Microsoft word - 2013 formulary table of contents.doc

PARTICIPATING NETWORK PHARMACY PROVIDERS…………………………….….………. i DIABETIC SUPPLIES………………………………………………………………………………. i SMOKING CESSATION.……………………………………………………………………………… i MAIL ORDER ……………….…………………………………………………………………………. OVER-THE-COUNTER (OTC) MEDICATIONS…………………………………….….…………. i LIFESTYLE MEDICATIONS………………………………………………………….……………… i SPECIALTY PHARMACEUTICALS………….…………………………………….………………. i CARE-ADVANTAGE…………………………………………………………………………………… i ADVANTAGE STEP THERAPY REQUIREMENTS………………………………………………… ii ADVANTAGE QUANTITY LIMITS……………………………………………………………………. ADVANTAGE PRESCRIPTION DRUG LIST…………….…………………………………………. ADVANTAGE 3-TIER FORMULARY
The information provided in this document pertains to your OVER-THE-COUNTER MEDICATIONS
Prescription Benefit Plan. ADVANTAGE Health Solutions, Inc. ADVANTAGE covers certain over-the-counter (OTC) uses this formulary to assist prescribers in managing your medications as part of their Prescription Benefit Plan. OTC prescriptions and cost. Please take a copy of this formulary to items listed on the formulary are covered, however, in order your physician so he/she can make an informed decision to be covered; they must be prescribed by your physician and regarding your prescription needs. You can link to this obtained from a participating pharmacy or our contracted mail formulary by logging on to www.advantageplan.com as a order pharmacy. Covered OTC items will be designated as member. The formulary & quantity limitation listing are
“OTC” on the attached list.
subject to change.
LIFESTYLE MEDICATIONS
Please note that this list contains the Tier 1, 2, and 3 drugs.
Any brand name drug not shown on this list should be
Lifestyle medications (noted as “LS”) are medications not
considered a Tier 3 (a non-preferred drug and subject to
routinely covered by your Plan. As an ADVANTAGE member the non-preferred copay). For all brand name drugs, if the
you may receive a discount on purchases of these generic is available and you choose the brand name drug, you medications. Examples of lifestyle drugs include, but are not will be responsible for both the applicable copay PLUS the cost limited to Caverject, Cialis, Levitra, Muse, Viagra, Xenical. For difference between the original brand name drug and the safety reasons, some lifestyle drugs may have quantity limits. generic alternative. If no generic is available, you will only be responsible for the applicable copay; however, your copay will SPECIALTY PHARMACEUTICALS
This section applies if your benefit includes specialty pharmacy coverage. Specialty medications are those oral Certain medications may require prior approval and are noted and injectable medications that typically require significant on the attached list with “PA”. Some drugs have quantity limits
education, training, special injection services, or must be and are listed with “QL”. Some non-preferred drugs that are
administered in your physician’s office or may be available not listed may also have quantity limits.
from only a few pharmacies in the country. Copayment/coinsurance for specialty agents apply regardless INCLUSION ON LIST DOES NOT GUARANTEE COVERAGE
of where the medication is obtained. Drugs subject to Your Prescription Benefit Plan does not cover all drugs. Even Specialty Copayment will be designated as "SP" in on the
though a medication may be listed on this formulary, that is not attached list. The codes listed (i.e. J1438) for some of these a guarantee that it is a covered medication under your specific employer sponsored plan. Some plans and employers may exclude some listed medications, however, the item is included Care-ADVANTAGE
for those plans which do offer coverage for that specific Care-ADVANTAGE is a program developed by ADVANTAGE to help you manage long-term health problems; often called “chronic” conditions or illnesses. When you join Care- PARTICIPATING NETWORK PHARMACY PROVIDERS
ADVANTAGE you may be eligible for reduced prescription The following national chains participate in the ADVANTAGE copays on medicines you take for your chronic health Pharmacy Provider Network. In addition, many local problem(s) through the ADVANTAGE prescription mail order independent retailers participate, as well as Orchard program. Eligible medications are noted on the attached list Pharmaceutical Services, our contracted Mail Order pharmacy. with a “CA” and are subject to change.
CHEMOTHERAPY DRUGS
Certain medications are used as chemotherapy drugs and those drugs are noted on the attached list with a “CH”.
PREFERRED ALTERNATIVES
SMOKING CESSATION
As part of ADVANTAGE’s commitment to helping our members ADVANTAGE covers the following smoking cessation drugs: and clients utilize the tools of the benefits they choose, we • buproban (generic for ZYBAN®) – Generic Tier have listed preferred alternatives for the most commonly • CHANTIX (varenicline) – Brand Non-Preferred Tier prescribed and utilized Brand Non-Preferred agents. This is • ZYBAN (bupropion) – Brand Non-Preferred Tier intended to assist members in working with their physicians to • NICOTROL NASAL SPRAY - Brand Non-Preferred Tier choose alternative drug therapies when they are using a Brand Members receiving CHANTIX may utilize www.GETQUIT.com for Please note that inclusion on the listing does not eliminate the need for required generic substitution, or Step Therapy MAIL ORDER IS AVAILABLE
You may save as much as one copay by using the mail order for maintenance medications. If you have a flat dollar copay,
It is important to note that the alternatives in some cases are you normally pay 2-times the retail pharmacy copay for a 3 not generic drugs, but rather, other brand name agents often month (90 day) supply (saving the 3rd copay). If you have a used to treat the same or similar condition. Remember, percentage copay, you will pay the same percentage. For
changing your medications at any time should only be done prescription refills by telephone, the mail order pharmacy can be reached at 866.909.5170. Mail order also offers online services and you can visit their website at www.orchardrx.com 24 hours a day. Use of the mail order pharmacy is not a
guarantee of savings.
i Effective 1/1/2013, Revised 11/13/12 (3-Tier) For specific questions about your pharmacy benefits you may call ADVANTAGE Member Services at 800.553.8933 or visit us on the web at www.advantageplan.com. ADVANTAGE STEP THERAPY REQUIREMENTS
For some conditions, your doctor will need to prescribe one medication before trying another–to use “Drug A” before trying “Drug B”. Step Therapy is a program that encourages the use of safe and effective first-line medications.
