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2015
CIGNA-HEALTHSPRING®
COMPREHENSIVE DRUG LIST
(Formulary)
Lista de medicamentos completa
de Cigna-HealthSpring
(Formulario)
Please read: This document contains information about all of the drugs we cover in this plan.
Favor de leer: Este documento incluye información sobre todos los medicamentos que se cubren
con este plan.
Plans covered / Planes en cobertura
Cigna-HealthSpring Primary (HMO)
Cigna-HealthSpring TotalCare (HMO SNP)
Cigna-HealthSpring TotalCare AR (HMO SNP)
Cigna-HealthSpring TotalCare SMS (HMO SNP)
Cigna-HealthSpring Traditions (HMO SNP)
This drug list was updated on August 2014. For more recent information or other questions, please contact Cigna-HealthSpring
Customer Service, at 1-800-668-3813 or, for TTY users, 711, 7 days a week, 8 a.m. – 8 p.m., or visit www.cignahealthspring.com.
Esta lista de medicamentos se actualizó en agosto de 2014. Para información más reciente u otras preguntas, favor de
contactar al Departamento de servicio al cliente de Cigna-HealthSpring, al 1-800-668-3813 o, para los usuarios de TTY, 711,
7 días de la semana, 8 a.m. – 8 p.m., o visite www.cignahealthspring.com.
Cigna-HealthSpring is contracted with Medicare for PDP plans, HMO and PPO plans in select states, and with select State
Medicaid programs. Enrollment in Cigna-HealthSpring depends on contract renewal. Cigna-HealthSpring tiene contrato con
Medicare para planes PDP, y planes HMO y PPO en ciertos estados, y con ciertos programas estatales de Medicaid. La inscripción
en Cigna-HealthSpring depende de la renovación de contrato.
HPMS Approved Formulary File Submission ID 15164, Version Number 5 Y0036_15_18973bBL_Final_1 Approved 08152014
Note to existing customers: This drug list 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 Cigna-HealthSpring. When it refers to “plan” or “our plan,” it
means Cigna-HealthSpring Primary (HMO), Cigna-HealthSpring TotalCare (HMO SNP), Cigna-HealthSpring TotalCare AR (HMO
SNP), Cigna-HealthSpring TotalCare SMS (HMO SNP), or Cigna-HealthSpring Traditions (HMO SNP).
This document includes a list of the drugs for our plan which is current as of August 2014. For an updated drug list, please
contact us. Our contact information, along with the date we last updated the drug list, 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, 2016, and from time to time during the year.
What is the Cigna-HealthSpring Comprehensive Drug List?
A drug list is a list of covered drugs selected by Cigna-HealthSpring 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. Cigna-HealthSpring will
generally cover the drugs listed in our drug list as long as the drug is medically necessary, the prescription is filled at a CignaHealthSpring 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 Drug List (formulary) change?
Generally, if you are taking a drug on our 2015 drug list that was covered at the beginning of the year, we will not discontinue or
reduce coverage of the drug during the 2015 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 drug list changes, such
as removing a drug from our drug list, will not affect customers who are currently taking the drug. It will remain available at the
same cost-sharing for those customers 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 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 drug list, 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 customers of the change at least 60 days before the change becomes
effective, or at the time the customer requests a refill of the drug, at which time the customer will receive a 60-day supply of the
drug. If the Food and Drug Administration deems a drug on our drug list to be unsafe or the drug’s manufacturer removes the
drug from the market, we will immediately remove the drug from our drug list and provide notice to customers who take the drug.
The enclosed drug list is current as of August 2014. To get updated information about the drugs covered by Cigna-HealthSpring,
please contact us. Our contact information appears on the front and back cover pages. If there are significant changes made to
the printed drug list within the covered year, you may be notified by mail identifying the changes. Drug lists located on our website
are reviewed and updated on a monthly basis.
How do I use the Drug List?
There are two ways to find your drug within the drug list:
Medical Condition
The drug list begins on page 30. The drugs in this drug list 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 30. Then look under the category name for your drug.
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Alphabetical Listing
If you are not sure what category to look under, you should look for your drug in the Alphabetical Drug List section that begins on
page 1. The Alphabetical Drug List provides a list of all of the drugs included in this document. Both brand name drugs and
generic drugs are in the Drug List. Look in the Alphabetical Drug List section of the document and find your drug. Next to your
drug, you will see the drug tier, requirements/limits (Reqs./Limits), and page number where you can find coverage information.
Turn to the page listed in the Alphabetical Drug List section and find the name of your drug in the first column of the list.
What are generic drugs?
Cigna-HealthSpring 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: Cigna-HealthSpring requires you or your doctor to get prior authorization for certain drugs. This
means that you will need to get approval from Cigna-HealthSpring before you fill your prescriptions. If you don’t get
approval, Cigna-HealthSpring may not cover the drug.
 Quantity Limits: For certain drugs, Cigna-HealthSpring limits the amount of the drug that Cigna-HealthSpring will cover.
For example, Cigna-HealthSpring provides 30 (tablets) per prescription for CRESTOR. This may be in addition to a
standard one-month or three-month supply.
 Step Therapy: In some cases, Cigna-HealthSpring 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,
Cigna-HealthSpring may not cover Drug B unless you try Drug A first. If Drug A does not work for you, CignaHealthSpring will then cover Drug B.
You can find out if your drug has any additional requirements or limits by looking in the drug list 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 drug list, appears on the front and back cover pages.
You can ask Cigna-HealthSpring 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 Cigna-HealthSpring’s drug list?” on page A4 for
information about how to request an exception.
Options for Maintenance Medications
Taking the medications prescribed by your doctor is important to your health.
We are committed to helping you achieve control of chronic conditions by making it easy for you to receive your maintenance
medications. As part of our commitment to coordinating your healthcare needs, we have set a goal of helping you take your
medications at least 80% of the time. There are several ways we can work together to accomplish this goal:


Talk with your doctor about whether a 90 day supply of your ongoing, stable medications may be appropriate. Taking
these medications every day as prescribed is important for your overall health, and getting 90 day prescriptions of these
medications can ensure that you don’t miss a dose.
Talk to your pharmacist if you are experiencing any new challenges with your maintenance medications.
How can I use my prescription drug coverage to save money on my medications?
There may be opportunities for you to save money on your medications using your Cigna-HealthSpring coverage.

Ask your doctor if there are any lower-cost generic alternatives available for any of your current medications.

Explore whether the ‘CMS extra help’ program may offer additional financial support for your medications.
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
If your medication is not covered on the Cigna-HealthSpring drug list, talk with your doctor about alternative medications
which are covered in the drug list.
What if my drug is not in the Drug List?
If your drug is not included in this drug list, you should first contact Customer Service and ask if your drug is covered. If you learn
that Cigna-HealthSpring does not cover your drug, you have two options:


You can ask Customer Service for a list of similar drugs that are covered by Cigna-HealthSpring. When you receive the
list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Cigna-HealthSpring.
You can ask Cigna-HealthSpring to make an exception and cover your drug. See below for information about how to
request an exception.
How do I request an exception to the Cigna-HealthSpring’s Drug List?
You can ask Cigna-HealthSpring 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 in our drug list. If approved, this drug will be covered at a pre-determined
cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.

You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Cigna-HealthSpring
limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and
cover a greater amount.
Generally, Cigna-HealthSpring will only approve your request for an exception if the alternative drugs included on the plan’s drug
list, 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 drug list, tiering or utilization restriction exception. When you
request a drug list, tiering or utilization restriction exception you should submit a statement from your prescriber or
doctor 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.
What do I do before I can talk to my doctor about changing my drugs or requesting an exception?
As a new or continuing customer in our plan you may be taking drugs that are not in our drug list. Or, you may be taking a drug
that is on our drug list 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 drug list 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 customer of our plan.
For each of your drugs that is not on our drug list 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 customer 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 a 93day 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 customer of our plan. If you need a drug that is not in our drug list
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 drug list exception.
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In order to accommodate unexpected transitions of our customers that do not leave time for advanced planning, such as level-ofcare changes due to discharge from a hospital to a nursing facility or to a home, Cigna-HealthSpring will allow a one-time 31-day
supply (unless the prescription is written for fewer days).
For more information
For more detailed information about your Cigna-HealthSpring prescription drug coverage, please review your Evidence of
Coverage and other plan materials.
If you have questions about Cigna-HealthSpring, please contact us. Our contact information, along with the date we last updated
the drug list, appears on the front and back cover pages.
If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-6334227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov.
If you are a customer of Cigna-HealthSpring please contact your state’s Medicaid Agency to find out which drugs are covered
under Medicaid. For your state Medicaid Agency contact information, please refer to Chapter 2 section of your Evidence of
Coverage.
Cigna-HealthSpring’s Drug List
The comprehensive drug list provides coverage information about all of the drugs covered by Cigna-HealthSpring. If you have
trouble finding your drug in the list, turn to the Alphabetical Drug List that begins on page 1.
The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., CRESTOR) and generic drugs are listed
in lower-case italics (e.g., simvastatin).
The information in the Requirements/Limits column tells you if Cigna-HealthSpring has any special requirements for coverage of
your drug.
We provide quantity limits on certain drugs which are indicated with a QL in the Alphabetical Drug list on page 1 along with the
amount dispensed per the days supplied. (For example: CRESTOR 30/30; this means the drug CRESTOR is limited to 30 tablets
per 30 days).
Key:
B/D = This prescription drug has a Part B versus D administrative prior authorization requirement. This drug may be
covered under Medicare Part B or D depending on circumstances. Information may need to be submitted describing use
and setting of the drug to make the determination.
PA = This drug requires prior authorization
QL = This drug has quantity limits
ST = This drug has step therapy requirements
Generally all medications in the drug list are available through mail order, except when special circumstances or situations prohibit
mailing a particular medication to your home.
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Nota para los clientes: Esta lista de medicamentos ha cambiado desde el año pasado. Favor de revisar el documento y
asegurarse de que los medicamentos que toma aún se encuentren en la lista.
Cuando esta lista de medicamentos (formulario) se refiera a “nosotros”, “nos”, o “nuestro”, esto significa CignaHealthSpring. Cuando se refiera al “plan” o “nuestro plan”, significa Cigna-HealthSpring Primary (HMO), Cigna-HealthSpring
TotalCare (HMO SNP), Cigna-HealthSpring TotalCare AR (HMO SNP), Cigna-HealthSpring TotalCare SMS (HMO SNP), o
Cigna-HealthSpring Traditions (HMO SNP).
Este documento incluye una lista de los medicamentos para nuestro plan, la cual se actualizó en agosto de 2014. Para una
versión actualizada de la lista de medicamentos, por favor póngase en contacto con nosotros. Nuestra información de
contacto, junto con la fecha de la última actualización de la lista de medicamentos, aparece en la portada y al reverso de
este folleto.
Por lo general, debe acudir a farmacias de la red para usar su beneficio de medicamentos recetados. Es posible que los
beneficios, el formulario, las farmacias de la red, y/o copagos/coseguros cambien el 1 de enero de 2016, y de vez en cuando
durante el año.
¿Qué es la Lista de medicamentos completa de Cigna-HealthSpring?
Una lista de medicamentos es una lista de medicamentos que selecciona Cigna-HealthSpring, en conjunto con un equipo de
proveedores de servicios de atención médica, y que representa las terapias con medicamentos recetados que se considera son
una parte esencial de un programa de tratamiento de calidad. En general, Cigna-HealthSpring cubre los medicamentos incluidos
en nuestra lista de medicamentos, siempre que sean médicamente necesarios, la receta se surta en una farmacia de la red de
Cigna-HealthSpring y se respeten las otras reglas del plan. Para más información sobre cómo surtir sus recetas, consulte la
Evidencia de cobertura.
¿Puede cambiar la Lista de medicamentos (Formulario)?
Por lo general, si está tomando un medicamento que se encontraba en nuestra Lista de medicamentos del 2015 a
principios del año, no dejaremos, ni reduciremos la cobertura del medicamento durante el año de cobertura del 2015, a
menos que ponga a la venta un medicamento genérico más económico o se presente información adversa sobre la
seguridad o efectividad del medicamento. Otros tipos de cambios que se hagan a la lista de medicamentos, como el retiro
de algún medicamento, no afectaran a clientes que estén tomando dicho medicamento. Éste seguirá estando disponible y
al mismo costo compartido para dichos clientes, por el resto del año de cobertura. Creemos que es muy importante que
tenga acceso continuo durante el año de cobertura a los medicamentos que estaban disponibles cuando seleccionó nuestro
plan, a menos que se presente la opción de que ahorre dinero o podamos garantizar su seguridad.
Si quitamos medicamentos de la lista de medicamentos, agregamos previa autorización, límites de cantidad y/o restricciones de
terapia escalonada a un medicamento o movemos un medicamento a un nivel de costo compartido más alto, debemos notificar a
los clientes que tomen dicho medicamento con al menos 60 días de anticipación a la fecha en que entre en vigencia el cambio o
cuando el cliente renueve el medicamento, momento en que recibirá un suministro de 60 días. Si la Food and Drug Administration
considera que un medicamento de nuestra lista de medicamentos es poco seguro o el fabricante lo retira del mercado,
retiraremos inmediatamente el medicamento de la lista de medicamentos y daremos aviso a los clientes que lo tomen. La lista de
medicamentos adjunta se actualizó en agosto de 2014. Para obtener información actualizada sobre los medicamentos que cubre
Cigna-HealthSpring, por favor póngase en contacto con nosotros. Nuestra información aparece en la portada y al reverso de este
folleto. En caso de que se hagan cambios importantes a la lista de medicamentos impresa dentro del año en cobertura, es
posible que se le avise por correo sobre cuáles son los cambios. La lista de medicamentos de nuestra página de internet se
revisa y actualiza cada mes.
¿Cómo utilizo la Lista de medicamentos?
Existen dos formas de encontrar un medicamento en la lista de medicamentos:
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Problema médico
La lista de medicamentos comienza en la página 30. Los medicamentos de esta lista de medicamentos están agrupados en
categorías por tipo de problema médico que tratan. Por ejemplo, los medicamentos para tratar una afección cardíaca se incluyen
dentro de la categoría, “AGENTES CARDIOVASCULARES”. Si sabe para lo que se utiliza el medicamento, busque la categoría
en la lista que comienza en la página 30. Después, busque el medicamento bajo dicha categoría.
Lista por orden alfabético
Si no está seguro de la categoría bajo la cual debe buscar, busque el medicamento en la sección de la Lista por orden alfabético
de medicamentos que comienza en la página 1. La lista por orden alfabético de medicamentos proporciona un listado de todos
los medicamentos que aparecen en el documento. Tanto los medicamentos de marca como los genéricos están en la Lista de
medicamentos. Busque en la sección de la Lista por orden alfabético de medicamentos del documento y encuentre su
medicamento. Junto al medicamento, encontrará el nivel del medicamento, los límites/requisitos y el número de la página donde
puede encontrar información sobre la cobertura. Vaya a la página indicada en la sección de la Lista por orden alfabético de
medicamentos y localice el nombre del medicamento en la primera columna de la lista.
¿Qué son los medicamentos genéricos?
Cigna-HealthSpring cubre tanto los medicamentos de marca como los genéricos. Un medicamento genérico está aprobado por la
FDA por tener el mismo ingrediente activo que el medicamento de marca. En general, los medicamentos genéricos cuestan
menos que los de marca.
¿Existe alguna restricción en la cobertura?
Algunos medicamentos que entran en cobertura pueden tener requisitos o límites adicionales de cobertura. Estos requisitos y
límites pueden incluir:

Autorización previa: Cigna-HealthSpring exige que usted o su médico obtengan una autorización previa para ciertos
medicamentos. Esto significa que necesitará de la aprobación de Cigna-HealthSpring antes de surtir sus recetas
médicas. Si no obtiene la aprobación, es posible que Cigna-HealthSpring no cubra el medicamento.

Límites de cantidad: Para ciertos medicamentos, Cigna-HealthSpring limita la cantidad de medicamento que entran en
cobertura. Por ejemplo, Cigna-HealthSpring proporciona 30 (tabletas) por receta médica de CRESTOR. Esto puede ser,
además de un suministro normal de un mes ó tres meses.

Terapia escalonada: En algunos casos, Cigna-HealthSpring le pedirá que pruebe primero con determinados
medicamentos para tratar su enfermedad, antes de cubrir otros. Por ejemplo, si un medicamento A y un medicamento B
sirven para tratar su condición médica, es posible que Cigna-HealthSpring no cubra el medicamento B a menos que
usted pruebe el medicamento A, primero. Si el medicamento A no funciona, entonces Cigna-HealthSpring cubrirá el
medicamento B.
Para saber si un medicamento tiene algún requisito o límite adicional, consulte la lista de medicamentos que comienza en la
página 1. Puede obtener más información sobre las restricciones que se aplican a ciertos medicamentos visitando nuestra
página de Internet. Hemos publicado documentos en línea que explican nuestras restricciones de autorización previa y
terapia escalonada. También puede pedirnos que le enviemos una copia. Nuestra información de contacto, junto con la
fecha de la última actualización de la lista de medicamentos, aparece en la portada y al reverso de este folleto.
Puede solicitarle a Cigna-HealthSpring que haga una excepción a estas restricciones o límites, o pedirle una lista de otros
medicamentos similares que pueden tratar su condición de salud. Consulte la sección “¿Cómo solicito una excepción para la
Lista de medicamentos de Cigna-HealthSpring?" en la página A8 para obtener información sobre cómo solicitar una excepción.
Opciones para Medicamentos de Mantenimiento
Tomar los medicamentos que le receta su médico es importante para su salud.
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Estamos comprometidos a ayudarle a que logre controlar sus enfermedades crónicas facilitándole la obtención de sus
medicamentos de mantenimiento. Como parte de nuestro compromiso para coordinar sus necesidades de atención médica, nos
propusimos la meta de ayudarle a tomar sus medicamentos al menos el 80% del tiempo. Hay varias maneras en las que
podemos trabajar juntos para lograr esta meta:


Hablar con su médico para saber si sería apropiado un suministro de 90 días de sus medicamentos fijos y regulares.
Tomar estos medicamentos todos los días exactamente como se los receta el médico es importante para su salud en
general, y recibir recetas por 90 días de estos medicamentos puede garantizar que usted no pierda ninguna dosis.
Hablar con su farmacéutico en caso de que tenga dificultades con sus medicamentos de mantenimiento.
¿Cómo puedo usar mi cobertura de medicamentos recetados para ahorrar dinero en la compra de mis medicamentos?
Es posible que haya oportunidades para que ahorre dinero en la compra de sus medicamentos al usar su cobertura de CignaHealthSpring.

Pregúntele a su médico si hay algunas alternativas genéricas de bajo costo disponibles para algunos de sus
medicamentos actuales.

Investigue si el programa de ‘ayuda adicional de CMS’ puede ofrecer ayuda financiera adicional para sus medicamentos.

Si su medicamento no entra en cobertura de la lista de medicamentos de Cigna-HealthSpring, hable con su médico sobre
medicamentos alternos que entren en cobertura en la lista de medicamentos.
¿Qué pasa si mi medicamento no se encuentra la Lista de medicamentos?
En caso de que su medicamento no se incluya en esta lista de medicamentos, debe primero contactar al Departamento de
servicio al cliente y preguntar si su medicamento entra en cobertura. En caso de que le confirmen que Cigna-HealthSpring no
cubre su medicamento, tiene dos opciones:

Puede solicitar al Departamento de servicio al cliente una lista de medicamentos similares que entren en la cobertura de
Cigna-HealthSpring. Cuando la reciba, muéstresela a su médico y pídale que le recete un medicamento similar que entre
en la cobertura de Cigna-HealthSpring.

Puede pedirle a Cigna-HealthSpring que haga una excepción y cubra su medicamento. Consulte a continuación la
información sobre cómo solicitar una excepción.
¿Cómo solicito una excepción a la Lista de medicamentos de Cigna-HealthSpring?
Puede pedirle a Cigna-HealthSpring que haga una excepción a sus reglas de cobertura. Existen varios tipos de excepciones que
puede solicitar que hagamos.

Puede solicitarnos que cubramos un medicamento, incluso si no se encuentra en nuestra lista de medicamentos. Si lo
aprobamos, el medicamento se cubrirá a un nivel de costo compartido predeterminado, y no podrá solicitarnos que le
brindemos el medicamento a un nivel de costo compartido menor.

