BCBS AFFILIATEMD, DC, VAPBM: CVS Caremark

CareFirst BCBS (MD, DC, Northern VA) Prior Authorization Guide

Submit prior authorization requests and appeal denials with CareFirst BCBS. Phone numbers, fax numbers, appeal deadlines, step therapy override rights, and clinical documentation tips for MD, DC, VA providers.

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Prior Authorization Contacts

PA PHONE

1-866-773-2884

PA FAX

1-866-209-9632

TURNAROUND

15 days standard, 72h expedited

TIMELY FILING

180 days

APPEALS MAILING ADDRESS

CareFirst BCBS, Attn: Appeals, PO Box 14114, Lexington, KY 40512

Common Denial Reasons

⚠ CareFirst Medical Policy criteria not met
⚠ Step therapy required
⚠ Non-preferred formulary
⚠ Site of care

Step Therapy Requirements & Override Rights

CareFirst serves MD, DC, and Northern VA. Maryland HB 1370 (2017) requires step therapy override provisions. DC has similar protections. For biologics, typically requires 3-month conventional DMARD trial.

Tips for CareFirst BCBS Submissions

1. CareFirst covers MD, DC, and Northern Virginia
2. Maryland HB 1370 provides step therapy override rights
3. Submit via CareFirst Direct
4. CVS Caremark handles pharmacy

External Review Authority

If CareFirst BCBS denies your final internal appeal, you have the right to request an external review through: Maryland Insurance Administration / DC Department of Insurance, Securities and Banking.

External review decisions are binding on the insurer.