TIER 1Preferred Generic Drugs Covered at a First Tier

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TIER 1Preferred Generic Drugs Covered at a First Tier Powered By Docstoc
					                                                                                                 Presbyterian Health Plan
                                                                                    Presbyterian Insurance Company, Inc.

                                          Commercial 4 Tier/PIC Preferred Drug Listing
                                              Alphabetical Listing by Tier - 2010

TIER 1 Preferred Generic Drugs Covered at a First Tier Copayment (some medications may be excluded as determined by benefit)
                                   CICLOPIROX 8% NAIL LACQUER
       ACCU-CHEK STRIPS (QL)       (QL)                                LANSOPRAZOLE (QL)          PANTOPRAZOLE (QL)
                                                                       LEVOTHYROXINE TAB
       ADAPALENE GEL (AG)          CLARITHROMYCIN (QL)                 (MYLAN BRAND ONLY)         PILOCARPINE TAB (QL)
       AMPHETAMINE/DEXTROAMP
       HETAMINE (QL)               FENTANYL PATCH (QL)                 METHYLPHENIDATE (QL)       SUMATRIPTAN (QL)
       AMPHETAMINE/DEXTROAMP                                           METHYLPHENIDATE SR
       HETAMINE SR (QL)            FLUCONAZOLE SUSP (QL)               (QL)                       TERBINAFINE
       BUDESONIDE NEB (AG)         GRANISETRON TAB (ST) (QL)           OMEPRAZOLE (QL)            TRETINOIN TOPICAL (AG)
                                                                                                  VENLAFAXINE ER CAP (ST)
       BUPROPION SR (QL)           KETOROLAC TAB (QL)                  ONDANSETRON (QL)           (QL)
                                                                                                  WARFARIN (TEVA BRAND
       BUPROPION XL (QL)                                               ONDANSETRON ODT (QL) ONLY)
                                                                                                  ZOLPIDEM (QL)
TIER 2 Preferred Brand Drugs Covered at a Second Tier Copayment (some medications may be excluded as determined by benefit)
       ABILIFY
       ACCOLATE                    BLEPHAMIDE                          ESTRACE VAGINAL CREAM
       ACIPHEX (ST) (QL)           BLEPHAMIDE S.O.P.                   ESTRADERM                  MATULANE
       ACTIVELLA                   BUPHENYL                            ESTRATEST                  MAXAIR
       ACTONEL                     CANASA SUPP                         ESTRATEST HS               MAXALT (QL)
       ACTONEL w/ CALCIUM          CARAFATE SUSP                       EURAX                      MAXALT MLT (QL)
       ACTOPLUS MET (ST)           CARBATROL                           EVISTA                     MEGACE ES (PE)
       ACTOS                       CEENU                               FANSIDAR                   MENEST
       ADEKs                       CELLCEPT                            FEMHRT                     MEPHYTON
       ADVAIR DISKUS (ST)          CHEMSTRIP UGK                       FEMHRT LOW DOSE            MEPRON
       ADVAIR HFA (ST)             CIPRO SUSP                          FINACEA                    METADATE CD (QL)
       ADVICOR (ST)                CIPRODEX OTIC                       FK506                      METHERGINE
       ALKERAN                     CLEOCIN PEDIATRIC GRANULES          FLOVENT DISKUS             METROGEL
       ALLEGRA SUSPENSIN (AG) COMBIPATCH (ST)                          FLOVENT HFA                MIACALCIN IM, SC
       ALOMIDE                     COMBIVENT                           FLUMIST                    MIGRANAL
       ALORA                       COMBIVIR                            FML                        MOBAN
       ALPHAGAN P                  COMTAN                              FML FORTE                  MYCOBUTIN
       AMOXIL SUSP 50MG/ML         CONCERTA (QL)                       FORADIL                    MYLERAN
       ANTABUSE                    CRESTOR                             FOSAMAX D (QL)
       APTIVUS                     CRIXIVAN                            FURADANTIN                 NAMENDA
       ARICEPT (QL)                CUPRIMINE                           FUZEON                     NARDIL
                                   DAPSONE                             GENGRAF                    NASACORT AQ
       ARMOUR THYROID              DENAVIR                             GEODON                     NECON 10/11
       ASACOL (ST)                 DETROL                              GLUCAGON                   NEORAL
       ASMANEX (30,60,120 MDI)     DETROL LA                           GRIS-PEG                   NEURONTIN SOLN
       ASTELIN                     DIASTAT (ST)                        HECTOROL                   NIASPAN
       ASTEPRO NASAL SPRAY         DIFFERIN CRM. (AG)                  HYCAMTIN
       ATRIPLA                     DILANTIN 30MG CAPS                  INVIRASE                   NORVIR
       ATROVENT HFA                DILANTIN INFATABS                   ISOPTO CARBACHOL           NOVOLIN
       AUGMENTIN CHEW 250;62.5 DIOVAN                                  ISOPTO HOMATROPINE         NOVOLOG
       AUGMENTIN SUS 125; 31.25MG  DIOVAN HCT                          ISOPTO HYOSCINE            NOVOLOG MIX 70/30
       AUGMENTIN SUS 250;62.5/5ML  DIPENTUM (ST)                       KALETRA                    NUVARING
       AVALIDE                     DIVIGEL
       AVANDAMET (ST)              DUAC                                LANTUS                     PANCREASE MT
       AVANDIA                     DUETACT (ST)                        LEUKERAN                   PATANOL
       AVAPRO                      EDECRIN                             LEVEMIR                    *PAXIL ER (ST)
       AVELOX                                                          LEXAPRO (ST)               PEAKFLOW METER
       AVODART                     ELESTAT                             LEXIVA                     PENTASA (ST)
       AZELEX                      EMTRIVA                             LIPITOR                    PHISOHEX
       AZOPT                       EPIPEN                              LOESTRIN 24 FE             PHOSPHOLINE IODIDE
       BECONASE AQ                 EPIVIR                              LOTEMAX (ST)               PLAVIX
       BENICAR                     EPIVIR HBV                          LOVENOX (QL)               PREFEST
       BENICAR HCT                 EPZICOM                             LUMIGAN
       BENZACLIN                   ERGOTRATE                           LYSODREN
       BENZAMYCINPAK               ERY-TAB
       BETOPTIC-S
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TIER
  2  Continued

