Webformulary.qxd

Physicians Plus Insurance Corporation Drug Formulary Website: www.pplusic.com Last Updated 7/08
This is a summary by category of formulary alternatives. Physicians Plus reserves the right to change the formulary at any time. When an acceptable generic is available, the generic product is considered the covered, formulary product. Prior Authorization FAX # 608-258-1905, Pharmacy Services phone # 800-545-5015 Ext. 7803. Formulary also at www.epocrates.com.
ALLERGY & ASTHMA
Fluoroquinolones
fish oil - OTC*
Electrolyte Replacement
Antihistamines
ciprofloxacin
orphenadrine
gemfibrozil
slow-k, micro-k, klor-con, k-dur
$0 chlorpheniramine OTC
tizanidine TS
lovastatin TS QL-45 GS
kaochlor liquid, k-lor powder
loratadine QL-30 GS
Macrolides
Narcotics / Misc.
simvastatin TS QL-45 GS
Vasodilators
loratadine-D
erythromycin
hydralazine MD, minoxidil
fexofenadine, hydroxyzine tabs
azithromycin
morphine, oxycodone
isordil Tembids - generic
1 cetirizine OTC
clarithromycin, XL
tramadol
Lovaza ST (PA)
nitroglycerine, nitrostat
Allegra-D ST, Allegra Suspension
Penicillins
codeine/APAP
nitroglycerine patches
penicillin VK
hydrocodone/APAP
Vytorin QL-30 TS
imdur / ismo - generic
Nasal Sprays
amoxicillin 250, 500mg
propoxyphene/APAP
Crestor TS QL-45
dicloxacillin
oxycod 5mg/APAP 325
Lipitor (PA) TS QL-45
ipratropium
augmentin, ES
ms contin
Anti-Coagulants/Platelets
fluticasone GS
oxycodone ER QL-120 (PA)
coumadin
Tikosyn (PA),Tracleer (PA)
Antifungals
Avinza QL-60
ticlopidine
CNS DRUGS
nystatin
Kadian QL-60
cilostazol
Anti-Convulsants
lotrisone
fentanyl patch QL-10
phenobarbital, primidone
Bronchodilators
Lovenox QL-28 syringes
dilantin
albuterol Nebs
miconazole-3 200mg supp
ibuprofen MD GS
Beta- Blockers
ipratropium Nebs
spectazole
naproxen MD GS
atenolol MD GS
Lamictal TS QL-120
theophylline (Slo-phyllin,
fluconazole
indomethacin & SR
atenolol/chlorthalidone MD
Uniphyl generics)
terbinafine (PA) -preferred
piroxicam, sulindac
labetalol
itraconazole (PA)
oxaprozin GS
metoprolol MD GS
gabapentin TS
diclofenac (Voltaren) MD GS
pindolol
Topamax TS
metronidazole
etodolac (NOT SR)
propranolol MD, ER
Trileptal TS
bactrim SS/DS-generics
Celebrex (ST) 100 mg QL-30
propranolol/HCTZ MD
Lyrica (PA) QL-120
tetracycline, clindamycin
CARDIOVASCULAR
nadolol, betapace
Anti-Depressants
doxycycline, minocycline
ACE Inhib & ARB's
carvedilol
amitriptyline, imipramine
macrobid
captopril MD
clomipramine, doxepin
Preventative
Bactroban QL-30 grams
enalapril MD GS
Metoprolol ER (PA)
bupropion
Zyvox (PA)
enalapril HCTZ MD GS
Coreg CR (PA)
bupropion SR TS GS
Tamiflu, Relenza QL 2 Rx / year
lisinopril MD GS
Ca+ Channel Blockers
budeprion XL
lisinopril/HCTZ MD GS
adalat CC - generics
nortriptyline, desipramine
ANALGESICS
benazepril MD GS
verapamil SR tabs only
trazodone TS
Migraine
benazepril HCTZ MD GS
dilacor XR - generics
$0 fluoxetine GS
butalbital/APAP/Caffeine
ramipril (PA)
felodipine
citalopram TS QL-45 GS
Pulmicort Respul AL < or = 8yrs
midrin - generics
Benicar 20 & 40mg / HCT TS
tiazac - generics
paroxetine HCL TS QL-45 GS
Cozaar & Hyzaar TS
amlodipine TS QL-45
mirtazepine
ANTI-INFECTIVES
Diuretics
Maxalt/Maxalt MLT QL 12/24
Alpha- Blockers
venlafaxine
