H9115_ MEM0053 Approved 09222015 MetroPlus FIDA Plan 2016 List of Covered s (Formulary) This is a list of drugs that Participants can get in MetroPlus FIDA Plan (Medicare-Medicaid Plan). MetroPlus FIDA Plan is a managed care plan that contracts with both Medicare and the New York State Department of Health (Medicaid) to provide benefits of both programs to Participants through the Fully Integrated Duals Advantage (FIDA) Demonstration. The List of Covered s and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you. Benefits may change on January 1 of each year. You can always check MetroPlus FIDA Plan s up-to-date List of Covered s online at www.metroplus.org/fida or by calling MetroPlus FIDA Plan Participant Services at 1-844-288- FIDA (3432) (TTY: 711). Limitations and restrictions may apply. For more information, call MetroPlus FIDA Plan Participant Services or read the MetroPlus FIDA Plan Participant Handbook. There are no copays for any covered drugs. You can get this information for free in other formats, such as large print, braille, or audio. Call 1-844-288-FIDA (3432) and 711 during 8am-8pm, Monday-Saturday, February 15-September 30 and 8am-8pm, 7 days a week, October 1-February 14. After 8pm, Sundays & Holidays, call our 24/7 Medical Answering Service 1-800-442-2560. The call is free. You can get this information for free in other languages. Call 1-844-288-FIDA (3432) and 711 during 8am-8pm, Monday-Saturday, February 15-September 30 and 8am-8pm, 7 days a week, October 1-February 14. After 8pm, Sundays & Holidays, call our 24/7 Medical Answering Service 1-800-442-2560. The call is free. Puede obtener esta información en otros idiomas sin ningún costo. Llame al Plan MetroPlus FIDA al 1-844-288-FIDA (3432), usuarios de TTY: 711, de lunes a sábado, de 8:00 a. m. a 8:00 p. m.; domingos y días festivos: Servicio de Recepción de Llamadas para Médicos, las 24 horas del día, los 7 días de la semana al número arriba mencionados. La llamada es gratuita. Ou kapab jwenn enfòmasyon sa yo pou gratis nan lòt lang yo. Rele MetroPlus FIDA Plan nan nimewo 1-844-288-FIDA (3432), TTY: 711, Lendi - Samdi, 8 am - 8 pm. Apre 8pm, jou dimanch ak Jou Ferye: Sèvis 24/7 Repondè Medikal Otomatik nan nimewo ki endike anwo a. Koutfil la gratis.? If you have questions, please call MetroPlus FIDA Plan at 1-844-288-FIDA (3432) (TTY: 711), 8am-8pm, Monday-Saturday, February 15-September 30 and 8am-8pm, 7 days a week, October 1-February 14. After 8pm, Sundays & Holidays, call our 24/7 Medical Answering Service 1-800- 442-2560. The call is free. For more information, visit www.metroplus.org/fida. I
È possibile ottenere queste informazioni in altre lingue senza alcun costo. Potete contattare i responsabili del programma MetroPlus Fida al numero 1-844-288-FIDA (3432), TTY: 711, dalle ore 8 alle 20 dal lunedì al sabato e dopo le 20 la domenica e nei giorni festivi. È possibile telefonare per una consulenza medica ai numeri indicati, 24 ore su 24, 7 giorni su 7. La chiamata è gratuita. 您可免費取得此資訊的其他語言版本 請於週一至週六上午 8 點至晚上 8 點洽 MetroPlus FIDA Plan, 電話是 1-844-288-FIDA (3432),TTY 專線 :711 晚上 8 點後 週日及假日 : 請撥打上方所列的 24 小時醫療諮詢服務專線 此電話號碼為免付費專線 Вы можете получить эту информацию бесплатно на других языках. Звоните в MetroPlus FIDA Plan по номеру 1-844-288-FIDA (3432), для пользователей с нарушениями слуха: 711, с понедельника по субботу, с 8:00 до 20:00. После 20:00, по воскресеньям и праздничным дням: круглосуточная медицинская справочная служба, номера указаны выше. Звонок бесплатный. 이정보는다른언어로도무료로제공됩니다. MetroPlus FIDA Plan 에전화번호 1-844- 288-FIDA(3432), TTY: 711 로월요일 - 토요일, 오전 8 시부터오후 8 시사이에연락하시기바랍니다. 오후 8 시이후와일요일및공휴일에는상기표시된번호로전화하시면 24 시간의료 ARS 가제공됩니다. 통화는무료입니다. The State of New York has created a participant ombudsman program called the Independent Consumer Advocacy Network (ICAN) to provide Participants free, confidential assistance on any services offered by MetroPlus FIDA Plan. ICAN may be reached toll-free at 1-844-614-8800 or online at icannys.org.? If you have questions, please call MetroPlus FIDA Plan at 1-844-288-FIDA (3432) (TTY: 711), 8am-8pm, Monday-Saturday, February 15-September 30 and 8am-8pm, 7 days a week, October 1-February 14. After 8pm, Sundays & Holidays, call our 24/7 Medical Answering Service 1-800- 442-2560. The call is free. For more information, visit www.metroplus.org/fida. II
Frequently Asked Questions (FAQ) Find answers here to questions you have about this List of Covered s. 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 s? (We call the List of Covered s the List for short.) The drugs on the List of Covered s that starts on page 11 are the drugs covered by MetroPlus FIDA 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 you services. We refer to these pharmacies as network pharmacies. MetroPlus FIDA Plan will cover all drugs on the List if: your doctor or other prescriber says you need them to get better or stay healthy, the drug is medically necessary for your condition, and you fill the prescription at a MetroPlus FIDA Plan network pharmacy. MetroPlus FIDA Plan may have additional steps to access certain drugs (see question #5 below). In some cases, you may have to do something before you can get a drug, like try other drugs first. You can also see an up-to-date list of drugs that we cover on our website at www.metroplus.org/fida or call Participant Services at 1-844-288-FIDA (3432), TTY: 711. 2. Does the List ever change? Yes. MetroPlus FIDA Plan may add or remove drugs on the List during the year. Generally, the List will only change if: a new drug comes along that works as well as a drug on the 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 MetroPlus FIDA Plan or your Interdisciplinary Team (IDT) before you can get a drug.)? If you have questions, please call MetroPlus FIDA Plan at 1-844-288-FIDA (3432) (TTY: 711), 8am-8pm, Monday-Saturday, February 15-September 30 and 8am-8pm, 7 days a week, October 1-February 14. After 8pm, Sundays & Holidays, call our 24/7 Medical Answering Service 1-800- 442-2560. The call is free. For more information, visit www.metroplus.org/fida. III
