Prescription Drug Questions

What is a Preferred Drug List (PDL)?
The Preferred Drug List is a list of the most commonly prescribed generic drugs and preferred brand-name drugs. The preferred drug list is subject to change and is periodically updated. Generic drugs are covered at the Tier 1 co-pay level. Preferred brand-name drugs are covered at the Tier 2 co-pay level.

Other brand-name drugs are covered by your plan, but are considered non-preferred. Non-preferred brand name drugs are covered at the Tier 3 co-pay level.

How to use the Preferred Drug List?
Share this list with your doctor. Ask your doctor to prescribe generic drugs whenever possible. You will pay the lowest co-pay when using generics. If a generic isn't available, ask your doctor to consider prescribing a brand-name drug from this list. These preferred brand-name drugs are available at a lower co-pay than non-preferred brand-name drugs.

What is a 3-Tier Prescription Drug Plan?
The “tiers” refer to the co-pay level for the drug. The costs shown below are for MHIP members. MHIP+ may have lower costs for some drugs.

Tier 1 - Generic drugs, $20 for a 31-day supply/$40 for a 90-day supply
Tier 2 - Preferred brand-name drugs, $27 for a 31-day supply/$54 for a 90-day supply + the difference between the piece of the brand name and generic drug.
Tier 3 - Non-preferred brand-name drugs, $47 for a 31-day supply/$94 for a 90-day supply + the difference between the piece of the brand name and generic drug.

What types of medications are covered under my pharmacy benefit?
The Preferred Drug List includes most generic and some preferred brand-name drugs that have been approved by the Food and Drug Administration (FDA).

What are generic drugs?
Generic drugs are reviewed and approved by the Food and Drug Administration (FDA). They have the same active ingredients and come in the same strength and dosage form as their brand-name counterparts. You can expect the generic drug to produce the same effects as the comparable brand-name drug.

For additional information about generic drugs, you can visit the generic drug section of CareFirst BlueCross Blue Shield’s Web site.

What is the difference between a brand-name and a generic drug?
A pharmaceutical manufacturer markets a brand-name drug under a specific trade name. A generic drug has the same active ingredients and the same dosage form as a brand-name drug. The generic drug is therapeutically equivalent to the brand-name drug but is sold under its chemical or "generic" name.

For additional information about generic drugs, you can visit the generic drug section of CareFirst BlueCross Blue Shield’s Web site.

Do all drugs have a generic equivalent?
Generics are available for many drugs, but not for the newest drugs approved by the FDA. New drugs are granted an exclusive patent, but once the patent expires, any pharmaceutical company can manufacture a generic version, with FDA approval. In a very few instances, a brand-name drug may be too technically difficult, or too unique, for a generic version to be produced.

Do I have to use a generic if it is available?
No, however, you will pay the lowest co-pay for the generic drug. In some cases you will be allowed to receive the brand-name drug at the lower co-pay if the generic equivalent is not covered under the Preferred Drug List. For example, Lanoxin and Dilantin are only covered as brand-name drugs, but the generic co-pay will apply.

If a generic drug is available, but a brand-name drug is dispensed you will pay the applicable co-pay amount, plus the price difference between the brand-name and generic drug.

Do I have a choice of pharmacies?
Yes. To find a pharmacy in your area you can do one of the following:

You can use our online pharmacy locator.
You can also use non-participating pharmacies, but you will have to pay the full cost of the drug at the time of purchase and submit an out-of-network claim for reimbursement. An Out-Of-Network Claim Form is available on the Pharmacy Services page of this Web site. Reimbursement will be paid at the allowable amount under your prescription benefit plan.

What is a Quantity Limit (QL)?
Certain prescription drugs can only be prescribed in limited quantities. The quantity limit (QL) list includes dosage limits for some drugs and is based on current medical literature and input from a committee of doctors and pharmacists. The QL list is available on the Pharmacy Services page of this Web site. The QL list is subject to change and is periodically updated.

What is pre-authorization (PA)?
Maryland Health Insurance Plan requires doctors to obtain pre-authorization (PA) before writing a prescription for some drugs. The Pre-Authorization Form and the Pre-Authorization List of drugs requiring PA is available on the Pharmacy Services page of this Web site. The PA list is subject to change and is periodically updated.

What do I do if I am at the pharmacy and am told that my medication requires a pre-authorization (PA) but none was requested in advance?
Have your pharmacist call your physician to start the pre-authorization (PA) process. The request will be approved or denied within 48 hours after the physician provides information to CareFirst. The Pre-Authorization Form is available on the Pharmacy Services page of this Web site.

MHIP is administered by CareFirst BlueCross BlueShield and CareFirst BlueChoice, independent licensees of the BlueCross BlueShield Association.