Preferred Drug List (Formulary) CareFirst BlueCross BlueShield

Transcription

1 Prescription drugs can account for a large percentage of your health care costs. By using the (CareFirst) preferred drug list, also called a formulary, you can discuss with your physician and your pharmacist about how to make safe and cost-effective decisions to better manage your health care. Generic Drugs (Tier 1) n Copays for generic drugs are the lowest. Preferred Brand Name Drugs (Tier 2) Non-Preferred Brand Name Drugs * *Non-preferred brand name drugs are not part of the preferred drug list but are covered at the highest copay. What is a preferred drug list? CareFirst s preferred drug list is part of the 3-Tier Prescription Drug Program that consists of both generic (Tier 1) and preferred brand name (Tier 2) drugs that are selected for their effectiveness and affordability. Non-preferred brand name (Tier 3) drugs are not part of the preferred drug list, but are covered by your pharmacy benefits at the highest copay. How do drugs get on the preferred drug list? The preferred drug list is based on current medical research and input from a committee of doctors and pharmacists who serve the CareFirst region. Drugs are selected for their quality, effectiveness and cost. The preferred drug list changes frequently in response to Food and Drug Administration (FDA) requirements. The list is also adjusted when a generic drug is introduced for a brand name drug. When that happens, the generic drug will be added to the Tier 1 list and the brand name drug will automatically move from Tier 2 to Tier 3. n Most generic drugs are on the preferred drug list and available at the lowest copay. n Copays for preferred brand name drugs are higher than generic drugs. n When a generic version of a preferred brand name drug becomes available, the brand name version moves from Tier 2 to Tier 3 (non preferred brand name drugs). n Copays for non preferred brand name drugs are the highest. n If your brand name drug has a generic equivalent, the brand name drug will not be on the preferred drug list and will be a Tier 3 drug. n You will pay the lowest copay (Tier 1) if you choose the generic version of a drug and the highest copay if you choose the brand name version of a drug. n Some plans require members who choose a Tier 3 drug over its generic equivalent (Tier 1) to pay the highest copay PLUS the difference in cost between the brand name drug and the generic drug. Please refer to your member contract for details.

2 Prior Authorization Some prescriptions require advance approval before they can be dispensed. Prior Authorization is used to ensure that you meet necessary medical criteria to obtain a particular drug. When you receive a prescription for one of these drugs, please explain to your physician that prior authorization is needed before benefits will be available to you. Without proper authorization, you will pay the full price of the prescription rather than only your copay or coinsurance amount. Your physician must call to begin the prior authorization process. If you are already at the pharmacy, they too can call your doctor to start the process. Members with questions about prior authorization should call Argus Health Systems, Inc. at (800) The drugs listed to the right require prior authorization. This list is subject to your benefit plan and may change periodically. For the most up to date prior authorization list, visit the prescription drug web site at ACIPHEX* ACTIQ* AFINITOR APLENZIN* ARANESP* AVINZA* AVITA* AVONEX* BETASERON* BRAVELLE CELEBREX* CESAMET* CETROTIDE CIMZIA PRE- FILLED SYRINGE* COPAXONE DAYTRANA* DIFFERIN* ENBREL EPIDUO* EPOGEN* EXTAVIA* FENTORA* FLECTOR PATCH* FOLLISTIM AQ* FORTEO* GENOTROPIN* GLEEVEC GONAL-F HUMATROPE* HUMIRA HYCAMTIN INCRELEX* KADIAN* KAPIDEX* KINERET* LANTUS* LEUKINE* LOVAZA* LUVERIS* MENOPUR NEULASTA* NEUMEGA* NEUPOGEN NEXAVAR NEXIUM* NORDITROPIN NOVAREL* NUTROPIN* NUVIGIL* OMNITROPE* ONSOLIS* OPANA* OVIDREL PEG-INTRON* PEGASYS PREGNYL* PREVICID 30MG* PRILOSEC 10MG* PRILOSEC 40MG* PROCRIT PROVIGIL* REBIF REPRONEX RETIN-A CREAM AND GEL* RETIN-A LIQUID* RETIN-A MICRO GEL* *Non-preferred brand name drugs are not part of the preferred drug list. REVLIMID SAIZEN* SEROSTIM SIMPONI* SPRYCEL SUTENT SYMLIN* TARCEVA TASIGNA TAZORAC TEMODAR TEV-TROPIN* THALOMID TRETIN-X* TYKERB VOLTAREN GEL* VOTRIENT XELODA ZEGERID* ZIANA* ZOLINZA ZORBTIVE* Quantity Limits Certain prescription drugs may only be prescribed in limited quantities. These limits are set to ensure that alternatives are regularly reconsidered by your physician. This list is subject to change and will be periodically updated. For the most up-to-date list of drugs with quantity limits, visit the prescription drug web site at ACCU-CHEK METER TEST STRIPS AMERGE* ANZEMET* AXERT* CAVERJECT* CIALIS* CIPRO XR* DEPO-PROVERA* EDEX* EMEND FLECTOR PATCH* FROVA* GLUCOMETER DEX TEST SENSORS* GLUCOMETER ELITE TEST STRIPS* GLUCOMETER ENCORE TEST STRIPS* IMITREX* (ALL FORMS) MAXALT* MIGRANAL* MUSE* ONETOUCH METER TEST STRIPS OXYCONTIN* PROQUIN XR* RELENZA* RELPAX* SANCUSO* SEASONALE* TREXIMET* VIAGRA XIFAXAN* ZITHROMAX SUSP* ZITHROMAX TABLETS* ZMAX* ZOMIG* EPIPEN; EPIPEN JR. KYTRIL* TAMIFLU* ESTRING* LEVITRA* TORADOL* *Non-preferred brand name drugs are not part of the preferred drug list.

