preferred drug list - premera blue cross

3-Tier PDL for AAG and WYGetting the most from your prescription drug benefit .....................2
About generic and brand-name drugs ............................................3
Advantages of generic drugs ...........................................................3
Preferred and non-preferred brand-name drugs ...............................4
How to know if your drug is Tier 1, 2, or 3 .....................................5
Getting your prescription filled ........................................................5
Save time and money with Medco By Mail .....................................5
Ordering prescription drugs through Medco By Mail ........................6
Specialty Pharmacies .......................................................................7
Additional services ...........................................................................7
Which drugs are included ................................................................8
How the program works .................................................................9
Preferred Drug List ..........................................................................13
Commonly prescribed Tier 3 drugs with generic equivalents ..........25
Cost-Saving Tips ..................................................... inside back cover
Important Telephone Numbers .........................................back cover

Introduction Welcome to our 3-Tier Pharmacy Benefit plan. We understand the importance of prescription coverage and want to give you a quality benefit—one that helps promote the use of safe and cost-effective medications, while still offering you choices.
What is the Prescription Drug 3-Tier Benefit?
The program is simple. With this benefit, your prescriptions fall into one of three categories or “tiers.” Each tier has a different copay.
Here are the tiers and how they affect your copay:
Tier 1 All generic drugs Lowest copay
Tier 2 Preferred brand-name drugs Higher copay
Tier 3 Non-preferred brand-name drugs Highest copay
Note: The term “copay” is used throughout this book. Your actual benefit may provide fixed-dollar copay tiers, percentage coinsurance tiers or a combination of both.
This booklet includes a list of drugs on the Preferred Drug List along with each drug’s copay tier.
• Generic drugs, listed or not listed, are covered with a Tier 1 copay. These drugs are marked with an asterisk (*) in the list.
• Brand-name drugs listed in this booklet are considered “preferred” and are covered with a Tier 2 copay (see Preferred Drug List).
• Brand-name drugs NOT on the Preferred Drug List are covered with a Tier 3 copay. These drugs are not listed in this book. Some plans require that you must pay the difference in cost between brand-name and generic if a generic is available.
Getting the most from your prescription drug benefit
At your physician or health-care provider’s office:
• Ask your health-care provider to prescribe a generic drug, whenever possible.
• If a generic drug is not appropriate, ask your health-care provider to consider prescribing a preferred brand-name drug from the Preferred Drug List.
At the pharmacy:

About generic and brand-name drugs
Brand-name drugs are usually sold under a manufacturer’s trade name. Generic drugs are usually sold under the generic or chemical names. Both brand-name drugs and generic equivalents are regulated by the Food and Drug Administration (FDA). However, not all brand-name drugs have a generic equivalent.
Advantages of generic drugs • Same level of quality, strength, effectiveness and purity.
• Excellent value—generally cost less because they are created without the development, advertising and sales expense of brand-name drugs. Also, competition among generic drug-makers lowers the price.
• Lowest copay* (Tier 1) can save you money.
* Classification of a drug as generic is based on whether a generic product is available and on the cost, compared to the brand-name version. Occasionally, a product labeled “generic” by the pharmacy will have similar cost to the brand product. In such cases, a Tier 2 copay may apply.
We encourage you to use a generic drug whenever one is available and allowed by your health-care provider. Even if your drug does not have a generic equivalent, there may be another generic available within the same group of drugs that will work just as well. Visit your Web site for more information about how you can save with generics.
Q&As about generic drugs Q. How can I be sure to pay the lowest possible copay?
A. Ask your health-care provider if there is a generic drug that is right for you. If there is a generic equivalent available for your drug, ask your health-care provider to indicate “substitution permitted” on your prescription. Then ask your pharmacist to use a generic to fill the prescription. If there is no generic equivalent for your drug, talk to your doctor about generic drugs available within the same drug class or generic alternative.
Q. What if my prescription does not have a generic alternative available?
A. If there is no generic available, you will receive the brand-name drug.

Preferred and non-preferred brand-name drugs
The list of commonly prescribed drugs in this booklet shows some drugs as Tier 2 preferred brand-name drugs and some as Tier 3 non-preferred brand-name drugs.
Our Pharmacy and Therapeutics Committee makes decisions about which brand-name drugs are preferred and non-preferred. This group includes physicians, other health-care providers and pharmacists from the community, plus a member representative. The committee:
• Uses current medical studies and research to choose safe and effective drugs.
• Reviews and updates the Preferred Drug List regularly by adding the latest safe and effective drugs, and removing those that are no longer considered safe and effective, or which now have better alternatives available.
• Recommends that health-care providers prescribe preferred brand-name drugs when a generic is not available. These preferred brand-name drugs are covered with a Tier 2 copay.
Brand-name drugs not listed in this booklet are considered Tier 3 non-preferred drugs and have the highest copay. These drugs may be non-preferred for a variety of reasons:
• There are generic equivalents available.
• There are preferred brand-name alternatives available.
• Our Pharmacy and Therapeutics Committee has concerns about their safety and/or effectiveness.
Your health-care provider has access to a copy of the Preferred Drug List to use when writing a prescription.
Important items to note when using this booklet:
• Drugs listed in this booklet are arranged in alphabetical order.
• The Preferred Drug List in this booklet does not include non-preferred brand- name drugs. Any brand-name drug not on the list is considered non-preferred and is covered at the Tier 3 copay. Some plans require that you must pay the difference in cost between brand-name and generic if a generic is available. For your convenience, we have listed the most commonly prescribed Tier 3 drugs and their generic or Tier 2 alternatives (see page 24 for this listing).

How to know if your drug is Tier 1, 2 or 3: • The copay tier is listed to the right of the drug name.
• Ask your pharmacist. The pharmacy computer systems have the most up-to-date version of this drug list.
• Call Customer Service—the number is listed on the back of your ID card.
• Visit the Web site listed on the back of your ID card.
Getting your prescription filled Convenient national retail pharmacy network
We use a national network of more than 60,000 retail pharmacies. To receive the highest coverage under your plan’s prescription program, you need to use a pharmacy in this network. If you go to a pharmacy not in the network, you may be covered at a lower level. In some cases, you may receive no benefits at all. Please refer to your benefit booklet for details on coverage at a non-network pharmacy.
Most pharmacies in your area are part of the network. If you need a prescription filled while you’re traveling, you’ll find network pharmacies throughout the United States. Call the toll-free 24-hour Pharmacy Locator Line at 1-800-391-9701 (this number is also printed on the back of your ID card) to find a network pharmacy near you. You can also use the provider directory on your Web site listed on the back of your ID card.
Your 3-Tier benefit provides a 30-day supply of medication for one copay at a retail pharmacy. You still pay the full copay amount even for part of a 30-day supply. For example, if your prescription is for a 34-day supply, you are charged two full copays.
Save time and money with Medco By Mail
If you take a long-term medication, we offer a mail-service program through Medco By Mail, which has many advantages:
• It’s convenient.
• It saves you time and may save you money.

The 3-tier copay structure applies when you use Medco By Mail. However, Medco By Mail copay amounts for generic, preferred and non- preferred brand-name drugs differ from retail pharmacy copay amounts. Please check your benefit booklet for the Medco By Mail copay amounts for your plan. Since Medco By Mail copays are based on the 90-day or other supply maximum allowed by your plan, be sure to ask your health- care provider or practitioner to write this quantity on your prescription. If the prescription is written for anything less, you’ll receive the smaller quantity of medication and still be charged the Medco By Mail copay. The Medco By Mail pharmacy staff can’t change the quantity written by your health-care provider.
Note: Medco By Mail copay amounts differ from retail pharmacy copay amounts. Please read your benefit booklet for specific information about your copay amounts and terms of coverage.
Important items to note about Medco By Mail:
• It takes about two weeks to receive your prescriptions through Medco By Mail.
• To avoid any delay in starting your medicine, ask your health-care provider to write two separate prescriptions—one for 30 days that you can fill at a local pharmacy right away, and one for the 90-day or supply maximum allowed by your plan that you can mail in within two weeks of your medicine running out.
• If your health-care provider allows Medco By Mail refills, be sure he/she indicates that on the prescription and order refills about two weeks before your medicine runs out.
• Prescriptions come to your home in sealed, tamper-evident, discreetly labeled packaging. Some drugs may require special handling, such as controlled substances and items that must be refrigerated or frozen during shipment. For more information, call 1-800-391-9701.
Ordering prescription drugs through Medco By Mail
• Mail: For new prescriptions and refills—use a Medco By Mail order form to mail your prescription. To request a form, please call our Customer Service department or go online to the Web site also listed on the back of your ID card.
• Phone: For prescription refills—call Medco By Mail at 1-800-391-9701.

