3-Tier PDL for AAG and WYGetting the most from your prescription
drug benefit .....................2
About generic and brand-name drugs
............................................3
Advantages of generic drugs
...........................................................3
Preferred and non-preferred brand-name drugs
...............................4
How to know if your drug is Tier 1, 2, or 3
.....................................5
Getting your prescription filled
........................................................5
Save time and money with Medco By Mail
.....................................5
Ordering prescription drugs through Medco By Mail
........................6
Specialty Pharmacies
.......................................................................7
Additional services
...........................................................................7
Which drugs are included
................................................................8
How the program works
.................................................................9
Preferred Drug List
..........................................................................13
Commonly prescribed Tier 3 drugs with generic equivalents
..........25
Cost-Saving Tips
..................................................... inside back
cover
Important Telephone Numbers
.........................................back cover
Introduction Welcome 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.
• Generic drugs, listed or not listed, are covered with a Tier 1
copay. These drugs are marked with an asterisk (*) in the
list.
• Brand-name drugs listed in this booklet are considered
“preferred” and are covered with a Tier 2 copay (see Preferred Drug
List).
• Brand-name drugs NOT on the Preferred Drug List are covered with
a Tier 3 copay. These drugs are not listed in this book. Some plans
require that you must pay the difference in cost between brand-name
and generic if a generic is available.
Getting the most from your prescription drug benefit
At your physician or health-care provider’s office:
• Ask your health-care provider to prescribe a generic drug,
whenever possible.
• If a generic drug is not appropriate, ask your health-care
provider to consider prescribing a preferred brand-name drug from
the Preferred Drug List.
At the pharmacy:
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 • Same level of quality, strength,
effectiveness and purity.
• Excellent value—generally cost less because they are created
without the development, advertising and sales expense of
brand-name drugs. Also, competition among generic drug-makers
lowers the price.
• Lowest copay* (Tier 1) can save you money.
* 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 drugs Q. How can I be sure to pay the lowest
possible copay?
A. Ask your health-care provider if there is a generic drug that is
right for you. If there is a generic equivalent available for your
drug, ask your health-care provider to indicate “substitution
permitted” on your prescription. Then ask your pharmacist to use a
generic to fill the prescription. If there is no generic equivalent
for your drug, talk to your doctor about generic drugs available
within the same drug class or generic alternative.
Q. What if my prescription does not have a generic alternative
available?
A. If there is no generic available, you will receive the
brand-name drug.
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:
• Uses current medical studies and research to choose safe and
effective drugs.
• Reviews and updates the Preferred Drug List regularly by adding
the latest safe and effective drugs, and removing those that are no
longer considered safe and effective, or which now have better
alternatives available.
• Recommends that health-care providers prescribe preferred
brand-name drugs when a generic is not available. These preferred
brand-name drugs are covered with a Tier 2 copay.
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:
• There are generic equivalents available.
• There are preferred brand-name alternatives available.
• Our Pharmacy and Therapeutics Committee has concerns about their
safety and/or effectiveness.
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:
• Drugs listed in this booklet are arranged in alphabetical
order.
• The Preferred Drug List in this booklet does not include
non-preferred brand- name drugs. Any brand-name drug not on the
list is considered non-preferred and is covered at the Tier 3
copay. Some plans require that you must pay the difference in cost
between brand-name and generic if a generic is available. For your
convenience, we have listed the most commonly prescribed Tier 3
drugs and their generic or Tier 2 alternatives (see page 24 for
this listing).
How to know if your drug is Tier 1, 2 or 3: • The copay tier is
listed to the right of the drug name.
• Ask your pharmacist. The pharmacy computer systems have the most
up-to-date version of this drug list.
• Call Customer Service—the number is listed on the back of your ID
card.
• Visit the Web site listed on the back of your ID card.
Getting your prescription filled Convenient 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’s convenient.
• It saves you time and may save you money.
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:
• It takes about two weeks to receive your prescriptions through
Medco By Mail.
• To avoid any delay in starting your medicine, ask your
health-care provider to write two separate prescriptions—one for 30
days that you can fill at a local pharmacy right away, and one for
the 90-day or supply maximum allowed by your plan that you can mail
in within two weeks of your medicine running out.
• If your health-care provider allows Medco By Mail refills, be
sure he/she indicates that on the prescription and order refills
about two weeks before your medicine runs out.
• Prescriptions come to your home in sealed, tamper-evident,
discreetly labeled packaging. Some drugs may require special
handling, such as controlled substances and items that must be
refrigerated or frozen during shipment. For more information, call
1-800-391-9701.
Ordering prescription drugs through Medco By Mail
• Mail: For new prescriptions and refills—use a Medco By Mail order
form to mail your prescription. To request a form, please call our
Customer Service department or go online to the Web site also
listed on the back of your ID card.
• Phone: For prescription refills—call Medco By Mail at
1-800-391-9701.
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:
• Coordination of care and care management.
• Medication adherence and compliance monitoring, including refill
reminders.
• Educational material, counseling and product information.
• Access to clinical assistance from pharmacists and nurses.
• Coordination of medication delivery time and location, including
free delivery and supplies.
Prior Authorization Program Maintaining 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:
• Improve the quality of your drug therapies.
• Promote appropriate use of medications.
• Ensure the appropriate length of drug therapy.
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
Omeprazole
Protonix®
Aciphex®
Nexium®
Prilosec®*
Prevacid®
Zegerid®
* This does not apply to prescriptions for Prilosec® 10mg per day
or Prevacid® 15mg per day. These doses do not require this
exception.
CNS Stimulant Drugs
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:
• When your prescription is submitted by your pharmacy, our
computer system checks the prescription drug therapy to see if it
meets recommended guidelines.
• If it meets the guidelines, your prescription is filled without
interruption.
• If it does not meet the guidelines, your prescription is filled
at the pharmacy one time and initiates the Prior Authorization
process.
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
Atacand®
Anzemet®
Kytril®
0
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 Questions Q. What are my copays?
A. Copay amounts vary by the employer group. You need to refer to
your benefit booklet for your specific copay amounts. Note that
copays are different for drugs dispensed at a retail pharmacy than
when dispensed through Medco By Mail.
Q. What if I am on a non-preferred drug and want to stay on
it?
A. As always, it is your choice. If you choose to stay on a
non-preferred drug for which a generic is available, you may have
to pay the cost difference between the generic and brand, plus the
copay. See your Benefit Booklet for more information or contact
Customer Service.
Q. Are the preferred drugs just the ones that are the
cheapest?
A. No. A committee of physicians and pharmacists chooses drugs as
preferred only if they are FDA-approved, safe and effective. When
several drugs are similar in safety and effectiveness, one or more
of the lower cost choices are selected for the Preferred Drug
List.
Q. I’ve heard that some people can’t take generic drugs. Why
not?
A. A brand-name drug and its generic equivalent have the same
active ingredients. However, different manufacturers sometimes use
different inactive ingredients to hold the active ingredients
together to make a pill or capsule. In rare instances, people may
have an allergy to the inactive ingredients. This type of allergy
can happen just as often with a brand as with a generic drug.
0
Q. What if I want to get a brand-name drug even though there is a
generic available?
