Post on 28-Jun-2020
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.
Date: June 9, 2015 Market: All fully insured groups,
Consumer Direct members and 100-199 self-insured groups
Clarification: Pharmacy Update – Upcoming Formulary Changes
As a follow up to the Sales Flash released on April 17, please review the information below for clarification about upcoming formulary changes. Communications notifying impacted members and providers of these changes have been sent – you should not reach out to your accounts; there is no action that you need to take. Fully Insured (Groups and Consumer Direct): Effective July 1, 2015, all fully insured groups (regardless of size) and Consumer Direct members in Maryland and Virginia will be transitioning to CareFirst Formulary 2 with prior authorizations (PA). The transition to CareFirst Formulary 2 with PA means 90* additional drugs will require a medical necessity prior authorization before they are covered by our prescription drug benefit. This is the only drug option available to fully insured groups and Consumer Direct members in Maryland and Virginia. Attached you will find a list of the additional 90 drugs that will require prior authorization. 100-199 Self-Insured Groups: Beginning July 1, 2015, all new and renewing 100-199 self-insured groups will move to CareFirst Formulary 2 with exclusions. This means approximately 90* drugs will be excluded from the list of covered drugs starting July 1. CareFirst Formulary 2 with exclusions will be the only option available to 100-199 self-insured groups. A list of the 90 drugs that will be excluded is also attached to this Sales Flash. 200+ Self-Insured Groups: No impact. Self-insured groups can continue to choose between CareFirst Formulary 1, CareFirst Formulary 2 with exclusions, and CareFirst Formulary 3 with exclusions. Note: No paperwork is required to implement these changes. Please keep in mind, formulary management is a proven way to encourage continued savings while minimizing member disruption, which enables accounts to stay ahead of market shifts. By driving employee behavior to lower-cost options, accounts may see improved savings in pharmacy costs. Below are some key messages for reference when talking with your impacted groups. Key messages
Impacted members and their prescribing physicians were notified by mail of this change.
Effective July 1, 2015 there will be two versions of CareFirst Formulary 2 – one with a medical necessity PA requirement on 90 additional drugs (fully insured groups and Consumer Direct in MD & VA) and one with 90 excluded drugs (100-199 self-insured groups).
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.
We have enhanced My Account to reflect the member’s formulary. Members can use the Drug Pricing Tool to research whether specific drugs require a PA or if they are excluded.
New ID cards will NOT be issued as a result of these changes. However, every ID card issued after July 1 will display RX, RX2 or RX3 and will include a carrier strip directing the member to log in to My Account to check their formulary.
Fully Insured (Groups and Consumer Direct):
90 additional drugs (out of our open formulary of 5,000 drugs) will now require a medical necessity prior authorization.
Since these additional 90 drugs are on the non-preferred brand tier, impacted members may save money by switching to one of the many available alternatives because they will be on a lower cost-share tier.
Members will still be able to get these drugs with an approved prior authorization IF the drug is found to be medically necessary by CareFirst based on information received from the prescribing physician.
This change impacts about four percent of fully insured members that have CareFirst prescription coverage.
Letters were mailed to all impacted fully insured groups and consumer direct members in Maryland and Virginia the week of April 27. The member letter listed the impacted drug and alternative drug options. Physicians were notified by mail on May 1.
Effective July 1, 2015, the Drug Search Tool on www.carefirst.com/rx will reflect the formulary options for fully insured members.
100-199 Self-Insured Groups:
CareFirst Formulary 2 with exclusions is the only formulary option for 100-199 self-insured groups.
For groups transitioning to CareFirst Formulary 2 effective July 1, letters were mailed to impacted members May 5 and physicians were notified the week of May 25.
All self-insured members will receive a separate Benefit Summary with a unique URL (www.carefirst.com/rxgroup) to view their formulary options.
Prior authorization process The prescribing physician must initiate the prior authorization process by completing an online request through the Provider Portal at http://www.carefirst.com/providerlogin. Should you have any questions, please contact your broker sales representative.
C. Shekar Subramaniam Vice President, Sales Small Medium SBU *The number of drug exclusions or drugs requiring a medical necessity prior authorization for both versions of CareFirst Formulary 2 may change on an annual basis. For July 1, 2015 we know 90 drugs are impacted.
