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Microsoft word - 2013 uhc drug list.docx

2013 Advantage Three-Tier Prescription Drug List
Quick-Reference Guide 
Anti-Infectives - Antibiotics (Oral, inhaled and ear antibiotics are listed)
Tier 1
Amoxicillin
Vancomycin SL
Tier 2
Augmentin
Cayston N
Tier 3
Adoxa E Doryx
E Solodyn
Amoxicillin-Clavulanate ER E Doxycycline
Augmentin XR E Enteric-Coated
Capsule 150 mg E
Anti-Infectives - Antifungals (Oral and topical antifungals are listed)
Tier 1
Clotrimazole
Terbinafine Tablet SL
Itraconazole Capsule SL Nystatin
Tier 2
Clindesse Vaginal
Some medications are noted with ½ T, DSN, E, MC, N, P, RS, SDP, or SL. The definitions for these symbols are listed below. Depending on your benefit you may have notification or prior authorization requirements for select medications.
1/2T Eligible for Half Tablet Program
P Progression Rx
DSN Designated Specialty Network
RS May be eligible for the Refill and Save Program
E May be excluded from coverage
SDP Select Designated Pharmacy
MC Multiple copay applies
SL Supply limit
N Notification or Prior Authorization required*
 *Exception Basis Only. Call the Archdiocese of St. Louis Office of Human Resources at 314-792-7540 2013 Advantage Three-Tier Prescription Drug List
Quick-Reference Guide 
Tier 3
Gynazole-1 Vaginal
Lamisil Granules SL
Ketoconazole Foam SL Mycostatin
Anti-Infectives - Antivirals
Tier 1
Acyclovir
Ribavirin DSN N
Tier 2
Baraclude DSN Hepsera
DSN Incivek
Valacyclovir SL
Epivir HBV DSN
DSN N SL Rebetol Valcyte
Famciclovir SL Solution
Tier 3
Relenza SL Tamiflu
SL Victrelis
Ribapak DSN E N
Cardiovascular/Heart Disease - Coagulation Therapy
Tier 1
Cilostazol Pentoxifylline
Tier 2
Coumadin
Fondaparinux SL Xarelto
Enoxaparin SL
Tier 3
Aggrenox Fragmin
SL Pradaxa
Effient SL Innohep
Some medications are noted with ½ T, DSN, E, MC, N, P, RS, SDP, or SL. The definitions for these symbols are listed below. Depending on your benefit you may have notification or prior authorization requirements for select medications.
1/2T Eligible for Half Tablet Program
P Progression Rx
DSN Designated Specialty Network
RS May be eligible for the Refill and Save Program
E May be excluded from coverage
SDP Select Designated Pharmacy
MC Multiple copay applies
SL Supply limit
N Notification or Prior Authorization required*
 *Exception Basis Only. Call the Archdiocese of St. Louis Office of Human Resources at 314-792-7540 2013 Advantage Three-Tier Prescription Drug List
Quick-Reference Guide 
Cardiovascular/Heart Disease - High Blood Pressure
Tier 1
Amlodipine Atenolol
Atenolol/Chlorthalidone Enalapril/Hydrochlorothiazide Eprosartan SL Moexipril
1/2T Torsemide
Trandolapril 1/2T
Tier 2
Aldactazide 50-50 mg
Micardis SL
Benicar 1/2T SL
Micardis HCT SL
Benicar HCT SL
Perindopril Erbumine 1/2T
Dutoprol SL Sustained-Action
Sustained-Release Tablet 50, 100, 200 mg Some medications are noted with ½ T, DSN, E, MC, N, P, RS, SDP, or SL. The definitions for these symbols are listed below. Depending on your benefit you may have notification or prior authorization requirements for select medications.
