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St. George’s University
Student Health Plan
Prescription Drug Program
2014-2015
Handbook
Updated 6.2014
General Information
The St. George’s University Prescription Drug Program (the “Program” or
the “Plan”) is a part of the St. George’s University Health Plan (sometimes
also called the “Plan”). The purpose of the Program is to provide eligible
employees and their spouses and dependents with low-cost availability of
most prescription drugs. The prescription drug benefits are provided under
the St. George’s University Health Plan pursuant to a contract between
Employee Health Insurance Management, Inc. (“EHIM”) and St. George’s
University which is incorporated in this summary by reference.
Under the Prescription Drug Program, the Plan generally will pay, subject
to the co-payments (see p.2), limitations (see pgs.4-7) and exclusions (see
pg.17) described below, for all prescription drugs that are necessary for
the treatment of an illness or injury of a covered individual (as described
in the general provisions of the St. George’s University Health Plan).
EHIM, as the Prescription Plan Supervisor, is responsible for the routine
processing of claims and benefits under this Program. In addition, EHIM
maintains a list of Participating Pharmacies. If you elect to obtain
prescription drugs at a Participating Pharmacy, the Plan will pay the full
cost of any covered prescription other than the applicable copayment
(described below).
If you elect to use a Non-Participating Pharmacy, your final cost may
exceed the applicable copayment. Also, you will have to pay the full
pharmacy charge at the time of service and then seek reimbursement from
the Plan.
Further information about the Program is found in the following pages.
This summary of the Prescription Drug Program is a supplement to the
Summary Plan Description of the St. George’s University Health Plan.
Certain Health Plan information required by ERISA may be found in the
primary Summary Plan Description. To the extent of any conflict between
the primary Summary Plan Description and the terms of this summary
regarding the Prescription Drug Program, this summary will control.
While this summary is intended to be an accurate summary of the benefits
available, in the event of any conflict between the terms of this summary
and the Plan itself, the terms of the Plan will control. The Plan is intended
to create certain legally enforceable rights for Plan participants.
Therefore, you are specifically advised that you should contact EHIM, the
Prescription Plan Supervisor before making a decision about expenditures
that may be covered under the Plan.
Page |1
Updated 6.2014
St. George’s University
Prescription Drug Program
Schedule of Participant Co-payments
$10
$30, then
20%
$50, then
20%
Tier 1 Copayment: (all covered GENERIC Drugs)
Tier 2 Copayment: (all covered Preferred BRAND NAME Drugs)
Tier 3 Copayment: (all Non Preferred Medications)
(See pages 8-15)
Specialty Drugs (Prior Authorization Required)
$50, then
20%
(Examples: Oncology, Multiple Sclerosis, Organ Transplant..)
Please contact EHIM 1-800-311-3446 for additional information
$0.00
$6,000
Single
$8,000 –
family
Copayment for EHIM OTC Program and certain medication
acknowledged by the Affordable Care Act (ACA)
Your plan includes a maximum out of pocket (OOP) for prescription
benefits. Only medications filled at participating pharmacies will go
towards the maximum out of pocket. Once the OOP is met, eligible
medications will be covered at 100% for the remaining plan year
Only GENERIC Drugs are to be dispensed unless the prescription
states “Dispense as Written” (DAW) per the prescribing physician.
If you or your physician request a brand name prescription to be dispensed when
there is an exact generic equivalent (DAW), you will be responsible for the
difference in cost between the brand and generic plus the applicable copayment
(Tier 3 copayment).
COVERED DRUGS




All Prescription drugs not specifically excluded
Compounded prescriptions which contain at least one legend drug
Insulin on prescription and needles and syringes when dispensed with
Insulin
Contraceptives
Page |2
Updated 6.2014
PRIOR AUTHORIZATION – The following categories of medication require
medical documentation submitted by treating physician and are subject
to clinical review and approval:


Specialty Medications (see list)
All ADHD/ADD Medications
EHIM’s Prior Authorization process is as follows:
1. The member, pharmacist or physician contacts EHIM’s
pharmacy help desk at (800)311-3446 to initiate the prior
authorization process.
2. Once EHIM is contacted, the assigned clinical case manager
will send the necessary paperwork to the prescribing physician for
their completion. The physician may be asked to provide medical
documentation to EHIM outlining the member’s diagnosis,
previous failed treatments, duration of therapy, and specific
course of treatment the physician is requesting.
3. Upon receiving the completed documentation from the
prescribing physician, the clinical case manager will then review
the information, and a determination will be made to approve or
deny the request. Once the determination has been made, the
patient will be notified. This entire process is dependent upon the
prescribing physician’s response time to EHIM’s request for
information. Determinations are made fairly quickly, typically
within 24 – 48 hours of our receipt of all required documentation.
Please keep in mind that any medical or prescription information
submitted to EHIM is highly confidential and used only to help
determine whether the Prior Authorization request may be
approved.
Specialty Medications – Tier 3 Copayment
Specialty medications are generally used to treat and manage
complex conditions such as Multiple Sclerosis, Cancer, and
Transplants. In addition to their high cost, these specialty
medications may be self-injected, may require special handling.
Coverage of these medications is subject to the terms and
conditions of your specific plan description as administered by
EHIM. Examples of specialty medications are listed below, but
are not all-inclusive. This list is subject to change without notice.
Page |3
Updated 6.2014
Prescription Right to Appeal an Adverse Determination
If the claim you have submitted using EHIM’s Prescription Reimbursement
Form is denied in whole or in part, or if your coverage is rescinded or
terminated for cause, you will be notified in writing or by e-mail. The
notice, as applicable, will provide information to help you identify the
claim, explain the reason for the denial, make specific references to the
provisions of the plan on which the decision is based, list any rules,
standards or guidelines used in making the decision, and describe any
additional information needed to approve your claim. If your claim is
denied based on medical necessity, experimental treatment, or a similar
exclusion or limit, the notification will either explain the scientific or
clinical judgment underlying the denial, or advise you that an explanation
will be provided free of charge. The notice will also explain your right to
appeal the decision, including a statement of your right to bring a civil
action under ERISA Section 502(a) if your claim is denied on appeal and
provide contact information for an office of health insurance consumer
assistance or a health insurance ombudsman program, if such a service has
been established in your state.
If you were undergoing a course of treatment that required prior
authorization, and the plan reduces or terminates that course of treatment
(other than because the plan has been amended or terminated), you will
also receive an explanation of the change and of your right to appeal the
decision. If your claim involves an urgent care situation, the notification
will also explain the expedited review process available for such claims.
Internal Review Procedures
First Level Review
Within 180 calendar days after you receive a notice of denial, you or your
authorized representative may appeal the decision. You may review and
receive at no cost a copy of the plan document and any other documents
relevant to your claim. If, after reviewing these documents, you think your
claim is valid, you may request a review by your plan. When requesting a
review, please submit any documents and comments you believe relevant
to your claim to the address specified in the written notice denying your
claim. Your request for review must raise any and all issues you believe
relevant to your claim. Also include your group number, daytime
telephone and service date.
The appeal will be assigned to a reviewer who did not make the initial
determination and does not work for the person who did. The reviewer
will not give any deference to the prior decision denying your claim, but
will take into account all comments, documents, testimony and other
information and evidence you have submitted, regardless of whether this
information was considered when your claim was denied. If the denial is
based in whole or in part on a medical judgment, the reviewer may consult
with another health care professional who is trained and experienced in
the field of medicine involved in the medical judgment and who was
Page |4
Updated 6.2014
neither consulted in connection with the denial nor a subordinate of such
an individual.
If the reviewer consults with another health care
professional and your appeal is denied, the reviewer will provide you with
information about the other health care professional whether or not the
reviewer relied on the health care professional’s advice.
Before the reviewer makes a decision, the plan will notify you of any
additional evidence or rationale for denying the claim and provide you with
an opportunity to present additional evidence in response. You will be
notified of the appeal decision within 30 days either in writing or
electronically (15 days in the case of a prior authorization request; 72 hours
if the claim involves an urgent care situation).
Right to a Second Review
If your claim denial is upheld at the first level of review, you may request
a second level of review within 60 calendar days of the first decision.
Again, you may review and receive at no cost documents relevant to your
claim, and may submit any evidence you would like considered to the
address specified in the notice your received regarding the first-level
review decision. The second level review will not be conducted by anyone
who made the prior decision denying your claim nor the subordinate of
someone who denied your claim. The review will not give any deference
to the prior decisions denying your claim, but will take into account all
comments, documents, testimony, and other information you have
submitted, regardless of whether the information was submitted or
considered in the prior determinations. Your request for a second level
review must raise any and all issues you believe relevant to your claim.
As with the first-level review, a health care professional will be consulted
if necessary, and you will be given information about the health care
professional if your claim is denied. Before a final decision is made, the
plan will notify you of any additional grounds for denying your claim and
provide you with an opportunity to present additional evidence in
response.
You will be notified of the final determination within 30 days of the date
you submitted your request for a second-level review. The decision is final,
unless you choose to voluntarily submit your appeal to an independent
review organization (see “External Review”) below.
Second-Level Review for Prior authorization Requests
If you request a second-level review of a decision denying a prior
authorization request, the appeal will follow the same procedures
described above, except that the plan will notify you of the results within
15 days of your written request.
External Review
Page |5
Updated 6.2014
Once you have exhausted the internal appeals procedures described above,
you or your authorized representative have the right to request a
voluntary, external review from an Independent Reviewing Organization
(“IRO”). This external review process is available if your claim was denied
based on a medical judgment or if your appeal involves a rescission of
coverage (whether or not the rescission has any effect on any particular
benefit at the time of the rescission). Claims regarding plan eligibility and
contractual or legal interpretations of the plan are not eligible for external
review. This external review procedure is voluntary and you do not have
to seek an external review in order to have your claim reviewed by a court.
You will have 120 days from the date you receive the final notice of claim
denial to request an external review, following the procedures set forth in
the claim denial letter. Once the plan receives your request for an
external review, the plan will have five business days to complete a
preliminary review to determine whether your claim is eligible for external
review.
