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Effective
January 1, 2012
2012 EMPIRE PLAN FLEXIBLE FORMULARY
Administered by UnitedHealthcare
The following is a list of the most commonly prescribed generic and brand-name drugs included on the 2012 Empire Plan Flexible Formulary. This is not a complete list of all prescription drugs on the flexible formulary or covered under The Empire Plan. This list and
excluded medications are subject to change. New prescription drugs may be subject to exclusion when they become available in

the market. For specific questions about your prescriptions, coverage and copayments, please call The Empire Plan toll free at 1-877-7-NYSHIP
(1-877-769-7447) and select The Empire Plan Prescription Drug Program or visit the website at https://www.cs.ny.gov. Click on Benefit Programs, then NYSHIP Online. Provide your group and plan information if prompted. On the resulting NYSHIP Online page, select Using Your Benefits and scroll to the 2012 Empire Plan Flexible Formulary links.
For the enrollee: Enrollees are encouraged to ask their doctors to prescribe covered generic versions of brand-name drugs whenever
appropriate, as this will result in a lower copayment, unless the brand-name drug has been placed on Level 1. Brand products
on Level 1 will be less expensive than the generic equivalent. Generic medications contain the same active ingredients as their
corresponding brand-name medications, although they may look different in color or shape. They have been FDA-approved under
strict standards.
For the physician: Please prescribe covered Level 1 and Level 2 or preferred products when medically appropriate for your patients.

