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Fill and Sign the Authorization to Defer Compensation Rsa 1 Deferred Compensation Plan Una Form

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Formulary Changes 2008 Formulary Additions Accolate Aceon Advicor Allegra-D Alomide Asmanex Astelin Azelex Benicar Benicar HCT Betimol Crestor (5mg ST) Combivent Dallergy Dynacirc CR Effexor XR (ST) Estraderm Golytely Kadian Lidoderm Lumigan Maxalt Menest Metrogel (ST) Micardis Micardis HCT Nuvaring Phenavent LA PhosLo Prenate Elite Prilosec OTC PrimaCare ONE Formulary Deletions Proair HFA (generic copay) Protopic Pseudovent Quixin Seroquel XR Sular Testim (PA) Transderm-scop Triglide Uroxatral Vivelle-Dot Yasmin Yaz Zaditor OTC Zemplar Formulary Alternatives Moved to third tier coverage for selected plans Abilify……………………………………………… Actonel…………………………………………… Adderall XR (PA for ≥ 18 years of age)…………... Altace………………………………………………. Amerge……………………………………………... Androderm (PA)………………………………… . . Androgel (PA)……………………………………. Anzemet…………………………………………… Arthrotec…………………………………………… Byetta (PA)…………………………………………. Clozaril*, Risperdal, Seroquel Fosamax Adderall*, Ritalin*, Ritalin SR*, Metadate ER*, Concerta Prinivil*, Lotensin*, Accupril*, Vasotec* Imitrex, Maxalt Testim (PA) Testim (PA) Compazine*, Phenergan*, Tigan*, Zofran* Voltaren* plus Cytotec* Amaryl*, Diabeta*, Glucotrol*, Glynase*, Micronase*, Glucophage* Celebrex…………………………………………… Motrin*, Naprosyn*, Mobic*, Voltaren*, Orudis*, Clinoril*, Disalcid*, Relafen* Cipro HC…………………………………………… Ciprodex Cosopt………………………………………………. Timoptic* plus Azopt Cozaar……………………………………………… Benicar, Micardis Cymbalta (PA)……………………………………… Celexa*, Prozac*, Zoloft*, Paxil* Detrol/Detrol LA…………………………………… Ditropan* Differin…………………………………………… . Retin-A*, Retin-A Micro, Azelex Diovan……………………………………………… Benicar, Micardis Diovan HCT………………………………………... Benicar HCT, Micardis HCT FemHRT……………………………………………. Prempro, Premphase Flomax……………………………………………… Cardura*, Hytrin*, Proscar*, Uroxatral Hyzaar……………………………………………… Benicar HCT, Micardis HCT Lamictal……………………………………………. phenobarbital, Tegretol*, Tegretol XR, Carbatrol, Dilantin*, Depakene*, Depakote, Depakote ER, Neurontin* Levaquin……………………………………………. Cipro*, Avelox Lipitor……………………………………………… Zocor*, Prevachol*, Mevacor*, AltoPrev, Crestor (5mg ST), Vytorin (10/10mg ST) 2/1/2008 Formulary Deletions Formulary Alternatives Moved to third tier coverage for selected plans phenobarbital, Tegretol*, Tegretol XR, Carbatrol, Dilantin*, Depakene*, Depakote, Depakote ER, Neurontin* Nasacort…………………………………………… Flonase*, Nasonex, Nasalide* Nexium (ST)………………………………………... Prilosec OTC™ (covered with prescription for generic copay), Prilosec*, Protonix Pataday……………………………………………. Alaway, Zaditor OTC (covered with prescription for Lyrica (PA)…………………………………………. generic copay) Patanol……………………………………………. . Alaway, Zaditor OTC (covered with prescription for generic copay) Paxil CR (ST)……………………………………… Proventil HFA……………………………………… Provigil (PA)………………………………………. Restasis…………………………………………… Strattera…………………………………………….. Topamax……………………………………………. Tricor……………………………………………….. Tussionex…………………………………………... Vagifem……………………………………………. Viagra……………………………………………… Vigamox……………………………………………. Xalatan……………………………………………... Zaditor……………………………………………… Zetia………………………………………………… Zomig, Zomig ZMT………………………………... Zyprexa (PA) ……………………………………… (PA) indicates prior authorization required (ST) indicates step therapy required * A generic equivalent is available at the lowest copay 2/1/2008 Celexa*, Prozac*, Zoloft*, Paxil* Proair HFA (generic copay) Ritalin*, Dexedrine*, Adderall* Various OTC artificial tears available Ritalin*, Adderall*, Concerta phenobarbital, Tegretol*, Tegretol XR, Carbatrol, Dilantin*, Depakene*, Depakote, Depakote ER, Neurontin* Lofibra*, Lopid*, Triglide Robitussin AC*, Hycodan* Premarin Cream, Estrace Cream, Ogen Cream All erectile dysfunction drugs covered under non formulary copay Tobrex*, gentamicin, Ciloxan*, Ocuflox* Lumigan, Travatan Zaditor OTC (requires doctor’s prescription – generic copay) Zocor*, Pravachol*, Niaspan, Vytorin (10/10mg ST) Imitrex, Maxalt Risperdal, Seroquel Please refer to your health plan documents regarding any limitations or exclusions that may apply to your pharmacy benefit.

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