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Regencerx Preferred Medication List/Formulary Regencerx Preferred Effective February 1, 2008 ©2008

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Regencerx Preferred Medication List/Formulary Regencerx Preferred Effective February 1, 2008 ©2008 RegenceRx Preferred Medication List/Formulary Help to stretch your prescription dollar February1, 2008 ©2008. RegenceRx. All Rights Reserved. ©2008. RegenceRx. Effective February 1,2008 Effective 2 Your Preferred Medication List/Formulary 3 Common Questions and Answers Preferred/Formulary Medications 4-11 • By Category • A to Z Listing 12-17 – Generics 18-22 – Preferred/Formulary Brands Non-Preferred/Non-Formulary Brands 23-27 • Generic and Preferred Brand Alternatives Table of Contents Table Effective February 1, 2008 ©2008. RegenceRx. All Rights Reserved. RegenceRx is dedicated to provide the tools you need to understand your options and be a more informed consumer. This preferred medication list/formulary will help—with the answers you need to access affordable prescription benefits. Determining Cost Newly-introduced How much you pay for a prescription generic medications depends on whether it’s a: When a generic is introduced to the • Generic marketplace, it immediately becomes • Preferred/formulary brand name available at the lowest copay. After a • Non-preferred/non-formulary generic is available, the brand name brand name (brand name medication will only be available at the medication not on the list) non-preferred/non-formulary copay. Your cost is lowest for generic Preferred/formulary medications and highest for non- brand name medications preferred/non-formulary brand name Brand name medications on the medications. You can find specific preferred medication list (PML) coverage and copay information in have been chosen because our your summary of benefits. professional review has shown each Generic medications of them to be high-quality, effective, Generics provide the same and affordable. Preferred/formulary therapeutic benefits of their brand brand name medications are either name counterparts, without the more effective or equally effective—at brand name price. In fact, generic a lower cost—than other brand name medications are generally 20-60% medications not listed. less expensive. The U.S. Food and Non-preferred/non-formulary Drug Administration assures both brand name medications generic and brand name medications Non-preferred/non-formulary brand meet the same high standards for name medications are those that do strength, quality, and purity. not appear on the PML due to side effects, therapeutic performance, or higher cost. You may still opt for these medications, but your copay will be higher than any other prescription type. Effective February 1, 2008 ©2008. RegenceRx. All Rights Reserved. How can I use the PML/formulary What if my medication needs to get the best benefit? prior authorization? Ask your doctor to prescribe Certain medications may need prior generic medications whenever authorization. This means that we possible. If a generic is not available, will need to review information from ask your doctor to choose a your doctor before the medication preferred/formulary brand name can be approved for coverage. For a medication. Take this list when you list of medications that need prior go to the doctor so you can discuss authorization, please visit our Web your options. site at www.regencerx.com or contact our Customer Service How can I tell if a listed medication Department at the phone number is a generic? listed on your member card. Generic medications are listed If you decide to purchase the in lower case bold, like this: medication without authorization, you fluconazole. will be responsible for the total cost of the prescription. How can I tell if a listed medication is a brand? What resources were used to Brand name medications start with determine what medications would a capital letter and are followed by be on the PML/formulary? a registered trademark symbol like Information from the US Food and this: ®. Drug Administration (FDA), medical Brand name medications listed in literature (including scientific studies), parentheses after a generic are: and national treatment guidelines were reviewed by the RegenceRx • non-preferred/non-formulary Pharmacy and Therapeutics (P&T) • only listed as a reference for a Committee. This committee includes generically available medication practicing doctors and pharmacists. When there are choices, medications Please remember that not all brands with the best value were included on are preferred/formulary. the PML/formulary. What if my medication is not on the PML/formulary? First, check with your doctor. There are preferred/formulary alternatives in most cases, and your doctor can determine an acceptable alternative for your medical If you have questions, please condition. If you remain on a contact our Customer Service