A. That is between you and your health-care provider or
practitioner. You can have your prescription filled for a
brand-name drug even when a generic equivalent is available and
your health-care provider or practitioner allows it. However, you
may have to pay the cost difference between the generic and brand,
plus the copay. See your Benefit Booklet for more information or
contact Customer Service.
Q. Are there any excluded categories of drugs?
A. Yes. Even though this benefit covers non-preferred brand-name
drugs, there still may be exclusions for drugs used to treat
certain conditions. Review your benefit booklet for your plan’s
exclusions.
Q. Can I use any pharmacy I want?
A. We contract with a national network of pharmacies. To receive
the highest level of benefits under this program, you need to use a
contracted network pharmacy. If you go to a pharmacy not in the
network, you may receive reduced benefits or, in some cases, no
benefits at all. For most plans, specialty drugs are only covered
when purchased through our Preferred Specialty Pharmacy vendors.
Refer to your benefit booklet for details about Specialty Pharmacy
and coverage at a non-network pharmacy.
Q. How do I find a network pharmacy near my home or when I am
away?
A. Most pharmacies in your area are likely to be part of the
network. There are also network pharmacies throughout the United
States. Use the toll-free 24- hour Pharmacy Locator Line
(1-800-391-9701) to find a network pharmacy near you. Or, visit
your Web site listed on the back of your ID card.
* = Generic = Prior Authorization Program = Requires medical review
for coverage § = Specialty drug
How to read the Preferred Drug List • Drugs are listed
alphabetically.
• Generic drugs, (printed in lowercase letters) are shown with a
(1) and covered at the lowest copay.
• Preferred brand-name drugs, (printed in CAPITAL letters) are
shown with a (2) and covered at a moderate copay.
• Non-preferred brand-name drugs are not included in the Preferred
Drug List. However, we do have a separate section of the most
commonly prescribed non-preferred drugs at the back of the book.
These drugs are covered at the highest copay. This list also shows
you the generic and/or Tier 2 equivalent.
• Generic drugs not listed in this booklet are covered (unless
excluded in your benefit) at the lowest copay.
• Brand-name drugs not listed in this book are non-preferred and
are covered (unless excluded in your benefit) at the highest copay.
Some plans require that you must pay the difference in cost between
brand-name and generic if a generic is available.
KEY
Please note the following symbols that may appear with some drugs
on the Preferred Drug List.
* = Generic forms of this drug are covered at Tier 1 copay. Brand
equivalents are Tier 3. Please consult your health-care provider,
practitioner or pharmacist.
= Prior Authorization Program drug. If exception is needed, your
practitioner or pharmacist should call 1-888-261-1756.
= This drug requires medical review for coverage in some cases. For
exceptions, call the Customer Service number listed on the back of
your ID card.
§ = This is a specialty drug. Most plans limit specialty drugs to a
30-day supply. For many plans, specialty drugs are only covered
when purchased through our Preferred Specialty Pharmacy vendors.
See your benefit booklet or call Customer Service.
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 List Drug Name Tier aminoglutethimide 2
* aminophylline 1 * * amiodarone 1 * * amitriptyline 1 *
amlodipine 2
* ammonium lactate 1 * * amoxapine 1 * * amoxicillin 1 * *
amoxicillin/clavulanic acid 1 * * amphetamine/dextroamphetamine 1
*
amphetamine/dextroamphetamine sr 2
* ampicillin 1 * ANA-KIT 2 anastrozole 2 ANCOBON 2 ANDRODERM 2
ANDROGEL 2 ANTARA 2 anthralin 2 APIDRA 2
§ APOKYN 2 § apomorphine 2
apraclonidine 2 APTIVUS 2
§ ARANESP 2 ARICEPT 2 ARIMIDEX 2 aripiprazole 2 ARISTOCORT 2
§ ARIXTRA 2 artificial tear insert 2 ASACOL 2 ASMANEX 2
* aspirin/butalbital/caffeine 1 * *
aspirin/butalbital/caffeine/codeine 1 * * aspirin/codeine 1 * *
aspirin/oxycodone 1 *
* atropine ophthalmic 1 * ATROVENT 2 auranofin 2 aurothioglucose
2
AVALIDE 2 AVANDAMET (Avandia combinations also Tier 2) 2 AVANDARYL
2
AVANDIA (Avandia combinations also Tier 2) 2 AVAPRO 2
AVC 2 AVELOX 2
Drug Name Tier A
* acetaminophen/butalbital 1 * * acetaminophen/butalbital/caffeine
1 * * acetaminophen/butalbital/caffeine/codeine 1 * *
acetaminophen/codeine (Liquid is Tier 2) 1 * *
acetaminophen/hydrocodone (Liquid is Tier 2) 1 * *
acetaminophen/oxycodone 1 * * acetazolamide (500mg Sequels are Tier
2) 1 * * acetic acid 1 *
* acetic acid/aluminum acetate otic (Generic
equivalent of Domeboro Otic) 1 *
* acetic acid/hydrocortisone liquid 1 * * acetic
acid/oxyquin/ricin/glycerin 1 * * acetylcysteine 1 *
acitretin 2 § ACTIMMUNE 2
ACTOS (Actos combinations also Tier 2) 2 * acyclovir 1 *
acyclovir topical 2 § adalimumab 2
ADDERALL XR 2 adefovir 2 ADVICOR 2 AEROBID, AEROBID-M 2 ALBENZA
2
* albuterol metered dose inhaler 1 * * albuterol nebulized 1 * *
albuterol tablet & oral liquid 1 *
ALDARA 2 § ALDURAZYME 2
§ ALFERON-N 2 ALKERAN 2
* alprazolam 1 * ALTACE 2 altretamine 2 aluminum chloride 2
* amantadine 1 * AMBIEN 2 AMERGE (Max 23 mg/30 days) 2
