CareFirst Prescription Drug Program

Sample Notes Page - CareFirst BlueCross BlueShield

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Prescription Drug Detail

Brand Name

Brand Tier

Generic Name

Generic Tier

SYMBICORT

(Tier 2)

Not
Available

Prior Authorization Required: No

Quantity Limit: No

Category: Respiratory problems\asthma & COPD (miscellaneous inhalers)

Maintenance Drug: Yes

Notes:

Attachments:

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Serving Maryland, the District of Columbia and portions of Virginia. CareFirst BlueCross BlueShield is the shared
business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst BlueChoice, Inc.,
an affiliate company, also offers health benefit products and services on this site.

CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are 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.

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