If your request for an external review is incomplete, the plan will give you
additional time to submit the additional information—either until the end
of the four-month appeal deadline, or if the deadline has already expired,
then 48 hours from the time you receive notice that the claim is
incomplete.
The IRO will notify you once it has received the external appeal and will
give you at least 10 business days to submit any additional information that
you want the IRO to consider when reviewing your claim. The IRO will
notify you in writing of its decision within 45 days of receiving your
claim. The IRO’s decision will be binding on you and the plan, unless
additional remedies are available to you under state or federal law.
Expedited Review
Expedited Review in Urgent Care Situations
Prior authorization requests in urgent care situations are handled on an
expedited basis, and have only one level of review. An urgent care
situation exists if (a) the ordinary time frame for an appeal would seriously
jeopardize your life, health or ability to regain maximum functionality or,
in the opinion of your physician, would cause you severe pain that cannot
be managed without the requested services, or (b) your appeal involves
non-authorization of an admission or continuing inpatient hospital stay.
When you submit a prior authorization request in an urgent care situation,
you will be notified of the decision within 72 hours of your submission
(unless your submission was incomplete, in which case you will be notified
within 24 hours, and given 48 hours to submit the additional information
needed to evaluate your claim). The notice of denial (as described above)
may be provided to you orally, in which case you will be sent a written or
electronic confirmation within three days of the oral notification.
Page |6
Updated 6.2014
If you decide to appeal the decision, you may make your request for an
appeal to the plan orally or in writing. The appeal will be handled by a
reviewer using the same procedures noted above for first-level reviews,
but on an expedited basis. You may submit information that you wish the
reviewer to consider by telephone, facsimile, e-mail, or other expeditious
method acceptable to the reviewer. You must raise any and all issues that
you wish the reviewer to consider. The plan will notify you of the decision
as soon as possible, taking into account the medical exigencies, but not
later than 72 hours after receiving your request for a review.
Expedited Review with an Independent Review Organization
You may request an expedited external review with an Independent Review
Organization (IRO) before exhausting the internal claims appeal process if
the time frame for an expedited internal appeal would seriously jeopardize
your life or health or jeopardize your ability to regain maximum
function. You may also seek an expedited external review after going
through the internal claims appeal process if either: (a) the normal time
frame for an external review would seriously jeopardize your life or health
or would jeopardize your ability to regain maximum function; or (b) your
claim involves an admission, availability of care, continued stay or health
care item or service for which you have received emergency services, but
have not been discharged from a facility.
Upon receiving your request for an expedited external review, the plan will
immediately determine whether your claim is eligible for external review,
and if it is eligible will expeditiously forward your appeal record to an
IRO. The IRO will notify you of its determination within 72 hours and will
confirm the decision in writing within an additional 48 hours. The IRO’s
decision will be binding on you and the plan, unless additional remedies
are available to you under state or federal law.
You Must Follow the Appeals Process
You will not be able to file a lawsuit for benefits under the plan unless you
have exhausted the appeals process described above for every issue you
believe relevant to your claim. You must file your lawsuit within one year
from the date of the notice denying your appeal. You may not raise issues
in your lawsuit that you have not previously raised during the appeals
process.
Anti-coagulants
&
Blood
Aranesp
Modifiers
Arixtra
Enoxacin
Fragmin
Heparin
Innohep
Lovenox
Cystic Fibrosis
Pulmozyme
Tobi
HIV
Atripla
Fuzeon
Isentress
Page |7
Pulmonary
Hypertension
Adcirca
Letairis
Revatio
Tracleer
Tyvaso
Ventavis
Updated 6.2014
Neulasta
Neumega
Neupogen
Procrit
Chemotherapy
Afinitor
Arimidex
Aromasin
Casodex
Eligard
Femara
Gleevac
Hycamtin
Iressa
Nexavar
Revlimid
Sprycel
Tarceva
Tasigna
Temodar
Thalomid
Tykerb
Xeloda
Zoladex
Zolinza
Kaletra
Sustiva
Truvada
Valcyte
Zerit
Immunosuppressants
Cellcept
Cyclosporine oral
Gengraf
Mycophenolate
Myfortic
Neoral
Prograf
Rapamune
Sandimmune
Tacrolimus
Psoriasis
Enbrel
Humira
Multiple Sclerosis
Ampyra
Avonex
Betaseron
Copaxone
Gilenya
Rebif
Page |8
Rheumatoid
Arthritis
Cimzia
Enbrel
Humira
Kineret
Simponi
Miscellaneous
Forteo
Lupron
Lupron Depot
Lysteda
Sensipar
Vfend
Hepatitis
Baraclude
Copegus
Intron A
Pegasys
Rebetrol
Ribavirin
Tyzeka
Updated 6.2014
PRESCRIPTION LIMITATIONS
The following medications are subject to QUANTITY LIMITATIONS as
outlined below:
Drug Name
Strength
Analgesics (Pain)
Abstral
All strengths
Actiq
All strengths
Avinza
All strengths
Butrans
All strengths
Duragesic
All strengths
Embeda
All strengths
Exalgo
All strengths
Fentora
All strengths
Flector
All strengths
MS Contin
All strengths
Kadian
All strengths
Nucynta
All strengths
Nucynta ER
All strengths
Onsolis
All strengths
Opana
All strengths
Opana ER
All strengths
Oramorph
All strengths
Oxycontin
All strengths
Oxecta
All strengths
Oxycodone IR
All strengths
Pennsaid
All strengths
Rybix ODT
All strengths
Ryzolt
All strengths
Sprix
All strengths
Ultram
All strengths
Ultram ER
All strengths
Vimovo
All strengths
Voltaren Gel
All strengths
Androgens/Hypogonadism
Androderm
2mg
Androderm
4mg
Androgel Pump
1%
Androgel Pump
1.62%
Axiron
All strengths
Depo-Testosterone
All strengths
Delatestryl
All strengths
First-Testosterone
All strengths
Testim
All strengths
Testosterone Cypionate
All strengths
Fortesta
All strengths
Striant
All strengths
Page |9
30 Day Limit
128 tablets
120 lozenges
60 capsules
4 patches
20 patches
60 capsules
60 capsules
120 tablets
60 patches
120 tablets
120 capsules
120 tablets
60 tablets
120 films
100 tablets
60 tablets
120 tablets
120 tablets
120 tablets
240 capsules
2 (150 ml) btls
90 tablets
30 tablets
5 (1.7g) btl
240 tablets
30 tablets
60 capsules
10(100g) tubes
60 patches
30 patches
150 gm (2 x75)
150 gm (2 x75)
90 (1 Bottle)
10 ml
5 ml
60 gm
150 gm
10 (90 days supply)
60 gm
60 Each
Updated 6.2014
Drug Name
Lamictal
Lamictal XR
Alsuma
Amerge
Axert
Frova
Imitrex
Imitrex Injection
Imitrex Kits/Refills
Imitrex Nasal
Maxalt/Maxalt MLT
Migranal
Relpax
Stadol Nasal
Sumavel
Treximet
Zomig Nasal
Zomig/Zomig ZMT
Anzemet
Emend
Emend
Kytril
Sancuso
Zofran Solution
Zuplenz
Abilify/Abilify ODT
Fanapt
Geodon
Invega
Latuda
Saphris
Seroquel
Seroquel
Seroquel XR
Symbyax
Zyprexa
Zyprexa Zydis
Strength
Anticonvulsants (Seizures)
All strengths
All strengths
Migraine Headaches
6 mg/0.5ml
All strengths
All strengths
2.5mg
All strengths
6 mg/0.5ml
All strengths
All strengths
All strengths
4 mg/ml
All strengths
All strengths
6mg/0.5ml
85mg/500mg
All strengths
All strengths
Anti-Nausea
All strengths
80 mg
125 mg
All strengths
3.1 mg
4 mg/5ml
All strengths
Antipsychotics
All strengths
All strengths
All strengths
All strengths
All strengths
All strengths
<300 mg
>300 mg
All strengths
All strengths
All strengths
All strengths
P a g e | 10
30 Day Limit
60 tablets
30 tablets
4
9
9
9
9
5
2
6
9
1
9
1
6
9
1
6
injectors (2 bx)
tablets
tablets
tablets
tablets
vials (1 box)
kits
dispensors
tablets
pk (8 x1mL btl)
tablets
bottle
vials (1 box)
tablets
package (6 btl)
tablets
10 tablets
4 tablets
2 tablets
28 tablets
2 patches
50ml
20 films
30
60
60
30
30
60
90
60
60
30
30
30
tablets
tablets
capsules
capsules
tablets
tablets
tablets
tablets
tablets
tablets
tablets
tablets
Updated 6.2014
Drug Name
Strength
30 Day Limit
Anti-Ulcer Agents (Acid Reflux)
Aciphex
All strengths
30 tablets
Dexilant
All strengths
30 capsules
Nexium
All strengths
30 capsules
Prevacid
All strengths
30 capsules
Zegerid
All strengths
30 capsules
Bisphosphonates/Anti-Resorptive (Osteoporosis) Agents
Actonel
35 mg
4 tablets
Actonel
75 mg
2 tablets
Actonel
150 mg
1 tablet
Actonel
5 mg, 30 mg
30 tablets
Actonel/Cal
35 mg/1250 mg
28 tablets
Atelvia
All strengths
4 tablets
Boniva
150 mg
1 tablet
Fosamax
5mg,10mg & 40mg
30 tablets
Fosamax
35 mg, 70 mg
4 tablets
Fosamax/Vitamin D
All strengths
4 tablets
Forteo
All strengths
1 pen
Bronchodilators (Asthma/Breathing)
Accuneb Neb
All strengths
375ml
Advair Diskus/HFA
All strengths
1 inh
Albuterol Neb
0.083%
375ml
Albuterol Neb
0.5%
60ml
Alvesco
All strengths
1 inh
Arcapta
All strengths
1 box (30 caps)
Asmanex
All strengths
1 inh
Atrovent
All strengths
1 inh
Atrovent Neb
All strengths
300ml
Azmacort
All strengths
1 inh
Brovana Neb
All strengths
60 vials (120ml)
Combivent
All strengths
1 inh
Dulera
All strengths
1 inh
Foradil Aerolizer
All strengths
1 inh
Flovent Diskus/HFA
All strengths
1 inh
Maxair
All strengths
1 inh
Perforomist
All strengths
60 vials (120ml)
Pro-Air HFA
All strengths
2 inhs
Proventil HFA
All strengths
2 inhs
Pulmicort Respules
All strengths
60 vials (120ml)
Pulmicort Turbohaler
All strengths
1 inh
QVAR
All strengths
1 inh
Servent Diskus
All strengths
1 inh
Spiriva
All strengths
1 box
Symbicort
All strengths
1 inh
Ventolin HFA
All strengths
2 inhs
Xopenex HFA
All strengths
2 inhs
Xopenex Neb
All strengths
72 vials (3 boxes)
P a g e | 11
Updated 6.2014
Drug Name
Strength
30 Day Limit
Nasal Antihistamines/Corticosteroids
Astelin
All strengths
1 inh (30ml)
Astepro
All strengths
1 inh (30ml)
Atrovent
All strengths
1 inh (30ml)
Beconase AQ
All strengths
1 inh (25g)
Flonase
All strengths
1 inh (16g)
Nasacort AQ
All strengths
1 inh (16.5g)
Nasarel
All strengths
1 inh (25ml)
Nasonex
All strengths
1 inh (17g)
Omnaris
All strengths
1 inh (12.5g)
Patanase
All strengths
1 inh (30.5g)
Rhinocort AQ
All strengths
1 inh (8.6g)
Veramyst
All strengths
1 inh (10g)
Sleep Aids
Ambien/Ambien CR
All strengths
30 tablets
Doral
All strengths
30 capsules
Edluar
All strengths
30 tablets
Intermezzo
All Strengths
30 tablets
Lunesta
All strengths
30 tablets
Rozerem
All strengths
30 tablets
Silenor
All strengths
30 capsules
Sonata
All strengths
30 capsules
Zolpimist
5 mg
7.7ml
Topical
Taclonex
All strengths
240gm
Anaphylaxis (Allergic Reaction)
Epipen
Epipen Jr.
