Download 2009 PDL Standard Group and Carolina Direct

2009 PDL Standard Group
and Carolina Direct Series II
Please read this booklet for valuable information regarding your prescription drug benefit.
•
•
•
•
We have provided this information as educational material only. We designed it to help you understand your new
pharmacy benefit as well as communicate more effectively with your physician and pharmacist.
This information is not intended to replace the expertise and advice of your physician. Always consult your doctor or
pharmacist before taking prescription medication.
You can request another copy of this guide and have it mailed directly to you by calling the Customer Service number
on your medical ID card or the Member Services number on your pharmacy ID card.
If you have questions about your prescription drug program, please see your prescription drug rider with your Certificate
of Coverage or Summary Plan Description or call the number on your Carolina Care Plan pharmacy ID card.
Prescription Drug Benefits
Please review your Certificate of Coverage or Summary Plan Description for your specific drug benefits and
copayment amounts. Copayments are defined in your Certificate of Coverage or Summary Plan Description as the charge
you are required to pay for certain covered health services. Depending on your benefit plan, a copayment may be either
a set dollar amount or a percentage of eligible expenses.
Tier 1:
•
Generic Drugs
•
Tier 2:
Preferred Brand
Name Drugs
Tier 3:
Non-Preferred
Brand Name Drugs
Tier 4:
Other
Generics are basically a copy of a brand name medication. The color or shape may be
different, but the active ingredients are the same. By law, generic drugs must have the
same Food & Drug Administration (FDA) standards for quality, strength, and purity as the
brand.
Generic drugs are covered for your lowest copay, so always ask your physician about
prescribing generic drugs. If a brand name drug is dispensed when a generic is available,
the member will be responsible for the generic copayment and the difference in cost
between the brand name and generic (ancillary charge). See the Brand-to-Generic
Cross-Reference Guide in this brochure to help you and your physician find generic
alternatives to brand name drugs. For more information, call the number listed on your
pharmacy ID card or visit carolinacareplan.com.
These drugs are listed in this booklet and are covered for your 2nd tier copayment.
• Review your medications to see if they are listed. If you take a brand name drug that is
not on the list, ask your physician if a drug on the list could be used.
• Always take this PDL to your doctor’s office. Before leaving, ask the nurse or office
manager to make sure your doctor has prescribed a generic or a brand name drug on the
PDL. Remember, if your doctor prescribes a brand name drug not on the list, then
you may be responsible for the entire prescription cost.
Tier 3 is only available on some plans. See your prescription drug rider in your
Certificate of Coverage or Summary Plan Description or call the phone number on your
pharmacy ID card.
• Standard Group Plans – These drugs are not listed in this PDL and are usually covered
at a higher copayment. Ask your physician or pharmacist if there is an appropriate preferred brand name drug on the PDL or generic drug.
• Generics Preferred – Includes non-preferred and excluded drugs; such as, smoking cessation
products, non-sedating antihistamines, erectile dysfunction drugs, compounded prescriptions,
growth hormones, fertility drugs, and cough, cold, and flu medications. You are responsible
for 100% of the cost of these drugs, but you will receive the pharmacy-contracted rate
when you show your pharmacy ID card. This typically saves members 20% -30% off the
Average Wholesale Price of a drug.
Tier 4 is only available on some plans. See your prescription drug rider in your Certificate
of Coverage or Summary Plan Description or call the phone number on your pharmacy
ID card. These drugs include compounded drug products, lifestyle condition drugs, and certain
symptomatic condition drugs.
Benefit Exclusions & not covered drugs. Refer to your benefit materials for information regarding drugs or drug classes
that are not covered.
You and your physician always make final decisions regarding your treatment. However, your plan may not cover some
drugs or may require a higher copayment or ancillary charge. Always refer to your benefit materials to determine your
level of drug coverage and copayment amounts. If you have questions, call the number on your pharmacy ID card.
Z7048 R12/08
Your Pharmacy Options
Network Retail Pharmacy- We contract with over 57,000 retail pharmacies nationally. Always use a network retail pharmacy.
When you present a prescription at a network pharmacy, the pharmacist can create a personal drug profile for you to
help improve your safety or benefit use. He/she may call your physician to discuss changing your prescription. Please
use the same pharmacy every time you fill a prescription and discuss your medication therapy with your physician or
pharmacist.
Mail Service Pharmacy- This benefit can save you time and money! By switching your prescriptions to our mail service
pharmacy, you can order up to a 90-day supply for your mail service copayment. The copayments for generic and preferred
medications at mail are equal to two copayments. The copayment for non-preferred medications at mail is equal to two
and one-half retail copayments. And, your medications and/or supplies are delivered right to your home, free of shipping
costs! If you or a covered family member is prescribed an ongoing medication, take advantage of this opportunity by taking
these easy steps:
1. Ask your physician for a new prescription. Contact your physician’s office and request two prescriptions:
• A prescription for a 90-day*^ supply, with refills if appropriate, to send to Express Scripts Mail Service Pharmacy,
and
• If using the mail service for the first time, a prescription to get a limited supply from a network retail pharmacy
while the mail service request is activated.