AMICAR 2
* = 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 * * azelaic acid 1 * * azithromycin 2 *
AZMACORT 2 AZOPT 2
beclomethasone oral inhaler 2 BECLOVENT 2
* belladonna /phenobarbital 1 * benazepril 2 benazepril/amlodipine
2
* benazepril/hctz 1 * BENZACLIN 2 BENZAMYCIN 2
* benzocaine/antipyrine liquid 1 * benzoyl peroxide/clinamycin 2
benzoyl peroxide/erythromycin 2
* benztropine 1 * * betamethasone dipropionate 1 *
betamethasone dipropionate augmented 2
betaxolol ophthalmic 2
* bethanechol 1 * BETOPTIC, BETOPTIC-S 2 bicalutamide 2 BILTRICIDE
2 bimatoprost 2
* bisoprolol/hctz 1 * § bosentan (Mfr special access program)
2
* brimonidine 1 * brinzolamide 2
* bumetanide 1 * * bupropion 1 * * bupropion sr 1 * * bupropion xl
1 *
busulfan 2 * butorphanol (Max 3 cannisters/30 days) 1 * BYETTA
2
C
* calcitriol 1 * § capecitabine 2
CARMOL 40 2 CARNITOR 2
* carvedilol 1 * carvedilol CR 2 CASODEX 2 CEENU 2 cefdinir
suspension 2
* cefuroxime 1 * CELLCEPT 2
* cephalexin 1 * § CEREZYME 2
* chloral hydrate 1 * chlorambucil 2
* chloramphenicol 1 * * chlorhexidine 1 * * chloroquine 1 * *
chlorothiazide 1 *
chloroxine 2
ciclopirox 2 CILOXIN 2
* cimetidine 1 * § cinacalcet 2
* citalopram 1 * citric acid/gluconic acid 2
* clarithromycin 2 * CLEOCIN 2
clindamycin vaginal gel 2 clofazimine 2
* clomipramine 1 * * clonazepam 1 * * clonidine 1 * *
clonidine/chlorthalidone 1 *
clopidogrel 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 COLESTID 2 colestipol 2 COMBIPATCH 2 COMBIVENT 2
COMBIVIR 2 COMTAN 2 CONCERTA 2 conjugated estrogens (Includes
vaginal cream) 2 conjugated estrogens/medroxyprogesterone 2
§ COPAXONE 2 COREG CR 2 CORTENEMA 2 CORTIFOAM 2 COSOPT 2 CRESTOR 2
CRIXIVAN 2
* cromolyn inhaled (All forms are covered) 1 * crotamiton 2
CUPRIMINE 2 cyanocobalamin nasal 2 CYCLESSA 2
* cyclobenzaprine 1 * * cyclopentolate 1 *
cyclophosphamide 2 cycloserine 2
* cyproheptadine 1 * CYTADREN 2 CYTOMEL 2 CYTOVENE 2 CYTOXAN
2
D § dalteparin 2
* danazol 1 * DANTRIUM 2 dantrolene 2 DAPSONE 2 DARANIDE 2 DARAPRIM
2
§ darbepoetin 2 darunavir 2
§ dasatinib 2 DDAVP TABLET 2 deferasirox 2
§ deferasirox 2 demecarium 2 DEMSER 2 DEMULEN 2 DENAVIR 2 DEPAKOTE
2
* desipramine 1 * * desmopressin nasal 1 *
desmopressin tablet 2 desogestrel/ethinyl estradiol 2
* desonide 1 * * desoximetasone 1 *
* dexamethasone 1 * * dexamethasone ophthalmic (Maxidex is Tier 2)
1 * * dextroamphetamine (Including SR) 1 *
diabetic blood testing strips 2 diabetic urine testing products 2
DIASTAT 2
* diazepam 1 * diazepam rectal 2 DIBENZYLINE 2 dichlorphenamide
2
* diclofenac 1 * * diclofenac ophthalmic 1 * * dicloxacillin
(Liquid is Tier 2) 1 * * dicyclomine 1 *
didanosine 2 dienestrol vaginal cream 2 DIFLUCAN VC 2
* diflunisal 1 * * digoxin 1 * dihydroergotamine (Max 8 amps/30
days) 2
* diltiazem (All generics are Tier 1) 1 * * diphenoxylate/atropine
1 * * dipivefrin ophthalmic 1 *
DIPROLENE 2 DIPROLENE AF 2
* dipyridamole 1 * * disopyramide (Including CR) 1 * * disulfiram 1
*
divalproex 2 donepezil 2
* doxazosin 1 * * doxepin 1 * * doxycycline 1 *
DRITHOCREME 2 DRYSOL 2 DUAC 2 DUETACT 2 DURAGESIC 2 DYCLONE 2
dyclonine 2
E EBRIVA 2 echothiophate ophthalmic 2
§ efalizumab 2 efavirenz 2 efavirenz/emtricitabine/tenofovir 2
EFUDEX 2
eletriptan 2 ELIDEL 2 ELMIRON 2 ELOCON 2 EMADINE 2 EMCYT 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 emedastine 2 emtricitabine 2 emtricitabine/tenofovir
2
* enalapril 1 * * enalapril/hctz 1 * § ENBREL 2 § enfuvirtide 2 §
enoxaparin 2
entacapone 2 ENTOCORT EC 2 epinephrine allergy kit 2
* epinephrine ophthalmic 1 * epinephrine syringe 2 epinephryl
borate 2 EPI-PEN 2 EPIVIR 2 EPPY-N 2 ERGAMISOL 2
* ergocalciferol 1 * * ergoloid mesylates 1 *
ERGOMAR 2 ergotamine 2
* erythromycin (All generic forms) 1 * * erythromycin ophthalmic 1
* * erythromycin topical 1 * * erythromycin/sulfisoxazole 1 * §
erythropoietin (Epogen is non-preferred) 2
ESERINE 2
* estradiol transdermal patch (Strengths not
available as generic are Tier 2) 1 *
* estradiol transdermal patch 1 * estradiol vaginal ring 2
estradiol/desogestrel 2 estradiol/ethynodiol 2
estradiol/norethindrone 2 estradiol/norethindrone transderm 2
estramustine 2 ESTRATEST 2 ESTRING 2
* estropipate 1 * ESTROSTEP FE 2
§ etanercept 2 ethambutol 2 ethinyl estradiol/drospirenone 2
ethinyl estradiol/levonorgestrel 2
* ethinyl estradiol/levonorgestrel 7/7/7 (Triphasil
is Tier 2) 1 *
ethinyl estradiol/norelgestomin transderm 2
* ethinyl estradiol/norethindrone (Ortho Novum
is Tier 2) 1 *
Drug Name Tier ethinyl estradiol/norgestrel 2 ETHMOZINE 2
* ethosuximide 1 * * etidronate 1 * * etodolac 1 *
etonoogestrel/ethinyl estradiol vaginal ring 2
* etoposide 1 * EURAX 2 EVISTA 2 EXELDERM 2 EXELON 2
exenatide 2 EXJADE 2
§ EXJADE 2 ezetimibe 2
* famotidine 1 * FAMVIR 2
FANSIDAR 2 FARESTON 2 felbamate 2 FELBATOL 2 FEMARA 2 FEMHRT 2
fenofibrate 2 fentanyl transdermal 2
* fexofenadine 1 * § filgrastim 2
* finasteride 1 * * flecainide 1 *
FLOMAX 2 FLOVENT 2 FLOXIN OTIC 2
* fluconazole 1 * fluconazole 150mg oral single-dose 2 flucytosine
2 FLUDARA 2 fludarabine 2
* fludrocortisone 1 * * flunisolide nasal (Generic only) 1 *
flunisolide oral inhaler 2
* fluocinolone 1 * * fluocinonide 1 * * fluoride 1 * *