All strengths
All strengths
4 Pen Injectors
4 Pen Injectors
Affects Brand & Generic Medications when available
Quantity Limitations are based on a 1 month supply. The Limitation is
tripled if the medication is available in a 90 day supply through your plan
design.
Medications that are subject to quantity limits are to help ensure these
medications are not utilized inappropriately or recommended maximum
dosages are not exceeded. EHIM’s Quantity Limitations are based on FDAapproved dosing recommendations, pharmaceutical guidelines and have
been reviewed and approved by our licensed, clinical staff.
P a g e | 12
Updated 6.2014
The
EHIM formulary is a listing of medications that classifies the prescriptions
as Generic, Preferred or Non Preferred. The medications listed on the
formulary are the most commonly utilized and is not all-inclusive and does
not guarantee coverage. Your pharmacy plan may not cover certain
medications even though some may be listed on the formulary. The
Pharmacy Plan Design supersedes the actual published formulary and this
formulary may change or may be updated at any time without notice.
Please refer to your policy document for covered and excluded therapy
classes. All Multisource medications (Brands with exact Generics available)
are classified as Non Preferred medications. If you or your physician
request the brand name medication to be dispensed when an exact
generic is available, you will be required to pay the difference in cost
between the brand & generic plus the applicable copayment (Tier 3
copay). Specific classes of medications, such as specialty medications, will
require an approved Prior Authorization to be covered by the plan. Please
contact the EHIM Pharmacy help desk 800-311-3446 with any inquiries
regarding coverage or the copay of your medications.
GENERIC (Tier 1)
PREFERRED (Tier 2)
NON PREFERRED (Tier 3)
5-Alpha Reductase Inhibitors
finasteride
Avodart (dutasteride)
Jalyn (dutasteride/tamulosin)
Proscar (finasteride)
5-HT3 Antagonists
ondansetron
Anzemet
ondansetron ODT
Kytril (granisetron)
Zofran (ondansetron)
Zuplenz (ondansetron oral soluble film)
Alpha-Adrenergic Blockers
doxazosin
Cardura (doxazosin)
prazosin
Flomax (tamulosin)
tamulosin
Hytrin (terazosin)
terazosin
Jalyn (dutasteride/tamulosin)
Minipress (prazosin)
Rapaflo (sildosin)
Uroxatrol (alfuzosin)
P a g e | 13
Updated 6.2014
Antibacterials- Tetracyclines: Acne
doxycycline
Adoxa (doxycycline)
minocycline
Doryx (doxycycline)
tetracycline
Dynacin (minocycline)
Minocin (minocycline)
Monodox (doxycycline)
Myrac (minocycline)
Oracea (doxycycline)
Periostat (doxycycline)
Solodyn (minocycline)
Ximino (minocycline)
Antibiotics
GENERIC (Tier 1)
PREFERRED (Tier 2)
NON PREFERRED (Tier 3)
amoxiciliin
Avelox
Augmentin (amoxicillin/clavulanate)
amoxiciliin/clavulanate
Dificid
Biaxin (clarithromycin)
azithromycin
Ketek
Cipro (ciprofloxacin)
cefaclor
Moxtag
Zithromax (azithromycin)
cephalexin
Suprax
ciprofloxacin
Vantin
moxifloxacin
Anticoagulants (Oral)
warfarin
Coumadin (warfarin)
Eliquis (apixaban)
Pradaxa (dabigatran)
Xarelto (rivaroxaban)
GENERIC (Tier 1)
PREFERRED (Tier 2)
NON PREFERRED (Tier 3)
Anticonvulsants
carbamazepine
Banzel (rufinamide)
carbamazepine XR
Carbatrol (carbamazepine)
clonazepam
Depakote, Depakote ER (divalproex)
divalproex
Diastat (diazepam)
divalproex ER
Dilantin (phenytoin)
ethosuximide
Equetro (carbamazepine)
gabapentin
Felbatol (felbamate)
lamotrigine
Fycompa (perampanel)
levetiracetam
Gabitril (tiagabine)
oxcarbazepine
Horizant (gabapentin)
phenobarbital
Keppra, Keppra XR (levetiracetam)
phenytoin
Klonopin (clonazepam)
primidone
Lamictal, Lamictal XR (lamotrigine)
P a g e | 14
Updated 6.2014
GENERIC (Tier 1)
PREFERRED (Tier 2)
NON PREFERRED (Tier 3)
topiramate
Lyrica (pregabalin)
valproate, valproic acid
Mebaral (mephobarbital)
zonisamide
Mysoline (primidone)
Neurontin (gabapentin)
Onfi (clobazam)
Oxtellar XR (oxcarbazepine)
Phenytek (phenytoin)
Potiga (ezogabine)
Tegretol, Tegretol XR (carbamazepine)
Topamax (topiramate)
Trileptal (oxcarbazepine)
Vimpat (lacosamide)
Zonegran (zonisamide)
Antidepressants
Selective Serotonin Re-Uptake Inhibitors (SSRIs)
citalopram
Celexa (citalopram)
escitalopram
Fluvox (fluvoxamine)
fluoxetine
Lexapro (escitalopram)
fluvoxamine
Paxil (paroxetine)
paroxetine
Paxil CR (paroxetine)
sertraline
Pexeva (paroxetine)
Prozac (fluoxetine)
Prozac Weekly (fluoxetine)
Zoloft (sertraline)
Selective Serotonin and Norepinephrine Re-Uptake Inhibitors (SNRIs)
duloxetine
Cymbalta (duloxetine)
venlafaxine
Effexor (venlafaxine)
venlafaxine ER
Effexor XR (venlafaxine XR)
Pristiq (desvenlafaxine)
Savella (milnacipran)
Serotonin Modulators
nefazodone
Desyrel (trazadone)
trazadone
Oleptro (trazadone ER)
Serzone (nefazodone)
Miscellaneous Antidepressants
bupropion
Abilify (aripiprazole)
bupropion SR
Aplenzin (bupropion)
bupropion XL
Forfivo XL (bupropion)
mirtazapine Reg, ODT
Remeron, Remeron SolTab (mirtazapine)
Wellbutrin, Wellbutrin SR/XL (bupropion)
Viibryd (vilazodone)
Zyban (bupropion)
P a g e | 15
Updated 6.2014
GENERIC (Tier 1)
PREFERRED (Tier 2)
NON PREFERRED (Tier 3)
Anti-Gout Agents
allopurinol
Colcrys (colchicine)
colchicine
Krystexxa (pegloticase)
Uloric (febuxostat)
Zyloprim (allopurinol)
Antihypertensives
Vasodilators
dipyridamole
Adcirca (tadalafil)
hydralazine
Apresoline (hydralazine)
isosorbide
BiDil (isosorbide/hydralazine)
isoxsuprine
Imdur/Isordil (isorsorbide)
minoxidil
Letairis (ambrisentan)
nitroglycerin
Persantine (dipyridamole)
Remodulin/Tyvaso (treprostinil)
Revatio (sildenafil)*
Tracleer (bosentan)
Vasodilan (isoxsuprine)
Angiotension Receptor Blockers & Renin Inhibitors
candesartan/HCTZ
Amturnide (aliskerin, amlodipine, HCTZ)
eprosartan
Atacand, Atacand HCT (candesartan)
irbesartan
Avapro, Avalide (irbesartan)
irbesartan/HCTZ
Benicar, Benicar HCT (olmesartan)
losartan
Cozaar (losartan)
losartan/HCTZ
Diovan, Diovan HCT (valsartan)
telmisartan/amlodipine
Edarbi (azilsartan)
telmisartan/HCTZ
Edarbychlor (azilsartan, chlorthalidone)
valsartan/HCTZ
Exforge (valsartan, amlodipine)
Hyzaar (losartan w/HCTZ)
Micardis, Micardis HCT (telmisartan)
Tekalmo (aliskerin, amlodipine)
Tekturna, Tekturna-HCT (aliskerin)
Tevetan, Tevetan HCT (eprosartan)
Twynsta (telmisartan, amlodipine)
Valturna (valsartan, aliskerin)
Beta-Blockers
atenolol
Bystolic (nebivolol)
acebutolol
Coreg (carvedilol)
betaxolol
Coreg CR (carvedilol CR)
bisoprolol
Inderal LA (propranolol)
carvedilol
Kerlone (betaxolol)
labetalol
Lopressor/Toprol (metoprolol)
metoprolol
Pindolol
P a g e | 16
Updated 6.2014
GENERIC (Tier 1)
PREFERRED (Tier 2)
NON PREFERRED (Tier 3)
metoprolol XL
Spectral (acebutolol)
pindolol
Tenormin (atenolol)
propranolol
Trandate (labetalol)
propranolol XL
Zebeta (bisoprolol)
timolol
Calcium Channel Blockers
amlodipine
Cardene (nicardipine)
diltiazem
Cardene SR (nicardipine SR)
felodipine
Cardizem, Cardizem LA/XL (diltiazem)
nicardipine
Dynacirc (isradipine)
nifedipine
Norvasc (amlodipine)
nifedipine XL
Plendil (felodipine)
verapamil
Procardia/Adalat (nifedipine)
Sular (nislodipine)
Tekalmo (aliskerin, amlodipine)
Veralan PM/Covera/Calan (verapamil)
Central-Acting Alpha Agonists
clonidine
Aldomet (methyldopa)
methyldopa
Catapres (clonidine)
