CAREFIRST ABRIDGED EXCHANGE FORMULARY 2020
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CareFirst Abridged Exchange
Formulary
2020
PLEASE READ: This document contains information about the drugs we
cover in this plan. This formulary is for:
■ Individuals or families purchasing their own plan, and
■ embers of an employer group with less than 51 employees
M
purchasing a plan
This abridged drug list is a list of drugs used to treat common conditions
only. It does not include all drugs covered by your benefit plan. For a
complete and updated list, visit carefirst.com/rx, click on Drug Search and
select the Exchange Formulary to view the full list of covered drugs. Note
that the abridged formulary listed below is not an all-inclusive list and is
subject to change.
For more recent information or other questions, please
contact CareFirst Pharmacy Services at 800-241-3371 or visit
carefirst.com/rx.
Last updated 04/01/2020Introduction
A formulary is a list of covered prescription drugs. Your doctor may need to provide
drugs. Our drug list is reviewed and approved by some of your medical history or laboratory
an independent national committee comprised tests to determine if these medications are
of physicians, pharmacists and other health appropriate. Without prior authorization from
care professionals, known as the Pharmacy and CareFirst, your drugs may not be covered.
Therapeutics Committee. This committee makes ■ Step Therapy requires that you try lower-
sure the drugs on the formulary are safe and cost, equally effective drugs that treat the
clinically effective. same medical condition before trying a
Within the formulary, prescription drugs are higher-cost alternative. Your doctor will need
divided into tiers as described below. Depending to provide information to CareFirst about
on your plan, prescription drugs fall into one of five your experience with these alternatives prior
drug tiers which determines the price you pay. to dispensing a more expensive drug.
■ Quantity Limits have been placed on the
Using Your Formulary use of selected drugs for quality or safety
The first column of the formulary lists drugs by reasons. Limits may be placed on the amount
name. If the drugs are shown in lowercase italics, of the drug covered per prescription or for a
they are generic drugs. If the drugs are bold and defined period of time. For example, quantity
capitalized, they are BRAND-NAME DRUGS. limits apply to specialty drugs. Specialty
drugs are medications that may be used to
You may search the formulary for a drug by
treat complex and/or rare health conditions
pressing “CTRL” and “F” at the same time to
and require special handling, administration
prompt a search.
or monitoring. Specialty drugs are typically
The second column indicates the drug tier for covered for a one-month supply.
a covered drug.
Members can view specific cost-share (copay
The third column indicates any prescription or coinsurance) information and prescription
guidelines a drug requires such as prior authorization guidelines by logging in to My Account at
(PA), step therapy (ST) or quantity limits (QL). carefirst.com/myaccount and clicking on Tools
and Drug Pricing Tool or by reviewing their annual
■■ Prior Authorization from CareFirst is required
summary of benefits.
before you fill prescriptions for certain
Tier 0: $0 Drugs ■■ Preventive drugs (e.g. statins, aspirin, folic acid, fluoride, iron supplements, smoking cessation
products and FDA-approved contraceptives for women) are available at a zero-dollar cost share
if prescribed under certain medical criteria by your doctor.
■■ Oral chemotherapy drugs and diabetic supplies (e.g. insulin syringes, pen needles, lancets, test
strips, and alcohol swabs) are also available at a zero-dollar cost share.
Tier 1: Generic Drugs $ ■■ Generic drugs are the same as brand-name drugs in dosage form, safety, strength, route of
administration, quality, performance characteristics and intended use.
■■ Generic drugs generally cost less than brand-name drugs.
Tier 2: Preferred Brand ■■ Preferred brand drugs are brand-name drugs that may not be available in generic form, but are chosen for
Drugs $$ their cost effectiveness compared to alternatives. Your cost-share will be more than generics but less than
non-preferred brand drugs. If a generic drug becomes available, the preferred brand drug may be moved to
the non-preferred brand category.
Tier 3: Non-preferred ■■ Non-preferred brand drugs often have a generic or preferred brand drug option where your
Brand Drugs $$$ cost-share will be lower.
Tier 4: Preferred ■■ Preferred specialty drugs are medications that may be used to treat complex and/or rare health conditions.
Specialty Drugs $$$$ These drugs may have a lower cost-share than non-preferred specialty drugs.
Tier 5: Non-Preferred ■■ Non-preferred specialty drugs often have a specialty drug option where your cost-share will be lower.
Specialty Drugs $$$$CareFirst Exchange Formulary - 5-Tier eff 04/01/2020
Drug Name Drug Tier Requirements/Limits
ANALGESICS
COX-2 INHIBITORS
celecoxib 1
GOUT
allopurinol 1
colchicine 1
colchicine w/ probenecid 1
febuxostat 1 ST; PA**
probenecid 1
NON-OPIOID ANALGESICS§
butalbital-acetaminophen-caffeine CAPS 1 QL (48 caps / 25 days)
butalbital-acetaminophen-caffeine TABS 1 QL (48 tabs / 25 days)
butalbital-aspirin-caffeine 1 QL (48 caps / 25 days)
NSAIDS, COMBINATIONS§
diclofenac w/ misoprostol 1
NSAIDS§
diclofenac potassium 1
diclofenac sodium 1
etodolac 1
fenoprofen calcium 1
flurbiprofen 1
ibuprofen 1
ketoprofen 1
ketorolac tromethamine 1 QL (20 tabs / 25 days)
meclofenamate sodium 1
mefenamic acid 1
meloxicam 1
nabumetone 1
naproxen 1
oxaprozin 1
piroxicam 1
sulindac 1
tolmetin sodium 1
OPIOID AGONIST/ANTAGONIST§
buprenorphine hcl-naloxone hcl dihydrate 0 QL (90 tabs / 25 days);
$0 copay
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 1
counter M - Covered Under the Medical Benefit Only PA** - PA Applies if Step is Not
Met
Note: Coverage of prescription drugs and supplies listed on this formulary (drug list) is
subject to your plan and benefits. For the most accurate information on your drug cost and
pricing, please log in to My Account (www.carefirst.com/myaccount) and click on Drug &
Pharmacy Resources under Quick Links.Drug Name Drug Tier Requirements/Limits
buprenorphine hcl-naloxone hcl sl film 1 QL (90 units / 25 days)
2-0.5 mg (base equiv)
buprenorphine hcl-naloxone hcl sl film 4-1 1 QL (90 units / 25 days)
mg (base equiv)
buprenorphine hcl-naloxone hcl sl film 8-2 1 QL (90 units / 25 days)
mg (base equiv)
buprenorphine hcl-naloxone hcl sl film 12-3 1 QL (60 units / 25 days)
mg (base equiv)
ZUBSOLV SUB 0.7-0.18 2 QL (90 units / 25 days)
ZUBSOLV SUB 1.4-0.36 2 QL (90 units / 25 days)
ZUBSOLV SUB 2.9-0.71 2 QL (90 units / 25 days)
ZUBSOLV SUB 5.7-1.4 2 QL (90 units / 25 days)
ZUBSOLV SUB 8.6-2.1 2 QL (60 units / 25 days)
ZUBSOLV SUB 11.4-2.9 2 QL (30 units / 25 days)
OPIOID ANALGESICS§
acetaminophen w/ codeine 1 QL (2700 ml / 25 days),
ST; Subject to initial
3-day limit for 19 and
younger; 7-day initial
limit for all other ages
