CareFirst Preferred Drug List - Formulary 2

Transcription

1 January 2015 CareFirst Preferred Drug List - Formulary 2 The CareFirst Preferred Drug List - Formulary 2 is a guide to help you identify products that are both clinically appropriate and costeffective. 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 brandname drugs in CAPS 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 is not an all-inclusive list 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 brandname 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. You may be responsible for the full cost of products that are not listed on the Preferred Drug List. For specific information regarding your prescription benefit plan, please visit and log in to My Account or contact CareFirst Pharmacy Services at 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 is not all-inclusive and does not guarantee coverage. 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. Visit the Drug Search tool on to check coverage for a specific drug and any restrictions. ANALGESICS NSAIDs diclofenac sodium meloxicam naproxen NSAIDs, diclofenac sodiummisoprostol NSAIDs, TOPICAL diclofenac sodium solution VOLTAREN GEL COX-2 INHIBITORS CELEBREX GOUT allopurinol probenecid COLCRYS ULORIC OPIOID ANALGESICS codeine-acetaminophen fentanyl transdermal fentanyl transmucosal lozenge hydrocodone-acetaminophen hydromorphone hydromorphone ext-rel methadone morphine morphine ext-rel morphine suppository oxycodone oxycodone-acetaminophen tramadol tramadol ext-rel BUTRANS FENTORA PA LAZANDA PA NUCYNTA NUCYNTA ER OPANA ER OXYCONTIN QL VISCOSUPPLEMENTS GEL-ONE # HYALGAN # SUPARTZ # 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 ANTIVIRALS HEPATITIS C ribavirin PA, SP SOVALDI PA, SP VICTRELIS PA, SP HERPES acyclovir valacyclovir INFLUENZA amantadine rimantadine RELENZA QL TAMIFLU QL MISCELLANEOUS clindamycin metronidazole nitrofurantoin sulfamethoxazoletrimethoprim XIFAXAN 550 MG PA ANTINEOPLASTIC KINASE INHIBITORS BOSULIF PA, SP GLEEVEC PA, SP SPRYCEL PA, SP CARDIOVASCULAR ACE INHIBITORS fosinopril

2 lisinopril quinapril ramipril ACE INHIBITOR / DIURETIC fosinopril-hydrochlorothiazide lisinopril-hydrochlorothiazide quinapril-hydrochlorothiazide ANGIOTENSIN II RECEPTOR ANTAGONISTS / DIURETIC candesartan / candesartanhydrochlorothiazide eprosartan irbesartan / irbesartanhydrochlorothiazide losartan / losartanhydrochlorothiazide telmisartan / telmisartanhydrochlorothiazide valsartan / valsartanhydrochlorothiazide BENICAR / BENICAR HCT ANGIOTENSIN II RECEPTOR ANTAGONIST / CALCIUM CHANNEL BLOCKER AZOR EXFORGE ANGIOTENSIN II RECEPTOR ANTAGONIST / CALCIUM CHANNEL BLOCKER / DIURETIC EXFORGE HCT TRIBENZOR ANTILIPEMICS BILE ACID RESINS cholestyramine WELCHOL CHOLESTEROL ABSORPTION INHIBITORS ZETIA FIBRATES fenofibrate fenofibric acid HMG-CoA REDUCTASE INHIBITORS / atorvastatin fluvastatin lovastatin pravastatin simvastatin CRESTOR VYTORIN NIACINS / niacin ext-rel SIMCOR OMEGA-3 FATTY ACIDS LOVAZA PA BETA-BLOCKERS atenolol carvedilol metoprolol succinate ext-rel metoprolol tartrate nadolol propranolol propranolol ext-rel BYSTOLIC COREG CR CALCIUM CHANNEL BLOCKERS amlodipine diltiazem ext-rel nifedipine ext-rel verapamil ext-rel CALCIUM CHANNEL BLOCKER / ANTILIPEMIC amlodipine-atorvastatin DIGITALIS GLYCOSIDES digoxin DIRECT RENIN INHIBITORS / DIURETIC TEKTURNA / TEKTURNA HCT DIRECT RENIN INHIBITOR / CALCIUM CHANNEL BLOCKER TEKAMLO DIRECT RENIN