-
Prescription Guidelines (effective April 1, 2018)
Some medications are only intended to be used in limited
quantities, others require advanced approval or prior authorization
by your doctor before they can be filled and some are prescribed in
steps. Quantity limits have been placed on the use of selected
drugs for quality, safety or utilization reasons. Limits may be on
the amount of the drug that we cover per prescription or for a
defined period of time.
Prior Authorization is required before you fill prescriptions
for certain drugs. Without prior approval, your drugs may not be
covered. Step Therapy ensures lower costs. When similar medications
are available, step therapy guides your doctor to prescribe the
lower-cost option first. You may than move up the cost levels until
you find the drug that works best for you. Higher step drugs will
require advanced approval or prior authorization by your doctor
before they can be filled. Note: Due to the lack of Food and Drug
Administration (FDA) approval for many ingredients included in
compounds, as well as the lack of validated clinical support for
use of these high-cost compounds, they may not be covered by your
prescription plan or may require prior authorization. If the
compound ingredients are not covered, you will be responsible for
the full cost of those ingredients. In situations where the
compound ingredients are covered through prior authorization, you
will pay the cost share specified in your prescription plan.
QUANTITY LIMITS
ALBENZA 336 tablets per 365 days
ALSUMA INJ 12 injections per month
AMERGE (naratriptan) 12 tablets per month
ANZEMET 6 tablets per 21 days
AXERT (almotriptan) 12 tablets per month
BILTRICIDE 24 tablets per 365 days
CIALIS 2.5 mg, 5 mg 30 tablets per month
CIALIS 10 mg, 20 mg 6 tablets per month CAVERJECT 6 units per
month diabetic test strips - all brands 204 test strips per
month diclofenac sodium solution 1.5% 150 mL per 21
days doxepin cream 5% 90 grams per
month EDEX 6 units per month EMEND (aprepitant caps) 40 mg 3
caps per 180
days EMEND (aprepitant caps) 80 mg 4 caps per 21 days EMEND
(aprepitant caps) 125 mg 2 caps per 21 days EMEND INJ 150 mg 2
vials per 21 days EMEND SUSP 125 mg 6 kits per 21 days EMEND
TRIPACK (aprepitant pack) 80 mg & 125mg
2 packs per 21 days
EMVERM 12 tablets per 365 days
FROVA (frovatriptan) 18 tablets per month
granisetron tabs 1 mg 12 tablets per 21 days
IMITREX (sumatriptan) 12 tablets per month
IMITREX INJ (sumatriptan inj) 4 mg 18 syringes per month
IMITREX INJ (sumatriptan inj) 6 mg 12 syringes per month
IMITREX NASAL SPRAY (sumatriptan nasal spray) 5 mg
24 units per month
IMITREX NASAL SPRAY (sumatriptan nasal spray) 20 mg
12 units per month
LEVITRA 6 tablets per month lidocaine gel 2%, 4% 30 grams
per
month lidocaine ointment 5% 50 grams per
month lidocaine solution 4% 50 mL per month lidocaine-prilocaine
cream 2.5%-2.5% 30 grams per
month lidocaine-tetracaine cream 30 grams per
month MAXALT (rizatriptan) 18 tablets per
month MAXALT MLT (rizatriptan orally disintegrating tabs)
18 tablets per month
MIGRANAL NS (dihydroergotamine spray) 1 x 8 mL per month MUSE 6
units per month ondansetron tabs 24 mg 2 tablets per 21
days ONZETRA XSAIL 1 box per month PENNSAID 112 grams per 21
days PRUDOXIN CREAM 90 grams per
month RELENZA 40 blisters per 90
days RELPAX (eletriptan) 12 tablets per
month
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SANCUSO 2 patches per 21 days
STAXYN 6 tablets per month STENDRA 6 tablets per month SUMAVEL 6
injections per
month SYNERA (lidocaine-tetracaine patch) 2 patches per
month TAMIFLU (oseltamivir) 30 mg 28 capsules per 90
days TAMIFLU (oseltamivir) 45 mg, 75 mg 14 capsules per 90
days TAMIFLU SUSP(oseltamivir susp) 3 bottles every 90
days TREXIMET 9 tablets per month VARUBI 4 tablets per 21
days VIAGRA (sildenafil) 6 tablets per month
XYREM 540 mL per month ZEMBRACE SYMTOUCH 24 injectors per
month ZOFRAN (ondansetron soln) 4 mg/5mL 200 mL per 21
days ZOFRAN (ondansetron tabs) 4 mg, 8 mg 18 tablets per 21
days ZOFRAN ODT (ondansetron orally disintegrating tabs) 4 mg, 8
mg
18 tablets per 21 days
ZOMIG (zolmitriptan) 12 tablets per month
ZOMIG NASAL SPRAY 12 units per month ZOMIG ZMT (zolmitriptan
orally disintegrating tabs)
12 tablets per month
ZONALON CREAM 90 grams per month
ZUPLENZ 18 film per 21 days
OPIOID QUANTITY LIMITS Immediate-release opioid prescriptions
(including combination products) are limited to a 7-day supply for
the first fill or if previous fills were less than 7 days.
