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2008 URx Focus Formulary 3 Tier Drug Class 8 5 x 11

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2008 URx Focus Formulary 3 Tier Drug Class 8 5 x 11 Powered By Docstoc
					                                                                         DRUGS FOR INFECTIONS                                           Miscellaneous Antiinfectives. . . . . . . . . . . . . . . . . . . . .                   DRUGS FOR DIABETES
                                                                                                                                        Tier 1   clindamycin, metronidazole
                                                        ANTIBIOTICS-------------------------------------------------                                                                                            INSULINS --------------------------------------------------------
                                                                                                                                                 nitrofurantoin macro
                                                        Penicillins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                                           Tier 1    Lantus
                                                                                                                                        Tier 3   Alinia, Dapsone, Ketek, Lamprene, Lorabid,
                                                        Tier 1     ampicillin, amoxicillin, cloxacillin, dicloxacillin,                                                                                         Tier 2    Apidra, Novolin R, L, N, 70/30, Novalog,
                                                                                                                                                 Mepron, Zyvox
                                                                   amoxicllin w/ potassium clavulanate, penicillin                                                                                                        Novolog Mix, Novolin Innolet, Velosulin BR
                                                                                                                                                          DRUGS FOR CANCER                                      Tier 3    Humalog, Humalog Mix 75/25
  2008 FOCUS Drug Formulary                             Tier 3     Augmentin XR
                                                        Cephalosporins. . . . . . . . . . . . . . . . . . . . . . . . . . . . .         Tier 1      cyclophosphamide, etoposide, flutamide                      Tier 3    Humulin R, L, N, U, 70/30, 50/50, Levemir
and Pharmacy Benefit Guidelines                         Tier 1     cefaclor, cefadroxil, cefdinir, cefradine,                                       hydroxyurea, leucovorin, megestrol,                         ORAL ------------------------------------------------------------
                                                                   cefpodoxime, cefprozil, cefuroxime,                                              methotrexate, tamoxifen                                     Tier 1    glimepiride, glipizide, glipizide XL, glyburide
The Universal Rx Focus Drug Formulary                              cephalexin                                                           Tier 3      Alkeran, Arimidex, Aromasin, Casodex,                                 metformin, metformin XR
                                                        Tier 2     Spectracef                                                                       Emcyt, Fareston, Femara, Leukeran,                          Tier 1    glyburide w/ metformin, glipizide w/ metformin
defines the copayment tier status of the                                                                                                                                                                        Tier 2    Actos,
                                                        Tier 3     Cedax, Omnicef, Suprax                                                           Myleran, Nolvadex, Teslac, Thioguanine,
medicines most commonly prescribed for                  Macrolides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                Vepesid                                                     Tier 2    ActoPlus Met, Duetact,
Universal Rx members. It may not include                Tier 1     azithromycin, clarithromycin, erythromycin                                                                                                   Tier 2    Prandin
                                                                                                                                                                  HORMONES
all drugs covered by your prescription                             estolate, erythromycin ethyl succinate,                                                                                                      Tier 2    Precose
                                                                                                                                        GLUCOCORTICOIDS ---------------------------------------------
drug benefit. For benefit coverage or                              erythromycin stearate
                                                                                                                                        Tier 1 dexamethasone, methylprednisolone,
                                                                                                                                                                                                                Tier 3    Avandia
restrictions please check your benefit plan             Tier 2     Biaxin XL
                                                                                                                                               prednisolone, prednisone
                                                                                                                                                                                                                Tier 3    Januvia
                                                        Tier 3     Dynabac, EryPed, PCE Disperstabs, Zmax                                                                                                       Tier 3    Glyset, Starlix
document(s). This listing is revised from                                                                                               Tier 3 Celestone
                                                        Tetracyclines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                                                Tier 3    Avandamet, Avandaryl, Glucovance,
time to time as new drugs and new                       Tier 1     doxycycline, minocycline, tetracycline
                                                                                                                                        ANDROGENS---------------------------------------------------                      Janumet, Metaglip
prescribing information becomes                         Tier 3     Adoxa, Doryx, Dynacin, Monodox, Oracea,
                                                                                                                                        Tier 3 Androderm, Androgel, First Testosterone                          OTHER ------------------------------------------------------------
available.                                                         Periostat
                                                                                                                                               Cream, Striant, Testim                                           Tier 3    Byetta* (PA)
                                                                                                                                        ESTROGENS ---------------------------------------------------           Tier 3    Symlin* (PA)
                                                        Quinolones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
                                                                                                                                        Tier 1 estradiol, estropipate, estradiol patch
The coverage tier for each medication has               Tier 1     ciprofloxacin, ofloxacin
                                                                                                                                        Tier 2 Climara, Estrasorb, Estrogel, Premarin                                 THYROID AND ANTITHYROID AGENTS
been indicated. Members pay a Tier 1                    Tier 2     Avelox, Avelox ABC, Cipro XR
                                                                                                                                        Tier 2 Premarin Vag Cream, Vagifem Vag Tab                              THYROID ---------------------------------------------------------
copay for most generic drugs and selected               Tier 3     Cipro, Factive, Floxin, Levaquin, Noroxin
                                                                                                                                        Tier 3 Alora, Cenestin, Divigel, Enjuvia, Esclim,                       Tier 1  levothyroxine (ex. Levoxyl, etc.)
