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Presbyterian Health Plan
Presbyterian Insurance Company, Inc.
Commercial 4 Tier/PIC Preferred Drug Listing TIER 1 Preferred Generic Drugs Covered at a First Tier Copayment (some medications may be excluded as determined by benefit)
TRETINOIN TOPICAL (AG)VENLAFAXINE ER CAP (ST) TIER 2 Preferred Brand Drugs Covered at a Second Tier Copayment (some medications may be excluded as determined by benefit)
This Listing is not all inclusive nor does it imply a guarantee of coverage, but it represents an abbreviation of the drug Listinging. Substitution of generic products is mandatory when a generic is available. If brand name is desired, member pays the difference in cost between the brand and the generic drug. PRIOR AUTHORIZATION MAY BE REQUIRED.
Continued
TIER 3 Non-Preferred Drugs Covered at a Third Tier Copayment (some medications may be excluded as
determined by benefit)
ABILIFY DISCMELT (PA)
This Listing is not all inclusive nor does it imply a guarantee of coverage, but it represents an abbreviation of the drug Listinging. Substitution of generic products is mandatory when a generic is available. If brand name is desired, member pays the difference in cost between the brand and the generic drug. PRIOR AUTHORIZATION MAY BE REQUIRED.
Tier 4 Non-Preferred Drugs Covered at a Fourth Tier Copayment (some medications may be excluded as
determined by benefit)
This Listing is not all inclusive nor does it imply a guarantee of coverage, but it represents an abbreviation of the drug Listinging. Substitution of generic products is mandatory when a generic is available. If brand name is desired, member pays the difference in cost between the brand and the generic drug. PRIOR AUTHORIZATION MAY BE REQUIRED.
DISCLAIMER
Please be sure a Prescription Drug benefit is part of your specific coverage before consulting this list. If you do not know which list is correct,
please contact the Presbyterian Customer Service Center at (505) 923-5678 or toll-free at 1-800-356-2219, Monday through Friday from 7:00
a.m. to 6:00 p.m. TTY users may call 1-877-298-7407.
Coverage for some drugs may be limited to specific dosage forms and/or strengths. Your benefit design determines what is covered for you and
what your copayment will be. Additional limitations or exclusions may apply for members of Presbyterian Individual Plans. Please refer to your
benefit materials for your specific coverage information.The medications listed on this Formulary/Preferred Drug Listing (PDL) are subject to
change pursuant to the Formulary/PDL management activities of Presbyterian Health Plan. This list is not all-inclusive nor does it imply a
guarantee of coverage. In addition, coverage for some drugs listed may be limited to specific dosage forms and/or strengths. Substitution of a
generic product for a brand-name drug is mandatory when a generic equivalent is available. If a member requests the brand-name drug in this
situation, a prior authorization may be required and the member must pay the difference in cost between the generic and branded versions. Non-
formulary medications are not considered for coverage unless trial and failure of formulary alternatives are documented.
EXPLANATION OF INDICATORS
You will see these indicators next to some drug names:
1. Prior Authorization (PA) -- a drug that requires prior approval before the Plan will cover it, and when the patient meets the established
criteria. The doctor must submit a Pharmacy Prior Authorization Form. The doctor can submit the request by fax, phone, or regular mail.
2. Step Edit (ST) -- a drug that requires a prescription history of specific drugs in the pharmacy claims or data system, and these specific drugs
must be taken during a given time frame. After the specific drugs have been taken within the given time frame, online coverage of the newly-
prescribed drug occurs at the pharmacy. Step Edits make it easier to access drugs that would normally require a Prior Authorization.
3. Medical Exception -- a drug that is not on the Plan’s formulary. Non-formulary drugs require an Exception to the formulary due to al ergy,
adverse reactions, or no response to all formulary drugs.
4. Quantity Limit (QL) -- a coverage limit on the medication quantity covered for a defined days' supply (usually 30 or 90 days) based on safety,
efficacy and/or dose optimization issues.
5. Age Limitation (AG) -- a coverage limit based on minimum or maximum age of the member imposed as a result of safety, efficacy or dosage
form considerations.
6. Specialty (SP) -- Tier 4 medications obtained through the pharmacy benefit. Tier 4 medications are defined as high cost (greater than $600
per 30 day supply) injectable, infused, oral or inhaled drugs that generally require complex care and supervision. These medications involve
unique distribution and are usually provided by a specialty pharmacy vendor. Specialty pharmaceuticals are self-administered, meaning they are
administered by the patient or to the patient by a family member or caregiver. Non-formulary medications, when approved by prior authorization,
may be subject to specialty pharmacy requirements.
7. Medical Drugs (MED) -- Medications obtained through the medical benefit. Medical drugs are defined as medications administered in the
office or facility that require a health care professional to administer. These medications include, but are not limited to, injectable, infused, oral or
inhaled drugs. They may involve unique distribution and may be provided by a specialty pharmacy vendor. Some Medical Drugs may require
Benefit Certification before they can be obtained. Office administered applies to all outpatient settings including, but are not limited to, physician's
offices, emergency rooms, urgent care facilities and outpatient surgery facilities. For a complete list of Medical Drugs and to determine which
require Benefit Certification please see the Presbyterian Pharmacy web site at: http://www.phs.org/PHS/programs/pharmacy/formulary/index.htm
* = Generic preferred/ Generic equivalent available.

Source: http://benefits.nmsu.edu/wp-content/uploads/sites/15/2013/04/B_I_Presbyterian_Formulary-Alphabetical.pdf