Cephalosporins
hydrochlorothiazide MD GS
Imitrex Tabs QL & Injection QL
prazosin, doxazosin GS
fluvoxamine TS QL-90
cephalexin
furosemide MD, bumetanide MD
nefazodone TS
ONLY QL 6/12
Antihyperlipidemics
cefadroxil capsules only
spironolactone/HCTZ
sertraline TS QL-45 GS
Muscle Relaxants
$0 niacin generic OTC's
cefuroxime tabs only
triamterene/HCTZ MD
Lexapro TS QL-45
baclofen
cholestyramine (cans only)
cefdinir
metolazone
Cymbalta 20mg QL-60
cyclobenzaprine
colestipol granules, tablets
cefpodoxime
chlorthalidone MD GS
Cymbalta 30mg & 60 mg QL-30
methocarbamol
fenofibrate 67, 134, & 200mg
KEY: Underline = best economic choice
TS = voluntary tab split; #15 / month reduces member copay by one-half or coinsurance reduction.
1= "generic drug", bolded, lowercase indicates Tier 1 copay ($5 - $10).
GS = Generic Sampling Program. Initial one-month supply of select prescriptions at a $0 copay.
2= "Brand Drug", not bolded, uppercase indicates Tier 2 copay ($10 - 30%).
QL = Quantity Limits (PA required for greater quantities): (PA)= Prior Authorization required. If PA approved = Tier 2; If PA denied or not obtained = Tier 3.
- QL-20 = 20mL / month per type of insulin. $10 insulin copay.
AL = Age Limit; PA required if >35 years.
MD = Maintenance Drug, 3 months / 3 copays - QL-45 = 45 tabs / month use higher strength if possible. PA may be required for high quantities.
ST = Step Therapy: * loratadine or fexofenadine required step before Allegra-D is Tier 2.
- Imitrex/Maxalt: 9 tabs / copay, 18 tabs / month; Imitrex Syr or Nasal: 6 / copay, 12 / month.
* methylphenidate required step before Focalin, XR is Tier 2.
- Byetta (PA): QL 1.2mL / month for 5mcg pen. QL 2.4mL / month for 10mcg pen.
* Age >60 yrs, warfarin, OR chronic steroid step before Celebrex is Tier 2.
* Fish Oil OTC: MaxEPA, Super Omega-3, Fish Oil Concentrate Paxil CR QL-45
Differin AL <35
Formulary Agents: $0 Copay w/ a Prescription
Emsam QL-30 (PA)
Anti-Parkinson's
medroxyprogesterone MD Fluoxetine (Rx)
selegiline, trihexyphenidyl
betamethasone
bromocriptine, pergolide
fluocinolone
sinemet & CR
hydrocortisone
GI / Urinary
desonide
H2 Antagonists
cyclocort
cimetidine MD
Nicotine Cessation Coverage
Neupro (PA) QL-30
fluocinonide
famotidine MD GS
alclometasone
ranitidine MD GS
estratest & HS
Members must receive a prescription order of nicotine cessation therapy methylphenidate & SR
fluticasone propionate
for 3 consecutive months per member per calendar year. Prescriptions may Proton Pump Inhibitors
dexedrine & spansules
mometasone
prilosec-OTC QL-60
adderall TS
clobetasol
Protonix QL-30
Tier 1: Bupropion SR, nicotine patches, gum, and lozenge QL-288/month.
desoximetasone
Tier 2: Nicotine OTC patches (QL-30), Nicotrol Nasal Spray
diflorasone
Menostar QL-4 patches
(QL-40ml/month), Nicotrol Inhaler (QL-4 boxes/month), and Chantix QL- diprolene
oxybutynin GS
Daytrana QL-30
halobetasol
oxybutynin XL QL-30
Focalin QL-90 ST
Prior Authorization Medications & Limitations
Focalin XR QL-30 ST
Taclonex (PA)
(PA) indicates that prior authorization criteria apply and requires a prior Alzheimer's
Protopic (PA)
Enablex QL-30
authorization form be faxed to 608-258-1905; call 800-545-5015 Ext.
