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Effective
January 1, 2013
2013 EMPIRE PLAN FLEXIBLE FORMULARY
Administered by UnitedHealthcare
The following is a list of the most commonly prescribed generic and brand-name drugs included on the 2013 Empire Plan Flexible Formulary. This is not a complete list of all prescription drugs on the flexible formulary or covered under The Empire Plan. This list and
excluded medications are subject to change. New prescription drugs may be subject to exclusion when they become available in
the market. For specific questions about your prescriptions, coverage and copayments, please call The Empire Plan toll free at 1-877-7-NYSHIP
(1-877-769-7447) and select The Empire Plan Prescription Drug Program or visit the website at https://www.cs.ny.gov. Click on Benefit Programs, then NYSHIP Online. Provide your group and plan information if prompted. On the resulting NYSHIP Online page, select Using Your Benefits and scroll to the 2013 Empire Plan Prescription Drug Program links.
For the enrollee: Enrollees are encouraged to ask their doctors to prescribe covered generic versions of brand-name drugs whenever
appropriate, as this will result in a lower copayment, unless the brand-name drug has been placed on Level 1. Brand products
on Level 1 will be less expensive than the generic equivalent. Generic medications contain the same active ingredients as their
corresponding brand-name medications, although they may look different in color or shape. They have been FDA-approved under
strict standards.
For the physician: Please prescribe covered Level 1 and Level 2 or preferred products when medically appropriate for your patients.
CARDIOVASCULAR
trandolapril ½T
Antiarrhythmics
losartan (generic Cozaar) ½T
losartan with hydrochlorothiazide valsartan (generic Diovan)½T
moexipril ½T
Blood Modifiers
Atacand*½T
Atacand HCT*
Benicar ½T
perindopril (generic Aceon) ½T
Cardizem LA (g)*
Blood Pressure Lowering
irbesartan (generic Avapro)½T
Cholesterol Lowering
atorvastatin (generic Lipitor) ½T
Generic Drugs are listed in lower case letters. Brand-name drugs are listed with the first letter of the name capitalized.
Symbol Meaning
*
This drug may be available as a generic in 2012 or 2013. When a generic version is available, mandatory generic substitution will apply, unless the brand-name drug has been placed on Level 1. Use of a covered Level 3 or non-preferred brand-name drug when the generic is available will result in the enrollee paying the applicable Level 3 or non-preferred copayment plus the difference in cost between the brand-name drug and the generic, not to exceed the full retail cost of the drug, unless the brand-name drug has been placed on Level 1 of the Flexible Formulary.
A generic is currently available for at least one or more strengths of the brand medication. When a generic is available for a particular strength of the brand-name drug, that strength (if covered) may be Level 3 or non-preferred. A brand-name medication with a Level 1 copayment.
Certain strengths of this medication may be eligible for the Half Tablet Program.
Antifungal Drugs-Oral
pravastatin (generic Pravachol) ½T
GASTROINTESTINAL
simvastatin (generic Zocor) ½T
itraconazole (PA)
Advicor*
GERD/Peptic Ulcer
Crestor ½T
topiramate (generic Topamax) ½T
terbinafine (generic Lamisil) (PA)
Dilantin (g)
Vfend (g)*
Gabitril*
Niaspan*
Antifungal Drugs-Topical
Tegretol XR (g)*
DERMATOLOGY/
Heart Failure
SKIN DISORDER
Gastrointestinal-Other
adapalene (generic Differin) (PA)
Antiviral Drugs
Nitrates/Other Angina
Pancreatic Enzymes
Pulmonary Artery
Ulcerative Colitis
valacyclovir (generic Valtrex) ½T
Hypertension Agents
Adcirca (PA)
Letairis (PA)
Hepatitis
Revatio*(PA)
Tracleer (PA)
Tyvaso (PA)
Ventavis (PA)
Infergen (PA)
CENTRAL NERVOUS
Intron-A (PA)
Pegasys (PA)
GROWTH HORMONES
Peg-Intron (PA)
Alzheimer’s Disease
tretinoin (PA)
Nutropin/Nutropin AQ (PA)
Saizen (PA)
MIGRAINE HEADACHE
Serostim (PA)
Tev-Tropin (PA)
Stelara (PA)
Zorbtive (PA)
DIABETES
INFECTION
Multiple Sclerosis
Antibiotics-Oral
Ampyra (PA)
Avonex (PA)
Copaxone (PA)
Rebif (PA)
Nausea/Vomiting
MUSCLE RELAXANTS
pioglitazone (generic Actos)½T
Parkinson’s Disease
Duetact*
OPHTHALMIC (EYE)
Glaucoma
Seizure Disorder
Allergy-Nasal Antihistamines
WEIGHT LOSS
phentermine (PA)
Other Eye Medications
Allergy-Nasal Corticosteroids
WOMEN’S HEALTH
