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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
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REVATIO |
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For specific coverage or copay information, please call RESTAT Customer Service at 1-800-248-1062.
| ABILIFY |
ACCU-CHEK TEST STRIPS |
ACEON |
| ACTONEL |
ACTOPLUS MET |
ACTOS |
| ACULAR |
ACULAR PF |
ADVAIR DISKUS |
| ADVAIR HFA |
ADVICOR |
ALLEGRA D |
| ALPHAGAN-P |
ALREX |
ALTABAX |
| AMBIEN CR |
ANDROGEL |
ANTARA |
| APIDRA |
ARICEPT |
ASACOL |
| ASMANEX |
ASTELIN |
ASTEPRO |
| ATACAND |
ATACAND HCT |
AVALIDE |
| AVANDAMET |
AVANDARYL |
AVANDIA |
| AVAPRO |
AVELOX/AVELOX-ABC |
AVINZA |
| AVODART |
AZILECT |
AZOR |
|
| BARACLUDE |
B-D SYRINGES/NEEDLES |
BENICAR |
| BENICAR HCT |
BENZACLIN |
BETIMOL |
| BETOPTIC-S |
| |
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| CADUET |
CAMPRAL |
CANASA |
| CARAC |
CELEBREX |
CENESTIN |
| CHANTIX |
CIPRODEX |
CLIMARA PRO |
| COMBIVENT |
COMTAN |
CONCERTA |
| CONDYLOX GEL ONLY |
COREG CR |
CORTEF |
| CORTIFOAM |
CREON |
CUPRIMINE |
| CYMBALTA |
| |
|
| DAPSONE |
DEPAKOTE |
DEPAKOTE ER |
| DEPAKOTE SPRINKLE |
DETROL |
DETROL LA |
| DIASTAT |
DIFFERIN |
DILANTIN |
| DOVONEX (CREAM/OINT ONLY) |
DUAC CS |
DUETACT |
| DYNACIRC CR |
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| EFFEXOR XR |
ELMIRON |
ENABLEX |
| ENJUVIA |
ENTOCORT EC |
EPIPEN/EPIPEN JR |
| ESTRADERM |
EVISTA |
EVOXAC |
| EXELON |
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| FEMRING |
FLOMAX |
FLOVENT |
| FLOVENT ROTADISK |
FOCALIN XR |
FORADIL |
| FOSRENOL |
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| HALFLYTELY |
HECTORAL |
HEPSERA |
| HUMALOG |
HUMULIN |
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| IMITREX NASAL SPRAY/INJ |
INTAL INHALERS |
INVEGA |
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| LANTUS |
LEVAQUIN |
LEVEMIR |
| LEXAPRO |
LIDODERM |
LIPITOR |
| LO SEASONIQUE |
LOPROX GEL, SHAMPOO & LOTION (ONLY) |
LOTEMAX |
| LOVAZA |
LUMIGAN |
LUNESTA |
| LUXIQ |
LYRICA |
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| MALARONE |
MAXALT |
METADATE CD |
| MICARDIS |
MICARDIS HCT |
MIRAPEX |
| MOVIPREP |
| |
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| NAMENDA |
NARDIL |
NASACORT AQ |
| NASONEX |
NEUPRO |
NEXIUM |
| NIASPAN |
NOVOLIN |
NOVOLOG |
| NUVARING |
| |
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| ONE TOUCH TEST STRIPS |
OPANA ER |
OPTIVAR |
| ORTHO EVRA |
ORTHO TRI-CYCLEN LO |
OSMOPREP |
| OVIDE |
OXYCONTIN |
OXYTROL |
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| PENTASA |
PHOSLO |
PLAVIX |
| PRANDIN |
PRED MILD |
PREMARIN |
| PREMARIN CREAM |
PREMPHASE |
PREMPRO |
| PREVACID |
PRO-AIR HFA |
PROMETRIUM |
| PROVENTIL HFA |
PULMICORT |
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| RANEXA |
RAZADYNE |
RAZADYNE ER |
| RENAGEL |
RETIN-A MICRO |
REVATIO |
| RHINOCORT AQUA |
RIDAURA |
RYTHMOL SR |
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| SANCTURA XR |
SEASONIQUE |
SEREVENT DISKUS |
| SEROQUEL |
SEROQUEL XR |
SIMCOR |
| SINGULAIR |
SKELAXIN |
SOLARAZE |
| SPIRIVA |
STALEVO |
STRATTERA |
| SYMBICORT |
SYMLIN |
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| TARKA |
TAZORAC |
TOBRADEX |
| TOPAMAX |
TRAVATAN/TRAVATAN R |
TREXIMET |
| TRICOR |
TRUSOPT |
TYZEKA |
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| VALCYTE |
VALTREX |
VERAMYST |
| VESICARE |
VFEND |
VIGAMOX |
| VIMPAT |
VIOKASE |
VISICOL
Expires: 08/01/09 |
| VIVELLE/VIVELLE DOT |
VYTORIN |
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| XALATAN |
XIBROM |
XOPENEX |
| XYREM |
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| ZEMPLAR |
ZETIA |
ZIANA GEL |
| ZOMIG tabs/nasal spray/ZMT tabs |
ZYLET |
ZYMAR |
| ZYPREXA |
ZYPREXA ZYDIS |
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