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SecureScript
ILLUSTRATIVE
MANAGED FORMULARY

Introduction
The formulary has been developed, organized and is administered to promote rational, clinically appropriate, safe and cost effective drug All FDA-approved generic medications are included in the formulary unless safety or efficacy information warrants further consideration. Therefore, the formulary management and development process primarily considers single-source and multi-source brand (collectively, Brands ) medications for which no generic equivalent is available.
Not all classes of drugs are managed by this formulary. This is due several factors such as the number of branded competitive products, generic product availability and utilization patterns. The number of managed drug classes may increase or decrease due to these factors (unless otherwise excluded under your drug benefit design), the brand name drug within that drug class is considered a formulary New drugs approved by the FDA will be considered as non-formulary, third-tier co-payment until such time as the drug is reviewed for formulary consideration and placement.
The preferred Drug formulary will not supersede any coverage limitations included in your Benefit Design or appropriate use or utilization management programs that may be applicable to your benefit.
SPECIALTY PHARMACY
Your health plan requires that selected drugs be dispensed by the *Indicates a generic equivalent for the brand drug is available Contents
Introduction
Formulary
Allergy Asthma
Inhaled Oral Bronchodilators/Corticosteroids Anitbiotics, Macrolide/KetolidesAntibiotics, Fluroquinolones Insomnia/Sleeping Aids, Nonbenzodiazepines AntinauseantsHeartburn/Ulcer Agents/Proton Pump Inhibitors Long Acting Narcotic AnalgesicsRhematoid Arthritis Agents, Injectable Overactive Bladder AgentsProstate Agents Generic Copay
Brand Copay
Non Formulary Copay
Allergy/Asthma
Antihistamines
Inhaled Allergy (Nasal)
Inhaled Corticosteroids (Oral)
Inhaled Broncodilators (Oral)
Inhaled Bronchodilators/Corticosteroids
Leukotriene Modifiers
Generic Copay Brand Copay
Non Formulary Copay
Anti-Infectives
Beta-Lactams
Macrolides/Ketolides
Fluroquinolones
Antiviral, Antiherpes
Antiviral, HEP C
NOTE: HEP C Agents may be provided by Specialty Pharmacy Program & Generic Copay
Brand Copay
Non Formulary Copay
Cardiovascular
ACE Inhibitors
Angiotensin Receptor Blockers (ARBS)
Beta Blockers
Calcium Channel Blockers
Cholesterol Management Agents
Generic Copay
Brand Copay
Non Formulary Copay
Central Nervous System
Alzheimers Agents

Atypical Antipsychotics
Haloperidol
CNS Stimulants
Ritalin Adderall
Antidepressants/Affective Disorder

Hypnotics
Dalmane
Halcion
Prosom
Multiple Sclerosis Agents (MS)
NOTE: MS Agents may be provided by Specialty Pharmacy Program & Prior Authorization

Topical Immunosuppressive
Generic Copay
Brand Copay
Non Formulary Copay
Endocrine
Oral Antidiabetic Agents
Diabinese
Growth Hormone (GH)
NOTE: GH Agents may provided by Specialty Pharmacy Program Generic Copay
Brand Copay
Non Formulary Copay
Endocrine cont.
Contraceptives
Ortho Cept/Ortho Cyclen Tri-Levlen/TriPhasil Osteoporosis Agents
Hormone Replacement Therapy (HRT), Female

Generic Copay
Brand Copay
Non Formulary Copay
Gastointestinal

Heartburn/Ulcer Agents, Proton Pump Inhibitors (PPI)
Axid

Prilosec (10 & 20mg)
Antinauseants
Osteoporosis Agents
Hormone Replacement Therapy (HRT), Female
Generic Copay
Brand Copay Non Formulary Copay
Ophthalmics
Antiglaucoma Agents
Fluoroquinolone Ophthalmics
Generic Copay
Brand Copay
Non Formulary Copay
Pain/Anti-Inflammatory
COX-II Inhibitors
Narcotic Analgesics (Long Acting)
Anti-Migraine Agents
(Triptans)
Rhematoid Arthritis
NOTE: May be covered by Specialty Pharmacy Program .
Generic Copay
Brand Copay
Non Formulary Copay
Urologicals
Overactive Bladder Agents
Ditropan
Erectile Dysfunction Agents
Prostate Agents
Cardura

Source: http://secureoneinc.com/securescript/pdfs/SecureScript_MANAGED_FORMULARY-2006.pdf