Upper Peninsula Health Plan MI Health Link (Medicare-Medicaid Plan) 2015 Formulary (List of Covered Drugs)

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1 H1977_001_2015_P17003bLP Upper Peninsula Health Plan MI Health Link (Medicare-Medicaid Plan) 2015 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN We have made no changes to this formulary since 10/27 /2015. For more recent information or other questions, please contact UPHP MI Health Link (Medicare-Medicaid Plan) Customer Service at (TTY 711) 24 hours/ 7 days a week. The call is free. Or visit Upper Peninsula Health Plan MI Health Link (Medicare- Medicaid Plan) is a health plan that contracts with both Medicare and Michigan Medicaid to provide benefits of both programs to enrollees. If have questions, please call UPHP MI Health Link (Medicare-Medicaid Plan) at Hours a Day / 7 Days a Week. The call is free. For more information, visit 1

2 Upper Peninsula Health Plan MI Health Link (Medicare- Medicaid Plan) 2015 List of Covered Drugs (Formulary) This is a list of drugs that members can get in Upper Peninsula Health Plan MI Health Link (Medicare-Medicaid Plan). Upper Peninsula Health Plan MI Health Link (Medicare- Medicaid Plan) is a health plan that contracts with both Medicare and Michigan Medicaid to provide benefits of both programs to enrollees. Benefits, List of Covered Drugs, and pharmacy and provider networks may change from time to time throughout the year and on January 1 of each year. Please contact the plan for more details. You can always check Upper Peninsula Health Plan MI Health Link (Medicare-Medicaid Plan) s up-to-date List of Covered Drugs online at Limitations, restrictions, and patient pay amounts may apply. This means that may have to pay for some services and that need to follow certain rules to have Upper Peninsula Health Plan MI Health Link (Medicare- Medicaid Plan) pay for r services. For more information, call Upper Peninsula Health Plan MI Health Link (Medicare-Medicaid Plan) Customer Services or read the Upper Peninsula Health Plan MI Health Link? If have questions, please call UPHP MI Health Link (Medicare-Medicaid Plan) at Hours a Day / 7 Days a Week. The call is free. For more information, visit H1977_001_2015_P17003bLP 2

3 (Medicare- Medicaid Plan) Member Handbook. You can ask for this information in other formats, such as Braille or large print. Call TTY The call is free. You can speak to someone about getting this information in other languages. Call TTY 711. The call is free. Usted puede hablar con alguien acerca de cómo obtener esta información en otros idiomas. Llame al TTY 711. La llamada es gratuita.? If have questions, please call UPHP MI Health Link (Medicare-Medicaid Plan) at Hours a Day / 7 Days a Week. The call is free. For more information, visit H1977_001_2015_P17003bLP 3

4 Frequently Asked Questions (FAQ) Find answers here to questions have about this List of Covered Drugs. You can read all of the FAQ to learn more, or look for a question and answer. 1. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the Drug List for short.) The drugs on the List of Covered Drugs that starts on page17 are the drugs covered by UPHP MI Health Link (Medicare-Medicaid Plan). These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide services. We refer to these pharmacies as network pharmacies.? UPHP MI Health Link (Medicare-Medicaid Plan) will cover all medically necessary drugs on the Drug List if: r doctor or other prescriber says need them to get better or stay healthy, and fill the prescription at a UPHP MI Health Link (Medicare-Medicaid Plan) network pharmacy. UPHP MI Health Link (Medicare-Medicaid Plan) may have additional steps to access certain drugs (see question #5 below). You can also see an up-to-date list of drugs that we cover on our website at or call Customer Services at (TTY 711). If have questions, please call UPHP MI Health Link (Medicare-Medicaid Plan) at Hours a Day / 7 Days a Week. The call is free. For more information, visit H1977_001_2015_P17003bLP 4

5 2. Does the Drug List ever change? Yes. UPHP MI Health Link (Medicare-Medicaid Plan) may add or remove drugs on the Drug List during the year. Generally, the Drug List will only change if: a cheaper drug comes along that works as well as a drug on the Drug List now, or we learn that a drug is not safe. We may also change our rules about drugs. For example, we could: Decide to require or not require prior approval for a drug. (Prior approval is permission from UPHP MI Health Link (Medicare-Medicaid Plan) before can get a drug.) Add or change the amount of a drug can get (called quantity limits ). Add or change step therapy restrictions on a drug. (Step therapy means must try one drug before we will another drug.) (For more information on these drug rules, see page 16.) We will tell when a drug are taking is removed from the Drug List. We will also tell when we change our rules for covering a drug. Questions 3, 4, and 7 below have more information on what happens when the Drug List changes.? If have questions, please call UPHP MI Health Link (Medicare-Medicaid Plan) at Hours a Day / 7 Days a Week. The call is free. For more information, visit H1977_001_2015_P17003bLP 5

6 You can always check UPHP MI Health Link (Medicare- Medicaid Plan) s up to date Drug List online at You can also call Customer Services to check the current Drug List at (TTY 711). 3. What happens when a cheaper drug comes along that works as well as a drug on the Drug List now? If are taking a drug that is removed because a cheaper drug that works just as well comes along, we will tell. We will tell at least 60 days before we remove it from the Drug List or when ask for a refill. Then can get a 60- day supply of the drug before the change to the Drug List is made. You will receive this notification in the mail and at the pharmacy when ask for a refill. 4. What happens when we find out a drug is not safe?? If the Food and Drug Administration (FDA) says a drug are taking is not safe, we will take it off the Drug List right away. We will also send a letter telling that. You can call Customer Service for a list of similar drugs that are covered by UPHP MI Health Link (Medicare-Medicaid Plan). When receive the list, show it to r doctor and ask him or her to prescribe a similar drug that is covered by UPHP MI If have questions, please call UPHP MI Health Link (Medicare-Medicaid Plan) at Hours a Day / 7 Days a Week. The call is free. For more information, visit H1977_001_2015_P17003bLP 6

7 Health Link (Medicare-Medicaid Plan). Or, can ask UPHP MI Health Link (Medicare-Medicaid Plan) to make an exception and cover r drug. Please see question 11 for more information about exceptions. 5. Are there any restrictions or limits on drug coverage? Or are there any required actions to take in order to get certain drugs? Yes, some drugs have coverage rules or have limits on the amount can get. In some cases must do something before can get the drug. For example:? Prior approval (or prior authorization): For some drugs, or r doctor or other prescriber must get approval from UPHP MI Health Link (Medicare-Medicaid Plan) before fill r prescription. If don t get approval, UPHP MI Health Link (Medicare- Medicaid Plan) may not cover the drug. Quantity limits: Sometimes UPHP MI Health Link (Medicare-Medicaid Plan) limits the amount of a drug can get. Step therapy: Sometimes UPHP MI Health Link (Medicare-Medicaid Plan) requires to do step therapy. This means will have to try drugs in a certain order for r medical condition. You might have to try one drug before we will cover another drug. If r prescriber thinks the first drug doesn t work for, then we will cover the second. If have questions, please call UPHP MI Health Link (Medicare-Medicaid Plan) at Hours a Day / 7 Days a Week. The call is free. For more information, visit H1977_001_2015_P17003bLP 7

8 You can find out if r drug has any additional requirements or limits by looking in the tables on pages You can also get more information by visiting our web site at We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send a copy. You can also ask for an exception from these limits. Please see question 11 for more information on exceptions. If are in a nursing home or other long-term care facility and need a drug that is not on the Drug List, or if cannot easily get the drug need, we can help. We will cover a 31-day emergency supply of the drug need (unless have a prescription for fewer days), whether or not are a new UPHP MI Health Link (Medicare- Medicaid Plan) member. This will give time to talk to r doctor or other prescriber. He or she can help decide if there is a similar drug on the Drug List can take instead or whether to request an exception. Please see question 11 for more information about exceptions. 6. How will know if the drug want has limitations or if there are required actions to take to get the drug? The List of Covered Drugs on page 17 has a column labeled.? If have questions, please call UPHP MI Health Link (Medicare-Medicaid Plan) at Hours a Day / 7 Days a Week. The call is free. For more information, visit H1977_001_2015_P17003bLP 8

