Your Choice Pharm GD

8/7/2019 Your Choice Pharm GD

1/36

Your ChoicePharmacy Beneit Guide

Eective January 1, 2011

www.upmchealthplan.com


2/36


3/36

Table o Contents

Your Choice Overview .......................................... 1

Formulary Management Terms ............................. 2

Formulary ...................................................... 2

Prior Authorization......................................... 2

Step Therapy.................................................. 2Quantity Limits ............................................... 2

Brands/Generics ................................................... 3

Network Pharmacy Providers ................................ 3

Retail ............................................................. 3

Mail Order ..................................................... 3

Specialty Medications ..................................... 4

Other Supplies o Medication ............................... 5

Vacation Supply ............................................. 5

Medication Supplies Not Coveredby UPMC Health Plan ................................. 5

Formulary Overview ............................................. 5

Your Choice Formulary......................................... 6

Medications Not Covered by Your Choice .......... 27

Non-Covered Medications with Covered

Alternatives .................................................. 28

Your Choice Brand/Generic Reerence Guide ...... 31


4/36

1

Your Choice Overview

Good value and reedom o choice the YourChoice pharmacy program provides both byoering you a variety o high-quality, eectivegeneric and brand-name prescription drugs.

When you need a prescription medication, you andyour doctor can choose rom our dierent levels,

or tiers, to help you manage your prescriptiondrug costs. This gives you and your doctor thereedom to choose the medication that is right oryou while helping you to better budget your healthcare dollars.

The Your Choice ormulary guide providesinormation that is applicable to mostmembers. Please reer to your prescriptiondrug rider to see i your specic plan has anydierences.

UPMC Your ChoiceContact Numbers

Current Members:UPMC Health Plan Pharmacy Services:1-800-396-4139

UPMC Health Plan Member Services:1-888-876-2756

TTY Services: 1-800-361-2629

Prospective Members:Prospective members should direct their questionsto their companys benets administrator or to theUPMC Health Plan Enrollment Hotline at1-800-644-1046.

Online inormation is available atwww.upmchealthplan.com/pharmacy.


5/36

2

FormularyManagement Terms

Formulary

A ormulary is a list o Food and DrugAdministration (FDA) approved medications thatthe UPMC Health Plan Pharmacy and Therapeutics

(P&T) Committee determine will be covered.The P&T Committee, made up o physicians andpharmacists rom communities throughout theUPMC Health Plan service area, decides whichmedications to include in the Your Choiceprogram based on a drugs saety, eectiveness,and cost. The P&T Committees job is to makesure that the Your Choice Pharmacy programprovides you with high-quality, cost-eectiveprescription medications. The P&T Committeereviews and updates the Your Choice ormularyregularly throughout the year.

The most commonly prescribed Your Choicedrugs are listed in the ormulary section o thisbooklet. Please note that there are other drugcategories and drugs that Your Choice coversbesides the ones listed in the table. For the latestinormation on the Your Choice drug table andother pharmacy benets, visit our website atwww.upmchealthplan.com/pharmacy. SelectYour Choice to access the searchable drug list.Or you may call our Member Advocates at thenumber listed on the back o your UPMC HealthPlan ID card. Another option is to use the Express

Scripts, Inc., online price check eature to lookor the specic member and exact medication inquestion.

Medications not on the ormulary are listed inthe Medications Not Covered by Your Choiceand Non-Covered Medications with CoveredAlternatives sections o this booklet.

Prior Authorization

I a drug requires prior authorization, your doctormust consult with UPMC Health Plan beore

prescribing it. Prior authorizations are set on adrug-by-drug basis and require specic criteriaor approval based upon FDA and manuacturerguidelines, medical literature, saety concerns,and appropriate use. Drugs that require priorauthorization may be newer drugs or whichUPMC Health Plan wants to track usage, drugsnot used as a standard rst option in treatinga medical condition, or drugs with potentialside eects that UPMC Health Plan wants tomonitor or patient saety. The UPMC HealthPlan Pharmacy Services Department mustauthorize the use o these drugs beore Your

Choice will begin to cover them.These drugs are designated with the symbolPA on the ormulary tables in this booklet. Inaddition, new drugs recently approved by theFDA may require prior authorization until theirplacement on the ormulary has been determined.Also, all compounded medications requireprior authorization. The only exceptions arecompounded hormone replacement therapies

and compounded narcotic analgesics, which arenot covered by the Your Choice benet. All priorauthorization criteria are reviewed by the P&TCommittee.

Step Therapy

Step therapy is the practice o using specicmedications rst when beginning drug therapyor a medical condition. The preerred rstcourse o treatment may be drugs that are morecost-eective or considered the standard rst-line treatment. The rules or each step therapy

medication are built into the computer les oUPMC Health Plans prescription claims processingsystem. Medications that require step therapyare automatically approved i there is a recordthat the member has already tried the preerredmedication(s). I there is no record o the preerredmedication(s) in the members medication history,the physician must submit clinical inormation tothe Health Plan. Once that inormation is received,the Health Plan will make a decision on paymentor the requested medication. Medicationsaected by this process are designated with thesymbol ST on the ormulary listing in this booklet.

Quantity Limits

Quantity limits are drug-specic and limit theamounts o certain drugs that can be dispensedduring a specic period o time. For these drugs,the P&T Committee ollows FDA guidelines andother clinical literature to limit how much o thedrug you may receive in a certain period o timeor how long you may stay on the drug.

Quantity limits promote appropriate use o the

drug, prevent waste, and control costs. Drugsthat have quantity limits are designated with thesymbol QL on the ormulary tables included inthis booklet.

Prescriptions or controlled substances arelimited to a 30-day supply.

For some drugs, the manuacturers dosingguidelines may recommend that patients takethe medication one time a day in a larger dose


6/36

3

instead o several times a day in smaller doses. Forthese drugs, Your Choice ollows the guidelinesand covers one larger dose per day. I there is amedical reason that prevents you rom taking themedication once per day in a larger dose, yourdoctor can call the UPMC Health Plan PharmacyServices Department at 1-800-979-UPMC (8762)to request a medical exception or you.

Brands/GenericsGeneric drugs are cost-eective alternativesthat oer the same level o saety and qualityas their brand-name equivalents. Generic drugshave the same active ingredients as brand-namemedications, but inactive ingredients can vary,such as dyes used to color generic medicationsor powders used to shape the tablets. Thesedierences do not aect how generic medicationswork in the body. Generic drugs deliver the sameamount o active ingredients in the same amounto time as their brand-name equivalents.

Not all drugs have a generic equivalent. Generally,new drugs are given patent protection or 20years rom the date o submission o the patent.Once the patent expires, other pharmaceuticalcompanies can produce the same drug in ageneric ormulation.

The FDA regulates generic drug manuacturersjust as it regulates the makers o brand-namemedications. Prior to selling generic medications inthe United States, a company must meet certaincriteria. To gain FDA approval, the maker o ageneric drug must prove that the drugs activeingredients, drug strength, and dosage orm areidentical to those o the corresponding brand-name drug. The generic drug must also pass strictFDA measurements to ensure that it delivers thesame amount o active ingredient in the sametime rame as its brand-name counterpart. Finally,the manuacturer o the generic drug must provethat its product is produced under the same strictguidelines as the brand-name drug.

