Prescription Drug Plan Claims Customer Service
c/o Argus Health Systems
Dept. #303
PO Box 419019
Kansas City, MO 64141

We will respond to your problem as fast as we can and no later than 30 days after the day we get it. There are times when we may need more information to resolve your problem. In these cases, we may need up to 14 more days. If we need more time, we will let you know.

Note: You must tell us about your problem no more than 60 days after it happened.

More Information
More information about the grievance, appeals, exceptions and coverage determination processes is available on our Appeals & Exceptions page.

How do I appoint a representative?

Complete the Appointment of Representative Form (92KB, 2 pgs., PDF) and send it to:

Medicare Prescription Drug Plan Enrollment Center
c/o CGI Technologies and Solutions
P.O. Box 2668
Fort Worth, TX 76113

Viewing and printing PDFs requires Adobe Acrobat Reader, which can be downloaded free from the Adobe site.

How do I get prior authorization?

Note: Prior Authorization forms must be completed and submitted by the prescribing physician.

The form is specific to the drug, and is displayed in the formulary listing. A list of all drugs that require Prior Authorization can be found on our formulary.

Medicare Prescription Drug Plan Claims Center
Attention: Prior Authorization Department
Fax: 1-800-315-4025

If your doctor has any questions about a prior authorization request or the process, he or she can contact Argus Health Systems at 1-800-314-2872.

If you have questions about prior authorization, please call:

Claims Customer Service
1-800-693-1434
1-800-693-0765 (TTY)
24 hours a day, 7 days a week

More Information
More information about the grievance, appeals, exceptions and coverage determination processes is available on our Appeals & Exceptions page.

How does the new Brand Manufacturer Coverage Gap Discount Program work?

The Medicare Coverage Gap Discount program provides discounts on most covered Part D brand drugs. This program is available to eligible members who have reached the coverage gap. Discounts are based on agreements between the federal government and certain drug manufacturers. For this reason, most, but not all, brand name drugs are discounted. Members who already receive federal extra help for drug premiums and costs are not eligible.

Those members who are eligible, and are in the coverage gap, can take advantage of the discount. When a brand drug is filled at a pharmacy, the discount is taken BEFORE the member pays. The member pays the discounted amount plus a small dispensing fee. The discounted amount is shown on the member’s Explanation of Benefits.

Here is an example of how the discount works:

  • If the brand cost of Drug A is $200
  • And the Brand Manufacturer Coverage Gap Discount for Drug A is $100
  • And the pharmacy's dispensing fee is $2.50
  • Then, the member pays $102.50:
      $200 (original drug cost)
    - $100 (discount on drug)
    + $2.50 (dispensing fee)
    = $102.50

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Coverage Gap Program

What is the Medicare Coverage Gap Discount Program?

The Medicare Coverage Gap Discount Program provides discounts on most covered Part D brand-name drugs.

  • This program is available to Part D enrollees who have reached the Coverage Gap Stage and are not already receiving a Low Income Subsidy.
  • Discounts are based on agreements between the federal government and certain drug manufacturers.

A change in the law requires manufacturers of brand-name prescription drugs to give a discount on those drugs to Medicare.

  • Beginning January 1, 2011, prescription drugs made and sold by companies that have not agreed to give a discount to Medicare can no longer be covered (paid for) by any Medicare Prescription Drug Plans.
  • For this reason, most, but not all, brand-name drugs are discounted.

How does the discount work?

The discount is taken before you pay the copay. You are responsible for the cost of the drug after the brand manufacturer discount plus the dispensing fee. So if a brand drug costs $200 and if there is a dispensing fee of $1.25, you would pay 50% of the drug cost or $100 plus the $1.25 dispensing fee. You would pay $101.25 for the drug at the pharmacy vs. the $200 cost.

How will I know the cost of the brand manufacturer discount?

The discounted amount for the drug will appear on your Explanation of Benefits.

Does the discount go toward my out-of-pocket?

