Revised June 2008 Commonly Prescribed Medications from Empire’s Formulary
To assist you in making informed choices regarding your prescription drug plan, we are providing you with this abbreviated version of Empire’sformulary, our preferred drug list. Empire’s formulary is developed by our Pharmacy and Therapeutics Committee. This committee regularlyreviews and selects new and existing drugs to ensure the formulary remains responsive to the needs of our members. All formulary drugs havebeen approved by the Food and Drug Administration (FDA). Choosing drugs from the formulary can lower a member’s cost and save money every time a prescription is filled because formulary drugs have lower copayments. How members can save on prescription costs: • Ask your physician to prescribe drugs on Empire’s formulary and be sure to bring the formulary with you to every doctor visit. • Ask your physician to consider prescribing generic substitutions whenever possible. Generics result in lower costs to you. All generic drugs are approved by
the FDA; they are as effective as their brand-name alternatives and meet the same quality and safety standards.
• Keep in mind that brand-name drugs not on this list will generally cost you the most money. How your Empire pharmacy coverage works: Every time you fill a covered prescription, you pay a copay amount. Copayment amount may appear next to either “Rx” or “Rx Co-Pay” on your member ID card. If you do not see any copayments indicated, please refer to your benefits material. ID cards issued prior to July 2005 look like this: ID cards issued after July 2005 look like this: If your plan has 3 copayment amounts, you will pay the lowest amount for generic drugs, the middle amount for brand-name drugs listed on the formulary and the highest amount for brand-name drugs not listed on the formulary. If your plan has only 2 copayment amounts, you will pay the lower amount for generic drugs and the higher amount for brand-name drugs listed on the formulary. Check your benefit materials to see whether your plan covers brand-name drugs not listed on the formulary. If your plan does cover drugs not listed on the formulary, then you will pay the higher amount for those. The formulary is subject to change, so to get the most up-to-date and complete medication listings: • Empire members can register or log on to Member Online Services at www.empireblue.com. From your secure, personalized home page, link to the Pharmacy. • If you are not yet a registered Empire member, simply go to www.empireblue.com and click on “Search the Formulary.” • If you do not have Internet access, you can call Member Services at the phone number on the back of your member ID card. Important: • Certain drugs require prior authorization by Empire before you fill a prescription. They are noted on this list as “PAR” (prior authorization required). Some drugs have
quantity limits and require authorization only if a prescription is written for more than the monthly allowed amount. They are noted as “QL” (quantity limit) on thislist. Your physician or pharmacist can request any required authorization by calling Empire Pharmacy Services at the Member Services phone number listed on theback of your member ID card. If the PAR drug or the additional quantity of a drug is approved, it will be covered under Empire’s pharmacy plan.
• In order for certain specialty injectable medications to be covered under Empire's pharmacy plan, prescriptions for these medications must be filled by PrecisionRx
Specialty Solutions. Those particular medications are listed with the symbol SRx next to them. For further information regarding filling a prescription with PrecisionRxSpecialty Solutions, call toll free 1-800-870-6419, Monday - Friday, 8:00 a.m. - 9:00 p.m. EST.
• Some generic and/or brand-name drugs included in this formulary may not be covered by all health plans. Please check your benefit materials or contact Member
Services for coverage details under your specific plan. How to use this list: • Brand-name drugs start with the first letter of their name in a capital letter, e.g., “Altace.” • Generic drugs appear all in lowercase letters, e.g.,”atenolol.”
For questions regarding our pharmaceutical policies and procedures or if you would like additional copies of this list, please call EmpirePharmacy Services at the Member Services phone number on the back of your member ID card Monday – Friday, 7:00 a.m. – 10:00 p.m.;Saturday 9:00 a.m. – 9:00 p.m.; Sunday 9:00 a.m. – 5:30 p.m. EST. Legend: PAR – prior authorization required SRx – prescription must be filled through PrecisionRx Specialty Solutions QL – quantity limit Quantity Limitations (QL)
* Non-formulary# Atacand should be reserved for participants who meet CHARM (Candesartan in Heart Failure - Assessment of Reduction in Mortality and Morbidity) trial criteria.
Please refer to your benefits to determine whether this list applies to your coverage. This list is subject to change at any time. For the most up-to-date listings, visit www.empireblue.com. Prior Authorization Required (PAR)
Please refer to your benefits to determine whether this list applies to your coverage. This list is subject to change at any time. For the most up-to-date listings, visit www.empireblue.com.
