MEDICATIONS EXCLUDED FROM MAIL-ORDER COVERAGE April 1, 2011

Transcription

1 MEDICATIONS EXCLUDED FROM MAIL-ORDER COVERAGE April 1, 2011 Network Health does not cover the medications listed below for Network Health Forward (Commonwealth Care) Plan Type II and III members through our mail-order vendor, Wellpartner. We list all products alphabetically by their brand name. The brand names are for reference only, and do not mean they are covered. Generic drugs have the same active ingredient and work the same as brand-name drugs. We only cover brand-name medications when a generic medication is not available. Your provider may prescribe the covered medications from the list below for you to fill only at a retail pharmacy or at our specialty pharmacy, Caremark. Some of the medications listed below may have coverage limitations. Excluded mail-order medications (only covered at retail pharmacies) Accutane Actiq Fentanyl lozenge Adderall, Adderall XR Dextroamphetamine/Amphetamine salts Aloxi Palonosetron Ambien, Ambien CR Zolpidem Amerge Naratriptan Amnesteem Anadrol-50 Oxymetholone Androderm Testosterone transdermal system Androgel Testosterone gel Antabuse Disulfiram Anzemet Dolasetron Apokyn Apomorphine Arixtra Fondaparinux Avinza Morphine sulphate SR - 24 hour Axert Almotriptan AzaSite Azithromycin Azelex Azelaic acid Cafcit Caffeine citrate Campral Acamprosate Caverject Chantix Varenicline Cialis Tadalafil Claravis Medications excluded from mail-order coverage April 1,

2 Clozaril Coartem Codeine Phosphate Codeine Sulfate Colyte Commit Concerta Cyclogyl D.H.E. 45 Darvocet-N Darvon Compound Darvon-N Daytrana Delatestryl Demerol Depo-Testosterone Dexedrine DHC Plus Diastat, Diastat AcuDial Dilaudid Duragesic Edex Edluar Elidel Elimite Embeda Emend Empirin #2, #3, #4 Exalgo Eurax lotion Fentora Finacea Fioricet/Codeine Fiorinal/Codeine Flector Patch Flolan Flumadine Focalin, Focalin XR Fragmin Frova Golytely Clozapine Artemether/lumefantrine Codeine phosphate Codeine sulfate Nicotine, Polacrilex Methylphenidate ER Cyclopentolate Dihydroergotamine Propoxyphene napsylate/apap Propoxyphene/ASA/Caffeine Propoxyphene napsylate Methylphenidate Testosterone enanthate (in oil) Meperidine Testosterone cypionate Dextroamphetamine Dihydrocodeine/APAP/Caffeine Diazepam Hydromorphone Fentanyl Ambiel SL Pimecrolimus Permethrin Morphine/Naltrexone Aprepitant Codeine/Aspirin Hydromorphone ER Crotamiton Fentanyl Buccal Tablets Azelaic Acid Butalbital/APAP/Caffeine/Codeine Butalbital/Aspirin/Caffeine/Codeine Diclofenac patch Epoprostenol sodium Rimantadine Dexmethylphenidate Dalteparin Frovatriptan Medications excluded from mail-order coverage April 1,

3 HalfLytely Helidac Tetracycline/Bismuth/Metronidazole Hycodan Hydrocodone bitartrate Imitrex, Imitrex Inj., Imitrex Nasal Sumatriptan Innohep Tinzaparin Iprivasc Desirudin Isopto Homatropine 5% Homatropaire 5% Kadian Morphine sulphate SR - 12 hour Koromex Coil Diaphragm Kwell Lindane Kytril Granisetron Lamisil Terbinafine Levitra Vardenafil Lovenox Enoxaparin Lunesta Eszopiclone Marinol Dronabinol Maxalt, Maxalt MLT Rizatriptan Metadate CD Methylphenidate ER Methadone Methadone Methitest Methyltestosterone Migranal, Migranal Nasal Dihydroergotamine Moviprep MS Contin Morphine SR MSIR Morphine Muse Nicotrol, Nicotrol NS Nicotine Nulytely Nuvigil Armodafinil Onsolis Fentanyl buccal film Opana, Opana ER Oxymorphone IR, Oxymorphone ER Ortho All-Flex Diaphragm OsmoPrep Bowel evacuant Ovide Malathion Oxandrin Oxandrolone Oxycontin Oxycodone ER Oxyfast Oxycodone OxyIR Oxycodone Percocet Oxycodone/APAP Percodan Oxycodone/Aspirin Plan B, Plan B One-Step Levonorgestrel Ponstel Mefenamic acid Medications excluded from mail-order coverage April 1,

4 Pradaxa Prevpac Protopic Provigil Prudoxin Pylera Reclast Relenza Relistor Relpax Reprexain Revia Ritalin, Ritalin SR, Ritalin LA Rozerem Samsca Sancuso Santyl Ointment Solaraze Gel Soma Soma Compound Sonata Sotret Stadol Striant Suboxone Subutex Suprep Tamiflu Testopel Toradol Transderm-Scop Trypsin-balsam peru-castor oil Tussionex Tylenol #2, #3, #4 Tylox Ultracet Ultram, Ultram ER Urea 40% Cream and Lotion Urea 50% Cream and Ointment Valcyte Dabigatran Lansoprazole/Amoxicillin/Clarithromycin Tacrolimus Modafinil Doxepin Cream Bismuth subcitrate potassium/metronidazole/tetracycline Zoledronic acid Zanamivir Methylnaltrexone Eletriptan Hydrocodone/Ibuprofen Naltrexone Methylphenidate Ramelteon Tolvaptan Granisetron Collagenase ointment Diclofenac gel Carisoprodol Carisoprodol/Aspirin Zaleplon Butorphanol tartrate Testosterone buccal system Buprenorphine/Naloxone Buprenorphine Oral Colon Lavage Solution Oseltamivir Testosterone pellets Ketorolac tromethamine Scopolamine Trypsin-balsam peru-castor oil Hydrocodone/Chlorpheniramine Acetaminophen/Codeine Oxycodone/APAP Tramadol/APAP Tramadol, Tramadol ER Urea 40% cream and lotion Urea 50% cream and ointment Valganciclovir Medications excluded from mail-order coverage April 1,

5 Viagra Sildenafil Vicodin, Vicodin ES Acetaminophen/Hydrocodone Vicoprofen Hydrocodone/Ibuprofen Virazole Ribavirin Voltaren Gel Diclofenac Gel Vyvanse Lisdexamfetamine Xifaxan Rifaximin Xyrem Sodium oxybate Zofran, Zofran ODT Ondansetron Zometa Zoledronic acid Zomig, Zomig ZMT, Zomig Nasal Zolmitriptan Zovirax Cream Acyclovir Zyban Bupropion Zyvox Linezolid Excluded mail-order specialty medications (only covered at Caremark) See a complete list of medications Caremark provides. Other mail-order exclusions* All injectable oncology medications All Schedule II and Schedule III controlled substance medications *If you are unsure of its status, please call us at to verify that a specific drug is covered under the mail-order benefit Medications excluded from mail-order coverage April 1,