Aricept, Exelon, Patch QL-30
EYE / EAR DROPS
Forteo (PA)
7803 with questions or for a copy of the form. Members with a 2-tier Oral Contraceptives
Vesicare QL-30
drug plan require prior authorization for PA and non-formulary drugs. If $0 naphcon A, opcon A OTC
zovia, kelnor MD
a request is approved for a PA agent, members of a 3-tier drug plan will BZD's / Anxiety / Sleep
levora MD
lactulose
be charged the usual Tier 2 copay as appropriate. If the request is denied, diazepam, clonazepam
Patanol (PA)
aviane, lessina, lutera MD
azulfidine
members may obtain these agents at 50% coinsurance / Tier 3.
alprazolam, flurazepam
Anti-Infective & Viral
microgestin, junel MD
loperamide caps
buspirone TS
acetic acid OTIC
necon, norinyl, nortrel MD
misoprostol
temazepam, oxazepam
sulfacetamide 10%
low-ogestrel, cryselle MD
dicyclomine
lorazepam
gentamicin, tobramycin
apri, solia, reclipsen MD
levbid / levsinex
Lipitor (PA) TS
zolpidem
ciprofloxacin, ofloxacin
kariva MD
golytely / nulytely
mononessa, previfem MD
Mood Stabilizers
erythromycin
cortifoam
sprintec MD
lithium, eskalith-CR
bacitracin
trivora, enpresse MD
neosporin
Emend (PA) QL-5
Neupro (PA) QL-30
trifluridine
camila, errin, jolivette MD
Nausea / Vertigo
tilia Fe, tri-legest Fe MD
meclizine
Entocort EC (PA)
trinessa, trisprintec MD
prochlorperazine
HORMONES
triprevifem MD
Transderm Scop QL-4
Antidiabetic Agents
promethazine
Corticosteroid Combo
glipizide MD GS
neodecadron
glyburide MD GS
Ortho-TriCyclen Lo MD
ondansetron
cortisporin solution
$10 Humulin-insulin QL-20
Targeted Tablet Splitting Program
Neuroleptics
maxitrol
$10 Humalog-insulin QL-20
Yasmin MD,Yaz MD
If a member chooses to split #15 tabs/month, the coinsurance will be haloperidol,
$10 Lantus- insulin QL-20
MISCELLANEOUS
reduced or the copay will be reduced by half (e.g. $20 reduced to $10).
chlorpromazine
$10 Levemir QL-20
leflunomide
benztropine
Ciprodex OTIC (PA)
metformin GS
Avanesp QL-4 mL
sertraline
fluphenazine
metformin XR
fluvoxamine
simvastatin
thiothixine, thioridazine
Pain & Miscellaneous
metformin / glyburide
Betaseron (PA)
amphetamine salt
gabapentin
tizanidine
clozapine TS
auralgan OTIC
glimepiride
Enbrel (PA)
combo (Adderall)
Abilify TS
cerumenex OTIC
Epogen / Procrit QL-4 vials Benicar
trazodone
Zyprexa TS
Humira (PA), Kineret (PA)
Seroquel TS, Seroquel XR
Restasis (PA)
Neupogen QL-4 vials
bupropion SR
Avandaryl ST (PA)
Raptiva (PA)
buspirone
lovastatin
Risperdal TS, Invega (PA)
Glaucoma
Januvia QL-30/ Janumet
pilocarpine, various
Rebif (PA)
citalopram
nefazodone
DERMATOLOGIC
Byetta (PA) QL
epinephrine, various
Regranex (PA)
clozapine
paroxetine HCL
timoptic & XE
tretinoin AL <35
dipivefrin, ocupress
HRT / Osteoporosis
estradiol MD
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Source: https://inside.fammed.wisc.edu/system/files/dmt/webformulary.pdf