Microsoft Word - MM_CareFirst Plan District of Columbia

2023

CareFirst BlueCross BlueShield Community

Health Plan District of Columbia Formulary

CareFirst BlueCross BlueShield Community Health Plan District of Columbia is an independent

licensee of the Blue Cross and Blue Shield Association. BLUE CROSS®, BLUE SHIELD® and the

Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield

Association, an association of independent Blue Cross and Blue Shield Plans.

CareFirst Plan DC

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Contents

Introduction ........................................................................................................................................... 3

The CareFirst CHPDC Pharmacy and Therapeutics Committee (P&T) ................................................ 3

Notice .................................................................................................................................................... 3

Preface ................................................................................................................................................. 3

Product Selection Criteria ..................................................................................................................... 3

Formulary Components ........................................................................................................................ 4

Generic Substitution .............................................................................................................................. 4

Covered Medications without Authorization .......................................................................................... 4

Non-Covered Benefits ........................................................................................................................... 4

Prior Authorization ................................................................................................................................ 4

Step Therapy ........................................................................................................................................ 4

Specialty Medications ........................................................................................................................... 4

Benefit Exception .................................................................................................................................. 5

Pharmacy Benefit Management ............................................................................................................ 5

Formulary Drug List .............................................................................................................................. 9

Drug Name ............................................................................................................................................ 9

Index ................................................................................................................................................... 78

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Introduction

CareFirst BlueCross BlueShield Community Health Plan District of Columbia (CareFirst CHPDC)

formerly known as Trusted Health Plan (District of Columbia), Inc, is pleased to provide an updated

2020 Medicaid Formulary as a reference and informational tool for physicians, pharmacists and

patients. The CareFirst Community Health Plan, District of Columbia Formulary is designed to assist

practitioners in selecting clinically appropriate and cost-effective products for their patients.

The CareFirst CHPDC Pharmacy and Therapeutics Committee (P&T)

The medications on this formulary have been reviewed by the CareFirst CHPDC P&T Committee.

The Committee includes physicians, pharmacists and health professionals. The clinical information

within the formulary is primarily derived from medical literature and is reviewed and approved by the

P&T Committee.

Notice

The information contained in this formulary is provided by CareFirst CHPDC, solely for the

convenience of medical providers. This formulary is not intended to be a substitute for the knowledge,

expertise, skill and judgment of the medical provider in their choice of prescription drugs. CareFirst

CHPDC assumes no responsibility for the actions or omissions of any medical provider based upon

reliance, in whole or in part, on the information contained herein. The medical provider should consult

the drug manufacturer’s product literature or standard references for more detailed information.

Preface

The CareFirst CHPDC formulary is organized by sections. Each section includes therapeutic groups

identified by either drug class or disease state. Products are listed by its dispensable name. Brand

names are included as a reference to assist in product recognition. CareFirst CHPDC will not cover

prescription drugs that are prescribed for experimental, investigational or non-FDA approved

indications, dosages, or routes of administration. CareFirst CHPDC does not cover any medication

excluded by District of Columbia Medicaid

(https://dc.fhsc.com/downloads/providers/dcrx_pdl_listing.pdf).

Product Selection Criteria

The CareFirst CHPDC P&T Committee considers clinical information on new to market drugs that are

typically included in an outpatient pharmacy benefit. The primary goal of the CareFirst CHPDC P&T

Committee is to preserve and evaluate the CareFirst CHPDC formulary based upon an objective

analysis of the safety, efficacy, approved indications, adverse effects, contraindications, patient

administration/compliance considerations and cost effectiveness. When a new drug is considered for

formulary inclusion, it will be reviewed relative to similar drugs currently included in the CareFirst

CHPDC Formulary. Formulary decisions are communicated quarterly on the CareFirst CHPDC

website. Therapeutic substitution occurs when a preferred drug is approved for use because it has

similar treatment effects but is not identical to a non-preferred drug.

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Formulary Components

The CareFirst CHPDC Formulary contains the following components: Covered medications without

authorization, medications that must meet Step Therapy Protocol, medications that require Prior

Authorization, Specialty medications and medications that are subject to Quantity Limits. Members

will not be charged a co-pay when CareFirst CHPDC covers a medication.

Generic Substitution

CareFirst CHPDC is a mandatory generic plan. The brand and common names listed in the formulary

are for reference only. Generic medication will be dispensed where available.

Covered Medications without Authorization

CareFirst CHPDC covers many medications without any authorization required. These medications

include many prescription and over-the-counter medications (when ordered by a physician).

Non-Covered Benefits

The following categories are not covered benefits: Medications used for cosmetic purposes, to

promote fertility, for sexual dysfunction, for experimental or investigational purposes, or medications

that are not licensed for use in the United States.

Prior Authorization

Drugs indicated with "PA" require Prior Authorization for coverage. Details of the PA criteria are listed

next to the drug name. Please call the Abarca Health Help Desk at 866-287-6156 or fax a completed

Prior Authorization form to 866-839-2372. All requests must be accompanied by pertinent clinical

information and are reviewed within 24 hours.

Step Therapy

Drugs indicated with a "ST" require Step Therapy for coverage. The required step is listed next to the

drug name. Step Therapy ensures clinically appropriate and cost-effective drugs are used before

other alternatives.

Specialty Medications

All specialty medications are handled by Abarca Health. To order a specialty medication by fax, send

the prescription and a completed prior authorization form to 866-839-2372 or call Abarca Health Help

Desk at 866-287-6156.

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Quantity Limits

Drugs indicated with a "QL" have a set quantity limit imposed. These limits are based on FDA

recommended dosing guidelines. The quantity limit is listed next to the drug name. All medications

are subject to a maximum of 30 days per prescription.

Benefit Exception

The process for requesting non-formulary medication(s) requires faxing of a completed Formulary

Exception form indicating the request for an exception to the formulary. This request will need to

include pertinent clinical documentation showing trial and failure of all formulary agents. It should also

contain information showing the medication is the standard of care for the indication provided (Peer

reviewed journal articles may be required). Please call the Abarca Health Help Desk at 866-287-6156

or fax a completed Formulary Exception form to 866-839-2372.

Pharmacy Benefit Management

CareFirst CHPDC utilizes Abarca Health to manage each member’s pharmacy benefit. Abarca Health

provides CareFirst CHPDC with a pharmacy network, pharmacy claims management services, and

claims adjudication. Abarca Health Help Desk can be contacted at 866-287-6156.

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Table of Contents

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS ........................................................... 9

AMINOGLYCOSIDES ........................................................................................................................ 10

ANALGESICS - ANTI-INFLAMMATORY ........................................................................................... 10

ANALGESICS - NONNARCOTIC ...................................................................................................... 12

ANALGESICS - OPIOID ..................................................................................................................... 13

ANORECTAL AGENTS ..................................................................................................................... 16

ANTACIDS ......................................................................................................................................... 16

ANTIANGINAL AGENTS ................................................................................................................... 17

ANTIANXIETY AGENTS .................................................................................................................... 17

ANTIARRHYTHMICS ......................................................................................................................... 18

ANTIASTHMATIC AND BRONCHODILATOR AGENTS................................................................... 18

ANTICOAGULANTS .......................................................................................................................... 20

ANTICONVULSANTS ........................................................................................................................ 20

ANTIDEMENTIA AGENTS - DRUGS TO TREAT ALZHEIMER'S DISEASE AND DEMENTIA ........ 22

ANTIDEPRESSANTS ......................................................................................................................... 22

ANTIDIABETICS ................................................................................................................................ 24

ANTIDIARRHEAL/PROBIOTIC AGENTS .......................................................................................... 27

ANTIDOTES AND SPECIFIC ANTAGONISTS .................................................................................. 27

ANTIEMETICS .................................................................................................................................... 27

ANTIFUNGALS .................................................................................................................................. 27

ANTIHISTAMINES ............................................................................................................................. 28

ANTIHYPERLIPIDEMICS ................................................................................................................... 30

ANTIHYPERTENSIVES ..................................................................................................................... 30

ANTI-INFECTIVE AGENTS - MISC. ................................................................................................... 32

ANTIMALARIALS .............................................................................................................................. 33

ANTIMYASTHENIC/CHOLINERGIC AGENTS .................................................................................. 33

ANTIMYCOBACTERIAL AGENTS .................................................................................................... 33

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ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES .................................................................... 33

ANTIPARKINSON AND RELATED THERAPY AGENTS.................................................................. 34

ANTIPSYCHOTICS/ANTIMANIC AGENTS ....................................................................................... 35

ANTIVIRALS ...................................................................................................................................... 37

BETA BLOCKERS ............................................................................................................................. 38

CALCIUM CHANNEL BLOCKERS .................................................................................................... 38

CARDIOTONICS ................................................................................................................................ 39

CARDIOVASCULAR AGENTS - MISC. ............................................................................................. 39

CENTRAL NERVOUS SYSTEM AGENTS......................................................................................... 40

CEPHALOSPORINS .......................................................................................................................... 40

CONTRACEPTIVES ........................................................................................................................... 40

CORTICOSTEROIDS ......................................................................................................................... 44

COUGH/COLD/ALLERGY ................................................................................................................. 45

DERMATOLOGICALS ....................................................................................................................... 47

DIAGNOSTIC PRODUCTS ................................................................................................................ 52

DIGESTIVE AIDS ............................................................................................................................... 52

DIURETICS ......................................................................................................................................... 52

ENDOCRINE AND METABOLIC AGENTS - MISC. .......................................................................... 53

ESTROGENS ..................................................................................................................................... 54

FLUOROQUINOLONES ..................................................................................................................... 54

GASTROINTESTINAL AGENTS - DRUGS TO TREAT BOWEL, INTESTINE AND STOMACH

CONDITIONS ..................................................................................................................................... 55

GASTROINTESTINAL AGENTS - MISC............................................................................................ 55

GENITOURINARY AGENTS - MISCELLANEOUS ............................................................................ 56

GOUT AGENTS .................................................................................................................................. 56

HEMATOLOGICAL AGENTS - MISC. ............................................................................................... 56

HEMATOPOIETIC AGENTS .............................................................................................................. 56

HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS ................................................................. 57

LAXATIVES ........................................................................................................................................ 57

LOCAL ANESTHETICS-PARENTERAL ............................................................................................ 59

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MACROLIDES .................................................................................................................................... 59

MEDICAL DEVICES AND SUPPLIES ............................................................................................... 59

MIGRAINE PRODUCTS ..................................................................................................................... 62

MINERALS & ELECTROLYTES ........................................................................................................ 63

MISCELLANEOUS THERAPEUTIC CLASSES ................................................................................. 63

MOUTH/THROAT/DENTAL AGENTS ............................................................................................... 64

MULTIVITAMINS ................................................................................................................................ 64

MUSCULOSKELETAL THERAPY AGENTS ..................................................................................... 65

NASAL AGENTS - SYSTEMIC AND TOPICAL ................................................................................. 65

OPHTHALMIC AGENTS .................................................................................................................... 65

OPHTHALMIC AGENTS - DRUGS TO TREAT EYE CONDITIONS .................................................. 68

OTIC AGENTS ................................................................................................................................... 68

OXYTOCICS ....................................................................................................................................... 68

PASSIVE IMMUNIZING AND TREATMENT AGENTS ...................................................................... 68

PENICILLINS ...................................................................................................................................... 68

PROGESTINS .................................................................................................................................... 69

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. ................................................ 69

RESPIRATORY AGENTS - MISC. ..................................................................................................... 71

TETRACYCLINES .............................................................................................................................. 71

THYROID AGENTS ............................................................................................................................ 71

TOXOIDS ............................................................................................................................................ 72

ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS............................................................ 72

URINARY ANTI-INFECTIVES ............................................................................................................ 73

URINARY ANTISPASMODICS .......................................................................................................... 73

VACCINES ......................................................................................................................................... 74

VAGINAL AND RELATED PRODUCTS ............................................................................................ 76

VASOPRESSORS .............................................................................................................................. 77

VITAMINS ........................................................................................................................................... 77

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Formulary Drug List

Drug Name

Drug

Tier

Reference Name Requirements/Limits

THERAPEUTIC CATEGORY

Therapeutic Class

ADHD/ANTI

NARCOLEPSY/ANTI

OBESITY/ANOREXIANTS

Amphetamines

amphetamine-dextroamphet er 10

mg cap er 24 hr, 15 mg cap er 24

hr, 20 mg cap er 24 hr, 25 mg cap

er 24 hr, 30 mg cap er 24 hr, 5 mg

cap er 24 hr

ADDERALL XR

QL(60 / 30)

amphetamine-dextroamphetamine

30 mg tab

ADDERALL

QL(60 / 30)

amphetamine-dextroamphetamine

10 mg tab, 15 mg tab, 20 mg tab, 5

mg tab

ADDERALL

QL(90 / 30)

dextroamphetamine sulfate 10 mg

tab, 5 mg tab

DEXTROSTAT

QL(120 / 30)

dextroamphetamine sulfate 15 mg

tab

ZENZEDI

QL(60 / 30)

dextroamphetamine sulfate er 10

mg cap er 24 hr, 15 mg cap er 24

DEXEDRINE

QL(60 / 30)

Attention

deficit/hyperactivity Disorder (adhd) Agents

clonidine hcl er 0.1 mg tab er 12 hr

KAPVAY

90 Days Supply Drug

guanfacine hcl er 1 mg tab er 24 hr,

2 mg tab er 24 hr, 3 mg tab er 24

hr, 4 mg tab er 24 hr

INTUNIV

90 Days Supply Drug

Stimulants

Misc.

dexmethylphenidate hcl 10 mg tab

FOCALIN

QL(60 / 30)

dexmethylphenidate hcl 2.5 mg tab,

5 mg tab

FOCALIN

QL(120 / 30)

dexmethylphenidate hcl er 10 mg

cap er 24 hr, 15 mg cap er 24 hr,

20 mg cap er 24 hr, 25 mg cap er

24 hr, 30 mg cap er 24 hr, 40 mg

cap er 24 hr, 5 mg cap er 24 hr

FOCALIN XR

QL(30 / 30)

methylphenidate hcl 10 mg tab, 20

mg tab, 5 mg tab

RITALIN

QL(90 / 30)

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Drug Name

Drug

Tier

Reference Name Requirements/Limits

methylphenidate hcl er 18 mg tab

er 24 hr, 27 mg tab er 24 hr, 54 mg

tab er 24 hr

QL(30 / 30)

methylphenidate hcl er 36 mg tab

er 24 hr

QL(60 / 30)

methylphenidate hcl er 10 mg tab

er, 20 mg tab er

RITALIN SR

QL(90 / 30)

methylphenidate hcl er (la) 20 mg

cap er 24 hr, 40 mg cap er 24 hr

RITALIN LA

QL(60 / 30)

methylphenidate hcl er (osm) 18

mg tab er, 27 mg tab er, 54 mg tab

CONCERTA

QL(30 / 30)

methylphenidate hcl er (osm) 36

mg tab er

CONCERTA

QL(60 / 30)

modafinil 100 mg tab, 200 mg tab

PROVIGIL

AMINOGLYCOSIDES

Aminoglycosides

tobramycin 300 mg/5ml inh neb

soln

TOBI

ANALGESICS

ANTI

INFLAMMATORY

Antirheumatic

Enzyme Inhibitors

XELJANZ 10 mg tab, 5 mg tab

XELJANZ XR 11 mg tab er 24 hr,

22 mg tab er 24 hr

Anti

tnf

alpha

Monoclonal Antibodies

HUMIRA 40 mg/0.8ml sc pfs kit

SP, PA

HUMIRA PEN 40 mg/0.8ml sc pen-

inj kit

SP, PA

HUMIRA PEN-CD/UC/HS

STARTER 40 mg/0.8ml sc pen-inj

kit

SP, PA

HUMIRA PEN-PS/UV/ADOL HS

START 40 mg/0.8ml sc pen

inj kit

SP, PA

Interleukin

1 Receptor Antagonist (il

1ra)

KINERET 100 mg/0.67ml sc soln

pfs

SP, PA

Nonsteroidal

Anti

inflammatory Agents (nsaids)

celecoxib 100 mg cap, 200 mg cap,

400 mg cap

CELEBREX

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Drug Name

Drug

Tier

Reference Name Requirements/Limits

childrens ibuprofen 100 mg/5ml

susp

MOTRIN CHILDRENS

diclofenac sodium 25 mg tab dr, 50

mg tab dr, 75 mg tab dr

VOLTAREN

diclofenac sodium er 100 mg tab er

24 hr

VOLTAREN XR

gnp childrens ibuprofen 100

mg/5ml susp

MOTRIN CHILDRENS

goodsense ibuprofen 200 mg tab

MOTRIN

goodsense ibuprofen childrens 100

mg/5ml susp

MOTRIN CHILDRENS

goodsense ibuprofen infants 50

mg/1.25ml susp

hm ibuprofen childrens 100 mg/5ml

susp

MOTRIN CHILDRENS

ibu

200 200 mg tab

MOTRIN

ibuprofen 200 mg cap

ADVIL

ibuprofen 200 mg tab, 400 mg tab,

600 mg tab, 800 mg tab

MOTRIN

ibuprofen 100

mg/5ml susp

MOTRIN CHILDRENS

ibuprofen childrens 100 mg/5ml

susp

MOTRIN CHILDRENS

ibuprofen infants 50 mg/1.25ml

susp

ibuprofen junior strength 100 mg

tab chew

MOTRIN CHILDRENS

ketorolac tromethamine 10 mg tab

TORADOL

meloxicam 15 mg tab, 7.5 mg tab

MOBIC

nabumetone 500 mg tab, 750 mg

tab

RELAFEN

naproxen 250 mg tab, 375 mg tab,

375 mg tab dr, 500 mg tab, 500 mg

tab dr

NAPROSYN

naproxen 125 mg/5ml susp

NAPROSYN

naproxen dr 375 mg tab dr, 500 mg

tab dr

NAPROSYN

naproxen sodium 275 mg tab, 550

mg tab

ANAPROX

naproxen sodium er 500 mg tab er

24 hr

NAPRELAN

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Drug Name

Drug

Tier

Reference Name Requirements/Limits

oxaprozin 600 mg tab

DAYPRO

sm childrens ibuprofen 100 mg/5ml

susp

MOTRIN CHILDRENS

sm ibuprofen 200 mg tab

MOTRIN

sm ibuprofen ib 200 mg tab

MOTRIN

sm ibuprofen ib 100 mg tab chew

MOTRIN CHILDRENS

sm infants ibuprofen 50 mg/1.25ml

susp

sulindac 150 mg tab, 200 mg tab

CLINORIL

Pyrimidine Synthesis Inhibitors

leflunomide 10 mg tab, 20 mg tab

ARAVA

Soluble Tumor Necrosis Factor Receptor Agents

ENBREL 50 mg/ml sc

soln pfs

SP, PA

ENBREL SURECLICK 50 mg/ml sc

soln auto

inj

SP, PA

ANALGESICS

NONNARCOTIC

Analgesic Combinations

butalbital-apap-caffeine 50-300-40

mg cap

FIORICET

QL(45 / 25)

butalbital-aspirin-caffeine 50-325-

40 mg tab

QL(180 / 25)

Analgesics Other

acetaminophen 325 mg tab, 500

mg tab

acetaminophen 160 mg/5ml liq

acetaminophen extra strength 500

mg tab

apap 160 mg/5ml liq

goodsense pain relief extra st 500

mg tab

sm pain reliever 325 mg tab

sm pain reliever ex st 500 mg tab

tactinal 325 mg tab

Salicylates

adult aspirin regimen 81 mg tab dr

aspirin 325 mg tab, 81 mg tab

chew, 81 mg tab dr

aspirin 81 81 mg tab dr

aspirin adult low dose 81 mg tab dr

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Drug Name

Drug

Tier

Reference Name Requirements/Limits

aspirin adult low strength 81 mg tab

chew

aspirin ec 325 mg tab dr

aspirin ec low strength 81 mg tab dr

aspirin low dose 81 mg tab chew,

81 mg tab dr

diflunisal 500 mg tab

DOLOBID

gnp aspirin 81 mg tab dr

gnp aspirin low dose 81 mg tab dr

goodsense aspirin 81 mg tab chew

hm aspirin 81 mg tab chew

hm aspirin ec low dose 81 mg tab

sm aspirin 325 mg tab

sm aspirin adult low strength 81 mg

tab chew, 81 mg tab dr

sm aspirin ec 325 mg tab dr

sm aspirin low dose 81 mg tab

chew

sm childrens aspirin 81 mg tab

chew

ANALGESICS

OPIOID

Opioid Agonists

fentanyl 100 mcg/hr td patch 72 hr,

12 mcg/hr td patch 72 hr, 25 mcg/hr

td patch 72 hr, 50 mcg/hr td patch

72 hr, 75 mcg/hr td patch 72 hr

DURAGESIC

PA, QL(10 / 30)

hydromorphone hcl 8 mg tab

DILAUDID

QL(60 / 30)

hydromorphone hcl 4 mg tab

DILAUDID

QL(150 / 30)

hydromorphone hcl 2 mg tab

DILAUDID

QL(330 / 30)

hydromorphone hcl er 12 mg tab er

24 hr, 16 mg tab er 24 hr, 32 mg

tab er 24 hr, 8 mg tab er 24 hr

PA, QL(30 / 30)

morphine

sulfate 30 mg tab

QL(90 / 30)

morphine sulfate 15 mg tab

QL(180 / 30)

morphine sulfate er 100 mg cap er

24 hr, 50 mg cap er 24 hr, 60 mg

cap er 24 hr, 80 mg cap er 24 hr

KADIAN

PA, QL(30 / 30)

morphine sulfate er 40 mg cap er

24 hr

KADIAN

PA, QL(60 / 30)

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Drug Name

Drug

Tier

Reference Name Requirements/Limits

morphine sulfate er 30 mg cap er

24 hr

KADIAN

PA, QL(90 / 30)

morphine sulfate er 20 mg cap er

24 hr

KADIAN

PA, QL(120 / 30)

morphine sulfate er 10 mg cap er

24 hr

KADIAN

PA, QL(270 / 30)

morphine sulfate er 100 mg tab er,

200 mg tab er, 60 mg tab er

MS CONTIN

PA, QL(30 / 3

morphine sulfate er 30 mg tab er

MS CONTIN

PA, QL(90 / 30)

morphine sulfate er 15 mg tab er

MS CONTIN

PA, QL(120 / 30)

morphine sulfate er beads 120 mg

cap er 24 hr, 60 mg cap er 24 hr,

75 mg cap er 24 hr, 90 mg cap er

24 hr

AVINZA

PA, QL(30 / 30)

morphine sulfate er beads 45 mg

cap er 24 hr

AVINZA

PA, QL(60 / 30)

morphine sulfate er beads 30 mg

cap er 24 hr

AVINZA

PA, QL(90 / 30)

oxycodone hcl 5 mg cap

OXYIR

QL(360 / 30)

oxycodone hcl 30 mg tab

ROXICODONE

QL(60 / 30)

oxycodone hcl 20 mg tab

ROXICODONE

QL(90 / 30)

oxycodone hcl 15 mg tab

ROXICODONE

QL(120 / 30)

oxycodone hcl 10 mg tab

ROXICODONE

QL(180 / 30)

oxycodone hcl 5 mg tab

ROXICODONE

QL(360 / 30)

oxycodone hcl 5 mg/5ml soln

ROXICODONE

QL(1800 / 30)

tramadol hcl 50 mg tab

ULTRAM

QL(240 / 30)

tramadol hcl er 100 mg cap er 24 hr

CONZIP

PA, QL(90 / 30)

tramadol hcl er 200 mg tab er 24 hr

ULTRAM ER

PA, QL(30 / 25)

tramadol hcl er 300 mg tab er 24 hr

ULTRAM ER

PA, QL(30 / 30)

tramadol hcl er 100 mg tab er 24 hr

ULTRAM ER

PA, QL(90 / 30)

tramadol hcl er (biphasic) 100 mg

tab er 24 hr

RYZOLT

PA, QL(30 / 25)

Opioid Combinations

acetaminophen-codeine 300-60 mg

tab

TYLENOL WITH

CODEINE

QL(180 / 30)

acetaminophen-codeine 300-15 mg

tab

TYLENOL WITH

CODEINE

QL(360 / 30)

acetaminophen-codeine 120-12

mg/5ml soln

TYLENOL WITH

CODEINE

QL(4500 / 30)

