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Microsoft word - 2009 apex formulary 4th qtr

HORMONES
acarbose, glyburide, glipizide, glipizide XL, glipizide w metformin, glimepiride, metformin, captopril/ HCTZ, enalapril w/ HCTZ, fosinopril/ GLUCOCORTICOIDS ---------------------------------------------
Tetracyclines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
metformin XR, glyburide w metformin, nateglinide HCTZ, lisinopril w/ HCTZ, moexipril/HCTZ, doxycycline, minocycline, Myrac, tetracycline Adoxa Pak, Doryx (PA), Oracea (PA), Solodyn Avalide, Atacand HCT, Diovan HCT, Exforge ANDROGENS---------------------------------------------------
Quinolones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2009 Drug Formulary
OTHER ------------------------------------------------------------
Androderm, Androgel, First Testosterone Oint, DIURETICS ------------------------------------------------------
and Pharmacy Benefit Guidelines Tier 3 Factive, Levaquin, Noroxin
ESTROGENS ---------------------------------------------------
Aminoglycosides. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
bumetanide, eplerenone (ST), furosemide, THYROID AND ANTITHYROID AGENTS
The following is a listing by drug class of
THYROID ---------------------------------------------------------
Sulfonamides. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
medications most commonly prescribed for Apex
ANTILIPIDEMICS ----------------------------------------------
members under the Apex Prescription Drug Benefit.
propylthiouracil, methimazole, liothyronine ZERO COPAY FOR lovastatin (QL=30), simvastatin (QL=30),
Apex three tiered prescription drug benefits are
Cenestin, Menest, Enjuvia, Evamist (QL=2) Drugs for Tuberculosis. . . . . . . . . . . . . . . . . . . . . . . . .
generic-based. Prescription drug benefits vary, but
ethambutol, Isonarif, isoniazide, pyrazinamide, OSTEOPOROSIS and PAGET’S DISEASE
gemfibrozil, cholestyramine, colestipol in most cases, brand name medications that have a
generic equivalent require the patient to pay a Tier 3
copay or the difference in cost between the brand
ESTROGEN AND ANDROGENS --------------------------
Drugs for Fungal Infections. . . . . . . . . . . . . . . . . . . . .
Advicor 20/500mg (QL=30), Advicor 20/1000mg and generic medication. Some benefits may exclude
fluconazole, itraconazole, ketoconazole, (QL=60), Altoprev (QL=30), Caduet, Crestor certain drugs on this list. Refer to your Prescription
(QL=30), Lescol (QL=30), Lescol XL (QL=30), Drug benefits for more coverage information.
ESTROGEN AND PROGESTERONES-------------------
MISCELLANEOUS ENDOCRINE
Members pay a Tier 1 copay for most generic drugs
Drugs for Viral Infections. . . . . . . . . . . . . . . . . . . . . . .
Antara, Fibricor, Tricor, Triglide, Welchol and selected over-the-counter drugs. Members pay
acyclovir, amantadine, famciclovir, rimantidine a Tier 2 copay for higher cost generic drugs and
MISCELLANEOUS CARDIOVASCULAR DRUGS---------
preferred brand name drugs. Members pay a Tier 3
copay for non-preferred.
PROGESTINS -----------------------------------------------
Agenerase, Aptivus, Combivir, Crixivan, Note: Some benefits may have a 4th copay level.
CARDIOVASCULAR DRUGS
Fortovase, Ganciclovir, Hivid, Intelence, CARDIOTONICS ----------------------------------------------
Key to Notations:
Crinone (PA), Endometrin (PA), Prochieve (PA) Isentress, Invirase, Kaletra, Lexiva, Prezista, ANTICOAGULANTS/ANTITHROMBOTICS-------------
PA: Prior authorization is required for this
Rescriptor, Reyataz, Selzentry, Sustiva, Trizivir, CONTRACEPTIVES
anagrelide, cilostazol, dipyridamole, ticlopidine, medication. Please refer to the boxed section at the
Truvada, Valcyte, Videx, Viracept, Viramune, ORAL MONO-PHASIC ----------------------------------------
ANTI-ANGINA ----------------------------------------------
end of this document.
