guide to
prescription drug
benefits
table of contents
Contact Us
- Phone Number 1
- Web site
Using Your Prescription Drug Benefit
- Retail, mail order, and Specialty Pharmacy 2
- Refills
Be A Wise Health Care Consumer
- Generic
3
- Preferred Brand
- Non-preferred Brand
Accessing Your Information
4
- Web Site Information
Preferred Medication Listing 5-7
Prior Authorization 8-11
Drug Quantity Management Program 12-14
Generic Substitution Program 14
CuraScript®, Inc.
14-15
- Specialty Medication List
Pharmacy Network 16-17
guide to prescription drug benefits
contact us
Customer Service On the Web
If you have questions about your prescription drug Visit the Capital BlueCross Web site at
benefit, contact CVS Caremark customer service capbluecross.com to learn more about your
at 1-800-585-5794 (TTY: 1-866-236-1069). CVS prescription drug benefit. Members can link
Caremark pharmacists and customer service to CVS Caremark from the Capital BlueCross
representatives are available any time of the day, Web site (see page 4 to learn more). You can
seven days a week. The CVS Caremark customer also download the most up-to-date versions
service team also offers interpretive services in 140 of the Formulary, Preferred Medication List,
languages, including in-house, Spanish-speaking Prior Authorization Program, the Drug Quantity
representatives. Management Program, and other useful
information1.
1
These documents are subject to change.
On behalf of Capital BlueCross, CVS Caremark assists in the administration of our prescription drug program. CVS Caremark is an independent
pharmacy benefit manager.
one
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Welcome to the using your prescription
Capital BlueCross prescription
drug benefit
drug program. To help
Capital BlueCross makes it easy for you to fill
you understand how your your prescriptions.
prescription drug benefit works • Retail (local neighborhood or chain store
and how you can get the most pharmacy) — Simply present your Capital BlueCross
ID card at any participating retail pharmacy when
out of your health care dollar, we you have a prescription to fill.2
have created this simple guide. • Mail Order —You can have medications that you
If you need more information, take regularly delivered to your home. Simply
complete the enclosed mail service order form,
please refer to your Certificate include your doctor’s prescription, and mail to
of Coverage, visit our Web site at CVS Caremark at: CVS Caremark, P.O. Box 2110,
Pittsburgh, PA 15230-2110. You can also download a
capbluecross.com. mail service order form from our Web site.2
• Specialty — CuraScript will deliver your specialty
medications right to your doorstep. Specially trained
staff are ready to assist you with managing your
treatment and to answer questions about your
unique health needs.2 (See page 14-15)
mail order refills
• Telephone — Getting a mail order refill is easy too.
Simply call CVS Caremark at the toll-free Rx Member
Services number found on your ID card to request a
refill. (Please remember that you will need to supply
a method of payment when placing your order.)
You can also check on the status of a prescription
or locate a participating pharmacy.
• Web Site — Once you have registered, mail order
prescription refills can be requested online. Link to
CVS Caremark from the Capital BlueCross Web site
(see page 4) to submit a prescription refill. And,
check out the various payment options offered by
CVS Caremark.
• U.S. Mail —You can also mail your refill slip to
CVS Caremark at: CVS Caremark, P.O. Box 2110,
Pittsburgh, PA 15230-2110.
For additional information on using mail order, visit
capbluecross.com.
two 2
The amount of medication you can obtain at a retail or mail order pharmacy
depends on your drug benefit. Please refer to your Certificate of Coverage.
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be a wise health care consumer
The Capital BlueCross formulary is a reference Brand-name 3 drugs are marketed under a specific
list that includes generic and brand-name trade name and are protected by a patent.
prescription drugs that have been approved Brand-name drugs can be either preferred or
by the U.S. Food and Drug Administration (FDA). non-preferred.
The formulary is updated on a quarterly basis or
• Preferred brand-name drugs (tier two)
when new generic or brand-name medications
are usually available at a slightly higher
become available and as discontinued drugs are
copayment or coinsurance than generic
removed from the marketplace.
drugs. These drugs are designated preferred
While you cannot control drug prices, there are brand because they have been proven to be
some things you can do to lower your out-of- safe, effective, and favorably priced compared
pocket costs. You can use information in the to other brand drugs that treat the same
formulary to help you identify the tier status of condition.
medication you are taking and discuss less
• Non-preferred brand-name drugs (tier three)
expensive alternatives with your doctor.
usually have the highest copayment or
The Capital BlueCross formulary includes three coinsurance. These drugs are listed as non-
tiers of medications: generic, preferred brand- preferred because they have not been found
name drugs, and non-preferred brand-name to be any more cost effective than available
drugs. Your copayment or coinsurance for generics, preferred brands, or over-the-counter
prescription medication is based on which tier drugs.
your drug falls into.
Non-preferred brand medications are not covered
3
Generic drugs (tier one) are typically the most under a closed formulary benefit plan. You or your
affordable and offer you the lowest available physician may request coverage for medically
copayment or coinsurance. The active ingredient necessary non-preferred drugs through the Non-
in a generic drug is chemically identical to the formulary Consideration Process.
active ingredient of the corresponding brand- 3
Drugs sold in the United States are approved by the Food and Drug
Administration (FDA) whether they are brand-name or generic.
name drug. To help lower your out-of-pocket
costs, we encourage you to choose a generic
medication whenever possible.
three
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Visit the pharmacy page on
the Capital BlueCross Web site
at capbluecross.com to learn
more about your prescription
drug benefit, to download forms,
and for the most up-to-date
information.
accessing your prescription drug information
Web access gives you an opportunity to explore “Terms and Conditions” the first time, you will
health information, find out about your benefits, not be asked to do it again.
and estimate the price of drugs you are taking.
• Congratulations! You can now begin to explore
You can access your prescription drug information the many tools and information that can
on the CVS Caremark Web site by following these help you and your family better manage your
instructions: prescription drug benefits. To learn more about
viewing online prescription information for
• Go to capbluecross.com
covered dependents age 18 and older, please
• Enter your “username” and “password” in the visit capbluecross.com/transition.