Specialty Pharmacies
Specialty drugs are high-cost drugs, often self-injected and used to treat complex or rare conditions including rheumatoid arthritis, multiple sclerosis and hepatitis C. These drugs are available through one of our Preferred Specialty Pharmacy vendors. These pharmacies specialize in the delivery and clinical management of specialty drugs and also provide extra clinical services to help you manage your illness at no additional cost.
Because of the complicated therapy and high cost (commonly $1,500 per month), most plans limit specialty drugs to a 30-day supply at a retail copay or coinsurance. For many plans, specialty drugs are only covered when purchased through our Preferred Specialty Pharmacy vendors. See your Benefit Booklet for more information or contact Customer Service.
Specialty drugs are identified in this book with a § symbol. For a complete list of specialty drugs, refer to the Pharmacy section of the Web site listed on the back of your ID card.
Additional services
By using a Preferred Specialty Pharmacy vendor, you have access to additional clinical support, including:
• Coordination of care and care management.
• Medication adherence and compliance monitoring, including refill reminders.
• Educational material, counseling and product information.
• Access to clinical assistance from pharmacists and nurses.
• Coordination of medication delivery time and location, including free delivery and supplies.

Prior Authorization Program Maintaining the optimal drug therapy
Our Prior Authorization Program is designed to improve the quality of pharmacy care for our members. We work together with your doctor and pharmacist to make sure you’re receiving the right medication therapy.
The goals of this program are to:
• Improve the quality of your drug therapies.
• Promote appropriate use of medications.
• Ensure the appropriate length of drug therapy.
Note: The Prior Authorization Program applies to most plans. To check whether your plan has this program, call the Customer Service number on the back of your ID card or check your specific Web site.
Which drugs are included
We currently manage the following medications through the Pharmacy Prior Authorization Program:
Migraine Headache Therapy Drugs
Omeprazole
Protonix®
Aciphex®
Nexium®
Prilosec®*
Prevacid®
Zegerid®
* This does not apply to prescriptions for Prilosec® 10mg per day or Prevacid® 15mg per day. These doses do not require this exception.
CNS Stimulant Drugs
How you benefit from the Prior Authorization Program
Maintaining good health and using your medications correctly is important. The Pharmacy Prior Authorization Program allows us to improve care by promoting appropriate medication use and facilitating follow-up care with your doctor. This program supports you and your doctor as you make decisions about your care and the use of prescription drugs.
How the program works
Here’s how the Pharmacy Prior Authorization Program works:
• When your prescription is submitted by your pharmacy, our computer system checks the prescription drug therapy to see if it meets recommended guidelines.
• If it meets the guidelines, your prescription is filled without interruption.
• If it does not meet the guidelines, your prescription is filled at the pharmacy one time and initiates the Prior Authorization process.
Before your next refill of the prescription, we collect information about your drug therapy. We’ll send you a letter and fax form that you’ll need to take to your doctor. If your doctor wants you to continue on the same
Continued
Atacand®
Anzemet®
Kytril®
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drug therapy, your doctor can fax the form to our Pharmacy Service Center. Your doctor can also contact us directly for a fax form.
Our review process takes one to two business days. Once we’ve received your doctor’s information, we’ll send you a letter confirming the decision made regarding your drug therapy. Your prescription can be refilled at your pharmacy on the same day an approval decision is made.
Frequently Asked Questions Q. What are my copays?
A. Copay amounts vary by the employer group. You need to refer to your benefit booklet for your specific copay amounts. Note that copays are different for drugs dispensed at a retail pharmacy than when dispensed through Medco By Mail.
Q. What if I am on a non-preferred drug and want to stay on it?
A. As always, it is your choice. If you choose to stay on a non-preferred drug for which a generic is available, you may have to pay the cost difference between the generic and brand, plus the copay. See your Benefit Booklet for more information or contact Customer Service.
Q. Are the preferred drugs just the ones that are the cheapest?
A. No. A committee of physicians and pharmacists chooses drugs as preferred only if they are FDA-approved, safe and effective. When several drugs are similar in safety and effectiveness, one or more of the lower cost choices are selected for the Preferred Drug List.
Q. I’ve heard that some people can’t take generic drugs. Why not?
A. A brand-name drug and its generic equivalent have the same active ingredients. However, different manufacturers sometimes use different inactive ingredients to hold the active ingredients together to make a pill or capsule. In rare instances, people may have an allergy to the inactive ingredients. This type of allergy can happen just as often with a brand as with a generic drug.
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Q. What if I want to get a brand-name drug even though there is a generic available?
A. That is between you and your health-care provider or practitioner. You can have your prescription filled for a brand-name drug even when a generic equivalent is available and your health-care provider or practitioner allows it. However, you may have to pay the cost difference between the generic and brand, plus the copay. See your Benefit Booklet for more information or contact Customer Service.
Q. Are there any excluded categories of drugs?
A. Yes. Even though this benefit covers non-preferred brand-name drugs, there still may be exclusions for drugs used to treat certain conditions. Review your benefit booklet for your plan’s exclusions.
Q. Can I use any pharmacy I want?
A. We contract with a national network of pharmacies. To receive the highest level of benefits under this program, you need to use a contracted network pharmacy. If you go to a pharmacy not in the network, you may receive reduced benefits or, in some cases, no benefits at all. For most plans, specialty drugs are only covered when purchased through our Preferred Specialty Pharmacy vendors. Refer to your benefit booklet for details about Specialty Pharmacy and coverage at a non-network pharmacy.
Q. How do I find a network pharmacy near my home or when I am away?
A. Most pharmacies in your area are likely to be part of the network. There are also network pharmacies throughout the United States. Use the toll-free 24- hour Pharmacy Locator Line (1-800-391-9701) to find a network pharmacy near you. Or, visit your Web site listed on the back of your ID card.
* = Generic = Prior Authorization Program = Requires medical review for coverage § = Specialty drug
How to read the Preferred Drug List • Drugs are listed alphabetically.
• Generic drugs, (printed in lowercase letters) are shown with a (1) and covered at the lowest copay.
• Preferred brand-name drugs, (printed in CAPITAL letters) are shown with a (2) and covered at a moderate copay.
• Non-preferred brand-name drugs are not included in the Preferred Drug List. However, we do have a separate section of the most commonly prescribed non-preferred drugs at the back of the book. These drugs are covered at the highest copay. This list also shows you the generic and/or Tier 2 equivalent.
• Generic drugs not listed in this booklet are covered (unless excluded in your benefit) at the lowest copay.
• Brand-name drugs not listed in this book are non-preferred and are covered (unless excluded in your benefit) at the highest copay. Some plans require that you must pay the difference in cost between brand-name and generic if a generic is available.
KEY
Please note the following symbols that may appear with some drugs on the Preferred Drug List.
* = Generic forms of this drug are covered at Tier 1 copay. Brand equivalents are Tier 3. Please consult your health-care provider, practitioner or pharmacist.
= Prior Authorization Program drug. If exception is needed, your practitioner or pharmacist should call 1-888-261-1756.
= This drug requires medical review for coverage in some cases. For exceptions, call the Customer Service number listed on the back of your ID card.
§ = This is a specialty drug. Most plans limit specialty drugs to a 30-day supply. For many plans, specialty drugs are only covered when purchased through our Preferred Specialty Pharmacy vendors. See your benefit booklet or call Customer Service.