3 Maintenance Drugs A maintenance drug is a prescription drug anticipated to be required for six months or more to treat a chronic condition. Maintenance drugs can be ordered up to a 90-day supply. For the most up-to-date list of maintenance medication, visit the prescription drug web site at Blood Blood Thinners (Anticoagulants)- Coumadin Only Stroke Prevention Central Nervous System Alzheimer s Drugs Anti-Parkinson Drugs Attention Deficit Disorders (ADD) Seizure Medications (Anticonvulsants) Chest Pain & Heart Disease (Nitrates) Diabetes & High Blood Sugar Antidiabetic Drugs Blood Sugar Test Strips Diseases Arthritis (Rheumatoid) Bone Disease (Paget s) Bone Disease Gout Hepatitis Multiple Sclerosis Drugs Myasthenia Gravis Drugs Thyroid Disease ENT (Ear/Nose/Throat) Allergies & Colds (Nasal) Allergies (Oral) Eye Glaucoma Drugs Heart Rhythm Disorders High Blood Pressure & Heart Disease ACE Inhibitors Alpha Beta Blockers Angiotensin II Blockers Beta Blockers Calcium Channel Blockers Combination Drugs Sympatholytics Water Pills Or Diuretics High Cholesterol Drugs (Antilipemics) HIV & AIDS Combination Drugs Non-Nucleoside Reverse Transcriptase Inhibitors Nucleoside Reverse Transcriptase Inhibitors Protease Inhibitors Hormones Growth Hormone Replacement Drugs Male Miscellaneous Immune System Anti-Rejection (Immunosuppressants) Infections Tuberculosis (Antituberculosis Drug) Low Blood Pressure Mental Health/Schizophrenia Mental Health Antidepressants Antipsychotic Drugs Manic-Depression or Bipolar Drugs Narcolepsy OB-GYN Birth Control Patch (Monophasic Contraceptives) Birth Control Pills (Monophasic Contraceptives) Birth Control Pills (Progestin Only) Birth Control Pills (Triphasic Contraceptives) Birth Control Ring (Monophasic) Breast Cancer (Anti-Estrogens) Endometriosis Female Hormones (Estrogens) Female Hormones (Progestins) Female Hormones (Replacement Combination) Prenatal Vitamins Pain Management (Analgesics)- Only Non-Narcotic Drugs Pain Management (COX 2) Respiratory Problems Asthma & COPD (Miscellaneous Inhalers) Asthma (Bronchodilators) Asthma (Methylxanthines) Asthma (Oral Bronchodilators) Asthma (Steroid Inhalers) Miscellaneous Drugs Stomach & Digestive Disorders Acid & Stomach Ulcers Bowel & Colon Disease Malabsorption Disease Severe Heartburn & Reflux Supplements Potassium (Eff. Tablet) Potassium (Liquid) Potassium (Tablets) Vitamin D Urology Bladder Control (Antispasmodics) Bladder Control (Cholinergic Agents) Prostate Disease (Benign Prostatic Hypertrophy)