“login” box. If you are not registered, you will
Once you have Web access to CVS Caremark,
need to complete the registration process first.
some features available at your fingertips include:
• Once you are logged in, you can access your
• Online prescription services — place mail order
prescription drug information by clicking on
refill requests and track prescription orders.
the “Rx Information” tab located in the gray bar
at the top of the mycapbluecross.com Web • Check drug cost — get the estimated cost of
page. your medication and find out about possible
generic alternatives, mail order options, and
• From the “Pharmacy Information” page, you
savings opportunities.
can access the CVS Caremark Web site by
clicking the “View CVS Caremark Rx Coverage” • Personal reminders — create and schedule
link located under the “Your Program Tools” box refill reminders and order status alerts for mail
on the right. service prescriptions.
NOTE: If you want to access a specific topic, • Drug and health information — search the
you can also choose one of the direct links formulary to find out the tier status of your
that are located on the “Pharmacy Information” drug, check drug interaction and side effects,
page under the CVS Caremark logo. compare your drug to other drugs in the same
therapy class, and get health and wellness
• The first time you access the CVS Caremark
information.
Web site, you will be asked to agree to the
“Terms and Conditions.” Once you agree to the
four
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accessing your prescription drug
information (continued)
• Pharmacy locator — find a participating Consideration by following the instructions
pharmacy. provided.
• Online customer service — use email to contact • Methods of payment — pay by credit card,
a CVS Caremark service representative for any check, or money order. Or use Bill Me Later®
questions about your prescription drug benefit. for mail-order prescriptions.
• Coverage exception requests — initiate a
request for prior authorization or Non-formulary
preferred medication list
The Preferred Medication List is an abbreviated You can easily identify generic, preferred brand,
version of the Formulary list containing the names or non-preferred brand drugs on the Preferred
of some of the most commonly prescribed drugs Medication List as they will have the following
(pages 6-7). symbols next to them:
The Capital BlueCross formulary serves as a
Generic
reference for all prescription drug benefit designs G
listed in bold lower case print
ranging from an open formulary to a
closed formulary. Preferred Brand
P
listed in all UPPER CASE PRINT
• An Open Formulary Plan provides access to
generic (tier-one), preferred brand (tier-two), Non-preferred Brand
and non-preferred brand-name (tier-three) NP
listed in all UPPER CASE PRINT
medications.
Members are encouraged to use generic or
• A closed formulary provides access to both
preferred brand drugs which are typically less
generic (tier-one) and preferred brand-name
expensive than non-preferred brand drugs.
(tier-two) drugs. You or your physician may
To help maximize the value of your prescription
request coverage for medically necessary
drug benefit, the names of the preferred formulary
non-preferred drugs through the Non-formulary
alternatives are provided.
Consideration Process.
five
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Alternatives Alternatives
Drug Name Drug Name
(please discuss with your physician) (please discuss with your physician)
ABILIFY NP risperidone DETROL, -LA NP oxybutymin/-er, trospium
ACCOLATE NP zafirlukast lansoprazole (QLL), omeprazole (QLL),
DEXILANT (EPA, QLL) NP
pantoprazole (QLL)
ACCU-CHECK NP ASCENSIA, ONETOUCH
DILANTIN NP phenytoin
ACEON (EPA) NP perindopril
DIOVAN, -HCT (EPA) P
ACIPHEX (EPA, QLL) P
donepezil G
ACTONEL (EPA, QLL) NP alendronate (QLL)
DULERA (QLL) P
ACTOS P
EDARBI (EPA) NP losartan, DIOVAN
ADCIRCA (PAR) P
EFFEXOR XR (EPA, QLL) NP venlafaxine ER (QLL)
ADDERALL, -XR NP amphetamine salt combo
EFFIENT P
ADVAIR (QLL) P
ELIDEL P
AFINITOR P
enalapril, -hctz G
alendronate (QLL) G
EPIPEN, -JR P
ALPHAGAN-P P
eplerenone G
ALVESCO INHALER (QLL) NP ASMANEX, FLOVENT
estradiol G
AMBIEN CR (EPA, QLL) NP zolpidem ER (QLL)
EVISTA P
amlodipine (QLL) G
EXELON (EPA) NP rivastigmine
AMPYRA (PAR, QLL) P
EXFORGE (EPA) P
ARICEPT (EPA) NP donepezil
FANAPT NP risperidone
ARICEPT ODT (EPA) NP donepezil ODT
FEMHRT NP ethinyl estradiol/norethindrone
ASCENSIA P
fenofibrate G
ASMANEX (QLL) P
FLECTOR PATCH (EPA) NP meloxicam, naproxen
ASTELIN NP azelastine
FLOMAX NP tamsulosin
losartan/-hctz, BENICAR HCT (EPA),
AVALIDE (EPA) NP FLOVENT HFA (QLL) P
DIOVAN HCT (EPA)
AVANDIA P fluoxetine (QLL) G
losartan, BENICAR (EPA), fluticasone nasal spray (QLL) G
AVAPRO (EPA) NP
DIOVAN (EPA) gabapentin G
AVELOX P galantamine/-ER G
AVODART P gemfibrozil G
azithromycin G GEODON P
AZOR (EPA) P glimepiride G
BENICAR, -HCT (EPA) P glipizide/-ER G
BENZACLIN NP clindamycin/benzoyl peroxide glyburide, -metformin G
bisoprolol, -hctz G HUMULIN/HUMALOG P
BONIVA tabs (EPA, QLL) P HYZAAR (EPA) NP losartan/hctz
buprenorphine G IMITREX (EPA, QLL) NP sumatriptan (QLL)
bupropion, -sr, -xl G INTUNIV NP methylphenidate
BYETTA (EPA) P JALYN P
BYSTOLIC (EPA) NP carvedilol, metoprolol xl JANUVIA/JANUMET P
carbidopa/levodopa G KADIAN (QLL) P
carvedilol G KEPPRA, -XR NP levetiracetam