Note: The Preferred Drug List is updated several times a year as new drugs become available and is subject to change without notice. For updates and the entire Preferred Drug List, visit your Web site listed on the back of your ID card.
2008 Preferred Drug List Drug Name Tier aminoglutethimide 2
* aminophylline 1 * * amiodarone 1 * * amitriptyline 1 *
amlodipine 2
* ammonium lactate 1 * * amoxapine 1 * * amoxicillin 1 * * amoxicillin/clavulanic acid 1 * * amphetamine/dextroamphetamine 1 *
amphetamine/dextroamphetamine sr 2
* ampicillin 1 * ANA-KIT 2 anastrozole 2 ANCOBON 2 ANDRODERM 2 ANDROGEL 2 ANTARA 2 anthralin 2 APIDRA 2
§ APOKYN 2 § apomorphine 2
apraclonidine 2 APTIVUS 2
§ ARANESP 2 ARICEPT 2 ARIMIDEX 2 aripiprazole 2 ARISTOCORT 2
§ ARIXTRA 2 artificial tear insert 2 ASACOL 2 ASMANEX 2
* aspirin/butalbital/caffeine 1 * * aspirin/butalbital/caffeine/codeine 1 * * aspirin/codeine 1 * * aspirin/oxycodone 1 *
* atropine ophthalmic 1 * ATROVENT 2 auranofin 2 aurothioglucose 2
AVALIDE 2 AVANDAMET (Avandia combinations also Tier 2) 2 AVANDARYL 2
AVANDIA (Avandia combinations also Tier 2) 2 AVAPRO 2
AVC 2 AVELOX 2
Drug Name Tier A
* acetaminophen/butalbital 1 * * acetaminophen/butalbital/caffeine 1 * * acetaminophen/butalbital/caffeine/codeine 1 * * acetaminophen/codeine (Liquid is Tier 2) 1 * * acetaminophen/hydrocodone (Liquid is Tier 2) 1 * * acetaminophen/oxycodone 1 * * acetazolamide (500mg Sequels are Tier 2) 1 * * acetic acid 1 *
* acetic acid/aluminum acetate otic (Generic
equivalent of Domeboro Otic) 1 *
* acetic acid/hydrocortisone liquid 1 * * acetic acid/oxyquin/ricin/glycerin 1 * * acetylcysteine 1 *
acitretin 2 § ACTIMMUNE 2
ACTOS (Actos combinations also Tier 2) 2 * acyclovir 1 *
acyclovir topical 2 § adalimumab 2
ADDERALL XR 2 adefovir 2 ADVICOR 2 AEROBID, AEROBID-M 2 ALBENZA 2
* albuterol metered dose inhaler 1 * * albuterol nebulized 1 * * albuterol tablet & oral liquid 1 *
ALDARA 2 § ALDURAZYME 2
§ ALFERON-N 2 ALKERAN 2
* alprazolam 1 * ALTACE 2 altretamine 2 aluminum chloride 2
* amantadine 1 * AMBIEN 2 AMERGE (Max 23 mg/30 days) 2
AMICAR 2
* = Generic = Prior Authorization Program = Requires medical review for coverage § = Specialty drug * = Generic = Prior Authorization Program = Requires medical review for coverage § = Specialty drug
Drug Name Tier § AVONEX 2
* azathioprine 1 * * azelaic acid 1 * * azithromycin 2 *
AZMACORT 2 AZOPT 2
beclomethasone oral inhaler 2 BECLOVENT 2
* belladonna /phenobarbital 1 * benazepril 2 benazepril/amlodipine 2
* benazepril/hctz 1 * BENZACLIN 2 BENZAMYCIN 2
* benzocaine/antipyrine liquid 1 * benzoyl peroxide/clinamycin 2 benzoyl peroxide/erythromycin 2
* benztropine 1 * * betamethasone dipropionate 1 *
betamethasone dipropionate augmented 2
betaxolol ophthalmic 2
* bethanechol 1 * BETOPTIC, BETOPTIC-S 2 bicalutamide 2 BILTRICIDE 2 bimatoprost 2
* bisoprolol/hctz 1 * § bosentan (Mfr special access program) 2
* brimonidine 1 * brinzolamide 2
* bumetanide 1 * * bupropion 1 * * bupropion sr 1 * * bupropion xl 1 *
busulfan 2 * butorphanol (Max 3 cannisters/30 days) 1 * BYETTA 2
C
* calcitriol 1 * § capecitabine 2
CARMOL 40 2 CARNITOR 2
* carvedilol 1 * carvedilol CR 2 CASODEX 2 CEENU 2 cefdinir suspension 2
* cefuroxime 1 * CELLCEPT 2
* cephalexin 1 * § CEREZYME 2
* chloral hydrate 1 * chlorambucil 2
* chloramphenicol 1 * * chlorhexidine 1 * * chloroquine 1 * * chlorothiazide 1 *
chloroxine 2
ciclopirox 2 CILOXIN 2
* cimetidine 1 * § cinacalcet 2
* citalopram 1 * citric acid/gluconic acid 2
* clarithromycin 2 * CLEOCIN 2
clindamycin vaginal gel 2 clofazimine 2
* clomipramine 1 * * clonazepam 1 * * clonidine 1 * * clonidine/chlorthalidone 1 *
clopidogrel 2
Drug Name Tier COLESTID 2 colestipol 2 COMBIPATCH 2 COMBIVENT 2 COMBIVIR 2 COMTAN 2 CONCERTA 2 conjugated estrogens (Includes vaginal cream) 2 conjugated estrogens/medroxyprogesterone 2
§ COPAXONE 2 COREG CR 2 CORTENEMA 2 CORTIFOAM 2 COSOPT 2 CRESTOR 2 CRIXIVAN 2
* cromolyn inhaled (All forms are covered) 1 * crotamiton 2 CUPRIMINE 2 cyanocobalamin nasal 2 CYCLESSA 2
* cyclobenzaprine 1 * * cyclopentolate 1 *
cyclophosphamide 2 cycloserine 2
* cyproheptadine 1 * CYTADREN 2 CYTOMEL 2 CYTOVENE 2 CYTOXAN 2
D § dalteparin 2
* danazol 1 * DANTRIUM 2 dantrolene 2 DAPSONE 2 DARANIDE 2 DARAPRIM 2
§ darbepoetin 2 darunavir 2
§ dasatinib 2 DDAVP TABLET 2 deferasirox 2
§ deferasirox 2 demecarium 2 DEMSER 2 DEMULEN 2 DENAVIR 2 DEPAKOTE 2
* desipramine 1 * * desmopressin nasal 1 *
desmopressin tablet 2 desogestrel/ethinyl estradiol 2
* desonide 1 * * desoximetasone 1 *
* dexamethasone 1 * * dexamethasone ophthalmic (Maxidex is Tier 2) 1 * * dextroamphetamine (Including SR) 1 *
diabetic blood testing strips 2 diabetic urine testing products 2 DIASTAT 2
* diazepam 1 * diazepam rectal 2 DIBENZYLINE 2 dichlorphenamide 2
* diclofenac 1 * * diclofenac ophthalmic 1 * * dicloxacillin (Liquid is Tier 2) 1 * * dicyclomine 1 *
didanosine 2 dienestrol vaginal cream 2 DIFLUCAN VC 2
* diflunisal 1 * * digoxin 1 * dihydroergotamine (Max 8 amps/30 days) 2
* diltiazem (All generics are Tier 1) 1 * * diphenoxylate/atropine 1 * * dipivefrin ophthalmic 1 *
DIPROLENE 2 DIPROLENE AF 2
* dipyridamole 1 * * disopyramide (Including CR) 1 * * disulfiram 1 *
divalproex 2 donepezil 2
* doxazosin 1 * * doxepin 1 * * doxycycline 1 *
DRITHOCREME 2 DRYSOL 2 DUAC 2 DUETACT 2 DURAGESIC 2 DYCLONE 2 dyclonine 2
E EBRIVA 2 echothiophate ophthalmic 2
§ efalizumab 2 efavirenz 2 efavirenz/emtricitabine/tenofovir 2 EFUDEX 2
eletriptan 2 ELIDEL 2 ELMIRON 2 ELOCON 2 EMADINE 2 EMCYT 2
Drug Name Tier emedastine 2 emtricitabine 2 emtricitabine/tenofovir 2
* enalapril 1 * * enalapril/hctz 1 * § ENBREL 2 § enfuvirtide 2 § enoxaparin 2
entacapone 2 ENTOCORT EC 2 epinephrine allergy kit 2
* epinephrine ophthalmic 1 * epinephrine syringe 2 epinephryl borate 2 EPI-PEN 2 EPIVIR 2 EPPY-N 2 ERGAMISOL 2
* ergocalciferol 1 * * ergoloid mesylates 1 *
ERGOMAR 2 ergotamine 2
* erythromycin (All generic forms) 1 * * erythromycin ophthalmic 1 * * erythromycin topical 1 * * erythromycin/sulfisoxazole 1 * § erythropoietin (Epogen is non-preferred) 2
ESERINE 2
* estradiol transdermal patch (Strengths not
available as generic are Tier 2) 1 *
* estradiol transdermal patch 1 * estradiol vaginal ring 2 estradiol/desogestrel 2 estradiol/ethynodiol 2 estradiol/norethindrone 2 estradiol/norethindrone transderm 2 estramustine 2 ESTRATEST 2 ESTRING 2
* estropipate 1 * ESTROSTEP FE 2
§ etanercept 2 ethambutol 2 ethinyl estradiol/drospirenone 2 ethinyl estradiol/levonorgestrel 2
* ethinyl estradiol/levonorgestrel 7/7/7 (Triphasil
is Tier 2) 1 *
ethinyl estradiol/norelgestomin transderm 2
* ethinyl estradiol/norethindrone (Ortho Novum
is Tier 2) 1 *
Drug Name Tier ethinyl estradiol/norgestrel 2 ETHMOZINE 2
* ethosuximide 1 * * etidronate 1 * * etodolac 1 *
etonoogestrel/ethinyl estradiol vaginal ring 2
* etoposide 1 * EURAX 2 EVISTA 2 EXELDERM 2 EXELON 2
exenatide 2 EXJADE 2
§ EXJADE 2 ezetimibe 2
* famotidine 1 * FAMVIR 2
FANSIDAR 2 FARESTON 2 felbamate 2 FELBATOL 2 FEMARA 2 FEMHRT 2 fenofibrate 2 fentanyl transdermal 2
* fexofenadine 1 * § filgrastim 2
* finasteride 1 * * flecainide 1 *
FLOMAX 2 FLOVENT 2 FLOXIN OTIC 2
* fluconazole 1 * fluconazole 150mg oral single-dose 2 flucytosine 2 FLUDARA 2 fludarabine 2
* fludrocortisone 1 * * flunisolide nasal (Generic only) 1 *
flunisolide oral inhaler 2
* fluocinolone 1 * * fluocinonide 1 * * fluoride 1 * * fluorometholone ophthalmic (FML is Tier 2) 1 *
FLUOROPLEX 2 fluorouracil 2
* fluoxetine 1 * * fluoxymesterone 1 * * fluphenazine 1 * * flurbiprofen 1 * * flutamide 1 * * fluticasone nasal 1 *
fluticasone oral inhaler and diskhaler 2
* folic acid 1mg 1 * § fondaparinux 2
Drug Name Tier FORADIL 2 formoterol 2
FORTOVASE 2 FOSAMAX 2 fosamprenavir 2
* fosinopril 1 * * fosinopril/hctz 1 * § FRAGMIN 2
FURADANTIN 2 furazolidone 2
* furosemide 1 * FUROXONE 2
* gabapentin 1 * GABITRIL 2 galantamine 2 ganciclovir 2 GANTANOL 2
* gemfibrozil 1 * * generic oral contraceptives (All) 1 * * gentamicin 1 * * gentamicin ophthalmic 1 *
GEODON 2 § glatiramer 2
* glimepiride 1 * * glipizide (Including XL) 1 * * glucagon 1 * * glyburide 1 *
glycerin 2
selected in 2008) * guaifenesin/codeine liquid 1 * * guaifenesin/hydrocodone liquid 1 * * guanabenz 1 * * guanfacine 1 *
H
* homatropine ophthalmic 1 * HUMALOG 2
§ HUMIRA 2 HUMORSOL 2 HUMULIN 2
* hydralazine 1 * * hydrochlorothiazide 1 * * hydrocortisone (2.5% only) 1 * * hydrocortisone anorectal cream 1 *
hydrocortisone enema 2
* hydrocortisone tablet 1 * * hydrocortisone/pramoxine 1 * * hydromorphone 1 * * hydroxychloroquine 1 * * hydroxyprogesterone 1 * * hydroxyurea 2 * * hydroxyzine 1 * * hyoscyamine 1 *
I
nasal sprays, or 24 (50mg) tablets) 2
* indapamide 1 * indinavir 2
* indomethacin 1 * insulin aspart 2 insulin detemir 2 insulin glargine 2 insulin glulisine 2 insulin lispro 2 insulin syringes and needles 2 insulin, human 2
§ interferon alfa-2a 2 § interferon alfa-2b 2 interferon alfa-2b/ribavirin 2 § interferon alfa-n3 2 § interferon beta-1a 2 § interferon beta-1b 2 § interferon gamma-1b 2 § INTRON-A 2
INVIRASE 2