First-line drugs are well established and known to be both safe and effective. These drugs are preferred therapy for most people. Clinical committees select first-line and second-line drugs after careful review of medical literature,
manufacturer product information, and consultation with medical professionals. These steps are taken to ensure that protocols reflect current and appropriate drug therapy recommendations. Medications that have a Step Therapy
requirement are noted on the attached list with an “ST”. Please note not all medications requiring Step Therapy are included on this listing, and physician-provided samples will not satisfy a step therapy requirement.
If you are a new member or just enrolling with ADVANTAGE and are currently taking or have taken one of the second line medications listed below within the past six months, please ask for a “Step Therapy Plan Exception
Request Form”. Have your physician or pharmacist complete the form and fax it to the fax number listed on the form.
ANGIOTENSIN-2 INHIBITORS (A-2)
LEUKOTRIENE MODIFIERS (LTM)
First Line Medications
Second Line Medications
First Line Medications
Second Line Medications
(ACE / ACE COMBO)
(ARB / ARB COMBO)
(NON-STEROIDAL ANTIHISTAMINE/NASAL
(LEUKOTRIENE MODIFIERS)
CORTICOSTEROIDS OR DX OF
ASTHMA/COPD)
albuterol/ipratropium bromide (COMBIVENT) albuterol/ipratropium bromide (DUONEB) zileutin lisinopril/HCTZ(PRINZIDE, ZESTORETIC) eprosartan PROTON PUMP INHIBITORS (PPI)
(Some plans do not cover PPI’s)
First Line Medications
Second Line Medications
(OTC & GENERIC RX PPI’S)
(BRAND RX PPI’S)
lansoprazole (OTC on a prescription or Rx Generic) omeprazole (OTC on a prescription or Rx Generic) COX-2 INHIBITORS (COX-2)
First Line Medications
Second Line Medications
(GENERIC NSAIDS / GENERIC COX-1)
**Must be on a written prescription**
SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRI)
* CELEBREX may be used first line if patient is First Line Medications
Second Line Medications
taking warfarin, any Proton Pump Inhibitor, or (GENERIC SSRI’S)
(BRAND SSRI’S)
fluoxetine (PROZAC, PROZAC WEEKLY-BRAND) AGENTS FOR DIABETIC NEUROPATHIC PAIN (SNRI)
Insulin or other Injectable Anti-Diabetic Agent SELECTIVE NOREPINEPHRINE REUPTAKE INHIBITORS (SNRI)
ANTILIPIDEMIC DRUGS
First Line Medications
Second Line Medications
venlafaxine (ir, sr, or xr) (EFFEXOR or EFFEXOR XR) ii For specific questions about your pharmacy benefits you may call ADVANTAGE Member Services at 800.553.8933 or visit us on the web at www.advantageplan.com. Updated 01/03/13 2013 ADVANTAGE QUANTITY LIMITS
Brand Drug Name
Generic Drug Name
Retail quantity (30 day fill)
Mail Order Quantity (90 day fill)
ANALGESICS
360 units
IMITREX 4 mg/0.5 ml 6 mg/0.5 ml Injection MAXALT 5 mg, 10 mg , 5 mg MLT, 10 mg MLT tab PERCOCET 10/650 mg tab oxycodone/acetaminophen SUMAVEL 4 mg/0.5 ml 6 mg/0.5 ml Injection ZOMIG 2.5 mg, 2.5 mg ZMT, 5 mg, 5 mg ZMT Tabs ANTIBACTERIALS
ANTI-VERTIGO AND ANTI-EMETIC AGENTS
BIOPHOSPHONATES
SMOKING CESSATION DRUGS
120 days of total therapy across all smoking iii For specific questions about your pharmacy benefits you may call ADVANTAGE Member Services at 800.553.8933 or visit us on the web at www.advantageplan.com. Updated 01/03/13 2013 ADVANTAGE QUANTITY LIMITS
Brand Drug Name
Generic Drug Name
Retail quantity (30 day fill)
Mail Order Quantity (90 day fill)
BRONCHIODILATORS AND RELATED AGENTS
DRUGS AND VITAMINS AFFECTING COAGULATION
Knee–12 days; Hip–35 days; other DX 30 tabs PULMONARY CORTICOSTEROIDS / ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS
FLOVENT HFA 110 mcg, 220 mcg inhaler 12 gm FLOVENT ROTADISK 50 mcg, 100 mcg, 250 mcg MISCELLANEOUS
MAXIMUM PER YEAR
LIFESTYLE DRUGS (Not covered ; Eligible for discount only)
CAVERJECT
iv For specific questions about your pharmacy benefits you may call ADVANTAGE Member Services at 800.553.8933 or visit us on the web at www.advantageplan.com. Updated 01/03/13 Brand Name medications are listed in ALL CAPS. Generic medications are listed in lower case. Generic drugs are listed with the brand name drug directly after them.
