Formulary Comprehensive. (Complete list of covered drugs) AARP MedicareRx Saver Plus (PDP) Inside

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1 01 Comprehensive Formulary (Complete list of covered drugs) AARP MedicareRx Saver Plus (PDP) Inside tiers and drug payment stages and limits Complete list of drugs by category Index of covered drugs Please read: This document contains information about the drugs covered by this plan. Note to existing members: This complete formulary has changed since last year. Please review this document to make sure it still contains the drugs you take , 8 Y0066_9818_000_Final_P0 CMS Approved

2 About this complete drug list This is a complete list of prescription drugs that are covered by the AARP MedicareRx Saver Plus (PDP) plan, insured through UnitedHealthcare, for the 01 plan year. It is called the Comprehensive Formulary (drug list) and includes all of the drugs covered by the plan. For your drug to be covered by the plan, it must be included in the complete drug list. In most cases, your prescription must also be filled at one of our more than 65,000 network pharmacies. To find out if your drug is covered: 1. See if your drug is included in this complete drug list.. Visit the plan website at You can use online tools to look up your drugs. The information is updated on a regular basis.. Call UnitedHealthcare Customer Service at , TTY 711, 8 a.m. to 8 p.m. local time, 7 days a week. UnitedHealthcare Customer Service can look up your drugs and let you know if they are covered. For more information Please take the time to review your Evidence of Coverage and any other 01 plan materials you have received. These materials give more detailed information about your drug coverage in the plan. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ), hours a day, 7 days a week. TTY/TDD users should call Or visit Questions? If you have questions, we re here to help. Call UnitedHealthcare Customer Service at , TTY a.m. to 8 p.m. local time, 7 days a week Or visit Online tools Visit to Look up your drugs and see what you could save with lower-cost drugs View your cost and benefits summary Track your payment status and claims history Find network pharmacies Print plan forms and materials If you are a member of a group sponsored plan (your coverage is provided through a former employer, union group or trust), please call the UnitedHealthcare Customer Service number on the back of your member ID card.

3 01 Complete drug list The AARP MedicareRx Saver Plus plan is designed to help you manage your prescription drug costs. An important part of this is giving you choices so you and your doctor can choose the best course of treatment for you. A formulary is a list of the drugs covered by a Part D plan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. The plan will generally cover the drugs listed in the formulary as long as the drug is medically necessary, the prescription is filled at a plan network pharmacy and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. With your doctor s help, you can use this drug list as a tool to choose the drugs that work best for you and to find lower-cost drugs, if needed. Using the drug list There are two ways to find your prescription drugs in this complete drug list: 1. Alphabetical list (index): Turn to the Index of covered drugs section, which begins on page 6, to see the list of drug names in alphabetical order.. Medical condition: Turn to the Covered drugs by category section, which begins on page 8, to look for drug names based on your medical conditions. For example, if you want to find drugs used to treat high cholesterol, go to the Cardiovascular s category and look under Cholesterol Control s. Is it a generic or brand name drug? The drug list shows brand name drugs in bold type (for example, Crestor) and generic drugs in plain type (for example, Simvastatin). More information about your drug Some drugs have requirements or limits. Please see the and limits section on page for more information on drugs you may use. This document is a complete list of covered drugs. If your drug is not included in this drug list, you should contact UnitedHealthcare Customer Service to ask if it s covered, or go to to look it up online. If you learn that the plan does not cover your drug, you have two options: 1. You can ask UnitedHealthcare Customer Service for a list of similar drugs that are covered by the plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by the plan.. You can ask the plan to make an exception and cover your drug. See the Coverage decisions section on page 5 for information about how to request an exception. 1