Anti-Lipemic Agents
Bile Acid Sequestrants
cholestyramine
Colestid (colestipol)
colestipol
Questran, Questran Lite (cholestyramine)
Welchol (colesevelam)
Cholesterol Absorption Inhibitors
Vytorin (simvastatin/ezetimibe)
Zetia (ezetimibe)
Fibric Acid Derivatives
fenofibrate
Antara (fenofibrate)
fenofibric acid
Lofibra (fenofibrate)
gemofibrozil
Lopid (gemfibrozil)
Tricor (fenofibrate)
Triglide (fenofibrate)
Trilipix (fenofibric acid)
HMG Co-A Reductase Inhibitors (Statins)
atorvastatin
Advicor (lovastatin/niacin)
fluvastatin
Altoprev (lovastatin XL)
lovastatin
Caduet (atorvastatin/amlodipine)
pravastatin
Crestor (rosuvastatin)
simvastatin
Juvisync (sitagliptin, simvastatin)
Lescol, Lescol XL (fluvastatin)
P a g e | 17
Updated 6.2014
GENERIC (Tier 1)
PREFERRED (Tier 2)
NON PREFERRED (Tier 3)
Lipitor (atorvastatin)
Livalo (pitavastatin)
Mevacor (lovastatin)
Pravachol (pravastatin)
Vytorin (simvastatin/ezetimibe)
Zocor (simvastatin)
Miscellaneous Anti-Lipemics
Fish Oil OTC
Juxtapid (lomitapide)
Niacin OTC
Lovaza (omega-3-acid ethyl esters)
omega-3-acid ethyl esters
Niaspan (niacin XR)
Vascepa (icosapent)
Anti-Migraine Agents (Triptans)
naratriptan
Alsuma (sumatriptan) injection
rizatriptan
Amerge (naratryptan)
sumatriptan
Axert (almotriptan)
sumatriptan vials
Frova (frovatriptan)
sumatriptan nasal
Imitrex (sumatriptan)
zolmitriptan
Maxalt (rizatriptan)
Maxalt MLT (rizatriptan ODT)
Relpax (eletriptan)
Sumavel DosePro (sumatriptan needleless)
Treximet (naproxen/sumatriptan)
Zecuity (sumatriptan) Patch
Zomig (zolmitriptan)
Zomig Nasal (zolmitriptan)
Zomig ZMT (zolmitriptan ODT)
Antivirals
GENERIC (Tier 1)
PREFERRED (Tier 2)
NON PREFERRED (Tier 3)
acyclovir
Cytovene (ganciclovir)
adefovir
Famvir (famciclovir)
amantadine
Flumadine (rimantidine)
famciclovir
Hepsera (adefovir)
ganciclovir
Rebetol/copegus (ribavirin)
Relenza (zanamivir)
Valcyte (valganciclovir)
rimantidine
Symmetrel (amantadine)
Tamiflu (oseltamivir)
Valtrex (valacyclovir)
valacyclovir
Zovirax (acyclovir)
Anxiolytics, Sedatives, & Hypnotics
alprazolam
Ativan (lorazepam)
buspirone
Buspar (buspirone)
chlorazepate
Dalmane (flurazepam)
chlordiazepoxide
Doral (quazepam)
P a g e | 18
Updated 6.2014
GENERIC (Tier 1)
PREFERRED (Tier 2)
NON PREFERRED (Tier 3)
chlordiazepoxide/amitriptyline
Halcion (triazolam)
chlordiazepoxide/clidinium
Librax (chlordiazepoxide/clidinium)
diazepam
Librium (chlordiazepoxide)
estazolam
Limbitrol (chlordiazepoxide/amitriptyline)
hydroxyzine
Meprobamate/Equagesic
lorazepam
Niravam (alprazolam ODT)
oxazepam
Restoril (temazepam)
temazepam
Serax (oxazepam)
triazolam
Tranxene (chlorazepate)
Valium (diazepam)
Versed Oral Sol (midazolam)
Xanax (alprazolam)
Xanax XR (alprazolam XR)
Atypical Antipsychotics
clozapine
Abilify (aripiprazole)
olanzepine
Clozaril (clozapine)
olanzepine, fluoxetine
Fanapt (iloperidone)
quetiapine
Geodon (ziprasidone)
risperidone
Invega (paliperidone)
ziprasidone
Invega Sustenna (paliperidone)
Latuda (lurasidone)
Risperdal (risperidone)
Risperdal Consta (risperidone inj)
Saphris (asenapine)
Seroquel, Seroquel XR (quetiapine)
Symbyax (fluoxetine/olanzapine)
Zyprexa, Zyprexa Zydis (olanzapine)
Bisphosphonates
alendronate
Actonel (risedronate)
ibandronate
Atelvia (risedronate)
Binosto (alendronate)
Boniva (ibandronate)
Fosamax (alendronate)
Fosamax + D
P a g e | 19
Updated 6.2014
GENERIC (Tier 1)
PREFERRED (Tier 2)
NON PREFERRED (Tier 3)
CNS Stimulants - Requires Prior Authorization
Amphetamines & Related Compounds
amphetamine salt combo
Adderall (amphetamine/dextroamphetamine)
amphetamine salt combo ER
Adderall XR (amphetamine/dextroamphetamine)
clonidine ER
Adipex/Ionamin (phentermine)
demethylphenidate
Concerta (methylphenidate CR)
dextroamphetamine
Daytrana Patch (methylphenidate)
methylphenidate
Dexedrine (dextroamphetamine)
methylphenidate ER
Belviq (lorcaserin)
methylphenidate SR
Fastin (phentermine)
methylphenidate XR
Focalin, Focalin XR (dexmethylphenidate)
modafinil
Intuniv (guanfacine)
Kapvay (clonidine)
Meridia (sibutramine)
Metadate CD (methylphenidate)
Nuvigil (armodafinil)
Provigil (modafinil)
Qsymia (phentermine, topiramate)
Quillivant XR (methylphenidate XR)
Ritalin (methylphenidate)
Ritalin SR (methylphenidate)
Ritalin LA (methylphenidate)
Straterra (atomoxetine)
Suprenza (phentermine)
Tenuate (diethylpropion)
Vyvanse (lisdexamfetamine)
Diabetes
acarbose
All Insulins
Actos (pioglitazone)
chlorpropamide
All Diabetic Supplies
Acto-PlusMet (pioglitazone, metformin
glimepiride
Avandamet
Bydureon (exenatide)
glipizide, glipizide XL
Avandryl
Byetta (exenatide)
glipizide, metformin
Avandia
Glucophage (metformin)
glyburide
Duetact
Glucophage XR (metformin)
glyburide (micronized)
Fortamet
Precose (acarbose)
glyburide, metformin
Galvus
Starlix (nateglinide)
metformin
Glumetza
Symlin (pramlintide)
metformin XR
Glyset
Victoza (liraglutide)
nateglinide
Janumet, Janumet XR
pioglitazone
Januvia
pioglitazone, glimepiride
Jentadueto
pioglitazone, metformin
Juvisync
repaglinide
Kazano
rosiglitazone
Kombiglyze
P a g e | 20
Updated 6.2014
GENERIC (Tier 1)
PREFERRED (Tier 2)
tolazamide
Kombiglyze XR
tolbutamide
Nesina
NON PREFERRED (Tier 3)
Onglyza
Oseni
Prandin
Riomet
Tradjenta
GENERIC (Tier 1)
PREFERRED (Tier 2)
NON PREFERRED (Tier 3)
Eye, Ear, & Nose
Antiglaucoma Agents
betaxolol solution
Alphagan (brimonidine) Solution
brimonidine solution
Alphagan-P (brimonidine) Solution
dorzolamide solution
Azopt (brinzolamide) Suspension
latanoprost solution
Betagan (levobunolol) Solution
levobunolol solution
Betimol (timolol hemihydrate) Solution
pilocarpine solution
Betoptic (betaxolol) Solution
timolol solution
Betoptic-S (betaxolol) Suspension
timolol GFS solution
Cosopt, Cosopt PF (timolol/dorzolamide)
timolol/dorzolamide sol
Isopto-Carbachol (carbachol) Solution
travoprost
Isopto-Carpine (pilocarpine) Solution
Lumigan (bimatoprost) Solution
Mitosol (mitomycin) Solution
Pilocar/Pilopine (pilocarpine) Solution
Timoptic (timolol maleate) Solution
Timoptic-GFS (timolol maleate) Solution
Travatan (travoprost) Solution
Trusopt (dorzolamide) Solution
Xalatan (latanoprost) Solution
Zioptan (tafluprost) Solution
P a g e | 21
Updated 6.2014
GENERIC (Tier 1)
PREFERRED (Tier 2)
NON PREFERRED (Tier 3)
Antihistamines
Nasal
azelastine nasal
Astelin Nasal (azelastine)
cromolyn nasal
Nasalcrom Nasal (cromolyn)
Dymista (azelastine, fluticasone)
Ophthalmic
azelastine ophthalmic
Alamast (pemirolast)
cromolyn ophthalmic
Alocril (nedocromil)
epinastine ophthalmic
Alomide (lodoxamide)
ketotifen ophthalmic
Alrex (lotepredenol)
Bepreve (bepotastine)
Crolom (cromolyn)
Elestat (epinastine)
Optivar (azelastine)
Pataday (olopatadine 0.2%)
Patanol (olopatadine 0.1%)
Zaditor (ketotifen)
Anti-Inflammatory
Ophthalmic
Steroidal
Steroidal
fluorometholone
Alrex (loteprednol)
prednisolone acetate
AK-Pred (prednisolone sodium phosphate)
prednisolone sodium
Durezol (difluprednate) Emulsion
Econopred Plus (prednisolone acetate)
Non-Steroidal
Flarex (fluorometholone)
diclofenac solution
FML (fluorometholone)
flurbiprofen solution
FML (fluorometholone)
ketorolac solution
FML Forte (fluorometholone)
Inflamase (prednisolone sodium phosphate)
Lotemax (loteprednol)
Omnipred (prednisolone acetate)
Pred Forte (prednisolone acetate)