Drug Name
Preferred Alternatives/Comments
FreeStyle or Bayer products are preferred alternatives FreeStyle or Bayer products are preferred alternatives FreeStyle or Bayer products are preferred alternatives FreeStyle or Bayer products are preferred alternatives FreeStyle or Bayer products are preferred alternatives FreeStyle or Bayer products are preferred alternatives FreeStyle or Bayer products are preferred alternatives acetaminophen/butalbital (AXOCET/PHRENILINE/FORTE) acetaminophen/caffeine/butalbital (FIORCET /ESGIC/ZEBUTAL/PLUS) acetaminophen/caffeine/butalbital/codeine (FIORCET/CODEINE) acetaminophen/isometheptene/dichloralphenazone (MIDRIN) acetic acid/aluminum acetate (BOROFAIR OTIC) acetic acid/aluminum acetate (DOMEBORO OTIC) Must fail 60-day trial of OTC PPI or generic Rx PPI on written prescription Will only be approved for DX: Cancer Pain Amphetamine, methylphenidate are preferred alternatives ADVAIR Disc/ADVAIR HFA (salmeterol/fluticasone) ADVATE (antihemophilic factor recombinant) Lovastatin plus niacin is a preferred alternative FLOVENT, PULMICORT are preferred alternatives Aspirin/dipyridamole is a preferred alternative ALLEGRA-D OTC (fexofenadine/pseudoephedrine) CLIMARA, VIVELLE, MENOSTAR, ESTRADERM are preferred alternatives ALPHANATE (factor viii, human plasma deriv) Generic mupirocin is a preferred alternative Lovastatin plus niacin is a preferred alternative Sumatriptan, RELPAX, ZOMIG are preferred alternatives amiloride/hydrochlorothiazide (MODURETIC) amitriptyline hcl/perphenazine (ETRAFONE/FORTE) amitriptyline/chlordiazepixide (LIMBITROL) SP=Specialty PA=Prior Auth ST=Step Therapy MD=Medical CH=Chemo OTC=Over-The-Counter QL=Quantity Limit CA=Care-ADVANTAGE Brand Name medications are listed in ALL CAPS. Generic medications are listed in lower case. Generic drugs are listed with the brand name drug directly after them.
Drug Name
Preferred Alternatives/Comments
amoxicillin & k clavulanate (AUGMENTIN) amoxicillin & k clavulanate susp (AUGMENTIN SUSP) Must fail ACE or ACE/Diuretic Combo; Preferred alternative-losartan ANDRODERM (testosterone transdermal patch) ARALAST NP (alpha-1 proteinase inhibitor) Must use generic or pay DAW penalty; PA if used continuously for more than 14 days ASMANEX TWISTHALER (mometasone inhalation) aspirin/caffeine/butalbital/codeine (FIORINAL/CODEINE) Acetaminophen/caffeine/butalbital/codeine (FIORCET/CODEINE) is a preferred alternative Must fail ACE or ACE/Diuretic Combo; losartan, BENICAR, DIOVAN, MICARDIS are preferred alternatives ATACAND HCT (candesartan/ hydrochlorothiazide) Must fail ACE or ACE/Diuretic Combo; losartan hctz, BENICAR HCT, DIOVAN HCT, MICARDIS HCT preferred atenolol/hydrochlorothiazide (TENORETIC) ATGAM (lymphocyte immune globulin anti-thymocyte G) ATRIPLA (emtricitabine/tenofovir/efavirenz) J3490; Must try and fail interferon or COPAXONE first.
AVALIDE (irbesartan/ hydrochlorothiazide) Must fail ACE or ACE/Diuretic Combo; losartan, BENICAR, DIOVAN, MICARDIS are preferred alternatives Must fail ACE or ACE/Diuretic Combo; losartan, BENICAR, DIOVAN, MICARDIS are preferred alternatives Ciprofloxacin is a preferred alternative Oxycodone er or fentanyl patch are preferred alternatives J1826 & Q3025; Must try and fail interferon or COPAXONE first.
Sumatriptan, RELPAX, ZOMIG are preferred alternatives ANDRODERM, ANDROGEL are preferred alternatives Must fail ACE or ACE/Diuretic Combo; losartan, BENICAR, DIOVAN, MICARDIS are preferred alternatives SP=Specialty PA=Prior Auth ST=Step Therapy MD=Medical CH=Chemo OTC=Over-The-Counter QL=Quantity Limit CA=Care-ADVANTAGE Brand Name medications are listed in ALL CAPS. Generic medications are listed in lower case. Generic drugs are listed with the brand name drug directly after them.
Drug Name
Preferred Alternatives/Comments
Fluticasone, NASONEX, NASACORT AQ are preferred alternatives benazepril/ hydrochlorothiazide (LOTENSIN HCT) Must fail ACE or ACE/Diuretic Combo; Preferred alternative-losartan BENICAR HCT (olmesartan/ hydrochlorothiazide) Must fail ACE or ACE/Diuretic Combo; Preferred alternative-losartan hctz benzoyl peroxide - erythromycin gel (BENZAMYCIN) betamethasone/propylene glycol (DIPROLENE AF) betamethasone/propylene glycol (DIPROLENE) J1830; Must try and fail interferon or COPAXONE first.
both ingredients available generically, isosorbide/hydralazine BIOCLATE (antihemophilic factor recombinant) Alendronate, EVISTA are preferred alternatives brompheniramine/phenylephrine (BROMFED/PD) Oxycodone er or fentanyl patch are preferred alternatives captopril/ hydrochlorothiazide (CAPOZIDE) CARAFATE SUSPENSION (sucralfate suspension) SP=Specialty PA=Prior Auth ST=Step Therapy MD=Medical CH=Chemo OTC=Over-The-Counter QL=Quantity Limit CA=Care-ADVANTAGE Brand Name medications are listed in ALL CAPS. Generic medications are listed in lower case. Generic drugs are listed with the brand name drug directly after them.