fluorometholone ophthalmic (FML is Tier 2) 1 *
FLUOROPLEX 2 fluorouracil 2
* fluoxetine 1 * * fluoxymesterone 1 * * fluphenazine 1 * *
flurbiprofen 1 * * flutamide 1 * * fluticasone nasal 1 *
fluticasone oral inhaler and diskhaler 2
* folic acid 1mg 1 * § fondaparinux 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 FORADIL 2 formoterol 2
FORTOVASE 2 FOSAMAX 2 fosamprenavir 2
* fosinopril 1 * * fosinopril/hctz 1 * § FRAGMIN 2
FURADANTIN 2 furazolidone 2
* furosemide 1 * FUROXONE 2
* gabapentin 1 * GABITRIL 2 galantamine 2 ganciclovir 2 GANTANOL
2
* gemfibrozil 1 * * generic oral contraceptives (All) 1 * *
gentamicin 1 * * gentamicin ophthalmic 1 *
GEODON 2 § glatiramer 2
* glimepiride 1 * * glipizide (Including XL) 1 * * glucagon 1 * *
glyburide 1 *
glycerin 2
selected in 2008) * guaifenesin/codeine liquid 1 * *
guaifenesin/hydrocodone liquid 1 * * guanabenz 1 * * guanfacine 1
*
H
* homatropine ophthalmic 1 * HUMALOG 2
§ HUMIRA 2 HUMORSOL 2 HUMULIN 2
* hydralazine 1 * * hydrochlorothiazide 1 * * hydrocortisone (2.5%
only) 1 * * hydrocortisone anorectal cream 1 *
hydrocortisone enema 2
* hydrocortisone tablet 1 * * hydrocortisone/pramoxine 1 * *
hydromorphone 1 * * hydroxychloroquine 1 * * hydroxyprogesterone 1
* * hydroxyurea 2 * * hydroxyzine 1 * * hyoscyamine 1 *
I
nasal sprays, or 24 (50mg) tablets) 2
* indapamide 1 * indinavir 2
* indomethacin 1 * insulin aspart 2 insulin detemir 2 insulin
glargine 2 insulin glulisine 2 insulin lispro 2 insulin syringes
and needles 2 insulin, human 2
§ interferon alfa-2a 2 § interferon alfa-2b 2 interferon
alfa-2b/ribavirin 2 § interferon alfa-n3 2 § interferon beta-1a 2 §
interferon beta-1b 2 § interferon gamma-1b 2 § INTRON-A 2
INVIRASE 2
* iodoquinol 1 * IOPIDINE 2 ipratropium metered dose inhaler 2
ipratropium/albuterol metered dose inhaler 2
irbesartan 2 irbesartan/hctz 2
ivermectin 2
* ketoconazole 1 * ketotifen 2
* = 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
* labetalol 1 * LACRISERT 2
* lactulose liquid 1 * LAMICTAL 2 lamivudine 2
lamivudine/zidovudine 2 lamotrigine 2 LAMPRENE 2 lancets 2 LANTUS 2
LARODOPA 2
§ laronidase 2 latanoprost 2
§ lenalidomide 2 letrozole 2
* leucovorin 1 * LEUKERAN 2
§ LEUKINE 2 § leuprolide 2
* levobunolol liquid 1 * levocarnitine 2 levodopa 2
* levodopa/carbidopa (Including CR) 1 * levonorgestrel/ethinyl
estradiol 2
* levothyroxine 1 * LEXIVA 2
* lidocaine 1 * * lindane 1 *
liothyronine 2 liotrix 2
* lipase/amylase/protease 1 * LIPITOR 2
* lisinopril 1 * * lisinopril/hctz 1 * * lithium carbonate
(Eskalith CR is Tier 2) 1 * * lithium citrate 1 *
lodoxamide 2 LOESTRIN, LOESTRIN 24 2 lomustine 2 LOOVRAL 2
lopinavir/ritonavir 2 LOPROX 2
* lorazepam 1 * LOTENSIN 2 LOTREL 2
* lovastatin 1 * § LOVENOX 2
* loxapine 1 * LUMIGAN 2
§ LUPRON 2 LYSODREN 2
* mebendazole 1 * * meclizine 1 * * meclofenamate 1 * *
medroxyprogesterone 1 *
medrysone ophthalmic 2
melphalan 2 memantine 2
* meperidine 1 * * mephobarbital 1 *
MEPHYTON 2 MEPRON 2 mercaptopurine 2 mesalamine (Enema,
suppository) 2 mesalamine 2 MESTINON SR 2 METADATE CD 2
* metformin (XR is Tier 3) 1 * * metformin/glyburide 1 * *
methadone 1 * * methazolamide 1 *
METHERGINE 2
methoxsalen 2
* methylprednisolone 1 * * methyltestosterone 1 *
METROGEL VAGINAL 2 METROGEL, METROCREAM, METROLOTION 2
* metronidazole (375mg is Tier 3) 1 * metronidazole topical 2
metronidazole vaginal gel 2 metyrosine 2
* mexiletine 1 * MIACALCIN 2
MICRONOR 2
* = 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
* minocycline 1 * * minoxidil 1 *
MINTEZOL 2 MIRAPEX 2 MIRCETTE 2
* misoprostol 1 * mitotane 2 MOBAN 2
modafinil 2 molindone 2 mometasone 2 mometasone oral inh 2
mometasone oral inhaler and diskhaler 2 moricizine 2 morphine
(Suppository) 2
* morphine sulfate 1 * * morphine sulfate sr 1 *
moxifloxacin 2 MS CONTIN 2
* multivitamin/fluoride chew or liquid 1 * *
multivitamin/fluoride/iron chew or liquid 1 * * mupirocin 1 *
MYAMBUTOL 2 MYCELEX-G 1 MYCOBUTIN 2 mycophenolate 2 MYLERAN 2
N
* nadolol 1 * nafarelin 2 NAMENDA 2
* naphazoline 1 * * naproxen 1 * * naproxen sodium 1 * naratriptan
(Max 23 mg/30 days) 2
NARDIL 2 NASCOBAL 2 NEBUPENT 2 nedocromil (All forms are covered) 2
nelfinavir 2
* neomycin 1 * * neomycin/bacitracin/polymyxin/hc ophthalmic 1 * *
neomycin/dexamethasone ophthalmic 1 * *
neomycin/polymyxin/bacitracin ophthalmic 1 * *
neomycin/polymyxin/dexamethasone ophthalmic 1 * *
neomycin/polymyxin/gramicidin ophthalmic 1 * *
neomycin/polymyxin/hc ophthalmic 1 * * neomycin/polymyxin/hc otic 1
*
neomycin/polymyxin/pred ophthalmic 2 neostigmine 2
§ NEUMEGA 2 § NEUPOGEN 2
nevirapine 2 § NEXAVAR 2
niacin sr 2 niacin sr/lovastatin 2
Drug Name Tier NIASPAN 2 nicotine nasal spray 2 NICOTROL NS 2
* nifedipine 1 * * nifedipine cc 1 *
NILANDRON 2 nilutamide 2 nimodipine 2 NIMOTOP 2 nitrofurantoin
2
* nitrofurantoin macro 1 * * nitrofurantoin monohydrate macro 1 * *
nitroglycerin oral 1 *
nitroglycerin sl 2
* nizatidine 1 * NORDETTE 2
* norethindrone 1 * norfloxacin 2 NOR-QD 2
* nortriptyline 1 * NORVASC 2 NORVIR 2 NOVOLIN 2 NOVOLOG 2 NUVARING
2
* nystatin 1 * * nystatin vaginal 1 * * nystatin/triamcinolone 1
*
O § octreotide 2
* omeprazole (Exception required for > 90-day Rx) 1 * OMNICEF
SUSPENSION 2
* ondansetron 1 * § oprelvekin 2
