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April 2017 CareFirst Preferred Drug List 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 brandname 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 HEALTH CARE PROVIDER 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. 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: 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 brandname 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. • 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. • 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. ANALGESICS § NSAIDs diclofenac sodium meloxicam naproxen § NSAIDs, COMBINATIONS diclofenac sodium-misoprostol § NSAIDs, TOPICAL diclofenac sodium solution VOLTAREN GEL § COX-2 INHIBITORS celecoxib § GOUT allopurinol colchicine tablet probenecid COLCRYS ULORIC § OPIOID ANALGESICS codeine-acetaminophen fentanyl transdermal fentanyl transmucosal lozenge PA hydrocodone-acetaminophen hydromorphone hydromorphone ext-rel methadone morphine morphine ext-rel morphine suppository oxycodone oxycodone-acetaminophen tramadol tramadol ext-rel BUTRANS FENTORA PA HYSINGLA ER NUCYNTA NUCYNTA ER OPANA ER OXYCONTIN QL SUBSYS PA 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 ATRIPLA COMPLERA DESCOVY EPZICOM 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 C AGENTS ribavirin PA SP EPCLUSA (genotypes 2, 3) PA SP HARVONI (genotypes 1, 4, 5, 6) PA SP § HERPES AGENTS acyclovir valacyclovir INFLUENZA AGENTS RELENZA QL TAMIFLU QL § MISCELLANEOUS clindamycin ivermectin metronidazole nitrofurantoin sulfamethoxazole-trimethoprim ALBENZA SIVEXTRO XIFAXAN 550 MG PA ANTINEOPLASTIC AGENTS HORMONAL ANTINEOPLASTIC AGENTS § ANTIANDROGENS bicalutamide ZYTIGA PA SP § KINASE INHIBITORS imatinib mesylate PA SP BOSULIF PA SP SPRYCEL PA SP § MISCELLANEOUS VISTOGARD SP CARDIOVASCULAR § ACE INHIBITORS fosinopril lisinopril quinapril ramipril § ACE INHIBITOR / DIURETIC COMBINATIONS fosinopril-hydrochlorothiazide lisinopril-hydrochlorothiazide quinapril-hydrochlorothiazide § ANGIOTENSIN II RECEPTOR ANTAGONISTS / DIURETIC COMBINATIONS candesartan / candesartanhydrochlorothiazide eprosartan irbesartan / irbesartanhydrochlorothiazide losartan / losartanhydrochlorothiazide telmisartan / telmisartanhydrochlorothiazide valsartan / valsartanhydrochlorothiazide BENICAR / BENICAR HCT metoprolol succinate ext-rel metoprolol tartrate nadolol propranolol propranolol ext-rel BYSTOLIC COREG CR § CALCIUM CHANNEL BLOCKERS amlodipine diltiazem ext-rel 2 nifedipine ext-rel verapamil ext-rel § CALCIUM CHANNEL BLOCKER / ANTILIPEMIC COMBINATIONS amlodipine-atorvastatin § ANGIOTENSIN II RECEPTOR ANTAGONIST / CALCIUM CHANNEL BLOCKER COMBINATIONS amlodipine-telmisartan amlodipine-valsartan AZOR § DIGITALIS GLYCOSIDES digoxin § ANGIOTENSIN II RECEPTOR ANTAGONIST / CALCIUM CHANNEL BLOCKER / DIURETIC COMBINATIONS amlodipine-valsartanhydrochlorothiazide TRIBENZOR § DIURETICS amiloride furosemide hydrochlorothiazide metolazone spironolactone-hydrochlorothiazide torsemide triamterene-hydrochlorothiazide § ANTIARRHYTHMICS sotalol ANTILIPEMICS § BILE ACID RESINS cholestyramine WELCHOL CHOLESTEROL ABSORPTION INHIBITORS ZETIA § FIBRATES fenofibrate fenofibric acid § HMG-CoA REDUCTASE INHIBITORS / COMBINATIONS atorvastatin fluvastatin lovastatin pravastatin rosuvastatin simvastatin VYTORIN § NIACINS niacin ext-rel § OMEGA-3 FATTY ACIDS omega-3 acid ethyl esters PA VASCEPA PA PCSK9 INHIBITORS REPATHA PA SP SI § BETA-BLOCKERS atenolol carvedilol DIRECT RENIN INHIBITORS / DIURETIC COMBINATIONS TEKTURNA / TEKTURNA HCT HEART FAILURE BIDIL CORLANOR ENTRESTO PA § NITRATES nitroglycerin lingual spray nitroglycerin sublingual NITROLINGUAL PULMONARY ARTERIAL HYPERTENSION ENDOTHELIN RECEPTOR ANTAGONISTS LETAIRIS PA SP TRACLEER PA SP § PHOSPHODIESTERASE INHIBITORS sildenafil PA SP PROSTAGLANDIN VASODILATORS ORENITRAM PA SP SOLUBLE GUANYLATE CYCLASE STIMULATORS ADEMPAS PA SP § 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 QUDEXY XR TROKENDI XR VIMPAT § ANTIDEMENTIA donepezil galantamine galantamine ext-rel memantine rivastigmine rivastigmine transdermal NAMENDA XR ANTIDEPRESSANTS § SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs) citalopram escitalopram fluoxetine paroxetine paroxetine ext-rel sertraline FLUOXETINE 60 MG TRINTELLIX VIIBRYD § SEROTONIN NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIs) duloxetine venlafaxine venlafaxine ext-rel capsule PRISTIQ § MISCELLANEOUS AGENTS bupropion bupropion ext-rel mirtazapine trazodone § ANTIPARKINSONIAN AGENTS amantadine carbidopa-levodopa carbidopa-levodopa ext-rel carbidopa-levodopa-entacapone entacapone pramipexole ropinirole ropinirole ext-rel selegiline AZILECT MIRAPEX ER NEUPRO ANTIPSYCHOTICS § ATYPICALS aripiprazole clozapine olanzapine quetiapine risperidone ziprasidone ARISTADA SI LATUDA SEROQUEL XR § NARCOLEPSY armodafinil § INSULIN SENSITIZERS pioglitazone POSTHERPETIC NEURALGIA GRALISE § INSULIN SENSITIZER / BIGUANIDE COMBINATIONS pioglitazone-metformin § ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine-dextroamphetamine mixed salts amphetamine-dextroamphetamine mixed salts ext-rel guanfacine ext-rel methylphenidate methylphenidate ext-rel APTENSIO XR QUILLIVANT XR STRATTERA VYVANSE § PARTIAL OPIOID AGONIST / OPIOID ANTAGONIST COMBINATIONS buprenorphine-naloxone sublingual tablet SUBOXONE FILM FIBROMYALGIA LYRICA SAVELLA § HUNTINGTON'S DISEASE AGENTS tetrabenazine PA SP HYPNOTICS § NONBENZODIAZEPINES eszopiclone zolpidem zolpidem ext-rel zolpidem sublingual TRICYCLICS SILENOR MIGRAINE § SELECTIVE SEROTONIN AGONISTS naratriptan QL rizatriptan