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April 2018
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 members 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
solution PA QL VOLTAREN GEL COX-2 INHIBITORS celecoxib GOUT
allopurinol colchicine tablet probenecid COLCRYS ULORIC
OPIOID ANALGESICS codeine-acetaminophen QL fentanyl transdermal
QL fentanyl transmucosal lozenge PA hydrocodone-acetaminophen QL
hydromorphone QL hydromorphone ext-rel QL methadone QL morphine QL
morphine ext-rel QL morphine suppository QL oxycodone QL
oxycodone-acetaminophen QL tramadol QL tramadol ext-rel QL BELBUCA
QL BUTRANS QL FENTORA PA HYSINGLA ER QL NUCYNTA QL NUCYNTA ER QL
OXYCONTIN QL SUBSYS PA
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 COMPLERA DESCOVY EVOTAZ
GENVOYA ODEFSEY PREZCOBIX STRIBILD TRIUMEQ
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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 PA SP EPCLUSA (genotypes 1, 2, 3, 4,
5, 6) PA SP HARVONI (genotypes 1, 4, 5, 6) PA SP VOSEVI 2 PA SP
HERPES AGENTS acyclovir valacyclovir INFLUENZA AGENTS oseltamivir
QL RELENZA QL MISCELLANEOUS clindamycin ivermectin metronidazole
nitrofurantoin sulfamethoxazole-trimethoprim EMVERM QL SIVEXTRO
XIFAXAN 550 MG
ANTINEOPLASTIC AGENTS
HORMONAL ANTINEOPLASTIC AGENTS ANTIANDROGENS bicalutamide XTANDI
PA SP ZYTIGA PA SP KINASE INHIBITORS imatinib mesylate PA SP
BOSULIF PA SP CABOMETYX PA SP IBRANCE PA SP IRESSA PA SP KISQALI PA
SP KISQALI FEMARA CO-PACK PA SP RYDAPT PA SP SPRYCEL PA SP
MISCELLANEOUS ODOMZO PA SP VISTOGARD SP
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 WELCHOL 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 PA PCSK9 INHIBITORS PRALUENT PA SP SI
REPATHA PA SP SI 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 PA SP OPSUMIT PA SP TRACLEER PA SP
PHOSPHODIESTERASE INHIBITORS sildenafil 20 mg PA SP
PROSTACYCLIN RECEPTOR AGONISTS UPTRAVI PA SP PROSTAGLANDIN
VASODILATORS ORENITRAM PA SP SOLUBLE GUANYLATE CYCLASE STIMULATORS
ADEMPAS PA SP 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 NAMENDA XR NAMZARIC ANTIDEPRESSANTS
SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs) citalopram
escitalopram fluoxetine paroxetine HCl paroxetine HCl ext-rel
sertraline FLUOXETINE 60 MG TRINTELLIX VIIBRYD SEROTONIN
NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIs) desvenlafaxine ext-rel
duloxetine venlafaxine
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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 ropinirole
ropinirole ext-rel selegiline AZILECT MIRAPEX ER NEUPRO
ANTIPSYCHOTICS ATYPICALS aripiprazole clozapine olanzapine
quetiapine risperidone ziprasidone ABILIFY MAINTENA SI ARISTADA SI
LATUDA VRAYLAR ATTENTION DEFICIT HYPERACTIVITY DISORDER
amphetamine-dextroamphetamine
mixed salts amphetamine-dextroamphetamine
mixed salts ext-rel atomoxetine guanfacine ext-rel
methylphenidate methylphenidate ext-rel APTENSIO XR QUILLIVANT XR
VYVANSE FIBROMYALGIA LYRICA SAVELLA HUNTINGTON'S DISEASE AGENTS
tetrabenazine PA SP AUSTEDO PA SP HYPNOTICS NONBENZODIAZEPINES
eszopiclone zolpidem zolpidem ext-rel zolpidem sublingual BELSOMRA
TRICYCLICS SILENOR MIGRAINE ERGOTAMINE DERIVATIVES
ergotamine-caffeine
SELECTIVE SEROTONIN AGONISTS eletriptan QL naratriptan QL
rizatriptan QL sumatriptan QL zolmitriptan QL ONZETRA XSAIL QL
ZEMBRACE SYMTOUCH QL SI ZOMIG NASAL SPRAY QL SELECTIVE SEROTONIN
AGONIST / NONSTEROIDAL ANTI-INFLAMMATORY DRUG (NSAID) COMBINATIONS
TREXIMET QL MULTIPLE SCLEROSIS AGENTS glatiramer Rx,MB PA SP SI
AUBAGIO PA SP BETASERON Rx,MB PA SP SI COPAXONE 40 MG Rx,MB PA SP
SI GILENYA PA SP REBIF Rx,MB PA SP SI TECFIDERA PA SP
MUSCULOSKELETAL THERAPY AGENTS cyclobenzaprine NARCOLEPSY
armodafinil PA POSTHERPETIC NEURALGIA (PHN) GRALISE
PSYCHOTHERAPEUTIC - MISCELLANEOUS OPIOID ANTAGONISTS naloxone
injection SI 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 Rx,MB PA SP SI ANDROGENS testosterone gel 2%
testosterone solution ANDRODERM ANDROGEL 1.62% ANTIDIABETICS AMYLIN
ANALOGS SYMLINPEN SI
BIGUANIDES metformin metformin ext-rel 4 BIGUANIDE /
SULFONYLUREA COMBINATIONS glipizide-metformin DIPEPTIDYL
