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Prescription Guidelines (effective October 1, 2017)
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 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 EDEX 6 units per month EMVERM 12
tablets per 365 days FROVA (frovatriptan) 18 tablets per month
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 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 ONZETRA XSAIL 1 box per month PLIAGLIS
(lidocaine-tetracaine cream) 30 grams per month RELENZA 40 blisters
per 90 days RELPAX (eletriptan) 12 tablets per month STAXYN 6
tablets per month STENDRA 6 tablets per month SUMAVEL 4 mg 18
injections per month SUMAVEL 6 mg 12 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 180 mL per 90
days TREXIMET 9 tablets per month VIAGRA 6 tablets per month XYREM
540 mL per month ZEMBRACE SYMTOUCH 24 injectors per month ZOMIG
(zolmitriptan) 12 tablets per month ZOMIG NASAL SPRAY 12 units per
month ZOMIG ZMT (zolmitriptan orally disintegrating tabs)
12 tablets per month
OPIOID QUANTITY LIMITS
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
aspirin/caffeine/dihydrocodeine 356.4/30/16 mg
300 capsules 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
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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 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
XARTEMIS XR 120 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.
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NON-SPECIALTY PRODUCTS REQUIRING PRIOR AUTHORIZATION ABSTRAL
ACCU-CHEK STRIPS AND KITS ACTIQ ATRALIN BREEZE 2 STRIPS AND KITS
clindamycin/tretinoin CONTOUR NEXT STRIPS AND KITS CONTOUR STRIPS
AND KITS ENTRESTO FABIOR fentanyl transmucosal lozenge FENTORA
FORTAMET FREESTYLE STRIPS AND KITS GLUMETZA LAZANDA LOVAZA
metformin ext-rel (generic FORTAMET) metformin ext-rel (generic
GLUMETZA) omega-3 acid ethyl esters REGRANEX RETIN-A RETIN-A MICRO
SUBSYS tazarotene TAZORAC tretinoin cream, gel TRETIN-X VASCEPA
VELTIN XIFAXAN 550 MG 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
BOSULIF BOTOX BUPHENYL CABOMETYX capecitabine CAPRELSA CARBAGLU
CARIMUNE NF CAYSTON CERDELGA CEREZYME CHOLBAM CIMZIA CINRYZE
COMETRIQ COPAXONE COPEGUS COSENTYX COTELLIC CYSTAGON CYSTARAN
CYTOGAM DAKLINZA dofetilide
DUPIXENT DYSPORT EGRIFTA ELAPRASE ELELYSO ELIGARD ELOCTATE
EMFLAZA ENBREL ENTYVIO EPCLUSA EPOGEN * epoprostenol ERBITUX
ERIVEDGE ESBRIET EUFLEXXA EXJADE EXTAVIA EYLEA FABRAZYME FARYDAK
FEIBA NF FEIBA VH FERRIPROX FIRAZYR FIRMAGON FLEBOGAMMA FLOLAN
FORTEO
FUZEON GAMASTAN S/D GAMMAGARD LIQUID GAMMAGARD S/D GAMMAKED
GAMMAPLEX GAMUNEX-C GATTEX GEL-ONE GELSYN-3 GEMZAR GENOTROPIN
GENVISC 850 GILENYA GILOTRIF GLASSIA glatiramer GLEEVEC GRANIX H.P.
ACTHAR GEL HAEGARDA HARVONI HELIXATE FS HEMOFIL M HERCEPTIN HETLIOZ
HIZENTRA HUMATE-P HUMATROPE HUMIRA
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HYALGAN HYCAMTIN HYMOVIS 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 KYNAMRO LEMTRADA LENVIMA LETAIRIS LEUKINE leuprolide acetate
LONSURF LUCENTIS LUMIZYME LUPRON LUPRON DEPOT LYNPARZA MAVYRET
MEKINIST MIRCERA * MONOCLATE-P MONONINE MONOVISC MYALEPT MYOBLOC
NAGLAZYME NATPARA NERLYNX NEULASTA *
NEUPOGEN NEXAVAR NINLARO NITYR NORDITROPIN NORTHERA NOVOSEVEN RT
NPLATE NUPLAZID NUTROPIN AQ OCALIVA OCTAGAM octreotide acetate
ODOMZO OFEV OLYSIO OMNITROPE OPSUMIT ORENCIA ORENITRAM ORFADIN
ORKAMBI ORTHOVISC 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 REPATHA REVATIO REVLIMID RIBAPAK
RIBASPHERE ribavirin caps ribavirin tabs RITUXAN RIXUBIS RUBRACA
RUCONEST RYDAPT SABRIL SAIZEN SAMSCA SANDOSTATIN SANDOSTATIN LAR
SENSIPAR SEROSTIM SIGNIFOR sildenafil SILIQ SIMPONI SIMPONI ARIA
SOLIRIS SOMATULINE DEPOT SOMAVERT SOVALDI SPINRAZA SPRYCEL STELARA
STIVARGA STRENSIQ SUPARTZ FX SUTENT SYLATRON SYNAGIS SYNVISC
SYNVISC ONE 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 VIDAZA
VIEKIRA PAK VIEKIRA XR VIMIZIM VOSEVI VOTRIENT VPRIV WILATE XALKORI
XELJANZ XELJANZ XR XELODA XENAZINE XEOMIN XERMELO XGEVA XOLAIR
XTANDI XYNTHA YERVOY 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.
DRUGS REQUIRING STEP THERAPY
You must try one of these drugs first or your doctor must
request an exception for you
Used to
before you can get coverage for these drugs
First Choice Drugs treat Second Choice Drugs minocycline
(immediate or extended release) or
doxycycline (immediate or extended release) Acne Solodyn
(minocycline extended release)
-
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.
2017. All rights reserved. www.carefirst.com SUM2712-1P
(10/01/17 v2)
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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., First Care,
Inc. and The Dental Network are 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.
NDLA (6/17)
-
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
numero ng telepono na nasa likuran ng kanilang
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
incluya fechas clave y que usted tenga que realizar alguna accin
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derecho a obtener esta informacin y asistencia en su idioma sin
ningn costo. Los asegurados deben llamar al
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identificacin. Todos los dems pueden llamar al
855-258-6518 y esperar la grabacin hasta que se les indique que
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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Mitarbeiter die gewnschte Sprache an, damit er Sie mit einem
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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 1017 40194 (modified) fmt usec
v2QUANTITY LIMITSOPIOID QUANTITY LIMITSNON-SPECIALTY PRODUCTS
REQUIRING PRIOR AUTHORIZATIONSPECIALTY DRUGS REQUIRING PRIOR
AUTHORIZATIONDRUGS REQUIRING STEP THERAPY
NDLA_ENGLISH_Sep2017