Yes. The brand discount also goes toward your out-of-pocket limit.

Why doesn’t the brand manufacturer discount apply to those getting federal extra help?

Those getting federal extra help have no coverage gap and already pay low copays in the coverage gap.

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Medication Therapy Management Program

What is a Medication Therapy Management (MTM) program?

Medication Therapy Management (MTM) is a free program designed to help you get the most benefit from your drugs. It may also help you save money.

All members can use this program. Members who are taking several drugs may benefit the most. For more information about this program, please visit our Medication Therapy Management page.

If you have questions about the MTM program or need help finding an MTM pharmacy, please see the Pharmacy Directory in your Member Welcome Book or call Claims Customer Service for assistance at 1-800-693-1434 (TTY: 1-800-693-0765), 24 hours a day/7 days a week.

How can the Medication Therapy Management (MTM) program save me money?

Your MTM pharmacist will review your medicines with you. He or she will tell you if less expensive similar medicines are available. You may also find out that you are taking multiple drugs that have the same purpose. If so, the pharmacist will talk with your doctors, with your permission, to find out if changes can be made to your prescriptions.

Can I use my regular pharmacy and see a MTM Pharmacist at a different pharmacy?

Yes. Not all local pharmacists have completed the MTM training. You can see a MTM pharmacist for your review at a different pharmacy than you regularly use.

Will I pay any additional costs or fees associated with the MTM program?

No. MTM services are free to all BlueRx (PDP) plan members.

Why would I use the MTM program?

If you take several medicines or have a serious condition, the MTM review can help spot potential problems in how your medicines work together. It can also help you find out if there are less expensive, but equally effective, medicines you can take.

Will I be required to join the MTM program?

All members are automatically enrolled in the free MTM program. It is up to you whether you want to participate in the program. To participate, all you have to do is call an MTM pharmacist to set up your annual Comprehensive Medication Check-Up. To find an MTM pharmacist, check your Pharmacy Directory, or call Claims Customer Service at 1-800-693-1434 (TTY: 1-800-693-0765), 24 hours a day, 7 days a week.

How do I find an MTM pharmacist?

Call Claims Customer Service at 1-800-693-1434 (TTY: 1-800-693-0765), 24 hours a day/7 days a week to find a participating MTM pharmacist. There is also a list of MTM pharmacists in the Pharmacy Directory that new members receive with their Welcome Package. Call to set up your review. Be sure to bring all your medicine. Also bring any vitamins, herbal products or supplements you are taking. You should plan on the appointment lasting 20-30 minutes.

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Should I Apply?

How much do the Medi-CareFirst plans cost?

Medi-CareFirst offers two prescription drug plans: The BlueRx Standard (PDP) and BlueRx Enhanced (PDP). The two plans vary in cost and coverage. Please see our Cost & Benefits page for more detailed information.

If you have limited financial resources, you may qualify for Federal or state-provided extra help. For more information on receiving Federal Extra Help, or to see if you qualify, call:

  • 1-800-MEDICARE (1-800-633-4227). TTY/TDD users should call 1-877-486-2048, 24 hours a day/7 days a week.
  • The Social Security Administration at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY/TDD users should call 1-800-325-0778. You can also visit the Social Security Web site.
  • Your local State Medicaid Office.
  • You can also refer to Medi-CareFirst.com's extra help page.

What should I do if I have other prescription drug coverage and want to join Medi-CareFirst?

If you or your spouse has, or is able to get, employer group drug coverage:

  • You should talk to your employer to find out how your benefits will be affected if you join a BlueRx (PDP) plan.
  • Get this information before you decide to enroll in this plan.

If your current Prescription Drug coverage offers benefits that are at least as good as the new Medicare Drug plan:

  • You will need to decide which plan you want to have.
  • If you keep your current coverage, but later your company decides to stop offering coverage to retirees, you can enroll in the Medicare plan
  • You must enroll within 60 days of losing your coverage to avoid paying a penalty

If your coverage is not as good as the new Medicare coverage and you keep it:

  • You will have to pay the extra cost if you enroll after your Initial Enrollment Period.

