1. Healthcare

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION
ABOUT THE DRUGS WE COVER IN THIS PLAN.
Formulary ID: 14602.000, Version: 20
S9579_14_CHOICECOMPFORM_VERSION1 ACCEPTED
MRXFCR13R
Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still
contains the drugs you take.
When this drug list (formulary) refers to “we,” “us”, or “our,” it means Stonebridge Life Insurance Company. When it refers
to “plan” or “our plan,” it means Transamerica MedicareRx Choice (PDP).
This document includes a list of the drugs (formulary) for our plan which is current as of November 1, 2014. For an updated
formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front
and back cover pages.
You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network,
premium and/or copayments/coinsurance may change on January 1, 2015.
What is the Transamerica MedicareRx Choice (PDP) Formulary?
A formulary is a list of covered drugs selected by Transamerica MedicareRx Choice (PDP) 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.
Transamerica MedicareRx Choice (PDP) will generally cover the drugs listed in our formulary as long as the drug is medically
necessary, the prescription is filled at a Transamerica MedicareRx Choice (PDP) network pharmacy, and other plan rules are
followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.
Can the Formulary (drug list) change?
Generally, if you are taking a drug on our 2014 formulary that was covered at the beginning of the year, we will not discontinue
or reduce coverage of the drug during the 2014 coverage year except when a new, less expensive generic drug becomes
available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary
changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain
available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important
that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you
chose our plan, except for cases in which you can save additional money or we can ensure your safety.
If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or
move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change
becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a
60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s
manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to
members who take the drug. The enclosed formulary is current as of November 1, 2014. To get updated information about the
drugs covered by Transamerica MedicareRx Choice (PDP), please contact us. Our contact information appears on the front and
back cover pages. If mid-year non-maintenance formulary changes occur, affected members will be notified of formulary
changes in “Your Monthly Prescription Drug Summary”, also referred to as their Part D Explanation of Benefits (EOB).
How do I use the Formulary?
There are two ways to find your drug within the formulary:
Medical Condition
The formulary begins on page 9. The drugs in this formulary are grouped into categories depending on the type of medical
conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category,
“Cardiac Drugs”. If you know what your drug is used for, look for the category name in the list that begins on page
9. Then look under the category name for your drug.
Alphabetical Listing
If you are not sure what category to look under, you should look for your drug in the Index that begins on page I-1. The
Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs
are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you
can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the
list.
2
What are generic drugs?
Transamerica MedicareRx Choice (PDP) 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: Transamerica MedicareRx Choice (PDP) requires you or your physician to get prior
authorization for certain drugs. This means that you will need to get approval from Transamerica MedicareRx
Choice (PDP) before you fill your prescriptions. If you don’t get approval, Transamerica MedicareRx Choice (PDP)
may not cover the drug.
 Quantity Limits: For certain drugs, Transamerica MedicareRx Choice (PDP) limits the amount of the drug that
Transamerica MedicareRx Choice (PDP) will cover. For example, Transamerica MedicareRx Choice (PDP) provides 18
tablets in 28 days per prescription for Maxalt. This may be in addition to a standard one-month or three-month supply.
 Step Therapy: In some cases, Transamerica MedicareRx Choice (PDP) 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, Transamerica MedicareRx Choice (PDP) may not cover Drug B unless you try Drug A first.
If Drug A does not work for you, Transamerica MedicareRx Choice (PDP) will then cover Drug B.
You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 9. You
can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. Our contact
information, along with the date we last updated the formulary, appears on the front and back cover pages.
You can ask Transamerica MedicareRx Choice (PDP) 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
Transamerica MedicareRx Choice (PDP) formulary?” on page 3 for information about how to request an exception.
What if my drug is not on the Formulary?
If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your
drug is covered.
If you learn that Transamerica MedicareRx Choice (PDP) does not cover your drug, you have two options:
 You can ask Member Services for a list of similar drugs that are covered by Transamerica MedicareRx
Choice (PDP). When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is
covered by Transamerica MedicareRx Choice (PDP).
 You can ask Transamerica MedicareRx Choice (PDP) 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 Transamerica MedicareRx Choice (PDP)’s Formulary?
You can ask Transamerica MedicareRx Choice (PDP) to make an exception to our coverage rules. There are several
types of exceptions that you can ask us to make.
 You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a predetermined 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 cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If
approved this would lower the amount you must pay for your drug.
 You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Transamerica
MedicareRx Choice (PDP) 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, Transamerica MedicareRx Choice (PDP) will only approve your request for an exception if the alternative drugs
included on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in
treating your condition and/or would cause you to have adverse medical effects.
3
You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception.
When you request a formulary, tiering or utilization restriction exception you should submit a statement from your
prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your
prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your
health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must
give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.
What do I do before I can talk to my doctor about changing my drugs or requesting an exception?
As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking
a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before
you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover
or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right
course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary
31-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first
31-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.
If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with
93-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days).
We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not
on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will
cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary
exception.
If you experience a change in your setting of care (such as being discharged or admitted to a long term care facility), your
physician or pharmacy can request a one-time prescription override. This one-time override will provide you with temporary
coverage (up to a 31-day supply) for the applicable drug(s).
For more information
For more detailed information about your Transamerica MedicareRx Choice (PDP) prescription drug coverage, please review
your Evidence of Coverage and other plan materials.
If you have questions about Transamerica MedicareRx Choice (PDP), please contact us. Our contact information, along with
the date we last updated the formulary, appears on the front and back cover pages.
If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or, visit www.medicare.gov.
Transamerica MedicareRx Choice (PDP) Formulary
The formulary that begins on page 9 provides coverage information about some of the drugs covered by Transamerica
MedicareRx Choice (PDP). If you have trouble finding your drug in the list, turn to the Index that begins on page I-1.
The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., SINGULAIR) and generic drugs are
listed in lower-case italics (e.g., montelukast sodium ).
The information in the Requirements/Limits column tells you if we Transamerica MedicareRx Choice (PDP) has any special
requirements for coverage of your drug.
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The following abbreviations may be found within the body of this document
COVERAGE NOTES ABBREVIATIONS
ABBREVIATION
DESCRIPTION
Prior
Authorization
Restriction
PA
PA BvD
PA NSO
QL
Prior
Authorization
Restriction for
Part B vs Part D
Determination
Prior
Authorization
Restriction for
New Starts Only
Quantity Limit
Restriction
ST
Step Therapy
Restriction
ABBREVIATION
DESCRIPTION
LA
Limited Access
Drug
NM
Non-Mail Order
Drug
EXPLANATION
Utilization Management Restrictions
You (or your physician) are required to get prior authorization from
Transamerica MedicareRx Choice (PDP) before you fill your prescription for this
drug. Without prior approval, we may not cover this drug.
This drug may be eligible for payment under Medicare Part B or Part D. You (or
your physician) are required to get prior authorization from Transamerica
MedicareRx Choice (PDP) to determine that this drug is covered under Medicare
Part D before you fill your prescription for this drug. Without prior approval, we may
not cover this drug.
If you are a new member, you (or your physician) are required to get prior
authorization from Transamerica MedicareRx Choice (PDP) before you fill your
prescription for this drug. Without prior approval, we may not cover this drug.
Transamerica MedicareRx Choice (PDP) limits the amount of this drug that is
covered per prescription, or within a specific time frame.
Before Transamerica MedicareRx Choice (PDP) will provide coverage for
this drug, you must first try another drug(s) to treat your medical condition.
This drug may only be covered if the other drug(s) does not work for you.
EXPLANATION
Other Special Requirements for Coverage
This prescription may be available only at certain pharmacies. For more
information consult your Pharmacy Directory or call Member Services at 1-888672-7206, 24 hours a day, 365 days a year. TTY/TDD users should call 711.
You may be able to receive greater than a 1-month supply of most of the drugs
on your formulary via mail order at a reduced cost share. Drugs not available via
your mail order benefit are noted with “NM” in the Requirements/Limits column of
your formulary.
The following table includes your cost sharing for each drug tier that is listed in the drug list that follows.
Tier Number / Name
31-day supply at Retail
90-day supply at Retail
90-day supply at Mail
Order
Your Copayment/Coinsurance During Initial Coverage Stage
Tier 1/ Preferred Generic drugs
$0 copay
$0 copay
$0 copay
Tier 2 / Non-Preferred Generic drugs
$20 copay
$60 copay
$50 copay
Tier 3 / Preferred Brand drugs
$45 copay
$135 copay
$115 copay
Tier 4 / Non-Preferred Brand drugs
$95 copay
$285 copay
$240 copay
Tier 5 / Specialty drugs
33% coinsurance
33% coinsurance
33% coinsurance
The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the
plan.
5
ABBREVIATION
adh. patch
aer br act
aer pow
aer pow ba
aer refill
aer w/adap
ampul
blkbaginj
cap dr mp
cap ds pk
cap er 12h
cap er 24h
cap er deg
cap er pel
cap mphase
cap.sa 24h
cap.sr 12h
cap.sr 24h
cap24h pct
cap24h pel
cap sprink
cap sr pel
cap w/dev
capsule dr
capsule er
capsule sa
cmb cappad
cmb ont fm
cmb ont lt
cmb tabpad
combo. pkg
cpmp 12hr
cpmp 24hr
cpmp 30-70
cpmp 50-50
cream(g), cream(gm)
cream(ml)
cream/appl
cream, er (g)
cream pack
dehp fr bg
dis needle
disk w/dev
disp syrin
drops susp
drps hpvis
emul adhes
emul packt
emulsn(g)
STRENGTH AND DOSAGE FORM ABBREVIATIONS
DESCRIPTION
adhesive patch
aerosol, breath activated
aerosol, powder
aerosol powder, breath activated
aerosol refill
aerosol with adapter
ampule
bulk bag injection
capsule, delayed release multiphasic
capsule, dose pack
capsule, 12 hour extended release
capsule, 24 hour extended release
capsule, extended release degradable
capsule, extended release pellets
capsule, multiphasic
capsule, 24 hour sustained action
capsule, 12 hour sustained release
capsule, 24 hour sustained release
capsule, 24 hour controlled-onset pellets
capsule, 24 hour sustained release pellets
capsule, sprinkle
capsule sustained release pellets
capsule with device
capsule, delayed release
capsule, extended release
capsule, sustained action
combination: capsule, pad
combination: ointment, foam
combination: ointment, lotion
combination: tablet, pad
combination package
capsule, 12 hour multiphasic
capsule, 24 hour multiphasic
capsule, multiphasic, 30%-70%
capsule, multiphasic, 50%-50%
cream (grams)
cream (milliliters)
cream with applicator
cream, extended release (grams)
cream, package
di(2-ethylhexyl)phthalate free bag
disposable needle
disk with inhalation device
disposable syringe
drops, suspension
drops, hyperviscous
emulsion adhesive
emulsion packet
emulsion (grams)
6
ABBREVIATION
foam/appl.
froz.piggy
g
gel/pf app
gel (gm)
gel (ml)
gel md pmp
gel w/appl
gel w/pump
gran pack
hfa aer ad
infus. btl
insuln pen
ip soln
irrig soln
iv soln.
jel
jelly/app
jel/pf app
kit cl&crm
kt crm le
kt lotn ce
kt oint le
lotion, er
lozenge hd
m.ht patch
ma buc tab
mcg
med. pad
med. swab
med. tape
mg
ml
muc er 12h
ndl fr inj
nl fm susp
oint. (g), oint.(gm)
oral conc
oral susp
paste (g)
patch td24
patch td72
patch tdsw
patch tdwk
pca syring
pca vial
pellet(ea)
pen ij kit
pen injctr
pggybk btl
DESCRIPTION
foam with applicator
frozen piggyback
gram
gel with prefilled applicator
gel (grams)
gel (milliliters)
gel in metered dose pump
gel with applicator
gel with pump
granule pack
hfa aerosol adapter
infusion bottle
insulin pen
intraperitoneal solution
irrigating solution
intravenous solution
jelly
jelly with applicator
jelly with pre-filled applicator
kit: cleanser and cream
kit: cream, lotion emollient
kit: lotion, cream emollient
kit: ointment, lotion emollient
lotion, extended release
lozenge handle
medicated heated patch
mucoadhesive buccal tablet
microgram
medicated pad
medicated swab
medicated tape
milligram
milliliter
mucoadhesive system, 12 hour extended release
needle for injection
nail film suspension
ointment (grams)
oral concentrate
oral suspension
paste (grams)
patch, 24 hour transdermal
patch, 72 hour transdermal
patch, biweekly transdermal
patch, weekly transdermal
patient-controlled analgesic syringe
patient-controlled analgesic vial
pellet (each)
pen injector kit
pen injector
piggyback bottle
7
ABBREVIATION
plast. bag
powd pack
sol md pmp
sol w/appl
sol/pf app
sol-gel
soln recon
soln(gram)
spray susp
spray/pump
stick(ea)
supp.rect
supp.vag
suppos.
sus er 24h
sus er rec
sus mc rec
suspdr pkt
susp recon
syringekit
tab chew
tab er 12h
tab er 24h
tab er prt
tab er seq
tab disper
tab ds pk
tab er 24
tab mphase
tab part
tab rap dr
tab rapdis
tab subl
tab.sr 12h
tab.sr 24h
tabergr24hr
tablet dr
tablet, er
tablet eff
tablet sa
tablet sol
tb er dspk
tb mp dspk
tb rd dspk
tbdspk 3mo
tbmp 12hr
tbmp 24hr
u
vag ring
DESCRIPTION
plastic bag
powder pack
solution with multi-dose pump
solution with applicator
solution with pre-filled applicator
solution, gel-forming
solution, reconstituted
solution (grams)
spray, suspension
spray with pump
stick (each)
suppository, rectal
suppository, vaginal
suppository
suspension, 24 hour extended release
suspension, extended release reconstituted
suspension, microcapsule reconstituted
suspension, delayed release packet
suspension, reconstituted
syringe kit
tablet, chewable
tablet, 12 hour extended release
tablet, 24 hour extended release
tablet, extended release particles
tablet, extended release sequels
tablet, dispersible
tablet, dose pack
tablet, 24 hour extended release
tablet, multiphasic
tablet, particles
tablet, rapid disintegrating delayed release
tablet, rapid disintegrating
tablet, sublingual
tablet, 12 hour sustained release
tablet, 24 hour sustained release
tablet, 24 hour gradual extended release
tablet, delayed release
tablet, extended release
tablet, effervescent
tablet, sustained action
tablet, soluble
tablet, extended release dose pack
tablet, multiphasic dose pack
tablet, rapid disintegrating dose pack
tablet, 3-month dose pack
tablet, 12 hour multiphasic
tablet, 24 hour multiphasic
unit
vaginal ring
8
Drug Name
Drug Tier
Requirements/Limits
Analgesics
Analgesics, Miscellaneous
acetaminophen with codeine
acetaminophen with codeine
buprenorphine hcl
butalb/acetaminophen/caffeine
2
2
2
2
QL: 180 in 30 days
QL: 360 in 30 days
butalb/acetaminophen/caffeine
2
PA, QL: 2700 in 30 days
butalbit/acetamin/caff/codeine
2
PA, QL: 180 in 30 days
butalbit/acetamin/caff/codeine
2
PA, QL: 180 in 30 days
butalbital/acetaminophen
2
PA, QL: 180 in 30 days
butorphanol tartrate
butorphanol tartrate
BUTRANS
2
2
3
QL: 5 in 28 days
QL: 4 in 28 days
BUTRANS
codeine phos/acetaminophen
codeine sulfate
codeine/butalbital/asa/caffein
3
2
2
2
QL: 4 in 28 days
QL: 2500 in 30 days
QL: 180 in 30 days
PA, QL: 180 in 30 days
fentanyl citrate
fentanyl
hydrocodone/acetaminophen
hydrocodone/acetaminophen
5
2
2
2
PA, QL: 120 in 30 days
PA
QL: 150 in 30 days
QL: 180 in 30 days
hydrocodone/acetaminophen
hydrocodone/acetaminophen
2
2
QL: 2025 in 30 days
QL: 240 in 30 days
hydrocodone/acetaminophen
hydrocodone/acetaminophen
hydrocodone/acetaminophen
2
2
2
QL: 2700 in 30 days
QL: 2700 in 30 days
QL: 360 in 30 days
hydrocodone/acetaminophen
2
QL: 390 in 30 days
hydrocodone/ibuprofen
hydromorphone hcl/pf
hydromorphone hcl/pf
hydromorphone hcl
hydromorphone hcl
hydromorphone hcl
hydromorphone hcl
ibuprofen/oxycodone hcl
LAZANDA
levorphanol tartrate
2
2
2
2
2
2
2
2
5
2
QL: 150 in 30 days
PA, QL: 180 in 30 days
QL: 1200 in 30 days
QL: 180 in 30 days
QL: 240 in 30 days
QL: 28 in 30 days
PA, QL: 30 in 30 days
QL: 180 in 30 days
9
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
tablet: 300mg-60mg
tablet: 300mg-15mg, 300mg-30mg
(injectable)
tablet: 50-325-40, (High Risk Med
for Ages 65 and Older)
solution, (High Risk Med for Ages
65 and Older)
capsule: 50-300-30, (High Risk
Med for Ages 65 and Older)
capsule: 50-325-30, (High Risk
Med for Ages 65 and Older)
tablet: 50mg-325mg, (High Risk
Med for Ages 65 and Older)
syringe, vial
spray
patch tdwk: 5mcg/hr, 10mcg/hr,
15mcg/hr, 20mcg/hr
patch tdwk: 7.5mcg/hr
tablet
(High Risk Med for Ages 65 and
Older)
tablet: 7.5-750mg, 10-750mg
tablet: 7.5-650mg, 10-660mg,
10mg-650mg
solution: 10-300/15
capsule, tablet: 2.5-500mg, 5mg500mg, 7.5-500mg, 10mg-500mg
solution: 7.5-325/15
solution: 7.5-500/15, 10-325/15
tablet: 2.5-325mg, 5mg-325mg, 7.5325mg, 10mg-325mg
tablet: 5mg-300mg, 7.5-300mg,
10mg-300mg
ampul
vial
syringe
liquid
tablet: 2mg, 4mg
tablet: 8mg
Effective: November 01, 2014
Drug Name
Drug Tier
Requirements/Limits
methadone hcl
methadone hcl
methadone hcl
methadone hcl
methadone hcl
morphine sulfate/0.9% nacl/pf
morphine sulfate/pf
morphine sulfate
2
2
2
2
2
2
2
2
morphine sulfate
morphine sulfate
MORPHINE SULFATE
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
nalbuphine hcl
NUCYNTA ER
NUCYNTA
OFIRMEV
oxycodone hcl/acetaminophen
oxycodone hcl/acetaminophen
oxycodone hcl/acetaminophen
2
2
2
2
2
2
2
2
3
3
4
2
2
2
oxycodone hcl/acetaminophen
2
QL: 360 in 30 days
oxycodone hcl/aspirin
oxycodone hcl
oxycodone hcl
OXYCONTIN
OXYCONTIN
2
2
2
3
3
QL: 360 in 30 days
QL: 1300 in 30 days
QL: 180 in 30 days
QL: 120 in 30 days
QL: 60 in 30 days
oxymorphone hcl
oxymorphone hcl
oxymorphone hcl
2
2
2
QL: 120 in 30 days
QL: 180 in 30 days
QL: 60 in 30 days
tramadol hcl/acetaminophen
2
tramadol hcl
2
XARTEMIS XR
3
Nonsteroidal Anti-inflammatory Agents
butalbital/aspirin/caffeine
2
CALDOLOR
CELEBREX
choline sal/mag salicylate
diclofenac potassium
diclofenac sodium/misoprostol
4
3
2
2
2
QL: 1800 in 30 days
QL: 1800 in 30 days
QL: 360 in 30 days
QL: 90 in 30 days
QL: 120 in 30 days
QL: 180 in 30 days
QL: 180 in 30 days
QL: 200 in 30 days
QL: 300 in 30 days
QL: 700 in 30 days
vial
oral conc
solution
tablet
tablet sol
ampul, cartridge: 8mg/ml, 10mg/ml,
15mg/ml; pen injctr, supp.rect,
syringe, vial, vial port
cartridge: 2mg/ml, 4mg/ml
tablet er: 30mg, 60mg, 100mg
tablet er: 15mg, 200mg
solution: 100mg/5ml
solution: 20mg/5ml
solution: 10mg/5ml
QL: 60 in 30 days
QL: 181 in 30 days
QL: 180 in 30 days
QL: 1800 in 30 days
QL: 240 in 30 days
QL: 240 in 30 days
QL: 240 in 30 days
QL: 360 in 30 days
PA, QL: 180 in 30 days
tablet: 10mg-650mg
solution
capsule, tablet: 5mg-500mg, 7.5500mg
tablet: 2.5-325mg, 5mg-325mg, 7.5325mg, 10mg-325mg
solution
capsule, oral conc, tablet
tab er 12h: 80mg
tab er 12h: 10mg, 15mg, 20mg,
30mg, 40mg, 60mg
tab er 12h: 30mg, 40mg
tablet
tab er 12h: 5mg, 7.5mg, 10mg,
15mg, 20mg
tablet
(High Risk Med for Ages 65 and
Older)
ST, QL: 60 in 30 days
10
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
Effective: November 01, 2014
Drug Name
Drug Tier
Requirements/Limits
diclofenac sodium
diflunisal
etodolac
fenoprofen calcium
FLECTOR
flurbiprofen
ibuprofen
ibuprofen
indomethacin sodium
2
2
2
2
3
2
1
2
2
gel (gram), tab er 24h, tablet dr
PA
indomethacin
2
PA, QL: 120 in 30 days
indomethacin
2
PA, QL: 240 in 30 days
indomethacin
2
PA, QL: 60 in 30 days
ketoprofen
ketorolac tromethamine
ketorolac tromethamine
ketorolac tromethamine
ketorolac tromethamine
mefenamic acid
meloxicam
meloxicam
nabumetone
naproxen sodium
naproxen
naproxen
piroxicam
salsalate
sulindac
tolmetin sodium
VOLTAREN
2
2
2
2
2
2
1
2
2
1
1
2
2
2
2
2
3
QL: 20 in 30 days
QL: 20 in 30 days
QL: 40 in 30 days
QL: 40 in 30 days
tablet
oral susp: 100mg/5ml
(High Risk Med for Ages 65 and
Older)
capsule: 50mg, (High Risk Med for
Ages 65 and Older)
capsule: 25mg, (High Risk Med for
Ages 65 and Older)
capsule er, (High Risk Med for
Ages 65 and Older)
cartridge: 30mg/ml
tablet, vial: 60mg/2ml
cartridge: 15mg/ml
vial: 15mg/ml
tablet
oral susp
tablet
oral susp, tablet dr
(Topical Gel)
Anesthetics
Local Anesthetics
cocaine hcl
lidocaine hcl/pf
2
2
lidocaine hcl
lidocaine hcl
2
2
lidocaine hcl
lidocaine/prilocaine
lidocaine
LIDODERM
2
2
2
2
PA BvD
PA BvD
PA BvD
PA BvD
11
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
ampul: 15mg/ml, 40mg/ml, (PA for
ESRD Only)
disp syrin, solution: 4%
jel (ml), jel/pf app, solution: 2%,
40mg/ml
vial, (PA for ESRD Only)
(PA for ESRD Only)
oint. (g), (PA for ESRD Only)
Effective: November 01, 2014
Drug Name
Drug Tier
Requirements/Limits
Anti-addiction/substance Abuse Treatment Agents
Anti-addiction/substance Abuse Treatment Agents
acamprosate calcium
2
buprenorphine hcl/naloxone hcl
2
PA, QL: 90 in 30 days
buprenorphine hcl
2
PA, QL: 90 in 30 days
CAMPRAL
4
CHANTIX
3
QL: 168 in 84 days
CHANTIX
3
QL: 53 in 28 days
CHANTIX
3
QL: 56 in 28 days
disulfiram
2
naloxone hcl
2
naloxone hcl
2
naltrexone hcl
2
NICOTROL
4
QL: 2016 in 365 days
SUBOXONE
4
PA, QL: 60 in 30 days
SUBOXONE
4
PA, QL: 90 in 30 days
ZUBSOLV
3
PA, QL: 90 in 30 days
Benzodiazepines
alprazolam
alprazolam
chlordiazepoxide hcl
clonazepam
clonazepam
2
2
2
2
2
QL: 60 in 30 days
QL: 90 in 30 days
QL: 120 in 30 days
QL: 300 in 30 days
QL: 90 in 30 days
clorazepate dipotassium
clorazepate dipotassium
DIASTAT ACUDIAL
diazepam
diazepam
diazepam
diazepam
estazolam
flurazepam hcl
lorazepam
lorazepam
lorazepam
midazolam hcl/pf
midazolam hcl
midazolam hcl
ONFI
2
2
4
2
2
2
2
2
2
2
2
2
2
2
2
4
QL: 120 in 30 days
QL: 60 in 30 days
ONFI
ONFI
temazepam
triazolam
4
4
2
2
tab ds pk
tablet: 0.5mg, 1mg
tab ds pk
tablet: 1mg
syringe: 0.4mg/ml; vial
syringe: 1mg/ml
film: 12mg-3mg
film: 2mg-0.5mg, 4mg-1mg, 8mg2mg
Antianxiety Agents
QL: 120 in 30 days
QL: 1200 in 30 days
QL: 2 in 28 days
QL: 30 in 30 days
QL: 30 in 30 days
QL: 150 in 30 days
QL: 2 in 30 days
QL: 90 in 30 days
QL: 2 in 30 days
QL: 10 in 30 days
QL: 2 in 30 days
PA NSO, QL: 480 in 30
days
PA NSO, QL: 60 in 30 days
PA NSO, QL: 60 in 30 days
QL: 30 in 30 days
QL: 30 in 30 days
12
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
tab er 24h: 1mg, 2mg, 3mg
tab er 24h: 0.5mg; tab rapdis, tablet
tab rapdis: 2mg; tablet: 2mg
tab rapdis: 0.125mg, 0.25mg,
0.5mg, 1mg; tablet: 0.5mg, 1mg
tablet: 15mg
tablet: 3.75mg, 7.5mg
kit
tablet
oral conc, solution
syringe
oral conc
syringe, vial
tablet
syrup
syringe
oral susp
tablet: 10mg, 20mg
tablet: 5mg
Effective: November 01, 2014
Drug Name
Drug Tier
Requirements/Limits
Antibacterials
Aminoglycosides
BETHKIS
gentamicin in nacl, iso-osm
gentamicin in nacl, iso-osm
5
2
2
gentamicin sulfate/pf
gentamicin sulfate
kanamycin sulfate
neomycin sulfate
streptomycin sulfate
TOBI PODHALER
tobramycin in 0.225% nacl
tobramycin sulfate
tobramycin/sodium chloride
tobramycin/sodium chloride
Antibacterials, Miscellaneous
bacitracin
chloramphenicol sod succ
clindamycin hcl
clindamycin palmitate hcl
clindamycin phosphate/d5w
clindamycin phosphate
colistin (colistimethate na)
CUBICIN
FUROXONE
methenamine hippurate
nitrofurantoin macrocrystal
2
2
2
2
2
5
5
2
2
2
nitrofurantoin
2
polymyxin b sulfate
SYNERCID
trimethoprim
vancomycin hcl/d5w
vancomycin hcl
vancomycin hcl
VANCOMYCIN HCL
vancomycin hcl
ZYVOX
2
5
2
2
2
2
4
5
5
2
2
2
2
2
2
2
5
3
2
2
PA BvD
piggyback: 100mg/50ml
piggyback: 60mg/50ml, 70mg/50ml,
80mg/100ml, 80mg/50ml, 90mg/
100ml, 100mg/0.1l
QL: 224 in 28 days
PA BvD
piggyback: 60mg/50ml
piggyback: 80mg/100ml
vial port
PA BvD
(PA for ESRD Only)
PA, QL: 120 in 30 days
(High Risk Med. QL applies to all
members; PA required for 65 years
and older with over 90 days
cumulative use of nitrofurantoin
drugs)
(High Risk Med. QL applies to all
members; PA required for 65 years
and older with over 90 days
cumulative use of nitrofurantoin
drugs)
PA, QL: 2400 in 30 days
PA BvD
PA BvD
13
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
vial: 1g, 10g, (PA for ESRD Only)
vial: 750mg, (PA for ESRD Only)
capsule
Effective: November 01, 2014
Drug Name
Cephalosporins
cefaclor
cefadroxil
cefazolin sodium/dextrose,iso
cefazolin sodium/dextrose,iso
cefazolin sodium
cefdinir
cefditoren pivoxil
cefditoren pivoxil
cefepime hcl
CEFEPIME
CEFEPIME-DEXTROSE
cefotaxime sodium
cefotetan disod/dextrose,iso
cefotetan disodium
cefoxitin sodium/dextrose,iso
cefoxitin sodium
cefpodoxime proxetil
cefprozil
ceftazidime pentahydrate
ceftazidime pentahydrate
ceftibuten dihydrate
ceftriaxone na/dextrose,iso
ceftriaxone sodium
cefuroxime axetil
cefuroxime sodium/dextrose,iso
cefuroxime sodium
cephalexin
cephalexin
SUPRAX
TAZICEF IN DEXTROSE
tea tree oil
Macrolides
azithromycin
clarithromycin
DIFICID
ery e-succ/sulfisoxazole
ERY-TAB
ERYTHROCIN
LACTOBIONATE
ERYTHROCIN
LACTOBIONATE
erythromycin base
erythromycin base
erythromycin ethylsuccinate
erythromycin ethylsuccinate
erythromycin stearate
Drug Tier
Requirements/Limits
2
2
2
2
2
2
2
2
2
4
4
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
froz.piggy
piggyback
tablet: 200mg
tablet: 400mg
vial
vial port
tablet
capsule: 250mg, 500mg; susp
recon, tablet
capsule: 750mg
tab chew, tablet
1
4
4
1
2
2
5
2
2
4
QL: 20 in 10 days
vial port: 1g
4
vial port: 500mg
2
2
2
2
2
capsule dr
tablet, tablet dr
susp recon
tablet
14
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
Effective: November 01, 2014
Drug Name
Drug Tier
KETEK
Miscellaneous B-lactam Antibiotics
aztreonam
CAYSTON
imipenem/cilastatin sodium
INVANZ
INVANZ
meropenem
Penicillins
amoxicillin trihydrate
amoxicillin/potassium clav
amoxicillin
ampicillin sodium/sulbactam na
ampicillin sodium/sulbactam na
ampicillin sodium
ampicillin sodium
ampicillin trihydrate
BICILLIN C-R
BICILLIN L-A
dicloxacillin sodium
NAFCILL IN DEXTROSE
nafcillin sodium
nafcillin sodium
oxacillin sodium/dextrose,iso
oxacillin sodium
pen g pot/dextrose-water
pen g pot/dextrose-water
penicillin g potassium/d5w
penicillin g potassium
penicillin g procaine
penicillin g procaine
penicillin v potassium
piperacillin sodium/tazobactam
Quinolones
AVELOX ABC PACK
AVELOX IV
ciprofloxacin hcl
ciprofloxacin lactate/d5w
ciprofloxacin lactate
ciprofloxacin/ciprofloxa hcl
ciprofloxacin
levofloxacin/d5w
levofloxacin
levofloxacin
moxifloxacin hcl
nalidixic acid
ofloxacin
4
2
5
2
4
4
2
Requirements/Limits
ST
LA
1
2
1
2
2
2
2
1
4
4
2
2
2
2
2
2
2
2
2
2
2
2
2
2
3
4
1
2
2
2
2
2
1
2
2
2
2
15
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
vial
vial port
capsule, susp recon, tab chew,
tablet
vial
vial port
vial
vial port
vial
vial port
froz.piggy: 1mm/50ml
froz.piggy: 2mm/50ml, 3mm/50ml
syringe: 1.2mm/2ml
syringe: 600000/ml
tablet
solution, vial
Effective: November 01, 2014
Drug Name
Sulfonamides
sulfadiazine
sulfamethoxazole/trimethoprim
sulfamethoxazole/trimethoprim
sulfasalazine
Tetracyclines
demeclocycline hcl
doxycycline hyclate
doxycycline hyclate
doxycycline monohydrate
doxycycline monohydrate
MINOCIN
minocycline hcl
tetracycline hcl
TYGACIL
Drug Tier
Requirements/Limits
2
1
2
2
tablet
oral susp, vial
2
2
2
2
2
capsule dr, tablet: 100mg
capsule, tablet: 20mg; tablet dr, vial
capsule: 150mg
capsule: 75mg, 100mg; susp recon,
tablet
vial
5
2
2
5
Anticancer Agents
Anticancer Agents
ABRAXANE
ADCETRIS
AFINITOR DISPERZ
5
5
5
AFINITOR
ALIMTA
anastrozole
ARRANON
ARZERRA
AVASTIN
azacitidine
BELEODAQ
BEXXAR
bicalutamide
BICNU
bleomycin sulfate
BOSULIF
5
5
2
5
5
5
5
5
5
2
4
2
5
BOSULIF
BUSULFEX
CAPRELSA
CAPRELSA
carboplatin
CEENU
CEENU
cisplatin
cladribine
CLOLAR
COMETRIQ
5
5
5
5
2
3
3
2
2
5
5
PA NSO, QL: 3 in 21 days
PA NSO, QL: 112 in 28
days
PA NSO, QL: 28 in 28 days
PA NSO
PA NSO, QL: 80 in 30 days
PA NSO
PA NSO
PA BvD
PA NSO, QL: 120 in 30
tablet: 100mg
days
PA NSO, QL: 30 in 30 days tablet: 500mg
PA NSO, QL: 30 in 30 days tablet: 300mg
PA NSO, QL: 60 in 30 days tablet: 100mg
capsule: 100mg
capsule: 10mg, 40mg
PA BvD
PA NSO, QL: 112 in 28
days
16
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
Effective: November 01, 2014
Drug Name
cyclophosphamide
cyclophosphamide
CYCLOPHOSPHAMIDE
CYRAMZA
cytarabine/pf
cytarabine/pf
dacarbazine
dactinomycin
daunorubicin hcl
DAUNOXOME
decitabine
DOCEFREZ
docetaxel
docetaxel
doxorubicin hcl peg-liposomal
doxorubicin hcl
DROXIA
ELIGARD
ELIGARD
ELIGARD
ELIGARD
ELSPAR
EMCYT
epirubicin hcl
ERBITUX
ERIVEDGE
ERWINAZE
ETOPOPHOS
etoposide
exemestane
FARESTON
FASLODEX
FIRMAGON
floxuridine
fludarabine phosphate
fluorouracil
fluorouracil
flutamide
FOLOTYN
GAZYVA
gemcitabine hcl
GILOTRIF
GLEEVEC
GLEEVEC
HALAVEN
HERCEPTIN
HEXALEN
hydroxyurea
Drug Tier
2
2
4
5
2
2
2
2
2
4
5
5
5
5
5
2
3
4
4
4
5
3
3
2
5
5
5
4
2
2
5
5
4
2
5
2
2
2
5
5
5
5
5
5
5
5
5
2
Requirements/Limits
PA BvD, ST
PA BvD
PA BvD, ST
PA NSO
PA BvD
PA BvD
tablet
vial
vial: 1g, 100mg
vial: 500mg
vial: 20mg/2ml, 20mg/ml(1)
vial: fnl20mg/2
PA BvD
PA BvD
vial: 10mg
QL: 1 in 112 days
QL: 1 in 28 days
QL: 1 in 84 days
QL: 1 in 168 days
syringe: 30mg
syringe: 7.5mg
syringe: 22.5mg
syringe: 45mg
PA NSO
PA NSO, QL: 30 in 30 days
PA NSO, QL: 60 in 30 days
PA NSO
PA BvD
PA BvD
PA BvD
vial: 1g/20ml
vial: 500mg/10ml
PA NSO
PA NSO, QL: 30 in 30 days
PA NSO, QL: 60 in 30 days tablet: 400mg
PA NSO, QL: 90 in 30 days tablet: 100mg
PA NSO, QL: 24 in 28 days
PA NSO
17
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
Effective: November 01, 2014
Drug Name
Drug Tier
ICLUSIG
ICLUSIG
idarubicin hcl
ifosfamide/mesna
ifosfamide
IMBRUVICA
5
5
2
5
2
5
INLYTA
5
INLYTA
irinotecan hcl
ISTODAX
IXEMPRA
JAKAFI
JEVTANA
KADCYLA
KYPROLIS
letrozole
LEUKERAN
leuprolide acetate
lomustine
LUPRON DEPOT
LUPRON DEPOT
LUPRON DEPOT
LUPRON DEPOT-PED
LUPRON DEPOT-PED
LYSODREN
MARQIBO
MATULANE
MEGACE ES
megestrol acetate
MEKINIST
MEKINIST
melphalan hcl
mercaptopurine
methotrexate sodium/pf
methotrexate sodium
methotrexate sodium
mitomycin
mitoxantrone hcl
MUSTARGEN
NEXAVAR
5
5
5
5
5
5
5
5
2
4
2
2
5
5
5
5
5
3
5
5
3
2
5
5
5
2
2
2
2
2
2
3
5
NILANDRON
ONCASPAR
ONTAK
oxaliplatin
paclitaxel
3
5
5
5
2
Requirements/Limits
PA NSO, QL: 30 in 30 days tablet: 45mg
PA NSO, QL: 60 in 30 days tablet: 15mg
PA BvD
kit: 1g-1g, 3g-1g
PA BvD
PA NSO, QL: 120 in 30
days
PA NSO, QL: 180 in 30
tablet: 1mg
days
PA NSO, QL: 60 in 30 days tablet: 5mg
PA NSO
PA NSO, QL: 60 in 30 days
PA NSO, QL: 2 in 21 days
PA NSO, QL: 6 in 21 days
PA NSO
QL: 2 in 28 days
QL: 1 in 168 days
QL: 1 in 28 days
QL: 1 in 84 days
QL: 1 in 112 days
QL: 1 in 28 days
syringekit: 45mg
syringekit: 3.75mg
syringekit: 11.25mg, 22.5mg
syringekit: 30mg
kit, syringekit: 11.25mg
PA NSO, QL: 4 in 28 days
PA NSO, QL: 30 in 30 days tablet: 2mg
PA NSO, QL: 90 in 30 days tablet: 0.5mg
PA BvD
PA BvD, ST
PA BvD
PA BvD
tablet
vial
PA NSO, QL: 120 in 30
days
18
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
Effective: November 01, 2014
Drug Name
Drug Tier
pentostatin
PERJETA
POMALYST
PROLEUKIN
PURIXAN
REVLIMID
5
5
5
5
5
5
RITUXAN
SOLTAMOX
SPRYCEL
