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3-Tier Drug List

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3-Tier Drug List Medications covered by MESSA Choices with 3-Tier Rx and MESSA ABC with 3-Tier Rx with and without mandatory mail Use this list to find information about drug coverage and therapeutic options. This list is ordered alphabetically and includes generic and brand name drugs. Drugs are identified according to their tier placement; prior authorization (PA), step therapy (ST) or quantity limit (QL) requirements are noted where applicable. We encourage you to talk to your doctor to find the right drug therapies that your health plan covers. This chart contains tier information for Choices plans and ABC plans. Please refer to the appropriate column for medication details. If your 3-Tier Rx plan includes mandatory mail, please refer to the list of long-term maintenance medications requiring home delivery to see if your drug requires home delivery. Up to 34-day supply 90-day supply Specific preventive medications are covered 100 No cost to you No cost to you percent with no deductible required. Age and gender limits apply. ***ABC plans have a list of specific preventive medications in addition to those mandated by federal law. Tier 1 $10 copayment $25 copayment Generics Tier 2 20 percent coinsurance 20 percent coinsurance Most brand drugs with no generic equivalent $40 minimum - $80 maximum $100 minimum - $200 maximum Tier 3 20 percent coinsurance 20 percent coinsurance Most brand drugs with a generic equivalent or $60 minimum - $100 maximum $150 minimum - $250 maximum therapeutic alternative Note: The amount you pay for brand name medications varies because coinsurance is based on the price of the drug when it is filled. If you obtain a Tier 3 drug when a Tier 1 drug is available, you will pay the Tier 3 coinsurance plus the difference in cost between the Tier 1 drug and the Tier 3 drug. These drugs are identified with an asterisk (*) in the list below. A drug may switch from one tier to another. Up to a 90-day supply of insulin may be obtained for the same payment as a 34-day supply from any in-network provider. This list is current as of November 13, 2017. It is subject to change without notice. If you have a question about any drug, call MESSA Member Services at 800.336.0013. Drug name Category of drug Choices Tier ABC Tier Limits Generic equivalent if available 8-Mop* Antipsoriatic and antiseborrheic 3 3 None Methoxsalen Aa/Antpy/Bcaine/Polico/Al Acet Otic preparations 1 1 None This medication is generic Abacavir HIV 1 1 None This medication is generic Abacavir Sulfate Antiretrovirals 1 1 None This medication is generic Abacavir Sulfate/Lamivudine Antiretrovirals 1 1 None This medication is generic Abacavir/Lamivudine/Zidovudine Antiretrovirals 1 1 None This medication is generic Abilify* Antipsychotics 3 3 None Aripiprazole Absorica Acne treatment 3 3 ST No generic available Abstral Narcotics 3 3 PA, QL No generic available Acamprosate Calcium Miscellaneous CNS 1 Free As None This medication is generic Preventive Acanya Acne treatment 3 3 None No generic available Acarbose Non-insulin hypoglycemic agents 1 1 None This medication is generic Accolate* Miscellaneous respiratory agents 3 3 QL Zafirlukast Accuneb; Albuterol nebulizer solution* Inhaled beta-agonists 3 3 None Albuterol Sulfate Accupril* ACE-Inhibitors and combinations 3 3 None Quinapril Hcl Accuretic* ACE-Inhibitors and combinations 3 3 None Quinapril/Hydrochlorothiazide Acebutolol Hcl Beta blockers and combinations 1 Free As None This medication is generic Preventive Aceon* ACE-Inhibitors and combinations 3 3 None Perindopril Erbumine Acetasol HC; Vosol HC* Otic preparations 3 3 None Acetic Acid/Hydrocortisone Acetazolamide Anticonvulsants/Diuretic 1 1 None This medication is generic Acetic Acid Otic preparations 1 1 None This medication is generic Acetic Acid/Aluminum Acetate Otic preparations 1 1 None This medication is generic Acetic Acid/Hydrocortisone Otic preparations 1 1 None This medication is generic Acetylcysteine Miscellaneous respiratory agents 1 1 None This medication is generic Aciphex Sprinkle Proton Pump Inhibitors (PPI) 3 3 ST, QL No generic available Aciphex* Proton Pump Inhibitors (PPI) 3 3 None Rabeprazole Sodium Acitretin Antipsoriatic and antiseborrheic 1 1 None This medication is generic Aclovate* Corticosteroids - low potency 3 3 None Alclometasone Dipropionate Actemra syringe Non-Tumor Necrosis Factor (TNF) 3 3 PA, QL No generic available blocking agents Acthar H.P. Anticonvulsants 3 3 PA, QL No generic available Acticlate 150mg Tetracyclines, Acne Treatment 3 3 PA, QL Doxycycline Hyclate Acticlate 75mg Tetracyclines, Acne Treatment 3 3 PA, QL Doxycycline Hyclate Actigall* Bile acids 3 3 None Ursodiol Actimmune Interferons and MS therapy 2 2 None No generic available Actiq* Narcotics 3 3 