My drug plan Pocket reference guide

My drug plan
My plan sponsor/employer: Ryerson University
My name:
My contract number: 25180
My drug plan
Pocket reference guide
For employees who are covered under
Sun Life’s My drug plan.
My member ID number:
mysunlife.ca
ALLERGIES & BREATHING DISORDERS
ALLERGIES
ALOCRIL, ALOMIDE, ATARAX (hydroxyzine), ATROVENT (ipratropium),
AVAMYS, beclomethasone, EMADINE, EPIPEN, FLONASE (fluti ne), LIVOSTIN,
NALCROM, NASACORT, NASONEX, OMNARIS, PATADAY, PATANOL,
REACTINE (cetirizine), RHINALAR (flunisolide), RHINOCORT (budesonide),
SINGULAIR (montelukast), TWINJECT, WINPRED (prednisone), ZADITOR
ASTHMA
ACCOLATE, ADVAIR, A-HYDROCORT INJ (hydrocortisone),
AIROMIR (salbutamol), ALVESCO (cromolyn), ASMANEX, ATROVENT
(ipratropium), BRICANYL, CHOLEDYL (oxtriphylline), COMBIVENT
(salbutamol/ ipratropium), CORTEF (hydrocortisone), DEPO-MEDROL
(methylprednisolone), DUOVENT, ELIXIR DE THEOPHYLLINE
(theophylline), FLOVENT, FORADIL, ketotifen, MEDROL,
METHYLPREDNISOLONE SODIUM SUCCINATE INJECTION, ONBREZ,
orciprenaline, OXEZE, PULMICORT NEBUAMP, PULMICORT TURBUHALER,
QVAR, SEREVENT, SINGULAIR (montelukast), SOLU-CORTEF, SOLUMEDROL, SPIRIVA, SYMBICORT, THEOLAIR, UNIPHYL (theophylline),
VENTOLIN, VENTOLIN NEBULES/SOLN, WINPRED (prednisone), ZENHALE
FOLD 1
BRAIN & NERVOUS SYSTEM
EPILEPSY
CELONTIN, DEPAKENE (valproic acid), DIASTAT (diazepam), DILANTIN
(phenytoin), EPIVAL (valproic acid), FRISIUM (clobazam), KEPPRA
(levetiracetam), LAMICTAL (lamotrigine), NEURONTIN (gabapentin),
phenobarbital, primidone, RIVOTRIL (clonazepam), SABRIL, TEGRETOL
(carbamazepine), TOPAMAX (topiramate), TRILEPTAL (oxcarbazepine),
VIMPAT, ZARONTIN
MIGRAINES
AMERGE (naratriptan), AXERT (almotriptan), CAFERGOT,
DIHYDROERGOTAMINE, dihydroergotamine, ERGODRYL, FIORINAL
(butalbital + acetylsalicylic acid + caffeine), FIORINAL C, flunarizine,
FROVA, IMITREX (sumatriptan), MAXALT (rizatriptan), MIGRANAL
(dihydroergotamine), RELPAX, SANDOMIGRAN, ZOMIG (zolmitriptan)
HORMONES
ACROMEGALY
Life’s brighter
under the SOMATULINE
sun
SANDOSTATIN, SANDOSTATIN
LAR (octreotide),
AUTOGEL
ANDROGEN
ANDRIOL (testosterone), ANDRODERM, ANDROGEL, DELATESTRYL,
DEPO-TESTOSTERONE, TESTIM 1%
The drugs with bolded names are eligible under the preferred tier (Tier 1).
The unbolded names are eligible under a non preferred tier (Tier 2 or 3)
with a different payment level.
This list includes the most commonly used drugs but it is not all
inclusive. In addition, not all strengths and formulation of the drugs
listed are eligible.
