MG40118C 1199 2H10 SEIU PDL BiFold_v4 5/6/10 12:26 PM Page a 1199SEIU Preferred Drug List Please take this guide with you the next time you visit your doctor. © 2010 Medco Health Solutions, Inc. All rights reserved. Medco is a registered trademark of Medco Health Solutions, Inc. If you have questions about your prescription drug benefit, visit www.medco.com or call Medco Member Services at (800) 818-6720. For questions about your 1199SEIU benefits, call the 1199SEIU Benefit Funds’ Member Services representatives at (646) 473-9200. FPO MG40118C FPO (Ed. 4/10) Medco manages your prescription drug benefit for the 1199SEIU Benefit Funds. MG40118C 1199 2H10 SEIU PDL BiFold_v4 5/6/10 12:26 PM Page 1 This Preferred Drug List includes classes of widely used drugs that are preferred by the 1199SEIU Benefit Funds. These medications have been carefully selected to provide safety and value. If you receive any generic drug or preferred brand, you will have no out-of-pocket expense (except for GNY Benefit Fund and Rochester-area members, who may have small co-payments for certain brand-name drugs). However, if you get a nonpreferred brand when a preferred drug is available, you will be responsible for the difference in cost between the preferred and nonpreferred drugs. (Please note that this list is subject to change.) Section II provides a listing of nonpreferred brands and their possible preferred alternatives. SAFETY CONSIDERATION SYMBOLS Here is a quick guide that explains our safety symbols. These symbols appear next to certain medications. A dose lower than the manufacturer’s guidelines is often recommended for people 65 and older. ▲ Use by people 65 and older is associated with increased risk; safer alternatives may be available. If used, the dosage should generally be lowered. Weigh the risk of birth defects and other adverse outcomes. Do not use during pregnancy. PRESCRIPTION PROGRAM CONSIDERATION SYMBOLS For more information, please call Medco: (800) 753-2851. [PA] This symbol next to a drug name indicates that this medication is subject to the Prior Authorization Program. [ST] This symbol next to a drug name indicates that this medication is subject to the Step Therapy Program. [QD] This symbol next to a drug name indicates that this medication is subject to the Quantity Duration Program. OTHER SYMBOLS: [AC] This symbol next to a drug name indicates that this specialty medication must be obtained through Accredo. Please call Accredo: (800) 803-2523. Shaded areas indicate the most recent additions to the Preferred Drug List. Drugs Not Covered by the 1199SEIU Benefit Funds Cosmetic Drugs Non-Sedating Antihistamines Fertility Drugs All Over-the-Counter drugs (except diabetic supplies) Investigational/experimental drugs Select Cough & Cold Drugs Erectile Dysfunction Drugs Please refer to your Summary Plan Description for a complete list of excluded drugs. Information was in effect at the time of printing and may be subject to change. For the most up-to-date 1199SEIU Benefit Funds Preferred Drug List go to www.1199SEIUBenefits.org. 1 MG40118C 1199 2H10 SEIU PDL BiFold_v4 5/6/10 12:26 PM Page 2 SECTION I: THERAPEUTIC DRUG CATEGORIES ANTICONVULSANTS (EFFECTIVE 7-1-10) G carbamazepine G phenobarbital P Lamictal ODT G carbamazepine XR G phenytoin extended-release P Lyrica [PA] G clonazepam G primidone P Peganone G divalproex sodium G topiramate [PA] P Vimpat G divalproex sodium ER G valproic acid G divalproex sodium sprinkles P Banzel G ethosuximide P Celontin G gabapentin P Diastat G lamotrigine P Dilantin 30mg G levetiracetam P Felbatol G mephobarbital P Gabitril ANTI-INFECTIVES (Antibiotics) Oral Penicillins Oral Cephalosporins Oral Quinolones G amoxicillin trihydrate G cefaclor G ciprofloxacin HCl tablet G amoxicillin trihydrate/ G cefadroxil hydrate G ofloxacin potassium clavulanate G cefdinir P Avelox G ampicillin trihydrate G cefpodoxime proxetil tablet P Cipro Suspension G dicloxacillin sodium G cefprozil P Cipro Tablet 100mg G penicillin v potassium G cefuroxime axetil tablet P Augmentin Chewable Tablet G cefuroxime suspension 125 - 31.25mg, 250 - 62.5mg G cephalexin monohydrate P Augmentin Suspension G cephradine 125 - 31.25mg/5, 250 - 62.5mg/5 Oral Erythromycins and other Oral Tetracyclines Macrolides G doxycycline hyclate capsule G azithromycin G doxycycline hyclate tablet G clarithromycin G doxycycline monohydrate G erythromycin base G minocycline HCl G erythromycin ethylsuccinate G tetracycline HCl G erythromycin ethylsuccinate/ sulfisoxazole acetyl G erythromycin stearate ANTIPARKINSONISM AGENTS (EFFECTIVE 1-1-10) G amantadine G pramipexole Di-HCl 0.125mg, 0.25mg, P Comtan G benztropine 0.5mg, 1mg, 1.5mg P Lodosyn G bromocriptine G ropinirole P Mirapex 0.75mg G carbidopa/levadopa G selegiline G carbidopa/levadopa