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2008 Three-Tier Prescription Drug List Reference Guide Acetaminophen with Codeine QLL/QD
and Butalbital QLL/QD
Bupropion QLL
Bupropion Sustained Action QLL, N
300mg QLL, N
Butorphanol Nasal Spray QLL
Alendronate QLL
Cefdinir QLL
Amlodipine and Benazepril QLL
Ciclopirox Solution, Topical QLL
Estradiol Patch QLL
Asmanex QLL
Citalopram QLL
Famciclovir QLL
Fast Take Test Strips QLL, DS
Fentanyl Citrate Lollipop QLL/QD, N
Fentanyl Transdermal System QLL/QD
Fexofenadine QLL/QD
Finasteride N
Fluconazole 50, 100, 200mg N
Fluconazole 150mg QLL
Flunisolide Nasal Spray QLL
Some medications are noted with N, QD, QLL, or DS. The definitions for these symbols are listed below. Your benefit plan determines how these medications may be covered for you.
= Notification. There are a few medications that your doctor must notify us of to make sure their use is covered within your benefit.
= Progression Rx.
QD = Quantity Duration. Some medications have a limited amount that can be covered for a specific period of time.
QLL = Quantity Level Limit. Some medications have a limited amount that can be covered at one time.
DS = Diabetic Supplies. Diabetic supplies may be covered by your benefit plan.
1/2T = Eligible for Half Tablet Program.
2008 Three-Tier Prescription Drug List Reference Guide Mirtazapine Dispersible Tablet QLL
Fluoxetine QLL
Moexipril 1/2T
Fluticasone Nasal Spray QLL
Leflunomide QLL
Fluvoxamine QLL
Foradil QLL
Release QLL/QD
Fortical QLL
Dosepack, 3 Month QLL
Freestyle Lite Test Strips QLL, DS
Freestyle Test Strips QLL, DS
Frova QLL
Nefazodone QLL
Lovastatin QLL/QD
Maxalt QLL
Maxalt MLT QLL
Medroxyprogesterone 150mg/ml QLL
Mefloquine QLL
Granisetron Tablet QLL
Meloxicam QLL
Omeprazole QLL/QD
Ondansetron QLL
One Touch Test Strips QLL, DS
One Touch Ultra Test Strips QLL, DS
Oxybutynin Sustained Release QLL
Itraconazole QLL, N
Oxycodone with Ibuprofen QLL
Pantoprazole QLL/QD
Paroxetine QLL
Mirtazapine QLL
Some medications are noted with N, QD, QLL, or DS. The definitions for these symbols are listed below. Your benefit plan determines how these medications may be covered for you.
= Notification. There are a few medications that your doctor must notify us of to make sure their use is covered within your benefit.
= Progression Rx.
QD = Quantity Duration. Some medications have a limited amount that can be covered for a specific period of time.
QLL = Quantity Level Limit. Some medications have a limited amount that can be covered at one time.
DS = Diabetic Supplies. Diabetic supplies may be covered by your benefit plan.
1/2T = Eligible for Half Tablet Program.
2008 Three-Tier Prescription Drug List Reference Guide Zomig QLL
Zomig ZMT QLL
Pravastatin QLL/QD
Surestep Test Strips QLL, DS
Precision Q-I-D Test Strips QLL, DS
Precision Xtra Test Strips QLL, DS
Terbinafine Tablet QLL, N
Terconazole Cream QLL
Terconazole Suppository QLL
Tramadol QLL
Tramadol with Acetaminophen QLL
Trandolapril 1/2T
Tretinoin N
Pulmicort Flexhaler QLL
Pulmicort Turbuhaler QLL
Relpax QLL
Ribavirin QLL, N
Venlafaxine QLL
Sertraline QLL, 1/2T
Xopenex HFA QLL
Simvastatin QLL/QD
Zolpidem QLL/QD
Some medications are noted with N, QD, QLL, or DS. The definitions for these symbols are listed below. Your benefit plan determines how these medications may be covered for you.
= Notification. There are a few medications that your doctor must notify us of to make sure their use is covered within your benefit.
= Progression Rx.
QD = Quantity Duration. Some medications have a limited amount that can be covered for a specific period of time.
QLL = Quantity Level Limit. Some medications have a limited amount that can be covered at one time.
DS = Diabetic Supplies. Diabetic supplies may be covered by your benefit plan.
1/2T = Eligible for Half Tablet Program.
