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Website alpha drug list 06-08-04.xls

PICA Drug List - Alphabetial Listing
Key:
MAND. MAIL
= the indicated medication must be ordered through CFI Mail Order.
STP = the indicated medication is subject to the Step Therapy Program:use 1st line agents (or
generics) first
FER = the indicated medication is indicated for the treatment of infertility. SPBM = the indicated medication is only available through CuraScript after one fill the retail pharmacy.
A 90-day (or 3 cycle) lifetime limit applies for all Fertility medications.
All prescriptions dispensed by CuraScript will be for a 30-day supply. PA = the indicated medication requires prior approval
* = this symbol next to a drug signifies that it is subject to non-
formulary status when a generic equivalent is available
Formulary Status:
F
= Medication is a formulary drug and will pay at the 1st or 2nd tier copay.
N = Medication is a NOT a formulary drug and will pay at the 3rd tier copay.
Formulary Mandatory
Medication Name
PICA Category
Please be advised that this list is not all-inclusive and does not guarantee coverage.
PICA Drug List - Alphabetial Listing
Key:
MAND. MAIL
= the indicated medication must be ordered through CFI Mail Order.
STP = the indicated medication is subject to the Step Therapy Program:use 1st line agents (or
generics) first
FER = the indicated medication is indicated for the treatment of infertility. SPBM = the indicated medication is only available through CuraScript after one fill the retail pharmacy.
A 90-day (or 3 cycle) lifetime limit applies for all Fertility medications.
All prescriptions dispensed by CuraScript will be for a 30-day supply. PA = the indicated medication requires prior approval
* = this symbol next to a drug signifies that it is subject to non-
formulary status when a generic equivalent is available
Formulary Status:
F
= Medication is a formulary drug and will pay at the 1st or 2nd tier copay.
N = Medication is a NOT a formulary drug and will pay at the 3rd tier copay.
Formulary Mandatory
Medication Name
PICA Category
Please be advised that this list is not all-inclusive and does not guarantee coverage.
PICA Drug List - Alphabetial Listing
Key:
MAND. MAIL
= the indicated medication must be ordered through CFI Mail Order.
STP = the indicated medication is subject to the Step Therapy Program:use 1st line agents (or
generics) first
FER = the indicated medication is indicated for the treatment of infertility. SPBM = the indicated medication is only available through CuraScript after one fill the retail pharmacy.
A 90-day (or 3 cycle) lifetime limit applies for all Fertility medications.
All prescriptions dispensed by CuraScript will be for a 30-day supply. PA = the indicated medication requires prior approval
* = this symbol next to a drug signifies that it is subject to non-
formulary status when a generic equivalent is available
Formulary Status:
F
= Medication is a formulary drug and will pay at the 1st or 2nd tier copay.
N = Medication is a NOT a formulary drug and will pay at the 3rd tier copay.
Formulary Mandatory
Medication Name
PICA Category
Please be advised that this list is not all-inclusive and does not guarantee coverage.
PICA Drug List - Alphabetial Listing
Key:
MAND. MAIL
= the indicated medication must be ordered through CFI Mail Order.
STP = the indicated medication is subject to the Step Therapy Program:use 1st line agents (or
generics) first
FER = the indicated medication is indicated for the treatment of infertility. SPBM = the indicated medication is only available through CuraScript after one fill the retail pharmacy.
A 90-day (or 3 cycle) lifetime limit applies for all Fertility medications.
All prescriptions dispensed by CuraScript will be for a 30-day supply. PA = the indicated medication requires prior approval
* = this symbol next to a drug signifies that it is subject to non-
formulary status when a generic equivalent is available
Formulary Status:
F
= Medication is a formulary drug and will pay at the 1st or 2nd tier copay.
N = Medication is a NOT a formulary drug and will pay at the 3rd tier copay.
Formulary Mandatory
Medication Name
PICA Category
Please be advised that this list is not all-inclusive and does not guarantee coverage.
