40625NYMENEBS Effective 1/15

Select Drug ListPending Regulatory Approval

3 Tier Formulary

2B_5215655_1078231 40625NYMENEBS 2015 EBS Select Drug List SH 09 14

1

Empire BlueCross Select Drug List

Your prescription drug benefit includes coverage for medicines that you’ll find on the Select Drug List. You can often find more savings when your doctor prescribes medicine that is on our Select Drug List. Here are some commonly asked questions and answers about how the Select Drug List works with your prescription drug plan.

Q. What is a Select Drug List?

A. The Drug List that identifies the prescription drugs covered under Empire’s Individual and Small Group benefit plans is called the “Select Formulary.” It contains the prescription drugs subject to coverage if you buy (1) an Empire Individual plan on the New York State of Health Marketplace (“Marketplace”) or (2) an Individual or Small Group plan directly from Empire outside of the Marketplace. The Select Formulary has three levels, or tiers, and includes a select number of drugs in different categories and classes. The Select Formulary is available online at www.empireblue.com/EBSSelectdrugtier3. You can also find out if a specific drug is on the Select Formulary by calling the number on your ID card.

Q. What are Tiers?

A. Drugs on the Select Drug List are grouped into tiers. There are several factors that are used to determine under which tier a drug will be put in. This can include (but it’s not limited to):

�} Cost of the drug

�} Cost of the drug in comparison to other drugs used for

the same type of treatment

�} Availability of over-the-counter options

�} Other clinical and cost factors.

Q. What is a brand-name drug?

A. These are drugs that are developed by a company who holds the rights to sell them. When the rights expire, other drug companies can make their own version of the drugs (see generic drugs below). You may be more familiar with brand-name drugs through advertising or because you know people who take them.

Q. What is a generic drug?

A. Generics are simply copies of brand-name drugs. Brand-name and generic drugs have the same active ingredients, strength and dose. And the FDA requires that generic drugs meet the same high standards for purity, quality, safety and strength.

Q. Is this list a complete listing of all covered drugs

under the Select Drug List?

A. No. This piece lists the most commonly used drugs that are covered as part of the Select Drug List. If the drug you are looking for is not listed, you may call customer service for more information.

Q. What if my medication is not on the Select Drug List?

A. You may want to first check with your doctor about prescribing a drug that is on the Select Drug List. If your doctor prescribes a drug that’s not on the Select Drug List, you will have to pay the amount described in your policy for non-formulary drugs.

Q. Can I request that a drug be added to the

Select Drug List?

A. You or your doctor can put in a request to add a drug to the Select Drug List. You can do this either in writing or on our website. Requests are reviewed by the P&T Process team during the Select Drug List review. Please

note that if a drug request is approved, it does not

guarantee coverage. Some drugs, such as those used

for cosmetic purposes, may be excluded from your

benefits. Please refer to your insurance Certificate or

Evidence of Coverage to know for sure.

Q. What if my medication is not covered?

A. You may want to first check with your doctor about prescribing a drug that is covered. If your doctor prescribes a drug that’s not covered, you will need to pay the out of pocket cost that applies to drugs not on the formulary.

Preventive Care Drugs: We cover preventive care drugs with zero cost share in compliance with the Affordable Care Act (ACA).

Please note: In selecting medications for the prescription drug list, the therapeutic efficacy and cost effectiveness are addressed for each category. All therapeutic categories are represented on the drug list by at least one medication. When a closed drug list is in effect, only medications that are included on the drug list are a covered service. In certain clinical situations, a member may require use of a non-covered product. Empire has criteria that permits a member to obtain a non-covered medication in a closed drug list plan. If specific criteria are met, a member can receive a non-covered drug for a drug list co-pay. The criteria preserves the clinical integrity of the drug list and provides a process by which deviations from the drug list may be allowed. An appeals process is in place for any medications that do not meet the criteria.

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Tier 1

Acarbose

Acebutolol

Acetasol HC

Acetazolamide tab, ER cap

Aclometasone

Acticin

Acyclovir tab, cap, oral susp.

