Senior Preferred Formulary. (List of Covered Drugs)

Transcription

1 Senior Preferred 07 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary ID: Version This formulary was updated on 0/4/07. For more recent information or other questions, please contact us, Senior Preferred, at or, for TTY users, TTY/TDD 7 or , 7 days a week between October, 06 and February 4, 07, 8:00 AM to 8:00 PM, or visit H56_6 7 CMS Accepted

2 Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means Senior Preferred. When it refers to plan or our plan, it means UW Health Senior Preferred. This document includes a list of the drugs (formulary) for our plan which is current as of 0/4/07. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January, 07, and from time to time during the year. What is the Senior Preferred Formulary? A formulary is a list of covered drugs selected by our plan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Our plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a UW Health Senior Preferred network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 07 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 07 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of 0/4/07. To get updated information about the drugs covered by our plan, please contact us. Our contact information appears on the front and back cover pages. In the event of non-maintenance changes to the formulary throughout the plan year, Senior Preferred may make changes via errata sheets mailed to you. Additionally, you may visit our website for a link to the errata sheet.

3 How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 8. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins below. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 6. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? Our plan covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: Our plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from our plan before you fill your prescriptions. If you don t get approval, our plan may not cover the drug. Quantity Limits: For certain drugs, our plan limits the amount of the drug that our plan will cover. For example, our plan provides thirty tablets per month per prescription for digoxin. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, our plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, our plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, our plan will then cover Drug B. 3

4 You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 8. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask our plan to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the Senior Preferred formulary? on page 4 for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered. If you learn that our plan does not cover your drug, you have two options: You can ask Customer Service for a list of similar drugs that are covered by our plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by our plan. You can ask our plan to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the Senior Preferred Formulary? You can ask our plan to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier or any of the preferred tier (, 3) levels. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, our plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. 4

5 Generally, our plan will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering, or utilization restriction exception. When you request a formulary, tiering, or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 7 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 7 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 4 hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with 93-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 3-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. Exceptions are available for members who have experienced a change in the level of care they are receiving which requires them to transition from one facility or treatment center to another. Examples of situations in which members would be eligible for the one-time temporary fill exception when they are outside of the three month effective date into the Part D program are as follows: i. Members who are discharged from the hospital are provided a discharge list of medications based upon the formulary of the hospital ii. Members who end their skilled nursing facility Medicare Part A stay (where payments include all pharmacy charges) and who need to revert back to their Part D plan formulary. iii. Members who give up Hospice Status to revert back to standard Medicare Part A and B benefits, and iv. Members who are discharged from Chronic Psychiatric Hospitals with medication regimens that are highly individualized. 5

6 All of these situations would warrant a temporary one-time fill exception regardless of if the beneficiary is in their first ninety (90) days of program enrollment. For more information For more detailed information about your plan prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about our plan, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) 4 hours a day/7 days a week. TTY users should call Or, visit UW Health Senior Preferred Formulary The formulary below provides coverage information about the drugs covered by our plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 6. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., CHANTIX) and generic drugs are listed in lower-case italics (e.g., lisinopril). The information in the Requirements/Limits column tells you if our plan has any special requirements for coverage of your drug. 6

7 UW Health Senior Preferred Medicare 07 Part D (List of Covered Drugs) ANALGESICS NONSTEROIDAL ANTI-INFLAMMATORY DRUGS celecoxib (50 mg capsule, 00 mg capsule, 400 mg capsule) QL (60 PER 30 DAYS) celecoxib 00 mg capsule QL (90 PER 30 DAYS) diclofenac.5% topical soln 4 diclofenac pot 50 mg tablet diclofenac sod er 00 mg tab diclofenac sodium (dr 5 mg tab, dr 50 mg tab, dr 75 mg tab, ec 5 mg tab, ec 50 mg tab, ec 75 mg tab) diclofenac sodium-misoprostol (50-00, 50-0., 75-0., 75-00) diflunisal 500 mg tablet etodolac (00 mg capsule, 300 mg capsule, 400 mg tablet, 500 mg tablet) etodolac er (er 400 mg tablet, er 500 mg tablet, er 600 mg tablet) fenoprofen calcium (400 mg capsule, 600 mg tablet) FLECTOR.3% PATCH 4 PA, QL (60 PER 30 DAYS) flurbiprofen (50 mg tablet, 00 mg tablet) ibuprofen (400 mg tablet, 600 mg tablet, 800 mg tablet) ibuprofen 00 mg/5 ml susp ketoprofen (50 mg capsule, 75 mg capsule) ketoprofen er 00 mg capsule 4 ketorolac tromethamine (5 mg/ml vial, 5 mg/ml syringe) ketorolac tromethamine (30 mg/ml syringe, 30 mg/ml vial, 30 mg/ml isecure syr, 60 mg/ ml syringe, 60 mg/ ml vial, 300 mg/0 ml vial) meclofenamate sodium (50 mg capsule, 00 mg capsule) FFF PA, QL (40 PER 30 DAYS) PA, QL (0 PER 30 DAYS) 7 LAST UPDATED /07

8 mefenamic acid 50 mg capsule meloxicam (7.5 mg tablet, 5 mg tablet) FFF meloxicam 7.5 mg/5 ml susp QL (300 PER 30 DAYS) nabumetone (500 mg tablet, 750 mg tablet) FFF naproxen (5 mg/5 ml suspen, 50 mg tablet, dr 500 mg tablet, ec 375 mg tablet, 375 mg tablet, dr 375 mg tablet, 500 mg kit, 500 mg tablet, ec 500 mg tablet) FFF naproxen sodium (75 mg tab, 550 mg tab) FFF naproxen sodium ds 550 mg tab FFF oxaprozin (600 mg caplet, 600 mg tablet) piroxicam (0 mg capsule, 0 mg capsule) sulindac (50 mg tablet, 00 mg tablet) tolmetin sodium (00 mg tab, 400 mg cap, 600 mg tab) OPIOID ANALGESICS, LONG-ACTING BELBUCA (75 MCG, 50 MCG, 300 MCG, 450 MCG, 600 MCG, 750 MCG, 900 MCG) buprenorphine (5 mcg/hr patch, 7.5 mcg/hr patch, 0 mcg/hr patch, 5 mcg/hr patch, 0 mcg/hr patch) BUTRANS (5 MCG/HR PATCH, 7.5 MCG/HR PATCH, 0 MCG/HR PATCH, 5 MCG/HR PATCH, 0 MCG/HR PATCH) EMBEDA (ER MG CAPSULE, ER MG CAPSULE) EMBEDA (ER 30-. MG CAPSULE, ER 50- MG CAPSULE) 4 QL (60 PER 30 DAYS) QL (4 PER 8 DAYS) 3 QL (4 PER 8 DAYS) 3 QL (0 PER 30 DAYS) 3 QL (60 PER 30 DAYS) EMBEDA ER 00-4 MG CAPSULE 3 QL (90 PER 30 DAYS) EMBEDA ER MG CAPSULE 3 QL (80 PER 30 DAYS) fentanyl ( mcg/hr patch, 5 mcg/hr patch, 50 mcg/hr patch) QL (5 PER 30 DAYS) fentanyl (75 mcg/hr patch, 00 mcg/hr patch) QL (30 PER 30 DAYS) levorphanol mg tablet QL (480 PER 30 DAYS) methadone hcl (0 mg/ml vial, 00 mg/0 ml vl) PA - TO CONFIRM PART D COVERAGE methadone hcl (5 mg tablet, 0 mg tablet) QL (360 PER 30 DAYS) 8 LAST UPDATED /07

