Cdphp three-tier list for select drugs

CDPHP Three–Tier List for Selected Drugs (Revised October 27, 2008)
This list represents the tier status for drugs in selected highly utilized drug categories. For drugs not found on this list and/or specific cost information,
members should log in to www.caremark.com.
Drugs listed in tier 1 are generically available and offer low cost alternatives, but may not be generic equivalents to drugs listed in tier 2 and tier 3.
Allergy Drugs
Consider over the counter cetirizine or loratadine for low or non-sedating antihistamine therapeutic needs.
NASAL DRUGS
flunisolide
Astelin nasal sprayNasacort AQNasonexVeramyst ORAL DRUGS
fexofenadine
Alzheimer’s Disease Drugs
Anticonvulsants
Anti-Inflammatory/Arthritis Drugs
diclofenac sodium del-rel, diclofenac sodium ext-rel Voltaren, Voltaren topical gel, Voltaren XR Antipsychotic Drugs
Antipsychotic Drugs (continued)
InvegaSeroquel, Seroquel XRZyprexa, Zyprexa Zydis Attention Deficit Hyperactivity Disorder Drugs
amphetamine-dextroamphetamine mixed salts dextroamphetamine, dextroamphetamine ext-rel Concerta, Metadate CD, Methylin chewable tabs Metadate ER, Ritalin, Ritalin LA, Ritalin-SR Blood Pressure and Heart Disease Drugs
ACE INHIBITORS AND COMBINATIONS
benazepril, benazepril-HCTZ
ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS
amlodipine-benazepril
ANGIOTENSIN II RECEPTOR ANTAGONISTS AND COMBINATIONS
Atacand*, Atacand HCTAvapro, AvalideCozaar, Hyzaar Benicar, Benicar HCTDiovan, Diovan HCTMicardis, Micardis HCTTeveten, Teveten HCT ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATION S
BETA-BLOCKERS AND COMBINATIONS
atenolol, atenolol-chlorthalidone
metoprolol, metoprolol succinate ext-rel, propranolol, propranolol ext-rel, propranolol-HCTZ Inderal, Inderal LA, Inderide, Innopran XL CALCIUM CHANNEL BLOCKERS
amlodipine
verapamil, verapamil ext-rel, verapamil sust-rel Calan, Calan SR, Covera-HS, Isoptin SR, Verelan, CALCIUM CHANNEL BLOCKER/CHOLESTEROL LOWERING COMBINATION
DIURETICS
eplerenone
NITRATES
isosorbide mononitrate, isosorbide mononitrate ext-rel
nitroglycerin sublingual, nitroglycerin transdermal MISCELLANEOUS
clonidine
Cholesterol and Triglyceride Lowering Drugs
cholestyramine, cholestyramine light, Prevalite Contraceptives
ORAL
Apri, Reclipsen, Solia
Junel, Junel Fe, Microgestin, Microgestin Fe Contraceptives
ORAL (continued)
Necon 10/11Ortho Tri-Cyclen Lo OvretteSeasoniqueYaz Depression, Anxiety, and PMDD Drugs
ANTIDEPRESSANTS
amitriptyline
bupropion, bupropion ext-rel
ANXIETY
alprazolam, alprazolam ext-rel
Gastrointestinal Drugs
Consider over the counter omeprazole or Prilosec OTC for occasional heartburn as a cost-effective alternative.
GERD/ULCER
cimetidine
omeprazole 20 mg OTC, omeprazoleQL, Prilosec OTC AciphexQLPrevacidQL, Prevacid SoluTabQL, PrevPac MISCELLANEOUS
diphenoxylate-atropine sulfate
Hormone Replacement Drugs
ORAL
estradiol
estradiol-norethindrone acetate 1 mg/0.5 mg EnjuviaPremarinPremphase, PremproPrometrium TRANSDERMAL
estradiol transdermal
Estrace vaginal creamEstring, FemringPremarin vaginal creamVagifem tabs Incontinence Drugs/BPH/Erectile Dysfunction
BENIGN PROSTATIC HYPERPLASIA (BPH)
doxazosin
ERECTILE DYSFUNCTION
INCONTINENCE
oxybutynin, oxybutynin ext-rel
Migraine Drugs
MaxaltQL, Maxalt-MLTQLZomig tabsQL, Zomig-ZMTQL, Zomig nasal sprayQL Osteoporosis Drugs
Respiratory Drugs
albuterol: inhaler, solution, solution for nebulizer ipratropium-albuterol solution for nebulizer Advair Diskus, Advair HFAAsmanexCombiventEpipen, Epipen Jr.
Flovent HFAForadil AerolizerPulmicort QVARSerevent DiskusSingulairSpirivaQLSymbicort AccolateAlvescoAzmacortBrovanaMaxair AutohalerXopenex, Xopenex HFA Sleep Disorder Drugs
Miscellaneous Drugs
colchicinelevothyroxine, Levothroid, Levoxyl, Unithroid This list represents the tier status for drugs in selected highly utilized drug categories. The drugs are sorted by common use or therapeutic category. For drugs not found on this
list and/or specific cost information, members should log in to www.caremark.com. Coverage of any drug listed in this document is subject to the member's contract and
prescription drug rider. Quantity limitations, prior authorization, step therapy and/or dose optimization may apply. This list, including the drugs listed and any applicable quantity
limitations, prior authorization, step therapy and dose optimization criteria are subject to change. The information contained within this list is current as of the revision date
listed on the document.
Drugs listed in tier 1 are generically available and offer lower cost alternatives, but may not be generic equivalents to drugs listed in tier 2 and tier 3. The following therapeutic drugclasses are not included in this document: antibiotics, biotech/specialty drugs, dermatology, dietary supplements, immunosuppressants, ophthalmic and drugs used in the treatmentof cancer, diabetes, HIV and pain management. The drug names listed here are the registered and/or unregistered trademarks of third-party pharmaceutical companies unrelated to and unaffiliated with CDPHP. Thesetrademarked brand names are included here for informational purposes only and are not intended to imply or suggest any affiliation between CDPHP and such third-partypharmaceutical companies.
* Atacand should be reserved for patients who meet CHARM (Candesartan in Heart Failure - Assessment of Reduction in Mortality and Morbidity) trial criteria.
PA Prior Authorization requiredQL Quantity Limitations apply

Source: http://www.childrensmedgroup.com/uploads/files/Three-tier_Drug_Brochure_As_Of_10-2008.pdf