CHOLESTEROL
ADVICOR, BEZALIP SR (bezafibrate), CADUET (amlodipine/
atorvastatin), COLESTID, CRESTOR (rosuvastatin), EZETROL, LESCOL
(fluvastatin), LIPIDIL (fenofibrate), LIPITOR (atorvastatin), LOPID
(gemfibrozil), MEVACOR (lovastatin),NIASPAN, OLESTYR, PRAVACHOL
(pravastatin), PRAVASA, ZOCOR (simvastatin)
THYROID
ELTROXIN, SYNTHROID, THYROID, TAPAZOLE, PROPYL-THYRACIL
MENTAL HEALTH
MULTIPLE SCLEROSIS
DEPO-MEDROL (methylprednisolone), DEPO-MEDROL WITH LIDOCAINE,
DEXAMETHASONE OMEGA, DEXASONE, (dexamethasone), MEDROL,
(methylprednisolone) METHYLPREDNISOLONE SODIUM SUCCINATE
INJECTION, SOLU-MEDROL, WINPRED (prednisone)
DIABETES
ACCU-CHEK test strips (test strips), ACTOS (pioglitazone), AMARYL
(glimepiride), APIDRA, BYETTA, chlorpropamide, DIABETA (glyburide),
DIAMICRON (gliclazide), DIAMICRON MR, GLUCOBAY, GLUCONORM
(repaglinide), GLUCOPHAGE (metformin), GLUMETZA, HUMALOG, HUMULIN,
HYPURIN, JANUMET, JANUVIA, lancets, LANTUS, LEVEMIR, needles, NOVOLIN,
NOVOMIX, NOVORAPID, ONGLYZA, STARLIX, syringes, tolbutamide,
TRAJENTA, VICTOZA
HEART & CIRCULATION
BLOOD PRESSURE
ACCUPRIL, ADALAT XL (nifedipine), ALDACTONE (spironolactone),
ALTACE (ramipril), ALTACE HCT (ramipril/hydrochlorothiazide), ATACAND
(candesartan), ATACAND PLUS (candesartan hydrochlorothiazide), AVALIDE
(irbesartan/hydrochlorothiazide), AVAPRO (irbesartan), bisoprolol, BURINEX,
carvedilol, COVERSYL, COZAAR (losartan), DIOVAN (valsartan), DIOVAN HCT
(valsartan/hydrochlorothiazide), hydrochlorothiazide, HYZAAR (losartan/
hydrochlorothiazide), INDERAL (propranolol), LONITEN, LOPRESOR (metoprolol),
LOZIDE (indapamide), MAVIK, MICARDIS (telmisartan), MICARDIS PLUS
(telmisartan/ hydrochlorothiazide), MINITRAN (nitroglycerin), NIMOTOP,
NITRO-DUR, NITROL, NITROLINGUAL PUMPSPRAY, NITROSTAT, PRINIVIL
(lisinopril), PROCAN SR, PROGLYCEM, RENEDIL, RYTHMODAN, TENORMIN (atenolol),
TIAZAC XC, TOLOXIN, TRANDATE, ZAROXOLYN (methyldopa)
BLOOD THINNERS
AGGRENOX, COUMADIN (warfarin), dipyridamole, HEPARIN (heparin), PLAVIX
(clopidogrel), SINTROM, ticlopidine
ADHD
ADDERALL XR, CONCERTA (methylphenidate), DEXEDRINE, RITALIN,
STRATTERA (atomoxetine), VYVANSE
ANXIETY & SLEEP
ALERTEC (modafinil), ATIVAN (lorazepam), buspirone, chloral hydrate,
chlordiazepoxide, IMOVANE (zopiclone), LECTOPAM (bromazepam),
MOGADON (nitrazepam), oxazepam, ESTORIL (temazepam), SUBLINOX,
triazolam, VALIUM (diazepam), XANAX (alprazolam), XYREM
BIPOLAR & SCHIZOPHRENIA
ABILIFY, CARBOLITH (lithium), chlorpromazine, chlorpromazine
hydrochloride, CLOPIXOL, CLOZARIL (clozapine), FLUANXOL (flupendixol),
FLUPHENAZINE OMEGA (fluphenazine decanoate), fluphenazine
hydrochloride, haloperidol, haloperidol decanoate, INVEGA, INVEGA