Puede solicitarnos que retiremos las restricciones o los límites de cobertura de su medicamento. Por ejemplo, para
ciertos medicamentos, Cigna-HealthSpring limita la cantidad de medicamento que cubrirá. Si su medicamento tiene un
límite de cantidad, puede solicitarnos que no apliquemos el límite y cubramos una cantidad mayor.
Por lo general, Cigna-HealthSpring sólo aprobará su solicitud de excepción si los medicamentos alternativos incluidos en la lista
de medicamentos del plan, los medicamentos de un costo compartido más bajo o aquellos a los que se les aplican restricciones
de uso adicionales, no tuviesen la misma efectividad para tratar su enfermedad y/o le ocasionaran efectos médicos adversos.
Póngase en contacto con nosotros para solicitar una decisión sobre la cobertura inicial en el caso de una excepción a la lista de
medicamentos, o a la restricción de uso. Cuando solicite una excepción a la lista de medicamentos, o a la restricción de
uso, debe presentar una declaración de su médico o la persona que le recete, que respalde su solicitud. Por lo general,
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debemos tomar una decisión en un plazo de 72 horas, a partir del momento en que presente la declaración del médico que le
hizo la receta. Puede solicitar una respuesta más expedita (rápida) si usted o su médico creen que su salud resultaría afectada
por la espera del plazo de 72 horas para obtener una respuesta. En caso de que se autorice la respuesta rápida, le daremos una
respuesta en un término de 24 horas después de que recibamos la declaración de su médico o de la persona que realizó la
receta médica.
¿Qué debo hacer antes de decirle a mi médico que quiero cambiar mis medicamentos o solicitar una excepción?
Como cliente nuevo o continuo de nuestro plan, puede estar tomando medicamentos que no se encuentran en nuestra lista de
medicamentos. O bien, es posible que esté tomando un medicamento que se encuentre en nuestra lista de medicamentos, pero
su capacidad para obtenerlo es limitada. Por ejemplo, puede requerir de nuestra autorización previa antes de surtir sus recetas.
Hable con su médico para determinar si debe cambiar a un medicamento que entre en cobertura o solicitar una excepción a la
lista de medicamentos para que se cubra el medicamento que está tomando. Mientras habla con su médico para determinar la
medida correcta a seguir, podremos cubrir su medicamento en ciertos casos durante los primeros 90 días que sea cliente de
nuestro plan.
Para cada uno de los medicamentos que no se encuentran en nuestra lista de medicamentos, o que están limitados, daremos
una cobertura temporal de un suministro de 30 días (a menos que su receta indique un suministro de menos días) cuando acuda
a surtir su receta en un farmacia de la red. Después de su suministro de 30 días, dejaremos de cubrir el costo de estos
medicamentos, incluso si usted ha sido cliente de este plan por menos de 90 días.
Si usted vive en un centro de atención médica de largo plazo, le permitiremos volver a surtir su receta hasta que le hayamos
proporcionado un suministro de transición temporal de 93 días, consistente con el incremento de dispensación, (a menos que su
receta indique un suministro de menos días). Cubriremos más de un relleno (refill) de dichos medicamentos por los primeros 90
días que usted sea cliente de nuestro plan. En caso de que necesite de un medicamento que no se encuentre en la lista de
medicamentos o que esté limitado, y ya tenga más 90 días de su membresía en nuestro plan, cubriremos un suministro de
emergencia de 31 días del medicamento (a menos que su receta indique un suministro de menos días) mientras solicita que se
haga una excepción a la lista de medicamentos.
Para adaptar transiciones inesperadas de nuestros clientes que no permiten hacer planes con anticipación, como los cambios de
nivel de atención para pasar de un hospital a un centro de enfermería especializada o al hogar, Cigna-HealthSpring permitirá un
único suministro de 31 días (a menos que la receta sea por menos días).
Para más información
Para obtener información más detallada sobre su cobertura de medicamentos recetados de Cigna-HealthSpring, consulte su
Evidencia de cobertura y otros materiales del plan.
Si tiene alguna pregunta sobre Cigna-HealthSpring, por favor póngase en contacto con nosotros. Nuestra información de
contacto, junto con la fecha de la última actualización de la lista de medicamentos, aparece en la portada y al reverso de este
folleto.
Si tiene preguntas generales sobre la cobertura de medicamentos recetados de Medicare, llame a Medicare al 1-800-MEDICARE
(1-800-633-4227), las 24 horas del día, los 7 días de la semana. Los usuarios de TTY deben llamar al 1-877-486-2048. O bien,
visite http://www.medicare.gov.
Si usted es cliente de Cigna-HealthSpring, por favor póngase en contacto con su agencia estatal de Medicaid para saber qué
medicamentos entran en cobertura de Medicaid. Para la información de contacto de su agencia estatal de Medicaid, por favor
consulte el Capítulo 2 sección de su Evidencia de cobertura.
Lista de medicamentos de Cigna-HealthSpring
La lista de medicamentos completa siguiente ofrece información sobre la cobertura de todos los medicamentos que cubre CignaHealthSpring. En caso de que tenga problemas para encontrar su medicamento en la lista, consulte la Lista por orden alfabético
de medicamentos que comienza en la página 1.
A9
La primera columna de la tabla indica el nombre del medicamento. Los nombres de los medicamentos de marca están en
mayúscula (p. ej. CRESTOR) y los de medicamentos genéricos en minúscula y cursiva (p. ej. simvastatin).
La información en la columna de Requisitos/Límites indica si Cigna-HealthSpring tiene algún requisito especial para la cobertura
de su medicamento.
Brindamos límites de cantidad para ciertos medicamentos que están indicados con QL en la lista por orden alfabético que
comienza en la página 1 junto con la cantidad despachada para los días suministrados. (Por ejemplo: CRESTOR 30/30; esto
significa que el medicamento CRESTOR está limitado a 30 cápsulas por 30 días).
Clave:
B/D = Este medicamento tiene un requisito de autorización de la Parte B vs la Parte D. El medicamento puede entrar en
cobertura con la Parte B o la D de Medicare, dependiendo de las circunstancias. Debe enviarse información que
describa el uso y la base del medicamento para tomar esta decisión.
PA =
Este medicamento requiere de autorización previa.
QL =
Este medicamento tiene límite de cantidad.
ST =
Este medicamento tiene requerimientos de terapia escalonada.
Generalmente todos los medicamentos de la lista de medicamentos están disponibles a través de la orden por correo, excepto
cuando existan situaciones o circunstancias especiales que prohíban el envío por correo de un medicamento en particular.
A10
Drug Tier and Cost-Share Table
The following table represents the plan name, plan service area, the drug tier number as it appears in the drug list, and the costshare amount for that tier number. Your plan has one tier named “Covered Drugs”. Please refer to the following chart. You may
also refer to your Evidence of Coverage document for additional details.
To locate your drug cost, please refer to the table(s) below to find your service area and the Medicare Advantage plan in
which you are currently enrolled or would like to enroll.
Tabla del nivel del medicamento y costo compartido
La siguiente tabla representa el nombre del plan, el área de servicio del plan, el número de nivel de medicamento, tal y como
aparece en la lista de medicamentos, y la cantidad de costo compartido para ese número de nivel. Su plan tiene un nivel llamado
“Medicamentos en cobertura”. Por favor consulte la siguiente tabla. Para obtener más detalles, puede también consultar su
Evidencia de cobertura
Para localizar el costo de su medicamento, por favor consulte la (s) tabla (s) que están a continuación para encontrar su
área de servicio y el plan de Medicare Advantage en el que actualmente está inscrito o en el que le gustaría inscribirse.
Service Area: Alabama, Arkansas
Área de servicio: Alabama, Arkansas
H0150-007
Cigna-HealthSpring TotalCare (HMO SNP)
Autauga, Baldwin, Bibb, Blount, Cherokee, Chilton,
Colbert, Cullman, Dallas, DeKalb, Elmore, Etowah,
Jackson, Jefferson, Lauderdale, Lawrence, Limestone,
Lowndes, Madison, Marshall, Mobile, Montgomery,
Morgan, Shelby, St. Clair, Talladega, Tuscaloosa, and
Walker.
Standard Retail
Cost-Sharing
30, 60, 90 Days
Standad Mail Order
Cost-Sharing
30 and 90 Days
Costo compartido al
menudeo estándar
30, 60, 90 días
Costo compartido orden
por correo estándar
30 y 90 días
30/60/90 Days
30/60/90 días
30/90 Days
30/90 días
25%
25%
H4454-034
Cigna-HealthSpring TotalCare AR (HMO)
Crittenden, Craighead, Greene, Lawrence, Mississippi,
Poinsett
Tier 1: Covered Drugs
Nivel 1: Medicamentos en cobertura
A11
Service Area: Atlanta
Área de servicio: Atlanta
H0439-002
Cigna-HealthSpring TotalCare (HMO SNP)
Banks, Barrow, Bartow, Butts, Chattooga, Cherokee,
Clarke, Clayton, Cobb (30006, 30007, 30060, 30061,
30063, 30065, 30067, 30068, 30069, 30080, 30081,
30082, 30126, 30168, 30339), Dawson, DeKalb, Fayette,
Floyd, Forsyth, Franklin, Fulton, Greene, Gwinnett,
Habersham, Hall, Jackson, Lumpkin, Madison, Morgan,
Newton, Oconee, Oglethorpe, Pickens, Polk, Rockdale,
Spalding, Stephens, Walton, White
Standard Retail
Cost-Sharing
30, 60, 90 Days
Standard Mail Order
Cost-Sharing
30 and 90 Days
Costo compartido al
menudeo estándar
30, 60, 90 días
Costo compartido orden
por correo estándar
30 y 90 días
30/60/90 Days
30/60/90 días
30/90 Days
30/90 días
25%
25%
Standard Retail
Cost-Sharing
30, 60, 90 Days
Standard Mail Order
Cost-Sharing
30 and 90 Days
Costo compartido al
menudeo estándar
30, 60, 90 días
Costo compartido orden
por correo estándar
30 y 90 días
30/60/90 Days
30/60/90 días
30/90 Days
30/90 días
25%
25%
Tier 1: Covered Drugs
Nivel 1: Medicamentos en cobertura
Service Area: Illinois, Indiana
Área de servicio: Illinois, Indiana
H1415-005
Cigna-HealthSpring TotalCare (HMO SNP)
Cook, DuPage, Kane, Will
H1415-024, H3945-002
Cigna-HealthSpring Primary (HMO)
Cook, DuPage, Kane, Will
Lake, Indiana
Tier 1: Covered Drugs
Nivel 1: Medicamentos en cobertura
A12
Service Area: Florida, Mississippi, North
Carolina
Área de servicio: Florida, Mississippi, North
Carolina
H5410-013
Cigna-HealthSpring TotalCare (HMO SNP)
Bay, Escambia, Santa Rosa, Walton, Okaloosa
H4407-004
Cigna-HealthSpring TotalCare SMS (HMO SNP)
Covington, Forrest, George, Hancock, Harrison, Hinds,
Jackson, Jones, Lamar, Madison, Marion, Pearl River,
Perry, Ranking, Stone
Standard Retail
Cost-Sharing
30, 60, 90 Days
Standard Mail Order
Cost-Sharing
30 and 90 Days
Costo compartido al
menudeo estándar
30, 60, 90 días
Costo compartido orden
por correo estándar
30 y 90 días
30/60/90 Days
30/60/90 días
30/90 Days
30/90 días
25%
25%
Standard Retail
Cost-Sharing
30, 60, 90 Days
Standard Mail Order
Cost-Sharing
30 and 90 Days
Costo compartido al
menudeo estándar
30, 60, 90 días
Costo compartido orden
por correo estándar
30 y 90 días
30/60/90 Days
30/60/90 días
30/90 Days
30/90 días
25%
25%
H9725-003
Cigna-HealthSpring TotalCare (HMO SNP)
Cabarrus, Davidson, Davie, Forsyth, Gaston, Rowan,
Stokes, Yadkin, Catawba, Iredell, Alexander, Lincoln,
Union
Tier 1: Covered Drugs
Nivel 1: Medicamentos en cobertura
Service Area: Mid Atlantic
Área de servicio: Mid Atlantic
H2108-001
Cigna-HealthSpring TotalCare (HMO SNP)
Anne Arundel, Baltimore, Baltimore City, Harford, Howard,
Montgomery, and Prince Georges, MD; Washington, DC;
Kent, New Castle, Sussex, DE
Tier 1: Covered Drugs
Nivel 1: Medicamentos en cobertura
A13
Service Area: Mid Atlantic
Área de servicio: Mid Atlantic
H2108-020
Cigna-HealthSpring Traditions (HMO SNP)
Anne Arundel, Baltimore, Baltimore City, Harford, Howard,
Montgomery, and Prince Georges, MD; Washington, DC;
Kent, New Castle, Sussex, DE
Standard Retail
Cost-Sharing
30, 60, 90 Days
Standard Mail Order
Cost-Sharing
30 and 90 Days
Costo compartido al
menudeo estándar
30, 60, 90 días
Costo compartido orden
por correo estándar
30 y 90 días
30/60/90 Days
30/60/90 días
30/90 Days
30/90 días
25%
Not covered
Standard Retail
Cost-Sharing
30, 60, 90 Days
Standard Mail Order
Cost-Sharing
30 and 90 Days
Costo compartido al
menudeo estándar
30, 60, 90 días
Costo compartido orden
por correo estándar
30 y 90 días
30/60/90 Days
30/60/90 días
30/90 Days
30/90 días
25%
25%
Standard Retail
Cost-Sharing
30, 60, 90 Days
Standard Mail Order
Cost-Sharing
30 and 90 Days
Costo compartido al
menudeo estándar
30, 60, 90 días
30/60/90 Days
30/60/90 días
Costo compartido orden
por correo estándar
30 y 90 días
30/90 Days
30/90 días
25%
Not covered
Tier 1: Covered Drugs
Nivel 1: Medicamentos en cobertura
Service Area: Pennsylvania
Área de servicio: Pennsylvania
H3949-009
Cigna-HealthSpring TotalCare (HMO SNP)
Bucks, Chester, Cumberland, Delaware, Lancaster,
Montgomery, Philadelphia, York
Tier 1: Covered Drugs
Nivel 1: Medicamentos en cobertura
Service Area: Pennsylvania
Área de servicio: Pennsylvania
H3949-016
Cigna-HealthSpring Traditions (HMO SNP)
Bucks, Chester, Delaware, Montgomery, Philadelphia,
Tier 1: Covered Drugs
Nivel 1: Medicamentos en cobertura
A14
Service Area: Tennessee
Área de servicio: Tennessee
H4454-020
Cigna-HealthSpring TotalCare (HMO SNP)
Bedford, Benton, Cannon, Carroll, Cheatham, Chester,
Clay, Coffee, Crockett, Cumberland, Davidson, Decatur,
DeKalb, Dickson, Fayette, Fentress, Gibson, Giles,
Hardeman, Hardin, Haywood, Henderson, Hickman,
Houston, Humphreys, Jackson, Lauderdale, Lawrence,
Lewis, Lincoln, Macon, Madison, Marshall, Maury,
McNairy, Montgomery, Moore, Overton, Perry, Pickett,
Putnam, Robertson, Rutherford, Shelby, Smith, Stewart,
Sumner, Tipton, Trousdale, Van Buren, Warren, Wayne,
White, Williamson, Wilson
Standard Retail
Cost-Sharing
30, 60, 90 Days
Standard Mail Order
Cost-Sharing
30 and 90 Days
Costo compartido al
menudeo estándar
30, 60, 90 días
Costo compartido al
menudeo estándar
30, 60, 90 días
30/60/90 Days
30/60/90 días
30/90 Days
30/90 días
25%
25%
H4454-028
Cigna-HealthSpring Primary (HMO)
Bradley, Grundy, Hamilton, Marion, McMinn, Meigs,
Sequatchie
Tier 1: Covered Drugs
Nivel 1: Medicamentos en cobertura
A15
Service Area: Texas
Área de servicio: Texas
H4513-010
Cigna-HealthSpring TotalCare (HMO SNP)
Angelina, Brazoria, Cameron, Chambers, Fort Bend,
Galveston (77510, 77511, 77517, 77518, 77539, 77546,
77549, 77563. 77565, 77568, 77573, 77574, 77590,
77591, and 77592), Hardin, Harris, Hidalgo, Jasper,
Jefferson, Liberty, Montgomery, Nacogdoches, Newton,
Orange, Polk, San Jacinto, Tyler, Walker, Waller, Webb,
Willacy
H2165-019
Cigna-HealthSpring TotalCare (HMO SNP)
Cherokee, Grayson, Gregg, Henderson, Lubbock, Rains,
Rusk, Smith, Upshur, Van Zandt, Wood
Standard Retail
Cost-Sharing
30, 60, 90 Days
Standard Mail Order
Cost-Sharing
30 and 90 Days
Costo compartido al
menudeo estándar
30, 60, 90 días
Costo compartido al
menudeo estándar
30, 60, 90 días
30/60/90 Days
30/60/90 días
30/90 Days
30/90 días
25%
25%
H4528-002
Cigna-HealthSpring TotalCare (HMO SNP)
Bexar, Collin, Dallas, Denton, El Paso, Hood, Johnson,
Parker, Tarrant, Wise
Tier 1: Covered Drugs
Nivel 1: Medicamentos en cobertura
A16
My Medications
In this section, you can write down all of the medications you are currently taking. You can then find your drug in the following drug
list pages. Look and see what tier your drug is on. Once you find out what tier your drug is on, you can look at the charts before
this page and locate your cost-share for that drug. If you need help locating your drugs and cost-share, please call Customer
Service at 1-800-668-3813, 7 days a week, 8 a.m. – 8 p.m. TTY users can call 711.
Mis medicamentos
En esta sección puede escribir todos los medicamentos que toma actualmente; de esta manera, puede encontrar su
medicamento en las siguientes páginas de la lista de medicamentos, así como buscar y ver en qué nivel está su medicamento.
Una vez que encuentre el nivel en el que está su medicamento, puede buscar en las tablas anteriores a esta página y localizar su
costo compartido para ese medicamento. Si necesita ayuda para localizar sus medicamentos y el costo compartido, por favor
llame al Departamento de servicio al cliente al 1-800-668-3813, 7 días de la semana, 8 a.m. – 8 p.m. Los usuarios de TTY
pueden llamar al 711.
My Medications
Mis medicamentos
Page Number in the
Drug List
Número de página
en la Lista de
medicamentos
Cost-Share through
Cigna-HealthSpring
Costo compartido a
través de
Cigna-HealthSpring
A17
Generic Available?
Generic Cost-Share
¿Existe un genérico
disponible?
Costo compartido
del genérico
Drug Name
A
abacavir
abacavir
sulfate/lamivudine/zidovudine
ABELCET
ABILIFY INJ
ABILIFY ORAL SOLN
ABILIFY TABS
ABILIFY DISCMELT
ABILIFY MAINTENA INJ
300MG
ABILIFY MAINTENA INJ
400MG
ABRAXANE
acamprosate calcium dr
acarbose
acebutolol hcl
acetaminophen/codeine oral
soln
acetaminophen/codeine tabs
300mg 60mg
acetaminophen/codeine tabs
300mg 15mg
acetaminophen/codeine #2
acetaminophen/codeine #3
acetaminophen/codeine #4
acetasol hc
acetazolamide
acetazolamide er
acetazolamide sodium
acetic acid
acetylcysteine inhalation soln
acitretin
ACTHIB
acticin
ACTIMMUNE
ACTONEL TABS 35MG
ACTONEL TABS 30MG, 5MG
acyclovir
acyclovir sodium inj 1000mg,
50mg/ml
ADACEL
Drug Reqs./Limits
Tier
1
1
Page
39
39
1
1
1
1
1
1
PA
ST
QL(900/30) ST
QL(30/30) ST
QL(60/30) ST
QL(1.5/30)
35
38
38
38
38
38
1
QL(2/30)
38
1
1
1
1
1
B/D PA
PA
QL(90/30)
QL(5000/30)
37
31
40
43
30
1
QL(240/30)
30
1
QL(360/30)
30
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
QL(360/30)
QL(360/30)
QL(240/30)
30
30
30
51
43
51
43
51
52
45
49
38
49
50
50
40
40
1
B/D PA
PA
PA
QL(4/28)
QL(30/30)
49
Drug Name
ADAGEN
adefovir dipivoxil
adriamycin
adrucil inj 2.5gm/50ml
ADVAIR DISKUS
ADVAIR HFA
afeditab cr
AFINITOR
AFINITOR DISPERZ
AGGRENOX
a-hydrocort
ak-poly-bac
ala cort
ALA SCALP
ALBENZA
albuterol sulfate nebu 0.5%
albuterol sulfate nebu 0.083%,
0.63mg/3ml, 1.25mg/3ml
albuterol sulfate syrp
albuterol sulfate tabs
albuterol sulfate er
alclometasone dipropionate
alcohol preps pads
ALDURAZYME
alendronate sodium tabs
35mg, 70mg
alendronate sodium tabs
10mg, 40mg, 5mg
ALIMTA INJ 500MG
ALINIA
allopurinol
ALOCRIL
ALORA
ALOXI
alphatrex
alprazolam tabs 0.25mg,
0.5mg
alprazolam tabs 2mg
alprazolam tabs 1mg
alprazolam odt tbdp 0.25mg,
0.5mg
Drug
Tier
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Reqs./Limits
Page
PA
QL(30/30)
B/D PA
B/D PA
QL(60/30)
QL(24/30)
PA QL(30/30)
PA QL(60/30)
QL(60/30)
B/D PA
QL(360/30)
B/D PA
QL(375/30)
45
39
37
36
51
51
43
37
37
42
46
31
46
46
38
52
52
1
1
1
1
1
1
1
PA
QL(4/28)
52
52
52
46
31
45
50
1
QL(30/30)
50
1
1
1
1
1
1
1
1
B/D PA
QL(90/30)
37
38
36
50
47
35
46
40
QL(150/30)
QL(300/30)
QL(90/30)
40
40
40
1
1
1
PA QL(8/28)
B/D PA
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply;
B/D= Drugs covered under Medicare Part B or Part D
Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa;
ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D
1
Nombre del
medicamento
Nivel del
medicamento
Requ./
Límites
QL(150/30)
QL(300/30)
Página
Nombre del
medicamento
Nivel del
Requ./
Página
medicamento Límites
alprazolam odt tbdp 2mg
1
40
amoxicillin/clavulanate
1
32
potassium
alprazolam odt tbdp 1mg
1
40
amoxicillin/clavulanate
1
32
altavera
1
47
potassium
er
alyacen 1/35
1
47
amphetamine/dextroampheta
1 QL(60/30)
44
alyacen 7/7/7
1
47
mine cp24
amantadine hcl
1
40
amphetamine/dextroampheta
1 QL(90/30)
44
AMBISOME
1 PA
35
mine tabs
amcinonide
1
46
AMPHOTEC INJ 50MG
1 PA
35
a-methapred
1
46
amphotericin b
1 PA
35
amifostine
1 B/D PA
37
ampicillin
1
32
amikacin sulfate inj 500mg/2ml 1
31
ampicillin sodium
1
32
amiloride hcl
1
43
ampicillin-sulbactam inj 10gm
1
32
amiloride/hydrochlorothiazide
1
43
5gm, 2gm 1gm
AMINO ACIDS
1 B/D PA
52
AMPYRA
1 PA QL(60/30)
44
aminophylline
1
52
AMTURNIDE
1 ST
43
AMINOSYN
1 B/D PA
52
ANADROL-50
1 PA
47
AMINOSYN
1 B/D PA
52
anagrelide hydrochloride
1
42
7%/ELECTROLYTES
anastrozole
1 QL(30/30)
37
AMINOSYN
1 B/D PA
52
ANDROGEL GEL
1 PA
47
8.5%/ELECTROLYTES
25MG/2.5GM, 50MG/5GM
AMINOSYN II
1 B/D PA
52
ANDROGEL PUMP
1 PA
47
AMINOSYN II
1 B/D PA
52
ANDROXY
1 PA
47
8.5%/ELECTROLYTES
apexicon
1
46
AMINOSYN M
1 B/D PA
52
APOKYN
1 PA QL(60/30)
38
AMINOSYN-HBC
1 B/D PA
52
apraclonidine
1
51
AMINOSYN-HF
1 B/D PA
52
apri
1
47
AMINOSYN-PF
1 B/D PA
52
APRISO
1
50
AMINOSYN-PF 7%
1 B/D PA
52
APTIOM TABS 200MG,
1 QL(30/30)
33
amiodarone hcl inj 50mg/ml
1
43
400MG, 800MG
amiodarone hcl tabs
1
43
APTIOM TABS 600MG
1 QL(60/30)
33
AMITIZA
1 QL(60/30)
46
APTIVUS
1
40
amitriptyline hcl
1 PA
35
ARALAST NP INJ 1000MG
1 B/D PA
52
amlodipine besylate
1
43
aranelle
1
47
amlodipine
1
43
ARANESP ALBUMIN FREE
1 PA
42
besylate/benazepril hcl
INJ 100MCG/0.5ML,
amlodipine
1
43
100MCG/ML, 150MCG/0.3ML,
besylate/benazepril
200MCG/0.4ML, 200MCG/ML,
hydrochloride
25MCG/0.42ML, 25MCG/ML,
ammonium lactate
1
45
300MCG/0.6ML, 300MCG/ML,
amnesteem
1
45
40MCG/0.4ML, 40MCG/ML,
500MCG/ML, 60MCG/0.3ML,
amoxapine
1
35
60MCG/ML
amoxicillin
1
32
ARCALYST
1 PA
49
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply;
B/D= Drugs covered under Medicare Part B or Part D
Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa;
ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D
2
Drug Name
