2009 Freescale Preferred Drug List

Transcription

1 April Freescale Preferred Drug List The Freescale Preferred Drug List is a guide within select therapeutic categories for Freescale plan participants and health care providers. Generics should be considered the first line of prescribing. If there is no generic available, there may be more than one brand-name medicine to treat a condition. These preferred brand-name medicines are listed to help identify products that are clinically appropriate and cost-effective. PLAN PARTICIPANT Your benefit plan provides you with a prescription benefit program administered by CVS Caremark. Ask your doctor to consider prescribing, when medically appropriate, a preferred medicine from this list. Take this list along when you or a covered family member sees a doctor. Please note: Your specific prescription benefit plan design may not cover certain categories, regardless of their appearance in this document. For specific information regarding your prescription benefit coverage and copay 1 information, please visit or contact a CVS Caremark Customer Care representative. CVS Caremark may contact your doctor after receiving your prescription to request consideration of a drug list product or generic equivalent. This may result in your doctor prescribing, when medically appropriate, a different brand-name product or generic equivalent in place of your original prescription. HEALTH CARE PROVIDER Your patient is covered under a prescription benefit plan administered by CVS Caremark. As a way to help manage health care costs, authorize generic substitution whenever possible. If you believe a brand-name product is necessary, consider prescribing a brand name on this list. Please note: Generics should be considered the first line of prescribing. This drug list represents a summary of prescription coverage. It is not inclusive and does not guarantee coverage. The plan participant s specific prescription benefit plan may have a different copay for specific products on the list. Unless specifically indicated, drug list products will include all dosage forms. Log in to to check coverage and copay information for a specific medicine. ANALGESICS COX-2 CELEBREX NARCOTIC ANALGESICS, CII AVINZA KADIAN OPANA ER OXYCONTIN VISCOSUPPLEMENTS EUFLEXXA SUPARTZ SYNVISC ANTI-INFECTIVES ANTIBACTERIALS FLUOROQUINOLONES AVELOX CIPRO SUSPENSION LEVAQUIN SULFONAMIDES GANTRISIN ANTIFUNGALS GRIS-PEG VFEND ANTIMALARIALS MALARONE ANTIRETROVIRALS ANTIRETROVIRAL ATRIPLA COMBIVIR EPZICOM TRIZIVIR TRUVADA CHEMOKINE RECEPTOR ANTAGONISTS SELZENTRY INTEGRASE ISENTRESS NON-NUCLEOSIDE REVERSE-TRANSCRIPTASE INTELENCE RESCRIPTOR SUSTIVA VIRAMUNE NUCLEOSIDE REVERSE- TRANSCRIPTASE EMTRIVA EPIVIR VIDEX SOLUTION ZIAGEN NUCLEOTIDE REVERSE- TRANSCRIPTASE VIREAD PROTEASE APTIVUS CRIXIVAN INVIRASE KALETRA LEXIVA NORVIR PREZISTA REYATAZ VIRACEPT ANTIVIRALS CYTOMEGALOVIRUS VALCYTE HEPATITIS BARACLUDE EPIVIR-HBV HEPSERA REBETOL SOLUTION TYZEKA HERPES VALTREX INFLUENZA TAMIFLU FURADANTIN ANTINEOPLASTICS ALKYLATING ALKERAN CEENU HEXALEN LEUKERAN MYLERAN TEMODAR ANTIMETABOLITES TREXALL XELODA HORMONAL ANTINEOPLASTIC ANTIANDROGENS CASODEX ANTIESTROGENS FARESTON FASLODEX AROMATASE ARIMIDEX AROMASIN FEMARA LUTEINIZING HORMONE- RELEASING HORMONE (LHRH) AGONISTS TRELSTAR ZOLADEX KINASE GLEEVEC NEXAVAR SPRYCEL SUTENT TARCEVA TASIGNA TYKERB TOPOISOMERASE HYCAMTIN CAPSULES LYSODREN MATULANE TARGRETIN CAP ZOLINZA CARDIOVASCULAR ACE INHIBITOR/CALCIUM CHANNEL BLOCKER TARKA a CVS Caremark Customer Care representative.

