Mg926922 health plus of louisiana 6-tier_v4

MG926922 HEALTH PLUS of LOUISIANA 6-TIER_v4 3/10/09 8:26 AM Page 1 Health Plus of Louisiana
Member Guide (6 Level)
Please bring this guide
with you to your next
doctor visit.
If you have questions about your prescription drug benefit,
visit www.medco.com or call Member Services.
Medco is a registered trademark of Medco Health Solutions, Inc.
2009 Medco Health Solutions, Inc. All rights reserved.
Medco manages your pharmacy benefit at the request of your health plan.
MG926922 HEALTH PLUS of LOUISIANA 6-TIER_v4 3/10/09 8:26 AM Page 2 THE BENEFITS OF THE HEALTH PLUS OF LA MEMBER GUIDE
A formulary is a list of medications that may be covered under your prescription drug plan. This
list was reviewed by an independent group of practicing doctors and pharmacists, and it contains
medications made by most pharmaceutical manufacturers. It includes medications for many
covered conditions.
SAVING MONEY ON PRESCRIPTIONS
Your plan may prefer some medications over others. These are defined by copay levels and have
varying copays.
Copay Level 1 - Lowest co-payment for generic drugs Copay Level 2 - Higher co-payment for generic drugs Copay Level 3 - Co-payment for preferred brand-name drugs Copay Level 4 - Copayment for non-preferred brand-name drugs Copay Level 5 - Copayment or Co-Insurance for Injectable Chemotherapy Agents Copay Level 6 - Copayment or Co-Insurance for Specialty Drugs Your doctor may be able to help you save money by prescribing generic and preferred brand-namedrugs if appropriate. So be sure to bring this guide with you on every visit to your doctor. Somecommonly prescribed non-preferred drugs are also listed in this guide for your reference.
Your plan may also require PRIOR AUTHORIZATION (PA) or QUANTITY LIMIT (QL)
on certain medications. These medications are indicated with a PA (Prior Authorization) or
QL (Quantity Limit) in the Requirements/Limits column on the following pages. The
pharmacist will inform you if additional information is needed to determine coverage.
Please note: This guide does not contain a complete list of formulary medications. It only lists themost commonly prescribed drugs. For an updated and complete listing of your prescriptionformulary, you can visit the member information section at www.healthplus.com and click onHealth Plus of LA formulary or the “Benefit Highlights” section at www.medco.com and click onthe “View your preferred drug list” link.
FINDING MEDICATION WITH LOWER CO-PAYMENTS
This guide lists medications to help you find some generic, preferred, and non-preferred brand name
drugs. Medications are listed alphabetically by category. Within each category, drug names are listed
in alphabetical order.
After each non-preferred brand-name drug, you will find possible generic and preferred brand-namealternatives.
This information is in effect at the time of printing, and may be subject to change. In some cases, your health plan
may not cover certain medications listed in this member guide.