                                                        Aminoglycosides. . . . . . . . . . . . .. . . . . . . . . . . . . . . . . .
OTC medicines. Members pay a Tier 2                     Tier 1     Neomycin Tablets
                                                                                                                                               Estraderm, Estring, Evamist, Femring,                            Tier 1  methimazole, propylthiouracil
copay for higher cost generic drugs and                 Sulfonamides. . . . . . . . . . . . .. . . . . . . . . . . . . . . . . .
                                                                                                                                               Menest, Vivelle/DOT                                              Tier 2  Cytomel, Synthroid
formulary (“preferred”) brand name drugs.                                                                                               ESTROGEN AND ANDROGENS --------------------------                                    DRUGS FOR OSTEOPOROSIS
                                                        Tier 1     EES/Sulf’zole, TMP-SMX, TMP-SMX DS
                                                                                                                                        Tier 3 Estratest, Estratest HS
Members pay a Tier 3 copay for non-                     Tier 2     Gantrisin Suspension
                                                                                                                                        ESTROGEN AND PROGESTERONES-------------------
                                                                                                                                                                                                                Tier 2       alendrolate, Actonel, Actonel-D
formulary and highest cost brand name                   Drugs for Tuberculosis. . . . . . . . . . . . . . . . . . . . . . . . .
                                                                                                                                        Tier 2 Climera Pro, Premphase, Prempro
                                                                                                                                                                                                                             Fortical, Menostar
drugs.                                                  Tier 1     ethambutol, isoniazid, pyrazinamide,                                                                                                         Tier 3       Boniva, Evista, Fosamax, Fosamax-D,
                                                                                                                                        Tier 3 Activella, Angeliq, Combipatch, Femhrt,
                                                                   rifampin                                                                                                                                                  Didronel, Miacalcin/NS, Skelid
                                                                                                                                               Prefest
                                                        Tier 2     Priftin                                                                                                                                                  MISCELLANEOUS ENDOCRINE
It is recommended that you have this list of            Tier 3     Myambutol, Mycobutin, Rifamate
                                                                                                                                        PROGESTINS -----------------------------------------------
medications available when you are with                 Drugs for Fungal Infections. . . . . . . . . . . . . . . . . . . . .
                                                                                                                                        Tier 1 medroxyprogesterone, megestrol                                   Tier 2       desmopressing spray / tablets, cabergoline
                                                                                                                                        Tier 3 Prometrium                                                       Tier 3       Carnitor, DDAVP spray and tablets, Dostinex
your physician and a prescription drug is               Tier 1     fluconazole, ketoconazole, nystatin,
                                                                                                                                        Tier 3 Crinone (PA), Prochieve (PA)                                                  CARDIOVASCULAR DRUGS
going to be part of the treatment for a                            terbinafine
clinical condition.                                     Tier 3     Diflucan, Gris-Peg, Lamisil, Nizoral, Noxafil                                            CONTRACEPTIVES                                      CARDIOTONICS ----------------------------------------------
                                                                   Sporanox, Vfend                                                      ORAL MONO-PHASIC ----------------------------------------               Tier 1  Digoxin
                                                        Drugs For Viral Infections. . . . . . . . . . . . . . . . . . . . . . .         Tier 1  multiple generic options (ex. Apri, etc.)                       Tier 2  Lanoxin
Key to Notations:                                       Tier 1     acyclovir, rimantidine, zidovudine                                                                                                           ANTI-ANGINA ----------------------------------------------
                                                                                                                                        Tier 2  Yasmin, YAZ
                                                        Tier 2     famciclovir, ganciclovir, Tamiflu (QL)                               Tier 3  Lybrel, Ovcon Chewable, Ovcon-35 FE                             Tier 1  isosorbide dinitrate, isosorbide mononitrate
PA: Prior authorization to ensure clinical              Tier 2     Agenerase, Aptivus, Combivir, Crixivan,                                      Seasonale (3 copays per prescription)                                   nitroglycerin subligual tabs and patches
appropriateness of this or previous                                Emtriva, Epivir, Epivir HBV, Epzicom,                                        Seasonique (3 copays per prescription)                          Tier 3  Dilatrate-SR, Nitrolingual, Ranexa(ST)
therapy with other similar medications may                         Fortovase, Hivid, Invirase, Isentress,                               ORAL BIPHASIC ----------------------------------------                  BETA-ADRENERGIC BLOCKERS----------------------
be needed before claims for one of these                           Kaletra, Lexiva, Prezista, Rescriptor,                               Tier 1  multiple generic options (ex. Kariva, etc.)                     Tier 1  atenolol, carvedilol metoprolol, metoprolol XL,
                                                                   Reyataz, Selzentry, Sustiva,                                         ORAL TRI-PHASIC ----------------------------------------                        propranolol
medications will be accepted.