Add or change the amount of a drug you can get (called quantity limits ). Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.) (For more information on these drug rules, see page 5.) We will tell you when a drug you are taking is removed from the List. We will also tell you when we change our rules for covering a drug. Questions 3, 4, and 7 below have more information on what happens when the List changes. You can always check MetroPlus FIDA Plan s up to date List online at www.metroplus.org/fida. You can also call Participant Services to check the current List at 1-844-288-FIDA (3432), TTY: 711. 3. What happens when a cheaper drug comes along that works as well as a drug on the List now? If a cheaper drug becomes available that works as well as a drug on the List now: Your pharmacist may give you the cheaper drug the next time you fill your prescription. If you and your provider decide that the cheaper drug is not right for you, your provider can tell the pharmacist to continue to give you the drug you take now. MetroPlus FIDA Plan may decide to take the more expensive drug off of the List. If you are taking a drug that we remove from the List because a cheaper drug that works just as well comes along, we will tell you at least 60 days before we remove it from the List or when you ask for a refill. Then you can get a 60-day supply of the drug before the change to the List is made. You will be notified of any changes in writing, via mail. 4. What happens when we find out a drug is not safe? If the Food and Administration (FDA) says a drug you are taking is not safe, we will take it off the List right away. We will also send you a letter and call you to tell you that the unsafe drug was taken off the List. You can call MetroPlus FIDA Plan Participant Services with questions about these changes to our List.? If you have questions, please call MetroPlus FIDA Plan at 1-844-288-FIDA (3432) (TTY: 711), 8am-8pm, Monday-Saturday, February 15-September 30 and 8am-8pm, 7 days a week, October 1-February 14. After 8pm, Sundays & Holidays, call our 24/7 Medical Answering Service 1-800- 442-2560. The call is free. For more information, visit www.metroplus.org/fida. IV
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 you can get. In some cases you or your doctor or other prescriber must do something before you can get the drug. For example: Prior approval (or prior authorization): For some drugs, you or your doctor or other prescriber must get approval from MetroPlus FIDA Plan or your Interdisciplinary Team (IDT) before you fill your prescription. If you don t get approval, MetroPlus FIDA Plan may not cover the drug. Quantity limits: Sometimes MetroPlus FIDA Plan limits the amount of a drug you can get. Step therapy: Sometimes MetroPlus FIDA Plan requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn t work for you, then we will cover the second. You can find out if your drug has any additional requirements or limits by looking in the tables beginning on page 11. You can also get more information by visiting our web site at www.metroplus.org/fida. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. You can ask for an exception from these limits. Please see question 11 for more information on exceptions. If you are in a nursing facility or other long-term care facility and need a drug that is not on the List, or if you cannot easily get the drug you need, we can help. We will cover a 31-day emergency supply of the drug you need (unless you have a prescription for fewer, whether or not you are a new MetroPlus FIDA Plan Participant. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the List you can take instead or whether to request an exception. Please see question 11 for more information about exceptions. 6. How will you know if the drug you want has limitations or if there are required actions to take to get the drug? The List of Covered s on page 11 has a column labeled Necessary actions, restrictions, or limits on use.? If you have questions, please call MetroPlus FIDA Plan at 1-844-288-FIDA (3432) (TTY: 711), 8am-8pm, Monday-Saturday, February 15-September 30 and 8am-8pm, 7 days a week, October 1-February 14. After 8pm, Sundays & Holidays, call our 24/7 Medical Answering Service 1-800- 442-2560. The call is free. For more information, visit www.metroplus.org/fida. V
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 you if we add prior approval, quantity limits, and/or step therapy restrictions on a drug. We will tell you at least 60 days before the restriction is added or when you next ask for a refill. Then, you can get a 60-day supply of the drug before the change to the List is made. This gives you time to talk to your doctor or other prescriber about what to do next. 8. How can you find a drug on the List? There are two ways to find a drug: You can search alphabetically (if you know how to spell the drug), or You can search by medical condition. To search alphabetically, go to the Alphabetical Listing section on page 85. Then look for the name of your drug in the list. To search by medical condition, find the section labeled List of drugs by medical condition on page 11. The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, Cardiovascular s to treat heart and circulation conditions. That is where you will find drugs that treat heart conditions. 9. What if the drug you want to take is not on the List? If you don t see your drug on the List, call Participant Services at 1-844-288-FIDA (3432) (TTY: 711) and ask about it. If you learn that MetroPlus FIDA Plan will not cover the drug, you can do one of these things: Ask Participant Services for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the List that is like the one you want to take. Or You can ask the plan or your Interdisciplinary Team (IDT) to make an exception to cover your drug. Please see question 11 for more information about exceptions.? If you have questions, please call MetroPlus FIDA Plan at 1-844-288-FIDA (3432) (TTY: 711), 8am-8pm, Monday-Saturday, February 15-September 30 and 8am-8pm, 7 days a week, October 1-February 14. After 8pm, Sundays & Holidays, call our 24/7 Medical Answering Service 1-800- 442-2560. The call is free. For more information, visit www.metroplus.org/fida. VI