4 Three Tier Preferred Drug List** List is not all-inclusive. For the most complete and up-to-date formulary, please visit Generic Drugs (Tier 1) Lowest Copay Blood Blood Thinners/ Modifiers, Stroke Prevention cilostazol pentoxifylline ticlopidine warfarin anagrelide Blood Stimulators Bone Disease Arthritis hydroxychloroquine methotrexate leflunomide Osteoporosis estradiol estradiol transdermal alendronate calcitonin nasal spray ARIXTRA COUMADIN FRAGMIN LOVENOX PLAVIX NEUPOGEN PROCRIT ENBREL HUMIRA PREMARIN EVISTA Central Nervous System Attention Deficit Disorder amphetamine/ dextroamphetamine dextroamphetamine methylphenidate methylphenidate sr Sedatives chloral hydrate flurazepam temazepam zolpidem zaleplon CONCERTA Diabetes and High Blood Sugar Anti-Diabetic Drugs acarbose glipizide glyburide glimepiride glyburide/metformin metformin nateglinide Insulin Preferred Brand Name Drugs (Tier 2) ACTOS AVANDAMET AVANDARYL AVANDIA BYETTA DUETACT JANUMET JANUVIA PRANDIN LEVEMIR NOVO INSULIN NOVOLOG Non-Preferred Brand Name Drugs AGRYLIN PLETAL TICLID TRENTAL ARANESP EPOGEN NEULASTA ARAVA CUPRIMINE KINERET RHEUMATREX DOSE PACK ACTONEL BONIVA CLIMARA FORTEO FOSAMAX FOSAMAX PLUS D MIACALCIN ADDERALL DAYTRANA DESOXYN DEXEDRINE FOCALIN RITALIN STRATTERA AMBIEN DALMANE LUNESTA RESTORIL ROZEREM SONATA AMARYL DIABETA GLUCOPHAGE GLUCOTROL GLUCOVANCE ONGLYZA PRECOSE STARLIX SYMLIN HUMALOG HUMULIN LANTUS Generic Drugs Preferred Brand (Tier 1) Name Drugs Lowest Copay (Tier 2) Ear/Nose/Throat (ENT)- Allergy Cold - Nasal fluticasone flunisolide Oral clemastine fumarate fexofenadine ASTELIN BECONASE AQ FLONASE NASACORT AQ NASAREL NASONEX ALLEGRA-D ALLEGRA CLARINEX XYZAL High Blood Pressure and Heart Disease ACE Inhibitors captopril enalapril lisinopril ramipril Angiotensin Receptor Blockers MULTA Q AVAPRO DIOVAN High Cholesterol Drugs Statins lovastatin simvastatin pravastatin Infections Cephalosporins cefaclor cefadroxil cefdinir cefuroxime cephalexin LIPITOR NIASPAN TRICOR ACCUPRIL ALTACE MONOPRIL PRINIVIL VASOTEC ZESTRIL ATACAND COZAAR MICARDIS ADVICOR CRESTOR LESCOL XL MEVACOR VYTORIN ZOCOR CECLOR CEFTIN CEFZIL DURICEF LORABID OMNICEF SUPRAX VANTIN Quinolones ciprofloxacin LEVAQUIN AVELOX CIPRO CIPRO XR FLOXIN Macrolides erythromycin clarithromycin azithromycin Penicillin penicillin amoxicillin amoxicillin/ clavulanate AUGMENTIN XR Non-Preferred Brand Name Drugs BIAXIN BIAXIN XL ZITHROMAX AMOXIL AUGMENTIN ES

