Transcription

CareFirst Formulary 32021PLEASE READ: This document contains information about the drugs wecover in this plan. T his formulary is for members of an employer group with 51 or moreemployees. For your specific prescription benefit plan information,log into your account at carefirst.com.For more recent information or other questions, pleasecontact CareFirst Pharmacy Services at 800-241-3371 or visitcarefirst.com/rx.Last updated 6/01/2021

IntroductionA formulary is a list of covered prescriptiondrugs. Our drug list is reviewed and approved byan independent national committee comprisedof physicians, pharmacists and other healthcare professionals, known as the Pharmacy andTherapeutics Committee. This committee makessure the drugs on the formulary are safe andclinically effective.drugs. Your doctor may need to providesome of your medical history or laboratorytests to determine if these medications areappropriate. Without prior authorization fromCareFirst, your drugs may not be covered. Step Therapy requires that you try lowercost, equally effective drugs that treat thesame medical condition before trying ahigher-cost alternative. Your doctor will needto provide information to CareFirst aboutyour experience with these alternatives priorto dispensing a more expensive drug. Quantity Limits have been placed on theuse of selected drugs for quality or safetyreasons. Limits may be placed on the amountof the drug covered per prescription or for adefined period of time. For example, quantitylimits apply to specialty drugs. Specialtydrugs are medications that may be used totreat complex and/or rare health conditionsand require special handling, administrationor monitoring. Specialty drugs are typicallycovered for a one-month supply.Within the formulary, prescription drugs aredivided into tiers as described below. Dependingon your plan, prescription drugs fall into one of fivedrug tiers which determines the price you pay.Using Your FormularyThe first column of the formulary lists drugs byname. If the drugs are shown in lowercase italics,they are generic drugs. If the drugs are bold andcapitalized, they are BRAND-NAME DRUGS.You may search the formulary for a drug bypressing “CTRL” and “F” at the same time toprompt a search.The second column indicates the drug tier fora covered drug.The third column indicates any prescriptionguidelines a drug requires such as prior authorization(PA), step therapy (ST) or quantity limits (QL). Prior Authorization from CareFirst is requiredbefore you fill prescriptions for certainTier 0: 0 Drugs Tier 1: Generic Drugs Tier 2: Preferred BrandDrugs Tier 3: Non-preferredBrand Drugs Tier 4: PreferredSpecialty Drugs Tier 5: Non-PreferredSpecialty Drugs Members can view specific cost-share (copayor coinsurance) information and prescriptionguidelines by logging in to My Account atcarefirst.com/myaccount and clicking on Toolsand Drug Pricing Tool or by reviewing their annualsummary of benefits.Preventive drugs (e.g. statins, aspirin, folic acid, fluoride, iron supplements, smoking cessationproducts and FDA-approved contraceptives for women) are available at a zero-dollar cost shareif prescribed under certain medical criteria by your doctor. Oral chemotherapy drugs and diabetic supplies (e.g. insulin syringes, pen needles, lancets, teststrips, and alcohol swabs) are also available at a zero-dollar cost share.Generic drugs are the same as brand-name drugs in dosage form, safety, strength, route ofadministration, quality, performance characteristics and intended use. Generic drugs generally cost less than brand-name drugs. Preferred brand drugs are brand-name drugs that may not be available in generic form, but are chosen fortheir cost effectiveness compared to alternatives. Your cost-share will be more than generics but less thannon-preferred brand drugs. If a generic drug becomes available, the preferred brand drug may be moved tothe non-preferred brand category. Non-preferred brand drugs often have a generic or preferred brand drug option where yourcost-share will be lower. Preferred specialty drugs are medications that may be used to treat complex and/or rare health conditions.These drugs may have a lower cost-share than non-preferred specialty drugs. Non-preferred specialty drugs often have a specialty drug option where your cost-share will be lower.

