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Commonly prescribed medications from empire’s formulary

Effective August 2006
Commonly Prescribed Medications from Empire’s Formulary
To assist you in making informed choices regarding your prescription drug plan, we are providing you with this abbreviated version of Empire’sformulary, our preferred drug list. Empire’s formulary is developed by our Pharmacy and Therapeutics Committee. This committee regularlyreviews and selects new and existing drugs to ensure the formulary remains responsive to the needs of our members. All formulary drugs havebeen approved by the Food and Drug Administration (FDA).
Choosing drugs from the formulary can lower a member’s cost and save money every time a prescription is filled because
formulary drugs have lower co-payments.

How members can save on prescription costs:
• Ask your physician to prescribe drugs on Empire’s formulary and be sure to bring the formulary with you to every doctor visit.
• Ask your physician to consider prescribing generic substitutions whenever possible. Generics result in lower costs to you. All generic drugs are approved by
the FDA; they are as effective as their brand-name alternatives and meet the same quality and safety standards.
• Keep in mind that brand-name drugs not on this list will generally cost you the most money.
How your Empire pharmacy coverage works:
Every time you fill a covered prescription, you pay a co-pay amount. Co-payment amounts may appear next to either “Rx” or “Rx Co-Pay” on
your member ID card. If you do not see any co-payments indicated, please refer to your benefits materials.
ID cards issued prior to July 2005 look like this:
ID cards issued after July 2005 look like this:
If your plan has 3 co-payment amounts, you will pay the lowest amount for generic drugs, the middle amount for brand-name drugs
listed on the formulary and the highest amount for brand-name drugs not listed on the formulary.
If your plan has only 2 co-payment amounts, you will pay the lower amount for generic drugs and the higher amount for brand-
name drugs listed on the formulary. Check your benefit materials to see whether your plan covers brand-name drugs not listed on the formulary.
If your plan does cover drugs not listed on the formulary, then you will pay the higher amount for those.
The formulary is subject to change, so to get the most up-to-date and complete medication listings:
• Empire members can register or log on to Member Online Services at www.empireblue.com. From your secure, personalized home page, link to the Pharmacy.
• If you are not yet a registered Empire member, simply go to www.empireblue.com and click on “Search the Formulary.”
• If you do not have Internet access, you can call Member Services at the phone number on the back of your member ID card.
Important:
• Certain drugs require prior authorization by Empire before you fill a prescription. They are noted on this list as “PAR” (prior authorization required). Some drugs have
quantity limits and require authorization only if a prescription is written for more than the monthly allowed amount. They are noted as “QL” (quantity limit) on thislist. Your physician or pharmacist can request any required authorization by calling Empire Pharmacy Services at the Member Services phone number listed on theback of your member ID card. If the PAR drug or the additional quantity of a drug is approved, it will be covered under Empire’s pharmacy plan.
• In order for certain specialty injectable medications to be covered under Empire’s pharmacy plan, prescriptions for these medications must be filled by Caremark Specialty Pharmacy Services. Those particular medications are listed with the symbol SRx next to them. For further information regarding filling a prescription withCaremark Specialty Pharmacy Services, call toll free 1-866-295-2779, Monday - Friday, 8:00 a.m. – 7:00 p.m. EST.
• Some generic and/or brand-name drugs included in this formulary may not be covered by all health plans. Please check your benefit materials or contact customer service for coverage details under your specific plan.
How to use this list:
• Brand-name drugs start with the first letter of their name in a capital letter, e.g., “Altace.”
• Generic drugs appear all in lower case letters, e.g.,”atenolol.”
For questions regarding our pharmaceutical policies and procedures or if you would like additional copies of this list, please call EmpirePharmacy Services at the Member Services phone number on the back of your member ID card Monday – Friday, 7:00 a.m. – 10:00 p.m.;Saturday 9:00 a.m. – 9:00 p.m.; Sunday 9:00 a.m. – 5:30 p.m. EST.
Legend:
PAR
– prior authorization required
SRx – prescription must be filled through Caremark Specialty Pharmacy Services
QL – quantity limit
Commonly Prescribed Medications from Empire’s Formulary
Blood Pressure Lowering
Miscellaneous
Alzheimer's Disease
Multiple Sclerosis
Diabetic Supplies
Parkinson's Disease
GERD/Peptic Ulcer
Antiarrhythmics
Gastrointestinal Spasm
Seizure Disorder
Cholesterol Lowering
Pancreatic Enzymes
ARB/Heart Failure
Ulcerative Colitis
Blood Modifiers
Diabetic Medications
Miscellaneous
Nitrates
Commonly Prescribed Medications from Empire’s Formulary
Other Medications
Antibiotics-Oral
Phosphate Binders
Antiviral Drugs
Antifungal Drugs-Oral
Antifungal Drugs-Topical
Hepatitis
Glaucoma
Antibiotics-Topical
HIV/AIDS
Anti-Infectives
Commonly Prescribed Medications from Empire’s Formulary
Insomnia
Asthma-Oral Drugs
Psychosis
Attention Deficit
Hyperactivity Disorder
Benign Prostatic
Hyperplasia (BPH)
Allergy-Antihistamines
Erectile Dysfunction
Allergy-Antihistamines/
Decongestants
Miscellaneous
Allergy-Decongestants/
Depression
Expectorants
Minerals & Electrolytes
Allergy-Nasal
Corticosteroids
Allergy-Nasal Antihistamine
Asthma-Inhalers
Commonly Prescribed Medications from Empire’s Formulary
Prenatal Vitamins
Hormone Therapy-
The drug names listed here are theregistered and/or unregistered trademarks Miscellaneous
unrelated to and unaffiliated with Empire.
Infertility
intended to imply or suggest any affiliation Hormone Therapy-Oral
Contraceptives
Osteoporosis
Hormone Therapy-Patches
Commonly Prescribed Medications from Empire’s Formulary
Formulary and Over-the-Counter Alternatives to Empire’s Top Non-Formulary Medications
Non-Formulary Medication

