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) AMITRIPT YLINE HCL AMOX APINE BUDEPRION SR BUDEPRION XL BUPROPION HCL BUPROPION HCL SR BUPROPION XL CHLORDIA ZEPOXIDE-AMITRIPT YLINE TRICYCLIC ANTIDEPRESSANT/BENZODIAZEPINE COMBINATNS CITALOPRAM CITALOPRAM HBR CLOMIPRAMINE HCL DESIPR AMINE HCL DESVENL AFA XINE DOXEPIN HCL DULOXETINE ESCITALOPR AM OX AL ATE FLUOXETINE DR FLUOXETINE HCL FLUVOX AMINE MALE ATE IMIPRAMINE HCL IMIPRAMINE PAMOATE MAPROTILINE HCL MIRTA ZAPINE ALPHA-2 RECEPTOR ANTAGONIST ANTIDEPRESSANTS NEFA ZODONE HCL SEROTONIN-2 ANTAGONIST/REUPTAKE INHIBITORS (SARIS) NORTRIPT YLINE HCL PAROXETINE HCL PERPHENA ZINE-AMITRIPT YLINE TRICYCLIC ANTIDEPRESSANT/PHENOTHIA ZINE COMBINATNS PHENELZINE SULFATE MAOIS - NON-SELECTIVE & IRREVERSIBLE PROTRIPT YLINE HCL SELFEMR A SERTRALINE HCL TRANYLCYPROMINE SULFATE MAOIS - NON-SELECTIVE & IRREVERSIBLE
ANTIDEPRESSANT DRUGS (DEPRESSION) TRAZODONE HCL SEROTONIN-2 ANTAGONIST/REUPTAKE INHIBITORS (SARIS) VENL AFA XINE HCL VENL AFA XINE HCL ER ACEBUTOLOL HCL AFEDITAB CR AMILORIDE HCL AMILORIDE-HYDROCHLOROTHIA ZIDE IN COMBINATION AMLODIPINE BESYL ATE AMLODIPINE BESYL ATE-BENA ZEPRIL ACE INHIBITOR/C ALCIUM CHANNEL BLOCKER COMBINATION ATENOLOL ATENOLOL-CHLORTHALIDONE /THIAZIDE & REL ATED BENA ZEPRIL HCL BENA ZEPRIL-HYDROCHLOROTHIA ZIDE BETA XOLOL HCL BISOPROLOL FUMARATE BISOPROLOL-HYDROCHLOROTHIA ZIDE /THIAZIDE & REL ATED BUMETANIDE C ANDESARTAN C ANDESARTAN-HYDROCHLOROTHIA ZIDE ANGIOTENSIN RECEPTOR ANTAG./THIA ZIDE DIURETIC COMB C APTOPRIL C APTOPRIL-HYDROCHLOROTHIAZIDE C ARTIA XT C ARVEDILOL ALPHA/ CHLOROTHIA ZIDE CHLORTHALIDONE CLONIDINE CLONIDINE HCL CLORPRES DILT-CD DILTIA XT DILTIA ZEM 24HR ER DILTIA ZEM ER DILTIA ZEM HCL DILT-XR DILTZAC ER DOX A ZOSIN MESYL ATE ENAL APRIL MALEATE ENAL APRIL MALEATE-HYDROCHLOROTIZE ACE INHIBITOR/THIAZIDE & THIAZIDE-LIKE DIURETIC EPLERENONE EPROSARTAN MESYL ATE FELODIPINE ER FOSINOPRIL SODIUM
FOSINOPRIL-HYDROCHLOROTHIAZIDE FUROSEMIDE GUANABENZ ACETATE GUANFACINE HCL HYDROCHLOROTHIA ZIDE INDAPAMIDE IRBESARTAN IRBESARTAN-HYDROCHLOROTHIAZIDE ANGIOTENSIN RECEPTOR ANTAG./THIA ZIDE DIURETIC COMB ISRADIPINE L ABETALOL HCL ALPHA/ LISINOPRIL LISINOPRIL-HYDROCHLOROTHIAZIDE LOSARTAN POTA SSIUM LOSARTAN-HYDROCHLOROTHIAZIDE ANGIOTENSIN RECEPTOR ANTAG./THIA ZIDE DIURETIC COMB METHYCLOTHIAZIDE METHYLDOPA METHYLDOPA-HYDROCHLOROTHIA ZIDE