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January 2019
CareFirst Preferred Drug List - Formulary 2
The CareFirst Preferred Drug List is a guide to help you
identify products that are both clinically appropriate and
cost-effective. These drugs are selected for their quality,
effectiveness and cost based on current medical research and input
from a committee of doctors and pharmacies who serve the CareFirst
region. The drugs on the Preferred Drug List are grouped into
therapeutic categories for representational purposes only. This
list represents brand-name drugs in CAPS, branded generics in
upper- and lowercase Italics, and generic products in lowercase
italics. Generic drugs should be considered the first line of
prescribing; however, if there is no generic available, there may
be more than one brand-name drug to treat a condition. Please note
this list does not include all covered drugs and is subject to
change.
PLAN MEMBER Ask your doctor to consider prescribing, when
appropriate, a preferred drug from this list. Take this list along
when you or a covered family member sees a doctor. Please note:
• Our Pharmacy Benefit Manager, CVS Caremark®,1 may contact your
doctor after receiving your prescription to request consideration
of a generic equivalent or preferred brand drug, which may lower
your out-of-pocket costs.
• In most cases, when a generic becomes available for a
brand-name drug, the brand-name drug is moved to the non-preferred
brand category, which may have a higher cost-share.
• Check your specific prescription benefit plan design to
determine your cost-share for a specific product on this list.
• Your specific prescription benefit plan design may not cover
certain products or categories, regardless of their appearance in
this document. Products recently approved by the U.S. Food and Drug
Administration (FDA) may not be covered upon release to the
market.
• To learn more about your specific drug benefit, log into My
Account at www.carefirst.com/myaccount and click on Drug &
Pharmacy Resources under Quick Links or call CareFirst Pharmacy
Services at 800-241-3371.
HEALTH CARE PROVIDER As a way to help manage health care costs,
authorize generic substitution whenever possible. If you believe a
brand-name product is necessary, consider prescribing a brand name
on this list. Please note:
• Generics should be considered the first line of prescribing. •
This drug list represents a summary of prescription coverage.
It does not include all covered drugs and does not guarantee
coverage. The member’s specific prescription benefit plan design
may not cover certain products or categories, regardless of their
appearance in this document. Products recently approved by the FDA
may not be covered upon release to the market.
• The member's prescription benefit plan may have a different
copay/coinsurance for specific products on the list.
• Unless specifically indicated, drug list products will include
all dosage forms.
ANALGESICS
§ NSAIDs diclofenac sodium meloxicam naproxen § NSAIDs,
COMBINATIONS diclofenac sodium-misoprostol § NSAIDs, TOPICAL
diclofenac sodium gel 1% diclofenac sodium solution § COX-2
INHIBITORS celecoxib § GOUT allopurinol colchicine tablet
probenecid COLCRYS ULORIC
§ OPIOID ANALGESICS codeine-acetaminophen fentanyl transdermal
fentanyl transmucosal lozenge hydrocodone-acetaminophen
hydromorphone hydromorphone ext-rel methadone morphine morphine
ext-rel morphine suppository oxycodone oxycodone-acetaminophen
tramadol tramadol ext-rel ABSTRAL BELBUCA BUTRANS EMBEDA HYSINGLA
ER NUCYNTA NUCYNTA ER OXYCONTIN SUBSYS
ANTI-INFECTIVES
ANTIBACTERIALS § CEPHALOSPORINS cefdinir cefprozil cefuroxime
axetil cephalexin SUPRAX § ERYTHROMYCINS / MACROLIDES azithromycin
clarithromycin clarithromycin ext-rel erythromycins DIFICID §
FLUOROQUINOLONES ciprofloxacin ciprofloxacin ext-rel levofloxacin
moxifloxacin § PENICILLINS amoxicillin
amoxicillin-clavulanate dicloxacillin penicillin VK §
TETRACYCLINES doxycycline hyclate minocycline tetracycline §
ANTIFUNGALS fluconazole itraconazole terbinafine tablet
ANTIRETROVIRAL AGENTS § ANTIRETROVIRAL COMBINATIONS
abacavir-lamivudine ATRIPLA BIKTARVY COMPLERA DESCOVY EVOTAZ
GENVOYA
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ODEFSEY PREZCOBIX STRIBILD TRIUMEQ TRUVADA INTEGRASE INHIBITORS
ISENTRESS TIVICAY § NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS
abacavir tablet lamivudine § PROTEASE INHIBITORS NORVIR PREZISTA
REYATAZ ANTIVIRALS § CYTOMEGALOVIRUS AGENTS valganciclovir §
HEPATITIS B AGENTS VEMLIDY § HEPATITIS C AGENTS ribavirin EPCLUSA
(genotypes 1, 2, 3, 4, 5, 6) HARVONI (genotypes 1, 4, 5, 6) VOSEVI
2 § HERPES AGENTS acyclovir valacyclovir § INFLUENZA AGENTS
oseltamivir RELENZA § MISCELLANEOUS clindamycin ivermectin
linezolid metronidazole nitrofurantoin
sulfamethoxazole-trimethoprim EMVERM XIFAXAN 550 MG
ANTINEOPLASTIC AGENTS
HORMONAL ANTINEOPLASTIC AGENTS § ANTIANDROGENS bicalutamide
ERLEADA XTANDI ZYTIGA § KINASE INHIBITORS imatinib mesylate BOSULIF
CABOMETYX IBRANCE IRESSA KISQALI KISQALI FEMARA CO-PACK RYDAPT
SPRYCEL
§ MISCELLANEOUS ODOMZO VISTOGARD ZEJULA
CARDIOVASCULAR
§ ACE INHIBITORS fosinopril lisinopril quinapril ramipril § ACE
INHIBITOR / DIURETIC COMBINATIONS fosinopril-hydrochlorothiazide
lisinopril-hydrochlorothiazide quinapril-hydrochlorothiazide §
ANGIOTENSIN II RECEPTOR ANTAGONISTS / DIURETIC COMBINATIONS
candesartan / candesartan-
hydrochlorothiazide eprosartan irbesartan / irbesartan-
hydrochlorothiazide losartan / losartan-
hydrochlorothiazide olmesartan / olmesartan-
hydrochlorothiazide telmisartan / telmisartan-
hydrochlorothiazide valsartan / valsartan-
hydrochlorothiazide § ANGIOTENSIN II RECEPTOR ANTAGONIST /
CALCIUM CHANNEL BLOCKER COMBINATIONS amlodipine-olmesartan
amlodipine-telmisartan amlodipine-valsartan § ANGIOTENSIN II
RECEPTOR ANTAGONIST / CALCIUM CHANNEL BLOCKER / DIURETIC
COMBINATIONS amlodipine-valsartan-
hydrochlorothiazide olmesartan-amlodipine-
hydrochlorothiazide § ANTIARRHYTHMICS sotalol MULTAQ
ANTILIPEMICS § BILE ACID RESINS cholestyramine colesevelam §
CHOLESTEROL ABSORPTION INHIBITORS ezetimibe § FIBRATES fenofibrate
fenofibric acid § HMG-CoA REDUCTASE INHIBITORS / COMBINATIONS
atorvastatin
ezetimibe-simvastatin fluvastatin lovastatin pravastatin
rosuvastatin simvastatin § NIACINS niacin ext-rel § OMEGA-3 FATTY
ACIDS omega-3 acid ethyl esters VASCEPA PCSK9 INHIBITORS REPATHA §
BETA-BLOCKERS atenolol carvedilol metoprolol succinate ext-rel
metoprolol tartrate nadolol pindolol propranolol propranolol
ext-rel BYSTOLIC COREG CR § CALCIUM CHANNEL BLOCKERS amlodipine
diltiazem ext-rel 3 nifedipine ext-rel verapamil ext-rel § CALCIUM
CHANNEL BLOCKER / ANTILIPEMIC COMBINATIONS amlodipine-atorvastatin
§ DIGITALIS GLYCOSIDES digoxin DIRECT RENIN INHIBITORS / DIURETIC
COMBINATIONS TEKTURNA / TEKTURNA HCT § DIURETICS amiloride
furosemide hydrochlorothiazide metolazone
spironolactone-hydrochlorothiazide torsemide
triamterene-hydrochlorothiazide HEART FAILURE BIDIL CORLANOR
ENTRESTO § NITRATES nitroglycerin lingual spray nitroglycerin
sublingual PULMONARY ARTERIAL HYPERTENSION ENDOTHELIN RECEPTOR
ANTAGONISTS LETAIRIS OPSUMIT TRACLEER
§ PHOSPHODIESTERASE INHIBITORS sildenafil PROSTACYCLIN RECEPTOR
AGONISTS UPTRAVI § PROSTAGLANDIN VASODILATORS ORENITRAM SOLUBLE
GUANYLATE CYCLASE STIMULATORS ADEMPAS § MISCELLANEOUS RANEXA
CENTRAL NERVOUS SYSTEM
§ ANTICONVULSANTS carbamazepine carbamazepine ext-rel diazepam
rectal gel divalproex sodium divalproex sodium ext-rel ethosuximide
gabapentin lamotrigine lamotrigine ext-rel levetiracetam
levetiracetam ext-rel oxcarbazepine phenobarbital phenytoin
phenytoin sodium extended primidone tiagabine topiramate valproic
acid zonisamide FYCOMPA OXTELLAR XR TROKENDI XR VIMPAT §
ANTIDEMENTIA donepezil galantamine galantamine ext-rel memantine
rivastigmine rivastigmine transdermal NAMZARIC ANTIDEPRESSANTS §
SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs) citalopram
escitalopram fluoxetine paroxetine HCl paroxetine HCl ext-rel
sertraline TRINTELLIX VIIBRYD § SEROTONIN NOREPINEPHRINE REUPTAKE
INHIBITORS (SNRIs) desvenlafaxine ext-rel duloxetine
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venlafaxine venlafaxine ext-rel capsule § MISCELLANEOUS AGENTS
bupropion bupropion ext-rel mirtazapine trazodone §
