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FORMULARY

Your Benefit Plan provides you with a prescription drug benefit program that is administrated by RESTAT.

RESTAT's goal is to provide the highest quality pharmaceutical care, at lower costs. The most effective way to control costs are through the use of generic drugs and a drug formulary. Ask your physician to authorize a generic substitution whenever possible. When a generic is not available, there may be more than one brand name drug that may be appropriate for you. That is why this formulary was developed. The brand name medications listed here are those that have been deemed preferred and were selected based on their ability to meet patient needs at a lower cost.

Ask your physician to prescribe a preferred brand whenever possible, if a generic medication is not available to meet your need.

For members that have a 3-tier copay, the following guidelines apply.

If your prescription is for a generic medication, you will pay the lowest copay.

If you or your doctor chooses to use a brand medication when a generic is available, you will usually pay the highest copay.

(With some benefit plans, you may be required to pay the difference if a brand is received when a generic is available.)

If your brand medication is on this list and there is not a generic available, you will pay the middle copay.

IMPORTANT

Always ask for a Generic when available to minimize your out of pocket cost.

Generics will take the lowest Copay
Brands with Generics will take the highest Copay
Brands on the list (without Generics) will take the middle

Note: Some of the medications on the list may be in categories not covered by your plan. Their presence on the list does not indicate coverage.

The following medications are Preferred medications, but are in categories most often not covered.
ALL SINGLE SOURCE CANCER DRUGS ALL SINGLE SOURCE DRUGS USED FOR TRANSPLANTS ALL SINGLE SOURCE HIV DRUGS ALL SYRINGES ARANESP BYETTA
CETROTIDE COPAXONE ENBREL EPINEPHRINE INJECTION FORTEO GENOTROPIN
HUMIRA INTRON A NEULASTA NEUPOGEN NORDITROPIN NUTROPIN
PEG-INTRON PEGASYS PROCRIT REBETRON REBIF REVATIO


For specific coverage or copay information, please call RESTAT Customer Service at 1-800-248-1062.


ABILIFY ACCU-CHEK TEST STRIPS ACEON
ACTONEL ACTONEL PLUS CALCIUM ACTOPLUS MET
ACTOS ACULAR ACULAR PF
ADVAIR DISKUS ADVAIR HFA ADVICOR
ALLEGRA D ALPHAGAN-P ALREX
ALTABAX ANDROGEL APIDRA
ARICEPT ASACOL ASMANEX
ASTELIN ATACAND ATACAND HCT
AVALIDE AVANDAMET AVANDARYL
AVANDIA AVAPRO AVELOX/AVELOX-ABC
AVINZA AVODART AZILECT


BARACLUDE B-D SYRINGES/NEEDLES BENICAR
BENICAR HCT BENZACLIN BETIMOL
BETOPTIC-S     


CADUET CAMPRAL CANASA
CARAC CELEBREX CENESTIN
CIPRODEX CLIMARA PRO COMBIVENT
COMTAN CONCERTA CONDYLOX GEL ONLY
COREG CR CORTEF CORTIFOAM
CREON CUPRIMINE CYMBALTA
CYPROHEPTADINE SYRUP     


DAPSONE DEPAKOTE DEPAKOTE ER
DEPAKOTE SPRINKLE DETROL DETROL LA
DIASTAT DILANTIN DOVONEX
DUAC CS DUETACT DYNACIRC CR


EFFEXOR XR ELMIRON ENABLEX
ENJUVIA ENTOCORT EC EPIPEN/EPIPEN JR
ESTRADERM EVISTA EVOXAC
EXELON     


FEMRING FINACEA FLOMAX
FLOVENT FLOVENT ROTADISK FOCALIN XR
FORADIL     


GEODON GLUCAGON GRIS-PEG


HALFLYTELY HECTORAL HEPSERA
HUMALOG HUMULIN   


IMITREX INTAL INHALERS INVEGA




KEPPRA KRISTALOSE   


LAMICTAL ORAL TABS & KITS LANTUS LEVAQUIN
LEVEMIR LEXAPRO LIDODERM
LIPITOR LOPROX GEL, SHAMPOO & LOTION (ONLY) LOTEMAX
LOVAZA LUMIGAN LUNESTA
LUXIQ LYRICA   


MALARONE MAXALT METADATE CD
MICARDIS MICARDIS HCT MIRAPEX


NAMENDA NARDIL NASACORT AQ
NASONEX NEUPRO NEXIUM
NIASPAN NOVOLIN NOVOLOG
NUVARING     


OLUX ONE TOUCH TEST STRIPS OPTIVAR
ORTHO EVRA ORTHO TRI-CYCLEN LO OVIDE
OXYCONTIN OXYTROL   


PAXIL CR PENTASA PHOSLO
PLAVIX PRANDIN PRED MILD
PREDNISONE 1MG PREMARIN PREMARIN CREAM
PREMPHASE PREMPRO PREVACID
PRO-AIR HFA PROMETHAZINE VC PROMETRIUM
PROVENTIL HFA PULMICORT   


QUIXIN     


RANEXA RAZADYNE RAZADYNE ER
RENAGEL REQUIP RETIN-A MICRO
REVATIO RHINOCORT AQUA RIDAURA
RISPERDAL RYTHMOL SR   


SEREVENT DISKUS SEROQUEL SINGULAIR
SPIRIVA STALEVO STRATTERA
SYMBICORT SYMLIN   


TARKA TAZORAC TOBRADEX
TOPAMAX TRAVATAN/TRAVATAN R TRICOR
TRUSOPT TYZEKA   


ULTRASE ULTRASE MT URSO


VALCYTE VALTREX VESICARE
VFEND VIGAMOX VIOKASE
VISICOL VIVELLE/VIVELLE DOT VYTORIN


WELCHOL     


XALATAN XOPENEX XYREM


YASMIN YAZ   


ZEMPLAR ZETIA ZIANA GEL
ZOMIG tabs/nasal spray/ZMT tabs ZYLET ZYMAR
ZYPREXA ZYPREXA ZYDIS   


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