Drug Name
Preferred Alternatives/Comments
Amlodipine besylate, diltiazem er, verapamil er are preferred alternatives CAVERJECT (alprostadil intracavernous/urethral) Must fail generic NSAID or meloxicam or be taking warfarin, any PPI, or over age 60 PREMARIN, ESTRACE are preferred alternatives Covered when prescribed; $5/30-days or $10/90-days (High Ded plans excluded) FreeStyle or Bayer products are preferred alternatives Ciprofloxacin, VIGAMOX are preferred alternatives chlorpheniramine/methscopolamine/phenylephrine (EXTENDRYL SR/JR/CHEW) cholestyramine/aspartame (QUESTRAN LIGHT) Lifestyle benefit only for Erectile Dysfunction. Not covered for Benign Prostatic Hypertrophy Must fail ENBREL/HUMIRA OR statement of clinical necessity from doctor; J0718 CIPRO HC (ciprofloxacin/hydrocortisone otic) CIPRODEX (ciprofloxacin/dexamethasone otic) citric acid/potassium citrate (POLYCITRA-K) Generic cetirizine, fexofenadine, loratadine, ALAVERT are preferred alternatives Covered when prescribed; $5/30-days or $10/90-days (High Ded plans excluded) CLEOCIN VAGINAL SUPPOSITORY/CREAM (clindamycin phosphate vaginal suppository) Generic clindamycin is a preferred alternative clindamycin phosphate/benzoyl peroxide (BENZACLIN) Generic clobetasol is a preferred alternative SP=Specialty PA=Prior Auth ST=Step Therapy MD=Medical CH=Chemo OTC=Over-The-Counter QL=Quantity Limit CA=Care-ADVANTAGE Brand Name medications are listed in ALL CAPS. Generic medications are listed in lower case. Generic drugs are listed with the brand name drug directly after them.
Drug Name
Preferred Alternatives/Comments
clotrimazole/betamethasone dipropionate (LOTRIMIN) codeine phosphate/acetaminophen (TYLENOL W/CODEINE) codeine/apap/caffeine/butalb (FIORICET W/CODEINE) codeine/asa/caffeine/butalb (FIORINAL W/CODEINE) colchicine & probenecid (COL-BENEMID) COMBIPATCH (estradiol/norethindrone acetate) Amphetamine, methylphenidate are preferred alternatives CORIFACT (factor viii concentrated, human) CORTISPORIN (hydrocortisone/neomycin/polymyxin B) Amlodipine besylate, diltiazem er, verapamil er are preferred alternatives Must fail ACE or ACE/Diuretic Combo; Must use generic losartan or pay DAW penalty Must fail atorvastatin, lovastatin, pravastatin, or simvastatin J8530, J9070, J9080, J9090, J9091, J9092 Must fail generic SNRI or have confirmed DX of Diabetic Neuropathic Pain / Fibromyalgia CYTOGAM (cytomegalovirus immune globulin) DALLERGY (chlorpheniramine/phenylephrine/methscopolamine) Amphetamine, methylphenidate are generic alternatives Must fail 60-day trial of OTC PPI or generic Rx PPI on written prescription SP=Specialty PA=Prior Auth ST=Step Therapy MD=Medical CH=Chemo OTC=Over-The-Counter QL=Quantity Limit CA=Care-ADVANTAGE Brand Name medications are listed in ALL CAPS. Generic medications are listed in lower case. Generic drugs are listed with the brand name drug directly after them.
Drug Name
Preferred Alternatives/Comments
diclofenac ophthalmic solution (VOLTAREN OPHTHALMIC SOLUTION) didanosine delayed release cap (VIDEX EC) Must use generic or pay DAW penalty; Age Restrictions Apply Must fail ACE or ACE/Diuretic Combo; Losartan is a preferred alternative DIOVAN HCT (valsartan/ hydrochlorothiazide) Must fail ACE or ACE/Diuretic Combo; Losartan hctz is a preferred alternative disphenoxylate/atropine sulfate (LOMOTIL) Medical Benefit Only; PA is provided through medical coverage Medical Benefit Only; PA is provided through medical coverage DONNATAL EXTENTAB (belladonna alkaloids/ phenobarbital) DULERA (mometasone/formoterol inhalation) ADVAIR, SYMBICORT are preferred alternatives.
EDEX (alprostadil intercavernous/urethral) enalapril/ hydrochlorothiazide (VASERETIC) PA if used continuously for more than 14 days ergotamine/belladonna/ phenobarbital (BELLERGAL-S) ergotamine/belladonna/phenobarbital (BELLAMINE-S) SP=Specialty PA=Prior Auth ST=Step Therapy MD=Medical CH=Chemo OTC=Over-The-Counter QL=Quantity Limit CA=Care-ADVANTAGE Brand Name medications are listed in ALL CAPS. Generic medications are listed in lower case. Generic drugs are listed with the brand name drug directly after them.
Drug Name
Preferred Alternatives/Comments
ergotamine/caffeine/ belladonna / phenobarbital (BELCOMP-PB) ERWINAZE (asparaginase erwinia chrysanthemi) erythromycin base/benzoyl peroxide (BENZAMYCIN) CLIMARA, VIVELLE, MENOSTAR, ESTRADERM are preferred alternatives ESTRACE VAGINAL CREAM (estradiol vaginal cream) estradiol & norethindrone acetate (ACTIVELLA) Estradiol/methyltestosterone, PREMARIN/ESTRACE are preferred alternatives ESTRATEST/HS (esterified estrogens and methyltestosterone) Estradiol/methyltestosterone, PREMARIN/ESTRACE are preferred alternatives ethinyl estradiol-ethynodiol diacetate (DEMULEN) ethinyl estradiol-levonorgestrel (ALESSE) ethinyl estradiol-levonorgestrel (NORDETTE) ethinyl estradiol-levonorgestrel (TRIPHASIL) Must fail ACE or ACE/Diuretic Combo; Preferred alternative-losartan EXFORGE HCT (amlodipine/valsartan/ hydrochlorothiazide) Must fail ACE or ACE/Diuretic Combo; Preferred alternative-losartan hctz J1830; Must try and fail interferon or COPAXONE first.