9 7. What happens if we change our rules on how we cover some drugs? For example, if we add prior authorization (approval), quantity limits, and/or step therapy restrictions on a drug. We will tell if we add prior approval, quantity limits, and/or step therapy restrictions on a drug. We will tell at least 60 days before the restriction is added or when next ask for a refill. Then, can get a 60-day supply of the drug before the change to the Drug List is made. This gives time to talk to r doctor or other prescriber about what to do next. 8. How can find a drug on the Drug List? There are two ways to find a drug: You can search alphabetically (if know how to spell the drug), or You can search by medical condition. To search alphabetically, go to the Alphabetical Listing section. You can find it starting on page 163. The section 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 r drug. Next to r drug, will see the? If have questions, please call UPHP MI Health Link (Medicare-Medicaid Plan) at Hours a Day / 7 Days a Week. The call is free. For more information, visit H1977_001_2015_P17003bLP 9

10 page number where can find coverage information. Turn to the page listed in the Index and find the name of r drug in the first column of the list. To search by medical condition, find the section labeled List of drugs by medical condition on page 17. Then find r medical condition. For example, if have a heart condition, should look in that category. That is where will find drugs that treat heart conditions. 9. What if the drug want to take is not on the Drug List? If don t see r drug on the Drug List, call Customer Services at (TTY 711) and ask about it. If learn that UPHP MI Health Link (Medicare-Medicaid Plan) will not cover the drug, can do one of these things: Ask Customer Services for a list of drugs like the one want to take. Then show the list to r doctor or other prescriber. He or she can prescribe a drug on Drug List that is like the one want to take. Or You can ask the health plan to make an exception to r drug. Please see question 11 for more information about exceptions.? 10. What if are a new UPHP MI Health Link (Medicare-Medicaid Plan) member and can t find If have questions, please call UPHP MI Health Link (Medicare-Medicaid Plan) at Hours a Day / 7 Days a Week. The call is free. For more information, visit H1977_001_2015_P17003bLP 10

11 r drug on the Drug List or have a problem getting r drug? We can help. We may cover a temporary 30-day supply of r drug during the first 90 days are a member of UPHP MI Health Link (Medicare-Medicaid Plan). This will give time to talk to r doctor or other prescriber. He or she can help decide if there is a similar drug on the Drug List can take instead or whether to request an exception. We will cover a 30-day supply of r drug if: are taking a drug that is not on our Drug List, or health plan rules do not let get the amount ordered by r prescriber, or the drug requires prior approval by UPHP MI Health Link (Medicare-Medicaid Plan), or are taking a drug that is part of a step therapy restriction. If live in a nursing home or other long-term care facility, may refill r prescription for as long as 98 days. You may refill the drug multiple times during the 90 days. This gives r prescriber time to change r drugs to ones on the Drug List or ask for an exception. Exceptions are available in situations where experience? If have questions, please call UPHP MI Health Link (Medicare-Medicaid Plan) at Hours a Day / 7 Days a Week. The call is free. For more information, visit H1977_001_2015_P17003bLP 11

12 a change in the level of care are receiving that also requires to transition from one facility or treatment center to another. In such circumstances, would be eligible for a temporary, one-time fill exception even if are outside of the first 90 days as a member of the plan. 11. Can ask for an exception to cover r drug? Yes. You can ask UPHP MI Health Link (Medicare- Medicaid Plan) to make an exception to cover a drug that is not on the Drug List. You can also ask us to change the rules on r drug. For example, UPHP MI Health Link (Medicare-Medicaid Plan) may limit the amount of a drug we will cover. If r drug has a limit, can ask us to change the limit and cover more. Other examples: You can ask us to drop step therapy restrictions or prior approval requirements. 12. How long does it take to get an exception?? First, we must receive a statement from r prescriber supporting r request for an exception. After we receive the statement, we will give a decision on r If have questions, please call UPHP MI Health Link (Medicare-Medicaid Plan) at Hours a Day / 7 Days a Week. The call is free. For more information, visit H1977_001_2015_P17003bLP 12

13 exception request within 72 hours. If or r prescriber think r health may be harmed if have to wait 72 hours for a decision, can ask for an expedited exception. This is a faster decision. If r prescriber supports r request, we will give a decision within 24 hours of receiving r prescriber s supporting statement. 13. How can ask for an exception? To ask for an exception, call Customer Services. Your Customer Services representative will work with and r provider to help ask for an exception. 14. What are generic drugs? Generic drugs are made up of the same active ingredients as brand name drugs. They usually cost less than the brand name drug and usually don t have wellknown names. Generic drugs are approved by the Food and Drug Administration (FDA). UPHP MI Health Link (Medicare-Medicaid Plan) covers both brand name drugs and generic drugs. 15. What are OTC drugs?? If have questions, please call UPHP MI Health Link (Medicare-Medicaid Plan) at Hours a Day / 7 Days a Week. The call is free. For more information, visit H1977_001_2015_P17003bLP 13

14 14

15 List of Covered Drugs The list of covered drugs that begins on the next page gives information about the drugs covered by UPHP MI Health Link (Medicare-Medicaid Plan). If have trouble finding r drug in the list, turn to the Index that begins on page 163. The first column of the chart lists the name of the drug. Brand name drugs are capitalized (e.g., CRESTOR) and generic drugs are listed in lower-case italics (e.g., simvastatin). The information in the necessary column tells if UPHP MI Health Link (Medicare-Medicaid Plan) has any rules for covering r drug. Note: The * next to a drug means the drug is not a Part D drug. These drugs have different rules for appeals. An appeal is a formal way of asking us to review a coverage decision and to change it if think we made a mistake. For example, we might decide that a drug that want is not covered or is no longer covered by Medicare or Michigan Medicaid. If or r prescriber disagrees with our decision, can appeal. To ask for instructions on how to appeal, call Customer Services at You can also read the Member Handbook to learn how to appeal a decision. If have questions, please call UPHP MI Health Link (Medicare-Medicaid Plan) at Hours a Day / 7 Days a Week. The call is free. For more information, visit H1977_001_2015_P17003bLP 15

16 Legend Tier Description 1 Generics ($0) 2 Brands ($0) Symbol QL PA ST BD Description Quantity limit, dispense limit for 30 days, unless otherwise noted You (or r physician) are required to get prior authorization before fill r prescription for this drug. Without prior approval, we may not cover this drug. Step therapy exception required Covered under Medicare Part B or D * Non-Part D drugs or OTC items that are covered by Medicaid (g) M Only the generic version of this drug is covered. The brand name version is not covered. The brand name version of this drug is in Tier 2. The generic version is in Tier 1 If have questions, please call UPHP MI Health Link (Medicare-Medicaid Plan) at Hours a Day / 7 Days a Week. The call is free. For more information, visit 16

