2009 OUTCOMES Drug Formulary and Pharmacy Benefit

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2009 OUTCOMES Drug Formulary and Pharmacy Benefit Powered By Docstoc
					                                                                         DRUGS FOR INFECTIONS                                                          DRUGS FOR CANCER                                 PROGESTIN ONLY------------------------------------------------
                                                                                                                                                                                                        Tier 1 multiple generic options (ex. Camilla, etc.)
                                                        ANTIBIOTICS-------------------------------------------------                    Tier 1     cyclophosphamide, etoposide, flutamide               Tier 2 Ovrette
                                                        Penicillins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .              hydroxyurea, leucovorin, leuprolide acetate,
                                                        Tier 1     ampicillin, amoxicillin, cloxacillin, dicloxacillin,                            tretinoin, vinorelbine tartrate, megestrol,                          DRUGS FOR DIABETES
                                                                   amoxicllin w/ potassium clavulanate, penicillin                                 methotrexate, tamoxifen                              INSULINS --------------------------------------------------------
                                                        Tier 2     Augmentin 125-31.25mg Chewable Tablet                                Tier 2     Alkeran, Arimidex, Aromasin, Avastin,                Tier 1    Lantus
                                                                   Augmentin 250-62.5mg Chewable Tablet                                            Casodex, CeeNu, Droxia, Emcyt, Erbitux,              Tier 2    Apidra, Humalog, Humalog Mix 75/25,
                                                                   Augmentin 250-62.5mg Oral Suspension                                            Femara, Gleevec, Herceptin, Hexalen,                           Humulin R, L, N, U, 70/30, 50/50, Novolin R,
                                                                   Augmentin XR                                                                    Hycamtin, Ixempra, Kepivance, Leukeran,                        L, N, 70/30, Novolog, Novolog Mix, Novolin
2009 OUTCOMES Drug Formulary                            Cephalosporins. . . . . . . . . . . . . . . . . . . . . . . . . . . . .                    Leukine, Lysodren, Matulane, Mesnex,                           Innolet
                                                                                                                                                                                                        ORAL ------------------------------------------------------------
and Pharmacy Benefit Guidelines                         Tier 1     cefaclor, cefadroxil, cefdinir, cefradine,
                                                                   cefpodoxime, cefprozil, cephalexin
                                                                                                                                                   Myleran, Neulast, Neupogen, Nexavar,
                                                                                                                                                   Novantrone, Proleukin, Revlimd, Rituxan,             Tier 1    acarbose, glimepiride, glipizide, glipizide XL,
                                                        Tier 2     Ceftin Oral Suspension, Ceftin 125mg Tab                                        Sandostatin, Sprycel, Somatuline Depot,                        glyburide, metformin, metformin XR
The MedBen Outcomes Preferred Drug List                 Macrolides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .               Supprelin LA, Sutent, Tarceva, Tasigna,              Tier 1    glyburide w/ metformin, glipizide w/ metformin
defines the copayment tier status of                    Tier 1     azithromycin, clarithromycin, erythromycin                                      Temodar, Teslac, Thioguanine, Torisel,               Tier 2    Actos, Avandia, Byetta, Januvia, Prandin,
                                                                   estolate, erythromycin ethyl succinate,                                         Trexall, Tykerb, Vantas, Velcade Vidaza,                       Starlix, Symlin
“preferred” medicines most commonly                                                                                                                                                                     Tier 2    ActoPlus Met, Avandamet, Avandaryl,
                                                                   erythromycin stearate                                                           Xeloda, Zoladex
prescribed for members. It may not                      Tetracyclines. . . . . . . . . . . . . . . . . . . . . . . . . . .. . .                                                                                   Duetact, Janumet
include all drugs covered by your                                                                                                          INTERFERONS & IMMUNOMODULATORS
                                                        Tier 1     doxycycline, minocycline, tetracycline                                                                                               DIABETES RELATED DRUGS & SUPPLIES--------------
prescription drug benefit and “Non-                     Tier 2     Adoxa, Adoxa PAK, Oracea, Vibramycin Oral                            Tier 1     azathioprine, hydroxychloroquine,                    Tier 2    Glucagon
Preferred” or Tier 3 medicines do not                              Suspension                                                                      leflunomide, methotrexate, sulfasalazine             Tier 2    Accu-Chek Active Test Strips, Accu-Chek
                                                                                                                                        Tier 2     Actimmune, Avonex, Betaseron, Copaxone,
appear. For benefit coverage or                         Quinolones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
                                                                                                                                                   Intron A, Peg-Intron, Peg-Intron Redipen,
