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Preferred Choice 3-Tier
Non-Formulary Drug And Formulary Alternatives List

The CVS Caremark Preferred Choice 3-Tier Non-Formulary Drug And Formulary Alternatives List, formerly the PharmaCare
Preferred Choice 3-Tier Non-Formulary Drug And Formulary Alternatives List,
is a guide for clients, plan participants and health care
providers. Generics should be considered the first line of prescribing. If there is no generic available, there may be more than
one brand-name medicine to treat a condition. These preferred brand-name medicines are listed to help identify products that are
clinically appropriate and cost-effective. This list represents brand products in CAPS, branded generics in upper- and lowercase Italics,
and generic products in lowercase italics.
PLAN PARTICIPANT
HEALTH CARE PROVIDER
Your benefit plan provides you with a prescription benefit program Your patient is covered under a prescription benefit plan administered administered by CVS Caremark. Ask your doctor to consider prescribing, by CVS Caremark. As a way to help manage health care costs, authorize when medically appropriate, a preferred medicine from this list. Take this generic substitution whenever possible. If you believe a brand-name list along when you or a covered family member sees a doctor.
product is necessary, consider prescribing a brand name on this list. Please note:
Please note:
● Your specific prescription benefit plan design may not cover certain ● Generics should be considered the first line of prescribing.
products, regardless of their appearance in this document.
● This drug list represents a summary of prescription coverage. It is ● For specific information regarding your prescription benefit coverage not inclusive and does not guarantee coverage. and copay1 information, please visit www.caremark.com or contact a
● The plan participant’s specific prescription benefit plan may have CVS Caremark Customer Care representative.
a different copay for specific products on the list. ● CVS Caremark may contact your doctor after receiving your prescription ● Unless specifically indicated, drug list products will include all to request consideration of a drug list product or generic equivalent.
This may result in your doctor prescribing, when medically appropriate,a different brand-name product or generic equivalent in place of your ● Log in to www.caremark.com to check coverage and copay
information for a specific medicine.
● Any brand drug for which a generic product becomes available may be designated as a non-formulary product.
NON-FORMULARY DRUGS
FORMULARY ALTERNATIVE(S)*
NON-FORMULARY DRUGS
FORMULARY ALTERNATIVE(S)*
ADVICOR, CRESTOR, LIPITOR, pravastatin, SIMCOR,simvastatin KAPIDEX, NEXIUM, omeprazole, pantoprazole estradiol-norethindrone, PREMPHASE, PREMPRO estradiol-norethindrone, PREMPHASE, PREMPRO ASMANEX, FLOVENT, FLOVENT HFA, PULMICORT, QVAR ALOCRIL, ALOMIDE, azelastine, cromolyn, PATANOL spironolactone-hydrochlorothiazide ACANYA, clindamycin soln, clindamycin-benzoyl peroxide, DIFFERIN, DUAC CS, EPIDUO, erythromycin soln, CLIMARA, ESTRADERM, estradiol, VIVELLE-DOT erythromycin-benzoyl peroxide, RETIN-A MICRO, sulfacetamide-sulfur, tretinoin * The formulary alternative products in this list are a broad representation within therapeutic categories of available treatment options and do not necessarily represent clinical equivalency. Your specific prescription benefit plan design may not cover certain products, regardless of their appearance in this document. For specific information, visit www.caremark.com or contact a CVS Caremark Customer Care representative.