Drug Reqs./Limits Page
Drug Name
Drug Reqs./Limits Page
Tier
Tier
ARRANON
1
37
B
baciim
1
31
ARZERRA
1 B/D PA
38
BACITRACIN INJ
1
31
ascomp/codeine
1 PA QL(180/30)
30
ASTAGRAF XL
1 B/D PA
49
bacitracin ophthalmic oint
1
31
atenolol
1
43
bacitracin/polymyxin b
1
31
baclofen
1
39
atenolol/chlorthalidone
1
43
ATGAM
1 B/D PA
49
BACTROBAN NASAL
1
31
atorvastatin calcium
1 QL(30/30)
44
balsalazide disodium
1
50
atovaquone
1
38
balziva
1
47
atovaquone/proguanil hcl
1
38
BANZEL
1 PA
34
ATRIPLA
1
40
BARACLUDE
1
39
atropine sulfate inj 0.05mg/ml,
1
45
benazepril hcl
1
42
0.1mg/ml
benazepril
1
42
ATROVENT HFA
1 QL(26/30)
51
hcl/hydrochlorothiazide
aubra
1
47
BENICAR
1 QL(30/30) ST
42
augmented betamethasone
1
46
BENICAR HCT
1 QL(30/30) ST
42
dipropionate
benztropine mesylate
1 PA
38
AUGMENTIN SUSR
1
32
betamethasone dipropionate
1
46
125MG/5ML 31.25MG/5ML
betamethasone valerate
1
46
AVASTIN INJ 100MG/4ML
1 B/D PA
38
betaxolol hcl
1
43
AVELOX INJ
1
33
betaxolol hcl
1
51
aviane
1
47
bethanechol chloride
1
46
AVODART
1
46
bicalutamide
1
36
AVONEX
1 PA QL(4/28)
44
BICILLIN L-A
1
32
AVONEX PEN
1 PA QL(4/28)
44
BICNU
1 B/D PA
36
AZACITIDINE
1 B/D PA
37
bisoprolol fumarate
1
43
AZACTAM IN ISO-OSMOTIC
1
32
bisoprolol
1
43
DEXTROSE
fumarate/hydrochlorothiazide
AZASAN
1 B/D PA
49
BIVIGAM
1 B/D PA
49
AZASITE
1
33
bleomycin sulfate
1 B/D PA
37
azathioprine
1 B/D PA
49
BLEPHAMIDE
1
33
azelastine hcl ophthalmic soln
1
50
blephamide s.o.p.
1
33
azelastine hcl nasal soln
1 QL(60/30)
51
BOOSTRIX
1
49
AZILECT
1
38
BOSULIF
1 PA
37
azithromycin inj 500mg
1
33
briellyn
1
47
AZITHROMYCIN PACK
1 QL(3/30)
33
BRILINTA
1 QL(60/30)
42
azithromycin susr 200mg/5ml
1 QL(75/30)
33
BRIMONIDINE TARTRATE
1
51
azithromycin susr 100mg/5ml
1 QL(150/30)
33
OPHTHALMIC SOLN 0.15%
azithromycin tabs
1 QL(12/28)
33
brimonidine tartrate
1
51
AZOPT
1
51
ophthalmic soln 0.2%
aztreonam
1
32
BRINTELLIX
1 QL(30/30) ST
34
azurette
1
47
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply;
B/D= Drugs covered under Medicare Part B or Part D
Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa;
ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D
3
Nombre del
medicamento
Nivel del
medicamento
Requ./
Límites
Página
Nombre del
medicamento
Nivel del
Requ./
medicamento Límites
calcitonin-salmon
1 QL(3.7/30)
calcitrene
1 QL(120/30)
CALCITRIOL OINT
1
calcitriol caps
1
calcitriol inj
1 B/D PA
calcitriol oral soln
1
calcium acetate caps
1
calcium acetate tabs 667mg
1
calcium folinate
1
camila
1
CANCIDAS
1 PA
candesartan cilexetil
1
candesartan
1
cilexetil/hydrochlorothiazide
CAPASTAT SULFATE
1
CAPRELSA
1 PA
captopril
1
captopril/hydrochlorothiazide
1
CARAC
1
CARAFATE SUSP
1
CARBAGLU
1
carbamazepine
1
carbamazepine er
1
carbidopa
1
carbidopa/levodopa
1
carbidopa/levodopa er
1
carbidopa/levodopa odt
1
CARBIDOPA/LEVODOPA/EN
1
TACAPONE
carboplatin
1 B/D PA
carteolol hcl
1
cartia xt
1
carvedilol
1
caziant
1
cefaclor caps
1
cefaclor er
1
cefadroxil
1
cefazolin sodium inj 10gm,
1
1gm, 1gm 5%, 500mg
cefazolin sodium/dextrose inj
1
2gm 3%
cefdinir
1
Página
bromfenac
1
50
bromocriptine mesylate
1
38
budesonide cp24
1
46
budesonide susp 32mcg/act
1 QL(17.2/30)
51
budesonide susp 0.25mg/2ml,
1 B/D PA
51
0.5mg/2ml
QL(120/30)
bumetanide
1
43
BUPHENYL TABS
1
45
buprenorphine hcl inj
1 PA
31
buprenorphine hcl subl
1 PA QL(24/30)
31
buprenorphine hcl/naloxone
1 PA QL(90/30)
31
hcl
buproban
1 QL(60/30)
31
bupropion hcl
1
34
bupropion hcl er tb12 100mg,
1 QL(60/30)
34
200mg
bupropion hcl er tb12 150mg
1 QL(90/30)
34
bupropion hcl sr tb12 150mg
1 QL(60/30)
31
bupropion hcl sr tb12 100mg,
1 QL(60/30)
34
200mg
bupropion hcl sr tb12 150mg
1 QL(90/30)
34
bupropion hcl xl tb24 300mg
1 QL(30/30)
34
bupropion hcl xl tb24 150mg
1 QL(90/30)
34
buspirone hcl
1
40
BUSULFEX
1 B/D PA
36
butal/asa/caff
1 PA QL(180/30)
30
butalbital/acetaminophen/caffe 1 PA QL(180/30)
30
ine
butalbital/acetaminophen/caffe 1 PA QL(180/30)
44
ine/codeine caps 325mg
50mg 40mg 30mg
butalbital/aspirin/caffeine/codei 1 PA QL(180/30)
30
ne
butorphanol tartrate inj
1
30
butorphanol tartrate nasal soln 1 QL(6/30)
30
BYDUREON
1 QL(4/28)
40
BYETTA
1 QL(2.4/30)
40
C
cabergoline
1
48
cafergot
1
36
calcipotriene crea
1
45
calcipotriene external soln
1
45
calcipotriene oint
1 QL(120/30)
45
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply;
B/D= Drugs covered under Medicare Part B or Part D
Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa;
ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D
4
50
45
45
50
50
50
53
53
37
48
35
42
43
36
36
42
42
45
46
53
34
34
38
38
38
38
38
37
51
43
43
47
32
32
32
32
32
32
Drug Name
cefepime inj 1gm, 1gm/50ml
5%, 2gm, 2gm/100ml,
2gm/50ml 5%
cefotaxime sodium
cefotetan
cefoxitin sodium inj 10gm,
1gm, 2gm
cefpodoxime proxetil
cefprozil
ceftazidime inj 1gm, 2gm, 6gm
ceftazidime/dextrose
ceftriaxone in iso-osmotic
dextrose
ceftriaxone sodium
cefuroxime axetil
cefuroxime sodium inj 1.5gm,
7.5gm, 750mg
CELEBREX
CELLCEPT SUSR
CELLCEPT INTRAVENOUS
CELONTIN
cephalexin caps 250mg,
500mg
cephalexin susr
cephalexin tabs
CEREZYME INJ 400UNIT
CERVARIX
CHANTIX
CHANTIX CONTINUING
MONTH PAK
CHANTIX STARTING MONTH
PAK
chateal
CHEMET
chloramphenicol sodium
succinate
chlorhexidine gluconate oral
rinse
chloroquine phosphate
chlorothiazide
chlorothiazide sodium
chlorpromazine hcl
Drug Reqs./Limits
Tier
1
Page
32
Drug Name
Drug Reqs./Limits
Tier
1
Page
chlorthalidone tabs 25mg,
50mg
chlorzoxazone
1 PA
1
32
cholestyramine
1
1
32
cholestyramine light
1
1
32
chorionic gonadotropin
1 PA
ciclopirox sham
1
1
32
ciclopirox susp
1
1
32
ciclopirox nail lacquer
1
1
32
ciclopirox olamine
1
1
32
cidofovir
1
1
32
cilostazol
1
CILOXAN OINT
1
1
32
cimetidine
1
1
32
cimetidine hcl
1
1
32
CINRYZE
1 PA
CIPRO HC
1
1 QL(60/30) ST
30
CIPRODEX
1
1 B/D PA
49
ciprofloxacin inj 400mg/40ml
1
1 B/D PA
49
ciprofloxacin susr
1
1
33
ciprofloxacin er
1
1
32
ciprofloxacin hcl
1
ciprofloxacin i.v.-in d5w
1
1
32
cisplatin inj 100mg/100ml
1 B/D PA
1
32
citalopram hydrobromide oral
1 QL(600/30)
1 B/D PA
45
soln
1
49
citalopram hydrobromide tabs
1 QL(30/30)
1 PA QL(336/365) 31
40mg
1 PA QL(336/365) 31
citalopram hydrobromide tabs
1 QL(60/30)
10mg, 20mg
1 PA QL(106/365) 31
cladribine
1 B/D PA
claravis
1
1
47
clarithromycin
1
1
52
clarithromycin er
1 QL(60/30)
1
31
clindacin etz pledgets
1
clindacin-p
1
1
44
clindamax
1
clindamycin hcl
1
1
38
clindamycin phosphate crea
1
1
43
clindamycin phosphate inj
1
1
43
150mg/ml
1
38
clindamycin phosphate
1
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply;
B/D= Drugs covered under Medicare Part B or Part D
Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa;
ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D
43
52
44
44
47
35
35
35
35
39
42
33
45
45
49
33
33
33
33
33
33
33
37
34
34
34
36
45
33
33
45
45
31
31
31
32
45
5
Nombre del
medicamento
Nivel del
medicamento
external soln
clindamycin phosphate gel
clindamycin phosphate lotn
clindamycin phosphate swab
clindamycin phosphate addvantage
CLINDAMYCIN PHOSPHATE
IN D5W
CLINIMIX 2.75%/DEXTROSE
5%
clinimix 4.25%/dextrose 10%
clinimix 4.25%/dextrose 20%
clinimix 4.25%/dextrose 25%
CLINIMIX 4.25%/DEXTROSE
5%
CLINIMIX 5%/DEXTROSE
15%
CLINIMIX 5%/DEXTROSE
20%
CLINIMIX 5%/DEXTROSE
25%
CLINIMIX E
4.25%/DEXTROSE 25%
clinisol sf 15%
clobetasol propionate crea
clobetasol propionate external
soln
clobetasol propionate foam
clobetasol propionate gel
clobetasol propionate oint
clobetasol propionate e
clobetasol propionate
emollient crea
CLOLAR
clomipramine hcl
clonazepam tabs 0.5mg, 1mg
clonazepam tabs 2mg
clonazepam odt tbdp
0.125mg, 0.25mg, 0.5mg, 1mg
clonazepam odt tbdp 2mg
clonidine hcl ptwk 0.1mg/24hr,
0.2mg/24hr
clonidine hcl ptwk 0.3mg/24hr
Requ./
Límites
Página
1
1
1
1
45
45
45
31
1
31
1
B/D PA
53
1
1
1
1
B/D PA
B/D PA
B/D PA
B/D PA
53
41
53
53
1
B/D PA
41
1
B/D PA
41
1
B/D PA
53
1
B/D PA
41
1
1
1
B/D PA
53
46
46
1
1
1
1
1
46
46
46
46
46
1
1
1
1
1
B/D PA
PA
QL(90/30)
QL(300/30)
QL(90/30)
36
35
34
34
33
1
1
QL(300/30)
QL(4/28)
33
42
1
QL(8/28)
42
Nombre del
medicamento
Nivel del
Requ./
medicamento Límites
clonidine hcl tabs
1
clonidine hcl er
1
clopidogrel tabs 300mg
1 QL(1/30)
clopidogrel tabs 75mg
1 QL(30/30)
clorazepate dipotassium tabs
1 QL(90/30)
3.75mg, 7.5mg
clorazepate dipotassium tabs
1 QL(120/30)
15mg
clotrimazole external crea
1
clotrimazole external soln
1
clotrimazole troc
1
clotrimazole/betamethasone
1
dipropionate
clozapine
1
CLOZAPINE ODT
1
COARTEM
1
COLCRYS
1
colestipol hcl
1
colistimethate sodium
1
colocort
1
COLY-MYCIN S
1
COMBIGAN
1
COMBIVENT RESPIMAT
1 QL(8/30)
COMETRIQ
1 PA
compazine supp
1
COMPLERA
1
compro
1
COMVAX
1
constulose
1
COPAXONE INJ 20MG/ML
1 QL(30/30)
COREG CR
1
cormax scalp application
1
cortisone acetate
1
CORTISPORIN-TC
1
COSMEGEN
1 B/D PA
COUMADIN INJ
1
CREON
1
CRESTOR
1 QL(30/30)
CRIXIVAN
1
cromolyn sodium conc
1
cromolyn sodium ophthalmic
1
soln
Página
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply;
B/D= Drugs covered under Medicare Part B or Part D
Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa;
ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D
6
42
42
42
42
40
40
35
35
35
46
39
39
38
36
44
32
46
51
50
51
37
38
39
38
49
46
44
43
46
46
51
37
41
45
44
40
45
50
Drug Name
cromolyn sodium nebu
cryselle-28
CUBICIN
CUPRIMINE
curity gauze pads 2x2
cyclafem 1/35
cyclafem 7/7/7
cyclobenzaprine hcl tabs
10mg, 5mg
CYCLOPHOSPHAMIDE
CAPS
cyclophosphamide inj
cyclophosphamide tabs
cycloserine
CYCLOSET
cyclosporine
cyclosporine modified
CYSTADANE
CYSTAGON
cytarabine
cytarabine aqueous
D
dacarbazine
DALIRESP
danazol
dantrolene sodium
dapsone
DAPTACEL
DARAPRIM
dasetta 1/35
dasetta 7/7/7
daunorubicin hcl
DAUNOXOME
decitabine
DELZICOL
demeclocycline hcl
DEMSER
DENAVIR
DEPEN TITRATABS
DEPO-ESTRADIOL
DEPO-MEDROL INJ
Drug
Tier
1
1
1
1
1
1
1
1
1
Reqs./Limits
B/D PA
Page
PA
52
47
32
52
45
47
47
52
B/D PA
36
B/D PA
1
1
1
1
1
1
1
1
1
1
B/D PA
B/D PA
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
B/D PA
PA QL(30/30)
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
36
36
36
40
49
49
45
45
37
37
36
52
47
39
36
49
38
47
47
37
37
37
50
33
43
40
52
47
46
Drug Name
20MG/ML
DEPO-PROVERA
desipramine hcl
desloratadine
desloratadine odt
desmopressin acetate inj
DESMOPRESSIN ACETATE
NASAL SOLN 0.01%
desmopressin acetate nasal
soln 0.01%
desmopressin acetate tabs
desogestrel/ethinyl estradiol
tabs 0.15mg 30mcg
desonide lotn
desonide oint
desoximetasone crea
desoximetasone gel
desoximetasone oint 0.25%
dexamethasone elix
dexamethasone tabs
DEXAMETHASONE
INTENSOL
dexamethasone sodium
phosphate inj 10mg/ml,
120mg/30ml
dexamethasone sodium
phosphate ophthalmic soln
dexmethylphenidate hcl
dexrazoxane inj 250mg
dextroamphetamine sulfate
oral soln
dextroamphetamine sulfate
tabs 5mg
dextroamphetamine sulfate
tabs 10mg
dextroamphetamine sulfate er
cp24 10mg, 5mg
dextroamphetamine sulfate er
cp24 15mg
dextrose 10%/nacl 0.45%
dextrose 5% /electrolyte #48
viaflex
dextrose 10% flex container
Drug Reqs./Limits
Tier
1
1
1
1
1
1
Page
QL(30/30)
QL(30/30)
48
35
51
51
47
47
1
47
1
1
47
47
1
1
1
1
1
1
1
1
46
46
46
46
46
46
46
46
1
46
1
50
1
1
1
QL(60/30)
B/D PA
QL(1800/30)
44
37
44
1
QL(90/30)
44
1
QL(180/30)
44
1
QL(90/30)
44
1
QL(120/30)
44
1
1
B/D PA
B/D PA
41
53
1
B/D PA
41
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply;
B/D= Drugs covered under Medicare Part B or Part D
Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa;
ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D
7
Nombre del
medicamento
Nivel del
medicamento
dextrose 10%/nacl 0.2%
dextrose 2.5%/nacl 0.45%
dextrose 2.5%/sodium chloride
0.45%
dextrose 5%
dextrose 5%/nacl 0.2%
dextrose 5%/nacl 0.225%
dextrose 5%/nacl 0.33%
dextrose 5%/nacl 0.45%
dextrose 5%/nacl 0.9%
dextrose 5%/potassium
chloride 0.15%
dextrose 5%/sodium chloride
0.2%
dextrose 5%/sodium chloride
0.45%
DIAZEPAM GEL
diazepam oral soln
diazepam tabs
DIBENZYLINE
diclofenac potassium
diclofenac sodium ophthalmic
soln
diclofenac sodium dr
diclofenac sodium er
dicloxacillin sodium
dicyclomine hcl
didanosine
diflorasone diacetate
diflunisal
digox tabs 125mcg
digox tabs 250mcg
digoxin inj
digoxin tabs 125mcg
digoxin tabs 250mcg
dihydroergotamine mesylate
inj
dilantin caps 30mg
diltiazem cd
diltiazem hcl inj 100mg,
25mg/5ml, 50mg/10ml
diltiazem hcl tabs
1
1
1
Requ./
Límites
B/D PA
B/D PA
B/D PA
1
1
1
1
1
1
1
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
41
41
41
41
41
41
53
1
B/D PA
41
1
B/D PA
41
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
QL(1200/30)
QL(120/30)
QL(30/30)
PA
PA
QL(30/30)
PA
Página
41
41
41
34
40
40
42
30
51
30
30
32
45
39
46
30
43
43
43
43
43
36
1
1
1
34
43
43
1
43
Nombre del
medicamento
Nivel del
Requ./
Página
medicamento Límites
diltiazem hcl er cp12
1
43
diltiazem hcl er cp24
1
43
dilt-xr
1
43
DIPHENHYDRAMINE HCL
1
51
INJ
diphenoxylate/atropine
1
45
DIPHTHERIA/TETANUS
1
49
TOXOIDS ADSORBED
PEDIATRIC
disulfiram
1
31
divalproex sodium
1
34
divalproex sodium dr
1
34
divalproex sodium er
1
34
DOCEFREZ
1 B/D PA
37
docetaxel inj 140mg/7ml,
1 B/D PA
37
20mg/ml, 80mg/4ml,
80mg/8ml
donepezil hcl tabs 23mg, 5mg
1 QL(30/30)
34
donepezil hcl tabs 10mg
1 QL(60/30)
34
donepezil hcl tbdp 5mg
1 QL(30/30)
34
donepezil hcl tbdp 10mg
1 QL(60/30)
34
dorzolamide hcl
1
51
dorzolamide hcl/timolol
1
51
maleate
doxazosin mesylate tabs 1mg, 1 QL(30/30)
46
2mg, 4mg
doxazosin mesylate tabs 8mg
1 QL(60/30)
46
doxepin hcl
1 PA
35
doxercalciferol caps
1
50
doxercalciferol inj
1 B/D PA
50
doxorubicin hcl inj 2mg/ml
1 B/D PA
37
DOXORUBICIN HCL
1 B/D PA
37
LIPOSOME
doxycycline caps 75mg
1
33
doxycycline susr
1
33
doxycycline hyclate
1
33
doxycycline monohydrate
1
33
dronabinol
1 PA QL(90/30)
35
DROXIA
1
37
DULERA
1 QL(13/30)
51
duloxetine hcl cpep 20mg,
1 QL(60/30)
34
60mg
duloxetine hcl cpep 30mg
1 QL(90/30)
34
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply;
B/D= Drugs covered under Medicare Part B or Part D
Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa;
ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D
8
Drug Name
duramorph
DUREZOL
E
e.e.s. 400
E.E.S. GRANULES
e.s.p.
econazole nitrate
EDECRIN
EDURANT
ELAPRASE
ELIDEL
ELIGARD INJ 30MG
ELIGARD INJ 45MG
ELIGARD INJ 7.5MG
ELIGARD INJ 22.5MG
elinest
ELIQUIS
ELITEK
ELLA
ELLENCE INJ 200MG/100ML
ELMIRON
EMCYT
EMEND CAPS 40MG
EMEND CAPS 125MG
EMEND CAPS 80MG
EMEND CAPS
Drug Reqs./Limits
Tier
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
PA
PA QL(1/120)
PA QL(1/180)
PA QL(1/30)
PA QL(1/90)
PA QL(60/30)
B/D PA
B/D PA
B/D PA QL(2/30)
B/D PA QL(4/30)
B/D PA QL(8/30)
B/D PA
QL(12/30)
Page
30
51
33
33
33
35
43
39
45
45
48
48
49
49
47
41
37
48
37
46
36
35
35
35
35
Drug Name
enoxaparin sodium inj
60mg/0.6ml
enoxaparin sodium inj
120mg/0.8ml, 80mg/0.8ml
enoxaparin sodium inj
100mg/ml, 150mg/ml
enoxaparin sodium inj
300mg/3ml
enpresse-28
enskyce
entacapone
enulose
epinastine hcl
EPINEPHRINE HCL INJ
0.1MG/ML
epinephrine hcl inj 1mg/ml
EPIPEN 2-PAK
EPIPEN-JR 2-PAK
epirubicin hcl inj
200mg/100ml, 50mg/25ml
epitol
EPIVIR ORAL SOLN
EPIVIR HBV ORAL SOLN
EPZICOM
ERBITUX
ergoloid mesylates
ERIVEDGE
errin
ERWINAZE
ery
ERYPED 200
ERYPED 400
ERY-TAB
ERYTHROCIN
LACTOBIONATE
erythrocin stearate
erythromycin external soln
erythromycin gel
erythromycin oint
erythromycin pads
erythromycin base
erythromycin ethylsuccinate
Drug Reqs./Limits
Tier
1 QL(18/30)
Page
41
1
QL(24/30)
41
1
QL(30/30)
41
1
QL(90/30)
41
1
1
1
1
1
1
47
47
38
46
50
52
1
1
1
1
52
52
52
37
1
1
1
1
1
1
1
1
1
1
1
1
1
1
QL(2/30)
QL(2/30)
B/D PA
B/D PA
PA
PA QL(30/30)
emoquette
1
47
B/D PA
EMSAM
1
34
EMTRIVA
1
39
enalapril maleate
1
42
enalapril
1
42
maleate/hydrochlorothiazide
ENBREL
1 PA QL(8/28)
49
ENBREL SURECLICK
1 PA QL(8/28)
49
1
endocet tabs 325mg 10mg,
1 QL(360/30)
30
1
325mg 5mg, 325mg 7.5mg
1
ENGERIX-B
1 B/D PA
49
1
enoxaparin sodium inj
1 QL(9/30)
41
1
30mg/0.3ml
1
enoxaparin sodium inj
1 QL(12/30)
41
1
40mg/0.4ml
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply;
B/D= Drugs covered under Medicare Part B or Part D
Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa;
ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D
34
40
40
40
38
34
37
48
37
33
33
33
33
33
33
33
33
33
33
33
33
9
Nombre del
medicamento
Nivel del
medicamento
erythromycin/benzoyl peroxide
escitalopram oxalate oral soln
escitalopram oxalate tabs
ESOMEPRAZOLE SODIUM
estarylla
estradiol ptwk
estradiol tabs
estradiol valerate
estradiol/norethindrone
acetate
ESTRING
ethambutol hcl
ethosuximide
etidronate disodium
etodolac
etodolac er
ETOPOPHOS
ETOPOSIDE INJ
EXELON PT24
exemestane
EXFORGE
EXFORGE HCT
EXJADE
F
FABRAZYME
falmina
famciclovir
famotidine inj 20mg/2ml
famotidine tabs 20mg, 40mg
famotidine premixed
FANAPT
FANAPT TITRATION PACK
FARESTON
FASLODEX
FAZACLO
felbamate
felodipine er
FEMRING
fenofibrate caps 130mg, 43mg
fenofibrate tabs
fenofibrate micronized
fenofibric acid dr
1
1
1
1
1
1
1
1
1
Requ./
Límites
QL(600/30)
QL(60/30)
PA QL(4/28)
PA
PA
1
1
1
1
1
1
1
1
1
1
1
1
1
QL(1/90)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
B/D PA
B/D PA
B/D PA
QL(30/30)
QL(21/7)
QL(60/30) ST
QL(16/30) ST
B/D PA
ST
Página
45
34
34
46
47
47
47
47
47
47
36
33
50
30
30
37
37
34
37
43
43
52
45
47
40
45
45
45
38
38
36
36
39
34
43
48
44
44
44
44
Nombre del
medicamento
Nivel del
Requ./
Página
medicamento Límites
fenoprofen calcium
1
30
fentanyl
1 QL(15/30)
30
fentanyl citrate
1 B/D PA
30
FENTANYL CITRATE ORAL
1 PA QL(120/30)
30
TRANSMUCOSAL
FETZIMA
1 QL(30/30) ST
35
FETZIMA TITRATION PACK
1 QL(28/28) ST
35
finasteride tabs 5mg
1 QL(30/30)
46
FIRAZYR
1 PA
49
firmagon inj 80mg
1 B/D PA QL(4/28) 49
firmagon inj 120mg
1 B/D PA
49
QL(6/365)
flavoxate hcl
1
46
FLEBOGAMMA DIF
1 B/D PA
49
flecainide acetate
1
43
FLOVENT DISKUS AEPB
1 QL(120/30)
51
250MCG/BLIST,
50MCG/BLIST
FLOVENT DISKUS AEPB
1 QL(180/30)
51
100MCG/BLIST
FLOVENT HFA AERO
1 QL(22/30)
51
44MCG/ACT
FLOVENT HFA AERO
1 QL(24/30)
51
110MCG/ACT, 220MCG/ACT
fluconazole susr
1
35
fluconazole tabs 100mg,
1
35
200mg, 50mg
35
fluconazole tabs 150mg
1 QL(8/30)
fluconazole in dextrose
1
35
fluconazole in nacl
1
35
flucytosine
1
35
fludarabine phosphate
1 B/D PA
37
fludrocortisone acetate
1
46
flunisolide
1
51
fluocinolone acetonide
1
46
fluocinolone acetonide
1
46
fluocinonide
1
46
fluocinonide-e
1
46
fluoride chew 0.25mg, 1.1mg,
1
53
2.2mg
fluoritab chew
1
53
FLUOROMETHOLONE
1
51
FLUOROPLEX
1
45
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply;
B/D= Drugs covered under Medicare Part B or Part D
Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa;
ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D
10
Drug Name
fluorouracil inj 2.5gm/50ml
fluorouracil crea
fluorouracil external soln
fluoxetine dr
fluoxetine hcl caps
fluoxetine hcl oral soln
fluoxetine hcl tabs 10mg,
20mg
fluphenazine decanoate
fluphenazine hcl
flurbiprofen
flurbiprofen sodium
flutamide
fluticasone propionate crea
fluticasone propionate oint
fluticasone propionate susp
fluvastatin caps 20mg
fluvastatin caps 40mg
fluvoxamine maleate
fluvoxamine maleate er cp24
150mg
fluvoxamine maleate er cp24
100mg
FOLOTYN
fomepizole
fondaparinux sodium inj
5mg/0.4ml
fondaparinux sodium inj
2.5mg/0.5ml
fondaparinux sodium inj
7.5mg/0.6ml
fondaparinux sodium inj
10mg/0.8ml
FORADIL AEROLIZER
FORTEO
foscarnet sodium
fosinopril sodium
fosinopril
sodium/hydrochlorothiazide
fosphenytoin sodium
FOSRENOL
FREAMINE III
Drug Reqs./Limits
Tier
1 B/D PA
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Page
37
45
45
35
35
35
35
QL(60/30)
38
38
30
51
36
47
47
51
44
44
35
35
1
QL(90/30)
35
1
1
1
B/D PA
QL(12/30)
37
50
41
1
QL(15/30)
41
1
QL(18/30)
41
1
QL(24/30)
41
1
1
1
1
1
QL(60/30)
PA QL(2.4/28)
52
50
39
42
42
1
1
1
QL(16/30)
QL(30/30)
QL(60/30)
ST
B/D PA
34
46
53
Drug Name
FREAMINE III 3%
furosemide
FUSILEV
FUZEON
FYCOMPA
G
gabapentin
GABITRIL TABS 16MG
GABITRIL TABS 12MG
galantamine
galantamine hydrobromide
cp24
galantamine hydrobromide
oral soln
galantamine hydrobromide
tabs
gamastan s/d
GAMMAGARD LIQUID
GAMMAKED
GAMMAPLEX INJ
10GM/200ML, 2.5GM/50ML,
5GM/100ML
GAMUNEX-C
ganciclovir
GARDASIL
gavilyte-c
gavilyte-n/flavor pack
GAZYVA
gemcitabine
gemcitabine hcl
gemfibrozil
generlac
gengraf
gentak
gentamicin sulfate crea
GENTAMICIN SULFATE INJ
10MG/ML
gentamicin sulfate inj
10mg/ml, 40mg/ml
gentamicin sulfate oint
gentamicin sulfate ophthalmic
soln
Drug Reqs./Limits
Tier
1 B/D PA
1
1
1 QL(60/30)
1
Page
53
43
37
40
33
1
1
1
1
1
QL(90/30)
QL(120/30)
QL(60/30)
QL(30/30)
34
34
34
34
34
1
QL(200/30)
34
1
QL(60/30)
34
1
1
1
1
B/D PA
B/D PA
B/D PA
B/D PA
49
49
49
49
1
1
1
1
1
1
1
1
1
1
1
1
1
1
B/D PA
B/D PA
49
39
49
46
46
38
37
37
44
46
49
31
31
31
PA
B/D PA
B/D PA
B/D PA
1
31
1
1
31
31
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply;
B/D= Drugs covered under Medicare Part B or Part D
Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa;
ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D
11
Nombre del
medicamento
Nivel del
medicamento
Requ./
Límites
Página
gentamicin sulfate pediatric
gentamicin sulfate/0.9%
sodium chloride
gentamicin sulfate/sodium
chloride
GEODON INJ
gildagia
gildess 1.5/30
gildess 1/20
gildess fe 1.5/30
gildess fe 1/20
GILOTRIF
GLEEVEC
glimepiride tabs 1mg, 2mg
glimepiride tabs 4mg
glipizide
glipizide er
glipizide/metformin hcl
GLUCAGEN HYPOKIT
glyburide/metformin hcl
glycopyrrolate inj 4mg/20ml
glycopyrrolate tabs
GLYSET
granisetron hcl inj 0.1mg/ml,
1mg/ml
granisetron hcl tabs
1
1
31
31
1
31
griseofulvin microsize
griseofulvin ultramicrosize
GUANIDINE HCL
H
HALAVEN
halobetasol propionate
