CareFirst Preferred Drug List - Formulary 2 · name drugs in CAPS, branded generics in upper- and...

January 2019

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 member’s 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 § COX-2 INHIBITORS celecoxib § GOUT allopurinol colchicine tablet 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 ABSTRAL BELBUCA BUTRANS EMBEDA HYSINGLA ER NUCYNTA NUCYNTA ER OXYCONTIN SUBSYS

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 BIKTARVY 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 EPCLUSA (genotypes 1, 2, 3, 4, 5, 6) HARVONI (genotypes 1, 4, 5, 6) VOSEVI 2 § HERPES AGENTS acyclovir valacyclovir § INFLUENZA AGENTS oseltamivir RELENZA § MISCELLANEOUS clindamycin ivermectin linezolid metronidazole nitrofurantoin sulfamethoxazole-trimethoprim EMVERM XIFAXAN 550 MG

ANTINEOPLASTIC AGENTS

HORMONAL ANTINEOPLASTIC AGENTS § ANTIANDROGENS bicalutamide ERLEADA XTANDI ZYTIGA § KINASE INHIBITORS imatinib mesylate BOSULIF CABOMETYX IBRANCE IRESSA KISQALI KISQALI FEMARA CO-PACK RYDAPT SPRYCEL

§ MISCELLANEOUS ODOMZO VISTOGARD ZEJULA

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 colesevelam § 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 PCSK9 INHIBITORS REPATHA § 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 OPSUMIT TRACLEER

§ PHOSPHODIESTERASE INHIBITORS sildenafil PROSTACYCLIN RECEPTOR AGONISTS UPTRAVI § PROSTAGLANDIN VASODILATORS ORENITRAM SOLUBLE GUANYLATE CYCLASE STIMULATORS ADEMPAS § 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 pramipexole ext-rel rasagiline ropinirole ropinirole ext-rel selegiline NEUPRO ANTIPSYCHOTICS § ATYPICALS aripiprazole clozapine olanzapine quetiapine quetiapine ext-rel risperidone ziprasidone ABILIFY MAINTENA ARISTADA LATUDA VRAYLAR § ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine-dextroamphetamine

mixed salts amphetamine-dextroamphetamine

mixed salts ext-rel atomoxetine guanfacine ext-rel methylphenidate methylphenidate ext-rel MYDAYIS VYVANSE FIBROMYALGIA LYRICA SAVELLA § HUNTINGTON'S DISEASE AGENTS tetrabenazine AUSTEDO HYPNOTICS § NONBENZODIAZEPINES eszopiclone zolpidem zolpidem ext-rel zolpidem sublingual BELSOMRA TRICYCLICS SILENOR

MIGRAINE § ERGOTAMINE DERIVATIVES ergotamine-caffeine MONOCLONAL ANTIBODIES AJOVY EMGALITY § SELECTIVE SEROTONIN AGONISTS eletriptan naratriptan rizatriptan sumatriptan zolmitriptan ONZETRA XSAIL ZEMBRACE SYMTOUCH ZOMIG NASAL SPRAY SELECTIVE SEROTONIN AGONIST / NONSTEROIDAL ANTI-INFLAMMATORY DRUG (NSAID) COMBINATIONS TREXIMET § MULTIPLE SCLEROSIS AGENTS glatiramer AUBAGIO BETASERON COPAXONE GILENYA REBIF TECFIDERA § MUSCULOSKELETAL THERAPY AGENTS cyclobenzaprine § NARCOLEPSY armodafinil POSTHERPETIC NEURALGIA (PHN) GRALISE PSYCHOTHERAPEUTIC - MISCELLANEOUS § OPIOID ANTAGONISTS naloxone injection 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 § ANDROGENS testosterone gel

testosterone solution ANDRODERM ANDROGEL 1.62% ANTIDIABETICS AMYLIN ANALOGS SYMLINPEN § BIGUANIDES metformin metformin ext-rel 4 § BIGUANIDE / SULFONYLUREA COMBINATIONS glipizide-metformin DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS JANUVIA DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITOR / BIGUANIDE COMBINATIONS JANUMET JANUMET XR INCRETIN MIMETIC AGENTS OZEMPIC TRULICITY VICTOZA INCRETIN MIMETIC AGENT / INSULIN COMBINATIONS SOLIQUA 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 JARDIANCE

SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITOR / BIGUANIDE COMBINATIONS SYNJARDY SYNJARDY XR XIGDUO XR SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITOR / DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITOR COMBINATIONS GLYXAMBI QTERN § SULFONYLUREAS glimepiride glipizide glipizide ext-rel SUPPLIES ACCU-CHEK AVIVA PLUS

STRIPS AND KITS 5 ACCU-CHEK COMPACT PLUS

STRIPS AND KITS 5 ACCU-CHEK GUIDE

STRIPS AND KITS 5 ACCU-CHEK SMARTVIEW

STRIPS AND KITS 5 BD ULTRAFINE INSULIN

SYRINGES AND NEEDLES DEXCOM CONTINUOUS GLUCOSE

MONITORING SYSTEM * ANTIOBESITY INJECTABLE SAXENDA ORAL BELVIQ BELVIQ XR CALCIUM REGULATORS § BISPHOSPHONATES alendronate ibandronate risedronate § CALCITONINS calcitonin-salmon PARATHYROID HORMONES FORTEO TYMLOS § CARNITINE DEFICIENCY AGENTS levocarnitine CONTRACEPTIVES § MONOPHASIC ethinyl estradiol-drospirenone ethinyl estradiol-drospirenone-

levomefolate ethinyl estradiol-norethindrone

acetate ethinyl estradiol-norethindrone

acetate-iron SAFYRAL

§ BIPHASIC LO LOESTRIN FE § 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 OVULATION STIMULANTS, GONADOTROPINS GONAL-F OVIDREL GAUCHER DISEASE CERDELGA § GLUCOCORTICOIDS dexamethasone methylprednisolone prednisolone solution prednisone GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT

