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 ESL Twynsta
Avapro 1/2T SL
Exforge HCT ESL 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 ESL 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 ESL 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 MCSL 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
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
FIRST PRESBYTERIAN CHURCH YOUTH 1100 Carter Creek Parkway, Bryan, Texas 77802-1129 MEDICAL RELEASE AND CONSENT Name _______________________________________________________________________ Address _____________________________________________ Phone ___________________ Parent _____________________ Home ______________ Work _____________ Cell ________ Parent _____________________ Home ____
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2013 Advantage Three-Tier Prescription Drug List 
2013 Advantage Three-Tier Prescription Drug List 
2013 Advantage Three-Tier Prescription Drug List 
2013 Advantage Three-Tier Prescription Drug List 
2013 Advantage Three-Tier Prescription Drug List 
2013 Advantage Three-Tier Prescription Drug List 
2013 Advantage Three-Tier Prescription Drug List