INHIBITOR / CALCIUM CHANNEL BLOCKER / DIURETIC AMTURNIDE NITRATES nitroglycerin sublingual spray NITROLINGUAL NITROSTAT NITRATE / VASODILATOR BIDIL PULMONARY ARTERIAL HYPERTENSION ENDOTHELIN RECEPTOR ANTAGONISTS LETAIRIS PA, SP TRACLEER PA, SP PHOSPHODIESTERASE INHIBITORS sildenafil 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 LAMICTAL ODT VIMPAT ANTIDEMENTIA donepezil galantamine galantamine ext-rel rivastigmine EXELON PATCH NAMENDA NAMENDA XR ANTIDEPRESSANTS SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs) citalopram escitalopram fluoxetine paroxetine paroxetine ext-rel sertraline VIIBRYD SEROTONIN NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIs) duloxetine venlafaxine venlafaxine ext-rel PRISTIQ MISCELLANEOUS bupropion bupropion ext-rel mirtazapine trazodone ANTIPARKINSONIAN carbidopa-levodopa carbidopa-levodopa ext-rel DIURETICS furosemide hydrochlorothiazide metolazone spironolactonehydrochlorothiazide torsemide triamterenehydrochlorothiazide carbidopa-levodopaentacapone entacapone pramipexole ropinirole ropinirole ext-rel selegiline AZILECT MIRAPEX ER NEUPRO ZELAPAR ANTIPSYCHOTICS ATYPICALS clozapine olanzapine quetiapine risperidone ziprasidone ABILIFY LATUDA SEROQUEL XR ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetaminedextroamphetamine mixed salts amphetaminedextroamphetamine mixed salts ext-rel methylphenidate methylphenidate ext-rel DAYTRANA INTUNIV QUILLIVANT XR STRATTERA VYVANSE FIBROMYALGIA LYRICA SAVELLA HYPNOTICS NONBENZODIAZEPINES eszopiclone zolpidem zolpidem ext-rel TRICYCLICS SILENOR MIGRAINE SELECTIVE SEROTONIN AGONISTS naratriptan QL rizatriptan QL sumatriptan QL zolmitriptan QL RELPAX QL SUMAVEL DOSEPRO SI, QL ZOMIG NASAL SPRAY QL SELECTIVE SEROTONIN AGONIST / NONSTEROIDAL ANTI-INFLAMMATORY DRUG (NSAID) TREXIMET QL MULTIPLE SCLEROSIS AVONEX PA, SP, SI COPAXONE PA, SP, SI EXTAVIA PA, SP, SI GILENYA PA, SP TECFIDERA PA, SP MUSCULOSKELETAL THERAPY cyclobenzaprine NARCOLEPSY NUVIGIL POSTHERPETIC NEURALGIA GRALISE PSYCHOTHERAPEUTIC - MISCELLANEOUS PARTIAL OPIOID AGONIST / OPIOID ANTAGONIST buprenorphine-naloxone sublingual tablet ZUBSOLV ENDOCRINE AND METABOLIC ANDROGENS ANDRODERM AXIRON FORTESTA ANTIDIABETICS BIGUANIDES metformin metformin ext-rel BIGUANIDE / SULFONYLUREA glipizide-metformin DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS JANUVIA TRADJENTA DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITOR JANUMET JANUMET XR JENTADUETO INCRETIN MIMETIC BYDUREON SI VICTOZA SI INSULINS HUMULIN R U-500 LANTUS LEVEMIR NOVOLIN 70/30 NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG MIX 70/30

3 INSULIN SENSITIZERS pioglitazone INSULIN SENSITIZER / BIGUANIDE pioglitazone-metformin INSULIN SENSITIZER / SULFONYLUREA pioglitazone-glimepiride MEGLITINIDES nateglinide repaglinide SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS INVOKANA SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITOR / BIGUANIDE INVOKAMET SULFONYLUREAS glimepiride glipizide glipizide ext-rel SUPPLIES BD INSULIN SYRINGES AND NEEDLES DEXCOM G4 ONETOUCH ULTRA STRIPS AND KITS 2 ONETOUCH VERIO STRIPS AND KITS 2 ANTIOBESITY QSYMIA CALCIUM REGULATORS BISPHOSPHONATES alendronate ibandronate ACTONEL ATELVIA CALCITONINS calcitonin-salmon PARATHYROID HORMONES FORTEO PA, SP, SI CONTRACEPTIVES MONOPHASIC ethinyl estradioldrospirenone ethinyl estradiolnorethindrone acetate BEYAZ LO LOESTRIN FE MINASTRIN 24 FE TRIPHASIC ethinyl estradiol-norgestimate