CARDIOVASCULAR
Antiarrhythmics
Cholesterol Lowering
perindopril (generic Aceon) ½T
pravastatin (generic Pravachol) ½T
simvastatin (generic Zocor) ½T
Blood Modifiers
Crestor ½T
Lovenox (g)*
trandolapril ½T
Lipitor*
Blood Pressure Lowering
losartan (generic Cozaar) ½T
Atacand*½T
losartan with hydrochlorothiazide Atacand HCT*
Benicar ½T
Heart Failure
Cardizem LA (g)*
moexipril ½T
Generic Drugs are listed in lower case letters. Brand-name drugs are listed with the first letter of the name capitalized.
The symbol * next to a brand-name drug signifies that this drug may be available as a generic in 2011 or 2012. When a generic version is available, mandatory generic substitution
will apply, unless the brand-name drug has been placed on Level 1. Use of a covered Level 3 or non-preferred brand-name prescription drug when the generic is available will result in the enrollee paying the applicable Level 3 or non-preferred copayment plus the difference in cost between the brand-name drug and the generic, not to exceed the full retail cost of the drug, unless the brand-name drug has been placed on Level 1 of the Flexible Formulary. The symbol (g) next to a brand-name drug indicates that a generic is currently
available for at least one or more strengths of the brand medication. When a generic is available for a particular strength of the brand-name drug, that strength of the brand-name drug, if covered, may be Level 3 or non-preferred. The symbol (PA) next to a drug name indicates that prior authorization is required. The symbol ♦ next to a drug indicates a
brand-name medication with a Level 1 copayment. The symbol ½T next to a drug indicates that certain strengths may be eligible for the Half Tablet Program.
Nitrates/Other Angina
DERMATOLOGY/
Gastrointestinal-Other
SKIN DISORDER
Antiviral Drugs
adapalene (generic Differin) (PA)
Pulmonary Artery
Pancreatic Enzymes
Hypertension Agents
Adcirca (PA)
Letairis (PA)
Ulcerative Colitis
valacyclovir (generic Valtrex) ½T
Revatio*(PA)
Tracleer (PA)
Tyvaso (PA)
Hepatitis
Ventavis (PA)
ribavirin (PA)
CENTRAL NERVOUS
Infergen (PA)
Alzheimer’s Disease
Intron-A (PA)
GROWTH HORMONES
Pegasys (PA)
tretinoin (PA)
Peg-Intron (PA)
Nutropin/Nutropin AQ (PA)
Condylox (g)*
Saizen (PA)
MIGRAINE HEADACHE
Dovonex (g)*
Serostim (PA)
Tev-Tropin (PA)
Zorbtive (PA)
Multiple Sclerosis
Ampyra (PA)
Stelara (PA)
INFECTION
Avonex (PA)
Copaxone (PA)
DIABETES
Antibiotics-Oral
Rebif (PA)
Nausea/Vomiting
MUSCLE RELAXANTS
Parkinson’s Disease
Actoplus Met*
Actos*½T
OPHTHALMIC (EYE)
Seizure Disorder
Glaucoma
Antifungal Drugs-Oral
GASTROINTESTINAL
itraconazole (PA)
Other Eye Medications
topiramate (generic Topamax) ½T
Dilantin (g)
GERD/Peptic Ulcer
terbinafine (generic Lamisil) (PA)
Gabitril*
Tegretol XR (g)*
Antifungal Drugs-Topical
Hormone Therapy-Oral
Pulmicort Respules (g)*
OTIC (EAR)
Asthma-Oral Drugs
Depression
PAIN/ARTHRITIS
Hormone Therapy-Patches
Singulair*
REPLACEMENT
fentanyl citrate lollipop (PA)
Hormone Therapy-
Miscellaneous
URINARY TRACT
Infertility
Benign Prostatic Hyperplasia
sertraline (generic Zoloft) ½T
Erectile Dysfunction
Osteoporosis
capsule (generic Effexor XR)
Miscellaneous
Anticholinergics/
Psychosis
Antispasmodics-Other
Forteo (PA)
Other Agents
Cimzia (PA)
Enbrel (PA)
Seroquel (except for XR)*½T
Symbyax*
RESPIRATORY
Simponi (PA)
Allergy-Antihistamines
VITAMIN DEFICIENCY
PSYCHOTHERAPEUTIC hydroxyzine
Allergy-Nasal Antihistamines
WEIGHT LOSS
Anxiety, Insomnia and
phentermine (PA)
Sedative Agents
Allergy-Nasal Corticosteroids
WOMEN’S HEALTH
Contraceptives
Allergy-Other
Asthma-Inhaled Drugs
Attention Deficit
Hyperactivity Disorder (ADHD)
Examples of Level 3 or Non-Preferred Drugs with 2012 Empire Plan Flexible Formulary Alternatives
Level 3 or Non-Preferred Drugs
Empire Plan Flexible Formulary Alternatives
Abilify ½T
olanzapine (generic Zyprexa), risperidone (generic Risperdal), Geodon*,
Seroquel (except for XR)*½T
omeprazole (generic Prilosec), pantoprazole (generic Protonix) Avalide*
losartan with hydrochlorothiazide (generic Hyzaar), Atacand HCT*,
Benicar HCT, Micardis HCT
Avapro*½T
losartan (generic Cozaar) ½T, Atacand*½T, Benicar ½T, Micardis
ciprofloxacin, levofloxacin (generic Levaquin), ofloxacin doxazosin, finasteride (generic Proscar), tamsulosin (generic Flomax), terazosin amlodipine (generic Norvasc) plus Benicar ½T
Betaseron (PA) Avonex
(PA), Copaxone (PA), Rebif (PA)
venlafaxine (generic Effexor), venlafaxine extended release capsule (generic Effexor XR) Diovan*½T
losartan (generic Cozaar) ½T, Atacand*½T, Benicar ½T, Micardis
Diovan HCT*
losartan with hydrochlorothiazide (generic Hyzaar), Atacand HCT*,
Benicar HCT, Micardis HCT
Flovent Alvesco♦, Asmanex♦, QVAR♦
Humira (PA) Cimzia
(PA), Enbrel (PA), Simponi (PA), Stelara (PA)
Lexapro*½T
citalopram (generic Celexa), fluoxetine (generic Prozac), paroxetine (generic Paxil),
paroxetine sustained release 24 hour (generic Paxil CR), sertraline (generic Zoloft) ½T,
venlafaxine (generic Effexor), venlafaxine extended release capsule (generic Effexor XR)
zaleplon (generic Sonata), zolpidem (generic Ambien) Retin-A Micro (PA) tretinoin
simvastatin (generic Zocor) ½T plus Niaspan
omeprazole (generic Prilosec), pantoprazole (generic Protonix) lovastatin, pravastatin (generic Pravachol) ½T, simvastatin (generic Zocor) ½T,
Crestor ½T, Lipitor*, Vytorin, Welchol
For enrollee groups eligible for the Enhanced Flexible Formulary, you have an additional feature called
Brand for Generic (B4G) which saves you money on certain Brand-Name drugs that have a new generic

