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Third Tier Drugs

Tier 3 co-pay ($22)	Tier 2 co-pay ( $9)	Tier 1 co-pay ($3)
ACE Inhibitors/Diuretic Combinations:
Moexipril / HCTZ	N/A	Benazepril/HCTZ Captopril/HCTZ Enalapril/HCTZ Fosinopril/HCTZ Lisinopril/HCTZ
ACE Inhibitors:
Aceon Moexipril Ramipril	N/A	Benazepril Captopril Enalapril Fosinopril Lisinopril Quinapril
Alzheimer’s Disease:
Cognex	Aricept Aricept ODT Exelon Cap/Sol Namenda Razadyne Sol	Galantamine Tab/Cap
Angiotensin II Receptor Blockers:
Avapro Benicar Diovan Teveten	Atacand Cozaar Micardis	N/A
Angiotensin II Receptor Blocker Combination:
Avalide Benicar HCT Diovan HCT Teveten HCT	Atacand HCT Hyzaar Micardis HCT	N/A
Antidepressants:
Cymbalta Lexapro Tab/Sol Paroxetine SR Prozac Weekly Sarafem Buproprion XL Pristiq	Effexor XR Pexeva	Buproprion Buproprion SR Citalopram Tab/Sol Fluoxetine Tab/Sol Fluvoxamine Paroxcetine Tab/Sol Trazodone Miratzapine Nafazadone Sertraline
Antidepressants - MAOI:
Emsam	Nardil Marplan	Parnate (generic)
Antihistamines:
Clarinex Tab Clarinex Susp Clarinex Tab Rapids Clarinex-D Xyzal Tab Xyzal Sol	Semprex-D Allegra-D Allegra Oral Susp Allegra ODT	Fexofenadine
Antiemetic Agents:
Anzemet	Emend Transderm Scop	Meclizine Prochlorperazine Promethazine Trimethobenzamide Ondasetron Tab/Sol/ODT Granisetron Dronabinol
(Topical) Antifungal Drugs:
Vusion	N/A	Miconazole Clotrimazole Nystatin
Antilipidemic Agents - Misc:
Antara Lovaza Tricor Welchol	Zetia Niaspan Trilipix	Triglide Lofibra Colestipol Fenofibrate Gemfibrozil Niacor Cholestyramine Fenoglide
Antilipidemic Agents - HMG-CoA Reductase Inhibitors:
Crestor Caduet	Lipitor Vytorin Lescol XL Lescol Altoprev Advicor	Simvastatin Pravastatin Lovastatin
Attention Deficit Hyperactivity Drugs:
Daytrana Dexmethylphenidate Focalin XR Vyvanse	Adderall XR Concerta Desoxyn Metadate CD Ritalin LA Straterra	Dextroamphetamine Methylin Methylin ER Methylphenidate Methylphenidate SR
Beta-Blockers:
Bystolic	Coreg CR	Atenolol Metoprolol Tartrate Metoprolol Succinate Timolol Maleate Carvedilol
*Short Acting Beta Agonist:**
Metaproterenol inhalation solution Maxair inhaler	Ventolin HFA Proair HFA Proventil HFA Accuneb	Albuterol inhalation solution
Calcium Channel Blockers - Nondihydropyridines:
Cardizem LA Verelan Verelin SR Covera HS Verapamil ER Cap 24HR	Cardizem SR	Cartia XT Diltiazem SR Diltiazem XR Diltiazem Diltiazem CD Verapamil SR
Calcium Channel Blockers - Dihydropyridines:
Dynacirc CR Isradipine Cardene SR Nicardipine	Sular	Amlodipine Felodipine Nifedipine ER Nifedipine SR Nifedipine XR
Calcitonins:
Miacalcin spray	Fortical spray	Calcitonic-Salmon spray
Erectile Dysfunction:
Cialis Viagra	Levitra	N/A
Fungal Infections (Dermatology):
Ertaczo Exelderm Ciclopirox Oxistat Econazole	Mentax	Clortriamazole Ketoconazole Miconazole Nystatin
Gamma-aminobutyric acid (GABA) Analog Agents:
Lyrica	Gabitril Topamax	Gabapentin Lamotrigine
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:
Azopt	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 Rozerem Zaleplon *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 Patanase Omnaris	Nasonex	Fluticasone Flunisolide
Leukotriene Modifiers:
Zyflo Zyflo-CR	Accolate Singulair
Macrolides:
Ketek Zmax		Azithromycin Clarithromycin Clarithromycin ER Erythromycin
Migraine - Selective Serotonin Agonist:
Amerge Axert Frova	Maxalt Maxalt MLT Imitrex Spray Zomig Zomig ZMT Zomig Spray Relpax Treximet	Sumatriptan Inj Sumatriptan Tab
Miscellaneous Antihypertensive Agents:
Lexxel Tarka	Lotrel	Amlodipine/Benazepril
Monophasic Oral Contraceptives with 20mcg Estrogen:
Loestrin 24 Fe Lybrel Femcon Fe Tilia Fe	Yaz	Alesse Levlite Loestrin Fe 1/20 Microgestin 1/20
Monophasic Oral Contraceptives with 30mcg Estrogen:
Jolessa Quasense 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:
Balziva Ovcon-35 (Chewable) Zenchent	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 Sanctura XR	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	N/A	N/A
Symptomatic Benign Prostatic Hypertrophy:
Flomax Avodart	Uroxatral	Doxazosin Terazosin Finasteride
Targeted Immunomodulatory Biologics:
Enbrel Kineret	Amevive Humira Raptiva	N/A
Triphasic Oral Contraceptives:
Estrostep Fe	Ortho Tri-Cyclen Lo	Ortho Tri-Cyclen (generic) Triphasil (generic) Tri-Norinyl (generic) Ortho Novum 7/7/7 (generic)