Adapalene

Afeditab CR QL DO

Albuterol inhl soln., syrup

Alendronate QL

Alfuzosin

Allopurinol tab

Alprazolam tab

Amantadine

Amcinonide

Amiloride tab

Amitriptyline

Amlodipine QL DO

Amlodipine/atorvastatin

QL DO

Amlodipine/benazepril

Ammonium lactate cream, lotion

Amnesteem PACAmoxapine

Amoxicillin

Amoxicillin/clavulanate

Amoxicillin/clavulanate ER

Amphetamine/dextroamphetamine salts, ER PA QL

Androxy PA

Antipyrine/benzocaine ear drop

Apraclonidine

Atenolol

Atenolol/chlorthalidone

Atorvastatin QL DO

Atovaquone/proguanil

Azelastine nasal spray, drops QL

Azithromycin tab, susp., packet QL

Bacitracin/polymixin B

Baclofen

Balsalazide

Benazepril

Benazepril/HCTZ

Benzonatate

Benzoyl peroxide

Benztropine

Betamethasone dipropionate

Betamethasone valerate

Betaxolol

Birth Control (generic oral contraceptives)

Bisoprolol

Bisoprolol/HCTZ

Brimonidine

Bromocriptine

Budesonide 0.25mg/2mL, 0.5mg/2mL QL

Bumetanide tab

Buprenorphine tab PA QL

Bupropion QL

Bupropion SR, XL QL DO

Buspirone

Butalbital/acetaminophen

Butalbital/acetaminophen/caffeine

Butalbital/acetaminophen/caffeine/codeine QL

Butalbital/aspirin/caffeine

Butalbital/aspirin/caffeine/codeine

Butorphanol nasal spray

PA QL

Cabergoline

Calcipotriene

Calcitriol cap, soln, oint

Candesartan QL DO

Candesartan/HCTZ QL DO

Captopril

Carbamazepine, ER, XR

Carbidopa/Levodopa, ER, ODT

Carbinoxamine

Carisoprodol

Carteolol

Cartia XT QL DO

Carvedilol

Cefaclor, ER

Cefadroxil

Cefdinir

Cefditoren Pivoxil

Cefprozil

Cefuroxime Axetil

Cephalexin

Cetirizine syrup QL

Chlorhexidine gluconate

Chlorhexidine Rinse

Chloroquine

Chlorothiazide tab

Chlorpromazine tab PA

Chlorpropamide

Chlorthalidone

Chlorzoxazone

Cholestyramine

Ciclopirox

Cimetidine tab, soln.

Ciprofloxacin ear and eye drops

Ciprofloxacin tab QL

Citalopram QL DO

Claravis PA

Clarithromycin, ER

Clemastine 2.68mg

Clemastine syrup

Clindamycin cap, oral soln, topical preparations

Clindamycin/Benzoyl Peroxide Gel

Clobetasol

Clomipramine

Clonazepam, ODT

Clonidine ER PA

Clonidine tab

Clopidogrel QL

Clotrimazole 1% cream, troche

Clotrimazole/betamethasone

Codeine sulfate tabs QL

Codeine/acetaminophen

QL

Codeine/butalbital/aspirin/caffeine

Colestipol

Cortisone tab

Covaryx, H.S.

Cromolyn eye drops QL

Cromolyn neb soln.

Cyclobenzaprine tab

Cyproheptadine

Depade

Dermazene

Desloratadine, ODT QL

Desmopressin nasal spray, tab PA

Desonide

Desoximetasone

Dexamethasone eye drop

Dexamethasone tab, oral soln.

Dexchlorpheneramine

Dexmethylphenidate, ER

PA QL

Dextroamphetamine, ER

PA QL

Diazepam tab, oral soln.

Diclofenac eye drop

Diclofenac, ER

Dicloxacillin

Dicylomine cap, tab, syrup

Diflorasone

Diflunisal

Digoxin tab, oral soln.

Diltiazem

Diltiazem ER, XR, CD

QL DO

Diphenhydramine 50mg cap

Diphenoxylate/atropine

Dipyridamole tab

Disopyramide

Disulfiram

Divalproex, ER, DR

Donepezil 5mg, 10mg, ODT QL

Dorzolamide eye drops

Dorzolamide/timolol eye drops

Doxazosin

Doxepin

Doxycycline hyclate tab, cap

Doxycycline hyclate, delayed release PA

Doxycycline monohydrate tab, cap

Econazole

Enalapril

Enalapril/HCTZ

Endocet QL

Endodan QL

Epidrin

Epinastine eye drops QL

Epitol

For more information about your drug plan, you can do the following:

�} Go to empireblue.com.

�} Call Customer Service at

the number on your ID card.