1/2T Eligible for Half Tablet Program
P Progression Rx
DSN Designated Specialty Network
RS May be eligible for the Refill and Save Program
E May be excluded from coverage
SDP Select Designated Pharmacy
MC Multiple copay applies
SL Supply limit
N Notification or Prior Authorization required*
 *Exception Basis Only. Call the Archdiocese of St. Louis Office of Human Resources at 314-792-7540 2013 Advantage Three-Tier Prescription Drug List
Quick-Reference Guide 
Tier 3
Aceon 1/2T Coreg
E SL Tekamlo
E SL Tekturna
Amlodipine/Benazepril SL Diovan
SDP SL Tekturna HCT
Amturnide E SL Diovan
SDP SL Teveten HCT SL
Atacand 1/2T SDP SL Edarbi
SL Trandolapril/Verapamil
Atacand HCT SDP SL Edarbyclor
SL Tribenzor
Avalide SL Exforge
E SL Twynsta
Avapro 1/2T SL
Exforge HCT E SL Verapamil
Irbesartan/Hydrochlorothiazide SL 24
Nexiclon XR E
Weekly Patch SL
Cardiovascular/Heart Disease - High Cholesterol
Tier 1
Atorvastatin 1/2T SL
SL Pravastatin
Simvastatin 1/2T
Tier 2
Antara
Crestor 1/2T SL Lipofen
Tier 3
Advicor SL Lipitor
1/2T E SL Triglide
Altoprev E SL Livalo
SL Trilipix
Amlodipine/Atorvastatin E SL Lovaza
N Vytorin
Caduet E SL Niaspan
Lescol XL SL Tricor
Cardiovascular/Heart Disease - Other
Tier 1
Amiodarone Isosorbide
Some medications are noted with ½ T, DSN, E, MC, N, P, RS, SDP, or SL. The definitions for these symbols are listed below. Depending on your benefit you may have notification or prior authorization requirements for select medications.
1/2T Eligible for Half Tablet Program
P Progression Rx
DSN Designated Specialty Network
RS May be eligible for the Refill and Save Program
E May be excluded from coverage
SDP Select Designated Pharmacy
MC Multiple copay applies
SL Supply limit
N Notification or Prior Authorization required*
 *Exception Basis Only. Call the Archdiocese of St. Louis Office of Human Resources at 314-792-7540 2013 Advantage Three-Tier Prescription Drug List
Quick-Reference Guide 
Tier 2
Lanoxin Nitrostat Ranexa
Multaq
Tier 3
Nitroglycerin Spray E SL Nitromist
SL Propafenone
Nitrolingual E SL Sustained-Release
Central Nervous System - Attention Deficit Disorder
Tier 1
Amphetamine Salt Combo
Tier 2
Adderall XR SL Intuniv
SL Vyvanse
Tier 3
Amphetamine Aspartate/
Daytrana SL
Focalin XR SL 24
E Methylphenidate
Capsule SL
24 Hour Capsule SL
Ritalin LA SL
Concerta SL Strattera
Central Nervous System - Depression
Tier 1
Amitriptyline
Delayed-Release Capsule SL Phenelzine
Sertraline 1/2T
Sustained-Release Capsule SL
Tier 3
Aplenzin E SL Oleptro
E SL Pexeva
Cymbalta SDP SL Paroxetine
Escitalopram 1/2T SL Sustained-Release Venlafaxine
Lexapro 1/2T SL 24
SL Extended-Release
Luvox CR SL
Some medications are noted with ½ T, DSN, E, MC, N, P, RS, SDP, or SL. The definitions for these symbols are listed below. Depending on your benefit you may have notification or prior authorization requirements for select medications.