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Drug Name

Drug

Tier

Reference Name Requirements/Limits

acetaminophen-codeine #2 300-15

mg tab

TYLENOL WITH

DEINE

QL(360 / 30)

acetaminophen-codeine #3 300-30

mg tab

TYLENOL WITH

CODEINE

QL(360 / 30)

acetaminophen-codeine #4 300-60

mg tab

TYLENOL WITH

CODEINE

QL(180 / 30)

butalbital-apap-caff-cod 50-300-40-

30 mg cap

FIORICET WITH

CODEINE

QL(45 / 25)

butalbital-asa-caff-codeine 50-325-

30 mg cap

FIORINAL WITH

CODEINE

QL(360 / 30)

hydrocodone-acetaminophen 5-325

mg tab

NORCO

QL(360 / 30)

hydrocodone-acetaminophen 5-300

mg tab

VICODIN

QL(390 / 30)

LORCET 5

325 mg tab

QL(360 / 30)

oxycodone-acetaminophen 5-325

mg tab

PERCOCET

QL(360 / 30)

tramadol-acetaminophen 37.5-325

mg tab

ULTRACET

QL(300 / 30)

Opioid Partial Agonists

BUNAVAIL 6.3

1 mg bucc film

QL(60 / 30)

BUNAVAIL 4.2

0.7 mg bucc film

QL(90 / 30)

BUNAVAIL 2.1

0.3 mg bucc film

QL(180 / 30)

buprenorphine hcl 8 mg tab subl

SUBUTEX

QL(90 / 30)

buprenorphine hcl 2 mg

tab subl

SUBUTEX

QL(360 / 30)

buprenorphine hcl-naloxone hcl 12-

3 mg subl film

SUBOXONE

QL(60 / 30)

buprenorphine hcl-naloxone hcl 8-2

mg subl film, 8

2 mg tab subl

SUBOXONE

QL(90 / 30)

buprenorphine hcl-naloxone hcl 4-1

mg subl film

SUBOXONE

QL(180 / 30)

buprenorphine hcl-naloxone hcl 2-

0.5 mg subl film, 2

0.5 mg tab subl

SUBOXONE

QL(360 / 30)

SUBLOCADE 100 mg/0.5ml sc

soln pfs

QL(0.5 / 30)

SUBLOCADE 300 mg/1.5ml sc

soln pfs

QL(1.5 / 30)

SUBOXONE 12

3 mg subl film

QL(60 / 30)

SUBOXONE 8

2 mg

subl film

QL(90 / 30)

SUBOXONE 4

1 mg subl film

QL(180 / 30)

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Drug Name

Drug

Tier

Reference Name Requirements/Limits

SUBOXONE 2

0.5 mg subl film

QL(360 / 30)

ZUBSOLV 11.4

2.9 mg tab subl

QL(30 / 30)

ZUBSOLV 8.6

2.1 mg tab subl

QL(60 / 30)

ZUBSOLV 5.7

1.4 mg tab subl

QL(90 / 30)

ZUBSOLV 2.9

0.71 mg tab subl

QL(150 / 30)

ZUBSOLV 1.4

0.36 mg tab subl

QL(330 / 30)

ZUBSOLV 0.7

0.18 mg tab subl

QL(690 / 30)

ANORECTAL AGENTS

Rectal Combinations

hemorrhoidal 1

0.25

14.4

15 % crm

lidocaine-hydrocortisone ace 3-1 %

rect kit

ANAMANTLE HC

Rectal Steroids

anucort

hc 25 mg

rect supp

hydrocortisone (perianal) 1 % crm

PROCTOCORT

hydrocortisone acetate 25 mg rect

supp

hydrocortisone acetate 30 mg rect

supp

PROCTOCORT

ANTACIDS

Antacid Combinations

antacid 200

200

20 mg/5ml susp

antacid anti-gas max strength 400-

400

40 mg/5ml susp

antacid fast acting 200-200-20

mg/5ml susp

antacid maximum strength 400-

400

40 mg/5ml susp

hm antacid/antigas 200-200-20

mg/5ml susp

sm antacid advanced max st 400-

400

40 mg/5ml susp

sm antacid/antigas 200-200-20

mg/5ml susp

Antacids

Aluminum Salts

aluminum hydroxide gel 320

mg/5ml susp

Antacids

Calcium Salts

calcium antacid 500 mg

tab chew

CareFirst Plan DC

Page 17 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

calcium carbonate antacid 648 mg

tab

calcium carbonate antacid 1250

mg/5ml susp

Antacids

Magnesium Salts

magnesium oxide 400 (240 Mg) mg

tab, 400 mg tab

ANTIANGINAL AGENTS

Nitrates

isosorbide dinitrate 10 mg tab, 20

mg tab, 30 mg tab, 5 mg tab

ISORDIL TITRADOSE

isosorbide mononitrate 10 mg tab,

20 mg tab

MONOKET

isosorbide mononitrate er 120 mg

tab er 24 hr, 30 mg tab er 24 hr, 60

mg tab er 24 hr

IMDUR

nitroglycerin 0.2 mg/hr td patch

24hr, 0.4 mg/hr td patch 24hr

NITRO

DUR

nitroglycerin 0.3 mg tab subl, 0.4

mg tab subl

NITROSTAT

ANTIANXIETY AGENTS

Antianxiety Agents

Misc.

buspirone hcl 10 mg tab, 15 mg

tab, 30 mg tab, 5 mg tab, 7.5 mg

tab

BUSPAR

hydroxyzine hcl 10 mg tab, 25 mg

tab, 50 mg tab

ATARAX

hydroxyzine hcl 10 mg/5ml syr

ATARAX

hydroxyzine pamoate 100 mg cap,

25 mg cap, 50 mg cap

VISTARIL

Benzodiazepines

alprazolam 0.25 mg tab, 0.5 mg

tab, 1 mg tab, 2 mg tab

XANAX

QL(90 / 30)

chlordiazepoxide hcl 10 mg cap, 25

mg cap, 5 mg cap

LIBRIUM

QL(120 / 30)

diazepam 5 mg/5ml soln

VALIUM

diazepam 10 mg tab, 2 mg tab, 5

mg tab

VALIUM

QL(120 / 30)

lorazepam 0.5 mg tab, 1 mg tab, 2

mg tab

ATIVAN

QL(120 / 30)

CareFirst Plan DC

Page 18 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

oxazepam 10 mg cap, 15 mg cap,

30 mg cap

SERAX

QL(120 /

30)

ANTIARRHYTHMICS

Antiarrhythmics Type I

flecainide acetate 50 mg tab

TAMBOCOR

propafenone hcl er 325 mg cap er

12 hr, 425 mg cap er 12 hr

RYTHMOL SR

Antiarrhythmics Type Iii

amiodarone hcl 200 mg tab

CORDARONE

ANTIASTHMATIC AND BRONCHODILATOR AGENTS

Bronchodilators

Anticholinergics

ATROVENT HFA 17 mcg/act inh

aer soln

INCRUSE ELLIPTA 62.5 mcg/act

inh aer pwdr br act

ipratropium bromide 0.02 % inh

soln

ATROVENT

90 Days Supply Drug

SPIRIVA HANDIHALER 18 mcg inh

cap

SPIRIVA RESPIMAT 1.25 mcg/act

inh aer soln, 2.5 mcg/act inh aer

soln

Leukotriene Modulators

montelukast sodium 10 mg tab, 4

mg pckt, 4 mg tab chew, 5 mg tab

chew

SINGULAIR

90 Days Supply Drug

zafirlukast 10 mg tab, 20 mg tab

ACCOLATE

90 Days Supply Drug

Steroid Inhalants

budesonide 0.25 mg/2ml inh susp,

0.5 mg/2ml inh susp

PULMICORT

90 Days Supply Drug

FLOVENT DISKUS 100 mcg/act

inh aer pwdr br act, 250 mcg/act

inh aer pwdr br act, 50 mcg/act inh

aer pwdr br act

90 Days Supply Drug

fluticasone propionate hfa 110

mcg/act inh aer, 220 mcg/act inh

aer, 44 mcg/act inh aer

90 Days Supply Drug

PULMICORT FLEXHALER 180

mcg/act inh aer pwdr br act, 90

mcg/act inh aer pwdr br act

90 Days Supply Drug

CareFirst Plan DC

Page 19 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

QVAR REDIHALER 40 mcg/act inh

aer br act, 80 mcg/act inh aer br act

Sympathomimetics

ADVAIR HFA 115-21 mcg/act inh

aer, 230-21 mcg/act inh aer, 45-21

mcg/act inh aer

90 Days Supply Drug

AIRDUO RESPICLICK 113/14 113-

14 mcg/act inh aer pwdr br act

90 Days Supply Drug

AIRDUO RESPICLICK 232/14 232-

14 mcg/act inh aer pwdr br

act

90 Days Supply Drug

AIRDUO RESPICLICK 55/14 55-14

mcg/act inh aer pwdr br act

90 Days Supply Drug

albuterol sulfate 0.63 mg/3ml inh

neb soln, 1.25 mg/3ml inh neb soln

ACCUNEB

albuterol sulfate 2.5 mg/0.5ml inh

neb soln, 4 mg tab

PROVENTIL

albuterol sulfate (2.5 MG/3ML)

0.083% inh neb soln, (5 MG/ML)

0.5% inh neb soln, 2 mg/5ml syr

PROVENTIL

albuterol sulfate hfa 108 (90 Base)

mcg/act inh aer soln

PROAIR HFA

90 Days Supply Drug

budesonide-formoterol fumarate

160-4.5 mcg/act inh aer, 80-4.5

mcg/act inh aer

SYMBICORT

Days Supply Drug

COMBIVENT RESPIMAT 20-100

mcg/act inh aer soln

DULERA 100-5 mcg/act inh aer,

200

5 mcg/act inh aer

90 Days Supply Drug

fluticasone-salmeterol 100-50

mcg/act inh aer pwdr br act, 250-50

mcg/act inh aer pwdr br act, 500-50

mcg/act inh aer pwdr br act

ADVAIR DISKUS

90 Days Supply Drug

fluticasone-salmeterol 113-14

mcg/act inh aer pwdr br act, 232-14

mcg/act inh aer pwdr br act

IRDUO

90 Days Supply Drug

levalbuterol hcl 0.31 mg/3ml inh

neb soln, 0.63 mg/3ml inh neb soln,

1.25 mg/3ml inh neb soln

XOPENEX

levalbuterol tartrate 45 mcg/act inh

aer

XOPENEX HFA

90 Days

Supply Drug

CareFirst Plan DC

Page 20 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

SEREVENT DISKUS 50 mcg/act

inh aer pwdr br act

STIOLTO RESPIMAT 2.5-2.5

mcg/act inh aer soln

terbutaline sulfate 2.5 mg tab

BRETHINE

WIXELA INHUB 100-50 mcg/act

inh aer pwdr br act, 250-50 mcg/act

inh aer pwdr br act, 500-50 mcg/act

inh aer pwdr br act

90 Days Supply Drug

XOPENEX HFA 45 mcg/act inh aer

90 Days Supply Drug

Xanthines

theophylline er 300 mg

tab er 12 hr

THEO

DUR

90 Days Supply Drug

ANTICOAGULANTS

Coumarin Anticoagulants

warfarin sodium 1 mg tab, 10 mg

tab, 2 mg tab, 2.5 mg tab, 3 mg tab,

4 mg tab, 5 mg tab, 6 mg tab, 7.5

mg tab

COUMADIN

Direct Factor Xa Inhibitors

ELIQUIS 2.5 mg tab, 5 mg tab

QL(60 / 30)

ELIQUIS DVT/PE STARTER PACK

5 mg tab pack

QL(74 / 30)

XARELTO 10 mg tab, 15 mg tab,

20 mg tab

QL(35 / 28)

XARELTO 2.5 mg tab

QL(60 / 30)

Heparins And Heparinoid

like Agents

enoxaparin sodium 100 mg/ml inj

soln pfs, 120 mg/0.8ml inj soln pfs,

150 mg/ml inj soln pfs, 30 mg/0.3ml

inj soln pfs, 300 mg/3ml inj soln, 40

mg/0.4ml inj soln pfs, 60 mg/0.6ml

inj soln pfs, 80 mg/0.8ml inj soln pfs

LOVENOX

Thrombin Inhibitors

dabigatran etexilate mesylate 150

mg cap

PRADAXA

ANTICONVULSANTS

Anticonvulsants

Benzodiazepines

clobazam 10 mg tab

ONFI

clonazepam 0.125 mg tab disint,

0.25 mg tab disint, 0.5 mg tab, 0.5

KLONOPIN

QL(90 /

30)

CareFirst Plan DC

Page 21 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

mg tab disint, 1 mg tab, 1 mg tab

disint, 2 mg tab, 2 mg tab disint

diazepam 10 mg rect gel, 2.5 mg

rect gel, 20 mg rect gel

DIASTAT

Anticonvulsants

Misc.

carbamazepine 100 mg tab chew,

200 mg tab

TEGRETOL

carbamazepine er 100 mg tab er 12

TEGRETOL XR

gabapentin 100 mg cap, 300 mg

cap, 400 mg cap, 600 mg tab, 800

mg tab

NEURONTIN

gabapentin 250 mg/5ml soln

NEURONTIN

lamotrigine 100 mg tab, 150 mg

tab, 200 mg tab, 25 mg tab, 25 mg

tab chew, 25 mg tab disint, 5 mg

tab chew

LAMICTAL

lamotrigine er 100 mg tab er 24 hr,

200 mg tab er 24 hr, 300 mg tab er

24 hr, 50 mg tab er 24 hr

LAMICTAL

levetiracetam 1000 mg tab, 250 mg

tab, 500 mg

tab, 750 mg tab

KEPPRA

levetiracetam 100 mg/ml soln

KEPPRA

levetiracetam er 500 mg tab er 24

hr, 750 mg tab er 24 hr

KEPPRA XR

oxcarbazepine 150 mg tab, 300 mg

tab, 600 mg tab

TRILEPTAL

oxcarbazepine 300 mg/5ml susp

TRILEPTAL

pregabalin 300 mg cap

LYRICA

QL(60 / 30)

pregabalin 100 mg cap, 150 mg

cap, 200 mg cap, 225 mg cap, 25

mg cap, 50 mg cap, 75 mg cap

LYRICA

QL(90 / 30)

primidone 50 mg tab

MYSOLINE

topiramate 100 mg tab, 200 mg tab,

25 mg cap sprinkle, 25 mg tab, 50

mg tab

TOPAMAX

zonisamide 100 mg cap, 25 mg

cap, 50 mg cap

ZONEGRAN

Hydantoins

phenytoin 50 mg tab chew

DILANTIN

phenytoin 125 mg/5ml susp

DILANTIN

CareFirst Plan DC

Page 22 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

PHENYTOIN INFATABS 50 mg tab

chew

phenytoin sodium extended 100 mg

cap,

200 mg cap, 300 mg cap

DILANTIN

Succinimides

ethosuximide 250 mg cap

ZARONTIN

ethosuximide 250 mg/5ml soln

ZARONTIN

Valproic Acid

divalproex sodium 125 mg cap dr

sprinkle, 125 mg tab dr, 250 mg tab

dr, 500 mg tab dr

DEPAKOTE

divalproex sodium er 250 mg tab er

24 hr, 500 mg tab er 24 hr

DEPAKOTE ER

valproic acid 250 mg cap

DEPAKENE

ANTIDEMENTIA AGENTS

DRUGS TO TREAT ALZHEIMER'S DISEASE AND DEMENTIA

N-methyl-d-aspartate (nmda) Receptor Antagonist - Alzheimer's Disease And Dementia

Drugs

memantine hcl 10 mg tab, 28 x 5

MG & 21 x 10 mg tab, 5 mg tab

NAMENDA

ANTIDEPRESSANTS

Alpha

2 Receptor Antagonists (tetracyclics)

mirtazapine 15 mg tab, 15 mg tab

disint, 30 mg tab, 45 mg tab, 7.5

mg tab

REMERON

90 Days Supply Drug

Antidepressants

Misc.

bupropion hcl 100 mg tab, 75 mg

tab

WELLBUTRIN

90 Days Supply Drug

bupropion hcl er (sr) 100 mg tab er

12 hr, 150 mg tab er 12 hr, 200 mg

tab er 12 hr

WELLBUTRIN SR

90 Days Supply Drug

bupropion hcl er (xl) 450 mg tab er

24 hr

FORFIVO XL

90 Days Supply Drug

bupropion hcl er (xl) 150 mg tab er

24 hr, 300 mg tab er 24 hr

WELLBUTRIN XL

90 Days Supply Drug

Monoamine Oxidase

Inhibitors (maois)

phenelzine sulfate 15 mg tab

NARDIL

90 Days Supply Drug

tranylcypromine sulfate 10 mg tab

PARNATE

90 Days Supply Drug

Selective Serotonin Reuptake Inhibitors (ssris)

citalopram hydrobromide 10 mg

tab, 20 mg tab, 40 mg tab

CELEXA

90 Days Supply Drug

CareFirst Plan DC

Page 23 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

escitalopram oxalate 10 mg tab, 20

mg tab, 5 mg tab

LEXAPRO

90 Days Supply Drug

fluoxetine hcl 10 mg cap, 10 mg

tab, 20 mg cap, 20 mg tab, 40 mg

cap

PROZAC

90 Days Supply Drug

fluoxetine hcl 20 mg/5ml soln

PROZAC

90 Days Supply Drug

fluvoxamine maleate 100 mg tab,

25 mg tab, 50 mg tab

LUVOX

90 Days Supply Drug

paroxetine hcl 10 mg tab, 20 mg

tab, 30 mg tab, 40 mg tab

PAXIL

90 Days Supply Drug

paroxetine hcl er 12.5 mg tab er 24

hr, 25 mg tab er 24 hr, 37.5 mg tab

er 24 hr

PAXIL CR

90 Da

ys Supply Drug

sertraline hcl 100 mg tab, 25 mg

tab, 50 mg tab

ZOLOFT

90 Days Supply Drug

sertraline hcl 20 mg/ml oral conc

ZOLOFT

90 Days Supply Drug

Serotonin Modulators

trazodone hcl 100 mg tab, 150 mg

tab, 300 mg tab, 50 mg tab

DESYREL

90 Days Supply Drug

Serotonin

norepinephrine Reuptake Inhibitors (snris)

duloxetine hcl 30 mg cap dr prt

CYMBALTA

90 Days Supply Drug,

QL(30 / 30)

duloxetine hcl 20 mg cap dr prt, 60

mg cap dr prt

CYMBALTA

90 Days Supply Drug,

QL(60 / 30)

venlafaxine hcl 25 mg tab, 37.5 mg

tab, 50 mg tab, 75 mg tab

EFFEXOR

90 Days Supply Drug

venlafaxine hcl er 225 mg tab er 24

hr, 37.5 mg tab er 24 hr

90 Days Supply Drug

venlafaxine hcl er 150 mg cap er 24

hr, 37.5 mg cap er 24 hr, 75 mg

cap er 24 hr

EFFEXOR XR

90 Days Supply Drug

Tricyclic Agents

amitriptyline hcl 10 mg tab, 100 mg

tab, 150 mg tab, 25 mg tab, 50 mg

tab, 75 mg tab

ELAVIL

90 Days Supply Drug

clomipramine hcl 25 mg cap, 50 mg

cap

ANAFRANIL

90 Days Supply Drug

doxepin hcl 10 mg cap, 100 mg

cap, 150 mg cap, 25 mg cap, 50

mg cap, 75 mg cap

SINEQUAN

90 Days Supply Drug

doxepin hcl 10 mg/ml oral conc

SINEQUAN

90 Days Supply Drug

CareFirst Plan DC

Page 24 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

imipramine hcl 10 mg tab, 25 mg

tab, 50 mg tab

TOFRANIL

90 Days Supply Drug

imipramine pamoate 100 mg cap

TOFRANIL

90 Days Supply Drug

nortriptyline hcl 10 mg cap, 25 mg

cap, 50 mg cap, 75 mg cap

PAMELOR

90 Days Supply

Drug

ANTIDIABETICS

Alpha

glucosidase Inhibitors

acarbose 25 mg tab, 50 mg tab

PRECOSE

90 Days Supply Drug

Antidiabetic Combinations

alogliptin-metformin hcl 12.5-1000

mg tab, 12.5

500 mg tab

KAZANO

90 Days Supply Drug

glipizide-metformin hcl 2.5-500 mg

tab, 5

500 mg tab

METAGLIP

90 Days Supply Drug

glyburide

metformin 5

500 mg tab

GLUCOVANCE

90 Days

Supply Drug

JANUMET 50-1000 mg tab, 50-500

mg tab

JANUMET XR 100-1000 mg tab er

24 hr, 50-1000 mg tab er 24 hr, 50-

500 mg tab er 24 hr

pioglitazone hcl-glimepiride 30-2

mg tab, 30

4 mg tab

DUETACT

pioglitazone hcl-metformin hcl 15-

850 mg tab

ACTOPLUS MET

SEGLUROMET 2.5-1000 mg tab,

2.5-500 mg tab, 7.5-1000 mg tab,

7.5

500 mg tab

90 Days

Supply Drug

SYNJARDY 12.5-1000 mg tab,

12.5-500 mg tab, 5-1000 mg tab, 5-

500 mg tab

90 Days Supply Drug

SYNJARDY XR 10-1000 mg tab er

24 hr, 12.5-1000 mg tab er 24 hr,

25-1000 mg tab er 24 hr, 5-1000

mg tab er 24 hr

90 Days Supply Drug

Biguanides

metformin hcl 1000 mg tab, 500 mg

tab, 850 mg tab

GLUCOPHAGE

90 Days Supply Drug

metformin hcl er 500 mg tab er 24

hr, 750 mg tab er 24 hr

GLUCOPHAGE XR

90 Days

Supply Drug

metformin hcl er (mod) 1000 mg

tab er 24 hr, 500 mg tab er 24 hr

GLUMETZA

90 Days Supply Drug

CareFirst Plan DC

Page 25 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

metformin hcl er (osm) 1000 mg tab

er 24 hr, 500 mg tab er 24 hr

FORTAMET

90 Days Supp

ly Drug

Diabetic Other

GLUCAGEN HYPOKIT 1 mg inj

soln

glucagon emergency 1 mg inj kit

GLUCAGON

EMERGENCY

Dipeptidyl Peptidase

4 (dpp

4) Inhibitors

alogliptin benzoate 12.5 mg tab, 25

tab, 6.25 mg tab

NESINA

90 Days Supply Drug

JANUVIA 100 mg tab, 25 mg tab,

50 mg tab

ONGLYZA 2.5 mg tab, 5 mg tab

90 Days Supply Drug

Incretin Mimetic Agents (glp

1 Receptor

Agonists)

BYDUREON 2 mg sc susp er

BYDUREON BCISE 2 mg/0.85ml

Subcutaneous Auto

injector

BYETTA 10 MCG PEN 10

mcg/0.04ml sc soln pen

inj

QL(2.4 / 30)

BYETTA 5 MCG PEN 5

mcg/0.02ml sc soln pen

inj

QL(1.2 / 30)

TRULICITY 0.75 mg/0.5ml sc soln

pen-inj, 1.5 mg/0.5ml sc soln pen-

inj, 3 mg/0.5ml sc soln pen-inj, 4.5

mg/0.5ml sc soln pen

inj

Insulin

ADMELOG 100 unit/ml inj

soln

ADMELOG SOLOSTAR 100

unit/ml sc soln pen

inj

BASAGLAR KWIKPEN 100 unit/ml

sc soln pen

inj

HUMALOG MIX 50/50 KWIKPEN

(50

50) 100 unit/ml sc susp pen

inj

HUMALOG MIX 75/25 (75-25) 100

unit/ml sc susp

HUMALOG MIX 75/25 KWIKPEN

(75

25) 100 unit/ml sc susp pen

inj

HUMULIN 70/30 (70-30) 100

unit/ml sc susp

CareFirst Plan DC

Page 26 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

HUMULIN 70/30 KWIKPEN (70-30)

100 unit/ml sc susp pen

inj

HUMULIN N 100 unit/ml sc susp

HUMULIN N KWIKPEN 100 unit/ml

sc susp pen

inj

HUMULIN R 100

unit/ml inj soln

HUMULIN R U-500

(CONCENTRATED) 500 unit/ml sc

soln

insulin asp prot & asp flexpen (70-

30) 100 unit/ml sc susp pen

inj

NOVOLOG MIX

70/30

NOVOLIN 70/30 (70-30) 100

unit/ml sc susp

NOVOLIN 70/30 RELION (70-30)

