Generic Drugs (Tier 1) n �Copays�for�generic�drugs�are�the�lowest.

n �Most�generic�drugs�are�on�the�preferred�drug�list�and�available�at�the�lowest�copay.

Preferred Brand Name Drugs (Tier 2)

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).

Non-Preferred Brand Name Drugs (Tier 3)*

*Non-preferred brand name drugs are not part of the preferred drug list but are covered at the highest copay.

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�(Tier�3)�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.

Prescription�drugs�can�account�for�a�large�percentage�of�your�health�care�costs.�By�using�the�CareFirst�BlueCross�BlueShield�(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.

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.

Preferred Drug List (Formulary)CareFirst BlueCross BlueShield

Prior AuthorizationSome�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)�241‑3371.�

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�www.carefirst.com/rx.

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*

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*

*Non-preferred brand name drugs are not part of the preferred drug list.

Quantity LimitsCertain�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�www.carefirst.com/rx.

ACCU‑CHEK�

METER��

TEST�STRIPS��

AMERGE*��

ANZEMET*��

AXERT*��

CAVERJECT*

CIALIS*

CIPRO�XR*

DEPO‑PROVERA*

EDEX*

EMEND

EPIPEN;�EPIPEN�JR.

ESTRING*��

FLECTOR�PATCH*��

FROVA*��

GLUCOMETER�

DEX�TEST�

SENSORS*��

GLUCOMETER�

ELITE�TEST�

STRIPS*��

GLUCOMETER�

ENCORE�TEST�

STRIPS*��

IMITREX*�

(ALL�FORMS)��

KYTRIL*�

LEVITRA*��

MAXALT*

MIGRANAL*��

MUSE*��

ONETOUCH�

METER��

TEST�STRIPS��

OXYCONTIN*�

PROQUIN�XR*��

RELENZA*��

RELPAX*��

SANCUSO*

SEASONALE*

TAMIFLU*

TORADOL*�

TREXIMET*��

VIAGRA��

XIFAXAN*��

ZITHROMAX�

SUSP*�

ZITHROMAX�

TABLETS*�

ZMAX*��

ZOMIG*

*Non-preferred brand name drugs are not part of the preferred drug list.

Preferred Drug List (Formulary)CareFirst BlueCross BlueShield

Maintenance DrugsA�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�www.carefirst.com/rx.

Blood Blood�Thinners�(Anticoagulants)‑�Coumadin�Only

Stroke�Prevention

Central Nervous SystemAlzheimer’s�Drugs

Anti‑Parkinson�Drugs

Attention�Deficit�Disorders�(ADD)

Seizure�Medications�(Anticonvulsants)

Chest Pain & Heart Disease (Nitrates)Diabetes & High Blood SugarAntidiabetic�Drugs

Blood�Sugar�Test�Strips

DiseasesArthritis�(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)

EyeGlaucoma�Drugs

Heart Rhythm DisordersHigh Blood Pressure & Heart DiseaseACE�Inhibitors

Alpha�Beta�Blockers

Angiotensin�II�Blockers

Beta�Blockers

Calcium�Channel�Blockers

Combination�Drugs

Sympatholytics

Water�Pills�Or�Diuretics

High Cholesterol Drugs (Antilipemics)HIV & AIDSCombination�Drugs

Non‑Nucleoside�Reverse�Transcriptase�Inhibitors

Nucleoside�Reverse�Transcriptase�Inhibitors

Protease�Inhibitors

HormonesGrowth

Hormone�Replacement�Drugs

Male

Miscellaneous

Immune SystemAnti‑Rejection�(Immunosuppressants)

InfectionsTuberculosis�(Antituberculosis�Drug)

Low Blood PressureMental Health/SchizophreniaMental HealthAntidepressants

Antipsychotic�Drugs

Manic‑Depression�or�Bipolar�Drugs

NarcolepsyOB-GYNBirth�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 DrugsPain Management (COX 2)Respiratory ProblemsAsthma�&�COPD�(Miscellaneous�Inhalers)

