LDI 2016 PRESCRIPTION DRUG LIST PRESCRIPTION DRUG LIST FEATURES

LDI 2016 PRESCRIPTION
DRUG LIST
PRESCRIPTION DRUG LIST FEATURES
Quick-reference guide to the Formulary
Drug listing by specific drug class or major therapeutic use
Reference for drugs available as generics
Reference for Non-Preferred Brand Alternatives
FORMULARY & BENEFIT QUESTIONS, PRIOR AUTHORIZATION
Phone: 314.652.3121 or toll free 1.866.516.3121
AUTOMATED REFILLS ONLY
Phone: 314.652.1121 or toll free 1.866.516.1121
YOUR PRESCRIPTION DRUG LIST
This Prescription Drug List (PDL) outlines the most commonly prescribed medications from your
plan’s complete pharmacy benefit coverage list, also known as a formulary. A formulary identifies
the drugs available for certain conditions and organizes them into cost levels, known as tiers.
An important part of the PDL is giving you choices so you and your doctor can choose the best
course of treatment for you.
Effective January 1, 2016
Health Solutions Made Personal.
At LDI, we want to help you better understand your medication options.
Your pharmacy benefit offers flexibility and choice in determining the right medication for you. To help
you get the most out of your pharmacy benefit, we’ve included some of the most commonly asked
questions about the Prescription Drug List.
What is a Prescription Drug List (PDL)?
This document is a list of commonly prescribed medications preferred by your plan sponsor for their
safety, cost and effectiveness. Drugs are listed by common categories or class. They are placed into
cost levels known as tiers. It includes both brand and generic prescription medications approved by
the U.S. Food and Drug Administration (FDA).
Please note: Where differences are noted between this PDL and your benefit plan documents, the
benefit plan documents will rule. It is not intended to be a complete list of medications, and not all
medications listed may be covered under your plan.
Please look at your benefit plan documents provided by your employer or plan sponsor to see what
medications are covered under your plan.
How do I use my Prescription Drug List?
When choosing a medication, you and your doctor should consult the PDL. It will help you and your
doctor choose the most cost-effective prescription drugs. This guide tells you if a medication is
generic or brand, and if special rules apply. Bring this list with you when you see your doctor. It is
organized by common medical conditions.
What is the difference between brand-name and generic medications?
Generic medications contain the same active ingredients (what makes the medication work) as
brand-name medications, but they often cost less. Once the patent of a
brand-name medication ends, the FDA can approve a generic version with the same active ingredients.
These types of medications are known as generic medications. Sometimes the same company that
makes a brand-name medication also makes the generic version.
Is it a generic or brand-name drug?
The drug list shows brand-name drugs in bold type (for example, Coumadin) and generic drugs in
plain type (for example, Warfarin). What if my doctor writes a brand-name prescription? The next time
your doctor gives you a prescription for a brand-name medication, ask if a generic equivalent or
lower-cost option is available and if it might be right for you. Generic medications are usually your
lowest-cost option.
2
WHAT ARE TIERS
Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost,
which is determined by your employer or plan sponsor. This is how much you will pay when you
fill a prescription. Tier 1 medications are your lowest-cost options. If your medication is placed in
Tier 2 or 3, look to see if there is a Tier 1 option available. Discuss these options with your doctor.
Check your benefit plan documents to find out your specific pharmacy plan costs.
$
Drug Tier
Tier 1 Lowest
Cost
Tier 2
Mid-range
Cost
Tier 3
Highest Cost
Includes
Lower-cost drugs.
Some low-cost brands
are also included.
Mix of brands and
generics.
Helpful tips
Use Tier 1 drugs for the
lowest out-of-pocket costs.
Use Tier 2 drugs, instead of
Tier 3 to help reduce your outof-pocket costs.
Many Tier 3 drugs have
Mostly higher-cost
lower-cost options in Tier 1 or
brand as well as
select generic drugs.
2. Ask your doctor if they could
work for you.
Please note: Some plans may have two or four tiers, while others may not have any.
PROGRAMS AND LIMITS
Some medications are noted with letters or symbols next to them. The letters and symbols
refer to our pharmacy benefit programs and are provided to help you check which medications
may have a program or limit. Your benefit plan determines how these medications may be covered
for you.
PA
Prior Authorization – Your doctor is required to provide additional
information to determine coverage.