* iodoquinol 1 * IOPIDINE 2 ipratropium metered dose inhaler 2 ipratropium/albuterol metered dose inhaler 2
irbesartan 2 irbesartan/hctz 2
ivermectin 2
* ketoconazole 1 * ketotifen 2
Drug Name Tier
* labetalol 1 * LACRISERT 2
* lactulose liquid 1 * LAMICTAL 2 lamivudine 2 lamivudine/zidovudine 2 lamotrigine 2 LAMPRENE 2 lancets 2 LANTUS 2 LARODOPA 2
§ laronidase 2 latanoprost 2
§ lenalidomide 2 letrozole 2
* leucovorin 1 * LEUKERAN 2
§ LEUKINE 2 § leuprolide 2
* levobunolol liquid 1 * levocarnitine 2 levodopa 2
* levodopa/carbidopa (Including CR) 1 * levonorgestrel/ethinyl estradiol 2
* levothyroxine 1 * LEXIVA 2
* lidocaine 1 * * lindane 1 *
liothyronine 2 liotrix 2
* lipase/amylase/protease 1 * LIPITOR 2
* lisinopril 1 * * lisinopril/hctz 1 * * lithium carbonate (Eskalith CR is Tier 2) 1 * * lithium citrate 1 *
lodoxamide 2 LOESTRIN, LOESTRIN 24 2 lomustine 2 LOOVRAL 2 lopinavir/ritonavir 2 LOPROX 2
* lorazepam 1 * LOTENSIN 2 LOTREL 2
* lovastatin 1 * § LOVENOX 2
* loxapine 1 * LUMIGAN 2
§ LUPRON 2 LYSODREN 2
* mebendazole 1 * * meclizine 1 * * meclofenamate 1 * * medroxyprogesterone 1 *
medrysone ophthalmic 2
melphalan 2 memantine 2
* meperidine 1 * * mephobarbital 1 *
MEPHYTON 2 MEPRON 2 mercaptopurine 2 mesalamine (Enema, suppository) 2 mesalamine 2 MESTINON SR 2 METADATE CD 2
* metformin (XR is Tier 3) 1 * * metformin/glyburide 1 * * methadone 1 * * methazolamide 1 *
METHERGINE 2
methoxsalen 2
* methylprednisolone 1 * * methyltestosterone 1 *
METROGEL VAGINAL 2 METROGEL, METROCREAM, METROLOTION 2
* metronidazole (375mg is Tier 3) 1 * metronidazole topical 2 metronidazole vaginal gel 2 metyrosine 2
* mexiletine 1 * MIACALCIN 2
MICRONOR 2
Drug Name Tier
* minocycline 1 * * minoxidil 1 *
MINTEZOL 2 MIRAPEX 2 MIRCETTE 2
* misoprostol 1 * mitotane 2 MOBAN 2
modafinil 2 molindone 2 mometasone 2 mometasone oral inh 2 mometasone oral inhaler and diskhaler 2 moricizine 2 morphine (Suppository) 2
* morphine sulfate 1 * * morphine sulfate sr 1 *
moxifloxacin 2 MS CONTIN 2
* multivitamin/fluoride chew or liquid 1 * * multivitamin/fluoride/iron chew or liquid 1 * * mupirocin 1 *
MYAMBUTOL 2 MYCELEX-G 1 MYCOBUTIN 2 mycophenolate 2 MYLERAN 2
N
* nadolol 1 * nafarelin 2 NAMENDA 2
* naphazoline 1 * * naproxen 1 * * naproxen sodium 1 * naratriptan (Max 23 mg/30 days) 2
NARDIL 2 NASCOBAL 2 NEBUPENT 2 nedocromil (All forms are covered) 2 nelfinavir 2
* neomycin 1 * * neomycin/bacitracin/polymyxin/hc ophthalmic 1 * * neomycin/dexamethasone ophthalmic 1 * * neomycin/polymyxin/bacitracin ophthalmic 1 * * neomycin/polymyxin/dexamethasone ophthalmic 1 * * neomycin/polymyxin/gramicidin ophthalmic 1 * * neomycin/polymyxin/hc ophthalmic 1 * * neomycin/polymyxin/hc otic 1 *
neomycin/polymyxin/pred ophthalmic 2 neostigmine 2
§ NEUMEGA 2 § NEUPOGEN 2
nevirapine 2 § NEXAVAR 2
niacin sr 2 niacin sr/lovastatin 2
Drug Name Tier NIASPAN 2 nicotine nasal spray 2 NICOTROL NS 2
* nifedipine 1 * * nifedipine cc 1 *
NILANDRON 2 nilutamide 2 nimodipine 2 NIMOTOP 2 nitrofurantoin 2
* nitrofurantoin macro 1 * * nitrofurantoin monohydrate macro 1 * * nitroglycerin oral 1 *
nitroglycerin sl 2
* nizatidine 1 * NORDETTE 2
* norethindrone 1 * norfloxacin 2 NOR-QD 2
* nortriptyline 1 * NORVASC 2 NORVIR 2 NOVOLIN 2 NOVOLOG 2 NUVARING 2
* nystatin 1 * * nystatin vaginal 1 * * nystatin/triamcinolone 1 *
O § octreotide 2
* omeprazole (Exception required for > 90-day Rx) 1 * OMNICEF SUSPENSION 2
* ondansetron 1 * § oprelvekin 2
OPTIPRANOLOL 2 ORTHO EVRA 2 ORTHO NOVUM 2 ORTHO NOVUM 10/11 2 ORTHO NOVUM 7/7/7 2 ORTHO-CEPT 2 ORTHO-CYCLEN 2 ORTHO-DIENESTROL 2 ORTHO-TRICYCLEN 2 ORTHO-TRICYCLEN LO 2 oseltamivir 2 OSMOGLYN 2 OVCON 2 OVRAL 2 oxcarbazepine 2 OXSORALEN 2
* oxybutynin (XL is Tier 3) 1 *
0 * = Generic = Prior Authorization Program = Requires medical review for coverage § = Specialty drug
Drug Name Tier oxybutynin transdermal 2 OXYTROL 2
P palonosetron 2
* pancrelipase 1 * * paregoric 1 * * paromomycin 1 * * paroxetine (Including CR) 1 *
PATANOL 2
* peg electrolyte bowel prep 1 * § PEGASYS 2 § peg-interferon alfa-2a 2 § peg-interferon alfa-2b 2 § PEG-INTRON 2 § pegvisomant
pemoline 2 penciclovir cream 2 penicillamine 2
* penicillin 1 * * pentamidine injection 1 *
pentamidine nebulized 2 PENTASA 2 pentazocine/naloxone 2 pentosan polysulfate sodium 2
* pentoxifylline 1 * * permethrin 1 * * perphenazine 1 * * phenazopyridine 1 *
phenelzine 2 pheniramine/pyrilamine/phenyltoloxamine (Liquid) 2
* phenobarbital 1 * phenoxybenzamine 2 phentolamine mesylate 2
* phenylephrine 1 *
* pilocarpine 1 * * pilocarpine ophthalmic 1 * * pilocarpine/epinephrine ophthalmic 1 *
pimecrolimus 2
pioglitazone/glimepiride 2 pioglitazone/metformin 2
* piroxicam 1 * PLAVIX 2
pramipexole 2 pramlintide 2
PREMARIN (Includes vaginal cream) 2 PREMPRO, PREMPHASE 2
* prenatal vitamins 1 * PREZISTA 2
* primaquine 1 * * primidone 1 * * probenecid 1 *
procainamide (All generics are Tier 1) 2 PROCANBID (All generics are Tier 1) 2 procarbazine 2
* prochlorperazine 1 * § PROCRIT (Epogen is non-preferred) 2
PROFENAL 2
* promethazine 1 * * promethazine/codeine syrup 1 * * promethazine/dextromethorphan liquid 1 * * promethazine/pe/codeine syrup 1 *
PROMETRIUM 2
* propafenone (300mg is Tier 2) 1 * * propantheline 1 * * propoxyphene (All generic combinations are Tier 1) 1 * * propranolol (Including LA) 1 * * propranolol/hctz 1 * * propylthiouracil 1 *
PROSTIGMIN 2
* pseudoephedrine/chlorpheniramine 1 * * pseudoephedrine/guaifenesin la 1 *
PULMICORT 2 PULMICORT RESPULES 2
§ PULMOZYME 2 PURINETHOL 2
* pyrazinamide 1 * * pyridostigmine 1 *
Q quetiapine 2
* quinapril 1 * * quinidine (Brand-only forms are Tier 2) 1 * * quinine 1 *
R raloxifene 2 ramipril 2
* ranitidine 1 * § RAPTIVA 2
0 * = Generic = Prior Authorization Program = Requires medical review for coverage § = Specialty drug
Drug Name Tier REBETRON 2
REGITINE 2 RELPAX 2
RENACIDIN 2 REQUIP 2
* reserpine 1 * RESTASIS 2
§ REVLIMID 2 REYATAZ 2 REZADYNE 2 RHINOCORT (Including AQ) 2
§* ribavirin 1 * RIDAURA 2 rifabutin 2
* rifampin 1 * RILUTEK 2 riluzole 2 risedronate 2 RISPERDAL (Liquid not covered) 2 risperidone (Liquid not covered) 2 ritonavir 2 rivastigmine 2
rizatriptan (Max 120 mg/30 days) 2 RMS (Suppository) 2
§ ROFERON-A 2 ropinirole 2
also Tier 2) 2
S salicylic acid 2
salmeterol (Including Diskus) 2
* salsalate 1 * SANDIMMUNE 2
§ SANDOSTATIN 2 saquinavir 2
§ sargramostim 2 scopolamine 2 SEBIZON 2
* selegiline 1 * * selenium sulfide 1 * § SENSIPAR 2 SEREVENT (Including Diskus) 2
SEROMYCIN 2 SEROQUEL 2
simvastatin/ezetimibe 2
§ SOMAVERT § sorafenib 2
* spironolactone 1 * * spironolactone/hctz 1 * § SPRYCEL 2
stavudine 2 STRATTERA 2
* sucralfate 1 * sulconazole nitrate 2 sulfacetamide 2
* sulfacetamide ophthalmic 1 * * sulfacetamide/prednisolone ophthalmic 1 * * sulfacetamide/sulfur 1 * * sulfadiazine 1 *
sulfamethoxazole 2 sulfanilamide vaginal gel 2
* sulfasalazine (Including EC) 1 * * sulfinpyrazone 1 * * sulfisoxazole (Liquid is Tier 2) 1 * * sulindac 1 *
sumatriptan (Max 1200 mg/30 days: 4 inj kits, 12 nasal sprays, or 24 (50mg) tablets) 2
§ sunitinib 2 suprofen 2 SUSTIVA 2
§ SUTENT 2 SYMLIN 2 SYNAREL 2
T tacrolimus 2 TALWIN NX 2 TAMIFLU 2
* tamoxifen 1 * tamsulosin 2
telmisartan 2 telmisartan/hctz 2
* terazosin 1 * * terbutaline 1 *
terconazole vaginal cream 2 TESLAC 2 testolactone 50mg 2 testosterone transdermal gel 2 testosterone transdermal patch 2
* tetracycline 1 * § thalidomide 2 § THALOMID 2
* theophylline 1 * * theophylline sr 1 *
thiabendazole 2
Drug Name Tier THIOGUANINE 2
* thiothixene 1 * THYROID 2 THYROLAR 2 tiagabine 2 TICLID 2 ticlopidine 2 TILADE (All forms are covered) 2
* timolol 1 * * timolol ophthalmic 1 *
TINDAMAX 2 tinidazole 2 tiotropium 2 tipranavir 2
* tizanidine 1 * § TOBI 2
* tobramycin ophthalmic 1 * tobramycin/dexamethasone ophthalmic 2
* tolazamide 1 * * tolmetin 1 *
tolterodine (Incl LA) 2 TOPAMAX 2 topiramate 2 toremifene 2
* torsemide 1 * § TRACLEER (Mfr special access program) 2
trandolapril/verapamil 2 TRANSDERM-SCOP 2
* trazodone 1 * * tretinoin 1 *
triamcinolone oral 2 triamcinolone oral inhaler 2
* triamterene/hydrochlorothiazide 1 * * triazolam 1 *
TRICOR 2 triethanolamine 2
* trihexyphenidyl 1 * TRILEPTAL 2
trioxsalen 2 TRIPHASIL 2
* tropicamide 1 *
U urea 40% 2
* valproic acid 1 * VALTREX 2
VANCERIL (Including DS) 2 VANCOCIN 2 vancomycin 2 varenicline 2
* venlafaxine 1 * * verapamil (Including SR) 1 *
VESANOID 2 vidarabine ophthalmic 2 VIDEX 2 VIRA-A 2 VIRACEPT 2 VIRAMUNE 2 VIREAD 2 VIROPTIC 2
* vitamin a 1 * * vitamins acd/fluoride/iron chew or liquid 1 *
VIVELLE (Incl Vivelle Dot) 2 § vorinostat 2
VYTORIN 2
* warfarin 1 * XALATAN 2
§ XELODA 2 YASMIN 2 YAZ 2 ZADITOR 2 ZAROXOLYN 2 ZERIT 2 ZETIA 2 ZIAGEN 2
* zidovudine 1 * ziprasidone 2
§ ZOLINZA 2 zolpidem 2
Appendix Commonly prescribed Tier 3 drugs with alternatives
Some drugs that are not on the Preferred Drug List have possible alternatives. These are similar drugs that are on the Preferred Drug List. The list on the following pages includes the most commonly prescribed Tier 3 drugs and their Tier 1 or Tier 2 alternatives.

