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Introduction

DRUGS FOR INFECTIONS
Drugs for Malaria. . . . . . . . . . . . . . . . . . . . . . . . . .
PROGESTINS -----------------------------------------------
ANTIBIOTICS-------------------------------------------------
Crinone (PA), Endometrin(PA), Makena(PA) Penicillins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ampicillin, amoxicillin, cloxacillin, dicloxacillin, Drugs for Parasites. . . . . . . . . . . . . . . . . . . . . . . . . .
MISCELLANEOUS OB/GYN DRUGS-----------------------
amoxicllin w/ potassium clavulanate, penicillin Cephalosporins. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Bravelle (PA), Follistim(PA), Menopur(PA) 2014 Outcomes Drug Formulary
cefaclor, cefadroxil, cefdinir, cefradine, Neevo, Prefera-OB, Prenate Elite, Prenate and Pharmacy Benefit Guidelines
Miscellaneous Antiinfectives. . . . . . . . . . . . . . . . . . . .
GROWTH HORMONES ---------------------------------------
clindamycin, metronidazole, nitrofurantoin Macrolides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The MedBen Outcomes Drug Formulary
azithromycin, clarithromycin, erythromycin ethyl defines the copayment tier status of the
CONTRACEPTIVES
medicines most commonly prescribed for
ORAL------------------------------------------------------------------
MedBen members. It may not include all
DRUGS FOR CANCER
multiple generic options (ex. Apri, etc.) drugs covered by your prescription drug
Tetracyclines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
benefit. For benefit coverage or
cyclophosphamide, etoposide, exemestane, restrictions please check your benefit plan
Ella, Lybrel, LoSeasonique, Necon 10/11, document(s). This listing is revised from
leucovorin, leuprolide acetate, tretinoin, Quinolones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
time to time as new drugs and new
ciprofloxacin, ciprofloxacin XR, levofloxacin, OTHER CONTRACEPTIVES----------------------------------
prescribing information becomes
available.
PROGESTIN ONLY------------------------------------------------
The coverage tier for each medication has
Aminoglycosides. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hexalen(PA), Hycamtin(PA), Leukeran(PA), been indicated. Members pay a Tier 1
Lysodren(PA). Matulane(PA), Myleran(PA), Sulfonamides. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
copay for most generic drugs and selected
Nexavar(PA), Nilandron(PA), Revlemid(PA), DRUGS FOR DIABETES
sulfisoxazole w erythromycin ethylsuccinate OTC medicines. Members pay a Tier 2
INSULINS --------------------------------------------------------
sulfamethoxazole w trimethoprim (SMX-TMP) Tarceva(PA), Targretin (PA), Tasigna(PA), copay for higher cost generic drugs and
Drugs for Tuberculosis. . . . . . . . . . . . . . . . . . . . . . . . .
Temodar(PA), Teslac(PA), Thioguanine(PA), formulary (“preferred”) brand name drugs.
Members pay a Tier 3 copay for non-
formulary and highest cost brand name
IMMUNOMODULATORS
Drugs for Fungal Infections. . . . . . . . . . . . . . . . . . . . .
fluconazole, itraconazole, ketoconazole, cyclosporine modified, hydroxychloroquine, It is recommended that you have this list of
Novolin R(ST), Novolin 70/30(ST), Novolin medications available when you are with
your physician and a prescription drug is
Drugs For Viral Infections - Influenza & RSV. . . . . .
Arcalyst, Azasan, Cimzia (PA) Rapamune, ORAL & NON INSULIN INJECTABLES--------------------
going to be part of the treatment for a
Revlimid(PA), Simponi(PA), Stelara (PA), Thalomid(PA), Zortress acarbose, glimepiride, glipizide, glipizide XL, clinical condition.
HORMONES
Drugs For Viral Infections - Herpes. . . . . . . . . . . . . . .
Key to Notations:
GLUCOCORTICOIDS ---------------------------------------------
glyburide w/ metformin, glipizide w/ metformin Drugs For Viral Infections - Hepatitis. . . . . . . . . . . . .
