Tier 3 co-pay ($22) | Tier 2 co-pay ( $9) | Tier 1 co-pay ($3) |
ACE Inhibitors/Diuretic Combinations: |
Accuretic
Uniretic | N/A | Benazepril/HCTZ
Captopril/HCTZ
Enalapril/HCTZ
Fosinopril/HCTZ
Lisinopril/HCTZ |
| ACE Inhibitors: |
Aceon
Accupril
Altace
Univasc | N/A | Benazepril
Captopril
Enalapril
Fosinopril
Lisinopril |
| Alzheimer’s Disease: |
Cognex | Aricept
Exelon
Namenda
Razadyne | N/A |
| Angiotensin II Receptor Blockers: |
Teveten
Avapro
Benicar
Diovan | Atacand
Cozaar
Micardis | N/A |
| Angiotensin II Receptor Blocker Combination: |
Teveten HCT
Avalide
Benicar HCT
Diovan HCT | Micardis HCT
Atacand HCT
Hyzaar | N/A |
| Antidepressants: |
Cymbalta
Lexapro
Paxil CR
Prozac Weekly
Sarafem
Wellbutrin XL | Effexor
Effexor XR
Pexeva | Buproprion
Buproprion SR
Citalopram
Fluoxetine
Fluvoxamine
Paroxcetine
Trazodone
Miratzapine
Nafazadone
sertraline |
| Antidepressants - MAOI: |
| Emsam | Nardil
Marplan | Parnate (generic) |
| Antihistamines: |
Clarinex
Clarinex-D | Zyrtec
Semprex-D
Allegra-D
Zyrtec-D | Fexofenadine |
| Antiemetic Agents: |
Anzemet | Emend
Kytril
Marinol
Transderm Scop
| Meclizine
Prochlorperazine
Promethazine
Trimethobenzamide
Ondasetron |
(Topical) Antifungal Drugs: |
| Vusion | N/A | Miconazole
Clotrimazole
Nystatin |
| Antilipidemic Agents - Misc: |
Antara
Lovaza
Tricor
Welchol | Zetia
Niaspan | Triglide
Lofibra
Colestipol
Fenofibrate
Gemfibrozil
Niacor
Cholestyramine |
| Antilipidemic Agents - HMG-CoA Reductase Inhibitors: |
Crestor
Caduet | Lipitor
Vytorin
Lescol XL
Lescol
Altoprev
Advicor | Simvastatin
Pravastatin
Lovastatin |
Attention Deficit Hyperactivity Drugs: |
Focalin
Focalin XR
Daytrana
Vyvanse | Adderall XR
Concerta
Desoxyn
Metadate CD
Ritalin LA
Straterra | Dextroamphetamine
Methylin
Methylin ER
Methylphenidate |
| Calcium Channel Blockers - Mondihydropyridines: |
Cardizem LA
Verelan, Verelin SR
Verelan PM
Covera HS | Cardizem SR | Cartia XT
Diltiazem SR
Diltiazem XR
Diltiazem
Diltiazem CD
Verapamil SR |
| Calcium Channel Blockers - Dihydropyridines |
Norvasc
Dynacirc, Dynacirc CR
Cardene, Cardene SR | Sular | Felodipine
Nifedipine ER
Nifedipine XR |
| Erectile Dysfunction: |
Cialis
Viagra | Levitra | N/A |
| Fungal Infections (Dermatology): |
Ertaczo
Exelderm
Loprox
Oxistat
Spectazole | Mentax | Clortriamazole
Ketoconazole
Miconazole
Nystatin |
| Gamma-aminobutyric acid (GABA) Analog Agents: |
Lyrica | Gabitril
Topamax | Gabapentin |
| Topical Glaucoma Agents - Prostaglandins: |
Travatan
Travatan Z | Xalatan
Lumigan | N/A |
| Topical Glaucoma Agents - Beta Blockers: |
Istalol
Betimol | Betoptic S
Timoptic Ocudose | Timoptic (generic)
Timoptic XE (generic)
Betoptic (generic)
Ocupress (generic)
Betagan (generic)
Optipranolol (generic) |
| Topical Glaucoma Agents - Carbonic Anhydrase Inhibitors: |
Travatan