CareFirst Formulary 3 5T eff 6/1/2021Drug NameDrug Tier TY/ANOREXIANTSAMPHETAMINESamphetamine extended release susp 1.25mg/mlamphetamine sulfate tab 5 mgamphetamine sulfate tab 10 mgAMPHETAMINE-DEXTROAMPHETAMINE CAPER 24HR 5 MGAMPHETAMINE-DEXTROAMPHETAMINE CAPER 24HR 10 MGAMPHETAMINE-DEXTROAMPHETAMINE CAPER 24HR 15 MGAMPHETAMINE-DEXTROAMPHETAMINE CAPER 24HR 20 MGAMPHETAMINE-DEXTROAMPHETAMINE CAPER 24HR 25 MGAMPHETAMINE-DEXTROAMPHETAMINE CAPER 24HR 30 MGamphetamine-dextroamphetamine tab 5mgamphetamine-dextroamphetamine tab 7.5mgamphetamine-dextroamphetamine tab 10mgamphetamine-dextroamphetamine tab12.5 mgamphetamine-dextroamphetamine tab 15mgamphetamine-dextroamphetamine tab 20mgamphetamine-dextroamphetamine tab 30mgdextroamphetamine sulfate cap er 24hr 5mgDEXTROAMPHETAMINE SULFATE CAP ER24HR 5 MGdextroamphetamine sulfate cap er 24hr 10mgDEXTROAMPHETAMINE SULFATE CAP ER24HR 10 MGdextroamphetamine sulfate cap er 24hr 15mg1QL (540 mL / month)1111QL (150 tabs / month)QL (150 tabs / month)QL (120 caps / month);Tier 1 with DAW9QL (120 caps / month);Tier 1 with DAW9QL (30 caps / month);Tier 1 with DAW9QL (30 caps / month);Tier 1 with DAW9QL (30 caps / month);Tier 1 with DAW9QL (30 caps / month);Tier 1 with DAW9QL (120 tabs / month)1QL (120 tabs / month)1QL (120 tabs / month)1QL (120 tabs / month)1QL (60 tabs / month)1QL (60 tabs / month)1QL (30 tabs / month)1QL (150 caps / month)3QL (150 caps / month)1QL (150 caps / month)3QL (150 caps / month)1QL (60 caps / month)11111PA - Prior Authorization QL - Quantity Limits ST - Step TherapyNote: Coverage of prescription drugs and supplies listed on this formulary (drug list) is subject to your planand benefits. For the most accurate information on your drug cost and pricing, please log in to My Account(www.carefirst.com/myaccount) and click on Drug & Pharmacy Resources under Quick Links.1

CareFirst Formulary 3 5T eff 6/1/2021Drug NameDrug TierDEXTROAMPHETAMINE SULFATE CAP ER324HR 15 MGdextroamphetamine sulfate oral solution 51mg/5mldextroamphetamine sulfate tab 5 mg1dextroamphetamine sulfate tab 10 mg1DYANAVEL XR SUS 2.5MG/ML3methamphetamine hcl tab 5 mg1METHAMPHETAMINE HCL TAB 5 MG3MYDAYIS CAP 12.5MG2MYDAYIS CAP 25MG2MYDAYIS CAP 37.5MG2MYDAYIS CAP 50MG2VYVANSE CAP 10MG2VYVANSE CAP 20MG2VYVANSE CAP 30MG2VYVANSE CAP 40MG2VYVANSE CAP 50MG2VYVANSE CAP 60MG2VYVANSE CAP 70MG2VYVANSE CHW 10MG2VYVANSE CHW 20MG2VYVANSE CHW 30MG2VYVANSE CHW 40MG2VYVANSE CHW 50MG2VYVANSE CHW 60MG2zenzedi tab 2.5mg1zenzedi tab 7.5mg1zenzedi tab 15mg1zenzedi tab 20mg1zenzedi tab 30mg1Requirements/LimitsQL (60 caps / month)QL (1440 mL / QLQLQLQLQL(150 tabs / month)(150 tabs / month)(300 mL / month)(180 tabs / month)(180 tabs / month)(60 caps / month)(60 caps / month)(30 caps / month)(30 caps / month)(60 caps / month)(60 caps / month)(60 caps / month)(30 caps / month)(30 caps / month)(30 caps / month)(30 caps / month)(60 tabs / month)(60 tabs / month)(60 tabs / month)(30 tabs / month)(30 tabs / month)(30 tabs / month)(150 tabs / month)(150 tabs / month)(60 tabs / month)(60 tabs / month)(30 tabs / month)ANALEPTICScaffeine citrate oral soln 60 mg/3ml (10mg/ml base equiv)1ANTIOBESITY AGENTS, INJECTABLESAXENDA INJ 18MG/3ML2Coverage is subject toyour plan/benefits1Coverage is subject toyour plan/benefitsANTIOBESITY AGENTS, ORALbenzphetamine hcl tab 25 mgPA - Prior Authorization QL - Quantity Limits ST - Step TherapyNote: Coverage of prescription drugs and supplies listed on this formulary (drug list) is subject to your planand benefits. For the most accurate information on your drug cost and pricing, please log in to My Account(www.carefirst.com/myaccount) and click on Drug & Pharmacy Resources under Quick Links.2