2. Place your order online, by fax or mail.
• Online. Login to the Member section at carolinacareplan.com, click on Pharmacy Benefits Manager, click
on the link to the online Express Scripts Mail Pharmacy Service Form and follow the directions.
• By Fax from Your Physician. Provide your member ID number to the physician and ask your physician’s
office to call 1-800-879-9080 to request fax forms and instructions.
• By Mail. Request an Express Scripts Mail Pharmacy Service Form from our Customer Relations staff or
call the Member Services number on the back of your Carolina Care Plan ID card. Complete the form and
mail it in the return envelope with your new prescription for the 90-day supply and your required copayment.
Your first mail service prescription should arrive at your home within two weeks from when Express Scripts receives your
complete request.
* Due to a recent change in South Carolina law, controlled substances are limited to a one-month supply. 90-day supplies
of these controlled substances are not available through our mail service pharmacy. A 31-day supply can be filled
through the mail service pharmacy or at a local network retail pharmacy. If you are not sure whether a 90-day supply
of your prescription can be filled at our mail service pharmacy, please call our Pharmacy staff at the phone number above.
^ To receive a 90-day supply of medication, your physician must write the prescription for that amount. Express Scripts
cannot “combine” refills if your physician orders less than a 90-day supply. We will not reduce your mail service copayment
if less than a 90-day supply.
Online Tools for Managing Your Prescriptions
My Prescription Manager is a convenient, secure, and personalized way to get the most from your pharmacy benefit. Log in to
the Member section at carolinacareplan.com, click on Prescription Drug Manager, and click on the Express Scripts link to:
•
•
View benefit details, such as copay amounts or
drug coverage
Complete a Mail Service Pharmacy form
Check the status of prescription orders
•
•
•
Review up to 12 months of prescription history
Learn more about your current medication
Locate participating local pharmacies
Identification Card Requirements
According to your Contract, you must present your Carolina Care Plan ID card at the time of service. This will allow the
pharmacy to accurately process your prescription. If you do not present your ID card, you may be charged the entire
cost of the prescription. If you lose your pharmacy ID card, please call Customer Service.
Special Phone Services
Call the Member Service number listed on your pharmacy ID card for these services:
• Emergency consultation with a registered pharmacist is available at any time.
• AT&T language line to serve the needs of our foreign language-speaking members.
Hearing-impaired members may use our TTD number: 1-800-899-2114.
Manual Claims Address
Express-Scripts, BWE, P.O. Box 390873, Bloomington, MN 55439-0873, Attn: Claims Department
Programs and Requirements for Specific Medications
Our Pharmacy and Therapeutics (P&T) Committee reviews and approves additions to these programs and requirements.
These requirements and programs are subject to change periodically without notice. See your quarterly newsletter or
carolinacareplan.com for PDL updates.
Diabetic Supplies- Your pharmacy benefit covers certain diabetic supplies such as Humulin, Humalog, and Lantus insulin,
B-D syringes, B-D needles, Accu-Chek blood glucose test strips, and Accu-Chek blood glucose monitors. Covered diabetic
supplies are listed in the PDL with a “DS” by their names.
Drugs With Quantity Limits- You may receive up to a 31-day day supply of covered drugs at any network retail pharmacy.
To ensure both proper prescribing and correct billing, some drugs have additional limits regarding the amount that can be
dispensed at one time, or in one month, for one copayment. Our P&T Committee bases decisions on the manufacturers’
and FDA recommendations for dosing instructions. These drugs have a “QL” following the drug name on your PDL.
Drugs That Require Notification- Some drugs require our notification from your doctor before we will cover the prescription.
This is to ensure the diagnosis the medication was prescribed to treat is a benefit covered by your plan. These drugs have
an “N” following the drug name on your PDL. Doctors that participate with us also have a list of these drugs.
Durable Medical Equipment- Glucose meters with an average wholesale price of $100 or less, aerochambers, and spacers
are covered under your pharmacy benefits. No other durable medical equipment is covered by your pharmacy benefits.
Half Tablet Program- When clinically appropriate, we may require the use of the higher strength of a drug, when the tablets
are scored and can be easily halved. If the half-tablet program is not clinically appropriate, your physician can obtain an
override by calling our Pharmacy Benefit Manager at 800-417-8164. Coverage is only provided with authorization.