10. What if you are a new MetroPlus FIDA Plan Participant and can t find your drug on the List or have a problem getting your drug? We can help. We must cover up to 90 days of temporary supplies of your drug, as needed, during the first 90 days you are a Participant of MetroPlus FIDA Plan. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the List you can take instead or whether to request an exception. We will cover up to 90 days of temporary supplies of your drug if: you are taking a drug that is not on our List, or health plan rules do not let you get the amount ordered by your prescriber, or the drug requires prior approval by MetroPlus FIDA Plan or your Interdisciplinary Team (IDT), or you are taking a drug that is part of a step therapy restriction. If you live in a nursing facility or other long-term care facility, you may refill your prescription for as long as 91 days. You may refill the drug multiple times during your first 90 days in the plan. This gives your prescriber time to change your drugs to ones on the List or ask for an exception. During the first 90 days of your enrollment in MetroPlus FIDA Plan, our Transition Policy provides for at least a one-time, temporary 30-day refill, If your prescription is for less than 30 days, multiple refills are allowed to provide you with a 30 days supply. You are also allowed a ninety (90) day supply of drugs if you request a refill of a non-part D drug that is covered by Medicaid. If you are in a long-term care setting, MetroPlus FIDA Plan will provide for a 98 day prescription, beginning in the first 90 days of your enrollment in the plan. After the first 90 days, we will provide for up to a 31-day emergency supply of non-formulary Part D drugs while an exception or prior authorization determination is pending. If you are being admitted to or discharged from a longterm care facility, early refill edits will not be used to limit appropriate and necessary access to your benefit, and you will be allowed to access a refill upon admission or discharge. 11. Can you ask for an exception to cover your drug? Yes. You can ask MetroPlus FIDA Plan or your Interdisciplinary Team (IDT) to make an exception to cover a drug that is not on the List.? If you have questions, please call MetroPlus FIDA Plan at 1-844-288-FIDA (3432) (TTY: 711), 8am-8pm, Monday-Saturday, February 15-September 30 and 8am-8pm, 7 days a week, October 1-February 14. After 8pm, Sundays & Holidays, call our 24/7 Medical Answering Service 1-800- 442-2560. The call is free. For more information, visit www.metroplus.org/fida. VII
You can also ask MetroPlus FIDA Plan or your IDT to change the rules on your drug. For example, MetroPlus FIDA Plan may limit the amount of a drug we will cover. If your drug has a limit, you can ask us or your IDT to change the limit and cover more. Other examples: You can ask us or your IDT to drop step therapy restrictions or prior approval requirements. 12. How long does it take to get an exception? First, MetroPlus FIDA Plan or your Interdisciplinary Team (IDT) must receive a statement from your prescriber supporting your request for an exception. After we receive the statement, you will get a decision on your exception request within 72 hours. If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, you will get a decision within 24 hours of receiving your prescriber s supporting statement. 13. How can you ask for an exception? To ask for an exception, call your Care Manager. Your Care Manager will work with you and your provider to help you ask for an exception. 14. What are generic drugs? Generic drugs are made up of the same ingredients as brand name drugs. They usually cost less than the brand name drug and usually don t have well-known names. Generic drugs are approved by the Food and Administration (FDA). MetroPlus FIDA Plan covers both brand name drugs and generic drugs. 15. What are OTC drugs? OTC stands for over-the-counter. MetroPlus FIDA Plan covers some OTC drugs when they are written as prescriptions by your provider.? If you have questions, please call MetroPlus FIDA Plan at 1-844-288-FIDA (3432) (TTY: 711), 8am-8pm, Monday-Saturday, February 15-September 30 and 8am-8pm, 7 days a week, October 1-February 14. After 8pm, Sundays & Holidays, call our 24/7 Medical Answering Service 1-800- 442-2560. The call is free. For more information, visit www.metroplus.org/fida. VIII
You can read the MetroPlus FIDA Plan List to see what OTC drugs are covered. 16. Does MetroPlus FIDA Plan cover OTC non-drug products? MetroPlus FIDA Plan covers some OTC non-drug products when they are written as prescriptions by your provider. Non-drug OTC products include items such as alcohol swabs and gauze pads. You can read the MetroPlus FIDA Plan List to see what OTC non-drug products are covered. 17. What is your copay? You will not be charged a copay for drugs on the List. 18. What are drug tiers? MetroPlus FIDA Plan has three tiers of drugs. s are groups of drugs. Every drug on the plan s List is in one of three tiers. There is no cost to you for drugs on any of the tiers. 1 drugs are generic drugs. 2 drugs are brand name drugs. 3 drugs are over-the-counter drugs and non-medicare covered prescription drugs.? If you have questions, please call MetroPlus FIDA Plan at 1-844-288-FIDA (3432) (TTY: 711), 8am-8pm, Monday-Saturday, February 15-September 30 and 8am-8pm, 7 days a week, October 1-February 14. After 8pm, Sundays & Holidays, call our 24/7 Medical Answering Service 1-800- 442-2560. The call is free. For more information, visit www.metroplus.org/fida. IX
