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
Teaching innovatively (with focus on ICT) and its impact on the quality of education” LESSON PLAN CHEMISTRY Teacher: Fazilet TURNA Level: 9th Grade Unit: Substance and Its Features Topic: Naming Compounds Time: 40 Minutes Materials: Publications, software, slide 1. To be able to write the name of the ionic compound the formula of which 2. To be able to write formula of the
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