ST
Step Therapy – Trial of a lower cost medication is required before a
higher-cost medication is covered.
QL
Quantity Limits – Amount of medication covered per copayment or in a
specific time period.
AR
Age Restrictions – Some restrictions may apply based on patient age.
SP
Specialty Medication- Medication is designated as a specialty
pharmacy drug.
GR
Gender Restrictions – Some restrictions may apply based on
patient gender.
3
When does the Prescription Drug List change?
•Medications may move to a lower tier at any time.
•Medications may move to a higher tier when its generic becomes available.
•Medications may move to a higher tier or be excluded from coverage on January 1 or July
1 of each year.
When a medication changes tiers, you may have to pay a different amount for that
medication.
INDEX
Anti-Infective................................
5
Infertility.............................................
13
Cancer................................................ 5
Inflammatory Conditions.............
13
Cardiovascular/Heart Disease.......... 5, 6, 7
Men’s Health......................................
13
Central Nervous System..............
7, 8
Miscellaneous.................................... 13, 14
Dermatology...................................
9
Musculoskeletal................................
14
Diabetes.......................................... 9, 10, 11
Overactive Bladder.........................
14
Endocrine..........................................
11
Respiratory.........................................
15
Eye Conditions..............................
11, 12
Gastrointestinal............................
12
HIV/AIDS.............................................. 12
Transplant........................................... 15
Vitamins/Electrolytes........................ 15, 16
Women’s Health...............................
16
4
Drug Name
Drug
Tier
Programs
and Limits
SulfamethoxazoleTrimethoprim
SulfamethoxazoleTrimethoprim DS
Anti-Infective: Antibiotics
Amoxicillin
Amoxicillin/
Clavulanate
Azithromycin
Bethkis
Cefdinir
Cefuroxime Tab
Cephalexin
Ciprodex Otic
Suspension
Ciprofloxacin
Clarithromycin
Clindamycin Cap
Dificid
Doxycycline Hyclate
Doxycycline Hyclate
Tab (immediate
release)
Doxycycline
Monohydrate
Cap
Levofloxacin
Metronidazole Tab
Minocycline Cap
Neomycin/
Polymyxin/HC
Otic Suspension,
Solution
Nitrofurantoin
Macrocrystalline
Nitrofurantoin
Monohydrate
Macrocrystalline
Ofloxacin Otic
Solution
Oracea
Penicillin VK
Solodyn
1
1
1
2
1
1
1
Drug
Tier
Drug Name
Programs
and Limits
1
1
Anti-Infectives: Antifungals
Fluconazole
Nystatin Suspension
Terbinafine Tab
SP
1
1
1
QL
Anti-Infectives: Antivirals
3
1
1
1
3
1
PA
QL
1
QL
1
QL
Acyclovir Tab, Cap,
Suspension
Baraclude
Famciclovir Tab
Olysio
Pegasys
Solvaldi
Tamiflu
Valacyclovir
1
3
1
3
2
2
2
1
SP
