Msn.gcfcu.net

Effective
January 1, 2012
2012 EMPIRE PLAN PREFERRED DRUG LIST
Administered by UnitedHealthcare
The following is a list of the most commonly prescribed generic and brand-name drugs included on the 2012 Empire Plan Preferred Drug List. This is not a complete list of all prescription drugs on the preferred drug list or covered under the Empire Plan. This list is subject to
change due to FDA approval of new brand and generic drugs and product availability. For specific questions about your prescriptions, coverage and copayments, please call The Empire Plan toll free at 1-877-7-NYSHIP (1-877-769-7447) and select The Empire Plan Prescription Drug Program or visit the website at https://www.cs.ny.gov. Click on Benefit Programs, then NYSHIP Online. Provide your group and plan information if prompted. On the resulting NYSHIP Online page, select Using Your Benefits and scroll to the 2012 Empire Plan Preferred Drug List link.
For the enrollee: Enrollees are encouraged to ask their doctors to prescribe generic versions of brand-name drugs whenever
appropriate, as this will result in a lower copayment. Generic medications contain the same active ingredients as their corresponding
brand-name medications, although they may look different in color or shape. They have been FDA-approved under strict standards.
For the physician: Please prescribe Level 1 or generic and Level 2 or preferred products when medically appropriate for your patients.
CARDIOVASCULAR
Pulmonary Artery
Hypertension Agents
Antiarrhythmics
Atacand*½T
Adcirca (PA)
Atacand HCT*
Letairis (PA)
Benicar ½T
Revatio*(PA)
Tracleer (PA)
Tyvaso (PA)
Cardizem LA (g)*
Ventavis (PA)
CENTRAL NERVOUS
Blood Modifiers
Cholesterol Lowering
losartan (generic Cozaar) ½T
Alzheimer’s Disease
losartan with hydrochlorothiazide colestipol Lovenox(g)*
Blood Pressure Lowering
moexipril ½T
pravastatin (generic Pravachol) ½T
simvastatin (generic Zocor) ½T
Multiple Sclerosis
Ampyra (PA)
Avonex (PA)
Crestor ½T
Copaxone (PA)
perindopril (generic Aceon) ½T
Rebif (PA)
Lipitor*
Nausea/Vomiting
Parkinson’s Disease
Heart Failure
Nitrates/Other Angina
trandolapril ½T
Generic Drugs are listed in lower case letters. Brand-name drugs are listed with the first letter of the name capitalized.
The symbol * next to a brand-name drug signifies that this drug may be available as a generic in 2011 or 2012. When a generic version is available, mandatory generic substitution will
apply. Use of a Level 3 or non-preferred brand-name prescription drug when the generic is available will result in the enrollee paying the applicable Level 3 or non-preferred copayment
plus the difference in cost between the brand-name drug and the generic, not to exceed the full retail cost of the drug. The symbol (g) next to a brand-name drug indicates that a
generic is currently available for at least one or more strengths of the brand medication. When a generic is available for a particular strength of the brand-name drug, that strength of the
brand-name drug is Level 3 or non-preferred. The symbol (PA) next to a drug name indicates that prior authorization is required. The symbol ½T next to a drug indicates that certain
strengths may be eligible for the Half Tablet Program.
Seizure Disorder
MUSCLE RELAXANTS
topiramate (generic Topamax) ½T
Dilantin (g)
GASTROINTESTINAL
Gabitril*
GERD/Peptic Ulcer
OPHTHALMIC (EYE)
Tegretol XR (g)*
Glaucoma
DERMATOLOGY/
SKIN DISORDER
adapalene (generic Differin) (PA)
Antifungal Drugs-Oral
itraconazole (PA)
terbinafine (generic Lamisil) (PA)
Gastrointestinal-Other
Other Eye Medications
Antifungal Drugs-Topical
Pancreatic Enzymes
tretinoin (PA)
Ulcerative Colitis
Antiviral Drugs
Condylox (g)*
Dovonex (g)*
valacyclovir (generic Valtrex) ½T
Stelara (PA)
DIABETES
Hepatitis
ribavirin (PA)
GROWTH HORMONES
Nutropin/Nutropin AQ (PA)
Saizen (PA)
Infergen (PA)
Serostim (PA)
Intron-A (PA)
OTIC (EAR)
Tev-Tropin (PA)
Pegasys (PA)
Zorbtive (PA)
Peg-Intron (PA)
INFECTION
PAIN/ARTHRITIS
MIGRAINE HEADACHE
Antibiotics-Oral
Actoplus Met*
Actos*½T
Generic Drugs are listed in lower case letters. Brand-name drugs are listed with the first letter of the name capitalized.