If you have a Medigap (Medicare Supplement) policy that includes prescription drug coverage:

  • You must contact your Medigap insurance company to let them know that you have joined a Medicare Prescription Drug Plan.

If you decide to keep your current Medigap supplement policy:

  • Your Medigap insurance company will remove the prescription drug coverage part of the policy and adjust your premium.
  • In some cases, you can also buy a different Medigap policy without prescription drug coverage sold by your Medigap insurance company.
  • Your Medigap insurance company cannot charge you more, based on any past or present health problems.
  • Call your current Medigap insurance company for details.

If you live in Virginia, the BlueCross BlueShield Prescription Drug Plan is offered through Anthem BlueCross BlueShield.

How will I know if my current Prescription Drug coverage is as good as the new Medicare Prescription Drug coverage?

If you have group coverage, your current employer is required to let you know. If you have individual (non-group) insurance, your insurance carrier is required to let you know. The specific term used is “creditable coverage” which means that the benefit is equal to or better than the Medicare coverage.

What is the penalty if I miss the Initial Enrollment Period?

If you don't join a plan when you become eligible, and you don’t currently have a drug plan that, on average, covers at least as much as standard Medicare prescription drug coverage, you will have to wait until the Annual Coordinated Election Period to join (November 15 to December 31).

When you do join, your premium cost may go up at least 1% of the national average premium for every month that you wait to join. Like other insurance, you would pay this penalty as long as you have Medicare prescription drug coverage. If you join during the 2010 Annual Coordinated Election Period, your coverage will begin January 1, 2011.

Some people may not be penalized if eligible for and join during a Special Enrollment Period.

Should I join a Medicare Prescription Drug Plan even if I don't take many prescription drugs?

You should still consider joining a Medicare drug plan. As we age, most people need prescription drugs to stay healthy. For most people, joining now means you will pay the lowest possible monthly premium.

If you don’t join a plan when you become eligible, and you don’t currently have a drug plan that, on average, covers at least as much as standard Medicare prescription drug coverage, you will have to wait until the Annual Coordinated Election Period to join (November 15 to December 31). When you do join, your premium cost may go up at least 1% of the national average premium for every month that you wait to join. Like other insurance, you would pay this penalty as long as you have Medicare prescription drug coverage. If you join during the 2010 Annual Coordinated Election Period, your coverage will begin January 1, 2011.

Some people may not be penalized if eligible for and join during a Special Enrollment Period.

How do I get extra help paying for my Prescription Drug Plan?

Medicare will notify you about getting extra help, if you are currently:

  • Receiving benefits from both Medicaid and Medicare
  • Enrolled in a Medicare Savings Program or
  • Receiving Supplemental Security Income benefits and have Medicare.

If you are not in one of the groups noted above, but have a limited income and resources, you will need to apply for extra help. Information is available on the Social Security Web site.

For more information:

  • You can also call Medicare for more information at 1-800-MEDICARE (1-800-633-4227)/ TTY 1-877-486-2048.
  • If you live in Maryland, please call the Maryland Senior Prescription Drug Assistance Program (SPDAP). Call 1-800-551-5995/ TTY 1-800-877-5156 (9 a.m. - 5 p.m., weekdays).
  • If you live in Delaware, please call the Delaware Prescription Drug Assistance or Delaware Chronic Renal Disease programs. Call 1-800-996-9969, Option 2, Option 1.
  • You can also refer to Medi-CareFirst.com's extra help page.

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What are the Benefits?

  • What drugs are covered by BlueRx (PDP) plans?

    BlueRx (PDP) plans cover all of the drugs that have been approved by Medicare for the Medicare Prescription Drug program and that are not available over-the-counter. This is important to consider in choosing your plan. Some carriers cover only brand-name drugs when no generic is available or offer a limited selection of covered drugs.