�} Speech and hearing

impaired users (TDD/TTY)

should call 800-221-6915,

Monday – Friday, 8:30 a.m.

– 5 p.m., ET.

TIER DEFINITIONS

Tier 1 drugs have the lowest cost

share. These drugs offer the greatest

value compared to others that treat the

same conditions.

Tier 2 drugs have a medium cost

share. They may be preferred drugs,

based on their effectiveness and value.

Some are newer, more expensive

generic drugs.

Tier 3 drugs have a higher cost

share. They may cost more than others

used to treat the same condition. Tier 3

may also include drugs that were

recently approved by the FDA.

3

Eprosartan QL

Ergocalciferol (Vit D2) caps

Ery-Tab 250mg, 333mg tab

Erythromcyin eye oint.

Erythromycin 2% gel, topical solution

Erythromycin ethylsuccinate 400mg Filmtab

Erythromycin Filmtab, 250mg cap

Erythromycin stearate

Erythromycin/benzoyl peroxide gel

Erythromycin/sulfisoxazole

Escitalopram QL DO

Estradiol patch QL

Estradiol tab

Estrogen/methyltestosterone

Estropipate

Eszopiclone PA QL

Ethambutol

Ethosuximide

Etodolac, ER

Famciclovir

Famotidine tab, oral soln.

Felbamate

Felodipine ER QL

Fenofibrate

Fenofibric acid, DR

Fenoprofen

Finasteride 5mg tab PA

Flavoxate

Fluconazole tab, oral soln.

Flucytosine

Fludrocortisone

Flunisolide nasal spray

ST QL

Fluocinolone body oil, scalp oil PA

Fluocinolone cream, topical soln., oint., ear drop

Fluocinonide

Fluorometholone eye drops

Fluorouracil cream, topical solution

Fluoxetine, DR (except 60mg) QL DO

Fluphenazine tab, oral soln. PA

Flurbiprofen eye drop

Flurbiprofen tab

Fluticasone nasal spray

QL

Fluticasone topical

Fluvastatin QL DO

Fluvoxamine QL DO

Folic acid 1mg

Fosinopril

Fosinopril/HCTZ

Furosemide tab, oral soln.

Garamycin eye drops

Gatifloxacin eye drops

Gemfibrozil

Gentamycin eye drops, oint.

Glimepiride

Glipizide, ER, XL

Glipizide/metformin

Glyburide

Glyburide/metformin

Griseofulvin

Guaifenesin/codeine syrup

Guanfacine

Guanidine

Halac

Halobetasol propionate

Haloperidol tab PA

Hydralazine tab

Hydrochlorothiazide

Hydrocodone/acetaminophen QL

Hydrocortisone tab

Hydrocortisone 2.5% cream, lotion, oint.

Hydrocortisone acetate 2% gel

Hydrocortisone acetate suppository

Hydrocortisone butyrate 0.1% cream, oint., soln.

Hydrocortisone enema

Hydrocortisone valerate 0.2% cream, ointment

Hydrocortisone/acetic acid ear drops

Hydrocortisone/pramoxine cream, ointment

Hydromorphone suppository

Hydromorphone tab, oral soln. QL

Hydroxychloroquine

Hydroxyzine HCL tab, oral soln.

Hydroxyzine pamoate

Ibandronate ST QL

Ibuprofen

Imipramine HCL tab

Imiquimod PA QL

Indapamide

Indomethacin, ER cap

Ipratropium bromide neb soln. QL

Irbesartan QL DO

Irbesartan/HCTZ QL DO

Isometheptene/acetaminophen/caffeine

Isometheptene/acetaminophen/dichloralphenazone

Isonarif

Isoniazid tab, oral soln.

Isosorbide dinitrate, ER tab

Isosorbide mononitrate, ER tablet

Isradipine

Ketoconazole

Ketoprofen, ER

Ketorolac eye drops

Ketorolac tab QL

Klor-Con tab

Labetolol tab

Lactulose

Lamotrigine tab (immediate release)

Lansoprazole, DR QL

Latanoprost

Levobunolol eye drops

Levofloxacin tab QL

Levothroid

Levothyroxine tab

Levoxyl

Lidocaine viscous soln.

Lidocaine/hydrocortisone 3/0.5% cream

Lidocaine/prilocaine

Lindane

Liothyronine tab

Lisinopril

Lisinopril/HCTZ

Lithium carbonate, ER

Lithium citrate oral soln.