9 methadone hcl (5 mg/5 ml solution, 0 mg/5 ml solution, 0 mg/ml oral conc) QL (800 PER 30 DAYS) methadone intensol 0 mg/ml QL (800 PER 30 DAYS) morphine sulfate er (er 0 mg cap, er 0 mg cap, er 30 mg cap, er 45 mg cap, er 50 mg cap, er 60 mg cap, er 75 mg cap, er 80 mg cap, er 90 mg cap) morphine sulfate er (sulf er 5 mg tablet, sulf er 30 mg tablet, sulf er 60 mg tablet, sulf er 00 mg tablet, sulf er 00 mg tablet, sulfate er 00 mg cap, sulfate er 0 mg cap) OPANA ER (ER 5 MG TABLET, ER 7.5 MG TABLET, ER 0 MG TABLET, ER 5 MG TABLET, ER 0 MG TABLET, ER 30 MG TABLET, ER 40 MG TABLET) oxycodone hcl er (er 0 mg tablet, er 0 mg tablet, er 40 mg tablet) oxycodone hcl er (er 5 mg tablet, er 30 mg tablet, er 60 mg tablet) QL (0 PER 30 DAYS) QL (80 PER 30 DAYS) 4 QL (0 PER 30 DAYS) QL (0 PER 30 DAYS) 4 QL (0 PER 30 DAYS) oxycodone hcl er 80 mg tablet QL (80 PER 30 DAYS) OXYCONTIN (0 MG TABLET, 5 MG TABLET, 0 MG TABLET, 30 MG TABLET, 40 MG TABLET, 60 MG TABLET) 3 QL (0 PER 30 DAYS) OXYCONTIN 80 MG TABLET 3 QL (80 PER 30 DAYS) tramadol hcl er (er 00 mg tablet, er 00 mg tablet, er 300 mg tablet, hcl er 00 mg capsule, hcl er 00 mg tablet, hcl er 00 mg tablet, hcl er 00 mg capsule, hcl er 300 mg capsule, hcl er 300 mg tablet) ZOHYDRO ER (ER 0 MG CAPSULE, ER 5 MG CAPSULE, ER 0 MG CAPSULE, ER 30 MG CAPSULE, ER 40 MG CAPSULE, ER 50 MG CAPSULE) OPIOID ANALGESICS, SHORT-ACTING ABSTRAL (00 MCG TAB, 00 MCG TAB, 300 MCG TAB, 400 MCG TAB, 600 MCG TAB, 800 MCG TAB) QL (30 PER 30 DAYS) 4 QL (60 PER 30 DAYS) 5 PA, QL (0 PER 30 DAYS) acetaminophen-cod # tablet QL (390 PER 30 DAYS) acetaminophen-cod #3 tablet QL (360 PER 30 DAYS) acetaminophen-cod #4 tablet QL (80 PER 30 DAYS) acetaminophen-codeine (acetamin-codein mg/.5, acetaminop-codeine 0- mg/5) QL (4500 PER 30 DAYS) 9 LAST UPDATED /07

10 butorphanol 0 mg/ml spray QL (0 PER 30 DAYS) butorphanol tartrate ( mg/ml vial, mg/ml vial) codeine sulfate (5 mg tablet, 30 mg tablet, 60 mg tablet) DURAMORPH (5 MG/0 ML AMPUL, 0 MG/0 ML AMPUL) PA - TO CONFIRM PART D COVERAGE QL (80 PER 30 DAYS) 4 PA - TO CONFIRM PART D COVERAGE endocet ( mg tablet, 0-35 mg tablet) QL (360 PER 30 DAYS) endocet.5-35 mg tablet 4 QL (360 PER 30 DAYS) endocet 5-35 tablet QL (360 PER 30 DAYS) fentanyl citrate (00 mcg, 400 mcg) 4 PA, QL (0 PER 30 DAYS) fentanyl citrate (cit,00 mcg, cit,600 mcg, citrate 600 mcg, citrate 800 mcg) hydrocodone-acetaminophen (.5-35, 5-35 mg, , 0-35 mg) hydrocodone-acetaminophen (hydrocodoneacetamin.5-08/5, hydrocodone-acetamin 5-7/0, hydrocodone-acetamn /5) 5 PA, QL (0 PER 30 DAYS) QL (360 PER 30 DAYS) QL (5550 PER 30 DAYS) hydrocodone-ibuprofen QL (50 PER 30 DAYS) hydromorphone hcl (0.5 mg/0.5 ml, hcl mg/ml amp, mg/ml carpujct, mg/ml syringe, mg/ml vial, hcl mg/ml amp, hcl 4 mg/ml amp, 4 mg/ml carpujct, hcl 0 mg/ml vl, 0 mg/ml vial, hcl 0 mg/ml amp, 50 mg/5 ml vial, 500 mg/50 ml via) hydromorphone hcl ( mg/ml solution, 5 mg/5 ml soln) hydromorphone hcl ( mg tablet, 4 mg tablet, 8 mg tablet) hydromorphone hcl ( mg/ml carpujct, mg/ml isecure) meperidine hcl (5 mg/ml vial, 50 mg/ml vial, 00 mg/ml vial) PA - TO CONFIRM PART D COVERAGE QL (4800 PER 30 DAYS) QL (360 PER 30 DAYS) PA morphine sulf 0 mg/5 ml soln QL (3600 PER 30 DAYS) morphine sulf 00 mg/5 ml soln QL (540 PER 30 DAYS) morphine sulf 0 mg/5 ml soln QL (700 PER 30 DAYS) 0 LAST UPDATED /07

11 morphine sulfate (0.5 mg/ml vial, mg/ml vial p-f, sulfate mg/ml vial, mg/ml isecure syr, mg/ml carpuject, 4 mg/ml syringe, 4 mg/ml carpuject, 4 mg/ml isecure syr, sulfate 4 mg/ml vial, 5 mg/ml vial, 8 mg/ml syringe, sulfate 8 mg/ml vial, 8 mg/ml isecure syrng, sulfate 0 mg/ml vial, 0 mg/ml isecure syrg, 0 mg/ml syringe, 0 mg/ml carpuject, 30 mg/30 ml syringe) PA - TO CONFIRM PART D COVERAGE morphine sulfate (ir 5 mg tab, ir 30 mg tab) QL (360 PER 30 DAYS) nalbuphine hcl (0 mg/ml ampul, 0 mg/ml ampul, 00 mg/0 ml vial, 00 mg/0 ml vial) oxycodone hcl (5 mg tablet, 0 mg tablet, 5 mg tablet, 0 mg tablet, 30 mg tablet) PA - TO CONFIRM PART D COVERAGE QL (480 PER 30 DAYS) oxycodone hcl 00 mg/5 ml soln QL (360 PER 30 DAYS) oxycodone hcl 5 mg capsule QL (480 PER 30 DAYS) oxycodone hcl 5 mg/5 ml soln QL (700 PER 30 DAYS) oxycodone-acetaminophen (oxycodonacetaminophen.5-35, oxycodonacetaminophen , oxycodoneacetaminophen 0-35) QL (360 PER 30 DAYS) oxycodone-acetaminophen 5-35 QL (360 PER 30 DAYS) oxycodone-acetaminophn 5-35/5 QL (860 PER 30 DAYS) oxycodone-aspirin QL (360 PER 30 DAYS) oxycodone-ibuprofen tab QL (0 PER 30 DAYS) tramadol hcl 50 mg tablet QL (40 PER 30 DAYS) tramadol-acetaminophn QL (40 PER 30 DAYS) ANESTHETICS LOCAL ANESTHETICS bupivacaine hcl (ampul, vial) 4 bupivacaine hcl-epinephrine (0.5%-epi :00000, 0.5%-epi :00,000) glydo % jelly syringe lidocaine % viscous soln lidocaine 5% ointment lidocaine 5% patch PA, QL (90 PER 30 DAYS) 4 LAST UPDATED /07