OPTIPRANOLOL 2 ORTHO EVRA 2 ORTHO NOVUM 2 ORTHO NOVUM 10/11 2 ORTHO
NOVUM 7/7/7 2 ORTHO-CEPT 2 ORTHO-CYCLEN 2 ORTHO-DIENESTROL 2
ORTHO-TRICYCLEN 2 ORTHO-TRICYCLEN LO 2 oseltamivir 2 OSMOGLYN 2
OVCON 2 OVRAL 2 oxcarbazepine 2 OXSORALEN 2
* oxybutynin (XL is Tier 3) 1 *
0 * = 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 oxybutynin transdermal 2 OXYTROL 2
P palonosetron 2
* pancrelipase 1 * * paregoric 1 * * paromomycin 1 * * paroxetine
(Including CR) 1 *
PATANOL 2
* peg electrolyte bowel prep 1 * § PEGASYS 2 § peg-interferon
alfa-2a 2 § peg-interferon alfa-2b 2 § PEG-INTRON 2 §
pegvisomant
pemoline 2 penciclovir cream 2 penicillamine 2
* penicillin 1 * * pentamidine injection 1 *
pentamidine nebulized 2 PENTASA 2 pentazocine/naloxone 2 pentosan
polysulfate sodium 2
* pentoxifylline 1 * * permethrin 1 * * perphenazine 1 * *
phenazopyridine 1 *
phenelzine 2 pheniramine/pyrilamine/phenyltoloxamine (Liquid)
2
* phenobarbital 1 * phenoxybenzamine 2 phentolamine mesylate
2
* phenylephrine 1 *
* pilocarpine 1 * * pilocarpine ophthalmic 1 * *
pilocarpine/epinephrine ophthalmic 1 *
pimecrolimus 2
pioglitazone/glimepiride 2 pioglitazone/metformin 2
* piroxicam 1 * PLAVIX 2
pramipexole 2 pramlintide 2
PREMARIN (Includes vaginal cream) 2 PREMPRO, PREMPHASE 2
* prenatal vitamins 1 * PREZISTA 2
* primaquine 1 * * primidone 1 * * probenecid 1 *
procainamide (All generics are Tier 1) 2 PROCANBID (All generics
are Tier 1) 2 procarbazine 2
* prochlorperazine 1 * § PROCRIT (Epogen is non-preferred) 2
PROFENAL 2
* promethazine 1 * * promethazine/codeine syrup 1 * *
promethazine/dextromethorphan liquid 1 * * promethazine/pe/codeine
syrup 1 *
PROMETRIUM 2
* propafenone (300mg is Tier 2) 1 * * propantheline 1 * *
propoxyphene (All generic combinations are Tier 1) 1 * *
propranolol (Including LA) 1 * * propranolol/hctz 1 * *
propylthiouracil 1 *
PROSTIGMIN 2
* pseudoephedrine/chlorpheniramine 1 * *
pseudoephedrine/guaifenesin la 1 *
PULMICORT 2 PULMICORT RESPULES 2
§ PULMOZYME 2 PURINETHOL 2
* pyrazinamide 1 * * pyridostigmine 1 *
Q quetiapine 2
* quinapril 1 * * quinidine (Brand-only forms are Tier 2) 1 * *
quinine 1 *
R raloxifene 2 ramipril 2
* ranitidine 1 * § RAPTIVA 2
0 * = 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 REBETRON 2
REGITINE 2 RELPAX 2
RENACIDIN 2 REQUIP 2
* reserpine 1 * RESTASIS 2
§ REVLIMID 2 REYATAZ 2 REZADYNE 2 RHINOCORT (Including AQ) 2
§* ribavirin 1 * RIDAURA 2 rifabutin 2
* rifampin 1 * RILUTEK 2 riluzole 2 risedronate 2 RISPERDAL (Liquid
not covered) 2 risperidone (Liquid not covered) 2 ritonavir 2
rivastigmine 2
rizatriptan (Max 120 mg/30 days) 2 RMS (Suppository) 2
§ ROFERON-A 2 ropinirole 2
also Tier 2) 2
S salicylic acid 2
salmeterol (Including Diskus) 2
* salsalate 1 * SANDIMMUNE 2
§ SANDOSTATIN 2 saquinavir 2
§ sargramostim 2 scopolamine 2 SEBIZON 2
* selegiline 1 * * selenium sulfide 1 * § SENSIPAR 2 SEREVENT
(Including Diskus) 2
SEROMYCIN 2 SEROQUEL 2
simvastatin/ezetimibe 2
§ SOMAVERT § sorafenib 2
* spironolactone 1 * * spironolactone/hctz 1 * § SPRYCEL 2
stavudine 2 STRATTERA 2
* sucralfate 1 * sulconazole nitrate 2 sulfacetamide 2
* sulfacetamide ophthalmic 1 * * sulfacetamide/prednisolone
ophthalmic 1 * * sulfacetamide/sulfur 1 * * sulfadiazine 1 *
sulfamethoxazole 2 sulfanilamide vaginal gel 2
* sulfasalazine (Including EC) 1 * * sulfinpyrazone 1 * *
sulfisoxazole (Liquid is Tier 2) 1 * * sulindac 1 *
sumatriptan (Max 1200 mg/30 days: 4 inj kits, 12 nasal sprays, or
24 (50mg) tablets) 2
§ sunitinib 2 suprofen 2 SUSTIVA 2
§ SUTENT 2 SYMLIN 2 SYNAREL 2
T tacrolimus 2 TALWIN NX 2 TAMIFLU 2
* tamoxifen 1 * tamsulosin 2
telmisartan 2 telmisartan/hctz 2
* terazosin 1 * * terbutaline 1 *
terconazole vaginal cream 2 TESLAC 2 testolactone 50mg 2
testosterone transdermal gel 2 testosterone transdermal patch
2
* tetracycline 1 * § thalidomide 2 § THALOMID 2
* theophylline 1 * * theophylline sr 1 *
thiabendazole 2
Drug Name Tier THIOGUANINE 2
* thiothixene 1 * THYROID 2 THYROLAR 2 tiagabine 2 TICLID 2
ticlopidine 2 TILADE (All forms are covered) 2
* timolol 1 * * timolol ophthalmic 1 *
TINDAMAX 2 tinidazole 2 tiotropium 2 tipranavir 2
* tizanidine 1 * § TOBI 2
* tobramycin ophthalmic 1 * tobramycin/dexamethasone ophthalmic
2
* tolazamide 1 * * tolmetin 1 *
tolterodine (Incl LA) 2 TOPAMAX 2 topiramate 2 toremifene 2
* torsemide 1 * § TRACLEER (Mfr special access program) 2
trandolapril/verapamil 2 TRANSDERM-SCOP 2
* trazodone 1 * * tretinoin 1 *
triamcinolone oral 2 triamcinolone oral inhaler 2
* triamterene/hydrochlorothiazide 1 * * triazolam 1 *
TRICOR 2 triethanolamine 2
* trihexyphenidyl 1 * TRILEPTAL 2
trioxsalen 2 TRIPHASIL 2
* tropicamide 1 *
U urea 40% 2
* valproic acid 1 * VALTREX 2
VANCERIL (Including DS) 2 VANCOCIN 2 vancomycin 2 varenicline
2
* venlafaxine 1 * * verapamil (Including SR) 1 *
VESANOID 2 vidarabine ophthalmic 2 VIDEX 2 VIRA-A 2 VIRACEPT 2
VIRAMUNE 2 VIREAD 2 VIROPTIC 2
* vitamin a 1 * * vitamins acd/fluoride/iron chew or liquid 1
*
VIVELLE (Incl Vivelle Dot) 2 § vorinostat 2
VYTORIN 2
* warfarin 1 * XALATAN 2
§ XELODA 2 YASMIN 2 YAZ 2 ZADITOR 2 ZAROXOLYN 2 ZERIT 2 ZETIA 2
ZIAGEN 2
* zidovudine 1 * ziprasidone 2
§ ZOLINZA 2 zolpidem 2
Appendix Commonly 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.
