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Preferred Drug List

Your 3-Tier

Prescription

Drug Benefit

2008

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Table of contentsIntroduction .......................................................................................2

WhatisthePrescriptionDrug3-TierBenefit?...................................2

Gettingthemostfromyourprescriptiondrugbenefit.....................2

Aboutgenericandbrand-namedrugs............................................3

Advantagesofgenericdrugs...........................................................3

Q&Asaboutgenericdrugs..............................................................3

Preferredandnon-preferredbrand-namedrugs...............................4

HowtoknowifyourdrugisTier1,2,or3.....................................5

Getting your prescription filled ........................................................5

Convenientnationalretailpharmacynetwork..................................5

SavetimeandmoneywithMedcoByMail.....................................5

OrderingprescriptiondrugsthroughMedcoByMail........................6

SpecialtyPharmacies.......................................................................7

Additionalservices...........................................................................7

Prior Authorization Program ............................................................8

Maintainingtheoptimaldrugtherapy.............................................8

Whichdrugsareincluded................................................................8

HowyoubenefitfromthePriorAuthorizationProgram..................9

Howtheprogramworks.................................................................9

Frequently Asked Questions ...........................................................10

How to read the Preferred Drug List ..............................................12

Preferred Drug List ..........................................................................13

Appendix ..........................................................................................23

CommonlyprescribedTier3drugswithalternatives......................23

CommonlyprescribedTier3drugswithgenericequivalents..........25

Cost-Saving Tips ..................................................... inside back cover

Important Telephone Numbers .........................................back cover

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IntroductionWelcome to our 3-Tier Pharmacy Benefit plan. We understand the importance of prescription coverage and want to give you a quality benefit—one that helps promote the use of safe and cost-effective medications, while still offering you choices.

What is the Prescription Drug 3-Tier Benefit?

The program is simple. With this benefit, your prescriptions fall into one of three categories or “tiers.” Each tier has a different copay.

Here are the tiers and how they affect your copay:

Tier 1 All generic drugs Lowest copay

Tier 2 Preferred brand-name drugs Higher copay

Tier 3 Non-preferred brand-name drugs Highest copay

Note: The term “copay” is used throughout this book. Your actual benefit may provide fixed-dollar copay tiers, percentage coinsurance tiers or a combination of both.

This booklet includes a list of drugs on the Preferred Drug List along with each drug’s copay tier.

•Genericdrugs,listedornotlisted,arecoveredwithaTier1copay.Thesedrugsaremarkedwithanasterisk(*)inthelist.

•Brand-namedrugslistedinthisbookletareconsidered“preferred”andarecoveredwithaTier2copay(seePreferredDrugList).

•Brand-namedrugsNOTonthePreferredDrugListarecoveredwithaTier3copay.Thesedrugsarenotlistedinthisbook.Someplansrequirethatyoumustpaythedifferenceincostbetweenbrand-nameandgenericifagenericisavailable.

Getting the most from your prescription drug benefit

At your physician or health-care provider’s office:

•Askyourhealth-careprovidertoprescribeagenericdrug,wheneverpossible.

•Ifagenericdrugisnotappropriate,askyourhealth-careprovidertoconsiderprescribingapreferredbrand-namedrugfromthePreferredDrugList.

At the pharmacy:

•Askyourpharmacisttofillyourprescriptionwithagenericdrugwhenavailable.

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About generic and brand-name drugs

Brand-name drugs are usually sold under a manufacturer’s trade name. Generic drugs are usually sold under the generic or chemical names. Both brand-name drugs and generic equivalents are regulated by the Food and Drug Administration (FDA). However, not all brand-name drugs have a generic equivalent.

Advantages of generic drugs•Samelevelofquality,strength,effectivenessandpurity.

•Excellentvalue—generallycostlessbecausetheyarecreatedwithoutthedevelopment,advertisingandsalesexpenseofbrand-namedrugs.Also,competitionamonggenericdrug-makerslowerstheprice.

•Lowestcopay*(Tier1)cansaveyoumoney.

* Classification of a drug as generic is based on whether a generic product is available and on the cost, compared to the brand-name version. Occasionally, a product labeled “generic” by the pharmacy will have similar cost to the brand product. In such cases, a Tier 2 copay may apply.

We encourage you to use a generic drug whenever one is available and allowed by your health-care provider. Even if your drug does not have a generic equivalent, there may be another generic available within the same group of drugs that will work just as well. Visit your Web site for more information about how you can save with generics.

Q&As about generic drugsQ. How can I be sure to pay the lowest possible copay?

A.Askyourhealth-careproviderifthereisagenericdrugthatisrightforyou.Ifthereisagenericequivalentavailableforyourdrug,askyourhealth-careprovidertoindicate“substitutionpermitted”onyourprescription.Thenaskyourpharmacisttouseagenerictofilltheprescription.Ifthereisnogenericequivalentforyourdrug,talktoyourdoctoraboutgenericdrugsavailablewithinthesamedrugclassorgenericalternative.

Q. What if my prescription does not have a generic alternative available?

A. Ifthereisnogenericavailable,youwillreceivethebrand-namedrug.

Q. What happens if I get a brand-name drug when a generic is available?

A. Someplansrequirethatyoumustpaythedifferenceincostbetweenbrand-nameandgenericifagenericisavailable.Youcanrequestabrand-namedrugevenwhenagenericequivalentisavailable.

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Preferred and non-preferred brand-name drugs

The list of commonly prescribed drugs in this booklet shows some drugs as Tier 2 preferred brand-name drugs and some as Tier 3 non-preferred brand-name drugs.

Our Pharmacy and Therapeutics Committee makes decisions about which brand-name drugs are preferred and non-preferred. This group includes physicians, other health-care providers and pharmacists from the community, plus a member representative. The committee:

•Usescurrentmedicalstudiesandresearchtochoosesafeandeffectivedrugs.

•ReviewsandupdatesthePreferredDrugListregularlybyaddingthelatestsafeandeffectivedrugs,andremovingthosethatarenolongerconsideredsafeandeffective,orwhichnowhavebetteralternativesavailable.

•Recommendsthathealth-careprovidersprescribepreferredbrand-namedrugswhenagenericisnotavailable.Thesepreferredbrand-namedrugsarecoveredwithaTier2copay.

Brand-name drugs not listed in this booklet are considered Tier 3 non-preferred drugs and have the highest copay. These drugs may be non-preferred for a variety of reasons:

•Therearegenericequivalentsavailable.

•Therearepreferredbrand-namealternativesavailable.

•OurPharmacyandTherapeuticsCommitteehasconcernsabouttheirsafetyand/oreffectiveness.

Your health-care provider has access to a copy of the Preferred Drug List to use when writing a prescription.

Important items to note when using this booklet:

•Drugslistedinthisbookletarearrangedinalphabeticalorder.

•ThePreferredDrugListinthisbookletdoesnotincludenon-preferredbrand-namedrugs.Anybrand-namedrugnotonthelistisconsiderednon-preferredandiscoveredattheTier3copay.Someplansrequirethatyoumustpaythedifferenceincostbetweenbrand-nameandgenericifagenericisavailable.Foryourconvenience,wehavelistedthemostcommonlyprescribedTier3drugsandtheirgenericorTier2alternatives(seepage24forthislisting).

•Dependingonyourprescriptiondrugbenefit,certaindrugcategoriesmaynotbecovered.Refertoyourbenefitbookletforspecificinformationaboutcoveragelimitations.

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How to know if your drug is Tier 1, 2 or 3:•Thecopaytierislistedtotherightofthedrugname.

•Askyourpharmacist.Thepharmacycomputersystemshavethemostup-to-dateversionofthisdruglist.

•CallCustomerService—thenumberislistedonthebackofyourIDcard.

•VisittheWebsitelistedonthebackofyourIDcard.

Getting your prescription filledConvenient national retail pharmacy network

We use a national network of more than 60,000 retail pharmacies. To receive the highest coverage under your plan’s prescription program, you need to use a pharmacy in this network. If you go to a pharmacy not in the network, you may be covered at a lower level. In some cases, you may receive no benefits at all. Please refer to your benefit booklet for details on coverage at a non-network pharmacy.

Most pharmacies in your area are part of the network. If you need a prescription filled while you’re traveling, you’ll find network pharmacies throughout the United States. Call the toll-free 24-hour Pharmacy Locator Line at 1-800-391-9701 (this number is also printed on the back of your ID card) to find a network pharmacy near you. You can also use the provider directory on your Web site listed on the back of your ID card.

Your 3-Tier benefit provides a 30-day supply of medication for one copay at a retail pharmacy. You still pay the full copay amount even for part of a 30-day supply. For example, if your prescription is for a 34-day supply, you are charged two full copays.

Save time and money with Medco By Mail

If you take a long-term medication, we offer a mail-service program through Medco By Mail, which has many advantages:

•It’sconvenient.

•Itsavesyoutimeandmaysaveyoumoney.