multiple generic options (ex. Apri, Aviane, isosorbide, nitroglycerin subligual tabs and ST: A step therapy protocol is in place for this
Baraclude (ST), Hepsera (ST), Tyzeka (ST) Arixtra*(PA), Fragmin*(PA), Lovenox*(PA) medication. Claims for this medication will be
covered based on the member's previous
Infergen* (PA), Intron-A* (PA), Peg-Intron*(PA), BETA-BLOCKERS----------------------
RESPIRATORY / ASTHMA
medication history. If prior medication history does
atenolol, carvedilol, metroprolol, metoprolol XL, not meet clinical guidelines, prior authorization will
DRUGS FOR ALLERGY -------------------------------
propranolol, propranolol er, propranolol XL be required.
Oral Antihistamines and Combinations. . . . . . . .
ORAL BIPHASIC ----------------------------------------
Bystolic, Coreg CR, Innopran XL, Levatol Alavert, OTC Claritin, OTC Zyrtec, OTC Zyrtec- Drugs for Malaria. . . . . . . . . . . . . . . . . . . . . . . . . .
CALCIUM CHANNEL BLOCKERS -----------------------
QL: Quantity limitations (maximum number of
D, cetirizine, and store brands, loratadine chloroquine, hydroxychloroquine, mefloquine ORAL TRI-PHASIC ----------------------------------------
amlodipine, diltiazem CD, diltiazem XR, felodipine, tablets/capsules, etc. per retail prescription) are in
multiple generics (ex. Cesia, Tri-Sprintec, Tilia place for this medication. Prior authorization is
fexofenadine (ST) 30&180mg (QL=30) 60mg required for increased quantities.
Drugs for Parasites. . . . . . . . . . . . . . . . . . . . . . . . . .
Allegra-D 24hr (ST) (QL=30), Allegra-D 12hr PROGESTIN ONLY------------------------------------------------
(ST) (QL=60), Clarinex (ST) (QL=30), Clarinex *: This is a specialty drug that is provided by our
multiple generic options (ex. Camila, Errin, ANTIARRHYTHMICS ----------------------------------------
D 12 hr (ST) (QL=60), Singulair for allergic specialty pharmacy. Some benefits may cover these
drugs at a higher co-pay level. Refer to your
Miscellaneous Anti-infectives. . . . . . . . . . . . . . . . .
mexiletine, propafenone, quinidine, sotalol Nasal Medications. . . . . . . . . . . . . . . . . . . . . . .
Prescription Drug benefits for more information.
clindamycin, metronidazole, nitrofurantoin flunisolide, fluticasone, ipratropium nasal spray DRUGS FOR INFECTIONS
Depo-SQ Prov (3 copays per prescription) EMERGENCY CONTRACEPTION-----------------------
ACE INHIBITORS ---------------------------------------------
ANTIBIOTICS-------------------------------------------------
Beconase AQ, Nasacort AQ, Nasarel, Omnaris, benazepril, captopril, enalapril, fosinopril, Penicillins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DRUGS FOR CANCER
OTHER CONTRACEPTIVES----------------------------------
lisinopril, moexipril, quinapril, ramipril, amoxicillin, amoxicillin w K+ clavulanate, COUGH AND COLD MEDICATIONS -------------------------
ampicillin, cloxacillin, dicloxacillin, penicillin bicalutimide, cyclophosphamide, etoposide, guaifenesin w/ pseudoephedrine, multiple flutamide, hydroxyurea, leucovorin, megestrol, ANGIOTENSIN II ANTAGONISTS (ARBS)------------------------
Cephalosporins. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DRUGS FOR DIABETES
DRUGS FOR ASTHMA AND COPD --------------------------
cefaclor, cefaclor ER, cefadroxil, cefdinir, Alkeran, Arimidex, Aromasin, Emcyt, Fareston, INSULINS --------------------------------------------------------
Sympathomimetics. . . . . . . . . . . . . . . . . . . . . . . .
