Your Choice

Pharmacy Benefit Guide

Effective January 1, 2011

www.upmchealthplan.com
Table of Contents
Your Choice Overview........................................... 1
Formulary Management Terms.............................. 2
Formulary....................................................... 2
Prior Authorization.......................................... 2
Step Therapy................................................... 2
Quantity Limits................................................ 2
Brands/Generics.................................................... 3
Network Pharmacy Providers................................. 3
Retail.............................................................. 3
Mail Order...................................................... 3
Specialty Medications...................................... 4
Other Supplies of Medication................................ 5
Vacation Supply.............................................. 5
Medication Supplies Not Covered
by UPMC Health Plan.................................. 5
Formulary Overview.............................................. 5
Your Choice Formulary.......................................... 6
Medications Not Covered by Your Choice........... 27
Non-Covered Medications with Covered
Alternatives................................................... 28
Your Choice Brand/Generic Reference Guide....... 31
Your Choice Overview
Good value and freedom of choice — the Your
Choice pharmacy program provides both by
offering you a variety of high-quality, effective
generic and brand-name prescription drugs.

When you need a prescription medication, you and

your doctor can choose from four different levels,
or “tiers,” to help you manage your prescription
drug costs. This gives you and your doctor the
freedom to choose the medication that is right for
you while helping you to better budget your health
care dollars.

The Your Choice formulary guide provides

information that is applicable to most
members. Please refer to your prescription
drug rider to see if your specific plan has any
differences.

UPMC Your Choice

Contact Numbers
Current Members:
UPMC Health Plan Pharmacy Services:
1-800-396-4139
UPMC Health Plan Member Services:
1-888-876-2756
TTY Services: 1-800-361-2629

Prospective Members:
Prospective members should direct their questions
to their company’s benefits administrator or to the
UPMC Health Plan Enrollment Hotline at
1-800-644-1046.

Online information is available at

www.upmchealthplan.com/pharmacy.

1
Formulary
Management Terms
Formulary
A formulary is a list of Food and Drug
Administration (FDA) approved medications that
the UPMC Health Plan Pharmacy and Therapeutics
(P&T) Committee determine will be covered.
The P&T Committee, made up of physicians and
pharmacists from communities throughout the
UPMC Health Plan service area, decides which
medications to include in the Your Choice
program based on a drug’s safety, effectiveness,
and cost. The P&T Committee’s job is to make
sure that the Your Choice Pharmacy program
provides you with high-quality, cost-effective
prescription medications. The P&T Committee
reviews and updates the Your Choice formulary
regularly throughout the year.
The most commonly prescribed Your Choice
drugs are listed in the formulary section of this
booklet. Please note that there are other drug
categories and drugs that Your Choice covers
besides the ones listed in the table. For the latest
information on the Your Choice drug table and
other pharmacy benefits, visit our website at
www.upmchealthplan.com/pharmacy. Select
“Your Choice” to access the searchable drug list.
Or you may call our Member Advocates at the
number listed on the back of your UPMC Health
Plan ID card. Another option is to use the Express
Scripts, Inc., online price check feature to look
for the specific member and exact medication in
question.
Medications not on the formulary are listed in
the “Medications Not Covered by Your Choice”
and “Non-Covered Medications with Covered
Alternatives” sections of this booklet.
Prior Authorization
If a drug requires prior authorization, your doctor
must consult with UPMC Health Plan before
prescribing it. Prior authorizations are set on a
drug-by-drug basis and require specific criteria
for approval based upon FDA and manufacturer
guidelines, medical literature, safety concerns,
and appropriate use. Drugs that require prior
authorization may be newer drugs for which
UPMC Health Plan wants to track usage, drugs
not used as a standard first option in treating
a medical condition, or drugs with potential
side effects that UPMC Health Plan wants to
monitor for patient safety. The UPMC Health
Plan Pharmacy Services Department must
authorize the use of these drugs before Your
Choice will begin to cover them.
These drugs are designated with the symbol
PA on the formulary tables in this booklet. In
addition, new drugs recently approved by the
FDA may require prior authorization until their
placement on the formulary has been determined.
Also, all compounded medications require
prior authorization. The only exceptions are
compounded hormone replacement therapies
and compounded narcotic analgesics, which are
not covered by the Your Choice benefit. All prior
authorization criteria are reviewed by the P&T
Committee.
Step Therapy
Step therapy is the practice of using specific
medications first when beginning drug therapy
for a medical condition. The preferred first
course of treatment may be drugs that are more
cost-effective or considered the standard first-
line treatment. The rules for each step therapy
medication are built into the computer files of
UPMC Health Plan’s prescription claims processing
system. Medications that require step therapy
are automatically approved if there is a record
that the member has already tried the preferred
medication(s). If there is no record of the preferred
medication(s) in the member’s medication history,
the physician must submit clinical information to
the Health Plan. Once that information is received,
the Health Plan will make a decision on payment
for the requested medication. Medications
affected by this process are designated with the
symbol ST on the formulary listing in this booklet.
Quantity Limits
Quantity limits are drug-specific and limit the
amounts of certain drugs that can be dispensed
during a specific period of time. For these drugs,
the P&T Committee follows FDA guidelines and
other clinical literature to limit how much of the
drug you may receive in a certain period of time
or how long you may stay on the drug.
Quantity limits promote appropriate use of the
drug, prevent waste, and control costs. Drugs
that have quantity limits are designated with the
symbol QL on the formulary tables included in
this booklet.
Prescriptions for controlled substances are
limited to a 30-day supply.
For some drugs, the manufacturer’s dosing
guidelines may recommend that patients take
the medication one time a day in a larger dose
2
instead of several times a day in smaller doses. For
these drugs, Your Choice follows the guidelines
and covers one larger dose per day. If there is a
medical reason that prevents you from taking the
medication once per day in a larger dose, your
doctor can call the UPMC Health Plan Pharmacy
Services Department at 1-800-979-UPMC (8762)
to request a medical exception for you.
Brands/Generics
Generic drugs are cost-effective alternatives
that offer the same level of safety and quality
as their brand-name equivalents. Generic drugs
have the same active ingredients as brand-name
medications, but inactive ingredients can vary,
such as dyes used to color generic medications
or powders used to shape the tablets. These
differences do not affect how generic medications
work in the body. Generic drugs deliver the same
amount of active ingredients in the same amount
of time as their brand-name equivalents.
Not all drugs have a generic equivalent. Generally,
new drugs are given patent protection for 20
years from the date of submission of the patent.
Once the patent expires, other pharmaceutical
companies can produce the same drug in a
generic formulation.
The FDA regulates generic drug manufacturers
just as it regulates the makers of brand-name
medications. Prior to selling generic medications in
the United States, a company must meet certain
criteria. To gain FDA approval, the maker of a
generic drug must prove that the drug’s active
ingredients, drug strength, and dosage form are
identical to those of the corresponding brand-
name drug. The generic drug must also pass strict
FDA measurements to ensure that it delivers the
same amount of active ingredient in the same
time frame as its brand-name counterpart. Finally,
the manufacturer of the generic drug must prove
that its product is produced under the same strict
guidelines as the brand-name drug.
The manufacturer can produce the generic
medicine only after these requirements are met.
After approval, the FDA continues to regularly
inspect all manufacturing facilities of both brand
and generic products to ensure that only high-
quality medications are sold in the United States.
Generic drugs have the same active ingredients
as their brand-name equivalents, but cost
significantly less. Before the FDA allows a brand-
name drug to be sold in the United States,
scientists spend years testing the medication to
3
establish its safety and efficacy in treating an
illness or condition. Once a brand-name drug is
approved, the company that developed it spends
millions of dollars to promote the drug through
advertising and educational programs.
Companies that make generic drugs do not have
to invest large amounts of money in research,
since the brand-name drug manufacturers have
already done this. In addition, generic companies
do not market their drugs. As a result, generic
drug manufacturers spend significantly less money
on magazine and television advertisements than
brand-name manufacturers do for their products.
Companies that make generic drugs pass these
savings on to you.
The Your Choice program requires you to
use a generic version of the drug if one is
available. This means that if you receive a brand-
name drug when a generic is available, you must
pay the brand copayment in addition to the retail
cost difference between the brand-name and
generic forms of the drug.
Network Pharmacy Providers
Retail
UPMC Health Plan’s network of retail pharmacies
includes hundreds of locations — independent
pharmacies as well as multistore chains —
throughout the region. You can take your
prescription to any pharmacy in the network
and the pharmacist will confirm your eligibility
for benefits, fill your prescription, accept your
copayment, and process your claim. Seventy-
five percent of your medication must be used
before you can get a refill. For specific pharmacy
names, locations, and telephone numbers, look
in the provider directory sent to you during open
enrollment, or on the Health Plan website at
www.upmchealthplan.com/pharmacy. You
may also call our Member Advocates at the phone
number listed on the back of your member ID
card or on page 1 of this booklet.
Mail Order
UPMC Health Plan has a contract with a mail-
order pharmacy fulfillment center to offer you
cost-savings and the convenience of having
prescriptions for maintenance drugs sent
directly to your home. Maintenance drugs are
drugs that you take on a regular, long-term
basis. They include medications that treat high
blood pressure, asthma, diabetes, arthritis, high
cholesterol, and other chronic conditions.
With this convenient mail-order service:
• You receive a 90-day supply of most
drugs, plus refills, as prescribed by your
doctor.
• You usually pay a lower out-of-pocket cost for
a 90-day supply than you would pay at a retail
pharmacy.
• You enjoy strict quality and safety controls for
every prescription filled.
Refer to your UPMC Health Plan prescription drug
schedule of benefits or your UPMC Health Plan ID
card for your actual prescription copayments.
For a first-time prescription or a new medication,
UPMC Health Plan recommends that you try a
30-day supply of the drug from a retail pharmacy
before requesting a 90-day supply through the
mail-order program. This approach reduces
wasted medication and unnecessary copayments
by giving your doctor a chance to make sure that
the medication is the right dose for you and that
it does not cause you any side effects.
To use the mail-order program, ask your doctor
to write a prescription for a 90-day supply of
each maintenance drug that you need (plus
refills if appropriate). If your prescription is for
a new medication, or if you need to start your
medication immediately, have your doctor write
two prescriptions:
• One for your initial 30-day supply that you
can fill immediately at a retail pharmacy to
determine whether the medication works for
you, and
• A second one for your longer 90-day
maintenance supply that you can send to
UPMC Health Plan’s contracted mail-order
pharmacy.
You can request a mail-order form from UPMC
Health Plan by calling our Member Advocates or
requesting the form on the UPMC Health Plan
website at
www.upmchealthplan.com/pharmacy. On the
mail-order form, fill out the patient information
section (name, member ID number, date of birth,
relationship to subscriber, gender, doctor, and
doctor’s phone number) for each new prescription
you send. New prescription slip(s) must list the
patient’s full name, date of birth, and address, as
well as the doctor’s name and phone number.
To avoid running out of your mail-order
prescription, reorder your medication while you
still have an adequate supply remaining, allowing
a few weeks for processing and delivery.To
4
request refills, you may order over the telephone
or the Internet. Refer to UPMC Health Plan’s mail-
order prescription program description included in
your Welcome Book or to the Health Plan website
for the latest contact information, telephone
numbers, and website addresses regarding mail-
order prescription services.
When you mail a request for a new prescription or
a refill, please include your copayment in the mail-
order envelope. You may pay by check, money
order, or credit card (American Express,
Discover, MasterCard, or Visa). Do not send cash.
If ordering refills by phone or online, you must pay
by credit card.
Typically, mail-order prescriptions are written
for a 90-day supply. If the physician writes for a
30-day supply with two refills and you send it to
the mail-order facility, they may consolidate the
prescription to make one 90-day supply. If you do
not intend to receive a 90-day supply from the
mail-order facility, please indicate this on the mail-
order form.
Your prescription drug order will be processed
promptly and shipped to you along with
instructions for future orders. Using mail order
promotes the convenience of home delivery plus
cost savings.
Specialty Medications
Specialty medications are a category of drugs
created because of advancements in drug
development. This category includes high-
cost medications and biologicals regardless of
how they are administered (injectable, oral,
transdermal, or inhalant).
These medications are often used to treat
complex clinical conditions and usually require
close management by a physician because of
their potential side effects and the need for
frequent dosage adjustments. Some specialty
medications may require prior authorization and/
or have quantity limits. These medications require
the third-tier copayment but are included in a
separate specialty tier.
Most specialty medications must be obtained
through our designated specialty provider, which
provides convenient mail-order delivery. By using
a specialty provider, you have improved access
to drugs, as many retail pharmacies do not carry
these types of medications. In addition, specialty
providers improve care by providing education
for our members and expanded access to health
care professionals trained in the proper use of
these specialty medications. A specialty provider
offers cost-effective health care and medication
management and compliance programs.
Specialty medications are limited to a 30-day
supply.
Other Supplies of Medication
Vacation Supply
UPMC Health Plan uses a nationwide pharmacy
benefits company to help manage the Your
Choice pharmacy program. Your prescription
needs are covered even when you travel outside
of the western Pennsylvania area. Thousands of
pharmacies across the country will honor your
UPMC Health Plan member ID card.
To fill a prescription outside of the UPMC Health
Plan service area, simply present your Health Plan
member ID card at a pharmacy that participates
in our pharmacy benefits manager’s nationwide
network. To locate a participating pharmacy, or
to be put in contact with the national pharmacy
benefits management company, please contact
our Member Advocates at the phone number
listed on the back of your member ID card or on
page 1 of this booklet.
When you receive your prescription, some
pharmacies may ask you to pay the full price
of the medication rather than your normal
copayment. If this should happen, you can
Formulary Overview
Your Choice prescription drugs are organized into
four tiers:
1. The first tier is for generic drugs, which have
the lowest copayment. Generic drugs are
cost-effective alternatives that offer the same
level of safety and quality as their brand-name
equivalents.
2. The second tier is for preferred-brand drugs,
which have the middle level of copayment.
UPMC Health Plan classifies these drugs
as “preferred” because of their value and
effectiveness.
3. The third tier is for non-preferred brand drugs,
which have the highest copayment level.
4. The fourth tier is for specialty drugs, which
are high-cost medications and biologicals,
regardless of how they are administered
(injectable, oral, transdermal, or inhalant).
These drugs also have the highest level of
copayment. These medications are often used
5
submit a Direct Reimbursement Claim to UPMC
Health Plan and ask to be reimbursed. The form is
available on the website at
www.upmchealthplan.com. Under the
“Members” link at the bottom right of the
screen, select “Commonly Used Forms,” and then
“Pharmacy Program Direct Reimbursement Claim
Form.” Or you may call the UPMC Health Plan
Member Services Department to request the form.
If your claim is approved, you will be reimbursed
the amount that you paid for the medication, less
the appropriate copayment.
If you will be gone for an extended period of time,
or if you will be traveling outside of the country,
you may consider using our mail-order system so
that you receive a 90-day supply prior to traveling
with no interruptions in use.
Medication Supplies Not Covered by UPMC
Health Plan
• No authorizations will be provided for
medications that are reported by the
member, provider, or pharmacy to be lost,
misplaced, stolen, destroyed, or damaged.
• Medications received at no charge to
the member (workers’ compensation,
medications purchased with a
manufacturer’s coupon, etc.) will not be
covered.
• Prescriptions that are written more than
a year ago will not be covered. A new
prescription should be written by the
physician.
to treat complex clinical conditions and usually
require close management by a physician
because of their potential side effects and the
need for frequent dosage adjustments.
If you are a current UPMC Health Plan member,
please refer to your Schedule of Benefits for
your copayment amounts. If you did not receive
a Schedule of Benefits in your Welcome Book,
please contact our Member Advocates at the
number on the back of your member ID card. Your
member ID card should also list your copayment
amounts.
If you are thinking about joining UPMC Health
Plan and would like information about copayment
amounts, review the Schedule of Benefits, which
you may have received from your company’s
Benefits Administrator or Human Resources
Department. If you did not receive a Schedule of
Benefits, contact your Benefits Administrator or
the UPMC Health Plan Enrollment Hotline listed on
page 1 of this booklet.
Effective January 1, 2011