• Aceon 4mg
• Lexapro 10mg
• Paxil 10mg
• Valtrex 500mg
• Sertraline 50mg
• Celexa 20mg
• mirtazapine 7.5mg
• paroxetine 10mg tablets
• Zoloft 50mg tablets
Self-Administered Injectable (SAI) Medications- The SAIs listed below are covered for $75 under your pharmacy benefit.
Covered SAIs are under contract with our preferred provider, CuraScript Pharmacy Inc.
• Humira N
• Neulasta
• Roferon-A
• Actimmune
• Depo-Provera QL
N
• Alferon
• Eligard
• Infergen QL
• Neumega QL
• Sandostatin
• Innohep
• Neupogen
• Xolair N
• Apokyn
• Enbrel N
• Aranesp
• Epogen
• Intron A
• Peg-Intron N, QL
• Zoladex
N
N
• Arixtra
• Forteo
• Kineret
• Pegasys N, QL
• Avonex QL
• Fragmin
• Leukine
• Procrit
• Betaseron QL
• Fuzeon N
• Lovenox
• Raptiva N
• Copaxone QL
• Ganirelix
• Lupron/Depot QL,N • Rebif QL
N = Notification QL = Quantity Limit
CuraScript can also arrange convenient delivery directly to your home or your physician’s office and provide you with drug
education, refill reminders, and even the necessary supplies, if applicable. Ask your physician to contact CuraScript at (888)
773-7376 to order these medications for you, or call if you have questions. If you receive one of these medications in your
provider’s office, you may be responsible for your prescription copay.
Smoking Cessation Products- Under the Smoking Cessation Rider in your Benefit Handbook (Certificate of Coverage
or Summary Plan Description), we cover two products to help you quit smoking. In order to receive the full benefits of
this rider, you must have your physician write a prescription for each of the covered products you use, even the over-thecounter product, and have it filled at one of our retail network pharmacies. Do not use the mail service pharmacy for this
program. You should call the American Cancer Society (ACS) Quitline to receive more information about quitting smoking.
ACS can provide you with materials to help you quit. The following products are covered under this rider:
• Chantix 56 tablets per prescription or refill
• Zyban 150mg SA. 60 tablets per prescription or refill
• NicoDerm CQ 7mg patches. 28 per prescription or refill
• NicoDerm CQ 14mg patches. 28 per prescription or refill
• NicoDerm CQ 21mg patches. 28 per prescription or refill
Specialty Injectable Medications- These drugs, such as Remicade and Amevive, require administration by a health
care professional. Intravenous drugs, vaccines, and drugs used for diagnostic testing are just a few examples. While
these are not covered under your pharmacy benefit, they may be covered under your medical benefit. Ask your physician
to call CuraScript at (888) 773-7376 to order covered specialty injectable medications for you, or call if you have questions.
Step Therapy Program- We are committed to providing quality health care benefits while maximizing the use of valuable
resources. In order for us to cover certain drugs without notification and approval, you and your physician must first try
other clinically proven medications. We realize there might be instances where the step therapy program is not clinically
appropriate. If so, the physician can call our Pharmacy Benefit Manager at (800) 417-8164 for an override.
2009 Preferred Drug List
Please be aware of that this list is subject to change without notice. This list of 2nd tier, preferred brand name drugs,
applies only to those prescription plans with a 3- or 4-tier benefit. A member’s Certificate of Coverage or Summary Plan
Description determines if a medication on this list is covered. Throughout the year a brand-name medication may become
available generically. In such cases, the generic alternative becomes the preferred drug and the brand-name drug is
removed from the Preferred Drug List. Check the Brand-to-Generic Cross-Reference Guide in this brochure to find less
expensive generic alternatives to brand name drugs.
