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EmblemHealth Pharmacy Benefit Services
2013 Small Group Formulary Summary

This is a list of the most commonly prescribed preferred drugs for members of small group (if your employer has 50 or less employees eligible for health benefits) plans with prescription drug coverage. Make sure to ask your doctor to prescribe generic drugs whenever appropriate; this may lower your out-of-pocket expenses. NOTE: Not all drugs listed are covered by all pharmacy benefit programs, so coverage is not guaranteed. Check your benefit materials for the copay and any other responsibilities you may have under your pharmacy benefit. For additional questions about your prescription drug coverage, please call the phone number on the back of your ID card.
baclofen
ciprofloxacin hcl
divalproex sodium/er
abacavir
ciprofloxacin otic
donepezil hcl
jolivette
acarbose
balsalazide disodium
citalopram (QLL)
dorzolamide hcl (QLL)
fosinopril sodium
junel/fe
acebutolol hcl
citalopram hbr (QLL)
dorzolamide-timolol
fosinopril-
acetaminophen-
clarithromycin/er
doxazosin mesylate
hydrochlorothiazide
codeine (QLL)
benazepril hcl
doxepin hcl (QLL)
acetazolamide
benazepril-hctz
clindamycin hcl
doxycycline hyclate
clindamycin phosphate
doxycycline monohydrate
benzonatate
clobetasol propionate
dronabinol
kelnor 1-35
benzoyl peroxide
clomiphene citrate (PA)
furosemide
ketoconazole
benztropine mesylate
clomipramine hcl
ketoprofen
acyclovir
betamethasone
clonazepam
ketorolac tromethamine
adapalene
dipropionate
clonidine
econazole nitrate
gabapentin
betamethasone valerate
clonidine hcl
galantamine hbr
bethanechol chloride
clopidogrel (QLL)
gemfibrozil
bicalutamide
clorazepate dipotassium
enalapril maleate
gentamicin sulfate (PA)
bisoprolol fumarate
clotrimazole
enalapril-
albuterol sulfate (QLL)
bisoprolol-hctz
clotrimazole-
hydrochlorothiazide
glimepiride
alclometasone
brimonidine tartrate
betamethasone
glipizide/er
labetalol hcl
dipropionate
bromocriptine mesylate
clozapine/ODT
endocet (QLL)
glipizide-metformin
lactulose
alendronate sodium (QLL)
budesonide (QLL)
enoxaparin sodium (PA)
glyburide
lamivudine
allopurinol
bumetanide
colestipol hcl
enpresse
glyburide micronized
lamivudine-zidovudine
bupropion hcl
glyburide-metformin hcl
lamotrigine
bupropion hcl sr
granisetron hcl (QLL)
bupropion xl (QLL)
guaifenesin-codeine
lansoprazole (QLL)
alprazolam
buspirone hcl
guanfacine hcl
alprazolam er
butalbital compound-
eplerenone
leflunomide (QLL)
alprazolam xr
eprosartan mesylate
amantadine
butalbital-aspirin-caffeine
amethia/lo
butorphanol tartrate (QLL)
leucovorin calcium (PA)
amiloride hcl
erythromycin
halobetasol propionate
leuprolide acetate (PA)
amiodarone hcl
erythromycin-benz
haloperidol
levalbuterol solution
amitriptyline hcl
peroxide
heparin sodium (PA)
amlodipine-atorvastatin
calcipotriene
escitlopram
levetiracetam
amlodipine besylate (QLL)
calcitonin nasal spray
estazolam
hydrochlorothiazide
levetiracetam er
amlodipine-
cromolyn sodium (QLL)
hydrocodone bit-ibuprofen
levobunolol hcl
benazepril (QLL)
calcitriol
cryselle
estradiol (QLL)
hydrocodone-acetamin
levocarnitine (PA)
amoxicillin
calcium acetate
cyclobenzaprine hcl
estradiol/noreth acetate
levocetirizine
amoxicillin- clavulanate
cyclopentolate hcl
hydrocortisone
dihydrochloride
amoxicillin-clavulanate er
methyltestosterone
hydrocortisone acetate
levora-28
amphetamine salt combo
cyproheptadine hcl
estropipate
hydrocortisone butyrate
levothyroxine sodium
captopril
etidronate disodium
hydrocortisone valerate
anagrelide hcl
captopril-
etodolac
hydromorphone hcl (QLL)
anastrozole
hydrochlorothiazide
hydroxychloroquine
lidocaine hcl (PA)
carbamazepine
lidocaine-prilocaine
antipyrine-benzocaine