Tier 3 Drug Suggested Alternative(s) Tier 1 Tier 2
ACHIPEX omeprazole Prilosec OTC (not covered, but available for
$16-25 for a 30-day supply.)
X
ALLEGRA ALLEGRA-D
Nonprescription generic loratadine (not covered, but available in
stores for $15-20 for a 30-day supply.)
AMARYL glyburide, glipizide X
AMBIEN temazepam, triazolam X
CELEBREX ibuprofen, naproxen, sulindac, diclofenac X
CENESTIN PREMARIN X
COVERA HS verapamil long-acting X
DAYPRO ibuprofen, naproxen, indomethacin, piroxicam, sulindac
X
X X
EFFEXOR XR capsules, extended release
venlafaxine tablets X
KYTRIL ondansetron X
X X
NASONEX fluticasone propionate RHINOCORT
PAXIL CR fluoxetine, paroxetine, citalopram X
PLENDIL nifedipine long-acting amlodipine
X X
PREVACID omeprazole PROTONIX Prilosec OTC (not covered, but
available for $16-25 for a 30-day supply.)
X X
SPORANOX terbinafine X
TIAZAC diltiazem long-acting X
ULTRACET acetaminophen + tramadol X
X
VANTIN cefuroxime X
VICOPROFEN hydrocodone + acetaminophen X
ZYRTEC ZYRTEC D
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 quinapril ACCUTANE isotretinoin ADALAT-CC nifedipine-ER
ALDACTONE spironolactone ALPHAGAN brimonidine eye drops AMBIEN
zolpidem AMOXIL amoxicillin ANAPROX naproxen sodium ANTABUSE
disulfiram ARISTOCORT triamcinolone ATIVAN lorazepam AUGMENTIN
amoxicillin/clavulanic acid AURALGAN benzocaine/antipyrine ear
drops AXID nizatidine AYGESTIN norethindrone AZELEX azelaic acid
AZULFIDINE sulfasalazine BACTRIM trimethoprim/sulfamethoxazole
BACTROBAN mupirocin ointment BENTYL dicyclomine BETAGAN levobunolol
eye drops BETAPACE sotalol BUMEX bumetanide BUSPAR buspirone
CARAFATE sucralfate CARDIZEM diltiazem CARDURA doxazosin CATAPRES
clonidine CECLOR cefaclor CEFTIN cefuroxime CELEXA citalopram
CEPHULAC lactulose liquid CIPRO ciprofloxacin CLEOCIN-T clindamycin
topical CLINORIL sulindac CLOZARIL clozapine COLYTE PEG electrolyte
liquid COMPAZINE prochlorperazine COPEGUS ribavirin CORDARONE
amiodarone COUMADIN warfarin CREON lipase/amylase/protease
Brand Name Generic Equivalent (Tier 3) (Tier 1)
CYCRIN nadolol CYTOTEC misoprostol DANOCRINE danazol DARVOCET
propoxyphene/acetaminophen DARVON propoxyphene/acetaminophen DAYPRO
oxaprozin DEMEROL meperidine DEXEDRINE dextroamphetamine DIAMOX
acetazolamide DIFLUCAN fluconazole DILAUDID hydromorphone
DIPROLENE, DIPROSONE betamethasone dipropionate DISALCID salsalate
DITROPAN oxybutynin DOLOBID diflunisal DYAZIDE
triamterene/hydrochlorothiazide EFUDEX fluorouracil solution
ELDEPRIL selegiline ELIMITE permethrin EPIFRIN epinephrine eye
drops ESTRACE micronized estradiol ESTRATAB esterified estrogen
FELDENE piroxicam FIORICET acetaminophen/butalbital/caffeine
FIORINAL aspirin/butalbital/caffeine FLAGYL metronidazole FLEXERIL
cyclobenzaprine FLORINEF fludrocortisone FML fluorometholone
opthalmic FLOXIN ofloxacin GLUCOPHAGE metformin GLUCOTROL glipizide
GLUCOVANCE glyburide/metformin GOLYTELY PEG electrolyte liquid
HALCION triazolam HALDOL haloperidol HYTRIN terazosin IMDUR
isosorbide mononitrate sr IMURAN azathioprine INDERAL propranolol
INDOCIN indomethacin INTAL cromolyn inhaled
ISORDIL isosorbide dinitrate KAYEXALATE sodium polystyrene
sulfonate KEFLEX cephalexin KENALOG triamcinolone KLONOPIN
clonazepam KWELL lindane LAC-HYDRIN ammonium lactate LANOXIN
digoxin LASIX furosemide LEVSIN hyoscyamine LIBRAX
clidinium/chlordiazepoxide LIDEX fluocinonide LOMOTIL
diphenoxylate/atropine LOPID gemfibrozil LOPRESSOR metoprolol
LOPROX ciclopirox LOTENSIN benazepril LOTENSIN HCT benazepril /HCTZ
LOTRIMIN clotrimazole 1% LOXITANE loxapine LUVOX fluvoxamine
MAXZIDE triamterene/hydrochlorothiazide MEGACE megestrol METROCREAM
metronidazole topical MEVACOR lovastatin MEXITIL mexiletine
MIACALCIN calcitonin injection MICRONASE glyburide MIDRIN
isomethepene/
dichloralphenazone/apap MINIPRESS prazosin MODURETIC amiloride/hctz
MONOPRIL fosinopril MOTRIN ibuprofen MUCOMYST acetylcysteine
MYCELEX clotriamzole troches MYCOLOG nystatin/triamcinolone
MYCOSTATIN nystatin MYSOLINE primidone NAPROYSN naproxen NEORAL
cyclosporine microemulsion NEURONTIN gabapentin NITOBID
nitroglyercin oral NIZORAL ketoconazole NORMODYNE labetalol NORPACE
disopyramide NORVASC amlodipine NULYTELY PEG electrolyte liquid
OCUFEN flurbiprofen OCUFLOX ofloxacin OGEN estropipate ORAMORPH
morphine sulfate sr ORTHO NOVUM ethinyl estradiol/ norethindrone
PAMELOR nortriptyline PANCREASE pancrelipase PARLODEL bromocriptine
PAXIL paroxetine
Brand Name Generic Equivalent (Tier 3) (Tier 1)
PEDIAZOLE erythromycin/sulfisoxazole PEPCID famotidine PERCOCET
oxycodone/acetaminophen PERCODAN oxycodone/aspirin PERIACTIN
cyproheptadine PHENERGAN promethazine PHRENILIN
acetaminophen/butalbital PLAQUENIL hydroxychloroquine POLYTRIM
trimethoprim/polymixin b PRILOSEC omeprazole PRINIVIL lisinopril
PRINIZIDE lisinopril/hctz PROCARDIA XL nifedipne XL PROCTOFOAM-HC
hydrocortisone/parmoxine PROLIXIN fluphenazine PROPINE dipivefrin
eye drops PROVENTIL albuterol PROVERA medroxyprogesterone PROZAC
fluoxetine PYRIDIUM phenazopyridine QUESTRAN chloestyrmaine
QUINIDEX quindine REBETOL ribavirin REGLAN metoclopramide RELAFEN
nabumetone REMERON mirtazepine RESTORIL temazepam RETIN-A tretinoin
RHEUMATREX methotrexate RIMACTANE rifampin RITALIN methylphenidate
ROBAXIN methocarbamol ROBITUSSIN AC guaifenesin/codeine liquid
ROCALTROL calcitriol ROXICODONE oxycodone/acetaminophen RYTHMOL
propafenone SARAFEM fluoxetine SELSUN selenium sulfide SEPTRA
trimethoprim/sulfamethoxazole SIVALDENE silver sulfadiazine SINEMET
levodopa/carbidopa SOMA carisoprodol SSKI potassium iodide STADOL
butorphanol STELAZINE trifluoperazine SULFACET-R