A
B
ABILIFY (excluding
Discmelt & solution)
ACCU-CHEK
Active
ACCU-CHEK
Advantage
ACCU-CHEK
Aviva
ACCU-CHEK
Comfort curve
ACCU-CHEK
Compact
ACCU-CHEK
Complete
ACTIVELLA
ACTONEL
with calcium
ACTOPLUS
MET
ACTOS
ADVAIR
DISKUS, HFA N
ADVICOR
AGGRENOX
ALPHAGAN P
ANALPRAM-HC*
ANDRODERM
ANDROGEL
APOKYN
ARICEPT
ARIMIDEX
AROMASIN
ASACOL
ASTELIN
AVELOXAGRYLIN
AVELOX
AZOR ST
DS
G
ST
BACTROBAN CREAM
BENICAR, HCT N
BYETTA INJ
C
CANASA
CARAC
CASODEX
CELEBREX N
CELLCEPT
CEENU
CIPRODEX
CLIMARA PRO
COMBIVEN
CONCERTA N
CREON
CRESTOR N
D
DAPSONE
DEPAKOTE
DIFFERIN N
DIOVAN HCT N
DROXIA
DUETACT
E
EFFEXOR XR N
EMCYT
ENTOCORT EC
EPIPEN JR INJ
ESTRADERM QL
EXELON
EXFORGE ST
F
FEMARC
FINACEA
FLOMAX
FLOVENT DISCUS,
HFA
= Diabetic Supplies
F
M
FORADIL
G
GANTRISIN
GLEEVAC
GLUCAGEN
H
HECTOROL
HUMALOG vials only
HUMULIN vials only
I
INTAL inhaler
IRESSA
J
JANUMET N
JANUVIA N
K
KALETRA
KEPPRA
KLARON 10%
K-LYTE DS
K-PHOS original
L
LATAIRIS
LANTUS vials only
LEVEMIR VIALS
LEVITRA
LEVOXYL
LEXPRO ST
LIALDA
LOTREL ST
LOTRONEX
LOVAZA
LUMIGAN
LYRICA ST
N
MENEST
METADATE CD
METANX
MUSE
N
NAMENDA
NASONEX
NATACYN
NEXIUM ST
NIASPAN
NILANDRON
NOVAREL
NOVOFINE 30
NOVOLIN vials only
NOVOLOG vials only
= Generic is available for at least one or more strengths of the brand-name medication.
U
Q
QVAR
R
RAPTAMUNE
RAZADYNE
RENAGEL
RESTASIS N
REVATIO N
RISPERDAL (excluding
m-tabs)
S
SEREVENT DISKUS
SEROQUEL XR N
SIMCOR ST
SINGULAIR ST
SKELAXIN
O
SOMAVERT
ONE TOUCH DS QL
SPIRIVA
OPANA ER
STARLIX
ORTHO TRI-CYCLEN LO STRATTERA ST
OXYCONTIN
SULAR
OXYTROL ST
SURESTEP DS
SYMBICORT
P
SYMLIN INJ
PERFOROMIST
T
PLAVIX
PRANDIN
TARCERA
PRECISION SURE DOSE TAZORAC N
PRECISION XTRA
TEGRETOL XR
PREMARIN
TEMODAR
PREMPHASE
TIKOSYN
PREMPRO
TILADE
PENTASA
TOPAMAX N
PREVACID ST
TRICOR N
PREVPAC
TRUSOPT
PROAIR HFA
TUSSIONEX
PROGRAF
TWINJECT INJ
PROMETRIUM
PROTOPIC ST
PROVENTIL HFA
PROVIGIL N
= Prior Authorization Required
= Step therapy may apply to some or all strengths of drug.
PULMICORT
QL
QL
ULTRASE MT
UNIPHYL G
UROXATRAL
URSO, FORTE
V
VAGIFEM
VFEND N
VENTOLIN HFA
VENTARIS
VEPESID
VIGOMOX
VIVELLE DOT
VYTORIN N
W-X-Y-Z
XALATAN
XELODA
YASMIN
YAZ
ZADITOR
ZETIA N
ZOMIG, ZMT QL
ZOVIRAX OINT
ZYLET
ZYMAR
ZYMPLAR
ZYPREXA
(excluding Zydis)
= Quantity Limits
Brand-to-Generic Cross-Reference Guide
Find less expensive generic alternatives to brand name drugs
Take this guide to your next doctor’s visit and ask you physician about prescribing generic drugs.
• Generics are as safe and effective as their brand name counterparts.
• Most generics cost 40% to 50% less than brand name drugs.
• Generics are widely accepted by physicians and pharmacists.
• There are hundreds of generics that treat a wide range of medical conditions including heartburn, allergies,
depression, diabetes, and high blood pressure.
• Using generics helps keep medical care affordable for you.
This guide will help you and your physician choose a generic alternative for a brand-name medication. It will not only
provide you with a selection of drug choices, it could also save you money.
A
ACCURETIC.................................
ACCUTANE ..................................
ADALAT CC..................................
ADALAT ........................................
ADDERAL.....................................
ALDACTONE................................
ALLEGRA .....................................
AMARYL .......................................
AMBIEN ........................................
ARAVA ..........................................
ATARAX ........................................
ATIVAN .........................................
ATROVENT ..................................
AUGMENTIN ................................
AZASAN .......................................
E
quinaretic
amnesteem, sotret
nifediac
nifedipine
amphetamine salts
spironolactone
fexofenadine
glimepride
zolpidem
leflunomide
hydroxyzine
lorazepam
ipratropium
amox TR/K CLV
azathioprine
mupirocin
sotalol
timolol
bumetanide
buspirone
C
CARDIZEM...................................
CARDIZEM CD ............................
CARDIZEM SR.............................
CARDURA....................................
CATAPRES...................................
