Maintenance Drug List (April 2018)

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

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

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

The drugs noted with an asterisk (*) on this list are included in our Maintenance Choice plans. You may be enrolled in a plan that has Mandatory or Voluntary Maintenance Choice.

Mandatory Maintenance Choice: You may fill two 30-day prescriptions for a long-term, maintenance medication before you must fill the prescription in a 90-day supply through CVS Caremark Mail Service or at a CVS Pharmacy.

Voluntary Maintenance Choice: You have the option to fill a 90-day supply of a long-term, maintenance medication through CVS Caremark Mail Service or at a CVS Pharmacy. You may also continue to fill a 30-day supply of these medications at any participating network pharmacy.

If you have questions about your prescription drug plan, please visit www.carefirst.com and log in to My Account or call CareFirst Pharmacy Services at 800-241-3371.

http://www.carefirst.com/

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Allergies desloratidine* desloratidine odt CLARINEX*

Alz h eimers Disease donepezil* donepezil odt galantamine* galantamineer memantine rivastigmine* ARICEPT EXELON NAMENDA* NAMENDA XR NAMZARIC* RAZADYNE RAZADYNE ER

Anti-Anxiety buspirone

Anti-Narcolepsy armodafinil NUVIGIL

Anticoagulants warfarin BEVYXXA COUMADIN JANTOVEN SAVAYSA

Antipsychotics Aripiprazole aripiprazole odt lithium* loxapine* molindone olanzapine* olanzapine odt paliperidone* pimozide quetiapine quetiapine er risperidone* risperidone odt thiothixene* ziprasidone* ABILIFY* ABILIFY DISCMELT ARISTADA EQUETRO* GEODON

INVEGA* INVEGA TRINZA LATUDA* LITHOBID NUPLAZID ORAP* REXULTI* RISPERDAL RISPERDAL M-TAB SEROQUEL SEROQUEL XR* VRAYLAR ZYPREXA ZYPREXA ZYDIS

-Combinations olanzapine/fluoxetine* SYMBYAX

Antivirals abacavir acyclovir adefovir didanosine entecavir famciclovir lamivudine nevirapine stavudine valacyclovir valganciclovir zidovudine APTIVUS ATRIPLA BARACLUDE CRIXIVAN EDURANT EMTRIVA EPIVIR EPIVIR HBV FAMVIR FUZEON HEPSERA INTELENCE INVIRASE ISENTRESS LEXIVA NORVIR PREZISTA RESCRIPTOR RETROVIR REYATAZ SELZENTRY SITAVIG SUSTIVA TIVICAY TYBOST TYZEKA VALCYTE VALTREX VEMLIDY VIDEX VIDEX EC VIRACEPT VIRAMUNE VIRAMUNE XR VIREAD VITEKTA ZERIT ZIAGEN ZOVIRAX

-Combinations abacavir/lamivudine lamivudine/zidovudine lopinavir/ritonavir COMBIVIR COMPLERA DESCOVY EPZICOM EVOTAZ GENVOYA JULUCA KALETRA ODEFSEY PREZCOBIX STRIBILD

TRIUMEQ TRIZIVIR TRUVADA

Attention Deficit/Hyperactivity Disorder (ADHD) atomoxetine clonidine er* guanfacine er* methylphenidate LA 60mg cap ADZENYS XR-ODT APTENSIO XR COTEMPLA XR DYANAVEL XR INTUNIV KAPVAY MYDAYIS QUILLICHEW ER RITALIN LA 60mg cap STRATTERA*

Blood Modifiers anagrelide* asa/dipyridamole cilostazol* clopidogrel* dipyridamole* pentoxifylline* pentoxifylline er persantine prasugrel* ticlopidine* AGGRENOX* AGRYLIN BRILINTA* DURLAZA EFFIENT* PLAVIX PLETAL YOSPRALA ZONTIVITY*

Cancer anastrozole* aromasin exemestane* letrozole* tamoxifen* ARIMIDEX FARESTON* FEMARA SOLTAMOX

Contraceptives/ Hormone Replacement altavera alyacen amethia amethia lo amethyst apri aranelle ashlyna aviane azurette balziva briellyn camila camrese

