100_8106 t1000 5_08 digi_9
2008 Three-Tier Prescription Drug List Reference Guide
Acetaminophen with Codeine
QLL/QD
and Butalbital
QLL/QD
Bupropion
QLL
Bupropion Sustained Action
QLL, N
300mg
QLL, N
Butorphanol Nasal Spray
QLL
Alendronate
QLL
Cefdinir
QLL
Amlodipine and Benazepril
QLL
Ciclopirox Solution, Topical
QLL
Estradiol Patch
QLL
Asmanex
QLL
Citalopram
QLL
Famciclovir
QLL
Fast Take Test Strips
QLL, DS
Fentanyl Citrate Lollipop
QLL/QD, N
Fentanyl Transdermal System
QLL/QD
Fexofenadine
QLL/QD
Finasteride
N
Fluconazole 50, 100, 200mg
N
Fluconazole 150mg
QLL
Flunisolide Nasal Spray
QLL
Some medications are noted with N, QD, QLL, or DS. The definitions for these symbols are listed below. Your benefit plan determines how these medications may be covered for you.
= Notification. There are a few medications that your doctor must notify us of to make sure their use is covered within your benefit.
= Progression Rx.
QD = Quantity Duration. Some medications have a limited amount that can be covered for a specific period of time.
QLL = Quantity Level Limit. Some medications have a limited amount that can be covered at one time.
DS = Diabetic Supplies. Diabetic supplies may be covered by your benefit plan.
1/2T = Eligible for Half Tablet Program.
2008 Three-Tier Prescription Drug List Reference Guide
Mirtazapine Dispersible Tablet
QLL
Fluoxetine
QLL
Moexipril
1/2T
Fluticasone Nasal Spray
QLL
Leflunomide
QLL
Fluvoxamine
QLL
Foradil
QLL
Release
QLL/QD
Fortical
QLL
Dosepack, 3 Month
QLL
Freestyle Lite Test Strips
QLL, DS
Freestyle Test Strips
QLL, DS
Frova
QLL
Nefazodone
QLL
Lovastatin
QLL/QD
Maxalt
QLL
Maxalt MLT
QLL
Medroxyprogesterone 150mg/ml
QLL
Mefloquine
QLL
Granisetron Tablet
QLL
Meloxicam
QLL
Omeprazole
QLL/QD
Ondansetron
QLL
One Touch Test Strips
QLL, DS
One Touch Ultra Test Strips
QLL, DS
Oxybutynin Sustained Release
QLL
Itraconazole
QLL, N
Oxycodone with Ibuprofen
QLL
Pantoprazole
QLL/QD
Paroxetine
QLL
Mirtazapine
QLL
Some medications are noted with N, QD, QLL, or DS. The definitions for these symbols are listed below. Your benefit plan determines how these medications may be covered for you.
= Notification. There are a few medications that your doctor must notify us of to make sure their use is covered within your benefit.
= Progression Rx.
QD = Quantity Duration. Some medications have a limited amount that can be covered for a specific period of time.
QLL = Quantity Level Limit. Some medications have a limited amount that can be covered at one time.
DS = Diabetic Supplies. Diabetic supplies may be covered by your benefit plan.
1/2T = Eligible for Half Tablet Program.
2008 Three-Tier Prescription Drug List Reference Guide
Zomig
QLL
Zomig ZMT
QLL
Pravastatin
QLL/QD
Surestep Test Strips
QLL, DS
Precision Q-I-D Test Strips
QLL, DS
Precision Xtra Test Strips
QLL, DS
Terbinafine Tablet
QLL, N
Terconazole Cream
QLL
Terconazole Suppository
QLL
Tramadol
QLL
Tramadol with Acetaminophen
QLL
Trandolapril
1/2T
Tretinoin
N
Pulmicort Flexhaler
QLL
Pulmicort Turbuhaler
QLL
Relpax
QLL
Ribavirin
QLL, N
Venlafaxine
QLL
Sertraline
QLL, 1/2T
Xopenex HFA
QLL
Simvastatin
QLL/QD
Zolpidem
QLL/QD
Some medications are noted with N, QD, QLL, or DS. The definitions for these symbols are listed below. Your benefit plan determines how these medications may be covered for you.