METOL A ZONE METOPROLOL SUCCINATE METOPROLOL TARTRATE METOPROLOL-HYDROCHLOROTHIAZIDE /THIAZIDE & REL ATED MOEXIPRIL HCL MOE XIPRIL-HYDROCHLOROTHIA ZIDE NADOLOL NADOLOL-BENDROFLUMETHIA ZIDE /THIAZIDE & REL ATED NIC ARDIPINE HCL NIFEDIAC CC NIFEDIC AL XL NIFEDIPINE NIFEDIPINE ER NIFEDIPINE XL NIMODIPINE NISOLDIPINE PERINDOPRIL ERBUMINE PINDOLOL PRA ZOSIN HCL PROPRANOLOL HCL PROPRANOLOL-HYDROCHLOROTHIA ZIDE /THIAZIDE & REL ATED QUINAPRIL HCL QUINAPRIL-HYDROCHLOROTHIA ZIDE R AMIPRIL RESERPINE SOTALOL SOTALOL AF SPIRONOL ACTONE SPIRONOL ACTONE-HYDROCHLOROTHIAZIDE IN COMBINATION
TA ZTIA XT TELMISARTAN TELMISARTAN-HYDROCHLOROTHIA ZIDE ANGIOTENSIN RECEPTOR ANTAG./THIA ZIDE DIURETIC COMB TER AZOSIN HCL TIMOLOL MALE ATE TORSEMIDE TR ANDOL APRIL 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 VER APAMIL ER PM VER APAMIL HCL ANTILIPEMIC DRUGS (CHOLESTEROL) ATORVA STATIN CHOLEST YRAMINE CHOLEST YR AMINE LIGHT COLESTIPOL HCL FENOFIBRATE FENOFIBRIC ACID FLUVA STATIN GEMFIBROZIL LOFIBRA LOVA STATIN NIACOR PR AVA STATIN SODIUM PREVALITE SIMVA STATIN ASTHMA, COPD (LUNG DISEASE) ALBUTEROL SULFATE (syrup, tablet and nebulizer solution) BUDESONIDE COPD CORTISONE CROMOLYN SODIUM DE X AMETHA SONE DEX AMETHASONE INTENSOL DIFIL-G 400 DY-G LIQUID DYPHYLLINE GG HYDROCORTISONE IPRATROPIUM BROMIDE, OR ALLY INHALED MA ST CELL STABILIZERS
ASTHMA, COPD (LUNG DISEASE) IPRATROPIUM-ALBUTEROL JAY-PHYL LEVALBUTEROL CONCENTR ATE METAPROTERENOL SULFATE METHYLPREDNISOLONE MILLIPRED MILLIPRED DP MONTELUK AST PREDNISOLONE PREDNISOLONE SODIUM PHOSPHATE PREDNISONE PREDNISONE INTENSOL TERBUTALINE SULFATE TRIAMCINOLONE ACETONIDE Z AFIRLUK AST BETA-ADRENERGIC AND ANTICHOLINERGIC COMBINATIONS GENER AL BRONCHODIL ATOR AGENTS LEUKOTRIENE RECEPTOR ANTAGONISTS LEUKOTRIENE RECEPTOR ANTAGONISTS DIABETIC DRUGS (BLOOD SUGAR) ACARBOSE ANTIHYPERGLYCEMIC, ALPHA-GLUCOSIDASE INHIB (N-S) CHLORPROPAMIDE GLIMEPIRIDE GLIPIZIDE GLIPIZIDE ER GLIPIZIDE XL GLIPIZIDE-METFORMIN GLYBURIDE GLYBURIDE MICRONIZED 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 PIOGLITA ZONE ANTIHYPERGLYCEMIC, THIA ZOLIDINEDIONE (PPARG AGONIST ) PIOGLITA ZONE-METFORMIN ANTIHYPERGLYCEMIC, THIA ZOLIDINEDIONE & BIGUANIDE PIOGLITA ZONE-GLIMEPIRIDE ANTIHYPERGLYCEMIC, THIA ZOLIDINEDIONE & SULFONYLUREA REPAGLINIDE TOL AZAMIDE TOLBUTAMIDE 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)