Lonox

Losartan QL DO

Losartan/HCTZ QL DO

Lovastatin QL DO

Loxapine PA

Malathion

Maprotiline

Matzim LA QL DO

Mebendazole

Meclizine tab

Meclofenamate cap

Medroxyprogesterone tab

Mefenamic acid

Mefloquine

Megestrol

Meloxicam oral suspension

Meloxicam tab QL

Meperidine tab, oral soln. QL

Meprobamate QL

Metadate ER PA QL

Metaproterenol

Metaxalone

Metformin, ER

Methadone tab, oral soln. QL

Methamphetamine PA QL

Methazolamide

Methimazole

Methocarbamol

Methscopolamine bromide

Methyclothiazide

Methyldopa

Methyldopa/HCTZ

Methylergonovine tab

Methylphenidate, CD, ER, SR PA QL

Methylprednisolone tab

Metipranolol eye drops

Metoclopramide tab, oral soln.

Metoprolol tab, ER

Metoprolol/HCTZ

Metronidazole 0.75% gel

Metronidazole tab, capsule, cream, lotion

Miconazole 200mg vaginal suppository

Minocycline

Minocycline ER PA

Minoxidil tab

Mirtazapine

Misoprostol PA

Modafinil PA QL

Moexipril

Moexipril/HCTZ

Mometasone cream, oint, topical soln.

Montelukast QL

Morphine sulfate IR tab QL

Morphine sulfate oral soln. QL

Morphine sulfate supppository

Mupirocin oint.

Nabumetone

Nadolol

Nadolol/bendroflumethiazide

Naltrexone

Naphazoline eye drops

Naproxen, DR

Naratriptan QL

Nature-Throid

Nefazodone

Neomycin tab

Neomycin/polymixin/bacitracin eye oint.

Neomycin/polymixin/bacitracin/hydrocortisone eye oint.

Neomycin/polymixin/dexamethasone eye drops, oint.

Neomycin/polymixin/gramicidin eye drops

Neomycin/polymixin/hydrocortisone ear and eye drops

Niacin ER

Nicardipine caps

Nifedipine cap

Nifedipine tab ER, XL

QL DO

Nisoldipine ER QL DO

Nitro-Bid oint.

Nitrofurantoin

Nitroglycerin, ER, SR

Nizatidine

Norethindrone

nortriptyline

NP Thyroid

Nystatin cream, oint., powder, tab

Nystatin/triamcinolone

Ofloxacin ear and eye drops

Ofloxacin tab QL

Omeprazole caps QL

Orphenadrine ER

Oxaprozin

Oxcarbazepine

Oxybutynin, ER

Oxycodone QL

Oxycodone/acetaminophen tab, cap QL

Oxycodone/aspirin QL

Oxymorphone

Oxymorphone ER QL

Pancrelipase, DR

Paramomycin

Paroxetine, CR, ER QL DO

Penicillin VK

Pentoxifylline, ER

Perindopril

Permethrin cream

Perphenazine PA

Phenazopyridine

Phenelzine

Phenobarbital tab, oral soln.

Phenytoin ext. cap

Pilocarpine eye drops

Pindolol

Pioglitazone QL

Piroxicam

Podofilox

Polymixin/trimethoprim eye drops

Potassium chloride ER tab, ER cap

Potassium Citrate ER Tab

Pramipexole

Pravastatin QL DO

Prazosin

Prednicarbate

4

Prednisolone eye drops

Prednisolone oral soln.

Prednisone

Prenatal Vitamins (all generic covered)

Primidone

Probenecid

Probenecid/colchicine

Procentra QL

Prochlorperazine tab

Progesterone, micronized cap

Promethazine tab, suppository, syrup

Promethazine VC syrup

Promethazine VC syrup with codeine

Promethazine/codeine syrup

Promethazine-DM syrup

Propranolol ER

Propranolol HCTZ

Propranolol tab, oral soln.

Propylthiouracil

Protriptyline

Pyrazinamide

Quetiapine PA

Quinapril

Quinapril/HCTZ

Quinidine sulfate, ER

Quinine sulfate PA QL

Raloxifene

Ramipril

Ranitidine 150, 300mg tab, cap

Ranitidine oral soln.