acetaminophen w/ codeine tab 300-15 mg 1 QL (400 tabs / 25 days),
ST; Subject to initial
3-day limit for 19 and
younger; 7-day initial
limit for all other ages
acetaminophen w/ codeine tab 300-30 mg 1 QL (360 tabs / 25 days),
ST; Subject to initial
3-day limit for 19 and
younger; 7-day initial
limit for all other ages
acetaminophen w/ codeine tab 300-60 mg 1 QL (180 tabs / 25 days),
ST; Subject to initial
3-day limit for 19 and
younger; 7-day initial
limit for all other ages
butorphanol tartrate 1 QL (2 bottles / 25 days)
codeine sulfate 30mg 1 QL (42 tabs / 25 days),
ST; Subject to initial
3-day limit for 19 and
younger; 7-day initial
limit for all other ages
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 2
counter M - Covered Under the Medical Benefit Only PA** - PA Applies if Step is Not
Met
Note: Coverage of prescription drugs and supplies listed on this formulary (drug list) is
subject to your plan and benefits. For the most accurate information on your drug cost and
pricing, please log in to My Account (www.carefirst.com/myaccount) and click on Drug &
Pharmacy Resources under Quick Links.Drug Name Drug Tier Requirements/Limits
CODEINE SULFATE 60mg 1 QL (42 tabs / 25 days),
ST; Subject to initial
3-day limit for 19 and
younger; 7-day initial
limit for all other ages
EMBEDA CAP 20-0.8MG 2 QL (60 caps / 25 days),
ST
EMBEDA CAP 30-1.2MG 2 QL (60 caps / 25 days),
ST
EMBEDA CAP 50-2MG 2 QL (30 caps / 25 days),
ST
EMBEDA CAP 60-2.4MG 2 QL (30 caps / 25 days),
ST
EMBEDA CAP 80-3.2MG 2 QL (30 caps / 25 days),
ST
EMBEDA CAP 100-4MG 2 PA, ST; High Strength
Requires PA
endocet 1 QL (180 tabs / 25 days),
ST; Subject to initial
3-day limit for 19 and
younger; 7-day initial
limit for all other ages
endocet 1 QL (240 tabs / 25 days),
ST; Subject to initial
3-day limit for 19 and
younger; 7-day initial
limit for all other ages
endocet 1 QL (360 tabs / 25 days),
ST; Subject to initial
3-day limit for 19 and
younger; 7-day initial
limit for all other ages
fentanyl 12mcg/hr, 25mcg/hr 1 QL (10 patches / 25
days), ST
fentanyl 50mcg/hr, 75mcg/hr, 100mcg/hr 1 PA, ST; High Strength
Requires PA
fentanyl citrate 1 QL (120 lozenges / 25
days), PA
hydrocodone-acetaminophen 1 QL (2700 ml / 25 days),
ST; Subject to initial
3-day limit for 19 and
younger; 7-day initial
limit for all other ages
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 3
counter M - Covered Under the Medical Benefit Only PA** - PA Applies if Step is Not
Met
Note: Coverage of prescription drugs and supplies listed on this formulary (drug list) is
subject to your plan and benefits. For the most accurate information on your drug cost and
pricing, please log in to My Account (www.carefirst.com/myaccount) and click on Drug &
Pharmacy Resources under Quick Links.Drug Name Drug Tier Requirements/Limits
hydrocodone-acetaminophen tab 5-325 mg 1 QL (240 tabs / 25 days),
ST; Subject to initial
3-day limit for 19 and
younger; 7-day initial
limit for all other ages
hydrocodone-acetaminophen tab 7.5-325 1 QL (180 tabs / 25 days),
mg ST; Subject to initial
3-day limit for 19 and
younger; 7-day initial
limit for all other ages
hydrocodone-acetaminophen tab 10-325 1 QL (180 tabs / 25 days),
mg ST; Subject to initial
3-day limit for 19 and
younger; 7-day initial
limit for all other ages
hydrocodone-ibuprofen 1 QL (50 tabs / 25 days),
ST; Subject to initial
3-day limit for 19 and
younger; 7-day initial
limit for all other ages
hydromorphone hcl T24A 8mg, 12mg, 1 QL (30 tabs / 25 days),
16mg ST
hydromorphone hcl T24A 32mg 1 PA, ST; High Strength
Requires PA
hydromorphone hcl TABS 2mg 1 QL (180 tabs / 25 days),
ST; Subject to initial
3-day limit for 19 and
younger; 7-day initial
limit for all other ages
hydromorphone hcl TABS 4mg 1 QL (150 tabs / 25 days),
ST; Subject to initial
3-day limit for 19 and
younger; 7-day initial
limit for all other ages
hydromorphone hcl TABS 8mg 1 QL (60 tabs / 25 days),
ST; Subject to initial
3-day limit for 19 and
younger; 7-day initial
limit for all other ages
methadone hcl CONC 1 QL (30 ml / 25 days);
(indicated for opioid
addiction)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 4
counter M - Covered Under the Medical Benefit Only PA** - PA Applies if Step is Not
Met
Note: Coverage of prescription drugs and supplies listed on this formulary (drug list) is
subject to your plan and benefits. For the most accurate information on your drug cost and
pricing, please log in to My Account (www.carefirst.com/myaccount) and click on Drug &
Pharmacy Resources under Quick Links.Drug Name Drug Tier Requirements/Limits
methadone hcl SOLN 5mg/5ml 1 QL (450 ml / 25 days),
ST
methadone hcl SOLN 10mg/5ml 1 QL (300 mL / 25 days),
ST
methadone hcl SOLN 10mg/ml M M
methadone hcl TABS 5mg 1 QL (90 tabs / 25 days),
ST
methadone hcl TABS 10mg 1 QL (60 tabs / 25 days),
ST
methadone hcl TBSO 1 QL (9 tabs / 25 days)
methadone hcl intensol 1 QL (60 mL / 25 days),
ST; (generic of
Methadone Intensol,
indicated for pain)
methadose 1 QL (9 tabs / 25 days)
morphine sulfate CP24 10mg, 20mg, 1 QL (60 caps / 25 days),
30mg ST
morphine sulfate CP24 50mg, 60mg, 1 QL (30 caps / 25 days),
80mg ST
morphine sulfate CP24 100mg 1 PA, ST; High Strength
Requires PA
morphine sulfate SOLN 10mg/5ml 1 QL (900 ml / 25 days),
ST; Subject to initial
3-day limit for 19 and
younger; 7-day initial
limit for all other ages
morphine sulfate SOLN 20mg/5ml 1 QL (675 mL / 25 days),
ST; Subject to initial
3-day limit for 19 and
younger; 7-day initial
limit for all other ages
morphine sulfate SOLN 100mg/5ml 1 QL (135 mL / 25 days),
ST; Subject to initial
3-day limit for 19 and
younger; 7-day initial
limit for all other ages
morphine sulfate SUPP 5mg, 10mg 1 QL (180 suppositories /
25 days), ST; Subject to
initial 3-day limit for 19
and younger; 7-day
initial limit for all other
ages
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 5
counter M - Covered Under the Medical Benefit Only PA** - PA Applies if Step is Not
Met
Note: Coverage of prescription drugs and supplies listed on this formulary (drug list) is
subject to your plan and benefits. For the most accurate information on your drug cost and
pricing, please log in to My Account (www.carefirst.com/myaccount) and click on Drug &
Pharmacy Resources under Quick Links.Drug Name Drug Tier Requirements/Limits
morphine sulfate SUPP 20mg 1 QL (120 supp / 25
days), ST; Subject to
initial 3-day limit for 19
and younger; 7-day
initial limit for all other
ages
morphine sulfate SUPP 30mg 1 QL (90 supp / 25 days),
ST; Subject to initial
3-day limit for 19 and
younger; 7-day initial
limit for all other ages
morphine sulfate TABS 15mg 1 QL (180 tabs / 25 days),
ST; Subject to initial
3-day limit for 19 and
younger; 7-day initial
limit for all other ages
morphine sulfate TABS 30mg 1 QL (90 tabs / 25 days),
ST; Subject to initial
3-day limit for 19 and
younger; 7-day initial
limit for all other ages
morphine sulfate TBCR 15mg, 30mg 1 QL (90 tabs / 25 days),
ST
morphine sulfate TBCR 60mg, 100mg, 1 PA, ST; High Strength
200mg Requires PA
morphine sulfate beads 30mg, 45mg, 1 QL (30 caps / 25 days),
60mg, 75mg, 90mg ST
morphine sulfate beads 120mg 1 PA, ST; High Strength
Requires PA