•Youcangetprescriptionsuptothesupplymaximumallowedbyyourplan—typically90days—andpaylessthanwhatyouwouldpayforthesameamountatalocalretailpharmacy.

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The 3-tier copay structure applies when you use Medco By Mail. However, Medco By Mail copay amounts for generic, preferred and non-preferred brand-name drugs differ from retail pharmacy copay amounts. Please check your benefit booklet for the Medco By Mail copay amounts for your plan. Since Medco By Mail copays are based on the 90-day or other supply maximum allowed by your plan, be sure to ask your health-care provider or practitioner to write this quantity on your prescription. If the prescription is written for anything less, you’ll receive the smaller quantity of medication and still be charged the Medco By Mail copay. The Medco By Mail pharmacy staff can’t change the quantity written by your health-care provider.

Note: Medco By Mail copay amounts differ from retail pharmacy copay amounts. Please read your benefit booklet for specific information about your copay amounts and terms of coverage.

Important items to note about Medco By Mail:

•IttakesabouttwoweekstoreceiveyourprescriptionsthroughMedcoByMail.

•Toavoidanydelayinstartingyourmedicine,askyourhealth-careprovidertowritetwoseparateprescriptions—onefor30daysthatyoucanfillatalocalpharmacyrightaway,andoneforthe90-dayorsupplymaximumallowedbyyourplanthatyoucanmailinwithintwoweeksofyourmedicinerunningout.

•Ifyourhealth-careproviderallowsMedcoByMailrefills,besurehe/sheindicatesthatontheprescriptionandorderrefillsabouttwoweeksbeforeyourmedicinerunsout.

•Prescriptionscometoyourhomeinsealed,tamper-evident,discreetlylabeledpackaging.Somedrugsmayrequirespecialhandling,suchascontrolledsubstancesanditemsthatmustberefrigeratedorfrozenduringshipment.Formoreinformation,call1-800-391-9701.

Ordering prescription drugs through Medco By Mail

•Mail:Fornewprescriptionsandrefills—useaMedcoByMailorderformtomailyourprescription.Torequestaform,pleasecallourCustomerServicedepartmentorgoonlinetotheWebsitealsolistedonthebackofyourIDcard.

•Phone:Forprescriptionrefills—callMedcoByMailat1-800-391-9701.

•Internet:Forprescriptionrefills—visitthePharmacysectionatyourWebsitelistedonthebackofyourIDcard.ThengotoMyPharmacyPlusforaccesstoMedcoByMail.

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Specialty Pharmacies

Specialty drugs are high-cost drugs, often self-injected and used to treat complex or rare conditions including rheumatoid arthritis, multiple sclerosis and hepatitis C. These drugs are available through one of our Preferred Specialty Pharmacy vendors. These pharmacies specialize in the delivery and clinical management of specialty drugs and also provide extra clinical services to help you manage your illness at no additional cost.

Because of the complicated therapy and high cost (commonly $1,500 per month), most plans limit specialty drugs to a 30-day supply at a retail copay or coinsurance. For many plans, specialty drugs are only covered when purchased through our Preferred Specialty Pharmacy vendors. See your Benefit Booklet for more information or contact Customer Service.

Specialty drugs are identified in this book with a § symbol. For a complete list of specialty drugs, refer to the Pharmacy section of the Web site listed on the back of your ID card.

Additional services

By using a Preferred Specialty Pharmacy vendor, you have access to additional clinical support, including:

•Coordinationofcareandcaremanagement.

•Medicationadherenceandcompliancemonitoring,includingrefillreminders.

•Educationalmaterial,counselingandproductinformation.

•Accesstoclinicalassistancefrompharmacistsandnurses.

•Coordinationofmedicationdeliverytimeandlocation,includingfreedeliveryandsupplies.

For more information about our Specialty Pharmacies program, please see the Pharmacy section of your Web site or contact our Customer Service department at the number listed on the back of your ID card.

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Prior Authorization ProgramMaintaining the optimal drug therapy

Our Prior Authorization Program is designed to improve the quality of pharmacy care for our members. We work together with your doctor and pharmacist to make sure you’re receiving the right medication therapy.

The goals of this program are to:

•Improvethequalityofyourdrugtherapies.

•Promoteappropriateuseofmedications.

•Ensuretheappropriatelengthofdrugtherapy.

Note: The Prior Authorization Program applies to most plans. To check whether your plan has this program, call the Customer Service number on the back of your ID card or check your specific Web site.

Which drugs are included

We currently manage the following medications through the Pharmacy Prior Authorization Program:

Migraine Headache Therapy Drugs

Axert®

Imitrex®

Maxalt®

Amerge®

Migranal®

Stadol®

Relpax®

Zomig®

Frova®

Hypnotic Drugs

Sonata®

Rozerem®

Lunesta®

AmbienCR®

Antiviral Agents

Acyclovir

Famvir®

Valtrex®

COX-2 Drugs

Celebrex®

Drugs for Ulcers and Other Acid-Related Disorders

Omeprazole

Protonix®

Aciphex®

Nexium®

Prilosec®*

Prevacid®

Zegerid®

*ThisdoesnotapplytoprescriptionsforPrilosec®10mgperdayorPrevacid®15mgperday.Thesedosesdonotrequirethisexception.

CNS Stimulant Drugs

Strattera®

Pain Medications

Actiq®

Fentora®

Lyrica®

continued

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How you benefit from the Prior Authorization Program

Maintaining good health and using your medications correctly is important. The Pharmacy Prior Authorization Program allows us to improve care by promoting appropriate medication use and facilitating follow-up care with your doctor. This program supports you and your doctor as you make decisions about your care and the use of prescription drugs.

How the program works

Here’s how the Pharmacy Prior Authorization Program works:

• Whenyourprescriptionissubmittedbyyourpharmacy,ourcomputersystemcheckstheprescriptiondrugtherapytoseeifitmeetsrecommendedguidelines.

•Ifitmeetstheguidelines,yourprescriptionisfilledwithoutinterruption.

• Ifitdoesnotmeettheguidelines,yourprescriptionisfilledatthepharmacyonetimeandinitiatesthePriorAuthorizationprocess.

Before your next refill of the prescription, we collect information about your drug therapy. We’ll send you a letter and fax form that you’ll need to take to your doctor. If your doctor wants you to continue on the same

Continued

Angiotensin Receptor Blocker (ARB) Therapy

Atacand®

AtacandHCT®

Teveten®

TevetenHCT®

Avapro®

Avalide®

Cozaar®

Hyzaar®

Benicar®

BenicarHCT®

Micardis®

MicardisHCT®

Diovan®

DiovanHCT®

Narcolepsy Drug

Provigil®

Asthma Medications

Singulair®

Accolate®

Zyflo®

ZyfloCR®

Diabetes Medications

Januvia®

Actos®

Avandia®

Byetta®

Medications for nausea and vomiting

Anzemet®

Kytril®

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drug therapy, your doctor can fax the form to our Pharmacy Service Center. Your doctor can also contact us directly for a fax form.

Our review process takes one to two business days. Once we’ve received your doctor’s information, we’ll send you a letter confirming the decision made regarding your drug therapy. Your prescription can be refilled at your pharmacy on the same day an approval decision is made.

Frequently Asked QuestionsQ. What are my copays?

A.Copayamountsvarybytheemployergroup.Youneedtorefertoyourbenefitbookletforyourspecificcopayamounts.NotethatcopaysaredifferentfordrugsdispensedataretailpharmacythanwhendispensedthroughMedcoByMail.

Q. What if I am on a non-preferred drug and want to stay on it?

A.Asalways,itisyourchoice.Ifyouchoosetostayonanon-preferreddrugforwhichagenericisavailable,youmayhavetopaythecostdifferencebetweenthegenericandbrand,plusthecopay.SeeyourBenefitBookletformoreinformationorcontactCustomerService.

Q. Are the preferred drugs just the ones that are the cheapest?

A.No.AcommitteeofphysiciansandpharmacistschoosesdrugsaspreferredonlyiftheyareFDA-approved,safeandeffective.Whenseveraldrugsaresimilarinsafetyandeffectiveness,oneormoreofthelowercostchoicesareselectedforthePreferredDrugList.

Q. I’ve heard that some people can’t take generic drugs. Why not?

A.Abrand-namedruganditsgenericequivalenthavethesameactiveingredients.However,differentmanufacturerssometimesusedifferentinactiveingredientstoholdtheactiveingredientstogethertomakeapillorcapsule.Inrareinstances,peoplemayhaveanallergytotheinactiveingredients.Thistypeofallergycanhappenjustasoftenwithabrandaswithagenericdrug.

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Q. What if I want to get a brand-name drug even though there is a generic available?

A. Thatisbetweenyouandyourhealth-careproviderorpractitioner.Youcanhaveyourprescriptionfilledforabrand-namedrugevenwhenagenericequivalentisavailableandyourhealth-careproviderorpractitionerallowsit.However,youmayhavetopaythecostdifferencebetweenthegenericandbrand,plusthecopay.SeeyourBenefitBookletformoreinformationorcontactCustomerService.