Tier 3 Drug Suggested Alternative(s) Tier 1 Tier 2
ACHIPEX omeprazole Prilosec OTC (not covered, but available for $16-25 for a 30-day supply.)
X
ALLEGRA ALLEGRA-D
Nonprescription generic loratadine (not covered, but available in stores for $15-20 for a 30-day supply.)
AMARYL glyburide, glipizide X
AMBIEN temazepam, triazolam X
CELEBREX ibuprofen, naproxen, sulindac, diclofenac X
CENESTIN PREMARIN X
COVERA HS verapamil long-acting X
DAYPRO ibuprofen, naproxen, indomethacin, piroxicam, sulindac
X
X X
EFFEXOR XR capsules, extended release
venlafaxine tablets X
KYTRIL ondansetron X
X X
NASONEX fluticasone propionate RHINOCORT
PAXIL CR fluoxetine, paroxetine, citalopram X
PLENDIL nifedipine long-acting amlodipine
X X
PREVACID omeprazole PROTONIX Prilosec OTC (not covered, but available for $16-25 for a 30-day supply.)
X X
SPORANOX terbinafine X
TIAZAC diltiazem long-acting X
ULTRACET acetaminophen + tramadol X
X
VANTIN cefuroxime X
VICOPROFEN hydrocodone + acetaminophen X
ZYRTEC ZYRTEC D