HEREDITARY TYROSINEMIA TYPE 1 AGENTS ORFADIN HUMAN GROWTH HORMONES HUMATROPE § 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 meclizine metoclopramide ondansetron prochlorperazine promethazine trimethobenzamide DICLEGIS SANCUSO VARUBI § 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 § PHOSPHODIESTERASE INHIBITORS sildenafil CIALIS § 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 PROCRIT ZARXIO HEREDITARY ANGIOEDEMA RUCONEST § PLATELET AGGREGATION INHIBITORS clopidogrel dipyridamole ext-rel-aspirin prasugrel BRILINTA

IMMUNOLOGIC AGENTS

ALLERGENIC EXTRACTS GRASTEK ORALAIR RAGWITEK AUTOIMMUNE AGENTS COSENTYX ENBREL HUMIRA KEVZARA OTEZLA STELARA SUBCUTANEOUS (Plaque

Psoriasis and Psoriatic Arthritis only) XELJANZ XELJANZ XR § DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) RASUVO

NUTRITIONAL / SUPPLEMENTS

§ ELECTROLYTES potassium chloride liquid VITAMINS AND MINERALS § PRENATAL VITAMINS prenatal vitamins CITRANATAL

RESPIRATORY

§ ANAPHYLAXIS TREATMENT AGENTS epinephrine auto-injector EPIPEN EPIPEN JR § 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 BETHKIS § 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 OFEV STEROID / BETA AGONIST COMBINATIONS ADVAIR BREO ELLIPTA SYMBICORT § STEROID INHALANTS budesonide inhalation suspension ARNUITY ELLIPTA ASMANEX FLOVENT DISKUS

FLOVENT HFA PULMICORT FLEXHALER QVAR QVAR REDIHALER

TOPICAL

DERMATOLOGY ACNE § Topical adapalene benzoyl peroxide clindamycin solution clindamycin-benzoyl peroxide erythromycin solution erythromycin-benzoyl peroxide tretinoin ATRALIN DIFFERIN EPIDUO RETIN-A MICRO TAZORAC § ACTINIC KERATOSIS fluorouracil cream 5% fluorouracil solution imiquimod PICATO TOLAK ZYCLARA § ANTIFUNGALS ciclopirox clotrimazole econazole ketoconazole nystatin JUBLIA LUZU NAFTIN § ANTIPSORIATICS acitretin calcipotriene methoxsalen ATOPIC DERMATITIS Injectable DUPIXENT § Topical tacrolimus ELIDEL EUCRISA 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 RHO KINASE INHIBITORS RHOPRESSA § 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 ABSTRAL ACCU-CHEK AVIVA PLUS

STRIPS AND KITS 5 ACCU-CHEK COMPACT PLUS

STRIPS AND KITS 5 ACCU-CHEK GUIDE

STRIPS AND KITS 5 ACCU-CHEK SMARTVIEW

STRIPS AND KITS 5 acitretin ACUVAIL acyclovir adapalene ADEMPAS ADVAIR AJOVY 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 ARANESP aripiprazole ARISTADA armodafinil ARNUITY ELLIPTA ASMANEX atenolol atomoxetine atorvastatin ATRALIN ATRIPLA AUBAGIO AUSTEDO azelastine azithromycin AZOPT

B balsalazide BASAGLAR

BD ULTRAFINE INSULIN SYRINGES AND NEEDLES

BELBUCA BELSOMRA BELVIQ BELVIQ XR benzoyl peroxide BESIVANCE BETASERON BETHKIS BETIMOL BETOPTIC S BEVESPI AEROSPHERE bicalutamide BIDIL BIKTARVY BOSULIF BREO ELLIPTA BRILINTA brimonidine bromfenac budesonide capsule budesonide inhalation suspension buprenorphine-naloxone

sublingual tablet bupropion bupropion ext-rel BUTRANS BYSTOLIC

C CABOMETYX 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 CETROTIDE cholestyramine CIALIS 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 colchicine tablet COLCRYS colesevelam COMBIGAN COMBIPATCH COMBIVENT RESPIMAT COMPLERA COPAXONE COREG CR CORLANOR CORTIFOAM COSENTYX 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 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 DUREZOL dutasteride dutasteride-tamsulosin DYMISTA

E econazole

eletriptan ELIDEL ELIQUIS EMBEDA EMGALITY EMVERM ENBREL ENDOMETRIN entacapone ENTRESTO EPCLUSA EPIDUO epinephrine auto-injector EPIPEN EPIPEN JR EPISIL eprosartan ergotamine-caffeine ERLEADA erythromycin erythromycin solution erythromycin-benzoyl peroxide erythromycins ESBRIET 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-norethindrone

acetate-iron ethinyl estradiol-norgestimate ethosuximide EUCRISA EVAMIST EVOTAZ ezetimibe ezetimibe-simvastatin

F FARXIGA fenofibrate fenofibric acid fentanyl transdermal fentanyl transmucosal lozenge 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 fosinopril fosinopril-hydrochlorothiazide furosemide FYCOMPA

G gabapentin galantamine galantamine ext-rel gentamicin GENVOYA GILENYA glatiramer glimepiride glipizide glipizide ext-rel glipizide-metformin GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT GLYXAMBI GONAL-F GRALISE granisetron GRASTEK guanfacine ext-rel

H HARVONI HUMATROPE HUMIRA HUMULIN R U-500 hydrochlorothiazide hydrocodone-acetaminophen hydrocortisone hydrocortisone butyrate hydrocortisone enema hydromorphone hydromorphone ext-rel HYSINGLA ER

I ibandronate IBRANCE ILEVRO imatinib mesylate imiquimod INCRUSE ELLIPTA ipratropium inhalation solution ipratropium-albuterol inhalation

solution irbesartan irbesartan-hydrochlorothiazide IRESSA ISENTRESS itraconazole ivermectin