PICA Drug List - Alphabetial Listing
Key:
MAND. MAIL
= the indicated medication must be ordered through CFI Mail Order.
STP = the indicated medication is subject to the Step Therapy Program:use 1st line agents (or
generics) first
FER = the indicated medication is indicated for the treatment of infertility. SPBM = the indicated medication is only available through CuraScript after one fill the retail pharmacy.
A 90-day (or 3 cycle) lifetime limit applies for all Fertility medications.
All prescriptions dispensed by CuraScript will be for a 30-day supply. PA = the indicated medication requires prior approval
* = this symbol next to a drug signifies that it is subject to non-
formulary status when a generic equivalent is available
Formulary Status:
F
= Medication is a formulary drug and will pay at the 1st or 2nd tier copay.
N = Medication is a NOT a formulary drug and will pay at the 3rd tier copay.
Formulary Mandatory
Medication Name
PICA Category
Please be advised that this list is not all-inclusive and does not guarantee coverage.
PICA Drug List - Alphabetial Listing
Key:
MAND. MAIL
= the indicated medication must be ordered through CFI Mail Order.
STP = the indicated medication is subject to the Step Therapy Program:use 1st line agents (or
generics) first
FER = the indicated medication is indicated for the treatment of infertility. SPBM = the indicated medication is only available through CuraScript after one fill the retail pharmacy.
A 90-day (or 3 cycle) lifetime limit applies for all Fertility medications.
All prescriptions dispensed by CuraScript will be for a 30-day supply. PA = the indicated medication requires prior approval
* = this symbol next to a drug signifies that it is subject to non-
formulary status when a generic equivalent is available
Formulary Status:
F
= Medication is a formulary drug and will pay at the 1st or 2nd tier copay.
N = Medication is a NOT a formulary drug and will pay at the 3rd tier copay.
Formulary Mandatory
Medication Name
PICA Category
Please be advised that this list is not all-inclusive and does not guarantee coverage.
PICA Drug List - Alphabetial Listing
Key:
MAND. MAIL
= the indicated medication must be ordered through CFI Mail Order.
STP = the indicated medication is subject to the Step Therapy Program:use 1st line agents (or
generics) first
FER = the indicated medication is indicated for the treatment of infertility. SPBM = the indicated medication is only available through CuraScript after one fill the retail pharmacy.
A 90-day (or 3 cycle) lifetime limit applies for all Fertility medications.
All prescriptions dispensed by CuraScript will be for a 30-day supply. PA = the indicated medication requires prior approval
* = this symbol next to a drug signifies that it is subject to non-
formulary status when a generic equivalent is available
Formulary Status:
F
= Medication is a formulary drug and will pay at the 1st or 2nd tier copay.
N = Medication is a NOT a formulary drug and will pay at the 3rd tier copay.
Formulary Mandatory
Medication Name
PICA Category
Please be advised that this list is not all-inclusive and does not guarantee coverage.
PICA Drug List - Alphabetial Listing
Key:
MAND. MAIL
= the indicated medication must be ordered through CFI Mail Order.
STP = the indicated medication is subject to the Step Therapy Program:use 1st line agents (or
generics) first
FER = the indicated medication is indicated for the treatment of infertility. SPBM = the indicated medication is only available through CuraScript after one fill the retail pharmacy.
A 90-day (or 3 cycle) lifetime limit applies for all Fertility medications.
All prescriptions dispensed by CuraScript will be for a 30-day supply. PA = the indicated medication requires prior approval
* = this symbol next to a drug signifies that it is subject to non-
formulary status when a generic equivalent is available
Formulary Status:
F
= Medication is a formulary drug and will pay at the 1st or 2nd tier copay.
N = Medication is a NOT a formulary drug and will pay at the 3rd tier copay.
Formulary Mandatory
Medication Name
PICA Category
Please be advised that this list is not all-inclusive and does not guarantee coverage.
PICA Drug List - Alphabetial Listing
Key:
MAND. MAIL
= the indicated medication must be ordered through CFI Mail Order.