100 unit/ml sc susp

NOVOLIN N 100 unit/ml sc susp

NOVOLIN N RELION 100 unit/ml

sc susp

NOVOLIN R 100 unit/ml inj soln

NOVOLIN R RELION 100 unit/ml

inj soln

Insulin Sensitizing Agents

pioglitazone hcl 15 mg tab, 30 mg

tab, 45 mg tab

ACTOS

90 Days Supply Drug

Meglitinide Analogues

repaglinide 1 mg tab

PRANDIN

Sodium

glucose Co

transporter 2 (sglt2) Inhibitors

JARDIANCE 10 mg tab, 25 mg tab

QL(30 / 30)

STEGLATRO 15 mg tab, 5 mg tab

90 Days Supply Drug

Sulfonylureas

glimepiride 1 mg tab, 2 mg tab, 4

mg tab

AMARYL

90 Days Supply Drug

glipizide 10 mg tab, 5 mg tab

GLUCOTROL

90 Days Supply Drug

glipizide er 10 mg tab er 24 hr, 2.5

mg tab er 24 hr, 5 mg tab er 24 hr

GLUCOTROL XL

90 Days Supply Drug

glipizide xl 10 mg tab er 24 hr, 2.5

mg tab er 24 hr, 5 mg tab er 24 hr

GLUCOTROL XL

90 Days Supply Drug

glyburide 1.25 mg tab, 2.5 mg tab,

5 mg tab

DIABETA

90 Days Supply Drug

glyburide micronized 6 mg tab

GLYNASE

90 Days Supply Drug

CareFirst Plan DC

Page 27 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

ANTIDIARRHEAL/PROBIOTIC AGENTS

Antidiarrheal/probiotic Agents

Misc.

gnp pink bismuth 262 mg tab

chew

sm stomach relief 262 mg tab, 262

mg tab chew

Antiperistaltic Agents

anti

diarrheal 2 mg tab

diphenoxylate-atropine 2.5-0.025

mg tab

LOMOTIL

loperamide hcl 1 mg/5ml liq

sm anti

diarrheal 2 mg tab

sm anti

diarrheal 2 mg cap

IMODIUM

ANTIDOTES AND SPECIFIC ANTAGONISTS

Antidotes

Chelating Agents

deferasirox 125 mg tab sol, 250 mg

tab sol, 500 mg tab sol

EXJADE

Opioid Antagonists

KLOXXADO 8 mg/0.1ml nasal liq

naloxone hcl 4 mg/0.1ml nasal liq

NARCAN

naloxone hcl 0.4 mg/ml inj soln

NARCAN

naltrexone hcl 50 mg tab

REVIA

QL(30 / 30)

NARCAN 4 mg/0.1ml nasal liq

VIVITROL 380 mg im susp

QL(1 / 30)

ANTIEMETICS

ht3 Receptor Antagonists

granisetron hcl 1 mg tab

KYTRIL

ondansetron hcl 4 mg/5ml soln

ZOFRAN

ondansetron hcl 4 mg tab, 8 mg tab

ZOFRAN

QL(30 / 25)

Antiemetics

Anticholinergic

meclizine hcl 25 mg tab chew

meclizine hcl 12.5 mg tab, 25 mg

tab

ANTIVERT

Antiemetics

Miscellaneous

dronabinol 2.5 mg cap, 5 mg cap

MARINOL

ANTIFUNGALS

Antifungals

griseofulvin microsize 500 mg tab

GRIFULVIN V

griseofulvin microsize 125 mg/5ml

susp

GRIFULVIN V

CareFirst Plan DC

Page 28 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

griseofulvin ultramicrosize 125 mg

tab, 250 mg tab

GRIS

PEG

terbinafine hcl 250 mg tab

LAMISIL

Imidazole

related Antifungals

fluconazole 100 mg tab, 200 mg

tab, 50 mg tab

DIFLUCAN

fluconazole 10 mg/ml susp, 40

mg/ml

susp

DIFLUCAN

fluconazole 150 mg tab

DIFLUCAN

QL(2 / 25)

itraconazole 100 mg cap

SPORANOX

ketoconazole 200 mg tab

NIZORAL

ANTIHISTAMINES

Antihistamines

Ethanolamines

allergy relief 25 mg cap, 25 mg tab

allergy relief childrens 12.5 mg/5ml

liq

BANOPHEN 25 mg cap, 50 mg cap

clemastine fumarate 2.68 mg

tab

TAVIST

diphenhydramine hcl 25 mg cap, 50

mg cap

diphenhydramine hcl 50 mg/ml inj

soln

BENADRYL

gnp childrens allergy 12.5 mg/5ml

liq

sm allergy relief 12.5 mg/5ml liq

Antihistamines

Non

sedating

all day allergy 10 mg tab

ZYRTEC ALLERGY

all day allergy childrens 5 mg/5ml

soln

ZYRTEC

allergy childrens 5 mg/5ml syr

CLARITIN

allergy relief 180 mg tab

ALLEGRA

QL(30 / 30)

allergy relief 10 mg tab

CLARITIN

cetirizine hcl 5 mg tab

cetirizine hcl 10 mg tab chew, 5 mg

tab chew

ZYRTEC

cetirizine hcl 1 mg/ml soln

ZYRTEC

cetirizine hcl 10 mg tab

ZYRTEC ALLERGY

cetirizine hcl allergy child 5 mg/5ml

soln

ZYRTEC

CareFirst Plan DC

Page 29 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

cetirizine hcl childrens 10 mg tab

chew, 5 mg tab chew

ZYRTEC

cetirizine hcl childrens alrgy 1

mg/ml soln

ZYRTEC

childrens loratadine 5 mg/5ml soln,

5 mg/5ml syr

CLARITIN

fexofenadine hcl 180 mg tab

ALLEGRA

QL(30 / 30)

fexofenadine hcl childrens 30

mg/5ml susp

QL(120 / 30)

gnp all day allergy childrens 5

mg/5ml soln

ZYRTEC

gnp loratadine 10 mg tab

CLARITIN

gnp loratadine 5 mg/5ml syr

CLARITIN

goodsense all day allergy 10 mg

tab

ZYRTEC ALLERGY

hm all day allergy 10 mg tab

ZYRTEC ALLERGY

hm loratadine 10 mg tab

CLARITIN

hm loratadine childrens 5 mg/5ml

syr

CLARITIN

levocetirizine dihydrochloride 5 mg

tab

XYZAL

levocetirizine dihydrochloride 2.5

mg/5ml soln

XYZAL

loratadine 10 mg tab

CLARITIN

loratadine childrens 5 mg/5ml soln,

5 mg/5ml syr

CLARITIN

qc loratadine allergy relief 10 mg

tab

CLARITIN

sm all day allergy 10 mg tab

ZYRTEC ALLERGY

sm all day allergy childrens 5

mg/5ml soln

ZYRTEC

sm childrens loratadine 5 mg/5ml

syr

CLARITIN

sm fexofenadine hcl 180 mg tab

ALLEGRA

QL(30 / 30)

sm loratadine 10 mg tab

CLARITIN

sm loratadine 5 mg/5ml syr

CLARITIN

Antihistamines

Phenothiazines

promethazine hcl 12.5 mg rect

supp, 12.5 mg tab, 25 mg rect

supp, 25 mg tab, 50 mg tab

PHENERGAN

CareFirst Plan DC

Page 30 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

promethazine hcl 6.25 mg/5ml soln,

6.25 mg/5ml syr

PHENERGAN

Antihistamines

Piperidines

cyproheptadine hcl 4 mg tab

PERIACTIN

cyproheptadine hcl 2 mg/5ml syr

PERIACTIN

ANTIHYPERLIPIDEMICS

Bile Acid Sequestrants

cholestyramine 4 gm/dose oral

pwdr

QUESTRAN

cholestyramine light 4 gm pckt

QUESTRAN LIGHT

cholestyramine light 4 gm/dose oral

pwdr

QUESTRAN LIGHT

Fibric Acid Derivatives

fenofibrate 145 mg tab, 160 mg tab,

48 mg tab, 54 mg tab

TRICOR

fenofibrate micronized 134 mg cap,

200 mg cap, 67 mg cap

TRICOR

gemfibrozil 600 mg tab

LOPID

Hmg Coa Reductase Inhibitors

atorvastatin calcium 10 mg tab, 20

mg tab, 40 mg tab, 80 mg tab

LIPITOR

90 Days Supply Drug

lovastatin 10 mg tab, 20 mg tab, 40

mg tab

MEVACOR

90 Days Supply Drug

pravastatin sodium 10 mg tab, 20

mg tab, 40 mg tab, 80 mg tab

PRAVACHOL

90 Days

Supply Drug

rosuvastatin calcium 10 mg tab, 20

mg tab, 40 mg tab, 5 mg tab

CRESTOR

90 Days Supply Drug

simvastatin 10 mg tab, 20 mg tab,

40 mg tab, 5 mg tab, 80 mg tab

ZOCOR

90 Days Supply Drug

Intestinal Cholesterol Absorption Inhibitors

ezetimibe 10 mg tab

ZETIA

ZETIA 10 mg tab

Nicotinic Acid Derivatives

niacin er (antihyperlipidemic) 500

mg tab er

NIASPAN

ANTIHYPERTENSIVES

Ace Inhibitors

benazepril hcl 10 mg tab, 20 mg

tab, 40 mg tab, 5 mg tab

LOTENSIN

90 Days Supply Drug

CareFirst Plan DC

Page 31 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

enalapril maleate 10 mg tab, 2.5

mg tab, 20 mg tab, 5 mg tab

VASOTEC

90 Days Supply Drug

lisinopril 10 mg tab, 2.5 mg tab, 20

mg tab, 30 mg tab, 40 mg tab, 5 mg

tab

ZESTRIL

90 Days Supply Drug

quinapril hcl 10 mg tab, 40 mg tab

ACCUPRIL

90 Days

Supply Drug

Angiotensin Ii Receptor Antagonists

irbesartan 150 mg tab, 300 mg tab,

75 mg tab

AVAPRO

90 Days Supply Drug,

QL(30 / 30)

losartan potassium 100 mg tab, 50

mg tab

COZAAR

90 Days Supply Drug,

QL(30 / 30)

losartan potassium 25 mg tab

COZAAR

90 Days Supply Drug,

QL(60 / 30)

olmesartan medoxomil 20 mg tab,

40 mg tab, 5 mg tab

BENICAR

90 Days Supply Drug,

QL(30 / 30)

valsartan 160 mg tab, 320 mg tab,

40 mg tab, 80 mg tab

DIOVAN

Antiadrenergic Antihypertensives

clonidine 0.1 mg/24hr tdwk patch,

0.2 mg/24hr tdwk patch, 0.3

mg/24hr tdwk patch

CATAPRES

TTS

90 Days Supply Drug,

QL(4 / 30)

clonidine hcl 0.1 mg tab, 0.2 mg

tab, 0.3 mg tab

CATAPRES

90 Days Supply Drug

doxazosin mesylate 1 mg tab, 2 mg

tab, 4 mg tab, 8 mg tab

CARDURA

90 Days Supply Drug

guanfacine hcl 1 mg tab, 2

mg tab

TENEX

90 Days Supply Drug

methyldopa 250 mg tab, 500 mg

tab

ALDOMET

90 Days Supply Drug

prazosin hcl 1 mg cap, 2 mg cap, 5

mg cap

MINIPRESS

90 Days Supply Drug

terazosin hcl 1 mg cap, 10 mg cap,

2 mg cap, 5 mg cap

HYTRIN

90 Days Supply Drug

Antihypertensive Combinations

amlodipine-olmesartan 10-20 mg

tab, 10-40 mg tab, 5-20 mg tab, 5-

40 mg tab

AZOR

90 Days Supply Drug,

QL(30 / 30)

atenolol-chlorthalidone 100-25 mg

tab, 50

25 mg tab

TENORETIC

90 Days Supply Drug

AZOR 10-20 mg tab, 10-40 mg tab,

20 mg tab, 5

40 mg tab

90 Days Supply Drug,

QL(30 / 30)

CareFirst Plan DC

Page 32 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

benazepril-hydrochlorothiazide 10-

12.5 mg tab, 20

25 mg tab

LOTENSIN HCT

90 Days Supply Drug

bisoprolol-hydrochlorothiazide 10-

6.25 mg tab

ZIAC

90 Days Supply Drug

enalapril-hydrochlorothiazide 5-

12.5 mg tab

VASERETIC

90 Days Supply Drug

lisinopril-hydrochlorothiazide 10-

12.5 mg tab, 20-12.5 mg tab, 20-25

mg tab

ZESTORETIC

90 Days

Supply Drug

losartan potassium-hctz 100-12.5

mg tab, 100-25 mg tab, 50-12.5 mg

tab

HYZAAR

90 Days Supply Drug,

QL(30 / 30)

metoprolol-hydrochlorothiazide

100

25 mg tab, 50

25 mg tab

LOPRESSOR HCT

90 Days Supply Drug

propranolol

hctz 40

25 mg tab

INDERIDE

90 Days Supply Drug

TEKTURNA HCT 300

25 mg tab

valsartan-hydrochlorothiazide 160-

12.5 mg tab, 160-25 mg tab, 320-

12.5 mg tab, 320-25 mg tab, 80-

12.5 mg tab

DIOVAN HCT

Direct Renin Inhibitors

aliskiren fumarate 150 mg tab, 300

mg tab

TEKTURNA

Selective Aldosterone Receptor Antagonists (saras)

eplerenone 25 mg tab, 50 mg tab

INSPRA

Vasodilators

hydralazine hcl 10 mg tab, 100 mg

tab, 25 mg tab, 50 mg tab

APRESOLINE

90 Days Supply Drug

ANTI

INFECTIVE AGENTS

MISC.

Anti

infective Agents

Misc.

metronidazole 250 mg tab, 375 mg

cap, 500 mg tab

FLAGYL

trimethoprim 100 mg tab

PROLOPRIM

Anti

infective Misc.

Combinations

sulfamethoxazole-trimethoprim

400

80 mg tab, 800

160 mg tab

SEPTRA

sulfamethoxazole-trimethoprim

200

40 mg/5ml susp

SEPTRA

Leprostatics

dapsone 100 mg tab

CareFirst Plan DC

Page 33 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

Lincosamides

clindamycin hcl 150 mg cap, 300

mg cap, 75 mg cap

CLEOCIN

clindamycin palmitate hcl 75

mg/5ml soln

CLEOCIN

ANTIMALARIALS

Antimalarial Combinations

atovaquone-proguanil hcl 250-100

mg tab, 62.5

25 mg tab

MALARONE

Antimalarials

chloroquine phosphate 500 mg tab

ARALEN

hydroxychloroquine sulfate 200 mg

tab

PLAQUENIL

mefloquine hcl 250 mg tab

ANTIMYASTHENIC/CHOLINERGIC AGENTS

Antimyasthenic/cholinergic Agents

pyridostigmine bromide 60 mg tab

MESTINON

ANTIMYCOBACTERIAL AGENTS

Antimycobacterial Agents

ethambutol hcl 400 mg tab

MYAMBUTOL

isoniazid 100 mg

tab, 300 mg tab

isoniazid 50 mg/5ml syr

pyrazinamide 500 mg tab

rifampin 300 mg cap

RIFADIN

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES

Alkylating Agents

GLEOSTINE 40 mg cap

temozolomide 140 mg cap, 180 mg

cap

TEMODAR

SP, PA

Antimetabolites

capecitabine 150 mg tab, 500 mg

tab

XELODA

mercaptopurine 50 mg tab

PURINETHOL

methotrexate 2.5 mg tab

methotrexate sodium 2.5 mg tab

TABLOID 40 mg tab

Antineoplastic

Hedgehog Pathway Inhibitors

ERIVEDGE 150 mg cap

SP, PA

Antineoplastic

Hormonal And Related Agents

abiraterone acetate 250 mg tab

ZYTIGA

SP, PA

CareFirst Plan DC

Page 34 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

anastrozole 1 mg tab

ARIMIDEX

bicalutamide 50 mg tab

CASODEX

ELIGARD 22.5 mg sc kit, 30 mg sc

kit, 45 mg sc kit, 7.5 mg sc kit

SP, PA

FIRMAGON 120 mg sc soln, 80 mg

sc soln

SP, PA

FIRMAGON (240 MG DOSE) 120

mg/vial sc soln

SP, PA

letrozole 2.5 mg tab

FEMARA

LUPRON DEPOT (4-MONTH) 30

mg im kit

SP, PA

LUPRON DEPOT (6-MONTH) 45

mg im kit

SP, PA

megestrol acetate 20 mg tab, 40

mg tab

MEGACE

megestrol acetate 40 mg/ml susp

MEGACE

tamoxifen citrate 20 mg tab

NOLVADEX

XTANDI 40 mg cap

SP, PA

Antineoplastic Enzyme Inhibitors

erlotinib hcl 100 mg tab, 150 mg

tab

TARCEVA

SP, PA, QL(30 / 30)

erlotinib hcl 25 mg tab

TARCEVA

SP, PA, QL(90 / 30)

everolimus 2.5 mg tab, 5 mg tab,

7.5 mg tab

AFINITOR

SP, PA

imatinib mesylate 400 mg tab

GLEEVEC

SP, PA, QL(60 / 30)

imatinib mesylate 100 mg tab

GLEEVEC

SP, PA, QL(120 / 30)

JAKAFI 10 mg tab

SP, PA

TARCEVA 100 mg tab, 150 mg tab

SP, PA, QL(30 / 30)

TARCEVA 25 mg

tab

SP, PA, QL(90 / 30)

VERZENIO 100 mg tab, 150 mg

tab, 200 mg tab, 50 mg tab

SP, PA

XALKORI 250 mg cap

SP, PA

Antineoplastics Misc.

hydroxyurea 500 mg cap

HYDREA

ANTIPARKINSON AND RELATED THERAPY AGENTS

Antiparkinson Anticholinergics

benztropine mesylate 0.5 mg tab, 1

mg tab, 2 mg tab

COGENTIN

trihexyphenidyl hcl 2 mg tab, 5 mg

tab

ARTANE

CareFirst Plan DC

Page 35 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

Antiparkinson Dopaminergics

amantadine hcl 100 mg cap

SYMMETREL

bromocriptine mesylate 2.5 mg tab,

5 mg cap

PARLODEL

carbidopa-levodopa 10-100 mg tab,

100 mg tab, 25

250 mg tab

SINEMET

pramipexole dihydrochloride 0.125

mg tab, 0.25 mg tab, 0.5 mg tab

MIRAPEX

ropinirole hcl 0.25 mg tab, 0.5 mg

tab

REQUIP

ANTIPSYCHOTICS/ANTIMANIC AGENTS

Antimanic Agents

lithium carbonate 150 mg cap, 600

mg cap

90 Days Supply Drug

lithium carbonate 300 mg cap

ESKALITH

90 Days Supply Drug

lithium

carbonate 300 mg tab

LITHOBID

90 Days Supply Drug

lithium carbonate er 450 mg tab er

ESKALITH CR

90 Days Supply Drug

lithium carbonate er 300 mg tab er

LITHOBID

Days Supply Drug

Antipsychotics

Misc.

lurasidone hcl 120 mg tab, 20 mg

tab, 40 mg tab, 60 mg tab, 80 mg

tab

ziprasidone hcl 20 mg cap, 40 mg

cap, 60 mg cap, 80 mg cap

GEODON

90 Days Supply Drug,

Benzisoxazoles

INVEGA HAFYERA 1092 mg/3.5ml

im susp pfs, 1560 mg/5ml im susp

pfs

90 Days Supply Drug

INVEGA SUSTENNA 117

mg/0.75ml im susp pfs, 156 mg/ml

im susp pfs, 234 mg/1.5ml im susp

pfs, 39 mg/0.25ml im susp pfs, 78

mg/0.5ml im susp pfs

90 Days Supply Drug,

INVEGA TRINZA 273 mg/0.88ml

im susp pfs, 410 mg/1.32ml im

susp pfs, 546 mg/1.75ml im susp

pfs, 819 mg/2.63ml im susp pfs

90 Days Supply Drug,

paliperidone er 1.5 mg tab er 24 hr,

3 mg tab er 24 hr, 6 mg tab er 24

hr, 9 mg tab er 24 hr

INVEGA

CareFirst Plan DC

Page 36 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

risperidone 0.25 mg tab, 0.5 mg

tab, 1 mg tab, 2 mg tab, 3 mg tab, 4

mg tab

RISPERDAL

90 Days Supply Drug,

Butyrophenones

haloperidol 0.5 mg tab, 1 mg tab,

10 mg tab, 2 mg tab, 20 mg tab, 5

mg tab

HALDOL

90 Days Supply Drug,

haloperidol decanoate 100 mg/ml

im soln, 50 mg/ml im soln

HALDOL

90 Days Supply Drug,

Dibenzapines

clozapine 25 mg tab

CLOZARIL

90 Days Supply Drug,

QL(120 / 25), AL

clozapine 100 mg tab

CLOZARIL

90 Days Supply Drug,

QL(270 / 25), AL

olanzapine 10 mg tab, 15 mg tab,

2.5 mg tab, 20 mg tab, 5 mg tab,

7.5 mg tab

ZYPREXA

90 Days Supply Drug,

QL(30 / 25), AL

olanzapine 10 mg tab disint, 15 mg

tab disint, 20 mg tab disint, 5 mg

tab disint

ZYPREXA ZYDIS

90 Days Supply Drug,

QL(30 / 25), AL

quetiapine fumarate 100 mg tab,

200 mg tab, 300 mg tab, 400 mg

tab

SEROQUEL

90 Days Supply Drug,

QL(60 / 25), AL

quetiapine fumarate 25 mg tab, 50

mg tab

SEROQUEL

90 Days Supply Drug,

QL(90 / 30), AL

quetiapine fumarate er 150 mg tab

er 24 hr, 200 mg tab er 24 hr, 300

mg tab er 24 hr, 400 mg tab er 24

hr, 50 mg tab er 24 hr

SEROQUEL XR

90 Days Supply Drug,

QL(60 / 25), AL

Phenothiazines

fluphenazine decanoate 25 mg/ml

inj soln

PROLIXIN

90 Days Supply Drug,

fluphenazine hcl 1 mg tab, 10 mg

tab, 5 mg tab

PROLIXIN

90 Days Supply Drug,

fluphenazine hcl 2.5 mg/5ml oral

elix

PROLIXIN

90 Days Supply Drug,

perphenazine 2 mg tab, 4 mg tab

TRILAFON

90 Days Supply Drug,

prochlorperazine maleate 10 mg

tab, 5 mg tab

COMPAZINE

90 Days Supply Drug,

CareFirst Plan DC

Page 37 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

trifluoperazine hcl 1 mg tab, 10 mg

tab, 2 mg tab, 5 mg tab

STELAZINE

90 Days Supply Drug,

Quinolinone Derivatives

ABILIFY MAINTENA 300 mg im

pfs, 300 mg Intramuscular

Suspension Reconstituted ER, 400

mg im pfs, 400 mg Intramuscular

Suspension Reconstituted ER

aripiprazole 10 mg tab, 15 mg tab,

2 mg tab, 20 mg tab, 30 mg tab, 5

mg tab

ABILIFY

90 Days Supply Drug,

ARISTADA 441 mg/1.6ml im pfs

QL(1.6 / 30), AL

ARISTADA 662 mg/2.4ml im pfs

QL(2.4 / 30), AL

ARISTADA 882 mg/3.2ml im pfs

QL(3.2 / 30), AL

ARISTADA 1064 mg/3.9ml im pfs

QL(3.9 / 60), AL

ARISTADA INITIO 675 mg/2.4ml

im pfs

QL(2.4 / 30), AL

Thioxanthenes

thiothixene 2 mg cap

NAVANE

90 Days Supply Drug,

ANTIVIRALS

Antiretrovirals

DESCOVY 200

25 mg tab

Alliance Enrollees only,

emtricitabine-tenofovir df 200-300

mg tab

TRUVADA

QL(30 / 30)

