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Opioid Analgesics 3 – Tiered Prescription Drug Formulary July 2013
This formulary listing is to serve as a reference guide for the selection
of cost-effective medications and does not guarantee coverage or
imply therapeutic equivalence. Certain products may be excluded from
Anesthetics
your plan or require additional authorization. Please see your plan
Local Anesthetics
document for exact details as coverage may vary. This formulary is not all inclusive. Generic products will process as Tier 1 drugs at your
lowest copay, Tier 2 contains formulary brands, and Tier 3 contains
non-preferred brands and are subject to your highest copay.
Anticonvulsants
This formulary is to be used with your medical practitioner to be sure
that any medication selected is both cost effective and clinically
appropriate. This formulary listing is subject to change, please contact
the ProAct help desk number on the back of your card for the most up
Analgesics Migraine Antidotes, Deterrents, and Toxicologic Agents Antidotes Muscle Relaxants Deterrents Anti-Infective Amebicides Anti-Bacterials; Aminoglycosides Nonsteroidal Anti-inflammatory Drugs Antibiotic; Cephalosporins Antibiotic; Macrolides Antibiotic; Penicillins
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Antimetabolites Antibiotic; Quinolones Hormonal Antibiotic; Sulfonamides Antibiotic; Tetracyclines Cardiovascular Agents Alpha-adrenergic Agonists Antibacterials; Other Alpha-adrenergic Blocking Agents Antiarrhythmics Antifungals
clotrimazole Natacyn Diflucan digoxin (AB rated)
Beta-adrenergic Blocking Agents Anti-influenza Agents Antimycobacterials, Other Anti-parasitics Blood Modifiers/Coagulation Inhibitors Antitubercular Agents Anti-Virals Calcium Channel Blocking Agents
Valtrex diltiazem/ER/SR Exforge/HCT Cardizem/SR/CD
Antimyasthenic Agents Parasympathomimetics Diuretics Antineoplastics Alkylating Agents
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Dyslipidemics
atorvastatin Crestor Advicor entacapone Parlodel cholestyramine Lipofen
Cough/Cold
Lipofen Antihistamines Angiotensin Converting Enzyme Inhibitors Antitussive Dermatological Agents Angiotensin II Antagonists
candesartan/hctz Benicar/HCT Atacand/HCT acitretin Finacea
Actinic Keratosis Antihypertensive Combinations Antibacterials Renin Inhibitors Vasodilators Antifungals Cardiovascular; Other Atopic Dermatitis Central Nervous System Agents Cerebral Stimulants; Amphetamines Glucocorticoids/Mineralocorticoids Cerebral Stimulants; Non-Amphetamines Dementia Dermatological Agents; Other Parkinsons
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Pediculicides/Scabicides Glucocorticoids/Mineralocorticoids Hormone Replacement Therapy Diabetes Diabetic items including supplies and medication may be subject to alternate copays and/or coverage strategy. Please see your plan document or contact ProAct for additional details. Antidiabetic Agents Metabolic Bone Disease Agents Diabetic Supplies Pituitary Agents Glycemic Agents Gastrointestinal Agents Antiemetics Insulins /Misc. Antispasmodics Endocrine Androgens Proton Pump Inhibitors
Testim Testred lansoprazole Dexilant Aciphex
Antiandrogens Ulcer Agents Contraception Gastrointestinal Agents, Other
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Genitourinary Agents Otic Agents Antispasmodics; Urinary Anesthetics
VESIcare Enablex Antibacterials Benign Prostatic Hypertrophy Agents Psychological
finasteride Jalyn Proscar Anti-Depressants; MAOi Erectile Dysfunction Anti-Depressants; SSRIs/SNRIs Phosphate Binders Genitourinary Agents; Other Anti-Depressants; Tricyclics Antigout Agents
allopurinol Colcrys Indocin clomipramine Pamelor
probenecid Uloric Zyloprim desipramine Parnate
Immunological Agents Immunomodulators Antidepressants; Other Ophthalmic Agents Anti-allergy Agents
Alocril Antipsychotics
nedocromil Patanol Alomide chlorpromazine Abilify/Discmelt
Antibacterials Anti-Inflammatory
Flarex Bipolar Agents Sedatives and Hypnotics Glaucoma Agents
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Respiratory Tract Agents Bronchodilators, Anticholinergic
Please contact the ProAct Clinical Department at:
1‐877‐776‐2285 x3624or email us at
Bronchodilators, Phosphodiesterase Inhibitors (Xanthines)
for recommendations on cost saving alternatives
Bronchodilators; Sympathomimetic Leukotriene Inhibitors Mast Cell Stabilizers Nasal Inhalations Oral Corticosteroids Respiratory Device Supplements Electrolytes/Minerals Enzyme Replacements/Modifiers Vitamins and misc. ProAct Specialty Drug Listing Specialty medications can be described as medications that are high cost, highly complex, or typically require specialized administration, handling or distribution. They are often biology-based and mimic substances found in the body to produce their effects. These medications will process according to your plan design, and may require prior authorization and/or have other restrictions.
Medications listed as bold are available generically.
(*) Indicates product is a formulary item, all others are non-formulary.
Abacavir Granisetron Lamivudine Octreotide Ribasphere Enoxaparin Lamiv/Zidov Epirubicin Ribavirin Topotecan Carboplatin Epoprostenol Tranexamic acid Zemplar (IV) Tretinoin (oral) Adriamycin Oxaliplatin Paclitaxel Zidovudine Etoposide
Lupron-Dep Ped* Pamidronate Cisplatin Zoledronic acid Cladribine Pentostatin Sildenafil Idarubicin Melphalan Ifosfamide Amifostine Stavudine Mitomycin Cyclophophamide Floxuridine Mitoxantrone Cyclosporine Vinblastine Fludarabine Vincasar Fluorouracil Vincristine Cytarabine Vinorelbine Mycophenolate Promacta Dacarbazine Fondaparinux Irinotecan Dactinomycin Daunorubicin Dexrazoxane Didanosine Tacrolimus Docetaxel Nevirapine Doxorubicin Gemcitabine Bleomycin
Specialty list not all‐inclusive. Please contact the ProAct Helpdesk at 1‐877‐776‐2285 with questions regarding specialty medications.
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Christoph Berger, Publications Original Papers: 1a. Berger Ch, Holzach P, Matter P. Die Skidaumenverletzung beim Kind. Helv Chir Acta 1993;60:615- 1b. Berger Ch, Holzach P, Matter P. Die Skidaumenverletzung beim Kind. Z Unfallchir Versicherungsmed 1993 Suppl 1:222-231. 2. Berger C, Uehlinger J, Ghelfi D, Blau N, Fanconi S. Comparison of C-reactive protein and white blood cell
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ProAct Specialty Drug Listing