available. When advantageous to the Plan, this feature allows a Brand-Name drug to be placed on Level 1,
the lowest copayment level, and the new generic equivalent to be placed on Level 3, the highest
copayment level or excluded. These placements are for a limited time, typically six months, and may
be revised mid-year when such changes are advantageous to The Empire Plan.
UnitedHealthcare will notify you when B4G savings are available.
We will also notify your pharmacist so that the lowest cost option will always be dispensed.
Please refer to the DCS website at https://www.cs.ny.gov
for the most current information regarding the B4G feature.
Generic Drugs are listed in lower case letters. Brand-name drugs are listed with the first letter of the name capitalized.
The symbol * next to a brand-name drug signifies that this drug may be available as a generic in 2011 or 2012. When a generic version is available, mandatory generic substitution will
apply, unless the brand-name drug has been placed on Level 1. Use of a covered Level 3 or non-preferred brand-name prescription drug when the generic is available will result in the enrollee paying the applicable Level 3 or non-preferred copayment plus the difference in cost between the brand-name drug and the generic, not to exceed the full retail cost of the drug, unless the brand-name drug has been placed on Level 1 of the Flexible Formulary. The symbol (g) next to a brand-name drug indicates that a generic is currently available for at least
one or more strengths of the brand medication. When a generic is available for a particular strength of the brand-name drug, that strength of the brand-name drug, if covered, may be Level 3 or non-preferred. The symbol (PA) next to a drug name indicates that prior authorization is required. The symbol ♦ next to a drug indicates a brand-name medication with a
Level 1 copayment. The symbol ½T next to a drug indicates that certain strengths may be eligible for the Half Tablet Program.
Excluded drugs with 2012 Empire Plan Flexible Formulary Alternatives
Excluded Drugs†
Empire Plan Flexible Formulary Alternatives
diclofenac sodium drops (generic Voltaren Ophthalmic), ketorolac tromethamine drops bupropion hcl extended release, bupropion hcl sustained release amlodipine (generic Norvasc) plus Lipitor*
Cambia diclofenac carisoprodol 250mg (generic Soma 250mg) cyclobenzaprine extended release capsule oxybutynin, oxybutynin extended release, trospium (generic Sanctura), Enablex, Sanctura XR, Vesicare omeprazole (generic Prilosec), pantoprazole (generic Protonix) Doryx doxycyclinedoxycycline hyclate extended release tablet zaleplon (generic Sonata), zolpidem (generic Ambien) adapalene (generic Differin) (PA) plus benzoyl peroxide
(PA), Copaxone (PA), Rebif (PA)
Genotropin (PA)° Nutropin
(PA), Nutropin AQ (PA), Saizen (PA), Tev-Tropin (PA)
Humatrope (PA)°° Nutropin
(PA), Nutropin AQ (PA), Saizen (PA), Tev-Tropin (PA)
finasteride (generic Proscar) plus tamsulosin (generic Flomax) omeprazole (generic Prilosec), pantoprazole (generic Protonix) mometasone furoate topical plus ammonium lactate omeprazole (generic Prilosec), pantoprazole (generic Protonix) Norditropin (PA)°°° Nutropin
(PA), Nutropin AQ (PA), Saizen (PA), Tev-Tropin (PA)
omeprazole (generic Prilosec), pantoprazole (generic Protonix) Omnitrope (PA)° Nutropin
(PA), Nutropin AQ (PA), Saizen (PA), Tev-Tropin (PA)
Orbivan butalbital/acetaminophen/caffeine ° Excluded, except for the treatment of growth failure due to Prader-Willi syndrome or Small for Gestational Age.
°° Excluded, except for the treatment of growth failure due to SHOX deficiency or Small for Gestational Age.
°°° Excluded, except for the treatment of short stature associated with Noonan syndrome or Small for Gestational Age.
† Coverage for prescription drugs excluded under the benefit plan design are not subject to exception. This includes prescription medications excluded from coverage under The Empire Plan Flexible Formulary. New prescription drugs may be subject to exclusion when they become available in the market. Please refer to the DCS website
at https://www.cs.ny.gov or call The Empire Plan Prescription Drug Program toll free at 1-877-7-NYSHIP (1-877-769-7447) for current information regarding exclusions of newly
launched prescription drugs.
Excluded drugs with 2012 Empire Plan Flexible Formulary Alternatives Continued
Excluded Drugs†
Empire Plan Flexible Formulary Alternatives
omeprazole (generic Prilosec), pantoprazole (generic Protonix) terbinafine (generic Lamisil) (PA)
tobramycin/dexamethasone drops (generic Tobradex) naproxen sodium plus sumatriptan (generic Imitrex) amlodipine (generic Norvasc) plus hydrochlorothiazide plus Benicar ½T
or amlodipine (generic Norvasc) plus Benicar HCT
fenofibrate, Antara, Fenoglide, Lipofen, Triglide fenofibrate, Antara, Fenoglide, Lipofen, Triglide amlodipine (generic Norvasc) plus Micardis (PA) plus clindamycin topical
flunisolide, fluticasone (generic Flonase), Nasonex naproxen plus omeprazole (generic Prilosec) omeprazole (generic Prilosec), pantoprazole (generic Protonix) (PA) plus clindamycin topical
° Excluded, except for the treatment of growth failure due to Prader-Willi syndrome or Small for Gestational Age.
°° Excluded, except for the treatment of growth failure due to SHOX deficiency or Small for Gestational Age.
°°° Excluded, except for the treatment of short stature associated with Noonan syndrome or Small for Gestational Age.
† Coverage for prescription drugs excluded under the benefit plan design are not subject to exception. This includes prescription medications excluded from coverage under The Empire Plan Flexible Formulary. New prescription drugs may be subject to exclusion when they become available in the market. Please refer to the DCS website
at https://www.cs.ny.gov or call The Empire Plan Prescription Drug Program toll free at 1-877-7-NYSHIP (1-877-769-7447) for current information regarding exclusions of newly
launched prescription drugs.

Source: http://www.nyspef.org/healthbenefits/pdffiles/flex_formulary2012.pdf

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