Microsoft word - kpp.1q11.3-tier_pdl.doc

Macrolides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
mexiletine, propafenone, quinidine, sotalol azithromycin, clarithromycin, erythromycin ACE INHIBITORS ---------------------------------------------
OTHER CONTRACEPTIVES----------------------------------
benazepril, captopril, enalapril, fosinopril, Tetracyclines. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
lisinopril, moexipril, perindopril, quinapril, PROGESTIN ONLY------------------------------------------------
ANGIOTENSIN II ANTAGONISTS-------------------------
EMERGENCY CONTRACEPTION-----------------------
January 2011
Fluroquinolones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Preferred Drug List
DRUGS FOR DIABETES
ANTI-ADRENERGIC BLOCKERS–CENTRAL------
INSULINS --------------------------------------------------------
The KPP Preferred Drug List defines the
Apidra, Humalog, Humulin, Levemir, Novolog, Aminoglycosides. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
COMBINATION AND MISC ANTIHYPERTENSIVES---
copayment tier status of the most
commonly prescribed medicines. It may
Sulfonamides. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ORAL ------------------------------------------------------------
not include all drugs covered by your
lisinopril w/ HCTZ, losartan/HCT, moexipril acarbose, glimepiride (w/ metformin), glipizide prescription drug benefit. For benefit
(w/ metformin), glyburide (w/ metformin), coverage or restrictions please check your
Drugs for Fungal Infections. . . . . . . . . . . . . . . . . . . . .
HCT, Exforge, Exforge HCT, Micardis HCT, benefit plan document(s). This listing is
ActoPlus Met, Actos, Avandamet, Avandaryl, revised periodically as new drugs and new
prescribing information becomes
Avalide, Caduet, Lexxel, Tarka, Teveten available.
Drugs For Viral Infections. . . . . . . . . . . . . . . . . . . . . . .
DIURETICS ------------------------------------------------------
OTHER ------------------------------------------------------------
The coverage tier for each medication has
been indicated. Members pay a Tier 1
copayment for most generic drugs.
Members pay a Tier 2 copayment for
Miscellaneous Antiinfectives. . . . . . . . . . . . . . . . . . . . .
ANTIHYPERLIPIDEMICS------------------------------------------
formulary (preferred) brand name drugs.
clindamycin, metronidazole, nitrofurantoin THYROID AND ANTITHYROID AGENTS
cholestyramine, fenofibrate, gemfibrozil, Members pay a Tier 3 copayment for non-
THYROID ---------------------------------------------------------
formulary (non-preferred) brand name
Alinia, Cayston, Coartem, Dapsone, Xifaxin Altoprev, Crestor, Lipitor, Lipofen, Lovaza, drugs. For most brands with generics
Niaspan, Simcor, Tricor, Triglide, Trilipix, available, the generic will be available at
Advicor, Antara, Colestid, Fenoglide, Lescol, the Tier 1 copayment.
DRUGS FOR OSTEOPOROSIS
HORMONES
MISCELLANEOUS CARDIOVASCULAR DRUGS---------
It is recommended that you bring this list of
GLUCOCORTICOIDS ---------------------------------------------
Boniva Tablet, Evista, Fosamax D, Forteo medications when you or a covered family
ANTICOAGULANTS/ANTITHROMBOTICS-------------
member sees a physician or other
healthcare provider.
ANDROGENS---------------------------------------------------
MISCELLANEOUS ENDOCRINE
desmopressin spray / tablets, cabergoline Formulary Disclaimer: Coverage for some drugs may be DRUGS FOR MISCELLANEOUS BLOOD DISORDERS--
limited to specific dosage forms and/or strengths. The First Testosterone, Striant
CARDIOVASCULAR DRUGS
benefit design determines what is covered and the ESTROGENS ---------------------------------------------------
RESPIRATORY / ASTHMA
applicable co-payment. The medications listed on this CARDIOTONICS ----------------------------------------------
formulary are subject to change pursuant to the formulary DRUGS FOR ALLERGY -------------------------------
management activities of KPP. The presence of a ANTI-ANGINA ----------------------------------------------
Oral Antihistamines and Combinations. . . . . . . .
medication on this formulary list does not guarantee isosorbide dinitrate, isosorbide mononitrate, Alora, Estrasorb, Estrogel, Femring, Menest nitroglycerin sublingual tabs and patches Dilatrate-SR, Minitran, Nitrolingual, Ranexa ESTROGEN AND ANDROGENS --------------------------
BETA-ADRENERGIC BLOCKERS----------------------
Misc Allergy . . . . . . .…………………………………….
DRUGS FOR INFECTIONS
Esterified estrogens and methyltestosterone ANTIBIOTICS-------------------------------------------------
NASAL MEDICATIONS -------------------------------------
Penicillins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ESTROGEN AND PROGESTERONES-------------------
Astelin, Nasonex, Nasacort AQ, Rhinocort amoxicllin w/ potassium clavulanate, penicillin Combipatch, Crinone, Premphase, Prempro, CALCIUM CHANNEL BLOCKERS -----------------------
Cephalosporins. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
cefaclor, cefadroxil, cefdinir, cefradine, felodipine, isradipine, nifedipine XL, suldipine, MISC HORMONES-------------------------------------------
COUGH AND COLD MEDICATIONS -------------------------
CONTRACEPTIVES
ANTIARRHYTHMICS ----------------------------------------
ORAL - MONO, BI AND TRI-PHASIC -------------------------
Kroger Prescription Plans Preferred Drug List - Effective January 1, 2011. INCONTINENCE AGENTS-------------------------------
Concerta, Daytrana, Metadate-CD, Provigil, DERMATOLOGICALS
RESPIRATORY / ASTHMA (CONT)
ACNE AND ANTIBIOTICS-----------------------------------------
DRUGS FOR ALZHEIMER’S DISEASE-----------------------
DRUGS FOR ASTHMA / COPD -------------------------------
Acanya, Azelex, BenzaClin, Differin, Duac donepezil, galantamine, galantamine ER, Sympathomimetics. . . . . . . . . . . . . . . . . . . . . . . .