CECLOR.......................................
CEFTIN.........................................
CEFTIN SUSPENSION................
CELEXA........................................
CIPRO ..........................................
CLIMARA......................................
CLEOCIN VAGINAL OVULE ......
CLINORIL .....................................
CODICLEAR DH ..........................
COLAZAL .....................................
CORGARD ...................................
CORTISPORIN.............................
COUMADIN ..................................
diltiazem
cartia
diltiazem ER
doxazosin mesylate
clonidine
cefaclor
cefuroxime
cefuroxime suspension
citalopram
ciprofloxacin
estradiol tds
clindamycin 2% vaginal cream
sulindac
hydrocodone/guaifenesin
balsalazide disodium
nadolol
NEO/polymyxin/HC ear
warfarin
F
FLEXERIL.....................................
FLONASE.....................................
FLOXIN OTIC ...............................
FOSAMAX PLUS D..........................
cyclobenzaprine
fluticasone
ofloxacin eye drops
alendronate tablet plus vitamin D
GLUCOPHAGE ............................ metformin
GLUCOTROL ............................... glipizide, glipizide ER
GLUCOVANCE............................. glyburide/metformin
H
HALCION......................................
HYDRODIURIL.............................
HYTONE.......................................
HYTRIN ........................................
triazolam
hyrdochlorothiazide
hyrdocortisone
terazosin
I
IMITREX TABLET, INJECTION*....
IMURAN........................................
INDERAL ......................................
INDOCIN.......................................
ISMO.............................................
ISTALOL .......................................
sumatriptan
azathioprine
propranolol
indomethacin
isosorbide mononitrate
timolol
J
JENEST ........................................ necon
K
KEFLEX ........................................
KLARON 10% ..............................
KLONOPIN ...................................
KYTRIL .........................................
cephalexin
Sulfacetamide Sodium 10%
clonazepam
granisetron
L
D
DAYPRO.......................................
DEMADEX....................................
DEMEROL....................................
DEMULEN ....................................
DESOGEN....................................
DESYREL.....................................
DIABETA.......................................
DIFLUCAN....................................
DILANTIN .....................................
DIPROLENE AF ...........................
DOVONEX SOLUTION................
DURICEF......................................
venlafaxine
fluorouracil cream
fluorouracil cream
guaifenex PSE
erythromycin base
lithium carbonate
estradiol
syntest D.S.
syntest H.S.
G
B
BACTROBAN ...............................
BETAPACE ...................................
BETIMOL ......................................
BUMEX .........................................
BUSPAR .......................................
EFFEXOR.....................................
EFUDEX 5% CREAM ..................
EFUDEX OCCLUSION PACK .....
ENTEX PSE .................................
ERY/TAB.......................................
ESKALITH ....................................
ESTRACE.....................................
ESTRATEST D.S..........................
ESTRATEST H.S..........................
oxaprozin
torsemide
meperidine
zovia
apri, solia
trazodone
glyburide
fluconazole
phenytoin
betamethasone dipropionate
calcipotriene solution
cefadroxil
LAMISIL ........................................
LAMICTAL ....................................
LEVBID, LEVSIN..........................
LEVLEN ........................................
LEVLITE .......................................
LO/OVRAL....................................
LODINE ........................................
LOESTRIN....................................
LOPID ...........................................
LOPRESSOR ...............................
LORCET .......................................
LOTENSIN....................................
LOTENSIN HCT ...........................
LOTREL........................................
LUVOX..........................................
terbenifine
lamotrigine
hyoscyamine
portia, levora
aviane
cryselle, low/ogestrel
etodolac
junel, microgestin
gemfibrozil
metoprolol
hydrocodone/apap
benazepril
benazepril /HCTZ
benazeril/amlopidine
fluvoxamine
Brand-to-Generic Cross-Reference Guide (continued)
M
MACROBID ..................................
MACRODANTIN...........................
MAXIDE ........................................
MEDROL ......................................
MEVACOR....................................
MICRO K ......................................
MICRO K 8 MEQ EXTENCAPS ..
MINOCIN ......................................
MIRCETTE ...................................
MOBIC ..........................................
MONOPRIL ..................................
MS CONTIN, MSIR ......................
S
nitrofurantoin/macro
nitrofurantoin MC
triamterene/HCTZ
methylprednisolone
lovastatin
klor/con, potassium CL
potassium chloride er
minocycline
kariva
meloxicam
fosinopril
morphine
SECTRAL .....................................
SERAX..........................................
SERZONE ....................................
SEASONIQUE..............................
SINEMET......................................
SINEQUAN...................................
SLO/PHYLLIN ..............................
SOMA ...........................................
SONATA........................................
SPORANOX .................................
SUDAL..........................................
SUMYCIN .....................................