April 2015
Drugs Requiring Prior Authorization for Medical Necessity for Formulary 2 Below is a list of medicines by drug class that require prior authorization for medical necessity on your plan's formulary. If you continue using one of the drugs listed below and identified as a drug requiring prior authorization for medical necessity, your doctor will be required to request prior authorization or you may be required to pay the full cost.
If you are currently using one of the drugs requiring prior authorization for medical necessity, ask your doctor to contact CVS/caremark1
at 1-855-240-0536 to request prior authorization or choose one of the generic or brand formulary options listed below.
Category * Drug Class
Drugs Requiring Prior Authorization for Medical Necessity 2
Formulary Options
Allergic Reaction (Anaphylaxis) Treatment *
ADRENACLICK
AUVI-Q SI, EPIPEN SI, EPIPEN JR SI
Allergies * Nasal Steroids / Combinations
BECONASE AQ OMNARIS QNASL RHINOCORT AQUA VERAMYST ZETONNA
flunisolide spray, fluticasone spray, triamcinolone spray, NASONEX
DYMISTA flunisolide spray, fluticasone spray, triamcinolone spray or NASONEX WITH azelastine spray or olopatadine spray
Allergies * Ophthalmic
LASTACAFT azelastine, cromolyn sodium, PATADAY, PATANOL
Anti-infectives, Antivirals * Hepatitis C Agents
VIEKIRA PAK HARVONI PA SP
Anti-infectives, Antivirals * Herpes Agents
VALTREX acyclovir, valacyclovir
Asthma * Beta Agonists, Short-Acting
PROVENTIL HFA VENTOLIN HFA XOPENEX HFA
PROAIR HFA
Asthma * Steroid Inhalants
AEROSPAN ALVESCO
ASMANEX, FLOVENT, PULMICORT FLEXHALER, QVAR
Asthma * or Chronic Obstructive Pulmonary Disease (COPD) * Steroid / Beta Agonist Combinations
SYMBICORT ADVAIR, DULERA
Attention Deficit Hyperactivity Disorder Agents *
ADDERALL XR amphetamine-dextroamphetamine mixed salts, amphetamine-dextroamphetamine mixed salts ext-rel, methylphenidate, methylphenidate ext-rel, DAYTRANA, QUILLIVANT XR, STRATTERA, VYVANSE
Cardiovascular Antilipemics * Fibrates
TRICOR fenofibrate, fenofibric acid
Cardiovascular Antilipemics * HMG-CoA Reductase Inhibitors (HMGs or Statins) / Combinations
ADVICOR ALTOPREV LESCOL XL LIPITOR LIPTRUZET LIVALO
atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin, CRESTOR, SIMCOR, VYTORIN
Category * Drug Class
Drugs Requiring Prior Authorization for Medical Necessity 2
Formulary Options
Chronic Obstructive Pulmonary Disease (COPD) * Anticholinergics
TUDORZA SPIRIVA
Depression * Antidepressants
OLEPTRO trazodone
Dermatology Skin Inflammation and Hives * Corticosteroids
OLUX-E clobetasol propionate foam 0.05%, CLOBEX SPRAY
APEXICON E desoximetasone, fluocinonide
Diabetes * Biguanides
FORTAMET GLUMETZA RIOMET
metformin, metformin ext-rel
Diabetes * Dipeptidyl Peptidase-4 (DPP-4) Inhibitors
NESINA ONGLYZA
JANUVIA, TRADJENTA
Diabetes * Dipeptidyl Peptidase-4 (DPP-4) Inhibitor Combinations
KAZANO KOMBIGLYZE XR OSENI
JANUMET, JANUMET XR, JENTADUETO
Diabetes* Injectable Incretin Mimetics
BYETTA BYDUREON SI, VICTOZA SI
Diabetes * Insulins
APIDRA HUMALOG
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
NOTE: Humulin R U-500 concentrate will not be subject to prior authorization and will continue to be covered.
