Microsoft word - prescription sol'n wallchart_january 2013

(Generic)                  
Opioid Analgesics
3 – Tiered Prescription Drug Formulary  
January 2013 
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. Certain products may be excluded from Anesthetics
your plan or require additional authorization. Please see your plan Local Anesthetics
document for exact details as coverage may vary. This formulary is not all inclusive. Generic products will process as Tier 1 drugs at your lowest copay, Tier 2 contains formulary brands, and Tier 3 contains non-preferred brands and are subject to your highest copay. Anticonvulsants
This formulary is to be used with your medical practitioner to be sure that any medication selected is both 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 Analgesics
Migraine
Antidotes, Deterrents, and Toxicologic Agents
Antidotes
Muscle Relaxants
Deterrents
Anti-Infective
Amebicides
Anti-Bacterials; Aminoglycosides
Nonsteroidal Anti-inflammatory Drugs
Antibiotic; Cephalosporins
Antibiotic; Macrolides
Antibiotic; Penicillins
(Generic)                   (Generic)                   Antimetabolites
Antibiotic; Quinolones
Hormonal

Antibiotic; Sulfonamides
Antibiotic; Tetracyclines
Cardiovascular Agents
Alpha-adrenergic Agonists
Antibacterials; Other
Alpha-adrenergic Blocking Agents
Antiarrhythmics
Antifungals
Beta-adrenergic Blocking Agents
Anti-influenza Agents
Antimycobacterials, Other
Anti-parasitics
Blood Modifiers/Coagulation Inhibitors
Antitubercular Agents
Anti-Virals
Calcium Channel Blocking Agents
Valtrex diltiazem/ER/SR Exforge/HCT Cardizem/SR/CD Antimyasthenic Agents
Parasympathomimetics
Diuretics
Antineoplastics
Alkylating Agents
(Generic)                   (Generic)                   Dyslipidemics
atorvastatin Antara Advicor entacapone Parlodel cholestyramine Crestor Cough/Cold
Lipofen Antihistamines
Angiotensin Converting Enzyme Inhibitors
Antitussive
Dermatological Agents

Angiotensin II Antagonists
candesartan/hctz Benicar/HCT Atacand/HCT isotretinoin Retin-A Actinic Keratosis
Antihypertensive Combinations
Antibacterials
Renin Inhibitors
Vasodilators
Antifungals
Cardiovascular; Other
Atopic Dermatitis
Central Nervous System Agents
Cerebral Stimulants; Amphetamines
Glucocorticoids/Mineralocorticoids
Cerebral Stimulants; Non-Amphetamines
Dementia
Dermatological Agents; Other
Parkinsons
(Generic)                   (Generic)                   Pediculicides/Scabicides
Glucocorticoids/Mineralocorticoids
Hormone Replacement Therapy
Diabetes
Diabetic items including supplies and medication may be subject to alternate copays and/or coverage strategy. Please see your plan document or contact ProAct for additional details. Antidiabetic Agents
Metabolic Bone Disease Agents
tolazamide Onglyza Metaglip alendronate Evista Actonel/Calcium Diabetic Supplies
Pituitary Agents
Glycemic Agents
Gastrointestinal Agents
Antiemetics
Insulins
Humalog/Mix (Vials & Pens) Prefilled Antispasmodics
Endocrine
Androgens
Proton Pump Inhibitors
Antiandrogens
Ulcer Agents
Contraception
Gastrointestinal Agents, Other
(Generic)                   (Generic)                   Genitourinary Agents
Otic Agents
Antispasmodics; Urinary
Anesthetics
VESIcare Enablex Antibacterials
Benign Prostatic Hypertrophy Agents
Psychological
finasteride Jalyn Proscar Anti-Depressants; MAOi
Erectile Dysfunction
Anti-Depressants; SSRIs/SNRIs
Phosphate Binders
Genitourinary Agents; Other
Anti-Depressants; Tricyclics
Antigout Agents
allopurinol Uloric Colcrys clomipramine Pamelor Immunological Agents
Immunomodulators
Antidepressants; Other
Ophthalmic Agents
Anti-allergy Agents
Alocril Antipsychotics
nedocromil Patanol Alomide chlorpromazine Abilify/Discmelt Antibacterials
ciprofloxacin Vigamox Polytrim perphenazine Zyprexa/Zydis Anti-Inflammatory
Flarex Bipolar Agents
Sedatives and Hypnotics
Glaucoma Agents
(Generic)                   (Generic)                   Respiratory Tract Agents
Bronchodilators, Anticholinergic
Please contact the ProAct Clinical Department at:  1‐877‐776‐2285 x3624or email us at  Bronchodilators, Phosphodiesterase Inhibitors (Xanthines)
for recommendations on cost saving alternatives  Bronchodilators; Sympathomimetic
Leukotriene Inhibitors
Mast Cell Stabilizers
Nasal Inhalations
Oral Corticosteroids
Respiratory Device
Supplements
Electrolytes/Minerals
Enzyme Replacements/Modifiers
Vitamins
ProAct Specialty Drug Listing
Specialty medications can be described as medications that are high cost, highly complex, or typically require specialized administration, handling or distribution. They are often biology-based and mimic substances found in the body to produce their effects. These medications will process according to your plan design, and may require prior authorization and/or have other restrictions. Medications listed as bold are available generically.
(*) indicates product is a formulary item, all others are non-formulary.
Abacavir
Melphalan
Vinblastine
Stavudine
Vincasar
Etoposide
Vincristine
Vinorelbine
Idarubicin
Mitomycin
Adriamycin
Cisplatin
Mitoxantrone
Cladribine
Ifosfamide
Mycophenolate Pulmozyme
Tacrolimus
Floxuridine
Cyclophophamide Fludara
Cyclosporine
Fludarabine
Amifostine
Fluorouracil
Cytarabine
Irinotecan
Dacarbazine
Fondaparinux
Nevirapine
Dactinomycin
Daunorubicin
Dexrazoxane
Didanosine
Topotecan
Docetaxel
Doxorubicin
Ribasphere
Tranexamic
Gemcitabine
Octreotide
Ribavirin
Tretinoin (oral)
Lamivudine
Zidovudine
Lamivudine/Zidovudine Oncaspar
Leuprolide
Bleomycin
Granisetron
Enoxaparin
Oxaliplatin
Epirubicin
Paclitaxel
Pamidronate
Epoprostenol
Carboplatin
Pentostatin
Specialty list not all‐inclusive.  Please contact the ProAct Helpdesk at 1‐877‐776‐2285 with questions regarding specialty medications. 

Source: http://files.sllboces.org/files/1420/Formulary%20Jan%202013.pdf