Prescription Guidelines - Providers & Physicians Home 20mg/10mg tramadol 50 mg 180 tablets per month...

Prescription Guidelines (effective October 1, 2017)

Some medications are only intended to be used in limited quantities, others require advanced approval or prior authorization by your doctor before they can be filled and some are prescribed in steps. Quantity limits have been placed on the use of selected drugs for quality, safety or utilization reasons. Limits may be on the amount of the drug that we cover per prescription or for a defined period of time.

Prior Authorization is required before you fill prescriptions for certain drugs. Without prior approval, your drugs may not be covered. Step Therapy ensures lower costs. When similar medications are available, step therapy guides your doctor to prescribe the lower-cost option first. You may than move up the cost levels until you find the drug that works best for you. Higher step drugs will require advanced approval or prior authorization by your doctor before they can be filled. Note: Due to the lack of Food and Drug Administration (FDA) approval for many ingredients included in compounds, as well as the lack of validated clinical support for use of these high-cost compounds, they may not be covered by your prescription plan or may require prior authorization. If the compound ingredients are not covered, you will be responsible for the full cost of those ingredients. In situations where the compound ingredients are covered through prior authorization, you will pay the cost share specified in your prescription plan.

QUANTITY LIMITS

ALBENZA 336 tablets per 365 days ALSUMA INJ 12 injections per month AMERGE (naratriptan) 12 tablets per month AXERT (almotriptan) 12 tablets per month BILTRICIDE 24 tablets per 365 days CIALIS 2.5 mg, 5 mg 30 tablets per month CIALIS 10 mg, 20 mg 6 tablets per month CAVERJECT 6 units per month EDEX 6 units per month EMVERM 12 tablets per 365 days FROVA (frovatriptan) 18 tablets per month IMITREX (sumatriptan) 12 tablets per month IMITREX INJ (sumatriptan inj) 4 mg 18 syringes per month IMITREX INJ (sumatriptan inj) 6 mg 12 syringes per month IMITREX NASAL SPRAY (sumatriptan nasal spray) 5 mg

24 units per month

IMITREX NASAL SPRAY (sumatriptan nasal spray) 20 mg

12 units per month

LEVITRA 6 tablets per month lidocaine gel 2%, 4% 30 grams per month lidocaine ointment 5% 50 grams per month lidocaine solution 4% 50 mL per month lidocaine-prilocaine cream 2.5%-2.5% 30 grams per month MAXALT (rizatriptan) 18 tablets per month MAXALT MLT (rizatriptan orally disintegrating tabs)

18 tablets per month

MIGRANAL NS (dihydroergotamine spray)

1 x 8 mL per month

MUSE 6 units per month ONZETRA XSAIL 1 box per month PLIAGLIS (lidocaine-tetracaine cream) 30 grams per month RELENZA 40 blisters per 90 days RELPAX (eletriptan) 12 tablets per month STAXYN 6 tablets per month STENDRA 6 tablets per month SUMAVEL 4 mg 18 injections per month SUMAVEL 6 mg 12 injections per month SYNERA (lidocaine-tetracaine patch) 2 patches per month TAMIFLU (oseltamivir) 30 mg 28 capsules per 90 days TAMIFLU (oseltamivir) 45 mg, 75 mg 14 capsules per 90 days TAMIFLU SUSP 180 mL per 90 days TREXIMET 9 tablets per month VIAGRA 6 tablets per month XYREM 540 mL per month ZEMBRACE SYMTOUCH 24 injectors per month ZOMIG (zolmitriptan) 12 tablets per month ZOMIG NASAL SPRAY 12 units per month ZOMIG ZMT (zolmitriptan orally disintegrating tabs)


OPIOID QUANTITY LIMITS

acetaminophen/caffeine/dihydrocodeine 320.5/30/16 mg

300 capsules per month

acetaminophen/codeine 300/15 mg 400 tablets per month acetaminophen/codeine 300/30 mg 360 tablets per month acetaminophen/codeine 300/60 mg 180 tablets per month acetaminophen/codeine solution, suspension 120-12 mg/5 mL

