Microsoft word - prescription sol'n wallchart_july 2011.docx

(Generic)                   Opioid Analgesics
3 – Tiered Prescription Drug Formulary  
July 2011 
This formulary listing is to serve as a reference guide for the selection of cost-effective medications and does not guarantee coverage or imply therapeutic equivalence. Please use this formulary with your Anesthetics
medical practitioner to be sure that any medication selected is both Local Anesthetics
cost effective and clinically appropriate. This formulary listing is subject to change, please contact the ProAct help desk number on the back of your card for the most up to date formulary. Anticonvulsants
This formulary is not all inclusive. Generic products will process as Tier 1 drugs at your lowest copay. Tier 2 contains formulary brands and will process at your middle tier. Tier 3 contains non-preferred brands and are subject to your highest copay. Certain products may be excluded from your plan or require additional authorization. Analgesics
Migraine
Antidotes, Deterrents, and Toxicologic Agents
Imitrex Antidotes
Muscle Relaxants
Deterrents
Anti-Infective
Amebicides
Anti-Bacterials; Aminoglycosides
Nonsteroidal Anti-inflammatory Drugs
Antibiotic; Cephalosporins
Antibiotic; Macrolides
Antibiotic; Penicillins
(Generic)                   (Generic)                   Antibiotic; Quinolones
Anti-parasitics
Antibiotic; Sulfonamides
Bactrim/DS Antitubercular Agents
Antibiotic; Tetracyclines
Anti-Virals
Antibacterials; Other
Antimyasthenic Agents
Parasympathomimetics
Antifungals
Antineoplastics
Alkylating Agents
itraconazole Natacyn Sporanox cyclophosphamide Alkeran Anti-HIV Agents;
NNRTIs
Antimetabolites
Anti-HIV Agents; NRTIs
Hormonal
Molecular Target Inhibitors
Anti-HIV Agents, Protease Inhibitors
Antineoplastics, Other
Cardiovascular Agents
Alpha-adrenergic Agonists
Alpha-adrenergic Blocking Agents
Anti-HIV Agents, Other
Antiarrhythmics
Anti-influenza Agents
Antimycobacterials, Other
(Generic)                   (Generic)                   Beta-adrenergic Blocking Agents
acebutolol Levatol Bystolic Angiotensin II Antagonists
Antihypertensive Combinations
Blood Modifiers/Coagulation Inhibitors
Renin Inhibitors
Ticlid Vasodilators
Calcium Channel Blocking Agents
diltiazem/ER/SR Exforge/HCT Cardizem/SR/CD Cardiovascular; Other
Central Nervous System Agents
Cerebral Stimulants; Amphetamines
Diuretics
Cerebral Stimulants; Non-Amphetamines
bumetanide Clorpres Bumex methylphenidate/SR Concerta Dementia
Parkinsons
Dyslipidemics
gemfibrozil Lipitor Lipofen selegiline tablet Cough/Cold
pravastatin Lovaza Triglide Antihistamines
Angiotensin Converting Enzyme Inhibitors
Antitussive
(Generic)                   (Generic)                   Dermatological Agents
Respiratory Device
Actinic Keratosis
Antibacterials
Diabetes
Antidiabetic Agents
Antifungals
Glycemic Agents
Atopic Dermatitis
Insulins
Humalog/Mix (Vials & Pens) Prefilled Glucocorticoids/Mineralocorticoids
Endocrine
Androgens
Antiandrogens
Dermatological Agents; Other
Contraception
Pediculicides/Scabicides
**May be excluded from coverage, see plan for details Glucocorticoids/Mineralocorticoids
Diabetic Supplies
(Generic)                   (Generic)                   Hormone Replacement Therapy
Benign Prostatic Hypertrophy Agents
Erectile Dysfunction
Estratest/HS Prometrium Phosphate Binders
Genitourinary Agents; Other
Metabolic Bone Disease Agents
Antigout Agents
Immunological Agents
Pituitary Agents
Immunomodulators
Ophthalmic Agents
Anti-allergy Agents
Gastrointestinal Agents
Antiemetics
Antibacterials
Antispasmodics
Anti-Inflammatory
Proton Pump Inhibitors
Ulcer Agents
Glaucoma Agents
Gastrointestinal Agents, Other
Genitourinary Agents
Antispasmodics; Urinary
(Generic)                   (Generic)                   Otic Agents
Respiratory Tract Agents
Anesthetics
Bronchodilators, Anticholinergic
Bronchodilators, Phosphodiesterase Inhibitors (Xanthines)
Antibacterials
Bronchodilators; Sympathomimetic
Psychological
Anti-Depressants; MAOi
Anti-Depressants; SSRIs/SNRIs
Leukotriene Inhibitors
Mast Cell Stabilizers
Anti-Depressants; Tricyclics
Nasal Inhalations
Antidepressants; Other
Oral Corticosteroids
Antipsychotics
Supplements
Electrolytes/Minerals
Enzyme Replacements/Modifiers
Vitamins
Bipolar Agents
Sedatives and Hypnotics
**Specialty medications will process according to plan design** 
Please contact the ProAct Clinical Department at:  1‐877‐776‐2285 x3624or email us at  for recommendations on cost saving alternatives 

Source: http://www.co.st-lawrence.ny.us/data/files/departments/HumanResources/Prescription%20Sol'n%20Wallchart_July%202011.pdf