Q. Are there any excluded categories of drugs?

A.Yes.Eventhoughthisbenefitcoversnon-preferredbrand-namedrugs,therestillmaybeexclusionsfordrugsusedtotreatcertainconditions.Reviewyourbenefitbookletforyourplan’sexclusions.

Q. Can I use any pharmacy I want?

A.Wecontractwithanationalnetworkofpharmacies.Toreceivethehighestlevelofbenefitsunderthisprogram,youneedtouseacontractednetworkpharmacy.Ifyougotoapharmacynotinthenetwork,youmayreceivereducedbenefitsor,insomecases,nobenefitsatall.Formostplans,specialtydrugsareonlycoveredwhenpurchasedthroughourPreferredSpecialtyPharmacyvendors.RefertoyourbenefitbookletfordetailsaboutSpecialtyPharmacyandcoverageatanon-networkpharmacy.

Q. How do I find a network pharmacy near my home or when I am away?

A.Mostpharmaciesinyourareaarelikelytobepartofthenetwork.TherearealsonetworkpharmaciesthroughouttheUnitedStates.Usethetoll-free24-hourPharmacyLocatorLine(1-800-391-9701)tofindanetworkpharmacynearyou.Or,visityourWebsitelistedonthebackofyourIDcard.

�� * = Generic✪ = Prior Authorization Program ✔= Requires medical review for coverage § = Specialty drug

How to read the Preferred Drug List•Drugsarelistedalphabetically.

•Genericdrugs,(printedinlowercaseletters)areshownwitha(1)andcoveredatthelowestcopay.

•Preferredbrand-namedrugs,(printedinCAPITALletters)areshownwitha(2)andcoveredatamoderatecopay.

•Non-preferredbrand-namedrugsarenotincludedinthePreferredDrugList.However,wedohaveaseparatesectionofthemostcommonlyprescribednon-preferreddrugsatthebackofthebook.Thesedrugsarecoveredatthehighestcopay.Thislistalsoshowsyouthegenericand/orTier2equivalent.

•Genericdrugsnotlistedinthisbookletarecovered(unlessexcludedinyourbenefit)atthelowestcopay.

•Brand-namedrugsnotlistedinthisbookarenon-preferredandarecovered(unlessexcludedinyourbenefit)atthehighestcopay.Someplansrequirethatyoumustpaythedifferenceincostbetweenbrand-nameandgenericifagenericisavailable.

KEY

Please note the following symbols that may appear with some drugs on the Preferred Drug List.

*=GenericformsofthisdrugarecoveredatTier1copay.BrandequivalentsareTier3.Pleaseconsultyourhealth-careprovider,practitionerorpharmacist.

✪=PriorAuthorizationProgramdrug.Ifexceptionisneeded,yourpractitionerorpharmacistshouldcall1-888-261-1756.

✔=Thisdrugrequiresmedicalreviewforcoverageinsomecases.Forexceptions,calltheCustomerServicenumberlistedonthebackofyourIDcard.

§ =Thisisaspecialtydrug.Mostplanslimitspecialtydrugstoa30-daysupply.Formanyplans,specialtydrugsareonlycoveredwhenpurchasedthroughourPreferredSpecialtyPharmacyvendors.SeeyourbenefitbookletorcallCustomerService.

Note: The Preferred Drug List is updated several times a year as new drugs become available and is subject to change without notice. For updates and the entire Preferred Drug List, visit your Web site listed on the back of your ID card.

�� * = Generic✪ = Prior Authorization Program ✔= Requires medical review for coverage § = Specialty drug

2008 Preferred Drug ListDrug Name Tieraminoglutethimide 2

* aminophylline 1 ** amiodarone 1 ** amitriptyline 1 *

amlodipine 2

* ammoniumlactate 1 ** amoxapine 1 ** amoxicillin 1 ** amoxicillin/clavulanicacid 1 ** amphetamine/dextroamphetamine 1 *

amphetamine/dextroamphetaminesr 2

* ampicillin 1 *ANA-KIT 2anastrozole 2ANCOBON 2ANDRODERM 2ANDROGEL 2ANTARA 2anthralin 2APIDRA 2

§ APOKYN 2§ apomorphine 2

apraclonidine 2APTIVUS 2

§ ARANESP 2ARICEPT 2ARIMIDEX 2aripiprazole 2ARISTOCORT 2

§ ARIXTRA 2artificialtearinsert 2ASACOL 2ASMANEX 2

* aspirin/butalbital/caffeine 1 ** aspirin/butalbital/caffeine/codeine 1 ** aspirin/codeine 1 ** aspirin/oxycodone 1 *

atazanavir 2

* atenolol 1 ** atenolol/chlorthalidone 1 *✪ atomoxetine 2

atorvastatin 2atovaquone 2ATRIPLA 2

* atropineophthalmic 1 *ATROVENT 2auranofin 2aurothioglucose 2

✪ AVALIDE 2AVANDAMET(AvandiacombinationsalsoTier2) 2AVANDARYL 2

✪ AVANDIA(AvandiacombinationsalsoTier2) 2✪ AVAPRO 2

AVC 2AVELOX 2

Drug Name TierA

abacavir 2abacavir/zidovudine/lamivudine 2ABILIFY 2

* acetaminophen/butalbital 1 ** acetaminophen/butalbital/caffeine 1 ** acetaminophen/butalbital/caffeine/codeine 1 ** acetaminophen/codeine(LiquidisTier2) 1 ** acetaminophen/hydrocodone(LiquidisTier2) 1 ** acetaminophen/oxycodone 1 ** acetazolamide(500mgSequelsareTier2) 1 ** aceticacid 1 *

*aceticacid/aluminumacetateotic(Generic

equivalentofDomeboroOtic) 1 *

* aceticacid/hydrocortisoneliquid 1 ** aceticacid/oxyquin/ricin/glycerin 1 ** acetylcysteine 1 *

acitretin 2§ ACTIMMUNE 2

ACTINEX 2ACTONEL 2ACTOPLUSMET 2

✪ ACTOS(ActoscombinationsalsoTier2) 2✪* acyclovir 1 *

acyclovirtopical 2§ ✔ adalimumab 2

ADDERALLXR 2adefovir 2ADVICOR 2AEROBID,AEROBID-M 2ALBENZA 2

* albuterolmetereddoseinhaler 1 ** albuterolnebulized 1 ** albuteroltablet&oralliquid 1 *

ALDARA 2§ ALDURAZYME 2

albendazole 2alendronate 2ALESSE 2

§ ALFERON-N 2ALKERAN 2

* allopurinol 1 *ALOMIDE 2ALOXI 2

* alprazolam 1 *ALTACE 2altretamine 2aluminumchloride 2

* amantadine 1 *✪ AMBIEN 2✪ AMERGE(Max23mg/30days) 2

AMICAR 2

* amiloride 1 ** amiloride/hctz 1 *

aminocaproicacid 2

��* = Generic✪ = Prior Authorization Program ✔= Requires medical review for coverage § = Specialty drug

��* = Generic✪ = Prior Authorization Program ✔= Requires medical review for coverage § = Specialty drug * = Generic✪ = Prior Authorization Program ✔= Requires medical review for coverage § = Specialty drug

Drug Name Tier§ AVONEX 2

* azathioprine 1 ** azelaicacid 1 ** azithromycin 2 *

AZMACORT 2AZOPT 2

B

* bacitracinophthalmic 1 ** baclofen 1 *

beclomethasoneoralinhaler 2BECLOVENT 2

* belladonna/phenobarbital 1 *benazepril 2benazepril/amlodipine 2

* benazepril/hctz 1 *BENZACLIN 2BENZAMYCIN 2

* benzocaine/antipyrineliquid 1 *benzoylperoxide/clinamycin 2benzoylperoxide/erythromycin 2

* benztropine 1 ** betamethasonedipropionate 1 *

betamethasonedipropionateaugmented 2

* betamethasonevalerate 1 *§ BETASERON 2

betaxololophthalmic 2

* bethanechol 1 *BETOPTIC,BETOPTIC-S 2bicalutamide 2BILTRICIDE 2bimatoprost 2

* bisoprolol/hctz 1 *§ bosentan(Mfrspecialaccessprogram) 2

* brimonidine 1 *brinzolamide 2

* bromocriptine 1 *budesonideinhalationsuspension 2budesonidenasal(IncludingAQ) 2budesonideoralcapsules 2budesonideoralinhaler 2