PA: Prior authorization to ensure clinical
appropriateness of this or previous
Incivek(PA), Pegasys, Victrelis(PA), Viread ANDROGENS---------------------------------------------------
therapy with other similar medications may
be needed before claims for one of these
medications will be accepted.
ESTROGENS ---------------------------------------------------
Drugs For Viral Infections – HIV/AIDS. . . . . . . . . . . . .
ST: A step therapy protocol is in place for
this medication. If prior medication history
does not meet clinical guidelines,
DIABETES RELATED DRUGS & SUPPLIES--------------
authorization may be required prior to
Fortovase, Fuzeon(PA), Hivid, Intelence, Invirase, Isentress, Kaletra, Lexiva, Prezista, acceptance of claims.
One Touch Basic, One Touch FastTake, One Rescriptor, Reyataz, Selzentry, Sustiva, Touch Surestep, OneTouch Ultra, One Touch Trizivir, Truvada, Valcyte(PA), Viracept, ESTROGEN COMBINATIONS------------------------------
QL: Quantity limitations (maximum
number of tablets/capsules, etc. per month
Atripla, Complera, Edurant, Norvir, Stribild, ethinyl estradiol & norethindrone acetate or year) are in place for this medication.
esterified estrogens & methyltestosterone This document is in effect January 1, 2014. Formulary consultation and administrative support to provided by: Engineering Efficient + Effective Drug Therapy ™ COMBINATION ANTIHYPERTENSIVES--------------
DRUGS FOR ASTHMA / COPD -------------------------------
GENITO-URINARY
AccuChek Lancets, Fastclix, Multiclix, Soft Corticosteroids. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ANTI-INFECTIVES------------------------------------------
NovoFine Insulin Syringes, Novofine Needles, Alvesco (ST), Azmacort (ST), Breo Elipta (ST), INCONTINENCE AGENTS-------------------------------
NovoTwist, Prodigy Insulin Syringes, Prodigy oxybutynin, oxybutynin XL, tolterodine, Sympathomimetics. . . . . . . . . . . . . . . . . . . . . . . .
Detrol LA, Gelnique, Myrbetriq, Oxytrol
Arcapta, Foradil, Perforomist, ProAir HFA, Boeh-Mann Lancets, Lifescan Misc., Minimed VAGINAL ANTIINFECTIVES -------------------------------
THYROID AND ANTITHYROID AGENTS
Combination Drugs and Others. . . . . . . . . . . . . . . .
THYROID ---------------------------------------------------------
AVC Cream, Cleocin Vaginal Tab, Gynazole, DIURETICS ------------------------------------------------------
DRUGS FOR OSTEOPOROSIS
DRUGS FOR BPH-------------------------------------------
acetazolamide ER, amiloride, bumetanide, Adcirca(PA), Combivent, Daliresp, Dulera, alfuzosin, doxazosin, tamsulosin, terazosin, alendronate sodium (generic for Fosamax) triamterene, indapamide, spironolactone, ANTILIPEMICS
----------------------------------------------
MISCELLANEOUS UROLOGICALS-----------------------
atorvastatin, cholestyramine, colestipol, Boniva, Fortical, Fosamax-D, Didronel,
Antileukotrienes. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
MISCELLANEOUS ENDOCRINE
Caverject, Levitra (QL)(ST), Staxyn (QL) Theophyllines…. . . . . . . . . . . . . . . . . . . . . . . .
Crestor, Lipofen, Liptruzet, Lovaza, Niaspan, CENTRAL NERVOUS SYSTEM
Cetrotide, Somatuline Depot(PA), Zemplar Simcor, TriLipix, Vascepa, Vytorin, Welchol, PSYCHOTHERAPEUTIC AGENTS -----------------------
GASTROINTESTINAL
Antidepressants . . . . . . . . . . . . . . . . . . . . . . . . . . .
