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2009 BEHP Thrptc Clss Full Formulary_Rvsd 040109

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2009 BEHP Thrptc Clss Full Formulary_Rvsd 040109 Powered By Docstoc
					                                                    2009 Beaumont Employee Health Plan Thrptc Clss Formulary
                                                                                               Benefit designs may vary and formulary changes can occur at any time


      Tier                                                                                                                      Generic
                                             generic drug name - BRAND DRUG NAME                                                                                Preferred Alternatives / Comments
 1   2 3 4 5                                                                                                                    Status

 If the word 'generic' appears in the Generic Status column, that indicates that a generic equivalent is available for the listed Brand Drug Name. The cost of that generic will be indicated, for Classic members, by the Tier
listed to the left. The Brand Name drug will appear on Tier 4. If the member or their physician requests the Brand Name of a drug which has a generic equivalnet available, a DAW Penalty (the cost of the generic copay,
                            plus the difference in cost between the brand and the generic) will apply. This penalty will NOT apply toward Choice and HSA deductibles or out-of-pocket maximums.

                                                                                                     ANESTHETICS
TOPICAL ANESTHETICS
      3                                                  lidocaine – LIDODERM
         4                                     lidocaine/pilocaine – EMLA
                                                                                                   ANTI-INFECTIVES
PENICILLINS
 1                                                      amoxicillin    –   AMOXIL                                               generic
 1                                                       ampicillin    –                                                        generic
 1                                                       cloxacillin   –                                                        generic
 1                                         penicillin v potassium      –                                                        generic
    2                                                  dicloxacillin   –                                                        generic
    2                                      penicillin g potassium      –                                                        generic
    2                                     amoxicillin/clavulanate      –   AUGMENTIN TABLETS                                    generic
    2                                     amoxicillin/clavulanate      –   AUGMENTIN ES                                         generic
    2                                     amoxicillin/clavulanate      –   AUGMENTIN SUSPENSION                                             Some strengths available as generic
    2                                     amoxicillin/clavulanate      –   AUGMENTIN XR
CEPHALOSPORINS
 1                                                    cephalexin       –   KEFLEX                                               generic
    2                                                    cefaclor      –   CECLOR                                               generic
    2                                                    cefaclor      –   CECLOR CD                                            generic
    2                                           cefuroxime axetil      –   CEFTIN TABLETS/ SUSP                                 generic
    2                                                    cefprozil     –   CEFZIL                                               generic
    2                                                   cefadroxil     –   DURICEF                                              generic
    2                                                   cefadroxil     –   DURICEF SUSPENSION 125mg                             generic
    2                                                     cefdinir     –   OMNICEF, OMNICEF OS                                  generic
    2                                       cefpodoxime proxetil       –   VANTIN SUSPENSION                                    generic
    2                                       cefpodoxime proxetil       –   VANTIN TABLETS                                       generic
          4                                            ceftibuten      –   CEDAX                                                            Generic AUGMENTIN, Generic cephs, Generic OMNICEF
          4                                            loracarbef      –   LORABID                                                          Generic AUGMENTIN, Generic cephs, Generic OMNICEF
          4                                              cefixime      –   SUPRAX                                                           Generic AUGMENTIN, Generic cephs, Generic OMNICEF
          4                                           cephradine       –   VELOSEF                                                          Generic AUGMENTIN, Generic cephs, Generic OMNICEF
CLINDAMYCINS
    2                                            clindamycin hcl – CLEOCIN                                                      generic
       3                                   clindamycin palmitate – CLEOCIN PEDIATRIC
MACROLIDES
 1                                 erythromycin ethylsuccinate         –   E.E.S                                                generic
 1                                          erythromycin base          –   E-MYCIN                                              generic
 1                                 erythromycin ethylsuccinate         –   ERYPED                                               generic Some strengths available as generic
 1                                       erythromycin stearate         –                                                        generic
    2                                            clarithromycin        –   BIAXIN TABLETS                                       generic
    2                                             azithromycin         –   ZITHROMAX                                            generic
                                                                                                                                        Generic erythromycins, Generic BIAXIN tablets, Generic
             4                                      clarithromycin – BIAXIN SUSPENSION
                                                                                                                                        ZITHROMAX
                                                                                                                                        Generic erythromycins, Generic BIAXIN tablets, Generic
             4                                      clarithromycin – BIAXIN XL
                                                                                                                                        ZITHROMAX
                                                                                                                                        Generic erythromycins, Generic BIAXIN tablets, Generic
             4                                        dirithromycin – DYNABAC
                                                                                                                                        ZITHROMAX
                                                                                                                                        Generic erythromycins, Generic BIAXIN tablets, Generic
             4                                 erythromycin base – ERY-TAB
                                                                                                                                        ZITHROMAX
                                                                                                                                        Generic erythromycins, Generic BIAXIN tablets, Generic
             4                                       erythromycin – PCE
                                                                                                                                        ZITHROMAX
                                                                                                                                        Generic erythromycins, Generic BIAXIN tablets, Generic
             4                                        azithromycin – ZMAX
                                                                                                                                        ZITHROMAX
KETOLIDES
        4                            telithromycin                     – KETEK
SULFONAMIDES & COMBINATIONS
 1                sulfamethoxazole/trimethoprim                        –   BACTRIM/DS, SEPTRA/DS                                generic
    2                         sulfisoxazole acetyl                     –   GANTRISIN                                            generic
    2                  erythromycin/sulfisoxazole                      –   PEDIAZOLE                                            generic
      3                       sulfisoxazole acetyl                     –   GANTRISIN PEDIATRIC
TETRACYCLINES
 1                                                     tetracycline – ACHROMYCIN, SUMYCIN CAPSULES                              generic
 1                                           doxycycline hyclate       –   VIBRA-TABS, VIBRAMYCIN                               generic
     2                                               minocycline       –   DYNACIN                                              generic
     2                                               minocycline       –   DYNACIN CAPSULES, MINOCIN                            generic
         3                                           tetracycline      –   SUMYCIN TABLET/SUSPENSION
         4                                 doxycycline (rosacea)       –   ORACEA
         4                                           minocycline       –   SOLODYN
URINARY ANTI-INFECTIVES
 1                     nitrofurantoin/nitrofuran mac                   –   MACROBID                                             generic
 1                       nitrofurantoin macrocrystal                   –   MACRODANTIN                                          generic
 1                                      trimethoprim                   –   PROLOPRIM, TRIMPEX                                   generic
      3                                nitrofurantoin                  –   FURADANTIN SUSPENSION




         2009 BEHP Custom Formulary                                                                        1 of 25
                                                    2009 Beaumont Employee Health Plan Thrptc Clss Formulary
                                                                                               Benefit designs may vary and formulary changes can occur at any time


      Tier                                                                                                                      Generic
                                             generic drug name - BRAND DRUG NAME                                                                                Preferred Alternatives / Comments
 1   2 3 4 5                                                                                                                    Status

 If the word 'generic' appears in the Generic Status column, that indicates that a generic equivalent is available for the listed Brand Drug Name. The cost of that generic will be indicated, for Classic members, by the Tier
listed to the left. The Brand Name drug will appear on Tier 4. If the member or their physician requests the Brand Name of a drug which has a generic equivalnet available, a DAW Penalty (the cost of the generic copay,
                            plus the difference in cost between the brand and the generic) will apply. This penalty will NOT apply toward Choice and HSA deductibles or out-of-pocket maximums.

URINARY ANTI-INFECTIVES (continued)
         4                                    fosfomycin               – MONUROL
         4                                trimethoprim                 – PRIMSOL
QUINOLONES
 1                                        ciprofloxacin                –   CIPRO                                                generic
 1                                        ciprofloxacin                –   CIPRO XR                                             generic
    2                                           ofloxacin              –   FLOXIN                                               generic
      3                                   moxifloxacin                 –   AVELOX
      3                                     levofloxacin               –   LEVAQUIN                                                         Generic CIPRO, Generic FLOXIN, AVELOX
         4                                gemifloxacin                 –   FACTIVE                                                          Generic CIPRO, Generic FLOXIN, AVELOX
         4                                    norfloxacin              –   NOROXIN                                                          Generic CIPRO, Generic FLOXIN, AVELOX
         4                           ciprofloxacin hcl                 –   PROQUIN XR                                                       Generic CIPRO, Generic FLOXIN, AVELOX
TOPICAL ANTIBACTERIAL DRUGS
 1                                            gentamicin               –   GARAMYCIN                                            generic
 1                                 silver sulfadiazine                 –   SILVADENE                                            generic
    2                                          mupirocin               –   BACTROBAN                                            generic
    2                                          bacitracin              –                                                        generic
    2                                    chlorhexidine                 –                                                        generic
      3                            mafenide acetate                    –   SULFAMYLON
         4                                  retapamulin                –   ALTABAX
ORAL ANTIFUNGAL DRUGS
 1                                           fluconazole               –   DIFLUCAN                                             generic
 1                                            terbinafine              –   LAMISIL                                              generic
 1                                                nystatin             –   NILSTAT, MYCOSTATIN                                  generic
    2             griseofulvin microsize suspension                    –   GRIFULVIN V SUSPENSION                               generic
    2                                      clotrimazole                –   MYCELEX TROCHE                                       generic
    2                                   ketoconazole                   –   NIZORAL TABLETS                                      generic
    2                                      itraconazole                –   SPORANOX                                             generic
      3                griseofulvin microsize tablets                  –   GRIS-PEG
         4                              posaconazole                   –   NOXAFIL                                                          Generic SPORANOX, LAMISIL
         4                                      ciclopirox             –   PENLAC                                                           Generic NIZORAL
         4                                 itraconazole                –   SPORANOX SOLUTION                                                Generic SPORANOX, LAMISIL
VAGINAL ANTIFUNGALS
 1                                                nystatin             –                                                        generic
    2                                       terconazole                – TERAZOL 3 SUPP                                         generic
    2                                      clotrimazole                –                                                        generic
    2                             miconazole nitrate                   –                                                        generic
    2                                       terconazole                – TERAZOL 3 and 7 CREAM                                  generic
      3                           miconazole nitrate                   – MONISTAT DUAL-PAK
TOPICAL ANTIFUNGAL DRUGS
                                                                           LOPROX LOTION, SUSPENSION,
     2                                         ciclopirox olamine –                                                             generic
                                                                           CREAM
                      clotrimazole, betamethasone
    2                                                   – LOTRISONE                                                             generic
                                        dipropionate
    2                                    clotrimazole – MYCELEX                                                                 generic
    2                                  ketoconazole – NIZORAL CREAM, SHAMPOO                                                    generic
    2                              econazole nitrate – SPECTAZOLE                                                               generic
         4                            sertaconazole – ERTACZO                                                                               OTC LAMISIL, Generic NIZORAL, Generic SPECTAZOLE
         4                     sulfoconazole nitrate – EXELDERM                                                                             OTC LAMISIL, Generic NIZORAL, Generic SPECTAZOLE
         4                             ketoconazole – EXTINA                                                                                OTC LAMISIL, Generic NIZORAL, Generic SPECTAZOLE
         4                        ciclopirox olamine – LOPROX GEL, SHAMPOO                                                                  OTC LAMISIL, Generic NIZORAL, Generic SPECTAZOLE
         4                                 butenafine – MENTAX                                                                              OTC LAMISIL, Generic NIZORAL, Generic SPECTAZOLE
         4                       oxiconazole nitrate – OXISTAT                                                                              OTC LAMISIL, Generic NIZORAL, Generic SPECTAZOLE
         4                             ketoconazole – XOLEGEL                                                                               OTC LAMISIL, Generic NIZORAL, Generic SPECTAZOLE
TOPICAL ANTIFUNGAL-CORTICOSTEROID COMBINATIONS
 1                                             nystatin – MYCOSTATIN                                                            generic
 1                            nystatin/triamcinolone – MYCOLOG                                                                  generic
    2                                    clotrimazole – LOTRIMIN, MYCELEX                                                       generic
    2                            miconazole nitrate – MONISTAT-DERM                                                             generic
    2                                  ketoconazole –                                                                           generic
    2                neo/gramicid/nystatin/triamcin –                                                                           generic
         4           undecylenic acid/chloroxylenol – GORDOCHOM
ORAL ANTIVIRAL DRUGS
 1                                            acyclovir – ZOVIRAX                                                               generic
    2                                      ganciclovir – CYTOVENE                                                               generic
    2                                      famciclovir – FAMVIR                                                                 generic
    2                                    rimantadine – FLUMADINE                                                                generic
    2                                      zidovudine – RETROVIR                                                                generic
    2                                    amantadine – SYMMETREL                                                                 generic
    2                                     didanosine – VIDEX EC                                                                 generic
      3                                   amprenavir – AGENERASE
      3                                      tipranavir – APTIVUS
      3            efavirenz-emtricitabine-tenofovir – ATRIPLA
      3                      lamivudine/zidovudine – COMBIVIR




         2009 BEHP Custom Formulary                                                                        2 of 25
                                                    2009 Beaumont Employee Health Plan Thrptc Clss Formulary
                                                                                               Benefit designs may vary and formulary changes can occur at any time


      Tier                                                                                                                      Generic
                                             generic drug name - BRAND DRUG NAME                                                                                Preferred Alternatives / Comments
 1   2 3 4 5                                                                                                                    Status

 If the word 'generic' appears in the Generic Status column, that indicates that a generic equivalent is available for the listed Brand Drug Name. The cost of that generic will be indicated, for Classic members, by the Tier
listed to the left. The Brand Name drug will appear on Tier 4. If the member or their physician requests the Brand Name of a drug which has a generic equivalnet available, a DAW Penalty (the cost of the generic copay,
                            plus the difference in cost between the brand and the generic) will apply. This penalty will NOT apply toward Choice and HSA deductibles or out-of-pocket maximums.

ORAL ANTIVIRAL DRUGS (continued)
       3                                     indinavir                 –   CRIXIVAN
       3                                emtricitabine                  –   EMTRIVA
       3                                  lamivudine                   –   EPIVIR/HBV
       3                       abacavir/lamivudine                     –   EPZICOM
       3                                   saquinavir                  –   FORTOVASE
       3                                  zalcitabine                  –   HIVID
       3                       saquinavir mesylate                     –   INVIRASE
       3                                    etravirine                 –   INTELENCE
       3                                   raltegravir                 –   ISENTRESS
       3                        lopinavir - ritonavor                  –   KALETRA
       3                              fosamprenavir                    –   LEXIVA
       3                                      ritonavir                –   NORVIR
       3                                    darunavir                  –   PREZISTA
       3                      delavirdine mesylate                     –   RESCRIPTOR
       3                                  zidovudine                   –   RETROVIR 100mg tablet
       3                                   atazanavir                  –   REYATAZ
       3                                   maroviroc                   –   SELZENTRY
       3                                    efavirenz                  –   SUSTIVA
       3                                  oseltamivir                  –   TAMIFLU
       3            zidovudine/lamivudine/abacavir                     –   TRIZIVIR
       3                     emtricitabine/tenofovir                   –   TRUVADA
       3                                  telbivudine                  –   TYZEKA
       3                                 valacyclovir                  –   VALTREX
       3                                  didanosine                   –   VIDEX/EC 125mg
       3                         nelfinavir mesylate                   –   VIRACEPT
       3                                   nevirapine                  –   VIRAMUNE
       3                                     tenofovir                 –   VIREAD
       3                                    stavudine                  –   ZERIT
       3                            abacavir sulfate                   –   ZIAGEN
         4                                  zanamivir                  –   RELENZA
         4                             valganciclovir                  –   VALCYTE
TOPICAL ANTIVIRAL DRUGS
       3                                  penciclovir                  – DENAVIR
       3                                     acyclovir                 – ZOVIRAX OINTMENT
INJECTABLE ANTIVIRAL DRUGS
                                                                                                                                            Systematic lookback for antiretrovirals in last 6 months; reject for
                 5                                      enfuvirtide – FUZEON
                                                                                                                                            quantity > 1 kit per month
ANTI-INFECTIVES SPECIALIZED INDICATIONS
 1                                     metronidazole                   –   FLAGYL                                               generic
 1                                              isoniazid              –   IZONID, NIAZID, NYDRAZID                             generic
    2                         chloroquine phosphate                    –   ARALEN                                               generic
    2                                         bacitracin               –   BACITRACIN                                           generic
    2                                    paromomycin                   –   HUMATIN                                              generic
    2                                       mefloquine                 –   LARIAM                                               generic
    2                                      ethambutol                  –   MYAMBUTOL                                            generic
    2                            hydroxychloroquine                    –   PLAQUENIL                                            generic
    2                                            rifampin              –   RIFADIN, RIMACTANE                                   generic
    2                                    mebendazole                   –   VERMOX                                               generic
    2                                         neomycin                 –                                                        generic
    2                               piperazine citrate                 –                                                        generic
    2                                       primaquine                 –                                                        generic
    2                                    pyrazinamide                  –                                                        generic
    2                                     voriconazole                 –   VFEND
       3                                  albendazole                  –   ALBENZA
       3                                  nitazoxanide                 –   ALINIA
       3                                  praziquantel                 –   BILTRICIDE
       3                                        dapsone                –   DAPSONE
       3                               pyrimethamine                   –   DARAPRIM
       3                pyrimethamine/sulfadoxine                      –   FANSIDAR
       3                                  furazolidone                 –   FUROXONE
       3                                   halofantrine                –   HALFAN
       3                                   clofazimine                 –   LAMPRENE
       3                                   atovaquone                  –   MEPRON
       3                                thiabendazole                  –   MINTEZOL
       3                                         rifabutin             –   MYCOBUTIN
       3                                  pentamidine                  –   NEBUPENT
       3                     isoniazid/pyridoxine hcl                  –   NIAZID-B6
       3                          aminosalicylic acid                  –   PASER
       3                                     rifapentine               –   PRIFTIN
       3                      primaquine phosphate                     –   PRIMAQUINE
       3                           rifampin/isoniazid                  –   RIFAMATE
       3                 rifampin/inh/pyrazinamide                     –   RIFATER




         2009 BEHP Custom Formulary                                                                        3 of 25
                                                    2009 Beaumont Employee Health Plan Thrptc Clss Formulary
                                                                                               Benefit designs may vary and formulary changes can occur at any time


      Tier                                                                                                                      Generic
                                             generic drug name - BRAND DRUG NAME                                                                                Preferred Alternatives / Comments
 1   2 3 4 5                                                                                                                    Status

 If the word 'generic' appears in the Generic Status column, that indicates that a generic equivalent is available for the listed Brand Drug Name. The cost of that generic will be indicated, for Classic members, by the Tier
listed to the left. The Brand Name drug will appear on Tier 4. If the member or their physician requests the Brand Name of a drug which has a generic equivalnet available, a DAW Penalty (the cost of the generic copay,
                            plus the difference in cost between the brand and the generic) will apply. This penalty will NOT apply toward Choice and HSA deductibles or out-of-pocket maximums.

