HealthyBlue Select Generics list
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HealthyBlue Select Generics $0 – Drug List for CDH Plans only Certain drugs are considered “generic preventive” by CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc.’s Pharmacy Management Team. As a HealthyBlue CDH member, the drugs listed below are not subject to your deductible and have a $0 copay. For the most up-to-date list, visit www.carefirst.com/hbselectgenerics. ANTIDEPRESSANT DRUGS (DEPRESSION) Drug Name Therapeutic Class Description AMITRIPT YLINE HCL TRICYCLIC ANTIDEPRESSANTS & REL. NON-SEL. RU-INHIB AMOX APINE TRICYCLIC ANTIDEPRESSANTS & REL. NON-SEL. RU-INHIB BUDEPRION SR NOREPINEPHRINE AND DOPAMINE REUPTAKE INHIB (NDRIS) BUDEPRION XL NOREPINEPHRINE AND DOPAMINE REUPTAKE INHIB (NDRIS) BUPROPION HCL NOREPINEPHRINE AND DOPAMINE REUPTAKE INHIB (NDRIS) BUPROPION HCL SR NOREPINEPHRINE AND DOPAMINE REUPTAKE INHIB (NDRIS) BUPROPION XL NOREPINEPHRINE AND DOPAMINE REUPTAKE INHIB (NDRIS) CHLORDIA ZEPOXIDE-AMITRIPT YLINE TRICYCLIC ANTIDEPRESSANT/BENZODIAZEPINE COMBINATNS CITALOPRAM SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) CITALOPRAM HBR SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) CLOMIPRAMINE HCL TRICYCLIC ANTIDEPRESSANTS & REL. NON-SEL. RU-INHIB DESIPR AMINE HCL TRICYCLIC ANTIDEPRESSANTS & REL. NON-SEL. RU-INHIB DESVENL AFA XINE SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS) DOXEPIN HCL TRICYCLIC ANTIDEPRESSANTS & REL. NON-SEL. RU-INHIB DULOXETINE SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS) ESCITALOPR AM OX AL ATE SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) FLUOXETINE DR SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) FLUOXETINE HCL SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) FLUVOX AMINE MALE ATE SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) IMIPRAMINE HCL TRICYCLIC ANTIDEPRESSANTS & REL. NON-SEL. RU-INHIB IMIPRAMINE PAMOATE TRICYCLIC ANTIDEPRESSANTS & REL. NON-SEL. RU-INHIB MAPROTILINE HCL TRICYCLIC ANTIDEPRESSANTS & REL. NON-SEL. RU-INHIB MIRTA ZAPINE ALPHA-2 RECEPTOR ANTAGONIST ANTIDEPRESSANTS NEFA ZODONE HCL SEROTONIN-2 ANTAGONIST/REUPTAKE INHIBITORS (SARIS) NORTRIPT YLINE HCL TRICYCLIC ANTIDEPRESSANTS & REL. NON-SEL. RU-INHIB PAROXETINE HCL SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) PERPHENA ZINE-AMITRIPT YLINE TRICYCLIC ANTIDEPRESSANT/PHENOTHIA ZINE COMBINATNS PHENELZINE SULFATE MAOIS - NON-SELECTIVE & IRREVERSIBLE PROTRIPT YLINE HCL TRICYCLIC ANTIDEPRESSANTS & REL. NON-SEL. RU-INHIB SELFEMR A SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) SERTRALINE HCL SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) TRANYLCYPROMINE SULFATE MAOIS - NON-SELECTIVE & IRREVERSIBLE HealthyBlue Select Generics $0 – Drug List for CDH Plans only ANTIDEPRESSANT DRUGS (DEPRESSION) Drug Name Therapeutic Class Description TRAZODONE HCL SEROTONIN-2 ANTAGONIST/REUPTAKE INHIBITORS (SARIS) VENL AFA XINE HCL SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS) VENL AFA XINE HCL ER SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS) ANTIHYPERTENSIVE DRUGS (HIGH BLOOD PRESSURE) Drug Name Therapeutic Class Description ACEBUTOLOL HCL BETA-ADRENERGIC BLOCKING AGENTS AFEDITAB CR CALCIUM CHANNEL BLOCKING AGENTS AMILORIDE HCL POTASSIUM SPARING DIURETICS AMILORIDE-HYDROCHLOROTHIA ZIDE POTASSIUM SPARING DIURETICS IN COMBINATION AMLODIPINE BESYL ATE CALCIUM CHANNEL BLOCKING AGENTS AMLODIPINE BESYL ATE-BENA ZEPRIL ACE INHIBITOR/C ALCIUM CHANNEL BLOCKER COMBINATION ATENOLOL BETA-ADRENERGIC BLOCKING AGENTS ATENOLOL-CHLORTHALIDONE BETA-ADRENERGIC BLOCKING AGENTS/THIAZIDE & REL ATED BENA ZEPRIL HCL ANTIHYPERTENSIVES, ACE INHIBITORS BENA ZEPRIL-HYDROCHLOROTHIA ZIDE ACE INHIBITOR/THIA ZIDE & THIA ZIDE-LIKE DIURETIC BETA XOLOL HCL BETA-ADRENERGIC BLOCKING AGENTS BISOPROLOL FUMARATE BETA-ADRENERGIC BLOCKING AGENTS BISOPROLOL-HYDROCHLOROTHIA ZIDE BETA-ADRENERGIC BLOCKING AGENTS/THIAZIDE & REL ATED BUMETANIDE LOOP DIURETICS C ANDESARTAN ANTIHYPERTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONIST C ANDESARTAN-HYDROCHLOROTHIA ZIDE ANGIOTENSIN RECEPTOR ANTAG./THIA ZIDE DIURETIC COMB C APTOPRIL ANTIHYPERTENSIVES, ACE INHIBITORS C APTOPRIL-HYDROCHLOROTHIAZIDE ACE INHIBITOR/THIA ZIDE & THIA ZIDE-LIKE DIURETIC C ARTIA XT CALCIUM CHANNEL BLOCKING AGENTS C ARVEDILOL ALPHA/BETA-ADRENERGIC BLOCKING AGENTS CHLOROTHIA ZIDE THIA ZIDE AND REL ATED DIURETICS CHLORTHALIDONE THIA ZIDE AND REL ATED DIURETICS CLONIDINE ANTIHYPERTENSIVES, SYMPATHOLY TIC CLONIDINE HCL ANTIHYPERTENSIVES, SYMPATHOLY TIC CLORPRES ANTIHYPERTENSIVES, SYMPATHOLY TIC DILT-CD CALCIUM CHANNEL BLOCKING AGENTS DILTIA XT CALCIUM CHANNEL BLOCKING AGENTS DILTIA ZEM 24HR ER CALCIUM CHANNEL BLOCKING AGENTS DILTIA ZEM ER CALCIUM CHANNEL BLOCKING AGENTS DILTIA ZEM HCL CALCIUM CHANNEL BLOCKING AGENTS DILT-XR CALCIUM CHANNEL BLOCKING AGENTS DILTZAC ER CALCIUM CHANNEL BLOCKING AGENTS DOX A ZOSIN MESYL ATE ALPHA-ADRENERGIC BLOCKING AGENTS ENAL APRIL MALEATE ANTIHYPERTENSIVES, ACE INHIBITORS ENAL APRIL