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Prescription Guidelines (effective October 1, 2017)
Some medications are only intended to be used in limited quantities, others require advanced approval or prior authorization by your doctor before they can be filled and some are prescribed in steps. Quantity limits have been placed on the use of selected drugs for quality, safety or utilization reasons. Limits may be on the amount of the drug that we cover per prescription or for a defined period of time.
Prior Authorization is required before you fill prescriptions for certain drugs. Without prior approval, your drugs may not be covered. Step Therapy ensures lower costs. When similar medications are available, step therapy guides your doctor to prescribe the lower-cost option first. You may than move up the cost levels until you find the drug that works best for you. Higher step drugs will require advanced approval or prior authorization by your doctor before they can be filled. Note: Due to the lack of Food and Drug Administration (FDA) approval for many ingredients included in compounds, as well as the lack of validated clinical support for use of these high-cost compounds, they may not be covered by your prescription plan or may require prior authorization. If the compound ingredients are not covered, you will be responsible for the full cost of those ingredients. In situations where the compound ingredients are covered through prior authorization, you will pay the cost share specified in your prescription plan.
QUANTITY LIMITS
ALBENZA 336 tablets per 365 days ALSUMA INJ 12 injections per month AMERGE (naratriptan) 12 tablets per month AXERT (almotriptan) 12 tablets per month BILTRICIDE 24 tablets per 365 days CIALIS 2.5 mg, 5 mg 30 tablets per month CIALIS 10 mg, 20 mg 6 tablets per month CAVERJECT 6 units per month EDEX 6 units per month EMVERM 12 tablets per 365 days FROVA (frovatriptan) 18 tablets per month IMITREX (sumatriptan) 12 tablets per month IMITREX INJ (sumatriptan inj) 4 mg 18 syringes per month IMITREX INJ (sumatriptan inj) 6 mg 12 syringes per month IMITREX NASAL SPRAY (sumatriptan nasal spray) 5 mg
24 units per month
IMITREX NASAL SPRAY (sumatriptan nasal spray) 20 mg
12 units per month
LEVITRA 6 tablets per month lidocaine gel 2%, 4% 30 grams per month lidocaine ointment 5% 50 grams per month lidocaine solution 4% 50 mL per month lidocaine-prilocaine cream 2.5%-2.5% 30 grams per month MAXALT (rizatriptan) 18 tablets per month MAXALT MLT (rizatriptan orally disintegrating tabs)
18 tablets per month
MIGRANAL NS (dihydroergotamine spray)
1 x 8 mL per month
