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Maintenance List (September 2019)

Maintenance are medications prescribed to treat chronic, long-term conditions and are taken on a regular, recurring basis. Examples of maintenance drugs are those used to treat high pressure, heart , and . When medically appropriate, maintenance drugs can be filled for up to a 90-day supply.

The maintenance drug list represents brand products in CAPITAL LETTERS and generic products in lower case italics. Where a generic is available, it is listed by the generic name. If no generic is available, then the brand name appears. Due to the large number of available , this list is not all inclusive. Please note this list does not guarantee coverage and is subject to change. Your plan may not cover certain products or categories, regardless of their appearance on this list.

If your medication is not on this list your doctor may request it on your behalf, using the Maintenance Medication Exception Form on the last page of this document. The request will be reviewed by a . If approved, maintenance drugs can be filled for up to a 90-day supply per fill. If denied, the drug is still covered for the days’ supply allowed by your specific plan.

The drugs noted with an asterisk (*) on this list are included in our Maintenance Choice® plans. You may be enrolled in a plan that has Mandatory or Voluntary Maintenance Choice.  Mandatory Maintenance Choice: You may fill two 30-day prescriptions for a long-term, maintenance medication before you must fill the prescription in a 90-day supply through CVS Caremark® Mail Service or at a CVS ®.  Voluntary Maintenance Choice: You have the option to fill a 90-day supply of a long-term, maintenance medication through CVS Caremark Mail Service or at a CVS Pharmacy. You may also continue to fill a 30-day supply of these medications at any participating network pharmacy.

If you have questions about your prescription drug plan, please visit www.carefirst.com and log in to My Account or call CareFirst Pharmacy Services at 800-241-3371. -Combinations TRIUMEQ olanzapine/fluoxetine* TRIZIVIR desloratidine* SYMBYAX TRUVADA desloratidine odt CLARINEX* Antivirals Attention Deficit/Hyperactivity Alzheimer’s acyclovir Disease adefovir Disorder (ADHD) atomoxetine donepe zil* entecavir clonidine er* donepezil odt guanfacine er* galantami n e* famciclovir INTUNIV galantami n eer lami vudine KAPVAY memantine nevirapine rivastigmine* stavudine STRATTERA* ARICEPT valacyclovir EXELON valganciclovir Blood Modifiers NAMENDA* zidovudine anagreli de* NAME N DA XR APTIVUS asa/di py ridam ol e NAMZARIC* ATRIPLA cilost a zol* RAZADYNE BARACLUDE clopidogrel* RAZA D Y NE ER CRIXIVAN dipyridam ol e* EDURANT pentoxifyll i ne* EMTRIVA pentoxifyll i ne er Anti-Anxiety persanti ne buspirone EPIVIR EPIVIR HBV prasugrel* FAMVIR ticlopidine* Anti- FUZEON AGGRE N OX* armodafinil HEPSERA AGRYLIN NUVIGIL INTELENCE BRILINTA* INVIRASE DURLAZA ISENTRESS EFFIENT* PLAVIX LEXIVA NORVIR PLETAL BEVYXXA YOSPRALA COUMADIN PREZISTA RESCRIPTOR ZONTIVITY* JANTOVEN RETROVIR SAVAYSA REYATAZ Cancer SELZENTRY anastroz ol e* SITAVIG aroma si n Aripiprazole SUSTIVA exemestane* aripiprazole odt TIVICAY letrozol e* * TYBOST * * TYZEKA ARIMI DEX molindone VALCYTE FARE S T O N* olanzapine* VALTREX FEMA RA olan zapi ne odt VEMLIDY SOLT A M OX paliperi don e* VIDEX pimozi de VIDEX EC queti api n e VIRACEPT Contraceptives/ queti api n e er VIRAMUNE risperidone* VIRAMUNE XR Replacement risperidone odt VIREAD altavera thiothi x ene* VITEKTA alyacen ziprasi d one* ZERIT amethia ABILIF Y* ZIAGEN amethia lo ABILIFY DIS CM E L T ZOVIRAX amethyst ARISTADA apri EQUETRO* -Combinations aranelle GEODON abacavir/lamivudine ashlyna INVEGA* lami vudine/zidovudine aviane LATUDA* lopinavir/ritonavir azurette LITHOBID COMBIVIR balziva NUPLAZID COMPLERA briellyn ORAP* DESCOVY camila REXULTI* EPZICOM camrese RISPERDAL EVOTAZ camrese lo RISPERDAL M-TAB GENVOYA caziant SEROQUEL JULUCA cesia SEROQUEL XR* KALETRA cryselle-28 VRAYLAR ODEFSEY cyclafem ZYPREXA PREZCOBIX cyred ZYPREXA ZYDIS STRIBILD dasetta daysee