NUCYNTA 50mg 2 QL (120 tabs / 25 days),
ST; Subject to initial
3-day limit for 19 and
younger; 7-day initial
limit for all other ages
NUCYNTA 75mg 2 QL (90 tabs / 25 days),
ST; Subject to initial
3-day limit for 19 and
younger; 7-day initial
limit for all other ages
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 6
counter M - Covered Under the Medical Benefit Only PA** - PA Applies if Step is Not
Met
Note: Coverage of prescription drugs and supplies listed on this formulary (drug list) is
subject to your plan and benefits. For the most accurate information on your drug cost and
pricing, please log in to My Account (www.carefirst.com/myaccount) and click on Drug &
Pharmacy Resources under Quick Links.Drug Name Drug Tier Requirements/Limits
NUCYNTA 100mg 2 QL (60 tabs / 25 days),
ST; Subject to initial
3-day limit for 19 and
younger; 7-day initial
limit for all other ages
oxycodone hcl CAPS 1 QL (180 caps / 25
days), ST; Subject to
initial 3-day limit for 19
and younger; 7-day
initial limit for all other
ages
oxycodone hcl CONC 1 QL (90 mL / 25 days),
ST; Subject to initial
3-day limit for 19 and
younger; 7-day initial
limit for all other ages
oxycodone hcl SOLN 1 QL (900 ml / 25 days),
ST; Subject to initial
3-day limit for 19 and
younger; 7-day initial
limit for all other ages
oxycodone hcl T12A 10mg, 15mg, 20mg, 1 QL (60 tabs / 25 days),
30mg ST
oxycodone hcl T12A 40mg, 60mg, 80mg 1 PA, ST; High Strength
Requires PA
oxycodone hcl TABS 5mg, 10mg 1 QL (180 tabs / 25 days),
ST; Subject to initial
3-day limit for 19 and
younger; 7-day initial
limit for all other ages
oxycodone hcl TABS 15mg 1 QL (120 tabs / 25 days),
ST; Subject to initial
3-day limit for 19 and
younger; 7-day initial
limit for all other ages
oxycodone hcl TABS 20mg 1 QL (90 tabs / 25 days),
ST; Subject to initial
3-day limit for 19 and
younger; 7-day initial
limit for all other ages
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 7
counter M - Covered Under the Medical Benefit Only PA** - PA Applies if Step is Not
Met
Note: Coverage of prescription drugs and supplies listed on this formulary (drug list) is
subject to your plan and benefits. For the most accurate information on your drug cost and
pricing, please log in to My Account (www.carefirst.com/myaccount) and click on Drug &
Pharmacy Resources under Quick Links.Drug Name Drug Tier Requirements/Limits
oxycodone hcl TABS 30mg 1 QL (60 tabs / 25 days),
ST; Subject to initial
3-day limit for 19 and
younger; 7-day initial
limit for all other ages
oxycodone w/ acetaminophen 1 QL (1800 ml / 25 days),
ST; Subject to initial
3-day limit for 19 and
younger; 7-day initial
limit for all other ages
oxycodone w/ acetaminophen tab 2.5-325 1 QL (360 tabs / 25 days),
mg ST; Subject to initial
3-day limit for 19 and
younger; 7-day initial
limit for all other ages
oxycodone w/ acetaminophen tab 5-325 1 QL (360 tabs / 25 days),
mg ST; Subject to initial
3-day limit for 19 and
younger; 7-day initial
limit for all other ages
oxycodone w/ acetaminophen tab 7.5-325 1 QL (240 tabs / 25 days),
mg ST; Subject to initial
3-day limit for 19 and
younger; 7-day initial
limit for all other ages
oxycodone w/ acetaminophen tab 10-325 1 QL (180 tabs / 25 days),
mg ST; Subject to initial
3-day limit for 19 and
younger; 7-day initial
limit for all other ages
oxycodone-aspirin 1 QL (360 tabs / 25 days),
ST; Subject to initial
3-day limit for 19 and
younger; 7-day initial
limit for all other ages
oxycodone-ibuprofen 1 QL (28 tabs / 25 days),
ST; Subject to initial
3-day limit for 19 and
younger; 7-day initial
limit for all other ages
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 8
counter M - Covered Under the Medical Benefit Only PA** - PA Applies if Step is Not
Met
Note: Coverage of prescription drugs and supplies listed on this formulary (drug list) is
subject to your plan and benefits. For the most accurate information on your drug cost and
pricing, please log in to My Account (www.carefirst.com/myaccount) and click on Drug &
Pharmacy Resources under Quick Links.Drug Name Drug Tier Requirements/Limits
oxymorphone hcl TABS 5mg 1 QL (180 tabs / 25 days),
ST; Subject to initial
3-day limit for 19 and
younger; 7-day initial
limit for all other ages
oxymorphone hcl TABS 10mg 1 QL (90 tabs / 25 days),
ST; Subject to initial
3-day limit for 19 and
younger; 7-day initial
limit for all other ages
oxymorphone hcl TB12 5mg, 7.5mg, 1 QL (60 tabs / 25 days),
10mg, 15mg ST
oxymorphone hcl TB12 20mg, 30mg, 1 PA, ST; High Strength
40mg Requires PA
tramadol hcl TABS 50mg 1 QL (180 tabs / 25 days),
ST; Subject to initial
3-day limit for 19 and
younger; 7-day initial
limit for all other ages
tramadol hcl TABS 100mg 1 QL (90 tabs / 25 days),
ST; Subject to initial
3-day limit for 19 and
younger; 7-day initial
limit for all other ages
tramadol hcl TB24 100mg 1 QL (30 tabs / 25 days),
ST
tramadol hcl TB24 200mg, 300mg 1 PA, ST; High Strength
Requires PA
tramadol-acetaminophen 1 QL (40 tabs / 25 days),
ST; Subject to initial
3-day limit for 19 and
younger; 7-day initial
limit for all other ages
XTAMPZA ER 9mg, 13.5mg, 18mg, 27mg 2 QL (60 caps / 25 days),
ST
XTAMPZA ER 36mg 2 PA, ST; High Strength
Requires Prior Auth
OPIOID PARTIAL AGONISTS§
BELBUCA 75mcg, 150mcg, 300mcg, 2 QL (60 films / 25 days),
450mcg ST
BELBUCA 600mcg, 750mcg, 900mcg 2 PA, ST; High Strength
Requires Prior Auth
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 9
counter M - Covered Under the Medical Benefit Only PA** - PA Applies if Step is Not
Met
Note: Coverage of prescription drugs and supplies listed on this formulary (drug list) is
subject to your plan and benefits. For the most accurate information on your drug cost and
pricing, please log in to My Account (www.carefirst.com/myaccount) and click on Drug &
Pharmacy Resources under Quick Links.Drug Name Drug Tier Requirements/Limits
buprenorphine hcl 0 QL (90 tabs / 25 days);
$0 copay; Must obtain
approval after the first
30 day supply
SALICYLATES
diflunisal 1
ANTI-INFECTIVES
ANTI-BACTERIALS - MISCELLANEOUS
neomycin sulfate 1
paromomycin sulfate 1
tinidazole 1
ANTI-INFECTIVES - MISCELLANEOUS
atovaquone 1
clindamycin hcl 1
clindamycin palmitate hydrochloride 1
dapsone 1
ertapenem sodium M M
ivermectin 1
linezolid 1
methenamine hippurate 1
metronidazole 1
nitrofurantoin 1 PA; High Risk
Medications require PA
for members age 70 and
older
nitrofurantoin macrocrystal 1 PA; High Risk
Medications require PA
for members age 70 and
older
nitrofurantoin monohyd macro 1 PA; High Risk
Medications require PA
for members age 70 and
older
pentamidine isethionate 300mg 1
pentamidine isethionate 300mg M M
praziquantel 1 QL (24 tabs / 365 days)
PRIMSOL 2
sulfamethoxazole-trimethoprim 1
trimethoprim 1
vancomycin hcl 1 QL (80 caps / 10 days)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 10
counter M - Covered Under the Medical Benefit Only PA** - PA Applies if Step is Not
Met
Note: Coverage of prescription drugs and supplies listed on this formulary (drug list) is
subject to your plan and benefits. For the most accurate information on your drug cost and
pricing, please log in to My Account (www.carefirst.com/myaccount) and click on Drug &