ORTHO TRI-CYCLEN LO FOUR PHASE NATAZIA EXTENDED CYCLE ethinyl estradiollevonorgestrel TRANSDERMAL ethinyl estradiolnorelgestromin VAGINAL NUVARING ESTROGENS ORAL estradiol estropipate PREMARIN TRANSDERMAL estradiol DIVIGEL EVAMIST MINIVELLE VAGINAL ESTRACE CREAM PREMARIN CREAM VAGIFEM ESTROGEN / PROGESTINS, ORAL estradiol-norethindrone PREMPHASE PREMPRO ESTROGEN / SELECTIVE ESTROGEN RECEPTOR MODULATOR DUAVEE FERTILITY REGULATORS GNRH / LHRH ANTAGONISTS CETROTIDE SI OVULATION STIMULANTS, GONADOTROPINS FOLLISTIM AQ SI OVIDREL SI GLUCOCORTICOIDS methylprednisolone prednisone GLUCOSE ELEVATING GLUCAGEN HYPOKIT SI GLUCAGON EMERGENCY KIT SI HUMAN GROWTH HORMONES HUMATROPE PA, SP, SI NORDITROPIN PA, SP, SI PHOSPHATE BINDER calcium acetate PHOSLYRA RENVELA VELPHORO PROGESTINS ORAL medroxyprogesterone progesterone, micronized MEGACE ES VAGINAL CRINONE SELECTIVE ESTROGEN RECEPTOR MODULATORS raloxifene OSPHENA THYROID SUPPLEMENTS levothyroxine SYNTHROID GASTROINTESTINAL ANTIEMETICS dronabinol granisetron meclizine metoclopramide ondansetron prochlorperazine promethazine trimethobenzamide DICLEGIS SANCUSO H2 RECEPTOR ANTAGONISTS ranitidine INFLAMMATORY BOWEL DISEASE ORAL balsalazide sulfasalazine sulfasalazine delayed-rel APRISO LIALDA PENTASA UCERIS RECTAL hydrocortisone enema mesalamine rectal suspension CANASA CORTIFOAM IRRITABLE BOWEL SYNDROME AMITIZA LINZESS LOTRONEX 3 LAXATIVES lactulose peg 3350-electrolytes MOVIPREP SUCLEAR SUPREP PANCREATIC ENZYMES CREON ULTRESA VIOKACE ZENPEP PROTON PUMP INHIBITORS lansoprazole omeprazole omeprazole-sodium bicarbonate capsule pantoprazole DEXILANT NEXIUM STEROIDS, RECTAL PROCTOFOAM-HC ULCER THERAPY PYLERA MISCELLANEOUS RELISTOR SI GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin ext-rel doxazosin finasteride tamsulosin terazosin AVODART RAPAFLO URINARY ANTISPASMODICS oxybutynin oxybutynin ext-rel tolterodine tolterodine ext-rel trospium trospium ext-rel GELNIQUE MYRBETRIQ VESICARE HEMATOLOGIC ANTICOAGULANTS warfarin ELIQUIS PRADAXA XARELTO HEMATOPOIETIC GROWTH FACTORS ARANESP PA, SP, SI PROCRIT PA, SP, SI PLATELET AGGREGATION INHIBITORS clopidogrel AGGRENOX BRILINTA EFFIENT IMMUNOLOGIC BIOLOGIC DISEASE- MODIFYING ENBREL PA, SP, SI HUMIRA PA, SP, SI NUTRITIONAL PRENATAL VITAMINS prenatal vitamins CITRANATAL RESPIRATORY ANAPHYLAXIS TREATMENT AUVI-Q SI EPIPEN SI EPIPEN JR SI ANTICHOLINERGICS SPIRIVA ANTICHOLINERGIC / BETA AGONIST ipratropium-albuterol inhalation solution ANORO ELLIPTA COMBIVENT RESPIMAT BETA AGONISTS, INHALANTS SHORT ACTING albuterol inhalation solution LONG ACTING ARCAPTA FORADIL PERFOROMIST SEREVENT LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast zafirlukast NASAL ANTIHISTAMINES azelastine PATANASE NASAL STEROIDS flunisolide fluticasone triamcinolone NASONEX STEROID / BETA AGONIST ADVAIR DULERA STEROID INHALANTS budesonide inhalation suspension ASMANEX FLOVENT DISKUS FLOVENT HFA PULMICORT FLEXHALER QVAR

