Quickscript.net

2006 Member Pharmacy
NPS
PROCESSING
G E N E R I C M E D I C A T I O N P O L I C Y D I S P E N S I N G L I M I T A T I O N S P R E S C R I B I N G G U I D E L I N E S Pharmaceutical Technologies, Inc.®, P.T.I.®, The Pharmacy SmartCard™, National Pharmaceutical Services®, and others are registered trademarks, trademarks and/or service marks of Pharmaceutical Technologies, Inc.®.
INTRODUCTION
For the most up-to-date information about National Pharmaceutical Services ®/ Pharmaceutical Technologies, Inc.’s® (P.T.I.®) Formulary (the Formulary), please see the Formulary information on our website at www.pti-nps.com. This Formulary
includes most, but not all, therapeutic classes of prescription drugs and is subject to change at any time upon review by PTI.
Our national Formulary is reviewed each month by a Pharmacy and Therapeutics (P&T) Committee. The Formulary applies
only to outpatient prescription medications dispensed by participating pharmacies. It does not apply to inpatient medications
or the medications obtained from and/or administered by a physician. All information in the Formulary is provided as a refer-
ence for drug therapy selection. Physicians and Pharmacists are encouraged to review the Formulary and utilize it when pre-
scribing for our members. This is extremely important since a member’s prescription benefit is based on medications being
prescribed from the Formulary. The Formulary is not intended to interfere with independent medical judgment that is based
upon the patient-physician relationship. The final choice of specific drug selection for an individual patient rests solely with the
prescriber. Products on Formulary may not include all strengths or dosage forms associated with the brand name product. All
drugs included in the Formulary are not necessarily covered by each member’s prescription drug benefit plan. The inclusion
of a drug on this list does not imply coverage under all plans. Coverage of listed products will be subject to limita-
tions of the prescription drug benefit plan design. Members should consult their prescription drug benefit manual or
contact a customer service representative to determine specific coverage.
DEVELOPMENT OF THE DRUG FORMULARY
The multitude of drugs available in the consumer market makes it mandatory that plans introduce a sound program of drug usage. This tool is developed to ensure members receive the best care and protection possible in a cost-effective manner. Sucha program should involve the thorough evaluation, selection, and use of medicinal agents. This is the basis for rational drug ther-apy. The concept of a Formulary provides a method for achieving rational drug therapy in a cost-effective manner, while providingoptimal therapeutic outcomes for the member. The Formulary is the cornerstone of drug therapy quality assurance and cost con-tainment efforts. A Formulary supports and maximizes the effectiveness of prescribing guidelines and protocols for therapy. Assuch, the development and maintenance of the Formulary is necessarily an on-going and dynamic process.
The Formulary is a continually revised compilation of pharmaceuticals which reflects the current clinical judgment of the Pharmacy and Therapeutics Committee as they evaluate, appraise, and select from the numerous available medicinal agentsand dosage forms that are considered most useful in patient care. The P&T Committee considers published scientific and clin-ical data, treatment guidelines, FDA approved indications, plan utilization and cost in the selection process. It is the ultimategoal of the P&T Committee to make the Formulary comprehensive, pro-active, and easy to use.
The Formulary system also serves other purposes. By minimizing duplication, it lowers the costs to clients of PTI of pro- viding the prescription drug card benefit to its members. All of these factors result in lower drug costs for the drug benefit plan.
Some drugs that are included in the Formulary may be excluded from coverage under certain benefit plans. The Formulary isdesigned around the drug product’s ability to restore the member’s health and sustain or improve their quality of life. As youuse the Formulary, we invite your suggestions to improve the format or content. On behalf of our self-insured employer groups,Pharmacy SmartCard members, and all at-risk plans, we want to thank you for your cooperation in using our global Formulary.
PHARMACY AND THERAPEUTICS (P&T) COMMITTEE
The P&T Committee includes physicians and pharmacists. They must adhere to the standards of the ethics policy set forth by the P&T Committee. They review the medications in each therapeutic class for efficacy, adverse events, and cost oftreatment, and then select agents in each category for inclusion/exclusion in the Formulary. The maintenance of the Formularyis a dynamic process, and new medications and information concerning existing medications are continually reviewed by theP&T Committee.
PRODUCT SELECTION CRITERIA
When a new drug is considered for Formulary inclusion, an attempt will be made to examine the drug relative to similar drugs currently on Formulary. In addition, entire therapeutic classes are periodically reviewed. The class review process mayresult in deletion or non-Formulary (NF) status of drug(s) in a particular therapeutic class, in an effort to continually promote themost clinically useful and cost-effective agents.