2 ANGIOTENSIN II RECEPTOR ANTAGONISTS/ ATACAND 2 /ATACAND HCT AVAPRO/AVALIDE BENICAR/BENICAR HCT MICARDIS/MICARDIS HCT ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER AZOR EXFORGE ANTIARRHYTHMICS TIKOSYN ANTILIPEMICS BILE ACID RESINS WELCHOL CHOLESTEROL ABSORPTION ZETIA FIBRATES ANTARA LIPOFEN HMG-CoA REDUCTASE CRESTOR LIPITOR NIACINS/ ADVICOR NIASPAN SIMCOR BETA-BLOCKERS BYSTOLIC COREG CR TOPROL-XL CALCIUM CHANNEL BLOCKER/ANTILIPEMIC CADUET NITRATE/VASODILATOR BIDIL PULMONARY ARTERIAL HYPERTENSION ENDOTHELIN RECEPTOR ANTAGONISTS LETAIRIS TRACLEER PHOSPHODIESTERASE REVATIO PROSTAGLANDIN VASODILATORS REMODULIN VENTAVIS RANEXA CENTRAL NERVOUS SYSTEM ANTICONVULSANTS DIASTAT DILANTIN INFATABS KEPPRA XR LYRICA TOPAMAX ANTIDEMENTIA ARICEPT EXELON EXELON PATCH NAMENDA ANTIDEPRESSANTS MONOAMINE OXIDASE (MAOIS) NARDIL SELECTIVE SEROTONIN REUPTAKE (SSRIS) LEXAPRO SEROTONIN NOREPINEPHRINE REUPTAKE (SNRIS) 3 CYMBALTA EFFEXOR XR ANTIPARKINSONIANS AZILECT COMTAN MIRAPEX NEUPRO STALEVO ANTIPSYCHOTICS ABILIFY ABILIFY INJECTION GEODON INVEGA SEROQUEL SEROQUEL XR ZYPREXA ATTENTION DEFICIT HYPERACTIVITY DISORDER ADDERALL XR CONCERTA DAYTRANA FOCALIN XR METADATE CD RITALIN LA STRATTERA VYVANSE HYPNOTICS, NONBENZODIAZEPINES AMBIEN CR LUNESTA MIGRAINE SELECTIVE SEROTONIN AGONISTS MAXALT ZOMIG MULTIPLE SCLEROSIS COPAXONE REBIF NARCOLEPSY/CATAPLEXY PROVIGIL XYREM ENDOCRINE AND METABOLIC ANDROGENS ANDRODERM ANDROGEL ANTIDIABETICS AMYLIN ANALOGS SYMLIN BIGUANIDES GLUMETZA DIPEPTIDYL PEPTIDASE-4 (DPP-4) JANUVIA DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITOR/ BIGUANIDE JANUMET INCRETIN MIMETIC BYETTA INSULINS APIDRA HUMALOG HUMULIN LANTUS LEVEMIR NOVOLIN NOVOLOG INSULIN SENSITIZERS ACTOS AVANDIA INSULIN SENSITIZER/ BIGUANIDE ACTOPLUS MET AVANDAMET INSULIN SENSITIZER/ SULFONYLUREA AVANDARYL DUETACT MEGLITINIDES PRANDIN CALCIUM REGULATORS BISPHOSPHONATES BONIVA PARATHYROID HORMONES FORTEO CONTRACEPTIVES MONOPHASIC YAZ TRIPHASIC ORTHO TRI-CYCLEN LO EXTENDED CYCLE SEASONIQUE CONTINUOUS LYBREL EMERGENCY CONTRACEPTION PLAN B TRANSDERMAL ORTHO EVRA VAGINAL NUVARING ESTROGENS ORAL ENJUVIA PREMARIN TRANSDERMAL, ESTROGENS ESTRADERM VIVELLE-DOT ORAL ESTROGEN/PROGESTINS PREMPHASE PREMPRO TRANSDERMAL ESTROGEN/PROGESTINS CLIMARA PRO VAGINAL ESTRACE CREAM FEMRING PREMARIN VAGINAL CREAM GLUCOSE ELEVATING GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT HUMAN GROWTH HORMONES GENOTROPIN HUMATROPE NORDITROPIN NUTROPIN NUTROPIN AQ SAIZEN HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS HECTOROL ZEMPLAR PHENYLKETONURIA TREATMENT KUVAN PHOSPHATE BINDER FOSRENOL RENAGEL RENVELA PROGESTINS PROMETRIUM SELECTIVE ESTROGEN RECEPTOR MODULATORS EVISTA THYROID SUPPLEMENTS CYTOMEL GASTROINTESTINAL ANTIEMETICS TRANSDERM SCOP CHOLELITHOLYTICS URSO INFLAMMATORY BOWEL DISEASE INJECTABLE CIMZIA ORAL ASACOL ENTOCORT EC LIALDA PENTASA RECTAL CANASA CORTIFOAM LAXATIVES GOLYTELY HALFLYTELY KRISTALOSE VISICOL PANCREATIC ENZYMES CREON ULTRASE ULTRASE MT VIOKASE PROTON PUMP NEXIUM 4 PREVACID 4 GETOURINARY GENITOURINARY BENIGN PROSTATIC HYPERPLASIA AVODART FLOMAX a CVS Caremark Customer Care representative. 2