J JANUMET JANUMET XR JANUVIA JARDIANCE JUBLIA

K ketoconazole ketorolac KEVZARA KISQALI KISQALI FEMARA CO-PACK

L lactulose lamivudine lamotrigine lamotrigine ext-rel lansoprazole lanthanum carbonate LASTACAFT latanoprost LATUDA LETAIRIS 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 methoxsalen methylphenidate methylphenidate ext-rel methylprednisolone metoclopramide metolazone metoprolol succinate ext-rel metoprolol tartrate metronidazole MINIVELLE minocycline mirtazapine mometasone montelukast morphine morphine ext-rel morphine suppository MOVANTIK MOXEZA moxifloxacin MUGARD

MULTAQ MUSE MYDAYIS MYRBETRIQ

N nadolol NAFTIN naloxone injection NAMZARIC naproxen naratriptan 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 NUCYNTA ER NUEDEXTA NUVARING nystatin

O ODEFSEY ODOMZO OFEV ofloxacin olanzapine olmesartan olmesartan-amlodipine-

hydrochlorothiazide olmesartan-hydrochlorothiazide olopatadine omega-3 acid ethyl esters omeprazole ondansetron ONZETRA XSAIL OPSUMIT ORACEA ORALAIR ORENITRAM ORFADIN oseltamivir OSPHENA OTEZLA OVIDREL oxcarbazepine OXTELLAR XR oxybutynin oxybutynin ext-rel oxycodone oxycodone-acetaminophen OXYCONTIN OZEMPIC

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 pramipexole ext-rel 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 PROCTOFOAM-HC progesterone, micronized promethazine propranolol propranolol ext-rel PULMICORT FLEXHALER PYLERA

Q QTERN quetiapine quetiapine ext-rel quinapril quinapril-hydrochlorothiazide QVAR QVAR REDIHALER

R RAGWITEK raloxifene ramipril RANEXA ranitidine RAPAFLO rasagiline RASUVO REBIF RELENZA repaglinide

REPATHA RESTASIS RETIN-A MICRO REYATAZ RHOPRESSA ribavirin risedronate risperidone rivastigmine rivastigmine transdermal rizatriptan ropinirole ropinirole ext-rel rosuvastatin RUCONEST RYDAPT

S SAFYRAL SANCUSO SAVELLA SAXENDA selegiline SEREVENT sertraline sevelamer carbonate sildenafil SILENOR SIMBRINZA simvastatin SOLIQUA SOMAVERT SOOLANTRA sotalol SPIRIVA spironolactone-hydrochlorothiazide SPRYCEL STELARA SUBCUTANEOUS STIOLTO RESPIMAT STRIBILD STRIVERDI RESPIMAT SUBOXONE FILM

SUBSYS sulfacetamide sulfamethoxazole-trimethoprim sulfasalazine sulfasalazine delayed-rel sumatriptan SUPRAX SUPREP SYMBICORT SYMLINPEN SYNJARDY SYNJARDY XR SYNTHROID

T tacrolimus tamsulosin TAZORAC TECFIDERA TEKTURNA TEKTURNA HCT telmisartan telmisartan-hydrochlorothiazide terazosin terbinafine tablet testosterone gel testosterone solution tetrabenazine tetracycline tiagabine timolol maleate solution TIVICAY TOBRADEX OINTMENT TOBRADEX ST tobramycin tobramycin inhalation solution tobramycin-dexamethasone TOLAK tolterodine tolterodine ext-rel topiramate torsemide

TOVIAZ TRACLEER tramadol tramadol ext-rel TRAVATAN Z trazodone TRELEGY ELLIPTA TRESIBA tretinoin TREXIMET triamcinolone triamterene-hydrochlorothiazide trimethobenzamide TRINTELLIX TRIUMEQ TROKENDI XR trospium trospium ext-rel TRULICITY TRUVADA TYMLOS

U UCERIS ULORIC UPTRAVI

V valacyclovir valganciclovir valproic acid valsartan valsartan-hydrochlorothiazide VARUBI VASCEPA VELPHORO VELTASSA VEMLIDY venlafaxine venlafaxine ext-rel capsule verapamil ext-rel VESICARE

VIBERZI VICTOZA VIIBRYD VIMPAT VIOKACE VISTOGARD VOSEVI 2 VRAYLAR VYVANSE

W warfarin

X XARELTO XELJANZ XELJANZ XR XIFAXAN 550 MG XIGDUO XR XIIDRA XTANDI

Z zafirlukast ZARXIO ZEJULA ZEMBRACE SYMTOUCH ZENPEP zileuton ext-rel ziprasidone zolmitriptan zolpidem zolpidem ext-rel zolpidem sublingual ZOMIG NASAL SPRAY zonisamide ZUBSOLV ZYCLARA ZYLET ZYTIGA

PREFERRED OPTIONS LIST NON-PREFERRED OR EXCLUDED DRUG(S)

PREFERRED OPTION(S)†

ABILIFY aripiprazole, clozapine, olanzapine, quetiapine, quetiapine ext-rel, risperidone, ziprasidone, LATUDA, VRAYLAR

ACANYA adapalene, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, ATRALIN, DIFFERIN, EPIDUO, RETIN-A MICRO, TAZORAC

ACTEMRA ENBREL, HUMIRA, KEVZARA, XELJANZ, XELJANZ XR

ACTICLATE doxycycline hyclate

ACTOS pioglitazone

ADDERALL XR amphetamine-dextroamphetamine mixed salts ext-rel, methylphenidate ext-rel, MYDAYIS, VYVANSE

ALCORTIN A desonide, hydrocortisone

ALEVICYN GEL, ALEVICYN KIT, ALEVICYN SG, Alevicyn solution

desonide, hydrocortisone

ALLISON MEDICAL INSULIN SYRINGES 7

BD ULTRAFINE INSULIN SYRINGES

ALORA estradiol, DIVIGEL, EVAMIST, MINIVELLE

NON-PREFERRED OR EXCLUDED DRUG(S)