A central factor in successful management of the Formulary is the review and evaluation of the drug products available in the consumer market and a means to make changes to the Formulary in response to changing therapies and economic fac-tors. The P&T Committee utilizes the following criterion in the evaluation of product selection for the Formulary: The drug product must demonstrate unequivocal safety for medical use.
The drug product must be efficacious and be medically necessary for the treatment, maintenance, or prophylaxis ofa medical condition.
The drug product does not have alternative/similar agents on the Formulary that could be substituted.
The drug product must demonstrate a therapeutic outcome.
The medical community must accept the drug product for use.
The drug product must have an equitable cost ratio for the treatment of the medical condition.
FORMULARY CONTROL MEASURES
To promote the most appropriate utilization of selected high risk or higher cost medications, PTI will use one of or a com- bination of the following to enforce Formulary compliance. (1) NDC lock and block at the point of sale, (2) Formulary filling feeincentives for pharmacists, (3) copay differentials for members, (4) on-line Formulary messaging, (5) prior authorization, (6) dol-lar limits per claim before prior authorization and (7) quantity limitations. The P&T Committee has established Formulary crite-ria with input from participating physicians and consideration of current medical literature.
FORMULARY MODIFICATION/QUESTIONS
If a physician requests that a new or existing medication be considered for addition to the Formulary, a letter indicating the significant advantages of the drug product over current Formulary medications in this class should be mailed to the follow-ing address: Chairman, Pharmacy and Therapeutics Committee • Pharmaceutical Technologies, Inc. • P.O. Box 407 • Boys Town,NE 68010. Or e-mail [email protected].
Page 1 THREE- TIER FORMULARY CO-PAYMENT STRUCTURE
This Formulary is divided into three tiers and is color coded to easily identify the status of a particular agent in a thera- peutic category on the Formulary. The 1st tier contains generic drugs. All generic medications are included in the first tier andare considered the preferred agents. Generic drugs offer an excellent value to the consumer because they are chemically iden-tical to brand drugs but are priced at a fraction of the cost of the corresponding brand drug. The U.S. Food and DrugAdministration (FDA) requires that generic drugs provide the same effectiveness and safety as their brand name counterparts.
The FDA requires drug manufacturers to show that the generic version enters the bloodstream the same way, contains the sameamount of active ingredient, comes in the same dosage form and is taken the same way as the brand name drug. Members willpay the lowest co-payment for generic medications. These agents can be easily identied in the Formulary as the agents in thegreen shaded column. The 2nd tier contains Preferred Brand Name Medications. These are medications that are still patentprotected and may not have generic alternatives available. The P&T Committee has reviewed these medications and foundthem to either be therapeutically superior, offer a better outcome for the member, or provide the same therapeutic effect, butsave the plan sponsor money compared to an agent in the 3rd tier. Members will pay the middle co-payment for Preferred BrandName Medications. These agents can be easily identified in the Formulary as the agents in the yellow shaded column. The 3rdtier lists the Non-Preferred Brand Name Medications. These are brand-name drugs that either have equally effective and lesscostly generic equivalents or may have one or more alternative Preferred Brand Name Medications available in the 2nd tier thatprovide the same therapeutic effect. You or your doctor may decide that a medication in this category is best for you. If youchoose a 3rd tier drug, you may be covered at the highest copayment level, which still represents a significant savings to youcompared to the medication’s full retail cost. These agents can be easily identified in the Formulary as the agents in the redshaded column. Always refer to your benefit materials, or call the PTI/NPS help desk telephone number on your ID card, todetermine what level of coverage you have for your prescription drugs.
FORMULARY ALTERNATIVES
Suggested therapeutic alternatives are selected drug products that represent options to non-Formulary medications. On- line Formulary messaging gives pharmacists suggested alternatives for non-preferred agents. Formulary alternatives representopportunities to help the pharmacy benefit plan sponsor keep the benefit affordable and sustainable. In a three-tier Formulary,preferred alternatives result in lower co-payments for patients and save plan sponsors benefit dollars. Formulary alternativesrequire the prescriber’s authorization and are recommended only after considering patient-specific disease states, contraindi-cations, therapeutic history, present medications and other relevant circumstances.
THERAPEUTIC INTERCHANGE (TI) POLICY
The use of therapeutic interchange programs as part of a comprehensive approach to quality, cost-effective patient care is recommended. Therapeutic interchange is the practice of replacing, with the prescribing physician’s approval, a prescriptiondrug originally prescribed for a patient with a prescription drug that is its therapeutic equivalent. Two or more drugs are consid-ered therapeutically equivalent if they can be expected to produce identical levels of clinical effectiveness and sound medicaloutcomes in patients. The term therapeutic interchange must be distinguished from the term therapeutic substitution.