= Notification. There are a few medications that your doctor must notify us of to make sure their use is covered within your benefit.
= Progression Rx.
QD = Quantity Duration. Some medications have a limited amount that can be covered for a specific period of time.
QLL = Quantity Level Limit. Some medications have a limited amount that can be covered at one time.
DS = Diabetic Supplies. Diabetic supplies may be covered by your benefit plan.
1/2T = Eligible for Half Tablet Program.
2008 Three-Tier Prescription Drug List Reference Guide
Cozaar
QLL/QD, 1/2T
Micardis HCT
QLL/QD
Crestor
QLL/QD, 1/
Aciphex
QLL/QD
Nasonex
QLL
Actonel
QLL
Actonel with Calcium
QLL
Actoplus Met
QLL
Norditropin
QLL/QD, N
Actos
QLL
Diovan
QLL/QD, 1/2T
Adderall XR
QLL
Diovan HCT
QLL/QD
Dovonex
QLL
Nutropin
QLL/QD, N
Duetact
QLL
Effexor XR
QLL
Oxycontin
QLL/QD
Alphagan P
QLL
Emend
QLL
Enablex
QLL
Pegasys
QLL, N
Altoprev
QLL/QD
Peg-Intron
QLL, N
Androgel
QLL
Epogen
QLL/QD
Prandin
QLL
Esclim
QLL
Estraderm
QLL
Aranesp
QLL/QD
Aricept
QLL
Aricept ODT
QLL
Estring
QLL
Arixtra
QLL
Prevacid Solutab
QLL/QD
Fosamax Plus D
QLL
Prevpac
QLL
Astelin
QLL
Procrit
QLL/QD
Avandamet
QLL
Geodon
QLL
Avandaryl
QLL
Avandia
QLL
Protonix
QLL/QD
Avonex
QLL
Humatrope
QLL/QD, N
Protopic
QLL, N
Hyzaar
QLL/QD
Pulmicort Respules
QLL
Imitrex Injection
QLL
Bactroban Cream, Nasal Ointment
QLL
Intal
QLL
Ranexa
QLL
Benicar
QLL/QD, 1/
Janumet
QLL
Benicar HCT
QLL/QD
Januvia
QLL
Betaseron
QLL/QD
Retin-A Micro
QLL, N
Risperdal (M-Tab = Tier 3)
QLL
Roferon A
QLL, N
Boniva
QLL
Seroquel
QLL
Byetta
QLL
Lidoderm
QLL/QD
Serostim
QLL/QD, N
Singulair
QLL
Lipitor
QLL/QD, 1/2T
Spiriva
QLL
Lovenox
QLL
Lumigan
QLL
Tazorac
QLL, N
Climara
QLL
Testim 1%
QLL
Copaxone
QLL
Tev-Tropin
QLL/QD, N
Micardis
QLL/QD
Tilade
QLL
Some medications are noted with N, QD, QLL, or DS. The definitions for these symbols are listed below. Your benefit plan determines how these medications may be covered for you.
= Notification. There are a few medications that your doctor must notify us of to make sure their use is covered within your benefit.
= Progression Rx.
QD = Quantity Duration. Some medications have a limited amount that can be covered for a specific period of time.
QLL = Quantity Level Limit. Some medications have a limited amount that can be covered at one time.
DS = Diabetic Supplies. Diabetic supplies may be covered by your benefit plan.
1/2T = Eligible for Half Tablet Program.
2008 Three-Tier Prescription Drug List Reference Guide
Travatan
QLL
Travatan Z
QLL
Tricor Tablet
Triglide
Triphasil
Trusopt
Twinject
QLL
Urso
Urso Forte
Valtrex
QLL
Vesicare
QLL
Vivelle
QLL
Vivelle-Dot
QLL
Vytorin
QLL
Vyvanse
QLL
Welchol
Yasmin
Yaz
Zegerid
QLL/QD
Zomig Nasal Spray
QLL
Zovirax Ointment, Cream
Zylet
Zyprexa (Zydis = Tier 3)
QLL
Some medications are noted with N, QD, QLL, or DS. The definitions for these symbols are listed below. Your benefit plan determines how these medications may be covered for you.