MG926922 HEALTH PLUS of LOUISIANA 6-TIER_v4 3/10/09 8:26 AM Page 3 Co-pay Level
Req./ Generic
DRUG NAME
SUGGESTED PREFERRED ALTERNATIVES
Anti-Infectives (Antibiotics/Antifungals)
Oral Penicillins
amoxicillin trihydrate
amoxicillin trihydrate/potassium clavulanate amoxicillin trihydrate/potassium clavulanate (generic) amoxicillin trihydrate/potassium clavulanate (generic) amoxicillin trihydrate suspension (generic), amoxicillin trihydratechewable tablet (generic) Oral Tetracyclines
doxycycline hyclate capsule
Oral Cephalosporins
cefaclor x
cefadroxil hydrate
cephalexin monohydrate xcephradine xCeftin Suspension cefaclor capsule (generic), cefuroxime axetil (generic), Omnicef®(Abbott) cefaclor capsule (generic), cefuroxime axetil (generic), Omnicef®(Abbott) cefaclor (generic), cefuroxime axetil (generic), Omnicef® (Abbott) cefaclor (generic), cefuroxime axetil (generic), Omnicef® (Abbott) cefaclor (generic), cefuroxime axetil (generic), Omnicef® (Abbott) Oral Erythromycins
azithromycin x
erythromycin base
erythromycin ethylsuccinate/sulfisoxazole acetyl MG926922 HEALTH PLUS of LOUISIANA 6-TIER_v4 3/10/09 8:26 AM Page 4 Co-pay Level
Req./ Generic
DRUG NAME
SUGGESTED PREFERRED ALTERNATIVES
erythromycin base (generic) SUGGESTED PREFERREDALTERNATIVES Oral Quinolones
ciprofloxacin HCl (generic), Avelox® (Bayer), Levaquin® (J&J),Tequin® (Bristol-Myers Squibb) Oral Sulfas
erythromycin ethylsuccinate/sulfisoxazole acetyl Oral Urinary Tract Agents
nitrofurantoin/nitrofurantoin macrocrystal sulfamethoxazole/trimethoprim (generic), trimethoprim (generic),ciprofloxacin HCl (generic), Noroxin® (Merck) Oral Antifungal Agents
griseofulvin ultramicrosize (generic), ketoconazole (generic),Lamisil® (Novartis), Sporanox® (Janssen) griseofulvin ultramicrosize (generic), ketoconazole (generic),Lamisil® (Novartis), Sporanox® (Janssen) MG926922 HEALTH PLUS of LOUISIANA 6-TIER_v4 3/10/09 8:26 AM Page 5 Co-pay Level
Req./ Generic
DRUG NAME
SUGGESTED PREFERRED ALTERNATIVES
Oral Miscellaneous Agents
Vaginal Antifungals
fluconazole xmiconazole nitrate vaginal suppository miconazole nitrate vaginal suppository (generic) Antivirals
Tamiflu xRelenza xBaraclude xHepsera xEpivir-HBV x CNS Drugs
Alzheimer Agents
Cognex x
Aricept® (Eisai Inc), Reminyl® (Janssen) Aricept® (Eisai Inc), Reminyl® (Janssen) Antiemetic Agents
granisetron HCl tablet
Migraine Agents
sumatriptan succinate injection, tablets
Zomig NS® (Med Pointe Pharm), Imitrex NS® (GlaxoSmithKline) Zomig NS® (Med Pointe Pharm), Imitrex NS® (GlaxoSmithKline) CNS Stimulants
pemoline
amphetamine salt combo, methylphenidate (generic) Non-preferred through age 17 amphetamine sulfate, methylphenidate (generic) Non-preferredthrough age 17 D-amphetamine sulfate (generic) Non-preferred through age 17 D-amphetamine sulfate (generic) Non-preferred through age 17 methylphenidate (generic) Non-preferred through age 17 MG926922 HEALTH PLUS of LOUISIANA 6-TIER_v4 3/10/09 8:26 AM Page 6 Co-pay Level
Req./ Generic
DRUG NAME
SUGGESTED PREFERRED ALTERNATIVES
