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Member Drug Formulary
Alphabetical Listing 2008
The Member Drug Formulary is an alphabetical list of approved medicines covered by your benefit plan. In the Member Drug Formulary, generic drugs are listed by their generic name and begin with lower case letters. You will pay the lowest copay when you buy generic drugs. Formulary brand drugs are listed alphabetically by brand name. The names of brand name drugs begin with upper case letters. You will pay a higher copay for formulary brand drugs. For example: Brand name with no generic available: PlavixBrand name drugs followed by an asterisk have a generic available. Ask your doctor if you can substitute a generic on your prescription. If so, you will receive the generic and pay the lowest copay. For example: Brand name with generic available - Accupril*.
Please note that when a generic equivalent becomes available for a brand name drug on formulary, the brand name formulary drug becomes non formulary.
Please consult your Plan coverage documents for more information on your specific benefit design. Some benefit plans allow you to get non formulary drugs at the highest copay level. Some benefit plans do not cover non formulary drugs.
We have included a list of common non formulary drugs with their formulary alternatives. This list follows the formulary drug list. We strongly recommend that you take the formulary with you to every doctor visit. Sharing the formulary with your doctor will help ensure that your doctor considers a drug from our formulary when prescribing a medicine for you.
Please Note: This is not meant to be a complete list of the drugs covered under your plan. Not all dosage forms of the drugs listed
*A generic equivalent is available at the lowest copay.
below are covered. Brand names are listed for informational reference. Under some circumstances, formulary drugs may be excluded You will pay more for brand name medications. If you
from your plan (for example, oral contraceptives, growth hormone). We periodically review our Drug Formulary listing. This is the most need more information, ask your employer, read your
current list at the time of printing and is subject to change. Some medications may require prior authorization (PA) or have quantity prescription drug rider, or call Member Service at the
number on the back of your member ID card.
(PA) Prior Authorization Required
Prior Authorization
We have two broad goals for the prescription drug benefit we offer. One is to never compromise the quality or effectiveness of treatment. The second is to provide a comprehensive, affordable pharmacy benefit. One of the tools we use to help control prescription drug costs is to require prior approval, or authorization, before our organization will cover the cost of certain medications. The medications include those that (1) are not suggested for first-line therapy, (2) may require special tests before starting them or (3) have very limited approval for use. Drugs that could require Prior Authorization are identified by (PA).
Step Therapy is an automated form of Prior Authorization based on previous pharmaceutical treatment. Drugs designated as stepped therapy will require prior authorization if the condition is not met when the pharmacist would attempt to transmit a prescription claim. Drugs that could require Step Therapy are identified by (ST).
Only your physician can provide the information necessary to complete the prior authorization process. If you have been prescribed one of the drugs identified by (PA) or (ST), make sure your doctor knows that this medication requires prior autthorization.
Common Non Formulary Drugs and their Formulary
Alternatives

Listed below are some common non formulary drugs and their formulary alternatives. Some benefit plans allow you to get non formulary drugs at the highest copay level. If you do no know which plan you have or need more information, ask your employer or read *A generic equivalent is available at the lowest copay for formulary drugs.
πBrand name medications with a generic equivalent are covered at the highest copay plus the difference between the cost of the brand and generic; the generic equivalent The lower cost alternatives are listed only as suggestions. Please discuss their appropriateness with your doctor.
Non-Formulary
Formulary Alternatives
Non-Formulary
Formulary Alternatives
Non-Formulary
Formulary Alternatives
Non-Formulary
Formulary Alternatives
Non-Formulary
Formulary Alternatives
Non-Formulary
Formulary Alternatives
Prevacid Capsules (Not Prilosec OTC (covered with a Non-Formulary
Formulary Alternatives
Non-Formulary
Formulary Alternatives
U
Ultracet
(PA) indicates prior authorization required The lower cost alternatives are listed only as suggestions. Please discuss their appropriateness with your Doctor.
* A generic equivalent is available at the the lowest copay Z
Zaditor

Source: http://www.mutual-seniorcare.com/documents/mug6319_2008.pdf

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