The symbol * next to a brand-name drug signifies that this drug may be available as a generic in 2011 or 2012. When a generic version is available, mandatory generic substitution will
apply. Use of a Level 3 or non-preferred brand-name prescription drug when the generic is available will result in the enrollee paying the applicable Level 3 or non-preferred copayment
plus the difference in cost between the brand-name drug and the generic, not to exceed the full retail cost of the drug. The symbol (g) next to a brand-name drug indicates that a
generic is currently available for at least one or more strengths of the brand medication. When a generic is available for a particular strength of the brand-name drug, that strength of the
brand-name drug is Level 3 or non-preferred. The symbol (PA) next to a drug name indicates that prior authorization is required. The symbol ½T next to a drug indicates that certain
strengths may be eligible for the Half Tablet Program.
fentanyl citrate lollipop (PA)
Depression
Pulmicort Respules (g)*
Asthma-Oral Drugs
Hormone Therapy-Oral
Singulair*
REPLACEMENT
sertraline (generic Zoloft) ½T
Hormone Therapy-Patches
URINARY TRACT
Cimzia (PA)
Benign Prostatic Hyperplasia
capsule (generic Effexor XR)
Enbrel (PA)
Psychosis
Hormone Therapy-
Miscellaneous
Simponi (PA)
PSYCHOTHERAPEUTIC
Erectile Dysfunction
Infertility
Seroquel (except for XR)*½T
Miscellaneous
Anxiety, Insomnia and
Symbyax*
Anticholinergics/
Sedative Agents
Antispasmodics-Other
RESPIRATORY
Allergy-Antihistamines
Osteoporosis
Allergy-Nasal Antihistamines
(generic Astelin)
Allergy-Nasal Corticosteroids
VITAMIN DEFICIENCY
Attention Deficit
Hyperactivity Disorder (ADHD)
Forteo (PA)
Allergy-Other
Other Agents
WEIGHT LOSS
phentermine (PA)
Asthma-Inhaled Drugs
WOMEN’S HEALTH
Contraceptives
Generic Drugs are listed in lower case letters. Brand-name drugs are listed with the first letter of the name capitalized.
The symbol * next to a brand-name drug signifies that this drug may be available as a generic in 2011 or 2012. When a generic version is available, mandatory generic substitution will
apply. Use of a Level 3 or non-preferred brand-name prescription drug when the generic is available will result in the enrollee paying the applicable Level 3 or non-preferred copayment
plus the difference in cost between the brand-name drug and the generic, not to exceed the full retail cost of the drug. The symbol (g) next to a brand-name drug indicates that a
generic is currently available for at least one or more strengths of the brand medication. When a generic is available for a particular strength of the brand-name drug, that strength of the
brand-name drug is Level 3 or non-preferred. The symbol (PA) next to a drug name indicates that prior authorization is required. The symbol ½T next to a drug indicates that certain
strengths may be eligible for the Half Tablet Program.