12 lidocaine hcl (0.5% vial, % 50 mg/5 ml vl, % abboject, % ampul, % vial, % 0 mg/ ml vl, % 300 mg/30 ml, % syringe, % 0 mg/ ml, % 50 mg/5 ml, % luer-jet, % syringe, % 40 mg/ ml vl, % ampul, % abboject, % 40 mg/ ml, % vial, % 00 mg/5 ml) lidocaine hcl % jelly lidocaine hcl 4% solution lidocaine-prilocaine cream sensorcaine 0.5% vial 4 sensorcaine-mpf (ampul, vial) 4 sensorcaine-mpf epinephrine (sensorc mpf 0.5%-epi, sensorc mpf 0.75%-epi, sensorcn-mpf 0.5%-epi) XYLOCAINE (0.5% VIAL, % VIAL, % VIAL, 4% SOLUTION) XYLOCAINE %-EPI :00,000 4 XYLOCAINE IV % AMPUL 4 XYLOCAINE WITH EPINEPHRINE (0.5%-EPI :00,000, %-EPI :00,000, %-EPI :00,000, %-EPI :00,000) XYLOCAINE-MPF (0.5% VIAL, % VIAL, % AMPUL,.5% AMPUL, % VIAL, % AMPUL) XYLOCAINE-MPF WITH EPINEPHRINE (XYLOCAIN.5-EPI :00,000-MPF, XYLOCAINE-MPF %-EPI :00,000) ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS ALCOHOL DETERRENTS/ANTI-CRAVING acamprosate calc dr 333 mg tab disulfiram (50 mg tablet, 500 mg tablet) naltrexone 50 mg tablet VIVITROL 380 MG VIAL + DILUENT 5 PA OPIOID DEPENDENCE TREATMENTS buprenorphine hcl (0.3 mg/ml syring, 0.3 mg/ml vial) PA - TO CONFIRM PART D COVERAGE buprenorphine hcl ( mg tablet, 8 mg tablet) QL (90 PER 30 DAYS) LAST UPDATED /07

13 buprenorphine-naloxone (buprenorphin-naloxon 8- mg, buprenorphn-naloxn -0.5 mg) 4 QL (90 PER 30 DAYS) SUBOXONE ( MG-0.5 MG, 8 MG- MG) 4 QL (90 PER 30 DAYS) SUBOXONE (4 MG- MG, MG-3 MG) 4 QL (60 PER 30 DAYS) OPIOID REVERSAL AGENTS naloxone hcl (0.4 mg/ml vial, 0.4 mg/ml carpuject, mg/ ml syringe, 4 mg/0 ml vial) NARCAN 4 MG NASAL SPRAY 3 QL (4 PER DAYS) SMOKING CESSATION AGENTS buproban 50 mg tablet QL (60 PER 30 DAYS) bupropion hcl sr 50 mg tablet QL (60 PER 30 DAYS) CHANTIX (0.5 MG TABLET, MG CONT MONTH BOX, MG TABLET) 4 QL (60 PER 30 DAYS) CHANTIX STARTING MONTH BOX 4 QL (53 PER 8 DAYS) NICOTROL CARTRIDGE INHALER 4 QL (304 PER 80 DAYS) NICOTROL NS 0 MG/ML SPRAY 4 QL (70 PER 80 DAYS) ANTIBACTERIALS AMINOGLYCOSIDES garamycin (0.3% drops, 3 mg/ml drops) gentak 0.3 % eye ointment gentamicin sulfate (0.% cream, 0.% ointment, 0.3% eye ointment, 0.3% eye drops, 3 mg/gm eye oint, 3 mg/ml eye drops) gentamicin sulfate (0 mg/ml vial, 0 mg/ ml vial, ped 0 mg/ ml vial, 40 mg/ml vial, 80 mg/ ml vial, 800 mg/0 ml vial) gentamicin sulfate in ns (isoton 60 mg/50 ml, 70 mg/ns 50 ml pb, isoton 80 mg/50 ml, 80 mg/ns 00 ml pb, 00 mg/ns 00 ml, iso 00 mg/00 ml, iso 0 mg/00 ml, isoton 80 mg/00 ml, 80 mg/ns 50 ml pb, 90 mg/ns 00 ml pb, isoton 00 mg/50 ml) neomycin 500 mg tablet paromomycin 50 mg capsule 4 PA - TO CONFIRM PART D COVERAGE streptomycin sulf gm vial 4 PA - TO CONFIRM PART D COVERAGE 3 LAST UPDATED /07

14 TOBRADEX EYE OINTMENT 4 tobramycin 0.3% eye drops tobramycin 60 mg/50 ml ns 4 tobramycin sulfate (. gram/30 ml vial,. gm vial, 0 mg/ml vial, 40 mg/ml vial, 80 mg/ ml vial,,00 mg/30 ml vial) TOBREX 0.3% EYE OINTMENT 4 ANTIBACTERIALS, OTHER PA - TO CONFIRM PART D COVERAGE baciim 50,000 unit vial PA - TO CONFIRM PART D COVERAGE bacitracin 50,000 unit vial bacitracin 500 unit/gm ophth BACTROBAN NASAL % OINTMENT 4 chloramphen na succ gm vl PA - TO CONFIRM PART D COVERAGE CLEOCIN 00 MG VAGINAL OVULE 4 clindamax % gel clindamycin 75 mg/5 ml soln 4 clindamycin hcl (75 mg capsule, 50 mg capsule, 300 mg capsule) clindamycin pediatr 75 mg/5 ml 4 clindamycin phosphate (ph % solution, ph % gel, % vaginal cream, ph 9 g/60 ml vial, 300 mg/ ml addvan, ph 600 mg/4 ml vl, 600 mg/4 ml addvan, ph 900 mg/6 ml vl, phosp % lotion, 50 mg/ml addvan, ph 300 mg/ ml vl, 900 mg/6 ml addvan) clindamycin phosphate-d5w (300 mg/50 ml, 600 mg/50 ml, 900 mg/50 ml) colistimethate 50 mg vial 4 PA - TO CONFIRM PART D COVERAGE CUBICIN 500 MG VIAL 5 PA - TO CONFIRM PART D COVERAGE CUBICIN RF 500 MG VIAL 5 PA - TO CONFIRM PART D COVERAGE DALVANCE 500 MG VIAL 5 daptomycin 500 mg vial 5 PA - TO CONFIRM PART D COVERAGE LINCOCIN 300 MG/ML VIAL 4 lincomycin hcl (3 gm/0 ml vial, 600 mg/ ml vl) 4 linezolid (00 mg/5 ml susp, 600 mg/300 ml iv sol) 5 4 LAST UPDATED /07

15 linezolid 600 mg tablet 4 linezolid-0.9% nacl 600 mg/300 5 methenamine hipp gm tablet metronidazole (0.75% lotion, topical 0.75% gl, 0.75% cream, top % gel pump, topical % gel, 50 mg tablet, 500 mg tablet, 500 mg/00 ml) metronidazole vaginal 0.75% gl MONUROL 3 GM SACHET 4 mupirocin % cream mupirocin % ointment neomycin-polymyxin b (40 mg/ml vl, 40 mg/ml amp) nitrofurantoin (5 mg/5 ml susp, mcr 5 mg cap, mcr 50 mg cap, mcr 00 mg cap) nitrofurantoin mono-mcr 00 mg SIVEXTRO 00 MG TABLET 5 QL (6 PER 30 DAYS) SULFAMYLON 8.5% CREAM 4 SYNERCID 500 MG VIAL 5 tigecycline 50 mg vial 5 PA tinidazole (50 mg tablet, 500 mg tablet) 4 trimethoprim 00 mg tablet TYGACIL 50 MG VIAL 5 PA vancomycin 750 mg/50 ml bag vancomycin hcl (5 mg capsule, 50 mg capsule) vancomycin hcl (hcl g/00 ml bag, gm vial, gm add-van vial, hcl 5 gm vial, hcl 0 gm vial, 500 mg vial, 500 mg a-v vial, hcl 750 mg vial) vancomycin-d5w 500 mg/00 ml VANDAZOLE VAGINAL 0.75% GEL XIFAXAN (00 MG TABLET, 550 MG TABLET) 5 ZERBAXA.5 GRAM VIAL 5 PA - TO CONFIRM PART D COVERAGE BETA-LACTAM, CEPHALOSPORINS CEDAX 80 MG/5 ML SUSPENSION LAST UPDATED /07