deblitane previfem LO LOESTRIN* delyla quasense LOESTRIN elinest raloxifene* LOES T R IN 21 reclipsen LOES T R IN FE emoquette enpresse-28 setlakin LOSE A S O N I Q UE enskyce sharobel MIBELAS solia MENEST* errin estarylla sprintec MENOSTAR sronyx * MINIVELLE estradiol estropipate* syeda MINASTRIN FE estropipate tarina fe MIRCETTE estradiol gel* tilia fe MODICON estradiol transdermal* tri-estarylla NATAZIA* ethinyl estradiol-desogestrel* tri-legest fe NORINYL tri-linyah NOR-QD ethinyl estradiol-drospirenone* ethinyl estradiol-ethynodiol* tri-lo estarylla NUVA RING * tri-lo marzia ethinyl estradiol-levonorgestrel* OR THO EVRA OR T HO tri-lo sprintec ethinyl estradiol-norelgestromin* MICRO N OR ethinyl estradiol-norethindrone* trinessa OR TH O - T RI-CYCL E N OR TH O - ethinyl estradiol-norgestimate* tri-previfem TRI CYCLEN LO ethinyl estradiol-norgestrel* tri-sprintec OR TH O - CEPT falmina trivora OR TH O - CYC LE N gianvi velivet OR TH O - NOV UM gildagia vesture OVCO N -35 gildes viorele PRE FE S T gildess 24 fe vyfemla PRE M A RIN* heather wera PREMA RIN CREA M jencycla wymzya fe PRE M P H ASE jinteli xulane PRE M P R O* jolessa zarah QU A RTETTE jolivette zenchant RAJA N I SAFY RA L* juleber zenchant fe SEAS O NIQU E junel zovia TAY TULLA ACTIVELLA junel fe TRI-NORINYL kariva ALORA VAGIFEM kelnor AMABELZ VIENVA kurvelo ANGELIQ VIVELLE-DOT larin AUBRA XULANE larin fe BEKYREE YASMIN 28 layolis fe BEYAZ* YAZ leena BLISOVI FE YUVAFEM lessina BREVICON levonest CENESTIN* Corticoste roids CHATEAL levora prednisone lomedia 24 fe CLIMARA DIS DELTASONE CLIMARA PRO* lopreeza RAYOS loryna COMBIPATCH* CYCLESSA low-ogestrel Cystic Fibrosis lutera DEP O -P R O V E R A INJ DEP O -P R O V E R A SQ tobramycin nebulizer lyza BETHKIS marlissa DES O G E N medroxyprogesterone inj DES O G E N -28 KITABIS TOBI microgestin DIVIGEL ORKAMBI microgestin fe ELESTRIN mimvey ENJUVIA* mimvey lo ESTRACE Depression mono-linyah ESTRA CE CRE A M bupropion* mononessa ESTRING* citalopram* myzilra ESTRO S T E P FE desvenlafaxine* necon EVAMIST* * EVISTA nikki escitalopram* nora-be DUAVEE* fluoxetine* norethindrone FALESSA* fluoxetine dr norlyroc FEMCON FE fluvoxamine* norgestrel FEMHRT* fluvoxamine er nortrel FEMRING mirtazapine* ocelli FEMYNOR nefazodone* oge str el FYAVOLV paroxetine* orsythia GENERESS FE paroxetine er ortho-est INTROVALE phenelzine philith JEVANTIQUE LO sertraline* pimtre a KAITLIB FE tranylcypromine pirmell a KIMIDESS trazodone* porti a-28 LARISSIA

