Microsoft word - newmember_quicklist_hdhp_spt2012 _2_

Drug Classes Key
Pexeva, Pristiq, Prozac/-Weekly, Remeron, Surmontil, Tofranil/-PM, Wellbutrin/-SR, Retail $40 Co-pay; Mail Order $80 Co-pay ciprofloxacin/-ER, levofloxacin, ofloxacin Anti-Fungals
fluconazole, griseofulvin, itraconazole, Highlighted meds No Deductible with HDHP Plans
Sulfadiazine, sulfamethoxazole/trimethoprim DS Ancobon, Biostatin, Diflucan, Grifulvin V, Gris- Allergy – Antihistamines
ethambutol, isoniazid, pyrazinamide,rifampin Call 1-888-5-ASK-URx (527-5879)
Anti-Lipemic Agents
hydroxyzine, PSE/Chlorpheniramine, levocetirizne, and discuss question(s) with URx
chloroquine, hydroxychloroquine, mefloquine, experts and the University of
cholestryramine/-light, colestipol, fenofibrate, Montana Pharmacy School. You
gemfibrozil, niaspan, Prevalite, atorvastain (QL) can ask questions about your
Allegra/-D, Clarinex/-D, Claritin, Xyzal prescriptions or alternative drugs
Allergy – Nasal Corticosteroids
Advicor, Altoprev, Antara, Colestid, Fenoglide, that may be available.
Fibracor, Lescol/-XL, Lipofen, Lofibra, Lopid, Beconase AQ,Flonase, Nasacort AQ, Nasarel, Lovaza, Mevacor, Pravachol, Questran/-Light, This reference list divides medications into URx’s value based Simcor, Tricor, Trilipix, Vytorin, Welchol, Zocor drug classifications, A through F, arranged by major therapeutic Daraprim, Fansidar, Malarone, Primaquine, Anti-migraine Agents
classes. This list is not all-inclusive, nor does it guarantee Analgesics - Opioids
Qualaquin, Yodoxin, Albenza, Biltricide, amidrine, APAP/dichloral/isometh, Duradrine, coverage. Changes to the medications list can occur during the APAP/codeine (QL), asp/butal/caff/cod (QL), Strometctol, Cleocin Pediatric Granules, Dapsone, plan year and you are encouraged to ask your pharmacist to verify butalbital/APAP/caff/codeine (QL), butorphanol Mepron, Nebupent, Primsol, Vancomycin, Xifaxan, the current copay amount at the time your prescription is filled. (QL), codeine sulfate (QL), fentanyl (QL), hydrocodone/APAP (QL), hydrocodone/ibu (QL), Present this Drug Key guide during your next physician visit if a hydromorphone tabs (QL), merperidine tabs (QL), Axert (ST,QL), Frova (ST,QL), Maxalt/-MLT methadone tabs (QL), morphine rectal/tabs (QL), (ST,QL), Relpax (ST,QL), Zomig/-ZMT (ST,QL) oxycodone tabs (QL), oxycodone/APAP (QL), If you need additional information regarding your prescription Amerge,Cafergot, Ergomar, Imitrex, Midrin, benefit, please contact URx customer service agents at 1-877 501- propoxyphene/-APAP (QL), pentazocine/naloxone Cedax, Ceftin, Keflex, Omnicef, Spectracef, Suprax, 1064 or visit the State Bankers Trust URx web site at: (QL), tramadol /APAP (QL), morphine sulfate ER Anti-Ulcer/Gastrointestinal Agents
Avinza (ST, QL), Combunox (QL), Darvocet-N Biaxin/-XL, EES Granules, Eryped, Ery-Tab, PCE, Edits Key **Edits reflect movement from one Drug Class to
(QL), Darvon (QL), Demerol (QL), Dilaudid (QL), cimetidine, dicyclomine, famotidine, hyoscyamine, another when certain pre-defined criteria are met**