Pharmacy Resources under Quick Links.Drug Name Drug Tier Requirements/Limits
XIFAXAN 200mg 2 QL (9 tabs / 25 days)
XIFAXAN 550mg 2 PA
ANTIFUNGALS
BIO-STATIN CAPS 2
bio-statin POWD 1
fluconazole 1
griseofulvin microsize 1
griseofulvin ultramicrosize 1
itraconazole 1 PA
nystatin 1
posaconazole 1 PA
terbinafine hcl 1 PA
ANTIMALARIALS
atovaquone-proguanil hcl 1
chloroquine phosphate 1
mefloquine hcl 1
primaquine phosphate 1
quinine sulfate 1
ANTIRETROVIRAL AGENTS
abacavir sulfate SOLN 1 QL (900 mL / 30 days)
abacavir sulfate TABS 1 QL (60 tabs / 30 days)
atazanavir sulfate 150mg, 300mg 1 QL (30 caps / 30 days)
atazanavir sulfate 200mg 1 QL (60 caps / 30 days)
didanosine 1 QL (30 caps / 30 days)
efavirenz CAPS 1 QL (90 caps / 30 days)
efavirenz TABS 1 QL (30 tabs / 30 days)
fosamprenavir calcium 1 QL (120 tabs / 30 days)
ISENTRESS CHEW 2 QL (180 tabs / 30 days)
ISENTRESS PACK 2 QL (60 packets / 30
days)
ISENTRESS TABS 2 QL (120 tabs / 30 days)
ISENTRESS HD 2 QL (60 tabs / 30 days)
lamivudine SOLN 1 QL (900 ml / 30 days)
lamivudine TABS 150mg 1 QL (60 tabs / 30 days)
lamivudine TABS 300mg 1 QL (30 tabs / 30 days)
nevirapine SUSP 1 QL (1200 mL / 30 days)
nevirapine TABS 1 QL (60 tabs / 30 days)
nevirapine TB24 100mg 1 QL (90 tabs / 30 days)
nevirapine TB24 400mg 1 QL (30 tabs / 30 days)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 11
counter M - Covered Under the Medical Benefit Only PA** - PA Applies if Step is Not
Met
Note: Coverage of prescription drugs and supplies listed on this formulary (drug list) is
subject to your plan and benefits. For the most accurate information on your drug cost and
pricing, please log in to My Account (www.carefirst.com/myaccount) and click on Drug &
Pharmacy Resources under Quick Links.Drug Name Drug Tier Requirements/Limits
NORVIR PACK 2 QL (360 packets / 30
days)
NORVIR SOLN 2 QL (480 mL / 30 days)
PREZISTA SUSP 2 QL (400 ml / 30 days)
PREZISTA TABS 75mg 2 QL (300 tabs / 30 days)
PREZISTA TABS 150mg 2 QL (180 tabs / 30 days)
PREZISTA TABS 600mg 2 QL (60 tabs / 30 days)
PREZISTA TABS 800mg 2 QL (30 tabs / 30 days)
REYATAZ 2 QL (180 packets / 30
days)
ritonavir 1 QL (360 tabs / 30 days)
stavudine 1 QL (60 caps / 30 days)
tenofovir disoproxil fumarate 1 QL (30 tabs / 30 days)
TIVICAY 2 QL (60 tabs / 30 days)
VIDEX EC 2 QL (30 caps / 30 days)
VIDEX PEDIATRIC 2 QL (1200 ml / 30 days)
ZERIT 2 QL (2400 ml / 30 days)
zidovudine CAPS 1 QL (180 caps / 30 days)
zidovudine SYRP 1 QL (1800 ml / 30 days)
zidovudine TABS 1 QL (60 tabs / 30 days)
ANTIRETROVIRAL COMBINATION AGENTS
abacavir sulfate-lamivudine 1 QL (30 tabs / 30 days)
abacavir sulfate-lamivudine-zidovudine 1 QL (60 tabs / 30 days)
BIKTARVY 2 QL (30 tabs / 30 days)
CIMDUO 2 QL (30 tabs / 30 days)
DESCOVY 2 QL (30 tabs / 30 days)
EVOTAZ 2 QL (30 tabs / 30 days)
GENVOYA 2 QL (30 tabs / 30 days)
KALETRA TAB 100-25MG 2 QL (240 tabs / 30 days)
KALETRA TAB 200-50MG 2 QL (120 tabs / 30 days)
lamivudine-zidovudine 1 QL (60 tabs / 30 days)
lopinavir-ritonavir 1 QL (390 mL / 30 days)
ODEFSEY 2 QL (30 tabs / 30 days)
PREZCOBIX 2 QL (30 tabs / 30 days)
SYMFI 2 QL (30 tabs / 30 days)
SYMFI LO 2 QL (30 tabs / 30 days)
TEMIXYS 2 QL (30 tabs / 30 days)
TRIUMEQ 2 QL (30 tabs / 30 days)
TRUVADA TAB 100-150 2 QL (30 tabs / 30 days)
TRUVADA TAB 133-200 2 QL (30 tabs / 30 days)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 12
counter M - Covered Under the Medical Benefit Only PA** - PA Applies if Step is Not
Met
Note: Coverage of prescription drugs and supplies listed on this formulary (drug list) is
subject to your plan and benefits. For the most accurate information on your drug cost and
pricing, please log in to My Account (www.carefirst.com/myaccount) and click on Drug &
Pharmacy Resources under Quick Links.Drug Name Drug Tier Requirements/Limits
TRUVADA TAB 167-250 2 QL (30 tabs / 30 days)
TRUVADA TAB 200-300 2 QL (30 tabs / 30 days),
ST; PA**; coverage for
pre and post-exposure
prophylaxis only
ANTITUBERCULAR AGENTS
cycloserine 1
ethambutol hcl 1
isoniazid 1
pyrazinamide 1
rifabutin 1
rifampin 1
ANTIVIRALS§
acyclovir 1
EPIVIR HBV 2
famciclovir 1
lamivudine (hbv) 1
oseltamivir phosphate CAPS 30mg 1 QL (40 caps / 90 days)
oseltamivir phosphate CAPS 45mg, 75mg 1 QL (20 caps / 90 days)
oseltamivir phosphate SUSR 1 QL (360 mL / 90 days)
RELENZA DISKHALER 2 QL (2 inhalers / 90
days)
rimantadine hydrochloride 1
valacyclovir hcl 1
CEPHALOSPORINS
cefaclor 1
cefadroxil 1
cefdinir 1
cefixime 1
cefpodoxime proxetil 1
cefprozil 1
ceftibuten 1
CEFTIN 2
cefuroxime axetil 1
cephalexin 1
SUPRAX 2
ERYTHROMYCINS/MACROLIDES
azithromycin 1
clarithromycin 1
DIFICID 2 PA
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 13
counter M - Covered Under the Medical Benefit Only PA** - PA Applies if Step is Not
Met
Note: Coverage of prescription drugs and supplies listed on this formulary (drug list) is
subject to your plan and benefits. For the most accurate information on your drug cost and
pricing, please log in to My Account (www.carefirst.com/myaccount) and click on Drug &
Pharmacy Resources under Quick Links.Drug Name Drug Tier Requirements/Limits
e.e.s. 400 1
ery-tab 1
erythrocin stearate 1
erythromycin base 1
erythromycin ethylsuccinate 1
FLUOROQUINOLONES
ciprofloxacin 1
ciprofloxacin hcl 1
ciprofloxacin-ciprofloxacin hcl 1
levofloxacin 1
moxifloxacin hcl 1
moxifloxacin hcl in sodium chloride M M
ofloxacin 1
HEPATITIS C
EPCLUSA 4 QL (28 tabs / 28 days),
PA
HARVONI 4 QL (28 tabs / 28 days),
PA
REBETOL 4 PA
ribasphere CAPS 1 PA
ribasphere TABS 200mg, 600mg 1 PA
RIBASPHERE TABS 400mg 1 PA
ribavirin (hepatitis c) 1 PA
VOSEVI 4 QL (28 tabs / 28 days),
PA
PENICILLINS
amoxicillin 1
amoxicillin & pot clavulanate 1
ampicillin 1
AUGMENTIN 2
dicloxacillin sodium 1
penicillin v potassium 1
TETRACYCLINES
avidoxy 1
demeclocycline hcl 1
doxycycline (monohydrate) 1
doxycycline hyclate 1
minocycline hcl 1
morgidox 1x100mg 1
tetracycline hcl 1
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 14
counter M - Covered Under the Medical Benefit Only PA** - PA Applies if Step is Not
Met
Note: Coverage of prescription drugs and supplies listed on this formulary (drug list) is
subject to your plan and benefits. For the most accurate information on your drug cost and
pricing, please log in to My Account (www.carefirst.com/myaccount) and click on Drug &
Pharmacy Resources under Quick Links.Drug Name Drug Tier Requirements/Limits
ANTINEOPLASTIC AGENTS
ALKYLATING AGENTS
carmustine M M
cyclophosphamide 0
melphalan 0
ANTIMETABOLITES
mercaptopurine 0
ANTIMITOTIC, TAXOIDS
docetaxel M M
BIOLOGIC RESPONSE MODIFIERS
KISQALI 4 QL (63 tabs / 28 days),
PA
LYNPARZA CAPS 0 QL (480 caps / 30
days), PA
LYNPARZA TABS 100mg 0 QL (180 tabs / 30 days),
PA
LYNPARZA TABS 150mg 0 QL (120 tabs / 30 days),
PA
ZEJULA 0 QL (90 caps / 30 days),
PA
HORMONAL ANTINEOPLASTIC AGENTS
abiraterone acetate 0 QL (120 tabs / 30 days),
PA
anastrozole 0
bicalutamide 0
exemestane 0
flutamide 0
fulvestrant M M
letrozole 0
megestrol acetate 0
megestrol acetate (appetite) 0
nilutamide 0
NUBEQA 0 QL (120 tabs / 30 days),
PA
tamoxifen citrate 0 $0 copay for women
ages 35 and older for
