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Mg40675u 1199 1h11 seiu pdl bifold_v5

MG40675U 1199 1H11 SEIU PDL BiFold_v5 12/2/10 9:01 AM Page a 1199SEIU
Preferred Drug List
Please take this guide
with you the next time
you visit your doctor.
2011 Medco Health Solutions, Inc. All rights reserved.
Medco is a registered trademark of Medco Health Solutions, Inc.
If you have questions about your prescription drug benefit,
visit www.medco.com or call Medco Member Services at (800) 818-6720.
For questions about your 1199SEIU benefits, call the 1199SEIU Benefit Funds’ Member Services representatives at (646) 473-9200.
Medco manages your prescription drug benefit for the 1199SEIU Benefit Funds.
MG40675U 1199 1H11 SEIU PDL BiFold_v5 12/2/10 9:01 AM Page 1 This Preferred Drug List includes classes of widely used drugs that are preferred by the 1199SEIU BenefitFunds. These medications have been carefully selected to provide safety and value. If you receive anygeneric drug or preferred brand, you will have no out-of-pocket expense (except for GNY Benefit Fundand Rochester-area members, who may have small co-payments for certain brand-name drugs).
However, if you get a nonpreferred brand when a preferred drug is available, you will be responsible forthe difference in cost between the preferred and nonpreferred drugs. (Please note that this list is subjectto change.) Section II provides a listing of nonpreferred brands and their possible preferred alternatives.
SAFETY CONSIDERATION SYMBOLS
Here is a quick guide that explains our safety symbols. These symbols appear next to certain
medications.
A dose lower than the manufacturer’s guidelines is often recommended for people 65 and older. Use by people 65 and older is associated with increased risk; safer alternatives may be available. Ifused, the dosage should generally be lowered.
Weigh the risk of birth defects and other adverse outcomes.
PRESCRIPTION PROGRAM CONSIDERATION SYMBOLS
For more information, please call Medco: (800) 753-2851.
[PA] This symbol next to a drug name indicates that this medication is subject to the Prior [ST] This symbol next to a drug name indicates that this medication is subject to the Step Therapy [QD] This symbol next to a drug name indicates that this medication is subject to the Quantity Duration OTHER SYMBOLS:[AC] This symbol next to a drug name indicates that this specialty medication must be obtained through Accredo. Please call Accredo: (800) 803-2523.
Shaded areas indicate the most recent additions to the Preferred Drug List.
Drugs Not Covered by the 1199SEIU Benefit Funds
All Over-the-Counter drugs (except diabetic supplies) Please refer to your Summary Plan Description for a complete list of excluded drugs. Information was in effect at the time of printing and may be subject to change.
For the most up-to-date 1199SEIU Benefit Funds Preferred Drug List go to www.1199SEIUBenefits.org.
MG40675U 1199 1H11 SEIU PDL BiFold_v5 12/2/10 9:01 AM Page 2 SECTION I: THERAPEUTIC DRUG CATEGORIES
ADRENAL HORMONES (EFFECTIVE 3-1-11)
ANTIANDROGENS (EFFECTIVE 3-1-11)
ANTICONVULSANTS (EFFECTIVE 7-1-10)
ANTI-INFECTIVES (Antibiotics)
Oral Penicillins
Oral Cephalosporins
Oral Quinolones
Oral Erythromycins and other
Oral Tetracyclines
Macrolides
erythromycin ethylsuccinate/sulfisoxazole acetyl ANTIPARKINSONISM AGENTS (EFFECTIVE 1-1-10)
ANTIVERTIGO & ANTIEMETIC DRUGS (EFFECTIVE 4-1-10)
Key: G = Preferred generic medication.
This symbol next to a drug name indicates that this medication is subject tothe Prior Authorization Program.
This symbol next to a drug name indicates that this medication is subject to = A dose lower than the manufacturer’s guidelines is often recommended for This symbol next to a drug name indicates that this medication is subject to ▲ = Use by people 65 and older is associated with increased risk; safer alternatives may be available. If used, the dosage should generally be lowered.
This symbol indicates that this specialty medication must be obtained = Weigh risk of birth defects or other adverse outcomes.
through Accredo. Please call: (800) 501-7210.