    What if I forget to pay my premium?

    Medi-CareFirst will let you know, in writing, that your premium is past due. The letter will tell you that you have a 60-day grace period, and when that grace period began. If you don’t pay your premium before the grace period is over, you will be disenrolled. Disenrollment will end your membership in your BlueRx (PDP) plan.

    I have a discount drug card. Can I use my discount drug card with this plan?

    If you have a discount drug card, you will probably find that the benefits under BlueRx (PDP) plans are better. However, if you have a BlueRx (PDP) plan and keep your discount drug card, you can use that card for any drugs not covered by your Medicare Prescription Drug plan.

    What is a "multisource" drug?

    A multisource drug is a preferred brand-name drug that the drug manufacturer offers to your insurance plan at the same cost as a generic drug. These are also known as brand names that are treated as generics.

    Can I change drug plans?

    Yes, you will have the following opportunities to change your plan.

    1. Annual Coordinated Election Period – Missed your Initial Enrollment Period? Not satisfied with your existing plan? If you did not join when you were first eligible or if you wish to change plans, you can join from November 15-December 31. If you apply during this period, your coverage will be effective January 1 of the following year.

    Remember, if you missed your Initial Enrollment Period you will likely pay a higher premium every month, for as long as you have a Medicare Prescription Drug Plan.

    2. Special Enrollment Periods (SEP) – Under unique circumstances, you are eligible to enroll or change plans throughout the year. If you meet any of the following criteria, you may be eligible to enroll in BlueRx (PDP):

    • Involuntarily lose your coverage that is creditable prescription drug coverage "as good as Medicare's."
    • Have both Medicare and Medicaid or your state helps pay for your Medicare premiums.
    • Receive extra help paying for your Medicare Prescription Drug coverage or are no longer eligible for extra help in paying for your Medicare prescription drugs.
    • Have recently moved to Maryland, Delaware or the District of Columbia as your permanent residence and your new home is outside of the service area of your current prescription drug plan.
    • Receive help from a State Pharmacy Assistance Program (SPAP).

    Note: You can only be enrolled in one Medicare Prescription Drug Plan at a time. If you are enrolled in a Medicare Advantage Plan, you cannot enroll in a Medicare Prescription Drug Plan unless you are a member of a MA Private Fee-For-Service (PFFS) Plan that does not already include drug coverage, a MA Medical Savings Account Plan (MSA), or a 1876 Cost Plan.

    Where are BlueRx (PDP) plans available?

    The service area for BlueRx (PDP) plans includes Delaware, District of Columbia and Maryland. You must live in one of these places to join a plan. Virginia residents are offered coverage through Anthem BlueCross BlueShield.

    If you are in prison, you can't join this plan.

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    What Drugs are Covered?

    Does my plan have a prescription drug formulary?

    Yes. A formulary is a list of drugs that Medi-CareFirst covers. Our formulary was developed with the help of a team of health care providers and includes all of the drugs that Medicare allows to be covered as part of the Medicare Prescription Drug plan.

    Changes may be made to the formulary periodically. Affected members will be notified 60 days before the change is made. Upcoming changes will be noted on your Explanation of Benefits and in the News and Drug Search sections of www.medi-carefirst.com.

    How do I search the formulary?

    To search the formulary, follow the steps below:

    1. Enter the name of the drug you are interested in, in the search box
    2. Press the “go” button to the right of the search box
    3. Locate your specific drug and dosage in the results table. In this table, you will find:
      • the drug name
      • dosage
      • drug tier
      • drug class
      • the generic equivalent (if available)
      • rules that apply to prescribing the drug
    4. You can click on the drug name, the drug tier, or the class to find out more information about that category.

    Are any drugs excluded?