carbidopa-levodopa
hydroxyurea
lisinopril
anucort-hc
carbidopa-
desipramine hcl
hydroxyzine
lisinopril-
levodopa-entacapone
desloratadine
famciclovir
hyoscyamine sulfate
hydrochlorothiazide
aranelle
carisoprodol (QLL)
desmopressin acetate
famotidine
lithium carbonate
arbinoxa
cartia xt (QLL)
desonide
felbamate
loperamide
carvedilol
desoximetasone
felodipine er (QLL)
Ibandronate (QLL)
lorazepam (QLL)
cefaclor er
fenofibrate
ibuprofen
losartan potassium (QLL)
cefadroxil
fentanyl
imipramine hcl
losartan-
cefdinir
dexamethasone
fentanyl citrate loz (QLL)
hydrochlorothiazide
cefpodoxime proxetil
dexamethasone sod phos
finasteride
indapamide
lovastatin (QLL)
atenolol
cefprozil
flecainide acetate
indomethacin
low-ogestrel
atenolol-chlorthalidone
cefuroxime
dexmethylphenidate hcl
atorvastatin calcium (QLL)
dextroamphetamine
fluconazole (QLL)
ipratropium bromide (QLL)
atropine sulfate
cephalexin
dextroamphet-
fludrocortisone acetate
ipratropium-albuterol
amphetamine
flunisolide (QLL)
diazepam (QLL)
fluocinolone acetonide
irbesartan/hctz (QLL)
meclizine hcl
chlordiazepoxide hcl
diclofenac potassium
fluocinonide
medroxyprogesterone
chlordiazepoxide-
diclofenac sodium
flucytosine
isoniazid
acetate (PA/QLL)
clidinium
dicloxacillin sodium
fluorometholone
isosorbide
mefloquine hcl
chlorpromazine hcl
dicyclomine hcl
fluorouracil
isosorbide dinitrate
megestrol acetate
chlorthalidone
diflunisal
fluoxetine hcl (QLL)
isotretinoin
meloxicam (QLL)
chlorzoxazone
fluphenazine hcl (QLL)
itraconazole
mercaptopurine
cholestyramine
flurazepam hcl
metaproterenol sulfate
azathioprine
choline mag trisalicylate
diltiazem/er
flurbiprofen
azithromycin
diltiazem 24hr er
fluticasone propionate
metaxalone
ciclopirox
metformin hcl
cilostazol
diphenhydramine hcl
fluvastatin (QLL)
metformin hcl er (QLL)
cimetidine
diphenoxylate-atropine
fluvoxamine maleate
jevantique
methadone hcl (QLL)
bacitracin
dipyridamole
folic acid
methimazole
bacitracin-polymyxin
ciprofloxacin er
disulfiram
methocarbamol
EmblemHealth Pharmacy Benefit Services
2013 Small Group Formulary Summary (continued)

methotrexate (PA)
nitroglycerin patch
phenazopyridine hcl
sucralfate
trihexyphenidyl hcl
methyldopa
phenobarbital
pyridostigmine bromide
sulfacetamide sodium
tri-legest fe
methylphenidate er
nizatidine
phentermine hcl (PA)
sulfamethoxazole-TMP
trilyte with flavor packets
methylphenidate hcl (QLL)
sulfasalazine
trimethoprim
methylphenidate sr
phenytoin sodium
sulindac
trinessa
methylprednisolone
extended
Quasense
sumatriptan (QLL)
tri-previfem
metoclopramide hcl
pilocarpine hcl
quetiapine
tri-sprintec
metolazone
norethindrone acetate
pindolol
quinapril hcl
trivora-28
metoprolol succinate
pioglitazone (QLL)
quinapril-
metoprolol tartrate
nortriptyline hcl (QLL)
pioglitazone-metformin
hydrochlorothiazide
metoprolol-
hydrochlorothiazide
novarel (PA)
piroxicam
polymyxin b
ramipril
metronidazole
sul-trimethoprim
ursodiol
microgestin
ranitidine hcl
microgestin fe
potassium chloride (QLL)
tamoxifen citrate
minocycline hcl
potassium citrate
tamsulosin hcl
valacyclovir
minoxidil
reclipsen
valproic acid
mirtazapine
pramipexole
valsartan-hctz (QLL)
misoprostol
nystatin
dihydrochloride
vancomycin caps
modafanil
nystatin-triamcinolone
temazepam
vandazole
moexipril hcl
pravastatin sodium (QLL)
reprexain
terazosin hcl
moexipril-
terbinafine hcl
prazosin hcl
venlafaxine hcl/er
hydrochlorothiazide
terconazole
mometasone furoate
ribapak (PA)
mononessa
ofloxacin
prednisolone
rifampin
testosterone cypionate
verapamil
montelukast (QLL)
ogestrel
prednisolone acetate
veripred 20
morphine sulfate (QLL)
olanzapine/odt
prednisolone sod
risperidone (QLL)
tetracycline hcl
olanzapine-fluoxetine
phosphate
rivastigmine
theophylline
mupirocin