SYNTHROID ................................
naproxen
gabapentin
ketoconazole
tamoxifen
portia, levora
labetalol
camila
amlodipine
T
N
NAPROSYN .................................
NEURONTIN ................................
NIZORAL TABLETS .....................
NOLVADEX...................................
NORDETTE..................................
NORMADYNE ..............................
NOR/Q/D ......................................
NORVASC ....................................
O
OMINICEF ....................................
ORTHO TRI/CYCLEN ..................
ORTHO/CEPT ..............................
ORTHO/CYCLEN.........................
OXYIR...........................................
cefdinir
trinessa, tri/sprintec
apri, solia
sprintec
oxycodone
P
PANLOR DC.................................
PARNATE .....................................
PAXIL ............................................
PERCOCET..................................
PLAQUENIL .................................
PLENDIL.......................................
PLETAL.........................................
POLYTRIM....................................
PRAVACHOL ................................
PRECOSE ....................................
PRED FORTE ..............................
PRINIVIL.......................................
PRINZIDE .....................................
PROCARDIA ................................
PROCARDIA XL...........................
PROSCAR....................................
PROTONIX ...................................
PROVERA ....................................
PROZAC.......................................
trezix capsule
tranylcypromine sulfate
paroxetine
endocet, oxycodone/apap
hydroxychloroquine
felodipine
cilostazol
polymyxin B/TMP
pravastatin
acarbose
prednisolone acetate
lisinopril
lisinopril/HCTZ
nifedipine
nifedical
finasteride
pantoprazole
medroxyprogesterone
fluoxetine
R
RELAFEN .....................................
REMERON ...................................
REMERON SOLTAB ....................
RESTORIL....................................
RETIN-A .......................................
RHEUMATREX.............................
RITALIN ........................................
ROXICODONE.............................
RELAFEN .....................................
REMERON ...................................
REMERON SOLTAB ....................
REQUIP, STARTER KIT...............
RESTORIL....................................
RETIN-A .......................................
RHEUMATREX.............................
RITALIN ........................................
ROXICODONE.............................
nabumetone
mirtazapine tablet
mirtazapine soltab
temazepam
tretinoin
methotrexate
methylphenidate
oxycodone
nabumetone
mirtazapine tablet
mirtazapine soltab
ropinirole
temazepam
tretinoin
methotrexate
methylphenidate
oxycodone
TAGAMET.....................................
TEGRETOL ..................................
TEMOVATE ..................................
TENORETIC.................................
TENORMIN ..................................
THEO/DUR...................................
TIAZAC .........................................
TIMOPTIC.....................................
TOBREX .......................................
TOFRANIL ....................................
TOPICORT ...................................
TORADOL ....................................
TOPROL XL..................................
TRANDATE...................................
TRANXENE T/TAB.......................
TRI/LEVLEN .................................
acebutolol
oxazepam
nefazodone
quasense, jolessa
carbidopa/levodopa
doexpin
theophylline
carisoprodol
zaleplon
iraconzaole
guaifen/pseudoephedrine
tetracycline
levothyroxine
cimetidine
carbamazepine
clobetasol
atenolol/chlorthal
atenolol
theophylline
taztia
timolol
tobramycin
imipramine
desoximetasone
ketorolac
metoprolol succinate
labetalol
clorazepate
enpresse, trivora
U
ULTRAM .......................................
UNITHROID..................................
UNIPHYL ......................................
UTIRA-C .......................................
tramadol
levothyroxine
theophyline er
urogesic-blue
V
VASORETIC .................................
VASOTEC.....................................
VICODIN.......................................
VOLTAREN...................................
VOLTAREN 0.1% EYE DROPS...
enalapril/HCTZ
enalapril maleate
hydrocodone/apap
diclofenac
diclofenac sodium eye drops
W
WELLBUTRIN SR ........................ bupropion
WELLBUTRIN XL......................... bupropion ER
X
XANAX.......................................... alprazolam
Z
ZESTORETIC...............................
ZESTRIL .......................................
ZIAC..............................................
ZOCOR.........................................
ZOLOFT........................................
ZONEGRAN .................................
lisinopril/HCTZ
lisinopril
bisoprolol/HCTZ
simvastatin
sertraline
zonisamide
Nonpreferred Medications with Selected
preferred Alternatives
The following is a list of some non-preferred medications that are commonly prescribed and examples of selected alternatives
that are included on the Preferred Drug List.
Take this guide to your next doctor’s visit and ask you physician about prescribing medications that are including on the
Preferred Drug List.
