To order additional copies, please call Massachusetts Medical

Lipid-Lowering Drugs
Name AETNA BCBSMA BMCHP FCHP HPHC HNE NHP NTWK MAHLTH THP
NIACIN ER [Niaspan] X* X* X X X X X X X*
OMEgA-3-ACID ETHyL EsTERs
[Lovaza]
X* NC PA PA X NC PA NC
PRAVAsTATIN DL* DL* X X X DL DL X DL X*
PRAVAsTATIN [Pravachol] DL FE NC DL
sT
PA X NC PA NC sT
ROsUVAsTATIN [Crestor] DL sT* DL sT* PA DL X DL sT PA PA sT*
sIMVAsTATIN DL* DL* X X X DL DL X DL X*
sIMVAsTATIN [zocor] DL FE NC DL
sT
PA X NC PA NC sT
sIMVAsTATIN/EzETIMIBE [Vytorin] DL* sT DL sT PA DL sT PA PA sT*
Migraine Therapy
ALMOTRIPTAN [Axert] DL FE NC DL DL sT DL4 DL1 sT PA DL2 sT sT
DIHyDROERgOTAMINE injection X3 X X X X DL X
DIHyDROERgOTAMINE nasal spray DL FE DL DL X X X DL PA DL
[Migranal] sT
ELETRIPTAN [Relpax] DL FE DL sT DL sT DL DL4 X5 DL1 sT PA DL2 sT
ERgOTAMINE [Ergomar] X X* X X X X X X
ERgOTAMINE/CAFFEINE X* X* X X X X X X X X
FROVATRIPTAN [Frova] DL FE NC DL DL sT DL6 DL1 sT PA DL1 sT sT
IsOMETHEPTENE/
DICHLORALPHENAzONE/APAP
X X X
IsOMETHEPTENE/
DICHLORALPHENAzONE/APAP
[Midrin]
X X X NC X
NARATRIPTAN [Amerge] DL* DL sT DL sT DL7 DL5 DL1 sT PA DL1 RIzATRIPTAN tablets [Maxalt] DL* NC DL DL sT DL8 DL1 sT PA DL* 1
sT
1 9 tabs/30 days
2 6 tabs/30 days
3 Not covered under pharmacy benefit; may be covered under medical benefit
4 Maximum of 12 tabs/copay depending on strength
5 12 tabs/30 days
6 9 tabs/copay
7 Maximum of 15 tabs/copay depending on strength
8 Maximum of 18 tabs/copay depending on strength
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