the primary prevention
of breast cancer
toremifene citrate 0
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 15
counter M - Covered Under the Medical Benefit Only PA** - PA Applies if Step is Not
Met
Note: Coverage of prescription drugs and supplies listed on this formulary (drug list) is
subject to your plan and benefits. For the most accurate information on your drug cost and
pricing, please log in to My Account (www.carefirst.com/myaccount) and click on Drug &
Pharmacy Resources under Quick Links.Drug Name Drug Tier Requirements/Limits
KINASE INHIBITORS
ALECENSA 0 QL (240 caps / 30
days), PA
imatinib mesylate 100mg 0 QL (90 tabs / 30 days),
PA
imatinib mesylate 400mg 0 QL (60 tabs / 30 days),
PA
MISCELLANEOUS
arsenic trioxide M M
hydroxyurea 0
ODOMZO 0 QL (30 caps / 30 days),
PA
tretinoin (chemotherapy) 0
PROTECTIVE AGENTS
leucovorin calcium 0
TOPOISOMERASE INHIBITORS
etoposide 0
CARDIOVASCULAR
ACE INHIBITOR COMBINATIONS
amlodipine besylate-benazepril hcl 1
benazepril & hydrochlorothiazide 1
captopril & hydrochlorothiazide 1
enalapril maleate & hydrochlorothiazide 1
fosinopril sodium & hydrochlorothiazide 1
lisinopril & hydrochlorothiazide 1
moexipril-hydrochlorothiazide 1
quinapril-hydrochlorothiazide 1
trandolapril-verapamil hcl 1
ACE INHIBITORS
benazepril hcl 1
captopril 1
enalapril maleate 1
fosinopril sodium 1
lisinopril 1
moexipril hcl 1
perindopril erbumine 1
quinapril hcl 1
ramipril 1
trandolapril 1
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 16
counter M - Covered Under the Medical Benefit Only PA** - PA Applies if Step is Not
Met
Note: Coverage of prescription drugs and supplies listed on this formulary (drug list) is
subject to your plan and benefits. For the most accurate information on your drug cost and
pricing, please log in to My Account (www.carefirst.com/myaccount) and click on Drug &
Pharmacy Resources under Quick Links.Drug Name Drug Tier Requirements/Limits
ALDOSTERONE RECEPTOR ANTAGONISTS
eplerenone 1
ALPHA BLOCKERS
doxazosin mesylate 1
prazosin hcl 1
terazosin hcl 1
ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS
amlodipine besylate-olmesartan medoxomil 1
amlodipine besylate-valsartan 1
amlodipine-valsartan-hydrochlorothiazide 1
candesartan cilexetil-hydrochlorothiazide 1
irbesartan-hydrochlorothiazide 1
losartan potassium & hydrochlorothiazide 1
olmesartan 1
medoxomil-amlodipine-hydrochlorothiazide
olmesartan medoxomil-hydrochlorothiazide 1
telmisartan-amlodipine 1
telmisartan-hydrochlorothiazide 1
valsartan-hydrochlorothiazide 1
ANGIOTENSIN II RECEPTOR ANTAGONISTS
candesartan cilexetil 1
eprosartan mesylate 1
irbesartan 1
losartan potassium 1
olmesartan medoxomil 1
telmisartan 1
valsartan 1
ANTIARRHYTHMICS
amiodarone hcl 1
disopyramide phosphate 1
dofetilide 1 PA
flecainide acetate 1
mexiletine hcl 1
NORPACE CR 2
pacerone 1
propafenone hcl 1
sorine 1
sotalol hcl 1
sotalol hcl (afib/afl) 1
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 17
counter M - Covered Under the Medical Benefit Only PA** - PA Applies if Step is Not
Met
Note: Coverage of prescription drugs and supplies listed on this formulary (drug list) is
subject to your plan and benefits. For the most accurate information on your drug cost and
pricing, please log in to My Account (www.carefirst.com/myaccount) and click on Drug &
Pharmacy Resources under Quick Links.Drug Name Drug Tier Requirements/Limits
ANTILIPEMICS, BILE ACID RESINS
cholestyramine 1
cholestyramine light 1
colestipol hcl 1
prevalite 1
ANTILIPEMICS, CHOLESTEROL ABSORPTION INHIBITOR
ezetimibe 1
ANTILIPEMICS, FIBRATES
choline fenofibrate 1
fenofibrate 1
fenofibrate micronized 1
gemfibrozil 1
ANTILIPEMICS, HMG-COA REDUCTASE
INHIBITORS/COMBINATIONS
ezetimibe-simvastatin 1
ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS
atorvastatin calcium 10mg, 20mg 1 $0 copay for members
age 40 through 75
atorvastatin calcium 40mg, 80mg 1
fluvastatin sodium 1 $0 copay for members
age 40 through 75
lovastatin 1 $0 copay for members
age 40 through 75
pravastatin sodium 1 $0 copay for members
age 40 through 75
rosuvastatin calcium 5mg, 10mg 1 ST; $0 copay for
members age 40
through 75; PA**
rosuvastatin calcium 20mg, 40mg 1
simvastatin 5mg, 10mg, 20mg, 40mg 1 $0 copay for members
age 40 through 75
simvastatin 80mg 1 ST; PA**
ANTILIPEMICS, MISCELLANEOUS
niacin (antihyperlipidemic) 1
ANTILIPEMICS, OMEGA-3 FATTY ACIDS
omega-3-acid ethyl esters 1 PA
ANTILIPEMICS, PCSK9 INHIBITORS
REPATHA 4 QL (2 syringes / 28
days), PA
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 18
counter M - Covered Under the Medical Benefit Only PA** - PA Applies if Step is Not
Met
Note: Coverage of prescription drugs and supplies listed on this formulary (drug list) is
subject to your plan and benefits. For the most accurate information on your drug cost and
pricing, please log in to My Account (www.carefirst.com/myaccount) and click on Drug &
Pharmacy Resources under Quick Links.Drug Name Drug Tier Requirements/Limits
REPATHA PUSHTRONEX SYSTEM 4 QL (1 cartridge / 28
days), PA
REPATHA SURECLICK 4 QL (2 pens / 28 days),
PA
BETA-BLOCKER/DIURETIC COMBINATIONS
atenolol & chlorthalidone 1
bisoprolol & hydrochlorothiazide 1
metoprolol & hydrochlorothiazide 1
nadolol & bendroflumethiazide 1
propranolol & hydrochlorothiazide 1
BETA-BLOCKERS
acebutolol hcl 1
atenolol 1
betaxolol hcl 1
bisoprolol fumarate 1
carvedilol 1
carvedilol phosphate 1
labetalol hcl 1
metoprolol succinate 1
metoprolol tartrate 1
nadolol 1
pindolol 1
propranolol hcl 1
timolol maleate 1
CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS
amlodipine besylate-atorvastatin calcium 1
CALCIUM CHANNEL BLOCKERS
afeditab cr 1
amlodipine besylate 1
CARDIZEM LA 2
cartia xt 1
diltiazem hcl 1
diltiazem hcl coated beads 1
diltiazem hcl extended release beads 1
felodipine 1
isradipine 1
matzim la 1
nicardipine hcl 1
nifedipine 1
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 19
counter M - Covered Under the Medical Benefit Only PA** - PA Applies if Step is Not
Met
Note: Coverage of prescription drugs and supplies listed on this formulary (drug list) is
subject to your plan and benefits. For the most accurate information on your drug cost and
pricing, please log in to My Account (www.carefirst.com/myaccount) and click on Drug &
Pharmacy Resources under Quick Links.Drug Name Drug Tier Requirements/Limits
nimodipine 1
nisoldipine 1
taztia xt 1
verapamil hcl 1
DIGITALIS GLYCOSIDES
digox 1
digoxin 1
LANOXIN 2
DIRECT RENIN INHIBITORS/COMBINATIONS
aliskiren fumarate 1
DIURETICS
acetazolamide 1
ALDACTAZIDE 2
amiloride & hydrochlorothiazide 1
amiloride hcl 1
bumetanide 1
chlorothiazide 1
chlorthalidone 1
ethacrynic acid 1
furosemide 1
hydrochlorothiazide 1
indapamide 1
mannitol M M
methazolamide 1
methyclothiazide 1
metolazone 1
osmitrol viaflex M M
spironolactone 1
spironolactone & hydrochlorothiazide 1
torsemide 1
triamterene 1
triamterene & hydrochlorothiazide 1
MISCELLANEOUS
clonidine hcl 1
ENTRESTO 2
guanfacine hcl 1
hydralazine hcl 1
methyldopa 1
midodrine hcl 1
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 20
counter M - Covered Under the Medical Benefit Only PA** - PA Applies if Step is Not