CAYSTON NP TOBI LAMICTAL NP lamotrigine
CELEBREX (EPA) NP LANTUS P
CIALIS (QLL) NP LEVITRA (QLL) LANTUS SOLOSTAR NP LANTUS
CIMZIA (PAR, QLL) NP ENBREL (PAR, QLL), HUMIRA (PAR, QLL) LATUDA NP risperidone
citalopram (QLL) G LEVAQUIN NP AVELOX
CLARINEX (EPA) NP levocetirizine LEVEMIR P
COMBIVENT P levetiracetam G
CONCERTA NP methylphenidate ER LEVITRA (QLL) P
COREG CR NP carvedilol, metoprolol xl levothyroxine G
COSOPT NP dorzolamide/timolol LEXAPRO (EPA, QLL) NP citalopram (QLL)
COUMADIN NP warfarin simvastatin (QLL), CRESTOR (QLL),
LIPITOR (EPA, QLL) NP
COZAAR (EPA) NP losartan VYTORIN (QLL)
CRESTOR (QLL) P lisinopril, -hctz G
CYMBALTA (EPA) NP venlafaxine ER (QLL) simvastatin (QLL), CRESTOR (QLL),
LIVALO (EPA, QLL) NP
VYTORIN (QLL)
lovastatin (QLL) G
six
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Alternatives Alternatives
Drug Name Drug Name
(please discuss with your physician) (please discuss with your physician)
LUMIGAN P SEROQUEL XR (QLL) NP SEROQUEL
LUNESTA (EPA, QLL) NP zaleplon (QLL), zolpidem (QLL) sertraline G
LYRICA (EPA) P SIMCOR (EPA) P
MAXALT, - MLT (EPA, QLL) P SIMPONI (EPA, QLL) NP ENBREL (PAR, QLL), HUMIRA (PAR, QLL)
meloxicam G simvastatin (QLL) G
metformin/-ER G SINGULAIR (EPA) P
metoprolol, -xl G SKELAXIN NP metaxalone
MIRAPEX NP pramipexole SPIRIVA P
mirtazapine G STARLIX NP nateglinide
MULTAQ NP amiodarone STAXYN (QLL) NP LEVITRA (QLL)
NAMENDA P STRATTERA NP methylphenidate ER
NASACORT AQ (EPA) NP fluticasone nasal spray (QLL) sumatriptan (QLL) G
NASONEX (EPA) NP fluticasone nasal spray (QLL) SYMBICORT (QLL) P
lansoprazole (QLL), omeprazole (QLL), SYMLIN (EPA) P
NEXIUM (EPA, QLL) NP
pantoprazole (QLL)
SYNTHROID NP levothyroxine
NIASPAN P
tacrolimus G
NOVOLIN/NOVOLOG P
TEKTURNA, -HCT (EPA) P
omeprazole G
TOBRADEX NP tobramycin/dexamethasone
OMNARIS (EPA) NP fluticasone (QLL)
TOPAMAX NP topiramate
ondansetron (QLL) G
TRADJENTA NP JANUVIA, ONGLYZA
ONETOUCH P
tramadol/-ER (QLL) G
ONGLYZA P
TRAVATAN Z P
ONSOLIS (QLL) NP fentanyl
TREXIMET (EPA, QLL) NP sumatriptan (QLL) + naproxen
ORTHO EVRA NP tri-sprintec
triamterene/-hctz G
ORTHO TRI-CYCLEN LO NP tri-sprintec
TRICOR P
oxybutynin/-ER G
VALTREX NP valacyclovir
morphine er (QLL), oxycodone (QLL),
OXYCONTIN (QLL) NP VALTURNA (EPA) P
KADIAN (QLL)
pantoprazole (QLL) G venlafaxine G
paroxetine (QLL) G VENTOLIN HFA P
PATANOL, PATADAY NP Zaditor OTC (not covered) VERAMYST (EPA, QLL) NP fluticasone (QLL)
PAXIL, -CR (EPA, QLL) NP paroxetine, -cr (QLL) verapamil/-ER G
PLAVIX P VESICARE P
PRADAXA (PAR) NP warfarin VIAGRA (QLL) NP LEVITRA (QLL)
PRANDIN P VICTOZA (EPA) NP BYETTA (EPA)
pravastatin (QLL) G VOTRIENT P
PREMARIN, PREMPRO P VYTORIN (QLL) P
PREVACID (EPA, QLL) NP lansoprazole (QLL) VYVANSE P
PRISTIQ (EPA, QLL) NP venlafaxine ext-rel (QLL) warfarin G
PROAIR HFA P XALATAN NP latanoprost
PROMACTA P XOPENEX HFA NP PROAIR HFA, VENTOLIN HFA
PROVENTIL HFA NP PROAIR HFA, VENTOLIN HFA XYZAL (EPA) NP levocetirizine
PULMICORT INHALER (QLL) NP ASMANEX (QLL), FLOVENT HFA (QLL) YASMIN NP ocella
quinapril, quinaretic G zaleplon (QLL) G
ramipril G ZETIA P
RANEXA (PAR) P zolpidem, /-ER (QLL) G
naratriptan (QLL), sumatriptan (QLL), ZOMIG/-ZMT (EPA, QLL) NP naratriptan (QLL), sumatriptan (QLL)
RELPAX (EPA, QLL) NP
MAXALT/-MLT (EPA, QLL) ZYPREXA (QLL) P
RHINOCORT AQUA (EPA) NP fluticasone (QLL)
G: Generics QLL: Quantity Level Limit
risperidone G P: Preferred Brands PAR: Prior Authorization Required
ropinirole G NP: Non-preferred Brands EPA: Enhanced Prior Authorization
ROZEREM P
SABRIL NP carbamazepine, gabapentin This list is not all-inclusive and does not guarantee coverage. Please
SANCUSO PATCH (QLL) NP granisetron (QLL), ondansetron (QLL) check your Certificate of Coverage for detailed information regarding
individual drug coverage, pharmaceutical management procedures,
SAPHRIS NP risperidone benefit limitations and exclusions.
SAVELLA (EPA) P The preferred medication list does not apply to Medicare Advantage
SEREVENT DISKUS P or Medicare part D programs.
SEROQUEL P Current as of January 2012. seven
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committed to your
safety and well being
Prior Authorization4
The prior authorization process helps to ensure that
certain drugs are prescribed appropriately and in
keeping with FDA guidelines. You can easily identify
these drugs on our formulary list as they will have a
PAR symbol next to them (refer to the Preferred
Medication List on pages 5 – 7).
To help prevent possible delays in filling your
prescription, you, your physician, or your authorized
representative should request a prior authorization
before your prescriptions are filled. Medications
that require prior authorization will not be covered if
authorization is not obtained prior to dispensing. Your
physician can direct prior authorization requests to
CVS Caremark by calling 1-800-294-5979 (fax: 1-888-
836-0730).
You can also initiate a prior authorization request
or start the Non-formulary Consideration Process
by phone or online. Please be sure to mention the
following information:
• Your name (as it appears on your ID card)
• Your member ID number
• Your date of birth
• Name of the drug
• Name of the physician who prescribed the drug
• Physician phone number with area code
• Physician fax number with area code (if available)
Be sure to select ‘prior authorization’ or ‘non-formulary
drug’ when making your request.