QL sumatriptan QL zolmitriptan QL RELPAX QL ZOMIG NASAL SPRAY QL SELECTIVE SEROTONIN AGONIST / NONSTEROIDAL ANTIINFLAMMATORY DRUG (NSAID) COMBINATIONS TREXIMET QL § MULTIPLE SCLEROSIS AGENTS glatiramer Rx,MB PA SP SI AUBAGIO PA SP BETASERON Rx,MB PA SP SI COPAXONE 40 MG Rx,MB PA SP SI GILENYA PA SP REBIF Rx,MB PA SP SI TECFIDERA PA SP § MUSCULOSKELETAL THERAPY AGENTS cyclobenzaprine PSYCHOTHERAPEUTIC MISCELLANEOUS § OPIOID ANTAGONISTS naloxone injection SI NARCAN NASAL SPRAY VASOMOTOR SYMPTOM AGENTS BRISDELLE ENDOCRINE AND METABOLIC ACROMEGALY SOMAVERT Rx,MB PA SP SI § ANDROGENS testosterone gel 2% ANDRODERM AXIRON ANTIDIABETICS AMYLIN ANALOGS SYMLINPEN SI § BIGUANIDES metformin metformin ext-rel § BIGUANIDE / SULFONYLUREA COMBINATIONS glipizide-metformin DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS JANUVIA TRADJENTA DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITOR / BIGUANIDE COMBINATIONS JANUMET JANUMET XR JENTADUETO JENTADUETO XR INCRETIN MIMETIC AGENTS TRULICITY SI VICTOZA SI INSULINS BASAGLAR HUMULIN R U-500 LEVEMIR NOVOLIN 70/30 NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG MIX 70/30 TRESIBA § 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 XIGDUO XR § SULFONYLUREAS glimepiride glipizide glipizide ext-rel SUPPLIES BD ULTRAFINE INSULIN SYRINGES AND NEEDLES DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM * ONETOUCH ULTRA STRIPS AND KITS 3 ONETOUCH VERIO STRIPS AND KITS 3 ANTIOBESITY INJECTABLE SAXENDA SI ORAL BELVIQ BELVIQ XR CONTRAVE CALCIUM REGULATORS § BISPHOSPHONATES alendronate ibandronate risedronate ATELVIA § CALCITONINS calcitonin-salmon PARATHYROID HORMONES FORTEO Rx,MB PA SP SI § CARNITINE DEFICIENCY AGENTS levocarnitine CONTRACEPTIVES § MONOPHASIC ethinyl estradiol-drospirenone ethinyl estradiolnorethindrone acetate BEYAZ LO LOESTRIN FE MINASTRIN 24 FE SAFYRAL § 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 ESTRACE CREAM PREMARIN CREAM VAGIFEM ESTROGEN / PROGESTINS § ORAL estradiol-norethindrone PREMPHASE PREMPRO TRANSDERMAL CLIMARA PRO COMBIPATCH ESTROGEN / SELECTIVE ESTROGEN RECEPTOR MODULATOR COMBINATIONS DUAVEE FERTILITY REGULATORS GNRH / LHRH ANTAGONISTS CETROTIDE Rx,MB SP SI § OVULATION STIMULANTS, GONADOTROPINS FOLLISTIM AQ Rx,MB SP SI OVIDREL Rx,MB SP SI § GLUCOCORTICOIDS dexamethasone methylprednisolone prednisone GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT SI GLUCAGON EMERGENCY KIT SI HUMAN GROWTH HORMONES HUMATROPE Rx,MB PA SP SI § PHOSPHATE BINDER AGENTS calcium acetate PHOSLYRA RENVELA VELPHORO MOVIPREP SUPREP POTASSIUM-REMOVING AGENTS VELTASSA PANCREATIC ENZYMES CREON VIOKACE ZENPEP ALLERGENIC EXTRACTS GRASTEK ORALAIR RAGWITEK § PROTON PUMP INHIBITORS esomeprazole lansoprazole omeprazole pantoprazole DEXILANT BIOLOGIC DISEASE-MODIFYING AGENTS ENBREL PA SP SI HUMIRA PA SP SI PROGESTINS § ORAL medroxyprogesterone progesterone, micronized MEGACE ES 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 OPIOID-INDUCED CONSTIPATION MOVANTIK § STEROIDS, RECTAL PROCTOFOAM-HC § ULCER THERAPY COMBINATIONS PYLERA GENITOURINARY § BENIGN PROSTATIC HYPERPLASIA alfuzosin ext-rel doxazosin dutasteride dutasteride-tamsulosin finasteride tamsulosin terazosin CARDURA XL RAPAFLO ERECTILE DYSFUNCTION ALPROSTADIL AGENTS MUSE QL PHOSPHODIESTERASE INHIBITORS CIALIS QL § URINARY ANTISPASMODICS darifenacin ext-rel oxybutynin oxybutynin ext-rel tolterodine tolterodine ext-rel trospium trospium ext-rel MYRBETRIQ TOVIAZ VESICARE HEMATOLOGIC § RECTAL AGENTS hydrocortisone enema mesalamine rectal suspension CANASA CORTIFOAM § ANTICOAGULANTS warfarin ELIQUIS XARELTO § IRRITABLE BOWEL SYNDROME AMITIZA LINZESS LOTRONEX VIBERZI HEMATOPOIETIC GROWTH FACTORS ARANESP Rx,MB PA SP SI PROCRIT Rx,MB PA SP SI ZARXIO Rx,MB PA SP SI § LAXATIVES lactulose peg 3350-electrolytes § PLATELET AGGREGATION INHIBITORS clopidogrel dipyridamole ext-rel-aspirin BRILINTA EFFIENT IMMUNOLOGIC AGENTS § DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) RASUVO Rx,MB PA SP SI NUTRITIONAL / SUPPLEMENTS § ELECTROLYTES potassium chloride liquid VITAMINS AND MINERALS § PRENATAL VITAMINS prenatal vitamins CITRANATAL RESPIRATORY § ANAPHYLAXIS TREATMENT AGENTS epinephrine auto-injector SI EPIPEN SI EPIPEN JR SI § ANTICHOLINERGICS ipratropium inhalation solution SPIRIVA ANTICHOLINERGIC / BETA AGONIST COMBINATIONS § SHORT ACTING ipratropium-albuterol inhalation solution COMBIVENT RESPIMAT LONG ACTING ANORO ELLIPTA BEVESPI AEROSPHERE BETA AGONISTS, INHALANTS § SHORT ACTING albuterol inhalation solution PROAIR HFA PROAIR RESPICLICK LONG ACTING Hand-held Active Inhalation SEREVENT STRIVERDI RESPIMAT Nebulized Passive Inhalation PERFOROMIST § CYSTIC FIBROSIS tobramycin inhalation solution Rx,MB PA SP BETHKIS Rx,MB PA SP § LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast zafirlukast § NASAL ANTIHISTAMINES azelastine olopatadine § NASAL STEROIDS / COMBINATIONS flunisolide fluticasone mometasone triamcinolone DYMISTA PHOSPHODIESTERASE-4 INHIBITORS DALIRESP PULMONARY FIBROSIS AGENTS ESBRIET PA SP OFEV PA SP STEROID / BETA AGONIST COMBINATIONS ADVAIR BREO ELLIPTA DULERA § STEROID INHALANTS budesonide inhalation suspension ASMANEX FLOVENT DISKUS FLOVENT HFA PULMICORT FLEXHALER QVAR TOPICAL DERMATOLOGY § ACNE adapalene benzoyl peroxide clindamycin solution clindamycin-benzoyl peroxide erythromycin solution erythromycin-benzoyl peroxide tretinoin PA ACANYA ATRALIN PA BENZACLIN DIFFERIN EPIDUO RETIN-A MICRO PA TAZORAC PA § ACTINIC KERATOSIS fluorouracil cream 5% fluorouracil solution imiquimod PICATO ZYCLARA § ANTIFUNGALS ciclopirox clotrimazole econazole ketoconazole nystatin JUBLIA LUZU