MUSE 6 units per month ONZETRA XSAIL 1 box per month PLIAGLIS (lidocaine-tetracaine cream) 30 grams per month RELENZA 40 blisters per 90 days RELPAX (eletriptan) 12 tablets per month STAXYN 6 tablets per month STENDRA 6 tablets per month SUMAVEL 4 mg 18 injections per month SUMAVEL 6 mg 12 injections per month SYNERA (lidocaine-tetracaine patch) 2 patches per month TAMIFLU (oseltamivir) 30 mg 28 capsules per 90 days TAMIFLU (oseltamivir) 45 mg, 75 mg 14 capsules per 90 days TAMIFLU SUSP 180 mL per 90 days TREXIMET 9 tablets per month VIAGRA 6 tablets per month XYREM 540 mL per month ZEMBRACE SYMTOUCH 24 injectors per month ZOMIG (zolmitriptan) 12 tablets per month ZOMIG NASAL SPRAY 12 units per month ZOMIG ZMT (zolmitriptan orally disintegrating tabs)
12 tablets per month
OPIOID QUANTITY LIMITS
acetaminophen/caffeine/dihydrocodeine 320.5/30/16 mg
300 capsules per month
acetaminophen/codeine 300/15 mg 400 tablets per month acetaminophen/codeine 300/30 mg 360 tablets per month acetaminophen/codeine 300/60 mg 180 tablets per month acetaminophen/codeine solution, suspension 120-12 mg/5 mL
2700 mL per month
ARYMO 15mg, 30mg 90 mL per month
aspirin/caffeine/dihydrocodeine 356.4/30/16 mg
300 capsules per month
AVINZA (morphine ext-rel) 30 mg, 45 mg, 60 mg, 75 mg, 90 mg
30 capsules per month
BELBUCA 75 mcg, 150 mcg, 300 mcg, 450 mcg
60 films per month
buprenorphine transdermal 4 patches per month butorphanol nasal spray 2 inhalers per month
BUTRANS 5 mcg/hr, 7.5 mcg/hr, 10 mcg/hr
4 patches per month
codeine sulfate 15 mg, 30 mg, 60 mg 42 tablets per month codeine sulfate oral soln 30 mg/5 mL 210 mL per month CONZIP (tramadol ext-rel caps) 100 mg
30 capsules per month
DOLOPHINE (methadone) 5 mg, 10 mg 90 tablets per month DURAGESIC (fentanyl transdermal) 12 mcg, 25 mcg, 37.5 mcg
10 patches per month
EMBEDA 20/0.8 mg, 30/1.2 mg 60 capsules per month EMBEDA 50/2 mg, 60/2.4 mg, 80/3.2 mg
30 capsules per month
EXALGO (hydromorphone ext-rel) 8 mg, 12 mg, 16 mg
30 tablets per month
hydrocodone/acetaminophen 2.5/325 mg
360 tablets per month
hydrocodone/acetaminophen 5/300 mg, 5/325 mg
240 tablets per month
hydrocodone/acetaminophen 7.5/300 mg, 7.5/325 mg, 10/300 mg, 10/325 mg
180 tablets per month
hydrocodone/acetaminophen elixir 10-300 mg/15 mL
2025 mL per month
hydrocodone/acetaminophen solution 7.5 mg-325 mg/15 mL, 10-325 mg/15 mL
2700 mL per month
hydrocodone/ibuprofen 2.5/200 mg, 5/200 mg, 7.5 mg/200 mg, 10/200 mg
50 tablets per month
hydromorphone 2 mg 180 tablets per month hydromorphone 4 mg 150 tablets per month hydromorphone 8 mg 60 tablets per month hydromorphone liquid 1 mg/mL 600 mL per month hydromorphone suppositories 3 mg 120 supp per month HYSINGLA ER 20 mg, 30 mg, 40 mg, 60 mg, 80 mg
30 tablets per month
KADIAN (morphine ext-rel) 10 mg, 20 mg, 30 mg, 40 mg
60 capsules per month
KADIAN (morphine ext-rel) 50 mg, 60 mg, 70 mg, 80 mg
30 capsules per month
levorphanol 2 mg 120 tablets per month meperidine 50 mg, 100 mg 18 tablets per month meperidine oral solution 50 mg/5 mL 90 mL per month methadone 5 mg, 10 mg 90 tablets per month METHADONE INTENSOL 10mg/mL 90 mL per month methadone oral soln 5 mg/5mL, 10 mg/5 mL
450 mL per month
METHADOSE 5mg, 10 mg 90 tabs per month MORPHABOND 15 mg, 30 mg 60 tablets per month morphine sulfate 15 mg 180 tablets per month morphine sulfate 30 mg 90 tablets per month morphine sulfate oral concentrate 20 mg/mL