MALEATE-HYDROCHLOROTIZE ACE INHIBITOR/THIAZIDE & THIAZIDE-LIKE DIURETIC EPLERENONE POTASSIUM SPARING DIURETICS EPROSARTAN MESYL ATE ANTIHYPERTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONIST FELODIPINE ER CALCIUM CHANNEL BLOCKING AGENTS FOSINOPRIL SODIUM ANTIHYPERTENSIVES, ACE INHIBITORS HealthyBlue Select Generics $0 – Drug List for CDH Plans only ANTIHYPERTENSIVE DRUGS (HIGH BLOOD PRESSURE) Drug Name Therapeutic Class Description FOSINOPRIL-HYDROCHLOROTHIAZIDE ACE INHIBITOR/THIA ZIDE & THIA ZIDE-LIKE DIURETIC FUROSEMIDE LOOP DIURETICS GUANABENZ ACETATE ANTIHYPERTENSIVES, SYMPATHOLY TIC GUANFACINE HCL ANTIHYPERTENSIVES, SYMPATHOLY TIC HYDROCHLOROTHIA ZIDE THIA ZIDE AND REL ATED DIURETICS INDAPAMIDE THIA ZIDE AND REL ATED DIURETICS IRBESARTAN ANTIHYPERTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONIST IRBESARTAN-HYDROCHLOROTHIAZIDE ANGIOTENSIN RECEPTOR ANTAG./THIA ZIDE DIURETIC COMB ISRADIPINE CALCIUM CHANNEL BLOCKING AGENTS L ABETALOL HCL ALPHA/BETA-ADRENERGIC BLOCKING AGENTS LISINOPRIL ANTIHYPERTENSIVES, ACE INHIBITORS LISINOPRIL-HYDROCHLOROTHIAZIDE ACE INHIBITOR/THIA ZIDE & THIA ZIDE-LIKE DIURETIC LOSARTAN POTA SSIUM ANTIHYPERTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONIST LOSARTAN-HYDROCHLOROTHIAZIDE ANGIOTENSIN RECEPTOR ANTAG./THIA ZIDE DIURETIC COMB METHYCLOTHIAZIDE THIA ZIDE AND REL ATED DIURETICS METHYLDOPA ANTIHYPERTENSIVES, SYMPATHOLY TIC METHYLDOPA-HYDROCHLOROTHIA ZIDE ANTIHYPERTENSIVES, SYMPATHOLY TIC METOL A ZONE THIA ZIDE AND REL ATED DIURETICS METOPROLOL SUCCINATE BETA-ADRENERGIC BLOCKING AGENTS METOPROLOL TARTRATE BETA-ADRENERGIC BLOCKING AGENTS METOPROLOL-HYDROCHLOROTHIAZIDE BETA-ADRENERGIC BLOCKING AGENTS/THIAZIDE & REL ATED MOEXIPRIL HCL ANTIHYPERTENSIVES, ACE INHIBITORS MOE XIPRIL-HYDROCHLOROTHIA ZIDE ACE INHIBITOR/THIA ZIDE & THIA ZIDE-LIKE DIURETIC NADOLOL BETA-ADRENERGIC BLOCKING AGENTS NADOLOL-BENDROFLUMETHIA ZIDE BETA-ADRENERGIC BLOCKING AGENTS/THIAZIDE & REL ATED NIC ARDIPINE HCL CALCIUM CHANNEL BLOCKING AGENTS NIFEDIAC CC CALCIUM CHANNEL BLOCKING AGENTS NIFEDIC AL XL CALCIUM CHANNEL BLOCKING AGENTS NIFEDIPINE CALCIUM CHANNEL BLOCKING AGENTS NIFEDIPINE ER CALCIUM CHANNEL BLOCKING AGENTS NIFEDIPINE XL CALCIUM CHANNEL BLOCKING AGENTS NIMODIPINE CALCIUM CHANNEL BLOCKING AGENTS NISOLDIPINE CALCIUM CHANNEL BLOCKING AGENTS PERINDOPRIL ERBUMINE ANTIHYPERTENSIVES, ACE INHIBITORS PINDOLOL BETA-ADRENERGIC BLOCKING AGENTS PRA ZOSIN HCL ALPHA-ADRENERGIC BLOCKING AGENTS PROPRANOLOL HCL BETA-ADRENERGIC BLOCKING AGENTS