      PREMARIN                                                         TOPAMAX (QL)
      PREMARIN VAGINAL CRM        SANDIMMUNE                           TOPAMAX SPRINKLE (QL)    VIREAD
      PREMPHASE                   SELZENTRY                            TREXALL                  VIVELLE-DOT
      PREMPRO                     SEREVENT DISKUS                      TRIZIVIR                 VYTORIN
      PREZISTA                    SEROQUEL                             TRUVADA
      PRIMAQUINE                  SIMCOR (ST)                                                   WELCHOL
      PROAIR HFA                  SINGULAIR (ST)                       ULTRASE
      PROMETRIUM                  SPIRIVA                              ULTRASE MT               XALATAN
      PULMICORT RESPULES (AG)     SUPRAX                               UROCIT-K
      PULMICORT FLEXHALER         SUSTIVA                                                       ZEGERID (ST) (QL)
                                  SYMBICORT (ST)                       VAGIFEM                  ZERIT
      QVAR                                                                                      ZETIA
      RELPAX (QL)                 TABLOID                              VENTOLIN HFA             ZIAGEN
      RESCRIPTOR                  TAZORAC                              VIDEX                    ZOVIRAX, TOPICAL
      REYATAZ                     TEGRETOL                             VIOKASE                  ZYPREXA (QL)
      RHINOCORT AQ (ST)           TEGRETOL XR                          VIRACEPT
      RIDAURA                     TOBRADEX OINTMENT                    VIRAMUNE