Pred-G (prednisolone acetate/gentamicin)
Pred-G (prednisolone acetate/gentamicin)
Pred Mild (prednisolone acetate)
Maxidex (dexamethasone)
P a g e | 22
Updated 6.2014
GENERIC (Tier 1)
PREFERRED (Tier 2)
NON PREFERRED (Tier 3)
Anti-Inflammatory Continued
Otic
Retisert (fluocinolone)
acetic acid/hydrocort
Tobraflex (fluorometholone/tobramycin)
Vexol (rimexolone)
Non-Steroidal
Acular (ketorolac)
Acular LS (ketorolac)
Nevanac (nepafenac)
Ocufen (flurbiprofen)
Restasis (cyclosporine)
Xibrom (bromfenac)
Voltaren (diclofenac)
Acetasol-HC (acetic acid/hydrocortisone)
VoSol-HC (acetic acid/hydrocortisone)
Intranasal Steroids
flunisolide
Beconase (beclomethasone)
fluticasone
Dymista (azelastine, fluticasone)
triamcinolone
Flonase (fluticasone)
Nasacort AQ (triamcinolone)
Nasacort HFA (triamcinolone)
Nasarel (flunisolide)
Nasonex (mometasone)
Omnaris (ciclesonide)
QNasl (beclomethasone)
Rhinacort AQ (budesonide)
Vancenase (beclomethasone)
Veramyst (fluticasone)
Zetonna (ciclesonide)
Anti-Infectives
Ophthalmic
bacitracin ointment
Ciloxan Ointment
Bleph-10 (sulfacetamide)
bacitracin/polymyxin oint
Collyrium
Blephamide (sulfacetamide, prednisolone)
boric acid eye wash
Moxeza
Belphamide (sulfacetamide, prednisolone)
ciprofloxacin solution
Natacyn
Ciloxan (ciprofloxacin)
erythromycin ointment
Pred-G Ointment
E-Mycin Ointment (erythromycin)
gatifloxacin solution
Pred-G Suspension
gentamicin oint and sol
TobraFlex
Gentak (gentamicin) Ointment
Maxitrol (neomycin,
polymyxin,dexamethasone)
levofloxacin solution
Vigamox Solution
Neosporin (neomycin, polymyxin, bacitracin)
neomycin, polymyxin, dexam
Zirgan Gel
Neosporin (neomycin, polymyxin, gramicidin)
neomycin, polymyxin, gramicidin
Zylet Suspension
Ocuflox (ofloxacin)
ofloxacin solution
Polysporin (bacitracin, polymyxin)
P a g e | 23
Updated 6.2014
GENERIC (Tier 1)
PREFERRED (Tier 2)
NON PREFERRED (Tier 3)
polymyxin, trimethoprim
Polytrim (polymyxin, trimethoprim)
sulfacetamide solution
Quixin (levofloxacin)
sulfacetamide, prednisolone
Tobradex (tobramycin, dexamethasone)
tobramycin solution
Tobraflex (fluorometholone/tobramycin)
tobramycin, dexamethasone
Tobrex (tobramycin)
trifluridine solution
Tobrex (tobramycin)
Viroptic (trifluridine)
Zymar (gatifloxacin)
Zymaxid (gatifloxacin)
Otic
carbamide peroxide
Cipro-Dex Suspension
Cortisporin Solution
colistin, neomycin, hydrocort
Cipro-HC Suspension
Cortisporin Suspension
neomycin, polymyxin, hydrocort
Coly-Mycin Suspension
Debrox (carbamide peroxide)
Floxin (ofloxacin) Suspension
GENERIC (Tier 1)
PREFERRED (Tier 2)
NON PREFERRED (Tier 3)
Local Anesthetics
Ophthalmic
proparacaine solution
Ophthetic/Parcaine (proparacaine)
tetracaine solution
Tetcaine (tetracaine)
Tetravisc (tetracaine viscous)
Otic
antipyrine/benzocaine sol(A/B)
Americaine-Otic (benzocaine)
Auralgan (antipyrine/benzocaine)
Aurodex (antipyrine/benzocaine)
Treagan (antipyrine/benzocaine)
Mydriatics (Ophthalmic)
atropine sol and oint
Cyclogyl Solution
AK-Dilate (phenylephrine)
cyclopentolate solution
E-Pilo
Cyclomydril (cyclopentolate, phenylephrine)
homatropine solution
Iopidine
E-Pilo (epinephrine, pilocarpine)
phenylephrine solution
Isopto-Hyoscine
Isopto-Atropine (atropine)
tropicamide solution
Isopto-Homatropine (homatropine)
Mydfrin (phenylephrine)
Mydriacyl (tropicamide)
Neo-Synephrine (phenylephrine)
Ocu-Pfrin (phenylephrine)
Tropiacyl (tropicamide)
P a g e | 24
Updated 6.2014
GENERIC (Tier 1)
PREFERRED (Tier 2)
NON PREFERRED (Tier 3)
Vasoconstricting Agents
Ophthalmic
naphazoline OTC solutions
Naphcon/AllClear/Clear Eyes (naphazoline)
tetrahydrozoline OTC sol
Naphcon-A/Ophcon A/Visine A Sol
Gastrointestinal
Antidiarrhea Agents
bismuth subsalicylate
Devrom (bismuth subgallate)
diphenoxylate, atropine
Fulyzaq (crofelemer)
loperamide
Imodium (loperamide)
Lactinex/Probiata/Probiotic (lactobacillus)
Lomotil/Lonox (diphenoxylate, atropine)
Pepro-Bismol/Kaopectate/Maalox Total
Acid Suppressants & Antiulcer Agents
famotidine tabs
Axid (nizatidine)
nizatidine caps
Carafate (sucralafate)
ranitidine tabs and syrup
Pepcid (famotidine)
sucralafate tabs and liquid
Tagamet (cimetidine)
Zantac (ranitidine)
Proton Pump Inhibitors
lansoprazole
Aciphex (rabeprazole)
omeprazole
Dexilant (dexlansoprazole)
pantoprazole
Nexium (esomeprazole)
rabeprazole
Prilosec (omeprazole)
Nexium OTC
Protonix (pantoprazole)
Prevacid OTC
Zegerid (omperazole w/sodium bicarbonate)
Prilosec OTC
Miscellaneous, GI Agents
Amitiza (lubiprostone)
Linzess (linaclotide)
Lotronex (alosetron)
Relistor (methylnaltrexone)
Zelnorm (tegaserod)
metocloperamide
Metozolv ODT (metocloperamide)
Heliobacter Pylori Kits
Helidac
Omeclamox
P a g e | 25
Updated 6.2014
GENERIC (Tier 1)
PREFERRED (Tier 2)
NON PREFERRED (Tier 3)
Heliobacter Pylori Kits
lansoprazole/amoxicillin/clarithromycin
Prevpac
Pylera
Antiemetics
granisetron
Aloxi
Kytril (granisetron)
ondansetron
Anzemet
Zofran (ondansetron)
Emend
Zuplenz (ondansetron) oral soluble film
Rezonic
dimenhydrinate
Cesamet
Antivert/Bonine (meclizine)
meclizine
Vontrol
Compazine (prochlorperazine)
prochlorperazine tabs
Dramamine/Triptone (dimenhydrinate)
trimethobenzamide
Tigan (trimethobenzamide)
Anti-Inflammatory
balsalazide capsules
Apriso
Colazal (balsalazide) Capsules
mesalamine suppositories
Asacol
Rowasa (mesalamine) Suppositories
prednisone
Canasa Supp
Entocort (budesonide) Capsules
Dipentum
Giazo
Lialda
Pentasa
Bowel Preparations
PEG powder
Dulcolax Bowel Prep (bisacodyl)
Colyte (PEG w/electrolytes)
Evac-Q-Kwik (bisacodyl, magnesium citrate)
GoLytely (PEG w/electrolytes)
Half-Lytely (bisacodyl, PEG w/electrolytes)
LoSo Prep Kit (bisacodyl, magenisum citrate)
Moviprep (PEG w/electrolytes)
NuLytely (PEG w/electrolytes)
Osmoprep (sodium phosphate) Tablets
Prepopik (sodium picosulfate)
Suprep (sodium sulfate)
Tridate (bisacodyl, magnesium citrate)
Trilyte (PEG w/electrolytes)
Visicol (sodium phosphate tablets)
X-Prep (bisacodyl, senna)
P a g e | 26
Updated 6.2014
GENERIC (Tier 1)
PREFERRED (Tier 2)
NON PREFERRED (Tier 3)
Cholelitholytics
ursodiol capsules
Actigall (ursodiol) capsules
Urso/Urso Forte (ursodiol) tablets
Laxatives & Related Compounds
bisacodyl OTC
Dulcolax (bisacodyl)
castor oil OTC
Ex-Lax/Sennakot (senna)
docusate OTC
Miralax (polyethylene glycol –PEG 3350)
Metamucil OTC
Surfak/Colace/Therevac (docusate)
milk of magnesia OTC
mineral oil OTC
PEG powder OTC
senna tabs OTC
senna/docusate OTC
Androgens
testosterone CYP Inj
Androderm
Depo-Testosterone Inj
Androgel
Android
Androxy
Axiron
Fortesta
Halotestin
Methitest
Striant XR
Testim
Testred
Virilon
Hormones & Synthetic Substitutes Continued
Contraceptives (generics covered for $0 per ACA)
Apri
Beyaz
Alesse (ethinyl estradiol, levonorgestrel)
Aranelle
Nuva Ring
Altavera (ethinyl estradiol, levonorgestrel)
Aviane
Safyral
Angeliq (estradiol, drosperinone)
Balziva
Yaz
Azurette (ethinyl estradiol, desogtesrel)
Briellyn
Brevicon (ethinyl estradiol, norethindrone)
Camilla
Cyclafem (ethinyl estradiol, norethindrone)
Caziant
Cesia
Cyclessa (ethinyl estradiol, desogtesrel)
Demulen (ethinyl estradiol, ethynodiol
diacetate)
Cryselle
Depo-Provera (medroxyprogesterone)
Dasetta
Depo-SubQ-Provera (medroxyprogesterone)
Elinest
Desogen (ethinyl estradiol, desogestrel)
Enpresse