LAGEVRIO 200 mg cap

QL(40 / 5), AL

PAXLOVID (300/100) 20 x 150 MG

& 10 x 100mg tab pack

QL(30 / 5), AL

Hepatitis Agents

adefovir dipivoxil 10 mg tab

HEPSERA

entecavir 0.5 mg tab, 1 mg tab

BARACLUDE

lamivudine 100 mg tab

EPIVIR HBV

MAVYRET 100

40 mg tab

sofosbuvir-velpatasvir 400-100 mg

tab

EPCLUSA

Non-preferred require

PA, PA

Herpes Agents

acyclovir 200 mg cap, 400 mg tab,

800 mg tab

ZOVIRAX

acyclovir 200 mg/5ml susp

ZOVIRAX

CareFirst Plan DC

Page 38 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

famciclovir 250 mg tab, 500 mg tab

FAMVIR

valacyclovir hcl 1 gm tab, 500 mg

tab

VALTREX

Influenza Agents

oseltamivir phosphate 30 mg cap,

45 mg cap, 75 mg cap

TAMIFLU

oseltamivir phosphate 6 mg/ml

susp

TAMIFLU

rimantadine hcl 100 mg tab

FLUMADINE

TAMIFLU 30 mg cap, 45 mg cap,

75 mg cap

BETA BLOCKERS

Alpha

beta Blockers

carvedilol 12.5 mg tab, 25 mg tab,

3.125 mg tab, 6.25 mg tab

COREG

90 Days Supply Drug,

QL(120 / 30)

labetalol hcl 100 mg tab, 200 mg

tab, 300 mg tab

NORMODYNE

90 Days Supply Drug

Beta Blockers

Cardio

selective

atenolol 100 mg tab, 25 mg tab, 50

mg tab

TENORMIN

90 Days Supply Drug

bisoprolol fumarate 10 mg tab, 5

mg tab

ZEBETA

90 Days Supply Drug

metoprolol succinate er 100 mg tab

er 24 hr, 200 mg tab er 24 hr, 25

mg tab er 24 hr, 50 mg tab er 24 hr

TOPROL XL

90 Days Supply Drug

metoprolol tartrate 100 mg tab, 25

mg tab, 50 mg tab

LOPRESSOR

90 Days Supply Drug

Beta Blockers

Non

selective

nadolol 20 mg tab, 40 mg tab

CORGARD

90 Days Supply Drug

propranolol hcl 10 mg tab, 20 mg

tab, 40 mg tab, 60 mg tab, 80 mg

tab

INDERAL

90 Days Supply Drug

propranolol hcl 20 mg/5ml soln

INDERAL

90 Days Supply Drug

propranolol hcl er 120 mg cap er 24

hr, 60 mg cap er 24 hr, 80 mg cap

er 24 hr

INDERAL LA

90 Days Supply Drug

sotalol hcl 80 mg tab

BETAPACE

90 Days

Supply Drug

CALCIUM CHANNEL BLOCKERS

Calcium Channel Blockers

CareFirst Plan DC

Page 39 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

amlodipine besylate 10 mg tab, 2.5

mg tab, 5 mg tab

NORVASC

90 Days Supply Drug,

QL(30 / 30)

diltiazem hcl 120 mg tab, 30 mg

tab, 60 mg tab, 90 mg tab

CARDIZEM

90 Days Supply Drug

diltiazem hcl er 120 mg cap er 12

hr, 60 mg cap er 12 hr, 90 mg cap

er 12 hr

CARDIZEM

90 Days Supply Drug

diltiazem hcl er 120 mg cap er 24

hr, 240 mg cap er 24 hr

DILACOR XR

90 Days Supply Drug

diltiazem hcl er beads 120 mg cap

er 24 hr, 180 mg cap er 24 hr, 240

mg cap er 24 hr, 360 mg cap er 24

hr, 420 mg cap er 24 hr

TIAZAC

90 Days Supply Drug

diltiazem hcl er coated beads 120

mg cap er 24 hr, 180 mg cap er 24

hr, 240 mg cap er 24 hr, 300 mg

cap er 24 hr, 360 mg cap er 24 hr

CARDIZEM CD

90 Days Supply Drug

diltiazem hcl er coated beads 300

mg tab er 24 hr

CARDIZEM LA

90 Days Supply Drug

nifedipine 10 mg cap, 20 mg cap

PROCARDIA

90 Days Supply Drug

nifedipine er 30 mg tab er 24 hr, 60

mg tab er 24 hr, 90 mg tab er 24 hr

ADALAT CC

90 Days

Supply Drug

nifedipine er osmotic release 30 mg

tab er 24 hr, 60 mg tab er 24 hr, 90

mg tab er 24 hr

PROCARDIA XL

90 Days Supply Drug

verapamil hcl 120 mg tab, 40 mg

tab, 80 mg tab

CALAN

Days Supply Drug

verapamil hcl er 120 mg tab er, 180

mg tab er, 240 mg tab er

CALAN

90 Days Supply Drug

verapamil hcl er 120 mg cap er 24

hr, 180 mg cap er 24 hr, 300 mg

cap er 24 hr

VERELAN

90 Days

Supply Drug

CARDIOTONICS

Cardiac Glycosides

digoxin 125 mcg tab, 250 mcg tab

LANOXIN

digoxin 0.05 mg/ml soln

LANOXIN

CARDIOVASCULAR AGENTS

MISC.

Cardiovascular Agents Misc.

Combinations

ENTRESTO 24-26 mg tab, 49-51

mg tab, 97

103 mg tab

CareFirst Plan DC

Page 40 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

isosorb dinitrate-hydralazine 20-

37.5 mg tab

BIDIL

Pulmonary Hypertension

Endothelin Receptor Antagonists

ambrisentan 10 mg tab, 5 mg

tab

LETAIRIS

SP, PA

Pulmonary Hypertension

Phosphodiesterase Inhibitors

sildenafil citrate 20 mg tab

REVATIO

SP, QL(90 / 30)

CENTRAL NERVOUS SYSTEM AGENTS

Central Nervous System, Other

Miscellaneous Central Nervous System Drugs

INGREZZA 40 & 80 mg cap pack,

40 mg cap, 80 mg cap

CEPHALOSPORINS

Cephalosporins

1st Generation

cefadroxil 1 gm tab, 500 mg cap

DURICEF

cephalexin 250 mg cap, 500 mg

cap

KEFLEX

cephalexin 125 mg/5ml susp, 250

mg/5ml susp

KEFLEX

Cephalosporins

2nd Generation

cefaclor 500 mg cap

CECLOR

cefaclor 250 mg/5ml susp

CECLOR

cefprozil 250 mg tab

CEFZIL

cefprozil 125 mg/5ml susp, 250

mg/5ml susp

CEFZIL

cefuroxime axetil 250 mg tab, 500

mg tab

CEFTIN

Cephalosporins

3rd Generation

cefdinir 300 mg cap

OMNICEF

cefdinir 125 mg/5ml susp, 250

mg/5ml susp

OMNICEF

CONTRACEPTIVES

Combination Contraceptives

Oral

ALTAVERA 0.15

30 mg

mcg tab

alyacen 1/35 1

35 mg

mcg tab

APRI 0.15

30 mg

mcg tab

ARANELLE 0.5/1/0.5-35 mg-mcg

tab

ASHLYNA 0.15

0.03 &0.01 mg tab

AVIANE 0.1

20 mg

mcg tab

BALZIVA 0.4

35 mg

mcg tab

CareFirst Plan DC

Page 41 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

BLISOVI FE 1.5/30 1.5-30 mg-mcg

tab

BLISOVI FE 1/20 1

20 mg

mcg tab

CAMRESE 0.15

0.03 &0.01 mg tab

CAMRESE LO 0.1-0.02 & 0.01 mg

tab

CRYSELLE

28 0.3

30 mg

mcg tab

CYCLAFEM 1/35 1

35 mg

mcg tab

CYCLAFEM 7/7/7 0.5/0.75/1-35

mcg tab

DASETTA 1/35 1

35 mg

mcg tab

DASETTA 7/7/7 0.5/0.75/1-35 mg-

mcg tab

DAYSEE 0.15

0.03 &0.01 mg tab

drospirenone-ethinyl estradiol 3-

0.03 mg tab

YASMIN

drospirenone-ethinyl estradiol 3-

0.02 mg tab

YAZ

ELINEST 0.3

mcg tab

EMOQUETTE 0.15

30 mg

mcg tab

ENPRESSE-28 50-30/75-40/ 125-

30 mcg tab

ENSKYCE 0.15

30 mg

mcg tab

ESTARYLLA 0.25

35 mg

mcg tab

FALMINA

0.1

20 mg

mcg tab

GIANVI 3

0.02 mg tab

JULEBER 0.15

30 mg

mcg tab

JUNEL 1.5/30 1.5

30 mg

mcg tab

JUNEL 1/20 1

20 mg

mcg tab

JUNEL FE 1.5/30 1.5-30 mg-mcg

tab

JUNEL FE 1/20 1

20 mg

mcg tab

KARIVA 0.15-0.02/0.01 mg (21/5)

tab

KURVELO 0.15

30 mg

mcg tab

LARIN 1.5/30 1.5

30 mg

mcg tab

LARIN 1/20 1

20 mg

mcg tab

LARIN FE 1.5/30 1.5-30 mg-mcg

tab

LARIN FE 1/20 1

20 mg

mcg tab

CareFirst Plan DC

Page 42 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

LARISSIA 0.1

20 mg

mcg tab

LESSINA 0.1

20 mg

mcg tab

levonorgest-eth estrad 91-day 0.1-

0.02 & 0.01 mg tab

LOSEASONIQUE

levonorgest-eth estrad 91-day 0.15-

0.03 &0.01 mg tab

SEASONIQUE

levonorgestrel-ethinyl estrad 0.1-20

mcg tab

ALESSE

levonorgestrel-ethinyl estrad 0.15-

30 mg

mcg tab

NORDETTE

levonorg-eth estrad triphasic 50-

30/75

40/ 125

30 mcg tab

ENPRESSE 28 DAY

LEVORA 0.15/30 (28) 0.15-30 mg-

mcg tab

LILLOW 0.15

30 mg

mcg tab

LOESTRIN 1.5/30 (21) 1.5-30 mg-

mcg tab

LOESTRIN FE 1.5/30 1.5-30 mg-

mcg tab

LORYNA 3

0.02 mg tab

LOW-OGESTREL 0.3-30 mg-mcg

tab

LUTERA 0.1

20 mg

mcg tab

marlissa 0.15

30 mg

mcg tab

NORDETTE

MICROGESTIN 1.5/30 1.5-30 mg-

mcg tab

MICROGESTIN 1/20 1-20 mg-mcg

tab

MICROGESTIN FE 1.5/30 1.5-30

mcg tab

MICROGESTIN FE 1/20 1-20 mg-

mcg tab

MILI

0.25

35 mg

mcg tab

MIRCETTE 0.15-0.02/0.01 mg

(21/5) tab

MONO-LINYAH 0.25-35 mg-mcg

tab

MONONESSA 0.25

35 mg

mcg tab

MYZILRA 50-30/75-40/ 125-30 mcg

tab

CareFirst Plan DC

Page 43 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

NECON 0.5/35 (28) 0.5-35 mg-mcg

tab

NIKKI 3

0.02 mg tab

norethin ace-eth estrad-fe 1-20 mg-

mcg tab

LOESTRIN FE

norethindrone acet-ethinyl est 1-20

mcg tab

LOESTRIN

norgestimate-eth estradiol 0.25-35

mcg tab

ORTHO

CYCLEN (28)

norgestim-eth estrad triphasic

0.18/0.215/0.25 mg

35 mcg tab

ORTHO TRI

CYCLEN

NORTREL 1/35 (21) 1-35 mg-mcg

tab

NORTREL 1/35 (28) 1-35 mg-mcg

tab

NORTREL 7/7/7 0.5/0.75/1-35 mg-

mcg tab

OCELLA 3

0.03 mg tab

ORSYTHIA 0.1

20 mg

mcg tab

ORTHO TRI-CYCLEN (28)

0.18/0.215/0.25 mg

35 mcg tab

ORTHO-NOVUM 1/35 (28) 1-35

mcg tab

PIMTREA 0.15-0.02/0.01 mg (21/5)

tab

PORTIA

28 0.15

30 mg

mcg tab

RECLIPSEN 0.15

30 mg

mcg tab

SPRINTEC 28 0.25

35 mg

mcg tab

SRONYX 0.1

20 mg

mcg tab

SYEDA 3

0.03 mg tab

TRI FEMYNOR 0.18/0.215/0.25

35 mcg tab

TRI-LEGEST FE 1-20/1-30/1-35

mcg tab

TRI-LINYAH 0.18/0.215/0.25 mg-

35 mcg tab

TRI-SPRINTEC 0.18/0.215/0.25

35 mcg tab

VIENVA 0.1

20 mg

mcg tab

CareFirst Plan DC

Page 44 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

viorele 0.15-0.02/0.01 mg (21/5)

tab

MIRCETTE

WERA 0.5

35 mg

mcg tab

ZARAH 3

0.03 mg tab

Combination Contraceptives

Transdermal

XULANE 150-35 mcg/24hr tdwk

patch

QL(3 / 25)

Combination Contraceptives

Vaginal

etonogestrel-ethinyl estradiol 0.12-

0.015 mg/24hr vag ring

NUVARING

QL(1 / 25)

Emergency

Contraceptives

AFTERA 1.5 mg tab

ELLA 30 mg tab

levonorgestrel 1.5 mg tab

PLAN B ONE

STEP

MY WAY 1.5 mg tab

OPCICON ONE

STEP 1.5 mg tab

OPTION 2 1.5 mg tab

PLAN B ONE

STEP 1.5 mg tab

TAKE ACTION 1.5 mg tab

Progestin Contraceptives

Implants

NEXPLANON 68 mg sc implant

Progestin

Contraceptives

Injectable

medroxyprogesterone acetate 150

mg/ml im susp, 150 mg/ml im susp

pfs

DEPO

PROVERA

Progestin Contraceptives

Oral

CAMILA 0.35 mg tab

DEBLITANE 0.35 mg tab

ERRIN 0.35 mg tab

HEATHER 0.35 mg tab

JENCYCLA 0.35 mg tab

JOLIVETTE 0.35 mg tab

NORA

BE 0.35 mg tab

norethindrone 0.35 mg tab

NOR

SHAROBEL 0.35 mg tab

CORTICOSTEROIDS

Glucocorticosteroids

budesonide 3 mg cap dr prt

ENTOCORT

dexamethasone 1 mg tab, 2 mg tab

dexamethasone 0.5

mg/5ml soln

CareFirst Plan DC

Page 45 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

dexamethasone 0.5 mg/5ml oral

elix

BAYCADRON

dexamethasone 0.5 mg tab, 4 mg

tab, 6 mg tab

DECADRON

hydrocortisone 10 mg tab, 20 mg

tab, 5 mg tab

CORTEF

methylprednisolone 32 mg tab, 4

mg tab, 4 mg tab pack

MEDROL

prednisolone sodium phosphate 25

mg/5ml soln

prednisolone sodium phosphate 10

mg/5ml soln

MILLIPRED

prednisolone sodium phosphate 15

mg tab disint, 30 mg tab disint

ORAPRED

prednisolone sodium phosphate 15

mg/5ml soln

ORAPRED

prednisolone sodium phosphate 6.7

(5 Base) mg/5ml soln

PEDIAPRED

prednisone 1 mg tab, 10 mg (21)

tab pack, 10 mg (48) tab pack, 10

mg tab, 2.5 mg tab, 20 mg tab, 5

mg (21) tab pack, 5 mg (48) tab

pack, 5 mg tab, 50 m

g tab

prednisone 5 mg/5ml soln

Mineralocorticoids

fludrocortisone acetate 0.1 mg tab

FLORINEF

COUGH/COLD/ALLERGY

Antitussives

benzonatate 100 mg cap, 200 mg

cap

TESSALON

benzonatate 150 mg cap

ZONATUSS

dextromethorphan polistirex er 30

mg/5ml susp er

DELSYM

Cough/cold/allergy Combinations

all day allergy-d 5-120 mg tab er 12

ZYRTEC-D ALLERGY

& CONGESTION

allergy relief d-24 10-240 mg tab er

24 hr

QL(30 / 30)

allergy/congestion relief 5-120 mg

tab er 12 hr

CareFirst Plan DC

Page 46 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

cetirizine-pseudoephedrine er 5-

120 mg tab er 12 hr

ZYRTEC-D ALLERGY

& CONGESTION

cheratussin ac 100

10 mg/5ml syr

dextromethorphan-guaifenesin 10-

100 mg/5ml syr

fexofenadine-pseudoephed er 60-

120 mg tab er 12 hr

ALLEGRA

D 12 HOUR

QL(60 / 30)

gnp tussin dm 20

200 mg/10ml liq

guaifenesin-codeine 100-10

mg/5ml soln

guaifenesin

dm 100

10 mg/5ml syr

hm allergy & congestion 5-120 mg

tab er 12 hr

hm allergy relief/nasal decong 10-

240 mg tab er 24 hr

QL(30 / 30)

hm tussin adult dm 100-10 mg/5ml

liq

loratadine-d 24hr 10-240 mg tab er

24 hr

QL(30 / 30)

promethazine-dm 6.25-15 mg/5ml

soln, 6.25

15 mg/5ml syr

pseudoeph-bromphen-dm 30-2-10

mg/5ml syr

sm all day allergy-d 5-120 mg tab

er 12 hr

ZYRTEC-D ALLERGY

& CONGESTION

sm loratadine d 5-120 mg tab er 12

sm lorata-dine d 10-240 mg tab er

24 hr

QL(30 / 30)

sm tussin dm 100

10 mg/5ml syr

tussin dm 100

10 mg/5ml syr

Expectorants

cough syrup 100 mg/5ml liq

gnp tussin 100 mg/5ml syr

gnp tussin mucus & chest cong 100

mg/5ml liq

guaifenesin 100 mg/5ml liq, 100

mg/5ml soln

sm tussin mucus+chest congest

100 mg/5ml liq

CareFirst Plan DC

Page 47 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

tussin mucus+chest congestion

100 mg/5ml liq

DERMATOLOGICALS

Acne Products

ABSORICA 40 mg cap

adapalene 0.1 % crm, 0.1 % gel,

0.3 % gel

DIFFERIN

benzoyl peroxide 10 % gel, 2.5 %

gel, 5 % gel

benzoyl peroxide wash 10 % ext

liq, 5 % ext liq

benzoyl peroxide wash 10 % ext

liq, 5 % ext liq

CLARAVIS 10 mg cap, 20 mg cap,

30 mg cap, 40 mg cap

clindamycin phosphate 1 % swab

CLEOCIN

clindamycin phosphate 1 % gel

CLEOCIN

clindamycin phosphate 1 % ext

soln, 1 % gel, 1 % lot

CLEOCIN

clindamycin phosphate 1 % foam

EVOCLIN

dapsone 5 % gel

ACZONE

erythromycin 2 % pad

erythromycin 2 % ext soln

ERYDERM

erythromycin 2 % gel

ERYGEL

isotretinoin 10 mg cap, 20 mg cap,

30 mg cap, 40 mg cap

ABSORICA

MYORISAN 10 mg cap, 20 mg cap,

30 mg cap, 40 mg cap

sulfacetamide sodium (acne) 10 %

lot

KLARON

sulfacetamide sodium-sulfur 8-4 %

ext susp

SUMAXIN TS

tretinoin 0.05 % gel

ATRALIN

tretinoin 0.025 % gel

RETIN

tretinoin 0.01 % gel, 0.025 % crm,

0.05 % crm, 0.1 % crm

RETIN

ZENATANE 30 mg cap, 40 mg cap

Antibiotics

Topical

bacitracin 500 unit/gm oint

CareFirst Plan DC

Page 48 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

bacitracin zinc 500 unit/gm oint

bacitracin-neomycin-polymyxin

400

5000 oint

double antibiotic 500-10000 unit/gm

oint

gentamicin sulfate 0.1 % crm

GARAMYCIN

hm triple antibiotic 3.5-400-5000

oint

mupirocin 2 % oint

BACTROBAN

mupirocin calcium 2 % crm

BACTROBAN

sm double antibiotic 500-10000

unit/gm oint

triple antibiotic 3.5

400

5000 oint

triple antibiotic 3.5-400-5000 oint,

400

5000 oint

Antifungals

Topical

ciclopirox 0.77 % gel

LOPROX

ciclopirox 1 % shampoo

LOPROX

ciclopirox 8 % ext soln

PENLAC

ciclopirox olamine 0.77 % crm

LOPROX

ciclopirox olamine 0.77 % ext susp

LOPROX

clotrimazole 1 % crm

LOTRIMIN

clotrimazole anti

fungal 1 % crm

LOTRIMIN

clotrimazole-betamethasone 1-0.05

% crm

LOTRISONE

clotrimazole-betamethasone 1-0.05

% lot

LOTRISONE

econazole nitrate 1 % crm

SPECTAZOLE

gnp terbinafine hydrochloride 1 %

crm

ketoconazole 2 % foam

EXTINA

ketoconazole 2 % crm

NIZORAL

ketoconazole 2 % shampoo

NIZORAL

miconazole nitrate 2 % crm

nystatin 100000 unit/gm crm,

100000 unit/gm ext pwdr, 100000

unit/gm oint

MYCOSTATIN

CareFirst Plan DC

Page 49 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

nystatin-triamcinolone 100000-0.1

unit/gm-% crm, 100000-0.1

unit/gm

% oint

MYCOLOG

sm antifungal clotrimazole 1 % crm

LOTRIMIN

sm antifungal tolnaftate 1 % crm

sm athletes foot 1 % crm

terbinafine hcl 1 % crm

tolnaftate 1 % crm, 1 % ext pwdr

Anti

inflammatory Agents

Topical

diclofenac sodium 1.5 % ext soln

PENNSAID

diclofenac sodium 1 % gel

VOLTAREN

Antineoplastic Or Premalignant Lesion Agents

Topical

diclofenac sodium 3 % gel

SOLARAZE

fluorouracil 5 % crm

EFUDEX

Antipsoriatics

calcipotriene 0.005 % crm, 0.005 %

oint

DOVONEX

calcipotriene 0.005 % ext soln

DOVONEX

calcitriol 3 mcg/gm oint

VECTICAL

tazarotene 0.1 % crm

TAZORAC

TAZORAC 0.05 % crm

Antiseborrheic Products

selenium sulfide 2.25 % shampoo

sulfacetamide sodium 10 % ext liq

Burn Products

silver sulfadiazine 1 % crm

SILVADENE

Corticosteroids

Topical

alclometasone dipropionate 0.05 %

crm

ACLOVATE

anti-itch maximum strength 1 %

crm

ALA

CORT

betamethasone dipropionate 0.05

% crm, 0.05 % oint

DIPROSONE

betamethasone dipropionate 0.05

% lot

DIPROSONE

betamethasone dipropionate aug

0.05 % crm, 0.05 % gel, 0.05 %

oint

DIPROLENE

betamethasone dipropionate aug

0.05 % lot

DIPROLENE

CareFirst Plan DC

Page 50 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

betamethasone valerate 0.1 % crm,

0.1 % oint

BETA

VAL

betamethasone valerate 0.1 %

lot

BETA

VAL

betamethasone valerate 0.12 %

foam

LUXIQ

clobetasol prop emollient base 0.05

% crm

TEMOVATE

clobetasol propionate 0.05 % lot,

0.05 % shampoo

CLOBEX

clobetasol propionate 0.05 % foam

OLUX

clobetasol propionate 0.05 % gel,

0.05 % oint

TEMOVATE

clobetasol propionate 0.05 % ext

soln

TEMOVATE

clobetasol propionate 0.05 % crm

TEMOVATE

clobetasol propionate e 0.05 % crm

TEMOVATE

clobetasol propionate emulsion

0.05 % foam

OLUX

desonide 0.05 % crm, 0.05 % oint

DESOWEN

desonide 0.05 % lot

DESOWEN

desoximetasone 0.05 % crm, 0.05

% gel, 0.05 % oint, 0.25 % crm,

0.25 % oint

TOPICORT

diflorasone diacetate 0.05 % crm,

0.05 % oint

PSORCON

fluocinolone acetonide 0.01 % crm,

0.025 % crm, 0.025 % oint

SYNALAR

fluocinolone acetonide 0.01 % ext

soln

SYNALAR

fluocinolone acetonide body 0.01 %

ext oil

DERMA

SMOOTHE/FS

fluocinolone acetonide scalp 0.01

% ext oil

DERMA

SMOOTHE/FS

fluocinonide 0.05 % crm, 0.05 %

gel, 0.05 % oint

LIDEX

fluocinonide 0.05 % ext soln

LIDEX

fluocinonide 0.1 % crm

VANOS

fluticasone propionate 0.005 %

oint, 0.05 %

crm

CUTIVATE

90 Days Supply Drug

gnp hydrocortisone 0.5 % crm

CareFirst Plan DC

Page 51 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

gnp hydrocortisone max st 1 % oint

HYTONE

halobetasol propionate 0.05 % crm,

0.05 % oint

ULTRAVATE

hydrocortisone 0.5 % crm, 0.5 %

oint

hydrocortisone 1 % crm

ALA

CORT

hydrocortisone 1 % oint, 2.5 % crm,

2.5 % oint

HYTONE

hydrocortisone 2.5 % lot

HYTONE

hydrocortisone butyrate 0.1 % crm,

0.1 % oint

LOCOID

hydrocortisone butyrate 0.1 % ext

soln, 0.1 % lot

LOCOID

hydrocortisone max st 1 % crm

ALA

CORT

hydrocortisone max st/12 moist 1 %

crm

ALA

CORT

mometasone furoate 0.1 % crm,

0.1 % oint

ELOCON

mometasone furoate 0.1 % ext soln

ELOCON

sm hydrocortisone 1 % crm

ALA

CORT

sm hydrocortisone max st 1 % oint

HYTONE

triamcinolone acetonide 0.025 %

oint, 0.1 %

oint

KENALOG

triamcinolone acetonide 0.025 %

lot, 0.1 % lot

KENALOG

triamcinolone acetonide 0.025 %

crm, 0.1 % crm

TRIDERM

Emollients

ammonium lactate 12 % crm, 12 %

lot

LAC

HYDRIN

hm glycerin ext liq

Immunomodulating Agents

Topical

imiquimod 5 % crm

ALDARA

Immunosuppressive Agents

Topical

tacrolimus 0.03 %

oint, 0.1 % oint

PROTOPIC

Keratolytic/antimitotic Agents

gnp wart remover 17 % ext liq

podofilox 0.5 % ext soln

CONDYLOX

wart remover maximum strength 40

% ext strip

CareFirst Plan DC

Page 52 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

Local Anesthetics

Topical

capsaicin 0.025 % crm

lidocaine 5 % oint

lidocaine 5 % patch

LIDODERM

lidocaine hcl 3 % crm

LIDAMANTLE

lidocaine hcl 4 % ext soln

XYLOCAINE

lidocaine hcl urethral/mucosal 2 %

External Prefilled Syringe

GLYDO

lidocaine hcl urethral/mucosal 2 %

gel

XYLOCAINE

lidocaine

prilocaine 2.5

2.5 % crm

EMLA

Rosacea Agents

metronidazole 0.75 % crm

METROCREAM

metronidazole 0.75 % gel, 1 % gel

METROGEL

Scabicides & Pediculicides

gnp lice treatment 1 % ext liq

lice killing maximum strength 0.33-

4 % shampoo

malathion 0.5 % lot

OVIDE

permethrin 5 % crm

ELIMITE

sm lice treatment 1 % lot

spinosad 0.9 % ext susp

Wound Care Products

REGRANEX 0.01 % gel

DIAGNOSTIC PRODUCTS

Diagnostic Tests

BINAXNOW COVID-19 AG HOME

TEST in vitro kit

QL(9 / 30)