Services provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association, an association ofindependent Blue Cross and Blue Shield Plans. Generic Alternatives Available to Empire’s Top Brand Medications Drug Name Generic Name
amphetamine/dextroamphetamine mixed salts
Norvasc*^ amlodipine^Oxycontin^ oxycodone
Generic Alternatives Available to Empire’s Top Brand Medications (continued) Drug Name Generic Name
Brand-name drugs start with the first letter of their name in a capital letter, e.g., “Altace Capsules.”Generic drugs are all in lowercase letters, e.g. “ramipril.”
* Non-formulary^ Quantity Limitation# Prior Authorization Required
Formulary and Over-The-Counter Alternatives to Empire’s Top Non-Formulary Medications Non-Formulary Medication Formulary and OTC Alternatives
omeprazole*, pantoprazole*, Nexium*†, Prevacid*†, Prilosec OTC
amphetamine/dextroamphetamine mixed salts, dexmethylphenidate immed-rel, dextroamphetamine ext-rel, methylphenidate ext-rel, Concerta, Metadate ER,Strattera*
cetirizine OTC, fexofenadine*, loratadine OTC, loratadine/pseudoephedrine OTC,
Alavert OTC, Alavert D OTC, Claritin OTC, Claritin-D OTC, Zyrtec OTC, Zyrtec-D OTC
clindamycin lotion or gel, erythromycin gel, erythromycin/benzoyl peroxide, tretinoin^ cream or gel, Benzamycin Pak, Duac CS, Finacea
cetirizine OTC, fexofenadine*, loratadine OTC, loratadine/pseudoephedrine OTC,
Alavert OTC, Alavert D OTC, Claritin OTC, Claritin-D OTC, Zyrtec OTC, Zyrtec-D OTC
clobetasol cream, gel, lotion & ointment
lovastatin*, pravastatin*, simvastatin*, Caduet*, Lipitor*, Vytorin*
clindamycin lotion or gel, erythromycin gel, erythromycin/benzoyl peroxide, tretinoin^ cream or gel, Benzamycin Pak, Differin, Duac CS, Finacea, Sulfacet-R Lotion
amphetamine/dextroamphetamine mixed salts, dexmethylphenidate immed-rel, dextroamphetamine ext-rel, methylphenidate ext-rel, Concerta, Metadate ER,Strattera*
alendronate*, Actonel*, Actonel with Calcium*, Fosamax Plus D*
carbamazepine, gabapentin, oxcarbazepine, Dilantin, Gabitril, Tegretol XR
Brand-name drugs start with the first letter of their name in a capital letter, e.g., "Ambien."Generic drugs appear all in lowercase letters, e.g., “zolpidem.” OTC (over-the-counter) medications do not require a prescription for purchase and are available at drug stores, food markets, convenience stores and many other types of retailstores. They are not covered by your pharmacy plan.
^ Prior Authorization Required* Quantity Limitation
† May require use of a generic agent first
# Atacand should be reserved for participants who meet CHARM (Candesartan in Heart Failure - Assessment of Reduction in Mortality and Morbidity) trial criteria. Formulary and Over-The-Counter Alternatives to Empire’s Top Non-Formulary Medications (continued) Non-Formulary Medication Formulary and OTC Alternatives
apri, aviane, junel, junel Fe, kariva, low-ogestrel, microgestin, microgestin Fe, mononessa, necon 7/7/7, previfem, reclipsen, solia, sprintec, Yasmin, Yaz
amlodipine*, amlodipine/benazepril, benazepril, captopril, diltiazem ext-rel*, enalapril, lisinopril, nifedipine, ramipril*
Alphagan P, Cosopt, Travatan, Travatan Z, Trusopt, Xalatan
amlodipine*, cartia XT, diltiazem, diltiazem ext-rel*, felodipine*, nifedipine ext-rel, verapamil, verapamil ext-rel*
betamethasone valerate cream & lotion, clobetasol cream, gel, lotion & ointment, fluocinonide cream, gel & solution
fentanyl patch*, hydromorphone, morphine ext-rel, oxycodone/acetaminophen, tramadol, tramadol/acetaminophen, Avinza, Oxycontin*
cal-nate, nutrinate chewable, nutrispire, or any other generic prenatal vitamin
omeprazole*, pantoprazole*, Nexium*†, Prevacid*†, Prilosec OTC
bupropion ext-rel*, citalopram*, fluvoxamine*, fluoxetine*, paroxetine*, sertraline*, venlafaxine, Effexor XR*, Lexapro*, Paxil CR*