STP = the indicated medication is subject to the Step Therapy Program:use 1st line agents (or
generics) first
FER = the indicated medication is indicated for the treatment of infertility. SPBM = the indicated medication is only available through CuraScript after one fill the retail pharmacy.
A 90-day (or 3 cycle) lifetime limit applies for all Fertility medications.
All prescriptions dispensed by CuraScript will be for a 30-day supply. PA = the indicated medication requires prior approval
* = this symbol next to a drug signifies that it is subject to non-
formulary status when a generic equivalent is available
Formulary Status:
F
= Medication is a formulary drug and will pay at the 1st or 2nd tier copay.
N = Medication is a NOT a formulary drug and will pay at the 3rd tier copay.
Formulary Mandatory
Medication Name
PICA Category
Please be advised that this list is not all-inclusive and does not guarantee coverage.
PICA Drug List - Alphabetial Listing
Key:
MAND. MAIL
= the indicated medication must be ordered through CFI Mail Order.
STP = the indicated medication is subject to the Step Therapy Program:use 1st line agents (or
generics) first
FER = the indicated medication is indicated for the treatment of infertility. SPBM = the indicated medication is only available through CuraScript after one fill the retail pharmacy.
A 90-day (or 3 cycle) lifetime limit applies for all Fertility medications.
All prescriptions dispensed by CuraScript will be for a 30-day supply. PA = the indicated medication requires prior approval
* = this symbol next to a drug signifies that it is subject to non-
formulary status when a generic equivalent is available
Formulary Status:
F
= Medication is a formulary drug and will pay at the 1st or 2nd tier copay.
N = Medication is a NOT a formulary drug and will pay at the 3rd tier copay.
Formulary Mandatory
Medication Name
PICA Category
Please be advised that this list is not all-inclusive and does not guarantee coverage.
PICA Drug List - Alphabetial Listing
Key:
MAND. MAIL
= the indicated medication must be ordered through CFI Mail Order.
STP = the indicated medication is subject to the Step Therapy Program:use 1st line agents (or
generics) first
FER = the indicated medication is indicated for the treatment of infertility. SPBM = the indicated medication is only available through CuraScript after one fill the retail pharmacy.
A 90-day (or 3 cycle) lifetime limit applies for all Fertility medications.
All prescriptions dispensed by CuraScript will be for a 30-day supply. PA = the indicated medication requires prior approval
* = this symbol next to a drug signifies that it is subject to non-
formulary status when a generic equivalent is available
Formulary Status:
F
= Medication is a formulary drug and will pay at the 1st or 2nd tier copay.
N = Medication is a NOT a formulary drug and will pay at the 3rd tier copay.
Formulary Mandatory
Medication Name
PICA Category
Please be advised that this list is not all-inclusive and does not guarantee coverage.
PICA Drug List - Alphabetial Listing
Key:
MAND. MAIL
= the indicated medication must be ordered through CFI Mail Order.
STP = the indicated medication is subject to the Step Therapy Program:use 1st line agents (or
generics) first
FER = the indicated medication is indicated for the treatment of infertility. SPBM = the indicated medication is only available through CuraScript after one fill the retail pharmacy.
A 90-day (or 3 cycle) lifetime limit applies for all Fertility medications.
All prescriptions dispensed by CuraScript will be for a 30-day supply. PA = the indicated medication requires prior approval
* = this symbol next to a drug signifies that it is subject to non-
formulary status when a generic equivalent is available
Formulary Status:
F
= Medication is a formulary drug and will pay at the 1st or 2nd tier copay.
N = Medication is a NOT a formulary drug and will pay at the 3rd tier copay.
Formulary Mandatory
Medication Name
PICA Category
Please be advised that this list is not all-inclusive and does not guarantee coverage.
PICA Drug List - Alphabetial Listing
Key:
MAND. MAIL
= the indicated medication must be ordered through CFI Mail Order.