1/2T Eligible for Half Tablet Program
P Progression Rx
DSN Designated Specialty Network
RS May be eligible for the Refill and Save Program
E May be excluded from coverage
SDP Select Designated Pharmacy
MC Multiple copay applies
SL Supply limit
N Notification or Prior Authorization required*
 *Exception Basis Only. Call the Archdiocese of St. Louis Office of Human Resources at 314-792-7540 2013 Advantage Three-Tier Prescription Drug List
Quick-Reference Guide 
Central Nervous System - Migraine
Tier 1
Acetaminophen/Butalbital/ Aspirin/Butalbital/Caffeine
Caffeine SL Naratriptan
Injection, Tablet SL
Tier 2
Ergomar Sumatriptan
Nasal Spray SL
Tier 3
Alsuma E SL Maxalt
SDP SL Zomig
Axert SDP SL Maxalt
Zomig Nasal Spray SL
Cambia E SL Sumavel
Frova SDP SL Treximet
Central Nervous System - Multiple Sclerosis
Tier 2
Ampyra DSN N SL Copaxone
Avonex DSN N SL Rebif
Tier 3
Betaseron DSN N SL ST Extavia DSN E N SL ST Gilenya
DSN N SL ST
Central Nervous System - Sedatives/Hypnotics
Tier 1
Temazepam
Zaleplon SL
Zolpidem Tablet SL
Tier 3
Ambien SL ST Rozerem
Ambien CR SL ST Silenor
E SL Multiphasic-Release
Edluar E SL ST Sonata
SL ST Zolpimist
Lunesta SL ST
Some medications are noted with ½ T, DSN, E, MC, N, P, RS, SDP, or SL. The definitions for these symbols are listed below. Depending on your benefit you may have notification or prior authorization requirements for select medications.
1/2T Eligible for Half Tablet Program
P Progression Rx
DSN Designated Specialty Network
RS May be eligible for the Refill and Save Program
E May be excluded from coverage
SDP Select Designated Pharmacy
MC Multiple copay applies
SL Supply limit
N Notification or Prior Authorization required*
 *Exception Basis Only. Call the Archdiocese of St. Louis Office of Human Resources at 314-792-7540 2013 Advantage Three-Tier Prescription Drug List
Quick-Reference Guide 
Central Nervous System - Seizure Disorders
Tier 1
Carbamazepine
Diazepam Rectal Gel SL
Tier 2
Carbamazepine
24 Hour Tablet ST
Tier 3
Carbamazepine
Keppra XR ST
Lyrica SDP SL
ST Stavzor
Lamictal Dose Pack SL ST Topamax
Depakote ER ST Lamictal
Keppra ST
Central Nervous System - Other
Tier 1
Alprazolam
Tier 2
Apokyn DSN
Olanzapine Tablet SL Xyrem
SL Ziprasidone
Quetiapine SL
Some medications are noted with ½ T, DSN, E, MC, N, P, RS, SDP, or SL. The definitions for these symbols are listed below. Depending on your benefit you may have notification or prior authorization requirements for select medications.
1/2T Eligible for Half Tablet Program
P Progression Rx
DSN Designated Specialty Network
RS May be eligible for the Refill and Save Program
E May be excluded from coverage
SDP Select Designated Pharmacy
MC Multiple copay applies
SL Supply limit
N Notification or Prior Authorization required*
 *Exception Basis Only. Call the Archdiocese of St. Louis Office of Human Resources at 314-792-7540 2013 Advantage Three-Tier Prescription Drug List
Quick-Reference Guide 
Tier 3
Abilify 1/2T SL Modafinil
E N SL Ropinirole
Aricept 23 mg E
24 Hour Tablet E
Nuvigil N SL Seroquel
Fanapt SL
Seroquel XR SL
Geodon SL
Tablet SL Symbyax
Invega SL Provigil
E N SL Zyprexa
Mirapex ER E Requip
E Zyprexa
Dermatology
Tier 1
Alclometasone Dipropionate
Tretinoin N
Tier 2
Azelex SL Ciclopirox
MC Oxsoralen-Ultra
Benzaclin Gel 1%-5% 25 g SL
Differin Cream, Gel 0.1% N SL Protopic
Imiquimod SL Regranex
Calcipotriene Cream, Ointment SL Isotretinoin
Some medications are noted with ½ T, DSN, E, MC, N, P, RS, SDP, or SL. The definitions for these symbols are listed below. Depending on your benefit you may have notification or prior authorization requirements for select medications.