NAFTIN § ANTIPSORIATICS acitretin calcipotriene methoxsalen CORTICOSTEROIDS § Low Potency desonide hydrocortisone § Medium Potency hydrocortisone butyrate mometasone triamcinolone CLODERM LOCOID LOTION § High Potency desoximetasone fluocinonide § Very High Potency clobetasol cream, foam, gel, lotion, ointment, shampoo § IMMUNOMODULATORS tacrolimus ELIDEL § ROSACEA metronidazole FINACEA ORACEA SOOLANTRA MOUTH / THROAT / DENTAL AGENTS PROTECTANTS EPISIL MUGARD OPHTHALMIC § ANTIALLERGICS azelastine cromolyn sodium olopatadine PATADAY PAZEO § ANTI-INFECTIVES ciprofloxacin erythromycin gentamicin levofloxacin ofloxacin sulfacetamide tobramycin BESIVANCE MOXEZA VIGAMOX § ANTI-INFECTIVE / ANTI-INFLAMMATORY COMBINATIONS neomycin-polymyxin B-bacitracinhydrocortisone neomycin-polymyxin Bdexamethasone tobramycin-dexamethasone TOBRADEX OINTMENT TOBRADEX ST ZYLET ANTI-INFLAMMATORIES § Nonsteroidal bromfenac diclofenac ketorolac PROLENSA § Steroidal dexamethasone ALREX DUREZOL LOTEMAX BETA-BLOCKERS § Nonselective timolol maleate solution BETIMOL Selective BETOPTIC S § CARBONIC ANHYDRASE INHIBITORS dorzolamide AZOPT § CARBONIC ANHYDRASE INHIBITOR / BETA-BLOCKER COMBINATIONS dorzolamide-timolol COSOPT PF CARBONIC ANHYDRASE INHIBITOR / SYMPATHOMIMETIC COMBINATIONS SIMBRINZA DRY EYE DISEASE RESTASIS XIIDRA § PROSTAGLANDINS latanoprost travoprost TRAVATAN Z ZIOPTAN § SYMPATHOMIMETICS brimonidine ALPHAGAN P SYMPATHOMIMETIC / BETABLOCKER COMBINATIONS COMBIGAN OTIC § ANTI-INFECTIVE / ANTI-INFLAMMATORY COMBINATIONS CIPRODEX QUICK REFERENCE DRUG LIST A abacavir tablet ACANYA acitretin acyclovir adapalene ADEMPAS PA SP ADVAIR ALBENZA albuterol inhalation solution alendronate alfuzosin ext-rel allopurinol ALPHAGAN P ALREX amantadine amiloride AMITIZA amlodipine amlodipine-atorvastatin amlodipine-telmisartan amlodipine-valsartan amlodipine-valsartanhydrochlorothiazide amoxicillin amoxicillin-clavulanate amphetamine-dextroamphetamine mixed salts amphetamine-dextroamphetamine mixed salts ext-rel ANDRODERM ANORO ELLIPTA APRISO APTENSIO XR ARANESP Rx,MB PA SP SI aripiprazole ARISTADA SI armodafinil ASMANEX ATELVIA atenolol atorvastatin ATRALIN PA ATRIPLA AUBAGIO PA SP AXIRON azelastine AZILECT azithromycin AZOPT AZOR B balsalazide BASAGLAR BD ULTRAFINE INSULIN SYRINGES AND NEEDLES BELVIQ BELVIQ XR BENICAR BENICAR HCT BENZACLIN benzoyl peroxide BESIVANCE BETASERON Rx,MB PA SP SI BETHKIS Rx,MB PA SP BETIMOL BETOPTIC S BEVESPI AEROSPHERE BEYAZ bicalutamide BIDIL BOSULIF PA SP BREO ELLIPTA BRILINTA brimonidine BRISDELLE bromfenac budesonide capsule budesonide inhalation suspension buprenorphine-naloxone sublingual tablet bupropion bupropion ext-rel BUTRANS BYSTOLIC C calcipotriene calcitonin-salmon calcium acetate CANASA candesartan candesartan-hydrochlorothiazide carbamazepine carbamazepine ext-rel carbidopa-levodopa carbidopa-levodopa ext-rel carbidopa-levodopa-entacapone CARDURA XL carvedilol cefdinir cefprozil cefuroxime axetil celecoxib cephalexin CETROTIDE Rx,MB SP SI cholestyramine CIALIS QL ciclopirox 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 CLODERM clopidogrel clotrimazole clozapine codeine-acetaminophen colchicine tablet COLCRYS COMBIGAN COMBIPATCH COMBIVENT RESPIMAT COMPLERA CONTRAVE COPAXONE 40 MG Rx,MB PA SP SI COREG CR CORLANOR CORTIFOAM COSOPT PF CREON CRINONE cromolyn sodium cyclobenzaprine D DALIRESP darifenacin ext-rel DESCOVY desonide desoximetasone dexamethasone DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM * DEXILANT diazepam rectal gel DICLEGIS diclofenac diclofenac sodium diclofenac sodium solution diclofenac sodium-misoprostol dicloxacillin DIFFERIN DIFICID digoxin diltiazem ext-rel 2 dipyridamole ext-rel-aspirin divalproex sodium divalproex sodium ext-rel DIVIGEL donepezil dorzolamide dorzolamide-timolol doxazosin doxycycline hyclate dronabinol DUAVEE DULERA duloxetine DUREZOL dutasteride dutasteride-tamsulosin DYMISTA E econazole EFFIENT ELIDEL ELIQUIS ENBREL PA SP SI ENDOMETRIN entacapone ENTRESTO PA EPCLUSA PA SP EPIDUO epinephrine auto-injector SI EPIPEN SI EPIPEN JR SI EPISIL eprosartan EPZICOM erythromycin erythromycin solution erythromycin-benzoyl peroxide erythromycins ESBRIET PA SP escitalopram esomeprazole ESTRACE CREAM estradiol estradiol-norethindrone estropipate eszopiclone ethinyl estradiol-drospirenone ethinyl estradiol-levonorgestrel ethinyl estradiol-norelgestromin ethinyl estradiol-norethindrone acetate ethinyl estradiol-norgestimate ethosuximide EVAMIST EVOTAZ F FARXIGA fenofibrate fenofibric acid fentanyl transdermal fentanyl transmucosal lozenge PA FENTORA PA FINACEA finasteride FLOVENT DISKUS FLOVENT HFA fluconazole flunisolide fluocinonide fluorouracil cream 5% fluorouracil solution fluoxetine FLUOXETINE 60 MG fluticasone fluvastatin FOLLISTIM AQ Rx,MB SP SI FORTEO Rx,MB PA SP SI fosinopril fosinopril-hydrochlorothiazide furosemide FYCOMPA G gabapentin galantamine galantamine ext-rel gentamicin GENVOYA GILENYA PA SP glatiramer Rx,MB PA SP SI glimepiride glipizide glipizide ext-rel glipizide-metformin GLUCAGEN HYPOKIT SI GLUCAGON EMERGENCY KIT SI GRALISE granisetron GRASTEK guanfacine ext-rel H HARVONI PA SP HUMATROPE Rx,MB PA SP SI HUMIRA PA SP SI HUMULIN R U-500 hydrochlorothiazide hydrocodone-acetaminophen hydrocortisone hydrocortisone butyrate hydrocortisone enema hydromorphone hydromorphone ext-rel HYSINGLA ER I ibandronate imatinib mesylate PA SP imiquimod ipratropium inhalation solution ipratropium-albuterol inhalation solution irbesartan irbesartan-hydrochlorothiazide ISENTRESS itraconazole ivermectin J JANUMET JANUMET XR JANUVIA JARDIANCE JENTADUETO JENTADUETO XR JUBLIA