List of Covered s The list of covered drugs that begins on the next page gives you information about the drugs covered by MetroPlus FIDA Plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 85. The first column of the chart lists the name of the drug. Brand name drugs are capitalized (e.g., COLCRYS)) and generic drugs are listed in lower-case italics (e.g., penicillin). The information in the necessary actions, restrictions, or limits on use column tells you if MetroPlus FIDA Plan has any rules for covering your 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 for a review of and change to a coverage decision if you think there was a mistake. For example, MetroPlus FIDA Plan or your Interdisciplinary Team (IDT) might decide that a drug that you want is not covered or is no longer covered by Medicare or Medicaid. If you or your doctor or other prescriber disagrees with the decision, you can appeal. To ask for instructions on how to appeal, call Participant Services at 1-844-288-FIDA (3432) (TTY: 711) or the Independent Consumer Advocacy Network (ICAN) at 1-844-614-8800. You can also read the Participant Handbook to learn how to appeal a decision.? If you have questions, please call MetroPlus FIDA Plan at 1-844-288-FIDA (3432) (TTY: 711), 8am-8pm, Monday-Saturday, February 15-September 30 and 8am-8pm, 7 days a week, October 1-February 14. After 8pm, Sundays & Holidays, call our 24/7 Medical Answering Service 1-800- 442-2560. The call is free. For more information, visit www.metroplus.org/fida. X
NY_MMP_CY16_2T_STND eff 01/01/2016 Name ANALGESICS - DRUGS TO TREAT PAIN AND INFLAMMATION GOUT - DRUGS TO TREAT GOUT allopurinol tab 100 mg 1 $0 allopurinol tab 300 mg 1 $0 colchicine w/ probenecid tab 0.5-1 $0 500 mg COLCRYS TAB 0.6MG 2 $0 QL (120 tabs / 30 probenecid tab 500 mg 1 $0 ULORIC TAB 40MG 2 $0 ST ULORIC TAB 80MG 2 $0 ST MISCELLANEOUS ACEPHEN SUP 120MG 3 $0 NM; * acephen sup 325mg 3 $0 NM; * acephen sup 650mg 3 $0 NM; * acetamin jr tab 160mg rt 3 $0 NM; * ACETAMINOPHE TAB 650MG 3 $0 NM; * acetaminophen soln 160 mg/5ml 3 $0 NM; * ADVIL JR ST TAB 100MG 3 $0 NM; * all day pain tab 220mg 3 $0 NM; * APAP 500 LIQ 500/5ML 3 $0 NM; * aspirin suppos 300 mg 3 $0 NM; * aspirin suppos 600 mg 3 $0 NM; * aspirin tab 81 mg 3 $0 NM; * aspirin tab 325 mg 3 $0 NM; * aspirin tab delayed release 325 mg 3 $0 NM; * aspirin tab delayed release 500 mg 3 $0 NM; * aspirin tab delayed release 650 mg 3 $0 NM; * child apap tab 80mg 3 $0 NM; * ed-apap liq 80mg/2.5 3 $0 NM; * FEBROL SOL 325/5ML 3 $0 NM; * FEVERALL INF SUP 80MG 3 $0 NM; * 8 hour pain tab 650mg 3 $0 NM; * ibuprofen cap 200 mg 3 $0 NM; * ibuprofen dro 50/1.25 3 $0 NM; * ibuprofen jr chw 100mg 3 $0 NM; * ibuprofen sus 100/5ml 3 $0 NM; * motrin ib tab 200mg 3 $0 NM; * NAPROXEN SODIUM CAP 220 MG 3 $0 NM; * non-asa jr tab 160mg 3 $0 NM; * * - Non-Part D s, or OTC items that are covered by Medicaid 1
Name non-aspirin chw 80mg 3 $0 NM; * pain relief dro 80/0.8ml 3 $0 NM; * pain relief liq 500/15ml 3 $0 NM; * pain relief sus 160/5ml 3 $0 NM; * pain relief tab 500mg 3 $0 NM; * pain relievr tab 325mg 3 $0 NM; * q-pap infant dro 80/0.8ml 3 $0 NM; * tri-buff asa tab 325mg 3 $0 NM; * TRIAMINIC SYP INFANT 3 $0 NM; * NSAIDS - DRUGS TO TREAT PAIN AND INFLAMMATION celecoxib cap 50 mg 1 $0 QL (60 caps / 30 celecoxib cap 100 mg 1 $0 QL (60 caps / 30 celecoxib cap 200 mg 1 $0 QL (60 caps / 30 celecoxib cap 400 mg 1 $0 QL (60 caps / 30 diclofenac potassium tab 50 mg 1 $0 diclofenac sodium tab delayed 1 $0 release 25 mg diclofenac sodium tab delayed 1 $0 release 50 mg diclofenac sodium tab delayed 1 $0 release 75 mg diclofenac sodium tab sr 24hr 100 1 $0 mg diflunisal tab 500 mg 1 $0 etodolac cap 200 mg 1 $0 etodolac cap 300 mg 1 $0 etodolac tab 400 mg 1 $0 etodolac tab 500 mg 1 $0 etodolac tab sr 24hr 400 mg 1 $0 etodolac tab sr 24hr 500 mg 1 $0 etodolac tab sr 24hr 600 mg 1 $0 flurbiprofen tab 50 mg 1 $0 flurbiprofen tab 100 mg 1 $0 ibuprofen susp 100 mg/5ml 1 $0 ibuprofen tab 400 mg 1 $0 ibuprofen tab 600 mg 1 $0 ibuprofen tab 800 mg 1 $0 ketoprofen cap 50 mg 1 $0 ketoprofen cap 75 mg 1 $0 MELOXICAM SUSP 7.5 MG/5ML 1 $0 meloxicam tab 7.5 mg 1 $0 meloxicam tab 15 mg 1 $0 nabumetone tab 500 mg 1 $0 2 * - Non-Part D s, or OTC items that are covered by Medicaid
Name nabumetone tab 750 mg 1 $0 naproxen dr tab 375mg 1 $0 naproxen dr tab 500mg 1 $0 naproxen sodium tab 275 mg 1 $0 naproxen sodium tab 550 mg 1 $0 naproxen susp 125 mg/5ml 1 $0 naproxen tab 250 mg 1 $0 naproxen tab 375 mg 1 $0 naproxen tab 500 mg 1 $0 piroxicam cap 10 mg 1 $0 piroxicam cap 20 mg 1 $0 sulindac tab 150 mg 1 $0 sulindac tab 200 mg 1 $0 OPIOID ANALGESICS - DRUGS TO TREAT PAIN acetaminophen w/ codeine soln 120-12 mg/5ml 1 $0 QL (5000 ml / 30 acetaminophen w/ codeine tab 300-15 mg 1 $0 QL (400 tabs / 30 acetaminophen w/ codeine tab 300-30 mg 1 $0 QL (400 tabs / 30 acetaminophen w/ codeine tab 300-60 mg 1 $0 QL (400 tabs / 30 butorphanol tartrate inj 1 mg/ml 1 $0 butorphanol tartrate inj 2 mg/ml 1 $0 nalbuphine hcl inj 10 mg/ml 1 $0 nalbuphine hcl inj 20 mg/ml 1 $0 tramadol hcl tab 50 mg 1 $0 QL (240 tabs / 30 tramadol-acetaminophen tab 37.5-325 mg 1 $0 QL (240 tabs / 30 OPIOID ANALGESICS, CII - DRUGS TO TREAT PAIN DURAMORPH INJ 0.5MG/ML 1 $0 B/D DURAMORPH INJ 1MG/ML 1 $0 B/D endocet tab 5-325mg 1 $0 QL (360 tabs / 30 endocet tab 7.5-325 1 $0 QL (360 tabs / 30 endocet tab 10-325mg 1 $0 QL (360 tabs / 30 fentanyl citrate lozenge on a handle 200 mcg 2 $0 QL (120 lozenges / 30, PA fentanyl citrate lozenge on a handle 400 mcg 2 $0 QL (120 lozenges / 30, PA * - Non-Part D s, or OTC items that are covered by Medicaid 3
Name fentanyl citrate lozenge on a handle 600 mcg 2 $0 QL (120 lozenges / 30, PA fentanyl citrate lozenge on a handle 800 mcg 2 $0 QL (120 lozenges / 30, PA fentanyl citrate lozenge on a handle 1200 mcg 2 $0 QL (120 lozenges / 30, PA fentanyl citrate lozenge on a handle 1600 mcg 2 $0 QL (120 lozenges / 30, PA fentanyl td patch 72hr 12 mcg/hr 1 $0 QL (10 patches / 30 fentanyl td patch 72hr 25 mcg/hr 1 $0 QL (10 patches / 30 fentanyl td patch 72hr 50 mcg/hr 1 $0 QL (10 patches / 30, PA fentanyl td patch 72hr 75 mcg/hr 1 $0 QL (10 patches / 30, PA fentanyl td patch 72hr 100 mcg/hr 1 $0 QL (10 patches / 30, PA FENTORA TAB 100MCG 2 $0 QL (120 tabs / 30, PA FENTORA TAB 200MCG 2 $0 QL (120 tabs / 30, PA FENTORA TAB 400MCG 2 $0 QL (120 tabs / 30, PA FENTORA TAB 600MCG 2 $0 QL (120 tabs / 30, PA FENTORA TAB 800MCG 2 $0 QL (120 tabs / 30, PA hydrocodone-acetaminophen soln 7.5-325 mg/15ml 1 $0 QL (5400 ml / 30 hydrocodone-acetaminophen tab 5-325 mg 1 $0 QL (360 tabs / 30 hydrocodone-acetaminophen tab 7.5-325 mg 1 $0 QL (360 tabs / 30 hydrocodone-acetaminophen tab 10-325 mg 1 $0 QL (360 tabs / 30 hydrocodone-ibuprofen tab 7.5-200 mg 1 $0 QL (150 tabs / 30 hydromorphone hcl liqd 1 mg/ml 1 $0 hydromorphone hcl preservative 1 $0 B/D free (pf) inj 10 mg/ml hydromorphone hcl tab 2 mg 1 $0 QL (270 tabs / 30 hydromorphone hcl tab 4 mg 1 $0 QL (270 tabs / 30 * - Non-Part D s, or OTC items that are covered by Medicaid 4