PA, SP
PA, SP
PA, SP
QL
Cancer
Anastrozole
Gleevec
Letrozole
Revlimid
Tamoxifen
Tasigna
Zytiga
1
1
1
1
1
2
1
3
1
2
3
PA, SP
PA
PA, ST
PA, SP
PA, SP
Cardiovascular/Heart Disease:
Anticoagulants
1
1
1
3
1
3
[Bold type = Brand name drug]
[Plain type = Generic drug]
QL, PA
QL, PA
Aggrenox
Brilinta
Clopidogrel
Coumadin
Effient
Eliquis
Enoxaparin
Pradaxa
Warfarin
Xarelto
PA Prior Authorization
ST Step Therapy
QL Quantity Limits
3
2
1
3
2
3
1
2
1
2
QL
QL
QL
QL
QL
AR Age Restrictions
SP Specialty Program
GR Gender Restrictions
5
Drug Name
Drug
Tier
Programs
and Limits
Cardiovascular/Heart Disease:
High Blood Pressure
Amlodipine
Amlodipine/
Benazepril
Atenolol
Atenolol/
Chlorthalidone
Azor
Benazepril
Benazepril/HCTZ
Benicar
Benicar HCT
Bisoprolol
Bisoprolol/HCTZ
Bumentanide
Bystolic
Cartia XT
Carvedilol
Chlorthalidone
Clonidine Tab
Coreg CR
Diovan
Doxazosin
Dutoprol
Edarbi
Edarbyclor
Enalapril
Exforge
Exforge HCT
Felodipine
Fosinopril
Furosemide
Guanfacine Tab
Hydralazine
Hydrochlorothiazide
Irbesartan
Irbesartan/HCTZ
Labetalol
Lisinopril
Lisinopril/HCTZ
Losartan
1
1
1
1
2
1
1
2
2
1
1
1
2
1
1
1
1
3
3
1
2
3
3
1
3
3
1
1
1
1
1
1
1
1
1
1
1
1
[Bold type = Brand name drug]
[Plain type = Generic drug]
ST
ST
ST
ST
Drug
Tier
Drug Name
Losartan/HCTZ
Metoprolol
Succinate
Metoprolol Tartrate
Nadolol
Nifedipine ER
Propranolol
Propranolol ER
Quinapril
Ramipril
Spironolactone
Tarka
Tekturna
Tekturna HCT
Telmisartan
Terazosin
Terazosin
Torsemide Tab
Triamterene/HCTZ
Tribenzor
Valsartan/HCTZ
Verapamil ER
Programs
and Limits
1
1
1
1
1
1
1
1
1
1
3
2
2
1
1
1
1
1
2
1
1
ST
ST
ST
Cardiovascular/Heart Disease:
High Cholesterol
QL
ST
ST
ST
ST
Atorvastatin
Crestor
Fenofibrate
Gemfibrozil
Lipitor
Lipofen
Livalo
Lovastatin
Lovaza
Niacin ER Tab
Omega-3 Acid Cap 1
gm
Pravastatin
Simvastatin
Simvastatin 80 mg
Vascepa
Vytorin
1
2
1
1
3
3
3
1
3
1
QL
QL, ST
QL
QL
QL
QL
QL, ST
1
QL
1
1
1
2
2
QL
QL
QL
QL
QL, ST
QL
PA Prior Authorization
ST Step Therapy
QL Quantity Limits
AR Age Restrictions
SP Specialty Program
GR Gender Restrictions
6
Drug
Tier
Programs
and Limits
Vytorin Tab 10-80 mg
2
QL, ST
Welchol
Zetia
2
3
Drug Name
QL, ST
1
1
1
1
1
2
2
1
Cardiovascular/Heart Disease:
Pulmonary Arterial Hypertension
Adcirca
Letairis
Opsumit
Sildenafil Tab 20mg
Tracleer
3
2
2
1
2
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
Central Nervous System:
Attention Deficit Disorder
AmphetamineDextroamphetamine
1
AR
1
QL, AR
Cap Sr 24Hr
Dexmethylphenidate
ER
Focalin XR
Intuniv
Methylphenidate
Cap ER
Methylphenidate ER
Tab
Methylphenidate Sa
Osm ER Tab
Methylphenidate Tab
Strattera
Programs
and Limits
2
QL, AR
Amitriptyline
Budeprion XL
Bupropion
Bupropion SR
Citalopram
Cymbalta
Doxepin
Duloxetine Cap
Escitalopram Tab
Fluoxetine Cap (not
PMDD)
Forfivo XL
Mirtazapine
Nortriptyline
Paroxetine
Pristiq
Sertraline