= Notification. There are a few medications that your doctor must notify us of to make sure their use is covered within your benefit.
= Progression Rx.
QD = Quantity Duration. Some medications have a limited amount that can be covered for a specific period of time.
QLL = Quantity Level Limit. Some medications have a limited amount that can be covered at one time.
DS = Diabetic Supplies. Diabetic supplies may be covered by your benefit plan.
1/2T = Eligible for Half Tablet Program.
2008 Three-Tier Prescription Drug List Reference Guide
Tier Three
Cosopt
QLL
Abilify
QLL
Lexapro
QLL, 1/2T
Accolate
QLL
Accu-Chek Test Strips
QLL, DS
Cymbalta
QLL/QD
Advair Diskus
QLL
Daytrana
QLL
Advair HFA
QLL
Lovaza
QLL
Allegra ODT
QLL/QD, Excluded
Lunesta
QLL/QD
Allegra Suspension
QLL/QD, Excluded
Allegra-D
QLL/QD, Excluded
Detrol LA
QLL
Differin
QLL, N
Lyrica
QLL/QD
Maxair Autohaler
QLL
Ambien CR
QLL/QD
Amerge
QLL
Elidel
QLL, N
Metadate CD
QLL
Anzemet
QLL
Miacalcin Nasal Spray
QLL
Enbrel
QLL/QD
Epipen
QLL
Ascensia Autodisc
QLL, DS
Epipen Jr.
QLL
Ascensia Elite
QLL, DS
Nasacort
QLL
Atacand
QLL/QD, 1/
Nasacort AQ
QLL
Atacand HCT
QLL/QD
Avalide
QLL/QD
Fentora
QLL/QD, N
Nexium
QLL/QD, Excluded
Avapro
QLL/QD, 1/
Avinza
QLL/QD
Flovent HFA
QLL
Avodart
QLL, N
Focalin
QLL
Axert
QLL
Focalin XR
QLL
Azmacort
QLL
Genotropin
QLL/QD, N
Beconase AQ
QLL
Glucometer Test Strips
QLL, DS
Ortho Evra
QLL
Caduet
QLL
Catapres-TTS
QLL
Celebrex
QLL/QD
Humira
QLL/QD
Cesamet
QLL, P
Imitrex Nasal Spray
QLL
Chemstrip BG Test Strips
QLL, DS
Imitrex Tablet
QLL
Cialis
QD
Intron A
QLL, N
Invega
QLL
Clarinex
QLL/QD, Excluded
Kadian
QLL/QD
Paxil CR
QLL
Clarinex-D
QLL/QD, Excluded
Climara Pro
QLL
Kineret
QLL/QD
Pexeva
QLL, 1/2T
Combipatch
QLL
Lescol
QLL/QD
Combivent
QLL
Lescol XL
QLL/QD
Concerta
QLL
Coreg CR
QLL
Levitra
QD
Some medications are noted with N, QD, QLL, or DS. The definitions for these symbols are listed below. Your benefit plan determines how these medications may be covered for you.
= Notification. There are a few medications that your doctor must notify us of to make sure their use is covered within your benefit.
= Progression Rx.
QD = Quantity Duration. Some medications have a limited amount that can be covered for a specific period of time.
QLL = Quantity Level Limit. Some medications have a limited amount that can be covered at one time.
DS = Diabetic Supplies. Diabetic supplies may be covered by your benefit plan.
1/2T = Eligible for Half Tablet Program.
Excluded = Many benefit plans exclude coverage of medications that are classified by the Pharmacy and Therapeutics Committee as therapeutically equivalent to over-the-counter
medications. Check your benefit plan documents for coverage information or call the Customer Care number on your ID card for more information.