                                                                   Trizivir,Truvada, Valcyte, Videx, Viracept,                          Tier 1  multiple generic options (ex. Cesia, Tri-                       Tier 3  Coreg, Coreg CR, Inderal LA, Innopran XL,
                                                                   Viramune, Viread, Zerit, Ziagen                                              Sprintec, Velivet, etc.)                                                Levatol, Toprol XL
ST: A step therapy protocol is in place for             Tier 3     Flumadine, Relenza (QL)                                              Tier 2  Ortho Tri-Cyclen Lo                                             CALCIUM CHANNEL BLOCKERS -----------------------
this medication. Claims for this medication             Tier 3     Famvir, Norvir, Retrovir, Valtrex                                    Tier 3  Estrostep Fe                                                    Tier 1  amlodipine, diltiazem CD, felodipine,
may be covered based on the enrollee's                  Tier 3     Baraclude, Hepsera, Tyzeka                                           OTHER CONTRACEPTIVES----------------------------------                          isradipine, nifedipine XL, verapamil SR,
previous medication history. If prior                   Drugs for Malaria. . . . . . . . . . . . . . . . . . . . . . . . . .            Tier 2  NuvaRing Vaginal Ring, Ortho-Evra Patch                         Tier 2  Cardizem LA
medication history does not meet clinical               Tier 1     chloroquine, hydroxychloroquine, quinine                             PROGESTIN ONLY------------------------------------------------          Tier 3  Cardene SR, Covera HS, DynaCirc/CR,
                                                        Tier 2     mefloquine                                                           Tier 1  multiple generic options (ex. Camilla, etc.)                            Norvasc, Sular, Tiazac, Verelan PM
guidelines, authorization may be required
                                                        Tier 3     Daraprim, Fansidar, Halfan, Lariam,                                  Tier 3  Depo-Provera*                                                   ANTIARRHYTHMICS ----------------------------------------
prior to acceptance of claims.                                     Malarone                                                             EMERGENCY CONTRACEPTION-----------------------                          Tier 1  amiodarone, disopyramide, flecainide,
                                                        Drugs for Parasites. . . . . . . . . . . . . . . . . . . . . . . . . .          Tier 3  Plan B                                                                  mexiletine, propafenone, quinidine, sotalol
QL: Quantity limitations (maximum                       Tier 1     mebendazole                                                                                                                                  Tier 3  Norpace CR, Procanbid, Rythmol SR,
number of tablets/capsules, etc. per month              Tier 2     Mintezol, Stromectol                                                                                                                                 Tikosyn
or year) are in place for this medication.              Tier 3     Albenza, Biltricide




This document is in effect beginning January 1, 2008. Formulary consultation and administrative support to provided by:
ACE INHIBITORS ---------------------------------------------          COUGH AND COLD MEDICATIONS -------------------------                         VAGINAL PREPARATIONS -------------------------------                    ANTICONVULSANTS ---------------------------------------
Tier 1   benazepril, captopril, enalapril, fosinopril,                Tier 1    multiple generic options                                           Tier 1  nystatin, metronidazole vaginal, terconazole                    Tier 1 carbamazepine, clonazepam, phenytoin
         lisinopril, moexipril, quinapril, trandolapril               Tier 3    all brand options                                                  Tier 3  AVC Cream, Cleocin Vaginal Cream/Ovule,                         Tier 1 primidone, valproic acid, zonisamide
Tier 3   Accupril, Aceon, Altace, Capoten, Lotensin                   DRUGS FOR ASTHMA / COPD -------------------------------                              Gynazole-1, MetroGel Vaginal, Terazol                           Tier 2 Depakote, Diastat, Dilantin, gabapentin,
         Mavik, Monopril, Prinivil, Univasc, Vasotec,                 Sympathomimetics. . . . . . . . . . . .. . . . . . . . . . . . .             DRUGS FOR BPH-------------------------------------------                       Gabitril, Keppra, Lamictal, Phenytek,
         Zestril                                                      Tier 1    albuterol                                                          Tier 1  doxazosin, terazosin, finasteride                                      Peganone, Trileptal, Zarontin
ANGIOTENSIN II ANTAGONISTS-------------------------                   Tier 2    Accuneb, Foradil, ProAir HFA,                                      Tier 3  Avodart (QL), Flomax, Proscar, Uroxatral                        Tier 3 Felbatol, Lyrica, Neurontin, Tegretol XR,
Tier 2   Avapro, Cozaar                                                         Proventil HFA                                                      DRUGS FOR ERECTILE DYSFUNCTION----------------                                 Topamax, Zonegran
Tier 3   Atacand, Benicar, Diovan, Micardis, Teveten                  Tier 3    Perforomist, Serevent, Xopenex,                                    Tier 3  Cialis (ST)(QL), Levitra (ST)(QL)                               DRUGS FOR PARKINSONS DISEASE ----------------------
DIRECT RENIN INHIBITOR----------------------------------                        Xopenex HFA (ST)                                                           Muse (ST)(QL), Viagra (QL)                                      Tier 1 benztropine, bromocriptine,
Tier 3   Tekturna                                                     Combination Drugs and Others. . . . . . . . . . . . . . . . .                           CENTRAL NERVOUS SYSTEM                                              carbidopa/levodopa, selegiline
ANTI-ADRENERGIC BLOCKERS–CENTRAL------                                Tier 1    ipratropium bromide for nebulization                                                                                                              trihexyphenidyl and other generic options
                                                                                                                                                   PSYCHOTHERAPEUTIC AGENTS -----------------------
Tier 1   clonidine                                                    Tier 2    Atrovent, Combivent, Duoneb, Spiriva                                                                                                       Tier 3 Azilect, COMTan, Kemadrin, Mirapex,
                                                                                                                                                   Antidepressants . . . . . . . . . . . . . . . . . . . . . . . . . . .