K ketoconazole ketorolac L lactulose lamivudine lamotrigine lamotrigine ext-rel lansoprazole latanoprost LATUDA LETAIRIS PA SP LEVEMIR levetiracetam levetiracetam ext-rel levocarnitine levofloxacin levothyroxine LIALDA LINZESS lisinopril lisinopril-hydrochlorothiazide LO LOESTRIN FE LOCOID LOTION losartan losartan-hydrochlorothiazide LOTEMAX LOTRONEX lovastatin LUZU LYRICA M meclizine medroxyprogesterone MEGACE ES meloxicam memantine mesalamine rectal suspension metformin metformin ext-rel methadone methoxsalen methylphenidate methylphenidate ext-rel methylprednisolone metoclopramide metolazone metoprolol succinate ext-rel metoprolol tartrate metronidazole MINASTRIN 24 FE MINIVELLE minocycline MIRAPEX ER mirtazapine mometasone montelukast morphine morphine ext-rel morphine suppository MOVANTIK MOVIPREP MOXEZA moxifloxacin MUGARD MUSE QL MYRBETRIQ N nadolol NAFTIN naloxone injection SI NAMENDA XR naproxen naratriptan QL NARCAN NASAL SPRAY NATAZIA nateglinide neomycin-polymyxin B-bacitracinhydrocortisone neomycin-polymyxin Bdexamethasone NEUPRO niacin ext-rel nifedipine ext-rel nitrofurantoin nitroglycerin lingual spray nitroglycerin sublingual NITROLINGUAL NORVIR NOVOLIN 70/30 NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG MIX 70/30 NUCYNTA NUCYNTA ER NUVARING nystatin O ODEFSEY OFEV PA SP ofloxacin olanzapine olopatadine omega-3 acid ethyl esters PA omeprazole ondansetron ONETOUCH ULTRA STRIPS AND KITS 3 ONETOUCH VERIO STRIPS AND KITS 3 OPANA ER ORACEA ORALAIR ORENITRAM PA SP OSPHENA OVIDREL Rx,MB SP SI oxcarbazepine OXTELLAR XR oxybutynin oxybutynin ext-rel oxycodone oxycodone-acetaminophen OXYCONTIN QL P pantoprazole paroxetine paroxetine ext-rel PATADAY PAZEO peg 3350-electrolytes penicillin VK PENTASA PERFOROMIST phenobarbital phenytoin phenytoin sodium extended PHOSLYRA PICATO pioglitazone pioglitazone-glimepiride pioglitazone-metformin potassium chloride liquid pramipexole pravastatin prednisone PREMARIN PREMARIN CREAM PREMPHASE PREMPRO prenatal vitamins PREZCOBIX PREZISTA primidone PRISTIQ PROAIR HFA PROAIR RESPICLICK probenecid prochlorperazine PROCRIT Rx,MB PA SP SI PROCTOFOAM-HC progesterone, micronized PROLENSA promethazine propranolol propranolol ext-rel PULMICORT FLEXHALER PYLERA Q QUDEXY XR quetiapine QUILLIVANT XR quinapril quinapril-hydrochlorothiazide QVAR R RAGWITEK raloxifene ramipril RANEXA ranitidine RAPAFLO RASUVO Rx,MB PA SP SI REBIF Rx,MB PA SP SI RELENZA QL RELPAX QL RENVELA repaglinide REPATHA PA SP SI RESTASIS RETIN-A MICRO PA REYATAZ ribavirin PA SP risedronate risperidone rivastigmine rivastigmine transdermal rizatriptan QL ropinirole ropinirole ext-rel rosuvastatin S SAFYRAL SANCUSO SAVELLA SAXENDA SI selegiline SEREVENT SEROQUEL XR sertraline sildenafil PA SP SILENOR SIMBRINZA simvastatin SIVEXTRO SOMAVERT Rx,MB PA SP SI SOOLANTRA sotalol SPIRIVA spironolactone-hydrochlorothiazide SPRYCEL PA SP STRATTERA STRIBILD STRIVERDI RESPIMAT SUBOXONE FILM SUBSYS PA sulfacetamide sulfamethoxazole-trimethoprim sulfasalazine sulfasalazine delayed-rel sumatriptan QL SUPRAX SUPREP SYMLINPEN SI SYNTHROID T tacrolimus TAMIFLU QL tamsulosin TAZORAC PA TECFIDERA PA SP TEKTURNA TEKTURNA HCT telmisartan telmisartan-hydrochlorothiazide terazosin terbinafine tablet testosterone gel 2% tetrabenazine PA SP tetracycline tiagabine timolol maleate solution TIVICAY TOBRADEX OINTMENT TOBRADEX ST tobramycin tobramycin inhalation solution Rx,MB PA SP tobramycin-dexamethasone tolterodine tolterodine ext-rel topiramate torsemide TOVIAZ TRACLEER PA SP TRADJENTA tramadol tramadol ext-rel TRAVATAN Z travoprost trazodone TRESIBA tretinoin PA TREXIMET QL triamcinolone triamterene-hydrochlorothiazide TRIBENZOR trimethobenzamide TRINTELLIX TRIUMEQ TROKENDI XR trospium trospium ext-rel TRULICITY SI TRUVADA U UCERIS ULORIC V VAGIFEM valacyclovir valganciclovir valproic acid valsartan valsartan-hydrochlorothiazide VARUBI VASCEPA PA VELPHORO VELTASSA venlafaxine venlafaxine ext-rel capsule verapamil ext-rel VESICARE VIBERZI VICTOZA SI VIGAMOX VIIBRYD VIMPAT VIOKACE VISTOGARD SP VOLTAREN GEL VYTORIN VYVANSE W warfarin WELCHOL X XARELTO XIFAXAN 550 MG PA XIGDUO XR XIIDRA Z zafirlukast ZARXIO Rx,MB PA SP SI ZENPEP ZETIA ZIOPTAN ziprasidone zolmitriptan QL zolpidem zolpidem ext-rel zolpidem sublingual ZOMIG NASAL SPRAY QL zonisamide ZYCLARA ZYLET ZYTIGA PA SP PREFERRED OPTIONS LIST NON-PREFERRED OR EXCLUDED DRUG(S) PREFERRED OPTION(S)† NON-PREFERRED OR EXCLUDED DRUG(S) PREFERRED OPTION(S)† ABILIFY aripiprazole, clozapine, olanzapine, quetiapine, risperidone, ziprasidone, LATUDA, SEROQUEL XR AZELEX ABSTRAL PA fentanyl transmucosal lozenge PA, FENTORA PA, SUBSYS PA adapalene, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin PA, ACANYA, ATRALIN PA, BENZACLIN, DIFFERIN, EPIDUO, RETIN-A MICRO PA, TAZORAC PA ACCU-CHEK STRIPS AND KITS 4 ONETOUCH ULTRA STRIPS AND KITS 3, ONETOUCH VERIO STRIPS AND KITS 3 BECONASE AQ flunisolide, fluticasone, mometasone, triamcinolone, DYMISTA ACTOS pioglitazone BENZAC AC, BENZAC W ADDERALL XR amphetamine-dextroamphetamine mixed salts, amphetamine-dextroamphetamine mixed salts ext-rel, guanfacine ext-rel, methylphenidate, methylphenidate ext-rel, APTENSIO XR, QUILLIVANT XR, STRATTERA, VYVANSE adapalene, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin PA, ACANYA, ATRALIN PA, BENZACLIN, DIFFERIN, EPIDUO, RETIN-A MICRO PA, TAZORAC PA BENZIQ ADRENACLICK SI epinephrine auto-injector SI, EPIPEN SI, EPIPEN JR SI ADVICOR atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin, VYTORIN adapalene, benzoyl peroxide, clindamycin solution, clindamycin-benzoyl peroxide, erythromycin