2016 Maintenance Drug List

Maintenance Drug List
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.
If you are enrolled in our Maintenance Choice plans, the drugs are noted with an asterisk (*) in the list
below. You may have a plan for Mandatory or Voluntary Maintenance Choice.
 For Mandatory Maintenance Choice, you have a grace period for two standard prescription
fulfillments of a one-month supply before you must use CVS mail or visit a CVS pharmacy to get a
90-day supply of maintenance drugs.
 Voluntary Maintenance Choice does not offer a grace period for prescription fulfillments. You
may continue to receive a one-month supply of maintenance drugs indefinitely at any
participating network pharmacy and an option to get a 90-day supply of maintenance drugs
through CVS mail or a CVS 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.
*Indicates a Maintenance Choice drug
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.
5-AMINOSALICYLIC ACID
ALDACTONE
ABILIFY*
ABILIFY DISCMELT
ABILIFY MAINTENA
alendronate*
alfuzosin hcl er
allopurinol*
ALORA
alosetron
ALPHAGAN-P
alprazolam tab
alprazolam tab ODT
alprazolam XR tab
ALTACE
altavera
ALTOPREV
ALVESCO*
alyacen
AMARYL
amethia
amethia lo
amethyst
amiloride*
aminophylline*
amiodarone hcl
acarbose*
ACCOLATE
ACCUPRIL
ACCURETIC
acebutolol*
ACEON
acetaminophen/codeine
elixir
acetaminophen/codeine
solution
acetaminophen/codeine tab
acetazolamide er
ACIPHEX*
ACTEMRA
ACTIGALL
ACTIVELLA
ACTONEL*
ACTONEL WITH CALCIUM
ACTOPLUS MET
ACTOPLUS MET XR
ACTOS
acyclovir
ADALAT CC
ADRENACLICK
ADVAIR DISKUS
ADVAIR HFA
ADVICOR*
AEROSPAN*
afeditab cr
AFREZZA
AGGRENOX*
AGRYLIN
albuterol
albuterol/ipratropium
ALDACTAZIDE
AMITIZA*
amlodipine*
amlodipine /atorvastatin*
amlodipine/hctz*
amlodipine /valsartan*
amlodipine/benazepril
amlodipine/valsartan/hctz*
AMPYRA
AMTURNIDE*
anagrelide*
ANAPROX
ANAPROX DS
anastrozole*
android
ANDROXY
ANGELIQ
ANORO ELLIPTA*
ANTARA*
APAP-CAFFEIN CAP
DIHYDROC
APIDRA
APIDRA SOLOSTAR
APLENZIN*
apri
APRISO
APTIOM*
aranelle
ARAVA
ARCAPTA NEOHALER
ARICEPT
ARIMIDEX
aripiprazole
ARISTADA
ARMOUR THYROID
ARNUITY ELLIPTA*
AROMASIN
ASACOL HD
ashlyna
ASMANEX*
ASMANEX HFA
aspirin/caffeine/butalbital/co
deine capsule
aspirin/codeine tab
aspirin/dipyridamole
ASTELIN
ASTEPRO
ASTEPRO NASL SPRAY
ATACAND
ATACAND HCT
ATELVIA
atenolol*
atenolol/chlorthalidone*
ATIVAN TAB
atorvastatin*
ATROVENT HFA
AUBAGIO
2
*Indicates a Maintenance Choice drug
AURYXIA*
AUVI-Q
AVALIDE
AVANDAMET*
AVANDARYL*
AVANDIA*