CARDIOVASCULAR DRUGS
ANTIULCER -----------------------------------------------------
Advicor, Altoprev, Antara, Juxtapid, Lescol, amitriptyline, bupropion, SR, XL, citalopram, CARDIOTONICS ----------------------------------------------
doxepin, escitalopram, fluoxetine, imipramine, MISCELLANEOUS CARDIOVASCULAR DRUGS---------
ANTI-ANGINA ----------------------------------------------
paroxetine CR, protriptyline, trazodone, isosorbide dinitrate, isosorbide mononitrate ANTICOAGULANTS/ANTITHROMBOTICS-------------
dipyridamole, enoxaparin, pentoxifylline, BETA-ADRENERGIC BLOCKERS----------------------
Aggrenox, Brilinta, Effient, Eliquis, (PA), Antipsychotic Agents . . . . . . . . . . . . . . . . . . . . . . .
ANTIEMETIC/ANTIVERTIGO -----------------------------
atenolol, carvedilol, labetolol, metoprolol, chlorpromazine, clozapine, haloperidol, metoprolol XL, propranolol, propranololLA DRUGS FOR MISCELLANEOUS BLOOD DISORDERS--
CALCIUM CHANNEL BLOCKERS -----------------------
Aranesp(PA), Exjade, Nascobal, Neulasta(PA), amlodipine, diltiazemCD, diltiazemSR 24, Equetro, Fanapt, Fazaclo, Geodon, Invega, felodipine, nifedipineXL, nisoldipine, verapamil, DIGESTANTS ---------------------------------------------------
ANXIOLYTICS, SEDATIVES, AND HYPNOTICS----
RESPIRATORY / ASTHMA
ANTIARRHYTHMICS ----------------------------------------
temazepam, triazolam, zaleplon, zolpidem, DRUGS FOR ALLERGY -------------------------------
Oral Antihistamines and Combinations. . . . . . . .
OTHER GI PRODUCTS -----------------------------------
mexiletine, propafenone, propafenone SR, Alavert, cetirizine, cetirizine-D, Claritin, Claritin-D, desloratadine, fexofenadine, CEREBRAL STIMULANTS / ADD-ADHD------------
lactulose, mesalamine rectal misoprostol, ACE INHIBITORS ---------------------------------------------
levocetirizine, loratadine, montelukast, benazepril, captopril, enalapril, fosinopril, Amitiza(PA), Apriso, Asacol HD, Canasa, lisinopril, moexipril, perindopril, quinapril, Delzicol, Fosrenol, Halflytely w Bisacodyl, NASAL MEDICATIONS -------------------------------------
ANGIOTENSIN II ANTAGONISTS-------------------------
azelastine nasal, flunisolide, fluticasone ipratropium nasal, triamcinolone acetonide Cimzia(PA), Dipentum, Golytely, Levbid ER, Atacand, Avapro, Edarbi, Micardis,Teveten Linzess, Lotronex, Metozolv ODT, Nulytely, DIRECT RENIN INHIBITOR----------------------------------
ANTI-ADRENERGIC BLOCKERS–CENTRAL------
This document is in effect January 1, 2014. Formulary consultation and administrative support to provided by: Engineering Efficient + Effective Drug Therapy ™ DRUGS FOR ALZHEIMER’S DISEASE-----------------------
DRUGS FOR PARKINSONS DISEASE ----------------------
DERMATOLOGICALS
SPECIALTY DRUGS
ACNE -------------------------------------------------------------
adapalene, benzoyl peroxide w clindamycin, Coverage for “Specialty Drugs” varies from
plan to plan. Your prescription benefit may
MISCELLANEOUS DRUGS FOR CNS----------------------
ropinirole XL, selegiline, trihexyphenidyl not cover some or all of these items. Please
sulfacetamide sodium external suspension check your pharmacy benefit information if
sulfacetamide w sulfur external emulsion, you have questions.