•
•
Column one lists examples of non-preferred medications
Column two list some examples of alternatives that can be prescribed
A
D
ACCOLATE .................... Singulair
ACEON .......................... Generic Ace Inhibitor
ACIPHEX ....................... omeprazole, pantoprazole, Nexium,
Prevacid
ACULAR, LS, PF ........... Voltaren Ophthalmic
AEROBID, M.................. Flovent Diskus/HFA, Pulmicort, Qvar
AGGRENOX .................. aspirin + dipyridamole
ALAMAST ...................... cromolyn sodium
ALLEGRA-D................... loratadine-D Otc
ALOCRIL........................ cromolyn sodium
ALOMIDE ....................... cromolyn sodium
ALORA ........................... Generic Patches, Estraderm, Vivelle Dot
ALREX ........................... Generic steroids
ALTACE.......................... Generic Ace Inhibitor
ALTOPREV
lovastatin, pravastatin, simvastatin,
Crestor, Vytorin
ST
AMBIEN CR ................ zolpidem tartrate
AMERGE ....................... Imitrex*, Zomig/ZMT
ANGELIQ ....................... Activella, Prempro/Premphase
ANTARA......................... fenofibrate, Tricor
ANZEMET ...................... ondansetron
APIDRA.......................... Humalog vials, Novolog vials
ASCENSIA ..................... Accu-Chek, One-Touch
ASMANEX ..................... Flovent Diskus/HFA, Pulmicort, Qvar
ATACAND ...................... Benicar, Diovan
ATACAND, HCT ............. Benicar HCT, Diovan HCT
ATRALIN PA ..................... Tretinion, Differin
AVALIDE ........................ Benicar HCT, Diovan HCT
AVANDAMET ................. Actoplus Met
AVANDARYL .................. Duetact
AVANDIA........................ Actos
AVAPRO......................... Benicar, Diovan
AVITA ............................. tretinoin
AVODART ...................... finasteride, Flomax, Uroxatral
AXERT ........................... Imitrex*, Zomig/ZMT
AZELEX ......................... tretinoin, Finacea
AZMACORT ................... Flovent Diskus/HFA, Pulmicort, Qvar
AZOPT ............................ brimonidine tartrate, Alphagan P, Trusopt*
DETROL, LA .................. oxybutynin/er
DIFFERIN XL ................. tretinoin
DIPENTUM .................... Asacol, Colazal*, Pentasa
DITROPAN..................... oxybutynin cl er
DIVIGEL ......................... Generic patches, Alora
DUAC gel ....................... benzoyl peroxide + generic clindamycin
DYNACIRC,CR
amlodipine besylate, felodipine er,
nifedipine er, Sular*
B
GEODON ....................... Abilify (regular tabs),
Risperdal* (non M-tabs),
Seroquel/XR, Zyprexa (non-Zydis)
BECONASE ................... fluticasone, Nasonex
BENZACLIN ................... benzoyl peroxide + generic clindamycin
BENZAMYCIN, PAK ...... erythromycin/benzoyl peroxide
BIAXIN, XL..................... clarithromycin, er
BONIVA tabs .................. Actonel, Fosamax*
BROVANA...................... Perforomist
C
CADUET ......................... amlodipine + HMG – simvastatin, Crestor
CARDENE SR
amlodipine besylate, felodipine er,
nifedipine er, Sular*
CEDAX........................... amox tr/k clv,cefdinir
CENESTIN ..................... Menest, Premarin
CIALIS............................ Levitra
COMBIPATCH................ Climara Pro
COSOPT ......................... brimonidine tartrate, Alphagan P, Trusopt*
COVERA-HS.................. verapamil er
COZAAR ........................ Benicar, Diovan
CYCLESSA .................... cesia, velivet
CYMBALTA .................... Effexor, Venlafaxine
E
EDEX ............................. Caverject, Muse, Levitra
ELESTAT........................ cromolyn sodium
ELESTRIN ..................... Generic patches, Alora
ELIDEL........................... Protopic*
EMADINE....................... cromolyn sodium
ENABLEX ...................... oxybutynin/er
ENJUVIA ........................ Menest, Premarin
ESTRASORB ................. Generic patches, Alora
ESTRATEST,H.S............ syntest d.s, h.s
ESTROGEL ................... Generic patches, Alora
EXUBERA ...................... Humalog vials, Novolog vials
F
FACTIVE ........................ ciprofloxacin/er, ofloxacin, Avelox, Levaquin
FAMVIR.......................... acyclovir
FemHRT......................... Activella, Prempro/Premphase
FEMTRACE ................... Menest, Premarin
FLOXIN OTIC ................ Ciprodex*
FML FORTE................... Generic steroids