4 tiers and drug payment stages The amount you pay for a covered drug will depend on: Your drug payment stage. The plan has different stages of drug coverage. When you fill a prescription, the amount you pay depends on the stage you re in. The drug tier for your drug. Each covered drug is in one of five drug tiers. Each tier has a different copay or coinsurance amount. The chart below shows the differences between the tiers. For more information about drug payment stages and copay or coinsurance amounts for each tier, please refer to the plan s Evidence of Coverage (EOC). If you qualify for extra help If you qualify for extra help for your prescription drugs, your copays and coinsurance may be lower. Members who qualify for extra help will receive the Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription s (LIS Rider). Please read it to find out what your costs are. You can also contact UnitedHealthcare Customer Service. Copay or Coinsurance 1: Preferred generic Lowest copay : Non-preferred generic Low copay : Preferred brand Medium copay : Non-preferred brand Highest copay 5: Specialty tier Coinsurance Includes Lower-cost, commonly used generic drugs. Most generic drugs. Many common brand name drugs, called preferred brands, and some higher cost generic drugs. Non preferred generic and non-preferred brand name drugs. Unique and/or very high cost drugs. Helpful Tips Use 1 drugs for the lowest out of-pocket costs. Use drugs, instead of or, to help reduce your out-of-pocket costs. Many drugs have lower cost options in 1 or. Ask your doctor if they could work for you. Many drugs have lower-cost options in 1, or. Ask your doctor if you can switch to one of these drugs to help reduce your out of-pocket costs. You pay a percentage of the total drug cost, called coinsurance.

5 Generic drugs The plan covers both brand name and generic drugs. The Food and Administration (FDA) requires a generic drug to have the same active ingredient as the brand name drug. Using generic drugs, whether preferred or non-preferred, may save you money on your copays or coinsurance and may help you stay out of the coverage gap if you have one. To pay less out of pocket, talk with your doctor to see if any of the brand name drugs you take have generic versions. While most generics are in of the drug list, some generics can be found in 1. While generic drugs usually cost less than brand name drugs, newly available generic drugs can be expensive so they may be in, or of the drug list. Vaccines The plan covers a number of Part D vaccines. Our coverage may include the cost of both the vaccine medication and the administration of the vaccine shot. Some vaccines, like those for the flu and pneumonia, may be covered by Medicare Part B (doctor and outpatient health care). For the best coverage, the plan recommends that you get vaccines at a network pharmacy if your state allows it. The administration fee likely will be lower at a network pharmacy than at your doctor s office. You also won t have to fill out a form to get paid back (reimbursed). If the administration fee is less than $0, you will pay only your copay or coinsurance amount. If it is more than $0, you will pay the extra amount. If you get your vaccines at your doctor s office, you will pay the entire cost of the vaccine and administration fee to your doctor. You will have to submit a form to the plan to get reimbursed. You will pay your copay or coinsurance amount, plus the difference between $0 and the administration fee charged by your doctor. Please see your Evidence of Coverage for more information about vaccines and their costs. To make sure a recommended vaccine is covered or to request a reimbursement form, call UnitedHealthcare Customer Service at , TTY 711. Or visit to download a reimbursement form.

6 and limits Some of the plan s drugs have requirements or limits to help ensure safe, effective and affordable use. If your drug has any requirements or limits, there will be a code(s) in the & Limits column of the drug list starting on page 8. The codes and what they mean are shown below. Visit for more information. You and your doctor may ask the plan for an exception to the requirement and/or limit for your drug. See the Coverage decisions section on the next page or see your Evidence of Coverage to learn more. If you do not get prior approval from the plan for a drug with a requirement or limit, you may be responsible for paying the full cost of the drug. B/D LA PA ST Medicare Part B or Part D Depending on how this drug is used, it may be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide the plan with more information about how this drug will be used to make sure it s correctly covered by Medicare. Limited access s are considered limited access if the FDA says the drug can be given out only by certain facilities or doctors. These drugs may require extra handling, provider coordination or patient education that can t be done at a network pharmacy. Prior authorization The plan requires you or your doctor to get prior authorization for certain drugs. This means the plan needs more information from your doctor to make sure the drug is being used correctly for a medical condition covered by Medicare. If you don t get approval, the plan may not cover the drug. Step therapy There are effective, lower-cost drugs that treat the same medical condition as this drug. You may be required to try one or more of these other drugs before the plan will cover your drug. If you have already tried other drugs or your doctor thinks they are not right for you, you or your doctor can ask the plan to cover this drug. For more information about requirements and limits, call UnitedHealthcare Customer Service at , TTY 711.