GLUCOCARD SHINE TEST in vitro

strip

QL(100 / 25)

QUICKVUE AT-HOME COVID-19

TEST in vitro kit

QL(9 / 30)

DIGESTIVE AIDS

Digestive Enzymes

CREON 12000-38000 unit cap dr

prt, 24000-76000 unit cap dr prt,

6000

19000 unit cap dr prt

DIURETICS

Carbonic Anhydrase Inhibitors

CareFirst Plan DC

Page 53 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

acetazolamide 125 mg tab, 250 mg

tab

DIAMOX

acetazolamide er 500 mg cap er 12

DIAMOX

methazolamide 50 mg tab

NEPTAZANE

Diuretic Combinations

triamterene

hctz 37.5

25 mg cap

DYAZIDE

Days Supply Drug

triamterene-hctz 37.5-25 mg tab,

50 mg tab

MAXZIDE

90 Days Supply Drug

Loop Diuretics

bumetanide 0.5 mg tab, 1 mg tab, 2

mg tab

BUMEX

90 Days Supply Drug

furosemide 20 mg tab, 40 mg tab,

80 mg tab

LASIX

90 Days Supply Drug

furosemide 10 mg/ml soln

LASIX

90 Days Supply Drug

torsemide 10 mg tab, 20 mg tab, 5

mg tab

DEMADEX

90 Days Supply Drug

Potassium Sparing Diuretics

spironolactone 100 mg tab, 25 mg

tab, 50 mg tab

ALDACTONE

90 Days Supply Drug

Thiazides And Thiazide

like Diuretics

chlorthalidone 25 mg tab, 50 mg

tab

HYGROTON

90 Days Supply Drug

hydrochlorothiazide 25 mg tab, 50

mg tab

HYDRODIURIL

90 Days Supply Drug

hydrochlorothiazide 12.5 mg cap,

12.5 mg tab

MICROZIDE

90 Days Supply Drug

indapamide 2.5 mg tab

LOZOL

90 Days Supply Drug

metolazone 10 mg tab, 2.5 mg tab,

5 mg tab

ZAROXOLYN

90 Days Supply Drug

ENDOCRINE AND METABOLIC AGENTS

MISC.

Bone Density Regulators

alendronate sodium 35 mg tab, 70

mg tab

FOSAMAX

QL(4 / 25)

alendronate sodium 10 mg tab

FOSAMAX

QL(30 / 30)

Lhrh/gnrh Agonist Analog Pituitary Suppressants

LUPRON DEPOT-PED (1-MONTH)

15 mg im kit, 7.5 mg im kit

SP, PA

CareFirst Plan DC

Page 54 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

LUPRON DEPOT-PED (3-MONTH)

11.25 mg (ped) im kit, 30 mg (ped)

im kit

SP, PA

Metabolic Modifiers

calcitriol 0.25 mcg cap, 0.5 mcg

cap

ROCALTROL

calcitriol 1 mcg/ml soln

ROCALTROL

Posterior Pituitary Hormones

desmopressin acetate 0.1 mg tab,

0.2 mg tab

DDAVP

desmopressin acetate spray 0.01

% nasal soln

DDAVP

ESTROGENS

Estrogen Combinations

PREMPRO 0.3-1.5 mg tab, 0.45-

1.5 mg tab, 0.625-2.5 mg tab,

0.625

5 mg tab

Estrogens

estradiol 0.025 mg/24hr tdwk patch,

0.0375 mg/24hr tdwk patch, 0.05

mg/24hr tdwk patch, 0.1 mg/24hr

tdwk patch

CLIMARA

estradiol 0.5 mg tab, 1 mg tab, 2

mg tab

ESTRACE

estradiol 0.0375 mg/24hr tdbiw

patch, 0.05 mg/24hr tdbiw patch,

0.1 mg/24hr tdbiw patch

VIVELLE

DOT

PREMARIN 0.3 mg tab, 0.625 mg

tab, 0.9

mg tab, 1.25 mg tab

FLUOROQUINOLONES

Fluoroquinolones

CIPRO 250 MG/5ML (5%) susp

ciprofloxacin 500 MG/5ML (10%)

susp

CIPRO

ciprofloxacin hcl 250 mg tab, 500

mg tab, 750 mg tab

CIPRO

ciprofloxacin-ciproflox hcl er 1000

mg tab er 24 hr

CIPRO XR

ciprofloxacin-ciproflox hcl er 500

mg tab er 24 hr

CIPRO XR

QL(3 / 25)

CareFirst Plan DC

Page 55 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

levofloxacin 250 mg tab, 500 mg

tab, 750 mg tab

LEVAQUIN

GASTROINTESTINAL AGENTS - DRUGS TO TREAT BOWEL, INTESTINE AND STOMACH

CONDITIONS

Laxatives

Drugs To Treat Constipation

SUPREP BOWEL PREP KIT 17.5-

3.13

1.6 gm/177ml soln

GASTROINTESTINAL AGENTS

MISC.

Antiflatulents

simethicone 125 mg tab chew, 180

mg cap, 80 mg tab chew

simethicone 40 mg/0.6ml susp

sm gas

relief 80 mg tab chew

Gallstone Solubilizing Agents

ursodiol 300 mg cap

ACTIGALL

ursodiol 250 mg tab

URSO

Gastrointestinal Chloride Channel Activators

lubiprostone 24 mcg cap, 8 mcg

cap

AMITIZA

Gastrointestinal Stimulants

metoclopramide hcl 5 mg tab disint

METOZOLV

metoclopramide hcl 10 mg tab, 5

mg tab

REGLAN

metoclopramide hcl 10 mg/10ml

soln, 5

mg/5ml soln

REGLAN

Inflammatory Bowel Agents

mesalamine 1.2 gm tab dr

LIALDA

sulfasalazine 500 mg tab, 500 mg

tab dr

AZULFIDINE

Intestinal Acidifiers

generlac 10

gm/15ml soln

CONSTULOSE

lactulose encephalopathy 10

gm/15ml soln

CONSTULOSE

Phosphate Binder Agents

calcium acetate 667 mg tab

ELIPHOS

calcium acetate (phos binder) 667

mg tab

ELIPHOS

calcium acetate (phos binder) 667

mg cap

PHOSLO

sevelamer hcl 800 mg tab

RENAGEL

CareFirst Plan DC

Page 56 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

GENITOURINARY AGENTS

MISCELLANEOUS

Alkalinizers

potassium citrate er 10 MEQ (1080

mg) tab er, 15 MEQ (1620 mg) tab

UROCIT

Genitourinary Irrigants

acetic acid 0.25 % irrig soln

Interstitial Cystitis Agents

ELMIRON 100

mg cap

Prostatic Hypertrophy Agents

alfuzosin hcl er 10 mg tab er 24 hr

UROXATRAL

dutasteride 0.5 mg cap

AVODART

finasteride 5 mg tab

PROSCAR

tamsulosin hcl

0.4 mg cap

FLOMAX

Urinary Analgesics

phenazopyridine hcl 100 mg tab,

200 mg tab

PYRIDIUM

sm urinary pain relief max st 97.5

mg tab

GOUT AGENTS

Gout

Agents

allopurinol 100 mg tab, 300 mg tab

ZYLOPRIM

colchicine 0.6 mg tab

COLCRYS

Uricosurics

probenecid 500 mg tab

BENEMID

HEMATOLOGICAL AGENTS

MISC.

Antihemophilic

Products

RECOMBINATE 1801-2400 unit iv

soln, 801

1240 unit iv soln

tranexamic acid 650 mg tab

LYSTEDA

Platelet Aggregation Inhibitors

anagrelide hcl 1 mg cap

AGRYLIN

cilostazol 100 mg tab

PLETAL

clopidogrel bisulfate 75 mg tab

PLAVIX

HEMATOPOIETIC AGENTS

Agents For Sickle Cell Anemia

DROXIA 200 mg cap, 300 mg cap,

400 mg cap

Cobalamins

CareFirst Plan DC

Page 57 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

cyanocobalamin 1000 mcg/ml inj

soln

Folic Acid/folates

folic acid 1 mg tab

Hematopoietic Growth Factors

ARANESP (ALBUMIN FREE) 40

mcg/0.4ml inj soln pfs

SP, PA

NEUPOGEN 300 mcg/ml inj soln

SP, PA

NPLATE 250 mcg sc soln

SP, PA

NYVEPRIA 6 mg/0.6ml sc soln pfs

ZIEXTENZO 6 mg/0.6ml sc soln pfs

Iron

FEROSUL 325 (65 Fe) mg

tab

ferrous sulfate 325 (65 Fe) mg tab

ferrous sulfate 220 (44 Fe) mg/5ml

oral elix

ferrousul 325 (65 Fe) mg tab

HYPNOTICS/SEDATIVES/SLEEP DISORDER AGENTS

Barbiturate Hypnotics

phenobarbital 15 mg tab, 30 mg

tab, 32.4 mg tab

phenobarbital 20 mg/5ml soln

Non

barbiturate Hypnotics

temazepam 15 mg cap, 30 mg cap,

7.5 mg cap

RESTORIL

QL(30 / 30)

zolpidem tartrate 10 mg tab, 5 mg

tab

AMBIEN

QL(14 / 25)

zolpidem tartrate 1.75 mg tab subl

INTERMEZZO

QL(14 / 25)

zolpidem tartrate er 12.5 mg tab er,

6.25 mg tab er

AMBIEN CR

QL(14 / 25)

LAXATIVES

Bulk Laxatives

sm fiber 28.3 % oral pwdr

Laxative Combinations

GAVILYTE

C 240 gm soln

gnp senna plus

8.6

50 mg tab

peg 3350/electrolytes 240 gm soln

peg 3350-kcl-na bicarb-nacl 420

gm soln

NULYTELY

peg

3350/electrolytes 236 gm soln

GOLYTELY

CareFirst Plan DC

Page 58 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

sennosides-docusate sodium 8.6-

50 mg tab

sm senna

s 8.6

50 mg tab

sm stool softener 8.6

50 mg tab

stimulant laxative 8.6

50 mg

tab

Laxatives

Miscellaneous

CLEARLAX 17 gm/scoop oral pwdr

GOODSENSE CLEARLAX 17

gm/scoop oral pwdr

lactulose 10 gm/15ml soln

CONSTULOSE

peg 3350 17

gm pckt

MIRALAX

peg 3350 17 gm/scoop oral pwdr

MIRALAX

polyethylene glycol 3350 17 gm

pckt

MIRALAX

polyethylene glycol 3350 17

gm/scoop oral pwdr

MIRALAX

SM CLEARLAX 17 gm/scoop oral

pwdr

Saline Laxatives

hm magnesium citrate 1.745

gm/30ml soln

hm milk of magnesia 1200 mg/15ml

susp

magnesium citrate 1.745 gm/30ml

soln

milk of magnesia 1200 mg/15ml

susp, 400 mg/5ml susp, 7.75 %

susp

sm magnesium citrate 1.745

gm/30ml soln

Stimulant Laxatives

bisacodyl 10 mg

rect supp

bisacodyl ec 5 mg tab dr

hm senna 8.6 mg tab

laxative 10 mg rect supp

senna 8.6 mg tab

senna

lax 8.6 mg tab

senna

tabs 8.6 mg tab

SENOKOT 8.6 mg tab

sm senna laxative 8.6 mg tab

CareFirst Plan DC

Page 59 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

stimulant laxative 5 mg tab dr

Surfactant Laxatives

docusate sodium 100 mg cap, 100

mg tab

docusate sodium 50 mg/5ml liq

DOCUSIL 100 mg cap

DOK 100 mg cap

gnp stool softener 100 mg cap

hm stool softener 100 mg

cap

sm stool softener 100 mg cap

stool softener 100 mg cap

LOCAL ANESTHETICS

PARENTERAL

Local Anesthetics

Amides

lidocaine hcl (pf) 1 % inj soln

XYLOCAINE

MACROLIDES

Azithromycin

azithromycin 1 gm pckt, 600 mg tab

ZITHROMAX

azithromycin 100 mg/5ml susp, 200

mg/5ml susp

ZITHROMAX

azithromycin 500 mg tab

ZITHROMAX

QL(4 / 25)

azithromycin 250 mg tab

ZITHROMAX

QL(8 / 25)

Clarithromycin

clarithromycin 250 mg tab, 500 mg

tab

BIAXIN

clarithromycin 125 mg/5ml susp,

250 mg/5ml susp

BIAXIN

clarithromycin er 500 mg tab er 24

BIAXIN XL

Erythromycins

erythromycin base 250 mg cap dr

prt, 250 mg tab

erythromycin base 500 mg tab

ERY

TAB

erythromycin ethylsuccinate 400

mg tab

E.E.S.

erythromycin ethylsuccinate 200

mg/5ml susp

ERYPED

MEDICAL DEVICES AND SUPPLIES

Diabetic Supplies

ACCU-CHEK SOFT TOUCH

LANCETS misc

QL(100 / 25)

CareFirst Plan DC

Page 60 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

AGAMATRIX ULTRA-THIN

LANCETS misc

QL(100 / 25)

AQUALANCE LANCETS 30G misc

QL(100 / 25)

BAYER MICROLET LANCETS

misc

QL(100 / 25)

BD LANCET ULTRAFINE 30G

misc

QL(100 / 25)

BD LANCET ULTRAFINE 33G

misc

QL(100 / 25)

cvs lancets micro thin 33g misc

QL(100 / 25)

cvs lancets thin 26g misc

QL(100 / 25)

cvs lancets ultra thin 30g misc

QL(100 / 25)

cvs lancets ultra

thin 30g misc

QL(100 / 25)

DEXCOM G6 RECEIVER dev

DEXCOM G6 SENSOR misc

DEXCOM G6 TRANSMITTER misc

easy comfort lancets misc

QL(100 / 25)

EASY TOUCH LANCETS

28G/TWIST misc

QL(100 / 25)

EASY TOUCH LANCETS

30G/TWIST misc

QL(100 / 25)

EASY TOUCH LANCETS

33G/TWIST misc

QL(100 / 25)

E-Z JECT LANCET SUPER THIN

30G misc

QL(100 / 25)

E-Z JECT LANCETS THIN 26G

misc

QL(100 / 25)

FREESTYLE LANCETS misc

QL(100 / 25)

GLUCOCARD SHINE w/Device kit

QL(1 / 365)

GLUCOCARD SHINE CONNEX

w/Device kit

QL(1 / 365)

GLUCOCARD SHINE CONTROL

in vitro soln

GLUCOCARD SHINE EXPRESS

w/Device kit

QL(1 / 365)

GLUCOCARD SHINE XL dev

QL(1 / 365)

GLUCOCOM LANCETS 33G misc

QL(100 / 25)

gnp lancets super thin 30g misc

QL(100 / 25)

lancets misc

QL(100 / 25)

lancets 30g misc

QL(100 / 25)

CareFirst Plan DC

Page 61 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

LANCETS ULTRA FINE misc

QL(100 / 25)

LANCETS ULTRA THIN misc

QL(100 / 25)

lancing device misc

QL(1 / 365)

leader advanced lancing device

misc

QL(1 / 365)

MICROLET LANCETS misc

QL(100 / 25)

ONETOUCH DELICA LANCETS

30G misc

QL(100 / 25)

ONETOUCH DELICA LANCETS

33G misc

QL(100 / 25)

ONETOUCH ULTRASOFT

LANCETS misc

QL(100 / 25)

PHARMACIST CHOICE LANCETS

misc

QL(100 / 25)

STERILANCE TL misc

QL(100 / 25)

sure comfort lancets 30g misc

QL(100 / 25)

TECHLITE LANCETS misc

QL(100 / 25)

TECHLITE LANCETS 30G misc

QL(100 / 25)

TRUEPLUS LANCETS 28G misc

QL(100 / 25)

TRUEPLUS LANCETS 30G misc

QL(100 / 25)

TRUEPLUS LANCETS 33G misc

QL(100 / 25)

TRUEPLUS SAFETY LANCETS

28G misc

QL(100 / 25)

ULTRA

THIN II LANCETS misc

QL(100 / 25)

UNILET COMFORTOUCH

LANCET misc

QL(100 / 25)

UNILET GP 28 ULTRA THIN misc

QL(100 / 25)

UNISTIK 3 COMFORT misc

QL(100 / 25)

Misc. Devices

alcohol pads 70 % pad

QL(100 / 30)

cvs alcohol prep pads 70 % pad

QL(100 / 30)

meijer alcohol swabs 70 % pad

QL(100 / 30)

RELION ALCOHOL SWABS pad

QL(100 / 30)

SHOPKO ALCOHOL SWABS 70 %

pad

QL(100 / 30)

ultra-care alcohol prep pads 70 %

pad

QL(100 / 30)

Parenteral Therapy Supplies

techlite insulin syringe 29G X 1/2"

0.3 ml misc, 29G X 1/2" 0.5 ml

QL(100 / 30)

CareFirst Plan DC

Page 62 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

misc, 29G X 1/2" 1 ml misc, 30G X

1/2" 0.3 ml misc, 30G X 1/2" 0.5 ml

misc, 30G X 1/2" 1 ml misc, 30G X

5/16" 0.3 ml misc, 30G X 5/16" 0.5

ml misc, 30G X 5/16" 1 ml misc,

31G X 15/64" 0.3 ml misc, 31G X

15/64" 0.5 ml misc, 31G X 15/64" 1

ml misc, 31G X 5/16" 0.3 ml misc,

31G X 5/16" 0.5 ml misc, 31G X

5/16" 1 ml misc

TECHLITE PEN NEEDLES 31G X

5 MM misc

TECHLITE PEN NEEDLES 29G X

12MM misc, 31G X 5 MM misc,

31G X 8 MM misc, 32G X 4 MM

misc, 32G X 6 MM misc, 32G X 8

MM misc

QL(100 / 30)

Respiratory Therapy Supplies

AEROCHAMBER PLUS FLO-VU

misc

AEROCHAMBER PLUS FLO-VU

LARGE misc

AEROCHAMBER PLUS FLO-VU

SMALL misc

AEROCHAMBER PLUS FLO-VU

W/MASK misc

EASIVENT misc

Z SPACER dev

FLEXICHAMBER dev

INSPIRACHAMBER/LARGE dev

INSPIRACHAMBER/MEDIUM dev

INSPIRACHAMBER/MOUTHPIEC

E dev

INSPIRACHAMBER/SMALL dev

MIGRAINE PRODUCTS

Migraine Products

dihydroergotamine mesylate 4

mg/ml nasal soln

MIGRANAL

Serotonin Agonists

rizatriptan benzoate 10 mg tab, 5

mg tab

MAXALT

QL(9 / 30)

CareFirst Plan DC

Page 63 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

rizatriptan benzoate 10 mg tab

disint, 5 mg tab disint

MAXALT MLT

QL(9 / 30)

sumatriptan 20 mg/act nasal soln, 5

mg/act nasal soln

IMITREX

sumatriptan succinate 6 mg/0.5ml

sc soln

IMITREX

QL(2 / 30)

sumatriptan succinate 100 mg tab,

25 mg tab, 50 mg tab

IMITREX

QL(9 / 30)

sumatriptan succinate 4 mg/0.5ml

sc soln auto-inj, 6 mg/0.5ml sc soln

auto

inj

IMITREX STATDOSE

QL(2 / 30)

zolmitriptan 2.5 mg tab, 5 mg nasal

soln, 5 mg tab, 5 mg tab disint

ZOMIG

QL(9 / 30)