Ella (ulipristal)
Errin
Estrostep FE (ethinyl estradiol, norethindrone)
P a g e | 27
Updated 6.2014
GENERIC (Tier 1)
PREFERRED (Tier 2)
NON PREFERRED (Tier 3)
Falmina
Femcon FE (ethinyl estradiol, norethindrone)
Gildess
Levlen (ethinyl estradiol, levonorgestrel)
Jolessa
Levlite (ethinyl estradiol, levonorgestrel)
Jolivette
Levonest (ethinyl estradiol, levonorgestrel)
Junel
Loestrin (ethinyl estradiol, norethindrone)
Junel FE
Loestrin FE (ethinyl estradiol, norethindrone)
Kariva
LoOvral (ethinyl estradiol, norgestrel)
Kelnor
Lybrel (ethinyl estradiol, levonorgestrel)
Leena
Micronor (norethindrone)
Lessina
Mircette (ethinyl estradiol, desogtesrel)
Levora
Modicon (ethinyl estradiol, norethindrone)
Loryna
Nordette (ethinyl estradiol, levonorgestrel)
Low-Ogestrel
Norinyl (ethinyl estradiol, norethindrone)
Lutera
Nor-QD (norethindrone)
Medroxyprogesterone inj
Ogestrel (ethinyl estradiol, norgestrel)
Microgestin
Ortho-Cept (ethinyl estradiol, desogtesrel)
Microgestin FE
Ortho-Evra (ethinyl estradiol, norelgestromin)
Mono-Linyah
Necon
Ortho-Novum (ethinyl estradiol, norethindrone)
Ortho Tri-Cyclen (ethinyl estradiol,
norgestimate)
Ortho Tri-Cyclen LO (ethinyl estradiol,
norgestimate)
Nora-B
Ovcon (ethinyl estradiol, norethindrone)
Nortrel
Seasonale (ethinyl estradiol, levonorgestrel)
Ocella
Seasanique (ethinyl estradiol, levonorgestrel)
Orsythia
Tri-Norinyl (ethinyl estradiol, norethindrone)
Philith
Triphasil (ethinyl estradiol, levonorgestrel)
Portia
Yasmin (ethinyl estradiol, drosperinone)
Mononessa
Previfem
Quasense
Reclipsen
Xulane (150/35 mcg only)
Zenchent
P a g e | 28
Updated 6.2014
GENERIC (Tier 1)
PREFERRED (Tier 2)
NON PREFERRED (Tier 3)
Hormones & Synthetic Substitutes Continued
Contraceptives
Solia
Sprintec
Sronyx
Tilia FE
Tri-Legest FE
Tri-Linyah
Tri-Nessa
Tri-Previfem
Tri-Sprintec
Trivora
Velivet
Zovia
Hormones & Synthetic Substitutes Continued
Breast Cancer
anastrazole
Arimidex (anastrazole)
letrozole
Femara (letrozole)
tamoxifen
Nolvadex (tamoxifen)
Estrogens & Related Compounds
estradiol tablets
Activella (estradiol, norethindrone) Tabs
estradiol patches
Alora (estradiol) Patch
estradiol valerate injection
Cenestin (conjugated estrogens)
estropipate
Climara (estradiol) Patch
Combipatch (estradiol, norethindrone)
Delestrogen (estradiol valerate) Inj
Depo-Estradiol (estradiol cypionate) Inj
Depo-Testadiol (estradiol cyp, testosterone
cyp)
Divigel (estradiol)
Elestrin Gel (estradiol)
Enjuvia (conjugated estrogens)
Estrace Tablets & Vaginal Cream (estradiol)
Estraderm (estradiol) Patch
Estrasorb (estradiol) Emulsion
Estratest (esterified estrogens,
methyltestosterone)
Estring Vaginal Ring (estradiol)
Estrogel (estradiol)
Evamist Spray (estradiol)
Femhrt (ethinyl estradiol, norethindrone)
Femring Vaginal Ring (estradiol)
Femtrace (estradiol)
Menest (esterified estrogens) Tablets
Menostar (estradiol) Patch
Natazia (dienogest/estradiol valerate)
Ogen (estropipate)
P a g e | 29
Updated 6.2014
Ortho-Est (estropipate)
Pennsaid (diclofenac)
Orudis/Oruvail (ketoprofen)
Relafen (nabumetone)
Siprix Nasal spray (ketorolac)
Solaraze 3% Gel (diclofenac)
Vimovo (naproxen, esomeprazole)
Voltaren, Voltaren XR (diclofenac)
Volatren Gel (diclofenac)
Zipsor (diclofenac)
Premarin (conjugated estrogens)
Premphase (estrogens,
medroxyprogesterone)
Prempro (estrogens, medroxyprogesterone)
Vagifem Vaginal Tablets (estradiol)
Vivelle/Vivelle-Dot (estradiol) Patch
Parathyroid
Fortical (calcitonin)
Forteo (teriparatide)
Miacalcin (calcitonin)
Pituitary
desmopressin
DDVAP (desmopressin)
HGH (human growth hormone)
Increlex (mecasermin)
Somavert (pegvisomant)
Progestins
medroxyprogesterone
Aygestin (norethindrone)
norethindrone
Crinone Gel (progesterone)
Procheive (progesterone)
Prometrium (progesterone)
Provera (medroxyprogesterone)
Thyroid*
levothyroxine
Armour Thyroid
Cytomel
Levothroid (levothyroxine)
Thyrolar
Levoxyl (levothyroxine)
Synthroid (levothyroxine)
Thyrolar (levothyroxine, liothyronine)
P a g e | 30
Updated 6.2014
Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)
diclofenac
Ansaid (flurbiprofen)
diclofenac/misoprostol
Arthrotec (diclofenac/misoprostol)
etodolac
Cambia (diclofenac) Packets
ibuprofen
Celebrex (celecoxib)
indomethacin
Clinoril (sulindac)
ketoprofen
Daypro (oxaprozin)
meloxicam
Duexis (iburpfen, famotidine)
nabumetone
Feldene (piroxicam)
naproxen, naproxen DS
Flector Patch (diclofenac)
oxaprozin
Indocin (indomethacin)
piroxicam
Lodine, Lodine XL (etodolac)
sulindac
Mobic (meloxicam)
Motrin (ibuprofen)
Naflon (fenoprofen)
Naprapac (naproxen/lansoprazole)
Naprelam (naproxen)
Naprosyn (naproxen)
Nexcede (ketoprofen) oral film
Prevacid Prevpac (naproxen, lansoprazole)
Opioid and Opioid-Like Analgesics
codeine, codeine/APAP
Abstral (fentanyl SL)
fentanyl patch
Actiq (fentanyl lozenge)
hydrocodone/APAP
Avinza (morphine)
hydrocodone/ibuprofen
Butrans (buprenorphine) Transderm
hydromorphone
Combunox (oxycodone/ibuprofen)
levorphanol
Demerol (meperidine)
methadone
Dilaudid (hydromorphone)
morphine
Duragesic (fentanyl)
morphine ER
Embeda (morphine/naltrexone)
P a g e | 31
Updated 6.2014
GENERIC (Tier 1)
PREFERRED (Tier 2)
NON PREFERRED (Tier 3)
Opioid and Opioid-Like Analgesics Cotinued
buprenorphine/naloxone
Exalgo (hydromorphone XR)
oxycodone
Fentora (fentanyl buccal)
oxycodone/APAP
Kadian (morphine)
oxycodone/ibuprofen
Lazanda Spray (fentanyl)
oxycodone ER
Levo-Dromoran (levorphanol)
oxymorphone IR
Lortab/Lorcet (hydrocodone/APAP)
tramadol
MS Contin (morphine)
tramadol/APAP
Norco (hydrocodone/APAP)
Nucynta, Nucynta ER (tapentadol)
Onsolis (fentanyl buccal)
Opana, Opana ER (oxymorphone)
Oramorph (morphine)
Oxecta (oxycodone)
Oxycontin (oxycodone)
Rybix ODT (tramadol ODT)
Ryzolt (tramadol)
Suboxone (buprenorphine/naloxone)
Subsys (fentanyl) Spray
Subutex (buprenorphine)
Ultram ER (tramadol)
Vicodin, Vicodin ES/HP (hydrocodone/APAP)
Vicoprofen (hydrocodone/ibuprofen)
Parasympathomimetics (Alzheimer’s Disease)
donepezil
Aricept, Aricept ODT (donepezil)
galantamine
Cognex (tacrine)
galantamine XR
Exelon, Exelon Patch (rivastigmine)
rivastigmine
Razadyne, Razadyne ER (galantamine)
RESPIRATORY
albuterol
Advair
Accolate
budesonide respules
Alvesco
Atrovent Solution
ipratropium solution
Asmanex
Pulmicort Respules
levalbuterol solution
AtroventHFA
Singulair
montelukast
Azmacort
Xopenex Solution
zafirlukast
Combivent
Dulera
Flovent
Foradil
Proair
Pulmicort
Qvar
P a g e | 32
Updated 6.2014
GENERIC (Tier 1)
PREFERRED (Tier 2)
NON PREFERRED (Tier 3)
Serevent
Spiriva
Symbicort
Tudorza
Ventolin HFA
Xopenex HFA
Skeletal Muscle Relaxants
baclofen
Amrix (cyclobenzaprine)
carisoprodol
Dantrium (dantrolene)
chlorzoxazone
Flexeril (cyclobenzaprine)
cyclobenzaprine
Flexeril SR (cyclobenzaprine)
dantrolene
Lioresol (baclofen)
methocarbamol
Norflex (orphenadrine)
orphenadrine
Parafon Forte (chlorzoxazone)
tizanidine
Robaxin (methocarbamol)
Skelaxin (metaxalone)
Soma 250mg (carisoprodol)
Zanaflex
GENERIC (Tier 1)
PREFERRED (Tier 2)
/
NON PREFERRED (Tier 3)
Skin & Skin Diseases Products
Acne Topicals
adapalene
Atralin (tretinoin) 0.05% gel
tretinoin
Avage (tazarotene) cream
Avita (tretinoin) 0.025% cream and gel
Azelex (azelaic acid) cream
Differin 0.1% (adapalene) cream, gel, lotion