* bumetanide 1 ** bupropion 1 ** bupropionsr 1 ** bupropionxl 1 *

busulfan 2✪* butorphanol(Max3cannisters/30days) 1 *✪ BYETTA 2

C

* cabergoline 1 *calcipotriene 2

* calcitonininjection 1 *calcitoninnasal 2

* calcitriol 1 *§ capecitabine 2

CAPITROL 2

* captopril 1 *

Drug Name Tier

* captopril/hctz 1 *CARAC 2

* carbacholophthalmic 1 ** carbamazepine 1 ** carisoprodol 1 *

CARMOL40 2CARNITOR 2

* carvedilol 1 *carvedilolCR 2CASODEX 2CEENU 2cefdinirsuspension 2

* cefuroxime 1 *CELLCEPT 2

* cephalexin 1 *§ ✔ CEREZYME 2

CERUMENEX 2CHANTIX 2CHEMET 2CHIBROXIN 2

* chloralhydrate 1 *chlorambucil 2

* chloramphenicol 1 ** chlorhexidine 1 ** chloroquine 1 ** chlorothiazide 1 *

chloroxine 2

* chlorpromazine 1 ** chlorthalidone 1 ** cholestyramine 1 ** cholestyraminelight 1 ** choline/magsalicylates 1 *

ciclopirox 2CILOXIN 2

* cimetidine 1 *§ cinacalcet 2

* ciprofloxacin 1 *ciprofloxacinophthalmic 2

* citalopram 1 *citricacid/gluconicacid 2

* clarithromycin 2 *CLEOCIN 2

* clidinium/chlordiazepoxide 1 ** clindamycin(150mg) 1 ** clindamycintopical 1 *

clindamycinvaginalgel 2clofazimine 2

* clomipramine 1 ** clonazepam 1 ** clonidine 1 ** clonidine/chlorthalidone 1 *

clopidogrel 2

* clotrimazole 1 *clotrimazolevaginalsuppository 1

* clozapine 1 ** codeine 1 ** colchicine 1 *



Drug Name TierCOLESTID 2colestipol 2COMBIPATCH 2COMBIVENT 2COMBIVIR 2COMTAN 2CONCERTA 2conjugatedestrogens(Includesvaginalcream) 2conjugatedestrogens/medroxyprogesterone 2

§ COPAXONE 2COREGCR 2CORTENEMA 2CORTIFOAM 2COSOPT 2CRESTOR 2CRIXIVAN 2

* cromolyninhaled(Allformsarecovered) 1 *crotamiton 2CUPRIMINE 2cyanocobalaminnasal 2CYCLESSA 2

* cyclobenzaprine 1 ** cyclopentolate 1 *

cyclophosphamide 2cycloserine 2

* cyclosporinemicroemulsion 1 *cyclosporineophthalmic 2CYLERT 2

* cyproheptadine 1 *CYTADREN 2CYTOMEL 2CYTOVENE 2CYTOXAN 2

D§ dalteparin 2

* danazol 1 *DANTRIUM 2dantrolene 2DAPSONE 2DARANIDE 2DARAPRIM 2

§ darbepoetin 2darunavir 2

§ ✔ dasatinib 2DDAVPTABLET 2deferasirox 2

§ deferasirox 2demecarium 2DEMSER 2DEMULEN 2DENAVIR 2DEPAKOTE 2

* desipramine 1 ** desmopressinnasal 1 *

desmopressintablet 2desogestrel/ethinylestradiol 2

* desonide 1 ** desoximetasone 1 *

Drug Name TierDETROL(InclLA) 2

* dexamethasone 1 ** dexamethasoneophthalmic(MaxidexisTier2) 1 ** dextroamphetamine(IncludingSR) 1 *

diabeticbloodtestingstrips 2diabeticurinetestingproducts 2DIASTAT 2

* diazepam 1 *diazepamrectal 2DIBENZYLINE 2dichlorphenamide 2

* diclofenac 1 ** diclofenacophthalmic 1 ** dicloxacillin(LiquidisTier2) 1 ** dicyclomine 1 *

didanosine 2dienestrolvaginalcream 2DIFLUCANVC 2

* diflunisal 1 ** digoxin 1 *✪ dihydroergotamine(Max8amps/30days) 2

* diltiazem(AllgenericsareTier1) 1 ** diphenoxylate/atropine 1 ** dipivefrinophthalmic 1 *

DIPROLENE 2DIPROLENEAF 2

* dipyridamole 1 ** disopyramide(IncludingCR) 1 ** disulfiram 1 *

divalproex 2donepezil 2

§ dornasealfa 2dorzolamide 2dorzolamide/timolol 2DOVONEX 2

* doxazosin 1 ** doxepin 1 ** doxycycline 1 *

DRITHOCREME 2DRYSOL 2DUAC 2DUETACT 2DURAGESIC 2DYCLONE 2dyclonine 2

EEBRIVA 2echothiophateophthalmic 2

§ ✔ efalizumab 2efavirenz 2efavirenz/emtricitabine/tenofovir 2EFUDEX 2

✪ eletriptan 2ELIDEL 2ELMIRON 2ELOCON 2EMADINE 2EMCYT 2



Drug Name Tieremedastine 2emtricitabine 2emtricitabine/tenofovir 2

* enalapril 1 ** enalapril/hctz 1 *§ ✔ ENBREL 2§ enfuvirtide 2§ enoxaparin 2

entacapone 2ENTOCORTEC 2epinephrineallergykit 2

* epinephrineophthalmic 1 *epinephrinesyringe 2epinephrylborate 2EPI-PEN 2EPIVIR 2EPPY-N 2ERGAMISOL 2

* ergocalciferol 1 ** ergoloidmesylates 1 *

ERGOMAR 2ergotamine 2

* ergotamine/caff/belladonna/phenobarbital 1 ** ergotamine/caffeine 1 *§ ✔ erlotinib 2

* erythromycin(Allgenericforms) 1 ** erythromycinophthalmic 1 ** erythromycintopical 1 ** erythromycin/sulfisoxazole 1 *§ erythropoietin(Epogenisnon-preferred) 2

ESERINE 2

* esterifiedestrogen 1 *esterifiedestrogens/methyltestosterone 2

* estradiolmicronized(Includesvaginalcream) 1 *

*estradioltransdermalpatch(Strengthsnot

availableasgenericareTier2) 1 *

* estradioltransdermalpatch 1 *estradiolvaginalring 2estradiol/desogestrel 2estradiol/ethynodiol 2estradiol/norethindrone 2estradiol/norethindronetransderm 2estramustine 2ESTRATEST 2ESTRING 2

* estropipate 1 *ESTROSTEPFE 2

§ ✔ etanercept 2ethambutol 2ethinylestradiol/drospirenone 2ethinylestradiol/levonorgestrel 2

*ethinylestradiol/levonorgestrel7/7/7(Triphasil

isTier2) 1 *

ethinylestradiol/norelgestomintransderm 2

*ethinylestradiol/norethindrone(OrthoNovum

isTier2) 1 *

ethinylestradiol/norethindrone 2

* ethinylestradiol/norethindrone10/11 1 *ethinylestradiol/norgestimate 2

Drug Name Tierethinylestradiol/norgestrel 2ETHMOZINE 2

* ethosuximide 1 ** etidronate 1 ** etodolac 1 *

etonoogestrel/ethinylestradiolvaginalring 2

* etoposide 1 *EURAX 2EVISTA 2EXELDERM 2EXELON 2

✪ exenatide 2EXJADE 2

§ EXJADE 2ezetimibe 2

Ffamciclovir 2

* famotidine 1 *✪ FAMVIR 2

FANSIDAR 2FARESTON 2felbamate 2FELBATOL 2FEMARA 2FEMHRT 2fenofibrate 2fentanyltransdermal 2

* fexofenadine 1 *§ filgrastim 2

* finasteride 1 ** flecainide 1 *

FLOMAX 2FLOVENT 2FLOXINOTIC 2

* fluconazole 1 *fluconazole150mgoralsingle-dose 2flucytosine 2FLUDARA 2fludarabine 2

* fludrocortisone 1 ** flunisolidenasal(Genericonly) 1 *

flunisolideoralinhaler 2

* fluocinolone 1 ** fluocinonide 1 ** fluoride 1 ** fluorometholoneophthalmic(FMLisTier2) 1 *

FLUOROPLEX 2fluorouracil 2

* fluoxetine 1 ** fluoxymesterone 1 ** fluphenazine 1 ** flurbiprofen 1 ** flutamide 1 ** fluticasonenasal 1 *

fluticasoneoralinhaleranddiskhaler 2

* folicacid1mg 1 *§ fondaparinux 2



Drug Name Tier✪ FORADIL 2✪ formoterol 2

FORTOVASE 2FOSAMAX 2fosamprenavir 2

* fosinopril 1 ** fosinopril/hctz 1 *§ FRAGMIN 2

FURADANTIN 2furazolidone 2

* furosemide 1 *FUROXONE 2

§ FUZEON 2

G

* gabapentin 1 *GABITRIL 2galantamine 2ganciclovir 2GANTANOL 2

* gemfibrozil 1 ** genericoralcontraceptives(All) 1 ** gentamicin 1 ** gentamicinophthalmic 1 *