4 TOPICAL DERMATOLOGY ACNE adapalene benzoyl peroxide clindamycin solution clindamycin-benzoyl peroxide erythromycin solution erythromycin-benzoyl peroxide tretinoin ACANYA ATRALIN PA BENZACLIN DIFFERIN EPIDUO RETIN-A MICRO PA TAZORAC PA ACTINIC KERATOSIS fluorouracil imiquimod CARAC PICATO ZYCLARA ANTIFUNGALS ciclopirox clotrimazole econazole ketoconazole nystatin MENTAX ANTIPSORIATICS acitretin calcipotriene methoxsalen SORILUX CORTICOSTEROIDS Low Potency desonide hydrocortisone Medium Potency mometasone triamcinolone CLODERM LOCOID LIPOCREAM LOCOID LOTION High Potency desoximetasone fluocinonide Very High Potency clobetasol CLOBEX SPRAY IMMUNOMODULATORS ELIDEL PROTOPIC ROSACEA metronidazole sulfacetamide-sulfur FINACEA ORACEA MOUTH / THROAT / DENTAL PROTECTANTS EPISIL MUGARD PA, SP OPHTHALMIC ANTIALLERGICS azelastine cromolyn sodium PATADAY PATANOL ANTI-INFECTIVES ciprofloxacin erythromycin gentamicin levofloxacin ofloxacin sulfacetamide tobramycin BESIVANCE MOXEZA VIGAMOX ANTI-INFECTIVE / ANTI-INFLAMMATORY neomycin-polymyxin B- bacitracin-hydrocortisone neomycin-polymyxin B- tobramycin- TOBRADEX OINTMENT TOBRADEX ST ZYLET ANTI-INFLAMMATORIES Nonsteroidal bromfenac diclofenac ketorolac Steroidal ALREX DUREZOL LOTEMAX BETA-BLOCKERS Nonselective timolol maleate solution BETIMOL Selective BETOPTIC S QUICK REFERENCE DRUG LIST CARBONIC ANHYDRASE INHIBITORS dorzolamide AZOPT CARBONIC ANHYDRASE INHIBITOR / BETA- BLOCKER dorzolamide-timolol COSOPT PF CARBONIC ANHYDRASE INHIBITOR / SYMPATHOMIMETIC SIMBRINZA IMMUNOMODULATORS RESTASIS PROSTAGLANDINS latanoprost travoprost TRAVATAN Z ZIOPTAN SYMPATHOMIMETICS brimonidine ALPHAGAN P SYMPATHOMIMETIC / BETA- BLOCKER COMBIGAN OTIC ANTI-INFECTIVE / ANTI-INFLAMMATORY CIPRODEX A ABILIFY ACANYA acitretin ACTONEL acyclovir adapalene ADVAIR AGGRENOX albuterol inhalation solution alendronate alfuzosin ext-rel allopurinol ALPHAGAN P ALREX amantadine AMITIZA amlodipine amlodipine-atorvastatin amoxicillin amoxicillin-clavulanate amphetaminedextroamphetamine mixed salts amphetaminedextroamphetamine mixed salts ext-rel AMTURNIDE ANDRODERM ANORO ELLIPTA APRISO ARANESP PA, SP, SI ARCAPTA ASMANEX ATELVIA atenolol atorvastatin ATRALIN PA AUVI-Q SI AVODART AVONEX PA, SP, SI AXIRON azelastine AZILECT azithromycin AZOPT AZOR B balsalazide BD INSULIN SYRINGES AND NEEDLES BENICAR BENICAR HCT BENZACLIN benzoyl peroxide BESIVANCE BETIMOL BETOPTIC S BEYAZ BIDIL BOSULIF PA, SP BRILINTA brimonidine bromfenac budesonide inhalation suspension buprenorphine-naloxone sublingual tablet bupropion bupropion ext-rel BUTRANS BYDUREON SI BYSTOLIC C calcipotriene calcitonin-salmon calcium acetate CANASA candesartan candesartanhydrochlorothiazide CARAC carbamazepine carbamazepine ext-rel carbidopa-levodopa carbidopa-levodopa ext-rel carbidopa-levodopaentacapone carvedilol cefdinir cefprozil cefuroxime axetil CELEBREX cephalexin CETROTIDE SI cholestyramine ciclopirox CIPRODEX ciprofloxacin ciprofloxacin ext-rel citalopram CITRANATAL clarithromycin clarithromycin ext-rel clindamycin clindamycin solution clindamycin-benzoyl peroxide clobetasol CLOBEX SPRAY CLODERM clopidogrel clotrimazole clozapine codeine-acetaminophen COLCRYS COMBIGAN COMBIVENT RESPIMAT COPAXONE PA, SP, SI COREG CR CORTIFOAM COSOPT PF CREON CRESTOR CRINONE cromolyn sodium cyclobenzaprine D DAYTRANA desonide desoximetasone DEXCOM G4 DEXILANT diazepam rectal gel DICLEGIS diclofenac diclofenac sodium diclofenac sodium solution diclofenac sodiummisoprostol dicloxacillin DIFFERIN DIFICID digoxin diltiazem ext-rel divalproex sodium divalproex sodium ext-rel DIVIGEL donepezil dorzolamide dorzolamide-timolol doxazosin doxycycline hyclate dronabinol DUAVEE DULERA duloxetine DUREZOL