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camrese lo caziant cesia cryselle-28 cyclafem cyred dasetta daysee deblitane delyla elinest emoquette enpresse-28 enskyce errin estarylla estradiol* estradiol estropipate*

ocelli ogestrel orsythia ortho-est philith pimtrea pirmella portia-28 previfem quasense raloxifene* reclipsen setlakin sharobel solia sprintec sronyx syeda

FEMYNOR FYAVOLV GENERESS FE INTROVALE JEVANTIQUE LO KAITLIB FE KIMIDESS LARISSIA LO LOESTRIN* LOESTRIN LOESTRIN 21 LOESTRIN FE LOSEASONIQUE MIBELAS MENEST* MENOSTAR MINIVELLE MINASTRIN FE

estropipate tarina fe MIRCETTE estradiol gel* tilia fe MODICON estradiol transdermal* tri-estarylla NATAZIA* ethinyl estradiol-desogestrel* tri-legest fe NORINYL ethinyl estradiol-drospirenone* tri-linyah NOR-QD ethinyl estradiol-ethynodiol* tri-lo estarylla NUVARING* ethinyl estradiol- levonorgestrel* tri-lo marzia ORTHO EVRA ORTHO ethinyl estradiol- norelgestromin* tri-lo sprintec MICRONOR ethinyl estradiol- norethindrone* trinessa ORTHO-TRI-CYCLEN ethinyl estradiol- norgestimate* tri-previfem ORTHO-TRI CYCLEN LO ethinyl estradiol- norgestrel* tri-sprintec ORTHO-CEPT falmina trivora ORTHO-CYCLEN gianvi velivet ORTHO-NOVUM gildagia vesture OVCON-35 gildes viorele PREFEST gildess 24 fe vyfemla PREMARIN* heather wera PREMARIN CREAM jencycla wymzya fe PREMPHASE jinteli xulane PREMPRO* jolessa zarah QUARTETTE jolivette zenchant RAJANI juleber zenchant fe SAFYRAL* junel zovia SEASONIQUE junel fe ACTIVELLA TAYTULLA kariva ALORA TRI-NORINYL kelnor AMABELZ VAGIFEM kurvelo ANGELIQ VIENVA larin AUBRA VIVELLE-DOT larin fe BEKYREE XULANE layolis fe BEYAZ* YASMIN 28 leena BLISOVI FE YAZ lessina BREVICON YUVAFEM levonest CENESTIN* levora CHATEAL Corticosteroids lomedia 24 fe CLIMARA DIS lopreeza CLIMARA PRO* prednisone

loryna COMBIPATCH* DELTASONE

low-ogestrel CYCLESSA RAYOS

lutera DEPO-PROVERA INJ lyza DEPO-PROVERA SQ Cystic Fibrosis marlissa DESOGEN tobramycin nebulizer

medroxyprogesterone inj DESOGEN-28 BETHKIS

microgestin DIVIGEL KITABIS

microgestin fe ELESTRIN TOBI

mimvey ENJUVIA* ORKAMBI

mimvey lo ESTRACE mono-linyah ESTRACE CREAM Depression mononessa ESTRING* bupropion* myzilra ESTROSTEP FE citalopram* necon EVAMIST* desvenlafaxine* nikki EVISTA duloxetine* nora-be DUAVEE* escitalopram* norethindrone FALESSA* fluoxetine* norlyroc FEMCON FE fluoxetine dr norgestrel FEMHRT* fluvoxamine* nortrel FEMRING fluvoxamine er

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mirtazapine* nefazodone* paroxetine* paroxetine er phenelzine sertraline* tranylcypromine trazodone* venlafaxine* venlafaxine er APLENZIN* BRINTELLIX* BRISDELLE* CELEXA CYMBALTA EFFEXOR XR EMSAM FETZIMA* FLUOXETINE 60MG FORFIVO XL IRENKA KHEDEZLA LEXAPRO MARPLAN NARDIL OLEPTRO* PARNATE PAXIL PACIL CR PAXEVA PRISTIQ* PROZAC REMERON TRINTELLIX VIIBRYD* WELLBUTRIN WELLBUTRIN SR WELLBUTRIN XL ZOLOFT

Diabetes acarbose* chlorpropamide* glimepiride* glipizide* glipizide er glipizide xl glyburide* metformin* metformin er miglitol nateglinide* pioglitazone* repaglinidine* tolazamide* tolbutamide* ACTOS ADLYXIN* AFREZZA AMARYL APIDRA AVANDIA* BASAGLAR BYDUREON* BYETTA* CYCLOSET* DIABETA DUETACT FARXIGA* FIASP GLYNASE GLYSET* GLUCOPHAGE GLUCOPHAGE XR