4
The following list is not intended to be a complete list of drug classifications and is
subject to change. Some classifications of drugs may not be covered under your
prescription drug program. Please refer to your Certificate of Coverage for specific
terms, conditions, exclusions, and limitations relating to our coverage.
Prior authorization requests are processed as soon as possible once all
information/documentation is received by CVS Caremark For requests that meet
predetermined clinical criteria, notification of approval will be communicated
to the physician and to the Member in writing. If prior authorization is denied,
written notification, including the reason for the denial, will be sent to the Member
and the prescribing physician. Participating physicians and Members have the
right to appeal a denial. Appeal instructions are provided with the written denial
notification.
eight Prior Authorization applies to all applicable generic equivalents of the brand-name
products listed in the following list.
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If you are initiating the request by phone, please • If authorization is not approved, you have the
follow the prompts and select the option to speak following choices:
to a customer service representative. Be sure to tell
— You may still have the prescription filled but
the representative who answers the phone that
you will pay the entire cost of the drug.
you are calling to request prior authorization for a
drug or to start the Non-formulary Consideration — You may ask your physician to prescribe
Process. an alternative drug that is covered by your
Prescription Drug Benefit.
• If authorization is approved, your prescription
will be filled and the appropriate copayment — You may initiate an appeal of the decision.
or coinsurance will be applied.
The following list of prescription medications requires prior authorization.5
Classification Product Name (s)
Antifungal Agents • Lamisil tablets
• Sporanox
Cardiovascular Vasodilators • Adcirca • Tracleer
• Letairis • Tyvaso
• Revatio • Ventavis
Chelating Agent • Exjade
Erythroid Stimulants • Aranesp • Procrit
• Epogen
Growth Hormones All products, examples include:
• Genotropin • Omnitrope
• Humatrope • Saizen
• Increlex • Serostim
• Norditropin • Tev-tropin
• Nutropin, -AQ, -Depot
Injectable Biologicals • Cimzia • Humira
• Enbrel • Kineret
• Forteo
Miscellaneous Agents • Egrifta • Somatuline Depot
• Incivek • Sylatron
• Mozobil • Victrelis
• Pradaxa • Xenazine
• Pulmicort Respules (> age 12) • Zytiga
• Ranexa
Multiple Sclerosis - Oral Agents • Ampyra • Gilenya
Narcolepsy Agents • Nuvigil • Xyrem
• Provigil
Topical Acne Products (> age 25) • Altinac • Retin-A Micro
• Avita • Tazorac
NOTE: Renova and Avage are benefit exclusions across all prescription drug plans
• Retin-A • Trefin -X
since their indications are considered cosmetic.
Weight Loss Drugs All products, examples include:
• Bontril • Ionamin
• Desoxyn • Tenuate
• Didrex • Xenical
Wound Healing Agents • Regranex
5
Current as of January 2012.
nine
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Enhanced Prior Authorization (step therapy)6
Certain medications are subject to enhanced prior authorization (or step therapy) due to health care
concerns and/or safety reasons. In order to have these medications covered under your prescription
drug benefit, you may be required to first try a formulary alternative or complete the authorization
process. To obtain authorization, your physician or pharmacist should call or fax a request with
supporting clinical information to CVS Caremark at 1-800-294-5979 (fax: 1-888-836-0730). You may
initiate an authorization by calling CVS Caremark at 1-800-585-5794, or by visiting the Web site at
capbluecross.com.
The following list of prescription medications requires enhanced prior authorization.7
Classification Product Name (s)
Aldosterone Antagonists (Brand-name) • Inspra
NOTE: For most conditions, generic spironolactone or eplerenone must be utilized before
receiving prior authorization for the medications in this program.
Alzheimer’s Disease Agents • Aricept/-ODT
• Exelon
NOTE: For most conditions, a generic cholinesterase inhibitor must be utilized before
• Razadyne/-ER
receiving prior authorization for the medications in this program.
Antidepressant Agents (Brand-name) • Aplenzin ER • Pexeva
• Cymbalta • Pristiq
NOTE: For most conditions, a generic antidepressant agent must be utilized before receiving
• Effexor XR • Prozac Weekly
prior authorization for the medications in this program.
• Emsam • Sarafem
• Lexapro • Viibryd
• Paxil • Wellbutrin/SR/XL
• Paxil CR • Zoloft
Antidiabetic Agents • Byetta
• Symlin
NOTE: For most conditions, one (1) oral diabetes drug must be utilized before receiving prior
• Victoza
authorization for Byetta and Victoza, metformin must be utilized before receiving prior
authorization for Januvia and Onglyza, and either one (1) oral diabetes drug or insulin must be
utilized before receiving prior authorization for Symlin.
Antidotes • Relistor
NOTE: For most conditions, concurrent use of a pain medication is required.
Anti-Inflammatory Agents • Celebrex
• Flector Patch
NOTE: For most conditions, two (2) generic non-steroidal anti-inflammatory drugs (NSAID)
must be utilized before receiving prior authorization for Celebrex and one generic NSAID for
Flector Patch.
Beta-Blockers • Bystolic
NOTE: For most conditions, a generic beta-blocker must be utilized before receiving prior
authorization for Bystolic
Cholesterol Lowering Agents All brand-name products, examples include:
NOTE: For most conditions, a generic statin must be utilized before receiving prior
• Altoprev • Lipitor
authorization for the medications in this program.
• Lescol/XL • Livalo
Injectable Biologicals • Simponi
NOTE: For most conditions, Enbrel or Humira must be utilized before receiving prior
authorization for the medications in this program.
Leukotriene Modifiers • Accolate • Zyflo, -CR
• Singulair
NOTE: For most conditions, a nasal steroid and an antihistamine must be utilized before
receiving prior authorization for the medications in this program.
ten
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Classification Product Name (s)
Migraine Therapy • Alsuma • Maxalt/-MLT
• Amerge • Relpax
NOTE: For most conditions, sumatriptan or naratriptan must be utilized before receiving prior
• Axert • Sumavel
authorization for medications in this program.
• Frova • Treximet
• Imitrex • Zomig/-ZMT
Miscellaneous Anticonvulsants • Banzel • Savella
• Lyrica • Vimpat
NOTE: For most conditions, gabapentin must be utilized before receiving prior authorization for
the medications in this program.