AVAPRO
aviane
AVODART*
AVONEX
AXID
AZASAN
azathioprine*
azelastine
AZILECT
AZOPT*
AZOR*
AZULFIDINE
AZULFIDINE EN-TABS
azurette
balsalazide disodium
balziva
BANZEL
BECLOMETHASONE
DIPROPIONATE INHAL AERO
BECLOMETHASONE
DIPROPIONATE MONOHYD
NASAL INHAL 0.084%
BECONASE AQ
benazepril*
benazepril /hctz*
BENICAR
BENICAR HCT*
benztropine mesylate
BETAGAN
BETAPACE
BETAPACE AF
BETASERON
betaxolol hcl
BETHKIS
BETIMOL
BETOPTIC-S
BEYAZ*
BIDIL*
bimatoprost*
BINOSTO*
bisoprolol*
bisoprolol/hctz*
BONIVA
BREO ELLIPTA*
BREVICON
briellyn
BRILINTA*
brimonidine*
BRINTELLIX*
BRISDELLE*
bromocriptine*
BROVANA*
budesonide
bumetanide
bupropion*
bupropion er
buspirone
butalbital/apap/caffeine
capsule w/codeine
butalbital/asa/caffeine cap
butalbital/asa/caffeine tab
butorphanol spray nasal
BYDUREON*
BYETTA*
BYSTOLIC*
CADUET
CALAN
CALAN SR
calcitonin salmon
calcitriol*
camila
camrese
camrese lo
CANASA
candesartan*
candesartan/hctz*
CAPITAL/COD SUSPENSION
captopril*
CARAFATE
carbamazepine*
carbamazepine er
CARBATROL
carbidopa*
carbidopa/levodopa*
carbidopa/levodopa/entacap
one*
CARDENE
CARDENE SR
CARDIOQUIN
CARDIZEM
CARDURA
CARNITOR
carteolol*
cartia xt
carvedilol*
CATAFLAM
CATAPRES
CATAPRES-TTS
captopril/hctz
carbachol*
caziant
CELEBREX
celecoxib
CELEXA
CELONTIN*
CENESTIN*
cesia
cetirizine
cevimeline*
chlordiazepoxide cap
chlorothiazide
chlorpropamide*
chlorthalidone*
cholestyramine*
cholestyramine light
cilostazol*
cimetidine*
CIMZIA
3
*Indicates a Maintenance Choice drug
citalopram*
CLARINEX*
clidinium plus
CLIMARA
CUVPOSA*
cyclafem
cyclandelate
CYCLESSA
CLIMARA PRO*
clonazepam
clonidine*
clonidine er*
clonidine/chlorthalidone*
clopidogrel*
clorpres
COLAZAL
COLESTID
colestipol hcl
CYCLOSET*
cyclosporine modified
CYMBALTA
cyred
CYTOMEL
CYTOTEC
CYTOVENE
DALIRESP*
dasetta
DAYPRO
daysee
deblitane
deltasone
delyla
DELZICOL
DEMADEX
DEPAKENE
DEPAKOTE
DEPAKOTE ER
DEPAKOTE SPRINKLES
DEPO-PROVERA
DEPO-SUBQ PROVERA 104
DESOGEN
COMBIGAN*
COMBIPATCH*
COMBIVENT
COMBIVENT RESPIMAT
COMBIVIR
COMTAN
conjugated estrogens
CONZIP CAP
COPAXONE
CORDARONE
COREG
COREG CR
CORGARD
CORLANOR*
CORZIDE
COSENTYX
COSOPT
COSOPT PF
COUMADIN
covaryx
covaryx hs
COZAAR
CREON*
CRESTOR*
CRIXIVAN
cromolyn sodium
cryselle-28
desloratidine*
desogestrel/ethinyl estra
DESVENLAFAXINE ER
DETROL
DETROL LA
DEXILANT*
DIABETA
DIABETIC SUPPLIE
DIAMOX SEQUELS
diazepam concentrate
diazepam soln
diazepam tab
diclofenac
digitek
digox
digoxin
DIHYDROCOD/ CAP
ASA/CAFF
DILACOR XR
DILANTIN
DILANTIN INFATABS
diltiazem*
diltiazem cd