acetaminophen/caffeine/dihydrocodeine 320.5/30/16 mg
300 capsules per month
acetaminophen/codeine 300/15 mg 400 tablets per month
acetaminophen/codeine 300/30 mg 360 tablets per month
acetaminophen/codeine 300/60 mg 180 tablets per month
acetaminophen/codeine solution, suspension 120-12 mg/5 mL
2700 mL per month
ARYMO 15mg, 30mg 90 mL per month AVINZA (morphine ext-rel) 30
mg, 45 mg, 60 mg, 75 mg, 90 mg
30 capsules per month
BELBUCA 75 mcg, 150 mcg, 300 mcg, 450 mcg
60 films per month
buprenorphine transdermal 4 patches per month
butorphanol nasal spray 2 inhalers per month
BUTRANS 5 mcg/hr, 7.5 mcg/hr, 10 mcg/hr 4 patches per month
codeine sulfate 15 mg, 30 mg, 60 mg 42 tablets per month
codeine sulfate oral soln 30 mg/5 mL 210 mL per month
CONZIP (tramadol ext-rel caps) 100 mg 30 capsules per month
DOLOPHINE (methadone) 5 mg, 10 mg 90 tablets per month
DURAGESIC (fentanyl transdermal) 12 mcg, 25 mcg, 37.5 mcg
10 patches per month
EMBEDA 20/0.8 mg, 30/1.2 mg 60 capsules per month
EMBEDA 50/2 mg, 60/2.4 mg, 80/3.2 mg 30 capsules per month
EXALGO (hydromorphone ext-rel) 8 mg, 12 mg, 16 mg
30 tablets per month
hydrocodone/acetaminophen 2.5/325 mg 360 tablets per month
hydrocodone/acetaminophen 5/300 mg, 5/325 mg
240 tablets per month
hydrocodone/acetaminophen 7.5/300 mg, 7.5/325 mg, 10/300 mg,
10/325 mg
180 tablets per month
hydrocodone/acetaminophen elixir 10-300 mg/15 mL
2025 mL per month
hydrocodone/acetaminophen solution 7.5 mg-325 mg/15 mL, 10-325
mg/15 mL
2700 mL per month
hydrocodone/ibuprofen 2.5/200 mg, 5/200 mg, 7.5 mg/200 mg,
10/200 mg
50 tablets per month
hydromorphone 2 mg 180 tablets per month
hydromorphone 4 mg 150 tablets per month
hydromorphone 8 mg 60 tablets per month
hydromorphone liquid 1 mg/mL 600 mL per month
hydromorphone suppositories 3 mg 120 supp per month
HYSINGLA ER 20 mg, 30 mg, 40 mg, 60 mg, 80 mg
30 tablets per month
KADIAN (morphine ext-rel) 10 mg, 20 mg, 30 mg, 40 mg
60 capsules per month
KADIAN (morphine ext-rel) 50 mg, 60 mg, 70 mg, 80 mg
30 capsules per month
levorphanol 2 mg 120 tablets per month
meperidine 50 mg, 100 mg 18 tablets per month
meperidine oral solution 50 mg/5 mL 90 mL per month methadone 5
mg, 10 mg 90 tablets per
month METHADONE INTENSOL 10mg/mL 90 mL per month
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methadone oral soln 5 mg/5mL, 10 mg/5 mL 450 mL per month