Miscellaneous Medications • Toviaz • Uloric
(overactive bladder) (gout)
Multiple Sclerosis Agents • Betaseron • Rebif
• Extavia
NOTE: For most conditions, Avonex or Copaxone must be utilized before receiving prior
authorization for the medications in this program. Avonex, Betaseron, Copaxone, or Rebif must
be utilized as concomitant therapy with Ampyra.
Nasal Corticosteroids All brand-name products, examples include:
NOTE: For most conditions, fluticasone or flunisolide nasal spray must be utilized before
• Beconase AQ • Omnaris
receiving prior authorization for the medications in this program.
• Nasacort • Rhinocort Aqua
• Nasonex • Veramyst
Non-Sedating Antihistamines • Clarinex • Xyzal
• Clarinex -D
NOTE: For most conditions, levocetirizine must be utilized before receiving prior authorization
for the medications in this program.
Osteoporosis Agents • Actonel • Fosamax
• Atelvia • Fosamax +D
NOTE: For most conditions, alendronate must be utilized before receiving prior authorization
• Boniva
for the medications in this program.
Proton Pump Inhibitors (PPI) LEVEL 1 LEVEL 2
• Aciphex • Dexilant
NOTE: A generic PPI (lansoprazole, omeprazole, or pantoprazole) does not require prior
• Nexium
authorization.
• Prevacid/-Solutabs
Level 1: A generic PPI must be utilized before receiving prior authorization for a Level 1 PPI.
• Prilosec
Level 2: A generic PPI + a Level 1 brand preferred PPI must be utilized before receiving prior
• Protonix
authorization for a Level 2 PPI.
• Zegerid
Renin-Angiotensin System Antagonists (Brand-name) All brand-name products, examples include:
NOTE: For most conditions, a generic ACE inhibitor /- combination or a generic ARB /- • Atacand/-HCT • Exforge/-HCT
combination must be utilized before receiving prior authorization for the medications in this • Avapro/Avalide • Micardis/-HCT
program. • Azor • Tekturna/-HCT
• Benicar/-HCT • Teveten/-HCT
• Cozaar/Hyzaar • Twynsta
• Diovan/-HCT • Valturna
• Edarbi
Sedatives/Hypnotics • Ambien, -CR • Sonata
• Lunesta
NOTE: For most conditions, zaleplon or zolpidem/-CR must be utilized before receiving prior
authorization for the medications in this program.
Short-Acting Fentanyl Products • Abstral • Fentora
• Actiq • Onsolis
NOTE: For most conditions, a long-acting narcotic agent must be used in combination with Actiq or
• Fentanyl citrate
Fentora .
Topical Acne Product • Aczone
NOTE: For most conditions, a topical anti-acne product must be utilized before receiving prior
authorization for Aczone.
6
This list is not intended to be a complete list of drug classifications and is subject to change. Some classifications of drugs may not be covered under
your prescription drug program. Please refer to your Certificate of Coverage for specific terms, conditions, exclusions, and limitations relating to our
coverage.
Prior authorization requests are processed as soon as possible once all information/documentation is received by CVS Caremark For requests that
meet predetermined clinical criteria, notification of approval will be communicated to the physician and to the Member in writing. If prior authorization
is denied, written notification, including the reason for the denial, will be sent to the Member and the prescribing physician. Participating physicians
and Members have the right to appeal a denial. Appeal instructions are provided with the written denial notification.
7
Current as of January 2012.
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focusing on your safety
Drug Quantity Management Program8
Quantity limits help to promote appropriate use of selected medications and enhance patient safety.
If your prescription is written for more than the allowed quantity, your prescription will be filled up to the
allowed quantity. You can easily identify these drugs on our formulary and Preferred Medication List as
they will have a QLL symbol next to them (refer to the Preferred Medication List on pages 5 – 7).
Your physician can direct Drug Quantity Management (DQM) override requests to CVS Caremark by
calling or faxing the request with supporting clinical information to 1-800-294-5979 (fax: 1-888-836-0730).
Classification Drug Name Retail Maximum Quantity Level
ANTIDEPRESSANT THERAPY • Celexa tablets • 30 tablets of 10mg, 40mg; 90 tablets of 20mg per 30-day period
• Effexor XR tablets • 30 tablets of 225mg; 60 tablets of 150mg; 90 tablets of 37.5mg,
(venlafaxine ER) 75mg per 30-day period
• Lexapro tablets • 30 tablets of 5mg, 10mg, 20mg per 30-day period
• Lexapro suspension • 3 bottles ( 720ml ) per 30-day period
• Paxil tablets • 30 tablets of 10mg, 20mg, 40mg; 60 tablets of 30mg
per 30-day period
• Paxil CR tablets • 30 tablets of 12.5mg, 25mg per 30-day period
• Pristiq tablets • 30 tablets of 50mg, 100mg per 30-day period
• Prozac capsules • 30 capsules of 10mg, 20mg per 30-day period
• Prozac Weekly • 4 capsules of 90mg per 30-day period
ANTIEMETIC THERAPY • Anzemet tablets • 5 tablets of 50mg, 100mg per prescription
(nausea/vomiting) • Emend capsules • 8 capsules of 40mg, 80mg; 4 capsules of 125mg; 4 packs
per prescription
• Kytril tablets • 8 tablets of 1mg per prescription
• Kytril suspension • 2 bottles (60ml) per prescription
• Sancuso patch • 2 patches per 30-day period
• Zofran/-ODT tablets, • 24 tablets of 4mg, 8mg; 4 tablets of 24mg per prescription
Zuplenz film
• Zofran suspension • 5 bottles (250ml) per prescription
ANTI-FLU THERAPY • Relenza inhalations • 1 kit per prescription; max of 2 prescriptions per year
• Tamiflu capsules • 10 capsules of 30mg, 45mg, 75mg per prescription; max of
2 prescriptions per year
• Tamiflu suspension • 1 bottle (75 ml) per prescription; max of 2 prescriptions per year
ANTI-HYPERTENSIVE THERAPY • Lotrel capsules • 30 capsules of 2.5/10mg, 5/10mg per 30-day period
(blood pressure) • Norvasc tablets • 30 tablets of 2.5mg, 5mg per 30-day period
• Tarka tablets • 30 tablets of 1/240mg, 2/180mg per 30-day period
BISPHOSPHONATE THERAPY • Actonel tablets • 4 tablets of 35mg; 2 tablets of 75mg per 28-day period