1/2T Eligible for Half Tablet Program
P Progression Rx
DSN Designated Specialty Network
RS May be eligible for the Refill and Save Program
E May be excluded from coverage
SDP Select Designated Pharmacy
MC Multiple copay applies
SL Supply limit
N Notification or Prior Authorization required*
 *Exception Basis Only. Call the Archdiocese of St. Louis Office of Human Resources at 314-792-7540 2013 Advantage Three-Tier Prescription Drug List
Quick-Reference Guide 

Tier 3
Acanya Clobex
E SL Naftin
Aczone SL Condylox
Adapalene N SL
Cutivate Lotion MC Olux-E
Altabax SL Denavir
Atralin MC N SL Desonate
SL Retin-A
Avita Gel N SL Differin
N SL Taclonex
Bactroban SL Differin
N SL Taclonex
Benzaclin Gel 1%-5% SL Dovonex
SL Tazorac
Clindagel E SL Duac
SL Tretin-X
Clindamycin Foam 1% SL Elidel
N SL Vanos
Epiduo E SL Vectical
Evoclin SL Veltin
Verdeso SL
Gel E SL Finacea
Fluticasone Propionate Lotion MC Xerese
Benzoyl Peroxide Gel 1%-5% SL Locoid
Xolegel MC
Clobetasol Propionate Foam SL Locoid
Clobetasol Propionate Lotion SL Loprox
MC Zovirax
Clobetasol Propionate Shampoo E SL Metrogel
MC Zyclara
Clobex SL Metrolotion
Diabetes/Endocrine - Blood Glucose Monitoring
Tier 1
Accu-Chek Active Test Strips SL
Accu-Chek Compact Test Strips SL
One Touch Ultra Test Strips SL
Test Strips SL
Test Strip SL
One Touch Test Strips SL
Test Strips SL
Test Strips SL
Tier 3
Ascensia Autodisc
Contour Test Strips SDP SL
Precision Xtra Test Strips SDP SL
Test Strips SDP SL
Freestyle Lite Test Strips SDP SL
Freestyle Test Strips SDP SL
Test Strips SDP SL
Some medications are noted with ½ T, DSN, E, MC, N, P, RS, SDP, or SL. The definitions for these symbols are listed below. Depending on your benefit you may have notification or prior authorization requirements for select medications.
1/2T Eligible for Half Tablet Program
P Progression Rx
DSN Designated Specialty Network
RS May be eligible for the Refill and Save Program
E May be excluded from coverage
SDP Select Designated Pharmacy
MC Multiple copay applies
SL Supply limit
N Notification or Prior Authorization required*
 *Exception Basis Only. Call the Archdiocese of St. Louis Office of Human Resources at 314-792-7540 2013 Advantage Three-Tier Prescription Drug List
Quick-Reference Guide 
Diabetes/Endocrine - Insulin
Tier 1
Humalog Vials
Tier 2
Humalog KwikPen
Tier 3
Apidra Solostar SDP
Novolin Vials SDP
Apidra Vial SDP Levemir
Diabetes/Endocrine - Non-Insulin
Tier 1
Acarbose
Tier 2
Byetta SL Duetact SL Kombiglyze
XR SL Pioglitazone/Metformin
Nateglinide SL Prandin
Onglyza SL Tradjenta
Jentadueto SL Pioglitazone
Tier 3
Actoplus Met SL Fortamet
Actoplus Met XR SDP SL
Actos 1/2T SL Janumet
SDP SL Symlin
Avandamet SL Janumet
XR SDP SL Victoza
Avandaryl SL Januvia
Avandia SL Juvisync
Some medications are noted with ½ T, DSN, E, MC, N, P, RS, SDP, or SL. The definitions for these symbols are listed below. Depending on your benefit you may have notification or prior authorization requirements for select medications.