7 Coverage decisions At times you may need to ask for drug coverage that s not normally provided by the plan. When you do, the plan will consider your request and respond with a coverage decision (coverage determination). Examples of coverage decisions you may ask for include: Asking the plan to pay you back for the cost of a drug you bought at an out of network pharmacy. Asking for an exception to the plan s coverage rules. How to request an exception You can ask the plan to make an exception to the coverage rules. There are several types of exceptions that you can ask the plan to make. You can ask the plan to cover your drug even if it is not on the formulary (formulary exception). You can ask the plan to waive coverage restrictions or limits on your drug (utilization exception). For example, for certain drugs, the plan limits the amount of the drug that it will cover. You can ask the plan to provide a higher level of coverage for your drug (tier exception). If your drug is in the non-preferred tier, you can ask the plan to cover it at the cost-sharing amount that applies to drugs in the preferred tier instead. This would lower the amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not in the plan s formulary, you may not ask us to provide a higher level of coverage for the drug. exceptions are not available for drugs in the specialty tier. Generally, the plan will only approve your request for an exception if the alternative drugs included in the plan s formulary, the lower-tiered drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. Asking for a coverage decision You (or your authorized representative) and your doctor can ask for an initial coverage decision by calling UnitedHealthcare Customer Service at , TTY 711. When you are requesting a formulary, tiering or utilization restriction exception, your prescriber or physician should submit a statement supporting your request. See your Evidence of Coverage for more information. Receiving a coverage decision Generally, the plan will make a coverage decision within 7 hours after receiving your prescribing physician s statement. You can request an expedited, or fast, decision if you or your doctor believe your health requires it. If the plan agrees to a fast decision, you will receive a decision within hours after the plan receives your prescriber s or prescribing physician s supporting statement. 5

8 list changes The plan recognizes that drug list stability is very important to you. That is why the plan tries to make as few changes to the drug list as possible during the plan year. From time to time, drug list changes may be necessary for safety or other reasons. The drug list may change throughout the year when the plan: Adds a new drug. Removes a drug. Changes the requirements or limits for a drug. Moves a drug to a lower-cost tier. Moves a drug to a higher-cost tier. If the FDA declares a drug to be unsafe or the drug s manufacturer removes the drug from the market, the plan will immediately remove the drug from the drug list and inform affected members. If a drug moves to a higher cost tier or undergoes some other change, the plan will inform affected members at least 60 days before the change or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. Generally, if you are taking a drug on the 01 drug list that was covered at the beginning of the year, the plan will not remove the drug from the drug list or move a drug to a higher tier during the 01 coverage year except when a new, less expensive generic equivalent drug becomes available (for example, the brand name drug moves to a higher tier and the less expensive drug is on the lower tier), or when new information about the safety or effectiveness of a drug is released. Other types of changes, such as removing a drug from the drug list, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. It is important that you have continued access for the remainder of the coverage year to the list of drugs that were available when you chose the plan, except for cases in which you can save additional money or your safety is a concern. If there are changes to the drug list such as regular or necessary updates, members may see information in the Explanation of Benefits statement, member newsletters or other member mailings. If there are changes to the drug list outside of regular or necessary updates, members may receive a special mailing. The plan website also has updated information. 6

9 Transition supply process New or continuing members As a new or continuing member in the plan, you may be taking drugs that are not on the formulary. Or you may be taking a drug that is on the formulary but your ability to get it is limited. For example, you may need prior authorization before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that the plan covers, or request a formulary exception so that the plan will cover the drug you take. While you talk to your doctor to determine the right course of action for you, the plan may cover your drug in certain cases during the first 90 days you are a member of the plan. For each of your drugs that is not on the formulary, or if your ability to get your drugs is limited, the plan will cover a temporary 1-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 1-day supply, the plan will not pay for these drugs, even if you have been a member of the plan less than 90 days. Long-term care facility residents If you re a resident of a long-term care facility, the plan will allow you to refill your prescription until we have provided you with a 91- and up to a 98-day transition supply of the drug consistent with dispensing increment (unless your prescription is for fewer days). The plan will also cover one or more refills for the first 90 days of your membership. If you need a drug that s not on the drug list or if you have limited ability to get your drugs but you are past the first 90 days of your plan membership, the plan will cover a 1-day emergency supply of the drug (unless your prescription is for fewer days) while you request a formulary exception. Other transitions You may have an unplanned transition, like a hospital discharge or a change in your level of care, after the first 90 days of your plan membership. If this happens and your doctor prescribes a drug that s not on the drug list, or if it s difficult for you to get your drugs, you are required to use the plan s exception process. You may ask for a one-time emergency supply of up to 1 days to give you time to talk to your doctor about other treatment options or to try to get a formulary exception. For more information For more detailed information about AARP MedicareRx Saver Plus prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions, please call UnitedHealthcare Customer Service at , TTY a.m. to 8 p.m. local time, 7 days a week Or visit If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ), hours a day, 7 days a week. TTY/TDD users should call Or visit 7