GEODON 2§ glatiramer 2

* glimepiride 1 ** glipizide(IncludingXL) 1 ** glucagon 1 ** glyburide 1 *

glycerin 2

* goldsodiumthiomalate 1 *GRANULEX 2

* griseofulvinmicrosize 1 ** griseofulvinultramicrosize 1 *

✔GROWTHHORMONE(preferredbrandswillbe

selectedin2008)* guaifenesin/codeineliquid 1 ** guaifenesin/hydrocodoneliquid 1 ** guanabenz 1 ** guanfacine 1 *

H

* haloperidol 1 ** heparin 1 *

HEPSERA 2HERPLEX 2HEXALEN 2HMS 2

* homatropineophthalmic 1 *HUMALOG 2

§ ✔ HUMIRA 2HUMORSOL 2HUMULIN 2

* hydralazine 1 ** hydrochlorothiazide 1 ** hydrocortisone(2.5%only) 1 ** hydrocortisoneanorectalcream 1 *

hydrocortisoneenema 2

Drug Name Tierhydrocortisonefoam 2

* hydrocortisonetablet 1 ** hydrocortisone/pramoxine 1 ** hydromorphone 1 ** hydroxychloroquine 1 ** hydroxyprogesterone 1 ** hydroxyurea 2 ** hydroxyzine 1 ** hyoscyamine 1 *

I

* ibuprofen 1 *idoxuridine 2

§ ✔ imiglucerase 2

* imipramine 1 *imiquimod 2

✪IMITREX(Max1200mg/30days:4injkits,12

nasalsprays,or24(50mg)tablets) 2

* indapamide 1 *indinavir 2

* indomethacin 1 *insulinaspart 2insulindetemir 2insulinglargine 2insulinglulisine 2insulinlispro 2insulinsyringesandneedles 2insulin,human 2

§ interferonalfa-2a 2§ interferonalfa-2b 2✔ interferonalfa-2b/ribavirin 2§ interferonalfa-n3 2§ interferonbeta-1a 2§ interferonbeta-1b 2§ interferongamma-1b 2§ INTRON-A 2

INVIRASE 2

* iodoquinol 1 *IOPIDINE 2ipratropiummetereddoseinhaler 2ipratropium/albuterolmetereddoseinhaler 2

✪ irbesartan 2✪ irbesartan/hctz 2

* isometheptene/dichloralphenazone/apap 1 ** isoniazid 1 ** isosorbidedinitrate 1 ** isosorbidemononitrate 1 ** isosorbidemononitratesr 1 ** isotretinoin 1 ** isoxsuprine 1 *

ivermectin 2

KKALETRA 2KEPPRA 2KERALYT 2

* ketoconazole 1 *ketotifen 2



Drug Name Tier

L

* labetalol 1 *LACRISERT 2

* lactuloseliquid 1 *LAMICTAL 2lamivudine 2lamivudine/zidovudine 2lamotrigine 2LAMPRENE 2lancets 2LANTUS 2LARODOPA 2

§ laronidase 2latanoprost 2

§ ✔ lenalidomide 2letrozole 2

* leucovorin 1 *LEUKERAN 2

§ LEUKINE 2§ leuprolide 2

levamisole 2LEVEMIR 2levetiracetam 2

* levobunololliquid 1 *levocarnitine 2levodopa 2

* levodopa/carbidopa(IncludingCR) 1 *levonorgestrel/ethinylestradiol 2

* levothyroxine 1 *LEXIVA 2

* lidocaine 1 ** lindane 1 *

liothyronine 2liotrix 2

* lipase/amylase/protease 1 *LIPITOR 2

* lisinopril 1 ** lisinopril/hctz 1 ** lithiumcarbonate(EskalithCRisTier2) 1 ** lithiumcitrate 1 *

lodoxamide 2LOESTRIN,LOESTRIN24 2lomustine 2LOOVRAL 2lopinavir/ritonavir 2LOPROX 2

* lorazepam 1 *LOTENSIN 2LOTREL 2

* lovastatin 1 *§ LOVENOX 2

* loxapine 1 *LUMIGAN 2

§ LUPRON 2LYSODREN 2

Drug Name Tier

M

* maprotiline 1 *masoprocol 2MATULANE 2

✪ MAXALT(Max120mg/30days) 2

* mebendazole 1 ** meclizine 1 ** meclofenamate 1 ** medroxyprogesterone 1 *

medrysoneophthalmic 2

* mefloquine 1 ** megestrol 1 ** meloxicam 1 *

melphalan 2memantine 2

* meperidine 1 ** mephobarbital 1 *

MEPHYTON 2MEPRON 2mercaptopurine 2mesalamine(Enema,suppository) 2mesalamine 2MESTINONSR 2METADATECD 2

* metformin(XRisTier3) 1 ** metformin/glyburide 1 ** methadone 1 ** methazolamide 1 *

METHERGINE 2

* methimazole 1 ** methocarbamol 1 ** methotrexate 1 *

methoxsalen 2

* methylclothiazide 1 ** methyldopa 1 *

methylergonovine 2

* methylphenidate(IncludinggenericSR) 1 *methylphenidateir/er 2

* methylprednisolone 1 ** methyltestosterone 1 *

metipranolol 2

* metoclopramide 1 *metolazone 2

* metoprolol 1 ** metoprololsuccinate 1 *

METROGELVAGINAL 2METROGEL,METROCREAM,METROLOTION 2

* metronidazole(375mgisTier3) 1 *metronidazoletopical 2metronidazolevaginalgel 2metyrosine 2

* mexiletine 1 *MIACALCIN 2

✪ MICARDIS 2✪ MICARDISHCT 2

MICRONOR 2



Drug Name Tier

* midodrine 1 *✪ MIGRANAL(Max8amps/30days) 2

* minocycline 1 ** minoxidil 1 *

MINTEZOL 2MIRAPEX 2MIRCETTE 2

* misoprostol 1 *mitotane 2MOBAN 2

✪ modafinil 2molindone 2mometasone 2mometasoneoralinh 2mometasoneoralinhaleranddiskhaler 2moricizine 2morphine(Suppository) 2

* morphinesulfate 1 ** morphinesulfatesr 1 *

moxifloxacin 2MSCONTIN 2

* multivitamin/fluoridecheworliquid 1 ** multivitamin/fluoride/ironcheworliquid 1 ** mupirocin 1 *

MYAMBUTOL 2MYCELEX-G 1MYCOBUTIN 2mycophenolate 2MYLERAN 2

N

* nadolol 1 *nafarelin 2NAMENDA 2

* naphazoline 1 ** naproxen 1 ** naproxensodium 1 *✪ naratriptan(Max23mg/30days) 2

NARDIL 2NASCOBAL 2NEBUPENT 2nedocromil(Allformsarecovered) 2nelfinavir 2

* neomycin 1 ** neomycin/bacitracin/polymyxin/hcophthalmic 1 ** neomycin/dexamethasoneophthalmic 1 ** neomycin/polymyxin/bacitracinophthalmic 1 ** neomycin/polymyxin/dexamethasoneophthalmic 1 ** neomycin/polymyxin/gramicidinophthalmic 1 ** neomycin/polymyxin/hcophthalmic 1 ** neomycin/polymyxin/hcotic 1 *

neomycin/polymyxin/predophthalmic 2neostigmine 2

§ NEUMEGA 2§ NEUPOGEN 2

nevirapine 2§ ✔ NEXAVAR 2

niacinsr 2niacinsr/lovastatin 2

Drug Name TierNIASPAN 2nicotinenasalspray 2NICOTROLNS 2

* nifedipine 1 ** nifedipinecc 1 *

NILANDRON 2nilutamide 2nimodipine 2NIMOTOP 2nitrofurantoin 2

* nitrofurantoinmacro 1 ** nitrofurantoinmonohydratemacro 1 ** nitroglycerinoral 1 *

nitroglycerinsl 2

* nitroglycerintransdermal 1 *NITROSTAT 2

* nizatidine 1 *NORDETTE 2

* norethindrone 1 *norfloxacin 2NOR-QD 2

* nortriptyline 1 *NORVASC 2NORVIR 2NOVOLIN 2NOVOLOG 2NUVARING 2

* nystatin 1 ** nystatinvaginal 1 ** nystatin/triamcinolone 1 *

O§ octreotide 2

OCUFLOX 2

* ofloxacin 1 *ofloxacin 2olanzapine 2olopatadine 2

✪* omeprazole(Exceptionrequiredfor>90-dayRx) 1 *OMNICEFSUSPENSION 2

* ondansetron 1 *§ oprelvekin 2

OPTIPRANOLOL 2ORTHOEVRA 2ORTHONOVUM 2ORTHONOVUM10/11 2ORTHONOVUM7/7/7 2ORTHO-CEPT 2ORTHO-CYCLEN 2ORTHO-DIENESTROL 2ORTHO-TRICYCLEN 2ORTHO-TRICYCLENLO 2oseltamivir 2OSMOGLYN 2OVCON 2OVRAL 2oxcarbazepine 2OXSORALEN 2