GLUCOTROL GLUCOTROL XL HUMALOG HUMULIN N HUMULIN R INSULIN* INVOKANA* JANUVIA* JARDIANCE* LANTUS LEVEMIR NESINA* NOVOLIN NOVOLIN N NOVOLIN R NOVOLOG MIX ONGLYZA* PRANDIN PRECOSE RIOMET STARLIX STEGLATRO SYMLIN* SYNJARDY* SYNJARDY XR TANZEUM* TOUJEO SOLOSTAR TRADJENTA* TRESIBA TRULICITY* VICTOZA* XULTOPHY

-Combinations alogliptin/piogliptazone glipizide/metformin* glyburide/metformin* pioglitazone/glimepiride* pioglitazone/metformin* ACTOPLUS MET ACTOPLUS MET ER AVANDAMET* AVANDARYL* GLUCOVANCE GLYXAMBI* INVOKAMET IR*/XR* JANUMET* JENTADUETO IR*/XR* JUVISYNC* KAZANO* KOMBIGLYZE XR* OSENI* PRANDIMET* QTERN SEGLUROMET SOLIQUA* STEGLUJAN XIGDUO XR*

-Diabetes Supplies*

Digestive Enzymes pancrelipase* CREON* PANCREAZE* PERTZYE SUCRAID* ULTRESA VIOKACE ZENPEP*

Diuretics acetazolamide*

acetazolamide er amiloride* chlorthalidone* chlorothiazide dyrenium* hydrochlorothiazide (hctz)* indapamide methazolamide* methyclothiazide metolazone neptazane spironolactone* ALDACTONE DIAMOX SEQUELS ER DIURIL MICROZIDE

-Combinations hctz/amiloride hctz/spironolactone* hctz/triamterene* ALDACTAZIDE CAROSPIR DYAZIDE MAXZIDE

Genitourinary Agents alfuzosin* dutasteride dutasteride/tamsulosin finasteride* tamsulosin* terazosin* AVODART* CARDURA XL* FLOMAX JALYN* PROSCAR RAPAFLO* UROXATRAL

Gout allopurinol* probenecid/colchicine* DUZALLO ULORIC* ZURAMPIC ZYLOPRIM

Heart Disease & High Blood Pressure -Ace Inhibitors benazepril* captopril* enalapril* fosinopril* lisinopril* moexipril* perindopril* quinapril* ramipril* trandolapril* ACCUPRIL ACEON ALTACE LOTENSIN MAVIK PRINIVIL QBRELIS VASOTEC ZESTRIL

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-Angiotensin II Receptor Antagonists candesartan* eprosartan* irbesartan* losartan* olmesartan telmisartan* valsartan* ATACAND AVAPRO BENICAR COZAAR DIOVAN EDARBI* MICARDIS TEVETEN*

-Antiarrhythmics amiodarone* disopyramide* flecainide* mexiletine* pacerone propafenone* propafenone er quinidine gluconate* quinidine sulfate* quinidine er NORPACE NORPACE CR MULTAQ* RYTHMOL RYTHMOL SR

-Beta Blockers acebutolol* atenolol* betaxolol* bisoprolol* carvedilol* labetalol* levatol* metoprolol* metoprolol er nadolol* pindolol* propranolol* propranolol er sotalol* sotalol af timolol* BETAPACE BETAPACE AF BYSTOLIC* COREG COREG CR CORGARD INDERAL LA INDERAL XL INNOPRAN XL LOPRESSOR SECRAL SORINE SOTYLIZE TENORMIN TOPROL XL TRANDATE ZEBETA

-Calcium Channel Blockers amlodipine* diltiazem*

diltiazem cd diltiazem er diltiazem sr felodipine* isradipine* nicardipine nifedipine* nifedipine er nisoldipine* nisoldipine er verapamil* verapamil cr verapamil er verapamil sa verapamil sr ADALAT CC AFEDITAB CR CALAN CALAN SR CARDIZEM CARDIZEM CD CARDIZEM LA CARTIA XT DILT-XR ISOPTIN SR MATZIM LA NIFEDIAC CC NIFEDICAL XL NORVASC PROCARDIA PROCARDIA XL SULAR TAZTIA XT TIAZAC VERELAN SR VERELAN PM EXT REL