10 Covered drugs by category The comprehensive formulary (drug list) below provides coverage information about all of the drugs covered by the plan. It is current as of January 1, 01. The first column of the chart lists the drug name. Brand name drugs are listed in bold type (for example, Crestor) and generic drugs are listed in plain type (for example, Simvastatin). The information in the column tells you if the plan has any special requirements for coverage of your drug. If you have trouble finding your drug in the list, turn to the Index of covered drugs section that begins on page 6. If your prescription is not in this complete formulary, please visit or call UnitedHealthcare Customer Service at , TTY 711, for additional help. Name Name Analgesics s to Treat Pain, Inflammation, and Muscle and Joint Conditions Nonsteroidal Anti-Inflammatory s Pain/Anti-Inflammatory s Diclofenac Potassium Diclofenac Sodium DR Diclofenac Sodium ER Diflunisal Etodolac (00mg Capsule, Tablet) Flurbiprofen Ibuprofen (Suspension, 00mg Tablet, 600mg Tablet, 800mg Tablet) Indomethacin (Capsule) Ketoprofen Ketorolac Tromethamine (Tablet) Ketorolac Tromethamine (15mg/ml Injection, PA 0mg/ml Injection) Mefenamic Acid Meloxicam (Tablet) 1 Meloxicam (Suspension) Naproxen Naproxen DR Naproxen Sodium (75mg Tablet, 550mg Tablet) Oxycodone/Ibuprofen Sulindac Opioid Analgesics, Long-Acting Opioid Pain Relievers Astramorph Duramorph Exalgo Fentanyl (Patch) Levorphanol Tartrate Bold type = Brand name drug B/D = Medicare Part B or Part D PA = Prior authorization ST = Step therapy LA = Limited access drug 8

11 Name Name Methadone HCl (Concentrate, Oral Solution, Tablet) Methadone HCl (Injection) Methadose (Tablet) Morphine Sulfate (Oral Solution, Tablet) Morphine Sulfate ER Nucynta ER Opioid Analgesics, Short-Acting Opioid Pain Relievers Acetaminophen/Codeine Butorphanol Tartrate Co-Gesic Codeine Sulfate (Tablet) Fentanyl Citrate Oral Transmucosal 5 PA Hydrocodone/ Acetaminophen (Oral Solution, 00mg; 10mg Tablet, 00mg; 5mg Tablet, 00mg; 7.5mg Tablet, 5mg; 10mg Tablet, 5mg; 5mg Tablet, 5mg; 7.5mg Tablet, 500mg; 10mg Tablet, 500mg;.5mg Tablet, 500mg; 5mg Tablet, 500mg; 7.5mg Tablet, 650mg; 10mg Tablet, 650mg; 7.5mg Tablet, 660mg; 10mg Tablet, 750mg; 10mg Tablet, 750mg; 7.5mg Tablet) Hydrocodone/Ibuprofen Hydromorphone HCl (Tablet) Nalbuphine HCl Onsolis 5 PA Oxycodone HCl (Capsule, Concentrate, 15mg Tablet, 0mg Tablet, 5mg Tablet) Oxycodone/ Acetaminophen Oxycodone/Aspirin Roxicet (500mg; 5mg Tablet) Stagesic Tramadol HCl Tramadol HCl/ Acetaminophen Anesthetics s for Numbing Local Anesthetics Lidocaine (Ointment) B/D Lidocaine HCl (External Solution) Lidocaine HCl (0.5% Injection, 1% Injection) B/D Lidocaine HCl (Gel) Lidocaine Viscous Lidocaine/Prilocaine (Cream) B/D Lidoderm Antibacterials s to Treat Bacterial Infections Aminoglycosides Antibiotics Amikacin Sulfate (500mg/ml Injection, 50mg/ml Injection) Gentak (Ointment) Gentamicin Sulfate (Cream, Injection, 0.1% Ointment, Ophthalmic Solution) Gentamicin Sulfate/NaCl (1.mg/ml; 0.9% Injection, 1.6mg/ml; 0.9% Injection, 1mg/ml; 0.9% Injection) 9