The manuacturer can produce the generic

medicine only ater these requirements are met.Ater approval, the FDA continues to regularlyinspect all manuacturing acilities o both brandand generic products to ensure that only high-quality medications are sold in the United States.

Generic drugs have the same active ingredientsas their brand-name equivalents, but costsignicantly less. Beore the FDA allows a brand-name drug to be sold in the United States,scientists spend years testing the medication to

establish its saety and ecacy in treating anillness or condition. Once a brand-name drug isapproved, the company that developed it spendsmillions o dollars to promote the drug throughadvertising and educational programs.

Companies that make generic drugs do not haveto invest large amounts o money in research,since the brand-name drug manuacturers have

already done this. In addition, generic companiesdo not market their drugs. As a result, genericdrug manuacturers spend signicantly less moneyon magazine and television advertisements thanbrand-name manuacturers do or their products.Companies that make generic drugs pass thesesavings on to you.

The Your Choice program requires you touse a generic version o the drug i one isavailable. This means that i you receive a brand-name drug when a generic is available, you mustpay the brand copayment in addition to the retail

cost dierence between the brand-name andgeneric orms o the drug.

Network Pharmacy Providers

Retail

UPMC Health Plans network o retail pharmaciesincludes hundreds o locations independentpharmacies as well as multistore chains throughout the region. You can take yourprescription to any pharmacy in the networkand the pharmacist will conrm your eligibilityor benets, ll your prescription, accept yourcopayment, and process your claim. Seventy-ve percent o your medication must be usedbeore you can get a rell. For specic pharmacynames, locations, and telephone numbers, lookin the provider directory sent to you during openenrollment, or on the Health Plan website atwww.upmchealthplan.com/pharmacy. Youmay also call our Member Advocates at the phonenumber listed on the back o your member IDcard or on page 1 o this booklet.

Mail OrderUPMC Health Plan has a contract with a mail-order pharmacy ulllment center to oer youcost-savings and the convenience o havingprescriptions or maintenance drugs sentdirectly to your home. Maintenance drugs aredrugs that you take on a regular, long-termbasis. They include medications that treat highblood pressure, asthma, diabetes, arthritis, highcholesterol, and other chronic conditions.


7/36

4

With this convenient mail-order service:You receive a 90-day supply o mostdrugs, plus rells, as prescribed by yourdoctor.You usually pay a lower out-o-pocket cost ora 90-day supply than you would pay at a retailpharmacy.You enjoy strict quality and saety controls orevery prescription lled.

Reer to your UPMC Health Plan prescription drugschedule o benets or your UPMC Health Plan IDcard or your actual prescription copayments.

For a rst-time prescription or a new medication,UPMC Health Plan recommends that you try a30-day supply o the drug rom a retail pharmacybeore requesting a 90-day supply through themail-order program. This approach reduceswasted medication and unnecessary copaymentsby giving your doctor a chance to make sure thatthe medication is the right dose or you and that

it does not cause you any side eects.

To use the mail-order program, ask your doctorto write a prescription or a 90-day supply oeach maintenance drug that you need (plusrells i appropriate). I your prescription is ora new medication, or i you need to start yourmedication immediately, have your doctor writetwo prescriptions:

One or your initial 30-day supply that youcan ll immediately at a retail pharmacy todetermine whether the medication works oryou, andA second one or your longer 90-daymaintenance supply that you can send toUPMC Health Plans contracted mail-orderpharmacy.

You can request a mail-order orm rom UPMCHealth Plan by calling our Member Advocates orrequesting the orm on the UPMC Health Planwebsite atwww.upmchealthplan.com/pharmacy. On themail-order orm, ll out the patient inormation

section (name, member ID number, date o birth,relationship to subscriber, gender, doctor, anddoctors phone number) or each new prescriptionyou send. New prescription slip(s) must list thepatients ull name, date o birth, and address, aswell as the doctors name and phone number.

To avoid running out o your mail-orderprescription, reorder your medication while youstill have an adequate supply remaining, allowinga ew weeks or processing and delivery.To

request rells, you may order over the telephoneor the Internet. Reer to UPMC Health Plans mail-order prescription program description included inyour Welcome Book or to the Health Plan websiteor the latest contact inormation, telephonenumbers, and website addresses regarding mail-order prescription services.

When you mail a request or a new prescription or

a rell, please include your copayment in the mail-order envelope. You may pay by check, moneyorder, or credit card (American Express,Discover, MasterCard, or Visa). Do not send cash.I ordering rells by phone or online, you must payby credit card.

Typically, mail-order prescriptions are writtenor a 90-day supply. I the physician writes or a30-day supply with two rells and you send it tothe mail-order acility, they may consolidate theprescription to make one 90-day supply. I you donot intend to receive a 90-day supply rom the

mail-order acility, please indicate this on the mail-order orm.

Your prescription drug order will be processedpromptly and shipped to you along withinstructions or uture orders. Using mail orderpromotes the convenience o home delivery pluscost savings.

Specialty Medications

Specialty medications are a category o drugs

created because o advancements in drugdevelopment. This category includes high-cost medications and biologicals regardless ohow they are administered (injectable, oral,transdermal, or inhalant).

These medications are oten used to treatcomplex clinical conditions and usually requireclose management by a physician because otheir potential side eects and the need orrequent dosage adjustments. Some specialtymedications may require prior authorization and/or have quantity limits. These medications require

the third-tier copayment but are included in aseparate specialty tier.

Most specialty medications must be obtainedthrough our designated specialty provider, whichprovides convenient mail-order delivery. By usinga specialty provider, you have improved accessto drugs, as many retail pharmacies do not carrythese types o medications. In addition, specialtyproviders improve care by providing educationor our members and expanded access to healthcare proessionals trained in the proper use o


8/36

5

these specialty medications. A specialty provideroers cost-eective health care and medicationmanagement and compliance programs.

Specialty medications are limited to a 30-daysupply.

Other Supplies o Medication

Vacation SupplyUPMC Health Plan uses a nationwide pharmacybenets company to help manage the YourChoice pharmacy program. Your prescriptionneeds are covered even when you travel outsideo the western Pennsylvania area. Thousands opharmacies across the country will honor yourUPMC Health Plan member ID card.

To ll a prescription outside o the UPMC HealthPlan service area, simply present your Health Planmember ID card at a pharmacy that participatesin our pharmacy benets managers nationwide

network. To locate a participating pharmacy, orto be put in contact with the national pharmacybenets management company, please contactour Member Advocates at the phone numberlisted on the back o your member ID card or onpage 1 o this booklet.

When you receive your prescription, somepharmacies may ask you to pay the ull priceo the medication rather than your normalcopayment. I this should happen, you can

submit a Direct Reimbursement Claim to UPMCHealth Plan and ask to be reimbursed. The orm isavailable on the website atwww.upmchealthplan.com. Under theMembers link at the bottom right o thescreen, select Commonly Used Forms, and thenPharmacy Program Direct Reimbursement ClaimForm. Or you may call the UPMC Health PlanMember Services Department to request the orm.