2700 mL per month

ARYMO 15mg, 30mg 90 mL per month

aspirin/caffeine/dihydrocodeine 356.4/30/16 mg


AVINZA (morphine ext-rel) 30 mg, 45 mg, 60 mg, 75 mg, 90 mg


BELBUCA 75 mcg, 150 mcg, 300 mcg, 450 mcg

60 films per month

buprenorphine transdermal 4 patches per month butorphanol nasal spray 2 inhalers per month

BUTRANS 5 mcg/hr, 7.5 mcg/hr, 10 mcg/hr

4 patches per month

codeine sulfate 15 mg, 30 mg, 60 mg 42 tablets per month codeine sulfate oral soln 30 mg/5 mL 210 mL per month CONZIP (tramadol ext-rel caps) 100 mg


DOLOPHINE (methadone) 5 mg, 10 mg 90 tablets per month DURAGESIC (fentanyl transdermal) 12 mcg, 25 mcg, 37.5 mcg

10 patches per month

EMBEDA 20/0.8 mg, 30/1.2 mg 60 capsules per month EMBEDA 50/2 mg, 60/2.4 mg, 80/3.2 mg


EXALGO (hydromorphone ext-rel) 8 mg, 12 mg, 16 mg


hydrocodone/acetaminophen 2.5/325 mg


hydrocodone/acetaminophen 5/300 mg, 5/325 mg


hydrocodone/acetaminophen 7.5/300 mg, 7.5/325 mg, 10/300 mg, 10/325 mg


hydrocodone/acetaminophen elixir 10-300 mg/15 mL

2025 mL per month

hydrocodone/acetaminophen solution 7.5 mg-325 mg/15 mL, 10-325 mg/15 mL

2700 mL per month

hydrocodone/ibuprofen 2.5/200 mg, 5/200 mg, 7.5 mg/200 mg, 10/200 mg


hydromorphone 2 mg 180 tablets per month hydromorphone 4 mg 150 tablets per month hydromorphone 8 mg 60 tablets per month hydromorphone liquid 1 mg/mL 600 mL per month hydromorphone suppositories 3 mg 120 supp per month HYSINGLA ER 20 mg, 30 mg, 40 mg, 60 mg, 80 mg


KADIAN (morphine ext-rel) 10 mg, 20 mg, 30 mg, 40 mg


KADIAN (morphine ext-rel) 50 mg, 60 mg, 70 mg, 80 mg


levorphanol 2 mg 120 tablets per month meperidine 50 mg, 100 mg 18 tablets per month meperidine oral solution 50 mg/5 mL 90 mL per month methadone 5 mg, 10 mg 90 tablets per month METHADONE INTENSOL 10mg/mL 90 mL per month methadone oral soln 5 mg/5mL, 10 mg/5 mL

450 mL per month

METHADOSE 5mg, 10 mg 90 tabs per month MORPHABOND 15 mg, 30 mg 60 tablets per month morphine sulfate 15 mg 180 tablets per month morphine sulfate 30 mg 90 tablets per month morphine sulfate oral concentrate 20 mg/mL

135 mL per month

morphine sulfate oral solution 10 mg/5 mL

900 mL per month

morphine sulfate oral solution 20 mg/5 mL

675 mL per month

morphine sulfate suppositories 5 mg, 10 mg

180 supp per month

morphine sulfate suppositories 20 mg 120 supp per month morphine sulfate suppositories 30 mg 90 supp per month MS CONTIN (morphine ext-rel) 15 mg, 30 mg


NUCYNTA 50 mg 120 tablets per month NUCYNTA 75 mg 90 tablets per month NUCYNTA 100 mg 60 tablets per month NUCYNTA ER 50 mg, 100 mg 60 tablets per month OXAYDO 5 mg, 7.5 mg 180 tablets per month oxycodone capsules 5 mg 180 capsules per month oxycodone oral concentrate 100 mg/5 mL