    Medicare has excluded some types of drugs from Medicare Prescription Drug coverage. They include:

    • Medicare Part A and Part B prescription drugs.
    • Prescription drugs intended solely for cosmetic use.
    • Erectile Dysfunction (ED) drugs, like Viagra, Cialis, Levitra and Caverject.
    • Drugs, drug therapies or devices that are considered experimental or investigative by Medi-CareFirst or the FDA.
    • Over-the-counter drugs (non-prescription).
    • Drugs bought outside the United States and its territories.
    • Drugs when used for the relief of cough and cold symptoms.

    Please refer to the Evidence of Coverage for additional information about excluded drugs.

    What is an exception?

    An exception is a request to Medi-CareFirst to pay for a drug that is not covered, to pay for a drug at a different cost, or to waive restrictions or limits on your drug.

    There are several types of exceptions that you can ask us to make:

    • You can ask us to cover your drug even if it is not on our formulary.
    • You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Medi-CareFirst limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit.
    • You can ask us to provide a higher level of coverage for your drug. For example, if your drug is a non-preferred brand-name drug, you can ask us to cover it as a preferred brand-name drug instead. This would lower the amount you must pay for your drug.
    • Please note: if we grant your request to cover a drug that is not on our formulary, we will not change the pricing level for that drug.

    Generally, Medi-CareFirst will only approve your request for an exception if the alternative drugs included on the plan’s formulary or the lower-tiered drug would not be as effective in treating your condition, and/or it would cause you to have an adverse medical reaction.

    What are Part B drugs and where do you get them?

    Medicare covers certain prescription drugs as part of your basic Medicare benefits. These are often called "Part B drugs." These are drugs that are usually administered to you by a healthcare professional in a doctor’s office or administered in your home through an infusion device or Durable Medical Equipment, such as Nebulizers.

    The following kinds of prescription drugs are usually Medicare-covered Part B drugs. In certain situations, they may be covered under a Part D benefit.

    • Immunosuppressant drugs, if you have had an organ transplant covered by Medicare.
    • Certain oral anti-cancer drugs and anti-nausea drugs.
    • Erythropoietin drugs for individuals who receive kidney dialysis or when administered by the physician.
    • Parenteral nutrition, for individuals with permanent dysfunction of the digestive tract.
    • Inhaled medications that require a Nebulizer to administer. Only covered by Part B for persons residing at home.
    • Influenza and pneumococcal-23 vaccines and administration.
    • Hepatitis B vaccine and administration for patients who are considered Intermediate to High risk for contracting Hepatitis B. For all other patients, coverage for the vaccine and administration is provided under Part D.
    • Injections that are usually not self-administered, and may be administered in a doctor's office or administered at home through an infusion device.

    Where you can and cannot get Part B drugs:

    • You cannot get Part B drugs from a retail pharmacy that is not a “Part B provider” and receive coverage for them.
    • Part B drugs are available only from providers who can supply and bill for your Medicare Part B medical benefits (e.g. DME suppliers and specialty pharmaceutical companies that specialize in diabetic supplies and Part B drugs).
    • Your physician may help you find a DME supplier.
    • Part B drugs are not covered under your Medicare Part D Prescription Drug coverage.

    Are vaccines covered under Part D?

    If you have a Medicare Part D plan, a number of Part D vaccines – including vaccine administration – are covered. Some vaccines are covered under Part B. Please see your Evidence of Coverage or read our Part D vaccine/administration policyAdobe PDF.

    What if my current prescription drugs are not on the formulary or are limited on the formulary?

    New Members

    As a new member in our plan, you may currently be taking drugs that aren’t on our formulary or that are subject to certain restrictions, such as prior authorization or quantity limit.

    • In instances like these, you need to talk with your doctor about taking an alternative prescription drug that is on our formulary. If there are no appropriate alternative prescription drugs on our formulary, you or your doctor can request a formulary exception.
    • If the exception is approved, you will be able to obtain the drug you are taking for a specified period of time.
    • While you are talking with your doctor to determine your course of action, you may be eligible to receive an initial 30-day transition supply of the non-formulary drug. This transition supply is only available during the first 90 days you are a member.
    • When you go to a network pharmacy and we provide a temporary supply of a drug that isn’t on our formulary, or that has coverage restrictions or limits (but is otherwise considered a “Part D drug”), we will cover a 30-day supply (unless the prescription is written for fewer days). After we cover the temporary 30-day supply, we generally will not continue to pay for these drugs under the transition policy.
    • We will provide you with a written notice after we cover your temporary supply. This notice will explain the steps you can take to request an exception and how to work with your doctor to decide if you should switch to an appropriate drug that we cover.