ANTI-INFECTIVES SPECIALIZED INDICATIONS (continued)
       3                                    cycloserine – SEROMYCIN
       3                                      ivermectin – STROMECTOL
       3                                  ethionamide – TRECATOR-SC
       3                                  vancomycin – VANCOCIN
       3                          diiodohydroxyquin – YODOXIN
       3                                          linezolid – ZYVOX
         4                             metronidazole – FLAGYL ER                                       Generic FLAGYL
         4                    atovaquone-progaunil – MALARONE
         4                                      quinoline – QUALAQUIN
         4                                       rifaximin – XIFAXAN                                   Generic CIPRO
            5                               tobramycin – TOBI                                          For nebulization; reject for Max Quantity > 380/ month
                                                                 ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS
 1                                            leucovorin – LEUCOVORIN                          generic
 1                                             megestrol – MEGACE                              generic
    2                                        anagrelide – AGRYLIN                              generic
    2                            cyclophosphamide – CYTOXAN                                    generic
    2                                           flutamide – EULEXIN                            generic
    2                                     hydroxyurea – HYDREA                                 generic
    2                                     azathioprine – IMURAN                                generic
    2                                    cyclosporine – NEORAL, SANDIMMUNE                     generic
    2                                          tamoxifen – NOLVADEX                            generic
    2                                mercaptopurine – PURINETHOL                               generic
    2                                   methotrexate – RHEUMATREX                              generic
    2                                          etoposide – VEPESID                             generic
    2                                             tretinoin – VESANOID                         generic
    2                                      thioguanine –                                       generic
       3                                        paclitaxel – ABRAXANE
       3                                     melphalan – ALKERAN
       3                                   anastrozole – ARIMIDEX
       3                                  exemestane – AROMASIN
       3                                  azathioprine – AZASAN
       3                                 bicalutamide – CASODEX
       3                                       lomustine – CEENU
       3                    mycophenolate mofetil – CELLCEPT
       3                                    clofarabine – CLOLAR
       3            estramustine phosphate sodium – EMCYT
       3                                     toremifene – FARESTON
       3                                         letrozole – FEMARA
       3                                           gefitinib – IRESSA
       3                                 chlorambucil – LEUKERAN
       3                                         mitotane – LYSODREN
       3                                procarbazine – MATULANE
       3                                            mesna – MESNEX
       3                                         busulfan – MYLERAN
       3                                      nilutamide – NILANDRON
       3                                      tacrolimus – PROGRAF
       3                                        sirolimus – RAPAMUNE
       3                                    bexarotene – TARGRETIN
       3                                          erlotinib – TASIGNA
       3                                  testolactone – TESLAC
       3                                methotrexate – TREXALL
         4                  mycophenolate sodium – MYFORTIC
         4                                     tamoxifen – SOLTAMOX                                    Generic NOLVADEX
            5                                      imatinib – GLEEVEC
            5                               altretamine – HEXALEN
            5                                   sorafenib – NEXAVAR
            5                            lenalidomide – REVLIMID
            5                                   dasatinib – SPRYCEL
            5                        sunitinib malate – SUTENT
            5                                     erlotinib – TARCEVA
            5                          temozolomide – TEMODAR
            5                              thalidomide – THALOMID
                                                                                                       Systematic lookback for GPI; reject for Max Quantity > 6 vials per
            5                         thyrotropin alfa         THYROGEN
                                                                                                       month
            5                                    lapatinib – TYKERB                                    Limited distribution drug - Medmark/Walgreens Specialty
            5                            capecitabine – XELODA
            5                                  vorinostat – ZOLINZA
DRUGS TO TREAT PROSTATE CANCER
                 5                             leuprolide acetate – ELIGARD                                                                 Systematic lookback for GPI; reject for quantity > 1 vial per month
                 5                                          abarelix – PLENAXIS                                                             Limited distribution drug - 1-800-PLENAXIS




         2009 BEHP Custom Formulary                                                                        4 of 25
                                                    2009 Beaumont Employee Health Plan Thrptc Clss Formulary
                                                                                               Benefit designs may vary and formulary changes can occur at any time


      Tier                                                                                                                      Generic
                                             generic drug name - BRAND DRUG NAME                                                                                Preferred Alternatives / Comments
 1   2 3 4 5                                                                                                                    Status

 If the word 'generic' appears in the Generic Status column, that indicates that a generic equivalent is available for the listed Brand Drug Name. The cost of that generic will be indicated, for Classic members, by the Tier
listed to the left. The Brand Name drug will appear on Tier 4. If the member or their physician requests the Brand Name of a drug which has a generic equivalnet available, a DAW Penalty (the cost of the generic copay,
                            plus the difference in cost between the brand and the generic) will apply. This penalty will NOT apply toward Choice and HSA deductibles or out-of-pocket maximums.

DRUGS TO TREAT PROSTATE CANCER (continued)
                 5                            triptorelin pamoate – TRELSTAR DEPOT / LA                                                     Systematic lookback for GPI; reject for quantity > 1 vial per month

                 5                                histrelin acetate – VANTAS                                                                Systematic lookback for GPI; reject for quantity > 1 vial per month

                 5                             leuprolide acetate – VIADUR                                                                  Systematic lookback for GPI; reject for quantity > 1 vial per month

                 5                                        goserelin – ZOLADEX                                                               Systematic lookback for GPI; reject for quantity > 1 vial per month
                                                                                        CARDIOVASCULAR MEDICATIONS
CARDIAC GLYCOSIDES
 1                                                          digoxin – LANOXIN                                                   generic
 1                                                          digoxin – LANOXIN
      3                                                     digoxin – LANOXICAPS
CALCIUM ANTAGONISTS
 1                                                  amlodipine         –   NORVASC                                              generic
 1                                                   verapamil         –   CALAN/SR, ISOPTIN/SR                                 generic
 1                                                    diltiazem        –   CARDIZEM                                             generic
    2                              nifedipine extended-release         –   ADALAT CC                                            generic
    2                                               nicardipine        –   CARDENE                                              generic
    2                               diltiazem extended release         –   CARDIZEM/SR/CD, DILACOR XR                           generic
    2                                                isradipine        –   DYNACIRC                                             generic
    2                                               nimodipine         –   NIMOTOP                                              generic
    2                                                felodipine        –   PLENDIL                                              generic
    2                              nifedipine extended-release         –   PROCARDIA XL                                         generic
    2                                                 diltiazem        –   TIAZAC                                               generic Use Taztia XT
    2                              verapamil extended-release          –   VERELAN PM                                           generic
    2                                                nifedipine        –                                                        generic
      3                                               diltiazem        –   CARDIZEM LA
      3                                             nisoldipine        –   SULAR
                                                                                                                                            Generic diltiazem xr, Generic verapamil xr, CARDIZEM LA, Generic
             4                    nicardipine extended-release – CARDENE SR
                                                                                                                                            NORVASC, Generic VERELAN PM
                                                                                                                                            Generic diltiazem xr, Generic verapamil xr, CARDIZEM LA, Generic
             4                     verapamil extended-release – COVERA-HS
                                                                                                                                            NORVASC, Generic VERELAN PM
                                                                                                                                            Generic diltiazem xr, Generic verapamil xr, CARDIZEM LA, Generic
             4                                           isradipine – DYNACIRC, CR
                                                                                                                                            NORVASC, Generic VERELAN PM
DIURETICS
 1                               spironolactone – ALDACTONE                                                                     generic
 1                                  bumetanide – BUMEX                                                                          generic
 1                              hctz/triamterene – DYAZIDE, MAXZIDE                                                             generic
 1                          hydrochlorothiazide – ESIDRIX, HYDRODIURIL                                                          generic
 1                                chlorthalidone – HYGROTON                                                                     generic
 1                                    furosemide – LASIX                                                                        generic
 1                                   indapamide – LOZOL                                                                         generic
 1                                      amiloride – MIDAMOR                                                                     generic
 1                                hctz/amiloride – MODURETIC                                                                    generic
    2                       spironolactone/hctz – ALDACTAZIDE                                                                   generic
    2                          methyclothiazide – AQUATENSEN, ENDURON                                                           generic
    2                                  torsemide – DEMADEX                                                                      generic
    2                             chlorothiazide – DIURIL                                                                       generic
    2                                 eplerenone – INSPRA                                                                       generic
    2                                metolazone – ZAROXOLYN                                                                     generic
BETA-ADRENERGIC ANTAGONIST DRUGS & BETA-BLOCKER / DIURETIC COMBINATIONS
 1                                      carvedilol – COREG                                                                      generic
 1                                         nadolol – CORGARD                                                                    generic
 1                                    propranolol – INDERAL                                                                     generic
 1                           metoprolol tartrate – LOPRESSOR                                                                    generic
 1                                       labetalol – NORMODYNE, TRANDATE                                                        generic
 1                                        atenolol – TENORMIN                                                                   generic
 1                       chlorthalidone/atenolol – TENORETIC                                                                    generic
 1                                        pindolol – VISKEN                                                                     generic
 1                               hctz/ bisoprolol – ZIAC                                                                        generic
    2                                       timolol – BLOCADREN                                                                 generic
    2               bendroflumethiazide/nadolol – CORZIDE                                                                       generic
    2                  propranolol extended rel – INDERAL LA                                                                    generic
    2                           hctz/propranolol – INDERIDE                                                                     generic
    2                            metoprolol/hctz – LOPRESSOR HCT                                                                generic
    2                                  acebutolol – SECTRAL                                                                     generic
    2                      metoprolol succinate – TOPROL XL                                                                     generic
    2                                   bisoprolol – ZEBETA                                                                     generic
    2                                    betaxolol – KERLONE                                                                    generic
       3                                carvedilol – COREG CR




         2009 BEHP Custom Formulary                                                                        5 of 25
                                                    2009 Beaumont Employee Health Plan Thrptc Clss Formulary
                                                                                               Benefit designs may vary and formulary changes can occur at any time


      Tier                                                                                                                      Generic
                                             generic drug name - BRAND DRUG NAME                                                                                Preferred Alternatives / Comments
 1   2 3 4 5                                                                                                                    Status

 If the word 'generic' appears in the Generic Status column, that indicates that a generic equivalent is available for the listed Brand Drug Name. The cost of that generic will be indicated, for Classic members, by the Tier
listed to the left. The Brand Name drug will appear on Tier 4. If the member or their physician requests the Brand Name of a drug which has a generic equivalnet available, a DAW Penalty (the cost of the generic copay,
                            plus the difference in cost between the brand and the generic) will apply. This penalty will NOT apply toward Choice and HSA deductibles or out-of-pocket maximums.

BETA-ADRENERGIC ANTAGONIST DRUGS & BETA-BLOCKER / DIURETIC COMBINATIONS (continued)
                                                                                                                                            Generic CORGARD, Generic TENORMIN, Generic TOPROL,
             4                                            nebivolol – BYSTOLIC
                                                                                                                                            Generic ZEBETA, Generic TOPROL XL
                                                                                                                                            Generic CORGARD, Generic TENORMIN, Generic TOPROL,
             4                                         propranolol – INNOPRAN XL
                                                                                                                                            Generic ZEBETA, Generic TOPROL XL
                                                                                                                                            Generic CORGARD, Generic TENORMIN, Generic TOPROL,
             4                                          penbutolol – LEVATOL
                                                                                                                                            Generic ZEBETA, Generic TOPROL XL
ACE INHIBITORS & ACE / DIURETIC COMBINATIONS
 1                                      benazepril                     –   LOTENSIN                                             generic
 1                                         captopril                   –   CAPOTEN                                              generic
 1                                         lisinopril                  –   PRINIVIL                                             generic
 1                                  lisinopril/hctz                    –   PRINZIDE                                             generic
 1                                  enalapril/hctz                     –   VASERETIC                                            generic
 1                                         enalapril                   –   VASOTEC                                              generic
 1                                  lisinopril/hctz                    –   ZESTORETIC                                           generic
 1                                         lisinopril                  –   ZESTRIL                                              generic
    2                               quinapril/hctz                     –   ACCURETIC                                            generic Use QUINARETIC
    2                             benazepril/hctz                      –   LOTENSIN HCT                                         generic
    2                                  trandolapril                    –   MAVIK                                                generic
    2                                     fosinopril                   –   MONOPRIL                                             generic
    2                              moexipril/hctz                      –   UNIRETIC                                             generic
    2                                      quinapril                   –   ACCUPRIL                                             generic
    2                                       ramipril                   –   ALTACE Capsules                                      generic
    2                               captopril/hctz                     –   CAPOZIDE                                             generic
    2                              fosinopril/hctz                     –   MONOPRIL HCT                                         generic
    2                                     moexipril                    –   UNIVASC                                              generic
          4                                 ramipril                   –   ALTACE Tablets                                               Generic ALTACE
                                                                                                                                        Generic ACCUPRIL, Generic ALTACE, Generic CAPOTEN,
             4                                          perindopril – ACEON                                                             Generic LOTENSIN, Generic MONOPRIL, Generic PRINIVIL,
                                                                                                                                        Generic UNIVASC, Generic VASOTEC, Generic ZESTRIL
ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARBS) & ARB / DIURETIC COMBINATIONS
      3                            olmesartan – BENICAR
      3                       olmesartan/hctz – BENICAR HCT
      3                               losartan – COZAAR
      3                              valsartan – DIOVAN
      3                         valsartan/hctz – DIOVAN HCT
                                                                                                                                            Generic ACCUPRIL, Generic ALTACE, Generic CAPOTEN,
                                                                                                                                            Generic LOTENSIN, Generic MONOPRIL, Generic PRINIVIL,
         3                                            candesartan – ATACAND
                                                                                                                                            Generic UNIVASC, Generic VASOTEC, Generic ZESTRIL,
                                                                                                                                            ALTACE, BENICAR, DIOVAN
                                                                                                                                            Generic ACCURETIC, Generic CAPOZIDE, Generic LOTENSIN
                                                                                                                                            HCT, Generic MONOPRIL HCT, Generic PRINZIDE, Generic
         3                                      candesartan/hctz – ATACAND HCT
                                                                                                                                            VASERETIC, Generic ZESTORETIC, BENICAR HCT, DIOVAN
                                                                                                                                            HCT
                                                                                                                                            Generic ACCURETIC, Generic CAPOZIDE, Generic LOTENSIN
                                                                                                                                            HCT, Generic MONOPRIL HCT, Generic PRINZIDE, Generic
         3                                         irbesartan/hctz – AVALIDE
                                                                                                                                            VASERETIC, Generic ZESTORETIC, BENICAR HCT, DIOVAN
                                                                                                                                            HCT
                                                                                                                                            Generic ACCUPRIL, Generic ALTACE, Generic CAPOTEN,
                                                                                                                                            Generic LOTENSIN, Generic MONOPRIL, Generic PRINIVIL,
         3                                               irbesartan – AVAPRO
                                                                                                                                            Generic UNIVASC, Generic VASOTEC, Generic ZESTRIL,
                                                                                                                                            ALTACE, BENICAR, DIOVAN
                                                                                                                                            Generic ACCURETIC, Generic CAPOZIDE, Generic LOTENSIN
                                                                                                                                            HCT, Generic MONOPRIL HCT, Generic PRINZIDE, Generic
         3                                            losartan/hctz – HYZAAR
                                                                                                                                            VASERETIC, Generic ZESTORETIC, BENICAR HCT, DIOVAN
                                                                                                                                            HCT
                                                                                                                                            Generic ACCUPRIL, Generic ALTACE, Generic CAPOTEN,
                                                                                                                                            Generic LOTENSIN, Generic LOTREL, Generic MONOPRIL,
             4                amlodipine besylate/olmesartan – AZOR
                                                                                                                                            Generic NORVASC, Generic PRINIVIL, Generic UNIVASC, Generic
                                                                                                                                            VASOTEC, Generic ZESTRIL, ALTACE, BENICAR, DIOVAN

                                                                                                                                            Generic ACCUPRIL, Generic ALTACE, Generic CAPOTEN,
                                                                                                                                            Generic LOTENSIN, Generic MONOPRIL, Generic PRINIVIL,
             4                   amlodipine besylate/valsartan – EXFORGE
                                                                                                                                            Generic UNIVASC, Generic VASOTEC, Generic ZESTRIL, Generic
                                                                                                                                            NORVASC, Generic LOTREL, ALTACE, BENICAR, DIOVAN
                                                                                                                                            Generic ACCUPRIL, Generic ALTACE, Generic CAPOTEN,
                                                                                                                                            Generic LOTENSIN, Generic MONOPRIL, Generic PRINIVIL,
             4                                          telmisartan – MICARDIS
                                                                                                                                            Generic UNIVASC, Generic VASOTEC, Generic ZESTRIL,
                                                                                                                                            ALTACE, BENICAR, DIOVAN




         2009 BEHP Custom Formulary                                                                        6 of 25
                                                    2009 Beaumont Employee Health Plan Thrptc Clss Formulary
                                                                                               Benefit designs may vary and formulary changes can occur at any time


      Tier                                                                                                                      Generic
                                             generic drug name - BRAND DRUG NAME                                                                                Preferred Alternatives / Comments
 1   2 3 4 5                                                                                                                    Status

 If the word 'generic' appears in the Generic Status column, that indicates that a generic equivalent is available for the listed Brand Drug Name. The cost of that generic will be indicated, for Classic members, by the Tier
listed to the left. The Brand Name drug will appear on Tier 4. If the member or their physician requests the Brand Name of a drug which has a generic equivalnet available, a DAW Penalty (the cost of the generic copay,
                            plus the difference in cost between the brand and the generic) will apply. This penalty will NOT apply toward Choice and HSA deductibles or out-of-pocket maximums.

ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARBS) & ARB / DIURETIC COMBINATIONS (continued)
                                                                                                                                            Generic ACCURETIC, Generic CAPOZIDE, Generic LOTENSIN
                                                                                                                                            HCT, Generic MONOPRIL HCT, Generic PRINZIDE, Generic
             4                                    telmisartan/hctz – MICARDIS HCT
                                                                                                                                            VASERETIC, Generic ZESTORETIC, BENICAR HCT, DIOVAN
                                                                                                                                            HCT
                                                                                                                                            Generic ACCUPRIL, Generic CAPOTEN, Generic LOTENSIN,
                                                                                                                                            Generic MONOPRIL, Generic PRINIVIL, Generic UNIVASC,
             4                                          eprosartan – TEVETEN
                                                                                                                                            Generic VASOTEC, Generic ZESTRIL, ALTACE, BENICAR,
                                                                                                                                            BENICAR HCT, DIOVAN, DIOVAN HCT
                                                                                                                                            Generic ACCURETIC, Generic CAPOZIDE, Generic LOTENSIN
                                                                                                                                            HCT, Generic MONOPRIL HCT, Generic PRINZIDE, Generic
             4                                    eprosartan/hctz – TEVETEN HCT
                                                                                                                                            VASERETIC, Generic ZESTORETIC, BENICAR HCT, DIOVAN
                                                                                                                                            HCT
ACE INHIBITOR & CALCIUM CHANNEL BLOCKER COMBINATIONS
    2                benazepril/amlodipine besylate – LOTREL                                                                    generic
          4             enalapril maleate/felodipine – LEXXEL                                                                               Generic LOTREL
          4                   trandolapril/verapamil – TARKA                                                                                Generic LOTREL
RENIN INHIBITORS & COMBINATIONS
          4                                   aliskiren – TEKTURNA
OTHER ANTIHYPERTENSIVES
 1                                       methyldopa – ALDOMET                                                                   generic
 1                                  hydralazine/hctz – APRESAZIDE                                                               generic
 1                                        hydralazine – APRESOLINE                                                              generic
 1                                         doxazosin – CARDURA                                                                  generic
 1                                           clonidine – CATAPRES                                                               generic
 1                                           terazosin – HYTRIN                                                                 generic
 1                                            prazosin – MINIPRESS                                                              generic
 1                                        guanfacine – TENEX                                                                    generic
    2                               methyldopa/hctz – ALDORIL                                                                   generic Some strengths available as generic
    2                   clonidine hcl/chlorthalidone – COMBIPRES                                                                generic
    2                                         minoxidil – LONITEN                                                               generic
    2                                     guanabenz – WYTENSIN                                                                  generic
          4                                  clonidine – CATAPRES TTS                                                                   Generic CATAPRES
DRUGS FOR PHEOCHROMOCYTOMA
       3                         phenoxybenzamine – DIBENZYLINE
VASODILATING DRUGS
 1                          isosorbide mononitrate – IMDUR                                                                      generic
                                                          NITROSTAT, NITRO-BID, NITROL,
 1                                       nitroglycerin –                                                                        generic
                                                          NITRO-DUR
                                                          ISORDIL, SORBITRATE,
    2                            isosorbide dinitrate –                                                                         generic
                                                          DILATRATE-SR
       3                                 nitroglycerin – NITROLINGUAL PUMP SPRAY
       3               ranolazine extended-release – RANEXA
          4                isosorbide dinitrate/hctz – BIDIL                                                                                Generic HYDRALAZINE, Generic ISORDIL
ANTIDYSRHYTHMIC DRUGS
CLASS 1 - MEMBRANE-STABILIZING
       3                                   moricizine – ETHMOZINE
CLASS 1A
    2                                  disopyramide – NORPACE/CR                                                                generic
    2                                  procainamide – PRONESTYL/SR, PROCANBID                                                   generic
    2                            quinidine gluconate – QUINAGLUTE DURA-TAB                                                      generic
    2                            quinidine sulfate er – QUINIDEX                                                                generic
CLASS 1B
    2                                      mexiletine – MEXITIL                                                                 generic
CLASS 1C
 1                                          flecainide – TAMBOCOR                                                               generic
    2                                   propafenone – RYTHMOL                                                                   generic
       3                            propafenone SR – RYTHMOL SR                                                                             Generic RYTHMOL
OTHER ANTIARRHYTHMICS
 1                                              sotalol – BETAPACE/AF                                                           generic
    2                                    amiodarone – CORDARONE                                                                 generic
       3                                     dofetilide – TIKOSYN
ANTILIPIDEMIC DRUGS
 1                                        gemfibrozil – LOPID                                                                   generic
    2                      fenofibrate (micronized) – LOFIBRA                                                                   generic
    2                                       colestipol – COLESTID                                                               generic
    2                      cholestyramine/sucrose – QUESTRAN                                                                    generic
    2                    cholestyramine/aspartame – QUESTRAN LIGHT                                                              generic
       3                    amlodipine/atorvastatin – CADUET
       3                 omega-3-acid ethyl esters – LOVAZA
       3                                         niacin – NIASPAN
       3                 omega-3-acid ethyl esters – OMACOR




         2009 BEHP Custom Formulary                                                                        7 of 25
                                                    2009 Beaumont Employee Health Plan Thrptc Clss Formulary
                                                                                               Benefit designs may vary and formulary changes can occur at any time


      Tier                                                                                                                      Generic
                                             generic drug name - BRAND DRUG NAME                                                                                Preferred Alternatives / Comments
 1   2 3 4 5                                                                                                                    Status

 If the word 'generic' appears in the Generic Status column, that indicates that a generic equivalent is available for the listed Brand Drug Name. The cost of that generic will be indicated, for Classic members, by the Tier
listed to the left. The Brand Name drug will appear on Tier 4. If the member or their physician requests the Brand Name of a drug which has a generic equivalnet available, a DAW Penalty (the cost of the generic copay,
                            plus the difference in cost between the brand and the generic) will apply. This penalty will NOT apply toward Choice and HSA deductibles or out-of-pocket maximums.

ANTILIPIDEMIC DRUGS (continued)
       3                                 fenofibrate –                     TRICOR
       3                               colesevelam –                       WELCHOL
       3                                  ezetimibe –                      ZETIA
          4                fenofibrate (micronized) –                      ANTARA                                                           Generic LOFIBRA, TRICOR, WELCHOL
          4                              fenofibrate –                     LIPOFEN                                                          Generic LOFIBRA, TRICOR, WELCHOL
          4                              fenofibrate –                     TRIGLIDE                                                         Generic LOFIBRA, TRICOR, WELCHOL
HMG-COA REDUCTASE INHIBITORS & COMBINATIONS
 1                                      pravastatin –                      PRAVACHOL                                            generic
 1                                      simvastatin –                      ZOCOR                                                generic
 1                                        lovastatin –                     MEVACOR                                              generic
       3                           lovastatin/niacin –                     ADVICOR
       3                               rosuvastatin –                      CRESTOR
       3                      atorvastatin calcium –                       LIPITOR
       3                         simvastatin/niacin –                      SIMCOR
                                                                                                                                            Generic MEVACOR, Generic PRAVACHOL, Generic ZOCOR,
         3                                 simvastatin/ezetimibe – VYTORIN
                                                                                                                                            LIPITOR
                                                                                                                                            Generic MEVACOR, Generic PRAVACHOL, Generic ZOCOR,
             4                     lovastatin extended-release – ALTOPREV
                                                                                                                                            LIPITOR
                                                                                                                                            Generic MEVACOR, Generic PRAVACHOL, Generic ZOCOR,
             4                                           fluvastatin – LESCOL/ XL
                                                                                                                                            LIPITOR
                                                                                                                                            Generic MEVACOR, Generic PRAVACHOL, Generic ZOCOR,
             4                              pravastatin & aspirin – PRAVIGARD
                                                                                                                                            LIPITOR & OTC Aspirin
OTHER CARDIOVASCULAR DRUGS
 1                                                   pentoxifylline – TRENTAL                        generic
                                                                             AUTONOMIC AND CNS MEDICATIONS
ANALGESICS
 1                             propoxyphene napsylate/apap             –   DARVOCET-N                                           generic
 1                               hydrocodone bitartrate/apap           –   LORTAB, VICODIN/ES                                   generic
 1                                  codeine phosphate/apap             –   TYLENOL/CODEINE                                      generic
 1                                                  tramadol           –   ULTRAM                                               generic
 1                          propoxyphene hcl/acetaminophen             –   WYGESIC                                              generic
   2                              opium/belladonna alkaloids           –   B&O                                                  generic
   2                                   oxycodone/ibuprofen             –   COMBUNOX                                             generic
   2                           propoxyphene hcl/asa/caffeine           –   DARVON                                               generic
   2                                             meperidine            –   DEMEROL                                              generic
   2                                         hydromorphone             –   DILAUDID                                             generic
   2                                             methadone             –   DOLOPHINE                                            generic
   2                                                 fentanyl          –   DURAGESIC                                            generic
     2                                                  oxycodone – OXYCONTIN 10mg,20mg,40mg,80mg                               generic
     2                                            oxycodone – OXYIR                                                             generic
     2                            oxycodone/acetaminophen – PERCOCET                                                            generic
     2                                     oxycodone/aspirin – PERCODAN                                                         generic
                                                                RMS-SUPP, ROXANOL, MS CONTIN,
     2                                             morphine –                                                                   generic
                                                                MSIR
     2                                 pentazocine/naloxone – TALWIN NX                                                         generic
     2                              tramadol/acetaminophen – ULTRACET                                                           generic
     2                      hydrocodone bitartrate/ibuprofen – VICOPROFEN                                                       generic
     2                            codeine phosphate/aspirin –                                                                   generic
     2                                        codeine sulfate –                                                                 generic
     2                                           levorphanol –                                                                  generic
         3                 morphine sulfate extended-release – AVINZA
         3                 morphine sulfate extended-release – KADIAN
         3             oxymorphone hydrochloride/extended – OPANA/ OPANA ER
         3                              oxycodone                      –   OXYCONTIN 15mg, 30mg, 60mg
         4                 fentanyl citrate lollipop                   –   ACTIQ                                                            Generic DILAUDID, Generic MSIR, Generic OXYIR
         4            fentanyl citrate effervescent                    –   FENTORA                                                          Generic DILAUDID, Generic MSIR, Generic OXYIR
         4            dihydrocodeine/asa/caffeine                      –   SYNALGOS DC                                                      Generic PERCOCET, Generic PERCODAN
DRUGS TO PREVENT AND TREAT HEADACHES
 1                 acetaminophen/caffeine/butalb                       –   ESGIC/PLUS, FIORICET, ZEBUTAL                        generic
 1                   codeine/apap/caffeine/butalb                      –   FIORICET/CODEINE #3                                  generic
 1                 apap/isometheptene/dichlphen                        –   MIDRIN                                               generic
    2                    acetaminophen/butalbital                      –   AXOCET, PHRENILIN/FORTE                              generic
    2                 codeine/asa/caffeine/butalb                      –   FIORINAL/CODEINE #3                                  generic
    2                                  butorphanol                     –   STADOL NS                                            generic
    2                    aspirin/caffeine/butalbital                   –                                                        generic
      3                                  divalproex                    –   DEPAKOTE ER
      3                         dihydroergotamine                      –   MIGRANAL
TRIPTAN AGENTS
    2                                  sumatriptan                     – IMITREX (injection, nasal, tabs)                       generic Some strengths and dosage forms available in generic form
      3                                sumatriptan                     – IMITREX (injection, nasal, tabs)
      3                                   rizatriptan                  – MAXALT / MLT




         2009 BEHP Custom Formulary                                                                        8 of 25
                                                    2009 Beaumont Employee Health Plan Thrptc Clss Formulary
                                                                                               Benefit designs may vary and formulary changes can occur at any time


      Tier                                                                                                                      Generic
                                             generic drug name - BRAND DRUG NAME                                                                                Preferred Alternatives / Comments
 1   2 3 4 5                                                                                                                    Status

 If the word 'generic' appears in the Generic Status column, that indicates that a generic equivalent is available for the listed Brand Drug Name. The cost of that generic will be indicated, for Classic members, by the Tier
listed to the left. The Brand Name drug will appear on Tier 4. If the member or their physician requests the Brand Name of a drug which has a generic equivalnet available, a DAW Penalty (the cost of the generic copay,
                            plus the difference in cost between the brand and the generic) will apply. This penalty will NOT apply toward Choice and HSA deductibles or out-of-pocket maximums.

TRIPTAN AGENTS (continued)
      3                                                   eletriptan   –   RELPAX
         4                                              naratriptan    –   AMERGE                                                           IMITREX, MAXALT
         4                                             almotriptan     –   AXERT                                                            IMITREX, MAXALT
         4                                             frovatriptan    –   FROVA                                                            IMITREX, MAXALT
         4                                             zolmitriptan    –   ZOMIG (nasal, tabs) / ZMT                                        IMITREX, MAXALT
ANXIOLYTICS
 1                                                    lorazepam        –   ATIVAN                                               generic
 1                                                     buspirone       –   BUSPAR                                               generic
 1                                          chlordiazepoxide hcl       –   LIBRIUM                                              generic
 1                                                     diazepam        –   VALIUM                                               generic
 1                                               hydroxyzine hcl       –   VISTARIL                                             generic
 1                                                    alprazolam       –   XANAX                                                generic
 1                                                    alprazolam       –   XANAX XR                                             generic
    2                                                  oxazepam        –   SERAX                                                generic
    2                                                clorazepate       –   TRANXENE                                             generic
         4                                      alprazolam ODT         –   NIRAVAM                                                          Generic XANAX
         4                                           clorazepate       –   TRANXENE SD                                                      Generic TRANXENE
SEDATIVE / HYPNOTIC DRUGS
 1                                               zolpidem tartrate     –   AMBIEN                                               generic
 1                                                     flurazepam      –   DALMANE                                              generic
 1                                                        triazolam    –   HALCION                                              generic
 1                                                    temazepam        –   RESTORIL                                             generic
    2                                              chloral hydrate     –   AQUACHLORAL                                          generic
    2                                                   estazolam      –   PROSOM                                               generic
    2                                                      zaleplon    –   SONATA                                               generic
                                                                                                                                            Generic AMBIEN, Generic DALMANE, Generic HALCION, Generic
         3                                       zolpidem tartrate – AMBIEN CR
                                                                                                                                            RESTORIL
                                                                                                                                            Generic AMBIEN, Generic DALMANE, Generic HALCION, Generic
             4                                         eszopiclone – LUNESTA
                                                                                                                                            RESTORIL
                                                                                                                                            Generic AMBIEN, Generic DALMANE, Generic HALCION, Generic
             4                                         temazepam – RESTORIL 7.5 MG
                                                                                                                                            RESTORIL
                                                                                                                                            Generic AMBIEN, Generic DALMANE, Generic HALCION, Generic
             4                                           ramelteon – ROZEREM
                                                                                                                                            RESTORIL
ANTIMANIA DRUGS
 1                                              lithium carbonate – LITHONATE, ESKALITH/CR, LITHOBID                            generic
    2                                                lithium citrate –                                                          generic
ANTICONVULSANT DRUGS
 1                                                   clonazepam        –   KLONOPIN                                             generic
 1                                                    gabapentin       –   NEURONTIN                                            generic
 1                                               carbamazepine         –   TEGRETOL                                             generic
 1                                                 phenobarbital       –                                                        generic
    2                                               valproic acid      –   DEPAKENE                                             generic
    2                                                  divalproex      –   DEPAKOTE                                             generic
    2                                                   phenytoin      –   DILANTIN                                             generic
    2                                              levetiracetam       –   KEPPRA                                               generic
    2                                                 lamotrigine      –   LAMICTAL                                             generic
    2                                             mephobarbital        –   MEBARAL                                              generic
    2                                                   primidone      –   MYSOLINE                                             generic
    2                                             oxcarbazepine        –   TRILEPTAL                                            generic
    2                                              ethosuximide        –   ZARONTIN                                             generic
    2                                                 zonisamide       –   ZONEGRAN                                             generic
      3                                                rufinamide      –   BANZEL                                                           added 3/23/09
      3                                          carbamazepine         –   CARBATROL
      3                                            methsuximide        –   CELONTIN
      3                                                divalproex      –   DEPAKOTE ER
      3                                                 diazepam       –   DIASTAT
      3                                      phenytoin chewable        –   DILANTIN/INFATABS
      3                                                 felbamate      –   FELBATOL
      3                                                  tiagabine     –   GABITRIL
      3                                         levetiracetam sr       –   KEPPRA XR
      3                                                pregabalin      –   LYRICA
                                                                           NEURONTIN SUSPENSION &
         3                                              gabapentin –
                                                                           SOLUTION
         3                                               ethotoin      –   PEGANONE
         3                                         phenacemide         –   PHENURONE
         3                                             phenytoin       –   PHENYTEK
         3                                       carbamazepine         –   TEGRETOL XR
         3                                            topiramate       –   TOPAMAX
         3                                        oxcarbazepine        –   TRILEPTAL SUSPENSION
         3                                           lacosamide        –   VIMPAT TABLETS                                                   added 3/23/09
             4                                carbamazepine SR         –   EQUETRO                                                          Generic TEGRETOL, TEGRETOL ZR
                 5                                   lacosamide        –   VIMPAT IV INFUSION                                               added 3/23/09




         2009 BEHP Custom Formulary                                                                        9 of 25
                                                    2009 Beaumont Employee Health Plan Thrptc Clss Formulary
                                                                                               Benefit designs may vary and formulary changes can occur at any time


      Tier                                                                                                                      Generic
                                             generic drug name - BRAND DRUG NAME                                                                                Preferred Alternatives / Comments
 1   2 3 4 5                                                                                                                    Status

 If the word 'generic' appears in the Generic Status column, that indicates that a generic equivalent is available for the listed Brand Drug Name. The cost of that generic will be indicated, for Classic members, by the Tier
listed to the left. The Brand Name drug will appear on Tier 4. If the member or their physician requests the Brand Name of a drug which has a generic equivalnet available, a DAW Penalty (the cost of the generic copay,
                            plus the difference in cost between the brand and the generic) will apply. This penalty will NOT apply toward Choice and HSA deductibles or out-of-pocket maximums.

TRICYCLIC ANTIDEPRESSANTS
 1                                       nortriptyline                 –   AVENTYL, PAMELOR                                     generic
 1                                         trazodone                   –   DESYREL                                              generic
 1                                      amitriptyline                  –   ELAVIL                                               generic
 1                                             doxepin                 –   SINEQUAN                                             generic
    2                                 clomipramine                     –   ANAFRANIL                                            generic
    2                                     amoxapine                    –   ASENDIN                                              generic
    2               amitriptyline hcl/perphenazine                     –   ETRAFON/FORTE, TRIAVIL                               generic
    2                amitriptyline/chlordiazepoxide                    –   LIMBITROL                                            generic
    2                                     maprotiline                  –   LUDIOMIL                                             generic
    2                                   desipramine                    –   NORPRAMIN                                            generic
    2                                  trimipramine                    –   SURMONTIL 25MG, 50MG                                 generic
    2                                imipramine hcl                    –   TOFRANIL                                             generic
       3                                 protriptyline                 –   VIVACTIL                                                         generic is available
       3                               trimipramine                    –   SURMONTIL 100MG
         4                           imipramine hcl                    –   TOFRANIL PM                                                      Generic TOFRANIL
SSRI ANTIDEPRESSANTS
 1                                        citalopram                   –   CELEXA                                               generic
 1                                           sertraline                –   ZOLOFT                                               generic
 1                                        paroxetine                   –   PAXIL                                                generic
 1                                          fluoxetine                 –   PROZAC capsules                                      generic
 1                                          fluoxetine                 –   SARAFEM 20mg capsules                                generic
    2                                   fluvoxamine                    –   LUVOX                                                generic
    2                 paroxetine extended-release                      –   PAXIL CR 12.5, 25mg                                  generic Some strengths available as generic
    2                                       fluoxetine                 –   PROZAC tablets                                       generic
       3                               escitalopram                    –   LEXAPRO
                                                                                                                                            Generic CELEXA, Generic PAXIL, Generic PROZAC,
             4                                        fluvoxamine – LUVOX CR
                                                                                                                                            Generic ZOLOFT, LEXAPRO
                                                                                                                                            Generic CELEXA, Generic PAXIL, Generic PROZAC,
             4                                          paroxetine – PAXIL CR 37.5mg
                                                                                                                                            Generic ZOLOFT, LEXAPRO
                                                                                                                                            Generic CELEXA, Generic PAXIL, Generic PROZAC,
             4                               paroxetine mesylate – PEXEVA
                                                                                                                                            Generic ZOLOFT, LEXAPRO
                                                                                                                                            Generic CELEXA, Generic PAXIL, Generic PROZAC,
             4                                           fluoxetine – PROZAC ONCE WEEKLY
                                                                                                                                            Generic ZOLOFT, LEXAPRO
         4                               fluoxetine                    – SARAFEM                                                            Generic PROZAC
OTHER ANTIDEPRESSANTS
    2                                  venlafaxine                     –   EFFEXOR                                              generic
    2                                  mirtazapine                     –   REMERON                                              generic
    2                                  mirtazapine                     –   REMERON SOLTAB                                       generic
    2                                  nefazodone                      –   SERZONE                                              generic
    2                                    bupropion                     –   WELLBUTRIN                                           generic
    2                                    bupropion                     –   WELLBUTRIN SR                                        generic
    2                                    bupropion                     –   WELLBUTRIN XL 300mg ONLY                             generic
      3                                  duloxetine                    –   CYMBALTA
      3                                venlafaxine                     –   EFFEXOR XR
      3                            desvenlafaxine                      –   PRISTIQ
      3                                  bupropion                     –   WELLBUTRIN XL
MAO INHIBITORS
    2                             tranylcypromine                      – PARNATE                                                generic
      3                                 phenelzine                     – NARDIL
         4                 selegiline transdermal                      – EMSAM                                                              Generic PARNATE, NARDIL
ANTIVERTIGO AND ANTIEMETIC DRUGS
 1                                    meclizine hcl                    –   ANTIVERT                                             generic
 1                     prochlorperazine edisylate                      –   COMPAZINE                                            generic
    2                                  granisetron                     –   KYTRIL                                               generic Kytril IV Tier 5
    2                                promethazine                      –   PHENERGAN                                            generic
    2                         trimethobenzamide                        –   TIGAN                                                generic
    2                                 ondansetron                      –   ZOFRAN                                               generic Zofran IV Tier 5 - May have Quantity Level Limits
      3                                  aprepitant                    –   EMEND
      3                      dolasetron mesylate                       –   ANZEMET                                                          Generic ZOFRAN; Oral Tier 3, IV Tier 5
         4                                 nabilone                    –   CESAMET                                                          Generic ZOFRAN
         4                   granisetron td patch                      –   SANCUSO                                                          Generic KYTRIL
ANTIPARKINSON'S DRUGS
 1                                 trihexyphenidyl                     –   ARTANE                                               generic
 1                                     benztropine                     –   COGENTIN                                             generic
    2                                     selegiline                   –   ELDEPRYL                                             generic
    2                         carbidopa/levodopa                       –   PARCOPA                                              generic
    2                     bromocriptine mesylate                       –   PARLODEL                                             generic
    2                                     ropinirole                   –   REQUIP                                               generic
    2                         carbidopa/levodopa                       –   SINEMET/CR                                           generic
      3                   biperiden hydrochloride                      –   AKINETON
      3                       rasagiline mesylate                      –   AZILECT
      3                                entacapone                      –   COMTAN