STIVARGA
SUTENT
SYLVANT
SYLVANT
SYNRIBO
TABLOID
TAFINLAR
5
4
5
5
5
5
5
5
3
5
tamoxifen citrate
TARCEVA
TARGRETIN
2
5
5
TASIGNA
5
TEMODAR
teniposide
thiotepa
topotecan hcl
TORISEL
TREANDA
TRELSTAR
TRELSTAR
TRELSTAR
tretinoin
TREXALL
TRISENOX
TYKERB
VALSTAR
VECTIBIX
VELCADE
vinblastine sulfate
vincristine sulfate
vinorelbine tartrate
VOTRIENT
5
2
2
5
5
5
5
5
5
5
4
5
5
5
5
5
2
2
2
5
VUMON
XALKORI
4
5
Requirements/Limits
PA NSO, QL: 14 in 21 days
PA NSO, QL: 21 in 28 days
LA, PA NSO, QL: 28 in 28
days
PA NSO
PA NSO, QL: 30 in 30 days
PA NSO, QL: 84 in 28 days
PA NSO, QL: 30 in 30 days
PA NSO
vial: 100mg
PA NSO
vial: 400mg
PA NSO, QL: 28 in 28 days
PA NSO, QL: 120 in 30
days
PA NSO, QL: 30 in 30 days
PA NSO, QL: 420 in 30
days
PA NSO, QL: 112 in 28
days
PA NSO
(vial only)
PA BvD, QL: 4 in 28 days
QL: 1 in 168 days
QL: 1 in 28 days
QL: 1 in 84 days
vial
syringe: 3.75mg/2ml
syringe: 11.25/2ml
(capsule: 10mg)
PA BvD, ST
PA NSO
PA NSO
PA BvD
PA BvD
PA NSO, QL: 120 in 30
days
PA NSO, QL: 60 in 30 days
19
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
Effective: November 01, 2014
Drug Name
Drug Tier
XTANDI
5
YERVOY
ZALTRAP
ZANOSAR
ZELBORAF
5
5
3
5
ZOLADEX
ZOLADEX
ZOLINZA
ZYDELIG
ZYKADIA
4
4
5
5
5
ZYTIGA
5
Requirements/Limits
PA NSO, QL: 120 in 30
days
PA NSO
PA NSO
PA NSO, QL: 240 in 30
days
QL: 1 in 28 days
QL: 1 in 84 days
implant: 3.6mg
implant: 10.8mg
PA NSO, QL: 60 in 30 days
PA NSO, QL: 140 in 28
days
PA NSO, QL: 120 in 30
days
Anticholinergic Agents
Antimuscarinics/antispasmodics
ANORO ELLIPTA
atropine sulfate
atropine sulfate
propantheline bromide
3
2
2
2
QL: 60 in 30 days
4
4
2
3
3
2
2
2
2
3
2
3
4
2
2
2
2
4
3
3
2
4
3
2
ST
ST
syringe
vial
Anticonvulsants
Anticonvulsants
APTIOM
BANZEL
carbamazepine
CELONTIN
DILANTIN
divalproex sodium
ethosuximide
felbamate
fosphenytoin sodium
FYCOMPA
gabapentin
GABITRIL
LAMICTAL
lamotrigine
lamotrigine
levetiracetam in nacl (iso-os)
levetiracetam
LUMINAL SODIUM
LYRICA
LYRICA
oxcarbazepine
OXTELLAR XR
PEGANONE
phenobarbital sodium
capsule: 30mg
ST
tablet: 12mg, 16mg
tb chw dsp: 2mg
tab ds pk
tab er 24, tablet, tb chw dsp
QL: 2 in 30 days
QL: 90 in 30 days
QL: 900 in 30 days
syringe
capsule
solution
ST
QL: 2 in 30 days
20
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
vial: 65mg/ml, 130mg/ml
Effective: November 01, 2014
Drug Name
Drug Tier
phenobarbital
phenobarbital
phenobarbital
2
2
2
PHENYTEK
phenytoin sodium extended
phenytoin sodium
phenytoin sodium
phenytoin
POTIGA
POTIGA
primidone
QUDEXY XR
SABRIL
TEGRETOL XR
tiagabine hcl
topiramate
topiramate
TRILEPTAL
TROKENDI XR
valproic acid (as sodium salt)
valproic acid
VIMPAT
VIMPAT
VIMPAT
zonisamide
3
2
2
2
2
4
4
2
4
5
3
2
2
2
4
4
2
2
4
4
4
2
Requirements/Limits
QL: 1500 in 30 days
QL: 200 in 30 days
QL: 90 in 30 days
elixir: 20mg/5ml
tablet: 30mg
tablet: 15mg, 16.2mg, 32.4mg,
60mg, 64.8mg, 97.2mg, 100mg
ampul
syringe
ST, QL: 270 in 30 days
ST, QL: 90 in 30 days
tablet: 50mg
tablet: 200mg, 300mg, 400mg
ST
tab er 12h: 100mg
cap spr 24
cap sprink, tablet
oral susp
ST
ST, QL: 1200 in 30 days
ST, QL: 200 in 5 days
ST, QL: 60 in 30 days
solution
vial
tablet
QL: 30 in 30 days
QL: 30 in 30 days
QL: 232 in 30 days
QL: 200 in 30 days
QL: 30 in 30 days
QL: 60 in 30 days
QL: 28 in 28 days
QL: 30 in 30 days
QL: 360 in 30 days
QL: 49 in 28 days
QL: 60 in 30 days
QL: 60 in 30 days
patch td24
solution
solution
cap24h pel
tablet
cap24 dspk
cap spr 24
solution
tab ds pk
tablet
Antidementia Agents
Antidementia Agents
donepezil hcl
EXELON
EXELON
galantamine hbr
galantamine hbr
galantamine hbr
NAMENDA XR
NAMENDA XR
NAMENDA
NAMENDA
NAMENDA
rivastigmine tartrate
2
3
4
2
2
2
3
3
3
3
3
2
21
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
Effective: November 01, 2014
Drug Name
Drug Tier
Requirements/Limits
Antidepressants
Antidepressants
amitriptyline hcl
2
amoxapine
BRINTELLIX
bupropion hcl
citalopram hydrobromide
citalopram hydrobromide
clomipramine hcl
2
4
2
1
2
2
desipramine hcl
DESVENLAFAXINE ER
doxepin hcl
2
4
2
duloxetine hcl
duloxetine hcl
EMSAM
escitalopram oxalate
escitalopram oxalate
FETZIMA
fluoxetine hcl
fluoxetine hcl
fluvoxamine maleate
imipramine hcl
2
2
4
2
2
4
1
2
2
2
QL: 30 in 30 days
QL: 60 in 30 days
QL: 30 in 30 days
QL: 30 in 30 days
QL: 697 in 30 days
ST
imipramine pamoate
2
PA NSO
KHEDEZLA
maprotiline hcl
MARPLAN
mirtazapine
nefazodone hcl
nortriptyline hcl
olanzapine/fluoxetine hcl
paroxetine hcl
PAXIL
perphenazine/amitriptyline hcl
4
2
4
2
2
2
2
2
4
2
ST, QL: 30 in 30 days
phenelzine sulfate
PRISTIQ ER
protriptyline hcl
sertraline hcl
sertraline hcl
SILENOR
tranylcypromine sulfate
trazodone hcl
2
4
2
1
2
3
2
1
PA NSO
(High Risk Med for Ages 65 and
Older)
ST
QL: 30 in 30 days
PA NSO
ST, QL: 30 in 30 days
PA NSO
tablet
solution
(High Risk Med for Ages 65 and
Older)
(High Risk Med for Ages 65 and
Older)
capsule dr: 30mg
capsule dr: 20mg, 60mg
tablet
solution
capsule
capsule dr, solution, tablet
PA NSO
PA NSO
(High Risk Med for Ages 65 and
Older)
(High Risk Med for Ages 65 and
Older)
oral susp
(High Risk Med for Ages 65 and
Older)
ST, QL: 30 in 30 days
tablet
oral conc
QL: 30 in 30 days
22
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
Effective: November 01, 2014
Drug Name
Drug Tier
Requirements/Limits
trimipramine maleate
2
PA NSO
VENLAFAXINE HCL ER
VENLAFAXINE HCL ER
venlafaxine hcl
VIIBRYD
2
4
2
4
PA NSO, QL: 30 in 30 days
Antidiabetic Agents, Miscellaneous
acarbose
BYDUREON PEN
BYDUREON
BYETTA
BYETTA
CYCLOSET
GLYSET
INVOKAMET
INVOKAMET
2
3
3
4
4
4
4
3
3
QL: 90 in 30 days
ST, QL: 4 in 28 days
ST, QL: 4 in 28 days
ST, QL: 1.2 in 28 days
ST, QL: 2.4 in 28 days
QL: 180 in 30 days
QL: 90 in 30 days
ST, QL: 120 in 30 days
ST, QL: 60 in 30 days
INVOKANA
INVOKANA
JANUMET XR
3
3
3
ST, QL: 30 in 30 days
ST, QL: 60 in 30 days
QL: 30 in 30 days
JANUMET XR
JANUMET
JANUVIA
JENTADUETO
JUVISYNC
KORLYM
metformin hcl
metformin hcl
metformin hcl
metformin hcl
metformin hcl
metformin hcl
nateglinide
PRANDIMET
repaglinide
SYMLIN
SYMLINPEN 120
SYMLINPEN 60
TANZEUM
TRADJENTA
Insulins
HUMALOG MIX 50-50
HUMALOG MIX 50-50
HUMALOG MIX 75-25
HUMALOG MIX 75-25
HUMALOG
3
3
3
3
3
5
1
1
1
2
2
2
2
3
2
4
4
4
3
3
QL: 60 in 30 days
QL: 60 in 30 days
QL: 30 in 30 days
QL: 60 in 30 days
QL: 30 in 30 days
PA, QL: 112 in 28 days
QL: 150 in 30 days
QL: 60 in 30 days
QL: 90 in 30 days
QL: 120 in 30 days
QL: 60 in 30 days
QL: 90 in 30 days
QL: 90 in 30 days
QL: 150 in 30 days
QL: 240 in 30 days
PA, QL: 20 in 28 days
PA, QL: 10.8 in 28 days
PA, QL: 6 in 28 days
ST
QL: 30 in 30 days
(High Risk Med for Ages 65 and
Older)
tab er 24: 37.5mg, 75mg, 150mg
tab er 24: 225mg
Antidiabetic Agents
3
3
3
3
3
QL: 30 in 28 days
QL: 40 in 28 days
QL: 30 in 28 days
QL: 40 in 28 days
QL: 30 in 28 days
23
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
pen injctr: 5mcg/0.02
pen injctr: 10mcg/0.04
tablet: 50mg-500mg
tablet: 50-1000mg, 150-1000mg,
150-500mg
tablet: 300mg
tablet: 100mg
tbmp 24hr: 50mg-500mg, 1001000mg
tbmp 24hr: 50-1000mg
tablet: 500mg
tablet: 1000mg
tablet: 850mg
tab er 24h: 500mg
tab er 24
tab er 24h: 750mg
insuln pen
vial
insuln pen
vial
cartridge
Effective: November 01, 2014
Drug Name
Drug Tier
Requirements/Limits
HUMALOG
HUMULIN 70-30
HUMULIN 70-30
HUMULIN N
HUMULIN N
HUMULIN R
LANTUS SOLOSTAR
LANTUS
LEVEMIR FLEXPEN
LEVEMIR
NOVOLIN 70-30
NOVOLIN 70-30
NOVOLIN N
NOVOLIN N
NOVOLIN R
NOVOLIN R
NOVOLOG FLEXPEN
NOVOLOG MIX 70-30
FLEXPEN
NOVOLOG MIX 70-30
NOVOLOG
Sulfonylureas
glimepiride
glimepiride
glipizide/metformin hcl
glipizide/metformin hcl
glipizide
glipizide
glipizide
glipizide
glyburide,micronized
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
QL: 40 in 28 days
QL: 30 in 28 days
QL: 40 in 28 days
QL: 30 in 28 days
QL: 40 in 28 days
QL: 40 in 28 days
QL: 30 in 28 days
QL: 40 in 28 days
ST, QL: 30 in 28 days
ST, QL: 40 in 28 days
QL: 30 in 28 days
QL: 40 in 28 days
QL: 30 in 28 days
QL: 40 in 28 days
QL: 30 in 28 days
QL: 40 in 28 days
QL: 30 in 28 days
QL: 30 in 28 days
3
3
QL: 40 in 28 days
QL: 40 in 28 days
1
1
2
2
1
1
2
2
2
QL: 30 in 30 days
QL: 60 in 30 days
QL: 120 in 30 days
QL: 240 in 30 days
QL: 120 in 30 days
QL: 60 in 30 days
QL: 30 in 30 days
QL: 60 in 30 days
PA, QL: 30 in 30 days
glyburide,micronized
2
PA, QL: 60 in 30 days
glyburide/metformin hcl
2
PA, QL: 120 in 30 days
glyburide/metformin hcl
2
PA, QL: 240 in 30 days
glyburide
2
PA, QL: 120 in 30 days
glyburide
2
PA, QL: 30 in 30 days
tolazamide
tolazamide
tolbutamide
Thiazolidinediones
ACTOPLUS MET XR
2
2
2
QL: 120 in 30 days
QL: 60 in 30 days
QL: 180 in 30 days
3
QL: 60 in 30 days
24
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
vial
insuln pen
vial
insuln pen
vial
cartridge
vial
cartridge
vial
cartridge
vial
tablet: 1mg, 2mg
tablet: 4mg
tablet: 2.5-500mg, 5mg-500mg
tablet: 2.5-250mg
tablet: 10mg
tablet: 5mg
tab er 24: 2.5mg, 5mg
tab er 24: 10mg
tablet: 1.5mg, 3mg, (High Risk Med
for Ages 65 and Older)
tablet: 6mg, (High Risk Med for
Ages 65 and Older)
tablet: 2.5-500mg, 5mg-500mg,
(High Risk Med for Ages 65 and
Older)
tablet: 1.25-250mg, (High Risk Med
for Ages 65 and Older)
tablet: 5mg, (High Risk Med for
Ages 65 and Older)
tablet: 1.25mg, 2.5mg, (High Risk
Med for Ages 65 and Older)
tablet: 250mg
tablet: 500mg
Effective: November 01, 2014
Drug Name
AVANDAMET
AVANDARYL
AVANDIA
pioglitazone hcl/glimepiride
pioglitazone hcl/metformin hcl
pioglitazone hcl
Drug Tier
Requirements/Limits
4
4
4
2
2
2
PA, QL: 60 in 30 days
PA, QL: 30 in 30 days
PA, QL: 30 in 30 days
QL: 30 in 30 days
QL: 90 in 30 days
QL: 30 in 30 days
5
2
5
2
2
2
2
2
5
4
2
1
2
5
2
2
2
2
5
5
2
2
4
2
2
5
PA BvD
PA BvD
Antihistamines
carbinoxamine maleate
carbinoxamine maleate
2
2
PA
PA
clemastine fumarate
clemastine fumarate
2
2
PA
PA
clemastine fumarate
2
PA
cyproheptadine hcl
2
PA
diphenhydramine hcl
2
Antifungals
Antifungals
ABELCET
amphotericin b
CANCIDAS
ciclopirox olamine
ciclopirox
clotrimazole/betamethasone dip
clotrimazole
econazole nitrate
ERAXIS (WATER DILUENT)
EXELDERM
fluconazole in nacl,iso-osm
fluconazole
fluconazole
flucytosine
griseofulvin ultramicrosize
griseofulvin, microsize
itraconazole
ketoconazole
NOXAFIL
NOXAFIL
nystatin/triamcin
nystatin
SPORANOX
terbinafine hcl
voriconazole
voriconazole
tablet
susp recon
oral susp, tablet dr
vial
solution
vial
susp recon, tablet
Antihistamines
25
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
liquid: 4mg/5ml; tablet: 4mg
liquid: 4mg/5ml; tablet: 4mg, (High
Risk Med for Ages 65 and Older)
syrup, tablet: 2.68mg
syrup, tablet: 2.68mg, (High Risk
Med for Ages 65 and Older)
tablet: 1.34mg, (High Risk Med for
Ages 65 and Older)
(High Risk Med for Ages 65 and
Older)
syringe
Effective: November 01, 2014
Drug Name
Drug Tier
diphenhydramine hcl
levocetirizine dihydrochloride
p-epd tan/chlor-tan
promethazine hcl
2
2
2
2
tripelennamine hcl
2
Requirements/Limits
vial
PA
(High Risk Med for Ages 65 and
Older)
QL: 30 in 28 days
QL: 4 in 28 days
QL: 40 in 28 days
QL: 18 in 28 days
QL: 18 in 28 days
QL: 18 in 28 days
QL: 4 in 28 days
QL: 4 in 28 days
QL: 12 in 28 days
QL: 12 in 28 days
ampul
spray/pump
Anti-infectives (Skin and Mucous Membrane)
Anti-infectives (Skin and Mucous Membrane)
AVC
3
clindamycin phosphate
2
metronidazole
2
miconazole nitrate
2
sod propion/inositol/aa14/urea
2
terconazole
2
Antimigraine Agents
Antimigraine Agents
dihydroergotamine mesylate
dihydroergotamine mesylate
ERGOMAR
naratriptan hcl
rizatriptan benzoate
sumatriptan succinate
sumatriptan succinate
sumatriptan succinate
sumatriptan
zolmitriptan
2
2
3
2
2
2
2
2
2
2
tablet
cartridge: 4mg/0.5ml
cartridge: 6mg/0.5ml; vial
Antimycobacterials
Antimycobacterials
CAPASTAT SULFATE
dapsone
ethambutol hcl
isoniazid
isoniazid
PASER
PRIFTIN
rifabutin
rifampin
RIFATER
SEROMYCIN
SIRTURO
TRECATOR
4
2
2
1
2
4
4
2
2
4
4
5
4
tablet
solution, vial
PA, QL: 188 in 168 days
Antinausea Agents
Antinausea Agents
CESAMET
dimenhydrinate
dronabinol
EMEND
4
2
2
4
QL: 180 in 30 days
PA BvD, QL: 1 per fill
26
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
capsule: 40mg, 125mg
Effective: November 01, 2014
Drug Name
EMEND
EMEND
EMEND
granisetron hcl/pf
granisetron hcl
granisetron hcl
granisetron hcl
meclizine hcl
ondansetron hcl
ondansetron hcl
ondansetron
prochlorperazine edisylate
prochlorperazine maleate
prochlorperazine maleate
promethazine hcl
promethazine hcl
Drug Tier
4
4
4
2
2
2
2
2
2
2
2
2
1
2
2
2
Requirements/Limits
PA BvD, QL: 2 per fill
PA BvD, QL: 3 per fill
QL: 2 in 28 days
capsule: 80mg
cap ds pk
vial
PA BvD
PA BvD
vial
solution
tablet
PA BvD
PA BvD
PA
PA
vial
solution, tablet
tablet
supp.rect
supp.rect, tablet
supp.rect, tablet, (High Risk Med
for Ages 65 and Older)
Antiparasite Agents
Antiparasite Agents
ALBENZA
ALINIA
atovaquone/proguanil hcl
atovaquone
BILTRICIDE
COARTEM
DARAPRIM
HALFAN
hydroxychloroquine sulfate
mefloquine hcl
metronidazole/sodium chloride
metronidazole
NEBUPENT
paromomycin sulfate
PENTAM 300
pentamidine isethionate
PRIMAQUINE
quinine sulfate
STROMECTOL
tinidazole
4
4
2
5
4
4
4
4
2
2
2
2
4
2
4
2
4
2
3
2
PA BvD
QL: 90 in 30 days
PA, QL: 42 in 30 days
Antiparkinsonian Agents
Antiparkinsonian Agents
amantadine hcl
APOKYN
AZILECT
benztropine mesylate
benztropine mesylate
2
5
3
1
1
QL: 60 in 30 days
PA
PA
27
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
tablet
tablet, (High Risk Med for Ages 65
and Older)
Effective: November 01, 2014
Drug Name
Drug Tier
benztropine mesylate
2
bromocriptine mesylate
cabergoline
carbidopa/levodopa/entacapone
carbidopa/levodopa
carbidopa
entacapone
NEUPRO
pramipexole di-hcl
ropinirole hcl
selegiline hcl
trihexyphenidyl hcl
2
2
2
2
2
2
3
2
2
2
2
Requirements/Limits
PA
vial, (High Risk Med for Ages 65
and Older)
ST, QL: 30 in 30 days
PA
(High Risk Med for Ages 65 and
Older)
tab rapdis: 15mg
tab rapdis: 10mg
Antipsychotic Agents
Antipsychotic Agents
ABILIFY DISCMELT
ABILIFY DISCMELT
ABILIFY MAINTENA
ABILIFY
ABILIFY
3
3
5
3
3
ST, QL: 60 in 30 days
ST, QL: 90 in 30 days
QL: 1 in 28 days
ST, QL: 161.2 in 28 days
ST, QL: 30 in 30 days
ABILIFY
ABILIFY
ADASUVE
chlorpromazine hcl
chlorpromazine hcl
clozapine
clozapine
clozapine
clozapine
FANAPT
FANAPT
FAZACLO
FAZACLO
fluphenazine decanoate
fluphenazine hcl
GEODON
haloperidol decanoate
haloperidol lactate
haloperidol
INVEGA SUSTENNA
INVEGA SUSTENNA
INVEGA SUSTENNA
INVEGA SUSTENNA
INVEGA SUSTENNA
INVEGA
INVEGA
3
3
5
2
2
2
2
2
2
4
4
4
4
2
2
4
2
2
2
3
3
5
5
5
4
4
ST, QL: 60 in 30 days
ST, QL: 900 in 30 days
vial
tablet: 5mg, 10mg, 15mg, 20mg,
30mg
tablet: 2mg
solution
QL: 135 in 30 days
QL: 270 in 30 days
QL: 90 in 30 days
ST, QL: 90 in 30 days
ST, QL: 60 in 30 days
ST, QL: 8 in 28 days
ST, QL: 120 in 30 days
ST, QL: 180 in 30 days
ampul, tablet
oral conc.
tablet: 200mg
tablet: 100mg
tablet: 25mg, 50mg
tab rapdis
tablet
tab ds pk
tab rapdis: 200mg
tab rapdis: 150mg
QL: 6 in 28 days
vial
QL: 0.25 in 28 days
QL: 0.5 in 28 days
QL: 0.75 in 28 days
QL: 1 in 28 days
QL: 1.5 in 28 days
ST, QL: 30 in 30 days
ST, QL: 60 in 30 days
28
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
syringe: 39mg/0.25
syringe: 78mg/0.5ml
syringe: 117mg/0.75
syringe: 156mg/ml
syringe: 234mg/1.5
tab er 24: 1.5mg, 3mg, 9mg
tab er 24: 6mg
Effective: November 01, 2014
Drug Name
Drug Tier
Requirements/Limits
LATUDA
LATUDA
loxapine succinate
MOBAN
olanzapine
4
4
2
4
2
ST, QL: 30 in 30 days
ST, QL: 60 in 30 days
tablet: 20mg, 40mg, 60mg, 120mg
tablet: 80mg
QL: 30 in 30 days
olanzapine
ORAP
perphenazine
quetiapine fumarate
RISPERDAL CONSTA
risperidone
risperidone
risperidone
2
4
2
2
4
2
2
2
QL: 31 in 30 days
tab rapdis: 5mg, 10mg, 15mg;
tablet, vial
tab rapdis: 20mg
SAPHRIS
SEROQUEL XR
SEROQUEL XR
4
4
4
ST, QL: 60 in 30 days
ST, QL: 30 in 30 days
ST, QL: 60 in 30 days
thioridazine hcl
2
PA NSO
thioridazine hcl
2
PA NSO
thiothixene
trifluoperazine hcl
VERSACLOZ
ziprasidone hcl
ZYPREXA RELPREVV
2
2
5
2
5
ST, QL: 540 in 30 days
QL: 60 in 30 days
QL: 2 in 28 days
QL: 90 in 30 days
QL: 4 in 28 days
QL: 120 in 30 days
QL: 480 in 30 days
QL: 60 in 30 days
tab rapdis: 3mg, 4mg
solution
tab rapdis: 0.25mg, 0.5mg, 1mg,
2mg; tablet
tab er 24h: 200mg
tab er 24h: 50mg, 150mg, 300mg,
400mg
oral conc., (High Risk Med for Ages
65 and Older)
tablet, (High Risk Med for Ages 65
and Older)
Antivirals (systemic)
Antiretrovirals
abacavir sulfate
abacavir/lamivudine/zidovudine
APTIVUS
APTIVUS
ATRIPLA
COMPLERA
CRIXIVAN
didanosine
EDURANT
EMTRIVA
EPIVIR HBV
EPIVIR
EPZICOM
FUZEON
INTELENCE
INTELENCE
INVIRASE
ISENTRESS
2
5
4
5
5
5
4
2
5
3
4
4
5
5
3
5
5
3
29
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
solution
capsule
solution
solution
tablet: 25mg
tablet: 100mg, 200mg
powd pack, tab chew
Effective: November 01, 2014
Drug Name
ISENTRESS
KALETRA
KALETRA
lamivudine/zidovudine
lamivudine
LEXIVA
LEXIVA
nevirapine
NORVIR
PREZISTA
PREZISTA
PREZISTA
PREZISTA
RESCRIPTOR
RETROVIR
REYATAZ
REYATAZ
SELZENTRY
stavudine
STRIBILD
SUSTIVA
SUSTIVA
TIVICAY
TRIUMEQ
TRUVADA
VIDEX
VIRACEPT
VIRAMUNE XR
VIREAD
ZIAGEN
zidovudine
Antivirals, Miscellaneous
foscarnet sodium
RELENZA
rimantadine hcl
SYNAGIS
TAMIFLU
TAMIFLU
TAMIFLU
TAMIFLU
Hcv Protease Inhibitors
INCIVEK
OLYSIO
VICTRELIS
Interferons
ALFERON N
INTRON A
INTRON A
Drug Tier
Requirements/Limits
5
3
5
5
2
3
5
2
4
3
4
5
5
4
3
3
5
5
2
5
4
4
5
5
5
3
4
3
5
4
2
tablet
tablet: 100mg-25mg
solution, tablet: 200mg-50mg
oral susp
tablet
tablet: 75mg, 150mg
oral susp
tablet: 400mg
tablet: 600mg, 800mg
vial
capsule: 100mg
capsule: 150mg, 200mg, 300mg
capsule: 100mg
capsule: 50mg, 200mg; tablet
tab er 24h: 100mg
solution
2
4
2
5
3
3
3
3
PA BvD
5
5
5
PA, QL: 168 in 28 days
PA, QL: 28 in 28 days
PA, QL: 336 in 28 days
5
4
4
QL: 42 in 180 days
QL: 48 in 180 days
QL: 540 in 180 days
QL: 84 in 180 days
PA NSO
PA NSO
30
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
capsule: 75mg
capsule: 45mg
susp recon
capsule: 30mg
pen ij kit, vial: 18mmunit, 50mmunit
vial: 6mmunit/ml, 10mmunit
Effective: November 01, 2014
Drug Name
PEGASYS PROCLICK
PEGASYS
PEGINTRON REDIPEN
PEGINTRON
SYLATRON 4-PACK
Nucleosides And Nucleotides
acyclovir sodium
acyclovir
adefovir dipivoxil
BARACLUDE
BARACLUDE
cidofovir
entecavir
famciclovir
ganciclovir sodium
ribavirin
ribavirin
ribavirin
SOVALDI
TYZEKA
valacyclovir hcl
VALCYTE
Drug Tier
Requirements/Limits
5
5
5
5
5
PA
PA
PA
PA
PA NSO, QL: 1 in 28 days
2
2
5
4
5
5
5
2
2
2
5
5
5
5
2
5
PA BvD
solution
tablet
PA BvD
capsule, tablet
tab ds pk: 200-400mg
tab ds pk: 400-400mg, 600-400mg
PA, QL: 28 in 28 days
tablet
Blood Products/modifiers/volume Expanders
Anticoagulants
CEPROTIN
ELIQUIS
enoxaparin sodium
enoxaparin sodium
enoxaparin sodium
enoxaparin sodium
enoxaparin sodium
enoxaparin sodium
enoxaparin sodium
enoxaparin sodium
fondaparinux sodium
fondaparinux sodium
fondaparinux sodium
fondaparinux sodium
heparin sod,pork in 0.45% nacl
heparin sodium,porcine/d5w
heparin sodium,porcine/d5w
heparin sodium,porcine/ns/pf
heparin sodium,porcine/pf
heparin sodium,porcine/pf
heparin sodium,porcine/pf
heparin sodium,porcine
IPRIVASK
5
3
2
2
2
2
2
5
5
5
2
2
2
2
2
2
2
2
2
2
2
2
5
QL: 13.6 in 30 days
QL: 18 in 30 days
QL: 20.4 in 30 days
QL: 27.2 in 30 days
QL: 36 in 30 days
QL: 27.2 in 30 days
QL: 34 in 30 days
QL: 36 in 30 days
QL: 12 in 30 days
QL: 15 in 30 days
QL: 18 in 30 days
QL: 24 in 30 days
syringe: 40mg/0.4ml
syringe: 30mg/0.3ml
syringe: 60mg/0.6ml
syringe: 80mg/0.8ml
vial
syringe: 120mg/.8ml
syringe: 150mg/ml
syringe: 100mg/ml
syringe: 5mg/0.4ml
syringe: 2.5mg/0.5
syringe: 7.5mg/0.6
syringe: 10mg/0.8ml
iv soln: 12500/250, 25000/500
iv soln: 20k/500ml, 25000/250
PA BvD
PA BvD
PA BvD
PA, QL: 24 in 28 days
31
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
vial port
syringe, (PA for ESRD Only)
vial, (PA for ESRD Only)
(PA for ESRD Only)
Effective: November 01, 2014
Drug Name
Drug Tier
Requirements/Limits
PRADAXA
warfarin sodium
XARELTO
Blood Formation Modifiers
BERINERT
CINRYZE
EPOGEN
GRANIX
LEUKINE
LEUKINE
MOZOBIL
NEULASTA
NEUMEGA
NEUPOGEN
PROCRIT
4
1
3
PA, QL: 60 in 30 days
5
5
3
5
5
5
5
5
5
5
3
PA, QL: 9 in 30 days
PA, QL: 20 in 28 days
PA, QL: 12 in 28 days
PROCRIT
5
PROCRIT
5
PROMACTA
5
Hematologic Agents, Miscellaneous
aminocaproic acid
2
anagrelide hcl
2
protamine sulfate
2
tranexamic acid
2
tranexamic acid
2
Platelet-aggregation Inhibitors
AGGRENOX
4
BRILINTA
3
cilostazol
2
clopidogrel bisulfate
2
EFFIENT
3
pentoxifylline
2
Volume Expanders
ALBUKED-25
4
ALBUKED-5
4
ALBUMIN (HUMAN)
4
ALBUMINAR-25
4
ALBUMINAR-5
4
ALBURX
4
ALBUTEIN
4
BUMINATE
4
FLEXBUMIN
4
KEDBUMIN
4
PLASBUMIN-25
4
PLASBUMIN-5
4
STERILE DILUENT
4
PA, QL: 12 in 28 days
PA, QL: 6 in 28 days
PA, QL: 30 in 30 days
vial: 250mcg
vial: 500mcg/ml
PA, QL: 9.6 per fill
PA, QL: 12 in 28 days
PA BvD
QL: 30 in 30 days
vial: 2000/ml, 3000/ml, 4000/ml,
10000/ml
vial: 20000/ml
vial: 40000/ml
(PA for ESRD Only)
vial
tablet
QL: 60 in 30 days
QL: 30 in 30 days
32
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
Effective: November 01, 2014
Drug Name
Drug Tier
Requirements/Limits
Caloric Agents
Caloric Agents
AMINO ACIDS
AMINOSYN II
AMINOSYN II
AMINOSYN II
AMINOSYN II
AMINOSYN II
AMINOSYN M
AMINOSYN with
ELECTROLYTES
AMINOSYN
AMINOSYN
AMINOSYN
AMINOSYN
AMINOSYN
AMINOSYN-HBC
AMINOSYN-PF
AMINOSYN-PF
AMINOSYN-RF
CLINIMIX E
CLINIMIX E
CLINIMIX E
CLINIMIX E
CLINIMIX E
CLINIMIX E
CLINIMIX E
CLINIMIX E
CLINIMIX E
CLINIMIX
CLINIMIX
CLINIMIX
CLINIMIX
CLINIMIX
CLINIMIX
CLINIMIX
CLINIMIX
CLINISOL
cysteine hcl
dextrose 10 % and 0.2 % nacl
dextrose 10 % and 0.2 % nacl
dextrose 10 % and 0.9 % nacl
dextrose 10%-0.5 normal saline
dextrose 10%-water
dextrose 2.5 % in water
dextrose 2.5% in half ringers
dextrose 2.5%-0.5normal saline
dextrose 20%-water
4
4
4
4
4
4
4
4
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
2
2
2
2
2
2
2
2
2
2
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
iv soln: 10%
iv soln: 15%
iv soln: 7%
iv soln: 8.5%
iv soln: 8.5%
iv soln: 10%
iv soln: 3.5%
iv soln: 7%
iv soln: 8.5%
iv soln: 8.5%
iv soln: 10%
iv soln: 7%
iv soln: 2.75%
iv soln: 2.75%
iv soln: 4.25%
iv soln: 4.25%
iv soln: 4.25%
iv soln: 5%
iv soln: 5%
iv soln: 5%
iv soln: 5%
iv soln: 2.75%
iv soln: 4.25%
iv soln: 4.25%
iv soln: 4.25%
iv soln: 4.25%
iv soln: 5%
iv soln: 5%
iv soln: 5%
dehp fr bg
iv soln
PA BvD
PA BvD
PA BvD
33
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
Effective: November 01, 2014
Drug Name
dextrose 25 % in water
dextrose 40%-water
dextrose 5 % and 0.3 % nacl
dextrose 5 % and 0.9 % nacl
dextrose 5 % in water
dextrose 5 %-0.2 % nacl
dextrose 5 %-0.45 % nacl
dextrose 5% in ringers
dextrose 5%-lactated ringers
dextrose 50 % in water
dextrose 60 % in water
dextrose 70%-water
FREAMINE HBC
FREAMINE III
FREAMINE III
fructose 10%
HEPATAMINE
HEPATASOL
INTRALIPID
INTRALIPID
KABIVEN
LIPOSYN II
LIPOSYN III
LIPOSYN III
NEPHRAMINE
NOVAMINE
PERIKABIVEN
PREMASOL
PREMASOL
PROCALAMINE
PROSOL
QUICK MIX with LYTES
TRAVAMULSION
TRAVASOL W/DEXTROSE
TRAVASOL W/ELECTROLYTES
TRAVASOL W/
ELECTROLYTES
TRAVASOL with DEXTROSE
TRAVASOL with DEXTROSE
TRAVASOL with DEXTROSE
TRAVASOL with ELECTROLYTES
TRAVASOL
TRAVASOL
TRAVASOL
TRAVASOL
TRAVERT IN NORMAL SALINE
TRAVERT
TRAVERT
Drug Tier
2
2
2
2
2
2
2
2
2
2
2
2
4
4
4
2
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
Requirements/Limits
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
34
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
iv soln: 10%
iv soln: 8.5%
emulsion: 10%
emulsion: 20%, 30%
emulsion: 10%, 20%
emulsion: 30%
iv soln: 10%
iv soln: 6%
iv soln.: 5.5%
iv soln.: 8.5%
iv soln: 8.5%
iv soln: 8.5%
iv soln: 8.5%
iv soln.
iv soln: 10%
iv soln: 5.5%
iv soln: 8.5%
iv soln: 10%
iv soln: 5%
Effective: November 01, 2014
Drug Name
TROPHAMINE
TROPHAMINE
Drug Tier
Requirements/Limits
4
4
PA BvD
PA BvD
iv soln: 10%
iv soln: 6%
2
1
2
2
2
2
QL: 4 in 28 days
QL: 8 in 28 days
patch tdwk: 0.1mg/24hr, 0.2mg/24hr
patch tdwk: 0.3mg/24hr
PA
(High Risk Med for Ages 65 and
Older)
Cardiovascular Agents
Alpha-adrenergic Agents
clonidine hcl/chlorthalidone
clonidine hcl
clonidine
clonidine
doxazosin mesylate
guanfacine hcl
midodrine hcl
2
phenylephrine hcl
2
prazosin hcl
2
Angiotensin Ii Receptor Antagonists
BENICAR HCT
3
BENICAR
3
candesartan cilexetil
2
candesartan/hydrochlorothiazid
2
DIOVAN
2
eprosartan mesylate
2
irbesartan/hydrochlorothiazide
2
irbesartan
2
losartan potassium
1
losartan/hydrochlorothiazide
2
telmisartan/hydrochlorothiazid
2
telmisartan
2
TRIBENZOR
3
valsartan/hydrochlorothiazide
2
Angiotensin-converting Enzyme Inhibitors
benazepril hcl
1
benazepril/hydrochlorothiazide
2
captopril/hydrochlorothiazide
2
captopril
1
enalapril maleate
1
enalapril/hydrochlorothiazide
2
enalaprilat dihydrate
2
fosinopril sodium
2
fosinopril/hydrochlorothiazide
2
lisinopril/hydrochlorothiazide
1
lisinopril
1
moexipril hcl
2
moexipril/hydrochlorothiazide
2
perindopril erbumine
2
quinapril hcl
2
quinapril/hydrochlorothiazide
2
ramipril
2
trandolapril
2
35
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
Effective: November 01, 2014
Drug Name
Drug Tier
Antiarrhythmic Agents
amiodarone hcl
amiodarone hcl
disopyramide phosphate
flecainide acetate
lidocaine hcl/d5w/pf
lidocaine hcl/pf
lidocaine hcl/pf
mexiletine hcl
MULTAQ
procainamide hcl
procainamide hcl
PRONESTYL
propafenone hcl
quinidine gluconate
quinidine sulfate
TIKOSYN
XYLOCAINE
Beta-Adrenergic Blocking Agents
acebutolol hcl
atenolol/chlorthalidone
atenolol
betaxolol hcl
bisoprolol fumarate/hctz
bisoprolol fumarate
BYSTOLIC
carvedilol
COREG CR
DUTOPROL
esmolol hcl
labetalol hcl
metoprolol succinate
metoprolol tartrate
metoprolol tartrate
metoprolol/hydrochlorothiazide
nadolol
pindolol
propranolol hcl
propranolol/hydrochlorothiazid
sotalol hcl
SOTALOL HCL
timolol maleate
Calcium-Channel Blocking Agents
diltiazem hcl
diltiazem hcl
verapamil hcl
2
2
2
2
2
2
2
2
3
2
2
4
2
2
2
3
2
2
1
1
2
2
2
3
1
3
3
2
2
2
1
2
2
2
2
2
2
2
4
2
Requirements/Limits
ampul, tablet
syringe
PA BvD
iv soln: 2mg/ml, 8mg/ml
syringe, vial: 100mg/ml, 200mg/ml
vial: 20mg/ml, (PA for ESRD Only)
capsule, tablet sa
vial
PA BvD
1
2
1
36
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
tablet
vial
tablet
cap er 12h, cap er 24h, cap er deg,
capsule er, syringe, tab er 24h, vial
port
tablet
Effective: November 01, 2014
Drug Name
verapamil hcl
Drug Tier
Requirements/Limits
2
ampul, cap24h pct, cap24h pel,
tablet er
syringe
verapamil hcl
2
Cardiovascular Agents, Miscellaneous
digoxin
2
PA, QL: 30 in 30 days
digoxin
2
PA
DIGOXIN
3
PA, QL: 75 in 30 days
dobutamine hcl/d5w
dobutamine hcl
dopamine hcl/d5w
dopamine hcl/dextrose 5%water
dopamine hcl
ephedrine sulfate
epinephrine
epinephrine
EPIPEN 2-PAK
EPIPEN JR 2-PAK
ethanolamine oleate
FIRAZYR
hydralazine hcl
hydralazine/hydrochlorothiazid
LANOXIN
2
2
2
2
PA BvD
PA BvD
PA BvD
PA BvD
2
2
2
2
3
3
2
5
2
2
4
PA BvD
milrinone lactate/d5w
milrinone lactate
norepinephrine bitartrate
ORENITRAM ER
ORENITRAM ER
papaverine hcl
RANEXA
VECAMYL
Dihydropyridines
amlodipine besylate/benazepril
amlodipine besylate
AZOR
CLEVIPREX
EXFORGE HCT
EXFORGE
felodipine
isradipine
5
5
2
3
5
2
3
5
PA BvD
PA BvD
PA BvD
PA
PA
PA
tablet, (High Risk Med for Ages 65
and Older and Dose is Greater Than
125mcg Per Day)
ampul, (High Risk Med for Ages 65
and Older)
(High Risk Med for Ages 65 and
Older and Dose is Greater Than
125mcg Per Day)
ampul
auto injct, syringe
PA, QL: 30 in 30 days
tablet: 62.5mcg, 187.5mcg, (High
Risk Med for Ages 65 and Older and
Dose is Greater Than 125mcg Per
Day)
tablet er: 0.125mg
tablet er: 0.25mg, 1mg, 2.5mg
2
1
3
4
3
2
2
2
37
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
Effective: November 01, 2014
Drug Name
Drug Tier
nicardipine hcl
2
nifedipine
2
nifedipine
2
Diuretics
amiloride hcl
2
amiloride/hydrochlorothiazide
2
bumetanide
2
chlorothiazide sodium
2
chlorothiazide
1
chlorthalidone
1
DYRENIUM
4
furosemide
1
furosemide
2
furosemide
2
hydrochlorothiazide
1
indapamide
1
methyclothiazide
2
metolazone
2
torsemide
2
triamterene/hydrochlorothiazid
2
Dyslipidemics
amlodipine/atorvastatin
2
atorvastatin calcium
2
cholestyramine (with sugar)
2
cholestyramine/aspartame
2
colestipol hcl
2
CRESTOR
3
fenofibrate nanocrystallized
2
fenofibrate,micronized
2
fenofibrate
2
fenofibric acid (choline)
2
fenofibric acid
2
fluvastatin sodium
2
gemfibrozil
2
KYNAMRO
5
PA, QL: 4 in 28 days
lovastatin
1
niacin
2
omega-3 acid ethyl esters
2
pravastatin sodium
1
simvastatin
1
QL: 30 in 30 days
VASCEPA
3
WELCHOL
3
ZETIA
4
Renin-Angiotensin-Aldosterone System Inhibitors
eplerenone
2
spironolact/hydrochlorothiazid
2
spironolactone
2
38
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
Requirements/Limits
tab er 24, tablet er: 30mg, 60mg
tablet er: 90mg
tablet
solution, syringe: 10mg/ml; vial
syringe: 10mg/ml
tablet
tab er 24h, tablet
Effective: November 01, 2014
Drug Name
Drug Tier
Requirements/Limits
Vasodilators
isosorbide dinitrate
isosorbide dinitrate
isosorbide dinitrate
isosorbide mononitrate
minoxidil
NITRO-BID
nitroglycerin/d5w
nitroglycerin
nitroglycerin
nitroglycerin
1
1
2
2
2
3
2
2
2
2
nitroglycerin
NITROSTAT
nylidrin hcl
PROGLYCEM
2
3
2
4
QL: 60 in 30 days
5
2
2
2
2
2
2
2
PA, QL: 60 in 30 days
QL: 60 in 30 days
QL: 120 in 30 days
QL: 180 in 30 days
QL: 30 in 30 days
tablet
capsule er
tablet: 5mg, 10mg
cap er 24h: 5mg, 10mg, 15mg
2
QL: 60 in 30 days
cap er 24h: 20mg, 25mg, 30mg;
tablet
tab subl: 2.5mg
tab subl: 5mg
tablet, tablet er
QL: 30 in 30 days
vial: 50mg/10ml
vial: 5mg/ml
patch td24: 0.1mg/hr, 0.2mg/hr,
0.6mg/hr
patch td24: 0.4mg/hr
Central Nervous System Agents
Central Nervous System Agents
AMPYRA
caffeine citrated
caffeine/sodium benzoate
clonidine hcl
dexmethylphenidate hcl
dextroamphetamine sulfate
dextroamphetamine sulfate
dextroamphetamine/
amphetamine
dextroamphetamine/
amphetamine
flumazenil
INTUNIV
lithium carbonate
lithium citrate
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
NUEDEXTA
QUILLIVANT XR
riluzole
SAVELLA
STRATTERA
XENAZINE
2
4
2
2
2
2
2
2
2
3
3
2
3
3
5
QL: 30 in 30 days
QL: 30 in 30 days
QL: 60 in 30 days
QL: 90 in 30 days
QL: 90 in 30 days
QL: 900 in 30 days
QL: 60 in 30 days
cpbp 30-70, cpbp 50-50: 20mg,
40mg; tab er 24: 18mg, 27mg, 54mg
cpbp 50-50: 30mg; tab er 24: 36mg
tablet er: 10mg
tablet, tablet er: 20mg
solution
QL: 60 in 30 days
PA, QL: 112 in 28 days
39
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
Effective: November 01, 2014
Drug Name
Drug Tier
Requirements/Limits
Contraceptives
Contraceptives
desog-e.estradiol/e.estradiol
desogestrel-ethinyl estradiol
ethinyl estradiol/drospirenone
ethynodiol d-ethinyl estradiol
levonorgestrel
levonorgestrel-ethin estradiol
levonorgestrel-ethin estradiol
l-norgest-eth estr/ethin estra
l-norgest-eth estr/ethin estra
norelgestromin/ethin.estradiol
noreth-ethinyl estradiol/iron
norethindrone ac-eth estradiol
norethindrone
norethindrone-e.estradiol-iron
norethindrone-ethinyl estrad
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
norethindrone-mestranol
norgestimate-ethinyl estradiol
norgestrel-ethinyl estradiol
NUVARING
ORTHO EVRA
2
2
2
3
4
QL: 91 in 84 days
QL: 91 in 84 days
QL: 91 in 84 days
tablet: 0.1-0.02, 0.15-0.03, 6-5-10
tbdspk 3mo
tbdspk 3mo: 100-20(84)
tbdspk 3mo: 150-30(84)
tablet: 0.4-0.035, 0.5-0.035, 1mg35mcg, 7-9-5, 7daysx3, 10-11
ST, QL: 1 in 28 days
ST, QL: 3 in 28 days
Dental And Oral Agents
Dental And Oral Agents
cevimeline hcl
chlorhexidine gluconate
KEPIVANCE
pilocarpine hcl
triamcinolone acetonide
2
2
5
2
2
Dermatological Agents
Dermatological Agents, Other
8-MOP
acitretin
acyclovir
adapalene
alcohol antiseptic pads
aluminum chloride
ammonium lactate
ANACAINE
calcipotriene/betamethasone
calcipotriene
calcitriol
CARAC
CONDYLOX
DENAVIR
FLUOROPLEX
4
5
2
2
1
2
2
4
2
2
2
4
4
4
4
QL: 30 in 30 days
40
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
gel (gram)
Effective: November 01, 2014
Drug Name
Drug Tier
fluorouracil
2
imiquimod
2
LEVULAN
4
mafenide acetate
2
methoxsalen, rapid
5
METVIXIA
4
OXSORALEN-ULTRA
5
PANRETIN
5
PICATO
3
PICATO
3
podofilox
2
podophyllum resin
2
potassium hydroxide
2
SANTYL
4
silver nitrate applicator
2
UVADEX
4
VALCHLOR
5
XERAC AC
3
ZOVIRAX
4
Dermatological Antibacterials
clindamycin phos/benzoyl perox
2
clindamycin phosphate
2
erythromycin base/ethanol
2
erythromycin/benzoyl peroxide
2
gentamicin sulfate
2
metronidazole
2
mupirocin calcium
2
mupirocin
2
neomy sulf/polymyxin b sulfate
2
selenium sulfide
2
selenium sulfide
2
silver nitrate
2
silver sulfadiazine
2
sulfacetamide sodium
2
THERMAZENE
2
Dermatological Anti-inflammatory Agents
alclometasone dipropionate
2
APEXICON E
4
betamethasone dipropionate
2
betamethasone valerate
2
betamethasone/propylene glyc
2
clobetasol propionate
2
clocortolone pivalate
2
CLODERM
4
CORDRAN
4
CORDRAN
4
desonide
2
desoximetasone
2
Requirements/Limits
PA NSO, QL: 24 in 30 days
QL: 2 in 56 days
QL: 3 in 56 days
gel (ea): 0.05%
gel (ea): 0.015%
QL: 15 in 30 days
cream (g)
41
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
gel (gram): 1%-5%
shampoo
suspension
cream (g), lotion, oint. (g)
med. tape
Effective: November 01, 2014
Drug Name
Drug Tier
diflorasone diacetate
ELIDEL
fluocinonide
2
3
2
fluticasone propionate
halobetasol propionate
hydrocortisone acetate/aloe v
hydrocortisone acetate/urea
hydrocortisone acetate
hydrocortisone butyrate
hydrocortisone valerate
hydrocortisone
2
2
2
2
2
2
2
2
hydrocortisone
LOCOID
mometasone furoate
prednicarbate
PROTOPIC
PROTOPIC
triamcinolone acetonide
2
4
2
2
4
4
2
triamcinolone acetonide
Dermatological Retinoids
adapalene
TARGRETIN
TAZORAC
tretinoin microspheres
tretinoin
Scabicides And Pediculicides
EURAX
malathion
permethrin
spinosad
2
2
5
4
2
2
Requirements/Limits
PA
(PA for Ages < 2)
cream (g): 0.05%; gel (gram), oint.