MINERALS & ELECTROLYTES

Calcium

calcium carbonate 1250 (500 Ca)

mg tab

Potassium

KLOR

CON M20 20 meq tab er

KLOR

CON/EF 25 meq tab eff

QL(35 / 28)

potassium chloride 20 meq pckt

potassium chloride 20 MEQ/15ML

(10%)

soln

SOL

potassium chloride crys er 10 meq

tab er

potassium chloride crys er 20 meq

tab er

KLOR

CON

potassium chloride er 10 meq tab

er, 8 meq tab

KLOR

CON

potassium chloride er 10 meq cap

MICRO

Potassium Removing Agent

sodium polystyrene sulfonate oral

pwdr

KAYEXALATE

MISCELLANEOUS THERAPEUTIC CLASSES

Immunosuppressive Agents

AZASAN 100 mg tab, 75 mg tab

azathioprine 50 mg tab

IMURAN

cyclosporine modified 100 mg cap

NEORAL

CareFirst Plan DC

Page 64 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

cyclosporine modified 100 mg/ml

soln

NEORAL

mycophenolate mofetil 250 mg cap,

500 mg tab

CELLCEPT

mycophenolate mofetil 200 mg/ml

susp

CELLCEPT

sirolimus 0.5 mg tab, 1 mg tab

RAPAMUNE

sirolimus 1 mg/ml soln

RAPAMUNE

tacrolimus 0.5 mg cap, 1 mg cap, 5

mg cap

PROGRAF

MOUTH/THROAT/DENTAL AGENTS

Anesthetics Topical Oral

lidocaine viscous 2 % m/t soln

XYLOCAINE

lidocaine viscous hcl 2 % m/t soln

XYLOCAINE

Anti

infectives

Throat

clotrimazole 10 mg m/t troche

MYCELEX

nystatin

100000 unit/ml m/t susp

MYCOSTATIN

Antiseptics

Mouth/throat

chlorhexidine gluconate 0.12 % m/t

soln

PERIDEX

Lozenges

CEPACOL SORE THROAT &

COUGH 5

7.5 mg m/t lozg

Steroids

Mouth/throat/dental

triamcinolone acetonide 0.1 % m/t

paste

KENALOG IN

ORABASE

MULTIVITAMINS

Ped Multi Vitamins W/fl & Fe

POLY-VI-FLOR/IRON 0.25-7 mg/ml

susp

Ped Mv W/ Fluoride

multivitamin/fluoride 0.5 mg tab

chew

POLY

FLOR 0.25 mg/ml susp

Ped Mv W/ Iron

POLY

SOL/IRON 11 mg/ml soln

Prenatal Vitamins

classic prenatal 28

0.8 mg tab

CAL FA 27

1 mg tab

CareFirst Plan DC

Page 65 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

pnv prenatal plus multivitamin 27-1

mg tab

prenatal 27

1 mg tab

prenatal 19 tab chew

prenatal vitamin plus low iron 27-1

mg tab

prenatal vitamins 28

0.8 mg tab

pretab 29

1 mg tab

MUSCULOSKELETAL THERAPY AGENTS

Central Muscle Relaxants

baclofen 10 mg tab, 20 mg tab

LIORESAL

carisoprodol 250 mg tab, 350 mg

tab

SOMA

cyclobenzaprine hcl 7.5 mg tab

FEXMID

QL(90 / 30)

cyclobenzaprine hcl 10 mg tab

FLEXERIL

cyclobenzaprine hcl 5 mg tab

FLEXERIL

QL(90 / 30)

metaxalone 400 mg tab, 800 mg

tab

SKELAXIN

methocarbamol 500 mg tab, 750

mg tab

ROBAXIN

orphenadrine citrate er 100 mg tab

er 12 hr

NORFLEX

tizanidine hcl 2 mg cap, 2 mg tab, 4

mg cap, 4 mg tab, 6 mg cap

ZANAFLEX

NASAL AGENTS

SYSTEMIC AND TOPICAL

Nasal Antiallergy

azelastine hcl 0.1 % nasal soln,

137 mcg/spray nasal soln

ASTELIN

azelastine hcl 0.15 % nasal soln

ASTEPRO

cromolyn sodium 5.2 mg/act nasal

aer soln

Nasal Anticholinergics

ipratropium bromide 0.03 % nasal

soln, 0.06 % nasal soln

ATROVENT

90 Days Supply Drug

Nasal Steroids

flunisolide 25 MCG/ACT (0.025%)

nasal soln

NASALIDE

fluticasone propionate 50 mcg/act

nasal susp

FLONASE

90 Days Supply Drug

OPHTHALMIC AGENTS

CareFirst Plan DC

Page 66 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

Artificial Tears And Lubricants

artificial tears 83

15 % ophth oint

artificial tears 1.4 % ophth soln

BION TEARS PF 0.1-0.3 % ophth

soln

GENTEAL TEARS 0.1-0.3 % ophth

soln

GENTEAL TEARS PF 0.1-0.3 %

ophth soln

liquitears 1.4 % ophth soln

natural balance tears 0.1-0.3 %

ophth soln

natures tears 0.1

0.3 % ophth soln

Beta

blockers

Ophthalmic

dorzolamide hcl-timolol mal 22.3-

6.8 mg/ml ophth soln

COSOPT

timolol maleate 0.25 % ophth soln,

0.5 % ophth soln

TIMOPTIC

timolol maleate 0.25 % ophth gfs,

0.5 % ophth gfs

TIMOPTIC XE

timolol maleate (once-daily) 0.5 %

ophth soln

ISTALOL

Cycloplegic Mydriatics

atropine sulfate 1 % ophth soln

ISOPTO ATROPINE

Miotics

pilocarpine hcl 1 % ophth soln

ISOPTO CARPINE

Ophthalmic Adrenergic Agents

ALPHAGAN P 0.1 % ophth soln

brimonidine tartrate 0.15 % ophth

soln, 0.2 % ophth soln

ALPHAGAN

Ophthalmic

Anti

infectives

bacitracin 500 unit/gm ophth oint

BACI

bacitracin-polymyxin b 500-10000

unit/gm ophth oint

POLYSPORIN

ciprofloxacin hcl 0.3 % ophth soln

CILOXAN

erythromycin 5 mg/gm ophth oint

ILOTYCIN

gentamicin sulfate 0.3 % ophth soln

GARAMYCIN

levofloxacin 0.5 % ophth soln

QUIXIN

neomycin-bacitracin zn-polymyx 5-

400

10000 ophth oint

NEOSPORIN

CareFirst Plan DC

Page 67 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

neomycin-polymyxin-gramicidin

1.75

10000

.025 ophth soln

NEOSPORIN

NEO-POLYCIN 3.5-400-10000

ophth oint

ofloxacin 0.3 % ophth soln

OCUFLOX

polymyxin b-trimethoprim 10000-

0.1 unit/ml

% ophth soln

POLYTRIM

sulfacetamide sodium 10 % ophth

soln

BLEPH

tobramycin 0.3 % ophth soln

TOBREX

trifluridine 1 % ophth soln

VIROPTIC

Ophthalmic Steroids

bacitra-neomycin-polymyxin-hc 1 %

ophth oint

CORTISPORIN

fluorometholone 0.1 % ophth susp

FML

FML FORTE 0.25 % ophth susp

LOTEMAX 0.5 % ophth oint

loteprednol etabonate 0.5 % ophth

gel

LOTEMAX

loteprednol etabonate 0.5 % ophth

susp

LOTEMAX

neomycin-polymyxin-dexameth 3.5-

10000

0.1 ophth oint

MAXITROL

neomycin-polymyxin-dexameth 3.5-

10000

0.1 ophth susp

MAXITROL

neomycin-polymyxin-hc 3.5-10000-

1 ophth susp

CORTISPORIN

prednisolone acetate 1 % ophth

susp

PRED FORTE

tobramycin-dexamethasone 0.3-0.1

% ophth susp

TOBRADEX

Ophthalmics

Misc.

azelastine hcl 0.05 %

ophth soln

OPTIVAR

brinzolamide 1 % ophth susp

AZOPT

cromolyn sodium 4 % ophth soln

OPTICROM

diclofenac sodium 0.1 % ophth soln

VOLTAREN

dorzolamide hcl 2 % ophth soln

TRUSOPT

eye itch relief 0.025 % ophth soln

ZADITOR

hm eye itch relief 0.025 % ophth

soln

ZADITOR

CareFirst Plan DC

Page 68 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

ketorolac tromethamine 0.4 %

ophth soln, 0.5 %

ophth soln

ACULAR

ketotifen fumarate 0.025 % ophth

soln

ZADITOR

sm eye itch relief 0.025 % ophth

soln

ZADITOR

sodium chloride (hypertonic) 5 %

ophth soln

Prostaglandins

Ophthalmic

bimatoprost 0.03 % ophth soln

LUMIGAN

latanoprost 0.005 % ophth soln

XALATAN

ZIOPTAN 0.0015 % ophth soln

OPHTHALMIC AGENTS

DRUGS TO TREAT EYE CONDITIONS

Ophthalmic Agents, Other

Miscellaneous Eye Drugs

cyclosporine 0.05 % ophth emul

RESTASIS

OTIC AGENTS

Otic Agents

Miscellaneous

acetic acid 2 % otic soln

VOSOL

Otic Anti

infectives

ofloxacin 0.3 % otic soln

FLOXIN

Otic Combinations

neomycin-polymyxin-hc 1 % otic

soln, 3.5-10000-1 otic soln, 3.5-

10000

1 otic susp

CORTISPORIN

OXYTOCICS

Oxytocics

methylergonovine maleate 0.2 mg

tab

METHERGINE

PASSIVE IMMUNIZING AND TREATMENT AGENTS

Immune Serums

GAMUNEX-C 10 gm/100ml inj soln,

20 gm/200ml inj soln, 5 gm/50ml inj

soln

RHOGAM ULTRA-FILTERED

PLUS 1500 unit im soln pfs

Monoclonal Antibodies

SYNAGIS 100 mg/ml im soln, 50

mg/0.5ml im soln

SP, PA

PENICILLINS

Aminopenicillins

CareFirst Plan DC

Page 69 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

amoxicillin 250 mg cap, 500 mg

cap, 875 mg tab

AMOXIL

amoxicillin 125 mg/5ml susp, 200

mg/5ml susp, 250 mg/5ml susp,

400 mg/5ml susp

AMOXIL

ampicillin 500 mg cap

Natural Penicillins

penicillin g procaine 600000 unit/ml

im susp

penicillin v potassium 500 mg tab

PEN

VEE K

penicillin v potassium 250 mg tab

VEETIDS

penicillin v potassium 125 mg/5ml

soln, 250 mg/5ml soln

VEETIDS

Penicillin Combinations

amoxicillin-pot clavulanate 200-

28.5 mg tab chew, 250-125 mg tab,

400-57 mg tab chew, 500-125 mg

tab, 875

125 mg tab

AUGMENTIN

amoxicillin-pot clavulanate 200-

28.5 mg/5ml susp, 250-62.5

mg/5ml susp, 400-57 mg/5ml susp,

600

42.9 mg/5ml susp

AUGMENTIN

Penicillinase

resistant Penicillins

dicloxacillin sodium 250 mg cap

DYCILL

PROGESTINS

Progestins

hydroxyprogesterone caproate 250

mg/ml im oil

MAKENA

MAKENA 250 mg/ml im oil

medroxyprogesterone acetate 10

mg tab, 2.5 mg tab, 5 mg tab

PROVERA

norethindrone acetate 5 mg tab

AYGESTIN

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS

MISC.

Agents For

Chemical Dependency

acamprosate calcium 333 mg tab

CAMPRAL

disulfiram 250 mg tab, 500 mg tab

ANTABUSE

LUCEMYRA 0.18 mg tab

QL(480 / 30)

Antidementia Agents

donepezil hcl 10

mg tab, 5 mg tab

ARICEPT

CareFirst Plan DC

Page 70 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

Multiple Sclerosis Agents

AVONEX PREFILLED 30

mcg/0.5ml im pfs kit

dimethyl fumarate 120 mg cap dr,

240 mg cap dr

TECFIDERA

dimethyl fumarate starter pack 120

& 240 mg oral misc

TECFIDERA

REBIF 22 mcg/0.5ml sc soln pfs,

44 mcg/0.5ml sc soln pfs

SP, PA

Premenstrual Dysphoric Disorder (pmdd) Agents

fluoxetine hcl (pmdd) 10 mg tab, 20

mg tab

SARAFEM

90 Days Supply Drug

Smoking Deterrents

apo-varenicline 0.5 mg tab, 1 mg

tab

CHANTIX

QL(56 / 28)

bupropion hcl er (smoking det) 150

mg tab er 12 hr

ZYBAN

90 Days Supply Drug

goodsense nicotine 4 mg m/t gum

NICORETTE

hm nicotine 14 mg/24hr td patch

24hr, 21 mg/24hr td patch 24hr

NICODERM CQ

hm nicotine polacrilex 2 mg m/t

gum, 4

mg m/t gum

NICORETTE

nicotine 21

7 mg/24hr td kit

nicotine 14 mg/24hr td patch 24hr,

21 mg/24hr td patch 24hr, 7

mg/24hr td patch 24hr

NICODERM CQ

nicotine polacrilex 2 mg m/t gum, 2

mg m/t lozg, 4 mg m/t gum, 4 mg

m/t lozg

NICORETTE

nicotine step 1 21 mg/24hr td patch

24hr

NICODERM CQ

nicotine step 2 14 mg/24hr td patch

24hr

NICODERM CQ

nicotine step 3 7 mg/24hr td patch

24hr

NICODERM CQ

NICOTROL 10 mg inhaler

NICOTROL NS 10 mg/ml nasal

soln

sm nicotine 14 mg/24hr td patch

24hr, 21 mg/24hr td patch 24hr, 7

mg/24hr td

patch 24hr

NICODERM CQ

CareFirst Plan DC

Page 71 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

sm nicotine 2 mg m/t lozg, 4 mg m/t

gum

NICORETTE

sm nicotine polacrilex 2 mg m/t

gum, 4 mg m/t gum, 4 mg m/t lozg

NICORETTE

varenicline tartrate 0.5 MG X 11 &

1 mg x 42 tab pack

CHANTIX

QL(53 / 28)

varenicline tartrate 0.5 mg tab, 1

mg tab

CHANTIX

QL(56 / 28)

RESPIRATORY AGENTS

MISC.

Cystic Fibrosis Agents

PULMOZYME 2.5 mg/2.5ml inh

soln

SP, PA

TETRACYCLINES

Tetracyclines

doxycycline hyclate 100 mg tab dr,

150 mg tab dr, 200 mg tab dr

DORYX

doxycycline hyclate 20 mg tab

PERIOSTAT

doxycycline hyclate 100 mg tab

VIBRA

TABS

doxycycline hyclate 100 mg cap, 50

mg cap

VIBRAMYCIN

minocycline hcl 100 mg tab, 50 mg

tab

DYNACIN

minocycline hcl 100 mg cap, 50 mg

cap

MINOCIN

tetracycline hcl 250 mg cap, 500

mg cap

THYROID AGENTS

Antithyroid Agents

methimazole 10 mg tab, 5 mg tab

TAPAZOLE

propylthiouracil 50 mg tab

Thyroid Hormones

levothyroxine sodium 100 mcg tab,

112 mcg tab, 125 mcg tab, 137

mcg tab, 150 mcg tab, 175 mcg

tab, 200 mcg tab, 25 mcg tab, 300

mcg tab, 50 mcg tab, 75 mcg tab,

88 mcg tab

SYNTHROID

liothyronine sodium 25 mcg tab, 5

mcg tab

CYTOMEL

CareFirst Plan DC

Page 72 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

SYNTHROID 125 mcg tab, 150

mcg tab, 200 mcg tab

UNITHROID 125 mcg tab

TOXOIDS

Toxoid Combinations

ADACEL 5-2-15.5 lf-mcg/0.5 im

susp

QL(0.5 / 365), AL

BOOSTRIX 5-2.5-18.5 lf-mcg/0.5

im susp

QL(0.5 / 365), AL

DECAVAC 5

2 lfu im inj

QL(0.5 / 365), AL

diphtheria-tetanus toxoids 6.7-5

lfu/0.5ml im inj

QL(0.5 / 365), AL

TDVAX 2

2 lf/0.5ml im susp

QL(1.5 / 365), AL

TENIVAC 5

2 lfu im inj

QL(1.5 / 365), AL

tetanus-diphtheria toxoids td 2-2

lf/0.5ml im susp

QL(0.5 / 365), AL

Toxoids

tetanus toxoid adsorbed 5 lfu im

soln

QL(0.5 / 365), AL

ULCER DRUGS/ANTISPASMODICS/ANTICHOLINERGICS

Antispasmodics

dicyclomine hcl 10 mg cap, 20 mg

tab

BENTYL

hyoscyamine sulfate 0.125 mg tab

disint

ANASPAZ

hyoscyamine sulfate 0.125 mg tab

LEVSIN

hyoscyamine sulfate 0.125 mg tab

subl

LEVSIN/SL

2 Antagonists

cimetidine 300 mg tab, 400 mg tab

TAGAMET

cimetidine hcl 300 mg/5ml soln

TAGAMET

famotidine 20 mg tab, 40 mg tab

PEPCID

QL(60 / 30)

famotidine 40 mg/5ml

susp

PEPCID

QL(300 / 30)

ranitidine 150 max strength 150 mg

tab

ZANTAC

ranitidine hcl 150 mg cap, 150 mg

tab, 300 mg cap, 300 mg tab

ZANTAC

ranitidine hcl 15 mg/ml syr, 75

mg/5ml syr

ZANTAC

sm acid reducer max st 150 mg tab

ZANTAC

CareFirst Plan DC

Page 73 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

Misc. Anti

ulcer

sucralfate 1 gm tab

CARAFATE

sucralfate 1 gm/10ml susp

CARAFATE

Proton

Pump Inhibitors

esomeprazole magnesium 20 mg

cap dr, 40 mg cap dr

NEXIUM

lansoprazole 15 mg cap dr, 30 mg

cap dr

PREVACID

omeprazole 20 mg tab dr

omeprazole 10 mg cap dr, 20 mg

cap dr, 40 mg cap dr

PRILOSEC

pantoprazole sodium 20 mg tab dr,

40 mg tab dr

PROTONIX

sm omeprazole 20 mg tab dr

Ulcer Drugs

Prostaglandins

misoprostol 100 mcg tab, 200 mcg

tab

CYTOTEC

URINARY ANTI

INFECTIVES

Urinary Anti

infectives

nitrofurantoin 25 mg/5ml susp

FURADANTIN

nitrofurantoin macrocrystal 100 mg

cap, 25 mg cap, 50 mg cap

MACRODANTIN

nitrofurantoin monohyd macro 100

mg cap

MACROBID

URINARY ANTISPASMODICS

Urinary Antispasmodic

Antimuscarinics (anticholinergic)

darifenacin hydrobromide er 15 mg

tab er 24

hr, 7.5 mg tab er 24 hr

ENABLEX

oxybutynin chloride 5 mg tab

DITROPAN

oxybutynin chloride 5 mg/5ml syr

DITROPAN

oxybutynin chloride er 10 mg tab er

24 hr, 15 mg tab er 24 hr, 5 mg tab

er 24 hr

DITROPAN

tolterodine tartrate 1 mg tab, 2 mg

tab

DETROL

tolterodine tartrate er 2 mg cap er

24 hr, 4 mg cap er 24 hr

DETROL LA

trospium chloride er 60 mg cap er

24 hr

SANCTURA XR

Urinary Antispasmodics

Cholinergic Agonists

CareFirst Plan DC

Page 74 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

bethanechol chloride 5 mg tab

URECHOLINE

VACCINES

Bacterial Vaccines

BEXSERO im susp pfs

QL(1 / 365), AL

HIBERIX 10 mcg inj soln

QL(2 / 365), AL

MENACTRA im inj

QL(0.5 / 365), AL

MENOMUNE sc soln

QL(1 / 365), AL

MENVEO im soln

QL(1 /

365), AL

PNEUMOVAX 23 25 mcg/0.5ml inj

QL(0.5 / 365), AL

PREVNAR 13 im susp

QL(0.5 / 365), AL

PREVNAR 20 0.5 ml im susp pfs

QL(0.5 / 365), AL

TRUMENBA im susp pfs

QL(1.5 / 365), AL

Viral Vaccines

AFLURIA QUADRIVALENT 0.25 ml

im susp pfs

QL(0.5 / 365)

AFLURIA QUADRIVALENT im

susp, 0.5 ml im susp pfs

QL(1 / 365)

astrazeneca covid-19 vaccine 0.5

ml im

susp

QL(0.5 / 28)

BOOSTRIX 5-2.5-18.5 lf-mcg/0.5

im susp pfs

QL(0.5 / 365), AL

COMIRNATY 30 mcg/0.3ml im

susp

ENGERIX-B 10 mcg/0.5ml inj susp,

10 mcg/0.5ml Injection Suspension

Prefilled Syringe

QL(1.5 / 365), AL

ENGERIX-B 20 mcg/ml inj susp, 20

mcg/ml Injection Suspension

Prefilled Syringe

QL(3 / 365), AL

ENGERIX-B 20 mcg/ml Injection

Suspension Prefilled Syringe

QL(3 / 365), AL

FLUAD 0.5 ml im susp pfs

QL(1 / 365)

FLUAD QUADRIVALENT 0.5 ml im

pfs

QL(1 / 365)

FLUARIX QUADRIVALENT 0.5 ml

im susp pfs

QL(1 / 365)

FLUBLOK QUADRIVALENT 0.5 ml

im soln pfs

QL(1 / 365)

FLUCELVAX QUADRIVALENT im

susp, 0.5 ml im susp pfs

QL(1 / 365)

CareFirst Plan DC

Page 75 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

FLULAVAL im inj, im susp

QL(1 / 365)

FLULAVAL QUADRIVALENT im

susp, 0.5 ml im susp pfs

QL(1 / 365)

FLUMIST QUADRIVALENT nasal

susp

QL(1 / 365)

FLUZONE HIGH-DOSE

QUADRIVALENT 0.7 ml im susp

pfs

QL(1.4

/ 365)

FLUZONE QUADRIVALENT 0.25

ml im susp pfs

QL(0.5 / 365)

FLUZONE QUADRIVALENT im

susp, 0.5 ml im susp, 0.5 ml im

susp pfs

QL(1 / 365)

GARDASIL im susp

QL(1.5 /

365), AL

GARDASIL 9 im susp, im susp pfs

QL(1.5 / 365), AL

HAVRIX 720 el u/0.5ml im susp

QL(1 / 365), AL

HAVRIX 1440 el u/ml im susp

QL(2 / 365), AL

HEPLISAV-B 20 mcg/0.5ml im

soln, 20

mcg/0.5ml im soln pfs

QL(1 / 365), AL

IMOVAX RABIES 2.5 unit/ml im

susp

QL(3 / 365), AL

IPOL inj

QL(1.5 / 365), AL

IXIARO im susp

QL(1 / 365)

janssen covid-19 vaccine 0.5 ml im

susp

QL(0.5 / 1)

MENACTRA im soln

QL(0.5 / 365), AL

R II inj soln

QL(2 / 365), AL

moderna covid-19 bival booster 50

mcg/0.5ml im susp

moderna covid-19 vac (booster) 50

mcg/0.5ml im susp

QL(0.5 / 120)

moderna covid-19 vacc 6-11y 50

mcg/0.5ml im susp

moderna covid-19 vacc 6m-5y 25

mcg/0.25ml im susp

moderna covid-19 vaccine 100

mcg/0.5ml im susp

QL(0.5 / 28)

novavax covid-19 vaccine 5

mcg/0.5ml im susp

CareFirst Plan DC

Page 76 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

pfizer covid-19 vac bival 5-11 10

mcg/0.2ml im

susp

pfizer covid-19 vac bivalent 30

mcg/0.3ml im susp

pfizer covid-19 vac-tris 5-11y 10

mcg/0.2ml im susp

QL(0.2 / 21), AL

pfizer covid-19 vac-tris 6m-4y 3

mcg/0.2ml im susp

pfizer-biont covid-19 vac-tris 30

mcg/0.3ml im susp

QL(0.3 / 21)

pfizer-biontech covid-19 vacc 30

mcg/0.3ml im susp

QL(0.3 / 21)