                                                                                                                                                                                                                  Aviva Test Strips, Accu-Chek Comfort Curve
restrictions please check your benefit plan             Tier 1     ciprofloxacin, ofloxacin                                                                                                                       Test Strips, Accu-Chek Compact Test Strips,
                                                        Tier 2     Cipro Suspension, Cipro 100mg Tab                                               Pegasys, Rebif                                                 Accu-Chek Multiclix Lancets, Accu-Chek
document(s). This listing is revised from                                                                                               Tier 2     Arcalyst, Azasan, Cellcept, Cuprimine,                         Softclix Lancets, Accu-Chek Soft Touch
                                                                   Levaquin, Noroxin
time to time as new drugs and new                       Aminoglycosides. . . . . . . . . . . . .. . . . . . . . . . . . . . . . . .                 Enbrel, Humira, Neoral, Orencia, Prograf,                     Lancets, B-D Insulin Syringe, Chemstrip K,
prescribing information becomes                         Tier 1     neomycin tablets                                                                 Rapamune, Ridaura, Sandimmune                                 Fast Take Test Strips, Lancets, Novofine,
available.                                              Sulfonamides. . . . . . . . . . . . .. . . . . . . . . . . . . . . . . .                   Solganal, Trexall                                              One Touch Test Strips, One Touch Ultra Test
                                                        Tier 1     sulfisoxazole w/ erythromycin ethylsuccinate                                                HORMONES                                           Strips, Pen Needle, Surestep, Surestep Pro
It is recommended that you have this list of                       sulfamethoxazole w/ trimethoprim                                     GLUCOCORTICOIDS ---------------------------------------------         THYROID AND ANTITHYROID AGENTS
medications available when you are with                 Drugs for Tuberculosis. . . . . . . . . . . . . . . . . . . . . . . . .         Tier 1 dexamethasone, methylprednisolone,                       THYROID ---------------------------------------------------------
                                                        Tier 1     ethambutol, isoniazid, pyrazinamide,                                        prednisolone, prednisone
your physician and a prescription drug is                          rifampin
                                                                                                                                                                                                        Tier 1  levothyroxine, thyroid
                                                                                                                                        ANDROGENS---------------------------------------------------
going to be part of the treatment for a                 Tier 2     Lamprene, Mycobutin, Seromycin                                       Tier 2  Androderm, Androgel, Methitest, Testim,
                                                                                                                                                                                                        Tier 1  methimazole, propylthiouracil
clinical condition.                                                                                                                                                                                     Tier 2  Cytomel, Synthroid
                                                        Drugs for Fungal Infections. . . . . . . . . . . . . . . . . . . . .                   Testosterone Cypionate
                                                        Tier 1     fluconazole, ketoconazole, nystatin,                                 ESTROGENS ---------------------------------------------------                DRUGS FOR OSTEOPOROSIS
Key to Notations:                                                  Terbinafine                                                          Tier 1 estradiol, estradiol patch, estropipate                  Tier 1       alendronate
                                                        Tier 2     Ancobon, Lamisil Oral Granules, Noxafil,                             Tier 2  Activella, Alora, Cenestin, Enjuvia, Esclim,            Tier 2       Boniva, Fosamax Plus D, Evista, Forteo,
                                                                   Sporonox Oral Solution, Vfend                                                                                                                     Miacalcin
PA: Prior authorization to ensure clinical                                                                                                     Estraderm, Estring, Evamist, Premarin,
                                                        Drugs For Viral Infections. . . . . . . . . . . . . . . . . . . . . . .                Premarin Cream, Vagifem, Vivelle,                                    MISCELLANEOUS ENDOCRINE
appropriateness of this or previous                     Tier 1     acyclovir, amantadine, didanosine,                                          Vivelle DOT
therapy with other similar medications may                         famciclovir, ganciclovir, ribavirin, rimantidine,                    ESTROGEN AND PROGESTERONES-------------------
                                                                                                                                                                                                        Tier 1       cabergoline, desmopressin spray / tablets
be needed before claims for one of these                                                                                                                                                                Tier 2       Aldurazyme, Cerezyme, Cytadren, Elaprase,
                                                                   zidovudine                                                           Tier 2  Combipatch, Estratest, Estratest H.S.,                               Fabrazyme, Hectorol, Kuvan, Methergine,
medications will be accepted.                           Tier 2     Agenerase, Aptivus, Baraclude, Combivir,                                     Premphase, Prempro                                                   Myozyme, Naglazyme, Sandosatatin,