Differin 0.3 % (adapalene) gel
Fabior (tazarotene) Foam
Finacea, Finacea Plus (azelaic acid) gel
Panretin (alitretinoin)
Refissa (tretinoin) 0.05% cream
Renova (tretinoin) 0.02%, 0.05% Cream
Retin-A (tretinoin) 0.025%, 0.05%, 0.1%
Retin-A (tretinoin) 0.025%, 0.1% gel
Retin-A Micro (tretinoin) 0.04%, 0.1% gel
Tazorac (tazarotene) cream, gel
Tretin-X (tretinoin) kits
Ziana (clindamycin, tretinoin) gel
P a g e | 33
Updated 6.2014
GENERIC (Tier 1)
PREFERRED (Tier 2)
NON PREFERRED (Tier 3)
Antifungals
ciclopirox
Desenex
Fungoid Solution (clotrimazole)
ciclopirox
Ertaczo
Fungoid Tincture (miconazole)
clotrimazole
Exelderm
Gyne-Lotrimin (clotrimazole)
clotrimazole, betamethasone
Extina Foam
Kuric (ketoconazole)
econazole cream
Gynazole-1
Loprox (ciclopirox)
ketoconazole cream
Mentax
Lotrimin (clotrimazole)
miconazole
Miactin
Lotrimin AF Lotion, Solution (clotrimazole)
nystatin
Mycelex-3
Lotrisone (clotrimazole, betamethasone)
nystatin, triamcinolone
Naftin
Mycelex-7 (clotrimazole)
terconazole cream, supp
Oxistat
Mykacet (nystatin, triamcinolone)
tioconazole vag ointment
Tinactin
Nizoral Cream, Shampoo (ketoconazole)
Vytone
Penlac Topical Solution (ciclopirox)
Zeasorb AF
Spectazole (econazole)
Vagistat (tioconazole)
Xolagel (ketoconazole)
Scabicides
malathion
Eurax
Acticin Cream (permethrin)
permethrin
Lindane
Ovide (malathion)
Natroba
Pronto Plus
Sklice Solution
Skin Diseases, Miscellaneous
podofilox 0.5% solution
Podocon-25
Condylox (podofilox) 0.5% gel, solution
Carac (fluorouracil)
Veregan
Aldara (imiquimod)
calcipotriene
Fluroplex
Efudex (fluorouracil) 2%, 5% solution
calcipotriene/betamethasone
Elidel
Efudex (fluorouracil) 5% cream
fluorouracil 5% cream
Protopic
Propecia (finasteride) tablets
fluorouracil 2%, 5% solution
Zyclara
Vaniqa (eflornithine) cream
imiquimod
Picato Gel
Dovonex (calcipotriene)
finasteride
Taclonex
Sorilux (calcipotriene)
Rectiv
Targretin
Antibacterials
bacitracin
Acanya gel (clindamycin, benzoyl peroxide)
Double Antibiotic (baci, poly)
Aknemycin ointment (erythromycin)
Chlorhexidine
clindamycin
Altabax (retapamulin)
Bactine, (bacitracin, lidocaine, polymyxin,
neomycin)
clindamycin vaginal cream
Bactroban Cream (mupirocin)
mupirocin ointment
P a g e | 34
Updated 6.2014
GENERIC (Tier 1)
PREFERRED (Tier 2)
NON PREFERRED (Tier 3)
Skin & Skin Diseases Products
clindamycin/benzoyl peroxide
Bactroban Nasal (mupirocin)
erythromycin gel, solution
Bactroban Ointment (mupirocin)
erythromycin, benzoyl peroxide
Benzaclin (clindamycin, benozyl peroxide)
Benzamycin (erythromycin, benzoyl
peroxide)
gentamicin
mafenide
metronidazole
Cleocin T (clindamycin)
Cleocin Vaginal Cream, Ovules
(clindamycin)
metronidazole vaginal gel
Clindaderm (clindamycin)
mupirocin ointment
Clindagel (clindamycin)
silver sulfadiazine
Clindamax (clindamycin)
tetracycline ointment
Clindesse Vaginal Cream (clindamycin)
Vandazole gel (metronidazole)
Clindets Pledgets (clindamycin)
Duac (clindamycin, benzoyl peroxide)
Erygel (erythromycin)
Erythraderm Solution (erythromycin)
Evoclin foam (clindamycin)
Garamycin (gentamicin)
Metrocream (metronidazole)
Metrogel Kit
Metrogel (metronidazole)
Metro Lotion (metronidazole)
Mycitracin (bacitracin, polymyxin,
neomycin)
Mycitracin Plus (bacitracin, pramoxine,
polymyxin, neomycin)
Neosporin, Polysporin (bacitracin,
polymyxin, neomycin)
Neosporin Plus (bacitracin, pramoxine,
polymyxin, neomycin)
Noritate (metronidazole)
Rozex Emulsion (metronidazole)
Spectrocin Plus (bacitracin, pramoxine,
polymyxin, neomycin)
Sulfamylon (mafenide)
Ziana Gel (clindamycin, tretinoin)
P a g e | 35
Updated 6.2014
GENERIC (Tier 1)
PREFERRED (Tier 2)
NON PREFERRED (Tier 3)
Anti-Inflammatory & Anti-Pruritics
aclometasone
Aclovate (aclometasone)
amcinonide
Analpram-HC (hydrocortisone, pramoxine)
betamethasone dipiprionate
ApexiCon E (diflorasone)
betamethasone valerate
Aristocort (triamcinolone)
clobetasol
Betatrex (betamethasone valerate)
clotrimazole, betamethasone
Capex Shampoo (fluocinolone)
desonide
Carmol-HC (hydrocort, urea)
desoximetasone
Clobex (clobetasol)
diflorasone
Cloderm (clocortolone)
fluocinolone
Cordran (flurandrenolide)
fluocinonide
Cortaid (hydrocortisone)
fluticasone
Cortifoam Aerosol, Foam (hydrocortisone)
halobetasol
Cyclocort (amcinonide)
hydrocortisone 0.5%
Derma Smooth Oil (fluocinolone)
hydrocortisone 1, 2.5%
Dermatop (prednicarbate)
hydrocortisone, pramoxine
Desonate (desonide)
hydrocortisone butyrate
DesOwen (desonide)
hydrocortisone valerate
Diprolene (betamethasone dipip)
mometasone
Elecon (mometasone)
GENERIC (Tier 1)
PREFERRED (Tier 2)
NON PREFERRED (Tier 3)
Skin & Skin Diseases Products Continued
hydrocortisone butyrate cream 0.1%
Epifoam (hydrocortisone, pramoxine)
triamcinolone
Halog (halcinonide)
triamcinolone 0.025%
Kenalog Aerosol (triamcinolone)
U-Cort
Kenalog (triamcinolone)
Lida Mantle HC (hydrocortisone, lidocaine)
Lidex (fluocinolone)
Locoid (hydcort butyrate)
Locoid Lipocream (hydrocort butyrate)
Lokara Lotion (desonide)
Lotrisone (clotrimazole, betamethasone)
Luxiq Foam (betamethasone valerate)
Mantadil (hydrocortisone, chlorcyclizine)
Massengill Pledget (hydrocortisone)
Olux aerosol foam (clobetasol)
Pandel (hydrocortisone buteprate)
Penecort (hydrocortisone)
P a g e | 36
Updated 6.2014
GENERIC (Tier 1)
PREFERRED (Tier 2)
NON PREFERRED (Tier 3)
Pramosone (hydrocort, pramoxine)
Prudoxin (doxepin)
Psorcon, Psorcon E (diflorasone)
Synalar (fluocinolone)
Synemol E (fluocinolone)
Taclonex (betamethasone, calcipotriene)
Temovate, Temovate E (clobetasol)
Texacort (hydrocortisone)
Topicort (desoximetasone)
Tridesilon (desonide)
Valisone (betamethasone valerate)
Vanoxide-HC
Verdeso Foam (desonide)
Westcort (hydrocortisone valerate)
Zonalon (doxepin) cream
Antivirals
Denavir (penciclovir)
Zovirax (acyclovir)
Sleep Agents (non-BZD)
eszopiclone
Ambien (zolpidem)
zaleplon
Ambien CR (zolpidem)
zolpidem
Edluar (zolpidem)
Intermezzo (zolpidem)
Lunesta (eszopiclone)
Silenor (doxepin)
Rozerem (ramelteon)
Sonata (zaleplon)
Zolpimist (zolpidem)
Urinary/Bladder Health
oxybutynin
Anturol (oxybutynin)
solifenacin
Detrol, Detrol LA (tolterodine)
tolterodine
Ditropan, Ditropan XL (oxybutynin)
trospium
Elmiron (pentosan)
Enablex (darifenacin)
Oxytrol (oxybutynin)
Sanctura, Sanctura XR (trospium)
Toviaz (fesoterodine)
Urispas (flavoxate)
Vesicare (solifenacin)
P a g e | 37
Updated 6.2014
Formulary Notes:
All MULTISOURCE Medications (Brand Name Medications that
have an EXACT Generic Equivalent) are subject to the NonPreferred Copay (Not All MULTISORUCE Medications are listed on
this Formulary)
All forms (oral, liquid, topical…) and dosages (DR, ER, LA, XR….)
of the medications listed are classified as Non-Preferred
This Formulary is subject to change at any time without notice
List of Preventive Care Drugs - Covered for $0.00 copayment
With preventive care services under the Affordable Care Act, several
therapeutic classes of medications must have therapies available to
members without any member cost-share. In short, the following list
of medications are available to members for a $0 copayment. If the
members opt to use a medication within these therapy classes and the
medication is NOT listed below, the member will have a cost-share
based on the plan design.