         2009 BEHP Custom Formulary                                                                        10 of 25
                                                    2009 Beaumont Employee Health Plan Thrptc Clss Formulary
                                                                                               Benefit designs may vary and formulary changes can occur at any time


      Tier                                                                                                                      Generic
                                             generic drug name - BRAND DRUG NAME                                                                                Preferred Alternatives / Comments
 1   2 3 4 5                                                                                                                    Status

 If the word 'generic' appears in the Generic Status column, that indicates that a generic equivalent is available for the listed Brand Drug Name. The cost of that generic will be indicated, for Classic members, by the Tier
listed to the left. The Brand Name drug will appear on Tier 4. If the member or their physician requests the Brand Name of a drug which has a generic equivalnet available, a DAW Penalty (the cost of the generic copay,
                            plus the difference in cost between the brand and the generic) will apply. This penalty will NOT apply toward Choice and HSA deductibles or out-of-pocket maximums.

ANTIPARKINSON'S DRUGS (continued)
       3                                  procyclidine – KEMADRIN
       3                                      levodopa – LARODOPA
       3                                     carbidopa – LODOSYN
       3                                 pramipexole – MIRAPEX
       3                                      rotigotine – NEUPRO
       3                                ropinirole hcl – REQUIP XL
       3                                     tolcapone – TASMAR
       3                                selegiline hcl – ZELAPAR
         4         carbidopa/levodopa/entacapone – STALEVO                                                                                  Generic SINEMET/CR, COMTAN
           5                            apomorphine – APOKYN                                                                                Systematic check for GPI; Limited distribution - Accredo
ANTIPSYCHOTICS
 1                                         haloperidol – HALDOL                                                                 generic
 1                                        thioridazine – MELLARIL, MELLARIL-S                                                   generic
 1                                 fluphenazine hcl – PERMITIL, PROLIXIN                                                        generic
    2                                        clozapine – CLOZARIL                                                               generic
    2                            loxapine succinate – LOXITANE                                                                  generic
    2                                      thiothixene – NAVANE                                                                 generic
    2                                      risperidone – RISPERDAL                                                              generic
    2                                 trifluoperazine – STELAZINE                                                               generic
    2                               chlorpromazine – THORAZINE                                                                  generic
    2                                  perphenazine – TRILAFON                                                                  generic
       3                                    aripirazole – ABILIFY/DISCMELT
       3                                  ziprasidone – GEODON
       3                                    molindone – MOBAN
       3                                      pimozide – ORAP
       3                                   risperidone – RISPERDAL M-TAB
       3                       quetiapine fumarate – SEROQUEL
       3                       quetiapine fumarate – SEROQUEL XR
       3                                   olanzapine – ZYPREXA
       3                                   olanzapine – ZYPREXA ZYDIS
         4                             mesoridazine – SERENTIL
         4                                   clozapine – FAZALCO                                                                            Generic CLOZARIL
         4                               paliperidone – INVEGA                                                                              RISPERDAL
         4                    olanzapine/fluoxetine – SYMBYAX                                                                               Generic PROZAC, ZYPREXA
CNS STIMULANT DRUGS TO TREAT ATTENTION DEFICIT DISORDER (ADD)
    2                          dexmethylphenidate – FOCALIN                                                                     generic
    2               amphetamine salt combination – ADDERALL                                                                     generic
    2                            methamphetamine – DESOXYN                                                                      generic
    2                          dextroamphetamine – DEXEDRINE, DEXTROSTAT                                                        generic
    2                              methylphenidate – RITALIN/SR                                                                 generic
       3                     methylphenidate HCL – CONCERTA
       3                                 atomoxetine – STRATTERA
       3            amphetamine salt combination – ADDERALL XR
       3                           methylphenidate – METADATE CD
       3                           methylphenidate – RITALIN LA
       3                       dexmethylphenidate – FOCALIN XR
                                                                                                                                            Generic amphetamine/dextroamphetamine,
             4                    methylphenidate transdermal – DAYTRANA                                                                    Generic dextroamphetamine, Generic methylphenidate,
                                                                                                                                            CONCERTA, STRATERRA
                                                                                                                                            Generic amphetamine/dextroamphetamine,
             4                               lisdexamphetamine – VYVANSE                                                                    Generic dextroamphetamine, Generic methylphenidate,
                                                                                                                                            CONCERTA, STRATERRA
DRUGS TO TREAT ALZHEIMER'S DISEASE
    2                                galantamine                       –   RAZADYNE / ER                                        generic
      3                                 donepezil                      –   ARICEPT
      3                     rivastigmine tartrate                      –   EXELON
      3                               memantine                        –   NAMENDA
      3                               memantine                        –   NAMENDA TITRATION PAK
      3                              galantamine                       –   RAZADYNE SOLUTION
        4                                  tacrine                     –   COGNEX                                                           ARICEPT, EXELON, NAMENDA, RAZADYNE
DRUGS TO TREAT MULTIPLE SCLEROSIS
            5                           glatiramer                     –   COPAXONE                                                         Reject for Max Quantity > 1 box or 30 vials per 23 days
            5                  interferon beta-1a                      –   REBIF                                                            Reject for Max Quantity > 6 per 21 days
            5                  interferon beta-1a                      –   REBIF TITRATION PACK                                             Reject for Max Quantity > 5 per 21 days
            5                  interferon beta-1a                      –   AVONEX                                                           Reject for Max Quantity > 4 vials per 21 days
            5                  interferon beta-1b                      –   BETASERON                                                        Reject for Max Quantity > 15 vials per 23 days
            5                        mitoxantrone                      –   NOVANTRONE                                                       Systematic lookback for GPI
            5                        natalizumab                       –   TYSABRI                                                          Reject for Max Quantity > 5 per 21 days
OTHER CNS / AUTONOMIC DRUGS
    2                              pyridostigmine                      – MESTINON                                               generic Some strengths available as generic
      3                            pyridostigmine                      – MESTINON TIMESPAN




         2009 BEHP Custom Formulary                                                                        11 of 25
                                                    2009 Beaumont Employee Health Plan Thrptc Clss Formulary
                                                                                               Benefit designs may vary and formulary changes can occur at any time


      Tier                                                                                                                      Generic
                                             generic drug name - BRAND DRUG NAME                                                                                Preferred Alternatives / Comments
 1   2 3 4 5                                                                                                                    Status

 If the word 'generic' appears in the Generic Status column, that indicates that a generic equivalent is available for the listed Brand Drug Name. The cost of that generic will be indicated, for Classic members, by the Tier
listed to the left. The Brand Name drug will appear on Tier 4. If the member or their physician requests the Brand Name of a drug which has a generic equivalnet available, a DAW Penalty (the cost of the generic copay,
                            plus the difference in cost between the brand and the generic) will apply. This penalty will NOT apply toward Choice and HSA deductibles or out-of-pocket maximums.

OTHER CNS / AUTONOMIC DRUGS (continued)
      3                   ambenonium chloride                          –   MYTELASE
      3                   neostigmine bromide                          –   PROSTIGMIN
      3                               modafinil                        –   PROVIGIL
      3                          tetrabenazine                         –   XENAZINE                                                         added 3/23/09
            5                  sodium oxybate                          –   XYREM                                                            Limited distribution drug - Express Scripts
                                                                                    DERMATOLOGICAL MEDICATIONS
ANTIACNE DRUGS
 1             erythromycin base/benzoyl peroxide – BENZAMYCIN                                                                  generic
                                                                  A/T/S, EMGEL, ERYCETTE, ERYDERM,
 1                                    erythromycin base topical –                                                               generic
                                                                  ERYGEL, ERYMAX, T-STAT
                                                                  BENZAC/AC/W, BENZAGEL,
 1                                       benzoyl peroxide gel – DESQUAM/E/X, PANOXYL/AQ, TRIAZ                                  generic
                                                                  GEL
 1                              clindamycin phosphate topical – CLEOCIN T, CLINDA-DERM                                          generic
     2                                             isotretinoin – ACCUTANE                                                      generic
     2                                                tretinoin – AVITA                                                         generic
                                                                  NOVACET, SULFACET-R, VANOCIN,
     2                         sulfacetamide/sulfur, sublimed –                                                                 generic
                                                                  PLEXION
     2                                                tretinoin – RETIN-A                                                       generic
     2                                       benzoyl peroxide – TRIAZ PADS                                                      generic
     2                                  benzoyl peroxide/urea – ZODERM                                                          generic
                              clindamycin phosphate/benzoyl
         3                                                      – BENZACLIN
                                                      peroxide
         3                                        azelaid acid – FINACEA
         3                             benzoyl peroxide/sulfur – SULFOXYL/STRONG
         3                                   benzoyl peroxide – TRIAZ
         3                    clindamycin phosphate-tretinoin – ZIANA
         3                                            tretinoin – RETIN-A MICRO                                                             Generic AVITA, Generic RETIN-A
         4                                        azelaid acid – AZELEX                                                                     Generic RETIN-A, FINACEA
         4                                   benzoyl peroxide – BREVOXYL GEL/WASH/LOTION                                                    Generic benzoyl peroxide,TRIAZ
         4                                          adapalene – DIFFERIN                                                                    Generic RETIN-A
         4                       benzoyl peroxide/clindamycin – DUAC                                                                        Genreic benzoyl peroxide, Generic clindamycin
         4                                   benzoyl peroxide – INOVA                                                                       Generic benzoyl peroxide,TRIAZ
         4                                    minocycline hcl – SOLODYN                                                                     Generic minocycline, Generic clindamycin
         4                              benzoyl peroxide/urea – ZODERM 4.5% CREAM / PADS                                                    Generic benzoyl peroxide
KERATOLYTIC DRUGS
    2                                       podofilox –                    CONDYLOX SOLUTION                                    generic
      3                                     podofilox –                    CONDYLOX GEL
TOPICAL ANTIPSORIASIS AND ANTI-ECZEMA DRUGS
 1                                 selenium sulfide –                      EXSEL, SELSUN                                        generic
    2                        sulfacetamide sodium –                        KLARON                                               generic
      3                                   chloroxine –                     CAPITROL SHAMPOO
      3                                calcipotriene –                     DOVONEX
      3                                  tazarotene –                      TAZORAC
                      calcipotriene-betamethasone
         4                                             –                   TACLONEX
                                       dipropionate
OTHER ANTIPSORIASIS
      3                                      acitretin –                   SORIATANE
      3                                      acitretin –                   SORIATANE KIT
           5                               alefacept –                     AMEVIVE                                                          Systematic lookback for GPI; if not PA required
           5                             etanercept –                      ENBREL
           5                            efalizumab –                       RAPTIVA                                                          Systematic lookback for GPI; if not PA required
TOPICAL IMMUNOMODULATORS
      3                               pimecrolimus –                       ELIDEL
      3                                   tacrolimus –                     PROTOPIC
TOPICAL CORTICOSTEROID DRUGS
 1                    betamethasone dipropionate –                         DIPROSONE, MAXIVATE                                  generic
                                                                           HYTONE, ANUSOL, PROCTOCREAM
 1                                         hydrocortisone cream –          HC, HYDROCORT, LACTICARE HC,                         generic
                                                                           SYNACORT, ELDECORT 2.5% ONLY
                                                                           KENALOG, FLUTEX, KENONEL,
 1                             triamcinolone acetonide topical –                                                                generic
                                                                           TRIDERM CREAM, OINTMENT
 1                                                   fluocinonide      –   LIDEX/E                                              generic
 1                                       fluocinolone acetonide        –   SYNALAR                                              generic
 1                                         clobetasol propionate       –   TEMOVATE/E                                           generic
 1                                     betamethasone valerate          –   VALISONE                                             generic
 1                                      hydrocortisone valerate        –   WESTCORT                                             generic
     2                              aclometasone dipropionate          –   ACLOVATE OINTMENT, CREAM                             generic
     2                                    fluticasone propionate       –   CUTIVATE                                             generic
     2                                                amcinonide       –   CYCLOCORT                                            generic
     2                                             prednicarbate       –   DERMATOP                                             generic




         2009 BEHP Custom Formulary                                                                        12 of 25
                                                    2009 Beaumont Employee Health Plan Thrptc Clss Formulary
                                                                                               Benefit designs may vary and formulary changes can occur at any time


      Tier                                                                                                                      Generic
                                             generic drug name - BRAND DRUG NAME                                                                                Preferred Alternatives / Comments
 1   2 3 4 5                                                                                                                    Status

 If the word 'generic' appears in the Generic Status column, that indicates that a generic equivalent is available for the listed Brand Drug Name. The cost of that generic will be indicated, for Classic members, by the Tier
listed to the left. The Brand Name drug will appear on Tier 4. If the member or their physician requests the Brand Name of a drug which has a generic equivalnet available, a DAW Penalty (the cost of the generic copay,
                            plus the difference in cost between the brand and the generic) will apply. This penalty will NOT apply toward Choice and HSA deductibles or out-of-pocket maximums.

TOPICAL CORTICOSTEROID DRUGS (continued)
    2                                  desonide – DESOWEN, TRIDESILON                                                           generic
    2                  betameth/propylene glycol – DIPROLENE AF                                                                 generic
    2                  betameth/propylene glycol – DIPROLENE CREAM, OINTMENT                                                    generic
     2                                      mometasone furoate – ELOCON OINTMENT, CREAM, LOTION                                 generic
     2                    diflorasone diacetate cr                     –   FLORONE/E                                            generic
     2                    hydrocortisone butyrate                      –   LOCOID                                               generic
     2                                   diflorasone                   –   PSORCON/E                                            generic
     2                            desoximetasone                       –   TOPICORT/LP                                          generic
     2                     halobetasol propionate                      –   ULTRAVATE                                            generic
      3                    hydrocortisone acetate                      –   CORTANE
      3                    fluocinolone acetonide                      –   DERMA-SMOOTHE/FS OIL
      3                betameth/propylene glycol                       –   DIPROLENE LOTION
      3                   hydrocortisone butyrate                      –   LOCOID LIPOCREAM
      3                  betamethasone valerate                        –   LUXIQ
      3                                fluocinonide                    –   VANOS
         4                    clocortolone pivalate                    –   CLODERM                                                          Generic topical steroids
         4                         flurandrenolide                     –   CORDRAN                                                          Generic topical steroids
         4                              halcinonide                    –   HALOG/E                                                          Generic topical steroids
         4                   clobetasol propionate                     –   OLUX-E                                                           Generic topical steroids
         4              hydrocortisone buteprate                       –   PANDEL                                                           Generic topical steroids
         4                                 desonide                    –   VERDESO                                                          Generic topical steroids
TOPICAL CORTICOSTEROID COMBINATION DRUGS
    2                hydrocortisone acetate/urea                       –   CARMOL HC                                            generic
    2                   clioquinol/hydrocortisone                      –   HYSONE                                               generic
    2                  pramoxine/hydrocortisone                        –   PRAMOSONE 2.5% Cream                                 generic
    2                  iodoquinol/hydrocortisone                       –   VYTONE                                               generic
    2                          neomycin sulfate/hc                     –                                                        generic
      3                     pramoxine/hc acetate                       –   EPIFOAM
                                                                           PRAMOSONE 1% Cream, Lotion & oint,
         3                            pramoxine/hydrocortisone –
                                                                           2.5% Lotion & oint
OTHER DERMATOLOGICAL DRUGS
 1                                metronidazole                        –   METROCREAM                       generic
 1                                metronidazole                        –   METROLOTION                      generic
    2             aluminum chloride hexahydrate                        –   DRYSOL                           generic
    2                                 fluorouracil                     –   EFUDEX                           generic
    2                                 permethrin                       –   ELIMITE                          generic
    2                        hyaluronate sodium                        –   HYLIRA                           generic
      3                                imiquimod                       –   ALDARA
      3                               fluorouracil                     –   CARAC, FLUOROPLEX
      3                                crotamiton                      –   EURAX CREAM
      3                                    lindane                     –   LINDANE
      3                           metronidazole                        –   METROGEL, NORITATE
      3                         emollient cream                        –   MIMYX
      3                                 malathion                      –   OVIDE
      3                             methoxsalen                        –   OXSORALEN-ULTRA, 8-MOP
      3                              becaplermin                       –   REGRANEX
      3                            sinecatechins                       –   VEREGEN
        4                              alitretinoin                    –   PANRETIN                                 Generic RETIN-A
        4                     mequinol-tretinoin                       –   SOLAGE                                   Generic RETIN-A
        4      miconazole-zincoxide-white petrol.                      –   VUSION                                   Generic nystatin ointment
                                                                                   EAR, NOSE & THROAT MEDICATIONS
DRUGS AFFECTING THE EAR
 1                           antipyrine/benzocaine                     –   AURALGAN                                             generic
   2                neomycin sulfate/polymyxin/hc                      –   CORTISPORIN                                          generic
   2                 acetic acid/aluminum acetate                      –   DOMEBORO OTIC, BOROFAIR OTIC                         generic
   2                                          ofloxacin                –   FLOXIN OTIC                                          generic
   2               neomycin suf/polymy/buffers/hc                      –   PEDIOTIC                                             generic
   2                                       acetic acid                 –   VOSOL                                                generic
   2                     acetic acid/hydrocortisone                    –   VOSOL HC                                             generic
      3               trolamine polypeptide oleate                     –   CERUMENEX
      3              ciprofloxacin/dexamethasone                       –   CIPRODEX
        4                            ciprofloxacin/hc                  –   CIPRO HC
NASAL CORTICOSTEROIDS
   2                         fluticasone propionate                    –   FLONASE                                              generic
   2                                        flunisolide                –   NASAREL                                              generic
      3                                   budesonide                   –   RHINOCORT AQUA                                                   Generic FLONASE, NASONEX, NASACORT/AQ
      3                                 mometasone                     –   NASONEX
      3                                triamcinolone                   –   NASACORT/AQ
        4                           beclomethasone                     –   BECONASE/AQ                                                      Generic FLONASE, NASONEX, NASACORT/AQ




         2009 BEHP Custom Formulary                                                                        13 of 25
                                                    2009 Beaumont Employee Health Plan Thrptc Clss Formulary
                                                                                               Benefit designs may vary and formulary changes can occur at any time


      Tier                                                                                                                      Generic
                                             generic drug name - BRAND DRUG NAME                                                                                Preferred Alternatives / Comments
 1   2 3 4 5                                                                                                                    Status

 If the word 'generic' appears in the Generic Status column, that indicates that a generic equivalent is available for the listed Brand Drug Name. The cost of that generic will be indicated, for Classic members, by the Tier
listed to the left. The Brand Name drug will appear on Tier 4. If the member or their physician requests the Brand Name of a drug which has a generic equivalnet available, a DAW Penalty (the cost of the generic copay,
                            plus the difference in cost between the brand and the generic) will apply. This penalty will NOT apply toward Choice and HSA deductibles or out-of-pocket maximums.