135 mL per month
morphine sulfate oral solution 10 mg/5 mL
900 mL per month
morphine sulfate oral solution 20 mg/5 mL
675 mL per month
morphine sulfate suppositories 5 mg, 10 mg
180 supp per month
morphine sulfate suppositories 20 mg 120 supp per month morphine sulfate suppositories 30 mg 90 supp per month MS CONTIN (morphine ext-rel) 15 mg, 30 mg
90 tablets per month
NUCYNTA 50 mg 120 tablets per month NUCYNTA 75 mg 90 tablets per month NUCYNTA 100 mg 60 tablets per month NUCYNTA ER 50 mg, 100 mg 60 tablets per month OXAYDO 5 mg, 7.5 mg 180 tablets per month oxycodone capsules 5 mg 180 capsules per month oxycodone oral concentrate 100 mg/5 mL
90 mL per month
oxycodone oral solution 5 mg/5 mL 900 mL per month oxycodone tablets 5 mg, 10 mg 180 tablets per month oxycodone tablets 15 mg 120 tablets per month oxycodone tablets 20 mg 90 tablets per month oxycodone tablets 30 mg 60 tablets per month oxycodone/acetaminophen 2.5/325 mg, 5/300 mg, 5/325 mg
360 tablets per month
oxycodone/acetaminophen 10/300 mg, 10/325 mg
180 tablets per month
oxycodone/acetaminophen oral solution 5-325 mg/5 mL
1800 mL per month
oxycodone/aspirin 4.8355/325 mg 360 tablets per month oxycodone/ibuprofen 5/400 mg 28 tablets per month OXYCONTIN 10 mg, 15 mg, 20 mg, 30 mg
60 tablets per month
oxymorphone 5 mg 180 tablets per month oxymorphone 10 mg 90 tablets per month pentazocine/naloxone 50/0.5 mg 120 tablets per month TARGINIQ ER 10mg/5mg, 20mg/10mg
60 tabs per month
tramadol 50 mg 180 tablets per month tramadol ext-rel 100 mg 30 tablets per month tramadol ext-rel 150 mg 30 capsules per month tramadol/acetaminophen 37.5/325 mg 40 tablets per month TROXYCA ER 10/1.2 mg, 20/2.4 mg, 30/3.6 mg
60 capsules per month
ULTRAM ER (tramadol ext-rel) 100 mg 30 tablets per month XARTEMIS XR 120 tablets per month XTAMPZA ER 9 mg, 13.5 mg, 18 mg, 27 mg
60 capsules per month
ZOHYDRO ER 10 mg, 15 mg, 20 mg, 30 mg, 40 mg
60 capsules per month
The initial limit for additional strengths not listed here is zero. All requests for strengths not listed will be considered through post limit prior authorization.
NON-SPECIALTY PRODUCTS REQUIRING PRIOR AUTHORIZATION ABSTRAL ACCU-CHEK STRIPS AND KITS ACTIQ ATRALIN BREEZE 2 STRIPS AND KITS clindamycin/tretinoin CONTOUR NEXT STRIPS AND KITS CONTOUR STRIPS AND KITS ENTRESTO FABIOR fentanyl transmucosal lozenge FENTORA FORTAMET FREESTYLE STRIPS AND KITS GLUMETZA LAZANDA LOVAZA metformin ext-rel (generic FORTAMET) metformin ext-rel (generic GLUMETZA) omega-3 acid ethyl esters REGRANEX RETIN-A RETIN-A MICRO SUBSYS tazarotene TAZORAC tretinoin cream, gel TRETIN-X VASCEPA VELTIN XIFAXAN 550 MG ZIANA All other glucose test strips that are not ONETOUCH brand Compound drugs with a cost of $300 or more
SPECIALTY DRUGS REQUIRING PRIOR AUTHORIZATION ABRAXANE ACTEMRA ACTIMMUNE ADAGEN ADCIRCA ADEMPAS ADVATE ADYNOVATE AFINITOR ALDURAZYME ALECENSA ALIMTA ALPHANATE ALPHANINE SD ALPROLIX ALUNBRIG AMPYRA APOKYN ARALAST NP ARANESP * ARCALYST AUBAGIO AUSTEDO AVASTIN AVONEX azacitidine BEBULIN BENDEKA BENEFIX BENLYSTA