FreeStyle or Bayer products are preferred alternatives FEIBA VH (anti-inhibitor coagulant complex, vapor heated) FEMCON FE (norethindrone/ethinyl estradiol) SP=Specialty PA=Prior Auth ST=Step Therapy MD=Medical CH=Chemo OTC=Over-The-Counter QL=Quantity Limit CA=Care-ADVANTAGE Brand Name medications are listed in ALL CAPS. Generic medications are listed in lower case. Generic drugs are listed with the brand name drug directly after them.
Drug Name
Preferred Alternatives/Comments
FLOVENT ROTADISK (fluticasone inhalation) FLOVENT/FLOVENT HFA (fluticasone inhalation) PA if used continuously for more than 14 days ANDRODERM, ANDROGEL are preferred alternatives fosinopril/hydrochlorothiazide (MONOPRIL HCT) PA if used continuously for more than 14 days Sumatriptan, RELPAX, ZOMIG are preferred alternatives GAMMAR-PIV (immune globulin (IgIV) [human]) GENOTROPIN (somatropin, E. Coli derived) J3490, J8499; Must try and fail interferon or COPAXONE first.
GLASSIA (alpha-1 proteinase inhibitor human) GOLYTELY (polyethylene glycol bowel prep) Covered only for DX: Postherpetic Neuralgia griseofulvin microsize susp (GRIFULVIN SUSP) guaifenesin / phenylpropanolamine (ENTEX PSE) guaifenesin / pseudoephedrine (GUAIBID D) guaifenesin / pseudoephedrine (GUAIMAX -D) guaifenesin/hydromorphone (DILAUDID COUGH SYRUP) SP=Specialty PA=Prior Auth ST=Step Therapy MD=Medical CH=Chemo OTC=Over-The-Counter QL=Quantity Limit CA=Care-ADVANTAGE Brand Name medications are listed in ALL CAPS. Generic medications are listed in lower case. Generic drugs are listed with the brand name drug directly after them.
Drug Name
Preferred Alternatives/Comments
Medical Benefit Only; PA is provided through medical coverage; J9179 HALFLYTELY (electrolyte solution/polyethylene glycol/bisacodyl) HELIDAC (bismuth subsalicylate/metronidazole/tetracycline) Generic bismuth,metronidazole, tetracycline are preferred alternatives HELIXATE FS (antihemophilic factor VIII, recombinant) HEMOFIL (antihemophilic factor VIII, human) HUMATE-P (antihemophilic factor VII/von Willebrand factor complex, human) HUMATROPE (somatropin, E. Coli derived) HUMULIN PRODUCTS (insulin human isophane(NPH)/insulin regular human) hydralazine/ hydrochlorothiazide (APRESAZIDE) Hydrocodone bitartrate/homatropine (HYCODAN) hydrocodone bitartrate/ibuprofen (VICOPROFEN) hydrocortisone /pramoxine/chloroxylenol lotion (CORTANE B LOT) hydrocortisone acetate w/pramoxine cr (ANALPRAM-HC) HYPERRHO (rho D immune globulin (human) (IM) Must fail ACE or ACE/Diuretic Combo; Must use generic losartan/hctz Must use generic propranolol la or pay DAW penalty Must fail PEGASYS/PEG-INTRON OR statement of clinical necessity from doctor; J9212; CONSIDERED SP WHEN DX IS HEPATITIS PA if used continuously for more than 14 days Must fail PEGASYS/PEG-INTRON OR statement of clinical necessity from doctor; J9214; CONSIDERED SP WHEN DX IS HEPATITIS Prefer generic guanfacine at generic copayment SP=Specialty PA=Prior Auth ST=Step Therapy MD=Medical CH=Chemo OTC=Over-The-Counter QL=Quantity Limit CA=Care-ADVANTAGE Brand Name medications are listed in ALL CAPS. Generic medications are listed in lower case. Generic drugs are listed with the brand name drug directly after them.
Drug Name
Preferred Alternatives/Comments
Must fail 60-day trial of OTC PPI or generic Rx PPI on written prescription Azithromycin, cephalexin, erythromcyin are preferred alternatives ketotifen fumarate ophthalmic solution (ZADITOR) Must fail ENBREL/HUMIRA OR statement of clinical necessity from doctor; J3590 K-LYTE DS (potassium bicarbonate/potassium citrate) KLOR-CON/KLOR-CON M TABLET (potassium chloride xr) KOGENATE FS (antihemophilic factor recombinant) KRONOFED-A (chlorpheniramine/pseudoephedrine) KRONOFED-A JR (chlorpheniramine/pseudoephedrine) Covered when prescribed; $5/30-days or $10/90-days (High Ded plans excluded) LANTUS/LANTUS SOLOSTAR (insulin glargine) LATISSE (bimatoprost ophthalmic solution) OTC cetirizine is covered @ $5/30-days or $10/90-days (High Ded plans excluded) levonorgestrel & ethinyl estradiol (LEVLEN/LEVLITE) levonorgestrel & ethinyl estradiol (SEASONALE) levonorgestrel-ethin estradiol (TRI-LEVLEN) SP=Specialty PA=Prior Auth ST=Step Therapy MD=Medical CH=Chemo OTC=Over-The-Counter QL=Quantity Limit CA=Care-ADVANTAGE Brand Name medications are listed in ALL CAPS. Generic medications are listed in lower case. Generic drugs are listed with the brand name drug directly after them.
