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The following is a list of commonly prescribed drugs covered under the EmblemHealth pharmacy program. To
obtain the complete formulary, please visit www.emblemhealth.com. The list is not all inclusive and does not
guarantee coverage. We encourage you to ask your doctor to prescribe generic drugs whenever appropriate.
PLEASE NOTE: Drugs listed on this document may become non-Preferred if a generic equivalent product
becomes available during the year*. Not all the drugs listed are covered by all pharmacy benefit programs.
Check your benefit materials for the specific drugs covered, the copay and any other subscriber responsibilities
2010 Pharmacy Services
under your pharmacy benefit program. For specific questions about your coverage, please call the phone Formulary Summary
Examples of Non-Preferred Medications with their Preferred Alternatives
The following is a list of some non-Preferred brand medications with examples of Preferred alternatives that are on the formulary. Column 1 lists examples of non-Preferred medications.
Column 2 lists some alternatives that can be prescribed. Thank you for your compliance.
Non-Preferred
Preferred Alternative
Non-Preferred
Preferred Alternative
benazepril, enalapril, lisinopril, ramipril benazepril, enalapril, lisinopril, ramipril citalopram, fluxotine (daily), paroxetine Brand name drugs are listed in CAPITAL letters.
Generic drugs are listed in lower case letters.
* all brand drugs will convert to non-Preferred status when generic is available throughout the year.
The symbol [inj] next to a drug indicates that the drug is available in injectable form only.
The symbol [PA] next to a drug stands for Prior Authorization, which is needed prior to coverage of this drug, plan dependent.
The symbol [ST] next to a drug name stands for Step Therapy which is in place on this drug, plan dependent.
The symbol [DQ] next to a drug stands for Drug Quantity, which is a limitation on amount dispensed.
For the member: Generic medications contain the same active ingredients as their corresponding brand name medications, although they may look different in color or shape. They have been FDA-
approved under strict standards.
For the physician: Please prescribe preferred products and allow generic substitutions when medically appropriate.
THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2010 THROUGH DECEMBER 31, 2010. THIS LIST IS SUBJECT TO CHANGE.
You can get more information and updates to this document at the HIP Website at www.hipusa.com. [EMBLEM Website at www.emblemhealth.com].
Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies.

Source: http://www.caiinsurancesolutions.com/uploads/documents/EH_FRM_007809_2010%20DrugFormulary_Final.pdf

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