Diabetes * Insulin Sensitizers
ACTOS pioglitazone
Diabetes * Sodium-Glucose Co-transporter 2 (SGLT2) Inhibitors
FARXIGA INVOKANA
Diabetes * Supplies 3, 4
ACCU-CHEK STRIPS AND KITS BREEZE 2 STRIPS AND KITS CONTOUR NEXT STRIPS AND KITS CONTOUR STRIPS AND KITS FREESTYLE STRIPS AND KITS All other test strips that are not ONETOUCH brand
ONETOUCH ULTRA STRIPS AND KITS 3, ONETOUCH VERIO STRIPS AND KITS 3
Erectile Dysfunction * Phosphodiesterase Inhibitors
LEVITRA CIALIS QL, VIAGRA QL
Gastrointestinal Agents * Proton Pump Inhibitors (PPIs)
PREVACID PROTONIX
lansoprazole, omeprazole, omeprazole-sodium bicarbonate capsule, pantoprazole, DEXILANT, NEXIUM
Category * Drug Class
Drugs Requiring Prior Authorization for Medical Necessity 2
Formulary Options
Glaucoma * Prostaglandin Analogs
LUMIGAN latanoprost, travoprost, TRAVATAN Z, ZIOPTAN
Growth Hormones * GENOTROPIN NUTROPIN AQ OMNITROPE SAIZEN TEV-TROPIN
HUMATROPE PA SP SI, NORDITROPIN PA SP SI
Hematologic * Platelet Aggregation Inhibitors
PLAVIX clopidogrel, BRILINTA, EFFIENT
High Blood Pressure * Angiotensin II Receptor Antagonists
ATACAND EDARBI TEVETEN
candesartan, eprosartan, irbesartan, losartan, telmisartan, valsartan, BENICAR
High Blood Pressure * Angiotensin II Receptor Antagonist / Diuretic Combinations
ATACAND HCT DIOVAN HCT EDARBYCLOR TEVETEN HCT
candesartan-hydrochlorothiazide, irbesartan-hydrochlorothiazide, losartan-hydrochlorothiazide, telmisartan-hydrochlorothiazide, valsartan-hydrochlorothiazide, BENICAR HCT
High Blood Pressure * Calcium Channel Blockers
NORVASC amlodipine
Inflammatory Bowel Disease (IBD), Ulcerative Colitis * Aminosalicylates
ASACOL HD DELZICOL
balsalazide, budesonide capsule, sulfasalazine, sulfasalazine delayed-rel, APRISO, LIALDA, PENTASA, UCERIS
Multiple Sclerosis Agents* REBIF 5 COPAXONE PA SP SI, EXTAVIA PA SP SI, GILENYA PA SP, PLEGRIDY PA SP SI, TECFIDERA PA SP
Musculoskeletal Agents* AMRIX cyclobenzaprine
Opioid Dependence Agents * SUBOXONE FILM buprenorphine-naloxone sublingual tablet, ZUBSOLV
Osteoarthritis * Viscosupplements
EUFLEXXA MB ORTHOVISC MB
GEL-ONE MB, HYALGAN MB, SUPARTZ MB
Overactive Bladder / Incontinence * Urinary Antispasmodics
DETROL LA OXYTROL TOVIAZ
oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, GELNIQUE, MYRBETRIQ, VESICARE
Pain and Inflammation * Corticosteroids
RAYOS dexamethasone, methylprednisolone, prednisone
Pain and Inflammation * Nonsteroidal Anti-inflammatory Drugs (NSAIDs) / Combinations
ARTHROTEC DUEXIS VIMOVO
CELEBREX; diclofenac sodium, meloxicam or naproxen WITH lansoprazole, omeprazole, omeprazole-sodium bicarbonate capsule, pantoprazole, DEXILANT or NEXIUM
FLECTOR PENNSAID
diclofenac sodium, diclofenac sodium solution, meloxicam, naproxen, VOLTAREN GEL
NAPRELAN diclofenac sodium, meloxicam, naproxen, CELEBREX
Prostate Condition * Benign Prostatic Hyperplasia Agents / Combinations
JALYN finasteride or AVODART WITH alfuzosin ext-rel, doxazosin, tamsulosin, terazosin or RAPAFLO
Sleep * Hypnotics, Non-benzodiazepines
INTERMEZZO LUNESTA ROZEREM
eszopiclone, zolpidem, zolpidem ext-rel, SILENOR
Category * Drug Class
Drugs Requiring Prior Authorization for Medical Necessity 2
Formulary Options
Testosterone Replacement * Androgens
testosterone gel 1% 6 ANDROGEL NATESTO TESTIM VOGELXO
ANDRODERM, AXIRON, FORTESTA
Transplant * Immunosuppressants, Calcineurin Inhibitors
Hecoria tacrolimus
Category * Drug Class
Formulary Options
New to Market Agents 2 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).