12 Name Name Gentamicin Sulfate/ NaCl (0.9mg/ml; 0.9% Injection, 1.mg/ml; 0.9% Injection) Isotonic Gentamicin (0.8mg/ml; 0.9% Injection) Kanamycin Sulfate Neomycin Sulfate Neomycin/Polymyxin B Sulfates Paromomycin Sulfate Streptomycin Sulfate Tobi 5 B/D Tobramycin Sulfate (Ophthalmic Solution) Tobramycin Sulfate (10mg/ml Injection, 80mg/ml Injection) Tobramycin Sulfate/ Sodium Chloride Tobrex (Ointment) Antibacterials, Other Antibiotics Baciim Bacitracin (Injection, Ophthalmic Ointment) Bacitracin/Polymyxin B Chloramphenicol Sodium Succinate Cleocin (75mg Capsule) Cleocin Galaxy Cleocin in D5W Cleocin Phosphate (900mg/6ml Injection) Clindamycin HCl (150mg Capsule, 00mg Capsule) Clindamycin Phosphate (Cream) Clindamycin Phosphate Add-Vantage Colistimethate Sodium Cubicin 5 B/D Flagyl ER Lincocin Methenamine Hippurate Metronidazole Metronidazole in NaCl 0.79% Metronidazole Vaginal Mupirocin Neomycin/Bacitracin/ Polymyxin Neomycin/Polymyxin/ Gramicidin Nitrofurantoin Nitrofurantoin Macrocrystalline (50mg Capsule) Nitrofurantoin Monohydrate Polymyxin B Sulfate Primsol Silver Sulfadiazine SSD Synercid 5 Thermazene Trimethoprim Bold type = Brand name drug B/D = Medicare Part B or Part D PA = Prior authorization ST = Step therapy LA = Limited access drug 10

13 Name Name Trimethoprim Sulfate/ Polymyxin B Sulfate Tygacil Vancocin HCl 5 PA Vancomycin HCl (1000mg Injection, 10gm Injection, B/D 500mg Injection) Vancomycin HCl (Capsule) 5 PA Vandazole Vibativ (50mg Injection) Xifaxan (00mg Tablet) Xifaxan (550mg Tablet) 5 Zyvox 5 PA Beta-Lactam, Cephalosporins Antibiotics Cedax (Capsule) Cefaclor Cefaclor ER Cefadroxil Cefazolin Sodium (10gm Injection, 1gm Injection, 1gm; 5% Injection, 500mg Injection) Cefdinir Cefepime (1gm Injection, gm Injection) Cefotaxime Sodium (10gm Injection, 1gm Injection, gm Injection) Cefoxitin Sodium Cefoxitin Sodium/ Dextrose Cefpodoxime Proxetil Cefprozil Ceftazidime (1gm Injection, gm Injection, 6gm Injection) Ceftazidime/Dextrose Ceftriaxone Sodium Cefuroxime Axetil (Tablet) Cefuroxime Sodium (1.5gm Injection, 7.5gm Injection, 750mg Injection) Cephalexin Claforan (1gm Injection) Fortaz (1gm/50ml; 5% Injection, gm Injection, gm/50ml; 5% Injection, 6gm Injection) Suprax Zinacef (750mg Injection) Zinacef in Iso-Osmotic Dextrose Zinacef in Iso-Osmotic Diluent Beta-Lactam, Other Antibiotics Azactam in Iso-Osmotic Dextrose Aztreonam (1gm Injection) Cayston 5 PA Cefotetan Doribax (500mg Injection) Imipenem/Cilastatin Invanz Meropenem (500mg Injection) Primaxin Beta-Lactam, Penicillins Antibiotics Amoxicillin Amoxicillin/Potassium Clavulanate Amoxicillin/Potassium Clavulanate ER Ampicillin Ampicillin Sodium (10gm Injection, 15mg Injection, 1gm Injection) 11