Commonly prescribed Tier 3 drugs with generic equivalents
Brand-name drugs that have generic equivalents are not on the Preferred Drug List. These brands are Tier 3, but their generic equivalents are Tier 1. Unless your doctor or practitioner has specified that you must have a brand-name drug, your pharmacist can substitute the generic product at your request. (Availability of Tier 1 copay is subject to generic product availability at the pharmacy. From time to time, generics of a particular drug may be unavailable.)
Brand Name Generic Equivalent (Tier 3) (Tier 1)
ACCUPRIL quinapril ACCUTANE isotretinoin ADALAT-CC nifedipine-ER ALDACTONE spironolactone ALPHAGAN brimonidine eye drops AMBIEN zolpidem AMOXIL amoxicillin ANAPROX naproxen sodium ANTABUSE disulfiram ARISTOCORT triamcinolone ATIVAN lorazepam AUGMENTIN amoxicillin/clavulanic acid AURALGAN benzocaine/antipyrine ear drops AXID nizatidine AYGESTIN norethindrone AZELEX azelaic acid AZULFIDINE sulfasalazine BACTRIM trimethoprim/sulfamethoxazole BACTROBAN mupirocin ointment BENTYL dicyclomine BETAGAN levobunolol eye drops BETAPACE sotalol BUMEX bumetanide BUSPAR buspirone CARAFATE sucralfate CARDIZEM diltiazem CARDURA doxazosin CATAPRES clonidine CECLOR cefaclor CEFTIN cefuroxime CELEXA citalopram CEPHULAC lactulose liquid CIPRO ciprofloxacin CLEOCIN-T clindamycin topical CLINORIL sulindac CLOZARIL clozapine COLYTE PEG electrolyte liquid COMPAZINE prochlorperazine COPEGUS ribavirin CORDARONE amiodarone COUMADIN warfarin CREON lipase/amylase/protease
CYCRIN nadolol CYTOTEC misoprostol DANOCRINE danazol DARVOCET propoxyphene/acetaminophen DARVON propoxyphene/acetaminophen DAYPRO oxaprozin DEMEROL meperidine DEXEDRINE dextroamphetamine DIAMOX acetazolamide DIFLUCAN fluconazole DILAUDID hydromorphone DIPROLENE, DIPROSONE betamethasone dipropionate DISALCID salsalate DITROPAN oxybutynin DOLOBID diflunisal DYAZIDE triamterene/hydrochlorothiazide EFUDEX fluorouracil solution ELDEPRIL selegiline ELIMITE permethrin EPIFRIN epinephrine eye drops ESTRACE micronized estradiol ESTRATAB esterified estrogen FELDENE piroxicam FIORICET acetaminophen/butalbital/caffeine FIORINAL aspirin/butalbital/caffeine FLAGYL metronidazole FLEXERIL cyclobenzaprine FLORINEF fludrocortisone FML fluorometholone opthalmic FLOXIN ofloxacin GLUCOPHAGE metformin GLUCOTROL glipizide GLUCOVANCE glyburide/metformin GOLYTELY PEG electrolyte liquid HALCION triazolam HALDOL haloperidol HYTRIN terazosin IMDUR isosorbide mononitrate sr IMURAN azathioprine INDERAL propranolol INDOCIN indomethacin INTAL cromolyn inhaled