ALTOPREV atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin

ALVESCO ARNUITY ELLIPTA, ASMANEX, FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER, QVAR, QVAR REDIHALER

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

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 ACCU-CHEK AVIVA PLUS STRIPS AND KITS 5, ACCU-CHEK COMPACT PLUS STRIPS AND KITS 5, ACCU-CHEK GUIDE STRIPS AND KITS 5, ACCU-CHEK SMARTVIEW STRIPS AND KITS 5

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

AVENOVA Consult doctor

AXERT eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, ONZETRA XSAIL, ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY

AZELEX adapalene, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, ATRALIN, DIFFERIN, EPIDUO, RETIN-A MICRO, 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

BENZAC AC adapalene, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, ATRALIN, DIFFERIN, EPIDUO, RETIN-A MICRO, TAZORAC

BENZACLIN adapalene, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, ATRALIN, DIFFERIN, EPIDUO, RETIN-A MICRO, TAZORAC

BENZIQ adapalene, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, ATRALIN, DIFFERIN, EPIDUO, RETIN-A MICRO, TAZORAC

BETAPACE, BETAPACE AF sotalol

BREEZE 2 STRIPS AND KITS 6 ACCU-CHEK AVIVA PLUS STRIPS AND KITS 5, ACCU-CHEK COMPACT PLUS STRIPS AND KITS 5, ACCU-CHEK GUIDE STRIPS AND KITS 5, ACCU-CHEK SMARTVIEW STRIPS AND KITS 5

butalbital-acetaminophen-caffeine capsule

diclofenac sodium, naproxen

BYDUREON OZEMPIC, TRULICITY, VICTOZA

BYETTA OZEMPIC, TRULICITY, VICTOZA

CAFERGOT eletriptan, ergotamine-caffeine, naratriptan, rizatriptan, sumatriptan, zolmitriptan, ONZETRA XSAIL, ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY

CAMBIA diclofenac sodium, meloxicam, naproxen

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 COSENTYX, ENBREL, HUMIRA, KEVZARA, OTEZLA, STELARA SUBCUTANEOUS (Plaque Psoriasis and Psoriatic Arthritis only), XELJANZ, XELJANZ XR

CLINDAGEL erythromycin solution

clobetasol spray clobetasol foam

CLOBEX SPRAY clobetasol foam

COLAZAL balsalazide

CONTOUR NEXT STRIPS AND KITS 6

ACCU-CHEK AVIVA PLUS STRIPS AND KITS 5, ACCU-CHEK COMPACT PLUS STRIPS AND KITS 5, ACCU-CHEK GUIDE STRIPS AND KITS 5, ACCU-CHEK SMARTVIEW STRIPS AND KITS 5

CONTOUR STRIPS AND KITS 6 ACCU-CHEK AVIVA PLUS STRIPS AND KITS 5, ACCU-CHEK COMPACT PLUS STRIPS AND KITS 5, ACCU-CHEK GUIDE STRIPS AND KITS 5, ACCU-CHEK SMARTVIEW STRIPS AND KITS 5

CONTRAVE BELVIQ, BELVIQ XR, SAXENDA

CRESTOR atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin

CYMBALTA desvenlafaxine ext-rel, duloxetine, venlafaxine, venlafaxine ext-rel capsule

DAKLINZA EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6)

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

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 naloxone injection, NARCAN NASAL SPRAY

EXFORGE amlodipine-olmesartan, amlodipine-telmisartan, amlodipine-valsartan

EXFORGE HCT amlodipine-valsartan-hydrochlorothiazide, olmesartan-amlodipine-hydrochlorothiazide

EXTAVIA glatiramer, AUBAGIO, BETASERON, COPAXONE, GILENYA, REBIF, TECFIDERA

FANAPT aripiprazole, clozapine, olanzapine, quetiapine, quetiapine ext-rel, 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 GONAL-F

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 ACCU-CHEK AVIVA PLUS STRIPS AND KITS 5, ACCU-CHEK COMPACT PLUS STRIPS AND KITS 5, ACCU-CHEK GUIDE STRIPS AND KITS 5, ACCU-CHEK SMARTVIEW STRIPS AND KITS 5

FROVA eletriptan, naratriptan, rizatriptan, sumatriptan, zolmitriptan, ONZETRA XSAIL, ZEMBRACE SYMTOUCH, ZOMIG NASAL SPRAY

GENOTROPIN HUMATROPE

GLEEVEC imatinib mesylate, BOSULIF, SPRYCEL

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 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, MYDAYIS, VYVANSE

INVOKAMET SYNJARDY, SYNJARDY XR, XIGDUO XR

INVOKAMET XR SYNJARDY, SYNJARDY XR, XIGDUO XR

INVOKANA FARXIGA, JARDIANCE



ISTALOL timolol maleate solution, BETIMOL

JALYN dutasteride-tamsulosin; dutasteride or finasteride WITH alfuzosin ext-rel, doxazosin, tamsulosin, terazosin, or RAPAFLO

JENTADUETO JANUMET, JANUMET XR

JENTADUETO XR JANUMET, JANUMET XR

KAZANO JANUMET, JANUMET XR

KINERET ENBREL, HUMIRA, KEVZARA, XELJANZ, XELJANZ XR

KOMBIGLYZE XR JANUMET, JANUMET XR

LANOXIN TABLET (125 MCG and 250 MCG only)

digoxin

LANTUS BASAGLAR, LEVEMIR, TRESIBA

LAZANDA fentanyl transmucosal lozenge, ABSTRAL, SUBSYS

LESCOL XL atorvastatin, ezetimibe-simvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin

levorphanol fentanyl transdermal, hydromorphone ext-rel, methadone, morphine ext-rel, EMBEDA, HYSINGLA ER, NUCYNTA ER, OXYCONTIN

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 EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6), VOSEVI 2

