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41466 Metavante_FormularyI:GHI_2008_FormularyI 5/23/08 8:00 PM Page 1 The fol owing is a list of the most commonly prescribed drugs. It represents an abbreviated version
of the drug list (formulary) that is at the core of your pharmacy benefit plan. The list is not al -
inclusive and does not guarantee coverage. In addition to using the list, you are encouraged to ask
your doctor to prescribe generic drugs whenever appropriate.
PLEASE NOTE: Drugs listed on this document may become non-Preferred if a generic equivalent
product becomes available throughout the year. Not al the drugs listed are covered by al
Pharmacy Services
pharmacy benefit programs. Check your benefit materials for the specific drugs covered and the
copay information for your pharmacy benefit program. For specific questions about your coverage,
Formulary I
please cal the phone number printed on your ID card.
41466 Metavante_FormularyI:GHI_2008_FormularyI 5/23/08 8:00 PM Page 2 Examples of Non-Preferred Medications with Their Preferred Alternatives
The following is a list of some non-Preferred brand medications with examples of Preferred alternatives that are on the formulary. Column 1 lists examples of non-Preferred medications.
Column 2 lists some alternatives that can be prescribed. Thank you for your compliance.
Non-Preferred
Preferred Alternative
Non-Preferred
Preferred Alternative
benazepril, enalapril, lisinopril, ALTACE* lovastatin, CRESTOR, VYTORIN, ADVICOR, simvastatin amox tr/potassium clavulanate, AUGMENTIN XR benazepril, enalapril, lisinopril, ALTACE lovastatin, CRESTOR, VYTORIN, simvastatin citalopram, fluxotine (daily), paroxetine amox tr/potassium clavulanate, AUGMENTIN XR methylphenidate, CONCERTA, Metadate CD/ER amox tr/potassium clavulanate, AUGMENTIN XR ABILIFY, RISPERDAL (non M-Tab), SEROQUEL, ZYPREXA (non- Zydis) benazepril/HCTZ, enalapril/hctz, lisinopril/hctz amox tr/potassium clavulanate, AUGMENTIN XR lovastatin, CRESTOR, VYTORIN, simvastatin Brand name drugs are listed in CAPITAL let ers.
Generic drugs are listed in lower case let ers.
The symbol * next to a drug signifies brand drug wil convert to non-Preferred status when generic is available throughout the year.
The symbol [inj] next to a drug indicates that the drug is available in injectable form only.
The symbol [PA] next to a drug stands for Prior Authorization, which is needed prior to coverage of this drug, plan dependent.
The symbol [ST] next to a drug name stands for Step Therapy which is in place on this drug, plan dependent.
The symbol [DQ] next to a drug stands for Drug Quantity, which is a limitation on amount dispensed.
For the member: Generic medications contain the same active ingredients as their corresponding brand name medications, although they may look dif erent in color or shape. They
have been FDA-approved under strict standards.
For the physician: Please prescribe preferred products and al ow generic substitutions when medical y appropriate.
THIS DOCUMENT LIST IS EFFECTIVE JULY 1, 2008 THROUGH DECEMBER 31, 2008. THIS LIST IS SUBJECT TO CHANGE.
You can get more information and updates to this document at the GHI Web site at www.ghi.com.

Source: http://www.insuranceny.net/41464%20Metavante.pdf

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This formulary is a closed, non-tiered formulary. It is a supplement to the alphabetic listing. (C) means that the drug is only available for administration at the clinic. (B) means the drug is available through BuyRite Pharmacy for contract eligible patients only. (S) means that the drug is not stocked, but wil be ordered if requested. (R) means that there is one or more restrictions on the d

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