Asthma�(Bronchodilators)

Asthma�(Methylxanthines)

Asthma�(Oral�Bronchodilators)

Asthma�(Steroid�Inhalers)

Miscellaneous�Drugs�

Stomach & Digestive DisordersAcid�&�Stomach�Ulcers

Bowel�&�Colon�Disease

Malabsorption�Disease

Severe�Heartburn�&�Reflux

SupplementsPotassium�(Eff�.�Tablet)

Potassium�(Liquid)

Potassium�(Tablets)

Vitamin�D

UrologyBladder�Control�(Antispasmodics)

Bladder�Control�(Cholinergic�Agents)

Prostate�Disease�(Benign�Prostatic�Hypertrophy)

Preferred Drug List (Formulary)CareFirst BlueCross BlueShield

BloodBlood� Thinners/Modifiers,�Stroke�Preventioncilostazolpentoxifyllineticlopidinewarfarinanagrelide

●�ARIXTRA�●�COUMADIN�●�FRAGMIN�●�LOVENOX�●�PLAVIX

AGRYLINPLETAL�TICLIDTRENTAL

Blood�Stimulators ●�NEUPOGEN●�PROCRIT

●�ARANESP●�EPOGEN●�NEULASTA

Bone DiseaseArthritishydroxychloroquinemethotrexateleflunomide

●�ENBREL●�HUMIRA

ARAVACUPRIMINE●�KINERETRHEUMATREXDOSE�PACK

Osteoporosisestradiolestradiol�transdermalalendronate�calcitonin�nasal�spray

PREMARINEVISTA

ACTONELBONIVACLIMARA●�FORTEOFOSAMAXFOSAMAX�PLUS�DMIACALCIN

Central Nervous SystemAttention�Deficit�Disorderamphetamine/dextroamphetaminedextroamphetaminemethylphenidatemethylphenidate�sr

CONCERTA ADDERALLDAYTRANA�DESOXYNDEXEDRINEFOCALINRITALINSTRATTERA

Sedativeschloral�hydrateflurazepamtemazepamzolpidemzaleplon

AMBIENDALMANELUNESTARESTORILROZEREMSONATA

Diabetes and High Blood SugarAnti‑Diabetic�Drugsacarboseglipizideglyburideglimepirideglyburide/metformin�metformin�nateglinide

ACTOSAVANDAMETAVANDARYLAVANDIABYETTADUETACTJANUMETJANUVIAPRANDIN

AMARYLDIABETAGLUCOPHAGEGLUCOTROLGLUCOVANCEONGLYZAPRECOSESTARLIXSYMLIN

Insulin ●�LEVEMIR●�NOVO�INSULIN●�NOVOLOG

●�HUMALOG●�HUMULIN●�LANTUS

Ear/Nose/Throat (ENT)- AllergyCold�‑�Nasalfluticasoneflunisolide

ASTELIN BECONASE�AQ�FLONASENASACORT�AQNASARELNASONEX

Oralclemastine�fumaratefexofenadine

ALLEGRA‑DALLEGRACLARINEXXYZAL

High Blood Pressure and Heart DiseaseACE�Inhibitorscaptoprilenalaprillisinoprilramipril

MULTA�Q ACCUPRILALTACEMONOPRILPRINIVILVASOTEC�ZESTRIL

Angiotensin�Receptor�Blockers

AVAPRODIOVAN

ATACANDCOZAARMICARDIS

High Cholesterol DrugsStatinslovastatinsimvastatinpravastatin

LIPITORNIASPANTRICOR

ADVICORCRESTORLESCOL�XLMEVACORVYTORINZOCOR

InfectionsCephalosporins CECLOR

CEFTINCEFZILDURICEFLORABIDOMNICEFSUPRAXVANTIN

cefaclorcefadroxilcefdinir�cefuroximecephalexin

Quinolonesciprofloxacin LEVAQUIN AVELOX

CIPROCIPRO�XRFLOXIN

Macrolideserythromycinclarithromycinazithromycin

BIAXIN�BIAXIN�XLZITHROMAX

Penicillinpenicillinamoxicillinamoxicillin/clavulanate

AUGMENTIN�XR AMOXILAUGMENTIN�ES

Generic Drugs (Tier 1)