Contraceptives
Allergy-Other
diclofenac sodium drops (generic zaleplon (generic Sonata) Asthma-Inhaled Drugs
Attention Deficit
Hyperactivity Disorder (ADHD)
Hormone Therapy-Oral
Pulmicort Respules (g)*
OTIC (EAR)
Asthma-Oral Drugs
PAIN/ARTHRITIS
Depression
Hormone Therapy-Patches
fentanyl citrate lollipop (PA)
Vivelle-Dot*
escitalopram (generic Lexapro) ½T
REPLACEMENT
Hormone Therapy-
Miscellaneous
URINARY TRACT
Infertility
Benign Prostatic Hyperplasia
sertraline (generic Zoloft) ½T
Erectile Dysfunction
Osteoporosis
capsule (generic Effexor XR)
Miscellaneous
Psychosis
Anticholinergics/
Antispasmodics-Other
olanzapine (generic Zyprexa) ½T
Cimzia (PA)
quetiapine (generic Seroquel) ½T
Enbrel (PA)
Forteo (PA)
Other Agents
Simponi (PA)
Symbyax (g)*
RESPIRATORY
Sanctura XR*
PSYCHOTHERAPEUTIC Allergy-Antihistamines
VITAMIN DEFICIENCY
Anxiety, Insomnia and
Sedative Agents
Examples of Level 3 or Non-Preferred Drugs with 2013 Empire Plan Flexible Formulary Alternatives
Level 3 or Non-Preferred Drugs
Empire Plan Flexible Formulary Alternatives
Abilify ½T
olanzapine (generic Zyprexa) ½T, quetiapine (generic Seroquel) ½T, risperidone
(generic Risperdal), ziprasidone (generic Geodon) Aciphex*
omeprazole (generic Prilosec), pantoprazole (generic Protonix) alendronate sodium tablet (generic Fosamax), ibandronate tablet (generic Boniva) ciprofloxacin, levofloxacin (generic Levaquin), ofloxacin doxazosin, finasteride (generic Proscar), tamsulosin (generic Flomax), terazosin amlodipine (generic Norvasc) plus Benicar ½T
Betaseron (PA) Avonex
(PA), Copaxone (PA), Rebif (PA)
imiquimod (generic Aldara), podofilox solution Cymbalta*
venlafaxine (generic Effexor), venlafaxine extended release capsule (generic Effexor XR) oxybutynin, oxybutynin extended release, tolterodine (generic Detrol), trospium (generic Sanctura), Sanctura XR*, Vesicare
sumatriptan (generic Imitrex), Maxalt*, Relpax, Zomig*
Humira (PA) Cimzia
(PA), Enbrel (PA), Simponi (PA), Stelara (PA)
zaleplon (generic Sonata), zolpidem (generic Ambien), zolpidem extended release Retin-A Micro (PA) tretinoin
simvastatin (generic Zocor) ½T plus Niaspan*
atorvastatin (generic Lipitor) ½T, lovastatin, pravastatin (generic Pravachol) ½T, simvastatin
(generic Zocor) ½T, Crestor ½T, Welchol
omeprazole (generic Prilosec), pantoprazole (generic Protonix) atorvastatin (generic Lipitor) ½T, lovastatin, pravastatin (generic Pravachol) ½T, simvastatin
(generic Zocor) ½T, Crestor ½T,Welchol
For enrollee groups eligible for the Enhanced Flexible Formulary, you have an additional feature called
Brand for Generic (B4G) which saves you money on certain Brand-Name drugs that have a new generic
available. When advantageous to the Plan, this feature allows a Brand-Name drug to be placed on Level 1,
the lowest copayment level, and the new generic equivalent to be placed on Level 3, the highest
copayment level or excluded. These placements are for a limited time, typically six months, and may
be revised mid-year when such changes are advantageous to The Empire Plan.
UnitedHealthcare will notify you when B4G savings are available.
We will also notify your pharmacist so that the lowest cost option will always be dispensed.
Please refer to the DCS website at https://www.cs.ny.gov
for the most current information regarding the B4G feature.
Generic Drugs are listed in lower case letters. Brand-name drugs are listed with the first letter of the name capitalized.
Symbol Meaning
*
This drug may be available as a generic in 2012 or 2013. When a generic version is available, mandatory generic substitution will apply, unless the brand-name drug has been placed on Level 1. Use of a covered Level 3 or non-preferred brand-name drug when the generic is available will result in the enrollee paying the applicable Level 3 or non-preferred copayment plus the difference in cost between the brand-name drug and the generic, not to exceed the full retail cost of the drug, unless the brand-name drug has been placed on Level 1 of the Flexible Formulary.
A generic is currently available for at least one or more strengths of the brand medication. When a generic is available for a particular strength of the brand-name drug, that strength (if covered) may be Level 3 or non-preferred. A brand-name medication with a Level 1 copayment.
Certain strengths of this medication may be eligible for the Half Tablet Program.
