Microsoft word - formulary.doc

Select Over-the-Counter (OTC)
If approved by the Medical Manager an effective 2014 Formulary
Prescription Coverage
date will be assigned based upon the date signed by the provider on the Medical Necessity Review medications are available at no cost to the of Excluded Drugs/ Override form. The Benefits The following is a listing of drugs broken down by Subscriber with a valid prescription. To
Coordinator will notify the Subscriber and the conditions they are used to treat. Under each The Plan pays all covered charges incurred in receive the benefit at the retail pharmacy, the Prescription Drug carrier of the effective date. condition, the drugs are listed in three tiers. Tier I Subscriber must submit a valid prescription at
Purchases after the effective date may be eligible is the least expensive; followed by Tier 2 which is the pharmacy counter for payment through
for reimbursement allowable under the Plan. less expensive; and Tier 3 which is the most Benefits apply for prescriptions purchased at the pharmacy benefits. A 90-day supply of Approvals are subject to the plan design and any expensive. Tier 1 drugs always costs the least Participating Pharmacies only. Visit the employee one of the following OTC medications may amount and are as effective and safe as Brand website for a listing of participating pharmacies. also be purchased through the mail order Drugs. Remember: Select Over-the-Counter program by sending in a valid prescription. When a brand product is dispensed solely at the drugs with a valid prescription are free to you and request of the Subscriber and a generic equivalent Use RxEOB to shop for the most appropriate and is available, the Subscriber is responsible for any lowest cost drug for you and the Plan. View cost differential between the two products in While there are more than 10,000 drugs available pharmacy benefits and get price quotes at on the market, this listing provides the most Zyrtec, Zyrtec D, Claritin Syrup, Claritin www.rxeob.com. To register for this service, frequently prescribed medications. If a drug is not Tablets, Claritin Reditab, Alavert Syrup, included on this list, please contact the Pharmacy Retail Pharmacy Co-Pay Amount
Alavert Tablets, store brand loratadine, Benefit Manager. Price fluctuations, changes in Maximum 34 day supply
Tier levels, and/or method of purchase (retail/mail Claritin-D 12 Tablets, Claritin-D 24 Tablets, order) may result in higher out of pocket Selected
Prescription Coverage Contact
expenses. Drugs may change throughout the Information
Pharmacy Benefits Manager
Please note that while a drug may be listed in
the formulary, the drug may fall under the
Plan’s excluded and limited services listing.
Mail Order Benefit
Please contact the Pharmacy Benefit Manager
Retail Pharmacies
for specific coverage information.
The mail order program allows Subscribers to fill a 90-day prescription. The initial order It is important that you share this information with Mail Order Co-Pay Amount
requires the original prescription from your your physician and follow his/her advice. This Maximum 90 day supply
doctor. Due to the processing of the order, information is not meant as a substitute for the care of your physician. Rather, it is available to Selected
help you and your physician select a less Mail Order
Refills may be obtained by calling a toll free Prescription Coverage Contact Information in DRUGS FOR INFECTIONS
ANTIBIOTICS-------------------------------------------------
Penicillins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Medical Review
Tier 1 ampicillin, amoxicillin, cloxacillin, dicloxacillin, Coverage for excluded and limited services amoxicllin w/ potassium clavulanate, penicillin Cephalosporins. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
See the Plan Document for a complete list of Employee Website
Tier 1 cefaclor, cefadroxil, cefdinir, cefradine, Medical Manager and/or Plan Administrator www.co.wood.oh.us/employee
If approved under the Medical Review Process, seeking coverage for a prescription on the prescriptions are covered at the following level: Excluded and Limited Services listing shall Macrolides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
information, access to Subscriber Booklet, Pharmacy: $15 plus 50% of the AWP;
complete a Medical Necessity Review form with Tier 1 azithromycin, clarithromycin, erythromycin claim, and reimbursement forms, along with maximum $150 out-of-pocket
physician assistance prior to purchase.