90 mL per month

oxycodone oral solution 5 mg/5 mL 900 mL per month oxycodone tablets 5 mg, 10 mg 180 tablets per month oxycodone tablets 15 mg 120 tablets per month oxycodone tablets 20 mg 90 tablets per month oxycodone tablets 30 mg 60 tablets per month oxycodone/acetaminophen 2.5/325 mg, 5/300 mg, 5/325 mg


oxycodone/acetaminophen 10/300 mg, 10/325 mg


oxycodone/acetaminophen oral solution 5-325 mg/5 mL

1800 mL per month

oxycodone/aspirin 4.8355/325 mg 360 tablets per month oxycodone/ibuprofen 5/400 mg 28 tablets per month OXYCONTIN 10 mg, 15 mg, 20 mg, 30 mg


oxymorphone 5 mg 180 tablets per month oxymorphone 10 mg 90 tablets per month pentazocine/naloxone 50/0.5 mg 120 tablets per month TARGINIQ ER 10mg/5mg, 20mg/10mg

60 tabs per month

tramadol 50 mg 180 tablets per month tramadol ext-rel 100 mg 30 tablets per month tramadol ext-rel 150 mg 30 capsules per month tramadol/acetaminophen 37.5/325 mg 40 tablets per month TROXYCA ER 10/1.2 mg, 20/2.4 mg, 30/3.6 mg


ULTRAM ER (tramadol ext-rel) 100 mg 30 tablets per month XARTEMIS XR 120 tablets per month XTAMPZA ER 9 mg, 13.5 mg, 18 mg, 27 mg


ZOHYDRO ER 10 mg, 15 mg, 20 mg, 30 mg, 40 mg


The initial limit for additional strengths not listed here is zero. All requests for strengths not listed will be considered through post limit prior authorization.

NON-SPECIALTY PRODUCTS REQUIRING PRIOR AUTHORIZATION ABSTRAL ACCU-CHEK STRIPS AND KITS ACTIQ ATRALIN BREEZE 2 STRIPS AND KITS clindamycin/tretinoin CONTOUR NEXT STRIPS AND KITS CONTOUR STRIPS AND KITS ENTRESTO FABIOR fentanyl transmucosal lozenge FENTORA FORTAMET FREESTYLE STRIPS AND KITS GLUMETZA LAZANDA LOVAZA metformin ext-rel (generic FORTAMET) metformin ext-rel (generic GLUMETZA) omega-3 acid ethyl esters REGRANEX RETIN-A RETIN-A MICRO SUBSYS tazarotene TAZORAC tretinoin cream, gel TRETIN-X VASCEPA VELTIN XIFAXAN 550 MG ZIANA All other glucose test strips that are not ONETOUCH brand Compound drugs with a cost of $300 or more

SPECIALTY DRUGS REQUIRING PRIOR AUTHORIZATION ABRAXANE ACTEMRA ACTIMMUNE ADAGEN ADCIRCA ADEMPAS ADVATE ADYNOVATE AFINITOR ALDURAZYME ALECENSA ALIMTA ALPHANATE ALPHANINE SD ALPROLIX ALUNBRIG AMPYRA APOKYN ARALAST NP ARANESP * ARCALYST AUBAGIO AUSTEDO AVASTIN AVONEX azacitidine BEBULIN BENDEKA BENEFIX BENLYSTA

BENLYSTA SC BERINERT BETASERON BETHKIS bexarotene caps BIVIGAM BOSULIF BOTOX BUPHENYL CABOMETYX capecitabine CAPRELSA CARBAGLU CARIMUNE NF CAYSTON CERDELGA CEREZYME CHOLBAM CIMZIA CINRYZE COMETRIQ COPAXONE COPEGUS COSENTYX COTELLIC CYSTAGON CYSTARAN CYTOGAM DAKLINZA dofetilide