* oxybutynin(XLisTier3) 1 *

�0* = Generic✪ = Prior Authorization Program ✔= Requires medical review for coverage § = Specialty drug


Drug Name Tieroxybutynintransdermal 2OXYTROL 2

Ppalonosetron 2

* pancrelipase 1 ** paregoric 1 ** paromomycin 1 ** paroxetine(IncludingCR) 1 *

PATANOL 2

* pegelectrolytebowelprep 1 *§ ✔ PEGASYS 2§ ✔ peg-interferonalfa-2a 2§ ✔ peg-interferonalfa-2b 2§ ✔ PEG-INTRON 2§ pegvisomant

pemoline 2penciclovircream 2penicillamine 2

* penicillin 1 ** pentamidineinjection 1 *

pentamidinenebulized 2PENTASA 2pentazocine/naloxone 2pentosanpolysulfatesodium 2

* pentoxifylline 1 ** permethrin 1 ** perphenazine 1 ** phenazopyridine 1 *

phenelzine 2pheniramine/pyrilamine/phenyltoloxamine(Liquid) 2

* phenobarbital 1 *phenoxybenzamine 2phentolaminemesylate 2

* phenylephrine 1 *

*phenylephrine/chlorpheniramine/hydrocodone

liquid 1 *

PHENYTEK 2

* phenytoin 1 *PHOSPHOLINEIODIDE 2physostigmine 2phytonadione 2

* pilocarpine 1 ** pilocarpineophthalmic 1 ** pilocarpine/epinephrineophthalmic 1 *

pimecrolimus 2

* pindolol 1 *✪ pioglitazone(ActoscombinationsalsoTier2) 2

pioglitazone/glimepiride 2pioglitazone/metformin 2

* piroxicam 1 *PLAVIX 2

* podofilox 1 *POLYHISTINE(Liquid) 2POLY-PRED 2

* potassium(Allgenerics) 1 ** potassiumiodide 1 *

pramipexole 2pramlintide 2

Drug Name Tier

* pravastatin 1 *praziquantel 2

* prazosin 1 ** prednisolone 1 ** prednisoloneophthalmic 1 ** prednisone 1 *

PREMARIN(Includesvaginalcream) 2PREMPRO,PREMPHASE 2

* prenatalvitamins 1 *PREZISTA 2

* primaquine 1 ** primidone 1 ** probenecid 1 *

procainamide(AllgenericsareTier1) 2PROCANBID(AllgenericsareTier1) 2procarbazine 2

* prochlorperazine 1 *§ PROCRIT(Epogenisnon-preferred) 2

PROFENAL 2

* progesteroneinjection 1 *progesteronemicronized 2PROGRAF 2

* promethazine 1 ** promethazine/codeinesyrup 1 ** promethazine/dextromethorphanliquid 1 ** promethazine/pe/codeinesyrup 1 *

PROMETRIUM 2

* propafenone(300mgisTier2) 1 ** propantheline 1 ** propoxyphene(AllgenericcombinationsareTier1) 1 ** propranolol(IncludingLA) 1 ** propranolol/hctz 1 ** propylthiouracil 1 *

PROSTIGMIN 2

* protriptyline 1 *✪ PROVIGIL(TentativelyPreferredasof10/05) 2

* pseudoephedrine/chlorpheniramine 1 ** pseudoephedrine/guaifenesinla 1 *

PULMICORT 2PULMICORTRESPULES 2

§ PULMOZYME 2PURINETHOL 2

* pyrazinamide 1 ** pyridostigmine 1 *

pyridostigminesr 2pyrimethamine 2pyrimethamine/sulfadoxine 2

Qquetiapine 2

* quinapril 1 ** quinidine(Brand-onlyformsareTier2) 1 ** quinine 1 *

Rraloxifene 2ramipril 2

* ranitidine 1 *§ ✔ RAPTIVA 2

�0* = Generic✪ = Prior Authorization Program ✔= Requires medical review for coverage § = Specialty drug


Drug Name Tier✔ REBETRON 2

REGITINE 2✪ RELPAX 2

RENACIDIN 2REQUIP 2

* reserpine 1 *RESTASIS 2

§ ✔ REVLIMID 2REYATAZ 2REZADYNE 2RHINOCORT(IncludingAQ) 2

§* ribavirin 1 *RIDAURA 2rifabutin 2

* rifampin 1 *RILUTEK 2riluzole 2risedronate 2RISPERDAL(Liquidnotcovered) 2risperidone(Liquidnotcovered) 2ritonavir 2rivastigmine 2

✪ rizatriptan(Max120mg/30days) 2RMS(Suppository) 2

§ ROFERON-A 2ropinirole 2

✪ rosiglitazone(AvandiacombinationsalsoTier2) 2rosiglitazone/glimepiride 2rosiglitazone/metformin(Avandiacombinations

alsoTier2) 2

rosuvastatin 2ROWASA(Enema,suppository) 2

Ssalicylicacid 2

✪ salmeterol(IncludingDiskus) 2

* salsalate 1 *SANDIMMUNE 2

§ SANDOSTATIN 2saquinavir 2

§ sargramostim 2scopolamine 2SEBIZON 2

* selegiline 1 ** seleniumsulfide 1 *§ SENSIPAR 2✪ SEREVENT(IncludingDiskus) 2

SEROMYCIN 2SEROQUEL 2

* sertraline 1 ** silversulfadiazine 1 ** simvastatin 1 *

simvastatin/ezetimibe 2

* sodiumpolystyrenesulfonateliquid 1 *SOLGANAL 2

§ SOMAVERT§ ✔ sorafenib 2

SORIATANE 2

* sotalol 1 *

Drug Name TierSPIRIVA 2

* spironolactone 1 ** spironolactone/hctz 1 *§ ✔ SPRYCEL 2

stavudine 2✪ STRATTERA 2

* streptomycin 1 *STROMECTOL 2succimer 2

* sucralfate 1 *sulconazolenitrate 2sulfacetamide 2

* sulfacetamideophthalmic 1 ** sulfacetamide/prednisoloneophthalmic 1 ** sulfacetamide/sulfur 1 ** sulfadiazine 1 *

sulfamethoxazole 2sulfanilamidevaginalgel 2

* sulfasalazine(IncludingEC) 1 ** sulfinpyrazone 1 ** sulfisoxazole(LiquidisTier2) 1 ** sulindac 1 *✪

sumatriptan(Max1200mg/30days:4injkits,12nasalsprays,or24(50mg)tablets) 2

§ ✔ sunitinib 2suprofen 2SUSTIVA 2

§ ✔ SUTENT 2SYMLIN 2SYNAREL 2

Ttacrolimus 2TALWINNX 2TAMIFLU 2

* tamoxifen 1 *tamsulosin 2

§ ✔ TARCEVA 2TARKA 2tazarotene 2TAZORAC 2

✪ telmisartan 2✪ telmisartan/hctz 2

* temazepam 1 *tenofovir 2TERAZOL7 2

* terazosin 1 ** terbutaline 1 *

terconazolevaginalcream 2TESLAC 2testolactone50mg 2testosteronetransdermalgel 2testosteronetransdermalpatch 2

* tetracycline 1 *§ thalidomide 2§ THALOMID 2

* theophylline 1 ** theophyllinesr 1 *

thiabendazole 2


Drug Name TierTHIOGUANINE 2

* thiothixene 1 *THYROID 2THYROLAR 2tiagabine 2TICLID 2ticlopidine 2TILADE(Allformsarecovered) 2

* timolol 1 ** timololophthalmic 1 *

TINDAMAX 2tinidazole 2tiotropium 2tipranavir 2

* tizanidine 1 *§ TOBI 2

TOBRADEX 2§ tobramycinnebulized 2

* tobramycinophthalmic 1 *tobramycin/dexamethasoneophthalmic 2

* tolazamide 1 ** tolmetin 1 *

tolterodine(InclLA) 2TOPAMAX 2topiramate 2toremifene 2

* torsemide 1 *§ TRACLEER(Mfrspecialaccessprogram) 2

trandolapril/verapamil 2TRANSDERM-SCOP 2

* tranylcypromine 1 *TRAVATAN 2travoprost 2

* trazodone 1 ** tretinoin 1 *

tretinoin 2

* triamcinolone 1 ** triamcinoloneinorabase 1 *

triamcinoloneoral 2triamcinoloneoralinhaler 2

* triamterene/hydrochlorothiazide 1 ** triazolam 1 *

TRICOR 2triethanolamine 2

* trifluoperazine 1 *trifluridineophthalmic 2

* trihexyphenidyl 1 *TRILEPTAL 2

* trimethoprim/polymixinb 1 ** trimethoprim/sulfamethoxazole 1 *

trioxsalen 2TRIPHASIL 2

* triplesulfavaginalcream 1 *TRISORALEN 2TRIZIVIR 2

* tropicamide 1 *

Drug Name TierTRUSOPT 2TRUVADA 2trypsin 2

Uurea40% 2

* ursodiol 1 *

Vvalacyclovir 2VALCYTE 2valganciclovir 2

* valproicacid 1 *✪ VALTREX 2

VANCERIL(IncludingDS) 2VANCOCIN 2vancomycin 2varenicline 2

* venlafaxine 1 ** verapamil(IncludingSR) 1 *

VESANOID 2vidarabineophthalmic 2VIDEX 2VIRA-A 2VIRACEPT 2VIRAMUNE 2VIREAD 2VIROPTIC 2