solution, erythromycin-benzoyl peroxide, tretinoin PA, ACANYA, ATRALIN PA, BENZACLIN, DIFFERIN, EPIDUO, RETIN-A MICRO PA, TAZORAC PA AEROSPAN ASMANEX, FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER, QVAR ALCORTIN A hydrocortisone ALLISON MEDICAL INSULIN SYRINGES 5 BD ULTRAFINE INSULIN SYRINGES ALOQUIN hydrocortisone ALORA estradiol, DIVIGEL, EVAMIST, MINIVELLE ALTOPREV atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin, VYTORIN ALVESCO ASMANEX, FLOVENT DISKUS, FLOVENT HFA, PULMICORT FLEXHALER, QVAR AMRIX cyclobenzaprine ANDROGEL ANGELIQ BETAPACE, BETAPACE AF BREEZE 2 STRIPS AND KITS sotalol 4 ONETOUCH ULTRA STRIPS AND KITS 3, ONETOUCH VERIO STRIPS AND KITS 3 butalbital-acetaminophencaffeine capsule naratriptan QL, rizatriptan QL, sumatriptan QL, zolmitriptan QL, RELPAX QL, ZOMIG NASAL SPRAY QL BYDUREON SI TRULICITY SI, VICTOZA SI BYETTA SI TRULICITY SI, VICTOZA SI CAFERGOT naratriptan QL, rizatriptan QL, sumatriptan QL, zolmitriptan QL, RELPAX QL, ZOMIG NASAL SPRAY QL CARAC fluorouracil cream 5%, fluorouracil solution, imiquimod, PICATO, ZYCLARA testosterone gel 2%, ANDRODERM, AXIRON CARDIZEM diltiazem ext-rel (except generic CARDIZEM LA) estradiol-norethindrone, PREMPHASE, PREMPRO CARDIZEM CD diltiazem ext-rel (except generic CARDIZEM LA) ANTARA fenofibrate, fenofibric acid CARDIZEM LA (and its generics) diltiazem ext-rel (except generic CARDIZEM LA) APEXICON E desoximetasone, fluocinonide CARNITOR levocarnitine APIDRA NOVOLOG CARNITOR SF levocarnitine ARMOUR THYROID levothyroxine, SYNTHROID CLINDAGEL erythromycin solution ARTHROTEC celecoxib; diclofenac sodium, meloxicam or naproxen WITH esomeprazole, lansoprazole, omeprazole, pantoprazole or DEXILANT clobetasol spray clobetasol foam CLOBEX SPRAY clobetasol foam ASACOL HD balsalazide, sulfasalazine, sulfasalazine delayed-rel, APRISO, LIALDA, PENTASA, UCERIS CONTOUR NEXT STRIPS AND KITS 4 ONETOUCH ULTRA STRIPS AND KITS 3, ONETOUCH VERIO STRIPS AND KITS 3 ASCENSIA STRIPS AND KITS 4 ONETOUCH ULTRA STRIPS AND KITS 3, ONETOUCH VERIO STRIPS AND KITS 3 CONTOUR STRIPS AND KITS 4 ONETOUCH ULTRA STRIPS AND KITS 3, ONETOUCH VERIO STRIPS AND KITS 3 ATACAND, ATACAND HCT candesartan, candesartan-hydrochlorothiazide, eprosartan, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide, BENICAR, BENICAR HCT CRESTOR atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin, VYTORIN CYMBALTA duloxetine, venlafaxine, venlafaxine ext-rel capsule, PRISTIQ DAKLINZA PA SP EPCLUSA (genotypes 2, 3) PA SP, HARVONI (genotypes 1, 4, 5, 6) PA SP ATROVENT HFA ipratropium inhalation solution AVONEX Rx,MB PA SP SI glatiramer Rx,MB PA SP SI, AUBAGIO PA SP, BETASERON Rx,MB PA SP SI, COPAXONE 40 MG Rx,MB PA SP SI, GILENYA PA SP, REBIF Rx,MB PA SP SI, TECFIDERA PA SP DELZICOL balsalazide, sulfasalazine, sulfasalazine delayed-rel, APRISO, LIALDA, PENTASA, UCERIS DETROL LA darifenacin ext-rel, oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ, TOVIAZ, VESICARE naratriptan QL, rizatriptan QL, sumatriptan QL, zolmitriptan QL, RELPAX QL, ZOMIG NASAL SPRAY QL DEXPAK dexamethasone, methylprednisolone, prednisone AXERT QL NON-PREFERRED OR EXCLUDED DRUG(S) PREFERRED OPTION(S)† NON-PREFERRED OR EXCLUDED DRUG(S) PREFERRED OPTION(S)† DIOVAN, DIOVAN HCT candesartan, candesartan-hydrochlorothiazide, eprosartan, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide, BENICAR, BENICAR HCT GLUMETZA metformin, metformin ext-rel HUMALOG NOVOLOG HUMALOG MIX 50/50 NOVOLOG MIX 70/30 HUMALOG MIX 75/25 NOVOLOG MIX 70/30 DORAL eszopiclone, zolpidem, zolpidem ext-rel, zolpidem sublingual, SILENOR HUMULIN NOVOLIN DUTOPROL metoprolol succinate ext-rel WITH hydrochlorothiazide INCRUSE ELLIPTA SPIRIVA DYRENIUM amiloride INNOPRAN XL EDARBI, EDARBYCLOR candesartan, candesartan-hydrochlorothiazide, eprosartan, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide, BENICAR, BENICAR HCT atenolol, carvedilol, metoprolol succinate ext-rel, metoprolol tartrate, nadolol, propranolol, propranolol ext-rel, BYSTOLIC, COREG CR INTERMEZZO eszopiclone, zolpidem, zolpidem ext-rel, zolpidem sublingual, SILENOR INTUNIV amphetamine-dextroamphetamine mixed salts, amphetamine-dextroamphetamine mixed salts ext-rel, guanfacine ext-rel, methylphenidate, methylphenidate ext-rel, APTENSIO XR, QUILLIVANT XR, STRATTERA, VYVANSE EDLUAR eszopiclone, zolpidem, zolpidem ext-rel, zolpidem sublingual, SILENOR E.E.S. GRANULES erythromycins INVOKAMET XIGDUO XR ENABLEX darifenacin ext-rel, oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ, TOVIAZ, VESICARE INVOKANA FARXIGA, JARDIANCE ISTALOL timolol maleate solution, BETIMOL ENJUVIA estradiol, estropipate, PREMARIN JALYN dutasteride-tamsulosin ERYPED erythromycins KAZANO ESTRING ESTRACE CREAM, PREMARIN CREAM, VAGIFEM JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR EVZIO SI naloxone injection SI, NARCAN NASAL SPRAY KLOR-CON/25 potassium chloride liquid EXFORGE amlodipine-telmisartan, amlodipine-valsartan, AZOR KOMBIGLYZE XR JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR EXFORGE HCT amlodipine-valsartan-hydrochlorothiazide, TRIBENZOR digoxin EXTAVIA Rx,MB PA SP SI glatiramer Rx,MB PA SP SI, AUBAGIO PA SP, BETASERON Rx,MB PA SP SI, COPAXONE 40 MG Rx,MB PA SP SI, GILENYA PA SP, REBIF Rx,MB PA SP SI, TECFIDERA PA SP LANOXIN TABLET (125 MCG and 250 MCG only) LANTUS BASAGLAR, LEVEMIR, TRESIBA LASTACAFT azelastine, cromolyn sodium, olopatadine, PATADAY, PAZEO FEMRING ESTRACE CREAM, PREMARIN CREAM, VAGIFEM LESCOL XL FETZIMA duloxetine, venlafaxine, venlafaxine ext-rel capsule, PRISTIQ atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin, VYTORIN LEVITRA QL CIALIS QL LIPITOR atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin, VYTORIN LIVALO atorvastatin, fluvastatin, lovastatin, pravastatin, rosuvastatin, simvastatin, VYTORIN LUMIGAN latanoprost, travoprost, TRAVATAN Z, ZIOPTAN LUNESTA eszopiclone, zolpidem, zolpidem ext-rel, zolpidem sublingual, SILENOR FIORICET CAPSULE naratriptan QL, rizatriptan QL, sumatriptan QL, zolmitriptan QL, RELPAX QL, ZOMIG NASAL SPRAY QL FIRST TESTOSTERONE testosterone gel 2%, ANDRODERM, AXIRON fluorouracil cream 0.5% fluorouracil cream 5%, fluorouracil solution, imiquimod, PICATO, ZYCLARA FORTAMET metformin, metformin ext-rel FORTESTA testosterone gel 2%, ANDRODERM, AXIRON MACRODANTIN nitrofurantoin FOSAMAX PLUS D alendronate, ibandronate, risedronate, ATELVIA Matzim LA diltiazem ext-rel (except generic CARDIZEM LA) FOSRENOL calcium acetate, PHOSLYRA, RENVELA, VELPHORO MENEST estradiol, estropipate, PREMARIN MENOSTAR estradiol MIACALCIN INJECTION SI alendronate, calcitonin-salmon, ibandronate, risedronate, ATELVIA, FORTEO Rx,MB PA SP SI MIACALCIN NASAL SPRAY calcitonin-salmon MICARDIS, MICARDIS HCT candesartan, candesartan-hydrochlorothiazide, eprosartan, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide, BENICAR, BENICAR HCT MILLIPRED dexamethasone, methylprednisolone, prednisone FREESTYLE STRIPS AND KITS 4 ONETOUCH ULTRA STRIPS AND KITS 3, ONETOUCH VERIO STRIPS AND KITS 3 FROVA QL naratriptan QL, rizatriptan QL, sumatriptan QL, zolmitriptan QL, RELPAX QL, ZOMIG NASAL SPRAY QL GELNIQUE darifenacin ext-rel, oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ, TOVIAZ, VESICARE GENOTROPIN Rx,MB PA SP SI HUMATROPE Rx,MB PA SP SI GLEEVEC PA SP imatinib mesylate PA SP, BOSULIF PA SP, SPRYCEL PA SP NON-PREFERRED OR EXCLUDED DRUG(S) PREFERRED OPTION(S)† NON-PREFERRED OR EXCLUDED DRUG(S) PREFERRED OPTION(S)† NAPRELAN celecoxib, diclofenac sodium, meloxicam, naproxen PROTONIX NATESTO testosterone gel 2%, ANDRODERM, AXIRON esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT NESINA JANUVIA, TRADJENTA PROTOPIC tacrolimus, ELIDEL NEUPOGEN Rx,MB PA SP SI ZARXIO Rx,MB PA SP SI PROVENTIL HFA PROAIR HFA, PROAIR RESPICLICK NEXIUM esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT QNASL flunisolide, fluticasone, mometasone, triamcinolone, DYMISTA NILANDRON bicalutamide, ZYTIGA PA SP QSYMIA BELVIQ, BELVIQ XR, CONTRAVE, SAXENDA SI NITROMIST nitroglycerin lingual spray, nitroglycerin sublingual, NITROLINGUAL RAYOS dexamethasone, methylprednisolone, prednisone RELION INSULIN NOVOLIN INSULIN NORITATE metronidazole, FINACEA, SOOLANTRA RELISTOR SI MOVANTIK NORVASC amlodipine RHINOCORT AQUA flunisolide, fluticasone, mometasone, triamcinolone, DYMISTA RIOMET metformin, metformin ext-rel ROZEREM eszopiclone, zolpidem, zolpidem ext-rel, zolpidem sublingual, SILENOR HUMATROPE Rx,MB PA SP SI NOVACORT NOVO NORDISK NEEDLES hydrocortisone 5 BD ULTRAFINE NEEDLES NUTROPIN AQ Rx,MB PA SP SI HUMATROPE Rx,MB PA SP SI OLEPTRO trazodone SAIZEN Rx,MB PA SP SI OLUX-E clobetasol foam STRIANT OLYSIO PA SP HARVONI (genotypes 1, 4, 5, 6) PA SP SURE-TEST STRIPS AND KITS OMNARIS flunisolide, fluticasone, mometasone, triamcinolone, DYMISTA SYMBICORT ADVAIR, BREO ELLIPTA, DULERA OMNITROPE Rx,MB PA SP SI HUMATROPE Rx,MB PA SP SI TANZEUM SI TRULICITY SI, VICTOZA SI ONGLYZA JANUVIA, TRADJENTA TASIGNA PA SP OPSUMIT PA SP LETAIRIS PA SP, TRACLEER PA SP imatinib mesylate PA SP, BOSULIF PA SP, SPRYCEL PA SP OSENI JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XR TECHNIVIE PA SP HARVONI (genotypes 1, 4, 5, 6) PA SP TESTIM testosterone gel 2%, ANDRODERM, AXIRON OWEN MUMFORD NEEDLES 5 BD ULTRAFINE NEEDLES testosterone gel 1% 6 testosterone gel 2%, ANDRODERM, AXIRON OXYTROL darifenacin ext-rel, oxybutynin ext-rel, tolterodine, tolterodine ext-rel, trospium, trospium ext-rel, MYRBETRIQ, TOVIAZ, VESICARE TOBI Rx,MB PA SP tobramycin inhalation solution Rx,MB PA SP, BETHKIS Rx,MB PA SP PANCREAZE CREON, VIOKACE, ZENPEP TOBI PODHALER Rx,MB PA SP tobramycin inhalation solution Rx,MB PA SP, BETHKIS Rx,MB PA SP PENNSAID diclofenac sodium, diclofenac sodium solution, meloxicam, naproxen, VOLTAREN GEL TOUJEO BASAGLAR, LEVEMIR, TRESIBA PERRIGO NEEDLES 5 BD ULTRAFINE NEEDLES TRICOR fenofibrate, fenofibric acid PERTZYE CREON, VIOKACE, ZENPEP TRIGLIDE fenofibrate, fenofibric acid PEXEVA citalopram, escitalopram, fluoxetine, paroxetine, paroxetine ext-rel, sertraline, FLUOXETINE 60 MG, TRINTELLIX, VIIBRYD TRILIPIX fenofibrate, fenofibric acid testosterone gel 2%, ANDRODERM, AXIRON 4 ONETOUCH ULTRA STRIPS AND KITS 3, ONETOUCH VERIO STRIPS AND KITS 3 TRIVIDIA INSULIN SYRINGES 5 BD ULTRAFINE INSULIN SYRINGES TRUETEST STRIPS AND KITS ONETOUCH ULTRA STRIPS AND KITS 3, ONETOUCH VERIO STRIPS AND KITS 3 4 PLAVIX clopidogrel, BRILINTA, EFFIENT PLEGRIDY Rx,MB PA SP SI glatiramer Rx,MB PA SP SI, AUBAGIO PA SP, BETASERON Rx,MB PA SP SI, COPAXONE 40 MG Rx,MB PA SP SI, GILENYA PA SP, REBIF Rx,MB PA SP SI, TECFIDERA PA SP TRUETRACK STRIPS AND KITS 4 PRADAXA warfarin, ELIQUIS, XARELTO ULTIMED NEEDLES PRALUENT PA SP SI REPATHA PA SP SI UROXATRAL alfuzosin ext-rel, tamsulosin PRECISION XTRA STRIPS AND KITS 4 ONETOUCH ULTRA STRIPS AND KITS 3, ONETOUCH VERIO STRIPS AND KITS 3 VALCYTE valganciclovir PRED MILD dexamethasone, DUREZOL, LOTEMAX VALTREX acyclovir, valacyclovir PREFERAOB generic prenatal vitamins, CITRANATAL VANOXIDE-HC benzoyl peroxide PREFEST estradiol-norethindrone, PREMPHASE, PREMPRO venlafaxine ext-rel tablet (except 225 mg) duloxetine, venlafaxine, venlafaxine ext-rel capsule, PRISTIQ PRENATAL PLUS generic prenatal vitamins, CITRANATAL PREVACID esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT VENLAFAXINE