1/2T Eligible for Half Tablet Program
P Progression Rx
DSN Designated Specialty Network
RS May be eligible for the Refill and Save Program
E May be excluded from coverage
SDP Select Designated Pharmacy
MC Multiple copay applies
SL Supply limit
N Notification or Prior Authorization required*
 *Exception Basis Only. Call the Archdiocese of St. Louis Office of Human Resources at 314-792-7540 2013 Advantage Three-Tier Prescription Drug List
Quick-Reference Guide 
Endocrine - Growth Hormone
Tier 2
Nutropin, AQ, NuSpin DSN N SL Serostim
Saizen DSN N SL Tev-Tropin
Tier 3
Genotropin DSN E N SL Norditropin
DSN E N SL Zorbtive
Humatrope DSN E N SL Omnitrope
Endocrine - Other
Tier 1
Calcitriol
Octreotide Acetate DSN N
Tier 2
Androderm SL Levoxyl
Testim SL
Kuvan DSN N SL Pediapred
Tier 3
Androgel E SL Axiron
E SL Orapred
Fortesta E SL
Eye Conditions - Anti-Allergy
Tier 1
Ketorolac Tromethamine
Tier 3
Azelastine HCl SL Emadine
E Optivar
Bepreve E SL Epinastine
E SL Pataday
Elestat E SL Lastacaft
SL Patanol
Some medications are noted with ½ T, DSN, E, MC, N, P, RS, SDP, or SL. The definitions for these symbols are listed below. Depending on your benefit you may have notification or prior authorization requirements for select medications.
1/2T Eligible for Half Tablet Program
P Progression Rx
DSN Designated Specialty Network
RS May be eligible for the Refill and Save Program
E May be excluded from coverage
SDP Select Designated Pharmacy
MC Multiple copay applies
SL Supply limit
N Notification or Prior Authorization required*
 *Exception Basis Only. Call the Archdiocese of St. Louis Office of Human Resources at 314-792-7540 2013 Advantage Three-Tier Prescription Drug List
Quick-Reference Guide 
Eye Conditions - Antibiotics
Tier 1
Ciprofloxacin Neomycin/Polymyxin B
Erythromycin Sulfate/Dexamethasone Tobramycin Tier 2
Blephamide S.O.P.
Tier 3
Azasite SL Tobradex
E SL Zylet
Eye Conditions - Glaucoma
Tier 1
Acetazolamide
Tier 2
Alphagan P 0.1% SL Brimonidine
SL Lumigan
Azopt SL Combigan
SL Pilopine
Betimol SL Dorzolamide
Travatan Z SL
Tier 3
Iopidine 1%
Gastrointestinal - Acid Suppression
Tier 1
Cimetidine Omeprazole
Tier 2
Helidac Prevpac
Some medications are noted with ½ T, DSN, E, MC, N, P, RS, SDP, or SL. The definitions for these symbols are listed below. Depending on your benefit you may have notification or prior authorization requirements for select medications.
1/2T Eligible for Half Tablet Program
P Progression Rx
DSN Designated Specialty Network
RS May be eligible for the Refill and Save Program
E May be excluded from coverage
SDP Select Designated Pharmacy
MC Multiple copay applies
SL Supply limit
N Notification or Prior Authorization required*
 *Exception Basis Only. Call the Archdiocese of St. Louis Office of Human Resources at 314-792-7540 2013 Advantage Three-Tier Prescription Drug List
Quick-Reference Guide 
Tier 3
Aciphex SL
Prilosec Rx 40 mg E
Capsule E SL Protonix
Dexilant SL
Zegerid Capsule E SL
Lansoprazole E SL Enteric-Coated
E SL Zegerid
Nexium Capsule E SL Prevacid
Prilosec Rx 10, 20 mg E
Gastrointestinal - Nausea/Vomiting
Tier 1
Ondansetron Prochlorperazine
Tier 2
Emend SL Granisetron
Tier 3
Anzemet SL Sancuso
E SL Zuplenz
Gastrointestinal - Other
Tier 1
Balsalazide Lactulose Sulfasalazine
Belladona/Phenobarbital
Chlordiazepoxide/Clidinium Metoclopramide Tier 2
Apriso Canasa Lotronex
Tier 3
Amitiza N SL Dipentum
Asacol SDP Halflytely-Bisacodyl
Asacol HD E SDP Metozolv
E Pentasa
Men’s Health Erectile Dysfunction
Tier 3
Caverject SL Levitra
SL Viagra
Cialis SL Muse
Edex SL Staxyn
Some medications are noted with ½ T, DSN, E, MC, N, P, RS, SDP, or SL. The definitions for these symbols are listed below. Depending on your benefit you may have notification or prior authorization requirements for select medications.