17 Analgesics Nonsteroidal Anti-inflammatory Drugs acetaminophen (120 mg supp.rect, 160 mg/5ml oral susp, 325 mg tablet, 500 mg capsule, 500 mg tablet, 650 mg supp.rect, 650 mg tablet er) * aspirin 81 mg tablet dr * CELEBREX (100 MG CAPSULE, 200 MG CAPSULE, 50 MG CAPSULE) QL (60) CELEBREX 400 MG CAPSULE QL (30) celecoxib (100 mg capsule, 200 mg capsule, 50 mg capsule) $0 (Tier 1) QL (60), (g) celecoxib 400 mg capsule $0 (Tier 1) QL (30), (g) CHILDREN'S MOTRIN 100 MG/5 ML $0 (Tier 1) COMFORT PAC-MELOXICAM KIT $0 (Tier 1) COMFORT PAC-NAPROXEN KIT $0 (Tier 1) diclofenac potassium 50 mg tablet diclofenac sodium (100 mg tab er 24h, 25 mg tablet dr, 50 mg tablet dr, 75 mg tablet dr) diclofenac sodium/misoprostol (50 mg-200 tab ir dr, 75 mg-200 tab ir dr) If have questions, please call UPHP MI Health Link (Medicare-Medicaid Plan) at

18 Analgesics etodolac (200 mg capsule, 300 mg capsule, 400 mg tab er 24h, 400 mg tablet, 500 mg tab er 24h, 500 mg tablet, 600 mg tab er 24h) flurbiprofen (100 mg tablet, 50 mg tablet) ibuprofen (100 mg tab chew, 100 mg/5ml oral susp, 200 mg capsule, 200 mg tablet, 50 mg/1.25 drops susp) * ibuprofen (400 mg tablet, 600 mg tablet, 800 mg tablet) ibuprofen/irr cnt-irrit cmb #2 800 mg kit ketoprofen (50 mg capsule, 75 mg capsule) ketorolac tromethamine 10 mg tablet meloxicam (15 mg tablet, 7.5 mg tablet) nabumetone (500 mg tablet, 750 mg tablet) naproxen (125 mg/5ml oral susp, 250 mg tablet, 375 mg tablet, 375 mg tablet dr, 500 mg tablet, 500 mg tablet dr) $0 (Tier 1) PA, (g) If have questions, please call UPHP MI Health Link (Medicare-Medicaid Plan) at

19 Analgesics naproxen sodium (275 mg tablet, 550 mg tablet) naproxen sodium 220 mg tablet * oxaprozin 600 mg tablet PAIN & FEVER 500 MG TABLET * piroxicam (10 mg capsule, 20 mg capsule) sulindac (150 mg tablet, 200 mg tablet) tolmetin sodium 400 mg capsule VOLTAREN 1% GEL ST Opioid Analgesics, Long-acting fentanyl (100 mcg/hr patch td72, 12 mcg/hr patch td72, 25mcg/hr patch td72, 50mcg/hr patch td72, 75mcg/hr patch td72) $0 (Tier 1) QL (15), (g) levorphanol tartrate 2 mg tablet QL (120), (g) methadone hcl 10 mg tablet $0 (Tier 1) QL (360), (g) methadone hcl 5 mg tablet $0 (Tier 1) QL (180), (g) morphine sulfate (100 mg tablet er, 15 mg tablet er, 200 mg tablet er, 30 mg tablet er, 60 mg tablet er) $0 (Tier 1) QL (90), (g) morphine sulfate 10 mg cap er pel $0 (Tier 1) QL (60), (g) If have questions, please call UPHP MI Health Link (Medicare-Medicaid Plan) at

20 Analgesics NUCYNTA ER (ER 100 MG TABLET, ER 150 MG TABLET, ER 200 MG TABLET, ER 250 MG TABLET, ER 50 MG TABLET) OPANA ER (ER 10 MG TABLET, ER 15 MG TABLET, ER 20 MG TABLET, ER 30 MG TABLET, ER 40 MG TABLET, ER 5 MG TABLET, ER 7.5 MG TABLET) OXYCONTIN (10 MG TABLET, 15 MG TABLET, 20 MG TABLET, 30 MG TABLET, 40 MG TABLET) OXYCONTIN (60 MG TABLET, 80 MG TABLET) tramadol hcl (100 mg tab er 24h, 100 mg tbmp 24hr, 200 mg tab er 24h, 200 mg tbmp 24hr) ZOHYDRO ER (ER 10 MG CAPSULE, ER 15 MG CAPSULE, ER 20 MG CAPSULE, ER 30 MG CAPSULE, ER 40 MG CAPSULE, ER 50 MG CAPSULE) Opioid Analgesics, Short-acting acetaminophen with codeine 300mg-60mg tablet QL (60) QL (60) QL (60) QL (120) $0 (Tier 1) QL (30), (g) PA, QL (60) $0 (Tier 1) QL (180), (g) If have questions, please call UPHP MI Health Link (Medicare-Medicaid Plan) at

21 Analgesics acetaminophen with codeine phosphate (300mg-15mg tablet, 300mg-30mg tablet) butorphanol tartrate (1 mg/ml vial, 10 mg/ml spray, 2 mg/ml vial) codeine sulfate (15 mg tablet, 30 mg tablet, 60 mg tablet) DURAMORPH (10 MG/10 ML AMPUL, 5 MG/10 ML AMPUL) fentanyl citrate (1200 mcg lozenge hd, 1600 mcg lozenge hd, 200 mcg lozenge hd, 400 mcg lozenge hd, 600 mcg lozenge hd, 800 mcg lozenge hd) hydrocodone bitartrate/acetaminophen (10mg- 300mg tablet, 10mg-325mg tablet, mg tablet, mg tablet) hydrocodone bitartrate/acetaminophen ( /5 solution, 5-217mg/10 solution, /15 solution) hydrocodone bitartrate/acetaminophen (5 mg- 325mg tablet, 5mg-300mg tablet) $0 (Tier 1) QL (360), (g) $0 (Tier 1) QL (180), (g) $0 (Tier 1) PA $0 (Tier 1) PA, QL (120), (g) $0 (Tier 1) QL (180), (g) $0 (Tier 1) QL (3600), (g) $0 (Tier 1) QL (360), (g) If have questions, please call UPHP MI Health Link (Medicare-Medicaid Plan) at

22 Analgesics hydrocodone/ibuprofen (10mg- 200mg tablet, mg tablet) hydromorphone hcl (2 mg tablet, 4 mg tablet, 8 mg tablet) $0 (Tier 1) QL (150), (g) $0 (Tier 1) QL (180), (g) hydromorphone hcl 1 mg/ml liquid $0 (Tier 1) QL (1440), (g) hydromorphone hcl/pf (10 mg/ml ampul, 10 mg/ml vial) LAZANDA (100 MCG NASAL SPRAY, 400 MCG NASAL SPRAY) morphine sulfate 10 mg/5 ml solution morphine sulfate 100 mg/5ml solution $0 (Tier 1) PA, (g) PA, QL (30) $0 (Tier 1) QL (2700), (g) $0 (Tier 1) QL (270), (g) morphine sulfate 15 mg tablet QL (240), (g) morphine sulfate 20 mg/5 ml solution $0 (Tier 1) QL (1350), (g) morphine sulfate 30 mg tablet QL (180), (g) oxycodone hcl (10 mg tablet, 15 mg tablet, 20 mg tablet, 30 mg tablet) $0 (Tier 1) QL (180), (g) oxycodone hcl 5 mg tablet $0 (Tier 1) QL (360), (g) oxycodone hcl/acetaminophen ( mg tablet, 5 mg-325mg tablet) oxycodone hcl/acetaminophen 10mg-325mg tablet $0 (Tier 1) QL (360), (g) $0 (Tier 1) QL (180), (g) If have questions, please call UPHP MI Health Link (Medicare-Medicaid Plan) at

