Tier 3 co-pay ($22) | Tier 2 co-pay ( $9) | Tier 1 co-pay ($3) |
ACE Inhibitors: |
Altace
Aceon
Univasc
Accupril | N/A | Benazepril
Captopril
Enalapril
Fosinopril
Lisinopril |
| ACE Inhibitor/Diuretic Combinations: |
Accuretic
Uniretic | N/A | Benazepril/HCTZ
Captopril/HCTZ
Enalapril/HCTZ
Fosinopril/HCTZ
Lisinopril/HCTZ |
| Alzheimer’s Disease: |
Cognex | Aricept
Exelon
Namenda
Razadyne | N/A |
| 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 | Micardis HCT
Atacand HCT
Hyzaar | |
| Antidepressants: |
Cymbalta
Lexapro
Paxil CR
Prozac Weekly
Sarafem
Wellbutrin XL | Effexor
Effexor XR
Pexeva | Buproprion
Buproprion SR
Buproprion XL
Citalopram
Fluoxetine
Fluvoxamine
Paroxcetine
Trazodone
Miratzapine
Nafazadone
Sertraline |
| Antidepressants - MAOI: |
| Emsam | Nardil
Marplan | Parnate (generic) |
| Antiemetic Agents: |
Anzemet | Emend
Kytril
Marinol
Transderm Scop | Meclizine
Ondasetron
Prochlorperazine
Promethazine
Trimethobenzamide |
| (Topical) Antifungal Drugs: |
| Vusion | N/A | Miconazole
Clotrimazole
Nystatin |
Antilipidemic Agents- Misc: |
Antara
Lovaza
Tricor
Welchol | Niaspan
Zetia | 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
Ritalin LA
Metadate CD
Straterra
Desoxyn | Methylphenidate
Dextroamphetamine
MethylinMethylin ER |
| Calcium Channel Blockers (Nondihydropyridines): |
Cardizem LA
Verelan Verelan SR
Verelan PM
Covera HS | Cardizem SR | Diltiazem SR
Diltiazem XR
Diltiazem
Diltiazem CD
Cartia XT
Verapamil SR |
| Calcium Channel Blockers (Dihydropyridines): |
Norvasc
Dynacirc, Dynacirc CR
Cardene, Cardene SR | Sular | Nifedipine XR
Nifedipine ER
Felodipine |
| Erectile Dysfunction: |
Cialis
Viagra | Levitra | N/A |
| Fungal Infections (Dermatology): |
Ertazo
Exelderm
Loprox
Oxistat
Spectazole | Mentax | Ketoconazole
Clortriamazole
Miconazole
Nystatin |
| Gamma-aminobutyric acid (GABA) Analog Agents: |
Lyrica | Gabitril
Topamax | Gabapentin |
| (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 |
| (Topical) Glaucoma Agents - Prostaglandins |
Travatan
Travatan Z | Xalatan
Lumigan | N/A |
| Sedative Hypnotic Agents: |
Ambien CR
Sonata
Rozerem | Lunesta | Zolpidem |
| Intranasal Steroids: |
Beconase AQ
Nasacort AQ
Rhinocort AQ
Vancenase AQ
Vancenase AQ DS | Nasonex
Veramyst | Fluticasone
Flunisolide |
| Macrolides: |
Ketek
Zmax | N/A | Azithromycin
Clarithromycin
Clarithromycin ER
Erythromycin |
| Miscellaneous Antihypertensive Agents: |
Lexxel
Tarka | N/A | Amlodipine/Benazepril |
Monophasic Oral Contraceptives with 20mcg Estrogen: |
| Loestrin 24 Fe | 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)Microgestin 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 Opioids – 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 | N/A | Nexium
Omeprazole |
| Symptomatic Benign Prostatic Hypertrophy: |
Flomax
Avodart | Uroxatral | Doxazosin
Finasteride
Terazosin |
Triphasic Oral Contraceptives: |
| Estrostep Fe | Ortho Tri-Cyclen Lo | Ortho Tri-Cyclen (generic)
Triphasil (generic)
Tri-Norinyl (generic)
Ortho Novum 7/7/7 (generic) |