EXTREL TABLET (except 225 mg) duloxetine, venlafaxine, venlafaxine ext-rel capsule, PRISTIQ VENTOLIN HFA PROAIR HFA, PROAIR RESPICLICK ONETOUCH ULTRA STRIPS AND KITS 3, ONETOUCH VERIO STRIPS AND KITS 3 TUDORZA SPIRIVA ULTIMED INSULIN SYRINGES 5 5 BD ULTRAFINE INSULIN SYRINGES BD ULTRAFINE NEEDLES NON-PREFERRED OR EXCLUDED DRUG(S) PREFERRED OPTION(S)† NON-PREFERRED OR EXCLUDED DRUG(S) PREFERRED OPTION(S)† VERAMYST flunisolide, fluticasone, mometasone, triamcinolone, DYMISTA XTANDI PA SP bicalutamide, ZYTIGA PA SP VIAGRA QL CIALIS QL ZEGERID esomeprazole, lansoprazole, omeprazole, pantoprazole, DEXILANT VIEKIRA PAK PA SP HARVONI (genotypes 1, 4, 5, 6) PA SP ZEPATIER PA SP HARVONI (genotypes 1, 4, 5, 6) PA SP VIEKIRA XR PA SP HARVONI (genotypes 1, 4, 5, 6) PA SP ZETONNA VITAFOL-ONE generic prenatal vitamins, CITRANATAL flunisolide, fluticasone, mometasone, triamcinolone, DYMISTA VOGELXO testosterone gel 2%, ANDRODERM, AXIRON ZONEGRAN zonisamide XENAZINE PA SP tetrabenazine PA SP ZUBSOLV buprenorphine-naloxone sublingual tablet, SUBOXONE FILM XOPENEX HFA PROAIR HFA, PROAIR RESPICLICK ZYFLO, ZYFLO CR montelukast, zafirlukast 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 until the product has been evaluated, determined to be clinically appropriate and cost-effective, and approved by a National Pharmacy and Therapeutics Committee (or other appropriate reviewing body). 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. † § * PA QL Rx,MB SI SP 1 2 3 4 5 6 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. Prior authorization required for prescription benefits coverage Quantity limits May be covered under either prescription or medical benefits. Please consult your plan to determine coverage. Self-injectable product - refer to plan details for more information; some plans may have self-injectable products on the 4th benefit tier. Specialty product CVS Caremark is an independent company that provides pharmacy benefit management services. Listing does not include generic CARDIZEM LA. A ONETOUCH blood glucose meter may be provided at no charge by the manufacturer to those individuals currently using a meter other than OneTouch. For more information on how to obtain a blood glucose meter, call: 800-588-4456. ONETOUCH brand test strips are the only preferred options. BD ULTRAFINE syringes and needles are the only preferred options. 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. ©2017. All rights reserved. SUM2665-1P (04/01/17) Notice of Nondiscrimination and Availability of Language Assistance Services CareFirst BlueCross BlueShield, CareFirst BlueChoice, Inc. 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 interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats) ■ Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages 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. Civil Rights Coordinator, Corporate Office of Civil Rights Telephone Number Mailing Address Fax Number Email Address 410-528-7820 P.O. Box 8894 Baltimore, Maryland 21224 410-505-2011 [email protected] You can file a grievance by mail, fax or email. If you need help filing a grievance, our CareFirst Civil Rights Coordinator is available to help you. 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-BW-1-17 Foreign Language Assistance 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) Ìtẹtíléko: Àkíyèsí yìí ní ìwífún nípa iṣẹ́ adójútòfò rẹ. Ó le ní àwọn déètì pàtó o sì le ní láti ́ gbé ìgbésẹ̀ ní àwọn ọjọ́ gbèdéke kan. O ni ẹtọ ̀ ́ láti gba ìwífún yìí àti ìrànlọwọ ́ ́ ní èdè rẹ lọfẹẹ. ́ ̀ ́ Àwọn ọmọ-ẹgbẹ́ gbọdọ pe nọmbà fóònù tó wà lẹyìn káàdì ìdánimọ wọn. Àwọn míràn le pe 855-258-6518 kí o sì dúró nípasẹ̀ ìjíròrò ́ ̀ ́ ́ ̀ títí a ó fi sọ fún ọ láti tẹ 0. Nígbàtí aṣojú kan bá dáhùn, sọ èdè tí o fẹ́ a ó sì so ọ́ pọ̀ mọ́ ògbufọ̀ kan. Tiếng Việt (Vietnamese) Chú ý: Thông báo này chứa thông tin về phạm vi bảo hiểm của quý vị. Thông báo có thể chứa những ngày quan trọng và quý vị cần hành động trước một số thời hạn nhất định. Quý vị có quyền nhận được thông tin này và hỗ trợ bằng ngôn ngữ của quý vị hoàn toàn miễn phí. Các thành viên nên gọi số điện thoại ở mặt sau của thẻ nhận dạng. Tất cả những người khác có thể gọi số 855-258-6518 và chờ hết cuộc đối thoại cho đến khi được nhắc nhấn phím 0. Khi một tổng đài viên trả lời, hãy nêu rõ ngôn ngữ quý vị cần và quý vị sẽ được kết nối với một thông dịch viên. Tagalog (Tagalog) Atensyon: Ang abisong ito ay naglalaman ng impormasyon tungkol sa nasasaklawan ng iyong insurance. Maaari itong maglaman ng mga pinakamahalagang petsa at maaaring kailangan mong gumawa ng aksyon ayon sa ilang deadline. May karapatan ka na makuha ang impormasyong ito at tulong sa iyong sariling wika nang walang gastos. Dapat tawagan ng mga Miyembro ang numero ng telepono na nasa likuran ng kanilang identification card. Ang lahat ng iba ay maaaring tumawag sa 855-258-6518 at maghintay hanggang sa dulo ng diyalogo hanggang sa diktahan na pindutin ang 0. Kapag sumagot ang ahente, sabihin ang wika na kailangan mo at ikokonekta ka sa isang interpreter. Español (Spanish) Atención: Este aviso contiene información sobre su cobertura de seguro. Es posible que incluya fechas clave y que usted tenga que realizar alguna acción antes de ciertas fechas límite. Usted tiene derecho a obtener esta información y asistencia en su idioma sin ningún costo. Los asegurados deben llamar al número de teléfono que se encuentra al reverso de su tarjeta de identificación. Todos los demás pueden llamar al 855-258-6518 y esperar la grabación hasta que se les indique que deben presionar 0. Cuando un agente de seguros responda, indique