3 URINARY ANTISPASMODICS DETROL DETROL LA ENABLEX OXYTROL SANCTURA XR VESICARE ELMIRON HEMATOLOGIC HEMATOPOIETIC GROWTH FACTORS ARANESP NEULASTA NEUPOGEN PROCRIT PLATELET AGGREGATION PLAVIX IMMUNOLOGIC DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) CUPRIMINE ENBREL HUMIRA RHEUMATREX RIDAURA IMMUNOMODULATORS INTERFERONS INFERGEN INTRON A PEGASYS PEGINTRON IMMUNOSUPPRESSANTS ANTIMETABOLITES AZASAN CELLCEPT CALCINEURIN PROGRAF RAPAMYCIN DERIVATIVES RAPAMUNE NUTRITIONAL PRENATAL VITAMINS CITRANATAL ASSURE CITRANATAL DHA CITRANATAL 90 DHA PRECARE CHEWABLES PRECARE CONCEIVE PRECARE PREMIER PRECARE PRENATAL PREMESISRX PRIMACARE PRIMACARE ONE RESPIRATORY ANAPHYLAXIS TREATMENT EPIPEN EPIPEN JR ANTICHOLINERGICS SPIRIVA ANTICHOLINERGIC/ BETA AGONISTS COMBIVENT ANTIHISTAMINE/ DECONGESTANTS ALLEGRA-D 4 BETA AGONISTS INHALANTS, SHORT ACTING PROAIR HFA PROVENTIL HFA XOPENEX XOPENEX HFA INHALANTS, LONG ACTING FORADIL SEREVENT LEUKOTRIENE RECEPTOR ANTAGONISTS MAST CELL STABILIZERS INTAL INHALER NASAL ANTIHISTAMINES ASTELIN ASTEPRO NASAL STEROIDS NASACORT AQ NASONEX RHINOCORT AQUA STEROID/BETA AGONIST ADVAIR ADVAIR HFA SYMBICORT STEROID INHALANTS ASMANEX FLOVENT HFA PULMICORT QVAR TOPICAL DERMATOLOGY ACNE BENZACLIN DIFFERIN DUAC CS RETIN-A MICRO ACTINIC KERATOSIS CARAC ANTIBIOTICS ALTABAX ANTIPSORIATICS DOVONEX CREAM TAZORAC IMMUNOMODULATORS ELIDEL PROTOPIC LOCAL ANALGESICS LIDODERM ROSACEA FINACEA ORACEA SCABICIDES AND PEDICULICIDES OVIDE OPHTHALMIC ANTIALLERGICS OPTIVAR PATADAY ANTI-INFECTIVES QUIXIN VIGAMOX ZYMAR ANTI-INFECTIVE/ ANTI-INFLAMMATORIES BLEPHAMIDE SOP TOBRADEX ZYLET ANTI-INFLAMMATORIES, NONSTEROIDAL ACULAR XIBROM ANTI-INFLAMMATORIES, STEROIDAL LOTEMAX PRED MILD BETA-BLOCKERS, NONSELECTIVE BETIMOL BETA-BLOCKERS, SELECTIVE BETOPTIC S PROSTAGLANDINS LUMIGAN TRAVATAN XALATAN SYMPATHOMIMETICS ALPHAGAN P SYMPATHOMIMETIC/ BETA-BLOCKER COMBIGAN OTIC ANTI-INFECTIVE/ ANTI-INFLAMMATORIES CIPRODEX QUICK REFERENCE DRUG LIST A ABILIFY ABILIFY INJECTION ACTOPLUS MET ACTOS ACULAR ADDERALL XR ADVAIR ADVAIR HFA ADVICOR ALKERAN ALLEGRA-D 4 ALPHAGAN P ALTABAX AMBIEN CR ANDRODERM ANDROGEL ANTARA APIDRA APTIVUS ARANESP ARICEPT ARIMIDEX AROMASIN ASACOL ASMANEX ASTELIN ASTEPRO ATACAND 2 ATACAND HCT ATRIPLA AVALIDE AVANDAMET AVANDARYL AVANDIA AVAPRO AVELOX AVINZA AVODART AZASAN AZILECT AZOR B BARACLUDE BENICAR BENICAR HCT BENZACLIN BETIMOL BETOPTIC S BIDIL BLEPHAMIDE SOP BONIVA BYETTA BYSTOLIC C CADUET CANASA CARAC CASODEX CEENU CELEBREX CELLCEPT CIMZIA CIPRO SUSPENSION CIPRODEX CITRANATAL ASSURE CITRANATAL DHA CITRANATAL 90 DHA CLIMARA PRO COMBIGAN COMBIVENT COMBIVIR COMTAN CONCERTA COPAXONE COREG CR CORTIFOAM CREON CRESTOR CRIXIVAN CUPRIMINE CYMBALTA CYTOMEL D DAYTRANA DETROL DETROL LA DIASTAT DIFFERIN DILANTIN INFATABS a CVS Caremark Customer Care representative. 3