amphetamine salt combo (generic) Non-preferred through age 17 amphetamine salt combo (generic) Non-preferred through age 17 D-amphetamine sulfate (generic) Non-preferred through age 17 Lithium xamphetamine asp/amphetamine sul/ amphetamine sulfate, methylphenidate (generic) Non-preferredthrough age 17 Psychotherapeutics (Anxiety/Depression)
Hypnotic Agents
chloral hydrate
triazolam (generic), chloral hydrate (generic), temazepam (generic), temazepam (generic), triazolam (generic), zolpidem (generic) Tricyclic Antidepressants
amitriptyline HCl
Miscellaneous Antidepressants
bupropion HCl tablet
MG926922 HEALTH PLUS of LOUISIANA 6-TIER_v4 3/10/09 8:26 AM Page 7 Co-pay Level
Req./ Generic
DRUG NAME
SUGGESTED PREFERRED ALTERNATIVES
mirtazapine (generic), Remeron SolTab® (Organon) Antipsychotics
chlorpromazine HCl
haloperidol xhaloperidol lactate concentrate, oral thiothixene xthiothixene HCl concentrate, oral Abilify xClozaril xMoban xOrap xRisperdal xSeroquel xSeroquel XR Abilify® (Otsuka America), Risperdal® (Janssen), Seroquel®(AstraZeneca), Zyprexa® (Eli Lilly) fluoxetine HCl (generic), Zyprexa® (Eli Lilly), Abilify® (OtsukaAmerica), Risperdal® (Janssen), Seroquel® (AstraZeneca) Anxiolytics
alprazolam x
buspirone HCl
oxazepam (generic), diazepam (generic), lorazepam (generic),clorazepate dipotassium (generic) MAOI Antidepressants
Nardil
SSRI Antidepressants
citalopram HBr
paroxetine HCl sustained release tablet (generic) MG926922 HEALTH PLUS of LOUISIANA 6-TIER_v4 3/10/09 8:26 AM Page 8 Co-pay Level
Req./ Generic
DRUG NAME
SUGGESTED PREFERRED ALTERNATIVES
fluoxetine HCl (generic), paroxetine HCl (generic), Paxil CR®(GlaxoSmithKline), Zoloft® (Pfizer) Cardiovascular
(Blood Pressure/Heart/Cholesterol)
Beta Blockers
propranolol HCl capsule, sustained action 24 hr propranolol HCl capsule, sustained action 24 hr (generic) acebutolol HCl (generic), atenolol (generic), metoprolol tartrate(generic) Calcium Blockers
diltiazem HCl capsule, sustained release 12 hr diltiazem HCl capsule, sustained release 24 hr verapamil HCl capsule, sustained release 24 hr verapamil HCl tablet, sustained action (generic) diltiazem HCl capsule, sustained release (generic) diltiazem HCl capsule, sustained release (generic) verapamil HCl tablet, sustained action (generic) diltiazem HCl capsule, sustained release (generic) Dihydropyridines
MG926922 HEALTH PLUS of LOUISIANA 6-TIER_v4 3/10/09 8:26 AM Page 9 Co-pay Level
Req./ Generic
DRUG NAME
SUGGESTED PREFERRED ALTERNATIVES
nifedipine tablet, sustained release osmotic push amlodipine (generic), nifedipine ER tablet, sustained action (generic) amlodipine (generic), nifedipine ER (generic) amlodipine (generic), nifedipine ER (generic), nisoldipine (generic) amlodipine (generic), nifedipine ER (generic), nisoldipine (generic) Nitroglycerin Patches
nitroglycerin patch (generic), Minitran Patch® (3M) Miscellaneous
Adrenergic Antagonists & Related Drugs
Angiotensin II Blockers
Benicar® (Sankyo), Cozaar® (Merck), Diovan® (Novartis), Micardis®(BIPI) Benicar HCT® (Sankyo), Diovan HCT® (Novartis), Hyzaar®(Merck), Micardis HCT® (BIPI) HCT® (Sankyo), Diovan HCT® (Novartis), Hyzaar® Benicar® (Sankyo), Cozaar® (Merck), Diovan® (Novartis), Micardis®(BIPI) Benicar® (Sankyo), Cozaar® (Merck), Diovan® (Novartis), Micardis®(BIPI) Benicar HCT® (Sankyo), Diovan HCT® (Novartis), Hyzaar®(Merck), Micardis HCT® (BIPI) Antilipidemics