2008 Three-Tier Prescription Drug List Reference Guide Cozaar QLL/QD, 1/2T
Micardis HCT QLL/QD
Crestor QLL/QD, 1/
Aciphex QLL/QD
Nasonex QLL
Actonel QLL
Actonel with Calcium QLL
Actoplus Met QLL
Norditropin QLL/QD, N
Actos QLL
Diovan QLL/QD, 1/2T
Adderall XR QLL
Diovan HCT QLL/QD
Dovonex QLL
Nutropin QLL/QD, N
Duetact QLL
Effexor XR QLL
Oxycontin QLL/QD
Alphagan P QLL
Emend QLL
Enablex QLL
Pegasys QLL, N
Altoprev QLL/QD
Peg-Intron QLL, N
Androgel QLL
Epogen QLL/QD
Prandin QLL
Esclim QLL
Estraderm QLL
Aranesp QLL/QD
Aricept QLL
Aricept ODT QLL
Estring QLL
Arixtra QLL
Prevacid Solutab QLL/QD
Fosamax Plus D QLL
Prevpac QLL
Astelin QLL
Procrit QLL/QD
Avandamet QLL
Geodon QLL
Avandaryl QLL
Avandia QLL
Protonix QLL/QD
Avonex QLL
Humatrope QLL/QD, N
Protopic QLL, N
Hyzaar QLL/QD
Pulmicort Respules QLL
Imitrex Injection QLL
Bactroban Cream, Nasal Ointment QLL
Intal QLL
Ranexa QLL
Benicar QLL/QD, 1/
Janumet QLL
Benicar HCT QLL/QD
Januvia QLL
Betaseron QLL/QD
Retin-A Micro QLL, N
Risperdal (M-Tab = Tier 3) QLL
Roferon A QLL, N
Boniva QLL
Seroquel QLL
Byetta QLL
Lidoderm QLL/QD
Serostim QLL/QD, N
Singulair QLL
Lipitor QLL/QD, 1/2T
Spiriva QLL
Lovenox QLL
Lumigan QLL
Tazorac QLL, N
Climara QLL
Testim 1% QLL
Copaxone QLL
Tev-Tropin QLL/QD, N
Micardis QLL/QD
Tilade QLL
Some medications are noted with N, QD, QLL, or DS. The definitions for these symbols are listed below. Your benefit plan determines how these medications may be covered for you.
= Notification. There are a few medications that your doctor must notify us of to make sure their use is covered within your benefit.
= Progression Rx.
QD = Quantity Duration. Some medications have a limited amount that can be covered for a specific period of time.
QLL = Quantity Level Limit. Some medications have a limited amount that can be covered at one time.
DS = Diabetic Supplies. Diabetic supplies may be covered by your benefit plan.
1/2T = Eligible for Half Tablet Program.
2008 Three-Tier Prescription Drug List Reference Guide Travatan QLL
Travatan Z QLL
Tricor Tablet
Triglide
Triphasil
Trusopt
Twinject QLL
Urso
Urso Forte
Valtrex QLL
Vesicare QLL
Vivelle QLL
Vivelle-Dot QLL
Vytorin QLL
Vyvanse QLL
Welchol
Yasmin
Yaz
Zegerid QLL/QD
Zomig Nasal Spray QLL
Zovirax Ointment, Cream
Zylet
Zyprexa (Zydis = Tier 3) QLL
Some medications are noted with N, QD, QLL, or DS. The definitions for these symbols are listed below. Your benefit plan determines how these medications may be covered for you.
= Notification. There are a few medications that your doctor must notify us of to make sure their use is covered within your benefit.
= Progression Rx.
QD = Quantity Duration. Some medications have a limited amount that can be covered for a specific period of time.
QLL = Quantity Level Limit. Some medications have a limited amount that can be covered at one time.
DS = Diabetic Supplies. Diabetic supplies may be covered by your benefit plan.
1/2T = Eligible for Half Tablet Program.