MENEST estradiol, estropipate, PREMARIN

MENOSTAR estradiol

MIACALCIN INJECTION alendronate, calcitonin-salmon, ibandronate, risedronate, FORTEO, TYMLOS

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

NAPRELAN diclofenac sodium, meloxicam, naproxen

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

NESINA JANUVIA

NEUPOGEN ZARXIO

NEXIUM esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT

NILANDRON bicalutamide, XTANDI, ZYTIGA

NITROMIST nitroglycerin lingual spray, nitroglycerin sublingual

NORDITROPIN HUMATROPE

NORITATE metronidazole, FINACEA, SOOLANTRA



NORVASC amlodipine

NOVACORT desonide, hydrocortisone

NOVO NORDISK NEEDLES 7 BD ULTRAFINE NEEDLES

NUTROPIN AQ HUMATROPE

NUVIGIL armodafinil

OLEPTRO trazodone

OLUX-E clobetasol foam

OMNARIS flunisolide, fluticasone, mometasone, triamcinolone, DYMISTA

OMNITROPE HUMATROPE

ONETOUCH ULTRA STRIPS AND KITS 6


ONETOUCH VERIO STRIPS AND KITS 6


ONEXTON adapalene, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, ATRALIN, DIFFERIN, EPIDUO, RETIN-A MICRO, TAZORAC

ONGLYZA JANUVIA

ORENCIA CLICKJECT COSENTYX, ENBREL, HUMIRA, KEVZARA, OTEZLA, STELARA SUBCUTANEOUS (Plaque Psoriasis and Psoriatic Arthritis only), XELJANZ, XELJANZ XR

ORENCIA INTRAVENOUS COSENTYX, ENBREL, HUMIRA, KEVZARA, OTEZLA, STELARA SUBCUTANEOUS (Plaque Psoriasis and Psoriatic Arthritis only), XELJANZ, XELJANZ XR

ORENCIA SUBCUTANEOUS COSENTYX, ENBREL, HUMIRA, KEVZARA, OTEZLA, STELARA SUBCUTANEOUS (Plaque Psoriasis and Psoriatic Arthritis only), XELJANZ, XELJANZ XR

OSENI JANUMET, JANUMET 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

PENNSAID diclofenac sodium, diclofenac sodium gel 1%, diclofenac sodium solution, 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 REPATHA

PRECISION XTRA STRIPS AND KITS 6


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 hydrocodone-acetaminophen, hydromorphone, morphine, oxycodone-acetaminophen, NUCYNTA

PROTONIX esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT

PROTOPIC tacrolimus, ELIDEL, EUCRISA

PROVENTIL HFA levalbuterol tartrate CFC-free aerosol, PROAIR HFA, PROAIR RESPICLICK

QNASL flunisolide, fluticasone, mometasone, triamcinolone, DYMISTA

QSYMIA BELVIQ, BELVIQ XR, SAXENDA

RAYOS dexamethasone, methylprednisolone, prednisolone solution, prednisone

RELION INSULIN NOVOLIN INSULIN

RELISTOR MOVANTIK

RIOMET metformin, metformin ext-rel (except generic FORTAMET or generic GLUMETZA)

ROZEREM eszopiclone, zolpidem, zolpidem ext-rel, zolpidem sublingual, BELSOMRA, SILENOR

SAIZEN HUMATROPE

SEROQUEL XR aripiprazole, clozapine, olanzapine, quetiapine, quetiapine ext-rel, risperidone, ziprasidone, LATUDA, VRAYLAR

SIMPONI COSENTYX, ENBREL, HUMIRA, KEVZARA, OTEZLA, STELARA SUBCUTANEOUS (Plaque Psoriasis and Psoriatic Arthritis only), XELJANZ, XELJANZ XR

SORILUX calcipotriene

SPRIX diclofenac sodium, meloxicam, naproxen

STENDRA sildenafil, CIALIS

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

SURE-TEST STRIPS AND KITS 6 ACCU-CHEK AVIVA PLUS STRIPS AND KITS 5, ACCU-CHEK COMPACT PLUS STRIPS AND KITS 5, ACCU-CHEK GUIDE STRIPS AND KITS 5, ACCU-CHEK SMARTVIEW STRIPS AND KITS 5

SYNERDERM desonide, hydrocortisone

TALTZ COSENTYX, ENBREL, HUMIRA, OTEZLA, STELARA SUBCUTANEOUS (Plaque Psoriasis and Psoriatic Arthritis only), XELJANZ, XELJANZ XR

TANZEUM OZEMPIC, TRULICITY, VICTOZA

TARGADOX doxycycline hyclate

TASIGNA imatinib mesylate, BOSULIF, SPRYCEL

TECHNIVIE EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6)

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

testosterone gel 1% 8 testosterone gel, testosterone solution, ANDRODERM, ANDROGEL 1.62%

TIROSINT levothyroxine, SYNTHROID

TOBI tobramycin inhalation solution, BETHKIS

TOBI PODHALER tobramycin inhalation solution, BETHKIS

TOUJEO BASAGLAR, LEVEMIR, TRESIBA



TRADJENTA JANUVIA

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 ACCU-CHEK AVIVA PLUS STRIPS AND KITS 5, ACCU-CHEK COMPACT PLUS STRIPS AND KITS 5, ACCU-CHEK GUIDE STRIPS AND KITS 5, ACCU-CHEK SMARTVIEW STRIPS AND KITS 5

TRUETRACK STRIPS AND KITS 6


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

VANATOL LQ diclofenac sodium, naproxen

VANATOL S diclofenac sodium, naproxen

Vanoxide-HC adapalene, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, ATRALIN, DIFFERIN, EPIDUO, RETIN-A MICRO, TAZORAC

VELTIN adapalene, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, ATRALIN, DIFFERIN, EPIDUO, RETIN-A MICRO, 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 sildenafil, CIALIS

VIEKIRA PAK EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6)

VIEKIRA XR EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6)