Excluded drugs with 2013 Empire Plan Flexible Formulary Alternatives
Excluded Drugs†
Empire Plan Flexible Formulary Alternatives
diclofenac sodium drops (generic Voltaren Ophthalmic), ketorolac tromethamine drops alendronate sodium tablet (generic Fosamax), ibandronate tablet (generic Boniva) atorvastatin (generic Lipitor) ½T, lovastatin, pravastatin (generic Pravachol) ½T, simvastatin
(generic Zocor) ½T, Crestor ½T
amlodipine/atorvastatin (generic Caduet) amlodipine (generic Norvasc) plus atorvastatin (generic Lipitor) ½T
bupropion hcl extended release, bupropion hcl sustained release bromfenac sodium drops, diclofenac sodium drops (generic Voltaren Ophthalmic), amlodipine (generic Norvasc) plus atorvastatin (generic Lipitor) ½T
cyclobenzaprine extended release capsule oxybutynin, oxybutynin extended release, tolterodine (generic Detrol), trospium (generic Sanctura), Sanctura XR*, Vesicare
omeprazole (generic Prilosec), pantoprazole (generic Protonix) doxycycline hyclate extended release tablet zaleplon (generic Sonata), zolpidem (generic Ambien), zolpidem extended release adapalene (generic Differin) (PA) plus benzoyl peroxide
amlodipine (generic Norvasc) plus valsartan (generic Diovan) ½T
amlodipine (generic Norvasc) plus valsartan (generic Diovan) ½T plus hydrochlorothiazide
(PA), Copaxone (PA), Rebif (PA)
Genotropin (PA)° Nutropin
(PA), Nutropin AQ (PA), Saizen (PA), Tev-Tropin (PA)
Humatrope (PA)°° Nutropin
(PA), Nutropin AQ (PA), Saizen (PA), Tev-Tropin (PA))
finasteride (generic Proscar) plus tamsulosin (generic Flomax) omeprazole (generic Prilosec), pantoprazole (generic Protonix) ° Excluded, except for the treatment of growth failure due to Prader-Willi syndrome or Small for Gestational Age.
°° Excluded, except for the treatment of growth failure due to SHOX deficiency or Small for Gestational Age.
°°° Excluded, except for the treatment of short stature associated with Noonan syndrome or Small for Gestational Age.
† Coverage for prescription drugs excluded under the benefit plan design are not subject to exception. This includes prescription medications excluded from coverage under The Empire Plan Flexible Formulary. New prescription drugs may be subject to exclusion when they become available in the market. Please refer to the DCS website
at https://www.cs.ny.gov or call The Empire Plan Prescription Drug Program toll free at 1-877-7-NYSHIP (1-877-769-7447) for current information regarding exclusions of newly
launched prescription drugs.
Excluded drugs with 2013 Empire Plan Flexible Formulary Alternatives
Excluded Drugs†
Empire Plan Flexible Formulary Alternatives
mometasone furoate topical plus ammonium lactate omeprazole (generic Prilosec), pantoprazole (generic Protonix) Norditropin (PA)°°° Nutropin
(PA), Nutropin AQ (PA), Saizen (PA), Tev-Tropin (PA)
omeprazole (generic Prilosec), pantoprazole (generic Protonix) Omnitrope (PA)° Nutropin
(PA), Nutropin AQ (PA), Saizen (PA), Tev-Tropin (PA))
Orbivan butalbital/acetaminophen/caffeine hydrocortisone/pramoxine cream, Pramosone omeprazole (generic Prilosec), pantoprazole (generic Protonix) ropinirole extended release (generic Requip XL) ropinirole (generic Requip) terbinafine (generic Lamisil) (PA)
tobramycin/dexamethasone drops (generic Tobradex) naproxen sodium plus sumatriptan (generic Imitrex) amlodipine (generic Norvasc) plus hydrochlorothiazide plus Benicar ½T or amlodipine
fenofibrate, Antara, Fenoglide, Lipofen, Triglide fenofibrate, Antara, Fenoglide, Lipofen, Triglide amlodipine (generic Norvasc) plus Micardis (PA) plus clindamycin topical
flunisolide, fluticasone (generic Flonase), Nasonex naproxen plus omeprazole (generic Prilosec) omeprazole (generic Prilosec), pantoprazole (generic Protonix) (PA) plus clindamycin topical
zaleplon (generic Sonata), zolpidem (generic Ambien), zolpidem extended release ° Excluded, except for the treatment of growth failure due to Prader-Willi syndrome or Small for Gestational Age.
°° Excluded, except for the treatment of growth failure due to SHOX deficiency or Small for Gestational Age.
°°° Excluded, except for the treatment of short stature associated with Noonan syndrome or Small for Gestational Age.
† Coverage for prescription drugs excluded under the benefit plan design are not subject to exception. This includes prescription medications excluded from coverage under The Empire Plan Flexible Formulary. New prescription drugs may be subject to exclusion when they become available in the market. Please refer to the DCS website
at https://www.cs.ny.gov or call The Empire Plan Prescription Drug Program toll free at 1-877-7-NYSHIP (1-877-769-7447) for current information regarding exclusions of newly
launched prescription drugs.

Source: http://www.careylong.com/media/13660/2013_Empire_PreferredDrugList.pdf