Rifampin

Rimantadine

Risperidone, ODT, oral soln. PA

Rizatriptan, ODT QL

Ropinirole, ER

Roxicet tab, caplet QL

Selegiline

Selenium sulfide 2.5% lotion, shampoo

Sertraline QL DO

Silver sulfadiazine cream

Simvastatin 80mg PA

QL DO

Simvastatin QL DO

Sodium polystyrene sulfate 30gm/120ml enema

Sodium polystyrene sulfate powder

Sodium polystyrene sulfonate

Sodium sulfacetamide/sulfur

Sodium sulfacetamide/sulfur/urea

Spinosad

Spironolactone

Sucralfate

Sulfacetamide eye drops, oint.

Sulfacetamide sodium

Sulfacetamide sodium/prednisolone eye drops

Sulfacetamide sodium/sulfur

Sulfacetamide sodium/sulfur/urea

Sulfacetamide sodium/urea

Sulfamethoxazole/trimethoprim, DS

Sulfasalazine

Sulindac

Sumatriptan tab QL

Tamsulosin

Taztia XT QL DO

Telmisartan QL DO

Terazosin

Terbinafine tab PA

Terbutaline tab

Terconazole

Tetracycline caps

Theochron ER

Theophylline ER, oral soln.

Thioridazine PA

Thiothixene PA

Ticlopidine

Timolol eye drops, gel

Timolol tab

Tizanidine

Tobramycin eye drops

Tobramycin/dexamethasone eye drops

Tolazamide

Tolbutamide

Tolmetin

Tolterodine

Topiramate PA

Torsemide tab

Tramadol, ER tab QL

Trandolapril

Tranexamic acid 650mg

Tranylcypromine

Trazodone

Tretinoin cream, gel PA

Triamcinolone cream, lotion, oint.

Triamcinolone nasal spray QL

Triamcinolone paste

Triamterene/HCTZ

Trifluoperazine PA

Trifluridine eye drops

Trihexyphenidyl

Trimethobenzamide cap

Trimethoprim

Trimipramine

Tropicamide eye drops

Unithroid

Valacyclovir

Valproid acid cap, oral soln.

Valsartan QL DO

Valsartan/HCTZ QL DO

Venlafaxine

Venlafaxine, ER QL DO

Verapamil tab, ER PM

QL DO

Verapamil tab, ER tab, cap

Vicodin, ES, HP QL

Warfarin

Westhroid

Zafirlukast

Zaleplon ST QL

Ziprasidone PA

Zolmitriptan QL

Zolpidem (immediate release) QL

Tier 2

Acamprosate

Acitretin

Advair Diskus, HFA QL

Anaspaz ODT

Asmanex Twisthaler QL

Atovaquone susp

Bethanechol tab

Bromfenac eye drops

Budesonide EC

Buprenorphine syringe, vial

Calcitonin QL

Calcium acetate tab

Carbidopa ST

Cefpodoxime

Ceftibuten

Cevimeline

Cilostazol

Clozapine, ODT PA

Danazol

Dantrolene

Demeclocycline

Desipramine

Diclofenac Gel PA QL

Dulera QL

Duloxetine PA QL DO

Eliphos

Entacapone

Epipen, Jr.

Eplerenone

Ergoloid

Fentanyl patch ST QL

Flecainide

Flovent HFA QL

Flovent QL

Fortical nasal spray QL

Gabapentin

Galantamine, ER QL

Glucagen

Granisetron tab QL

Humalog

Humalog Mix

Humulin N, R, 70-30

Hydromorphone ER ST

Itraconazole PA

Ketorolac inj. QL

Lantus

Lantus Solostar

Leflunomide

Levalbuterol neb soln.

Levemir

Levetiracetam

Levetiracetam ER PA QL

Levocarnitine tab, oral soln.