Therapeutic substitution has been defined as a practice in which the pharmacists can substitute any drug believed by the phar-macist to have a similar therapeutic effect as the drug prescribed, without the approval of the prescriber.Therapeutic interchangeinvolves the collaboration of pharmacists and prescribers in reviewing available drug products with equivalent therapeutic effectsin order to provide patients with the safest, most rational, and most cost-effective drug therapy. Therapeutic interchange ensuresthat prescribers are informed regarding drug therapy options. The prescriber retains the authority to decide upon the patient'sultimate therapy. Therapeutic interchange programs are guided by clinically-based prescribing guidelines that are reviewed bythe P&T Committee. However, therapeutic interchange is not always about lower drug costs. Therapeutic interchange oftenoccurs when overall health care savings can be achieved. Replacing one drug with a more expensive one may result in fewertreatment failures, better patient adherence to the treatment plan, and fewer side effects. Such efficient use of medical resourceshelps keep medical costs down, improves the patient’s access to more affordable health care, and enhances the patient’s qual-ity of life. Therapeutic interchange requires the authorization of the prescriber. Therapeutic interchange requires the evalua-tion of each patient prior to changing the medication order. When possible, therapeutic interchange is prospective. When ther-apeutic interchange is implemented, it is preferable to provide the therapeutic equivalent medication prior to the first dose ofprescribed medication. Conducting the therapeutic interchange prior to administration of the first dose to the patient enhancesthe efficiency of the program and improves patient acceptance.
GENERIC DRUG POLICY
It is the policy of PTI to utilize high quality generic medications when available. A generic drug is identical, or bioequiva- lent, to a brand name drug in dosage form, safety, strength, route of administration, quality, performance characteristics,and intended use. Although generic drugs are chemically identical to their branded counterparts, they are typically soldat substantial discounts from the brand name price. It is the policy of PTI to encourage pharmacies to utilize the samegeneric product that was distributed by the same company that was dispensed on the original prescription on all subsequentrefills for the drug product selection. According to a 1998 report by the Congressional Budget Office, generic drugs saveconsumers an estimated $8 to $10 billion a year at retail pharmacies. The average price per prescription that is savedwhen using a generic medication is approximately $18 per prescription. Pharmacists may drug product select for a phar-maceutically equivalent (as defined by the FDA Orange Book) when state regulations allow. Otherwise, the pharmacist mustget approval from the prescribing physician to use the generic equivalent product. PTI does not recommend that genericsubstitution be exercised with multi-source products that cannot be considered therapeutically equivalent to others in thesame category. It is also recommended that generic substitution not be undertaken for any unrated products that might beconsidered narrow therapeutic index (NTI) drugs or which are known not to be bioequivalent. Finally, it is important to notethat state laws and regulations govern the practice of generic substitution for certain drug products. Requests for exceptionto the generic policy must clearly document specific reasons for medical necessity and appropriateness.
Preserving Benefits for the Workers of America’s Corporations TM P.O. Box 407 • Boys Town, NE 68010 • www.pti-nps.com Copyrighted by Pharmaceutical Technologies, Inc. 2006. Illegal to reproduce.
Tradenames are the registered trademarks of the respective product manufacturers.
Medications that have generic equivalents available are covered at a generic reimbursement level and should be prescribed and dispensed in the generic form. Maximum Allowable Cost (MAC) limits have been established for specific dosage forms of thesedrugs. The MAC list sets a ceiling price for the reimbursement of certain multi-source prescription drugs. This price will typicallycover the acquisition of most generics but not branded versions of the same drug. The products selected for inclusion on the MAClist are commonly prescribed and dispensed and have gone through the FDA’s review and approval process.
When generic substitution conflicts with state regulations or restrictions, the pharmacist must get approval from theprescriber to use the generic equivalent.
Pharmacists are reminded that a drug preceded by an asterisk indicates one or more (but not necessarily all) forms ofthe drug are subject to a Maximum Allowable Cost (MAC), and the MAC list should be consulted.
If a member insists on the brand name product for a prescription of a medication included in the MAC list after theirphysician has approved the generic version, the patient will have to pay the cost difference between the brand namedrug and the MAC amount (ancillary charge). The appropriate dispense as written (DAW) code of 2 should be uti-lized when submitting the prescription claim for reimbursement.
OVER-THE-COUNTER (OTC) MEDICATIONS
Over-the-counter (OTC) products may be covered and some are listed for informational purposes (when available, non- prescription products may be less costly to the plan than a covered product). If a prescription product is available in the identi-cal strength, dosage form, and active ingredient(s) as an OTC product, the prescription product will not be covered. In theseinstances, physicians and pharmacists should refer participants to the OTC equivalent product. If the member or physicianinsists on the prescription equivalent product, the member must pay the entire cost of the prescription.
OFF-LABEL USE OF MEDICATIONS
The Food and Drug Administration (FDA) has required that drugs used in the United States be both safe and effective.