-Combinations amlodipine/atorvastatin* amlodipine/benazepril amlodipine/hctz* amlodipine/olmesartan amlodipine/olmesartan/hctz amlodipine/valsartan* amlodipine/valsartan/hctz* atenolol/chlorthalidone* benazepril/ hctz* bisoprolol/ hctz* candesartan/ hctz* clonidine/chlorthalidone* captopril/ hctz* enalapril/ hctz* fosinopril/ hctz* irbesartan/ hctz* lisinopril / hctz* losartan/ hctz* methyldopa/ hctz* metoprolol/ hctz* moexipril/ hctz* nadolol/bendroflumethiazide* olmesartan/hctz propranolol/ hctz* quinapril/ hctz* telmisartan/amlodipine* telmisartan/hctz* trandolapril/verapamil* valsartan/hctz* ACCURETIC AMTURNIDE* ATACAND HCT AVALIDE AZOR* BENICAR HCT*

BYVALSON* CADUET CLORPRES CORZIDE DIOVAN HCT DUTOPROL EDARBYCLOR* ENTRESTO* EPANED EXFORGE EXFORGE HCT HYZAAR LOPRESSOR HCT LOTENSIN HCT LOTREL MICARDIS PRESTALIA* TARKA TEKAMLO* TEKTURNA HCT* TENORETICTEVET EN HCT* TRIBENZOR* TWYNSTA VASERETIC ZESTORETIC ZIAC

-Cardiotonics digoxin DIGITEK LANOXIN

-Miscellaneous Cardiovascular clonidine* doxazosin eplerenone guanfacine* hydralazine* isoxsuprine* methyldopa* minoxidil* prazosin* reserpine* CARDURA CATAPRES CATAPRES TTS BIDIL* CORLANOR* INSPRA MINIPRESS RANEXA* TENEX TEKTURNA*

High Cholesterol atorvastatin* cholestyramine* colestipol* ezetimibe ezetimibe/simvastatin*

(exception: 10/80 mg) fenofibrate micronized* fenofibric acid fluvastatin* gemfibrozil* lovastatin* omega-3-acid ethyl ester* niacin er* pravastatin* rosuvastatin* simvastatin* (exception: 80 mg) ADVICOR

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ALTOPREV Miscellaneous Osteoporo Hypocalce alendronate* calcitonin* calcitriol* calcium aceta ibandronate* risedronate* risedronate dr ACTONEL* ATELVIA BINOSTO* BONIVA ELIPHOS FORTICAL FOSAMAX FOSAMAX D* MIACALCIN NATPARA PHOSLO PHOSLYRA ROCATROL STRENSIQ

Overactiv

ANTARA cevimeline* COLESTID ergoloid mesylate* CRESTOR* folic acid (400 & 800 mcg) FENOGLIDE levocarnitine FIBRICOR pilocarpine* FLOLIPID riluzole* LESCOL ursodiol* LESCOL XL ACTIGALL LIPITOR CARNITOR LIPOFEN CHOLBAM LIVALO* CUVPOSA* LOFIBRA DROXIA LOPID ELIPHOS LOVAZA EVOXAC NIASPAN FOSRENOL PRALUENT GASTROCROM PREVALITE NASCOBAL* QUESTRAN NUEDEXTA* REPATHA OCALIVA SIMCOR* ORFADIN TRICOR OSPHENA TRIGLIDE RAYALDEE TRILIPIX RILUTEK VASCEPA* SALAGEN VYTORIN* SARAFEM

(exception: 10/80mg) SAVELLA* darifenacin* WELCHOL* TRULANCE flavoxate* ZETIA* URSO 250 oxybutynin* ZOCOR (exception: 80mg) URSO FORTE tolterodine*

XURIDEN tolteridone er

sis/ mia

te

e Bladder

Hypogonadism Depo-Testosterone testosterone cypionate testosterone enanthate

Inflammatory Bowel Disease 5-aminosalicylic acid azulfidine sulfasalazine* sulfasalazine dr sulfazine mesalamine APRISO ASACOL HD CANASA DELZICOL DIPENTUM* GIAZO LIALDA PENTASA ROWASA SFROWASA

