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Mg42849g tlc member guide_v2_mg42849g tlc member guide_v2

MG42849G TLC MEMBER GUIDE_v2_MG42849G TLC MEMBER GUIDE_v2 6/15 REMEMBER TO SHARE THIS GUIDE WITH YOUR DOCTOR.
MG42849G TLC MEMBER GUIDE_v2_MG42849G TLC MEMBER GUIDE_v2 6/15 Introduction
Welcome to your three-tier outpatient prescription drug plan!
Your three-tier drug program gives you access to all medications in coveredclasses within the confines of your plan’s benefit design. This plan excludescoverage for certain drugs or drug classes such as those prescribed for dietary supplements and cosmetic conditions.
Under this program, covered brand-name and generic drugs are categorizedinto three specific tiers, and each tier is assigned a co-payment level. (A co-payment is a fixed-dollar amount you pay for each prescription.) Some diabetic supplies, such as test strips and blood glucose meters, requirecoinsurance with no deductible in lieu of co-payment. (Coinsurance is a percentage you pay for each prescription.) Your Local Choice Drug Plan provides a prescription drug benefit that divides your prescriptions into three categories (tiers). A number of factorsare considered when classifying medications into tiers including, but notlimited to: •The cost of the medication relative to other medications in the same •The availability of over-the-counter alternatives Drugs may move periodically from one tier to another. Tiers contain the following types of drugs: Typically,
co-payment
generic drugs
Moderate
Typically, lower-cost
co-payment
brand-name drugs
Typically, higher-cost
co-payment
brand-name drugs
Mandatory generic program
Your prescription drug benefit is a mandatory generic program. This means
you will pay more if you purchase a brand-name drug when a generic is
available. The three-tier prescription drug program provides an excellent
opportunity for you to take an active role in your healthcare. Talk with your
doctor about the medications being prescribed for you and discuss possible
alternatives.
Beginning July 1, 2011, the prescription drug program was enhanced to provide a maximum out-of-pocket cost each time a member purchases abrand-name drug in three prescription drug categories when a generic isavailable. The three categories are Immunosuppressants, Anticonvulsants, andPsychotherapeutics. Members who take these drugs will pay no more than$100 per 34-day supply at retail and $200 per 90-day supply via mail service. The following pages list the most commonly prescribed covered drugs andtheir tier assignments or coinsurance percentage. This guide was developedto illustrate how the prescription drug program works and to provide examples of the choices available to you. It also serves as a reference pointfor discussing prescription options with your doctors. Together you canchoose not only the most appropriate medication for your condition, butmedications that can help keep your expenses as low as possible.
This booklet was designed so that generic products are listed
in each drug category. Corresponding brand-name versions
for these generics are shown in italics as a reference.
Please call your Member Services representative at 1 800 355-8279 or refer
to the Prescription Drug section of our website at www.medco.com for
information on medications not listed in this guide.
MG42849G TLC MEMBER GUIDE_v2_MG42849G TLC MEMBER GUIDE_v2 6/15 Dear Doctor:
Please refer to the Three-Tier Drug Program Guide when prescribing for
this patient. This guide does not contain a complete list of drugs in the
program. A complete listing is available in the Prescription Drug section
of our website at www.medco.com.
Please note: This guide is not intended to substitute for your professional
judgment. Rather, we offer it as a tool to help you maintain clinical
efficacy while taking into account drug therapy problems and costs.
Important Comments for Members:
This guide is subject to change. Your group’s plan design may include orexclude additional drugs. Please refer to your The Local Choice PlanMember Handbook for the three-tier co-payments that apply to your plan.
If there is a difference between this guide and The Local Choice PlanMember Handbook, the provisions of the member handbook will govern.
Important: This brochure is only one piece of your entire enrollmentpackage. Exclusions and limitations can be found in your member handbook.
A 1-month supply will allow up to 34 days of medication. The Medco
Pharmacy
® will provide up to a 90-day supply of medication.
Remember to ask your doctor to consider this when writing prescriptions
for you.
Symbols Used Throughout This Guide:
= Dosage reduction may be required in patients over 65.
▲ = Use in patients over 65 is associated with increased risk; safer alternatives may be available. If used, dosage shouldgenerally be lowered.