5 E econazole EFFIENT ELIDEL ELIQUIS ENBREL PA, SP, SI entacapone EPIDUO EPIPEN JR SI EPIPEN SI EPISIL eprosartan erythromycin erythromycin solution erythromycin-benzoyl peroxide erythromycins escitalopram ESTRACE CREAM estradiol estradiol-norethindrone estropipate eszopiclone ethinyl estradioldrospirenone ethinyl estradiollevonorgestrel ethinyl estradiolnorelgestromin ethinyl estradiolnorethindrone acetate ethinyl estradiol-norgestimate ethosuximide EVAMIST EXELON PATCH EXFORGE EXFORGE HCT EXTAVIA PA, SP, SI F fenofibrate fenofibric acid fentanyl transdermal fentanyl transmucosal lozenge FENTORA PA FINACEA finasteride FLOVENT DISKUS FLOVENT HFA fluconazole flunisolide fluocinonide fluorouracil fluoxetine fluticasone fluvastatin FOLLISTIM AQ SI FORADIL FORTEO PA, SP, SI FORTESTA fosinopril fosinopril-hydrochlorothiazide furosemide G gabapentin galantamine galantamine ext-rel GELNIQUE GEL-ONE # gentamicin GILENYA PA, SP GLEEVEC PA, SP glimepiride glipizide glipizide ext-rel glipizide-metformin GLUCAGEN HYPOKIT SI GLUCAGON EMERGENCY KIT SI GRALISE granisetron H HUMATROPE PA, SP, SI HUMIRA PA, SP, SI HUMULIN R U-500 HYALGAN # hydrochlorothiazide hydrocodone-acetaminophen hydrocortisone hydrocortisone enema hydromorphone hydromorphone ext-rel I ibandronate imiquimod INTUNIV INVOKAMET INVOKANA ipratropium-albuterol inhalation solution irbesartan irbesartanhydrochlorothiazide itraconazole J JANUMET JANUMET XR JANUVIA JENTADUETO K ketoconazole ketorolac L lactulose LAMICTAL ODT lamotrigine lamotrigine ext-rel lansoprazole LANTUS latanoprost LATUDA LAZANDA PA LETAIRIS PA, SP LEVEMIR levetiracetam levetiracetam ext-rel levofloxacin levothyroxine LIALDA LINZESS lisinopril lisinopril-hydrochlorothiazide LO LOESTRIN FE LOCOID LIPOCREAM LOCOID LOTION losartan losartan-hydrochlorothiazide LOTEMAX LOTRONEX 3 lovastatin LOVAZA PA LYRICA M meclizine medroxyprogesterone MEGACE ES meloxicam MENTAX mesalamine rectal suspension metformin metformin ext-rel methadone 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 morphine ext-rel morphine suppository MOVIPREP MOXEZA moxifloxacin MUGARD PA, SP MYRBETRIQ N nadolol NAMENDA NAMENDA XR naproxen naratriptan QL NASONEX NATAZIA nateglinide neomycin-polymyxin B- bacitracin-hydrocortisone neomycin-polymyxin B- NEUPRO NEXIUM niacin ext-rel nifedipine ext-rel nitrofurantoin nitroglycerin sublingual spray NITROLINGUAL NITROSTAT NORDITROPIN PA, SP, SI NOVOLIN 70/30 NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG MIX 70/30 NUCYNTA NUCYNTA ER NUVARING NUVIGIL nystatin O ofloxacin olanzapine omeprazole omeprazole-sodium bicarbonate capsule ondansetron ONETOUCH ULTRA STRIPS AND KITS 2 ONETOUCH VERIO STRIPS AND KITS 2 OPANA ER ORACEA ORTHO TRI-CYCLEN LO OSPHENA OVIDREL SI oxcarbazepine oxybutynin oxybutynin ext-rel oxycodone oxycodone-acetaminophen OXYCONTIN QL P pantoprazole paroxetine paroxetine ext-rel PATADAY PATANASE PATANOL peg 3350-electrolytes penicillin VK PENTASA PERFOROMIST phenobarbital phenytoin phenytoin sodium extended PHOSLYRA PICATO pioglitazone pioglitazone-glimepiride pioglitazone-metformin PRADAXA pramipexole pravastatin prednisone PREMARIN PREMARIN CREAM PREMPHASE PREMPRO prenatal vitamins primidone PRISTIQ probenecid prochlorperazine PROCRIT PA, SP, SI PROCTOFOAM-HC progesterone, micronized promethazine propranolol propranolol ext-rel PROTOPIC PULMICORT FLEXHALER PYLERA Q QSYMIA quetiapine QUILLIVANT XR quinapril quinapril-hydrochlorothiazide QVAR R raloxifene ramipril RANEXA ranitidine RAPAFLO RELENZA QL RELISTOR SI RELPAX QL RENVELA repaglinide RESTASIS RETIN-A MICRO PA ribavirin PA, SP rimantadine risperidone rivastigmine rizatriptan QL ropinirole ropinirole ext-rel S SANCUSO SAVELLA selegiline SEREVENT SEROQUEL XR sertraline sildenafil PA, SP SILENOR SIMBRINZA SIMCOR simvastatin SORILUX SOVALDI PA, SP SPIRIVA spironolactonehydrochlorothiazide SPRYCEL PA, SP STRATTERA SUCLEAR sulfacetamide sulfacetamide-sulfur sulfamethoxazoletrimethoprim sulfasalazine sulfasalazine delayed-rel sumatriptan QL SUMAVEL DOSEPRO SI, QL SUPARTZ # SUPRAX SUPREP SYNTHROID T TAMIFLU QL