(g), solution
cream (g), oint. (g)
cream (g), cream/appl, enema,
lotion, oint. (g)
cream(gm)
cream (g)
PA
PA
(0.03%; PA for Ages < 2)
(0.1%; PA for Ages < 15)
cream (g), lotion, oint. (g): 0.025%,
0.1%, 0.5%
cream, oint. (g): 0.05%
PA NSO, QL: 60 in 28 days
PA
PA
4
2
2
2
Devices
Devices
needles, insulin disposable
syring w-ndl,disp,insul,0.3ml
syring w-ndl,disp,insul,0.5ml
syring w-o ndl,disp,insul, 1ml
2
2
2
2
Enzyme Replacement/modifiers
Enzyme Replacement/modifiers
ADAGEN
ALDURAZYME
CEREZYME
CHENODAL
CIMZIA
CREON
5
5
5
5
5
3
PA, QL: 210 in 30 days
PA, QL: 3 in 28 days
42
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
Effective: November 01, 2014
Drug Name
ELAPRASE
ELELYSO
ELITEK
FABRAZYME
KRYSTEXXA
KUVAN
LINZESS
lipase/protease/amylase
LOTRONEX
LUMIZYME
MYOZYME
NAGLAZYME
ORFADIN
PULMOZYME
VIMIZIM
VPRIV
ZAVESCA
ZENPEP
Drug Tier
5
5
5
5
5
5
3
2
5
5
5
5
5
5
5
5
5
3
Requirements/Limits
QL: 30 in 30 days
PA BvD
PA
QL: 90 in 30 days
Eye, Ear, Nose, Throat Agents
Eye, Ear, Nose, Throat Anti-infectives Agents
acetic acid/hydrocortisone
2
acetic acid
2
bacitracin/polymyxin b sulfate
2
bacitracin
2
BLEPHAMIDE S.O.P.
3
BLEPHAMIDE
4
CIPRO HC
3
CIPRODEX
3
ciprofloxacin hcl
2
ciprofloxacin hcl
2
COLY-MYCIN S
4
CORTISPORIN-TC
4
erythromycin base
2
gatifloxacin
2
gentamicin sulfate
2
levofloxacin
2
MOXEZA
3
NATACYN
3
neo/polymyx b sulf/dexameth
2
neomy sulf/bacitra/polymyxin b
2
neomy sulf/bacitrac zn/poly/hc
2
neomycin sulfate/dex na ph
2
neomycin/polymyxin b sulf/hc
2
neomycin/polymyxn b/
2
gramicidin
ofloxacin
2
polymyxin b sulf/trimethoprim
2
sulfacetamide sodium
2
43
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
droperette
drops
Effective: November 01, 2014
Drug Name
Drug Tier
sulfacetamide/prednisolone sp
2
tobramycin sulfate
2
tobramycin/dexamethasone
2
trifluridine
2
VIGAMOX
3
ZYLET
3
Eye, Ear, Nose, Throat Anti-inflammatory Agents
ALREX
3
BROMDAY
3
bromfenac sodium
2
dexamethasone sod phosphate
2
diclofenac sodium
2
DUREZOL
3
fluorometholone
2
flurbiprofen sodium
2
ILEVRO
3
ketorolac tromethamine
2
LOTEMAX
3
NEVANAC
3
prednisolone acetate
2
prednisolone sod phosphate
2
PROLENSA
3
Eye, Ear, Nose, Throat Drugs, Miscellaneous
AKTEN
4
apraclonidine hcl
2
atropine sulfate
2
azelastine hcl
2
azelastine hcl
2
QL: 30 in 25 days
carteolol hcl
2
cromolyn sodium
2
CYCLOGYL
3
cyclopentolate hcl
2
CYSTARAN
5
epinastine hcl
2
homatropine hbr
2
ISOPTO HOMATROPINE
3
LACRISERT
3
naphazoline hcl/antazoline
2
PATADAY
3
ST
PATANOL
3
ST
phenylephrine hcl
1
phenylephrine hcl
2
proparacaine hcl
2
proparacaine/fluorescein sod
2
tetracaine hcl/pf
2
TYZINE
4
TYZINE
4
44
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
Requirements/Limits
drops
spray/pump
drops: 0.5%
drops: 2%
drops: 2.5%
drops: 10%
drops: 0.05%
drops: 0.1%; spray
Effective: November 01, 2014
Drug Name
Drug Tier
Requirements/Limits
Gastrointestinal Agents
Antiulcer Agents And Acid Suppressants
CARAFATE
3
cimetidine hcl
2
cimetidine hcl
2
cimetidine in 0.9 % nacl
2
cimetidine
2
esomeprazole sodium
2
famotidine in nacl,iso-osm/pf
2
famotidine
1
famotidine
1
famotidine
2
famotidine
2
lansoprazole/amoxiciln/clarith
2
lansoprazole
2
misoprostol
2
nizatidine
2
omeprazole
2
pantoprazole sodium
2
ranitidine hcl
1
ranitidine hcl
2
sucralfate
sucralfate
Gastrointestinal Agents, Other
AMITIZA
BUPHENYL
CARBAGLU
cromolyn sodium
dicyclomine hcl
diphenoxylate hcl/atropine
FULYZAQ
glycopyrrolate
isopropamide/prochlorperazine
lactulose
lactulose
loperamide hcl
methscopolamine bromide
metoclopramide hcl
metoclopramide hcl
metoclopramide hcl
NUTRESTORE
paregoric
RAVICTI
RELISTOR
RELISTOR
sodium phenylbutyrate
ursodiol
oral susp
solution
vial
(Rx Product Only)
tablet
tablet, (Rx Product Only)
oral susp, vial
oral susp, vial, (Rx Product Only)
(Rx Product Only)
tablet, (Rx Product Only)
capsule, syrup, vial, (Rx Product
Only)
oral susp
tablet
2
2
3
5
5
5
2
2
4
2
2
2
2
2
2
1
2
2
4
2
5
4
4
5
2
QL: 60 in 30 days
tablet
QL: 60 in 30 days
solution: 10; syrup
solution: 10g/15ml
tablet
disp syrin
solution, vial
PA
PA, QL: 28 in 28 days
PA, QL: 28 in 28 days
45
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
syringe: 12mg/0.6ml
syringe: 8mg/0.4ml
Effective: November 01, 2014
Drug Name
Laxatives
MOVIPREP
peg 3350/na sulf,bicarb,cl/kcl
polyethylene glycol 3350
sodium chloride/nahco3/kcl/peg
Phosphate Binders
calcium acetate
calcium carbonate/mag carb/fa
PHOSLYRA
RENAGEL
RENVELA
sodium polystyrene sulfonate
sodium polystyrene sulfonate
Drug Tier
Requirements/Limits
3
2
2
2
2
2
4
3
3
2
2
enema
oral susp
Genitourinary Agents
Antispasmodics, Urinary
flavoxate hcl
oxybutynin chloride
oxybutynin chloride
tolterodine tartrate
trospium chloride
VESICARE
2
1
2
2
2
3
tablet
tab er 24
Heavy Metal Antagonists
Heavy Metal Antagonists
deferoxamine mesylate
edetate disodium
EXJADE
EXJADE
FERRIPROX
GALZIN
na nitrite/na thiosul/amyl nit
sodium thiosulfate
SYPRINE
2
2
4
5
5
4
2
2
5
PA BvD
tab disper: 125mg
tab disper: 250mg, 500mg
Hormonal Agents, Stimulant/replacement/modifying
Androgens
ANADROL-50
ANDRODERM
ANDROGEL
ANDROGEL
ANDROGEL
AXIRON
danazol
fluoxymesterone
oxandrolone
testosterone cypionate
testosterone enanthate
5
3
3
3
3
3
2
2
2
2
2
PA, QL: 30 in 30 days
PA, QL: 150 in 30 days
PA, QL: 150 in 30 days
PA, QL: 300 in 30 days
PA, QL: 180 in 28 days
gel md pmp
gel packet: 1.25g-1.62
gel packet: 50mg(1%)
PA
PA, QL: 5 in 28 days
46
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
Effective: November 01, 2014
Drug Name
Drug Tier
Requirements/Limits
Estrogens and Antiestrogens
COMBIPATCH
3
PA, QL: 8 in 28 days
DUAVEE
3
PA
ESTRACE
estradiol valerate
estradiol valerate
estradiol/norethindrone acet
estradiol/norethindrone acet
3
2
2
2
2
PA
PA
estradiol
2
PA, QL: 4 in 28 days
estradiol
2
PA
ESTRASORB
4
PA, QL: 97.44 in 28 days
estropipate
2
PA
FEMRING
MENEST
4
4
QL: 1 in 84 days
PA
norethindrone ac-eth estradiol
2
PA
PREMARIN
PREMARIN
3
3
PA
PREMPHASE
3
PA
PREMPRO
3
PA
raloxifene hcl
VAGIFEM
VIVELLE-DOT
2
3
3
QL: 18 in 28 days
PA, QL: 8 in 28 days
Glucocorticoids/mineralocorticoids
A-HYDROCORT
betamet acet/betamet na ph
cortisone acetate
dexamethasone acetate
dexamethasone sod phosphate
dexamethasone
dexamethasone
fludrocortisone acetate
hydrocortisone sod succinate
hydrocortisone
methylprednisolone acetate
methylprednisolone sod succ
4
2
2
2
2
1
2
2
2
2
2
2
(High Risk Med for Ages 65 and
Older)
(High Risk Med for Ages 65 and
Older)
cream/appl
vial: 10mg/ml
vial: 20mg/ml, 40mg/ml
(High Risk Med for Ages 65 and
Older)
patch tdwk, (High Risk Med for
Ages 65 and Older)
tablet, (High Risk Med for Ages 65
and Older)
(High Risk Med for Ages 65 and
Older)
(High Risk Med for Ages 65 and
Older)
(High Risk Med for Ages 65 and
Older)
(High Risk Med for Ages 65 and
Older)
cream/appl, vial
tablet, (High Risk Med for Ages 65
and Older)
(High Risk Med for Ages 65 and
Older)
(High Risk Med for Ages 65 and
Older)
(High Risk Med for Ages 65 and
Older)
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
tablet
elixir
PA BvD
PA BvD
PA BvD
PA BvD
vial: 40mg, 125mg
47
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
Effective: November 01, 2014
Drug Name
Drug Tier
methylprednisolone sod succ
methylprednisolone
prednisolone acetate
prednisolone sod phosphate
prednisolone
PREDNISONE INTENSOL
prednisone
prednisone
prednisone
SOLU-CORTEF
SOLU-MEDROL
triamcinolone acetonide
UCERIS
Pituitary
DDAVP
desmopressin (nonrefrigerated)
desmopressin acetate
desmopressin acetate
GENOTROPIN
GENOTROPIN
2
2
2
2
2
4
1
2
2
4
4
2
5
HUMATROPE
INCRELEX
NORDITROPIN FLEXPRO
NORDITROPIN NORDIFLEX
NORDITROPIN
NOVAREL
NUTROPIN AQ NUSPIN
NUTROPIN AQ
NUTROPIN
NUTROPIN
octreotide acetate
octreotide acetate
OMNITROPE
OMNITROPE
SAIZEN
SAIZEN
SANDOSTATIN LAR
SEROSTIM
SOMATULINE DEPOT
SOMAVERT
SOMAVERT
SUPPRELIN LA
TEV-TROPIN
VANTAS
vasopressin
ZORBTIVE
5
5
5
5
5
4
5
5
5
5
2
5
4
5
5
5
5
5
5
5
5
5
4
5
2
5
4
2
2
2
4
5
Requirements/Limits
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
ST
vial: 500mg, 1000mg
tablet
solution
tab ds pk
vial: 40mg/ml
ampul: 15mcg/ml
QL: 15 in 30 days
QL: 15 in 30 days
PA
PA
tablet, vial
solution
syringe: 0.2mg/0.25
various dosage and/or strengths are
available
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
vial: 10mg
vial: 5mg
ampul, vial: 100mcg/ml, 200mcg/ml
vial: 1000mcg/ml
cartridge: 10mg/1.5ml
cartridge: 5mg/1.5ml; vial
cartridge, vial: 5mg
vial: 8.8mg
PA
QL: 1 in 28 days
vial: 10mg, 15mg, 20mg
vial: 25mg, 30mg
QL: 1 in 360 days
PA
QL: 1 in 360 days
PA
48
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
Effective: November 01, 2014
Drug Name
Progestins
DEPO-PROVERA
medroxyprogesterone acet
medroxyprogesterone acetate
medroxyprogesterone acetate
medroxyprogesterone acetate
norethindrone acetate
progesterone,micronized
progesterone
Thyroid and Antithyroid Agents
levothyroxine sodium
levothyroxine sodium
levothyroxine sodium
liothyronine sodium
methimazole
methimazole
propylthiouracil
Drug Tier
4
2
2
2
2
2
2
2
Requirements/Limits
QL: 10 in 28 days
vial: 400mg/ml
QL: 1 in 84 days
QL: 1 in 84 days
tablet
syringe
vial
1
2
2
2
2
2
2
tablet
vial: 100mcg
vial: 200mcg, 500mcg
tablet: 20mg
tablet: 5mg, 10mg
Immunological Agents
Immunological Agents
ARCALYST
ASTAGRAF XL
AUBAGIO
azathioprine sodium
azathioprine
CARIMUNE NF
NANOFILTERED
CELLCEPT
CELLCEPT
cyclosporine, modified
cyclosporine
ENBREL
ENBREL
ENBREL
FLEBOGAMMA DIF
FLEBOGAMMA
GAMASTAN S-D
GAMMAGARD LIQUID
GAMMAPLEX
GAMUNEX-C
HUMIRA
HUMIRA
HYPERRAB S-D
HYPERRHO S-D
ILARIS
IMOGAM RABIES-HT
KINERET
leflunomide
5
4
5
2
2
5
4
5
2
2
5
5
5
5
5
3
5
5
5
5
5
4
4
5
4
5
2
PA BvD
PA, QL: 28 in 28 days
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA, QL: 7.84 in 28 days
PA, QL: 8 in 28 days
PA, QL: 8.16 in 28 days
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA, QL: 4 in 28 days
PA, QL: 6 in 28 days
vial
susp recon
pen injctr
vial
syringe
kit, pen ij kit: 40mg/0.8ml
pen ij kit: 40mg/0.8ml, (Starter Kit)
PA, QL: 2 in 28 days
PA, QL: 18.76 in 28 days
49
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
Effective: November 01, 2014
Drug Name
Drug Tier
MICRHOGAM ULTRAFILTERED PLUS
mycophenolate mofetil
mycophenolate sodium
NULOJIX
OCTAGAM
ORENCIA
ORENCIA
PRIVIGEN
PROGRAF
RAPAMUNE
RAPAMUNE
RHOGAM ULTRA-FILTERED
PLUS
RHOPHYLAC
RIDAURA
sirolimus
tacrolimus
TYSABRI
WINRHO SDF
ZORTRESS
4
ZORTRESS
5
Vaccines
ACTHIB
ADACEL TDAP
ADACEL TDAP
BCG VACCINE (TICE STRAIN)
BOOSTRIX TDAP
CERVARIX
COMVAX
DAPTACEL DTAP
DIPHTHERIA-TETANUS
TOXOIDS-PED
ENGERIX-B ADULT
ENGERIX-B PEDIATRICADOLESCENT
GARDASIL
HAVRIX
HAVRIX
IMOVAX RABIES VACCINE
INFANRIX DTAP
INFANRIX PF
IPOL
IXIARO
JE-VAX
KINRIX
2
2
5
5
5
5
5
4
3
5
4
4
5
2
2
5
4
4
3
3
3
3
3
4
3
3
3
3
3
4
3
3
3
3
3
3
3
3
3
Requirements/Limits
PA BvD
PA BvD
PA BvD
PA BvD
PA, QL: 4 in 28 days
PA, QL: 4 in 28 days
PA BvD
PA BvD
PA BvD
PA BvD
syringe
vial
ampul
solution
tablet: 1mg, 2mg
PA BvD
PA BvD
LA, PA, QL: 15 in 28 days
PA BvD, QL: 120 in 30
days
PA BvD, QL: 120 in 30
days
tablet: 0.25mg
tablet: 0.5mg, 0.75mg
syringe
vial
PA BvD
PA BvD
PA BvD
syringe: 1440/ml
syringe: 720/0.5ml; vial
PA BvD
50
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
Effective: November 01, 2014
Drug Name
Drug Tier
MENACTRA
MENHIBRIX
MENOMUNE-A-C-Y-W-135
MENVEO A-C-Y-W-135-DIP
M-M-R II VACCINE
PEDIARIX
PEDVAXHIB
PENTACEL ACTHIB
COMPONENT
PENTACEL DTAP-IPV
COMPONENT
PENTACEL
PROQUAD
RABAVERT
RECOMBIVAX HB
ROTARIX
ROTATEQ
TE ANATOXAL BERNA
TENIVAC
TETANUS DIPHTHERIA
TOXOIDS
TETANUS TOXOID
ADSORBED
THERACYS
TWINRIX
TWINRIX
TYPHIM VI
VAQTA
VARIVAX VACCINE
YF-VAX
ZOSTAVAX
Requirements/Limits
3
3
3
3
3
3
3
3
3
3
4
3
3
3
3
3
3
3
PA BvD
PA BvD
PA BvD
3
PA BvD
3
3
3
3
3
3
3
3
PA BvD
syringe
vial
Inflammatory Bowel Disease Agents
Inflammatory Bowel Disease Agents
APRISO
3
balsalazide disodium
2
budesonide
5
DIPENTUM
4
ST
Irrigating Solutions
Irrigating Solutions
acetic acid
GLYCINE
LACTATED RINGERS
mannitol/sorbitol solution
ringers solution
sodium chloride irrig solution
sorbitol solution
2
2
3
2
2
2
2
51
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
Effective: November 01, 2014
Drug Name
Drug Tier
urologic solution-g
water for irrigation,sterile
Requirements/Limits
3
2
Metabolic Bone Disease Agents
Metabolic Bone Disease Agents
ACTONEL
ACTONEL
ACTONEL
alendronate sodium
alendronate sodium
alendronate sodium
calcitonin,salmon,synthetic
calcitriol
doxercalciferol
etidronate disodium
FORTEO
FORTICAL
ibandronate sodium
ibandronate sodium
MIACALCIN
pamidronate disodium
paricalcitol
PROLIA
risedronate sodium
XGEVA
ZEMPLAR
zoledronic acid/mannitol&water
zoledronic acid/mannitol&water
zoledronic acid
ZOMETA
3
3
3
1
1
2
2
2
2
2
4
4
2
2
3
2
2
4
2
5
3
2
2
2
5
ST, QL: 1 in 28 days
ST, QL: 30 in 30 days
ST, QL: 4 in 28 days
5
5
5
2
1
2
2
5
PA, QL: 3.6 in 28 days
PA, QL: 40 in 30 days
5
5
5
2
4
4
2
ST
PA, QL: 2 in 28 days
ST
QL: 4 in 28 days
QL: 300 in 28 days
QL: 3.7 in 28 days
PA BvD
PA BvD
PA, QL: 3 in 28 days
QL: 3.7 in 28 days
PA BvD, QL: 3 in 84 days
QL: 1 in 28 days
PA BvD
PA BvD
PA BvD
PA, QL: 1 in 180 days
QL: 1 in 28 days
PA, QL: 1.7 in 28 days
PA BvD
QL: 100 in 300 days
tablet: 150mg
tablet: 5mg, 30mg
tablet: 35mg
tablet: 5mg, 10mg, 40mg
tablet: 35mg, 70mg
solution
(PA for ESRD Only)
(PA for ESRD Only)
vial, (PA for ESRD Only)
tablet
vial, (PA for ESRD Only)
(PA for ESRD Only)
(PA for ESRD Only)
vial, (PA for ESRD Only)
piggyback
infus. btl
infus. btl
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
ACTEMRA
ACTEMRA
ACTIMMUNE
allopurinol sodium
allopurinol
amifostine crystalline
ammonium chloride
AVONEX ADMINISTRATION
PACK
AVONEX
BENLYSTA
BETASERON
bethanechol chloride
BOTOX
BOTOX
buspirone hcl
syringe
vial
ST
QL: 1 in 90 days
QL: 4 in 90 days
52
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
vial: 200unit
vial: 100unit
Effective: November 01, 2014
Drug Name
Drug Tier
citrate phosphate dextros soln
colchicine/probenecid
COLCRYS
COPAXONE
CYSTADANE
dexrazoxane
droperidol
DUODOTE
DYSPORT
ELMIRON
EXTAVIA
finasteride
fomepizole
FUSILEV
gauze bandage
GILENYA
GLUCAGEN
GLUCAGON EMERGENCY KIT
glutethimide
guanidine hcl
H.P. ACTHAR
hydroxyzine hcl
2
2
3
5
5
2
2
3
4
4
5
2
5
5
1
5
3
3
2
2
5
2
hydroxyzine pamoate
2
KALBITOR
leucovorin calcium
levocarnitine (with sugar)
levocarnitine
LITHOSTAT
mesna
MESNEX
MESTINON
methylene blue
methylergonovine maleate
methylergonovine maleate
MYOBLOC
MYTELASE
neostigmine methylsulfate
NPLATE
OTEZLA
physostigmine salicylate
PRALIDOXIME CHLORIDE
probenecid
PROCYSBI
PROSTIGMIN
PROTOPAM CHLORIDE
pyridostigmine bromide
5
2
2
2
3
2
5
4
2
2
2
4
4
2
5
5
2
4
2
5
4
4
2
Requirements/Limits
ST
PA, QL: 28 in 28 days
PA, QL: 35 in 28 days
PA
PA
PA BvD
PA BvD
(High Risk Med for Ages 65 and
Older)
(High Risk Med for Ages 65 and
Older)
(PA for ESRD Only)
(PA for ESRD Only)
tablet
syrup, tablet er
ampul
tablet
QL: 1 in 90 days
PA, QL: 8 in 28 days
PA, QL: 60 in 30 days
53
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
Effective: November 01, 2014
Drug Name
REBIF REBIDOSE
REBIF
REGONOL
REMICADE
SENSIPAR
SENSIPAR
SIGNIFOR
SIMPONI ARIA
SIMPONI
SIMPONI
SIMULECT
sodium morrhuate
sodium tetradecyl sulfate
SOLIRIS
STELARA
STELARA
STELARA
SYNAREL
TECFIDERA
TECFIDERA
THALOMID
VORAXAZE
XELJANZ
Drug Tier
5
5
4
5
3
5
5
5
5
5
5
2
2
5
5
5
5
5
5
5
5
5
5
Requirements/Limits
PA
tablet: 30mg
tablet: 60mg, 90mg
QL: 60 in 30 days
PA, QL: 24 in 28 days
PA, QL: 0.5 in 28 days
PA, QL: 3 in 28 days
PA BvD
PA, QL: 10 in 360 days
PA, QL: 10 in 360 days
PA, QL: 5 in 360 days
pen injctr
syringe
syringe: 45mg/0.5ml
vial
syringe: 90mg/ml
PA, QL: 14 in 30 days
capsule dr: 120mg
PA, QL: 60 in 30 days
capsule dr: 120-240mg, 240mg
PA NSO, QL: 60 in 30 days
PA, QL: 60 in 30 days
Ophthalmic Agents
Antiglaucoma Agents
acetazolamide sodium
acetazolamide
AZOPT
betaxolol hcl
BETIMOL
brimonidine tartrate
COMBIGAN
dorzolamide hcl/timolol maleat
dorzolamide hcl
ISOPTO CARPINE
ISTALOL
latanoprost
levobunolol hcl
levobunolol hcl
methazolamide
metipranolol
PHOSPHOLINE IODIDE
pilocarpine hcl
PILOPINE HS
SIMBRINZA
timolol maleate
TRAVATAN Z
2
2
3
2
4
2
3
2
2
3
4
2
2
2
2
2
4
2
4
3
2
3
ST
QL: 2.5 in 25 days
54
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
(drops: 0.15%, 0.20%)
drops: 8%
drops: 0.25%
drops: 0.5%
Effective: November 01, 2014
Drug Name
travoprost (benzalkonium)
Drug Tier
2
Requirements/Limits
QL: 2.5 in 25 days
Replacement Preparations
Replacement Preparations
0.9 % sodium chloride
calcium chloride
calcium gluconate
citric acid/sodium citrate
dex 2.5%-half str lact.ringers
DEXTROSE W/ELECTROLYTE A
DEXTROSE W/ELECTROLYTE B
electrolyte-48 solution/d5w
electrolyte-48/fructose 10%
electrolyte-48/fructose 5%
electrolyte-75 solution/d5w
electrolyte-75/fructose 5%
HYPERLYTE CR
HYPERLYTE R
IONOSOL B with DEXTROSE 5%
IONOSOL MB-DEXTROSE 5%
IONOSOL T-DEXTROSE 5%
ISOLYTE E
ISOLYTE H W/DEXTROSE
ISOLYTE M W/DEXTROSE
ISOLYTE P with DEXTROSE
ISOLYTE R W/DEXTROSE
ISOLYTE S with DEXTROSE
ISOLYTE S
K-PHOS NO.2
magnesium chloride
magnesium sulfate in water
magnesium sulfate/d5w
magnesium sulfate
magnesium sulfate
NORMOSOL-M and DEXTROSE
NORMOSOL-R PH 7.4
NUTRILYTE II
NUTRILYTE
phosphorus #1
PLASMA-LYTE 148
PLASMA-LYTE 56 IN DEXTROSE
PLASMA-LYTE A PH 7.4
PLASMA-LYTE M IN DEXTROSE
pot chloride/pot bicarb/cit ac
potassium acetate
potassium bicarbonate/cit ac
potassium chlorid/d10-0.2%nacl
potassium chloride in 0.9%nacl
2
2
2
2
2
4
4
2
2
2
2
2
4
4
4
4
4
4
4
4
4
2
4
4
3
2
2
2
2
2
4
4
4
4
2
4
4
4
4
2
2
2
2
2
PA BvD
55
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
(PA for ESRD Only)
infus. btl
syringe, vial
Effective: November 01, 2014
Drug Name
Drug Tier
potassium chloride in d5w
potassium chloride in d5w
potassium chloride in lr-d5
potassium chloride/d5-0.2%nacl
potassium chloride/d5-0.2%nacl
potassium chloride/d5-0.25ns
potassium chloride/d5-0.3%nacl
potassium chloride/d5-0.45nacl
potassium chloride/d5-0.9%nacl
potassium chloride-0.45% nacl
potassium chloride
2
2
2
2
2
2
2
2
2
2
2
potassium chloride
potassium citrate/citric acid
potassium gluconate
potassium phos,m-basic-dbasic
ringers solution
SHOHL'S MODIFIED
sod/pot/k cit/sod cit/cit acid
sodium acetate
sodium bicarbonate
sodium chloride 0.45 %
sodium chloride 3%
sodium chloride 5%
sodium chloride
sodium chloride
SODIUM LACTATE
sodium lactate
sodium phos,m-basic-d-basic
TPN ELECTROLYTES
TRAVERT-ELECTROLYTE NO.1
TRAVERT-ELECTROLYTE NO.2
TRAVERT-ELECTROLYTE NO.2
TRAVERT-ELECTROLYTE NO.3
TRAVERT-ELECTROLYTE NO.4
2
2
2
2
Requirements/Limits
iv soln: 10meq/l, 30meq/l
iv soln: 20meq/l, 40meq/l
iv soln: 10meq/l, 30meq/l, 40meq/l
iv soln: 20meq/l
capsule er, piggyback, syringe, tab
er prt, tablet er
liquid, packet, tablet sa
2
2
2
2
2
2
2
2
2
2
2
2
2
4
4
4
4
4
4
vial: 2.5meq/ml
vial: 4meq/ml
iv soln: 10%
iv soln: 5%
Respiratory Tract Agents
Anti-inflammatories, Inhaled Corticosteroids
ADVAIR DISKUS
3
ADVAIR HFA
3
BREO ELLIPTA
3
DULERA
3
flunisolide
2
flunisolide
2
NASONEX
3
QNASL
3
QVAR
3
QL: 60 in 30 days
QL: 12 in 28 days
QL: 60 in 30 days
QL: 13 in 28 days
QL: 50 in 25 days
QL: 50 in 25 days
QL: 34 in 28 days
QL: 8.7 in 28 days
QL: 17.4 in 25 days
56
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
spray: 25mcg
spray: 29mcg
Effective: November 01, 2014
Drug Name
Drug Tier
triamcinolone acetonide
Antileukotrienes
montelukast sodium
zafirlukast
Bronchodilators
albuterol sulfate
albuterol sulfate
2
aminophylline
aminophylline
ATROVENT HFA
COMBIVENT RESPIMAT
COMBIVENT
FORADIL
ipratropium bromide
ipratropium bromide
metaproterenol sulfate
PROAIR HFA
SEREVENT DISKUS
SPIRIVA
terbutaline sulfate
theophylline anhydrous
theophylline/d5w
VENTOLIN HFA
Respiratory Tract Agents, Other
acetylcysteine
ARALAST NP
cromolyn sodium
DALIRESP
KALYDECO
XOLAIR
ZEMAIRA
2
2
3
3
3
3
2
2
2
3
3
3
2
2
2
3
Requirements/Limits
QL: 16.5 in 30 days
2
2
2
2
2
5
2
3
5
5
5
PA BvD
QL: 25.8 in 28 days
QL: 8 in 30 days
QL: 29.4 in 30 days
QL: 62 in 30 days
QL: 15 in 10 days
QL: 30 in 28 days
syrup, tab er 12h, tablet
solution, vial-neb: 0.63mg/3ml,
1.25mg/3ml
liquid
vial
spray: 42mcg
spray: 21mcg
QL: 17 in 25 days
QL: 60 in 30 days
QL: 30 in 30 days
QL: 36 in 25 days
PA BvD
PA BvD
QL: 30 in 30 days
PA, QL: 60 in 30 days
PA, QL: 6 in 28 days
Skeletal Muscle Relaxants
Skeletal Muscle Relaxants
baclofen
carisoprodol
2
2
PA, QL: 120 in 30 days
carisoprodol
2
PA, QL: 120 in 30 days
chlorzoxazone/acetaminophen
2
PA
chlorzoxazone
2
PA
cyclobenzaprine hcl
2
PA
dantrolene sodium
dantrolene sodium
2
2
57
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
tablet: 250mg, (High Risk Med for
Ages 65 and Older)
tablet: 350mg, (High Risk Med for
Ages 65 and Older)
(High Risk Med for Ages 65 and
Older)
(High Risk Med for Ages 65 and
Older)
(High Risk Med for Ages 65 and
Older)
capsule
vial
Effective: November 01, 2014
Drug Name
Drug Tier
Requirements/Limits
metaxalone
2
PA
methocarbamol
2
PA
tizanidine hcl
2
(High Risk Med for Ages 65 and
Older)
(High Risk Med for Ages 65 and
Older)
Sleep Disorder Agents
Sleep Disorder Agents
BUTISOL SODIUM
BUTISOL SODIUM
BUTISOL SODIUM
modafinil
ROZEREM
XYREM
zaleplon
4
4
4
2
3
5
2
QL: 120 in 30 days
QL: 473 in 30 days
QL: 60 in 30 days
PA, QL: 60 in 30 days
zolpidem tartrate
2
PA, QL: 30 in 30 days
LA
PA, QL: 60 in 30 days
tablet: 30mg
elixir: 30mg/5ml
tablet: 50mg
(High Risk Med. QL applies to all
members; PA required for 65 years
and older with over 90 days
cumulative use with any nonbenzodiazepine hypnotic drug)
(High Risk Med. QL applies to all
members; PA required for 65 years
and older with over 90 days
cumulative use with any nonbenzodiazepine hypnotic drug)
Sympatholytic Adrenergic Blocking Agents
Alpha-Adrenergic Blocking Agents
alfuzosin hcl
phentolamine mesylate
tamsulosin hcl
terazosin hcl
2
2
2
1
PA
Vasodilating Agents
Vasodilating Agents
ADCIRCA
ADEMPAS
alprostadil
epoprostenol sodium (glycine)
epoprostenol sodium (glycine)
ISOVEX
LETAIRIS
OPSUMIT
REMODULIN
REVATIO
sildenafil citrate
TRACLEER
5
5
2
2
5
4
5
5
5
5
2
5
PA, QL: 60 in 30 days
PA, QL: 90 in 30 days
PA
PA BvD
PA BvD
PA, QL: 30 in 30 days
PA, QL: 30 in 30 days
PA BvD
PA, QL: 37.5 in 1 day
PA, QL: 90 in 30 days
LA, PA, QL: 60 in 30 days
58
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
vial: 0.5mg
vial: 1.5mg
vial
Effective: November 01, 2014
Drug Name
TYVASO
VENTAVIS
Drug Tier
5
5
Requirements/Limits
PA BvD
PA BvD
Vitamins and Minerals
Vitamins and Minerals
LOZI-FLUR
pedi m.vit no.17 with fluoride
pedi mvi no.12/sodium fluoride
pnv with ca,no.72/iron/fa
2
2
2
3
59
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
(All Rx Prenatal Vitamins Covered)
Effective: November 01, 2014
INDEX
0.9 % sodium chloride ................ 55
8-MOP ....................................... 40
abacavir sulfate .......................... 29
abacavir/lamivudine/zidovudine . 29
ABELCET .................................. 25
ABILIFY ..................................... 28
ABILIFY DISCMELT .................. 28
ABILIFY MAINTENA .................. 28
ABRAXANE ............................... 16
acamprosate calcium ................. 12
acarbose .................................... 23
acebutolol hcl ............................. 36
acetaminophen with codeine........ 9
acetazolamide ............................ 54
acetazolamide sodium ............... 54
acetic acid ............................ 43, 51
acetic acid/hydrocortisone.......... 43
acetylcysteine ............................ 57
acitretin ...................................... 40
ACTEMRA ................................. 52
ACTHIB ...................................... 50
ACTIMMUNE ............................. 52
ACTONEL .................................. 52
ACTOPLUS MET XR ................. 24
acyclovir ............................... 31, 40
acyclovir sodium ........................ 31
ADACEL TDAP .......................... 50
ADAGEN .................................... 42
adapalene ............................ 40, 42
ADASUVE .................................. 28
ADCETRIS ................................. 16
ADCIRCA ................................... 58
adefovir dipivoxil ........................ 31
ADEMPAS ................................. 58
ADVAIR DISKUS ....................... 56
ADVAIR HFA ............................. 56
AFINITOR .................................. 16
AFINITOR DISPERZ.................. 16
AGGRENOX .............................. 32
A-HYDROCORT ........................ 47
AKTEN ....................................... 44
ALBENZA .................................. 27
ALBUKED-25 ............................. 32
ALBUKED-5 ............................... 32
ALBUMIN HUMAN ..................... 32
ALBUMINAR-25 ......................... 32
ALBUMINAR-5 ........................... 32
ALBURX .................................... 32
ALBUTEIN ................................. 32
albuterol sulfate.......................... 57
alclometasone dipropionate ........41
alcohol antiseptic pads ...............40
ALDURAZYME ...........................42
alendronate sodium ....................52
ALFERON N ...............................30
alfuzosin hcl ................................58
ALIMTA .......................................16
ALINIA ........................................27
allopurinol ...................................52
allopurinol sodium .......................52
alprazolam ..................................12
alprostadil ...................................58
ALREX ........................................44
aluminum chloride.......................40
amantadine hcl ...........................27
amifostine crystalline ..................52
amiloride hcl................................38
amiloride/hydrochlorothiazide .....38
AMINO ACIDS ............................33
aminocaproic acid .......................32
aminophylline ..............................57
AMINOSYN.................................33
AMINOSYN II..............................33
AMINOSYN M.............................33
AMINOSYN with ELECTROLYTES
...............................................33
AMINOSYN-HBC ........................33
AMINOSYN-PF ...........................33
AMINOSYN-RF...........................33
amiodarone hcl ...........................36
AMITIZA .....................................45
amitriptyline hcl ...........................22
amlodipine besylate ....................37
amlodipine besylate/benazepril...37
amlodipine/atorvastatin ...............38
ammonium chloride ....................52
ammonium lactate ......................40
amoxapine ..................................22
amoxicillin ...................................15
amoxicillin trihydrate ...................15
amoxicillin/potassium clav...........15
amphotericin b ............................25
ampicillin sodium ........................15
ampicillin sodium/sulbactam na ..15
ampicillin trihydrate .....................15
AMPYRA.....................................39
ANACAINE .................................40
ANADROL-50 .............................46
anagrelide hcl .............................32
anastrozole .................................16
I-1
ANDRODERM ............................ 46
ANDROGEL ............................... 46
ANORO ELLIPTA ....................... 20
APEXICON E.............................. 41
APOKYN .................................... 27
apraclonidine hcl......................... 44
APRISO ...................................... 51
APTIOM...................................... 20
APTIVUS .................................... 29
ARALAST NP ............................. 57
ARCALYST................................. 49
ARRANON.................................. 16
ARZERRA .................................. 16
ASTAGRAF XL ........................... 49
atenolol ....................................... 36
atenolol/chlorthalidone ................ 36
atorvastatin calcium .................... 38
atovaquone ................................. 27
atovaquone/proguanil hcl ........... 27
ATRIPLA .................................... 29
atropine sulfate ..................... 20, 44
ATROVENT HFA ........................ 57
AUBAGIO ................................... 49
AVANDAMET ............................. 25
AVANDARYL .............................. 25
AVANDIA .................................... 25
AVASTIN .................................... 16
AVC ............................................ 26
AVELOX ABC PACK .................. 15
AVELOX IV ................................. 15
AVONEX .................................... 52
AVONEX ADMINISTRATION
PACK ..................................... 52
AXIRON ...................................... 46
azacitidine .................................. 16
azathioprine ................................ 49
azathioprine sodium ................... 49
azelastine hcl .............................. 44
AZILECT..................................... 27
azithromycin ............................... 14
AZOPT ....................................... 54
AZOR ......................................... 37
aztreonam................................... 15
bacitracin .............................. 13, 43
bacitracin/polymyxin b sulfate ..... 43
baclofen ...................................... 57
balsalazide disodium .................. 51
BANZEL ..................................... 20
BARACLUDE.............................. 31
BCG VACCINE TICE STRAIN.... 50
BELEODAQ ............................... 16
benazepril hcl ............................. 35
benazepril/hydrochlorothiazide .. 35
BENICAR ................................... 35
BENICAR HCT........................... 35
BENLYSTA ................................ 52
benztropine mesylate ........... 27, 28
BERINERT ................................. 32
betamet acet/betamet na ph ...... 47
betamethasone dipropionate...... 41
betamethasone valerate ............ 41
betamethasone/propylene glyc .. 41
BETASERON ............................. 52
betaxolol hcl ......................... 36, 54
bethanechol chloride .................. 52
BETHKIS ................................... 13
BETIMOL ................................... 54
BEXXAR .................................... 16
bicalutamide ............................... 16
BICILLIN C-R ............................. 15
BICILLIN L-A .............................. 15
BICNU........................................ 16
BILTRICIDE ............................... 27
bisoprolol fumarate .................... 36
bisoprolol fumarate/hctz ............. 36
bleomycin sulfate ....................... 16
BLEPHAMIDE ............................ 43
BLEPHAMIDE S.O.P. ................ 43
BOOSTRIX TDAP ...................... 50
BOSULIF ................................... 16
BOTOX ...................................... 52
BREO ELLIPTA ......................... 56
BRILINTA ................................... 32
brimonidine tartrate .................... 54
BRINTELLIX .............................. 22
BROMDAY ................................. 44
bromfenac sodium ..................... 44
bromocriptine mesylate .............. 28
budesonide ................................ 51
bumetanide ................................ 38
BUMINATE ................................ 32
BUPHENYL................................ 45
buprenorphine hcl .................. 9, 12
buprenorphine hcl/naloxone hcl . 12
bupropion hcl ............................. 22
buspirone hcl.............................. 52
BUSULFEX ................................ 16
butalb/acetaminophen/caffeine .... 9
butalbit/acetamin/caff/codeine...... 9
butalbital/acetaminophen ............. 9
butalbital/aspirin/caffeine ........... 10
BUTISOL SODIUM .................... 58
butorphanol tartrate ..................... 9
BUTRANS.................................... 9
BYDUREON ...............................23
BYDUREON PEN .......................23
BYETTA ......................................23
BYSTOLIC ..................................36
cabergoline .................................28
caffeine citrated ..........................39
caffeine/sodium benzoate ...........39
calcipotriene................................40
calcipotriene/betamethasone ......40
calcitonin,salmon,synthetic .........52
calcitriol .................................40, 52
calcium acetate ...........................46
calcium carbonate/mag carb/fa ...46
calcium chloride ..........................55
calcium gluconate .......................55
CALDOLOR ................................10
CAMPRAL ..................................12
CANCIDAS .................................25
candesartan cilexetil ...................35
candesartan/hydrochlorothiazid ..35
CAPASTAT SULFATE ................26
CAPRELSA.................................16
captopril ......................................35
captopril/hydrochlorothiazide ......35
CARAC .......................................40
CARAFATE.................................45
CARBAGLU ................................45
carbamazepine ...........................20
carbidopa ....................................28
carbidopa/levodopa ....................28
carbidopa/levodopa/entacapone .28
carbinoxamine maleate ...............25
carboplatin ..................................16
CARIMUNE NF NANOFILTERED
...............................................49
carisoprodol ................................57
carteolol hcl.................................44
carvedilol.....................................36
CAYSTON ..................................15
CEENU .......................................16
cefaclor .......................................14
cefadroxil ....................................14
cefazolin sodium .........................14
cefazolin sodium/dextrose,iso .....14
cefdinir ........................................14
cefditoren pivoxil .........................14
CEFEPIME .................................14
cefepime hcl................................14
CEFEPIME-DEXTROSE.............14
cefotaxime sodium ......................14
I-2
cefotetan disod/dextrose,iso ....... 14
cefotetan disodium ..................... 14
cefoxitin sodium .......................... 14
cefoxitin sodium/dextrose,iso...... 14
cefpodoxime proxetil................... 14
cefprozil ...................................... 14
ceftazidime pentahydrate............ 14
ceftibuten dihydrate .................... 14
ceftriaxone na/dextrose,iso ......... 14
ceftriaxone sodium ..................... 14
cefuroxime axetil......................... 14
cefuroxime sodium ..................... 14
cefuroxime sodium/dextrose,iso . 14
CELEBREX ................................ 10
CELLCEPT ................................. 49
CELONTIN ................................. 20
cephalexin .................................. 14
CEPROTIN ................................. 31
CEREZYME................................ 42
CERVARIX ................................. 50
CESAMET .................................. 26
cevimeline hcl ............................. 40
CHANTIX .................................... 12
CHENODAL................................ 42
chloramphenicol sod succ .......... 13
chlordiazepoxide hcl ................... 12
chlorhexidine gluconate .............. 40
chlorothiazide ............................. 38
chlorothiazide sodium ................. 38
chlorpromazine hcl ..................... 28
chlorthalidone ............................. 38
chlorzoxazone ............................ 57
chlorzoxazone/acetaminophen ... 57
cholestyramine (with sugar) ........ 38
cholestyramine/aspartame.......... 38
choline sal/mag salicylate ........... 10
ciclopirox .................................... 25
ciclopirox olamine ....................... 25
cidofovir ...................................... 31
cilostazol ..................................... 32
cimetidine ................................... 45
cimetidine hcl .............................. 45
cimetidine in 0.9 % nacl .............. 45
CIMZIA ....................................... 42
CINRYZE .................................... 32
CIPRO HC .................................. 43
CIPRODEX ................................. 43
ciprofloxacin................................ 15
ciprofloxacin hcl .................... 15, 43
ciprofloxacin lactate .................... 15
ciprofloxacin lactate/d5w ............ 15
ciprofloxacin/ciprofloxa hcl .......... 15
cisplatin ...................................... 16
citalopram hydrobromide ........... 22
citrate phosphate dextros soln ... 53
citric acid/sodium citrate ............. 55
cladribine ................................... 16
clarithromycin ............................. 14
clemastine fumarate ................... 25
CLEVIPREX ............................... 37
clindamycin hcl........................... 13
clindamycin palmitate hcl ........... 13
clindamycin phos/benzoyl perox 41
clindamycin phosphate .. 13, 26, 41
clindamycin phosphate/d5w ....... 13
CLINIMIX ................................... 33
CLINIMIX E ................................ 33
CLINISOL .................................. 33
clobetasol propionate ................. 41
clocortolone pivalate .................. 41
CLODERM ................................. 41
CLOLAR .................................... 16
clomipramine hcl ........................ 22
clonazepam................................ 12
clonidine..................................... 35
clonidine hcl ......................... 35, 39
clonidine hcl/chlorthalidone ........ 35
clopidogrel bisulfate ................... 32
clorazepate dipotassium ............ 12
clotrimazole ................................ 25
clotrimazole/betamethasone dip 25
clozapine .................................... 28
COARTEM ................................. 27
cocaine hcl ................................. 11
codeine phos/acetaminophen ...... 9
codeine sulfate ............................. 9
codeine/butalbital/asa/caffein ....... 9
colchicine/probenecid ................ 53
COLCRYS.................................. 53
colestipol hcl .............................. 38
colistin (colistimethate na) .......... 13
COLY-MYCIN S ......................... 43
COMBIGAN ............................... 54
COMBIPATCH ........................... 47
COMBIVENT.............................. 57
COMBIVENT RESPIMAT .......... 57
COMETRIQ................................ 16
COMPLERA ............................... 29
COMVAX ................................... 50
CONDYLOX ............................... 40
COPAXONE............................... 53
CORDRAN ................................. 41
COREG CR................................ 36
cortisone acetate........................ 47
CORTISPORIN-TC .....................43
CREON .......................................42
CRESTOR ..................................38
CRIXIVAN ...................................29
cromolyn sodium.............44, 45, 57
CUBICIN .....................................13
cyclobenzaprine hcl ....................57
CYCLOGYL ................................44
cyclopentolate hcl .......................44
cyclophosphamide ......................17
CYCLOPHOSPHAMIDE .............17
CYCLOSET ................................23
cyclosporine ................................49
cyclosporine, modified ................49
cyproheptadine hcl......................25
CYRAMZA ..................................17
CYSTADANE ..............................53
CYSTARAN ................................44
cysteine hcl .................................33
cytarabine/pf ...............................17
dacarbazine ................................17
dactinomycin ...............................17
DALIRESP ..................................57
danazol .......................................46
dantrolene sodium ......................57
dapsone ......................................26
DAPTACEL DTAP ......................50
