State of Michigan Wrap Coverage
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- Garey Hutchinson
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1 State of Michigan Wrap Coverage Effective January, 208 Please read: This document contains information about the drugs covered under your pharmacy benefit plan. For a complete list of covered drugs or if you have questions: Call the toll-free member phone number on your ID card. Visit your plan s member website listed on your ID card. Locate a participating retail pharmacy by zip code. Look up possible lower-cost medication alternatives. Compare medication pricing and options. OptumRx
2 Acne Products AVAR LS LIQ 0-2% BP CLEANSING EMU 0-4% BPO GEL 4% ROSULA LIQ 0-4.5% SOD SUL/SULF EMU 0-5% SOD SUL/SULF LIQ WASH Antiangina Medications NITROGLYCER CAP 2.5MG ER NITROGLYCER CAP 6.5MG ER NITROGLYCER CAP 9MG ER NITRO-TIME CAP 2.5MG CR NITRO-TIME CAP 6.5MG CR NITRO-TIME CAP 9MG CR Antifungals - Topical ALA-QUIN CRE -0.5% 2 ALCORTIN A GEL 2 ALCORTIN A GEL -2-% 2 ALOQUIN GEL.25-% 2 DERMAZENE CRE % HYDROCORT CRE IODOQUIN HYDROCORT/CRE IODOQUIN VYTONE CRE -.9% Antihistamines ALAVERT TAB 0MG ALL DAY ALLG TAB 0MG ALLERCLEAR TAB 0MG ALLERGY TAB 0MG ALLERGY REL TAB 0MG ALLERGY RELF SYP 5MG/5ML ALLERGY RELF TAB.4MG ALLERGY RELF TAB 0MG ALLERGY RLF TAB 0MG ALLERHIST- TAB.4MG ALLER-TEC TAB 0MG CETIRIZINE TAB 0MG CLARITIN SOL 5MG/5ML CLARITIN SYP 5MG/5ML CLARITIN TAB 0MG CLARITIN RDT TAB 0MG CLARITIN RDT TAB 5MG 2 CLEMASTINE TAB.4MG CVS ALLERGY TAB 0MG CVS LORATADINE TAB 0 MG DAYHIST ALRG TAB 2 HOUR EQ DAYHIST TAB.4MG EQL ALL DAY TAB ALLERGY EQL DAYHIST TAB.4MG GNP ALL DAY TAB ALLERGY GNP DAYHIST TAB.4MG KP LORATADIN TAB 0MG LORADAMED TAB 0MG LORATADINE SOL 5MG/5ML LORATADINE SYP 5MG/5ML LORATADINE TAB 0MG PX DAYHIST TAB.4MG QC ALLERGY TAB 0MG QLEARQUIL 24 TAB 0MG RA CETIRIZIN TAB 0MG SB ALLERGY TAB 0MG SM ALL DAY TAB 0MG SM ALL DAY TAB ALLERGY TAVIST TAB.4MG TRIAMINIC TAB 0MG WAL-HIST TAB.4MG WAL-ITIN SYP 5MG/5ML WAL-ITIN TAB 0MG WAL-ITIN CHL SOL 5MG/5ML WAL-VERT TAB 0MG WAL-ZYR TAB 0MG ZYRTEC ALLGY TAB 0MG Anti-Obesity Agents BELVIQ TAB 0MG CONTRAVE TAB 8-90MG DIETHYLPROP TAB 25MG 2