MG40675U 1199 1H11 SEIU PDL BiFold_v5 12/2/10 9:01 AM Page 3 ANTIPSORIATIC/ANTISEBORRHEIC (EFFECTIVE 3-1-11)
Anti-Psoriatic/Anti-Seborrheic
Topical Agents
G
BENIGN PROSTATE HYPERPLASIA (BPH) THERAPY
BIOTECHNOLOGY DRUGS (EFFECTIVE 7-1-10)
Factor VIII - Recombinant Drugs
P
CARDIOVASCULAR (Blood Pressure/Heart/Cholesterol)
Beta Blockers
ACE Inhibitors
propranolol HCl capsule, sustained Angiotensin II Blockers
Calcium Channel Blockers
Antilipidemics - Statin Drugs
Long Acting Nitrates (Topical)
(EFFECTIVE 7-1-10)
Antiplatelet Agents
(EFFECTIVE 7-1-10)
Other Antilipidemics
Dihydropyridines Calcium
Channel Blocker
Select Combination
Antihypertensives
Key: G = Preferred generic medication.
This symbol next to a drug name indicates that this medication is subject tothe Prior Authorization Program.
This symbol next to a drug name indicates that this medication is subject to = A dose lower than the manufacturer’s guidelines is often recommended for This symbol next to a drug name indicates that this medication is subject to ▲ = Use by people 65 and older is associated with increased risk; safer alternatives may be available. If used, the dosage should generally be lowered.
This symbol indicates that this specialty medication must be obtained = Weigh risk of birth defects or other adverse outcomes.
through Accredo. Please call: (800) 501-7210.
MG40675U 1199 1H11 SEIU PDL BiFold_v5 12/2/10 9:01 AM Page 4 DRUGS TO TREAT OVERACTIVE BLADDER (EFFECTIVE 1-1-10)
ENDOCRINE (Diabetes/Hormones/Contraceptives)
Insulin Therapy
Blood Glucose Test Strips
Estrogen Agents (oral/vaginal)
Oral Hypoglycemic Agents
(EFFECTIVE 1-1-09)
EVISED – EFFECTIVE 4-1-10)
Blood Glucose Monitoring
Androgen Replacement Agents
EVISED – EFFECTIVE 10-1-09)
Contraceptive Agents
(EFFECTIVE 10-1-09)
Estrogen Patches (EFFECTIVE 7-1-09)
G I (Ulcer)
Ulcer Drugs
GOUT THERAPY (EFFECTIVE 3-1-11)
Key: G = Preferred generic medication.
This symbol next to a drug name indicates that this medication is subject tothe Prior Authorization Program.
This symbol next to a drug name indicates that this medication is subject to = A dose lower than the manufacturer’s guidelines is often recommended for This symbol next to a drug name indicates that this medication is subject to ▲ = Use by people 65 and older is associated with increased risk; safer alternatives may be available. If used, the dosage should generally be lowered.
This symbol indicates that this specialty medication must be obtained = Weigh risk of birth defects or other adverse outcomes.
through Accredo. Please call: (800) 501-7210.
MG40675U 1199 1H11 SEIU PDL BiFold_v5 12/2/10 9:01 AM Page 5 GROWTH HORMONES (REVISED – EFFECTIVE 7-1-10)
IMMUNOGLOBULIN AGENTS (INJECTABLES) (EFFECTIVE 5-1-09)
INTERFERONS (EFFECTIVE 10-1-09)
Hepatitis C Agents
Injectable Multiple Sclerosis
Agents (EFFECTIVE 3-1-11)
MISCELLANEOUS GASTROINTESTINAL AGENTS (EFFECTIVE 7-1-10)
Ulcerative Colitis Agents
MISCELLANEOUS RHEUMATOLOGICAL AGENTS (EFFECTIVE 7-1-10)
Rheumatoid Arthritis Agents
(Injectables)
MUSCLE RELAXANTS (EFFECTIVE 10-1-09)
NARCOTIC ANALGESICS (Pain Relievers)
Narcotics
Miscellaneous Analgesic
Therapy (EFFECTIVE 1-1-09)
Key: G = Preferred generic medication.
This symbol next to a drug name indicates that this medication is subject tothe Prior Authorization Program.
This symbol next to a drug name indicates that this medication is subject to = A dose lower than the manufacturer’s guidelines is often recommended for This symbol next to a drug name indicates that this medication is subject to ▲ = Use by people 65 and older is associated with increased risk; safer alternatives may be available. If used, the dosage should generally be lowered.