I your claim is approved, you will be reimbursedthe amount that you paid or the medication, lessthe appropriate copayment.

I you will be gone or an extended period o time,or i you will be traveling outside o the country,you may consider using our mail-order system sothat you receive a 90-day supply prior to travelingwith no interruptions in use.

Medication Supplies Not Covered by UPMCHealth Plan

No authorizations will be provided or

medications that are reported by themember, provider, or pharmacy to be lost,misplaced, stolen, destroyed, or damaged.Medications received at no charge tothe member (workers compensation,medications purchased with amanuacturers coupon, etc.) will not becovered.Prescriptions that are written more thana year ago will not be covered. A newprescription should be written by thephysician.

Formulary Overview

Your Choice prescription drugs are organized intoour tiers:

The rst tier is or generic drugs, which have1.the lowest copayment. Generic drugs arecost-eective alternatives that oer the samelevel o saety and quality as their brand-nameequivalents.The second tier is or preerred-brand drugs,2.which have the middle level o copayment.UPMC Health Plan classies these drugsas preerred because o their value andeectiveness.The third tier is or non-preerred brand drugs,3.which have the highest copayment level.The ourth tier is or specialty drugs, which4.are high-cost medications and biologicals,regardless o how they are administered(injectable, oral, transdermal, or inhalant).These drugs also have the highest level ocopayment. These medications are oten used

to treat complex clinical conditions and usuallyrequire close management by a physicianbecause o their potential side eects and theneed or requent dosage adjustments.

I you are a current UPMC Health Plan member,please reer to your Schedule o Benefts oryour copayment amounts. I you did not receivea Schedule o Benefts in your Welcome Book,

please contact our Member Advocates at thenumber on the back o your member ID card. Yourmember ID card should also list your copaymentamounts.

I you are thinking about joining UPMC HealthPlan and would like inormation about copaymentamounts, review the Schedule o Benefts, which

you may have received rom your companysBenefts Administrator or Human ResourcesDepartment. I you did not receive a Schedule oBenefts, contact your Benefts Administrator orthe UPMC Health Plan Enrollment Hotline listed on

page 1 o this booklet.


9/36

6

KEY COPAYMENT TIER QL = Quantity Limits 1 = Generic Medications

PA = Prior Authorization required 2 = Preerred-Brand MedicationsST = Step Therapy required 3 = Non-Preerred Brand Medications & Specialty Medications

* Age restrictions apply to some medications.


Drug Name

Generic

Preferred

Non-preferred

Specialty

SuggestedAlternative(s)

Abiliy PA, QL (ST

35 years o age)

1

Adcirca PA, QL 3Specialtymedication

Adrenaclick 3 EpiPen

Drug Name

Generic

Preferred

Non-preferred

Specialty


Advair 2

Advicor 3lovastatin,pravastatin,simvastatin, Lipitor

Aerobid 3 Flovent HFA, Qvar

Aerobid- M 3 Flovent HFA, Qvar

Anitor PA, QL 3Specialtymedication

Aggrenox 3Plavix, ticlopidine,dipyridamole

Alamast 3azelastine, Elestat,Patanol

alagesic 1albuterol QL 1

alclometasonedipropionate

1

Aldurazyme PA 3Specialtymedication

alendronate 1

allopurinol 1

Alocril 3azelastine, Elestat,Patanol

Alomide 3

azelastine, Elestat,

Patanol

Alora QL 3 estradiol

Aloxi ST, QL 3 ondansetron (QL)

alprazolam 1

alprazolam ODT 1

Alrex 3fuorometholone,prednisolone

Alvesco 3 Flovent HFA, Qvar

amantadine 1

amcinonide 1

Amevive PA, QL 3 Specialtymedication

Amitiza QL 3 lactulose

amitriptyline 1


10/36

7




Drug Name

Generic

Preferred

Non-preferred

Specialty


amlodipine

besylate

1

amlodipinebesylate/benazepril

1

ammoniumlactate

1

Amnesteem 1

amoxicillin 1

amoxicillin/clavulanate

1

amoxicillin/

clavulanate ER

1

amphetamine/dextroamphetamineER QL

1

amphetaminesalts QL

1

Ampyra PA, QL 3Specialtymedication

Analpram HC 3hydrocortisone/pramoxine

anastrozole 1

Androderm PA 3

testosterone

injection

Androgel PA 3testosteroneinjection

Android PA 3testosteroneinjection

Angeliq 3 Premarin

Antara 3 enobrate, Tricor

antibiotics(generic oral)

1

Anzemet ST,QL 3 ondansetron (QL)

Apidra 3 Humalog, NovologApokyn QL 3

Specialtymedication

apraclonidine 1

Apri 1

Apriso 2

Drug Name

Generic

Preferred

Non-preferred

Specialty


Aptivus 2

Aquoral 3 Caphosol

Aralast NP PA 3Specialtymedication

Aranelle 1

Aranesp PA 3Specialtymedication

Arcalyst PA, QL 3Specialtymedication

Aricept PA 2

Arixtra QL 3Specialtymedication

Aromasin 2

Arthrotec 3

Generic NSAIDS(naproxen,ibuproen,dicloenac,nabumetone)

Asacol 2

Asacol HD 2

Ascensia bloodglucose products

2

Asmanex 3 Flovent HFA, Qvar

Atacand ST 3lisinopril, captopril,quinapril, losartan,Diovan, Micardis

Atacand HCT ST 3

lisinopril, captopril,quinapril, losartan,HCTZ, Diovan HCT,Micardis HCT

Atripla 2

Atrovent HFA 2

atenolol 1

Avalide ST 3

lisinopril, captopril,

quinapril, losartan,HCTZ, Diovan HCT,Micardis HCT

Avandamet 2

Avandaryl 2

Avandia 2


11/36

8





Drug Name

Generic

Preferred

Non-preferred

Specialty


Avapro ST 3


quinapril, losartan,Diovan, Micardis

Avelox 3 ciprofoxacin

Aviane 1

Avodart 2

Avonex QL 3Specialtymedication

Axert QL 3sumatriptan (QL),naratriptan (QL)Maxalt (QL)

Azasite 3 erythromycin

azelastine 1Azelex (PA >35years o age)