The listed formulary options are subject to change.
List of Drugs Requiring Prior Authorization for Medical Necessity 2 ACCU-CHEK STRIPS AND KITS 4 ACTOS ADDERALL XR ADRENACLICK ADVICOR AEROSPAN ALTOPREV ALVESCO AMRIX ANDROGEL APEXICON E APIDRA ARTHROTEC ASACOL HD ATACAND ATACAND HCT BECONASE AQ BREEZE 2 STRIPS AND KITS 4 BYETTA CONTOUR NEXT STRIPS AND KITS 4 CONTOUR STRIPS AND KITS 4 DELZICOL DETROL LA DIOVAN HCT DUEXIS DYMISTA EDARBI EDARBYCLOR EUFLEXXA FARXIGA FLECTOR FORTAMET FREESTYLE STRIPS AND KITS 4 GENOTROPIN GLUMETZA
Hecoria HUMALOG HUMALOG MIX 50/50 HUMALOG MIX 75/25 HUMULIN 70/30 HUMULIN N HUMULIN R INTERMEZZO JALYN KAZANO KOMBIGLYZE XR LASTACAFT LESCOL XL LEVITRA LIPITOR LIPTRUZET LIVALO LUMIGAN LUNESTA NAPRELAN NATESTO NESINA NORVASC NUTROPIN AQ OLEPTRO OLUX-E OMNARIS OMNITROPE ONGLYZA ORTHOVISC OSENI
OXYTROL PENNSAID PLAVIX PREVACID PROTONIX PROVENTIL HFA QNASL RAYOS REBIF 5 RHINOCORT AQUA RIOMET ROZEREM SAIZEN SUBOXONE FILM SYMBICORT TESTIM testosterone gel 1% 6 TEVETEN TEVETEN HCT TEV-TROPIN TOVIAZ TRICOR TUDORZA VALTREX VENTOLIN HFA VERAMYST VIEKIRA PAK VIMOVO VOGELXO XOPENEX HFA ZETONNA
This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. This is not an all-inclusive list of available covered options. Go to www.carefirst.com and log in to My Account to check coverage and copay/coinsurance information for a specific drug. Discuss this information with your doctor or health care provider. This information is not a substitute for medical advice or treatment. Talk to your doctor or health care provider about this information and any health-related questions you have. CareFirst and CVS/caremark assume no liability whatsoever for the information provided or for any diagnosis or treatment made as a result of this information. This list is subject to change. There may be additional plan restrictions. Please consult your plan for further information. Subject to applicable laws and regulations. * This list indicates the common uses for which the drug is prescribed. Some drugs are prescribed for more than one condition. MB Covered under the medical benefit. PA Prior authorization required. QL Quantity limits SI Self-injectable product SP Specialty product 1 CVS/caremark is an independent company that provides pharmacy benefit management services. 2 If your doctor believes you have a specific clinical need for one of these products, he or she should contact the Prior Authorization department toll-free at: 1-855-240-0536. 3 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: 1-800-588-4456. Members must have CVS Caremark Mail Service Pharmacy benefits to qualify. 4 OneTouch brand test strips are the only preferred options. 5 Members on existing Rebif therapy will not be subject to exclusions while remaining adherent on these therapies. 6 Listing reflects the authorized generics for Testim and Vogelxo. Your privacy is important to us. Our employees are trained regarding the appropriate way to handle your private health information. This document contains confidential and proprietary information of CareFirst and CVS/caremark and cannot be reproduced, distributed or printed without written permission from CareFirst. CareFirst may receive rebates, discounts and service fees from pharmaceutical manufacturers for certain listed products. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with CareFirst or CVS/caremark. Listed products are for informational purposes only and are not intended to replace the clinical judgment of the doctor.