Irritable Bowel Syndrome alosetron AMITIZA* LINZESS* LOTRONEX

Kidney Disease calcitriol* calcium acetate* sevelamer* AURYXIA* FOSRENOL* RENAGEL* RENVELA* VELPHORO*

Opthalmic Agents betaxolol* bimatoprost* brimonidine* carbachol* carteolol* dorzolamide* latanoprost* levobunolol* methazolamide* metipranolol* phospholine* pilocarpine* timolol* travoprost* ALPHAGAN P AZOPT* BETAGAN BETIMOL BETOPTIC-S COSOPT COSOPT PF ISOPTO CARP ISTALOL LUMIGAN* RESCULA* RESTASIS TIMOPTIC TIMOPTIC-XE TRAVATAN Z* TRUSOPT VYZULTA XALATAN XIIDRA* ZIOPTAN*

-Combinations dorzolamide/timolol* COMBIGAN* SIMBRINZA*

trospium* trospium er DETROL DETROL LA DITROPAN XL ENABLEX* FLAVOXTE GELNIQUE MYRBETRIQ* OXYTROL* TOVIAZ* VESICARE*

Parkinson s Disease benztropine* bromocriptine* carbidopa*

carbidopa/levodopa* carbidopa/levodopa/entacapone* entacapone* pramipexole* pramipexole er ropinirole* ropinirole er selegiline tolcapone* trihexyphenidyl* AZILECT COMTAN DUOPA ELDEPRYL LODOSYN MIRAPEX MIRAPEX ER NEUPRO* PARLODEL REQUIP REQUIP XL RYTARY* SINEMET SINEMET CR STALEVO

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TASMAR* XADAGO ZELAPAR

Respiratory Agents albuterol nebulizer solution albuterol syrup albuterol tablet albuterol er aminophylline* azelastine budesonide* cromolyn* dyphylline* elixophylline formoterol* flunisolide fluticasone ipratropium* ipratropium/albuterol* levalbuterol nebulizer solution metaproterenol* mometasone montelukast* terbutaline* theophylline* triamcinolone zafirlukast* ACCOLATE ADVAIR* AEROSPAN* AIRDUO ALVESCO* ANORO ELLIPTA* ARCAPTA* ARMONAIR ARNUITY ELLIPTA* ASMANEX* ASTEPRO ATROVENT BECONASE AQ BEVESPI* BREO ELLIPTA* BROVANA* DALIRESP* DULERA* FLONASE FLOVENT* FORADIL INCRUSE ELLIPTA* LUFYLLIN NASONEX NUCALA OMNARIS PERFOROMIST PULMICORT PULMOZYME* QNASL QNASL CHILD QVAR* RHINOCORT AQUA SEEBRI* SEREVENT* SINGULAIR SPIRIVA* STIOLTO RESPIMAT* STRIVERDI* SYMBICORT* TRELEGY ELLIPTA

TUDORZA* UTIBRON*

VERAMYST VOSPIRE ER XOPENEX ZETONNA ZYFLO* ZYFLO CR

Rheumatoid Arthritis leflunomide* ARAVA RHEUMATREX* RIDAURA*

Seizure Disorders carbamazepine* divalproex* ethosuximide* felbamate* gabapentin* lamotrigine* lamotrigine er lamotrigine odt levetiracetam* levatiracetam er oxcarbazepine* primidone* tiagabine* topiramate* topiramate er* topiramate sprinkle valproic acid* zonisamide* APTIOM* BANZEL BRIVIACT CARBATROL CELONTIN* DEPAKENE DEPAKOTE DEPAKOTE ER DEPAKOTE SPRINKLE DILANTIN EPITOL FYCOMPA GABITRIL* GRALISE

HORIZANT* KEPPRA KEPPRA XR LAMICTAL LAMICTAL ODT LAMICTAL XR MYSOLINE NEURONTIN OXTELLAR XR PEGANONE* PHENYTEK PHENYTOIN PHENYTOIN EX QUDEXY XR ROWEEPRA SPRITAM TEGRETOL TEGRETOL XR TOPAMAX TOPAMAX SPRINKLE TRILEPTAL TROKENDI XR* ZARONTIN

ZONEGRAN

Thyroid levothyroxine* liothyronine* methimazole propylthiouracil tapazole thyroid* CYTOMEL LEVOXYL SYNTHROID THYROLAR* TIROSINT