Examples of Level 3 or Non-Preferred Brand-Name Drugs with 2012 Empire Plan Preferred Drug List Alternatives
Level 3 or Non-Preferred Drugs Empire Plan Preferred Drug List Alternatives
Abilify ½T
olanzapine (generic Zyprexa), risperidone (generic Risperdal), Geodon*, Seroquel (except for XR)*½T
lansoprazole capsule (generic Prevacid capsule), omeprazole (generic Prilosec), omeprazole/sodium bicarbonate capsule (generic Zegerid capsule), pantoprazole (generic Protonix) Avalide*
losartan with hydrochlorothiazide (generic Hyzaar), Atacand HCT*, Benicar HCT, Micardis HCT
Avapro*½T
losartan (generic Cozaar) ½T, Atacand*½T, Benicar ½T, Micardis
ciprofloxacin, levofloxacin (generic Levaquin), ofloxacin doxazosin, finasteride (generic Proscar), tamsulosin (generic Flomax), terazosin amlodipine (generic Norvasc) plus Benicar ½T
Betaseron (PA) Avonex
(PA), Copaxone (PA), Rebif (PA)
amlodipine (generic Norvasc) plus Lipitor*
venlafaxine (generic Effexor), venlafaxine extended release capsule (generic Effexor XR) lansoprazole capsule (generic Prevacid capsule), omeprazole (generic Prilosec), omeprazole/sodium bicarbonate capsule (generic Zegerid capsule), pantoprazole (generic Protonix) Diovan*½T
losartan (generic Cozaar) ½T, Atacand*½T, Benicar ½T, Micardis
Diovan HCT*
losartan with hydrochlorothiazide (generic Hyzaar), Atacand HCT*, Benicar HCT, Micardis HCT
Humatrope (PA) Nutropin
(PA), Nutropin AQ (PA), Saizen (PA), Tev-Tropin (PA)
Humira (PA) Cimzia
(PA), Enbrel (PA), Simponi (PA), Stelara (PA)
Lexapro*½T
citalopram (generic Celexa), fluoxetine (generic Prozac), paroxetine (generic Paxil), paroxetine sustained release 24 hour (generic Paxil CR), sertraline (generic Zoloft) ½T, venlafaxine
(generic Effexor), venlafaxine extended release capsule (generic Effexor XR) zaleplon (generic Sonata), zolpidem (generic Ambien) lansoprazole capsule (generic Prevacid capsule), omeprazole (generic Prilosec), omeprazole/sodium bicarbonate capsule (generic Zegerid capsule), pantoprazole (generic Protonix) Norditropin (PA) Nutropin
(PA), Nutropin AQ (PA), Saizen (PA), Tev-Tropin (PA)
estradiol, estropipate, Cenestin, Enjuvia estradiol/norethindrone (generic Activella), Prefest estradiol/norethindrone (generic Activella), Prefest Provigil*(PA)
amphetamine with dextroamphetamine salt combination, amphetamine with dextroamphetamine salt combination extended release (generic Adderall XR), dextroamphetamine, methylphenidate Retin-A Micro (PA) tretinoin
simvastatin (generic Zocor) ½T plus Niaspan
amphetamine with dextroamphetamine salt combination extended release (generic Adderall XR), Tazorac*(PA)
adapalene (generic Differin) (PA), tretinoin (PA)
fenofibrate, Antara, Fenoglide, Lipofen, Triglide flunisolide, fluticasone (generic Flonase), Nasonex Xopenex Inhalation Solution (g)*
lovastatin, pravastatin (generic Pravachol) ½T, simvastatin (generic Zocor) ½T, Crestor ½T,
Lipitor*, Vytorin, Welchol
Generic Drugs are listed in lower case letters. Brand-name drugs are listed with the first letter of the name capitalized.
The symbol * next to a brand-name drug signifies that this drug may be available as a generic in 2011 or 2012. When a generic version is available, mandatory generic substitution will
apply. Use of a Level 3 or non-preferred brand-name prescription drug when the generic is available will result in the enrollee paying the applicable Level 3 or non-preferred copayment
plus the difference in cost between the brand-name drug and the generic, not to exceed the full retail cost of the drug. The symbol (g) next to a brand-name drug indicates that a
generic is currently available for at least one or more strengths of the brand medication. When a generic is available for a particular strength of the brand-name drug, that strength of the
brand-name drug is Level 3 or non-preferred. The symbol (PA) next to a drug name indicates that prior authorization is required. The symbol ½T next to a drug indicates that certain
strengths may be eligible for the Half Tablet Program.

Source: http://msn.gcfcu.net/media/9837/2012-Empire-Plan-Preferred-Drug_List.pdf