Name hydromorphone hcl tab 8 mg 1 $0 QL (270 tabs / 30 methadone con 10mg/ml 1 $0 QL (120 ml / 30 methadone hcl soln 5 mg/5ml 1 $0 QL (600 ml / 30 methadone hcl soln 10 mg/5ml 1 $0 QL (600 ml / 30 methadone hcl tab 5 mg 1 $0 QL (240 tabs / 30 methadone hcl tab 10 mg 1 $0 QL (240 tabs / 30 MORPHINE SUL INJ 2MG/ML 1 $0 B/D MORPHINE SUL INJ 4MG/ML 1 $0 B/D MORPHINE SUL INJ 8MG/ML 1 $0 B/D MORPHINE SULFATE (CONCENTRATE) ORAL SOLN 20 MG/ML 1 $0 morphine sulfate beads cap sr 24hr 1 $0 QL (60 caps / 30 30 mg morphine sulfate beads cap sr 24hr 1 $0 QL (60 caps / 30 45 mg morphine sulfate beads cap sr 24hr 1 $0 QL (60 caps / 30 60 mg morphine sulfate beads cap sr 24hr 1 $0 QL (60 caps / 30 75 mg morphine sulfate beads cap sr 24hr 1 $0 QL (60 caps / 30 90 mg morphine sulfate beads cap sr 24hr 1 $0 QL (60 caps / 30 120 mg morphine sulfate cap sr 24hr 10 1 $0 QL (60 caps / 30 mg morphine sulfate cap sr 24hr 20 1 $0 QL (60 caps / 30 mg morphine sulfate cap sr 24hr 30 1 $0 QL (60 caps / 30 mg morphine sulfate cap sr 24hr 50 1 $0 QL (60 caps / 30 mg morphine sulfate cap sr 24hr 60 1 $0 QL (60 caps / 30 mg morphine sulfate cap sr 24hr 80 2 $0 QL (60 caps / 30 mg morphine sulfate cap sr 24hr 100 mg 2 $0 QL (60 caps / 30 morphine sulfate inj pf 0.5 mg/ml 1 $0 B/D morphine sulfate inj pf 1 mg/ml 1 $0 B/D * - Non-Part D s, or OTC items that are covered by Medicaid 5
Name MORPHINE SULFATE IV SOLN 1 1 $0 B/D MG/ML MORPHINE SULFATE IV SOLN PF 1 $0 B/D 10 MG/ML MORPHINE SULFATE IV SOLN PF 1 $0 B/D 15 MG/ML MORPHINE SULFATE ORAL SOLN 1 $0 10 MG/5ML MORPHINE SULFATE ORAL SOLN 1 $0 20 MG/5ML MORPHINE SULFATE TAB 15 MG 1 $0 QL (180 tabs / 30 MORPHINE SULFATE TAB 30 MG 1 $0 QL (180 tabs / 30 morphine sulfate tab cr 15 mg 1 $0 QL (90 tabs / 30 morphine sulfate tab cr 30 mg 1 $0 QL (90 tabs / 30 morphine sulfate tab cr 60 mg 1 $0 QL (90 tabs / 30 morphine sulfate tab cr 100 mg 1 $0 QL (90 tabs / 30 morphine sulfate tab cr 200 mg 1 $0 QL (60 tabs / 30 oxycodone hcl cap 5 mg 1 $0 QL (180 caps / 30 oxycodone hcl conc 100 mg/5ml (20 mg/ml) 1 $0 OXYCODONE HCL SOLN 5 MG/5ML 1 $0 oxycodone hcl tab 5 mg 1 $0 QL (180 tabs / 30 oxycodone hcl tab 10 mg 1 $0 QL (180 tabs / 30 oxycodone hcl tab 15 mg 1 $0 QL (180 tabs / 30 oxycodone hcl tab 20 mg 1 $0 QL (180 tabs / 30 oxycodone hcl tab 30 mg 1 $0 QL (180 tabs / 30 oxycodone w/ acetaminophen tab 2.5-325 mg 1 $0 QL (360 tabs / 30 oxycodone w/ acetaminophen tab 5-325 mg 1 $0 QL (360 tabs / 30 oxycodone w/ acetaminophen tab 7.5-325 mg 1 $0 QL (360 tabs / 30 oxycodone w/ acetaminophen tab 10-325 mg 1 $0 QL (360 tabs / 30 roxicet sol 5-325/5 2 $0 QL (1800 ml / 30 * - Non-Part D s, or OTC items that are covered by Medicaid 6
Name ANESTHETICS - DRUGS FOR NUMBING LOCAL ANESTHETICS lidocaine hcl local inj 0.5% 1 $0 B/D lidocaine hcl local inj 1% 1 $0 B/D lidocaine hcl local inj 1.5% 1 $0 B/D lidocaine hcl local inj 2% 1 $0 B/D lidocaine hcl local preservative free 1 $0 B/D (pf) inj 0.5% lidocaine hcl local preservative free 1 $0 B/D (pf) inj 1% ANTI-INFECTIVES - DRUGS TO TREAT INFECTIONS ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate inj 1 gm/4ml (250 1 $0 mg/ml) amikacin sulfate inj 500 mg/2ml 1 $0 (250 mg/ml) gentam/nacl inj 0.9mg/ml 1 $0 gentam/nacl inj 1.4mg/ml 1 $0 gentamicin in saline inj 0.8 mg/ml 1 $0 gentamicin in saline inj 1 mg/ml 1 $0 gentamicin in saline inj 1.2 mg/ml 1 $0 gentamicin in saline inj 1.6 mg/ml 1 $0 gentamicin in saline inj 2 mg/ml 1 $0 gentamicin sulfate inj 10 mg/ml 1 $0 gentamicin sulfate inj 40 mg/ml 1 $0 gentamicin sulfate iv soln 10 1 $0 mg/ml neomycin sulfate tab 500 mg 1 $0 paromomycin sulfate cap 250 mg 1 $0 streptomycin sulfate for inj 1 gm 1 $0 sulfadiazine tab 500mg 2 $0 tobra/nacl inj 80/0.9 2 $0 tobramycin nebu soln 300 mg/5ml 2 $0 B/D, NM tobramycin sulfate for inj 1.2 gm 1 $0 tobramycin sulfate inj 1.2 gm/30ml 1 $0 (40 mg/ml) tobramycin sulfate inj 2 gm/50ml 1 $0 (40 mg/ml) tobramycin sulfate inj 10 mg/ml 1 $0 tobramycin sulfate inj 80 mg/2ml 1 $0 (40 mg/ml) ANTI-INFECTIVES - MISCELLANEOUS ALBENZA TAB 200MG 2 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 7
Name ALINIA SUS 100/5ML 2 $0 ALINIA TAB 500MG 2 $0 atovaquone susp 750 mg/5ml 2 $0 AZACTAM/DEX INJ 1GM 2 $0 AZACTAM/DEX INJ 2GM 2 $0 aztreonam for inj 1 gm 1 $0 aztreonam for inj 2 gm 1 $0 BILTRICIDE TAB 600MG 2 $0 CAYSTON INH 75MG 2 $0 NM, LA, PA clindamycin hcl cap 75 mg 1 $0 clindamycin hcl cap 150 mg 1 $0 clindamycin hcl cap 300 mg 1 $0 clindamycin palmitate hcl for soln 1 $0 75 mg/5ml (base equiv) clindamycin phosphate in d5w iv 1 $0 soln 300 mg/50ml clindamycin phosphate in d5w iv 1 $0 soln 600 mg/50ml clindamycin phosphate in d5w iv 1 $0 soln 900 mg/50ml clindamycin phosphate inj 9 1 $0 gm/60ml clindamycin phosphate inj 300 1 $0 mg/2ml clindamycin phosphate inj 600 1 $0 mg/4ml clindamycin phosphate inj 900 mg/6ml 1 $0 clindamycin phosphate iv soln 300 1 $0 mg/2ml clindamycin phosphate iv soln 600 1 $0 mg/4ml clindamycin phosphate iv soln 900 1 $0 mg/6ml colistimethate sodium for inj 150 1 $0 mg CUBICIN SOL 500MG 2 $0 dapsone tab 25 mg 1 $0 dapsone tab 100 mg 1 $0 DARAPRIM TAB 25MG 2 $0 imipenem-cilastatin intravenous for 1 $0 soln 250 mg imipenem-cilastatin intravenous for 1 $0 soln 500 mg * - Non-Part D s, or OTC items that are covered by Medicaid 8