DARAPRIM .................................27
daunorubicin hcl..........................17
DAUNOXOME ............................17
DDAVP .......................................48
decitabine ...................................17
deferoxamine mesylate ...............46
demeclocycline hcl......................16
DENAVIR ....................................40
DEPO-PROVERA .......................49
desipramine hcl...........................22
desmopressin (nonrefrigerated) ..48
desmopressin acetate .................48
desog-e.estradiol/e.estradiol .......40
desogestrel-ethinyl estradiol .......40
desonide .....................................41
desoximetasone..........................41
DESVENLAFAXINE ER ..............22
dex 2.5%-half str lact.ringers ......55
dexamethasone ..........................47
dexamethasone acetate .............47
dexamethasone sod phosphate 44,
47
dexmethylphenidate hcl ..............39
dexrazoxane ...............................53
dextroamphetamine sulfate.........39
I-3
dextroamphetamine/amphetamine
............................................... 39
dextrose 10 % and 0.2 % nacl .... 33
dextrose 10 % and 0.9 % nacl .... 33
dextrose 10%-0.5 normal saline . 33
dextrose 10%-water.................... 33
dextrose 2.5 % in water .............. 33
dextrose 2.5% in half ringers ...... 33
dextrose 2.5%-0.5normal saline . 33
dextrose 20%-water.................... 33
dextrose 25 % in water ............... 34
dextrose 40%-water.................... 34
dextrose 5 % and 0.3 % nacl ...... 34
dextrose 5 % and 0.9 % nacl ...... 34
dextrose 5 % in water ................. 34
dextrose 5 %-0.2 % nacl ............. 34
dextrose 5 %-0.45 % nacl ........... 34
dextrose 5% in ringers ................ 34
dextrose 5%-lactated ringers ...... 34
dextrose 50 % in water ............... 34
dextrose 60 % in water ............... 34
dextrose 70%-water.................... 34
DEXTROSE W/ELECTROLYTE A
............................................... 55
DEXTROSE W/ELECTROLYTE B
............................................... 55
DIASTAT ACUDIAL .................... 12
diazepam .................................... 12
diclofenac potassium .................. 10
diclofenac sodium ................. 11, 44
diclofenac sodium/misoprostol.... 10
dicloxacillin sodium ..................... 15
dicyclomine hcl ........................... 45
didanosine .................................. 29
DIFICID ...................................... 14
diflorasone diacetate .................. 42
diflunisal ..................................... 11
digoxin ........................................ 37
DIGOXIN .................................... 37
dihydroergotamine mesylate....... 26
DILANTIN ................................... 20
diltiazem hcl ................................ 36
dimenhydrinate ........................... 26
DIOVAN...................................... 35
DIPENTUM ................................. 51
diphenhydramine hcl ............ 25, 26
diphenoxylate hcl/atropine .......... 45
DIPHTHERIA-TETANUS
TOXOIDS-PED ...................... 50
disopyramide phosphate ............ 36
disulfiram .................................... 12
divalproex sodium....................... 20
dobutamine hcl........................... 37
dobutamine hcl/d5w ................... 37
DOCEFREZ ............................... 17
docetaxel ................................... 17
donepezil hcl .............................. 21
dopamine hcl.............................. 37
dopamine hcl/d5w ...................... 37
dopamine hcl/dextrose 5%-water37
dorzolamide hcl .......................... 54
dorzolamide hcl/timolol maleat ... 54
doxazosin mesylate ................... 35
doxepin hcl ................................. 22
doxercalciferol ............................ 52
doxorubicin hcl ........................... 17
doxorubicin hcl peg-liposomal .... 17
doxycycline hyclate .................... 16
doxycycline monohydrate........... 16
dronabinol .................................. 26
droperidol ................................... 53
DROXIA ..................................... 17
DUAVEE .................................... 47
DULERA .................................... 56
duloxetine hcl ............................. 22
DUODOTE ................................. 53
DUREZOL .................................. 44
DUTOPROL ............................... 36
DYRENIUM ................................ 38
DYSPORT.................................. 53
econazole nitrate........................ 25
edetate disodium........................ 46
EDURANT.................................. 29
EFFIENT .................................... 32
ELAPRASE ................................ 43
electrolyte-48 solution/d5w......... 55
electrolyte-48/fructose 10%........ 55
electrolyte-48/fructose 5%.......... 55
electrolyte-75 solution/d5w......... 55
electrolyte-75/fructose 5%.......... 55
ELELYSO .................................. 43
ELIDEL ...................................... 42
ELIGARD ................................... 17
ELIQUIS..................................... 31
ELITEK ...................................... 43
ELMIRON .................................. 53
ELSPAR ..................................... 17
EMCYT ...................................... 17
EMEND ................................ 26, 27
EMSAM ...................................... 22
EMTRIVA ................................... 29
enalapril maleate........................ 35
enalapril/hydrochlorothiazide ..... 35
enalaprilat dihydrate................... 35
ENBREL .....................................49
ENGERIX-B ADULT ...................50
ENGERIX-B PEDIATRICADOLESCENT .......................50
enoxaparin sodium .....................31
entacapone .................................28
entecavir .....................................31
ephedrine sulfate ........................37
epinastine hcl ..............................44
epinephrine .................................37
EPIPEN 2-PAK ...........................37
EPIPEN JR 2-PAK ......................37
epirubicin hcl ...............................17
EPIVIR ........................................29
EPIVIR HBV................................29
eplerenone ..................................38
EPOGEN ....................................32
epoprostenol sodium (glycine) ....58
eprosartan mesylate ...................35
EPZICOM ...................................29
ERAXIS WATER DILUENT ........25
ERBITUX ....................................17
ERGOMAR .................................26
ERIVEDGE .................................17
ERWINAZE .................................17
ery e-succ/sulfisoxazole ..............14
ERY-TAB ....................................14
ERYTHROCIN LACTOBIONATE14
erythromycin base ................14, 43
erythromycin base/ethanol ..........41
erythromycin ethylsuccinate........14
erythromycin stearate .................14
erythromycin/benzoyl peroxide ...41
escitalopram oxalate ...................22
esmolol hcl ..................................36
esomeprazole sodium .................45
estazolam ...................................12
ESTRACE ...................................47
estradiol ......................................47
estradiol valerate ........................47
estradiol/norethindrone acet .......47
ESTRASORB..............................47
estropipate ..................................47
ethambutol hcl ............................26
ethanolamine oleate ...................37
ethinyl estradiol/drospirenone .....40
ethosuximide...............................20
ethynodiol d-ethinyl estradiol ......40
etidronate disodium ....................52
etodolac ......................................11
ETOPOPHOS .............................17
etoposide ....................................17
I-4
EURAX ....................................... 42
EXELDERM ................................ 25
EXELON ..................................... 21
exemestane ................................ 17
EXFORGE .................................. 37
EXFORGE HCT.......................... 37
EXJADE ..................................... 46
EXTAVIA .................................... 53
FABRAZYME.............................. 43
famciclovir................................... 31
famotidine ................................... 45
famotidine in nacl,iso-osm/pf ...... 45
FANAPT ..................................... 28
FARESTON ................................ 17
FASLODEX ................................ 17
FAZACLO ................................... 28
felbamate .................................... 20
felodipine .................................... 37
FEMRING ................................... 47
fenofibrate .................................. 38
fenofibrate nanocrystallized ........ 38
fenofibrate,micronized ................ 38
fenofibric acid ............................. 38
fenofibric acid (choline) ............... 38
fenoprofen calcium ..................... 11
fentanyl ......................................... 9
fentanyl citrate .............................. 9
FERRIPROX............................... 46
FETZIMA .................................... 22
finasteride ................................... 53
FIRAZYR .................................... 37
FIRMAGON ................................ 17
flavoxate hcl................................ 46
FLEBOGAMMA .......................... 49
FLEBOGAMMA DIF ................... 49
flecainide acetate........................ 36
FLECTOR ................................... 11
FLEXBUMIN ............................... 32
floxuridine ................................... 17
fluconazole ................................. 25
fluconazole in nacl,iso-osm......... 25
flucytosine .................................. 25
fludarabine phosphate ................ 17
fludrocortisone acetate ............... 47
flumazenil ................................... 39
flunisolide ................................... 56
fluocinonide ................................ 42
fluorometholone .......................... 44
FLUOROPLEX ........................... 40
fluorouracil ............................ 17, 41
fluoxetine hcl............................... 22
fluoxymesterone ......................... 46
fluphenazine decanoate ............. 28
fluphenazine hcl ......................... 28
flurazepam hcl............................ 12
flurbiprofen ................................. 11
flurbiprofen sodium .................... 44
flutamide .................................... 17
fluticasone propionate ................ 42
fluvastatin sodium ...................... 38
fluvoxamine maleate .................. 22
FOLOTYN .................................. 17
fomepizole ................................. 53
fondaparinux sodium.................. 31
FORADIL ................................... 57
FORTEO .................................... 52
FORTICAL ................................. 52
foscarnet sodium........................ 30
fosinopril sodium ........................ 35
fosinopril/hydrochlorothiazide..... 35
fosphenytoin sodium .................. 20
FREAMINE HBC ........................ 34
FREAMINE III ............................ 34
fructose 10% .............................. 34
FULYZAQ .................................. 45
furosemide ................................. 38
FUROXONE............................... 13
FUSILEV .................................... 53
FUZEON .................................... 29
FYCOMPA ................................. 20
gabapentin ................................. 20
GABITRIL .................................. 20
galantamine hbr ......................... 21
GALZIN ...................................... 46
GAMASTAN S-D........................ 49
GAMMAGARD LIQUID .............. 49
GAMMAPLEX ............................ 49
GAMUNEX-C ............................. 49
ganciclovir sodium ..................... 31
GARDASIL ................................. 50
gatifloxacin ................................. 43
gauze bandage .......................... 53
GAZYVA .................................... 17
gemcitabine hcl .......................... 17
gemfibrozil ................................. 38
GENOTROPIN ........................... 48
gentamicin in nacl, iso-osm ........ 13
gentamicin sulfate .......... 13, 41, 43
gentamicin sulfate/pf .................. 13
GEODON ................................... 28
GILENYA ................................... 53
GILOTRIF .................................. 17
GLEEVEC .................................. 17
glimepiride ................................. 24
glipizide .......................................24
glipizide/metformin hcl ................24
GLUCAGEN................................53
GLUCAGON EMERGENCY KIT.53
glutethimide ................................53
glyburide .....................................24
glyburide,micronized ...................24
glyburide/metformin hcl ...............24
GLYCINE ....................................51
glycopyrrolate .............................45
GLYSET .....................................23
granisetron hcl ............................27
granisetron hcl/pf ........................27
GRANIX ......................................32
griseofulvin ultramicrosize...........25
griseofulvin, microsize ................25
guanfacine hcl.............................35
guanidine hcl...............................53
H.P. ACTHAR .............................53
HALAVEN ...................................17
HALFAN......................................27
halobetasol propionate ...............42
haloperidol ..................................28
haloperidol decanoate ................28
haloperidol lactate.......................28
HAVRIX ......................................50
heparin sod,pork in 0.45% nacl...31
heparin sodium,porcine ..............31
heparin sodium,porcine/d5w .......31
heparin sodium,porcine/ns/pf ......31
heparin sodium,porcine/pf...........31
HEPATAMINE ............................34
HEPATASOL ..............................34
HERCEPTIN ...............................17
HEXALEN ...................................17
homatropine hbr..........................44
HUMALOG............................23, 24
HUMALOG MIX 50-50 ................23
HUMALOG MIX 75-25 ................23
HUMATROPE .............................48
HUMIRA......................................49
HUMULIN 70-30 .........................24
HUMULIN N ................................24
HUMULIN R ................................24
hydralazine hcl ............................37
hydralazine/hydrochlorothiazid ...37
hydrochlorothiazide.....................38
hydrocodone/acetaminophen....... 9
hydrocodone/ibuprofen ................ 9
hydrocortisone ......................42, 47
hydrocortisone acetate ...............42
hydrocortisone acetate/aloe v .....42
I-5
hydrocortisone acetate/urea ....... 42
hydrocortisone butyrate .............. 42
hydrocortisone sod succinate ..... 47
hydrocortisone valerate .............. 42
hydromorphone hcl ....................... 9
hydromorphone hcl/pf ................... 9
hydroxychloroquine sulfate ......... 27
hydroxyurea ................................ 17
hydroxyzine hcl ........................... 53
hydroxyzine pamoate ................. 53
HYPERLYTE CR ........................ 55
HYPERLYTE R........................... 55
HYPERRAB S-D......................... 49
HYPERRHO S-D ........................ 49
ibandronate sodium .................... 52
ibuprofen .................................... 11
ibuprofen/oxycodone hcl ............... 9
ICLUSIG ..................................... 18
idarubicin hcl............................... 18
ifosfamide ................................... 18
ifosfamide/mesna ....................... 18
ILARIS ........................................ 49
ILEVRO ...................................... 44
IMBRUVICA................................ 18
imipenem/cilastatin sodium......... 15
imipramine hcl ............................ 22
imipramine pamoate ................... 22
imiquimod ................................... 41
IMOGAM RABIES-HT ................ 49
IMOVAX RABIES VACCINE....... 50
INCIVEK ..................................... 30
INCRELEX.................................. 48
indapamide ................................. 38
indomethacin .............................. 11
indomethacin sodium.................. 11
INFANRIX DTAP ........................ 50
INFANRIX PF ............................. 50
INLYTA ....................................... 18
INTELENCE ............................... 29
INTRALIPID ................................ 34
INTRON A .................................. 30
INTUNIV ..................................... 39
INVANZ ...................................... 15
INVEGA ...................................... 28
INVEGA SUSTENNA ................. 28
INVIRASE ................................... 29
INVOKAMET .............................. 23
INVOKANA ................................. 23
IONOSOL B with DEXTROSE 5%
............................................... 55
IONOSOL MB-DEXTROSE 5% .. 55
IONOSOL T-DEXTROSE 5% ..... 55
IPOL........................................... 50
ipratropium bromide ................... 57
IPRIVASK .................................. 31
irbesartan ................................... 35
irbesartan/hydrochlorothiazide ... 35
irinotecan hcl .............................. 18
ISENTRESS......................... 29, 30
ISOLYTE E ................................ 55
ISOLYTE H W/DEXTROSE ....... 55
ISOLYTE M W/DEXTROSE ....... 55
ISOLYTE P with DEXTROSE .... 55
ISOLYTE R W/DEXTROSE ....... 55
ISOLYTE S ................................ 55
ISOLYTE S with DEXTROSE .... 55
isoniazid ..................................... 26
isopropamide/prochlorperazine .. 45
ISOPTO CARPINE .................... 54
ISOPTO HOMATROPINE .......... 44
isosorbide dinitrate ..................... 39
isosorbide mononitrate ............... 39
ISOVEX ..................................... 58
isradipine ................................... 37
ISTALOL .................................... 54
ISTODAX ................................... 18
itraconazole................................ 25
IXEMPRA ................................... 18
IXIARO....................................... 50
JAKAFI....................................... 18
JANUMET .................................. 23
JANUMET XR ............................ 23
JANUVIA .................................... 23
JENTADUETO ........................... 23
JE-VAX ...................................... 50
JEVTANA ................................... 18
JUVISYNC ................................. 23
KABIVEN ................................... 34
KADCYLA .................................. 18
KALBITOR ................................. 53
KALETRA .................................. 30
KALYDECO ............................... 57
kanamycin sulfate ...................... 13
KEDBUMIN ................................ 32
KEPIVANCE .............................. 40
KETEK ....................................... 15
ketoconazole .............................. 25
ketoprofen .................................. 11
ketorolac tromethamine ....... 11, 44
KHEDEZLA ................................ 22
KINERET ................................... 49
KINRIX ....................................... 50
KORLYM .................................... 23
K-PHOS NO.2 ............................ 55
KRYSTEXXA ..............................43
KUVAN .......................................43
KYNAMRO..................................38
KYPROLIS ..................................18
labetalol hcl .................................36
LACRISERT................................44
LACTATED RINGERS ................51
lactulose .....................................45
LAMICTAL ..................................20
lamivudine...................................30
lamivudine/zidovudine ................30
lamotrigine ..................................20
LANOXIN ....................................37
lansoprazole ...............................45
lansoprazole/amoxiciln/clarith .....45
LANTUS......................................24
LANTUS SOLOSTAR .................24
latanoprost ..................................54
LATUDA......................................29
LAZANDA .................................... 9
leflunomide .................................49
LETAIRIS ....................................58
letrozole ......................................18
leucovorin calcium ......................53
LEUKERAN ................................18
LEUKINE ....................................32
leuprolide acetate .......................18
LEVEMIR ....................................24
LEVEMIR FLEXPEN ...................24
levetiracetam ..............................20
levetiracetam in nacl (iso-os) ......20
levobunolol hcl ............................54
levocarnitine................................53
levocarnitine (with sugar) ............53
levocetirizine dihydrochloride ......26
levofloxacin ...........................15, 43
levofloxacin/d5w .........................15
levonorgestrel .............................40
levonorgestrel-ethin estradiol ......40
levorphanol tartrate ...................... 9
levothyroxine sodium ..................49
LEVULAN ...................................41
LEXIVA .......................................30
lidocaine .....................................11
lidocaine hcl ................................11
lidocaine hcl/d5w/pf ....................36
lidocaine hcl/pf ......................11, 36
lidocaine/prilocaine .....................11
LIDODERM .................................11
LINZESS .....................................43
liothyronine sodium .....................49
lipase/protease/amylase .............43
I-6
LIPOSYN II ................................. 34
LIPOSYN III ................................ 34
lisinopril ...................................... 35
lisinopril/hydrochlorothiazide....... 35
lithium carbonate ........................ 39
lithium citrate .............................. 39
LITHOSTAT ................................ 53
l-norgest-eth estr/ethin estra ....... 40
LOCOID ...................................... 42
lomustine .................................... 18
loperamide hcl ............................ 45
lorazepam ................................... 12
losartan potassium ..................... 35
losartan/hydrochlorothiazide ....... 35
LOTEMAX .................................. 44
LOTRONEX ................................ 43
lovastatin .................................... 38
loxapine succinate ...................... 29
LOZI-FLUR ................................. 59
LUMINAL SODIUM..................... 20
LUMIZYME ................................. 43
LUPRON DEPOT ....................... 18
LUPRON DEPOT-PED............... 18
LYRICA ...................................... 20
LYSODREN ................................ 18
mafenide acetate ........................ 41
magnesium chloride ................... 55
magnesium sulfate ..................... 55
magnesium sulfate in water ........ 55
magnesium sulfate/d5w .............. 55
malathion .................................... 42
mannitol/sorbitol solution ............ 51
maprotiline hcl ............................ 22
MARPLAN .................................. 22
MARQIBO................................... 18
MATULANE ................................ 18
meclizine hcl ............................... 27
medroxyprogesterone acet ......... 49
medroxyprogesterone acetate .... 49
mefenamic acid .......................... 11
mefloquine hcl ............................ 27
MEGACE ES .............................. 18
megestrol acetate ....................... 18
MEKINIST................................... 18
meloxicam .................................. 11
melphalan hcl ............................. 18
MENACTRA ............................... 51
MENEST .................................... 47
MENHIBRIX................................ 51
MENOMUNE-A-C-Y-W-135........ 51
MENVEO A-C-Y-W-135-DIP ...... 51
mercaptopurine........................... 18
meropenem ................................ 15
mesna ........................................ 53
MESNEX .................................... 53
MESTINON ................................ 53
metaproterenol sulfate ............... 57
metaxalone ................................ 58
metformin hcl ............................. 23
methadone hcl ........................... 10
methazolamide........................... 54
methenamine hippurate ............. 13
methimazole............................... 49
methocarbamol .......................... 58
methotrexate sodium ................. 18
methotrexate sodium/pf ............. 18
methoxsalen, rapid..................... 41
methscopolamine bromide ......... 45
methyclothiazide ........................ 38
methylene blue........................... 53
methylergonovine maleate ......... 53
methylphenidate hcl ................... 39
methylprednisolone .................... 48
methylprednisolone acetate ....... 47
methylprednisolone sod succ47, 48
metipranolol ............................... 54
metoclopramide hcl .................... 45
metolazone ................................ 38
metoprolol succinate .................. 36
metoprolol tartrate ...................... 36
metoprolol/hydrochlorothiazide .. 36
metronidazole ................ 26, 27, 41
metronidazole/sodium chloride .. 27
METVIXIA .................................. 41
mexiletine hcl ............................. 36
MIACALCIN ............................... 52
miconazole nitrate ...................... 26
MICRHOGAM ULTRA-FILTERED
PLUS ..................................... 50
midazolam hcl ............................ 12
midazolam hcl/pf ........................ 12
midodrine hcl.............................. 35
milrinone lactate ......................... 37
milrinone lactate/d5w ................. 37
MINOCIN ................................... 16
minocycline hcl........................... 16
minoxidil ..................................... 39
mirtazapine ................................ 22
misoprostol................................. 45
mitomycin ................................... 18
mitoxantrone hcl......................... 18
M-M-R II VACCINE .................... 51
MOBAN ...................................... 29
modafinil .................................... 58
moexipril hcl ................................35
moexipril/hydrochlorothiazide .....35
mometasone furoate ...................42
montelukast sodium ....................57
morphine sulfate .........................10
MORPHINE SULFATE ...............10
morphine sulfate/0.9% nacl/pf.....10
morphine sulfate/pf .....................10
MOVIPREP .................................46
MOXEZA.....................................43
moxifloxacin hcl ..........................15
MOZOBIL....................................32
MULTAQ .....................................36
mupirocin ....................................41
mupirocin calcium .......................41
MUSTARGEN .............................18
mycophenolate mofetil ................50
mycophenolate sodium ...............50
MYOBLOC ..................................53
MYOZYME..................................43
MYTELASE.................................53
na nitrite/na thiosul/amyl nit ........46
nabumetone ................................11
nadolol ........................................36
NAFCILL IN DEXTROSE ............15
nafcillin sodium ...........................15
NAGLAZYME..............................43
nalbuphine hcl.............................10
nalidixic acid ...............................15
naloxone hcl................................12
naltrexone hcl .............................12
NAMENDA ..................................21
NAMENDA XR ............................21
naphazoline hcl/antazoline..........44
naproxen .....................................11
naproxen sodium ........................11
naratriptan hcl .............................26
NASONEX ..................................56
NATACYN...................................43
nateglinide ..................................23
NEBUPENT ................................27
needles, insulin disposable .........42
nefazodone hcl ...........................22
neo/polymyx b sulf/dexameth .....43
neomy sulf/bacitra/polymyxin b ...43
neomy sulf/bacitrac zn/poly/hc ....43
neomy sulf/polymyxin b sulfate ...41
neomycin sulfate .........................13
neomycin sulfate/dex na ph ........43
neomycin/polymyxin b sulf/hc .....43
neomycin/polymyxn b/gramicidin 43
neostigmine methylsulfate ..........53
I-7
NEPHRAMINE............................ 34
NEULASTA................................. 32
NEUMEGA ................................. 32
NEUPOGEN ............................... 32
NEUPRO .................................... 28
NEVANAC .................................. 44
nevirapine ................................... 30
NEXAVAR .................................. 18
niacin .......................................... 38
nicardipine hcl............................. 38
NICOTROL ................................. 12
nifedipine .................................... 38
NILANDRON .............................. 18
NITRO-BID ................................. 39
nitrofurantoin............................... 13
nitrofurantoin macrocrystal ......... 13
nitroglycerin ................................ 39
nitroglycerin/d5w......................... 39
NITROSTAT ............................... 39
nizatidine .................................... 45
NORDITROPIN .......................... 48
NORDITROPIN FLEXPRO ......... 48
NORDITROPIN NORDIFLEX ..... 48
norelgestromin/ethin.estradiol..... 40
norepinephrine bitartrate ............ 37
noreth-ethinyl estradiol/iron ........ 40
norethindrone ............................. 40
norethindrone acetate ................. 49
norethindrone ac-eth estradiol ... 40,
47
norethindrone-e.estradiol-iron..... 40
norethindrone-ethinyl estrad ....... 40
norethindrone-mestranol............. 40
norgestimate-ethinyl estradiol ..... 40
norgestrel-ethinyl estradiol.......... 40
NORMOSOL-M and DEXTROSE
............................................... 55
NORMOSOL-R PH 7.4 ............... 55
nortriptyline hcl ........................... 22
NORVIR ..................................... 30
NOVAMINE ................................ 34
NOVAREL .................................. 48
NOVOLIN 70-30 ......................... 24
NOVOLIN N ................................ 24
NOVOLIN R ................................ 24
NOVOLOG ................................. 24
NOVOLOG FLEXPEN ................ 24
NOVOLOG MIX 70-30 ................ 24
NOVOLOG MIX 70-30 FLEXPEN
............................................... 24
NOXAFIL .................................... 25
NPLATE ..................................... 53
NUCYNTA.................................. 10
NUCYNTA ER............................ 10
NUEDEXTA ............................... 39
NULOJIX .................................... 50
NUTRESTORE .......................... 45
NUTRILYTE ............................... 55
NUTRILYTE II ............................ 55
NUTROPIN ................................ 48
NUTROPIN AQ .......................... 48
NUTROPIN AQ NUSPIN............ 48
NUVARING ................................ 40
nylidrin hcl .................................. 39
nystatin ...................................... 25
nystatin/triamcin ......................... 25
OCTAGAM ................................. 50
octreotide acetate ...................... 48
OFIRMEV .................................. 10
ofloxacin............................... 15, 43
olanzapine ................................. 29
olanzapine/fluoxetine hcl ............ 22
OLYSIO ..................................... 30
omega-3 acid ethyl esters .......... 38
omeprazole ................................ 45
OMNITROPE ............................. 48
ONCASPAR ............................... 18
ondansetron ............................... 27
ondansetron hcl ......................... 27
ONFI .......................................... 12
ONTAK ...................................... 18
OPSUMIT .................................. 58
ORAP......................................... 29
ORENCIA .................................. 50
ORENITRAM ER ....................... 37
ORFADIN ................................... 43
ORTHO EVRA ........................... 40
OTEZLA ..................................... 53
oxacillin sodium.......................... 15
oxacillin sodium/dextrose,iso ..... 15
oxaliplatin ................................... 18
oxandrolone ............................... 46
oxcarbazepine............................ 20
OXSORALEN-ULTRA ................ 41
OXTELLAR XR .......................... 20
oxybutynin chloride .................... 46
oxycodone hcl ............................ 10
oxycodone hcl/acetaminophen... 10
oxycodone hcl/aspirin ................ 10
OXYCONTIN.............................. 10
oxymorphone hcl........................ 10
paclitaxel .................................... 18
pamidronate disodium................ 52
PANRETIN ................................. 41
pantoprazole sodium ..................45
papaverine hcl ............................37
paregoric .....................................45
paricalcitol ...................................52
paromomycin sulfate ...................27
paroxetine hcl .............................22
PASER .......................................26
PATADAY ...................................44
PATANOL ...................................44
PAXIL .........................................22
pedi m.vit no.17 with fluoride ......59
pedi mvi no.12/sodium fluoride ...59
PEDIARIX ...................................51
PEDVAXHIB ...............................51
peg 3350/na sulf,bicarb,cl/kcl......46
PEGANONE ...............................20
PEGASYS...................................31
PEGASYS PROCLICK ...............31
PEGINTRON ..............................31
PEGINTRON REDIPEN..............31
pen g pot/dextrose-water ............15
penicillin g potassium ..................15
penicillin g potassium/d5w ..........15
penicillin g procaine ....................15
penicillin v potassium ..................15
PENTACEL .................................51
PENTACEL ACTHIB
COMPONENT ........................51
PENTACEL DTAP-IPV
COMPONENT ........................51
PENTAM 300 ..............................27
pentamidine isethionate ..............27
pentostatin ..................................19
pentoxifylline ...............................32
p-epd tan/chlor-tan......................26
PERIKABIVEN ............................34
perindopril erbumine ...................35
PERJETA....................................19
permethrin...................................42
perphenazine ..............................29
perphenazine/amitriptyline hcl ....22
phenelzine sulfate .......................22
phenobarbital ..............................21
phenobarbital sodium .................20
phentolamine mesylate ...............58
phenylephrine hcl..................35, 44
PHENYTEK ................................21
phenytoin ....................................21
phenytoin sodium........................21
phenytoin sodium extended ........21
PHOSLYRA ................................46
PHOSPHOLINE IODIDE.............54
I-8
phosphorus #1 ............................ 55
physostigmine salicylate ............. 53
PICATO ...................................... 41
pilocarpine hcl....................... 40, 54
PILOPINE HS ............................. 54
pindolol ....................................... 36
pioglitazone hcl ........................... 25
pioglitazone hcl/glimepiride......... 25
pioglitazone hcl/metformin hcl .... 25
piperacillin sodium/tazobactam... 15
piroxicam .................................... 11
PLASBUMIN-25.......................... 32
PLASBUMIN-5............................ 32
PLASMA-LYTE 148 .................... 55
PLASMA-LYTE 56 IN DEXTROSE
............................................... 55
PLASMA-LYTE A PH 7.4............ 55
PLASMA-LYTE M IN DEXTROSE
............................................... 55
pnv with ca,no.72/iron/fa ............. 59
podofilox ..................................... 41
podophyllum resin ...................... 41
polyethylene glycol 3350 ............ 46
polymyxin b sulf/trimethoprim ..... 43
polymyxin b sulfate ..................... 13
POMALYST ................................ 19
pot chloride/pot bicarb/cit ac ....... 55
potassium acetate ...................... 55
potassium bicarbonate/cit ac ...... 55
potassium chlorid/d10-0.2%nacl . 55
potassium chloride...................... 56
potassium chloride in 0.9%nacl .. 55
potassium chloride in d5w .......... 56
potassium chloride in lr-d5 .......... 56
potassium chloride/d5-0.2%nacl . 56
potassium chloride/d5-0.25ns ..... 56
potassium chloride/d5-0.3%nacl . 56
potassium chloride/d5-0.45nacl .. 56
potassium chloride/d5-0.9%nacl . 56
potassium chloride-0.45% nacl ... 56
potassium citrate/citric acid......... 56
potassium gluconate ................... 56
potassium hydroxide ................... 41
potassium phos,m-basic-d-basic 56
POTIGA ...................................... 21
PRADAXA .................................. 32
PRALIDOXIME CHLORIDE........ 53
pramipexole di-hcl ...................... 28
PRANDIMET .............................. 23
pravastatin sodium ..................... 38
prazosin hcl ................................ 35
prednicarbate.............................. 42
prednisolone .............................. 48
prednisolone acetate ............ 44, 48
prednisolone sod phosphate 44, 48
prednisone ................................. 48
PREDNISONE INTENSOL ........ 48
PREMARIN ................................ 47
PREMASOL ............................... 34
PREMPHASE ............................ 47
PREMPRO ................................. 47
PREZISTA ................................. 30
PRIFTIN ..................................... 26
PRIMAQUINE ............................ 27
primidone ................................... 21
PRISTIQ ER............................... 22
PRIVIGEN .................................. 50
PROAIR HFA ............................. 57
probenecid ................................. 53
procainamide hcl ........................ 36
PROCALAMINE ......................... 34
prochlorperazine edisylate ......... 27
prochlorperazine maleate........... 27
PROCRIT ................................... 32
PROCYSBI ................................ 53
progesterone .............................. 49
progesterone,micronized ........... 49
PROGLYCEM ............................ 39
PROGRAF ................................. 50
PROLENSA ............................... 44
PROLEUKIN .............................. 19
PROLIA...................................... 52
PROMACTA............................... 32
promethazine hcl.................. 26, 27
PRONESTYL ............................. 36
propafenone hcl ......................... 36
propantheline bromide ............... 20
proparacaine hcl ........................ 44
proparacaine/fluorescein sod ..... 44
propranolol hcl ........................... 36
propranolol/hydrochlorothiazid ... 36
propylthiouracil ........................... 49
PROQUAD ................................. 51
PROSOL .................................... 34
PROSTIGMIN ............................ 53
protamine sulfate ....................... 32
PROTOPAM CHLORIDE ........... 53