METHADOSE 5mg, 10 mg 90 tabs per month
MORPHABOND 15 mg, 30 mg 60 tablets per month
morphine sulfate 15 mg 180 tablets per month
morphine sulfate 30 mg 90 tablets per month
morphine sulfate oral concentrate 20 mg/mL 135 mL per month
morphine sulfate oral solution 10 mg/5 mL 900 mL per month
morphine sulfate oral solution 20 mg/5 mL 675 mL per month
morphine sulfate suppositories 5 mg, 10 mg 180 supp per
month
morphine sulfate suppositories 20 mg 120 supp per month
morphine sulfate suppositories 30 mg 90 supp per month
MS CONTIN (morphine ext-rel) 15 mg, 30 mg 90 tablets per
month
NUCYNTA 50 mg 120 tablets per month
NUCYNTA 75 mg 90 tablets per month
NUCYNTA 100 mg 60 tablets per month
NUCYNTA ER 50 mg, 100 mg 60 tablets per month
OXAYDO 5 mg, 7.5 mg 180 tablets per month
oxycodone capsules 5 mg 180 capsules per month
oxycodone oral concentrate 100 mg/5 mL 90 mL per month oxycodone
oral solution 5 mg/5 mL 900 mL per
month oxycodone tablets 5 mg, 10 mg 180 tablets per
month oxycodone tablets 15 mg 120 tablets per
month
oxycodone tablets 20 mg 90 tablets per month
oxycodone tablets 30 mg 60 tablets per month
oxycodone/acetaminophen 2.5/325 mg, 5/300 mg, 5/325 mg
360 tablets per month
oxycodone/acetaminophen 10/300 mg, 10/325 mg
180 tablets per month
oxycodone/acetaminophen oral solution 5-325 mg/5 mL
1800 mL per month
oxycodone/aspirin 4.8355/325 mg 360 tablets per month
oxycodone/ibuprofen 5/400 mg 28 tablets per month
OXYCONTIN 10 mg, 15 mg, 20 mg, 30 mg 60 tablets per month
oxymorphone 5 mg 180 tablets per month
oxymorphone 10 mg 90 tablets per month
pentazocine/naloxone 50/0.5 mg 120 tablets per month
TARGINIQ ER 10mg/5mg, 20mg/10mg 60 tabs per month
tramadol 50 mg 180 tablets per month
tramadol ext-rel 100 mg 30 tablets per month
tramadol ext-rel 150 mg 30 capsules per month
tramadol/acetaminophen 37.5/325 mg 40 tablets per month
TROXYCA ER 10/1.2 mg, 20/2.4 mg, 30/3.6 mg 60 capsules per
month
ULTRAM ER (tramadol ext-rel) 100 mg 30 tablets per month
XTAMPZA ER 9 mg, 13.5 mg, 18 mg, 27 mg 60 capsules per month
ZOHYDRO ER 10 mg, 15 mg, 20 mg, 30 mg, 40 mg
60 capsules per month
The initial limit for additional strengths not listed here is
zero. All requests for strengths not listed will be considered
through post limit prior authorization.