Name INVANZ INJ 1GM 2 $0 ivermectin tab 3 mg 1 $0 linezolid iv soln 2 mg/ml 2 $0 LINEZOLID TAB 600 MG 2 $0 meropenem iv for soln 1 gm 1 $0 meropenem iv for soln 500 mg 1 $0 methenamine hippurate tab 1 gm 1 $0 metronidazole in nacl 0.79% iv 1 $0 soln 500 mg/100ml metronidazole tab 250 mg 1 $0 metronidazole tab 500 mg 1 $0 NEBUPENT INH 300MG 2 $0 B/D nitrofurantoin macrocrystalline cap 50 mg nitrofurantoin macrocrystalline cap 100 mg nitrofurantoin monohydrate macrocrystalline cap 100 mg PENTAM 300 INJ 300MG 2 $0 SIVEXTRO INJ 200MG 2 $0 SIVEXTRO TAB 200MG 2 $0 sulfamethoxazole-trimethoprim iv 1 $0 soln 400-80 mg/5ml sulfamethoxazole-trimethoprim susp 200-40 mg/5ml 1 $0 sulfamethoxazole-trimethoprim tab 1 $0 400-80 mg sulfamethoxazole-trimethoprim tab 1 $0 800-160 mg SYNERCID INJ 500MG 2 $0 trimethoprim tab 100 mg 1 $0 TYGACIL INJ 50MG 2 $0 vancomycin hcl cap 125 mg 2 $0 vancomycin hcl cap 250 mg 2 $0 vancomycin hcl for inj 10 gm 1 $0 vancomycin hcl for inj 500 mg 1 $0 vancomycin hcl for inj 1000 mg 1 $0 vancomycin hcl for inj 5000 mg 1 $0 vancomycin inj 750mg 1 $0 ZYVOX SUS 100MG/5M 2 $0 2 $0 PA; 90 day limit per calendar year if 65 years and older 2 $0 PA; 90 day limit per calendar year if 65 years and older 2 $0 PA; 90 day limit per calendar year if 65 years and older * - Non-Part D s, or OTC items that are covered by Medicaid 9
Name ZYVOX TAB 600MG 2 $0 ANTIFUNGALS - DRUGS TO TREAT FUNGAL INFECTIONS ABELCET INJ 5MG/ML 2 $0 B/D AMBISOME INJ 50MG 2 $0 B/D amphotericin b for inj 50 mg 1 $0 B/D CANCIDAS INJ 50MG 2 $0 CANCIDAS INJ 70MG 2 $0 fluconazole for susp 10 mg/ml 1 $0 fluconazole for susp 40 mg/ml 1 $0 fluconazole in dextrose inj 200 1 $0 mg/100ml fluconazole in dextrose inj 400 1 $0 mg/200ml fluconazole in nacl 0.9% inj 200 1 $0 mg/100ml fluconazole in nacl 0.9% inj 400 1 $0 mg/200ml fluconazole tab 50 mg 1 $0 fluconazole tab 100 mg 1 $0 fluconazole tab 150 mg 1 $0 fluconazole tab 200 mg 1 $0 flucytosine cap 250 mg 2 $0 flucytosine cap 500 mg 2 $0 griseofulvin microsize susp 125 mg/5ml 1 $0 griseofulvin microsize tab 500 mg 1 $0 griseofulvin ultramicrosize tab 125 1 $0 mg griseofulvin ultramicrosize tab 250 1 $0 mg itraconazole cap 100 mg 1 $0 PA ketoconazole tab 200 mg 1 $0 PA MYCAMINE INJ 50MG 2 $0 MYCAMINE INJ 100MG 2 $0 NOXAFIL SUS 40MG/ML 2 $0 NOXAFIL TAB 100MG 2 $0 nystatin tab 500000 unit 1 $0 terbinafine hcl tab 250 mg 1 $0 QL (90 tabs / 365 voriconazole for inj 200 mg 1 $0 voriconazole for susp 40 mg/ml 2 $0 voriconazole tab 50 mg 2 $0 voriconazole tab 200 mg 2 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 10
Name ANTIMALARIALS - DRUGS TO TREAT MALARIA atovaquone-proguanil hcl tab 62.5-1 $0 25 mg atovaquone-proguanil hcl tab 250-1 $0 100 mg chloroquine phosphate tab 250 mg 1 $0 chloroquine phosphate tab 500 mg 1 $0 COARTEM TAB 20-120MG 2 $0 mefloquine hcl tab 250 mg 1 $0 PRIMAQUINE TAB 26.3MG 2 $0 quinine sulfate cap 324 mg 1 $0 PA ANTIRETROVIRAL AGENTS - DRUGS TO SUPPRESS HIV/AIDS INFECTION abacavir sulfate tab 300 mg (base 1 $0 equiv) APTIVUS CAP 250MG 2 $0 APTIVUS SOL 2 $0 CRIXIVAN CAP 200MG 2 $0 CRIXIVAN CAP 400MG 2 $0 didanosine delayed release capsule 1 $0 125 mg didanosine delayed release capsule 1 $0 200 mg didanosine delayed release capsule 1 $0 250 mg didanosine delayed release capsule 1 $0 400 mg EDURANT TAB 25MG 2 $0 EMTRIVA CAP 200MG 2 $0 EMTRIVA SOL 10MG/ML 2 $0 FUZEON INJ 90MG 2 $0 NM INTELENCE TAB 25MG 2 $0 INTELENCE TAB 100MG 2 $0 INTELENCE TAB 200MG 2 $0 INVIRASE CAP 200MG 2 $0 INVIRASE TAB 500MG 2 $0 ISENTRESS CHW 25MG 2 $0 ISENTRESS CHW 100MG 2 $0 ISENTRESS POW 100MG 2 $0 ISENTRESS TAB 400MG 2 $0 lamivudine oral soln 10 mg/ml 1 $0 lamivudine tab 150 mg 1 $0 lamivudine tab 300 mg 1 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 11
Name LEXIVA SUS 50MG/ML 2 $0 LEXIVA TAB 700MG 2 $0 NEVIRAPINE SUSP 50 MG/5ML 1 $0 nevirapine tab 200 mg 1 $0 nevirapine tab sr 24hr 400 mg 1 $0 NORVIR CAP 100MG 2 $0 NORVIR SOL 80MG/ML 2 $0 NORVIR TAB 100MG 2 $0 PREZISTA SUS 100MG/ML 2 $0 PREZISTA TAB 75MG 2 $0 PREZISTA TAB 150MG 2 $0 PREZISTA TAB 600MG 2 $0 PREZISTA TAB 800MG 2 $0 RESCRIPTOR TAB 100 MG 2 $0 RESCRIPTOR TAB 200MG 2 $0 RETROVIR INJ 10MG/ML 2 $0 REYATAZ CAP 150MG 2 $0 REYATAZ CAP 200MG 2 $0 REYATAZ CAP 300MG 2 $0 REYATAZ POW 50MG 2 $0 SELZENTRY TAB 150MG 2 $0 SELZENTRY TAB 300MG 2 $0 stavudine cap 15 mg 1 $0 stavudine cap 20 mg 1 $0 stavudine cap 30 mg 1 $0 stavudine cap 40 mg 1 $0 stavudine for oral soln 1 mg/ml 1 $0 SUSTIVA CAP 50MG 2 $0 SUSTIVA CAP 200MG 2 $0 SUSTIVA TAB 600MG 2 $0 TIVICAY TAB 50MG 2 $0 TYBOST TAB 150MG 2 $0 VIDEX SOL 2GM 2 $0 VIDEX SOL 4GM 2 $0 VIRACEPT TAB 250MG 2 $0 VIRACEPT TAB 625MG 2 $0 VIRAMUNE XR TAB 100MG 2 $0 VIREAD POW 40MG/GM 2 $0 VIREAD TAB 150MG 2 $0 VIREAD TAB 200MG 2 $0 VIREAD TAB 250MG 2 $0 VIREAD TAB 300MG 2 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 12
Name VITEKTA TAB 85MG 2 $0 VITEKTA TAB 150MG 2 $0 ZIAGEN SOL 20MG/ML 2 $0 zidovudine cap 100 mg 1 $0 zidovudine syrup 10 mg/ml 1 $0 zidovudine tab 300 mg 1 $0 ANTIRETROVIRAL COMBINATION AGENTS - DRUGS TO SUPPRESS HIV/AIDS INFECTION abacavir sulfate-lamivudinezidovudine 2 $0 tab 300-150-300 mg ATRIPLA TAB 2 $0 COMPLERA TAB 2 $0 EPZICOM TAB 600-300 2 $0 EVOTAZ TAB 300-150 2 $0 KALETRA SOL 2 $0 KALETRA TAB 100-25MG 2 $0 KALETRA TAB 200-50MG 2 $0 lamivudine-zidovudine tab 150-3002 $0 mg PREZCOBIX TAB 800-150 2 $0 STRIBILD TAB 2 $0 TRIUMEQ TAB 2 $0 TRUVADA TAB 200-300 2 $0 QL (30 tabs / 30 ANTITUBERCULAR AGENTS - DRUGS TO TREAT TUBERCULOSIS CAPASTAT SUL INJ 1GM 2 $0 cycloserine cap 250 mg 2 $0 ethambutol hcl tab 100 mg 1 $0 ethambutol hcl tab 400 mg 1 $0 isoniazid inj 100 mg/ml 1 $0 isoniazid syrup 50 mg/5ml 1 $0 isoniazid tab 100 mg 1 $0 isoniazid tab 300 mg 1 $0 paser gra 4gm 2 $0 PRIFTIN TAB 150MG 2 $0 pyrazinamide tab 500 mg 1 $0 rifabutin cap 150 mg 1 $0 rifampin cap 150 mg 1 $0 rifampin cap 300 mg 1 $0 rifampin for inj 600 mg 1 $0 RIFATER TAB 2 $0 SIRTURO TAB 100MG 2 $0 LA, PA TRECATOR TAB 250MG 2 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 13
Name ANTIVIRALS - DRUGS TO TREAT VIRAL INFECTIONS acyclovir cap 200 mg 1 $0 acyclovir sodium for inj 500 mg 1 $0 B/D acyclovir sodium iv soln 50 mg/ml 1 $0 B/D acyclovir susp 200 mg/5ml 1 $0 acyclovir tab 400 mg 1 $0 acyclovir tab 800 mg 1 $0 adefovir dipivoxil tab 10 mg 2 $0 BARACLUDE SOL.05MG/ML 2 $0 entecavir tab 0.5 mg 2 $0 entecavir tab 1 mg 2 $0 EPIVIR HBV SOL 5MG/ML 2 $0 famciclovir tab 125 mg 1 $0 famciclovir tab 250 mg 1 $0 famciclovir tab 500 mg 1 $0 foscarnet sodium inj 24 mg/ml 1 $0 ganciclovir sodium for inj 500 mg 1 $0 B/D HARVONI TAB 90-400MG 2 $0 NM, PA lamivudine tab 100 mg (hbv) 1 $0 moderiba pak 600/day 2 $0 NM moderiba pak 800/day 2 $0 NM moderiba pak 1000/day 2 $0 NM MODERIBA PAK 1200/DAY 2 $0 NM PEG-INTRON KIT 50MCG 2 $0 NM, PA PEG-INTRON KIT 50MCG RP 2 $0 NM, PA PEG-INTRON KIT 80MCG RP 2 $0 NM, PA PEG-INTRON KIT 120 RP 2 $0 NM, PA PEG-INTRON KIT 150 RP 2 $0 NM, PA PEGINTRON KIT 80MCG 2 $0 NM, PA PEGINTRON KIT 120MCG 2 $0 NM, PA PEGINTRON KIT 150MCG 2 $0 NM, PA REBETOL SOL 40MG/ML 2 $0 NM RELENZA MIS DISKHALE 2 $0 ribapak pak 600/day 2 $0 NM ribapak pak 800/day 2 $0 NM ribapak pak 1000/day 2 $0 NM ribapak pak 1200/day 2 $0 NM ribasphere cap 200mg 1 $0 NM ribasphere tab 200mg 1 $0 NM ribasphere tab 400mg 1 $0 NM ribasphere tab 600mg 2 $0 NM ribavirin cap 200 mg 1 $0 NM * - Non-Part D s, or OTC items that are covered by Medicaid 14