haloperidol
haloperidol decanoate
haloperidol lactate
HAVRIX
heather
hecoria
heparin sodium inj
10000unit/ml, 1000unit/ml,
20000unit/ml, 2000unit/ml,
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
QL(60/30)
1
B/D PA
QL(60/30)
1
1
1
1
1
1
1
1
1
PA QL(30/30)
PA QL(60/30)
QL(30/30)
QL(60/30)
PA
B/D PA
38
48
48
48
48
48
37
37
40
40
40
40
40
41
40
45
45
40
35
35
35
35
36
PA
B/D PA
37
47
38
38
38
49
48
49
42
Nombre del
medicamento
Nivel del
Requ./
medicamento Límites
2500unit/ml, 5000unit/ml
heparin sodium/d5w
1
heparin sodium/nacl 0.9%
1
hepatamine
1 B/D PA
HEPATASOL
1 B/D PA
HERCEPTIN
1 B/D PA
HEXALEN
1
HUMALOG
1
HUMALOG KWIKPEN
1
humalog mix 50/50
1
humalog mix 50/50 kwikpen
1
humalog mix 75/25
1
humalog mix 75/25 kwikpen
1
HUMIRA INJ 20MG/0.4ML
1 PA QL(2/28)
HUMIRA INJ 40MG/0.8ML
1 PA QL(6/28)
HUMIRA PEN
1 PA QL(6/28)
HUMIRA PEN-CROHNS
1 PA QL(6/28)
DISEASESTARTER
humulin 70/30
1
HUMULIN 70/30 KWIKPEN
1
humulin 70/30 pen
1
humulin n
1
HUMULIN N KWIKPEN
1
humulin n u-100 pen
1
humulin r
1
humulin r u-500 (concentrated) 1
hydralazine hcl
1
hydrochlorothiazide
1
hydrocodone
1 QL(5400/30)
bitartrate/acetaminophen oral
soln
hydrocodone
1 QL(360/30)
bitartrate/acetaminophen tabs
325mg 2.5mg
hydrocodone
1 QL(390/30)
bitartrate/acetaminophen tabs
300mg 10mg, 300mg 5mg,
300mg 7.5mg
hydrocodone/acetaminophen
1 QL(360/30)
tabs
hydrocodone/ibuprofen tabs
1 QL(150/30)
7.5mg 200mg
hydrocortisone crea 1%, 2.5%
1
Página
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply;
B/D= Drugs covered under Medicare Part B or Part D
Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa;
ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D
12
42
42
53
53
38
36
41
41
41
41
41
41
49
49
49
49
41
41
41
41
41
41
41
41
44
43
30
30
30
30
30
47
Drug Name
Drug Reqs./Limits
Tier
1
1
1
1
1
Page
Drug Name
Drug
Tier
1
1
1
1
1
1
Reqs./Limits
Page
hydrocortisone lotn 2.5%
47
INTELENCE TABS 200MG
QL(60/30)
INTELENCE TABS 100MG
QL(120/30)
hydrocortisone oint 1%, 2.5%
47
hydrocortisone tabs
47
INTELENCE TABS 25MG
QL(180/30)
intralipid inj 2.25% 20%
B/D PA
hydrocortisone butyrate
47
INTRON-A
hydrocortisone butyrate
47
(lipophilic)
INTRON-A W/DILUENT INJ
10MU, 18MU
hydrocortisone in absorbase
1
47
introvale
1
hydrocortisone valerate
1
47
INVANZ
1
hydrocortisone/acetic acid
1
51
INVEGA TB24 1.5MG, 3MG,
1 QL(30/30) ST
30
HYDROMORPHONE HCL INJ 1
9MG
1MG/ML, 2MG/ML,
500MG/50ML
INVEGA TB24 6MG
1 QL(60/30) ST
hydromorphone hcl inj 2mg/ml
1
30
INVEGA SUSTENNA INJ
1 QL(0.25/28)
39MG/0.25ML
hydromorphone hcl liqd
1 QL(1200/30)
30
INVEGA SUSTENNA INJ
1 QL(0.5/28)
hydromorphone hcl tabs
1 QL(240/30)
30
78MG/0.5ML
hydroxychloroquine sulfate
1
38
INVEGA SUSTENNA INJ
1 QL(0.75/28)
hydroxyurea
1
37
117MG/0.75ML
I
INVEGA SUSTENNA INJ
1 QL(1/28)
ibandronate sodium tabs
1 QL(1/28)
50
156MG/ML
ibuprofen susp
1
30
INVEGA SUSTENNA INJ
1 QL(1.5/28)
ibuprofen tabs 400mg, 600mg, 1
30
234MG/1.5ML
800mg
INVIRASE
1
ICLUSIG
1 PA
37
IPOL INACTIVATED IPV
1
idarubicin hcl inj 10mg/10ml
1 B/D PA
37
ipratropium bromide inhalation 1 B/D PA
ifosfamide inj 1gm, 3gm
1 B/D PA
36
soln
QL(300/30)
ifosfamide/mesna
1 B/D PA
36
ipratropium bromide nasal soln 1 QL(30/30)
ILARIS
1 PA
49
0.06%
ilotycin
1
33
ipratropium bromide nasal soln 1 QL(60/30)
IMBRUVICA
1 PA QL(120/30)
37
0.03%
imipenem/cilastatin
1
32
ipratropium bromide/albuterol
1 B/D PA
imipramine hcl
1 PA
35
sulfate
QL(540/30)
imipramine pamoate
1 PA
35
irbesartan
1
imiquimod
1
45
irbesartan/hydrochlorothiazide
1
IMOVAX RABIES (H.D.C.V.)
1
49
irinotecan inj 100mg/5ml
1 B/D PA
INCIVEK
1 PA QL(180/30)
39
ISENTRESS CHEW 100MG
1 QL(180/30)
INCRELEX
1 PA
47
ISENTRESS CHEW 25MG
1 QL(360/30)
indapamide
1
43
ISENTRESS PACK
1
INFANRIX
1
49
ISENTRESS TABS
1 QL(60/30)
infumorph 200
1
30
isoditrate er
1
infumorph 500
1
30
isolyte-m/dextrose 5%
1 B/D PA
INLYTA TABS 5MG
1 PA QL(120/30)
37
isoniazid
1
INLYTA TABS 1MG
1 PA QL(240/30)
37
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply;
B/D= Drugs covered under Medicare Part B or Part D
Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa;
ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D
39
39
39
54
39
39
48
32
39
39
38
38
38
38
39
40
49
51
51
51
52
42
42
37
39
39
39
39
44
53
36
13
Nombre del
medicamento
Nivel del
medicamento
isosorbide dinitrate
isosorbide dinitrate er
isosorbide mononitrate
isosorbide mononitrate er
isotonic gentamicin inj
0.8mg/ml 0.9%, 1.2mg/ml
0.9%, 1.6mg/ml 0.9%, 1mg/ml
0.9%
isradipine
ISTODAX
itraconazole
IXEMPRA KIT
IXIARO
J
JAKAFI
JALYN
jantoven
JANUMET
JANUMET XR TB24 1000MG
100MG
JANUMET XR TB24 1000MG
50MG, 500MG 50MG
JANUVIA
jencycla
JENTADUETO
JEVTANA
junel 1.5/30
junel 1/20
junel fe 1.5/30
junel fe 1/20
K
KADCYLA
KALETRA
kariva
kcl 0.075%/d5w/nacl 0.45%
kcl 0.15%/d5w/ nacl 0.3%
KCL 0.15%/D5W/LR
kcl 0.15%/d5w/nacl 0.2%
kcl 0.15%/d5w/nacl 0.45%
kcl 0.15%/d5w/nacl 0.9%
kcl 0.3%/d5w/nacl 0.45%
kelnor 1/35
Requ./
Límites
Página
1
1
1
1
1
44
44
44
44
31
1
1
1
1
1
43
37
36
37
49
PA
PA QL(120/30)
B/D PA
1
1
1
1
1
PA QL(60/30)
QL(60/30)
QL(30/30)
37
46
42
40
40
1
QL(60/30)
40
1
1
1
1
1
1
1
1
QL(30/30)
40
48
40
37
48
48
48
48
1
1
1
1
1
1
1
1
1
1
1
PA
QL(60/30)
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
38
40
48
41
41
41
41
41
41
41
48
Nombre del
medicamento
Nivel del
Requ./
Página
medicamento Límites
KETEK
1 QL(20/30)
33
ketoconazole
1
36
ketoprofen
1
30
ketoprofen er
1
30
ketorolac tromethamine
1
51
ophthalmic soln
kionex
1
52
klor-con
1
53
klor-con m10
1
53
klor-con m20
1
53
kurvelo
1
48
KUVAN
1 PA
45
k-vescent pack
1
53
KYPROLIS
1 PA QL(6/28)
37
L
labetalol hcl
1
43
laclotion
1
45
LACRISERT
1
50
lactated ringers inj 3meq/l
1
53
109meq/l 28meq/l 4meq/l
130meq/l
lactated ringers dextrose 5%
1
53
viaflex
lactated ringers irrigation
1
50
lactated ringers viaflex
1
53
lactulose
1
46
1
40
lamivudine
lamivudine/zidovudine
1
40
lamotrigine
1
34
lamotrigine er
1
34
LANOXIN PEDIATRIC
1 PA
43
lansoprazole
1 QL(60/30)
46
lansoprazole/amoxicillin/clarith 1
32
romycin
lantus
1
41
lantus solostar
1
41
larin 1/20
1
48
larin fe 1.5/30
1
48
1
48
larin fe 1/20
latanoprost
1 QL(5/30)
50
LATUDA TABS 120MG,
1 QL(30/30) ST
39
20MG, 40MG, 60MG
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply;
B/D= Drugs covered under Medicare Part B or Part D
Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa;
ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D
14
Drug Name
Drug Reqs./Limits Page
Drug Name
Drug Reqs./Limits Page
Tier
Tier
lidocaine hcl inj 0.5%, 1%, 2%
1
31
LATUDA TABS 80MG
1 QL(60/30) ST
39
LAZANDA
1 PA QL(44/28)
30
lidocaine hcl inj 10mg/ml
1
43
lidocaine hcl jelly
1
31
leflunomide
1 QL(30/30)
49
lessina
1
48
lidocaine viscous
1
31
LETAIRIS
1 PA QL(30/30)
52
lidocaine/prilocaine crea
1
31
letrozole
1 QL(30/30)
37
LINCOCIN
1
32
leucovorin calcium inj 100mg,
1
37
lindane
1
38
350mg, 500mg, 50mg
liothyronine sodium
1
48
leucovorin calcium tabs
1
37
LIPODOX
1 B/D PA
37
LEUKERAN
1
36
LIPODOX 50
1 B/D PA
37
LEUKINE
1 PA
42
LIPOFEN
1
44
leuprolide acetate
1 PA QL(30/30)
49
liposyn iii inj 2.5% 30%
1 B/D PA
54
levemir
1
41
lisinopril
1
42
levemir flexpen
1
41
lisinopril/hydrochlorothiazide
1
42
levetiracetam
1
33
lithium carbonate
1
40
levetiracetam er
1
33
lithium carbonate er
1
40
LEVOBUNOLOL HCL
1
51
lofene
1
45
OPHTHALMIC SOLN 0.25%
LOMUSTINE
1
36
levobunolol hcl ophthalmic
1
51
lonox
1
45
soln 0.5%
loperamide hcl caps
1
45
levocarnitine inj
1 B/D PA
50
lorazepam conc
1 QL(120/30)
40
levocarnitine oral soln
1
50
lorazepam inj 2mg/ml, 4mg/ml
1
40
levocarnitine tabs
1
50
lorazepam tabs
1 QL(120/30)
40
levocetirizine dihydrochloride
1 QL(300/30)
51
lorcet
1 QL(360/30)
30
oral soln
lorcet hd
1 QL(360/30)
30
levocetirizine dihydrochloride
1 QL(30/30)
51
lorcet plus
1 QL(360/30)
30
tabs
lortab tabs
1 QL(360/30)
30
levofloxacin inj
1
33
1 QL(30/30)
42
losartan potassium tabs
levofloxacin oral soln
1
33
100mg
levofloxacin tabs
1
33
losartan potassium tabs 50mg
1 QL(60/30)
42
levofloxacin in d5w
1
33
losartan potassium tabs 25mg
1 QL(90/30)
42
levonest
1
48
losartan
1 QL(30/30)
42
levonorgestrel/ethinyl estradiol 1
48
potassium/hydrochlorothiazide
levora 0.15/30-28
1
48
tabs 12.5mg 100mg, 25mg
levorphanol tartrate
1 QL(180/30)
30
100mg
levothyroxine sodium tabs
1
48
losartan
1 QL(60/30)
42
LEVOXYL
1
48
potassium/hydrochlorothiazide
tabs 12.5mg 50mg
LEXIVA
1
40
LOTRONEX
1 PA QL(60/30)
46
lidocaine oint
1
31
lovastatin tabs 40mg
1 QL(60/30)
44
lidocaine ptch
1 PA QL(90/30)
31
lovastatin tabs 10mg, 20mg
1 QL(90/30)
44
lidocaine hcl external soln
1
31
low-ogestrel
1
48
lidocaine hcl gel
1
31
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply;
B/D= Drugs covered under Medicare Part B or Part D
Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa;
ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D
15
Nombre del
medicamento
Nivel del
medicamento
loxapine
loxapine succinate
ludent
LUMIGAN
LUMIZYME
LUPRON DEPOT
LUPRON DEPOT-PED
lutera
LYRICA CAPS 225MG,
25MG, 300MG
LYRICA CAPS 100MG,
150MG, 200MG, 50MG, 75MG
LYRICA ORAL SOLN
LYSODREN
lyza
M
magnesium sulfate inj 50%
MAKENA
malathion
maprotiline hcl
margesic
marlissa
MARPLAN
MATULANE
matzim la
meclizine hcl tabs
meclofenamate sodium
MEDROL TABS 2MG
medroxyprogesterone acetate
inj
medroxyprogesterone acetate
tabs
mefloquine hcl
megestrol acetate
MEKINIST
meloxicam tabs
melphalan hydrochloride
MENACTRA
MENEST
MENOMUNE-A/C/Y/W-135
MENOSTAR
MENVEO
1
1
1
1
1
1
1
1
1
1
Requ./
Límites
Página
QL(60/30)
38
38
53
50
45
49
49
48
33
QL(90/30)
33
QL(5/30)
PA
PA QL(1/30)
PA QL(1/30)
1
1
1
QL(900/30)
33
48
48
1
1
1
1
1
1
1
1
1
1
1
1
1
B/D PA
53
48
38
34
30
48
34
36
43
35
30
47
48
PA QL(180/30)
QL(1/90)
1
48
1
1
1
1
1
1
1
1
1
1
38
48
37
30
36
50
37
50
48
50
PA
PA
B/D PA
PA
PA QL(4/28)
Nombre del
medicamento
Nivel del
Requ./
medicamento Límites
mercaptopurine
1
meropenem
1
mesalamine
1
mesna
1 B/D PA
MESNEX TABS
1
MESTINON TIMESPAN
1
metadate er
1 QL(90/30)
metaproterenol sulfate
1
metformin hcl
1
metformin hcl er tb24 500mg,
1
750mg
methadone hcl conc
1 QL(500/30)
methadone hcl inj
1
methadone hcl oral soln
1 QL(2000/30)
10mg/5ml
methadone hcl oral soln
1 QL(4000/30)
5mg/5ml
methadone hcl tabs
1 QL(360/30)
methadose tabs
1 QL(360/30)
methazolamide
1
methenamine hippurate
1
methimazole
1
methotrexate
1
methotrexate sodium
1
methoxsalen
1
methscopolamine bromide
1
methyldopate hcl
1 PA
methylphenidate hcl
1 QL(90/30)
methylphenidate hcl er tbcr
1 QL(90/30)
20mg
methylphenidate hcl er tbcr
1 QL(180/30)
10mg
methylphenidate hcl sr
1 QL(90/30)
methylprednisolone
1
methylprednisolone acetate
1
methylprednisolone dose pack 1
methylprednisolone
1
sodiumsuccinate inj 125mg,
40mg
metipranolol
1
metoclopramide hcl
1
metolazone
1
Página
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply;
B/D= Drugs covered under Medicare Part B or Part D
Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa;
ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D
16
37
32
50
37
37
36
44
52
40
40
30
30
30
30
30
30
51
32
49
49
49
45
45
42
44
44
44
44
47
47
47
47
51
45
43
Drug Name
Drug
Tier
metoprolol succinate er
1
metoprolol tartrate
1
metoprolol/hydrochlorothiazide 1
metronidazole crea
1
metronidazole gel
1
metronidazole lotn
1
metronidazole tabs
1
metronidazole in nacl 0.79%
1
metronidazole vaginal
1
mexiletine hcl
1
MIACALCIN INJ
1
microgestin 1.5/30
1
microgestin 1/20
1
microgestin fe
1
microgestin fe 1.5/30
1
midodrine hcl
1
migergot
1
mimvey
1
mimvey lo
1
minitran
1
MINIVELLE PTTW
1
0.1MG/24HR
minocycline hcl
1
minoxidil tabs
1
mirtazapine
1
mirtazapine odt
1
MISOPROSTOL TABS
1
200MCG
misoprostol tabs 100mcg
1
mitomycin
1
MITOXANTRONE HCL
1
M-M-R II W/DILUENT 10
1
DOSE
MODAFINIL TABS 100MG
1
modafinil tabs 200mg
1
MODERIBA MISC
1
moderiba tabs
1
MODERIBA 1200 DOSE
1
PACK
MODERIBA 800 DOSE PACK
1
moexipril hcl
1
Reqs./Limits
PA
PA
PA QL(8/28)
QL(30/30)
QL(30/30)
Page
43
43
43
32
32
32
32
32
32
43
50
48
48
48
48
42
36
48
48
44
48
33
44
34
34
46
B/D PA
B/D PA
46
37
37
50
PA QL(30/30)
PA QL(60/30)
PA
PA
PA
52
52
39
39
39
PA
39
42
Drug Name
Drug Reqs./Limits
Tier
moexipril/hydrochlorothiazide
1
mometasone furoate
1
mono-linyah
1
montelukast sodium
1 QL(30/30)
morgidox 1x100mg caps
1
morgidox 2x100mg caps
1
morphine sulfate inj 0.5mg/ml,
1
10mg/ml, 1mg/ml, 5mg/ml
morphine sulfate oral soln
1 QL(540/30)
20mg/ml
morphine sulfate oral soln
1 QL(2700/30)
20mg/5ml
morphine sulfate oral soln
1 QL(5400/30)
10mg/5ml
MORPHINE SULFATE TABS
1 QL(360/30)
morphine sulfate er tbcr
1 QL(90/30)
MOVIPREP
1
MOXEZA
1
moxifloxacin hcl
1
MOZOBIL
1 QL(9.6/30)
MULTAQ
1 QL(60/30)
mupirocin
1
mupirocin calcium
1
MUSTARGEN
1 B/D PA
mycophenolate mofetil
1 B/D PA
mycophenolic acid dr
1 B/D PA
mydral
1
myorisan
1
myzilra
1
N
nabumetone
1
nadolol
1
nadolol/bendroflumethiazide
1
nafcillin sodium
1
nafrinse
1
NAFTIN
1
NAGLAZYME
1 PA
nalbuphine hcl
1
naloxone hcl
1
naltrexone hcl
1 PA
NAMENDA ORAL SOLN
1 QL(300/30)
Page
42
47
48
51
33
33
30
30
30
30
30
30
46
33
33
53
43
32
32
36
49
49
50
45
48
30
43
43
32
53
36
45
30
31
31
34
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply;
B/D= Drugs covered under Medicare Part B or Part D
Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa;
ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D
17
Nombre del
medicamento
Nivel del
medicamento
NAMENDA XR
NAMENDA XR TITRATION
PACK
naphazoline hcl
naproxen
naproxen dr
naproxen sodium tabs 275mg,
550mg
naratriptan hcl
NATACYN
nateglinide
NEBUPENT
necon 0.5/35-28
necon 1/35
necon 10/11-28
necon 7/7/7
nefazodone hcl
neomycin sulfate
neomycin/bacitracin/polymyxin
neomycin/polymyxin b sulfates
neomycin/polymyxin/bacitracin
zinc
neomycin/polymyxin/bacitracin
/hydrocortisone
neomycin/polymyxin/dexameth
asone
neomycin/polymyxin/gramicidi
n
neomycin/polymyxin/hc
neomycin/polymyxin/hydrocorti
sone
neomycin/polymyxin/hydrocorti
sone
neo-polycin
NEULASTA
NEUMEGA
NEUPOGEN INJ
300MCG/0.5ML,
480MCG/0.8ML,
480MCG/1.6ML
NEUPRO
NEUTREXIN
NEVIRAPINE SUSP
1
1
Requ./
Límites
QL(30/30)
QL(28/28)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Página
34
34
50
30
30
30
QL(9/30)
QL(90/30)
B/D PA
QL(60/30)
36
36
40
38
48
48
48
48
34
31
32
31
50
1
32
1
51
1
32
1
1
51
32
1
51
1
1
1
1
1
1
1
PA
PA
PA
PA QL(30/30)
50
42
42
42
38
38
39
Nombre del
medicamento
Nivel del
Requ./
Página
medicamento Límites
nevirapine tabs
1
39
nevirapine er
1
39
NEXAVAR
1 PA
37
niacin er tbcr 500mg
1 QL(30/30)
44
niacin er tbcr 1000mg, 750mg
1 QL(60/30)
44
niacor
1
44
nicardipine hcl
1
43
NICOTROL INHALER
1 PA QL(504/30)
31
NICOTROL NS
1 PA QL(40/30)
31
nifediac cc tb24 30mg, 60mg
1
43
nifedical xl
1
43
nifedipine er
1
43
NILANDRON
1
36
nimodipine
1
43
nisoldipine
1
43
nisoldipine er
1
43
nitrofurantoin
1 QL(900/365)
32
nitrofurantoin macrocrystals
1 QL(90/365)
32
nitrofurantoin monohydrate
1 QL(90/365)
32
nitroglycerin
1
44
nitroglycerin lingual
1
44
translingual soln
nitroglycerin transdermal
1
44
NITROSTAT
1
44
nizatidine caps
1
45
norethindrone
1
48
norethindrone acetate
1
48
norgestimate/ethinyl estradiol
1
48
NORITATE
1
32
normosol-m in d5w
1 B/D PA
53
NORMOSOL-R
1 B/D PA
53
normosol-r in d5w
1 B/D PA
41
nortrel 0.5/35 (28)
1
48
nortrel 1/35
1
48
nortrel 7/7/7
1
48
nortriptyline hcl
1
35
NORVIR
1
40
novarel
1 PA
47
novofine 30gx8mm
1 QL(200/30)
50
novofine 31
1 QL(200/30)
50
novofine 32gx6mm
1 QL(200/30)
50
novofine autocover 30gx8mm
1 QL(200/30)
50
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply;
B/D= Drugs covered under Medicare Part B or Part D
Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa;
ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D
18
Drug Name
Drug
Tier
novotwist 30gx8mm
1
novotwist 32gx5mm
1
NOXAFIL SUSP
1
NOXAFIL TBEC
1
NUEDEXTA
1
NULOJIX
1
nyamyc
1
nystatin crea
1
nystatin oint
1
nystatin powd 100000unit/gm
1
nystatin susp
1
nystatin tabs
1
nystatin/triamcinolone
1
nystop
1
NEEDLES AND SYRINGES
bd insulin syringe
1
safetyglide/1ml/29g x 1/2
bd insulin syringe
1
ultrafine/0.3ml/31g x 5/16
bd insulin syringe
1
ultrafine/0.5ml/30g x 1/2
bd insulin syringe
1
ultrafine/1ml/31g x 5/16
bd insulin syringe ultrafine/u1
100/0.3ml/31g x 15/64
bd insulin syringe ultrafine/u1
100/0.5ml/31g x 15/64
bd insulin syringe ultrafine/u1
100/1ml/31g x 15/64
bd pen
1
needle/mini/ultrafine/31g x
3/16
bd pen needle/nano/ultra
1
fine/32g x 4mm
bd pen needle/ultrafine/29g x
1
12.7mm
1
monoject insulin
syringe/detach needle/1ml/27g
x 1/2
1
monoject insulin
syringe/safety/perm
needle/0.3ml/29g x 1/2
monoject insulin syringe/u1
Reqs./Limits
Page
QL(200/30)
QL(200/30)
PA QL(600/30)
PA QL(93/30)
PA
PA
50
50
36
36
44
49
36
36
36
36
36
36
36
36
QL(200/30)
55
QL(200/30)
55
QL(200/30)
55
QL(200/30)
55
QL(200/30)
55
QL(200/30)
55
QL(200/30)
55
QL(200/30)
55
QL(200/30)
55
QL(200/30)
55
QL(200/30)
55
QL(200/30)
55
QL(200/30)
55
Drug Name
Drug Reqs./Limits
Tier
100/0.5ml/30g x 5/16
monoject insulin syringe/u100/1ml/30g x 5/16
monoject ultra comfort insulin
syringe/0.3ml/30g x 5/16
monoject ultra comfort insulin
syringe/0.5ml/28g x 1/2
monoject ultra comfort insulin
syringe/0.5ml/29g x 1/2
monoject ultra comfort insulin
syringe/1ml/28g x 1/2
ulticare insulin syringe/u100/0.3ml/30g x 1/2
ulticare insulin syringe/u100/0.5ml/31g x 5/16
ulticare insulin syringe/u100/1ml/30g x 1/2
O
OB COMPLETE 400
OB COMPLETE/DHA
OCTAGAM INJ 10GM/200ML,
2.5GM/50ML, 5GM/100ML
octreotide acetate
ofloxacin
ogestrel
olanzapine inj
olanzapine tabs
olanzapine odt
olanzapine/fluoxetine
OLYSIO
omega-3-acid ethyl esters
omeprazole cpdr
ONCASPAR
ondansetron hcl inj 4mg/2ml
ondansetron hcl oral soln
ondansetron hcl tabs 24mg
ondansetron hcl tabs 4mg,
8mg
ondansetron odt
1
ONFI SUSP
ONFI TABS 10MG
1
1
Page
1
QL(200/30)
55
1
QL(200/30)
55
1
QL(200/30)
55
1
QL(200/30)
55
1
QL(200/30)
55
1
QL(200/30)
55
1
QL(200/30)
55
1
QL(200/30)
55
B/D PA
54
54
49
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
PA
QL(30/30)
QL(30/30)
QL(30/30)
PA QL(30/30)
QL(120/30)
QL(60/30)
B/D PA
B/D PA
B/D PA QL(5/30)
B/D PA
QL(90/30)
B/D PA
QL(90/30)
QL(480/30)
QL(60/30)
49
33
48
39
39
39
35
39
44
46
37
35
35
35
35
35
34
34
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply;
B/D= Drugs covered under Medicare Part B or Part D
Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa;
ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D
19
Nombre del
medicamento
Nivel del
medicamento
ONFI TABS 20MG
oralone
ORAP
ORFADIN
orphenadrine citrate er
orsythia
OSMOPREP
oxacillin sodium inj 10gm, 2gm
oxaliplatin inj 100mg/20ml
oxandrolone tabs 10mg
oxandrolone tabs 2.5mg
oxaprozin
oxazepam
oxcarbazepine
oxybutynin chloride
oxybutynin chloride er tb24
5mg
oxybutynin chloride er tb24
10mg, 15mg
oxycodone hcl caps
oxycodone hcl conc
oxycodone hcl oral soln
oxycodone hcl tabs
oxycodone/acetaminophen
tabs 325mg 10mg, 325mg
5mg, 325mg 7.5mg
oxycodone/aspirin
oxycodone/ibuprofen
OXYCONTIN
oxymorphone hydrochloride er
P
pacerone
paclitaxel inj 300mg/50ml
pamidronate disodium inj
30mg/10ml, 6mg/ml,
90mg/10ml
PANCRELIPASE
PANRETIN
pantoprazole sodium tbec
parcaine
paricalcitol
paromomycin sulfate
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Requ./
Límites
QL(120/30)
Página
QL(30/30)
34
44
38
45
52
48
45
32
37
47
47
30
40
34
46
46
1
QL(60/30)
46
1
1
1
1
1
QL(240/30)
QL(360/30)
QL(1200/30)
QL(240/30)
QL(360/30)
31
31
31
31
31
1
1
1
1
QL(360/30)
QL(150/30)
PA QL(60/30)
QL(60/30)
31
30
30
30
B/D PA
B/D PA
43
37
50
1
1
1
1
1
1
1
1
1
PA
B/D PA
PA QL(60/30)
PA QL(120/30)
QL(120/30)
QL(60/30)
45
38
46
50
50
31
Nombre del
medicamento
Nivel del
Requ./
medicamento Límites
paroxetine hcl tabs 10mg
1 QL(30/30)
paroxetine hcl tabs 20mg,
1 QL(60/30)
30mg, 40mg
paroxetine hcl er tb24 12.5mg
1 QL(30/30)
paroxetine hcl er tb24 37.5mg
1 QL(60/30)
paroxetine hcl er tb24 25mg
1 QL(90/30)
PASER
1
PATADAY
1
PATANOL
1
PAXIL SUSP
1 QL(900/30)
pedi-dri
1
PEDVAX HIB
1
peg 3350/electrolytes
1
peg-3350/nacl/na
1
bicarbonate/kcl
PEGANONE
1
1 PA
PEG-INTRON
PEG-INTRON REDIPEN
1 PA
PEG-INTRON REDIPEN PAK
1 PA
4
penicillin g potassium inj
1
20000000unit, 5mu
penicillin v potassium
1
PENTAM 300
1
pentoxifylline er
1
PERFOROMIST
1 B/D PA
QL(120/30)
perindopril erbumine
1
periogard
1
PERJETA
1 PA
permethrin crea
1
perphenazine
1
perphenazine/amitriptyline
1 PA
PFIZERPEN-G INJ 5MU
1
phenadoz
1 PA
phenelzine sulfate
1
phenobarbital
1
phenytoin
1
phenytoin infatabs
1
phenytoin sodium
1
phenytoin sodium extended
1
philith
1
Página
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply;
B/D= Drugs covered under Medicare Part B or Part D
Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa;
ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D
20
35
35
35
35
35
36
50
50
35
36
50
46
46
34
39
39
39
32
32
38
43
52
42
44
38
38
38
35
33
35
34
33
34
34
34
34
48
Drug Name
PHOSLYRA
PHOSPHOLINE IODIDE
PHYSIOLYTE
physiosol irrigation
PICATO
pilocarpine hcl tabs
PILOCARPINE HCL
OPHTHALMIC SOLN
pilocarpine hydrochloride
pimtrea
pindolol
PIOGLITAZONE HCL TABS
45MG
pioglitazone hcl tabs 15mg,
30mg
pioglitazone hcl/metformin hcl
pioglitazone hcl-glimepiride
piperacillin sodium/
tazobactam sodium
piperacillin sodium/tazobactam
sodium
piperacillin/tazobactam
pirmella 1/35
pirmella 7/7/7
piroxicam
podofilox
polycin
polycin b
poly-dex
polyethylene glycol 3350 powd
polymyxin b sulfate
polymyxin b
sulfate/trimethoprim sulfate
POMALYST
portia-28
potassium chloride inj
10meq/100ml, 20meq/100ml,
2meq/ml, 40meq/100ml
potassium chloride liqd
potassium chloride pack
potassium chloride 0.15%
d5w/nacl 0.33%
Drug Reqs./Limits
Tier
1
1
1 B/D PA
1
1 ST