VITAFOL-ONE generic prenatal vitamins, CITRANATAL

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

XENAZINE tetrabenazine, AUSTEDO

XOPENEX HFA levalbuterol tartrate CFC-free aerosol, PROAIR HFA, PROAIR RESPICLICK

ZEGERID esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT

ZEPATIER EPCLUSA (genotypes 1, 2, 3, 4, 5, 6), HARVONI (genotypes 1, 4, 5, 6)

ZETIA ezetimibe

ZETONNA flunisolide, fluticasone, mometasone, triamcinolone, DYMISTA

ZIANA adapalene, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin, ATRALIN, DIFFERIN, EPIDUO, RETIN-A MICRO, TAZORAC

ZOLPIMIST eszopiclone, zolpidem, zolpidem ext-rel, zolpidem sublingual, BELSOMRA, SILENOR

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

ZUPLENZ granisetron, ondansetron, SANCUSO

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. 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 An ACCU-CHEK blood glucose meter may be provided at no charge by the manufacturer to those individuals currently using a meter other than ACCU-CHEK. For more information on

how to obtain a blood glucose meter, call: 1-877-418-4746. 6 ACCU-CHEK 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 (01/01/19)

Notice of Nondiscrimination and Availability of Language Assistance Services

CareFirst BlueCross BlueShield, CareFirst BlueChoice, Inc., CareFirst Diversified Benefits 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)

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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.

(UPDATED 7/12/18)

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 and CareFirst Diversified Benefits are the business names of First Care, Inc. In Virginia, CareFirst MedPlus and CareFirst Diversified Benefits are the business names 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.

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.

አማርኛ (Amharic) ማሳሰቢያ፦ ይህ ማስታወቂያ ስለ መድን ሽፋንዎ መረጃ ይዟል። ከተወሰኑ ቀነ-ገደቦች በፊት ሊፈጽሟቸው የሚገቡ ነገሮች ሊኖሩ ስለሚችሉ እነዚህን ወሳኝ ቀናት ሊይዝ ይችላል። ይኽን መረጃ የማግኘት እና ያለምንም ክፍያ በቋንቋዎ እገዛ የማግኘት መብት አለዎት። አባል ከሆኑ ከመታወቂያ ካርድዎ በስተጀርባ ላይ ወደተጠቀሰው የስልክ ቁጥር መደወል ይችላሉ። አባል ካልሆኑ ደግሞ ወደ ስልክ ቁጥር

855-258-6518 ደውለው 0ን እንዲጫኑ እስኪነገርዎ ድረስ ንግግሩን መጠበቅ አለብዎ። አንድ ወኪል መልስ ሲሰጥዎ፣ የሚፈልጉትን ቋንቋ ያሳውቁ፣ ከዚያም ከተርጓሚ ጋር ይገናኛሉ።

Èdè Yorùbá (Yoruba) Ìtẹ́tíléko: Àkíyèsí yìí ní ìwífún nípa iṣẹ́ adójútòfò rẹ. Ó le ní àwọn déètì pàtó o sì le ní láti

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हिन्दी (Hindi) ध्यान दें: इस सचूना में आपकी बीमा कवरेज के बारे में जानकारी दी गई िै। िो सकता िै कक इसमें मखु्य ततथियों का उल्लेख िो और आपके ललए ककसी तनयत समय-सीमा के भीतर काम करना ज़रूरी िो। आपको यि जानकारी और सबंथंित सिायता अपनी भाषा में तनिःशलु्क पाने का अथिकार िै। सदस्यों को अपने पिचान पत्र के पीछे हदए गए फोन नबंर पर कॉल करना चाहिए। अन्य सभी लोग 855-258-6518 पर कॉल कर सकत ेिैं और जब तक 0 दबाने के ललए न किा जाए, तब तक सवंाद की प्रतीक्षा करें। जब कोई एजेंट उत्तर दे तो उस ेअपनी भाषा बताए ँऔर आपको व्याख्याकार से कनेक्ट कर हदया जाएगा।

Ɓǎsɔ́ɔ̀-wùɖù (Bassa) Tò Ɖùǔ Cáo! Bɔ ̃̌ nìà kɛ ɓá nyɔ ɓě ké m̀ gbo kpá ɓó nì fu ̀ à-fṹá-tìǐn nyɛɛ jè dyí. Bɔ ̃̌ nìà kɛ

ɓéɖé wé jɛ́ɛ́ ɓě ɓɛ́ m̀ ké ɖɛ wa mɔ́ m̀ ké nyuɛɛ nyu hwɛ̀ ɓɛ́ wé ɓěa ké zi. Ɔ mɔ̀ nì kpé ɓɛ́ m̀ ké bɔ ̃̌ nìà kɛ kè gbo-

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I.D. káàɔ̀ ɖeín nyɛ. Nyɔ tɔ̀ɔ̀ séín mɛ ɖá nɔ̀ɓà nìà kɛ: 855-258-6518, ké m̀ mɛ fò tee ɓɛ́ wa kéɛ m̀ gbo cɛ ɓɛ́ m̀ ké

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ɓɛ́ ɔ ké nì wuɖuɔ̀ mú zà.