(osteoporosis) • Atelvia tablets • 4 tablets of 35mg per 28-day period
• Boniva tablets • 1 tablet of 150mg per 28-day period
• Fosamax tablets • 4 tablets of 35mg, 70mg per 28-day period
• Fosamax+D tablets • 4 tablets per 28-day period
CHOLESTEROL-LOWERING THERAPY • Altoprev tablets • 30 tablets of 20mg per 30-day period
• Crestor tablets • 30 tablets of 5mg, 10mg, 20mg, 40mg per 30-day period
• Lescol XL tablets • 30 tablets of 80mg per 30-day period
• Lipitor tablets • 30 tablets of 10mg, 20mg, 40mg per 30-day period
• Livalo tablets • 30 tablets of 1mg, 2mg, 4mg per 30-day period
• Mevacor tablets • 30 tablets of 20mg per 30-day period; 60 tablets of 40mg
• Pravachol tablets per 30-day period
• Simcor tablets • 30 tablets of 10mg, 20mg, 40mg per 30-day period
• Vytorin tablets • 60 tablets of 500/20mg, 750/20mg, 1,000/20mg per 30-day period
• Zocor tablets • 30 tablets of 10mg/10mg, 10mg/20mg, 10mg/40mg per 30-day period
• 30 tablets of 5mg, 10mg, 40mg per 30-day period
DISEASE MODIFYING • Cimzia • 8 injectables of 200mg per 30-day period
ANTI-RHEUMATIC DRUG (DMARD) INJECTABLE • Enbrel • 4 injectables of 50mg; 8 injectables of 25mg per day 30-day period
BIOLOGICALS • Humira • 2 injectables of 40mg per 30-day period
• Simponi • 1 injectable of 50mg per 30-day period
ERECTILE DYSFUNCTION THERAPY • Caverject injection Therapy class allows 6 units (any combination of products) per
• Cialis tablets 30-day supply
• Edex injection
• Levitra tablets
• Muse inserts
• Staxyn tablets
• Viagra tablets
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Classification Drug Name Retail Maximum Quantity Level
MIGRAINE THERAPY • Alsuma injection • 4 kits (8 autoinjectors) per prescription
• Amerge tablets • 9 tablets of 2.5mg; 20 tablets of 1mg per prescription
• Axert tablets • 8 tablets of 12.5mg; 18 tablets of 6.25mg per prescription
• Frova tablets • 9 tablets of 2.5mg per prescription
• Imitrex tablets • 9 tablets of 100mg; 18 tablets of 50mg; 36 tablets of 25mg
per prescription
• Imitrex nasal spray • 8 nasal sprays of 20mg; 32 of 5mg per prescription
• Imitrex injection • 4 kits (8 syringes or vials) per prescription
• Maxalt/-MLT tabs • 12 tablets of 10mg; 24 tablets of 5mg per prescription
• Migranal NS spray • 1 kit (8 ampules) per prescription
• Relpax tablets • 6 tablets of 40mg; 12 tablets of 20mg per prescription
• Stadol NS spray • 4 spray pumps of 2.5ml per prescription
• Sumavel injection • 4 kits (8 syringes or vials) per prescription
• Treximet tablets • 9 tablets per prescription
• Zomig tablets • 9 tablets of 5mg; 18 tablets of 2.5mg per prescription
• Zomig nasal spray • 8 nasal sprays of 5mg per prescription
NARCOTIC PAIN RELIEVER THERAPY • Abstral tablets • 120 tablets per 30-day period
• Actiq lozenges • 120 lozenges per 30-day period
• Avinza capsules • 60 capsules per 30-day period
• Butrans patch • 4 patches per 28-day period
• codeine with acetaminophen • 4500 mls of 12/120mg per 5ml soln per 30-day period
(e.g., TYLENOL w/CODEINE #2, 400 tablets of 15/300mg per 30-day period
3, and 4) 360 tablets of 30/300mg per 30-day period
180 tablets of 60/300mg, 30/650mg, and 60/650mg
per 30-day period
• codeine with aspirin • 360 tablets of 15/325mg and 30/325mg per 30-day period
180 tablets of 60/325mg per 30-day period
• Duragesic patches • 20 patches per 30-day period
• Fentora lozenges • 120 lozenges per 30-day period
• hydrocodone with • 400 tablets of 5/300mg, 7.5/300mg, and 10/300mg
acetaminophen per 30-day period
(e.g., LORCET, LORTAB, 360 tablets of 5/325mg 7.5/325mg, and 10/325mg
VICODIN) per 30-day period
300 tablets of 5/400mg, 7.5/400mg, and 10/400mg
per 30-day period
240 tablets of 2.5/500mg, 5/500mg, and 7.5/500mg
per 30-day period
180 tablets of 7.5/650mg, 10/500mg, 10/650mg, and10/660mg
per 30-day period
160 tablets of 7.5/750mg and 10/750mg per 30-day period
• hydrocodone with ibuprofen • 150 tablets or capsules per 30-day period
(e.g., VICOPROFEN)
• Kadian capsules • 60 capsules per 30-day period
• MS Contin tablets • 90 tablets per 30-day period
• Nucynta tablets • 360 tablets of 50mg; 240 tablets of 75mg; 180 tablets of 100mg
per 30-day period
• Onsolis soluble films • 120 films per 30-day period
• Opana ER tablets • 90 tablets per 30-day period
• oxycodone with • 400 tablets of 5/300mg and 10/300mg per 30-day period
acetaminophen 360 tablets of 2.5/325mg, 5/325mg, 7.5/325mg, and 10/325mg
(e.g., PERCOCET, ENDOCET, per 30-day period
ROXICET) 300 tablets of 5/400mg, 7.5/400mg, and 10/400mg
per 30-day period
240 tablets of 5/500mg, 7.5/300mg, 7.5/500mg, and 10/500mg
per 30-day period
180 tablets of 10/650mg per 30-day period
• oxycodone with aspirin • 360 tablets of 4.5/325mg per 30-day period
(e.g., PERCODAN tablets)
• oxycodone with ibuprofen • 120 tablets of 5/400mg per 30-day period
(e.g., COMBUNOX tablets)
• Oxycontin tablets • 90 tablets per 30-day period
• Ryzolt ER tablets • 30 tablets per 30-day period
• tramadol extended release • 90 tablets of 100mg per 30-day period
(e.g., ULTRAM ER) • 30 tablets of 200mg per 30-day period
• 30 tablets of 300mg per 30-day period
• Ultram/Ultracet, Rybix ODT • 240 tablets per 30-day period
NON-STEROIDAL
• Mobic tablets • 30 tablets of 7.5mg, 15mg per 30-day period
ANTI-INFLAMMATORY THERAPY
• Mobic suspension • 3 bottles (300ml) per 30-day period
PROTON PUMP INHIBITOR THERAPY • Aciphex tablets • 30 tablets/capsules per 30-day period
(stomach acid) • Dexilant capsules (all products in therapy class)
• Nexium capsules
• Prevacid
• Prilosec capsules
• Protonix tablets
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Classification Drug Name Retail Maximum Quantity Level
RESPIRATORY MEDICATIONS • Advair • 1 inhaler per 30-day period
(inhalers) • Alvesco (all products in therapy class)
• Asmanex
• Dulera
• Flovent/- HFA
• Pulmicort
• Qvar
• Symbicort
SEDATIVE/HYPNOTIC THERAPY • Ambien tablets Therapy class allows 30 units (any combination of products) per
(sleep aids) • Ambien CR tablets 30-day period.