PEPTIDASE-4 (DPP-4) INHIBITORS JANUVIA TRADJENTA DIPEPTIDYL
PEPTIDASE-4 (DPP-4) INHIBITOR / BIGUANIDE COMBINATIONS JANUMET
JANUMET XR JENTADUETO JENTADUETO XR INCRETIN MIMETIC AGENTS
TRULICITY SI VICTOZA SI INCRETIN MIMETIC AGENT / INSULIN
COMBINATIONS SOLIQUA SI 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 INVOKANA SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2)
INHIBITOR / BIGUANIDE COMBINATIONS INVOKAMET INVOKAMET XR XIGDUO
XR
SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITOR / DIPEPTIDYL
PEPTIDASE-4 (DPP-4) INHIBITOR COMBINATIONS QTERN SULFONYLUREAS
glimepiride glipizide glipizide ext-rel SUPPLIES BD ULTRAFINE
INSULIN
SYRINGES AND NEEDLES DEXCOM CONTINUOUS GLUCOSE
MONITORING SYSTEM * ONETOUCH ULTRA
STRIPS AND KITS 5 QL ONETOUCH VERIO
STRIPS AND KITS 5 QL ANTIOBESITY INJECTABLE SAXENDA SI ORAL
BELVIQ BELVIQ XR CONTRAVE CALCIUM REGULATORS BISPHOSPHONATES
alendronate ibandronate risedronate CALCITONINS calcitonin-salmon
PARATHYROID HORMONES FORTEO Rx,MB PA SP SI TYMLOS PA SP SI
CARNITINE DEFICIENCY AGENTS levocarnitine CONTRACEPTIVES MONOPHASIC
ethinyl estradiol-drospirenone ethinyl estradiol-norethindrone
acetate BEYAZ LO LOESTRIN FE MINASTRIN 24 FE SAFYRAL TRIPHASIC
ethinyl estradiol-norgestimate FOUR PHASE NATAZIA EXTENDED CYCLE
ethinyl estradiol-levonorgestrel TRANSDERMAL ethinyl
estradiol-norelgestromin VAGINAL NUVARING
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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 Rx,MB SP SI OVULATION STIMULANTS, GONADOTROPINS GONAL-F
Rx,MB SP SI OVIDREL Rx,MB SP SI GAUCHER DISEASE CERDELGA PA SP
GLUCOCORTICOIDS dexamethasone methylprednisolone prednisolone
solution prednisone GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT SI
GLUCAGON EMERGENCY KIT SI HUMAN GROWTH HORMONES HUMATROPE Rx,MB PA
SP SI 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 QL meclizine metoclopramide
ondansetron QL prochlorperazine promethazine trimethobenzamide
DICLEGIS SANCUSO QL VARUBI QL 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 AMITIZA
LINZESS LOTRONEX 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 QL
PHOSPHODIESTERASE INHIBITORS sildenafil QL CIALIS QL 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 Rx,MB PA SP SI PROCRIT Rx,MB PA SP SI ZARXIO Rx,MB
PA SP SI HEREDITARY ANGIOEDEMA RUCONEST Rx,MB PA SP SI PLATELET
AGGREGATION INHIBITORS clopidogrel dipyridamole ext-rel-aspirin
prasugrel BRILINTA
IMMUNOLOGIC AGENTS
ALLERGENIC EXTRACTS GRASTEK ORALAIR RAGWITEK
AUTOIMMUNE AGENTS COSENTYX Rx,MB PA SP SI ENBREL PA SP SI HUMIRA
PA SP SI KEVZARA PA SP SI OTEZLA PA SP STELARA SUBCUTANEOUS
(Plaque Psoriasis and Psoriatic Arthritis only) Rx,MB PA SP
SI
DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) RASUVO Rx,MB PA
SP SI
NUTRITIONAL / SUPPLEMENTS
ELECTROLYTES potassium chloride liquid VITAMINS AND MINERALS
PRENATAL VITAMINS prenatal vitamins CITRANATAL
RESPIRATORY
ANAPHYLAXIS TREATMENT AGENTS epinephrine auto-injector SI EPIPEN
SI EPIPEN JR SI ANTICHOLINERGICS ipratropium inhalation solution
INCRUSE ELLIPTA SPIRIVA ANTICHOLINERGIC / BETA AGONIST COMBINATIONS
SHORT ACTING ipratropium-albuterol inhalation
solution COMBIVENT RESPIMAT LONG ACTING ANORO ELLIPTA 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
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CYSTIC FIBROSIS tobramycin inhalation
solution Rx,MB PA SP BETHKIS Rx,MB PA SP 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 PA SP OFEV PA
SP STEROID / BETA AGONIST COMBINATIONS ADVAIR BREO ELLIPTA
SYMBICORT STEROID INHALANTS budesonide inhalation suspension
ASMANEX FLOVENT DISKUS FLOVENT HFA PULMICORT FLEXHALER QVAR
TOPICAL
DERMATOLOGY ACNE adapalene benzoyl peroxide clindamycin solution
clindamycin-benzoyl peroxide erythromycin solution
erythromycin-benzoyl peroxide tretinoin PA ACANYA
ATRALIN PA BENZACLIN DIFFERIN EPIDUO RETIN-A MICRO PA TAZORAC
ACTINIC KERATOSIS fluorouracil cream 5% fluorouracil solution
imiquimod PICATO TOLAK ZYCLARA ANTIFUNGALS ciclopirox clotrimazole
econazole ketoconazole nystatin JUBLIA PA LUZU NAFTIN
ANTIPSORIATICS acitretin calcipotriene methoxsalen ATOPIC
DERMATITIS Injectable DUPIXENT PA SP SI Topical tacrolimus ELIDEL
