select drug...
TRANSCRIPT
40625NYMENEBS Rev. 07/15 Effective 01/15
Three-tier formulary
1332531 40625NYMENEBS Select Drug List SH 05 15
Select Drug ListSubject to regulatory approval
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Empire BlueCross BlueShield Select Drug List
Your prescription drug benefit includes coverage for medicines that you’ll find on the Select Drug List. You can often find more savings when your doctor prescribes medicine that is on our Select Drug List. Here are some commonly asked questions and answers about how the Select Drug List works with your prescription drug plan.
Q. What is a Select Drug List?A. The Drug List that identifies the prescription drugs
covered under Empire’s Individual and Small Group benefit plans is called the “Select Formulary.” It contains the prescription drugs subject to coverage if you buy 1) an Empire Individual plan on the New York State of Health Marketplace (“Marketplace”) or 2) an Individual or Small Group plan directly from Empire outside of the Marketplace. The Select Formulary has three levels, or tiers, and includes a select number of drugs in different categories and classes. The Select Formulary is available online at empireblue.com/EBSSelectdrugtier3. You can also find out if a specific drug is on the Select Formulary by calling the number on your ID card.
Q. What are Tiers?A. Drugs on the Select Drug List are grouped into tiers.
There are several factors that are used to determine under which tier a drug will be put in. This can include (but it’s not limited to):
�Cost of the drug.
�Cost of the drug in comparison to other drugs used for the same type of treatment.
�Availability of over-the-counter options.
�Other clinical and cost factors.
Q. What is a brand-name drug?A. These are drugs that are developed by a company who
holds the rights to sell them. When the rights expire, other drug companies can make their own version of the drugs (see generic drugs below). You may be more familiar with brand-name drugs through advertising or because you know people who take them.
Q. What is a generic drug? A. Generics are simply copies of brand-name drugs.
Brand-name and generic drugs have the same active ingredients, strength and dose. And the FDA requires that generic drugs meet the same high standards for purity, quality, safety and strength.
Q. Is this list a complete listing of all covered drugs under the Select Drug List?
A. No this piece lists the most commonly used drugs that are covered as part of the Select Drug List. If the drug you are looking for is not listed, you may call Customer Service for more information.
Q. What if my medication is not on the Select Drug List?A. You may want to first check with your doctor about
prescribing a drug that is on the Select Drug List. If your doctor prescribes a drug that’s not on the Select Drug List, you will have to pay the amount described in your policy for nonformulary drugs.
Q. Can I request that a drug be added to the Select Drug List?
A. You or your doctor can put in a request to add a drug to the Select Drug List. You can do this either in writing or on our website. Requests are reviewed by the P&T Process team during the Select Drug List review. Please note that if a drug request is approved, it does not guarantee coverage. Some drugs, such as those used for cosmetic purposes, may be excluded from your benefits. Please refer to your insurance Certificate or Evidence of Coverage to know for sure.
Q. What if my medication is not covered?A. You may want to first check with your doctor about
prescribing a drug that is covered. If your doctor prescribes a drug that’s not covered, you will need to pay the out-of-pocket cost that applies to drugs not on the formulary.
Preventive care drugs: We cover preventive care drugs with zero cost share in compliance with the Affordable Care Act (ACA).
Please note: In selecting medications for the prescription drug list, the therapeutic efficacy and cost effectiveness are addressed for each category. All therapeutic categories are represented on the drug list by at least one medication. When a closed drug list is in effect, only medications that are included on the drug list are a covered service. In certain clinical situations, a member may require use of a noncovered product. Empire has criteria that permits a member to obtain a noncovered medication in a closed drug list plan. If specific criteria are met, a member can receive a noncovered drug for a drug list copay. The criteria preserves the clinical integrity of the drug list and provides a process by which deviations from the drug list may be allowed. An appeals process is in place for any medications that do not meet the criteria.
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Tier 1
AcarboseAcebutololAcetasol HCAcetazolamide tab, ER cap
AclometasoneActicinAcyclovir tab, cap, oral susp.
