Prior Authorization

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.

Medical Benefit Policies

To search for a specific drug, open the PDF below. Then click “CTRL” and “F” at the same time. To print or save an individual drug policy, open the PDF, click “File”, select “Print” and enter the desired page range. 

For questions about a prior authorization covered under the medical benefit, please contact CVS Caremark* at 888-877-0518.

Medical Benefit Policies 

Pharmacy Benefit Policies

To search for a specific drug, open the PDF below. Then click “CTRL” and “F” at the same time. To print or save an individual drug policy, open the PDF, click “File”, select “Print” and enter the desired page range. 

For questions about a prior authorization covered under the pharmacy benefit, please contact CVS Caremark* at 855-582-2038.

Pharmacy Benefit Policies  

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.