Mail Order: $30 plus 50% of the AWP:
Representative or on-line. Completed forms Tetracyclines. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
maximum $300 out-of-pocket
shall be returned to the Benefits Coordinator in Database of Low Cost/Free
Tier 1 doxycycline, minocycline, tetracycline the Commissioners’ Office for processing. Medications
Insufficient or incomplete information may result Quinolones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Tier 1 ciprofloxacin, levofloxacin, ofloxacin Find free or low cost medications at local This document is in effect January 1, 2014. Printed 12/10/2013 - Formulary consultation and administrative support to provided by: Engineering Efficient + Effective Drug Therapy ™ Aminoglycosides. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
MISCELLANEOUS ENDOCRINE
MISCELLANEOUS CARDIOVASCULAR DRUGS--------
Sulfonamides. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ANTICOAGULANTS/ANTITHROMBOTICS-----------------
sulfisoxazole w erythromycin ethylsuccinate ESTROGEN COMBINATIONS-------------------------------
anagrelide, cilostazol, clopidogrel, dipyridamole, sulfamethoxazole w trimethoprim (SMX-TMP) CARDIOVASCULAR DRUGS
Drugs for Tuberculosis. . . . . . . . . . . . . . . . . . . . . . . .
ethinyl estradiol & norethindrone acetate CARDIOTONICS -------------------------------------------------
ethambutol, isoniazid, pyrazinamide, rifampin esterified estrogens & methyltestosterone Aggrenox, Brilinta, Effient, Pradaxa, Xarelto ANTI-ANGINA ----------------------------------------------------
DRUGS FOR MISCELLANEOUS BLOOD DISORDERS-
Angeliq, Climara Pro, Femhrt, Jinteli, Prefest isosorbide dinitrate, isosorbide mononitrate Drugs for Fungal Infections. . . . . . . . . . . . . . . . . . . . .
PROGESTINS ----------------------------------------------------
fluconazole, ketoconazole, nystatin, terbinafine BETA-ADRENERGIC BLOCKERS----------------------------
RESPIRATORY / ASTHMA
atenolol, carvedilol, metoprolol, metoprolol XL, DRUGS FOR ALLERGY -------------------------------------------
Drugs For Viral Infections - Influenza & RSV . . . . . .
DRUGS FOR DIABETES
Oral Antihistamines and Combinations. . . . . . . . . . . . .
INSULINS ----------------------------------------------------------
Zyrtec, Zyrtec D, Claritin Syrup, Claritin Tablets, Claritin Reditab, Alavert Syrup, Alavert Tablets, CALCIUM CHANNEL BLOCKERS ---------------------------
store brand loratadine, Tavist ND Tablets, Drugs For Viral Infections - Herpes. . . . . . . . . . . . . . .
amlodipine, diltiazem, diltiazem CD, diltiazem Dimetapp ND Tablets, Claritin-D 12 Tablets, SR, felodipine, nifedipine XL, verapamil SR Humulin U500, Lantus, Lantus 3ml, Lantus Claritin-D 24 Tablets, store brand loratadine-D Drugs For Viral Infections - Hepatitis. . . . . . . . . . . . .
Apidra, Apidra Solostar, Novolin R, Novolin montelukast, levocetirizine, fexofenadine ANTIARRHYTHMICS ---------------------------------------------
desloratadine, fexofenadine w/pseudoephedrine Drugs for Malaria. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
mexiletine, propafenone, quinidine, sotalol ORAL ---------------------------------------------------------------
NASAL MEDICATIONS -------------------------------------------
acarbose, glimepiride, glipizide, glipizide XL, flunisolide, fluticasone, ipratropium bromide, ACE INHIBITORS -------------------------------------------------
benazepril, captopril, enalapril, fosinopril, pioglitazone, glyburide w/ metformin, glipizide Astapro, azelastine nasal, Nasonex, Qnasl Drugs for Parasites. . . . . . . . . . . . . . . . . . . . . . . . . . . .
lisinopril, moexipril, perindopril, quinapril, nateglinide, pioglitazone-glimepriride, ANGIOTENSIN II ANTAGONISTS-----------------------------
DRUGS FOR ASTHMA / COPD ---------------------------------
Corticosteroids. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Miscellaneous Antiinfectives. . . . . . . . . . . . . . . . . . . .