Non-preferred

Non-preferred
Preferred

Preferred
Specialty

Specialty
Generic

Generic
Suggested Suggested
Drug Name Drug Name
Alternative(s) Alternative(s)

Abilify PA, QL (ST Advair 2

2
<12 years of age) lovastatin,
acarbose 1 Advicor 3 pravastatin,
Accolate 3 Singulair (ST) simvastatin, Lipitor
acebutolol 1 Aerobid 3 Flovent HFA, Qvar
acetaminophen/ Aerobid- M 3 Flovent HFA, Qvar
caffeine/ 1 Specialty
Afinitor PA, QL 3
dihydrocode QL medication
acetaminophen/ Plavix, ticlopidine,
1 Aggrenox 3
codeine QL dipyridamole
acetazolamide ER azelastine, Elestat,
1 Alamast 3
capsule Patanol
acetic acid 1 alagesic 1
acetic acid/ albuterol QL 1
1
hydrocortisone alclometasone
1
Specialty dipropionate
Actemra PA, QL 3
medication Specialty
Aldurazyme PA 3
Specialty medication
Actimmune PA 3
medication alendronate 1
Actonel QL 2 allopurinol 1
Actonel Weekly QL 2 azelastine, Elestat,
Alocril 3
Actonel with Patanol
2
Calcium QL azelastine, Elestat,
Alomide 3
ActoPlus Met 2 Patanol
Actos 2 Alora QL 3 estradiol
ketorolac, Aloxi ST, QL 3 ondansetron (QL)
Acuvail QL 3
diclofenac alprazolam 1
acyclovir 1 alprazolam ODT 1
tretinoin, benzoyl fluorometholone,
Alrex 3
peroxide, prednisolone
Aczone 3
clindamycin, Alvesco 3 Flovent HFA, Qvar
adapalene (PA)
amantadine 1
Specialty
Adagen PA 3 amcinonide 1
medication
adapalene (PA Specialty
1 Amevive PA, QL 3
>35 years of age) medication

Specialty Amitiza QL 3 lactulose

Adcirca PA, QL 3 amitriptyline 1
medication
Adrenaclick 3 EpiPen

KEY COPAYMENT TIER

QL = Quantity Limits 1 = Generic Medications
PA = Prior Authorization required 2 = Preferred-Brand Medications
ST = Step Therapy required 3 = Non-Preferred Brand Medications & Specialty Medications

* Age restrictions apply to some medications.

6
 Non-preferred

Non-preferred
Preferred

Preferred
Specialty

Specialty
Generic

Generic
Suggested Suggested
Drug Name Drug Name
Alternative(s) Alternative(s)

amlodipine Aptivus 2
1
besylate Aquoral 3 Caphosol
amlodipine Specialty
besylate/ 1 Aralast NP PA 3
medication
benazepril
Aranelle 1
ammonium
1 Specialty
lactate Aranesp PA 3
medication
Amnesteem 1
Specialty
amoxicillin 1 Arcalyst PA, QL 3
medication
amoxicillin/ Aricept PA 2
1
clavulanate
Specialty
amoxicillin/ Arixtra QL 3
1 medication
clavulanate ER
Aromasin 2
amphetamine/
dextroamphetamine 1 Generic NSAIDS
ER QL (naproxen,
amphetamine Arthrotec 3 ibuprofen,
1 diclofenac,
salts QL
nabumetone)
Specialty
Ampyra PA, QL 3 Asacol 2
medication
hydrocortisone/ Asacol HD 2
Analpram HC 3
pramoxine Ascensia blood
2
anastrozole 1 glucose products
testosterone Asmanex 3 Flovent HFA, Qvar
Androderm PA 3
injection lisinopril, captopril,
testosterone Atacand ST 3 quinapril, losartan,
Androgel PA 3 Diovan, Micardis
injection
testosterone lisinopril, captopril,
Android PA 3 quinapril, losartan,
injection Atacand HCT ST 3
HCTZ, Diovan HCT,
Angeliq 3 Premarin
Micardis HCT
Antara 3 fenofibrate, Tricor
Atripla 2
antibiotics
1 Atrovent HFA 2
(generic oral)
atenolol 1
Anzemet ST, QL 3 ondansetron (QL)
lisinopril, captopril,
Apidra 3 Humalog, Novolog
quinapril, losartan,
Specialty Avalide ST 3
Apokyn QL 3 HCTZ, Diovan HCT,
medication Micardis HCT
apraclonidine 1 Avandamet 2
Apri 1 Avandaryl 2
Apriso 2 Avandia 2
KEY COPAYMENT TIER
QL = Quantity Limits 1 = Generic Medications
PA = Prior Authorization required 2 = Preferred-Brand Medications
ST = Step Therapy required 3 = Non-Preferred Brand Medications & Specialty Medications

* Age restrictions apply to some medications.