diltiazem er
diltzac
DIOVAN
DIOVAN HCT
DIPENTUM*
di-phen
dipyridamole*
disopyramide*
DITROPAN XL
DIURIL
divalproex sodium
DIVIGEL
DOLAGESIC CAP
donepezil*
dorzolamide*
dorzolamide/timolol*
doxazosin
drospirenone/ethinyl estr
DUAVEE*
DUETACT
DULERA*
duloxetine*
DUONEB
DURLAZA
dutasteride
DUTOPROL
DYAZIDE
DYLOJECT
DYRENIUM*
EC-NAPROSYN
EDARBI*
EDARBYCLOR*
4
*Indicates a Maintenance Choice drug
EDECRIN
eemt
eemt hs
EFFEXOR XR
EFFIENT*
ELDEPRYL
ELESTRIN
elinest
ELIPHOS
ELIQUIS
ELIXOPHYLLIN
emoquette
EMSAM
ENABLEX*
enalapril*
enalapril/hctz*
ENBREL
ENJUVIA*
enpresse-28
enskyce
entacapone*
ENTRESTO*
ENVARSUS XR
EPIPEN
EPIPEN-JR
EPISNAP
epitol
EPIVIR
EPIVIR HBV
eplerenone
eprosartan mesylate
EQUAGESIC TAB
EQUETRO*
ergoloid mesylates*
errin
escitalopram oxalate
esomeprazole magnesium
esomeprazole sodium
ESOMEPRAZOLE
STRONTIUM*
estarylla
esterified estrogens/meth
ESTRACE
estradiol*
estradiol estropipate*
estradiol gel*
estradiol transdermal*
estradiol/norethindrone
ESTRASORB
ESTRING*
ESTROGEL
estropipate
ESTROSTEP FE
ethinyl estradioldesogestrel*
ethinyl estradioldrospirenone*
ethinyl estradiol -ethynodiol*
ethinyl estradiollevonorgestrel*
ethinyl estradiolnorethindrone*
ethinyl estradiolnorgestimate*
ethinyl estradiol- norgestrel*
ethinyl estradiolnorelgestromin
ethosuximide*
etodolac
etodolac er
EVAMIST*
EVISTA
EVOXAC
EXELON
exemestane*
EXFORGE
EXFORGE HCT
EXTAVIA
FALESSA*
falmina
famciclovir
famotidine*
FAMVIR
FARESTON*
FARXIGA*
felbamate*
FELBATOL
FELDENE
felodipine er
FEMARA
FEMCON FE
FEMHRT*
FEMRING
fenofibrate
FENOGLIDE
fenoprofen
FETZIMA*
FIBRICOR
finasteride*
FIORICET/COD CAP APAP
FIORINAL CAP
FIORINAL/COD CAP
flavoxate hcl
flecainide acetate
FLOMAX
FLONASE
FLOVENT DISKUS
FLOVENT HFA
flunisolide
fluoxetine*
fluoxymesterone
flurbiprofen
fluticasone propionate
fluvastatin
fluvastatin er
fluvoxamine*
fluvoxamine er
FORADIL AEROLIZER
FORFIVO XL
FORTAMET
FORTICAL
FOSAMAX
FOSAMAX PLUS D*
fosinopril*
5
*Indicates a Maintenance Choice drug
fosinopril/hctz*
FOSRENOL*
furosemide
gabapentin*
GABITRIL*
galantamine*
galantamine er
ganciclovir
GASTROCROM
GELNIQUE
gemfibrozil*
GENERESS FE
GEODON
gianvi
GIAZO
gildagia
gildess
gildess 24 fe
GILENYA
glatopa
glimepiride*
glipizide*
glipizide er
glipizide/metformin hcl
GLUCOPHAGE
GLUCOPHAGE XR
GLUCOTROL
GLUCOTROL XL
GLUCOVANCE
GLUMETZA
glyburide*
glyburide/metformin*
glycron
GLYNASE
GLYSET*
GLYXAMBI*
GRALISE
guanabenz acetate
guanfacine*
guanfacine er*
guanfacine gynodiol
hctz/triamterene
heather
HEPSERA