The label information or the package insert of a medication indicates drug use only in certain "approved" doses and routes ofadministration for a particular condition or disease state. The use of a drug for a disease state or condition not listed on the label,or in a dose or by a route not listed on the label, is considered to be a "non-approved" or "un-labeled" or "off-label" use of thedrug. A prior authorization is required when a medication is used outside of its FDA approved route of administration, dosage,or indication. Coverage will be determined in the same manner and subject to the same conditions and limitations as any otherprescription drug. Prior authorizations for unlabeled uses of medications may be granted provided that: a) the medication isapproved by the FDA; and b) two or more peer-reviewed professional medical journals have recognized, based on scientificmedical criteria, the safety and effectiveness of the medication or combination of medications, for treatment of the indication forwhich the medication has been prescribed unless two articles from major peer-reviewed professional medical journals have con-cluded, based on scientific or medical criteria, that the drug or combination of drugs is unsafe or ineffective or the safety andeffectiveness of the drug or combination of drugs cannot be determined for the treatment of the indication for which the drug orcombination of drugs has been prescribed.
EXPERIMENTAL MEDICATIONS
Any medication or drug that has not been approved by the FDA to be both safe and effective for use in the United States will not be covered. This includes both FDA approved and non-approved medications that are in experimental or investigation-al trials to determine new indications, new routes of administration, or new dosage forms.
TABLET SPLITTING
Medications listed in the Formulary in bold print represent potential 1/2 tablet opportunities for some strengths. In some
instances, cutting higher dosage tablets in half can save as much as 50 percent of the prescription drug cost. Your doctor or phar-macist can tell you if tablet splitting will work for you and if there is a cost savings for the specific medications that you are taking.
PRIOR AUTHORIZATION
To promote appropriate utilization, selected high-risk or high-cost medications may require prior authorization to be eligible for coverage under the member’s prescription drug benefit. The P&T Committee has established prior authorization criteria. Inorder for a member to receive coverage for a medication requiring prior authorization, the member’s physician should contact thecustomer service center at 1-800-546-5677 to obtain a prior authorization request form. Your physician may then be required todocument the reason why a Formulary medication is not acceptable for treatment of your disease state or medical condition. Yourphysician will want to include in his/her letter your diagnosis and previous therapies that have failed.
MAINTENANCE AND NON-MAINTENANCE MEDICATIONS
Prescription drug card benefit plans often differ in their plan design. In some plans, the benefits may vary depending upon whether the medication is considered to be an acute or a maintenance medication. Your medication copay and the quantity of
medication you can receive in a prescription can vary depending upon the status of your medication. Non-Maintenance (Acute)
Medications: Acute medications are medications that are to be used for a short period of time. This can include medications
that are given as a starter dose. A starter dose of medication is a medication that may become a maintenance medication but,
based on its generic name and strength, has not been obtained within the previous six-month period. Medications such as antibi-
otics or other agents that are given to cure or treat a condition from which recovery is predicted are considered curative treat-
ments and are classified as non-maintenance medications, or a short-term medication. Maintenance Medications: Maintenance
medications can also be referred to as long-term medications. The following is the criteria that is used to determine if a medica-
tion is a maintenance medication: a) The drug has a low probability for dosage or therapy changes due to side effects, serum
drug concentration monitoring, or therapeutic response over a course of prolonged therapy; b) The drug’s most common use is
to treat a chronic disease state. (A drug may have an indication for maintenance therapy but lacks the maintenance drug code if
that indication is not the most common use of the drug); c) Therapy with the drug is not considered curative or promoting of recov-
ery; and d) The drug is administered continuously rather than intermittently. The criteria listed above are limited to the typical out-
patient use of a drug. Dosage forms that are not practical for large dispensing quantities (such as liquids) or have limited expira-
tion dating are excluded. Drugs known for life-threatening toxicity when taken in overdose may be excluded. Non-drug products
and non-prescription drug products, with the exception of insulin (if covered by the plan), are excluded.
Page 3
NEW DRUGS INTRODUCED INTO THE CONSUMER MARKET
As the U.S. Food and Drug Administration (FDA) approves new drugs and therapies available to the consumer market after the Plan Summary Documents have been distributed, the Drug Benefit Plan reserves the right to extend or deny coverageto these medications after the printing of this document. The Drug Benefit Plan also reserves the right to assign a unique copayor coinsurance to these medications and/or limit the quantities of these medications.