1/2T Eligible for Half Tablet Program
P Progression Rx
DSN Designated Specialty Network
RS May be eligible for the Refill and Save Program
E May be excluded from coverage
SDP Select Designated Pharmacy
MC Multiple copay applies
SL Supply limit
N Notification or Prior Authorization required*
 *Exception Basis Only. Call the Archdiocese of St. Louis Office of Human Resources at 314-792-7540 2013 Advantage Three-Tier Prescription Drug List
Quick-Reference Guide 
Men’s Health Prostate
Tier 1
Alfuzosin Finasteride
Tier 3
Avodart N SDP Jalyn
E Rapaflo
Miscellaneous
Tier 1
Anastrozole
Tier 2
Cellcept Suspension DSN Fareston
Epipen SL Lidoderm
SL Pegasys
Epipen Jr SL Lysteda
SL Rapamune
DSN Sandimmune
Tier 3
Acuvail E SL Hydrocodone/Chlorpheniramine
DSN N SL ST
SL Restasis
Bromday E SL Infergen
DSN N SL Tussionex
Bromfenac SL Intron
Miscellaneous - Overactive Bladder
Tier 1
Dicyclomine Tablet
Tier 2
Gelnique Sanctura
Tier 3
Detrol
Toviaz SDP
Detrol LA E Tolterodine
Some medications are noted with ½ T, DSN, E, MC, N, P, RS, SDP, or SL. The definitions for these symbols are listed below. Depending on your benefit you may have notification or prior authorization requirements for select medications.
1/2T Eligible for Half Tablet Program
P Progression Rx
DSN Designated Specialty Network
RS May be eligible for the Refill and Save Program
E May be excluded from coverage
SDP Select Designated Pharmacy
MC Multiple copay applies
SL Supply limit
N Notification or Prior Authorization required*
 *Exception Basis Only. Call the Archdiocese of St. Louis Office of Human Resources at 314-792-7540 2013 Advantage Three-Tier Prescription Drug List
Quick-Reference Guide 
Musculoskeletal - Osteoporosis
Tier 1
Alendronate SL
Tier 2
Calcitonin Salmon Nasal Spray
Forteo DSN N Ibandronate
Tier 3
Actonel SL Atelvia
E SL Fosamax
Musculoskeletal - Pain Relief
Tier 1
Acetaminophen/Butalbital/ Ibuprofen
Caffeine/Codeine SL Ibuprofen/Hydrocodone Naproxen
Acetaminophen/Codeine SL Ibuprofen/Oxycodone
Acetaminophen/Hydrocodone Bit SL Indomethacin
Acetaminophen/Oxycodone SL
Tramadol/Acetaminophen SL
Duragesic SL Etodolac
Tier 2
Acetaminophen/Hydrocodone Bit
Opana ER SL Tramadol
Oral Solution SL OxyContin
SL Sustained-Release
Butorphanol Nasal Spray SL Oxymorphone
Fentanyl Citrate Lollipop N SL Extended-Release
12 Hour Tablet SL
Some medications are noted with ½ T, DSN, E, MC, N, P, RS, SDP, or SL. The definitions for these symbols are listed below. Depending on your benefit you may have notification or prior authorization requirements for select medications.