4 DOVONEX CREAM DUAC CS DUETACT E EFFEXOR XR ELIDEL ELMIRON EMTRIVA ENABLEX ENBREL ENJUVIA ENTOCORT EC EPIPEN EPIPEN JR EPIVIR EPIVIR-HBV EPZICOM ESTRACE CREAM ESTRADERM EUFLEXXA EVISTA EXELON EXELON PATCH EXFORGE F FARESTON FASLODEX FEMARA FEMRING FINACEA FLOMAX FLOVENT HFA FOCALIN XR FORADIL FORTEO FOSRENOL FURADANTIN G GANTRISIN GENOTROPIN GEODON GLEEVEC GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT GLUMETZA GOLYTELY GRIS-PEG H HALFLYTELY HECTOROL HEPSERA HEXALEN HUMALOG HUMATROPE HUMIRA HUMULIN HYCAMTIN CAPSULES I INFERGEN INTAL INHALER INTELENCE INTRON A INVEGA INVIRASE ISENTRESS J JANUMET JANUVIA K KADIAN KALETRA KEPPRA XR KRISTALOSE KUVAN L LANTUS LETAIRIS LEUKERAN LEVAQUIN LEVEMIR LEXAPRO LEXIVA LIALDA LIDODERM LIPITOR LIPOFEN LOTEMAX LUMIGAN LUNESTA LYBREL LYRICA LYSODREN M MALARONE MATULANE MAXALT METADATE CD MICARDIS MICARDIS HCT MIRAPEX MYLERAN N NAMENDA NARDIL NASACORT AQ NASONEX NEULASTA NEUPOGEN NEUPRO NEXAVAR NEXIUM 4 NIASPAN NORDITROPIN NORVIR NOVOLIN NOVOLOG NUTROPIN NUTROPIN AQ NUVARING O OPANA ER OPTIVAR ORACEA ORTHO EVRA ORTHO TRI-CYCLEN LO OVIDE OXYCONTIN OXYTROL P PATADAY PEGASYS PEGINTRON PENTASA PLAN B PLAVIX PRANDIN PRECARE CHEWABLES PRECARE CONCEIVE PRECARE PREMIER PRECARE PRENATAL PRED MILD PREMARIN PREMARIN VAGINAL CREAM PREMESISRX PREMPHASE PREMPRO PREVACID 4 PREZISTA PRIMACARE PRIMACARE ONE PROAIR HFA PROCRIT PROGRAF PROMETRIUM PROTOPIC PROVENTIL HFA PROVIGIL PULMICORT Q QUIXIN QVAR R RANEXA RAPAMUNE REBETOL SOLUTION REBIF REMODULIN RENAGEL RENVELA RESCRIPTOR RETIN-A MICRO REVATIO REYATAZ RHEUMATREX RHINOCORT AQUA RIDAURA RITALIN LA S SAIZEN SANCTURA XR SEASONIQUE SELZENTRY SEREVENT SEROQUEL SEROQUEL XR SIMCOR SPIRIVA SPRYCEL STALEVO STRATTERA SUPARTZ SUSTIVA SUTENT SYMBICORT SYMLIN SYNVISC T TAMIFLU TARCEVA TARGRETIN CAP TARKA TASIGNA TAZORAC TEMODAR TIKOSYN TOBRADEX TOPAMAX TOPROL-XL TRACLEER TRANSDERM SCOP TRAVATAN TRELSTAR TREXALL TRIZIVIR TRUVADA TYKERB TYZEKA U ULTRASE ULTRASE MT URSO V VALCYTE VALTREX VENTAVIS VESICARE VFEND VIDEX SOLUTION VIGAMOX VIOKASE VIRACEPT VIRAMUNE VIREAD VISICOL VIVELLE-DOT VYVANSE W WELCHOL X XALATAN XELODA XIBROM XOPENEX XOPENEX HFA XYREM Y YAZ Z ZEMPLAR ZETIA ZIAGEN ZOLADEX ZOLINZA ZOMIG ZYLET ZYMAR ZYPREXA a CVS Caremark Customer Care representative. 4

5 PREFERRED ALTERNATIVES LIST DRUG NAME PREFERRED ALTERNATIVE(S)* DRUG NAME PREFERRED ALTERNATIVE(S)* ACCOLATE ESTROGEL ACIPHEX NEXIUM 4, PREVACID 4 FEMHRT PREMPHASE, PREMPRO W/CALCIUM FEMTRACE AEROBID, AEROBID M ASMANEX, FLOVENT, FLOVENT HFA, PULMICORT, QVAR FENOGLIDE ALORA FIRST TESTOSTERONE ANDRODERM, ANDROGEL ALTOPREV CRESTOR, LIPITOR FOSAMAX PLUS D ALVESCO ASMANEX, FLOVENT, FLOVENT HFA, PULMICORT, QVAR ISTALOL BETIMOL AMERGE MAXALT, ZOMIG LESCOL, LESCOL XL CRESTOR, LIPITOR ANGELIQ PREMPHASE, PREMPRO MENEST ARMOUR THYROID SYNTHROID MENOSTAR ATROVENT HFA AXERT AZELEX AZMACORT BECONASE AQ SPIRIVA MAXALT, ZOMIG ASMANEX, FLOVENT, FLOVENT HFA, PULMICORT, QVAR