Microsoft word - irx.4q10.3-tier_pdl.eff.100110.doc

Macrolides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
mexiletine, propafenone, quinidine, sotalol azithromycin, clarithromycin, erythromycin ACE INHIBITORS ---------------------------------------------
OTHER CONTRACEPTIVES----------------------------------
benazepril, captopril, enalapril, fosinopril, Tetracyclines. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
lisinopril, moexipril, perindopril, quinapril, PROGESTIN ONLY------------------------------------------------
ANGIOTENSIN II ANTAGONISTS-------------------------
EMERGENCY CONTRACEPTION-----------------------
October 2010
Fluroquinolones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ANTI-ADRENERGIC BLOCKERS–CENTRAL------
Preferred Drug List
DRUGS FOR DIABETES
INSULINS --------------------------------------------------------
Apidra, Humalog, Humulin, Levemir, Novolog, The informedRx Preferred Drug List
Aminoglycosides. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
COMBINATION AND MISC ANTIHYPERTENSIVES---
defines the copayment tier status of the
most commonly prescribed medicines. It
Sulfonamides. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ORAL ------------------------------------------------------------
lisinopril w/ HCTZ, losartan/HCT, moexipril may not include all drugs covered by your
acarbose, glimepiride (w/ metformin), glipizide prescription drug benefit. For benefit
(w/ metformin), glyburide (w/ metformin), Drugs for Fungal Infections. . . . . . . . . . . . . . . . . . . . .
coverage or restrictions please check your
ActoPlus Met, Actos, Avandamet, Avandaryl, benefit plan document(s). This listing is
Tekturna, Tekturna HCT, Twynsta, Valturna revised periodically as new drugs and new
prescribing information becomes
Drugs For Viral Infections. . . . . . . . . . . . . . . . . . . . . . .
DIURETICS ------------------------------------------------------
available.
OTHER ------------------------------------------------------------
The coverage tier for each medication has
been indicated. Members pay a Tier 1
copayment for most generic drugs.
ANTIHYPERLIPIDEMICS------------------------------------------
Members pay a Tier 2 copayment for
Miscellaneous Antiinfectives. . . . . . . . . . . . . . . . . . . . .
cholestyramine, fenofibrate, gemfibrozil, THYROID AND ANTITHYROID AGENTS
formulary (preferred) brand name drugs.
clindamycin, metronidazole, nitrofurantoin THYROID ---------------------------------------------------------
Members pay a Tier 3 copayment for non-
Alinia, Cayston, Coartem, Dapsone, Xifaxin Lipitor, Lovaza, Niaspan, Simcor, Tricor, formulary (non-preferred) brand name
Triglide, Trilipix, Vytorin, Welchol, Zetia drugs. For most brands with generics
Antara, Colestid, Lescol, Lescol XL, Lofibra available, the generic will be available at
MISCELLANEOUS CARDIOVASCULAR DRUGS---------
the Tier 1 copayment.
HORMONES
DRUGS FOR OSTEOPOROSIS
ANTICOAGULANTS/ANTITHROMBOTICS-------------
GLUCOCORTICOIDS ---------------------------------------------
It is recommended that you bring this list of
Boniva Tablet, Evista, Fosamax D, Forteo medications when you or a covered family
member sees a physician or other
healthcare provider.
ANDROGENS---------------------------------------------------
MISCELLANEOUS ENDOCRINE
DRUGS FOR MISCELLANEOUS BLOOD DISORDERS--
desmopressin spray / tablets, cabergoline Formulary Disclaimer: Coverage for some drugs may be First Testosterone, Striant
RESPIRATORY / ASTHMA
limited to specific dosage forms and/or strengths. The ESTROGENS ---------------------------------------------------
CARDIOVASCULAR DRUGS
DRUGS FOR ALLERGY -------------------------------
benefit design determines what is covered and the CARDIOTONICS ----------------------------------------------
Oral Antihistamines and Combinations. . . . . . . .
applicable co-payment. The medications listed on this formulary are subject to change pursuant to the formulary ANTI-ANGINA ----------------------------------------------
management activities of informedRx. The presence of a isosorbide dinitrate, isosorbide mononitrate, medication on this formulary list does not guarantee Alora, Estrasorb, Estrogel, Femring, Menest nitroglycerin sublingual tabs and patches Misc Allergy . . . . . . .…………………………………….
Dilatrate-SR, Minitran, Nitrolingual, Ranexa ESTROGEN AND ANDROGENS --------------------------
BETA-ADRENERGIC BLOCKERS----------------------
NASAL MEDICATIONS -------------------------------------
DRUGS FOR INFECTIONS
Esterified estrogens and methyltestosterone Astelin, Nasonex, Nasacort AQ, Rhinocort ANTIBIOTICS-------------------------------------------------
Penicillins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ESTROGEN AND PROGESTERONES-------------------
CALCIUM CHANNEL BLOCKERS -----------------------
amoxicllin w/ potassium clavulanate, penicillin Combipatch, Crinone, Premphase, Prempro, COUGH AND COLD MEDICATIONS -------------------------
Cephalosporins. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
felodipine, isradipine, nifedipine XL, suldipine, cefaclor, cefadroxil, cefdinir, cefradine, MISC HORMONES-------------------------------------------
DRUGS FOR ASTHMA / COPD -------------------------------
Sympathomimetics. . . . . . . . . . . . . . . . . . . . . . . .