Name ribavirin tab 200 mg 1 $0 NM rimantadine hydrochloride tab 100 1 $0 mg SOVALDI TAB 400MG 2 $0 NM, PA TAMIFLU CAP 30MG 2 $0 TAMIFLU CAP 45MG 2 $0 TAMIFLU CAP 75MG 2 $0 TAMIFLU SUS 6MG/ML 2 $0 TYZEKA TAB 600MG 2 $0 valacyclovir hcl tab 1 gm 1 $0 valacyclovir hcl tab 500 mg 1 $0 VALCYTE SOL 50MG/ML 2 $0 valganciclovir hcl tab 450 mg (base 2 $0 equivalent) CEPHALOSPORINS - DRUGS TO TREAT INFECTIONS cefaclor cap 250 mg 1 $0 cefaclor cap 500 mg 1 $0 cefaclor er tab 500mg 2 $0 cefaclor for susp 125 mg/5ml 1 $0 cefaclor for susp 250 mg/5ml 1 $0 cefaclor for susp 375 mg/5ml 1 $0 cefadroxil cap 500 mg 1 $0 cefadroxil for susp 250 mg/5ml 1 $0 cefadroxil for susp 500 mg/5ml 1 $0 cefadroxil tab 1 gm 1 $0 cefazolin inj 1gm/50ml 2 $0 cefazolin sodium for inj 1 gm 1 $0 cefazolin sodium for inj 10 gm 1 $0 cefazolin sodium for inj 20 gm 1 $0 cefazolin sodium for inj 500 mg 1 $0 cefazolin sodium for iv soln 1 gm 1 $0 cefdinir cap 300 mg 1 $0 cefdinir for susp 125 mg/5ml 1 $0 cefdinir for susp 250 mg/5ml 1 $0 cefepime hcl for inj 1 gm 1 $0 cefepime hcl for inj 2 gm 1 $0 cefixime for susp 100 mg/5ml 1 $0 cefixime for susp 200 mg/5ml 1 $0 cefotaxime sodium for inj 1 gm 1 $0 cefotaxime sodium for inj 2 gm 1 $0 cefotaxime sodium for inj 500 mg 1 $0 cefoxitin sodium for inj 10 gm 1 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 15
Name cefoxitin sodium for iv soln 1 gm 1 $0 cefoxitin sodium for iv soln 2 gm 1 $0 cefpodoxime proxetil for susp 50 mg/5ml 1 $0 cefpodoxime proxetil for susp 100 1 $0 mg/5ml cefpodoxime proxetil tab 100 mg 1 $0 cefpodoxime proxetil tab 200 mg 1 $0 cefprozil for susp 125 mg/5ml 1 $0 cefprozil for susp 250 mg/5ml 1 $0 cefprozil tab 250 mg 1 $0 cefprozil tab 500 mg 1 $0 ceftazidime for inj 1 gm 1 $0 ceftazidime for inj 2 gm 1 $0 ceftazidime for inj 6 gm 1 $0 CEFTAZIDIME/ SOL D5W 1GM 2 $0 CEFTAZIDIME/ SOL D5W 2GM 2 $0 ceftriaxone sodium for inj 1 gm 1 $0 ceftriaxone sodium for inj 2 gm 1 $0 ceftriaxone sodium for inj 10 gm 1 $0 ceftriaxone sodium for inj 250 mg 1 $0 ceftriaxone sodium for inj 500 mg 1 $0 ceftriaxone sodium for iv soln 1 gm 1 $0 ceftriaxone sodium for iv soln 2 gm 1 $0 cefuroxime axetil tab 250 mg 1 $0 cefuroxime axetil tab 500 mg 1 $0 cefuroxime inj 7.5gm 1 $0 cefuroxime sodium for inj 1.5 gm 1 $0 cefuroxime sodium for inj 7.5 gm 1 $0 cefuroxime sodium for inj 750 mg 1 $0 cefuroxime sodium for iv soln 1.5 1 $0 gm cephalexin cap 250 mg 1 $0 cephalexin cap 500 mg 1 $0 cephalexin for susp 125 mg/5ml 1 $0 cephalexin for susp 250 mg/5ml 1 $0 SUPRAX CAP 400MG 2 $0 suprax chw 100mg 2 $0 suprax chw 200mg 2 $0 SUPRAX SUS 500/5ML 2 $0 tazicef inj 1gm 1 $0 tazicef inj 2gm 1 $0 tazicef inj 6gm 1 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 16
Name TEFLARO INJ 400MG 2 $0 TEFLARO INJ 600MG 2 $0 ERYTHROMYCINS/MACROLIDES - DRUGS TO TREAT INFECTIONS azithromycin for susp 100 mg/5ml 1 $0 azithromycin for susp 200 mg/5ml 1 $0 azithromycin iv for soln 500 mg 1 $0 AZITHROMYCIN POWD PACK FOR 1 $0 SUSP 1 GM azithromycin tab 250 mg 1 $0 azithromycin tab 500 mg 1 $0 azithromycin tab 600 mg 1 $0 clarithromycin for susp 125 1 $0 mg/5ml clarithromycin for susp 250 1 $0 mg/5ml clarithromycin tab 250 mg 1 $0 clarithromycin tab 500 mg 1 $0 clarithromycin tab sr 24hr 500 mg 1 $0 DIFICID TAB 200MG 2 $0 e.e.s. 400 tab 400mg 1 $0 ery-tab tab 250mg ec 2 $0 ery-tab tab 333mg ec 2 $0 ery-tab tab 500mg ec 2 $0 erythrocin inj 500mg 2 $0 erythrocin tab 250mg 1 $0 erythromycin ethylsuccinate tab 1 $0 400 mg erythromycin tab 250 mg 1 $0 erythromycin tab 500 mg 1 $0 erythromycin w/ delayed release particles cap 250 mg 1 $0 FLUOROQUINOLONES - DRUGS TO TREAT INFECTIONS ciprofloxacin 200 mg/100ml in d5w 1 $0 ciprofloxacin 400 mg/200ml in d5w 1 $0 ciprofloxacin for oral susp 250 1 $0 mg/5ml (5%) (5 gm/100ml) ciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml) 1 $0 ciprofloxacin hcl tab 100 mg (base 1 $0 equiv) ciprofloxacin hcl tab 250 mg (base 1 $0 equiv) * - Non-Part D s, or OTC items that are covered by Medicaid 17
Name ciprofloxacin hcl tab 500 mg (base 1 $0 equiv) ciprofloxacin hcl tab 750 mg (base 1 $0 equiv) ciprofloxacin iv soln 200 mg/20ml 1 $0 (1%) ciprofloxacin iv soln 400 mg/40ml 1 $0 (1%) ciprofloxacin-ciprofloxacin hcl tab 1 $0 sr 24hr 500 mg (base eq) ciprofloxacin-ciprofloxacin hcl tab 1 $0 sr 24hr 1000 mg(base eq) levofloxacin in d5w iv soln 250 1 $0 mg/50ml levofloxacin in d5w iv soln 500 1 $0 mg/100ml levofloxacin in d5w iv soln 750 1 $0 mg/150ml levofloxacin iv soln 25 mg/ml 1 $0 levofloxacin oral soln 25 mg/ml 1 $0 levofloxacin tab 250 mg 1 $0 levofloxacin tab 500 mg 1 $0 levofloxacin tab 750 mg 1 $0 PENICILLINS - DRUGS TO TREAT INFECTIONS amoxicillin & k clavulanate chew 1 $0 tab 200-28.5 mg amoxicillin & k clavulanate chew tab 400-57 mg 1 $0 amoxicillin & k clavulanate for susp 1 $0 200-28.5 mg/5ml amoxicillin & k clavulanate for susp 1 $0 250-62.5 mg/5ml amoxicillin & k clavulanate for susp 1 $0 400-57 mg/5ml amoxicillin & k clavulanate for susp 1 $0 600-42.9 mg/5ml amoxicillin & k clavulanate tab 1 $0 250-125 mg amoxicillin & k clavulanate tab 1 $0 500-125 mg amoxicillin & k clavulanate tab 1 $0 875-125 mg amoxicillin & k clavulanate tab sr 12hr 1000-62.5 mg 1 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 18