PA, QL Fentanyl Citrate Activella* Estrogen and progestin combinations 3 3 None Estradiol/Norethindrone Acet Updated 11/13/2017 Drug name Category of drug Choices Tier ABC Tier Limits Generic equivalent if available Actonel* Osteoporosis and bone resorption 3 3 ST, QL Risedronate Sodium Actoplus MET XR Non-insulin hypoglycemic agents 3 3 None No generic available Actoplus MET* Non-insulin hypoglycemic agents 3 3 None Pioglitazone Hcl/Metformin Hcl Actos* Non-insulin hypoglycemic agents 3 3 None Pioglitazone Hcl Acular, LS* Ophthalmic anti-inflammatory agents 3 3 None Ketorolac Tromethamine Acuvail Ophthalmic anti-inflammatory agents 3 3 None No generic available Acyclovir Antivirals 1 1 None This medication is generic Aczone 5% Acne treatment 3 3 None No generic available Adacel Vaccines Free As Free As None No generic available Preventive Preventive Vaccine Vaccine Adapalene Acne treatment 1 1 None This medication is generic Adapalene 0.1% lotion Acne treatment 3 3 None No generic available Adapalene-Benzoyl Peroxide Acne treatment 1 1 None This medication is generic Adapin; Sinequan* Antidepressants 3 3 None Doxepin Hcl Adcirca Pulmonary Hypertension Agents 2 2 PA, QL No generic available Adderall XR* CNS stimulants 3 3 QL Amphet Asp/Amphet/D-Amphet Adderall* CNS stimulants 3 3 QL Amphet Asp/Amphet/D-Amphet Addyi Sexual Dysfunction 3 3 PA, QL No generic available Adefovir Dipivoxil Antivirals 1 1 None This medication is generic Adempas Pulmonary Hypertension Agents 2 2 PA, QL No generic available Adipex, P* Weight Loss Preparations 3 3 None Phentermine Hcl Adoxa capsule* Tetracyclines/Acne treatment 3 3 PA Doxycycline Monohydrate Adoxa tablet* Tetracyclines/Acne treatment 3 3 PA Doxycycline Monohydrate Adrenalin chloride nasal Epinephrine 3 3 None No generic available Advair Inhaled steroid and beta-agonist 2 2 QL No generic available combinations Adzenys XR-ODT CNS stimulants 3 3 ST, QL No generic available Aerospan Inhaled steroids 3 3 QL No generic available Afinitor, Disperz Kinase inhibitors and molecular target 2 2 QL No generic available inhibitors Afluria, Quad Vaccines Free As Free As None No generic available Preventive Preventive Vaccine Vaccine Afrezza Insulins 3 3 PA No generic available Aggrenox* Anticoagulants and hemostasis agents 3 3 None Aspirin/Dipyridamole Agrylin* Anticoagulants and hemostasis agents 3 3 None Anagrelide Hcl Akynzeo Antiemetics 3 3 PA, QL No generic available Ala-Scalp HP* Corticosteroids - low potency 3 3 None Hydrocortisone Albalon* Miscellaneous ophthalmic agents 3 3 None Naphazoline Hcl Albenza Antiparasitics and anthelmintics 2 2 QL No generic available Albuterol Sulfate Oral beta-agonists/inhaled beta- 1 1 None This medication is generic agonists Alclometasone Dipropionate Corticosteroids - low potency 1 1 None This medication is generic Aldactazide 50/50mg Diuretics 3 Free As None No generic available Preventive Aldactazide* Diuretics 3 3 None Spironolact/Hydrochlorothiazid Aldactone* Diuretics 3 3 None Spironolactone Aldara* Topical antineoplastic agents and 3 3 None Imiquimod immunomodulators Aldomet* Alpha-adrenergic agents 3 3 None Methyldopa Aldoril* Alpha-adrenergic agents 3 3 None Methyldopa/Hydrochlorothiazide Alecensa Kinase inhibitors and molecular target 2 2 PA, QL No generic available inhibitors Alendronate Sodium Osteoporosis and bone resorption 1 1 QL This medication is generic Alesse, Levlite* Contraceptives-Monophasic 3 3 None Levonorgestrel-Eth Estra Alferon N Interferons and MS therapy 2 2 None No generic available Alfuzosin Hcl BPH Treatment 1 1 None This medication is generic Alinia Antiparasitics and anthelmintics 2 2 None No generic available Alkeran tablet Alkylating agents 2 2 None Melphalan tablet Allopurinol Gout therapy 1 1 None This medication is generic Almotriptan Malate Migraine therapy 1 1 ST, QL This medication is generic Updated 11/13/2017 Drug name Category of drug Choices Tier ABC Tier Limits Generic equivalent if available Alocril Ophthalmic anti-allergy agents 2 2 None No generic available Alogliptin Non-insulin hypoglycemic agents 3 3 ST, QL No generic available Alogliptin-metformin Non-insulin hypoglycemic agents 3 3 ST, QL No generic available Alogliptin-pioglitazone Non-insulin hypoglycemic agents 3 3 ST, QL No generic available Alomide Ophthalmic anti-allergy agents 2 2 None No generic available Alora Estrogens/Osteoporosis and hormonal 2 2 QL No generic available treatment Alosetron Hcl Miscellaneous gastrointestinal agents 1 1 None This medication is generic Alphagan 0.2%, P 0.15%* Glaucoma agents 3 3 None Brimonidine Tartrate Alphagan P 0.1% Glaucoma agents 2 2 None No generic available Alprazolam Anxiolytics 1 1 None This medication is generic Alrex Ophthalmic steroids 3 3 None No generic available Alsuma* Migraine therapy 3 3 QL Sumatriptan Succinate Altabax Topical
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