PDL Change Archive

1/1/10
Up-Tiers Down-Tiers Exclusions
Asacol
Betoptic S
Peg-Intron
Frova
Maxalt / Maxalt MLT
Zomig / Zomig ZMT
Zomig Nasal Spray
Mononessa, Previfem, Sprintec
Camila, Errin, Jolivette, Nora-B
Nortrel, Necon
Trinessa, Tri-Previfem, Tri-Sprintec
 Arcalyst
Cimzia
Humira
Hycamtin
Lialda
Relistor
Ortho-Cyclen
Ortho Micronor
Ortho-Novum 777
Ortho Tri-Cyclen
cefprozil
ciclopirox solution
famciclovir
fentanyl
finasteride
glycopyrrolate
leuprolide acetate
Mesalamine Enema
nabumetone
omeprazole
oxybutynin extended-release tablet
sumatriptan spray
sumatriptan tablet
terbinafine
terconazole cream
trandolapril
zaleplon
 Amrix
Venflafaxine ER
Asacol HD
Augmentin XR
Clobex Shampoo
Detrol LA
Epiduo
Flector Patch
Olux Complete Pack
Soma 250
Venlafaxine ER
Xopenex Nebulized Solution
5/1/09
Up-Tiers Down-Tiers Exclusions
Nascobal Bystolic
CaloMist
Exjade
Noxafil
Sanctura XR
divalproex sodium
dlyburide/metformin
ramipril
 Soma 250
Venflafaxine ER
1/1/09
Up-Tiers Down-Tiers Exclusions
Diovan/Diovan HCT
Oral Contraceptives: Alesse, Cyclessa, Desogen, Lo-Ovral and Triphasil 		Intelence
Insentress
Selzentry
Generic Cyclessa
Generic Desogen
Generic Lo-Ovral
Fenoglide
Lipofen
Simcor
Minocycline
Siazen 		Prevacid SoluTab
Adoxa & Doryx
Caduet
Coreg CR
Testim
Veramyst
Growth Hormones: Genotropin, Humatrope, Norditropin and Omnitrope
9/1/08
Up-Tiers Down-Tiers Exclusions
None Azor
Combigan
Vagifem 		None
5/1/08
Up-Tiers Down-Tiers Exclusions
Bactroban Cream
fexofenadine
Fosamax-D
Premarin
Premphase
Prempro 		Pylera
Vyvanse 		None
1/1/08
Up-Tiers Down-Tiers Exclusions
Differin
Lialda
Oscion
generic Protonix
 Byetta
Janumet
Januvia
Levemir Vials
Retin-A Micro
Tazorac 		None