• Lunesta tablets
• Sonata capsules
MISCELLANEOUS MEDICATIONS • Ampyra tablets • 60 tablets per 30-day period
• Estrogel • 1 pump (93g) per prescription (at mail, limit is 2 pumps
per prescription)
• Flonase nasal spray • 1 nasal spray per prescription
• Invega tablets • 60 tablets per 30-day period
• Lysteda tablets • 30 tablets per 5-day period
• Relistor injection • First prescription limited to 3 doses with therapy duration no longer
than 4 months
• Seroquel XR tablets • 60 tablets per 30-day period
• Veramyst nasal spray • 1 nasal spray per prescription
• Zyprexa tablets • 30 tablets of all strengths per 30-day period
• Zyprexa Zydis tablets • 30 tablets of 5mg, 10mg, 15mg, 20mg per 30-day period
8
This list is not intended to be a complete list of drug classifications and is subject to change. Some classifications of drugs may not be covered under
your prescription drug program. Please refer to your Certificate of Coverage for specific terms, conditions, exclusions, and limitations relating to our
coverage.
DQM override requests are processed as soon as possible once all information/documentation is received by CVS Caremark. For requests that meet
predetermined clinical criteria, notification of approval will be communicated to the physician and to the Member in writing. If DQM override request is
denied, written notification, including the reason for the denial, will be sent to the Member and the prescribing physician. Participating physicians and
Members have the right to appeal a denial. Appeal instructions are provided with the written denial notification.
Drug quantity level limits apply to all applicable generic equivalents of the brand-name products listed in this document.
Applicable mail service quantity levels are two to three times the retail quantity level limits, depending on the prescription drug benefit design
chosen by the Member or employer group.
Current as of January 2012.
• Mandatory Generic Substitution Program is when a generic drug is
substituted for a brand-name product. If a generic drug is available
Generic Substitution Program and is not substituted for a brand-name drug even if your doctor has
Generic substitution programs requested Brand necessary, you will be charged the brand-name
help to reduce the Member’s copayment or coinsurance plus the cost difference between the
out-of-pocket expenses and generic and brand-name medication.
help to contain the rising • Restrictive Generic Substitution Program allows your physician to
costs of providing prescription specify that a brand-name drug be dispensed by indicating “No
drug benefits. Capital Generic Substitution Permissible” on the written prescription. In this
BlueCross offers two types of case, you will only be charged the brand-name copayment or
generic substitution programs: coinsurance. But, if you request a brand-name drug when a generic
mandatory and restrictive. is available, you will be charged the brand-name copayment or
coinsurance plus the cost difference between the generic and brand-
name medication.
CuraScript®, Inc
Committed to providing affordable care, one patient at a time
Through a special arrangement with CuraScript, Inc., Capital BlueCross makes it easy for you to get the
patient care you deserve and the speciality medications (self-administered) you need to help manage
your unique health conditions.
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CuraScript®, Inc. The following medications are available through
CuraScript, Inc.:
Offering a broad range of services ACTIMMUNE* HUMIRA REBIF
ADCIRCA* HYCAMTIN* RECOMBINATE*
• A patient care coordinator who will work ADVATE* INCIVEK* REFACTO*
with you and your physician to answer AFINITOR* INCRELEX REPRONEX
ALFERON N* INFERGEN REVATIO*
questions, obtain prior authorizations, and
ALPHANATE* INNOHEP* REVLIMID
much more. Your patient care coordinator will
ALPHANINE* INTRON A RIBAPAK*
even contact you when it’s time to refill your
AMPYRA* IRESSA RIBASPHERE*
prescription. ARANESP KINERET RIBAVIRIN
• A complete specialty pharmacy that offers ARIXTRA* KOATE-DVI* ROFERON-A*
AVONEX KOGENATE FS* SABRIL*
many products and services which aren’t
BEBULIN* KUVAN* SAIZEN
usually available from your local retail
BENEFIX* LETAIRIS* SAMSCA*
pharmacy. You get the convenience of having BETASERON LEUKINE SANDOSTATIN*
your specialty medications delivered directly BRAVELLE LEUPROLIDE ACETATE SENSIPAR*
to your home at no additional cost. CAPRELSA* LOVENOX* SEROSTIM
CETROTIDE LUPRON, -DEPOT SIMPONI*
• Access to necessary supplies (like free
CHORIOINIC GONAD* LUVERIS* SYLATRON*
needles, syringes, and disposal containers CIMZIA* MENOPUR* SOMATULINE*
for used medical supplies) you need to COPAXONE MONARC-M* SOMAVERT*
administer your injectable medications. COPEGUS MONOCLATE-P* SPRYCEL
DDAVP MONONINE* STIMATE*
• You will also have access to detailed personal
EGRIFTA* MOZOBIL* SUTENT
instructions and educational materials to ELIGARD* NEULASTA SYNAREL*
ensure you get the training, education, ENBREL NEUMEGA TARCEVA
and support you need to administer your ENOXAPARIN* NEUPOGEN TARGRETIN*
medications. These services are offered at no EPOGEN NEXAVAR TASIGNA
additional cost to you. EXJADE* NORDITROPIN TEMODAR
EXTAVIA* NOVAREL TEV-TROPIN*
• Care management programs that help you FEIBA NF* NOVOSEVEN* THALOMID
achieve the best results from your prescribed FEIBA VH* NUTROPIN, -AQ TIKOSYN*
drug therapy. These programs are designed FIRMAGON* OCTREOTIDE* TOBI*
to help you get the most benefit from your FOLLISTIM, -AQ OMNITROPE* TRACLEER*
specialty medications FONDAPARINUX* ONDANSETRON* TYKERB
FORTEO ORENCIA* VICTRELIS*
For more information about CuraScript, Inc. and FRAGMIN* OVIDREL VIVAGLOBIN*
the services available to you, please contact a FUZEON PEGASYS VOTRIENT*
CuraScript, Inc. representative at 1-877-595-3707, GANIRELEX ACETATE PEGINTRON WILATE*
Monday thru Friday, 8 a.m. to 9 p.m. and Saturday GENOTROPIN PREGNYL XELODA
GILENYA* PROCRIT XENAZINE*
9 a.m. to 1 p.m. (fax: 1-888-773-7386).