HIVID
HORIZANT*
HUMALOG
HUMIRA
HUMULIN
hydralazine*
hydralazine/hctz
hydralazine/reserpine/hctz
hydrochlorothiazide*
hydrochlorothiazide/reserpin
e
HYDRODIURIL
hydroflumethiazide
hydroflumethiazide/reserpin
e
HYZAAR
ibandronate sodium
ibuprofen
IMDUR
IMURAN
INCRUSE ELLIPTA*
indapamide
INDERAL LA
INDERAL XL
indomethacin
INNOPRAN XL
INSPRA
introvale
INTUNIV
INVEGA*
INVIRASE
INVOKAMET*
INVOKANA*
ipratropium bromide*
ipratropium
bromide/albuterol*
irbesartan*
irbesartan/hctz*
IRENKA
ISOPTIN SR
ISOPTO CARPINE
ISORDIL
isosorbide dinitrate
isosorbide mononitrate
isoxsuprine hcl
isradipine*
ISTALOL
JALYN*
JANUMET*
JANUMET XR
JANUVIA*
JARDIANCE*
jencycla
JENTADUETO*
jinteli
jolessa
jolivette
juleber
junel
junel fe
KALETRA
KAPVAY
kariva
KAZANO*
kelnor 1/35
KEPPRA
KEPPRA XR
KERLONE
ketoprofen
ketoprofen er
KHEDEZLA
KINERET
KITABIS PAK
KLONOPIN
klor-con
KOMBIGLYZE XR*
kurvelo
labetalol hcl
LAMICTAL
LAMICTAL ODT
6
*Indicates a Maintenance Choice drug
LAMICTAL XR
lamotrigine*
lamotrigine chewable
lamotrigine er
lamotrigine odt
LANOXICAPS
LANOXIN
lansoprazole*
lansoprazole odt
LANTUS
LANTUS SOLOSTAR
larin
larin 24 fe
larin fe
LASIX
latanoprost*
LATUDA*
layolis fe
leena
leflunomide*
LESCOL
LESCOL XL*
lessina
letrozole*
levalbuterol
levocetirizine*
LEVATOL
LEVEMIR
LEVLEN
LEVLEN
levobunolol*
levodopa
levonest
levonorgestrel and ethinyl
levora
levothyroxine*
levoxyl
LEXAPRO
LIALDA
LIBRITABS TAB
LINZESS*
liothyronine*
LIPITOR
LIPOFEN
LOXITANE
l-thyroxine
LUFYLLIN
LIPTRUZET*
lisinopril*
lisinopril/hctz*
LITHIUM*
LITHIUM CARBONATE
LITHIUM CITRATE
LITHOBID
LUMIGAN*
lutera
LUVOX CR
LYRICA
lyza
marlissa
MARPLAN
matzim la
MAVIK
MAXZIDE
meclofen sod cap
meclofenamate sodium
medroxyprogesterone
acetate
meloxicam
memantine hcl
MENEST*
MENOSTAR
MESALAMINE
metaproterenol sulfate
LIVALO*
LO LOESTRIN FE
LO MINASTRIN FE
LO/OVRAL
LO/OVRAL-28
LODOSYN
LOESTRIN
LOESTRIN
LOESTRIN 24 FE
LOESTRIN FE
LOFIBRA
lomedia 24 fe
LOPID
lopreeza
LOPRESSOR
lorazepam concentrate
lorazepam tab
LORCET PLUS TAB
LORTAB
loryna
losartan*
losartan/hctz*
LOSEASONIQUE
LOTENSIN
LOTENSIN HCT
LOTREL
LOTRONEX*
lovastatin*
LOVAZA*
low-ogestrel
loxapine*
metformin*
metformin hcl er
methazolamide*
methimazole
METHITEST
methotrexate
methyclothiazide
methyldopa*
methyldopa/chlorothiazide
methyldopa/hctz*
methyltesterone/esterified
methyltestosterone
metipranolol*
metolazone
metoprolol*
metoprolol/hctz*
MEVACOR
mexiletine*
7
*Indicates a Maintenance Choice drug
MIACALCIN
MIACALCIN NASAL SPRAY
MICARDIS