This symbol indicates that this specialty medication must be obtained = Weigh risk of birth defects or other adverse outcomes.
through Accredo. Please call: (800) 501-7210.
MG40675U 1199 1H11 SEIU PDL BiFold_v5 12/2/10 9:01 AM Page 6 NON-NARCOTIC ANALGESICS (Pain Relievers)
Migraine/Headache Therapy
(EFFECTIVE 1-1-09)
Osteoarthritis Agents
NSAID COX-2 Inhibitors
(Injectable) (EFFECTIVE 7-1-09)
OPHTHALMICS (Eye Preparations)
Ophthalmic-Steroids
Ophthalmic Beta-Blockers
Ophthalmic Anti-Inflammatory
(EFFECTIVE 1-1-10)
(EFFECTIVE 1-1-10)
Agents (NSAIDs) (EFFECTIVE 3-1-11)
Ophthalmic Steroid-Antibiotic
Miscellaneous Ophthalmics-
Combinations (EFFECTIVE 3-1-11)
Antihistamine & Mast-Cell
Antibiotic-Ophthalmics
Stabilizers (EFFECTIVE 3-1-11)
(EFFECTIVE 1-1-09)
Miscellaneous Glaucoma Agents
(EFFECTIVE 5-1-09)
Ophthalmic Carbonic Anhdyrase
Inhibitors (EFFECTIVE 1-1-10)
OSTEOPOROSIS/PAGET’S DISEASE
Key: G = Preferred generic medication.
This symbol next to a drug name indicates that this medication is subject tothe Prior Authorization Program.
This symbol next to a drug name indicates that this medication is subject to = A dose lower than the manufacturer’s guidelines is often recommended for This symbol next to a drug name indicates that this medication is subject to ▲ = Use by people 65 and older is associated with increased risk; safer alternatives may be available. If used, the dosage should generally be lowered.
This symbol indicates that this specialty medication must be obtained = Weigh risk of birth defects or other adverse outcomes.
through Accredo. Please call: (800) 501-7210.
MG40675U 1199 1H11 SEIU PDL BiFold_v5 12/2/10 9:01 AM Page 7 OTICS (Ear Preparations) (EFFECTIVE 4-1-10)
PSYCHOTHERAPEUTICS (Anxiety/Depression)
Hypnotic Agents
Anxiolytics
Miscellaneous Antidepressants
SSRI Antidepressants
Attention Deficit Hyperactivity
Disorder (EFFECTIVE 5-1-09)
Antipsychotics
RESPIRATORY (Allergy/Asthma/COPD)
Beta Agonist Inhalers
PDATED 5-1-09)
Nasal Corticosteroids
Miscellaneous Pulmonary Agents
(EFFECTIVE 1-1-09)
Inhaled Corticosteroid Therapy
(EFFECTIVE 1-1-09)
TOPICAL ACNE THERAPY (EFFECTIVE 1-1-09)
Key: G = Preferred generic medication.
This symbol next to a drug name indicates that this medication is subject tothe Prior Authorization Program.
This symbol next to a drug name indicates that this medication is subject to = A dose lower than the manufacturer’s guidelines is often recommended for This symbol next to a drug name indicates that this medication is subject to ▲ = Use by people 65 and older is associated with increased risk; safer alternatives may be available. If used, the dosage should generally be lowered.
This symbol indicates that this specialty medication must be obtained = Weigh risk of birth defects or other adverse outcomes.
through Accredo. Please call: (800) 501-7210.
MG40675U 1199 1H11 SEIU PDL BiFold_v5 12/2/10 9:01 AM Page 8 TOPICAL ANTIFUNGALS
TOPICAL ANTIVIRAL THERAPY (EFFECTIVE 1-1-09)
TOPICAL CORTICOSTEROIDS (Topical Skin Products)
Low Potency
High Potency
Very High Potency
Medium Potency
VITAMINS — All generics are preferred (Most commonly used listed below) (EFFECTIVE 1-1-09)
Prenatal Vitamin Therapy
Vitamin B Therapy
Multivitamin Therapy
Iron Supplement Therapy
Key: G = Preferred generic medication.
This symbol next to a drug name indicates that this medication is subject tothe Prior Authorization Program.