venl afaxi ne* JARDIANCE* methyclothiazide venl afaxi ne er LANTUS metolazone neptazane APLE N ZIN * LEVEMIR NESINA* * BRINT ELLIX* BRIS D ELLE* NOVOLIN ALDACTONE CELE X A NOVOLIN N DIAMOX SEQUELS ER NOVOLIN R CYMBALT A DIURIL EFF EXOR XR NOVOLOG MIX MICROZIDE EMSAM ONGLYZA* FETZIM A* PRANDIN -Combinations FLUOXET INE 60MG PRECOSE hctz/amiloride FORF IVO XL RIOMET hctz/s pi ronol actone* IRE NKA STARLIX hctz/triamterene* KHEDEZLA STEGLATRO ALDACTAZIDE SYMLIN* LEXAPRO CAROSPIR MARPLAN SYNJARDY* DYAZIDE NARDIL SYNJARDY XR MAXZIDE OLEPTRO* TANZEUM* PARNATE TOUJEO SOLOSTAR TRADJENTA* Genitourinary Agents PAXIL alfuzosin* PACIL CR TRESIBA TRULICITY* dutasteride PAXEVA dutasteride/tamsulosin PRISTIQ* VICTOZA* XULTOPHY finasteride* PROZAC tamsul osi n* REMERON terazosi n* TRINTELLIX -Combinations AVODART* VIIBRYD* alogliptin/piogliptazone CARDURA XL* WELLBUTRIN glipizide/* FLOMAX WELLBUTRIN SR glyburide/metformin* JALYN* WELLBUTRIN XL pioglitaz one/gl i m epi ri de* PROSCAR ZOLOFT /metformin* RAPAFLO* ACTOPLUS MET UROXATRAL ACTOPLUS MET ER Diabetes AVANDAMET* acarbose* AVANDARYL* Gout chlorprop ami de* GLUCOVANCE allopurinol * glimepiride* GLYXAMBI* probeneci d/col c hi ci ne* glipizide* INVOKAMET IR*/XR* DUZA LLO glipizide er JANUMET* ULORIC* glipizide xl JENTADUETO IR*/XR* ZURAMPIC glyburide* JUVISYNC* ZYLOPRIM metformin* KAZANO* metformin er KOMBIGLYZE XR* Heart Disease & High OSENI* nateglinide* PRA NDIM E T * pioglitazone* QTERN -Ace Inhibitors repaglinidine* SEGLUR O M ET benazepril* * SOLIQUA* captopril* tolbutamide* STEGLUJAN enalapril* ACTOS XIGDUO XR* fosinopril* ADLYXIN* lisinopril* AFREZZA moexipril* AMARYL -Diabetes Supplies* * APIDRA quinapril* AVANDIA* Digestive Enzymes ramipril* BASAGLAR pancreli pas e* trandolapril* BYDUREON* CRE O N* ACCUPRIL BYETTA* PANCRE A Z E* ACEON CYCLOSET* PERTZ YE ALTA C E DIABETA SUCR A ID* LOTEN SIN DUETACT ULTR ESA MAVIK FARXIGA* VIOKA C E PRINIVIL FIASP ZENP EP* QB RELIS GLYNASE VASOT EC GLYSET* ZESTRIL GLUCOPHAGE acetaz ol am i de* GLUCOPHAGE XR acetaz ol ami de er -Angiotensin II Receptor GLUCOTROL amiloride* Antagonists GLUCOTROL XL chlorthali done* candes artan* HUMALOG chlorothi azi d e eprosartan* HUMULIN N dyrenium* irbesartan* HUMULIN R losartan* * hydrochlorothiazide (hctz)* olme s artan INVOKANA* telmi sartan* JANUVIA* methazolami de*