3Generic topicalacne agents

Azilect 3

carbidopa/levodopa,ropinirole,pramipexole,selegiline

azithromycin QL 1

Azmacort 3 Flovent HFA, Qvar

Azopt 2

Azor ST 3lisinopril, captopril,quinapril, losartan,Diovan, Micardis

bacloen 1

Bactroban cream 3mupirocinointment

Bactroban nasalointment

3mupirocinointment

balsalazidedisodium

1

Banzel PA 3

elbamate,

lamotrigine,topiramate,valproate

Beconase AQ ST 3futicasone,funisolide,Veramyst

Drug Name

Generic

Preferred

Non-preferred

Specialty


befex 1

benazepril 1benazepril/HCTZ 1

Benicar ST 3lisinopril, captopril,quinapril, losartan,Diovan, Micardis

Benicar HCT ST 3


benprox 1

Benzaclin 2 3erythromycin/

benzoyl peroxidebenzoyl peroxide 1

benztropine 1

Bepreve 3azelastine, Elestat,Patanol

Berinert PA 3Specialtymedication

Besivance 3ciprofoxacin,ofoxacin,Vigamox, Zymar

betamethasone 1

betaxolol 1Betimol 3 timolol, Betoptic S

Betoptic S 2

bicalutamide 1

bisoprolol 1

bisoprolol/HCTZ 1

Boniva tablet QL 3alendronate,Actonel

Boniva IV syringePA, QL

3alendronate,Actonel

Botox PA, QL 3 Specialtymedication

bp 10-1 wash 1

BPO gel 1

brimonidinetartrate

1


12/36

9




Drug Name

Generic

Preferred

Non-preferred

Specialty


Brovana 3 Serevent, Foradil

budeprion XL QL 1budesoniderespules (< 9years o age)

1

Buphenyl PA 3SpecialtyMedication

buprenorphinePA, QL

1

bupropion 1

bupropion SA 1

buspirone 1

butorphanol nasalspray QL

1

Byetta QL 2

Bystolic ST 3atenolol,metoprolol,propranolol

Caduet 2

calcipotriene 1

calcitriol 1

calcium acetate 1

Camila 1Campral 2

Canasa 3

Asacol, balsalazidedisodium,sulasalazine,sulasalazine EC,Apriso

Caphosol 2

captopril 1

captopril/HCTZ 1

carbamazepine

XR

1

carbidopa/levodopa

1

carboptic 3% 1

Drug Name

Generic

Preferred

Non-preferred

Specialty


Cardene SR 3

diltiazem, cartia

XT, niedipine,niedipineER, taztia XT,verapamil,verapamil SR,Niediac CC,amlodipinebesylate

Cardura XL QL 3 doxazosin

carisoprodol 1

carteolol 1

cartia XT 1

carvedilol 1

Cayston QL 3Specialtymedication

Cedax 3cepodoxime,cedinir

ceaclor 1

ceadroxil 1

cedinir 1

cepodoxime 1

ceprozil 1

ceuroxime 1

Celebrex ST, QL 3

Generic NSAIDS(naproxen,ibuproen,dicloenac,nabumetone)

Cenestin 3Premarin, estradiol,estropipate

cephalexin 1

Cerezyme PA 3Specialtymedication

Cetraxal 3 Ciprodex, CiproHC, ofoxacin

chlordiazepoxide 1

chlorpropamide 1


13/36

10





Drug Name

Generic

Preferred

Non-preferred

Specialty


chlorpromazine

(ST


14/36

11




Drug Name

Generic

Preferred

Non-preferred

Specialty


Cutivate 3Generic topical

steroidscyclobenzaprine 1

cyclosporine 1

cyclosporinemodied

1

Cymbalta ST, QL 2

dantrolene 1

Dapsone 2

Delatestryl PA 3testosteroneinjection

Denavir 3

For cold sore

treatment use overthe counter agents

Depo-Provera QL 3Generic oralcontraceptives

Depo-TestosteronePA

3testosteroneinjection

Derma-Smoothe/FS 3Generic topicalsteroids

Dermatop 3Generic topicalsteroids

desonide 1

desoximetasone 1

Detrol 2

Detrol LA 2

dexmethylphenidateQL

1

dextroamphetamineQL

1

Diastat QL 2

diazepam 1

dicloenac 1

dicloenac

ophthalmicsolution

1

dicloxacillin 1

didanosine 1

diforasone 1

Drug Name

Generic

Preferred

Non-preferred

Specialty


diltiazem 1

diltiazem ER 1Diovan 2

Diovan HCT 2

Dipentum 3

sulasalazine,sulasalazineEC, balsalazidedisodium, Asacol,Apriso

dipyridamole 1

divalproexsodium

1

divalproexsodium ER

1

Divigel 3 estradiol

dorzolamide 1

dorzolamide-timolol

1

doxazosin 1

doxycycline 1

Drithocreme 2

dronabinol 1

Duetact 2Dulera 3 Advair, Symbicort

Durasal 3 salicyclic acid

Durezol 3fuorometholone,prednisolone

Dynacirc CR 3

diltiazem, cartiaXT, niedipine,niedipineER, taztia XT,verapamil,verapamil SR,Niediac CC,

amlodipinebesylate

dyphylline gg 1

Dysport PA, QL 3Specialtymedication


15/36

12





Drug Name

Generic

Preferred

Non-preferred

Specialty


Eent QL 2

Elaprase PA 3 Specialtymedication

Elestat 2

Elidel PA 3Generic topicalsteroids

Eligard PA, QL 3Specialtymedication

eliphos 1

Emadine 3azelastine, Elestat,Patanol

Emend QL 2

Emtriva 2

Enablex 3

oxybutynin,oxybutynin ER,trospium, Detrol,Detrol LA, Vesicare

enalapril 1

Enbrel PA, QL 3Specialtymedication

Enjuvia 3estradiol,estropipate,Premarin

enoxaparin QL 1Enpresse 1

Entocort EC 2

epiklor 1

Epinephrine 3 EpiPen

EpiPen 2

Epivir 2

eplerenone 1

Epogen PA 3Specialtymedication

Epoprostenol PA 3 Specialtymedication

Epzicom 2

ergotamine/caeine

1

Drug Name

Generic

Preferred

Non-preferred

Specialty


Errin 1

erythromycin 1erythromycin/benzoyl peroxidegel

1

Estrace cream 3estradiol,estropipate,Premarin

Estraderm QL 3 estradiol

estradiol 1

estradiol patch QL 1

estradiol-

norethindrone1

Estring 3estradiol,estropipate,Premarin

Estrogel 3 Premarin

estropipate 1

etidronate 1

etodolac 1

Evamist 3 estradiol

Evista 2

Evoxac 2Exorge 2

Exorge HCT 2

Fabrazyme PA 3Specialtymedication

Factive QL 3 ciprofoxacin

amciclovir QL 1

amotidine 1

Fanapt PA, QL (ST


16/36


17/36

14





Drug Name

Generic

Preferred

Non-preferred

Specialty


glipizide ER 1

glipizide/metormin

1

Glucagon 2

glyburidemicronized

1

glyburide/metormin

1

Glyset 2

granisetron ST, QL 1 ondansetron (QL)

granisol ST, QL 1 ondansetron (QL)

Halfytely 3

halobetasol 1

Halog 3Generic topicalsteroids

haloperidol (ST


18/36

15




Drug Name

Generic

Preferred

Non-preferred

Specialty


Invega Sustenna

PA, QL (ST


19/36

16





Drug Name

Generic

Preferred

Non-preferred

Specialty


Liescan Blood

Glucose products(One TouchBasic, One TouchUltra, One TouchUltraSmart, OneTouch Ultra 2, OneTouch Surestep)