MG926922 HEALTH PLUS of LOUISIANA 6-TIER_v4 3/10/09 8:26 AM Page 10 Co-pay Level
Req./ Generic
DRUG NAME
SUGGESTED PREFERRED ALTERNATIVES
Omacor x
ACE Inhibitors
benazepril HCl
benazepril HCl (generic), enalapril maleate (generic), lisinopril(generic), Aceon® (Solvay), Altace® (Monarch) benazepril HCl/hydrochlorothiazide (generic) benazepril HCl (generic), enalapril maleate (generic), lisinopril(generic), Accupril® (Pfizer), Aceon® (Solvay), Altace® (Monarch) Combination Antihypertensives
atenolol/chlorthalidone
captopril/hydrochlorothiazide xenalapril maleate/hydrochlorothiazide lisinopril/hydrochlorothiazide xmethyldopa/hydrochlorothiazide xpropranolol HCl/hydrochlorothiazide quinapril HCl/hydrochlorothiazide/mag carb reserpine/hydrochlorothiazide xAccuretic quinapril/hydrochlorothiazide/mag carb (generic) propranolol HCl (generic), hydrochlorothiazide (generic) propranolol HCl/hydrochlorothiazide (generic) MG926922 HEALTH PLUS of LOUISIANA 6-TIER_v4 3/10/09 8:26 AM Page 11 Co-pay Level
Req./ Generic
DRUG NAME
SUGGESTED PREFERRED ALTERNATIVES
benazepril HCl/hydrochlorothiazide (generic), enalaprilmaleate/hydrochlorothiazide (generic) benazepril HCl/hydrochlorothiazide (generic), enalaprilmaleate/hydrochlorothiazide (generic) enalapril maleate/hydrochlorothiazide (generic) Endocrine
(Diabetes/Hormones/Contraceptives)
Insulin Therapy
Humalog, Mix x
Humulin x
Lantus x
Novolin x
NovoLog x
ReliOn x
Non-Insulin Hypoglycemics
Symlin PA
Byetta x
Oral Hypoglycemics
acarbose
acetohexamide xchlorpropamide xglimepiride glipizide tablet, sustained release osmotic push metformin HCl tablet, sustained release 24 hr metformin HCl ER tablet, sustained release 24 hr (generic),metformin HCl tablet (generic) Blood Glucose Test Strips
alcohol antiseptic pads
MG926922 HEALTH PLUS of LOUISIANA 6-TIER_v4 3/10/09 8:26 AM Page 12 Co-pay Level
Req./ Generic
DRUG NAME
SUGGESTED PREFERRED ALTERNATIVES
Contraceptive Agents
desogestrel-ethinyl estradiol
desogestrel-ethinyl estradiol/ethinyl estradiol norethindrone xnorethindrone a-e estradiol norethindrone a-e estradiol/ferrous fumarate norethindrone-mestranol xnorgestimate-ethinyl estradiol Ortho-Cept xOrtho-Cyclen xOrtho-Novum xPlan B norethindrone a-e estradiol/ferrous fumarate (generic), LoestrinFe® (Duramed/Barr), Mircette® (Organon), Ortho-Cept® (Ortho) Alesse® (Wyeth), Nordette® (Monarch), Lo/Ovral® (Wyeth),Ortho-Cept® (Ortho) levonorgestrel-ethinyl estradiol (generic), Alesse® (Wyeth),Nordette® (Monarch), Triphasil® (Wyeth) Estrogens/Estrogen Combinations
estradiol patch
estropipate xmethyltestosterone/estrogens, esterified xClimara Patch MG926922 HEALTH PLUS of LOUISIANA 6-TIER_v4 3/10/09 8:26 AM Page 13 Co-pay Level
Req./ Generic
DRUG NAME
SUGGESTED PREFERRED ALTERNATIVES
estradiol (generic), estropipate (generic), Premarin® (Wyeth) estradiol/noreth ac (generic), Premphase® (Wyeth), Prempro®(Wyeth) Estraderm® (Novartis), Vivelle® (Novartis), Climara® (Berlex) estradiol (generic), estropipate (generic), Premarin® (Wyeth) Estring® (Pfizer), Premarin Vaginal Cream® (Wyeth) estradiol (generic), estropipate (generic), Premarin® (Wyeth) Miscellaneous