valsartan* nisoldipine er EXFORGE HCT verapamil* ATACAND HYZAAR verapamil cr AVAPRO LOPRESSOR HCT verapamil er LOTENSIN HCT BENICAR verapamil sa COZAAR LOTREL verapamil sr DIOVAN MICARDIS ADALAT CC PRESTALIA* EDARBI* MICARDIS AFEDITAB CR TARKA TEVETEN* CALAN TEKAMLO* CALAN SR TEKTURNA HCT* CARDIZEM TENORETICTEVET -Antiarrhythmics CARDIZEM CD EN HCT* * CARDIZEM LA TRIBENZOR* * CARTIA XT TWYNSTA flecainide* DILT-XR VASERETIC * ISOPTIN SR ZESTORETIC pacerone MATZIM LA ZIAC propafenone* NIFEDIAC CC propafenone er NIFEDICAL XL -Cardiotonics quinidine gluconate* NORVASC quinidine sulfate* PROCARDIA DIGITEK quinidine er PROCARDIA XL NORPACE LANOX IN SULAR NORPACE CR TAZTIA XT MULTAQ* -M iscellaneous TIAZAC Cardiovascular RYTHMOL VERELAN SR RYTH M OL SR clonidine* VERELAN PM EXT REL

-Beta Blockers eplerenone acebutolol* -Combinations guanfacine* amlodipine/atorvastatin* hydralazine* atenolol* amlodipine/benazepril betaxolol* isoxsuprine* amlodipine/hctz* methyldopa* bisoprolol* amlodipine/olme sartan carvedilol* * amlodi pi ne/ol mesa rta n/hctz prazosin* labetalol* amlodipine/valsartan* levatol* * amlodipine/valsartan/hctz* CARDURA CATAPRES metoprolol* atenolol/chlorthalidone* metoprolol er CATAPRES TTS benazepril/ hctz* BIDIL* nadolol* bisoprolol/ hctz* pindol ol* CORLA N O R * candesartan/ hctz* INSPRA propran ol ol* clonidine/chlorthalidone* prop ra nol ol er MINIPRESS captopril/ hctz* RANEXA* sotal ol * enalapril/ hctz* sotal ol af TENEX fosinopril/ hctz* timolol * TEKTURNA* irbesartan/ hctz* BETA P A C E lisinopril / hctz* BETAPACE AF losartan/ hctz* High BYSTOLIC* methyldopa/ hctz* atorvastatin* COREG metoprolol/ hctz* cholestyramine* COREG CR moexipril/ hctz* colestipol* CORGARD nadolol/bendr ofl umethi azi de* ezetimibe INDERAL LA ezetimibe/* olmes artan/hctz INDERAL XL (exception: 10/80 mg) INNOPRAN XL propranolol/ hctz* quinapril/ hctz* fenofibrate micronized* LOPRESSOR /aml odi pi ne* fenofibric acid SECRAL telmisartan/hctz* * SORINE trandol ap ril /verap amil * gemfibrozil* SOTYLIZE valsartan/hctz* * TENORMIN ACCURETIC omega-3-acid ethyl ester* TOPROL XL niacin er* TRANDATE AMTURNIDE* ATACAND HCT * ZEBETA AVALIDE rosuvastatin* AZOR* si mvastati n* (excep ti on: 80 mg) -Calcium Channel Blockers BENICAR HCT* ADVICOR amlodipine* BYVALSON* ALTOPR EV diltiazem* CADUET ANTA R A diltiazem cd CLORPRES COLES TID diltiazem er CORZIDE CREST O R* diltiazem sr DIOVAN HCT FENOG LID E felodipine* DUTOPROL FIB RIC OR isradipine* EDA RB Y C LO R* FLOLIP ID ENTRESTO* LES COL nifedipine* EPANED LES COL XL nifedipine er EXFORGE LIPITOR nisoldipine*