Tier 3   Catapres TTS                                                           Symbicort                                                                                                                                         Neupro, Requip, Tasmar, Stalevo, Zelapar
                                                                                                                                                   Tier 1   amitriptyline, bupropion, bupropion SR,
ANTI-ADRENERGIC BLOCKERS–PERIPHERAL --                                Tier 3    Advair, Intal, Tilade                                                                                                                      SKELETAL MUSCLE RELAXANTS -------------------------
                                                                                                                                                            bupropion XL, citalopram, doxepin, fluoxetine,
Tier 1   doxazosin, prazosin, terazosin                               Theophyllines…. . . . . . . . . . . . . . . . . . . . . . . .                                                                                        Tier 1 baclofen, carisoprodol, cyclobenzaprine
                                                                                                                                                            imipramine, mirtazapine, nortriptyline,
COMBINATION ANTIHYPERTENSIVES--------------                           Tier 1    multiple medicines w/ generic alternatives                                                                                                        methocarbamol, tizanidine, etc.
                                                                                                                                                            protriptyline, trazodone, sertraline, venlafaxine
Tier 1   benazepril w/HCTZ, captopril w/HCTZ,                         Corticosteroids. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                                           Tier 3 Amrix, Dantrium, Skelaxin
                                                                                                                                                   Tier 2   Effexor XR, paroxetine
         enalapril w/ HCTZ, fosinopril w/HCTZ,                        Tier 2    Asmanex, Pulmicort                                                                                                                                                 OPHTHALMIC
                                                                                                                                                   Tier 3   Celexa, Cymbalta, Effexor, Emsam (ST),
         lisinopril w/ HCTZ, amlodipine w/ benazepril                 Tier 3    Aerobid, Aerobid M, Azmacort, Flovent,
                                                                                                                                                            Lexapro, Paxil CR, Pexeva, Prozac Weekly,                      ANTI-ALLERGIC AGENTS----------------------------------
Tier 2   Uniretic                                                               QVAR
                                                                                                                                                            Remeron, Sarafem, Wellbutrin XL, Zoloft                        Tier 1   Alaway(OTC), ketotifen(OTC), Zaditor(OTC)
Tier 2   Avalide, Hyzaar                                              Antileukotrienes. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
                                                                                                                                                   Antipsychotic Agents . . . . . . . . . . . . . . . . . . . . . . .      Tier 2   Optivar
Tier 2   Tarka                                                        Tier 2    Accolate
                                                                                                                                                   Tier 1   chlorpromazine, haloperidol                                    Tier 3   Alamast, Alocril, Alomide, Elestat, Emadine,
Tier 3   Atacand HCT, Benicar HCT, Diovan HCT,                        Tier 3    Singulair, Zyflo CR
                                                                                                                                                            perphenazine and other generics                                         Patanol
        Micardis HCT, Teveten HCT                                                       GASTROINTESTINAL                                           Tier 2   Abilify, clozapine, Invega, risperidone, Orap,                 ANTI-GLAUCOMA AGENTS -----------------------------
Tier 3   Caduet
                                                                      ANTIULCER -----------------------------------------------------                       Serentil, Seroquel                                             Tier 1   brimonidine, dipivefrin, betaxolol, carteolol
Tier 3   Azor, Exforge, Lexxel, Lotrel
                                                                      Tier 1  cimetidine, dicyclomine, famotidine,                                 Tier 3   Clozaril, Geodon, Risperdal, Symbyax,                                   levobunolol, metipranolol, timolol, etc.