Adapalene Afeditab CR QL DOAlbuterol inhl soln., syrupAlendronate QLAlfuzosinAllopurinol tabAlprazolam tabAmantadine Amcinonide Amiloride tabAmitriptylineAmlodipine QL DOAmlodipine/atorvastatin QL DO
Amlodipine/benazeprilAmmonium lactate cream, lotion
Amnesteem PACAmoxapine
Amoxicillin Amoxicillin/clavulanate Amoxicillin/clavulanate ER
Amphetamine/dextroamphetamine salts, ER PA QL
Androxy PAAntipyrine/benzocaine ear drop
ApraclonidineAtenololAtenolol/chlorthalidoneAtorvastatin QL DOAtovaquone/proguanilAzelastine nasal spray, drops QL
Azithromycin tab, susp., packet QL
Bacitracin/polymixin BBaclofen BalsalazideBenazepril
Benazepril/HCTZBenzonatateBenzoyl peroxideBenztropineBetamethasone dipropionate
Betamethasone valerate Betaxolol Birth Control (generic oral contraceptives)
BisoprololBisoprolol/HCTZBrimonidineBromocriptine Budesonide 0.25mg/2mL, 0.5mg/2mL QL
Bumetanide tabBuprenorphine tab PA QLBupropion QLBupropion SR, XL QL DOBuspirone Butalbital/acetaminophen
Butalbital/acetaminophen/caffeine
Butalbital/acetaminophen/caffeine/codeine QL
Butalbital/aspirin/caffeine
Butalbital/aspirin/caffeine/codeine
Butorphanol nasal spray PA QL
CabergolineCalcipotriene Calcitriol cap, soln, ointCandesartan QL DOCandesartan/HCTZ QL DOCaptopril Carbamazepine, ER, XRCarbidopa/Levodopa, ER, ODT
CarbinoxamineCarisoprodolCarteololCartia XT QL DOCarvedilolCefaclor, ERCefadroxilCefdinirCefditoren Pivoxil
CefprozilCefuroxime AxetilCephalexinCetirizine syrup QLChlorhexidine gluconateChlorhexidine RinseChloroquineChlorothiazide tabChlorpromazine tab PAChlorpropamideChlorthalidoneChlorzoxazoneCholestyramineCiclopiroxCimetidine tab, soln.Ciprofloxacin ear and eye drops
Ciprofloxacin tab QLCitalopram QL DOClaravis PAClarithromycin, ERClemastine 2.68mgClemastine syrupClindamycin cap, oral soln, topical preparations
Clindamycin/Benzoyl Peroxide Gel
ClobetasolClomipramineClonazepam, ODTClonidine ER PA Clonidine tabClopidogrel QLClotrimazole 1% cream, troche
Clotrimazole/betamethasone
Codeine sulfate tabs QLCodeine/acetaminophen QL
Codeine/butalbital/aspirin/caffeine
ColestipolCortisone tabCovaryx, H.S.Cromolyn eye drops QLCromolyn neb soln.Cyclobenzaprine tabCyproheptadine DepadeDermazene
Desloratadine, ODT QLDesmopressin nasal spray, tab PA
DesonideDesoximetasoneDexamethasone eye dropDexamethasone tab, oral soln.
DexchlorpheneramineDexmethylphenidate, ER PA QL
Dextroamphetamine, ER PA QL
Diazepam tab, oral soln.Diclofenac eye dropDiclofenac, ERDicloxacillinDicylomine cap, tab, syrup
DiflorasoneDiflunisalDigoxin tab, oral soln.DiltiazemDiltiazem ER, XR, CD QL DO
Diphenhydramine 50mg cap
Diphenoxylate/atropineDipyridamole tabDisopyramideDisulfiramDivalproex, ER, DRDonepezil 5mg, 10mg, ODT QL
Dorzolamide eye dropsDorzolamide/timolol eye drops
DoxazosinDoxepin Doxycycline hyclate tab, cap
Doxycycline hyclate, delayed release PA
Doxycycline monohydrate tab, cap
EconazoleEnalaprilEnalapril/HCTZEndocet QLEndodan QLEpidrinEpinastine eye drops QLEpitol
For more information about your drug plan, you can do the following:�Go to empireblue.com.