3 DIETHYLPROP TAB 75MG ER PHENDIMETRAZ CAP 05MG ER PHENDIMETRAZ TAB 5MG PHENTERMINE CAP 5MG PHENTERMINE CAP 0MG PHENTERMINE CAP 7.5MG PHENTERMINE TAB 7.5MG QSYMIA CAP 5-92MG QSYMIA CAP.75-2 QSYMIA CAP MG SAXENDA INJ 6MG/ML Antispasmodics ANASPAZ TAB 0.25MG B-DONNA TAB 6.2MG BELLA/OPIUM SUP BELLA/OPIUM SUP CHLORD/CLIDI CAP 5-2.5MG DONNATAL ELX 2 DONNATAL ELX GRAPE 2 DONNATAL ELX MINT 2 DONNATAL TAB DONNATAL TAB 6.2MG DONNATAL TAB EXTENTAB 2 HYOSCYAMINE DRO 0.25/ML HYOSCYAMINESUB 0.25MG HYOSCYAMINETAB 0.25MG HYOSCYAMINE TAB 0.75 ER LIBRAX CAP 5-2.5MG PHENOHYTRO TAB Antitussives BENZONATATE CAP 00MG BENZONATATE CAP 50MG BENZONATATE CAP 200MG HYDROC/HOMAT TAB 5-.5MG HYDROCOD/HOM SYP 5-.5/5 HYDROMET SYP 5-.5/5 TESSALON PER CAP 00MG TUSSIGON TAB 5-.5MG ZONATUSS CAP 50MG Bronchodilator EPINEPHRINE INJ MG/ML FORADIL CAP AEROLIZE 2 Corticosteroids - Topical CORTANE-B LOT 2 HC PRAMOXINE CRE 2.5-% NOVACORT GEL PRAMOSONE CRE -2.5% PRAMOSONE OIN % 2 PRAMOSONE OIN 2.5% 2 PRAMOSONE E CRE -2.5% 2 Cough/Cold/Allergy Combinations ACTIDOM DMX LIQ 2 ALAHIST DM LIQ ALAVERT ALRG TAB /SINUS ALBATUSSIN CAP 2 ALBATUSSIN LIQ NN ALL DAY ALRG TAB 5-20MG ALLER/CONGES TAB 0-240MG ALLERCLEAR TAB D-24HR ALLERCLEAR D TAB 5-20MG ALLERCLR-D TAB 0-240MG ALLERGY D TAB 5-20MG ALLERGY REL/ TAB DECONGES ALLERGY RELF TAB / CONGEST ALLERGY RELF TAB /NSL DEC ALLERGY RELF TAB 5-20MG
4 ALLERGY RELF TAB D ALLERGY RELF TAB D 24 HR ALLERGY RELF TAB D2 ALLERGY RELF TAB D-24 ALLERGY RELF TAB DECONGES ALLERGY/CONG TAB 5-20MG ALLERGY/CONG TAB RELIEF ALLERGY+ CON TAB 5-20MG ALLERGY-D TAB 5-20MG ALLER-TEC D TAB 5-20MG ALLGY COMP-D TAB 5-20MG ALLRGY REL D TAB 0-240MG ALLRGY REL-D TAB 0-240MG ALLRGY RELF TAB 5-20MG ALLRGY RLF-D TAB 0-240MG ALLRGY RLF-D TAB 5-20MG ALTARUSSN DM SYP 00-0/5 AMBITUSSIN SOL 00-0/5 AP-HIST DM LIQ BIOGTUSS LIQ BIOTUSS LIQ BIOTUSS LIQ PEDIATRC BPM PSEUDO TAB 6-45MG BROM/PSE/DM SYP BROMFED DM SYP BRONTUSS SF LIQ CARBAPHEN 2 LIQ 2 CARBAPHEN 2 SUS PED 2 CETIRIZ/PSE TAB 5-20MG CHERATUSSIN SOL DAC CHERATUSSIN SYP 00-0/5 CLARITIN-D TAB 0-240MG CLARITIN-D TAB 5-20MG CLEAR-ATADIN TAB D 24HR CODEINE/GG SOL 0-00/5 COUGH DM SYP 00-0/5 CPB WC LIQ 2 DECON-A ELX 2-5MG/5M 2 DECON-G DRO 2--40MG 2 DESGEN PED DRO DESPEC EDA DRO DOMETUSS-DMX LIQ DURAFLU TAB 2 ENTRE-B SUS 6-0MG/5 ENTRE-HIST LIQ EQ TUSSIN SYP DM EQ TUSSIN DM SYP CGH/ CHST EQL ALLERGY TAB 0-240MG EQL TUSSIN SYP DM EXACTUSS LIQ EXAPHEX TR TAB 0-88MG 2 EXTRA ACTION SYP 00-0/5 G TUSSIN AC LIQ 00-0/5 GERI-TUSSIN SYP DM GG/CODEINE SOL 00-0/5 GG/DM SYP 00-0/5 GILPHEX TR TAB 0-88MG 2 GILTUSS LIQ GILTUSS PED LIQ G-SUPRESS DX DRO PEDIATRC GUAIATUSSIN SYP 00-0/5 GUAICON DMS SYP 00-0/5 GUAIFENESIN SOL DAC GUAIFENESIN SYP 00-0/5 GUAIFENESIN SYP DM HISTEX-PE SYP 2.5-0/5 2 HYD POL/CPM SUS 0-8/5ML HYDR/CPM/PSE LIQ MG HYDRO/CHLOR/ LIQ MG IOPHEN C-NR LIQ 00-0/5 LORATA-DINE TAB D 24HR 4