* vitamina 1 ** vitaminsacd/fluoride/ironcheworliquid 1 *

VIVELLE(InclVivelleDot) 2§ ✔ vorinostat 2

VYTORIN 2

WXYZ

* warfarin 1 *XALATAN 2

§ XELODA 2YASMIN 2YAZ 2ZADITOR 2ZAROXOLYN 2ZERIT 2ZETIA 2ZIAGEN 2

* zidovudine 1 *ziprasidone 2

§ ✔ ZOLINZA 2✪ zolpidem 2

ZONEGRAN 2zonisamide 2ZOVIRAXTOPICAL 2ZYPREXA 2


AppendixCommonly prescribed Tier 3 drugs with alternatives

Some drugs that are not on the Preferred Drug List have possible alternatives. These are similar drugs that are on the Preferred Drug List. The list on the following pages includes the most commonly prescribed Tier 3 drugs and their Tier 1 or Tier 2 alternatives.

In many cases, it is appropriate to try an alternative to a Tier 3 drug; however, only the doctor or practitioner who prescribed the drug for you can determine whether it would be appropriate to try the suggested alternative. Please ask your doctor or practitioner for advice if you are interested in taking advantage of the lower copay opportunity.

��

Tier 3 Drug Suggested Alternative(s) Tier 1 Tier 2

ACHIPEX omeprazolePrilosecOTC(notcovered,butavailablefor$16-25fora30-daysupply.)

X

ACTIVELLA PREMPRO,FEMHRT X

ADVAIR FLOVENT,orFLOVENT+SEREVENT X

ALLEGRAALLEGRA-D

Nonprescriptiongenericloratadine(notcovered,butavailableinstoresfor$15-20fora30-daysupply.)

AMARYL glyburide,glipizide X

AMBIEN temazepam,triazolam X

ANZEMET ondansetron X

ATACAND MICARDIS,AVAPRO X

AVIANE ALESSE X

CEFZIL amoxicillin,cephalexin,defuroxime X

CELEBREX ibuprofen,naproxen,sulindac,diclofenac X

CENESTIN PREMARIN X

CLARINEX NonprescriptionALAVERTorgenericloratadine(notcovered,butavailableinstoresfor$15-20fora30-daysupply.)

COVERAHS verapamillong-acting X

DAYPRO ibuprofen,naproxen,indomethacin,piroxicam,sulindac

X

DESOGEN ORTHO-CEPT X

DIFFERIN RETIN-A X

DITROPANXL oxybutyninDETROLLA

X X

��

Tier 3 Drug Suggested Alternative(s) Tier 1 Tier 2

EFFEXORXRcapsules,extendedrelease

venlafaxinetablets X

KYTRIL ondansetron X

LESCOL lovastatin,simvastatinLIPITOR,CRESTOR,VYTORINORPRAVACHOL

X X

LEVAQUIN AVELOX X

LEXAPRO citalopram X

LUNESTA zolpidem X

MOBIC ibuprofen,naproxen,sulindac,diclofenac X

NASONEX fluticasonepropionateRHINOCORT

X X

ORTHO-PREFEST

FEMHRT,PREMPRO X

OXYCONTIN morphinesulfatelong-acting X

PAXILCR fluoxetine,paroxetine,citalopram X

PLENDIL nifedipinelong-actingamlodipine

XX

PREVACID omeprazolePROTONIXPrilosecOTC(notcovered,butavailablefor$16-25fora30-daysupply.)

X X

PROTOPIC ELIDEL X

ROZEREM zolpidem X

SKELAXIN carisoprodol,cyclobenzaprine,methocarbamol X

SONATA temazepam,triazolam,zolpidem X

SPORANOX terbinafine X

SULAR nifedipinelong-acting,amlodipine X

TIAZAC diltiazemlong-acting X

TORADOL ibuprofen,naproxen,sulindac,diclofenac X

ULTRACET acetaminophen+tramadol X

ULTRAVATE clobetasol,betamethasonedipropionateaugmented

X

VAGIFEM PREMARINVAGINALCREAM,ESTRING X

VANTIN cefuroxime X

VASOTEC enalapril,lisinopril,fosinopril,quinapril X

VICOPROFEN hydrocodone+acetaminophen X

ZOLOFT sertraline X

ZOMIG AXERT,MAXALT,IMITREX X

ZYRTECZYRTECD

NonprescriptionALAVERTorgenericloratadine(notcovered,butavailableinstoresfor$15-20fora30-daysupply.)

��

Commonly prescribed Tier 3 drugs with generic equivalents

Brand-name drugs that have generic equivalents are not on the Preferred Drug List. These brands are Tier 3, but their generic equivalents are Tier 1. Unless your doctor or practitioner has specified that you must have a brand-name drug, your pharmacist can substitute the generic product at your request. (Availability of Tier 1 copay is subject to generic product availability at the pharmacy. From time to time, generics of a particular drug may be unavailable.)

Brand Name Generic Equivalent (Tier 3) (Tier 1)

ACCUPRIL quinaprilACCUTANE isotretinoinADALAT-CC nifedipine-ERALDACTONE spironolactoneALPHAGAN brimonidineeyedropsAMBIEN zolpidemAMOXIL amoxicillinANAPROX naproxensodiumANTABUSE disulfiramARISTOCORT triamcinoloneATIVAN lorazepamAUGMENTIN amoxicillin/clavulanicacidAURALGAN benzocaine/antipyrineeardropsAXID nizatidineAYGESTIN norethindroneAZELEX azelaicacidAZULFIDINE sulfasalazineBACTRIM trimethoprim/sulfamethoxazoleBACTROBAN mupirocinointmentBENTYL dicyclomineBETAGAN levobunololeyedropsBETAPACE sotalolBUMEX bumetanideBUSPAR buspironeCARAFATE sucralfateCARDIZEM diltiazemCARDURA doxazosinCATAPRES clonidineCECLOR cefaclorCEFTIN cefuroximeCELEXA citalopramCEPHULAC lactuloseliquidCIPRO ciprofloxacinCLEOCIN-T clindamycintopicalCLINORIL sulindacCLOZARIL clozapineCOLYTE PEGelectrolyteliquidCOMPAZINE prochlorperazineCOPEGUS ribavirinCORDARONE amiodaroneCOUMADIN warfarinCREON lipase/amylase/protease


CYCRIN nadololCYTOTEC misoprostolDANOCRINE danazolDARVOCET propoxyphene/acetaminophenDARVON propoxyphene/acetaminophenDAYPRO oxaprozinDEMEROL meperidineDEXEDRINE dextroamphetamineDIAMOX acetazolamideDIFLUCAN fluconazoleDILAUDID hydromorphoneDIPROLENE,DIPROSONE betamethasonedipropionateDISALCID salsalateDITROPAN oxybutyninDOLOBID diflunisalDYAZIDE triamterene/hydrochlorothiazideEFUDEX fluorouracilsolutionELDEPRIL selegilineELIMITE permethrinEPIFRIN epinephrineeyedropsESTRACE micronizedestradiolESTRATAB esterifiedestrogenFELDENE piroxicamFIORICET acetaminophen/butalbital/caffeineFIORINAL aspirin/butalbital/caffeineFLAGYL metronidazoleFLEXERIL cyclobenzaprineFLORINEF fludrocortisoneFML fluorometholoneopthalmicFLOXIN ofloxacinGLUCOPHAGE metforminGLUCOTROL glipizideGLUCOVANCE glyburide/metforminGOLYTELY PEGelectrolyteliquidHALCION triazolamHALDOL haloperidolHYTRIN terazosinIMDUR isosorbidemononitratesrIMURAN azathioprineINDERAL propranololINDOCIN indomethacinINTAL cromolyninhaled