�Call Customer Service at the number on your ID card.
�Speech and hearing impaired users (TDD/TTY) should call 1-800-221-6915, Monday – Friday, 8:30 a.m. – 5 p.m. ET.
Tier definitions
Tier 1 drugs have the lowest cost share. These drugs offer the greatest value compared to others that treat the same conditions.
Tier 2 drugs have a medium cost share. They may be preferred drugs, based on their effectiveness and value. Some are newer, more expensive generic drugs.
Tier 3 drugs have a higher cost share. They may cost more than others used to treat the same condition. Tier 3 may also include drugs that were recently approved by the FDA.
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Eprosartan QLErgocalciferol (Vit D2) caps
Ery-Tab 250mg, 333mg tab
Erythromcyin eye oint.Erythromycin 2% gel, topical solution
Erythromycin ethylsuccinate 400mg Filmtab
Erythromycin Filmtab, 250mg cap
Erythromycin stearateErythromycin/benzoyl peroxide gel
Erythromycin/sulfisoxazole
Escitalopram QL DOEstradiol patch QLEstradiol tabEstrogen/methyltestosterone
EstropipateEszopiclone PA QLEthambutolEthosuximideEtodolac, ERFamciclovirFamotidine tab, oral soln.FelbamateFelodipine ER QLFenofibrateFenofibric acid, DRFenoprofenFinasteride 5mg tab PAFlavoxateFluconazole tab, oral soln.
FlucytosineFludrocortisoneFlunisolide nasal spray ST QL
Fluocinolone body oil, scalp oil PA
Fluocinolone cream, topical soln., oint., ear drop
FluocinonideFluorometholone eye drops
Fluorouracil cream, topical solution
Fluoxetine, DR (except 60mg) QL DO
Fluphenazine tab, oral soln. PA
Flurbiprofen eye dropFlurbiprofen tabFluticasone nasal spray QL
Fluticasone topicalFluvastatin QL DOFluvoxamine QL DOFolic acid 1mgFosinoprilFosinopril/HCTZFurosemide tab, oral soln.Garamycin eye dropsGatifloxacin eye dropsGemfibrozilGentamycin eye drops, oint.
GlimepirideGlipizide, ER, XLGlipizide/metforminGlyburideGlyburide/metforminGriseofulvinGuaifenesin/codeine syrup
GuanfacineGuanidineHalacHalobetasol propionateHaloperidol tab PAHydralazine tabHydrochlorothiazideHydrocodone/acetaminophen QL
Hydrocortisone tabHydrocortisone 2.5% cream, lotion, oint.
Hydrocortisone acetate 2% gel
Hydrocortisone acetate suppository
Hydrocortisone butyrate 0.1% cream, oint., soln.
Hydrocortisone enemaHydrocortisone valerate 0.2% cream, ointment
Hydrocortisone/acetic acid ear drops
Hydrocortisone/pramoxine cream, ointment
Hydromorphone suppository
Hydromorphone tab, oral soln. QL
HydroxychloroquineHydroxyzine HCL tab, oral soln.