NASAL CORTICOSTEROIDS (continued)
        4                               ciclesonide                    – OMNARIS                                                            Generic FLONASE, NASONEX, NASACORT/AQ
        4                              olopatadine                     – PATANASE                                                           Generic FLONASE, NASONEX, NASACORT/AQ
        4                      fluticasone furoate                     – VERAMYST                                                           Generic FLONASE, NASONEX, NASACORT/AQ
OTHER DRUGS AFFECTING THE NOSE
    2                                   ipratropium                    – ATROVENT NASAL SPRAY                                   generic
      3                              azelastine hcl                    – ASTELIN
DRUGS AFFECTING THE THROAT AND MOUTH
 1                       triamcinolone acetonide               KENALOG IN ORABASE
                                                                       –                       generic
 1                                   chlorhexidine             PERIDEX, PERIOGARD
                                                                       –                       generic
 1                                         lidocaine           XYLOCAINE VISCOUS/GEL
                                                                       –                       generic
    2                         doxycycline hyclate              PERIOSTAT
                                                                       –                       generic
    2                               pilocarpine hcl            SALAGEN –                       generic
      3                                  cevimeline            EVOXAC  –
      3                                   palifermin           KEPIVANCE
                                                                       –
      3                                    lidocaine           XYLOCAINE ORAL SPRAY
                                                                       –
                                                                           ENDOCRINE MEDICATIONS
ANTIDIABETIC AGENTS - ALPHA-GLUCOSIDASE INHIBITORS
    2                                            acarbose – PRECOSE                            generic
       3                                            miglitol – GLYSET
ANTIDIABETIC AGENTS - MEGLITINIDES
       3                                       repaglinide – PRANDIN
       3                                       nateglinide – STARLIX
ANTIDIABETIC AGENTS - SULFONYLUREAS
 1                                             glimepiride – AMARYL                            generic
 1                                      chlorpropamide –                                       generic
                                                               DIABETA, GLYCRON, GLYNASE,
 1                                               glyburide –                                   generic
                                                               MICRONASE
 1                                                glipizide – GLUCOTROL                        generic
    2                                             glipizide – GLUCOTROL XL                     generic
ANTIDIABETIC AGENTS - THIAZOLIDINEDIONES (TZDs)
       3                                     pioglitazone – ACTOS
       3                         rosiglitazone maleate – AVANDIA
ANTIDIABETIC AGENTS - OTHER
 1                                              metformin – GLUCOPHAGE                         generic
 1                                              metformin – GLUCOPHAGE XR                      generic
    2                              glyburide/metformin – GLUCOVANCE                            generic
    2                               glipizide/metformin – METAGLIP                             generic
       3                       pioglitazone/metformin          ACTOPLUS MET
       3            rosiglitazone maleate/metformin – AVANDAMET
       3         rosiglitazone maleate / glimepriride – AVANDARYL
       3                                        exenatide – BYETTA
       3                      pioglitazone/glimepiride – DUETACT
       3                         sitagliptin / metformin – JANUMET
       3                                         sitagliptin – JANUVIA
       3                                       pramlintide – SYMLIN
         4                                      metformin – FORTAMET                                                                        Generic GLUCOPHAGE
         4                                 metformin hcl – GLUMETZA                                                                         Generic GLUCOPHAGE
INSULIN
       3                                insulin, glargine – LANTUS
       3                                  insulin detemir – LEVEMIR
       3                                  insulin, human – NOVOLIN, NOVOLIN INNOLET
       3                        insulin, human aspart – NOVOLOG, NOVOLOG PENFILL
                                                               NOVOLOG MIX, NOVOLOG MIX
       3                 insulin, human aspart & prot –
                                                               PENFILL
       3                                 insulin glulisine – APIDRA
       3                                    insulin, lisopr – HUMALOG, HUMALOG PEN                                                          NOVOLIN, NOVOLOG
       3                           insulin, lisopr & prot – HUMALOG MIX, HUMALOG MIX PEN                                                    NOVOLIN, NOVOLOG
       3                                  insulin, human – HUMULIN, HUMULIN PEN                                                             NOVOLIN, NOVOLOG
         4          insulin human inhalation powder – EXUBERA                                                                               NOVOLOG
DRUGS TO TREAT OSTEOPOROSIS
 1                                            alendronate – FOSAMAX                            generic
       3                                      risedronate – ACTONEL
       3                                      risedronate – ACTONEL with calcium
       3                                     alendronate – FOSAMAX plus D
       3                                     alendronate – FOSAMAX SOL
       3                                         calcitonin – MIACALCIN
         4                                   ibandronate – BONIVA                                                                           ACTONEL, FOSAMAX
                                                                                                                                            Systematic lookback for hormones or bisphosphonates in past 6
                 5                                     teriparatide – FORTEO
                                                                                                                                            months; reject for Max Quantity > 3 (ml)
                 5                                 zoledronic acid – ZOMETA                                                                 Systematic lookback for GPI; if not PA required
                 5                                 zoledronic acid – RECLAST                                                                Systematic lookback for GPI; if not PA required




         2009 BEHP Custom Formulary                                                                        14 of 25
                                                    2009 Beaumont Employee Health Plan Thrptc Clss Formulary
                                                                                               Benefit designs may vary and formulary changes can occur at any time


      Tier                                                                                                                      Generic
                                             generic drug name - BRAND DRUG NAME                                                                                Preferred Alternatives / Comments
 1   2 3 4 5                                                                                                                    Status

 If the word 'generic' appears in the Generic Status column, that indicates that a generic equivalent is available for the listed Brand Drug Name. The cost of that generic will be indicated, for Classic members, by the Tier
listed to the left. The Brand Name drug will appear on Tier 4. If the member or their physician requests the Brand Name of a drug which has a generic equivalnet available, a DAW Penalty (the cost of the generic copay,
                            plus the difference in cost between the brand and the generic) will apply. This penalty will NOT apply toward Choice and HSA deductibles or out-of-pocket maximums.

ADRENAL CORTICOSTEROID DRUGS
 1                               dexamethasone                         –   DECADRON, HEXADROL                                   generic
 1                                      prednisone                     –   DELTASONE                                            generic
 1                            methylprednisolone                       –   MEDROL                                               generic Some strengths available as generic
 1                    prednisolone sod phosphate                       –   ORAPRED                                              generic
 1                    prednisolone sod phosphate                       –   PEDIAPRED                                            generic
 1                                    prednisolone                     –   PRELONE                                              generic
    2                              hydrocortisone                      –   CORTEF                                               generic
    2                              fludrocortisone                     –   FLORINEF                                             generic
      3               prednisolone sod phosphate                       –   ORAPRED ODT
THYROID AND ANTI-THYROID DRUGS
 1                                            thyroid                  –   ARMOUR THYROID                                       generic
 1                                   levothyroxine                     –   LEVOXYL                                              generic
 1                                   levothyroxine                     –   LEVOTHROID                                           generic
 1                                   levothyroxine                     –   SYNTHROID                                            generic
 1                                   levothyroxine                     –   UNITHROID                                            generic
 1                                            thyroid                  –   ARMOUR THYROID                                                   Brands considered generic
 1                                   levothyroxine                     –   LEVOTHROID                                                       Brands considered generic
 1                                   levothyroxine                     –   LEVOXYL                                                          Brands considered generic
 1                                   levothyroxine                     –   SYNTHROID                                                        Brands considered generic
 1                                   levothyroxine                     –   UNITHROID                                                        Brands considered generic
    2                                 methimazole                      –   TAPAZOLE                                             generic
    2                             propylthiouracil                     –                                                        generic
      3                   potassium iodine/iodine                      –   IODINE STRONG
         4                             liothyronine                    –   CYTOMEL
         4                           methimazole                       –   NORTHYX
OTHER ENDOCRINE DRUGS
    2                       desmopressin acetate                       –   DDAVP NASAL SPRAY, TABLETS                           generic
    2                                     etidronate                   –   DIDRONEL                                             generic
    2                                  cabergoline                     –   DOSTINEX                                             generic
         4                               tiludronate                   –   SKELID                                                           ACTONEL, FOSAMAX
GROWTH HORMONES
           5                            somatropin                     –   GENOTROPIN/MINIQUICK                                             Not covered benefit for age >18; Systematic lookback for GPI
           5                            somatropin                     –   HUMATROPE                                                        Not covered benefit for age >18; Systematic lookback for GPI
           5                            somatropin                     –   NORDITROPIN                                                      Not covered benefit for age >18; Systematic lookback for GPI
           5                            somatropin                     –   SAIZEN                                                           Not covered benefit for age >18; Systematic lookback for GPI
           5                            somatropin                     –   NUTROPIN/AQ/DEPOT                                                Not covered benefit for age >18; Systematic lookback for GPI
           5                            somatropin                     –   TEV-TROPIN                                                       Not covered benefit for age >18; Systematic lookback for GPI
           5                            somatropin                     –   OMNITROPE                                                        Not covered benefit for age >18; Systematic lookback for GPI
           5                            somatropin                     –   SEROSTIM                                                         Not covered benefit for age >18; Systematic lookback for GPI
           5                            somatropin                     –   ZORBITIVE                                                        Not covered benefit for age >18; Systematic lookback for GPI
OTHER HORMONES
           5                          mecasermin                  – INCRELEX                                                                Not covered benefit for age >18; Systematic lookback for GPI
                                                                    LUPRON DEPOT, LUPRON DEPOT 3
                                               leuprolide acetate – MONTH, LUPRON DEPOT 4 MONTH,                                includes
                 5                                                  LUPRON DEPOT-PEDS                                           generics Reject for Max Quantity > 1 box per 30 days
                 5                             leuprolide acetate – LUPRON SQ                                                            Reject for Max Quantity > 1 kit per 30 days
                                                                                                                                         Systematic lookback for GPI; if not PA required. Reject for Max
                                               octreotide acetate –
                 5                                                    SANDOSTATIN LAR DEPOT                                              Quantity > 1 kit per 30 days
                 5                                histrelin acetate – SUPPRELIN LA                                                       Systematic lookback for GPI; if not PA required.
         3                                                nafarelin – SYNAREL                                                            PA required for Max Quantity > 16 (ml) per 30 days
            5                                          pegvisomet – SOMAVERT                                                             Systematic lookback for GPI; if not PA required.
FERTILITY DRUGS
            5                                       urofollitropin     –   BRAVELLE                                                         Systematic lookback for fertility GPIs; if not PA required
            5                                       urofollitropin     –   FERTINEX                                                         Systematic lookback for fertility GPIs; if not PA required
            5                                          follitropin     –   GONAL-F / -RFF                                                   Systematic lookback for fertility GPIs; if not PA required
            5                                          follitropin     –   FOLLISTIM                                                        Systematic lookback for fertility GPIs; if not PA required
            5                                          cetrorelix      –   CETROTIDE                                                        Systematic lookback for fertility GPIs; if not PA required
            5                            chorionic gonadatropin        –   PROFASI                                                          Systematic lookback for fertility GPIs; if not PA required
            5                            chorionic gonadatropin        –   PREGNYL                                                          Systematic lookback for fertility GPIs; if not PA required
            5                            chorionic gonadatropin        –   NOVAREL                                                          Systematic lookback for fertility GPIs; if not PA required
            5                            chorionic gonadatropin        –   OVIDREL                                                          Systematic lookback for fertility GPIs; if not PA required
            5                                        menotropin        –   MENOPUR                                                          Systematic lookback for fertility GPIs; if not PA required
            5                                        menotropin        –   REPRONEX                                                         Systematic lookback for fertility GPIs; if not PA required
            5                                  ganirelix acetate       –                                                                    Systematic lookback for fertility GPIs; if not PA required
            5                                       lutropin alfa      –   LUVERIS                                                          Systematic lookback for fertility GPIs; if not PA required
                                                                                       GASTROINTESTINAL MEDICATIONS
ANTISPASMODICS / DRUGS AFFECTING GI MOTILITY
                                                                           ANASPAZ, LEVSIN/SL, LEVSINEX,
 1                                                   hyoscyamine –                                                              generic
                                                                           CYSTOSPAZ
 1                                       belladonna alkaloids          –   ANTI-SPAS                                            generic
 1                                                dicyclomine          –   BENTYL                                               generic
 1                            belladonna alkaloids/phenobarb           –   DONNATAL/EXTENTAB                                    generic
 1                             diphenoxylate/atropine sulfate          –   LOMOTIL                                              generic




         2009 BEHP Custom Formulary                                                                        15 of 25
                                                    2009 Beaumont Employee Health Plan Thrptc Clss Formulary
                                                                                               Benefit designs may vary and formulary changes can occur at any time


      Tier                                                                                                                      Generic
                                             generic drug name - BRAND DRUG NAME                                                                                Preferred Alternatives / Comments
 1   2 3 4 5                                                                                                                    Status

 If the word 'generic' appears in the Generic Status column, that indicates that a generic equivalent is available for the listed Brand Drug Name. The cost of that generic will be indicated, for Classic members, by the Tier
listed to the left. The Brand Name drug will appear on Tier 4. If the member or their physician requests the Brand Name of a drug which has a generic equivalnet available, a DAW Penalty (the cost of the generic copay,
                            plus the difference in cost between the brand and the generic) will apply. This penalty will NOT apply toward Choice and HSA deductibles or out-of-pocket maximums.

ANTISPASMODICS / DRUGS AFFECTING GI MOTILITY (continued)
 1                                  metoclopramide – REGLAN                                                                     generic
    2               hyoscyamine sulfate/phenobarb – LEVSIN/PB                                                                   generic
    2                    clidinium/chlordiazepoxide –                                                                           generic
    2                             methscopolamine – PAMINE/FORTE                                                                generic
    2                                 glycopyrrolate – ROBINUL/FORTE                                                            generic
    2                                     loperamide –                                                                          generic
      3                                 lubiprostone – AMITIZA
      3                                mepenzolate – CANTIL
      3                                     alosetron – LOTRONEX
      3                           methscopolamine – PAMINE FQ KIT
      3                               propantheline – PRO-BANTHINE
        4      chlordiazepoxide / methscopolamine – LIBRAX                                                                                  Old version: clidinium/chlordiazepoxide still available
ANTIULCER DRUGS
 1                                         famotidine – PEPCID                                                                  generic
 1                                         cimetidine – TAGAMET                                                                 generic
 1                                           ranitidine – ZANTAC                                                                generic
    2                                       nizatidine – AXID                                                                   generic
    2                                       sucralfate – CARAFATE TABLETS                                                       generic
    2                                    misoprostol – CYTOTEC                                                                  generic
      3                                     sucralfate – CARAFATE SUSPENSION
                                                                                                                                            Generic/OTC AXID, Generic/OTC PEPCID, Generic/OTC
             4                                            nizatidine – AXID ORAL SOLUTION
                                                                                                                                            TAGAMET, Generic/OTC ZANTAC
                                                                                                                                            Generic/OTC AXID, Generic/OTC PEPCID, Generic/OTC
             4                                            ranitidine – ZANTAC EFFERDOSE
                                                                                                                                            TAGAMET, Generic/OTC ZANTAC
PROTON PUMP INHIBITORS
   2                                                omeprazole         –   PRILOSEC                                             generic
   2                                        pantoprazole sodium        –   PROTONIX                                             generic
      3                                           esomeprazole         –   NEXIUM, GRANULES
      3                                            lansoprazole        –   PREVACID, SOLUTABS, SUSP
                                                                                                                                            PRILOSEC OTC, Generic PRILOSEC, Generic PROTONIX,
             4                               rabeprazole sodium – ACIPHEX                                                                   PREVACID, NEXIUM Generic/OTC AXID, Generic/OTC PEPCID,
                                                                                                                                            Generic/OTC TAGAMET, Generic/OTC ZANTAC
                                                                                                                                            PRILOSEC OTC, Generic PRILOSEC, Generic PROTONIX,
             4                                         omeprazole – ZEGERID                                                                 PREVACID, NEXIUM Generic/OTC AXID, Generic/OTC PEPCID,
                                                                                                                                            Generic/OTC TAGAMET, Generic/OTC ZANTAC
HELICOBACTER PYLORI COMBINATION AGENTS
         3                         lansoprazole/amox tr/clarith – PREVPAC

         3               bismuth, metronidazole, tetracycline – PYLERA
        4      bismuth, metronidazole, tetracycline – HELIDAC                                                                               Generic bismuth, metronidazole, tetracycline, PYLERA
OTHER GASTROINTESTINAL
                                                                  ANUSOL-HC, ANUCORT-HC, CORT-
 1                                       hydrocortisone acetate – DOME HIGH POTENCY,                                            generic
                                                                  HEMORRHOIDAL HC SUPPOSITORIES
     2                                                  ursodiol       –   ACTIGALL                                             generic
     2                                pramoxine/hydrocortisone         –   ANALPRAM-HC                                          generic
     2                                             sulfasalazine       –   AZULFIDINE                                           generic
     2                                               balsalazide       –   COLAZAL                                              generic
     2                                    electrolyte sol’n/peg's      –   COLYTE, GOLYTELY, NULYTELY                           generic
     2                                           hydrocortisone        –   PROCTOCORT HC, CORTENEMA                             generic
     2                                              mesalamine         –   ROWASA                                               generic
         3                                          mesalamine         –   ASACOL, PENTASA
         3                                          mesalamine         –   CANASA
         3                               hydrocortisone acetate        –   CORTIFOAM                                                        Generic ANUSOL-HC
                                                                 COTAZYM, PANCREASE/MT,
         3                             amylase/lipase/protease – PANCRON, PROTILASE, ULTRASE/MT,
                                                                 CREON, KU–ZYME HP, VIOKASE
         3                                          budesonide         – ENTOCORT EC
         3                           amylase/lipase/protease           – ENZYMAX
         3                     bisacodyl/electrolyte sol’n/peg's       – HALFLYTELY
         3                             naproxen/lansoprazole             PREVACID NapraPAC
         3                          pramoxine/hydrocortisone           – PROCTOFOAM-HC
         3                                         sacrosidase         – SUCRAID
         3                                             ursodiol        – URSO/FORTE
             4                                       olsalazine        – DIPENTUM
             4                    mesalamine delayed release           – LIALDA                                                             ASACOL, PENTASA
             4                           electrolyte sol’n/peg's       – MOVIPREP                                                           Generic GOLYTELY, Generic NULYTELY




         2009 BEHP Custom Formulary                                                                        16 of 25
                                                    2009 Beaumont Employee Health Plan Thrptc Clss Formulary
                                                                                               Benefit designs may vary and formulary changes can occur at any time


      Tier                                                                                                                      Generic
                                             generic drug name - BRAND DRUG NAME                                                                                Preferred Alternatives / Comments
 1   2 3 4 5                                                                                                                    Status

 If the word 'generic' appears in the Generic Status column, that indicates that a generic equivalent is available for the listed Brand Drug Name. The cost of that generic will be indicated, for Classic members, by the Tier
listed to the left. The Brand Name drug will appear on Tier 4. If the member or their physician requests the Brand Name of a drug which has a generic equivalnet available, a DAW Penalty (the cost of the generic copay,
                            plus the difference in cost between the brand and the generic) will apply. This penalty will NOT apply toward Choice and HSA deductibles or out-of-pocket maximums.