23 Analgesics oxycodone hcl/acetaminophen mg tablet oxycodone hcl/aspirin tablet SUBSYS (1,200 MCG SPRAY, 1,600 MCG SPRAY, 100 MCG SPRAY, 200 MCG SPRAY, 400 MCG SPRAY, 600 MCG SPRAY, 800 MCG SPRAY) $0 (Tier 1) QL (240), (g) $0 (Tier 1) QL (360), (g) PA, QL (120) tramadol hcl 50 mg tablet $0 (Tier 1) QL (240), (g) tramadol hcl/acetaminophen mg tablet Anesthetics $0 (Tier 1) QL (240), (g) Local Anesthetics ADV DNA MEDICATED COLLECT KIT $0 (Tier 1) lidocaine 5 % oint. (g) lidocaine 5%(700mg) adh. patch $0 (Tier 1) PA, (g) lidocaine hcl (2 % jel (ml), 2 % jel/pf app, 2 % solution, 40 mg/ml solution) If have questions, please call UPHP MI Health Link (Medicare-Medicaid Plan) at

24 Anesthetics lidocaine/prilocaine (2.5 %-2.5% cream (g), 2.5 %-2.5% kit) Anti-Addiction/ Substance Abuse Treatment Agents Alcohol Deterrents/ Anti-craving acamprosate calcium 333 mg tablet dr disulfiram (250 mg tablet, 500 mg tablet) Opioid Dependence Treatments buprenorphine hcl (2 mg tab subl, 8 mg tab subl) buprenorphine hcl/naloxone hcl (/naloxone 2 mg-0.5mg tab subl, /naloxone 8 mg-2 mg tab subl) BUTRANS (10 MCG/HR PATCH, 15 MCG/HR PATCH, 20 MCG/HR PATCH, 5 MCG/HR PATCH, 7.5 MCG/HR PATCH) $0 (Tier 1) PA, (g) $0 (Tier 1) PA, (g) QL (4 PER 28 DAYS) naltrexone hcl 50 mg tablet If have questions, please call UPHP MI Health Link (Medicare-Medicaid Plan) at

25 Anti-Addiction/ Substance Abuse Treatment Agents SUBOXONE (12 MG-3 MG SL FILM, 2 MG-0.5 MG SL FILM, 4 MG-1 MG SL FILM, 8 MG-2 MG SL FILM) VIVITROL (380 MG VIAL, 380 MG VIAL + DILUENT) PA Opioid Reversal Agents naloxone hcl 1 mg/ml syringe Smoking Cessation Agents bupropion hcl 150 mg tablet er CHANTIX (0.5 MG TABLET, 1 MG CONT MONTH BOX, 1 MG TABLET, STARTING MONTH BOX) nicotine (14mg/24hr patch td24, 21 mg/24hr patch td24, 7mg/24hr patch td24) * nicotine polacrilex (2 mg gum, 2 mg lozenge, 4 mg gum, 4 mg lozenge) * QL (336 PER 365 DAYS) NICOTROL CARTRIDGE INHALER NICOTROL NS 10 MG/ML SPRAY Antibacterials If have questions, please call UPHP MI Health Link (Medicare-Medicaid Plan) at

26 Aminoglycosides amikacin sulfate (1000mg/4ml vial, 500 mg/2ml vial) Antibacterials gentamicin sulfate (0.1 % cream (g), 0.1 % oint. (g)) gentamicin sulfate (0.3 % drops, 0.3 % oint. (g), 20 mg/2 ml vial, 40 mg/ml vial) gentamicin sulfate in sodium chloride, iso-osmotic (gentamic100mg/0.1l piggyback, gentamic120mg/0.1l piggyback, gentamic60 mg/50ml piggyback, gentamic80 mg/50ml piggyback, gentamic80mg/100ml piggyback) gentamicin sulfate in sodium chloride, iso-osmotic (gentamic70 mg/50ml piggyback, gentamic90mg/100ml piggyback) gentamicin sulfate/pf (100mg/10ml vial port, 20 mg/2 ml vial, 60 mg/6 ml vial port, 80 mg/8 ml vial port) (g) (g) If have questions, please call UPHP MI Health Link (Medicare-Medicaid Plan) at

27 Antibacterials neomycin sulfate 500 mg tablet paromomycin sulfate 250 mg capsule streptomycin sulfate 1 g vial (g) tobramycin 0.3 % drops tobramycin sulfate (1.2 g vial, 10 mg/ml vial, 40 mg/ml vial) tobramycin/sodium chloride 80mg/100ml piggyback (g) Antibacterials, Other bacitracin 500 unit/g oint. (g) (g) bacitracin/polymyxin b sulfate k/g oint. (g) chloramphenicol sod succ 1 g vial (g) clindamycin hcl (150 mg capsule, 300 mg capsule, 75 mg capsule) clindamycin phosphate (1 % gel (gram), 1 % lotion, 1 % med. swab, 1 % solution, 150 mg/ml vial, 2 % cream/appl, 300 mg/2ml vial port, 600 mg/4ml vial port, 900mg/6ml vial port) If have questions, please call UPHP MI Health Link (Medicare-Medicaid Plan) at

28 Antibacterials colistin (colistimethate na) 150 mg vial CUBICIN 500 MG VIAL DALVANCE 500 MG VIAL linezolid 600 mg tablet $0 (Tier 1) PA, (g) linezolid 600mg/300 iv soln methenamine hippurate 1 g tablet methenamine mandelate 1 g tablet METRO IV 500 MG/100 ML $0 (Tier 1) metronidazole (0.75 % cream (g), 0.75 % gel (gram), 0.75 % gel w/appl, 0.75 % lotion, 1 % gel (gram), 1 % gel w/pump, 250 mg tablet, 375 mg capsule, 500 mg tablet) metronidazole/sodium chloride 500mg/0.1l piggyback mupirocin 2 % oint. (g) neomycin su/bacitra/polymyxin 3.5mg-400 oint. (g) neomycin sulfate/polymyxin b sulfate (ampul, vial) neomycin/polymyxn b/gramicidin 1.75mg-10k drops If have questions, please call UPHP MI Health Link (Medicare-Medicaid Plan) at

29 Antibacterials nitrofurantoin 25 mg/5 ml oral susp $0 (Tier 1) QL (7200 PER 365 DAYS), (g) nitrofurantoin macrocrystal (100 mg capsule, 50 mg capsule) nitrofurantoin monohyd/m-cryst 100 mg capsule polymyxin b sulf/trimethoprim /ml drops $0 (Tier 1) QL (360 PER 365 DAYS), (g) $0 (Tier 1) QL (180 PER 365 DAYS), (g) SIVEXTRO 200 MG TABLET PA SIVEXTRO 200 MG VIAL SYNERCID 500 MG VIAL trimethoprim 100 mg tablet TYGACIL 50 MG VIAL vancomycin hcl (1 g vial, 1 g vial port, 10 g vial, 125 mg capsule, 250 mg capsule, 5 g vial, 500 mg vial, 500 mg vial port, 750 mg vial) vancomycin hcl/dextrose 5 % in water (1g/200ml froz.piggy, 500mg/0.1l froz.piggy) vancomycin in dextrose,iso-osm 750mg/.15l froz.piggy VANDAZOLE VAGINAL 0.75% GEL $0 (Tier 1) If have questions, please call UPHP MI Health Link (Medicare-Medicaid Plan) at

30 Antibacterials ZYVOX (100 MG/5 ML SUSPENSION, 600 MG TABLET) ZYVOX (200 MG/100 ML IV SOLN, 600 MG/300 ML IV SOLN) PA Beta-lactam, Cephalosporins cefaclor (250 mg capsule, 500 mg capsule) cefadroxil (1 g tablet, 250 mg/5ml susp recon, 500 mg capsule, 500 mg/5ml susp recon) cefazolin sodium (1 g vial, 10 g vial, 100 g bulkbaginj, 20 g vial, 300g bulkbaginj, 500 mg vial) cefdinir (125 mg/5ml susp recon, 250 mg/5ml susp recon, 300 mg capsule) cefepime hcl (1 g vial, 2 g vial) cefotaxime sodium (1 g vial, 2 g vial, 500 mg vial) cefoxitin sodium (1 g vial, 10 g vial, 2 g vial) cefpodoxime proxetil (100 mg tablet, 100 mg/5ml susp recon, 200 mg tablet, 50 mg/5 ml susp recon) If have questions, please call UPHP MI Health Link (Medicare-Medicaid Plan) at