CONTRACEPTIVES - ORAL ($0.00
Copay)
Drug
Rx Name
Type
CONTRACEPTIVES - ORAL ($0.00
Copay)
Jolivette
Generic
Apri
Generic
Jolessa
Generic
Aranelle
Generic
Junel 1/20
Generic
Aviane
Generic
Junel Fe 1/20
Generic
Azurette
Generic
Junel 1.5/30
Generic
Balziva
Generic
Junel Fe 1.5/30
Generic
Camila
Generic
Kariva
Generic
Caziant
Generic
Kelnor 1/30
Generic
Cesia
Generic
Leena
Generic
Cryselle-28
Generic
Levora
Generic
Enpresse-28
Generic
Low-Orgestrel
Generic
Errin
Generic
Lutera
Generic
Gianvi
Generic
Microgestin 1/20
Generic
Gildess Fe 1/20
Generic
Microgestin 1.5/30
Generic
Gildess Fe 1.5/30
Generic
Microgestin Fe
Generic
Heather
Generic
Microgestin Fe 1.5/30
Generic
P a g e | 38
Updated 6.2014
MonoNessa
Generic
Zenchant
Generic
Necon 0.5/35-28
Generic
Zovia
Generic
Necon 1/35-28
Generic
CONTRACEPTIVES - EMERGENCY ($0.00
Copay)
Necon 1/50-28
Generic
Rx Name
Necon 10/11-28
Generic
Levonorgestrel, Next
Choice
Necon 7/7/7
Generic
Nora-BE
Generic
CONTRACEPTIVES - PATCH ($0.00
Copay)
Norinyl
Generic
Rx Name
Nortrel 0.5/35 (28)
Generic
Ortho Evra
Nortrel 1/35 (21)
Generic
Nortrel 1/35 (28)
Generic
CONTRACEPTIVES - RING ($0.00 Copay)
Nortrel 7/7/7
Generic
Rx Name
Drug Type
Ocella
Generic
Nuvaring
Brand
Ogestrel
Generic
Portia
Generic
CONTRACEPTIVES - DIAPHRAGM ($0.00
Copay)
Quasense
Generic
Rx Name
Drug Type
Reclipsen
Generic
Femcap
Brand
Solia
Generic
Ortho All Flex
Brand
Sprintec-28
Generic
Ortho-Diaphragm
Brand
Sronyx
Generic
Tilia Fe
Generic
CONTRACEPTIVES - IMPLANTABLE
($0.00 Copay)
Tri-Legest Fe
Generic
Rx Name
Drug Type
TriNessa
Generic
Paraguard
Brand
Tri-Sprintec
Generic
Implanon
Brand
Tri-Lo-Sprintec
Generic
Trivora-28
Generic
CONTRACEPTIVES - INJECTABLE ($0.00
Copay)
Velivet
Generic
Medroxyprogesterone
P a g e | 39
Drug Type
Generic
Drug Type
Brand
Generic
Updated 6.2014
SMOKING CESSATION - ORAL ($0.00 Copay)
Rx Name
Drug Type
Bupropion SR 150
Generic
SMOKING CESSATION - INHALER ($0.00 Copay)
Rx Name
Drug Type
Nicotrol
Brand
SMOKING CESSATION - GUM ($0.00 Copay)
Rx Name
Drug Type
Nicotine Gum
OTC
SMOKING CESSATION - LOZENGE ($0.00 Copay)
Rx Name
Drug Type
Nicotine Lozenge
OTC
SMOKING CESSATION - PATCH ($0.00 Copay)
Rx Name
Drug Type
Nicotine Patch
OTC
PREVENTIVE MEDICATIONS ($0.00 Copay)
Rx Name
Drug Type
Aspirin 81mg (males 45-79 yrs)
Generic
(females 55-79 yrs)
Folic Acid .4mg - .8mg
Generic
Oral Fluoride (under 4yrs old)
Generic
Iron Supplement (6mos - 1yr)
Generic
P a g e | 40
Updated 6.2014
OTC (Over-the-Counter) drugs, prescription required: The following
OTC medications are available for a $0 copay:
A prescription from the physician is required. The physician must
specify OTC on the prescription after the medication name.
OTC Anti-Ulcer Medications
**Therapeutic Equivalent alternatives to Nexium (40mg), Dexilant &
Aciphex
Brand Name
Generic Name
Axid
Nexium OTC
Pepcid
Prevacid OTC 15mg
Prilosec OTC 20mg
Tagamet
Zantac
Zegerid OTC
nizatidine
esomeprazole magnesium
famotidine
lansoprazole
omeprazole Magnesium
cimetidine
ranitidine
omeprazole / sodium bicarbonate
OTC Allergy Medications
**Therapeutic Equivalent alternatives to Flonase, Nasacort, Nasonex,
Rhinocort, Vermayst & Xyzal
Brand Name
Allegra / Allegra D
Benadryl
Claritin/Alavert
Claritin D/Alavert D
Nasacort Allergy 24HR
Zyrtec
Zyrtec-D
Generic Name
fexofenadine / fexofenadine D
diphenhydramine
loratadine
loratadine D
triamcinolone nasal inhaler
cetirizine HCL
cetirizine-D HCL
OTC Overactive Bladder Medications
**Therapeutic Equivalent alternatives to Detrol LA, Oxytrol Patch &
Vesicare
Brand Name
Oxytrol for Women OTC Patch
Generic Name
Oxybutynin for Women Patch
All prescriptions other than those specifically outlined above or
Maintenance Drugs are limited to a 30-day supply.
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Updated 6.2014
REFILL LIMITATIONS
As indicated; up to one year from original order.
EXCLUSIONS
The following are not covered under the St. George’s Univeristy
Prescription Drug Plan:





Fertility Medications
Growth Hormones
Medical Devices / Appliances
Impotency Agents
Cosmetic Drugs
1.
Any prescription filled in excess of the quantity limit or day
supply limit covered by the Plan
2. Any prescription refilled in excess of the number specified by
the physician, or any refill dispensed after one year from the
physician’s original order
3. Experimental or Investigational medications.
A drug is
considered “investigational” or “experimental” if its use has not
been approved by the U.S. Food and Drug Administration or if it
is an approved drug but is not being used in a therapy for which
it is generally prescribed. The Plan Administrator’s decision
whether a drug or its use are “investigational” or
“experimental” shall be binding.
4. Compounded Drugs that do not contain at least one ingredient
that has been approved by the US Food & Drug Administration
and requires a Prescription Order of Refill.
5. Compounded drugs that are available as a similar commercially
available Prescription Drug Product.
6. Drugs available over the counter that do not require a prescription
order or refill by federal or state law before being dispensed, unless
the Company has designated the over the counter medications
eligible for coverage and it is obtained with a prescription order or
refill from a physician.
7. Any product for which the primary use is a source of nutrition,
nutritional supplements, or dietary management of disease, even
when used for the treatment of Sickness or Injury, except as required
by State mandate.
8. Medication which is to be taken by or administered to an individual,
in whole or in part, while he/she is a patient in a licensed hospital,
rest home, sanitarium, extended care facility, convalescent hospital,
nursing home or similar institution which operates on its premises, or
allows to be operated on its premises, a facility for dispensing
pharmaceuticals
9. Prescriptions refilled before 85% of the previous filling has been used
10. Prescriptions that are forged or otherwise wrongfully obtained
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Updated 6.2014
A drug is considered “investigational” or “experimental” if its use has not
been approved by the U.S. Food and Drug Administration or if it is an
approved drug but is not being used in a therapy for which it is generally
prescribed. The Plan Administrator’s decision whether a drug or its use
are “investigational” or “experimental” shall be binding.
PRESCRIPTION UTILIZATION PROCESS
In order to receive the maximum benefit from the EHIM Prescription Drug
Program provided by St. George’s University, please follow the appropriate
steps listed below.
PARTICIPATING PHARMACIES:
An Identification Card will be issued to each employee by EHIM to be used
at any Participating Pharmacy. When purchasing a prescription and/or
refill at a Participating Pharmacy follow these steps:
1.
Present your Identification Card and the prescription to the
Pharmacist.
2.
The Pharmacist will contact EHIM to verify that the prescription
is for a covered drug and to ascertain the appropriate copayment
as specified on page 2 of this summary under the caption
“Schedule of Co-payments.”
3.
If the prescription is for a covered drug, the Pharmacist will
charge you the appropriate copayment.
4.
If you need assistance in locating a Participating Pharmacy, please
call EHIM at 1-800-311-3446 or e-mail EHIM at [email protected].
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Updated 6.2014
Copyright 2014 EHIM, Inc.
Employee Health Insurance Management, Inc.
26711 Northwestern Highway, Suite 400
Southfield, MI 48033
Phone: (248) 948-9900
Fax: (248) 948-9904
Toll Free: (800) 311-3446
Website: www.ehimrx.com
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