Levorphanol tab QL

Mafenide Acetate

Methanamine MD

Methenamine hippurate

Mexiletine

Morphine sulfate ER QL

Nateglinide PA

Nimodipine

Nitroglycerin spray

Nitrostat

Novolin N

Novolog

Novolog Mix

Olanzapine tab, ODT PA

Ondansetron tab, ODT, oral soln. QL

Oxandrolone PA

Pantoprazole QL

Pilocarpine tabs

Proair HFA ST QL

Propafenone

Prudoxin

Pulmicort 1mg/2mL respules QL

Pulmicort Flexhaler QL

Qvar QL

Rabeprazole QL

Relenza QL

Repaglinide PA

Rifabutin

Rivastigmine QL

Serevent Diskus QL

Sotalol tab, AF tab

Sulfadiazine

Sumatriptan inj QL

Symbicort QL

Tamiflu QL

Tiagabine PA

Tranexamic acid 1000mg/10mL

Trospium chloride ER ST

Ursodiol

Vancomycin caps PA

Zonisamide

Tier 3

Abacavir

Abacavir/Lamivudine/Zidovudine

Abilify tab PA

Actonel ST QL

Aczone

Adcirca PA

Adefovir Dipivoxil

Afinitor PA

Aggrenox QL

Alamast PA

Albenza

Alinia

Alkeran tab

Alocril PA QL

Alomide PA QL

Altabax

Amevive PA

Amitiza

Ampyra PA QL

Anadrol-50

Anagrelide

Anastrazole tab PA

Androgel PA QL

Antivert 50mg

Anzemet tablet QL

Apidra, Solostar ST

Apriso ER

Aptivus

Aranesp PA

Arestin

Aubagio PA QL

Avodart

Axert ST QL

Azathioprine tab

Azelex PA

Azilect

Azopt

Benicar PA QL DO

Bepreve PA QL

Besivance

Bicalutamide

Biltricide

Bosulif PA

Brilinta QL

Brovana QL

Buphenyl tablet PA

Bydureon ST QL

Bystolic

Cambia QL

Cantil

Capecitabine PA

Caprelsa PA

Carbaglu PA

CeeNU

5

Celebrex ST QL

Celontin

Cenestin

Cesamet PA

Chemet

Cialis 2.5mg, 5mg PA

Ciclodan

Cimzia PA QL

Cipro HC ear drops

Ciprodex ear drops PA

Clindacin

Cloderm

Coartem

Colcrys PA QL

Combigan

Cometriq PA

Cordran, SP

Cortisporin cream, oint.

Crestor ST QL DO

Cresylate

Crixivan

Cuprimine

Cyclophosphamide tab

Cyclosporine

Cyclosporine cap, soln.