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
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 SI ACANYA acitretin ACUVAIL acyclovir adapalene
ADEMPAS PA SP ADVAIR albuterol inhalation solution alendronate
alfuzosin ext-rel allopurinol 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 APTENSIO XR ARANESP Rx,MB PA SP SI aripiprazole ARISTADA SI
armodafinil PA ASMANEX atenolol atomoxetine atorvastatin ATRALIN PA
ATRIPLA AUBAGIO PA SP AUSTEDO PA SP azelastine AZILECT azithromycin
AZOPT
B balsalazide BASAGLAR BD ULTRAFINE INSULIN
SYRINGES AND NEEDLES BELBUCA QL BELSOMRA BELVIQ BELVIQ XR
BENZACLIN benzoyl peroxide BESIVANCE BETASERON Rx,MB PA SP SI
BETHKIS Rx,MB PA SP BETIMOL BETOPTIC S BEVESPI AEROSPHERE BEYAZ
bicalutamide BIDIL BOSULIF PA SP BREO ELLIPTA BRILINTA brimonidine
bromfenac budesonide capsule budesonide inhalation suspension
buprenorphine-naloxone
sublingual tablet bupropion bupropion ext-rel BUTRANS QL
BYSTOLIC
C CABOMETYX PA SP 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
PA SP CETROTIDE Rx,MB SP SI cholestyramine CIALIS QL 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 QL colchicine tablet COLCRYS
COMBIGAN
COMBIPATCH COMBIVENT RESPIMAT COMPLERA CONTRAVE COPAXONE 40 MG
Rx,MB PA SP SI COREG CR CORLANOR CORTIFOAM COSENTYX Rx,MB PA SP SI
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 solution PA QL
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 PA SP SI DUREZOL dutasteride
dutasteride-tamsulosin DYMISTA
E econazole eletriptan QL ELIDEL ELIQUIS EMVERM QL ENBREL PA SP
SI ENDOMETRIN entacapone ENTRESTO EPCLUSA PA SP EPIDUO epinephrine
auto-injector SI
EPIPEN SI EPIPEN JR SI EPISIL eprosartan ergotamine-caffeine
erythromycin erythromycin solution erythromycin-benzoyl peroxide
erythromycins ESBRIET PA SP escitalopram esomeprazole ESTRACE CREAM
estradiol estradiol-norethindrone ESTRING estropipate eszopiclone
ethinyl estradiol-drospirenone ethinyl estradiol-levonorgestrel
ethinyl estradiol-norelgestromin ethinyl
estradiol-norethindrone
acetate ethinyl estradiol-norgestimate ethosuximide EVAMIST
EVOTAZ ezetimibe ezetimibe-simvastatin
F FARXIGA fenofibrate fenofibric acid fentanyl transdermal QL
fentanyl transmucosal lozenge PA FENTORA PA FIASP FINACEA
finasteride FLAREX FLOVENT DISKUS FLOVENT HFA fluconazole
flunisolide fluocinonide fluorouracil cream 5% fluorouracil
solution fluoxetine FLUOXETINE 60 MG fluticasone fluvastatin FML
FORTE FML S.O.P. FORTEO Rx,MB PA SP SI fosinopril
fosinopril-hydrochlorothiazide furosemide FYCOMPA
G gabapentin galantamine galantamine ext-rel gentamicin GENVOYA
GILENYA PA SP
-
glatiramer Rx,MB PA SP SI glimepiride glipizide glipizide
ext-rel glipizide-metformin GLUCAGEN HYPOKIT SI GLUCAGON EMERGENCY
KIT SI GONAL-F Rx,MB SP SI GRALISE granisetron QL GRASTEK
guanfacine ext-rel
H HARVONI PA SP HUMATROPE Rx,MB PA SP SI HUMIRA PA SP SI HUMULIN
R U-500 hydrochlorothiazide hydrocodone-acetaminophen QL
hydrocortisone hydrocortisone butyrate hydrocortisone enema
hydromorphone QL hydromorphone ext-rel QL HYSINGLA ER QL
I ibandronate IBRANCE PA SP ILEVRO imatinib mesylate PA SP
imiquimod INCRUSE ELLIPTA INVOKAMET INVOKAMET XR INVOKANA
ipratropium inhalation solution ipratropium-albuterol
inhalation
solution irbesartan irbesartan-hydrochlorothiazide IRESSA PA SP
ISENTRESS itraconazole ivermectin
J JANUMET JANUMET XR JANUVIA JENTADUETO JENTADUETO XR JUBLIA
PA
K ketoconazole ketorolac KEVZARA PA SP SI KISQALI PA SP KISQALI
FEMARA CO-PACK PA SP
L lactulose lamivudine lamotrigine lamotrigine ext-rel
lansoprazole lanthanum carbonate LASTACAFT
latanoprost LATUDA LETAIRIS PA SP levalbuterol tartrate CFC-free
aerosol LEVEMIR levetiracetam levetiracetam ext-rel levocarnitine
levofloxacin levothyroxine LIALDA LINZESS lisinopril
lisinopril-hydrochlorothiazide LO LOESTRIN FE losartan
losartan-hydrochlorothiazide LOTRONEX lovastatin LUMIGAN LUZU
LYRICA
M MAXIDEX meclizine medroxyprogesterone megestrol acetate
meloxicam memantine mesalamine rectal suspension metformin
metformin ext-rel 4 methadone QL methoxsalen methylphenidate
methylphenidate ext-rel methylprednisolone metoclopramide
metolazone metoprolol succinate ext-rel metoprolol tartrate