                                                                    Crixivan, Emtriva, Epivir, Epivir HBV,                              PROGESTINS -----------------------------------------------                   Sensipar, Somavert, Stimate, Zemplar
ST: A step therapy protocol may apply to                           Epzicom, Fortovase, Fuzeon, Hepsera,                                 Tier 1  medroxyprogesterone, megestrol
                                                                   Hivid, Intelence, Invirase, Isentress,                               Tier 2  Crinone, Depo-Provera, Prometrium                                    CARDIOVASCULAR DRUGS
this medication. Claims for this medication
                                                                   Kaletra, Lexiva, Prezista, Relenza (QL),                             GROWTH HORMONES ---------------------------------------         CARDIOTONICS ----------------------------------------------
may be covered based on the enrollee's                             Rescriptor, Reyataz, Selzentry, Sustiva,                                                                                             Tier 1  digoxin
                                                                                                                                        Tier 2  Humatrope, Norditropin, Nutropin,
previous medication history. If prior                              Synagis, Tamiflu (QL),Trizivir, Truvada,                                     Nutropin AQ                                             Tier 2  Lanoxin
medication history does not meet clinical                          Valcyte, Valtrex, Viracept, Viramune, Viread,                        MISCELLANEOUS OB/GYN DRUGS-----------------------               ANTI-ANGINA ----------------------------------------------
guidelines, authorization may be required                          Zerit, Ziagen                                                        Tier 2  Lupron Depot, Lupron Depot-Ped, Synarel                 Tier 1  isosorbide dinitrate, isosorbide mononitrate
prior to acceptance of claims.                          Drugs for Malaria. . . . . . . . . . . . . . . . . . . . . . . . . .
                                                                                                                                                          CONTRACEPTIVES                                        nitroglycerin subligual tabs and patches
                                                        Tier 1     chloroquine, hydroxychloroquine,                                                                                                     Tier 2  Dilitrate-SR, Minitran, Nitrolingual,
                                                                   mefloquine                                                           ORAL MONO-PHASIC ----------------------------------------                Ranexa(ST)
QL: Quantity limitations (maximum                       Tier 2     Daraprim, Fansidar, Malarone, Primaquine,                            Tier 1  multiple generic options (ex. Apri, etc.)               BETA-ADRENERGIC BLOCKERS----------------------
number of tablets/capsules, etc. per month                         Qualaquin                                                            Tier 2  YAZ                                                     Tier 1  atenolol, carvedilol, metoprolol, metoprolol-XL
or year) may be applied to this medication.             Drugs for Parasites. . . . . . . . . . . . . . . . . . . . . . . . . .          ORAL BIPHASIC ----------------------------------------          Tier 2  Bystolic, Coreg CR
                                                        Tier 1     mebendazole, metronidazole, paromomycin                              Tier 1  multiple generic options (ex. Kariva, etc.)             CALCIUM CHANNEL BLOCKERS -----------------------
                                                        Tier 2     Albenza, Alinia, Biltricide, Mepron,                                 ORAL TRI-PHASIC ----------------------------------------        Tier 1  amlodipine, diltiazem CD, verapamil SR
                                                                   Mintezol, NebuPent, Stromectol, Tindamax,                            Tier 1  multiple generic options (ex. Cesia, Tri-               Tier 2  Cardizem LA, Covera-HS, Sular
                                                                   Yodoxin                                                                      Sprintec, Velivet, etc.)                                ANTIARRHYTHMICS ----------------------------------------
                                                        Miscellaneous Antiinfectives. . . . . . . . . . . . . . . . . . . . .           Tier 2  Ortho Tri-Cyclen Lo                                     Tier 1  amiodarone, disopyramide, flecainide
                                                        Tier 1     clindamycin, metronidazole, nitrofurantoin                           OTHER CONTRACEPTIVES----------------------------------                  mexiletine, propafenone, quinidine, sotalol
                                                        Tier 2     Dapsone, Tobi, Vancocin, Zyvox                                       Tier 2  NuvaRing Vaginal Ring                                   Tier 2  Ethmozine, Pacerone 100mg 200mg 300mg
                                                                                                                                                                                                                Procanbid, Rythmol SR, Tikosyn


This document is in effect beginning January 1, 2009.                                                                                                    Formulary consultation and administrative support to provided by:
ACE INHIBITORS ---------------------------------------------         Other Pulmonary Drugs. . . . . . . . . . . . . . . . .                       MISCELLANEOUS UROLOGICALS-----------------------                        DRUGS FOR PARKINSONS DISEASE ----------------------
Tier 1   captopril, enalapril, lisinopril                            Tier 1    ipratropium bromide for nebulization,                              Tier 2 Caverject, Cialis, Cystagon, Elmiron, Muse,                      Tier 1  amantadine, benztropine, bromocriptine,
Tier 2   Aceon                                                                 ipratropium w albuterol sulfate                                           Viagra (QL)                                                              carbidopa/levodopa, ropinirole, selegiline,
ANGIOTENSIN II ANTAGONISTS-------------------------                  Tier 2    Advair, Atrovent, Atrovent HFA, Combivent,                                    CENTRAL NERVOUS SYSTEM                                               trihexyphenidyl, etc.