                                                                                                  IMMUNOLOGICALS
DRUGS FOR THE TREATMENT OF HEPATITIS
           5                           ribavirin                       –   COPEGUS                                              generic Reject for Max Quantity > 168 tablets per 28 days
           5                           ribavirin                       –   REBETOL, RIBASPHERE                                  generic Reject for Max Quantity > 168 tablets per 28 days
           5                  adefovir dipivoxil                       –   HEPSERA                                                      Reject for Max Quantity > 30 tablets per 30 days
           5               Interferon alfacon-1                        –   INFERGEN                                                     Reject for Max Quantity > 12 vials per 21 days
                 5                            interferon alpha-2b – INTRON A                                                                Systematic lookback for other hepatitis drugs; if not PA required
                 5                       peginterferon alpha-2b – PEG INTRON                                                                Reject for Max Quantity > 4 boxes per 21 days
                 5                       peginterferon alpha-2a – PEGASYS                                                                   Reject for Max Quantity > 4 boxes per 21 days
                 5                          ribavirin oral solution – REBETOL ORAL SOLUTION                                                 Systematic lookback for other hepatitis drugs; if not PA required
                 5                  interferon alpha-2b/ribavirin – REBETRON                                                                Reject for Max Quantity > 2 boxes per 21 days
                 5                                      ribavirin – RIBATAB                                                                 Reject for Max Quantity > 56 capsules per 23 days
                 5                            interferon alph-2a – ROFERON-A                                                                Reject for Max Quantity > 12 vials per 21 days
INTERFERON
                 5              interferon gamma-1b – ACTIMMUNE                                                                             Reject for Max Quantity > 12 vials per 30 days
                 5                interferon alpha-n3 – ALFERON N                                                                           Systematic lookback for GPI; if not PA required
                                                                    MUSCULOSKELETAL MEDICATIONS
SALICYLATES AND RELATED DRUGS
 1                                             salsalate – DISALCID, SALFLEX              generic
    2                   choline/magnesium salicylate – TRILISATE                          generic
NON-STEROIDAL ANTI-INFLAMMATORY AGENTS
 1                                  naproxen sodium – ANAPROX/DS                          generic
 1                              diclofenac potassium – CATAFLAM                           generic
 1                                            naproxen – EC-NAPROSYN, NAPROSYN            generic
 1                                           piroxicam – FELDENE                          generic
 1                                      indomethacin – INDOCIN/SR                         generic
 1                                          meloxicam – MOBIC                             generic
 1                                            ibuprofen – MOTRIN                          generic
 1               naproxen sodium controlled-release – NAPRELAN 500MG                      generic
 1                diclofenac sodium delayed-release – VOLTAREN                            generic
    2                                      flurbiprofen – ANSAID                          generic
    2                                       fenoprofen –                                  generic
    2                                           sulindac – CLINORIL                       generic
    2                                        oxaprozin – DAYPRO                           generic
    2                                          etodolac – LODINE/XL                       generic
    2                                       ketoprofen – ORUDIS                           generic
    2                                    nabumetone – RELAFEN                             generic
    2                                           tolmetin – TOLECTIN/DS                    generic
    2                                         ketorolac – TORADOL                         generic
    2            diclofenac sodium extended-release – VOLTAREN XR                         generic
    2                                 meclofenamate –                                     generic
         4                                     diflunisal –                                                                                 Generic NSAIDs
         4             diclofenac sodium/misoprostol – ARTHROTEC                                                                            Generic NSAIDs and misoprostol
         4       naproxen sodium controlled-release – NAPRELAN 375MG                                                                        Generic NSAIDs
         4                            mefenamic acid – PONSTEL                                                                              Generic NSAIDs
COX 2 SELECTIVE NON-STEROIDAL ANTI-INFLAMMATORY AGENTS
         4                                    celecoxib – CELEBREX                                                                          Generic NSAIDs
OTHER DRUGS FOR ARTHRITIS
    2                                      leflunomide – ARAVA                            generic
       3                                 penicillamine – DEPEN TITRATABS, CUPRIMINE
       3                                      auranofin – RIDAURA
           5                                etanercept – ENBREL                                                                             Systematic lookback for GPI
           5                              adalimumab – HUMIRA                                                                               Systematic lookback for GPI
           5                                   anakinra – KINERET                                                                           Systematic lookback for GPI
                 5                                       abatacept – ORENCIA                                                                Systematic lookback for GPI; limited distribution - 1-800-ORENCIA
           5                             infliximab                    – REMICADE                                                           Systematic lookback for GPI
DRUGS TO PREVENT AND TREAT GOUT
 1                                      allopurinol                    –                                                        generic
 1                                       colchicine                    –                                                        generic
    2                    colchicine & probenecid                       –                                                        generic
    2                                  probenecid                      –                                                        generic
      3                            sulfinpyrazone                      – ANTURANE
SKELETAL MUSCLE RELAXANTS
 1                               cyclobenzaprine                       –   FLEXERIL                                             generic
 1                                         baclofen                    –   LIORESAL                                             generic
 1                                 chlorzoxazone                       –   PARAFON FORTE DSC                                    generic
 1                                methocarbamol                        –   ROBAXIN                                              generic
 1                                   carisoprodol                      –   SOMA                                                 generic
 1                                       tizanidine                    –   ZANAFLEX                                             generic
    2                                   dantrolene                     –   DANTRIUM                                             generic
    2                               orphenadrine                       –   NORFLEX                                              generic
    2               orphenadrine/aspirin/caffeine                      –   NORGESIC                                             generic



         2009 BEHP Custom Formulary                                                                        17 of 25
                                                    2009 Beaumont Employee Health Plan Thrptc Clss Formulary
                                                                                               Benefit designs may vary and formulary changes can occur at any time


      Tier                                                                                                                      Generic
                                             generic drug name - BRAND DRUG NAME                                                                                Preferred Alternatives / Comments
 1   2 3 4 5                                                                                                                    Status

 If the word 'generic' appears in the Generic Status column, that indicates that a generic equivalent is available for the listed Brand Drug Name. The cost of that generic will be indicated, for Classic members, by the Tier
listed to the left. The Brand Name drug will appear on Tier 4. If the member or their physician requests the Brand Name of a drug which has a generic equivalnet available, a DAW Penalty (the cost of the generic copay,
                            plus the difference in cost between the brand and the generic) will apply. This penalty will NOT apply toward Choice and HSA deductibles or out-of-pocket maximums.

    2                 methocarbamol & aspirin                          – ROBAXISAL                                              generic
SKELETAL MUSCLE RELAXANTS (continued)
    2                    carisoprodol & aspirin                        – SOMA COMPOUND                                          generic
      3                             metaxalone                         – SKELAXIN
        4                      cyclobenzaprine                         – AMRIX                                                              Generic FLEXERIL, Generic SOMA
OTHER MUSCULOSKELETAL DRUGS
        4                               riluzole                       – RILUTEK
                                                                                                       Not covered benefit for cosmetic reasons; Prior Authorization from
                 5                        botulinum toxin type a – BOTOX
                                                                                                       the Health Plan required
                                                                                                       Not covered benefit for cosmetic reasons; Prior Authorization from
            5                 botulinum toxin type b – MYOBLOC
                                                                                                       the Health Plan required
                                                                NUTRITION, BLOOD MODIFIERS, ELECTROLYTES
VITAMINS & MINERALS & RELATED PRODUCTS
 1                                             folic acid –                                    generic
 1                       multivitamins w/fluor & iron –                                        generic Pediatric
 1                          multivitamins w/fluoride –                                         generic Pediatric
 1                         triple vitamins w/fluoride –                                        generic Pediatric
 1                           triple vits w/fluor & iron –                                      generic Pediatric
 1                                 dihydrotachysterol – DHT, HYTAKEROL
 1                      polysaccaride iron complex – FERREX 150 FORTE
 1                        magnesium oxide tablets –                                            generic
 1                                     doxercalciferol – HECTOROL
 1                              l-methylfolate w/vit b – METANX
 1                                   cyanocobalamin –                                                  injection
 1                                       ergocalciferol – DRISDOL                              generic
 1                                              calcitriol – ROCALTROL                         generic
    2                                 calcium acetate – PHOSLO                                 generic
       3                                    paricalcitrol – ZEMPLAR                                    Other vitamins used in ESRD Covered at Tier 3
                                          levocarnitine – CARNITOR                                     Other Vitamin Products Not Covered by BEHP
                                l-methylfolate w/vit b – CEREFOLIN / CEREFOLIN NAC                     Other Vitamin Products Not Covered by BEHP
                                         l-methylfolate – DEPLIN                                       Other Vitamin Products Not Covered by BEHP
                                           zinc acetate – GALZIN                                       Other Vitamin Products Not Covered by BEHP
FLUORIDE PRODUCTS
 1                                    sodium fluoride – ETHEDENT CHEWABLE                      generic
POTASSIUM SUPPLEMENTS
                                                             K-DUR, K-LOR, K-TAB, KAOCHLOR/SF,
 1                                potassium chloride – KAON-CL, KAYCIEL, KLOTRIX, MICRO- generic
                                                             K 10
 1                               potassium bicarb/ca – KLOR-CON                                generic
 1                        pot bicarb/pot chloride/ca – K-LYTE/CL                               generic
 1                              potassium gluconate –                                          generic
                           sodium citrate/citric acid – CYTRA-2, BICITRA                       generic Other Vitamin Products Not Covered by BEHP
                                           phosphorus – K PHOS NEUTRAL                         generic Other Vitamin Products Not Covered by BEHP
                                           phosphorus – K PHOS/MF                                      Other Vitamin Products Not Covered by BEHP
                          pot bicarb/pot chloride/ca – K-LYTE DS                                       Other Vitamin Products Not Covered by BEHP
                               pot/bicarb/citrate/acet – TRI-K                                         Other Vitamin Products Not Covered by BEHP
                                           phosphorus – URO-KP-NEUTRAL                                 Other Vitamin Products Not Covered by BEHP
                                  potassium chloride – MICRO-K                                         Other Vitamin Products Not Covered by BEHP
POTASSIUM-REMOVING RESINS
    2                 sodium polystyrene sulfonate – KAYEXELATE, KIONEX                        generic
DRUGS AND VITAMINS AFFECTING COAGULATION
 1                                    warfarin sodium – COUMADIN                               generic
    2                                         cilostazol – PLETAL                              generic
    2                                     dipyridamole – PERSANTINE                            generic
    2                                        ticlopidine – TICLID                              generic
       3                              warfarin sodium – COUMADIN
       3                         aspirin/dipyridamole – AGGRENOX
       3                                phytonadione – MEPHYTON
       3                                    clopidogrel – PLAVIX
HEMATOPOIETIC AGENTS
            5                           erythropoietin – EPOGEN                                        SC Inj 3 x week; Max limit of 12; PA may be required
            5                           erythropoietin – PROCRIT                                       SC Inj 3 x week; Max limit of 12; PA may be required
            5                                oprelvekin – NEUMEGA                                      Systematic lookback for GPI; if not PA required
            5                               aldesleukin – PROLEUKIN                                    Systematic lookback for GPI; if not PA required
            5                              darbepoetin – ARANESP                                       Weekly injection; Max limit of 4; PA may be required
ANTIHEMOPHILIC AGENTS
                                                             ADVATE, ALPJANATE, HELIXATE-FS,
                                                             GENARC, HUMATE-P, HYATE-C,
                                                                                                       Systematic lookback for previous antihemophilic products; if not PA
            5                    antihemophlic factor – KOATE-DVI, KOATE-HP, KOGENATE-
                                                                                                       required
                                                             FS, KONYNE 80, MONARC-M,
                                                             MONOCLATE-P
                                                                                                       Systematic lookback for previous antihemophilic products; if not PA
            5       antiinhibitor coagulant complex – FEIBA VH IMMUNO, HEMOFIL-M
                                                                                                       required
                                                                                                       Systematic lookback for previous antihemophilic products; if not PA
            5                coagulation factor VIIA – NOVOSEVEN
                                                                                                       required



         2009 BEHP Custom Formulary                                                                        18 of 25
                                                    2009 Beaumont Employee Health Plan Thrptc Clss Formulary
                                                                                               Benefit designs may vary and formulary changes can occur at any time


      Tier                                                                                                                      Generic
                                             generic drug name - BRAND DRUG NAME                                                                                Preferred Alternatives / Comments
 1   2 3 4 5                                                                                                                    Status

 If the word 'generic' appears in the Generic Status column, that indicates that a generic equivalent is available for the listed Brand Drug Name. The cost of that generic will be indicated, for Classic members, by the Tier
listed to the left. The Brand Name drug will appear on Tier 4. If the member or their physician requests the Brand Name of a drug which has a generic equivalnet available, a DAW Penalty (the cost of the generic copay,
                            plus the difference in cost between the brand and the generic) will apply. This penalty will NOT apply toward Choice and HSA deductibles or out-of-pocket maximums.

ANTIHEMOPHILIC AGENTS (continued)
                                                                                                                                            Systematic lookback for previous antihemophilic products; if not PA
                 5                          coagulation factor IX – ALPHANINE SD, BENEFIX, MONONINE
                                                                                                                                            required
                                                                           BEBULIN VH, PROFILNINE SD,                                       Systematic lookback for previous antihemophilic products; if not PA
                 5                              factor IX complex –
                                                                           PROPLEX T                                                        required
LOW MOLECULAR WEIGHT HEPARINS
          5                     fondaparinux                           –   ARIXTRA                                                          Max 11-day supply
          5                        dalteparin                          –   FRAGMIN                                                          Max 14-day supply
          5                        tinzaparin                          –   INNOHEP                                                          Max 6-day supply
          5                       enoxaparin                           –   LOVENOX                                                          Max 14-day supply
HEMOSTATICS
   2                       aminocaproic acid                           – AMICAR                                                 generic
      3                      tranexamic acid                           – CYKLOKAPRON
BLOOD DETOXICANTS
                                                                           CEPHULAC, CHRONULAC, DUPHALAC,
 1                                                        lactulose –                                                           generic
                                                                           ENULOSE
      3                                     lathanum carbonate         –   FOSRENOL
      3                                               lactulose        –   KRISTALOSE
      3                                             sevelamer          –   RENAGEL
      3                                    sevelamer carbonate         –   RENVELA
      3                                              cinacalcet        –   SENSIPAR
IMMUNE GLOBULIN
                                                                   BAYGAM, CARIMUNE, CARIMUNE NF,
                                                                   FLEBOGAMMA, GAMMAGARD S/D,
                 5                               immune globulin – GAMMAR-P IV, GAMUNEX, IVEEGAM,
                                                                   OCTAGAM, PANGLOBULIN, POLYGAM
                                                                   S/D, VENOGLOBULIN-S
                                                               BAYRHO-D, MICRHOGAM, RHOGAM,
                 5                     RHO D immune globulin – RHOPHYLAC, WINRHO SDF ULTRA
                                                               FILTERED
MISCELLANEOUS
      3                                                sapropterin – KUVAN
                                                         plerixafor – MOZOBIL                             reviewed 3/23/09; Non-prescription - only Medical
                                                                                                          added 3/23/09; Systematic lookback (30 days) for IVIG and/or
                 5                                    eltrombopag – PROMACTA                              steroids; Prior Authorization from Health Plan and PROMACTA
                                                                                                          CARES physician registration required.
                                                                                                          Systematic lookback for GPI; Prior Authorization from Health Plan
                 5                                     eculizumab – SOLIRIS
                                                                                                          required
                                                                      OBSTETRICAL & GYNECOLOGICAL MEDICATIONS
PRENATAL VITAMINS
                                                                           NATALCARE PIC/PLUS, PRENATAL
 1                                              prenatal vitamins –
                                                                           PLUS
      3                              prenatal vitamins –                                                                                    Other prescription prenatal brands on Tier 3
SPECIALIZED OB/GYN DRUGS
      3                                         nafarelin – SYNAREL                                                                         PA required for Max Quantity > 16 (ml) per 30 days
OB/GYN TOPICAL ANTI-INFECTIVES
                                                            CLEOCIN VAGINAL CREAM,
 1                            clindamycin phosphate –                                                                           generic
                                                            CLINDAMAX, CLINDESS
      3                                   sulfanilamide – AVC
      3                       clindamycin phosphate – CLINDAMAX, CLINDESSE
      3                                 metronidazole – METROGEL-VAGINAL
      3                 sulfathiaz/sulfacet/sulfabenz – TRIPLE SULFA CREAM
ANDROGEN DRUGS
    2                                            danazol – DANAZOL                                                              generic
    2                                fluoxymesterone – HALOTESTIN                                                               generic
    2                                      oxandrolone – OXANDRIN                                                               generic
      3                                    testosterone – ANDROGEL
         4                              oxymetholone – ANADROL
         4                                 testosterone – ANDRODERM                                                                         ANDROGEL
         4                         methyltestosterone – ANDROID                                                                             Generic OXANDRIN
         4                        testosterone buccal – STRIANT                                                                             ANDROGEL
         4                                 testosterone – TESTIM                                                                            ANDROGEL
         4                         methyltestosterone – TESTRED                                                                             ANDROGEL
         4                                    stanozolol – WINSTROL                                                                         Generic OXANDRIN
ORAL ESTROGEN DRUGS
 1                                    estradiol tablets – ESTRACE                                                               generic
 1                                           estropipate – OGEN, ORTHO-EST                                                      generic
      3          methyl testosterone/estrogen, ester – ESTRATEST/HS
      3           estrogens, conjugated synthetic B – ENJUVIA
      3                        estrogens, conjugated – PREMARIN
      3                        estrogens, conjugated – PREMARIN LOW DOSE
         4        estrogens, conjugated synthetic A – CENESTIN                                                                              Generic ESTRACE, PREMARIN
         4                        esterified estrogens – MENEST                                                                             Generic ESTRACE, PREMARIN



         2009 BEHP Custom Formulary                                                                        19 of 25
                                                    2009 Beaumont Employee Health Plan Thrptc Clss Formulary
                                                                                               Benefit designs may vary and formulary changes can occur at any time


      Tier                                                                                                                      Generic
                                             generic drug name - BRAND DRUG NAME                                                                                Preferred Alternatives / Comments
 1   2 3 4 5                                                                                                                    Status

 If the word 'generic' appears in the Generic Status column, that indicates that a generic equivalent is available for the listed Brand Drug Name. The cost of that generic will be indicated, for Classic members, by the Tier
listed to the left. The Brand Name drug will appear on Tier 4. If the member or their physician requests the Brand Name of a drug which has a generic equivalnet available, a DAW Penalty (the cost of the generic copay,
                            plus the difference in cost between the brand and the generic) will apply. This penalty will NOT apply toward Choice and HSA deductibles or out-of-pocket maximums.