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.
©2015. All rights reserved. SUM 2657-1P (04/15)
April 2015
Drug Removals for Formulary 2 Below is a list of medicines by drug class that have been removed from your plan’s formulary. If you continue using one of the drugs listed below and identified as a Formulary Drug Removal, you may be required to pay the full cost.
If you are currently using one of the formulary drug removals, ask your doctor to choose one of the generic or brand formulary options listed below.
Category * Drug Class
Formulary Drug Removals
Formulary Options
Allergic Reaction (Anaphylaxis) Treatment *
ADRENACLICK
AUVI-Q SI, EPIPEN SI, EPIPEN JR SI
Allergies * Nasal Steroids / Combinations
BECONASE AQ OMNARIS QNASL RHINOCORT AQUA VERAMYST ZETONNA
flunisolide spray, fluticasone spray, triamcinolone spray, NASONEX
DYMISTA flunisolide spray, fluticasone spray, triamcinolone spray or NASONEX WITH azelastine spray or olopatadine spray
Allergies * Ophthalmic
LASTACAFT azelastine, cromolyn sodium, PATADAY, PATANOL
Anti-infectives, Antivirals * Hepatitis C Agents
VIEKIRA PAK HARVONI PA SP
Anti-infectives, Antivirals * Herpes Agents VALTREX acyclovir, valacyclovir
Asthma * Beta Agonists, Short-Acting
PROVENTIL HFA VENTOLIN HFA XOPENEX HFA
PROAIR HFA
Asthma * Steroid Inhalants
AEROSPAN ALVESCO
ASMANEX, FLOVENT, PULMICORT FLEXHALER, QVAR
Asthma * or Chronic Obstructive Pulmonary Disease (COPD) * Steroid / Beta Agonist Combinations
SYMBICORT ADVAIR, DULERA
Attention Deficit Hyperactivity Disorder Agents *
ADDERALL XR amphetamine-dextroamphetamine mixed salts, amphetamine-dextroamphetamine mixed salts ext-rel, methylphenidate, methylphenidate ext-rel, DAYTRANA, QUILLIVANT XR, STRATTERA, VYVANSE
Cardiovascular Antilipemics * Fibrates
TRICOR fenofibrate, fenofibric acid
Cardiovascular Antilipemics * HMG-CoA Reductase Inhibitors (HMGs or Statins) / Combinations
ADVICOR ALTOPREV LESCOL XL LIPITOR LIPTRUZET LIVALO
atorvastatin, fluvastatin, lovastatin, pravastatin, simvastatin, CRESTOR, SIMCOR, VYTORIN
Chronic Obstructive Pulmonary Disease (COPD) * Anticholinergics
TUDORZA SPIRIVA
Depression * Antidepressants
OLEPTRO trazodone
Category * Drug Class
Formulary Drug Removals
Formulary Options
Dermatology Skin Inflammation and Hives * Corticosteroids
OLUX-E clobetasol propionate foam 0.05%, CLOBEX SPRAY
APEXICON E desoximetasone, fluocinonide
Diabetes * Biguanides
FORTAMET GLUMETZA RIOMET
metformin, metformin ext-rel
Diabetes * Dipeptidyl Peptidase-4 (DPP-4) Inhibitors
NESINA ONGLYZA
JANUVIA, TRADJENTA
Diabetes * Dipeptidyl Peptidase-4 (DPP-4) Inhibitor Combinations
KAZANO KOMBIGLYZE XR OSENI
JANUMET, JANUMET XR, JENTADUETO
Diabetes* Injectable Incretin Mimetics
BYETTA BYDUREON SI, VICTOZA SI
Diabetes * Insulins
APIDRA HUMALOG
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
NOTE: Humulin R U-500 concentrate will not be subject to removal and will continue to be covered.