Tier 2   Atacand, Benicar, Cozaar, Diovan, Micardis                            Intal, Letairis, Pulmozyme, Revatio,                                                                                                       Tier 2  Apokyn, Azilect, Comtan, Lodosyn, Mirapex
                                                                                                                                                  PSYCHOTHERAPEUTIC AGENTS -----------------------
ANTI-ADRENERGIC BLOCKERS–CENTRAL------                                         Singulair, Spiriva, Symbicort, Tilade,                                                                                                     MISCELLANEOUS DRUGS FOR CNS----------------------
                                                                                                                                                  Antidepressants . . . . . . . . . . . . . . . . . . . . . . . . . . .
Tier 1   clonidine                                                             Tracleer, Ventavis                                                                                                                         Tier 2  Copaxone, Mestinon, Prostigmin
                                                                                                                                                  Tier 1   amitriptyline, bupropion, bupropion SR,
Tier 2   Catapress-TTS                                               Theophyllines…. . . . . . . . . . . . . . . . . . . . . . . .                                                                                        SKELETAL MUSCLE RELAXANTS -------------------------
                                                                                                                                                           bupropion XL, citalopram, desipramine,
ANTI-ADRENERGIC BLOCKERS–PERIPHERAL --                               Tier 1    multiple medicines w/ generic alternatives                                                                                                 Tier 1  baclofen, carisoprodol, chlorzoxazone,
                                                                                                                                                           doxepin, fluoxetine, imipramine, mirtazapine,
Tier 1   doxazosin, prazosin, terazosin                              Tier 2    Elixophyllline, Slo-Bid 50mg, 100mg, Theo-                                                                                                        cyclobenzaprine, dantrolene, diazepam,
                                                                                                                                                           nortriptyline, paroxetine, protriptyline,
DRUGS FOR PHEOCHROMOCYTOMA ----------------                                    24, Uniphyl                                                                                                                                       methocarbamol, tizanidine, etc.
                                                                                                                                                           sertraline, trazodone, venlafaxine
Tier 2   Demser, Dibenzyline                                         Corticosteroids. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                                                                           Tier 2  Skelaxin
                                                                                                                                                  Tier 2   Cymbalta, Effexor XR, Nardil, Pristiq,
VASODILATORS -------------------------------------------------       Tier 2    Asmanex, Flovent, Flovent Diskus, Pulmicort,                                                                                                                      OPHTHALMIC
                                                                                                                                                           Surmontil, Tofranil-PM
Tier 2   BiDil, Epoprostenol, Flolan, Remodulin                                Pulmicort Flexhaler, QVAR
                                                                                                                                                  Antipsychotic Agents . . . . . . . . . . . . . . . . . . . . . . .      ANTI-ALLERGIC AGENTS----------------------------------
COMBINATION ANTIHYPERTENSIVES--------------                                             GASTROINTESTINAL                                          Tier 1   chlorpromazine, haloperidol, perphenazine,                     Tier 1   Alaway(OTC) ketotifen, Zaditor(OTC)
Tier 1   amlodipine w/ benazepril, captopril w/HCTZ,
                                                                     ANTIULCER -----------------------------------------------------                       risperidone, other generics                                    Tier 2   Alamast, Lacrisert, Livostin, Lucentis,
         enalapril w/ HCTZ, lisinopril w/ HCTZ,
                                                                     Tier 1  cimetidine, dicyclomine, famotidine,                                 Tier 2   Abilify, Clozaril, Geodon, Moban, Orap,                                 Optivar, Pataday, Patanol, Restasis
Tier 2   Atacand HCT, Benicar HCT, Diovan HCT,
                                                                             misoprostol, nizatidine, omeprazole,                                          Seroquel, Seroquel XR, Zyprexa,                                ANTI-GLAUCOMA AGENTS -----------------------------
        Exforge, Hyzaar, Lotrel 5-40mg, Lotrel 10-
                                                                             propantheline, ranitidine, sucralfate                                         Zyprexa Zydis                                                  Tier 1   betaxolol, brimonidine, carteolol, dipivefrin,
        40mg, Micardis HCT, Tarka, Tekturna HCT
                                                                     Tier 1  Prilosec OTC                                                         ANXIOLYTICS, SEDATIVES, AND HYPNOTICS----                                        dorzolamide, levobunolol, metipranolol,
DIRECT RENIN INHIBITOR-----------------------------------
                                                                     Tier 2  Axid Oral Solution, Carafate Oral                                    Tier 1   alprazolam, buspirone, lorazepam, zaleplon,                             timolol, timolol maleate/dorzolamide, etc.