ANTIPARKINSONIAN AGENTS amantadine carbidopa-levodopa
carbidopa-levodopa ext-rel carbidopa-levodopa-entacapone entacapone
pramipexole pramipexole ext-rel rasagiline ropinirole ropinirole
ext-rel selegiline NEUPRO ANTIPSYCHOTICS § ATYPICALS aripiprazole
clozapine olanzapine quetiapine quetiapine ext-rel risperidone
ziprasidone ABILIFY MAINTENA ARISTADA LATUDA VRAYLAR § ATTENTION
DEFICIT HYPERACTIVITY DISORDER amphetamine-dextroamphetamine
mixed salts amphetamine-dextroamphetamine
mixed salts ext-rel atomoxetine guanfacine ext-rel
methylphenidate methylphenidate ext-rel MYDAYIS VYVANSE
FIBROMYALGIA LYRICA SAVELLA § HUNTINGTON'S DISEASE AGENTS
tetrabenazine AUSTEDO HYPNOTICS § NONBENZODIAZEPINES eszopiclone
zolpidem zolpidem ext-rel zolpidem sublingual BELSOMRA TRICYCLICS
SILENOR
MIGRAINE § ERGOTAMINE DERIVATIVES ergotamine-caffeine MONOCLONAL
ANTIBODIES AJOVY EMGALITY § SELECTIVE SEROTONIN AGONISTS eletriptan
naratriptan rizatriptan sumatriptan zolmitriptan ONZETRA XSAIL
ZEMBRACE SYMTOUCH ZOMIG NASAL SPRAY SELECTIVE SEROTONIN AGONIST /
NONSTEROIDAL ANTI-INFLAMMATORY DRUG (NSAID) COMBINATIONS TREXIMET §
MULTIPLE SCLEROSIS AGENTS glatiramer AUBAGIO BETASERON COPAXONE
GILENYA REBIF TECFIDERA § MUSCULOSKELETAL THERAPY AGENTS
cyclobenzaprine § NARCOLEPSY armodafinil POSTHERPETIC NEURALGIA
(PHN) GRALISE PSYCHOTHERAPEUTIC - MISCELLANEOUS § OPIOID
ANTAGONISTS naloxone injection NARCAN NASAL SPRAY § PARTIAL OPIOID
AGONIST / OPIOID ANTAGONIST COMBINATIONS buprenorphine-naloxone
sublingual tablet SUBOXONE FILM ZUBSOLV PSEUDOBULBAR AFFECT
AGENTS NUEDEXTA § VASOMOTOR SYMPTOM AGENTS paroxetine mesylate
ENDOCRINE AND METABOLIC
ACROMEGALY SOMAVERT § ANDROGENS testosterone gel
testosterone solution ANDRODERM ANDROGEL 1.62% ANTIDIABETICS
AMYLIN ANALOGS SYMLINPEN § BIGUANIDES metformin metformin ext-rel 4
§ BIGUANIDE / SULFONYLUREA COMBINATIONS glipizide-metformin
DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS JANUVIA DIPEPTIDYL
PEPTIDASE-4 (DPP-4) INHIBITOR / BIGUANIDE COMBINATIONS JANUMET
JANUMET XR INCRETIN MIMETIC AGENTS OZEMPIC TRULICITY VICTOZA
INCRETIN MIMETIC AGENT / INSULIN COMBINATIONS SOLIQUA INSULINS
BASAGLAR FIASP HUMULIN R U-500 LEVEMIR NOVOLIN 70/30 NOVOLIN N
NOVOLIN R NOVOLOG NOVOLOG MIX 70/30 TRESIBA § INSULIN SENSITIZERS
pioglitazone § INSULIN SENSITIZER / BIGUANIDE COMBINATIONS
pioglitazone-metformin § INSULIN SENSITIZER / SULFONYLUREA
COMBINATIONS pioglitazone-glimepiride § MEGLITINIDES nateglinide
repaglinide SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS
FARXIGA JARDIANCE
SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITOR / BIGUANIDE
COMBINATIONS SYNJARDY SYNJARDY XR XIGDUO XR SODIUM-GLUCOSE
CO-TRANSPORTER 2 (SGLT2) INHIBITOR / DIPEPTIDYL PEPTIDASE-4 (DPP-4)
INHIBITOR COMBINATIONS GLYXAMBI QTERN § SULFONYLUREAS glimepiride
glipizide glipizide ext-rel SUPPLIES ACCU-CHEK AVIVA PLUS
STRIPS AND KITS 5 ACCU-CHEK COMPACT PLUS
STRIPS AND KITS 5 ACCU-CHEK GUIDE
STRIPS AND KITS 5 ACCU-CHEK SMARTVIEW
STRIPS AND KITS 5 BD ULTRAFINE INSULIN
SYRINGES AND NEEDLES DEXCOM CONTINUOUS GLUCOSE
MONITORING SYSTEM * ANTIOBESITY INJECTABLE SAXENDA ORAL BELVIQ
BELVIQ XR CALCIUM REGULATORS § BISPHOSPHONATES alendronate
ibandronate risedronate § CALCITONINS calcitonin-salmon PARATHYROID
HORMONES FORTEO TYMLOS § CARNITINE DEFICIENCY AGENTS levocarnitine
CONTRACEPTIVES § MONOPHASIC ethinyl estradiol-drospirenone ethinyl
estradiol-drospirenone-
levomefolate ethinyl estradiol-norethindrone
acetate ethinyl estradiol-norethindrone
acetate-iron SAFYRAL
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§ BIPHASIC LO LOESTRIN FE § TRIPHASIC ethinyl
estradiol-norgestimate FOUR PHASE NATAZIA § EXTENDED CYCLE ethinyl
estradiol-levonorgestrel § TRANSDERMAL ethinyl
estradiol-norelgestromin VAGINAL NUVARING ESTROGENS § ORAL
estradiol estropipate PREMARIN § TRANSDERMAL estradiol DIVIGEL
EVAMIST MINIVELLE § VAGINAL estradiol ESTRACE CREAM ESTRING
PREMARIN CREAM ESTROGEN / PROGESTINS § ORAL estradiol-norethindrone
PREMPHASE PREMPRO TRANSDERMAL CLIMARA PRO COMBIPATCH ESTROGEN /
SELECTIVE ESTROGEN RECEPTOR MODULATOR COMBINATIONS DUAVEE FERTILITY
REGULATORS GNRH / LHRH ANTAGONISTS CETROTIDE OVULATION STIMULANTS,
GONADOTROPINS GONAL-F OVIDREL GAUCHER DISEASE CERDELGA §
GLUCOCORTICOIDS dexamethasone methylprednisolone prednisolone
solution prednisone GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT
GLUCAGON EMERGENCY KIT
HEREDITARY TYROSINEMIA TYPE 1 AGENTS ORFADIN HUMAN GROWTH
HORMONES HUMATROPE § PHOSPHATE BINDER AGENTS calcium acetate
lanthanum carbonate sevelamer carbonate PHOSLYRA VELPHORO
POTASSIUM-REMOVING AGENTS VELTASSA PROGESTINS § ORAL
medroxyprogesterone megestrol acetate progesterone, micronized
VAGINAL CRINONE ENDOMETRIN § SELECTIVE ESTROGEN RECEPTOR MODULATORS
raloxifene OSPHENA § THYROID SUPPLEMENTS levothyroxine
SYNTHROID
GASTROINTESTINAL
§ ANTIEMETICS dronabinol granisetron meclizine metoclopramide
ondansetron prochlorperazine promethazine trimethobenzamide
DICLEGIS SANCUSO VARUBI § H2 RECEPTOR ANTAGONISTS ranitidine
INFLAMMATORY BOWEL DISEASE § ORAL AGENTS balsalazide budesonide
capsule sulfasalazine sulfasalazine delayed-rel APRISO LIALDA
PENTASA UCERIS § RECTAL AGENTS hydrocortisone enema mesalamine
rectal suspension CANASA CORTIFOAM
§ IRRITABLE BOWEL SYNDROME alosetron AMITIZA LINZESS VIBERZI §
LAXATIVES lactulose peg 3350-electrolytes SUPREP OPIOID-INDUCED
CONSTIPATION MOVANTIK PANCREATIC ENZYMES CREON VIOKACE ZENPEP §
PROTON PUMP INHIBITORS esomeprazole lansoprazole omeprazole
pantoprazole DEXILANT § STEROIDS, RECTAL PROCTOFOAM-HC § ULCER
THERAPY COMBINATIONS PYLERA
GENITOURINARY
§ BENIGN PROSTATIC HYPERPLASIA alfuzosin ext-rel doxazosin
dutasteride dutasteride-tamsulosin finasteride tamsulosin terazosin
RAPAFLO ERECTILE DYSFUNCTION ALPROSTADIL AGENTS MUSE §
PHOSPHODIESTERASE INHIBITORS sildenafil CIALIS § URINARY
ANTISPASMODICS darifenacin ext-rel oxybutynin oxybutynin ext-rel
tolterodine tolterodine ext-rel trospium trospium ext-rel MYRBETRIQ
TOVIAZ VESICARE
HEMATOLOGIC
§ ANTICOAGULANTS warfarin ELIQUIS XARELTO
HEMATOPOIETIC GROWTH FACTORS ARANESP PROCRIT ZARXIO HEREDITARY
ANGIOEDEMA RUCONEST § PLATELET AGGREGATION INHIBITORS clopidogrel
dipyridamole ext-rel-aspirin prasugrel BRILINTA
IMMUNOLOGIC AGENTS
ALLERGENIC EXTRACTS GRASTEK ORALAIR RAGWITEK AUTOIMMUNE AGENTS
COSENTYX ENBREL HUMIRA KEVZARA OTEZLA STELARA SUBCUTANEOUS
(Plaque
Psoriasis and Psoriatic Arthritis only) XELJANZ XELJANZ XR §
DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) RASUVO
NUTRITIONAL / SUPPLEMENTS
§ ELECTROLYTES potassium chloride liquid VITAMINS AND MINERALS §
PRENATAL VITAMINS prenatal vitamins CITRANATAL
RESPIRATORY
§ ANAPHYLAXIS TREATMENT AGENTS epinephrine auto-injector EPIPEN
EPIPEN JR § ANTICHOLINERGICS ipratropium inhalation solution
INCRUSE ELLIPTA SPIRIVA ANTICHOLINERGIC / BETA AGONIST COMBINATIONS
§ SHORT ACTING ipratropium-albuterol inhalation
solution COMBIVENT RESPIMAT LONG ACTING ANORO ELLIPTA
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BEVESPI AEROSPHERE STIOLTO RESPIMAT ANTICHOLINERGIC / BETA
AGONIST / STEROID INHALANT COMBINATIONS TRELEGY ELLIPTA BETA
AGONISTS, INHALANTS § SHORT ACTING albuterol inhalation solution
levalbuterol tartrate CFC-free aerosol PROAIR HFA PROAIR RESPICLICK
LONG ACTING Hand-held Active Inhalation SEREVENT STRIVERDI RESPIMAT
Nebulized Passive Inhalation PERFOROMIST § CYSTIC FIBROSIS
tobramycin inhalation solution BETHKIS § LEUKOTRIENE MODULATORS
montelukast zafirlukast zileuton ext-rel § NASAL ANTIHISTAMINES
azelastine olopatadine § NASAL STEROIDS / COMBINATIONS flunisolide
fluticasone mometasone triamcinolone DYMISTA PHOSPHODIESTERASE-4
INHIBITORS DALIRESP PULMONARY FIBROSIS AGENTS ESBRIET OFEV STEROID
/ BETA AGONIST COMBINATIONS ADVAIR BREO ELLIPTA SYMBICORT § STEROID
INHALANTS budesonide inhalation suspension ARNUITY ELLIPTA ASMANEX
FLOVENT DISKUS
FLOVENT HFA PULMICORT FLEXHALER QVAR QVAR REDIHALER
TOPICAL
DERMATOLOGY ACNE § Topical adapalene benzoyl peroxide
clindamycin solution clindamycin-benzoyl peroxide erythromycin
solution erythromycin-benzoyl peroxide tretinoin ATRALIN DIFFERIN
EPIDUO RETIN-A MICRO TAZORAC § ACTINIC KERATOSIS fluorouracil cream
5% fluorouracil solution imiquimod PICATO TOLAK ZYCLARA §
ANTIFUNGALS ciclopirox clotrimazole econazole ketoconazole nystatin