31 Antibacterials cefprozil (125 mg/5ml susp recon, 250 mg tablet, 250 mg/5ml susp recon, 500 mg tablet) ceftazidime (1 g vial, 2 g vial, 6 g vial) ceftriaxone sodium (1 g pggybk btl, 1 g vial, 1 g vial port, 10 g vial, 100 g bulkbaginj, 2 g pggybk btl, 2 g vial, 2 g vial port, 250 mg vial, 500 mg vial) ceftriaxone sodium/dextrose, isoosmotic (1 g/50 ml froz.piggy, 1 g/50 ml piggyback, 2 g/50 ml froz.piggy, 2 g/50 ml piggyback) cefuroxime axetil (250 mg tablet, 500 mg tablet) cefuroxime sodium (1.5 g vial, 7.5 g vial, 7.5g vial, 750 mg vial) cephalexin (125 mg/5ml susp recon, 250 mg capsule, 250 mg/5ml susp recon, 500 mg capsule, 750 mg capsule) SUPRAX (100 MG TABLET CHEWABLE, 200 MG TABLET CHEWABLE, 400 MG CAPSULE, 400 MG TABLET) If have questions, please call UPHP MI Health Link (Medicare-Medicaid Plan) at

32 Antibacterials TEFLARO (400 MG VIAL, 600 MG VIAL) Beta-lactam, Other AZACTAM-ISO-OSMOTIC DEXTROSE (1 GM/50 ML, 2 GM/50 ML) aztreonam (1 g vial, 2 g vial) imipenem/cilastatin sodium (250 mg vial, 500 mg vial) INVANZ 1 GM VIAL meropenem (1 g vial, 500 mg vial) Beta-lactam, Penicillins amoxicillin (125 mg/5ml susp recon, 200 mg/5ml susp recon, 250 mg capsule, 250 mg/5ml susp recon, 400 mg/5ml susp recon, 500 mg capsule, 500 mg tablet, 875 mg tablet) amoxicillin/potassium clavulanate ( /5 susp recon, mg tab chew, mg tablet, mg tab chew, mg/5 susp recon, mg tablet, /5 susp recon, mg tablet) If have questions, please call UPHP MI Health Link (Medicare-Medicaid Plan) at

33 Antibacterials ampicillin sodium (1 g vial, 1 g vial port, 10 g vial, 2 g vial, 250 mg vial, 500 mg vial) ampicillin sodium/sulbactam sodium (1.5 g vial, 3 g vial) ampicillin trihydrate (125 mg/5ml susp recon, 250 mg/5ml susp recon) ampicillin trihydrate (250 mg capsule, 500 mg capsule) BICILLIN L-A (1,200,000 UNITS, 2,400,000 UNITS, 600,000 UNIT/ML) dicloxacillin sodium (250 mg capsule, 500 mg capsule) nafcillin sodium (1 g vial, 10 g vial, 2 g vial) penicillin g potassium (20mm unit vial, 5mm unit vial) penicillin g potassium/dextrosewater (2mm/50ml froz.piy, 3mm/50ml froz.piy) (g) (g) penicillin g sodium 5mm unit vial (g) penicillin v potassium (125 mg/5ml soln recon, 250 mg tablet, 250 mg/5ml soln recon, 500 mg tablet) If have questions, please call UPHP MI Health Link (Medicare-Medicaid Plan) at

34 Antibacterials piperacillin sodium/tazobactam sodium (2.25 g vial, g vial, g vial port, 4.5 g vial, 4.5 g vial port, 40.5 g vial) ZOSYN (2.25 GM/50 ML GALAXY BAG, GM/50 ML GALAXY, 4.5 GM/100 ML GALAXY BAG) Macrolides azithromycin (100 mg/5ml susp recon, 200 mg/5ml susp recon, 250 mg tablet, 500 mg tablet, 500 mg vial, 500 mg vial port, 600 mg tablet) azithromycin 1 g packet (g) clarithromycin (125 mg/5ml susp recon, 250 mg tablet, 250 mg/5ml susp recon, 500 mg tab er 24h, 500 mg tablet) DIFICID 200 MG TABLET E.E.S. 200 MG/5 ML GRANULES ERY-TAB (EC 250 MG TABLET, EC 333 MG TABLET, EC 500 MG TABLET) ERYPED 200 MG/5 ML SUSPENSION If have questions, please call UPHP MI Health Link (Medicare-Medicaid Plan) at

35 Antibacterials ERYPED 400 MG/5 ML SUSPENSION ERYTHROCIN 250 MG FILMTAB ERYTHROCIN LACTOBIONATE (500 MG ADDVNT VL, 500 MG VIAL) erythromycin base (250 mg tablet, 500 mg tablet) (g) erythromycin base 5 mg/g oint. (g) erythromycin base/ethyl alcohol (2 % med. swab, 2 % solution) ILOTYCIN 0.5% EYE OINTMENT $0 (Tier 1) Quinolones AVELOX IV 400 MG/250 ML BESIVANCE 0.6% SUSP ciprofloxacin (250 mg/5ml sus mc rec, 500 mg/5ml sus mc rec) ciprofloxacin hcl (0.3 % drops, 100 mg tablet, 250 mg tablet, 500 mg tablet, 750 mg tablet) ciprofloxacin lactate (200mg/20ml vial, 400mg/40ml vial) ciprofloxacin lactate/dextrose 5 % in water (200mg/0.1l piggyback, 400mg/0.2l piggyback) If have questions, please call UPHP MI Health Link (Medicare-Medicaid Plan) at

36 Antibacterials ciprofloxacin/ciprofloxacin hcl (1000 mg tbmp 24hr, 500 mg tbmp 24hr) levofloxacin (25 mg/ml vial, 250 mg tablet, 250mg/10ml solution, 500 mg tablet, 500mg/20ml solution, 750 mg tablet) levofloxacin/dextrose 5 % in water (250mg/50ml piggyback, 500mg/0.1l piggyback, 750mg/.15l piggyback) MOXEZA 0.5% EYE DROPS moxifloxacin hcl 400 mg tablet ofloxacin (0.3 % drops, 200 mg tablet, 300 mg tablet, 400 mg tablet) VIGAMOX 0.5% EYE DROPS Sulfonamides silver sulfadiazine 1 % cream (g) SSD 1% CREAM $0 (Tier 1) sulfacetamide sodium (10 % drops, 10 % suspension) sulfadiazine 500 mg tablet (g) If have questions, please call UPHP MI Health Link (Medicare-Medicaid Plan) at

37 Antibacterials sulfamethoxazole/trimethoprim 80-16mg/ml vial Tetracyclines demeclocycline hcl (150 mg tablet, 300 mg tablet) doxycycline hyclate (100 mg capsule, 100 mg tablet, 100 mg vial, 20 mg tablet, 50 mg capsule) doxycycline monohydrate (100 mg capsule, 100 mg tablet, 150 mg capsule, 150 mg tablet, 50 mg capsule, 50 mg tablet, 75 mg capsule, 75 mg tablet) minocycline hcl (100 mg capsule, 100 mg tablet, 50 mg capsule, 50 mg tablet, 75 mg capsule, 75 mg tablet) tetracycline hcl (250 mg capsule, 500 mg capsule) (g) (g) Anticonvulsants Anticonvulsants, Other If have questions, please call UPHP MI Health Link (Medicare-Medicaid Plan) at