7
Effective January 1, 2011

Non-preferred

Non-preferred
Preferred

Preferred
Specialty

Specialty
Generic

Generic
Suggested Suggested
Drug Name Drug Name
Alternative(s) Alternative(s)

lisinopril, captopril, beflex 1

Avapro ST 3 quinapril, losartan, benazepril 1
Diovan, Micardis
benazepril/HCTZ 1
Avelox 3 ciprofloxacin
lisinopril, captopril,
Aviane 1 Benicar ST 3 quinapril, losartan,
Avodart 2 Diovan, Micardis
Specialty lisinopril, captopril,
Avonex QL 3
medication quinapril, losartan,
Benicar HCT ST 3
sumatriptan (QL), HCTZ, Diovan HCT,
Axert QL 3 naratriptan (QL) Micardis HCT
Maxalt (QL) benprox 1
Azasite 3 erythromycin erythromycin/
Benzaclin 2 3
azelastine 1 benzoyl peroxide
Azelex (PA >35 Generic topical benzoyl peroxide 1
3
years of age) acne agents benztropine 1
carbidopa/ azelastine, Elestat,
Bepreve 3
levodopa, Patanol
Azilect 3 ropinirole, Specialty
pramipexole, Berinert PA 3
medication
selegiline
ciprofloxacin,
azithromycin QL 1 Besivance 3 ofloxacin,
Azmacort 3 Flovent HFA, Qvar Vigamox, Zymar
Azopt 2 betamethasone 1
lisinopril, captopril, betaxolol 1
Azor ST 3 quinapril, losartan, Betimol 3 timolol, Betoptic S
Diovan, Micardis
Betoptic S 2
baclofen 1
bicalutamide 1
mupirocin
Bactroban cream 3 bisoprolol 1
ointment
bisoprolol/HCTZ 1
Bactroban nasal mupirocin
3 alendronate,
ointment ointment Boniva tablet QL 3
Actonel
balsalazide
1 Boniva IV syringe alendronate,
disodium 3
PA, QL Actonel
felbamate,
lamotrigine, Specialty
Banzel PA 3 Botox PA, QL 3
topiramate, medication
valproate bp 10-1 wash 1
fluticasone, BPO gel 1
Beconase AQ ST 3 flunisolide,
brimonidine
Veramyst 1
tartrate

KEY COPAYMENT TIER

QL = Quantity Limits 1 = Generic Medications
PA = Prior Authorization required 2 = Preferred-Brand Medications
ST = Step Therapy required 3 = Non-Preferred Brand Medications & Specialty Medications

* Age restrictions apply to some medications.

8
 Non-preferred

Non-preferred
Preferred

Preferred
Specialty

Specialty
Generic

Generic
Suggested Suggested
Drug Name Drug Name
Alternative(s) Alternative(s)

Brovana 3 Serevent, Foradil diltiazem, cartia

budeprion XL QL 1 XT, nifedipine,
nifedipine
budesonide ER, taztia XT,
respules (< 9 1 Cardene SR 3 verapamil,
years of age) verapamil SR,
Specialty Nifediac CC,
Buphenyl PA 3
Medication amlodipine
buprenorphine besylate
1
PA, QL Cardura XL QL 3 doxazosin
bupropion 1 carisoprodol 1
bupropion SA 1 carteolol 1
buspirone 1 cartia XT 1
butorphanol nasal carvedilol 1
1
spray QL Specialty
Byetta QL 2 Cayston QL 3
medication
atenolol, cefpodoxime,
Bystolic ST 3 metoprolol, Cedax 3
cefdinir
propranolol cefaclor 1
Caduet 2 cefadroxil 1
calcipotriene 1 cefdinir 1
calcitriol 1 cefpodoxime 1
calcium acetate 1 cefprozil 1
Camila 1 cefuroxime 1
Campral 2 Generic NSAIDS
Asacol, balsalazide (naproxen,
disodium, Celebrex ST, QL 3 ibuprofen,
Canasa 3 sulfasalazine, diclofenac,
sulfasalazine EC, nabumetone)
Apriso Premarin, estradiol,
Caphosol 2 Cenestin 3
estropipate
captopril 1 cephalexin 1
captopril/HCTZ 1 Specialty
Cerezyme PA 3
carbamazepine medication
1
XR Ciprodex, Cipro
Cetraxal 3
carbidopa/ HC, ofloxacin
1
levodopa
chlordiazepoxide 1
carboptic 3% 1
chlorpropamide 1

KEY COPAYMENT TIER

QL = Quantity Limits 1 = Generic Medications
PA = Prior Authorization required 2 = Preferred-Brand Medications
ST = Step Therapy required 3 = Non-Preferred Brand Medications & Specialty Medications

* Age restrictions apply to some medications.

9
Effective January 1, 2011

Non-preferred

Non-preferred
Preferred

Preferred
Specialty

Specialty
Generic

Generic
Suggested Suggested
Drug Name Drug Name
Alternative(s) Alternative(s)

chlorpromazine clozapine (ST <12

1
(ST <12 years of 1 years of age)
age) Coartem 2
chlorzoxazone 1 codeine sulfate 1
cholestyramine 1 Cognex PA 3 Aricept (PA)
ciclopirox 1 colestipol 1
cilostazol 1 Combigan 2
ciprofloxacin, estradiol-
Ciloxan 3 ofloxacin, norethindrone,
Vigamox, Zymar Combipatch QL 3
Prempro,
cimetidine 1 Premphase
Specialty Combivir 2
Cimzia PA, QL 3
medication Comtan 2
Specialty Concerta QL 2
Cinryze PA, QL 3
medication
Specialty
Cipro HC 2 Copaxone QL 3
medication
Ciprodex 2 Specialty
Copegus QL 3
ciprofloxacin 1 medication
ciprofloxacin ER Generic topical
1 Cordran QL 3
QL steroids
citalopram 1 Generic topical
Cordran SP 3
Claravis 1 steroids
clarithromycin 1 Coreg CR 3 carvedilol
clarithromycin ER cortamox 1
1
QL hydrocortisone
Climara-PRO QL 3 estradiol suppositories,
Cortifoam 3
proctozone,
Clinac BPO 3 benzoyl peroxide proctocare
clindamycin 1 diltiazem, cartia
clindamycin topical XT, nifedipine,
Clindareach 3
products nifedipine
clobetasol 1 ER, taztia XT,
Covera- HS 3 verapamil,
Generic topical
Cloderm 3 verapamil SR,
steroids
Nifediac CC,
clonazepam 1 amlodipine
clonidine 1 besylate
clorazepate Creon 2
1
dipotassium Crixivan 2
clotrimazole 1 Cryselle 1

KEY COPAYMENT TIER

QL = Quantity Limits 1 = Generic Medications
PA = Prior Authorization required 2 = Preferred-Brand Medications
ST = Step Therapy required 3 = Non-Preferred Brand Medications & Specialty Medications

* Age restrictions apply to some medications.

10
 Non-preferred

Non-preferred
Preferred

Preferred
Specialty

Specialty
Generic

Generic
Suggested Suggested
Drug Name Drug Name
Alternative(s) Alternative(s)

Generic topical diltiazem 1

Cutivate 3
steroids diltiazem ER 1
cyclobenzaprine 1 Diovan 2
cyclosporine 1 Diovan HCT 2
cyclosporine sulfasalazine,
1
modified sulfasalazine
Cymbalta ST, QL 2 Dipentum 3 EC, balsalazide
dantrolene 1 disodium, Asacol,
Apriso
Dapsone 2
dipyridamole 1
testosterone
Delatestryl PA 3 divalproex
injection 1
sodium
For cold sore
Denavir 3 treatment use over divalproex
1
the counter agents sodium ER
Generic oral Divigel 3 estradiol
Depo-Provera QL 3
contraceptives dorzolamide 1
Depo-Testosterone testosterone dorzolamide-
3 1
PA injection timolol
Generic topical doxazosin 1
Derma-Smoothe/FS 3
steroids doxycycline 1
Generic topical Drithocreme 2
Dermatop 3
steroids
dronabinol 1
desonide 1
Duetact 2
desoximetasone 1
Dulera 3 Advair, Symbicort
Detrol 2
Durasal 3 salicyclic acid
Detrol LA 2
fluorometholone,
dexmethylphenidate Durezol 3
QL
1 prednisolone
dextroamphetamine diltiazem, cartia
QL
1 XT, nifedipine,
Diastat QL 2 nifedipine
ER, taztia XT,
diazepam 1 Dynacirc CR 3 verapamil,
diclofenac 1 verapamil SR,
diclofenac Nifediac CC,
ophthalmic 1 amlodipine
solution besylate
dicloxacillin 1 dyphylline gg 1
didanosine 1 Specialty
Dysport PA, QL 3
medication
diflorasone 1

KEY COPAYMENT TIER

QL = Quantity Limits 1 = Generic Medications
PA = Prior Authorization required 2 = Preferred-Brand Medications
ST = Step Therapy required 3 = Non-Preferred Brand Medications & Specialty Medications

* Age restrictions apply to some medications.