বাাংলা (Bengali) লক্ষ্য করুন: এই ননাটিশে আপনার ববমা কভাশরজ সম্পশকে তথ্য রশেশে। এর মশযয গুরুত্বপূর্ে তাবরখ থ্াকশত পাশর এবাং বনবদেষ্ট তাবরশখর মশযয আপনাশক পদশক্ষ্প বনশত হশত পাশর। ববনা খরশে বনশজর ভাষাে এই তথ্য পাওোর এবাং সহােতা পাওোর অবযকার আপনার আশে। সদসযশদরশক তাশদর পবরেেপশের বপেশন থ্াকা নম্বশর কল করশত হশব। অশনযরা 855-258-6518 নম্বশর কল কশর 0 টিপশত না বলা পর্েন্ত অশপক্ষ্া করশত পাশরন। র্খন নকাশনা এশজন্ট উত্তর নদশবন তখন আপনার বনশজর ভাষার নাম বলনু এবাং আপনাশক নদাভাষীর সশে সাংর্ুক্ত করা হশব।

یہ نوٹس آپ کے انشورینس کوریج سے متعلق معلومات پر مشتمل ہے۔ اس میں کلیدی تاریخیں ہو سکتی ہیں اور ممکن :توجہ (Urduاردو )ہے کہ آپ کو مخصوص آخری تاریخوں تک کارروائی کرنے کی ضرورت پڑے۔ آپ کے پاس یہ معلومات حاصل کرنے اور بغیر خرچہ

کو اپنے شناختی کارڈ کی پشت پر موجود فون نمبر پر کال کرنی چاہیے۔ سبھی دیگر کیے اپنی زبان میں مدد حاصل کرنے کا حق ہے۔ ممبران

دبانے کو کہے جانے تک انتظار کریں۔ ایجنٹ کے جواب دینے پر اپنی مطلوبہ زبان 0پر کال کر سکتے ہیں اور 6518-258-855لوگ

بتائیں اور مترجم سے مربوط ہو جائیں گے۔

توجه: این اعالمیه حاوی اطالعاتی درباره پوشش بیمه شما است. ممکن است حاوی تاریخ های مھمی باشد و الزم است تا تاریخ (Farsiفارسی ). مقرر شده خاصی اقدام کنید. شما از این حق برخوردار هستید تا این اطالعات و راهنمایی را به صورت رایگان به زبان خودتان دریافت کنید

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اتخاذ إلى تحتاج وقد مھمة، تواریخ على یحتوي وقد التأمینیة، تغطیتك بشأن معلومات على اإلخطار هذا یحتوي :تنبیه (Arabic) العربیة اللغة االتصال األعضاء على ینبغي .تكلفة أي تحمل بدون بلغتك والمعلومات المساعدة هذه على الحصول لك یحق .محددة نھائیة مواعید بحلول إجراءات

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855-258-6518

2019 Formulary 2 Preferred Drug ListANALGESICS§ NSAIDs§ NSAIDs, COMBINATIONS§ NSAIDs, TOPICAL§ COX-2 INHIBITORS§ GOUT§ OPIOID ANALGESICS

ANTI-INFECTIVESANTIBACTERIALS§ CEPHALOSPORINS§ ERYTHROMYCINS / MACROLIDES§ FLUOROQUINOLONES§ PENICILLINS§ TETRACYCLINES

§ ANTIFUNGALSANTIRETROVIRAL AGENTS§ ANTIRETROVIRAL COMBINATIONSINTEGRASE INHIBITORS§ NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS§ PROTEASE INHIBITORS

ANTIVIRALS§ CYTOMEGALOVIRUS AGENTS§ HEPATITIS B AGENTS§ HEPATITIS C AGENTS§ HERPES AGENTS§ INFLUENZA AGENTS

§ MISCELLANEOUS

ANTINEOPLASTIC AGENTSHORMONAL ANTINEOPLASTIC AGENTS§ ANTIANDROGENS

§ KINASE INHIBITORS§ MISCELLANEOUS

CARDIOVASCULAR§ ACE INHIBITORS§ ACE INHIBITOR / DIURETIC COMBINATIONS§ ANGIOTENSIN II RECEPTOR ANTAGONISTS / DIURETIC COMBINATIONS§ ANGIOTENSIN II RECEPTOR ANTAGONIST / CALCIUM CHANNEL BLOCKER COMBINATIONS§ ANGIOTENSIN II RECEPTOR ANTAGONIST / CALCIUM CHANNEL BLOCKER / DIURETIC COMBINATIONS§ ANTIARRHYTHMICSANTILIPEMICS§ BILE ACID RESINS§ CHOLESTEROL ABSORPTION INHIBITORS§ FIBRATES§ HMG-CoA REDUCTASE INHIBITORS / COMBINATIONS§ NIACINS§ OMEGA-3 FATTY ACIDSPCSK9 INHIBITORS

§ BETA-BLOCKERS§ CALCIUM CHANNEL BLOCKERS§ CALCIUM CHANNEL BLOCKER / ANTILIPEMIC COMBINATIONS§ DIGITALIS GLYCOSIDESDIRECT RENIN INHIBITORS / DIURETIC COMBINATIONS§ DIURETICSHEART FAILURE§ NITRATESPULMONARY ARTERIAL HYPERTENSIONENDOTHELIN RECEPTOR ANTAGONISTS§ PHOSPHODIESTERASE INHIBITORSPROSTACYCLIN RECEPTOR AGONISTS§ PROSTAGLANDIN VASODILATORSSOLUBLE GUANYLATE CYCLASE STIMULATORS

§ MISCELLANEOUS

CENTRAL NERVOUS SYSTEM§ ANTICONVULSANTS§ ANTIDEMENTIAANTIDEPRESSANTS§ SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs)§ SEROTONIN NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIs)§ MISCELLANEOUS AGENTS

§ ANTIPARKINSONIAN AGENTSANTIPSYCHOTICS§ ATYPICALS

§ ATTENTION DEFICIT HYPERACTIVITY DISORDERFIBROMYALGIA§ HUNTINGTON'S DISEASE AGENTSHYPNOTICS§ NONBENZODIAZEPINESTRICYCLICS

MIGRAINE§ ERGOTAMINE DERIVATIVESMONOCLONAL ANTIBODIES§ SELECTIVE SEROTONIN AGONISTSSELECTIVE SEROTONIN AGONIST / NONSTEROIDAL ANTI-INFLAMMATORY DRUG (NSAID) COMBINATIONS

§ MULTIPLE SCLEROSIS AGENTS§ MUSCULOSKELETAL THERAPY AGENTS§ NARCOLEPSYPOSTHERPETIC NEURALGIA (PHN)PSYCHOTHERAPEUTIC - MISCELLANEOUS§ OPIOID ANTAGONISTS§ PARTIAL OPIOID AGONIST / OPIOID ANTAGONIST COMBINATIONSPSEUDOBULBAR AFFECT AGENTS§ VASOMOTOR SYMPTOM AGENTS