MG42849G TLC MEMBER GUIDE_v2_MG42849G TLC MEMBER GUIDE_v2 6/15 SECTION I: THERAPEUTIC DRUG CATEGORIES
ANTI-INFECTIVES
Tetracyclines
(ANTIBIOTICS/ANTIFUNGALS)
Antifungals
Urinary Tract Agents
ketoconazole (Nizoral)nystatin (Mycostatin) Misc Agents
Cephalosporins
Vaginal Antifungals
Erythromycins and other
macrolides

Antiviral Therapy
Influenza
Quinolones
CARDIOVASCULAR
(BLOOD PRESSURE/HEART/
CHOLESTEROL)
Penicillins
ACE Inhibitors/Comb. Products
enalapril (Vasotec)fosinopril/fosinopril HCT moexipril (Univasc)perindopril (Aceon)quinapril (Accupril)ramipril (Altace)trandolapril (Mavik) MG42849G TLC MEMBER GUIDE_v2_MG42849G TLC MEMBER GUIDE_v2 6/15 CARDIOVASCULAR
(BLOOD PRESSURE/HEART/
CHOLESTEROL) CONT.
Nitroglycerin Patches
Antilipidemics
cholestyramine (Questran)colestipol granules (Colestid) Other Anti-Hypertensives
ENDOCRINE
(DIABETES/HORMONES/
Angiotensin II Blockers
CONTRACEPTIVES)
Insulin Therapy
Beta Blockers
acebutolol (Sectral)atenolol (Tenormin) Non-insulin Hypoglycemics
metoprolol (Lopressor)metoprolol (Toprol XL) metformin (Glucophage)nateglinide (Starlix) Calcium Blockers
Dihydropyridines
Tier 1amlodipine (Norvasc)felodipine (Plendil)isradipine (Dynacirc, CR)nifedipine, ER, XL (Procardia) MG42849G TLC MEMBER GUIDE_v2_MG42849G TLC MEMBER GUIDE_v2 6/15 ENDOCRINE
(DIABETES/HORMONES/
CONTRACEPTIVES) CONT.
Other G.I. Drugs
Estrogens
estropipate (Ogen)estradiol (Estrace) misoprostol (Cytotec)sucralfate (Carafate) Tier 2Estraderm, Vivelle, Climara Estratest, HS OSTEOPOROSIS
Oral Contraceptives
PSYCHOTHERAPEUTICS
(ANXIETY/DEPRESSION)
Tricyclic Antidepressants
Misc. Antidepressants
citalopram (Celexa)escitalopram (Lexapro) Ulcer Drugs/GERD Drugs
famotidine (Pepcid)nizatidine (Axid)omeprazole (Prilosec)pantoprazole (Protonix)ranitidine (Zantac) MG42849G TLC MEMBER GUIDE_v2_MG42849G TLC MEMBER GUIDE_v2 6/15 PSYCHOTHERAPEUTICS
(ANXIETY/DEPRESSION) CONT.
(PAIN RELIEVERS)
Anxiolytics
ketoprofen (Orudis)ketoprofen SR (Oruvail) Antipsychotics
nabumetone (Relafen)naproxen (Naprosyn) perphenazine (Trilafon)risperidone (Risperdal) NSAID COX-2 Inhibitors
MIGRAINE & CLUSTER
Hypnotic Agents
HEADACHE THERAPY
triazolam (Halcion)zaleplon (Sonata) Misc. Psychotherapeutic Agents
Tier 2Adderall/XRDexedrineMetadate CDRitalin, SRVyvanse UROLOGICALS
Tier 1flavoxate (Urispas)oxybutynin, ER (Ditropan, XL)propantheline (Pro-Banthine) Tier 2Detrol/LAEnablexGelniqueOxytrolToviazVesicare MG42849G TLC MEMBER GUIDE_v2_MG42849G TLC MEMBER GUIDE_v2 6/15 RESPIRATORY
Misc. Pulmonary Agents
(ALLERGY/ASTHMA)
Antihistamines
Beta Agonists
SMOKING CESSATION
Inhaled Steroids
Tier 2AsmanexAzmacortFlovent RotadiskPulmicortQvarSymbicort Nasal Corticosteroids
Tier 1fluticasone (Flonase)flunisolide (Nasarel) MG42849G TLC MEMBER GUIDE_v2_MG42849G TLC MEMBER GUIDE_v2 6/15 Section II:
Outpatient Medications Requiring a Coverage Review
Certain medications require a coverage review. In these cases, clinical
criteria based on current medical information and appropriate use must
be met. Information must be provided before coverage is approved. You,
your doctor, or your local pharmacist may call 1 800 753-2851 toll-free
to initiate a coverage review. When you use the Medco Pharmacy,
Medco will call your doctor to start the coverage review process. The
review uses plan rules based on FDA-approved prescribing and safety
information, clinical guidelines, and uses that are considered reason-
able, safe, and effective. Members with questions pertaining to a pre-
scription drug cover age review should contact Medco Member Services at
1 800 355-8279 for more information. The following drugs currently
require a coverage review. Please note that both lists are subject
to change.