CONTRACEPTIVES
ANTIARRHYTHMICS ----------------------------------------
ORAL - MONO, BI AND TRI-PHASIC -------------------------
informedRx Preferred Drug List - Effective October 1, 2010. DRUGS FOR ALZHEIMER’S DISEASE-----------------------
Acanya, Azelex, BenzaClin, Differin, Duac RESPIRATORY / ASTHMA (CONT)
VAGINAL ANTIINFECTIVE PREPARATIONS --------------
galantamine, galantamine ER, rivastigmine nystatin, metronidazole vaginal, terconazole DRUGS FOR PARKINSONS DISEASE ----------------------
Metrocream, MetroLotion, Noritate, Retin-A Combination Drugs and Others. . . . . . . . . . . . . . . . .
DRUGS FOR BPH-------------------------------------------
ANTIVIRALS ----------------------------------------------------
albuterol-ipratropium for nebulization, FUNGICIDES ----------------------------------------------------
Theophyllines…. . . . . . . . . . . . . . . . . . . . . . . .
DRUGS FOR ERECTILE DYSFUNCTION----------------
MIGRAINE AGENTS-------------------------------------------
Corticosteroids. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Exelderm, Extina, Naftin, Oxistat, Vusion, Asmanex, Flovent HFA / Diskus, Pulmicort, CENTRAL NERVOUS SYSTEM
TOPICAL ANTI-INFLAMMATORY AGENTS---------
ANALGESICS, NARCOTIC---------------------------------------
Low - Intermediate Potency . . . . . . . . . . . . . . . . .
Antileukotrienes. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
SKELETAL MUSCLE RELAXANTS -------------------------
Actiq, Kadian, Darvon N, Fentora, Opana/ ER, baclofen, carisoprodol, cyclobenzaprine, GASTROINTESTINAL
OxyIR, Phrenilin, Phrenilin Forte, Suboxone, High Potency . . . . . . . . . . . . . . . . . . . . . . . . . . .
ANTISPASMODICS
ANALGESICS, NSAIDs ----------------------------------------
dicyclomine, hyoscyamine, metoclopramide diclofenac, diflunisal, etodolac, ibuprofen, MISC NEUROLOGICAL----------------------------------------
OTHER DERMATOLOGICALS ----------------------------
ANTIULCER -----------------------------------------------------
OPHTHALMIC
ANTI-ALLERGIC AGENTS----------------------------------
ANTICONVULSANTS ---------------------------------------
Plus, Oxsoralen, Oxsoralen-Ultra, Panretin, Alocril, Alomide, Elestat, Emadine, Zaditor, levetiracetam, oxcarbazepine, phenytoin, ANTI-GLAUCOMA AGENTS -----------------------------
brimonidine, dipivefrin, betaxolol, carteolol, MISCELLANEOUS
ANTIEMETIC/ANTIVERTIGO -----------------------------
levobunolol, metipranolol, timolol, timolol/ meclizine, ondansetron, prochlorperazine, Carbatrol, Diastat, Dilantin (30 and 50mg), Felbatol, Gabitril, Keppra XR, Lamictal ODT, ANTI-INFECTIVE AGENTS--------------------------------
BOWEL EVACUANTS ---------------------------------------------
ANTIDEPRESSANTS --------------------------------------------
bupropion XL, citalopram, doxepin, fluoxetine, Besivance, Ciloxan Oint, Iquix, Natacyn, imipramine, mirtazapine, nortriptyline, DIGESTANTS ---------------------------------------------------
paroxetine, paroxetine CR, protriptyline, ANTI-INFLAMMATORY AGENTS---------------------------
Kutrase, Ku-Zyme, Pancrease MT, Pancrecarb OTHER GI PRODUCTS -----------------------------------
ANTIPSYCHOTIC AGENTS --------------------------------------
chlorpromazine, clozapine, haloperidol, ANTI-INFECTIVE AND ANTI-INFLAMMATORY
COMBINATIONS ---------------------------------------------
Anamantle HC, Anusol HC, Apriso, Asacol, Abilify, Clozaril, Geodon, Moban, Seroquel, Fazaclo, Invega, Risperdal Consta, Symbyax Gastrocrom, Kristalose, Lotronex, Pentasa, ANXIOLYTICS, SEDATIVES, AND HYPNOTICS----
NSAIDS-----------------------------------------------------------
Acular, Acular LS, Ocufen, Nevanac, Xibrom Actigall, Cytotec, Dipentum, Lialda, Rowasa GENITO-URINARY
ANTI-INFECTIVE, ANTI-INFLAMMATORY
ANTI-INFECTIVES------------------------------------------
CEREBRAL STIMULANTS--------------------------------
COMBINATIONS AND MISC----------------------------------------
INCONTINENCE AGENTS-------------------------------
Concerta, Daytrana, Metadate-CD, Provigil, DERMATOLOGICALS
ACNE AND ANTIBIOTICS-----------------------------------------
informedRx Preferred Drug List - Effective October 1, 2010.

Source: http://www.senecaconsulting.com/images/informedRx_PDL_effective_10.1.10.pdf