Hydroxyzine pamoateIbandronate ST QLIbuprofenImipramine HCL tabImiquimod PA QLIndapamideIndomethacin, ER capIpratropium bromide neb soln. QL
Irbesartan QL DOIrbesartan/HCTZ QL DOIsometheptene/acetaminophen/caffeine
Isometheptene/acetaminophen/dichloralphenazone
IsonarifIsoniazid tab, oral soln.Isosorbide dinitrate, ER tab
Isosorbide mononitrate, ER tablet
IsradipineKetoconazoleKetoprofen, ERKetorolac eye dropsKetorolac tab QLKlor-Con tabLabetolol tabLactuloseLamotrigine tab (immediate release)
Lansoprazole, DR QLLatanoprostLevobunolol eye dropsLevofloxacin tab QLLevothroidLevothyroxine tabLevoxylLidocaine viscous soln.Lidocaine/hydrocortisone 3/0.5% cream
Lidocaine/prilocaine
LindaneLiothyronine tabLisinoprilLisinopril/HCTZLithium carbonate, ERLithium citrate oral soln.LonoxLosartan QL DOLosartan/HCTZ QL DOLovastatin QL DOLoxapine PAMalathionMaprotilineMatzim LA QL DOMebendazoleMeclizine tabMeclofenamate capMedroxyprogesterone tab
Mefenamic acidMefloquineMegestrolMeloxicam oral suspension
Meloxicam tab QLMeperidine tab, oral soln. QL
Meprobamate QLMetadate ER PA QLMetaproterenolMetaxaloneMetformin, ERMethadone tab, oral soln. QL
Methamphetamine PA QLMethazolamideMethimazoleMethocarbamolMethscopolamine bromide
MethyclothiazideMethyldopaMethyldopa/HCTZMethylergonovine tabMethylphenidate, CD, ER, SR PA QL
Methylprednisolone tabMetipranolol eye dropsMetoclopramide tab, oral soln.
Metoprolol tab, ERMetoprolol/HCTZ
Metronidazole 0.75% gelMetronidazole tab, capsule, cream, lotion
Miconazole 200mg vaginal suppository
MinocyclineMinocycline ER PAMinoxidil tabMirtazapineMisoprostol PAModafinil PA QLMoexiprilMoexipril/HCTZMometasone cream, oint, topical soln.
Montelukast QLMorphine sulfate IR tab QL
Morphine sulfate oral soln. QL
Morphine sulfate supppository
Mupirocin oint.NabumetoneNadololNadolol/bendroflumethiazide
NaltrexoneNaphazoline eye dropsNaproxen, DRNaratriptan QLNature-ThroidNefazodoneNeomycin tabNeomycin/polymixin/bacitracin eye oint.
Neomycin/polymixin/bacitracin/hydrocortisone eye oint.
Neomycin/polymixin/dexamethasone eye drops, oint.
Neomycin/polymixin/gramicidin eye drops
Neomycin/polymixin/hydrocortisone ear and eye drops
Niacin ER Nicardipine capsNifedipine capNifedipine tab ER, XL QL DO
Nisoldipine ER QL DO
Nitro-Bid oint.Nitrofurantoin Nitroglycerin, ER, SRNizatidineNorethindronenortriptylineNP ThyroidNystatin cream, oint., powder, tab
Nystatin/triamcinoloneOfloxacin ear and eye drops
Ofloxacin tab QLOmeprazole caps QLOrphenadrine EROxaprozinOxcarbazepineOxybutynin, EROxycodone QLOxycodone/acetaminophen tab, cap QL
Oxycodone/aspirin QLOxymorphoneOxymorphone ER QLPancrelipase, DR ParamomycinParoxetine, CR, ER QL DOPenicillin VKPentoxifylline, ERPerindoprilPermethrin creamPerphenazine PAPhenazopyridinePhenelzinePhenobarbital tab, oral soln.