1
1
Page
53
51
50
50
37
44
51
Drug Name
Drug Reqs./Limits
Tier
1 B/D PA
Page
potassium chloride 0.15%
d5w/nacl 0.45%
potassium chloride 0.15%/d5w 1
potassium chloride 0.15%/nacl 1 B/D PA
0.9%
potassium chloride 0.22%
1 B/D PA
d5w/nacl 0.45%
potassium chloride
1 B/D PA
0.224%/d5w/nacl 0.45%
1
44
POTASSIUM CHLORIDE
1 B/D PA
1
48
0.3%/ NACL 0.9%
1
43
POTASSIUM CHLORIDE
1 B/D PA
1 QL(30/30)
40
0.3%/D5W
potassium chloride 0.3%/nacl
1 B/D PA
1 QL(30/30)
40
0.9%/viaflex
potassium chloride cr
1
1 QL(90/30)
40
potassium chloride er cpcr
1
1 QL(30/30)
40
POTASSIUM CHLORIDE ER
1
1
33
TBCR 10MEQ
potassium chloride er tbcr
1
1
33
10meq, 20meq
POTASSIUM CHLORIDE SR
1
1
33
POTASSIUM CITRATE
1
1
48
POTIGA
1 PA QL(90/30)
1
48
PRADAXA CAPS 150MG
1 PA QL(60/30)
1
30
PRADAXA CAPS 75MG
1 PA QL(120/30)
1
45
pramipexole dihydrochloride
1 QL(90/30)
1
50
pravastatin sodium tabs 80mg
1 QL(30/30)
1
32
pravastatin sodium tabs 40mg
1 QL(60/30)
1
51
pravastatin sodium tabs 10mg, 1 QL(90/30)
1
46
20mg
1
32
prazosin hcl
1
1
32
PRED MILD
1
PRED-G
1
1 PA QL(21/28)
37
PRED-G S.O.P.
1
1
48
prednicarbate oint
1
1 B/D PA
53
PREDNISOLONE ACETATE
1
prednisolone sodium
1
phosphate
1
53
prednisolone sodium
1
1
53
phosphate
1 B/D PA
41
prednisone
1
PREDNISONE INTENSOL
1
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply;
B/D= Drugs covered under Medicare Part B or Part D
Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa;
ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D
41
53
53
41
41
53
53
53
53
53
53
53
53
53
33
42
42
38
44
44
44
42
51
51
51
47
51
47
47
47
47
21
Nombre del
medicamento
Nivel del
medicamento
pregnyl w/diluent benzyl
alcohol/nacl
PREMARIN CREA
PREMARIN INJ
PREMARIN TABS
PREMASOL INJ 52MEQ/L
1760MG/100ML
880MG/100ML 34MEQ/L
1760MG/100ML
372MG/100ML
406MG/100ML
526MG/100ML
492MG/100ML
492MG/100ML
526MG/100ML
356MG/100ML
356MG/100ML
390MG/100ML 34MG/100ML
152MG/100ML
premasol inj 56meq/l
320mg/100ml 730mg/100ml
190mg/100ml 3meq/l
20mg/100ml 300mg/100ml
220mg/100ml 290mg/100ml
490mg/100ml 840mg/100ml
490mg/100ml 200mg/100ml
290mg/100ml 410mg/100ml
230mg/100ml 5meq/l
15mg/100ml 250mg/100ml
120mg/100ml 140mg/100ml
470mg/100ml
PRENATABS OBN
prevalite
previfem
PREZISTA SUSP
PREZISTA TABS 800MG
PREZISTA TABS 600MG
PREZISTA TABS 150MG
PREZISTA TABS 75MG
PRIFTIN
PRIMAQUINE PHOSPHATE
primidone
PRIMSOL
PRISTIQ
PRIVIGEN INJ 10GM/100ML,
1
Requ./
Límites
PA
Página
47
1
1
1
1
PA QL(30/30)
B/D PA
48
48
48
53
1
B/D PA
53
1
1
1
1
1
1
1
1
1
1
1
1
1
1
QL(400/30)
QL(30/30)
QL(60/30)
QL(180/30)
QL(360/30)
QL(30/30)
B/D PA
54
44
48
40
40
40
40
40
36
38
34
32
35
49
Nombre del
medicamento
Nivel del
Requ./
Página
medicamento Límites
20GM/200ML, 5GM/50ML
PROAIR HFA
1 QL(17/30)
52
probenecid
1
36
probenecid/colchicine
1
36
PROCALAMINE
1 B/D PA
53
procentra
1 QL(1800/30)
44
prochlorperazine
1
38
prochlorperazine edisylate
1
38
prochlorperazine maleate
1
38
PROCRIT
1 PA
42
procto-pak
1
47
proctosol hc
1
47
proctozone-hc
1
47
progesterone caps
1
48
PROGLYCEM
1
41
PROGRAF INJ
1 B/D PA
49
PROLASTIN-C
1 B/D PA
52
PROLEUKIN
1 B/D PA
37
PROLIA
1 QL(1/180) ST
50
PROMACTA
1 PA QL(30/30)
42
promethazine hcl supp
1 PA
35
12.5mg, 25mg
promethazine hcl inj
1 PA
51
promethazine hcl syrp
1 PA
51
promethazine hcl tabs
1 PA
51
promethazine hcl plain
1 PA
35
promethegan
1 PA
35
propafenone hcl
1
43
propafenone hcl er
1
43
propantheline bromide
1
45
proparacaine hcl
1
50
propranolol hcl
1
43
propranolol hcl er
1
43
propranolol/hydrochlorothiazid
1
43
e
propylthiouracil
1
49
PROQUAD
1
50
PROSOL
1 B/D PA
53
PROTOPIC
1
45
protriptyline hcl
1
35
PROVENGE
1 B/D PA
49
PRUDOXIN
1
45
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply;
B/D= Drugs covered under Medicare Part B or Part D
Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa;
ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D
22
Drug Name
Drug Reqs./Limits
Tier
1 B/D PA
1
1
PULMOZYME
pyrazinamide
pyridostigmine bromide
Q
quasense
1
quetiapine fumarate
1
quinapril hcl
1
quinapril/hydrochlorothiazide
1
quinidine sulfate
1
quinine sulfate
1
QVAR
1
R
RABAVERT
1
raloxifene hydrochloride
1
ramipril
1
RANEXA TB12 1000MG
1
RANEXA TB12 500MG
1
ranitidine hcl caps
1
ranitidine hcl inj 150mg/6ml
1
1
ranitidine hcl syrp
ranitidine hcl tabs
1
RAPAFLO
1
RAPAMUNE ORAL SOLN
1
RAPAMUNE TABS 1MG,
1
2MG
REBETOL ORAL SOLN
1
REBIF
1
REBIF REBIDOSE
1
REBIF REBIDOSE
1
TITRATION PACK
REBIF TITRATION PACK
1
reclipsen
1
RECOMBIVAX HB INJ
1
10MCG/ML, 40MCG/ML
regonol
1
REGRANEX
1
RELISTOR INJ 8MG/0.4ML
1
RELISTOR INJ VIAL12MG/0.6ML 1
RELISTOR INJ KIT 12MG/0.6ML 1
REMICADE
1
REMODULIN
1
QL(90/30)
QL(18/30)
Page
52
36
36
48
39
42
42
43
38
51
QL(30/30)
B/D PA
B/D PA
50
48
42
43
43
45
45
45
45
46
49
49
PA
PA QL(6/28)
PA QL(6/28)
PA QL(4.2/28)
39
44
44
44
PA QL(4.2/28)
B/D PA
44
48
50
PA
PA QL(12/30)
PA QL(18/30)
PA QL(28/28)
PA
B/D PA
36
45
45
45
45
49
52
QL(30/30)
QL(60/30) ST
QL(120/30) ST
Drug Name
RENVELA PACK
RENVELA TABS
repaglinide
RESCRIPTOR
RESTASIS
RETROVIR IV INFUSION
REVLIMID
REYATAZ
ribasphere
RIBASPHERE RIBAPAK
RIBATAB
ribavirin
RIDAURA
rifabutin
rifampin
RIFATER
riluzole
rimantadine hcl
ringers injection
ringers irrigation
RIOMET
risedronate sodium
RISPERDAL CONSTA
risperidone oral soln
risperidone tabs 0.25mg,
0.5mg, 1mg, 2mg, 3mg
risperidone tabs 4mg
risperidone m-tab tbdp 0.5mg,
1mg, 2mg, 3mg
risperidone m-tab tbdp 4mg
risperidone odt tbdp 0.25mg,
0.5mg, 1mg, 2mg, 3mg
risperidone odt tbdp 4mg
RITUXAN
rivastigmine tartrate
rizatriptan benzoate
rizatriptan benzoate odt
romycin
ropinirole hcl
rosadan gel
ROTARIX
Drug
Tier
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Reqs./Limits
Page
QL(360/30)
QL(90/30)
46
46
40
39
50
40
36
40
39
39
39
39
49
36
36
36
44
40
53
50
40
50
39
39
39
1
1
QL(120/30)
QL(90/30)
39
39
1
1
QL(120/30)
QL(90/30)
39
39
1
1
1
1
1
1
1
1
1
QL(120/30)
PA
QL(60/30)
QL(12/30)
QL(12/30)
39
38
34
36
36
33
38
32
50
QL(180/30)
QL(540/30)
QL(64/30)
PA QL(28/28)
PA
PA
PA
PA
QL(1/28)
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply;
B/D= Drugs covered under Medicare Part B or Part D
Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa;
ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D
23
Nombre del
medicamento
Nivel del
medicamento
ROTATEQ
roxicet tabs
ROZEREM
S
SABRIL PACK
SABRIL TABS
SAIZEN
SAIZEN CLICK.EASY
SAMSCA TABS 30MG
SAMSCA TABS 15MG
SANDOSTATIN LAR DEPOT
SANTYL
SAPHRIS
selegiline hcl
selenium sulfide lotn
SELZENTRY TABS 150MG
SELZENTRY TABS 300MG
SENSIPAR TABS 30MG,
60MG
SENSIPAR TABS 90MG
SEREVENT DISKUS
SEROQUEL XR TB24
150MG, 200MG
SEROQUEL XR TB24
300MG, 400MG, 50MG
sertraline hcl conc
sertraline hcl tabs 25mg
sertraline hcl tabs 100mg
sertraline hcl tabs 50mg
SILDENAFIL
SILENOR
SILVER SULFADIAZINE
SIMULECT
simvastatin tabs 20mg, 40mg,
80mg
simvastatin tabs 10mg, 5mg
sirolimus
SIRTURO
sodium bicarbonate inj 7.5%,
8.4%
sodium chloride inj 0.9%,
2.5meq/ml, 3%, 5%
1
1
1
Requ./
Límites
QL(360/30)
QL(30/30)
Página
50
31
52
1
1
1
1
1
1
1
1
1
1
1
1
1
1
PA QL(200/30)
PA QL(180/30)
PA
PA
PA QL(60/30)
PA QL(90/30)
PA
QL(60/30)
QL(120/30)
QL(60/30)
34
34
47
47
52
52
49
45
39
38
45
40
40
48
1
1
1
QL(120/30)
QL(60/30)
QL(30/30) ST
48
52
39
1
QL(60/30) ST
39
1
1
1
1
1
1
1
1
1
QL(300/30)
QL(30/30)
QL(60/30)
QL(90/30)
PA QL(90/30)
QL(30/30)
35
35
35
35
52
52
32
49
44
1
1
1
1
QL(90/30)
B/D PA
PA
44
49
36
52
1
B/D PA
54
QL(60/30) ST
B/D PA
QL(30/30)
Nombre del
medicamento
Nivel del
Requ./
Página
medicamento Límites
sodium chloride 0.45% viaflex
1 B/D PA
53
sodium chloride 0.9%
1
50
SODIUM EDECRIN
1
43
sodium fluoride chew 0.25mg,
1
54
0.5mg, 1mg, 2.2mg
sodium fluoride tabs
1
54
sodium lactate
1 B/D PA
52
sodium phenylbutyrate
1
45
sodium polystyrene sulfonate
1
52
powd
sodium polystyrene sulfonate
1
52
susp 15gm/60ml
sodium sulfacetamide
1
33
ophthalmic soln
SOLTAMOX
1
36
SOLU-CORTEF INJ 1000MG,
1
47
250MG, 500MG
SOMATULINE DEPOT
1 PA
49
SOMAVERT INJ 15MG, 20MG 1 PA QL(60/30)
49
SOMAVERT INJ 10MG
1 PA QL(90/30)
49
sorine
1
43
sotalol hcl
1
43
sotalol hcl (af)
1
43
SOVALDI
1 PA QL(30/30)
39
SPIRIVA HANDIHALER
1 QL(30/30)
52
spironolactone
1
43
spironolactone/hydrochlorothia 1
43
zide
SPORANOX ORAL SOLN
1 PA
36
sprintec 28
1
48
SPRYCEL
1 PA
37
sps
1
52
sronyx
1
48
SSD
1
32
stavudine
1
40
sterile water irrigation
1
50
STIMATE
1
47
STIVARGA
1 PA QL(84/21)
37
STRATTERA
1
44
streptomycin sulfate
1
31
STRIBILD
1
39
STROMECTOL
1
38
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply;
B/D= Drugs covered under Medicare Part B or Part D
Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa;
ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D
24
Drug Name
SUBOXONE
sucralfate
sulfacetamide sodium
ophthalmic soln
sulfacetamide sodium susp
sulfacetamide
sodium/prednisolone sodium
phosphate
sulfadiazine
sulfamethoxazole/trimethoprim
sulfamethoxazole/trimethoprim
ds
sulfasalazine tabs
sulfazine
sulfazine ec
sulindac
SUMATRIPTAN
sumatriptan succinate inj
4mg/0.5ml
sumatriptan succinate inj
4mg/0.5ml, 6mg/0.5ml
sumatriptan succinate tabs
sumatriptan succinate refill inj
6mg/0.5ml
sumatriptan succinate refill inj
4mg/0.5ml
SUPRAX SUSR
SUPRAX TABS
SURMONTIL
SUSTIVA
SUTENT CAPS 12.5MG,
25MG, 50MG
SYLATRON
SYMBICORT AERO
160MCG/ACT 4.5MCG/ACT
SYMBICORT AERO
80MCG/ACT 4.5MCG/ACT
SYMLINPEN 120
SYMLINPEN 60
SYNAGIS INJ 50MG/0.5ML
SYNAREL
SYNERCID
Drug Reqs./Limits
Tier
1 PA QL(90/30)
1
1
Page
31
46
33
1
1
45
33
1
1
1
33
33
33
1
1
1
1
1
1
QL(12/30)
QL(4/30)
50
50
50
30
36
36
1
QL(8/30)
36
1
1
QL(9/30)
QL(4/30)
36
36
1
QL(8/30)
36
1
1
1
1
1
PA
PA
32
32
35
39
37
1
1
PA
QL(11/30)
37
51
1
QL(14/30)
51
1
1
1
1
1
PA QL(11/30)
PA QL(6/30)
PA
PA
41
41
49
49
32
Drug Name
SYNRIBO
SYNTHROID
SYPRINE
T
TABLOID
tacrolimus
TAFINLAR
TAMIFLU CAPS 75MG
TAMIFLU CAPS 45MG
TAMIFLU CAPS 30MG
TAMIFLU SUSR
tamoxifen citrate
tamsulosin hcl
TARCEVA
TARGRETIN
TASIGNA
TASMAR
TAXOTERE
TAZICEF INJ 1GM/50ML
4.4%
tazicef inj 1gm, 2gm, 6gm
TAZORAC CREA
TAZORAC GEL
taztia xt
TEFLARO
TEGRETOL-XR TB12 100MG
TEKAMLO
TEKTURNA
TEKTURNA HCT
telmisartan
telmisartan/amlodipine
telmisartan/hydrochloroth
telmisartan/hydrochlorothiazid
e
temazepam
TEMODAR INJ
tenivac
terazosin hcl caps 1mg, 5mg
terazosin hcl caps 10mg, 2mg
terbinafine hcl tabs
terbutaline sulfate
Drug Reqs./Limits
Tier
1 PA
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Page
B/D PA
PA
QL(56/365)
QL(60/365)
QL(120/365)
QL(700/365)
PA
PA
B/D PA
QL(120/30)
QL(100/30)
ST
ST
ST
QL(30/30)
QL(30/30)
QL(30/30)
QL(30/30)
QL(90/365)
B/D PA
QL(30/30)
QL(60/30)
QL(180/365)
37
48
52
37
49
37
40
40
40
40
36
46
37
38
37
38
37
32
32
45
45
43
32
34
43
43
43
42
42
42
42
40
36
50
46
46
36
52
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply;
B/D= Drugs covered under Medicare Part B or Part D
Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa;
ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D
25
Nombre del
medicamento
Nivel del
medicamento
terconazole
TESTIM
testosterone cypionate
testosterone enanthate
tetanus toxoid adsorbed
tetanus/diphtheria toxoidsadsorbed adult
tetracycline hcl
TEXACORT
THALOMID CAPS 150MG,
200MG, 50MG
THALOMID CAPS 100MG
THEO-24
theochron
theophylline cr
theophylline er tb12 200mg,
300mg, 450mg
theophylline er tb24
THERMAZENE
thioridazine hcl
thiothixene
THYMOGLOBULIN
THYROLAR-1
THYROLAR-1/2
THYROLAR-1/4
THYROLAR-2
THYROLAR-3
tiagabine hydrochloride tabs
2mg
tiagabine hydrochloride tabs
4mg
TIKOSYN
tilia fe
TIMENTIN
timolol maleate
timolol maleate
tis-u-sol
TIVICAY
tizanidine hcl tabs
TOBI PODHALER
TOBRADEX OINT
tobramycin
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Requ./
Límites
PA
PA
PA
PA QL(60/30)
PA QL(90/30)
Página
36
47
47
47
50
50
33
47
36
36
52
52
52
52
1
1
1
1
1
1
1
1
1
1
1
QL(240/30)
52
32
38
38
49
48
48
48
48
48
34
1
QL(420/30)
34
1
1
1
1
1
1
1
1
1
1
1
PA
B/D PA
QL(60/30)
QL(1568/365)
B/D PA
43
48
33
43
51
50
39
39
52
51
52
Nombre del
medicamento
Nivel del
Requ./
Página
medicamento Límites
tobramycin sulfate inj
1
31
10mg/ml, 80mg/2ml
tobramycin sulfate inj 1.2gm
1 B/D PA
31
tobramycin sulfate ophthalmic
1
31
soln
tobramycin/dexamethasone
1
51
TOBREX OINT
1
31
tolmetin sodium
1
30
tolterodine tartrate
1
46
topiragen
1
34
topiramate
1
34
TOPOSAR
1 B/D PA
37
topotecan hcl inj 4mg
1
37
TORISEL
1 B/D PA
49
torsemide tabs
1
43
tpn electrolytes
1 B/D PA
54
TRACLEER
1 PA QL(60/30)
52
TRADJENTA
1 QL(30/30)
41
tramadol hcl
1 QL(240/30)
31
tramadol hcl er tb24
1 QL(30/30)
30
tramadol
1 QL(240/30)
31
hydrochloride/acetaminophen
trandolapril
1
42
tranexamic acid inj
1 PA
42
tranexamic acid tabs
1
42
TRANSDERM-SCOP
1 QL(12/36)
35
tranylcypromine sulfate
1
34
TRAVASOL
1 B/D PA
54
TRAVATAN Z
1 QL(5/30)
50
trazodone hcl
1
34
TREANDA
1 B/D PA
36
TRECATOR
1
36
TRELSTAR DEPOT
1 PA QL(1/28)
49
TRELSTAR DEPOT MIXJECT 1 PA QL(2/28)
49
TRELSTAR LA
1 PA QL(1/84)
49
TRELSTAR LA MIXJECT
1 PA QL(2/84)
49
TRELSTAR MIXJECT
1 PA QL(2/168)
49
tretinoin caps
1
38
tretinoin crea
1 PA QL(45/30)
45
tretinoin gel
1 PA QL(45/30)
45
tretinoin microsphere
1 PA QL(50/30)
45
tretinoin microsphere pump
1 PA QL(50/30)
45
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply;
B/D= Drugs covered under Medicare Part B or Part D
Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa;
ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D
26
Drug Name
Drug Reqs./Limits
Tier
Page
Drug Name
Drug Reqs./Limits
Tier
Page
gel 0.04%
0.78GM/100ML
triamcinolone acetonide pste
1
44
tropicamide
1
triamcinolone acetonide crea
1
47
TRUVADA
1
triamcinolone acetonide lotn
1
47
TWINRIX
1
triamcinolone acetonide oint
1
47
TYGACIL
1
triamcinolone acetonide inha
1 QL(16.5/30)
TYKERB
1 PA
51
TYPHIM VI
1
triamcinolone in orabase
1
44
triamterene/hydrochlorothiazid
1
43
TYSABRI
1 PA
e
TYZEKA
1 PA
triderm
1
47
TYZINE
1
tri-estarylla
1
48
TYZINE PEDIATRIC NASAL
1
DROPS
trifluoperazine hcl
1
38
trifluridine
1
40
U
u-cort
1
trihexyphenidyl hcl
1 PA
38
tri-legest fe
1
48
ULORIC
1 ST
UNITHROID
1
tri-linyah
1
48
UNITHROID DIRECT
1
trilyte
1
46
ursodiol
1
trimethoprim
1
32
UVADEX
1 B/D PA
trimethoprim sulfate/polymyxin 1
50
b sulfate
V
tri-previfem
1
48
valacyclovir hcl tabs 1000mg
1 QL(30/30)
TRISENOX
1 B/D PA
37
valacyclovir hcl tabs 500mg
1 QL(60/30)
tri-sprintec
1
48
VALCHLOR
1 PA
trivora-28
1
48
VALCYTE
1
TROKENDI XR CP24 100MG, 1 QL(30/30)
34
valproate sodium
1
25MG, 50MG
valproic acid
1
TROKENDI XR CP24 200MG
1 QL(60/30)
34
valsartan/hydrochlorothiazide
1
TROPHAMINE INJ 97MEQ/L
1 B/D PA
54
vancomycin hcl caps 125mg
1 QL(40/10)
0.54GM/100ML
vancomycin hcl caps 250mg
1 QL(80/10)
1.2GM/100ML
VANCOMYCIN HCL INJ
1
0.32GM/100ML 0 0
5000MG, 750MG
0.5GM/100ML
vancomycin hcl inj 1000mg,
1
0.36GM/100ML
10gm,
500mg
0.48GM/100ML
VANCOMYCIN HCL IN
1
0.82GM/100ML
DEXTROSE
1.4GM/100ML 1.2GM/100ML
0.34GM/100ML
VAQTA
1
0.48GM/100ML
VARIVAX
1
0.68GM/100ML
VECTIBIX INJ 100MG/5ML
1 B/D PA
0.38GM/100ML 5MEQ/L
VECTICAL
1
0.025GM/100ML
VELCADE
1 B/D PA
0.42GM/100ML
velivet
1
0.2GM/100ML
venlafaxine hcl
1 QL(120/30)
0.24GM/100ML
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply;
B/D= Drugs covered under Medicare Part B or Part D
Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa;
ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D
50
40
50
32
38
50
44
39
52
52
47
36
48
48
45
45
40
40
36
39
34
34
42
32
32
32
32
32
50
50
38
45
37
48
35
27
Nombre del
medicamento
Nivel del
medicamento
venlafaxine hcl er cp24
150mg, 37.5mg
venlafaxine hcl er cp24 75mg
venlafaxine hcl er tb24 150mg,
37.5mg
venlafaxine hcl er tb24 75mg
VENTOLIN HFA
verapamil hcl
verapamil hcl er
VERSACLOZ
VESICARE
vicodin
vicodin es
vicodin hp
VICTOZA
VICTRELIS
VIDEX PEDIATRIC
VIGAMOX
VIIBRYD
VIMPAT INJ
VIMPAT ORAL SOLN
VIMPAT TABS
vinblastine sulfate inj 1mg/ml
vincasar pfs
vincristine sulfate
vinorelbine tartrate
viorele
VIRACEPT
VIRAMUNE XR TB24 100MG
VIRAZOLE
VIREAD
VIVELLE-DOT
VOLTAREN
VORAXAZE
voriconazole
VOTRIENT
VPRIV
vyfemla
W
warfarin sodium
WELCHOL
wera
1
Requ./
Límites
QL(30/30)
Página
35
1
1
QL(90/30)
QL(30/30)
35
35
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
QL(90/30)
QL(36/30)
35
52
43
43
39
46
31
31
31
41
39
40
33
35
34
34
34
37
37
37
37
48
40
39
39
40
48
45
50
36
38
45
48
1
1
1
QL(30/30)
QL(390/30)
QL(390/30)
QL(390/30)
QL(9/30)
PA QL(360/30)
QL(30/30) ST
QL(1200/30)
QL(1200/30)
QL(60/30)
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
PA QL(8/28)
QL(1000/30) ST
PA
PA QL(120/30)
PA
42
44
48
Nombre del
medicamento
Nivel del
Requ./
medicamento Límites
X
XALKORI
XARELTO TABS 10MG,
20MG
XARELTO TABS 15MG
XENAZINE TABS 12.5MG
XENAZINE TABS 25MG
XGEVA
XIFAXAN TABS 200MG
XIFAXAN TABS 550MG
XOLAIR
XOLEGEL
XTANDI
XYREM
Y
YERVOY
yf-vax
Z
zafirlukast
zaleplon
ZALTRAP
ZANOSAR
ZAVESCA
zazole supp
ZELBORAF
ZEMAIRA
zenatane
zenchent
ZENPEP
ZETIA
ZIAGEN ORAL SOLN
zidovudine
ZINECARD INJ 250MG
ziprasidone hcl
ZIRGAN
ZMAX
zoledronic acid inj 4mg/5ml,
5mg/100ml
ZOLINZA
zolpidem tartrate
ZOMETA INJ 4MG/100ML
ZONALON
Página
1
1
PA QL(60/30)
PA QL(30/30)
38
42
1
1
1
1
1
1
1
1
1
1
PA QL(60/30)
PA QL(90/30)
PA QL(120/30)
PA
PA QL(9/30)
PA QL(60/30)
PA
42
44
44
50
32
32
52
36
36
52
1
1
B/D PA
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
PA QL(120/30)
PA QL(540/30)
QL(90/365)
PA
B/D PA
PA QL(240/30)
B/D PA
QL(30/30)
B/D PA
QL(60/30)
ST
QL(60/30)
B/D PA
QL(120/30)
PA QL(90/365)
B/D PA
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply;
B/D= Drugs covered under Medicare Part B or Part D
Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa;
ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D
28
38
50
51
52
37
36
45
36
38
52
45
48
45
44
40
40
37
39
39
33
50
37
52
50
45
Drug Name
zonisamide
ZORTRESS
ZOSTAVAX
ZOSYN INJ 5% 2GM/50ML
0.25GM/50ML, 5%
3GM/50ML 0.375GM/50ML
zovia 1/35e
zovia 1/50e
ZOVIRAX CREA
ZYCLARA
ZYKADIA
ZYLET
ZYPREXA RELPREVV
ZYTIGA
ZYVOX
Drug Reqs./Limits
Tier
1
1 B/D PA
1
1
1
1
1
1
1
1
1
1
1
PA
PA QL(120/30)
PA
Page
Drug Name
Drug Reqs./Limits
Tier
Page
33
49
50
33
48
48
40
45
38
31
39
36
32
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply;
B/D= Drugs covered under Medicare Part B or Part D
Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa;
ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D
29
Drug Name
Drug Reqs/Limits Drug Name
Drug Reqs/Limits
Tier
Tier
levorphanol tartrate
1 QL(180/30)
ANALGESICS
methadone
hcl
conc
1
QL(500/30)
ANALGESICS
methadone hcl inj
1
butal/asa/caff
1 PA
methadone
hcl
oral
1
QL(2000/30)
QL(180/30)
soln 10mg/5ml
butalbital/acetamino
1 PA
methadone hcl oral
1 QL(4000/30)
phen/caffeine
QL(180/30)
soln 5mg/5ml
margesic
1 PA
methadone
hcl tabs
1 QL(360/30)
QL(180/30)
methadose
tabs
1 QL(360/30)
NONSTEROIDAL ANTImorphine sulfate er
1 QL(90/30)
INFLAMMATORY DRUGS
tbcr
CELEBREX
1 QL(60/30)
OXYCONTIN
1 PA
ST
QL(60/30)
diclofenac
1
oxymorphone
1 QL(60/30)
potassium
hydrochloride
er
diclofenac sodium
1
tramadol hcl er tb24
1 QL(30/30)
dr
OPIOID
ANALGESICS,
SHORTdiclofenac sodium
1
ACTING
er
acetaminophen/cod
1 QL(360/30)
diflunisal
1
eine #2
etodolac
1
acetaminophen/cod
1 QL(360/30)
etodolac er
1
eine #3
fenoprofen calcium
1
acetaminophen/cod
1 QL(240/30)
flurbiprofen
1
eine #4
ibuprofen susp
1
acetaminophen/cod
1 QL(5000/30)
ibuprofen tabs
1
eine
oral
soln
400mg, 600mg,
acetaminophen/cod
1 QL(240/30)
800mg
eine
tabs
300mg;
ketoprofen
1
60mg
ketoprofen er
1
acetaminophen/cod
1 QL(360/30)
meclofenamate
1
eine tabs 300mg;
sodium
15mg
meloxicam tabs
1
ascomp/codeine
1 PA
nabumetone
1
QL(180/30)
naproxen
1
butalbital/aspirin/caf
1
PA
naproxen dr
1
feine/codeine
QL(180/30)
naproxen sodium
1
butorphanol
tartrate
1
tabs 275mg, 550mg
inj
oxaprozin
1
butorphanol tartrate
1 QL(6/30)
oxycodone/ibuprofe
1 QL(150/30)
nasal soln
n
duramorph
1
piroxicam
1
endocet tabs
1 QL(360/30)
sulindac
1
325mg;
10mg,
tolmetin sodium
1
OPIOID ANALGESICS, LONG-ACTING 325mg; 5mg,
325mg; 7.5mg
fentanyl
1 QL(15/30)
fentanyl
citrate
1 B/D PA
infumorph 200
1
infumorph 500
1
Drug Name
FENTANYL
CITRATE ORAL
TRANSMUCOSAL
hydrocodone
bitartrate/acetamino
phen oral soln
hydrocodone
bitartrate/acetamino
phen tabs 325mg;
2.5mg
hydrocodone
bitartrate/acetamino
phen tabs 300mg;
10mg, 300mg; 5mg,
300mg; 7.5mg
hydrocodone/aceta
minophen tabs
hydrocodone/ibupro
fen tabs 7.5mg;
200mg
HYDROMORPHON
E HCL INJ
1MG/ML, 2MG/ML,
500MG/50ML
hydromorphone hcl
inj 2mg/ml
hydromorphone hcl
liqd
hydromorphone hcl
tabs
LAZANDA
lorcet
lorcet hd
lorcet plus
lortab tabs
morphine sulfate inj
0.5mg/ml, 10mg/ml,
1mg/ml, 5mg/ml
morphine sulfate
oral soln 20mg/ml
morphine sulfate
oral soln 20mg/5ml
morphine sulfate
oral soln 10mg/5ml
MORPHINE
SULFATE TABS
nalbuphine hcl
Drug Reqs/Limits
Tier
1 PA
QL(120/30)
1 QL(5400/30)
1 QL(360/30)
1 QL(390/30)
1 QL(360/30)
1 QL(150/30)
1
1
1 QL(1200/30)
1 QL(240/30)
1 PA
QL(44/28)
1 QL(360/30)
1 QL(360/30)
1 QL(360/30)
1 QL(360/30)
1
1 QL(540/30)
1 QL(2700/30)
1 QL(5400/30)
1 QL(360/30)
1
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply;
B/D= Drugs covered under Medicare Part B or Part D
Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa;
ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D
30
Nombre del
Nivel del
Requ./
medicamento medicamento Límites
Nombre del
Nivel del
Requ./
medicamento medicamento Límites
Nombre del
Nivel del
Requ./
medicamento medicamento Límites
oxycodone hcl caps
1 QL(240/30)
oxycodone hcl conc
1 QL(360/30)
oxycodone hcl oral
1 QL(1200/30)
soln
oxycodone hcl tabs
1 QL(240/30)
1 QL(360/30)
oxycodone/acetami
nophen tabs
325mg; 10mg,
325mg; 5mg,
325mg; 7.5mg
oxycodone/aspirin
1 QL(360/30)
roxicet tabs
1 QL(360/30)
tramadol hcl
1 QL(240/30)
tramadol
1 QL(240/30)
hydrochloride/aceta
minophen
vicodin
1 QL(390/30)
vicodin es
1 QL(390/30)
vicodin hp
1 QL(390/30)
ANESTHETICS
LOCAL ANESTHETICS
lidocaine hcl
1
external soln
lidocaine hcl gel
1
1
lidocaine hcl inj
0.5%, 1%, 2%
lidocaine hcl jelly
1
lidocaine oint
1
lidocaine ptch
1 PA
QL(90/30)
lidocaine viscous
1
lidocaine/prilocaine
1
crea
ANTI-ADDICTION/SUBSTANCE
ABUSE TREATMENT AGENTS
ALCOHOL DETERRENTS/ANTICRAVING
acamprosate
1 PA
calcium dr
disulfiram
1
OPIOID DEPENDENCE TREATMENTS
buprenorphine hcl
1 PA
inj
buprenorphine hcl
1 PA
subl
QL(24/30)
buprenorphine
hcl/naloxone hcl
naltrexone hcl
SUBOXONE
gentamicin
1
sulfate/sodium
chloride
isotonic gentamicin
1
inj 0.8mg/ml; 0.9%,
1.2mg/ml; 0.9%,
1.6mg/ml; 0.9%,
1mg/ml; 0.9%
neomycin sulfate
1
neomycin/polymyxi
1
n b sulfates
paromomycin
1
sulfate
streptomycin sulfate
1
tobramycin sulfate
1
inj 10mg/ml,
80mg/2ml
tobramycin sulfate
1 B/D PA
inj 1.2gm
tobramycin sulfate
1
ophthalmic soln
TOBREX OINT
1
ZYLET
1
ANTIBACTERIALS, OTHER
ak-poly-bac
1
alcohol preps pads
1
baciim
1
BACITRACIN INJ
1
bacitracin
1
ophthalmic oint
bacitracin/polymyxi
1
nb
BACTROBAN
1
NASAL
chloramphenicol
1
sodium succinate
clindamax
1
clindamycin hcl
1
clindamycin
1
phosphate addvantage
clindamycin
1
phosphate crea
CLINDAMYCIN
1
PHOSPHATE IN
D5W
1 PA
QL(90/30)
1 PA
1 PA
QL(90/30)
OPIOID REVERSAL AGENTS
naloxone hcl
1
SMOKING CESSATION AGENTS
buproban
1 QL(60/30)
bupropion hcl sr
1 QL(60/30)
tb12 150mg
CHANTIX
1 PA
QL(336/365)
CHANTIX
1 PA
CONTINUING
QL(336/365)
MONTH PAK
CHANTIX
1 PA
STARTING
QL(106/365)
MONTH PAK
NICOTROL
1 PA
INHALER
QL(504/30)
NICOTROL NS
1 PA
QL(40/30)
ANTIBACTERIALS
AMINOGLYCOSIDES
amikacin sulfate inj
1
500mg/2ml
gentak
1
gentamicin sulfate
1
crea
GENTAMICIN
1
SULFATE INJ
10MG/ML
gentamicin sulfate
1
inj 10mg/ml,
40mg/ml
gentamicin sulfate
1
oint
gentamicin sulfate
1
ophthalmic soln
gentamicin sulfate
1
pediatric
gentamicin
1
sulfate/0.9%
sodium chloride
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply;
B/D= Drugs covered under Medicare Part B or Part D
Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa;
ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D
31
Drug Name
Drug Reqs/Limits Drug Name
Drug Reqs/Limits Drug Name
Drug Reqs/Limits
Tier
Tier
Tier
clindamycin
1
trimethoprim
1
cefuroxime axetil
1
phosphate inj
TYGACIL
1
cefuroxime sodium
1
150mg/ml
vancomycin hcl
1 QL(40/10)
inj 1.5gm, 7.5gm,
colistimethate
1
caps 125mg
750mg
sodium
vancomycin hcl
1 QL(80/10)
cephalexin caps
1
caps 250mg
250mg, 500mg
CUBICIN
1 B/D PA
lansoprazole/amoxi
1
VANCOMYCIN
1
cephalexin susr
1
cephalexin tabs
1
cillin/clarithromycin
HCL IN
LINCOCIN
1
DEXTROSE
SUPRAX SUSR
1
VANCOMYCIN
SUPRAX TABS
1
methenamine
1
1
HCL INJ 5000MG,
hippurate
TAZICEF INJ
1
750MG
metronidazole crea
1
1GM/50ML; 4.4%
metronidazole gel
1
vancomycin hcl inj
1
tazicef inj 1gm,
1
metronidazole in
1
2gm, 6gm
1000mg, 10gm,
nacl 0.79%
500mg
TEFLARO
1
metronidazole lotn
1
XIFAXAN TABS
1 PA QL(9/30)
BETA-LACTAM, OTHER
metronidazole tabs
1
200MG
AZACTAM IN ISO1
metronidazole
1
XIFAXAN TABS
1 PA
OSMOTIC
vaginal
550MG
QL(60/30)
DEXTROSE
mupirocin
1
ZYVOX
1 PA
aztreonam
1
mupirocin calcium
1
BETA-LACTAM, CEPHALOSPORINS
cefotetan
1
neomycin/bacitracin
1
cefaclor caps
1
imipenem/cilastatin
1
/polymyxin
cefaclor er
1
INVANZ
1
neomycin/polymyxi
1
cefadroxil
1
meropenem
1
n/bacitracin/hydroco
cefazolin sodium inj
1
BETA-LACTAM, PENICILLINS
rtisone
10gm, 1gm, 1gm;
amoxicillin
1
neomycin/polymyxi
1
5%, 500mg
amoxicillin/clavulan
1
n/gramicidin
cefazolin
1
ate potassium
neomycin/polymyxi
1
sodium/dextrose inj
amoxicillin/clavulan
1
n/hydrocortisone
2gm; 3%
ate potassium er
1 QL(900/365) cefdinir
nitrofurantoin
1
ampicillin
1
nitrofurantoin
1 QL(90/365)
cefepime inj 1gm,
1
ampicillin sodium
1
macrocrystals
1gm/50ml; 5%,
ampicillin1
nitrofurantoin
1 QL(90/365)
2gm, 2gm/100ml,
sulbactam inj 10gm;
monohydrate
2gm/50ml; 5%
5gm, 2gm; 1gm
NORITATE
1
cefotaxime sodium
1
AUGMENTIN
1
polycin b
1
cefoxitin sodium inj
1
SUSR 125MG/5ML;
polymyxin b sulfate
1
10gm, 1gm, 2gm
31.25MG/5ML
polymyxin b
1
cefpodoxime
1
BICILLIN L-A
1
sulfate/trimethoprim
proxetil
dicloxacillin sodium
1
sulfate
cefprozil
1
nafcillin sodium
1
PRIMSOL
1
ceftazidime inj 1gm,
1
oxacillin sodium inj
1
rosadan gel
1
2gm, 6gm
10gm, 2gm
SILVER
1
ceftazidime/dextros
1
penicillin g
1
SULFADIAZINE
e
potassium inj
SSD
1
ceftriaxone in iso1
20000000unit, 5mu
SYNERCID
1
osmotic dextrose
penicillin v
1
THERMAZENE
1
ceftriaxone sodium
1
potassium
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply;
B/D= Drugs covered under Medicare Part B or Part D
Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa;
ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D
32
Nombre del
Nivel del
Requ./
medicamento medicamento Límites
Nombre del
Nivel del
Requ./
medicamento medicamento Límites
Nombre del
Nivel del
Requ./
medicamento medicamento Límites
PFIZERPEN-G INJ
1
KETEK
1 QL(20/30)
doxycycline hyclate
1
romycin
1
doxycycline
1
5MU
piperacillin sodium/
1
ZMAX
1 QL(60/30)
monohydrate
tazobactam sodium
doxycycline susr
1
QUINOLONES
piperacillin
1
minocycline
hcl
1
AVELOX INJ
1
sodium/tazobactam
morgidox 1x100mg
1
CILOXAN OINT
1
sodium
caps
CIPRO HC
1
piperacillin/tazobact
1
morgidox 2x100mg
1
CIPRODEX
1
am
caps
ciprofloxacin er
1
TIMENTIN
1
tetracycline hcl
1
ciprofloxacin hcl
1
1
ZOSYN INJ 5%;
ANTICONVULSANTS
ciprofloxacin i.v.-in
1
2GM/50ML;
d5w
ANTICONVULSANTS, OTHER
0.25GM/50ML, 5%;
ciprofloxacin inj
1
APTIOM TABS
1 QL(30/30)
3GM/50ML;
400mg/40ml
200MG, 400MG,
0.375GM/50ML
ciprofloxacin susr
1
800MG
MACROLIDES
levofloxacin in d5w
1
APTIOM TABS
1 QL(60/30)
AZASITE
1
levofloxacin inj
1
600MG
azithromycin inj
1
levofloxacin oral
1
FYCOMPA
1
500mg
soln
levetiracetam
1
AZITHROMYCIN
1 QL(3/30)
levofloxacin tabs
1
levetiracetam er
1
PACK
MOXEZA
1
phenobarbital
1
azithromycin susr
1 QL(75/30)
moxifloxacin hcl
1
POTIGA
1 PA
ofloxacin
1
200mg/5ml
QL(90/30)
azithromycin susr
1 QL(150/30)
VIGAMOX
1
CALCIUM CHANNEL MODIFYING
100mg/5ml
SULFONAMIDES
AGENTS
azithromycin tabs
1 QL(12/28)
BLEPHAMIDE
1
CELONTIN
1
clarithromycin
1
blephamide s.o.p.
1
ethosuximide
1
clarithromycin er
1 QL(60/30)
sodium
1
LYRICA CAPS
1 QL(60/30)
e.e.s. 400
1
sulfacetamide
225MG, 25MG,
E.E.S. GRANULES
1
ophthalmic soln
300MG
e.s.p.
1
sulfacetamide
1
LYRICA CAPS
1 QL(90/30)
1
ery
sodium ophthalmic
100MG, 150MG,
ERY-TAB
1
soln
200MG, 50MG,
ERYPED 200
1
sulfacetamide
1
75MG
ERYPED 400
1
sodium/prednisolon
LYRICA ORAL
1 QL(900/30)
ERYTHROCIN
1
e sodium
SOLN
LACTOBIONATE
phosphate
zonisamide
1
erythrocin stearate
1
sulfadiazine
1
GAMMA-AMINOBUTYRIC ACID
erythromycin base
1
sulfamethoxazole/tri
1
(GABA) AUGMENTING AGENTS
erythromycin
1
methoprim
clonazepam odt
1 QL(90/30)
ethylsuccinate
sulfamethoxazole/tri
1
tbdp 0.125mg,
erythromycin
1
methoprim ds
0.25mg, 0.5mg,
external soln
TETRACYCLINES
1mg
erythromycin gel
1
demeclocycline hcl
1
clonazepam odt
1 QL(300/30)
erythromycin oint
1
doxycycline caps
1
tbdp 2mg
erythromycin pads
1
75mg
ilotycin
1
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply;
B/D= Drugs covered under Medicare Part B or Part D
Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa;
ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D
33
Drug Name
Drug Reqs/Limits Drug Name
Drug Reqs/Limits Drug Name
Drug Reqs/Limits
Tier
Tier
Tier
clonazepam tabs
1 QL(90/30)
fosphenytoin
1
BRINTELLIX
1 QL(30/30)
0.5mg, 1mg
sodium
ST
clonazepam tabs
1 QL(300/30)
oxcarbazepine
1
bupropion hcl
1
2mg
PEGANONE
1
bupropion hcl er
1 QL(60/30)
DIAZEPAM GEL
1
phenytoin
1
tb12 100mg, 200mg
divalproex sodium
1
phenytoin infatabs
1
bupropion hcl er
1 QL(90/30)
divalproex sodium
1
phenytoin sodium
1
tb12 150mg
phenytoin sodium
1
dr
bupropion hcl sr
1 QL(60/30)
extended
divalproex sodium
1
tb12 100mg, 200mg
er
TEGRETOL-XR
1
bupropion hcl sr
1 QL(90/30)
gabapentin
1
TB12 100MG
tb12 150mg
GABITRIL TABS
1 QL(90/30)
VIMPAT INJ
1 QL(1200/30) bupropion hcl xl
1 QL(30/30)
16MG
VIMPAT ORAL
1 QL(1200/30) tb24 300mg
GABITRIL TABS
1 QL(120/30)
SOLN
bupropion hcl xl
1 QL(90/30)
12MG
VIMPAT TABS
1 QL(60/30)
tb24 150mg
ONFI SUSP
1 QL(480/30)
ANTIDEMENTIA AGENTS
maprotiline hcl
1
ONFI TABS 10MG
1 QL(60/30)
mirtazapine
1 QL(30/30)
ANTIDEMENTIA AGENTS, OTHER
ONFI TABS 20MG
1 QL(120/30)
mirtazapine odt
1 QL(30/30)
ergoloid mesylates
1 PA
primidone
1
nefazodone
hcl
1 QL(60/30)
CHOLINESTERASE INHIBITORS
SABRIL PACK
1 PA
trazodone hcl
1
donepezil hcl tabs
1 QL(30/30)
QL(200/30)
MONOAMINE
OXIDASE
INHIBITORS
23mg, 5mg
SABRIL TABS
1 PA
EMSAM
1
donepezil hcl tabs
1 QL(60/30)
QL(180/30)
MARPLAN
1
10mg
tiagabine
1 QL(240/30)
phenelzine sulfate
1
donepezil hcl tbdp
1 QL(30/30)
hydrochloride tabs
tranylcypromine
1
5mg
2mg
sulfate
donepezil hcl tbdp
1 QL(60/30)
tiagabine
1 QL(420/30)
SSRIS/SNRIS (SELECTIVE
10mg
hydrochloride tabs
SEROTONIN REUPTAKE
EXELON PT24
1 QL(30/30)
4mg
INHIBITORS/SEROTONIN
AND
galantamine
1 QL(60/30)
valproate sodium
1
NOREPINEPHRINE REUPTAKE
galantamine
1 QL(30/30)
valproic acid
1
INHIBITOR
hydrobromide cp24
GLUTAMATE REDUCING AGENTS
galantamine
1 QL(200/30)
citalopram
1 QL(600/30)
felbamate
1
hydrobromide oral
hydrobromide oral
lamotrigine
1
soln
soln
lamotrigine er
1
galantamine
1 QL(60/30)
citalopram
1 QL(30/30)
topiragen
1
hydrobromide tabs
hydrobromide tabs
topiramate
1
rivastigmine tartrate
1 QL(60/30)
40mg
TROKENDI XR
1 QL(30/30)
citalopram
1 QL(60/30)
N-METHYL-D-ASPARTATE (NMDA)
CP24 100MG,
hydrobromide tabs
RECEPTOR ANTAGONIST
25MG, 50MG
10mg, 20mg
NAMENDA ORAL
1 QL(300/30)
TROKENDI XR
1 QL(60/30)
duloxetine hcl cpep
1 QL(60/30)
SOLN
CP24 200MG
20mg,
60mg
NAMENDA XR
1 QL(30/30)
SODIUM CHANNEL AGENTS
duloxetine hcl cpep
1 QL(90/30)
NAMENDA XR
1 QL(28/28)
BANZEL
1 PA
30mg
TITRATION PACK
carbamazepine
1
escitalopram
1 QL(600/30)
ANTIDEPRESSANTS
carbamazepine er
1
oxalate
oral
soln
ANTIDEPRESSANTS, OTHER
dilantin caps 30mg
1
escitalopram
1 QL(60/30)
epitol
1
oxalate tabs
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply;
B/D= Drugs covered under Medicare Part B or Part D
Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa;
ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D
34
Nombre del
Nivel del
Requ./
medicamento medicamento Límites
Nombre del
Nivel del
Requ./
medicamento medicamento Límites
Nombre del
Nivel del
Requ./
medicamento medicamento Límites
FETZIMA
venlafaxine hcl er
tb24 150mg,
37.5mg
venlafaxine hcl er
tb24 75mg
VIIBRYD
granisetron hcl tabs
FETZIMA
TITRATION PACK
fluoxetine dr
fluoxetine hcl caps
fluoxetine hcl oral
soln
fluoxetine hcl tabs
10mg, 20mg
fluvoxamine
maleate
fluvoxamine
maleate er cp24
150mg
fluvoxamine
maleate er cp24
100mg
olanzapine/fluoxetin
e
paroxetine hcl er
tb24 12.5mg
paroxetine hcl er
tb24 37.5mg
paroxetine hcl er
tb24 25mg
paroxetine hcl tabs
10mg
paroxetine hcl tabs
20mg, 30mg, 40mg
PAXIL SUSP
PRISTIQ
sertraline hcl conc
sertraline hcl tabs
25mg
sertraline hcl tabs
100mg
sertraline hcl tabs
50mg
venlafaxine hcl
venlafaxine hcl er
cp24 150mg,
37.5mg
venlafaxine hcl er
cp24 75mg
1 QL(30/30)
ST
1 QL(28/28)
ST
1
1
1
1
1
1 QL(60/30)
1 QL(90/30)
1 QL(30/30)
1 QL(30/30)
1 QL(60/30)
1 QL(90/30)
1 QL(30/30)
1 QL(60/30)
1
1
1
1
QL(900/30)
QL(30/30)
QL(300/30)
QL(30/30)
1 QL(60/30)
1 QL(90/30)
1 QL(120/30)
1 QL(30/30)
1 QL(90/30)
1 QL(30/30)
1 QL(90/30)
1 QL(30/30)
ST
TRICYCLICS
amitriptyline hcl
1 PA
amoxapine
1
clomipramine hcl
1 PA
desipramine hcl
1
doxepin hcl
1 PA
imipramine hcl
1 PA
imipramine
1 PA
pamoate
nortriptyline hcl
1
perphenazine/amitri
1 PA
ptyline
protriptyline hcl
1
SURMONTIL
1 PA
ANTIEMETICS
ANTIEMETICS, OTHER
meclizine hcl tabs
1
phenadoz
1 PA
promethazine hcl
1 PA
plain
promethazine hcl
1 PA
supp 12.5mg, 25mg
promethegan
1 PA
TRANSDERM1 QL(12/36)
SCOP
EMETOGENIC THERAPY ADJUNCTS
ALOXI
1 B/D PA
dronabinol
1 PA
QL(90/30)
EMEND CAPS
1 B/D PA
40MG
QL(2/30)
EMEND CAPS
1 B/D PA
125MG
QL(4/30)
EMEND CAPS
1 B/D PA
80MG
QL(8/30)
EMEND CAPS
1 B/D PA
QL(12/30)
granisetron hcl inj
1 B/D PA
0.1mg/ml, 1mg/ml
ondansetron hcl inj
4mg/2ml
ondansetron hcl
oral soln
ondansetron hcl
tabs 24mg
ondansetron hcl
tabs 4mg, 8mg
ondansetron odt
1 B/D PA
QL(60/30)
1
1 B/D PA
1 B/D PA
QL(5/30)
1 B/D PA
QL(90/30)
1 B/D PA
QL(90/30)
ANTIFUNGALS
ANTIFUNGALS
ABELCET
1 PA
AMBISOME
1 PA
AMPHOTEC INJ
1 PA
50MG
amphotericin b
1 PA
CANCIDAS
1 PA
ciclopirox nail
1
lacquer
ciclopirox olamine
1
ciclopirox sham
1
ciclopirox susp
1
clotrimazole
1
external crea
clotrimazole
1
external soln
clotrimazole troc
1
econazole nitrate
1
fluconazole in
1
dextrose
fluconazole in nacl
1
fluconazole susr
1
fluconazole tabs
1
100mg, 200mg,
50mg
fluconazole tabs
1 QL(8/30)
150mg
flucytosine
1
griseofulvin
1
microsize
griseofulvin
1
ultramicrosize
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply;
B/D= Drugs covered under Medicare Part B or Part D
Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa;
ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D
35
Drug Name
Drug Reqs/Limits Drug Name
Drug Reqs/Limits
Tier
Tier
itraconazole
1 PA
SUMATRIPTAN
1 QL(12/30)
sumatriptan
1 QL(4/30)
QL(120/30)
succinate inj
ketoconazole
1
4mg/0.5ml
NAFTIN
1
NATACYN
1
sumatriptan
1 QL(8/30)
NOXAFIL SUSP
1 PA
succinate inj
QL(600/30)
4mg/0.5ml,
NOXAFIL TBEC
1 PA
6mg/0.5ml
QL(93/30)
sumatriptan
1 QL(4/30)
succinate refill inj
nyamyc
1
nystatin crea
1
6mg/0.5ml
nystatin oint
1
sumatriptan
1 QL(8/30)
nystatin powd
1
succinate refill inj
100000unit/gm
4mg/0.5ml
nystatin susp
1
sumatriptan
1 QL(9/30)
nystatin tabs
1
succinate tabs
nystatin/triamcinolo
1
ANTIMYASTHENIC AGENTS
ne
PARASYMPATHOMIMETICS
nystop
1
GUANIDINE HCL
1
pedi-dri
1
MESTINON
1
SPORANOX ORAL
1 PA
TIMESPAN
SOLN
pyridostigmine
1
terbinafine hcl tabs
1 QL(180/365) bromide
terconazole
1
regonol
1
voriconazole
1 PA
ANTIMYCOBACTERIALS
XOLEGEL
1
ANTIMYCOBACTERIALS, OTHER
zazole supp
1
dapsone
1
ANTIGOUT AGENTS
rifabutin
1
ANTIGOUT AGENTS
ANTITUBERCULARS
allopurinol
1
CAPASTAT
1
COLCRYS
1
SULFATE
probenecid
1
cycloserine
1
probenecid/colchici
1
ethambutol hcl
1
ne
isoniazid
1
ULORIC
1 ST
PASER
1
ANTIMIGRAINE AGENTS
PRIFTIN
1
ERGOT ALKALOIDS
pyrazinamide
1
cafergot
1
rifampin
1
dihydroergotamine
1
RIFATER
1
mesylate inj
SIRTURO
1 PA
migergot
1
TRECATOR
1
SEROTONIN (5-HT) 1B/1D RECEPTOR
ANTINEOPLASTICS
AGONISTS
ALKYLATING AGENTS
naratriptan hcl
1 QL(9/30)
BICNU
1 B/D PA
rizatriptan benzoate
1 QL(12/30)
BUSULFEX
1 B/D PA
rizatriptan benzoate
1 QL(12/30)
CYCLOPHOSPHA
1 B/D PA
odt
MIDE CAPS
Drug Name
Drug Reqs/Limits
Tier
1 B/D PA
cyclophosphamide
inj
cyclophosphamide
1 B/D PA
tabs
dacarbazine
1 B/D PA
HEXALEN
1
ifosfamide inj 1gm,
1 B/D PA
3gm
ifosfamide/mesna
1 B/D PA
LEUKERAN
1
LOMUSTINE
1
MATULANE
1
melphalan
1 B/D PA
hydrochloride
MUSTARGEN
1 B/D PA
TEMODAR INJ
1 B/D PA
TREANDA
1 B/D PA
VALCHLOR
1 PA
ZANOSAR
1 B/D PA
ANTIANDROGENS
bicalutamide
1
flutamide
1
NILANDRON
1
XTANDI
1 PA
QL(120/30)
ZYTIGA
1 PA
QL(120/30)
ANTIANGIOGENIC AGENTS
CAPRELSA
1 PA
REVLIMID
1 PA
QL(28/28)
THALOMID CAPS
1 PA
150MG, 200MG,
QL(60/30)
50MG
THALOMID CAPS
1 PA
100MG
QL(90/30)
ANTIESTROGENS/MODIFIERS
EMCYT
1
FARESTON
1
FASLODEX
1 B/D PA
SOLTAMOX
1
tamoxifen citrate
1
ANTIMETABOLITES
adrucil inj
1 B/D PA
2.5gm/50ml
cladribine
1 B/D PA
CLOLAR
1 B/D PA
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply;
B/D= Drugs covered under Medicare Part B or Part D
Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa;
ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D
36
Nombre del
Nivel del
Requ./
medicamento medicamento Límites
Nombre del
Nivel del
Requ./
medicamento medicamento Límites
Nombre del
Nivel del
Requ./
medicamento medicamento Límites
cytarabine
1 B/D PA
cytarabine aqueous
1 B/D PA
DROXIA
1
ELITEK
1 B/D PA
fluorouracil inj
1 B/D PA
2.5gm/50ml
FOLOTYN
1 B/D PA
gemcitabine
1 B/D PA
gemcitabine hcl
1 B/D PA
hydroxyurea
1
mercaptopurine
1
TABLOID
1
ANTINEOPLASTICS
KYPROLIS
1 PA QL(6/28)
ZALTRAP
1 PA
ANTINEOPLASTICS, OTHER
ABRAXANE
1 B/D PA
adriamycin
1 B/D PA
ALIMTA INJ 500MG
1 B/D PA
amifostine
1 B/D PA
ARRANON
1
AZACITIDINE
1 B/D PA
bleomycin sulfate
1 B/D PA
calcium folinate
1
carboplatin
1 B/D PA
cisplatin inj
1 B/D PA
100mg/100ml
COMETRIQ
1 PA
COSMEGEN
1 B/D PA
daunorubicin hcl
1 B/D PA
DAUNOXOME
1 B/D PA
decitabine
1
dexrazoxane inj
1 B/D PA
250mg
DOCEFREZ
1 B/D PA
docetaxel inj
1 B/D PA
140mg/7ml,
20mg/ml,
80mg/4ml,
80mg/8ml
doxorubicin hcl inj
1 B/D PA
2mg/ml
DOXORUBICIN
1 B/D PA
HCL LIPOSOME
ELLENCE INJ
1 B/D PA
200MG/100ML
epirubicin hcl inj
200mg/100ml,
50mg/25ml
ERIVEDGE
VELCADE
1 B/D PA
vinblastine sulfate
1 B/D PA
inj 1mg/ml
vincasar pfs
1 B/D PA
vincristine sulfate
1 B/D PA
vinorelbine tartrate
1 B/D PA
ZINECARD INJ
1 B/D PA
250MG
ZOLINZA
1 QL(120/30)
AROMATASE INHIBITORS, 3RD
GENERATION
anastrozole
1 QL(30/30)
exemestane
1
letrozole
1 QL(30/30)
ENZYME INHIBITORS
ETOPOPHOS
1 B/D PA
ETOPOSIDE INJ
1 B/D PA
TOPOSAR
1 B/D PA
topotecan hcl inj
1
4mg
MOLECULAR TARGET INHIBITORS
AFINITOR
1 PA
QL(30/30)
AFINITOR
1 PA
DISPERZ
QL(60/30)
BOSULIF
1 PA
GILOTRIF
1 PA
QL(30/30)
GLEEVEC
1 PA
QL(60/30)
IMBRUVICA
1 PA
QL(120/30)
INLYTA TABS 5MG
1 PA
QL(120/30)
INLYTA TABS 1MG
1 PA
QL(240/30)
NEXAVAR
1 PA
SPRYCEL
1 PA
STIVARGA
1 PA
QL(84/21)
SUTENT CAPS
1 PA
12.5MG, 25MG,
50MG
TAFINLAR
1 PA
TARCEVA
1 PA
TASIGNA
1 PA
ERWINAZE
fludarabine
phosphate
FUSILEV
HALAVEN
ICLUSIG
idarubicin hcl inj
10mg/10ml
irinotecan inj
100mg/5ml
ISTODAX
IXEMPRA KIT
JAKAFI
JEVTANA
leucovorin calcium
inj 100mg, 350mg,
500mg, 50mg
leucovorin calcium
tabs
LIPODOX
LIPODOX 50
MEKINIST
MENEST
mesna
MESNEX TABS
mitomycin
MITOXANTRONE
HCL
ONCASPAR
oxaliplatin inj
100mg/20ml
paclitaxel inj
300mg/50ml
PICATO
POMALYST
1 B/D PA
1 PA
QL(30/30)
1 B/D PA
1 B/D PA
1
1 PA
1 PA
1 B/D PA
1 B/D PA
1 PA
1 B/D PA
1 PA
QL(60/30)
1 B/D PA
1
1
1
1
1
1
1
1
1
1
B/D PA
B/D PA
PA
PA
B/D PA
B/D PA
B/D PA
1 B/D PA
1 B/D PA
1 B/D PA
1 ST
1 PA
QL(21/28)
PROLEUKIN
1 B/D PA
SYLATRON
1 PA
SYNRIBO
1 PA
TAXOTERE
1 B/D PA
TRISENOX
1 B/D PA
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply;
B/D= Drugs covered under Medicare Part B or Part D
Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa;
ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D
37
Drug Name
Drug Reqs/Limits Drug Name
Drug Reqs/Limits Drug Name
Drug Reqs/Limits
Tier
Tier
Tier
TYKERB
1 PA
haloperidol
1
PEDICULICIDES/SCABICIDES
VOTRIENT
1 PA
decanoate
acticin
1
QL(120/30)
haloperidol lactate
1
lindane
1
loxapine
1
XALKORI
1 PA
malathion
1
QL(60/30)
loxapine succinate
1
permethrin crea
1
ZELBORAF
1 PA
ORAP
1
ANTIPARKINSON AGENTS
QL(240/30)
perphenazine
1
ANTICHOLINERGICS
prochlorperazine
ZYKADIA
1 PA
1
benztropine
1 PA
prochlorperazine
1
MONOCLONAL ANTIBODIES
mesylate
edisylate
ARZERRA
1 B/D PA
trihexyphenidyl hcl
1 PA
prochlorperazine
1
AVASTIN INJ
1 B/D PA
ANTIPARKINSON AGENTS, OTHER
maleate
100MG/4ML
entacapone
1
thioridazine hcl
1 PA
ERBITUX
1 B/D PA
TASMAR
1
thiothixene
1
GAZYVA
1 PA
DOPAMINE AGONISTS
trifluoperazine
hcl
1
HERCEPTIN
1 B/D PA
APOKYN
1 PA
2ND GENERATION/ATYPICAL
KADCYLA
1 PA
QL(60/30)
PERJETA
1 PA
ABILIFY
1 QL(60/30)
bromocriptine
1
RITUXAN
1 PA
DISCMELT
ST
mesylate
VECTIBIX INJ
1 B/D PA
ABILIFY INJ
1 ST
NEUPRO
1 PA
100MG/5ML
ABILIFY
1 QL(1.5/30)
QL(30/30)
YERVOY
1 B/D PA
MAINTENA INJ
pramipexole
1 QL(90/30)
300MG
RETINOIDS
dihydrochloride
ABILIFY
1 QL(2/30)
PANRETIN
1
ropinirole hcl
1
MAINTENA INJ
TARGRETIN
1
DOPAMINE PRECURSORS/L- AMINO 400MG
tretinoin caps
1
ACID DECARBOXYLASE INHIBITORS ABILIFY ORAL
1 QL(900/30)
ANTIPARASITICS
carbidopa
1
SOLN
ST
ANTHELMINTICS
carbidopa/levodopa
1
ABILIFY
TABS
1
QL(30/30)
ALBENZA
1
carbidopa/levodopa
1
ST
STROMECTOL
1
er
FANAPT
1
QL(60/30)
ANTIPROTOZOALS
carbidopa/levodopa
1
ST
ALINIA
1
odt
FANAPT
1 QL(16/30)
atovaquone
1
CARBIDOPA/LEVO
1
TITRATION PACK
ST
atovaquone/progua
1
DOPA/ENTACAPO
GEODON INJ
1 QL(60/30)
nil hcl
NE
INVEGA
1 QL(0.25/28)
chloroquine
1
MONOAMINE OXIDASE B (MAO-B)
SUSTENNA INJ
phosphate
INHIBITORS
39MG/0.25ML
COARTEM
1
AZILECT
1
INVEGA
1 QL(0.5/28)
DARAPRIM
1
selegiline hcl
1
SUSTENNA INJ
hydroxychloroquine
1
ANTIPSYCHOTICS
78MG/0.5ML
sulfate
1ST GENERATION/TYPICAL
INVEGA
1 QL(0.75/28)
mefloquine hcl
1
SUSTENNA INJ
chlorpromazine hcl
1
NEBUPENT
1 B/D PA
117MG/0.75ML
compazine supp
1
NEUTREXIN
1
INVEGA
1 QL(1/28)
compro
1
PENTAM 300
1
SUSTENNA INJ
fluphenazine
1
PRIMAQUINE
1
156MG/ML
decanoate
PHOSPHATE
fluphenazine hcl
1
quinine sulfate
1
haloperidol
1
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply;
B/D= Drugs covered under Medicare Part B or Part D
Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa;
ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D
38
Nombre del
Nivel del
Requ./
medicamento medicamento Límites
Nombre del
Nivel del
Requ./
medicamento medicamento Límites
Nombre del
Nivel del
Requ./
medicamento medicamento Límites
INVEGA
SUSTENNA INJ
234MG/1.5ML
INVEGA TB24
1.5MG, 3MG, 9MG
INVEGA TB24 6MG
clozapine
1
CLOZAPINE ODT
1
FAZACLO
1 ST
VERSACLOZ
1
ANTISPASTICITY AGENTS
ANTISPASTICITY AGENTS
baclofen
1
dantrolene sodium
1
tizanidine hcl tabs
1
ANTIVIRALS
ANTI-CYTOMEGALOVIRUS (CMV)
AGENTS
cidofovir
1
foscarnet sodium
1
ganciclovir
1 B/D PA
VALCYTE
1
ZIRGAN
1 ST
ANTI-HEPATITIS B (HBV) AGENTS
adefovir dipivoxil
1 QL(30/30)
BARACLUDE
1
INTRON-A
1
INTRON-A
1
W/DILUENT INJ
10MU, 18MU
TYZEKA
1 PA
ANTI-HEPATITIS C (HCV) AGENTS
INCIVEK
1 PA
QL(180/30)
MODERIBA 1200
1 PA
DOSE PACK
MODERIBA 800
1 PA
DOSE PACK
MODERIBA MISC
1 PA
moderiba tabs
1 PA
OLYSIO
1 PA
QL(30/30)
PEG-INTRON
1 PA
PEG-INTRON
1 PA
REDIPEN
PEG-INTRON
1 PA
REDIPEN PAK 4
REBETOL ORAL
1 PA
SOLN
ribasphere
1 PA
RIBASPHERE
1 PA
RIBAPAK