BENLYSTA SC BERINERT BETASERON BETHKIS bexarotene caps BIVIGAM BOSULIF BOTOX BUPHENYL CABOMETYX capecitabine CAPRELSA CARBAGLU CARIMUNE NF CAYSTON CERDELGA CEREZYME CHOLBAM CIMZIA CINRYZE COMETRIQ COPAXONE COPEGUS COSENTYX COTELLIC CYSTAGON CYSTARAN CYTOGAM DAKLINZA dofetilide
DUPIXENT DYSPORT EGRIFTA ELAPRASE ELELYSO ELIGARD ELOCTATE EMFLAZA ENBREL ENTYVIO EPCLUSA EPOGEN * epoprostenol ERBITUX ERIVEDGE ESBRIET EUFLEXXA EXJADE EXTAVIA EYLEA FABRAZYME FARYDAK FEIBA NF FEIBA VH FERRIPROX FIRAZYR FIRMAGON FLEBOGAMMA FLOLAN FORTEO
FUZEON GAMASTAN S/D GAMMAGARD LIQUID GAMMAGARD S/D GAMMAKED GAMMAPLEX GAMUNEX-C GATTEX GEL-ONE GELSYN-3 GEMZAR GENOTROPIN GENVISC 850 GILENYA GILOTRIF GLASSIA glatiramer GLEEVEC GRANIX H.P. ACTHAR GEL HAEGARDA HARVONI HELIXATE FS HEMOFIL M HERCEPTIN HETLIOZ HIZENTRA HUMATE-P HUMATROPE HUMIRA
HYALGAN HYCAMTIN HYMOVIS IBRANCE ICLUSIG IDHIFA ILARIS imatinib IMBRUVICA INCRELEX INFLECTRA INGREZZA INLYTA INTRON A IRESSA JADENU JAKAFI JUXTAPID KADCYLA KALBITOR KALYDECO KEVZARA KINERET KISQALI KISQALI FEMARA CO-PACK KITABIS PAK KOATE-DVI KOGENATE FS KORLYM KUVAN KYNAMRO LEMTRADA LENVIMA LETAIRIS LEUKINE leuprolide acetate LONSURF LUCENTIS LUMIZYME LUPRON LUPRON DEPOT LYNPARZA MAVYRET MEKINIST MIRCERA * MONOCLATE-P MONONINE MONOVISC MYALEPT MYOBLOC NAGLAZYME NATPARA NERLYNX NEULASTA *
NEUPOGEN NEXAVAR NINLARO NITYR NORDITROPIN NORTHERA NOVOSEVEN RT NPLATE NUPLAZID NUTROPIN AQ OCALIVA OCTAGAM octreotide acetate ODOMZO OFEV OLYSIO OMNITROPE OPSUMIT ORENCIA ORENITRAM ORFADIN ORKAMBI ORTHOVISC OTEZLA OTREXUP oxaliplatin PEGASYS PERJETA phenylbutyrate sodium PLEGRIDY POMALYST PRALUENT PRIVIGEN PROCRIT * PROCYSBI PROFILNINE SD PROLASTIN-C PROLIA PROMACTA PROVENGE PULMOZYME RASUVO RAVICTI REBETOL REBETOL SOLUTION REBIF RECLAST RECOMBINATE REMICADE REMODULIN REPATHA REVATIO REVLIMID RIBAPAK
RIBASPHERE ribavirin caps ribavirin tabs RITUXAN RIXUBIS RUBRACA RUCONEST RYDAPT SABRIL SAIZEN SAMSCA SANDOSTATIN SANDOSTATIN LAR SENSIPAR SEROSTIM SIGNIFOR sildenafil SILIQ SIMPONI SIMPONI ARIA SOLIRIS SOMATULINE DEPOT SOMAVERT SOVALDI SPINRAZA SPRYCEL STELARA STIVARGA STRENSIQ SUPARTZ FX SUTENT SYLATRON SYNAGIS SYNVISC SYNVISC ONE TAFINLAR TAGRISSO TALTZ TARCEVA TARGRETIN TARGRETIN GEL TASIGNA TAXOTERE TECFIDERA TECHNIVIE TEMODAR temozolomide tetrabenazine TEV-TROPIN THALOMID TIKOSYN TOBI TOBI PODHALER tobramycin inhalation solution
TRACLEER TREANDA TRELSTAR TREMFYA TYKERB TYMLOS TYSABRI TYVASO UPTRAVI VALCHLOR VANTAS VELCADE VELETRI VENCLEXTA VENTAVIS VIDAZA VIEKIRA PAK VIEKIRA XR VIMIZIM VOSEVI VOTRIENT VPRIV WILATE XALKORI XELJANZ XELJANZ XR XELODA XENAZINE XEOMIN XERMELO XGEVA XOLAIR XTANDI XYNTHA YERVOY ZARXIO ZAVESCA ZEJULA ZELBORAF ZEMAIRA ZEPATIER ZINBRYTA ZOLADEX zoledronic acid ZOLINZA ZOMACTON ZOMETA ZORBTIVE ZYDELIG ZYKADIA ZYTIGA
* Prior authorization required for prescription benefits coverage only.