Atacand, Avapro, Diovan, Micardis, Teveten cefpodoxime proxetil, cefprozil, cefuroxime, Femara, Gleevec* (PA), Leukeran, Myleran, ANTI-ADRENERGIC BLOCKING DRUGS --------------
Nexavar* (PA), Temodar, Teslac, Thioguanine, clonidine, clonidine TD patch, doxazosin, Afinitor* (PA), Casodex, Iressa* (PA), Megace Perforomist, Proventil HFA, Xopenex solution Macrolides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ES, Nolvadex, Sutent* (PA), Sprycel* (PA), azithromycin, clarithromycin, erythromycin ethyl Tarceva* (PA), Tasigna* (PA), Tykerb* (PA), ORAL ------------------------------------------------------------
Combination Drugs and Others. . . . . . . . . . . . . . . . .
COMBINATION ANTIHYPERTENSIVES--------------
This document is in effect beginning October 1, 2009. Advair HFA, Atrovent HFA, Combivent, Spiriva, Maxalt (QL=12), Maxalt MLT (QL=12) Relpax Letairis* (PA), Tracleer* (PA), Ventavis* (PA) Avodart (QL=30), Cardura XL, Flomax, Rapaflo Auralgan, Cipro HC Otic, Ciprodex Otic Susp. DERMATOLOGICALS
Theophyllines…. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CENTRAL NERVOUS SYSTEM
Amerge (QL=9), Axert (QL=12), Frova (QL=9), ACNE -------------------------------------------------------------
Treximet (ST) (QL=9), Zomig (QL=12), Zomig PSYCHOTHERAPEUTIC AGENTS -----------------------
multiple generics, minocycline, doxycycline Corticosteroids. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Antidepressants . . . . . . . . . . . . . . . . . . . . . . . . . . .
All generic topical retinoids (PA), Avita (PA) ANTICONVULSANTS ---------------------------------------
MISC-DIAGNOSTICS ---------------------------------------
amitriptyline, doxepin, imipramine, nortriptyline Amnesteem, Claravis, isotretinin, Sotret Azmacort, Flovent, Qvar, Pulmicort Inhaler Azelex, Differin (PA), Duac, EpiDuo (PA), Retin Coverage for diabetes test strips varies.
fluoxetine, citalopram, fluvoxamine, paroxetine, – A Micro (PA), Tazorac (PA), Triaz, Ziana (PA) Antileukotrienes. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Please refer to your Prescription Drug Rider or paroxetine CR, sertraline, venlafaxine, venlafaxine ANTIBIOTICS ---------------------------------------------------
Singulair when prescribed for asthma only erythromycin, clindamycin, metronidazole, Banzel, Dilantin Kapseals and Infatabs, Gabitril, Effexor XR 37.5mg (QL=30), Effexor XR 75mg DRUGS REQUIRING PRIOR AUTHORIZATION OR STEP
GASTROINTESTINAL
Refer to your Prescription Drug Rider to find out if prior ANTIULCER -----------------------------------------------------
Diastat, Dilantin Suspension, Equetro, Felbatol, authorization and step therapy apply to your benefit: ZERO COPAY FOR Prilosec OTC
Aplenzin (QL = 30), Cymbalta 20mg (QL=60), ANTIVIRALS ----------------------------------------------------
ACIPHEX, ACTIMMUNE*, ACTIQ, ADCIRCA*, AFINITOR*, DRUGS FOR PARKINSONS DISEASE ----------------------
(QL=30), Lexapro (QL=30), Luvox CR, Marplan, ALLEGRA-D, AMBIEN CR, APOKYN*, ARANESP*, Pexeva, Prozac Weekly, Pristiq (ST) (QL=30), ARCALYST, ARIXTRA*, AVITA, AVONEX*, AZELEX, BARACLUDE, BETASERON*, BYETTA, CAVERJECT, FUNGICIDES ----------------------------------------------------
trihexyphenidyl, and other generic options Aciphex (ST) (QL=30), Kapidex (ST) (QL=30), Antipsychotic Agents . . . . . . . . . . . . . . . . . . . . . . .
