Preferred Choice 3-Tier Non-Formulary Drug And Formulary Alternatives List

Transcription

1 April 2010 Preferred Choice 3-Tier Non-Formulary Drug And Formulary Alternatives List The CVS Caremark Preferred Choice 3-Tier Non-Formulary Drug And Formulary Alternatives List, formerly the PharmaCare Preferred Choice 3-Tier Non-Formulary Drug And Formulary Alternatives List, is a guide for clients, plan participants and health care providers. Generics should be considered the first line of prescribing. If there is no generic available, there may be more than one brand-name medicine to treat a condition. These preferred brand-name medicines are listed to help identify products that are clinically appropriate and cost-effective. This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. PLAN PARTICIPANT Your benefit plan provides you with a prescription benefit program administered by CVS Caremark. Ask your doctor to consider prescribing, when medically appropriate, a preferred medicine from this list. Take this list along when you or a covered family member sees a doctor. Please note: Your specific prescription benefit plan design may not cover certain products, regardless of their appearance in this document. For specific information regarding your prescription benefit coverage and copay 1 information, please visit or contact a CVS Caremark Customer Care representative. CVS Caremark may contact your doctor after receiving your prescription to request consideration of a drug list product or generic equivalent. This may result in your doctor prescribing, when medically appropriate, a different brand-name product or generic equivalent in place of your original prescription. Any brand drug for which a generic product becomes available may be designated as a non-formulary product. HEALTH CARE PROVIDER Your patient is covered under a prescription benefit plan administered by CVS Caremark. As a way to help manage health care costs, authorize generic substitution whenever possible. If you believe a brand-name product is necessary, consider prescribing a brand name on this list. Please note: Generics should be considered the first line of prescribing. This drug list represents a summary of prescription coverage. It is not inclusive and does not guarantee coverage. The plan participant s specific prescription benefit plan may have a different copay for specific products on the list. Unless specifically indicated, drug list products will include all dosage forms. Log in to to check coverage and copay information for a specific medicine. NON-FORMULARY DRUGS FORMULARY ALTERNATIVE(S)* NON-FORMULARY DRUGS FORMULARY ALTERNATIVE(S)* ACCOLATE SINGULAIR ALTACE ramipril ACCUPRIL ACCURETIC ACEON ACIPHEX ACTIVELLA ADALAT CC ADDERALL ADOXA, ADOXA PAK ADVANCE AEROBID, AEROBID M ALAMAST ALDACTAZIDE 25/25 mg ALDACTONE ALLEGRA ALORA quinapril quinapril-hydrochlorothiazide perindopril nifedipine ext-rel amphetamine-dextroamphetamine doxycycline ASMANEX, FLOVENT, FLOVENT HFA, PULMICORT, QVAR spironolactone-hydrochlorothiazide spironolactone fexofenadine ALTOPREV AMARYL AMBIEN AMERGE AMITIZA ANAPROX, ANAPROX DS ANASPAZ ANGELIQ ARMOUR THYROID ASCENSIA ATROVENT HFA AUGMENTIN, AUGMENTIN ES 600 AVAR GEL glimepiride lactulose naproxen sodium levothyroxine, Levoxyl, SYNTHROID SPIRIVA amoxicillin-clavulanate * The formulary alternative products in this list are a broad representation within therapeutic categories of available treatment options and do not necessarily represent clinical equivalency. Your specific prescription benefit plan design may not cover certain products, regardless of their appearance in this document. For specific information, visit or contact a CVS Caremark Customer Care representative.