DIURETICS ------------------------------------------------------
                                                                              misoprostol, propantheline, ranitidine,                                       Zyprexa, Zyprexa Zydis                                         Tier 2   Travatan
Tier 1   amiloride, bumetanide, furosemide
                                                                              sucralfate                                                           ANXIOLYTICS, SEDATIVES, AND HYPNOTICS----                               Tier 3   Alphagan P, Azopt, Betimol, Betoptic-S,
        HCTZ, HCTZ w/ triamterene, indapamide
                                                                      Tier 1  Prilosec OTC                                                         Tier 1   alprazolam, buspirone, lorazepam                                        Cosopt, Lumigan, Propine,
        spironolactone, torsemide
                                                                      Tier 2  Bentyl Syrup, nizatidine                                                      triazolam, zolpidem tartrate                                            Rescula, Timoptic XE, Trusopt, Xalatan
Tier 3   Diamox Sequels, Inspra, Renese
                                                                      Tier 2  omeprazole, Nexium, Protonix                                         Tier 2   Ambien CR                                                      ANTI-INFECTIVE AGENTS--------------------------------
ANTILIPEMICS         ----------------------------------------------
                                                                      Tier 3  Aciphex, Prevacid, PrevPac, Prevacid                                 Tier 3   Ambien, Lunesta, Restoril, Rozerem, Sonata                     Tier 1   ciprofloxacin, erythromycin, gentamicin
Tier 1   lovastatin, gemfibrozil, cholestyramine,
                                                                              Naprapac, Prilosec, Zegerid                                          CEREBRAL STIMULANTS--------------------------------                              ofloxacin, sulfacetaminde, tobramycin, etc.
         fenofibrate, pravastatin, simvastatin
                                                                      ANTIEMETIC/ANTIVERTIGO -----------------------------                         Tier 1   methylphenidate, amphetamine                                   Tier 2   Vigamox
Tier 2  Colestid 1Gm Tablets, Crestor, Niaspan,
                                                                      Tier 1  hydroxyzine, meclizine, ondansetron,                                          amphetamine/dextroamphetamine                                  Tier 3   Azasite, Ciloxan, Ocuflox, Quixin, Zymar
         Tricor, Vytorin, Zetia
                                                                              prochlorperazine, promethazine,                                      Tier 2   Metadate-CD                                                    ANTI-INFLAMMATORY AGENTS---------------------------
Tier 3   Advicor, Altoprev, Antara, Lescol, Lescol XL
                                                                              trimethobenzamide                                                    Tier 3   Adderall XR, Concerta, Daytrana (ST),                          Tier 1   dexamethasone, fluorometholone
        Lipitor, Lofibra, Pravachol, Triglide, Welchol,
                                                                      Tier 2  Torecan                                                                       Focalin, Provigil, Ritalin-LA, Strattera,                               prednisolone
        Zocor
                                                                      Tier 3  Anzemet (PA)(QL), Emend(PA)(QL),                                              Vyvanse                                                        Tier 2   Alrex, Lotemax
MISCELLANEOUS CARDIOVASCULAR DRUGS---------
                                                                              Kytril (PA)(QL), Marinol (PA)(QL),                                   DRUGS FOR ALZHEIMER’S DISEASE-----------------------                    Tier 3   Eflone, Flarex, FML Forte
Tier 3   Bidil
                                                                              Zofran (PA)(QL)                                                      Tier 2   Aricept, Namenda                                               ANTI-INFECTIVE AND ANTI-INFLAMMATORY
ANTICOAGULANTS/ANTITHROMBOTICS-------------
                                                                      Tier 3  Transderm-Scop                                                       Tier 3   Cognex, Exelon, Razadyne, Razadyne ER                          COMBINATIONS ---------------------------------------------
Tier 1   dipyridamole, pentoxifylline, ticlopidine
                                                                      DIGESTANTS ---------------------------------------------------               ANALGESICS, NARCOTIC---------------------------------------             Tier 1   multiple medicines w/ generics
        warfarin
                                                                      Tier 1  multiple medicines w/ generic                                        Tier 1   multiple medicines w/ generics                                 Tier 3   Blephamide, FML-S, Pred-G Tobradex,
Tier 2  Coumadin
                                                                      Tier 2  Creon                                                                Tier 2   Kadian, Oxycontin                                                       Zylet
Tier 3   Aggrenox, Agrylin, Plavix, Pletal
                                                                      Tier 3  Ku-Zyme, Pancrecarb                                                  Tier 3   Actiq (QL), Avinza, Duragesic, Fentora,                        NSAIDS-----------------------------------------------------------
DRUGS FOR MISCELLANEOUS BLOOD DISORDERS--
                                                                      OTHER GI PRODUCTS -----------------------------------                                 Opana, OxyIR                                                   Tier 1   flurbiprofen
Tier 2  Exjade
                                                                      Tier 1  lactulose, sulfasalazine                                             ANALGESICS, NSAIDs ----------------------------------------             Tier 2   Voltaren Opthalmic
                RESPIRATORY / ASTHMA                                  Tier 2  Asacol, Canasa, Dipentum, Entocort,                                  Tier 1   diclofenac, diflunisal, etodolac, ibuprofen,                   Tier 3   Acular, Acular LS, Ocufen, Profenal
DRUGS FOR ALLERGY -------------------------------                              Phoslo, urisdiol, URSO                                                       indomethacin, meloxicam, naproxen,                                                              OTIC
Oral Antihistamines and Combinations. . . . . . . .                   Tier 3  Actigall, Azulfidine, Colazal, Cytotec, Lialda,                               oxaprozin, etc.