2008 Three-Tier Prescription Drug List Reference Guide
Zetia
QLL/QD
Ziana
QLL
Prevacid Capsule
QLL/QD, Excluded
ProAir HFA
QLL
Proventil HFA
QLL
Provigil
QLL, N
Prozac Weekly
QLL
Quixin
Rebif
QLL/QD
Relenza
QLL, N
Restasis
QLL, N
Restoril 7.5, 22.5mg
Rhinocort
QLL
Rhinocort Aqua
QLL
Ritalin LA
QLL
Rosanil
Rozerem
QLL/QD
Sanctura
QLL
Sarafem
QLL
Seasonique
Sensipar
Serevent Diskus
QLL
Skelaxin
Sonata
QLL/QD
Starlix
QLL
Strattera
QLL
Symlin
QLL
Tamiflu
QLL, N
Tarka
Tekturna
QLL/QD
Tequin
Teveten
QLL/QD
Theo-24
Tobradex
Topamax
Tracer BG Test Strips
QLL, DS
Transderm-Scop
Tri-Norinyl
Triaz
Excluded
Tussionex
Uniretic
Uroxatral
QLL
Vagifem
Vantin
Ventolin HFA
QLL
Viagra
QD
• Compounded prescriptions are
Tier Three
Visicol
Wellbutrin XL
QLL, N
• Insulin pens & cartridges are Tier
Xalatan
QLL
Three except for Novolin and
Novolog pens and cartridges
Xyzal
QLL/QD
which are Tier Two.
Zelnorm
QLL/QD, N
Some medications are noted with N, QD, QLL, or DS. The definitions for these symbols are listed below. Your benefit plan determines how these medications may be covered for you.
= Notification. There are a few medications that your doctor must notify us of to make sure their use is covered within your benefit.
= Progression Rx.
QD = Quantity Duration. Some medications have a limited amount that can be covered for a specific period of time.
QLL = Quantity Level Limit. Some medications have a limited amount that can be covered at one time.
DS = Diabetic Supplies. Diabetic supplies may be covered by your benefit plan.
1/2T = Eligible for Half Tablet Program.
Excluded = Many benefit plans exclude coverage of medications that are classified by the Pharmacy and Therapeutics Committee as therapeutically equivalent to over-the-counter
medications. Check your benefit plan documents for coverage information or call the Customer Care number on your ID card for more information.
2008 Three-Tier Prescription Drug List Reference Guide
Additional Tier Three drugs
with a generic equivalent
Ditropan XL
QLL (Oxybutynin Sustained
Mevacor
QLL/QD (Lovastatin
QLL/QD)
in Tier One
Release
QLL)
Mobic
QLL (Meloxicam
QLL)
Actiq
QLL/QD, N (Fentanyl Citrate
Lollipop
QLL/QD, N)
Duragesic
QLL/QD (Fentanyl
Transdermal System
QLL/QD)
Allegra
QLL/QD (Fexofenadine
QLL/QD)
Ambien
QLL/QD (Zolpidem
QLL/QD)
Effexor
QLL (Venlafaxine
QLL)
Nasalide
QLL, Nasarel
QLL (Flunisolide
Nasal Spray
QLL)
Arava
QLL (Leflunomide
QLL)
Famvir
QLL (Famciclovir
QLL)
Omnicef
QLL (Cefdinir
QLL)
Paxil
QLL (Paroxetine
QLL)
Penlac
QLL (Ciclopirox Solution, Topical
Flonase
QLL (Fluticasone Nasal
Spray
QLL)
Percocet 5-325, 7.5-500, 10-650
QLL/QD
Fosamax
QLL (Alendronate
QLL)
Pravachol
QLL/QD, 1/2T (Pravastatin
QLL/QD, 1/2T)
Celexa
QLL (Citalopram
QLL)
Kytril Tablet
QLL (Granisetron Tablet
Proscar
N (Finasteride
N)
Lamisil Tablet
QLL, N (Terbinafine Tablet
Prozac
QLL (Fluoxetine
QLL)
Rebetol
QLL, N (Ribavirin
QLL, N)
Combunox
QLL (Oxycontin with
Ibuprofen
QLL)
Remeron
QLL (Mirtazapine
QLL)
Copegus
QLL, N (Ribavirin
QLL, N)
Remeron SolTab
QLL (Mirtazapine
Dispersible Tablet
QLL)
Darvocet-N
QLL/QD (Propoxyphene with
Acetaminophen
QLL/QD)
Depo-Provera
QLL
Lotrel
QLL (Amlodipine and
Sporanox
QLL, N (Itraconazole
QLL, N)
150mg/ml
QLL)
Benazepril
QLL)
Terazol
QLL (Terconazole
QLL)
Mavik
1/2T (Trandolapril
1/2T)
Tablet
N (Fluconazole
N)
Tylenol #3
QLL/QD (Acetaminophen with
Diflucan 150mg
QLL (Fluconazole
QLL)
Codeine
QLL/QD)
Some medications are noted with N, QD, QLL, or DS. The definitions for these symbols are listed below. Your benefit plan determines how these medications may be covered for you.