ISORDIL isosorbide dinitrate KAYEXALATE sodium polystyrene sulfonate KEFLEX cephalexin KENALOG triamcinolone KLONOPIN clonazepam KWELL lindane LAC-HYDRIN ammonium lactate LANOXIN digoxin LASIX furosemide LEVSIN hyoscyamine LIBRAX clidinium/chlordiazepoxide LIDEX fluocinonide LOMOTIL diphenoxylate/atropine LOPID gemfibrozil LOPRESSOR metoprolol LOPROX ciclopirox LOTENSIN benazepril LOTENSIN HCT benazepril /HCTZ LOTRIMIN clotrimazole 1% LOXITANE loxapine LUVOX fluvoxamine MAXZIDE triamterene/hydrochlorothiazide MEGACE megestrol METROCREAM metronidazole topical MEVACOR lovastatin MEXITIL mexiletine MIACALCIN calcitonin injection MICRONASE glyburide MIDRIN isomethepene/
dichloralphenazone/apap MINIPRESS prazosin MODURETIC amiloride/hctz MONOPRIL fosinopril MOTRIN ibuprofen MUCOMYST acetylcysteine MYCELEX clotriamzole troches MYCOLOG nystatin/triamcinolone MYCOSTATIN nystatin MYSOLINE primidone NAPROYSN naproxen NEORAL cyclosporine microemulsion NEURONTIN gabapentin NITOBID nitroglyercin oral NIZORAL ketoconazole NORMODYNE labetalol NORPACE disopyramide NORVASC amlodipine NULYTELY PEG electrolyte liquid OCUFEN flurbiprofen OCUFLOX ofloxacin OGEN estropipate ORAMORPH morphine sulfate sr ORTHO NOVUM ethinyl estradiol/ norethindrone PAMELOR nortriptyline PANCREASE pancrelipase PARLODEL bromocriptine PAXIL paroxetine
PEDIAZOLE erythromycin/sulfisoxazole PEPCID famotidine PERCOCET oxycodone/acetaminophen PERCODAN oxycodone/aspirin PERIACTIN cyproheptadine PHENERGAN promethazine PHRENILIN acetaminophen/butalbital PLAQUENIL hydroxychloroquine POLYTRIM trimethoprim/polymixin b PRILOSEC omeprazole PRINIVIL lisinopril PRINIZIDE lisinopril/hctz PROCARDIA XL nifedipne XL PROCTOFOAM-HC hydrocortisone/parmoxine PROLIXIN fluphenazine PROPINE dipivefrin eye drops PROVENTIL albuterol PROVERA medroxyprogesterone PROZAC fluoxetine PYRIDIUM phenazopyridine QUESTRAN chloestyrmaine QUINIDEX quindine REBETOL ribavirin REGLAN metoclopramide RELAFEN nabumetone REMERON mirtazepine RESTORIL temazepam RETIN-A tretinoin RHEUMATREX methotrexate RIMACTANE rifampin RITALIN methylphenidate ROBAXIN methocarbamol ROBITUSSIN AC guaifenesin/codeine liquid ROCALTROL calcitriol ROXICODONE oxycodone/acetaminophen RYTHMOL propafenone SARAFEM fluoxetine SELSUN selenium sulfide SEPTRA trimethoprim/sulfamethoxazole SIVALDENE silver sulfadiazine SINEMET levodopa/carbidopa SOMA carisoprodol SSKI potassium iodide STADOL butorphanol STELAZINE trifluoperazine SULFACET-R sulfacetamide/sulfur SYMMETREL amantadine SYNALAR fluocinolone SYNTHROID levothyroxine TAGAMET cimetidine TAMBOCOR flecainide TAPAZOLE methimazole TEGRETOL carbamazepine TENEX guanfacine TENORETIC atenolol/chlorthalidone TENORMIN atenolol TERAZOL 7 terconazole vaginal cream
THEO-DUR theophylline sr THORAZINE chlorpromazine TIAZAC diltiazem sr TICLID ticlopidine TIMOPTIC timolol eye drops TOLFRANIL imipramine TOLECTIN tolmetin TOPICORT desoximetasone TRENTAL pentoxifylline TRI-VI FLOR vitamins acd/fluoride/iron TRILAFON perphenazine TRILISATE choline/mag salicylates TRI-LEVLEN levonorgestrel/ethinylestradiol TRIVORA ethinyl estradio/
levonorgestrel TYLENOL/CODIENE acetaminophen/codeine TYLOX acetaminophen/oxycodone ULTRAM tramadol URECHOLINE bethanechol VALISONE betamethasone valerate VALIUM diazepam VASODILAN isoxsuprine VASORETIC enalapril/hctz VASOTEC enalapril VEPESID etoposide VERMOX mebendazole VIBRAMYCIN doxycycline VICODIN acetaminophen/hydrocodone VISKEN pindolol VISTARIL hydroxyzine VIVACTIL protriptyline VOLTAREN diclofenac VOSOL HC acetic acid/
hydrocortisone liquid WELLBUTRIN bupropion WYTENSIN guanabenz XANAX alprazolam XYLOCAINE lidocaine YODOXIN iodoquinol ZANAFLEX tizanidine ZANTAC ranitidine ZARONTIN ethosuximide ZAROXOLYN metolazone ZEPHREX LA pseudoephedrine/
guafenesin la ZESTORETIC lisinopril/hctz ZESTRIL lisinopril ZIAC bisoprolol/hctz ZOCOR simvastatin ZOFRAN ondansetron ZOLOFT sertraline ZOVIRAX acyclovir