ER P Apokyn ANTIVERTIGO & ANTIEMETIC DRUGS (EFFECTIVE 4-1-10) G ondansetron HCl [QD] G granisetron HCl [QD] P Emend [QD] Key: G = Preferred generic medication. [PA] This symbol next to a drug name indicates that this medication is subject to P = Preferred brand-name medication. the Prior Authorization Program. [ST] This symbol next to a drug name indicates that this medication is subject to = A dose lower than the manufacturer’s guidelines is often recommended for the Step Therapy Program. people 65 and older. [QD] This symbol next to a drug name indicates that this medication is subject to ▲ = Use by people 65 and older is associated with increased risk; safer alternatives the Quantity Duration Program. may be available. If used, the dosage should generally be lowered. [AC] This symbol indicates that this specialty medication must be obtained = Weigh risk of birth defects or other adverse outcomes. through Accredo. Please call: (800) 501-7210. = Do not use in pregnancy. 2 MG40118C 1199 2H10 SEIU PDL BiFold_v4 5/6/10 12:26 PM Page 3 BENIGN PROSTATE HYPERPLASIA (BPH) THERAPY G doxazosin G tamsulosin HCl G terazosin G finasteride [ST] BIOTECHNOLOGY DRUGS (EFFECTIVE 7-1-10) Factor VIII - Recombinant Drugs P Helixate FS CARDIOVASCULAR (Blood Pressure/Heart/Cholesterol) Beta Blockers ACE Inhibitors G benazepril HCl/ G acebutolol HCl G benazepril HCl hydrochlorothiazide G atenolol G captopril G bisoprolol fumarate/ G betaxolol HCl G enalapril maleate hydrochlorothiazide G bisoprolol fumarate G fosinopril sodium G captopril/ hydrochlorothiazide G carvedilol G lisinopril G enalapril maleate/ G labetalol HCl G moexipril HCl hydrochlorothiazide G metoprolol succinate XL G perindopril G fosinopril/ hydrochlorothiazide G hydralazine/ hydrochlorothiazide G metoprolol tartrate G quinapril G nadolol G lisinopril/ hydrochlorothiazide G ramipril capsules G methyldopa/ hydrochlorothiazide G pindolol G trandolapril G propranolol HCl G metoprolol/ hydrochlorothiazide G propranolol HCl capsule, sustained Angiotensin II Blockers G moexipril/ hydrochlorothiazide action 24 hr G losartan/hydrochlorthiazide [ST] G propranolol/ hydrochlorothiazide G timolol maleate G losartan potassium [ST] G quinapril/ hydrochlorothiazide Calcium Channel Blockers P Micardis [ST] P Lotrel 5-40mg & 10-40mg P Micardis HCT [ST] G diltiazem HCl Long Acting Nitrates (Topical) G diltiazem HCl capsule, sustained Antilipidemics - Statin Drugs (EFFECTIVE 7-1-10) release 12 hr G lovastatin G nitroglycerin patches G diltiazem HCl capsule, sustained G pravastatin release 24 hr G simvastatin Antiplatelet Agents G nimodipine P Lipitor (EFFECTIVE 7-1-10) G verapamil HCl Other Antilipidemics G cilostazol G verapamil HCl capsule, 24 hr G ticlopidine sustained release pellets G colestipol HCl P Aggrenox G verapamil HCl tablet, sustained G cholestyramine/aspartame P Effient action G cholestyramine/sucrose P Plavix G fenofibrate, micronized Dihydropyridines Calcium G gemfibrozil Channel Blocker G niacin G amlodipine besylate P Niaspan ER G felodipine P Welchol G isradipine P Zetia G nicardipine Select Combination G nifedipine Antihypertensives G nifedipine tablet, sustained action G nifedipine tablet, sustained release G amlodipine besylate/benazepril osmotic push G atenolol/chlorthalidone DRUGS TO TREAT OVERACTIVE BLADDER (EFFECTIVE 1-1-10) G ▲flavoxate G ▲oxybutynin chloride ER P Vesicare G ▲oxybutynin chloride Key: G = Preferred generic medication. [PA] This symbol next to a drug name indicates that this medication is subject to P = Preferred brand-name medication. the Prior Authorization Program. [ST] This symbol next to a drug name indicates that this medication is subject to = A dose lower than the manufacturer’s guidelines is often recommended for the Step Therapy Program. people 65 and older. [QD] This symbol next to a drug name indicates that this medication is subject to ▲ = Use by people 65 and older is associated with increased risk; safer alternatives the Quantity Duration Program. may be available. If used, the dosage should generally be lowered. [AC] This symbol indicates that this specialty medication must be obtained = Weigh risk of birth defects or other adverse outcomes. through Accredo. Please call: (800) 501-7210. = Do not use in pregnancy. 3 MG40118C 1199 2H10 SEIU PDL BiFold_v4 5/6/10 12:26 PM Page 4 ENDOCRINE (Diabetes/Hormones/Contraceptives) Insulin Therapy Blood Glucose Test Strips G Next Choice P Apidra P Accu-Chek Active Test Strips G norethindrone P Humalog P Accu-Chek Aviva Test Strips G norethindrone a-e estradiol P Humalog Mix 50/50 P Accu-Chek Comfort Curve Test G norethindrone a-e P Humalog Mix 75/25 Strips estradiol/ferrous fumarate P Humulin P Accu-Chek Compact Test Strips G norethindrone-ethinyl estradiol P Iletin P Accu-Chek Advantage