ciclopirox, clotrimazole, clotrimazole troches, Azilect, COMTan, Kemadrin, Mirapex, Neupro, CLARINEX-D, CRINONE, COPAXONE*, DDAVP INJ*, Nexium (ST) (QL=30), Prevacid (ST) (QL=30), chlorpromazine, haloperidol, perphenazine, DIFFERIN, DIHYDROERGOTAMINE INJ, DORYX, EDEX, PrevPac, Zegerid (ST) (QL=30), Zegerid Caps & ENBREL*, ENDOMETRIN, EPIDUO, EPLERENONE, Abilify, clozapine, Geodon, Orap, Seroquel, nystatin/triamcinolone, ciclopirox nail lacquer ANTIEMETIC/ANTIVERTIGO -----------------------------
SKELETAL MUSCLE RELAXANTS -------------------------
FORTEO*, FRAGMIN*, FUZEON*, GLEEVEC, HEPSERA, dronabinol, granisetron (QL=2), hydroxyzine, Fazaclo, Invega, Symbyax, Zyprexa, Zyprexa TOPICAL ANTI-INFLAMMATORY AGENTS---------
baclofen, carisoprodol, cyclobenzaprine, HUMIRA*, INFERGEN*, INNOHEP*, INTRON-A*, IRESSA, meclizine, ondansetron (QL), ondansetron-ODT Multiple products with generics including KAPIDEX, KINERET*, KUVAN*, LEFLUNAMIDE, LETAIRIS, dantrolene, methocarbamol, and other generic ANXIOLYTICS, SEDATIVES, AND HYPNOTICS----
aclometasone, betamethasone, fluocinonide, LOVENOX*, LUNESTA, NEXAVAR, NEXIUM, NOXAFIL, alprazolam, buspirone, lorazepam, temazepam, halobetasol, hydrocortisone, mometasone, NUVIGIL, OMEPRAZOLE, ORACEA, PANTOPRAZOLE, Anzemet 50mg (QL=4), Anzemet 100mg (QL=2), triazolam, zaleplon (ST), zolpidem, and other PEGASYS* PEG-INTRON*, PREVACID, PRILOSEC 40MG, MISCELLANEOUS CNS AGENTS -------------------------
Transderm-Scop, Emend 80mg (QL=2) Emend PROVIGIL, RANEXA, REBETOL, REBETRON*, REBIF*, RELISTOR*, RETIN-A PRODUCTS, REVATIO*, REVLIMID, 125mg (QL=1), Emend Tri-pack (QL=1), Sancuso Tier 3 OPHTHALMIC
Lipocream, Luxiq, Olux, Pandel, Pramosone RIBAVIRIN, RYZOLT, SANDOSTATIN*, SIMCOR, CEREBRAL STIMULANTS--------------------------------
ANTI-ALLERGIC AGENTS----------------------------------
OTHER DERMATOLOGICALS ----------------------------
SIMPONI*, SOLODYN, SUTENT, SPRYCEL, SYMLIN, (QL=6), Zofran 24mg (QL=1), Zofran-ODT 4mg anthralin, calcipotriene soln, fluorouracil, Alamast, Alocril, Alomide, Elestat, Emadine, TEKTURNA HCT, THALOMID, TRACLEER, TREXIMET, DIGESTANTS ---------------------------------------------------
TYKERB*, TYZEKA, ULORIC, VENTAVIS*, VYTORIN, ANTI-GLAUCOMA AGENTS -----------------------------
XELODA, XENAZINE*, XOPENEX FOR NEBULIZATION, Adderall XR, Concerta, Focalin XR, Ritalin-LA apraclonidine, brimonidine, carteolol, dipivefrin, XYZAL, ZALEPLON, ZAVESCA, ZEGERID, ZETIA Provigil (PA), Nuvigil (PA) (QL=30), Strattera, betaxolol, dorzolamide, dorzolamide + timolol, DRUGS WITH QUANTITY LIMITS
OTHER GI PRODUCTS -----------------------------------
levobunolol, timolol, timolol XE and other Refer to your Prescription Drug Rider to find out if quantity bisalazide disodium, dicyclomine, Hyomax, DRUGS FOR ALZHEIMER’S DISEASE-----------------------