6 tamsulosin TAZORAC PA TECFIDERA PA, SP TEKAMLO TEKTURNA TEKTURNA HCT telmisartan telmisartanhydrochlorothiazide terazosin terbinafine tablet tetracycline tiagabine timolol maleate solution TOBRADEX OINTMENT TOBRADEX ST tobramycin tobramycin- tolterodine tolterodine ext-rel topiramate torsemide TRACLEER PA, SP TRADJENTA tramadol tramadol ext-rel TRAVATAN Z travoprost trazodone tretinoin TREXIMET QL triamcinolone triamterenehydrochlorothiazide TRIBENZOR trimethobenzamide trospium trospium ext-rel U UCERIS ULORIC ULTRESA V VAGIFEM valacyclovir valproic acid valsartan valsartan-hydrochlorothiazide VELPHORO venlafaxine venlafaxine ext-rel verapamil ext-rel VESICARE VICTOZA SI VICTRELIS PA, SP VIGAMOX VIIBRYD VIMPAT VIOKACE VOLTAREN GEL VYTORIN VYVANSE W warfarin WELCHOL X XARELTO XIFAXAN 550 MG PA Z zafirlukast ZELAPAR ZENPEP ZETIA ZIOPTAN ziprasidone zolmitriptan QL zolpidem zolpidem ext-rel ZOMIG NASAL SPRAY QL zonisamide ZUBSOLV ZYCLARA ZYLET PREFERRED OPTIONS LIST DRUG NAME(S) PREFERRED OPTION(S) DRUG NAME(S) PREFERRED OPTION(S) ACCU-CHEK STRIPS AND KITS 4 ACTOS ADDERALL XR ADRENACLICK ADVICOR AEROSPAN ALORA ALTOPREV pioglitazone amphetamine-dextroamphetamine mixed salts ext-rel AUVI-Q SI, EPIPEN SI, EPIPEN JR SI ASMANEX, FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER, QVAR estradiol, DIVIGEL, EVAMIST, MINIVELLE, AXERT QL AZELEX BECONASE AQ BENZAC AC, BENZAC W BENZIQ naratriptan QL, rizatriptan QL, sumatriptan nasal spray QL, sumatriptan tablet QL, zolmitriptan QL, RELPAX QL, ZOMIG NASAL SPRAY QL erythromycin solution adapalene, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, ACANYA, ATRALIN PA, BENZACLIN, DIFFERIN, EPIDUO, RETIN-A MICRO PA, TAZORAC PA adapalene, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, ACANYA, ATRALIN PA, BENZACLIN, DIFFERIN, EPIDUO, RETIN-A MICRO PA, TAZORAC PA ALVESCO ASMANEX, FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER, QVAR BREEZE 2 STRIPS AND KITS 4 AMRIX cyclobenzaprine BREO ELLIPTA ADVAIR ANDROGEL BYETTA BYDUREON SI, VICTOZA SI ANGELIQ ANTARA APEXICON E APIDRA ARMOUR THYROID ARTHROTEC ASACOL HD estradiol-norethindrone, PREMPHASE, PREMPRO desoximetasone, fluocinonide NOVOLOG levothyroxine, SYNTHROID CELEBREX; diclofenac sodium, meloxicam, or naproxen WITH lansoprazole, omeprazole, DEXILANT or NEXIUM balsalazide, sulfasalazine, sulfasalazine delayed-rel, APRISO, LIALDA, PENTASA, UCERIS ASCENSIA STRIPS AND KITS 4 ATACAND, ATACAND HCT CARDURA XL CENESTIN CLINDAGEL CONTOUR NEXT STRIPS AND KITS 4 alfuzosin ext-rel, doxazosin, tamsulosin, terazosin, RAPAFLO estradiol, estropipate, PREMARIN erythromycin solution CONTOUR STRIPS AND KITS 4 DELZICOL DETROL LA DIOVAN, DIOVAN HCT DORAL balsalazide, sulfasalazine, sulfasalazine delayed-rel, APRISO, LIALDA, PENTASA, UCERIS oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, GELNIQUE, MYRBETRIQ, VESICARE ATROVENT HFA SPIRIVA

