CMI Marketplace 2015 (List of Covered Drugs)
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1 Analgesics Opioid Analgesics, Long-acting fentanyl 100 mcg/hr patch td72 fentanyl citrate 200 mcg lozenge hd morphine sulfate 30 mg tablet er oxymorphone hcl 7.5 mg tab er 12h Opioid Analgesics, Short-acting hydrocodone bitartrate/acetaminophen (5 mg-325mg tablet, mg tablet) oxycodone hcl/acetaminophen 10mg-325mg tablet tramadol hcl 50 mg tablet Anti-inflammatory Agents Glucocorticoids hydrocortisone 2.5 % oint. (g) TEXACORT Antibacterials Aminoglycosides amikacin sulfate 500 mg/2ml vial tobramycin sulfate 40 mg/ml vial Antibacterials, Other CLEOCIN 100 MG VAGINAL OVULE Beta-lactam, Cephalosporins cephalexin 500 mg capsule Beta-lactam, Penicillins amoxicillin 500 mg capsule 1
2 Macrolides ERYPED 200 Quinolones ciprofloxacin hcl 250 mg tablet Tetracyclines doxycycline hyclate 100 mg tablet minocycline hcl (45 mg tab er 24h, 75 mg capsule) Anticonvulsants Sodium Channel Agents VIMPAT 150 MG TABLET Antidementia Agents Cholinesterase Inhibitors donepezil hcl 5 mg tablet N-methyl-D-aspartate (NMDA) Receptor Antagonist NAMENDA 5 MG TABLET Antidepressants Antidepressants, Other mirtazapine 15 mg tablet Serotonin/Norepinephrine Reuptake Inhibitors citalopram hydrobromide 40 mg tablet fluoxetine hcl 20 mg capsule VENLAFAXINE HCL ER 37.5 MG TAB Antiemetics Antiemetics, Other meclizine hcl 12.5 mg tablet 2
3 promethazine hcl 12.5 mg tablet Emetogenic Therapy Adjuncts granisetron hcl 1 mg tablet Antifungals fluconazole 10 mg/ml susp recon Antimycobacterials Antituberculars isoniazid (100 mg tablet, 300 mg tablet) rifampin 300 mg capsule Antineoplastics Antineoplastics, Other SYLATRON 300 MCG 4-PACK Antiparkinson Agents Anticholinergics trihexyphenidyl hcl 5 mg tablet Antiparkinson Agents, Other STALEVO 150 Antipsychotics 2nd Generation/Atypical risperidone 0.5 mg tablet risperidone 2 mg tablet Antivirals Antiherpetic Agents famciclovir 250 mg tablet 3
4 Anxiolytics Anxiolytics, Other diazepam 5 mg tablet Bipolar Agents Mood Stabilizers lithium carbonate 300 mg tablet Blood Glucose Regulators Antidiabetic Agents pioglitazone hcl 15 mg tablet Blood Products/Modifiers/ Volume Expanders Coagulants CYKLOKAPRON 100 MG/ML AMPUL Cardiovascular Agents Alpha-adrenergic Agonists midodrine hcl 2.5 mg tablet Angiotensin II Receptor Antagonists irbesartan 150 mg tablet Angiotensin-converting Enzyme (ACE) Inhibitors captopril (12.5 mg tablet, 25 mg tablet, 50 mg tablet) lisinopril 5 mg tablet Antiarrhythmics NORPACE CR 150 MG CAPSULE Beta-adrenergic Blocking Agents metoprolol succinate 100 mg tab er 24h 4
5 metoprolol tartrate (50 mg tablet, 100 mg tablet) Cardiovascular Agents, Other digoxin 250 mcg tablet lisinopril/hydrochlorothiazide 20-25mg tablet quinapril/hydrochlorothiazide 20-25mg tablet Diuretics, Loop bumetanide 2 mg tablet furosemide 40 mg tablet Diuretics, Potassium-sparing eplerenone spironolactone 50 mg tablet Central Nervous System Agents Attention Deficit Hyperactivity Disorder Agents, Amphetamines dextroamphetamine/amphetamine 20 mg tablet dextroamphetamine/amphetamine 25 mg cap er 24h Central Nervous System Agents, Other phentermine hcl 30 mg capsule Dermatological Agents calcipotriene % solution isotretinoin 40 mg capsule mometasone furoate 0.1 % oint. (g) TAZORAC 0.1% GEL Gastrointestinal Agents Histamine2 (H2) Receptor Antagonists ranitidine hcl 15 mg/ml syrup 5
6 Genitourinary Agents Antispasmodics, Urinary TOVIAZ ER 4 MG TABLET Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal) Glucocorticoids/Mineralocorticoids dexamethasone 6 mg tablet hydrocortisone 10 mg tablet mometasone furoate 0.1 % solution Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) NORDITROPIN FLEXPRO 10 MG/1.5 Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) Estrogens ESTRING norethindrone ac-eth estradiol 1mg-5mcg tablet norethindrone-ethinyl estrad 1 mg-35mcg tablet Hormonal Agents, Suppressant (Thyroid) Antithyroid Agents propylthiouracil 50 mg tablet Immunological Agents Immune Suppressants methotrexate sodium/pf 25 mg/ml vial 6
7 Ophthalmic Agents Ophthalmic Prostaglandin and Prostamide Analogs LUMIGAN 0.01% EYE DROPS Otic Agents CIPRODEX Respiratory Tract Agents Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) theophylline anhydrous 300 mg tab er 12h Bronchodilators, Sympathomimetic ADVAIR HFA MCG INHALER Respiratory Tract Agents, Other hydrocodone bit/homatrop me-br mg/5 syrup Sleep Disorder Agents GABA Receptor Modulators zaleplon 10 mg capsule Therapeutic Nutrients/ Minerals/ Electrolytes Electrolyte/Mineral Replacement 0.9 % sodium chloride 0.9 % syringe folic acid 1 mg tablet KLOR-CON 7
8 This formulary was updated on null. For more recent information or other questions, please contact us, CMI Marketplace 2015, at [TOLL_FREE_NUMBER], [HOURS_OF_OPERATION], or visit [MEMBER_WEBSITE_LINK].
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Analgesics Opioid Analgesics, Long-acting fentanyl 100 mcg/hr patch td72 morphine sulfate 30 mg tablet er Opioid Analgesics, Short-acting fentanyl citrate 200 mcg lozenge hd hydrocodone/acetaminophen 5
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