16 cefaclor (50 mg capsule, 500 mg capsule) cefadroxil ( gm tablet, 50 mg/5 ml susp, 500 mg/5 ml susp) cefadroxil 500 mg capsule cefazolin sodium ( gm add-van vial, gm vial, 0 gm vial, 0 gm bulk vial, sod 00 gm bulk bag, sod 300 gm bulk bag, 500 mg vial) cefazolin sodium-dextrose ( g/50, g/00, g/50) cefdinir (5 mg/5 ml susp, 50 mg/5 ml susp) 4 cefdinir 300 mg capsule cefepime ( gm, gm) 4 PA - TO CONFIRM PART D COVERAGE cefepime hcl ( gm vial, gram vial) 4 PA - TO CONFIRM PART D COVERAGE cefepime-dextrose ( gm/50 ml, gm/50 ml) 4 cefixime (00 mg/5 ml susp, 00 mg/5 ml susp) cefotaxime sodium ( gm vial, gm vial, 500 mg vial) cefoxitin ( gm vial, gm vial, 0 gm vial) PA - TO CONFIRM PART D COVERAGE cefpodoxime proxetil (00 mg tablet, 00 mg tablet) cefpodoxime proxetil (50 mg/5 ml susp, 00 mg/5 ml susp) cefprozil (5 mg/5 ml susp, 50 mg tablet, 50 mg/5 ml susp, 500 mg tablet) ceftazidime ( gm vial, gm piggyback, gm piggyback, gm vial, 6 gm vial) ceftibuten (80 mg/5 ml susp, 400 mg capsule) ceftriaxone ( gm vial, 0 gm vial, 00 gram bulk bag) ceftriaxone ( gm-d5w bag, gm piggyback, gm-d5w bag, gm vial, gm piggyback, gm add vial, 50 mg vial, 500 mg vial) cefuroxime (50 mg tab, 500 mg tab) cefuroxime sodium (.5 gm vial, 7.5 gm vial, 750 mg vial) cephalexin (5 mg/5 ml susp, 50 mg/5 ml susp, 50 mg capsule, 500 mg capsule) 4 PA - TO CONFIRM PART D COVERAGE PA - TO CONFIRM PART D COVERAGE 6 LAST UPDATED /07

17 SUPRAX (00 MG TABLET CHEWABLE, 00 MG TABLET CHEWABLE, 00 MG/5 ML SUSPENSION, 400 MG CAPSULE, 500 MG/5 ML SUSPENSION) SUPRAX 400 MG TABLET 4 tazicef ( gram vial, gm add-vantage vial, gm add-vantage, gram vial, 6 gram vial) TEFLARO (400 MG VIAL, 600 MG VIAL) 5 BETA-LACTAM, OTHER AZACTAM-ISO-OSMOTIC DEXTROSE ( GM/50 ML, GM/50 ML) aztreonam ( gm vial, gm vial) 4 imipenem-cilastatin sodium (50 mg vl, 500 mg vl) INVANZ ( GM VIAL, GM ADD-VANTAGE VIAL) 4 meropenem ( gm vial, 500 mg vial) 4 BETA-LACTAM, PENICILLINS amox-clav er, mg tab amoxicillin (5 mg/5 ml susp, 5 mg tab chew, 00 mg/5 ml susp, 50 mg capsule, 50 mg tab chew, 50 mg/5 ml susp, 400 mg/5 ml susp, 500 mg tablet, 500 mg capsule, 875 mg tablet) amoxicillin-clavulanate potass ( mg tab chew, mg/5 ml sus, 50-5 mg tablet, mg tab chew, mg tablet, mg tablet) amoxicillin-clavulanate potass ( mg/5 ml sus, mg/5 ml susp, mg/5 ml sus) ampicillin sodium ( gm vial, gm add-vantage vl, gm add-vantage vl, gm vial, 0 gm vial, 5 mg vial, 50 mg vial, 500 mg vial) ampicillin trihydrate (5 mg/5 ml susp, 50 mg capsule, 50 mg/5 ml susp, 500 mg capsule) ampicillin-sulbactam (ampicillin-sulb 3 gm add vial, ampicillin-sulbactam.5 gm vl, ampicillinsulbactam 3 gm vial, ampicillin-sulbactam 5 gm vl) BICILLIN C-R (. MILLION UNIT, SYRINGE) PA - TO CONFIRM PART D COVERAGE PA - TO CONFIRM PART D COVERAGE 4 7 LAST UPDATED /07

18 BICILLIN L-A (600,000 UNIT/ML,,00,000 UNITS,,400,000 UNITS) dicloxacillin sodium (50 mg capsule, 500 mg capsule) nafcillin ( gm/ 50 ml, gm/ 00 ml) 4 nafcillin sodium ( gm vial, gm add-van vial, gm add-vant vial, gm vial, 0 gm bulk vial, 0 gm vial) oxacillin gm/ 50 ml inj oxacillin 0 gm vial 5 oxacillin gm/ 50 ml inj 4 oxacillin sodium ( gm add-vantage vl, gm vial, gm vial, gm add-vantage vl) 4 4 PA - TO CONFIRM PART D COVERAGE penicillin g na 5 million unit 4 PA - TO CONFIRM PART D COVERAGE penicillin g potassium (g k 5 million, gk 0 million) penicillin gk-iso-osm dextrose (pen million unit/50 ml, pen million unit/50 ml, pen 3 million unit/50 ml) penicillin v potassium (5 mg/5 ml soln, 50 mg tablet, 50 mg/5 ml soln, 500 mg tablet) piperacillin-tazobactam (piperacil-tazo.5 gm add vl, piperacil-tazobact.5 gm vl, piperaciltazobact gm vl, piperacil-tazobact 4.5 gm vial, piperacil-tazobact 3.5 gm vl, piperaciltazobact 40.5 gram) 4 PA - TO CONFIRM PART D COVERAGE ZOSYN (.5 GM/50 ML BAG, GM/50 ML) 4 PA - TO CONFIRM PART D COVERAGE MACROLIDES AZASITE % EYE DROPS 3 azithromycin ( gm pwd packet, 00 mg/5 ml susp, 00 mg/5 ml susp, 600 mg tablet) azithromycin (50 mg tablet, 500 mg tablet) azithromycin i.v. 500 mg vial PA - TO CONFIRM PART D COVERAGE clarithromycin (5 mg/5 ml sus, 50 mg tablet, 50 mg/5 ml sus, 500 mg tablet) clarithromycin er 500 mg tab 4 DIFICID 00 MG TABLET LAST UPDATED /07

19 E.E.S. 00 MG/5 ML GRANULES 4 ery % pads ERY-TAB (EC 50 MG TABLET, EC 333 MG TABLET, EC 500 MG TABLET) ERYPED 00 MG/5 ML SUSPENSION 4 ERYPED 400 MG/5 ML SUSPENSION 4 ERYTHROCIN 50 MG FILMTAB 4 ERYTHROCIN LACTOBIONATE ( GM ADDVANT VIAL, 500 MG VIAL, 500 MG ADDVNT VL) erythromycin (50 mg filmtab, ec 50 mg cap, 500 mg filmtab) erythromycin (gel, pledgets, solution) erythromycin 0.5% eye ointment erythromycin ethylsuccinate (00 mg/5 ml gran, es 400 mg tab) ILOTYCIN 0.5% EYE OINTMENT 4 KETEK (300 MG TABLET, 400 MG TABLET) 4 QUINOLONES BESIVANCE 0.6% SUSP 3 CILOXAN 0.3% OINTMENT 3 ciprofloxacin (00 mg/0 ml vl, 400 mg/40 ml vl) ciprofloxacin (50 mg/5 ml susp, 500 mg/5 ml susp) ciprofloxacin hcl (0.3% eye drop, hcl 50 mg tab, hcl 500 mg tab, hcl 750 mg tab) ciprofloxacin hcl 00 mg tab 4 ciprofloxacin-d5w (00 mg/00 ml, 400 mg/00 ml) gatifloxacin 0.5% eye drops 4 levofloxacin (0.5% eye drops, 500 mg/0 ml vial, 750 mg/30 ml vial) levofloxacin (5 mg/ml solution, 50 mg/0 ml soln, 500 mg/0 ml soln) levofloxacin (50 mg tablet, 500 mg tablet, 750 mg tablet) 3 4 PA - TO CONFIRM PART D COVERAGE LAST UPDATED /07