NON-SPECIALTY PRODUCTS REQUIRING PRIOR AUTHORIZATION ABSTRAL
ACCU-CHEK STRIPS AND KITS ACTIQ armodafinil ATRALIN BREEZE 2 STRIPS
AND KITS clindamycin/tretinoin CONTOUR NEXT STRIPS AND KITS CONTOUR
STRIPS AND KITS diclofenac sodium gel 3% diclofenac sodium solution
1.5% fentanyl transmucosal lozenge FENTORA FORTAMET
FREESTYLE STRIPS AND KITS GLUMETZA JUBLIA KERYDIN LAZANDA
lidocaine patch LIDODERM LOVAZA metformin ext-rel (generic
FORTAMET) metformin ext-rel (generic GLUMETZA) modafinil NUVIGIL
omeprazole-sodium bicarbonate PENNSAID
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PROVIGIL RETIN-A RETIN-A MICRO SOLARAZE GEL SUBSYS tretinoin
cream, gel
TRETIN-X VASCEPA VELTIN ZEGERID ZIANA
All other glucose test strips that are not ONETOUCH brand
Compound drugs with a cost of $300 or more
SPECIALTY DRUGS REQUIRING PRIOR AUTHORIZATION ABRAXANE ACTEMRA
ACTIMMUNE ADAGEN ADCIRCA ADEMPAS ADVATE ADYNOVATE AFINITOR
ALDURAZYME ALECENSA ALIMTA ALPHANATE ALPHANINE SD ALPROLIX ALUNBRIG
AMPYRA APOKYN ARALAST NP ARANESP * ARCALYST AUBAGIO AUSTEDO AVASTIN
AVONEX azacitidine BEBULIN BENDEKA BENEFIX BENLYSTA BENLYSTA SC
BERINERT BETASERON BETHKIS bexarotene caps BIVIGAM BORTEZOMIB
BOSULIF BUPHENYL CABOMETYX CALQUENCE capecitabine CAPRELSA CARBAGLU
CARIMUNE NF CAYSTON CERDELGA CEREZYME CHOLBAM CIMZIA CINRYZE
COMETRIQ COPAXONE COPEGUS COSENTYX COTELLIC CYSTAGON CYSTARAN
CYTOGAM DAKLINZA dofetilide DUPIXENT EGRIFTA ELAPRASE ELELYSO
ELIGARD ELOCTATE EMFLAZA ENBREL ENDARI ENTYVIO EPCLUSA EPOGEN *
epoprostenol ERBITUX ERIVEDGE ERLEADA ESBRIET EXJADE EXTAVIA EYLEA
FABRAZYME FARYDAK FASENRA FEIBA NF FEIBA VH FERRIPROX FIRAZYR
FIRMAGON FLEBOGAMMA FLOLAN FORTEO FUZEON GAMASTAN S/D GAMMAGARD
LIQUID GAMMAGARD S/D GAMMAKED GAMMAPLEX GAMUNEX-C GATTEX GEMZAR
GENOTROPIN GILENYA GILOTRIF GLASSIA glatiramer glatopa GLEEVEC
GRANIX H.P. ACTHAR GEL HAEGARDA HARVONI HELIXATE FS HEMLIBRA
HEMOFIL M HERCEPTIN
HETLIOZ HIZENTRA HUMATE-P HUMATROPE HUMIRA HYCAMTIN IBRANCE
ICLUSIG IDHIFA ILARIS imatinib IMBRUVICA INCRELEX INFLECTRA
INGREZZA INLYTA INTRON A IRESSA JADENU JAKAFI JUXTAPID KADCYLA
KALBITOR KALYDECO KEVZARA KINERET KISQALI KISQALI FEMARA CO-PACK
KITABIS PAK KOATE-DVI KOGENATE FS KORLYM KUVAN KYMRIAH KYNAMRO
LEMTRADA LENVIMA LETAIRIS LEUKINE leuprolide acetate LONSURF
LUCENTIS LUMIZYME LUPRON LUPRON DEPOT LYNPARZA MAVYRET MEKINIST
MIRCERA * MONOCLATE-P MONONINE MYALEPT NAGLAZYME NATPARA NERLYNX
NEULASTA * NEUPOGEN NEXAVAR
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NINLARO NITYR NORDITROPIN NORTHERA NOVOSEVEN RT NPLATE NUPLAZID
NUTROPIN AQ OCALIVA OCTAGAM octreotide acetate ODOMZO OFEV OLYSIO
OMNITROPE OPSUMIT ORENCIA ORENITRAM ORFADIN ORKAMBI OTEZLA OTREXUP
oxaliplatin PEGASYS PERJETA phenylbutyrate sodium PLEGRIDY POMALYST
PRALUENT PRIVIGEN PROCRIT * PROCYSBI PROFILNINE SD PROLASTIN-C
PROLIA PROMACTA PROVENGE PULMOZYME RASUVO RAVICTI REBETOL REBETOL
SOLUTION REBIF RECLAST RECOMBINATE REMICADE REMODULIN RENFLEXIS
REPATHA REVATIO REVLIMID RIBAPAK RIBASPHERE
ribavirin caps ribavirin tabs RITUXAN RIXUBIS RUBRACA RUCONEST
RYDAPT SABRIL SAIZEN SAMSCA SANDOSTATIN SANDOSTATIN LAR SENSIPAR
SEROSTIM SIGNIFOR sildenafil 20 mg SILIQ SIMPONI SIMPONI ARIA
SOLIRIS SOMATULINE DEPOT SOMAVERT SOVALDI SPINRAZA SPRYCEL STELARA
STIVARGA STRENSIQ SUTENT SYLATRON SYMDEKO SYNAGIS TAFINLAR TAGRISSO
TALTZ TARCEVA TARGRETIN TARGRETIN GEL TASIGNA TAXOTERE TECFIDERA
TECHNIVIE TEMODAR temozolomide tetrabenazine TEV-TROPIN THALOMID
TIKOSYN TOBI TOBI PODHALER tobramycin inhalation solution TRACLEER