metronidazole MINASTRIN 24 FE MINIVELLE minocycline MIRAPEX ER
mirtazapine mometasone montelukast morphine QL morphine ext-rel QL
morphine suppository QL MOVANTIK MOXEZA moxifloxacin MUGARD MULTAQ
MUSE QL MYRBETRIQ
N nadolol NAFTIN naloxone injection SI NAMENDA XR NAMZARIC
naproxen naratriptan QL 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 QL NUCYNTA ER QL NUEDEXTA NUVARING nystatin
O ODEFSEY ODOMZO PA SP OFEV PA SP ofloxacin olanzapine
olmesartan olmesartan-amlodipine-
hydrochlorothiazide olmesartan-hydrochlorothiazide olopatadine
omega-3 acid ethyl esters omeprazole ondansetron QL ONETOUCH
ULTRA
STRIPS AND KITS 5 QL ONETOUCH VERIO
STRIPS AND KITS 5 QL ONZETRA XSAIL QL OPSUMIT PA SP ORACEA
ORALAIR ORENITRAM PA SP oseltamivir QL OSPHENA OTEZLA PA SP OVIDREL
Rx,MB SP SI oxcarbazepine OXTELLAR XR oxybutynin oxybutynin ext-rel
oxycodone QL oxycodone-acetaminophen QL OXYCONTIN QL
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 PRALUENT PA SP SI
pramipexole 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 Rx,MB PA SP
SI PROCTOFOAM-HC progesterone, micronized promethazine propranolol
propranolol ext-rel PULMICORT FLEXHALER PYLERA
Q QTERN quetiapine QUILLIVANT XR quinapril
quinapril-hydrochlorothiazide QVAR
R RAGWITEK raloxifene ramipril RANEXA ranitidine RAPAFLO RASUVO
Rx,MB PA SP SI REBIF Rx,MB PA SP SI RELENZA QL repaglinide REPATHA
PA SP SI RESTASIS RETIN-A MICRO PA REYATAZ ribavirin PA SP
risedronate risperidone rivastigmine rivastigmine transdermal
rizatriptan QL ropinirole ropinirole ext-rel
-
rosuvastatin RUCONEST Rx,MB PA SP SI RYDAPT PA SP
S SAFYRAL SANCUSO QL SAVELLA SAXENDA SI selegiline SEREVENT
sertraline sevelamer carbonate sildenafil QL sildenafil 20 mg PA SP
SILENOR SIMBRINZA simvastatin SIVEXTRO SOLIQUA SI SOMAVERT Rx,MB PA
SP SI SOOLANTRA sotalol SPIRIVA spironolactone-hydrochlorothiazide
SPRYCEL PA SP STELARA
SUBCUTANEOUS Rx,MB PA SP SI STIOLTO RESPIMAT STRIBILD STRIVERDI
RESPIMAT SUBOXONE FILM SUBSYS PA sulfacetamide
sulfamethoxazole-trimethoprim sulfasalazine sulfasalazine
delayed-rel sumatriptan QL SUPRAX SUPREP
SYMBICORT SYMLINPEN SI SYNTHROID
T tacrolimus tamsulosin TAZORAC TECFIDERA PA SP TEKTURNA
TEKTURNA HCT telmisartan telmisartan-hydrochlorothiazide terazosin
terbinafine tablet testosterone gel 2% testosterone solution
tetrabenazine PA SP tetracycline tiagabine timolol maleate solution
TIVICAY TOBRADEX OINTMENT TOBRADEX ST tobramycin tobramycin
inhalation
solution Rx,MB PA SP tobramycin-dexamethasone TOLAK tolterodine
tolterodine ext-rel topiramate torsemide TOVIAZ TRACLEER PA SP
TRADJENTA tramadol QL tramadol ext-rel QL TRAVATAN Z trazodone
TRELEGY ELLIPTA TRESIBA tretinoin PA TREXIMET QL triamcinolone
triamterene-hydrochlorothiazide trimethobenzamide TRINTELLIX
TRIUMEQ TROKENDI XR trospium trospium ext-rel TRULICITY SI TRUVADA
TYMLOS PA SP SI
U UCERIS ULORIC UPTRAVI PA SP
V valacyclovir valganciclovir valproic acid valsartan
valsartan-hydrochlorothiazide VARUBI QL VASCEPA PA VELPHORO
VELTASSA VEMLIDY venlafaxine venlafaxine ext-rel capsule verapamil
ext-rel VESICARE VIBERZI VICTOZA SI VIIBRYD
VIMPAT VIOKACE VISTOGARD SP VOLTAREN GEL VOSEVI 2 PA SP VRAYLAR
VYVANSE
W warfarin WELCHOL
X XARELTO XIFAXAN 550 MG XIGDUO XR XIIDRA XTANDI PA SP
Z zafirlukast ZARXIO Rx,MB PA SP SI ZEMBRACE SYMTOUCH QL SI
ZENPEP zileuton ext-rel ziprasidone zolmitriptan QL zolpidem
zolpidem ext-rel zolpidem sublingual ZOMIG NASAL SPRAY QL
zonisamide ZUBSOLV ZYCLARA ZYLET ZYTIGA PA SP
PREFERRED OPTIONS LIST NON-PREFERRED OR EXCLUDED DRUG(S)
PREFERRED OPTION(S)
ABILIFY aripiprazole, clozapine, olanzapine, quetiapine,
risperidone, ziprasidone, LATUDA, VRAYLAR
ACCU-CHEK STRIPS AND KITS 6 QL
ONETOUCH ULTRA STRIPS AND KITS 5 QL, ONETOUCH VERIO STRIPS AND
KITS 5 QL
ACTEMRA Rx,MB PA SP SI ENBREL PA SP SI, HUMIRA PA SP SI, KEVZARA
PA SP SI
ACTOS pioglitazone
ADDERALL XR amphetamine-dextroamphetamine mixed salts ext-rel,
methylphenidate ext-rel, APTENSIO XR, QUILLIVANT XR, VYVANSE
AEROSPAN ASMANEX, FLOVENT DISKUS, FLOVENT HFA, PULMICORT
FLEXHALER, QVAR
ALCORTIN A desonide, hydrocortisone
ALEVICYN desonide, hydrocortisone
ALLISON MEDICAL INSULIN SYRINGES 7