2

liothyronine 1

Lipitor 2

Lipoen 3 enobrate, Tricor

lisinopril 1

lisinopril/HCTZ 1

Loestrin 24 FE 3Generic oralcontraceptives

loratadine OTC 1

lorazepam 1

LoSeasonique 3Generic oralcontraceptives

losartan 1

losartan/HCTZ 1

Lotemax 3fuorometholone,prednisolone

Lotronex 2lovastatin 1

Lovaza 3 enobrate, Tricor

Low-ogestrel 1

loxapine (ST 18 yearso age) QL

3

methylphenidate,amphetamine,dextroamphetamine,amphetamine-dextroamphetamineER, methylin,methylin ER,Concerta

Metadate ER QL 1

metaxalone 1

metormin 1

metormin ER 1

Methadose 1methamphetamineQL

1

methazolamide 1

methocarbamol 1


20/36

17




Drug Name

Generic

Preferred

Non-preferred

Specialty


methotrexate 1

Methylin ER QL 1Methylin QL 1

methylphenidateQL

1

methylprednisolone 1

metipranolol 1

metoclopramide 1

metoprolol 1

metoprolol/HCTZ 1

metoprolol SR 1

metronidazole 1

Miacalcin 3alendronate,Actonel

Micardis 2

Micardis HCT 2

Microgestin 1

Microgestin FE 1

Migergot 1

Millipred solution 3Prednisolonesolution

Mimvey 1

minocycline 1

Mirapex ER ST 3pramipexole,ropinirole

mirtazapine 1

Moban (ST


21/36

18





Drug Name

Generic

Preferred

Non-preferred

Specialty


Nexium ST, QL 3 Omeprazole OTC

Niaspan 2 3niediac CC 1

niedipine 1

niedipine ER 1

nimodipine 1

nisoldipine 1

nitrourantoin 1

nizatidine 1

Nora-BE 1

Norditropin PA 3Specialty

medicationNortrel 1

Norvir 2

Novolin 2

Novolin 70/30 2

Novolin N 2

Novolin R 2

Novolog 2

Novolog Mix 70/30 2

Noxal PA 3Specialty

medication

Nplate PA 3Specialtymedication

Numoisyn 3 Caphosol

Nuvaring 2

Nuvigil PA, QL 3

Provigil (PA),methylphenidate,amphetamine,dextroamphetamine,amphetamine-dextroamphetamineER, methylin,methylin ER,Concerta

NuZon 3 hydrocortisone

Ocella 1

octreotide 3Specialtymedication

Drug Name

Generic

Preferred

Non-preferred

Specialty


ofoxacin 1

Oorta PA 3 Specialtymedication

Ogestrel 1

omeprazole OTC 1

Omnaris ST 3futicasone,funisolide,Veramyst

Omnipred 3 prednisolone

ondansetron QL 1

Onglyza 2

Onsolis PA, QL 3

oxycodone,

morphine sulate,Opana

Opana 2 3

Opana ER QL 2 3

Orap (ST


22/36

19




Drug Name

Generic

Preferred

Non-preferred

Specialty


oxycodone/

acetaminophenQL 1

oxycodone/aspirin QL

1

oxycodone/ibuproen QL

1

Oxycontin PA,QL 3

Opana ER,morphine sulateER, entanylpatches

Oxytrol 3

oxybutynin,oxybutynin ER,

trospium, Detrol,Detrol LA, Vesicare

Pancreaze 3 Creon, Zenpep

Pandel 3Generic topicalsteroids

pantoprazole ST,QL

1 Omeprazole OTC

Parcopa 3carbidopa/levadopa

paroxetine 1

paroxetine CR QL 1

Pataday 3azelastine, Elestat,Patanol

Patanase nasalspray

3 azelastine

Patanol 2

peg-3350 1

Pegasys PA, QL 3Specialtymedication

Peg-Intron PA, QL 3Specialtymedication

pemoline 1

penicillin 1

Drug Name

Generic

Preferred

Non-preferred

Specialty


Pentasa 3

sulasalazine,

sulasalazineEC, balsalazidedisodium, Asacol,Apriso

pentazocine/acetaminophenQL

1

pentazocine/naloxone

1

Peroromist 3 Serevent, Foradil

perindopril 1

perphenazine (ST


23/36

20

Drug Name

Generic

Preferred

Non-preferred

Specialty


Pred Mild 3fuorometholone,

prednisoloneprednicarbate 1

prednisolone 1

Preest 3

estradiol/norethindrone,Prempro,Premphase

Premarin 2

Premarin Low Dose 2

Premarin VaginalCream

2

Premphase 2Prempro 2

Prenate Essential 2

Prevpac 3lansoprazole(ST), amoxicillin,clarithromycin

Prezista 2

Pristiq ST, QL 3

paroxetine,sertraline,citalopram,venlaaxine ER

capsules

Privigen PA 3Specialtymedication

ProAir HFA QL 3 Ventolin HFA

Procrit PA 3Specialtymedication

Prolastin PA 3Specialtymedication

Prolastin-C PA 3Specialtymedication

Proleukin 3Specialty

medication

Prolia PA, QL 3Specialtymedication

Promacta PA, QL 3Specialtymedication

propoxyphene 1

Drug Name

Generic

Preferred

Non-preferred

Specialty


propoxyphene/

acetaminophenQL 1

propranolol 1

propranolol/HCTZ

1

propranolol SA 1

Proquin XR QL 3 ciprofoxacin

protriptyline 1

Protopic PA 3Generic topicalsteroids

Proventil HFA QL 3 Ventolin HFA

Provigil PA, QL 3

methylphenidate,amphetamine,dextroamphetamine,amphetamine-dextroamphetamineER, methylin,methylin ER,Concerta

Prumyx cream 1

pruvate 21-7 1

Pulmicort Flexhaler 3 Qvar, Flovent HFA

Pulmozyme 3Specialty

medicationQuasense 1

quinapril 1

quinapril/HCTZ 1

Quixin 3ciprofoxacin,ofoxacin,Vigamox, Zymar

Qutenza PA, QL 3Specialtymedication

Qvar 2

ramipril 1

Ranexa 2

Raniclor 3 ceaclor

ranitidine 1

Rapafo 3terazosin, prazosin,doxazosin






24/36

21

Drug Name

Generic

Preferred

Non-preferred

Specialty


Rapamune PA 2

Rebi QL 3 Specialtymedication

Reclast PA, QL 3Specialtymedication

Regranex QL 2

Relenza QL 3 amantadine

Relistor PA 3Specialtymedication

Relpax QL 3sumatriptan (QL),naratriptan (QL)Maxalt (QL)

Remicade PA 3 Specialtymedication

Remodulin PA 3Specialtymedication

renalpren 1

Renvela 2

reprexain 1

Requip XL ST 3ropinirole,pramipexole

Rescriptor 2

Restasis 2

Retin-A Micro (PA>35 years o age)