5 Preferred Drug List (Formulary) Three Tier Preferred Drug List** Generic Drugs (Tier 1) Lowest Copay Preferred Brand Non-Preferred Name Drugs Brand Name Drugs (Tier 2) Mental Health EFFEXOR XR LEXAPRO Antipsychotics chlorpromazine fluphenezine haloperidol risperidone APLENZIN CELEXA CYMBALTA PAXIL PAXIL CR PROZAC WELLBUTRIN SR/XL ZOLOFT Fertility gonadotropin clomiphene ganirelix BRAVELLE CETROTIDE GONAL-F MENOPUR OVIDREL REPRONEX CLOMID FOLLISTIM AQ LUVERIS NOVAREL PREGNYL Pain Management Migraine sumatriptan MIGRANAL AMERGE AXERT FROVA RELPAX IMITREX MAXALT TREXIMET ZOMIG NSAID/COX-II Inhibitors ibuprofen nabumetone naproxen diclofenac piroxicam meloxicam COPD Problems cromolyn sodium ipratropium bromide ADVAIR COMBIVENT SPIRIVA INTAL PROAIR HFA SEREVENT VENTOLIN HFA FORADIL MAXAIR AUTOHALER PROVENTIL HFA XOPENEX AEROBID ASMANEX QVAR ACCOLATE ZYFLO Bronchodilators metaproterenol SEROQUEL OB/GYN chorionic Preferred Brand Non-Preferred Name Drugs Brand Name Drugs (Tier 2) Respiratory Problems - Asthma Antidepressants citalopram fluoxetine sertraline venlafaxine paroxetine bupropion Generic Drugs (Tier 1) Lowest Copay Inhaled Steroids FLOVENT HFA PULMICORT Asthma - Miscellaneous Drugs SINGULAIR Stomach and Digestive Disorders Acid and Stomach Disorders cimetidine nizatidine lansoprazole pantoprazole ACIPHEX KAPIDEX NEXIUM PREVACID PREVPAC PRILOSEC PROTONIX ZEGERID Urology Prostate Disease CELEBREX MOBIC doxazosin terazosin finasteride AVODART FLOMAX CARDURA HYTRIN PROSCAR **This list represents the most frequently prescribed drugs in each category. Discuss with your physician if there are specific alternatives to your current medication on lower tiers. Self-Administered Injectable Drugs (Some plans may require a coinsurance payment.)

6 Need more information? On the Phone If you have questions about your prescription drug coverage or the preferred drug list, call Argus Health Systems, Inc. at (800) You should contact your physician or pharmacist if you have questions regarding the type of drug, side effects, drug interactions, storage, etc. By Mail If you have questions about your mail order benefits, call Walgreens Mail Service at (800) On the Web For the most recent information regarding the 3-tier prescription drug program, changes to the preferred drug list, etc. visit the prescription drug web site at Using Generic Drugs Did you know that switching to a generic drug could save you money in out-ofpocket prescription costs? Generic drugs are made with the same active ingredients as brand-name drugs and have the same effects in the body. The difference? Name and price. Brand name drugs are protected by patents for up to 20 years and until the patent expires, no other companies can produce the generic equivalent. This keeps the cost to the consumer higher. However, when the patent expires, the drug is able to be released by other companies, thus creating competition. Facts About Generics n Clinically the same as brand-name drugs, but may look different because inactive ingredients, like color, can differ between manufacturers. n Required by the Food and Drug Administration (FDA) to have the same quality, strength, purity and stability as brand-name drugs. n Endorsed by the American Medical Association, the largest organization of medical doctors, as acceptable for the American public. n Routinely used by most hospitals when treating patients. n Held to the same federal FDA standards for safety and performance as brand name drugs. n Deliver the same amount of active ingredients in the same time as brand name drugs. n Companies that make brand name drugs are linked to an estimated 50 percent of generic drug production. n Sell for percent less that brand name drugs. For more information about generic drugs, visit our prescription drug web site at and click on Learn About Generic Drugs. The preferred drug list changes frequently in response to FDA requirements. The list is also adjusted when a generic drug is introduced for a brand name drug. When that happens, the generic drug will be added to the Tier 1 list and the brand name drug will automatically move from Tier 2 to Tier 3. For the most recent information about the preferred drug list, visit the prescription drug web site at BRC5943-4P (11/10) is an independent licensee 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.