14 Name Name Ampicillin-Sulbactam (10gm; 5gm Injection, gm; 1gm Injection) Bactocill in Dextrose (1gm/50ml Injection) Bactocill in Dextrose (gm/50ml Injection) 5 Bicillin C-R Bicillin L-A Dicloxacillin Sodium Nafcillin Sodium (10gm Injection, 1gm Injection) Nallpen/Dextrose (1gm/50ml Injection) Oxacillin Sodium (10gm Injection, 1gm Injection) Penicillin G Potassium (5mu Injection) Penicillin G Potassium in Iso-Osmotic Dextrose Penicillin G Procaine Penicillin G Sodium Penicillin V Potassium Pfizerpen-G (0mu Injection) Piperacillin Sodium/ Tazobactam Sodium (gm; 0.75gm Injection, gm; 0.5gm Injection) Timentin (0.1gm; gm Injection) Zosyn (gm; 0.75gm Injection, 5%; gm/50ml; 0.5gm/50ml Injection, 5%; gm/50ml; 0.75gm/50ml Injection) Macrolides Antibiotics Azithromycin (500mg Injection, Suspension Reconstituted, Tablet) Clarithromycin Clarithromycin ER Dificid 5 PA E.E.S. 00 E.E.S. Granules Ery Ery-Tab Eryped Erythrocin Lactobionate (500mg Injection) Erythrocin Stearate Erythromycin (External Solution, Gel, Ointment) Erythromycin Base Erythromycin Ethylsuccinate Ketek PA PCE Zmax Quinolones Antibiotics Avelox (Tablet) Avelox (Injection) Avelox ABC Pack Bold type = Brand name drug B/D = Medicare Part B or Part D PA = Prior authorization ST = Step therapy LA = Limited access drug 1

15 Name Name Cipro (Suspension Reconstituted) Cipro IV (00mg/100ml; 5% Injection) Ciprofloxacin (00mg/0ml Injection) Ciprofloxacin ER Ciprofloxacin HCl Factive Levofloxacin Levofloxacin in D5W (5%; 500mg/100ml Injection) Moxeza Noroxin Ofloxacin Sulfonamides Antibiotics Sodium Sulfacetamide (Ophthalmic Solution) Sulfacetamide Sodium (Ointment) Sulfadiazine Sulfamethoxazole/ Trimethoprim Sulfamethoxazole/ Trimethoprim DS Tetracyclines Antibiotics Demeclocycline HCl Doxycycline (75mg Capsule) Doxycycline Hyclate (Capsule, Injection, Tablet, 100mg Tablet Delayed Release, 75mg Tablet Delayed Release) Doxycycline Hyclate (150mg Tablet Delayed Release) Doxycycline Monohydrate (150mg Tablet, 50mg Tablet, 75mg Tablet) Minocycline HCl (Capsule) Minocycline HCl ER Tetracycline HCl Vibramycin (Syrup) Anticonvulsants s to Treat Seizures Anticonvulsants, Other Seizure Control s Levetiracetam (500mg/5ml Injection, Oral Solution, Tablet) Levetiracetam ER Phenobarbital (Elixir, 16.mg Tablet, 0mg Tablet,.mg Tablet, PA 6.8mg Tablet, 97.mg Tablet) Potiga Calcium Channel Modifying Agents Seizure Control s Celontin Ethosuximide Lyrica Zonisamide Gamma-Aminobutyric Acid (GABA) Augmenting Agents Seizure Control s Clonazepam PA Clonazepam ODT Clorazepate Dipotassium PA Diazepam (Gel) PA Divalproex Sodium Divalproex Sodium DR Divalproex Sodium ER Gabapentin Gabitril Onfi PA Primidone 1