Tier 2  Tekturna
                                                                             Suspension, Pylera                                                            zolpidem tartrate                                              Tier 2   Alphagan P, Azopt, Betimol, Betoptic S,
DIURETICS ------------------------------------------------------
                                                                     Tier 2  Nexium                                                               Tier 2   Ambien CR, Restoril 7.5mg, Restoril 22.5mg                              Phospholine Iodide, Pilopine HS, Isopto
Tier 1   amiloride, bumetanide, furosemide
                                                                     ANTISPASMODICS ------------------------------------------                    CEREBRAL STIMULANTS--------------------------------                              Carbachol, Lumigan, P6E1, Travatan,
        HCTZ, triamterene w/ HCTZ, indapamide
                                                                     Tier 1  dicyclomine, hyoscyamine, propantheline                              Tier 1   methylphenidate, amphetamine,                                           Travatan Z, Xalatan
        spironolactone, torsemide
                                                                     Tier 2  Levbid, Levsin, Levsin/SL, Levsinex, Motofen,                                 amphetamine/dextroamphetamine                                  ANTI-INFECTIVE AGENTS--------------------------------
ANTILIPEMICS        ----------------------------------------------
                                                                             NuLev, Pamine, Pamine Forte                                          Tier 2   Adderall XR, Concerta, Daytrana, Metadate-                     Tier 1   ciprofloxacin, erythromycin, gentamicin
Tier 1   colestipol, cholestyramine, fenofibrate,
                                                                     ANTIEMETIC/ANTIVERTIGO -----------------------------                                  CD, Metadate ER 20mg, Provigil, Strattera,                              ofloxacin, sulfacetaminde, tobramycin,
         gemfibrozil,lovastatin, pravastatin,
                                                                     Tier 1  granisetron, meclizine, ondansetron,                                          Vyvanse, Xyrem                                                          trifluridine, etc.