2 AXERT COZAAR AVAPRO, BENICAR, MICARDIS AYGESTIN norethindrone acetate CUTIVATE fluticasone propionate AZMACORT ASMANEX, FLOVENT, FLOVENT HFA, PULMICORT, QVAR CYCLESSA Velivet BECONASE AQ BENZAMYCIN, BENZAMYCIN PAK BENZIQ, BENZIQ LS BETAPACE, BETAPACE AF BLEPH-10 BREVICON BUSPAR CALAN SR CARDIZEM CD CARDURA CARDURA XL CATAPRES CEDAX CEFTIN CELEXA CENESTIN CILOXAN CIPRO, CIPRO XR CLARINEX CLEOCIN capsule 150 mg, CLEOCIN capsule 300 mg CLEOCIN-T CLINDAGEL CLOMID COGNEX COLAZAL CORTANE-B OTIC CORTISPORIN oint CORTISPORIN OTIC COSOPT sotalol, sotalol AF sulfacetamide buspirone verapamil ext-rel diltiazem ext-rel doxazosin doxazosin, FLOMAX, terazosin clonidine cefdinir cefuroxime citalopram ciprofloxacin, VIGAMOX ciprofloxacin, ciprofloxacin ext-rel fexofenadine clindamycin clomiphene ARICEPT, EXELON, galantamine, galantamine ext-rel, NAMENDA balsalazide CIPRODEX, neomycin-polymyxin B-hydrocortisone otic, ofloxacin otic bacitracin-polymyxin B-neomycin-hydrocortisone neomycin-polymyxin B-hydrocortisone otic dorzolamide-timolol CYTOTEC D.H.E. 45 DAYPRO DEMADEX DESOGEN DESOWEN DIDRONEL DIFLUCAN DILACOR XR DILAUDID DIOVAN, DIOVAN HCT DIPENTUM DITROPAN XL DORAL DORYX DOVONEX soln DURAGESIC DYNACIN DYNACIRC CR EC-NAPROSYN EFFEXOR ELDEPRYL ELESTAT ELOCON EMADINE EMSAM EPOGEN ERTACZO ESGIC, ESGIC-PLUS ESTRACE tablet ESTRASORB ESTROGEL ESTROSTEP FE FACTIVE FELDENE FEMHRT FEMTRACE misoprostol dihydroergotamine inj oxaprozin torsemide Apri desonide ACTONEL, alendronate, BONIVA, etidronate fluconazole diltiazem ext-rel hydromorphone AVALIDE, AVAPRO, BENICAR, BENICAR HCT, MICARDIS, MICARDIS HCT ASACOL, ASACOL HD, LIALDA, mesalamine, PENTASA, SFROWASA, sulfasalazine, sulfasalazine delayed-rel DETROL, DETROL LA, ENABLEX, GELNIQUE, oxybutynin, oxybutynin ext-rel, OXYTROL, SANCTURA XR, VESICARE doxycycline hyclate, tetracycline calcipotriene soln fentanyl minocycline amlodipine, nifedipine ext-rel naproxen venlafaxine selegiline mometasone selegiline ARANESP, PROCRIT ciclopirox, econazole, EXELDERM, ketoconazole topical, OXISTAT butalbital-acetaminophen-caffeine Tilia FE, Tri-Legest FE piroxicam estradiol a CVS Caremark Customer Care representative. 2

3 FENTORA fentanyl MAXITROL neomycin-polymyxin B-dexamethasone FIORICET butalbital-acetaminophen-caffeine MAXZIDE triamterene-hydrochlorothiazide FIORINAL butalbital-aspirin-caffeine MEGACE megestrol acetate FIRST-PROGESTERONE VGS CRINONE, PROCHIEVE, PROMETRIUM MENEST FLAGYL metronidazole MENOSTAR FLONASE FLUOROPLEX FOCALIN FORTAMET FREESTYLE GLUCOMETER DEX, GLUCOMETER ELITE, GLUCOMETER ENCORE GLUCOPHAGE, GLUCOPHAGE XR GLUCOTROL, GLUCOTROL XL GLYSET GYNAZOLE-1 HYCET HYTRIN HYZAAR INNOPRAN XL ISOPTIN SR ISORDIL KETEK KLONOPIN WAFERS LAC-HYDRIN LAMISIL tablet LASIX LEVBID LEVSIN, LEVSIN SL LEVSINEX LOESTRIN LOESTRIN FE LOFIBRA LOMOTIL LO/OVRAL LOPRESSOR, LOPRESSOR HCT LORCET, LORCET PLUS LORTAB LUNESTA MAVIK MAXAIR MAXIDONE CARAC, fluorouracil dexmethylphenidate metformin ext-rel metformin, metformin ext-rel glipizide, glipizide ext-rel acarbose terconazole terazosin AVALIDE, BENICAR HCT, MICARDIS HCT propranolol ext-rel verapamil ext-rel