11
Effective January 1, 2011

Non-preferred

Non-preferred
Preferred

Preferred
Specialty

Specialty
Generic

Generic
Suggested Suggested
Drug Name Drug Name
Alternative(s) Alternative(s)

Effient QL 2 Errin 1
Specialty erythromycin 1
Elaprase PA 3
medication erythromycin/
Elestat 2 benzoyl peroxide 1
Generic topical gel
Elidel PA 3
steroids estradiol,
Specialty Estrace cream 3 estropipate,
Eligard PA, QL 3 Premarin
medication
eliphos 1 Estraderm QL 3 estradiol
azelastine, Elestat, estradiol 1
Emadine 3
Patanol estradiol patch QL 1
Emend QL 2 estradiol-
1
Emtriva 2 norethindrone
oxybutynin, estradiol,
oxybutynin ER, Estring 3 estropipate,
Enablex 3 Premarin
trospium, Detrol,
Detrol LA, Vesicare Estrogel 3 Premarin
enalapril 1 estropipate 1
Specialty etidronate 1
Enbrel PA, QL 3
medication etodolac 1
estradiol, Evamist 3 estradiol
Enjuvia 3 estropipate,
Evista 2
Premarin
Evoxac 2
enoxaparin QL 1
Exforge 2
Enpresse 1
Exforge HCT 2
Entocort EC 2
Specialty
epiklor 1 Fabrazyme PA 3
medication
Epinephrine 3 EpiPen
Factive QL 3 ciprofloxacin
EpiPen 2
famciclovir QL 1
Epivir 2
famotidine 1
eplerenone 1
risperidone (ST),
Specialty Zyprexa (ST),
Epogen PA 3 Fanapt PA, QL (ST
medication 3 Seroquel (PA, ST),
<12 years of age)
Specialty Abilify (PA, ST),
Epoprostenol PA 3
medication Geodon (ST)
Epzicom 2 felodipine 1
ergotamine/
1
caffeine

KEY COPAYMENT TIER

QL = Quantity Limits 1 = Generic Medications
PA = Prior Authorization required 2 = Preferred-Brand Medications
ST = Step Therapy required 3 = Non-Preferred Brand Medications & Specialty Medications

* Age restrictions apply to some medications.

12
 Non-preferred

Non-preferred
Preferred

Preferred
Specialty

Specialty
Generic

Generic
Suggested Suggested
Drug Name Drug Name
Alternative(s) Alternative(s)

estradiol- flurbiprofen 1
norethindrone, fluticasone 1
FemHRT 3
Prempro,
fluvoxamine 1
Premphase
fluorometholone,
estradiol, FML Forte 3
prednisolone
Femring 3 estropipate,
Premarin Focalin XR QL 3 dexmethylphenidate
estradiol, Foradil 2
Femtrace 3 estropipate, Fortamet 3 metformin
Premarin
Specialty
fenofibrate 1 Forteo ST, QL 3
medication
fenoprofen 1 fosinopril 1
fentanyl citrate fosinopril/HCTZ 1
1
PA, QL
calcium acetate,
fentanyl Fosrenol 3
1 Renvela
transdermal QL
Specialty
fexofenadine 1 Fragmin QL 3
medication
fexofenadine/ sumatriptan (QL),
1
pseudoephedrine Frova QL 3 naratriptan (QL)
Generic topical Maxalt (QL)
Finacea 3
acne agents furosemide 1
finasteride 1 Specialty
Fuzeon 3
Specialty medication
Firmagon PA, QL 3
medication gabapentin 1
First-BXN diphenhydramine, galantamine PA 1
3
Mouthwash lidocaine, nystatin
galantamine ER
fluorometholone, 1
Flarex 3 PA
prednisolone
Specialty
Specialty Gammaplex PA 3
Flolan PA 3 medication
medication
ganciclovir 1
Flovent HFA 2
gavilyte-g 1
fluconazole QL 1
gemfibrozil 1
flunisolide 1
Geodon QL (ST
fluocinonide 1 2
<12 years of age)
fluorometholone 1 Gianvi 1
fluoxetine 1 Specialty
Gleevec PA, QL 3
fluoxetine DR QL 1 medication
fluphenazine (ST glimepiride 1
1
<12 years of age) glipizide 1

KEY COPAYMENT TIER

QL = Quantity Limits 1 = Generic Medications
PA = Prior Authorization required 2 = Preferred-Brand Medications
ST = Step Therapy required 3 = Non-Preferred Brand Medications & Specialty Medications

* Age restrictions apply to some medications.

13
Effective January 1, 2011

Non-preferred

Non-preferred
Preferred

Preferred
Specialty

Specialty
Generic

Generic
Suggested Suggested
Drug Name Drug Name
Alternative(s) Alternative(s)

glipizide ER 1 Humulin L 2
glipizide/ Humulin N 2
1
metformin Humulin R 2
Glucagon 2 Specialty
Hycamptin PA 3
glyburide medication
1
micronized hydrocodone/
glyburide/ acetaminophen 1
1
metformin QL
Glyset 2 hydrocodone/
1
granisetron ST, QL 1 ondansetron (QL) ibuprofen
granisol ST, QL 1 ondansetron (QL) hydrocort-
1
pramoxine cream
Halflytely 3
hydrocortisone 1
halobetasol 1
hydromorphone 1
Generic topical
Halog 3 hydroxychloroquine 1
steroids
haloperidol (ST hydroxyzine 1
1
<12 years of age) hyoscyamine 1
Halotin 3 nystatin ibuprofen 1
HCTZ 1 Specialty
Ilaris PA, QL 3
Heather 1 medication
Hectorol 2 imiquimod 1
bismuth Specialty
Increlex PA 3
subsalicylate (OTC), medication
Helidac 3
metronidazole, indomethacin 1
tetracycline Specialty
Infergen PA, QL 3
Specialty medication
Hexalen 3
medication atenolol,
Specialty Innopran XL ST 3 metoprolol,
Hizentra PA 3
medication propranolol
Humalog 2 Inova 3 benzoyl peroxide
Humalog 50/50 2 Intelence PA 2
Humalog 75/25 2 Specialty
Intron A PA 3
Specialty medication
Humatrope PA 3
medication Intuniv QL 3 guanfacine
Specialty risperidone (ST),
Humira PA, QL 3
medication Zyprexa (ST),
Invega PA, QL (ST
Humulin 50/50 2 3 Seroquel (PA, ST),
<12 years of age)
Abilify (PA, ST),
Humulin 70/30 2 Geodon (ST)

KEY COPAYMENT TIER

QL = Quantity Limits 1 = Generic Medications
PA = Prior Authorization required 2 = Preferred-Brand Medications
ST = Step Therapy required 3 = Non-Preferred Brand Medications & Specialty Medications

* Age restrictions apply to some medications.

14
 Non-preferred

Non-preferred
Preferred

Preferred
Specialty

Specialty
Generic

Generic
Suggested Suggested
Drug Name Drug Name
Alternative(s) Alternative(s)

Invega Sustenna Specialty

Specialty Kuvan PA 3
PA, QL (ST <12 3 medication
medication
years of age) lactulose 1
Invirase 2 lamotrigine QL 1
ipratropium- lansoprazole ST,
1 1 Omeprazole OTC
albuterol solution QL
ciprofloxacin, Lantus 2
Iquix 3 ofloxacin,
Leena 1
Vigamox, Zymar
leflunomide 1 3
Specialty
Iressa PA, QL 3 Lessina 1
medication
Isentress 2 Specialty
Letairis PA, QL 3
medication
isradipine 1
Specialty
itraconazole Leukine 3
1 medication
capsule PA, QL
Specialty
Jalyn 2 leuprolide PA 3
medication
Janumet 2
Levaquin 3 ciprofloxacin
Januvia 2
atenolol,
Jolessa 1 Levatol ST 3 metoprolol,
Jolivette 1 propranolol
Junel 1 Levemir 2
Junel FE 1 levetiracetam 1
Specialty Levlite 1
Kalbitor PA 3
medication levobunolol 1
Kaletra 2 Levora 1
Kariva 1 levothyroxine 1
levetiracetam, Lexapro ST, QL 2
Keppra XR 3
lamotrigine
Lexiva 2
azithromycin,
sulfasalazine,
Ketek QL 3 clarithromycin ER,
sulfasalazine
erythromycin
Lialda 3 EC, balsalazide
ketoconazole 1 disodium, Asacol,
ketoprofen 1 Apriso
ketorolac QL 1 lidocaine-hc gel 1
ketorolac Lidoderm ST, QL 2
ophthalmic 1
solution
Specialty
Kineret PA, QL 3
medication

KEY COPAYMENT TIER

QL = Quantity Limits 1 = Generic Medications
PA = Prior Authorization required 2 = Preferred-Brand Medications
ST = Step Therapy required 3 = Non-Preferred Brand Medications & Specialty Medications

* Age restrictions apply to some medications.

15
Effective January 1, 2011

Non-preferred

Non-preferred
Preferred

Preferred
Specialty

Specialty
Generic

Generic
Suggested Suggested
Drug Name Drug Name
Alternative(s) Alternative(s)

Lifescan Blood Lyrica PA, QL 3 gabapentin

Glucose products Generic NSAIDS
(One Touch (naproxen,
Basic, One Touch ibuprofen,
2
Ultra, One Touch Lysteda PA, QL 3 diclofenac,
UltraSmart, One nabumetone)
Touch Ultra 2, One and generic oral
Touch Surestep) contraceptives
liothyronine 1 malathion 1
Lipitor 2 Maxair 3 Ventolin HFA
Lipofen 3 fenofibrate, Tricor Maxalt QL 2
lisinopril 1 Maxaquin 3 ciprofloxacin
lisinopril/HCTZ 1 fluorometholone,
Maxidex 3
Generic oral prednisolone
Loestrin 24 FE 3
contraceptives meclizine 1
loratadine OTC 1 medroxyprogesterone
acetate injection
1 3
lorazepam 1
Generic oral meloxicam 1
LoSeasonique 3
contraceptives Premarin, estradiol,
Menest 3
losartan 1 estropipate
losartan/HCTZ 1 Menostar QL 3 estradiol
fluorometholone, meperidine tablet 1
Lotemax 3
prednisolone mesalamine 1
Lotronex 2 methylphenidate,
lovastatin 1 amphetamine,
dextroamphetamine,
Lovaza 3 fenofibrate, Tricor Metadate CD (Non-
amphetamine-
covered >18 years 3
Low-ogestrel 1 dextroamphetamine
of age) QL ER, methylin,
loxapine (ST <12 methylin ER,
1
years of age) Concerta
Specialty Metadate ER QL 1
Lucentis PA 3
medication
metaxalone 1
Lumigan 2
metformin 1
Specialty
Lumizyme PA 3 metformin ER 1
medication
Methadose 1
Lunesta ST, QL 3 zolpidem, zaleplon
methamphetamine
Specialty 1
Lupron PA, QL 3 QL
medication
methazolamide 1
Generic oral
Lybrel 3 methocarbamol 1
contraceptives

KEY COPAYMENT TIER

QL = Quantity Limits 1 = Generic Medications
PA = Prior Authorization required 2 = Preferred-Brand Medications
ST = Step Therapy required 3 = Non-Preferred Brand Medications & Specialty Medications

* Age restrictions apply to some medications.