7 DRUG NAME(S) PREFERRED OPTION(S) DUEXIS DYMISTA EDARBI, EDARBYCLOR EDLUAR ENABLEX ENJUVIA ESTRASORB ESTRING ESTROGEL CELEBREX; diclofenac sodium, meloxicam, or naproxen WITH lansoprazole, omeprazole, DEXILANT or NEXIUM flunisolide, fluticasone, triamcinolone, or NASONEX WITH azelastine or PATANASE oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, GELNIQUE, MYRBETRIQ, VESICARE estradiol, estropipate, PREMARIN estradiol, DIVIGEL, EVAMIST, MINIVELLE, ESTRACE CREAM, PREMARIN CREAM, VAGIFEM estradiol, DIVIGEL, EVAMIST, MINIVELLE, EUFLEXXA # GEL-ONE #, HYALGAN #, SUPARTZ # FARXIGA FEMRING FENOGLIDE FETZIMA FIRST TESTOSTERONE FLECTOR FORTAMET FOSAMAX PLUS D FOSRENOL FREESTYLE STRIPS AND KITS 4,5 FROVA QL GENOTROPIN GLUMETZA HUMALOG INVOKANA ESTRACE CREAM, PREMARIN CREAM, VAGIFEM duloxetine, venlafaxine, venlafaxine ext-rel, PRISTIQ diclofenac sodium, diclofenac sodium solution, meloxicam, naproxen, VOLTAREN GEL metformin, metformin ext-rel alendronate, ibandronate, ACTONEL, ATELVIA calcium acetate, PHOSLYRA, RENVELA, VELPHORO naratriptan QL, rizatriptan QL, sumatriptan nasal spray QL, sumatriptan tablet QL, zolmitriptan QL, RELPAX QL, ZOMIG NASAL SPRAY QL metformin, metformin ext-rel NOVOLOG HUMALOG MIX 50/50 NOVOLOG MIX 70/30 HUMALOG MIX 75/25 NOVOLOG MIX 70/30 HUMULIN INNOPRAN XL INTERMEZZO ISTALOL JALYN KAZANO KOMBIGLYZE XR LASTACAFT LESCOL XL NOVOLIN atenolol, carvedilol, metoprolol succinate ext-rel, metoprolol tartrate, nadolol, propranolol, propranolol ext-rel, BYSTOLIC, COREG CR timolol maleate solution, BETIMOL finasteride or AVODART WITH alfuzosin ext-rel, doxazosin, tamsulosin, terazosin or RAPAFLO JANUMET, JANUMET XR, JENTADUETO JANUMET, JANUMET XR, JENTADUETO azelastine, cromolyn sodium, PATADAY, PATANOL DRUG NAME(S) PREFERRED OPTION(S) LIPITOR LIPTRUZET LIVALO LUMIGAN LUNESTA MENEST MENOSTAR MICARDIS, MICARDIS HCT NAPRELAN NATESTO NESINA NITROMIST NORVASC NUTROPIN AQ OLUX-E OMNARIS OMNITROPE ONGLYZA latanoprost, travoprost, TRAVATAN Z, ZIOPTAN estradiol, estropipate, PREMARIN estradiol, diclofenac sodium, meloxicam, naproxen, CELEBREX JANUVIA, TRADJENTA nitroglycerin sublingual spray, NITROLINGUAL, NITROSTAT amlodipine clobetasol propionate foam, CLOBEX SPRAY JANUVIA, TRADJENTA ORTHOVISC # GEL-ONE #, HYALGAN #, SUPARTZ # OSENI OXYTROL PANCREAZE PENNSAID PERTZYE PEXEVA PLAVIX PRECISION XTRA STRIPS AND KITS 4 PRED MILD PREFERAOB PREFEST PRENATAL PLUS PREVACID PROTONIX PROVENTIL HFA QNASL RAYOS JANUMET, JANUMET XR, JENTADUETO oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, GELNIQUE, MYRBETRIQ, VESICARE CREON, ULTRESA, VIOKACE, ZENPEP diclofenac sodium, diclofenac sodium solution, meloxicam, naproxen, VOLTAREN GEL CREON, ULTRESA, VIOKACE, ZENPEP citalopram, escitalopram, fluoxetine, paroxetine, paroxetine ext-rel, sertraline, VIIBRYD clopidogrel, BRILINTA, EFFIENT, DUREZOL, LOTEMAX generic prenatal vitamins, CITRANATAL estradiol-norethindrone, PREMPHASE, PREMPRO generic prenatal vitamins, CITRANATAL lansoprazole, omeprazole, DEXILANT, NEXIUM lansoprazole, omeprazole, DEXILANT, NEXIUM, methylprednisolone, prednisone

8 DRUG NAME(S) PREFERRED OPTION(S) REBIF RELION INSULIN RHINOCORT AQUA RIOMET ROZEREM SAIZEN SKELID STRIANT SUBOXONE FILM SURE-TEST STRIPS AND KITS 4 SYMBICORT AVONEX PA, SP, SI, COPAXONE PA, SP, SI, EXTAVIA PA, SP, SI, GILENYA PA, SP, TECFIDERA PA, SP NOVOLIN INSULIN metformin, metformin ext-rel alendronate, ACTONEL buprenorphine-naloxone sublingual tablet, ZUBSOLV ADVAIR, DULERA SYNVISC #, SYNVISC-ONE # GEL-ONE #, HYALGAN #, SUPARTZ # TANZEUM SI TESTIM testosterone gel TEVETEN, TEVETEN HCT TEV-TROPIN BYDUREON SI, VICTOZA