DRUGS REQUIRING STEP THERAPY
You must try one of these drugs first or your doctor must request an exception for you
Used to
before you can get coverage for these drugs
First Choice Drugs treat Second Choice Drugs minocycline (immediate or extended release) or
doxycycline (immediate or extended release) Acne Solodyn (minocycline extended release)
Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. 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.
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.
2017. All rights reserved. www.carefirst.com SUM2712-1P (10/01/17 v2)
Notice of Nondiscrimination and Availability of Language Assistance Services
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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.
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., First Care, Inc. and The Dental Network are 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.
NDLA (6/17)
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your language at no cost. Members should call the phone number on the back of their member identification card.
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(Amharic) -
855-258-6518 0
d Yorb (Yoruba) ttlko: kys y n wfn npa i adjtf r. le n wn dt pt o s le n lti
gb gbs n wn j gbdke kan. O ni t lti gba wfn y ti rnlw n d r lf. wn m-gb
gbd pe nmb fn t w lyn kd dnim wn. wn mrn le pe 855-258-6518 k o s dr npas jrr
tt a fi s fn lti t 0. Ngbt aoj kan b dhn, s d t o f a s so p m gbuf kan.
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mt sau ca th nhn dng. Tt c nhng ngi khc c th gi s 855-258-6518 v ch ht cuc i thoi cho
n khi c nhc nhn phm 0. Khi mt tng i vin tr li, hy nu r ngn ng qu v cn v qu v s c
kt ni vi mt thng dch vin.
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(Russian) !
. ,
.
. ,
.
855-258-6518 , 0.
, .
(Hindi) : - 855-258-6518 0 ,
s-w (Bassa) To uu Cao! B nia k a ny e ke m gbo kpa o ni fu a-fa-tiin ny je dyi. B nia k
ee we j e m ke wa m m ke nyu nyu hw we ea ke zi. m ni kpe m ke b nia k ke gbo-
kpa-kpa m m dye e ni ii-wuu mu m ke se wii o p. Kpoo ny e m a fn-na nia e waa
I.D. kaa ein ny. Ny t sein m a na nia k: 855-258-6518, ke m m fo tee wa ke m gbo c m ke
na ma 0 k dyi paain hw. ju ke ny o dyi m g juin, po wuu m m po dyi, ke ny o mu o niin
ke ni wuu mu za.
(Bengali) : 855-258-6518 0
: (Urdu )
0 6518-258-855
: . (Farsi ). .
.
. 0 855-258-6518
.
: (Arabic) . .
.
.0 855-258-6518
.
(Traditional Chinese)
855-258-6518
0
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mkpa, nwere ike me ihe tupu fd bch njedebe. nwere ikike nweta ozi na enyemaka a nass g na
akwgh gw bla. Nd otu kwesr kp akara ekwent d naz nke kaad njirimara ha. Nd z niile nwere
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ass chr, a ga-ejik g na onye kwa okwu.
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. ID .
855-258-6518 0 .
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(Navajo)
855-258-6518
CareFirst Prescription Guidelines 1017 40194 (modified) fmt usec v2QUANTITY LIMITSOPIOID QUANTITY LIMITSNON-SPECIALTY PRODUCTS REQUIRING PRIOR AUTHORIZATIONSPECIALTY DRUGS REQUIRING PRIOR AUTHORIZATIONDRUGS REQUIRING STEP THERAPY
NDLA_ENGLISH_Sep2017