2-Tier Closed Preferred List - Sierra Health and Life
2-Tier Closed Preferred List - Sierra Health and Life
2-Tier Closed Preferred List - Sierra Health and Life
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Tri-sprintec, Trinessa, Tri-Previfem *ORTHO TRI-CYCLEN 1 QL (28 tablets/21 days) M<br />
NUVARING 2 QL (1 ring/month)<br />
ORTHO TRI-CYCLEN LO 2 QL (28 tablets/21 days) M<br />
YASMIN 2 QL (28 tablets/21 days) M<br />
6-E Progestins<br />
Generic Name Br<strong>and</strong> Name<br />
<strong>Tier</strong><br />
Notes<br />
medroxyprogesterone *PROVERA 1 M<br />
norethindrone *AYGESTIN 1 M<br />
6-F Oral Antidiabetics (diabetes)<br />
Generic Name Br<strong>and</strong> Name<br />
<strong>Tier</strong><br />
Notes<br />
acarbose *PRECOSE 1 QL (90 tablets/month) M<br />
chlorpropamide *DIABINESE 1 M<br />
glimepiride *AMARYL 1 QL (60 tablets/month) M<br />
glipizide *GLUCOTROL 5mg 1 QL (90 tablets/month) M<br />
glipizide *GLUCOTROL 10mg 1 QL (60 tablets/month) M<br />
glipizide CR *GLUCOTROL XL 2.5mg 1 QL (90 tablets/month) M<br />
glipizide CR *GLUCOTROL XL 5mg 1 QL (60 tablets/month) M<br />
glipizide CR *GLUCOTROL XL 10mg 1 QL (60 tablets/month) M<br />
glipizide-metformin *METAGLIP 1 QL (120 tablets/month) M<br />
glyburide *DIABETA 1 M<br />
glyburide micronized *GLYNASE 1 QL (60 tablets/month) M<br />
glyburide-metformin *GLUCOVANCE 1 QL (120 tablets/month) M<br />
metformin *GLUCOPHAGE 500mg 1 QL (150 tablets/month) M<br />
metformin *GLUCOPHAGE 850mg 1 QL (90 tablets/month) M<br />
metformin *GLUCOPHAGE 1000mg 1 QL (75 tablets/month) M<br />
metformin SR *GLUCOPHAGE XR 500mg 1 QL (120 tablets/month) M<br />
metformin SR *GLUCOPHAGE XR 750mg 1 QL (90 tablets/month) M<br />
nateglinide *STARLIX 1 QL (90 tablets/month)<br />
piolitazone ACTOS 2 QL (30 tablets/month) M<br />
piolitazone-glimepiride DUETACT 2 QL (30 tablets/month) M<br />
piolitazone-metformin ACTOPLUS MET 2 QL (90 tablets/month) M<br />
repaglinide PRANDIN 2 QL (120 tablets/month) M<br />
repaglinide-metformin PRANDIMET 2 M<br />
tolazamide *TOLINASE 1 M<br />
tolbutamide *TOLBUTAMIDE 1<br />
6-G Insulins<br />
6-H Glucagon<br />
QL - Quantity Limits<br />
Generic Name Br<strong>and</strong> Name<br />
insulin (human) HUMULIN 1<br />
insulin (human) HUMULIN PEN 2<br />
insulin glargine LEVEMIR 2<br />
insulin lispro HUMALOG 1<br />
insulin lispro HUMALOG PEN 2<br />
insulin lispro mix HUMALOG MIX 1<br />
insulin lispro mix HUMALOG MIX PEN 2<br />
LANTUS<br />
Generic Name Br<strong>and</strong> Name<br />
AL - Age Limits<br />
<strong>Tier</strong><br />
M<br />
M<br />
M<br />
M<br />
M<br />
M<br />
M<br />
<strong>Tier</strong><br />
Notes<br />
Notes<br />
PA - Prior Authorization Required<br />
ST - Step Therapy Required M - Mail-order/Maintenance drug<br />
SIO - Self-Injectable Orphan 15 2-<strong>Tier</strong> (closed) Drug Benefit Guide 01/04/12
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