= Notification. There are a few medications that your doctor must notify us of to make sure their use is covered within your benefit.
= Progression Rx.
QD = Quantity Duration. Some medications have a limited amount that can be covered for a specific period of time.
QLL = Quantity Level Limit. Some medications have a limited amount that can be covered at one time.
DS = Diabetic Supplies. Diabetic supplies may be covered by your benefit plan.
1/2T = Eligible for Half Tablet Program.
2008 Three-Tier Prescription Drug List Reference Guide
Ultracet
QLL (Tramadol with
Acetaminophen
QLL)
Ultram
QLL (Tramadol
QLL)
Ultravate Cream, Ointment (Halobetasol
Univasc
1/2T (Moexipril
1/2T)
Valium (Diazepam)
Vaseretic (Enalapril with
Vasotec (Enalapril)Verelan PM (Verapamil Sustained
Vicodin
QLL/QD, Vicodin ES
QLL/QD
(Acetaminophen with Hydrocodone
QLL/QD)
Voltaren Tablet (Diclofenac)
Wellbutrin
QLL (Bupropion
QLL)
Wellbutrin SR
QLL, N (Bupropion
Sustained Action
QLL, N)
Wellbutrin XL 300mg
QLL, N (Bupropion
Sustained Release 24 Hour
QLL, N)
Xanax, Xanax XR (Alprazolam)Zantac Syrup (Ranitidine Syrup)Ziac (Bisoprolol with
Zithromax (Azithromycin)
Zocor
QLL/QD, 1/2T
(Simvastatin
QLL/QD, 1/2T)
Zofran
QLL (Ondansetron
QLL)
Zoloft
QLL, 1/2T (Sertraline
QLL, 1/2T)
Zonegran (Zonisamide)
Zovirax Tablet, Capsule, Suspension
Some medications are noted with N, QD, QLL, or DS. The definitions for these symbols are listed below. Your benefit plan determines how these medications may be covered for you.
= Notification. There are a few medications that your doctor must notify us of to make sure their use is covered within your benefit.
= Progression Rx.
QD = Quantity Duration. Some medications have a limited amount that can be covered for a specific period of time.
QLL = Quantity Level Limit. Some medications have a limited amount that can be covered at one time.
DS = Diabetic Supplies. Diabetic supplies may be covered by your benefit plan.
1/2T = Eligible for Half Tablet Program.
Source: http://www.plcsi.com/drugformulary.pdf
July, 2012 STATE MEDICAL FACULTY OF WEST BENGAL Diploma in Pharmacy Course Examinations Pharmaceutics - II ANSWER ANY FIVE QUESTIONS TAKING AT LEAST TWO FROM EACH GROUP: USE SEPARATE ANSWER SCRIPT FOR EACH GROUP GROUP – A i) Inscription is the main part of a Prescription. (T/F)ii) Deliquescent drugs can be dispensed in powder form. (T/F)iii) Vanishing creams are _________ e
En Bogotá se comercializan más de 45 tipos deUn estudio de la Policía señaló que en la capital hay 130 puntos de venta de drogassintéticas, las cuales desplazaron el consumo de marihuana, cocaína y heroína. Elanálisis químico reveló que estos alucinógenos contienen desde viagra hasta Lee también: El estudio encontró que las organizaciones traficantes también incorporan a