Classification
Medications
Antipsychotic Agents . . . . . . . . . . .Abilify, Invega, Saphris, Latuda, Fanapt
Cancer Agents . . . . . . . . . . . . . . . . .Avastin, Erbitux, Nexavar, Sprycel, Sutent, Tarceva,
Cystic Fibrosis . . . . . . . . . . . . . . . . .TOBI (Tobramycin Inhalation Solution)
Dermatology . . . . . . . . . . . . . . . . . . .Avita, Retin-A and Tretin-X (greater than age 35),
Erythroid Stimulant Agents . . . .Aranesp, Epogen, Procrit
Gonadotropin Releasing
Hormones Analogs . . . . . . . . . . .Lupron, Synarel
Growth Hormones . . . . . . . . . . . . .Geref, Genotropin, Humatrope, Norditropin, Nutropin,
Protropin, Saizen, Serostim, Tev-Tropin, Omnitrope, et al Hypertension Agents (ARBs) . . .Atacand/HCT, Avapro, Avalide, Benicar/HCT,
Hypnotic Agents . . . . . . . . . . . . . . .Ambien CR, Lunesta, Rozerem
Immunoglobulins . . . . . . . . . . . . . .Gamimune N, Gammagard, Gammar-IV, Iveegam,
Venoglobulin, Sandoglobulin, Flebogamma, Octagom,Gammoplex, Hizentra, Gamunex-C, et al Interferons . . . . . . . . . . . . . . . . . . . .Actimmune, Alferon N, Intron A, PEG-Intron, Pegasys,
Intranasal Corticosteroids . . . . .Beconase AQ, Rhinocort AQ, Nasacort AQ, Omnaris,
Migraine Agents . . . . . . . . . . . . . . .Amerge, Axert, Frova, Treximet, Zomig
Miscellaneous Agents . . . . . . . . . .Amevive, Botox, Dacogen, Gleevec, Lotronex, Myobloc,
Provigil, Raptiva, Thalomid/Revlamid, Vidaza,Weight-loss medications, Xolair, Zelnorm Multiple Sclerosis Agents . . . . . .Betaseron, Copaxone, Rebif, Avonex, Tysabri,
Myeloid Stimulant Agents . . . . . .Neupogen, Neulasta, Leukine, Neumega
Non-Sedating Antihistamines . .Allegra/D, Clarinex/D, Xyzal
NSAIDs/COX-2 Inhibitors* . . . . .Celebrex*, Mobic*
Osteoporosis Agents . . . . . . . . . . .Actonel, Fosamax D, Atelvia
Proton Pump Inhibitors . . . . . . .Prevacid, Aciphex, Protonix, Zegerid, Prilosec 40mg
Pulmonary Arterial . . . . . . . . . . .Revatio, Tracleer, Letairis, Ventavis
Hypertension (PAH) Agents
Respiratory Syncytial . . . . . . . . . .Synagis, Respigram
Virus Prevention
Rheumatoid Arthritis . . . . . . . . . .Enbrel, Kineret, Remicade, Humira, Arava, Orencia,
*These medications will process at the pharmacy without a coverage review if certain criteria are met.
If the applicable criteria are not met, a coverage review will be required.
MG42849G TLC MEMBER GUIDE_v2_MG42849G TLC MEMBER GUIDE_v2 6/15 Medication With Quantity Limitations
The Plan has set quantity limitations for these drugs.