Dolopine (QL), Duragesic (QL), Fioricet/codeine misoprostol, nizatidine, pantoprazole(QL),Prevacid (QL), Fiorinal/codeine (QL), Kadian (ST, QL), MS Adoxa, Doryx, Dynacin, Minocin, Monodox, PA: Prior Authorization is required to ensure clinical
Contin (QL), Oramorph SR (QL), Panlor DC/-SS Oracea, Periostat, Solodyn, Vibramycin, Vibratab appropriateness of this therapy. If medically necessary, claims may (QL), Lortab (QL), Norco (QL), Nucynta (QL), Aciphex, Anaspaz, Axid, Bentyl, Carafate, Cytotec, be moved to an enhanced benefit tier. Call 1-877-501-1064 for Opana/-ER (ST, QL), oxycodone CR/-ER (ST), Dexilant,Helidac, Levbid, Levsin, Nexium, Pepcid, Oxycontin (ST), Percocet (QL), Percodan (QL), Prevacid, Prevpac, Prilosec, Protonix, Zantac, ST: Step Therapy protocol is in place to electronically verify prior
Roxicodone (QL), Ryzolt (QL), Subutex (PA), Myambutol, Mycobutin, Paser, Priftin, Rifadin, pharmacy claims. If first level therapies are on record, patients may Talwin NX (QL), Tylenol/Codeine (QL), Tylox be moved to an enhanced benefit tier. Call 1-877-501-1064 for (QL), Ultram/-ER (QL), Vicodin/-ES (QL), Zydone Asthma/Respiratory Agents
albuterol, aminophylline, budesonide, budesonide Halfan, Plaquenil, Bactrim/-DS, Cleocin, Flagyl/- PE: Plan Exceptions will coordinate plan members into appropriate
respules (QL), cromolyn sodium, dyphylline GG/- disease management programs, or to review the unique nature of an Antibiotics
individual plan member’s tolerance of a preferred drug class. Call Anti-Depressants
bromide/albuterol sulfate, metaproterenol, Proair amoxicillin, amoxicillin/clavulanate, Amoxil, amitriptyline, budeprion/-XL, bupropion/-XL, QL: Quantity Limit is in place to ensure appropriate use. Coverage
ampicillin, dicloxacillin, penicillin V, Trimox, citalopram, desipramine, doxepin, fluoxetine, Advair Diskus/-HFA (QL), Asmanex, Atrovent may be limited to specific quantities per prescription and/or time fluvoxamine, imipramine, mirtazapine/-ODT, HFA, Combivent, Flovent Diskus/-HFA,Dulera nefazodone, nortriptyline, paroxetine/-ER, (QL),Foradil (QL), Intal, Pulmicort resp (QL), GF: Continuation, or Grandfathering, of a plan member’s present
sertraline, trazodone, venlafaxine/-ER cap cefaclor/-ER, cefadroxil, cefdinir, cefpodoxime, Pulmicort Flexhaler, Serevent Diskus (QL), Spiriva, drug regimen onto the URx formulary. New plan members utilize the standard URx drug classification. Call 1-888-5-ASK-URX (1- azithromycin, clarithromycin/-ER, EES 400, Anafranil, Celexa, Effexor/-XR, Emsam (PA), Lexapro, Luvox CR, Pamelor, Paxil, Paxil CR, Accolate, Accuneb, Aerobid/-M, Alupent, Alvesco, Betapace/-AF, Bystolic, Coreg/-CR, Corgard, (ST,QL) Onglyza (ST,QL), Prandin (QL), Starlix Azmacort, Brovana, Duoneb, Elixophyllin, Foradil Inderal LA, Innopran XL, Kerlone, Lopressor/- Cortisporin, Cosopt, Cyclogyl, Maxitrol, (PA to C for members <18 years), Lufyllin, Maxair, HCT, Sectral, Tenormin, Toprol XL, Trandate, Mydriacyl, Pred Forte, Timoptic/-XE,Trusopt Perforomist, Proventil HFA, Qvar, Serevent (PA to Amaryl, Avandamet (ST, QL), Avandaryl (ST, C formembers <18 years old)Singulair (GF-ST), Cardiovascular – Calcium Channel