16
 Non-preferred

Non-preferred
Preferred

Preferred
Specialty

Specialty
Generic

Generic
Suggested Suggested
Drug Name Drug Name
Alternative(s) Alternative(s)

methotrexate 1 Multaq 2
Methylin ER QL 1 mupirocin 1
Methylin QL 1 mycophenolate
1
methylphenidate mofetil
1
QL Myfortic 2
methylprednisolone 1 Specialty
Myobloc PA, QL 3
metipranolol 1 medication
metoclopramide 1 Specialty
Myozyme PA 3
medication
metoprolol 1
nabumetone 1
metoprolol/HCTZ 1
nadolol 1
metoprolol SR 1
nadolol/
metronidazole 1 bendroflumethiazide
1
alendronate, Specialty
Miacalcin 3 Naglazyme PA 3
Actonel medication
Micardis 2 Namenda PA 2
Micardis HCT 2 naproxen 1
Microgestin 1 naratriptan QL 1
Microgestin FE 1 flunisolide,
Migergot 1 Nasacort AQ ST 3 fluticasone,
Veramyst
Prednisolone
Millipred solution 3 flunisolide,
solution
Nasonex ST 3 fluticasone,
Mimvey 1
Veramyst
minocycline 1
Generic oral
pramipexole, Natazia 3
Mirapex ER ST 3 contraceptives
ropinirole
nateglinide 1
mirtazapine 1
Necon 1
Moban (ST <12
2 antipyrine-
years of age) Neotic 3
benzocaine
moexipril 1
Specialty
moexipril/HCTZ 1 Neulasta PA 3
medication
mometasone 1 Specialty
Neumega 3
MonoNessa 1 medication
morphine sulfate Specialty
1 Neupogen PA 3
IR medication
morphine sulfate ketorolac,
1 Nevanac 3
SR QL diclofenac
Specialty Specialty
Mozobil PA, QL 3 Nexavar PA, QL 3
medication medication
KEY COPAYMENT TIER
QL = Quantity Limits 1 = Generic Medications
PA = Prior Authorization required 2 = Preferred-Brand Medications
ST = Step Therapy required 3 = Non-Preferred Brand Medications & Specialty Medications

* Age restrictions apply to some medications.

17
Effective January 1, 2011

Non-preferred

Non-preferred
Preferred

Preferred
Specialty

Specialty
Generic

Generic
Suggested Suggested
Drug Name Drug Name
Alternative(s) Alternative(s)

Nexium ST, QL 3 Omeprazole OTC ofloxacin 1

Niaspan 2 3 Specialty
Oforta PA 3
nifediac CC 1 medication
nifedipine 1 Ogestrel 1
nifedipine ER 1 omeprazole OTC 1
nimodipine 1 fluticasone,
Omnaris ST 3 flunisolide,
nisoldipine 1 Veramyst
nitrofurantoin 1 Omnipred 3 prednisolone
nizatidine 1 ondansetron QL 1
Nora-BE 1 Onglyza 2
Specialty
Norditropin PA 3 oxycodone,
medication Onsolis PA, QL 3 morphine sulfate,
Nortrel 1 Opana
Norvir 2 Opana 2 3
Novolin 2 Opana ER QL 2 3
Novolin 70/30 2 Orap (ST <12 years
2
Novolin N 2 of age)
Novolin R 2 Specialty
Orencia PA 3
medication
Novolog 2
Nuvaring, generic
Novolog Mix 70/30 2 Ortho Evra QL 3
oral contraceptives
Specialty
Noxafil PA 3 Ortho Tri-Cyclen LO 2
medication
estradiol/
Specialty
Nplate PA 3 norethindrone,
medication Ortho-Prefest 3
Prempro,
Numoisyn 3 Caphosol Premphase
Nuvaring 2 Acetic acid/
Otosporin ear drops 3
Provigil (PA), hydrocortisone
methylphenidate,
Generic oral
amphetamine, Ovcon 3
dextroamphetamine,
contraceptives
Nuvigil PA, QL 3 amphetamine- oxaprozin 1
dextroamphetamine
oxazepam 1
ER, methylin,
methylin ER, oxcarbazepine 1
Concerta oxybutynin 1
NuZon 3 hydrocortisone oxybutynin ER 1
Ocella 1 oxycodone IR 1
Specialty
octreotide 3
medication

KEY COPAYMENT TIER

QL = Quantity Limits 1 = Generic Medications
PA = Prior Authorization required 2 = Preferred-Brand Medications
ST = Step Therapy required 3 = Non-Preferred Brand Medications & Specialty Medications

* Age restrictions apply to some medications.

18
 Non-preferred

Non-preferred
Preferred

Preferred
Specialty

Specialty
Generic

Generic
Suggested Suggested
Drug Name Drug Name
Alternative(s) Alternative(s)

oxycodone/ sulfasalazine,
acetaminophen 1 sulfasalazine
QL Pentasa 3 EC, balsalazide
oxycodone/ disodium, Asacol,
1 Apriso
aspirin QL
oxycodone/ pentazocine/
1 acetaminophen 1
ibuprofen QL
QL
Opana ER,
morphine sulfate pentazocine/
Oxycontin PA, QL 3 1
ER, fentanyl naloxone
patches Perforomist 3 Serevent, Foradil
oxybutynin, perindopril 1
oxybutynin ER, perphenazine (ST
Oxytrol 3 1
trospium, Detrol, <12 years of age)
Detrol LA, Vesicare
phenobarbital 1
Pancreaze 3 Creon, Zenpep
Phospholine Iodide 3 pilocarpine
Generic topical
Pandel 3 pilocarpine 1
steroids
Pilopine HS 3 pilocarpine
pantoprazole ST,
1 Omeprazole OTC pindolol 1
QL
carbidopa/ piroxicam 1
Parcopa 3
levadopa Plavix 2
paroxetine 1 podofilox 1
paroxetine CR QL 1 Generic NSAIDS
azelastine, Elestat, (naproxen,
Pataday 3 Ponstel 3 ibuprofen,
Patanol
diclofenac,
Patanase nasal
3 azelastine nabumetone)
spray
Portia 1
Patanol 2
potassium
peg-3350 1 1
chloride
Specialty
Pegasys PA, QL 3 pramipexole 1
medication
hydrocortisone/
Specialty Pramosone 3
Peg-Intron PA, QL 3 pramoxine
medication
metformin,
pemoline 1 Prandimet 3
Prandin
penicillin 1
Prandin 2
pravastatin 1 3
prazosin 1

KEY COPAYMENT TIER

QL = Quantity Limits 1 = Generic Medications
PA = Prior Authorization required 2 = Preferred-Brand Medications
ST = Step Therapy required 3 = Non-Preferred Brand Medications & Specialty Medications

* Age restrictions apply to some medications.

19
Effective January 1, 2011

Non-preferred

Non-preferred
Preferred

Preferred
Specialty

Specialty
Generic

Generic
Suggested Suggested
Drug Name Drug Name
Alternative(s) Alternative(s)

fluorometholone, propoxyphene/
Pred Mild 3
prednisolone acetaminophen 1
prednicarbate 1 QL
prednisolone 1 propranolol 1
estradiol/ propranolol/
1
norethindrone, HCTZ
Prefest 3
Prempro, propranolol SA 1
Premphase Proquin XR QL 3 ciprofloxacin
Premarin 2 protriptyline 1
Premarin Low Dose 2 Generic topical
Protopic PA 3
Premarin Vaginal steroids
2
Cream Proventil HFA QL 3 Ventolin HFA
Premphase 2 methylphenidate,
Prempro 2 amphetamine,
dextroamphetamine,
Prenate Essential 2 amphetamine-
Provigil PA, QL 3
lansoprazole dextroamphetamine
Prevpac 3 (ST), amoxicillin, ER, methylin,
clarithromycin methylin ER,
Concerta
Prezista 2
Prumyx cream 1
paroxetine,
sertraline, pruvate 21-7 1
Pristiq ST, QL 3 citalopram, Pulmicort Flexhaler 3 Qvar, Flovent HFA
venlafaxine ER Specialty
capsules Pulmozyme 3
medication
Specialty Quasense 1
Privigen PA 3
medication
quinapril 1
ProAir HFA QL 3 Ventolin HFA
quinapril/HCTZ 1
Specialty
Procrit PA 3 ciprofloxacin,
medication
Quixin 3 ofloxacin,
Specialty Vigamox, Zymar
Prolastin PA 3
medication
Specialty
Specialty Qutenza PA, QL 3
Prolastin-C PA 3 medication
medication
Qvar 2
Specialty
Proleukin 3 ramipril 1
medication
Ranexa 2
Specialty
Prolia PA, QL 3 Raniclor 3 cefaclor
medication
Specialty ranitidine 1
Promacta PA, QL 3
medication terazosin, prazosin,
Rapaflo 3
propoxyphene 1 doxazosin

KEY COPAYMENT TIER

QL = Quantity Limits 1 = Generic Medications
PA = Prior Authorization required 2 = Preferred-Brand Medications
ST = Step Therapy required 3 = Non-Preferred Brand Medications & Specialty Medications

