Effective March 2015 Maintenance Drug List Maintenance drugs are prescriptions commonly used to treat conditions that are considered chronic or long-term. These conditions usually require regular, daily use of medicines. Examples of maintenance drugs are those used to treat high blood pressure, heart disease, asthma and diabetes. Due to the large number of available medicines, this list is not all inclusive. Please note this list does not guarantee coverage and is subject to change. Your prescription drug plan may not cover certain products or categories, regardless of their appearance on this list. This list represents brand products in CAPS 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. If you have questions about your prescription drug plan, please visit www.carefirst.com and log in to MyAccount or call CareFirst Pharmacy Services at 800-241-3371. ADHD Antiretrovirals, cont’d Contraceptives/ clonidine er EDURANT Hormone Replacement guanfacine er EMTRIVA estradiol KAPVAY EPZICOM estradiol estropipate STRATTERA FUZEON estradiol gel INVIRASE estradiol transdermal ISENTRESS Allergies ethinyl estradiol- desogestrel INTELENCE desloratidine ethinyl estradiol- drospirenone KALETRA levocetirizine ethinyl estradiol -ethynodiol LEXIVA ethinyl estradiol- levonorgestrel NORVIR ethinyl estradiol-norelgestromin Alzheimer’s Disease PREZCOBIX ethinyl estradiol- norethindrone donepezil PREZISTA ethinyl estradiol- norgestimate galantamine RESCRIPTOR ethinyl estradiol- norgestrel rivastigmine REYATAZ raloxifene norethindrone-mestranol NAMENDA SELZENTRY BEYAZ NAMZARIC STRIBILD CENESTIN SUSTIVA CLIMARA PRO TIVICAY Antifungals COMBIPATCH TRUVADO ENJUVIA NOXAFIL TRIUMEQ ESTRACE VIRACEPT ESTRING VIREAD Antipsychotics EVAMIST VITEKTA aripiprazole FALESSA loxapine olanzapine FEMHRT quetiapine Antivirals FEMRING risperidone - CMV FEMTRACE thiothixene valganciclovir GENERESS LO ziprasidone LOESTRIN EQUETRO MENEST INVEGA Blood Modifiers NATAZIA LATUDA anagrelide NUVARING ORAP cilostazol OSPHENA SEROQUEL XR clopidogrel PREMARIN dipyridamole PREMPHASE -Combinations pentoxifylline PREMPRO Olanzapine/fluoxetine ticlopidine SAFYRAL AGGRENOX BRILINTA Antiretrovirals EFFIENT Depression abacavir sulfate SOLTAMOX bupropion didanosine ZONTIVITY citalopram lamivudine desvenlafaxin lamivudine-zidovudine duloxetine nevirapine Cancer escitalopram stavudine anastrozole fluoxetine APTIVUS exemestane fluvoxamine ATRIPLA letrozole mirtazapine COMPLERA tamoxifen nefazodone CRIXIVAN FARESTON paroxetine Effective March 2015 Depression, cont’d Digestive Enzymes Heart Disease & High phenelzine pancrelipase Blood Pressure sertraline CREON tranylcypromin PANCREAZE -Ace Inhibitors trazodone PERTZYE benazepril venlafaxine SUCRAID captopril APLENZIN ULTRESA enalapril BRINTELLIX VIOKACE fosinopril EMSAM ZENPEP lisinopril FETZIMA moexipril perindopril MARPLAN Diuretics OLEPTRO quinapril acetazolamide PRISTIQ ramipril miloride VIIBRYD trandolapril chlorthalidone chlorothiazide -Angiotensin II Receptor Diabetes dyrenium Antagonists acarbose hydrochlorothiazide (hctz) candesartan chlorpropamide indapamide eprosartan glimepiride metolazone irbesartan glipizide methazolamide losartan glyburide spironolactone telmisartan metformin valsartan nateglinide -Combinations EDARBI pioglitazone hctz/spironolactone repaglinidine hctz/triamterene -Antiarrhythmics tolazamide hctz/amiloride amiodarone tolbutamide disopyramide AVANDIA flecainide BYDUREON Enlarged Prostate mexiletine BYETTA alfuzosin finasteride propafenone CYCLOSET quinidine FARXIGA tamsulosin terazosin gluconate GLYSET INSULIN quinidine INVOKANA AVODART sulfate JANUVIA CARDURA XL JALYN MULTAQ JARDIANCE NESINA RAPAFLO -Beta Blockers ONGLYZA acebutolol SYMLIN TANZEUM Glaucoma atenolol TRADJENTA betaxolol betaxolol bisoprolol TRULICITY binatoprost VICTOZA brimonidine carvedilol carbachol labetalol carteolol Metoprolol -Combinations nadolol glipizide/metformin dorzolamide latanoprost pindolol glyburide/metformin propranolol pioglitazone/glimepiride levobunolol sotalol pioglitazone/metformin methazolamide metipranolol timolol AVANDARYL BYSTOLIC AVANDAMET phospholine COREG CR GLYXAMBI timolol travoprost LEVATOL INVOKAMET JANUMET AZOPT JENTADUETO RESCULA -Calcium Channel Blockers amlodipine JUVISYNC ZIOPTAN KAZANO diltiazem felodipine KOMBIGLYZE XR -Combinations isradipine OSENI dorzolamide/timolol PRANDIMET COMBIGAN nicardipine nifedipine XIGDUO XR SIMBRINZA nisoldipine verapamil -Test Strips/Lancets/Meters Gout glucose meter allopurinol insulin pump probenecid/colchicine