Met
Note: Coverage of prescription drugs and supplies listed on this formulary (drug list) is
subject to your plan and benefits. For the most accurate information on your drug cost and
pricing, please log in to My Account (www.carefirst.com/myaccount) and click on Drug &
Pharmacy Resources under Quick Links.Drug Name Drug Tier Requirements/Limits
minoxidil 1
ranolazine 1 ST; PA**
NITRATES
ISORDIL TITRADOSE 2
isosorbide dinitrate 1
isosorbide mononitrate 1
minitran 1
NITRO-DUR 2
nitroglycerin 1
CENTRAL NERVOUS SYSTEM
ANTIANXIETY§
alprazolam 1 QL (150 tabs / 25 days)
ALPRAZOLAM INTENSOL 2 QL (300 mL / 25 days)
lorazepam CONC 1 QL (150 mL / 25 days)
lorazepam TABS 1 QL (150 tabs / 25 days)
meprobamate 1
oxazepam 1 QL (120 caps / 25 days)
ANTICONVULSANTS§
carbamazepine 1
clobazam 1 PA
clonazepam 1
clorazepate dipotassium 1 QL (180 tabs / 25 days)
diazepam SOLN 1 QL (1200 mL / 25 days)
diazepam TABS 1 QL (120 tabs / 25 days)
diazepam intensol 1 QL (240 mL / 25 days)
divalproex sodium 1
epitol 1
ethosuximide 1
felbamate 1
gabapentin 1
lamotrigine 1
levetiracetam 1
oxcarbazepine 1
phenobarbital 1
phenytoin 1
phenytoin sodium extended 1
pregabalin 1 ST; PA**
primidone 1
tiagabine hcl 1
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 21
counter M - Covered Under the Medical Benefit Only PA** - PA Applies if Step is Not
Met
Note: Coverage of prescription drugs and supplies listed on this formulary (drug list) is
subject to your plan and benefits. For the most accurate information on your drug cost and
pricing, please log in to My Account (www.carefirst.com/myaccount) and click on Drug &
Pharmacy Resources under Quick Links.Drug Name Drug Tier Requirements/Limits
topiramate 1
valproate sodium 1
valproic acid 1
vigabatrin 4 QL (180 packets / 30
days), PA
zonisamide 1
ANTIDEMENTIA
donepezil hydrochloride 1
ergoloid mesylates 1
galantamine hydrobromide 1
memantine hcl 1 PA; PA applies for
members less than 30
years of age
NAMENDA XR TITRATION PACK 2 PA; PA applies for
members less than 30
years of age
rivastigmine 1 PA
rivastigmine tartrate 1 PA
ANTIDEPRESSANTS§
amitriptyline hcl 10mg 1 QL (150 tabs / 25 days);
QL applies to members
age 65 and older
amitriptyline hcl 25mg 1 QL (60 tabs / 25 days);
QL applies to members
age 65 and older
amitriptyline hcl 50mg 1 QL (30 tabs / 25 days);
QL applies to members
age 65 and older
amitriptyline hcl 75mg, 100mg, 150mg 1 PA; Members 70 and
older subject to PA
amoxapine 25mg, 50mg, 100mg 1 QL (90 tabs / 25 days);
QL applies to members
age 65 and older
amoxapine 150mg 1 QL (60 tabs / 25 days);
QL applies to members
age 65 and older
bupropion hcl 1
citalopram hydrobromide 1
desipramine hcl 10mg, 25mg, 50mg 1 QL (90 tabs / 25 days);
QL applies to members
age 65 and older
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 22
counter M - Covered Under the Medical Benefit Only PA** - PA Applies if Step is Not
Met
Note: Coverage of prescription drugs and supplies listed on this formulary (drug list) is
subject to your plan and benefits. For the most accurate information on your drug cost and
pricing, please log in to My Account (www.carefirst.com/myaccount) and click on Drug &
Pharmacy Resources under Quick Links.Drug Name Drug Tier Requirements/Limits
desipramine hcl 75mg 1 QL (60 tabs / 25 days);
QL applies to members
age 65 and older
desipramine hcl 100mg, 150mg 1 QL (30 tabs / 25 days);
QL applies to members
age 65 and older
desvenlafaxine succinate 1 ST; (generic of Pristiq)
PA**
doxepin hcl CAPS 10mg, 25mg, 50mg 1 QL (90 caps / 25 days);
QL applies to members
age 65 and older
doxepin hcl CAPS 75mg 1 QL (60 caps / 25 days);
QL applies to members
age 65 and older
doxepin hcl CAPS 100mg, 150mg 1 QL (30 caps / 25 days);
QL applies to members
age 65 and older
doxepin hcl CONC 1 QL (450 mL / 25 days);
QL applies to members
age 65 and older
duloxetine hcl 1
escitalopram oxalate 1
fluoxetine hcl CAPS 1
fluoxetine hcl CPDR 1
fluoxetine hcl SOLN 1
fluoxetine hcl TABS 10mg, 20mg 1 (generic Sarafem not
covered)
fluoxetine hcl TABS 60mg 1
imipramine hcl 10mg, 25mg 1 QL (120 tabs / 25 days);
QL applies to members
age 65 and older
imipramine hcl 50mg 1 QL (60 tabs / 25 days);
QL applies to members
age 65 and older
imipramine pamoate 75mg, 100mg 1 QL (30 caps / 25 days);
QL applies to members
age 65 and older
imipramine pamoate 125mg, 150mg 1 PA; Members 70 and
older subject to PA
maprotiline hcl 1
mirtazapine 1
nefazodone hcl 1
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 23
counter M - Covered Under the Medical Benefit Only PA** - PA Applies if Step is Not
Met
Note: Coverage of prescription drugs and supplies listed on this formulary (drug list) is
subject to your plan and benefits. For the most accurate information on your drug cost and
pricing, please log in to My Account (www.carefirst.com/myaccount) and click on Drug &
Pharmacy Resources under Quick Links.Drug Name Drug Tier Requirements/Limits
nortriptyline hcl CAPS 10mg 1 QL (150 caps / 25
days); QL applies to
members age 65 and
older
nortriptyline hcl CAPS 25mg 1 QL (60 caps / 25 days);
QL applies to members
age 65 and older
nortriptyline hcl CAPS 50mg 1 QL (30 caps / 25 days);
QL applies to members
age 65 and older
nortriptyline hcl CAPS 75mg 1 PA; Members 70 and
older subject to PA
nortriptyline hcl SOLN 1 QL (750 mL / 25 days);
QL applies to members
age 65 and older
paroxetine hcl 1
phenelzine sulfate 1
protriptyline hcl 5mg 1 QL (90 tabs / 25 days);
QL applies to members
age 65 and older
protriptyline hcl 10mg 1 QL (60 tabs / 25 days);
QL applies to members
age 65 and older
sertraline hcl 1
tranylcypromine sulfate 1
trazodone hcl 1
trimipramine maleate 25mg, 50mg 1 QL (60 caps / 25 days);
QL applies to members
age 65 and older
trimipramine maleate 100mg 1 QL (30 caps / 25 days);
QL applies to members
age 65 and older
venlafaxine hcl 1
ANTIPARKINSONIAN AGENTS
amantadine hcl 1
benztropine mesylate 1
bromocriptine mesylate 1
carbidopa 1
carbidopa-levodopa 1
carbidopa-levodopa-entacapone 1
entacapone 1
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 24
counter M - Covered Under the Medical Benefit Only PA** - PA Applies if Step is Not
Met
Note: Coverage of prescription drugs and supplies listed on this formulary (drug list) is
subject to your plan and benefits. For the most accurate information on your drug cost and
pricing, please log in to My Account (www.carefirst.com/myaccount) and click on Drug &
Pharmacy Resources under Quick Links.Drug Name Drug Tier Requirements/Limits
pramipexole dihydrochloride 1
rasagiline mesylate 1
ropinirole hydrochloride 1
selegiline hcl 1
tolcapone 1
trihexyphenidyl hcl 1
ANTIPSYCHOTICS
aripiprazole 1
ARISTADA M M
ARISTADA INITIO M M
chlorpromazine hcl 1
clozapine 1
fluphenazine hcl 1
haloperidol 1
haloperidol lactate 1
LATUDA 2 ST; PA**
loxapine succinate 1
olanzapine 1
paliperidone 1
perphenazine 1
quetiapine fumarate 1
quetiapine fumarate er 1
risperidone 1
thioridazine hcl 1
thiothixene 1
trifluoperazine hcl 1
ziprasidone hcl 1
ATTENTION DEFICIT HYPERACTIVITY DISORDER§
amphetamine-dextroamphetamine cap er 1 QL (90 caps / 25 days)
24hr 5 mg
amphetamine-dextroamphetamine cap er 1 QL (90 caps / 25 days)