Trazodone
Venlafaxine
Venlafaxine ER Cap
Viibryd
1
1
1
1
1
3
1
1
1
QL
QL
QL
QL
1
2
1
1
1
2
1
1
1
1
3
QL
QL
QL, ST
Central Nervous System: Migraine
AmphetamineDextroamphetamine
Vyvanse
Drug
Tier
Central Nervous System: Depression
Cardiovascular/Heart Disease: Other
Amiodarone
Amlodipine/
Atorvastatin
Digoxin
Flecainide
Isosorbide
Mononitrate
Nitrostat
Ranexa
Sotalol
Drug Name
1
AR
3
3
QL, ST, AR
AR
1
QL, AR
1
QL, AR
1
QL, AR
1
2
QL, AR
QL, AR
[Bold type = Brand name drug]
[Plain type = Generic drug]
ButalbitalAcetaminophenCaffeine Cap
50-325-40mg
Migranal
Relpax
Rizatriptan Tab, ODT
Sumatriptan Tab and
Spray
Sumavel Dose
Zomig Nasal Spray
PA Prior Authorization
ST Step Therapy
QL Quantity Limits
1
QL
3
3
1
QL
QL
QL
1
QL
3
2
QL
QL
AR Age Restrictions
SP Specialty Program
GR Gender Restrictions
7
Drug Name
Drug
Tier
Programs
and Limits
Central Nervous System:
Multiple Sclerosis
Ampyra
Avonex Kit
Avonex Pen Kit
Avonex Prefill Kit
Betaseron
Copaxone
Gilenya*
Rebif
Rebif Titrtn
Tecfidera
2
2
2
2
3
2
3
3
3
2
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
PA, SP
Central Nervous System: Other
Abilify Tab
Abilify Disc
Abilify Solution
Alprazolam Tab
Benztropine
Buspirone
Carbidopa/
Levodopa Tab
Diazepam Tab
Donepezil Tab
Hydroxyzine HCl
Hydroxyzine
Pamoate
Lithium Carbonate
Lorazepam
Modafinil
Namenda Tab
Namenda XR
Olanzapine Tab
Pramipexole
Prochlorperazine
Quetiapine
3
2
3
1
1
1
QL
QL
QL
QL
1
1
1
1
PA, QL
QL
Drug
Tier
Risperidone Tab
Ropinirole
Saphris
Seroquel XR
Zelapar
Ziprasidone Cap
1
1
2
2
3
1
Programs
and Limits
QL
QL
Central Nervous System:
Sedatives/Hypnotics
Eszopiclone Tab
Lunesta
Silenor
Temazepam
Triazolam Tab
Zolpidem
Zolpidem ER
1
3
3
1
1
1
1
QL
QL
QL
QL
QL
Central Nervous System:
Seizure Disorders
1
1
1
1
3
2
1
1
1
1
Drug Name
Carbamazepine
Clonazepam
Divalproex DR
Divalproex ER
Gabapentin
Lamictal
Lamictal ODT
Lamictal XR
Lamotrigine
Lamotrigine ER
Levetiracetam
Levetiracetam ER
Lyrica Cap
Onfi
Oxcarbazepine
Phenytoin
Topiramate Tab
1
1
1
1
1
2
2
3
1
1
1
1
2
3
1
1
1
PA, SP
QL
*Tier 3 Preferred
[Bold type = Brand name drug]
[Plain type = Generic drug]
PA Prior Authorization
ST Step Therapy
QL Quantity Limits
AR Age Restrictions
SP Specialty Program
GR Gender Restrictions
8
Drug Name
Drug
Tier
Programs
and Limits
Nystatin Cream,
Ointment, Powder
Dermatology
Acanya Gel
Acyclovir Ointment
5%
Aczone Gel
Atralin
Benzaclin
Carac
Clindamycin Gel,
Lotion, Solution
Clindamycin/ Benzoyl
Peroxide Gel 1-5%
Clobetasol Cream,
Gel, Ointment
Clobex
Cloderm
Clotrimazole/
Betamethasone
Cream, Lotion
Condylox
Desonide Cream
Differin
Econazole Cream
Elidel
Epiduo
Finacea
Fluocinonide Cream,
Gel, Ointment
0.05%
Hydrocortisone
Cream 2.5%
Ketoconazole
Cream/Shampoo
Metrogel
Metronidazole gel
0.75%
Mometasone
Mupirocin
Drug
Tier
Drug Name
3
Programs
and Limits
1
QL, PA
1
3
3
3
3
PA
PA, QL, AR
PA, QL
PA
1
PA
1
PA
1
PA
3
3
PA
PA
1
3
1
3
1
2
3
2
1
2
PA
1
3
3
PA, AR
PA, QL, AR
1
3
PA
1
PA, AR
1
3
2
3
QL
Diabetes/Endocrine Blood:
Glucose Monitoring
PA
PA
QL, AR
PA, QL
PA
1
1
1
3
PA
1
PA
1
1
QL
[Bold type = Brand name drug]
[Plain type = Generic drug]
Nystatin/
Triamcinolone
Cream, Ointment
Oxsoralen-Ul
Permethrin Cream
5%
Protopic Ointment
Retin-A Micro
Silver Sulfadiazine
Cream 1%
Taclonex
Tretinoin
Microsphere Gel
Triamcinolone
Vectical
Zovirax Cream
Zyclara
Accu-Chek Act/ Gluc
Calibration
Liquid
Accu-Chek Aviva
Plus Test Strips
Accu-Chek Aviva
Test Strips
Accu-Chek Comfort
Test Strips
Accu-Chek Cpt/ Gluc
Calibration
Liquid
Accu-Chek Drum
Test Strips
Accu-Chek Kit
Aviva Plus
Accu-Chek Kit
Compact
Accu-Chek Kit
Fastclix
PA Prior Authorization
ST Step Therapy
QL Quantity Limits
3
2
QL
2
QL
2
QL
3
2
QL
2
2
2
AR Age Restrictions
SP Specialty Program
GR Gender Restrictions
9
Drug Name
Accu-Chek Kit
Multiclix
Accu-Chek Kit Nano
Accu-Chek Kit
Softclix
Accu-Chek Multiclix
Lancets
Accu-Chek Smart
Calibration
Liquid
Accu-Chek Smart
Test Strips
Accu-Chek Sol
Calibration
Liquid
Accu-Chek Sol
Comfort
Calibration
Liquid
Fastclix Lancets
Glucocard Test
Strips
Insulin Pen Needle
Insulin Syringe/
Needle
Novofine
Novofine Auto
Novotwist
Onetouch Kit Ult
Smart
Onetouch Kit Ultra
Onetouch Kit Ultra 2
Onetouch Kit Ultra
Mini
Onetouch Kit Verio
IQ
Onetouch Test
Strips
Onetouch Ultra Blue
Test Strips
Drug
Tier
Programs
and Limits
2
2
2
2
3
2
QL
Drug Name
Onetouch Verio IQ
Test Strips
Onetouch Verio
Test Strips
Soft Touch Lancets
Softclix Lan Mis
Device
Softclix Lancets
Surestep Test Strips
Truetrack Test
Strips
Drug
Tier
Programs
and Limits
2
QL
2
QL
2
3
2
3
QL
3
QL
Diabetes/Endocrine: Insulin
3
3
2
3
QL
2
2
3
3
3
2
2
2
2
2
2
QL
2
QL
[Bold type = Brand name drug]
[Plain type = Generic drug]
Humalog Vials
Humalog Kwik Pen
Humalog Mix 50/50
Kwik Pen
Humalog Mix
50/50 Vials
Humalog Mix 75/25
Kwik Pen
Humalog Mix
75/25 Vials
Humulin 70/30 Vials
Humulin N Vials
Humulin N Pen
Humulin Pen 70/30
Humulin R U-500
Humulin R Vials
Lantus Solostar
Lantus Vials
Levemir Flexpen
Levemir Vials
Novolin 70/30 Vials
Novolin N Vials
Novolin R Vials
Novolog Flexpen
Novolog Mix
Flexpen
Novolog Mix
70/30 Vials
PA Prior Authorization
ST Step Therapy
QL Quantity Limits
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
AR Age Restrictions
SP Specialty Program
GR Gender Restrictions
10
Drug Name
Novolog Penfill
Novolog Vials
Drug
Tier
Programs
and Limits
2
2
Diabetes/Endocrine: Non-Insulin
Byetta
Glimepiride
Glipizide
Glipizide ER
Glipizide XL
Glyburide
Glyburide/
Metformin
Invokamet
Invokana
Janumet
Janumet XR
Januvia
Jentadueto
Kombiglyze
Metformin
Metformin ER
Onglyza
Pioglitazone
Tradjenta
Victoza
2
1
1
1
1
1
QL, ST
1
2
2
2
2
2
3
2
1
1
2
1
3
2
2
2
2
2
Armour Thyroid
Levothyroxine
Liothyronine
Methimazole
Synthroid
Azelastine Solution
Pataday
Patanol
ST
QL
ST
ST
[Bold type = Brand name drug]
[Plain type = Generic drug]
2
PA, SP
1
1
1
3
SP
3
1
1
1
3
1
2
2
QL
Eye Conditions: Antibiotics
PA, SP
PA, SP
PA, SP
PA, SP
1
1
2
Programs
and Limits
Eye Conditions: Allergies
Endocrine: Other
Calcitriol Cap
Dexamethasone Tab
Lupron Depot 3.75 mg,
11.25 mg
Lupron Depot
7.5 mg, 22.5 mg,
30 mg, 45 mg
Methylprednisolone
Tab
Prednisolone
Solution
(5mg/5mL and
15mg/5mL)
Prednisone
Sensipar
Drug
Tier
Endocrine:
Thyroid Hormone Replacement
ST
ST
ST
ST
ST
ST
ST
Endocrine: Growth Hormone
Nutropin
Nutropin AQ
Saizen
Tev-Tropin
Drug Name
PA, SP
Ciprofloxacin
Erythromycin
Ointment
Gentamicin
Moxeza
Ofloxacin
Polymyxin B/
Trimethoprim
Solution
Tobramycin
Tobramycin/
Dexamethasone
Vigamox
PA Prior Authorization
ST Step Therapy
QL Quantity Limits
1
1
1
2
1
1
1
1
2
AR Age Restrictions
SP Specialty Program
GR Gender Restrictions
11
Drug Name
Drug
Tier
Programs
and Limits
Metoclopramide
Ondansetron Tab
Transderm-Scop
Eye Conditions: Glaucoma
Alphagan P
Azopt
Brimonidine
Combigan
Dorzolamide
-Timolol Maleate
Latanoprost
Lumigan
Timolol
Timoptic Ocudose
Travatan Z
2
2
1
2
QL
QL
QL
QL
QL
Eye Conditions: Other
Ketorolac Ophth
Solution
Prednisolone Ophth
Restasis
1
1
3
Gastrointestinal: Acid Suppression
Carafate Suspension
Dexilant
Famotidine Tab 20mg
and 40mg (Rx
only)
Lansoprazole (Rx
only)
Nexium (Rx Only)
Omeprazole (Rx
Only)
Pantoprazole
Rabeprazole
Ranitidine Tab, Cap,
Syrup (Rx Only)
Sucralfate Tab
2
2
QL, ST
1
QL
Amitiza
Apriso
Asacol HD
Canasa
Creon
Delzicol
Dicyclomine
Diphenoxylate/
Atropine
Halflytely Kit
Moviprep
Omeclamox Pak
Pentasa
Polyethylene
Glycol 3350
Pylera
Suclear Bowel Prep
Uceris
Zenpep (Not 5,000
units)
2
3
3
2
2
3
1
QL, AR
QL
1
3
3
2
3
1
2
3
3
2
HIV/AIDS
1
QL
3
QL
1
QL
1
1
QL
QL
1
1
Gastrointestinal: Nausea/Vomiting
Meclizine
1
1
3
Programs
and Limits
Gastrointestinal: Other
1
1
2
1
2
2
Drug
Tier
Drug Name
1
[Bold type = Brand name drug]
[Plain type = Generic drug]
Atripla
Complera
Epzicom
Intelence
Isentress
Kaletra
Norvir
Prezista
Reyataz
Stribild
Truvada
Viread
PA Prior Authorization
ST Step Therapy
QL Quantity Limits
2
2
2
2
2
2
2
2
2
2
2
2
SP
SP
SP
SP
SP
SP
SP
SP
SP
SP
PA, SP
SP
AR Age Restrictions
SP Specialty Program
GR Gender Restrictions
12
Drug Name
Drug
Tier
Programs
and Limits
Infertility
Follistim AQ
Gonal-f
Gonal-f RFF
Ovidrel
2
2
2
3
PA, SP
PA. SP
PA, SP
PA, SP
Inflammatory Conditions
Cimzia
Enbrel
Enbrel SureClick
Humira Kit
Humira Pen Kit
Humira Pen Kit
Crohns
Humira Pen Kit
Psoriasis
Hydroxychloroquine
Methotrexate Tab
Orencia SC
Simponi
Stelara
2
3
3
2
2
PA, SP
PA, ST, SP
PA, ST, SP
PA, SP
PA, SP
2
PA, SP
2
PA, SP
1
1
3
2
2
PA, ST, SP
PA, SP
PA, SP
Men’s Health: Erectile Dysfunction
Cialis
Levitra
Viagra
2
3
3
QL, AR, GR
QL, AR, GR
QL, AR, GR
Men’s Health: Prostate
Alfuzosin
Avodart
Doxazosin
Finasteride 5 mg
Jalyn
Rapaflo
Tamsulosin
Terazosin
1
2
1
1
2
2
1
1
QL
Men’s Health: Testosterone Therapy
Androderm
Androgel 1.62%
Fortesta
2
2
3
PA, QL, GR
PA, QL, GR
PA, QL, GR
[Bold type = Brand name drug]
[Plain type = Generic drug]
Drug Name
Testim
Testosterone
Cypionate IM
Injection
Drug
Tier
Programs
and Limits
3
PA, QL, GR
1
PA
Miscellaneous
Allopurinol
Antipyrine/
Benzocaine Otic
Solution 5.4-1.4%
Aranesp
Benzonatate
Botox 100, 200 unit
Injection
Chantix
Cheratussin
Chlorhexidine
Colcrys
Epipen 2-Pak
Euflexxa
Fosrenol
Hydrocortisone AC
Suppository 25 mg
1
Hydromet
Lidocaine Viscous
Solution 2%
Makena
Neupogen
Phenazopyridine (Rx
Only)
Phentermine Tab
Procrit
Promethazine DM
Syrup
Promethazine/
Codeine Syrup
Pulmozyme
Rectiv
Renvela
Rezira
1
PA Prior Authorization
ST Step Therapy
QL Quantity Limits
1
2
1
PA, SP
3
PA, SP
3
1
1
2
2
2
3
QL
QL
PA, SP
1
1
3
SP 2
PA, SP
SP, PA, QL
1
3
2
PA, SP
1
AR
1
AR
2
3
2
3
PA, SP
AR Age Restrictions
SP Specialty Program
GR Gender Restrictions
13
Drug Name
Drug
Tier
Programs
and Limits
2
3
2
2
2
3
PA
PA, SP
PA, SP
Suboxone Film
Synagis
Synvisc
Uloric
Zubsolv
Zutripro
PA
Musculoskeletal: Osteoporosis
Actonel
Alendronate Tab
Evista
Forteo
Ibandronate Tab
Raloxifene
3
1
3
2
1
1
QL
QL
PA, SP
Musculoskeletal: Other
Baclofen Tab
Carisoprodol 350 mg
Cyclobenzaprine
Tab 5, 10 mg
Metaxalone
Methocarbamol
Tizanidine Tab
1
1
1
1
1
1
Musculoskeletal: Pain Relief
Acetaminophen
w/ Codeine
Cambia
Celebrex
Diclofenac Tab
Endocet Tab
Etodolac
Fentanyl Patch
Gralise
Hydrocodone
w/ Ibuprofen Tab
7.5-200 mg
Hydrocodone
w/ APAP 5, 7.5,
10/325 mg
Hydromorphone Tab
1
QL
3
3
1
1
1
1
3
QL
QL, ST
1
QL
1
QL
QL
QL
ST
Drug
Tier
Drug Name
Ibuprofen Tab 400,
600, 800 mg (Rx
Only)
Indomethacin Cap
Lazanda
Lidoderm Patch 5%
Meloxicam
Methadone Tab
Morphine Sulfate ER
Tab
Nabumetone
Naproxen (Rx Only)
Nucynta
Nucynta ER
Oxycodone Tab 5,
15, 30 mg
Oxycodone
w/
Acetaminophen
Oxycontin
Sprix
Subsys
Tramadol Tab 50 mg
Tramadol
w/
Acetaminophen
Vicodin
Vicodin ES
Voltaren Gel
Programs
and Limits
1
1
3
1
1
1
PA, QL
QL
1
QL
1
1
3
3
QL
QL
1
1
QL
2
3
3
1
QL
1
QL
3
3
2
QL
QL
QL
3
1
1
1
3
2
QL
PA
QL
Overactive Bladder
Enablex
Oxybutynin
Oxybutynin ER
Tolterodine ER
Toviaz
Vesicare
QL
QL
QL
1
[Bold type = Brand name drug]
[Plain type = Generic drug]
PA Prior Authorization
ST Step Therapy
QL Quantity Limits
AR Age Restrictions
SP Specialty Program
GR Gender Restrictions
14
Drug Name
Drug
Tier
Programs
and Limits
Drug
Tier
Drug Name
Respiratory: Asthma/COPD
Respiratory: Nasal Allergies
Advair Diskus
Advair HFA
Aerospan
Albuterol
Nebulizer
Solution
Asmanex
Breo Ellipta
Budesonide
Combivent
Respimat
Dulera
Flovent Diskus
Flovent HFA
Ipratropium/
Albuterol
Levalbuterol
Nebulizer
Solution
Montelukast
Perforomist
Proair HFA
Proventil
Pulmicort Flexhaler
Qvar
Serevent Diskus
Spiriva
Symbicort
Tudorza Pressair
Ventolin HFA
Xolair
Xopenex HFA
Azelastine Spray
Dymista Spray
Fluticasone Spray
Ipratropium Spray
Nasonex
Omnaris
Triamcinolone
Veramyst
Zetonna
2
2
3
1
1
3
1
1
2
3
1
2
3
3
2
1
QL
2
QL
Respiratory: Oral Allergies
3
2
2
ST
Cetirizine
Promethazine Tab
Desloratadine
Levocetirizine
Loratadine
1
[Bold type = Brand name drug]
[Plain type = Generic drug]
QL
QL
QL
AR
QL
Transplant
1
1
3
2
3
2
2
2
2
2
2
2
3
3
1
1
1
1
1
Programs
and Limits
Azathioprine Tab
Cellcept Tab/
Suspension
Cyclosporine Cap
Mycophenolate
250 mg Cap/
500 mg Tab
Prograf Cap
Rapamune
Tacrolimus Cap
QL
QL
QL
QL
QL
ST
QL
PA, SP
1
3
SP
1
SP
1
SP
3
3
1
SP
Vitamins/Electrolytes
Cyanocobalamin
Injection
Folic Acid 1 mg (Rx
Only)
Klor-Con M10 and
M20
Multi-Vit/Fl Chew
Potassium Chloride
ER Tab, Cap
PA Prior Authorization
ST Step Therapy
QL Quantity Limits
1
1
1
1
1
AR Age Restrictions
SP Specialty Program
GR Gender Restrictions
15
Drug Name
Potassium Chloride
Micro ER
Vitamin D 50,000
units (Rx Only)
Drug
Tier
Programs
and Limits
1
1
Women’s Health: Contraceptives
Apri
Aviane
Beyaz
Cryselle-28
Generess Fe
Chewable
Gianvi
Gildess Fe
Jolivette
Junel Fe
Kariva
Levora 28
Lo Loestrin
Loryna
Low-Ogestrel
Lutera
Medroxyprogesterone
Acetate Injection
Microgestin
Microgestin Fe
Minastrin 24 Fe
Chewable
Mononessa
Natazia
Necon
Norgest/Ethi
Estradiol
Nortrel
Nuvaring
Ocella
Orsythia
Ortho Tri-Cyclen Lo
Previfem
Reclipsen
1
1
3
1
GR
GR
GR
GR
3
GR
1
1
1
1
1
1
3
1
1
1
GR
GR
GR
GR
GR
GR
GR
GR
GR
GR
1
1
1
GR
GR
3
GR
1
2
1
GR
GR
GR
1
GR
1
2
1
1
3
1
1
GR
[Bold type = Brand name drug]
[Plain type = Generic drug]
Drug Name
Drug
Tier
Safyral
Sprintec 28
Trinessa
Tri-Sprintec
Vestura
Viorele
3
1
1
1
1
1
Programs
and Limits
GR
GR
GR
GR
GR
GR
Women’s Health: Hormone
Replacement
Climara Pro
Divigel
Enjuvia
Estrace Vaginal
Cream
Estradiol Tab
Estradiol/Norethindrone
Tab
Medroxyprogesterone
Acetate
Premarin
Premarin Vaginal
Cream
Premphase
Prempro
Progesterone Cap
Vagifem
Vivelle-Dot
2
3
2
QL, GR
GR
QL, GR
3
1
QL, GR
1
1
2
QL, GR
2
2
2
1
3
2
QL, GR
QL, GR
GR
QL, GR
Women’s Health: Vaginal
Anti-Infectives
Metronidazole
Vaginal Gel
Terconazole
Vaginal Cream
1
1
QL
GR
GR
GR
GR
GR
PA Prior Authorization
ST Step Therapy
QL Quantity Limits
AR Age Restrictions
SP Specialty Program
GR Gender Restrictions
16
“My Medications” worksheet
Take this worksheet with you each time you visit a doctor. Each of your doctors should
be aware of every drug you take and you should have a list as well.
Name of
Medicine and
Strength
Drug Tier
I Take This
Medicine For
Directions
Doctor
Example: Lisinopril,
20 mg
Tier 1
High Blood
Pressure
One tablet daily
Dr. Johnson
17