Transplant azathioprine* cyclosporine mycophenolate mycophenolate dr sirolimus tacrolimus ASTAGRAF XL AZASAN CELLCEPT ENVARSUS XR GENGRAF IMURAN MYFORTIC NEORAL PROGRAF RAPAMUNE SANDIMMUNE ZORTRESS

Ulcer/ Gastroesophageal Reflux Disease (GERD) cimetidine* esomeprazole magnesium* esomeprazole strontium famotidine* lansoprazole* misoprostol nizatidine* omeprazole* omeprazole/sodium bicarbonate*

pantoprazole* rabeprazole* ranitidine* sucralfate* ACIPHEX

ACIPHEXSPRINKLE* AXID CARAFATE CUVPOSA* CYTOTEC DEXILANT* NEXIUM* NEXIUM GRA DR PANTOPRAXOLE PEPCID PREVACID PREVACID DR PRILOSEC PROTONIX ZANTAC ZEGERI

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MAINTENANCE MEDICATION EXCEPTION FORM

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

CRITERIA FOR APPROVAL

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

2.

Has the patient used the requested drug continuously/daily for the last 180 days or more?

Yes

No

3.

Does the prescriber intend to treat the member with the requested drug continuously over the next six months?

Yes

No

Patient Information

First Name: Last Name: Home Phone Number: Work Phone Number: Home Address: City: State: ZIP: Date of Birth: Allergies: Insurance ID: Group #:

Physician Information

Physician Name:

Physician DEA#: NPI #:

Address: City: State: ZIP:

Office Contact Name: Phone Number: Fax Number:

Primary Diagnosis

Primary ICD-9 (code):

Clinical Information

Drug and Dose Requested:

Related Diagnosis for the Drug Requested:

Quantity Requested (for a 90-day supply):

Optional: Rationale for Maintenance Exception (Please attach a letter with medical rationale to this form):

This maintenance medication exception authorization will be valid for 12 months.

I attest that this information is accurate and true, and that documentation supporting this information is available for review if requested.

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

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

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

Notice of Nondiscrimination and Availability of Language Assistance Services

CareFirst BlueCross BlueShield, CareFirst BlueChoice, Inc. and all of their corporate affiliates (CareFirst) comply with applicable federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability or sex. CareFirst does not exclude people or treat them differently because of race, color, national origin, age, disability or sex.

CareFirst:

Provides free aid and services to people with disabilities to communicate effectively with us, such as:Qualified sign language interpretersWritten information in other formats (large print, audio, accessible electronic formats, other formats)

Provides free language services to people whose primary language is not English, such as:Qualified interpretersInformation written in other languages

If you need these services, please call 855-258-6518.

If you believe CareFirst has failed to provide these services, or discriminated in another way, on the basis of race, color, national origin, age, disability or sex, you can file a grievance with our CareFirst Civil Rights Coordinator by mail, fax or email. If you need help filing a grievance, our CareFirst Civil Rights Coordinator is available to help you.

To file a grievance regarding a violation of federal civil rights, please contact the Civil Rights Coordinator as indicated below. Please do not send payments, claims issues, or other documentation to this office.

Civil Rights Coordinator, Corporate Office of Civil RightsMailing Address P.O. Box 8894 Baltimore, Maryland 21224

Email Address civilrightscoordinator@carefirst.com

Telephone Number 410-528-7820 Fax Number 410-505-2011

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., CareFirst BlueChoice, Inc., The Dental Network and First Care, Inc. are independent licensees of the Blue Cross and Blue Shield Association. In the District of Columbia and Maryland, CareFirst MedPlus is the business name of First Care, Inc. In Virginia, CareFirst MedPlus is the business name of First Care, Inc. of Maryland (used in VA by: First Care, Inc.). Registered trademark of the Blue Cross and Blue Shield Association. Registered trademark of CareFirst of Maryland, Inc.

REV. (12/17)

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and you may need to take action by certain deadlines. You have the right to get this information and assistance in

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All others may call 855-258-6518 and wait through the dialogue until prompted to push 0. When an agent

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(Amharic) -

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insurance. Maaari itong maglaman ng mga pinakamahalagang petsa at maaaring kailangan mong gumawa ng

aksyon ayon sa ilang deadline. May karapatan ka na makuha ang impormasyong ito at tulong sa iyong sariling

wika nang walang gastos. Dapat tawagan ng mga Miyembro ang numero ng telepono na nasa likuran ng kanilang

identification card. Ang lahat ng iba ay maaaring tumawag sa 855-258-6518 at maghintay hanggang sa dulo ng

diyalogo hanggang sa diktahan na pindutin ang 0. Kapag sumagot ang ahente, sabihin ang wika na kailangan mo

at ikokonekta ka sa isang interpreter.