VAGINAL ANTIINFECTIVE PREPARATIONS --------------
nystatin, metronidazole vaginal, terconazole DRUGS FOR PARKINSONS DISEASE ----------------------
Metrocream, MetroLotion, Noritate, Retin-A Combination Drugs and Others. . . . . . . . . . . . . . . . .
ANTIVIRALS ----------------------------------------------------
DRUGS FOR BPH-------------------------------------------
albuterol-ipratropium for nebulization, Combivent, Dulera, Intal, Symbicort, Spiriva FUNGICIDES ----------------------------------------------------
Theophyllines…. . . . . . . . . . . . . . . . . . . . . . . .
DRUGS FOR ERECTILE DYSFUNCTION----------------
MIGRAINE AGENTS-------------------------------------------
Corticosteroids. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Exelderm, Extina, Naftin, Oxistat, Vusion, Asmanex, Flovent HFA / Diskus, Pulmicort, CENTRAL NERVOUS SYSTEM
TOPICAL ANTI-INFLAMMATORY AGENTS---------
ANALGESICS, NARCOTIC---------------------------------------
Low - Intermediate Potency . . . . . . . . . . . . . . . . .
Antileukotrienes. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
SKELETAL MUSCLE RELAXANTS -------------------------
baclofen, carisoprodol, cyclobenzaprine, GASTROINTESTINAL
Actiq, Kadian, Fentora, Opana/ ER, OxyIR, High Potency . . . . . . . . . . . . . . . . . . . . . . . . . . .
ANTISPASMODICS
ANALGESICS, NSAIDs ----------------------------------------
dicyclomine, hyoscyamine, metoclopramide diclofenac, diflunisal, etodolac, ibuprofen, MISC NEUROLOGICAL----------------------------------------
OTHER DERMATOLOGICALS ----------------------------
ANTIULCER -----------------------------------------------------
OPHTHALMIC
ANTI-ALLERGIC AGENTS----------------------------------
ANTICONVULSANTS ---------------------------------------
Plus, Oxsoralen, Oxsoralen-Ultra, Panretin, Alocril, Alomide, Elestat, Emadine, Zaditor, divalproex ER, ethosuximide, gabapentin, lamotrigine, levetiracetam, oxcarbazepine, ANTI-GLAUCOMA AGENTS -----------------------------
MISCELLANEOUS
brimonidine, dipivefrin, betaxolol, carteolol, ANTIEMETIC/ANTIVERTIGO -----------------------------
topiramate, topiramate sprinkles, valproic levobunolol, metipranolol, timolol, timolol/ meclizine, ondansetron, prochlorperazine, Carbatrol, Dilantin (30 and 50mg), Felbatol, Gabitril, Keppra XR, Lamictal ODT, Lamictal ANTI-INFECTIVE AGENTS--------------------------------
BOWEL EVACUANTS ---------------------------------------------
ANTIDEPRESSANTS --------------------------------------------
bupropion XL, citalopram, doxepin, fluoxetine, imipramine, mirtazapine, nortriptyline, DIGESTANTS ---------------------------------------------------
paroxetine, paroxetine CR, protriptyline, ANTI-INFLAMMATORY AGENTS---------------------------
Creon, Ultrase, Ultrase MT, Viokase, Zenpep Kutrase, Ku-Zyme, Pancrease MT, Pancrecarb OTHER GI PRODUCTS -----------------------------------
ANTIPSYCHOTIC AGENTS --------------------------------------
chlorpromazine, clozapine, haloperidol, ANTI-INFECTIVE AND ANTI-INFLAMMATORY
Abilify, Clozaril, Geodon, Moban, Seroquel, COMBINATIONS ---------------------------------------------
Anamantle HC, Anusol HC, Apriso, Asacol, Fazaclo, Invega, Risperdal Consta, Symbyax ANXIOLYTICS, SEDATIVES, AND HYPNOTICS----
Gastrocrom, Kristalose, Lotronex, Pentasa, NSAIDS-----------------------------------------------------------
temazepam, triazolam, zaleplon and other Acular, Acular LS, Ocufen, Nevanac, Xibrom Actigall, Cytotec, Dipentum, Lialda, Rowasa GENITO-URINARY
CEREBRAL STIMULANTS--------------------------------
ANTI-INFECTIVE, ANTI-INFLAMMATORY
ANTI-INFECTIVES------------------------------------------
COMBINATIONS AND MISC----------------------------------------
Kroger Prescription Plans Preferred Drug List - Effective January 1, 2011.

Source: http://pace.ohea.us/files/2012/01/KPP.1Q11.3-Tier_PDL.pdf