Drug Name
Preferred Alternatives/Comments
lisinopril/ hydrochlorothiazide (PRINZIDE) lisinopril/ hydrochlorothiazide (ZESTORETIC) LOCOID Cream/Ointment/Solution (hydrocortisone) LOESTRIN (norethindrone/ethyinyl estradiol) Covered when prescribed; $5/30-days or $10/90-days (High Ded plans excluded) LORTAB ELIXIR (hydrocodone bitartrate/ acetaminophen) LOSEASONIQUE (ethinyl estradiol/levonorgestrel) Must use generic enoxaparin sod or pay DAW penalty; PA if used continuously for more than 14 days Zaleplon, zolpidem are preferred alternatives Medical Benefit Only; PA is provided through medical coverage; J9217, J9218, J1950 LYBREL (ethinyl estradiol/levonorgestrel) MACROBID (nitrofurantoin monohydrate/nitrofurantoin macrocrystals) Medical Benefit Only; PA is provided through medical coverage PROAIR HFA or VENTOLIN HFA are preferred alternatives Ciprofloxacin is a preferred alternative MEGACE ES SUSP (megestrol oral suspension) Medical Benefit Only; PA is provided through medical coverage; J9209 Amphetamine, methylphenidate are preferred alternatives Medical Benefit Only; PA is provided through medical coverage; J9250 & J9260 methyldopa/ hydrochlorothiazide (ALDORIL) Some strengths available as generic; Must use generic if available or pay DAW penalty SP=Specialty PA=Prior Auth ST=Step Therapy MD=Medical CH=Chemo OTC=Over-The-Counter QL=Quantity Limit CA=Care-ADVANTAGE Brand Name medications are listed in ALL CAPS. Generic medications are listed in lower case. Generic drugs are listed with the brand name drug directly after them.
Drug Name
Preferred Alternatives/Comments
Some strengths available as generic; Must use generic if available or pay DAW penalty MICARDIS HCT (telmisartan/ hydrochlorothiazide) moexipril/ hydrochlorothiazide (UNIRETIC) Some strengths available as generic; Must use generic if availabe or pay DAW penalty MONARC-M (antihemophilic factor VIII, human) MONOCLATE-P (antihemophilic factor VII, human, pasteurized) Must fail non-sedating antihistamine/nasal corticosteroids or DX of asthma or COPD MOVIPREP (polyethylene glycol/electrolytes) Naproxen, nabumetone, ibuprofen, generic NSAIDS are preferred alternatives NATAZIA (dienogestrel/estradiol valerate) neomycin sulfate/polymyxin/hydrocortisone (CORTISPORIN) neomycin/bacitracin/polymyxin (NEOSPORIN) neomycin/polymyxin B/hydrocortisone (PEDIOTIC) neomycin/polymyxin/dexamethasone (DEXACIDIN) neomycin/polymyxin/dexamethasone (MAXITROL) Must fail 60-day trial of OTC PPI or generic Rx PPI on written prescription NICOTROL NASAL SPRAY (nicotine nasal spray) SP=Specialty PA=Prior Auth ST=Step Therapy MD=Medical CH=Chemo OTC=Over-The-Counter QL=Quantity Limit CA=Care-ADVANTAGE Brand Name medications are listed in ALL CAPS. Generic medications are listed in lower case. Generic drugs are listed with the brand name drug directly after them.
Drug Name
Preferred Alternatives/Comments
nifedipine extended-release (ADALAT CC, PROCARDIA XL) nifedipine extended-release (PROCARDIA XL) nitrofurantoin macrocrystal (MACRODANTIN) NORDIFLEX (somatropin, E. Coli derived) NORDITROPIN (somatropin, E. Coli derived) noreth a-et estra/fe fumarate (LOESTRIN/FE) norgestimate-ethinyl estradiol (ORTHO CYCLEN) norgestimate-ethinyl estradiol (ORTHO TRI-CYCLEN LO) norgestimate-ethinyl estradiol (ORTHO TRI-CYCLEN) norgestimate-ethinyl estradiol fe (ESTROSTEP FE) Ciprofloxacin is a preferred alternative NOVAREL (human chorionic gonadotropin for injection) NOVOLIN 70/30 MIX (insulin human isophane(NPH)/insulin regular human) Medical Benefit Only, Must be EBV seropositive NUTROPIN/NUTROPIN AQ (somatropin, E. Coli derived) NUVARING (ethinyl estradiol/etonogestrel vaginal ring) Covered when prescribed; $5/30-days or $10/90-days (High Ded plans excluded) FreeStyle or Bayer products are preferred alternatives FreeStyle or Bayer products are preferred alternatives FreeStyle or Bayer products are preferred alternatives Must fail ENBREL/HUMIRA OR statement of clinical necessity from doctor; J0129 ORTHO TRI-CYCLEN LO (ethinyl estradiol/norgestimate) ORTHO-EVRA (ethinyl estradiol/norgestimin) PREMPRO, PREMPHASE are preferred alternatives OVCON FE (norethindrone/ethinyl estrardiol) OVIDREL (chorionic gonadotropin alfa, recombinant) SP=Specialty PA=Prior Auth ST=Step Therapy MD=Medical CH=Chemo OTC=Over-The-Counter QL=Quantity Limit CA=Care-ADVANTAGE Brand Name medications are listed in ALL CAPS. Generic medications are listed in lower case. Generic drugs are listed with the brand name drug directly after them.