CareFirst Formulary 3 5T eff 6/1/2021Drug NameBENZPHETAMINE HCL TAB 25 MGbenzphetamine hcl tab 50 mgdiethylpropion hcl tab 25 mgdiethylpropion hcl tab er 24hr 75 mgphendimetrazine tartrate cap er 24hr 105mgphendimetrazine tartrate tab 35 mgphentermine hcl cap 15 mgphentermine hcl cap 30 mgphentermine hcl cap 37.5 mgPHENTERMINE HCL CAP 37.5 MGphentermine hcl tab 37.5 mgPHENTERMINE HCL TAB 37.5 MGDrug Tier Requirements/Limits3Coverage is subject toyour plan/benefits1Coverage is subject toyour plan/benefits1Coverage is subject toyour plan/benefits1Coverage is subject toyour plan/benefits1Coverage is subject toyour plan/benefits1Coverage is subject toyour plan/benefits1Coverage is subject toyour plan/benefits1Coverage is subject toyour plan/benefits1Coverage is subject toyour plan/benefits3Coverage is subject toyour plan/benefits1Coverage is subject toyour plan/benefits3Coverage is subject toyour plan/benefitsATTENTION-DEFICIT/HYPERACTIVITY DISORDER (ADHD) AGENTSatomoxetine cap 10mgatomoxetine cap 18mgatomoxetine cap 25mgatomoxetine cap 40mgatomoxetine cap 60mgatomoxetine cap 80mgatomoxetine cap 100mgclonidine hcl tab er 12hr 0.1guanfacine hcl tab er 24hr 1equiv)guanfacine hcl tab er 24hr 2equiv)guanfacine hcl tab er 24hr 3equiv)guanfacine hcl tab er 24hr 4equiv)STRATTERA CAP 10MGmgmg (base111111111mg (base1mg (base1mg (base13QLQLQLQLQLQLQL(150 caps / month)(150 caps / month)(150 caps / month)(60 caps / month)(30 caps / month)(30 caps / month)(30 caps / month)QL (150 caps / month)PA - Prior Authorization QL - Quantity Limits ST - Step TherapyNote: Coverage of prescription drugs and supplies listed on this formulary (drug list) is subject to your planand benefits. For the most accurate information on your drug cost and pricing, please log in to My Account(www.carefirst.com/myaccount) and click on Drug & Pharmacy Resources under Quick Links.3