non-preferred/non-formulary brand Department at the phone number name medication, your benefit will listed on your member card. Or depend on your coverage. visit us at www.regencerx.com. Q and A Effective February 1, 2008 ©2008. RegenceRx. All Rights Reserved. Preferred/Formulary Medications: By Category Effective February 1, 2008 This list can be used to assist you and your doctor in choosing a generic or preferred/formulary medication. • Generic medications are listed in lower case bold. Example: fluconazole. • Brand name medications start with a capital letter and are followed by a registered trademark symbol like this ®. Example: Ancobon®. • Brand name medications listed in parenthesis after a generic are: - Non-preferred/non-formulary. - Only listed as a reference for a generically available medication. Example: fluconazole (Diflucan® ) Additional Information: - Preferred/formulary medications are limited to the dosage form and strength listed; if no strength is listed, all strengths for the listed dosage form are preferred/formulary. - Sustained action/release (SA/SR), extended release (ER/XR), long-acting (LA), and enteric coated (EC) medications are only preferred/formulary if listed. - Occasionally, preferred/formulary medications may be contract exclusions and, therefore, are not covered. - Some medications may require prior authorization or have quantity limits. Please note that the PML/formulary list may change. To view the most current list, visit our Web site at www.regencerx.com. For more detailed prescription benefit information, please refer to your benefits booklet. ANTIFUNGALS (Systemic) ANTI-INFECTIVES (cont.) fluconazole tablet, oral suspension (Diflucan®) erythromycin ethyl suc tablet, suspension (EES®) griseofulvin microsize oral suspension (Grifulvin V®) erythromycin/sulfisox suspension (Pediazole®) griseofulvin microsize tablet (Fulvicin® U/F) ethambutol tablet (Myambutol®) griseofulvin ultramicrosize tablet (Fulvicin® P/G) hydroxychloroquine tablet (Plaquenil®) itraconazole capsule (Sporanox®)* isoniazid tablet ketoconazole tablet (Nizoral®) mebendazole chewtabs (Vermox®) nystatin suspension, tablet (Mycostatin®) metronidazole tablet (Flagyl®) terbinafine HCL tablet (Lamisil®)* minocycline capsule (Minocin®) Ancobon® capsule nitrofurantoin capsule (Macrodantin®, Macrobid®) Mycelex® Troche ofloxacin tablet (Floxin®) Sporanox solution* penicillin V potassium tablet, suspension (Veetids®) Vfend® tablet, oral suspension pyrazinamide tablet rifampin capsule (Rifadin®) rifampin/isoniazid capsule (Rifamate®) ANTI-INFECTIVES sulfamethoxazole/trimethoprim tablet, suspension amoxicillin capsule, suspension, tablet, ® ® ® (Bactrim , Septra ) chews, drops (Amoxil ) sulfadiazine tablet (Microsulfon®) amoxicillin/pot. clavulanate tabs, chews, ® ® sulfisoxazole tablet, suspension (Gantrisin ) suspension (Augmentin ) ® ® tetracycline capsule (Achromycin ) azithromycin tablet, packet, suspension (Zithromax ) ® ® trimethoprim tablet (Proloprim ) cefaclor capsule, suspension (Ceclor ) ® ® Albenza tablet cefadroxil capsule, tablet, suspension (Duricef ) ® cefdinir capsule, suspension (Omnicef®) Alinia tablet, suspension ® cefprozil tablet, suspension (Cefzil®) Augmentin ES-600 oral suspension cefuroxime tablet (Ceftin®) Avelox® tablet cephalexin capsule (Keflex®) Biltricide® tablet cephradine capsule (Velosef®) Dapsone® tablet chloroquine tablet (Aralen®) Daraprim® tablet ciprofloxacin tablet, suspension (Cipro®) Fansidar® tablet clarithromycin tablet (Biaxin®) Furadantin® oral suspension clindamycin capsule (Cleocin®) Furoxone® tablet, oral suspension dicloxacillin capsule (Dynapen®) Humatin® capsule doxycycline capsule, tablet (Vibramycin®) Lamprene® capsule doxycycline hyclate tablet (Periostat®) Lariam® tablet erythromycin base EC tablet (Emycin®) Mepron® oral suspension Effective February 1, 2008 *May not be a covered benefit under some plans. 4 ©2008. RegenceRx. All Rights Reserved. ANTI-INFECTIVES (cont.) ANTI-VIRALS/HIV/AIDS (cont.) Mintezol® oral suspension, chewable Kaletra® capsule, oral solution Mycobutin® capsule Lexiva® tablet Primaquine tablet Norvir® capsule, oral solution Seromycin® capsule Prezista™ tablet Stromectal® tablet Rebetol® oral solution Yodoxin® tablet Rescriptor® tablet Zyvox® tablet, oral suspension Reyataz® capsule Sustiva® capsule, tablet Tamiflu® capsule, suspension for reconstitution ANTINEOPLASTICS Trizivir® tablet ® cyclophosphamide tablet (Cytoxan ) Valtrex® tablet ® ® etoposide capsule (Toposar , Vepesid ) Videx® chew tab, solution, packet ® flutamide capsule (Eulexin ) Viracept® tablet, powder for oral solution ® hydroxyurea capsule (Hydrea ) Viramune® tablet, oral suspension ® leucovorin tablet (Wellcovorin ) Viread® tablet ® megestrol tablet, syrup (Megace ) Zerit® capsule, oral solution ® tamoxifen tablet (Nolvadex ) Ziagen® tablet, oral solution tretinoin capsule (Vesanoid®) ® Alkeran
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