Members will receive notices regarding any Drug Benefit Plan modifications concerning drugs or therapies at such time that they present a prescription that is impacted by modifications to the Formulary. Network pharmacies are charged to com-municate these updates or changes to the program which may impact a member. The P&T Committee will review new drugsapproved by the FDA on a monthly basis. New products with an FDA designation of 1P (FDA priority review – therapeuticadvance over currently-marketed drugs) will automatically be considered for addition to the Formulary, even if not requested bya plan. New products with an FDA designation of 1S (FDA standard review – no therapeutic gain over currently marketed drugs)will not generally be considered for addition to the Formulary, unless requested by a plan, or the drug class is currently underreview by the P&T Committee. Members wanting to have newly approved therapies considered by the Plan may write and/or callthe Pharmacy SmartCard™ company servicing the Plan or may contact the Plan administrator.
DISPENSING LIMITATION LIST
The following list represents the P&T Committee recommendations for dispensing or quantity limitations per a specific amount of time. Quantity limit programming has become an acceptable pharmacy plan practice that may be appropriate to placeon some medications. The intentions are to safeguard members’ health and save plan benefit dollars. This program ensuresmembers do not receive a prescription for a quantity that exceeds recommended plan limits. Limits are set because some med-ications have the potential to be abused, misused, shared, or have a manufacturer’s limit on the maximum dose. These limitshave been reviewed by our clinical and medical staff, and the Pharmacy and Therapeutics Committee. The quantity limits arebased on FDA approved dosing schedules, current medical practices, evidence based clinical guidelines, and peer-reviewedmedical literature related to that particular drug. The inclusion of a medication on this list does not imply coverage under allplans, nor does the inclusion of a dispensing limitation imply that your specific benefit plan also has the same limitation. Plansmay elect their own limitations. Members should consult their prescription drug benefit manual or contact a customer servicerepresentative to determine specific coverage and/or inclusion of a medication in the dispensing limitations list, as the listis subject to change.
Prescription Drug
Prescription Drug
Amerge 2.5 mg tablets 9 tablets (1 box) per 30 days (Viagra, Cialis, Levitra) Combined limit of 6 tablets per 30 days Imitrex 100 mg tablets 9 tablets (1 box) per 30 days Any member with a request exceeding the current quantity limits should have a letter from their healthcare provider . The lettershould include diagnosis, reason for exceeding the quantity limit per month, and what the therapy plan will be for the member(i.e. tapering schedule). In most cases, the quantity limits we have selected are set to maximum dosages and should not beexceeded according to the current manufacturer’s recommendations. Prior authorizations for quantity limits exceeding theguidelines will be issued for 6-month intervals and will require a new letter from the member’s healthcare provider at the end ofthe 6-month period.
Preserving Benefits for the Workers of America’s Corporations TM P.O. Box 407 • Boys Town, NE 68010 • www.pti-nps.com Copyrighted by Pharmaceutical Technologies, Inc. 2006. Illegal to reproduce.
Tradenames are the registered trademarks of the respective product manufacturers.
MEMBER BILL OF RIGHTS
In an effort to recognize the member’s rights with respect to healthcare providers, products andpharmacy service, National Pharmaceutical Services (NPS) has adopted the following Member Billof Rights.
A MEMBER’S RIGHTS INCLUDE, BUT ARE NOT LIMITED TO, THE FOLLOWING:
• To exercise the foregoing rights without regard to age, sex, marital status, sexual orientation, race, color, religion, ethnicity, ancestry, national origin, mental or physical disability, genetic informa-tion, health status, source of payment, or utilization of services.
• To be treated with respect and recognition of their dignity and need for privacy.
• To have their prescriptions dispensed and pharmacy services provided from their choice of pharmacy providers in the NPS network. Subject to plan network limitations and restrictions.
• To know the terms and conditions of their prescription drug benefit plan, the content of preferred drug lists, and the procedures for obtaining exemptions or prior authorizations.
• To receive any legally prescribed product, realizing this may require them to bear the expense of • To ask for and receive any supplier’s product that will legally fulfill a generically written • To obtain relevant, current, and understandable information concerning their medication therapy and its relevance in the treatment plan from their healthcare provider.
• To discuss and request information related to their specific prescribed medication, the possible adverse side effects, and drug interactions.
• To expect that all records and discussions pertaining to their drug therapy will be treated as • To expect that their specific information regarding pharmaceutical medications will not be extract- ed, provided, or sold to outside parties without their informed and expressed written consent.
• To have the opportunity to voice complaints or appeals about NPS, or the care provided at NPS Network Pharmacy Providers, and to an appeals process to ensure fair resolution of a complaintor grievance.
A MEMBER’S RESPONSIBILITIES INCLUDE, BUT ARE NOT LIMITED TO THE FOLLOWING:
• Knowing, understanding and abiding by the terms, conditions and provisions of the NPS-admin- istered prescription drug benefit plan. This information is made available through the PlanSummary Document.
• Paying copayments, co-insurance, or deductibles as stated in the Plan Summary Document at the time service is provided and accepting financial obilgations for services rendered.