TIER 3 Non-Preferred Drugs Covered at a Third Tier Copayment (some medications may be excluded as
       determined by benefit)
       ABILIFY DISCMELT (PE)       DIAMOX SEQUELS                                                 ROZEREM (PE) (QL)
       ACZONE (PE)                 DIBENZYLINE                       LOVAZA (QL)
       *ADIPEX-P (PE)              *DURAGESIC PATCHES (ST) (QL)      LUNESTA (PE) (QL)            SANCTURA (ST)
       AEROBID                     *DURICEF                          LYBREL                       SEASONIQUE
       AGGRENOX                    DYNACIRIC CR                      LYRICA (PE) (QL)             SENSIPAR (PE)
       ALAMAST                     ELIDEL (PE) (QL)                                               STALEVO
       ALBENZA                     EMEND CAPS (PE)                   MERIDIA (PE)                 STRATTERA (ST)
       ALOCRIL                     EMSAM TRANSDERMAL (PE) (QL) MULTAQ (PE) (QL)                   SUBOXONE (PE)
       ALORA                       ENABLEX (ST)                      NASONEX (AG)                 *SUBUTEX (PE)
       ALREX (ST)                  ENTOCORT EC                       NATAZIA                      SYMLIN (PE)
       AMBIEN CR (PE) (QL)         ESTRADERM                         NICOTROL INHALER (QL)
       *AMERGE (QL)                ESTRASORB                         NICOTROL NASAL (QL)          TAMIFLU (QL)
       ANDRODERM (PE) (QL)         ESTRING                           NOROXIN                      TASMAR
       ANDROGEL (PE) (QL)          ESTROGEL                          NULYTELY                     TESTIM (PE) (QL)
       ANDROID                     ETH-OXYDOSE                       ONGLYZA (PE) (QL)            TIKOSYN
       ANZEMET TAB (PE) (QL)       EVAMIST                           OPANA ER (ST) (QL)           TOBI
       AROMASIN                    *EXELON CAP., SOL.                ORAP                         TRANSDERM SCOP
       ARTHROTEC                   FACTIVE                           ORTHO-EVRA                   TRAVATAN
       ATACAND                     FELBATOL                          OVCON -50                    ULORIC (PE) (QL)
       ATACAND HCT                 FEMARA                            OXYFAST                      UROXATRAL
       AVINZA (ST) (QL)            FEMRING                           OXYTROL (ST)                 VANCOCIN (PE)
       AXERT (QL)                  FROVA (QL)                                                     VANCOCIN PULVULES (PE)
       AZMACORT                    GABITRIL                          PRANDIMET (ST)               VENLAFAXINE ER (ST) (QL)
                                   GOLYTLEY                          PRANDIN                      VESICARE (ST)
       BILTRICIDE                  GRIS-PEG                          PREPIDIL                     VEXOL
                                                                     PREVACID SOLUTAB (PE)
       BYETTA (PE) (QL)            HALFLYTELY                        (AG)                         VFEND (PE) (QL)
       BYSTOLIC                    HELIDAC                           PRIFTIN                      VICTOZA (PE) (QL)
                                   HUMALOG INSULINS                  PROCTOFOAM HC                VIGAMOX
       CAMPRAL (PE) (QL)           HUMULIN INSULINS                  PROTOPIC (PE) (QL)           VIVELLE-DOT
       CARDENE SR                  JANUMET (PE) (QL)                 PROVIGIL (PE)                VOLTAREN GEL (ST) (QL)
       CEFPODOXIME                 JANUVIA (PE) (QL)                                              VYVANSE (QL)
       CELEBREX (QL)                                                 RANEXA (ST)                  XELODA
       CENESTIN                    KADIAN (ST) (QL)                  RAPAMUNE                     XENICAL (PE)
       CHANTIX (QL)                *KYTRIL (PE) (QL)                 REGRANEX                     XIFAXAN 200MG TAB (PE)
       CIPRO HC OTIC                                                 RELENZA (QL)
       COGNEX                      LESCOL                            RENAGEL                      *YAZ
       COMBIGAN                    LESCOL XL                         RENVELA                      ZOMIG (QL)
       *COSOPT                     LEVATOL                           RESTASIS (PE)                ZOMIG ZMT (QL)
       CYMBALTA (PE) (QL)          LIDODERM PATCHES (PE) (QL)        REVATIO (PE) (QL)            ZYMAR
                                   LoSEASONIQUE                      RILUTEK                      ZYPREXA ZYDIS (PE) (QL)
                                   LOTREL 5/40, 10/40                RISPERDAL M-TAB (PE)         ZYVOX (PE)