Cost-Saving Tips: • Ask your doctor to prescribe a generic drug when appropriate. All generic
drugs are covered and have the lowest cost to you.
• If an exact generic equivalent for the drug you are taking is not available, ask your doctor whether there is a similar generic drug that might work as well for you.
• Find out whether a drug is on the Preferred Drug List by using the searchable Preferred Drug List at our Web site listed on the back of your Premera ID card.
• Ask your pharmacist to fill your prescriptions with a generic drug when allowed.
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018288 (10-2007)
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037338 (07-2016)
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(Chinese): Premera Blue Cross

800-722-1471 (TTY: 800-842-5357)
Oromoo (Cushite): Beeksisni kun odeeffannoo barbaachisaa qaba. Beeksisti kun sagantaa yookan karaa Premera Blue Cross tiin tajaajila keessan ilaalchisee odeeffannoo barbaachisaa qabaachuu danda’a. Guyyaawwan murteessaa ta’an beeksisa kana keessatti ilaalaa. Tarii kaffaltiidhaan deeggaramuuf yookan tajaajila fayyaa keessaniif guyyaa dhumaa irratti wanti raawwattan jiraachuu danda’a. Kaffaltii irraa bilisa haala ta’een afaan keessaniin odeeffannoo argachuu fi deeggarsa argachuuf mirga ni qabaattu. Lakkoofsa bilbilaa 800-722-1471 (TTY: 800-842-5357) tii bilbilaa. Français (French): Cet avis a d'importantes informations. Cet avis peut avoir d'importantes informations sur votre demande ou la couverture par l'intermédiaire de Premera Blue Cross. Le présent avis peut contenir des dates clés. Vous devrez peut-être prendre des mesures par certains délais pour maintenir votre couverture de santé ou d'aide avec les coûts. Vous avez le droit d'obtenir cette information et de l’aide dans votre langue à aucun coût. Appelez le 800-722-1471 (TTY: 800-842-5357). Kreyòl ayisyen (Creole): Avi sila a gen Enfòmasyon Enpòtan ladann. Avi sila a kapab genyen enfòmasyon enpòtan konsènan aplikasyon w lan oswa konsènan kouvèti asirans lan atravè Premera Blue Cross. Kapab genyen dat ki enpòtan nan avi sila a. Ou ka gen pou pran kèk aksyon avan sèten dat limit pou ka kenbe kouvèti asirans sante w la oswa pou yo ka ede w avèk depans yo. Se dwa w pou resevwa enfòmasyon sa a ak asistans nan lang ou pale a, san ou pa gen pou peye pou sa. Rele nan 800-722-1471 (TTY: 800-842-5357). Deutsche (German): Diese Benachrichtigung enthält wichtige Informationen. Diese Benachrichtigung enthält unter Umständen wichtige Informationen bezüglich Ihres Antrags auf Krankenversicherungsschutz durch Premera Blue Cross. Suchen Sie nach eventuellen wichtigen Terminen in dieser Benachrichtigung. Sie könnten bis zu bestimmten Stichtagen handeln müssen, um Ihren Krankenversicherungsschutz oder Hilfe mit den Kosten zu behalten. Sie haben das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Rufen Sie an unter 800-722-1471 (TTY: 800-842-5357). Hmoob (Hmong): Tsab ntawv tshaj xo no muaj cov ntshiab lus tseem ceeb. Tej zaum tsab ntawv tshaj xo no muaj cov ntsiab lus tseem ceeb txog koj daim ntawv thov kev pab los yog koj qhov kev pab cuam los ntawm Premera Blue Cross. Tej zaum muaj cov hnub tseem ceeb uas sau rau hauv daim ntawv no. Tej zaum koj kuj yuav tau ua qee yam uas peb kom koj ua tsis pub dhau cov caij nyoog uas teev tseg rau hauv daim ntawv no mas koj thiaj yuav tau txais kev pab cuam kho mob los yog kev pab them tej nqi kho mob ntawd. Koj muaj cai kom lawv muab cov ntshiab lus no uas tau muab sau ua koj hom lus pub dawb rau koj. Hu rau 800-722-1471 (TTY: 800-842-5357). Iloko (Ilocano): Daytoy a Pakdaar ket naglaon iti Napateg nga Impormasion. Daytoy a pakdaar mabalin nga adda ket naglaon iti napateg nga impormasion maipanggep iti apliksayonyo wenno coverage babaen iti Premera Blue Cross. Daytoy ket mabalin dagiti importante a petsa iti daytoy a pakdaar. Mabalin nga adda rumbeng nga aramidenyo nga addang sakbay dagiti partikular a naituding nga aldaw tapno mapagtalinaedyo ti coverage ti salun-atyo wenno tulong kadagiti gastos. Adda karbenganyo a mangala iti daytoy nga impormasion ken tulong iti bukodyo a pagsasao nga awan ti bayadanyo. Tumawag iti numero nga 800-722-1471 (TTY: 800-842-5357). Italiano (Italian): Questo avviso contiene informazioni importanti. Questo avviso può contenere informazioni importanti sulla tua domanda o copertura attraverso Premera Blue Cross. Potrebbero esserci date chiave in questo avviso. Potrebbe essere necessario un tuo intervento entro una scadenza determinata per consentirti di mantenere la tua copertura o sovvenzione. Hai il diritto di ottenere queste informazioni e assistenza nella tua lingua gratuitamente. Chiama 800-722-1471 (TTY: 800-842-5357).
(Japanese): Premera Blue Cross

800-722-1471 (TTY: 800-842-5357)
(Korean): . Premera Blue Cross . . . . 800-722-1471 (TTY: 800-842-5357) .
(Lao): . Premera Blue Cross. . . . 800-722-1471 (TTY: 800-842-5357). (Khmer):

Premera Blue Cross

800-722-1471 (TTY: 800-842-5357)
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Polskie (Polish): To ogoszenie moe zawiera wane informacje. To ogoszenie moe zawiera wane informacje odnonie Pastwa wniosku lub zakresu wiadcze poprzez Premera Blue Cross. Prosimy zwrócic uwag na kluczowe daty, które mog by zawarte w tym ogoszeniu aby nie przekroczy terminów w przypadku utrzymania polisy ubezpieczeniowej lub pomocy zwizanej z kosztami. Macie Pastwo prawo do bezpatnej informacji we wasnym jzyku. Zadzwocie pod 800-722-1471 (TTY: 800-842-5357). Português (Portuguese): Este aviso contém informações importantes. Este aviso poderá conter informações importantes a respeito de sua aplicação ou cobertura por meio do Premera Blue Cross. Poderão existir datas importantes neste aviso. Talvez seja necessário que você tome providências dentro de determinados prazos para manter sua cobertura de saúde ou ajuda de custos. Você tem o direito de obter esta informação e ajuda em seu idioma e sem custos. Ligue para 800-722-1471 (TTY: 800-842-5357).
Român (Romanian): Prezenta notificare conine informaii importante. Aceast notificare poate conine informaii importante privind cererea sau acoperirea asigurrii dumneavoastre de sntate prin Premera Blue Cross. Pot exista date cheie în aceast notificare. Este posibil s fie nevoie s acionai pân la anumite termene limit pentru a v menine acoperirea asigurrii de sntate sau asistena privitoare la costuri. Avei dreptul de a obine gratuit aceste informaii i ajutor în limba dumneavoastr. Sunai la 800-722-1471 (TTY: 800-842-5357). P (Russian): . Premera Blue Cross. . , , . . 800-722-1471 (TTY: 800-842-5357). Fa’asamoa (Samoan): Atonu ua iai i lenei fa’asilasilaga ni fa’amatalaga e sili ona taua e tatau ona e malamalama i ai. O lenei fa’asilasilaga o se fesoasoani e fa’amatala atili i ai i le tulaga o le polokalame, Premera Blue Cross, ua e tau fia maua atu i ai. Fa’amolemole, ia e iloilo fa’alelei i aso fa’apitoa olo’o iai i lenei fa’asilasilaga taua. Masalo o le’a iai ni feau e tatau ona e faia ao le’i aulia le aso ua ta’ua i lenei fa’asilasilaga ina ia e iai pea ma maua fesoasoani mai ai i le polokalame a le Malo olo’o e iai i ai. Olo’o iai iate oe le aia tatau e maua atu i lenei fa’asilasilaga ma lenei fa’matalaga i legagana e te malamalama i ai aunoa ma se togiga tupe. Vili atu i le telefoni 800-722-1471 (TTY: 800-842-5357). Español (Spanish): Este Aviso contiene información importante. Es posible que este aviso contenga información importante acerca de su solicitud o cobertura a través de Premera Blue Cross. Es posible que haya fechas clave en este aviso. Es posible que deba tomar alguna medida antes de determinadas fechas para mantener su cobertura médica o ayuda con los costos. Usted tiene derecho a recibir esta información y ayuda en su idioma sin costo alguno. Llame al 800-722-1471 (TTY: 800-842-5357). Tagalog (Tagalog): Ang Paunawa na ito ay naglalaman ng mahalagang impormasyon. Ang paunawa na ito ay maaaring naglalaman ng mahalagang impormasyon tungkol sa iyong aplikasyon o pagsakop sa pamamagitan ng Premera Blue Cross. Maaaring may mga mahalagang petsa dito sa paunawa. Maaring mangailangan ka na magsagawa ng hakbang sa ilang mga itinakdang panahon upang mapanatili ang iyong pagsakop sa kalusugan o tulong na walang gastos. May karapatan ka na makakuha ng ganitong impormasyon at tulong sa iyong wika ng walang gastos. Tumawag sa 800-722-1471 (TTY: 800-842-5357). (Thai):

preferred drug list - premera blue cross

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