Phenytoin ext. capPilocarpine eye dropsPindololPioglitazone QLPiroxicamPodofiloxPolymixin/trimethoprim eye drops
Potassium chloride ER tab, ER cap
Potassium Citrate ER TabPramipexolePravastatin QL DOPrazosinPrednicarbate
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Prednisolone eye dropsPrednisolone oral soln.PrednisonePrenatal Vitamins (all generic covered)
PrimidoneProbenecidProbenecid/colchicineProcentra QLProchlorperazine tabProgesterone, micronized cap
Promethazine tab, suppository, syrup
Promethazine VC syrupPromethazine VC syrup with codeine
Promethazine/codeine syrup
Promethazine-DM syrupPropranolol ERPropranolol HCTZPropranolol tab, oral soln.PropylthiouracilProtriptylinePyrazinamideQuetiapine PAQuinaprilQuinapril/HCTZQuinidine sulfate, ERQuinine sulfate PA QLRaloxifene RamiprilRanitidine 150, 300mg tab, cap
Ranitidine oral soln.RifampinRimantadineRisperidone, ODT, oral soln. PA
Rizatriptan, ODT QLRopinirole, ERRoxicet tab, caplet QLSelegilineSelenium sulfide 2.5% lotion, shampoo
Sertraline QL DOSilver sulfadiazine creamSimvastatin 80mg PA QL DO
Simvastatin QL DO
Sodium polystyrene sulfate 30gm/120ml enema
Sodium polystyrene sulfate powder
Sodium polystyrene sulfonate
Sodium sulfacetamide/sulfur
Sodium sulfacetamide/sulfur/urea
SpinosadSpironolactoneSucralfateSulfacetamide eye drops, oint.
Sulfacetamide sodiumSulfacetamide sodium/prednisolone eye drops
Sulfacetamide sodium/sulfur
Sulfacetamide sodium/sulfur/urea
Sulfacetamide sodium/urea
Sulfamethoxazole/trimethoprim, DS
SulfasalazineSulindacSumatriptan tab QLTamsulosinTaztia XT QL DOTelmisartan QL DOTerazosinTerbinafine tab PATerbutaline tabTerconazoleTetracycline capsTheochron ERTheophylline ER, oral soln.
Thioridazine PAThiothixene PATiclopidineTimolol eye drops, gelTimolol tabTizanidineTobramycin eye dropsTobramycin/dexamethasone eye drops
TolazamideTolbutamide
TolmetinTolterodineTopiramate PATorsemide tabTramadol, ER tab QLTrandolaprilTranexamic acid 650mgTranylcypromineTrazodoneTretinoin cream, gel PATriamcinolone cream, lotion, oint.
Triamcinolone nasal spray QL
Triamcinolone pasteTriamterene/HCTZTrifluoperazine PATrifluridine eye dropsTrihexyphenidylTrimethobenzamide capTrimethoprimTrimipramineTropicamide eye dropsUnithroidValacyclovirValproid acid cap, oral soln.
Valsartan QL DOValsartan/HCTZ QL DOVenlafaxineVenlafaxine, ER QL DOVerapamil tab, ER PM QL DO
Verapamil tab, ER tab, cap
Vicodin, ES, HP QLWarfarinWesthroidZafirlukastZaleplon ST QLZiprasidone PAZolmitriptan QLZolpidem (immediate release) QL
Tier 2
Acamprosate Acitretin Advair Diskus, HFA QLAnaspaz ODTAsmanex Twisthaler QL
Atovaquone suspBethanechol tabBromfenac eye dropsBudesonide ECBuprenorphine syringe, vial
Calcitonin QLCalcium acetate tabCarbidopa STCefpodoximeCeftibuten CevimelineCilostazolClozapine, ODT PADanazolDantroleneDemeclocyclineDesipramineDiclofenac Gel PA QLDulera QLDuloxetine PA QL DOEliphosEntacaponeEpipen, Jr.EplerenoneErgoloidFentanyl patch ST QLFlecainideFlovent HFA QLFlovent QLFortical nasal spray QLGabapentinGalantamine, ER QLGlucagenGranisetron tab QLHumalogHumalog MixHumulin N, R, 70-30Hydromorphone ER STItraconazole PAKetorolac inj. QLLantusLantus SolostarLeflunomideLevalbuterol neb soln.LevemirLevetiracetamLevetiracetam ER PA QLLevocarnitine tab, oral soln.