isosorbide azithromycin, clarithromycin, clarithromycin ext-rel, erythromycin clonazepam ODT ammonium lactate terbinafine tablet furosemide Junel, Microgestin Junel FE, Microgestin FE fenofibrate, TRICOR, TRILIPIX diphenoxylate-atropine Cryselle, Low-Ogestrel metoprolol, metoprolol-hydrochlorothiazide trandolapril PROAIR HFA, PROVENTIL HFA, VENTOLIN HFA METAGLIP METROCREAM METROGEL VAG METROLOTION MIACALCIN MICROZIDE MIMYX MINOCIN MIRCETTE MOBIC MODICON MONOPRIL MONOPRIL-HCT MOTRIN MS CONTIN NAPRELAN NAPROSYN NASAREL NASCOBAL NECON 10/11 NEURONTIN NEVANAC NEXGEN NIRAVAM NITROLINGUAL NITROSTAT NORCO NORDETTE NORINYL NOROXIN NORPRAMIN NORITATE NORVASC NOVACORT OCUFLOX OGEN OPANA ORTHO MICRONOR glipizide-metformin metronidazole cream metronidazole vag gel metronidazole lotion calcitonin-salmon, Fortical hydrochlorothiazide ammonium lactate minocycline Kariva meloxicam fosinopril fosinopril-hydrochlorothiazide ibuprofen morphine ext-rel naproxen sodium naproxen cyanocobalamin Kariva, Ocella, ORTHO TRI-CYCLEN LO, YAZ gabapentin diclofenac sodium ophth, ketorolac ophth, XIBROM alprazolam ODT nitroglycerin sublingual nitroglycerin sublingual Levora, Portia desipramine METROGEL, metronidazole amlodipine hydrocortisone valerate ofloxacin morphine Jolivette a CVS Caremark Customer Care representative. 3

4 ORTHO TRI-CYCLEN Trinessa, Tri-Previfem, Tri-Sprintec RELPAX ORTHO-CEPT Apri REMERON, REMERON SOLTAB mirtazapine, mirtazapine ODT ORTHO-CYCLEN Mononessa, Previfem, Sprintec REPREXAIN hydrocodone-ibuprofen ORTHO-NOVUM OVCON PANLOR DC, PANLOR SS PARAFON FORTE DSC PAXIL, PAXIL CR PCE PEDIAPRED PEDIOTIC chlorzoxazone paroxetine, paroxetine ext-rel erythromycin prednisolone CIPRODEX, neomycin-polymyxin B-hydrocortisone otic, ofloxacin otic RHINOCORT AQUA RIFADIN RITALIN, RITALIN-SR RYTHMOL SEASONALE SEB-PREV SELSEB SELSUN RX rifampin methylphenidate, methylphenidate ext-rel propafenone Quasense sulfacetamide-sulfur selenium sulfide shampoo selenium sulfide shampoo PEPCID famotidine SILVADENE silver sulfadiazine PERSANTINE dipyridamole SINEMET, SINEMET CR carbidopa-levodopa, carbidopa-levodopa ext-rel PEXEVA paroxetine, paroxetine ext-rel SKELID ACTONEL, alendronate, BONIVA PLAQUENIL hydroxychloroquine SOLARAZE CARAC, fluorouracil PLEXION, PLEXION SCT POLYSPORIN POLYTRIM PONSTEL PRAVACHOL PRECISION XTRA PRECOSE PRED FORTE PRELONE PRESTIGE PRILOSEC PRINIVIL PRINZIDE PROCARDIA XL PROQUIN XR polymyxin B-bacitracin polymyxin B-trimethoprim mefenamic acid acarbose prednisolone acetate prednisolone lisinopril lisinopril-hydrochlorothiazide nifedipine ext-rel SONATA SPECTRACEF STARLIX STRIANT SYMAX DUOTAB SYMBYAX SYNALGOS DC TAMBOCOR TAPAZOLE TASMAR TEMOVATE, TEMOVATE E TERAZOL TESTIM TEVETEN, TEVETEN HCT TRETIN-X AMBIEN CR, zaleplon, zolpidem cefdinir, SUPRAX nateglinide ANDRODERM, ANDROGEL fluoxetine, ZYPREXA flecainide methimazole COMTAN, STALEVO clobetasol propionate, clobetasol propionate emollient terconazole ANDRODERM, ANDROGEL AVALIDE, AVAPRO, BENICAR, BENICAR HCT, MICARDIS, MICARDIS HCT PROSCAR finasteride TRIGLIDE fenofibrate, TRICOR, TRILIPIX PROTONIX TRI-NORINYL Aranelle PROVERA medroxyprogesterone TRUE CARE PROZAC fluoxetine TRUETRACK PROZAC WEEKLY QUESTRAN, QUESTRAN LIGHT RANICLOR RAPIFLUX RELION INSULIN citalopram, fluoxetine, LEXAPRO, paroxetine, paroxetine ext-rel, sertraline cholestyramine, cholestyramine light, WELCHOL cefaclor fluoxetine HUMULIN INSULIN, NOVOLIN INSULIN TRUSOPT TWINJECT ULTIMA ULTRAM UNIVASC UROCIT-K dorzolamide EPIPEN, EPIPEN JR tramadol moexipril potassium citrate a CVS Caremark Customer Care representative. 4