ESTROGEN PATCHES
                                                                           ESTRADIOL TRANSDERMAL SYSTEM,
     2                                                     estradiol –                                                          generic
                                                                           CLIMARA
         3                                    estradiol                –   ESTRADERM
         3                                    estradiol                –   VIVELLE/DOT
         4                                    estradiol                –   ALORA                                                            Generic CLIMARA, ESTRADERM, VIVELLE/DOT
         4                                    estradiol                –   ESCLIM                                                           Generic CLIMARA, ESTRADERM, VIVELLE/DOT
         4           estradiol transdermal emulsion                    –   ESTRASORB                                                        Generic CLIMARA, ESTRADERM, VIVELLE/DOT
         4                                    estradiol                –   MENOSTAR                                                         Generic CLIMARA, ESTRADERM, VIVELLE/DOT
OTHER ESTROGEN PRODUCTS
      3                                   estradiol gel                –   DIVIGEL
      3                                       estradiol                –   ESTRACE VAGINAL CREAM
      3                                       estradiol                –   ESTRING
      3                                estradiol spray                 –   EVAMIST
      3                                       estradiol                –   FEMRING
      3                        estrogens, conjugated                   –   PREMARIN VAGINAL CREAM
      3                                       estradiol                –   VAGIFEM
         4                                estradiol gel                –   ESTROGEL                                                         ESTRACE, PREMARIN, VAGIFEM
         4                                estradiol gel                –   ELESTRIN                                                         ESTRACE, PREMARIN, VAGIFEM
ESTROGEN / PROGESTIN COMBINATIONS
    2               estradiol/norethindrone acetate                    – ACTIVELLA 1- 0.5mg                                     generic
      3             estradiol/norethindrone acetate                    – ACTIVELLA 0.5- 0.1mg
                                conjugated estrogen/
      3                                                                – PREMPHASE
                               medroxyprogesterone
                                conjugated estrogen/
      3                                                                – PREMPRO
                               medroxyprogesterone
                                conjugated estrogen/
      3                                                                – PREMPRO LOW DOSE
                               medroxyprogesterone
      3                      estradiol, levonorgestrel                 –   CLIMARA PRO                                                      PREMPHASE, PREMPRO
         4                    estradiol, drospirenone                  –   ANGELIQ                                                          PREMPHASE, PREMPRO
         4          estradiol/norethindrone acetate                    –   COMBIPATCH                                                       PREMPHASE, PREMPRO
         4           ethinyl estradiol noreth-acetate                  –   FEMHRT                                                           PREMPHASE, PREMPRO
         4                    estradiol, norgestimate                  –   PREFEST                                                          PREMPHASE, PREMPRO
SELECTIVE ESTROGEN RECEPTOR MODULATOR
      3                                     raloxifene                 – EVISTA
PROGESTIN DRUGS
 1                             medroxyprogesterone                     –   PROVERA                                              generic
    2                          norethindrone acetate                   –   AYGESTIN                                             generic
      3                                  progesterone                  –   CRINONE, PROCHIEVE
      3                                  progesterone                  –   ENDOMETRIM
      3                                  progesterone                  –   PROMETRIUM
ORAL CONTRACEPTIVES
    2                ethinyl estradiol-levonorgestrel                  –   ALESSE                                               generic     Use AVIANE, LESSINA
    2                   ethinyl estradiol-desogestrel                  –   CYCLESSA                                             generic     Use VELIVET
    2          ethinyl estradiol-ethynodiol diacetate                  –   DEMULEN                                              generic     Use ZOVIA
    2                   noreth a-et estra/fe fumarate                  –   ESTROSTEP/FE                                         generic     Use TRI-LEGEST FE, TILIA FE
    2                levonorgestrel-ethinyl estradiol                  –   LEVLEN                                               generic     Use LEVORA, PORTIA
    2                levonorgestrel-ethinyl estradiol                  –   LEVLITE                                              generic     Use AVIANE, LESSINA
    2                   ethinyl estradiol-desogestrel                  –   LO/OVRAL                                             generic     Use LOW-OGESTREL
    2                   noreth a-et estra/fe fumarate                  –   LOESTRIN/FE                                          generic     Use MICROGESTIN/FE
    2                   ethinyl estradiol-desogestrel                  –   MIRCETTE                                             generic     Use KARIVA
    2                 norethindrone-ethinyl estradiol                  –   MODICON, BREVICON                                    generic     Use NECON, NOTREL
    2                                   norethindrone                  –   NOR Q.D.                                             generic     Use CAMILA
    2                ethinyl estradiol-levonorgestrel                  –   NORDETTE                                             generic     Use LEVORA, PORTIA
    2                  norgestimate-ethinyl estradiol                  –   ORTHO CYCLEN                                         generic     Use MONONESSA, PREVIFEM, SPRINTEC
    2                                   norethindrone                  –   ORTHO MICRONOR                                       generic     Use ERRIN, JOLIVETTE
    2                 norethindrone-ethinyl estradiol                  –   ORTHO NOVUM 10/11                                    generic     Use NECON
    2                 norethindrone-ethinyl estradiol                  –   ORTHO NOVUM 7/7/7                                    generic     Use NECON, NOTREL
    2                       norethindrone-mestranol                    –   ORTHO NOVUM, NORINYL 1/35                            generic     Use NECON, NOTREL
    2                       norethindrone-mestranol                    –   ORTHO NOVUM, NORINYL 1/50                            generic     Use NECON
    2                  norgestimate-ethinyl estradiol                  –   ORTHO TRI-CYCLEN                                     generic     Use TRINESSA, TRI-PREVIFEM, TRI-SPRINTEC
    2                   desogestrel-ethinyl estradiol                  –   ORTHO-CEPT, DESOGEN                                  generic     Use APRI, SOLIA
    2                   ethinyl estradiol-desogestrel                  –   OVRAL                                                generic     Use OGESTREL
    2                levonorgestrel-ethinyl estradiol                  –   SEASONALE                                            generic     Use JOLESSA, QUASENSE
    2                levonorgestrel-ethinyl estradiol                  –   TRI-LEVLEN                                           generic     Use ENPRESSE, TRIVORA
    2                 ethinyl estradiol-norethindrone                  –   TRI-NORINYL                                          generic     Use ARANELLE
    2                ethinyl estradiol-levonorgestrel                  –   TRIPHASIL                                            generic     Use ENPRESSE, TRIVORA




         2009 BEHP Custom Formulary                                                                        20 of 25
                                                    2009 Beaumont Employee Health Plan Thrptc Clss Formulary
                                                                                               Benefit designs may vary and formulary changes can occur at any time


      Tier                                                                                                                      Generic
                                             generic drug name - BRAND DRUG NAME                                                                                Preferred Alternatives / Comments
 1   2 3 4 5                                                                                                                    Status

 If the word 'generic' appears in the Generic Status column, that indicates that a generic equivalent is available for the listed Brand Drug Name. The cost of that generic will be indicated, for Classic members, by the Tier
listed to the left. The Brand Name drug will appear on Tier 4. If the member or their physician requests the Brand Name of a drug which has a generic equivalnet available, a DAW Penalty (the cost of the generic copay,
                            plus the difference in cost between the brand and the generic) will apply. This penalty will NOT apply toward Choice and HSA deductibles or out-of-pocket maximums.

ORAL CONTRACEPTIVES (continued)
    2                drospirenone-ethinyl estradiol                    –   YASMIN                                               generic
      3               etonogestrel/ethinyl estradiol                   –   NUVARING
      3              norgestimate-ethinyl estradiol                    –   ORTHO TRI-CYCLEN LO
      3           norelgestromin/ethinyl estradiol                     –   ORTHO-EVRA
      3           levonorgestrel-ethinyl-estradiol                     –   SEASONIQUE
      3              drospirenone-ethinyl estradiol                    –   YAZ
        4           ethinyl estradiol-norethindrone                    –   OVCON                                                            generic contraceptives (above)
        4                                norgestrel                    –   OVRETTE                                                          generic contraceptives (above)
        4          levonorgestrel-ethinyl estradiol                    –   LYBREL                                                           generic contraceptives (above)
OXYTOCICS
      3                          methylergonovine                      – METHERGINE
                                                                                   OPHTHALMIC MEDICATIONS
OPHTHALMIC TOPICAL ANTIBACTERIAL DRUGS
 1                                        bacitracin                   –   AK-TRACIN                                            generic
 1                                      gentamicin                     –   GARAMYCIN, GENOPTIC                                  generic
 1                    erythromycin base - generic                      –   ILOTYCIN                                             generic
 1                                      tobramycin                     –   TOBREX SOLUTION                                      generic
   2                        sulfacetamide sodium                       –   BLEPH-10                                             generic
   2                              chloramphenicol                      –   CHLOROMYCETIN                                        generic
   2                                  ciprofloxacin                    –   CILOXAN SOLUTION                                     generic
   2                                       ofloxacin                   –   OCUFLOX                                              generic
      3                               azithromycin                     –   AZASITE
      3                               ciprofloxacin                    –   CILOXAN OINTMENT
      3                                 tobramycin                     –   TOBREX OINTMENT
        4                                norfloxacin                   –   CHIBROXIN                                                        Generic CILOXAN, Generic OCUFLOX
        4                              levofloxacin                    –   IQUIX                                                            Generic CILOXAN, Generic OCUFLOX
        4                              levofloxacin                    –   QUIXIN                                                           Generic CILOXAN, Generic OCUFLOX
        4                             moxifloxacin                     –   VIGAMOX                                                          Generic CILOXAN, Generic OCUFLOX
        4                               gatifloxacin                   –   ZYMAR                                                            Generic CILOXAN, Generic OCUFLOX
OPHTHALMIC TOPICAL ANTIVIRAL DRUGS
   2                                      trifluridine                 – VIROPTIC                                               generic
OPHTHALMIC CORTICOSTEROID DRUGS
   2               dexamethasone sod phosphate                         –   DECADRON                                             generic
   2                         prednisolone acetate                      –   ECONOPRED PLUS, PRED FORTE                           generic
   2                              fluorometholone                      –   FML LIQUIFILM                                        generic
   2                  prednisolone sod phosphate                       –   INFLAMASE FORTE                                      generic
      3                                 loteprednol                    –   ALREX
      3                     loteprednol etabonate                      –   LOTEMAX
                                                                                                                                            Generic DECODRON, Generic ECONOPRED PLUS, Generic
             4                                       difluprednate – DUREZOL                                                                PRED FORTE, Generic FML LIQUIFILM, Generic INFLAMASE
                                                                                                                                            FORTE
                                                                                                                                            Generic DECODRON, Generic ECONOPRED PLUS, Generic
             4                              prednisolone acetate – ECONOPRED, PRED MILD                                                     PRED FORTE, Generic FML LIQUIFILM, Generic INFLAMASE
                                                                                                                                            FORTE
                                                                                                                                            Generic DECODRON, Generic ECONOPRED PLUS, Generic
             4                                   fluorometholone – FML FORTE/S.O.P.                                                         PRED FORTE, Generic FML LIQUIFILM, Generic INFLAMASE
                                                                                                                                            FORTE
                                                                                                                                            Generic DECODRON, Generic ECONOPRED PLUS, Generic
             4                                          medrysone – HMS LIQUIFILM                                                           PRED FORTE, Generic FML LIQUIFILM, Generic INFLAMASE
                                                                                                                                            FORTE
                                                                                                                                            Generic DECODRON, Generic ECONOPRED PLUS, Generic
             4                     prednisolone sod phosphate – INFLAMASE MILD                                                              PRED FORTE, Generic FML LIQUIFILM, Generic INFLAMASE
                                                                                                                                            FORTE
                                                                                                                                            Generic DECODRON, Generic ECONOPRED PLUS, Generic
             4                                    dexamethasone – MAXIDEX                                                                   PRED FORTE, Generic FML LIQUIFILM, Generic INFLAMASE
                                                                                                                                            FORTE
                                                                                                                                            Generic DECODRON, Generic ECONOPRED PLUS, Generic
             4                         gentamicin/prednisolone – PRED–G/S.O.P.                                                              PRED FORTE, Generic FML LIQUIFILM, Generic INFLAMASE
                                                                                                                                            FORTE
                                                                                                                                            Generic DECODRON, Generic ECONOPRED PLUS, Generic
             4                                          rimexolone – VEXOL                                                                  PRED FORTE, Generic FML LIQUIFILM, Generic INFLAMASE
                                                                                                                                            FORTE
OPHTHALMIC ANTI-INFECTIVE / CORTICOSTEROID DRUGS
 1                   neomycin/polymyxin/dexameth – DEXACIDIN, MAXITROL                                                          generic
 1                          polymyxin b sulfate/tmp – POLYTRIM                                                                  generic
   2                 sulfacetamide/prednisolone ac – BLEPHAMIDE                                                                 generic
   2                    neomycin/bacitracin/poly/hc – CORTISPORIN                                                               generic
   2                 sulfacetamide/fluorometholone – FML-S                                                                      generic
   2                 neomycin/bacitracin/polymyxin – NEOSPORIN                                                                  generic
   2                       sulfacetamide/prednis sp – VASOCIDIN                                                                 generic
      3            neomycin sulf/dexamet sod phos – NEO DECADRON
      3               neomycin/polymyxin/prednisol – POLY-PRED
OPHTHALMIC ANTI-INFECTIVE / CORTICOSTEROID DRUGS (continued)
      3                tobramycin sulfate/dexameth – TOBRADEX



         2009 BEHP Custom Formulary                                                                        21 of 25
                                                    2009 Beaumont Employee Health Plan Thrptc Clss Formulary
                                                                                               Benefit designs may vary and formulary changes can occur at any time


      Tier                                                                                                                      Generic
                                             generic drug name - BRAND DRUG NAME                                                                                Preferred Alternatives / Comments
 1   2 3 4 5                                                                                                                    Status

 If the word 'generic' appears in the Generic Status column, that indicates that a generic equivalent is available for the listed Brand Drug Name. The cost of that generic will be indicated, for Classic members, by the Tier
listed to the left. The Brand Name drug will appear on Tier 4. If the member or their physician requests the Brand Name of a drug which has a generic equivalnet available, a DAW Penalty (the cost of the generic copay,
                            plus the difference in cost between the brand and the generic) will apply. This penalty will NOT apply toward Choice and HSA deductibles or out-of-pocket maximums.

      3                   tobramycin/loteprednol                       – ZYLET
OPHTHALMIC ANTIHISTAMINES
otc                            ketotifen fumarate                      –   ALAWAY                                                           OTC - Not covered benefit
    2                          ketotifen fumarate                      –   ZADITOR                                              generic
      3                            levocabastine                       –   LIVOSTIN
      3                                 azelastine                     –   OPTIVAR
      3                               olopatadine                      –   PATADAY
      3                               olopatadine                      –   PATANOL
             4                                           epinastine – ELESTAT                                                               Generic ZADITOR, LIVOSTIN, OPTIVAR, PATADAY, PATANOL

             4                                         emedastine – EMADINE                                                                 Generic ZADITOR, LIVOSTIN, OPTIVAR, PATADAY, PATANOL
OPHTHALMIC MAST CELL STABILIZERS
   2                                        cromolyn – CROLOM                                                                   generic
      3                                  nedocromil – ALOCRIL
        4                                 pemirolast – ALAMAST                                                                              Generic CROLOM, ALOCRIL
        4                               lodoxamide – ALOMIDE                                                                                Generic CROLOM, ALOCRIL
OPHTHALMIC NON-STEROIDAL ANTI-INFLAMMATORY DRUGS
   2                                      diclofenac – VOLTAREN                                                                 generic
      3                                     ketorolac – ACULAR/PF/LS
      3                                   nepafenac – NEVANAC
      3                                   bromfenac – XIBROM
GLAUCOMA AGENTS
 1                                      levobunolol – BETAGAN                                                                   generic
 1                                  acetazolamide – DIAMOX/SEQUELS                                                              generic
 1                                  pilocarpine hcl – PILOCAR                                                                   generic
 1                                             timolol – TIMOPTIC                                                               generic
   2                          brimonidine tartrate – ALPHAGAN                                                                   generic
   2                          dorzolamide/timolol – COSOPT                                                                      generic
   2                  pilocarpine hcl/epinephrine – E-PILO                                                                      generic
   2                                       carbachol – ISOPTO CARBACHOL                                                         generic Some strengths available as generic
   2                              homatropine hbr – ISOPTO HOMATROPINE                                                          generic
   2                               methazolamide – NEPTAZANE                                                                    generic
   2                                         carteolol – OCUPRESS                                                               generic
   2                                   metipranolol – OPTIPRANOLOL                                                              generic
   2                                        dipivefrin – PROPINE                                                                generic
   2                     timolol extended-release – TIMOPTIC XE                                                                 generic
   2                                   dorzolamide – TRUSOPT                                                                    generic
   2                                        betaxolol – BETOPTIC, S
      3                       brimonidine tartrate – ALPHAGAN P
      3                               brinzolamide – AZOPT
      3                            epinephrine hcl – EPIFRIN
      3                          epinephryl borate – EPINAL
      3                      echothiophate iodide – PHOSPHOLINE IODIDE
      3                             pilocarpine hcl – PILOPINE H.S.
      3                                   travoprost – TRAVATAN / TRAVATAN Z
      3                                  latanoprost – XALATAN
                                                                                                                                            Generic ALPHAGAN, Generic TIMOPTIC/XE, AZOPT, TRAVATAN,
             4                               timolol hemihydrate – BETIMOL
                                                                                                                                            XALATAN
                                                                                                                                            Generic ALPHAGAN, Generic TIMOPTIC/XE, AZOPT, TRAVATAN,
             4            brimonidine tartrate-timolol maleate – COMBIGAN
                                                                                                                                            XALATAN
                                                                                                                                            Generic ALPHAGAN, Generic TIMOPTIC/XE, AZOPT, TRAVATAN,
             4                                       apraclonidine – IOPIDINE
                                                                                                                                            XALATAN
                                                                                                                                            Generic ALPHAGAN, Generic TIMOPTIC/XE, AZOPT, TRAVATAN,
             4                                     timolol maleate – ISTALOL
                                                                                                                                            XALATAN
                                                                                                                                            Generic ALPHAGAN, Generic TIMOPTIC/XE, AZOPT, TRAVATAN,
             4                                         bimatoprost – LUMIGAN
                                                                                                                                            XALATAN
                                                                                                                                            Generic ALPHAGAN, Generic TIMOPTIC/XE, AZOPT, TRAVATAN,
             4                                        unoprostone – RESCULA
                                                                                                                                            XALATAN
OTHER OPHTHALMIC DRUGS
 1                                                atropine sulfate     –   ISOPTO ATROPINE                                      generic
    2                                                 tropicamide      –   MYDRIACYL                                            generic
    2                                           phenylephrine hcl      –   NEO-SYNEPHRINE                                       generic
      3                                            cyclopentolate      –   CYCLOGYL                                                         1% available as generic
      3                                              cyclosporine      –   RESTASIS




         2009 BEHP Custom Formulary                                                                        22 of 25
                                                    2009 Beaumont Employee Health Plan Thrptc Clss Formulary
                                                                                               Benefit designs may vary and formulary changes can occur at any time


      Tier                                                                                                                      Generic
                                             generic drug name - BRAND DRUG NAME                                                                                Preferred Alternatives / Comments
 1   2 3 4 5                                                                                                                    Status

 If the word 'generic' appears in the Generic Status column, that indicates that a generic equivalent is available for the listed Brand Drug Name. The cost of that generic will be indicated, for Classic members, by the Tier
listed to the left. The Brand Name drug will appear on Tier 4. If the member or their physician requests the Brand Name of a drug which has a generic equivalnet available, a DAW Penalty (the cost of the generic copay,
                            plus the difference in cost between the brand and the generic) will apply. This penalty will NOT apply toward Choice and HSA deductibles or out-of-pocket maximums.