Revatio PA, QL 3Specialtymedication

Revlimid PA, QL 3Specialtymedication

Reyataz 2

Rhinocort AQ ST 3funisolide,futicasone,Veramyst

ribavirin QL 3Specialtymedication

Riomet 3 metormin

Risperdal ConstaPA, QL(ST


25/36

22

Drug Name

Generic

Preferred

Non-preferred

Specialty


Selzentry PA 2

Sensipar 2Serevent 2

Seroquel PA, QL(ST


26/36

23

Drug Name

Generic

Preferred

Non-preferred

Specialty


Synvisc PA, QL 3Specialty

medication

Synvisc One PA, QL 3Specialtymedication

tacrolimus 1

Tamifu QL 3 amantadine

tamsulosin 1

Tarceva PA, QL 3Specialtymedication

Targretin PA 3Specialtymedication

Tasigna PA, QL 3Specialty

medicationTasmar 3 Comtan

Tazorac (PA >35years o age)


taztia XT 1

Tekturna ST 2

Tekturna HCT ST 2

Temodar PA 3Specialtymedication

temazepam 1

terazosin 1terbinane QL 1

Testim PA 3testosteroneinjection

testosterone PA 1 3

Testred PA 3testosteroneinjection

tetracaineophthalmic

1

tetracycline 1

Teveten ST 3


quinapril, losartan,Diovan, Micardis

Teveten HCT ST 3


Drug Name

Generic

Preferred

Non-preferred

Specialty


Thalomid PA, QL 3Specialty

medicationtheophylline 1

theophylline ER 1

thioridazine (ST


27/36

24

Drug Name

Generic

Preferred

Non-preferred

Specialty


Travatan 3 Xalatan, Lumigan

Travatan Z 3 Xalatan, Lumigantrazadone 1

Trelstar PA, QL 3Specialtymedication

tretinoin oral 3Specialtymedication

tretinoin topical 1

Trezix 1

triamcinolone 1

Tricor 2 3

trifuoperazine(ST


28/36

25

Drug Name

Generic

Preferred

Non-preferred

Specialty


Victoza QL 3 Byetta

Videx solution 2Vigamox 2

Vimpat PA 3

divalproex sodium,gabapentin,lamotrigine,levetiracetam,oxcarbazepine,topiramate,zonisamide

Viracept 2

Viramune 2

Viread 2visqid a/a 1

vistra 1

vitamins (genericpediatric)

1

vitamins (genericprenatal)

1

Vivelle-DOT QL 3 estradiol

Voltaren Gel QL 3dicloenac,ibuproen,naproxen

Votrient PA, QL 3 Specialtymedication

VPRIV PA 3Specialtymedication

Vytorin ST 2 3pravastatin,simvastatin, Lipitor,Zetia

Vyvanse QL 3

methylphenidate,amphetamine,dextroamphetamine,amphetamine-dextroamphetamine

ER, methylin,methylin ER,Concerta, Strattera

wararin 1

Welchol 2

Drug Name

Generic

Preferred

Non-preferred

Specialty


Xalatan 2

Xeloda PA 3 Specialtymedication

Xenazine PA, QL 3Specialtymedication

Xibrom 3ketorolac,dicloenac

Xiaxan PA,QL 3lactulose,ciprofoxacin,loperamide

Xolair PA, QL 3Specialtymedication

Xopenex ST 3 albuterolXopenex HFA QL 3 Ventolin HFA

Xyrem PA, QL 3Specialtymedication

Xyzal PA 3loratadine OTC,exoenadine

zaleplon 1

Zavesca 3Specialtymedication

Zelapar 3

carbidopa/levodopa,

ropinirole,pramipexole,Comtan, Stalevo

Zemaira PA 3Specialtymedication

Zemplar 3 Hectorol, Sensipar

Zenieva 1

Zenpep 2

Zetia 2

Ziagen 2

Ziana gel (PA >35years o age) 3

clindamycin,

tretinoin,adapalene (PA)

Zinotic ES 3acetic acid/hydrocortisone,Ciprodex





29/36

26

Drug Name

Generic

Preferred

Non-preferred

Specialty


Zirgan gel 3 trifuridine

Zithranol 3 Drithocreme

Zmax QL 3azithromycin,clarithromycin,erythromycin

Zoladex PA, QL 3Specialtymedication

Zolinza PA, QL 3Specialtymedication

zolpidem tartrate 1

Zomig QL 3sumatriptan (QL),naratriptan (QL)

Maxalt (QL)zonisamide 1

Zorbtive PA 3Specialtymedication

Zortress PA 2

Zovia 1

Zovirax topical 3 Oral antivirals

Zyfo 3 Singulair (ST)

Zyfo CR 3 Singulair (ST)

Zylet 3tobramycin/dexamethasone

Zymar 2

Zymaxid 3ciprofoxacin,ofoxacin,Vigamox, Zymar

Zyprexa QL(ST


30/36

27

Medications Not Covered by Your Choice

The ollowing medications are beneit exclusions and will not be covered under the pharmacy beneit:

Anabolic steroids

Antimalarial agents

Antiobesity medications, including, but not limited to, appetite suppressants andlipase inhibitors

Blood or blood plasma products*

Drugs labeled or investigational use

Drugs used or cosmetic purposes or hair growth

Fertility agents

Impotency drugs (examples are Viagra, Levitra, Cialis, Muse, Caverject)

Legend vitamins (other than prenatal, luoride, and certain therapeutic vitamins)

Most over-the-counter medications

Needles/syringes (other than insulin)*

Nutrition and dietary supplements*

Ostomy supplies*

Smoking deterrents

Therapeutic devices/appliances*

Urine strips (Because our doctors eel blood glucose strips are more accurate than urine test strips in measuring blood glucose, urine stripsare not a covered beneit.)

*Please note that, under certain circumstances, your medical beneits may cover the items marked with an asterisk (*). For inormationon these items, you can contact our Member Advocates at the number listed on the back o your member ID card. I you have not yetreceived an ID card, call our Member Advocates number listed on page 1 o this booklet.