* Age restrictions apply to some medications.
20
 Non-preferred

Non-preferred
Preferred

Preferred
Specialty

Specialty
Generic

Generic
Suggested Suggested
Drug Name Drug Name
Alternative(s) Alternative(s)

Rapamune PA 2 risperidone QL
Specialty (ST <12 years of 1
Rebif QL 3 age)
medication
Specialty risperidone ODT
Reclast PA, QL 3 QL (ST <12 years 1
medication
of age)
Regranex QL 2
methylphenidate,
Relenza QL 3 amantadine amphetamine,
Specialty dextroamphetamine,
Relistor PA 3 Ritalin LA (Non-
medication amphetamine-
covered >18 years 3
dextroamphetamine
sumatriptan (QL), of age) QL ER, methylin,
Relpax QL 3 naratriptan (QL) methylin ER,
Maxalt (QL) Concerta
Specialty Specialty
Remicade PA 3 Rituxan PA, QL 3 3
medication medication
Specialty rivastigmine PA 1
Remodulin PA 3
medication ropinirole 1
renalpren 1 Rythmol SR 2
Renvela 2 Specialty
Sabril PA, QL 3
reprexain 1 medication
ropinirole, Specialty
Requip XL ST 3 Samsca PA, QL 3
pramipexole medication
Rescriptor 2 oxybutynin,
Restasis 2 oxybutynin ER,
Sanctura XR 3
trospium, Detrol,
Retin-A Micro (PA Generic topical
3 Detrol LA, Vesicare
>35 years of age) acne agents
Sancuso ST, QL 3 ondansetron (QL)
Specialty
Revatio PA, QL 3 Sandostatin LAR Specialty
medication 3
PA, QL medication
Specialty
Revlimid PA, QL 3 Santyl 2
medication
Reyataz 2 risperidone (ST),
Zyprexa (ST),
flunisolide, Saphris ST, QL (ST
3 Seroquel (PA, ST),
Rhinocort AQ ST 3 fluticasone, <12 years of age)
Abilify (PA, ST),
Veramyst
Geodon (ST)
Specialty
ribavirin QL 3 Cymbalta (PA),
medication Savella PA, QL 3
gabapentin
Riomet 3 metformin
Generic oral
Risperdal Consta Seasonique 3
Specialty contraceptives
PA, QL (ST <12 3 3
medication selegiline 1
years of age)

KEY COPAYMENT TIER

QL = Quantity Limits 1 = Generic Medications
PA = Prior Authorization required 2 = Preferred-Brand Medications
ST = Step Therapy required 3 = Non-Preferred Brand Medications & Specialty Medications

* Age restrictions apply to some medications.

21
Effective January 1, 2011

Non-preferred

Non-preferred
Preferred

Preferred
Specialty

Specialty
Generic

Generic
Suggested Suggested
Drug Name Drug Name
Alternative(s) Alternative(s)

Selzentry PA 2 Specialty
Sprycel PA, QL 3
Sensipar 2 medication
Serevent 2 Stalevo 2
Seroquel PA, QL stavudine 1
(ST <12 years of 2 Specialty
Stelara PA, QL 3
age) medication
risperidone (ST), Strattera QL 2
Seroquel XR PA, QL Zyprexa (ST), testosterone
(ST <12 years of 3 Seroquel (PA, ST), Striant PA 3
injection
age) Abilify (PA, ST),
Suboxone PA, QL 2
Geodon (ST)
Specialty
Specialty Sucraid PA 3
Serostim PA 3 medication
medication
sulfacetamide
sertraline 1 1
sodium
simvastatin,
Simcor ST 2 sulfamethoxazole/
Niaspan 1
trimethoprim
Specialty
Simponi PA, QL 3 sulfasalazine 1
medication
sulfasalazine EC 1
simvastatin 1
sulfisoxazole 1
Singulair ST, QL 2
sulindac 1
SMZ-TMP 1
sumatriptan QL 1
sodium
sulfacetamide/ 1 Specialty
Supartz PA, QL 3
sulfur/urea medication
Specialty Supprelin LA PA, Specialty
Soliris PA 3 3
medication QL medication
Specialty cefpodoxime,
Somatuline PA, QL 3 Suprax 3
medication cefdinir
Specialty Sustiva 2
Somavert PA, QL 3
medication Specialty
Sutent PA, QL 3
Specialty medication
Soriatane 3
medication Symbicort 2
cefpodoxime, Symbyax PA, QL
Spectracef 3
cefdinir (ST <12 years of 2
Spiriva 2 age)
spironolactone 1 Symlin ST, QL 2
Sprintec 1 Specialty
Synagis PA, QL 3
medication
Sporanox solution itraconazole
3 Specialty
PA capsule (PA) Synarel PA, QL 3
medication

KEY COPAYMENT TIER

QL = Quantity Limits 1 = Generic Medications
PA = Prior Authorization required 2 = Preferred-Brand Medications
ST = Step Therapy required 3 = Non-Preferred Brand Medications & Specialty Medications

* Age restrictions apply to some medications.

22
 Non-preferred

Non-preferred
Preferred

Preferred
Specialty

Specialty
Generic

Generic
Suggested Suggested
Drug Name Drug Name
Alternative(s) Alternative(s)

Specialty Specialty
Synvisc PA, QL 3 Thalomid PA, QL 3
medication medication
Specialty theophylline 1
Synvisc One PA, QL 3
medication theophylline ER 1
tacrolimus 1 thioridazine (ST
1
Tamiflu QL 3 amantadine <12 years of age)
tamsulosin 1 thiothixene (ST
1
Specialty <12 years of age)
Tarceva PA, QL 3
medication Specialty
Thyrogen 3
Specialty medication
Targretin PA 3
medication ticlopidine 1
Specialty Tilia FE 1
Tasigna PA, QL 3
medication timolol maleate 1
Tasmar 3 Comtan Tirosint 3 levothyroxine
Tazorac (PA >35 Generic topical tizanidine 1
3
years of age) acne agents
Specialty
taztia XT 1 TOBI QL 3
medication
Tekturna ST 2 tobramycin/
1
Tekturna HCT ST 2 dexamethasone
Specialty ciprofloxacin,
Temodar PA 3
medication Tobrex 3 ofloxacin,
temazepam 1 Vigamox, Zymar
terazosin 1 tolazamide 1
terbinafine QL 1 tolbutamide 1 2
testosterone tolmetin 1
Testim PA 3
injection topiragen QL 1
testosterone PA 1 3 topiramate QL 1
testosterone topisulf 1
Testred PA 3
injection Specialty
Tracleer PA, QL 3
tetracaine medication
1
ophthalmic tramadol QL 1
tetracycline 1 tramadol ER QL 1
lisinopril, captopril, tramadol/
Teveten ST 3 quinapril, losartan, acetaminophen 1
Diovan, Micardis QL
lisinopril, captopril, trandolapril 1
quinapril, losartan,
Teveten HCT ST 3 trandolapril/
HCTZ, Diovan HCT, 1
verapamil
Micardis HCT
tranylcypromine 1
KEY COPAYMENT TIER
QL = Quantity Limits 1 = Generic Medications
PA = Prior Authorization required 2 = Preferred-Brand Medications
ST = Step Therapy required 3 = Non-Preferred Brand Medications & Specialty Medications

* Age restrictions apply to some medications.
23
Effective January 1, 2011

Non-preferred

Non-preferred
Preferred

Preferred
Specialty

Specialty
Generic

Generic
Suggested Suggested
Drug Name Drug Name
Alternative(s) Alternative(s)

Travatan 3 Xalatan, Lumigan urea 1

Travatan Z 3 Xalatan, Lumigan Urocit-K 3 potassium citrate
trazadone 1 terazosin, prazosin,
Uroxatral 3
Specialty doxazosin
Trelstar PA, QL 3
medication ursodiol 1
Specialty Premarin, estradiol,
tretinoin oral 3 Vagifem 3
medication estropipate
tretinoin topical 1 valacyclovir QL 1
Trezix 1 Valcyte QL 3 ganciclovir
triamcinolone 1 Valturna ST 2
Tricor 2 3 Vancocin capsules 2
trifluoperazine Vanoxide-HC 2 3 benzoyl peroxide
(ST <12 years of 1 Specialty
age) Vantas PA, QL 3
medication
Triglide 3 fenofibrate, Tricor Vasolex 3 Santyl
Tri-legest FE 1 Vectical QL 3 calcipotriene
Trilipix 3 fenofibrate, Tricor Velivet 1
Trinessa 1 venlafaxine 1
polymyxin/ venlafaxine ER
TriOxin otic 3 hydrocortisone, 1
capsule ST, QL
Cipro HC
Specialty
Tri-previfem 1 Ventavis PA 3
medication
Tri-sprintec 1 Ventolin HFA QL 2
Trivora 1 Veramyst 2
Trizivir 2 verapamil 1
trospium 1 verapamil ER PM 1
Truvada 2 verapamil
1
Twynsta 2 extended release
Specialty verapamil SR 1
Tykerb PA, QL 3
medication podofilox,
Veregen 3
Specialty imiquimod
Tysabri PA, QL 3
medication Vesicare 2
Specialty fluorometholone,
Tyvaso PA 3 Vexol 3
medication prednisolone
Specialty Vfend QL 2
Tyzeka 3
medication
Specialty
Ulesfia 2 Viadur PA 3
medication
Uloric ST, QL 3 allopurinol

KEY COPAYMENT TIER

QL = Quantity Limits 1 = Generic Medications
PA = Prior Authorization required 2 = Preferred-Brand Medications
ST = Step Therapy required 3 = Non-Preferred Brand Medications & Specialty Medications

* Age restrictions apply to some medications.