RECOMBIVAX HB 5 mcg/0.5ml inj

susp, 5 mcg/0.5ml Injection

Suspension Prefilled Syringe

QL(1.5 / 365), AL

RECOMBIVAX HB 10 mcg/ml inj

susp, 10 mcg/ml Injection

Suspension

Prefilled Syringe

QL(3 / 365), AL

RECOMBIVAX HB 40 mcg/ml inj

susp

QL(3 / 365), AL

SHINGRIX 50 mcg/0.5ml im susp

QL(2 / 365), AL

SPIKEVAX COVID-19 VACCINE

100 mcg/0.5ml im susp

TWINRIX 720-20 im susp, 720-20

elu-mcg/ml im susp, 720-20 elu-

mcg/ml im susp pfs

QL(3 / 365), AL

VAQTA 25 unit/0.5ml im susp

QL(1 / 365), AL

VAQTA 50 unit/ml im susp

QL(2 / 365), AL

VARIVAX 1350 pfu/0.5ml sc inj

QL(2 / 365), AL

ZOSTAVAX 19400 unt/0.65ml sc

susp

QL(1 / 365), AL

VAGINAL AND RELATED PRODUCTS

Vaginal Anti

infectives

3 day vaginal 2 % vag crm

CLEOCIN 100 mg vag supp

clindamycin phosphate 2 % vag

crm

CLEOCIN

clotrimazole 1 % vag crm

metronidazole 0.75 % vag gel

METROGEL

miconazole 7 100 mg vag supp

CareFirst Plan DC

Page 77 of 91

Update Date: 3/2023

Drug Name

Drug

Tier

Reference Name Requirements/Limits

miconazole 7 2 % vag crm

miconazole nitrate 2 % vag crm

sm 3

day vaginal 2 % vag crm

sm clotrimazole vaginal 1 % vag

crm

sm miconazole 7 100 mg vag supp

sm miconazole 7 2 % vag crm

terconazole 0.4 % vag crm, 0.8 %

vag crm

TERAZOL

terconazole 80 mg vag supp

TERAZOL 3

Vaginal Estrogens

estradiol 0.1 mg/gm vag crm

ESTRACE

PREMARIN 0.625 mg/gm vag crm

VASOPRESSORS

Anaphylaxis Therapy Agents

epinephrine 0.15 mg/0.15ml inj soln

auto-inj, 0.3 mg/0.3ml inj soln auto-

inj

ADRENACLICK

epinephrine 0.15 mg/0.3ml inj soln

auto

inj

EPIPEN JR

Vasopressors

epinephrine 1 mg/ml inj soln

midodrine hcl 10 mg tab, 5 mg tab

PROAMATINE

VITAMINS

Oil Soluble Vitamins

ergocalciferol 1.25 MG (50000 ut)

