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Generic Premium Member education Generic Premium With Generic Premium, you have coverage for low-cost generic drugs, plus some of the most common brand drugs. That means you can get the medicine you need, while saving money. Member education What is Generic Premium? How does Generic Premium work? Generic Premium can help you lower your prescription costs Talk to your doctor before you switch or stop taking any by covering most generic drugs. Some brand drugs are drugs. If you and your doctor agree that a covered drug is a covered by Generic Premium too. They include drugs that good option, you’ll need a new prescription. You can choose treat common conditions like high blood pressure, diabetes, to fi ll the prescription through home delivery or at a local high cholesterol, ulcers and more. So you can choose from a pharmacy. wide range of quality drugs. * Required by the U.S. Food and Drug Administration (FDA). Generics can help you save Generic Premium encourages you to use generic drugs. Why? Generics and their brand versions have the same active ingredient, strength and dose. Generics must meet the same high standards for purity, quality, safety and strength.* Plus, generics normally cost 30 to 60% less than the brand versions. With generics, you get the same quality for less money. Drug coverage at a glance The Generic Premium drug list includes products used for the health needs and conditions below, plus many more. See the next pages for a list of covered drugs. • Attention defi cit hyperactivity • High cholesterol disorder (ADHD) • Infections • Arthritis • Osteoporosis • Asthma • Overactive bladder • Birth control • Pain • Depression • Prenatal vitamins • Diabetes drugs and supplies • Seizures • Enlarged prostate • Sleep aids • Glaucoma • Ulcers • High blood pressure 2 | Generic Premium Generic drugs are listed in all ST = Step therapy is needed. lowercase letters. You may need to try another drug before we’ll provide coverage for Brand drugs are listed with a first the medicine. capital letter. DO = Dose optimization is needed. TIER 1 amlodipine besylate (Norvasc)* Tier 1 drugs have the lowest This usually means that you take DO QL copay. Many Tier 1 drugs are the drug once a day instead of contraceptives – all prescription generics. amlodipine besylate/atorvastatin twice a day. strength, self administered generic (Caduet)* contraceptives Tier 2 drugs have a medium copay * Generic versions of these drugs amlodipine besylate/benazepril cough and cold preparations – and offer a good value. are covered. The brand name in (Lotrel)* all prescription strength, self parenthesis is only for reference. administered, generic cough and amoxapine (Asendin)* Tier 3 drugs have the highest cold preparations amoxicillin trihydrate (Amoxil, copay. Many of these drugs treat ^ These drugs often require your pancreatic enzymes – all prescription Trimox, various)* complex, ongoing conditions and doctor to carefully monitor your may require special handling. strength, self administered, generic amoxicillin trihydrate/potassium dose to make sure the drug pancreatic enzymes clavulanate, ER (Augmentin, XR)* works best for you. In general, PA = Prior authorization is needed. PKU – all prescription strength, self you shouldn’t switch between amphetamine salt combo In this case, you must receive administered, generic PKU formulas (Adderall)* the brand and generic versions approval before the drug vitamins – all prescription strength, of these drugs. Your plan covers ampicillin trihydrate (Principen)* is covered. self administered, generic vitamins both the brand and generic anagrelide hcl (Agrylin)* versions. QL = Quantity limits are needed. antipyrine/benzocaine/glycerin Some drugs have limits on the (Auralgan)* † Once a generic is available, amount you receive for each acarbose (Precose)* aspirin/codeine phosphate the brand version will not prescription or each month. be covered. acebutolol hcl (Sectral)* atovaquone/proguanil acetaminophen/caffeine/butalbital (Malarone)* Key (Fioricet)* QL atenolol (Tenormin)* acetaminophen/codeine (Tylenol w/ atenolol/chlorthalidone Codeine)* QL (Tenoretic)* bromfenac (Xibrom)* carvedilol (Coreg)* acetaminophen/Phenyltoloxamine atorvastatin (Lipitor)* DO, QL budesonide EC (Entocort EC)* cefaclor (Ceclor, Ceclor CD)* (Dologesic, various)* atropine sulfate (Isopto Atropine)* bromocriptine mesylate (Parlodel)* cefadroxil hydrate (Duricef)* acetazolamide (Diamox)* azathioprine (Imuran)* bumetanide (Bumex)* cefdinir (Omnicef)* acetic acid (VoSol)* azelastine (Optivar)* QL buprenorphine (Subutex)* QL cefpodoxime proxetil (Vantin)* acetic acid/aluminum acetate azelastine (Astelin Nasal)* QL (Domeboro)* bupropion hcll (Wellbutrin, cefprozil (Cefzil)* azithromycin (Zithromax)* QL acetic acid/hydrocortisone Wellbutrin SR)* cefuroxime axetil (Ceftin)* bacitracin/polymyxin b sulfate (VoSol HC)* bupropion HCl (Wellbutrin XL)* DO, QL cephalexin monohydrate (Keflex)* (Polysporin Ointment)* (XL only) acetylcysteine (Mucomyst)* chloral hydrate (Somnote)* baclofen (Lioresal)* buspirone HCl (Buspar)* acyclovir (Zovirax)* chlordiazepoxide hcl (Librium)* balsalazide disodium butalbital/acetaminophen/caffeine adapalene (Differin)* chlorhexidine gluconate (Peridex)* belladonna alkaloids/phenobarbital (Esgic-Plus)* chloroquine phosphate (Aralen)* albuterol sulfate (Proventil)* (Donnatal)* butalbital/aspirin/caffeine (Fiorinal)* chlorothiazide (Diuril)* albuterol/ipratropium nebulizer soln benazepril hcl (Lotensin)* butorphanol (Stadol)* (Duoneb)* chlorpromazine hcl (Thorazine)* benazepril/hydrochlorothiazide cabergoline (Dostinex)* alclometasone dipropionate (Lotensin HCT)* chlorpropamide (Diabinese)* (Aclovate)* calcipotriene (Dovonex Oint.)* benzonatate (Tessalon Perles)* chlorthalidone (Hygroton)* alendronate (Fosamax)* QL captopril (Capoten)* benzoyl peroxide (Benzagel, chlorzoxazone (Parafon Forte DSC)* alfuzosin (Uroxatral)* captopril/hydrochlorothiazide Benzac AC, various)* (Capozide)* cholestyramine/aspartame allopurinol (Zyloprim)* benztropine mesylate (Cogentin)* carbamazepine (Carbatrol, Tegretol, (Questran Light)* alprazolam, ER (Xanax, Xanax XR)* betamethasone dipropionate Epitol)^ cholestyramine/sucrose (Questran)* amantadine hcl (Symmetrel)* (Diprosone, Diprolene, Diprosone)* carbamazepine, ER (Tegretol XR)* choline salicylate/magnesium amcinonide (Cyclocort)* betamethasone valerate (Betatrex)* carteolol (Ocupress)* salicylate (Tricosal)* amiloride (Midamor)* betametheasone dipropionate/ carbidopa/levodopa (Sinemet, ciclopirox (Loprox Shampoo)* propylene glycol (Diprolene AF)* amiloride/hydrrocholorthiazide Sinemet CR)* ciclopirox (Penlac)* (Moduretic)* betaxolol hcl (Betoptic)* carbidopa/levodopa/entacapone cilostazol (Pletal)* aminophylline bethanechol chloride (Urecholine)* (Stalevo)* cimetidine – prescription only amiodarone hcl (Cordarone, bisoprol/hydrochlorothiazide (Ziac)* carisoprodol (Soma)* (Tagamet)* Pacerone)^ bisoprolol fumarate (Zebeta)* carisoprodol/aspirin (Soma ciprofloxacin hcl (Cipro)* QL amitriptyline hcl (Elavil)* brimonidine tartrate (Alphagan)* Compound)* ciprofloxacin hcl drops (Ciloxan)* Generic Premium | 3 citalopram hydrobromide desoximetasone (Topicort)* erythromycin base (Ilotycin)* fluoxetine hcl 10, 20, 40mg only (Celexa)* DO, QL dexamethasone (Decadron)* erythromycin base/benzoyl peroxide (Prozac)* DO, QL citric acid/potassium citrate dexamethasone sodium phosphate (Benzamycin)* fluphenazine hcl (Prolixin)* (Polycitra - 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