You must obtain a coverage review to obtain quantities in excess of these limitations.
Medication
Quantity Limitation
Alsuma . . . . . . . . . . . . . . . . . . . . . . . .Any combination of tablets, not to exceed 12 per
Amerge . . . . . . . . . . . . . . . . . . . . . . . .Any combination of tablets, not to exceed 12 per
Axert . . . . . . . . . . . . . . . . . . . . . . . . . .Any combination of tablets, not to exceed 12 per
Bupropion . . . . . . . . . . . . . . . . . . . . .Limited to 3 months (90 days) per year (365 days)
Caverject . . . . . . . . . . . . . . . . . . . . . .Up to 8 injections within 30 days
Chantix . . . . . . . . . . . . . . . . . . . . . . . .Limited to 6 months (180 days) per year (365 days)
Cialis . . . . . . . . . . . . . . . . . . . . . . . . . .Up to 8 tablets within 30 days
Diflucan . . . . . . . . . . . . . . . . . . . . . .Up to 7,200 mg within 180 days
Diflucan (150 mg only) . . . . . . . .Up to 4 tablets per co-payment
Edex . . . . . . . . . . . . . . . . . . . . . . . . . . .Up to 8 injections within 30 days
Frova . . . . . . . . . . . . . . . . . . . . . . . . . .Any combination of tablets, not to exceed 12 per
Imitrex . . . . . . . . . . . . . . . . . . . . . . . .Any combination of tablets, injections, or nasal sprays,
Lamisil . . . . . . . . . . . . . . . . . . . . . . . .Up to 22,500 mg within 180 days
Levitra . . . . . . . . . . . . . . . . . . . . . . . . .Up to 8 tablets within 30 days
Maxalt . . . . . . . . . . . . . . . . . . . . . . . . .Any combination of tablets, not to exceed 12 per
Muse . . . . . . . . . . . . . . . . . . . . . . . . . .Up to 8 suppositories within 30 days
Nicotrol . . . . . . . . . . . . . . . . . . . . . . .Limited to 3 months (90 days) per year (365 days)
Relenza . . . . . . . . . . . . . . . . . . . . . . .Up to 20 tablets within 180 days
Relpax . . . . . . . . . . . . . . . . . . . . . . . . .Any combination of tablets, not to exceed 12 per
Sporanox . . . . . . . . . . . . . . . . . . . . . .Up to 18,000 mg within 180 days
Stadol Nasal Spray . . . . . . . . . . . . .Up to 4 canisters within 30 days
Sumavel . . . . . . . . . . . . . . . . . . . . . . .Any combination of tablets, not to exceed 12 per
Tamiflu . . . . . . . . . . . . . . . . . . . . . . . .Up to 10 tablets within 180 days
Toradol . . . . . . . . . . . . . . . . . . . . . . . .Up to 20 tablets or 20 injections per prescription
Treximet . . . . . . . . . . . . . . . . . . . . . . .Any combination of tablets, not to exceed 12 per
Viagra . . . . . . . . . . . . . . . . . . . . . . . . .Up to 8 tablets within 30 days
Zomig . . . . . . . . . . . . . . . . . . . . . . . . .Any combination of tablets, not to exceed 12 per
Zyban . . . . . . . . . . . . . . . . . . . . . . . . .Limited to 3 months (90 days) per year (365 days)
THIS LISTING WAS CURRENT AT THE TIME OF PRINTING.
MG42849G TLC MEMBER GUIDE_v2_MG42849G TLC MEMBER GUIDE_v2 6/15 If you have questions regarding your prescription drug benefit, you may contact Medco Member Services at 1 800 355-8279.
For the most recent drug listing, visit the Medco website at
www.medco.com.
This brochure is only one piece of your entire enrollment package. Exclusions and limitations can be found in your The Local Choice Plan Member Handbook.
The drug listing in this booklet was current at the
time of printing, but is subject to change.
Medco manages your prescription drug benefit at the request ofyour health plan.
This Three-tier Drug Program Guide is a service of Medco, your prescription drug benefit manager.
2012 Medco Health Solutions, Inc.
All rights reserved.
Medco is a registered trademark of Medco Health Solutions, Inc.

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