Tier 1    Alavert, OTC Claritin, loratadine                                   Pentasa, Rowasa                                                      Tier 3   Arthrotec, Celebrex (ST)(QL)                                   ANTI-INFECTIVE AND ANTI-INFLAMMATORY
          OTC Claritin-D, OTC Zyrtec, OTC Zyrtec-D                    Tier 3  Amitiza, Lotronex                                                    MIGRAINE AGENTS-------------------------------------------              COMBINATIONS ------------------------------------------------
Tier 2    cetirizine, cetirizine-D, fexofenadine                                                                                                   Tier 2   Depakote ER, Maxalt (QL), Maxalt MLT(QL),                      Tier 1   multiple medicines w/ generics
                                                                                           GENITO-URINARY                                                                                                                  Tier 2   Cerumenex, Ciprodex, Floxin Otic
Tier 3    Allegra, Allegra D, Clarinex, Clarinex-D,                                                                                                         Zomig (QL), Zomig ZMT (QL), Zomig Nasal
          Singulair, Xyzal                                            ANTI-INFECTIVES------------------------------------------                             Spray (QL)                                                     Tier 3   Cipro HC Otic
NASAL MEDICATIONS -------------------------------------               Tier 1   nitrofurantoin macro and other generics                             Tier 3   Amerge (QL), Axert (QL), Frova(QL), Imitrex                                      DERMATOLOGICALS
Tier 1    flunisolide nasal, fluticasone nasal                        Tier 3   Macrobid                                                                     Tabs (QL), Imitrex Nasal Spray (QL),Imitrex
                                                                      INCONTINENCE AGENTS-------------------------------                                                                                                   ACNE -------------------------------------------------------------
Tier 2    Astelin, Atrovent, Rhinocort Aqua                                                                                                                 injection Kits* (QL), Migranal, Relpax (QL)                    Tier 1    multiple medicines w/ generics
Tier 3    Bactroban Nasal Ointment                                    Tier 1   oxybutinin, oxybutinin XL
                                                                      Tier 2   Enablex, Oxytrol, Sanctura, Sanctura XR                                                                                                     Tier 2    BenzaClin, isotretinoin (oral)
Tier 3    Beconase AQ, Flonase, Nasacort AQ,                                                                                                                                                                               Tier 3    Accutane, Azelex (PA), Differin, Duac,
          Nasarel, Nasonex, Veramyst                                  Tier 3   Detrol, Detrol LA, Ditropan XL, Vesicare
                                                                                                                                                                                                                                     Klaron. Retin-A Micro (PA)




 This document is in effect beginning January 1, 2008. Formulary consultation and administrative support to provided by:
ANTIBIOTICS ---------------------------------------------------                                                                   DRUGS FOR CANCER--------------------------------------------   DRUGS FOR BLOOD DISORDERS----------------------------
Tier 1    erythromycin, clindamycin, metronidazole,
                                                                                    SPECIALTY DRUGS                               Tier 3/4 Abraxane*(PA), Adriamycin*(PA),                       Tier 3 /4 Aranesp*(PA), Epogen*(PA), Procrit*(PA)
          mupirocin                                                                                                                         Alimta*(PA), Alkeran*(PA), Aloxi*(PA),               Tier 3 /4 Arixtra* (PA) Fragmin*(PA), Heparin*(PA)
Tier 2    Noritate                                                       Coverage for “Specialty Drugs” varies from                         Aredia*(PA), Arranon*(PA), Avastin*(PA),                       Innohep*(PA), Kepivance*(PA), Leukine*(PA),
Tier 3    Altrabax, Bactroban, MetroGel, MetroLotion                     plan to plan. Your prescription benefit may                        Bexxar*(PA), BICNU*(PA), Blenoxane*(PA),                       Lovenox*(PA), Neulasta*(PA), Neumega*(PA),
ANTIVIRALS ----------------------------------------------------          not cover some or all of these items. Please                       Busulfex*(PA), Campath*(PA),                                   Neupogen*(PA), Soliris*(PA)
Tier 1    Abreva                                                         check your pharmacy benefit information if                         Captosar*(PA), Cerubidine*(PA),                      DRUGS FOR ASTHMA---------------------------------------------
Tier 2    Zovirax Ointment                                               you have questions.                                                Cisplatin*(PA), Clolar*(PA),                         Tier 3/4 Xolair*(PA)
Tier 3    Denavir                                                                                                                           Cosmegen*(PA), Cytarabine*(PA),                      DRUGS FOR ERECTILE DYSFUNCTION----------------
FUNGICIDES ----------------------------------------------------          Specialty Drugs are “bioengineered” oral or injectable             Dacogen*(PA), DaunoXome*(PA),                        Tier 3 /4 Caverject* (PA) (QL), Edex* (PA) (QL)