2008 Three-Tier Prescription Drug List Reference Guide Tier Three
Cosopt QLL
Abilify QLL
Lexapro QLL, 1/2T
Accolate QLL
Accu-Chek Test Strips QLL, DS
Cymbalta QLL/QD
Advair Diskus QLL
Daytrana QLL
Advair HFA QLL
Lovaza QLL
Allegra ODT QLL/QD, Excluded
Lunesta QLL/QD
Allegra Suspension QLL/QD, Excluded
Allegra-D QLL/QD, Excluded
Detrol LA QLL
Differin QLL, N
Lyrica QLL/QD
Maxair Autohaler QLL
Ambien CR QLL/QD
Amerge QLL
Elidel QLL, N
Metadate CD QLL
Anzemet QLL
Miacalcin Nasal Spray QLL
Enbrel QLL/QD
Epipen QLL
Ascensia Autodisc QLL, DS
Epipen Jr. QLL
Ascensia Elite QLL, DS
Nasacort QLL
Atacand QLL/QD, 1/
Nasacort AQ QLL
Atacand HCT QLL/QD
Avalide QLL/QD
Fentora QLL/QD, N
Nexium QLL/QD, Excluded
Avapro QLL/QD, 1/
Avinza QLL/QD
Flovent HFA QLL
Avodart QLL, N
Focalin QLL
Axert QLL
Focalin XR QLL
Azmacort QLL
Genotropin QLL/QD, N
Beconase AQ QLL
Glucometer Test Strips QLL, DS
Ortho Evra QLL
Caduet QLL
Catapres-TTS QLL
Celebrex QLL/QD
Humira QLL/QD
Cesamet QLL, P
Imitrex Nasal Spray QLL
Chemstrip BG Test Strips QLL, DS
Imitrex Tablet QLL
Cialis QD
Intron A QLL, N
Invega QLL
Clarinex QLL/QD, Excluded
Kadian QLL/QD
Paxil CR QLL
Clarinex-D QLL/QD, Excluded
Climara Pro QLL
Kineret QLL/QD
Pexeva QLL, 1/2T
Combipatch QLL
Lescol QLL/QD
Combivent QLL
Lescol XL QLL/QD
Concerta QLL
Coreg CR QLL
Levitra QD
Some medications are noted with N, QD, QLL, or DS. The definitions for these symbols are listed below. Your benefit plan determines how these medications may be covered for you.
= Notification. There are a few medications that your doctor must notify us of to make sure their use is covered within your benefit.
= Progression Rx.
QD = Quantity Duration. Some medications have a limited amount that can be covered for a specific period of time.
QLL = Quantity Level Limit. Some medications have a limited amount that can be covered at one time.
DS = Diabetic Supplies. Diabetic supplies may be covered by your benefit plan.
1/2T = Eligible for Half Tablet Program.
Excluded =
Many benefit plans exclude coverage of medications that are classified by the Pharmacy and Therapeutics Committee as therapeutically equivalent to over-the-counter
medications. Check your benefit plan documents for coverage information or call the Customer Care number on your ID card for more information.
2008 Three-Tier Prescription Drug List Reference Guide Zetia QLL/QD
Ziana QLL
Prevacid Capsule QLL/QD, Excluded
ProAir HFA QLL
Proventil HFA QLL
Provigil QLL, N
Prozac Weekly QLL
Quixin
Rebif QLL/QD
Relenza QLL, N
Restasis QLL, N
Restoril 7.5, 22.5mg
Rhinocort QLL
Rhinocort Aqua QLL
Ritalin LA QLL
Rosanil
Rozerem QLL/QD
Sanctura QLL
Sarafem QLL
Seasonique
Sensipar
Serevent Diskus QLL
Skelaxin
Sonata QLL/QD
Starlix QLL
Strattera QLL
Symlin QLL
Tamiflu QLL, N
Tarka
Tekturna QLL/QD
Tequin
Teveten QLL/QD
Theo-24
Tobradex
Topamax
Tracer BG Test Strips QLL, DS
Transderm-Scop
Tri-Norinyl
Triaz Excluded
Tussionex
Uniretic
Uroxatral QLL
Vagifem
Vantin
Ventolin HFA QLL
Viagra QD
• Compounded prescriptions are
Tier Three
Visicol
Wellbutrin XL QLL, N
• Insulin pens & cartridges are Tier
Xalatan QLL
Three except for Novolin and
Novolog pens and cartridges
Xyzal QLL/QD
which are Tier Two.
Zelnorm QLL/QD, N
Some medications are noted with N, QD, QLL, or DS. The definitions for these symbols are listed below. Your benefit plan determines how these medications may be covered for you.
= Notification. There are a few medications that your doctor must notify us of to make sure their use is covered within your benefit.
= Progression Rx.
QD = Quantity Duration. Some medications have a limited amount that can be covered for a specific period of time.
QLL = Quantity Level Limit. Some medications have a limited amount that can be covered at one time.
DS = Diabetic Supplies. Diabetic supplies may be covered by your benefit plan.
1/2T = Eligible for Half Tablet Program.
Excluded =
Many benefit plans exclude coverage of medications that are classified by the Pharmacy and Therapeutics Committee as therapeutically equivalent to over-the-counter
medications. Check your benefit plan documents for coverage information or call the Customer Care number on your ID card for more information.