LIPOFEN CUVPOSA* BINOSTO* LIVALO* DROXIA BONIVA LOFIBRA ELIPHOS ELIPHOS EVOXAC FORTICAL LOPID LOVAZA FOSRENOL FOSAMAX NIASPAN GASTROCROM FOSAMAX D* NASCOBAL* MIACALCIN PRALUENT PRE V A LITE NUEDEXTA* NATPARA QUE S T RAN OCALIVA PHOSLO REPATHA ORFADIN PHOSLYRA SIMCOR* OSPHENA ROCATROL TRICOR RAYALDEE STRENSIQ TRIGLIDE RILUTEK TRILIPIX SALAGEN SARAFEM Overactive Bladder VASCEPA* darifenaci n* SAVELLA* VYTORIN* flavox ate* TRULANCE (exception: 10/80mg) oxy butyni n* URSO 250 tolterodine* WELCH O L* URS O FORTE ZETIA* tolteridone er XURIDEN ZOCOR (exce pti o n: 80mg) trospium * trospi um er Hypogonadism Opthalmic Agents DETR OL betaxolol* Depo- DETR OL LA testosterone cypionate bimatoprost* DITROPAN XL * testosterone enanthate ENABLEX* carbachol* FLA V O X TE * GELNIQ U E Inflammatory Bowel dorzolamide* MYRB E TR IQ* Disease latanoprost* OXYT R O L* 5-aminosalicylic acid levobunolol* TOV IA Z* azulfidine methazolami de* VESICA RE* sulfasalazine* * sulfasalazine dr phospholine* Parkinson’s sulfazine pilocarpine* mesalamine timolol* Disease APRISO * benztropine* ASACOL HD ALPHAGAN P bromocriptine* CANASA AZOPT* * carbido pa/l ev odop a* carbidopa/levodopa/entacapo ne* DELZICOL BETAGAN DIPENTUM* BETIMOL entacapo ne* GIAZO BETOPTIC-S prami pex ol e* LIALDA COSOPT prami pex ol e er PENTASA COSOPT PF ropini rol e* ROWASA ISOPTO ropinirole er SFROWASA CARP selegiline ISTALOL tolcapone* LUMIGAN* trihexypheni dyl* Irritable Bowel Syndrome AZILECT alosetron RES CU LA* RES TASIS COMTAN AMITIZA* DUOPA LINZESS* TIMOPT IC TIMOPT IC -XE ELDEPRYL LOTRONEX TRAVA T AN Z* LODOSYN TRUSOPT MIRAPEX Kidney Disease VYZUL TA MIRAPEX ER calcitriol* XALATAN NEUPRO* calcium acetate* XIIDRA* PARLODEL sevelame r* ZIOP TA N* REQUIP AURYXIA* REQUIP XL FOSRENOL* RYTARY* -Combinations SINEMET RENAGEL* dorzolamide/timolol* SINEMET CR RENVELA* COMBIGAN* STALEVO VELPHORO* SIMBRINZA*

