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, or 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 Optum Home Delivery on the Capital Rx website. If you prefer to use JHOP, call their service center directly to arrange mail-order delivery.

Specialty Medications

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

If you prefer that JHOP manages your specialty medication rather than Optum Specialty Pharmacy, call 888-264-0393.

Accessing Dependent Information

Both Capital Rx and Optum Pharmacy follow specific guidelines to safeguard dependents’ protected health information. To learn more about these guidelines and how you can access pharmacy benefits information for your dependents, click here.

Johns Hopkins Outpatient Pharmacy

Available as an alternative to Optum Home Delivery for mail-order and prescription services, 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.

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.