fluticasone* nasal spray, Nasacort AQ*, Nasonex*
clindamycin gel & lotion, doxycycline, erythromycin gel, erythromycin/benzoyl peroxide, minocycline, tetracycline
betamethasone creams & ointments, Dovonex cream
erythromycin gel, erythromycin/benzoyl peroxide, tretinoin cream^, Differin, Finacea
carbamazepine, gabapentin, oxcarbazepine, Dilantin, Gabitril, Tegretol XR
atenolol, labetalol, metoprolol ext-rel, nadolol, pindolol, propranolol, propranolol ext-rel
doxazosin, finasteride, terazosin, Flomax
fluticasone nasal spray*, Nasacort AQ*, Nasonex*
budeprion XL*, budeprion SR*, bupropion ext-rel*
omeprazole*, pantoprazole*, Nexium*†, Prevacid*†, Prilosec OTC
lovastatin*, pravastatin*, simvastatin*, Caduet*, Lipitor*, Vytorin*
bupropion ext-rel*, citalopram*, fluoxetine*, paroxetine*, sertraline*, Effexor XR*, Lexapro*, Paxil CR*
Brand-name drugs start with the first letter of their name in a capital letter, e.g., "Ambien."Generic drugs appear all in lowercase letters, e.g., “zolpidem.” OTC (over-the-counter) medications do not require a prescription for purchase and are available at drug stores, food markets, convenience stores and many other types of retailstores. They are not covered by your pharmacy plan.
^ Prior Authorization Required* Quantity Limitation† May require use of a generic agent first
Commonly Prescribed Medications from Empire’s Formulary Miscellaneous Alzheimer's Disease Multiple Sclerosis Parkinson's Disease Diabetic Supplies Antiarrhythmics Seizure Disorder GERD/Peptic Ulcer Cholesterol Lowering Blood Modifiers Gastrointestinal Spasm Ulcerative Colitis Diabetic Medications Blood Pressure Lowering Nitrates
# Atacand should be reserved for participants who meet CHARM (Candesartan in Heart Failure - Assessment of Reduction in Mortality and Morbidity) trial criteria. † May require use of a generic agent first
Commonly Prescribed Medications from Empire’s Formulary Miscellaneous Glaucoma Antibiotics-Oral Phosphate Binders Antiviral Drugs Benign Prostatic Hyperplasia (BPH) Other Medications Antifungal Drugs-Oral Erectile Dysfunction Antifungal Drugs-Topical Hormone Therapy Hepatitis HIV/AIDS Antibiotics-Topical Anti-Infectives Commonly Prescribed Medications from Empire’s Formulary Allergy-Nasal Antihistamine Allergy-Nasal Corticosteroids Depression Asthma-Inhalers Asthma-Oral Drugs Insomnia Attention Deficit Hyperactivity Disorder Psychosis Allergy-Antihistamines
† May require use of a generic agent first
Commonly Prescribed Medications from Empire’s Formulary Hormone Therapy-Patches Contraceptives Hormone Therapy- Miscellaneous Minerals & Electrolytes Infertility Hormone Therapy-Oral Osteoporosis Prenatal Vitamins
The drug names listed here are the registered and/or unregistered trademarks of third-party pharmaceutical companies unrelated to and unaffiliated with Empire. These trademarks are included here for information purposes only and are not intended to imply or suggest any affiliation between Empire and such third-party pharmaceutical companies.
Individual Plan Medical Underwriting Guidelines M U G Insurability Because of the potential additional risk associated with certain medical conditions, some Applicants will be declined for all coverages. However, based on underwriting evaluation PacifiCare Individual PPO plans may be offered at a 20 percent
Central Valley Society of Health System Pharmacists Meeting Minutes Meeting Date: Tuesday, July 1st, 2008 Time: 6:30 – 8:00PM Location: Doctors Medical Center, Conference Room 1, Modesto Members in Attendance: Andrea Hinton, Bill Yee, Minnie Virk, Harminder Nahal, Koob Vang, Linda Truong, Thu-Anh Le, Gilbert Castillo, Kelli Haase, Dean Pham, Nicole Gordon, Martin Tuan Tran, Ruth Rod
Revised June 2008