• Being knowledgeable about their prescription drug therapy, including risks and limitations.
• Complying with their prescribed drug therapy regimen and maintaining a healthy lifestyle.
• Disclosing relevant information that is necessary for appropriate selection of drug therapy including health status, lifestyle, food and drug allergies, and medication history.
• To participate effectively in decision making, members must take responsibility for requesting information or clarification about the drugs they are taking when they do not fully understandinformation and instructions.
• To accept personal responsibility if they refuse treatments, medications, or services.
• Carrying their Pharmacy SmartCard™ identification card and identifying themselves as a Pharmacy SmartCard™ holder prior to receiving pharmaceutical products and/or services.
Copyrighted by Pharmaceutical Technologies, Inc. 2006. Illegal to reproduce.
Tradenames are the registered trademarks of the respective product manufacturers.
THERAPEUTIC
FIRST TIER
SECOND TIER
THIRD TIER
GENERICS
PREFERRED BRANDS
NON-PREFERRED BRANDS
ACNE PRODUCTS COVERAGE DEPENDS ON BENEFIT DESIGN
ALZHEIMER'S MEDICATIONS
ANAL/RECTAL PRODUCTS
ANTI-ARRHYTHMIC (TO REGULATE HEART RHYTHM)
ANTIBIOTICS
Amoxicillin
Amoxicillin/
Clavulanate
Penicillin
Levaquin
Cephalexin
Zithromax
Tetracycline
Doxycycline
Metronidazole
Minocycline
ANTIBIOTICS --TOPICAL
ANTICONVULSANTS
Clonazepam
Diazepam
Neurontin
Phenytoin SuspensionValproic Acid Suspension ANTIDEPRESSANTS
Amitriptyline
Fluoxetine
Trazodone
ANTIDIARRHEALS
The formulary is subject to change. Network pharmacies have the most up-to-date formulary informationat the time your prescription claim is presented. As generic products become available, their brand namemedication will be moved to the third tier or non-preferred status. The inclusion of a drug on this list does not THERAPEUTIC
FIRST TIER
SECOND TIER
THIRD TIER
GENERICS
PREFERRED BRANDS
NON-PREFERRED BRANDS
ANTIEMETICS (FOR NAUSEA AND/OR VOMITING)
Meclizine
Promethazine
ANTIFUNGALS
ANTIFUNGALS --TOPICAL
ANTIPSYCHOTICS
Risperdal
Seroquel
ANTIVIRALS
Acyclovir
ASTHMA / COPD INHALERS AND NEBULIZER SOLUTIONS
ASTHMA / COPD -- ORAL MEDICATIONS
Accolate
BLOOD MODIFIERS
Coumadin
Warfarin
CHOLESTEROL LOWERING AGENTS
Gemfibrozil
Lovastatin
Pravachol
Copyrighted by Pharmaceutical Technologies, Inc. 2006. Illegal to reproduce.
Tradenames are the registered trademarks of the respective product manufacturers.
THERAPEUTIC
FIRST TIER
SECOND TIER
THIRD TIER
GENERICS
PREFERRED BRANDS
NON-PREFERRED BRANDS
CONTRACEPTIVES (BIRTH CONTROL) COVERAGE DEPENDS ON BENEFIT DESIGN
CORTICOSTEROIDS -- ORAL
Prednisone
Methylprednisolone
CORTICOSTEROIDS --TOPICAL (FOR RASH, INFLAMMATION)
COUGH / COLD / ALLERGY PRODUCTS
NON-SEDATING ANTIHISTAMINES COVERAGE DEPENDS ON BENEFIT DESIGN
DIABETIC ORAL AGENTS
Glucovance
Metformin
Glipizide
Glyburide
DIABETIC SUPPLIES (METERS, TEST STRIPS, SYRINGES)
DIGESTANTS
The formulary is subject to change. Network pharmacies have the most up-to-date formulary informationat the time your prescription claim is presented. As generic products become available, their brand namemedication will be moved to the third tier or non-preferred status. The inclusion of a drug on this list does not THERAPEUTIC
FIRST TIER
SECOND TIER
THIRD TIER
GENERICS
PREFERRED BRANDS
NON-PREFERRED BRANDS
DIURETICS (WATER PILLS)
Spironolactone
Furosemide
Hydrochlorothiazide
ECZEMA/PSORIASIS MEDICATIONS
ERECTILE DYSFUNCTION (IMPOTENCY) COVERAGE DEPENDS ON BENEFIT DESIGN
GASTROINTESTINAL (HEARTBURN, ULCERS) COVERAGE DEPENDS ON BENEFIT DESIGN
GASTROINTESTINAL MISC PRODUCTS
Metoclopramide
GOUT MEDICATIONS
Allopurinol
HIGH BLOOD PRESSURE: ACE INHIBITORS
Captopril
Lisinopril
Accupril
Monopril
Prinivil
Enalapril
HIGH BLOOD PRESSURE: ACE INHIBITORS+ DIURETIC
Zestoretic
HIGH BLOOD PRESSURE: ANGIOTENSIN II RECEPTOR ANTAGONIST (ARB)
HIGH BLOOD PRESSURE: ARB + DIURETIC
Diovan HCT
HIGH BLOOD PRESSURE: CALCIUM CHANNEL BLOCKERS
Diltiazem
Verapamil
HIGH BLOOD PRESSURE: ACE-INHIBITOR + CALCIUM CHANNEL BLOCKER
HIGH BLOOD PRESSURE: BETA- BLOCKERS
Atenolol
Propranolol
Toprol XL
Labetalol
HIGH BLOOD PRESSURE: BETA - BLOCKERS + DIURETIC
Copyrighted by Pharmaceutical Technologies, Inc. 2006. Illegal to reproduce.