38 levetiracetam (100 mg/ml solution, 1000 mg tablet, 250 mg tablet, 500 mg tablet, 500 mg/5ml solution, 500 mg/5ml vial, 750 mg tablet) Anticonvulsants levetiracetam in sodium chloride, iso-osmotic (1000mg/100 piggyback, 1500mg/100 piggyback, 500mg/0.1l piggyback) POTIGA (200 MG TABLET, 300 MG TABLET, 400 MG TABLET, 50 MG TABLET) (g) Calcium Channel Modifying Agents CELONTIN 300 MG KAPSEAL ethosuximide (250 mg capsule, 250 mg/5ml solution) LYRICA (100 MG CAPSULE, 150 MG CAPSULE, 20 MG/ML ORAL SOLUTION, 200 MG CAPSULE, 225 MG CAPSULE, 25 MG CAPSULE, 300 MG CAPSULE, 50 MG CAPSULE, 75 MG CAPSULE) zonisamide (100 mg capsule, 25 mg capsule, 50 mg capsule) Gamma-aminobutyric Acid (GABA) Augmenting Agents DIASTAT 2.5 MG PEDI SYSTEM QL (5) If have questions, please call UPHP MI Health Link (Medicare-Medicaid Plan) at

39 Anticonvulsants DIASTAT ACUDIAL MG QL (40) DIASTAT ACUDIAL MG KT QL (20) diazepam kit QL (40), (g) diazepam 2.5 mg kit QL (5), (g) diazepam mg kit QL (20), (g) divalproex sodium (125 mg cap sprink, 125 mg tablet dr, 250 mg tab er 24h, 250 mg tablet dr, 500 mg tab er 24h, 500 mg tablet dr) gabapentin (100 mg capsule, 250 mg/5ml solution, 300 mg capsule, 300 mg/6ml solution, 400 mg capsule, 600 mg tablet, 800 mg tablet) GABITRIL (12 MG TABLET, 16 MG TABLET) ONFI (10 MG TABLET, 20 MG TABLET) PA, QL (60) ONFI 2.5 MG/ML SUSPENSION PA, QL (480) phenobarbital (100 mg tablet, 15 mg tablet, 30 mg tablet, 60 mg tablet, 64.8 mg tablet, 97.2mg tablet) phenobarbital (16.2 mg tablet, 20 mg/5 ml elixir, 32.4 mg tablet) PA, (g) $0 (Tier 1) PA, (g) If have questions, please call UPHP MI Health Link (Medicare-Medicaid Plan) at

40 Anticonvulsants primidone (250 mg tablet, 50 mg tablet) SABRIL (500 MG POWDER PACKET, 500 MG TABLET) tiagabine hcl (2 mg tablet, 4 mg tablet) valproic acid (as sodium salt) (valproate sodium) (250 mg/5ml solution, 500 mg/5ml vial, 500mg/10ml solution) valproic acid 250 mg capsule Glutamate Reducing Agents felbamate (400 mg tablet, 600 mg tablet, 600 mg/5ml oral susp) FYCOMPA (10 MG TABLET, 12 MG TABLET, 2 MG TABLET, 4 MG TABLET, 6 MG TABLET, 8 MG TABLET) LAMICTAL ODT (ODT 100 MG TABLET, ODT 200 MG TABLET, ODT 25 MG TABLET, ODT 50 MG TABLET) If have questions, please call UPHP MI Health Link (Medicare-Medicaid Plan) at

41 Anticonvulsants topiramate (100 mg tablet, 15 mg cap sprink, 200 mg tablet, 25 mg cap sprink, 25 mg tablet, 50 mg tablet) Sodium Channel Agents APTIOM (200 MG TABLET, 400 MG TABLET, 600 MG TABLET, 800 MG TABLET) BANZEL (200 MG TABLET, 40 MG/ML SUSPENSION, 400 MG TABLET) carbamazepine (100 mg cpmp 12hr, 100 mg tab chew, 100 mg/5ml oral susp, 200 mg cpmp 12hr, 200 mg tab er 12h, 200 mg tablet, 300 mg cpmp 12hr, 400 mg tab er 12h) DILANTIN 30 MG CAPSULE fosphenytoin sodium (100mg pe/2 vial, 500 pe/10 vial) oxcarbazepine (150 mg tablet, 300 mg tablet, 300 mg/5ml oral susp, 600 mg tablet) PEGANONE 250 MG TABLET phenytoin (100 mg/4ml oral susp, 125 mg/5ml oral susp, 50 mg tab chew) If have questions, please call UPHP MI Health Link (Medicare-Medicaid Plan) at

42 Anticonvulsants phenytoin sodium extended (100 mg capsule, 200 mg capsule, 300 mg capsule) TEGRETOL XR 100 MG TABLET VIMPAT (10 MG/ML SOLUTION, 100 MG TABLET, 150 MG TABLET, 200 MG TABLET, 200 MG/20 ML VIAL, 50 MG TABLET) Antidementia Agents Antidementia Agents, Other ergoloid mesylates 1 mg tablet PA, (g) Cholinesterase Inhibitors donepezil hcl (10 mg tab rapdis, 10 mg tablet, 23 mg tablet, 5 mg tab rapdis, 5 mg tablet) EXELON (13.3 MG/24HR PATCH, 4.6 MG/24HR PATCH, 9.5 MG/24HR PATCH) If have questions, please call UPHP MI Health Link (Medicare-Medicaid Plan) at

43 Antidementia Agents galantamine hbr (12 mg tablet, 16 mg cap24h pel, 24 mg cap24h pel, 4 mg tablet, 4 mg/ml solution, 8 mg cap24h pel, 8 mg tablet) rivastigmine tartrate (1.5 mg capsule, 3 mg capsule, 4.5 mg capsule, 6 mg capsule) N-methyl-D-aspartate (NMDA) Receptor Antagonist memantine hcl (10 mg tablet, 5 mg tablet, 5 mg-10 mg tab ds pk) NAMENDA (10 MG TABLET, 2 MG/ML SOLUTION, 5 MG TABLET, 5-10 MG TITRATION PK) NAMENDA XR (14 MG CAPSULE, 21 MG CAPSULE, 28 MG CAPSULE, 7 MG CAPSULE, TITRATION PACK) Antidepressants Antidepressants, Other bupropion hcl (100 mg tablet er, 150 mg tablet er, 200 mg tablet er, 75 mg tablet) $0 (Tier 1) QL (60), (g) If have questions, please call UPHP MI Health Link (Medicare-Medicaid Plan) at

44 Antidepressants bupropion hcl (150 mg tab er 24h, 300 mg tab er 24h) $0 (Tier 1) QL (30), (g) bupropion hcl 100 mg tablet $0 (Tier 1) QL (120), (g) mirtazapine (15 mg tab rapdis, 15 mg tablet, 30 mg tab rapdis, 30 mg tablet, 45 mg tab rapdis, 45 mg tablet, 7.5 mg tablet) Monoamine Oxidase Inhibitors EMSAM (12 MG/24 HOURS PATCH, 6 MG/24 HOURS PATCH, 9 MG/24 HOURS PATCH) $0 (Tier 1) QL (30), (g) MARPLAN 10 MG TABLET phenelzine sulfate 15 mg tablet tranylcypromine sulfate 10 mg tablet SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/ Serotonin and Norepinephrine Reuptake Inhibito BRINTELLIX (10 MG TABLET, 20 MG TABLET, 5 MG TABLET) QL (30) citalopram hydrobromide (10 mg tablet, 20 mg tablet, 40 mg tablet) citalopram hydrobromide 10 mg/5 ml solution $0 (Tier 1) QL (30), (g) $0 (Tier 1) QL (600), (g) If have questions, please call UPHP MI Health Link (Medicare-Medicaid Plan) at