BD ULTRAFINE INSULIN SYRINGES
ALOQUIN desonide, hydrocortisone
ALORA estradiol, DIVIGEL, EVAMIST, MINIVELLE
ALTOPREV atorvastatin, ezetimibe-simvastatin, fluvastatin,
lovastatin, pravastatin, rosuvastatin, simvastatin
NON-PREFERRED OR EXCLUDED DRUG(S)
PREFERRED OPTION(S)
ALVESCO ASMANEX, FLOVENT DISKUS, FLOVENT HFA, PULMICORT
FLEXHALER, QVAR
AMRIX cyclobenzaprine
ANDROGEL 1% testosterone gel 2%, 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
ASCENSIA STRIPS AND KITS 6 QL
ONETOUCH ULTRA STRIPS AND KITS 5 QL, ONETOUCH VERIO STRIPS AND
KITS 5 QL
-
NON-PREFERRED OR EXCLUDED DRUG(S)
PREFERRED OPTION(S)
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
AXERT QL eletriptan QL, naratriptan QL, rizatriptan QL,
sumatriptan QL, zolmitriptan QL, ONZETRA XSAIL QL, ZEMBRACE
SYMTOUCH QL SI, ZOMIG NASAL SPRAY QL
AZELEX adapalene, benzoyl peroxide, clindamycin solution,
clindamycin-benzoyl peroxide, erythromycin solution,
erythromycin-benzoyl peroxide, tretinoin PA, ACANYA, ATRALIN PA,
BENZACLIN, DIFFERIN, EPIDUO, RETIN-A MICRO PA, 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 PA, ACANYA, ATRALIN PA,
BENZACLIN, DIFFERIN, EPIDUO, RETIN-A MICRO PA, TAZORAC
BENZIQ adapalene, benzoyl peroxide, clindamycin solution,
clindamycin-benzoyl peroxide, erythromycin solution,
erythromycin-benzoyl peroxide, tretinoin PA, ACANYA, ATRALIN PA,
BENZACLIN, DIFFERIN, EPIDUO, RETIN-A MICRO PA, TAZORAC
BETAPACE, BETAPACE AF sotalol
BREEZE 2 STRIPS AND KITS 6 QL
ONETOUCH ULTRA STRIPS AND KITS 5 QL, ONETOUCH VERIO STRIPS AND
KITS 5 QL
butalbital-acetaminophen-caffeine capsule
eletriptan QL, ergotamine-caffeine, naratriptan QL, rizatriptan
QL, sumatriptan QL, zolmitriptan QL, ONZETRA XSAIL QL, ZEMBRACE
SYMTOUCH QL SI, ZOMIG NASAL SPRAY QL
BYDUREON SI TRULICITY SI, VICTOZA SI
BYETTA SI TRULICITY SI, VICTOZA SI
CAFERGOT eletriptan QL, ergotamine-caffeine, naratriptan QL,
rizatriptan QL, sumatriptan QL, zolmitriptan QL, ONZETRA XSAIL QL,
ZEMBRACE SYMTOUCH QL SI, ZOMIG NASAL SPRAY QL
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
CARNITOR SF levocarnitine
CIMZIA Rx,MB PA SP SI COSENTYX Rx,MB PA SP SI, ENBREL PA SP SI,
HUMIRA PA SP SI, KEVZARA PA SP SI, OTEZLA PA SP, STELARA
SUBCUTANEOUS (Plaque Psoriasis and Psoriatic Arthritis only) Rx,MB
PA SP SI
NON-PREFERRED OR EXCLUDED DRUG(S)
PREFERRED OPTION(S)
CLINDAGEL erythromycin solution
clobetasol spray clobetasol foam
CLOBEX SPRAY clobetasol foam
COLAZAL balsalazide
CONTOUR NEXT STRIPS AND KITS 6 QL
ONETOUCH ULTRA STRIPS AND KITS 5 QL, ONETOUCH VERIO STRIPS AND
KITS 5 QL
CONTOUR STRIPS AND KITS 6 QL
ONETOUCH ULTRA STRIPS AND KITS 5 QL, ONETOUCH VERIO STRIPS AND
KITS 5 QL
CRESTOR atorvastatin, ezetimibe-simvastatin, fluvastatin,
lovastatin, pravastatin, rosuvastatin, simvastatin
CYMBALTA desvenlafaxine ext-rel, duloxetine, venlafaxine,
venlafaxine ext-rel capsule
DAKLINZA PA SP EPCLUSA (genotypes 1, 2, 3, 4, 5, 6) PA SP,
HARVONI (genotypes 1, 4, 5, 6) PA SP
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
EVZIO SI naloxone injection SI, NARCAN NASAL SPRAY
EXFORGE amlodipine-olmesartan, amlodipine-telmisartan,
amlodipine-valsartan
EXFORGE HCT amlodipine-valsartan-hydrochlorothiazide,
olmesartan-amlodipine-hydrochlorothiazide
-
NON-PREFERRED OR EXCLUDED DRUG(S)
PREFERRED OPTION(S)
EXTAVIA Rx,MB PA SP SI glatiramer Rx,MB PA SP SI, AUBAGIO PA SP,
BETASERON Rx,MB PA SP SI, COPAXONE 40 MG Rx,MB PA SP SI, GILENYA PA
SP, REBIF Rx,MB PA SP SI, TECFIDERA PA SP
FANAPT aripiprazole, clozapine, olanzapine, quetiapine,
risperidone, ziprasidone, LATUDA, VRAYLAR
FEMRING estradiol, ESTRACE CREAM, ESTRING, PREMARIN CREAM
FETZIMA desvenlafaxine ext-rel, duloxetine, venlafaxine,
venlafaxine ext-rel capsule
FIORICET CAPSULE eletriptan QL, ergotamine-caffeine, naratriptan
QL, rizatriptan QL, sumatriptan QL, zolmitriptan QL, ONZETRA XSAIL
QL, ZEMBRACE SYMTOUCH QL SI, ZOMIG NASAL SPRAY QL
FIRST TESTOSTERONE testosterone gel 2%, testosterone solution,
ANDRODERM, ANDROGEL 1.62%
fluorouracil cream 0.5% fluorouracil cream 5%, fluorouracil
solution, imiquimod, PICATO, TOLAK, ZYCLARA
FOLLISTIM AQ Rx,MB SP SI GONAL-F Rx,MB SP SI