NASACORT AQ, NASONEX, RHINOCORT AQUA, OMNARIS OVACE PATANASE PEXEVA PREFEST NASACORT AQ, NASONEX, RHINOCORT AQUA, ASTELIN, ASTEPRO LEXAPRO PREMPHASE, PREMPRO BENZAC AC, BENZAC W BENZAGEL BENZIQ BREVOXYL CARDURA XL CENESTIN AVODART, FLOMAX CLARINEX D ALLEGRA-D 4 CLINDAGEL DESQUAM E, DESQUAM X DORAL ESTRASORB ESTRATEST, ESTRATEST HS AMBIEN CR, LUNESTA RELION INSULIN RELPAX ROZEREM SKELID STARLIX STRIANT TEVETEN, TEVETEN HCT TRIAZ TRIGLIDE TRILIPIX TWINJECT UROXATRAL ZODERM ZYFLO, ZYFLO CR HUMULIN INSULIN, NOVOLIN INSULIN MAXALT, ZOMIG AMBIEN CR, LUNESTA PRANDIN ANDRODERM, ANDROGEL AVALIDE, AVAPRO, BENICAR, BENICAR HCT, MICARDIS, MICARDIS HCT EPIPEN, EPIPEN JR AVODART, FLOMAX * The preferred alternative products in this list are a broad representation within therapeutic categories of available treatment options and do not necessarily represent clinical equivalency. Your specific prescription benefit plan design may not cover certain products, regardless of their appearance in this document. For specific information, visit or contact a CVS Caremark Customer Care representative. 5

6 FOR YOUR INFORMATION: Generics should be considered the first line of prescribing. This drug list represents a summary of prescription coverage. It is not inclusive and does not guarantee coverage. Specific prescription benefit plan design may not cover certain categories, regardless of their appearance in this document. The plan participant s prescription benefit plan may have a different copay for specific products on the list. Unless specifically indicated, drug list products will include all dosage forms. This is not an all-inclusive list. Listed products may be available generically in certain strengths or dosage forms. Dosage forms on this list will be consistent with the category and use where listed. Log in to to check coverage and copay information for a specific medicine. Generics are available in this class and should be considered the first line of prescribing. 1 Copayment, copay or coinsurance means the amount a plan participant is required to pay for a prescription in accordance with a Plan, which may be a deductible, a percentage of the prescription price, a fixed amount or other charge, with the balance, if any, paid by a Plan. 2 Atacand should be reserved for patients who meet CHARM (Candesartan in Heart Failure - Assessment of Reduction in Mortality and Morbidity) trial criteria. 3 Indicates the proposed mechanism of action, based on the American Psychiatric Association Summary of Treatment Recommendations. 4 For selected categories, listed products will adjudicate at the third tier. Your privacy is important to us. Our employees are trained regarding the appropriate way to handle your private health information. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers. Listed products are for informational purposes only and are not intended to replace the clinical judgment of the prescriber All rights reserved