                                                            RESPIRATORY MEDICATIONS
BRONCHODILATORS- BETA AGONISTS, SHORT-ACTING **Number of inhalers may vary depending on the size of the inhaler/unit
 1                                  albuterol – VOSPIRE ER                        generic
 1                           albuterol sulfate – ACCUNEB 1.25 MG                  generic
     2                                             metaproterenol – ALUPENT NEBULIZER SOLN, SYRUP                               generic
         3                                        albuterol sulfate    –   ACCUNEB 0.63MG
         3                                         metaproterenol      –   ALUPENT
         3                                               albuterol     –   PROAIR HFA
         3                                            levalbuterol     –   XOPENEX / HFA
         3                                               albuterol     –   PROVENTIL HFA
             4                                           albuterol     –   VENTOLIN HFA    PROAIR HFA, PROVENTIL HFA, XOPENEX HFA
                                                                                           Generic ACCUNEB, Generic PROVENTIL, Generic VENTOLIN,
             4                                            pirbuterol – MAXAIR AUTOHALER
                                                                                           XOPENEX HFA
BRONCHODILATORS- BETA AGONISTS, LONG-ACTING **Number of inhalers may vary depending on the size of the inhaler/unit
     3                            formoterol – FORADIL
     3                            salmeterol – SEREVENT DISKUS
             4                                        arformoterol         BROVANA                                                          Generic ACCUNEB, Generic PROVENTIL/ VENTOLIN, FORADIL

             4                               formoterol fumarate – PERFOROMIST                                                              Generic ACCUNEB, Generic PROVENTIL/ VENTOLIN, FORADIL
BRONCHODILATORS- COMBINATIONS **Number of inhalers may vary depending on the size of the inhaler/unit
    2                  albuterol sulfate/ipratropium – DUONEB                            generic  solution for inhalation
       3                      fluticasone/salmeterol – ADVAIR
       3               albuterol sulfate/ipratropium – COMBIVENT
       3                    budesonide/formorterol – SYMBICORT
BRONCHODILATORS- OTHER
 1                                              cromolyn – INTAL nebulization             generic
 1                               ipratropium bromide –                                    generic solution for inhalation
    2                               terbutaline sulfate – BRETHINE                        generic
    2                                         dyphylline – LUFYLLIN                       generic
    2                                    acetylcysteine – MUCOMYST                        generic
                                                            THEOCHRON, UNIPHYL, THEO-24,
    2                                  theophylline SR –                                  generic
                                                            THEOCAP
    2                                    aminophylline –                                  generic
    2                                ephedrine sulfate –                                  generic
    2                                   isoetharine hcl –                                 generic
    2                                  sodium chloride –                                  generic
       3                                    ipratropium – ATROVENT INHALER HFA
       3                                        cromolyn – INTAL INHALER
       3                           tiotropium bromide – SPIRIVA HANDIHALER
       3                                     nedocromil – TILADE
       3                               theophylline SR – UNIPHYL, THEOCAP, THEOCHRON
         4           guaifen/dyphylline/p-ephedrine – BRONCOMAR
         4                 guaifenesin/theophylline – ELIXOPHYLLIN-GG , KI
         4                                 theophylline – THEO-24
PULMONARY CORTICOSTEROIDS **Number of inhalers may vary depending on the size of the inhaler/unit
       3                        mometasone furoate – ASMANEX
       3                      fluticasone propionate – FLOVENT
       3                      fluticasone propionate – FLOVENT ROTADISK
       3                                    budesonide – PULMICORT FLEXHALER
       3                                    budesonide – PULMICORT RESPULES
       3                                    budesonide – PULMICORT TURBUHALER
         4                                    flunisolide – AEROBID,-M                            ASMANEX, FLOVENT, PULMICORT
         4                                  ciclesonide – ALVESCO                                 ASMANEX, FLOVENT, PULMICORT
         4                 triamcinolone acetonide – AZMACORT                                     ASMANEX, FLOVENT, PULMICORT
         4                            beclomethasone – QVAR                                       ASMANEX, FLOVENT, PULMICORT
RESPIRATORY DEVICES
                                                            AEROCHAMBER,
       3                                                  –
                                                            AEROCHAMBER/MASK
       3                                                  – EASIVENT, EASIVENT/MASK
LEUKOTRIENE MODIFIERS
       3                         montelukast sodium – SINGULAIR
         4                                    zafirlukast – ACCOLATE                              SINGULAIR
         4                                       zileuton – ZYFLO                                 SINGULAIR
         4                                   zileuton sr – ZYFLO CR                               SINGULAIR
ANTIHISTAMINE AND DECONGESTANT DRUGS
 1                                    diphenydramine – BENADRYL CAPSUKLES                 generic Prescription only
 1               chlorpheneir-phenyleph sugar free – CERON/ DM SYRUP & DROPS              generic Generic is available but this brand is in Royal Oak Pcy
 1                               guaifenesin/codeine –                                    generic Tablets only
 1                             hydroxyzine pamoate – VISTARIL                             generic
 1                                       promethazine – PHENERGAN                         generic
 1                promethazine /dextromethorphan –                                        generic Syrup




         2009 BEHP Custom Formulary                                                                        23 of 25
                                                    2009 Beaumont Employee Health Plan Thrptc Clss Formulary
                                                                                               Benefit designs may vary and formulary changes can occur at any time


      Tier                                                                                                                      Generic
                                             generic drug name - BRAND DRUG NAME                                                                                Preferred Alternatives / Comments
 1   2 3 4 5                                                                                                                    Status

 If the word 'generic' appears in the Generic Status column, that indicates that a generic equivalent is available for the listed Brand Drug Name. The cost of that generic will be indicated, for Classic members, by the Tier
listed to the left. The Brand Name drug will appear on Tier 4. If the member or their physician requests the Brand Name of a drug which has a generic equivalnet available, a DAW Penalty (the cost of the generic copay,
                            plus the difference in cost between the brand and the generic) will apply. This penalty will NOT apply toward Choice and HSA deductibles or out-of-pocket maximums.

ANTIHISTAMINE AND DECONGESTANT DRUGS (continued)
    2                                      pse/bpm – BROMFED/PD                                                                 generic
                                                       DECONSAL II, ENTEX PSE,
    2                                       gua/pse –                                                                           generic
                                                       GUAIMAX-D
    2                                      gua/hym – DILAUDID COUGH SYRUP                                                       generic
    2                                 pe/cpm/scop – EXTENDRYL/SR/JR/CHEW                                                        generic
    2                                       gua/pse – GUAIFED/PD, GUAIBID D                                                     generic
    2                                         hyd/ht – HYCODAN                                                                  generic
    2                                    azatadine – OPTIMINE                                                                   generic
    2                                   pe/cod/pro – PHENERGAN VC/CODEINE                                                       generic
    2                                       cod/pro – PHENERGAN/CODEINE                                                         generic
    2                dexchlorpheniramine maleate – POLARAMINE                                                                   generic
    2                pyrilamine/phenyltolox/phenir – POLY-HISTINE                                                               generic
    2                         clemastine fumarate – TAVIST                                                                      generic
    2                                  benzonatate – TESSALON PERLE                                                             generic
    2                             cyproheptadine –                                                                              generic
    2                                      pse/dbm –                                                                            generic
    2                                        pse/tri –                                                                          generic
       3                           tripelennamine – PBZ/SR
       3                                hydp/cpmp – TUSSIONEX
NON-SEDATING ANTIHISTAMINES
otc                                      loratadine – CLARITIN                                                                              OTC - Not covered benefit
otc                                 loratadine/pse – CLARITIN-D                                                                             OTC - Not covered benefit
otc                                 loratadine/pse – CLARITIN-D 24 HOUR                                                                     OTC - Not covered benefit
    2                                 fexofenadine – ALLEGRA                                                                    generic
       3                         pse/fexofenadine – ALLEGRA-D                                                                               12 Hour and 24 Hour
                                                                                                                                            OTC VERSIONS OF CLARITIN, CLARITIN-D, ALAVERT, Generic
             4                                       desloratadine – CLARINEX/-D
                                                                                                                                            ALLEGRA
                                                                                                                                            OTC VERSIONS OF CLARITIN, CLARITIN-D, ALAVERT, Generic
             4                                            cetirizine – ZYRTEC
                                                                                                                                            ALLEGRA
                                                                                                                                            OTC VERSIONS OF CLARITIN, CLARITIN-D, ALAVERT, Generic
             4                                 cetirizine HCL/pse – ZYRTEC/-D
                                                                                                                                            ALLEGRA
                                                                                                                                            OTC VERSIONS OF CLARITIN, CLARITIN-D, ALAVERT, Generic
             4                    levocetirizine dihydrochloride – XYZAL
                                                                                                                                            ALLEGRA
OTHER RESPIRATORY DRUGS
      3                             epinephrine – EPIPEN, EPIPEN JR
      3                             epinephrine – TWINJECT
          5          alpha-1 proteinase inhibitor – ARALAST                                                                                 Systematic lookback for GPI; limited distribution - Accredo
                                                                                                                                            Systematic lookback for other Cystic Fibrosis Drugs; if not PA
                 5                                                     –
                                                    colistimethate  COLY-MYCIN- M                                                           Required
                 5                                   epoprostenol – FLOLAN                                                                  Systematic lookback for GPI; limited distribution - Accredo
                                                                                                                                            Systematic lookback for GPI; if not PA Required; Max limit 30 per
                 5                                    ambrisentan – LETAIRIS
                                                                                                                                            month
                 5                  alpha-1 proteinase inhibitor – PROLASTIN                                                                Systematic lookback for GPI; limited distribution - Bayer Direct
                                                                                                                                            Systematic lookback for other Cystic Fibrosis Drugs; if not PA
                 5                            deoxyribonuclease – PULMOZYME
                                                                                                                                            Required; Max limit 75 per month
                 5                                      treprostinil – REMODULIN                                                            Systematic lookback for GPI
                                                                                                                                            Systematic lookback for ED drugs; if so will reject (not a benefit);
                 5                                        sildenafil – REVATIO
                                                                                                                                            reject for Max Quantity > 90 tablets per month
                 5                                     palivizumab – SYNAGIS                                                                Beaumont Infusion Pharmacy or Dr to bill Health Plan
                                                                                                                                            Systematic lookback for GPI; reject for Max Quantity > 60 tablets
                 5                                        bosentan – TRACLEER
                                                                                                                                            per month
                                                                                                                                            Systematic lookback for GPI; reject for Max Quantity > 60 amputles
                 5                                          iloprost – VENTAVIS
                                                                                                                                            per month
                 5                                 omalizumab – XOLAIR                                                                      Limited distribution drug - Accredo
                 5                  alpha-1 proteinase inhibitor – ZEMAIRA                                                                  Systematic lookback for GPI; limited distribution - Accredo
                                                                                            UROLOGICAL MEDICATIONS
ANTICHOLINERGIC ANTISPASMODICS
 1                                  oxybutynin                         –   DITROPAN                                             generic
 1                                hyoscyamine                          –   NULEV                                                generic
    2                               oxybutynin                         –   DITROPAN XL                                          generic
    2                                  flavoxate                       –   URISPAS                                              generic
      3                     tolterodine tartrate                       –   DETROL/LA
      3                             darifenacin                        –   ENABLEX
      3                             solifenacin                        –   VESICARE                                                         Generic DITROPAN/XL, DETROL, DETROL LA, ENABLEX
         4                          oxybutynin                         –   OXYTROL                                                          Generic DITROPAN/XL, DETROL, DETROL LA, ENABLEX
         4                   trospium chloride                         –   SANCTURA                                                         Generic DITROPAN/XL, DETROL, DETROL LA, ENABLEX
CHOLINERGIC STIMULANTS
    2                              bethanechol                         – URECHOLINE                                             generic
BENIGN PROSTATIC HYPERTROPHY DRUGS
 1                         doxazosin mesylate                          – CARDURA                                                generic
    2                                  terazosin                       – HYTRIN                                                 generic
    2                                finasteride                       – PROSCAR                                                generic




         2009 BEHP Custom Formulary                                                                        24 of 25
                                                    2009 Beaumont Employee Health Plan Thrptc Clss Formulary
                                                                                               Benefit designs may vary and formulary changes can occur at any time


      Tier                                                                                                                      Generic
                                             generic drug name - BRAND DRUG NAME                                                                                Preferred Alternatives / Comments
 1   2 3 4 5                                                                                                                    Status

 If the word 'generic' appears in the Generic Status column, that indicates that a generic equivalent is available for the listed Brand Drug Name. The cost of that generic will be indicated, for Classic members, by the Tier
listed to the left. The Brand Name drug will appear on Tier 4. If the member or their physician requests the Brand Name of a drug which has a generic equivalnet available, a DAW Penalty (the cost of the generic copay,
                            plus the difference in cost between the brand and the generic) will apply. This penalty will NOT apply toward Choice and HSA deductibles or out-of-pocket maximums.

BENIGN PROSTATIC HYPERTROPHY DRUGS (continued)
      3                         dutasteride – AVODART
      3                          tamsulosin – FLOMAX
                                                                                                                                            Generic CARDURA, Generic HYTRIN, AVODART, FLOMAX,
             4                                            alfuzosin – UROXATRAL
                                                                                                                                            PROSCAR
          4                       doxazosin mesylate – CARDURA XL                                                                           generic CARDURA
OTHER GENITOURINARY PRODUCTS
 1                                    phenazopyridine – PYRIDIUM                            generic
    2             sodium citrate & citric acid solution – BICITRA                           generic
    2                    citric acid/potassium citrate – CYTRA-K, POLYCITRA-K               generic
    2                          citric acid/k-na citrates – CYTRA-3, POLYCITRA/LC            generic
    2                meth/me blue/ba/salol/atp/hyos – URISED                                generic
    2                                 potassium citrate – UROCIT-K                          generic
        3                                   betaine hcl – CYSTADANE
        3               pentosan polysulfate sodium – ELMIRON
        3               pot acid phos/sod acid phos – K PHOS MODIFIED
        3                 potassium acid phosphate – K-PHOS ORIGINAL
        3                     gluconic acid/citric acid – RENACIDIN
DRUGS FOR ERECTILE DYSFUNCTION - COVERAGE FOR THESE PRODUCTS WILL VARY BY BENEFIT
                                               sildenafil – VIAGRA                                                                          Not covered by BEHP
                                            aloprostadil – CAVERJECT                                                                        Not covered by BEHP
                                                tadalafil – CIALIS                                                                          Not covered by BEHP
                                            aloprostadil – EDEX                                                                             Not covered by BEHP
                                              vardenafil – LEVITRA                                                                          Not covered by BEHP
                                            aloprostadil – MUSE                                                                             Not covered by BEHP
                                                                          DIABETIC SUPPLIES
GLUCOSE MONITORS
                      blood glucose testing supplies – ACCU-CHEK SYSTEMS                                                                    Not covered; Refer to Beaumont Home Medical
                      blood glucose testing supplies – ASCENSIA SYSTEMS                                                                     Not covered; Refer to Beaumont Home Medical
                      blood glucose testing supplies – ONE TOUCH SYSTEMS                                                                    Not covered; Refer to Beaumont Home Medical
                      blood glucose testing supplies – PRECISION SYSTEMS                                                                    Not covered; Refer to Beaumont Home Medical
                      blood glucose testing supplies – SURE STEP PRO                                                                        Not covered; Refer to Beaumont Home Medical
GLUCOSE TEST STRIPS
                      blood glucose testing supplies – ACCU-CHEK STRIPS                                                                     Not covered; Refer to Beaumont Home Medical
                      blood glucose testing supplies – ASCENSIA STRIPS                                                                      Not covered; Refer to Beaumont Home Medical
                      blood glucose testing supplies – CHEMSTRIP BG STRIPS                                                                  Not covered; Refer to Beaumont Home Medical
                      blood glucose testing supplies – ONE TOUCH STRIPS                                                                     Not covered; Refer to Beaumont Home Medical
                      blood glucose testing supplies – PRECISION STRIPS                                                                     Not covered; Refer to Beaumont Home Medical
MISC. DIABETIC SUPPLIES
    2             blood glucose syringe and needles – SYRINGE / NEEDLES                                                                     Tier 2 when obtained with Insulin or Insulin Product
        3         blood glucose syringe and needles – PEN NEEDLES                                                                           Tier 3 when obtained with other than Insulin or Insulin Products
        3             blood glucose testing supplies – NOVOFINE                                                                             Tier 3 when obtained with other than Insulin or Insulin Products
                      blood glucose testing supplies – ACCU-CHEK LANCETS                                                                    Not covered; Refer to Beaumont Home Medical
                      blood glucose testing supplies – ASCENSIA LANCETS                                                                     Not covered; Refer to Beaumont Home Medical
                      blood glucose testing supplies – ALCOHOL SWABS                                                                        OTC not covered by plan
                      blood glucose testing supplies – ONE TOUCH LANCETS                                                                    Not covered; Refer to Beaumont Home Medical
                      blood glucose testing supplies – PRECISION LANCETS                                                                    Not covered; Refer to Beaumont Home Medical
                      blood glucose testing supplies – SURE STEP LANCETS                                                                    Not covered; Refer to Beaumont Home Medical

                                                                       MISCELLANEOUS
SMOKING CESSATION **coverage may vary based on plan design
otc                                         nicotine – NICOTIN GUM/PATCHES                                                                  OTC not covered by plan
    2                                    buproprion – ZYBAN
         3                               varenicline – CHANTIX
         3                                  nicotine – NICOTROL INH/NS
WEIGHT LOSS **coverage may vary based on plan design
otc                                          orlistat – ALLI                                                                                OTC not covered by plan
    2                       phendimetrazine tartrate – BONTRIL                                                                  generic
    2                            benzphetamine hcl – DIDREX                                                                     generic
    2                             diethylpropion hcl –                                                                          generic
    2                                  phentermine –                                                                            generic
      3                           diethylpropion hcl – DIETHYLPROPION HCL TAB SR
      3                       phentermine complex – IONAMIN
      3                sibutramine hcl monohydrate – MERIDIA
      3                                      orlistat – XENICAL




         2009 BEHP Custom Formulary                                                                        25 of 25

				
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