20 levofloxacin-d5w (50 mg/50, 500 mg/00, 750 mg/50) MOXEZA 0.5% EYE DROPS 3 moxifloxacin 0.5% eye drops moxifloxacin hcl 400 mg tablet 4 QL (30 PER 30 DAYS) NOROXIN 400 MG TABLET 4 ofloxacin (00 mg tablet, 300 mg tablet, 400 mg tablet) ofloxacin (ear drops, eye drops) VIGAMOX 0.5% EYE DROPS 3 SULFONAMIDES silver sulfadiazine % cream SSD % CREAM sulfacetamide 0% eye drops sulfadiazine 500 mg tablet 4 sulfamethoxazole-tmp inj vial 4 PA - TO CONFIRM PART D COVERAGE sulfamethoxazole-trimethoprim (ds tablet, ss tablet, susp) SULFATRIM PEDIATRIC SUSPENSION 3 TETRACYCLINES demeclocycline hcl (50 mg tablet, 300 mg tablet) doxy 00 vial 4 doxycycline hyclate (hyc 00 mg vial, hyclate 0 mg tab, hyclate 50 mg cap, hyclate 00 mg tab, hyclate 00 mg cap) doxycycline ir-dr 40 mg cap 4 doxycycline mono 50 mg tablet 4 doxycycline monohydrate (50 mg cap, 50 mg tablet, 75 mg capsule, 75 mg tablet, 00 mg cap, 00 mg tablet) minocycline hcl (50 mg capsule, 75 mg capsule, 00 mg capsule) LAST UPDATED /07

21 ANTICONVULSANTS ANTICONVULSANTS, OTHER BRIVIACT (0 MG TABLET, 0 MG/ML ORAL SOLN, 5 MG TABLET, 50 MG TABLET, 75 MG TABLET, 00 MG TABLET) BRIVIACT 50 MG/5 ML VIAL 4 FYCOMPA ( MG TABLET, 4 MG TABLET, 6 MG TABLET, 8 MG TABLET, 0 MG TABLET, MG TABLET) 5 4 QL (30 PER 30 DAYS) FYCOMPA 0.5 MG/ML ORAL SUSP 4 QL (70 PER 30 DAYS) levetiracetam (00 mg/ml soln, 500 mg/5 ml soln) levetiracetam (50 mg tablet, 500 mg tablet, 750 mg tablet,,000 mg tablet) levetiracetam 500 mg/5 ml vial 4 levetiracetam er 500 mg tablet QL (80 PER 30 DAYS) levetiracetam er 750 mg tablet QL (0 PER 30 DAYS) levetiracetam-nacl (500 mg/00,,000mg/00,,500mg/00) POTIGA (00 MG TABLET, 300 MG TABLET, 400 MG TABLET) 4 5 QL (90 PER 30 DAYS) POTIGA 50 MG TABLET 5 QL (70 PER 30 DAYS) roweepra (500 mg tablet, 750 mg tablet,,000 mg tablet) SPRITAM (50 MG TABLET, 500 MG TABLET, 750 MG TABLET,,000 MG TABLET) CALCIUM CHANNEL MODIFYING AGENTS CELONTIN 300 MG KAPSEAL 4 ethosuximide (50 mg capsule, 50 mg/5 ml soln) zonisamide (5 mg capsule, 50 mg capsule, 00 mg capsule) GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS clonazepam (0.5 mg odt, 0.5 mg dis tab, 0.5 mg odt, 0.5 mg dis tablet, 0.5 mg odt, mg odt, mg dis tablet) 4 QL (90 PER 30 DAYS) LAST UPDATED /07

22 clonazepam (0.5 mg tablet, mg tablet) QL (90 PER 30 DAYS) clonazepam mg odt QL (300 PER 30 DAYS) clonazepam mg tablet QL (300 PER 30 DAYS) DIASTAT.5 MG PEDI SYSTEM 4 DIASTAT ACUDIAL ( MG KT, MG) diazepam (.5 mg rectal gel sys, 0 mg rectal gel syst, 0 mg rectal gel syst) divalproex dr 5 mg cap sprnk divalproex sodium (dr 5 mg tab, dr 50 mg tab, dr 500 mg tab) divalproex sodium er (er 50 mg tab, er 500 mg tab) gabapentin (00 mg capsule, 50 mg/5 ml soln, 300 mg capsule, 300 mg/6 ml soln, 400 mg capsule, 600 mg tablet, 800 mg tablet) GABITRIL ( MG TABLET, 6 MG TABLET) 4 4 FFF ONFI 0 MG TABLET 4 QL (60 PER 30 DAYS) ONFI.5 MG/ML SUSPENSION 5 QL (480 PER 30 DAYS) ONFI 0 MG TABLET 5 QL (60 PER 30 DAYS) phenobarbital (5 mg tablet, 6. mg tablet, 30 mg tablet, 3.4 mg tablet, 60 mg tablet, 64.8 mg tablet) phenobarbital (0 mg/5 ml soln, 0 mg/5 ml elix) QL (90 PER 30 DAYS) QL (500 PER 30 DAYS) phenobarbital 00 mg tablet QL (0 PER 30 DAYS) phenobarbital 97. mg tablet QL (60 PER 30 DAYS) phenobarbital sodium (65 mg/ml vial, 30 mg/ml vial) primidone (50 mg tablet, 50 mg tablet) SABRIL (500 MG POWDER PACKET, 500 MG TABLET) tiagabine hcl ( mg tablet, 4 mg tablet) 4 valproate sod 500 mg/5 ml vl valproic acid (50 mg/5 ml soln, 50 mg capsule, 500 mg/0 ml sol) 5 PA - FOR NEW STARTS ONLY, LA, QL (80 PER 30 DAYS) LAST UPDATED /07

23 vigabatrin 500 mg powder packt 5 PA - FOR NEW STARTS ONLY, LA, QL (80 PER 30 DAYS) GLUTAMATE REDUCING AGENTS felbamate (400 mg tablet, 600 mg tablet, 600 mg/5 ml susp) lamotrigine (5 mg tablet, 00 mg tablet, 50 mg tablet, 00 mg tablet) lamotrigine (5 mg tablet, 5 mg tab) lamotrigine er (er 5 mg tablet, er 50 mg tablet, er 00 mg tablet, er 00 mg tablet, er 50 mg tablet, er 300 mg tablet) topiramate (5 mg sprinkle cap, 5 mg tablet, 5 mg sprinkle cap, 50 mg tablet, 00 mg tablet, 00 mg tablet) topiramate er (er 5 mg capsule, er 50 mg capsule, er 00 mg capsule, er 50 mg capsule, er 00 mg capsule) SODIUM CHANNEL AGENTS APTIOM (600 MG TABLET, 800 MG TABLET) 5 QL (60 PER 30 DAYS) APTIOM 00 MG TABLET 4 QL (60 PER 30 DAYS) APTIOM 400 MG TABLET 5 QL (30 PER 30 DAYS) BANZEL 00 MG TABLET 4 QL (40 PER 30 DAYS) BANZEL 40 MG/ML SUSPENSION 5 QL (400 PER 30 DAYS) BANZEL 400 MG TABLET 5 QL (40 PER 30 DAYS) carbamazepine (00 mg/5 ml susp, 00 mg tab chew, 00 mg tablet) carbamazepine er (er 00 mg cap, er 00 mg tablet, er 00 mg cap, er 00 mg tablet, er 300 mg cap, er 400 mg tablet) CEREBYX (00 MG PE/ ML VIAL, 500 MG PE/0 ML VIAL) DILANTIN (50 MG INFATAB, 00 MG CAPSULE) 4 DILANTIN 5 MG/5 ML SUSP 4 DILANTIN 30 MG CAPSULE 3 epitol 00 mg tablet fosphenytoin sodium (00 mg pe/ ml vl, 500 mg pe/0 ml) PA - TO CONFIRM PART D COVERAGE PA - TO CONFIRM PART D COVERAGE 3 LAST UPDATED /07

