MEDICATIONS EXCLUDED FROM MAIL-ORDER COVERAGE October 1, 2012
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1 MEDICATIONS EXCLUDED FROM MAIL-ORDER COVERAGE October 1, 2012 Network Health does not cover the medications listed below for Network Health Forward (Commonwealth Care) Plan Type II and III members or Network Health Extend (Medical Security Plan) 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 through our specialty pharmacy, Caremark. Some of the medications listed below may have coverage limitations. Excluded mail-order medications (only covered at retail pharmacies) Brand name Abstral Fentanyl SL tablets Accutane Actiq Fentanyl lozenge Adcetris Brentuximab vedotin 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 Axiron Testosterone topical solution AzaSite Azithromycin Azelex Azelaic acid Butrans Buprenorphine patch Cafcit Caffeine citrate Campral Acamprosate Caverject
2 Chantix Cialis Claravis 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 Dexferrum DHC Plus Diastat, Diastat AcuDial Dificid Dilaudid Duragesic Edex Edluar Elidel Elimite Embeda Emend Empirin #2, #3, #4 Exalgo Eurax lotion Fentora Feraheme Ferrlecit Finacea Fioricet/Codeine Fiorinal/Codeine First-Testosterone Flector Patch Varenicline Tadalafil 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 Iron Dextran Dihydrocodeine/APAP/Caffeine Diazepam Fidaxomicin Hydromorphone Fentanyl Ambiel SL Pimecrolimus Permethrin Morphine/Naltrexone Aprepitant Codeine/Aspirin Hydromorphone ER Crotamiton Fentanyl buccal tablets Ferumoxytol Ferric Gluconate Azelaic acid Butalbital/APAP/Caffeine/Codeine Butalbital/Aspirin/Caffeine/Codeine Testosterone 2% ointment, 2% cream cmp kit Diclofenac patch
3 Flolan Epoprostenol sodium Flumadine Rimantadine Focalin, Focalin XR Dexmethylphenidate Fortesta Testosterone gel Fragmin Dalteparin Frova Frovatriptan Golytely HalfLytely Helidac Tetracycline/Bismuth/Metronidazole Hycodan Hydrocodone bitartrate Imitrex, Imitrex Inj., Imitrex Nasal Sumatriptan Infed Iron Dextran 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 Natroba Spinosad Nicotrol, Nicotrol NS Nicotine Nulecit Ferric Gluconate Nulytely Nuvigil Armodafinil Onsolis Fentanyl buccal film Opana, Opana ER Oxymorphone IR, Oxymorphone ER Opium Tincture Opium Tincture Ortho All-Flex Diaphragm OsmoPrep Bowel evacuant
4 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 Pradaxa Dabigatran Prevpac Lansoprazole/Amoxicillin/Clarithromycin Protopic Tacrolimus Provigil Modafinil Prudoxin Doxepin cream Pylera Bismuth subcitrate potassium/metronidazole/tetracycline Reclast Zoledronic acid Relenza Zanamivir Relistor Methylnaltrexone Relpax Eletriptan Reprexain Hydrocodone/Ibuprofen Revia Naltrexone Ritalin, Ritalin SR, Ritalin LA Methylphenidate Rozerem Ramelteon Salicylic Acid 26% Salicylic acid 26% Samsca Tolvaptan Sancuso Granisetron Santyl Ointment Collagenase ointment Solaraze Gel Diclofenac gel Soma Carisoprodol Soma Compound Carisoprodol/Aspirin Sonata Zaleplon Sotret Sprix Ketorolac nasal spray Stadol Butorphanol tartrate Striant Testosterone buccal system Suboxone Buprenorphine/Naloxone Subutex Buprenorphine Suprep Tamiflu Oseltamivir Testopel Testosterone pellets Toradol tablets, vials, cartridges Ketorolac tromethamine Transderm-Scop Scopolamine Trypsin-balsam peru-castor oil Trypsin-balsam peru-castor oil
5 Tussionex Hydrocodone/Chlorpheniramine Tylenol #2, #3, #4 Acetaminophen/Codeine Tylox Oxycodone/APAP Ultracet Tramadol/APAP Ultram, Ultram ER Tramadol, Tramadol ER Urea 40% Cream and Lotion Urea 40% cream and lotion Urea 50% Cream and Ointment Urea 50% cream and ointment Valcyte Valganciclovir Venofer Iron Sucrose Viagra Sildenafil Vicodin, Vicodin ES Acetaminophen/Hydrocodone Vicoprofen Hydrocodone/Ibuprofen Virazole Ribavirin 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 tthrough Caremark) Brand name See a complete list of medications Caremark provides. Other mail-order exclusions* Peak flow meters Spacers for asthma inhalers All injectable oncology medications All Schedule II and Schedule III controlled substance medications f you are unsure of its status, please call us at to verify that a specific drug is covered under the mail-order benefit. I
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