How to Use Your Pharmacy Benefit - Tufts Health Plan
How to Use Your Pharmacy Benefit - Tufts Health Plan
How to Use Your Pharmacy Benefit - Tufts Health Plan
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TIER 1 COPAYMENT<br />
ACETAMINOPHEN-CODEINE<br />
ACYCLOVIR<br />
ALBUTEROL SULFATE QL<br />
ALENDRONATE SODIUM<br />
ALLOPURINOL<br />
ALPRAZOLAM<br />
AMITRIPTYLINE HCL<br />
AMLODIPINE BESYLATE<br />
AMLODIPINE BESYLATE-BENAZEP<br />
AMOX TR-POTASSIUM CLAVULANA<br />
AMOXICILLIN<br />
AMPHETAMINE SALT COMBO<br />
APRI*<br />
ATENOLOL<br />
AVIANE*<br />
AZITHROMYCIN<br />
BENZONATATE<br />
BETAMETHASONE DIPROPIONATE<br />
BUPROPION HCL<br />
BUPROPION HCL SR<br />
BUPROPION XL<br />
BUSPIRONE HCL<br />
BUTALBITAL-ACETAMINOPHEN-CA<br />
CAMILA*<br />
CARVEDILOL<br />
CEPHALEXIN<br />
CHERATUSSIN AC<br />
CHLORHEXIDINE GLUCONATE<br />
CHLORTHALIDONE<br />
CIPROFLOXACIN HCL<br />
CITALOPRAM HBR<br />
CLINDAMYCIN HCL<br />
CLINDAMYCIN PHOSPHATE<br />
CLOBETASOL PROPIONATE<br />
CLONAZEPAM<br />
CLONIDINE HCL<br />
CLOTRIMAZOLE-BETAMETHASONE<br />
CRYSELLE*<br />
CYCLOBENZAPRINE HCL<br />
TIER 2 COPAYMENT<br />
ADVAIR DISKUS QL<br />
ANDROGEL<br />
ATORVASTATIN CALCIUM<br />
BENICAR<br />
CLOPIDOGREL<br />
COLCRYS QL<br />
DIOVAN<br />
ENBREL SP;PA;QL<br />
QL;STPA<br />
ABILIFY<br />
CELEBREXPA CIALIS QL<br />
CYMBALTAQL;STPA Top 200 Covered Drugs<br />
This is a list of the 200 medications most used by <strong>Tufts</strong> <strong>Health</strong> <strong>Plan</strong><br />
members. This is not a complete list of drugs covered by the <strong>Tufts</strong> <strong>Health</strong> <strong>Plan</strong><br />
pharmacy benefit. For a complete list, visit tuftshealthplan.com. For more detailed<br />
benefit information, please review your benefit<br />
TIER 3 COPAYMENT<br />
DESONIDE<br />
DEXTROAMPHETAMINE-AMPHETAMI<br />
DIAZEPAM<br />
DICLOFENAC SODIUM<br />
DILTIAZEM 24HR ER<br />
DIVALPROEX SODIUM<br />
DOXAZOSIN MESYLATE<br />
DOXYCYCLINE HYCLATE<br />
ENALAPRIL MALEATE<br />
ENPRESSE*<br />
ERYTHROMYCIN<br />
ESTRADIOL<br />
FENOFIBRATE<br />
FINASTERIDE<br />
FLUCONAZOLE<br />
FLUOCINONIDE<br />
FLUORIDE<br />
FLUOXETINE HCL<br />
FLUTICASONE PROPIONATE<br />
FOLIC ACID<br />
FUROSEMIDE<br />
GABAPENTIN<br />
GEMFIBROZIL<br />
GIANVI*<br />
GLIMEPIRIDE<br />
GLIPIZIDE<br />
GLIPIZIDE ER<br />
GLYBURIDE<br />
HYDROCHLOROTHIAZIDE<br />
HYDROCODONE-ACETAMINOPHEN<br />
HYDROCORTISONE<br />
HYDROMORPHONE HCL<br />
HYDROXYCHLOROQUINE SULFATE<br />
HYDROXYZINE HCL<br />
IBUPROFEN<br />
INDOMETHACIN<br />
IOPHEN-C NR<br />
JUNEL*<br />
JUNEL FE*<br />