31/36

28

Non-Covered Medications with Covered Alternatives

Non-Covered Drug Alternative Drugs

Acanya gel benzoyl peroxide, clindamycin

Aciphexomeprazole OTC, lansoprazole,pantoprazole, Nexium

ActosPlus Met XRActosPlusMet, Actos,

metorminAkten lidocaine

Allen codeine

Aloquin gelclotrimazole, miconazole,nystatin

AltoprevLipitor, lovastatin, pravastatin,simvastatin

Ambien CR zolpidem, zaleplon, Lunesta

Amrix cyclobenzaprine

Analpram E Kit pramoxine/hydrocortisone

Aplenzin ER bupropion SR, bupropion XL

Astepro azelastine

Atralin tretinoin, adapalene

Avidoxy DK Kitdoxycycline, topical salicylicacid products OTC

Avinza morphine sulate ER

Benzamycin Pak benzoyl peroxide/erythromycin

BenzEFoam benzoyl peroxide

Betaseron Avonex, Rebi, Copaxone

Bidil hydralazine, isosorbide dinitrate

Blood Glucose Monitors

Ascensia Breeze, Ascensia

Contour, One Touch Basic, OneTouch Sure Step

Blood Glucose TestStrips

Ascensia and Liescan teststrips

Brontex codeine

Cambia dicloenac

Carmol urea

Chenodal ursodiol

Clarinex exoenadine, loratadine OTC

Clarinex-D exoenadine, loratadine OTC

Claritin-D exoenadine, loratadine OTCCleanse & Treat Benzoyl peroxide

Clobex Clobetasol

Compounded HormoneReplacement Therapy

Prempro, Premphase,FemHRT, estradiol, estradiol-norethindrone

Compounded NarcoticAnalgesics

hydrocodone/acetaminophen,commercially available painproducts


CrestorLipitor, lovastatin, pravastatin,simvastatin

Daytrana

methylphenidate,amphetamine,dextroamphetamine,

amphetamine-dextroamphetamine ER,methylin, methylin ER,Concerta, Strattera

Darvon-N propoxyphene

Desonate desonide

Dex-Tuss codeine

Dexilantomeprazole OTC, lansoprazole,pantoprazole, Nexium

Dierin lotion tretinoin, adapalene

Dilaudid liquid hydromorphone

Doryx doxycycline hyclate

Duac CS kit benzoyl peroxide, clindamycin

Edluar zolpidem, zaleplon, Lunesta

Embeda morphine sulate ER

Emsamtranylcypromine sulate,fuoxetine, paroxetine,citalopram, sertraline

Epiduo gelbenzoyl peroxide, adapalene,tretinoin

Eufexxa Synvisc, Supartz

Exalgo hydromorphoneExtavia Avonex, Rebi, Copaxone

Fenobric acid enobrate, Tricor

Fenoglide enobrate, Tricor

Fentora oxycodone, morphine sulate

Fexmid cyclobenzaprine

Fibricor enobrate, Tricor

Flector patch Voltaren Gel, dicloenac

Fosamax Plus D alendronate

GelniqueDetrol, Detrol LA, oxybutynin,oxybutynin ER, Vesicare

Genotropin Humatrope, Norditropin

Glumetza metormin

Halonatetriamcinolone, betamethasone,clobetasol

Hyalgan Synvisc, Supartz

Hycet hydrocodone

Ibudone hydrocodone, ibuproen

IC400 Kit ibuproen, naproxen


32/36

29


IC800 Kit ibuproen, naproxen

Indocin suppositoryOral indomethacin, ibuproen,naproxen

Innohep Lovenox, Arixtra, Fragmin

J-Max DHC hydrocodone

Kadian morphine sulate ER

Keraoam ureaKeralac urea

Kerol urea, lactic acid

Lamictal XR lamotrigine

Lamictal ODT lamotrigine

Lamisil Granules terbinane

LescolLipitor, lovastatin, pravastatin,simvastatin

Lescol XLLipitor, lovastatin, pravastatin,simvastatin

LevorphanolOxycodone, hydromorphone,hydrocodone

Liquicet hydrocodone/acetaminophen

LivaloLipitor, lovastatin, pravastatin,simvastatin

Loratadine-D exoenadine, loratadine OTC

Luvox CR fuvoxamine

Lynox oxycodone/acetaminophen

Magnacet oxycodone/acetaminophen

Mar-co codeine

Meperidine solution meperidine tablet

Metadate CD (>18 yrold)

methylphenidate,amphetamine,dextroamphetamine,amphetamine-dextroamphetamine ER,methylin, methylin ER,Concerta, Strattera

Methadone Intensol methadone tablet

Metozolv ODT metoclopramide

MetroGel topical metronidazole

Midamorspironolactone, triamterene,eplerenone, amiloride

Millipred prednisolone

Mimyxammonium lactate, Prumyx,Zenieva

Momexin Combo Packmometasone, ammoniumlactate

Monodox doxycycline

Moxatag amoxicillin, penicillin

Naprelan CR naproxen


Neobenz Micro benzoyl peroxide

Neutrasal Caphosol, Aquoral

NitroMistnitroglycerin, Nitrostat,Nitroquick, Nitrolingual spray

Nucort lotion hydrocortisone

Nucyntahydrocodone, morphine

sulate, oxycodone, tramadolNutropin Humatrope, Norditropin

Oleptro trazodone, neazodone

Olux-Olux E clobetasol

Omeprazole 40mgomeprazole OTC, lansoprazole,pantoprazole, Nexium

Omeprazole/SodiumBicarbonate

omeprazole OTC, lansoprazole,pantoprazole, Nexium

Omnitrope Humatrope, Norditropin

Oracea doxycycline

Oravig

fuconazole, clotrimazole,

Nystatin, itraconazole

Orbivanacetaminophen/butalbital/caeine

Orthovisc Synvisc, Supartz

Ovace Plus Shampoo sodium sulacetamide

Pacnex Wash benzoyl peroxide

Pennsaid Voltaren Gel, dicloenac

Perloxx oxycodone/acetaminophen

Pexevaparoxetine, sertraline,citalopram

Pramosone E hydrocortisone/pramoxine

Prilosecomeprazole OTC, lansoprazole,pantoprazole, Nexium

Prevacid SoluTabsomeprazole OTC, lansoprazole,pantoprazole, Nexium

Protonixomeprazole OTC, lansoprazole,pantoprazole, Nexium

Pylera metronidazole, tetracycline

Ressa tretinoin, adapalene

Ritalin LA (>18 yr old)

methylphenidate,amphetamine,

dextroamphetamine,amphetamine-dextroamphetamine ER,methylin, methylin ER,Concerta, Strattera