insulin syringes and needles ULORIC ACCU-CHEK ALBUSTIX CHEMSTRIPS NOVA MAX PLUS KETONE Effective March 2015 -Combinations High Cholesterol Miscellaneous amlodipine/atorvastatin atorvastatin cevimeline amlodipine/benazepril cholestyramine ergoloid mesylate amlodipine/hctz colestipol eplerenone amlodipine/valsartan fenofibrate lithium nitroglycerin amlodipine/valsartan/hctz fenofibrate micronized pilocarpine atenolol/chlorthalidone fenofibric acid potassium benazepril/ hctz fluvastatin chloride potassium bisoprolol/hctz gemfibrozil gluconate riluzole candesartan/hctz lovastatin ursodiol clonidine/chlorthalidone niacin cr BRISDELLE captopril/hctz pravastatin CORLANOR enalapril/hctz simvastatin COPAXONE fosinopril/hctz ADVICOR GRALISE irbesartan/hctz ANTARA HORIZANT lisinopril /hctz CRESTOR NASCOBAL losartan/hctz LESCOL XL NUEDEXTA methyldopa/ hctz LIPTRUZET NUVIGIL metoprolol/ hctz LIVALO RESTATIS moexipril/ hctz LOVAZA SARAFEM nadolol/bendroflumethiazide SIMCOR SAVELLA propranolol/ hctz VASCEPA quinapril/ hctz VYTORIN Osteoporosis telmisartan/amlodipinee WELCHOL alendronate telmisartan/hctz ZETIA calcitonin trandolapril/verapamil valsartan/hctz ibandronate AMTURNIDE Immune Disorders risedronate AZOR azathioprine ACTONEL BENICAR HCT BINOSTO DUTOPROL Immunosuppressive FOSAMAX D EDARBYCLOR TEKAMLO Agents Overactive Bladder TEKTURNA HCT azathioprine Flavoxate TEVETEN HCT cyclosporine oxybutynin TRIBENZOR mycophenolate tolterodine VALTURNA sirolimus trospium tacrolimus ENABLEX ZORTRESS -Miscellaneous Cardiovascular MYRBETRIQ clonidine OXYTROL digoxin Inflammatory Bowel TOVIAZ guanfacine Disease VESICARE hydralazine methyldopa sulfasalazine minoxidil ASACOL Parkinson’s Disease prazosin APRISO benztropine reserpine DELZICOL bromocriptine BIDIL DIPENTUM carbidopa TEKTURNA PENTASA carbidopa/levodopa carbidopa/levodopa/entacapone Hepatitis Agents Irritable Bowel Syndrome entacapone pramipexole Adefovir AMITIZA ropinirole dipivoxil LINZESS selegiline entecavir LOTRONEX tolcapone lamivudine trihexyphenidyl TYZEKA Kidney Disease AZILECT calcitriol RYTARY calcium acetate levocarnitine Respiratory Agents sevelamer Albuterol AURYXIA sulfateaminophylline FOSRENOL budesonide RENAGEL cromolyn RENVELA dyphylline VELPHORO formoterol ipratropium ipratropium/albuterol levalbuterol Effective March 2015 Respiratory Agents, Seizure Disorders Ulcer/GERD cont’d carbamazepine cimetidine divalproex esomeprazole metaproterenol ethosuximide magnesium montelukast felbamate famotidine terbutaline gabapentin lansoprazole theophylline lamotrigine misoprostol zafirlukast levetiracetam nizatidine ADVAIR oxcarbazepine omeprazole AEROSPAN phenytoin omeprazole/sodium bicarbonate ALVESCO primidone pantoprazole ANORO ELLIPTA tiagabine rabeprazole ARCAPTA topiramate ranitidine ARNUITY ELLIPTA topiramate er sucralfate ASMANEX valproic acid DEXILANT ATROVENT HFA zonisamide ESOMEPRAZOLE BREO ELLIPTA APTIOM STRONTIUM BROVANA BANZEL DALIRESP CELONTIN DULERA GABITRIL FLOVENT OXTELLAR FORADIL PEGANONE INCRUSE ELLIPTA STAVZOR PERFOROMIST TROKENDI XR QVAR SEREVENT SPIRIVA Thyroid STRIVERDI levothyroxine SYMBICORT liothyronine TUDORZA methimazole ZYFLO propylthiouracil thyroid THYROLAR Rheumatoid Arthritis leflunomide RHEUMATREX RIDAURA 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 CareFirst of Maryland, Inc. SUM2723-1P (3/15) MAINTENANCE MEDICATION EXCEPTION FORM To initiate a maintenance medication exception authorization, please complete, review information and fax signed forms to CVS/caremark at 888-487-9257. This fax machine is located in a secure location as required by HIPAA regulations. If you have any questions please contact CVS/caremark at 800-241-3371. CRITERIA FOR APPROVAL 1. Is the requested drug a controlled substance (CII-CV) being prescribed for a 90 day supply? Yes No 2. Is the requested drug being prescribed for the treatment of a chronic condition? Yes No 3. Has the member used the requested drug continuously/daily for the last 180 days or more? Yes No 4. Does the prescriber intend to treat the member with the requested drug continuously over the Yes No next 6 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 Physician Name: Physician DEA#: NPI #: Address: City: State: Zip: Office Contact Name: Phone Number: Fax Number: Primary Diagnosis Primary ICD-9 (code): Clinical Information Drug & Dose Requested: Related Diagnosis for the Drug Requested: Quantity Requested (for a 90-day supply): Rationale for Maintenance Exception(please attach a letter with medical rationale to form): I attest