NON-FORMULARY DRUGS
FORMULARY ALTERNATIVE(S)*
NON-FORMULARY DRUGS
FORMULARY ALTERNATIVE(S)*
ASMANEX, FLOVENT, FLOVENT HFA, PULMICORT, QVAR flunisolide, fluticasone, NASACORT AQ, NASONEX, ACANYA, clindamycin soln, clindamycin-benzoyl peroxide, DIFFERIN, DUAC CS, EPIDUO, erythromycin soln, erythromycin-benzoyl peroxide, RETIN-A MICRO, ACANYA, clindamycin soln, clindamycin-benzoyl peroxide, DIFFERIN, DUAC CS, EPIDUO, erythromycin soln, erythromycin-benzoyl peroxide, RETIN-A MICRO, ACTONEL, alendronate, BONIVA, etidronate ASACOL, ASACOL HD, LIALDA, mesalamine, PENTASA, SFROWASA, sulfasalazine, sulfasalazine delayed-rel DETROL, DETROL LA, ENABLEX, GELNIQUE, oxybutynin, oxybutynin ext-rel, OXYTROL, SANCTURA XR, VESICARE doxazosin, FLOMAX, terazosin ENJUVIA, estradiol, estropipate, PREMARIN ciprofloxacin, ciprofloxacin ext-rel ALOCRIL, ALOMIDE, azelastine, cromolyn, PATANOL ACANYA, clindamycin soln, clindamycin-benzoyl peroxide, DIFFERIN, DUAC CS, EPIDUO, erythromycin soln, ALOCRIL, ALOMIDE, azelastine, cromolyn, PATANOL erythromycin-benzoyl peroxide, RETIN-A MICRO, ACANYA, clindamycin soln, clindamycin-benzoyl peroxide, ciclopirox, econazole, EXELDERM, ketoconazole topical, DIFFERIN, DUAC CS, EPIDUO, erythromycin soln, erythromycin-benzoyl peroxide, RETIN-A MICRO, sulfacetamide-sulfur, tretinoin ENJUVIA, estradiol, estropipate, PREMARIN ARICEPT, EXELON, galantamine, galantamine ext-rel, CLIMARA, ESTRADERM, estradiol, VIVELLE-DOT CLIMARA, ESTRADERM, estradiol, VIVELLE-DOT CIPRODEX, neomycin-polymyxin B-hydrocortisone otic, AVELOX, ciprofloxacin, ciprofloxacin ext-rel, LEVAQUIN bacitracin-polymyxin B-neomycin-hydrocortisone estradiol-norethindrone, PREMPHASE, PREMPRO neomycin-polymyxin B-hydrocortisone otic * The formulary alternative products in this list are a broad representation within therapeutic categories of available treatment options and do not necessarily represent clinical equivalency. Your specific prescription benefit plan design may not cover certain products, regardless of their appearance in this document. For specific information, visit www.caremark.com or contact
a CVS Caremark Customer Care representative.
NON-FORMULARY DRUGS
FORMULARY ALTERNATIVE(S)*
NON-FORMULARY DRUGS
FORMULARY ALTERNATIVE(S)*
neomycin-polymyxin B-dexamethasone ENJUVIA, estradiol, estropipate, PREMARIN CLIMARA, ESTRADERM, estradiol, VIVELLE-DOT flunisolide, fluticasone, NASACORT AQ, NASONEX, calcitonin-salmon, Fortical GLUCOMETER DEX, GLUCOMETER ELITE, ACCU-CHEK products, ONETOUCH products flunisolide, fluticasone, NASACORT AQ, NASONEX, azithromycin, clarithromycin, clarithromycin ext-rel, Kariva, Ocella, ORTHO TRI-CYCLEN LO, YAZ diclofenac sodium ophth, ketorolac ophth, XIBROM AVELOX, ciprofloxacin, ciprofloxacin ext-rel, LEVAQUIN metoprolol, metoprolol-hydrochlorothiazide ENJUVIA, estradiol, estropipate, PREMARIN * The formulary alternative products in this list are a broad representation within therapeutic categories of available treatment options and do not necessarily represent clinical equivalency. Your specific prescription benefit plan design may not cover certain products, regardless of their appearance in this document. For specific information, visit www.caremark.com or contact
a CVS Caremark Customer Care representative.