    Long-Term Care Facility Residents

    • If you are a resident of a long-term care facility (like a nursing home), we will cover a temporary 31-day transition supply (unless you have a prescription written for fewer days).
    • If necessary, we will cover more than one refill of these drugs during the first 90 days you are enrolled in our Plan, provided the total amount filled during the first 90 days you are a member of our plan does not exceed a 93-day supply.
    • If you have been enrolled in our Plan for more than 90 days and need a drug that isn’t on our formulary or is subject to other restrictions, such as quantity limits, we will cover a temporary 31-day emergency supply of that drug (unless the prescription is for fewer days) while the new member pursues a formulary exception.

    Level of Care Change

    If you are outside the transition period and are experiencing circumstances that involve a level of care change where you must change from one treatment setting to another, we will cover a temporary 31-day transition supply (unless you have a prescription written for fewer days) while you pursue a formulary exception.

    Continuing Members

    As a continuing member in the plan, you should have received your Evidence of Coverage package, including an abridged formulary, by October 31. You may notice that a formulary medication you are currently taking is either not on the upcoming year’s formulary, or its cost sharing or coverage is limited in the upcoming year.

    In this case, we will provide for a transition period consistent with the above transition process for new enrollees.

    For questions and help requesting a formulary exception, please call Claims Customer Service at 1-800-693-1434 (TTY: 1-800-693-0765), 24 hours a day/7 days a week.

    How do I request an exception to the Medi-CareFirst's Formulary?

    An Exception is a request to Medi-Carefirst to pay for a drug that is not covered, to pay for a drug of a different cost, or to waive restrictions or limits on your drug.

    To request an exception:

    1. Call

    Call Claims Customer Service for assistance at 1-800-693-1434 (TTY: 1-800-693-0765), 24 hours a day/7 days a week.

    2. Fax

    Fax the “Request for Medicare Prescription Drug Coverage Determination” form.

    Fax or mail the completed form and the required doctor’s statement* to:

    Fax to:
    Medicare Prescription Drug Plan Claims Center
    Attention: Prior Authorization Department
    Fax: 1-800-315-4025 (This fax machine is located in a secure location as required by HIPAA regulations.)

    3. Mail
    Mail to:
    Medicare Prescription Drug Plan Claims Center
    c/o Argus Health Systems
    Dept # 303
    PO Box 419019
    Kansas City, MO 64141

    You will receive a decision within 72 hours after it is received.

    *Your prescribing doctor must give us a written statement telling us why you need this exception.

    Note – One exception will not be considered:

    • You cannot get a brand-name drug and pay a generic drug copay.

    Expedited Exceptions
    If waiting 72 hours for a decision could seriously harm your life or health, you can ask for an expedited (fast) decision:

    1. Ask your prescribing doctor to call us at 1-800-932-0169.
    2. The doctor must tell us that waiting 72 hours for a decision could seriously harm your life or health.
    3. Your prescribing doctor could also use the Request for Coverage Determination form and fax it, as noted above.

    You will receive a decision within 24 hours. If we don't hear from your doctor, Medi-CareFirst will decide if your health condition requires a fast decision.

    Additional information about the grievance, appeals, exceptions and coverage determination processes is available in your Evidence of Coverage.

    2011: Evidence of Coverage



    *Viewing and printing PDFs requires Adobe Acrobat Reader, which can be downloaded free from the Adobe site.

    How do I appeal, if my exception request is denied?