24
 Non-preferred

Non-preferred
Preferred

Preferred
Specialty

Specialty
Generic

Generic
Suggested Suggested
Drug Name Drug Name
Alternative(s) Alternative(s)

Victoza QL 3 Byetta Xalatan 2

Videx solution 2 Specialty
Xeloda PA 3
Vigamox 2 medication
divalproex sodium, Specialty
Xenazine PA, QL 3
gabapentin, medication
lamotrigine, ketorolac,
Xibrom 3
Vimpat PA 3 levetiracetam, diclofenac
oxcarbazepine, lactulose,
topiramate, Xifaxan PA, QL 3 ciprofloxacin,
zonisamide loperamide
Viracept 2 Specialty
Xolair PA, QL 3
Viramune 2 medication
Viread 2 Xopenex ST 3 albuterol
visqid a/a 1 Xopenex HFA QL 3 Ventolin HFA
vistra 1 Specialty
Xyrem PA, QL 3
vitamins (generic medication
1
pediatric) loratadine OTC,
Xyzal PA 3
vitamins (generic fexofenadine
1
prenatal) zaleplon 1
Vivelle-DOT QL 3 estradiol Specialty
Zavesca 3
diclofenac, medication
Voltaren Gel QL 3 ibuprofen, carbidopa/
naproxen levodopa,
Specialty Zelapar 3 ropinirole,
Votrient PA, QL 3 pramipexole,
medication
Comtan, Stalevo
Specialty
VPRIV PA 3 Specialty
medication Zemaira PA 3
medication
pravastatin,
Vytorin ST 2 3 simvastatin, Lipitor, Zemplar 3 Hectorol, Sensipar
Zetia Zenieva 1
methylphenidate, Zenpep 2
amphetamine,
Zetia 2
dextroamphetamine,
amphetamine- Ziagen 2
Vyvanse QL 3
dextroamphetamine clindamycin,
ER, methylin, Ziana gel (PA >35
3 tretinoin,
methylin ER, years of age)
Concerta, Strattera adapalene (PA)
warfarin 1 acetic acid/
Zinotic ES 3 hydrocortisone,
Welchol 2 Ciprodex

KEY COPAYMENT TIER

QL = Quantity Limits 1 = Generic Medications
PA = Prior Authorization required 2 = Preferred-Brand Medications
ST = Step Therapy required 3 = Non-Preferred Brand Medications & Specialty Medications

* Age restrictions apply to some medications.

25
Effective January 1, 2011

Non-preferred
Preferred

Specialty
Generic
Suggested
Drug Name
Alternative(s)

Zirgan gel 3 trifluridine

Zithranol 3 Drithocreme
azithromycin,
Zmax QL 3 clarithromycin,
erythromycin
Specialty
Zoladex PA, QL 3
medication
Specialty
Zolinza PA, QL 3
medication
zolpidem tartrate 1
sumatriptan (QL),
Zomig QL 3 naratriptan (QL)
Maxalt (QL)
zonisamide 1
Specialty
Zorbtive PA 3
medication
Zortress PA 2
Zovia 1
Zovirax topical 3 Oral antivirals
Zyflo 3 Singulair (ST)
Zyflo CR 3 Singulair (ST)
tobramycin/
Zylet 3
dexamethasone
Zymar 2
ciprofloxacin,
Zymaxid 3 ofloxacin,
Vigamox, Zymar
Zyprexa QL (ST <12
2
years of age)
Zyprexa Relprevv
Specialty
PA, QL (ST <12 3
medication
years of age)
Zyprexa Zydis QL
(ST <12 years of 2
age)
Zyvox QL 2

KEY COPAYMENT TIER

QL = Quantity Limits 1 = Generic Medications
PA = Prior Authorization required 2 = Preferred-Brand Medications
ST = Step Therapy required 3 = Non-Preferred Brand Medications & Specialty Medications

* Age restrictions apply to some medications.

26
Medications Not Covered by Your Choice
The following medications are benefit exclusions and will not be covered under the pharmacy benefit:

Anabolic steroids
Antimalarial agents
Antiobesity medications, including, but not limited to, appetite suppressants and
lipase inhibitors
Blood or blood plasma products*
Drugs labeled for investigational use
Drugs used for cosmetic purposes or hair growth
Fertility agents
Impotency drugs (examples are Viagra, Levitra, Cialis, Muse, Caverject)
Legend vitamins (other than prenatal, fluoride, and certain therapeutic vitamins)
Most over-the-counter medications
Needles/syringes (other than insulin)*
Nutrition and dietary supplements*
Ostomy supplies*
Smoking deterrents
Therapeutic devices/appliances*
Urine strips (Because our doctors feel blood glucose strips are more accurate than urine test strips in measuring blood glucose, urine strips
are not a covered benefit.)

*Please note that, under certain circumstances, your medical benefits may cover the items marked with an asterisk (*). For information
on these items, you can contact our Member Advocates at the number listed on the back of your member ID card. If you have not yet
received an ID card, call our Member Advocates number listed on page 1 of this booklet.

27
Non-Covered Medications with Covered Alternatives
Non-Covered Drug Alternative Drugs Non-Covered Drug Alternative Drugs
Acanya gel benzoyl peroxide, clindamycin Lipitor, lovastatin, pravastatin,
Crestor
simvastatin
omeprazole OTC, lansoprazole,
Aciphex methylphenidate,
pantoprazole, Nexium
amphetamine,
ActosPlusMet, Actos, dextroamphetamine,
ActosPlus Met XR
metformin Daytrana amphetamine-
Akten lidocaine dextroamphetamine ER,
Allfen codeine methylin, methylin ER,
Concerta, Strattera
clotrimazole, miconazole,
Aloquin gel Darvon-N propoxyphene
nystatin
Lipitor, lovastatin, pravastatin, Desonate desonide
Altoprev
simvastatin Dex-Tuss codeine
Ambien CR zolpidem, zaleplon, Lunesta omeprazole OTC, lansoprazole,
Dexilant
Amrix cyclobenzaprine pantoprazole, Nexium
Analpram E Kit pramoxine/hydrocortisone Differin lotion tretinoin, adapalene
Aplenzin ER bupropion SR, bupropion XL Dilaudid liquid hydromorphone
Astepro azelastine Doryx doxycycline hyclate
Atralin tretinoin, adapalene Duac CS kit benzoyl peroxide, clindamycin
doxycycline, topical salicylic Edluar zolpidem, zaleplon, Lunesta
Avidoxy DK Kit
acid products OTC Embeda morphine sulfate ER
Avinza morphine sulfate ER tranylcypromine sulfate,
Benzamycin Pak benzoyl peroxide/erythromycin Emsam fluoxetine, paroxetine,
citalopram, sertraline
BenzEFoam benzoyl peroxide
benzoyl peroxide, adapalene,
Betaseron Avonex, Rebif, Copaxone Epiduo gel
tretinoin
Bidil hydralazine, isosorbide dinitrate
Euflexxa Synvisc, Supartz
Ascensia Breeze, Ascensia
Exalgo hydromorphone
Blood Glucose Monitors Contour, One Touch Basic, One
Touch Sure Step Extavia Avonex, Rebif, Copaxone
Blood Glucose Test Ascensia and Lifescan test Fenofibric acid fenofibrate, Tricor
Strips strips Fenoglide fenofibrate, Tricor
Brontex codeine Fentora oxycodone, morphine sulfate
Cambia diclofenac Fexmid cyclobenzaprine
Carmol urea Fibricor fenofibrate, Tricor
Chenodal ursodiol Flector patch Voltaren Gel, diclofenac
Clarinex fexofenadine, loratadine OTC Fosamax Plus D alendronate
Clarinex-D fexofenadine, loratadine OTC Detrol, Detrol LA, oxybutynin,
Gelnique
Claritin-D fexofenadine, loratadine OTC oxybutynin ER, Vesicare
Cleanse & Treat Benzoyl peroxide Genotropin Humatrope, Norditropin
Clobex Clobetasol Glumetza metformin
Prempro, Premphase, triamcinolone, betamethasone,
Compounded Hormone Halonate
FemHRT, estradiol, estradiol- clobetasol
Replacement Therapy
norethindrone Hyalgan Synvisc, Supartz
hydrocodone/acetaminophen, Hycet hydrocodone
Compounded Narcotic
commercially available pain Ibudone hydrocodone, ibuprofen
Analgesics
products
IC400 Kit ibuprofen, naproxen

