PRESCRIPTION DRUG - Public Employees' Benefits Program (PEBP)

$$$$$ DALIRESP(PAR) History of treatment withalbuterol and inhaled corticosteroidX(ST) History of treatment withalbuterol and inhaled corticosteroidQLL=2 inhalers/Rx Age Edit=$$$ DULERACovered for 12 years of age andolderX$$$$ DUONEB X albuterol + ipratropium$$$ FLOVENT HFA QLL=2 inhalers/Rx X$$ FLOVENT ROTADISK QLL=120 disks/Rx X$$$$$ INTAL* X cromolyn sodium!!!!! PULMICORT QLL=2 inhalers/Rx; X ASMANEX, FLOVENT HFA!!!!! PULMICORT RESPULESAge Edit= only covered for childrenbetween 1- 8 years of ageX$$ QVAR QLL=3 inhalers/Rx X!!!!! SPIRIVA (ST) history of albuterol X(ST) History of treatment withalbuterol and inhaled corticosteroidQLL=2 inhalers/Rx Age Edit=!!!!! SYMBICORTCovered for 12 years of age andolderX$$$$$ TILADE X15.1.4 LEUKOTRIENE MODIFIERS$$ zafirlukast X$$$$$ ACCOLATE(ST) history of FLOVENT or anyoral inhaled corticosteroidX!!!!! SINGULAIRQLL=30 tabs/Rx (ST)history of anyoral inhaled corticosteroid or anynasal steroid Age Edit= memberbetween 2 -14 yrs 2nd Tier;member >14yrs 3rd Tier X X ACCOLATE!!!!! ZYFLO(ST) history of Flovent or any oralinahled corticosteroidX15.2.1 ANTIHISTAMINES$ carbinoxamine maleate X$ cetirizine OTCRequires a prescription to apply 1sttier copayX$ chlorpheniramine (SA 12mg) (M) X$ cyproheptadine hcl (M) XNOT COVERED effective$ fexofenadine OTC (M)11/1/2011 X OTC loratadine, OTC cetirizine$$ hydroxyzine hcl (M) X$$ hydroxyzine pamoate (M) X$ loratadine OTCRequires a prescription to apply 1sttier copayX$ promethazine hcl (M) (PAR) chidlren