        simvastatin, Slo-Niacin (OTC)
                                                                             prochlorperazine, promethazine,                                      DRUGS FOR ALZHEIMER’S DISEASE-----------------------                    Tier 2   Ciloxan, Iquix, Natacyn, Quixin, Tobrex,
Tier 2  Advicor, Altoprev, Crestor, Fenoglide,
                                                                             trimethobenzamide                                                    Tier 1   galantamine hydrobromide                                                Vigamox, Zymar
        Lipitor, Lovaza, Niaspan, Simcor, Triglide,
                                                                     Tier 2  Anzemet, Emend (QL), Transderm-Scop                                  Tier 2   Aricept, Aricept ODT, Namenda, Exelon,                         ANTI-INFLAMMATORY AGENTS---------------------------
        Vytorin, Welchol, Zetia
                                                                     DIGESTANTS ---------------------------------------------------                        Razadyne ER                                                    Tier 1   dexamethasone, fluorometholone
ANTICOAGULANTS/ANTITHROMBOTICS-------------
                                                                     Tier 1  multiple medicines w/ generic                                        ANALGESICS, NARCOTIC---------------------------------------                      prednisolone
Tier 1   cilostazol, dipyridamole, pentoxifylline,
                                                                     Tier 2  Creon, Pancrease MT 12K-4K-12K,                                      Tier 1   multiple medicines w/ generics                                 Tier 2   Alrex, HMS, Lotemax, Pred Mild, Retisert
        ticlopidine, warfarin
                                                                             Ultrase, Ultrase MT, Viokase,                                        Tier 2   Avinza, MS Contin, MSIR, Oxycontin,                            ANTI-INFECTIVE AND ANTI-INFLAMMATORY
Tier 2  Arixtra, Aggrenox, Coumadin, Fragmin,
                                                                     BOWEL EVACUANTS---------------------------------------------                          OxyFAST, OxyIR, Phrenilin, Phrenilin Forte                     COMBINATIONS ---------------------------------------------
        Lovenox, Plavix
                                                                     Tier 1  multiple medicines w/ generic                                        ANALGESICS, NSAIDs ----------------------------------------             Tier 1   multiple medicines w/ generics
OTHER BLOOD RELATED PRODUCTS-------------
                                                                     Tier 2  Colyte, GoLYTELY, Halflytely, Halflytely w                           Tier 1   diclofenac, diflunisal, etodolac, ibuprofen,                   Tier 2   Blephamide, Blephamide S.O.P., Tobradex,
Tier 1   aminocaproic acid, pentoxyfylline,
                                                                             flavor packs, NuLytely                                                        indomethacin, meloxicam, naproxen,                                      Zylet
Tier 2  Aranesp, Mephyton, Procrit, Leukine, Neulasta,
                                                                     OTHER GI PRODUCTS -----------------------------------                                 oxaprozin, etc.                                                NSAIDS-----------------------------------------------------------
        Neumega, Neupogen
                                                                     Tier 1  balsalazide, lactulose, sulfasalazine,                               Tier 2   Celebrex                                                       Tier 1   diclofenac, flurbiprofen
               RESPIRATORY / ASTHMA                                          ursodiol                                                             ANALGESICS, MISCELLANEOUS ----------------------------
DRUGS FOR ALLERGY -------------------------------                    Tier 2  Phoslo, URSO, URSO Forte                                             Tier 1   naltrexone HCl
                                                                                                                                                                                                                                                         OTIC
Oral Antihistamines and Combinations. . . . . . . .                  Tier 2  Amitiza, Analpram-HC, Anamantle HC,                                  Tier 2   Synvisc                                                        ANTI-INFECTIVE AND ANTI-INFLAMMATORY
Tier 1    Alavert, Claritin(OTC), Claritin-D (OTC)                           Anamantle HC Forte, Anusol HC, Asacol,                               MIGRAINE AGENTS-------------------------------------------              COMBINATIONS ------------------------------------------------
          fexofenadine, loratadine, Zyrtec (OTC),                            Canasa, Cimzia, Cortifoam, Cystadane,                                Tier 2   Depakote ER, Amerge, Ergomar, Frova,                           Tier 1   multiple medicines w/ generics
          Zyrtec-D (OTC)                                                     Entocort EC, Gastrocrom, Lotronex,                                            Imitrex injection Kits* (QL), Imitrex Tabs                     Tier 2   Ciprodex, Cipro HC
Tier 2    Allegra, Allegra-D, Clarinex,                                      Pentasa, Proctocream-HC, Proctofoam HC,                                       (QL), Imitrex Nasal Spray (QL) Maxalt (QL),                                     DERMATOLOGICALS
          Clarinex Reditab, Deconamine, Deconamine                           Relistor.                                                                     Maxalt MLT (QL), Phrenelin, Phrenilin Forte,                   ACNE -------------------------------------------------------------
          SR, Histex, Histex Sr, Respi-Tann,                                                                                                               Relpax (QL), Zomig, Zomig ZMT
