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3 – Tiered Prescription Drug Formulary
This formulary listing is to serve as a reference guide for the selection
of cost-effective medications and does not guarantee coverage or
imply therapeutic equivalence. Certain products may be excluded from
your plan or require additional authorization. Please see your plan
document for exact details as coverage may vary. This formulary is not all inclusive. Generic products will process as Tier 1 drugs at your
lowest copay, Tier 2 contains formulary brands, and Tier 3 contains
non-preferred brands and are subject to your highest copay.
This formulary is to be used with your medical practitioner to be sure
that any medication selected is both cost effective and clinically
appropriate. This formulary listing is subject to change, please contact
the ProAct help desk number on the back of your card for the most up
Antidotes, Deterrents, and Toxicologic Agents
Nonsteroidal Anti-inflammatory Drugs
Alpha-adrenergic Blocking Agents
clotrimazole Natacyn Diflucan digoxin (AB rated)
Beta-adrenergic Blocking Agents
Blood Modifiers/Coagulation Inhibitors
Calcium Channel Blocking Agents
Valtrex diltiazem/ER/SR Exforge/HCT Cardizem/SR/CD
atorvastatin Crestor Advicor entacapone Parlodel cholestyramine Lipofen
gemfibrozil Welchol Livalo Antihistamines
Angiotensin Converting Enzyme Inhibitors
Angiotensin II Antagonists
candesartan/hctz Benicar/HCT Atacand/HCT acitretin Finacea
Central Nervous System Agents
Cerebral Stimulants; Amphetamines
Cerebral Stimulants; Non-Amphetamines
Dermatological Agents; Other
Hormone Replacement Therapy
Diabetic items including supplies and medication may be subject to
alternate copays and/or coverage strategy. Please see your plan
document or contact ProAct for additional details.
Metabolic Bone Disease Agents
Proton Pump Inhibitors
Testim Testred lansoprazole Dexilant Aciphex
Gastrointestinal Agents, Other
VESIcare Enablex Antibacterials
Benign Prostatic Hypertrophy Agents
finasteride Jalyn Proscar Anti-Depressants; MAOi
Genitourinary Agents; Other
allopurinol Colcrys Indocin clomipramine Pamelor
probenecid Uloric Zyloprim desipramine Parnate
nedocromil Patanol Alomide chlorpromazine Abilify/Discmelt
Flarex Bipolar Agents
Sedatives and Hypnotics
Respiratory Tract Agents
Please contact the ProAct Clinical Department at:
1‐877‐776‐2285 x3624or email us at
for recommendations on cost saving alternatives
Bronchodilators, Phosphodiesterase Inhibitors (Xanthines)
Mast Cell Stabilizers
Vitamins and misc.
ProAct Specialty Drug Listing
Specialty medications can be described as medications that are high cost, highly complex, or typically require specialized administration, handling or distribution. They are often biology-based and mimic substances found in the body to produce their effects. These medications will process according to your plan design, and may require prior authorization and/or have other restrictions.
Medications listed as bold
are available generically.
(*) Indicates product is a formulary item, all others are non-formulary.
Lupron-Dep Ped* Pamidronate
Specialty list not all‐inclusive. Please contact the ProAct Helpdesk at 1‐877‐776‐2285 with questions regarding specialty medications.
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An extract of black, green, and mulberry teas causes malabsorptionof carbohydrate but not of triacylglycerol in healthy volunteers1–3 Litao Zhong, Julie K Furne, and Michael D Levitt ABSTRACT in green tea are dimerized to form a variety of theaflavins (1); Background: In vitro studies suggest that extracts of black, green, thus, these teas may have different biological activities. and