Levorphanol tab QLMafenide Acetate Methanamine MDMethenamine hippurateMexiletineMorphine sulfate ER QLNateglinide PANimodipineNitroglycerin sprayNitrostatNovolin NNovologNovolog MixOlanzapine tab, ODT PAOndansetron tab, ODT, oral soln. QL
Oxandrolone PAPantoprazole QLPilocarpine tabsProair HFA ST QLPropafenonePrudoxinPulmicort 1mg/2mL respules QL
Pulmicort Flexhaler QLQvar QLRabeprazole QLRelenza QLRepaglinide PARifabutinRivastigmine QLSerevent Diskus QLSotalol tab, AF tabSulfadiazineSumatriptan inj QLSymbicort QLTamiflu QLTiagabine PATranexamic acid 1000mg/10mL
Trospium chloride ER STUrsodiolVancomycin caps PAZonisamide
Tier 3
AbacavirAbacavir/Lamivudine/Zidovudine
Abilify tab PAActonel ST QL
AczoneAdcirca PAAdefovir Dipivoxil Afinitor PAAggrenox QLAlamast PAAlbenzaAliniaAlkeran tabAlocril PA QLAlomide PA QLAltabaxAmevive PAAmitizaAmpyra PA QLAnadrol-50AnagrelideAnastrazole tab PAAndrogel PA QLAntivert 50mgAnzemet tablet QLApidra, Solostar STApriso ERAptivus Aranesp PAArestinAtripla Aubagio PA QLAvodartAxert ST QLAzathioprine tabAzelex PAAzilectAzoptBenicar PA QL DOBepreve PA QLBesivanceBicalutamideBiltricideBosulif PABrilinta QLBrovana QLBuphenyl tablet PABydureon ST QLBystolicCambia QLCantilCapecitabine PACaprelsa PACarbaglu PA
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CeeNUCelebrex ST QLCelontinCenestinCesamet PAChemetCialis 2.5mg, 5mg PACiclodanCimzia PA QLCipro HC ear dropsCiprodex ear drops PAClindacinClodermCoartemColcrys PA QLCombiganCometriq PACordran, SPCortisporin cream, oint.Crestor ST QL DOCresylateCrixivanCuprimineCyclophosphamide tabCyclosporine Cyclosporine cap, soln.Daliresp QLDapsoneDaraprimDexilant ST QLDibenzylineDidanosine DRDificid PADipentumDroxiaDurezol QLDyreniumEdarbi QL DOEdecrinEdurantEffient QL DOElidel PAEllaElmironEmadine PA QLEmcyt PAEmsam QLEmtrivaEnablex STEnbrel PA QL
EnjuviaEnoxaparin PAEpiduoEpivir HBV soln. PAEpzicomErivedge PAErtaczoEstringEtoposide capsEuraxExeldermExemestane Exjade PAExtavia STFactive QLFanapt PAFarestonFerriprox PAFinaceaFlector STFluoridexFluoroplexFlutamideFML S.O.PFondaparinux PAForteo PAFosamax Plus D ST QLFosrenol PAFragmin PAFrova ST QLFuzeonGengrafGleevec PAGlysetHalogHarvoni PAHexalenHorizant PAHumira PA QLHycamtin capsHydroxyureaIclusig PAIncrelex PAInfergen PAInlyta PAInnohep PAIntelenceIntron A PAIntuniv ER PAInvega tab PA
InviraseIressaIsentressJakafi PAJalynJanumet, XR QLJanuvia ST QLKaletraKapvay PAKetekKineret PALacrisertLamuvidineLamuvidine/ZidovudineLanoxin tabLatuda PALetairis PALetrozoleLeucovorin tabLeukeranLeuprolide PALevatolLexivaLivalo ST QL DOLotemaxLotronex PALumiganLyrica PA QLLysodrenMarplanMatulaneMaxair QLMenestMentaxMercaptopurineMethitestMethotrexate tabMorgidox PAMotofenMoviprepMultaqMycophenolateMyleranNaftin cream, 1% gelNamenda QLNatacynNatazia STNeulasta PA QLNeupogen PANevanac
NevirapineNexavar PANexium PA QLNilandronNoroxin QLNorvirNucynta, ER QLNuedextaNuoxNuvaringNuvigil PA QLOforta PAOmnaris ST QLOnglyza ST QLOraceaOrap PAOrfadinOxistatOxsoralen-Ultra PAOxycontin ST QLPanretinPataday PA QLPatanase QLPatanol PA QLPeganonePegasys PA QLPegintron PAPerforomist QLPhisohexPhospholine iodidePomalystPradaxa QLPred-GPred-G S.O.P Premarin CreamPremarin tab STPremphasePremproPrevident 5000 Booster Plus
