The CareFirst Community Health Plan Maryland (CareFirst CHPMD) Pharmacy and Therapeutics Committee review and approve all pharmaceutical management procedures during its meetings. Meetings take place four times a year. The committee members use policies and procedures to help create and manage CareFirst CHPMD’s list of covered drugs and products. You and your doctor may decide to use these drugs and products to help manage your health.
The decision to update the drug list is ongoing. An update is when a drug is added or removed from the list. The following standards help committee members make a decision on whether or not to make an update.
A drug or product:
- treats a condition that is not treated by a drug currently listed.
- treats a condition in a different way than a drug currently listed.
- has been reported as safe to use.
- is easier to use or can increase patient compliance.
- is readily available.
- works better than drugs or products currently listed.
- is lower or the same price in cost to those currently listed.
CareFirst CHPMD may also use additional pharmaceutical management procedures to manage the use of pharmaceuticals:
Generic Substitution
CareFirst Community Health Plan Maryland (CareFirst CHPMD) is required by state rules to dispense generic versions of drugs and products rather than brand-name drugs and products unless a provider requests otherwise.
Prior Authorization
CareFirst Community Health Plan Maryland (CareFirst CHPMD) may require providers to get approval before prescribing some drugs and products to make sure the drug or product is appropriate. Prior authorization requested by you or your provider may be reviewed by CareFirst CHPMD’s pharmacy benefits manager for clinical appropriateness. Please be prepared to provide supporting clinical documentation to show that the member has tried and failed a formulary option. Contact CVS Health at 1-877-418-4133 for medication request review. (A CVS clinical reviewer will provide the prior authorization criteria used for evaluating the requested drugs/products upon request during the call.)
Step Therapy
CareFirst Community Health Plan Maryland (CareFirst CHPMD) starts therapy with the most cost-effective and safest drugs and products. If needed, more costly or riskier therapies will be used. Contact CVS Health at 1-877-418-4133 for medication request review. (A CVS clinical reviewer will provide the step-therapy criteria used for evaluating the requested drugs/products upon request during the call.
Quantity Limits
CareFirst Community Health Plan Maryland (CareFirst CHPMD) limits the amount of specific drugs and/or products covered within a certain time period based on evidence-based treatment durations. Contact CVS Health at 1-877-418-4133 for medication request review. (A CVS clinical reviewer will provide drug or product specific quantity limits upon request during the call.)
Specialty Medications
Effective January 1, 2019, all specialty medications must be filled at CareFirst Community Health Plan Maryland (CareFirst CHPMD) preferred specialty pharmacy, which includes CVS Specialty Pharmacies and select University of Maryland Specialty Pharmacies.
Any specialty medications that are filled at a specialty pharmacy that is out of network will reject at the point-of-sale as “pharmacy not contracted” and will NOT be covered or reimbursed.
Network Pharmacies Include: *** pharmacies that only dispense specialty medications
-
- CVS Specialty***
- HUB: Monroeville, PA
- NPI# 1043382302 NCPDP# 3958898
- Call: 1-800-237-2767 Fax: 1-800-323-2445
- UMMC Midtown Campus Pharmacy
- 821 North Utah St, First Floor, Baltimore, MD 21201
- NPI# 1700237716 NCPDP# 2140351
- Call: 410-856-3650 Fax: 410-856-3854
- University Center Weinberg Pharmacy
- 22 South Greene, Baltimore, MD 21201
- NPI# 1144260894 NCPDP# 2118429
- Call: 410-328-1175 Fax: 410-328-0666
- University of Maryland Medical Center (UMMC) Pharmacy at Redwood
- 11 South Paca St., Baltimore, MD 21230
- NPI# 1760582928 NCPDP# 2120789
- Call: 410-328-5243 Fax: 410-328-2920
- University of Maryland Medical Solutions Home Infusion
- 825 N Hammonds Ferry Rd., Ste C, Linthicum Heights, MD 21090
- NPI# 1386016319 NCPDP# 2139954
- Call: 443-462-5850 Fax: 410-636-0309
- University of Maryland Medical System (UMMS) Pharmacy Services & Specialty Pharmacy***
- 920 Elkridge Landing Road, Linthicum, MD 21090
- NPI# 1912329434 NCPDP# 2138077
- Call: 855-547-4276 Fax: 410-684-3776
Age Limits
CareFirst Community Health Plan Maryland (CareFirst CHPMD) may require prior approval of certain drugs and products based on age. (A CVS clinical reviewer will provide drug or product specific age limits upon request during the call.)
Mail-Order
Effective 02/01/2019, members can use mail-order pharmacy for most chronic, non-opioid medications, including medications listed on our 90-day prescription fill list. These medications can be delivered directly to your home as long as you have a working phone number and an updated home address.
Members can contact CVS Caremark at 1-855-566-8397 to enroll in the mail-order benefit or for any questions about the mail-order benefit.
Providers can contact CVS Caremark at 1-800-378-5697 and select option 3. Providers can print fax form from www.caremark.com and fax required information to 1-800-378-0323.
Therapeutic Interchange
CareFirst Community Health Plan Maryland (CareFirst CHPMD) prohibits a pharmacist from switching a prescribed drug or product to an alternative drug or product within the same therapeutic drug class except when the pharmacist is servicing patients of a hospital, resident of a comprehensive care or extended care facility with an established procedure for therapeutic interchange.
Medication Exceptions
Non-covered drugs and products requested by you or your provider may be reviewed by CareFirst Community Health Plan Maryland (CareFirst CHPMD) pharmacy benefits manager when the formulary does not adequately accommodate your clinical needs. Please be prepared to provide supporting clinical documentation to show that the member has tried and failed a formulary option (medical necessity). Contact CVS Health at 1-877-418-4133 for a medication exception request review.
Opioids
The quantity of opioid products prescribed (including those that are combined with acetaminophen, aspirin or ibuprofen) will be limited to up to 90 morphine milligram equivalents (MME) per day based on a 30-day supply. Prescriptions that exceed 90 MME daily limits will be subject to UM criteria, such as prior authorization. Members who are opioid-naïve may be subject to additional step therapy requirements (use of an immediate-release (IR) formulation will be required before moving to an extended-release (ER) formulation) and quantity limit restrictions (first fill will be limited to seven days).