Tier 1    ciclopirox, clotrimazole, ketoconazole,                        medicines that target and treat complex medical                    DepoCyt*(PA), Doxil*(PA),                            DRUGS FOR RHEUMATOID ARTHRITIS-----------------
          clotrimazole/betamethasone, nystatin, etc.                     conditions including: blood disorders, cancers,                    DTIC-Dome*(PA), Eligard*(PA), Elitek*(PA),           Tier 3/4 Enbrel*(ST), Humira*(ST), Kineret*(ST),
Tier 2    Mycostatin Lozenges, Mycelex Troches                           infertility, hormone or enzyme deficiencies, multiple              Ellence*(PA), Eloxatin*(PA), Elspar*(PA),                      Orencia*(ST), Remicade*(ST), Rituxan*(ST)
Tier 3    Exelderm, Loprox, Mentax, Naftin,                              sclerosis, rheumatoid arthritis, and a growing list of             Erbitux*(PA), Ethyol*(PA), Etopophos*(PA),           DRUGS FOR OSTEOARTHRITIS----------------------------
Tier 3    Penlac, Oxistat, Spectazole                                    obscure or “orphan” diagnoses.                                     Faslodex*(PA), Floxuridine/DUDR*(PA),                Tier 3/4 Euflexxa*(PA), Hyalgan*(PA),
TOPICAL ANTI-INFLAMMATORY AGENTS---------                                                                                                   Fludara*(PA), Ganite*(PA), Gemzar*(PA),                        Orthovisc*(PA), Supartz*(PA), Synvisc*(PA)
Low - Intermediate Potency . . . . . . . . . . . . . . . . .             Specialty drugs are complex compounds and some                     Gleevec(PA), Gliadel(PA), Herceptin*(PA),            MULTIPLE SCLEROSIS AGENTS---------------------------
Tier 1    multiple medicines w/ generics                                 have unique “handling” requirements. The FDA in                    Hexalen(PA), Hycamtin*(PA),                          Tier 3/4 Avonex*(ST), Betaseron*(ST), Rebif*(ST)
Tier 3    Aclovate, Cloderm, Cordran, Diprolene,                         selected situations has required dispensing from a                 Idamycin*(PA), Ifex*(PA), Ifex/Mesnex*(PA),                    Copaxone*(ST)
          Elocon Locoid, Pandel                                          single pharmacy or a limited set of “approved”                     Iressa(PA), Leustatin*(PA), Mesna*(PA),              DRUGS FOR PARKINSONS DISEASE ----------------------
Highest Potency . . . . . . . . . . . . . . . . . . . . . . . . . . .    pharmacies. Some “specialty” drugs are oral tablets                Metastron*(PA), Mustargen*(PA),                      Tier 3/4 Apokyn*(PA),
Tier 1    multiple medicines w/ generics                                 or capsules while others require injection. The result             Mutamycin*(PA), Mylotarg*(PA),                       DRUGS FOR PSORIASIS-----------------------------------------
Tier 3    Diprolene AF, Ultravate                                        is that many drugs can be distributed directly to                  Navelbine*(PA), Nexavar (PA),                        Tier 3 /4 Amevive* (ST), Raptiva*(ST)
OTHER DERMATOLOGICALS ----------------------------                       patients,while otherswill be sent to physicians or                 NeuTrexin*(PA), Nipent*(PA),                         DRUGS FOR MACULAR DEGENERATION------------------
Tier 1    anthralin                                                      home health companies or other professional settings               Novantrone*(PA), Oncaspar*(PA),                      Tier 3 /4 Lucentis* (PA), Macugen*(PA),
Tier 2    Aldara, Dovonex, Efudex, Elidel, Fluoroplex                    for administration.                                                Ontak*(PA), Onxol*(PA), Paraplatin*(PA),                       Visudyne*(PA)
Tier 3    Lidoderm, Ovace, Protopic, Psoriatec,                                                                                             Photofrin*(PA), Proleukin*(PA),                      MISCELLANEOUS SPECIALTY DRUGS--------------------
          Soriatane, Synera, Tazorac                                     Most plan sponsors will apply “step edits” or prior                Quadramet*(PA), Revlimid (PA),                       Tier 3 /4 Ceprotin*(PA), Cerezyme*(PA),
                     MISCELLANEOUS                                       authorization criteria prior to the dispensing or                  Sensipar(PA), Sprycel (PA), Sutent (PA),                       Eleprase*(FA), Fabrazyme*(PA),
                                                                         administration of a specialty drug. These                          Tabloid(PA), Tarceva (PA), Targretin(PA),                      Myozyme*(PA), Zavesca (PA)
Tier 1  leflunomide (Generic for Arava) (ST)                                                                                                Taxol*(PA), Taxotere*(PA), Telac(PA),                Tier 3/4 Aralast*(PA), Prolastin*(PA), Zemaira*(PA)
Tier 2  Epipen, Epipen Jr                                                requirements ensure appropriate use of a specialty
                                                                         drug.                                                              Temodar (PA), Thalomid (PA),                         Tier 3/4 Botox*(PA), Prialt*(PA)
Tier 2  Evoxac                                                                                                                              TheraCys*(PA), Thiotepa*(PA),                        Tier 3 /4 Rilutek (PA)
Tier 2  Cellcept, Cuprimine, Prograf, Rapamune                                                                                              Thyrogen*(PA), TICE BCG*(PA),
Tier 3  Regranex                                                                                                                            Torisel*(PA), Trelstar*(PA), Trexall(PA),