sulfacetamide/sulfur SYMMETREL amantadine SYNALAR fluocinolone
SYNTHROID levothyroxine TAGAMET cimetidine TAMBOCOR flecainide
TAPAZOLE methimazole TEGRETOL carbamazepine TENEX guanfacine
TENORETIC atenolol/chlorthalidone TENORMIN atenolol TERAZOL 7
terconazole vaginal cream
Brand Name Generic Equivalent (Tier 3) (Tier 1)
THEO-DUR theophylline sr THORAZINE chlorpromazine TIAZAC diltiazem
sr TICLID ticlopidine TIMOPTIC timolol eye drops TOLFRANIL
imipramine TOLECTIN tolmetin TOPICORT desoximetasone TRENTAL
pentoxifylline TRI-VI FLOR vitamins acd/fluoride/iron TRILAFON
perphenazine TRILISATE choline/mag salicylates TRI-LEVLEN
levonorgestrel/ethinylestradiol TRIVORA ethinyl estradio/
levonorgestrel TYLENOL/CODIENE acetaminophen/codeine TYLOX
acetaminophen/oxycodone ULTRAM tramadol URECHOLINE bethanechol
VALISONE betamethasone valerate VALIUM diazepam VASODILAN
isoxsuprine VASORETIC enalapril/hctz VASOTEC enalapril VEPESID
etoposide VERMOX mebendazole VIBRAMYCIN doxycycline VICODIN
acetaminophen/hydrocodone VISKEN pindolol VISTARIL hydroxyzine
VIVACTIL protriptyline VOLTAREN diclofenac VOSOL HC acetic
acid/
hydrocortisone liquid WELLBUTRIN bupropion WYTENSIN guanabenz XANAX
alprazolam XYLOCAINE lidocaine YODOXIN iodoquinol ZANAFLEX
tizanidine ZANTAC ranitidine ZARONTIN ethosuximide ZAROXOLYN
metolazone ZEPHREX LA pseudoephedrine/
guafenesin la ZESTORETIC lisinopril/hctz ZESTRIL lisinopril ZIAC
bisoprolol/hctz ZOCOR simvastatin ZOFRAN ondansetron ZOLOFT
sertraline ZOVIRAX acyclovir
Cost-Saving Tips: • Ask your doctor to prescribe a generic drug
when appropriate. All generic
drugs are covered and have the lowest cost to you.
• If an exact generic equivalent for the drug you are taking is not
available, ask your doctor whether there is a similar generic drug
that might work as well for you.
• Find out whether a drug is on the Preferred Drug List by using
the searchable Preferred Drug List at our Web site listed on the
back of your Premera ID card.
• Ask your pharmacist to fill your prescriptions with a generic
drug when allowed.
Pharmacy Locator
Please call the number on the
back of your ID card.
To help us serve you better
and faster, please have your
ID card ready when you call.
018288 (10-2007)
Premera Blue Cross is an Independent Licensee of the Blue Cross
Blue Shield Association
037338 (07-2016)
Discrimination is Against the Law Premera Blue Cross 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 or sex. Premera: •
Provides free aids and services to people with disabilities to
communicate
effectively with us, such as: • Qualified sign language
interpreters • Written information in other formats (large print,
audio, accessible
electronic formats, other formats) • Provides free language
services to people whose primary language is not
English, such as: • Qualified interpreters • 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
800-842-5357 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
Avenue 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. Getting Help in
Other Languages This Notice has Important Information. This notice
may have important information about your application or coverage
through Premera Blue Cross. There may be key dates in this notice.
You may need to take action by certain deadlines to keep your
health coverage or help with costs. You have the right to get this
information and help in your language at no cost. Call 800-722-1471
(TTY: 800-842-5357). (Amharic): Premera Blue Cross 800-722-1471
(TTY: 800-842-5357)
:(Arabic) .
Premera Blue Cross. . . . (TTY: 800-842-5357) 1471-722-800
(Chinese): Premera Blue Cross
800-722-1471 (TTY: 800-842-5357)
Oromoo (Cushite): Beeksisni kun odeeffannoo barbaachisaa qaba.
Beeksisti kun sagantaa yookan karaa Premera Blue Cross tiin
tajaajila keessan ilaalchisee odeeffannoo barbaachisaa qabaachuu
danda’a. Guyyaawwan murteessaa ta’an beeksisa kana keessatti
ilaalaa. Tarii kaffaltiidhaan deeggaramuuf yookan tajaajila fayyaa
keessaniif guyyaa dhumaa irratti wanti raawwattan jiraachuu
danda’a. Kaffaltii irraa bilisa haala ta’een afaan keessaniin
odeeffannoo argachuu fi deeggarsa argachuuf mirga ni qabaattu.
Lakkoofsa bilbilaa 800-722-1471 (TTY: 800-842-5357) tii bilbilaa.
Français (French): Cet avis a d'importantes informations. Cet avis
peut avoir d'importantes informations sur votre demande ou la
couverture par l'intermédiaire de Premera Blue Cross. Le présent
avis peut contenir des dates clés. Vous devrez peut-être prendre
des mesures par certains délais pour maintenir votre couverture de
santé ou d'aide avec les coûts. Vous avez le droit d'obtenir cette
information et de l’aide dans votre langue à aucun coût. Appelez le
800-722-1471 (TTY: 800-842-5357). Kreyòl ayisyen (Creole): Avi sila
a gen Enfòmasyon Enpòtan ladann. Avi sila a kapab genyen enfòmasyon
enpòtan konsènan aplikasyon w lan oswa konsènan kouvèti asirans lan
atravè Premera Blue Cross. Kapab genyen dat ki enpòtan nan avi sila
a. Ou ka gen pou pran kèk aksyon avan sèten dat limit pou ka kenbe
kouvèti asirans sante w la oswa pou yo ka ede w avèk depans yo. Se
dwa w pou resevwa enfòmasyon sa a ak asistans nan lang ou pale a,
san ou pa gen pou peye pou sa. Rele nan 800-722-1471 (TTY:
800-842-5357). Deutsche (German): Diese Benachrichtigung enthält
wichtige Informationen. Diese Benachrichtigung enthält unter
Umständen wichtige Informationen bezüglich Ihres Antrags auf
Krankenversicherungsschutz durch Premera Blue Cross. Suchen Sie
nach eventuellen wichtigen Terminen in dieser Benachrichtigung. Sie
könnten bis zu bestimmten Stichtagen handeln müssen, um Ihren
Krankenversicherungsschutz oder Hilfe mit den Kosten zu behalten.