24 oxcarbazepine (50 mg tablet, 300 mg tablet, 300 mg/5 ml susp, 600 mg tablet) PEGANONE 50 MG TABLET 4 PHENYTEK (00 MG CAPSULE, 300 MG CAPSULE) 3 phenytoin (50 mg infatab, 50 mg tablet chew, 00 mg/4 ml susp, 5 mg/5 ml susp) phenytoin sodium (50 mg/ml vial, 50 mg/ml ampul, 50 mg/ml syringe, 00 mg/ ml vial, 50 mg/5 ml vial) phenytoin sodium extended (00 mg cap, 00 mg cap, 300 mg cap) TEGRETOL XR 00 MG TABLET 4 VIMPAT (0 MG/ML SOLUTION, 00 MG/0 ML VIAL) VIMPAT (50 MG TABLET, 00 MG TABLET, 50 MG TABLET, 00 MG TABLET) ANTIDEMENTIA AGENTS ANTIDEMENTIA AGENTS, OTHER ergoloid mesylates mg tab PA NAMZARIC (7 MG CAPSULE, 4 MG CAPSULE, MG CAPSULE, 8 MG CAPSULE) PA - TO CONFIRM PART D COVERAGE 4 QL (00 PER 30 DAYS) 4 QL (60 PER 30 DAYS) 3 QL (30 PER 30 DAYS) NAMZARIC TITRATION PACK 3 QL (56 PER OVER TIME) CHOLINESTERASE INHIBITORS donepezil hcl (5 mg tablet, 0 mg tablet) FFF donepezil hcl odt (odt 5 mg tablet, odt 0 mg tablet) EXELON (4.6 MG/4HR PATCH, 9.5 MG/4HR PATCH, 3.3 MG/4HR PATCH) QL (30 PER 30 DAYS) 4 QL (30 PER 30 DAYS) galantamine 4 mg/ml oral soln 4 QL (80 PER 30 DAYS) galantamine er (er 8 mg capsule, er 6 mg capsule, er 4 mg capsule) galantamine hbr (4 mg tablet, 8 mg tablet, mg tablet) rivastigmine (.5 mg capsule, 3 mg capsule, 4.5 mg capsule, 6 mg capsule) QL (30 PER 30 DAYS) QL (60 PER 30 DAYS) 4 LAST UPDATED /07

25 rivastigmine (4.6 mg/4hr patch, 9.5 mg/4hr patch, 3.3 mg/4hr ptch) N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST memantine hcl (hcl 5 mg tablet, 5-0 mg titration pk, hcl 0 mg tablet) memantine hcl mg/ml solution NAMENDA (5-0 MG TITRATION PK, 5 MG TABLET, 0 MG TABLET) 4 QL (30 PER 30 DAYS) FFF 4 QL (60 PER 30 DAYS) NAMENDA MG/ML SOLUTION 4 QL (300 PER 30 DAYS) NAMENDA XR (7 MG CAPSULE, 4 MG CAPSULE, MG CAPSULE, 8 MG CAPSULE, TITRATION PACK) ANTIDEPRESSANTS ANTIDEPRESSANTS, OTHER 3 QL (30 PER 30 DAYS) budeprion sr 50 mg tablet QL (90 PER 30 DAYS) bupropion hcl 00 mg tablet QL (0 PER 30 DAYS), FFF bupropion hcl 75 mg tablet QL (80 PER 30 DAYS), FFF bupropion hcl sr (00 mg tablet, 00 mg tab) QL (60 PER 30 DAYS), FFF bupropion hcl sr 00 mg tablet QL (0 PER 30 DAYS), FFF bupropion hcl sr 50 mg tablet QL (90 PER 30 DAYS), FFF bupropion xl (50 mg tablet, 300 mg tablet) FFF mirtazapine (5 mg odt, 30 mg odt, 45 mg odt) QL (30 PER 30 DAYS) mirtazapine (5 mg tablet, 30 mg tablet, 45 mg tablet) mirtazapine 7.5 mg tablet QL (30 PER 30 DAYS) MONOAMINE OXIDASE INHIBITORS EMSAM (6 MG/4 PATCH, 9 MG/4 PATCH, MG/4 PATCH) MARPLAN 0 MG TABLET 4 phenelzine sulfate 5 mg tab tranylcypromine sulf 0 mg tab 4 5 ST, QL (30 PER 30 DAYS) 5 LAST UPDATED /07

26 SSRIS/SNRIS (SELECTIVE SEROTONIN REUPTAKE INHIBITORS/SEROTONIN AND NOREPINEPHRINE REUPTAKE INHIBITOR BRINTELLIX (5 MG TABLET, 0 MG TABLET, 0 MG TABLET) citalopram hbr (0 mg tablet, 0 mg tablet, 40 mg tablet) 4 QL (30 PER 30 DAYS) FFF citalopram hbr 0 mg/5 ml soln QL (600 PER 30 DAYS) desvenlafaxine er (er 50 mg tablet, er 50 mg tab) 4 QL (30 PER 30 DAYS) desvenlafaxine er 00 mg tab 4 QL (0 PER 30 DAYS) desvenlafaxine suc er 00 mg QL (0 PER 30 DAYS) desvenlafaxine succinate er (er 5 mg, er 50 mg) QL (30 PER 30 DAYS) duloxetine hcl (dr 0 mg cap, dr 30 mg cap, dr 60 mg cap) escitalopram oxalate (5 mg tablet, 0 mg tablet, 0 mg tablet) QL (60 PER 30 DAYS) FFF escitalopram oxalate 5 mg/5 ml QL (600 PER 30 DAYS) FETZIMA (ER 0 MG CAPSULE, ER 40 MG CAPSULE, ER 80 MG CAPSULE, ER 0 MG CAPSULE) 4 ST, QL (30 PER 30 DAYS) FETZIMA 0-40 MG TITRATION PAK 4 ST, QL (8 PER 8 DAYS) fluoxetine 0 mg/5 ml solution QL (600 PER 30 DAYS) fluoxetine dr 90 mg capsule 4 QL (4 PER 8 DAYS) fluoxetine hcl (0 mg capsule, 0 mg capsule, 40 mg capsule) FFF fluoxetine hcl 0 mg tablet QL (45 PER 30 DAYS) fluoxetine hcl 0 mg tablet QL (0 PER 30 DAYS) fluvoxamine maleate (5 mg tab, 50 mg tab, 00 mg tab) fluvoxamine maleate er (er 00 mg capsule, er 50 mg capsule) QL (90 PER 30 DAYS) 4 QL (60 PER 30 DAYS) maprotiline 75 mg tablet QL (90 PER 30 DAYS) maprotiline hcl (5 mg tablet, 50 mg tablet) QL (0 PER 30 DAYS) nefazodone hcl (50 mg tablet, 00 mg tablet, 50 mg tablet, 00 mg tablet, 50 mg tablet) paroxetine cr.5 mg tablet QL (80 PER 30 DAYS) 6 LAST UPDATED /07