MICARDIS HCT
microgestin
microgestin fe
MICRO-K
MICRO-K EXTENCAPS
MICROZIDE
mimvey
mimvey lo
MINASTRIN 24 FE
MINIPRESS
minitran
MINIVELLE
minoxidil*
MIRAPEX
MIRAPEX ER
MIRCETTE
mirtazapine*
mirtazapine odt
misoprostol
MOBIC
modafinil
MODICON
moexipril*
moexipril/hctz*
mono-linyah
mononessa
MONOPRIL
montelukast*
MULTAQ*
MYRBETRIQ*
MYSOLINE
myzilra
nabumetone
nadolol*
nadolol/bendroflumethiazide
*
NALFON
NAMENDA*
NAMENDA XR
NAMZARIC*
NAPRELAN
NAPROSYN
naproxen
NARDIL
NASACORT AQ
NASCOBAL*
NASONEX
NATAZIA*
nateglinide*
necon
nefazodone*
NEPTAZANE
NESINA*
NEUPRO*
NEURONTIN
NEXIUM*
NIASPAN ER
nicardipine hcl
nifediac cc
nifedical xl
nifedipine*
nifedipine er
nikki
NIRAVAM TAB
nisoldipine*
nisoldipine er
NITRO-BID
NITRO-DUR
nitroglycerin oin 2%
nitroglycerin transdermal
NITROLINGUAL
NITROMIST
NITRONAL
NITROSTAT
nitro-time
nizatidine*
nora-be
NORCO TAB
nore/eth est chew
norethindrone
norethindrone acetate/eth
norethindrone/ethinyl est
norgestimate/ethinyl estr
norgestrel/ethinyl estrad
NORINYL
norlyroc
NORPACE
NORPACE CR
NOR-QD
nortrel
NORVASC
NORVIR
NOVOLIN
NOVOLOG
NUEDEXTA*
NUVARING*
ocella
ogestrel
olanzapine*
olanzapine odt
olanzapine/fluoxetine*
OLEPTRO*
omega-3-acid ethyl esters
omeprazole*
omeprazole/sod
bicarbonate*
OMNARIS
ONGLYZA*
ORALAIR
ORAP*
ORENCIA
orsythia
ORTHO EVRA
ORTHO TRI-CYCLEN
ORTHO TRI-CYCLEN LO
ORTHO-CEPT
ORTHO-CYCLEN
ortho-est tab
ORTHO-NOVUM
OSENI*
8
*Indicates a Maintenance Choice drug
OSPHENA
OTEZLA
OTREXUP
OVCON
oxaprozin
oxazepam cap
oxcarbazepine*
OXTELLAR XR
oxybutynin*
OXYTROL*
pacerone
paliperidone er
pancreatin 10
PANCREAZE*
pancrelipase*
pantoprazole*
PARCOPA
PARLODEL
PARNATE
paroxetine er
paroxetine hcl
PAXIL
PAXIL CR
PEGANONE*
pemoline
PENTASA
PENTAZ/NALOX TAB
pentoxifylline er
PEPCID
PERFOROMIST
pergolide mesylate
perindopril erbumine
PERSANTINE
PERTZYE
PEXEVA
phenelzine sulfate
phenobarbital
PHENYTEK
phenytoin
phenytoin infatabs
philith
PHOSLO
PHOSLYRA
PHOSPHOLINE IODIDE
pilocarpine*
pimozide
pimtrea
pindolol*
pioglitazone*
pioglitazone hcl-glimepir*
pioglitazone/metformin*
pirmella
piroxicam
PLAQUENIL
PLAVIX
PLEGRIDY
PLENDIL
PLETAL
portia-28
potassium chloride
PRADAXA
pramipexole*
PRANDIMET*
PRANDIN
PRAVACHOL
pravastatin sodium
prazosin*
PRECOSE
prednisone
PREFEST
PREMARIN*
PREMPHASE
PREMPRO*
prenatal 1+1
prenatal care
PRESTALIA*
PREVACID
PREVACID NAPRAPAC
PREVACID SOLUTAB
prevalite
previfem
PREZISTA
PRILOSEC
primidone*
PRINIVIL
PRISTIQ*
PROAIR RESPICLICK
probenecid/colchicine*
procainamide hcl
PROCARDIA
PROCARDIA XL