5 UROXATRAL doxazosin, FLOMAX, terazosin ZELAPAR AZILECT, selegiline VANSPAR buspirone ZESTORETIC lisinopril-hydrochlorothiazide VANTIN cefpodoxime ZESTRIL lisinopril VASERETIC enalapril-hydrochlorothiazide ZIAC bisoprolol-hydrochlorothiazide VASOTEC VIBRAMYCIN capsule VICODIN, VICODIN ES VOLTAREN, VOLTAREN XR VYTORIN WELLBUTRIN SR, WELLBUTRIN XL WESTCORT XANAX, XANAX XR XODOL XOLEGEL XOPENEX HFA YASMIN ZANAFLEX ZEGERID enalapril doxycycline hyclate diclofenac sodium, diclofenac sodium ext-rel bupropion ext-rel hydrocortisone valerate alprazolam, alprazolam ext-rel ketoconazole topical PROAIR HFA, PROVENTIL HFA, VENTOLIN HFA Ocella tizanidine ZIANA ZITHROMAX, Z-PAK ZMAX ZOCOR ZODERM ZOLOFT ZOVIRAX oral ZYDONE ZYFLO CR ZYLOPRIM azithromycin azithromycin sertraline acyclovir SINGULAIR allopurinol FOR YOUR INFORMATION: Generics should be considered the first line of prescribing. This drug list represents a summary of prescription coverage. It is not inclusive and does not guarantee coverage. Specific prescription benefit plan design may not cover certain products, regardless of their appearance in this document. The plan participant s prescription benefit plan may have a different copay for specific products on the list. Unless specifically indicated, drug list products will include all dosage forms. This list represents brand products in CAPS, branded generics in upperand lowercase Italics, and generic products in lowercase italics. Listed products may be available generically in certain strengths or dosage forms. Dosage forms on this list will be consistent with the category and use where listed. This is not a complete list of all formulary products. Any brand drug for which a generic product becomes available may be designated as a non-formulary product. Log in to to check coverage and copay information for a specific medicine. 1 Copayment, copay or coinsurance means the amount a plan participant is required to pay for a prescription in accordance with a Plan, which may be a deductible, a percentage of the prescription price, a fixed amount or other charge, with the balance, if any, paid by a Plan. Your privacy is important to us. Our employees are trained regarding the appropriate way to handle your private health information. CVS Caremark may receive rebates, discounts and service fees from pharmaceutical manufacturers for certain listed products. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers that are not affiliated with CVS Caremark. Listed products are for informational purposes only and are not intended to replace the clinical judgment of the prescriber Caremark. All rights reserved. CMK025_web