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accessing your prescription drug information (continued) Pharmacy locator — fi nd a participating Coverage exception requests — initiate a request for prior authorization or Non-formulary Consideration by following the instructions Online customer service — use email to contact a CVS Caremark service representative for any questions about your prescription drug benefi t.
Methods of payment — pay by credit card, check, or money order. Or use Bill Me Later®for mail-order prescriptions. Visit capbluecross.com to learn more.
The Preferred Medication List is an abbreviated You can easily identify generic, preferred brand, version of the Formulary list containing the names or non-preferred brand drugs on the Preferred of some of the most commonly prescribed drugs Medication List as they will have the following The Capital BlueCross formulary serves as a reference for all prescription drug benefi t designs ranging from an open formulary to aclosed formulary.
A closed formulary provides access to both generic (tier-one) and preferred brand-name (tier-two) drugs. You or your physician may request coverage for medically necessary non-preferred drugs through the Non-formulary Members are encouraged to use generic or preferred brand drugs which are typically less expensive than non-preferred brand drugs. An Open Formulary Plan provides access to To help maximize the value of your prescription generic (tier-one), preferred brand (tier-two), drug benefi t, the names of the preferred formulary and non-preferred brand-name (tier-three) Alternatives
Alternatives
Drug Name
Drug Name
risperidone
oxybutymin, -er
omeprazole, pantoprazole
perindopril
phenytoin
omeprazole, pantoprazole (QLL)
enalapril, lisinopril
alendronate (QLL)
beclomethasone valerate
amphetamine combinations
enalapril, -hctz
eplerenone
estradiol
alendronate (QLL)
fexofenadine, -PSE ER
brimonidine
galantamine, ARICEPT, NAMENDA
zolpidem (QLL)
risperidone
amlodipine (QLL)
fenofi brate
fexofenadine, -PSE ER
ibuprofen, naproxen
tamsulosin
fl uoxetine (QLL)
lisinopril/-hctz, BENICAR HCT (EPA),
fl uticasone nasal spray (QLL)
gabapentin
galantamine, -ER
lisinopril, BENICAR (EPA),
gemfi brozil
risperidone
glimepiride
glipizide, -er
azithromycin
glyburide, -metformin
enalapril, lisinopril
losartan/hctz
clindamycin/benzoyl peroxide
sumatriptan (QLL)
bisoprolol, -hctz
methylphenidate
alendronate (QLL)
metformin
buprenorphine
bupropion, -sr, -xl
levetiracetam
lamotrigine
carvedilol, metoprolol xl
carbidopa/levodopa
ciprofl oxacin, AVELOX
carvedilol
levetiracetam
meloxicam (QLL), nabumetone
levothyroxine
citalopram (QLL)
citalopram (QLL)
simvastatin (QLL), CRESTOR (EPA, QLL),
fexofenadine
lisinopril, -hctz
methylphenidate er
lovastatin (QLL)
carvedilol, metoprolol xl
dorzolamide/timolol
zaleplon (QLL), zolpidem (QLL)
warfarin
gabapentin
losartan
meloxicam (QLL)
venlafaxine
metformin, -er
Alternatives
Alternatives
Drug Name
Drug Name
metoprolol, -xl
metaxalone
pramipexole
mirtazapine
nateglinide
amiodarone
methylphenidate er, CONCERTA
sumatriptan tablets (QLL)
fl uticasone nasal spray (QLL)
fl uticasone nasal spray (QLL)
omeprazole, pantoprazole (QLL)
levothyroxine
tacrolimus
omeprazole
fl uticasone (QLL)
topiramate
ondansetron (QLL)
tramadol, -ER (QLL)
sumatriptan (QLL) + naproxen
fentanyl
triamterene -hctz
tri-sprintec
fenofi brate
tri-sprintec
oxybutynin, -er
valacyclovir
pantoprazole (QLL)
venlafaxine
paroxetine (QLL)
fl uticasone (QLL)
paroxetine, -CR (QLL)
verapamil, -sr
oxybutynin, -er
pravastatin (QLL)
lansoprazole (QLL)
venlafaxine
warfarin
fexofenadine
quinapril, quinaretic
ramipril
zaleplon (QLL)
sumatriptan (QLL), MAXALT/-MLT (EPA,
zolpidem (QLL)
sumatriptan (QLL)
fl uticasone (QLL)
risperidone
risperidone
ropinirole
G: Generics
QLL: Quantity Level Limit
P: Preferred Brands
PAR: Prior Authorization Required
zaleplon (QLL), zolpidem (QLL)
NP: Non-preferred Brands
EPA: Enhanced Prior Authorization
carbamazepine, gabapentin
granisetron, ondansetron
This list is not all-inclusive and does not guarantee coverage. Please risperidone
check your Certifi cate of Coverage for detailed information regarding individual drug coverage, pharmaceutical management procedures, benefi t limitations and exclusions.
The preferred medication list does not apply to Medicare Advantage or risperidone
risperidone
sertraline
simvastatin (QLL)

Source: http://www.lehighcounty.org/Portals/0/Intranet/PDF/HR/CVS_PreferredMedList2011.pdf

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Preventive medications In addition to a healthy lifestyle, preventive medications can help people avoid many illnesses and conditions. A consumer-directed health (CDH) plan that includespreventive medications can help support the goal ofongoing good health. This list provides examples of your plan’s preventivemedications by drug category. This is not an all-inclusive list. Coverage prior t

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