PROGRAF
propafenone*
propranolol hcl
propranolol/hctz*
propylthiouracil
PROSCAR
PROTONIX
PROVENTIL
PROVIGIL
PROZAC
PULMICORT FLEXHALER
PULMOZYME*
QNASL
QUARTETTE
quasense
QUDEXY XR
QUESTRAN
QUESTRAN LIGHT
quetiapine fumarate
quinapril*
quinapril/hctz*
quinidine gluconate*
QVAR*
rabeprazole sodium
raloxifene*
ramipril*
RANEXA*
ranitidine*
RAPAFLO*
RAPAMUNE
RASUVO
rauwolfia/bendroflumethia
9
*Indicates a Maintenance Choice drug
RAYOS
RAZADYNE
RAZADYNE ER
REBIF
reclipsen
REGLAN
REMERON
REMERON SOLTAB
REMINYL
RENAGEL*
RENVELA*
repaglinide*
REPATHA
REQUIP
REQUIP XL
RESCRIPTOR
RESCULA*
reserpine*
reserpine tab 0.1 mg
reserpine/chlorothiazide
reserpine/hctz
reserpine/hydralazine/hctz
RESTASIS
RETROVIR
REXULTI*
RHEUMATREX*
RHINOCORT AQUA
RIDAURA*
RILUTEK
riluzole*
RIOMET
risedronate*
RISPERDAL
RISPERDAL M-TAB
risperidone*
risperidone m-tab
risperidone odt
rivastigmine*
rivastigmine transdermal
ROCALTROL
ropinirole*
ropinirole er
ROWASA
ROZEREM
RYTARY*
RYTHMOL
RYTHMOL SR
SAFYRAL*
SALAGEN
SANCTURA
SANCTURA XR
SARAFEM
SAVELLA*
SAXENDA
SEASONIQUE
SECTRAL
selegiline
SEREVENT DISKUS
SEROQUEL
SEROQUEL XR*
sertraline hcl
setlakin
sevelamer carbonate
sharobel
SIMBRINZA*
SIMCOR*
SIMPONI
SIMPONI ARIA
simvastatin*
SINEMET
SINEMET CR
SINGULAIR
SITAVIG
solia
SOLTAMOX
sorine
sotalol hcl
SOTYLIZE
SPIRIVA HANDIHALER
SPIRIVA RESPIMAT
spironolactone*
spironolactone w/hctz*
sprintec
sronyx
STAGESIC-10 TAB
STALEVO
STARLIX
STAVZOR
STELARA
STIOLTO RESPIMAT*
STRATTERA*
STRIVERDI RESPIMAT
SUCRAID*
sucralfate*
SULAR
sulfadiazine
sulfasalazine*
sulfazine
sulfazine ec
sulindac
SUSTIVA
syeda
SYMBICORT*
SYMBYAX
SYMLIN*
SYNALGOS-DC CAP
SYNAPRYN SUSPENSION
SYNJARDY
SYNTHROID
tamoxifen*
tamsulosin hcl
TANZEUM*
TAPAZOLE
tarina fe 1/20
TARKA
TASMAR*
taztia xt
TECFIDERA
TEGRETOL
TEGRETOL-XR
TEKAMLO*
TEKTURNA*
TEKTURNA HCT*
10
*Indicates a Maintenance Choice drug
telmisartan*
telmisartan/amlodipine*
telmisartan/hctz*
TENEX
TENORETIC
TENORMIN
terazosin hcl
terbutaline sulfate
TESTOST CYP MDV
TESTOST ENAN MDV
TESTRED
TEVETEN*
TEVETEN HCT*
THEO-24
theochron
theophylline*
thiothixene*
THYROLAR*
tiagabine*
TIAZAC
ticlopidine*
TIKOSYN
tilia fe
timolol maleate
TIMOPTIC
TIMOPTIC-XE
TIROSINT
TOBI
tolazamide*
tolbutamide*
tolcapone tab 100mg
tolmetin sodium
tolterodine tartrate
tolterodine tartrate er
TOPAMAX
TOPAMAX SPRINKLE
topiragen
topiramate*
topiramate er*
TOPROL XL
torsemide
TOUJEO SOLOSTAR
TOVIAZ*
TRADJENTA*
tramadol TAB
tramadol cap ER
tramadol/apap tab
TRANDATE
trandolapril*