    [MPC071020]                                               Page 3 of 4                                                    08/2010
This Listing is not all inclusive nor does it imply a guarantee of coverage, but it represents an abbreviation of the drug Listinging. Substitution of
generic products is mandatory when a generic is available. If brand name is desired, member pays the difference in cost between the brand and
the generic drug. PHARMACY EXCEPTION MAY BE REQUIRED.




DISCLAIMER
Please be sure a Prescription Drug benefit is part of your specific coverage before consulting this list. If you do not know which list is correct,
please contact the Presbyterian Customer Service Center at (505) 923-5678 or toll-free at 1-800-356-2219, Monday through Friday from 7:00
a.m. to 6:00 p.m. TTY users may call 1-877-298-7407.


Coverage for some drugs may be limited to specific dosage forms and/or strengths. Your benefit design determines what is covered for you and
what your copayment will be. Additional limitations or exclusions may apply for members of Presbyterian Individual Plans. Please refer to your
benefit materials for your specific coverage information.The medications listed on this Formulary/Preferred Drug Listing (PDL) are subject to
change pursuant to the Formulary/PDL management activities of Presbyterian Health Plan. This list is not all-inclusive nor does it imply a
guarantee of coverage. In addition, coverage for some drugs listed may be limited to specific dosage forms and/or strengths. Substitution of a
generic product for a brand-name drug is mandatory when a generic equivalent is available. If a member requests the brand-name drug in this
situation, a pharmacy exception may be required and the member must pay the difference in cost between the generic and branded versions.
formulary medications are not considered for coverage unless trial and failure of formulary alternatives are documented.
EXPLANATION OF INDICATORS
You will see these indicators next to some drug names:
1. Pharmacy Exception (PE) -- a drug that requires prior approval before the Plan will cover it, and when the patient meets the established
criteria. The doctor must submit a Pharmacy Exception Form. The doctor can submit the request by fax, phone, or regular mail.

2. Step Edit (ST) -- a drug that requires a prescription history of specific drugs in the pharmacy claims or data system, and these specific drugs
must be taken during a given time frame. After the specific drugs have been taken within the given time frame, online coverage of the newly-
prescribed drug occurs at the pharmacy. Step Edits make it easier to access drugs that would normally require a Pharmacy Exception.
3. Medical Exception -- a drug that is not on the Plan’s formulary. Non-formulary drugs require an Exception to the formulary due to allergy,
adverse reactions, or no response to all formulary drugs.
4. Quantity Limit (QL) -- a coverage limit on the medication quantity covered for a defined days' supply (usually 30 or 90 days) based on safety,
efficacy and/or dose optimization issues.
5. Age Limitation (AG) -- a coverage limit based on minimum or maximum age of the member imposed as a result of safety, efficacy or dosage
form considerations.
6. Specialty (SP) (Tier 4 medications obtained through the pharmacy benefit) -- Tier 4 medications are defined as high cost (greater than $600
per 30 day supply) injectable, infused, oral or inhaled drugs that generally require complex care and supervision. These medications involve
unique distribution and are usually provided by a specialty pharmacy vendor. Specialty pharmaceuticals are self-administered, meaning they are
administered by the patient or to the patient by a family member or caregiver.

* = Generic preferred/ Generic equivalent available.

This list is not all inclusive nor does it imply a guarantee of coverage, but it represents an abbreviation of the drug listing. Substitution of generic
products is mandatory when a generic is available. If brand name is desired, member pays the difference in cost between the brand and the
generic drug. PHARMACY EXCEPTION MAY BE REQUIRED.




     [MPC071020]                                                            Page 4 of 4                                                               08/2010