SI DRUG NAME(S) PREFERRED OPTION(S) TOVIAZ TRICOR TRIGLIDE TRILIPIX TRUETEST STRIPS AND KITS 4 TRUETRACK STRIPS AND KITS 4 TUDORZA VALTREX VANOS VASCEPA PA VENTOLIN HFA VERAMYST VIMOVO VITAFOL-ONE VOGELXO XOPENEX HFA ZETONNA ZYFLO, ZYFLO CR oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, GELNIQUE, MYRBETRIQ, VESICARE SPIRIVA acyclovir, valacyclovir clobetasol LOVAZA PA CELEBREX; diclofenac sodium, meloxicam, or naproxen WITH lansoprazole, omeprazole, DEXILANT or NEXIUM generic prenatal vitamins, CITRANATAL montelukast, zafirlukast

9 You may be responsible for the full cost of certain non-formulary products that are removed from coverage. Please check with your plan sponsor for more information. FOR YOUR INFORMATION: Generics should be considered the first line of prescribing. This drug list represents a summary of prescription coverage. It is not all-inclusive and does not guarantee coverage. New to market products and new variations of products already in the marketplace will not be added to the formulary until the product has been evaluated, determined to be clinically appropriate and cost-effective, and approved by the CVS/caremark Pharmacy and Therapeutics Committee (or other appropriate reviewing body). In most instances, a brandname 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. 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 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 check coverage and copay/coinsurance information for a specific medicine, visit and log in to My Account. 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. # Covered under the medical benefit. QL Quantity limits PA Prior authorization required SI Self-injectable product - refer to plan details for more information; some plans may have self-injectable products on the 4 th benefit tier. SP Specialty product 1 CVS/caremark is an independent company that provides pharmacy benefit management services. 2 A OneTouch blood glucose meter will 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 toll-free: Members must have CVS Caremark Mail Service Pharmacy benefits to qualify. 3 For safety reasons, to prescribe Lotronex, the physician must be enrolled in the Prescribing program for Lotronex. Physicians must understand the benefits and risks of treatment with Lotronex for severe diarrhea-predominant IBS, including the information in the Prescribing Information, Medication Guide and Patient-Physician agreement for Lotronex. To enroll or for more information on the Prescribing program for Lotronex, call toll free: or visit to complete the Physician Enrollment form. CareFirst and CVS/caremark do not manage the Lotronex Prescribing program or operate the website. CareFirst and CVS/caremark are not responsible for the availability or reliability of the website's content. This listing does not imply or constitute an endorsement, sponsorship or recommendation by CareFirst or CVS/caremark. 4 OneTouch brand test strips are the only preferred options. 5 An exception process is in place for specific clinical circumstances that may require continued coverage for Freestyle diabetic test strips. If your doctor believes you have a specific clinical need for this product, he or she should fax an exception request toll-free to: Your plan may choose to provide an exception process for additional medications on this list. 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. SUM2666-1P (01/15)