Travatan Z | Trusopt | N/A |
| Growth Hormone: |
Genotropin
Genotropin Miniquick
Omnitrope
Humatrope
Saizen | Norditropin
Norditropin Nordiflex
Tev-Tropin
Nutropin
Nutropin AQ
Serostim
Zorbtive | N/A |
| Sedative Hypnotic Agents*: |
Ambien CR
Sonata
Rozerem
*Trial of zolpidem IR applies to new users of luneta, rozerem, sonata, ambien CR (no prescription for any of the above listed drugs in previous 180 days before non-formulary drug prescription) | Lunesta | Zolpidem |
| Intranasal Steroids: |
Beconase AQ
Nasacort AQ
Rhinocort AQ
Vancenase AQ
Vancenase AQ DS
Vermyst | Nasonex | Fluticasone
Flunisolide |
| Leukotriene Modifiers: | | |
Zyflo
Zyflo-CR | Accolate
Singulair | |
| Macrolides: |
Ketek
Zmax | | Azithromycin
Clarithromycin
Clarithromycin ER
Erythromycin |
| Miscellaneous Antihypertensive Agents: |
Lexxel
Tarka | N/A | Amlodipine/Benazepril |
Monophasic Oral Contraceptives with 20mcg Estrogen: |
Loestrin 24 Fe
Lybrel | Yaz | Alesse
Levlite
Loestrin Fe 1/20
Microgestin 1/20 |
Monophasic Oral Contraceptives with 30mcg Estrogen: |
Seasonale
Seasonique | Yasmin | Levlen 28 (generic)
Lo/Ovral (generic)
Orto-Cept (generic)
Loestrin 1.5/30 (generic)Loestrin Fe 1.5/30 (generic)Loestrin Fe 1.5/30 (generic)
Microdestin Fe 1.5/30 (generic) |
Monophasic Oral Contraceptives with 35mcg Estrogen: |
Ovcon 35
Ovcon-35 (Chewable) | N/A | Ortho-Cyclen (generic)
Ortho-Novum 1/35 (generic)
Modicon (generic)
Brevicon (generic)
Demulen 1/35 (generic) |
Monophasic Oral Contraceptives with 50mcg Estrogen: |
| Ovcon 50 | N/A | Necon (generic)
Ortho Novum 1/50 (generic)
Demulen 1/50 (generic)
Zovia 1/50 (generic) |
| Lower Potency Opiods - Single Analgesic Ingredient: |
Ultram ER | Darvon N | Tramadol
Darvon (generic)
Stadol (generic)
Nubain (generic)
Talwin NX (generic)
Buprenex (generic)
Butorphanol (generic) |
| Overactive Bladder Agents: |
Detrol
Oxytrol
Sanctura | Detrol LA
Enablex
Vesicare | Oxybutynin
Oxybutynin ER |
| Proton Pump Inhibitors*: |
Aciphex
Prevacid
Protonix
Zegerid
*Trial of mexium or omeprazole applies to new users of non-formulary PPIs (no prescription for PPI in previous 180 days before non-formulary drug prescription) | N/A | Nexium
Omeprazole |
| Renin Angiotensin Antihypertensive Agent: |
| Exforge | Azor | |
| Symptomatic Benign Prostatic Hypertrophy: |
Flomax "Trial of uroxatral required. This applies to new users of flomax (no prescription for uroselective alpha blockers in previous 180 days before non-formulary drug prescription"
Avodart | Uroxatral | Doxazosin
Terazosin
Finasteride |
| Targeted Immunomodulatory Biologics: |
Enbrel
Kineret | Amevive
Humira
Raptiva | |
Triphasic Oral Contraceptives: |
| Estrostep Fe | Ortho Tri-Cyclen Lo | Ortho Tri-Cyclen (generic)
Triphasil (generic)
Tri-Norinyl (generic)
Ortho Novum 7/7/7 (generic) |