DUPIXENT DYSPORT EGRIFTA ELAPRASE ELELYSO ELIGARD ELOCTATE EMFLAZA ENBREL ENTYVIO EPCLUSA EPOGEN * epoprostenol ERBITUX ERIVEDGE ESBRIET EUFLEXXA EXJADE EXTAVIA EYLEA FABRAZYME FARYDAK FEIBA NF FEIBA VH FERRIPROX FIRAZYR FIRMAGON FLEBOGAMMA FLOLAN FORTEO

FUZEON GAMASTAN S/D GAMMAGARD LIQUID GAMMAGARD S/D GAMMAKED GAMMAPLEX GAMUNEX-C GATTEX GEL-ONE GELSYN-3 GEMZAR GENOTROPIN GENVISC 850 GILENYA GILOTRIF GLASSIA glatiramer GLEEVEC GRANIX H.P. ACTHAR GEL HAEGARDA HARVONI HELIXATE FS HEMOFIL M HERCEPTIN HETLIOZ HIZENTRA HUMATE-P HUMATROPE HUMIRA

HYALGAN HYCAMTIN HYMOVIS IBRANCE ICLUSIG IDHIFA ILARIS imatinib IMBRUVICA INCRELEX INFLECTRA INGREZZA INLYTA INTRON A IRESSA JADENU JAKAFI JUXTAPID KADCYLA KALBITOR KALYDECO KEVZARA KINERET KISQALI KISQALI FEMARA CO-PACK KITABIS PAK KOATE-DVI KOGENATE FS KORLYM KUVAN KYNAMRO LEMTRADA LENVIMA LETAIRIS LEUKINE leuprolide acetate LONSURF LUCENTIS LUMIZYME LUPRON LUPRON DEPOT LYNPARZA MAVYRET MEKINIST MIRCERA * MONOCLATE-P MONONINE MONOVISC MYALEPT MYOBLOC NAGLAZYME NATPARA NERLYNX NEULASTA *

NEUPOGEN NEXAVAR NINLARO NITYR NORDITROPIN NORTHERA NOVOSEVEN RT NPLATE NUPLAZID NUTROPIN AQ OCALIVA OCTAGAM octreotide acetate ODOMZO OFEV OLYSIO OMNITROPE OPSUMIT ORENCIA ORENITRAM ORFADIN ORKAMBI ORTHOVISC OTEZLA OTREXUP oxaliplatin PEGASYS PERJETA phenylbutyrate sodium PLEGRIDY POMALYST PRALUENT PRIVIGEN PROCRIT * PROCYSBI PROFILNINE SD PROLASTIN-C PROLIA PROMACTA PROVENGE PULMOZYME RASUVO RAVICTI REBETOL REBETOL SOLUTION REBIF RECLAST RECOMBINATE REMICADE REMODULIN REPATHA REVATIO REVLIMID RIBAPAK

RIBASPHERE ribavirin caps ribavirin tabs RITUXAN RIXUBIS RUBRACA RUCONEST RYDAPT SABRIL SAIZEN SAMSCA SANDOSTATIN SANDOSTATIN LAR SENSIPAR SEROSTIM SIGNIFOR sildenafil SILIQ SIMPONI SIMPONI ARIA SOLIRIS SOMATULINE DEPOT SOMAVERT SOVALDI SPINRAZA SPRYCEL STELARA STIVARGA STRENSIQ SUPARTZ FX SUTENT SYLATRON SYNAGIS SYNVISC SYNVISC ONE TAFINLAR TAGRISSO TALTZ TARCEVA TARGRETIN TARGRETIN GEL TASIGNA TAXOTERE TECFIDERA TECHNIVIE TEMODAR temozolomide tetrabenazine TEV-TROPIN THALOMID TIKOSYN TOBI TOBI PODHALER tobramycin inhalation solution