ENDOCRINE AND METABOLICACROMEGALY§ ANDROGENSANTIDIABETICSAMYLIN ANALOGS§ BIGUANIDES§ BIGUANIDE / SULFONYLUREA COMBINATIONSDIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORSDIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITOR / BIGUANIDE COMBINATIONSINCRETIN MIMETIC AGENTSINCRETIN MIMETIC AGENT / INSULIN COMBINATIONSINSULINS§ INSULIN SENSITIZERS§ INSULIN SENSITIZER / BIGUANIDE COMBINATIONS§ INSULIN SENSITIZER / SULFONYLUREA COMBINATIONS§ MEGLITINIDESSODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORSSODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITOR / BIGUANIDE COMBINATIONSSODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITOR / DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITOR COMBINATIONS§ SULFONYLUREASSUPPLIES

ANTIOBESITYINJECTABLEORAL

CALCIUM REGULATORS§ BISPHOSPHONATES§ CALCITONINSPARATHYROID HORMONES

§ CARNITINE DEFICIENCY AGENTSCONTRACEPTIVES§ MONOPHASIC§ BIPHASIC§ TRIPHASICFOUR PHASE§ EXTENDED CYCLE§ TRANSDERMALVAGINAL

ESTROGENS§ ORAL§ TRANSDERMAL§ VAGINAL

ESTROGEN / PROGESTINS§ ORALTRANSDERMAL

ESTROGEN / SELECTIVE ESTROGEN RECEPTOR MODULATOR COMBINATIONSFERTILITY REGULATORSGNRH / LHRH ANTAGONISTSOVULATION STIMULANTS, GONADOTROPINS

GAUCHER DISEASE§ GLUCOCORTICOIDSGLUCOSE ELEVATING AGENTSHEREDITARY TYROSINEMIA TYPE 1 AGENTSHUMAN GROWTH HORMONES§ PHOSPHATE BINDER AGENTSPOTASSIUM-REMOVING AGENTSPROGESTINS§ ORALVAGINAL

§ SELECTIVE ESTROGEN RECEPTOR MODULATORS§ THYROID SUPPLEMENTS

GASTROINTESTINAL§ ANTIEMETICS§ H2 RECEPTOR ANTAGONISTSINFLAMMATORY BOWEL DISEASE§ ORAL AGENTS§ RECTAL AGENTS

§ IRRITABLE BOWEL SYNDROME§ LAXATIVESOPIOID-INDUCED CONSTIPATIONPANCREATIC ENZYMES§ PROTON PUMP INHIBITORS§ STEROIDS, RECTAL§ ULCER THERAPY COMBINATIONS

GENITOURINARY§ BENIGN PROSTATIC HYPERPLASIAERECTILE DYSFUNCTIONALPROSTADIL AGENTS§ PHOSPHODIESTERASE INHIBITORS

§ URINARY ANTISPASMODICS

HEMATOLOGIC§ ANTICOAGULANTSHEMATOPOIETIC GROWTH FACTORSHEREDITARY ANGIOEDEMA§ PLATELET AGGREGATION INHIBITORS

IMMUNOLOGIC AGENTSALLERGENIC EXTRACTSAUTOIMMUNE AGENTS§ DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs)

NUTRITIONAL / SUPPLEMENTS§ ELECTROLYTESVITAMINS AND MINERALS§ PRENATAL VITAMINS

RESPIRATORY§ ANAPHYLAXIS TREATMENT AGENTS§ ANTICHOLINERGICSANTICHOLINERGIC / BETA AGONIST COMBINATIONS§ SHORT ACTINGLONG ACTING

ANTICHOLINERGIC / BETA AGONIST / STEROID INHALANT COMBINATIONSBETA AGONISTS, INHALANTS§ SHORT ACTINGLONG ACTINGHand-held Active InhalationNebulized Passive Inhalation

§ CYSTIC FIBROSIS§ LEUKOTRIENE MODULATORS§ NASAL ANTIHISTAMINES§ NASAL STEROIDS / COMBINATIONSPHOSPHODIESTERASE-4 INHIBITORSPULMONARY FIBROSIS AGENTSSTEROID / BETA AGONIST COMBINATIONS§ STEROID INHALANTS

TOPICALDERMATOLOGYACNE§ Topical

§ ACTINIC KERATOSIS§ ANTIFUNGALS§ ANTIPSORIATICSATOPIC DERMATITISInjectable§ Topical

CORTICOSTEROIDS§ Low Potency§ Medium Potency§ High Potency§ Very High Potency

§ ROSACEA

MOUTH / THROAT / DENTAL AGENTSPROTECTANTS

OPHTHALMIC§ ANTIALLERGICS§ ANTI-INFECTIVES§ ANTI-INFECTIVE / ANTI-INFLAMMATORY COMBINATIONSANTI-INFLAMMATORIES§ Nonsteroidal§ Steroidal

BETA-BLOCKERS§ NonselectiveSelective

§ CARBONIC ANHYDRASE INHIBITORS§ CARBONIC ANHYDRASE INHIBITOR / BETA-BLOCKER COMBINATIONSCARBONIC ANHYDRASE INHIBITOR / SYMPATHOMIMETIC COMBINATIONSDRY EYE DISEASE§ PROSTAGLANDINSRHO KINASE INHIBITORS§ SYMPATHOMIMETICSSYMPATHOMIMETIC / BETA-BLOCKER COMBINATIONS

OTIC§ ANTI-INFECTIVE / ANTI-INFLAMMATORY COMBINATIONS

QUICK REFERENCE DRUG LISTABCDEFGHIJKLMNOPQRSTUVWXZPREFERRED OPTIONS LIST

NDLA-ENGLISH-7-18

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