45 Antidepressants duloxetine hcl (20 mg capsule dr, 30 mg capsule dr, 60 mg capsule dr) escitalopram oxalate (10 mg tablet, 20 mg tablet, 5 mg tablet) escitalopram oxalate 5 mg/5 ml solution FETZIMA (ER 120 MG CAPSULE, ER 20 MG CAPSULE, ER 40 MG CAPSULE, ER 80 MG CAPSULE) $0 (Tier 1) QL (60), (g) $0 (Tier 1) QL (30), (g) $0 (Tier 1) QL (600), (g) QL (30) FETZIMA MG TITRATION PAK QL (28 PER 28 DAYS) fluoxetine hcl (10 mg capsule, 10 mg tablet) fluoxetine hcl (20 mg capsule, 20 mg tablet) $0 (Tier 1) QL (30), (g) $0 (Tier 1) QL (120), (g) fluoxetine hcl 20 mg/5 ml solution $0 (Tier 1) QL (600), (g) fluoxetine hcl 40 mg capsule $0 (Tier 1) QL (60), (g) fluoxetine hcl 90 mg capsule dr $0 (Tier 1) QL (4 PER 28 DAYS), (g) fluvoxamine maleate (25 mg tablet, 50 mg tablet) $0 (Tier 1) QL (30), (g) fluvoxamine maleate 100 mg tablet $0 (Tier 1) QL (90), (g) maprotiline hcl (25 mg tablet, 50 mg tablet, 75 mg tablet) QL (90), (g) If have questions, please call UPHP MI Health Link (Medicare-Medicaid Plan) at

46 Antidepressants nefazodone hcl (100 mg tablet, 150 mg tablet, 200 mg tablet, 50 mg tablet) (g) nefazodone hcl 250 mg tablet paroxetine hcl (10 mg tablet, 12.5 mg tab er 24h, 20 mg tablet, 40 mg tablet) paroxetine hcl (25 mg tab er 24h, 30 mg tablet, 37.5 mg tab er 24h) $0 (Tier 1) QL (30), (g) $0 (Tier 1) QL (60), (g) PAXIL 10 MG/5 ML SUSPENSION QL (900) PRISTIQ ER (ER 100 MG TABLET, ER 25 MG TABLET, ER 50 MG TABLET) sertraline hcl (25 mg tablet, 50 mg tablet) QL (30) $0 (Tier 1) QL (30), (g) sertraline hcl 100 mg tablet $0 (Tier 1) QL (60), (g) sertraline hcl 20 mg/ml oral conc $0 (Tier 1) QL (300), (g) trazodone hcl (100 mg tablet, 150 mg tablet, 300 mg tablet, 50 mg tablet) venlafaxine hcl (100 mg tablet, 25 mg tablet, 37.5 mg tablet, 50 mg tablet, 75 mg cap er 24h, 75 mg tab er 24, 75 mg tablet) $0 (Tier 1) QL (90), (g) If have questions, please call UPHP MI Health Link (Medicare-Medicaid Plan) at

47 Antidepressants VENLAFAXINE HCL ER (ER 150 MG TAB, ER 37.5 MG TAB) $0 (Tier 1) QL (30) VENLAFAXINE HCL ER 75 MG TAB $0 (Tier 1) QL (90) VIIBRYD (10 MG TABLET, MG STARTER PACK, MG STARTER PK, 20 MG TABLET, 40 MG TABLET) Tricyclics amitriptyline hcl (10 mg tablet, 100 mg tablet, 150 mg tablet, 25 mg tablet, 50 mg tablet, 75 mg tablet) amoxapine (100 mg tablet, 150 mg tablet, 25 mg tablet, 50 mg tablet) clomipramine hcl (25 mg capsule, 50 mg capsule, 75 mg capsule) desipramine hcl (10 mg tablet, 100 mg tablet, 150 mg tablet, 25 mg tablet, 50 mg tablet, 75 mg tablet) doxepin hcl (10 mg capsule, 10 mg/ml oral conc, 100 mg capsule, 150 mg capsule, 25 mg capsule, 50 mg capsule) QL (30) $0 (Tier 1) PA, (g) (g) $0 (Tier 1) PA, (g) $0 (Tier 1) PA, (g) doxepin hcl 75 mg capsule PA, (g) imipramine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet) $0 (Tier 1) PA, (g) If have questions, please call UPHP MI Health Link (Medicare-Medicaid Plan) at

48 Antidepressants nortriptyline hcl (10 mg capsule, 25 mg capsule, 50 mg capsule, 75 mg capsule) nortriptyline hcl 10 mg/5 ml solution protriptyline hcl (10 mg tablet, 5 mg tablet) SURMONTIL (100 MG CAPSULE, 25 MG CAPSULE, 50 MG CAPSULE) (g) PA Antiemetics Antiemetics, Other chlorpromazine hcl (10 mg tablet, 100 mg tablet, 200 mg tablet, 25 mg tablet, 50 mg tablet) chlorpromazine hcl 25 mg/ml ampul (g) hydroxyzine hcl (10 mg tablet, 10 mg/5 ml solution, 25 mg tablet, 50 mg tablet) hydroxyzine hcl 50 mg/25ml solution $0 (Tier 1) PA, (g) If have questions, please call UPHP MI Health Link (Medicare-Medicaid Plan) at

49 Antiemetics meclizine hcl (12.5 mg tablet, 25 mg tablet) metoclopramide hcl (10 mg tablet, 10 mg/10ml solution, 5 mg tablet, 5 mg/5 ml solution) perphenazine (16 mg tablet, 2 mg tablet, 4 mg tablet, 8 mg tablet) PHENERGAN (12.5 MG SUPPOSITORY, 25 MG SUPPOSITORY) $0 (Tier 1) PA prochlorperazine 25 mg supp.rect prochlorperazine edisylate (10 mg/2 ml vial, 5 mg/ml vial) prochlorperazine maleate (10 mg tablet, 5 mg tablet) promethazine hcl (12.5 mg supp.rect, 12.5 mg tablet, 25 mg supp.rect, 25 mg tablet, 50 mg tablet, 6.25mg/5ml syrup) Emetogenic Therapy Adjuncts ALOXI 0.25 MG/5 ML VIAL dronabinol (10 mg capsule, 2.5 mg capsule, 5 mg capsule) $0 (Tier 1) PA, (g) $0 (Tier 1) PA, (g) If have questions, please call UPHP MI Health Link (Medicare-Medicaid Plan) at

50 Antiemetics granisetron hcl 1 mg tablet $0 (Tier 1) PA, (g) ondansetron (4 mg tab rapdis, 8 mg tab rapdis) ondansetron hcl (24 mg tablet, 4 mg tablet, 4 mg/5 ml solution, 8 mg tablet) $0 (Tier 1) PA, (g) $0 (Tier 1) PA, (g) ondansetron hcl 2 mg/ml vial ondansetron hcl/pf (4 mg/2 ml ampul, 4 mg/2 ml syringe, 4 mg/2 ml vial) SANCUSO 3.1 MG/24 HR PATCH QL (4 PER 28 DAYS) Antifungals Antifungals AMBISOME 50 MG VIAL PA amphotericin b 50 mg vial PA, (g) CANCIDAS (50 MG VIAL, 70 MG VIAL) ciclopirox (0.77 % gel (gram), 1 % shampoo, 8 % solution) If have questions, please call UPHP MI Health Link (Medicare-Medicaid Plan) at