alendronate sodium tablet
Actonel (PA is required if > or = 30 mg) Evista xFosamax Solution (PA is required if > or = 40 mg) Fosamax Tablet (PA is required if > or = 40 mg) Fosamax Plus D (PA is required if > or = 40 mg) Biotechnology Drugs
Erythroid Stimulants
Myeloid Stimulants
Growth Hormones
Genotropin® (Pfizer), Norditropin® (Novo Nordisk), Nutropin®(Gentiva), Tev-Tropin® (Teva) Genotropin® (Pfizer), Norditropin® (Novo Nordisk), Nutropin®(Gentiva), Tev-Tropin® (Teva) Genotropin® (Pfizer), Norditropin® (Novo Nordisk), Nutropin®(Gentiva), Tev-Tropin® (Teva) Genotropin® (Pfizer), Norditropin® (Novo Nordisk), Nutropin®(Gentiva), Tev-Tropin® (Teva) Genotropin® (Pfizer), Norditropin® (Novo Nordisk), Nutropin®(Gentiva), Tev-Tropin® (Teva) Interferons
Intron A® (Schering), PEG-Intron® (Schering) MG926922 HEALTH PLUS of LOUISIANA 6-TIER_v4 3/10/09 8:26 AM Page 14 Co-pay Level
Req./ Generic
DRUG NAME
SUGGESTED PREFERRED ALTERNATIVES
MS Therapy
Misc Agents
Octreotide Acetate Injection
Misc. Rheumatologicals
G I (Ulcer)
Ulcer Drugs
MG926922 HEALTH PLUS of LOUISIANA 6-TIER_v4 3/10/09 8:26 AM Page 15 Co-pay Level
Req./ Generic
DRUG NAME
SUGGESTED PREFERRED ALTERNATIVES
omeprazole (generic), Nexium® (AstraZeneca) Other G I Drugs
NSAIDs (Pain Relievers)
Non-Steroidal Anti-inflammatory Drugs
etodolac tablet, sustained release 24 hr ketoprofen capsule, 24 hr sustained release pellets naproxen sodium tablet, sustained action etodolac (generic), ibuprofen (generic), indomethacin (generic),naproxen (generic), sulindac (generic) NSAID COX-2 Inhibitors
Respiratory (Allergy/Asthma)
Beta Agonists Oral
Beta Agonist Inhalers
metaproterenol sulfate solution, non-oral MG926922 HEALTH PLUS of LOUISIANA 6-TIER_v4 3/10/09 8:26 AM Page 16 Co-pay Level
Req./ Generic
DRUG NAME
SUGGESTED PREFERRED ALTERNATIVES
albuterol (generic), Proventil HFA® (Schering) albuterol (generic), Proventil HFA® (Schering) Inhaled Steroids
Asmanex® (Schering), Flovent® (GlaxoSmithKline), Pulmicort® (AstraZeneca) Asmanex® (Schering), Flovent® (GlaxoSmithKline), Pulmicort® (AstraZeneca) Asmanex® (Schering), Flovent® (GlaxoSmithKline), Pulmicort® (AstraZeneca) Asmanex® (Schering), Flovent® (GlaxoSmithKline), Pulmicort® (AstraZeneca) Flovent® (GlaxoSmithKline), Pulmicort® (AstraZeneca) Flovent® (GlaxoSmithKline), Pulmicort® (AstraZeneca) Flovent® (GlaxoSmithKline), Pulmicort® (AstraZeneca) Nasal Corticosteroids
Miscellaneous Pulmonary Agents
Antihistamine/Decongestant Combinations
carbetapentane tannate/chlorpheniramine tannate carbetapentane tannate/ephedrine tannate/ phenylephrine/chlorpheniramine suspension carbetapentane tannate/phenylephrine tannate/ phenylephrine HCl/phenyltoloxamine citrate/ phenylephrine tannate/chlorpheniramine tannate phenylephrine tannate/pyrilamine tannate MG926922 HEALTH PLUS of LOUISIANA 6-TIER_v4 3/10/09 8:26 AM Page 17 Co-pay Level
Req./ Generic
DRUG NAME
SUGGESTED PREFERRED ALTERNATIVES