16 Name Name Sabril 5 PA Valproate Sodium (100mg/ml injection) Valproic Acid Glutamate Reducing Agents Seizure Control s Felbamate (Tablet) Felbamate (Suspension) 5 Felbatol (Tablet) Felbatol (Suspension) 5 Lamictal ODT (Tablet Dispersible) Lamictal Starter Kit Lamotrigine (Tablet) Lamotrigine (Tablet Chewable) Topiramate Sodium Channel Agents Seizure Control s Banzel Carbamazepine Carbamazepine ER (Capsule Extended Release 1 Hour) Dilantin Dilantin Infatabs Epitol Equetro Fosphenytoin Sodium (100mg pe/ml Injection) Oxcarbazepine Peganone Phenytek Phenytoin Phenytoin Sodium Phenytoin Sodium Extended Tegretol Tegretol-XR Trileptal (Suspension) Vimpat (Oral Solution, Tablet) Vimpat (Injection) PA Antidementia Agents s to Treat Alzheimer s Disease and Dementia Cholinesterase Inhibitors Alzheimer s Disease and Dementia s Donepezil HCl Exelon (Oral Solution) Exelon (Patch Hour) ST Rivastigmine Tartrate N-methyl-D-aspartate (NMDA) Receptor Antagonists Alzheimer s Disease and Dementia s Namenda Namenda Titration Pak Antidepressants s to Treat Depression Antidepressants, Other Antidepressants Budeprion SR Bupropion HCl Bupropion HCl SR Bupropion XL Maprotiline HCl Bold type = Brand name drug B/D = Medicare Part B or Part D PA = Prior authorization ST = Step therapy LA = Limited access drug 1

17 Name Name Mirtazapine Mirtazapine ODT (0mg Tablet Dispersible, 5mg Tablet Dispersible) Nefazodone HCl Trazodone HCl Monoamine Oxidase Inhibitors Antidepressants Emsam ST Marplan Nardil Phenelzine Sulfate Selegiline HCl Tranylcypromine Sulfate Serotonin/Norepinephrine Reuptake Inhibitors Antidepressants Citalopram Hydrobromide (Tablet) 1 Citalopram Hydrobromide (Oral Solution) Cymbalta PA Escitalopram Oxalate Fluoxetine DR Fluoxetine HCl (Capsule, Oral Solution, 10mg Tablet, 0mg Tablet) Fluvoxamine Maleate Paroxetine HCl Paroxetine HCl ER Paxil (Suspension) Pristiq PA Sertraline HCl (Tablet) 1 Sertraline HCl (Concentrate) Venlafaxine HCl ST Venlafaxine HCl ER (Capsule Extended Release Hour) Viibryd ST Tricyclics Antidepressants Amitriptyline HCl Amoxapine Clomipramine HCl Desipramine HCl Doxepin HCl Imipramine HCl Imipramine Pamoate Nortriptyline HCl Perphenazine/Amitriptyline Protriptyline HCl Trimipramine Maleate Antidotes, Deterrents and Toxicologic Agents s for Overdose or Deterrents Alcohol Deterrents/Anti-Craving Antidotes/Deterrents/Protectants Antabuse Disulfiram Naltrexone HCl Vivitrol 5 Opioid Antagonists Antidotes/ Deterrents/Protectants Buprenorphine HCl Naloxone HCl (1mg/ml Injection) Suboxone Smoking Cessation Agents Deterrents Buproban Chantix Chantix Pak Nicotrol Inhaler Nicotrol NS 15

18 Name Name Antiemetics s to Treat Nausea and Vomiting Antiemetics, Other Nausea and Vomiting s Meclizine HCl Emetogenic Therapy Adjuncts Nausea and Vomiting s Aloxi Anzemet (50mg Tablet) B/D Anzemet (100mg Tablet) 5 B/D Cesamet 5 B/D, PA Dronabinol (.5mg Capsule, 5mg Capsule) B/D, PA Dronabinol (10mg Capsule) 5 B/D, PA Emend (Capsule) B/D, PA Granisetron HCl (0.1mg/ml Injection, 1mg/ml Injection) Granisetron HCl (Tablet) B/D Granisol B/D Ondansetron HCl (Tablet) B/D Ondansetron HCl (mg/ml Injection) Ondansetron HCl (Oral Solution) B/D Ondansetron ODT B/D Sancuso 5 Antifungals s to Treat Fungal Infections Antifungals Fungal Infection s Abelcet 5 B/D AmBisome 5 B/D Amphotec (50mg Injection) B/D Amphotericin B B/D Ancobon 5 Cancidas 5 Ciclopirox Ciclopirox Nail Lacquer Ciclopirox Olamine Clotrimazole (External Cream, External Solution, Troche) Clotrimazole/ Betamethasone Dipropionate Econazole Nitrate Eraxis (100mg Injection) 5 Fluconazole Fluconazole in Dextrose (56mg/ml; 00mg/00ml Injection) Flucytosine 5 Gris-Peg Griseofulvin Microsize Itraconazole PA Ketoconazole (Cream, Shampoo, Tablet) Ketoconazole (Foam) Lamisil (Packet) Miconazole Mycamine 5 Natacyn Noxafil 5 Nyamyc Bold type = Brand name drug B/D = Medicare Part B or Part D PA = Prior authorization ST = Step therapy LA = Limited access drug 16