FORTAMET metformin, metformin ext-rel (except generic FORTAMET
or generic GLUMETZA)
FORTESTA testosterone gel 2%, 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 QL
ONETOUCH ULTRA STRIPS AND KITS 5 QL, ONETOUCH VERIO STRIPS AND
KITS 5 QL
FROVA QL eletriptan QL, naratriptan QL, rizatriptan QL,
sumatriptan QL, zolmitriptan QL, ONZETRA XSAIL QL, ZEMBRACE
SYMTOUCH QL SI, ZOMIG NASAL SPRAY QL
GENOTROPIN Rx,MB PA SP SI HUMATROPE Rx,MB PA SP SI
GLEEVEC PA SP imatinib mesylate PA SP, BOSULIF PA SP, SPRYCEL PA
SP
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 celecoxib, 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, APTENSIO
XR, QUILLIVANT XR, VYVANSE
ISTALOL timolol maleate solution, BETIMOL
NON-PREFERRED OR EXCLUDED DRUG(S)
PREFERRED OPTION(S)
JALYN dutasteride-tamsulosin; dutasteride or finasteride WITH
alfuzosin ext-rel, doxazosin, tamsulosin, terazosin, or RAPAFLO
JARDIANCE FARXIGA, INVOKANA
KAZANO JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR
KINERET Rx,MB PA SP SI ENBREL PA SP SI, HUMIRA PA SP SI, KEVZARA
PA SP SI
KOMBIGLYZE XR JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR
LANOXIN TABLET (125 MCG and 250 MCG only)
digoxin
LANTUS BASAGLAR, LEVEMIR, TRESIBA
LESCOL XL atorvastatin, ezetimibe-simvastatin, fluvastatin,
lovastatin, pravastatin, rosuvastatin, simvastatin
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 PA SP EPCLUSA (genotypes 1, 2, 3, 4, 5, 6) PA SP,
HARVONI (genotypes 1, 4, 5, 6) PA SP, VOSEVI 2 PA SP
MENEST estradiol, estropipate, PREMARIN
MENOSTAR estradiol
MIACALCIN INJECTION SI alendronate, calcitonin-salmon,
ibandronate, risedronate, FORTEO Rx,MB PA SP SI, TYMLOS PA SP
SI
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
MONODOX doxycycline hyclate
NAPRELAN ST celecoxib, diclofenac sodium, meloxicam,
naproxen
NATESTO testosterone gel 2%, testosterone solution, ANDRODERM,
ANDROGEL 1.62%
NESINA JANUVIA, TRADJENTA
NEUPOGEN Rx,MB PA SP SI ZARXIO Rx,MB PA SP SI
NEXIUM esomeprazole, lansoprazole, omeprazole, pantoprazole,
DEXILANT
NILANDRON bicalutamide, XTANDI PA SP, ZYTIGA PA SP
NITROMIST nitroglycerin lingual spray, nitroglycerin
sublingual
NORITATE metronidazole, FINACEA, SOOLANTRA
NORVASC amlodipine
NOVACORT desonide, hydrocortisone
NOVO NORDISK NEEDLES 7 BD ULTRAFINE NEEDLES
-
NON-PREFERRED OR EXCLUDED DRUG(S)
PREFERRED OPTION(S)
NUTROPIN AQ Rx,MB PA SP SI HUMATROPE Rx,MB PA SP SI
NUVIGIL PA armodafinil PA
OLEPTRO trazodone
OLUX-E clobetasol foam
OLYSIO PA SP EPCLUSA (genotypes 1, 2, 3, 4, 5, 6) PA SP, HARVONI
(genotypes 1, 4, 5, 6) PA SP
OMNARIS flunisolide, fluticasone, mometasone, triamcinolone,
DYMISTA
OMNITROPE Rx,MB PA SP SI HUMATROPE Rx,MB PA SP SI
ONGLYZA JANUVIA, TRADJENTA
ORENCIA CLICKJECT Rx,MB PA SP SI
COSENTYX Rx,MB PA SP SI, ENBREL PA SP SI, HUMIRA PA SP SI,
KEVZARA PA SP SI, OTEZLA PA SP, STELARA SUBCUTANEOUS (Plaque
Psoriasis and Psoriatic Arthritis only) Rx,MB PA SP SI
ORENCIA INTRAVENOUS Rx,MB PA SP SI
COSENTYX Rx,MB PA SP SI, ENBREL PA SP SI, HUMIRA PA SP SI,
KEVZARA PA SP SI, OTEZLA PA SP, STELARA SUBCUTANEOUS (Plaque
Psoriasis and Psoriatic Arthritis only) Rx,MB PA SP SI
ORENCIA SUBCUTANEOUS Rx,MB PA SP SI
COSENTYX Rx,MB PA SP SI, ENBREL PA SP SI, HUMIRA PA SP SI,
KEVZARA PA SP SI, OTEZLA PA SP, STELARA SUBCUTANEOUS (Plaque
Psoriasis and Psoriatic Arthritis only) Rx,MB PA SP SI
OSENI JANUMET, JANUMET XR, JENTADUETO, JENTADUETO 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 PA QL diclofenac sodium, diclofenac sodium solution PA
QL, meloxicam, naproxen, VOLTAREN GEL
PERRIGO NEEDLES 7 BD ULTRAFINE NEEDLES
PERTZYE CREON, VIOKACE, ZENPEP
PEXEVA citalopram, escitalopram, fluoxetine, paroxetine HCl,
paroxetine HCl ext-rel, sertraline, FLUOXETINE 60 MG, TRINTELLIX,
VIIBRYD
PLAVIX clopidogrel, prasugrel, BRILINTA
PRADAXA warfarin, ELIQUIS, XARELTO
PRECISION XTRA STRIPS AND KITS 6 QL
ONETOUCH ULTRA STRIPS AND KITS 5 QL, ONETOUCH VERIO STRIPS AND
KITS 5 QL
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
PRENATAL PLUS generic prenatal vitamins, CITRANATAL
PREVACID esomeprazole, lansoprazole, omeprazole, pantoprazole,
DEXILANT
PRIMLEV QL hydrocodone-acetaminophen QL, hydromorphone QL,
morphine QL, oxycodone-acetaminophen QL, NUCYNTA QL