51 Antifungals ciclopirox olamine (0.77 % cream (g), 0.77 % suspension) ciclopirox/ure/camph/menth/euc 8 % solution ciclopirox/vite/nail lacq remo 8%- 5% kit clotrimazole (1 % cream (g), 10 mg troche) clotrimazole 1 % cream/appl * CRESEMBA (186 MG CAPSULE, 372 MG VIAL) PA econazole nitrate 1 % cream (g) fluconazole (10 mg/ml susp recon, 100 mg tablet, 150 mg tablet, 200 mg tablet, 40 mg/ml susp recon, 50 mg tablet) fluconazole in dextrose, iso-osmotic (200mg/0.1l piggyback, 400mg/0.2l piggyback) fluconazole in sodium chloride, isoosmotic (100mg/50ml pggybk btl, 200mg/0.1l pggybk btl, 200mg/0.1l piggyback, 400mg/0.2l pggybk btl, 400mg/0.2l piggyback) flucytosine (250 mg capsule, 500 mg capsule) If have questions, please call UPHP MI Health Link (Medicare-Medicaid Plan) at

52 Antifungals griseofulvin ultramicrosize (125 mg tablet, 250 mg tablet) griseofulvin, microsize 125 mg/5ml oral susp itraconazole 100 mg capsule ketoconazole (2 % cream (g), 2 % shampoo, 200 mg tablet) LAMISIL AT 1% CREAM * miconazole nitrate (100 mg supp.vag, 2 % cream/appl, 200 mg- 2 % cmb pf crm, 200 mg-2 % kit, 4 % cream/appl) * MYCAMINE (100 MG VIAL, 50 MG VIAL) NATACYN EYE DROPS NOXAFIL 40 MG/ML SUSPENSION PA nystatin (100000/g cream (g), /g oint. (g), /g powder, /ml oral susp, 150mm unit powder(ea), 500k unit tablet, 500mm unit powder(ea), 50mm unit powder(ea)) terbinafine hcl 1 % cream (g) * terbinafine hcl 250 mg tablet If have questions, please call UPHP MI Health Link (Medicare-Medicaid Plan) at

53 Antifungals terconazole (0.4 % cream/appl, 0.8 % cream/appl, 80 mg supp.vag) tioconazole 6.5 % oin/pf app * voriconazole (200 mg tablet, 200 mg vial, 200 mg/5ml susp recon, 50 mg tablet) Antigout Agents $0 (Tier 1) PA, (g) Antigout Agents allopurinol (100 mg tablet, 300 mg tablet) ALOPRIM 500 MG VIAL colchicine/probenecid mg tablet COLCRYS 0.6 MG TABLET probenecid 500 mg tablet ULORIC (40 MG TABLET, 80 MG TABLET) If have questions, please call UPHP MI Health Link (Medicare-Medicaid Plan) at

54 Antimigraine Agents Antimigraine Agents butalbital/acetaminophen/caffeine/ codeine phosphate ( capsule, capsule) codeine/butalbital/asa/caffein capsule ergotamine tartrate/caffeine 2-100mg supp.rect $0 (Tier 1) PA, QL (180), (g) $0 (Tier 1) PA, QL (180), (g) (g) MIGRANAL NASAL SPRAY Serotonin (5-HT) 1b/1d Receptor Agonists naratriptan hcl (1 mg tablet, 2.5 mg tablet) $0 (Tier 1) QL (18), (g) rizatriptan benzoate (10 mg tab rapdis, 10 mg tablet, 5 mg tab rapdis, 5 mg tablet) sumatriptan (20 mg spray, 5 mg spray) sumatriptan succinate (100 mg tablet, 25 mg tablet, 50 mg tablet) sumatriptan succinate (6 mg/0.5ml cartridge, 6 mg/0.5ml pen injctr, 6 mg/0.5ml syringe, 6 mg/0.5ml vial) $0 (Tier 1) QL (18), (g) QL (12), (g) $0 (Tier 1) QL (18), (g) If have questions, please call UPHP MI Health Link (Medicare-Medicaid Plan) at

55 Antimyasthenic Agents Parasympathomimetics guanidine hcl 125 mg tablet (g) MESTINON (180 MG TIMESPAN, 60 MG/5 ML SYRUP) pyridostigmine bromide (180 mg tablet er, 60 mg tablet) Antimycobacterials Antimycobacterials, Other dapsone (100 mg tablet, 25 mg tablet) rifabutin 150 mg capsule Antituberculars CAPASTAT SULFATE 1 GM VIAL ethambutol hcl (100 mg tablet, 400 mg tablet) isoniazid (100 mg tablet, 300 mg tablet) isoniazid 100 mg/ml vial (g) If have questions, please call UPHP MI Health Link (Medicare-Medicaid Plan) at

56 Antimycobacterials PASER GRANULES 4 GM PACKET PRIFTIN 150 MG TABLET pyrazinamide 500 mg tablet rifampin (150 mg capsule, 300 mg capsule, 600 mg vial) TRECATOR 250 MG TABLET Antineoplastics Alkylating Agents BUSULFEX 60 MG/10 ML VIAL cyclophosphamide (25 mg capsule, 50 mg capsule) GLEOSTINE (10 MG CAPSULE, 100 MG CAPSULE, 40 MG CAPSULE) PA, (g) HEXALEN 50 MG CAPSULE PA LEUKERAN 2 MG TABLET LOMUSTINE (10 MG CAPSULE, 100 MG CAPSULE, 40 MG CAPSULE) MATULANE 50 MG CAPSULE PA If have questions, please call UPHP MI Health Link (Medicare-Medicaid Plan) at

57 Antineoplastics melphalan hcl 50 mg vial MUSTARGEN 10 MG VIAL VALCHLOR 0.016% GEL Antiandrogens bicalutamide 50 mg tablet flutamide 125 mg capsule NILANDRON 150 MG TABLET XTANDI 40 MG CAPSULE PA, QL (120) ZYTIGA 250 MG TABLET PA, QL (120) Antiangiogenic Agents POMALYST (1 MG CAPSULE, 2 MG CAPSULE, 3 MG CAPSULE, 4 MG CAPSULE) REVLIMID (10 MG CAPSULE, 2.5 MG CAPSULE, 5 MG CAPSULE) REVLIMID (15 MG CAPSULE, 20 MG CAPSULE, 25 MG CAPSULE) THALOMID (100 MG CAPSULE, 50 MG CAPSULE) THALOMID (150 MG CAPSULE, 200 MG CAPSULE) ZALTRAP (100 MG/4 ML VIAL, 200 MG/8 ML VIAL) PA, QL (21 PER 28 DAYS) PA, QL (30) PA, QL (21 PER 28 DAYS) PA, QL (30) PA, QL (60) If have questions, please call UPHP MI Health Link (Medicare-Medicaid Plan) at

58 Antineoplastics Antiestrogens/Modifiers EMCYT 140 MG CAPSULE FARESTON 60 MG TABLET SOLTAMOX 10 MG/5 ML SOLN tamoxifen citrate (10 mg tablet, 20 mg tablet) Antimetabolites fluorouracil (1 g/20 ml vial, 2.5 g/50ml vial, 5 g/100 ml vial, 500mg/10ml vial) FOLOTYN (20 MG/ML VIAL, 40 MG/2 ML VIAL) $0 (Tier 1) PA, (g) hydroxyurea 500 mg capsule mercaptopurine 50 mg tablet PURIXAN 20 MG/ML ORAL SUSP TABLOID 40 MG TABLET Antineoplastics DAUNOXOME 50 MG (2 MG/ML) VIAL Antineoplastics, Other ABRAXANE 100 MG VIAL If have questions, please call UPHP MI Health Link (Medicare-Medicaid Plan) at

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