RIBATAB
ribavirin
SOVALDI
LATUDA TABS
120MG, 20MG,
40MG, 60MG
LATUDA TABS
80MG
olanzapine inj
olanzapine odt
olanzapine tabs
quetiapine fumarate
RISPERDAL
CONSTA
risperidone m-tab
tbdp 0.5mg, 1mg,
2mg, 3mg
risperidone m-tab
tbdp 4mg
risperidone odt tbdp
0.25mg, 0.5mg,
1mg, 2mg, 3mg
risperidone odt tbdp
4mg
risperidone oral
soln
risperidone tabs
0.25mg, 0.5mg,
1mg, 2mg, 3mg
risperidone tabs
4mg
SAPHRIS
1 QL(1.5/28)
1 QL(30/30)
ST
1 QL(60/30)
ST
1 QL(30/30)
ST
1 QL(60/30)
ST
1
1 QL(30/30)
1 QL(30/30)
1 QL(90/30)
1
1 QL(90/30)
1 QL(120/30)
1 QL(90/30)
1 QL(120/30)
1 QL(360/30)
1 QL(90/30)
1 QL(120/30)
1 QL(60/30)
ST
1 QL(30/30)
ST
1 PA
1 PA
1 PA
QL(30/30)
VICTRELIS
1 PA
QL(360/30)
VIRAZOLE
1 B/D PA
ANTI-HIV AGENTS, INTEGRASE
INHIBITORS (INSTI)
ISENTRESS
1 QL(180/30)
CHEW 100MG
ISENTRESS
1 QL(360/30)
CHEW 25MG
ISENTRESS PACK
1
ISENTRESS TABS
1 QL(60/30)
TIVICAY
1 QL(60/30)
ANTI-HIV AGENTS, NONNUCLEOSIDE REVERSE
TRANSCRIPTASE INHIBITORS
(NNRTI)
COMPLERA
1
EDURANT
1
INTELENCE TABS
1 QL(60/30)
200MG
INTELENCE TABS
1 QL(120/30)
100MG
INTELENCE TABS
1 QL(180/30)
25MG
nevirapine er
1
NEVIRAPINE
1
SUSP
nevirapine tabs
1
RESCRIPTOR
1
STRIBILD
1
SUSTIVA
1
VIRAMUNE XR
1
TB24 100MG
ANTI-HIV AGENTS, NUCLEOSIDE
AND NUCLEOTIDE REVERSE
TRANSCRIPTASE INHIBITORS (NRTI)
abacavir
1
abacavir
1
sulfate/lamivudine/z
idovudine
didanosine
1
EMTRIVA
1
SEROQUEL XR
TB24 150MG,
200MG
SEROQUEL XR
1 QL(60/30)
TB24 300MG,
ST
400MG, 50MG
ziprasidone hcl
1 QL(60/30)
1
ZYPREXA
RELPREVV
TREATMENT-RESISTANT
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply;
B/D= Drugs covered under Medicare Part B or Part D
Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa;
ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D
39
Drug Name
Drug Reqs/Limits Drug Name
Drug Reqs/Limits
Tier
Tier
EPIVIR HBV ORAL
1
TAMIFLU CAPS
1 QL(56/365)
SOLN
75MG
EPIVIR ORAL
1
TAMIFLU CAPS
1 QL(60/365)
45MG
SOLN
EPZICOM
1
TAMIFLU CAPS
1 QL(120/365)
lamivudine
1
30MG
lamivudine/zidovudi
1
TAMIFLU SUSR
1 QL(700/365)
ne
ANTIHERPETIC AGENTS
RETROVIR IV
1
acyclovir
1
INFUSION
acyclovir sodium inj
1
stavudine
1
1000mg, 50mg/ml
TRUVADA
1
DENAVIR
1
VIDEX PEDIATRIC
1
famciclovir
1 QL(21/7)
VIREAD
1
trifluridine
1
ZIAGEN ORAL
1
valacyclovir hcl tabs
1 QL(30/30)
SOLN
1000mg
zidovudine
1
valacyclovir hcl tabs
1 QL(60/30)
ANTI-HIV AGENTS, OTHER
500mg
ATRIPLA
1
ZOVIRAX CREA
1
FUZEON
1 QL(60/30)
ANXIOLYTICS
SELZENTRY TABS
1 QL(60/30)
ANXIOLYTICS, OTHER
150MG
buspirone hcl
1
SELZENTRY TABS
1 QL(120/30)
BENZODIAZEPINES
300MG
alprazolam odt tbdp
1 QL(90/30)
ANTI-HIV AGENTS, PROTEASE
0.25mg, 0.5mg
INHIBITORS
alprazolam odt tbdp
1 QL(150/30)
APTIVUS
1
2mg
CRIXIVAN
1
alprazolam odt tbdp
1 QL(300/30)
INVIRASE
1
1mg
KALETRA
1
alprazolam tabs
1 QL(90/30)
LEXIVA
1
0.25mg, 0.5mg
NORVIR
1
alprazolam tabs
1 QL(150/30)
PREZISTA SUSP
1 QL(400/30)
2mg
PREZISTA TABS
1 QL(30/30)
alprazolam tabs
1 QL(300/30)
800MG
1mg
PREZISTA TABS
1 QL(60/30)
clorazepate
1 QL(90/30)
600MG
dipotassium tabs
PREZISTA TABS
1 QL(180/30)
3.75mg, 7.5mg
150MG
clorazepate
1 QL(120/30)
PREZISTA TABS
1 QL(360/30)
dipotassium tabs
75MG
15mg
REYATAZ
1
diazepam oral soln
1 QL(1200/30)
VIRACEPT
1
diazepam tabs
1 QL(120/30)
ANTI-INFLUENZA AGENTS
lorazepam conc
1 QL(120/30)
amantadine hcl
1
lorazepam inj
1
rimantadine hcl
1
2mg/ml, 4mg/ml
lorazepam tabs
1 QL(120/30)
Drug Name
Drug Reqs/Limits
Tier
oxazepam
1 QL(120/30)
temazepam
1 QL(90/365)
BIPOLAR AGENTS
MOOD STABILIZERS
lithium carbonate
1
lithium carbonate er
1
BLOOD GLUCOSE REGULATORS
ANTIDIABETIC AGENTS
acarbose
1 QL(90/30)
BYDUREON
1 QL(4/28)
BYETTA
1 QL(2.4/30)
CYCLOSET
1
glimepiride tabs
1 QL(30/30)
1mg, 2mg
glimepiride tabs
1 QL(60/30)
4mg
glipizide
1
glipizide er
1
glipizide/metformin
1
hcl
glyburide/metformin
1 PA
hcl
GLYSET
1
JANUMET
1 QL(60/30)
JANUMET XR
1 QL(30/30)
TB24 1000MG;
100MG
JANUMET XR
1 QL(60/30)
TB24 1000MG;
50MG, 500MG;
50MG
JANUVIA
1 QL(30/30)
JENTADUETO
1 QL(60/30)
metformin hcl
1
metformin hcl er
1
tb24 500mg, 750mg
nateglinide
1 QL(90/30)
PIOGLITAZONE
1 QL(30/30)
HCL TABS 45MG
pioglitazone hcl
1 QL(30/30)
tabs 15mg, 30mg
pioglitazone hcl1 QL(30/30)
glimepiride
pioglitazone
1 QL(90/30)
hcl/metformin hcl
repaglinide
1
RIOMET
1
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply;
B/D= Drugs covered under Medicare Part B or Part D
Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa;
ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D
40
Nombre del
Nivel del
Requ./
medicamento medicamento Límites
Nombre del
Nivel del
Requ./
medicamento medicamento Límites
Nombre del
Nivel del
Requ./
medicamento medicamento Límites
SYMLINPEN 120
GLUCAGEN
1
HYPOKIT
1
kcl
0.075%/d5w/nacl
0.45%
kcl 0.15%/d5w/ nacl
1
0.3%
KCL
1
0.15%/D5W/LR
kcl 0.15%/d5w/nacl
1
0.2%
kcl 0.15%/d5w/nacl
1
0.45%
kcl 0.15%/d5w/nacl
1
0.9%
kcl 0.3%/d5w/nacl
1
0.45%
normosol-r in d5w
1
potassium chloride
1
0.15% d5w/nacl
0.33%
potassium chloride
1
0.15% d5w/nacl
0.45%
potassium chloride
1
0.22% d5w/nacl
0.45%
potassium chloride
1
0.224%/d5w/nacl
0.45%
PROGLYCEM
1
INSULINS
HUMALOG
1
HUMALOG
1
KWIKPEN
humalog mix 50/50
1
humalog mix 50/50
1
kwikpen
humalog mix 75/25
1
humalog mix 75/25
1
kwikpen
humulin 70/30
1
HUMULIN 70/30
1
KWIKPEN
humulin 70/30 pen
1
humulin n
1
HUMULIN N
KWIKPEN
humulin n u-100
pen
humulin r
humulin r u-500
(concentrated)
lantus
lantus solostar
levemir
levemir flexpen
1 PA
QL(11/30)
SYMLINPEN 60
1 PA QL(6/30)
TRADJENTA
1 QL(30/30)
VICTOZA
1 QL(9/30)
GLYCEMIC AGENTS
1 B/D PA
clinimix
4.25%/dextrose
20%
CLINIMIX
1 B/D PA
5%/DEXTROSE
15%
CLINIMIX
1 B/D PA
5%/DEXTROSE
20%
CLINIMIX E
1 B/D PA
4.25%/DEXTROSE
25%
dextrose 10%/nacl
1 B/D PA
0.45%
dextrose 10% flex
1 B/D PA
container
dextrose 10%/nacl
1 B/D PA
0.2%
dextrose 2.5%/nacl
1 B/D PA
0.45%
dextrose
1 B/D PA
2.5%/sodium
chloride 0.45%
dextrose 5%
1 B/D PA
dextrose 5%/nacl
1 B/D PA
0.2%
dextrose 5%/nacl
1 B/D PA
0.225%
dextrose 5%/nacl
1 B/D PA
0.33%
dextrose 5%/nacl
1 B/D PA
0.45%
dextrose 5%/nacl
1 B/D PA
0.9%
dextrose
1 B/D PA
5%/sodium chloride
0.2%
dextrose
1 B/D PA
5%/sodium chloride
0.45%
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
B/D PA
1
1
1
1
1
1
1
1
BLOOD
PRODUCTS/MODIFIERS/VOLUME
EXPANDERS
ANTICOAGULANTS
COUMADIN INJ
1
ELIQUIS
1 PA
QL(60/30)
enoxaparin sodium
1 QL(9/30)
inj 30mg/0.3ml
1 QL(12/30)
enoxaparin sodium
inj 40mg/0.4ml
enoxaparin sodium
1 QL(18/30)
inj 60mg/0.6ml
enoxaparin sodium
1 QL(24/30)
inj 120mg/0.8ml,
80mg/0.8ml
enoxaparin sodium
1 QL(30/30)
inj 100mg/ml,
150mg/ml
enoxaparin sodium
1 QL(90/30)
inj 300mg/3ml
fondaparinux
1 QL(12/30)
sodium inj
5mg/0.4ml
fondaparinux
1 QL(15/30)
sodium inj
2.5mg/0.5ml
fondaparinux
1 QL(18/30)
sodium inj
7.5mg/0.6ml
fondaparinux
1 QL(24/30)
sodium inj
10mg/0.8ml
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply;
B/D= Drugs covered under Medicare Part B or Part D
Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa;
ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D
41
Drug Name
Drug Reqs/Limits Drug Name
Tier
1
PROMACTA
Drug Reqs/Limits Drug Name
Drug Reqs/Limits
Tier
Tier
1 PA
losartan
1 QL(30/30)
QL(30/30)
potassium/hydrochl
orothiazide tabs
COAGULANTS
12.5mg; 100mg,
tranexamic acid inj
1 PA
25mg; 100mg
tranexamic acid
1
1 QL(60/30)
losartan
tabs
potassium/hydrochl
PLATELET MODIFYING AGENTS
orothiazide tabs
AGGRENOX
1 QL(60/30)
12.5mg; 50mg
BRILINTA
1 QL(60/30)
telmisartan
1 QL(30/30)
cilostazol
1
telmisartan/amlodipi
1 QL(30/30)
clopidogrel tabs
1 QL(1/30)
ne
300mg
telmisartan/hydrochl
1 QL(30/30)
clopidogrel tabs
1 QL(30/30)
oroth
75mg
telmisartan/hydrochl
1 QL(30/30)
CARDIOVASCULAR AGENTS
orothiazide
ALPHA-ADRENERGIC AGONISTS
valsartan/hydrochlo
1
clonidine hcl er
1
rothiazide
clonidine hcl ptwk
1 QL(4/28)
ANGIOTENSIN-CONVERTING
0.1mg/24hr,
ENZYME (ACE) INHIBITORS
0.2mg/24hr
benazepril
hcl
1
clonidine hcl ptwk
1 QL(8/28)
benazepril
1
0.3mg/24hr
hcl/hydrochlorothiaz
clonidine hcl tabs
1
ide
methyldopate hcl
1 PA
captopril
1
midodrine hcl
1
captopril/hydrochlor
1
ALPHA-ADRENERGIC BLOCKING
othiazide
AGENTS
enalapril maleate
1
DIBENZYLINE
1
enalapril
1
prazosin hcl
1
maleate/hydrochlor
ANGIOTENSIN II RECEPTOR
othiazide
ANTAGONISTS
fosinopril sodium
1
BENICAR
1 QL(30/30)
fosinopril
1
ST
sodium/hydrochloro
BENICAR HCT
1 QL(30/30)
thiazide
ST
lisinopril
1
candesartan
1
lisinopril/hydrochlor
1
cilexetil
othiazide
irbesartan
1
moexipril hcl
1
irbesartan/hydrochl
1
moexipril/hydrochlor
1
orothiazide
othiazide
losartan potassium
1 QL(30/30)
perindopril
1
tabs 100mg
erbumine
losartan potassium
1 QL(60/30)
quinapril hcl
1
tabs 50mg
quinapril/hydrochlor
1
losartan potassium
1 QL(90/30)
othiazide
tabs 25mg
ramipril
1
heparin sodium inj
10000unit/ml,
1000unit/ml,
20000unit/ml,
2000unit/ml,
2500unit/ml,
5000unit/ml
heparin sodium/d5w
1
heparin sodium/nacl
1
0.9%
jantoven
1
PRADAXA CAPS
1 PA
150MG
QL(60/30)
PRADAXA CAPS
1 PA
75MG
QL(120/30)
warfarin sodium
1
XARELTO TABS
1 PA
10MG, 20MG
QL(30/30)
XARELTO TABS
1 PA
15MG
QL(60/30)
BLOOD FORMATION MODIFIERS
anagrelide
1
hydrochloride
ARANESP
1 PA
ALBUMIN FREE
INJ
100MCG/0.5ML,
100MCG/ML,
150MCG/0.3ML,
200MCG/0.4ML,
200MCG/ML,
25MCG/0.42ML,
25MCG/ML,
300MCG/0.6ML,
300MCG/ML,
40MCG/0.4ML,
40MCG/ML,
500MCG/ML,
60MCG/0.3ML,
60MCG/ML
LEUKINE
1 PA
NEULASTA
1 PA
NEUMEGA
1 PA
NEUPOGEN INJ
1 PA
300MCG/0.5ML,
480MCG/0.8ML,
480MCG/1.6ML
PROCRIT
1 PA
trandolapril
1
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply;
B/D= Drugs covered under Medicare Part B or Part D
Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa;
ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D
42
Nombre del
Nivel del
Requ./
medicamento medicamento Límites
Nombre del
Nivel del
Requ./
medicamento medicamento Límites
Nombre del
Nivel del
Requ./
medicamento medicamento Límites
ANTIARRHYTHMICS
amiodarone hcl inj
1
50mg/ml
amiodarone hcl
1
tabs
flecainide acetate
1
lidocaine hcl inj
1
10mg/ml
mexiletine hcl
1
MULTAQ
1 QL(60/30)
pacerone
1
propafenone hcl
1
propafenone hcl er
1
quinidine sulfate
1
sorine
1
sotalol hcl
1
sotalol hcl (af)
1
TIKOSYN
1
BETA-ADRENERGIC BLOCKING
AGENTS
acebutolol hcl
1
atenolol
1
atenolol/chlorthalido
1
ne
betaxolol hcl
1
bisoprolol fumarate
1
bisoprolol
1
fumarate/hydrochlor
othiazide
carvedilol
1
COREG CR
1
labetalol hcl
1
metoprolol
1
succinate er
metoprolol tartrate
1
metoprolol/hydrochl
1
orothiazide
nadolol
1
nadolol/bendroflum
1
ethiazide
pindolol
1
propranolol hcl
1
propranolol hcl er
1
propranolol/hydroch
1
lorothiazide
timolol maleate
1
CALCIUM CHANNEL BLOCKING
AGENTS
afeditab cr
1
amlodipine besylate
1
1
amlodipine
besylate/benazepril
hcl
amlodipine
1
besylate/benazepril
hydrochloride
cartia xt
1
dilt-xr
1
diltiazem cd
1
diltiazem hcl er
1
cp12
diltiazem hcl er
1
cp24
diltiazem hcl inj
1
100mg, 25mg/5ml,
50mg/10ml
diltiazem hcl tabs
1
EXFORGE
1
EXFORGE HCT
1
felodipine er
1
isradipine
1
matzim la
1
nicardipine hcl
1
nifediac cc tb24
1
30mg, 60mg
nifedical xl
1
nifedipine er
1
nimodipine
1
nisoldipine
1
nisoldipine er
1
taztia xt
1
verapamil hcl
1
verapamil hcl er
1
CARDIOVASCULAR AGENTS, OTHER
AMTURNIDE
1 ST
DEMSER
1
digox tabs 125mcg
1 QL(30/30)
digox tabs 250mcg
1 PA
digoxin inj
1 PA
digoxin tabs
1 QL(30/30)
125mcg
digoxin tabs
1 PA
250mcg
LANOXIN
1 PA
PEDIATRIC
pentoxifylline er
1
RANEXA TB12
1 QL(60/30)
1000MG
ST
RANEXA TB12
1 QL(120/30)
500MG
ST
TEKAMLO
1 ST
TEKTURNA
1 ST
TEKTURNA HCT
1 ST
DIURETICS, CARBONIC ANHYDRASE
INHIBITORS
acetazolamide
1
acetazolamide
1
sodium
DIURETICS, LOOP
bumetanide
1
EDECRIN
1
furosemide
1
SODIUM EDECRIN
1
torsemide tabs
1
DIURETICS, POTASSIUM-SPARING
amiloride hcl
1
amiloride/hydrochlo
1
rothiazide
spironolactone
1
spironolactone/hydr
1
ochlorothiazide
triamterene/hydroch
1
lorothiazide
DIURETICS, THIAZIDE
candesartan
1
cilexetil/hydrochloro
thiazide
chlorothiazide
1
chlorothiazide
1
sodium
chlorthalidone tabs
1
25mg, 50mg
hydrochlorothiazide
1
indapamide
1
metolazone
1
DYSLIPIDEMICS, FIBRIC ACID
DERIVATIVES
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply;
B/D= Drugs covered under Medicare Part B or Part D
Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa;
ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D
43
Drug Name
Drug Reqs/Limits Drug Name
Drug Reqs/Limits
Tier
Tier
minoxidil tabs
1
fenofibrate caps
1
VASODILATORS, DIRECT-ACTING
130mg, 43mg
ARTERIAL/VENOUS
fenofibrate
1
micronized
isoditrate er
1
fenofibrate tabs
1
isosorbide dinitrate
1
fenofibric acid dr
1
isosorbide dinitrate
1
gemfibrozil
1
er
LIPOFEN
1
isosorbide
1
DYSLIPIDEMICS, HMG COA
mononitrate
REDUCTASE INHIBITORS
isosorbide
1
mononitrate er
atorvastatin calcium
1 QL(30/30)
minitran
1
CRESTOR
1 QL(30/30)
nitroglycerin
1
fluvastatin caps
1 QL(30/30)
nitroglycerin lingual
1
20mg
translingual soln
fluvastatin caps
1 QL(60/30)
nitroglycerin
1
40mg
transdermal
lovastatin tabs
1 QL(60/30)
NITROSTAT
1
40mg
lovastatin tabs
1 QL(90/30)
CENTRAL NERVOUS SYSTEM
AGENTS
10mg, 20mg
pravastatin sodium
1 QL(30/30)
ATTENTION DEFICIT HYPERACTIVITY
tabs 80mg
DISORDER AGENTS,
pravastatin sodium
1 QL(60/30)
AMPHETAMINES
tabs 40mg
amphetamine/dextr
1 QL(60/30)
pravastatin sodium
1 QL(90/30)
oamphetamine
tabs 10mg, 20mg
cp24
simvastatin tabs
1 QL(30/30)
amphetamine/dextr
1 QL(90/30)
20mg, 40mg, 80mg
oamphetamine tabs
simvastatin tabs
1 QL(90/30)
dextroamphetamine
1 QL(90/30)
10mg, 5mg
sulfate er cp24
DYSLIPIDEMICS, OTHER
10mg, 5mg
cholestyramine
1
dextroamphetamine
1 QL(120/30)
cholestyramine light
1
sulfate er cp24
colestipol hcl
1
15mg
niacin er tbcr
1 QL(30/30)
dextroamphetamine
1 QL(1800/30)
500mg
sulfate oral soln
niacin er tbcr
1 QL(60/30)
dextroamphetamine
1 QL(90/30)
1000mg, 750mg
sulfate tabs 5mg
niacor
1
dextroamphetamine
1 QL(180/30)
omega-3-acid ethyl
1 QL(120/30)
sulfate tabs 10mg
esters
procentra
1 QL(1800/30)
prevalite
1
ATTENTION DEFICIT HYPERACTIVITY
WELCHOL
1
DISORDER AGENTS, NONZETIA
1 QL(30/30)
AMPHETAMINES
VASODILATORS, DIRECT-ACTING
dexmethylphenidate
1 QL(60/30)
ARTERIAL
hcl
hydralazine hcl
1
metadate er
1 QL(90/30)
Drug Name
Drug Reqs/Limits
Tier
methylphenidate hcl
1 QL(90/30)
methylphenidate hcl
1 QL(90/30)
er tbcr 20mg
methylphenidate hcl
1 QL(90/30)
sr
STRATTERA
1
CENTRAL NERVOUS SYSTEM,
OTHER
1 PA
butalbital/acetamino
QL(180/30)
phen/caffeine/codei
ne caps 325mg;
50mg; 40mg; 30mg
NUEDEXTA
1 PA
riluzole
1
XENAZINE TABS
1 PA
12.5MG
QL(90/30)
XENAZINE TABS
1 PA
25MG
QL(120/30)
MULTIPLE SCLEROSIS AGENTS
AMPYRA
1 PA
QL(60/30)
AVONEX
1 PA QL(4/28)
AVONEX PEN
1 PA QL(4/28)
COPAXONE INJ
1 QL(30/30)
20MG/ML
methylphenidate hcl
1 QL(180/30)
er tbcr 10mg
REBIF
1 PA QL(6/28)
REBIF REBIDOSE
1 PA QL(6/28)
REBIF REBIDOSE
1 PA
TITRATION PACK
QL(4.2/28)
REBIF TITRATION
1 PA
PACK
QL(4.2/28)
TYSABRI
1 PA
DENTAL AND ORAL AGENTS
DENTAL AND ORAL AGENTS
chlorhexidine
1
gluconate oral rinse
oralone
1
periogard
1
pilocarpine hcl tabs
1
pilocarpine
1
hydrochloride
triamcinolone
1
acetonide pste
triamcinolone in
1
orabase
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply;
B/D= Drugs covered under Medicare Part B or Part D
Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa;
ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D
44
Nombre del
Nivel del
Requ./
medicamento medicamento Límites
Nombre del
Nivel del
Requ./
medicamento medicamento Límites
Nombre del
Nivel del
Requ./
medicamento medicamento Límites
DERMATOLOGICAL AGENTS
DERMATOLOGICAL AGENTS
acitretin
1 PA
ammonium lactate
1
amnesteem
1
calcipotriene crea
1
calcipotriene
1
external soln
calcipotriene oint
1 QL(120/30)
calcitrene
1 QL(120/30)
CALCITRIOL OINT
1
CARAC
1
claravis
1
clindacin etz
1
pledgets
clindacin-p
1
clindamycin
1
phosphate external
soln
clindamycin
1
phosphate gel
clindamycin
1
phosphate lotn
clindamycin
1
phosphate swab
curity gauze pads
1
2"x2"
ELIDEL
1
erythromycin/benzo
1
yl peroxide
FLUOROPLEX
1
fluorouracil crea
1
fluorouracil external
1
soln
imiquimod
1
laclotion
1
methoxsalen
1
myorisan
1
podofilox
1
PROTOPIC
1
PRUDOXIN
1
REGRANEX
1 PA
SANTYL
1
selenium sulfide
1
lotn
sulfacetamide
sodium susp
TAZORAC CREA
TAZORAC GEL
tretinoin crea
atropine sulfate inj
1
0.05mg/ml,
0.1mg/ml
dicyclomine hcl
1
glycopyrrolate inj
1
4mg/20ml
glycopyrrolate tabs
1
methscopolamine
1
bromide
propantheline
1
bromide
GASTROINTESTINAL AGENTS,
OTHER
cromolyn sodium
1
conc
diphenoxylate/atropi
1
ne
lofene
1
lonox
1
loperamide hcl caps
1
metoclopramide hcl
1
OSMOPREP
1
RELISTOR INJ
1 PA
8MG/0.4ML
QL(12/30)
RELISTOR INJ VIAL 1 PA
12MG/0.6ML
QL(18/30)
1 PA
RELISTOR INJ KIT
QL(28/28)
12MG/0.6ML
ursodiol
1
HISTAMINE2 (H2) RECEPTOR
ANTAGONISTS
cimetidine
1
cimetidine hcl
1
famotidine inj
1
20mg/2ml
famotidine
1
premixed
famotidine tabs
1
20mg, 40mg
nizatidine caps
1
ranitidine hcl caps
1
ranitidine hcl inj
1
150mg/6ml
ranitidine hcl syrp
1
ranitidine hcl tabs
1
IRRITABLE BOWEL SYNDROME
tretinoin gel
tretinoin
microsphere
tretinoin
microsphere pump
gel 0.04%
UVADEX
VECTICAL
VOLTAREN
1
1 QL(120/30)
1 QL(100/30)
1 PA
QL(45/30)
1 PA
QL(45/30)
1 PA
QL(50/30)
1 PA
QL(50/30)
1 B/D PA
1
1 QL(1000/30)
ST
zenatane
1
ZONALON
1
ZYCLARA
1
ENZYME REPLACEMENT/MODIFIERS
ENZYME REPLACEMENT/MODIFIERS
ADAGEN
1 PA
ALDURAZYME
1 PA
BUPHENYL TABS
1
CEREZYME INJ
1 B/D PA
400UNIT
CREON
1
CYSTADANE
1
CYSTAGON
1
ELAPRASE
1 PA
FABRAZYME
1 B/D PA
KUVAN
1 PA
LUMIZYME
1 PA
NAGLAZYME
1 PA
ORFADIN
1
PANCRELIPASE
1
sodium
1
phenylbutyrate
VPRIV
1 PA
ZAVESCA
1
ZENPEP
1
GASTROINTESTINAL AGENTS
ANTISPASMODICS,
GASTROINTESTINAL
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply;
B/D= Drugs covered under Medicare Part B or Part D
Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa;
ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D
45
Drug Name
Drug Reqs/Limits Drug Name
Drug Reqs/Limits
Tier
Tier
doxazosin mesylate
1 QL(30/30)
AGENTS
tabs
1mg,
2mg,
AMITIZA
1 QL(60/30)
4mg
LOTRONEX
1 PA
doxazosin mesylate
1 QL(60/30)
QL(60/30)
tabs 8mg
LAXATIVES
finasteride
tabs
1 QL(30/30)
constulose
1
5mg
enulose
1
JALYN
1
gavilyte-c
1
RAPAFLO
1 QL(30/30)
gavilyte-n/flavor
1
tamsulosin hcl
1
pack
terazosin
hcl
caps
1
QL(30/30)
generlac
1
1mg, 5mg
lactulose
1
terazosin hcl caps
1 QL(60/30)
MOVIPREP
1
10mg, 2mg
peg
1
GENITOURINARY AGENTS, OTHER
3350/electrolytes
bethanechol
1
peg-3350/nacl/na
1
chloride
bicarbonate/kcl
ELMIRON
1
polyethylene glycol
1
PHOSPHATE BINDERS
3350 powd
trilyte
1
FOSRENOL
1 ST
RENVELA PACK
1 QL(180/30)
PROTECTANTS
RENVELA
TABS
1 QL(540/30)
CARAFATE SUSP
1
HORMONAL AGENTS,
MISOPROSTOL
1
STIMULANT/REPLACEMENT/MODIFYI
TABS 200MCG
NG (ADRENAL)
misoprostol tabs
1
100mcg
HORMONAL AGENTS,
sucralfate
1
STIMULANT/REPLACEMENT/MODIFYI
NG (ADRENAL)
PROTON PUMP INHIBITORS
a-hydrocort
1
ESOMEPRAZOLE
1
a-methapred
1
SODIUM
ala cort
1
lansoprazole
1 QL(60/30)
ALA
SCALP
1
omeprazole cpdr
1 QL(60/30)
alclometasone
1
pantoprazole
1 QL(60/30)
dipropionate
sodium tbec
alphatrex
1
GENITOURINARY AGENTS
amcinonide
1
ANTISPASMODICS, URINARY
apexicon
1
flavoxate hcl
1
augmented
1
oxybutynin chloride
1
betamethasone
oxybutynin chloride
1 QL(30/30)
dipropionate
er tb24 5mg
betamethasone
1
oxybutynin chloride
1 QL(60/30)
dipropionate
er tb24 10mg, 15mg
betamethasone
1
tolterodine tartrate
1
valerate
VESICARE
1 QL(30/30)
budesonide
cp24
1
BENIGN PROSTATIC HYPERTROPHY
clobetasol
1
AGENTS
propionate
crea
AVODART
1
Drug Name
clobetasol
propionate e
clobetasol
propionate
emollient crea
clobetasol
propionate external
soln
clobetasol
propionate foam
clobetasol
propionate gel
clobetasol
propionate oint
clotrimazole/betame
thasone
dipropionate
colocort
cormax scalp
application
cortisone acetate
DEPO-MEDROL
INJ 20MG/ML
desonide lotn
desonide oint
desoximetasone
crea
desoximetasone gel
desoximetasone
oint 0.25%
dexamethasone elix
DEXAMETHASON
E INTENSOL
dexamethasone
sodium phosphate
inj 10mg/ml,
120mg/30ml
dexamethasone
tabs
diflorasone
diacetate
fludrocortisone
acetate
fluocinolone
acetonide
fluocinonide
fluocinonide-e
Drug Reqs/Limits
Tier
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply;
B/D= Drugs covered under Medicare Part B or Part D
Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa;
ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D
46
Nombre del
Nivel del
Requ./
medicamento medicamento Límites
Nombre del
Nivel del
Requ./
medicamento medicamento Límites
Nombre del
Nivel del
Requ./
medicamento medicamento Límites
fluticasone
propionate crea
fluticasone
propionate oint
halobetasol
propionate
hydrocortisone
butyrate
hydrocortisone
butyrate (lipophilic)
hydrocortisone crea
1%, 2.5%
hydrocortisone in
absorbase
hydrocortisone lotn
2.5%
hydrocortisone oint
1%, 2.5%
hydrocortisone tabs
hydrocortisone
valerate
MEDROL TABS
2MG
methylprednisolone
methylprednisolone
acetate
methylprednisolone
dose pack
methylprednisolone
sodiumsuccinate inj
125mg, 40mg
mometasone
furoate
prednicarbate oint
prednisolone
sodium phosphate
prednisone
PREDNISONE
INTENSOL
procto-pak
proctosol hc
proctozone-hc
SOLU-CORTEF INJ
1000MG, 250MG,
500MG
TEXACORT
triamcinolone
1
acetonide crea
triamcinolone
1
acetonide lotn
triamcinolone
1
acetonide oint
triderm
1
u-cort
1
HORMONAL AGENTS,
STIMULANT/REPLACEMENT/MODIFYI
NG (PITUITARY)
HORMONAL AGENTS,
STIMULANT/REPLACEMENT/MODIFYI
NG (PITUITARY)
chorionic
1 PA
gonadotropin
desmopressin
1
acetate inj
DESMOPRESSIN
1
ACETATE NASAL
SOLN 0.01%
desmopressin
1
acetate nasal soln
0.01%
desmopressin
1
acetate tabs
INCRELEX
1 PA
novarel
1 PA
pregnyl w/diluent
1 PA
benzyl alcohol/nacl
SAIZEN
1 PA
SAIZEN
1 PA
CLICK.EASY
STIMATE
1
HORMONAL AGENTS,
STIMULANT/REPLACEMENT/MODIFYI
NG (SEX HORMONES/MODIFIERS)
ANABOLIC STEROIDS
ANADROL-50
1 PA
oxandrolone tabs
1 PA
10mg