28
Non-Covered Drug Alternative Drugs Non-Covered Drug Alternative Drugs
IC800 Kit ibuprofen, naproxen Neobenz Micro benzoyl peroxide
Oral indomethacin, ibuprofen, Neutrasal Caphosol, Aquoral
Indocin suppository
naproxen nitroglycerin, Nitrostat,
NitroMist
Innohep Lovenox, Arixtra, Fragmin Nitroquick, Nitrolingual spray
J-Max DHC hydrocodone Nucort lotion hydrocortisone
Kadian morphine sulfate ER hydrocodone, morphine
Nucynta
Kerafoam urea sulfate, oxycodone, tramadol
Keralac urea Nutropin Humatrope, Norditropin
Kerol urea, lactic acid Oleptro trazodone, nefazodone
Lamictal XR lamotrigine Olux-Olux E clobetasol
Lamictal ODT lamotrigine omeprazole OTC, lansoprazole,
Omeprazole 40mg
pantoprazole, Nexium
Lamisil Granules terbinafine
Omeprazole/Sodium omeprazole OTC, lansoprazole,
Lipitor, lovastatin, pravastatin,
Lescol Bicarbonate pantoprazole, Nexium
simvastatin
Omnitrope Humatrope, Norditropin
Lipitor, lovastatin, pravastatin,
Lescol XL Oracea doxycycline
simvastatin
Oxycodone, hydromorphone, fluconazole, clotrimazole,
Levorphanol Oravig
hydrocodone Nystatin, itraconazole
Liquicet hydrocodone/acetaminophen acetaminophen/butalbital/
Orbivan
caffeine
Lipitor, lovastatin, pravastatin,
Livalo Orthovisc Synvisc, Supartz
simvastatin
Loratadine-D fexofenadine, loratadine OTC Ovace Plus Shampoo sodium sulfacetamide
Luvox CR fluvoxamine Pacnex Wash benzoyl peroxide
Lynox oxycodone/acetaminophen Pennsaid Voltaren Gel, diclofenac
Magnacet oxycodone/acetaminophen Perloxx oxycodone/acetaminophen
Mar-cof codeine paroxetine, sertraline,
Pexeva
citalopram
Meperidine solution meperidine tablet
Pramosone E hydrocortisone/pramoxine
methylphenidate, omeprazole OTC, lansoprazole,
amphetamine, Prilosec
pantoprazole, Nexium
dextroamphetamine,
Metadate CD (>18 yr omeprazole OTC, lansoprazole,
amphetamine- Prevacid SoluTabs
old) pantoprazole, Nexium
dextroamphetamine ER,
methylin, methylin ER, omeprazole OTC, lansoprazole,
Protonix
Concerta, Strattera pantoprazole, Nexium
Methadone Intensol methadone tablet Pylera metronidazole, tetracycline
Metozolv ODT metoclopramide Refissa tretinoin, adapalene
MetroGel topical metronidazole methylphenidate,
spironolactone, triamterene, amphetamine,
Midamor dextroamphetamine,
eplerenone, amiloride
Ritalin LA (>18 yr old) amphetamine-
Millipred prednisolone dextroamphetamine ER,
ammonium lactate, Prumyx, methylin, methylin ER,
Mimyx
Zenieva Concerta, Strattera
mometasone, ammonium
Momexin Combo Pack Asacol, balsalazide disodium,
lactate
Rowasa sulfasalazine, sulfasalazine EC,
Monodox doxycycline Apriso
Moxatag amoxicillin, penicillin Roxicet caplet oxycodone/acetaminophen
Naprelan CR naproxen
29
Non-Covered Drug Alternative Drugs
Rozerem zolpidem, zaleplon, Lunesta
Rybix ODT tramadol, tramadol ER
loratadine, fexofenadine,
Ryneze
cetirizine
Ryzolt ER tramadol, tramadol ER
Saizen Humatrope, Norditropin
Salkera salicylic acid products OTC
Salvax salicylic acid products OTC
Sarafem tablets fluoxetine
doxepin, zolpidem, zaleplon,
Silenor
Lunesta
Solaraze gel tretinoin, adapalene
Solodyn ER minocycline
Sumavel DosePro sumatriptan
Sumaxin sodium sulfacetamide/sulfur
Synalgos hydrocodone
Taclonex betamethasone, calcipotriene
Terbinex terbinafine
Tetravisc Forte tetracaine, Tetravisc
Tev-Tropin Humatrope, Norditropin
Theophylline solution Oral theophylline
Detrol, Detrol LA, oxybutynin,
Toviaz
oxybutynin ER, Vesicare
sumatriptan, sumatriptan and
Treximet
naproxen, naratriptan, Maxalt
Triaz benzoyl peroxide
Umecta urea
venlafaxine ER capsules,
Venlafaxine ER tablet paroxetine, sertraline,
citalopram
Veripred prednisolone
Vimovo naproxen, lansoprazole
Vivitrol Oral naltrexone
Xodol hydrocodone/acetaminophen
Xolox oxycodone/acetaminophen
Zamicet hydrocodone
Zanaflex capsule tizanidine tablet
Zencia sodium sulfacetamide/sulfur
diclofenac, ibuprofen,
Zipsor
naproxen
Zonatuss benzonatate
imiquimod, tretinoin,
Zyclara
adapalene, fluorouracil
Zypram hydrocortisone/pramoxine

30
Your Choice Brand/Generic Reference Guide
Brand Generic Brand Generic
Accupril Quinapril Coumadin Warfarin
Aceon Perindopril Cozaar Losartan
Estradiol-Norethindrone, Cutivate (topical), Flonase
Activella Fluticasone
Mimvey (nasal spray)
Acular Ketorolac Cyclocort Amcinonide
Amphetamine-dextroam- Cytomel Liothyronine
Adderall XR
phetamine ER Propoxyphene/Acetamino-
Darvocet
Aldactone Spironolactone phen
Aldara Imiquimod Divalproex sodium, Dival-
Depakote, Depakote ER
Allegra Fexofenadine proex sodium ER
Alphagan Brimonidine Desoxyn Methamphetamine
Altace Ramipril Desyrel Trazodone
Amaryl Glimepiride Diabeta, Micronase Glyburide
Amerge Naratriptan Diamox sequels Acetazolamide ER
Ambien Zolpidem Tartrate Differin Adapalene
Amoxil Amoxicillin Diflucan Fluconazole
Analpram HC cream Hydrocort-Pramoxine cream Dovonex Calcipotriene
Arimidex Anastrozole Ipratropium/Albuterol Solu-
Duoneb
tion
Astelin Azelastine
Duragesic Fentanyl
Ativan Lorazepam
Duricef Cefadroxil Hydrate
Augmentin Amoxicillin/Clavulanate
Effexor Venlafaxine
Sulfamethoxazole/
Bactrim Effexor XR Venlafaxine ER Capsules
Trimethoprim
Bactroban Ointment Mupirocin Ointment Elavil Amitriptyline
Biaxan Clarithromycin Elocon Mometasone
Bleph-10 Sulfacetamide Sodium Exelon Rivastigmine
Buspar Buspirone Feldene Piroxicam
Calan Verapamil Flagyl Metronidazole
Cardizem CD Diltiazem Flexeril Cyclobenzaprine
Cardizem LA Diltiazem ER Flomax Tamsulosin
Casodex Bicalutamide Fosamax Alendronate
Catapres Clonidine Gengraf Cyclosporine modified
Ceftin Cefuroxime Glucophage Metformin
Celexa Citalopram Glucotrol Glipizide
Cellcept Mycophenolate Mofetil Golytely Gavilyte-G
Cipro Ciprofloxacin Hyzaar Losartan/HCTZ
Claritin OTC Loratadine OTC Imitrex Sumatriptan
Cleocin Clindamycin Inderal Propranolol
Climara Estradiol Patch Indocin Indomethacin
Cogentin Benztropine Inspra Eplerenone
Colazal Balsalazide Disodium Iopidine Apraclonidine
Coreg Carvedilol Keflex Cephalexin
Cosopt Dorzolamide-Timolol Kenalog (topical) Triamcinolone

31
Brand Generic Brand Generic
Keppra Levetiracetam Prograf Tacrolimus
Klonopin Clonazepam Protonix Pantoprazole
Kytril Granisetron Prozac Fluoxetine
Lamictal Lamotrigine Prozac Weekly Fluoxetine DR
Lasix Furosemide Pulmicort respules Budesonide respules
Lodine Etodolac Razadyne Galantamine
Lofibra Fenofibrate Reglan Metoclopramide
Lopid Gemfibrozil Remeron Mirtazapine
Lopressor Metoprolol Repliva 21-7 Pruvate 21-7
Amlodipine Besylate/ Requip Ropinirole
Lotrel
Benazepril Restoril Temazepam
Lovenox Enoxaparin Retin A Tretinoin
Macrodantin Nitrofurantoin Risperdal Risperidone
Malathion Ovide Lotion Ritalin Methylphenidate
Marinol Dronabinol Sodium Sulfacetamide/Sul-
Rosula
Mevacor Lovastatin fur/Urea
Mimyx cream Prumyx cream Rowasa Mesalamine
Minocin Minocycline Sanctura Trospium
Mirapex Pramipexole Sandimmune Cyclosporine
Motrin Ibuprofen Skelaxin Metaxalone
MS Contin Morphine Sulfate SR Soma Carisoprodol
Naprosyn Naproxen Sonata Zaleplon
Neoral Cyclosporine modified Starlix Nateglinide
Neurontin Gabapentin Subutex Buprenorphine
Nizoral Ketoconazole Sular Nisoldipine
Norvasc Amlodipine Besylate Tarka Trandolapril/Verapamil
Nulytely Peg-3350 Tegretol XR Carbamazepine XR
Omnicef Cefdinir Temovate Clobetasol
Optivar Azelastine Tenormin Atenolol
Paxil Paroxetine Tobramycin-Dexametha-
Tobradex
Paxil CR Paroxetine ER sone
Pepcid Famotidine Topamax Topiramate, Topiragen
Percocet Oxycodone/Acetaminophen Topicort Desoximetasone
PhosLo Calcium Acetate Toprol XL Metoprolol SR
Plendil Felodipine Trexall Methotrexate
Pravachol Pravastatin Tridesilon Desonide
Precose Acarbose Trileptal Oxcarbazepine
Prevacid Lansoprazole Trusopt Dorzolamide
Prilosec OTC Omeprazole OTC Tylenol # 3 Acetaminophen/Codeine
Prinivil, Zestril Lisinopril Ultram Tramadol
Prinzide, Zestoretic Lisinopril/Hctz Urso Ursodiol
Procardia Nifedipine Valium Diazepam

32
 Brand Generic
Valtrex Valacyclovir
Vasotec Enalapril
Veetids Penicillin
Vibramycin Doxycycline
Hydrocodone/Acetamino-
Vicodin, Vicodin ES
phen
Videx EC Didanosine
Vivactil Protriptyline
Voltaren Diclofenac
Wellbutrin Bupropion
Wellbutrin XL Budeprion XL
Xanax Alprazolam
Yasmin Ocella
Yaz Gianvi
Zantac Ranitidine
Zerit Stavudine
Zithromax Azithromycin
Zocor Simvastatin
Zofran Ondansetron
Zoloft Sertraline
Zonegran Zonisamide
Zovirax Acyclovir
Zyloprim Allopurinol

In this document, the term “UPMC Health Plan” refers to benefit
plans offered by UPMC Health Network, Inc., as well as plans
offered by UPMC Health Plan, Inc.
This managed care plan may not cover all your health care
expenses. Read your contract carefully to determine which
health care services are covered.
This Pharmacy Benefit Guide is current as of January 1, 2011. For
the latest information on the Your Choice drug table and other
pharmacy benefits, visit
www.upmchealthplan.com/pharmacy. Select “Your Choice”
to access the searchable drug list. Or you may call our Member
Advocates at the number listed on the back of your UPMC Health
Plan ID card.

Copyright 2010 UPMC Health Plan, Inc. All Rights Reserved.

33 YC PHARM GD 2011 C20101008-10 (MFS) 10/19/10 xxM xx