Atacand, Avapro, Edarbi, Micardis,Teveten DIRECT RENIN INHIBITOR--------------------------------------
Kazano, Actos, ActoPlus Met, Duetact, Glyset, Sympathomimetics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ANTI-ADRENERGIC BLOCKERS–CENTRAL-------------
DIABETES RELATED DRUGS & SUPPLIES--------------
Arcapta, Foradil, levalbuterol for inhalation, DRUGS FOR CANCER
COMBINATION ANTIHYPERTENSIVES--------------------
anastrozole, bicalutamide, cyclophosphamide, One Touch Basic, One Touch FastTake, One etoposide, exemestane, flutamide, hydroxyurea, Touch Surestep, OneTouch Ultra, One Touch letrozole, leucovorin, leuprolide acetate, Combination Drugs and Others. . . . . . . . . . . . . . . . . . . .
tretinoin, megestrol, methotrexate, tamoxifen, Adcirca, Dulera, Letairis, sildenafil, Spiriva, Afinitor, Alkeran, CeeNu, Emcyt, Fareston, AccuChek Lancets, Fastclix, Multicix, Soft Advair, Atrovent HFA, Combivent, Daliresp, NovoFine Insulin Syringes, Novofine Needles, Intal, Pulmozyme, Revatio, Tyvaso, Ventavis Caduet, Diovan HCT, Edarbyclor, Exforge, Nilandron, Sprycel, Sutent, Tabloid, Tarceva, Antileukotrienes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Exforge HCT, Micardis HCT, Tarka, Tekamlo, Temodar, Tasigna, Teslac, Thioguanine, Tykerb, Tier 3 DIURETICS ----------------------------------------------------------
HORMONES
Theophyllines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
GLUCOCORTICOIDS --------------------------------------------
Boeh-Mann Lancets, Lifescan Misc., Minimed THYROID AND ANTITHYROID AGENTS
GASTROINTESTINAL
THYROID -----------------------------------------------------------
ANTIULCER -----------------------------------------------------------
levothyroxine, liothyronine, methimazole, ANTILIPEMICS --------------------------------------------------
omeprazole OTC, Prevacid OTC, Zegerid OTC ANDROGENS-------------------------------------------------------
DRUGS FOR OSTEOPOROSIS
alendronate sodium (generic for Fosamax) ESTROGENS ------------------------------------------------
fluvastatin, Crestor, niacin ER oral tablet, Axid Solution, Bentyl Syrup, nizatidine, calcitonin (salmon) nasal solution, calcitriol Cenestin, Divigel, Enjuvia, Evamist, Premarin, Actonel, Actonel-D, Atelvia, Boniva, Evista, Advicor, Altoprev, Antara, Lescol, Lescol XL, Lipofen, Liptruzent, Livalo, Lovaza, Niaspan, ANTIEMETIC/ANTIVERTIGO ------------------------------------
Tricor, TriLipix, Triglide, Vascepa, Vytorin, This document is in effect January 1, 2014. Printed 12/10/2013 - Formulary consultation and administrative support to provided by: Engineering Efficient + Effective Drug Therapy ™ CEREBRAL STIMULANTS / ADD-ADHD---------------
SKELETAL MUSCLE RELAXANTS ------------------------
ANTIVIRALS ------------------------------------------------------
DIGESTANTS --------------------------------------------------------
dantrolene, methocarbamol, tizanidine, etc. Denavir, Lipsovir, Zovirax Cream/Ointment FUNGICIDES -----------------------------------------------------
OPHTHALMIC
methylphenidate SA OSM Tablets, Intuniv, ANTI-ALLERGIC & RELATED AGENTS-------------------