Tradenames are the registered trademarks of the respective product manufacturers.
THERAPEUTIC
FIRST TIER
SECOND TIER
THIRD TIER
GENERICS
PREFERRED BRANDS
NON-PREFERRED BRANDS
HIGH BLOOD PRESSURE: MISCELLANEOUS
Clonidine
Doxazosin
Terazosin
HORMONES
Estradiol
Estropipate
Premarin
Medroxyprogesterone
INFLAMMATORY BOWEL AGENTS
INSULINS
MIGRAINE MEDICATIONS QUANTITY LIMITATIONS MAY APPLY
Propranolol
MUSCLE RELAXANTS
Carisoprodol
Cyclobenzaprine
Skelaxin
NARCOTIC ANALGESICS (PAIN RELIEVERS-SEDATING)
Promethazine
Tramadol
The formulary is subject to change. Network pharmacies have the most up-to-date formulary informationat the time your prescription claim is presented. As generic products become available, their brand namemedication will be moved to the third tier or non-preferred status. The inclusion of a drug on this list does not THERAPEUTIC
FIRST TIER
SECOND TIER
THIRD TIER
GENERICS
PREFERRED BRANDS
NON-PREFERRED BRANDS
NASAL PRODUCTS
NITRATES (FOR HEART/ANGINA)
Isosorbide Mononitrate
NON-NARCOTIC ANALGESICS (PAIN)
NON-STEROIDAL ANTIINFLAMMATORY AGENTS (NSAIDS) AND ANTI-RHEUMATIC AGENTS
Diclofenac
Naproxen
Ibuprofen
OPHTHALMIC PRODUCTS - - GLAUCOMA
OPHTHALMIC PRODUCTS - - PAIN / INFLAMMATION
OPHTHALMIC PRODUCTS - - ANTI - INFECTIVES
OPHTHALMIC PRODUCTS - - ANTI - ALLERGICS
OPHTHALMIC PRODUCTS - - MISCELLANEOUS
OSTEOPOROSIS DRUGS
Copyrighted by Pharmaceutical Technologies, Inc. 2006. Illegal to reproduce.
Tradenames are the registered trademarks of the respective product manufacturers.
THERAPEUTIC
FIRST TIER
SECOND TIER
THIRD TIER
GENERICS
PREFERRED BRANDS
NON-PREFERRED BRANDS
OTIC PRODUCTS (FOR THE EAR)
PARKINSON'S DRUGS
Carbidopa/Levodopa
PROSTATE MEDICATIONS
SEDATIVE/HYPNOTICS AND ANTIANXIETY DRUGS
Alprazolam
Buspirone
Hydroxyzine
Ambien CR
Lorazepam
Diazepam
SMOKING DETERRENTS COVERAGE DEPENDS ON BENEFIT DESIGN
STIMULANTS (AMPHETAMINES)
THYROID MEDICATIONS
URINARY INCONTINENCE
VAGINAL PRODUCTS
WEIGHT LOSS PRODUCTS COVERAGE DEPENDS ON BENEFIT DESIGN
SPECIALTY PHARMACY PRODUCTS COVERAGE DEPENDS ON BENEFIT DESIGN
CATEGORY
MEDICATION
Lovenox, Arixtra, Fragmin, Heparin, Innohep, Hemophilia products Humatrop, Protropin, Norditropin, Nutropin, Saizen, Genotropin, Geref Infergen, Intron A, Peg-Intron, Pegasys, Rebetron, Roferon A The formulary is subject to change. Network pharmacies have the most up-to-date formulary informationat the time your prescription claim is presented. As generic products become available, their brand namemedication will be moved to the third tier or non-preferred status. The inclusion of a drug on this list does not PREFERRED FORMULARY ALTERNATIVES TO NON-PREFERRED FORMULARY AGENTS
Please note the Non-Preferred medications and the recommended Preferred Formulary alternatives listed below.