Diabetes * Insulin Sensitizers
ACTOS pioglitazone
Diabetes * Sodium-Glucose Co-transporter 2 (SGLT2) Inhibitors
FARXIGA INVOKANA
Diabetes * Supplies 1,2
ACCU-CHEK STRIPS AND KITS BREEZE 2 STRIPS AND KITS CONTOUR NEXT STRIPS AND KITS CONTOUR STRIPS AND KITS FREESTYLE STRIPS AND KITS 3 All other test strips that are not ONETOUCH brand
ONETOUCH ULTRA STRIPS AND KITS 1, ONETOUCH VERIO STRIPS AND KITS 1
Erectile Dysfunction * Phosphodiesterase Inhibitors
LEVITRA CIALIS QL, VIAGRA QL
Gastrointestinal Agents * Proton Pump Inhibitors (PPIs)
PREVACID PROTONIX
lansoprazole, omeprazole, omeprazole-sodium bicarbonate capsule, pantoprazole, DEXILANT, NEXIUM
Glaucoma * Prostaglandin Analogs
LUMIGAN latanoprost, travoprost, TRAVATAN Z, ZIOPTAN
Growth Hormones * GENOTROPIN NUTROPIN AQ OMNITROPE SAIZEN TEV-TROPIN
HUMATROPE PA SP SI, NORDITROPIN PA SP SI
Category * Drug Class
Formulary Drug Removals
Formulary Options
Hematologic * Platelet Aggregation Inhibitors
PLAVIX clopidogrel, BRILINTA, EFFIENT
High Blood Pressure * Angiotensin II Receptor Antagonists
ATACAND EDARBI TEVETEN
candesartan, eprosartan, irbesartan, losartan, telmisartan, valsartan, BENICAR
High Blood Pressure * Angiotensin II Receptor Antagonist / Diuretic Combinations
ATACAND HCT DIOVAN HCT EDARBYCLOR TEVETEN HCT
candesartan-hydrochlorothiazide, irbesartan-hydrochlorothiazide, losartan-hydrochlorothiazide, telmisartan-hydrochlorothiazide, valsartan-hydrochlorothiazide, BENICAR HCT
High Blood Pressure * Calcium Channel Blockers
NORVASC amlodipine
Inflammatory Bowel Disease (IBD), Ulcerative Colitis * Aminosalicylates
ASACOL HD DELZICOL
balsalazide, budesonide capsule, sulfasalazine, sulfasalazine delayed-rel, APRISO, LIALDA, PENTASA, UCERIS
Multiple Sclerosis Agents* REBIF 4 COPAXONE PA SP SI, EXTAVIA PA SP SI, GILENYA PA SP, PLEGRIDY PA SP SI, TECFIDERA PA SP
Musculoskeletal Agents* AMRIX cyclobenzaprine
Opioid Dependence Agents * SUBOXONE FILM buprenorphine-naloxone sublingual tablet, ZUBSOLV
Osteoarthritis * Viscosupplements
EUFLEXXA MB ORTHOVISC MB
GEL-ONE MB, HYALGAN MB, SUPARTZ MB
Overactive Bladder / Incontinence * Urinary Antispasmodics
DETROL LA OXYTROL TOVIAZ
oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, GELNIQUE, MYRBETRIQ, VESICARE
Pain and Inflammation * Corticosteroids
RAYOS dexamethasone, methylprednisolone, prednisone
Pain and Inflammation * Nonsteroidal Anti-inflammatory Drugs (NSAIDs) / Combinations
ARTHROTEC DUEXIS VIMOVO
CELEBREX; diclofenac sodium, meloxicam or naproxen WITH lansoprazole, omeprazole, omeprazole-sodium bicarbonate capsule, pantoprazole, DEXILANT or NEXIUM
FLECTOR PENNSAID
diclofenac sodium, diclofenac sodium solution, meloxicam, naproxen, VOLTAREN GEL
NAPRELAN diclofenac sodium, meloxicam, naproxen, CELEBREX
Prostate Condition * Benign Prostatic Hyperplasia Agents / Combinations
JALYN finasteride or AVODART WITH alfuzosin ext-rel, doxazosin, tamsulosin, terazosin or RAPAFLO
Sleep * Hypnotics, Non-benzodiazepines
INTERMEZZO LUNESTA ROZEREM
eszopiclone, zolpidem, zolpidem ext-rel, SILENOR
Testosterone Replacement * Androgens
testosterone gel 1% 5 ANDROGEL NATESTO TESTIM VOGELXO
ANDRODERM, AXIRON, FORTESTA
Transplant * Immunosuppressants, Calcineurin Inhibitors
Hecoria tacrolimus
Category * Drug Class
Formulary Options
New to Market Agents 3 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).