OTHER GI PRODUCTS --------------------------------------
Exelderm, Mentax, Naftin, Oxistat, Xolegel balsalazide, lactulose, mesalamine rectal Daytrana, Focalin XR, Kapvay, Metadate-CD TOPICAL ANTI-INFLAMMATORY AGENTS-------------
Nuvigil, Provigil, Ritalin-LA, Vyvanse, Xyrem Amitiza, Apriso, Asacol HD, budesonide EC DRUGS FOR ALZHEIMER’S DISEASE--------------------
calcium acetate (phosphate binder), Canasa, TOPICAL SCABICIDES/PEDICULICIDES ---------------
Fosrenol, Kristalose, Lialda, Rectiv, Relistor, ANTI-GLAUCOMA AGENTS ----------------------------------
lindane lotion, malathion lotion, Ulesfia brimonidine, dipivefrin, betaxolol, carteolol Dipentum, Linzess, Lotronex, Metozolv ODT, OTHER DERMATOLOGICALS ------------------------------
ANALGESICS, NARCOTIC------------------------------------
morphine IR, oxycodone IR, fentanyl patch, calcipotriene, Elidel, imiquimod, lidocaine GENITO-URINARY
butorphanol nasal spray, morphine ER cap, ANTI-INFECTIVES-------------------------------------------------
Nucynta, Nucynta ER, oxycodone SR, Opana Anamantle HC, Anamantle HC Forte, Anusol HC, Atopiclair, Condylox, Dovonex, Fluoroplex, INCONTINENCE AGENTS---------------------------------------
ANTI-INFECTIVE AGENTS------------------------------------
Ovace, Picato, Pramosone, Protopic, Solaraze, Mybetriq, tolterodine, Toviaz, trospium, ANALGESICS, NSAIDs ----------------------------------------
MISCELLANEOUS
diclofenac, diflunisal, etodolac, ibuprofen, Detrol, Detrol LA, Enablex, Gelnique, Oxytrol Auvi-Q, Buphenyl, Chemet, Orfadin, Regranex, VAGINAL ANTIINFECTIVES -----------------------------------
ANTI-INFLAMMATORY AGENTS---------------------------
clindamycin cream, nystatin, metronidazole, Arthrotec, Celebrex, Duexis, Flector Patch, Alrex, Durezol, llevro, Lotemax, Nevanac, Alphabetical Listing
AVC Cream, Cleocin Vaginal Tab, Gynazole, MIGRAINE AGENTS--------------------------------------------
DRUGS FOR BPH-------------------------------------------------
ANTI-INFECTIVE AND ANTI-INFLAMMATORY
divalproex ER, rizatriptan tabs, sumatriptan alfuzosin, doxazosin, tamsulosin, terazosin, COMBINATIONS -----------------------------------------------
Amerge, Axert, Cambia, Frova, Maxalt MLT, MISCELLANEOUS UROLOGICALS--------------------------
NSAIDS------------------------------------------------------------
ANALGESICS, MISCELLANEOUS -------------------------
CENTRAL NERVOUS SYSTEM
PSYCHOTHERAPEUTIC AGENTS ---------------------------
Cuprimine, Ridaura, Ryzolt, Savella, Uloric ANTI-INFECTIVE AND ANTI-INFLAMMATORY
Antidepressants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ANTICONVULSANTS ------------------------------------------
COMBINATIONS -------------------------------------------------
amitriptyline, bupropion SR, XL, citalopram, multiple medicines w/ generics, ofloxacin clonazepam, divalproex DR, divalproex ER, levetiracetam, oxcarbazepine, phenytoin, DERMATOLOGICALS
ACNE ----------------------------------------------------------------
Banzel, Carbatrol, Celontin, Diastat, Felbatol, adapalene, metronidazole lotion, Sulfacetami, Antipsychotic Agents . . . . . . . . . . . . . . . . . . . . . . . . . .