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ISORDIL isosorbidedinitrateKAYEXALATE sodiumpolystyrenesulfonateKEFLEX cephalexinKENALOG triamcinoloneKLONOPIN clonazepamKWELL lindaneLAC-HYDRIN ammoniumlactateLANOXIN digoxinLASIX furosemideLEVSIN hyoscyamineLIBRAX clidinium/chlordiazepoxideLIDEX fluocinonideLOMOTIL diphenoxylate/atropineLOPID gemfibrozilLOPRESSOR metoprololLOPROX ciclopiroxLOTENSIN benazeprilLOTENSINHCT benazepril/HCTZLOTRIMIN clotrimazole1%LOXITANE loxapineLUVOX fluvoxamineMAXZIDE triamterene/hydrochlorothiazideMEGACE megestrolMETROCREAM metronidazoletopicalMEVACOR lovastatinMEXITIL mexiletineMIACALCIN calcitonininjectionMICRONASE glyburideMIDRIN isomethepene/

dichloralphenazone/apapMINIPRESS prazosinMODURETIC amiloride/hctzMONOPRIL fosinoprilMOTRIN ibuprofenMUCOMYST acetylcysteineMYCELEX clotriamzoletrochesMYCOLOG nystatin/triamcinoloneMYCOSTATIN nystatinMYSOLINE primidoneNAPROYSN naproxenNEORAL cyclosporinemicroemulsionNEURONTIN gabapentinNITOBID nitroglyercinoralNIZORAL ketoconazoleNORMODYNE labetalolNORPACE disopyramideNORVASC amlodipineNULYTELY PEGelectrolyteliquidOCUFEN flurbiprofenOCUFLOX ofloxacinOGEN estropipateORAMORPH morphinesulfatesrORTHONOVUM ethinylestradiol/norethindronePAMELOR nortriptylinePANCREASE pancrelipasePARLODEL bromocriptinePAXIL paroxetine


PEDIAZOLE erythromycin/sulfisoxazolePEPCID famotidinePERCOCET oxycodone/acetaminophenPERCODAN oxycodone/aspirinPERIACTIN cyproheptadinePHENERGAN promethazinePHRENILIN acetaminophen/butalbitalPLAQUENIL hydroxychloroquinePOLYTRIM trimethoprim/polymixinbPRILOSEC omeprazolePRINIVIL lisinoprilPRINIZIDE lisinopril/hctzPROCARDIAXL nifedipneXLPROCTOFOAM-HC hydrocortisone/parmoxinePROLIXIN fluphenazinePROPINE dipivefrineyedropsPROVENTIL albuterolPROVERA medroxyprogesteronePROZAC fluoxetinePYRIDIUM phenazopyridineQUESTRAN chloestyrmaineQUINIDEX quindineREBETOL ribavirinREGLAN metoclopramideRELAFEN nabumetoneREMERON mirtazepineRESTORIL temazepamRETIN-A tretinoinRHEUMATREX methotrexateRIMACTANE rifampinRITALIN methylphenidateROBAXIN methocarbamolROBITUSSINAC guaifenesin/codeineliquidROCALTROL calcitriolROXICODONE oxycodone/acetaminophenRYTHMOL propafenoneSARAFEM fluoxetineSELSUN seleniumsulfideSEPTRA trimethoprim/sulfamethoxazoleSIVALDENE silversulfadiazineSINEMET levodopa/carbidopaSOMA carisoprodolSSKI potassiumiodideSTADOL butorphanolSTELAZINE trifluoperazineSULFACET-R sulfacetamide/sulfurSYMMETREL amantadineSYNALAR fluocinoloneSYNTHROID levothyroxineTAGAMET cimetidineTAMBOCOR flecainideTAPAZOLE methimazoleTEGRETOL carbamazepineTENEX guanfacineTENORETIC atenolol/chlorthalidoneTENORMIN atenololTERAZOL7 terconazolevaginalcream


THEO-DUR theophyllinesrTHORAZINE chlorpromazineTIAZAC diltiazemsrTICLID ticlopidineTIMOPTIC timololeyedropsTOLFRANIL imipramineTOLECTIN tolmetinTOPICORT desoximetasoneTRENTAL pentoxifyllineTRI-VIFLOR vitaminsacd/fluoride/ironTRILAFON perphenazineTRILISATE choline/magsalicylatesTRI-LEVLEN levonorgestrel/ethinylestradiolTRIVORA ethinylestradio/

levonorgestrelTYLENOL/CODIENE acetaminophen/codeineTYLOX acetaminophen/oxycodoneULTRAM tramadolURECHOLINE bethanecholVALISONE betamethasonevalerateVALIUM diazepamVASODILAN isoxsuprineVASORETIC enalapril/hctzVASOTEC enalaprilVEPESID etoposideVERMOX mebendazoleVIBRAMYCIN doxycyclineVICODIN acetaminophen/hydrocodoneVISKEN pindololVISTARIL hydroxyzineVIVACTIL protriptylineVOLTAREN diclofenacVOSOLHC aceticacid/

hydrocortisoneliquidWELLBUTRIN bupropionWYTENSIN guanabenzXANAX alprazolamXYLOCAINE lidocaineYODOXIN iodoquinolZANAFLEX tizanidineZANTAC ranitidineZARONTIN ethosuximideZAROXOLYN metolazoneZEPHREXLA pseudoephedrine/

guafenesinlaZESTORETIC lisinopril/hctzZESTRIL lisinoprilZIAC bisoprolol/hctzZOCOR simvastatinZOFRAN ondansetronZOLOFT sertralineZOVIRAX acyclovir

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Cost-Saving Tips:• Askyourdoctortoprescribeagenericdrugwhenappropriate.Allgeneric

drugsarecoveredandhavethelowestcosttoyou.

• Ifanexactgenericequivalentforthedrugyouaretakingisnotavailable,askyourdoctorwhetherthereisasimilargenericdrugthatmightworkaswellforyou.

• FindoutwhetheradrugisonthePreferredDrugListbyusingthesearchablePreferredDrugListatourWebsitelistedonthebackofyourPremeraIDcard.

• Askyourpharmacisttofillyourprescriptionswithagenericdrugwhenallowed.

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An independent licensee of the Blue Cross Blue Shield Association 037397 (11-06-2019)

Discrimination is Against the Law

Premera Blue Cross (Premera) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Premera does not exclude people or treat them differently because of race, color, national origin, age, disability, sex, gender identity, or sexual orientation. Premera provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print, audio, accessible electronic formats, other formats). Premera provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, contact the Civil Rights Coordinator. If you believe that Premera has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator ─ Complaints and Appeals, PO Box 91102, Seattle, WA 98111, Toll free: 855-332-4535, Fax: 425-918-5592, TTY: 711, Email [email protected]. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Ave SW, Room 509F, HHH Building, Washington, D.C. 20201, 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Language Assistance ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 800-722-1471 (TTY: 711). 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 800-722-1471（TTY：711）。 CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 800-722-1471 (TTY: 711). 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 800-722-1471

(TTY: 711) 번으로 전화해 주십시오. ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 800-722-1471

(телетайп: 711). PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad.

Tumawag sa 800-722-1471 (TTY: 711). УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби

мовної підтримки. Телефонуйте за номером 800-722-1471 (телетайп: 711). ប្រយ័ត្ន៖ បរើសិនជាអ្នកនិយាយ ភាសាខ្មែរ, បសវាជំនួយខ្ននកភាសា បោយមិនគិត្ឈ្ន លួ

គឺអាចមានសំរារ់រំបរ ើអ្នក។ ចូរ ទូរស័ព្ទ 800-722-1471 (TTY: 711)។ 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。800-722-1471（TTY:711）まで、お電話にてご連絡ください。

ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር ይደውሉ

800-722-1471 (መስማት ለተሳናቸው: 711). XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 800-722-1471 (TTY: 711).

.(711: والبكم الصم هاتف رقم) 800-722-1471 برقم اتصل. بالمجان لك تتوافر اللغوية المساعدة خدمات فإن اللغة، اذكر تتحدث كنت إذا: ملحوظةਧਿਆਨ ਧਿਓ: ਜੇ ਤੁਸੀਂ ਪੰਜਾਬੀ ਬੋਲਿੇ ਹੋ, ਤਾਂ ਭਾਸ਼ਾ ਧਵਿੱਚ ਸਹਾਇਤਾ ਸਵੇਾ ਤੁਹਾਡੇ ਲਈ ਮੁਫਤ ਉਪਲਬਿ ਹੈ। 800-722-1471

(TTY: 711) 'ਤੇ ਕਾਲ ਕਰੋ। ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung.

Rufnummer: 800-722-1471 (TTY: 711).

ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວົ້າພາສາ ລາວ, ການບໍລິການຊ່ວຍເຫຼືອດ້ານພາສາ, ໂດຍບໍ່ເສັຽຄ່າ, ແມ່ນມີພ້ອມໃຫ້ທ່ານ. ໂທຣ 800-722-1471 (TTY: 711).

ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 800-722-1471 (TTY: 711). ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 800-722-1471 (ATS : 711). UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 800-722-1471 (TTY: 711). ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 800-722-1471 (TTY: 711). ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero

800-722-1471 (TTY: 711). .ديریبگ تماس TTY: 711)-722-800) 1471 با. باشد یم فراهم شما یبرا گانيرا بصورت یزبان التیتسه د،یکن یم گفتگو فارسی زبان به اگر: توجه

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