24hr 10 mg
amphetamine-dextroamphetamine cap er 1 QL (30 caps / 25 days)
24hr 15 mg
amphetamine-dextroamphetamine cap er 1 QL (30 caps / 25 days)
24hr 20 mg
amphetamine-dextroamphetamine cap er 1 QL (30 caps / 25 days)
24hr 25 mg
amphetamine-dextroamphetamine cap er 1 QL (30 caps / 25 days)
24hr 30 mg
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 25
counter M - Covered Under the Medical Benefit Only PA** - PA Applies if Step is Not
Met
Note: Coverage of prescription drugs and supplies listed on this formulary (drug list) is
subject to your plan and benefits. For the most accurate information on your drug cost and
pricing, please log in to My Account (www.carefirst.com/myaccount) and click on Drug &
Pharmacy Resources under Quick Links.Drug Name Drug Tier Requirements/Limits
amphetamine-dextroamphetamine tab 5 1 QL (90 tabs / 25 days)
mg
amphetamine-dextroamphetamine tab 7.5 1 QL (90 tabs / 25 days)
mg
amphetamine-dextroamphetamine tab 10 1 QL (90 tabs / 25 days)
mg
amphetamine-dextroamphetamine tab 1 QL (90 tabs / 25 days)
12.5 mg
amphetamine-dextroamphetamine tab 15 1 QL (60 tabs / 25 days)
mg
amphetamine-dextroamphetamine tab 20 1 QL (60 tabs / 25 days)
mg
amphetamine-dextroamphetamine tab 30 1 QL (30 tabs / 25 days)
mg
atomoxetine hcl 1
dexmethylphenidate hcl CP24 5mg, 1 QL (60 caps / 25 days)
10mg, 15mg, 20mg
dexmethylphenidate hcl CP24 25mg, 1 QL (30 caps / 25 days)
30mg, 35mg, 40mg
dexmethylphenidate hcl TABS 2.5mg, 1 QL (120 tabs / 25 days)
5mg
dexmethylphenidate hcl TABS 10mg 1 QL (60 tabs / 25 days)
dextroamphetamine sulfate CP24 5mg, 1 QL (120 caps / 25 days)
10mg
dextroamphetamine sulfate CP24 15mg 1 QL (60 caps / 25 days)
dextroamphetamine sulfate SOLN 1 QL (1,200 mL / 25 days)
dextroamphetamine sulfate TABS 1 QL (120 tabs / 25 days)
guanfacine hcl (adhd) 1 ST; PA**
methamphetamine hcl 1 QL (150 tabs / 25 days)
methylphenidate hcl CHEW 1 QL (180 chew tabs / 25
days)
methylphenidate hcl CP24 20mg, 30mg 1 QL (60 caps / 25 days)
methylphenidate hcl CP24 40mg, 60mg 1 QL (30 caps / 25 days)
methylphenidate hcl CPCR 10mg, 20mg, 1 QL (60 caps / 25 days)
30mg
methylphenidate hcl CPCR 40mg, 50mg, 1 QL (30 caps / 25 days)
60mg
methylphenidate hcl SOLN 5mg/5ml 1 QL (1800 mL / 25 days)
methylphenidate hcl SOLN 10mg/5ml 1 QL (900 mL / 25 days)
methylphenidate hcl TABS 5mg, 10mg 1 QL (180 tabs / 25 days)
methylphenidate hcl TABS 20mg 1 QL (90 tabs / 25 days)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 26
counter M - Covered Under the Medical Benefit Only PA** - PA Applies if Step is Not
Met
Note: Coverage of prescription drugs and supplies listed on this formulary (drug list) is
subject to your plan and benefits. For the most accurate information on your drug cost and
pricing, please log in to My Account (www.carefirst.com/myaccount) and click on Drug &
Pharmacy Resources under Quick Links.Drug Name Drug Tier Requirements/Limits
methylphenidate hcl TB24 18mg, 27mg, 1 QL (60 tabs / 25 days)
36mg
methylphenidate hcl TB24 54mg 1 QL (30 tabs / 25 days)
methylphenidate hcl TBCR 10mg, 20mg 1 QL (90 tabs / 25 days)
methylphenidate hcl TBCR 18mg, 27mg, 1 QL (60 tabs / 25 days)
36mg
methylphenidate hcl TBCR 54mg 1 QL (30 tabs / 25 days)
VYVANSE CAPS 10mg, 20mg, 30mg 2 QL (60 caps / 25 days)
VYVANSE CAPS 40mg, 50mg, 60mg, 2 QL (30 caps / 25 days)
70mg
VYVANSE CHEW 10mg, 20mg, 30mg 2 QL (60 tabs / 25 days)
VYVANSE CHEW 40mg, 50mg, 60mg 2 QL (30 tabs / 25 days)
zenzedi 2.5mg, 7.5mg 1 QL (120 tabs / 25 days)
zenzedi 15mg, 20mg 1 QL (60 tabs / 25 days)
zenzedi 30mg 1 QL (30 tabs / 25 days)
HYPNOTICS§
BELSOMRA 2 ST; PA**
cvs sleep-aid nighttime 0 OTC
doxepin hcl (sleep) 1 QL (30 tabs / 25 days);
QL applies to member
age 65 and older
eszopiclone 1 QL (15 tabs / 25 days)
ramelteon 1 QL (15 tabs / 25 days)
SILENOR 2 QL (30 tabs / 25 days);
QL applies to members
age 65 and older
temazepam 1 QL (15 caps / 25 days)
zaleplon 1 QL (15 caps / 25 days)
zolpidem tartrate 1 QL (15 tabs / 25 days)
MIGRAINE§
almotriptan malate 1 QL (12 tabs / 25 days)
eletriptan hydrobromide 1 QL (12 tabs / 25 days)
ergotamine w/ caffeine 1
frovatriptan succinate 1 QL (18 tabs / 25 days)
naratriptan hcl 1 QL (12 tabs / 25 days)
rizatriptan benzoate 1 QL (18 tabs / 25 days)
sumatriptan 5mg/act 1 QL (24 sprays / 25
days)
sumatriptan 20mg/act 1 QL (12 sprays / 25
days)
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 27
counter M - Covered Under the Medical Benefit Only PA** - PA Applies if Step is Not
Met
Note: Coverage of prescription drugs and supplies listed on this formulary (drug list) is
subject to your plan and benefits. For the most accurate information on your drug cost and
pricing, please log in to My Account (www.carefirst.com/myaccount) and click on Drug &
Pharmacy Resources under Quick Links.Drug Name Drug Tier Requirements/Limits
sumatriptan succinate SOAJ 4mg/0.5ml 1 QL (18 syringes / 25
days)
sumatriptan succinate SOAJ 6mg/0.5ml 1 QL (12 units / 25 days)
sumatriptan succinate SOCT 4mg/0.5ml 1 QL (18 syringes / 25
days)
sumatriptan succinate SOCT 6mg/0.5ml 1 QL (12 units / 25 days)
sumatriptan succinate SOLN 1 QL (12 vials / 25 days)
sumatriptan succinate SOSY 1 QL (12 units / 25 days)
sumatriptan succinate TABS 1 QL (12 tabs / 25 days)
sumatriptan-naproxen sodium 3 QL (9 tabs / 25 days),
ST; PA**
zolmitriptan 1 QL (12 tabs / 25 days)
MISCELLANEOUS
buspirone hcl 1
clomipramine hcl 25mg, 50mg 1 QL (150 caps / 25
days); QL applies to
members age 65 and
older
clomipramine hcl 75mg 1 QL (90 caps / 25 days);
QL applies to members
age 65 and older
fluvoxamine maleate 1
lithium carbonate 1
pimozide 1
pyridostigmine bromide 1
riluzole 1
MULTIPLE SCLEROSIS AGENTS
AUBAGIO 4 QL (30 tabs / 30 days),
PA
BETASERON 4 QL (14 injections / 28
days), PA
COPAXONE INJ 20MG/ML 4 QL (30 injections / 30
days), PA
COPAXONE INJ 40MG/ML 4 QL (12 syringes / 28
days), PA
GILENYA 4 QL (30 caps / 30 days),
PA
glatiramer acetate 2 QL (12 syringes / 28
days), PA
glatopa 2 QL (30 injections / 30
days), PA
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 28
counter M - Covered Under the Medical Benefit Only PA** - PA Applies if Step is Not
Met
Note: Coverage of prescription drugs and supplies listed on this formulary (drug list) is
subject to your plan and benefits. For the most accurate information on your drug cost and
pricing, please log in to My Account (www.carefirst.com/myaccount) and click on Drug &
Pharmacy Resources under Quick Links.Drug Name Drug Tier Requirements/Limits
REBIF 4 QL (12 syringes / 28
days), PA
REBIF REBIDOSE 4 QL (12 syringes / 28
days), PA
REBIF REBIDOSE TITRATION 4 QL (1 box / 28 days), PA
REBIF TITRATION PACK 4 QL (1 box / 28 days), PA
TECFIDERA 120mg 4 QL (14 caps / 28 days),
PA
TECFIDERA 240mg 4 QL (60 caps / 30 days),
PA
TECFIDERA STARTER PACK 4 QL (1 kit / 30 days), PA
MUSCULOSKELETAL THERAPY AGENTS
baclofen 1
carisoprodol 1 PA; High Risk
Medications require PA
for members age 70 and
older
chlorzoxazone 1
cyclobenzaprine hcl 1 PA; High Risk
Medications require PA
for members age 70 and
older
dantrolene sodium 1
metaxalone 1 PA; High Risk
Medications require PA
for members age 70 and
older