TASMAR* Miscellaneous / XADAGO cevimeline* ZELAPAR ergoloid mesylate* Hypocalcemia folic acid (400 & 800 mcg) alendronate* levoca rniti ne * Respiratory Agents pilocarpine* calci tri ol* albuterol nebuli z er soluti o n calci um acetate * albuterol syrup ibandronate* ursodiol* albuterol risedronate* ACTIGALL albuterol er CARNIT OR risedronate dr aminophylline* ACTONEL* CHOLBAM azel asti n e ATELVIA bude s onide* Rheumatoid Thyroid cro molyn* dyphylline* leflunomide* levothyroxine* elixophylli n e ARAVA liothyronine* formoter ol * RHEUMATREX* me thima zole flunisoli de RIDAURA* prop yl thi ou racil fluticas one tapazole ipratro pi um* Seizure Disorders thyroid* CYTOMEL ipratropi um /albuterol* * LEVOXYL levalbuterol nebulizer solution divalproex* SYNTHROID metaproterenol* ethosuximide* THYROLAR* mometa so ne felbamate* TIROSINT montelukast* * terbutaline* * theophylline* lamotrigine er Transplant triamcinolone lamotrigine odt azathioprine* zafirlukast* levetiracetam* cyclosporine ACCOLATE levati ra ceta m er mycophenolate ADVAIR* * mycophenolate dr AEROSPAN* primidone* sirolimus AIRDUO * tacrolimus ALVESCO* topiramate* ASTAGRAF XL ANORO ELLIPTA* topiramate er* AZASAN ARCAPTA* topiramate sprinkle CELLCEPT ARMONAIR valproic acid* ENVARSUS XR ARNUITY ELLIPTA* * GENGRAF ASMANEX* APTIOM* IMURAN ASTEPRO BANZEL MYFORTIC ATROVENT BRIVIACT NEORAL BECO N A S E AQ CARBATROL PROGRAF BEVESPI* CELONTIN* RAPAMUNE BREO ELLIPTA* DEPAKENE SANDIMMUNE BROVANA* DEPAKOTE ZORTRESS DALIRESP* DEP A K O TE ER DULERA* DEP A K O TE SPRINK LE FLONASE DILANT IN Ulcer/ FLOVENT* EPITO L Gastroesophageal FORADIL FYCO M PA INCRUSE ELLIPTA* Reflux Disease GABITR IL* LUFYLLIN (GERD) GRA LISE NASONEX * HORIZ A NT* NUCALA esomeprazole magnesium* KEPP R A esomeprazole strontium OMNARIS KEPP R A XR PERFO ROM IS T famotidine* LAMICTAL lansopraz ol e* PULMICORT LAMICTAL ODT PULMOZYME* LAMICTAL XR QNASL nizatidine* MYS O LINE omeprazole* QNASL CHILD NEUR O NTIN QVAR REDIHALER omepra zol e/ sodi u m bicarbon at e* OXTE LL AR XR pantoprazole* RHINO C O RT AQUA PEGA N O N E* SEEBRI* rabeprazole* PHE NY TE K raniti di ne* SEREVENT* PHE NY T O IN SINGULAIR * PHE NY T O IN EX ACIPHEX SPIRIVA* QUDEXY XR STIOLTO RESPIMAT* ACIPHEX SPRINKLE* ROWE E P RA AXID STRIVERDI* SPRIT A M SYMBICORT* CARAFATE TEGRE T OL CUVPOSA* TRE LEGY ELLIPTA TEGRE T OL XR TUDORZA* CYTOTEC TOP A M AX DEXILANT* UTIBRON* TOP A M A X SPRINK L E VERAMYST NEXIUM* TRILEPTAL NEXIUM GRA DR VOSP IRE ER TROKENDI XR* XOPE N EX PANTOPRAXOLE ZARONTIN PEPCID ZETO NNA ZONEGRAN ZYFLO* PREVACID ZYFLO CR PREVACID DR PRILOSEC PROTONIX ZANTAC ZEGERID

MAINTENANCE MEDICATION EXCEPTION FORM

To initiate a maintenance medication exception authorization, please complete this form and fax it to 888-836-0730. This fax is located in a secure location as required by Health Insurance Portability and Accountability Act (HIPAA) regulations. If you have any questions, please contact 800-241-3371.

CRITERIA FOR APPROVAL

1. Is the requested drug being prescribed for the treatment of a chronic condition? Yes No

2. Has the used the requested drug continuously/daily for the last 180 days or Yes No more?

3. Does the prescriber intend to treat the member with the requested drug continuously Yes No over the next six months? Patient Information First Name: Last Name: Home Phone Number: Work Phone Number: Home Address: City: State: ZIP: Date of Birth: Allergies: Insurance ID: Group #:

Physician Information Name: Physician DEA#: NPI #: Address: City: State: ZIP: Office Contact Name: Phone Number: Fax Number:

Primary Diagnosis Primary ICD-9 (code):

Clinical Information Drug and Dose Requested: Related Diagnosis for the Drug Requested: Quantity Requested (for a 90-day supply): Optional: Rationale for Maintenance Exception (Please attach a letter with medical rationale to this form):

This maintenance medication exception authorization will be valid for 12 months. I attest that this information is accurate and true, and that documentation supporting this information is available for review if requested.

X Prescriber or Authorized Signature Date: (mm/dd/yy)

Note: This fax may contain medical information that is privileged and confidential and is solely for the use of individuals named above. If you are not the intended recipient you hereby are advised that any dissemination, distribution, or copying of this is prohibited. If you have receiv ed the fax in error, please immediately notif y the sender by telephone and destroy the original f ax message.

CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., First Care, Inc., and CareFirst BlueChoice, Inc. are independent licensees of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield Names and Symbols are registered trademarks of the Blue Cross and Blue Shield Association. ®’ Registered trademark of CareFirst of Maryland, Inc.

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