Daliresp QL

Dapsone

Daraprim

Dexilant ST QL

Dibenzyline

Didanosine DR

Dificid PA

Dipentum

Droxia

Durezol QL

Dyrenium

Edarbi QL DO

Edecrin

Edurant

Effient QL DO

Elidel PA

Ella

Elmiron

Emadine PA QL

Emcyt PA

Emsam QL

Emtriva

Enablex ST

Enbrel PA QL

Enjuvia

Enoxaparin PA

Epiduo

Epivir HBV soln. PA

Epzicom

Erivedge PA

Ertaczo

Estring

Etoposide caps

Eurax

Exelderm

Exemestane

Exjade PA

Extavia ST

Factive QL

Fanapt PA

Fareston

Ferriprox PA

Finacea

Flector ST

Fluoridex

Fluoroplex

Flutamide

FML S.O.P

Fondaparinux PA

Forteo PA

Fosamax Plus D ST QL

Fosrenol PA

Fragmin PA

Frova ST QL

Fuzeon

Gengraf

Gleevec PA

Glyset

Halog

Hexalen

Horizant PA

Humira PA QL

Hycamtin caps

Hydroxyurea

Iclusig PA

Increlex PA

Infergen PA

Inlyta PA

Innohep PA

Intelence

Intron A PA

Intuniv ER PA

Invega tab PA

Invirase

Iressa

Isentress

Jakafi PA

Jalyn

Janumet, XR QL

Januvia ST QL

Kaletra

Kapvay PA

Ketek

Kineret PA

Lacrisert

Lamuvidine

Lamuvidine/Zidovudine

Lanoxin tab

Latuda PA

Letairis PA

Letrozole

Leucovorin tab

Leukeran

Leuprolide PA

Levatol

Lexiva

Livalo ST QL DO

Lotemax

Lotronex PA

Lumigan

Lyrica PA QL

Lysodren

Marplan

Matulane

Maxair QL

Menest

Mentax

Mercaptopurine

Methitest

Methotrexate tab

Morgidox PA

Motofen

Moviprep

Multaq

Mycophenolate

Myleran

Naftin cream, 1% gel

Namenda QL

Natacyn

Natazia ST

Neulasta PA QL

Neupogen PA

Nevanac

Nevirapine

Nexavar PA

Nexium PA QL

Nilandron

Noroxin QL

Norvir

Nucynta, ER QL

Nuedexta

Nuox

Nuvaring

Nuvigil PA QL

Oforta PA

Omnaris ST QL

Onglyza ST QL

Oracea

Orap PA

Orfadin

Oxistat

Oxsoralen-Ultra PA

Oxycontin ST QL

Panretin

Pataday PA QL

Patanase QL

Patanol PA QL

Peganone

Pegasys PA QL

Pegintron PA

Perforomist QL

Phisohex

Phospholine iodide

Pomalyst

Pradaxa QL

Pred-G

Pred-G S.O.P

Premarin Cream

Premarin tab ST

Premphase

Prempro

Prevident 5000 Booster Plus

Prezista

Primaquine

Primsol

Pristiq QL DO

Procrit PA

Proglycem

Prolia PA

Promacta PA

Proquin XR

Protopic PA

Proventil HFA ST QL

Ranexa

Rapaflo

Rebif PA

Rectiv

Regranex PA

Relistor PA

Relpax ST QL

Remicade PA

Remodulin PA

Renvela PA

Rescriptor

Restasis

Revlimid PA QL

Reyataz

Ribavirin PA

Ridaura

Rifater

Riluzole

Rituxan PA

Rosadan

Rozerem ST QL

Sabril

Safyral ST

Samsca PA

Santyl

Saphris PA

Savella QL

Scopace

Selzentry

Sensipar

Seroquel XR PA

Sildenafil 20mg tab PA

Silenor ST

Simponi PA QL

Sirolimus

Skelid

Somatuline

Spiriva QL

Sprycel PA

Stavudine

Stelara PA QL

Stivarga PA

Strattera PA QL

Stromectol

Suprax tab, susp.

Sustiva

Sutent PA

Symlin PA

Synarel PA

Synera

Syprine

Tabloid

Taclonex scalp suspension

Taclonex suspension

Tacrolimus

Tamoxifen

Tarceva PA

Targretin PA

Tasigna PA

Tasmar

Tazorac PA

Tekturna QL DO

Temozolomide PA

Teveten 400mg QL

Tev-Tropin PA

Thalomid PA

Thyrolar

Tikosyn

Torisel

Toviaz ER ST

Tradjenta ST QL

Transderm-Scop PA

Travatan Z

Trelstar Depot PA

Trelstar PA

Tretinoin 10mg capsule

Truvada

Tykerb PA

Tysabri

Tyzeka PA

Tyzine

Ulesfia

Uloric ST

Vagifem

Vandetanib PA

Ventavis PA

Ventolin HFA ST QL

Veregen

Vesicare ST

Vexol

Victoza ST QL

Victrelis PA

Vigamox PA

Viibryd ST

Viracept

Viread PA

Vivelle-Dot PA QL

Voltaren gel

Votrient PA

Vyvanse PA QL

6

Welchol

Xalkori PA

Xarelto PA QL

Xenazine PA

Xopenex HFA ST QL

Xtandi PA

Xyrem PA

Zelboraf PA

Zetia PA QL

Ziana ST

Zidovudine

Zinotic

Zioptan

Zipsor

Zirgan

Zoledronic Acid

Zolinza PA

Zortress PA

Zyflo, CR PA

Zytiga PA

Zyvox tab, oral soln. PA QL

KEY

† = A generic equivalent of this drug recently became available or will be available soon. After the generic drug becomes available and notification requirements

are met, this brand-name drug may no longer be covered by your prescription drug plan. Check empireblue.com to find out about changes in tier status.

PA = PRIOR AUTHORIZATION REQUIRED. Prior authorization is the process of obtaining approval of benefits before certain prescriptions may be filled.

QL = QUANTITY LIMITS. Certain prescription drugs have specific quantity limits per prescription or per month.

ST = STEP THERAPY REQUIRED. You may need to use one medication before benefits for the use of another medication can be authorized.

DO = DOSE OPTIMIZATION REQUIRED. Normally involves the conversion from twice-daily dosing to a once-daily dosing schedule.

Not all medications and not all plans are subject to prior authorization and quantity limits. For more information regarding prior authorization

or quantity limits, contact Member Services at the telephone number listed on your identification card.

40625NYMENEBS Effective 1/15

For more information, please visit empireblue.com. �} If you have additional questions about your prescription benefits,

please call the Member Services number on your ID card.

�} Speech and hearing impaired (TDD/TTY users) should call

800-221-6915, Monday – Friday, 8:30 a.m. – 5 p.m., ET.

�} For the most current version of this Select Drug List,

please visit empireblue.com.

Services provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.