5 LORATADINE D TAB 5-20MG LORATADINE-D TAB 0-240MG LORATADINE-D TAB 5-20MG M-CLEAR WC LIQ MEDI-TUSSIN SYP DM M-HIST DM LIQ MYTUSSIN DAC SOL NEOTUSS PLUS LIQ 2 NIVA-HIST DM LIQ NORTUSS-DE DRO NORTUSS-DE LIQ DROPS NORTUSS-EX LIQ /5 PANATUSS DXP LIQ 2 PE/GUAIFENES DRO.5-20MG PHENHIST DH LIQ PROMETH VC/ SYP CODEINE PROMETH/COD SYP PROMETH/PE/ SYP CODEINE PROMETHAZINE SYP DM Q-TUSSIN DM SYP 00-0/5 RA CETIRI-D TAB 5-20MG RA LORATA-D TAB 24 HOUR RELCOF C SOL RELCOF DM LIQ RELHIST CHW 2 RESCON-JR TAB 2 REZIRA SOL 60-5/5ML 2 ROBAFEN DM SYP 00-0/5 ROBITUSSN DM SYP ROBITUSSN DM SYP PEAK CLD SILTUSSIN-DM SYP ALC FREE SM TUSSIN SYP DM SM TUSSIN SYP DM CLEAR SM TUSSIN DM SYP 00-0/5 SUPRESS-DX DRO PEDIATRC TGQ 5DM/5PE SYP H/2CPM TGQ 0/ SYP 50/5 TGQ 0/PSE/ SYP BRM/5DM TGQ 50PSE/ SYP BRM/0DM TGQ 7.5PEH/4 LIQ BRM/5DM TGT ALLERGY/ TAB CONGEST TUSNEL CAP 2 TUSNEL C SYP TUSSAFEX EX LIQ TUSSICAPS CAP 0-8MG 2 TUSSICAPS CAP 5-4MG 2 TUSSIN COUGH SYP DM TUSSIN DM SYP 00-0/5 TUSSIONEX SUS 0-8/5ML TUSSLIN LIQ TUSSLIN LIQ PEDIATRI VAZOBID-PD SUS 6-0MG/5 VIRTUSSIN SOL DAC VIRTUSSIN AC SOL 00-0/5 WAL-ITIN D TAB 0-240MG WAL-ITIN D TAB 24 HOUR WAL-ITIN D TAB 5-20MG WAL-TUSSIN SYP DM WAL-TUSSIN SYP DM CLEAR WAL-ZYR D TAB 5-20MG ZUTRIPRO LIQ MG ZYRTEC-D TAB 5-20MG Dental Products PREVDNT 5000 PST.% PREVIDENT CRE 5000 PLS PREVIDENT GEL.% PREVIDENT SOL 0.2% PRVDNT 5000 PST ENAML PR Dermatological Agents BENSAL HP OIN DERMASORB XM KIT 9% REA LO 40 CRE 40% REA LO 40 LOT 40% SALEX CREAM KIT 6% 5
6 SALICYLIC POW ACID SALICYLIC AC LIQ 27.5% ULTRASAL-ER SOL 28.5% UREA CRE 47% UREA CRE 50% UREA NAIL GEL 45% Diabetes Monitoring and Testing Supplies Your plan covers certain Part D diabetic and injectable supplies at a $0 cost share: Needles and Syringes Test Strips Lancets Insulin Pump Glucometer You must have a valid prescription and use a participating network pharmacy to get these diabetic supplies and injectable supplies at a $0 cost share. You must also have a prescription or ongoing therapy for insulin or another injectable medication in order to