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SGRX MANAGED FORMULARY
Formulary Alternatives for Common Non-Covered Drugs
POSSIBLE THERAPEUTIC ALTERNATIVES
The Formulary Alternatives list represents possible options to Not Covered drugs. These alternative medications can generally be prescribedwithout approval from the plan and can be dispensed with normal copayments for members. Therapeutic alternatives may represent a differentdrug class, contain different ingredients, or may be available in different strengths or dosage forms than the prescribed branded products.
Some medications are produced by more than one pharmaceutical manufacturer under different brand names. However, in some cases, onlyone of the brand-name products is listed in the SGRX Managed Formulary. The other brands are considered Not Covered. Providers areencouraged to select the preferred product.
Listed below are examples of therapeutic alternatives a patient’s physician may consider when determining appropriate treatment for the patient.
SGRX Managed Formulary Alternatives for Common Non-Covered Drugs
Not Covered
Formulary Alternative
Not Covered
Formulary Alternative
etc.), Benicar*, or Micardis* PLUSNorvasc(g) Cardizem(g), Cardizem CD(g),Cardizem SR(g) Lodine(g), Mobic(g), Motrin(g),Naprosyn(g), Voltaren(g), etc.
Naprosyn(g), Voltaren(g), etc. plusCytotec(g) Climara(g), Vivelle-DOT, orEstraderm plus a progestin Prozac(g), Wellbutrin, SR, XL(g);Lexapro*, Effexor XR* (g) Use generic equivalent<s> Specialty Drug* Prior Authorization or Step Therapy may be required.
Not Covered
Formulary Alternative
Not Covered
Formulary Alternative
Ultra OTC, Monistat-Derm(g),Nizoral cream, Spectazole (g) Climara(g), Estrace(g), Ogen(g),Vivelle-DOT, Estraderm Climara(g), Estrace(g), Ogen(g),Vivelle-DOT, Estraderm COMMIT LOZENGE OTC Generic nicotine lozenge, patch or Lotrel(g), Generic ACE Inhibitor(lisinopril, benazepril, etc.),Benicar*, or Micardis* PLUSNorvasc(g) DONNATAL EXTENTABS Bentyl(g), Donnatal(g), Robinul(g) Topical OTC analgesic balms, i.e.
trolamine salicylate Ambien(g), Halcion(g), Prosom(g),Restoril(g), Sonata(g) (g) Use generic equivalent<s> Specialty Drug* Prior Authorization or Step Therapy may be required.
Not Covered
Formulary Alternative
Not Covered
Formulary Alternative
Lotrimin(g), Monistat-Derm(g),Nizoral cr(g), Spectazole(g) Androxy(g), Depo-Testosterone(g),Oxandrin(g), Androderm, Delatestryl NAPRELAN 375MG Mobic(g), Motrin(g), Naprosyn, Long-acting nitrate, plus abeta-blocker or calcium channelblocker Ceclor(g), Ceftin(g), Duricef(g),Keflex(g), Omnicef(g) RHINOCORT AQUA Flonase(g), Nasalide(g), Nasarel(g), Ambien(g), Halcion(g), Prosom(g),Restoril(g) Prempro/Premphase, or Estradiolplus progestin Clozaril(g), Risperdal(g), Abilify,Geodon, Zyprexa, Seroquel(IR) (g) Use generic equivalent<s> Specialty Drug* Prior Authorization or Step Therapy may be required.
Not Covered
Formulary Alternative
Not Covered
Formulary Alternative
Ceclor(g), Ceftin(g), Duricef(g),Keflex(g), Omnicef(g) Adderall(g), Focalin(g), Ritalin(g),Adderall XR, Concerta, MetadateCD Androxy(g), Depo-testosterone(g),Oxandrin(g), Androderm, Delatestryl SULAR 8.5, 17, 25.5, Sular(g), Cardene(g), Norvasc(g),34mg tabs, Omeprazole (RX) caps; plusNaprosyn(g) Prilosec OTC*, Omeprazole DRTabs, Omeprazole (Rx) Caps Individual agents: Cleocin topical(g)and Retin-A(g) Lortab(g), Tylenol with Codeine(g),Vicodin(g), (g) Use generic equivalent<s> Specialty Drug* Prior Authorization or Step Therapy may be required.
Not Covered
Formulary Alternative
Not Covered
Formulary Alternative
Diprolene(g), Psorcon(g),Temovate(g), Ultravate(g) Flonase(g), Nasalide(g),Nasarel(g), Nasacort AQ* Elocon(g), Locoid(g), Synalarsolution(g), Capex Topical OTC analgesic balms, i.e.
trolamine salicylate (g) Use generic equivalent<s> Specialty Drug* Prior Authorization or Step Therapy may be required.

Source: http://www.scriptguiderx.com/UPLOADS/formularies/sgrx_facnd.pdf

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Altius Health Plans, Inc. Coventry Health Care plans Coventry Health and Life Insurance Company 2013 Prescription Drug List HealthAmerica Pennsylvania, Inc. HealthAssurance Pennsylvania, Inc. Alphabetical Listing The Prescription Drug List is an alphabetical list of approved medicines covered by your benefit plan. In the Prescription Drug List, generic drugs are listed by the

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