chlorpromazine, haloperidol, olanzapine, DRUGS FOR DEPENDENCY --------------------------------
sulfacetamide w sulfur external emulsion Abilify, clozapine, Latuda, risperidone ODT, clindamycin foam, isotretinoin (oral), tretinoin DRUGS FOR PARKINSONS DISEASE -------------------
Fanapt, Fazaclo, Geodon, Invega, Saphris, Clindareach, Differim, Differin gel, Duac, ANXIOLYTICS, SEDATIVES, AND HYPNOTICS-----
Duac CS, Epiduo, Finacea, Metrogel, Retin-A ANTIBIOTICS -----------------------------------------------------
erythromycin, clindamycin, metronidazole, Altabax, Bactroban Nasal Ointment, Noritate This document is in effect January 1, 2014. Printed 12/10/2013 - Formulary consultation and administrative support to provided by: Engineering Efficient + Effective Drug Therapy ™ This document is in effect January 1, 2014. Printed 12/10/2013 - Formulary consultation and administrative support to provided by: Engineering Efficient + Effective Drug Therapy ™ This document is in effect January 1, 2014. Printed 12/10/2013 - Formulary consultation and administrative support to provided by: Engineering Efficient + Effective Drug Therapy ™ This document is in effect January 1, 2014. Printed 12/10/2013 - Formulary consultation and administrative support to provided by: Engineering Efficient + Effective Drug Therapy ™ This document is in effect January 1, 2014. Printed 12/10/2013 - Formulary consultation and administrative support to provided by: Engineering Efficient + Effective Drug Therapy ™ Excluded and Limited Services
1. Drugs not requiring a prescription by federal 8. Vitamins, including Legend vitamins (other 16. Any prescription filled in excess of the Plan 21. All drugs for erectile dysfunction regardless of law unless otherwise noted under Covered limits, the number specified by the physician, or any refill dispensed after one year from the 22. All drugs for irritable bowel syndrome may be prescription by state law, but not by federal physician's original order or exceeding the subject to prior approval before dispensing. 23. Drugs over $1,000 will be subject to prior 2. The cost differential between brand-name any quantity limits defined in the formulary. product dispensed and the available generic 17. Any drug for the treatment of alopecia (hair 12. Therapeutic devices or appliances, including 24. Neuraminidase (Flu) inhibitors – 2 treatment support garments and other non-medicinal 18. Charges incurred on or after the date courses per year – retail pharmacy setting substances, hypodermic needles and syringes 3. Injectable drugs other than insulin, Epi-Pen, 19. Medication which is to be taken by or 13. Charges for immunization agents, vaccines, administered to an individual, in whole or in allergy extracts, biological sera, blood or blood 4. Topical products for cosmetic purposes with part, while he or she is a patient in a licensed 26. Drugs purchased at non-preferred providers. the exception of drugs for the treatment of hospital, rest home, sanitarium, extended care 14. Prescriptions that eligible Participants are facility, convalescent hospital, nursing home 27. Contraceptives for birth control purposes. entitled to receive without charge from any 5. Charges for drugs classed as dietary aids or or similar institution which operates on its Workers' Compensation Laws, and municipal, premises, or allows to be operated on its 29. Cox-2 inhibitors may be subject to step edit 6. Anorexics (any drug used for the purpose of 15. Drugs labeled: "Caution: Limited by Federal 30. All drugs newly on the market may be Law to investigational use", or experimental 20. Oral medications for migraine will have a 7. Smoking cessation or deterrent drugs. (May excluded for three years from approval by the drugs, even though a charge is made to the quantity limit per 30 calendar days. Migraine be available through the Wellness Program.) nasal spray and injectable drugs are excluded. Notable Changes for the 2014 Formulary
 
The following brand medicines have been moved from Tier 3 to Tier 2: 
 
The following Tier 2 generics will be moved to Tier 1: 
 
The following drugs have been moved from Tier 1 or Tier 2 to Tier 3 status due to unavailability or expiration of manufacturer contracts, or the availability of lower cost 
alternatives at Tier 1 or Tier 2: 
The following generics will be assigned a Tier 2 copayment due to high cost:  
With the availability of generic options at Tier 1 or Tier 2 the brand versions of these medicines will be assigned a Tier 3 copay where applicable:
The following drugs are no longer on the market: 
This document is in effect January 1, 2014. Printed 12/10/2013 - Formulary consultation and administrative support to provided by: Engineering Efficient + Effective Drug Therapy ™

Source: http://www.co.wood.oh.us/employee/insurance/2014%20documents/Formulary.pdf