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GEHA Standard Option, High Option, HDHP Drug List

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GEHA Standard Option, High Option, HDHP Drug List July 2021 GEHA Standard Option, High Option, HDHP Drug List This list only applies to Standard Option, High Option and HDHP members. The GEHA Standard Option, High Option, HDHP Drug List is a guide within select therapeutic categories for clients, plan members and health care providers. Generics should be considered the first line of prescribing. If there is no generic available, there may be more than one brand-name medicine to treat a condition. These preferred brand-name medicines are listed to help identify products that are clinically appropriate and cost-effective. Generics listed in therapeutic categories are for representational purposes only. This is not an all- inclusive list. This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. PLAN MEMBER HEALTH CARE PROVIDER Your benefit plan provides you with a prescription benefit program Your patient is covered under a prescription benefit plan administered administered by CVS Caremark®. Ask your physician to consider by CVS Caremark. As a way to help manage health care costs, prescribing, when medically appropriate, a preferred medicine from authorize generic substitution whenever possible. If you believe a this list. Take this list along when you or a covered family member brand-name product is necessary, consider prescribing a brand name sees a physician. on this list. Please note: Please note: • Your specific prescription benefit plan design may not cover • Generics should be considered the first line of prescribing. certain products or categories, regardless of their appearance in • This drug list represents a summary of prescription coverage. It is this document. Products recently approved by the U.S. Food and not all-inclusive and does not guarantee coverage. The member’s Drug Administration (FDA) may not be covered upon release specific prescription benefit plan design may not cover certain to the market. products or categories, regardless of their appearance in this • For specific information regarding your prescription benefit document. Products recently approved by the FDA may not be coverage and copay1 information, please visit Caremark.com covered upon release to the market. or contact a CVS Caremark Customer Care representative. • The member's prescription benefit plan may have a different • CVS Caremark may contact your physician after receiving your copay for specific products on the list. prescription to request consideration of a drug list product or • Unless specifically indicated, drug list products will include all generic equivalent. This may result in your physician prescribing, dosage forms. when medically appropriate, a different brand-name product or • Log in to Caremark.com to check coverage and copay generic equivalent in place of your original prescription. information for a specific medicine. • 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. ANALGESICS XTAMPZA ER § HERPES AGENTS § OPIOID ANALGESICS § PENICILLINS acyclovir capsule, tablet § NSAIDs buprenorphine transdermal amoxicillin ANTI-INFECTIVES valacyclovir diclofenac sodium codeine-acetaminophen amoxicillin-clavulanate ANTIBACTERIALS ibuprofen fentanyl transdermal dicloxacillin § INFLUENZA AGENTS § CEPHALOSPORINS meloxicam fentanyl transmucosal penicillin VK oseltamivir naproxen (except naproxen CR or lozenge cefdinir RELENZA § TETRACYCLINES naproxen suspension) hydrocodone ext-rel cefprozil hydrocodone-acetaminophen cefuroxime axetil doxycycline hyclate 20 mg § MISCELLANEOUS § NSAIDs, COMBINATIONS hydromorphone cephalexin doxycycline hyclate capsule clindamycin diclofenac sodium- hydromorphone ext-rel SUPRAX minocycline ivermectin misoprostol methadone tetracycline linezolid § ERYTHROMYCINS / morphine metronidazole § NSAIDs, TOPICAL MACROLIDES § ANTIFUNGALS morphine ext-rel nitrofurantoin fluconazole diclofenac sodium solution morphine suppository azithromycin pyrimethamine oxycodone clarithromycin itraconazole sulfamethoxazole- § COX-2 INHIBITORS terbinafine tablet oxycodone-acetaminophen clarithromycin ext-rel trimethoprim celecoxib tramadol (except NDC^ 52817019610) erythromycins vancomycin capsule ANTIVIRALS tramadol ext-rel DIFICID EMVERM § GOUT § CYTOMEGALOVIRUS BELBUCA XIFAXAN 550 MG allopurinol § FLUOROQUINOLONES AGENTS NUCYNTA colchicine tablet ciprofloxacin NUCYNTA ER valganciclovir probenecid levofloxacin SUBSYS MITIGARE moxifloxacin Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit Caremark.com or contact a CVS Caremark Customer Care representative. ANTINEOPLASTIC NEXLIZET § DIURETICS XCOPRI ABILIFY MAINTENA AGENTS amiloride LATUDA § BILE ACID RESINS § ANTIDEMENTIA furosemide PERSERIS HORMONAL cholestyramine donepezil hydrochlorothiazide VRAYLAR ANTINEOPLASTIC AGENTS colesevelam galantamine metolazone § ANTIANDROGENS galantamine ext-rel § ATTENTION DEFICIT § CHOLESTEROL spironolactone- memantine HYPERACTIVITY DISORDER bicalutamide hydrochlorothiazide ABSORPTION INHIBITORS rivastigmine amphetamine- torsemide § MISCELLANEOUS ezetimibe rivastigmine transdermal dextroamphetamine mixed triamterene NAMZARIC salts VISTOGARD § FIBRATES triamterene- atomoxetine hydrochlorothiazide (except fenofibrate tablet ANTIDEPRESSANTS CARDIOVASCULAR fenofibrate dexmethylphenidate ext-rel 120 mg) HEART FAILURE § SELECTIVE SEROTONIN guanfacine ext-rel § ACE INHIBITORS fenofibric acid delayed-rel REUPTAKE INHIBITORS BIDIL methylphenidate fosinopril CORLANOR (SSRIs) ADDERALL XR lisinopril § HMG-CoA REDUCTASE ENTRESTO citalopram CONCERTA quinapril INHIBITORS / escitalopram MYDAYIS ramipril COMBINATIONS § NITRATES fluoxetine (except fluoxetine tablet 60 VYVANSE atorvastatin isosorbide dinitrate (except mg, fluoxetine tablet [generics for § ACE INHIBITOR / ezetimibe-simvastatin § FIBROMYALGIA isosorbide dinitrate 40 mg) SARAFEM]) DIURETIC COMBINATIONS fluvastatin isosorbide mononitrate paroxetine HCl pregabalin fosinopril-hydrochlorothiazide lovastatin nitroglycerin lingual spray paroxetine HCl ext-rel lisinopril-hydrochlorothiazide pravastatin HYPNOTICS nitroglycerin sublingual sertraline quinapril-hydrochlorothiazide rosuvastatin TRINTELLIX § NONBENZODIAZEPINES simvastatin § MISCELLANEOUS eszopiclone § ANGIOTENSIN II § SEROTONIN RECEPTOR ANTAGONISTS / § NIACINS ranolazine ext-rel ramelteon NOREPINEPHRINE zolpidem DIURETIC COMBINATIONS niacin ext-rel CENTRAL NERVOUS REUPTAKE INHIBITORS zolpidem ext-rel candesartan / candesartan- SYSTEM (SNRIs) zolpidem sublingual hydrochlorothiazide § OMEGA-3 FATTY ACIDS desvenlafaxine ext-rel BELSOMRA irbesartan / irbesartan- omega-3 acid ethyl esters ANTIANXIETY duloxetine hydrochlorothiazide VASCEPA § BENZODIAZEPINES venlafaxine § TRICYCLICS losartan / losartan- § BETA-BLOCKERS alprazolam venlafaxine ext-rel capsule doxepin hydrochlorothiazide clonazepam atenolol olmesartan / olmesartan- diazepam § MISCELLANEOUS MIGRAINE carvedilol hydrochlorothiazide lorazepam AGENTS ACUTE MIGRAINE AGENTS telmisartan / telmisartan- carvedilol phosphate ext-rel oxazepam bupropion § Triptans hydrochlorothiazide metoprolol succinate ext-rel bupropion ext-rel (except valsartan / valsartan- metoprolol tartrate § ANTICONVULSANTS eletriptan bupropion ext-rel tablet 450 mg) naratriptan hydrochlorothiazide nadolol carbamazepine mirtazapine pindolol rizatriptan carbamazepine ext-rel trazodone § ANGIOTENSIN II propranolol sumatriptan clobazam RECEPTOR ANTAGONIST / propranolol ext-rel zolmitriptan diazepam rectal gel § ANTIPARKINSONIAN CALCIUM CHANNEL BYSTOLIC ONZETRA XSAIL divalproex sodium AGENTS BLOCKER COMBINATIONS ZEMBRACE SYMTOUCH § CALCIUM CHANNEL divalproex sodium ext-rel amantadine amlodipine-olmesartan ZOMIG NASAL SPRAY BLOCKERS ethosuximide carbidopa-levodopa amlodipine-telmisartan gabapentin carbidopa-levodopa ext-rel Miscellaneous amlodipine amlodipine-valsartan lamotrigine carbidopa-levodopa- diltiazem ext-rel (except generics NURTEC ODT lamotrigine ext-rel entacapone § ANGIOTENSIN II for CARDIZEM LA) REYVOW levetiracetam entacapone RECEPTOR ANTAGONIST / nifedipine ext-rel UBRELVY levetiracetam ext-rel pramipexole CALCIUM CHANNEL verapamil ext-rel BLOCKER / DIURETIC oxcarbazepine pramipexole ext-rel PREVENTIVE MIGRAINE COMBINATIONS § CALCIUM CHANNEL phenobarbital rasagiline AGENTS BLOCKER / ANTILIPEMIC phenytoin ropinirole amlodipine-valsartan- Monoclonal Antibodies COMBINATIONS phenytoin sodium extended ropinirole ext-rel hydrochlorothiazide AIMOVIG primidone selegiline olmesartan-amlodipine- amlodipine-atorvastatin AJOVY rufinamide NEUPRO EMGALITY hydrochlorothiazide § DIGITALIS GLYCOSIDES tiagabine ANTIPSYCHOTICS § ANTIARRHYTHMICS digoxin topiramate § MUSCULOSKELETAL valproic acid § ATYPICALS THERAPY AGENTS disopyramide § DIRECT RENIN zonisamide sotalol aripiprazole cyclobenzaprine (except INHIBITORS / DIURETIC FYCOMPA MULTAQ clozapine cyclobenzaprine tablet 7.5 mg) COMBINATIONS NAYZILAM olanzapine ANTILIPEMICS aliskiren OXTELLAR XR quetiapine § NARCOLEPSY ACL INHIBITORS / TEKTURNA HCT TROKENDI XR quetiapine ext-rel armodafinil COMBINATIONS VALTOCO risperidone modafinil VIMPAT ziprasidone SUNOSI NEXLETOL Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. For specific information, visit Caremark.com or contact a CVS Caremark Customer Care representative.
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