The listed formulary options are subject to change.
List of Formulary Drug Removals ACCU-CHEK STRIPS AND KITS 2 ACTOS ADDERALL XR ADRENACLICK ADVICOR AEROSPAN ALTOPREV ALVESCO AMRIX ANDROGEL APEXICON E APIDRA ARTHROTEC ASACOL HD ATACAND ATACAND HCT BECONASE AQ BREEZE 2 STRIPS AND KITS 2 BYETTA CONTOUR NEXT STRIPS AND KITS 2 CONTOUR STRIPS AND KITS 2 DELZICOL DETROL LA DIOVAN HCT DUEXIS DYMISTA EDARBI EDARBYCLOR EUFLEXXA FARXIGA FLECTOR FORTAMET FREESTYLE STRIPS AND KITS 2, 3 GENOTROPIN GLUMETZA
Hecoria HUMALOG HUMALOG MIX 50/50 HUMALOG MIX 75/25 HUMULIN 70/30 HUMULIN N HUMULIN R INTERMEZZO JALYN KAZANO KOMBIGLYZE XR LASTACAFT LESCOL XL LEVITRA LIPITOR LIPTRUZET LIVALO LUMIGAN LUNESTA NAPRELAN NATESTO NESINA NORVASC NUTROPIN AQ OLEPTRO OLUX-E OMNARIS OMNITROPE ONGLYZA ORTHOVISC OSENI
OXYTROL PENNSAID PLAVIX PREVACID PROTONIX PROVENTIL HFA QNASL RAYOS REBIF 4 RHINOCORT AQUA RIOMET ROZEREM SAIZEN SUBOXONE FILM SYMBICORT TESTIM testosterone gel 1% 5 TEVETEN TEVETEN HCT TEV-TROPIN TOVIAZ TRICOR TUDORZA VALTREX VENTOLIN HFA VERAMYST VIEKIRA PAK VIMOVO VOGELXO XOPENEX HFA ZETONNA
This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. This is not an all-inclusive list of available covered options. Go to www.carefirst.com and log in to My Account to check coverage and copay/coinsurance information for a specific drug. Discuss this information with your doctor or health care provider. This information is not a substitute for medical advice or treatment. Talk to your doctor or health care provider about this information and any health-related questions you have. CareFirst and CVS/caremark6 assume no liability whatsoever for the information provided or for any diagnosis or treatment made as a result of this information. This list is subject to change. There may be additional plan restrictions. Please consult your plan for further information. Subject to applicable laws and regulations. * This list indicates the common uses for which the drug is prescribed. Some drugs are prescribed for more than one condition. MB Covered under the medical benefit. PA Prior authorization required. QL Quantity limits SI Self-injectable product SP Specialty product 1 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: 1-800-588-4456. Members must have CVS Caremark Mail Service Pharmacy benefits to qualify. 2 OneTouch brand test strips are the only preferred options. 3 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: 1-888-487-9257. Your plan may choose to provide an exception process for additional medications on this list and new to market agents.
4 Members on existing Rebif therapy will not be subject to exclusions while remaining adherent on these therapies. 5 Listing reflects the authorized generics for Testim and Vogelxo. 6 CVS/caremark is an independent company that provides pharmacy benefit management services. Your privacy is important to us. Our employees are trained regarding the appropriate way to handle your private health information. This document contains confidential and proprietary information of CareFirst and CVS/caremark and cannot be reproduced, distributed or printed without written permission from CareFirst. CareFirst may receive rebates, discounts and service fees from pharmaceutical manufacturers for certain listed products. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with CareFirst or CVS/caremark. Listed products are for informational purposes only and are not intended to replace the clinical judgment of the doctor.
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.
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