JUBLIA LUZU NAFTIN § ANTIPSORIATICS acitretin calcipotriene
methoxsalen ATOPIC DERMATITIS Injectable DUPIXENT § Topical
tacrolimus ELIDEL EUCRISA CORTICOSTEROIDS § Low Potency desonide
hydrocortisone § Medium Potency clocortolone
hydrocortisone butyrate mometasone triamcinolone § High Potency
desoximetasone fluocinonide § Very High Potency clobetasol cream,
foam, gel, lotion,
ointment, shampoo § ROSACEA metronidazole FINACEA ORACEA
SOOLANTRA MOUTH / THROAT / DENTAL AGENTS PROTECTANTS EPISIL MUGARD
OPHTHALMIC § ANTIALLERGICS azelastine cromolyn sodium olopatadine
LASTACAFT PAZEO § ANTI-INFECTIVES ciprofloxacin erythromycin
gentamicin levofloxacin moxifloxacin ofloxacin sulfacetamide
tobramycin BESIVANCE CILOXAN OINTMENT MOXEZA § ANTI-INFECTIVE /
ANTI-INFLAMMATORY COMBINATIONS neomycin-polymyxin B-bacitracin-
hydrocortisone neomycin-polymyxin B-
dexamethasone tobramycin-dexamethasone TOBRADEX OINTMENT
TOBRADEX ST ZYLET ANTI-INFLAMMATORIES § Nonsteroidal bromfenac
diclofenac ketorolac
ACUVAIL ILEVRO NEVANAC § Steroidal dexamethasone prednisolone
acetate 1% DUREZOL FLAREX FML FORTE FML S.O.P. MAXIDEX PRED MILD
BETA-BLOCKERS § Nonselective timolol maleate solution BETIMOL
Selective BETOPTIC S § CARBONIC ANHYDRASE INHIBITORS dorzolamide
AZOPT § CARBONIC ANHYDRASE INHIBITOR / BETA-BLOCKER COMBINATIONS
dorzolamide-timolol CARBONIC ANHYDRASE INHIBITOR / SYMPATHOMIMETIC
COMBINATIONS SIMBRINZA DRY EYE DISEASE RESTASIS XIIDRA §
PROSTAGLANDINS latanoprost LUMIGAN TRAVATAN Z RHO KINASE INHIBITORS
RHOPRESSA § SYMPATHOMIMETICS brimonidine ALPHAGAN P SYMPATHOMIMETIC
/ BETA-BLOCKER COMBINATIONS COMBIGAN OTIC § ANTI-INFECTIVE /
ANTI-INFLAMMATORY COMBINATIONS CIPRODEX
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QUICK REFERENCE DRUG LIST A abacavir tablet abacavir-lamivudine
ABILIFY MAINTENA ABSTRAL ACCU-CHEK AVIVA PLUS
STRIPS AND KITS 5 ACCU-CHEK COMPACT PLUS
STRIPS AND KITS 5 ACCU-CHEK GUIDE
STRIPS AND KITS 5 ACCU-CHEK SMARTVIEW
STRIPS AND KITS 5 acitretin ACUVAIL acyclovir adapalene ADEMPAS
ADVAIR AJOVY albuterol inhalation solution alendronate alfuzosin
ext-rel allopurinol alosetron ALPHAGAN P amantadine amiloride
AMITIZA amlodipine amlodipine-atorvastatin amlodipine-olmesartan
amlodipine-telmisartan amlodipine-valsartan
amlodipine-valsartan-
hydrochlorothiazide amoxicillin amoxicillin-clavulanate
amphetamine-dextroamphetamine
mixed salts amphetamine-dextroamphetamine
mixed salts ext-rel ANDRODERM ANDROGEL 1.62% ANORO ELLIPTA
APRISO ARANESP aripiprazole ARISTADA armodafinil ARNUITY ELLIPTA
ASMANEX atenolol atomoxetine atorvastatin ATRALIN ATRIPLA AUBAGIO
AUSTEDO azelastine azithromycin AZOPT
B balsalazide BASAGLAR
BD ULTRAFINE INSULIN SYRINGES AND NEEDLES
BELBUCA BELSOMRA BELVIQ BELVIQ XR benzoyl peroxide BESIVANCE
BETASERON BETHKIS BETIMOL BETOPTIC S BEVESPI AEROSPHERE
bicalutamide BIDIL BIKTARVY BOSULIF BREO ELLIPTA BRILINTA
brimonidine bromfenac budesonide capsule budesonide inhalation
suspension buprenorphine-naloxone
sublingual tablet bupropion bupropion ext-rel BUTRANS
BYSTOLIC
C CABOMETYX calcipotriene calcitonin-salmon calcium acetate
CANASA candesartan candesartan-hydrochlorothiazide carbamazepine
carbamazepine ext-rel carbidopa-levodopa carbidopa-levodopa ext-rel
carbidopa-levodopa-entacapone carvedilol cefdinir cefprozil
cefuroxime axetil celecoxib cephalexin CERDELGA CETROTIDE
cholestyramine CIALIS ciclopirox CILOXAN OINTMENT CIPRODEX
ciprofloxacin ciprofloxacin ext-rel citalopram CITRANATAL
clarithromycin clarithromycin ext-rel CLIMARA PRO clindamycin
clindamycin solution clindamycin-benzoyl peroxide
clobetasol cream, foam, gel, lotion, ointment, shampoo
clocortolone clopidogrel clotrimazole clozapine
codeine-acetaminophen colchicine tablet COLCRYS colesevelam
COMBIGAN COMBIPATCH COMBIVENT RESPIMAT COMPLERA COPAXONE COREG CR
CORLANOR CORTIFOAM COSENTYX CREON CRINONE cromolyn sodium
cyclobenzaprine
D DALIRESP darifenacin ext-rel DESCOVY desonide desoximetasone
desvenlafaxine ext-rel dexamethasone DEXCOM CONTINUOUS GLUCOSE
MONITORING SYSTEM * DEXILANT diazepam rectal gel DICLEGIS
diclofenac diclofenac sodium diclofenac sodium gel 1% diclofenac
sodium solution diclofenac sodium-misoprostol dicloxacillin
DIFFERIN DIFICID digoxin diltiazem ext-rel 3 dipyridamole
ext-rel-aspirin divalproex sodium divalproex sodium ext-rel DIVIGEL
donepezil dorzolamide dorzolamide-timolol doxazosin doxycycline
hyclate dronabinol DUAVEE duloxetine DUPIXENT DUREZOL dutasteride
dutasteride-tamsulosin DYMISTA
E econazole
eletriptan ELIDEL ELIQUIS EMBEDA EMGALITY EMVERM ENBREL
ENDOMETRIN entacapone ENTRESTO EPCLUSA EPIDUO epinephrine
auto-injector EPIPEN EPIPEN JR EPISIL eprosartan
ergotamine-caffeine ERLEADA erythromycin erythromycin solution
erythromycin-benzoyl peroxide erythromycins ESBRIET escitalopram
esomeprazole ESTRACE CREAM estradiol estradiol-norethindrone
ESTRING estropipate eszopiclone ethinyl estradiol-drospirenone
ethinyl estradiol-drospirenone-
levomefolate ethinyl estradiol-levonorgestrel ethinyl
estradiol-norelgestromin ethinyl estradiol-norethindrone
acetate ethinyl estradiol-norethindrone
acetate-iron ethinyl estradiol-norgestimate ethosuximide EUCRISA
EVAMIST EVOTAZ ezetimibe ezetimibe-simvastatin
F FARXIGA fenofibrate fenofibric acid fentanyl transdermal
fentanyl transmucosal lozenge FIASP FINACEA finasteride FLAREX
FLOVENT DISKUS FLOVENT HFA fluconazole flunisolide fluocinonide
fluorouracil cream 5% fluorouracil solution fluoxetine
-
fluticasone fluvastatin FML FORTE FML S.O.P. FORTEO fosinopril
fosinopril-hydrochlorothiazide furosemide FYCOMPA
G gabapentin galantamine galantamine ext-rel gentamicin GENVOYA
GILENYA glatiramer glimepiride glipizide glipizide ext-rel
glipizide-metformin GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT
GLYXAMBI GONAL-F GRALISE granisetron GRASTEK guanfacine ext-rel
H HARVONI HUMATROPE HUMIRA HUMULIN R U-500 hydrochlorothiazide
hydrocodone-acetaminophen hydrocortisone hydrocortisone butyrate
hydrocortisone enema hydromorphone hydromorphone ext-rel HYSINGLA
ER
I ibandronate IBRANCE ILEVRO imatinib mesylate imiquimod INCRUSE
ELLIPTA ipratropium inhalation solution ipratropium-albuterol
inhalation
solution irbesartan irbesartan-hydrochlorothiazide IRESSA
ISENTRESS itraconazole ivermectin
J JANUMET JANUMET XR JANUVIA JARDIANCE JUBLIA
K ketoconazole ketorolac KEVZARA KISQALI KISQALI FEMARA
CO-PACK
L lactulose lamivudine lamotrigine lamotrigine ext-rel
lansoprazole lanthanum carbonate LASTACAFT latanoprost LATUDA
LETAIRIS levalbuterol tartrate CFC-free aerosol LEVEMIR
levetiracetam levetiracetam ext-rel levocarnitine levofloxacin
levothyroxine LIALDA linezolid LINZESS lisinopril
lisinopril-hydrochlorothiazide LO LOESTRIN FE losartan
losartan-hydrochlorothiazide lovastatin LUMIGAN LUZU LYRICA
M MAXIDEX meclizine medroxyprogesterone megestrol acetate
meloxicam memantine mesalamine rectal suspension metformin
metformin ext-rel 4 methadone methoxsalen methylphenidate
methylphenidate ext-rel methylprednisolone metoclopramide
metolazone metoprolol succinate ext-rel metoprolol tartrate
metronidazole MINIVELLE minocycline mirtazapine mometasone
montelukast morphine morphine ext-rel morphine suppository MOVANTIK
MOXEZA moxifloxacin MUGARD
MULTAQ MUSE MYDAYIS MYRBETRIQ
N nadolol NAFTIN naloxone injection NAMZARIC naproxen
naratriptan NARCAN NASAL SPRAY NATAZIA nateglinide
neomycin-polymyxin B-bacitracin-
hydrocortisone neomycin-polymyxin B-
dexamethasone NEUPRO NEVANAC niacin ext-rel nifedipine ext-rel
nitrofurantoin nitroglycerin lingual spray nitroglycerin sublingual
NORVIR NOVOLIN 70/30 NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG MIX 70/30
NUCYNTA NUCYNTA ER NUEDEXTA NUVARING nystatin
O ODEFSEY ODOMZO OFEV ofloxacin olanzapine olmesartan
olmesartan-amlodipine-
hydrochlorothiazide olmesartan-hydrochlorothiazide olopatadine
omega-3 acid ethyl esters omeprazole ondansetron ONZETRA XSAIL
OPSUMIT ORACEA ORALAIR ORENITRAM ORFADIN oseltamivir OSPHENA OTEZLA
OVIDREL oxcarbazepine OXTELLAR XR oxybutynin oxybutynin ext-rel
oxycodone oxycodone-acetaminophen OXYCONTIN OZEMPIC
P pantoprazole paroxetine HCl paroxetine HCl ext-rel paroxetine
mesylate PAZEO peg 3350-electrolytes penicillin VK PENTASA
PERFOROMIST phenobarbital phenytoin phenytoin sodium extended