CareFirst Formulary 3 5T eff 6/1/2021Drug GDrug Tier333333Requirements/LimitsQL (150 caps / month)QL (150 caps / month)QL (60 caps / month)QL (30 caps / month)QL (30 caps / month)QL (30 caps / month)DOPAMINE AND NOREPINEPHRINE REUPTAKE INHIBITORS(DNRIS)SUNOSI TAB 75MGSUNOSI TAB 150MG22STIMULANTS - MISC.armodafinil tab 50 mgarmodafinil tab 150 mgarmodafinil tab 200 mgarmodafinil tab 250 mgdexmethylph cap 15mg erdexmethylph cap 30mg erdexmethylph cap 40mg erdexmethylph tab 2.5mgdexmethylph tab 5mgdexmethylph tab 10mgdexmethylphe cap 5mg erdexmethylphe cap 10mg erdexmethylphe cap 20mg erdexmethylphe cap er 25mgdexmethylphe cap er 35mgFOCALIN TAB 2.5MGFOCALIN TAB 5MGFOCALIN TAB 10MGmethylphenid cap 20mg ermethylphenid cap 30mg ermethylphenid cap 40mg ermethylphenid tab 5mgmethylphenid tab 10mgmethylphenid tab 20mgMETHYLPHENID TAB 72MG ERmethylphenidate hcl cap er 10 mg (cd)methylphenidate hcl cap er 20 mg (cd)methylphenidate hcl cap er 24hr 10 QLQLQLQLQLQLQLQLQLQLQLQLQLQLQLQLQLQLQLQL(60 caps / month)(30 caps / month)(30 caps / month)(150 tabs / month)(150 tabs / month)(60 tabs / month)(60 caps / month)(60 caps / month)(60 caps / month)(30 caps / month)(30 caps / month)(150 tabs / month)(150 tabs / month)(60 tabs / month)(60 caps / month)(60 caps / month)(30 caps / month)(210 tabs / month)(210 tabs / month)(120 tabs / month)(30 tabs / month)(60 caps / month)(60 caps / month)(60 caps / month)PA - Prior Authorization QL - Quantity Limits ST - Step TherapyNote: Coverage of prescription drugs and supplies listed on this formulary (drug list) is subject to your planand benefits. For the most accurate information on your drug cost and pricing, please log in to My Account(www.carefirst.com/myaccount) and click on Drug & Pharmacy Resources under Quick Links.4

CareFirst Formulary 3 5T eff 6/1/2021Drug temethylphenidatehcl cap er 24hr 15 mgDrug Tier Requirements/Limits1QL (60 caps / month)hcl cap er 24hr 20 mg1QL (60 caps / month)hcl cap er 24hr 30 mg1QL (60 caps / month)hcl cap er 24hr 40 mg1QL (30 caps / month)hcl cap er 24hr 50 mg1QL (30 caps / month)hcl cap er 24hr 60 mg1QL (30 caps / month)hcl cap er 24hr 60 mg1QL (30 caps / month)hcl cap er 30 mg (cd)hcl cap er 40 mg (cd)11QL (60 caps / month)QL (30 TABLETS PERmonth)QL (30 caps / month)QL (30 caps / month)QL (210 tabs / month)QL (210 tabs / month)QL (210 tabs / month)QL (2160 mL / month)QL (2160 mL / month)QL (1080 mL / month)QL (1080 mL / month)QL (120 tabs / month)QL (120 tabs / month)QL (60 tabs / month)QL (60 tabs / month)QL (60 tabs / month)QL (30 tabs / month)QL (60 tabs / month);Tier 1 with DAW9QL (60 tabs / month);Tier 1 with DAW9QL (60 tabs / month);Tier 1 with DAW9QL (30 tabs / month);Tier 1 with DAW9QL (60 caps / month)PAmethylphenidate hcl cap er 50 mg (cd)methylphenidate hcl cap er 60 mg (cd)methylphenidate hcl chew tab 2.5 mgmethylphenidate hcl chew tab 5 mgmethylphenidate hcl chew tab 10 mgmethylphenidate hcl soln 5 mg/5mlMETHYLPHENIDATE HCL SOLN 5 MG/5MLmethylphenidate hcl soln 10 mg/5mlMETHYLPHENIDATE HCL SOLN 10 MG/5MLmethylphenidate hcl tab er 10 mgmethylphenidate hcl tab er 20 mgmethylphenidate hcl tab er 24hr 18 mgmethylphenidate hcl tab er 24hr 27 mgmethylphenidate hcl tab er 24hr 36 mgmethylphenidate hcl tab er 24hr 54 mgMETHYLPHENIDATE HCL TAB ER OSMOTICRELEASE (OSM) 18 MGMETHYLPHENIDATE HCL TAB ER OSMOTICRELEASE (OSM) 27 MGMETHYLPHENIDATE HCL TAB ER OSMOTICRELEASE (OSM) 36 MGMETHYLPHENIDATE HCL TAB ER OSMOTICRELEASE (OSM) 54 MGmethyphenid cap 10mg ermodafinil tab 100 mg111111313111111111111PA - Prior Authorization QL - Quantity Limits ST - Step TherapyNote: Coverage of prescription drugs and supplies listed on this formulary (drug list) is subject to your planand benefits. For the most accurate information on your drug cost and pricing, please log in to My Account(www.carefirst.com/myaccount) and click on Drug & Pharmacy Resources under Quick Links.5

CareFirst Formulary 3 5T eff 6/1/2021Drug Namemodafinil tab 200 mgQUILLICHEW CHW 20MG ERQUILLICHEW CHW 30MG ERQUILLICHEW CHW 40MG ERQUILLIVANT SUS 25MG/5MLRITALIN LA CAP 10MGRITALIN LA CAP 20MGRITALIN LA CAP 30MGRITALIN LA CAP 40MGRITALIN TAB 5MGRITALIN TAB 10MGRITALIN TAB 20MGDrug Tier133333333333Requirements/LimitsPAQL (60 tabs / month)QL (60 tabs / month)QL (30 tabs / month)QL (420 mL / month)QL (60 caps / month)QL (60 caps / month)QL (60 caps / month)QL (30 caps / month)QL (210 tabs / month)QL (210 tabs / month)QL (120 tabs / month)AMINOGLYCOSIDESAMINOGLYCOSIDESARIKAYCE SUSKITABIS PAK NEB 300/5ML55neomycin sulfate tab 500 mgparomomycin sulfate cap 250 mgtobramycin neb 300/5ml111tobramycin nebu soln 300 mg/4ml1TOBRAMYCIN NEBU SOLN 300 MG/4ML4PAPA, QL (56 AMPULESPER 28 DAYS)PA, QL (56 AMPULESPER 28 DAYS)PA, QL (56 AMPULESPER 28 DAYS)PA, QL (56 AMPULESPER 28 DAYS)ANALGESICS - ANTI-INFLAMMATORYANTI-TNF-ALPHA - MONOCLONAL ANTIBODIESHUMIRA INJ 10/0.1ML4PA, QL (2 PFS PER 28DAYS); Preferred for allapproved indications;Quantity Limits areconsistent withmaximum FDA approveddosing limits. Approvedquantity may be lessthan the listed limit.PA - Prior Authorization QL - Quantity Limits ST - Step TherapyNote: Coverage of prescription drugs and supplies listed on this formulary (drug list) is subject to your planand benefits. For the most accurate information on your drug cost and pricing, please log in to My Account(www.carefirst.com/myaccount) and click on Drug & Pharmacy Resources under Quick Links.6

CareFirst Formulary 3 5T eff 6/1/2021Drug NameHUMIRA INJ 20/0.2MLHUMIRA INJ 40/0.4MLHUMIRA KIT 40MG/0.8HUMIRA PEDIA INJ CROHNSDrug Tier Requirements/Limits4PA, QL (2 PFS PER 28DAYS); Preferred for allapproved indications;Quantity Limits areconsistent withmaximum FDA approveddosing limits. Approvedquantity may be lessthan the listed limit.4PA, QL (4 PFS PER 28DAYS); Preferred for allapproved indications;Quantity Limits areconsistent withmaximum FDA approveddosing limits. Approvedquantity may be lessthan the listed limit.4PA, QL (6 PFS PER 28DAYS); Preferred for allapproved indications;Quantity Limits areconsistent withmaximum FDA approveddosing limits. Approvedquantity may be lessthan the listed limit.4PA, QL (3 PFS PER 28DAYS); Preferred for allapproved indications;Quantity Limits areconsistent withmaximum FDA approveddosing limits. Approvedquantity may be lessthan the listed limit.PA - Prior Authorization QL - Quantity Limits ST - Step TherapyNote: Coverage of prescription drugs and supplies listed on this formulary (drug list) is subject to your planand benefits. For the most accurate information on your drug cost and pricing, please log in to My Account(www.carefirst.com/myaccount) and click on Drug & Pharmacy Resources under Quick Links.7

CareFirst Formulary 3 5T eff 6/1/2021Drug NameHUMIRA PEN INJ 40/0.4MLHUMIRA PEN INJ 40MG/0.8HUMIRA PEN INJ 80/0.8MLHUMIRA PEN INJ CD/UC/HSDrug Tier Requirements/Limits4PA, QL (4 PEN PER 28DAYS); Preferred for allapproved indications;Quantity Limits areconsistent withmaximum FDA approveddosing limits. Approvedquantity may be lessthan the listed limit.4PA, QL (4 PEN PER 28DAYS); Preferred for allapproved indications;Quantity Limits areconsistent withmaximum FDA approveddosing limits. Approvedquantity may be lessthan the listed limit.4PA, QL (3 PEN PER 28DAYS); Preferred for allapproved indications;Quantity Limits areconsistent withmaximum FDA approveddosing limits. Approvedquantity may be lessthan the listed limit.4PA, QL (4 PEN PER 28DAYS); Preferred for allapproved indications;Quantity Limits areconsistent withmaximum FDA approveddosing limits. Approvedquantity may be lessthan the listed limit.PA - Prior Authorization QL - Quantity Limits ST - Step TherapyNote: Coverage of prescription drugs and supplies listed on this formulary (drug list) is subject to your planand benefits. For the most accurate information on your drug cost and pricing, please log in to My Account(www.carefirst.com/myaccount) and click on Drug & Pharmacy Resources under Quick Links.8

CareFirst Formulary 3 5T eff 6/1/2021Drug NameHUMIRA PEN INJ PS/UVHUMIRA PEN KIT CD/UC/HSHUMIRA PEN KIT PED UCHUMIRA PEN KIT PS/UVDrug Tier Requirements/Limits4PA, QL (4 PEN PER 28DAYS); Preferred for allapproved indications;Quantity Limits areconsistent withmaximum FDA approveddosing limits. Approvedquantity may be lessthan the listed limit.4PA, QL (3 PEN PER 28DAYS); Preferred for allapproved indications;Quantity Limits areconsistent withmaximum FDA approveddosing limits. Approvedquantity may be lessthan the listed limit.4PA, QL (3 PEN PER 28DAYS); Preferred for allapproved indications;Quantity Limits areconsistent withmaximum FDA approveddosing limits. Approvedquantity may be lessthan the listed limit.4PA, QL (3 PEN PER 28DAYS); Preferred for allapproved indications;Quantity Limits areconsistent withmaximum FDA approveddosing limits. Approvedquantity may be lessthan the listed limit.PA - Prior Authorization QL - Quantity Limits ST - Step TherapyNote: Coverage of prescription drugs and supplies listed on this formulary (drug list) is subject to your planand benefits. For the most accurate information on your drug cost and pricing, please log in to My Account(www.carefirst.com/myaccount) and click on Drug & Pharmacy Resources under Quick Links.9

CareFirst Formulary 3 5T eff 6/1/2021Drug NameDrug Tier Requirements/LimitsANTIRHEUMATIC - ENZYME INHIBITORSRINVOQ TAB 15MG ER4XELJANZ SOL 1MG/ML4XELJANZ TAB 5MG4XELJANZ TAB 10MG4PA, QL (30 TABLETS PER30 DAYS); Preferredagent for RheumatoidArthritis; Quantity Limitsare consistent withmaximum FDA approveddosing limits. Approvedquantity may be lessthan the listed limit.PA, QL (240ML PER 24DAYS)PA, QL (60 TABLETS PER30 DA