GLEEVEC* PROFASI HD* XYNTHA*
Visit the CuraScript, Inc. Web site at curascript GONAL-F, -RFF PROFILNINE SD* ZOFRAN*
.com to learn more about CuraScript, Inc. and HELIXATE FS* PROMACTA* ZOLADEX*
the products and services they offer. HEMOFIL-M* PROPLEX T* ZOLINZA
HIZENTRA* PULMOZYME* ZORBTIVE
Please refer to your certificate of coverage HUMATE-P* RAPTIVA ZYTIGA*
for specific terms, conditions, exclusions, and HUMATROPE REBETOL
limitations relative to our coverage. Note: Bold medications are available exclusively through CuraScript,
Inc. Medications with an asterisk (*) may also be obtained at
network pharmacies.
Current as of January 2012.
On behalf of Capital BlueCross, CuraScript®, Inc. assists in the delivery
of specialty medications directly to our Members. CuraScript is an
independent company. fi fteen
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Capital BlueCross
Pharmacy Network
9
As a Capital BlueCross Member you have access
to the CVS Caremark National Pharmacy Network.
This network provides access to many chain and
independent pharmacies nationwide, with convenient
locations in the Capital BlueCross service area and
across the country. Mail service is provided by the
CVS Caremark Mail Service Pharmacy and specialty
medications are available through CuraScript.10
To find out if your pharmacy participates, you can:
• Check with the pharmacy.
• Use the pharmacy locator tool on the Web site. You
can link to the pharmacy locator from the Capital
BlueCross Web site.
• Contact CVS Caremark Member Services at
1-800-585-5794.
9
This list is not intended to be a complete list of Capital BlueCross participating
pharmacies. This list of network pharmacies is subject to change.
sixteen 10
Pharmacy participation is dependent on your specific prescription drug
benefit. Please refer to your Certificate of Coverage for more information.
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A&P Fagen Pharmacy Lewis Drug Safeway Pharmacy
A-1 Discount Pharmacy Family Drug Store Lewis Family Drug Sam’s Club
Lowes Marketplace
Acme Pharmacy Family Fare Pharmacy Schnucks Pharmacy
Pharmacy
Agnesian Pharmacy Farm Fresh Pharmacy Marsh Drug Store Scolari’s Pharmacy
AHF Pharmacy Food 4 Less Pharmacy Martin’s Pharmacy Scott’s Pharmacy
American Pharmaceutical
Food City Pharmacy Med Fast Pharmacy Shop ‘N Save
Svcs
Aurora Pharmacy Food Lion Pharmacy Medicap Pharmacy Shopko Pharmacy
Baker’s Pharmacy Food World Medicine Shoppe Shoppers Pharmacy
Bel Air Pharmacy Fred Meyer Pharmacy Medistat Pharmacy Srvcs Shoprite
Biggs Fruth Pharmacy Medstar Pharmacy Shurfine Pharmacy
Bi-Lo Pharmacy Fry’s Pharmacy Navarro Discount Pharmacy Smith’s Pharmacy
Blount Discount Pharmacy Genuardi’s Pharmacy NCS Healthcare Stop & Shop
Brookshire Brothers Gerbes Pharmacy Neighborcare Sunscript Pharmacy
Bruno’s Giant Discount Drug North Florida Pharmacy Super Fresh
Busch’s Pharmacy Giant Eagle Pharmacy Omnicare Pharmacy Superior Pharmacy
Carr - Gottstein Foods Giant Pharmacy P & C Food And Pharmacy Target Pharmacy
Cash Wise Pharmacy Glens Pharmacy Pamida Pharmacy Thrifty White Drug
City Market Happy Harry’s Inc. Park Nicollet Pharmacy Tom Thumb Pharmacy
Coborn’s Pharmacy Harris Teeter Pharmacy Pathmark Pharmacy Tops Pharmacy
Costco Pharmacy HEB Pavilions Pharmacy United Pharmacy
Cub Pharmacy Homeland Pharmacy Payless Pharmacy Village Pharmacy
CVS Hometown Pharmacy Pharmerica Vons Pharmacy
D&W Pharmacy Hy-Vee Price Chopper Pharmacy Waldbaum’s
IHC Health Center
Dahl’s Pharmacy QFC Pharmacy Walgreens
Pharmacy
Dean Pharmacy King Kullen Pharmacy Quality Pharmacy Wal-Mart
Dierberg Pharmacy King Soopers Pharmacy Raley’s Drug Center Wegmans Pharmacy
Dillon Pharmacy Klingensmith’s Drug Ralph’s Pharmacy Weis Pharmacy
Discount Drug Mart Kmart Pharmacy Randalls Pharmacy White Drug
Doc’s Drugs Kopp Drug Recept Pharmacy Wiley’s Pharmacy
Dominicks Pharmacy Kroger Pharmacy Rite Aid Williams Apothecary
Duane Reade Lawrence Bros Pharmacy Rosauers Pharmacy Winn-Dixie Pharmacy
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The information contained in this document was current at the time of printing and is subject to change. It is not intended to substitute your physician’s independent
medical judgement based on your specific needs. Please call the customer service number on your ID card for the most current formulary information and your
expected out-of-pocket expenses.
On behalf of Capital BlueCross, CVS Caremark assists in the administration of our prescription drug program. CVS Caremark is an independent pharmacy benefit
manager.
On behalf of Capital BlueCross, CuraScript®, Inc. assists in the delivery of specialty medications directly to our Members. CuraScript is an independent company.
Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company® and Keystone Health
Plan® Central. Independent licensees of the Blue Cross and Blue Shield Association. Communications issued by Capital BlueCross in its capacity as administrator of
programs and provider relations for all companies.
NF-681 (12/2011)
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