RowasaAsacol, balsalazide disodium,sulasalazine, sulasalazine EC,Apriso

Roxicet caplet oxycodone/acetaminophen


33/36

30


Rozerem zolpidem, zaleplon, Lunesta

Rybix ODT tramadol, tramadol ER

Rynezeloratadine, exoenadine,cetirizine

Ryzolt ER tramadol, tramadol ER

Saizen Humatrope, Norditropin

Salkera salicylic acid products OTCSalvax salicylic acid products OTC

Saraem tablets fuoxetine

Silenordoxepin, zolpidem, zaleplon,Lunesta

Solaraze gel tretinoin, adapalene

Solodyn ER minocycline

Sumavel DosePro sumatriptan

Sumaxin sodium sulacetamide/sulur

Synalgos hydrocodone

Taclonex betamethasone, calcipotrieneTerbinex terbinane

Tetravisc Forte tetracaine, Tetravisc

Tev-Tropin Humatrope, Norditropin

Theophylline solution Oral theophylline

ToviazDetrol, Detrol LA, oxybutynin,oxybutynin ER, Vesicare

Treximetsumatriptan, sumatriptan andnaproxen, naratriptan, Maxalt

Triaz benzoyl peroxide

Umecta urea

Venlaaxine ER tabletvenlaaxine ER capsules,paroxetine, sertraline,citalopram

Veripred prednisolone

Vimovo naproxen, lansoprazole

Vivitrol Oral naltrexone

Xodol hydrocodone/acetaminophen

Xolox oxycodone/acetaminophen

Zamicet hydrocodone

Zanafex capsule tizanidine tablet

Zencia sodium sulacetamide/sulur

Zipsordicloenac, ibuproen,naproxen

Zonatuss benzonatate

Zyclaraimiquimod, tretinoin,adapalene, fuorouracil

Zypram hydrocortisone/pramoxine


34/36

31

Your Choice Brand/Generic Reerence Guide

Brand Generic

Accupril Quinapril

Aceon Perindopril

ActivellaEstradiol-Norethindrone,Mimvey

Acular Ketorolac

Adderall XRAmphetamine-dextroam-phetamine ER

Aldactone Spironolactone

Aldara Imiquimod

Allegra Fexoenadine

Alphagan Brimonidine

Altace Ramipril

Amaryl Glimepiride

Amerge Naratriptan

Ambien Zolpidem TartrateAmoxil Amoxicillin

Analpram HC cream Hydrocort-Pramoxine cream

Arimidex Anastrozole

Astelin Azelastine

Ativan Lorazepam

Augmentin Amoxicillin/Clavulanate

BactrimSulamethoxazole/Trimethoprim

Bactroban Ointment Mupirocin Ointment

Biaxan Clarithromycin

Bleph-10 Sulacetamide Sodium

Buspar Buspirone

Calan Verapamil

Cardizem CD Diltiazem

Cardizem LA Diltiazem ER

Casodex Bicalutamide

Catapres Clonidine

Cetin Ceuroxime

Celexa Citalopram

Cellcept Mycophenolate MoetilCipro Ciprofoxacin

Claritin OTC Loratadine OTC

Cleocin Clindamycin

Climara Estradiol Patch

Cogentin Benztropine

Colazal Balsalazide Disodium

Coreg Carvedilol

Cosopt Dorzolamide-Timolol

Brand Generic

Coumadin Wararin

Cozaar Losartan

Cutivate (topical), Flonase(nasal spray)

Fluticasone

Cyclocort AmcinonideCytomel Liothyronine

DarvocetPropoxyphene/Acetamino-phen

Depakote, Depakote ERDivalproex sodium, Dival-proex sodium ER

Desoxyn Methamphetamine

Desyrel Trazodone

Diabeta, Micronase Glyburide

Diamox sequels Acetazolamide ER

Dierin Adapalene

Difucan Fluconazole

Dovonex Calcipotriene

DuonebIpratropium/Albuterol Solu-tion

Duragesic Fentanyl

Durice Ceadroxil Hydrate

Eexor Venlaaxine

Eexor XR Venlaaxine ER Capsules

Elavil Amitriptyline

Elocon Mometasone

Exelon Rivastigmine

Feldene Piroxicam

Flagyl Metronidazole

Flexeril Cyclobenzaprine

Flomax Tamsulosin

Fosamax Alendronate

Gengra Cyclosporine modied

Glucophage Metormin

Glucotrol Glipizide

Golytely Gavilyte-G

Hyzaar Losartan/HCTZ

Imitrex Sumatriptan

Inderal Propranolol

Indocin Indomethacin

Inspra Eplerenone

Iopidine Apraclonidine

Kefex Cephalexin

Kenalog (topical) Triamcinolone


35/36

32

Brand Generic

Keppra Levetiracetam

Klonopin Clonazepam

Kytril Granisetron

Lamictal Lamotrigine

Lasix FurosemideLodine Etodolac

Lobra Fenobrate

Lopid Gembrozil

Lopressor Metoprolol

LotrelAmlodipine Besylate/Benazepril

Lovenox Enoxaparin

Macrodantin Nitrourantoin

Malathion Ovide Lotion

Marinol DronabinolMevacor Lovastatin

Mimyx cream Prumyx cream

Minocin Minocycline

Mirapex Pramipexole

Motrin Ibuproen

MS Contin Morphine Sulate SR

Naprosyn Naproxen

Neoral Cyclosporine modied

Neurontin Gabapentin

Nizoral KetoconazoleNorvasc Amlodipine Besylate

Nulytely Peg-3350

Omnice Cedinir

Optivar Azelastine

Paxil Paroxetine

Paxil CR Paroxetine ER

Pepcid Famotidine

Percocet Oxycodone/Acetaminophen

PhosLo Calcium Acetate

Plendil Felodipine

Pravachol Pravastatin

Precose Acarbose

Prevacid Lansoprazole

Prilosec OTC Omeprazole OTC

Prinivil, Zestril Lisinopril

Prinzide, Zestoretic Lisinopril/Hctz

Procardia Niedipine

Brand Generic

Progra Tacrolimus

Protonix Pantoprazole

Prozac Fluoxetine

Prozac Weekly Fluoxetine DR

Pulmicort respules Budesonide respulesRazadyne Galantamine

Reglan Metoclopramide

Remeron Mirtazapine

Repliva 21-7 Pruvate 21-7

Requip Ropinirole

Restoril Temazepam

Retin A Tretinoin

Risperdal Risperidone

Ritalin Methylphenidate

Rosula Sodium Sulacetamide/Sul-ur/Urea

Rowasa Mesalamine

Sanctura Trospium

Sandimmune Cyclosporine

Skelaxin Metaxalone

Soma Carisoprodol

Sonata Zaleplon

Starlix Nateglinide

Subutex Buprenorphine

Sular NisoldipineTarka Trandolapril/Verapamil

Tegretol XR Carbamazepine XR

Temovate Clobetasol

Tenormin Atenolol

TobradexTobramycin-Dexametha-sone

Topamax Topiramate, Topiragen

Topicort Desoximetasone

Toprol XL Metoprolol SR

Trexall MethotrexateTridesilon Desonide

Trileptal Oxcarbazepine

Trusopt Dorzolamide

Tylenol # 3 Acetaminophen/Codeine

Ultram Tramadol

Urso Ursodiol

Valium Diazepam


36/36

In this document, the term UPMC Health Plan reers to benet

plans oered by UPMC Health Network, Inc., as well as plans

oered by UPMC Health Plan, Inc.

This managed care plan may not cover all your health care

expenses. Read your contract careully to determine which

health care services are covered.

This Pharmacy Benet Guide is current as o January 1, 2011. For

the latest inormation on the Your Choice drug table and other

pharmacy benets, visit

www.upmchealthplan.com/pharmacy. Select Your Choice

to access the searchable drug list. Or you may call our Member

Advocates at the number listed on the back o your UPMC Health

Plan ID card.

Brand Generic

Valtrex Valacyclovir

Vasotec Enalapril

Veetids Penicillin

Vibramycin Doxycycline

Vicodin, Vicodin ESHydrocodone/Acetamino-phen

Videx EC DidanosineVivactil Protriptyline

Voltaren Dicloenac

Wellbutrin Bupropion

Wellbutrin XL Budeprion XL

Xanax Alprazolam

Yasmin Ocella

Yaz Gianvi

Zantac Ranitidine

Zerit Stavudine

Zithromax AzithromycinZocor Simvastatin

Zoran Ondansetron

Zolot Sertraline

Zonegran Zonisamide

Zovirax Acyclovir

Zyloprim Allopurinol

Documents

Your Choice Pharm GD