                                                                                          GENITO-URINARY                                                                                                                  Tier 1    multiple medicines w/ generics
          Respi-Tann PD                                                                                                                           ANTICONVULSANTS ---------------------------------------                 Tier 2    Azelex, BenzaClin, Differin, Duac, Duac CS,
NASAL MEDICATIONS -------------------------------------              ANTI-INFECTIVES------------------------------------------                    Tier 1   carbamazepine, clonazepam, divalproex
                                                                     Tier 1   nitrofurantoin macro and other generics                                                                                                               Finacea, Metrocream, Metrogel 1%,
Tier 1    flunisolide nasal, fluticasone nasal                                                                                                             sodium, ethosuximide, gabapentin,                                        Metrolotion, Retin-A Micro, Retin-A Micro
Tier 2    Astelin, Nasacort AQ, Nasonex,                             Tier 2   Furadantin                                                                   lamotrigine, levetiracetam, mephobarbital,
                                                                     INCONTINENCE AGENTS-------------------------------                                                                                                             Pump, Rosanil, Rosula, Rosula CLK,
          Rhinocort Aqua, Veramyst                                                                                                                         phenobarbital, phenytoin, primidone,                                     Tazorac Zoderm
COUGH AND COLD MEDICATIONS -------------------------                 Tier 1   oxybutinin, oxybutinin XL                                                    valproic acid, zonisamide\
                                                                     Tier 2   Detrol, Detrol LA, Enablex, Oxytrol Patch,                                                                                                  ANTIBIOTICS ---------------------------------------------------
Tier 1    multiple generic options                                                                                                                Tier 2   Carbatrol, Celontin, Depakote ER,                              Tier 1    erythromycin, clindamycin, metronidazole,
Tier 2    Tussionex                                                           Vesicare                                                                     Depakote Sprinkle, Diastat, Dilantin,
                                                                     VAGINAL PREPARATIONS -------------------------------                                                                                                 Tier 2    Bactroban Nasal, Centany, Noritate,
                                                                                                                                                           Felbatol, Gabitril, Lyrica, Peganone,                                    Xylocaine Nasal Spray
DRUGS FOR ASTHMA / COPD -------------------------------              Tier 1   nystatin, metronidazole vaginal, terconazole                                 Phenytek,Tegretol XR, Topamax
                                                                     Tier 2   AVC, Clindesse, Vandazole, Gynazole-1                                                                                                       ANTIVIRALS ----------------------------------------------------
Sympathomimetics. . . . . . . . . . . .. . . . . . . . . . . . .                                                                                  DRUGS FOR DEPENDENCY ------------------------------                     Tier 1    Abreva
Tier 1  albuterol, isoetharine, metaproterenol                       DRUGS FOR BPH-------------------------------------------                     Tier 1   bupropion HCl SR, methadone
                                                                     Tier 1   doxazosin, terazosin, finasteride                                                                                                           Tier 2    Zovirax Ointment
Tier 2  Foradil, Maxair, Perforomist, ProAir HFA,                                                                                                 Tier 3   Chantix, Nicotrol, Suboxone, Subutex
        Serevent, Xopenex, Xopenex HFA                               Tier 2   Avodart (QL), Flomax, Uroxatral



 This document is in effect beginning January 1, 2009.                                                                                                               Formulary consultation and administrative support to provided by:
FUNGICIDES ----------------------------------------------------
Tier 1  betamethasone/clotrimazole, ciclopirox,
        clotrimazole, ketoconazole, nystatin, etc.
Tier 2  Ertaczo, Mentax, Mycostatin Lozenges,
        Mycelex Troches
TOPICAL ANESTHETICS ------------------------------------
Tier 2  Lidoderm, Xylocaine Spray


TOPICAL ANTI-INFLAMMATORY AGENTS---------
Tier 1  multiple medicines w/ generics
Tier 2  Clobex, Cordran Tape, Locoid, Locoid
        Lipocream, Capex Shampoo, DesOwen
TOPICAL SCABICIDES/PEDICULICIDES -------------------
Tier 2  Eurax, Ovide
ANTIPSORIATIC/ANTISEBORRHEIC ------------------------
Tier 2  Capitrol,Dovonex,Drithocream HP, Dritho-
        Scalp, Pramosone, Raptiva, Sebizon,
        Soriatane, Soriatan CK, Tazorac,
OTHER DERMATOLOGICAS ----------------------------
Tier 1  anthralin
Tier 2  Aldara, Carmol, Condylox, Efudex, Elidel,
        Keralac, Oxsoralen, Oxsoralen-Ultra,
        Pantretin, Protopic, Solaraze
                   MISCELLANEOUS
Tier 2      Actonel 30mg, Adagen, Antabuse,
            Buphenyl, Chemet, Epipen, Epipen Jr,,
            Evoxac, Exjade, Fosrenol, Mereidia,
            Orfadin, Prolastin, Renagel, Renvela,
            Rilutek, Soliris, Thalomid, Twinject




 This document is in effect beginning January 1, 2009.            Formulary consultation and administrative support to provided by: