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PROVIDENCE MEDICARE ADVANTAGE PLANS PRESCRIPTION DRUG FORMULARY
2018 LIST OF COVERED DRUGS
PLEASEREAD: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN
Formulary ID: 00018080, Version: 15
This formulary was updated on 8/16/2017. For more recent information or other questions, please contact Providence Health Assurance Customer Service, at 503-574-8000 or 1-800-603-2340 or, for TTY users, 711, seven days a week, between 8 a.m. and 8 p.m. (Pacific Time), or visit www.providencehealthassurance.com.
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Providence Medicare Advantage Plans
2018 Formulary
(List of Covered Drugs)
Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take.
When this drug list (formulary) refers to "we," "us", or "our," it means Providence Health Assurance. When it refers to "plan" or "our plan," it means Providence Medicare Advantage Plans.
This document includes a list of the drugs (formulary) for our plan which is current as of 1/1/2018. For an VQEBUFE formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.
You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2019, and from time to time during the year.
The Formulary may change at any time. You will receive notice when necessary.
Providence Medicare Advantage Plans is an HMO, HMO-POS, and HMO SNP plan with a Medicare and Oregon Health Plan contract. Enrollment in Providence Medicare Advantage Plans depends on contract renewal.
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What is the Providence Medicare Advantage Plans Formulary? A formulary is a list of covered drugs selected by Providence Medicare Advantage Plans 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. Providence Medicare Advantage Plans will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Providence Medicare Advantage Plans network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.
Can the Formulary (drug list) change? Generally, if you are taking a drug on our 2018 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2018 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, 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. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety.
If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, 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. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug's manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of January 1, 2018. To get updated information about the drugs covered by Providence Medicare Advantage Plans, please contact us. Our contact information appears on the front and back cover pages. If we make any mid-year non-maintenance changes to the Providence Medicare Advantage Plans formulary, we will mail you a copy of the formulary changes via errata sheets to ensure that you have a complete and updated formulary.
How do I use the Formulary? There are two ways to find your drug within the formulary:
Medical Condition
The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins on page 119.Then look under the category name for your drug.
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AlphabeticalListing
If you are not sure what category to look under, you should look for your drug in the Index that begins on page 98.The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.
What are generic drugs? Providence Medicare Advantage Plans covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.
Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:
• Prior Authorization: Providence Medicare Advantage Plans requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Providence Medicare Advantage Plans before you fill your prescriptions. If you don't get approval, Providence Medicare Advantage Plans may not cover the drug.
• Quantity Limits: For certain drugs, Providence Medicare Advantage Plans limits the amount of the drug that Providence Medicare Advantage Plans will cover. For example, Providence Medicare Advantage Plans provides 1 tablet per day per prescription for simvastatin 40mg tablets. This may be in addition to a standard one-month or three-month supply.
• Step Therapy: In some cases, Providence Medicare Advantage Plans requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Providence Medicare Advantage Plans may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Providence Medicare Advantage Plans will then cover Drug B.
You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.
You can ask Providence Medicare Advantage Plans to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, "How do I request an exception to the Providence Medicare Advantage Plans' formulary?" on page iv for information about how to request an exception.
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What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered.
If you learn that Providence Medicare Advantage Plans does not cover your drug, you have two options:
• You can ask Customer Service for a list of similar drugs that are covered by Providence MedicareAdvantage Plans. When you receive the list, show it to your doctor and ask him or her to prescribe asimilar drug that is covered by Providence Medicare Advantage Plans.
• You can ask Providence Medicare Advantage Plans to make an exception and cover your drug. Seebelow for information about how to request an exception.
How do I request an exception to the Providence Medicare Advantage Plans’ Formulary? You can ask Providence Medicare Advantage Plans to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.
• You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be coveredat a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at alower cost-sharing level.
• You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialtytier. If approved this would lower the amount you must pay for your drug.
• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs,Providence Medicare Advantage Plans limits the amount of the drug that we will cover. If your drughas a quantity limit, you can ask us to waive the limit and cover a greater amount.
Generally, Providence Medicare Advantage Plans will only approve your request for an exception if the alternative drugs included on the plan's formulary, the lower cost-sharing drug, or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
You should contact us to ask us for an initial coverage decision for a formulary, tiering, or utilization restriction exception. When you request a formulary, tiering, or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber's supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.
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What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.
If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with 93-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.
Level of care change: Day Supply For members transitioning from a SNF to LTC: 31 day supply SNF to Home (Retail): 30 day supply LTC-LTC: 31 day supply Hospital to Home (Retail): 30 day supply
For more information For more detailed information about your Providence Medicare Advantage Plans prescription drug coverage, please review your Evidence of Coverage and other plan materials.
If you have questions about Providence Medicare Advantage Plans, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.
If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov.
Providence Medicare Advantage Plans’ Formulary The formulary that begins on page 1 provides coverage information about the drugs covered by Providence Medicare Advantage Plans. If you have trouble finding your drug in the list, turn to the Index that begins on page 98.
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The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., JANUVIA®)) and generic drugs are listed in lower-case italics (e.g., captopril).
The second column of the chart lists the Drug Tier. The Drug Tier name lets you know the amount you will pay at the pharmacy.
• Tier 1 is the lowest cost share tier, and you will pay your preferred generic copay.• Tier 2 you will pay your generic drug copay• Tier 3 you will pay your preferred brand name drug copay• Tier 4 you will pay your non-preferred drug coinsurance• Tier 5 is the highest cost share tier, and you will pay your specialty coinsurance
Please note that the brand and generic status of a drug may be different during the Coverage Gap and Catastrophic Coverage Phases as determined by the Food and Drug Administration (FDA) regulatory status.
The information in the Requirements/Limits column tells you if Providence Medicare Advantage Plans has any special requirements for coverage of your drug.
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The following abbreviations may be found within the body of this document
COVERAGENOTES ABBREVIATIONS
ABBREVIATION DESCRIPTION EXPLANATION
UtilizationManagementRestrictions
PA Prior Authorization Restriction
You (or your physician) are required to get prior authorization from Providence Medicare Advantage Plans before you fill your prescription for this drug. Without prior approval, Providence Medicare Advantage Plans may not cover this drug.
QL QuantityLimit Restriction
Providence Medicare Advantage Plans limits the amount of this drug that is covered per prescription, or within a specific time frame.
ST Step Therapy Restriction
Before Providence Medicare Advantage Plans will provide coverage for this drug, you must first try another drug to treat your medical condition. This drug may only be covered if the other drug does not work for you.
Other Special Requirements for Coverage
LA Limited Access Drug
This prescription may be available only at certain pharmacies. For more information consult your Provider and Pharmacy Directory or call Customer Service at 503-574-8000 or 1-800-603-2340, seven days a week, between 8 a.m. and 8 p.m. (Pacific Time). TTY users should call 711.
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Non-discrimination Statement Providence Health Plan and Providence Health Assurance comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability, or sex. Providence Health Plan and Providence Health Assurance do not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
Providence Health Plan and Providence Health Assurance: x Provide free aids and services to people with disabilities to communicate effectively with us, such as:
o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other
formats) x Provide free language services to people whose primary language is not English, such as:
o Qualified interpreters o Information written in other languages
If you are a Medicare member who needs these services, call 503-574-8000 or 1-800-603-2340. All other members can call 503-574-7500 or 1-800-878-4445. Hearing impaired members may call our TTY line at 711.
If you believe that Providence Health Plan or Providence Health Assurance has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with our Non-discrimination Coordinator by mail:
Providence Health Plan and Providence Health Assurance Attn: Non-discrimination Coordinator
PO Box 4158
Portland, OR 97208-4158
If you need help filing a grievance, and you are a Medicare member call 503-574-8000 or 1-800- 603-2340. All other members can call 503-574-7500 or 1-800-878-4445 (TTY line at 711) for assistance. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services 200 Independence Avenue SW - Room 509F HHH Building Washington DC 20201 1-800-368-1019, 1-800-537-7697 (TTY)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
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Language Access Information
ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-800-603-2340 (TTY: 711).
Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-603-2340 (TTY: 711).
Chinese: 㲐シ烉⤪㝄ぐἧ䓐䷩橼ᷕ㔯ĭġぐ⎗ẍ屣䌚⼿婆妨㎜≑㚵⊁įġ婳农暣ġ1-800-603- 2340 ĩTTY: 711炸ġ
Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-603-2340 (TTY: 711).
Korean: 㨰㢌aG䚐ạ㛨⪰G㇠㟝䚌㐐⏈Gᷱ㟤SG㛬㛨G㫴㠄G㉐⽸㏘⪰Gⱨ⨀⦐G㢨㟝䚌㐘G㍌G㢼㏩⏼␘UG1-800-603-2340 �77
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Punjabi: ਿਧਆਨ ਿਦਓ: ਜੇ ਤੁ ੰ ਜਾਬੀ ਬੋ ੇ ੋ ੱ ਚ ਸਹਾਇਤਾ ਸੇ ੁ ੇ ਲਈ ਮੁਸ ਪ ਲਦ ਹ, ਤ ਭਾਸ਼ਾ ਿਵ ਵਾ ਤਹਾਡ ਫਤ ਉਪਲਬਧ ਹੈ। 1-800603-2340 (TTY: 711) 'ਤੇ ਕਾਲ ਕਰੋ।
German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-800-603-2340 (TTY: 711).
Laotian: ໂປດຊາບ��ຖ້◌ າວ່◌ າ ທ່◌ ້ ◌ າພາສາ ລາວ��ການບິ◌ລການຊ່◌ ວຍເຫຼ◌ ້ ◌ານເວ ອດານພາສາ��ໂດຍ່◌ບເສັ ຽຄ າ��ແມ ນມພ ອມໃຫ ທ ານ��ໂທຣ 1-800-603-2340 (TTY: 711). ◌ ່◌ ່ ◌ ້ ◌ ້ ◌ ່◌
Romanian: ATENȚIE: Dacă vorbiți limba română, vă stau la dispoziție servicii de asistență lingvistică, gratuit. Sunați la 1-800-603-2340 (TTY: 711).
French: ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-800-603-2340 (ATS: 711).
Thai: เรียน: ถ้าคุณพดูภาษาไทยคุณสามารถใช้บริการช่วยเหลอืทางภาษาได้ฟร ี โทร 1-800-603-2340 (TTY: 711)
Persian:
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Providence Medicare Advantage Plans is an HMO, HMO-POS, and HMO SNP plan with a Medicare and Oregon Health Plan contract. Enrollment in Providence Medicare Advantage Plans depends on contract renewal.
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You can find information on what the symbols and abbreviationson this table mean by going to page vii of the Introduction.
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Medicare Advantage Plans 2018 Formulary (List of Covered Drugs)
Drug Name Drug Tier Requirements/Limits
ANALGESICS
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS celecoxib (50 mg capsule, 100 mg capsule, 200 mg capsule)
2-Generic QL (2 PER 1 DAYS)
celecoxib 400 mg capsule 2-Generic QL (1 PER 1 DAYS)
diclofenac potassium 2-Generic
diclofenac sodium (25 mg tablet dr, 50 mg tablet dr, 75 mg tablet dr, 100 mg tab er 24h)
2-Generic
diflunisal 2-Generic
etodolac 2-Generic
flurbiprofen 2-Generic
ibuprofen (100 mg/5ml oral susp, 400 mg tablet, 600 mg tablet, 800 mg tablet)
2-Generic
KETOPROFEN 200 MG CAP24H PEL 4-Non-Preferred Drug
QL (1 PER 1 DAYS)
KETOPROFEN 50 MG CAPSULE 4-Non-Preferred Drug
QL (6 PER 1 DAYS)
KETOPROFEN 75 MG CAPSULE 4-Non-Preferred Drug
QL (4 PER 1 DAYS)
meclofenamate sodium 2-Generic
meloxicam (7.5 mg tablet, 7.5 mg/5ml oral susp, 15 mg tablet)
2-Generic
nabumetone 2-Generic
naproxen (125 mg/5ml oral susp, 250 mg tablet, 375 mg tablet, 375 mg tablet dr, 500 mg tablet dr, 500 mg tablet)
2-Generic
naproxen sodium (275 mg tablet, 550 mg tablet)
2-Generic
piroxicam 2-Generic
sulindac 2-Generic
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Medicare Advantage Plans 2018 Formulary (List of Covered Drugs)
You can find information on what the symbols and abbreviationson this table mean by going to page vii of the Introduction.
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tolmetin sodium 2-Generic
OPIOID ANALGESICS, LONG-ACTING FENTANYL (12 MCG/HR PATCH TD72, 25 MCG/HR PATCH TD72, 50MCG/HR PATCH TD72, 75MCG/HR PATCH TD72, 100 MCG/HR PATCH TD72)
4-Non-Preferred Drug
QL (15 PER 30 OVER TIME)
LEVORPHANOL TARTRATE 5-Specialty
methadone hcl (5 mg/5 ml solution, 10 mg/5 ml solution)
2-Generic
methadone hcl 10 mg tablet 2-Generic QL (4 PER 1 DAYS)
METHADONE HCL 10 MG/ML VIAL 4-Non-Preferred Drug
methadone hcl 5 mg tablet 2-Generic QL (8 PER 1 DAYS)
morphine sulfate (15 mg tablet er, 30 mg tablet er)
2-Generic QL (3 PER 1 DAYS)
morphine sulfate 100 mg tablet er 2-Generic QL (1 PER 1 DAYS)
morphine sulfate 60 mg tablet er 2-Generic QL (2 PER 1 DAYS)
OXYCODONE HCL (10 MG TAB ER 12H, 15 MG TAB ER 12H, 20 MG TAB ER 12H, 30 MG TAB ER 12H, 40 MG TAB ER 12H, 60 MG TAB ER 12H)
3-Preferred Brand QL (2 PER 1 DAYS)
OXYCODONE HCL 80 MG TAB ER 12H 3-Preferred Brand QL (4 PER 1 DAYS)
OXYCONTIN (10 MG TABLET, 15 MG TABLET, 20 MG TABLET, 30 MG TABLET, 40 MG TABLET, 60 MG TABLET)
3-Preferred Brand QL (2 PER 1 DAYS)
OXYCONTIN 80 MG TABLET 3-Preferred Brand QL (4 PER 1 DAYS)
TRAMADOL HCL (100 MG TBMP 24HR, 100 MG TAB ER 24H, 200 MG TBMP 24HR, 200 MG TAB ER 24H, 300 MG TAB ER 24H, 300 MG TBMP 24HR)
4-Non-Preferred Drug
QL (1 PER 1 DAYS)
OPIOID ANALGESICS, SHORT-ACTING acetaminophen with codeine phosphate (120-12mg/5 solution, 300mg/12.5 solution, 300mg-30mg tablet, 300mg-60mg tablet, 300mg-15mg tablet)
2-Generic
Drug Name Drug Tier Requirements/Limits
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Medicare Advantage Plans 2018 Formulary (List of Covered Drugs)
You can find information on what the symbols and abbreviationson this table mean by going to page vii of the Introduction.
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ascomp with codeine 2-Generic PA FOR 65 YEARS AND OLDER
ASTRAMORPH-PF (1 MG/ML AMPUL, 1 MG/2 ML AMPULE)
4-Non-Preferred Drug
butalbit/acetamin/caff/codeine 50-325-30 capsule
2-Generic PA FOR 65 YEARS AND OLDER
butalbital/aspirin/caffeine 50-325-40 capsule
2-Generic PA FOR 65 YEARS AND OLDER
BUTORPHANOL TARTRATE (1 MG/ML VIAL, 2 MG/ML VIAL)
4-Non-Preferred Drug
butorphanol tartrate 10 mg/ml spray 2-Generic
codeine phosphate/butalbital/aspirin/caffeine
2-Generic PA FOR 65 YEARS AND OLDER
endocet (2.5-325 mg tablet, 5-325 tablet, 7.5-325 mg tablet)
2-Generic
endocet 10-325 mg tablet 2-Generic QL (8 PER 1 DAYS)
FENTANYL CITRATE 4-Non-Preferred Drug
PA, QL (4 PER 1 DAYS)
hydrocodone bitartrate/acetaminophen (2.5-108/5 solution, 5 mg-325mg tablet, 5-217mg/10 solution, 7.5-325/15 solution, 7.5-325 mg tablet, 10mg-325mg tablet)
2-Generic
hydromorphone hcl (1 mg/ml liquid, 2 mg tablet)
2-Generic
hydromorphone hcl 4 mg tablet 2-Generic QL (8 PER 1 DAYS)
hydromorphone hcl 8 mg tablet 2-Generic QL (4 PER 1 DAYS)
HYDROMORPHONE HCL/PF 4-Non-Preferred Drug
LAZANDA 4-Non-Preferred Drug
PA
lorcet 2-Generic
lorcet hd 2-Generic
lorcet plus 7.5-325 mg tablet 2-Generic
lortab (5-325 mg tablet, 7.5-325 mg tablet, 10-325 mg tablet)
2-Generic
Drug Name Drug Tier Requirements/Limits
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Medicare Advantage Plans 2018 Formulary (List of Covered Drugs)
You can find information on what the symbols and abbreviationson this table mean by going to page vii of the Introduction.
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morphine sulfate (10 mg/5 ml solution, 20 mg/5 ml solution)
2-Generic
MORPHINE SULFATE (2 MG/ML CARTRIDGE, 2 MG/ML SYRINGE, 4 MG/ML SYRINGE, 4 MG/ML CARTRIDGE)
4-Non-Preferred Drug
morphine sulfate 100 mg/5ml solution 2-Generic QL (6 ML PER 1 DAYS)
morphine sulfate 15 mg tablet 2-Generic QL (8 PER 1 DAYS)
morphine sulfate 30 mg tablet 2-Generic QL (4 PER 1 DAYS)
MORPHINE SULFATE/PF (0.5 MG/ML VIAL, 1 MG/ML VIAL)
4-Non-Preferred Drug
oxycodone hcl (5 mg/5 ml solution, 5 mg capsule, 5 mg tablet)
2-Generic
oxycodone hcl 10 mg tablet 2-Generic QL (8 PER 1 DAYS)
oxycodone hcl 15 mg tablet 2-Generic QL (6 PER 1 DAYS)
oxycodone hcl 20 mg tablet 2-Generic QL (4 PER 1 DAYS)
oxycodone hcl 30 mg tablet 2-Generic QL (3 PER 1 DAYS)
oxycodone hcl/acetaminophen (2.5-325 mg tablet, 5-325/5 ml solution, 5 mg-325mg tablet, 7.5-325 mg tablet)
2-Generic
oxycodone hcl/acetaminophen 10mg-325mg tablet
2-Generic QL (8 PER 1 DAYS)
oxycodone hcl/aspirin 2-Generic
oxymorphone hcl 10 mg tablet 2-Generic QL (4 PER 1 DAYS)
oxymorphone hcl 5 mg tablet 2-Generic QL (8 PER 1 DAYS)
roxicet 2-Generic
tramadol hcl 50 mg tablet 2-Generic QL (8 PER 1 DAYS)
tramadol hcl/acetaminophen 2-Generic QL (10 PER 1 DAYS)
Drug Name Drug Tier Requirements/Limits
ANESTHETICS
LOCAL ANESTHETICS glydo 2-Generic
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Medicare Advantage Plans 2018 Formulary (List of Covered Drugs)
You can find information on what the symbols and abbreviationson this table mean by going to page vii of the Introduction.
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LIDOCAINE 5 % ADH. PATCH 4-Non-Preferred Drug
PA, QL (3 PER 1 DAYS)
LIDOCAINE 5 % OINT. (G) 4-Non-Preferred Drug
PA TO CONFIRM PART D COVERAGE
lidocaine hcl (2 % jelly(ml), 2 % solution, 2 % jel/pf app, 40 mg/ml solution)
2-Generic
LIDOCAINE HCL (5 MG/ML VIAL, 20 MG/ML VIAL)
4-Non-Preferred Drug
LIDOCAINE HCL/PF (5 MG/ML VIAL, 20 MG/ML AMPUL, 20 MG/ML VIAL)
4-Non-Preferred Drug
Drug Name Drug Tier Requirements/Limits
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS
ALCOHOL DETERRENTS/ANTI-CRAVING acamprosate calcium 2-Generic
disulfiram 2-Generic
naltrexone hcl 2-Generic
revia 2-Generic
OPIOID DEPENDENCE TREATMENTS BUPRENORPHINE HCL (0.3 MG/ML VIAL, 0.3 MG/ML SYRINGE)
4-Non-Preferred Drug
buprenorphine hcl (2 mg tab subl, 8 mg tab subl)
2-Generic QL (3 PER 1 DAYS)
buprenorphine hcl/naloxone hcl 2-Generic QL (3 PER 1 DAYS)
OPIOID REVERSAL AGENTS naloxone hcl 2-Generic
NARCAN 4-Non-Preferred Drug
QL (2 PER 30 OVER TIME)
SMOKING CESSATION AGENTS buproban 2-Generic
bupropion hcl 150 mg tab er 12h 2-Generic
CHANTIX 3-Preferred Brand
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Medicare Advantage Plans 2018 Formulary (List of Covered Drugs)
You can find information on what the symbols and abbreviationson this table mean by going to page vii of the Introduction.
6
NICOTROL 4-Non-Preferred Drug
NICOTROL NS 4-Non-Preferred Drug
Drug Name Drug Tier Requirements/Limits
ANTIBACTERIALS
AMINOGLYCOSIDES garamycin 2-Generic
gentak 2-Generic
gentamicin sulfate (0.1 % oint. (g), 0.1 % cream (g), 0.3 % oint. (g), 0.3 % drops)
2-Generic
GENTAMICIN SULFATE (20 MG/2 ML VIAL, 40 MG/ML VIAL)
4-Non-Preferred Drug
GENTAMICIN SULFATE/PF 4-Non-Preferred Drug
neomycin sulfate 2-Generic
paromomycin sulfate 2-Generic
STREPTOMYCIN SULFATE 4-Non-Preferred Drug
tobramycin 2-Generic
TOBRAMYCIN SULFATE (1.2 G VIAL, 10 MG/ML VIAL, 40 MG/ML VIAL)
4-Non-Preferred Drug
ANTIBACTERIALS, OTHER BACIIM 4-Non-Preferred
Drug
bacitracin 500 unit/g oint. (g) 2-Generic
BACITRACIN 50000 UNIT VIAL 4-Non-Preferred Drug
CHLORAMPHENICOL SOD SUCCINATE 4-Non-Preferred Drug
CLEOCIN PHOS 300 MG/2ML ADDVAN 4-Non-Preferred Drug
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Medicare Advantage Plans 2018 Formulary (List of Covered Drugs)
You can find information on what the symbols and abbreviationson this table mean by going to page vii of the Introduction.
7
clindacin etz 1% pledget 2-Generic
clindacin p 2-Generic
clindacin pac 2-Generic
clindamycin hcl 2-Generic
clindamycin palmitate hcl 2-Generic
CLINDAMYCIN PHOSPHATE (1 % FOAM, 150 MG/ML VIAL, 300 MG/2ML VIAL PORT, 600 MG/4ML VIAL PORT, 900MG/6ML VIAL PORT)
4-Non-Preferred Drug
clindamycin phosphate (1 % lotion, 1 % gel (gram), 1 % med. swab, 1 % solution, 2 % cream/appl)
2-Generic
CLINDAMYCIN PHOSPHATE IN 0.9 % SODIUM CHLORIDE
4-Non-Preferred Drug
CLINDAMYCIN PHOSPHATE/DEXTROSE 5 % IN WATER
4-Non-Preferred Drug
COLISTIN (AS COLISTIMETHATE SODIUM)
4-Non-Preferred Drug
DALVANCE 5-Specialty PA
DAPTOMYCIN 5-Specialty
erythromycin base/benzoyl peroxide 2-Generic
LINEZOLID (100 MG/5ML SUSP RECON, 600MG/300 IV SOLN, 600 MG TABLET)
5-Specialty
LINEZOLID IN 0.9 % SODIUM CHLORIDE 5-Specialty
methenamine hippurate 2-Generic
metronidazole (0.75 % gel w/appl, 250 mg tablet, 375 mg capsule, 500 mg tablet)
2-Generic
METRONIDAZOLE IN SODIUM CHLORIDE
4-Non-Preferred Drug
MONUROL 4-Non-Preferred Drug
mupirocin 2% ointment 2-Generic
NITROFURANTOIN 4-Non-Preferred Drug
Drug Name Drug Tier Requirements/Limits
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Medicare Advantage Plans 2018 Formulary (List of Covered Drugs)
You can find information on what the symbols and abbreviationson this table mean by going to page vii of the Introduction.
8
nitrofurantoin macrocrystal (50 mg capsule, 100 mg capsule)
2-Generic
nitrofurantoin monohydrate/macrocrystals
2-Generic
ORBACTIV 5-Specialty PA
SIVEXTRO 5-Specialty PA
SYNERCID 5-Specialty
TIGECYCLINE 4-Non-Preferred Drug
tinidazole 2-Generic
trimethoprim 2-Generic
VANCOMYCIN HCL 4-Non-Preferred Drug
VANCOMYCIN HCL/DEXTROSE 5 % IN WATER
4-Non-Preferred Drug
VANCOMYCIN IN 0.9 % SODIUM CHLORIDE (VANCOMYCIN/0.9 % 750MG/.15L FROZ.PIGGY, VANCOMYCIN/0.9 % 500MG/100 ML FROZ.PIGGY)
4-Non-Preferred Drug
vandazole 2-Generic
XIFAXAN 200 MG TABLET 3-Preferred Brand PA, QL (3 PER 1 DAYS)
XIFAXAN 550 MG TABLET 5-Specialty PA, QL (2 PER 1 DAYS)
BETA-LACTAM, CEPHALOSPORINS AVYCAZ 5-Specialty
CEDAX (180 MG/5 ML SUSPENSION, 400 MG CAPSULE)
4-Non-Preferred Drug
cefaclor (125 mg/5ml susp recon, 250 mg/5ml susp recon, 250 mg capsule, 375 mg/5ml susp recon, 500 mg capsule)
2-Generic
cefadroxil (1 g tablet, 250 mg/5ml susp recon, 500 mg capsule, 500 mg/5ml susp recon)
2-Generic
Drug Name Drug Tier Requirements/Limits
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Medicare Advantage Plans 2018 Formulary (List of Covered Drugs)
You can find information on what the symbols and abbreviationson this table mean by going to page vii of the Introduction.
9
CEFAZOLIN SODIUM 4-Non-Preferred Drug
cefdinir (125 mg/5ml susp recon, 250 mg/5ml susp recon, 300 mg capsule)
2-Generic
CEFEPIME HCL 4-Non-Preferred Drug
CEFEPIME HCL IN DEXTROSE 5 % IN WATER
4-Non-Preferred Drug
CEFOTAXIME SODIUM 4-Non-Preferred Drug
CEFOTETAN DISODIUM 4-Non-Preferred Drug
CEFOXITIN SODIUM 4-Non-Preferred Drug
cefpodoxime proxetil (50 mg/5 ml susp recon, 100 mg tablet, 100 mg/5ml susp recon, 200 mg tablet)
2-Generic
cefprozil (125 mg/5ml susp recon, 250 mg tablet, 250 mg/5ml susp recon, 500 mg tablet)
2-Generic
CEFTAZIDIME 4-Non-Preferred Drug
CEFTIBUTEN (180 MG/5ML SUSP RECON, 400 MG CAPSULE)
4-Non-Preferred Drug
CEFTRIAXONE SODIUM 4-Non-Preferred Drug
CEFTRIAXONE SODIUM IN ISO-OSMOTIC DEXTROSE (1 G/50 ML PIGGYBACK, 1 G/50 ML FROZ.PIGGY, 2 G/50 ML PIGGYBACK, 2 G/50 ML FROZ.PIGGY)
4-Non-Preferred Drug
cefuroxime axetil 2-Generic
CEFUROXIME SODIUM 4-Non-Preferred Drug
cephalexin (125 mg/5ml susp recon, 250 mg tablet, 250 mg capsule, 250 mg/5ml susp recon, 500 mg tablet, 500 mg capsule)
2-Generic
Drug Name Drug Tier Requirements/Limits
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Medicare Advantage Plans 2018 Formulary (List of Covered Drugs)
You can find information on what the symbols and abbreviationson this table mean by going to page vii of the Introduction.
10
TAZICEF 4-Non-Preferred Drug
ZERBAXA 5-Specialty
BETA-LACTAM, OTHER AZTREONAM 4-Non-Preferred
Drug
DORIBAX 500 MG VIAL 4-Non-Preferred Drug
DORIPENEM 4-Non-Preferred Drug
imipenem/cilastatin sodium 2-Generic
INVANZ 1 GM VIAL 4-Non-Preferred Drug
MEROPENEM 4-Non-Preferred Drug
MEROPENEM IN 0.9 % SODIUM CHLORIDE
4-Non-Preferred Drug
BETA-LACTAM, PENICILLINS amoxicillin (125 mg tab chew, 125 mg/5ml susp recon, 200 mg/5ml susp recon, 250 mg capsule, 250 mg tab chew, 250 mg/5ml susp recon, 400 mg/5ml susp recon, 500 mg tablet, 500 mg capsule, 875 mg tablet)
2-Generic
amoxicillin/potassium clavulanate (200-28.5mg tab chew, 200-28.5/5 susp recon, 250-125 mg tablet, 250-62.5/5 susp recon, 400-57mg tab chew, 400-57mg/5 susp recon, 500-125 mg tablet, 600-42.9/5 susp recon, 875-125 mg tablet, 1000-62.5 tab er 12h)
2-Generic
AMPICILLIN SODIUM 4-Non-Preferred Drug
AMPICILLIN SODIUM/SULBACTAM SODIUM
4-Non-Preferred Drug
ampicillin trihydrate (125 mg/5ml susp recon, 250 mg capsule, 250 mg/5ml susp recon, 500 mg capsule)
2-Generic
Drug Name Drug Tier Requirements/Limits
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Medicare Advantage Plans 2018 Formulary (List of Covered Drugs)
You can find information on what the symbols and abbreviationson this table mean by going to page vii of the Introduction.
11
BICILLIN C-R 4-Non-Preferred Drug
BICILLIN L-A 4-Non-Preferred Drug
dicloxacillin sodium 2-Generic
NAFCILLIN SODIUM (1 G VIAL, 1 G VIAL PORT, 2 G VIAL, 10 G VIAL)
4-Non-Preferred Drug
OXACILLIN SODIUM 4-Non-Preferred Drug
OXACILLIN SODIUM IN ISO-OSMOTIC DEXTROSE
4-Non-Preferred Drug
PENICILLIN G POTASSIUM 4-Non-Preferred Drug
PENICILLIN G PROCAINE 1.2MM/2 ML SYRINGE
4-Non-Preferred Drug
PENICILLIN G SODIUM 4-Non-Preferred Drug
penicillin v potassium (125 mg/5ml soln recon, 250 mg tablet, 250 mg/5ml soln recon, 500 mg tablet)
2-Generic
PFIZERPEN 4-Non-Preferred Drug
PIPERACILLIN SODIUM/TAZOBACTAM SODIUM
4-Non-Preferred Drug
MACROLIDES AZASITE 4-Non-Preferred
Drug
azithromycin (100 mg/5ml susp recon, 200 mg/5ml susp recon, 250 mg tablet, 500 mg tablet, 600 mg tablet)
2-Generic
AZITHROMYCIN (500 MG VIAL PORT, 500 MG VIAL)
4-Non-Preferred Drug
clarithromycin (125 mg/5ml susp recon, 250 mg/5ml susp recon, 250 mg tablet, 500 mg tab er 24h, 500 mg tablet)
2-Generic
E.E.S. 400 4-Non-Preferred Drug
Drug Name Drug Tier Requirements/Limits
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Medicare Advantage Plans 2018 Formulary (List of Covered Drugs)
You can find information on what the symbols and abbreviationson this table mean by going to page vii of the Introduction.
12
ery 2-Generic
ERY-TAB 4-Non-Preferred Drug
erygel 2-Generic
ERYTHROCIN LACTOBIONATE (500 MG VIAL, 500 MG ADDVNT VL)
4-Non-Preferred Drug
ERYTHROCIN STEARATE 4-Non-Preferred Drug
ERYTHROMYCIN BASE (250 MG TABLET, 500 MG TABLET)
4-Non-Preferred Drug
erythromycin base 5 mg/gram oint. (g) 2-Generic
erythromycin base/ethyl alcohol (2 % med. swab, 2 % solution, 2 % gel (gram))
2-Generic
ERYTHROMYCIN ETHYLSUCCINATE (200 MG/5ML SUSP RECON, 400 MG TABLET)
4-Non-Preferred Drug
QUINOLONES AVELOX IV 4-Non-Preferred
Drug
ciprofloxacin hcl (0.2 % droperette, 0.3 % drops, 100 mg tablet, 250 mg tablet, 500 mg tablet, 750 mg tablet)
2-Generic
CIPROFLOXACIN LACTATE 4-Non-Preferred Drug
CIPROFLOXACIN LACTATE/DEXTROSE 5 % IN WATER
4-Non-Preferred Drug
ciprofloxacin/ciprofloxacin hcl 2-Generic
GATIFLOXACIN 4-Non-Preferred Drug
levofloxacin (0.5 % drops, 250mg/10ml solution, 250 mg tablet, 500 mg tablet, 500mg/20ml solution, 750 mg tablet)
2-Generic
LEVOFLOXACIN 25 MG/ML VIAL 4-Non-Preferred Drug
LEVOFLOXACIN/DEXTROSE 5 % IN WATER
4-Non-Preferred Drug
Drug Name Drug Tier Requirements/Limits
-
Medicare Advantage Plans 2018 Formulary (List of Covered Drugs)
You can find information on what the symbols and abbreviationson this table mean by going to page vii of the Introduction.
13
moxifloxacin hcl 400 mg tablet 2-Generic
MOXIFLOXACIN HCL IN SODIUM ACETATE AND SULFATE,WATER,ISO-OSM
4-Non-Preferred Drug
ofloxacin (0.3 % drops, 300 mg tablet, 400 mg tablet)
2-Generic
VIGAMOX 3-Preferred Brand
SULFONAMIDES bleph-10 2-Generic
silver sulfadiazine 2-Generic
sulfacetamide sodium (10 % drops, 10 % suspension, 10 % oint. (g))
2-Generic
sulfadiazine 2-Generic
sulfamethoxazole/trimethoprim (200-40mg/5 oral susp, 400mg-80mg tablet, 800-160/20 oral susp, 800-160 mg tablet)
2-Generic
SULFAMETHOXAZOLE/TRIMETHOPRIM 80-16MG/ML VIAL
4-Non-Preferred Drug
sulfamide 2-Generic
TETRACYCLINES avidoxy 2-Generic
DEMECLOCYCLINE HCL 4-Non-Preferred Drug
DOXY 100 4-Non-Preferred Drug
doxycycline hyclate (20 mg tablet, 50 mg capsule, 100 mg capsule, 100 mg tablet)
2-Generic
DOXYCYCLINE HYCLATE 100 MG VIAL 4-Non-Preferred Drug
doxycycline monohydrate (25 mg/5 ml susp recon, 50 mg capsule, 50 mg tablet, 75 mg tablet, 100 mg tablet, 100 mg capsule, 150 mg tablet)
2-Generic
Drug Name Drug Tier Requirements/Limits
-
Medicare Advantage Plans 2018 Formulary (List of Covered Drugs)
You can find information on what the symbols and abbreviationson this table mean by going to page vii of the Introduction.
14
dynacin (50 mg tablet, 100 mg tablet) 2-Generic
minocycline hcl (50 mg tablet, 50 mg capsule, 75 mg capsule, 75 mg tablet, 100 mg capsule, 100 mg tablet)
2-Generic
mondoxyne nl (nl 50 mg capsule, nl 100 mg capsule)
2-Generic
morgidox (50 mg capsule, 100 mg capsule)
2-Generic
TETRACYCLINE HCL 4-Non-Preferred Drug
Drug Name Drug Tier Requirements/Limits
ANTICONVULSANTS
ANTICONVULSANTS, OTHER BRIVIACT (10 MG TABLET, 25 MG TABLET, 50 MG TABLET, 75 MG TABLET, 100 MG TABLET)
5-Specialty QL (2 PER 1 DAYS)
BRIVIACT (10 MG/ML ORAL SOLN, 50 MG/5 ML VIAL)
4-Non-Preferred Drug
levetiracetam (100 mg/ml solution, 250 mg tablet, 500 mg tab er 24h, 500 mg/5ml solution, 500 mg tablet, 750 mg tab er 24h, 750 mg tablet, 1000 mg tablet)
2-Generic
LEVETIRACETAM 500 MG/5ML VIAL 4-Non-Preferred Drug
LEVETIRACETAM IN SODIUM CHLORIDE, ISO-OSMOTIC
4-Non-Preferred Drug
POTIGA 4-Non-Preferred Drug
roweepra 2-Generic
SPRITAM 4-Non-Preferred Drug
PA FOR NEW STARTS ONLY
CALCIUM CHANNEL MODIFYING AGENTS CELONTIN 4-Non-Preferred
Drug
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Medicare Advantage Plans 2018 Formulary (List of Covered Drugs)
You can find information on what the symbols and abbreviationson this table mean by going to page vii of the Introduction.
15
ethosuximide (250 mg/5ml solution, 250 mg capsule)
2-Generic
zonisamide 2-Generic
GAMMA-AMINOBUTYRIC ACID (GABA) AUGMENTING AGENTS DIASTAT 3-Preferred Brand
DIAZEPAM (2.5 MG KIT, 5-7.5-10MG KIT, 12.5-15-20 KIT)
3-Preferred Brand
divalproex sodium 2-Generic
gabapentin (100 mg capsule, 250 mg/5ml solution, 300 mg capsule, 300 mg/6ml solution, 400 mg capsule, 600 mg tablet, 800 mg tablet)
2-Generic
GABITRIL (12 MG TABLET, 16 MG TABLET)
4-Non-Preferred Drug
ONFI (10 MG TABLET, 20 MG TABLET) 5-Specialty PA FOR NEW STARTS ONLY, QL (2 PER 1 DAYS)
ONFI 2.5 MG/ML SUSPENSION 4-Non-Preferred Drug
PA FOR NEW STARTS ONLY
phenobarbital (15 mg tablet, 16.2 mg tablet, 20 mg/5 ml elixir, 30 mg tablet, 32.4 mg tablet, 60 mg tablet, 64.8 mg tablet, 97.2mg tablet, 100 mg tablet)
2-Generic PA FOR NEW STARTS ONLY AND FOR 65 YEARS AND OLDER
primidone 2-Generic
SABRIL 5-Specialty LA
tiagabine hcl 2-Generic
valproic acid 2-Generic
valproic acid (as sodium salt) (valproate sodium) (salt) 250 mg/5ml solution, salt) 500mg/10ml solution)
2-Generic
VALPROIC ACID (AS SODIUM SALT) 500 MG/5ML VIAL
4-Non-Preferred Drug
GLUTAMATE REDUCING AGENTS felbamate (400 mg tablet, 600 mg tablet, 600 mg/5ml oral susp)
2-Generic
Drug Name Drug Tier Requirements/Limits
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Medicare Advantage Plans 2018 Formulary (List of Covered Drugs)
You can find information on what the symbols and abbreviationson this table mean by going to page vii of the Introduction.
16
FYCOMPA (0.5 MG/ML ORAL SUSP, 2 MG TABLET, 4 MG TABLET, 6 MG TABLET, 8 MG TABLET, 10 MG TABLET, 12 MG TABLET)
4-Non-Preferred Drug
PA FOR NEW STARTS ONLY
LAMICTAL (BLUE) 4-Non-Preferred Drug
LAMICTAL (GREEN) 4-Non-Preferred Drug
LAMICTAL (ORANGE) 4-Non-Preferred Drug
LAMICTAL XR (BLUE) 4-Non-Preferred Drug
LAMICTAL XR (GREEN) 4-Non-Preferred Drug
LAMICTAL XR (ORANGE) 4-Non-Preferred Drug
lamotrigine (5 mg tb chw dsp, 25 mg tablet, 25 mg tab er 24, 25mg (35) tab ds pk, 25 mg tb chw dsp, 50 mg tab er 24, 100 mg tab er 24, 100 mg tablet, 150 mg tablet, 200 mg tablet, 200 mg tab er 24, 250 mg tab er 24, 300 mg tab er 24)
2-Generic
topiramate (15 mg cap sprink, 25 mg cap sprink, 25 mg tablet, 50 mg tablet, 100 mg tablet, 200 mg tablet)
2-Generic
topiramate (25 mg cap spr 24, 50 mg cap spr 24, 100 mg cap spr 24, 150 mg cap spr 24, 200 mg cap spr 24)
2-Generic PA FOR NEW STARTS ONLY
SODIUM CHANNEL AGENTS APTIOM 4-Non-Preferred
Drug
BANZEL (40 MG/ML SUSPENSION, 200 MG TABLET, 400 MG TABLET)
4-Non-Preferred Drug
Drug Name Drug Tier Requirements/Limits
-
Medicare Advantage Plans 2018 Formulary (List of Covered Drugs)
You can find information on what the symbols and abbreviationson this table mean by going to page vii of the Introduction.
17
carbamazepine (100 mg tab er 12h, 100 mg cpmp 12hr, 100 mg tab chew, 100 mg/5ml oral susp, 200 mg tablet, 200 mg tab er 12h, 200 mg cpmp 12hr, 300 mg cpmp 12hr, 400 mg tab er 12h)
2-Generic
DILANTIN 30 MG CAPSULE 4-Non-Preferred Drug
epitol 2-Generic
FOSPHENYTOIN SODIUM 4-Non-Preferred Drug
oxcarbazepine (150 mg tablet, 300 mg tablet, 300 mg/5ml oral susp, 600 mg tablet)
2-Generic
PEGANONE 4-Non-Preferred Drug
phenytoin (50 mg tab chew, 100 mg/4ml oral susp, 125 mg/5ml oral susp)
2-Generic
PHENYTOIN SODIUM (50 MG/ML VIAL, 50 MG/ML AMPUL)
4-Non-Preferred Drug
phenytoin sodium extended 2-Generic
VIMPAT (10 MG/ML SOLUTION, 50 MG TABLET, 100 MG TABLET, 150 MG TABLET, 200 MG/20 ML VIAL, 200 MG TABLET)
4-Non-Preferred Drug
Drug Name Drug Tier Requirements/Limits
ANTIDEMENTIA AGENTS
CHOLINESTERASE INHIBITORS donepezil hcl (5 mg tab rapdis, 5 mg tablet, 10 mg tablet, 10 mg tab rapdis)
2-Generic
DONEPEZIL HCL 23 MG TABLET 4-Non-Preferred Drug
galantamine hbr (4 mg tablet, 4 mg/ml solution, 8 mg cap24h pel, 8 mg tablet, 12 mg tablet, 16 mg cap24h pel, 24 mg cap24h pel)
2-Generic
RIVASTIGMINE 4-Non-Preferred Drug
QL (1 PER 1 DAYS)
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Medicare Advantage Plans 2018 Formulary (List of Covered Drugs)
You can find information on what the symbols and abbreviationson this table mean by going to page vii of the Introduction.
18
rivastigmine tartrate 2-Generic QL (2 PER 1 DAYS)
N-METHYL-D-ASPARTATE (NMDA) RECEPTOR ANTAGONIST memantine hcl (5 mg tablet, 10 mg tablet)
2-Generic QL (2 PER 1 DAYS)
memantine hcl 2 mg/ml solution 2-Generic QL (12 ML PER 1 DAYS)
memantine hcl 5 mg-10 mg tab ds pk 2-Generic
NAMENDA XR (7 MG CAPSULE, 14 MG CAPSULE, 21 MG CAPSULE, 28 MG CAPSULE)
4-Non-Preferred Drug
PA, QL (1 PER 1 DAYS)
NAMENDA XR TITRATION PACK 4-Non-Preferred Drug
PA
Drug Name Drug Tier Requirements/Limits
ANTIDEPRESSANTS
ANTIDEPRESSANTS, OTHER budeprion sr 2-Generic
bupropion hcl (75 mg tablet, 100 mg tablet, 100 mg tab er 12h, 150 mg tab er 24h, 200 mg tab er 12h, 300 mg tab er 24h)
2-Generic
mirtazapine odt (15 mg, 45 mg, 30 mg) 2-Generic
mirtazapine tablet (15 mg, 45 mg, 7.5 mg, 30mg)
2-Generic
olanzapine/fluoxetine hcl 2-Generic
perphenazine/amitriptyline hcl 2-Generic
MONOAMINE OXIDASE INHIBITORS EMSAM 5-Specialty
MARPLAN 4-Non-Preferred Drug
phenelzine sulfate 2-Generic
TRANYLCYPROMINE SULFATE 4-Non-Preferred Drug
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Medicare Advantage Plans 2018 Formulary (List of Covered Drugs)
You can find information on what the symbols and abbreviationson this table mean by going to page vii of the Introduction.
19
SSRIS/SNRIS (SELECTIVE SEROTONIN REUPTAKE INHIBITOR/SEROTONIN AND NOREPINEPHRINE REUPTAKE INHIBITOR)
citalopram hydrobromide (10 mg tablet, 10 mg/5 ml solution, 20 mg tablet, 40 mg tablet)
2-Generic
DESVENLAFAXINE 4-Non-Preferred Drug
PA FOR NEW STARTS ONLY, QL (1 PER 1 DAYS)
DESVENLAFAXINE FUMARATE 4-Non-Preferred Drug
PA FOR NEW STARTS ONLY, QL (1 PER 1 DAYS)
DESVENLAFAXINE SUCCINATE 4-Non-Preferred Drug
PA FOR NEW STARTS ONLY, QL (1 PER 1 DAYS)
escitalopram oxalate (5 mg tablet, 5 mg/5 ml solution, 10 mg tablet, 20 mg tablet)
2-Generic
FETZIMA 4-Non-Preferred Drug
PA FOR NEW STARTS ONLY
fluoxetine hcl (10 mg tablet, 10 mg capsule, 20 mg tablet, 20 mg/5 ml solution, 20 mg capsule, 40 mg capsule, 60 mg tablet, 90 mg capsule dr)
2-Generic
fluvoxamine maleate (25 mg tablet, 50 mg tablet, 100 mg tablet)
2-Generic
maprotiline hcl 2-Generic
nefazodone hcl 2-Generic
paroxetine hcl (10 mg tablet, 20 mg tablet, 30 mg tablet, 40 mg tablet)
2-Generic
PAXIL 10 MG/5 ML SUSPENSION 4-Non-Preferred Drug
sertraline hcl (20 mg/ml oral conc, 25 mg tablet, 50 mg tablet, 100 mg tablet)
2-Generic
trazodone hcl 2-Generic
TRINTELLIX 4-Non-Preferred Drug
PA FOR NEW STARTS ONLY
Drug Name Drug Tier Requirements/Limits
-
Medicare Advantage Plans 2018 Formulary (List of Covered Drugs)
You can find information on what the symbols and abbreviationson this table mean by going to page vii of the Introduction.
20
venlafaxine hcl (25 mg tablet, 37.5 mg cap er 24h, 37.5 mg tablet, 50 mg tablet, 75 mg cap er 24h, 75 mg tablet, 100 mg tablet, 150 mg cap er 24h)
2-Generic
VENLAFAXINE HCL (37.5 MG TAB ER 24, 75 MG TAB ER 24, 150 MG TAB ER 24, 225 MG TAB ER 24)
4-Non-Preferred Drug
QL (1 PER 1 DAYS)
VIIBRYD 4-Non-Preferred Drug
PA FOR NEW STARTS ONLY
TRICYCLICS amitriptyline hcl 2-Generic
amoxapine 2-Generic
clomipramine hcl 2-Generic
desipramine hcl 2-Generic
imipramine hcl 2-Generic
imipramine pamoate 2-Generic
nortriptyline hcl (10 mg/5 ml solution, 10 mg capsule, 25 mg capsule, 50 mg capsule, 75 mg capsule)
2-Generic
protriptyline hcl 2-Generic
TRIMIPRAMINE MALEATE 4-Non-Preferred Drug
Drug Name Drug Tier Requirements/Limits
ANTIEMETICS
ANTIEMETICS, OTHER COMPRO 4-Non-Preferred
Drug
meclizine hcl (12.5 mg tablet, 25 mg tablet)
2-Generic
metoclopramide hcl (5 mg tablet, 5 mg/5 ml solution, 10 mg tablet)
2-Generic
METOCLOPRAMIDE HCL 5 MG/ML VIAL 4-Non-Preferred Drug
perphenazine 2-Generic
-
Medicare Advantage Plans 2018 Formulary (List of Covered Drugs)
You can find information on what the symbols and abbreviationson this table mean by going to page vii of the Introduction.
21
PROCHLORPERAZINE 4-Non-Preferred Drug
PROCHLORPERAZINE EDISYLATE 4-Non-Preferred Drug
prochlorperazine maleate 2-Generic
EMETOGENIC THERAPY ADJUNCTS AKYNZEO 4-Non-Preferred
Drug QL (4 PER 28 OVER TIME)
APREPITANT 125 MG CAPSULE 4-Non-Preferred Drug
QL (2 PER 30 OVER TIME)
APREPITANT 125MG-80MG CAP DS PK 4-Non-Preferred Drug
QL (6 PER 30 OVER TIME)
APREPITANT 40 MG CAPSULE 4-Non-Preferred Drug
QL (8 PER 30 OVER TIME)
APREPITANT 80 MG CAPSULE 4-Non-Preferred Drug
QL (4 PER 30 OVER TIME)
DRONABINOL 4-Non-Preferred Drug
PA
EMEND 125 MG POWDER PACKET 4-Non-Preferred Drug
QL (2 PER 30 OVER TIME)
GRANISETRON HCL 1 MG TABLET 4-Non-Preferred Drug
QL (2 PER 1 DAYS)
ondansetron 2-Generic
ondansetron hcl (4 mg/5 ml solution, 4 mg tablet, 8 mg tablet, 24 mg tablet)
2-Generic
ONDANSETRON HCL 2 MG/ML VIAL 4-Non-Preferred Drug
ONDANSETRON HCL/PF 4-Non-Preferred Drug
VARUBI 4-Non-Preferred Drug
QL (8 PER 28 OVER TIME)
Drug Name Drug Tier Requirements/Limits
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Medicare Advantage Plans 2018 Formulary (List of Covered Drugs)
You can find information on what the symbols and abbreviationson this table mean by going to page vii of the Introduction.
22
Drug Name Drug Tier Requirements/Limits
ANTIFUNGALS
ANTIFUNGALS ABELCET 4-Non-Preferred
Drug PA TO CONFIRM PART D COVERAGE
AMBISOME 4-Non-Preferred Drug
PA TO CONFIRM PART D COVERAGE
AMPHOTERICIN B 4-Non-Preferred Drug
PA TO CONFIRM PART D COVERAGE
CANCIDAS 5-Specialty
CASPOFUNGIN ACETATE 5-Specialty
ciclodan (0.77% cream, 8% solution) 2-Generic
ciclopirox (0.77 % gel (gram), 1 % shampoo, 8 % solution)
2-Generic
ciclopirox olamine (0.77 % cream (g), 0.77 % suspension)
2-Generic
clotrimazole (1 % cream (g), 1 % solution)
2-Generic
CLOTRIMAZOLE 10 MG TROCHE 4-Non-Preferred Drug
ECONAZOLE NITRATE 4-Non-Preferred Drug
fluconazole (10 mg/ml susp recon, 40 mg/ml susp recon, 50 mg tablet, 100 mg tablet, 150 mg tablet, 200 mg tablet)
2-Generic
FLUCONAZOLE IN DEXTROSE, ISO-OSMOTIC
4-Non-Preferred Drug
FLUCONAZOLE IN SODIUM CHLORIDE, ISO-OSMOTIC
4-Non-Preferred Drug
FLUCYTOSINE 5-Specialty
GRISEOFULVIN ULTRAMICROSIZE 4-Non-Preferred Drug
GRISEOFULVIN, MICROSIZE (125 MG/5ML ORAL SUSP, 500 MG TABLET)
4-Non-Preferred Drug
-
Medicare Advantage Plans 2018 Formulary (List of Covered Drugs)
You can find information on what the symbols and abbreviationson this table mean by going to page vii of the Introduction.
23
ITRACONAZOLE 4-Non-Preferred Drug
ketoconazole (2 % cream (g), 2 % foam, 2 % shampoo)
2-Generic
ketodan 2-Generic
miconazole nitrate 200 mg supp.vag 2-Generic
NATACYN 4-Non-Preferred Drug
NOXAFIL (40 MG/ML SUSPENSION, DR 100 MG TABLET)
4-Non-Preferred Drug
PA
nyamyc 2-Generic
nyata 2-Generic
nystatin (50mm unit powder(ea), 150mm unit powder(ea), 500mm unit powder(ea), 500k unit tablet, 100000/ml oral susp, 100000/g powder, 100000/g cream (g), 100000/g oint. (g))
2-Generic
NYSTATIN/TRIAMCINOLONE ACETONIDE
4-Non-Preferred Drug
nystop 2-Generic
terbinafine hcl 250 mg tablet 2-Generic
terconazole (0.4 % cream/appl, 0.8 % cream/appl, 80 mg supp.vag)
2-Generic
VORICONAZOLE (50 MG TABLET, 200 MG TABLET, 200 MG VIAL, 200 MG/5ML SUSP RECON)
4-Non-Preferred Drug
PA
Drug Name Drug Tier Requirements/Limits
ANTIGOUT AGENTS
ANTIGOUT AGENTS allopurinol 2-Generic
COLCHICINE 0.6 MG TABLET 3-Preferred Brand
COLCRYS 3-Preferred Brand
probenecid 2-Generic
-
Medicare Advantage Plans 2018 Formulary (List of Covered Drugs)
You can find information on what the symbols and abbreviationson this table mean by going to page vii of the Introduction.
24
probenecid/colchicine 2-Generic
ULORIC 4-Non-Preferred Drug
PA
ZURAMPIC 4-Non-Preferred Drug
PA
Drug Name Drug Tier Requirements/Limits
ANTIMIGRAINE AGENTS
ERGOT ALKALOIDS cafergot 2-Generic QL (40 PER 28 OVER TIME)
DIHYDROERGOTAMINE MESYLATE (1 MG/ML AMPUL, 1 MG/ML VIAL)
4-Non-Preferred Drug
QL (24 ML PER 28 OVER TIME)
DIHYDROERGOTAMINE MESYLATE 0.5MG/SPRY SPRAY/PUMP
5-Specialty QL (8 ML PER 30 OVER TIME)
ergotamine tartrate/caffeine 2-Generic QL (40 PER 28 OVER TIME)
MIGERGOT 4-Non-Preferred Drug
QL (20 PER 28 OVER TIME)
MIGRANAL 5-Specialty QL (8 ML PER 30 OVER TIME)
SEROTONIN (5-HT) 1B/1D RECEPTOR AGONISTS NARATRIPTAN HCL 4-Non-Preferred
Drug QL (9 PER 30 OVER TIME)
rizatriptan benzoate 2-Generic QL (12 PER 30 OVER TIME)
sumatriptan succinate (25 mg tablet, 50 mg tablet, 100 mg tablet)
2-Generic QL (9 PER 30 OVER TIME)
SUMATRIPTAN SUCCINATE (4 MG/0.5ML PEN INJCTR, 4 MG/0.5ML CARTRIDGE, 6 MG/0.5ML PEN INJCTR, 6 MG/0.5ML SYRINGE, 6 MG/0.5ML CARTRIDGE, 6 MG/0.5ML VIAL)
4-Non-Preferred Drug
QL (4 ML PER 30 OVER TIME)
ZOLMITRIPTAN 4-Non-Preferred Drug
ST, QL (9 PER 30 OVER TIME)
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Medicare Advantage Plans 2018 Formulary (List of Covered Drugs)
You can find information on what the symbols and abbreviationson this table mean by going to page vii of the Introduction.
25
Drug Name Drug Tier Requirements/Limits
ANTIMYASTHENIC AGENTS
PARASYMPATHOMIMETICS guanidine hcl 2-Generic
MESTINON 60 MG/5 ML SYRUP 3-Preferred Brand
pyridostigmine bromide 2-Generic
ANTIMYCOBACTERIALS
ANTIMYCOBACTERIALS, OTHER dapsone 2-Generic
RIFABUTIN 4-Non-Preferred Drug
ANTITUBERCULARS CAPASTAT SULFATE 4-Non-Preferred
Drug
cycloserine 2-Generic
ethambutol hcl 2-Generic
isoniazid (50 mg/5 ml solution, 100 mg tablet, 300 mg tablet)
2-Generic
ISONIAZID 100 MG/ML VIAL 4-Non-Preferred Drug
PASER 4-Non-Preferred Drug
PRIFTIN 4-Non-Preferred Drug
pyrazinamide 2-Generic
rifampin (150 mg capsule, 300 mg capsule)
2-Generic
RIFAMPIN 600 MG VIAL 4-Non-Preferred Drug
RIFATER 4-Non-Preferred Drug
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Medicare Advantage Plans 2018 Formulary (List of Covered Drugs)
You can find information on what the symbols and abbreviationson this table mean by going to page vii of the Introduction.
26
SIRTURO 5-Specialty LA
TRECATOR 4-Non-Preferred Drug
Drug Name Drug Tier Requirements/Limits
ANTINEOPLASTICS
ALKYLATING AGENTS CEENU 4-Non-Preferred
Drug
CYCLOPHOSPHAMIDE CAPSULES (25 MG, 50 MG)
3-Preferred Brand PA TO CONFIRM PART D COVERAGE
GLEOSTINE 4-Non-Preferred Drug
HEXALEN 5-Specialty
LEUKERAN 3-Preferred Brand
LOMUSTINE 4-Non-Preferred Drug
MATULANE 5-Specialty LA
VALCHLOR 5-Specialty LA
ANTIANDROGENS bicalutamide 2-Generic
flutamide 2-Generic
NILUTAMIDE 5-Specialty
XTANDI 5-Specialty PA FOR NEW STARTS ONLY, LA
ZYTIGA 5-Specialty PA FOR NEW STARTS ONLY
ANTIANGIOGENIC AGENTS POMALYST 5-Specialty PA FOR NEW STARTS ONLY, LA
REVLIMID 5-Specialty PA FOR NEW STARTS ONLY, LA
THALOMID 5-Specialty
ANTIESTROGENS/MODIFIERS EMCYT 4-Non-Preferred
Drug
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Medicare Advantage Plans 2018 Formulary (List of Covered Drugs)
You can find information on what the symbols and abbreviationson this table mean by going to page vii of the Introduction.
27
FARESTON 5-Specialty
FASLODEX 5-Specialty PA FOR NEW STARTS ONLY
SOLTAMOX 4-Non-Preferred Drug
tamoxifen citrate 2-Generic
ANTIMETABOLITES ALIMTA 5-Specialty
DROXIA 4-Non-Preferred Drug
fluorouracil (2 % solution, 5 % solution, 5 % cream (g))
2-Generic
hydroxyurea 2-Generic
mercaptopurine 2-Generic
PURIXAN 4-Non-Preferred Drug
TABLOID 4-Non-Preferred Drug
ANTINEOPLASTICS, OTHER ALUNBRIG 5-Specialty PA FOR NEW STARTS ONLY
AMIFOSTINE CRYSTALLINE 4-Non-Preferred Drug
BCG LIVE 3-Preferred Brand
leucovorin calcium (5 mg tablet, 10 mg tablet, 15 mg tablet, 25 mg tablet)
2-Generic
LEUCOVORIN CALCIUM (50 MG VIAL, 100 MG VIAL, 200 MG VIAL, 350 MG VIAL, 500 MG VIAL)
4-Non-Preferred Drug
LONSURF 15 MG-6.14 MG TABLET 5-Specialty PA FOR NEW STARTS ONLY, LA, QL (100 PER 28 OVER TIME)
LONSURF 20 MG-8.19 MG TABLET 5-Specialty PA FOR NEW STARTS ONLY, LA, QL (80 PER 28 OVER TIME)
LYSODREN 3-Preferred Brand
mitoxantrone hcl 2-Generic
Drug Name Drug Tier Requirements/Limits
-
Medicare Advantage Plans 2018 Formulary (List of Covered Drugs)
You can find information on what the symbols and abbreviationson this table mean by going to page vii of the Introduction.
28
NINLARO 5-Specialty PA FOR NEW STARTS ONLY
PROLEUKIN 5-Specialty
RUBRACA 5-Specialty PA FOR NEW STARTS ONLY, LA
RYDAPT 5-Specialty PA FOR NEW STARTS ONLY
SYLATRON 5-Specialty PA FOR NEW STARTS ONLY
SYLATRON 4-PACK 5-Specialty PA FOR NEW STARTS ONLY
SYNRIBO 5-Specialty PA FOR NEW STARTS ONLY
TRISENOX 4-Non-Preferred Drug
ZOLINZA 5-Specialty PA FOR NEW STARTS ONLY
AROMATASE INHIBITORS, 3RD GENERATION anastrozole 2-Generic
EXEMESTANE 4-Non-Preferred Drug
letrozole 2-Generic
ENZYME INHIBITORS etoposide 20 mg/ml vial 2-Generic
toposar 2-Generic
topotecan hcl 4 mg vial 2-Generic
MOLECULAR TARGET INHIBITORS AFINITOR 5-Specialty PA FOR NEW STARTS ONLY
AFINITOR DISPERZ 5-Specialty PA FOR NEW STARTS ONLY
ALECENSA 5-Specialty PA FOR NEW STARTS ONLY
BOSULIF 5-Specialty PA FOR NEW STARTS ONLY
CABOMETYX 5-Specialty PA FOR NEW STARTS ONLY
CAPRELSA 5-Specialty PA FOR NEW STARTS ONLY, LA
COMETRIQ 5-Specialty PA FOR NEW STARTS ONLY, LA
COTELLIC 5-Specialty PA FOR NEW STARTS ONLY, QL (63 PER 28 OVER TIME)
Drug Name Drug Tier Requirements/Limits
-
Medicare Advantage Plans 2018 Formulary (List of Covered Drugs)
You can find information on what the symbols and abbreviationson this table mean by going to page vii of the Introduction.
29
ERIVEDGE 5-Specialty PA FOR NEW STARTS ONLY, LA
FARYDAK 5-Specialty PA FOR NEW STARTS ONLY, QL (6 PER 21 OVER TIME)
GILOTRIF 5-Specialty PA FOR NEW STARTS ONLY, LA
IBRANCE 5-Specialty PA FOR NEW STARTS ONLY, LA, QL (21 PER 28 OVER TIME)
ICLUSIG 5-Specialty PA FOR NEW STARTS ONLY, LA
IMATINIB MESYLATE 5-Specialty PA FOR NEW STARTS ONLY
IMBRUVICA 5-Specialty PA FOR NEW STARTS ONLY, LA
INLYTA 5-Specialty PA FOR NEW STARTS ONLY, LA
IRESSA 5-Specialty PA FOR NEW STARTS ONLY, QL (1 PER 1 DAYS)
JAKAFI 5-Specialty PA FOR NEW STARTS ONLY, LA
KISQALI 5-Specialty PA FOR NEW STARTS ONLY
KISQALI FEMARA CO-PACK 5-Specialty PA FOR NEW STARTS ONLY
LENVIMA 5-Specialty PA FOR NEW STARTS ONLY, LA
LYNPARZA 50 MG CAPSULE 5-Specialty PA FOR NEW STARTS ONLY, LA
MEKINIST 5-Specialty PA FOR NEW STARTS ONLY
NEXAVAR 5-Specialty PA FOR NEW STARTS ONLY
ODOMZO 5-Specialty PA FOR NEW STARTS ONLY
SPRYCEL 5-Specialty PA FOR NEW STARTS ONLY
STIVARGA 5-Specialty PA FOR NEW STARTS ONLY
SUTENT 5-Specialty PA FOR NEW STARTS ONLY
TAFINLAR 5-Specialty PA FOR NEW STARTS ONLY
TAGRISSO 5-Specialty PA FOR NEW STARTS ONLY
TARCEVA 5-Specialty PA FOR NEW STARTS ONLY
TASIGNA 5-Specialty PA FOR NEW STARTS ONLY
TYKERB 5-Specialty PA FOR NEW STARTS ONLY
VENCLEXTA (10 MG TABLET, 50 MG TABLET)
3-Preferred Brand PA FOR NEW STARTS ONLY
Drug Name Drug Tier Requirements/Limits
-
Medicare Advantage Plans 2018 Formulary (List of Covered Drugs)
You can find information on what the symbols and abbreviationson this table mean by going to page vii of the Introduction.
30
VENCLEXTA 100 MG TABLET 5-Specialty PA FOR NEW STARTS ONLY
VENCLEXTA STARTING PACK 5-Specialty PA FOR NEW STARTS ONLY
VOTRIENT 5-Specialty PA FOR NEW STARTS ONLY
XALKORI 5-Specialty PA FOR NEW STARTS ONLY, LA
ZEJULA 5-Specialty PA FOR NEW STARTS ONLY
ZELBORAF 5-Specialty PA FOR NEW STARTS ONLY
ZYDELIG 5-Specialty PA FOR NEW STARTS ONLY, QL (2 PER 1 DAYS)
ZYKADIA 5-Specialty PA FOR NEW STARTS ONLY
MONOCLONAL ANTIBODY/ANTIBODY-DRUG CONJUGATE RITUXAN 5-Specialty PA FOR NEW STARTS ONLY
RITUXAN HYCELA 5-Specialty PA FOR NEW STARTS ONLY
SYLVANT 5-Specialty PA FOR NEW STARTS ONLY
RETINOIDS BEXAROTENE 5-Specialty PA FOR NEW STARTS ONLY
PANRETIN 5-Specialty
TARGRETIN 1% GEL 5-Specialty PA FOR NEW STARTS ONLY
TRETINOIN 10 MG CAPSULE 5-Specialty PA FOR NEW STARTS ONLY
TREATMENT ADJUNCTS ELITEK 5-Specialty
MESNEX 400 MG TABLET 3-Preferred Brand
Drug Name Drug Tier Requirements/Limits
ANTIPARASITICS
ANTIHELMINTHICS ALBENZA 4-Non-Preferred
Drug PA
EMVERM 4-Non-Preferred Drug
PA
ivermectin 2-Generic
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Medicare Advantage Plans 2018 Formulary (List of Covered Drugs)
You can find information on what the symbols and abbreviationson this table mean by going to page vii of the Introduction.
31
ANTIPROTOZOALS ALINIA 100 MG/5 ML SUSPENSION 4-Non-Preferred
Drug QL (150 ML PER 30 OVER TIME)
ALINIA 500 MG TABLET 3-Preferred Brand QL (6 PER 30 OVER TIME)
ATOVAQUONE 5-Specialty
ATOVAQUONE/PROGUANIL HCL 4-Non-Preferred Drug
chloroquine phosphate 2-Generic
COARTEM 4-Non-Preferred Drug
DARAPRIM 5-Specialty
hydroxychloroquine sulfate 2-Generic
mefloquine hcl 2-Generic
NEBUPENT 4-Non-Preferred Drug
PA TO CONFIRM PART D COVERAGE
PENTAM 300 4-Non-Preferred Drug
primaquine phosphate 2-Generic
PEDICULICIDES/SCABICIDES lindane 2-Generic
permethrin 5 % cream (g) 2-Generic
Drug Name Drug Tier Requirements/Limits
ANTIPARKINSON AGENTS
ANTICHOLINERGICS benztropine mesylate (0.5 mg tablet, 1 mg tablet, 2 mg tablet)
2-Generic
trihexyphenidyl hcl (2 mg/5 ml elixir, 2 mg tablet, 5 mg tablet)
2-Generic
ANTIPARKINSON AGENTS, OTHER amantadine hcl (50 mg/5 ml solution, 100 mg tablet, 100 mg capsule)
2-Generic
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Medicare Advantage Plans 2018 Formulary (List of Covered Drugs)
You can find information on what the symbols and abbreviationson this table mean by going to page vii of the Introduction.
32
CARBIDOPA/LEVODOPA/ENTACAPONE 4-Non-Preferred Drug
ENTACAPONE 4-Non-Preferred Drug
DOPAMINE AGONISTS APOKYN 5-Specialty PA, LA
bromocriptine mesylate 2-Generic
pramipexole di-hcl (0.125 mg tablet, 0.25 mg tablet, 0.5 mg tablet, 0.75 mg tablet, 1 mg tablet, 1.5 mg tablet)
2-Generic
ropinirole hcl (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet, 2 mg tablet, 3 mg tablet, 4 mg tablet, 5 mg tablet)
2-Generic
DOPAMINE PRECURSORS/L-AMINO ACID DECARBOXYLASE INHIBITORS CARBIDOPA 4-Non-Preferred
Drug
carbidopa/levodopa 2-Generic
MONOAMINE OXIDASE B (MAO-B) INHIBITORS RASAGILINE MESYLATE 4-Non-Preferred
Drug
selegiline hcl 2-Generic
Drug Name Drug Tier Requirements/Limits
ANTIPSYCHOTICS
1ST GENERATION/TYPICAL CHLORPROMAZINE HCL (10 MG TABLET, 25 MG TABLET, 25 MG/ML AMPUL, 50 MG TABLET, 100 MG TABLET, 200 MG TABLET)
4-Non-Preferred Drug
FLUPHENAZINE DECANOATE 4-Non-Preferred Drug
fluphenazine hcl (1 mg tablet, 2.5 mg/5ml elixir, 2.5 mg tablet, 5 mg tablet, 5 mg/ml oral conc, 10 mg tablet)
2-Generic
FLUPHENAZINE HCL 2.5 MG/ML VIAL 4-Non-Preferred Drug
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Medicare Advantage Plans 2018 Formulary (List of Covered Drugs)
You can find information on what the symbols and abbreviationson this table mean by going to page vii of the Introduction.
33
haloperidol 2-Generic
HALOPERIDOL DECANOATE 4-Non-Preferred Drug
HALOPERIDOL LACTATE (5 MG/ML VIAL, 5 MG/ML AMPUL)
4-Non-Preferred Drug
haloperidol lactate 2 mg/ml oral conc 2-Generic
loxapine succinate 2-Generic
molindone hcl 2-Generic
pimozide 2-Generic
thioridazine hcl 2-Generic PA FOR NEW STARTS ONLY AND FOR 65 YEARS AND OLDER
thiothixene 2-Generic
trifluoperazine hcl 2-Generic
2ND GENERATION/ATYPICAL ABILIFY MAINTENA 5-Specialty
aripiprazole (1 mg/ml solution, 2 mg tablet, 5 mg tablet, 10 mg tablet, 15 mg tablet, 20 mg tablet, 30 mg tablet)
2-Generic
ARIPIPRAZOLE (10 MG TAB RAPDIS, 15 MG TAB RAPDIS)
4-Non-Preferred Drug
ARISTADA 5-Specialty
FANAPT 4-Non-Preferred Drug
GEODON 20 MG/ML VIAL 4-Non-Preferred Drug
QL (6 PER 30 OVER TIME)
INVEGA SUSTENNA 117 MG/0.75 ML 5-Specialty QL (0.75 ML PER 30 OVER TIME)
INVEGA SUSTENNA 156 MG/ML SYRG 5-Specialty QL (1 ML PER 30 OVER TIME)
INVEGA SUSTENNA 234 MG/1.5 ML 5-Specialty QL (1.5 ML PER 30 OVER TIME)
INVEGA SUSTENNA 39 MG/0.25 ML 4-Non-Preferred Drug
QL (0.25 ML PER 30 OVER TIME)
INVEGA SUSTENNA 78 MG/0.5 ML 4-Non-Preferred Drug
QL (0.5 ML PER 30 OVER TIME)
Drug Name Drug Tier Requirements/Limits
-
Medicare Advantage Plans 2018 Formulary (List of Covered Drugs)
You can find information on what the symbols and abbreviationson this table mean by going to page vii of the Introduction.
34
INVEGA TRINZA 5-Specialty
LATUDA 5-Specialty PA FOR NEW STARTS ONLY, QL (1 PER 1 DAYS)
NUPLAZID 5-Specialty PA FOR NEW STARTS ONLY, LA, QL (2 PER 1 DAYS)
olanzapine (2.5 mg tablet, 5 mg tablet, 5 mg tab rapdis, 7.5 mg tablet, 10 mg tab rapdis, 10 mg tablet, 15 mg tab rapdis, 15 mg tablet, 20 mg tablet, 20 mg tab rapdis)
2-Generic
OLANZAPINE 10 MG VIAL 4-Non-Preferred Drug
paliperidone 2-Generic
quetiapine fumarate (25 mg tablet, 50 mg tablet, 100 mg tablet, 200 mg tablet, 300 mg tablet, 400 mg tablet)
2-Generic
QUETIAPINE FUMARATE (50 MG TAB ER 24H, 150 MG TAB ER 24H, 200 MG TAB ER 24H, 300 MG TAB ER 24H, 400 MG TAB ER 24H)
3-Preferred Brand
REXULTI 5-Specialty PA FOR NEW STARTS ONLY
RISPERDAL CONSTA (12.5 MG SYR, 25 MG SYR)
4-Non-Preferred Drug
QL (2 PER 28 OVER TIME)
RISPERDAL CONSTA (37.5 MG SYR, 50 MG SYR)
5-Specialty QL (2 PER 28 OVER TIME)
risperidone (0.25 mg tablet, 0.25 mg tab rapdis, 0.5 mg tab rapdis, 0.5 mg tablet, 1 mg tab rapdis, 1 mg/ml solution, 1 mg tablet, 2 mg tablet, 2 mg tab rapdis, 3 mg tab rapdis, 3 mg tablet, 4 mg tab rapdis, 4 mg tablet)
2-Generic
SAPHRIS 4-Non-Preferred Drug
PA FOR NEW STARTS ONLY
VRAYLAR 4-Non-Preferred Drug
PA FOR NEW STARTS ONLY
ziprasidone hcl 2-Generic
ZYPREXA RELPREVV 4-Non-Preferred Drug
Drug Name Drug Tier Requirements/Limits
-
Medicare Advantage Plans 2018 Formulary (List of Covered Drugs)
You can find information on what the symbols and abbreviationson this table mean by going to page vii of the Introduction.
35
TREATMENT-RESISTANT CLOZAPINE (12.5 MG TAB RAPDIS, 25 MG TAB RAPDIS, 100 MG TAB RAPDIS, 150 MG TAB RAPDIS, 200 MG TAB RAPDIS)
4-Non-Preferred Drug
clozapine (25 mg tablet, 50 mg tablet, 100 mg tablet, 200 mg tablet)
2-Generic
VERSACLOZ 4-Non-Preferred Drug
Drug Name Drug Tier Requirements/Limits
ANTISPASTICITY AGENTS
ANTISPASTICITY AGENTS baclofen 2-Generic
DANTROLENE SODIUM 4-Non-Preferred Drug
tizanidine hcl (2 mg tablet, 4 mg tablet) 2-Generic
ANTIVIRALS
ANTI-CYTOMEGALOVIRUS (CMV) AGENTS FOSCARNET SODIUM 4-Non-Preferred
Drug
GANCICLOVIR SODIUM 4-Non-Preferred Drug
PA TO CONFIRM PART D COVERAGE
VALGANCICLOVIR HCL (50 MG/ML SOLN RECON, 450 MG TABLET)
5-Specialty
ZIRGAN 3-Preferred Brand
ANTI-HEPATITIS B (HBV) AGENTS ADEFOVIR DIPIVOXIL 4-Non-Preferred
Drug
BARACLUDE 0.05 MG/ML SOLUTION 4-Non-Preferred Drug
ENTECAVIR 4-Non-Preferred Drug
-
Medicare Advantage Plans 2018 Formulary (List of Covered Drugs)
You can find information on what the symbols and abbreviationson this table mean by going to page vii of the Introduction.
36
EPIVIR HBV 25 MG/5 ML SOLN 3-Preferred Brand
lamivudine 100 mg tablet 2-Generic
VEMLIDY 5-Specialty
ANTI-HEPATITIS C (HCV) AGENTS, DIRECT ACTING AGENTS DAKLINZA 5-Specialty PA, QL (1 PER 1 DAYS)
EPCLUSA 5-Specialty PA, QL (1 PER 1 DAYS)
HARVONI 5-Specialty PA, QL (1 PER 1 DAYS)
OLYSIO 5-Specialty PA
SOVALDI 5-Specialty PA
TECHNIVIE 5-Specialty PA, QL (2 PER 1 DAYS)
VIEKIRA PAK 5-Specialty PA, QL (4 PER 1 DAYS)
VIEKIRA XR 5-Specialty PA, QL (3 PER 1 DAYS)
ZEPATIER 5-Specialty PA, QL (1 PER 1 DAYS)
ANTI-HEPATITIS C (HCV) AGENTS, OTHER INTRON A (10 MILLION UNITS VIL, 18 MILLION UNIT/3 ML, 18 MILLION UNITS VIL, 25 MILLION UNIT/2.5ML, 50 MILLION UNITS VIL)
5-Specialty
moderiba (200 mg tablet, 400-400 mg dosepack, 600-600 mg dosepack, 600-400 mg dosepack)
2-Generic
PEGASYS (180 MCG/ML VIAL, 180 MCG/0.5 ML SYRINGE)
5-Specialty
PEGASYS PROCLICK 5-Specialty
PEGINTRON 5-Specialty
PEGINTRON REDIPEN 5-Specialty
REBETOL 40 MG/ML SOLUTION 5-Specialty
ribasphere (200 mg tablet, 200 mg capsule)
2-Generic
ribavirin (200 mg capsule, 200 mg tablet)
2-Generic
Drug Name Drug Tier Requirements/Limits
-
Medicare Advantage Plans 2018 Formulary (List of Covered Drugs)
You can find information on what the symbols and abbreviationson this table mean by going to page vii of the Introduction.
37
ANTI-HIV AGENTS, INTEGRASE INHIBITORS (INSTI) GENVOYA 5-Specialty
ISENTRESS (100 MG TABLET CHEW, 400 MG TABLET)
5-Specialty
ISENTRESS (25 MG TABLET CHEW, 100 MG POWDER PACKET)
3-Preferred Brand
ISENTRESS HD 5-Specialty
STRIBILD 5-Specialty
TIVICAY (25 MG TABLET, 50 MG TABLET)
5-Specialty
TIVICAY 10 MG TABLET 3-Preferred Brand
ANTI-HIV AGENTS, NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI) ATRIPLA 5-Specialty
COMPLERA 5-Specialty
EDURANT 5-Specialty
INTELENCE (100 MG TABLET, 200 MG TABLET)
5-Specialty
INTELENCE 25 MG TABLET 3-Preferred Brand
nevirapine (50 mg/5 ml oral susp, 100 mg tab er 24h, 200 mg tablet, 400 mg tab er 24h)
2-Generic
ODEFSEY 5-Specialty
RESCRIPTOR 3-Preferred Brand
SUSTIVA 3-Preferred Brand
ANTI-HIV AGENTS, NUCLEOSIDE AND NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTI)
abacavir sulfate 2-Generic
abacavir sulfate/lamivudine 2-Generic
abacavir sulfate/lamivudine/zidovudine 2-Generic
DESCOVY 5-Specialty
didanosine 2-Generic
Drug Name Drug Tier Requirements/Limits
-
Medicare Advantage Plans 2018 Formulary (List of Covered Drugs)
You can find information on what the symbols and abbreviationson this table mean by going to page vii of the Introduction.
38
EMTRIVA (10 MG/ML SOLUTION, 200 MG CAPSULE)
3-Preferred Brand
lamivudine (10 mg/ml solution, 150 mg tablet, 300 mg tablet)
2-Generic
lamivudine/zidovudine 2-Generic
RETROVIR 200 MG/20 ML VIAL 4-Non-Preferred Drug
stavudine (1 mg/ml soln recon, 15 mg capsule, 20 mg capsule, 30 mg capsule, 40 mg capsule)
2-Generic
TRUVADA 5-Specialty
VIDEX 3-Preferred Brand
VIREAD (150 MG TABLET, 200 MG TABLET, 250 MG TABLET, 300 MG TABLET, POWDER)
5-Specialty
ZERIT 1 MG/ML SOLUTION 3-Preferred Brand
ZIAGEN 20 MG/ML SOLUTION 3-Preferred Brand
zidovudine (10 mg/ml syrup, 100 mg capsule, 300 mg tablet)
2-Generic
ANTI-HIV AGENTS, OTHER FUZEON 5-Specialty
SELZENTRY (20 MG/ML ORAL SOLN, 75 MG TABLET, 150 MG TABLET, 300 MG TABLET)
5-Specialty
SELZENTRY 25 MG TABLET 3-Preferred Brand
TRIUMEQ 5-Specialty
TYBOST 3-Preferred Brand
ANTI-HIV AGENTS, PROTEASE INHIBITORS APTIVUS (100 MG/ML SOLUTION, 250 MG CAPSULE)
5-Specialty
CRIXIVAN 3-Preferred Brand
EVOTAZ 5-Specialty
INVIRASE 5-Specialty
Drug Name Drug Tier Requirements/Limits
-
Medicare Advantage Plans 2018 Formulary (List of Covered Drugs)
You can find information on what the symbols and abbreviationson this table mean by going to page vii of the Introduction.
39
KALETRA 100-25 MG TABLET 3-Preferred Brand
KALETRA 200-50 MG TABLET 5-Specialty
LEXIVA 50 MG/ML SUSPENSION 3-Preferred Brand
LEXIVA 700 MG TABLET 5-Specialty
lopinavir/ritonavir 2-Generic
NORVIR (80 MG/ML SOLUTION, 100 MG TABLET, 100 MG SOFTGEL CAP)
3-Preferred Brand
PREZCOBIX 5-Specialty
PREZISTA (100 MG/ML SUSPENSION, 600 MG TABLET, 800 MG TABLET)
5-Specialty
PREZISTA (75 MG TABLET, 150 MG TABLET)
3-Preferred Brand
REYATAZ (50 MG POWDER PACKET, 150 MG CAPSULE, 200 MG CAPSULE, 300 MG CAPSULE)
5-Specialty
VIRACEPT 3-Preferred Brand
ANTI-INFLUENZA AGENTS oseltamivir phosphate 2-Generic
RELENZA 3-Preferred Brand
rimantadine hcl 2-Generic
ANTIHERPETIC AGENTS acyclovir (200 mg capsule, 200 mg/5ml oral susp, 400 mg tablet, 800 mg tablet)
2-Generic
ACYCLOVIR SODIUM (50 MG/ML VIAL, 500 MG VIAL, 1000 MG VIAL)
4-Non-Preferred Drug
PA TO CONFIRM PART D COVERAGE
famciclovir 2-Generic
TRIFLURIDINE 4-Non-Preferred Drug
valacyclovir hcl 2-Generic
Drug Name Drug Tier Requirements/Limits
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Medicare Advantage Plans 2018 Formulary (List of Covered Drugs)
You can find information on what the symbols and abbreviationson this table mean by going to page vii of the Introduction.
40
Drug Name Drug Tier Requirements/Limits
ANXIOLYTICS
ANXIOLYTICS, OTHER buspirone hcl 2-Generic
doxepin hcl (10 mg/ml oral conc, 10 mg capsule, 25 mg capsule, 50 mg capsule, 75 mg capsule, 100 mg capsule, 150 mg capsule)
2-Generic
BENZODIAZEPINES clonazepam 2-Generic PA FOR NEW STARTS ONLY
clorazepate dipotassium 2-Generic PA FOR NEW STARTS ONLY
diazepam (2 mg tablet, 5 mg/5 ml solution, 5 mg tablet, 5 mg/ml oral conc, 10 mg tablet)
2-Generic PA FOR NEW STARTS ONLY
lorazepam (0.5 mg tablet, 1 mg tablet, 2 mg tablet, 2 mg/ml oral conc)
2-Generic
lorazepam intensol 2-Generic
oxazepam 2-Generic
BIPOLAR AGENTS
MOOD STABILIZERS lithium carbonate 2-Generic
lithium citrate 2-Generic
BLOOD GLUCOSE REGULATORS
ANTIDIABETIC AGENTS acarbose 2-Generic
ALOGLIPTIN BENZOATE 4-Non-Preferred Drug
PA, QL (1 PER 1 DAYS)
ALOGLIPTIN BENZOATE/METFORMIN HCL
4-Non-Preferred Drug
PA
ALOGLIPTIN BENZOATE/PIOGLITAZONE HCL
4-Non-Preferred Drug
PA, QL (1 PER 1 DAYS)
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Medicare Advantage Plans 2018 Formulary (List of Covered Drugs)
You can find information on what the symbols and abbreviationson this table mean by going to page vii of the Introduction.