QL), Avandia (ST, QL), Cycloset, Diabinese, Osteoporosis Agents
Theo-24, Uniphyl Ventolin HFA, Vospire ER, Blockers/Combinations
Fortamet, Glucophage/-XR, Glucotrol/-XL, Xopenex/-HFA, Zyflo/-CR, Tudorza, Zetonna amlodipine, Cartia XT, diltiazem/-CD/-XR, Diltzac, Glucovance, Glumetza, Glynase, Glyset, Metaglip, calcitonin-salmon, Evista, Fortical, ibandronate Attention Deficit Hyperactivity Disorder
felodipine, isradipine, nicardipine, nifedipine/-ER, Micronase, Prandimet,Precose, Symlin (ST,QL) Diabetic Supplies (effective 10/01/2010)
dextroamphetamine/-CR/-ER, Liquadd, Methylin/- Adalat CC, Caduet, Calan/-SR, Cardene SR, All Roche test strips, lancets, glucose monitors, Sedatives/Hypnotics
Cardizem/-CD/-LA, Covera-HS, Dilacor XR, Dynacirc CR, Isoptin SR, Norvasc, Procardia/-XL, midazolam, temazepam, zaleplon, zolpidem Adderall/-XR, Concerta (QL), Daytrana (PA), Cardiovascular – Diuretics
Non-Roche test strips/meters (includes Abbott, Desoxyn, Dexedrine, Focalin/-XR, Intuniv, acetazolamide, amiloride/-HCT, bumetanide, Metadate CD, Modafinil (PA/PE),Nuvigil (PA), Hormone Replacement
Ambien, Ambien CR, Edluar, Halcion, Restoril, methazolamide, metolazone, spironoloactone/-HCT, Covaryx/-HS, danazol, EEMT/-HS, esterified Atypical Antipsychotics
estrogen/methyltest, estradiol/noreth, Estradiol MAIL ORDER PHARMACIES
clozapine, fluphenazine, haloperidol, Lithium/-ER, Aldactazide, Aldactone, Demadex, Diamox, Diuril, patch/tabs, estropipate, gynodiol, Ortho-est You may obtain up to a 90-day
loxapine, prochlorperazine, quetiapine, risperidone/- Dyrenium, Lasix, Maxzide, Microzide, Zaroxolyn Contraceptives
Climara Pro, Combipatch, Divigel, Elestrin, Abilify, Fanapt (titration pack limit to 1 time use), , levonogrestrel-ETH estra, l-norgest-eth estr/ethin Enjuvia, Estraderm, Estrasorb, Estrogel, Evamist, Latuda, Moban, olanzapine/-ODT,Seroquel XR, estradiol, levonorgestrel-eth estra, desogestrel- Femhrt/-Low Dose, Femtrace, Menest, Menostar, ethinyl estradiol, levonorgestrel, norethindrone, Methitest, Prefest, Premarin, Premphase, Prempro, norgestimate-ethinyl estradiol, ethynodiol d-ethinyl SPECIALTY DRUGS:
vial,,Haldol, Invega Sustenna (PA), Lithobid, Activella, Anadrol-50, Androxy, Axiron, Climara, Generic oral contraceptives including: Apri, Aviane, Specialty drugs are defined as high cost prescription Loxitane, Navane, Risperda/-Ml. Risperdal Consta Estrace, Estratest/-HS, Fortesta,Ogen, Oxandrin, Camila, Enpresse, Gianvi,Jolessa, Joviette, Junel/- drugs that may require special handling and/or oxandrolone (PE, QL), Provera, Striant, Testim FE, Kariva, Lessina, Levora, Low-ogestrel, administration to treat chronic, complex conditions. Benign Prostatic Hypertrophy
Microgestin/-FE, Necon, Nortrel, Portia, Previfem, These drugs may be taken orally but often are injectables Sprintec, Trinessa, Tri-Sprintec, Trivora, Zovia diclofenac, etodolac/-ER, fenoprofen, flurbiprofen, with complex manufacturing process or may be limited ibuprofen, indomethacin, ketoprofen, keterolac, leflunomide, meloxicam, nabumetone, naproxen, Cardiovascular –ACE Inhibitors/ARBs/Combinations