QL(60/30)
oxandrolone tabs
1 PA
2.5mg
QL(120/30)
ANDROGENS
ANDROGEL GEL
1 PA
25MG/2.5GM,
50MG/5GM
ANDROGEL PUMP
1 PA
ANDROXY
1 PA
danazol
1
TESTIM
1 PA
testosterone
1 PA
cypionate
testosterone
1 PA
enanthate
ESTROGENS
ALORA
1 PA QL(8/28)
altavera
1
alyacen 1/35
1
alyacen 7/7/7
1
apri
1
aranelle
1
aubra
1
aviane
1
azurette
1
balziva
1
briellyn
1
caziant
1
chateal
1
cryselle-28
1
cyclafem 1/35
1
cyclafem 7/7/7
1
dasetta 1/35
1
dasetta 7/7/7
1
DEPO-ESTRADIOL
1
desogestrel/ethinyl
1
estradiol tabs
0.15mg; 30mcg
elinest
1
emoquette
1
enpresse-28
1
enskyce
1
estarylla
1
estradiol ptwk
1 PA QL(4/28)
estradiol tabs
1 PA
estradiol valerate
1
estradiol/norethindr
1 PA
one acetate
ESTRING
1 QL(1/90)
falmina
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply;
B/D= Drugs covered under Medicare Part B or Part D
Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa;
ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D
47
Drug Name
Drug Reqs/Limits Drug Name
Drug Reqs/Limits Drug Name
Drug Reqs/Limits
Tier
Tier
Tier
FEMRING
1
progesterone caps
1
philith
1
gildagia
1
pimtrea
1
SELECTIVE ESTROGEN RECEPTOR
gildess 1.5/30
1
pirmella 1/35
1
MODIFYING AGENTS
gildess 1/20
1
pirmella 7/7/7
1
raloxifene
1 QL(30/30)
gildess fe 1.5/30
1
portia-28
1
hydrochloride
gildess fe 1/20
1
PREMARIN CREA
1
HORMONAL AGENTS,
introvale
1
PREMARIN INJ
1
STIMULANT/REPLACEMENT/MODIFYI
junel 1.5/30
1
PREMARIN TABS
1 PA
NG (THYROID)
junel 1/20
1
QL(30/30)
HORMONAL AGENTS,
previfem
1
junel fe 1.5/30
1
STIMULANT/REPLACEMENT/MODIFYI
junel fe 1/20
1
quasense
1
NG (THYROID)
reclipsen
1
kariva
1
levothyroxine
1
kelnor 1/35
1
sprintec 28
1
sodium tabs
sronyx
1
kurvelo
1
LEVOXYL
1
larin 1/20
1
tilia fe
1
liothyronine sodium
1
larin fe 1.5/30
1
1
tri-estarylla
SYNTHROID
1
larin fe 1/20
1
tri-legest fe
1
THYROLAR-1
1
lessina
1
tri-linyah
1
THYROLAR-1/2
1
levonest
1
tri-previfem
1
THYROLAR-1/4
1
levonorgestrel/ethin
1
tri-sprintec
1
THYROLAR-2
1
yl estradiol
trivora-28
1
THYROLAR-3
1
levora 0.15/30-28
1
velivet
1
1
UNITHROID
low-ogestrel
1
viorele
1
UNITHROID
1
lutera
1
VIVELLE-DOT
1 PA QL(8/28) DIRECT
marlissa
1
vyfemla
1
HORMONAL AGENTS,
MENOSTAR
1 PA QL(4/28) wera
1
SUPPRESSANT (ADRENAL)
microgestin 1.5/30
1
zenchent
1
HORMONAL AGENTS,
microgestin 1/20
1
zovia 1/35e
1
SUPPRESSANT (ADRENAL)
microgestin fe
1
zovia 1/50e
1
LYSODREN
1
microgestin fe
1
PROGESTERONE
HORMONAL AGENTS,
1.5/30
AGONISTS/ANTAGONISTS
SUPPRESSANT
(PARATHYROID)
mimvey
1 PA
ELLA
1
HORMONAL AGENTS,
mimvey lo
1 PA
PROGESTINS
SUPPRESSANT (PARATHYROID)
MINIVELLE PTTW
1 PA QL(8/28) camila
1
SENSIPAR
TABS
1 QL(60/30)
0.1MG/24HR
DEPO-PROVERA
1
30MG, 60MG
mono-linyah
1
errin
1
SENSIPAR TABS
1 QL(120/30)
myzilra
1
heather
1
90MG
necon 0.5/35-28
1
jencycla
1
HORMONAL AGENTS,
necon 1/35
1
lyza
1
SUPPRESSANT (PITUITARY)
necon 10/11-28
1
MAKENA
1
HORMONAL AGENTS,
necon 7/7/7
1
medroxyprogestero
1 QL(1/90)
SUPPRESSANT (PITUITARY)
norgestimate/ethinyl
1
ne acetate inj
estradiol
cabergoline
1
medroxyprogestero
1
nortrel 0.5/35 (28)
1
ELIGARD
INJ
1 PA
ne acetate tabs
nortrel 1/35
1
30MG
QL(1/120)
megestrol acetate
1 PA
nortrel 7/7/7
1
ELIGARD INJ
1 PA
norethindrone
1
ogestrel
1
45MG
QL(1/180)
norethindrone
1
orsythia
1
acetate
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply;
B/D= Drugs covered under Medicare Part B or Part D
Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa;
ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D
48
Nombre del
Nivel del
Requ./
medicamento medicamento Límites
Nombre del
Nivel del
Requ./
medicamento medicamento Límites
Nombre del
Nivel del
Requ./
medicamento medicamento Límites
1 PA QL(1/30)
CELLCEPT SUSR
1 B/D PA
cyclosporine
1 B/D PA
cyclosporine
1 B/D PA
modified
ENBREL
1 PA QL(8/28)
ENBREL
1 PA QL(8/28)
SURECLICK
gengraf
1 B/D PA
hecoria
1 B/D PA
HUMIRA INJ
1 PA QL(2/28)
20MG/0.4ML
HUMIRA INJ
1 PA QL(6/28)
40MG/0.8ML
HUMIRA PEN
1 PA QL(6/28)
HUMIRA PEN1 PA QL(6/28)
CROHNS
DISEASESTARTE
R
methotrexate
1
methotrexate
1
sodium
mycophenolate
1 B/D PA
mofetil
mycophenolic acid
1 B/D PA
dr
NULOJIX
1 PA
PROGRAF INJ
1 B/D PA
RAPAMUNE ORAL
1 B/D PA
SOLN
RAPAMUNE TABS
1 B/D PA
1MG, 2MG
REMICADE
1 PA
sirolimus
1 B/D PA
tacrolimus
1 B/D PA
TORISEL
1 B/D PA
ZORTRESS
1 B/D PA
IMMUNIZING AGENTS, PASSIVE
ATGAM
1 B/D PA
BIVIGAM
1 B/D PA
FLEBOGAMMA DIF
1 B/D PA
gamastan s/d
1 B/D PA
GAMMAGARD
1 B/D PA
LIQUID
GAMMAKED
1 B/D PA
GAMMAPLEX INJ
1 B/D PA
10GM/200ML,
2.5GM/50ML,
5GM/100ML
GAMUNEX-C
1 B/D PA
1 B/D PA
OCTAGAM INJ
10GM/200ML,
2.5GM/50ML,
5GM/100ML
PRIVIGEN INJ
1 B/D PA
10GM/100ML,
20GM/200ML,
5GM/50ML
THYMOGLOBULIN
1 B/D PA
IMMUNOMODULATORS
ACTIMMUNE
1 PA
ARCALYST
1 PA
ILARIS
1 PA
leflunomide
1 QL(30/30)
PROVENGE
1 B/D PA
RIDAURA
1
SIMULECT
1 B/D PA
SYNAGIS INJ
1 PA
50MG/0.5ML
VACCINES
ACTHIB
1
ADACEL
1
BOOSTRIX
1
CERVARIX
1
COMVAX
1
DAPTACEL
1
DIPHTHERIA/TETA
1
NUS TOXOIDS
ADSORBED
PEDIATRIC
ENGERIX-B
1 B/D PA
GARDASIL
1
HAVRIX
1
IMOVAX RABIES
1
(H.D.C.V.)
INFANRIX
1
IPOL
1
INACTIVATED IPV
IXIARO
1
ELIGARD INJ
7.5MG
ELIGARD INJ
22.5MG
firmagon inj 80mg
firmagon inj 120mg
leuprolide acetate
1 PA QL(1/90)
1 B/D PA
QL(4/28)
1 B/D PA
QL(6/365)
1 PA
QL(30/30)
1 PA QL(1/30)
1 PA QL(1/30)
LUPRON DEPOT
LUPRON DEPOTPED
octreotide acetate
1 PA
SANDOSTATIN
1 PA
LAR DEPOT
SOMATULINE
1 PA
DEPOT
SOMAVERT INJ
1 PA
15MG, 20MG
QL(60/30)
SOMAVERT INJ
1 PA
10MG
QL(90/30)
SYNAREL
1 PA
TRELSTAR DEPOT
1 PA QL(1/28)
TRELSTAR DEPOT
1 PA QL(2/28)
MIXJECT
TRELSTAR LA
1 PA QL(1/84)
TRELSTAR LA
1 PA QL(2/84)
MIXJECT
TRELSTAR
1 PA
MIXJECT
QL(2/168)
HORMONAL AGENTS,
SUPPRESSANT (THYROID)
ANTITHYROID AGENTS
methimazole
1
propylthiouracil
1
IMMUNOLOGICAL AGENTS
ANGIOEDEMA (HAE) AGENTS
CINRYZE
1 PA
FIRAZYR
1 PA
IMMUNE SUPPRESSANTS
ASTAGRAF XL
1 B/D PA
AZASAN
1 B/D PA
azathioprine
1 B/D PA
CELLCEPT
1 B/D PA
INTRAVENOUS
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply;
B/D= Drugs covered under Medicare Part B or Part D
Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa;
ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D
49
Drug Name
Drug Reqs/Limits Drug Name
Drug Reqs/Limits Drug Name
Drug Reqs/Limits
Tier
Tier
Tier
M-M-R II
1
alendronate sodium
1 QL(30/30)
physiosol irrigation
1
tabs 10mg, 40mg,
W/DILUENT 10
ringers irrigation
1
DOSE
5mg
sodium chloride
1
MENACTRA
1
calcitonin-salmon
1 QL(3.7/30)
0.9%
MENOMUNE1
calcitriol caps
1
sterile water
1
A/C/Y/W-135
calcitriol inj
1 B/D PA
irrigation
MENVEO
1
calcitriol oral soln
1
tis-u-sol
1
PEDVAX HIB
1
doxercalciferol caps
1
VORAXAZE
1
PROQUAD
1
doxercalciferol inj
1 B/D PA
OPHTHALMIC AGENTS
RABAVERT
1
etidronate disodium
1
OPHTHALMIC PROSTAGLANDIN
1 B/D PA
RECOMBIVAX HB
FORTEO
1 PA
AND PROSTAMIDE ANALOGS
INJ 10MCG/ML,
QL(2.4/28)
COMBIGAN
1
40MCG/ML
ibandronate sodium
1 QL(1/28)
latanoprost
1 QL(5/30)
ROTARIX
1
tabs
LUMIGAN
1 QL(5/30)
ROTATEQ
1
MIACALCIN INJ
1
TRAVATAN Z
1 QL(5/30)
tenivac
1
pamidronate
1 B/D PA
OPHTHALMIC AGENTS, OTHER
tetanus toxoid
1
disodium inj
LACRISERT
1
adsorbed
30mg/10ml,
mydral
1
tetanus/diphtheria
1
6mg/ml, 90mg/10ml
naphazoline hcl
1
paricalcitol
1
toxoids-adsorbed
neo-polycin
1
adult
PROLIA
1 QL(1/180)
neomycin/polymyxi
1
1
ST
TWINRIX
n/bacitracin zinc
TYPHIM VI
1
risedronate sodium
1 QL(1/28)
parcaine
1
VAQTA
1
XGEVA
1 PA
polycin
1
VARIVAX
1
zoledronic acid inj
1 B/D PA
proparacaine hcl
1
yf-vax
1
4mg/5ml,
RESTASIS
1 QL(64/30)
ZOSTAVAX
1
5mg/100ml
trimethoprim
1
ZOMETA INJ
1 B/D PA
INFLAMMATORY BOWEL DISEASE
sulfate/polymyxin b
4MG/100ML
AGENTS
sulfate
MISCELLANEOUS THERAPEUTIC
AMINOSALICYLATES
tropicamide
1
AGENTS
APRISO
1
OPHTHALMIC ANTI-ALLERGY
MISCELLANEOUS THERAPEUTIC
balsalazide
1
AGENTS
AGENTS
disodium
ALOCRIL
1
DELZICOL
1
fomepizole
1
azelastine hcl
1
mesalamine
1
lactated ringers
1
ophthalmic soln
irrigation
SULFONAMIDES
cromolyn sodium
1
levocarnitine inj
1 B/D PA
sulfasalazine tabs
1
ophthalmic soln
levocarnitine oral
1
sulfazine
1
epinastine hcl
1
soln
sulfazine ec
1
PATADAY
1
levocarnitine
tabs
1
METABOLIC BONE DISEASE AGENTS
PATANOL
1
1 QL(200/30)
METABOLIC BONE DISEASE AGENTS novofine 30gx8mm
OPHTHALMIC ANTInovofine 31
1 QL(200/30)
ACTONEL TABS
1 QL(4/28)
INFLAMMATORIES
novofine
32gx6mm
1
QL(200/30)
35MG
bromfenac
1
novofine autocover
1 QL(200/30)
ACTONEL TABS
1 QL(30/30)
dexamethasone
1
30gx8mm
30MG, 5MG
sodium phosphate
novotwist 30gx8mm
1 QL(200/30)
alendronate sodium
1 QL(4/28)
ophthalmic soln
novotwist 32gx5mm
1 QL(200/30)
tabs 35mg, 70mg
PHYSIOLYTE
1 B/D PA
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply;
B/D= Drugs covered under Medicare Part B or Part D
Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa;
ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D
50
Nombre del
Nivel del
Requ./
medicamento medicamento Límites
Nombre del
Nivel del
Requ./
medicamento medicamento Límites
Nombre del
Nivel del
Requ./
medicamento medicamento Límites
diclofenac sodium
1
PHOSPHOLINE
1
fluticasone
1 QL(16/30)
IODIDE
ophthalmic soln
propionate susp
DUREZOL
1
PILOCARPINE
1
QVAR
1 QL(18/30)
FLUOROMETHOL
1
HCL OPHTHALMIC
SYMBICORT
1 QL(11/30)
ONE
SOLN
AERO
timolol maleate
1
160MCG/ACT;
flurbiprofen sodium
1
ketorolac
1
4.5MCG/ACT
OTIC AGENTS
tromethamine
1 QL(14/30)
SYMBICORT
OTIC AGENTS
ophthalmic soln
AERO
acetasol hc
1
neomycin/polymyxi
1
80MCG/ACT;
acetic acid
1
n/dexamethasone
4.5MCG/ACT
COLY-MYCIN S
1
poly-dex
1
triamcinolone
1 QL(16.5/30)
CORTISPORIN-TC
1
PRED MILD
1
acetonide inha
fluocinolone
1
PRED-G
1
ANTIHISTAMINES
acetonide
PRED-G S.O.P.
1
azelastine
hcl
nasal
1 QL(60/30)
hydrocortisone/aceti
1
PREDNISOLONE
1
soln
c acid
ACETATE
desloratadine
1 QL(30/30)
neomycin/polymyxi
1
prednisolone
1
desloratadine odt
1 QL(30/30)
n/hc
sodium phosphate
DIPHENHYDRAMI
1
neomycin/polymyxi
1
TOBRADEX OINT
1
NE HCL INJ
n/hydrocortisone
tobramycin/dexame
1
1 QL(300/30)
RESPIRATORY TRACT/PULMONARY levocetirizine
thasone
dihydrochloride
oral
AGENTS
OPHTHALMIC ANTIGLAUCOMA
soln
ANTI-INFLAMMATORIES, INHALED
AGENTS
levocetirizine
1 QL(30/30)
CORTICOSTEROIDS
acetazolamide er
1
dihydrochloride tabs
ADVAIR DISKUS
1 QL(60/30)
apraclonidine
1
promethazine hcl inj
1 PA
ADVAIR HFA
1 QL(24/30)
AZOPT
1
1 PA
budesonide susp
1 QL(17.2/30) promethazine hcl
betaxolol hcl
1
syrp
32mcg/act
BRIMONIDINE
1
promethazine hcl
1 PA
budesonide susp
1 B/D PA
TARTRATE
tabs
0.25mg/2ml,
QL(120/30)
OPHTHALMIC
ANTILEUKOTRIENES
0.5mg/2ml
SOLN 0.15%
montelukast
sodium
1 QL(30/30)
DULERA
1 QL(13/30)
brimonidine tartrate
1
zafirlukast
1
FLOVENT DISKUS
1 QL(120/30)
ophthalmic soln
BRONCHODILATORS,
AEPB
0.2%
ANTICHOLINERGIC
250MCG/BLIST,
carteolol hcl
1
50MCG/BLIST
ATROVENT HFA
1 QL(26/30)
dorzolamide hcl
1
FLOVENT DISKUS
1 QL(180/30)
COMBIVENT
1 QL(8/30)
dorzolamide
1
RESPIMAT
AEPB
hcl/timolol maleate
100MCG/BLIST
ipratropium bromide
1 B/D PA
LEVOBUNOLOL
1
FLOVENT HFA
1 QL(22/30)
inhalation soln
QL(300/30)
HCL OPHTHALMIC
AERO 44MCG/ACT
ipratropium bromide
1 QL(30/30)
SOLN 0.25%
FLOVENT HFA
1 QL(24/30)
nasal soln 0.06%
levobunolol hcl
1
AERO
ipratropium bromide
1 QL(60/30)
ophthalmic soln
110MCG/ACT,
nasal soln 0.03%
0.5%
220MCG/ACT
methazolamide
1
flunisolide
1
metipranolol
1
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply;
B/D= Drugs covered under Medicare Part B or Part D
Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa;
ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D
51
Drug Name
Drug Reqs/Limits Drug Name
Drug Reqs/Limits
Tier
Tier
ipratropium
1 B/D PA
DALIRESP
1 PA
bromide/albuterol
QL(540/30)
QL(30/30)
sulfate
1
THEO-24
SPIRIVA
1 QL(30/30)
theochron
1
HANDIHALER
theophylline cr
1
theophylline er tb12
1
BRONCHODILATORS,
200mg, 300mg,
SYMPATHOMIMETIC
450mg
albuterol sulfate er
1
theophylline
er tb24
1
albuterol sulfate
1 B/D PA
PULMONARY ANTIHYPERTENSIVES
nebu 0.5%
QL(360/30)
1 B/D PA
albuterol sulfate
LETAIRIS
1 PA
QL(375/30)
nebu 0.083%,
QL(30/30)
0.63mg/3ml,
REMODULIN
1 B/D PA
1.25mg/3ml
SILDENAFIL
1 PA
albuterol sulfate
1
QL(90/30)
syrp
TRACLEER
1 PA
QL(60/30)
albuterol sulfate
1
tabs
RESPIRATORY TRACT AGENTS,
EPINEPHRINE
1
OTHER
HCL INJ 0.1MG/ML
acetylcysteine
1 B/D PA
epinephrine hcl inj
1
inhalation soln
1mg/ml
ARALAST NP INJ
1 B/D PA
EPIPEN 2-PAK
1 QL(2/30)
1000MG
EPIPEN-JR 2-PAK
1 QL(2/30)
PROLASTIN-C
1 B/D PA
FORADIL
1 QL(60/30)
TYZINE
1
AEROLIZER
TYZINE
1
metaproterenol
1
PEDIATRIC NASAL
sulfate
DROPS
PERFOROMIST
1 B/D PA
1 PA
XOLAIR
QL(120/30)
ZEMAIRA
1 B/D PA
PROAIR HFA
1 QL(17/30)
SKELETAL MUSCLE RELAXANTS
SEREVENT
1 QL(60/30)
SKELETAL MUSCLE RELAXANTS
DISKUS
chlorzoxazone
1 PA
terbutaline sulfate
1
cyclobenzaprine hcl
1 PA
VENTOLIN HFA
1 QL(36/30)
tabs 10mg, 5mg
CYSTIC FIBROSIS AGENTS
orphenadrine citrate
1 PA
PULMOZYME
1 B/D PA
er
TOBI PODHALER
1 QL(1568/36
SLEEP DISORDER AGENTS
5)
GABA RECEPTOR MODULATORS
tobramycin
1 B/D PA
zaleplon
1 QL(90/365)
MAST CELL STABILIZERS
zolpidem tartrate
1 PA
cromolyn sodium
1 B/D PA
QL(90/365)
nebu
SLEEP DISORDERS, OTHER
PHOSPHODIESTERASE INHIBITORS, MODAFINIL TABS
1 PA
AIRWAYS DISEASE
100MG
QL(30/30)
aminophylline
1
modafinil tabs
1 PA
200mg
QL(60/30)
Drug Name
ROZEREM
SILENOR
XYREM
Drug
Tier
1
1
1
Reqs/Limits
QL(30/30)
QL(30/30)
PA
QL(540/30)
THERAPEUTIC
NUTRIENTS/MINERALS/ELECTROLYT
ES
ELECTROLYTE/MINERAL MODIFIERS
CHEMET
1
CUPRIMINE
1
DEPEN
1
TITRATABS
EXJADE
1
kionex
1
SAMSCA TABS
1 PA
30MG
QL(60/30)
SAMSCA TABS
1 PA
15MG
QL(90/30)
sodium bicarbonate
1
inj 7.5%, 8.4%
sodium lactate
1 B/D PA
sodium polystyrene
1
sulfonate powd
sodium polystyrene
1
sulfonate susp
15gm/60ml
sps
1
SYPRINE
1
ELECTROLYTE/MINERAL
REPLACEMENT
AMINO ACIDS
1 B/D PA
AMINOSYN
1 B/D PA
AMINOSYN
1 B/D PA
7%/ELECTROLYTE
S
AMINOSYN
1 B/D PA
8.5%/ELECTROLY
TES
AMINOSYN II
1 B/D PA
AMINOSYN II
1 B/D PA
8.5%/ELECTROLY
TES
AMINOSYN M
1 B/D PA
AMINOSYN-HBC
1 B/D PA
AMINOSYN-HF
1 B/D PA
AMINOSYN-PF
1 B/D PA
AMINOSYN-PF 7%
1 B/D PA
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply;
B/D= Drugs covered under Medicare Part B or Part D
Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa;
ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D
52
Nombre del
Nivel del
Requ./
medicamento medicamento Límites
Nombre del
Nivel del
Requ./
medicamento medicamento Límites
Nombre del
Nivel del
Requ./
medicamento medicamento Límites
lactated ringers
1
PREMASOL INJ
calcium acetate
1
1 B/D PA
viaflex
52MEQ/L;
caps
calcium acetate
1
ludent
1
1760MG/100ML;
magnesium sulfate
880MG/100ML;
tabs 667mg
1 B/D PA
inj 50%
CARBAGLU
1
34MEQ/L;
CLINIMIX
1 B/D PA
MOZOBIL
1 QL(9.6/30)
1760MG/100ML;
nafrinse
1
2.75%/DEXTROSE
372MG/100ML;
5%
normosol-m in d5w
1 B/D PA
406MG/100ML;
1 B/D PA
clinimix
NORMOSOL-R
1 B/D PA
526MG/100ML;
4.25%/dextrose
PHOSLYRA
1
492MG/100ML;
10%
potassium chloride
1
492MG/100ML;
0.15%/d5w
clinimix
1 B/D PA
526MG/100ML;
4.25%/dextrose
potassium chloride
1 B/D PA
356MG/100ML;
25%
0.15%/nacl 0.9%
356MG/100ML;
CLINIMIX
1 B/D PA
POTASSIUM
1 B/D PA
390MG/100ML;
4.25%/DEXTROSE
CHLORIDE 0.3%/
34MG/100ML;
5%
NACL 0.9%
152MG/100ML
CLINIMIX
1 B/D PA
POTASSIUM
1 B/D PA
premasol inj
1 B/D PA
5%/DEXTROSE
CHLORIDE
56meq/l;
25%
0.3%/D5W
320mg/100ml;
clinisol sf 15%
1 B/D PA
potassium chloride
1 B/D PA
730mg/100ml;
dextrose 5%
1 B/D PA
0.3%/nacl
190mg/100ml;
/electrolyte #48
0.9%/viaflex
3meq/l;
viaflex
potassium chloride
1
20mg/100ml;
dextrose
1 B/D PA
cr
300mg/100ml;
5%/potassium
potassium chloride
1
220mg/100ml;
chloride 0.15%
290mg/100ml;
er cpcr
fluoride chew
1
POTASSIUM
1
490mg/100ml;
0.25mg, 1.1mg,
CHLORIDE ER
840mg/100ml;
2.2mg
TBCR 10MEQ
490mg/100ml;
fluoritab chew
1
potassium chloride
1
200mg/100ml;
FREAMINE III
1 B/D PA
er tbcr 10meq,
290mg/100ml;
FREAMINE III 3%
1 B/D PA
20meq
410mg/100ml;
hepatamine
1 B/D PA
potassium chloride
1 B/D PA
230mg/100ml;
HEPATASOL
1 B/D PA
inj 10meq/100ml,
5meq/l;
isolyte-m/dextrose
1 B/D PA
20meq/100ml,
15mg/100ml;
5%
2meq/ml,
250mg/100ml;
k-vescent pack
1
40meq/100ml
120mg/100ml;
klor-con
1
potassium chloride
1
140mg/100ml;
klor-con m10
1
liqd
470mg/100ml
klor-con m20
1
potassium chloride
1
PROCALAMINE
1 B/D PA
lactated ringers
1
pack
PROSOL
1 B/D PA
dextrose 5% viaflex
POTASSIUM
1
ringers injection
1
lactated ringers inj
1
CHLORIDE SR
sodium chloride
1 B/D PA
3meq/l; 109meq/l;
POTASSIUM
1
0.45% viaflex
28meq/l; 4meq/l;
CITRATE
130meq/l
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply;
B/D= Drugs covered under Medicare Part B or Part D
Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa;
ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D
53
Drug Name
Drug Reqs/Limits Drug Name
Tier
1 B/D PA
Drug Reqs/Limits Drug Name
Tier
Drug Reqs/Limits
Tier
sodium chloride inj
0.9%, 2.5meq/ml,
3%, 5%
sodium fluoride
1
chew 0.25mg,
0.5mg, 1mg, 2.2mg
sodium fluoride tabs
1
tpn electrolytes
1 B/D PA
TRAVASOL
1 B/D PA
TROPHAMINE INJ
1 B/D PA
97MEQ/L;
0.54GM/100ML;
1.2GM/100ML;
0.32GM/100ML; 0;
0; 0.5GM/100ML;
0.36GM/100ML;
0.48GM/100ML;
0.82GM/100ML;
1.4GM/100ML;
1.2GM/100ML;
0.34GM/100ML;
0.48GM/100ML;
0.68GM/100ML;
0.38GM/100ML;
5MEQ/L;
0.025GM/100ML;
0.42GM/100ML;
0.2GM/100ML;
0.24GM/100ML;
0.78GM/100ML
THERAPEUTIC
NUTRIENTS/MINERALS/ELECTROLYT
ES
intralipid inj 2.25%;
1 B/D PA
20%
liposyn iii inj 2.5%;
1 B/D PA
30%
VITAMINS
OB COMPLETE
1
400
OB
1
COMPLETE/DHA
PRENATABS OBN
1
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply;
B/D= Drugs covered under Medicare Part B or Part D
Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa;
ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D
54
Nombre del
Nivel del
Requ./
medicamento medicamento Límites
Needles And Syringes
MISCELLANEOUS THERAPEUTIC
AGENTS
MISCELLANEOUS THERAPEUTIC
AGENTS
bd insulin syringe
1 QL(200/30)
safetyglide/1ml/29g
x 1/2"
bd insulin syringe
1 QL(200/30)
ultrafine/0.3ml/31g
x 5/16"
bd insulin syringe
1 QL(200/30)
ultrafine/0.5ml/30g
x 1/2"
bd insulin syringe
1 QL(200/30)
ultrafine/1ml/31g x
5/16"
bd insulin syringe
1 QL(200/30)
ultrafine/u100/0.3ml/31g x
15/64"
1 QL(200/30)
bd insulin syringe
ultrafine/u100/0.5ml/31g x
15/64"
bd insulin syringe
1 QL(200/30)
ultrafine/u100/1ml/31g x
15/64"
1 QL(200/30)
bd pen
needle/mini/ultrafine
/31g x 3/16"
bd pen
1 QL(200/30)
needle/nano/ultra
fine/32g x 4mm
bd pen
1 QL(200/30)
needle/ultrafine/29g
x 12.7mm
monoject insulin
1 QL(200/30)
syringe/detach
needle/1ml/27g x
1/2"
monoject insulin
1 QL(200/30)
syringe/safety/perm
needle/0.3ml/29g x
1/2"
Nombre del
Nivel del
Requ./
medicamento medicamento Límites
monoject insulin
syringe/u100/0.5ml/30g x
5/16"
monoject insulin
syringe/u100/1ml/30g x 5/16"
monoject ultra
comfort insulin
syringe/0.3ml/30g x
5/16"
monoject ultra
comfort insulin
syringe/0.5ml/28g x
1/2"
monoject ultra
comfort insulin
syringe/0.5ml/29g x
1/2"
monoject ultra
comfort insulin
syringe/1ml/28g x
1/2"
ulticare insulin
syringe/u100/0.3ml/30g x
1/2"
ulticare insulin
syringe/u100/0.5ml/31g x
5/16"
ulticare insulin
syringe/u100/1ml/30g x 1/2"
Nombre del
Nivel del
Requ./
medicamento medicamento Límites
1 QL(200/30)
1 QL(200/30)
1 QL(200/30)
1 QL(200/30)
1 QL(200/30)
1 QL(200/30)
1 QL(200/30)
1 QL(200/30)
1 QL(200/30)
Key: QL= Quantity Limits listed as (qty/days); PA=Prior Authorization may be required; ST= Step Therapy rules apply;
B/D= Drugs covered under Medicare Part B or Part D
Clave: QL= Los límites de cantidad se indican como (cant./días); PA=Es posible que se requiera de autorización previa;
ST= Se aplican las reglas de la terapia escalonada; B/D= Medicamentos en cobertura de Medicare Parte B o Parte D
55
www.cignahealthspring.com
This drug list was updated on August 2014. For more recent information or other questions, please contact Cigna-HealthSpring
Customer Service, at 1-800-668-3813 or, for TTY users, 711, 7 days a week, 8 a.m. – 8 p.m., or visit www.cignahealthspring.com.
Esta lista de medicamentos se actualizó en agosto de 2014. Para información más reciente u otras preguntas, favor de
contactar al Departamento de servicio al cliente de Cigna-HealthSpring, al 1-800-668-3813 o, para los usuarios de TTY, 711,
7 días de la semana, 8 a.m. – 8 p.m., o visite www.cignahealthspring.com. This information is available for free in other languages.
Please call our Customer Service number at 1-800-668-3813 (TTY 711), 7 days a week, 8 a.m. – 8 p.m. Esta información está
disponible de forma gratuita en otros idiomas. Favor de contactar a nuestro Departamento de servicio al cliente llamando al
1-800-668-3813 (TTY 711), 7 días de la semana, 8 a.m. – 8 p.m.
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including
Cigna Health and Life Insurance Company, Cigna HealthCare of South Carolina, Inc., Cigna HealthCare of North Carolina, Inc.,
Cigna HealthCare of Georgia, Inc., Cigna HealthCare of Arizona, Inc., HealthSpring Life & Health Insurance Company, Inc.,
HealthSpring of Tennessee, Inc., HealthSpring of Alabama, Inc., HealthSpring of Florida, Inc., Bravo Health Mid-Atlantic, Inc.,
and Bravo Health Pennsylvania, Inc. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property,
Inc. Todos los productos y servicios de Cigna se brindan exclusivamente por o a través de subsidiarias operativas de Cigna
Corporation, incluyendo Cigna Health and Life Insurance Company, Cigna HealthCare of South Carolina, Inc., Cigna HealthCare
of North Carolina, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of Arizona, Inc., HealthSpring Life & Health Insurance
Company, Inc., HealthSpring of Tennessee, Inc., HealthSpring of Alabama, Inc., HealthSpring of Florida, Inc., Bravo Health
Mid-Atlantic, Inc., y Bravo Health Pennsylvania, Inc. El nombre de Cigna, los logotipos, y otras marcas de Cigna son propiedad
de Cigna Intellectual Property, Inc. © 2014 Cigna