Formulary and OTC Alternatives
amphetamine/dextroamphetamine mixed salts, methylphenidate extended-release,dextroamphetamine extended-release Concerta, Strattera* benzoyl peroxide with erythromycin Benzamycin Pak, DUAC Clarinex^*, Clarinex-D^*, Clarinex Syrup^* loratadine OTC, loratadine/pseudoephedrine OTC Alavert OTC, Alavert D OTC, Claritin OTC, Claritin-D OTC diclofenac, etodolac, meloxicam*, nabumetone, oxaprozin citalopram*, fluoxetine*, paroxetine* Effexor, Effexor XR*, Lexapro*, Paxil CR*, Wellbutrin XL*, Zoloft* albuterol inhalation solutionProventil inhalation solution Glycolax, Polyethylene Glycol 3350 Powder lovastatin*, pravastatin*, simvastatin*Crestor*, Lipitor* loratadine OTC, loratadine/pseudoephedrine OTCAlavert OTC, Alavert D OTC, Claritin OTC, Claritin-D OTC Brand name drugs start with the first letter of their name in a capital letter, e.g., "Ambien."Generic drugs appear all in lower case letters, e.g., “flurazepam.”OTC (over-the-counter) medications do not require a prescription for purchase and are available at drug stores, food markets, convenience stores and many other types of retailstores. They are not covered by your pharmacy plan.
^Prior Authorization Required*Quantity Limitation Commonly Prescribed Medications from Empire’s Formulary
Quantity Limitations (QL)
* Non-formulary
Please refer to your benefits to determine whether this list applies to your coverage. This list is subject to change at any time. For the most up-to-date listings,
visit www.empireblue.com.
Commonly Prescribed Medications from Empire’s Formulary
Prior Authorization Required (PAR)
* Non-formulary
Please refer to your benefits to determine whether this list applies to your coverage. This list is subject to change at any time. For the most up-to-date listings,
visit www.empireblue.com.
Services provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association, anassociation of independent Blue Cross and Blue Shield Plans.

Source: http://insuranceny.net/BlueCrossFormularyList1206.pdf

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