PHOSLYRA PICATO pindolol pioglitazone pioglitazone-glimepiride
pioglitazone-metformin potassium chloride liquid pramipexole
pramipexole ext-rel prasugrel pravastatin PRED MILD prednisolone
acetate 1% prednisolone solution prednisone PREMARIN PREMARIN CREAM
PREMPHASE PREMPRO prenatal vitamins PREZCOBIX PREZISTA primidone
PROAIR HFA PROAIR RESPICLICK probenecid prochlorperazine PROCRIT
PROCTOFOAM-HC progesterone, micronized promethazine propranolol
propranolol ext-rel PULMICORT FLEXHALER PYLERA
Q QTERN quetiapine quetiapine ext-rel quinapril
quinapril-hydrochlorothiazide QVAR QVAR REDIHALER
R RAGWITEK raloxifene ramipril RANEXA ranitidine RAPAFLO
rasagiline RASUVO REBIF RELENZA repaglinide
-
REPATHA RESTASIS RETIN-A MICRO REYATAZ RHOPRESSA ribavirin
risedronate risperidone rivastigmine rivastigmine transdermal
rizatriptan ropinirole ropinirole ext-rel rosuvastatin RUCONEST
RYDAPT
S SAFYRAL SANCUSO SAVELLA SAXENDA selegiline SEREVENT sertraline
sevelamer carbonate sildenafil SILENOR SIMBRINZA simvastatin
SOLIQUA SOMAVERT SOOLANTRA sotalol SPIRIVA
spironolactone-hydrochlorothiazide SPRYCEL STELARA SUBCUTANEOUS
STIOLTO RESPIMAT STRIBILD STRIVERDI RESPIMAT SUBOXONE FILM
SUBSYS sulfacetamide sulfamethoxazole-trimethoprim sulfasalazine
sulfasalazine delayed-rel sumatriptan SUPRAX SUPREP SYMBICORT
SYMLINPEN SYNJARDY SYNJARDY XR SYNTHROID
T tacrolimus tamsulosin TAZORAC TECFIDERA TEKTURNA TEKTURNA HCT
telmisartan telmisartan-hydrochlorothiazide terazosin terbinafine
tablet testosterone gel testosterone solution tetrabenazine
tetracycline tiagabine timolol maleate solution TIVICAY TOBRADEX
OINTMENT TOBRADEX ST tobramycin tobramycin inhalation solution
tobramycin-dexamethasone TOLAK tolterodine tolterodine ext-rel
topiramate torsemide
TOVIAZ TRACLEER tramadol tramadol ext-rel TRAVATAN Z trazodone
TRELEGY ELLIPTA TRESIBA tretinoin TREXIMET triamcinolone
triamterene-hydrochlorothiazide trimethobenzamide TRINTELLIX
TRIUMEQ TROKENDI XR trospium trospium ext-rel TRULICITY TRUVADA
TYMLOS
U UCERIS ULORIC UPTRAVI
V valacyclovir valganciclovir valproic acid valsartan
valsartan-hydrochlorothiazide VARUBI VASCEPA VELPHORO VELTASSA
VEMLIDY venlafaxine venlafaxine ext-rel capsule verapamil ext-rel
VESICARE
VIBERZI VICTOZA VIIBRYD VIMPAT VIOKACE VISTOGARD VOSEVI 2
VRAYLAR VYVANSE
W warfarin
X XARELTO XELJANZ XELJANZ XR XIFAXAN 550 MG XIGDUO XR XIIDRA
XTANDI
Z zafirlukast ZARXIO ZEJULA ZEMBRACE SYMTOUCH ZENPEP zileuton
ext-rel ziprasidone zolmitriptan zolpidem zolpidem ext-rel zolpidem
sublingual ZOMIG NASAL SPRAY zonisamide ZUBSOLV ZYCLARA ZYLET
ZYTIGA
PREFERRED OPTIONS LIST NON-PREFERRED OR EXCLUDED DRUG(S)
PREFERRED OPTION(S)†
ABILIFY aripiprazole, clozapine, olanzapine, quetiapine,
quetiapine ext-rel, risperidone, ziprasidone, LATUDA, VRAYLAR
ACANYA adapalene, benzoyl peroxide, clindamycin solution,
clindamycin-benzoyl peroxide, erythromycin solution,
erythromycin-benzoyl peroxide, tretinoin, ATRALIN, DIFFERIN,
EPIDUO, RETIN-A MICRO, TAZORAC
ACTEMRA ENBREL, HUMIRA, KEVZARA, XELJANZ, XELJANZ XR
ACTICLATE doxycycline hyclate
ACTOS pioglitazone
ADDERALL XR amphetamine-dextroamphetamine mixed salts ext-rel,
methylphenidate ext-rel, MYDAYIS, VYVANSE
ALCORTIN A desonide, hydrocortisone
ALEVICYN GEL, ALEVICYN KIT, ALEVICYN SG, Alevicyn solution
desonide, hydrocortisone
ALLISON MEDICAL INSULIN SYRINGES 7
BD ULTRAFINE INSULIN SYRINGES
ALORA estradiol, DIVIGEL, EVAMIST, MINIVELLE
NON-PREFERRED OR EXCLUDED DRUG(S)
PREFERRED OPTION(S)†
ALTOPREV atorvastatin, ezetimibe-simvastatin, fluvastatin,
lovastatin, pravastatin, rosuvastatin, simvastatin
ALVESCO ARNUITY ELLIPTA, ASMANEX, FLOVENT DISKUS, FLOVENT HFA,
PULMICORT FLEXHALER, QVAR, QVAR REDIHALER
AMRIX cyclobenzaprine
ANDROGEL 1% testosterone gel, testosterone solution, ANDRODERM,
ANDROGEL 1.62%
ANGELIQ estradiol-norethindrone, PREMPHASE, PREMPRO
ANTARA fenofibrate, fenofibric acid
APEXICON E desoximetasone, fluocinonide
APIDRA FIASP, NOVOLOG
ARMOUR THYROID levothyroxine, SYNTHROID
ARTHROTEC celecoxib; diclofenac sodium, meloxicam or naproxen
WITH esomeprazole, lansoprazole, omeprazole, pantoprazole or
DEXILANT
ASACOL HD balsalazide, sulfasalazine, sulfasalazine delayed-rel,
APRISO, LIALDA, PENTASA
-
NON-PREFERRED OR EXCLUDED DRUG(S)
PREFERRED OPTION(S)†
ASCENSIA STRIPS AND KITS 6 ACCU-CHEK AVIVA PLUS STRIPS AND KITS
5, ACCU-CHEK COMPACT PLUS STRIPS AND KITS 5, ACCU-CHEK GUIDE STRIPS
AND KITS 5, ACCU-CHEK SMARTVIEW STRIPS AND KITS 5
ATACAND, ATACAND HCT candesartan,
candesartan-hydrochlorothiazide, eprosartan, irbesartan,
irbesartan-hydrochlorothiazide, losartan,
losartan-hydrochlorothiazide, olmesartan,
olmesartan-hydrochlorothiazide, telmisartan,
telmisartan-hydrochlorothiazide, valsartan,
valsartan-hydrochlorothiazide
ATROVENT HFA ipratropium inhalation solution, INCRUSE ELLIPTA,
SPIRIVA
AVENOVA Consult doctor
AXERT eletriptan, naratriptan, rizatriptan, sumatriptan,
zolmitriptan, ONZETRA XSAIL, ZEMBRACE SYMTOUCH, ZOMIG NASAL
SPRAY
AZELEX adapalene, benzoyl peroxide, clindamycin solution,
clindamycin-benzoyl peroxide, erythromycin solution,
erythromycin-benzoyl peroxide, tretinoin, ATRALIN, DIFFERIN,
EPIDUO, RETIN-A MICRO, TAZORAC
BECONASE AQ flunisolide, fluticasone, mometasone, triamcinolone,
DYMISTA
BENICAR, BENICAR HCT candesartan,
candesartan-hydrochlorothiazide, eprosartan, irbesartan,
irbesartan-hydrochlorothiazide, losartan,
losartan-hydrochlorothiazide, olmesartan,
olmesartan-hydrochlorothiazide, telmisartan,
telmisartan-hydrochlorothiazide, valsartan,
valsartan-hydrochlorothiazide
BENSAL HP desonide, hydrocortisone
BENZAC AC adapalene, benzoyl peroxide, clindamycin solution,
clindamycin-benzoyl peroxide, erythromycin solution,
erythromycin-benzoyl peroxide, tretinoin, ATRALIN, DIFFERIN,
EPIDUO, RETIN-A MICRO, TAZORAC
BENZACLIN adapalene, benzoyl peroxide, clindamycin solution,
clindamycin-benzoyl peroxide, erythromycin solution,
erythromycin-benzoyl peroxide, tretinoin, ATRALIN, DIFFERIN,
EPIDUO, RETIN-A MICRO, TAZORAC
BENZIQ adapalene, benzoyl peroxide, clindamycin solution,
clindamycin-benzoyl peroxide, erythromycin solution,
erythromycin-benzoyl peroxide, tretinoin, ATRALIN, DIFFERIN,
EPIDUO, RETIN-A MICRO, TAZORAC
BETAPACE, BETAPACE AF sotalol
BREEZE 2 STRIPS AND KITS 6 ACCU-CHEK AVIVA PLUS STRIPS AND KITS
5, ACCU-CHEK COMPACT PLUS STRIPS AND KITS 5, ACCU-CHEK GUIDE STRIPS
AND KITS 5, ACCU-CHEK SMARTVIEW STRIPS AND KITS 5
butalbital-acetaminophen-caffeine capsule
diclofenac sodium, naproxen
BYDUREON OZEMPIC, TRULICITY, VICTOZA
BYETTA OZEMPIC, TRULICITY, VICTOZA
CAFERGOT eletriptan, ergotamine-caffeine, naratriptan,
rizatriptan, sumatriptan, zolmitriptan, ONZETRA XSAIL, ZEMBRACE
SYMTOUCH, ZOMIG NASAL SPRAY
CAMBIA diclofenac sodium, meloxicam, naproxen
CARAC fluorouracil cream 5%, fluorouracil solution, imiquimod,
PICATO, TOLAK, ZYCLARA
CARDIZEM diltiazem ext-rel (except generic CARDIZEM LA)
CARDIZEM CD diltiazem ext-rel (except generic CARDIZEM LA)
CARDIZEM LA (and its generics) diltiazem ext-rel (except generic
CARDIZEM LA)
CARNITOR levocarnitine
NON-PREFERRED OR EXCLUDED DRUG(S)
PREFERRED OPTION(S)†
CARNITOR SF levocarnitine
CIMZIA COSENTYX, ENBREL, HUMIRA, KEVZARA, OTEZLA, STELARA
SUBCUTANEOUS (Plaque Psoriasis and Psoriatic Arthritis only),
XELJANZ, XELJANZ XR
CLINDAGEL erythromycin solution
clobetasol spray clobetasol foam
CLOBEX SPRAY clobetasol foam
COLAZAL balsalazide
CONTOUR NEXT STRIPS AND KITS 6
ACCU-CHEK AVIVA PLUS STRIPS AND KITS 5, ACCU-CHEK COMPACT PLUS
STRIPS AND KITS 5, ACCU-CHEK GUIDE STRIPS AND KITS 5, ACCU-CHEK
SMARTVIEW STRIPS AND KITS 5
CONTOUR STRIPS AND KITS 6 ACCU-CHEK AVIVA PLUS STRIPS AND KITS
5, ACCU-CHEK COMPACT PLUS STRIPS AND KITS 5, ACCU-CHEK GUIDE STRIPS
AND KITS 5, ACCU-CHEK SMARTVIEW STRIPS AND KITS 5
CONTRAVE BELVIQ, BELVIQ XR, SAXENDA
CRESTOR atorvastatin, ezetimibe-simvastatin, fluvastatin,
lovastatin, pravastatin, rosuvastatin, simvastatin
CYMBALTA desvenlafaxine ext-rel, duloxetine, venlafaxine,
venlafaxine ext-rel capsule
DAKLINZA EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI
(genotypes 1, 4, 5, 6)
DELZICOL balsalazide, sulfasalazine, sulfasalazine delayed-rel,
APRISO, LIALDA, PENTASA
DETROL LA darifenacin ext-rel, oxybutynin ext-rel, tolterodine,
tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ, TOVIAZ,
VESICARE
DEXPAK dexamethasone, methylprednisolone, prednisolone solution,
prednisone
DIOVAN, DIOVAN HCT candesartan, candesartan-hydrochlorothiazide,
eprosartan, irbesartan, irbesartan-hydrochlorothiazide, losartan,
losartan-hydrochlorothiazide, olmesartan,
olmesartan-hydrochlorothiazide, telmisartan,
telmisartan-hydrochlorothiazide, valsartan,
valsartan-hydrochlorothiazide
DORAL eszopiclone, zolpidem, zolpidem ext-rel, zolpidem
sublingual, BELSOMRA, SILENOR
DORYX doxycycline hyclate
DORYX MPC doxycycline hyclate
DULERA ADVAIR, BREO ELLIPTA, SYMBICORT
DUTOPROL metoprolol succinate ext-rel WITH
hydrochlorothiazide
DYRENIUM amiloride
EDARBI, EDARBYCLOR candesartan, candesartan-hydrochlorothiazide,
eprosartan, irbesartan, irbesartan-hydrochlorothiazide, losartan,
losartan-hydrochlorothiazide, olmesartan,
olmesartan-hydrochlorothiazide, telmisartan,
telmisartan-hydrochlorothiazide, valsartan,
valsartan-hydrochlorothiazide
EDLUAR eszopiclone, zolpidem, zolpidem ext-rel, zolpidem
sublingual, BELSOMRA, SILENOR
E.E.S. GRANULES erythromycins
EFFEXOR XR desvenlafaxine ext-rel, duloxetine, venlafaxine,
venlafaxine ext-rel capsule
ENABLEX darifenacin ext-rel, oxybutynin ext-rel, tolterodine,
tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ, TOVIAZ,
VESICARE
ERYPED erythromycins
-
NON-PREFERRED OR EXCLUDED DRUG(S)
PREFERRED OPTION(S)†
EVZIO naloxone injection, NARCAN NASAL SPRAY
EXFORGE amlodipine-olmesartan, amlodipine-telmisartan,
amlodipine-valsartan
EXFORGE HCT amlodipine-valsartan-hydrochlorothiazide,
olmesartan-amlodipine-hydrochlorothiazide
EXTAVIA glatiramer, AUBAGIO, BETASERON, COPAXONE, GILENYA,
REBIF, TECFIDERA
FANAPT aripiprazole, clozapine, olanzapine, quetiapine,
quetiapine ext-rel, risperidone, ziprasidone, LATUDA, VRAYLAR
FEMRING estradiol, ESTRACE CREAM, ESTRING, PREMARIN CREAM
FETZIMA desvenlafaxine ext-rel, duloxetine, venlafaxine,
venlafaxine ext-rel capsule
FIORICET CAPSULE diclofenac sodium, naproxen
fluorouracil cream 0.5% fluorouracil cream 5%, fluorouracil
solution, imiquimod, PICATO, TOLAK, ZYCLARA
FOLLISTIM AQ GONAL-F
FORTAMET metformin, metformin ext-rel (except generic FORTAMET
or generic GLUMETZA)
FORTESTA testosterone gel, testosterone solution, ANDRODERM,
ANDROGEL 1.62%
FOSAMAX PLUS D alendronate, ibandronate, risedronate
FOSRENOL calcium acetate, lanthanum carbonate, sevelamer
carbonate, PHOSLYRA, VELPHORO
FREESTYLE STRIPS AND KITS 6 ACCU-CHEK AVIVA PLUS STRIPS AND KITS
5, ACCU-CHEK COMPACT PLUS STRIPS AND KITS 5, ACCU-CHEK GUIDE STRIPS
AND KITS 5, ACCU-CHEK SMARTVIEW STRIPS AND KITS 5
FROVA eletriptan, naratriptan, rizatriptan, sumatriptan,
zolmitriptan, ONZETRA XSAIL, ZEMBRACE SYMTOUCH, ZOMIG NASAL
SPRAY
GENOTROPIN HUMATROPE
GLEEVEC imatinib mesylate, BOSULIF, SPRYCEL
GLUMETZA metformin, metformin ext-rel (except generic FORTAMET
or generic GLUMETZA)
HORIZANT gabapentin, GRALISE
HUMALOG FIASP, NOVOLOG
HUMALOG MIX 50/50 NOVOLOG MIX 70/30
HUMALOG MIX 75/25 NOVOLOG MIX 70/30
HUMULIN 70/30 NOVOLIN 70/30
HUMULIN N NOVOLIN N
HUMULIN R NOVOLIN R
INDOCIN diclofenac sodium, meloxicam, naproxen
INNOPRAN XL atenolol, carvedilol, metoprolol succinate ext-rel,
metoprolol tartrate, nadolol, pindolol, propranolol, propranolol
ext-rel, BYSTOLIC, COREG CR
INTERMEZZO eszopiclone, zolpidem, zolpidem ext-rel, zolpidem
sublingual, BELSOMRA, SILENOR
INTUNIV amphetamine-dextroamphetamine mixed salts ext-rel,
atomoxetine, guanfacine ext-rel, methylphenidate ext-rel, MYDAYIS,
VYVANSE
INVOKAMET SYNJARDY, SYNJARDY XR, XIGDUO XR
INVOKAMET XR SYNJARDY, SYNJARDY XR, XIGDUO XR
INVOKANA FARXIGA, JARDIANCE
NON-PREFERRED OR EXCLUDED DRUG(S)
PREFERRED OPTION(S)†
ISTALOL timolol maleate solution, BETIMOL
JALYN dutasteride-tamsulosin; dutasteride or finasteride WITH
alfuzosin ext-rel, doxazosin, tamsulosin, terazosin, or RAPAFLO
JENTADUETO JANUMET, JANUMET XR
JENTADUETO XR JANUMET, JANUMET XR
KAZANO JANUMET, JANUMET XR
KINERET ENBREL, HUMIRA, KEVZARA, XELJANZ, XELJANZ XR
KOMBIGLYZE XR JANUMET, JANUMET XR
LANOXIN TABLET (125 MCG and 250 MCG only)
digoxin
LANTUS BASAGLAR, LEVEMIR, TRESIBA
LAZANDA fentanyl transmucosal lozenge, ABSTRAL, SUBSYS
LESCOL XL atorvastatin, ezetimibe-simvastatin, fluvastatin,
lovastatin, pravastatin, rosuvastatin, simvastatin
levorphanol fentanyl transdermal, hydromorphone ext-rel,
methadone, morphine ext-rel, EMBEDA, HYSINGLA ER, NUCYNTA ER,
OXYCONTIN
LIPITOR atorvastatin, ezetimibe-simvastatin, fluvastatin,
lovastatin, pravastatin, rosuvastatin, simvastatin
LIVALO atorvastatin, ezetimibe-simvastatin, fluvastatin,
lovastatin, pravastatin, rosuvastatin, simvastatin
LUNESTA eszopiclone, zolpidem, zolpidem ext-rel, zolpidem
sublingual, BELSOMRA, SILENOR
MACRODANTIN nitrofurantoin
Matzim LA diltiazem ext-rel (except generic CARDIZEM LA)
MAVYRET EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes
1, 4, 5, 6), VOSEVI 2
MENEST estradiol, estropipate, PREMARIN
MENOSTAR estradiol
MIACALCIN INJECTION alendronate, calcitonin-salmon, ibandronate,
risedronate, FORTEO, TYMLOS
MIACALCIN NASAL SPRAY calcitonin-salmon
MICARDIS, MICARDIS HCT candesartan,
candesartan-hydrochlorothiazide, eprosartan, irbesartan,
irbesartan-hydrochlorothiazide, losartan,
losartan-hydrochlorothiazide, olmesartan,
olmesartan-hydrochlorothiazide, telmisartan,
telmisartan-hydrochlorothiazide, valsartan,
valsartan-hydrochlorothiazide
MILLIPRED dexamethasone, methylprednisolone, prednisolone
solution, prednisone
MINOCIN minocycline
NAPRELAN diclofenac sodium, meloxicam, naproxen
NATESTO testosterone gel, testosterone solution, ANDRODERM,
ANDROGEL 1.62%
NESINA JANUVIA
NEUPOGEN ZARXIO
NEXIUM esomeprazole, lansoprazole, omeprazole, pantoprazole,
DEXILANT
NILANDRON bicalutamide, XTANDI, ZYTIGA
NITROMIST nitroglycerin lingual spray, nitroglycerin
sublingual
NORDITROPIN HUMATROPE
NORITATE metronidazole, FINACEA, SOOLANTRA
-
NON-PREFERRED OR EXCLUDED DRUG(S)
PREFERRED OPTION(S)†
NORVASC amlodipine
NOVACORT desonide, hydrocortisone
NOVO NORDISK NEEDLES 7 BD ULTRAFINE NEEDLES
NUTROPIN AQ HUMATROPE
NUVIGIL armodafinil
OLEPTRO trazodone
OLUX-E clobetasol foam
OMNARIS flunisolide, fluticasone, mometasone, triamcinolone,
DYMISTA
OMNITROPE HUMATROPE
ONETOUCH ULTRA STRIPS AND KITS 6
ACCU-CHEK AVIVA PLUS STRIPS AND KITS 5, ACCU-CHEK COMPACT PLUS
STRIPS AND KITS 5, ACCU-CHEK GUIDE STRIPS AND KITS 5, ACCU-CHEK
SMARTVIEW STRIPS AND KITS 5
ONETOUCH VERIO STRIPS AND KITS 6
ACCU-CHEK AVIVA PLUS STRIPS AND KITS 5, ACCU-CHEK COMPACT PLUS
STRIPS AND KITS 5, ACCU-CHEK GUIDE STRIPS AND KITS 5, ACCU-CHEK
SMARTVIEW STRIPS AND KITS 5
ONEXTON adapalene, benzoyl peroxide, clindamycin solution,
clindamycin-benzoyl peroxide, erythromycin solution,
erythromycin-benzoyl peroxide, tretinoin, ATRALIN, DIFFERIN,
EPIDUO, RETIN-A MICRO, TAZORAC
ONGLYZA JANUVIA
ORENCIA CLICKJECT COSENTYX, ENBREL, HUMIRA, KEVZARA, OTEZLA,
STELARA SUBCUTANEOUS (Plaque Psoriasis and Psoriatic Arthritis
only), XELJANZ, XELJANZ XR
ORENCIA INTRAVENOUS COSENTYX, ENBREL, HUMIRA, KEVZARA, OTEZLA,
STELARA SUBCUTANEOUS (Plaque Psoriasis and Psoriatic Arthritis
only), XELJANZ, XELJANZ XR
ORENCIA SUBCUTANEOUS COSENTYX, ENBREL, HUMIRA, KEVZARA, OTEZLA,
STELARA SUBCUTANEOUS (Plaque Psoriasis and Psoriatic Arthritis
only), XELJANZ, XELJANZ XR
OSENI JANUMET, JANUMET XR
OWEN MUMFORD NEEDLES 7 BD ULTRAFINE NEEDLES
OXYTROL darifenacin ext-rel, oxybutynin ext-rel, tolterodine,
tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ, TOVIAZ,
VESICARE
PANCREAZE CREON, VIOKACE, ZENPEP
PENNSAID diclofenac sodium, diclofenac sodium gel 1%, diclofenac
sodium solution, meloxicam, naproxen
PERRIGO NEEDLES 7 BD ULTRAFINE NEEDLES
PERTZYE CREON, VIOKACE, ZENPEP
PEXEVA citalopram, escitalopram, fluoxetine, paroxetine HCl,
paroxetine HCl ext-rel, sertraline, TRINTELLIX, VIIBRYD
PLAVIX clopidogrel, prasugrel, BRILINTA
PRADAXA warfarin, ELIQUIS, XARELTO
PRALUENT REPATHA
PRECISION XTRA STRIPS AND KITS 6
ACCU-CHEK AVIVA PLUS STRIPS AND KITS 5, ACCU-CHEK COMPACT PLUS
STRIPS AND KITS 5, ACCU-CHEK GUIDE STRIPS AND KITS 5, ACCU-CHEK
SMARTVIEW STRIPS AND KITS 5
PRED FORTE dexamethasone, prednisolone acetate 1%, DUREZOL,
FLAREX, FML FORTE, FML S.O.P., MAXIDEX, PRED MILD
PREFERAOB generic prenatal vitamins, CITRANATAL
PREFEST estradiol-norethindrone, PREMPHASE, PREMPRO
NON-PREFERRED OR EXCLUDED DRUG(S)
PREFERRED OPTION(S)†
PRENATAL PLUS generic prenatal vitamins, CITRANATAL
PREVACID esomeprazole, lansoprazole, omeprazole, pantoprazole,
DEXILANT
PRIMLEV hydrocodone-acetaminophen, hydromorphone, morphine,
oxycodone-acetaminophen, NUCYNTA
PROTONIX esomeprazole, lansoprazole, omeprazole, pantoprazole,
DEXILANT
PROTOPIC tacrolimus, ELIDEL, EUCRISA
PROVENTIL HFA levalbuterol tartrate CFC-free aerosol, PROAIR
HFA, PROAIR RESPICLICK
QNASL flunisolide, fluticasone, mometasone, triamcinolone,
DYMISTA
QSYMIA BELVIQ, BELVIQ XR, SAXENDA
RAYOS dexamethasone, methylprednisolone, prednisolone solution,
prednisone
RELION INSULIN NOVOLIN INSULIN
RELISTOR MOVANTIK
RIOMET metformin, metformin ext-rel (except generic FORTAMET or
generic GLUMETZA)
ROZEREM eszopiclone, zolpidem, zolpidem ext-rel, zolpidem
sublingual, BELSOMRA, SILENOR
SAIZEN HUMATROPE
SEROQUEL XR aripiprazole, clozapine, olanzapine, quetiapine,
quetiapine ext-rel, risperidone, ziprasidone, LATUDA, VRAYLAR
SIMPONI COSENTYX, ENBREL, HUMIRA, KEVZARA, OTEZLA, STELARA
SUBCUTANEOUS (Plaque Psoriasis and Psoriatic Arthritis only),
XELJANZ, XELJANZ XR
SORILUX calcipotriene
SPRIX diclofenac sodium, meloxicam, naproxen
STENDRA sildenafil, CIALIS
STRIANT testosterone gel, testosterone solution, ANDRODERM,
ANDROGEL 1.62%
SURE-TEST STRIPS AND KITS 6 ACCU-CHEK AVIVA PLUS STRIPS AND KITS
5, ACCU-CHEK COMPACT PLUS STRIPS AND KITS 5, ACCU-CHEK GUIDE STRIPS
AND KITS 5, ACCU-CHEK SMARTVIEW STRIPS AND KITS 5
SYNERDERM desonide, hydrocortisone
TALTZ COSENTYX, ENBREL, HUMIRA, OTEZLA, STELARA SUBCUTANEOUS
(Plaque Psoriasis and Psoriatic Arthritis only), XELJANZ, XELJANZ
XR
TANZEUM OZEMPIC, TRULICITY, VICTOZA
TARGADOX doxycycline hyclate
TASIGNA imatinib mesylate, BOSULIF, SPRYCEL
TECHNIVIE EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI
(genotypes 1, 4, 5, 6)
TESTIM testosterone gel, testosterone solution, ANDRODERM,
ANDROGEL 1.62%
testosterone gel 1% 8 testosterone gel, testosterone solution,
ANDRODERM, ANDROGEL 1.62%
TIROSINT levothyroxine, SYNTHROID
TOBI tobramycin inhalation solution, BETHKIS
TOBI PODHALER tobramycin inhalation solution, BETHKIS
TOUJEO BASAGLAR, LEVEMIR, TRESIBA
-
NON-PREFERRED OR EXCLUDED DRUG(S)
PREFERRED OPTION(S)†
TRADJENTA JANUVIA
TRICOR fenofibrate, fenofibric acid
TRIGLIDE fenofibrate, fenofibric acid
TRILIPIX fenofibrate, fenofibric acid
TRIVIDIA INSULIN SYRINGES 7 BD ULTRAFINE INSULIN SYRINGES
TRUETEST STRIPS AND KITS 6 ACCU-CHEK AVIVA PLUS STRIPS AND KITS
5, ACCU-CHEK COMPACT PLUS STRIPS AND KITS 5, ACCU-CHEK GUIDE STRIPS
AND KITS 5, ACCU-CHEK SMARTVIEW STRIPS AND KITS 5
TRUETRACK STRIPS AND KITS 6
ACCU-CHEK AVIVA PLUS STRIPS AND KITS 5, ACCU-CHEK COMPACT PLUS
STRIPS AND KITS 5, ACCU-CHEK GUIDE STRIPS AND KITS 5, ACCU-CHEK
SMARTVIEW STRIPS AND KITS 5
TUDORZA INCRUSE ELLIPTA, SPIRIVA
ULTIMED INSULIN SYRINGES 7 BD ULTRAFINE INSULIN SYRINGES
ULTIMED NEEDLES 7 BD ULTRAFINE NEEDLES
UROXATRAL alfuzosin ext-rel, doxazosin, tamsulosin, terazosin,
RAPAFLO
VALCYTE valganciclovir
VALTREX acyclovir, valacyclovir
VANATOL LQ diclofenac sodium, naproxen
VANATOL S diclofenac sodium, naproxen
Vanoxide-HC adapalene, benzoyl peroxide, clindamycin solution,
clindamycin-benzoyl peroxide, erythromycin solution,
erythromycin-benzoyl peroxide, tretinoin, ATRALIN, DIFFERIN,
EPIDUO, RETIN-A MICRO, TAZORAC
VELTIN adapalene, benzoyl peroxide, clindamycin solution,
clindamycin-benzoyl peroxide, erythromycin solution,
erythromycin-benzoyl peroxide, tretinoin, ATRALIN, DIFFERIN,
EPIDUO, RETIN-A MICRO, TAZORAC
venlafaxine ext-rel tablet (except 225 mg)
desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine
ext-rel capsule
VENLAFAXINE EXT-REL TABLET (except 225 MG)
desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine
ext-rel capsule
VENTOLIN HFA levalbuterol tartrate CFC-free aerosol, PROAIR HFA,
PROAIR RESPICLICK
NON-PREFERRED OR EXCLUDED DRUG(S)
PREFERRED OPTION(S)†
VIAGRA sildenafil, CIALIS
VIEKIRA PAK EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI
(genotypes 1, 4, 5, 6)
VIEKIRA XR EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI
(genotypes 1, 4, 5, 6)
VITAFOL-ONE generic prenatal vitamins, CITRANATAL
VOGELXO testosterone gel, testosterone solution, ANDRODERM,
ANDROGEL 1.62%
XENAZINE tetrabenazine, AUSTEDO
XOPENEX HFA levalbuterol tartrate CFC-free aerosol, PROAIR HFA,
PROAIR RESPICLICK
ZEGERID esomeprazole, lansoprazole, omeprazole, pantoprazole,
DEXILANT
ZEPATIER EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI
(genotypes 1, 4, 5, 6)
ZETIA ezetimibe
ZETONNA flunisolide, fluticasone, mometasone, triamcinolone,
DYMISTA
ZIANA adapalene, benzoyl peroxide, clindamycin solution,
clindamycin-benzoyl peroxide, erythromycin solution,
erythromycin-benzoyl peroxide, tretinoin, ATRALIN, DIFFERIN,
EPIDUO, RETIN-A MICRO, TAZORAC
ZOLPIMIST eszopiclone, zolpidem, zolpidem ext-rel, zolpidem
sublingual, BELSOMRA, SILENOR
ZONEGRAN carbamazepine, carbamazepine ext-rel, divalproex
sodium, divalproex sodium ext-rel, gabapentin, lamotrigine,
lamotrigine ext-rel, levetiracetam, levetiracetam ext-rel,
oxcarbazepine, phenobarbital, phenytoin, phenytoin sodium extended,
tiagabine, topiramate, valproic acid, zonisamide, FYCOMPA, OXTELLAR
XR, TROKENDI XR, VIMPAT
ZUPLENZ granisetron, ondansetron, SANCUSO
ZYFLO, ZYFLO CR montelukast, zafirlukast, zileuton ext-rel
-
FOR YOUR INFORMATION: Generics should be considered the first
line of prescribing. This drug list represents a summary of
prescription coverage. It does not list all covered drugs and does
not guarantee coverage. New-to-market products and new variations
of products already in the marketplace may not be added to the
formulary immediately. Each product will be evaluated for clinical
appropriateness and cost-effectiveness. Recommended additions to
the formulary will be presented to the CVS Caremark National
Pharmacy and Therapeutics Committee (or other appropriate reviewing
body) for review and approval. In most instances, a brand-name drug
for which a generic product becomes available will be designated as
a non-preferred option upon release of the generic product to the
market and will be removed from the Preferred Drug List. Specific
prescription benefit plan design may not cover certain products or
categories, regardless of their appearance in this document. The
member's prescription benefit plan may have a different
copay/coinsurance for specific products on the list. Unless
specifically indicated, drug list products will include all dosage
forms. This list represents brand products in CAPS, branded
generics in upper- and lowercase Italics, and generic products in
lowercase italics. Generics listed in therapeutic categories are
for representational purposes only. Listed products may be
available generically in certain strengths or dosage forms. Dosage
forms on this list will be consistent with the category and use
where listed. To learn more about your specific drug benefit, log
into My Account at www.carefirst.com/myaccount and click on Drug
& Pharmacy Resources under Quick Links or call CareFirst
Pharmacy Services at 800-241-3371. An exception process may exist
for specific clinical or regulatory circumstances that may require
coverage of an excluded medication. † The preferred options in this
list are a broad representation within therapeutic categories of
available treatment options and do not necessarily represent
clinical equivalency. § Generics are available in this class and
should be considered the first line of prescribing. * Blood glucose
monitoring kits are covered under the medical benefit. 1 CVS
Caremark is an independent company that provides pharmacy benefit
management services. 2 For use in patients previously treated with
an HCV regimen containing an NS5A inhibitor (for genotypes 1-6) or
sofosbuvir without an NS5A inhibitor (for genotypes 1a or 3). 3
Listing does not include generic CARDIZEM LA. 4 Listing does not
include generic FORTAMET or generic GLUMETZA. 5 An ACCU-CHEK blood
glucose meter may be provided at no charge by the manufacturer to
those individuals currently using a meter other than ACCU-CHEK. For
more information on
how to obtain a blood glucose meter, call: 1-877-418-4746. 6
ACCU-CHEK brand test strips are the only preferred options. 7 BD
ULTRAFINE syringes and needles are the only preferred options. 8
Listing reflects the authorized generics for TESTIM and
VOGELXO.
Plan member privacy is important to us. Our employees are
trained regarding the appropriate way to handle members' private
health information. This document contains references to brand-name
prescription drugs that are trademarks or registered trademarks of
pharmaceutical manufacturers. Listed products are for informational
purposes only and are not intended to replace the clinical judgment
of the prescriber. The document is subject to state-specific
regulations and rules, including, but not limited to, those
regarding generic substitution, controlled substance schedules,
preference for brands and mandatory generics whenever applicable.
The information contained in this document is proprietary. The
information may not be copied in whole or in part without written
permission.
CareFirst BlueCross BlueShield is the shared business name of
CareFirst of Maryland, Inc. and Group Hospitalization and Medical
Services, Inc.
CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc.
are both independent licensees of the Blue Cross and Blue Shield
Association. ® Registered trademark of the Blue Cross and Blue
Shield Association. ®’ Registered trademark of CareFirst of
Maryland, Inc.
©2018. All rights reserved. SUM2665-1P (01/01/19)
-
Notice of Nondiscrimination and Availability of Language
Assistance Services
CareFirst BlueCross BlueShield, CareFirst BlueChoice, Inc.,
CareFirst Diversified Benefits and all of their corporate
affiliates (CareFirst) comply with applicable federal civil rights
laws and do not discriminate on the basis of race, color, national
origin, age, disability or sex. CareFirst does not exclude people
or treat them differently because of race, color, national origin,
age, disability or sex.
CareFirst:
■ Provides free aid and services to people with disabilities to
communicate effectively with us, such as:Qualified sign language
interpretersWritten information in other formats (large print,
audio, accessible electronic formats, other formats)
■ Provides free language services to people whose primary
language is not English, such as:Qualified interpretersInformation
written in other languages
If you need these services, please call 855-258-6518.
If you believe CareFirst has failed to provide these services,
or discriminated in another way, on the basis of race, color,
national origin, age, disability or sex, you can file a grievance
with our CareFirst Civil Rights Coordinator by mail, fax or email.
If you need help filing a grievance, our CareFirst Civil Rights
Coordinator is available to help you.
To file a grievance regarding a violation of federal civil
rights, please contact the Civil Rights Coordinator as indicated
below. Please do not send payments, claims issues, or other
documentation to this office.
Civil Rights Coordinator, Corporate Office of Civil
RightsMailing Address P.O. Box 8894 Baltimore, Maryland 21224
Email Address [email protected]
Telephone Number 410-528-7820 Fax Number 410-505-2011
You can also file a civil rights complaint with the U.S.
Department of Health and Human Services, Office for Civil Rights
electronically through the Office for Civil Rights Complaint
portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
or by mail or phone at:
U.S. Department of Health and Human Services 200 Independence
Avenue, SW Room 509F, HHH Building Washington, D.C. 20201
800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at
http://www.hhs.gov/ocr/office/file/index.html.
(UPDATED 7/12/18)
CareFirst BlueCross BlueShield is the shared business name of
CareFirst of Maryland, Inc. and Group Hospitalization and Medical
Services, Inc. CareFirst of Maryland, Inc., Group Hospitalization
and Medical Services, Inc., CareFirst BlueChoice, Inc., The Dental
Network and First Care, Inc. are independent licensees of the Blue
Cross and Blue Shield Association. In the District of Columbia and
Maryland, CareFirst MedPlus and CareFirst Diversified Benefits are
the business names of First Care, Inc. In Virginia, CareFirst
MedPlus and CareFirst Diversified Benefits are the business names
of First Care, Inc. of Maryland (used in VA by: First Care, Inc.).
® Registered trademark of the Blue Cross and Blue Shield
Association. ®’ Registered trademark of CareFirst of Maryland,
Inc.
-
Foreign Language Assistance Attention (English): This notice
contains information about your insurance coverage. It may contain
key dates
and you may need to take action by certain deadlines. You have
the right to get this information and assistance in
your language at no cost. Members should call the phone number
on the back of their member identification card.
All others may call 855-258-6518 and wait through the dialogue
until prompted to push 0. When an agent
answers, state the language you need and you will be connected
to an interpreter.
አማርኛ (Amharic) ማሳሰቢያ፦ ይህ ማስታወቂያ ስለ መድን ሽፋንዎ መረጃ ይዟል። ከተወሰኑ
ቀነ-ገደቦች በፊት ሊፈጽሟቸው የሚገቡ ነገሮች ሊኖሩ ስለሚችሉ እነዚህን ወሳኝ ቀናት ሊይዝ ይችላል። ይኽን
መረጃ የማግኘት እና ያለምንም ክፍያ በቋንቋዎ እገዛ የማግኘት መብት አለዎት። አባል ከሆኑ ከመታወቂያ
ካርድዎ በስተጀርባ ላይ ወደተጠቀሰው የስልክ ቁጥር መደወል ይችላሉ። አባል ካልሆኑ ደግሞ ወደ ስልክ
ቁጥር
855-258-6518 ደውለው 0ን እንዲጫኑ እስኪነገርዎ ድረስ ንግግሩን መጠበቅ አለብዎ። አንድ ወኪል
መልስ ሲሰጥዎ፣ የሚፈልጉትን ቋንቋ ያሳውቁ፣ ከዚያም ከተርጓሚ ጋር ይገናኛሉ።
Èdè Yorùbá (Yoruba) Ìtẹ́tíléko: Àkíyèsí yìí ní ìwífún nípa iṣẹ́
adójútòfò rẹ. Ó le ní àwọn déètì pàtó o sì le ní láti
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yìí àti ìrànlọ́wọ́ ní èdè rẹ lọ́fẹ̀ẹ́. Àwọn ọmọ-ẹgbẹ́
gbọ́dọ̀ pe nọ́mbà fóònù tó wà lẹ́yìn káàdì ìdánimọ̀ wọn. Àwọn
míràn le pe 855-258-6518 kí o sì dúró nípasẹ̀ ìjíròrò
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Tiếng Việt (Vietnamese) Chú ý: Thông báo này chứa thông tin về
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ở mặt sau của thẻ nhận dạng. Tất cả những người khác có thể gọi
số 855-258-6518 và chờ hết cuộc đối thoại cho
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Tagalog (Tagalog) Atensyon: Ang abisong ito ay naglalaman ng
impormasyon tungkol sa nasasaklawan ng iyong
insurance. Maaari itong maglaman ng mga pinakamahalagang petsa
at maaaring kailangan mong gumawa ng
aksyon ayon sa ilang deadline. May karapatan ka na makuha ang
impormasyong ito at tulong sa iyong sariling
wika nang walang gastos. Dapat tawagan ng mga Miyembro ang
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855-258-6518 at maghintay hanggang sa dulo ng
diyalogo hanggang sa diktahan na pindutin ang 0. Kapag sumagot
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at ikokonekta ka sa isang interpreter.
Español (Spanish) Atención: Este aviso contiene información
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incluya fechas clave y que usted tenga que realizar alguna
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derecho a obtener esta información y asistencia en su idioma sin
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deben presionar 0. Cuando un agente de seguros
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Русский (Russian) Внимание! Настоящее уведомление содержит
информацию о вашем страховом
обеспечении. В нем могут указываться важные даты, и от вас может
потребоваться выполнить некоторые
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ответе агента укажите желаемый язык общения, и вас свяжут с
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हिन्दी (Hindi) ध्यान दें: इस सचूना में आपकी बीमा कवरेज के बारे
में जानकारी दी गई िै। िो सकता िै कक इसमें मखु्य ततथियों का उल्लेख
िो और आपके ललए ककसी तनयत समय-सीमा के भीतर काम करना ज़रूरी िो। आपको
यि जानकारी और सबंथंित सिायता अपनी भाषा में तनिःशलु्क पाने का अथिकार
िै। सदस्यों को अपने पिचान पत्र के पीछे हदए गए फोन नबंर पर कॉल करना
चाहिए। अन्य सभी लोग 855-258-6518 पर कॉल कर सकत ेिैं और जब तक 0
दबाने के ललए न किा जाए, तब तक सवंाद की प्रतीक्षा करें। जब कोई एजेंट
उत्तर दे तो उस ेअपनी भाषा बताए ँऔर आपको व्याख्याकार से कनेक्ट कर
हदया जाएगा।
Ɓǎsɔ́ɔ̀-wùɖù (Bassa) Tò Ɖùǔ Cáo! Bɔ ̃̌ nìà kɛ ɓá nyɔ ɓě
ké m̀ gbo kpá ɓó nì fu ̀ à-fṹá-tìǐn nyɛɛ jè dyí. Bɔ ̃̌
nìà kɛ
ɓéɖé wé jɛ́ɛ́ ɓě ɓɛ́ m̀ ké ɖɛ wa mɔ́ m̀ ké nyuɛɛ nyu hwɛ̀
ɓɛ́ wé ɓěa ké zi. Ɔ mɔ̀ nì kpé ɓɛ́ m̀ ké bɔ ̃̌ nìà kɛ kè
gbo-
kpá-kpá m̀ mɔ́ɛɛ dyé ɖé nì ɓíɖí-wùɖù mú ɓɛ́ m̀ ké se
wíɖí ɖò pɛ́ɛ̀. Kpooɔ̀ nyɔ ɓě mɛ ɖá fṹùn-nɔ̀ɓà nìà ɖé
waà
I.D. káàɔ̀ ɖeín nyɛ. Nyɔ tɔ̀ɔ̀ séín mɛ ɖá nɔ̀ɓà nìà kɛ:
855-258-6518, ké m̀ mɛ fò tee ɓɛ́ wa kéɛ m̀ gbo cɛ ɓɛ́ m̀
ké
nɔ̀ɓà mɔ̀à 0 kɛɛ dyi pàɖàìn hwɛ̀. Ɔ jǔ ké nyɔ ɖò dyi m̀
gɔ ̃̌ jǔǐn, po wuɖu m̀ mɔ́ poɛ dyiɛ, ké nyɔ ɖò mu ɓó
nììn
ɓɛ́ ɔ ké nì wuɖuɔ̀ mú zà.
