SHBP Co-pay/Co-insurance Waiver Medication List Form

The 2024 State Health Benefit Plan Copayment/Coinsurance Waiver Medication List As a State Health Benefit Plan member, if you enroll and actively participate in the Case Management Program for Anthem or UnitedHealthcare Disease Management programs for asthma, diabetes, coronary artery disease (CAD) or Medication for Addiction Treatment (MAT), you may be eligible to receive the products listed below at no cost. Please call the Member Services number for Anthem, 855-641-4862, or UnitedHealthcare Member Services number, 888-364-6352, for more details about program participation requirements. For more information about these medications, call CVS Caremark® Customer Care at 844-345-3241. Asthma • BREO ELLIPTA • BUDESONIDE NEBULIZER SUSP • FLUTICASONE- SALMETEROL • IPRATROPIUM BROMIDE • IPRATROPIUM- ALBUTEROL • PULMICORT FLEXHALER • SPIRIVA HANDIHALER • SPIRIVA RESPIMAT • TRELEGY ELLIPTA • WIXELA INHUB Coronary Artery Disease • BENAZEPRIL & HCTZ • BENAZEPRIL HCL • CAPTOPRIL • CATOPRIL & HCTZ • ENALAPRIL & HCTZ • ENALAPRIL MALEATE • FOSINOPRIL • FOSINOPRIL & HCTZ • LISINOPRIL • LISINOPRIL & HCTZ • MOEXIPRIL • MOEXIPRIL & HCTZ • PERINDOPRIL ERBUMINE • QUINAPRIL • QUINAPRIL & HCTZ • RAMIPRIL • TRANDOLAPRIL Diabetes • ACARBOSE • ACCU-CHEK AVIVA TEST STRIPS • ACCU-CHEK GUIDE TEST STRIPS • ACCU-CHECK LANCETS • ACCU-CHEK SMART TEST STRIPS • CHLOROPAMIDE • DEXCOM G6 SENSORS, TRANSMITTERS AND RECEIVERS • DEXCOM G7 SENSORS AND RECEIVERS • FARXIGA • FIASP • GLIMEPIRIDE • GLIPIZIDE • GLIPIZIDE ER • GLIPIZIDE XL • GLIPIZIDE-METFORMIN • GLYBURIDE • GLYBURIDE MICRONIZED • GLYBURIDE- METFORMIN • GLYXAMBI • HUMULIN R U-500 • INSULIN SYRINGES AND NEEDLES* • JANUMET/ JANUMETXR • JANUVIA • JARDIANCE • LANTUS • METFORMIN • METFORMIN ER (PA) • MOUNJARO (PA) • NATEGLINIDE • NOVOLOG CARTRIDGE • NOVOLOG MIX 70/30 PEN • NOVOLOG MIX 70/30 VIAL • NOVOLOG PEN • NOVOLOG VIAL • NOVOLIN MIX 70/30 PEN • NOVOLIN MIX 70/30 VIAL • NOVOLIN N PEN • NOVOLIN N VIAL • NOVOLIN R VIAL • OMNIPOD INSULIN PUMP/DASH • ONETOUCH LANCETS • ONETOUCH ULTRA TEST STRIPS • ONETOUCH VERIO FLEX TEST STRIPS • ONETOUCH VERIO REFLECT TEST STRIPS • ONETOUCH VERIO TEST STRIPS • OZEMPIC (PA) • PIOGLITAZONE • PIOGLITAZONE- GLIMEPIRIDE • PIOGLITAZONE- METFORMIN • REPAGLINIDE • REPAGLINIDE- METFORMIN • RYBELSUS (PA) • SOLIQUA • SYMLIN (PA) • SYNJARDY/SYNJARDY XR • TOLAZAMIDE • TOLBUTAMIDE • TOUJEO • TRESIBA FLEXTOUCH • TRIJARDY XR • TRULICITY (PA) • VICTOZA (PA) • XIGDUO XR • XULTOPHY Medication for Addiction Treatment • ACAMPROSATE CALCIUM DR • BUPRENORPHINE HCLSL • BUPRENORPHINE HCL/NALOXONE • DISULFIRAM • NALTREXONE HCL The DEXCOM G7 is currently not compatible with insulin pumps/delivery systems and digital health apps. *BD ULTRAFINE syringes and needles are the only preferred options. The symbol (PA) next to a drug name indicates that a prior authorization is required for coverage. All rights in the product names of all third- party products listed, whether or not appearing with the trademark symbol, belong exclusively to their respective owners. This document contains confidential and proprietary information of CVS Caremark and may not be reproduced, distributed or printed without written permission from CVS Caremark. This list is subject to change. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers not affiliated with CVS Caremark. ©2023 CVS Health and/or one of its affiliates. All rights reserved. 106-43258A 101723 Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. Independent licensee of the Blue Cross Blue Shield Association. Anthem is a registered trademark of Anthem Insurance Companies, Inc.
GABCBS-CM-049242-24 February 2024