carefirst preferred drug list - formulary 2 2018 carefirst preferred drug list ... to learn more...

July 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 gel 1% diclofenac sodium solution PA QL

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 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 linezolid metronidazole nitrofurantoin sulfamethoxazole-trimethoprim EMVERM QL 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

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 NAMZARIC

ANTIDEPRESSANTS

SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs)

citalopram escitalopram fluoxetine paroxetine HCl paroxetine HCl ext-rel sertraline TRINTELLIX VIIBRYD

SEROTONIN NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIs)

desvenlafaxine ext-rel duloxetine

venlafaxine venlafaxine ext-rel capsule

MISCELLANEOUS AGENTS

bupropion bupropion ext-rel mirtazapine trazodone

ANTIPARKINSONIAN AGENTS

amantadine carbidopa-levodopa carbidopa-levodopa ext-rel carbidopa-levodopa-entacapone entacapone pramipexole rasagiline ropinirole ropinirole ext-rel selegiline 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 MYDAYIS 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 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

OZEMPIC SI 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-drospirenone-

levomefolate ethinyl estradiol-norethindrone

acetate 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

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

HEREDITARY TYROSINEMIA TYPE 1 AGENTS

METABOLIC MODIFIERS

ORFADIN PA SP

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

alosetron AMITIZA LINZESS VIBERZI

LAXATIVES

lactulose peg 3350-electrolytes SUPREP

OPIOID-INDUCED CONSTIPATION

MOVANTIK

PANCREATIC ENZYMES

CREON VIOKACE ZENPEP

PROTON PUMP INHIBITORS

esomeprazole lansoprazole omeprazole pantoprazole DEXILANT

STEROIDS, RECTAL

PROCTOFOAM-HC

ULCER THERAPY COMBINATIONS

PYLERA

GENITOURINARY

BENIGN PROSTATIC HYPERPLASIA

alfuzosin ext-rel doxazosin dutasteride dutasteride-tamsulosin finasteride tamsulosin terazosin RAPAFLO

ERECTILE DYSFUNCTION

ALPROSTADIL AGENTS

MUSE 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

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

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 alosetron ALPHAGAN P amantadine amiloride

AMITIZA amlodipine amlodipine-atorvastatin amlodipine-olmesartan amlodipine-telmisartan amlodipine-valsartan amlodipine-valsartan-

hydrochlorothiazide amoxicillin amoxicillin-clavulanate

amphetamine-dextroamphetamine mixed salts

amphetamine-dextroamphetamine mixed salts ext-rel

ANDRODERM ANDROGEL 1.62% ANORO ELLIPTA APRISO 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 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 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 gel 1% 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-drospirenone-

levomefolate 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 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 linezolid LINZESS lisinopril lisinopril-hydrochlorothiazide LO LOESTRIN FE losartan losartan-hydrochlorothiazide lovastatin LUMIGAN LUZU LYRICA

M

MAXIDEX meclizine medroxyprogesterone megestrol acetate meloxicam memantine mesalamine rectal suspension metformin metformin ext-rel 4 methadone 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 MYDAYIS MYRBETRIQ

N

nadolol NAFTIN naloxone injection SI 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 ORFADIN 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 OZEMPIC SI

P

pantoprazole paroxetine HCl paroxetine HCl ext-rel paroxetine mesylate PAZEO peg 3350-electrolytes penicillin VK PENTASA PERFOROMIST phenobarbital phenytoin phenytoin sodium extended PHOSLYRA PICATO pindolol pioglitazone pioglitazone-glimepiride pioglitazone-metformin potassium chloride liquid pramipexole 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 rasagiline 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 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 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 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, MYDAYIS, QUILLIVANT XR, VYVANSE