Acanya, Aczone, Atralin, BenzaClin Pump, Differim 0.1% lotion, Differin gel 0.3%, Specialty Drugs are “bioengineered” oral or injectable SKELETAL MUSCLE RELAXANTS -------------------------
Epiduo, Finacea, Finaca Plus Veltin, Ziana medicines that target and treat complex medical baclofen, carisoprodol, cyclobenzaprine Azelex (PA), Metrogel, Retin-A Micro (PA), conditions including: blood disorders, cancers, dantrolene, methocarbamol, tizanidine, etc. ANTIBIOTICS ---------------------------------------------------
infertility, hormone or enzyme deficiencies, multiple ANALGESICS, NARCOTIC-----------------------------------
erythromycin, clindamycin, metronidazole, sclerosis, rheumatoid arthritis, and a growing list of butorphanol nasal spray, fentanyl patch, OPHTHALMIC
ANTI-ALLERGIC & RELATED AGENTS---------------------
Altabax, Bactroban Nasal Ointment, Noritate ANTIVIRALS ----------------------------------------------------
Specialty drugs are complex compounds and some have unique “handling” requirements. The FDA in Denavir, Lipsovir, Zovirax Cream / Ointment selected situations has required dispensing from a FUNGICIDES ----------------------------------------------------
single pharmacy or a limited set of “approved” pharmacies. Some “specialty” drugs are oral tablets Exalgo(ST), Kadian(ST), Onsolis
ANTI-GLAUCOMA AGENTS -----------------------------
or capsules while others require injection. The result ANALGESICS, NSAIDs ----------------------------------------
brimonidine, dipivefrin, betaxolol, carteolol is that many drugs can be distributed directly to diclofenac, diflunisal, etodolac, ibuprofen, Exelderm, Mentax, Naftin, Oxistat, Xolegel patients, while others will be sent to physicians or latanoprost, levobunolol, metipranolol, timolol, TOPICAL ANTI-INFLAMMATORY AGENTS---------
home health companies or other professional settings Alphagan P, Combigan, Lumigan, Travatan Z Kenalog Spray, Locoid, Locoid Lipocream, Most plan sponsors will apply “step edits” or prior Arthrotec, Duexis, Flector Patch,Pennsaid, ANTI-INFECTIVE AGENTS--------------------------------
authorization criteria prior to the dispensing or TOPICAL SCABICIDES/PEDICULICIDES -------------------
administration of a specialty drug. These MIGRAINE AGENTS-------------------------------------------
requirements ensure appropriate use of a specialty lindane shampoo, malathion lotion, Ulesfia OTHER DERMATOLOGICALS ----------------------------
rizatriptan MLT(QL) sumatriptan tabs (QL), calcipotriene, fluorouracil topical, imiquimod, sumatriptan(QL) nasal spray and injection, ANTI-INFLAMMATORY AGENTS---------------------------
Alrex, Durezol, Ilevro, Lotemax, Nevanac, Elidel, Pramosone, Pramosone E, Protopic, Migranal, Treximet (QL) Zomig (QL), Zomig ANTI-INFECTIVE AND ANTI-INFLAMMATORY
Anamantle HC, Anamantle HC Forte, Anusol COMBINATIONS ---------------------------------------------
ANALGESICS, MISCELLANEOUS ----------------------------
MISCELLANEOUS
NSAIDS-----------------------------------------------------------
Cuprimine, Phrenilin Forte, Ridaura, Ryzolt, ANTICONVULSANTS ---------------------------------------
Auvi-Q, Buphenyl, Chemet, Foltx, Orfadin, clonazepam, divalproex DR, divalproex ER, ANTI-INFECTIVE AND ANTI-INFLAMMATORY
COMBINATIONS ------------------------------------------------
levetiracetam, oxcarbazepine, phenytoin, multiple medicines w/ generics, ofloxacin Gralise, Lamictal ODT, Lyrica, Peganone, DRUGS FOR DEPENDENCY -------------------------------
This document is in effect January 1, 2014. Formulary consultation and administrative support to provided by: Engineering Efficient + Effective Drug Therapy ™

Source: http://www.medben.com/pdffiles/rxoutcomesclass2014.pdf

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