27 paroxetine cr 5 mg tablet QL (90 PER 30 DAYS) paroxetine cr 37.5 mg tablet QL (60 PER 30 DAYS) paroxetine er.5 mg tablet QL (80 PER 30 DAYS) paroxetine er 5 mg tablet QL (90 PER 30 DAYS) paroxetine er 37.5 mg tablet QL (60 PER 30 DAYS) paroxetine hcl (0 mg tablet, 0 mg tablet, 30 mg tablet, 40 mg tablet) FFF PAXIL 0 MG/5 ML SUSPENSION 4 QL (900 PER 30 DAYS) PRISTIQ (ER 5 MG TABLET, ER 50 MG TABLET) 3 QL (30 PER 30 DAYS) PRISTIQ ER 00 MG TABLET 3 QL (0 PER 30 DAYS) sertraline 0 mg/ml oral conc QL (300 PER 30 DAYS) sertraline hcl (5 mg tablet, 50 mg tablet, 00 mg tablet) trazodone 300 mg tablet trazodone hcl (50 mg tablet, 00 mg tablet, 50 mg tablet) TRINTELLIX (5 MG TABLET, 0 MG TABLET, 0 MG TABLET) venlafaxine hcl (5 mg tablet, 37.5 mg tablet, 50 mg tablet, 75 mg tablet, 00 mg tablet) venlafaxine hcl er (er 37.5 mg cap, er 75 mg cap, er 50 mg cap) VIIBRYD (0 MG TABLET, 0-0 MG STARTER PACK, MG STARTER PK, 0 MG TABLET, 40 MG TABLET) TRICYCLICS amitriptyline hcl (0 mg tab, 5 mg tab, 50 mg tab, 75 mg tab, 00 mg tab, 50 mg tab) amoxapine (5 mg tablet, 50 mg tablet, 00 mg tablet, 50 mg tablet) clomipramine hcl (5 mg capsule, 50 mg capsule, 75 mg capsule) desipramine hcl (0 mg tablet, 5 mg tablet, 50 mg tablet, 75 mg tablet, 00 mg tablet, 50 mg tablet) FFF 4 QL (30 PER 30 DAYS) FFF FFF 4 QL (30 PER 30 DAYS) PA - FOR NEW STARTS ONLY PA - FOR NEW STARTS ONLY doxepin 0 mg/ml oral conc PA - FOR NEW STARTS ONLY 7 LAST UPDATED /07

28 doxepin hcl (0 mg capsule, 5 mg capsule, 50 mg capsule, 75 mg capsule, 00 mg capsule, 50 mg capsule) imipramine hcl (0 mg tablet, 5 mg tablet, 50 mg tablet) nortriptyline 0 mg/5 ml sol nortriptyline hcl (0 mg cap, 5 mg cap, 50 mg cap, 75 mg cap) protriptyline hcl (5 mg tablet, 0 mg tablet) SURMONTIL (5 MG CAPSULE, 50 MG CAPSULE, 00 MG CAPSULE) trimipramine maleate (5 mg cap, 50 mg cap, 00 mg cp) ANTIEMETICS ANTIEMETICS, OTHER compro 5 mg suppository meclizine hcl (.5 mg tablet, 5 mg tablet) metoclopramide hcl (0 mg/ ml vial, 0 mg/ ml syr) metoclopramide hcl (5 mg tablet, 5 mg/5 ml syrup, 5 mg/5 ml soln, 0 mg tablet) perphenazine ( mg tablet, 4 mg tablet, 8 mg tablet, 6 mg tablet) prochlorperazine 5 mg supp prochlorperazine edisylate (5 mg/ml vial, 0 mg/ ml vl) prochlorperazine maleate (5 mg tablet, 0 mg tab) PA - FOR NEW STARTS ONLY PA - FOR NEW STARTS ONLY 4 PA - TO CONFIRM PART D COVERAGE scopolamine mg/3 day patch 4 QL (0 PER 30 DAYS) TRANSDERM-SCOP.5 MG/3 DAY 4 QL (0 PER 30 DAYS) EMETOGENIC THERAPY ADJUNCTS ALOXI 0.5 MG/5 ML VIAL 4 PA ANZEMET 00 MG TABLET 5 PA - TO CONFIRM PART D COVERAGE, QL (3 PER 3 DAYS) ANZEMET 0 MG/ML VIAL 4 PA - TO CONFIRM PART D COVERAGE 4 8 LAST UPDATED /07

29 ANZEMET 50 MG TABLET 4 PA - TO CONFIRM PART D COVERAGE, QL (6 PER 3 DAYS) aprepitant 5 mg capsule PA - TO CONFIRM PART D COVERAGE, QL ( PER DAYS) aprepitant mg pack PA - TO CONFIRM PART D COVERAGE, QL (3 PER 3 DAYS) aprepitant 40 mg capsule PA - TO CONFIRM PART D COVERAGE aprepitant 80 mg capsule PA - TO CONFIRM PART D COVERAGE, QL ( PER DAYS) dronabinol (.5 mg capsule, 5 mg capsule) 4 PA, QL (80 PER 30 DAYS) dronabinol 0 mg capsule 4 PA EMEND (5 MG CAPSULE, 5 MG POWDER PACKET) 3 PA - TO CONFIRM PART D COVERAGE, QL ( PER DAYS) EMEND 40 MG CAPSULE 3 PA - TO CONFIRM PART D COVERAGE EMEND 80 MG CAPSULE 3 PA - TO CONFIRM PART D COVERAGE, QL ( PER DAYS) EMEND TRIPACK 3 PA - TO CONFIRM PART D COVERAGE, QL (3 PER 3 DAYS) granisetron hcl (0. mg/ml vial, mg/ml vial, 4 mg/4 ml vial) granisetron hcl mg tablet PA - TO CONFIRM PART D COVERAGE, QL (6 PER 3 DAYS) granisol mg/0 ml solution PA - TO CONFIRM PART D COVERAGE ondansetron hcl (hcl 4 mg tablet, 4 mg/5 ml solution, hcl 8 mg tablet, hcl 4 mg tablet) ondansetron hcl (hcl 4 mg/ ml amp, 4 mg/ ml isecure, hcl 4 mg/ ml syr, hcl 4 mg/ ml vial, 40 mg/0 ml vial) ondansetron odt (odt 4 mg tablet, odt 8 mg tablet) PA - TO CONFIRM PART D COVERAGE PA - TO CONFIRM PART D COVERAGE SANCUSO 3. MG/4 HR PATCH 5 QL ( PER 8 DAYS) SUSTOL 0 MG/0.4 ML SYRINGE 5 QL (3.6 PER 30 DAYS) VARUBI 90 MG TABLET 4 PA - TO CONFIRM PART D COVERAGE, QL ( PER DAYS) ANTIFUNGALS ABELCET 00 MG/0 ML VIAL 5 PA - TO CONFIRM PART D COVERAGE 9 LAST UPDATED /07

30 AMBISOME 50 MG VIAL 5 PA - TO CONFIRM PART D COVERAGE amphotericin b 50 mg vial 4 PA - TO CONFIRM PART D COVERAGE CANCIDAS (50 MG VIAL, 70 MG VIAL) 5 PA - TO CONFIRM PART D COVERAGE caspofungin acetate (50 mg vial, 70 mg vial) 5 PA - TO CONFIRM PART D COVERAGE ciclopirox (0.77% topical susp, 0.77% cream, 0.77% gel, % shampoo, 8% solution) clotrimazole 0 mg troche CRESEMBA 86 MG CAPSULE 5 econazole nitrate % cream ERAXIS (WATER DILUENT) (DIL) 50 MG VIAL, DIL) 00 MG VIAL) EXELDERM (CREAM, SOLUTION) 4 fluconazole (0 mg/ml susp, 40 mg/ml susp, 50 mg tablet, 00 mg tablet, 00 mg tablet) fluconazole 50 mg tablet fluconazole in dextrose (00 mg/00 ml, 400 mg/00 ml) fluconazole in saline (00 mg/50 ml, 00 mg/00 ml, 400 mg/00 ml) fluconazole-nacl (00 mg/50 ml, 00 mg/00 ml, 400 mg/00 ml) flucytosine (50 mg capsule, 500 mg capsule) 5 griseofulvin 5 mg/5 ml susp griseofulvin micro 500 mg tab 4 griseofulvin ultramicrosize (5 mg tab, 50 mg tab) gynazole % cream 4 itraconazole 00 mg capsule 4 PA ketoconazole (% cream, % shampoo, 00 mg tablet) miconazole 3 00 mg vag supp naftifine hcl (% cream, % cream) 4 NAFTIN (% GEL, % GEL, % CREAM) 4 NATACYN EYE DROPS 3 NOXAFIL (40 MG/ML SUSPENSION, DR 00 MG TABLET) 5 PA - TO CONFIRM PART D COVERAGE PA - TO CONFIRM PART D COVERAGE PA - TO CONFIRM PART D COVERAGE LAST UPDATED /07