SUSTENNA, LITHANE, lithium, loxapine, MAJEPTIL, MODECATE
CONCENTRATE, NAVANE, NEULEPTIL (perphenazine), NOZINAN
(methotrimeprazine), ORAP (pimozide), PIPORTIL L4, prochlorperazine,
BIPOLAR & SCHIZOPHRENIA (continued)
RISPERDAL (risperidone), RISPERDAL CONSTA, SEROQUEL, SEROQUEL XR
(quetiapine), trifluoperazine, ZELDOX, ZYPREXA (olanzapine)
DEPRESSION
amitriptyline, ANAFRANIL (clomipramine), AVENTYL (nortriptyline),
CELEXA (citalopram), CIPRALEX, CTP 30, CYMBALTA, desipramine, EFFEXOR
(venlafaxine), imipramine, LUVOX (fluvoxamine), MANERIX (moclobemide),
maprotiline, NARDIL, PARNATE, PAXIL (paroxetine), PRISTIQ, PROZAC
(fluoxetine), REMERON (mirtazapine), SEROQUEL (quetiapine), SEROQUEL
XR, SINEQUAN (doxepin), trazodone, trimipramine, TRYPTAN (tryptophan),
WELLBUTRIN (bupropion), ZOLOFT (sertraline)
PAIN & ARTHRITIS
PAIN
282/292 TABLETS, ANAPROX (naproxen sodium), ATASOL, BUTRANS,
CELEBREX, CODEINE CONTIN, CODEINE PHOSPHATE SIROP DE
(codeine), CYMBALTA, DILAUDID (hydromorphone), DOLORAL,
PAIN (continued)
DURAGESIC MAT (fentanyl), EXDOL, HYDROMORPH, ibuprofen,
imipramine, KADIAN, ketoprofen, LYRICA (pregabalin), M-ESLON,
METADOL, M.O.S. SR (morphine), NAPROSYN, NAPROSYN E &
SR (naproxen), NEURONTIN (gabapentin), OXY.IR (oxycodone),
OXYNEO, PENNSAID (diclofenac sodium), PERCOCET (oxycodone
+ acetaminophen), PONSTAN (mefenamic acid), RALIVIA, STATEX,
ORADOL (ketorolac), TRAMACET (tramadol + acetaminophen),
TRIDURAL, TYLENOL WITH CODEINE NO. 2 & 3, TYLENOL WITH
CODEINE NO. 4 (codeine + acetaminophen), ULTRAM, VIMOVO,
VOLTAREN, VOLTAREN RAPIDE (diclofenac potassium), ZYTRAM
ARTHRITIS
A-HYDROCORT, ANAPROX (naproxen sodium), ANSAID
(flurbiprofen), ARAVA (leflunomide), ARISTOSPAN, ARTHROTEC,
CELEBREX, CELESTONE SOLUSPAN (betamethasone), chloroquine,
CORTEF, CORTISONE ACETATE, DAYPRO (oxaprozin), DEPOMEDROL (methylprednisolone), DEPO-MEDROL + LIDOCAINE,
DEXAMETHASONE, DEXASONE (dexamethasone), etodolac,
floctafenine, ibuprofen, IMURAN (azathioprine),
ECZEMA & PSORIASIS
ARISTOCORT (triamcinolone), BARRIERE HC (hydrocortisone),
betamethasone + salicylic acid, CAPEX, CELESTODERM-V, CLOBEX
(clobetasol), CORTATE, CORTISPORIN, CUTIVATE, CYCLOCORT (amcinonide),
DERMA SMOOTHE/FS, DERMAFLEX HC, DERMATOP, DERMOVATE,
DESOCORT OINTMENT 0.05%, (desonide), DIPROLENE, (betamethasone
dipropionate), DIPROSALIC, (betamethasone + salicylic acid), DIPROSONE,
(betamethasone dipropionate), DOVOBET, DOVONEX, ELIDEL, ELOCOM
(mometasone), EMO-CORT, FLUODERM CREAM, folic acid, FUCIDIN
H, LIDEX, LIDEMOL EMOLLIENT CREAM (fluocinonide), LOCACORTEN
VIOFORM, LOTRIDERM CREAM, LUXIQ, METHOTREXATE (methotrexate),
NEORAL (cyclosporine), NEORAL 10 mg Capsule, NERISONE, OXSORALEN,