PROPRANOLOL-HYDROCHLOROTHIA ZIDE BETA-ADRENERGIC BLOCKING AGENTS/THIAZIDE & REL ATED QUINAPRIL HCL ANTIHYPERTENSIVES, ACE INHIBITORS QUINAPRIL-HYDROCHLOROTHIA ZIDE ACE INHIBITOR/THIA ZIDE & THIA ZIDE-LIKE DIURETIC R AMIPRIL ANTIHYPERTENSIVES, ACE INHIBITORS RESERPINE ANTIHYPERTENSIVES, SYMPATHOLY TIC SOTALOL BETA-ADRENERGIC BLOCKING AGENTS SOTALOL AF BETA-ADRENERGIC BLOCKING AGENTS SPIRONOL ACTONE POTASSIUM SPARING DIURETICS SPIRONOL ACTONE-HYDROCHLOROTHIAZIDE POTASSIUM SPARING DIURETICS IN COMBINATION HealthyBlue Select Generics $0 – Drug List for CDH Plans only ANTIHYPERTENSIVE DRUGS (HIGH BLOOD PRESSURE) Drug Name Therapeutic Class Description TA ZTIA XT C ALCIUM CHANNEL BLOCKING AGENTS TELMISARTAN ANTIHYPERTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONIST TELMISARTAN-HYDROCHLOROTHIA ZIDE ANGIOTENSIN RECEPTOR ANTAG./THIA ZIDE DIURETIC COMB TER AZOSIN HCL ALPHA-ADRENERGIC BLOCKING AGENTS TIMOLOL MALE ATE BETA-ADRENERGIC BLOCKING AGENTS TORSEMIDE LOOP DIURETICS TR ANDOL APRIL ANTIHYPERTENSIVES, ACE INHIBITORS TR ANDOL APRIL-VER APAMIL ACE INHIBITOR/C ALCIUM CHANNEL BLOCKER COMBINATION TRIAMTERENE-HYDROCHLOROTHIA ZIDE POTA SSIUM SPARING DIURETICS IN COMBINATION VAL SARTAN-HYDROCHLOROTHIA ZIDE ANGIOTENSIN RECEPTOR ANTAG./THIA ZIDE DIURETIC COMB VER APAMIL ER C ALCIUM CHANNEL BLOCKING AGENTS VER APAMIL ER PM C ALCIUM CHANNEL BLOCKING AGENTS VER APAMIL HCL C ALCIUM CHANNEL BLOCKING AGENTS ANTILIPEMIC DRUGS (CHOLESTEROL) Drug Name Therapeutic Class Description ATORVA STATIN ANTIHYPERLIPIDEMIC - HMG COA REDUCTA SE INHIBITORS CHOLEST YRAMINE BILE SALT SEQUESTRANTS CHOLEST YR AMINE LIGHT BILE SALT SEQUESTRANTS COLESTIPOL HCL BILE SALT SEQUESTRANTS FENOFIBRATE LIPOTROPICS FENOFIBRIC ACID LIPOTROPICS FLUVA STATIN LIPOTROPICS GEMFIBROZIL LIPOTROPICS LOFIBRA LIPOTROPICS LOVA STATIN ANTIHYPERLIPIDEMIC - HMG COA REDUCTA SE INHIBITORS NIACOR LIPOTROPICS PR AVA STATIN SODIUM ANTIHYPERLIPIDEMIC - HMG COA REDUCTA SE INHIBITORS PREVALITE BILE SALT SEQUESTRANTS SIMVA STATIN ANTIHYPERLIPIDEMIC - HMG COA REDUCTA SE INHIBITORS ASTHMA, COPD (LUNG DISEASE) Drug Name Therapeutic Class Description ALBUTEROL SULFATE (syrup, tablet and nebulizer solution) BETA-ADRENERGIC AGENTS BUDESONIDE GLUCOCORTICOIDS, OR ALLY INHALED COPD GENERAL BRONCHODIL ATOR AGENTS CORTISONE GLUCOCORTICOIDS CROMOLYN SODIUM MA ST CELL STABILIZERS DE X AMETHA SONE GLUCOCORTICOIDS DEX AMETHASONE INTENSOL GLUCOCORTICOIDS DIFIL-G 400 GENERAL BRONCHODIL ATOR AGENTS DY-G LIQUID GENERAL BRONCHODIL ATOR AGENTS DYPHYLLINE GG