Prescription Drug Benefit

If you’re enrolled in a CareFirst medical plan, your prescription drugs and prescription drug claims are managed by Capital Rx.

• Wondering if one of your medications is covered by Capital Rx? Find out if your prescriptions are on the formulary—i.e., Capital Rx’s list of approved drugs—and search for approved pharmacies.

• You can also review Capital Rx’s approved preventive medications, medications that require prior authorization, and approved pharmacies including JHOP locations.

• Looking for on-demand access to your personal prescription information? Access the Capital Rx member app and follow these step-by-step instructions to create an account.

Quantum Health

Quantum Health is your free healthcare navigator as a CareFirst plan member. They can help you with your prescriptions by answering questions about coverage, finding a pharmacy, or finding the lowest-cost options for a drug. They can also can reach out to your provider to request a refill or a different formulary option.

Contact Quantum Health care coordinators at 1-844-460-2801, Monday through Friday from 8:30 a.m. to 10 p.m., or access the Quantum Health member portal. No request is too big or small for your care coordinator to help.

Mail-Order Prescriptions

Get convenient and cost-effective access to prescription drugs through mail-order delivery. Learn more about how to set up home delivery, request refills of current prescriptions, and more through Costco Mail Order Pharmacy on the Capital Rx website.

Your provider can e-prescribe to Costco Pharmacy Mail Order #1348, Zip Code 47130, or fax to 1-877-258-9584.

Specialty Medications

Specialty prescriptions are managed by Costco Specialty Pharmacy. Learn more about how to set up, refill, and track your specialty drug prescriptions.

Your provider can e-prescribe to Costco Specialty Pharmacy #1710 Zip Code 53717, or fax to 1-855-213-0125.

Tip: When creating your Costco Pharmacy account and when your doctor prescribes, spell your name exactly as it appears on your health insurance ID card—including hyphens or special characters—to ensure your prescriptions match correctly.

Accessing Dependent Information

Both Capital Rx and Costco Pharmacy follow specific guidelines to safeguard dependents’ protected health information. Learn more about these guidelines and how you can access pharmacy benefits information for your dependents.

Johns Hopkins Outpatient Pharmacy

Available as an alternative to Costco Mail Order and Specialty Pharmacy, Johns Hopkins Outpatient Pharmacy (JHOP) offers a full inventory of standard, specialty, and over-the-counter medications, as well as the convenience of discharge medication processing. You can fill your 90-day supply maintenance medications through one of its outpatient pharmacies or use their mail-order services. Here are the JHOP Locations. To transfer your prescriptions to JHOP, call their service center at 888-264-0393.

Your cost for prescription drugs under the medical plans for faculty and staff:

	CareFirst High Deductible Health Plan (HDHP)	CareFirst Core PPO Plan	CareFirst Enhanced PPO Plan
Out-of-pocket costs	After meeting the plan’s medical deductible, you pay a copay or coinsurance amount per prescription	No deductible; you pay a copay or coinsurance depending on the type of drug	No deductible; you pay a copay or coinsurance depending on the type of drug
Prescription drugs: retail (up to 30-day supply)	Generic: $10 copay after deductible	Generic: $10 copay	Generic: $10 copay
	Formulary brand name: You pay 20% after deductible	Formulary brand name: You pay 20% (max $60)	Formulary brand name: You pay 10% (max $30)
	Non-formulary brand: You pay 25% after deductible	Non-formulary brand: You pay 25% (max $125)	Non-formulary brand: You pay 10% (max $75)
Prescription drugs: mail order (up to 90-day supply)	Generic: $25 after deductible	Generic: $20 copay	Generic: $20 copay
	Formulary brand name: You pay 20% after deductible	Formulary brand name: You pay 20% (max $120)	Formulary brand name: You pay 10% (max $60)
	Non-formulary brand: You pay 25% after deductible	Non-formulary brand: You pay 25% (max $250)	Non-formulary brand: You pay 10% (max $150)

Your cost for prescription drugs under the medical plans for LiUNA bargaining unit members:

	CareFirst Core PPO Plan	LiUNA BU CareFirst Network Only Plan	Kaiser Permanente HMO Plan
Prescription drugs managed by	Capital Rx	Capital Rx	Kaiser Permanente
Prescription drugs: retail (up to 30-day supply)	Generic: $10 copay	Generic: $10 copay	Generic: $7 / $10 copay (Kaiser / community pharmacies)
	Formulary brand name: You pay 20% ($30 min/$45 max)	Formulary brand name: You pay 20% ($30 min/$45 max)	Formulary brand name: $15 / $20 copay (Kaiser / community pharmacies)
	Non-formulary brand: You pay 25% ($60 min/$100 max)	Non-formulary brand: You pay 25% ($60 min/$100 max)	Non-formulary brand: $30 / $35 copay (Kaiser / community pharmacies)
Prescription drugs: mail order (up to 90-day supply) You also can fill prescriptions through one of the Johns Hopkins Outpatient Pharmacies or use their mail-order services.	Generic: $25 copay	Generic: $25 copay	Generic: $14 copay
	Formulary brand name: $75 copay	Formulary brand name: $75 copay	Formulary brand name: $30 copay
	Non-formulary brand: $150 copay	Non-formulary brand: $150 copay	Non-formulary brand: $60 copay

Prescription drugs and prescription drug claims for employees and their family members enrolled in the Kaiser Permanente HMO Plan are managed by Kaiser Permanente.

The University wants to help you use your prescription drug benefits wisely. The following programs will help you get the best medication at the right price:

• Mandatory generics – Generic drugs are lower-cost medications that are just as effective as brand-name drugs. You may pay more if you purchase a brand medicine when a generic-equivalent drug is available. You will pay the generic copay plus the difference in cost between the brand and generic drug.
• Prior authorization – Some medications will require prior authorization, or review and approval, before the plan will cover the cost. This is to ensure that the medication you receive is safe and effective for your situation. Prior authorization may be required for drugs that:
  • Have potentially dangerous side effects
  • Are harmful when combined with other drugs
  • Are often misused
  • Are prescribed when less expensive drugs are as effective
  • Are specialty medications that are meant to treat very specific diseases and require appropriate clinical markers (biological characteristics that help assess whether a drug will be effective in a specific patient)
• Step therapy – Step therapy requires you to try lower-cost (often generic) medications first, before “stepping up” to medications that cost more. If your medication requires step therapy, you will be obligated to try a step-one medication before stepping up to a step-two (or step-three) medication. Step-one alternative medications are proven to be safe, effective, and affordable, and can provide the same health benefits as more expensive medications, at a lower cost to you.
• Quantity limitations – To reduce waste and ensure that the most cost-effective product strength is prescribed, all medications will be subject to quantity limitations (as determined by the FDA). If your treatment exceeds the quantity limitation of your drug, your prescription will require further authorization.

If your medication needs approval, either you or your pharmacist will need to let your doctor know. Your doctor might switch your therapy to another drug that does not require prior authorization, step therapy, or quantity limitations, by calling Capital Rx or Kaiser Permanente to start the approval process.