Tier 3  Renagel                                                                        SPECIALTY DRUGS                                      Tykerb (PA), Valstar*(PA),
Tier 3  Chantix (QL), Zyban (QL)                                                                                                            Vantas*(PA), Vectibix*(PA), Velcade*(PA),
                                                                        DRUGS FOR VIRAL INFECTIONS-----------------------------
Tier 3  Xyrem (PA)                                                                                                                          Vesanoid(PA), Viadur*(PA),
                                                                        Tier 3/4 Synagis*(PA)
MISC-DIAGNOSTICS ---------------------------------------                                                                                    Vinblastine*(PA), Vincasar*(PA),
                                                                        Tier 3 /4 Cytovene*(PA), Foscavir*(PA),
Tier 2  Novo Penneedles                                                                                                                     Vumon*(PA), Xeloda (PA), Zanosar*(PA),
                                                                                  Fuzeon*(PA), Valcyte (PA), Vistide*(PA)
Tier 2  Ascensia Test Strips                                                                                                                Zevalin*(PA), Zinecard*(PA), Zoladex*(PA),
                                                                        Tier 3 /4 Copegus (PA), Rebetol (PA), Ribavirin (PA)
        Coverage for diabetes test strips varies.                                                                                           Zolinza(PA), Zometa*(PA)
                                                                        Tier 3 /4 Pegasys*(PA), Peg-Intron* (PA)
        Please refer to your plan document or                                                                                     DRUGS FOR OSTEOPOROSIS---------------------------------
                                                                        DRUGS FOR IMMUNE DEFICIENCIES------------------------
        contact a customer service representative                                                                                 Tier 3/4 Boniva IV*(PA), Forteo*(PA), Reclast*(PA)
                                                                        Tier 3/4 Carimune*(PA), Flebogamma*(PA),
        for additional coverage information.                                                                                      MISCELLANEOUS ENDOCRINE DRUGS------------------
                                                                                  Gamastan*(PA), Gammagard*(PA),
                                                                                  Gamunex*(PA), Iveegam EN*(PA),                  Tier 3/4 Lupron*(PA), Sandostatin* (PA), Synarel
                                                                                  Octagam*(PA), Panglobulin*(PA),                 DRUGS FOR HEMOPHILIA---------------------------------------
                                                                                  PolygamS/D*(PA), Vivaglobin*(PA)                Tier 3 /4 Advate*(PA), Alphanate*(PA),
                                                                        DRUGS FOR INFERTILITY---------------------------------              AlphanineSD*(PA), Amicar*(PA),
                                                                        Tier 3 /4 Bravelle*(PA), Cetrotide*(PA),                            Bebulin VH*(PA), BeneFix*(PA),
                                                                                  Chorionic gonadatropin *(PA),                             Cyclokapron*(PA), Feiba VH Immuno*(PA),
                                                                                  Endometrin (PA), Fertinex*(PA)                            Genarc*(PA), Helixate FS*(PA),
                                                                                  Follistim AQ*(PA), Ganireliex*(PA),                       Hemofil M*(PA), Humate-P*(PA),
                                                                                  Gonal-F*(PA), Gonal-F RFF*(PA),                           Hyate:C*(PA), Koate-DVI*(PA),
                                                                                  Luveris*(PA), Menopur*(PA), Novarel*(PA),                 Kogenate FS*(PA), Monarc-M*(PA),
                                                                                  Ovidrel*(PA), Pregnyl*(PA),                               Monoclate-P*(PA), Mononine*(PA),
                                                                                  Progesterone in Oil*(PA), Repronex*(PA)                   NovoSeven*(PA), Profilnine*(PA),
                                                                        GROWTH HORMONE DRUGS---------------------------------               Proplex T*(PA), Recombinate*(PA),
                                                                        Tier 3 /4 Genotropin*(PA), Humatrope*(PA).                          Refacto*(PA)
                                                                                  Increlex*(PA), Iplex*(PA), Norditropin*(PA),    MISCELLANEOUS CARDIOVASCULAR DRUGS---------
                                                                                  Nutropin*(PA), Nutropin AQ*(PA),                Tier 2    Exjade, Revatio (PA)
                                                                                  Saizen*(PA), Serostim*(PA),                     Tier 3/4 Flolan*(PA), Letairis(PA), Remodulin*(PA),
                                                                                  Tev-Tropin*(PA), Zorbitive*(PA)                           Tracleer (PA), Ventavis (PA)




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