TREANDA
TRELSTAR TREMFYA TYKERB TYMLOS TYSABRI TYVASO UPTRAVI VALCHLOR
VANTAS VELCADE VELETRI VENCLEXTA VENTAVIS VERZENIO VIDAZA VIEKIRA
PAK VIEKIRA XR vigabatrin VIMIZIM VOSEVI VOTRIENT VPRIV WILATE
XALKORI XELJANZ XELJANZ XR XELODA XENAZINE XERMELO XGEVA XOLAIR
XTANDI XYNTHA XYREM YERVOY YESCARTA ZARXIO ZAVESCA ZEJULA ZELBORAF
ZEMAIRA ZEPATIER ZINBRYTA ZOLADEX zoledronic acid ZOLINZA ZOMACTON
ZOMETA ZORBTIVE ZYDELIG ZYKADIA ZYTIGA
* Prior authorization required for prescription benefits
coverage only.
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DRUGS REQUIRING STEP THERAPY
You must try one of these drugs first or your doctor must
request an exception
for you
Used to treat
before you can get coverage for these
drugs First Choice Drugs Second Choice Drugs
At least a 7-day supply of a generic topical corticosteroid AND
at least a 7-day supply
of topical tacrolimus (Protopic) or Elidel (pimecrolimus) within
the past 120 days
short-term (up to 8 days) management of moderate pruritus in
adult patients with
atopic dermatitis or lichen simplex chronicus
Prudoxin cream 5%, Zonalon cream 5%, or doxepin cream 5%
You must try one of these drugs first or your doctor must
request an exception for you
before you can get coverage for these drugs
First Choice Drugs Second Choice Drugs You must try at least a
30 day supply of a generic NSAID
within the past 180 days Cambia, Celebrex, Duexis, Flector,
Nalfon (fenoprofen), Naprelan,
Tivorbex, Vimovo, Vivlodex, Zipsor
Your specific prescription benefit plan design may not cover
certain products or categories, regardless of their appearance in
this document. 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.
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. www.carefirst.com SUM2712-1P
(04/01/18)
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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
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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
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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
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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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responda, indique el idioma que necesita y se le comunicar con
un intrprete.
(Russian) !
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-
(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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Franais (French) Attention: cet avis contient des informations
sur votre couverture d'assurance. Des dates
importantes peuvent y figurer et il se peut que vous deviez
entreprendre des dmarches avant certaines chances.
Vous avez le droit d'obtenir gratuitement ces informations et de
l'aide dans votre langue. Les membres doivent
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d'identification. Tous les autres peuvent appeler le
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lorsqu'ils seront invits le faire. Lorsqu'un(e)
employ(e) rpondra, indiquez la langue que vous souhaitez et vous
serez mis(e) en relation avec un interprte.
(Korean) : . .
. ID .
855-258-6518 0 .
.
(Navajo)
855-258-6518
CareFirst Prescription Guidelines 0418 43026 fmt usec
apvdQUANTITY LIMITSOPIOID QUANTITY LIMITSNON-SPECIALTY PRODUCTS
REQUIRING PRIOR AUTHORIZATIONSPECIALTY DRUGS REQUIRING PRIOR
AUTHORIZATIONDRUGS REQUIRING STEP THERAPY
NDLA_ENGLISH_Dec2017