Lowest Copay

Preferred Brand Name Drugs

(Tier 2) Middle Copay

Non-Preferred Brand Name Drugs

(Tier 3) Highest Copay

Generic Drugs (Tier 1)

Lowest Copay

Preferred Brand Name Drugs

(Tier 2) Middle Copay

Non-Preferred Brand Name Drugs

(Tier 3) Highest Copay

Three Tier Preferred Drug List**

Preferred Drug List (Formulary)CareFirst BlueCross BlueShield

List�is�not�all‑inclusive.�For�the�most�complete�and�up‑to‑date�formulary,�please�visit�www.carefirst.com/rx

Three Tier Preferred Drug List**

Mental HealthAntidepressants APLENZIN

CELEXACYMBALTAPAXILPAXIL�CRPROZACWELLBUTRIN�SR/XLZOLOFT

citalopramfluoxetinesertralinevenlafaxineparoxetinebupropion

Antipsychoticschlorpromazinefluphenezinehaloperidolrisperidone

EFFEXOR�XR�LEXAPRO

SEROQUEL

OB/GYNFertility●�chorionic�gonadotropinclomiphene●ganirelix

●BRAVELLE●CETROTIDE●GONAL‑F●MENOPUR●OVIDREL●REPRONEX

CLOMID�FOLLISTIM�AQLUVERIS●NOVAREL●PREGNYL�

Pain ManagementMigrainesumatriptan

●MIGRANAL AMERGEAXERTFROVARELPAX●IMITREXMAXALT�TREXIMETZOMIG

NSAID/COX‑II�Inhibitorsibuprofennabumetonenaproxendiclofenacpiroxicammeloxicam

CELEBREXMOBIC

Respiratory Problems - AsthmaCOPD�Problemscromolyn�sodiumipratropium�bromide

ADVAIRCOMBIVENTSPIRIVA

INTAL

Bronchodilatorsmetaproterenol

PROAIR�HFASEREVENTVENTOLIN�HFA

FORADILMAXAIR�AUTOHALERPROVENTIL�HFAXOPENEX

Inhaled�Steroids FLOVENT�HFAPULMICORT

AEROBIDASMANEXQVAR

Asthma�‑�Miscellaneous�Drugs

SINGULAIR ACCOLATEZYFLO

Stomach and Digestive DisordersAcid�and�Stomach�Disorderscimetidinenizatidinelansoprazolepantoprazole

ACIPHEXKAPIDEXNEXIUMPREVACIDPREVPAC�PRILOSECPROTONIXZEGERID

UrologyProstate�Diseasedoxazosinterazosinfinasteride

AVODARTFLOMAX

CARDURAHYTRINPROSCAR

**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.)

Generic Drugs (Tier 1)

Lowest Copay

Preferred Brand Name Drugs

(Tier 2) Middle Copay

Non-Preferred Brand Name Drugs

(Tier 3) Highest Copay

Generic Drugs (Tier 1)

Lowest Copay

Preferred Brand Name Drugs

(Tier 2) Middle Copay

Non-Preferred Brand Name Drugs

(Tier 3) Highest Copay

Preferred Drug List (Formulary)CareFirst BlueCross BlueShield

CareFirst BlueCross BlueShield 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.

BRC5943‑4P�(11/10)

Using Generic DrugsDid�you�know�that�switching�to�a�generic�drug�could�save�you�money�in�out‑of‑pocket�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�30‑75�percent�less�that�brand�name�drugs.�

For�more�information�about�generic�drugs,�visit�our�prescription�drug�web�site�at�www.carefirst.com/rx,�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�www.carefirst.com/rx.

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)�241‑3371.

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)�745‑6285.�

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�www.carefirst.com/rx.

Preferred Drug List (Formulary)CareFirst BlueCross BlueShield