Drug Name
Preferred Alternatives/Comments
PANGLOBULIN / PANGLOBULIN NF (immune globulin (IgIV) peg 3350-KCl-Sodium Bicarbonate-NaCl (NULYTELY) Ciprofloxacin is a preferred alternative polyethylene glycol bowel prep (GOLYTELY) polymyxin b sulfate/trimethoprim (POLYTRIM) POLY-PRED (prednisolone/neomycin/polymyxin B) Naproxen, nabumetone, ibuprofen, generic NSAIDS are prefered alternatives potassium bicarbonate/ potassium chloride/calcium (K-LYTE CL) PRAMOSONE Cream/Ointment/Lotion (pramoxine/hydrocortisone) PRAMOSONE E Cream (hydrocortisone/pramoxine cream) pramoxine/ hydrocortisone /chloroxylenol aqueous otic (CORTANE B AQ) pramoxine/ hydrocortisone /chloroxylenol otic (CORTANE B OTIC) Lovastatin, pravastatin, simvastatin are preferred alternatives SP=Specialty PA=Prior Auth ST=Step Therapy MD=Medical CH=Chemo OTC=Over-The-Counter QL=Quantity Limit CA=Care-ADVANTAGE Brand Name medications are listed in ALL CAPS. Generic medications are listed in lower case. Generic drugs are listed with the brand name drug directly after them.
Drug Name
Preferred Alternatives/Comments
PRED-G (prednisolone/gentamicin ophthalmic) prednisolone sod phosphate oral soln (ORAPRED) prednisolone sodium phosphate (INFLAMASE/FORTE) PREGNYL (human chorionic gonadotropin for injection) PREMARIN VAGINAL CREAM (conjugated estrogens vaginal cream) PREMPHASE (conjugated estrogens/medroxyprogesterone) PREMPRO (conjugated estrogens/medroxyprogesterone) PREMPRO LOW DOSE (conjugated estrogens/medroxyprogesterone) PREVPAC (amoxicillin/clarithromycin/lansoprazole) Must fail generic SNRI; venlafaxine ir, venlafaxine sr, venlafaxine xr PROFILNINE-SD (factor IX complex solvent treated) PROLASTIN (alpha-1 proteinase inhibitor human) Medical Benefit Only; PA is provided through medical coverage; J9217, J9218, J1950 promethazine/phenylephrine/codeine (PHENERGRAN VC/CODEINE) PROPLEX T (factor IX complex, heat treated) propranolol/ hydrochlorothiazide (INDERIDE) PROAIR HFA or VENTOLIN HFA are preferred alternatives Must fail generic SSRI; citalopram, fluoxetine, fluvoxamine, paroxetine, paroxetine CR, sertraline pseudoephedrine/dextromethorphan HBr (SUDAFED COUGH AND COLD) PULMICORT TURBUHALER/FLEXHALER (budesonide inhalation) Some strengths available as generic; Must use generic if available or pay DAW penalty pyrillamine/phenyltolox/phenir (POLY-HISTINE) quinapril/hydrochlorothiazide (ACCURETIC) J1826, Q3026; Must try and fail interferon or COPAXONE first.
Medical Benefit Only; PA is provided through medical coverage; J3488 RECOMBINATE rAHF (antihemophilic factor recombinant) REFACTO (antihemophilic factor VIII recombinant) SP=Specialty PA=Prior Auth ST=Step Therapy MD=Medical CH=Chemo OTC=Over-The-Counter QL=Quantity Limit CA=Care-ADVANTAGE Brand Name medications are listed in ALL CAPS. Generic medications are listed in lower case. Generic drugs are listed with the brand name drug directly after them.
Drug Name
Preferred Alternatives/Comments
Must fail ENBREL/HUMIRA OR statement of clinical necessity from doctor; J1745 RENACIDIN (citric acid/gluconolactone/magnesium carbonate) REZIRA (hydrocodone bitartrate/pseudoephedrine) Fluticasone, NASONEX, NASACORT AQ are preferred alternatives RIFATER (rifampin/isoniazid/pyrazinamide) J9310; Considered specialty for the DX:Rheumatoid Arthritis; Medical when chemotherapy.
ROWASA (mesalamine rectal suspension enema) SANDOGLOBULIN (immune globulin (IgIV) [human]) Must fail generic SSRI; citalopram, fluoxetine, fluvoxamine, paroxetine, paroxetine CR, sertraline SEASONIQUE (ethinyl estradiol/levonorgestrel) SEREVENT DISKUS (salmeterol xinafoate inhalation powder) Must fail ENBREL/HUMIRA OR statement of clinical necessity from doctor; J3490 Must fail non-sedating antihistamine/nasal corticosteroids or DX of asthma or COPD Alendronate, ACTONEL are preferred alternative sodium citrate & citric acid solution (BICITRA) sodium polystyrene sulfonate (KAYEXELATE) SPIRIVA (tiotropium bromide inhalation powder) spironolactone/ hydrochlorothiazide (ALDACTAZIDE) Oral ketorolac available at generic copayment J3357; Must fail ENBREL/HUMIRA first.
SP=Specialty PA=Prior Auth ST=Step Therapy MD=Medical CH=Chemo OTC=Over-The-Counter QL=Quantity Limit CA=Care-ADVANTAGE Brand Name medications are listed in ALL CAPS. Generic medications are listed in lower case. Generic drugs are listed with the brand name drug directly after them.