Oracea (ST), Ovace Plus, Rosula, Soriatane ACIPHEX, ACTIQ, ADVICOR, ALLEGRA-D, ALTOPREV, AMERGE, ANZEMET, APLENZIN, AXERT, AVODART, MISCELLANEOUS
CAVERJECT, CELEBREX, CHANTIX, CIALIS, CLARINEX, MULTIPLE SCLEROSIS AGENTS--------------------
CLARINEX-D 12 HR, CRESTOR, CYMBALTA, EDEX, ANTI-INFECTIVE AGENTS--------------------------------
FEXOFANADINE, FROVA, GRANISETRON, IMITREX, Asacol, Asacol HD, Apriso, Canasa, Dipentum, ANALGESICS---------------------------------
KAPIDEX, KYTRIL, LEXAPRO, LIPITOR, LESCOL, LESCOL acetaminophen w/ codeine, MSIR, OxyFAST, and XL, LEVITRA, LOVASTATIN, MAXALT MLT, MEVACOR, MUSE, MAXALT, NEXIUM, NUVIGIL, OMEPRAZOLE, ONDANSETRON, ONDANSETRON-ODT, OXYCONTIN, GENITO-URINARY
ANTI-INFLAMMATORY AGENTS---------------------------
Actiq (PA) (QL=120), Fentora (PA) (QL=112) dexamethasone, fluorometholone, prednisolone PREVACID, PRISTIQ, RAPAFLO, RELPAX, RELENZA, ANTI-INFECTIVES------------------------------------------
Avinza, Dozidox, Opana ER, OxyIR, Oxycontin RELISTOR, RYZOLT, SANCUSO, SAVELLA, SIMCOR, nitrofurantoin macro and other generic drugs Chantix (QL=duration of 24 weeks within 52- SIMVASTATIN, SUMATRIPTAN, TAMIFLU, TOVIAZ, INCONTINENCE AGENTS-------------------------------
Oxycontin 80MG (QL=120), Ryzolt (ST) (QL=30) ANTI-INFECTIVE AND ANTI-INFLAMMATORY
TREXIMET, VENLAFAXINE ER, VIAGRA, VIMPAT, XYZAL, ANALGESICS - NSAID ----------------------------------------
Cimzia* (PA), Enbrel* (PA), Humira* (PA), COMBINATIONS ---------------------------------------------
diclofenac, diflunisal, etodolac, ibuprofen, For further information regarding the Apex
Oxytrol Patch, Sanctura, Toviaz (QL = 30), prescription drug benefit please contact:
Arthrotec, Flector, Voltaren Gel, Naprelan SR VAGINAL PREPARATIONS -------------------------------
Celebrex (ST) (QL=30), Celebrex 400mg (PA) Viagra (QL=8), Cialis (QL=8), Levitra (QL=8), NSAIDS--------------------------------------------------------------
Apex Member Information:
clindamycin cream, metronidazole, nystatin, MIGRAINE AGENTS-------------------------------------------
Customer Service: (800) 753-8429
sumatriptan tabs (QL=9), sumatriptan nasal Persons with Hearing or Speech Disabilities:
spray (QL=12), sumatriptan injection (QL=10) Aranesp* (PA), Epogen* (PA), Procrit* (PA) Contact the Ohio Relay (TTY) at (800) 750-0750
Apex Provider Services:
DRUGS FOR BPH-------------------------------------------
ANTI-INFECTIVE AND COMBINATIONS ---------------------
(800) 996-8401
This document is in effect beginning October 1, 2009.

Source: http://www.apex-healthsolutions.com/elements/formulary09.pdf

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