Incentive Drug List
For Incentive Drug Plans
The drugs listed in the left column are available for a Tier 2 or 3 copay. The drugs in the right column are available for the incentive copay shown on your pharmacy summary of benefits. You may ask your doctor about switching to one of these incentive alternatives for your chronic condition to keep your out-of-pocket costs low. If you have questions, you are welcome to contact our Customer Service Department at (541) 684-5582, toll-free (888) 977-9299; e-mail cs@pacificsource.com. To obtain this excellent value, you must fill your prescription at a participating pharmacy. If you do not present your PacificSource ID card at the time of purchase, or if you use a nonparticipating pharmacy, your benefits for these medications will be reduced and you will be responsible for the nonparticipating copay shown on your pharmacy summary of benefits.
Tier 2 or 3 Copay Incentive Copay Antidepressants Celexa citalopram Effexor venlafaxine Paxil paroxetine Prozac fluoxetine Wellbutrin SR bupropion SR Zoloft sertraline Cymbalta, Effexor XR, one of the above Lexapro, Paxil CR Antidiabetic Agents Amaryl glimepiride Diabeta, Micronase glyburide Glucophage metformin Glucophage XR, metformin ER Fortamet Glucotrol glipizide Glucotrol XL glipizide ER Metaglip glipizide/metformin Actos, Avandia, Avandamet, Diabeta, Fortamet ER, one of the above Glucovance, Glynase, Glyset, Starlix Antihypertensives – Blood Pressure Lowering and Cardiac Drugs Accupril quinapril Accuretic quinapril/HCTZ Aldactazide spironolactone/HCTZ Aldactone spironolactone Aldoril methyldopa/HCTZ Bumex bumetanide Calan verapamil Capoten captopril Capozide captopril/HCTZ Cardene, nicardipine Cardene SR Cardizem CD, Tiazac diltiazem ER Catapres clonidine HCL Coreg, Coreg CR, labetalol HCL Trandate Corgard nadolol nadolol/bendroflumet Corzide hiazide Covera-HS, verapamil ER Verelan PM Demadex torsemide Dyazide, Maxide triamterene/HCTZ DynaCirc, isradipine DynaCirc CR Enduron methyclothiazide Tier 2 or 3 Copay Incentive Copay Antihypertensives – Blood Pressure Lowering and Cardiac Drugs CONTINUED hydrochlorothiazide Hydrodiuril (HCTZ) Hygorton, Thalitone chlorthalidone Inderal propranolol HCL Inderide propranolol HCTZ Lasix furosemide Loniten minoxidil Lopressor metoprolol tartrate Lotensin benazepril Lotensin HCT benazepril/HCTZ amlodipine/benazepril Lotrel Lozol indapamide Mavik trandolapril Moduretic amiloride/HCTZ Monopril fosinopril Monopril HCT fosinopril/HCTZ Mykrox metolazone Lopressor HCT metoprolol/HCTZ Norvasc amlodipine Plendil felodipine ER Prinzide, Zestoretic lisinopril/HCTZ Procardia XL, Adalat CC nifedipine ER Sectral acebutolol HCL Tenex guanfacine HCL atenolol/chlorthalidone Tenoretic Tenormin atenolol Toprol XL metoprolol ER Univasc moexipril HCL Vaseretic enalapril/HCTZ Vasotec enalapril Visken pindolol Zebeta bisoprolol Zestril, Prinivil lisinopril Ziac bisoprolol/HCTZ
Aceon, Altace, Atacand HCT, Avalide, Avapro, Benicar, Benicar HCT, Cozaar, Diovan, Diovan HCT, Hyzaar, Inderal LA, Innopran, Micardis, Tarka, Teveten
Tier 2 or 3 Copay Incentive Copay Antivirals Zovirax acyclovir Famvir, Valtrex one of the above Endocrine/Thyroid Cytomel, Levothroid. Levoxyl, Nature-Thriod, Levothyroxine, Synthroid, Thyrolar, Levothyrozine Thyro-Tabs, Tirosint, Sodium Unithroid, Westhroid Gastric Acid Agents Pepcid famotidine Prilosec omeprazole Protonix pantoprazole Tagamet cimetidine Zantac ranitidine Aciphex, Nexium, one of the above Prevacid Hormone Replacement Therapy Estrace estradiol Ogen, Ortho-Est estropipate Cenestin, Premarin one of the above Hyperlipidemics – Cholesterol Lowering Drugs Antara, Lipofen, fenofibrate Lofibra, Triglide, Tricor Colestitabs, Colestid colestipol Lopid gemfibrozil Mevacor lovastatin Pravachol pravastatin Questran, Questran cholestyramine Light, Prevalite Zocor simvastatin
Altocor, Altoprev, Crestor, Lescol, Lipitor, Vytorin
one of the above
one of the above
Anti-inflammatories (NSAIDs) Lodine etodolac Motrin ibuprofen Naprosyn naproxen Relafen nabumetone Voltaren diclofenac Arthrotec, Celebrex, one of the above Mobic
Men's Health Cardura doxazosin Hytrin terazosin Minipress prazosin Cardura XL, Flomax, Use one of the Uroxatral above Urinary Agents Ditropan, Ditropan XL, oxybutynin Oxytrol Detrol, Detrol LA, one of the above Sanctura, Vesicare
Please refer to your pharmacy Summary of Benefits in your benefit handbook for more details on your pharmacy benefits and how to use your pharmacy program. This list is subject to changes as new drugs constantly enter the market.
Incentive Drug List 0708 Updated July 2008