PROTOPIC ................................ 42
protriptyline hcl ........................... 22
PULMOZYME ............................ 43
PURIXAN ................................... 19
pyridostigmine bromide .............. 53
QNASL....................................... 56
QUDEXY XR .............................. 21
quetiapine fumarate ....................29
QUICK MIX with LYTES .............34
QUILLIVANT XR .........................39
quinapril hcl.................................35
quinapril/hydrochlorothiazide ......35
quinidine gluconate .....................36
quinidine sulfate ..........................36
quinine sulfate.............................27
QVAR .........................................56
RABAVERT ................................51
raloxifene hcl...............................47
ramipril ........................................35
RANEXA .....................................37
ranitidine hcl................................45
RAPAMUNE ...............................50
RAVICTI......................................45
REBIF .........................................54
REBIF REBIDOSE......................54
RECOMBIVAX HB ......................51
REGONOL ..................................54
RELENZA ...................................30
RELISTOR ..................................45
REMICADE .................................54
REMODULIN ..............................58
RENAGEL...................................46
RENVELA ...................................46
repaglinide ..................................23
RESCRIPTOR ............................30
RETROVIR .................................30
REVATIO ....................................58
REVLIMID ...................................19
REYATAZ ...................................30
RHOGAM ULTRA-FILTERED
PLUS ......................................50
RHOPHYLAC .............................50
ribavirin .......................................31
RIDAURA....................................50
rifabutin .......................................26
rifampin .......................................26
RIFATER ....................................26
riluzole ........................................39
rimantadine hcl ...........................30
ringers solution .....................51, 56
risedronate sodium .....................52
RISPERDAL CONSTA................29
risperidone ..................................29
RITUXAN ....................................19
rivastigmine tartrate ....................21
rizatriptan benzoate ....................26
ropinirole hcl ...............................28
ROTARIX ....................................51
ROTATEQ ..................................51
I-9
ROZEREM.................................. 58
SABRIL....................................... 21
SAIZEN ...................................... 48
salsalate ..................................... 11
SANDOSTATIN LAR .................. 48
SANTYL ..................................... 41
SAPHRIS .................................... 29
SAVELLA ................................... 39
selegiline hcl ............................... 28
selenium sulfide .......................... 41
SELZENTRY .............................. 30
SENSIPAR ................................. 54
SEREVENT DISKUS .................. 57
SEROMYCIN .............................. 26
SEROQUEL XR.......................... 29
SEROSTIM ................................. 48
sertraline hcl ............................... 22
SHOHL'S MODIFIED.................. 56
SIGNIFOR .................................. 54
sildenafil citrate ........................... 58
SILENOR .................................... 22
silver nitrate ................................ 41
silver nitrate applicator ................ 41
silver sulfadiazine ....................... 41
SIMBRINZA ................................ 54
SIMPONI .................................... 54
SIMPONI ARIA ........................... 54
SIMULECT ................................. 54
simvastatin.................................. 38
sirolimus ..................................... 50
SIRTURO ................................... 26
sod propion/inositol/aa14/urea.... 26
sod/pot/k cit/sod cit/cit acid ......... 56
sodium acetate ........................... 56
sodium bicarbonate .................... 56
sodium chloride .......................... 56
sodium chloride 0.45 % .............. 56
sodium chloride 3% .................... 56
sodium chloride 5% .................... 56
sodium chloride irrig solution ...... 51
sodium chloride/nahco3/kcl/peg . 46
sodium lactate ............................ 56
SODIUM LACTATE .................... 56
sodium morrhuate....................... 54
sodium phenylbutyrate ............... 45
sodium phos,m-basic-d-basic ..... 56
sodium polystyrene sulfonate ..... 46
sodium tetradecyl sulfate ............ 54
sodium thiosulfate....................... 46
SOLIRIS ..................................... 54
SOLTAMOX................................ 19
SOLU-CORTEF .......................... 48
SOLU-MEDROL......................... 48
SOMATULINE DEPOT .............. 48
SOMAVERT ............................... 48
sorbitol solution .......................... 51
sotalol hcl ................................... 36
SOTALOL HCL .......................... 36
SOVALDI ................................... 31
spinosad .................................... 42
SPIRIVA..................................... 57
spironolact/hydrochlorothiazid.... 38
spironolactone............................ 38
SPORANOX............................... 25
SPRYCEL .................................. 19
stavudine ................................... 30
STELARA .................................. 54
STERILE DILUENT.................... 32
STIVARGA ................................. 19
STRATTERA.............................. 39
streptomycin sulfate ................... 13
STRIBILD ................................... 30
STROMECTOL .......................... 27
SUBOXONE............................... 12
sucralfate ................................... 45
sulfacetamide sodium .......... 41, 43
sulfacetamide/prednisolone sp... 44
sulfadiazine ................................ 16
sulfamethoxazole/trimethoprim .. 16
sulfasalazine .............................. 16
sulindac...................................... 11
sumatriptan ................................ 26
sumatriptan succinate ................ 26
SUPPRELIN LA ......................... 48
SUPRAX .................................... 14
SUSTIVA ................................... 30
SUTENT .................................... 19
SYLATRON 4-PACK.................. 31
SYLVANT .................................. 19
SYMLIN ..................................... 23
SYMLINPEN 120 ....................... 23
SYMLINPEN 60 ......................... 23
SYNAGIS ................................... 30
SYNAREL .................................. 54
SYNERCID ................................ 13
SYNRIBO ................................... 19
SYPRINE ................................... 46
syring w-ndl,disp,insul,0.3ml ...... 42
syring w-ndl,disp,insul,0.5ml ...... 42
syring w-o ndl,disp,insul, 1ml ..... 42
TABLOID ................................... 19
tacrolimus .................................. 50
TAFINLAR.................................. 19
TAMIFLU ................................... 30
tamoxifen citrate .........................19
tamsulosin hcl .............................58
TANZEUM ..................................23
TARCEVA ...................................19
TARGRETIN .........................19, 42
TASIGNA ....................................19
TAZICEF IN DEXTROSE............14
TAZORAC...................................42
TE ANATOXAL BERNA ..............51
tea tree oil ...................................14
TECFIDERA ...............................54
TEGRETOL XR ..........................21
telmisartan ..................................35
telmisartan/hydrochlorothiazid ....35
temazepam .................................12
TEMODAR ..................................19
teniposide ...................................19
TENIVAC ....................................51
terazosin hcl................................58
terbinafine hcl .............................25
terbutaline sulfate .......................57
terconazole .................................26
testosterone cypionate ................46
testosterone enanthate ...............46
TETANUS DIPHTHERIA
TOXOIDS ...............................51
TETANUS TOXOID ADSORBED
...............................................51
tetracaine hcl/pf ..........................44
tetracycline hcl ............................16
TEV-TROPIN ..............................48
THALOMID .................................54
theophylline anhydrous ...............57
theophylline/d5w .........................57
THERACYS ................................51
THERMAZENE ...........................41
thioridazine hcl ............................29
thiotepa .......................................19
thiothixene ..................................29
tiagabine hcl................................21
TIKOSYN ....................................36
timolol maleate......................36, 54
tinidazole ....................................27
TIVICAY ......................................30
tizanidine hcl ...............................58
TOBI PODHALER.......................13
tobramycin in 0.225% nacl ..........13
tobramycin sulfate.................13, 44
tobramycin/dexamethasone ........44
tobramycin/sodium chloride ........13
tolazamide ..................................24
tolbutamide .................................24
I-10
tolmetin sodium .......................... 11
tolterodine tartrate ...................... 46
topiramate................................... 21
topotecan hcl .............................. 19
TORISEL .................................... 19
torsemide .................................... 38
TPN ELECTROLYTES ............... 56
TRACLEER ................................ 58
TRADJENTA .............................. 23
tramadol hcl ................................ 10
tramadol hcl/acetaminophen....... 10
trandolapril .................................. 35
tranexamic acid .......................... 32
tranylcypromine sulfate ............... 22
TRAVAMULSION ....................... 34
TRAVASOL ................................ 34
TRAVASOL W/DEXTROSE ....... 34
TRAVASOL W/ELECTROLYTES
............................................... 34
TRAVASOL with DEXTROSE .... 34
TRAVASOL with ELECTROLYTES
............................................... 34
TRAVATAN Z ............................. 54
TRAVERT ................................... 34
TRAVERT IN NORMAL SALINE 34
TRAVERT-ELECTROLYTE NO.1
............................................... 56
TRAVERT-ELECTROLYTE NO.2
............................................... 56
TRAVERT-ELECTROLYTE NO.3
............................................... 56
TRAVERT-ELECTROLYTE NO.4
............................................... 56
travoprost (benzalkonium) .......... 55
trazodone hcl .............................. 22
TREANDA .................................. 19
TRECATOR ................................ 26
TRELSTAR ................................. 19
tretinoin................................. 19, 42
tretinoin microspheres ................ 42
TREXALL ................................... 19
triamcinolone acetonide . 40, 42, 48,
57
triamterene/hydrochlorothiazid ... 38
triazolam ..................................... 12
TRIBENZOR ............................... 35
trifluoperazine hcl ....................... 29
trifluridine .................................... 44
trihexyphenidyl hcl ...................... 28
TRILEPTAL ................................ 21
trimethoprim................................ 13
trimipramine maleate .................. 23
tripelennamine hcl ...................... 26
TRISENOX................................. 19
TRIUMEQ .................................. 30
TROKENDI XR .......................... 21
TROPHAMINE ........................... 35
trospium chloride........................ 46
TRUVADA .................................. 30
TWINRIX .................................... 51
TYGACIL ................................... 16
TYKERB .................................... 19
TYPHIM VI ................................. 51
TYSABRI ................................... 50
TYVASO .................................... 59
TYZEKA ..................................... 31
TYZINE ...................................... 44
UCERIS ..................................... 48
urologic solution-g ...................... 52
ursodiol ...................................... 45
UVADEX .................................... 41
VAGIFEM ................................... 47
valacyclovir hcl ........................... 31
VALCHLOR................................ 41
VALCYTE .................................. 31
valproic acid ............................... 21
valproic acid (as sodium salt) ..... 21
valsartan/hydrochlorothiazide .... 35
VALSTAR .................................. 19
vancomycin hcl .......................... 13
VANCOMYCIN HCL .................. 13
vancomycin hcl/d5w ................... 13
VANTAS .................................... 48
VAQTA....................................... 51
VARIVAX VACCINE .................. 51
VASCEPA .................................. 38
vasopressin ................................ 48
VECAMYL .................................. 37
VECTIBIX .................................. 19
VELCADE .................................. 19
venlafaxine hcl ............................23
VENLAFAXINE HCL ER .............23
VENTAVIS ..................................59
VENTOLIN HFA..........................57
verapamil hcl.........................36, 37
VERSACLOZ ..............................29
VESICARE..................................46
VICTRELIS .................................30
VIDEX .........................................30
VIGAMOX ...................................44
VIIBRYD .....................................23
VIMIZIM ......................................43
VIMPAT ......................................21
vinblastine sulfate .......................19
vincristine sulfate ........................19
vinorelbine tartrate ......................19
VIRACEPT ..................................30
VIRAMUNE XR ...........................30
VIREAD ......................................30
VIVELLE-DOT ............................47
VOLTAREN ................................11
VORAXAZE ................................54
voriconazole................................25
VOTRIENT..................................19
VPRIV .........................................43
VUMON ......................................19
warfarin sodium ..........................32
water for irrigation,sterile.............52
WELCHOL ..................................38
WINRHO SDF.............................50
XALKORI ....................................19
XARELTO ...................................32
XARTEMIS XR ...........................10
XELJANZ ....................................54
XENAZINE ..................................39
XERAC AC .................................41
XGEVA .......................................52
XOLAIR ......................................57
I-11
XTANDI ...................................... 20
XYLOCAINE ............................... 36
XYREM....................................... 58
YERVOY .................................... 20
YF-VAX ...................................... 51
zafirlukast ................................... 57
zaleplon ...................................... 58
ZALTRAP ................................... 20
ZANOSAR .................................. 20
ZAVESCA ................................... 43
ZELBORAF................................. 20
ZEMAIRA.................................... 57
ZEMPLAR................................... 52
ZENPEP ..................................... 43
ZETIA ......................................... 38
ZIAGEN ...................................... 30
zidovudine .................................. 30
ziprasidone hcl............................ 29
ZOLADEX ................................... 20
zoledronic acid............................ 52
zoledronic acid/mannitol&water .. 52
ZOLINZA .................................... 20
zolmitriptan ................................. 26
zolpidem tartrate ......................... 58
ZOMETA .................................... 52
zonisamide ................................. 21
ZORBTIVE.................................. 48
ZORTRESS ................................ 50
ZOSTAVAX ................................ 51
ZOVIRAX .................................... 41
ZUBSOLV ................................... 12
ZYDELIG .................................... 20
ZYKADIA .................................... 20
ZYLET ........................................ 44
ZYPREXA RELPREVV ............... 29
ZYTIGA ...................................... 20
ZYVOX ....................................... 13
This formulary was updated on 11/01/2014. For more recent information or other questions, please contact Transamerica
MedicareRx Member Services, at 1-888-672-7206 or, for TTY users, 711, 24 hours a day, 365 days a year, or visit
www.transamericamedicarerx.com.
Stonebridge Life Insurance Company (a Transamerica Company) is a PDP plan sponsor with a Medicare contract.
Enrollment in this plan depends on contract renewal.
POR FAVOR LEA: ESTE DOCUMENTO CONTIENE INFORMACION ACERCA DE
LOS MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN
Formulary ID: 14602.000, Version: 20
S9579_14_CHOICECOMPFORM_SP_VERSION1
MRXFCR13R
Nota para miembros existentes: Este formulario cambió desde el año pasado. Por favor, revise este documento para
asegurarse de que aún contenga los medicamentos que usted toma.
Cuando en esta lista de medicamentos (formulario) hacemos referencia a “nosotros” o “nuestro”, significa Stonebridge
Life Insurance Company. Cuando hacemos referencia a “nosotros” o “nuestro”, significa Transamerica MedicareRx
Choice (PDP).
Este documento incluye una lista de medicamentos (formulario) para nuestro plan que fue actualizado el
11/01/2014. Para ver el formulario actualizado, por favor comuníquese con nosotros. Nuestra información de
contacto y la fecha de la última actualización aparecen en la primera página y en la última página del formulario.
En general, usted debe usar las farmacias de la red para obtener el beneficio de los medicamentos recetados. Los
beneficios, el formulario, la red de farmacias, las primas y/o los copagos/el coseguro pueden cambiar el 1 de enero de
2015.
¿Qué es el Formulario de Transamerica MedicareRx Choice (PDP)?
Un formulario es una lista de medicamentos cubiertos seleccionados por Transamerica MedicareRx Choice (PDP) junto
con un equipo de proveedores de atención médica, que representa a las terapias recetadas que se consideran parte
necesaria de un programa de tratamiento de calidad. Transamerica MedicareRx Choice (PDP) generalmente cubre los
medicamentos que se encuentran en nuestro formulario, siempre que tal medicamento sea médicamente necesario,
que la receta médica se presente en una farmacia de la red de Transamerica MedicareRx Choice (PDP), y se sigan
otras reglas del plan. Para obtener más información sobre cómo surtir sus recetas, consulte su Evidencia de Cobertura.
¿Puede cambiar el Formulario (la lista de medicamentos)?
En general, si toma un medicamento de nuestro formulario del año 2014 que se cubría al inicio del año, no vamos
a descontinuar ni reducir la cobertura del medicamento durante la cobertura del año 2014, a menos que esté
disponible un nuevo medicamento genérico más económico, o cuando se publique información nueva
desfavorable respecto de la seguridad o la eficacia de un medicamento. Otros tipos de cambios al formulario,
como la eliminación de un medicamento de nuestro formulario, no afectarán a los miembros que actualmente
toman el medicamento. Éste seguirá disponible al mismo costo compartido para esos miembros que lo toman
durante el resto del año de cobertura. Consideramos que es importante que tenga acceso continuo durante el
resto del año de cobertura a los medicamentos del formulario que se encontraban disponibles al momento de
optar por el plan, excepto por los casos en los que puede ahorrar dinero adicional o en los que podemos
garantizar la seguridad.
Si eliminamos medicamentos de nuestro formulario, agregamos autorización previa, los límites de cantidad y/o las
restricciones a la terapia en etapas o se mueve un medicamento a un nivel de costo compartido mayor, debemos
notificar a los miembros afectados sobre el cambio al menos 60 días antes de que el cambio entre en vigencia, o
en el momento que el miembro solicite una receta de un medicamento, en cuyo caso el miembro recibirá un
suministro del medicamento para 60 días. Si la Administración de Drogas y Alimentos de los Estados Unidos (FDA
por sus siglas en inglés) considera que un medicamento de nuestro formulario es inseguro o el fabricante del
medicamento retira el medicamento del mercado, de inmediato lo eliminaremos de nuestro formulario y
proporcionaremos la notificación a los miembros que toman el medicamento. El formulario adjunto está
actualizado a la fecha 11/01/2014. Para recibir información actualizada acerca de los medicamentos que cubre
Transamerica MedicareRx Choice (PDP), comuníquese con nosotros. Nuestra información de contacto aparece
en la primera página y en la parte de atrás del formulario. Si se producen cambios en el formulario no
mantenimiento medicados de año, los miembros afectados serán notificados de cambios en el formulario de "Su
resumen mensual de medicamentos recetados", también conocida como la explicación de la Parte D de
Beneficios (EOB).
¿Cómo se utiliza el Formulario?
Hay dos formas de buscar su medicamento en el formulario:
1
Condición médica
El formulario comienza en la página 10. Los medicamentos de este formulario están agrupados en categorías
según el tipo de enfermedad o condición médica para la que se utilizan. Por ejemplo, los medicamentos que se
usan para tratar una condición cardíaca se listan bajo la categoría Cardiac Drugs. Si sabe para qué usa su
medicamento, busque el nombre de la categoría en la lista que comienza en en la página 10. Luego busque bajo el
nombre de la categoría de su medicamento.
Listado alfabético
Si no está seguro en qué categoría buscar, debe buscar su medicamento en el Índice que comienza en la página II. El Índice proporciona una lista en orden alfabético de todos los medicamentos incluidos en este documento. Tanto
los medicamentos de marca como los genéricos aparecen en la lista del Índice. Para buscar su medicamento
busque en el Índice. Junto al medicamento, verá el número de página en el que puede buscar información sobre la
cobertura. Vaya a la página que se indica en el Índice y busque el nombre del medicamento en la primera columna
de la lista.
¿Qué son los medicamentos genéricos?
Transamerica MedicareRx Choice (PDP) cubre tanto medicamentos de marca como genéricos. Un medicamento
genérico está aprobado por la Administración de Drogas y Alimentos de los Estados Unidos (FDA) por tener el
mismo ingrediente activo que el medicamento de marca. En general, los medicamentos genéricos cuestan menos
que los de marca.
¿Existen restricciones en mi cobertura?
Algunos medicamentos cubiertos pueden tener requisitos adicionales o límites en la cobertura. Estos requisitos y límites
pueden ser:

Autorización previa: Transamerica MedicareRx Choice (PDP) requiere que usted o su médico obtengan una
autorización previa para ciertos medicamentos. Esto significa que necesitará la aprobación de Transamerica
MedicareRx Choice (PDP) antes de presentar sus recetas médicas. Si no obtiene la aprobación, Transamerica
MedicareRx Choice (PDP) no puede cubrir el medicamento.

Límites de cantidad: Para ciertos medicamentos, Transamerica MedicareRx Choice (PDP) limita la cantidad de
medicamento que cubre Transamerica MedicareRx Choice (PDP). Por ejemplo, Transamerica MedicareRx
Choice (PDP) proporciona 18 tabletas en 28 días por receta para Maxalt. Éste puede agregarse a un suministro
estándar para uno o tres meses.

Terapia en etapas: En algunos casos, Transamerica MedicareRx Choice (PDP) requiere que primero pruebe
con ciertos medicamentos para tratar su enfermedad antes de cubrir otro medicamento para dicha enfermedad.
Por ejemplo, si un Medicamento A y un Medicamento B tratan la misma enfermedad, Transamerica MedicareRx
Choice (PDP) puede no cubrir el Medicamento B a menos que primero pruebe el Medicamento A. Si el
Medicamento A no funciona en usted, Transamerica MedicareRx Choice (PDP) no cubrirá el Medicamento B.
Para averiguar si su medicamento tiene algún requisito o límite adicional, busque en el formulario que comienza en la
página 10. Además, para obtener más información acerca de las restricciones aplicadas a medicamentos cubiertos
específicos, visite nuestro sitio web. Nuestra información de contacto y la fecha de la última actualización aparecen en
la primera página y en la última página del formulario.
O puede solicitar a Transamerica MedicareRx Choice (PDP) que haga una excepción a estas restricciones o límites, o
para una lista de medicamentos similares que pudieran afectar su condición médica. Consulte la sección, “¿Cómo
solicitar una excepción al formulario de Transamerica MedicareRx Choice (PDP)?” en la página 3 para obtener
información acerca de cómo solicitar una excepción.
2
¿Qué ocurre si mi medicamento no está en el Formulario?
Si su medicamento no está incluido en la lista de medicamentos cubiertos, primero debe comunicarse con Servicios
para Miembros y consulte si su medicamento está cubierto. Este documento sólo incluye una lista parcial de
medicamentos cubiertos, por lo tanto, Transamerica MedicareRx Choice (PDP) pudiera cubrir su medicamento. Puede
comunicarse con nosotros. Nuestra información de contacto y la fecha de la última actualización aparecen en la primera
página y en la última página del formulario.
Si sabe que Transamerica MedicareRx Choice (PDP) no cubre su medicamento, tiene dos opciones:

Puede pedir a Servicios para Miembros una lista de medicamentos similares que cubre Transamerica
MedicareRx Choice (PDP). Cuando reciba la lista, preséntesela al médico y pídale que le recete algún
medicamento similar que cubra Transamerica MedicareRx Choice (PDP).

Puede solicitar a Transamerica MedicareRx Choice (PDP) que haga una excepción y cubra su medicamento.
Consulte a continuación para obtener información sobre cómo solicitar una excepción.
¿Cómo solicitar una excepción al Formulario de Transamerica MedicareRx Choice (PDP)?
Puede solicitar a Transamerica MedicareRx Choice (PDP) que haga una excepción a nuestras reglas de cobertura.
Existen diversos tipos de excepciones que nos puede solicitar.



Puede solicitarnos que cubramos su medicamento aunque no esté en nuestro formulario. Si se aprueba, este
medicamento estará cubierto a un nivel de costo compartido predeterminado y usted no podrá solicitarnos el
medicamento a un nivel de costo compartido menor.
Puede solicitarnos que proporcionemos un nivel mayor de cobertura para su medicamento si este medicamento
no está en el nivel de especialidad. Si se aprueba, esto reduciría el la cantidad que debe pagar por el
medicamento.
Puede solicitarnos que anulemos los límites de la cobertura en su medicamento. Por ejemplo, para ciertos
medicamentos, Transamerica MedicareRx Choice (PDP) limita la cantidad del medicamento que cubriremos. Si
su medicamento tiene un límite de cantidad, puede solicitarnos que anulemos el límite y cubramos una cantidad
mayor.
En general, Transamerica MedicareRx Choice (PDP) solamente aprobará su solicitud de excepción si los
medicamentos alternativos incluidos en el formulario del plan, el medicamento de menor costo compartido o las
restricciones adicionales a la utilización no fueran tan eficaces para el tratamiento de su enfermedad y/o causaran un
efecto adverso en su salud.
Debe comunicarse con nosotros para que tomemos una decisión inicial de cobertura de un formulario, nivel o excepción
en restricción de utilización. Cuando solicita un formulario, nivel o excepción de restricción de utilización, debe
enviar una declaración de quien emite la receta o el médico para justificar su solicitud. En general, debemos
tomar nuestra decisión en un plazo de 72 horas de recibida la declaración de respaldo del médico que emite la receta.
Puede solicitar una excepción urgente (rápida) si usted o su médico consideran que su salud podría verse gravemente
afectada si espera una decisión hasta 72 horas. Si se otorga su solicitud de excepción urgente, debemos comunicarle
una decisión antes de las 24 horas tras la recepción de la declaración de respaldo de quien emite la receta o el médico.
¿Qué debo hacer antes de hablar con mi médico acerca de cambiar mis medicamentos o
solicitar una excepción?
Como miembro nuevo o permanente de nuestro plan puede que esté tomando medicamentos que no formen parte de
nuestro formulario. O bien, puede que esté tomando un medicamento que forma parte de nuestro formulario pero que
su capacidad para obtenerlo sea limitada. Por ejemplo, puede que necesite nuestra autorización previa antes de poder
presentar su receta. Debe hablar con su médico para decidir si debe cambiar por un medicamento adecuado que
cubrimos o solicitar una excepción al formulario para que cubramos el medicamento que usted toma. Mientras habla
3
con su médico para determinar la medida indicada en su caso, puede que cubramos su medicamento en ciertos casos
durante los primeros 90 días que sea miembro de nuestro plan.
Para cada uno de sus medicamentos que no figure en nuestro formulario o si su capacidad para obtener sus
medicamentos es limitada, cubriremos un suministro temporal para 31 días (a menos que tenga una receta para menos
días) cuando vaya a una farmacia de la red. Después del primer suministro para 31 días, no pagaremos estos
medicamentos, aunque haya sido miembro del plan menos de 90 días.
Si vive en un centro de cuidado a largo plazo, le permitiremos presentar su receta médica hasta que le hayamos
proporcionado un suministro de transición para 93 días, conforme al incremento de dispensación, (a menos que tenga
una receta para menos días). Cubriremos más de una reposición de estos medicamentos durante los primeros 90 días
que sea miembro de nuestro plan. Si necesita un medicamento que no está en nuestro formulario o si su capacidad
para obtener sus medicamentos es limitada, pero ya pasaron los primeros 90 días de ser miembro en nuestro plan,
cubriremos un suministro de emergencia de ese medicamento para 31 días (a menos que tenga una receta para menos
días) mientras trata de obtener una excepción al formulario.
Si usted nota un cambio en la configuración de la atención (como ser dado de alta o admitido en un centro de atención
a largo plazo), su médico o farmacia pueden solicitar una anulación por prescripción de una sola vez. Esta anulación
por única vez le proporcionará la cobertura temporal (hasta un suministro de 31 días) para el medicamento aplicable(s).
Para obtener más información
Para obtener más información sobre la cobertura de medicamentos recetados de Transamerica MedicareRx Choice
(PDP), consulte su Evidencia de Cobertura y demás material del plan.
Si tiene preguntas acerca de Transamerica MedicareRx Choice (PDP), llámenos. Nuestra información de contacto y la
fecha de la última actualización aparecen en la primera página y en la última página del formulario.
Si tiene preguntas generales acerca de la cobertura de medicamentos recetados de Medicare, llame a Medicare al 1800-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, visite www.medicare.gov.
4
Formulario de Transamerica MedicareRx Choice (PDP)
El formulario que comienza en la página 10 proporciona información de cobertura acerca de algunos de los
medicamentos que cubre Transamerica MedicareRx Choice (PDP). Si tiene problemas para encontrar su medicamento
en la lista, vaya al Índice que comienza en la página I-1.
En la primera columna de la tabla aparece el nombre del medicamento. Los medicamentos de marca están en
mayúscula (por ejemplo, SINGULAIR) y los medicamentos genéricos aparecen en letra cursiva minúscula (por ejemplo,
montelukast sodium).
La información en la columna Requisitos/Límites le indica si Transamerica MedicareRx Choice (PDP) tiene algún
requisito parcial de cobertura de su medicamento.
Las siguientes abreviaturas pueden ser encontrados en el cuerpo de este documento
COBERTURA DE NOTAS SIGLAS
ABREVIATURA DEL
DESCRIPCIÓN
EXPLICACIÓN
Restricciones de gestión de utilización
Restricción de
Autorización Previa
Usted (o su médico) tiene la obligación de obtener autorización previa de
Transamerica MedicareRx Choice (PDP) antes de llenar su receta para
este medicamento. Sin autorización previa, es posible que no cubra el
medicamento.
PA BvD
Restricción de
autorización previa
para la Parte B vs
Determinación de
la Parte D
Este medicamento puede ser elegible para el pago bajo la Parte B de
Medicare o de la Parte D. Usted (o su médico) tienen la obligación de
obtener autorización previa de Transamerica MedicareRx Choice (PDP)
para determinar que este medicamento está cubierto por Medicare Parte
D antes de surtir su receta para este medicamento. Sin autorización
previa, es posible que no cubra el medicamento.
PA NSO
Restricción de
Autorización Previa
de New Starts Sólo
Si usted es un nuevo miembro, usted (o su médico) tiene la obligación de
obtener autorización previa de Transamerica MedicareRx Choice (PDP)
antes de llenar su receta para este medicamento. Sin autorización previa,
es posible que no cubra el medicamento.
QL
Cantidad Límite de
Restricción
Transamerica MedicareRx Choice (PDP) limita la cantidad de este
medicamento que esté cubierto por receta, o dentro de un marco de
tiempo específico.
ST
Terapia escalonada
Restricción
Antes de Transamerica MedicareRx Choice (PDP) proporcionará
cobertura de este medicamento, primero debe probar otro medicamento
(s) para el tratamiento de su condición médica. Este medicamento sólo
puede ser cubierto si el otro medicamento(s) no funciona para usted.
PA
5
ABREVIATURA
DEL
DESCRIPCIÓN
EXPLICACIÓN
Restricciones de gestión de utilización
LA
NM
Drogas de acceso
limitado
Drogas Orden
Non-Mail
Esta receta puede estar disponible sólo en ciertas farmacias. Para
obtener más información, consulte su Directorio de Farmacias o llame a
Servicio al Cliente al 1-888-672-7206, las 24 horas del día, los 365 días
del año. Los usuarios de TTY / TDD deben llamar al 711.
Es posible que pueda recibir más de un suministro de 1 mes de la
mayoría de los medicamentos incluidos en el formulario a través de
pedidos por correo a una cuota de precio reducido. Los medicamentos
no disponibles a través de su beneficio de pedidos por correo se indican
con "NM" en los Requerimientos / columna límites de su formulario.
La siguiente tabla incluye los costos compartidos para cada nivel de drogas que se muestra en la lista de
medicamentos que le sigue.
Nivel Número / Nombre
Suministro de 31 días a
menor
Suministro de 90 días a Suministro de 90 días en
menor
el pedido por correo
Su copago / coseguro Durante la Etapa de cobertura inicial
Nivel 1 / medicamentos genéricos $0 copago
$0 copago
$0 copago
preferidos
Nivel 2 / genéricos no preferidos
drugs
Nivel 3 / medicamentos de marca
preferidos
$20 copago
$60 copago
$50 copago
$45 copago
$135 copago
$115 copago
Nivel 4 / medicamentos de marca
no preferidos
$95 copago
$285 copago
$240 copago
Nivel 5 / medicamentos
especializados
33% de coseguro
33% de coseguro
33% de coseguro
La información de beneficios provista es un resumen breve, no una descripción completa de los beneficios. Para
obtener más información de contacto el plan.
6
Abreviatura del
adh. patch
aer br act
aer pow
aer pow ba
aer refill
aer w/adap
ampul
blkbaginj
cap dr mp
cap ds pk
cap er 12h
cap er 24h
cap er deg
cap er pel
cap mphase
cap.sa 24h
cap.sr 12h
cap.sr 24h
cap24h pct
cap24h pel
cap sprink
cap sr pel
cap w/dev
capsule dr
capsule er
capsule sa
cmb cappad
cmb ont fm
cmb ont lt
cmb tabpad
combo. pkg
cpmp 12hr
cpmp 24hr
cpmp 30-70
cpmp 50-50
cream(g), cream(gm)
cream(ml)
cream/appl
cream, er (g)
cream pack
dehp fr bg
dis needle
disk w/dev
disp syrin
drops susp
drps hpvis
emul adhes
emul packt
emulsn(g)
VIGOR Y DOSIS ABREVIATURAS FORMULARIO
Descripción
adhesive patch
aerosol, breath activated
aerosol, powder
aerosol powder, breath activated
aerosol refill
aerosol with adapter
ampule
bulk bag injection
capsule, delayed release multiphasic
capsule, dose pack
capsule, 12 hour extended release
capsule, 24 hour extended release
capsule, extended release degradable
capsule, extended release pellets
capsule, multiphasic
capsule, 24 hour sustained action
capsule, 12 hour sustained release
capsule, 24 hour sustained release
capsule, 24 hour controlled-onset pellets
capsule, 24 hour sustained release pellets
capsule, sprinkle
capsule sustained release pellets
capsule with device
capsule, delayed release
capsule, extended release
capsule, sustained action
combination: capsule, pad
combination: ointment, foam
combination: ointment, lotion
combination: tablet, pad
combination package
capsule, 12 hour multiphasic
capsule, 24 hour multiphasic
capsule, multiphasic, 30%-70%
capsule, multiphasic, 50%-50%
cream (grams)
cream (milliliters)
cream with applicator
cream, extended release (grams)
cream, package
di(2-ethylhexyl)phthalate free bag
disposable needle
disk with inhalation device
disposable syringe
drops, suspension
drops, hyperviscous
emulsion adhesive
emulsion packet
emulsion (grams)
7
Abreviatura del
foam/appl.
froz.piggy
g
gel/pf app
gel (gm)
gel (ml)
gel md pmp
gel w/appl
gel w/pump
gran pack
hfa aer ad
infus. btl
insuln pen
ip soln
irrig soln
iv soln.
jel
jelly/app
jel/pf app
kit cl&crm
kt crm le
kt lotn ce
kt oint le
lotion, er
lozenge hd
m.ht patch
ma buc tab
mcg
med. pad
med. swab
med. tape
mg
ml
muc er 12h
ndl fr inj
nl fm susp
oint. (g), oint.(gm)
oral conc
oral susp
paste (g)
patch td24
patch td72
patch tdsw
patch tdwk
pca syring
pca vial
pellet(ea)
pen ij kit
pen injctr
pggybk btl
Descripción
foam with applicator
frozen piggyback
gram
gel with prefilled applicator
gel (grams)
gel (milliliters)
gel in metered dose pump
gel with applicator
gel with pump
granule pack
hfa aerosol adapter
infusion bottle
insulin pen
intraperitoneal solution
irrigating solution
intravenous solution
jelly
jelly with applicator
jelly with pre-filled applicator
kit: cleanser and cream
kit: cream, lotion emollient
kit: lotion, cream emollient
kit: ointment, lotion emollient
lotion, extended release
lozenge handle
medicated heated patch
mucoadhesive buccal tablet
microgram
medicated pad
medicated swab
medicated tape
milligram
milliliter
mucoadhesive system, 12 hour extended release
needle for injection
nail film suspension
ointment (grams)
oral concentrate
oral suspension
paste (grams)
patch, 24 hour transdermal
patch, 72 hour transdermal
patch, biweekly transdermal
patch, weekly transdermal
patient-controlled analgesic syringe
patient-controlled analgesic vial
pellet (each)
pen injector kit
pen injector
piggyback bottle
8
Abreviatura del
plast. bag
powd pack
sol md pmp
sol w/appl
sol/pf app
sol-gel
soln recon
soln(gram)
spray susp
spray/pump
stick(ea)
supp.rect
supp.vag
suppos.