This symbol next to a drug name indicates that this medication is subject to = A dose lower than the manufacturer’s guidelines is often recommended for This symbol next to a drug name indicates that this medication is subject to ▲ = Use by people 65 and older is associated with increased risk; safer alternatives may be available. If used, the dosage should generally be lowered.
This symbol indicates that this specialty medication must be obtained = Weigh risk of birth defects or other adverse outcomes.
through Accredo. Please call: (800) 501-7210.
MG40675U 1199 1H11 SEIU PDL BiFold_v5 12/2/10 9:01 AM Page 9 If your prescribed drug is in the “non-preferred” column, ask your doctor if she or he can prescribe oneof the alternatives listed.
SECTION II: NONPREFERRED DRUGS AND THEIR POSSIBLE PREFERRED ALTERNATIVES
Nonpreferred Product
Possible Preferred Alternatives
Nonpreferred Product
Possible Preferred Alternatives
clozapine (generic), risperidone (generic), Geodon® (Pfizer), erythromycin ointment (generic), ciprofloxacin drops Seroquel® (AstraZeneca), Zyprexa® (Lilly) (generic), tobramycin sulfate drops (generic),Vigamox (Alcon) clindamycin (generic) + benzoyl peroxide (generic) Flovent HFA® (GlaxoSmithKline), Flovent Diskus® omeprazole (generic), omeprazole-sodium bicarbonate (GlaxoSmithKline), Pulmicort Respules® (AstraZeneca), Boniva® (Roche), alendronate 35mg (generic), alendronate Boniva® (Roche), alendronate 5mg (generic), alendronate flunisolide (generic), fluticasone propionate (generic), losartan potassium (generic), Micardis® (BIPI) diclofenac (generic), flurbiprofen (generic), ketorolac (generic) losartan/HCTZ (generic), Micardis HCT® (BIPI) benzoyl peroxide (generic), clindamycin phosphate (generic), clindamycin phosphate (generic), benzoyl peroxide (generic) cromolyn (generic), azelastine (generic), Patanol® (Alcon), lovastatin (generic), niacin (generic), simvastatin (generic), pravastatin (generic), Lipitor® (Pfizer), Niaspan ER® (Abbott) Flovent HFA® (GlaxoSmithKline), Flovent Diskus® betaxolol (generic), carteolol (generic), timolol (generic), (GlaxoSmithKline), Pulmicort Respules® (AstraZeneca), levobunolol (generic), metipranolol (generic) betaxolol (generic), carteolol (generic), timolol (generic), Flovent HFA® (GlaxoSmithKline), Flovent Diskus® levobunolol (generic), metipranolol (generic) (GlaxoSmithKline), Pulmicort Respules® (AstraZeneca),Qvar® (IVAX) Folic Acid + ethinyl estradiol/drospirenone (generic) fluocinolone acetonide solution, non oral (generic) cromolyn (generic), azelastine (generic), Patanol® (Alcon), chloral hydrate (generic), temazepam (generic), triazolam cromolyn (generic), azelastine (generic), Patanol® (Alcon), acebutolol HCl (generic), atenolol HCl (generic), metoprolol tartrate (generic), metoprolol succinate (generic), propranololHCl (generic) cromolyn (generic), azelastine (generic), Patanol® (Alcon),Pataday® (Alcon) amlodipine besylate (generic), Lipitor® (Pfizer) estradiol (generic), Estraderm (Novartis),Vivelle (Novartis), amlodipine besylate (generic), nifedipine ER (generic) ondansetron (generic), granisetron (generic), Emend® (Merck) diltiazem HCl capsule, sustained release 24 hr (generic) fluorometholone (generic), prednisolone (generic) Gamunex® (Talecris Biotherapeutics),Vivaglobin® (ZLB lovastatin (generic), simvastatin (generic), pravastatin acebutolol HCl (generic), atenolol tablet (generic), metoprolol tartrate tablet (generic), propranolol HCl tablet(generic), propranolol HCl capsule, sustained action 24 hr (generic), timolol maleate tablet (generic) zolpidem (generic), temazepam (generic), triazolam (generic), cefpodoxime (generic), cefaclor (generic), cefuroxime axetil Folbain Plus (generic),Vitaplex (generic), Folbic (generic), fenofibrate (generic), gemfibrozil (generic) ondansetron (generic), granisetron (generic), Emend® (Merck) Folbain Plus (generic),Vitaplex (generic), Folbic (generic),Folbee (generic), Renal Caps (generic) mesalamine (generic),Asacol® (Procter & Gamble), Pentasa®(Shire US) Foltrin (generic), Ferrex 150 Forte (generic), HematogenForte (generic), Ferotrinsic (generic), Poly-Iron 150 Forte diclofenac (generic), misoprostol (generic), Celebrex® (Pfizer) Flovent HFA® (GlaxoSmithKline), Flovent Diskus® Foltrin (generic), Ferrex 150 Forte (generic), Hematogen (GlaxoSmithKline), Pulmicort Respules® (AstraZeneca), Forte (generic), Ferotrinsic (generic), Poly-Iron 150 Forte losartan potassium (generic), Micardis® (BIPI) Foltrin (generic), Ferrex 150 Forte (generic), Hematogen losartan/HCTZ (generic), Micardis HCT® (BIPI) Forte (generic), Ferotrinsic (generic), Poly-Iron 150 Forte amoxicillin trihydrate/potassium clavulanate (generic) losartan/HCTZ (generic), Micardis HCT® (BIPI) losartan potassium (generic), Micardis® (BIPI) neomycin/polymyxin/HC (generic), ofloxacin (generic) neomycin/polymyxin/HC (generic), ofloxacin (generic) finasteride (generic), tamsulosin (generic) naratriptan (generic), sumatriptan (generic), Maxalt® (Merck), *Branded generics have the same co-payment as regular generics.
MG40675U 1199 1H11 SEIU PDL BiFold_v5 12/2/10 9:01 AM Page 10 Nonpreferred Product
Possible Preferred Alternatives
Nonpreferred Product
Possible Preferred Alternatives
betamethasone valerate cream (generic), desoximetasone cream (generic), fluocinolone acetonide cream (generic), hydromorphone (generic), morphine ER (generic), hydrocortisone valerate cream (generic), triamcinolone econazole nitrate (generic), ketoconazole (generic), nystatin neomycin/polymyxin/HC (generic), ofloxacin (generic) oxycodone w/acetaminophen (generic), oxycodone w/aspirin amlodipine (generic), benazepril (generic), betamethasone valerate cream (generic), desoximetasone cream (generic), fluocinolone acetonide cream (generic),hydrocortisone valerate cream (generic), triamcinolone Avonex® (Biogen), Betaseron® (Berlex Laboratories), ciprofloxacin (generic), Avelox® (Schering) neomycin/polymyxin/HC (generic), ofloxacin (generic) clozapine (generic), risperidone (generic), Geodon® (Pfizer),Seroquel® (AstraZeneca), Zyprexa® (Lilly) Therobec Plus (generic),Vitaplex Plus (generic),Vitacon Plus(generic), Formula B Plus (generic),Vita Forte (generic) Accu-Chek® (Roche), Ascensia® (Bayer), Breeze2® (Bayer),Contour® (Bayer) verapamil HCl tablet, sustained action (generic) simvastatin (generic), Lipitor® (Pfizer) methylphenidate ER (generic), Concerta® (McNeilConsumer),Adderall XR® (Shire US Inc.) fluocinolone acetonide solution, non oral (generic) Androderm® (Watson Pharmaceuticals),Androgel® (Unimed) desonide (generic), alclometasone (generic), hydrocortisone Gamunex® (Talecris Biotherapeutics),Vivaglobin® (ZLB flavoxate( generic), oxybutynin (generic), oxybutynin ER naproxen (generic), etodolac (generic), ibuprofen (generic) flavoxate( generic), oxybutynin (generic), oxybutynin ER dexmethylphenidate (generic), methylphenidate ER (generic), adapalene (generic), tretinoin (generic), Azelex® (Allergan), Concerta® (McNeil Consumer),Adderall XR® (Shire US Inc.) losartan potassium (generic), Micardis® (BIPI) losartan/HCTZ (generic), Micardis HCT® (BIPI) sulfasalazine (generic), balsalazide (generic),Asacol® (Procter & Gamble), Pentasa® ( Shire US) Accu-Chek® (Roche), Ascensia® (Bayer), Breeze2® (Bayer),Contour® (Bayer) naratriptan (generic), sumatriptan (generic), Maxalt (Merck), Gammagard® Liquid Gamunex® (Talecris Biotherapeutics),Vivaglobin® (ZLB clindamycin phosphate (generic), benzoyl peroxide (generic) Accu-Chek® (Roche), Ascensia® (Bayer), Breeze2® (Bayer), Gamunex® (Talecris Biotherapeutics),Vivaglobin® (ZLB oxybutynin (generic), oxybutynin ER (generic) Prenatal Plus (generic), OB-Natal Plus (generic), PNV-DHA Norditropin® (Nov Nordisk),Tev-Tropin® (Gate (generic),Taron-Prex Prenatal (generic), Pruet DHA (generic) Advair HFA® and Diskus® (GlaxoSmithKline) desoximetasone cream (generic), fluocinonide cream(generic) amlodipine besylate (generic), nifedipine ER (generic) Norditropin® (Nov Nordisk),Tev-Tropin® (Gate dextroamphetamine/amphetamine (generic), methylphenidate (generic), methylphenidate ER (generic), Concerta® (Janssen) flavoxate( generic), oxybutynin (generic), oxybutynin ER risperidone (generic), Seroquel® (AstraZeneca), adapalene (generic) + benzoyl peroxide (generic) ciprofloxacin drops (generic),Vigamox® (Alcon) carbamazepine (generic), divalproex (generic), lithium betaxolol (generic), carteolol (generic), timolol (generic), levobunolol (generic), metipranolol (generic) econazole nitrate (generic), ketoconazole (generic), nystatin tamsulosin (generic) + finasteride (generic) estradiol patch (generic), Estraderm® (Novartis),Vivelle®(Novartis),Vivelle-DOT® (Novartis) omeprazole (generic), Nexium® (AstraZeneca) Apri® (Barr-branded generic*), Kariva® (Barr-branded generic*), Microgestin Fe® (Watson-branded generic*) Hyalgan® (Sanofi Pharm), Synvisc® (Genzyme), Synvisc-One® lovastatin (generic), simvastatin (generic), pravastatin *Branded generics have the same co-payment as regular generics.
MG40675U 1199 1H11 SEIU PDL BiFold_v5 12/2/10 9:01 AM Page 11 Nonpreferred Product
Possible Preferred Alternatives
Nonpreferred Product
Possible Preferred Alternatives
lovastatin (generic), simvastatin (generic), pravastatin Norditropin® (NovoNordisk),Tev-Tropin® (Gate ciprofloxacin (generic), ofloxacin (generic),Avelox® (Schering) Norditropin® (NovoNordisk),Tev-Tropin® (Gate acebutolol HCl (generic), atenolol (generic), metoprolol Norditropin® (NovoNordisk),Tev-Tropin® (Gate citalopram solution (generic), fluoxetine HCl solution citalopram (generic), fluoxetine HCl (generic), Prenatal Plus (generic), OB-Natal Plus (generic), PNV-DHA paroxetine HCl (generic), sertraline HCl (generic) (generic),Taron-Prex Prenatal (generic), Pruet DHA (generic) balsalazide (generic),Asacol® (Procter & Gamble), Pentasa® Gamunex® (Talecris Biotherapeutics),Vivaglobin® (ZLB lovastatin (generic), pravastatin( generic), simvastatin flunisolide (generic), fluticasone propionate (generic), Norditropin® (Nov Nordisk),Tev-Tropin® (Gate cefaclor (generic), cefuroxime axetil (generic), cefdinir Accu-Chek® (Roche), Ascensia® (Bayer), Breeze2® (Bayer), fluorometholone (generic), prednisolone (generic) Accu-Chek® (Roche), Ascensia® (Bayer), Breeze2® (Bayer),Contour® (Bayer) fenofibrate (generic), Niaspan ER® (Abbott) temazepam (generic), triazolam (generic), zolpidem (generic),zaleplon (generic) morphine sulfate ER (generic), Oxycontin® (Purdue Pharma) doxycycline monohydrate (generic), minocycline (generic) trandolapril HCl (generic), benazepril HCl (generic), enalapril maleate (generic), lisinopril (generic), quinapril (generic), Hyalgan® (Sanofi Pharm), Synvisc® (Genzyme), fluorometholone (generic), prednisolone (generic) estradiol (generic), estropipate (generic), Cenestin estradiol (generic), Estraderm (Novartis),Vivelle (Novartis), econazole nitrate (generic), ketoconazole (generic), nystatin econazole nitrate (generic), ketoconazole (generic), oxybutynin (generic), oxybutynin ER (generic) betamethasone valerate cream (generic), desoximetasone Folbain Plus (generic),Vitaplex (generic), Folbic (generic), cream (generic), fluocinolone acetonide cream (generic), hydrocortisone valerate cream (generic), triamcinolone carbidopa/levadopa (generic), carbidopa/levadopa ER econazole nitrate (generic), ketoconazole (generic), etodolac (generic), ibuprofen (generic), naproxen (generic) etodolac (generic), ibuprofen (generic), indomethacin (generic), naproxen (generic), sulindac (generic) flunisolide (generic), fluticasone propionate (generic), neomycin/bacitracin/polymyxin B/HC (generic), neomycin/polymyxin B/dexamethasone (generic), flunisolide (generic), fluticasone propionate (generic), neomycin/polymyxin B/HC (generic),TobraDex® Oint (Alcon) etodolac (generic), ibuprofen (generic), indomethacin norethindrone/ethinyl estradiol (generic) (generic), naproxen (generic), sulindac (generic) diclofenac (generic), flurbiprofen (generic), ketorolac (generic) Foltrin (generic), Ferrex 150 Forte (generic), Hematogen metformin (generic),+ Prandin® (Novo Nordisk) Forte (generic), Ferotrinsic (generic), Poly-Iron 150 Forte Accu-Chek® (Roche), Ascensia® (Bayer), Breeze2® (Bayer), bicalutamide (generic), flutamide (generic) Accu-Chek® (Roche), Ascensia® (Bayer), Breeze2® (Bayer), tobramycin-dexamethasone (generic),neomycin/bacitracin/polymyxin B/HC (generic), ciprofloxacin (generic), ofloxacin (generic), Avelox® (Schering) neomycin/polymyxin B/dexamethasone (generic), neomycin/polymyxin B/HC (generic),TobraDex® Oint (Alcon) *Branded generics have the same co-payment as regular generics.
MG40675U 1199 1H11 SEIU PDL BiFold_v5 12/2/10 9:01 AM Page 12 Nonpreferred Product
Possible Preferred Alternatives
Nonpreferred Product
Possible Preferred Alternatives
estradiol (generic), Cenestin® (Barr/Duramed), Enjuvia® Therobec Plus (generic),Vitaplex Plus (generic),Vitacon Plus (generic), Formula B Plus (generic),Vita Forte (generic) Estrace® Vaginal Cream (Warner Chilcott) Therobec Plus (generic),Vitaplex Plus (generic),Vitacon Plus Prenatal Plus (generic), OB-Natal Plus (generic), PNV-DHA (generic), Formula B Plus (generic),Vita Forte (generic) (generic),Taron-Prex Prenatal (generic), Pruet DHA (generic) Therobec Plus (generic),Vitaplex Plus (generic),Vitacon Plus(generic), Formula B Plus (generic),Vita Forte (generic) Accu-Chek® (Roche), Ascensia® (Bayer), Breeze2® (Bayer),Contour® (Bayer) Hyalgan® (Sanofi Pharm), Synvisc® (Genzyme),Synvisc-One® (Genzyme) venlafaxine HCl (generic), citalopram HBR (generic),fluoxetine HCL (generic), paroxetine HCl (generic), sertraline cefuroxime axetil (generic), cefdinir (generic) Accu-Chek® (Roche), Ascensia® (Bayer), Breeze2® (Bayer), Therobec Plus (generic),Vitaplex Plus (generic),Vitacon Plus (generic), Formula B Plus (generic),Vita Forte (generic) Advair HFA® (GlaxoSmithKline), Advair Diskus® Flovent HFA® (GlaxoSmithKline), Flovent Diskus® fluoxetine HCl (generic), Zyprexa® (Eli Lilly) (GlaxoSmithKline), Pulmicort Respules® (AstraZeneca), tretinoin (generic),Azelex® (Allergan), Finacea® (Bayer) ciprofloxacin drops (generic),Vigamox® (Alcon) Micardis( BIPI) + amlodipine besylate (generic), losartan Avonex® (Biogen), Betaseron® (Berlex Laboratories), potassium (generic) + amlodipine besylate (generic) losartan