NON-FORMULARY DRUGS
FORMULARY ALTERNATIVE(S)*
NON-FORMULARY DRUGS
FORMULARY ALTERNATIVE(S)*
Trinessa, Tri-Previfem, Tri-Sprintec mirtazapine, mirtazapine ODT Mononessa, Previfem, Sprintec flunisolide, fluticasone, NASACORT AQ, NASONEX, VERAMYST methylphenidate, methylphenidate ext-rel CIPRODEX, neomycin-polymyxin B-hydrocortisone otic,ofloxacin otic carbidopa-levodopa, carbidopa-levodopa ext-rel paroxetine, paroxetine ext-rel ACANYA, clindamycin soln, clindamycin-benzoyl peroxide, AMBIEN CR, zaleplon, zolpidem DIFFERIN, DUAC CS, EPIDUO, erythromycin soln, erythromycin-benzoyl peroxide, RETIN-A MICRO, sulfacetamide-sulfur, tretinoin ADVICOR, CRESTOR, LIPITOR, pravastatin, SIMCOR, clobetasol propionate, clobetasol propionate emollient KAPIDEX, NEXIUM, omeprazole, pantoprazole ACANYA, clindamycin soln, clindamycin-benzoyl peroxide, DIFFERIN, DUAC CS, EPIDUO, erythromycin soln, erythromycin-benzoyl peroxide, RETIN-A MICRO, AVELOX, ciprofloxacin, ciprofloxacin ext-rel, LEVAQUIN KAPIDEX, NEXIUM, omeprazole, pantoprazole citalopram, fluoxetine, LEXAPRO, paroxetine, paroxetine ext-rel, sertraline cholestyramine, cholestyramine light, WELCHOL * The formulary alternative products in this list are a broad representation within therapeutic categories of available treatment options and do not necessarily represent clinical equivalency. Your specific prescription benefit plan design may not cover certain products, regardless of their appearance in this document. For specific information, visit www.caremark.com or contact
a CVS Caremark Customer Care representative.
NON-FORMULARY DRUGS
FORMULARY ALTERNATIVE(S)*
NON-FORMULARY DRUGS
FORMULARY ALTERNATIVE(S)*
doxazosin, FLOMAX, terazosin ACANYA, clindamycin soln, clindamycin-benzoyl peroxide, DIFFERIN, DUAC CS, EPIDUO, erythromycin soln, erythromycin-benzoyl peroxide, RETIN-A MICRO, diclofenac sodium, diclofenac sodium ext-rel ADVICOR, CRESTOR, LIPITOR, pravastatin, SIMCOR, ADVICOR, CRESTOR, LIPITOR, pravastatin, SIMCOR, ACANYA, clindamycin soln, clindamycin-benzoyl peroxide, DIFFERIN, DUAC CS, EPIDUO, erythromycin soln, erythromycin-benzoyl peroxide, RETIN-A MICRO, KAPIDEX, NEXIUM, omeprazole, pantoprazole * The formulary alternative products in this list are a broad representation within therapeutic categories of available treatment options and do not necessarily represent clinical equivalency. FOR YOUR INFORMATION: Generics should be considered the first line of prescribing. This drug list represents a summary of prescription coverage. It is not inclusive and does not guarantee
coverage. Specific prescription benefit plan design may not cover certain products, regardless of their appearance in this document. The plan participant’s prescription benefit plan may have a different copay for specific products on the list. Unless specifically indicated, drug list products will include all dosage forms. This list represents brand products in CAPS, branded generics in upper- and lowercase Italics, and generic products in lowercase italics. Listed products may be available generically in certain strengths or dosage forms. Dosage forms on this list will be consistent with thecategory and use where listed. This is not a complete list of all formulary products. Any brand drug for which a generic product becomes available may be designated as a non-formulary product. Log in to www.caremark.com to check coverage and copay information for a specific medicine.
1 Copayment, copay or coinsurance means the amount a plan participant is required to pay for a prescription in accordance with a Plan, which may be a deductible, a percentage of the prescription price, a fixed amount or other charge, with the balance, if any, paid by a Plan.
Your privacy is important to us. Our employees are trained regarding the appropriate way to handle your private health information.
CVS Caremark may receive rebates, discounts and service fees from pharmaceutical manufacturers for certain listed products.
This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers that are not affiliated with CVS Caremark. Listed products are for informational purposes only and are not intended to replace the clinical judgment of the prescriber.
2010 Caremark. All rights reserved. CMK025_web-0410 www.caremark.com

Source: http://www.nclm.org/SiteCollectionDocuments/RiskManagement/Caremark%20Forumulary%20Drug%20List.pdf

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2008 Four-Tier Prescription Drug List Reference Guide Your UnitedHealthcare pharmacy benefit Understanding Tiers offers flexibility and choice in finding the right Prescription medications are categorized within medication for you. four tiers. Each tier is assigned a copayment, theamount you pay when you fill a prescription,which is determined by your employer or healthplan. Consul

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