obtain the syringes and needles. Estrogens & Combos COVARYX TAB COVARYX HS TAB EEMT TAB EEMT HS TAB ENJUVIA TAB 0.MG ENJUVIA TAB 0.9MG EST ESTROGEN TAB MTEST EST ESTROGEN TAB MTEST HS ESTROG/MTEST TAB ESTROGEL GEL Hematopoietic Mixtures FA-B6-B2 TAB FERRALET 90 TAB FERRAPLUS 90 TAB 2 FOLIVANE-F CAP FOLIVANE-PLS CAP FUSION PLUS CAP MAXFE TAB MULTIGEN TAB MULTIGEN TAB FOLIC MULTIGEN PLS TAB NEPHRON FA TAB Impotence Agents CAVERJECT INJ 20MCG 2 Y CAVERJECT INJ 40MCG 2 Y CAVERJECT KIT 0MCG 2 Y CAVERJECT KIT 20MCG 2 Y CIALIS TAB 0MG 2 Y CIALIS TAB 20MG 2 Y EDEX KIT 0MCG 2 Y EDEX KIT 20MCG 2 Y EDEX KIT 40MCG 2 Y LEVITRA TAB 0MG 2 Y LEVITRA TAB 2.5MG 2 Y LEVITRA TAB 20MG 2 Y LEVITRA TAB 5MG 2 Y MUSE SUP 000MCG 2 Y MUSE SUP 25MCG 2 Y MUSE SUP 250MCG 2 Y MUSE SUP 500MCG 2 Y STAXYN TAB 0MG 2 Y STENDRA TAB 00MG STENDRA TAB 200MG STENDRA TAB 50MG VIAGRA TAB 00MG 2 Y VIAGRA TAB 25MG 2 Y VIAGRA TAB 50MG 2 Y Migraine Products ISOMETH/APAP CAP DICHLOR ISOMETH/CAFF TAB /APAP MIGRALAM CAP NODOLOR CAP PRODRIN TAB Miscellaneous ABREVA CRE 0% 2 6
7 ALENDRONATE TAB 40MG 2 ALTABAX OIN % CETACAINE AER 2 CHLORTHALID TAB 00MG CLEAR EYES DRO TRPL RLF 2 DEBACTEROL SOL 0-50% DIFIL-G FORT LIQ DRITHO-CREME CRE HP % 2 DRYSOL SOL 20% 2 ETHYL CHLOR AER MIST GELFOAM MIS SPONG 50 GELFOAM MIS SPONG00 GRANULEX AER HYDROQUINONE CRE 4% TR INSPIREASE MIS DD SYST 2 ISOXSUPRINE TAB 0MG ISOXSUPRINE TAB HCL 20MG LATISSE SOL 0.0% LIDOCAINE CRE % LUSTRA-AF CRE 4% MELQUIN SOL % MUGARD LIQ MURINE TEARS DRO PLUS 2 OVACE PLUS GEL 0% WASH PHENAZOPYRID TAB 00MG PHENAZOPYRID TAB 200MG REGENECARE GEL TBC AER TL HYDROQUIN CRE 4% TRAVOPROST DRO 0.004% TRI-CHLOR LIQ 80% TRI-LUMA CRE TRIMO-SAN GEL 2 VASOLEX OIN VERAMYST SPR 27.5MCG Oncology ALKERAN TAB 2MG 2 CAPECITABINE TAB 50MG CAPECITABINE TAB 500MG ETOPOSIDE CAP 50MG HYCAMTIN CAP 0.25MG 2 HYCAMTIN CAP MG 2 MYLERAN TAB 2MG 2 TEMODAR CAP 00MG TEMODAR CAP 40MG TEMODAR CAP 80MG TEMODAR CAP 20MG TEMODAR CAP 250MG TEMODAR CAP 5MG TEMOZOLOMIDE CAP 00MG TEMOZOLOMIDE CAP 40MG TEMOZOLOMIDE CAP 80MG TEMOZOLOMIDE CAP 20MG TEMOZOLOMIDE CAP 250MG TEMOZOLOMIDE CAP 5MG XELODA TAB 50MG XELODA TAB 500MG Otic Agents AERO OTIC HC SOL ANTIPY/BENZO SOL OTIC CORTANE-B DRO AQ OTIC 2 CORTANE-B DRO OTIC CORTIC-ND DRO CYOTIC DRO EXOTIC-HC DRO OTIC OTICIN HC DRO OTO-END 0 SOL OTOMAX-HC DRO Prenatal Vitamins NEEVO DHA CAP 27-. PRENATE TAB ELITE 2 VITAFOL CAP ULTRA Proton Pump Inhibitors HEARTBURN TR CAP 5MG Y LANSOPRAZOLE CAP 5MG DR Y 7