STP = the indicated medication is subject to the Step Therapy Program:use 1st line agents (or
generics) first
FER = the indicated medication is indicated for the treatment of infertility. SPBM = the indicated medication is only available through CuraScript after one fill the retail pharmacy.
A 90-day (or 3 cycle) lifetime limit applies for all Fertility medications.
All prescriptions dispensed by CuraScript will be for a 30-day supply. PA = the indicated medication requires prior approval
* = this symbol next to a drug signifies that it is subject to non-
formulary status when a generic equivalent is available
Formulary Status:
F
= Medication is a formulary drug and will pay at the 1st or 2nd tier copay.
N = Medication is a NOT a formulary drug and will pay at the 3rd tier copay.
Formulary Mandatory
Medication Name
PICA Category
Please be advised that this list is not all-inclusive and does not guarantee coverage.
PICA Drug List - Alphabetial Listing
Key:
MAND. MAIL
= the indicated medication must be ordered through CFI Mail Order.
STP = the indicated medication is subject to the Step Therapy Program:use 1st line agents (or
generics) first
FER = the indicated medication is indicated for the treatment of infertility. SPBM = the indicated medication is only available through CuraScript after one fill the retail pharmacy.
A 90-day (or 3 cycle) lifetime limit applies for all Fertility medications.
All prescriptions dispensed by CuraScript will be for a 30-day supply. PA = the indicated medication requires prior approval
* = this symbol next to a drug signifies that it is subject to non-
formulary status when a generic equivalent is available
Formulary Status:
F
= Medication is a formulary drug and will pay at the 1st or 2nd tier copay.
N = Medication is a NOT a formulary drug and will pay at the 3rd tier copay.
Formulary Mandatory
Medication Name
PICA Category
Please be advised that this list is not all-inclusive and does not guarantee coverage.
PICA Drug List - Alphabetial Listing
Key:
MAND. MAIL
= the indicated medication must be ordered through CFI Mail Order.
STP = the indicated medication is subject to the Step Therapy Program:use 1st line agents (or
generics) first
FER = the indicated medication is indicated for the treatment of infertility. SPBM = the indicated medication is only available through CuraScript after one fill the retail pharmacy.
A 90-day (or 3 cycle) lifetime limit applies for all Fertility medications.
All prescriptions dispensed by CuraScript will be for a 30-day supply. PA = the indicated medication requires prior approval
* = this symbol next to a drug signifies that it is subject to non-
formulary status when a generic equivalent is available
Formulary Status:
F
= Medication is a formulary drug and will pay at the 1st or 2nd tier copay.
N = Medication is a NOT a formulary drug and will pay at the 3rd tier copay.
Formulary Mandatory
Medication Name
PICA Category
Please be advised that this list is not all-inclusive and does not guarantee coverage.
PICA Drug List - Alphabetial Listing
Key:
MAND. MAIL
= the indicated medication must be ordered through CFI Mail Order.
STP = the indicated medication is subject to the Step Therapy Program:use 1st line agents (or
generics) first
FER = the indicated medication is indicated for the treatment of infertility. SPBM = the indicated medication is only available through CuraScript after one fill the retail pharmacy.
A 90-day (or 3 cycle) lifetime limit applies for all Fertility medications.
All prescriptions dispensed by CuraScript will be for a 30-day supply. PA = the indicated medication requires prior approval
* = this symbol next to a drug signifies that it is subject to non-
formulary status when a generic equivalent is available
Formulary Status:
F
= Medication is a formulary drug and will pay at the 1st or 2nd tier copay.
N = Medication is a NOT a formulary drug and will pay at the 3rd tier copay.
Formulary Mandatory
Medication Name
PICA Category
Please be advised that this list is not all-inclusive and does not guarantee coverage.

Source: http://www.osaunion.org/member/picadruglist.pdf

Microsoft word - retreat brochure 08.doc

Dosage____________________________________________________ Name of medication______________________________________ Dosage____________________________________________________ Name of medication______________________________________ I give permission for the following medicatio Only as needed for__________________________________ _________________ times a day start

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