el idioma que necesita y se le comunicará con un intérprete. Русский (Russian) Внимание! Настоящее уведомление содержит информацию о вашем страховом обеспечении. В нем могут указываться важные даты, и от вас может потребоваться выполнить некоторые действия до определенного срока. Вы имеете право бесплатно получить настоящие сведения и сопутствующую помощь на удобном вам языке. Участникам следует обращаться по номеру телефона, указанному на тыльной стороне идентификационной карты. Все прочие абоненты могут звонить по номеру 855-258-6518 и ожидать, пока в голосовом меню не будет предложено нажать цифру «0». При ответе агента укажите желаемый язык общения, и вас свяжут с переводчиком. हिन्दी (Hindi) ध्यान दें : इस सचना में आपकी बीमा कवरज े के बारे में जानकारी दी गई िै । िो सकता िै कक इसमें मख्य ू ु ततथियों का उल्लेख िो और आपके ललए ककसी तनयत समय-सीमा के भीतर काम करना ज़रूरी िो। आपको यि जानकारी और संबथं ित सिायता अपनी भाषा में तनिःशल्क पाने का अथिकार िै । सदस्यों को अपने पिचान पत्र के पीछे हदए गए फोन ु नंबर पर कॉल करना चाहिए। अन्य सभी लोग 855-258-6518 पर कॉल कर सकते िैं और जब तक 0 दबाने के ललए न किा जाए, तब तक संवाद की प्रतीक्षा करें । जब कोई एजेंट उत्तर दे तो उसे अपनी भाषा बताएँ और आपको व्याख्याकार से कनेक्ट कर हदया जाएगा। ̃̌ ̀ ̃̌ Ɓǎɔ́ ɔ̀Ǧîɖî (Bassa) TòƉùǔCáǨɔnìàɛɓáɔɓěkém ̀ kpáɓónìfuàǦṹáǦtìǐɛɛjèdyíǤɔnìàɛ ̃̌ ɓéɖéwéɛ́ ɛ́ɓěɓɛ́ m̀kéɖɛɔ́ m̀kéɛɛɛ̀ ɓɛ́ wéɓěké. Ɔ ɔ̀ nìkpéɓɛ́ m̀kéɔnìàɛkèǦ kpáǦkpám̀ɔ́ ɛɛdyéɖénìɓíɖíǦwùɖùmúɓɛ́ m̀kéwíɖíɖòɛ́ ɛ̀Ǥɔ̀ ɔɓěɛɖáṹîǦɔ̀ ɓànìàɖéwaà ǤǤkáàɔ̀ ɖeíɛǤɔɔ̀ ɔ̀séíɛɖáɔ̀ ɓànìàɛǣ855-258-6518ǡkém̀ɛfòɓɛ́ kéɛm̀ ɛɓɛ́ m̀ké ̃̌ ɔ̀ ɓàɔ̀ à0ɛɛpàɖàìɛ̀ . Ɔ jǔkéɔɖòm̀ɔjǔǐǡɖm ̀ ɔ́ ɛɛǡkéɔɖòɓónìì ɓɛ́ ɔkénìɖɔ̀ múzàǤ বাাংলা (Bengali) লক্ষ্য করুন: এই ননাটিশে আপনার ববমা কভাশরজ সম্পশকে তথ্য রশেশে। এর মশযয গুরুত্বপূর্ে তাবরখ থ্াকশত পাশর এবাং বনবদে ষ্ট 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 বলুন 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: ) توجہUrdu( اردو ہے کہ آپ کو مخصوص آخری تاریخوں تک کارروائی کرنے کی ضرورت پڑے۔ آپ کے پاس یہ معلومات حاصل کرنے اور بغیر خرچہ کیے اپنی زبان میں مدد حاصل کرنے کا حق ہے۔ ممبران کو اپنے شناختی کارڈ کی پشت پر موجود فون نمبر پر کال کرنی چاہیے۔ سبھی دیگر دبانے کو کہے جانے تک انتظار کریں۔ ایجنٹ کے جواب دینے پر اپنی مطلوبہ زبان0 پر کال کر سکتے ہیں اور855-258-6518 لوگ بتائیں اور مترجم سے مربوط ہو جائیں گے۔ ممکن است حاوی تاریخ های مھمی باشد و الزم است تا تاریخ. این اعالمیه حاوی اطالعاتی درباره پوشش بیمه شما است:) توجهFarsi( فارسی . شما از این حق برخوردار هستید تا این اطالعات و راهنمایی را به صورت رایگان به زبان خودتان دریافت کنید.مقرر شده خاصی اقدام کنید سایر افراد می توانند با شماره.اعضا باید با شماره درج شده در پشت کارت شناساییشان تماس بگیرند زبان، بعد از پاسخگویی توسط یکی از اپراتورها. را فشار دهند0 تماس بگیرند و منتظر بمانند تا از آنھا خواسته شود عدد855-258-6518 .مورد نیاز را تنظیم کنید تا به مترجم مربوطه وصل شوید وقد تحتاج إلى اتخاذ، وقد یحتوي على تواریخ مھمة،یحتوي هذا اإلخطار على معلومات بشأن تغطیتك التأمینیة: ( تنبیهArabic) اللغة العربیة ینبغي على األعضاء االتصال. یحق لك الحصول على هذه المساعدة والمعلومات بلغتك بدون تحمل أي تكلفة. إجراءات بحلول مواعید نھائیة محددة یمكن لآلخرین االتصال على الرقم. على رقم الھاتف المذكور في ظھر بطاقة تعریف الھویة الخاصة بھم اذكر اللغة التي تحتاج إلى التواصل بھا، عند إجابة أحد الوكالء0. واالنتظار خالل المحادثة حتى یطلب منھم الضغط على رقم855-258-6518 .وسیتم توصیلك بأحد المترجمین الفوریین 中文繁体 (Traditional Chinese) 注意：本聲明包含關於您的保險給付相關資訊。本聲明可能包含重要日期 及您在特定期限之前需要採取的行動。您有權利免費獲得這份資訊，以及透過您的母語提供的協助服 務。會員請撥打印在身分識別卡背面的電話號碼。其他所有人士可撥打電話 855-258-6518，並等候直到 對話提示按下按鍵 0。當接線生回答時，請說出您需要使用的語言，這樣您就能與口譯人員連線。 Igbo (Igbo) Nrụbama: Ọkwa a nwere ozi gbasara mkpuchi nchekwa onwe gị. Ọ nwere ike ịnwe ụbọchị ndị dị mkpa, ị nwere ike ịme ihe tupu ụfọdụ ụbọchị njedebe. Ị nwere ikike ịnweta ozi na enyemaka a n’asụsụ gị na akwụghị ụgwọ ọ bụla. Ndị otu kwesịrị ịkpọ akara ekwentị dị n’azụ nke kaadị njirimara ha. Ndị ọzọ niile nwere ike ịkpọ 855-258-6518 wee chere ụbụbọ ahụ ruo mgbe amanyere ịpị 0. Mgbe onye nnọchite anya zara, kwuo asụsụ ị chọrọ, a ga-ejikọ gị na onye ọkọwa okwu. Deutsch (German) Achtung: Diese Mitteilung enthält Informationen über Ihren Versicherungsschutz. Sie kann wichtige Termine beinhalten, und Sie müssen gegebenenfalls innerhalb bestimmter Fristen reagieren. Sie haben das Recht, diese Informationen und weitere Unterstützung kostenlos in Ihrer Sprache zu erhalten. Als Mitglied verwenden Sie bitte die auf der Rückseite Ihrer Karte angegebene Telefonnummer. Alle anderen Personen rufen bitte die Nummer 855-258-6518 an und warten auf die Aufforderung, die Taste 0 zu drücken. Geben Sie dem Mitarbeiter die gewünschte Sprache an, damit er Sie mit einem Dolmetscher verbinden kann. Français (French) Attention: cet avis contient des informations sur votre couverture d'assurance. Des dates importantes peuvent y figurer et il se peut que vous deviez entreprendre des démarches avant certaines échéances. Vous avez le droit d'obtenir gratuitement ces informations et de l'aide dans votre langue. Les membres doivent appeler le numéro de téléphone figurant à l'arrière de leur carte d'identification. Tous les autres peuvent appeler le 855-258-6518 et, après avoir écouté le message, appuyer sur le 0 lorsqu'ils seront invités à le faire. Lorsqu'un(e) employé(e) répondra, indiquez la langue que vous souhaitez et vous serez mis(e) en relation avec un interprète. 한국어(Korean) 주의: 이 통지서에는 보험 커버리지에 대한 정보가 포함되어 있습니다. 주요 날짜 및 조치를 취해야 하는 특정 기한이 포함될 수 있습니다. 귀하에게는 사용 언어로 해당 정보와 지원을 받을 권리가 있습니다. 회원이신 경우 ID 카드의 뒷면에 있는 전화번호로 연락해 주십시오. 회원이 아니신 경우 855-258-6518 번으로 전화하여 0을 누르라는 메시지가 들릴 때까지 기다리십시오. 연결된 상담원에게 필요한 언어를 말씀하시면 통역 서비스에 연결해 드립니다.
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