1/2T Eligible for Half Tablet Program
P Progression Rx
DSN Designated Specialty Network
RS May be eligible for the Refill and Save Program
E May be excluded from coverage
SDP Select Designated Pharmacy
MC Multiple copay applies
SL Supply limit
N Notification or Prior Authorization required*
 *Exception Basis Only. Call the Archdiocese of St. Louis Office of Human Resources at 314-792-7540 2013 Advantage Three-Tier Prescription Drug List
Quick-Reference Guide 
Tier 3
Abstral N SL Hycet
SL Kadian
E SL Lazanda N Pennsaid
Avinza SL
SL Mefenamic
Rybix ODT E SL
Celebrex SL Acid
Ryzolt E SL
Conzip E SL Sulfate
Duexis E SL
Embeda SL
Pellets E SL
Exalgo SL Naprelan
Tablet E SL
Fentanyl Transdermal SL Nucynta
SL Vimovo
Fentora E N SL Nucynta
SL Zipsor
Flector E Onsolis N SL
Musculoskeletal - Rheumatoid Arthritis
Tier 1
Azathioprine
Tier 2
Cimzia DSN N SL Enbrel
DSN N SL Trexall
Simponi DSN N SL
Tier 3
Humira DSN N SL ST Kineret
DSN N SL Orencia
Musculoskeletal Other
Tier 1
Allopurinol Carisoprodol
Tier 2
Colcrys Orphenadrine/Aspirin/
Orphenadrine
Tier 3
Amrix E Gralise
Soma 250 mg E
Carisoprodol 250 mg E Horizant
E SL Tizanidine
Uloric SL
24 Hour Capsule E Skelaxin
Some medications are noted with ½ T, DSN, E, MC, N, P, RS, SDP, or SL. The definitions for these symbols are listed below. Depending on your benefit you may have notification or prior authorization requirements for select medications.
1/2T Eligible for Half Tablet Program
P Progression Rx
DSN Designated Specialty Network
RS May be eligible for the Refill and Save Program
E May be excluded from coverage
SDP Select Designated Pharmacy
MC Multiple copay applies
SL Supply limit
N Notification or Prior Authorization required*
 *Exception Basis Only. Call the Archdiocese of St. Louis Office of Human Resources at 314-792-7540 2013 Advantage Three-Tier Prescription Drug List
Quick-Reference Guide 
Respiratory - Asthma/COPD
Tier 1
Albuterol Sulfate
Ventolin HFA SL
Alvesco SL QVAR
SL Zafirlukast
Asmanex SL Theophylline
Tier 2
Albuterol Sulfate/Ipratropium
Foradil SL Spiriva
Montelukast SL
Pulmicort Respules 1 mg/2 ml SL
0.25 mg/2 ml, 0.5 mg/2 ml SL
Tier 3
Advair Diskus RS SL Flovent
SDP SL Proventil
Advair HFA RS SL Flovent
SDP SL Pulmicort
Atrovent HFA SL
Serevent Diskus SL
Combivent SL
Nebulizer E SL Singulair
Combivent Respimat SL Maxair
SL Symbicort
Daliresp N SL Perforomist
SL Xopenex
Dulera RS SL Proair
HFA SL Xopenex
Respiratory - Nasal Allergy
Tier 1
Flunisolide
Fluticasone Propionate SL
Tier 2
Nasonex SL
Tier 3
Astelin E SL Nasacort
SL Rhinocort
Astepro SL Omnaris
SL Triamcinolone
Azelastine HCl SL Patanase
SL Veramyst
Beconase AQ SL
Respiratory - Oral Allergy
Tier 1
Cyproheptadine Levocetirizine
SL Promethazine
Some medications are noted with ½ T, DSN, E, MC, N, P, RS, SDP, or SL. The definitions for these symbols are listed below. Depending on your benefit you may have notification or prior authorization requirements for select medications.
1/2T Eligible for Half Tablet Program
P Progression Rx
DSN Designated Specialty Network
RS May be eligible for the Refill and Save Program
E May be excluded from coverage
SDP Select Designated Pharmacy
MC Multiple copay applies
SL Supply limit
N Notification or Prior Authorization required*
 *Exception Basis Only. Call the Archdiocese of St. Louis Office of Human Resources at 314-792-7540 2013 Advantage Three-Tier Prescription Drug List
Quick-Reference Guide 
Additional Tier 3 Drugs with a generic equivalent in Tier 1
Tier 3
Clarinex E SL Desloratadine
Levocetirizine Oral Solution SL
Clarinex-D E SL
Women’s Health - Estrogen/Progesterone
Tier 1
Estradiol Estropipate
Estradiol Transdermal
Weekly Patch SL Norethindrone
Tier 2
Cenestin
Climara SL Estradiol/Norethindrone
Crinone N Estring
MC SL Vivelle-Dot
Tier 3
Activella Alora
SL Climara Pro
Femring MC SL Premphase
SL Combipatch First-Progesterone
N Prempro
SL Estrasorb
SL Estrogel SL Weekly
Women’s Health - Prenatal Vitamins
Tier 1
Folic Acid
Tier 2
Advanced Care Plus
Tier 3
Brand Prenatal Vitamins
Some medications are noted with ½ T, DSN, E, MC, N, P, RS, SDP, or SL. The definitions for these symbols are listed below. Depending on your benefit you may have notification or prior authorization requirements for select medications.