phenylephrine tannate/pyrilamine tannate/ pseudoephedrine HCl/brompheniramine maleate pseudoephedrine HCl/brompheniramine maleate pseudoephedrine HCl/carbinoxamine maleate pseudoephedrine HCl/carbinoxamine maleate pseudoephedrine HCl/chlorpheniramine maleate pseudoephedrine tannate/chlorpheniramine pseudoephedrine tannate/dexchlorpheniramine pseudoephedrine HCl/chlorpheniramine maleate pseudoephedrine HCl/chlorpheniramine maleate capsule, sustainedrelease 12 hr Antihistamines
carbinoxamine maleate
Dermatologicals
tretinoin PA
Urological
Anticholinergic/Antispasmodic
Detrol, Detrol LA
Detrol, Detrol LA, Ditropan XL, oxybutynin (generic), oxybutyninXL (generic) Detrol, Detrol LA, Ditropan XL, oxybutynin (generic), oxybutyninXL (generic) Detrol, Detrol LA, Ditropan XL, oxybutynin (generic), oxybutyninXL (generic) MG926922 HEALTH PLUS of LOUISIANA 6-TIER_v4 3/10/09 8:26 AM Page 18 bupropion HCl tablet, sustained action .6,7 desogestrel-ethinyl estradiol/ethinyl estradiol.12 carbetapentane tannate/ephedrine tannate/ carbetapentane tannate/phenylephrine tannate/ diltiazem HCl capsule, sustained release 12 hr .8 diltiazem HCl capsule, sustained release 24 hr .8 glipizide tablet, sustained release osmotic push.11 amoxicillin trihydrate chewable tablet .3 amoxicillin trihydrate/potassium clavulanate .3 enalapril maleate/hydrochlorothiazide .10,11 indomethacin capsule, sustained action.15 ipratropium bromide solution, non-oral .16 etodolac tablet, sustained release 24 hr .15 ketoprofen capsule, 24 hr sustained release benazepril HCl/hydrochlorothiazide .10,11 cromolyn sodium ampul for nebulization.16 bisoprolol fumarate/hydrochlorothiazide.10 MG926922 HEALTH PLUS of LOUISIANA 6-TIER_v4 3/10/09 8:26 AM Page 19 sumatriptan succinate injection, tablets .5 nitrofurantoin/nitrofurantoin macrocrystal .4 propranolol HCl capsule, sustained action norethindrone a-e estradiol/ferrous fumarate .12 pseudoephedrine HCl/carbinoxamine maleate .17 maleate tablet, sustained release 12 hr.17 maleate capsule, sustained release 12 hr.17 pseudoephedrine tannate/chlorpheniramine pseudoephedrine tannate/dexchlorpheniramine metaproterenol sulfate solution, non-oral.15 metformin HCl ER tablet, sustained release quinapril HCl/hydrochlorothiazide/mag carb.10 quinapril/hydrochlorothiazide/mag carb .10 metformin HCl tablet, sustained release 24 hr.11 methyltestosterone/estrogens, esterified.12 miconazole nitrate vaginal suppository .5 paroxetine HCl sustained release tablet.7 verapamil HCl capsule, sustained release 24 hr .8 verapamil HCl tablet, sustained action.8,17 phenylephrine HCl/phenyltoloxamine citrate/ naproxen sodium tablet, sustained action .15 phenylephrine tannate/pyrilamine tannate.16 phenylephrine tannate/pyrilamine tannate/ MG926922 HEALTH PLUS of LOUISIANA 6-TIER_v4 3/10/09 8:26 AM Page 20 Y
Yasmin .12
Z
zaleplon .6
Zantac Syrup .14
Zantac Tablet .15
Zavesca .14
Zebeta .8
Zestoretic.11
Zestril.10
Zetia .10
Zmax.4
Zocor .10
Zofran.5
Zoloft .7,8
zolpidem.6
Zomig NS .5
Zomig, Zomig-ZMT, NS.5
Zorbtive.13
Zyflo .16
Zyprexa.7
Zyprexa Zydis .7
Zyrtec Rx Chewable .17
Zyrtec Rx Tablet .17
Zyrtec-D Rx .17
Zyvox.5

Source: http://www.wkhealthplus.com/FCKFiles/File/RX%206%20tier.pdf