Drug Name
Preferred Alternatives/Comments
For DX: Opiate Addiction Only, Not covered for Pain treatment.
sulfacetamide sodium lot (SEBIZON/KLARON) sulfacetamide/prednisolone ac (BLEPHAMIDE) sulfacetamide/sulfur, sublimed (SULFACET-R) sulfamethoxazole/trimethoprim (BACTRIM/BACTRIM DS) sulfamethoxazole/trimethoprim (SEPTRA/DS) Generic sumatriptan injection is a preferred alternative Medical Benefit Only; PA is provided through medical coverage; J9226 SUPREP BOWEL PREP (sodium sulfate, potassium sulfate, magnesium sulfate) FreeStyle or Bayer products are preferred alternatives Must fail generic SSRI; citalopram, fluoxetine, fluvoxamine, paroxetine, paroxetine CR, sertraline SYNALGOS DC (dihydrocodeine/aspirin/caffeine) Medical Benefit Only; PA is provided through medical coverage; J7320 Must fail ACE or ACE/Diuretic Combo; Preferred alternative-losartan Must fail ACE or ACE/Diuretic Combo; Preferred alternative-losartan TEKTURNA HCT (aliskiren/ hydrochlorothiazide) Must fail ACE or ACE/Diuretic Combo; Preferred alternative-losartan hctz ANDRODERM, ANDROGEL are preferred alternatives ANDRODERM, ANDROGEL are preferred alternatives Must fail ACE or ACE/Diuretic Combo; losartan, BENICAR, DIOVAN, MICARDIS are preferred alternatives TEVETEN HCT (eprosartan/ hydrochlorothiazide) Must fail ACE or ACE/Diuretic Combo; losartan hctz, BENICAR HCT, DIOVAN HCT, MICARDIS HCT preferred THYROGEN (thyrotropin alfa for injection) SP=Specialty PA=Prior Auth ST=Step Therapy MD=Medical CH=Chemo OTC=Over-The-Counter QL=Quantity Limit CA=Care-ADVANTAGE Brand Name medications are listed in ALL CAPS. Generic medications are listed in lower case. Generic drugs are listed with the brand name drug directly after them.
Drug Name
Preferred Alternatives/Comments
FreeStyle or Bayer products are preferred alternatives JANUVIA, JANUMET, ONGLYZA, KOMBIGLYZE are preferred alternatives.
Sumatriptan with naproxen separately is a preferred alternative triamcinolone acetonide (KENALOG W/ORABASE) TRI-K (potassium acetate/potassium bicarbonate/potassium citrate) TRINESSA (ethinyl estradiol/norgestimate) TRI-NORINYL (ethinyl estradiol/norethindrone) TRIPLE SULFA CREAM (sulfathiazole/sulfacetamide/sulfabenzamide) TRIZIVIR (abacavir/lamivudine/zidovudine) Betaxolol, brimonidine, carteolol are preferred alternatives J2323; Must try and fail interferon or COPAXONE first. Limited Distribution URO-KP-NEUTRAL (potassium phosphate/sodium phosphate) Must use generic alfuzosin or pay DAW penalty VANCENASE AQ/DS (beclomethasone intranasal) Fluticasone, NASONEX, NASACORT AQ are preferred alternatives Metronidazole is a preferred alternative Generic fluocinonide is a preferred alternative Clindamycin and tretinoin separately, available generically SP=Specialty PA=Prior Auth ST=Step Therapy MD=Medical CH=Chemo OTC=Over-The-Counter QL=Quantity Limit CA=Care-ADVANTAGE Brand Name medications are listed in ALL CAPS. Generic medications are listed in lower case. Generic drugs are listed with the brand name drug directly after them.
Drug Name
Preferred Alternatives/Comments
VERAMYST (fluticasone furoate intranasal) Must fail generic SSRI; citalopram, fluoxetine, fluvoxamine, paroxetine, paroxetine CR, sertraline VISICOL (sodium phosphate dibasic/sodium phosphate monobasic) VOLTAREN OPHTHALMIC SOLUTION (diclofenac ophthalmic) Consider statin (i.e. atorvastatin, simvastatin) agent as alternative Amphetamine, methylphenidate are preferred alternatives WILATE (antihemophilic factor VII/von Willebrand factor, human) XERESE (acyclovir/hydrocortisone topical) Medical Benefit Only; PA is provided through medical coverage XYLOCAINE ORAL SPRAY (lidocaine oral spray) XYNTHA (antihemophilic factor VII, recombinant, plasma/albumin free) Medical Benefit Only; PA is provided through medical coverage Must fail non-sedating antihistamine/nasal corticosteroids or DX of asthma or COPD Must fail 60-day trial of OTC PPI or generic Rx PPI on written prescription ZEMAIRA (alpha-1 proteinase inhibitor human) Consider statin (i.e. atorvastatin, simvastatin) agent as alternative Medical Benefit Only; PA is provided through medical coverage ZOMIG ZMT (zolmitriptan orally disintegrating tablets) ZUTRIPRO (chlorpheniramine maleate; hydrocodone bitartrate; pseudoephedrine hcl) Must fail non-sedating antihistamine/nasal corticosteroids or DX of asthma or COPD ZYLET OPHTHALMIC (tobramycin/loteprednol) Ciprofloxacin, VIGAMOX are preferred alternatives Ciprofloxacin, VIGAMOX are preferred alternatives Covered when prescribed; $5/30-days or $10/90-days (High Ded plans excluded) SP=Specialty PA=Prior Auth ST=Step Therapy MD=Medical CH=Chemo OTC=Over-The-Counter QL=Quantity Limit CA=Care-ADVANTAGE

Source: http://www2.advantageplan.com/pdfs/threetierformulary.pdf