EPIPEN 2-PAK QL<br />
ESCITALOPRAM OXALATE<br />
FLOVENT HFA QL<br />
HUMALOG<br />
HUMIRA SP;PA;QL<br />
JANUVIA<br />
LANTUS<br />
LANTUS SOLOSTAR<br />
DIOVAN HCT<br />
LEXAPRO STPA<br />
PANTOPRAZOLE SODIUM STPA<br />
PREMARIN<br />
Please note: A drug’s tier placement may change at any time during the year.<br />
The list of Top 200 Covered Drugs is current as of January 2013.<br />
*Generic product covered without copayment under Women’s <strong>Health</strong> Preventive<br />
Services Initiative.<br />
KARIVA*<br />
KETOCONAZOLE<br />
LABETALOL HCL<br />
LAMOTRIGINE<br />
LATANOPROST<br />
LEVETIRACETAM<br />
LEVOFLOXACIN<br />
LEVOTHYROXINE SODIUM<br />
LEVOXYL<br />
LISINOPRIL<br />
LISINOPRIL-HYDROCHLOROTHIAZ<br />
LITHIUM CARBONATE<br />
LORAZEPAM<br />
LOSARTAN POTASSIUM<br />
LOSARTAN-HYDROCHLOROTHIAZID<br />
LOVASTATIN<br />
LUTERA*<br />
MELOXICAM<br />
METFORMIN HCL<br />
METFORMIN HCL ER<br />
METHOTREXATE<br />
METHYLPHENIDATE HCL<br />
METHYLPREDNISOLONE<br />
METOPROLOL SUCCINATE<br />
METOPROLOL TARTRATE<br />
METRONIDAZOLE<br />
MICROGESTIN FE*<br />
MINOCYCLINE HCL<br />
MIRTAZAPINE<br />
MUPIROCIN<br />
NAPROXEN<br />
NECON*<br />
NIFEDIPINE ER<br />
NITROFURANTOIN MONO-MACRO<br />
NORTREL*<br />
NORTRIPTYLINE HCL<br />
NYSTATIN<br />
OCELLA*<br />
OMEPRAZOLE QL<br />
METHYLPHENIDATE ER<br />
MONTELUKAST SODIUM<br />
NASONEX QL<br />
NOVOLOG<br />
NUVARING<br />
ONE TOUCH ULTRA TEST STRIPS<br />
OXYCONTIN QL<br />
PROAIR HFA QL<br />
PA; QL<br />
SUBOXONE<br />
SYNTHROID<br />
VENTOLIN HFAQL VIAGRAQL ONDANSETRON HCL QL<br />
ONDANSETRON ODT QL<br />
OXCARBAZEPINE<br />
OXYCODONE HCL<br />
OXYCODONE-ACETAMINOPHEN<br />
PAROXETINE HCL<br />
PENICILLIN V POTASSIUM<br />
PRAVASTATIN SODIUM<br />
PREDNISOLONE ACETATE<br />
PREDNISOLONE SODIUM PHOSPHA<br />
PREDNISONE<br />
PROPRANOLOL HCL<br />
QUINAPRIL HCL<br />
RANITIDINE HCL<br />
RECLIPSEN*<br />
RISPERIDONE<br />
SERTRALINE HCL<br />
SIMVASTATIN<br />
SPIRONOLACTONE<br />
SPRINTEC*<br />
SULFAMETHOXAZOLE-TRIMETHOPR<br />
SUMATRIPTAN SUCCINATE QL<br />
TAMOXIFEN CITRATE<br />
TAMSULOSIN HCL<br />
TOPIRAMATE<br />
TRAMADOL HCL<br />
TRAZODONE HCL<br />
TRETINOIN PA<br />
TRI-SPRINTEC*<br />
TRIAMCINOLONE ACETONIDE<br />
TRIAMTERENE-HCTZ<br />
VALACYCLOVIR<br />
VENLAFAXINE HCL<br />
VENLAFAXINE HCL ER<br />
VERAPAMIL ER<br />
VITAMIN D2<br />
WARFARIN SODIUM<br />
ZOLPIDEM TARTRATE QL<br />
ZOVIA 1-35E*<br />
QUETIAPINE FUMARATE STPA<br />
SPIRIVA QL<br />
STRATTERA QL<br />
SYMBICORT QL<br />
VAGIFEM<br />
VYVANSE STPA<br />
ZETIA<br />
2/13 - 19380
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