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
Principal Life Over-The-Counter (OTC) Des Moines, IA 50392-0002 Insurance Company Drug List Guideline Flexible Spending Account The IRS defines eligible Over-The-Counter Drugs as pain relievers, antacids, cold remedies and allergy medications. In an effort to help define each of the categories we have established a list of examples. (This is not an all-inclusive list.) Th
Ten Ways to Help Prevent Breast Cancer Alexander Mostovoy, H.D., D.H.M.S., B.C.C.T. Avoid (HRT) Hormone Replacement Therapy. Natural Bio-identical hormones are OK, but synthetic HRT increases the risk of Breast Cancer. In 2002, a huge double blind placebo study called Women’s Health Initiative was sponsored by World Health Organization (WHO) was actually stopped because it was proven t
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