FOCALIN, XR ................ dexmethylphenidate, methylphenidate,
Concerta, Metadate CD
FOSAMAX SOLUTION .. alendronate tablet
FOSRENOL ................... Renagel
FREESTYLE .................. Accu-Chek, One Touch
FROVA ........................... Imitrex*, Zomig/ZMT
G
H
HELIDAC ....................... Prevpac
HUMALOG syringe ........ Humalog vial,
HUMULIN syringe .......... Humulin vial,
HYZAAR ........................ Benicar HCT, Diovan HCT
I
IMITREX NASAL............ Zomig Nasal
INNOPRAN XL............... propranolol er
INVEGA ......................... Abilify (regular tabs),
Risperdal* (non M-tabs),
seroquel/XR, Zyprexa (non- Zydis)
IOPIDINE ....................... brimonidine tartrate,
Alphagan P, Trusopt*
ISTALOL......................... timolol maleate
K
KRISTALOSE................. lactulose
KYTRIL .......................... ondansetron
Nonpreferred Medications with Selected Preferred Alternatives (continued)
L
R
LESCOL, XL
RELPAX ......................... Imitrex*, Zomig/ZMT
RHINOCORT AQUA ...... fluticasone, Nasonex
RITALIN LA .................... ethylphenidate, Concerta*
lovastatin, pravastatin,
simvastatin, Crestor, Vytorin
LEVEMIR ....................... Lantus vials
LIPITOR ......................... lovastatin, pravastatin, simvastatin, Crestor,
Vytorin
LOFIBRA........................ fenofibrate, Tricor
LUNESTA....................... zolpidem
M
MAXAIR ......................... Proair , Proventil , Ventolin (all HFA)
MAXALT,MLT ................. Imitrex*, Zomig/ZMT
MENOSTAR ................... Generic patches, Alora
METROCREAM,
GEL, LOTION ............ metronidazole
MICARDIS ..................... Benicar, Diovan
MICARDIS HCT ............. Benicar HCT, Diovan HCT
N
NASACORT AQ ............. fluticasone, Nasonex
NASAREL ...................... fluticasone, Nasonex
NEVANAC ...................... Voltaren Ophthalmic
NOROXIN ...................... ciprofloxacin/er, ofloxacin, Avelox,
Levaquin
NORVASC...................... amlodipine besylate
NOVOLIN cartridge........ Novolin vial
NOVOLOG cartridge...... Novolog vial
NUVARING .................... Ortho Tri-Cyclen Lo, Yasmin, Yaz
S
SANCTURA ................... oxybutynin/er
SEASONIQUE ............... quasense, jolessa
SKELID .......................... Actonel, Fosamax*
SOF-TACT ..................... Accu-Chek, One
Touch
SONATA......................... zolpidem
SPECTRACEF ............... amox tr/k clv, cefdinir
SYMBYAX ...................... fluoxetine+ Zyprexa (non-Zydis)
T
TESTIM .......................... Androderm, Androgel
TEVETEN ...................... Benicar, Diovan
TEVETEN HCT .............. Benicar HCT, Diovan HCT
TOBRADEX ................... Zylet
TRAVATAN ..................... Lumigan, Xalatan
TRIGLIDE ...................... fenofibrate, Tricor
U
ULTRASE, MT ............... amylase/
lipase/
protease
O
V
OMNICEF ...................... cefdinir
OPTIVAR........................ cromolyn sodium
ORTHO EVRA ............... Ortho Tri-Cyclen Lo, Yasmin, Yaz
VALTREX ....................... acyclovir
VERAMYST ................... fluticasone, Nasonex
VERELAN PM................ verapamil er
VESICARE ..................... oxybutynin/er
VEXOL ........................... generic steroid
VIAGRA ......................... Levitra
VYVANSE ...................... Concerta,
Metadate CD
P
PATADAY, PATANOL...... cromolyn sodium
PAXIL CR ....................... paroxetine (immediate release),
Lexapro
PEG-INTRON,
REDIPEN ....................... Pegasys
PENLAC......................... Generic antifungals
PRAMOSONE................ lidocaine-hc
PRECISION QID............ Accu-Chek, One Touch
PCX................................ Sof-Tact
PREFEST ...................... Activella, Prempro/Premphase
PREGNYL ...................... chorionic gonadotropin, Novarel
PROZAC WEEKLY
fluoxetine (daily), citalopram,
paroxetine, Lexapro
PYLERA ......................... Prevpac
W
WELCHOL ..................... cholestyramine, Colestipol
X
XIBROM ......................... Voltaren
ophthalmic
XOPENEX...................... albuterol neb
XOPENEX...................... albuterol, Proair, Proventil and Ventolin
HFA
Q
QUIXIN........................... ciprofloxacin, ofloxacin, Vigamox,
Zymar
Z
ZEGERID ST .................... omeprazole, pantoprazole, Nexium,
Prevacid
ZIANA ............................ tretinoin + clindamycin
ZOFRAN, ODT............... ondansetron