sus er 24h
sus er rec
sus mc rec
suspdr pkt
susp recon
syringekit
tab chew
tab er 12h
tab er 24h
tab er prt
tab er seq
tab disper
tab ds pk
tab er 24
tab mphase
tab part
tab rap dr
tab rapdis
tab subl
tab.sr 12h
tab.sr 24h
tabergr24hr
tablet dr
tablet, er
tablet eff
tablet sa
tablet sol
tb er dspk
tb mp dspk
tb rd dspk
tbdspk 3mo
tbmp 12hr
tbmp 24hr
u
vag ring
Descripción
plastic bag
powder pack
solution with multi-dose pump
solution with applicator
solution with pre-filled applicator
solution, gel-forming
solution, reconstituted
solution (grams)
spray, suspension
spray with pump
stick (each)
suppository, rectal
suppository, vaginal
suppository
suspension, 24 hour extended release
suspension, extended release reconstituted
suspension, microcapsule reconstituted
suspension, delayed release packet
suspension, reconstituted
syringe kit
tablet, chewable
tablet, 12 hour extended release
tablet, 24 hour extended release
tablet, extended release particles
tablet, extended release sequels
tablet, dispersible
tablet, dose pack
tablet, 24 hour extended release
tablet, multiphasic
tablet, particles
tablet, rapid disintegrating delayed release
tablet, rapid disintegrating
tablet, sublingual
tablet, 12 hour sustained release
tablet, 24 hour sustained release
tablet, 24 hour gradual extended release
tablet, delayed release
tablet, extended release
tablet, effervescent
tablet, sustained action
tablet, soluble
tablet, extended release dose pack
tablet, multiphasic dose pack
tablet, rapid disintegrating dose pack
tablet, 3-month dose pack
tablet, 12 hour multiphasic
tablet, 24 hour multiphasic
unit
vaginal ring
9
Nombre del medicamento
Niveles de
Drogas
Requisitos / Límites
Analgesics
Analgesics, Miscellaneous
acetaminophen with codeine
acetaminophen with codeine
buprenorphine hcl
butalb/acetaminophen/caffeine
2
2
2
2
QL: 180 in 30 days
QL: 360 in 30 days
butalb/acetaminophen/caffeine
2
PA, QL: 2700 in 30 days
butalbit/acetamin/caff/codeine
2
PA, QL: 180 in 30 days
butalbit/acetamin/caff/codeine
2
PA, QL: 180 in 30 days
butalbital/acetaminophen
2
PA, QL: 180 in 30 days
butorphanol tartrate
butorphanol tartrate
BUTRANS
2
2
3
QL: 5 in 28 days
QL: 4 in 28 days
BUTRANS
codeine phos/acetaminophen
codeine sulfate
codeine/butalbital/asa/caffein
3
2
2
2
QL: 4 in 28 days
QL: 2500 in 30 days
QL: 180 in 30 days
PA, QL: 180 in 30 days
fentanyl citrate
fentanyl
hydrocodone/acetaminophen
hydrocodone/acetaminophen
5
2
2
2
PA, QL: 120 in 30 days
PA
QL: 150 in 30 days
QL: 180 in 30 days
hydrocodone/acetaminophen
hydrocodone/acetaminophen
2
2
QL: 2025 in 30 days
QL: 240 in 30 days
hydrocodone/acetaminophen
hydrocodone/acetaminophen
hydrocodone/acetaminophen
2
2
2
QL: 2700 in 30 days
QL: 2700 in 30 days
QL: 360 in 30 days
hydrocodone/acetaminophen
2
QL: 390 in 30 days
hydrocodone/ibuprofen
hydromorphone hcl/pf
hydromorphone hcl/pf
hydromorphone hcl
hydromorphone hcl
hydromorphone hcl
hydromorphone hcl
ibuprofen/oxycodone hcl
LAZANDA
2
2
2
2
2
2
2
2
5
QL: 150 in 30 days
PA, QL: 180 in 30 days
QL: 1200 in 30 days
QL: 180 in 30 days
QL: 240 in 30 days
QL: 28 in 30 days
PA, QL: 30 in 30 days
10
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
tablet: 300mg-60mg
tablet: 300mg-15mg, 300mg-30mg
(injectable)
tablet: 50-325-40, (High Risk
Med for Ages 65 and Older)
solution, (High Risk Med for Ages
65 and Older)
capsule: 50-300-30, (High Risk
Med for Ages 65 and Older)
capsule: 50-325-30, (High Risk
Med for Ages 65 and Older)
tablet: 50mg-325mg, (High Risk
Med for Ages 65 and Older)
syringe, vial
spray
patch tdwk: 5mcg/hr, 10mcg/hr,
15mcg/hr, 20mcg/hr
patch tdwk: 7.5mcg/hr
tablet
(High Risk Med for Ages 65 and
Older)
tablet: 7.5-750mg, 10-750mg
tablet: 7.5-650mg, 10-660mg,
10mg-650mg
solution: 10-300/15
capsule, tablet: 2.5-500mg, 5mg500mg, 7.5-500mg, 10mg-500mg
solution: 7.5-325/15
solution: 7.5-500/15, 10-325/15
tablet: 2.5-325mg, 5mg-325mg,
7.5-325mg, 10mg-325mg
tablet: 5mg-300mg, 7.5-300mg,
10mg-300mg
ampul
vial
syringe
liquid
tablet: 2mg, 4mg
tablet: 8mg
Vigencia: 01 noviembre 2014
Nombre del medicamento
Niveles de
Drogas
Requisitos / Límites
levorphanol tartrate
methadone hcl
methadone hcl
methadone hcl
methadone hcl
methadone hcl
morphine sulfate/0.9% nacl/pf
morphine sulfate/pf
morphine sulfate
2
2
2
2
2
2
2
2
2
morphine sulfate
morphine sulfate
MORPHINE SULFATE
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
nalbuphine hcl
NUCYNTA ER
NUCYNTA
OFIRMEV
oxycodone hcl/acetaminophen
oxycodone hcl/acetaminophen
oxycodone hcl/acetaminophen
2
2
2
2
2
2
2
2
3
3
4
2
2
2
oxycodone hcl/acetaminophen
2
QL: 360 in 30 days
oxycodone hcl/aspirin
oxycodone hcl
oxycodone hcl
OXYCONTIN
OXYCONTIN
2
2
2
3
3
QL: 360 in 30 days
QL: 1300 in 30 days
QL: 180 in 30 days
QL: 120 in 30 days
QL: 60 in 30 days
oxymorphone hcl
oxymorphone hcl
oxymorphone hcl
2
2
2
QL: 120 in 30 days
QL: 180 in 30 days
QL: 60 in 30 days
tramadol hcl/acetaminophen
2
tramadol hcl
2
XARTEMIS XR
3
Nonsteroidal Anti-inflammatory Agents
butalbital/aspirin/caffeine
2
QL: 240 in 30 days
QL: 240 in 30 days
QL: 360 in 30 days
CALDOLOR
CELEBREX
choline sal/mag salicylate
4
3
2
QL: 180 in 30 days
QL: 1800 in 30 days
QL: 1800 in 30 days
QL: 360 in 30 days
QL: 90 in 30 days
QL: 120 in 30 days
QL: 180 in 30 days
QL: 180 in 30 days
QL: 200 in 30 days
QL: 300 in 30 days
QL: 700 in 30 days
vial
oral conc
solution
tablet
tablet sol
ampul, cartridge: 8mg/ml, 10mg/
ml, 15mg/ml; pen injctr, supp.rect,
syringe, vial, vial port
cartridge: 2mg/ml, 4mg/ml
tablet er: 30mg, 60mg, 100mg
tablet er: 15mg, 200mg
solution: 100mg/5ml
solution: 20mg/5ml
solution: 10mg/5ml
QL: 60 in 30 days
QL: 181 in 30 days
QL: 180 in 30 days
QL: 1800 in 30 days
QL: 240 in 30 days
PA, QL: 180 in 30 days
tablet: 10mg-650mg
solution
capsule, tablet: 5mg-500mg, 7.5500mg
tablet: 2.5-325mg, 5mg-325mg,
7.5-325mg, 10mg-325mg
solution
capsule, oral conc, tablet
tab er 12h: 80mg
tab er 12h: 10mg, 15mg, 20mg,
30mg, 40mg, 60mg
tab er 12h: 30mg, 40mg
tablet
tab er 12h: 5mg, 7.5mg, 10mg,
15mg, 20mg
tablet
(High Risk Med for Ages 65 and
Older)
ST, QL: 60 in 30 days
11
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
Vigencia: 01 noviembre 2014
Nombre del medicamento
Niveles de
Drogas
Requisitos / Límites
diclofenac potassium
diclofenac sodium/misoprostol
diclofenac sodium
diflunisal
etodolac
fenoprofen calcium
FLECTOR
flurbiprofen
ibuprofen
ibuprofen
indomethacin sodium
2
2
2
2
2
2
3
2
1
2
2
PA
indomethacin
2
PA, QL: 120 in 30 days
indomethacin
2
PA, QL: 240 in 30 days
indomethacin
2
PA, QL: 60 in 30 days
ketoprofen
ketorolac tromethamine
ketorolac tromethamine
ketorolac tromethamine
ketorolac tromethamine
mefenamic acid
meloxicam
meloxicam
nabumetone
naproxen sodium
naproxen
naproxen
piroxicam
salsalate
sulindac
tolmetin sodium
VOLTAREN
2
2
2
2
2
2
1
2
2
1
1
2
2
2
2
2
3
gel (gram), tab er 24h, tablet dr
QL: 20 in 30 days
QL: 20 in 30 days
QL: 40 in 30 days
QL: 40 in 30 days
tablet
oral susp: 100mg/5ml
(High Risk Med for Ages 65 and
Older)
capsule: 50mg, (High Risk Med
for Ages 65 and Older)
capsule: 25mg, (High Risk Med
for Ages 65 and Older)
capsule er, (High Risk Med for
Ages 65 and Older)
cartridge: 30mg/ml
tablet, vial: 60mg/2ml
cartridge: 15mg/ml
vial: 15mg/ml
tablet
oral susp
tablet
oral susp, tablet dr
(Topical Gel)
Anesthetics
Local Anesthetics
cocaine hcl
lidocaine hcl/pf
2
2
lidocaine hcl
lidocaine hcl
2
2
lidocaine hcl
lidocaine/prilocaine
2
2
PA BvD
PA BvD
PA BvD
12
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
ampul: 15mg/ml, 40mg/ml, (PA
for ESRD Only)
disp syrin, solution: 4%
jel (ml), jel/pf app, solution: 2%,
40mg/ml
vial, (PA for ESRD Only)
(PA for ESRD Only)
Vigencia: 01 noviembre 2014
Nombre del medicamento
lidocaine
LIDODERM
Niveles de
Drogas
2
2
Requisitos / Límites
PA BvD
oint. (g), (PA for ESRD Only)
Anti-addiction/substance Abuse Treatment Agents
Anti-addiction/substance Abuse Treatment Agents
acamprosate calcium
2
buprenorphine hcl/naloxone hcl
2
PA, QL: 90 in 30 days
buprenorphine hcl
2
PA, QL: 90 in 30 days
CAMPRAL
4
CHANTIX
3
QL: 168 in 84 days
CHANTIX
3
QL: 53 in 28 days
CHANTIX
3
QL: 56 in 28 days
disulfiram
2
naloxone hcl
2
naloxone hcl
2
naltrexone hcl
2
NICOTROL
4
QL: 2016 in 365 days
SUBOXONE
4
PA, QL: 60 in 30 days
SUBOXONE
4
PA, QL: 90 in 30 days
ZUBSOLV
3
PA, QL: 90 in 30 days
Benzodiazepines
alprazolam
alprazolam
2
2
QL: 60 in 30 days
QL: 90 in 30 days
chlordiazepoxide hcl
clonazepam
clonazepam
2
2
2
QL: 120 in 30 days
QL: 300 in 30 days
QL: 90 in 30 days
clorazepate dipotassium
clorazepate dipotassium
DIASTAT ACUDIAL
diazepam
diazepam
diazepam
diazepam
estazolam
flurazepam hcl
lorazepam
lorazepam
lorazepam
midazolam hcl/pf
midazolam hcl
midazolam hcl
ONFI
2
2
4
2
2
2
2
2
2
2
2
2
2
2
2
4
QL: 120 in 30 days
QL: 60 in 30 days
tab ds pk
tablet: 0.5mg, 1mg
tab ds pk
tablet: 1mg
syringe: 0.4mg/ml; vial
syringe: 1mg/ml
film: 12mg-3mg
film: 2mg-0.5mg, 4mg-1mg, 8mg2mg
Antianxiety Agents
QL: 120 in 30 days
QL: 1200 in 30 days
QL: 2 in 28 days
QL: 30 in 30 days
QL: 30 in 30 days
QL: 150 in 30 days
QL: 2 in 30 days
QL: 90 in 30 days
QL: 2 in 30 days
QL: 10 in 30 days
QL: 2 in 30 days
PA NSO, QL: 480 in 30
days
13
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
tab er 24h: 1mg, 2mg, 3mg
tab er 24h: 0.5mg; tab rapdis,
tablet
tab rapdis: 2mg; tablet: 2mg
tab rapdis: 0.125mg, 0.25mg,
0.5mg, 1mg; tablet: 0.5mg, 1mg
tablet: 15mg
tablet: 3.75mg, 7.5mg
kit
tablet
oral conc, solution
syringe
oral conc
syringe, vial
tablet
syrup
syringe
oral susp
Vigencia: 01 noviembre 2014
Nombre del medicamento
ONFI
ONFI
temazepam
triazolam
Niveles de
Drogas
Requisitos / Límites
4
4
2
2
PA NSO, QL: 60 in 30 days tablet: 10mg, 20mg
PA NSO, QL: 60 in 30 days tablet: 5mg
QL: 30 in 30 days
QL: 30 in 30 days
5
2
2
PA BvD
Antibacterials
Aminoglycosides
BETHKIS
gentamicin in nacl, iso-osm
gentamicin in nacl, iso-osm
piggyback: 100mg/50ml
piggyback: 60mg/50ml, 70mg/
50ml, 80mg/100ml, 80mg/50ml,
90mg/100ml, 100mg/0.1l
gentamicin sulfate/pf
gentamicin sulfate
kanamycin sulfate
neomycin sulfate
streptomycin sulfate
TOBI PODHALER
tobramycin in 0.225% nacl
tobramycin sulfate
tobramycin/sodium chloride
tobramycin/sodium chloride
Antibacterials, Miscellaneous
bacitracin
chloramphenicol sod succ
clindamycin hcl
clindamycin palmitate hcl
clindamycin phosphate/d5w
clindamycin phosphate
colistin (colistimethate na)
CUBICIN
FUROXONE
methenamine hippurate
nitrofurantoin macrocrystal
2
2
2
2
2
5
5
2
2
2
nitrofurantoin
2
PA, QL: 2400 in 30 days
polymyxin b sulfate
SYNERCID
trimethoprim
vancomycin hcl/d5w
vancomycin hcl
2
5
2
2
2
PA BvD
2
2
2
2
2
2
2
5
3
2
2
QL: 224 in 28 days
PA BvD
piggyback: 60mg/50ml
piggyback: 80mg/100ml
vial port
PA BvD
(PA for ESRD Only)
PA, QL: 120 in 30 days
(High Risk Med. QL applies to all
members; PA required for 65
years and older with over 90 days
cumulative use of nitrofurantoin
drugs)
(High Risk Med. QL applies to all
members; PA required for 65
years and older with over 90 days
cumulative use of nitrofurantoin
drugs)
14
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
vial: 1g, 10g, (PA for ESRD Only)
Vigencia: 01 noviembre 2014
Nombre del medicamento
Niveles de
Drogas
vancomycin hcl
VANCOMYCIN HCL
vancomycin hcl
ZYVOX
Cephalosporins
cefaclor
cefadroxil
cefazolin sodium/dextrose,iso
cefazolin sodium/dextrose,iso
cefazolin sodium
cefdinir
cefditoren pivoxil
cefditoren pivoxil
cefepime hcl
CEFEPIME
CEFEPIME-DEXTROSE
cefotaxime sodium
cefotetan disod/dextrose,iso
cefotetan disodium
cefoxitin sodium/dextrose,iso
cefoxitin sodium
cefpodoxime proxetil
cefprozil
ceftazidime pentahydrate
ceftazidime pentahydrate
ceftibuten dihydrate
ceftriaxone na/dextrose,iso
ceftriaxone sodium
cefuroxime axetil
cefuroxime sodium/dextrose,iso
cefuroxime sodium
cephalexin
2
4
5
5
cephalexin
SUPRAX
TAZICEF IN DEXTROSE
tea tree oil
Macrolides
azithromycin
clarithromycin
DIFICID
ery e-succ/sulfisoxazole
ERY-TAB
ERYTHROCIN LACTOBIONATE
ERYTHROCIN LACTOBIONATE
erythromycin base
erythromycin base
1
4
4
1
Requisitos / Límites
PA BvD
capsule
2
2
2
2
2
2
2
2
2
4
4
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
2
2
5
2
2
4
4
2
2
vial: 750mg, (PA for ESRD Only)
froz.piggy
piggyback
tablet: 200mg
tablet: 400mg
vial
vial port
tablet
capsule: 250mg, 500mg; susp
recon, tablet
capsule: 750mg
tab chew, tablet
QL: 20 in 10 days
15
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
vial port: 1g
vial port: 500mg
capsule dr
tablet, tablet dr
Vigencia: 01 noviembre 2014
Nombre del medicamento
Niveles de
Drogas
erythromycin ethylsuccinate
erythromycin ethylsuccinate
erythromycin stearate
KETEK
Miscellaneous B-lactam Antibiotics
aztreonam
CAYSTON
imipenem/cilastatin sodium
INVANZ
INVANZ
meropenem
Penicillins
amoxicillin trihydrate
amoxicillin/potassium clav
amoxicillin
2
2
2
4
ampicillin sodium/sulbactam na
ampicillin sodium/sulbactam na
ampicillin sodium
ampicillin sodium
ampicillin trihydrate
BICILLIN C-R
BICILLIN L-A
dicloxacillin sodium
NAFCILL IN DEXTROSE
nafcillin sodium
nafcillin sodium
oxacillin sodium/dextrose,iso
oxacillin sodium
pen g pot/dextrose-water
pen g pot/dextrose-water
penicillin g potassium/d5w
penicillin g potassium
penicillin g procaine
penicillin g procaine
penicillin v potassium
piperacillin sodium/tazobactam
Quinolones
AVELOX ABC PACK
AVELOX IV
ciprofloxacin hcl
ciprofloxacin lactate/d5w
ciprofloxacin lactate
ciprofloxacin/ciprofloxa hcl
ciprofloxacin
levofloxacin/d5w
levofloxacin
2
2
2
2
1
4
4
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
5
2
4
4
2
Requisitos / Límites
susp recon
tablet
ST
LA
1
2
1
3
4
1
2
2
2
2
2
1
16
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
vial
vial port
capsule, susp recon, tab chew,
tablet
vial
vial port
vial
vial port
vial
vial port
froz.piggy: 1mm/50ml
froz.piggy: 2mm/50ml, 3mm/50ml
syringe: 1.2mm/2ml
syringe: 600000/ml
tablet
Vigencia: 01 noviembre 2014
Nombre del medicamento
Niveles de
Drogas
levofloxacin
moxifloxacin hcl
nalidixic acid
ofloxacin
Sulfonamides
sulfadiazine
sulfamethoxazole/trimethoprim
sulfamethoxazole/trimethoprim
sulfasalazine
Tetracyclines
demeclocycline hcl
doxycycline hyclate
doxycycline hyclate
2
2
2
2
doxycycline monohydrate
doxycycline monohydrate
2
2
MINOCIN
minocycline hcl
tetracycline hcl
TYGACIL
5
2
2
5
Requisitos / Límites
solution, vial
2
1
2
2
tablet
oral susp, vial
2
2
2
capsule dr, tablet: 100mg
capsule, tablet: 20mg; tablet dr,
vial
capsule: 150mg
capsule: 75mg, 100mg; susp
recon, tablet
vial
Anticancer Agents
Anticancer Agents
ABRAXANE
ADCETRIS
AFINITOR DISPERZ
AFINITOR
ALIMTA
anastrozole
ARRANON
ARZERRA
AVASTIN
azacitidine
BELEODAQ
BEXXAR
bicalutamide
BICNU
bleomycin sulfate
BOSULIF
BOSULIF
BUSULFEX
CAPRELSA
CAPRELSA
carboplatin
CEENU
CEENU
cisplatin
5
5
5
5
5
2
5
5
5
5
5
5
2
4
2
5
5
5
5
5
2
3
3
2
PA NSO, QL: 3 in 21 days
PA NSO, QL: 112 in 28 days
PA NSO, QL: 28 in 28 days
PA NSO
PA NSO, QL: 80 in 30 days
PA NSO
PA NSO
PA BvD
PA NSO, QL: 120 in 30 days
PA NSO, QL: 30 in 30 days
tablet: 100mg
tablet: 500mg
PA NSO, QL: 30 in 30 days
PA NSO, QL: 60 in 30 days
tablet: 300mg
tablet: 100mg
17
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
capsule: 100mg
capsule: 10mg, 40mg
Vigencia: 01 noviembre 2014
Nombre del medicamento
cladribine
CLOLAR
COMETRIQ
cyclophosphamide
cyclophosphamide
CYCLOPHOSPHAMIDE
CYRAMZA
cytarabine/pf
cytarabine/pf
dacarbazine
dactinomycin
daunorubicin hcl
DAUNOXOME
decitabine
DOCEFREZ
docetaxel
docetaxel
doxorubicin hcl peg-liposomal
doxorubicin hcl
DROXIA
ELIGARD
ELIGARD
ELIGARD
ELIGARD
ELSPAR
EMCYT
epirubicin hcl
ERBITUX
ERIVEDGE
ERWINAZE
ETOPOPHOS
etoposide
exemestane
FARESTON
FASLODEX
FIRMAGON
floxuridine
fludarabine phosphate
fluorouracil
fluorouracil
flutamide
FOLOTYN
GAZYVA
gemcitabine hcl
GILOTRIF
GLEEVEC
GLEEVEC
Niveles de
Drogas
2
5
5
2
2
4
5
2
2
2
2
2
4
5
5
5
5
5
2
3
4
4
4
5
3
3
2
5
5
5
4
2
2
5
5
4
2
5
2
2
2
5
5
5
5
5
5
Requisitos / Límites
PA BvD
PA NSO, QL: 112 in 28 days
PA BvD, ST
PA BvD
PA BvD, ST
PA NSO
PA BvD
PA BvD
tablet
vial
vial: 1g, 100mg
vial: 500mg
vial: 20mg/2ml, 20mg/ml(1)
vial: fnl20mg/2
PA BvD
PA BvD
vial: 10mg
QL: 1 in 112 days
QL: 1 in 28 days
QL: 1 in 84 days
QL: 1 in 168 days
syringe: 30mg
syringe: 7.5mg
syringe: 22.5mg
syringe: 45mg
PA NSO
PA NSO, QL: 30 in 30 days
PA NSO, QL: 60 in 30 days
PA NSO
PA BvD
PA BvD
PA BvD
vial: 1g/20ml
vial: 500mg/10ml
PA NSO
PA NSO, QL: 30 in 30 days
PA NSO, QL: 60 in 30 days
PA NSO, QL: 90 in 30 days
18
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
tablet: 400mg
tablet: 100mg
Vigencia: 01 noviembre 2014
Nombre del medicamento
HALAVEN
HERCEPTIN
HEXALEN
hydroxyurea
ICLUSIG
ICLUSIG
idarubicin hcl
ifosfamide/mesna
ifosfamide
IMBRUVICA
INLYTA
INLYTA
irinotecan hcl
ISTODAX
IXEMPRA
JAKAFI
JEVTANA
KADCYLA
KYPROLIS
letrozole
LEUKERAN
leuprolide acetate
lomustine
LUPRON DEPOT
LUPRON DEPOT
LUPRON DEPOT
LUPRON DEPOT-PED
LUPRON DEPOT-PED
LYSODREN
MARQIBO
MATULANE
MEGACE ES
megestrol acetate
MEKINIST
MEKINIST
melphalan hcl
mercaptopurine
methotrexate sodium/pf
methotrexate sodium
methotrexate sodium
mitomycin
mitoxantrone hcl
MUSTARGEN
NEXAVAR
NILANDRON
ONCASPAR
ONTAK
Niveles de
Drogas
5
5
5
2
5
5
2
5
2
5
5
5
5
5
5
5
5
5
5
2
4
2
2
5
5
5
5
5
3
5
5
3
2
5
5
5
2
2
2
2
2
2
3
5
3
5
5
Requisitos / Límites
PA NSO, QL: 24 in 28 days
PA NSO
PA NSO, QL: 30 in 30 days
PA NSO, QL: 60 in 30 days
tablet: 45mg
tablet: 15mg
PA BvD
PA BvD
PA NSO, QL: 120 in 30 days
PA NSO, QL: 180 in 30 days
PA NSO, QL: 60 in 30 days
kit: 1g-1g, 3g-1g
tablet: 1mg
tablet: 5mg
PA NSO
PA NSO, QL: 60 in 30 days
PA NSO, QL: 2 in 21 days
PA NSO, QL: 6 in 21 days
PA NSO
QL: 2 in 28 days
QL: 1 in 168 days
QL: 1 in 28 days
QL: 1 in 84 days
QL: 1 in 112 days
QL: 1 in 28 days
syringekit: 45mg
syringekit: 3.75mg
syringekit: 11.25mg, 22.5mg
syringekit: 30mg
kit, syringekit: 11.25mg
PA NSO, QL: 4 in 28 days
PA NSO, QL: 30 in 30 days
PA NSO, QL: 90 in 30 days
tablet: 2mg
tablet: 0.5mg
PA BvD
PA BvD, ST
PA BvD
PA BvD
tablet
vial
PA NSO, QL: 120 in 30 days
19
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
Vigencia: 01 noviembre 2014
Nombre del medicamento
Niveles de
Drogas
oxaliplatin
paclitaxel
pentostatin
PERJETA
POMALYST
PROLEUKIN
PURIXAN
REVLIMID
5
2
5
5
5
5
5
5
RITUXAN
SOLTAMOX
SPRYCEL
STIVARGA
SUTENT
SYLVANT
SYLVANT
SYNRIBO
TABLOID
TAFINLAR
tamoxifen citrate
TARCEVA
TARGRETIN
TASIGNA
TEMODAR
teniposide
thiotepa
topotecan hcl
TORISEL
TREANDA
TRELSTAR
TRELSTAR
TRELSTAR
tretinoin
TREXALL
TRISENOX
TYKERB
VALSTAR
VECTIBIX
VELCADE
vinblastine sulfate
vincristine sulfate
vinorelbine tartrate
VOTRIENT
VUMON
XALKORI
XTANDI
YERVOY
5
4
5
5
5
5
5
5
3
5
2
5
5
5
5
2
2
5
5
5
5
5
5
5
4
5
5
5
5
5
2
2
2
5
4
5
5
5
Requisitos / Límites
PA NSO, QL: 14 in 21 days
PA NSO, QL: 21 in 28 days
LA, PA NSO, QL: 28 in 28
days
PA NSO
PA NSO, QL: 30 in 30 days
PA NSO, QL: 84 in 28 days
PA NSO, QL: 30 in 30 days
PA NSO
PA NSO
PA NSO, QL: 28 in 28 days
vial: 100mg
vial: 400mg
PA NSO, QL: 120 in 30 days
PA NSO, QL: 30 in 30 days
PA NSO, QL: 420 in 30 days
PA NSO, QL: 112 in 28 days
PA NSO
(vial only)
PA BvD, QL: 4 in 28 days
QL: 1 in 168 days
QL: 1 in 28 days
QL: 1 in 84 days
vial
syringe: 3.75mg/2ml
syringe: 11.25/2ml
(capsule: 10mg)
PA BvD, ST
PA NSO
PA NSO
PA BvD
PA BvD
PA NSO, QL: 120 in 30 days
PA NSO, QL: 60 in 30 days
PA NSO, QL: 120 in 30 days
PA NSO
20
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
Vigencia: 01 noviembre 2014
Nombre del medicamento
Niveles de
Drogas
ZALTRAP
ZANOSAR
ZELBORAF
ZOLADEX
ZOLADEX
ZOLINZA
ZYDELIG
ZYKADIA
ZYTIGA
Requisitos / Límites
5
3
5
4
4
5
5
5
5
PA NSO
3
2
2
2
QL: 60 in 30 days
4
4
2
3
3
2
2
2
2
3
2
3
4
2
2
2
2
4
3
3
2
4
3
2
ST
ST
PA NSO, QL: 240 in 30 days
QL: 1 in 28 days
QL: 1 in 84 days
implant: 3.6mg
implant: 10.8mg
PA NSO, QL: 60 in 30 days
PA NSO, QL: 140 in 28 days
PA NSO, QL: 120 in 30 days
Anticholinergic Agents
Antimuscarinics/antispasmodics
ANORO ELLIPTA
atropine sulfate
atropine sulfate
propantheline bromide
syringe
vial
Anticonvulsants
Anticonvulsants
APTIOM
BANZEL
carbamazepine
CELONTIN
DILANTIN
divalproex sodium
ethosuximide
felbamate
fosphenytoin sodium
FYCOMPA
gabapentin
GABITRIL
LAMICTAL
lamotrigine
lamotrigine
levetiracetam in nacl (iso-os)
levetiracetam
LUMINAL SODIUM
LYRICA
LYRICA
oxcarbazepine
OXTELLAR XR
PEGANONE
phenobarbital sodium
capsule: 30mg
ST
tablet: 12mg, 16mg
tb chw dsp: 2mg
tab ds pk
tab er 24, tablet, tb chw dsp
QL: 2 in 30 days
QL: 90 in 30 days
QL: 900 in 30 days
syringe
capsule
solution
ST
QL: 2 in 30 days
21
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
vial: 65mg/ml, 130mg/ml
Vigencia: 01 noviembre 2014
Nombre del medicamento
Niveles de
Drogas
phenobarbital
phenobarbital
phenobarbital
2
2
2
PHENYTEK
phenytoin sodium extended
phenytoin sodium
phenytoin sodium
phenytoin
POTIGA
POTIGA
primidone
QUDEXY XR
SABRIL
TEGRETOL XR
tiagabine hcl
topiramate
topiramate
TRILEPTAL
TROKENDI XR
valproic acid (as sodium salt)
valproic acid
VIMPAT
VIMPAT
VIMPAT
zonisamide
3
2
2
2
2
4
4
2
4
5
3
2
2
2
4
4
2
2
4
4
4
2
Requisitos / Límites
QL: 1500 in 30 days
QL: 200 in 30 days
QL: 90 in 30 days
elixir: 20mg/5ml
tablet: 30mg
tablet: 15mg, 16.2mg, 32.4mg,
60mg, 64.8mg, 97.2mg, 100mg
ampul
syringe
ST, QL: 270 in 30 days
ST, QL: 90 in 30 days
tablet: 50mg
tablet: 200mg, 300mg, 400mg
ST
tab er 12h: 100mg
cap spr 24
cap sprink, tablet
oral susp
ST
ST, QL: 1200 in 30 days
ST, QL: 200 in 5 days
ST, QL: 60 in 30 days
solution
vial
tablet
Antidementia Agents
Antidementia Agents
donepezil hcl
EXELON
EXELON
galantamine hbr
galantamine hbr
galantamine hbr
NAMENDA XR
NAMENDA XR
NAMENDA
NAMENDA
NAMENDA
rivastigmine tartrate
2
3
4
2
2
2
3
3
3
3
3
2
QL: 30 in 30 days
QL: 30 in 30 days
QL: 232 in 30 days
QL: 200 in 30 days
QL: 30 in 30 days
QL: 60 in 30 days
QL: 28 in 28 days
QL: 30 in 30 days
QL: 360 in 30 days
QL: 49 in 28 days
QL: 60 in 30 days
QL: 60 in 30 days
22
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
patch td24
solution
solution
cap24h pel
tablet
cap24 dspk
cap spr 24
solution
tab ds pk
tablet
Vigencia: 01 noviembre 2014
Nombre del medicamento
Niveles de
Drogas
Requisitos / Límites
Antidepressants
Antidepressants
amitriptyline hcl
2
amoxapine
BRINTELLIX
bupropion hcl
citalopram hydrobromide
citalopram hydrobromide
clomipramine hcl
2
4
2
1
2
2
desipramine hcl
DESVENLAFAXINE ER
doxepin hcl
2
4
2
duloxetine hcl
duloxetine hcl
EMSAM
escitalopram oxalate
escitalopram oxalate
FETZIMA
fluoxetine hcl
fluoxetine hcl
fluvoxamine maleate
imipramine hcl
2
2
4
2
2
4
1
2
2
2
QL: 30 in 30 days
QL: 60 in 30 days
QL: 30 in 30 days
QL: 30 in 30 days
QL: 697 in 30 days
ST
imipramine pamoate
2
PA NSO
KHEDEZLA
maprotiline hcl
MARPLAN
mirtazapine
nefazodone hcl
nortriptyline hcl
olanzapine/fluoxetine hcl
paroxetine hcl
PAXIL
perphenazine/amitriptyline hcl
4
2
4
2
2
2
2
2
4
2
ST, QL: 30 in 30 days
phenelzine sulfate
PRISTIQ ER
protriptyline hcl
sertraline hcl
sertraline hcl
SILENOR
tranylcypromine sulfate
trazodone hcl
2
4
2
1
2
3
2
1
PA NSO
(High Risk Med for Ages 65 and
Older)
ST
QL: 30 in 30 days
PA NSO
ST, QL: 30 in 30 days
PA NSO
tablet
solution
(High Risk Med for Ages 65 and
Older)
(High Risk Med for Ages 65 and
Older)
capsule dr: 30mg
capsule dr: 20mg, 60mg
tablet
solution
capsule
capsule dr, solution, tablet
PA NSO
PA NSO
(High Risk Med for Ages 65 and
Older)
(High Risk Med for Ages 65 and
Older)
oral susp
(High Risk Med for Ages 65 and
Older)
ST, QL: 30 in 30 days
tablet
oral conc
QL: 30 in 30 days
23
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
Vigencia: 01 noviembre 2014
Nombre del medicamento
Niveles de
Drogas
Requisitos / Límites
trimipramine maleate
2
PA NSO
VENLAFAXINE HCL ER
VENLAFAXINE HCL ER
venlafaxine hcl
VIIBRYD
2
4
2
4
PA NSO, QL: 30 in 30 days
Antidiabetic Agents, Miscellaneous
acarbose
BYDUREON PEN
BYDUREON
BYETTA
BYETTA
CYCLOSET
GLYSET
INVOKAMET
INVOKAMET
2
3
3
4
4
4
4
3
3
QL: 90 in 30 days
ST, QL: 4 in 28 days
ST, QL: 4 in 28 days
ST, QL: 1.2 in 28 days
ST, QL: 2.4 in 28 days
QL: 180 in 30 days
QL: 90 in 30 days
ST, QL: 120 in 30 days
ST, QL: 60 in 30 days
INVOKANA
INVOKANA
JANUMET XR
3
3
3
ST, QL: 30 in 30 days
ST, QL: 60 in 30 days
QL: 30 in 30 days
JANUMET XR
JANUMET
JANUVIA
JENTADUETO
JUVISYNC
KORLYM
metformin hcl
metformin hcl
metformin hcl
metformin hcl
metformin hcl
metformin hcl
nateglinide
PRANDIMET
repaglinide
SYMLIN
SYMLINPEN 120
SYMLINPEN 60
TANZEUM
TRADJENTA
Insulins
HUMALOG MIX 50-50
HUMALOG MIX 50-50
HUMALOG MIX 75-25
HUMALOG MIX 75-25
3
3
3
3
3
5
1
1
1
2
2
2
2
3
2
4
4
4
3
3
QL: 60 in 30 days
QL: 60 in 30 days
QL: 30 in 30 days
QL: 60 in 30 days
QL: 30 in 30 days
PA, QL: 112 in 28 days
QL: 150 in 30 days
QL: 60 in 30 days
QL: 90 in 30 days
QL: 120 in 30 days
QL: 60 in 30 days
QL: 90 in 30 days
QL: 90 in 30 days
QL: 150 in 30 days
QL: 240 in 30 days
PA, QL: 20 in 28 days
PA, QL: 10.8 in 28 days
PA, QL: 6 in 28 days
ST
QL: 30 in 30 days
3
3
3
3
QL: 30 in 28 days
QL: 40 in 28 days
QL: 30 in 28 days
QL: 40 in 28 days
(High Risk Med for Ages 65 and
Older)
tab er 24: 37.5mg, 75mg, 150mg
tab er 24: 225mg
Antidiabetic Agents
24
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
pen injctr: 5mcg/0.02
pen injctr: 10mcg/0.04
tablet: 50mg-500mg
tablet: 50-1000mg, 150-1000mg,
150-500mg
tablet: 300mg
tablet: 100mg
tbmp 24hr: 50mg-500mg, 1001000mg
tbmp 24hr: 50-1000mg
tablet: 500mg
tablet: 1000mg
tablet: 850mg
tab er 24h: 500mg
tab er 24
tab er 24h: 750mg
insuln pen
vial
insuln pen
vial
Vigencia: 01 noviembre 2014
Nombre del medicamento
Niveles de
Drogas
Requisitos / Límites
HUMALOG
HUMALOG
HUMULIN 70-30
HUMULIN 70-30
HUMULIN N
HUMULIN N
HUMULIN R
LANTUS SOLOSTAR
LANTUS
LEVEMIR FLEXPEN
LEVEMIR
NOVOLIN 70-30
NOVOLIN 70-30
NOVOLIN N
NOVOLIN N
NOVOLIN R
NOVOLIN R
NOVOLOG FLEXPEN
NOVOLOG MIX 70-30 FLEXPEN
NOVOLOG MIX 70-30
NOVOLOG
Sulfonylureas
glimepiride
glimepiride
glipizide/metformin hcl
glipizide/metformin hcl
glipizide
glipizide
glipizide
glipizide
glyburide,micronized
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
QL: 30 in 28 days
QL: 40 in 28 days
QL: 30 in 28 days
QL: 40 in 28 days
QL: 30 in 28 days
QL: 40 in 28 days
QL: 40 in 28 days
QL: 30 in 28 days
QL: 40 in 28 days
ST, QL: 30 in 28 days
ST, QL: 40 in 28 days
QL: 30 in 28 days
QL: 40 in 28 days
QL: 30 in 28 days
QL: 40 in 28 days
QL: 30 in 28 days
QL: 40 in 28 days
QL: 30 in 28 days
QL: 30 in 28 days
QL: 40 in 28 days
QL: 40 in 28 days
cartridge
vial
insuln pen
vial
insuln pen
vial
1
1
2
2
1
1
2
2
2
QL: 30 in 30 days
QL: 60 in 30 days
QL: 120 in 30 days
QL: 240 in 30 days
QL: 120 in 30 days
QL: 60 in 30 days
QL: 30 in 30 days
QL: 60 in 30 days
PA, QL: 30 in 30 days
glyburide,micronized
2
PA, QL: 60 in 30 days
glyburide/metformin hcl
2
PA, QL: 120 in 30 days
glyburide/metformin hcl
2
PA, QL: 240 in 30 days
glyburide
2
PA, QL: 120 in 30 days
glyburide
2
PA, QL: 30 in 30 days
tolazamide
tolazamide
tolbutamide
2
2
2
QL: 120 in 30 days
QL: 60 in 30 days
QL: 180 in 30 days
tablet: 1mg, 2mg
tablet: 4mg
tablet: 2.5-500mg, 5mg-500mg
tablet: 2.5-250mg
tablet: 10mg
tablet: 5mg
tab er 24: 2.5mg, 5mg
tab er 24: 10mg
tablet: 1.5mg, 3mg, (High Risk
Med for Ages 65 and Older)
tablet: 6mg, (High Risk Med for
Ages 65 and Older)
tablet: 2.5-500mg, 5mg-500mg,
(High Risk Med for Ages 65 and
Older)
tablet: 1.25-250mg, (High Risk
Med for Ages 65 and Older)
tablet: 5mg, (High Risk Med for
Ages 65 and Older)
tablet: 1.25mg, 2.5mg, (High Risk
Med for Ages 65 and Older)
tablet: 250mg
tablet: 500mg
25
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
cartridge
vial
cartridge
vial
cartridge
vial
Vigencia: 01 noviembre 2014
Nombre del medicamento
Thiazolidinediones
ACTOPLUS MET XR
AVANDAMET
AVANDARYL
AVANDIA
pioglitazone hcl/glimepiride
pioglitazone hcl/metformin hcl
pioglitazone hcl
Niveles de
Drogas
Requisitos / Límites
3
4
4
4
2
2
2
QL: 60 in 30 days
PA, QL: 60 in 30 days
PA, QL: 30 in 30 days
PA, QL: 30 in 30 days
QL: 30 in 30 days
QL: 90 in 30 days
QL: 30 in 30 days
5
2
5
2
2
2
2
2
5
4
2
1
2
5
2
2
2
2
5
5
2
2
4
2
2
5
PA BvD
PA BvD
Antihistamines
carbinoxamine maleate
carbinoxamine maleate
2
2
PA
PA
clemastine fumarate
clemastine fumarate
2
2
PA
PA
clemastine fumarate
2
PA
Antifungals
Antifungals
ABELCET
amphotericin b
CANCIDAS
ciclopirox olamine
ciclopirox
clotrimazole/betamethasone dip
clotrimazole
econazole nitrate
ERAXIS (WATER DILUENT)
EXELDERM
fluconazole in nacl,iso-osm
fluconazole
fluconazole
flucytosine
griseofulvin ultramicrosize
griseofulvin, microsize
itraconazole
ketoconazole
NOXAFIL
NOXAFIL
nystatin/triamcin
nystatin
SPORANOX
terbinafine hcl
voriconazole
voriconazole
tablet
susp recon
oral susp, tablet dr
vial
solution
vial
susp recon, tablet
Antihistamines
26
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
liquid: 4mg/5ml; tablet: 4mg
liquid: 4mg/5ml; tablet: 4mg,
(High Risk Med for Ages 65 and
Older)
syrup, tablet: 2.68mg
syrup, tablet: 2.68mg, (High Risk
Med for Ages 65 and Older)
tablet: 1.34mg, (High Risk Med
for Ages 65 and Older)
Vigencia: 01 noviembre 2014
Nombre del medicamento
Niveles de
Drogas
Requisitos / Límites
cyproheptadine hcl
2
PA
diphenhydramine hcl
diphenhydramine hcl
levocetirizine dihydrochloride
p-epd tan/chlor-tan
promethazine hcl
2
2
2
2
2
(High Risk Med for Ages 65 and
Older)
syringe
vial
PA
(High Risk Med for Ages 65 and
Older)
tripelennamine hcl
2
QL: 30 in 28 days
QL: 4 in 28 days
QL: 40 in 28 days
QL: 18 in 28 days
QL: 18 in 28 days
QL: 18 in 28 days
QL: 4 in 28 days
QL: 4 in 28 days
QL: 12 in 28 days
QL: 12 in 28 days
ampul
spray/pump
Anti-infectives (Skin and Mucous Membrane)
Anti-infectives (Skin and Mucous Membrane)
AVC
3
clindamycin phosphate
2
metronidazole
2
miconazole nitrate
2
sod propion/inositol/aa14/urea
2
terconazole
2
Antimigraine Agents
Antimigraine Agents
dihydroergotamine mesylate
dihydroergotamine mesylate
ERGOMAR
naratriptan hcl
rizatriptan benzoate
sumatriptan succinate
sumatriptan succinate
sumatriptan succinate
sumatriptan
zolmitriptan
2
2
3
2
2
2
2
2
2
2
tablet
cartridge: 4mg/0.5ml
cartridge: 6mg/0.5ml; vial
Antimycobacterials
Antimycobacterials
CAPASTAT SULFATE
dapsone
ethambutol hcl
isoniazid
isoniazid
PASER
PRIFTIN
rifabutin
rifampin
RIFATER
SEROMYCIN
SIRTURO
TRECATOR
4
2
2
1
2
4
4
2
2
4
4
5
4
tablet
solution, vial
PA, QL: 188 in 168 days
27
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
Vigencia: 01 noviembre 2014
Nombre del medicamento
Niveles de
Drogas
Requisitos / Límites
Antinausea Agents
Antinausea Agents
CESAMET
dimenhydrinate
dronabinol
EMEND
EMEND
EMEND
EMEND
granisetron hcl/pf
granisetron hcl
granisetron hcl
granisetron hcl
meclizine hcl
ondansetron hcl
ondansetron hcl
ondansetron
prochlorperazine edisylate
prochlorperazine maleate
prochlorperazine maleate
promethazine hcl
promethazine hcl
4
2
2
4
4
4
4
2
2
2
2
2
2
2
2
2
1
2
2
2
QL: 180 in 30 days
PA BvD, QL: 1 per fill
PA BvD, QL: 2 per fill
PA BvD, QL: 3 per fill
QL: 2 in 28 days
capsule: 40mg, 125mg
capsule: 80mg
cap ds pk
vial
PA BvD
PA BvD
vial
solution
tablet
PA BvD
PA BvD
PA
PA
vial
solution, tablet
tablet
supp.rect
supp.rect, tablet
supp.rect, tablet, (High Risk Med
for Ages 65 and Older)
Antiparasite Agents
Antiparasite Agents
ALBENZA
ALINIA
atovaquone/proguanil hcl
atovaquone
BILTRICIDE
COARTEM
DARAPRIM
HALFAN
hydroxychloroquine sulfate
mefloquine hcl
metronidazole/sodium chloride
metronidazole
NEBUPENT
paromomycin sulfate
PENTAM 300
pentamidine isethionate
PRIMAQUINE
quinine sulfate
STROMECTOL
tinidazole
4
4
2
5
4
4
4
4
2
2
2
2
4
2
4
2
4
2
3
2
PA BvD
QL: 90 in 30 days
PA, QL: 42 in 30 days
28
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
Vigencia: 01 noviembre 2014
Nombre del medicamento
Niveles de
Drogas
Requisitos / Límites
Antiparkinsonian Agents
Antiparkinsonian Agents
amantadine hcl
APOKYN
AZILECT
benztropine mesylate
benztropine mesylate
2
5
3
1
1
benztropine mesylate
2
bromocriptine mesylate
cabergoline
carbidopa/levodopa/entacapone
carbidopa/levodopa
carbidopa
entacapone
NEUPRO
pramipexole di-hcl
ropinirole hcl
selegiline hcl
trihexyphenidyl hcl
2
2
2
2
2
2
3
2
2
2
2
QL: 60 in 30 days
PA
PA
PA
tablet
tablet, (High Risk Med for Ages
65 and Older)
vial, (High Risk Med for Ages 65
and Older)
ST, QL: 30 in 30 days
PA
(High Risk Med for Ages 65 and
Older)
tab rapdis: 15mg
tab rapdis: 10mg
Antipsychotic Agents
Antipsychotic Agents
ABILIFY DISCMELT
ABILIFY DISCMELT
ABILIFY MAINTENA
ABILIFY
ABILIFY
3
3
5
3
3
ST, QL: 60 in 30 days
ST, QL: 90 in 30 days
QL: 1 in 28 days
ST, QL: 161.2 in 28 days
ST, QL: 30 in 30 days
ABILIFY
ABILIFY
ADASUVE
chlorpromazine hcl
chlorpromazine hcl
clozapine
clozapine
clozapine
clozapine
FANAPT
FANAPT
FAZACLO
FAZACLO
fluphenazine decanoate
fluphenazine hcl
GEODON
haloperidol decanoate
3
3
5
2
2
2
2
2
2
4
4
4
4
2
2
4
2
ST, QL: 60 in 30 days
ST, QL: 900 in 30 days
vial
tablet: 5mg, 10mg, 15mg, 20mg,
30mg
tablet: 2mg
solution
QL: 135 in 30 days
QL: 270 in 30 days
QL: 90 in 30 days
ST, QL: 90 in 30 days
ST, QL: 60 in 30 days
ST, QL: 8 in 28 days
ST, QL: 120 in 30 days
ST, QL: 180 in 30 days
ampul, tablet
oral conc.
