Health Plan Information

To use the Find a Doctor tool, log in or select the Guest option. Enter your zip code and then select a network. Choose All Plans, then Medical from the drop down list. You will then see an option to search Primary Care Providers. This tool will show you primary care physicians who are in-network for CareFirst's Blue Cross Blue Shield coverage, with their specialty, whether they are accepting new patients, what languages they speak, where they went to medical school, and their practice address and phone number. Learn more about selecting a doctor.

Members may seek specialty care and behavioral healthcare from in-network or out-of-network providers. Be sure to talk with your primary care provider about your preferences. Depending on your plan, you may need a referral from your primary care provider in order to access specialty care. Refer to your member benefit booklet for details.

Members can log in to My Account to find participating in-network providers and facilities with the Find a Doctor tool. Certain nonemergency hospital and other medical services require preapproval from CareFirst. Customer Service can assist you with the directory or help you locate a practitioner or facility within a specific geographic area.

Members have 24/7 access to our free nurse advice line for help when you can’t reach your PCP or are unsure about your symptoms.

Members are encouraged to download CareFirst’s free mobile app to locate providers, urgent care centers, emergency rooms and more, 24/7.

HMO plans: A health maintenance organization (HMO) plan is a network of doctors, hospitals and other healthcare providers who agree to provide care at a reduced rate within your plan’s service area (for instance, CareFirst’s service area covers Maryland, Washington, D.C. and Northern Virginia). An HMO will only pay for care from healthcare providers in your plan’s HMO network. However, when traveling outside your plan’s service area, an HMO provides coverage for emergency care.  

PPO plans: Like an HMO, a preferred provider organization (PPO) plan is a network of doctors, hospitals and other healthcare providers who agree to provide care at a certain rate. Unlike an HMO, you are not limited to providers who are in network. With a PPO plan, you can receive care from any provider—in or out of network. This means when you’re traveling out of area, you can receive care wherever you are.

Please note when you receive care from an in-network (participating) or preferred CareFirst provider, the provider will file your health insurance claim. CareFirst pays all participating and preferred healthcare providers directly. You are only responsible for any out-of-pocket expenses (non-covered services, deductibles, copays or coinsurance). If the provider does not participate with a BlueCross BlueShield plan, you must pay at the time of service.

When you receive services from a provider or pharmacy that participates in the CareFirst BlueCross BlueShield or CareFirst BlueChoice network, the provider’s office or the pharmacy will submit claims for you. However, if you visit a non-participating provider or non-participating pharmacy for service, you must submit the claim yourself. You can submit your claim one of two ways:

• Mail your claim form
  To print and mail your claim form, log in to My Account, select the My Documents tab, choose Forms. Choose the form for your type of claim and fill in the required information. Then, mail the form using the directions included. If you do not have internet access, you may request a paper claim form by calling Member Services at the telephone number on the back of your member ID card.
• Submit your claim form online
  CareFirst also offers online claims submission for medical, dental and behavioral health claims. From your computer or mobile device, log in to My Account and select Claims. Choose Submit a Claim Online, then Start New Claim. Enter the requested information, upload the required documents and submit.

The medical review process includes, but is not limited to:

• Preservice review
  The preservice review serves as a check to assure that members receive the right service in the right setting at the right time. Requests for review include high-cost, complex inpatient, experimental, cosmetic, and outpatient services. The preservice review also helps ensure services are provided by in-network providers. Your doctor must initiate your authorization request.
• Urgent review
  A hospital/facility will notify CareFirst when a member is admitted and the approved number of days of the initial admission. All admissions are reviewed and categorized by severity level. The urgent review process continues until the member is approved to go home. A concurrent review determines if the member needs to extend their stay in a hospital/facility. Concurrent review decisions are made within 24 hours. Adverse decisions are made by the medical director/physician reviewer.
• Post-service review
  Members may be eligible for a post-service review. CareFirst collaborates with facility administrators, medical clinicians and members to determine needs based on medical criteria and member benefits. Decisions must be made within 30 calendar days of the initial request. Adverse decisions are made by the medical director/physician reviewer.

To ensure you are receiving the most appropriate medication for your condition(s), additional information may be required from your doctor before filling certain prescriptions. In those instances, CareFirst will work with you and your doctor to manage the process.

• Generics are dispensed when available unless your provider determines that a brand-name drug is necessary for your overall health. There may be cost-sharing implications for choosing non-preferred brand medications when generics are available. You should always check with your doctor to make sure a generic alternative is right for you.
• Prior authorization from CareFirst is required before you fill prescriptions for certain drugs. Your doctor may need to provide some of your medical history or laboratory tests to determine if these medications are appropriate. Without prior authorization from CareFirst, your drugs may not be covered.
• Step therapy is a program designed to help you save on prescription drug costs. It ensures you receive a lower-cost but equally effective drug before “stepping up” to more expensive medication(s). If your doctor believes your treatment plan should begin with a more expensive drug, they may need to submit an authorization request to have it approved before it can be covered.
• Quantity limits have been placed on the use of selected drugs for quality or safety reasons. Limits may be placed on the amount of the drug covered per prescription or for a defined period of time.

Exception Requests

To see whether your drug is excluded or requires prior authorization, step therapy or quantity limits, visit the Drug Search page and select your plan year to find your specific formulary.

If the drug does not meet the needs of your particular condition or is excluded from the formulary, your doctor can request an exception.

To ensure our members have access to safe and effective care, CareFirst reviews new developments in medical technology and new applications of existing technology for inclusion as a covered benefit. We evaluate new and existing technologies for medical and behavioral health procedures, medications and devices through a formal review process. We also consider input from medical professionals, government agencies and published articles about scientific studies.

If you have concerns regarding a decision that adversely affect coverage, such as a denial, a reduction of benefits, or a denial of authorization for services, you may call the Member Services telephone number on the back of your member ID card. A representative can assist you with resolving the issue or initiating the appeal process. If needed, language interpretation is available.

If you would like to review the procedure for filing an appeal, visit carefirst.com/appeals. For a printed copy, call Member Services at the telephone number on the back of your member ID card. In addition, many members have a right to an independent external review of any final appeal or grievance decision. Refer to your Evidence of Coverage for more specific information regarding initiating an external review, a final appeal determination or a complaint.

If you need language assistance or have questions, call the Member Services telephone number on the back of your member ID card.