PROTONIX esomeprazole, lansoprazole, omeprazole, pantoprazole,
DEXILANT
PROTOPIC tacrolimus, ELIDEL
PROVENTIL HFA levalbuterol tartrate CFC-free aerosol, PROAIR
HFA, PROAIR RESPICLICK
NON-PREFERRED OR EXCLUDED DRUG(S)
PREFERRED OPTION(S)
QNASL flunisolide, fluticasone, mometasone, triamcinolone,
DYMISTA
QSYMIA BELVIQ, BELVIQ XR, CONTRAVE, SAXENDA SI
RAYOS dexamethasone, methylprednisolone, prednisolone solution,
prednisone
RELION INSULIN NOVOLIN INSULIN
RELISTOR SI MOVANTIK
RIOMET metformin, metformin ext-rel (except generic FORTAMET or
generic GLUMETZA)
ROZEREM eszopiclone, zolpidem, zolpidem ext-rel, zolpidem
sublingual, BELSOMRA, SILENOR
SAIZEN Rx,MB PA SP SI HUMATROPE Rx,MB PA SP SI
SEROQUEL XR aripiprazole, clozapine, olanzapine, quetiapine,
risperidone, ziprasidone, LATUDA, VRAYLAR
SIMPONI Rx,MB PA SP SI COSENTYX Rx,MB PA SP SI, ENBREL PA SP SI,
HUMIRA PA SP SI, KEVZARA PA SP SI, OTEZLA PA SP, STELARA
SUBCUTANEOUS (Plaque Psoriasis and Psoriatic Arthritis only) Rx,MB
PA SP SI
SPRIX diclofenac sodium, meloxicam, naproxen
STENDRA QL sildenafil QL, CIALIS QL
STRIANT testosterone gel 2%, testosterone solution, ANDRODERM,
ANDROGEL 1.62%
SUMAVEL DOSEPRO QL eletriptan QL, naratriptan QL, rizatriptan
QL, sumatriptan QL, zolmitriptan QL, ONZETRA XSAIL QL, ZEMBRACE
SYMTOUCH QL, ZOMIG NASAL SPRAY QL
SURE-TEST STRIPS AND KITS 6 QL
ONETOUCH ULTRA STRIPS AND KITS 5 QL, ONETOUCH VERIO STRIPS AND
KITS 5 QL
SYNJARDY INVOKAMET, INVOKAMET XR, XIGDUO XR
SYNJARDY XR INVOKAMET, INVOKAMET XR, XIGDUO XR
TALTZ PA SP SI COSENTYX Rx,MB PA SP SI, ENBREL PA SP SI, HUMIRA
PA SP SI, OTEZLA PA SP, STELARA SUBCUTANEOUS (Plaque Psoriasis and
Psoriatic Arthritis only) Rx,MB PA SP SI
TANZEUM SI TRULICITY SI, VICTOZA SI
TASIGNA PA SP imatinib mesylate PA SP, BOSULIF PA SP, SPRYCEL PA
SP
TECHNIVIE PA SP EPCLUSA (genotypes 1, 2, 3, 4, 5, 6) PA SP,
HARVONI (genotypes 1, 4, 5, 6) PA SP
TESTIM testosterone gel 2%, testosterone solution, ANDRODERM,
ANDROGEL 1.62%
testosterone gel 1% 8 testosterone gel 2%, testosterone
solution, ANDRODERM, ANDROGEL 1.62%
TOBI Rx,MB PA SP tobramycin inhalation solution Rx,MB PA SP,
BETHKIS Rx,MB PA SP
TOBI PODHALER Rx,MB PA SP tobramycin inhalation solution Rx,MB
PA SP, BETHKIS Rx,MB PA SP
TOUJEO BASAGLAR, LEVEMIR, TRESIBA
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 QL
ONETOUCH ULTRA STRIPS AND KITS 5 QL, ONETOUCH VERIO STRIPS AND
KITS 5 QL
TRUETRACK STRIPS AND KITS 6 QL
ONETOUCH ULTRA STRIPS AND KITS 5 QL, ONETOUCH VERIO STRIPS AND
KITS 5 QL
-
NON-PREFERRED OR EXCLUDED DRUG(S)
PREFERRED OPTION(S)
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
Vanoxide-HC adapalene, benzoyl peroxide, clindamycin solution,
clindamycin-benzoyl peroxide, erythromycin solution,
erythromycin-benzoyl peroxide, tretinoin PA, ACANYA, ATRALIN PA,
BENZACLIN, DIFFERIN, EPIDUO, RETIN-A MICRO PA, 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
VIAGRA QL sildenafil QL, CIALIS QL
VIEKIRA PAK PA SP EPCLUSA (genotypes 1, 2, 3, 4, 5, 6) PA SP,
HARVONI (genotypes 1, 4, 5, 6) PA SP
VIEKIRA XR PA SP EPCLUSA (genotypes 1, 2, 3, 4, 5, 6) PA SP,
HARVONI (genotypes 1, 4, 5, 6) PA SP
VITAFOL-ONE generic prenatal vitamins, CITRANATAL
NON-PREFERRED OR EXCLUDED DRUG(S)
PREFERRED OPTION(S)
VOGELXO testosterone gel 2%, testosterone solution, ANDRODERM,
ANDROGEL 1.62%
XELJANZ PA SP ENBREL PA SP SI, HUMIRA PA SP SI, KEVZARA PA SP
SI
XELJANZ XR PA SP ENBREL PA SP SI, HUMIRA PA SP SI, KEVZARA PA SP
SI
XENAZINE PA SP tetrabenazine PA SP, AUSTEDO PA SP
XOPENEX HFA levalbuterol tartrate CFC-free aerosol, PROAIR HFA,
PROAIR RESPICLICK
ZEGERID PA esomeprazole, lansoprazole, omeprazole, pantoprazole,
DEXILANT
ZEPATIER PA SP EPCLUSA (genotypes 1, 2, 3, 4, 5, 6) PA SP,
HARVONI (genotypes 1, 4, 5, 6) PA SP
ZETIA ezetimibe
ZETONNA flunisolide, fluticasone, mometasone, triamcinolone,
DYMISTA
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
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. PA Prior
authorization required for prescription benefits coverage QL
Quantity limits Rx,MB May be covered under either prescription or
medical benefits. Please consult your plan to determine coverage.