tablet: 200mg
tablet: 100mg
tablet: 25mg, 50mg
tab rapdis
tablet
tab ds pk
tab rapdis: 200mg
tab rapdis: 150mg
QL: 6 in 28 days
vial
29
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
Vigencia: 01 noviembre 2014
Nombre del medicamento
Niveles de
Drogas
Requisitos / Límites
haloperidol lactate
haloperidol
INVEGA SUSTENNA
INVEGA SUSTENNA
INVEGA SUSTENNA
INVEGA SUSTENNA
INVEGA SUSTENNA
INVEGA
INVEGA
LATUDA
LATUDA
loxapine succinate
MOBAN
olanzapine
2
2
3
3
5
5
5
4
4
4
4
2
4
2
olanzapine
ORAP
perphenazine
quetiapine fumarate
RISPERDAL CONSTA
risperidone
risperidone
risperidone
2
4
2
2
4
2
2
2
QL: 31 in 30 days
SAPHRIS
SEROQUEL XR
SEROQUEL XR
4
4
4
ST, QL: 60 in 30 days
ST, QL: 30 in 30 days
ST, QL: 60 in 30 days
thioridazine hcl
2
PA NSO
thioridazine hcl
2
PA NSO
thiothixene
trifluoperazine hcl
VERSACLOZ
ziprasidone hcl
ZYPREXA RELPREVV
2
2
5
2
5
ST, QL: 540 in 30 days
QL: 60 in 30 days
QL: 2 in 28 days
QL: 0.25 in 28 days
QL: 0.5 in 28 days
QL: 0.75 in 28 days
QL: 1 in 28 days
QL: 1.5 in 28 days
ST, QL: 30 in 30 days
ST, QL: 60 in 30 days
ST, QL: 30 in 30 days
ST, QL: 60 in 30 days
syringe: 39mg/0.25
syringe: 78mg/0.5ml
syringe: 117mg/0.75
syringe: 156mg/ml
syringe: 234mg/1.5
tab er 24: 1.5mg, 3mg, 9mg
tab er 24: 6mg
tablet: 20mg, 40mg, 60mg, 120mg
tablet: 80mg
QL: 30 in 30 days
tab rapdis: 5mg, 10mg, 15mg;
tablet, vial
tab rapdis: 20mg
QL: 90 in 30 days
QL: 4 in 28 days
QL: 120 in 30 days
QL: 480 in 30 days
QL: 60 in 30 days
tab rapdis: 3mg, 4mg
solution
tab rapdis: 0.25mg, 0.5mg, 1mg,
2mg; tablet
tab er 24h: 200mg
tab er 24h: 50mg, 150mg, 300mg,
400mg
oral conc., (High Risk Med for
Ages 65 and Older)
tablet, (High Risk Med for Ages
65 and Older)
Antivirals (systemic)
Antiretrovirals
abacavir sulfate
abacavir/lamivudine/zidovudine
APTIVUS
APTIVUS
ATRIPLA
COMPLERA
CRIXIVAN
didanosine
2
5
4
5
5
5
4
2
30
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
solution
capsule
Vigencia: 01 noviembre 2014
Nombre del medicamento
EDURANT
EMTRIVA
EPIVIR HBV
EPIVIR
EPZICOM
FUZEON
INTELENCE
INTELENCE
INVIRASE
ISENTRESS
ISENTRESS
KALETRA
KALETRA
lamivudine/zidovudine
lamivudine
LEXIVA
LEXIVA
nevirapine
NORVIR
PREZISTA
PREZISTA
PREZISTA
PREZISTA
RESCRIPTOR
RETROVIR
REYATAZ
REYATAZ
SELZENTRY
stavudine
STRIBILD
SUSTIVA
SUSTIVA
TIVICAY
TRIUMEQ
TRUVADA
VIDEX
VIRACEPT
VIRAMUNE XR
VIREAD
ZIAGEN
zidovudine
Antivirals, Miscellaneous
foscarnet sodium
RELENZA
rimantadine hcl
SYNAGIS
TAMIFLU
Niveles de
Drogas
Requisitos / Límites
5
3
4
4
5
5
3
5
5
3
5
3
5
5
2
3
5
2
4
3
4
5
5
4
3
3
5
5
2
5
4
4
5
5
5
3
4
3
5
4
2
2
4
2
5
3
solution
solution
tablet: 25mg
tablet: 100mg, 200mg
powd pack, tab chew
tablet
tablet: 100mg-25mg
solution, tablet: 200mg-50mg
oral susp
tablet
tablet: 75mg, 150mg
oral susp
tablet: 400mg
tablet: 600mg, 800mg
vial
capsule: 100mg
capsule: 150mg, 200mg, 300mg
capsule: 100mg
capsule: 50mg, 200mg; tablet
tab er 24h: 100mg
solution
PA BvD
QL: 42 in 180 days
31
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
capsule: 75mg
Vigencia: 01 noviembre 2014
Nombre del medicamento
Niveles de
Drogas
Requisitos / Límites
TAMIFLU
TAMIFLU
TAMIFLU
Hcv Protease Inhibitors
INCIVEK
OLYSIO
VICTRELIS
Interferons
ALFERON N
INTRON A
3
3
3
QL: 48 in 180 days
QL: 540 in 180 days
QL: 84 in 180 days
5
5
5
PA, QL: 168 in 28 days
PA, QL: 28 in 28 days
PA, QL: 336 in 28 days
5
4
PA NSO
INTRON A
PEGASYS PROCLICK
PEGASYS
PEGINTRON REDIPEN
PEGINTRON
SYLATRON 4-PACK
Nucleosides And Nucleotides
acyclovir sodium
acyclovir
adefovir dipivoxil
BARACLUDE
BARACLUDE
cidofovir
entecavir
famciclovir
ganciclovir sodium
ribavirin
ribavirin
ribavirin
SOVALDI
TYZEKA
valacyclovir hcl
VALCYTE
4
5
5
5
5
5
PA NSO
PA
PA
PA
PA
PA NSO, QL: 1 in 28 days
2
2
5
4
5
5
5
2
2
2
5
5
5
5
2
5
PA BvD
capsule: 45mg
susp recon
capsule: 30mg
pen ij kit, vial: 18mmunit,
50mmunit
vial: 6mmunit/ml, 10mmunit
solution
tablet
PA BvD
capsule, tablet
tab ds pk: 200-400mg
tab ds pk: 400-400mg, 600-400mg
PA, QL: 28 in 28 days
tablet
Blood Products/modifiers/volume Expanders
Anticoagulants
CEPROTIN
ELIQUIS
enoxaparin sodium
enoxaparin sodium
enoxaparin sodium
enoxaparin sodium
enoxaparin sodium
enoxaparin sodium
enoxaparin sodium
enoxaparin sodium
fondaparinux sodium
5
3
2
2
2
2
2
5
5
5
2
QL: 13.6 in 30 days
QL: 18 in 30 days
QL: 20.4 in 30 days
QL: 27.2 in 30 days
QL: 36 in 30 days
QL: 27.2 in 30 days
QL: 34 in 30 days
QL: 36 in 30 days
QL: 12 in 30 days
32
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
syringe: 40mg/0.4ml
syringe: 30mg/0.3ml
syringe: 60mg/0.6ml
syringe: 80mg/0.8ml
vial
syringe: 120mg/.8ml
syringe: 150mg/ml
syringe: 100mg/ml
syringe: 5mg/0.4ml
Vigencia: 01 noviembre 2014
Nombre del medicamento
Niveles de
Drogas
Requisitos / Límites
fondaparinux sodium
fondaparinux sodium
fondaparinux sodium
heparin sod,pork in 0.45% nacl
heparin sodium,porcine/d5w
heparin sodium,porcine/d5w
heparin sodium,porcine/ns/pf
heparin sodium,porcine/pf
heparin sodium,porcine/pf
heparin sodium,porcine/pf
heparin sodium,porcine
IPRIVASK
PRADAXA
warfarin sodium
XARELTO
Blood Formation Modifiers
BERINERT
CINRYZE
EPOGEN
GRANIX
LEUKINE
LEUKINE
MOZOBIL
NEULASTA
NEUMEGA
NEUPOGEN
PROCRIT
2
2
2
2
2
2
2
2
2
2
2
5
4
1
3
QL: 15 in 30 days
QL: 18 in 30 days
QL: 24 in 30 days
5
5
3
5
5
5
5
5
5
5
3
PA, QL: 9 in 30 days
PA, QL: 20 in 28 days
PA, QL: 12 in 28 days
PROCRIT
PROCRIT
PROMACTA
Hematologic Agents, Miscellaneous
aminocaproic acid
anagrelide hcl
protamine sulfate
tranexamic acid
tranexamic acid
Platelet-aggregation Inhibitors
AGGRENOX
BRILINTA
cilostazol
clopidogrel bisulfate
EFFIENT
pentoxifylline
Volume Expanders
ALBUKED-25
5
5
5
PA, QL: 12 in 28 days
PA, QL: 6 in 28 days
PA, QL: 30 in 30 days
2
2
2
2
2
PA BvD
4
3
2
2
3
2
syringe: 2.5mg/0.5
syringe: 7.5mg/0.6
syringe: 10mg/0.8ml
iv soln: 12500/250, 25000/500
iv soln: 20k/500ml, 25000/250
PA BvD
PA BvD
PA BvD
PA, QL: 24 in 28 days
PA, QL: 60 in 30 days
vial port
syringe, (PA for ESRD Only)
vial, (PA for ESRD Only)
(PA for ESRD Only)
vial: 250mcg
vial: 500mcg/ml
PA, QL: 9.6 per fill
PA, QL: 12 in 28 days
QL: 30 in 30 days
vial: 2000/ml, 3000/ml, 4000/ml,
10000/ml
vial: 20000/ml
vial: 40000/ml
(PA for ESRD Only)
vial
tablet
QL: 60 in 30 days
QL: 30 in 30 days
4
33
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
Vigencia: 01 noviembre 2014
Nombre del medicamento
Niveles de
Drogas
ALBUKED-5
4
ALBUMIN (HUMAN)
4
ALBUMINAR-25
4
ALBUMINAR-5
4
ALBURX
4
ALBUTEIN
4
BUMINATE
4
FLEXBUMIN
4
KEDBUMIN
4
PLASBUMIN-25
4
PLASBUMIN-5
4
STERILE DILUENT
4
Requisitos / Límites
Caloric Agents
Caloric Agents
AMINO ACIDS
AMINOSYN II
AMINOSYN II
AMINOSYN II
AMINOSYN II
AMINOSYN II
AMINOSYN M
AMINOSYN with
ELECTROLYTES
AMINOSYN
AMINOSYN
AMINOSYN
AMINOSYN
AMINOSYN
AMINOSYN-HBC
AMINOSYN-PF
AMINOSYN-PF
AMINOSYN-RF
CLINIMIX E
CLINIMIX E
CLINIMIX E
CLINIMIX E
CLINIMIX E
CLINIMIX E
CLINIMIX E
CLINIMIX E
4
4
4
4
4
4
4
4
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
34
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
iv soln: 10%
iv soln: 15%
iv soln: 7%
iv soln: 8.5%
iv soln: 8.5%
iv soln: 10%
iv soln: 3.5%
iv soln: 7%
iv soln: 8.5%
iv soln: 8.5%
iv soln: 10%
iv soln: 7%
iv soln: 2.75%
iv soln: 2.75%
iv soln: 4.25%
iv soln: 4.25%
iv soln: 4.25%
iv soln: 5%
iv soln: 5%
iv soln: 5%
Vigencia: 01 noviembre 2014
Nombre del medicamento
CLINIMIX E
CLINIMIX
CLINIMIX
CLINIMIX
CLINIMIX
CLINIMIX
CLINIMIX
CLINIMIX
CLINIMIX
CLINISOL
cysteine hcl
dextrose 10 % and 0.2 % nacl
dextrose 10 % and 0.2 % nacl
dextrose 10 % and 0.9 % nacl
dextrose 10%-0.5 normal saline
dextrose 10%-water
dextrose 2.5 % in water
dextrose 2.5% in half ringers
dextrose 2.5%-0.5normal saline
dextrose 20%-water
dextrose 25 % in water
dextrose 40%-water
dextrose 5 % and 0.3 % nacl
dextrose 5 % and 0.9 % nacl
dextrose 5 % in water
dextrose 5 %-0.2 % nacl
dextrose 5 %-0.45 % nacl
dextrose 5% in ringers
dextrose 5%-lactated ringers
dextrose 50 % in water
dextrose 60 % in water
dextrose 70%-water
FREAMINE HBC
FREAMINE III
FREAMINE III
fructose 10%
HEPATAMINE
HEPATASOL
INTRALIPID
INTRALIPID
KABIVEN
Niveles de
Drogas
4
4
4
4
4
4
4
4
4
4
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
4
4
4
2
4
4
4
4
4
Requisitos / Límites
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
iv soln: 5%
iv soln: 2.75%
iv soln: 4.25%
iv soln: 4.25%
iv soln: 4.25%
iv soln: 4.25%
iv soln: 5%
iv soln: 5%
iv soln: 5%
dehp fr bg
iv soln
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
35
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
iv soln: 10%
iv soln: 8.5%
emulsion: 10%
emulsion: 20%, 30%
Vigencia: 01 noviembre 2014
Nombre del medicamento
LIPOSYN II
LIPOSYN III
LIPOSYN III
NEPHRAMINE
NOVAMINE
PERIKABIVEN
PREMASOL
PREMASOL
PROCALAMINE
PROSOL
QUICK MIX with LYTES
TRAVAMULSION
TRAVASOL W/DEXTROSE
TRAVASOL W/ELECTROLYTES
TRAVASOL W/ELECTROLYTES
TRAVASOL with DEXTROSE
TRAVASOL with DEXTROSE
TRAVASOL with DEXTROSE
TRAVASOL with ELECTROLYTES
TRAVASOL
TRAVASOL
TRAVASOL
TRAVASOL
TRAVERT IN NORMAL SALINE
TRAVERT
TRAVERT
TROPHAMINE
TROPHAMINE
Niveles de
Drogas
Requisitos / Límites
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
Alpha-adrenergic Agents
clonidine hcl/chlorthalidone
clonidine hcl
clonidine
2
1
2
QL: 4 in 28 days
clonidine
doxazosin mesylate
guanfacine hcl
2
2
2
midodrine hcl
2
emulsion: 10%, 20%
emulsion: 30%
iv soln: 10%
iv soln: 6%
iv soln.: 5.5%
iv soln.: 8.5%
iv soln: 8.5%
iv soln: 8.5%
iv soln: 8.5%
iv soln.
iv soln: 10%
iv soln: 5.5%
iv soln: 8.5%
iv soln: 10%
iv soln: 5%
iv soln: 10%
iv soln: 6%
Cardiovascular Agents
QL: 8 in 28 days
PA
36
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
patch tdwk: 0.1mg/24hr, 0.2mg/
24hr
patch tdwk: 0.3mg/24hr
(High Risk Med for Ages 65 and
Older)
Vigencia: 01 noviembre 2014
Nombre del medicamento
Niveles de
Drogas
Requisitos / Límites
phenylephrine hcl
2
prazosin hcl
2
Angiotensin Ii Receptor Antagonists
BENICAR HCT
3
BENICAR
3
candesartan cilexetil
2
candesartan/hydrochlorothiazid
2
DIOVAN
2
eprosartan mesylate
2
irbesartan/hydrochlorothiazide
2
irbesartan
2
losartan potassium
1
losartan/hydrochlorothiazide
2
telmisartan/hydrochlorothiazid
2
telmisartan
2
TRIBENZOR
3
valsartan/hydrochlorothiazide
2
Angiotensin-converting Enzyme Inhibitors
benazepril hcl
1
benazepril/hydrochlorothiazide
2
captopril/hydrochlorothiazide
2
captopril
1
enalapril maleate
1
enalapril/hydrochlorothiazide
2
enalaprilat dihydrate
2
fosinopril sodium
2
fosinopril/hydrochlorothiazide
2
lisinopril/hydrochlorothiazide
1
lisinopril
1
moexipril hcl
2
moexipril/hydrochlorothiazide
2
perindopril erbumine
2
quinapril hcl
2
quinapril/hydrochlorothiazide
2
ramipril
2
trandolapril
2
37
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
Vigencia: 01 noviembre 2014
Nombre del medicamento
Niveles de
Drogas
Antiarrhythmic Agents
amiodarone hcl
amiodarone hcl
disopyramide phosphate
flecainide acetate
lidocaine hcl/d5w/pf
lidocaine hcl/pf
lidocaine hcl/pf
mexiletine hcl
MULTAQ
procainamide hcl
procainamide hcl
PRONESTYL
propafenone hcl
quinidine gluconate
quinidine sulfate
TIKOSYN
XYLOCAINE
Beta-Adrenergic Blocking Agents
acebutolol hcl
atenolol/chlorthalidone
atenolol
betaxolol hcl
bisoprolol fumarate/hctz
bisoprolol fumarate
BYSTOLIC
carvedilol
COREG CR
DUTOPROL
esmolol hcl
labetalol hcl
metoprolol succinate
metoprolol tartrate
metoprolol tartrate
metoprolol/hydrochlorothiazide
nadolol
pindolol
propranolol hcl
propranolol/hydrochlorothiazid
sotalol hcl
SOTALOL HCL
timolol maleate
Calcium-Channel Blocking Agents
diltiazem hcl
2
2
2
2
2
2
2
Requisitos / Límites
ampul, tablet
syringe
PA BvD
2
3
2
2
4
2
2
2
3
2
2
1
1
2
2
2
3
1
3
3
2
2
2
1
2
2
2
2
2
2
2
4
2
iv soln: 2mg/ml, 8mg/ml
syringe, vial: 100mg/ml, 200mg/ml
vial: 20mg/ml, (PA for ESRD
Only)
capsule, tablet sa
vial
PA BvD
1
38
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
tablet
vial
tablet
Vigencia: 01 noviembre 2014
Nombre del medicamento
Niveles de
Drogas
diltiazem hcl
2
verapamil hcl
verapamil hcl
1
2
Requisitos / Límites
cap er 12h, cap er 24h, cap er
deg, capsule er, syringe, tab er
24h, vial port
tablet
ampul, cap24h pct, cap24h pel,
tablet er
syringe
verapamil hcl
2
Cardiovascular Agents, Miscellaneous
digoxin
2
PA, QL: 30 in 30 days
digoxin
2
PA
DIGOXIN
3
PA, QL: 75 in 30 days
dobutamine hcl/d5w
dobutamine hcl
dopamine hcl/d5w
dopamine hcl/dextrose 5%-water
dopamine hcl
ephedrine sulfate
epinephrine
epinephrine
EPIPEN 2-PAK
EPIPEN JR 2-PAK
ethanolamine oleate
FIRAZYR
hydralazine hcl
hydralazine/hydrochlorothiazid
LANOXIN
2
2
2
2
2
2
2
2
3
3
2
5
2
2
4
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
milrinone lactate/d5w
milrinone lactate
norepinephrine bitartrate
ORENITRAM ER
ORENITRAM ER
papaverine hcl
RANEXA
VECAMYL
Dihydropyridines
amlodipine besylate/benazepril
amlodipine besylate
AZOR
CLEVIPREX
5
5
2
3
5
2
3
5
PA BvD
PA BvD
PA BvD
PA
PA
PA
tablet, (High Risk Med for Ages
65 and Older and Dose is Greater
Than 125mcg Per Day)
ampul, (High Risk Med for Ages
65 and Older)
(High Risk Med for Ages 65 and
Older and Dose is Greater Than
125mcg Per Day)
ampul
auto injct, syringe
PA, QL: 30 in 30 days
tablet: 62.5mcg, 187.5mcg, (High
Risk Med for Ages 65 and Older
and Dose is Greater Than 125mcg
Per Day)
tablet er: 0.125mg
tablet er: 0.25mg, 1mg, 2.5mg
2
1
3
4
39
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
Vigencia: 01 noviembre 2014
Nombre del medicamento
EXFORGE HCT
EXFORGE
felodipine
isradipine
nicardipine hcl
nifedipine
nifedipine
Diuretics
amiloride hcl
amiloride/hydrochlorothiazide
bumetanide
chlorothiazide sodium
chlorothiazide
chlorthalidone
DYRENIUM
furosemide
furosemide
furosemide
hydrochlorothiazide
indapamide
methyclothiazide
metolazone
torsemide
triamterene/hydrochlorothiazid
Dyslipidemics
amlodipine/atorvastatin
atorvastatin calcium
cholestyramine (with sugar)
cholestyramine/aspartame
colestipol hcl
CRESTOR
fenofibrate nanocrystallized
fenofibrate,micronized
fenofibrate
fenofibric acid (choline)
fenofibric acid
fluvastatin sodium
gemfibrozil
KYNAMRO
lovastatin
niacin
omega-3 acid ethyl esters
pravastatin sodium
simvastatin
VASCEPA
WELCHOL
Niveles de
Drogas
Requisitos / Límites
3
2
2
2
2
2
2
tab er 24, tablet er: 30mg, 60mg
tablet er: 90mg
2
2
2
2
1
1
4
1
2
2
1
1
2
2
2
2
2
2
2
2
2
3
2
2
2
2
2
2
2
5
1
2
2
1
1
3
3
tablet
solution, syringe: 10mg/ml; vial
syringe: 10mg/ml
tablet
PA, QL: 4 in 28 days
tab er 24h, tablet
QL: 30 in 30 days
40
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
Vigencia: 01 noviembre 2014
Nombre del medicamento
Niveles de
Drogas
Requisitos / Límites
ZETIA
4
Renin-Angiotensin-Aldosterone System Inhibitors
eplerenone
2
spironolact/hydrochlorothiazid
2
spironolactone
2
Vasodilators
isosorbide dinitrate
1
isosorbide dinitrate
1
isosorbide dinitrate
2
isosorbide mononitrate
2
minoxidil
2
NITRO-BID
3
nitroglycerin/d5w
2
nitroglycerin
2
nitroglycerin
2
nitroglycerin
2
QL: 30 in 30 days
nitroglycerin
NITROSTAT
nylidrin hcl
PROGLYCEM
tab subl: 2.5mg
tab subl: 5mg
tablet, tablet er
vial: 50mg/10ml
vial: 5mg/ml
patch td24: 0.1mg/hr, 0.2mg/hr,
0.6mg/hr
patch td24: 0.4mg/hr
2
3
2
4
QL: 60 in 30 days
5
2
2
2
2
2
2
2
PA, QL: 60 in 30 days
QL: 60 in 30 days
QL: 120 in 30 days
QL: 180 in 30 days
QL: 30 in 30 days
tablet
capsule er
tablet: 5mg, 10mg
cap er 24h: 5mg, 10mg, 15mg
2
QL: 60 in 30 days
cap er 24h: 20mg, 25mg, 30mg;
tablet
Central Nervous System Agents
Central Nervous System Agents
AMPYRA
caffeine citrated
caffeine/sodium benzoate
clonidine hcl
dexmethylphenidate hcl
dextroamphetamine sulfate
dextroamphetamine sulfate
dextroamphetamine/
amphetamine
dextroamphetamine/
amphetamine
flumazenil
INTUNIV
lithium carbonate
lithium citrate
methylphenidate hcl
2
4
2
2
2
QL: 30 in 30 days
QL: 30 in 30 days
methylphenidate hcl
2
QL: 60 in 30 days
methylphenidate hcl
methylphenidate hcl
2
2
QL: 90 in 30 days
QL: 90 in 30 days
41
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
cpbp 30-70, cpbp 50-50: 20mg,
40mg; tab er 24: 18mg, 27mg,
54mg
cpbp 50-50: 30mg; tab er 24:
36mg
tablet er: 10mg
tablet, tablet er: 20mg
Vigencia: 01 noviembre 2014
Nombre del medicamento
methylphenidate hcl
NUEDEXTA
QUILLIVANT XR
riluzole
SAVELLA
STRATTERA
XENAZINE
Niveles de
Drogas
2
3
3
2
3
3
5
Requisitos / Límites
QL: 900 in 30 days
QL: 60 in 30 days
solution
QL: 60 in 30 days
PA, QL: 112 in 28 days
Contraceptives
Contraceptives
desog-e.estradiol/e.estradiol
desogestrel-ethinyl estradiol
ethinyl estradiol/drospirenone
ethynodiol d-ethinyl estradiol
levonorgestrel
levonorgestrel-ethin estradiol
levonorgestrel-ethin estradiol
l-norgest-eth estr/ethin estra
l-norgest-eth estr/ethin estra
norelgestromin/ethin.estradiol
noreth-ethinyl estradiol/iron
norethindrone ac-eth estradiol
norethindrone
norethindrone-e.estradiol-iron
norethindrone-ethinyl estrad
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
norethindrone-mestranol
norgestimate-ethinyl estradiol
norgestrel-ethinyl estradiol
NUVARING
ORTHO EVRA
2
2
2
3
4
QL: 91 in 84 days
QL: 91 in 84 days
QL: 91 in 84 days
tablet: 0.1-0.02, 0.15-0.03, 6-5-10
tbdspk 3mo
tbdspk 3mo: 100-20(84)
tbdspk 3mo: 150-30(84)
tablet: 0.4-0.035, 0.5-0.035, 1mg35mcg, 7-9-5, 7daysx3, 10-11
ST, QL: 1 in 28 days
ST, QL: 3 in 28 days
Dental And Oral Agents
Dental And Oral Agents
cevimeline hcl
chlorhexidine gluconate
KEPIVANCE
pilocarpine hcl
triamcinolone acetonide
2
2
5
2
2
Dermatological Agents
Dermatological Agents, Other
8-MOP
acitretin
acyclovir
adapalene
alcohol antiseptic pads
aluminum chloride
4
5
2
2
1
2
QL: 30 in 30 days
42
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
Vigencia: 01 noviembre 2014
Nombre del medicamento
Niveles de
Drogas
ammonium lactate
2
ANACAINE
4
calcipotriene/betamethasone
2
calcipotriene
2
calcitriol
2
CARAC
4
CONDYLOX
4
DENAVIR
4
FLUOROPLEX
4
fluorouracil
2
imiquimod
2
LEVULAN
4
mafenide acetate
2
methoxsalen, rapid
5
METVIXIA
4
OXSORALEN-ULTRA
5
PANRETIN
5
PICATO
3
PICATO
3
podofilox
2
podophyllum resin
2
potassium hydroxide
2
SANTYL
4
silver nitrate applicator
2
UVADEX
4
VALCHLOR
5
XERAC AC
3
ZOVIRAX
4
Dermatological Antibacterials
clindamycin phos/benzoyl perox
2
clindamycin phosphate
2
erythromycin base/ethanol
2
erythromycin/benzoyl peroxide
2
gentamicin sulfate
2
metronidazole
2
mupirocin calcium
2
mupirocin
2
neomy sulf/polymyxin b sulfate
2
selenium sulfide
2
selenium sulfide
2
silver nitrate
2
silver sulfadiazine
2
sulfacetamide sodium
2
THERMAZENE
2
Dermatological Anti-inflammatory Agents
alclometasone dipropionate
2
APEXICON E
4
Requisitos / Límites
gel (gram)
PA NSO, QL: 24 in 30 days
QL: 2 in 56 days
QL: 3 in 56 days
gel (ea): 0.05%
gel (ea): 0.015%
QL: 15 in 30 days
cream (g)
43
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
gel (gram): 1%-5%
shampoo
suspension
Vigencia: 01 noviembre 2014
Nombre del medicamento
Niveles de
Drogas
betamethasone dipropionate
betamethasone valerate
betamethasone/propylene glyc
clobetasol propionate
clocortolone pivalate
CLODERM
CORDRAN
CORDRAN
desonide
desoximetasone
diflorasone diacetate
ELIDEL
fluocinonide
2
2
2
2
2
4
4
4
2
2
2
3
2
fluticasone propionate
halobetasol propionate
hydrocortisone acetate/aloe v
hydrocortisone acetate/urea
hydrocortisone acetate
hydrocortisone butyrate
hydrocortisone valerate
hydrocortisone
2
2
2
2
2
2
2
2
hydrocortisone
LOCOID
mometasone furoate
prednicarbate
PROTOPIC
PROTOPIC
triamcinolone acetonide
2
4
2
2
4
4
2
triamcinolone acetonide
Dermatological Retinoids
adapalene
TARGRETIN
TAZORAC
tretinoin microspheres
tretinoin
Scabicides And Pediculicides
EURAX
malathion
permethrin
spinosad
2
2
5
4
2
2
Requisitos / Límites
cream (g), lotion, oint. (g)
med. tape
PA
(PA for Ages < 2)
cream (g): 0.05%; gel (gram), oint.
(g), solution
cream (g), oint. (g)
cream (g), cream/appl, enema,
lotion, oint. (g)
cream(gm)
cream (g)
PA
PA
(0.03%; PA for Ages < 2)
(0.1%; PA for Ages < 15)
cream (g), lotion, oint. (g): 0.025%,
0.1%, 0.5%
cream, oint. (g): 0.05%
PA NSO, QL: 60 in 28 days
PA
PA
4
2
2
2
Devices
Devices
needles, insulin disposable
syring w-ndl,disp,insul,0.3ml
2
2
44
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
Vigencia: 01 noviembre 2014
Nombre del medicamento
syring w-ndl,disp,insul,0.5ml
syring w-o ndl,disp,insul, 1ml
Niveles de
Drogas
Requisitos / Límites
2
2
Enzyme Replacement/modifiers
Enzyme Replacement/modifiers
ADAGEN
ALDURAZYME
CEREZYME
CHENODAL
CIMZIA
CREON
ELAPRASE
ELELYSO
ELITEK
FABRAZYME
KRYSTEXXA
KUVAN
LINZESS
lipase/protease/amylase
LOTRONEX
LUMIZYME
MYOZYME
NAGLAZYME
ORFADIN
PULMOZYME
VIMIZIM
VPRIV
ZAVESCA
ZENPEP
5
5
5
5
5
3
5
5
5
5
5
5
3
2
5
5
5
5
5
5
5
5
5
3
PA, QL: 210 in 30 days
PA, QL: 3 in 28 days
QL: 30 in 30 days
PA BvD
PA
QL: 90 in 30 days
Eye, Ear, Nose, Throat Agents
Eye, Ear, Nose, Throat Anti-infectives Agents
acetic acid/hydrocortisone
2
acetic acid
2
bacitracin/polymyxin b sulfate
2
bacitracin
2
BLEPHAMIDE S.O.P.