omeprazole (QLL)
prednisone
ropinirole hcl/ER
theophylline anhydrous
omeprazole-sodium
thioridazine hcl
bicarbonate
roxicet (QLL)
thiothixene
ondansetron hcl (QLL)
ondansetron odt (QLL)
timolol maleate
nabumetone
salsalate
tinidazole
orphenadrine citrate
previfem
selenium sulfide
tizanidine hcl
naltrexone hcl
primidone
warfarin sodium
naproxen
oxaprozin
probenecid
tobramycin sulfate
naproxen sodium
oxazepam
prochlorperazine maleate
sertraline hcl (QLL)
tobramycin-
naratriptan hcl (QLL)
oxcarbazepine
proctosol-hc
silver sulfadiazine
dexamethasone
nateglinide
oxybutynin chloride/er
proctozone-hc
topiramate
oxycodone hcl (QLL)
simvastatin (QLL)
tolterodine
nefazodone hcl
oxycodone-acetamin
sodium fluoride
torsemide
neomycin-bacitracin-
progesterone in oil (PA)
sodium sulfacetamide-
tramadol hcl
polymyxin
oxymorphone hcl (QLL)
progesterone caps
tramadol hcl-acetamin
zaleplon (QLL)
neomycin-polymyxin-
zamicet (QLL)
dexameth
promethazine hcl
trandolapril
neomycin-polymyxin-hc
promethazine vc-codeine
spinosad
tranylcypromine sulfate
zenchent
nevirapine
promethazine-codeine
trazodone hcl
nifediac cc (QLL)
pantoprazole sodium (QLL)
promethazine-dm
spironolactone
tretinoin
ziprasidone
nifedical xl (QLL)
paroxetine hcl
promethegan
spironolactone-hctz
zolpidem tartrate (QLL)
nifedipine er (QLL)
peg 3350-electrolyte
propafenone hcl
sprintec
triamcinolone acetonide
zonisamide
nisoldipine
propranolol hcl
zovia 1-35e
nitrofurantoin
propylthiouracil
triamterene-hctz
zovia 1-50e
nitrofurantoin
penicillin v potassium
triazolam
mono-macro
pentoxifylline
trifluoperazine hcl
nitroglycerin
permethrin
perphenazine
trifluridine
Key:
Capital letters:
Prior Authorization – Prescriber needs to obtain EmblemHealth approval for coverage of this drug (as outlined in the member’s plan).
Quantity Level Limit – Quantities dispensed may be limited.
Step Therapy – Drug is part of a program where drug options are organized in a series of steps (as outlined in the member’s plan).
For the member:
Generic medications contain the same active ingredients as the corresponding brand-name medications, but may differ in color or shape. They have been FDA-approved For the physician:
Please prescribe preferred products and allow generic substitutions when medically appropriate.
THIS FORMULARY SUMMARY IS EFFECTIVE JANUARY 1, 2013 THROUGH DECEMBER 31, 2013, AND IS SUBJECT TO CHANGE.
You can get more information about our formularies and our Pharmacy Benefit Services program at www.emblemhealth.com.
Formulary Disclaimer
Please refer to your benefit materials for specific coverage information. Your benefit design determines what is covered for you and what your copayment will be. The presence of a medication on this formulary does not guarantee that you as a plan member will be covered for that drug. Additionally, these medications may be subject to Prior Authorization. Coverage for some drugs may be limited to specific dosage forms and/or strengths. The medications listed on this formulary are subject to change pursuant to the formulary management activities of EmblemHealth’s Pharmacy Benefit Services. As new generics become available, the corresponding brand name drug will no longer be considered a preferred agent.
Group Health Incorporated (GHI), GHI HMO Select, Inc. (GHI HMO), HIP Health Plan of New York (HIP), HIP Insurance Company of New York and EmblemHealth Services Company, LLC are EmblemHealth companies. EmblemHealth Services Company, LLC provides administrative services to the EmblemHealth companies.
EMB_MB_OTH_12769_SmallGrpStandard_2013_Formulary_12-12

Source: http://www.conferenceny.com/uploads/documents/Small_Grp_Formulary%202013.pdf

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