cap

DRISDOL

vitamin d (ergocalciferol) 1.25 MG

(50000 ut) cap

DRISDOL

Water

Soluble Vitamins

niacin er 250 mg cap er

thiamine hcl 100 mg tab

CareFirst Plan DC

Page 78 of 91

Update Date: 3/2023

Index

3 day vaginal ................................................. 76

ABILIFY MAINTENA ..................................... 37

abiraterone acetate ....................................... 33

ABSORICA ................................................... 47

acamprosate calcium .................................... 69

acarbose ....................................................... 24

ACCU-CHEK SOFT TOUCH LANCETS ....... 59

acetaminophen ............................................. 12

acetaminophen extra strength ....................... 12

acetaminophen-codeine ................................ 14

acetaminophen-codeine #2 ........................... 15

acetaminophen-codeine #3 ........................... 15

acetaminophen-codeine #4 ........................... 15

acetazolamide ............................................... 53

acetazolamide er ........................................... 53

acetic acid ............................................... 56, 68

acyclovir ........................................................ 37

ADACEL........................................................ 72

adapalene ..................................................... 47

adefovir dipivoxil ........................................... 37

ADMELOG .................................................... 25

ADMELOG SOLOSTAR................................ 25

adult aspirin regimen ..................................... 12

ADVAIR HFA ................................................ 19

AEROCHAMBER PLUS FLO-VU ................. 62

AEROCHAMBER PLUS FLO-VU LARGE .... 62

AEROCHAMBER PLUS FLO-VU SMALL ..... 62

AEROCHAMBER PLUS FLO-VU W/MASK .. 62

AFLURIA QUADRIVALENT .......................... 74

AFTERA ........................................................ 44

AGAMATRIX ULTRA-THIN LANCETS ......... 60

AIRDUO RESPICLICK 113/14 ...................... 19

AIRDUO RESPICLICK 232/14 ...................... 19

AIRDUO RESPICLICK 55/14 ........................ 19

albuterol sulfate ............................................. 19

albuterol sulfate hfa ....................................... 19

alclometasone dipropionate .......................... 49

alcohol pads .................................................. 61

alendronate sodium ...................................... 53

alfuzosin hcl er .............................................. 56

aliskiren fumarate .......................................... 32

all day allergy ................................................ 28

all day allergy childrens ................................. 28

all day allergy-d ............................................. 45

allergy childrens ............................................ 28

allergy relief ................................................... 28

allergy relief childrens .................................... 28

allergy relief d-24 ........................................... 45

allergy/congestion relief ................................. 45

allopurinol ...................................................... 56

alogliptin benzoate ........................................ 25

alogliptin-metformin hcl ................................. 24

ALPHAGAN P ............................................... 66

alprazolam ..................................................... 17

ALTAVERA ................................................... 40

aluminum hydroxide gel ................................ 16

alyacen 1/35 .................................................. 40

amantadine hcl .............................................. 35

ambrisentan .................................................. 40

amiodarone hcl .............................................. 18

amitriptyline hcl ............................................. 23

amlodipine besylate....................................... 39

amlodipine-olmesartan .................................. 31

ammonium lactate ......................................... 51

amoxicillin ...................................................... 69

amoxicillin-pot clavulanate ............................ 69

amphetamine-dextroamphet er ....................... 9

amphetamine-dextroamphetamine .................. 9

ampicillin ....................................................... 69

anagrelide hcl ................................................ 56

anastrozole .................................................... 34

antacid ........................................................... 16

antacid anti-gas max strength ....................... 16

antacid fast acting ......................................... 16

antacid maximum strength ............................ 16

anti-diarrheal ................................................. 27

anti-itch maximum strength ........................... 49

anucort-hc ..................................................... 16

apo-varenicline .............................................. 70

APRI .............................................................. 40

AQUALANCE LANCETS 30G ....................... 60

ARANELLE ................................................... 40

ARANESP (ALBUMIN FREE) ....................... 57

aripiprazole .................................................... 37

CareFirst Plan DC

Page 79 of 91

Update Date: 3/2023

ARISTADA .................................................... 37

ARISTADA INITIO ........................................ 37

artificial tears ................................................. 66

ASHLYNA ..................................................... 40

aspirin ........................................................... 12

aspirin 81 ...................................................... 12

aspirin adult low dose ................................... 12

aspirin adult low strength .............................. 13

aspirin ec....................................................... 13

aspirin ec low strength .................................. 13

aspirin low dose ............................................ 13

astrazeneca covid-19 vaccine ....................... 74

atenolol ......................................................... 38

atenolol-chlorthalidone .................................. 31

atorvastatin calcium ...................................... 30

atovaquone-proguanil hcl .............................. 33

atropine sulfate ............................................. 66

ATROVENT HFA .......................................... 18

AVIANE ......................................................... 40

AVONEX PREFILLED .................................. 70

AZASAN........................................................ 63

azathioprine .................................................. 63

azelastine hcl .......................................... 65, 67

azithromycin .................................................. 59

AZOR ............................................................ 31

bacitracin................................................. 47, 66

bacitracin zinc ............................................... 48

bacitracin-neomycin-polymyxin ..................... 48

bacitracin-polymyxin b .................................. 66

bacitra-neomycin-polymyxin-hc ..................... 67

baclofen ........................................................ 65

BALZIVA ....................................................... 40

BANOPHEN .................................................. 28

BASAGLAR KWIKPEN ................................. 25

BAYER MICROLET LANCETS ..................... 60

BD LANCET ULTRAFINE 30G ..................... 60

BD LANCET ULTRAFINE 33G ..................... 60

benazepril hcl ................................................ 30

benazepril-hydrochlorothiazide ..................... 32

benzonatate .................................................. 45

benzoyl peroxide ........................................... 47

benzoyl peroxide wash ................................. 47

benztropine mesylate .................................... 34

betamethasone dipropionate ......................... 49

betamethasone dipropionate aug .................. 49

betamethasone valerate ................................ 50

bethanechol chloride ..................................... 74

BEXSERO ..................................................... 74

bicalutamide .................................................. 34

bimatoprost ................................................... 68

BINAXNOW COVID-19 AG HOME TEST ..... 52

BION TEARS PF ........................................... 66

bisacodyl ....................................................... 58

bisacodyl ec .................................................. 58

bisoprolol fumarate ........................................ 38

bisoprolol-hydrochlorothiazide ....................... 32

BLISOVI FE 1.5/30 ........................................ 41

BLISOVI FE 1/20 ........................................... 41

BOOSTRIX .............................................. 72, 74

brimonidine tartrate ....................................... 66

brinzolamide .................................................. 67

bromocriptine mesylate ................................. 35

budesonide .............................................. 18, 44

budesonide-formoterol fumarate ................... 19

bumetanide ................................................... 53

BUNAVAIL .................................................... 15

buprenorphine hcl ......................................... 15

buprenorphine hcl-naloxone hcl .................... 15

bupropion hcl ................................................. 22

bupropion hcl er (smoking det) ...................... 70

bupropion hcl er (sr) ...................................... 22

bupropion hcl er (xl)....................................... 22

buspirone hcl ................................................. 17

butalbital-apap-caff-cod ................................. 15

butalbital-apap-caffeine ................................. 12

butalbital-asa-caff-codeine ............................ 15

butalbital-aspirin-caffeine .............................. 12

BYDUREON .................................................. 25

BYDUREON BCISE ...................................... 25

BYETTA 10 MCG PEN .................................. 25

BYETTA 5 MCG PEN .................................... 25

calcipotriene .................................................. 49

calcitriol ................................................... 49, 54

calcium acetate ............................................. 55

calcium acetate (phos binder) ....................... 55

calcium antacid ............................................. 16

CareFirst Plan DC

Page 80 of 91

Update Date: 3/2023

calcium carbonate ......................................... 63

calcium carbonate antacid ............................ 17

CAMILA......................................................... 44

CAMRESE .................................................... 41

CAMRESE LO .............................................. 41

capecitabine .................................................. 33

capsaicin ....................................................... 52

carbamazepine ............................................. 21

carbamazepine er ......................................... 21

carbidopa-levodopa ...................................... 35

carisoprodol .................................................. 65

carvedilol ....................................................... 38

cefaclor ......................................................... 40

cefadroxil....................................................... 40

cefdinir .......................................................... 40

cefprozil......................................................... 40

cefuroxime axetil ........................................... 40

celecoxib ....................................................... 10

CEPACOL SORE THROAT & COUGH ........ 64

cephalexin ..................................................... 40

cetirizine hcl .................................................. 28

cetirizine hcl allergy child .............................. 28

cetirizine hcl childrens ................................... 29

cetirizine hcl childrens alrgy .......................... 29

cetirizine-pseudoephedrine er ....................... 46

cheratussin ac ............................................... 46

childrens ibuprofen ........................................ 11

childrens loratadine ....................................... 29

chlordiazepoxide hcl ..................................... 17

chlorhexidine gluconate ................................ 64

chloroquine phosphate .................................. 33

chlorthalidone ................................................ 53

cholestyramine .............................................. 30

cholestyramine light ...................................... 30

ciclopirox ....................................................... 48

ciclopirox olamine ......................................... 48

cilostazol ....................................................... 56

cimetidine ...................................................... 72

cimetidine hcl ................................................ 72

CIPRO .......................................................... 54

ciprofloxacin .................................................. 54

ciprofloxacin hcl ...................................... 54, 66

ciprofloxacin-ciproflox hcl er .......................... 54

citalopram hydrobromide............................... 22

CLARAVIS .................................................... 47

clarithromycin ................................................ 59

clarithromycin er ............................................ 59

classic prenatal ............................................. 64

CLEARLAX ................................................... 58

clemastine fumarate ...................................... 28

CLEOCIN ...................................................... 76

clindamycin hcl .............................................. 33

clindamycin palmitate hcl .............................. 33

clindamycin phosphate ............................ 47, 76

clobazam ....................................................... 20

clobetasol prop emollient base ...................... 50

clobetasol propionate .................................... 50

clobetasol propionate e ................................. 50

clobetasol propionate emulsion ..................... 50

clomipramine hcl ........................................... 23

clonazepam ................................................... 20

clonidine ........................................................ 31

clonidine hcl .................................................. 31

clonidine hcl er ................................................ 9

clopidogrel bisulfate....................................... 56

clotrimazole ....................................... 48, 64, 76

clotrimazole anti-fungal ................................. 48

clotrimazole-betamethasone ......................... 48

clozapine ....................................................... 36

colchicine ...................................................... 56

COMBIVENT RESPIMAT .............................. 19

COMIRNATY ................................................. 74

cough syrup ................................................... 46

CREON ......................................................... 52

cromolyn sodium ..................................... 65, 67

CRYSELLE-28 .............................................. 41

cvs alcohol prep pads .................................... 61

cvs lancets micro thin 33g ............................. 60

cvs lancets thin 26g ....................................... 60

cvs lancets ultra thin 30g ............................... 60

cvs lancets ultra-thin 30g ............................... 60

cyanocobalamin ............................................ 57

CYCLAFEM 1/35 ........................................... 41

CYCLAFEM 7/7/7 .......................................... 41

cyclobenzaprine hcl ....................................... 65

cyclosporine .................................................. 68

cyclosporine modified .............................. 63, 64

cyproheptadine hcl ........................................ 30

CareFirst Plan DC

Page 81 of 91

Update Date: 3/2023

dabigatran etexilate mesylate ....................... 20

dapsone .................................................. 32, 47

darifenacin hydrobromide er ......................... 73

DASETTA 1/35 ............................................. 41

DASETTA 7/7/7 ............................................ 41

DAYSEE ....................................................... 41

DEBLITANE .................................................. 44

DECAVAC ..................................................... 72

deferasirox .................................................... 27

DESCOVY .................................................... 37

desmopressin acetate ................................... 54

desmopressin acetate spray ......................... 54

desonide ....................................................... 50

desoximetasone ............................................ 50

dexamethasone ...................................... 44, 45

DEXCOM G6 RECEIVER ............................. 60

DEXCOM G6 SENSOR ................................ 60

DEXCOM G6 TRANSMITTER ...................... 60

dexmethylphenidate hcl .................................. 9

dexmethylphenidate hcl er .............................. 9

dextroamphetamine sulfate ............................. 9

dextroamphetamine sulfate er ......................... 9

dextromethorphan polistirex er ...................... 45

dextromethorphan-guaifenesin ..................... 46

diazepam ................................................ 17, 21

diclofenac sodium ............................. 11, 49, 67

diclofenac sodium er ..................................... 11

dicloxacillin sodium ....................................... 69

dicyclomine hcl .............................................. 72

diflorasone diacetate ..................................... 50

diflunisal ........................................................ 13

digoxin .......................................................... 39

dihydroergotamine mesylate ......................... 62

diltiazem hcl .................................................. 39

diltiazem hcl er .............................................. 39

diltiazem hcl er beads ................................... 39

diltiazem hcl er coated beads ........................ 39

dimethyl fumarate ......................................... 70

dimethyl fumarate starter pack ...................... 70

diphenhydramine hcl ..................................... 28

diphenoxylate-atropine .................................. 27

diphtheria-tetanus toxoids ............................. 72

disulfiram....................................................... 69

divalproex sodium ......................................... 22

divalproex sodium er ..................................... 22

docusate sodium ........................................... 59

DOCUSIL ...................................................... 59

DOK .............................................................. 59

donepezil hcl ................................................. 69

dorzolamide hcl ............................................. 67

dorzolamide hcl-timolol mal ........................... 66

double antibiotic ............................................ 48

doxazosin mesylate ....................................... 31

doxepin hcl .................................................... 23

doxycycline hyclate ....................................... 71

dronabinol ..................................................... 27

drospirenone-ethinyl estradiol ....................... 41

DROXIA ........................................................ 56

DULERA ........................................................ 19

duloxetine hcl ................................................ 23

dutasteride .................................................... 56

EASIVENT .................................................... 62

easy comfort lancets ..................................... 60

EASY TOUCH LANCETS 28G/TWIST .......... 60

EASY TOUCH LANCETS 30G/TWIST .......... 60

EASY TOUCH LANCETS 33G/TWIST .......... 60

econazole nitrate ........................................... 48

ed-apap ......................................................... 12

ELIGARD ...................................................... 34

ELINEST ....................................................... 41

ELIQUIS ........................................................ 20

ELIQUIS DVT/PE STARTER PACK .............. 20

ELLA ............................................................. 44

ELMIRON ...................................................... 56

EMOQUETTE ............................................... 41

emtricitabine-tenofovir df ............................... 37

enalapril maleate ........................................... 31

enalapril-hydrochlorothiazide ........................ 32

ENBREL ........................................................ 12

ENBREL SURECLICK .................................. 12

ENGERIX-B .................................................. 74

enoxaparin sodium ........................................ 20

ENPRESSE-28 ............................................. 41

ENSKYCE ..................................................... 41

entecavir ........................................................ 37

ENTRESTO ................................................... 39

epinephrine ................................................... 77

CareFirst Plan DC

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Update Date: 3/2023

eplerenone .................................................... 32

ergocalciferol ................................................. 77

ERIVEDGE ................................................... 33

erlotinib hcl .................................................... 34

ERRIN ........................................................... 44

erythromycin ........................................... 47, 66

erythromycin base ......................................... 59

erythromycin ethylsuccinate .......................... 59

escitalopram oxalate ..................................... 23

esomeprazole magnesium ............................ 73

ESTARYLLA ................................................. 41

estradiol .................................................. 54, 77

ethambutol hcl ............................................... 33

ethosuximide ................................................. 22

etonogestrel-ethinyl estradiol ........................ 44

everolimus..................................................... 34

eye itch relief ................................................. 67

E-Z JECT LANCET SUPER THIN 30G ......... 60

E-Z JECT LANCETS THIN 26G .................... 60

E-Z SPACER ................................................ 62

ezetimibe....................................................... 30

FALMINA ...................................................... 41

famciclovir ..................................................... 38

famotidine ..................................................... 72

fenofibrate ..................................................... 30

fenofibrate micronized ................................... 30

fentanyl ......................................................... 13

FEROSUL ..................................................... 57

ferrous sulfate ............................................... 57

ferrousul ........................................................ 57

fexofenadine hcl ............................................ 29

fexofenadine hcl childrens............................. 29

fexofenadine-pseudoephed er ...................... 46

finasteride ..................................................... 56

FIRMAGON ................................................... 34

FIRMAGON (240 MG DOSE) ....................... 34

flecainide acetate .......................................... 18

FLEXICHAMBER .......................................... 62

FLOVENT DISKUS ....................................... 18

FLUAD .......................................................... 74

FLUAD QUADRIVALENT ............................. 74

FLUARIX QUADRIVALENT .......................... 74

FLUBLOK QUADRIVALENT ......................... 74

FLUCELVAX QUADRIVALENT .................... 74

fluconazole .................................................... 28

fludrocortisone acetate .................................. 45

FLULAVAL .................................................... 75

FLULAVAL QUADRIVALENT ....................... 75

FLUMIST QUADRIVALENT .......................... 75

flunisolide ...................................................... 65

fluocinolone acetonide ................................... 50

fluocinolone acetonide body .......................... 50

fluocinolone acetonide scalp ......................... 50

fluocinonide ................................................... 50

fluorometholone ............................................ 67

fluorouracil ..................................................... 49

fluoxetine hcl ................................................. 23

fluoxetine hcl (pmdd) ..................................... 70

fluphenazine decanoate ................................ 36

fluphenazine hcl ............................................ 36

fluticasone propionate ............................. 50, 65

fluticasone propionate hfa ............................. 18

fluticasone-salmeterol ................................... 19

fluvoxamine maleate ..................................... 23

FLUZONE HIGH-DOSE QUADRIVALENT ... 75

FLUZONE QUADRIVALENT ......................... 75

FML FORTE .................................................. 67

folic acid ........................................................ 57

FREESTYLE LANCETS ................................ 60

furosemide .................................................... 53

gabapentin .................................................... 21

GAMUNEX-C ................................................ 68

GARDASIL .................................................... 75

GARDASIL 9 ................................................. 75

GAVILYTE-C ................................................. 57

gemfibrozil ..................................................... 30

generlac ........................................................ 55

gentamicin sulfate ................................... 48, 66

GENTEAL TEARS......................................... 66

GENTEAL TEARS PF ................................... 66

GIANVI .......................................................... 41

GLEOSTINE .................................................. 33

glimepiride ..................................................... 26

glipizide ......................................................... 26

glipizide er ..................................................... 26

glipizide xl ...................................................... 26

CareFirst Plan DC

Page 83 of 91

Update Date: 3/2023

glipizide-metformin hcl .................................. 24

GLUCAGEN HYPOKIT ................................. 25

glucagon emergency ..................................... 25

GLUCOCARD SHINE ................................... 60

GLUCOCARD SHINE CONNEX ................... 60

GLUCOCARD SHINE CONTROL ................. 60

GLUCOCARD SHINE EXPRESS ................. 60

GLUCOCARD SHINE TEST ......................... 52

GLUCOCARD SHINE XL .............................. 60

GLUCOCOM LANCETS 33G ........................ 60

glyburide ....................................................... 26

glyburide micronized ..................................... 26

glyburide-metformin ...................................... 24

gnp all day allergy childrens .......................... 29

gnp aspirin .................................................... 13

gnp aspirin low dose ..................................... 13

gnp childrens allergy ..................................... 28

gnp childrens ibuprofen ................................. 11

gnp hydrocortisone ....................................... 50

gnp hydrocortisone max st ............................ 51

gnp lancets super thin 30g ............................ 60

gnp lice treatment ......................................... 52

gnp loratadine ............................................... 29

gnp pink bismuth ........................................... 27

gnp senna plus .............................................. 57

gnp stool softener ......................................... 59

gnp terbinafine hydrochloride ........................ 48

gnp tussin...................................................... 46

gnp tussin dm ................................................ 46

gnp tussin mucus & chest cong .................... 46

gnp wart remover .......................................... 51

goodsense all day allergy ............................. 29

goodsense aspirin ......................................... 13

GOODSENSE CLEARLAX ........................... 58

goodsense ibuprofen .................................... 11

goodsense ibuprofen childrens ..................... 11

goodsense ibuprofen infants ......................... 11

goodsense nicotine ....................................... 70

goodsense pain relief extra st ....................... 12

granisetron hcl .............................................. 27

griseofulvin microsize .................................... 27

griseofulvin ultramicrosize ............................. 28

guaifenesin.................................................... 46

guaifenesin-codeine ...................................... 46

guaifenesin-dm ............................................. 46

guanfacine hcl ............................................... 31

guanfacine hcl er ............................................. 9

halobetasol propionate .................................. 51

haloperidol ..................................................... 36

haloperidol decanoate ................................... 36

HAVRIX ......................................................... 75

HEATHER ..................................................... 44

hemorrhoidal ................................................. 16

HEPLISAV-B ................................................. 75

HIBERIX ........................................................ 74

hm all day allergy .......................................... 29

hm allergy & congestion ................................ 46

hm allergy relief/nasal decong ....................... 46

hm antacid/antigas ........................................ 16

hm aspirin ...................................................... 13

hm aspirin ec low dose .................................. 13

hm eye itch relief ........................................... 67

hm glycerin .................................................... 51

hm ibuprofen childrens .................................. 11

hm loratadine ................................................ 29

hm loratadine childrens ................................. 29

hm magnesium citrate ................................... 58

hm milk of magnesia ..................................... 58

hm nicotine .................................................... 70

hm nicotine polacrilex .................................... 70

hm senna ...................................................... 58

hm stool softener ........................................... 59

hm triple antibiotic ......................................... 48

hm tussin adult dm ........................................ 46

HUMALOG MIX 50/50 KWIKPEN ................. 25

HUMALOG MIX 75/25 ................................... 25

HUMALOG MIX 75/25 KWIKPEN ................. 25

HUMIRA ........................................................ 10

HUMIRA PEN ................................................ 10

HUMIRA PEN-CD/UC/HS STARTER ............ 10

HUMIRA PEN-PS/UV/ADOL HS START ...... 10

HUMULIN 70/30 ............................................ 25

HUMULIN 70/30 KWIKPEN .......................... 26

HUMULIN N .................................................. 26

HUMULIN N KWIKPEN ................................. 26

HUMULIN R .................................................. 26

HUMULIN R U-500 (CONCENTRATED) ...... 26

hydralazine hcl .............................................. 32

CareFirst Plan DC

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Update Date: 3/2023

hydrochlorothiazide ....................................... 53

hydrocodone-acetaminophen ........................ 15

hydrocortisone ........................................ 45, 51

hydrocortisone (perianal) .............................. 16

hydrocortisone acetate .................................. 16

hydrocortisone butyrate ................................ 51

hydrocortisone max st ................................... 51

hydrocortisone max st/12 moist .................... 51

hydromorphone hcl ....................................... 13

hydromorphone hcl er ................................... 13

hydroxychloroquine sulfate ........................... 33

hydroxyprogesterone caproate ..................... 69

hydroxyurea .................................................. 34

hydroxyzine hcl ............................................. 17

hydroxyzine pamoate .................................... 17

hyoscyamine sulfate ..................................... 72

ibu-200 .......................................................... 11

ibuprofen ....................................................... 11

ibuprofen childrens ........................................ 11

ibuprofen infants ........................................... 11

ibuprofen junior strength ............................... 11

imatinib mesylate .......................................... 34

imipramine hcl ............................................... 24

imipramine pamoate ..................................... 24

imiquimod...................................................... 51

IMOVAX RABIES .......................................... 75

INCRUSE ELLIPTA ...................................... 18

indapamide ................................................... 53

INGREZZA .................................................... 40

INSPIRACHAMBER/LARGE ......................... 62

INSPIRACHAMBER/MEDIUM ...................... 62

INSPIRACHAMBER/MOUTHPIECE ............. 62

INSPIRACHAMBER/SMALL ......................... 62

insulin asp prot & asp flexpen ....................... 26

INVEGA HAFYERA ...................................... 35

INVEGA SUSTENNA .................................... 35

INVEGA TRINZA .......................................... 35

IPOL .............................................................. 75

ipratropium bromide ................................ 18, 65

irbesartan ...................................................... 31

isoniazid ........................................................ 33

isosorb dinitrate-hydralazine ......................... 40

isosorbide dinitrate ........................................ 17

isosorbide mononitrate .................................. 17

isosorbide mononitrate er .............................. 17

isotretinoin ..................................................... 47

itraconazole ................................................... 28

IXIARO .......................................................... 75

JAKAFI .......................................................... 34

janssen covid-19 vaccine .............................. 75

JANUMET ..................................................... 24

JANUMET XR ............................................... 24

JANUVIA ....................................................... 25

JARDIANCE .................................................. 26

JENCYCLA ................................................... 44

JOLIVETTE ................................................... 44

JULEBER ...................................................... 41

JUNEL 1.5/30 ................................................ 41

JUNEL 1/20 ................................................... 41

JUNEL FE 1.5/30 .......................................... 41

JUNEL FE 1/20 ............................................. 41

KARIVA ......................................................... 41

ketoconazole ........................................... 28, 48

ketorolac tromethamine ........................... 11, 68

ketotifen fumarate ......................................... 68

KINERET ....................................................... 10

KLOR-CON M20 ........................................... 63

KLOR-CON/EF .............................................. 63

KLOXXADO .................................................. 27

KURVELO ..................................................... 41

labetalol hcl ................................................... 38

lactulose ........................................................ 58

lactulose encephalopathy .............................. 55

LAGEVRIO .................................................... 37

lamivudine ..................................................... 37

lamotrigine ..................................................... 21

lamotrigine er ................................................ 21

lancets ........................................................... 60

lancets 30g .................................................... 60

LANCETS ULTRA FINE ................................ 61

LANCETS ULTRA THIN ................................ 61

lancing device ............................................... 61

lansoprazole .................................................. 73

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Update Date: 3/2023

LARIN 1.5/30 ................................................ 41

LARIN 1/20 ................................................... 41

LARIN FE 1.5/30 ........................................... 41

LARIN FE 1/20 .............................................. 41

LARISSIA ...................................................... 42

latanoprost .................................................... 68

laxative .......................................................... 58

leader advanced lancing device .................... 61

leflunomide .................................................... 12

LESSINA ....................................................... 42

letrozole ........................................................ 34

levalbuterol hcl .............................................. 19

levalbuterol tartrate ....................................... 19

levetiracetam ................................................. 21

levetiracetam er ............................................ 21

levocetirizine dihydrochloride ........................ 29

levofloxacin ............................................. 55, 66

levonorgest-eth estrad 91-day ...................... 42

levonorgestrel ............................................... 44

levonorgestrel-ethinyl estrad ......................... 42

levonorg-eth estrad triphasic ......................... 42

LEVORA 0.15/30 (28) ................................... 42

levothyroxine sodium .................................... 71

lice killing maximum strength ........................ 52

lidocaine ........................................................ 52

lidocaine hcl .................................................. 52

lidocaine hcl (pf) ............................................ 59

lidocaine hcl urethral/mucosal ....................... 52

lidocaine viscous ........................................... 64

lidocaine viscous hcl ..................................... 64

lidocaine-hydrocortisone ace ........................ 16

lidocaine-prilocaine ....................................... 52

LILLOW ......................................................... 42

liothyronine sodium ....................................... 71

liquitears........................................................ 66

lisinopril ......................................................... 31

lisinopril-hydrochlorothiazide ......................... 32

lithium carbonate ........................................... 35

lithium carbonate er ...................................... 35

LOESTRIN 1.5/30 (21) .................................. 42

LOESTRIN FE 1.5/30 ................................... 42

loperamide hcl ............................................... 27

loratadine ...................................................... 29

loratadine childrens ....................................... 29

loratadine-d 24hr ........................................... 46

lorazepam ..................................................... 17

LORCET ........................................................ 15

LORYNA ....................................................... 42

losartan potassium ........................................ 31

losartan potassium-hctz ................................ 32

LOTEMAX ..................................................... 67

loteprednol etabonate.................................... 67

lovastatin ....................................................... 30

LOW-OGESTREL ......................................... 42

lubiprostone ................................................... 55

LUCEMYRA .................................................. 69

LUPRON DEPOT (4-MONTH) ...................... 34

LUPRON DEPOT (6-MONTH) ...................... 34

LUPRON DEPOT-PED (1-MONTH) .............. 53

LUPRON DEPOT-PED (3-MONTH) .............. 54

lurasidone hcl ................................................ 35

LUTERA ........................................................ 42

magnesium citrate ......................................... 58

magnesium oxide .......................................... 17

MAKENA ....................................................... 69

malathion ....................................................... 52

marlissa ......................................................... 42

MAVYRET ..................................................... 37

meclizine hcl .................................................. 27

medroxyprogesterone acetate ................. 44, 69

mefloquine hcl ............................................... 33

megestrol acetate .......................................... 34

meijer alcohol swabs ..................................... 61

meloxicam ..................................................... 11

memantine hcl ............................................... 22

MENACTRA ............................................ 74, 75

MENOMUNE ................................................. 74

MENVEO ....................................................... 74

mercaptopurine ............................................. 33

mesalamine ................................................... 55

metaxalone .................................................... 65

metformin hcl ................................................. 24

metformin hcl er ............................................ 24

metformin hcl er (mod) .................................. 24

metformin hcl er (osm) .................................. 25

methazolamide .............................................. 53

methimazole .................................................. 71

methocarbamol ............................................. 65

CareFirst Plan DC

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Update Date: 3/2023

methotrexate ................................................. 33

methotrexate sodium .................................... 33

methyldopa ................................................... 31

methylergonovine maleate ............................ 68

methylphenidate hcl ........................................ 9

methylphenidate hcl er .................................. 10

methylphenidate hcl er (la) ............................ 10

methylphenidate hcl er (osm) ........................ 10

methylprednisolone ....................................... 45

metoclopramide hcl ....................................... 55

metolazone ................................................... 53

metoprolol succinate er ................................. 38

metoprolol tartrate ......................................... 38

metoprolol-hydrochlorothiazide ..................... 32

metronidazole ................................... 32, 52, 76

miconazole 7 ........................................... 76, 77

miconazole nitrate ................................... 48, 77

MICROGESTIN 1.5/30 .................................. 42

MICROGESTIN 1/20 ..................................... 42

MICROGESTIN FE 1.5/30 ............................ 42

MICROGESTIN FE 1/20 ............................... 42

MICROLET LANCETS .................................. 61

midodrine hcl ................................................. 77

MILI ............................................................... 42

milk of magnesia ........................................... 58

minocycline hcl .............................................. 71

MIRCETTE .................................................... 42

mirtazapine ................................................... 22

misoprostol .................................................... 73

M-M-R II ........................................................ 75

modafinil........................................................ 10

moderna covid-19 bival booster .................... 75

moderna covid-19 vac (booster) ................... 75

moderna covid-19 vacc 6-11y ....................... 75

moderna covid-19 vacc 6m-5y ...................... 75

moderna covid-19 vaccine ............................ 75

mometasone furoate ..................................... 51

MONO-LINYAH ............................................. 42

MONONESSA ............................................... 42

montelukast sodium ...................................... 18

morphine sulfate ........................................... 13

morphine sulfate er ................................. 13, 14

morphine sulfate er beads............................. 14

multivitamin/fluoride ...................................... 64

mupirocin ...................................................... 48

mupirocin calcium.......................................... 48

MY WAY ........................................................ 44

mycophenolate mofetil .................................. 64

MYORISAN ................................................... 47

MYZILRA ....................................................... 42

nabumetone .................................................. 11

nadolol ........................................................... 38

naloxone hcl .................................................. 27

naltrexone hcl ................................................ 27

naproxen ....................................................... 11

naproxen dr ................................................... 11

naproxen sodium ........................................... 11

naproxen sodium er....................................... 11

NARCAN ....................................................... 27

natural balance tears ..................................... 66

natures tears ................................................. 66

NECON 0.5/35 (28) ....................................... 43

neomycin-bacitracin zn-polymyx ................... 66

neomycin-polymyxin-dexameth ..................... 67

neomycin-polymyxin-gramicidin .................... 67

neomycin-polymyxin-hc ........................... 67, 68

NEO-POLYCIN ............................................. 67

NEUPOGEN .................................................. 57

NEXPLANON ................................................ 44

niacin er ......................................................... 77

niacin er (antihyperlipidemic) ......................... 30

nicotine .......................................................... 70

nicotine polacrilex .......................................... 70

nicotine step 1 ............................................... 70

nicotine step 2 ............................................... 70

nicotine step 3 ............................................... 70

NICOTROL .................................................... 70

NICOTROL NS .............................................. 70

nifedipine ....................................................... 39

nifedipine er ................................................... 39

nifedipine er osmotic release ......................... 39

NIKKI ............................................................. 43

nitrofurantoin ................................................. 73

nitrofurantoin macrocrystal ............................ 73

nitrofurantoin monohyd macro ....................... 73

nitroglycerin ................................................... 17

NORA-BE ...................................................... 44

norethin ace-eth estrad-fe ............................. 43

CareFirst Plan DC

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Update Date: 3/2023

norethindrone ................................................ 44

norethindrone acetate ................................... 69

norethindrone acet-ethinyl est ....................... 43

norgestimate-eth estradiol ............................ 43

norgestim-eth estrad triphasic ....................... 43

NORTREL 1/35 (21) ..................................... 43

NORTREL 1/35 (28) ..................................... 43

NORTREL 7/7/7 ............................................ 43

nortriptyline hcl .............................................. 24

novavax covid-19 vaccine ............................. 75

NOVOLIN 70/30 ............................................ 26

NOVOLIN 70/30 RELION.............................. 26

NOVOLIN N .................................................. 26

NOVOLIN N RELION .................................... 26

NOVOLIN R .................................................. 26

NOVOLIN R RELION .................................... 26

NPLATE ........................................................ 57

nystatin ................................................... 48, 64

nystatin-triamcinolone ................................... 49

NYVEPRIA .................................................... 57

O-CAL FA ..................................................... 64

OCELLA ........................................................ 43

ofloxacin .................................................. 67, 68

olanzapine..................................................... 36

olmesartan medoxomil .................................. 31

omeprazole ................................................... 73

ondansetron hcl ............................................ 27

ONETOUCH DELICA LANCETS 30G .......... 61

ONETOUCH DELICA LANCETS 33G .......... 61

ONETOUCH ULTRASOFT LANCETS .......... 61

ONGLYZA ..................................................... 25

OPCICON ONE-STEP .................................. 44

OPTION 2 ..................................................... 44

orphenadrine citrate er .................................. 65

ORSYTHIA .................................................... 43

ORTHO TRI-CYCLEN (28) ........................... 43

ORTHO-NOVUM 1/35 (28) ........................... 43

oseltamivir phosphate ................................... 38

oxaprozin ...................................................... 12

oxazepam ..................................................... 18

oxcarbazepine ............................................... 21

oxybutynin chloride ....................................... 73

oxybutynin chloride er ................................... 73

oxycodone hcl ............................................... 14

oxycodone-acetaminophen ........................... 15

paliperidone er .............................................. 35

pantoprazole sodium ..................................... 73

paroxetine hcl ................................................ 23

paroxetine hcl er ............................................ 23

PAXLOVID (300/100) .................................... 37

peg 3350 ....................................................... 58

peg 3350/electrolytes .................................... 57

peg 3350-kcl-na bicarb-nacl .......................... 57

peg-3350/electrolytes .................................... 57

penicillin g procaine ....................................... 69

penicillin v potassium .................................... 69

permethrin ..................................................... 52

perphenazine ................................................ 36

pfizer covid-19 vac bival 5-11 ........................ 76

pfizer covid-19 vac bivalent ........................... 76

pfizer covid-19 vac-tris 5-11y ........................ 76

pfizer covid-19 vac-tris 6m-4y ....................... 76

pfizer-biont covid-19 vac-tris ......................... 76

pfizer-biontech covid-19 vacc ........................ 76

PHARMACIST CHOICE LANCETS .............. 61

phenazopyridine hcl ...................................... 56

phenelzine sulfate ......................................... 22

phenobarbital ................................................ 57

phenytoin ....................................................... 21

PHENYTOIN INFATABS ............................... 22

phenytoin sodium extended .......................... 22

pilocarpine hcl ............................................... 66

PIMTREA ...................................................... 43

pioglitazone hcl ............................................. 26

pioglitazone hcl-glimepiride ........................... 24

pioglitazone hcl-metformin hcl ....................... 24

PLAN B ONE-STEP ...................................... 44

PNEUMOVAX 23 .......................................... 74

pnv prenatal plus multivitamin ....................... 65

podofilox ........................................................ 51

polyethylene glycol 3350 ............................... 58

polymyxin b-trimethoprim .............................. 67

POLY-VI-FLOR ............................................. 64

POLY-VI-FLOR/IRON ................................... 64

POLY-VI-SOL/IRON ...................................... 64

PORTIA-28 .................................................... 43

CareFirst Plan DC

Page 88 of 91

Update Date: 3/2023

potassium chloride ........................................ 63

potassium chloride crys er ............................ 63

potassium chloride er .................................... 63

potassium citrate er ....................................... 56

pramipexole dihydrochloride ......................... 35

pravastatin sodium ........................................ 30

prazosin hcl ................................................... 31

prednisolone acetate ..................................... 67

prednisolone sodium phosphate ................... 45

prednisone .................................................... 45

pregabalin ..................................................... 21

PREMARIN ............................................. 54, 77

PREMPRO .................................................... 54

prenatal ......................................................... 65

prenatal 19 .................................................... 65

prenatal vitamin plus low iron ........................ 65

prenatal vitamins ........................................... 65

pretab ............................................................ 65

PREVNAR 13 ................................................ 74

PREVNAR 20 ................................................ 74

primidone ...................................................... 21

probenecid .................................................... 56

prochlorperazine maleate.............................. 36

promethazine hcl ..................................... 29, 30

promethazine-dm .......................................... 46

propafenone hcl er ........................................ 18

propranolol hcl .............................................. 38

propranolol hcl er .......................................... 38

propranolol-hctz ............................................ 32

propylthiouracil .............................................. 71

pseudoeph-bromphen-dm ............................. 46

PULMICORT FLEXHALER ........................... 18

PULMOZYME ............................................... 71

pyrazinamide ................................................. 33

pyridostigmine bromide ................................. 33

qc loratadine allergy relief ............................. 29

quetiapine fumarate ...................................... 36

quetiapine fumarate er .................................. 36

QUICKVUE AT-HOME COVID-19 TEST ...... 52

quinapril hcl ................................................... 31

QVAR REDIHALER ...................................... 19

ranitidine 150 max strength ........................... 72

ranitidine hcl .................................................. 72

REBIF ............................................................ 70

RECLIPSEN .................................................. 43

RECOMBINATE ............................................ 56

RECOMBIVAX HB ........................................ 76

REGRANEX .................................................. 52

RELION ALCOHOL SWABS ......................... 61

repaglinide ..................................................... 26

RHOGAM ULTRA-FILTERED PLUS ............. 68

rifampin ......................................................... 33

rimantadine hcl .............................................. 38

risperidone .................................................... 36

rizatriptan benzoate ................................. 62, 63

ropinirole hcl .................................................. 35

rosuvastatin calcium ...................................... 30

SEGLUROMET ............................................. 24

selenium sulfide ............................................ 49

senna ............................................................ 58

senna-lax ....................................................... 58

senna-tabs .................................................... 58

sennosides-docusate sodium ........................ 58

SENOKOT ..................................................... 58

SEREVENT DISKUS ..................................... 20

sertraline hcl .................................................. 23

sevelamer hcl ................................................ 55

SHAROBEL ................................................... 44

SHINGRIX ..................................................... 76

SHOPKO ALCOHOL SWABS ....................... 61

sildenafil citrate ............................................. 40

silver sulfadiazine .......................................... 49

simethicone ................................................... 55

simvastatin .................................................... 30

sirolimus ........................................................ 64

sm 3-day vaginal ........................................... 77

sm acid reducer max st ................................. 72

sm all day allergy .......................................... 29

sm all day allergy childrens ........................... 29

sm all day allergy-d ....................................... 46

sm allergy relief ............................................. 28

sm antacid advanced max st ......................... 16

sm antacid/antigas ........................................ 16

sm anti-diarrheal ........................................... 27

sm antifungal clotrimazole ............................. 49

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sm antifungal tolnaftate ................................. 49

sm aspirin...................................................... 13

sm aspirin adult low strength ......................... 13

sm aspirin ec ................................................. 13

sm aspirin low dose ...................................... 13

sm athletes foot ............................................. 49

sm childrens aspirin ...................................... 13

sm childrens ibuprofen .................................. 12

sm childrens loratadine ................................. 29

SM CLEARLAX ............................................. 58

sm clotrimazole vaginal ................................. 77

sm double antibiotic ...................................... 48

sm eye itch relief ........................................... 68

sm fexofenadine hcl ...................................... 29

sm fiber ......................................................... 57

sm gas relief .................................................. 55

sm hydrocortisone ......................................... 51

sm hydrocortisone max st ............................. 51

sm ibuprofen ................................................. 12

sm ibuprofen ib ............................................. 12

sm infants ibuprofen ...................................... 12

sm lice treatment ........................................... 52

sm loratadine ................................................ 29

sm loratadine d ............................................. 46

sm lorata-dine d ............................................ 46

sm magnesium citrate ................................... 58

sm miconazole 7 ........................................... 77

sm nicotine .............................................. 70, 71

sm nicotine polacrilex .................................... 71

sm omeprazole ............................................. 73

sm pain reliever ............................................. 12

sm pain reliever ex st .................................... 12

sm senna laxative ......................................... 58

sm senna-s ................................................... 58

sm stomach relief .......................................... 27

sm stool softener ..................................... 58, 59

sm tussin dm ................................................. 46

sm tussin mucus+chest congest ................... 46

sm urinary pain relief max st ......................... 56

sodium chloride (hypertonic) ......................... 68

sodium polystyrene sulfonate ........................ 63

sofosbuvir-velpatasvir ................................... 37

sotalol hcl ...................................................... 38

SPIKEVAX COVID-19 VACCINE .................. 76

spinosad........................................................ 52

SPIRIVA HANDIHALER ................................ 18

SPIRIVA RESPIMAT ..................................... 18

spironolactone ............................................... 53

SPRINTEC 28 ............................................... 43

SRONYX ....................................................... 43

STEGLATRO ................................................ 26

STERILANCE TL........................................... 61

stimulant laxative ..................................... 58, 59

STIOLTO RESPIMAT .................................... 20

stool softener ................................................. 59

SUBLOCADE ................................................ 15

SUBOXONE ............................................ 15, 16

sucralfate ....................................................... 73

sulfacetamide sodium .............................. 49, 67

sulfacetamide sodium (acne) ........................ 47

sulfacetamide sodium-sulfur .......................... 47

sulfamethoxazole-trimethoprim ..................... 32

sulfasalazine ................................................. 55

sulindac ......................................................... 12

sumatriptan ................................................... 63

sumatriptan succinate ................................... 63

SUPREP BOWEL PREP KIT ........................ 55

sure comfort lancets 30g ............................... 61

SYEDA .......................................................... 43

SYNAGIS ...................................................... 68

SYNJARDY ................................................... 24

SYNJARDY XR ............................................. 24

SYNTHROID ................................................. 72

TABLOID ....................................................... 33

tacrolimus ................................................ 51, 64

tactinal ........................................................... 12

TAKE ACTION .............................................. 44

TAMIFLU ....................................................... 38

tamoxifen citrate ............................................ 34

tamsulosin hcl ............................................... 56

TARCEVA ..................................................... 34

tazarotene ..................................................... 49

TAZORAC ..................................................... 49

TDVAX .......................................................... 72

techlite insulin syringe ................................... 61

TECHLITE LANCETS ................................... 61

TECHLITE LANCETS 30G ............................ 61

TECHLITE PEN NEEDLES ........................... 62

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TEKTURNA HCT .......................................... 32

temazepam ................................................... 57

temozolomide ................................................ 33

TENIVAC ...................................................... 72

terazosin hcl .................................................. 31

terbinafine hcl .......................................... 28, 49

terbutaline sulfate .......................................... 20

terconazole ................................................... 77

tetanus toxoid adsorbed ................................ 72

tetanus-diphtheria toxoids td ......................... 72

tetracycline hcl .............................................. 71

theophylline er ............................................... 20

thiamine hcl ................................................... 77

thiothixene..................................................... 37

timolol maleate .............................................. 66

timolol maleate (once-daily) .......................... 66

tizanidine hcl ................................................. 65

tobramycin .............................................. 10, 67

tobramycin-dexamethasone .......................... 67

tolnaftate ....................................................... 49

tolterodine tartrate ......................................... 73

tolterodine tartrate er ..................................... 73

topiramate ..................................................... 21

torsemide ...................................................... 53

tramadol hcl .................................................. 14

tramadol hcl er .............................................. 14

tramadol hcl er (biphasic) .............................. 14

tramadol-acetaminophen .............................. 15

tranexamic acid ............................................. 56

tranylcypromine sulfate ................................. 22

trazodone hcl ................................................ 23

tretinoin ......................................................... 47

TRI FEMYNOR ............................................. 43

triamcinolone acetonide .......................... 51, 64

triamterene-hctz ............................................ 53

trifluoperazine hcl .......................................... 37

trifluridine ...................................................... 67

trihexyphenidyl hcl ........................................ 34

TRI-LEGEST FE ........................................... 43

TRI-LINYAH .................................................. 43

trimethoprim .................................................. 32

triple antibiotic ............................................... 48

TRI-SPRINTEC ............................................. 43

trospium chloride er ...................................... 73

TRUEPLUS LANCETS 28G.......................... 61

TRUEPLUS LANCETS 30G .......................... 61

TRUEPLUS LANCETS 33G .......................... 61

TRUEPLUS SAFETY LANCETS 28G ........... 61

TRULICITY .................................................... 25

TRUMENBA .................................................. 74

tussin dm ....................................................... 46

tussin mucus+chest congestion .................... 47

TWINRIX ....................................................... 76

ultra-care alcohol prep pads .......................... 61

ULTRA-THIN II LANCETS ............................ 61

UNILET COMFORTOUCH LANCET ............. 61

UNILET GP 28 ULTRA THIN ........................ 61

UNISTIK 3 COMFORT .................................. 61

UNITHROID .................................................. 72

ursodiol .......................................................... 55

valacyclovir hcl .............................................. 38

valproic acid .................................................. 22

valsartan ........................................................ 31

valsartan-hydrochlorothiazide ....................... 32

VAQTA .......................................................... 76

varenicline tartrate ......................................... 71

VARIVAX ....................................................... 76

venlafaxine hcl .............................................. 23

venlafaxine hcl er .......................................... 23

verapamil hcl ................................................. 39

verapamil hcl er ............................................. 39

VERZENIO .................................................... 34

VIENVA ......................................................... 43

viorele ............................................................ 44

vitamin d (ergocalciferol) ............................... 77

VIVITROL ...................................................... 27

warfarin sodium ............................................. 20

wart remover maximum strength ................... 51

WERA ........................................................... 44

WIXELA INHUB ............................................ 20

XALKORI ....................................................... 34

XARELTO ..................................................... 20

XELJANZ ...................................................... 10

XELJANZ XR ................................................ 10

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XOPENEX HFA ............................................ 20

XTANDI ......................................................... 34

XULANE........................................................ 44

zafirlukast ...................................................... 18

ZARAH .......................................................... 44

ZENATANE ................................................... 47

ZETIA ............................................................ 30

ZIEXTENZO .................................................. 57

ZIOPTAN ....................................................... 68

ziprasidone hcl .............................................. 35

zolmitriptan .................................................... 63

zolpidem tartrate ........................................... 57

zolpidem tartrate er ....................................... 57

zonisamide .................................................... 21

ZOSTAVAX ................................................... 76

ZUBSOLV ..................................................... 16