    If you do not agree with a decision, you have the right to appeal. To begin the appeals process, or to follow up on an appeal, call Claims Customer Service for assistance at 1-800-693-1434 (TTY: 1-800-693-0765), 24 hours a day/7 days a week.

    They will give you specific instructions, depending on the nature of your request.

    For more information, including how to submit a written appeal, visit our Appeals & Exceptions page.

    What are Specialty Tier Drugs?

    Specialty Tier drugs are high-cost prescription drugs created through advances in research and technology and may require special handling, administration or monitoring.

    Specialty Tier drugs may be oral or injectable medications used to treat serious or chronic medical conditions such as cancer, multiple sclerosis, rheumatoid arthritis, hepatitis C and HIV/AIDS.

    Why did my drug move to the Specialty Tier (Tier 4)?

    In 2011, we changed Tier 4 from non-self-administered injectables to Specialty Tier drugs. CMS allows Part D plans to place high-cost prescription drugs on a Specialty Tier. Most Part D plans have placed specialty drugs on their Specialty Tier.

    What is the cost sharing for Specialty Tier drugs?

    Please refer to your Explanation of Benefit or Evidence of Coverage to see the co-insurance in each phase of your benefit.

    Can I ask for tiering exceptions or cost-sharing changes to Tier 4?

    No, you cannot ask for a change to the cost-sharing for any drug in Specialty Tier 4.

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    What Pharmacies Participate?

    Where can I get my prescriptions filled if I join this plan?

    It is expected that you will use in-network retail pharmacies. There are more than 1,400 in-network pharmacies in the Maryland/DC/Delaware area, and more than 60,000 nationwide. You can only use out-of-network pharmacies in special circumstances, including illness while traveling outside of the plan's service area where there is no network pharmacy.

    If you are traveling, you can call Claims Customer Service for in-network pharmacies in your area at 1-800-693-1434 (TTY: 1-800-693-0765), 24 hours a day/7 days a week.

    What if I'm out of town or have an emergency?

    If you need prescriptions on an emergency basis, or an urgent need arises while you are out of town, you can call Claims Customer Service for in-network pharmacies in your area at 1-800-693-1434 (TTY: 1-800-693-0765), 24 hours a day/7 days a week. You can also check our Web site at www.medi-carefirst.com.

    If you go to an out-of-network pharmacy, you may be responsible for paying the difference between what we would pay for a prescription filled at an in-network pharmacy and what the out-of-network pharmacy charges for your prescription.

    In this situation, you will have to pay the full cost (rather than paying just your copay or co-insurance) when you fill your prescription. You can ask us to reimburse you for our share of the cost by submitting a claim form.*

    However, you should obtain appropriate supplies of routine or maintenance prescriptions from your local pharmacy before you go out of town.

    *Viewing & printing this form requires Adobe Acrobat Reader, which can be downloaded free from the Adobe site.

    Are home infusion pharmacies in the Medi-CareFirst pharmacy network?

    Medi-CareFirst will cover home infusion therapy if:

    • Your prescription drug is on Medi-CareFirst’s formulary;
    • Medi-CareFirst has approved your prescription drug for home infusion therapy;
    • Your prescription is written by a doctor; and
    • You get your home infusion services from a Medi-CareFirst network pharmacy.

    Please call Claims Customer Service at 1-800-693-1434 (TTY 1-800-693-0765), 24 hours a day/7 days a week for information on home infusion. A list of home infusion pharmacies is also available in the Pharmacy Directory that new members receive with their Welcome Package.

    Are long-term care pharmacies in the Medi-CareFirst pharmacy network?

    In some cases, residents of a long-term care facility may receive their prescription drugs through a long-term care pharmacy. Please call Claims Customer Service at 1-800-693-1434 (TTY: 1-800-693-0765), 24 hours a day/7 days a week for information about long-term care pharmacies in the Medi-CareFirst Network. A list of long-term care pharmacies is also available in the Pharmacy Directory that new members receive with their Welcome Package.

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    Pending CMS Approval.