Certain medications require prior authorization to ensure safe and effective use. The drug policies listed below include criteria for prior authorization, site of care, quantity limits, and/or step therapy. They are subject to the terms of a member’s specific health plan.
The drug policies are broken out by drugs covered under the medical benefit or pharmacy benefit:
- Medical benefit: Typically, medications covered under the medical benefit are administered in an outpatient hospital, home or office setting.
- Pharmacy benefit: Typically, medications covered under the pharmacy benefit are oral, topical or inhaled products distributed by retail or mail pharmacies.
Specialty drugs may be covered either through the medical and/or pharmacy benefit. To view of a full list of drugs that have prior authorization and/or site of care requirements under the medical benefit, visit the Specialty Drug List.
How to Submit a Drug Prior Authorization
Prior authorization requests for drugs covered under the medical benefit must be submitted electronically through the CareFirst Provider Portal . To submit a prior authorization request online, log in to the Provider Portal and navigate to the Prior Auth/Notifications tab. For more information, please complete our Medication Prior Authorization training.
If you are experiencing technical difficulties with the Provider Portal, please contact the CareFirst Help Desk at 877-526-8390.
Prior Authorization Documents & Policies
To access all medical and pharmacy benefit policies and prior authorization fax forms, please visit the CVS Caremark* Prior Authorization Documents page.
For questions about a prior authorization covered under the medical benefit, please contact CVS Caremark* at 888-877-0518.
For questions about a prior authorization covered under the pharmacy benefit, please contact CVS Caremark* at 855-582-2038.
For questions about FEP members and their prior authorization, please call 800-469-7556.
*CVS Caremark is an independent company that provides pharmacy benefit management services.