41
BYDUREON 3-Preferred Brand
BYDUREON PEN 3-Preferred Brand
BYETTA 3-Preferred Brand
CYCLOSET 4-Non-Preferred Drug
FARXIGA 4-Non-Preferred Drug
PA
glimepiride 1-Preferred Generic
glipizide 1-Preferred Generic
glipizide/metformin hcl 2-Generic
GLYXAMBI 4-Non-Preferred Drug
PA
INVOKAMET 4-Non-Preferred Drug
PA
INVOKAMET XR 4-Non-Preferred Drug
PA
INVOKANA 4-Non-Preferred Drug
PA
JANUMET 4-Non-Preferred Drug
PA
JANUMET XR (50-1,000 MG TABLET, 100-1,000 MG TABLET)
4-Non-Preferred Drug
PA, QL (1 PER 1 DAYS)
JANUMET XR 50-500 MG TABLET 4-Non-Preferred Drug
PA, QL (2 PER 1 DAYS)
JANUVIA 4-Non-Preferred Drug
PA, QL (1 PER 1 DAYS)
JARDIANCE 4-Non-Preferred Drug
PA
JENTADUETO 4-Non-Preferred Drug
PA
JENTADUETO XR 4-Non-Preferred Drug
PA
KAZANO 4-Non-Preferred Drug
PA
Drug Name Drug Tier Requirements/Limits
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Medicare Advantage Plans 2018 Formulary (List of Covered Drugs)
You can find information on what the symbols and abbreviationson this table mean by going to page vii of the Introduction.
42
KOMBIGLYZE XR (5-1,000 MG TAB, 5-500 MG TABLET)
4-Non-Preferred Drug
PA, QL (1 PER 1 DAYS)
KOMBIGLYZE XR 2.5-1,000 MG TAB 4-Non-Preferred Drug
PA, QL (2 PER 1 DAYS)
metformin hcl (500 mg tablet, 750 mg tab er 24h, 850 mg tablet, 1000 mg tablet)
1-Preferred Generic
metformin hcl 500 mg tab er 24h (generic for glucophage xr)
1-Preferred Generic
nateglinide 2-Generic
NESINA 4-Non-Preferred Drug
PA, QL (1 PER 1 DAYS)
ONGLYZA 4-Non-Preferred Drug
PA, QL (1 PER 1 DAYS)
OSENI 4-Non-Preferred Drug
PA, QL (1 PER 1 DAYS)
pioglitazone hcl 1-Preferred Generic
pioglitazone hcl/glimepiride 2-Generic
pioglitazone hcl/metformin hcl 2-Generic
repaglinide 2-Generic
RIOMET 4-Non-Preferred Drug
SYMLINPEN 120 5-Specialty PA, QL (10.8 ML PER 30 OVER TIME)
SYMLINPEN 60 5-Specialty PA, QL (6 ML PER 30 OVER TIME)
SYNJARDY 4-Non-Preferred Drug
PA
SYNJARDY XR 4-Non-Preferred Drug
PA
tolbutamide 2-Generic
TRADJENTA 4-Non-Preferred Drug
PA, QL (1 PER 1 DAYS)
VICTOZA 2-PAK 3-Preferred Brand QL (9 ML PER 30 OVER TIME)
VICTOZA 3-PAK 3-Preferred Brand QL (9 ML PER 30 OVER TIME)
Drug Name Drug Tier Requirements/Limits
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Medicare Advantage Plans 2018 Formulary (List of Covered Drugs)
You can find information on what the symbols and abbreviationson this table mean by going to page vii of the Introduction.
43
XIGDUO XR 4-Non-Preferred Drug
PA
GLYCEMIC AGENTS GLUCAGON EMERGENCY KIT 3-Preferred Brand QL (2 PER 30 OVER TIME)
PROGLYCEM 4-Non-Preferred Drug
INSULINS HUMALOG 3-Preferred Brand
HUMALOG JUNIOR KWIKPEN 3-Preferred Brand
HUMALOG KWIKPEN U-100 3-Preferred Brand
HUMALOG KWIKPEN U-200 3-Preferred Brand
HUMALOG MIX 50-50 3-Preferred Brand
HUMALOG MIX 50-50 KWIKPEN 3-Preferred Brand
HUMALOG MIX 75-25 3-Preferred Brand
HUMALOG MIX 75-25 KWIKPEN 3-Preferred Brand
humulin 70-30 2-Generic
humulin 70/30 kwikpen 2-Generic
humulin n 2-Generic
humulin n kwikpen 2-Generic
humulin r 2-Generic
humulin r u-500 2-Generic
humulin r u-500 kwikpen 2-Generic
LANTUS 3-Preferred Brand
LANTUS SOLOSTAR 3-Preferred Brand
LEVEMIR 3-Preferred Brand
LEVEMIR FLEXTOUCH 3-Preferred Brand
TOUJEO SOLOSTAR 3-Preferred Brand
TRESIBA FLEXTOUCH U-100 3-Preferred Brand
TRESIBA FLEXTOUCH U-200 3-Preferred Brand
Drug Name Drug Tier Requirements/Limits
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Medicare Advantage Plans 2018 Formulary (List of Covered Drugs)
You can find information on what the symbols and abbreviationson this table mean by going to page vii of the Introduction.
44
Drug Name Drug Tier Requirements/Limits
BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS
ANTICOAGULANTS ELIQUIS 3-Preferred Brand
ENOXAPARIN SODIUM (100 MG/ML SYRINGE, 150 MG/ML SYRINGE)
4-Non-Preferred Drug
QL (2 ML PER 1 DAYS)
ENOXAPARIN SODIUM (80MG/0.8ML SYRINGE, 120MG/.8ML SYRINGE)
4-Non-Preferred Drug
QL (1.6 ML PER 1 DAYS)
ENOXAPARIN SODIUM 30MG/0.3ML SYRINGE
4-Non-Preferred Drug
QL (0.6 ML PER 1 DAYS)
ENOXAPARIN SODIUM 40MG/0.4ML SYRINGE
4-Non-Preferred Drug
QL (0.8 ML PER 1 DAYS)
ENOXAPARIN SODIUM 60MG/0.6ML SYRINGE
4-Non-Preferred Drug
QL (1.2 ML PER 1 DAYS)
FONDAPARINUX SODIUM 10MG/0.8ML SYRINGE
5-Specialty QL (0.8 ML PER 1 DAYS)
FONDAPARINUX SODIUM 2.5 MG/0.5 SYRINGE
4-Non-Preferred Drug
QL (0.5 ML PER 1 DAYS)
FONDAPARINUX SODIUM 5MG/0.4ML SYRINGE
5-Specialty QL (0.4 ML PER 1 DAYS)
FONDAPARINUX SODIUM 7.5MG/0.6 SYRINGE
5-Specialty QL (0.6 ML PER 1 DAYS)
FRAGMIN (2,500 UNITS/0.2 ML SYR, 5,000 UNITS/0.2 ML SYR)
4-Non-Preferred Drug
QL (6 ML PER 30 OVER TIME)
FRAGMIN (25,000 UNITS/ML VIAL, 95,000 UNITS/3.8 ML VL)
5-Specialty QL (30.4 ML PER 30 OVER TIME)
FRAGMIN 10,000 UNITS/ML SYRING 5-Specialty QL (30 ML PER 30 OVER TIME)
FRAGMIN 12,500 UNITS/0.5 ML 5-Specialty QL (15 ML PER 30 OVER TIME)
FRAGMIN 15,000 UNITS/0.6 ML 5-Specialty QL (18 ML PER 30 OVER TIME)
FRAGMIN 18,000 UNITS/0.72 ML 5-Specialty QL (21.6 ML PER 30 OVER TIME)
FRAGMIN 7,500 UNITS/0.3 ML SYR 5-Specialty QL (9 ML PER 30 OVER TIME)
HEPARIN SODIUM,PORCINE (5000/ML VIAL, 5000/ML(1) CARTRIDGE, 10000/ML VIAL, 20000/ML VIAL)
4-Non-Preferred Drug
-
Medicare Advantage Plans 2018 Formulary (List of Covered Drugs)
You can find information on what the symbols and abbreviationson this table mean by going to page vii of the Introduction.
45
HEPARIN SODIUM,PORCINE 1000/ML VIAL
4-Non-Preferred Drug
PA TO CONFIRM PART D COVERAGE
HEPARIN SODIUM,PORCINE IN 0.45 % SODIUM CHLORIDE
4-Non-Preferred Drug
HEPARIN SODIUM,PORCINE/DEXTROSE 5 % IN WATER
4-Non-Preferred Drug
HEPARIN SODIUM,PORCINE/PF 1000/ML VIAL
4-Non-Preferred Drug
PA TO CONFIRM PART D COVERAGE
HEPARIN SODIUM,PORCINE/PF 5000/0.5ML VIAL
4-Non-Preferred Drug
jantoven 2-Generic
PRADAXA 4-Non-Preferred Drug
SAVAYSA 4-Non-Preferred Drug
warfarin sodium 2-Generic
XARELTO 3-Preferred Brand
BLOOD FORMATION MODIFIERS anagrelide hcl 2-Generic
ARANESP (10 MCG/0.4 ML SYRINGE, 25 MCG/0.42 ML SYRING, 25 MCG/ML VIAL, 40 MCG/ML VIAL, 40 MCG/0.4 ML SYRINGE, 60 MCG/0.3 ML SYRINGE, 60 MCG/ML VIAL, 100 MCG/0.5 ML SYRINGE)
4-Non-Preferred Drug
PA
ARANESP (100 MCG/ML VIAL, 150 MCG/0.3 ML SYRINGE, 150 MCG/0.75 ML VIAL, 200 MCG/0.4 ML SYRINGE, 200 MCG/ML VIAL, 300 MCG/0.6 ML SYRINGE, 300 MCG/ML VIAL, 500 MCG/1 ML SYRINGE)
5-Specialty PA
EPOGEN (2,000 UNITS/ML VIAL, 3,000 UNITS/ML VIAL, 4,000 UNITS/ML VIAL, 10,000 UNITS/ML VIAL, 20,000 UNITS/2 ML VIAL)
4-Non-Preferred Drug
PA
EPOGEN (20,000 VIAL, 40,000 VIAL) 5-Specialty PA
Drug Name Drug Tier Requirements/Limits
-
Medicare Advantage Plans 2018 Formulary (List of Covered Drugs)
You can find information on what the symbols and abbreviationson this table mean by going to page vii of the Introduction.
46
GRANIX 5-Specialty
LEUKINE 250 MCG VIAL 5-Specialty
MOZOBIL 5-Specialty QL (2.4 ML PER 1 DAYS)
NEULASTA 5-Specialty QL (1.2 ML PER 28 OVER TIME)
NEUPOGEN 5-Specialty
PROCRIT (2,000 VIAL, 3,000 VIAL, 4,000 VIAL, 10,000 VIAL)
4-Non-Preferred Drug
PA
PROCRIT (20,000 VIAL, 40,000 VIAL) 5-Specialty PA
PROMACTA 5-Specialty PA
ZARXIO 5-Specialty
HEMOSTASIS AGENTS TRANEXAMIC ACID (1000 MG/10 VIAL, 1000 MG/10 AMPUL)
4-Non-Preferred Drug
tranexamic acid 650 mg tablet 2-Generic
PLATELET MODIFYING AGENTS aspirin/dipyridamole 2-Generic
BRILINTA 3-Preferred Brand
cilostazol 2-Generic
clopidogrel bisulfate 75 mg tablet 2-Generic
EFFIENT 3-Preferred Brand
Drug Name Drug Tier Requirements/Limits
CARDIOVASCULAR AGENTS
ALPHA-ADRENERGIC AGONISTS CLONIDINE 4-Non-Preferred
Drug
clonidine hcl (0.1 mg tablet, 0.2 mg tablet, 0.3 mg tablet)
1-Preferred Generic
midodrine hcl 2-Generic
NORTHERA 5-Specialty PA, LA
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Medicare Advantage Plans 2018 Formulary (List of Covered Drugs)
You can find information on what the symbols and abbreviationson this table mean by going to page vii of the Introduction.
47
ALPHA-ADRENERGIC BLOCKING AGENTS doxazosin mesylate 2-Generic
PHENOXYBENZAMINE HCL 5-Specialty
prazosin hcl 2-Generic
terazosin hcl 1-Preferred Generic
ANGIOTENSIN II RECEPTOR ANTAGONISTS candesartan cilexetil 2-Generic
eprosartan mesylate 2-Generic
irbesartan 1-Preferred Generic