2008 Three-Tier Prescription Drug List Reference Guide Additional Tier Three drugs
with a generic equivalent
Ditropan XL QLL (Oxybutynin Sustained
Mevacor QLL/QD (Lovastatin QLL/QD)
in Tier One
Release QLL)
Mobic QLL (Meloxicam QLL)
Actiq QLL/QD, N (Fentanyl Citrate
Lollipop QLL/QD, N)
Duragesic QLL/QD (Fentanyl
Transdermal System QLL/QD)
Allegra QLL/QD (Fexofenadine QLL/QD)
Ambien QLL/QD (Zolpidem QLL/QD)
Effexor QLL (Venlafaxine QLL)
Nasalide QLL, Nasarel QLL (Flunisolide
Nasal Spray QLL)
Arava QLL (Leflunomide QLL)
Famvir QLL (Famciclovir QLL)
Omnicef QLL (Cefdinir QLL)
Paxil QLL (Paroxetine QLL)
Penlac QLL (Ciclopirox Solution, Topical
Flonase QLL (Fluticasone Nasal
Spray QLL)
Percocet 5-325, 7.5-500, 10-650 QLL/QD
Fosamax QLL (Alendronate QLL)
Pravachol QLL/QD, 1/2T (Pravastatin
QLL/QD, 1/2T)
Celexa QLL (Citalopram QLL)
Kytril Tablet QLL (Granisetron Tablet
Proscar N (Finasteride N)
Lamisil Tablet QLL, N (Terbinafine Tablet
Prozac QLL (Fluoxetine QLL)
Rebetol QLL, N (Ribavirin QLL, N)
Combunox QLL (Oxycontin with
Ibuprofen QLL)
Remeron QLL (Mirtazapine QLL)
Copegus QLL, N (Ribavirin QLL, N)
Remeron SolTab QLL (Mirtazapine
Dispersible Tablet QLL)
Darvocet-N QLL/QD (Propoxyphene with
Acetaminophen QLL/QD)
Depo-Provera QLL
Lotrel QLL (Amlodipine and
Sporanox QLL, N (Itraconazole QLL, N)
150mg/ml QLL)
Benazepril QLL)
Terazol QLL (Terconazole QLL)
Mavik 1/2T (Trandolapril 1/2T)
Tablet N (Fluconazole N)
Tylenol #3 QLL/QD (Acetaminophen with
Diflucan 150mg QLL (Fluconazole QLL)
Codeine QLL/QD)
Some medications are noted with N, QD, QLL, or DS. The definitions for these symbols are listed below. Your benefit plan determines how these medications may be covered for you.
= Notification. There are a few medications that your doctor must notify us of to make sure their use is covered within your benefit.
= Progression Rx.
QD = Quantity Duration. Some medications have a limited amount that can be covered for a specific period of time.
QLL = Quantity Level Limit. Some medications have a limited amount that can be covered at one time.
DS = Diabetic Supplies. Diabetic supplies may be covered by your benefit plan.
1/2T = Eligible for Half Tablet Program.
2008 Three-Tier Prescription Drug List Reference Guide Ultracet QLL (Tramadol with
Acetaminophen QLL)
Ultram QLL (Tramadol QLL)
Ultravate Cream, Ointment (Halobetasol
Univasc 1/2T (Moexipril 1/2T)
Valium (Diazepam)
Vaseretic (Enalapril with
Vasotec (Enalapril)Verelan PM (Verapamil Sustained Vicodin QLL/QD, Vicodin ES QLL/QD
(Acetaminophen with Hydrocodone
QLL/QD)
Voltaren Tablet (Diclofenac)
Wellbutrin QLL (Bupropion QLL)
Wellbutrin SR QLL, N (Bupropion
Sustained Action QLL, N)
Wellbutrin XL 300mg QLL, N (Bupropion
Sustained Release 24 Hour QLL, N)
Xanax, Xanax XR (Alprazolam)Zantac Syrup (Ranitidine Syrup)Ziac (Bisoprolol with Zithromax (Azithromycin)
Zocor QLL/QD, 1/2T
(Simvastatin QLL/QD, 1/2T)
Zofran QLL (Ondansetron QLL)
Zoloft QLL, 1/2T (Sertraline QLL, 1/2T)
Zonegran (Zonisamide)
Zovirax Tablet, Capsule, Suspension
Some medications are noted with N, QD, QLL, or DS. The definitions for these symbols are listed below. Your benefit plan determines how these medications may be covered for you.
= Notification. There are a few medications that your doctor must notify us of to make sure their use is covered within your benefit.
= Progression Rx.
QD = Quantity Duration. Some medications have a limited amount that can be covered for a specific period of time.
QLL = Quantity Level Limit. Some medications have a limited amount that can be covered at one time.
DS = Diabetic Supplies. Diabetic supplies may be covered by your benefit plan.
1/2T = Eligible for Half Tablet Program.

Source: http://www.plcsi.com/drugformulary.pdf

Chm6230hiver201

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