AEROSPAN ASMANEX, FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER, QVAR

ALCORTIN A desonide, hydrocortisone

ALEVICYN GEL, ALEVICYN KIT, ALEVICYN SG, Alevicyn solution

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

ALVESCO ASMANEX, FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER, QVAR

AMRIX cyclobenzaprine

ANDROGEL 1% testosterone gel, testosterone solution, ANDRODERM, ANDROGEL 1.62%

ANGELIQ estradiol-norethindrone, PREMPHASE, PREMPRO

ANTARA fenofibrate, fenofibric acid

APEXICON E desoximetasone, fluocinonide

APIDRA FIASP, NOVOLOG

NON-PREFERRED OR EXCLUDED DRUG(S)

PREFERRED OPTION(S)

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


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


PREFERRED OPTION(S)

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


butalbital-acetaminophen-caffeine capsule

diclofenac sodium, naproxen

BYDUREON SI OZEMPIC SI, TRULICITY SI, VICTOZA SI

BYETTA SI OZEMPIC 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

CLINDAGEL erythromycin solution

clobetasol spray clobetasol foam

CLOBEX SPRAY clobetasol foam

COLAZAL balsalazide

CONTOUR NEXT STRIPS AND KITS 6 QL


CONTOUR STRIPS AND KITS 6 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


PREFERRED OPTION(S)

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

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 diclofenac sodium, naproxen

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, 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



PREFERRED OPTION(S)

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, MYDAYIS, QUILLIVANT XR, VYVANSE

ISTALOL timolol maleate solution, BETIMOL

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


PREFERRED OPTION(S)

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, 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

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


ORENCIA SUBCUTANEOUS 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


PREFERRED OPTION(S)

PENNSAID PA QL diclofenac sodium, diclofenac sodium gel 1%, diclofenac sodium solution PA QL, meloxicam, naproxen

PERRIGO NEEDLES 7 BD ULTRAFINE NEEDLES

PERTZYE CREON, VIOKACE, ZENPEP

PEXEVA citalopram, escitalopram, fluoxetine, paroxetine HCl, paroxetine HCl ext-rel, sertraline, TRINTELLIX, VIIBRYD

PLAVIX clopidogrel, prasugrel, BRILINTA

PRADAXA warfarin, ELIQUIS, XARELTO

PRALUENT PA SP SI REPATHA PA SP SI

PRECISION XTRA STRIPS AND KITS 6 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

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, 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



PREFERRED OPTION(S)

SYNERDERM desonide, hydrocortisone

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 OZEMPIC 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, testosterone solution, ANDRODERM, ANDROGEL 1.62%

testosterone gel 1% 8 testosterone gel, 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


TRUETRACK STRIPS AND KITS 6 QL


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

VOGELXO testosterone gel, testosterone solution, ANDRODERM, ANDROGEL 1.62%


PREFERRED OPTION(S)

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


PREFERRED OPTION(S)

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 (07/01/18)

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

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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 antes de ciertas fechas lmite. Usted tiene

derecho a obtener esta informacin y asistencia en su idioma sin ningn costo. Los asegurados deben llamar al

nmero de telfono que se encuentra al reverso de su tarjeta de 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) !

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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 ). .

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. 0 855-258-6518

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: (Arabic) . .

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.0 855-258-6518

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(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

wichtige Termine beinhalten, und Sie mssen gegebenenfalls innerhalb bestimmter Fristen reagieren. Sie haben

das Recht, diese Informationen und weitere Untersttzung kostenlos in Ihrer Sprache zu erhalten. Als Mitglied

verwenden Sie bitte die auf der Rckseite Ihrer Karte angegebene Telefonnummer. Alle anderen Personen rufen

bitte die Nummer 855-258-6518 an und warten auf die Aufforderung, die Taste 0 zu drcken. Geben Sie dem

Mitarbeiter die gewnschte Sprache an, damit er Sie mit einem Dolmetscher verbinden kann.

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

appeler le numro de tlphone figurant l'arrire de leur carte d'identification. Tous les autres peuvent appeler le

855-258-6518 et, aprs avoir cout le message, appuyer sur le 0 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

Preferred Drug List - Formulary 2 ASONDLA_ENGLISH_Dec2017

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