oxaprozin, piroxicam, sulindac, tolmetin The URx Specialty Drug program offers a variety of amlodipine/benazepril, atenolol/chlorthalidone, Loseasonique, Lybrel, Necon 10/11-28, Ogestrel, benazepril, bisoprolol HCT, captopril/-HCT, Ortho Cyclen 28, Ortho Tri-Cyclen Lo, Ovcon-50, Arava,Arthrotec (QL), Cataflam, Clinoril, Daypro, medications at $50 copay. This $50 specialty program
enalapril/-HCT, fosinopril/-HCT, irbesartan/-HCTZ, Natazia, Necon, Next Choice, Plan B/ -One, Yaz EC-Naprosyn, Feldene, Indocin/-SR, Mobic, includes medications to treat Hemophilia, Hepatitis C, losartan/-HCTZ, lisinopril/HCT, moexipril/-HCT, Nuvaring, Ortho Evra, Ortho Micronor, Ortho Tri- Naprelan, Ponstel, vimovo,Voltaren/-XR, Zipsor Arthritis, Multiple Sclerosis, RSV, Osteoporosis, quinapril/-HCT, ramipril, trandolapril/-HCT Cylen, Ortho-Cept, Ortho-Cyclen, Ortho-Novum, Ophthalmic Agents
Parkinson’s Disease, Pulmonary Arterial Hypertension, as well as medications for Oncology and Transplant Brevicon, Cyclessa, Depo-Provera, Desogen, patients. Other Specialty Drugs are available through the Accupril, Accuretic, Aceon, Altace, Atacand/-HCT Estrostep FE, Loestrin FE, Lo/Ovral, Mircette, dexamethasone, difclofenac, dorzolamide/-timolol, URx specialty program with a $200 copay. (GF-ST), Avalide/-Avapro (GF-ST), Azor, Benicar/- Modicon, Nordette, Norinyl, Nor-QD, Seasonale, erythromycin, flurometholone, gentamycin, HCT, Capoten, Capozide, Cozaar (GF-ST, QL), Seasonique, Tri-Norinyl 28, Yasmin, Angeliq Diovan/-HCt (GF-ST,QL), Edarbi, Exforge/-HCT, Diabetes Agents
Diplomat Specialty Pharmacy is the chosen URx
Hyzaar (GF-ST,QL), Lotensin/-HCT, Lotrel, Mavik, Micardis/-HCT (GF-ST), Monopril/-HCT, Prinivil, provider for specialty drug services. To enroll or for any acarbose, glimepiride, glipizide/-ER/-XL/- Prinzide, Tarka, Tekturna HCT, Teveten/-HCT (GF- metformin, glyburide/-metformin, glycron, all Acular/-LS/-PF, Azasite, Alocril, Alphagan/-P, questions regarding the specialty drug program, please ST), Twynsta, Uniretic, Univasc, Vasotec, Valturna, insulin vials; short-acting insulin cartridges/pens Alrex, apraclonidine,Bepreve, Betadine, Betimol, contact Diplomat at 1-877-319-6337.
chlorpropamide, Glucagen (QL), long- acting Betoptic-S, Blephamide (all forms), Combigan, Cardiovascular – Beta Blockers/Combinations
insulin pens/cartridge, glucose tabs (PE), Riomet, Cylclomydril, Durezol, Elestat, Emadine, Flarex, acebutolol, atenolol, betaxolol, carvedilol, labetalol, FML/-Forte/-SOP, Iopidine, Lotemax, Natacyn, metroprolol/-ER, nadolol, pindolol, propranolol, Nevanac, Optivar, Patanol, Pilopine HS, Pred- sotalol/-AF, timolol sotalol/-AF, timolol Bydureon/Byetta (ST,QL), Duetact (ST,QL), G/SOP, Retisert, Travatan-Z, Vexol, Vigamox, Jentadueto (ST,QL), Januvia (ST,QL), Kimbiglyze

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