TRACLEER TREANDA TRELSTAR TREMFYA TYKERB TYMLOS TYSABRI TYVASO UPTRAVI VALCHLOR VANTAS VELCADE VELETRI VENCLEXTA VENTAVIS VIDAZA VIEKIRA PAK VIEKIRA XR VIMIZIM VOSEVI VOTRIENT VPRIV WILATE XALKORI XELJANZ XELJANZ XR XELODA XENAZINE XEOMIN XERMELO XGEVA XOLAIR XTANDI XYNTHA YERVOY ZARXIO ZAVESCA ZEJULA ZELBORAF ZEMAIRA ZEPATIER ZINBRYTA ZOLADEX zoledronic acid ZOLINZA ZOMACTON ZOMETA ZORBTIVE ZYDELIG ZYKADIA ZYTIGA

* Prior authorization required for prescription benefits coverage only.

DRUGS REQUIRING STEP THERAPY

You must try one of these drugs first or your doctor must request an exception for you

Used to

before you can get coverage for these drugs

First Choice Drugs treat Second Choice Drugs minocycline (immediate or extended release) or

doxycycline (immediate or extended release) Acne Solodyn (minocycline extended release)

Your specific prescription benefit plan design may not cover certain products or categories, regardless of their appearance in this document. To learn more about your specific drug benefit, log into My Account at www.carefirst.com/myaccount and click on Drug & Pharmacy Resources under Quick Links or call CareFirst Pharmacy Services at 800-241-3371.

The information contained in this document is proprietary. The information may not be copied in whole or in part without written permission.

CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are both independent licensees of the Blue Cross and Blue Shield Association.

Registered trademark of the Blue Cross and Blue Shield Association. Registered trademark of CareFirst of Maryland, Inc.

2017. All rights reserved. www.carefirst.com SUM2712-1P (10/01/17 v2)

Notice of Nondiscrimination and Availability of Language Assistance Services

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

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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 [email protected]

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., First Care, Inc. and The Dental Network are independent licensees of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association. Registered trademark of CareFirst of Maryland, Inc.

NDLA (6/17)

Foreign Language Assistance Attention (English): This notice contains information about your insurance coverage. It may contain key dates

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

your language at no cost. Members should call the phone number on the back of their member identification card.

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) -

855-258-6518 0

d Yorb (Yoruba) ttlko: kys y n wfn npa i adjtf r. le n wn dt pt o s le n lti

gb gbs n wn j gbdke kan. O ni t lti gba wfn y ti rnlw n d r lf. wn m-gb

gbd pe nmb fn t w lyn kd dnim wn. wn mrn le pe 855-258-6518 k o s dr npas jrr

tt a fi s fn lti t 0. Ngbt aoj kan b dhn, s d t o f a s so p m gbuf kan.

Ting Vit (Vietnamese) Ch : Thng bo ny cha thng tin v phm vi bo him ca qu v. Thng bo c th

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mt sau ca th nhn dng. Tt c nhng ngi khc c th gi s 855-258-6518 v ch ht cuc i thoi cho

n khi c nhc nhn phm 0. Khi mt tng i vin tr li, hy nu r ngn ng qu v cn v qu v s c

kt ni vi mt thng dch vin.

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(Russian) !

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(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

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(Traditional Chinese)

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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.

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

(Korean) : . .

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(Navajo)

855-258-6518

CareFirst Prescription Guidelines 1017 40194 (modified) fmt usec v2QUANTITY LIMITSOPIOID QUANTITY LIMITSNON-SPECIALTY PRODUCTS REQUIRING PRIOR AUTHORIZATIONSPECIALTY DRUGS REQUIRING PRIOR AUTHORIZATIONDRUGS REQUIRING STEP THERAPY

NDLA_ENGLISH_Sep2017

Prescription Guidelines - Providers & Physicians Home 20mg/10mg tramadol 50 mg 180 tablets per month...

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