GENERAL BRONCHODIL ATOR AGENTS HYDROCORTISONE GLUCOCORTICOIDS IPRATROPIUM BROMIDE GENERAL BRONCHODIL ATOR AGENTS HealthyBlue Select Generics $0 – Drug List for CDH Plans only ASTHMA, COPD (LUNG DISEASE) Drug Name Therapeutic Class Description IPRATROPIUM-ALBUTEROL BETA-ADRENERGIC AND ANTICHOLINERGIC COMBINATIONS JAY-PHYL GENER AL BRONCHODIL ATOR AGENTS LEVALBUTEROL CONCENTR ATE BETA-ADRENERGIC AGENTS METAPROTERENOL SULFATE BETA-ADRENERGIC AGENTS METHYLPREDNISOLONE GLUCOCORTICOIDS MILLIPRED GLUCOCORTICOIDS MILLIPRED DP GLUCOCORTICOIDS MONTELUK AST LEUKOTRIENE RECEPTOR ANTAGONISTS PREDNISOLONE GLUCOCORTICOIDS PREDNISOLONE SODIUM PHOSPHATE GLUCOCORTICOIDS PREDNISONE GLUCOCORTICOIDS PREDNISONE INTENSOL GLUCOCORTICOIDS TERBUTALINE SULFATE BETA-ADRENERGIC AGENTS TRIAMCINOLONE ACETONIDE GLUCOCORTICOIDS Z AFIRLUK AST LEUKOTRIENE RECEPTOR ANTAGONISTS DIABETIC DRUGS (BLOOD SUGAR) Drug Name Therapeutic Class Description ACARBOSE ANTIHYPERGLYCEMIC, ALPHA-GLUCOSIDASE INHIB (N-S) CHLORPROPAMIDE ANTIHYPERGLYCEMIC, INSULIN-RELE ASE STIMUL ANT T YPE GLIMEPIRIDE ANTIHYPERGLYCEMIC, INSULIN-RELE ASE STIMUL ANT T YPE GLIPIZIDE ANTIHYPERGLYCEMIC, INSULIN-RELE ASE STIMUL ANT T YPE GLIPIZIDE ER ANTIHYPERGLYCEMIC, INSULIN-RELE ASE STIMUL ANT T YPE GLIPIZIDE XL ANTIHYPERGLYCEMIC, INSULIN-RELE ASE STIMUL ANT T YPE GLIPIZIDE-METFORMIN ANTIHYPERGLYCEMIC, INSULIN-RELE ASE STIMUL ANT T YPE GLYBURIDE ANTIHYPERGLYCEMIC, INSULIN-RELE ASE STIMUL ANT T YPE GLYBURIDE MICRONIZED ANTIHYPERGLYCEMIC, INSULIN-RELE ASE STIMUL ANT T YPE GLYBURIDE-METFORMIN HCL ANTIHYPERGLYCEMIC, INSULIN-REL STIM.& BIGUANIDE CMB METFORMIN HCL ANTIHYPERGLYCEMIC, BIGUANIDE T YPE(NON-SULFONYLUREA) METFORMIN HCL ER ANTIHYPERGLYCEMIC, BIGUANIDE T YPE(NON-SULFONYLUREA) NATEGLINIDE ANTIHYPERGLYCEMIC, INSULIN-RELE ASE STIMUL ANT T YPE PIOGLITA ZONE ANTIHYPERGLYCEMIC, THIA ZOLIDINEDIONE (PPARG AGONIST ) PIOGLITA ZONE-METFORMIN ANTIHYPERGLYCEMIC, THIA ZOLIDINEDIONE & BIGUANIDE PIOGLITA ZONE-GLIMEPIRIDE ANTIHYPERGLYCEMIC, THIA ZOLIDINEDIONE & SULFONYLUREA REPAGLINIDE ANTIHYPERGLYCEMIC, INSULIN-RELE ASE STIMUL ANT T YPE TOL AZAMIDE ANTIHYPERGLYCEMIC, INSULIN-RELE ASE STIMUL ANT T YPE TOLBUTAMIDE ANTIHYPERGLYCEMIC, INSULIN-RELE ASE STIMUL ANT T YPE This list may not be all inclusive and does not guarantee coverage. Please check your benefit materials for the terms of your current prescription drug coverage. The CareFirst BlueCross BlueShield family of health care plans 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. SU M1637-1P (8/14)