SI Self-injectable product - refer to plan details for more
information; some plans may have self-injectable products on the
4th benefit tier. SP Specialty product 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 A ONETOUCH blood
glucose meter may be provided at no charge by the manufacturer to
those individuals currently using a meter other than OneTouch. For
more information on
how to obtain a blood glucose meter, call: 800-588-4456. 6
ONETOUCH 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 (04/01/18)
-
Notice of Nondiscrimination and Availability of Language
Assistance Services
CareFirst BlueCross BlueShield, CareFirst BlueChoice, Inc. 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.
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 is the business name of First Care,
Inc. In Virginia, CareFirst MedPlus is the business name 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.
REV. (12/17)
-
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.
(Amharic) -
855-258-6518 0
d Yorb (Yoruba) ttlko: kys y n wfn npa i adjtf r. le n wn dt pt
o s le n lti
gb gbs n wn j gbdke kan. O ni t lti gba wfn y ti rnlw n d r lf.
wn m-gb
gbd pe nmb fn t w lyn kd dnim wn. wn mrn le pe 855-258-6518 k o
s dr npas jrr
tt a fi s fn lti t 0. Ngbt aoj kan b dhn, s d t o f a s so p m
gbuf kan.
Ting Vit (Vietnamese) Ch : Thng bo ny cha thng tin v phm vi bo
him ca qu v. Thng bo c th
cha nhng ngy quan trng v qu v cn hnh ng trc mt s thi hn nht nh.
Qu v c quyn nhn
c thng tin ny v h tr bng ngn ng ca qu v hon ton min ph. Cc thnh
vin nn gi s in thoi
mt sau ca th nhn dng. Tt c nhng ngi khc c th gi s 855-258-6518 v
ch ht cuc i thoi cho
n khi c nhc nhn phm 0. Khi mt tng i vin tr li, hy nu r ngn ng qu
v cn v qu v s c
kt ni vi mt thng dch vin.
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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identification card. Ang lahat ng iba ay maaaring tumawag sa
855-258-6518 at maghintay hanggang sa dulo ng
diyalogo hanggang sa diktahan na pindutin ang 0. Kapag sumagot
ang ahente, sabihin ang wika na kailangan mo
at ikokonekta ka sa isang interpreter.
Espaol (Spanish) Atencin: Este aviso contiene informacin sobre
su cobertura de seguro. Es posible que
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derecho a obtener esta informacin y asistencia en su idioma sin
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deben presionar 0. Cuando un agente de seguros
responda, indique el idioma que necesita y se le comunicar con
un intrprete.
(Russian) !
. ,
.
. ,
.
855-258-6518 , 0.
, .
-
(Hindi) : - 855-258-6518 0 ,
s-w (Bassa) To uu Cao! B nia k a ny e ke m gbo kpa o ni fu
a-fa-tiin ny je dyi. B nia k
ee we j e m ke wa m m ke nyu nyu hw we ea ke zi. m ni kpe m ke b
nia k ke gbo-
kpa-kpa m m dye e ni ii-wuu mu m ke se wii o p. Kpoo ny e m a
fn-na nia e waa
I.D. kaa ein ny. Ny t sein m a na nia k: 855-258-6518, ke m m fo
tee wa ke m gbo c m ke
na ma 0 k dyi paain hw. ju ke ny o dyi m g juin, po wuu m m po
dyi, ke ny o mu o niin
ke ni wuu mu za.
(Bengali) : 855-258-6518 0
: (Urdu )
0 6518-258-855
: . (Farsi ). .
.
. 0 855-258-6518
.
: (Arabic) . .
.
.0 855-258-6518
.
(Traditional Chinese)
855-258-6518
0
-
Igbo (Igbo) Nrbama: kwa a nwere ozi gbasara mkpuchi nchekwa onwe
g. nwere ike nwe bch nd d
mkpa, nwere ike me ihe tupu fd bch njedebe. nwere ikike nweta
ozi na enyemaka a nass g na
akwgh gw bla. Nd otu kwesr kp akara ekwent d naz nke kaad
njirimara ha. Nd z niile nwere
ike kp 855-258-6518 wee chere bb ah ruo mgbe amanyere p 0. Mgbe
onye nnchite anya zara, kwuo
ass chr, a ga-ejik g na onye kwa okwu.
Deutsch (German) Achtung: Diese Mitteilung enthlt Informationen
ber Ihren Versicherungsschutz. Sie kann
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innerhalb bestimmter Fristen reagieren. Sie haben
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Franais (French) Attention: cet avis contient des informations
sur votre couverture d'assurance. Des dates
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Vous avez le droit d'obtenir gratuitement ces informations et de
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(Korean) : . .
. ID .
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(Navajo)
855-258-6518
CareFirst Formulary 2 PDL SC 0418 42967 fmt usec apvdANALGESICS
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 DERIVATIVES 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
TRIPHASICFOUR PHASE EXTENDED CYCLE TRANSDERMALVAGINAL
ESTROGENS ORAL TRANSDERMAL VAGINAL
ESTROGEN / PROGESTINS ORALTRANSDERMAL
ESTROGEN / SELECTIVE ESTROGEN RECEPTOR MODULATOR
COMBINATIONSFERTILITY REGULATORSGNRH / LHRH ANTAGONISTS OVULATION
STIMULANTS, GONADOTROPINS
GAUCHER DISEASE GLUCOCORTICOIDSGLUCOSE ELEVATING 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
TOPICALDERMATOLOGY ACNE 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 PROSTAGLANDINS
SYMPATHOMIMETICSSYMPATHOMIMETIC / BETA-BLOCKER COMBINATIONS
OTIC ANTI-INFECTIVE / ANTI-INFLAMMATORY COMBINATIONS
QUICK REFERENCE DRUG LISTABCDEFGHIJKLMNOPQRSTUVWXZPREFERRED
OPTIONS LIST
NDLA_ENGLISH_Dec2017