trandolapril/verapamil hc
TRANXENE T TAB
tranylcypromine sulfate
TRAVATAN Z
travoprost
trazodone*
TREZIX CAP
triamterene/hctz*
TRIBENZOR*
TRICOR
tri-estarylla
TRIGLIDE
ULTRACET TAB
ULTRAM ER TAB
ULTRAM TAB
ULTRESA
UNIRETIC
unithroid
UNIVASC
UROXATRAL
URSO
URSO FORTE
ursodiol*
VAGIFEM
valacyclovir hcl
VALCYTE
VALIUM TAB
valproic acid*
valsartan*
valsartan hctz*
VALTREX
VALTURNA
trihexyphenidyl*
tri-legest fe
TRILEPTAL
tri-linyah
TRILIPIX
trinessa
TRI-NORINYL
TRIPHASIL
tri-previfem
tri-sprintec
trivora-28
TRIZIVIR
VASCEPA*
VASERETIC
VASOTEC
velivet
VELPHORO*
venlafaxine*
venlafaxine hcl er
VENTOLIN
VERAMYST
verapamil*
VERELAN
VERELAN PM
TROKENDI XR*
trospium chloride
VESICARE*
vestura
VICOPROFEN TAB
VICTOZA*
VIDEX
VIDEX EC
TRULICITY*
TRUSOPT
TUDORZA PRESSAIR
TWYNSTA
TYLENOL/COD TAB
TYZEKA
ULORIC*
VIIBRYD*
VIOKACE
viorele
11
*Indicates a Maintenance Choice drug
VIRACEPT
VIVELLE-DOT
VOLTAREN
VOSPIRE ER
vyfemla
VYTORIN*
warfarin sodium
WELCHOL*
WELLBUTRIN
WELLBUTRIN SR
WELLBUTRIN XL
wera
westhroid
wymzya fe
XALATAN
XANAX TAB
XANAX XR TAB
XARELTO
XELJANZ
XOPENEX
xulane
XYZAL
YASMIN 28
YAZ
zafirlukast*
ZANTAC
zarah
ZARONTIN
ZAROXOLYN
ZEBETA
ZEGERID
ZELAPAR
zenchent
zenchent fe
ZENPEP*
ZERIT
ZESTORETIC
ZESTRIL
XIGDUO XR*
ZETIA*
ZETONNA
ZIAC
zidovudine
ZIOPTAN*
ziprasidone*
ZIPSOR
ZOCOR
ZOLOFT
ZONEGRAN
zonisamide*
ZONTIVITY*
zovia
ZOVIRAX
ZYFLO*
ZYFLO CR
ZYLOPRIM
ZYPREXA
ZYPREXA ZYDIS
SUM2723-1P (11/15)
12
*Indicates a Maintenance Choice drug
MAINTENANCE MEDICATION EXCEPTION FORM
To initiate a maintenance medication exception authorization, please complete, review information and fax signed forms to 888-487-9257.
This fax machine is located in a secure location as required by 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
Yes
No
Does the prescriber intend to treat the member with the requested drug continuously over the
next 6 months?
Patient Information
First Name:
Last Name:
Home Phone Number:
Work Phone Number:
Home Address:
City:
State:
Date of Birth:
Allergies:
Insurance ID:
Group #:
3.
Physician Information
Physician Name:
Physician DEA#:
Address:
Office Contact Name:
NPI #:
City:
Phone Number:
State:
Fax Number:
Zip:
Primary Diagnosis
Primary ICD-9 (code):
Clinical Information
Drug & 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 form):
This maintenance medication exception authorization will be valid for five years.
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.
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.
Zip: