Microsoft word - a b-1530y4 3tier flrx 1.21.04.doc

2004: 3-Tier Medication Guide of Commonly Prescribed Drugs
The designation of drugs in the following categories is for reference only and is not a clinical comparison. Drug placement does not establish clinical comparability of products in individual situations. This list provides examples within categories and is not comprehensive. DRUG CLASS
(lowest member co-payment)
(highest member co-payment)
ALLERGY
Antihistamines (Oral)

Antihistamine/
Allegra-D, Optimine, Rynatan SA, Semprex-D, Decongestant
Combinations
Intranasal: Steroids/

Antihistamines/
Nasacort AQ, Nasarel, Nasalide, Tri-Nasal, Miscellaneous
ALZHEIMER’S
ARTHRITIS
Arava§, Enbrel§, Humira§, Kineret§, Rheumatrex gold, hydroxychloroquine,methotrexate, penicillamine,sulfasalazine ASTHMA
Inhaled Beta Agonists/

Advair, Foradil, Maxair, Maxair Autohaler, Proventil, Inhaled Respiratory
Proventil HFA, Tilade, Tornalate, Ventolin, Xopenox Agents (miscellaneous)
Inhaled Steroids

Advair, Aerobid, Aerobid M, QVAR, Vanceril, Leukotriene Inhibitors
Singulair (Tier 2 if history criteria met) Respiratory Drugs (oral)
Alupent, Brethine, Proventil SA, T-Phyl, Theo-Dur, ATTENTION DEFICIT
Adderall, Adderall XR, Concerta, Dexedrine, DISORDER
Dexedrine Spansules, Dextrostat, Focalin,Metadate CD, Ritalin, Ritalin LA, Strattera§ BLOOD
Anticoagulants

Antiplatelet
CARDIOVASCULAR / HEART
ACE Inhibitors

Accupril§, Aceon§, Capoten§, Lotensin§, Mavik§, Monopril§\, Prinivil§, Univasc§, Vasotec§, Zestril§ Angiotensin II Receptor
Atacand§, Benicar§, Cozaar§, Micardis§, Teveten§ Blockers
(high blood pressure)
Antiarrhythmics
Betapace, Cordarone, Mexitil, Norpace CR, Procan, Procanbid, Pronestyl, Quinidex, Quiniglute, Antihyperlipidemics
Altocor, Advicor, Colestid, Crestor, Crestor 10mg\, 20mg\, 40mg\§, Lescol§, Lescol XL§, Mevacor, Zetia (Tier 2 if history criteria are met) Antihypertensive
Accuretic§, Atacand HCT§, Benicar HCT§, Combinations
Capozide§, Hyzaar§, Lexxel, Lopressor HCT, Monopril HCT§, Prinzide§, Tarka, Teczem,Tenoretic, Tevetan HCT§, Uniretic§, Vaseretic§,Zestoretic§, Ziac Beta Blockers
Corgard, Inderal LA, Innopran XL, Kerlone, Levatol, Lopressor, Sectral, Tenormin, Trandate, Visken, Calcium Channel Blockers
Adalat CC, Calan, Calan SR, Cardene, Cardene SR, Cardizem, Cardizem CD, Cardizem LA , Covera, Covera HS, Dilacor XR, Dynacirc, Dynacirc CR, Plendil, Procardia XL, Sular, Tiazac, Verelan,Verelan PM List Subject to Change
Co-payment/Coinsurance for each tier is based on the specific rider chosen by the employer group.
The majority of benefits include additional member payment when a brand drug is used and a generic equivalent is available.
Brand drugs not listed are considered Tier 3. All compounds are considered Tier 3.
§ = Requires Prior Authorization
\ = Half Tablet opportunity: Certain strength tablets may be split to obtain lower dosage and reduce member out-of-pocket cost
V = May be Tier 2 for select prescribers/diagnoses
B-1530y4 Rev. 1/21/04
DRUG CLASS
(lowest member co-payment)
(highest member co-payment)
Diuretics
Aldactone, Bumex, Demadex, Dyazide, Dyrenium, Hydrodiuril, Hygroton, Lozol, Maxzide, Zaroxolyn indapamide, spironolactone,triamterene/HCTZ Nitrates (angina)
Deponit, Imdur, Ismo, Monoket, Nitrek, Nitrodisk,Nitro-Dur, Transderm-Nitro Potassium Supplements
CENTRAL NERVOUS
Cylert, Desoxyn, Dexedrine, Dexedrine Spansules, Provigil 100mg§, Provigil 200mg§\, Xyrem§ COUGH / COLD
Antitussives and

Amibid LA, Duratuss G, Humabid LA, Tussionex Expectorants
Antitussive Combinations
Genesin DM, Guaituss AC, Histussin, Histussin HC, DERMATOLOGY
Topical/Oral Acne

Accutane, A/T/S, Avita, Azelex, BenzaClin, Products
Benzamycin, Cleocin T, Desquam E, Differin, Emgel, Finacea, Finevin, Klaron, Novacet, Retin-A, Topical Antibiotics
erythromycin, gentamycin,neomycin/polymyxin, tobramycin,others Topical/Combination
Exelderm, Loprox, Lotrimin, Lotrisone, Mentax, Antifungals
Mycelex, Mycolog II, Naftin, Nizoral Cream, Oxistat, Topical/ Oral Steroids
Aclovate, Cloderm, Cordran, Cordran Tape, Diprolene/AF, Elocon, Florone/E, Halog/E, Locoid, Medrol Dose Pack, Pandel, Temovate, Psorcon/E,Topicort, Ultravate, Uticort Topicals:
Psoriasis/Eczema
DIABETES
Blood Glucose Supplies

Diabetic benefit and/or DME benefit applies: Preferred Meters are: Accu-check Active, Accu-check Advantage,
Accu-check Compact, Accu-check Complete, One Touch Sure Step, One Touch Ultra
DIABETIC BENEFIT APPLIES FOR ALL INSULINS
If Diabetic benefit DOES NOT apply please refer to the following tier classifications:
Oral Hypoglycemics
DIABETIC BENEFIT APPLIES FOR ALL ORAL HYPOGYLCEMICS
If Diabetic benefit DOES NOT apply, please refer to the following tier classifications:
Avandamet, Diabeta, Glucophage, Glucophage XR, Glucotrol, Glucovance, Glynase, Metaglip, Aurulgan, Cerumenex, Cortisporin, Pediotic, Vosol, ENTERAL FORMULAS
EYE
Ophthalmic

Anti-Inflammatory
fluorometholone, flurbiprofen,prednisolone Ophthalmic Antiallergics
Alamast, Alocril, Alomide, Alrex, Emadine, Livostin,Opticrom, Patanol Ophthalmic Antiinfectives
neosporin, polysporin, erythro,gent, sodium sulfacetamide,TMP/pol, tobra, others Ophthalmic Antivirals
Ophthalmic Combinations
dexamethasone sodiumphosphate solution, etc.
List Subject to Change
Co-payment/Coinsurance for each tier is based on the specific rider chosen by the employer group.
The majority of benefits include additional member payment when a brand drug is used and a generic equivalent is available.
Brand drugs not listed are considered Tier 3. All compounds are considered Tier 3.
§ = Requires Prior Authorization
\ = Half Tablet opportunity: Certain strength tablets may be split to obtain lower dosage and reduce member out-of-pocket cost
V = May be Tier 2 for select prescribers/diagnoses
B-1530y4 Rev. 1/21/04
DRUG CLASS
(lowest member co-payment)
(highest member co-payment)
Glaucoma
Azopt, Betagan, Betimol, Betoptic, Betoptic-S, Cosopt, Iopidine, Ocupress, Optipranolol, Pilopine gel, Propine, Rescula, Timoptic,Timoptic XE, Travatan colchicine/probenecid,probenecid, sulfinpyrazone GROWTH HORMONES
Genotropin§, Humatrope§, Norditropin§, Saizen§,
Serostim§, Tev-tropin§
HEPATITIS
Crixivan, Epivir, Fortovase, Norvir,Viracept, Viramune, Zerit IMMUNE SYSTEM
INFECTIONS: BACTERIAL, FUNGAL, VIRAL
Antibiotics

Augmentin, Augmentin XR, Avelox, Biaxin, Ceclor CD, Cedax, Ceftin, Cefzil, Cipro, Cipro XR, Cleocin, Dynabac, Floxin, Levaquin, Lorabid, Macrobid, Maxaquin, Monurol, Noroxin, Omnicef, PCE, Penetrax, Spectracef, Suprax, Tequin, Tobi, Trovan, Vantin, Vancocin, Zagam, Zithromax, Zyvox§ Antifungal Drugs (Oral)
Antiviral Drugs
Denavir, Famvir, Flumadine, Relenza§, Symmetrel, MEN’S HEALTH
BPH Agents (prostate)

Erectile Dysfunction
Hormones
Oral Androgens
MENTAL HEALTH
Antidepressants

Celexa 10mg, 20mg\, Desyrel, Elavil, Lexapro\, Prozac Weekly§, Remeron, Sarafem§, Sinequan,
Wellbutrin SR, Welllbutrin XL: Tier 2only if <13 years of age or historycriteria are met Antipsychosis
Clozaril, Haldol, Mellaril, Navane, Prolixin, Stelazine, Sedatives/Hypnotics/
Ativan, Buspar, Serax, Sonata, Valium, Xanax clonazepam, diazepam,triazolam), hydroxyzine MIGRAINE
Amerge, Axert, Frova, Imitrex 25mg tablets, Relpax, Imitrex 100mg & 50mg tablets, Imitrex nasal spray and injection MULTIPLE SCLEROSIS
OSTEOPOROSIS
Didronel, Forteo§, Skelid, Miacalcin Nasal List Subject to Change
Co-payment/Coinsurance for each tier is based on the specific rider chosen by the employer group.
The majority of benefits include additional member payment when a brand drug is used and a generic equivalent is available.
Brand drugs not listed are considered Tier 3. All compounds are considered Tier 3.
§ = Requires Prior Authorization
\ = Half Tablet opportunity: Certain strength tablets may be split to obtain lower dosage and reduce member out-of-pocket cost
V = May be Tier 2 for select prescribers/diagnoses
B-1530y4 Rev. 1/21/04
DRUG CLASS
(lowest member co-payment)
(highest member co-payment)
PAIN / INFLAMMATION
Muscle Relaxants

Arthrotec, Cataflam, Daypro, EC-Naprosyn, Lodine XL, Mobic, Naprelan, Oruvail, Ponstel, naproxen sodium, oxaprozin,piroxicam, salsalate, sulindac,tolmetinNo drugs listed at this time Step Therapy applies:Vioxx \, Vioxx Suspension, Bextra\, Celebrex (Patient must have failed a trial of Vioxx or Bextraprior to Celebrex approval) Pain Relievers (narcotic)
Avina, Avinza, Duragesic, Kadian, MS Contin, MSIR, Norco, Oramorph SR, OxyIR, Ultram, Zydone hydrocodone combinations,methadone, morphine(immediate & sustained release),others PARKINSON’S
Cogentin, Dopar, Eldepryl, Larodopa, Lodosyn, SEIZURE / PAIN
Gabitril, Keppra, Klonopin,Neurontin, Tegretol XR, Trileptal,Zonegran, Zarontin, othersNo drugs listed at this time SMOKING DETERRENTS
STOMACH / INTESTINAL
Antiemetics

Antispasmotic Drugs
Detrol, Detrol LA, Ditropan, Ditropan XL, Levsin, Digestants
Kutrase, Pancrease, Pancrease MT,Ultrase MT, Viokase, Zymase Inflammatory Bowel
Azulfidine (enteric coated), Colazal, Dipentum, Irritable Bowel Syndrome
Lotronex§, Zelnorm§
Ulcer/Heartburn
WEIGHT MANAGEMENT
Adipex-P, Adipost, Bontril-SR, Didrex, Meridia§,phentermine, Xenical§ WOMEN’S HEALTH
Hormones

Activella, Cenestin, Estrace, Estratab, FemHRT, Alora, Combipatch, Estraderm, Vivelle/Dot, Fertility Drugs*
Clomid, Crinone, Fertinex§, Follistim§, Gonal-F§, Humegon§, Metrodin§, Ovidrel§, Pergonal§, Oral Contraceptives*
Alesse, Brevicon, Cylessa, Demulen, Desogen, Estrostep, Estrostep FE, Jenest, Loestrin, Loestrin FE, Lo-Ovral, Mircette, Nordette, Norinyl, Nor QD, NuvaRing, Ovcon, Ovral, TriNessa, Ortho Tri-Cyclen, Portia,Sprintec, Trivora, Zovia Miscellaneous Tier 2 agents: DDAVP tablets, Diamox Sequels, Elmiron, Epipen, Epipen Jr., Evoxac, Glucagen, Mestinon, Metrogel Vaginal, Metrolotion,
Phoslo, Premarin Vaginal, Pulmozyme, Renagel, Rilutek, Salagen, Stimate, Synarel
List Subject to Change
Co-payment/Coinsurance for each tier is based on the specific rider chosen by the employer group.
The majority of benefits include additional member payment when a brand drug is used and a generic equivalent is available.
Brand drugs not listed are considered Tier 3. All compounds are considered Tier 3.
§ = Requires Prior Authorization
\ = Half Tablet opportunity: Certain strength tablets may be split to obtain lower dosage and reduce member out-of-pocket cost
V = May be Tier 2 for select prescribers/diagnoses
B-1530y4 Rev. 1/21/04

Source: http://locals.nysut.org/endicott/3tier2004.pdf

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