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Pharmacy Benefits (Part D Prescription Drug)

What are Medicare Part D Covered Drugs?

A Part D covered drug is available only by prescription, approved by the Food and Drug Administration (FDA) and used and sold in the United States. These medications are listed on the plan’s formulary.

Medicare covered Part D drugs include:

  • Prescription drugs
  • Biological products
  • Insulin as defined by the Centers for Medicare & Medicaid Services (CMS)
  • Certain vaccines
  • Medical supplies associated with the injection of insulin (syringes, needles, alcohol swabs, and gauze)

What are Medicare Part B Covered Drugs?

Medicare Part B covered drugs include a limited number of prescription drugs such as those you get in a hospital outpatient department under certain circumstances, injected drugs you get in a doctor's office, certain oral cancer drugs, and drugs used with some types of Durable Medical Equipment (like a nebulizer or infusion pump). Medicare Part B drugs include, but are not limited to, the following types of drugs.

  • Durable Medical Equipment (DME) Supply Drugs such as: nebulizers, external or implantable pumps
  • Hemophilia clotting factors: Self-administered clotting factors if you have hemophilia
  • Immunosuppressive Drugs: Immunosuppressive drug therapy a beneficiary receives after a Medicare-covered organ transplant
  • Oral Anti-Cancer and Anti-Nausea Drugs
  • Pneumococcal and Hepatitis B vaccines and administration

For additional information on Medicare Part B covered drugs, refer to your Evidence of Coverage.

For your safety, the number of opioid drug(s) to treat your pain will be limited based on recommendations from the U.S. Centers for Disease Control and Prevention (CDC). You may see a reduced quantity of your opioid prescription(s) when you get them filled at a network pharmacy. The quantity you receive will vary based on the opioid drug your provider has prescribed. Any Opioid prescriptions for larger quantities greater than recommended by the CDC will require a prior authorization. There are additional limitations depending on whether you have used an opioid drug previously or whether you are using the opioid drug for short-term or long-term use for pain relief.

For certain kinds of drugs, you can use CareFirst Medicare Advantage’s network mail-order which is called ReadyFill at Mail®. Most times, the drugs provided through mail order are drugs that you take on a regular basis, for a chronic or long-term medical condition. For mail-order, you can get prescription drugs shipped to your home through the network mail-order delivery program. Mail-order drugs usually arrive within 10 days. Please call Part D Member Services at 1-844-786-6762 (TTY users please call 711), 24-hours a day, 7 days a week, if you do not receive your mail-order drugs within this timeframe. CareFirst Medicare Advantage members please call the phone number listed on the back of your member ID card.