বাাংলা (Bengali) লক্ষ্য করুন: এই ননাটিশে আপনার ববমা কভাশরজ
সম্পশকে তথ্য রশেশে। এর মশযয গুরুত্বপূর্ে তাবরখ থ্াকশত পাশর এবাং
বনবদেষ্ট তাবরশখর মশযয আপনাশক পদশক্ষ্প বনশত হশত পাশর। ববনা খরশে
বনশজর ভাষাে এই তথ্য পাওোর এবাং সহােতা পাওোর অবযকার আপনার আশে।
সদসযশদরশক তাশদর পবরেেপশের বপেশন থ্াকা নম্বশর কল করশত হশব। অশনযরা
855-258-6518 নম্বশর কল কশর 0 টিপশত না বলা পর্েন্ত অশপক্ষ্া করশত
পাশরন। র্খন নকাশনা এশজন্ট উত্তর নদশবন তখন আপনার বনশজর ভাষার নাম
বলনু এবাং আপনাশক নদাভাষীর সশে সাংর্ুক্ত করা হশব।
یہ نوٹس آپ کے انشورینس کوریج سے متعلق معلومات پر مشتمل ہے۔ اس
میں کلیدی تاریخیں ہو سکتی ہیں اور ممکن :توجہ (Urduاردو )ہے کہ آپ کو
مخصوص آخری تاریخوں تک کارروائی کرنے کی ضرورت پڑے۔ آپ کے پاس یہ
معلومات حاصل کرنے اور بغیر خرچہ
کو اپنے شناختی کارڈ کی پشت پر موجود فون نمبر پر کال کرنی چاہیے۔
سبھی دیگر کیے اپنی زبان میں مدد حاصل کرنے کا حق ہے۔ ممبران
دبانے کو کہے جانے تک انتظار کریں۔ ایجنٹ کے جواب دینے پر اپنی
مطلوبہ زبان 0پر کال کر سکتے ہیں اور 6518-258-855لوگ
بتائیں اور مترجم سے مربوط ہو جائیں گے۔
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اتخاذ إلى تحتاج وقد مھمة، تواریخ على یحتوي وقد التأمینیة، تغطیتك
بشأن معلومات على اإلخطار هذا یحتوي :تنبیه (Arabic) العربیة اللغة
االتصال األعضاء على ینبغي .تكلفة أي تحمل بدون بلغتك والمعلومات
المساعدة هذه على الحصول لك یحق .محددة نھائیة مواعید بحلول
إجراءات
الرقم على االتصال لآلخرین یمكن .بھم الخاصة الھویة تعریف بطاقة
ظھر في المذكور الھاتف رقم على
بھا التواصل إلى تحتاج التي اللغة اذكر الوكالء، أحد إجابة عند .0
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中文繁体 (Traditional Chinese)
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(Navajo)
855-258-6518
2019 Formulary 2 Preferred Drug ListANALGESICS§ NSAIDs§ NSAIDs,
COMBINATIONS§ NSAIDs, TOPICAL§ COX-2 INHIBITORS§ GOUT§ OPIOID
ANALGESICS
ANTI-INFECTIVESANTIBACTERIALS§ CEPHALOSPORINS§ ERYTHROMYCINS /
MACROLIDES§ FLUOROQUINOLONES§ PENICILLINS§ TETRACYCLINES
§ ANTIFUNGALSANTIRETROVIRAL AGENTS§ ANTIRETROVIRAL
COMBINATIONSINTEGRASE INHIBITORS§ NUCLEOSIDE REVERSE TRANSCRIPTASE
INHIBITORS§ PROTEASE INHIBITORS
ANTIVIRALS§ CYTOMEGALOVIRUS AGENTS§ HEPATITIS B AGENTS§
HEPATITIS C AGENTS§ HERPES AGENTS§ INFLUENZA AGENTS
§ MISCELLANEOUS
ANTINEOPLASTIC AGENTSHORMONAL ANTINEOPLASTIC AGENTS§
ANTIANDROGENS
§ KINASE INHIBITORS§ MISCELLANEOUS
CARDIOVASCULAR§ ACE INHIBITORS§ ACE INHIBITOR / DIURETIC
COMBINATIONS§ ANGIOTENSIN II RECEPTOR ANTAGONISTS / DIURETIC
COMBINATIONS§ ANGIOTENSIN II RECEPTOR ANTAGONIST / CALCIUM CHANNEL
BLOCKER COMBINATIONS§ ANGIOTENSIN II RECEPTOR ANTAGONIST / CALCIUM
CHANNEL BLOCKER / DIURETIC COMBINATIONS§
ANTIARRHYTHMICSANTILIPEMICS§ BILE ACID RESINS§ CHOLESTEROL
ABSORPTION INHIBITORS§ FIBRATES§ HMG-CoA REDUCTASE INHIBITORS /
COMBINATIONS§ NIACINS§ OMEGA-3 FATTY ACIDSPCSK9 INHIBITORS
§ BETA-BLOCKERS§ CALCIUM CHANNEL BLOCKERS§ CALCIUM CHANNEL
BLOCKER / ANTILIPEMIC COMBINATIONS§ DIGITALIS GLYCOSIDESDIRECT
RENIN INHIBITORS / DIURETIC COMBINATIONS§ DIURETICSHEART FAILURE§
NITRATESPULMONARY ARTERIAL HYPERTENSIONENDOTHELIN RECEPTOR
ANTAGONISTS§ PHOSPHODIESTERASE INHIBITORSPROSTACYCLIN RECEPTOR
AGONISTS§ PROSTAGLANDIN VASODILATORSSOLUBLE GUANYLATE CYCLASE
STIMULATORS
§ MISCELLANEOUS
CENTRAL NERVOUS SYSTEM§ ANTICONVULSANTS§
ANTIDEMENTIAANTIDEPRESSANTS§ SELECTIVE SEROTONIN REUPTAKE
INHIBITORS (SSRIs)§ SEROTONIN NOREPINEPHRINE REUPTAKE INHIBITORS
(SNRIs)§ MISCELLANEOUS AGENTS
§ ANTIPARKINSONIAN AGENTSANTIPSYCHOTICS§ ATYPICALS
§ ATTENTION DEFICIT HYPERACTIVITY DISORDERFIBROMYALGIA§
HUNTINGTON'S DISEASE AGENTSHYPNOTICS§
NONBENZODIAZEPINESTRICYCLICS
MIGRAINE§ ERGOTAMINE DERIVATIVESMONOCLONAL ANTIBODIES§ SELECTIVE
SEROTONIN AGONISTSSELECTIVE SEROTONIN AGONIST / NONSTEROIDAL
ANTI-INFLAMMATORY DRUG (NSAID) COMBINATIONS
§ MULTIPLE SCLEROSIS AGENTS§ MUSCULOSKELETAL THERAPY AGENTS§
NARCOLEPSYPOSTHERPETIC NEURALGIA (PHN)PSYCHOTHERAPEUTIC -
MISCELLANEOUS§ OPIOID ANTAGONISTS§ PARTIAL OPIOID AGONIST / OPIOID
ANTAGONIST COMBINATIONSPSEUDOBULBAR AFFECT AGENTS§ VASOMOTOR
SYMPTOM AGENTS
ENDOCRINE AND METABOLICACROMEGALY§ ANDROGENSANTIDIABETICSAMYLIN
ANALOGS§ BIGUANIDES§ BIGUANIDE / SULFONYLUREA
COMBINATIONSDIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORSDIPEPTIDYL
PEPTIDASE-4 (DPP-4) INHIBITOR / BIGUANIDE COMBINATIONSINCRETIN
MIMETIC AGENTSINCRETIN MIMETIC AGENT / INSULIN
COMBINATIONSINSULINS§ INSULIN SENSITIZERS§ INSULIN SENSITIZER /
BIGUANIDE COMBINATIONS§ INSULIN SENSITIZER / SULFONYLUREA
COMBINATIONS§ MEGLITINIDESSODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2)
INHIBITORSSODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITOR /
BIGUANIDE COMBINATIONSSODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2)
INHIBITOR / DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITOR COMBINATIONS§
SULFONYLUREASSUPPLIES
ANTIOBESITYINJECTABLEORAL
CALCIUM REGULATORS§ BISPHOSPHONATES§ CALCITONINSPARATHYROID
HORMONES
§ CARNITINE DEFICIENCY AGENTSCONTRACEPTIVES§ MONOPHASIC§
BIPHASIC§ TRIPHASICFOUR PHASE§ EXTENDED CYCLE§
TRANSDERMALVAGINAL
ESTROGENS§ ORAL§ TRANSDERMAL§ VAGINAL
ESTROGEN / PROGESTINS§ ORALTRANSDERMAL
ESTROGEN / SELECTIVE ESTROGEN RECEPTOR MODULATOR
COMBINATIONSFERTILITY REGULATORSGNRH / LHRH ANTAGONISTSOVULATION
STIMULANTS, GONADOTROPINS
GAUCHER DISEASE§ GLUCOCORTICOIDSGLUCOSE ELEVATING
AGENTSHEREDITARY TYROSINEMIA TYPE 1 AGENTSHUMAN GROWTH HORMONES§
PHOSPHATE BINDER AGENTSPOTASSIUM-REMOVING AGENTSPROGESTINS§
ORALVAGINAL
§ SELECTIVE ESTROGEN RECEPTOR MODULATORS§ THYROID
SUPPLEMENTS
GASTROINTESTINAL§ ANTIEMETICS§ H2 RECEPTOR
ANTAGONISTSINFLAMMATORY BOWEL DISEASE§ ORAL AGENTS§ RECTAL
AGENTS
§ IRRITABLE BOWEL SYNDROME§ LAXATIVESOPIOID-INDUCED
CONSTIPATIONPANCREATIC ENZYMES§ PROTON PUMP INHIBITORS§ STEROIDS,
RECTAL§ ULCER THERAPY COMBINATIONS
GENITOURINARY§ BENIGN PROSTATIC HYPERPLASIAERECTILE
DYSFUNCTIONALPROSTADIL AGENTS§ PHOSPHODIESTERASE INHIBITORS
§ URINARY ANTISPASMODICS
HEMATOLOGIC§ ANTICOAGULANTSHEMATOPOIETIC GROWTH
FACTORSHEREDITARY ANGIOEDEMA§ PLATELET AGGREGATION INHIBITORS
IMMUNOLOGIC AGENTSALLERGENIC EXTRACTSAUTOIMMUNE AGENTS§
DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs)
NUTRITIONAL / SUPPLEMENTS§ ELECTROLYTESVITAMINS AND MINERALS§
PRENATAL VITAMINS
RESPIRATORY§ ANAPHYLAXIS TREATMENT AGENTS§
ANTICHOLINERGICSANTICHOLINERGIC / BETA AGONIST COMBINATIONS§ SHORT
ACTINGLONG ACTING
ANTICHOLINERGIC / BETA AGONIST / STEROID INHALANT
COMBINATIONSBETA AGONISTS, INHALANTS§ SHORT ACTINGLONG
ACTINGHand-held Active InhalationNebulized Passive Inhalation
§ CYSTIC FIBROSIS§ LEUKOTRIENE MODULATORS§ NASAL ANTIHISTAMINES§
NASAL STEROIDS / COMBINATIONSPHOSPHODIESTERASE-4
INHIBITORSPULMONARY FIBROSIS AGENTSSTEROID / BETA AGONIST
COMBINATIONS§ STEROID INHALANTS
TOPICALDERMATOLOGYACNE§ Topical
§ ACTINIC KERATOSIS§ ANTIFUNGALS§ ANTIPSORIATICSATOPIC
DERMATITISInjectable§ Topical
CORTICOSTEROIDS§ Low Potency§ Medium Potency§ High Potency§ Very
High Potency
§ ROSACEA
MOUTH / THROAT / DENTAL AGENTSPROTECTANTS
OPHTHALMIC§ ANTIALLERGICS§ ANTI-INFECTIVES§ ANTI-INFECTIVE /
ANTI-INFLAMMATORY COMBINATIONSANTI-INFLAMMATORIES§ Nonsteroidal§
Steroidal
BETA-BLOCKERS§ NonselectiveSelective
§ CARBONIC ANHYDRASE INHIBITORS§ CARBONIC ANHYDRASE INHIBITOR /
BETA-BLOCKER COMBINATIONSCARBONIC ANHYDRASE INHIBITOR /
SYMPATHOMIMETIC COMBINATIONSDRY EYE DISEASE§ PROSTAGLANDINSRHO
KINASE INHIBITORS§ SYMPATHOMIMETICSSYMPATHOMIMETIC / BETA-BLOCKER
COMBINATIONS
OTIC§ ANTI-INFECTIVE / ANTI-INFLAMMATORY COMBINATIONS
QUICK REFERENCE DRUG LISTABCDEFGHIJKLMNOPQRSTUVWXZPREFERRED
OPTIONS LIST
NDLA-ENGLISH-7-18