methocarbamol 1 PA; High Risk
Medications require PA
for members age 70 and
older
orphenadrine citrate 1 PA; High Risk
Medications require PA
for members age 70 and
older
tizanidine hcl 1
NARCOLEPSY/CATAPLEXY
armodafinil 1 PA
modafinil 1 PA
PSYCHOTHERAPEUTIC-MISC
acamprosate calcium 1 PA
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 29
counter M - Covered Under the Medical Benefit Only PA** - PA Applies if Step is Not
Met
Note: Coverage of prescription drugs and supplies listed on this formulary (drug list) is
subject to your plan and benefits. For the most accurate information on your drug cost and
pricing, please log in to My Account (www.carefirst.com/myaccount) and click on Drug &
Pharmacy Resources under Quick Links.Drug Name Drug Tier Requirements/Limits
bupropion hcl (smoking deterrent) 0 $0 limited to 2
treatment cycles/year
disulfiram 1
naltrexone hcl 0 $0 copay
NARCAN 2
ENDOCRINE AND METABOLIC
ANDROGENS
testosterone 1 PA
ANTIDIABETICS, ALPHA-GLUCOSIDASE INHIBITORS
acarbose 1
miglitol 1
ANTIDIABETICS, BIGUANIDE
metformin hcl 1
ANTIDIABETICS, BIGUANIDE/ SULFONYLUREA COMBINATIONS
glipizide-metformin hcl 1
glyburide-metformin 1 PA; High Risk
Medications require PA
for members age 70 and
older
ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 INHIBITORS
alogliptin benzoate 1
JANUVIA 2 ST; PA**
ANTIDIABETICS, DPP-4 INHIBITOR COMBINATIONS
JANUMET 2 ST; PA**
JANUMET XR 2 ST; PA**
ANTIDIABETICS, INCRETIN MIMETIC AGENTS
OZEMPIC 2 ST; PA**
TRULICITY 2 ST; PA**
VICTOZA 2 ST; PA**
ANTIDIABETICS, INCRETIN MIMETIC COMBINATION AGENTS
SOLIQUA 100/33 2 ST; PA**
XULTOPHY 100/3.6 2 ST; PA**
ANTIDIABETICS, INSULIN
BASAGLAR KWIKPEN 2
FIASP 2
FIASP FLEXTOUCH 2
FIASP PENFILL 2
HUMULIN R U-500 (CONCENTR 2
HUMULIN R U-500 KWIKPEN 2
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 30
counter M - Covered Under the Medical Benefit Only PA** - PA Applies if Step is Not
Met
Note: Coverage of prescription drugs and supplies listed on this formulary (drug list) is
subject to your plan and benefits. For the most accurate information on your drug cost and
pricing, please log in to My Account (www.carefirst.com/myaccount) and click on Drug &
Pharmacy Resources under Quick Links.Drug Name Drug Tier Requirements/Limits
LEVEMIR 2
LEVEMIR FLEXTOUCH 2
NOVOLIN 70/30 2 OTC; RELION not
covered
NOVOLIN 70/30 FLEXPEN 2 OTC; RELION not
covered
NOVOLIN N 2 OTC; RELION not
covered
NOVOLIN N FLEXPEN 2 OTC; RELION not
covered
NOVOLIN R 2 OTC; RELION not
covered
NOVOLIN R FLEXPEN 2 OTC; RELION not
covered
NOVOLOG 2
NOVOLOG FLEXPEN 2
NOVOLOG MIX 70/30 2
NOVOLOG MIX 70/30 FLEXPEN 2
NOVOLOG PENFILL 2
TRESIBA 2
TRESIBA FLEXTOUCH 2
ANTIDIABETICS, INSULIN SENSITIZER
pioglitazone hcl 1
ANTIDIABETICS, INSULIN SENSITIZER/BIGUANIDE COMBINATION
pioglitazone hcl-metformin hcl 1
ANTIDIABETICS, INSULIN SENSITIZER/SULFONYLUREA
COMBINATION
pioglitazone hcl-glimepiride 1
ANTIDIABETICS, MEGLITINIDE
nateglinide 1
repaglinide 1
ANTIDIABETICS, MEGLITINIDE/BIGUANIDE COMBINATION
repaglinide-metformin hcl 1
ANTIDIABETICS, SODIUM-GLUC CO-TRANSPOR2 INHIB (SGLT2)
COMBO
SYNJARDY 2 ST; PA**
SYNJARDY XR 2 ST; PA**
XIGDUO XR 2 ST; PA**
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 31
counter M - Covered Under the Medical Benefit Only PA** - PA Applies if Step is Not
Met
Note: Coverage of prescription drugs and supplies listed on this formulary (drug list) is
subject to your plan and benefits. For the most accurate information on your drug cost and
pricing, please log in to My Account (www.carefirst.com/myaccount) and click on Drug &
Pharmacy Resources under Quick Links.Drug Name Drug Tier Requirements/Limits
ANTIDIABETICS, SODIUM-GLUC CO-TRANSPOR2 INHIB
(SGLT2)/DPP-4 INHIBITOR COMBINATIONS
GLYXAMBI 2 ST; PA**
ANTIDIABETICS, SODIUM-GLUCOSE COTRANSPORTER2(SGLT2)
INHIB
FARXIGA 2 ST; PA**
JARDIANCE 2 ST; PA**
ANTIDIABETICS, SULFONYLUREA
glimepiride 1
glipizide 1
glyburide 1 PA; High Risk
Medications require PA
for members age 70 and
older
glyburide micronized 1 PA; High Risk
Medications require PA
for members age 70 and
older
BISPHOSPHONATES
alendronate sodium 1
ibandronate sodium 1
risedronate sodium 1
CHELATING AGENTS
kionex 1
penicillamine 1 PA
sodium polystyrene sulfonate 1
THYROSAFE 2 OTC
CONTRACEPTIVES
altavera 0
alyacen 1/35 0
alyacen 7/7/7 0
amethia 0
amethyst 0
ANNOVERA 0 QL (1 / 300 days)
apri 0
aranelle 0
ashlyna 0
aviane 0
azurette 0
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 32
counter M - Covered Under the Medical Benefit Only PA** - PA Applies if Step is Not
Met
Note: Coverage of prescription drugs and supplies listed on this formulary (drug list) is
subject to your plan and benefits. For the most accurate information on your drug cost and
pricing, please log in to My Account (www.carefirst.com/myaccount) and click on Drug &
Pharmacy Resources under Quick Links.Drug Name Drug Tier Requirements/Limits
BALCOLTRA 0
camila 0
caziant 0
chateal 0
cryselle-28 0
cyclafem 1/35 0
cyclafem 7/7/7 0
dasetta 1/35 0
dasetta 7/7/7 0
delyla 0
drospirenone-ethinyl estradiol 0
drospirenone-ethinyl 0
estradiol-levomefolate calcium
elinest 0
ELLA 0
emoquette 0
enpresse-28 0
enskyce 0
errin 0
ethynodiol diacet & eth estrad 0
etonogestrel-ethinyl estradiol 0 QL (13 / 300 days)
falmina 0
fayosim 0
gianvi 0
heather 0
introvale 0
jolessa 0
jolivette 0
junel 1.5/30 0
junel 1/20 0
junel fe 1.5/30 0
junel fe 1/20 0
kariva 0
kelnor 1/35 0
kurvelo 0
larin 1.5/30 0
leena 0
lessina 0
levonest 0
levonorgestrel & eth estradiol 0
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 33
counter M - Covered Under the Medical Benefit Only PA** - PA Applies if Step is Not
Met
Note: Coverage of prescription drugs and supplies listed on this formulary (drug list) is
subject to your plan and benefits. For the most accurate information on your drug cost and
pricing, please log in to My Account (www.carefirst.com/myaccount) and click on Drug &
Pharmacy Resources under Quick Links.Drug Name Drug Tier Requirements/Limits
levonorgestrel-ethinyl estradiol (91-day) 0
levora 0.15/30-28 0
LO LOESTRIN FE 0
loryna 0
low-ogestrel 0
lutera 0
marlissa 0
mibelas 24 fe 0
microgestin 1.5/30 0
mono-linyah 0
mononessa 0
myzilra 0
NATAZIA 0
necon 0.5/35-28 0
nikki 0
nora-be 0
norethin acet & estrad-fe 0
norethindrone & ethinyl estradiol-fe 0
norethindrone (contraceptive) 0
norethindrone acet & eth estra 0
norgestimate-ethinyl estradiol 0
norgestimate-ethinyl estradiol (triphasic) 0
nortrel 0.5/35 (28) 0
nortrel 1/35 0
nortrel 7/7/7 0
NUVARING 0 QL (13 / 300 days)
ocella 0
ogestrel 0
orsythia 0
pirmella 1/35 0
pirmella 7/7/7 0
portia-28 0
previfem 0
quasense 0
reclipsen 0
rivelsa 0
SLYND 0
sprintec 28 0
sronyx 0
syeda 0
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy OTC - Over the 34
counter M - Covered Under the Medical Benefit Only PA** - PA Applies if Step is Not
Met
Note: Coverage of prescription drugs and supplies listed on this formulary (drug list) is
subject to your plan and benefits. For the most accurate information on your drug cost and
pricing, please log in to My Account (www.carefirst.com/myaccount) and click on Drug &
Pharmacy Resources under Quick Links.You can also read