8 OMEPRA/BICAR CAP Y PREVACID 24H CAP 5MG DR Y ZEGERID OTC CAP Y Rectal Products ANALPRAM E KIT ANALPRAM HC CRE 2.5-% ANALPRAM-HC CRE -2.5% ANALPRAM-HC CRE SINGLES ANALPRM SNGL CRE HC 2.5- ANUCORT-HC SUP 25MG ANUSOL-HC SUP 25MG GRX HICORT SUP 25MG HEMMOREX-HC SUP 25MG HEMMOREX-HC SUP 0MG HYDROCORT AC SUP 25MG HYDROCORT AC SUP 0MG HYDROCORT/KIT PRAMOXIN LIDOCAINE/HC CRE %-0.5% LIDOCAINE/HC KIT %-% LIDOCAINE/HC KIT -2.5% PROCTOCORT SUP 0MG RECTACORT-HC SUP 25MG Thyroid Hormones NATURE THROI TAB 62.5MG NATURE-THROI TAB.75MG NATURE-THROI TAB 0MG NATURE-THROI TAB 46.25MG NATURE-THROI TAB 6.25MG NATURE-THROI TAB 95MG NATURE-THROI TAB 2.5MG NATURE-THROI TAB 48.75MG NATURE-THROI TAB 65MG NATURE-THROI TAB 8.25MG NATURE-THROI TAB 97.5MG Urinary Anti-Infectives & Combos HYOPHEN TAB METHENAM MAN TAB GM METHENAM MAN TAB 500MG 2 URELLE TAB URIBEL CAP 8MG UROGESIC-TAB BLUE Vaccines AFLURIA INJ AFLURIA INJ AFLURIA INJ AFLURIA INJ PF 4-5 AFLURIA INJ PF 5-6 AFLURIA INJ PF 6-7 AFLURIA QUAD INJ PF 6-7 EZ FLU SHOT INJ EZ FLU SHOT INJ EZ FLU SHOT INJ PF 4-5 EZ FLU SHOT KIT EZ FLU SHOT KIT FLUAD INJ FLUARIX PF INJ FLUARIX QUAD INJ FLUARIX QUAD INJ FLUARIX QUAD INJ FLUBLOK SOL FLUBLOK SOL FLUBLOK SOL FLUCELVAX INJ FLUCELVAX INJ FLUCLVX QUAD INJ FLULAVAL INJ FLULAVAL QUA INJ FLULAVAL QUA INJ FLULAVAL QUA INJ FLUMIST QUAD SUS
9 FLUMIST QUAD SUS FLUMIST QUAD SUS FLUVIRIN INJ FLUVIRIN INJ FLUVIRIN INJ FLUVIRIN PF INJ FLUZONE INJ INTRADRM FLUZONE INJ PF 4-5 FLUZONE HD INJ PF 4-5 FLUZONE HD INJ PF 5-6 FLUZONE HDINJ PF 6-7 FLUZONE QUAD INJ 4-5 FLUZONE QUAD INJ 5-6 FLUZONE QUAD INJ FLUZONE QUAD INJ FLUZONE SPLT INJ FLUZONE SPLT INJ INFLUENZA FIRUS VACCINE PNEUMOVAX 2 INJ 25/0.5 PREVNAR INJ VIVOTIF CAP EC MEPHYTON TAB 5MG 2 NEPHROCAPS CAP NICOMIDE TAB PABA TAB 00MG POT CHLORIDE TAB 25MEQ EF POTABA CAP 500MG 2 POTASSIUM P- POW AMINOBEN PYRIDOXINE INJ 00MG/ML SSKI SOL GM/ML 2 VITAMIN D CAP 50000UNT Vitamins & Supplements AMINOBEZ POT POW CYANOCOBALAM INJ 000MCG DIALYVITE TAB DIALYVITE/TAB ZINC DRISDOL CAP 50000UNT EFFER-K TAB 0MEQ EFFER-K TAB 20MEQ FOLBEE PLUS TAB FOLGARD OS TAB FOLIC ACID TAB 000MCG FOLIC ACID TAB MG GALZIN CAP 25MG KLOR-CON/EF TAB 25MEQ EF K-PHOS TAB K-PHOS TAB NEUTRAL 9
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