Name amoxicillin (trihydrate) cap 250 mg 1 $0 amoxicillin (trihydrate) cap 500 mg 1 $0 amoxicillin (trihydrate) chew tab 1 $0 125 mg amoxicillin (trihydrate) chew tab 1 $0 250 mg amoxicillin (trihydrate) for susp 1 $0 125 mg/5ml amoxicillin (trihydrate) for susp 1 $0 200 mg/5ml amoxicillin (trihydrate) for susp 1 $0 250 mg/5ml amoxicillin (trihydrate) for susp 400 mg/5ml 1 $0 amoxicillin (trihydrate) tab 500 mg 1 $0 amoxicillin (trihydrate) tab 875 mg 1 $0 ampicillin & sulbactam sodium for 1 $0 inj 1-0.5 gm ampicillin & sulbactam sodium for 1 $0 inj 2-1 gm ampicillin & sulbactam sodium for 1 $0 inj 10-5 gm ampicillin & sulbactam sodium for 1 $0 iv soln 1-0.5 gm ampicillin & sulbactam sodium for 1 $0 iv soln 2-1 gm ampicillin & sulbactam sodium for 1 $0 iv soln 10-5 gm ampicillin cap 250 mg 1 $0 ampicillin cap 500 mg 1 $0 ampicillin for susp 125 mg/5ml 1 $0 ampicillin for susp 250 mg/5ml 1 $0 ampicillin sodium for inj 1 gm 1 $0 ampicillin sodium for inj 2 gm 1 $0 ampicillin sodium for inj 125 mg 1 $0 ampicillin sodium for inj 250 mg 1 $0 ampicillin sodium for inj 500 mg 1 $0 ampicillin sodium for iv soln 1 gm 1 $0 ampicillin sodium for iv soln 2 gm 1 $0 ampicillin sodium for iv soln 10 gm 1 $0 BICILLIN L-A INJ 600000 2 $0 BICILLIN L-A INJ 1200000 2 $0 BICILLIN L-A INJ 2400000 2 $0 dicloxacillin sodium cap 250 mg 1 $0 * - Non-Part D s, or OTC items that are covered by Medicaid 19
Name dicloxacillin sodium cap 500 mg 1 $0 nafcillin sodium for inj 1 gm 1 $0 nafcillin sodium for inj 2 gm 2 $0 nafcillin sodium for inj 10 gm 2 $0 nafcillin sodium for iv soln 1 gm 1 $0 nafcillin sodium for iv soln 2 gm 2 $0 oxacillin sodium for inj 1 gm 1 $0 oxacillin sodium for inj 2 gm 1 $0 oxacillin sodium for inj 10 gm 2 $0 pen g proc inj 600000 2 $0 PENICILL GK/ INJ DEX 2MU 2 $0 PENICILL GK/ INJ DEX 3MU 2 $0 penicillin g potassium for inj 1 $0 5000000 unit penicillin g potassium for inj 20000000 unit 1 $0 penicillin g sodium for inj 5000000 1 $0 unit penicillin v potassium for soln 125 1 $0 mg/5ml penicillin v potassium for soln 250 1 $0 mg/5ml penicillin v potassium tab 250 mg 1 $0 penicillin v potassium tab 500 mg 1 $0 piperacillin sodium-tazobactam 1 $0 sodium for inj 2-0.25 gm piperacillin sodium-tazobactam 1 $0 sodium for inj 3-0.375 gm piperacillin sodium-tazobactam 1 $0 sodium for inj 4-0.5 gm piperacillin sodium-tazobactam sodium for inj 36-4.5 gm 1 $0 TETRACYCLINES - DRUGS TO TREAT INFECTIONS doxy 100 inj 100mg 1 $0 doxycycline hyclate cap 50 mg 1 $0 doxycycline hyclate cap 100 mg 1 $0 doxycycline hyclate for inj 100 mg 1 $0 doxycycline hyclate tab 20 mg 1 $0 doxycycline hyclate tab 100 mg 1 $0 doxycycline monohydrate cap 50 mg 1 $0 doxycycline monohydrate cap 100 1 $0 mg * - Non-Part D s, or OTC items that are covered by Medicaid 20
Name doxycycline monohydrate tab 50 1 $0 mg doxycycline monohydrate tab 75 1 $0 mg doxycycline monohydrate tab 100 1 $0 mg doxycycline monohydrate tab 150 1 $0 mg minocycline hcl cap 50 mg 1 $0 minocycline hcl cap 75 mg 1 $0 minocycline hcl cap 100 mg 1 $0 ANTINEOPLASTIC AGENTS - DRUGS TO TREAT CANCER ALKYLATING AGENTS BICNU INJ 100MG 2 $0 B/D BUSULFEX INJ 6MG/ML 2 $0 B/D CYCLOPHOSPH CAP 25MG 2 $0 B/D CYCLOPHOSPH CAP 50MG 2 $0 B/D cyclophosphamide for inj 1 gm 2 $0 B/D cyclophosphamide for inj 2 gm 1 $0 B/D cyclophosphamide for inj 500 mg 2 $0 B/D dacarbazine for inj 200 mg 1 $0 B/D EMCYT CAP 140MG 2 $0 HEXALEN CAP 50MG 2 $0 IFEX INJ 3GM 2 $0 B/D ifosfamide for inj 1 gm 1 $0 B/D IFOSFAMIDE INJ 3GM 2 $0 B/D ifosfamide iv inj 1 gm/20ml (50 1 $0 B/D mg/ml) ifosfamide iv inj 3 gm/60ml (50 1 $0 B/D mg/ml) LEUKERAN TAB 2MG 2 $0 LOMUSTINE CAP 10 MG 1 $0 LOMUSTINE CAP 40 MG 1 $0 LOMUSTINE CAP 100 MG 1 $0 melphalan hcl for inj 50 mg (base 2 $0 B/D equiv) MUSTARGEN INJ 10MG 2 $0 B/D TREANDA INJ 25MG 2 $0 B/D, NM TREANDA INJ 45/0.5ML 2 $0 B/D, NM TREANDA INJ 100MG 2 $0 B/D, NM TREANDA INJ 180/2ML 2 $0 B/D, NM ANTHRACYCLINES * - Non-Part D s, or OTC items that are covered by Medicaid 21
Name daunorubicin hcl inj 5 mg/ml (base 1 $0 B/D equiv) doxorubicin hcl for inj 50 mg 1 $0 B/D doxorubicin hcl inj 2 mg/ml 1 $0 B/D doxorubicin hcl liposomal inj (for iv 2 $0 B/D infusion) 2 mg/ml epirubicin hcl iv soln 50 mg/25ml 1 $0 B/D (2 mg/ml) epirubicin hcl iv soln 200 1 $0 B/D mg/100ml (2 mg/ml) idarubicin hcl iv inj 5 mg/5ml (1 mg/ml) 2 $0 B/D idarubicin hcl iv inj 10 mg/10ml (1 2 $0 B/D mg/ml) idarubicin hcl iv inj 20 mg/20ml (1 2 $0 B/D mg/ml) ANTIBIOTICS bleomycin sulfate for inj 15 unit 1 $0 B/D bleomycin sulfate for inj 30 unit 1 $0 B/D mitomycin for iv soln 5 mg 1 $0 B/D mitomycin for iv soln 20 mg 1 $0 B/D mitomycin for iv soln 40 mg 1 $0 B/D ANTIMETABOLITES adrucil inj 2.5g/50m 1 $0 B/D adrucil inj 5gm/100m 1 $0 B/D adrucil inj 500/10ml 1 $0 B/D ALIMTA INJ 100MG 2 $0 B/D ALIMTA INJ 500MG 2 $0 B/D azacitidine for inj 100 mg 2 $0 B/D, NM cladribine inj 1 mg/ml 2 $0 B/D cytarabine inj 20 mg/ml 1 $0 B/D fludarabine phosphate for inj 50 1 $0 B/D mg fludarabine phosphate inj 25 1 $0 B/D mg/ml fluorouracil inj 1 gm/20ml (50 1 $0 B/D mg/ml) fluorouracil inj 2.5 gm/50ml (50 1 $0 B/D mg/ml) fluorouracil inj 500 mg/10ml (50 1 $0 B/D mg/ml) gemcitabine hcl for inj 1 gm 2 $0 B/D gemcitabine hcl for inj 2 gm 2 $0 B/D * - Non-Part D s, or OTC items that are covered by Medicaid 22
Name gemcitabine hcl for inj 200 mg 2 $0 B/D GEMCITABINE INJ 1GM 2 $0 B/D GEMCITABINE INJ 2GM 2 $0 B/D GEMCITABINE INJ 200MG 2 $0 B/D mercaptopurine tab 50 mg 1 $0 methotrexate sodium for inj 1 gm 1 $0 B/D methotrexate sodium inj 25 mg/ml 1 $0 B/D methotrexate sodium inj pf 25 1 $0 B/D mg/ml NIPENT INJ 10MG 2 $0 B/D PURIXAN SUS 20MG/ML 2 $0 TABLOID TAB 40MG 2 $0 ANTIMITOTIC, TAXOIDS ABRAXANE INJ 100MG 2 $0 B/D DOCETAXEL FOR INJ CONC 20 2 $0 B/D MG/ML DOCETAXEL FOR INJ CONC 80 2 $0 B/D MG/4ML (20 MG/ML) DOCETAXEL INJ 80MG/8ML 2 $0 B/D docetaxel inj 140/7ml 2 $0 B/D DOCETAXEL INJ 200MG/20 2 $0 B/D paclitaxel iv conc 30 mg/5ml (6 1 $0 B/D mg/ml) paclitaxel iv conc 100 mg/16.7ml (6 mg/ml) 1 $0 B/D paclitaxel iv conc 150 mg/25ml (6 1 $0 B/D mg/ml) paclitaxel iv conc 300 mg/50ml (6 1 $0 B/D mg/ml) ANTIMITOTIC, VINCA ALKALOIDS vinblastine sulfate inj 1 mg/ml 2 $0 B/D vincasar pfs inj 1mg/ml 1 $0 B/D vincristine sulfate iv soln 1 mg/ml 1 $0 B/D vinorelbine tartrate inj 10 mg/ml (base equiv) 1 $0 B/D vinorelbine tartrate inj 50 mg/5ml 1 $0 B/D (10 mg/ml) (base equiv) BIOLOGIC RESPONSE MODIFIERS AVASTIN INJ 2 $0 B/D, NM, LA AVASTIN INJ 400/16ML 2 $0 B/D, NM, LA BELEODAQ INJ 500MG 2 $0 NM, PA ERIVEDGE CAP 150MG 2 $0 NM, LA, PA FARYDAK CAP 10MG 2 $0 NM, LA, PA * - Non-Part D s, or OTC items that are covered by Medicaid 23