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Date:
April 17, 2015
Market: All with CareFirst Pharmacy Coverage,
including 100-199 ASO
(200+ ASO groups not impacted)
Pharmacy Update – Upcoming Formulary Changes
All fully-insured groups (regardless of size) and consumer direct members with a CareFirst prescription drug plan
will be moving to CareFirst Formulary 2 with prior authorizations (PA). This means 90 additional drugs will now
require prior authorization before they are covered by our prescription drug benefit. CareFirst Formulary 2 with
prior authorization is the only drug option available to fully-insured groups and consumer direct members and is
not available to self-insured ASO groups.
The effective dates by jurisdiction are as follows:
Book of Business
Fully-insured groups
and consumer direct
Fully-insured groups
and consumer direct
100-199 self-insured
ASO groups
Jurisdiction
Maryland and
Virginia
District of
Columbia
All
Formulary
Effective Date
Implementation
Formulary 2 with PA
July 1, 2015
Turnkey
Formulary 2 with PA
January 1, 2016
Turnkey
Formulary 2 with
exclusions
July 1, 2015
Upon renewal and
new business
Sales paperwork is not required to implement this change.
Please note: 200+ self-insured groups are not impacted and will still have the same three formulary options they
have today – CareFirst Formulary 1 (open, includes some prior authorizations, but no exclusions), CareFirst
Formulary 2 (includes some prior authorizations and excludes 90 drugs) and CareFirst Formulary 3 (includes some
prior authorizations and excludes 240 drugs).
Please keep in mind formulary management is a proven way to encourage continued savings while minimizing
member disruption, which enables accounts to stay ahead of market shifts. By driving employee behavior to lowercost options, accounts may see improved outcomes and savings across both pharmacy and medical costs.
Key messages
Here are some key messages to keep in mind when talking with your impacted groups:
 90 additional drugs (out of our open formulary of 5,000 drugs) will now require a prior authorization.
 Since these additional 90 drugs are all on the non-preferred brand tier, impacted members will save
money by switching to one of the many available alternatives because they will all be on a lower costshare tier.
 Members will still be able to get these drugs with a prior authorization IF the drug is medically necessary.
 Less than one percent of existing CareFirst members will be impacted.
CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc.
CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are both independent licensees of the Blue Cross and Blue Shield Association.
® Registered trademark of the Blue Cross and Blue Shield Association. ®’ Registered trademark of CareFirst of Maryland, Inc.
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Impacted members and prescribing physicians will be notified by mail, prior to the change.
Effective July 1, 2015 there will be two versions of CareFirst Formulary 2 – one with 90 excluded drugs (selfinsured ASO groups only) and one with a PA requirement on 90 drugs (fully-insured groups and consumer
direct).
To inform our members, we will be enhancing My Account to reflect the member’s formulary and we will
also update the Drug Pricing Tool to list whether a drug requires PA or is excluded.
The Drug Search Tool on www.carefirst.com/rx will reflect the formulary options for fully-insured groups
and consumer direct members effective July 1, 2015.
Self-insured ASO groups will receive a separate benefit summary with a unique URL to view their formulary
options.
All impacted members in Maryland and Virginia will be notified by mail the week of April 15. The member letter will
include the impacted drug and a list of alternative drug options. Physicians will also be notified by mail the week of
May 18. A sample member letter is attached for your reference.
Prior authorization process
The prescribing physician must initiate the prior authorization process by completing an online request through the
Provider Portal at http://www.carefirst.com/providerlogin.
Should you have any questions, please contact your Broker Sales Representative.
C. Shekar Subramaniam
Vice President, Sales
Small Medium SBU
CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc.
CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are both independent licensees of the Blue Cross and Blue Shield Association.
® Registered trademark of the Blue Cross and Blue Shield Association. ®’ Registered trademark of CareFirst of Maryland, Inc.
<Date>
<Plan Member Name>
<Street Address>
<City, State Zip>
Dear <Plan Member Name>:
CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc.’s (CareFirst) pharmacy benefit
manager, CVS/caremark*, continually review medicines, products and prices to make sure the
drugs that work well and are cost-effective become part of your prescription drug benefit. As
part of this effort, there are changes that could affect your current drug choices.
As of [DATE], your current drug(s) listed below will require a medical necessity prior
authorization in order to be covered by your prescription drug benefit. You will pay the
full cost of the prescription without an approved medical necessity prior authorization.
Other covered options may be available to you.
Your current drug requiring prior authorization:
<non-preferred drug>
Your covered options:**
<preferred drugs>
Your next steps:
1. Talk to your doctor about getting a new prescription(s) for a covered option.
2. Fill your new prescription(s):
 At a retail pharmacy: Have your doctor call in the new prescription(s) or take your
prescription to your local pharmacy.
 To get started with mail service: Your doctor can call in the new prescription to us tollfree at 800-241-3371. Or you can call us toll-free at 800-241-3371, and we will contact
your doctor for you.
Visit the Drug Search section at www.carefirst.com/rx to learn more about drugs that require
prior authorization, covered options and more. You can also call us toll-free at the number
located on your member ID card.
Sincerely,
Arif Khan
Senior Director, Pharmacy Operations
MBR5543 (2/15)
*CVS/caremark is an independent company that provides pharmacy benefit management services.
**Certain drug options identified above may be subject to additional prior authorizations or other plan design restrictions. Please
consult your plan for further information.
CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc.
CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are both independent licensees of the Blue Cross and Blue Shield Association.
®’ Registered trademark of CareFirst of Maryland, Inc.
106-33813a 031815