1/2T Eligible for Half Tablet Program
P Progression Rx
DSN Designated Specialty Network
RS May be eligible for the Refill and Save Program
E May be excluded from coverage
SDP Select Designated Pharmacy
MC Multiple copay applies
SL Supply limit
N Notification or Prior Authorization required*
 *Exception Basis Only. Call the Archdiocese of St. Louis Office of Human Resources at 314-792-7540 2013 Advantage Three-Tier Prescription Drug List
Quick-Reference Guide 
Additional Tier 3 Drugs with a generic equivalent in Tier 1
Accolate SL (Zafirlukast SL) Depo-Provera
MC Metrogel
(Medroxyprogesterone 150mg/ml MC) Mevacor
Diastat Acudial SL
(Diazepam Rectal Gel SL) Prescription
Ambien SL ST (Zolpidem SL) Sustained-Release
Amerge SL (Naratriptan SL) Dyazide
Effexor XR SL (Venlafaxine
Sustained-Release Capsule SL) (Acetaminophen/Oxycodone
Fioricet SL (Acetaminophen/
Butalbital/Caffeine SL) Precose
Flonase SL
(Fluticasone Nasal Spray SL)
SL (Alendronate SL) (Lisinopril/Hydrochlorothiazide)
Glucotrol, XL (Glipizide) Extended-Release Hyzaar SL (Losartan/
Hydrochlorothiazide SL) Provera
Imitrex SL (Sumatriptan
Succinate Injection, Tablet SL)
Keppra P (Levetiracetam)
Lamictal ST (Lamotrigine)
Lamisil SL (Terbinafine Tablet SL) Requip
Cozaar 1/2T (Losartan 1/2T)
Lipitor 1/2T E SL(Atorvastatin 1/2 T SL) Ritalin
Depakote ER P
Mavik 1/2T (Trandolapril 1/2T) Sonata
ST SL (Zaleplon SL)
Some medications are noted with ½ T, DSN, E, MC, N, P, RS, SDP, or SL. The definitions for these symbols are listed below. Depending on your benefit you may have notification or prior authorization requirements for select medications.
1/2T Eligible for Half Tablet Program
P Progression Rx
DSN Designated Specialty Network
RS May be eligible for the Refill and Save Program
E May be excluded from coverage
SDP Select Designated Pharmacy
MC Multiple copay applies
SL Supply limit
N Notification or Prior Authorization required*
 *Exception Basis Only. Call the Archdiocese of St. Louis Office of Human Resources at 314-792-7540 2013 Advantage Three-Tier Prescription Drug List
Quick-Reference Guide 
Teveten SL (Eprosartan SL) Valium
Topamax ST (Topiramate)
Some medications are noted with ½ T, DSN, E, MC, N, P, RS, SDP, or SL. The definitions for these symbols are listed below. Depending on your benefit you may have notification or prior authorization requirements for select medications.
1/2T Eligible for Half Tablet Program
P Progression Rx
DSN Designated Specialty Network
RS May be eligible for the Refill and Save Program
E May be excluded from coverage
SDP Select Designated Pharmacy
MC Multiple copay applies
SL Supply limit
N Notification or Prior Authorization required*
 *Exception Basis Only. Call the Archdiocese of St. Louis Office of Human Resources at 314-792-7540

Source: http://archstl.org/files/field-file/2013%20UHC%20Drug%20List.pdf