19 Name Name Nystatin (Cream, Ointment, unit/gm Powder, Suspension, Tablet) Nystatin/Triamcinolone Nystop Pedi-Dri Sporanox (Oral Solution) PA Terbinafine HCl (Tablet) Terconazole (0.% Cream, Suppository) Vfend (Suspension Reconstituted) 5 Vfend (Tablet) 5 ST Vfend IV Voriconazole (Tablet) 5 Zazole (Cream) Antigout Agents s to Treat Gout Antigout Agents Gout s Allopurinol (Tablet) Allopurinol Sodium (Injection) Colcrys Probenecid Probenecid/Colchicine Uloric ST Antimigraine Agents s to Treat Migraines Ergot Alkaloids Migraine s Dihydroergotamine Mesylate Ergotamine Tartrate/ Caffeine Migergot Serotonin (5-HT) 1b/1d Receptor Agonists Migraine s Maxalt Maxalt-MLT Naratriptan HCl Sumatriptan Succinate (Tablet) Sumatriptan Succinate (6mg/0.5ml Injection) Antimyasthenic Agents s to Treat Myasthenia Gravis Parasympathomimetics Myasthenia Gravis s Mestinon (Syrup) Mestinon Timespan Mytelase Pyridostigmine Bromide Regonol Antimycobacterials s to Treat Infections Antimycobacterials, Other Miscellaneous Anti-Infectives Dapsone Mycobutin Antituberculars Tuberculosis s Capastat Sulfate Ethambutol HCl Isoniazid Paser Priftin Rifampin (Capsule) Rifampin (Injection) Rifater Seromycin Trecator Antineoplastics s to Treat Cancer Alkylating Agents Chemotherapy Agents BiCNU Busulfex 5 17

20 Name Name CeeNU Cyclophosphamide (Tablet) B/D Dacarbazine (00mg Injection) Hexalen 5 PA Ifosfamide (1gm Injection) Leukeran Matulane 5 Melphalan HCl 5 Mustargen 5 Thiotepa Treanda (100mg Injection) 5 PA Zanosar 5 Antiangiogenic Agents Chemotherapy Agents Caprelsa 5 PA Revlimid (10mg Capsule, 15mg Capsule, 5mg 5 PA, LA Capsule, 5mg Capsule) Thalomid 5 PA Antiestrogens/Modifiers Chemotherapy Agents Emcyt PA Fareston Faslodex 5 Tamoxifen Citrate Antimetabolites Chemotherapy Agents Cladribine 5 B/D Clolar 5 Cytarabine (500mg Injection) B/D Cytarabine Aqueous (0mg/ml Injection) B/D Cytarabine Aqueous (100mg/ml Injection) B/D Droxia Elitek (1.5mg Injection) 5 Fluorouracil (500mg/10ml Injection) B/D Folotyn (0mg/ml Injection) 5 PA Gemcitabine HCl (1gm Injection) 5 Gemzar (1gm Injection) 5 Hydroxyurea Mercaptopurine Pentostatin 5 Tabloid PA Antineoplastics, Other Chemotherapy Agents Abraxane 5 PA Adriamycin (mg/ml Injection) B/D Alimta (500mg Injection) 5 PA Amifostine 5 Arranon 5 Bleomycin Sulfate (0unit Injection) B/D Carboplatin (150mg/15ml Injection) Cerubidine Cisplatin (100mg/100ml Injection) Cosmegen Bold type = Brand name drug B/D = Medicare Part B or Part D PA = Prior authorization ST = Step therapy LA = Limited access drug 18

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