potassium (generic), Micardis® (BIPI) losartan/HCTZ (generic), Micardis HCT® (BIPI) Foltrin (generic), Ferrex 150 Forte (generic), HematogenForte (generic), Ferotrinsic (generic), Poly-Iron 150 Forte ciprofloxacin (generic), ofloxacin (generic),Avelox® (Schering) Androderm® (Watson Pharmaceuticals),Androgel® (Unimed Pharm) losartan potassium (generic), Micardis® (BIPI) flunisolide (generic), fluticasone propionate (generic),Nasonex® (Schering) losartan/HCTZ (generic), Micardis HCT® (BIPI) fluocinolone acetonide solution, non oral (generic) sodium sulfacetamide 10% and sulfur 5% (generic) tobramycin-dexamethasone (generic),neomycin/bacitracin/polymyxin B/HC (generic), sodium sulfacetamide 10% and sulfur 5% (generic) neomycin/polymyxin B/dexamethasone (generic), sodium sulfacetamide 10% and sulfur 5% (generic) neomycin/polymyxin B/HC (generic),TobraDex® Oint (Alcon) temazepam (generic), triazolam (generic), zolpidem (generic), oxybutynin ER (generic),Vesicare® (GlaxoSmithKline) divalproex (generic), lamotrigine (generic), levetiracetam sumatriptan (generic), naproxen (generic) Norditropin® (NovoNordisk),Tev-Tropin® (GatePharmaceuticals) Micardis( BIPI) + amlodipine besylate (generic), losartanpotassium (generic) + amlodipine besylate (generic) flavoxate( generic), oxybutynin (generic), oxybutynin ER(generic), trospium chloride (generic),Vesicare® ondansetron (generic), granisetron (generic), Emend® (Merck) cloxapine (generic), risperidone (generic), Seroquel® benazepril HCl (generic), enalapril (generic), fosinopril (generic), lisinopril (generic), quinapril (generic), Altace® chloral hydrate (generic), temazepam (generic), triazolam doxazosin (generic), terazosin (generic), tamsulosin (generic) Prenatal Plus (generic), OB-Natal Plus (generic), amlodipine (generic) + losarten (generic) or Micardis® (BIPI) PNV-DHA (generic),Taron-Prex Prenatal (generic), clobetasol propionate (generic), betamethasone dp augmented (generic), diflorasone diacetate (generic) Norditropin® (NovoNordisk),Tev-Tropin® (Gate cefaclor suspension (generic), cefdinir (generic), cefpodoxime zolpidem (generic), temazepam (generic), triazolam (generic), flunisolide (generic), fluticasone propionate (generic), simvastatin (generic) + Niaspan ER® (Abbott) carbidopa/levadopa (generic) + Comtan® (Novartis) Prenatal Plus (generic), OB-Natal Plus (generic), valproic acid (generic), divalproex (generic) PNV-DHA (generic),Taron-Prex Prenatal (generic), Androderm® (Watson Pharmaceuticals),Testim® (Auxilium etodolac (generic), ibuprofen (generic), naproxen (generic) *Branded generics have the same co-payment as regular generics.
MG40675U 1199 1H11 SEIU PDL BiFold_v5 12/2/10 9:01 AM Page 13 Nonpreferred Product
Possible Preferred Alternatives
Nonpreferred Product
Possible Preferred Alternatives
simvastatin (generic), Zetia® (Merck-Schering Plough), Lipitor® naratriptan (generic), sumatriptan (generic), Maxalt® (Merck), Zovirax Ointment (generic) + hydrocortisone (generic) alclometasone dipropionate (generic), fluocinolone acetonide diclofenac (generic), flurbiprofen (generic), ketorolac (generic) ciprofloxacin HCl (generic), Avelox® (Schering) neomycin/bacitracin/polymyxin B/HC (generic), neomycin/polymyxin B/dexamethasone (generic), clindamycin phosphate (generic), tretinoin (generic) neomycin/polymyxin B/HC (generic),TobraDex® Oint (Alcon) ciprofloxacin drops (generic),Vigamox® (Alcon) *Branded generics have the same co-payment as regular generics.

Source: http://1199seiubenefits.org/wp-content/uploads/2010/12/March-1-2011-PDL-member-guide.pdf