Espaol (Spanish) Atencin: Este aviso contiene informacin sobre su cobertura de seguro. Es posible que

incluya fechas clave y que usted tenga que realizar alguna accin antes de ciertas fechas lmite. Usted tiene

derecho a obtener esta informacin y asistencia en su idioma sin ningn costo. Los asegurados deben llamar al

nmero de telfono que se encuentra al reverso de su tarjeta de identificacin. Todos los dems pueden llamar al

855-258-6518 y esperar la grabacin hasta que se les indique que deben presionar 0. Cuando un agente de seguros

responda, indique el idioma que necesita y se le comunicar con un intrprete.

(Russian) !

. ,

.

. ,

.

855-258-6518 , 0.

, .

(Hindi) : - 855-258-6518 0 ,

s-w (Bassa) To uu Cao! B nia k a ny e ke m gbo kpa o ni fu a-fa-tiin ny je dyi. B nia k

ee we j e m ke wa m m ke nyu nyu hw we ea ke zi. m ni kpe m ke b nia k ke gbo-

kpa-kpa m m dye e ni ii-wuu mu m ke se wii o p. Kpoo ny e m a fn-na nia e waa

I.D. kaa ein ny. Ny t sein m a na nia k: 855-258-6518, ke m m fo tee wa ke m gbo c m ke

na ma 0 k dyi paain hw. ju ke ny o dyi m g juin, po wuu m m po dyi, ke ny o mu o niin

ke ni wuu mu za.

(Bengali) : 855-258-6518 0

: (Urdu )

0 6518-258-855

: . (Farsi ). .

.

. 0 855-258-6518

.

: (Arabic) . .

.

.0 855-258-6518

.

(Traditional Chinese)

855-258-6518

0

Igbo (Igbo) Nrbama: kwa a nwere ozi gbasara mkpuchi nchekwa onwe g. nwere ike nwe bch nd d

mkpa, nwere ike me ihe tupu fd bch njedebe. nwere ikike nweta ozi na enyemaka a nass g na

akwgh gw bla. Nd otu kwesr kp akara ekwent d naz nke kaad njirimara ha. Nd z niile nwere

ike kp 855-258-6518 wee chere bb ah ruo mgbe amanyere p 0. Mgbe onye nnchite anya zara, kwuo

ass chr, a ga-ejik g na onye kwa okwu.

Deutsch (German) Achtung: Diese Mitteilung enthlt Informationen ber Ihren Versicherungsschutz. Sie kann

wichtige Termine beinhalten, und Sie mssen gegebenenfalls innerhalb bestimmter Fristen reagieren. Sie haben

das Recht, diese Informationen und weitere Untersttzung kostenlos in Ihrer Sprache zu erhalten. Als Mitglied

verwenden Sie bitte die auf der Rckseite Ihrer Karte angegebene Telefonnummer. Alle anderen Personen rufen

bitte die Nummer 855-258-6518 an und warten auf die Aufforderung, die Taste 0 zu drcken. Geben Sie dem

Mitarbeiter die gewnschte Sprache an, damit er Sie mit einem Dolmetscher verbinden kann.

Franais (French) Attention: cet avis contient des informations sur votre couverture d'assurance. Des dates

importantes peuvent y figurer et il se peut que vous deviez entreprendre des dmarches avant certaines chances.

Vous avez le droit d'obtenir gratuitement ces informations et de l'aide dans votre langue. Les membres doivent

appeler le numro de tlphone figurant l'arrire de leur carte d'identification. Tous les autres peuvent appeler le

855-258-6518 et, aprs avoir cout le message, appuyer sur le 0 lorsqu'ils seront invits le faire. Lorsqu'un(e)

employ(e) rpondra, indiquez la langue que vous souhaitez et vous serez mis(e) en relation avec un interprte.

(Korean) : . .

. ID .

855-258-6518 0 .

.

(Navajo)

855-258-6518

CareFirst Maintenance Drug List 4.1.18NDLA_ENGLISH_Dec2017