Formulary with three columns.xls

Health Plan Select (HPS), Inc. ( is pleased to provide the 2011 Member Prescription Drug List (PDL) as a useful reference for drug product selection and is not specific to any benefit plan. The following is a list of some of the most commonly prescribed preferred drugs on your formulary. This is not meant to be a complete list of all drugs covered by Health Plan Select's Prescription Drug Benefit Plan. The Prescription Drug Formulary is reviewed quarterly by a Pharmacy and Therapeutics Committee, and brand name drugs will automatically be moved to third tier when generic equivalents and products are available. The Prescription Drug Formulary is available for review at Some medications on the Prescription Drug Formulary or the Preferred Drug List may require Prior Authorization (PA), Step Therapy (ST), and/or have a limited benefit.
If the drug you are looking for is not on the following list, please call the customer service number on your ID card. One of our customer service representatives will be happy to help you determine whether your prescription is covered under your particular plan.
NOTE: All of the material in the Prescription Drug Formulary listing is provided as a reference for drug therapy selection
only. Final drug selection for an individual patient rests solely with the prescriber.
Tier 1: (lower case) generic product available, member pays lowest copayment; equivalent branded product is non-preferred, and the highest copaymentTier 2: (All CAPS) preferred branded product, member will pay the preferred brand copayTier 3: non-preferred branded product, or specialty product, member pays the highest copayQL: Quantity Limits, PA: Prior Authorization Required, ST: Step Therapy RequiredRX: Prescription Required, AGE: Age limit, OTC: Over the Counter Prescription Drug Benefits and Limitations
The Prescriptiond Drug List includes generic and brand named drugs. Physicians may prescribe Non Preferred Drugs, those drugs not listed on the Preferred Drug List, and coverage for these medications will be at the highest copayment level (Tier 3).
Generic drugs will be dispensed unless a generic alternative does not exist. When a generic exists and is dispensed, the member is responsible for the generic copayment. When a generic does not exist and a Preferred Drug is dispensed, the member is responsible for the Preferred Drug copayment. If a generic does not exist and a Non Preferred Drug is dispensed, the member is responsible for the Non Preferred Drug copayment.
When available, FDA approved generic drugs will be dispensed regardless of the brand name indicated. If the member or physician requests a Preferred or Non Preferred Drug in place of the generic, the member will be responsible for payment of the generic copayment plus the difference in the cost (if any) between the generic and the Preferred or Non Preferred Drug.
TIER 1 (Lowest Copay)
TIER 1 (Lowest Copay)
TIER 1 (Lowest Copay)
quinine sulfateramiprilrifampinrimantadine hclrisperidoneropinirolesalsalateselegiline hclselenium sulfidesertraline hclsilver sulfadiazinesimvastatinsod chl/nahco3/kcl/pegsodium sulfa/prednisonesodsul/nahco3/kcl/pegsotalol hclspironolactonespironolactone/hctzsucralfatesulfacetamide sod/sulfur TIER 2 (Preferred Brand Copay)
TIER 3 (Non-Preferred Brand Copay)
TIER 3 (Non-Preferred Brand Copay)
TIER 3 (Non-Preferred Brand Copay)


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