Sie haben das Recht, kostenlose Hilfe und Informationen in Ihrer
Sprache zu erhalten. Rufen Sie an unter 800-722-1471 (TTY:
800-842-5357). Hmoob (Hmong): Tsab ntawv tshaj xo no muaj cov
ntshiab lus tseem ceeb. Tej zaum tsab ntawv tshaj xo no muaj cov
ntsiab lus tseem ceeb txog koj daim ntawv thov kev pab los yog koj
qhov kev pab cuam los ntawm Premera Blue Cross. Tej zaum muaj cov
hnub tseem ceeb uas sau rau hauv daim ntawv no. Tej zaum koj kuj
yuav tau ua qee yam uas peb kom koj ua tsis pub dhau cov caij nyoog
uas teev tseg rau hauv daim ntawv no mas koj thiaj yuav tau txais
kev pab cuam kho mob los yog kev pab them tej nqi kho mob ntawd.
Koj muaj cai kom lawv muab cov ntshiab lus no uas tau muab sau ua
koj hom lus pub dawb rau koj. Hu rau 800-722-1471 (TTY:
800-842-5357). Iloko (Ilocano): Daytoy a Pakdaar ket naglaon iti
Napateg nga Impormasion. Daytoy a pakdaar mabalin nga adda ket
naglaon iti napateg nga impormasion maipanggep iti apliksayonyo
wenno coverage babaen iti Premera Blue Cross. Daytoy ket mabalin
dagiti importante a petsa iti daytoy a pakdaar. Mabalin nga adda
rumbeng nga aramidenyo nga addang sakbay dagiti partikular a
naituding nga aldaw tapno mapagtalinaedyo ti coverage ti salun-atyo
wenno tulong kadagiti gastos. Adda karbenganyo a mangala iti daytoy
nga impormasion ken tulong iti bukodyo a pagsasao nga awan ti
bayadanyo. Tumawag iti numero nga 800-722-1471 (TTY: 800-842-5357).
Italiano (Italian): Questo avviso contiene informazioni importanti.
Questo avviso può contenere informazioni importanti sulla tua
domanda o copertura attraverso Premera Blue Cross. Potrebbero
esserci date chiave in questo avviso. Potrebbe essere necessario un
tuo intervento entro una scadenza determinata per consentirti di
mantenere la tua copertura o sovvenzione. Hai il diritto di
ottenere queste informazioni e assistenza nella tua lingua
gratuitamente. Chiama 800-722-1471 (TTY: 800-842-5357).
(Japanese): Premera Blue Cross
800-722-1471 (TTY: 800-842-5357)
(Korean): . Premera Blue Cross . . . . 800-722-1471 (TTY:
800-842-5357) .
(Lao): . Premera Blue Cross. . . . 800-722-1471 (TTY:
800-842-5357). (Khmer):
Premera Blue Cross
800-722-1471 (TTY: 800-842-5357)
(Punjabi):
. Premera Blue Cross . . ,
,
800-722-1471 (TTY: 800-842-5357).
:(Farsi) .
. Premera Blue Cross .
. .
)800-842-5357 TTY( 800-722-1471 .
Polskie (Polish): To ogoszenie moe zawiera wane informacje. To
ogoszenie moe zawiera wane informacje odnonie Pastwa wniosku lub
zakresu wiadcze poprzez Premera Blue Cross. Prosimy zwrócic uwag na
kluczowe daty, które mog by zawarte w tym ogoszeniu aby nie
przekroczy terminów w przypadku utrzymania polisy ubezpieczeniowej
lub pomocy zwizanej z kosztami. Macie Pastwo prawo do bezpatnej
informacji we wasnym jzyku. Zadzwocie pod 800-722-1471 (TTY:
800-842-5357). Português (Portuguese): Este aviso contém
informações importantes. Este aviso poderá conter informações
importantes a respeito de sua aplicação ou cobertura por meio do
Premera Blue Cross. Poderão existir datas importantes neste aviso.
Talvez seja necessário que você tome providências dentro de
determinados prazos para manter sua cobertura de saúde ou ajuda de
custos. Você tem o direito de obter esta informação e ajuda em seu
idioma e sem custos. Ligue para 800-722-1471 (TTY:
800-842-5357).
Român (Romanian): Prezenta notificare conine informaii importante.
Aceast notificare poate conine informaii importante privind cererea
sau acoperirea asigurrii dumneavoastre de sntate prin Premera Blue
Cross. Pot exista date cheie în aceast notificare. Este posibil s
fie nevoie s acionai pân la anumite termene limit pentru a v menine
acoperirea asigurrii de sntate sau asistena privitoare la costuri.
Avei dreptul de a obine gratuit aceste informaii i ajutor în limba
dumneavoastr. Sunai la 800-722-1471 (TTY: 800-842-5357). P
(Russian): . Premera Blue Cross. . , , . . 800-722-1471 (TTY:
800-842-5357). Fa’asamoa (Samoan): Atonu ua iai i lenei
fa’asilasilaga ni fa’amatalaga e sili ona taua e tatau ona e
malamalama i ai. O lenei fa’asilasilaga o se fesoasoani e
fa’amatala atili i ai i le tulaga o le polokalame, Premera Blue
Cross, ua e tau fia maua atu i ai. Fa’amolemole, ia e iloilo
fa’alelei i aso fa’apitoa olo’o iai i lenei fa’asilasilaga taua.
Masalo o le’a iai ni feau e tatau ona e faia ao le’i aulia le aso
ua ta’ua i lenei fa’asilasilaga ina ia e iai pea ma maua fesoasoani
mai ai i le polokalame a le Malo olo’o e iai i ai. Olo’o iai iate
oe le aia tatau e maua atu i lenei fa’asilasilaga ma lenei
fa’matalaga i legagana e te malamalama i ai aunoa ma se togiga
tupe. Vili atu i le telefoni 800-722-1471 (TTY: 800-842-5357).
Español (Spanish): Este Aviso contiene información importante. Es
posible que este aviso contenga información importante acerca de su
solicitud o cobertura a través de Premera Blue Cross. Es posible
que haya fechas clave en este aviso. Es posible que deba tomar
alguna medida antes de determinadas fechas para mantener su
cobertura médica o ayuda con los costos. Usted tiene derecho a
recibir esta información y ayuda en su idioma sin costo alguno.
Llame al 800-722-1471 (TTY: 800-842-5357). Tagalog (Tagalog): Ang
Paunawa na ito ay naglalaman ng mahalagang impormasyon. Ang paunawa
na ito ay maaaring naglalaman ng mahalagang impormasyon tungkol sa
iyong aplikasyon o pagsakop sa pamamagitan ng Premera Blue Cross.
Maaaring may mga mahalagang petsa dito sa paunawa. Maaring
mangailangan ka na magsagawa ng hakbang sa ilang mga itinakdang
panahon upang mapanatili ang iyong pagsakop sa kalusugan o tulong
na walang gastos. May karapatan ka na makakuha ng ganitong
impormasyon at tulong sa iyong wika ng walang gastos. Tumawag sa
800-722-1471 (TTY: 800-842-5357). (Thai):