PrezistaPrimaquinePrimsolPristiq QL DOProcrit PAProglycemProlia PAPromacta PAProquin XRProtopic PA
Proventil HFA ST QLRanexaRapafloRebif PARectivRegranex PARelistor PARelpax ST QLRemicade PARemodulin PARenvela PARescriptorRestasisRevlimid PA QLReyatazRibavirin PARidauraRifaterRiluzole Rituxan PARosadanRozerem ST QLSabrilSafyral STSamsca PASantylSaphris PASavella QLScopaceSelzentrySensiparSeroquel XR PASildenafil 20mg tab PASilenor STSimponi PA QLSirolimus SkelidSomatulineSpiriva QLSprycel PAStavudineStelara PA QLStivarga PAStrattera PA QLStromectolSuprax tab, susp.SustivaSutent PASymlin PASynarel PA
SyneraSyprineTabloidTaclonex scalp suspension
Taclonex suspensionTacrolimusTamoxifenTarceva PATargretin PATasigna PATasmarTazorac PATekturna QL DOTemozolomide PATeveten 400mg QLTev-Tropin PAThalomid PAThyrolarTikosynToriselToviaz ER STTradjenta ST QLTransderm-Scop PATravatan ZTrelstar Depot PATrelstar PATretinoin 10mg capsuleTruvadaTykerb PATysabriTyzeka PATyzineUlesfiaUloric STVagifemVandetanib PAVentavis PAVentolin HFA ST QLVeregenVesicare STVexolVictoza ST QLVictrelis PAVigamox PAViibryd STViraceptViread PAVivelle-Dot PA QLVoltaren gel
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Votrient PAVyvanse PA QLWelcholXalkori PAXarelto PA QLXenazine PAXopenex HFA ST QLXtandi PAXyrem PAZelboraf PAZetia PA QLZiana ST
ZidovudineZinoticZioptanZipsorZirganZoledronic Acid Zolinza PAZortress PAZyflo, CR PAZytiga PAZyvox tab, oral soln. PA QL
KEY
† = A generic equivalent of this drug recently became available or will be available soon. After the generic drug becomes available and notification requirements are met, this brand-name drug may no longer be covered by your prescription drug plan. Check empireblue.com to find out about changes in tier status.
PA = PRIOR AUTHORIZATION REQUIRED. Prior authorization is the process of obtaining approval of benefits before certain prescriptions may be filled.
QL = QUANTITY LIMITS. Certain prescription drugs have specific quantity limits per prescription or per month.
ST = STEP THERAPY REQUIRED. You may need to use one medication before benefits for the use of another medication can be authorized.
DO = DOSE OPTIMIZATION REQUIRED. Normally involves the conversion from twice-daily dosing to a once-daily dosing schedule.
Not all medications and not all plans are subject to prior authorization and quantity limits. For more information regarding prior authorization or quantity limits, contact Customer Service at the telephone number listed on your identification card.
40625NYMENEBS Rev. 07/15 Effective 01/15
For more information, please visit empireblue.com: �If you have additional questions about your prescription benefits,
please call the Customer Service number on your ID card.
�Speech and hearing impaired (TDD/TTY users) should call 1-800-221-6915, Monday – Friday, 8:30 a.m. – 5 p.m. ET.
�For the most current version of this Select Drug List, please visit empireblue.com.
Services provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.