NON-PREFERRED
PREFERRED FORMULARY
ALTERNATIVE
Accu-Check . . . . . . . . . . . . . . . . . . . . . . . BD Logic, Ascensia Contour, Allegra-D . . . . . . . . . . . . . . . . . . . . . . . . . Ioratadine D, Zyrtec DAltace . . . . . . . . . . . . . . . . . . . . . . . . . . . Lisinopril, Benazepril, Enalapril, Amerge . . . . . . . . . . . . . . . . . . . . . . . . . . Zomig, Relpax, ImitrexAvalide . . . . . . . . . . . . . . . . . . . . . . . . . . . Atacand HCT, Diovan HCTAvapro . . . . . . . . . . . . . . . . . . . . . . . . . . . Atacand, DiovanAzmacort . . . . . . . . . . . . . . . . . . . . . . . . . PulmicortBenicar . . . . . . . . . . . . . . . . . . . . . . . . . . Atacand, DiovanClarinex . . . . . . . . . . . . . . . . . . . . . . . . . . Loratadine, ZyrtecCovera HS . . . . . . . . . . . . . . . . . . . . . . . .Cardizem LACozaar . . . . . . . . . . . . . . . . . . . . . . . . . . . Atacand, DiovanDitropan XL . . . . . . . . . . . . . . . . . . . . . . . Oxybutynin, Detrol LA, EnablexEnbrel . . . . . . . . . . . . . . . . . . . . . . . . . . . HumiraForadil . . . . . . . . . . . . . . . . . . . . . . . . . . . SereventFrova . . . . . . . . . . . . . . . . . . . . . . . . . . . . Zomig, Relpax, ImitrexHyzaar . . . . . . . . . . . . . . . . . . . . . . . . . . . Atacand HCT, Diovan HCTLevoxyl . . . . . . . . . . . . . . . . . . . . . . . . . . . Levothyroxine, SynthroidLexapro . . . . . . . . . . . . . . . . . . . . . . . . . . Citalopram, Paroxetine, Fluoxetine, ZoloftLexxel . . . . . . . . . . . . . . . . . . . . . . . . . . . Tarka, LotrelLumigan . . . . . . . . . . . . . . . . . . . . . . . . . . XalatanMaxalt . . . . . . . . . . . . . . . . . . . . . . . . . . . Zomig, Imitrex, RelpaxNasonex . . . . . . . . . . . . . . . . . . . . . . . . . Flonase, Rhinocort AquaPatanol . . . . . . . . . . . . . . . . . . . . . . . . . . OptivarPravachol . . . . . . . . . . . . . . . . . . . . . . . . . Iovastatin, Lipitor, CrestorPrevacid . . . . . . . . . . . . . . . . . . . . . . . . . . OTC Prilosec, Omeprazole, NexiumOne Touch Ultra . . . . . . . . . . . . . . . . . . . . Ascensia Contour, Ascensia Breeze, Sonata . . . . . . . . . . . . . . . . . . . . . . . . . . Ambien, Ambien CRTravatan . . . . . . . . . . . . . . . . . . . . . . . . . . XalatanVerelan PM . . . . . . . . . . . . . . . . . . . . . . . Cardizem LAVytorin . . . . . . . . . . . . . . . . . . . . . . . . . . . Iovastatin, Lipitor, CrestorXenical . . . . . . . . . . . . . . . . . . . . . . . . . . . MeridiaZaditor . . . . . . . . . . . . . . . . . . . . . . . . . . . OptivarZocor . . . . . . . . . . . . . . . . . . . . . . . . . . . . Iovastatin, Lipitor, Crestor Copyrighted by Pharmaceutical Technologies, Inc. 2006. Illegal to reproduce.
Tradenames are the registered trademarks of the respective product manufacturers.
PREFERRED DRUG LIST MEDICATIONS
This list contains the Preferred Brand Name Medications listed on the second tier of the formulary.
The formulary is subject to change. Network pharmacies have the most up-to-date formulary informationat the time your prescription claim is presented. As generic products become available, their brand namemedication will be moved to the third tier or non-preferred status. The inclusion of a drug on this list does not PREFERRED DRUG LIST MEDICATIONS - CONTINUED
This list contains the Preferred Brand Name Medications listed on the second tier of the formulary.
Preserving Benefits for the Workers of America’s Corporations SM P.O. Box 407 • Boys Town, NE 68010 • www.pti-nps.com Copyrighted by Pharmaceutical Technologies, Inc. 2006. Illegal to reproduce.
Tradenames are the registered trademarks of the respective product manufacturers.

Source: http://www.quickscript.net/2006%20Formulary.pdf