PRAMOX XC, PREVEX B CREAM 0.1%, (betamethasone valerate), PREVEX
HC CREAM, PROPADERM-CREAM 0.025%, PROTOPIC, SARNA HC, SILKIS,
SORIATANE, SYNALAR, TAZORAC, TIAMOL, TOPACTIN, TOPICORT,
TOPIDERM HC, triamcinolone, triamcinolone + gramicidin + neomycin +
nystatin, ULTRAVATE, UREMOL HC, VALISONE G, VALISONE SCALP LOTION
0.1%, VERDESO, VIOFORM HYDROCORTISONE, XAMIOL
MENOPAUSE (continued)
OESCLIM, PREMARIN, PROVERA (medroxyprogesterone),
VAGIFEM 10 (estradiol)
STOMACH
DISCLAIMER
INFLAMMATORY BOWEL
A-HYDROCORT INJ (hydrocortisone), ARISTOSPAN, CELESTONE SOLUSPAN
(betamethasone), CORTEF, CORTISONE ACETATE TAB 25 MG, DEPOMEDROL, DEPO-MEDROL WITH LIDOCAINE, DEXAMETHASONE OMEGA
(dexamethasone), DEXASONE 4 MG, IMURAN (azathioprine), KENALOG
INJECTION (triamcinolone), MEDROL (methylprednisolone), METHOTREXATE
(methotrexate), METHYLPREDNISOLONE SODIUM SUCCINATE INJECTION,
NEORAL (cyclosporine), NEORAL 10 mg Capsule, PEDIAPRED (prednisolone),
PURINETHOL, SOLU-CORTEF, SOLU-MEDROL, WINPRED (prednisone)
This list of drugs is subject to change without notice. The decision regarding
which drugs are prescribed is between you and your physician/prescriber.
If a prescribed drug is not eligible, there may be other drugs on the formulary
that provide a similar benefit or a therapeutic alternative. Please discuss with
your physician/prescriber, who may prescribe, when appropriate, a drug
therapy covered under your plan. The association of drugs with the therapeutic
categories listed is for illustrative purposes only and not intended to define
indications for use.
ULCER
AXID (nizatidine), cimetidine, DEXILANT, esomeprazole, HP-PAC, LOSEC
(omeprazole), misoprostol, NEXIUM (esomeprazole), PANTOLOC
(pantoprazole), PARIET (rabeprazole), PEPCID (famotidine), PREVACID
(lansoprazole), PREVACID FASTAB, SULCRATE (sucralfate), SULCRATE
SUSPENSION PLUS, TECTA, ZANTAC (ranitidine)
Group Benefits are offered by Sun Life Assurance Company of Canada, a member
of the Sun Life Financial group of companies.
PDF6369-E 09-14 pt-an
OSTEOPOROSIS
ACLASTA, ACTONEL (risedronate), ACTONEL PLUS CALCIUM,
DIDROCAL (etidronate + calcium), etidronate, EVISTA
(raloxifene), FOSAMAX (alendronate), FOSAVANCE, PROLIA
FOLD 2
ARTHRITIS (continued)
indomethacin, KENALOG (triamcinolone), ketoprofen, METHOTREXATE
(methotrexate), METHYLPREDNISOLONE SODIUM SUCCINATE
INJECTION, MOBICOX (meloxicam), MYOCHRYSINE (sodium
aurothiomalate), nabumetone, NAPRELAN, NAPROSYN, NAPROSYN
E&SR (naproxen), NEORAL (cyclosporine), NEORAL 10 mg Capsule,
PEDIAPRED (prednisolone), PENNSAID (diclofenac sodium), piroxicam,
PLAQUENIL (hydroxychloroquine), PONSTAN (mefenamic acid),
PROCYTOX, PURINETHOL, RIDAURA, SALAZOPYRIN (sulfasalazine),
SOLU-CORTEF (hydrocortisone), SOLU-MEDROL, sulindac, tenoxicam,
tiaprofenic acid, TORADOL (ketorolac), VIMOVO, VOLTAREN, VOLTAREN
RAPIDE (diclofenac potassium), WINPRED (prednisone), ZUACTA
SKIN CONDITIONS
ACNE
ACCUTANE ROCHE, ACZONE, ALESSE (levonorgestrel + ethinyl
estradioll), BENOXYL, BENZAC AC 10 GEL 10%, BENZACLIN TOPICAL
GEL, BENZAMYCIN, BIACNA TOPICAL GEL, CLINDASOL, CLINDA-T
ACNE (continued)
(clindamycin), CLINDETS, CLINDOXYL GEL, DALACIN T, DIANE-35,
(cyproterone/ethinyl), DIFFERIN, FINACEA, isotretinoin, NEO-MEDROL
ACNE LOTION, OXYDERM LOTION, PANOXYL, RETIN-A, RETISOL-A,
SOLUGEL, STIEVA-A CREAM, STIEVAMYCIN, SULFACET-R, TACTUO,
TAZORAC, TRI-CYCLEN, VITAMIN A ACID GEL, YASMIN, YAZ
GET THE MOST VALUE OUT OF YOUR DRUG PLAN
• Fill your prescription for a longer period of time, if you have
a chronic condition
• Be aware of dispensing fees – they vary between pharmacies
• Carry your drug card with you and show it at the pharmacy
CONTRACEPTION
ALESSE (levonorgestrel + ethinyl estradiol), BREVICON, CYCLEN,
DEMULEN, DEPO-PROVERA (medroxyprogesterone), EVRA, LINESSA
(desogestrel + ethinyl estradiol), LOESTRIN 1.5/30, MARVELON,
MICRONOR, MINESTRIN 1/20, MIN-OVRAL, MIRENA, NUVARING, ORTHO,
ORTHO-CEPT, SEASONALE, SEASONIQUE, SELECT 1/35, SYNPHASIC, TRICYCLEN, TRI-CYCLEN LO, TRIQUILAR, YASMIN, YAZ, ZARAH
ENDOMETRIOSIS
CYCLOMEN, LUPRON DEPOT, NORLUTATE, PROVERA
(medroxyprogesterone), SUPREFACT, SYNAREL, TRELSTAR, VISANNE,
ZOLADEX
MENOPAUSE
ACTIVELLE, ANGELIQ, BELLEGRAL SPACETABS, C.E.S., CLIMARA, DIXARIT
(clonidine), ESTALIS 140/50, ESTALIS 250/50, ESTRACE, ESTRADERM,
ESTRADOT, ESTRAGYN VAGINAL CREAM, ESTRING, ESTROGEL, FEMHRT,
FOLD 4
WOMEN’S HEALTH
FOLD 3
ANTIBIOTICS
acyclovir sodium injection, ALDARA, CANTHARONE PLUS,
CONDYLINE, DIFLUCAN (fluconazole), EFUDEX, famciclovir,
FAMVIR (valacyclovir), FLAGYL, FLAGYSTATIN, FLAMAZINE
CREAM 1%, FUCIDIN, gentamicin, GYNAZOLE-1, idoxuridine,
ketoconazole, LAMISIL (terbinafin), LOPROX, METROCREAM,
METROGEL, METROLOTION, NEOSPORIN, NIDAGEL, NORITATE,
PENLAC (ciclopirox), PODOFILM, RELENZA, ROSASOL, SANTYL,
SOFRAMYCIN, SOFRA-TULLE, SPORANOX, TAMIFLU, TERAZOL
3 DUAL PAK, TERAZOL 7 (terconazole), TOCTINO, VALTREX
(valacyclovir), VYLOMA, WARTEC, ZOVIRAX (acyclovir), ZOVIRAX 5%,
ZYCLARA
Life’s brighter under the sun
Want to get the best value out of your prescription
drug plan? Reformulary Group’s Drug Finder is an
innovative online tool that helps you quickly and
easily learn what drugs are covered by the plan, identify
possible alternative drugs that could cost you less,
and print out a letter you can bring to your doctor.
Go to reformulary.com.

Download Report