31 NOXAFIL 300 MG/6.7 ML VIAL 4 nyamyc 00,000 units/gm powder nyata 00,000 unit/gm powder nystatin (00,000 units/gm oint, 00,000 unit/gm powd, 00,000 unit/gm cream, 00,000 unit/ml susp, 500,000 unit oral tab, 500,000 unit/5 ml sus, 50,000,000 units pwd, 50,000,000 units pwd, 500,000,000 units pwd) nystatin-triamcinolone (cream, ointm) nystop 00,000 units/gm powder ONMEL 00 MG TABLET 5 PA oxiconazole nitrate % cream 4 OXISTAT (CREAM, LOTION) 4 pedi-dri topical powder SPORANOX 0 MG/ML SOLUTION 5 PA terbinafine hcl 50 mg tablet terconazole (0.4% cream, 0.8% cream) terconazole 80 mg suppository voriconazole (50 mg tablet, 00 mg vial, 00 mg tablet) 4 PA voriconazole 40 mg/ml susp 5 PA zazole (0.4% cream, 0.8% cream) ANTIGOUT AGENTS allopurinol (00 mg tablet, 300 mg tablet) FFF colchicine (0.6 mg capsule, 0.6 mg tablet) QL (0 PER 30 DAYS) COLCRYS 0.6 MG TABLET 3 QL (0 PER 30 DAYS) MITIGARE 0.6 MG CAPSULE QL (0 PER 30 DAYS) probenecid 500 mg tablet probenecid-colchicine tabs ULORIC (40 MG TABLET, 80 MG TABLET) 3 ST, QL (30 PER 30 DAYS) 3 LAST UPDATED /07

32 ANTIMIGRAINE AGENTS ERGOT ALKALOIDS dihydroergotamine 4 mg/ml spry 4 dihydroergotamine mesylate ( mg/ml vl, mg/ml amp) ERGOMAR MG TABLET SL 3 migergot suppository 4 QL (0 PER 8 DAYS) SEROTONIN (5-HT) B/D RECEPTOR AGONISTS naratriptan ( mg tablet,.5 mg tablet) QL ( PER 30 DAYS), FFF naratriptan hcl ( mg tablet,.5 mg tablet) QL ( PER 30 DAYS), FFF rizatriptan (5 mg tablet, 5 mg odt, 0 mg tablet, 0 mg odt) 5 QL ( PER 30 DAYS), FFF sumatriptan 0 mg nasal spray 4 QL (8 PER 30 DAYS) sumatriptan 5 mg nasal spray 4 QL (3 PER 30 DAYS) sumatriptan succinate (5 mg tablet, 50 mg tablet, 00 mg tablet) sumatriptan succinate (4 mg/0.5 ml inject, 4 mg/0.5 ml cart) sumatriptan succinate (6 mg/0.5 ml refill, 6 mg/0.5 ml syrng, 6 mg/0.5 ml vial, 6 mg/0.5 ml inject) QL (8 PER 30 DAYS), FFF 4 4 QL (4 PER 30 DAYS) zolmitriptan (.5 mg tablet, 5 mg tablet) QL (9 PER 30 DAYS) zolmitriptan odt (.5 mg odt, 5 mg odt) QL (9 PER 30 DAYS) ANTIMYASTHENIC AGENTS PARASYMPATHOMIMETICS guanidine hcl 5 mg tablet MESTINON (60 MG/5 ML SYRUP, 80 MG TIMESPAN) pyridostigmine br 60 mg tablet pyridostigmine er 80 mg tab LAST UPDATED /07

33 ANTIMYCOBACTERIALS ANTIMYCOBACTERIALS, OTHER dapsone (5 mg tablet, 00 mg tablet) rifabutin 50 mg capsule 4 ANTITUBERCULARS CAPASTAT SULFATE GM VIAL 4 PA - TO CONFIRM PART D COVERAGE cycloserine 50 mg capsule ethambutol hcl (00 mg tablet, 400 mg tablet) isoniazid (00 mg tablet, 300 mg tablet) isoniazid (50 mg/5 ml solution, 00 mg/ml vial) 4 PASER GRANULES 4 GM PACKET 4 PRIFTIN 50 MG TABLET 4 pyrazinamide 500 mg tablet rifampin (50 mg capsule, 300 mg capsule) rifampin iv 600 mg vial 4 PA - TO CONFIRM PART D COVERAGE RIFATER TABLET 4 SIRTURO 00 MG TABLET 5 LA TRECATOR 50 MG TABLET 4 ANTINEOPLASTICS ALKYLATING AGENTS BENDEKA 00 MG/4 ML VIAL 5 BICNU 00 MG VIAL 5 PA - TO CONFIRM PART D COVERAGE busulfan 60 mg/0 ml vial 5 PA - TO CONFIRM PART D COVERAGE BUSULFEX 60 MG/0 ML VIAL 5 PA - TO CONFIRM PART D COVERAGE carboplatin (50 mg/5 ml vial, 50 mg vial, 50 mg/5 ml vial, 450 mg/45 ml vial, 600 mg/60 ml vial) cisplatin (50 mg/50 ml vial, 00 mg/00 ml vial, 00 mg/00 ml vial) cyclophosphamide ( gm vial, gm vial, 500 mg vial) PA - TO CONFIRM PART D COVERAGE PA - TO CONFIRM PART D COVERAGE 5 PA - TO CONFIRM PART D COVERAGE 33 LAST UPDATED /07

34 cyclophosphamide (5 mg capsule, 50 mg capsule) 4 PA - TO CONFIRM PART D COVERAGE cyclophosphamide (5 mg tab, 50 mg tablet) PA - TO CONFIRM PART D COVERAGE dacarbazine (00 mg vial, 00 mg vial) PA - TO CONFIRM PART D COVERAGE EVOMELA 50 MG VIAL 5 GLEOSTINE (5 MG CAPSULE, 0 MG CAPSULE, 40 MG CAPSULE, 00 MG CAPSULE) GLIADEL WAFER 5 LA HEXALEN 50 MG CAPSULE 5 ifosfamide ( gm/0 ml vial, gm vial, 3 gm vial, 3 gm/ 60 ml vial) ifosfamide-mesna kit 5 LEUKERAN MG TABLET 4 LOMUSTINE (0 MG CAPSULE, 40 MG CAPSULE, 00 MG CAPSULE) 3 4 PA - TO CONFIRM PART D COVERAGE LONSURF 5 MG-6.4 MG TABLET 5 PA - FOR NEW STARTS ONLY, QL (00 PER 8 DAYS) LONSURF 0 MG-8.9 MG TABLET 5 PA - FOR NEW STARTS ONLY, QL (80 PER 8 DAYS) MATULANE 50 MG CAPSULE 5 LA melphalan hcl (50 mg vial w-diluent, hcl 50 mg vial) 5 PA - TO CONFIRM PART D COVERAGE MUSTARGEN 0 MG VIAL 5 PA - TO CONFIRM PART D COVERAGE oxaliplatin (50 mg vial, 50 mg/0 ml vial, 00 mg/0 ml vial, 00 mg vial) TREANDA (5 MG VIAL, 45 MG/0.5 ML VIAL, 00 MG VIAL, 80 MG/ ML VIAL) 4 PA - TO CONFIRM PART D COVERAGE VALCHLOR 0.06% GEL 5 PA - FOR NEW STARTS ONLY, LA VYXEOS 44 MG-00 MG VIAL 5 PA - TO CONFIRM PART D COVERAGE ZANOSAR GM POWDER VIAL 5 PA - TO CONFIRM PART D COVERAGE ANTIANDROGENS bicalutamide 50 mg tablet flutamide 5 mg capsule NILANDRON 50 MG TABLET 5 nilutamide 50 mg tablet LAST UPDATED /07