3
BLEPHAMIDE
4
CIPRO HC
3
CIPRODEX
3
ciprofloxacin hcl
2
ciprofloxacin hcl
2
COLY-MYCIN S
4
CORTISPORIN-TC
4
erythromycin base
2
gatifloxacin
2
gentamicin sulfate
2
levofloxacin
2
45
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
droperette
drops
Vigencia: 01 noviembre 2014
Nombre del medicamento
Niveles de
Drogas
MOXEZA
3
NATACYN
3
neo/polymyx b sulf/dexameth
2
neomy sulf/bacitra/polymyxin b
2
neomy sulf/bacitrac zn/poly/hc
2
neomycin sulfate/dex na ph
2
neomycin/polymyxin b sulf/hc
2
neomycin/polymyxn b/gramicidin
2
ofloxacin
2
polymyxin b sulf/trimethoprim
2
sulfacetamide sodium
2
sulfacetamide/prednisolone sp
2
tobramycin sulfate
2
tobramycin/dexamethasone
2
trifluridine
2
VIGAMOX
3
ZYLET
3
Eye, Ear, Nose, Throat Anti-inflammatory Agents
ALREX
3
BROMDAY
3
bromfenac sodium
2
dexamethasone sod phosphate
2
diclofenac sodium
2
DUREZOL
3
fluorometholone
2
flurbiprofen sodium
2
ILEVRO
3
ketorolac tromethamine
2
LOTEMAX
3
NEVANAC
3
prednisolone acetate
2
prednisolone sod phosphate
2
PROLENSA
3
Eye, Ear, Nose, Throat Drugs, Miscellaneous
AKTEN
4
apraclonidine hcl
2
atropine sulfate
2
azelastine hcl
2
azelastine hcl
2
QL: 30 in 25 days
carteolol hcl
2
cromolyn sodium
2
CYCLOGYL
3
cyclopentolate hcl
2
CYSTARAN
5
epinastine hcl
2
homatropine hbr
2
ISOPTO HOMATROPINE
3
46
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
Requisitos / Límites
drops
spray/pump
drops: 0.5%
drops: 2%
Vigencia: 01 noviembre 2014
Nombre del medicamento
LACRISERT
naphazoline hcl/antazoline
PATADAY
PATANOL
phenylephrine hcl
phenylephrine hcl
proparacaine hcl
proparacaine/fluorescein sod
tetracaine hcl/pf
TYZINE
TYZINE
Niveles de
Drogas
3
2
3
3
1
2
2
2
2
4
4
Requisitos / Límites
ST
ST
drops: 2.5%
drops: 10%
drops: 0.05%
drops: 0.1%; spray
Gastrointestinal Agents
Antiulcer Agents And Acid Suppressants
CARAFATE
3
cimetidine hcl
2
cimetidine hcl
2
cimetidine in 0.9 % nacl
2
cimetidine
2
esomeprazole sodium
2
famotidine in nacl,iso-osm/pf
2
famotidine
1
famotidine
1
famotidine
2
famotidine
2
lansoprazole/amoxiciln/clarith
2
lansoprazole
2
misoprostol
2
nizatidine
2
omeprazole
2
pantoprazole sodium
2
ranitidine hcl
1
ranitidine hcl
2
sucralfate
sucralfate
Gastrointestinal Agents, Other
AMITIZA
BUPHENYL
CARBAGLU
cromolyn sodium
dicyclomine hcl
diphenoxylate hcl/atropine
FULYZAQ
glycopyrrolate
isopropamide/prochlorperazine
lactulose
lactulose
oral susp
solution
vial
(Rx Product Only)
tablet
tablet, (Rx Product Only)
oral susp, vial
oral susp, vial, (Rx Product Only)
(Rx Product Only)
tablet, (Rx Product Only)
capsule, syrup, vial, (Rx Product
Only)
oral susp
tablet
2
2
3
5
5
5
2
2
4
2
2
2
2
QL: 60 in 30 days
tablet
QL: 60 in 30 days
47
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
solution: 10; syrup
solution: 10g/15ml
Vigencia: 01 noviembre 2014
Nombre del medicamento
loperamide hcl
methscopolamine bromide
metoclopramide hcl
metoclopramide hcl
metoclopramide hcl
NUTRESTORE
paregoric
RAVICTI
RELISTOR
RELISTOR
sodium phenylbutyrate
ursodiol
Laxatives
MOVIPREP
peg 3350/na sulf,bicarb,cl/kcl
polyethylene glycol 3350
sodium chloride/nahco3/kcl/peg
Phosphate Binders
calcium acetate
calcium carbonate/mag carb/fa
PHOSLYRA
RENAGEL
RENVELA
sodium polystyrene sulfonate
sodium polystyrene sulfonate
Niveles de
Drogas
2
2
1
2
2
4
2
5
4
4
5
2
Requisitos / Límites
tablet
disp syrin
solution, vial
PA
PA, QL: 28 in 28 days
PA, QL: 28 in 28 days
syringe: 12mg/0.6ml
syringe: 8mg/0.4ml
3
2
2
2
2
2
4
3
3
2
2
enema
oral susp
Genitourinary Agents
Antispasmodics, Urinary
flavoxate hcl
oxybutynin chloride
oxybutynin chloride
tolterodine tartrate
trospium chloride
VESICARE
2
1
2
2
2
3
tablet
tab er 24
Heavy Metal Antagonists
Heavy Metal Antagonists
deferoxamine mesylate
edetate disodium
EXJADE
EXJADE
FERRIPROX
GALZIN
na nitrite/na thiosul/amyl nit
sodium thiosulfate
SYPRINE
2
2
4
5
5
4
2
2
5
PA BvD
48
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
tab disper: 125mg
tab disper: 250mg, 500mg
Vigencia: 01 noviembre 2014
Nombre del medicamento
Niveles de
Drogas
Requisitos / Límites
Hormonal Agents, Stimulant/replacement/modifying
Androgens
ANADROL-50
ANDRODERM
ANDROGEL
ANDROGEL
ANDROGEL
AXIRON
danazol
fluoxymesterone
oxandrolone
testosterone cypionate
testosterone enanthate
Estrogens and Antiestrogens
COMBIPATCH
5
3
3
3
3
3
2
2
2
2
2
PA, QL: 30 in 30 days
PA, QL: 150 in 30 days
PA, QL: 150 in 30 days
PA, QL: 300 in 30 days
PA, QL: 180 in 28 days
gel md pmp
gel packet: 1.25g-1.62
gel packet: 50mg(1%)
PA
PA, QL: 5 in 28 days
3
PA, QL: 8 in 28 days
DUAVEE
3
PA
ESTRACE
estradiol valerate
estradiol valerate
estradiol/norethindrone acet
estradiol/norethindrone acet
3
2
2
2
2
PA
PA
estradiol
2
PA, QL: 4 in 28 days
estradiol
2
PA
ESTRASORB
4
PA, QL: 97.44 in 28 days
estropipate
2
PA
FEMRING
MENEST
4
4
QL: 1 in 84 days
PA
norethindrone ac-eth estradiol
2
PA
PREMARIN
PREMARIN
3
3
PA
PREMPHASE
3
PA
PREMPRO
3
PA
raloxifene hcl
VAGIFEM
2
3
QL: 18 in 28 days
49
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
(High Risk Med for Ages 65 and
Older)
(High Risk Med for Ages 65 and
Older)
cream/appl
vial: 10mg/ml
vial: 20mg/ml, 40mg/ml
(High Risk Med for Ages 65 and
Older)
patch tdwk, (High Risk Med for
Ages 65 and Older)
tablet, (High Risk Med for Ages
65 and Older)
(High Risk Med for Ages 65 and
Older)
(High Risk Med for Ages 65 and
Older)
(High Risk Med for Ages 65 and
Older)
(High Risk Med for Ages 65 and
Older)
cream/appl, vial
tablet, (High Risk Med for Ages
65 and Older)
(High Risk Med for Ages 65 and
Older)
(High Risk Med for Ages 65 and
Older)
Vigencia: 01 noviembre 2014
Nombre del medicamento
Niveles de
Drogas
VIVELLE-DOT
Glucocorticoids/mineralocorticoids
A-HYDROCORT
betamet acet/betamet na ph
cortisone acetate
dexamethasone acetate
dexamethasone sod phosphate
dexamethasone
dexamethasone
fludrocortisone acetate
hydrocortisone sod succinate
hydrocortisone
methylprednisolone acetate
methylprednisolone sod succ
methylprednisolone sod succ
methylprednisolone
prednisolone acetate
prednisolone sod phosphate
prednisolone
PREDNISONE INTENSOL
prednisone
prednisone
prednisone
SOLU-CORTEF
SOLU-MEDROL
triamcinolone acetonide
UCERIS
Pituitary
DDAVP
desmopressin (nonrefrigerated)
desmopressin acetate
desmopressin acetate
GENOTROPIN
GENOTROPIN
HUMATROPE
INCRELEX
NORDITROPIN FLEXPRO
NORDITROPIN NORDIFLEX
NORDITROPIN
NOVAREL
NUTROPIN AQ NUSPIN
NUTROPIN AQ
NUTROPIN
NUTROPIN
Requisitos / Límites
3
PA, QL: 8 in 28 days
4
2
2
2
2
1
2
2
2
2
2
2
2
2
2
2
2
4
1
2
2
4
4
2
5
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
4
2
2
2
4
5
5
5
5
5
5
4
5
5
5
5
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
ST
(High Risk Med for Ages 65 and
Older)
tablet
elixir
vial: 40mg, 125mg
vial: 500mg, 1000mg
tablet
solution
tab ds pk
vial: 40mg/ml
ampul: 15mcg/ml
QL: 15 in 30 days
QL: 15 in 30 days
PA
PA
tablet, vial
solution
syringe: 0.2mg/0.25
various dosage and/or strengths
are available
PA
PA
PA
PA
PA
PA
PA
PA
50
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
vial: 10mg
vial: 5mg
Vigencia: 01 noviembre 2014
Nombre del medicamento
Niveles de
Drogas
octreotide acetate
2
octreotide acetate
OMNITROPE
OMNITROPE
SAIZEN
SAIZEN
SANDOSTATIN LAR
SEROSTIM
SOMATULINE DEPOT
SOMAVERT
SOMAVERT
SUPPRELIN LA
TEV-TROPIN
VANTAS
vasopressin
ZORBTIVE
Progestins
DEPO-PROVERA
medroxyprogesterone acet
medroxyprogesterone acetate
medroxyprogesterone acetate
medroxyprogesterone acetate
norethindrone acetate
progesterone,micronized
progesterone
Thyroid and Antithyroid Agents
levothyroxine sodium
levothyroxine sodium
levothyroxine sodium
liothyronine sodium
methimazole
methimazole
propylthiouracil
5
4
5
5
5
5
5
5
5
5
5
4
5
2
5
4
2
2
2
2
2
2
2
Requisitos / Límites
PA
PA
PA
PA
ampul, vial: 100mcg/ml, 200mcg/
ml
vial: 1000mcg/ml
cartridge: 10mg/1.5ml
cartridge: 5mg/1.5ml; vial
cartridge, vial: 5mg
vial: 8.8mg
PA
QL: 1 in 28 days
vial: 10mg, 15mg, 20mg
vial: 25mg, 30mg
QL: 1 in 360 days
PA
QL: 1 in 360 days
PA
QL: 10 in 28 days
vial: 400mg/ml
QL: 1 in 84 days
QL: 1 in 84 days
tablet
syringe
vial
1
2
2
2
2
2
2
tablet
vial: 100mcg
vial: 200mcg, 500mcg
tablet: 20mg
tablet: 5mg, 10mg
Immunological Agents
Immunological Agents
ARCALYST
ASTAGRAF XL
AUBAGIO
azathioprine sodium
azathioprine
CARIMUNE NF NANOFILTERED
CELLCEPT
CELLCEPT
cyclosporine, modified
cyclosporine
5
4
5
2
2
5
4
5
2
2
PA BvD
PA, QL: 28 in 28 days
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
51
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
vial
susp recon
Vigencia: 01 noviembre 2014
Nombre del medicamento
Niveles de
Drogas
Requisitos / Límites
ENBREL
ENBREL
ENBREL
FLEBOGAMMA DIF
FLEBOGAMMA
GAMASTAN S-D
GAMMAGARD LIQUID
GAMMAPLEX
GAMUNEX-C
HUMIRA
HUMIRA
HYPERRAB S-D
HYPERRHO S-D
ILARIS
IMOGAM RABIES-HT
KINERET
leflunomide
MICRHOGAM ULTRAFILTERED PLUS
mycophenolate mofetil
mycophenolate sodium
NULOJIX
OCTAGAM
ORENCIA
ORENCIA
PRIVIGEN
PROGRAF
RAPAMUNE
RAPAMUNE
RHOGAM ULTRA-FILTERED
PLUS
RHOPHYLAC
RIDAURA
sirolimus
tacrolimus
TYSABRI
WINRHO SDF
ZORTRESS
5
5
5
5
5
3
5
5
5
5
5
4
4
5
4
5
2
4
PA, QL: 7.84 in 28 days
PA, QL: 8 in 28 days
PA, QL: 8.16 in 28 days
PA BvD
PA BvD
2
2
5
5
5
5
5
4
3
5
4
PA BvD
PA BvD
PA BvD
PA BvD
PA, QL: 4 in 28 days
PA, QL: 4 in 28 days
PA BvD
PA BvD
PA BvD
PA BvD
ZORTRESS
5
Vaccines
ACTHIB
ADACEL TDAP
ADACEL TDAP
BCG VACCINE (TICE STRAIN)
BOOSTRIX TDAP
3
3
3
3
3
4
5
2
2
5
4
4
PA BvD
PA BvD
PA BvD
PA, QL: 4 in 28 days
PA, QL: 6 in 28 days
pen injctr
vial
syringe
kit, pen ij kit: 40mg/0.8ml
pen ij kit: 40mg/0.8ml, (Starter Kit)
PA, QL: 2 in 28 days
PA, QL: 18.76 in 28 days
syringe
vial
ampul
solution
tablet: 1mg, 2mg
PA BvD
PA BvD
LA, PA, QL: 15 in 28 days
PA BvD, QL: 120 in 30
days
PA BvD, QL: 120 in 30
days
tablet: 0.25mg
tablet: 0.5mg, 0.75mg
syringe
vial
PA BvD
52
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
Vigencia: 01 noviembre 2014
Nombre del medicamento
CERVARIX
COMVAX
DAPTACEL DTAP
DIPHTHERIA-TETANUS
TOXOIDS-PED
ENGERIX-B ADULT
ENGERIX-B PEDIATRICADOLESCENT
GARDASIL
HAVRIX
HAVRIX
IMOVAX RABIES VACCINE
INFANRIX DTAP
INFANRIX PF
IPOL
IXIARO
JE-VAX
KINRIX
MENACTRA
MENHIBRIX
MENOMUNE-A-C-Y-W-135
MENVEO A-C-Y-W-135-DIP
M-M-R II VACCINE
PEDIARIX
PEDVAXHIB
PENTACEL ACTHIB
COMPONENT
PENTACEL DTAP-IPV
COMPONENT
PENTACEL
PROQUAD
RABAVERT
RECOMBIVAX HB
ROTARIX
ROTATEQ
TE ANATOXAL BERNA
TENIVAC
TETANUS DIPHTHERIA
TOXOIDS
TETANUS TOXOID ADSORBED
THERACYS
TWINRIX
TWINRIX
TYPHIM VI
VAQTA
VARIVAX VACCINE
YF-VAX
Niveles de
Drogas
Requisitos / Límites
4
3
3
3
3
3
4
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
PA BvD
PA BvD
syringe: 1440/ml
syringe: 720/0.5ml; vial
PA BvD
3
3
4
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
53
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
syringe
vial
Vigencia: 01 noviembre 2014
Nombre del medicamento
Niveles de
Drogas
ZOSTAVAX
Requisitos / Límites
3
Inflammatory Bowel Disease Agents
Inflammatory Bowel Disease Agents
APRISO
balsalazide disodium
budesonide
DIPENTUM
3
2
5
4
ST
Irrigating Solutions
Irrigating Solutions
acetic acid
GLYCINE
LACTATED RINGERS
mannitol/sorbitol solution
ringers solution
sodium chloride irrig solution
sorbitol solution
urologic solution-g
water for irrigation,sterile
2
2
3
2
2
2
2
3
2
Metabolic Bone Disease Agents
Metabolic Bone Disease Agents
ACTONEL
ACTONEL
ACTONEL
alendronate sodium
alendronate sodium
alendronate sodium
calcitonin,salmon,synthetic
calcitriol
doxercalciferol
etidronate disodium
FORTEO
FORTICAL
ibandronate sodium
ibandronate sodium
MIACALCIN
pamidronate disodium
paricalcitol
PROLIA
risedronate sodium
XGEVA
ZEMPLAR
zoledronic acid/mannitol&water
zoledronic acid/mannitol&water
zoledronic acid
ZOMETA
3
3
3
1
1
2
2
2
2
2
4
4
2
2
3
2
2
4
2
5
3
2
2
2
5
ST, QL: 1 in 28 days
ST, QL: 30 in 30 days
ST, QL: 4 in 28 days
QL: 4 in 28 days
QL: 300 in 28 days
QL: 3.7 in 28 days
PA BvD
PA BvD
PA, QL: 3 in 28 days
QL: 3.7 in 28 days
PA BvD, QL: 3 in 84 days
QL: 1 in 28 days
PA BvD
PA BvD
PA BvD
PA, QL: 1 in 180 days
QL: 1 in 28 days
PA, QL: 1.7 in 28 days
PA BvD
QL: 100 in 300 days
54
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
tablet: 150mg
tablet: 5mg, 30mg
tablet: 35mg
tablet: 5mg, 10mg, 40mg
tablet: 35mg, 70mg
solution
(PA for ESRD Only)
(PA for ESRD Only)
vial, (PA for ESRD Only)
tablet
vial, (PA for ESRD Only)
(PA for ESRD Only)
(PA for ESRD Only)
vial, (PA for ESRD Only)
piggyback
infus. btl
infus. btl
Vigencia: 01 noviembre 2014
Nombre del medicamento
Niveles de
Drogas
Requisitos / Límites
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
ACTEMRA
ACTEMRA
ACTIMMUNE
allopurinol sodium
allopurinol
amifostine crystalline
ammonium chloride
AVONEX ADMINISTRATION
PACK
AVONEX
BENLYSTA
BETASERON
bethanechol chloride
BOTOX
BOTOX
buspirone hcl
citrate phosphate dextros soln
colchicine/probenecid
COLCRYS
COPAXONE
CYSTADANE
dexrazoxane
droperidol
DUODOTE
DYSPORT
ELMIRON
EXTAVIA
finasteride
fomepizole
FUSILEV
gauze bandage
GILENYA
GLUCAGEN
GLUCAGON EMERGENCY KIT
glutethimide
guanidine hcl
H.P. ACTHAR
hydroxyzine hcl
5
5
5
2
1
2
2
5
PA, QL: 3.6 in 28 days
PA, QL: 40 in 30 days
5
5
5
2
4
4
2
2
2
3
5
5
2
2
3
4
4
5
2
5
5
1
5
3
3
2
2
5
2
ST
PA, QL: 2 in 28 days
ST
hydroxyzine pamoate
2
PA
KALBITOR
leucovorin calcium
levocarnitine (with sugar)
levocarnitine
5
2
2
2
PA BvD
PA BvD
syringe
vial
ST
QL: 1 in 90 days
QL: 4 in 90 days
vial: 200unit
vial: 100unit
ST
PA, QL: 28 in 28 days
PA, QL: 35 in 28 days
PA
55
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
(High Risk Med for Ages 65 and
Older)
(High Risk Med for Ages 65 and
Older)
(PA for ESRD Only)
(PA for ESRD Only)
Vigencia: 01 noviembre 2014
Nombre del medicamento
LITHOSTAT
mesna
MESNEX
MESTINON
methylene blue
methylergonovine maleate
methylergonovine maleate
MYOBLOC
MYTELASE
neostigmine methylsulfate
NPLATE
OTEZLA
physostigmine salicylate
PRALIDOXIME CHLORIDE
probenecid
PROCYSBI
PROSTIGMIN
PROTOPAM CHLORIDE
pyridostigmine bromide
REBIF REBIDOSE
REBIF
REGONOL
REMICADE
SENSIPAR
SENSIPAR
SIGNIFOR
SIMPONI ARIA
SIMPONI
SIMPONI
SIMULECT
sodium morrhuate
sodium tetradecyl sulfate
SOLIRIS
STELARA
STELARA
STELARA
SYNAREL
TECFIDERA
TECFIDERA
THALOMID
VORAXAZE
XELJANZ
Niveles de
Drogas
3
2
5
4
2
2
2
4
4
2
5
5
2
4
2
5
4
4
2
5
5
4
5
3
5
5
5
5
5
5
2
2
5
5
5
5
5
5
5
5
5
5
Requisitos / Límites
tablet
syrup, tablet er
ampul
tablet
QL: 1 in 90 days
PA, QL: 8 in 28 days
PA, QL: 60 in 30 days
PA
tablet: 30mg
tablet: 60mg, 90mg
QL: 60 in 30 days
PA, QL: 24 in 28 days
PA, QL: 0.5 in 28 days
PA, QL: 3 in 28 days
PA BvD
PA, QL: 10 in 360 days
PA, QL: 10 in 360 days
PA, QL: 5 in 360 days
pen injctr
syringe
syringe: 45mg/0.5ml
vial
syringe: 90mg/ml
PA, QL: 14 in 30 days
capsule dr: 120mg
PA, QL: 60 in 30 days
capsule dr: 120-240mg, 240mg
PA NSO, QL: 60 in 30 days
PA, QL: 60 in 30 days
Ophthalmic Agents
Antiglaucoma Agents
acetazolamide sodium
acetazolamide
2
2
56
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
Vigencia: 01 noviembre 2014
Nombre del medicamento
AZOPT
betaxolol hcl
BETIMOL
brimonidine tartrate
COMBIGAN
dorzolamide hcl/timolol maleat
dorzolamide hcl
ISOPTO CARPINE
ISTALOL
latanoprost
levobunolol hcl
levobunolol hcl
methazolamide
metipranolol
PHOSPHOLINE IODIDE
pilocarpine hcl
PILOPINE HS
SIMBRINZA
timolol maleate
TRAVATAN Z
travoprost (benzalkonium)
Niveles de
Drogas
3
2
4
2
3
2
2
3
4
2
2
2
2
2
4
2
4
3
2
3
2
Requisitos / Límites
ST
(drops: 0.15%, 0.20%)
drops: 8%
drops: 0.25%
drops: 0.5%
QL: 2.5 in 25 days
QL: 2.5 in 25 days
Replacement Preparations
Replacement Preparations
0.9 % sodium chloride
calcium chloride
calcium gluconate
citric acid/sodium citrate
dex 2.5%-half str lact.ringers
DEXTROSE W/ELECTROLYTE A
DEXTROSE W/ELECTROLYTE B
electrolyte-48 solution/d5w
electrolyte-48/fructose 10%
electrolyte-48/fructose 5%
electrolyte-75 solution/d5w
electrolyte-75/fructose 5%
HYPERLYTE CR
HYPERLYTE R
IONOSOL B with DEXTROSE 5%
IONOSOL MB-DEXTROSE 5%
IONOSOL T-DEXTROSE 5%
ISOLYTE E
ISOLYTE H W/DEXTROSE
ISOLYTE M W/DEXTROSE
ISOLYTE P with DEXTROSE
ISOLYTE R W/DEXTROSE
ISOLYTE S with DEXTROSE
2
2
2
2
2
4
4
2
2
2
2
2
4
4
4
4
4
4
4
4
4
2
4
PA BvD
57
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
(PA for ESRD Only)
Vigencia: 01 noviembre 2014
Nombre del medicamento
Niveles de
Drogas
ISOLYTE S
K-PHOS NO.2
magnesium chloride
magnesium sulfate in water
magnesium sulfate/d5w
magnesium sulfate
magnesium sulfate
NORMOSOL-M and DEXTROSE
NORMOSOL-R PH 7.4
NUTRILYTE II
NUTRILYTE
phosphorus #1
PLASMA-LYTE 148
PLASMA-LYTE 56 IN DEXTROSE
PLASMA-LYTE A PH 7.4
PLASMA-LYTE M IN DEXTROSE
pot chloride/pot bicarb/cit ac
potassium acetate
potassium bicarbonate/cit ac
potassium chlorid/d10-0.2%nacl
potassium chloride in 0.9%nacl
potassium chloride in d5w
potassium chloride in d5w
potassium chloride in lr-d5
potassium chloride/d5-0.2%nacl
potassium chloride/d5-0.2%nacl
potassium chloride/d5-0.25ns
potassium chloride/d5-0.3%nacl
potassium chloride/d5-0.45nacl
potassium chloride/d5-0.9%nacl
potassium chloride-0.45% nacl
potassium chloride
4
3
2
2
2
2
2
4
4
4
4
2
4
4
4
4
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
potassium chloride
potassium citrate/citric acid
potassium gluconate
potassium phos,m-basic-d-basic
ringers solution
SHOHL'S MODIFIED
sod/pot/k cit/sod cit/cit acid
sodium acetate
sodium bicarbonate
sodium chloride 0.45 %
sodium chloride 3%
sodium chloride 5%
sodium chloride
sodium chloride
2
2
2
2
2
2
2
2
2
2
2
2
2
2
58
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
Requisitos / Límites
infus. btl
syringe, vial
iv soln: 10meq/l, 30meq/l
iv soln: 20meq/l, 40meq/l
iv soln: 10meq/l, 30meq/l, 40meq/l
iv soln: 20meq/l
capsule er, piggyback, syringe, tab
er prt, tablet er
liquid, packet, tablet sa
vial: 2.5meq/ml
vial: 4meq/ml
Vigencia: 01 noviembre 2014
Nombre del medicamento
SODIUM LACTATE
sodium lactate
sodium phos,m-basic-d-basic
TPN ELECTROLYTES
TRAVERT-ELECTROLYTE NO.1
TRAVERT-ELECTROLYTE NO.2
TRAVERT-ELECTROLYTE NO.2
TRAVERT-ELECTROLYTE NO.3
TRAVERT-ELECTROLYTE NO.4
Niveles de
Drogas
Requisitos / Límites
2
2
2
4
4
4
4
4
4
iv soln: 10%
iv soln: 5%
Respiratory Tract Agents
Anti-inflammatories, Inhaled Corticosteroids
ADVAIR DISKUS
3
ADVAIR HFA
3
BREO ELLIPTA
3
DULERA
3
flunisolide
2
flunisolide
2
NASONEX
3
QNASL
3
QVAR
3
triamcinolone acetonide
2
Antileukotrienes
montelukast sodium
2
zafirlukast
2
Bronchodilators
albuterol sulfate
2
albuterol sulfate
2
aminophylline
aminophylline
ATROVENT HFA
COMBIVENT RESPIMAT
COMBIVENT
FORADIL
ipratropium bromide
ipratropium bromide
metaproterenol sulfate
PROAIR HFA
SEREVENT DISKUS
SPIRIVA
terbutaline sulfate
theophylline anhydrous
theophylline/d5w
VENTOLIN HFA
Respiratory Tract Agents, Other
acetylcysteine
2
2
3
3
3
3
2
2
2
3
3
3
2
2
2
3
2
QL: 60 in 30 days
QL: 12 in 28 days
QL: 60 in 30 days
QL: 13 in 28 days
QL: 50 in 25 days
QL: 50 in 25 days
QL: 34 in 28 days
QL: 8.7 in 28 days
QL: 17.4 in 25 days
QL: 16.5 in 30 days
PA BvD
QL: 25.8 in 28 days
QL: 8 in 30 days
QL: 29.4 in 30 days
QL: 62 in 30 days
QL: 15 in 10 days
QL: 30 in 28 days
spray: 25mcg
spray: 29mcg
syrup, tab er 12h, tablet
solution, vial-neb: 0.63mg/3ml,
1.25mg/3ml
liquid
vial
spray: 42mcg
spray: 21mcg
QL: 17 in 25 days
QL: 60 in 30 days
QL: 30 in 30 days
QL: 36 in 25 days
PA BvD
59
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
Vigencia: 01 noviembre 2014
Nombre del medicamento
ARALAST NP
cromolyn sodium
DALIRESP
KALYDECO
XOLAIR
ZEMAIRA
Niveles de
Drogas
5
2
3
5
5
5
Requisitos / Límites
PA BvD
QL: 30 in 30 days
PA, QL: 60 in 30 days
PA, QL: 6 in 28 days
Skeletal Muscle Relaxants
Skeletal Muscle Relaxants
baclofen
carisoprodol
2
2
PA, QL: 120 in 30 days
carisoprodol
2
PA, QL: 120 in 30 days
chlorzoxazone/acetaminophen
2
PA
chlorzoxazone
2
PA
cyclobenzaprine hcl
2
PA
dantrolene sodium
dantrolene sodium
metaxalone
2
2
2
PA
methocarbamol
2
PA
tizanidine hcl
2
tablet: 250mg, (High Risk Med for
Ages 65 and Older)
tablet: 350mg, (High Risk Med for
Ages 65 and Older)
(High Risk Med for Ages 65 and
Older)
(High Risk Med for Ages 65 and
Older)
(High Risk Med for Ages 65 and
Older)
capsule
vial
(High Risk Med for Ages 65 and
Older)
(High Risk Med for Ages 65 and
Older)
Sleep Disorder Agents
Sleep Disorder Agents
BUTISOL SODIUM
4
QL: 120 in 30 days
tablet: 30mg
BUTISOL SODIUM
4
QL: 473 in 30 days
elixir: 30mg/5ml
BUTISOL SODIUM
4
QL: 60 in 30 days
tablet: 50mg
modafinil
2
PA, QL: 60 in 30 days
ROZEREM
3
XYREM
5
LA
zaleplon
2
PA, QL: 60 in 30 days
zolpidem tartrate
2
PA, QL: 30 in 30 days
60
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
(High Risk Med. QL applies to all
members; PA required for 65
years and older with over 90 days
cumulative use with any nonbenzodiazepine hypnotic drug)
(High Risk Med. QL applies to all
members; PA required for 65
years and older with over 90 days
cumulative use with any nonbenzodiazepine hypnotic drug)
Vigencia: 01 noviembre 2014
Nombre del medicamento
Niveles de
Drogas
Requisitos / Límites
Sympatholytic Adrenergic Blocking Agents
Alpha-Adrenergic Blocking Agents
alfuzosin hcl
phentolamine mesylate
tamsulosin hcl
terazosin hcl
2
2
2
1
PA
Vasodilating Agents
Vasodilating Agents
ADCIRCA
ADEMPAS
alprostadil
epoprostenol sodium (glycine)
epoprostenol sodium (glycine)
ISOVEX
LETAIRIS
OPSUMIT
REMODULIN
REVATIO
sildenafil citrate
TRACLEER
TYVASO
VENTAVIS
5
5
2
2
5
4
5
5
5
5
2
5
5
5
PA, QL: 60 in 30 days
PA, QL: 90 in 30 days
PA
PA BvD
PA BvD
PA, QL: 30 in 30 days
PA, QL: 30 in 30 days
PA BvD
PA, QL: 37.5 in 1 day
PA, QL: 90 in 30 days
LA, PA, QL: 60 in 30 days
PA BvD
PA BvD
vial: 0.5mg
vial: 1.5mg
vial
Vitamins and Minerals
Vitamins and Minerals
LOZI-FLUR
pedi m.vit no.17 with fluoride
pedi mvi no.12/sodium fluoride
pnv with ca,no.72/iron/fa
2
2
2
3
61
Transamerica MedicareRx Choice (PDP) 2014 Part D Formulary
Formulary ID: 14602.000, Version: 20
(All Rx Prenatal Vitamins
Covered)
Vigencia: 01 noviembre 2014
Índice de medicamentos
0.9 % sodium chloride ..............57
8-MOP .....................................42
abacavir sulfate ........................30
abacavir/lamivudine/zidovudine30
ABELCET ................................26
ABILIFY ...................................29
ABILIFY DISCMELT ................29
ABILIFY MAINTENA ................29
ABRAXANE .............................17
acamprosate calcium ...............13
acarbose ..................................24
acebutolol hcl ...........................38
acetaminophen with codeine....10
acetazolamide ..........................56
acetazolamide sodium .............56
acetic acid ..........................45, 54
acetic acid/hydrocortisone........45
acetylcysteine ..........................59
acitretin ....................................42
ACTEMRA ...............................55
ACTHIB ....................................52
ACTIMMUNE ...........................55
ACTONEL ................................54
ACTOPLUS MET XR ...............26
acyclovir .............................32, 42
acyclovir sodium ......................32
ADACEL TDAP ........................52
ADAGEN ..................................45
adapalene ..........................42, 44
ADASUVE ................................29
ADCETRIS ...............................17
ADCIRCA .................................61
adefovir dipivoxil ......................32
ADEMPAS ...............................61
ADVAIR DISKUS .....................59
ADVAIR HFA ...........................59
AFINITOR ................................17
AFINITOR DISPERZ................17
AGGRENOX ............................33
A-HYDROCORT ......................50
AKTEN .....................................46
ALBENZA ................................28
ALBUKED-25 ...........................33
ALBUKED-5 .............................34
ALBUMIN HUMAN ...................34
ALBUMINAR-25 .......................34
ALBUMINAR-5 .........................34
ALBURX ..................................34
ALBUTEIN ...............................34
albuterol sulfate ....................... 59
alclometasone dipropionate ..... 43
alcohol antiseptic pads ............ 42
ALDURAZYME ........................ 45
alendronate sodium ................. 54
ALFERON N ............................ 32
alfuzosin hcl ............................. 61
ALIMTA.................................... 17
ALINIA ..................................... 28
allopurinol ................................ 55
allopurinol sodium .................... 55
alprazolam ............................... 13
alprostadil ................................ 61
ALREX ..................................... 46
aluminum chloride.................... 42
amantadine hcl ........................ 29
amifostine crystalline ............... 55
amiloride hcl ............................ 40
amiloride/hydrochlorothiazide .. 40
AMINO ACIDS ......................... 34
aminocaproic acid .................... 33
aminophylline........................... 59
AMINOSYN ............................. 34
AMINOSYN II .......................... 34
AMINOSYN M ......................... 34
AMINOSYN with ELECTROLYTES34
AMINOSYN-HBC ..................... 34
AMINOSYN-PF........................ 34
AMINOSYN-RF ....................... 34
amiodarone hcl ........................ 38
AMITIZA .................................. 47
amitriptyline hcl ........................ 23
amlodipine besylate ................. 39
amlodipine besylate/benazepril 39
amlodipine/atorvastatin ............ 40
ammonium chloride ................. 55
ammonium lactate ................... 43
amoxapine ............................... 23
amoxicillin ................................ 16
amoxicillin trihydrate ................ 16
amoxicillin/potassium clav ....... 16
amphotericin b ......................... 26
ampicillin sodium ..................... 16
ampicillin sodium/sulbactam na16
ampicillin trihydrate .................. 16
AMPYRA ................................. 41
ANACAINE .............................. 43
ANADROL-50 .......................... 49
anagrelide hcl .......................... 33
I-1
anastrozole .............................. 17
ANDRODERM ......................... 49
ANDROGEL ............................ 49
ANORO ELLIPTA .................... 21
APEXICON E .......................... 43
APOKYN ................................. 29
apraclonidine hcl ..................... 46
APRISO................................... 54
APTIOM .................................. 21
APTIVUS ................................. 30
ARALAST NP .......................... 60
ARCALYST ............................. 51
ARRANON .............................. 17
ARZERRA ............................... 17
ASTAGRAF XL........................ 51
atenolol.................................... 38
atenolol/chlorthalidone ............ 38
atorvastatin calcium................. 40
atovaquone ............................. 28
atovaquone/proguanil hcl ........ 28
ATRIPLA ................................. 30
atropine sulfate .................. 21, 46
ATROVENT HFA..................... 59
AUBAGIO ................................ 51
AVANDAMET .......................... 26
AVANDARYL........................... 26
AVANDIA ................................ 26
AVASTIN ................................. 17
AVC ......................................... 27
AVELOX ABC PACK ............... 16
AVELOX IV ............................. 16
AVONEX ................................. 55
AVONEX ADMINISTRATION PACK
............................................ 55
AXIRON .................................. 49
azacitidine ............................... 17
azathioprine ............................. 51
azathioprine sodium ................ 51
azelastine hcl........................... 46
AZILECT ................................. 29
azithromycin ............................ 15
AZOPT .................................... 57
AZOR ...................................... 39
aztreonam ............................... 16
bacitracin ........................... 14, 45
bacitracin/polymyxin b sulfate.. 45
baclofen................................... 60
balsalazide disodium ............... 54
BANZEL .................................. 21
BARACLUDE ...........................32
BCG VACCINE TICE STRAIN .52
BELEODAQ .............................17
benazepril hcl ...........................37
benazepril/hydrochlorothiazide 37
BENICAR .................................37
BENICAR HCT.........................37
BENLYSTA ..............................55
benztropine mesylate ...............29
BERINERT ...............................33
betamet acet/betamet na ph ....50
betamethasone dipropionate....44
betamethasone valerate ..........44
betamethasone/propylene glyc 44
BETASERON ...........................55
betaxolol hcl .......................38, 57
bethanechol chloride ................55
BETHKIS .................................14
BETIMOL .................................57
BEXXAR ..................................17
bicalutamide .............................17
BICILLIN C-R ...........................16
BICILLIN L-A ............................16
BICNU......................................17
BILTRICIDE .............................28
bisoprolol fumarate ..................38
bisoprolol fumarate/hctz ...........38
bleomycin sulfate .....................17
BLEPHAMIDE ..........................45
BLEPHAMIDE S.O.P. ..............45
BOOSTRIX TDAP ....................52
BOSULIF .................................17
BOTOX ....................................55
BREO ELLIPTA .......................59
BRILINTA .................................33
brimonidine tartrate ..................57
BRINTELLIX ............................23
BROMDAY ...............................46
bromfenac sodium ...................46
bromocriptine mesylate ............29
budesonide ..............................54
bumetanide ..............................40
BUMINATE ..............................34
BUPHENYL..............................47
buprenorphine hcl ..............10, 13
buprenorphine hcl/naloxone hcl13
bupropion hcl ...........................23
buspirone hcl............................55
BUSULFEX ..............................17
butalb/acetaminophen/caffeine 10
butalbit/acetamin/caff/codeine..10
butalbital/acetaminophen .........10
butalbital/aspirin/caffeine ......... 11
BUTISOL SODIUM .................. 60
butorphanol tartrate ................. 10
BUTRANS ............................... 10
BYDUREON ............................ 24
BYDUREON PEN .................... 24
BYETTA................................... 24
BYSTOLIC ............................... 38
cabergoline .............................. 29
caffeine citrated ....................... 41
caffeine/sodium benzoate ........ 41
calcipotriene ............................ 43
calcipotriene/betamethasone ... 43
calcitonin,salmon,synthetic ...... 54
calcitriol.............................. 43, 54
calcium acetate ........................ 48
calcium carbonate/mag carb/fa 48
calcium chloride ....................... 57
calcium gluconate .................... 57
CALDOLOR ............................. 11
CAMPRAL ............................... 13
CANCIDAS .............................. 26
candesartan cilexetil ................ 37
candesartan/hydrochlorothiazid37
CAPASTAT SULFATE............. 27
CAPRELSA ............................. 17
captopril ................................... 37
captopril/hydrochlorothiazide ... 37
CARAC .................................... 43
CARAFATE ............................. 47
CARBAGLU ............................. 47
carbamazepine ........................ 21
carbidopa ................................. 29
carbidopa/levodopa ................. 29
carbidopa/levodopa/entacapone29
carbinoxamine maleate............ 26
carboplatin ............................... 17
CARIMUNE NF NANOFILTERED 51
carisoprodol ............................. 60
carteolol hcl ............................. 46
carvedilol ................................. 38
CAYSTON ............................... 16
CEENU .................................... 17
cefaclor .................................... 15
cefadroxil ................................. 15
cefazolin sodium ...................... 15
cefazolin sodium/dextrose,iso .. 15
cefdinir ..................................... 15
cefditoren pivoxil ...................... 15
CEFEPIME .............................. 15
cefepime hcl ............................ 15
CEFEPIME-DEXTROSE ......... 15
I-2
cefotaxime sodium .................. 15
cefotetan disod/dextrose,iso .... 15
cefotetan disodium .................. 15
cefoxitin sodium....................... 15
cefoxitin sodium/dextrose,iso .. 15
cefpodoxime proxetil ............... 15
cefprozil ................................... 15
ceftazidime pentahydrate ........ 15
ceftibuten dihydrate ................. 15
ceftriaxone na/dextrose,iso...... 15
ceftriaxone sodium .................. 15
cefuroxime axetil ..................... 15
cefuroxime sodium .................. 15
cefuroxime sodium/dextrose,iso15
CELEBREX ............................. 11
CELLCEPT .............................. 51
CELONTIN .............................. 21
cephalexin ............................... 15
CEPROTIN .............................. 32
CEREZYME ............................ 45
CERVARIX .............................. 53
CESAMET ............................... 28
cevimeline hcl .......................... 42
CHANTIX ................................ 13
CHENODAL ............................ 45
chloramphenicol sod succ ....... 14
chlordiazepoxide hcl ................ 13
chlorhexidine gluconate ........... 42
chlorothiazide .......................... 40
chlorothiazide sodium.............. 40
chlorpromazine hcl .................. 29
chlorthalidone .......................... 40
chlorzoxazone ......................... 60
chlorzoxazone/acetaminophen 60
cholestyramine (with sugar)..... 40
cholestyramine/aspartame ...... 40
choline sal/mag salicylate ........ 11
ciclopirox ................................. 26
ciclopirox olamine .................... 26
cidofovir ................................... 32
cilostazol ................................. 33
cimetidine ................................ 47
cimetidine hcl........................... 47
cimetidine in 0.9 % nacl ........... 47
CIMZIA .................................... 45
CINRYZE ................................ 33
CIPRO HC ............................... 45
CIPRODEX.............................. 45
ciprofloxacin ............................ 16
ciprofloxacin hcl ................. 16, 45
ciprofloxacin lactate ................. 16
ciprofloxacin lactate/d5w ......... 16
ciprofloxacin/ciprofloxa hcl .......16
cisplatin ....................................17
citalopram hydrobromide .........23
citrate phosphate dextros soln .55
citric acid/sodium citrate ...........57
cladribine .................................18
clarithromycin ...........................15
clemastine fumarate .................26
CLEVIPREX .............................39
clindamycin hcl.........................14
clindamycin palmitate hcl .........14
clindamycin phos/benzoyl perox43
clindamycin phosphate 14, 27, 43
clindamycin phosphate/d5w .....14
CLINIMIX .................................35
CLINIMIX E ........................34, 35
CLINISOL ................................35
clobetasol propionate ...............44
clocortolone pivalate ................44
CLODERM ...............................44
CLOLAR ..................................18
clomipramine hcl ......................23
clonazepam..............................13
clonidine...................................36
clonidine hcl .......................36, 41
clonidine hcl/chlorthalidone ......36
clopidogrel bisulfate .................33
clorazepate dipotassium ..........13
clotrimazole ..............................26
clotrimazole/betamethasone dip26
clozapine ..................................29
COARTEM ...............................28
cocaine hcl ...............................12
codeine phos/acetaminophen ..10
codeine sulfate .........................10
codeine/butalbital/asa/caffein ...10
colchicine/probenecid ..............55
COLCRYS................................55
colestipol hcl ............................40
colistin (colistimethate na) ........14
COLY-MYCIN S .......................45
COMBIGAN .............................57
COMBIPATCH .........................49
COMBIVENT............................59
COMBIVENT RESPIMAT ........59
COMETRIQ..............................18
COMPLERA .............................30
COMVAX .................................53
CONDYLOX .............................43
COPAXONE.............................55
CORDRAN ...............................44
COREG CR..............................38
cortisone acetate ..................... 50
CORTISPORIN-TC .................. 45
CREON.................................... 45
CRESTOR ............................... 40
CRIXIVAN................................ 30
cromolyn sodium ......... 46, 47, 60
CUBICIN .................................. 14
cyclobenzaprine hcl ................. 60
CYCLOGYL ............................. 46
cyclopentolate hcl .................... 46
cyclophosphamide ................... 18
CYCLOPHOSPHAMIDE .......... 18
CYCLOSET ............................. 24
cyclosporine............................. 51
cyclosporine, modified ............. 51
cyproheptadine hcl................... 27
CYRAMZA ............................... 18
CYSTADANE........................... 55
CYSTARAN ............................. 46
cysteine hcl .............................. 35
cytarabine/pf ............................ 18
dacarbazine ............................. 18
dactinomycin............................ 18
DALIRESP ............................... 60
danazol .................................... 49
dantrolene sodium ................... 60
dapsone ................................... 27
DAPTACEL DTAP ................... 53
DARAPRIM.............................. 28
daunorubicin hcl ...................... 18
DAUNOXOME ......................... 18
DDAVP .................................... 50
decitabine ................................ 18
deferoxamine mesylate............ 48
demeclocycline hcl................... 17
DENAVIR................................. 43
DEPO-PROVERA .................... 51
desipramine hcl ....................... 23
desmopressin (nonrefrigerated)50
desmopressin acetate.............. 50
desog-e.estradiol/e.estradiol .... 42
desogestrel-ethinyl estradiol .... 42
desonide .................................. 44
desoximetasone ...................... 44
DESVENLAFAXINE ER........... 23
dex 2.5%-half str lact.ringers ... 57
dexamethasone ....................... 50
dexamethasone acetate .......... 50
dexamethasone sod phosphate46, 50
dexmethylphenidate hcl ........... 41
dexrazoxane ............................ 55
dextroamphetamine sulfate ..... 41
I-3
dextroamphetamine/amphetamine 41
dextrose 10 % and 0.2 % nacl . 35
dextrose 10 % and 0.9 % nacl . 35
dextrose 10%-0.5 normal saline35
dextrose 10%-water ................ 35
dextrose 2.5 % in water ........... 35
dextrose 2.5% in half ringers ... 35
dextrose 2.5%-0.5normal saline35
dextrose 20%-water ................ 35
dextrose 25 % in water ............ 35
dextrose 40%-water ................ 35
dextrose 5 % and 0.3 % nacl ... 35
dextrose 5 % and 0.9 % nacl ... 35
dextrose 5 % in water .............. 35
dextrose 5 %-0.2 % nacl ......... 35
dextrose 5 %-0.45 % nacl ....... 35
dextrose 5% in ringers ............. 35
dextrose 5%-lactated ringers ... 35
dextrose 50 % in water ............ 35
dextrose 60 % in water ............ 35
dextrose 70%-water ................ 35
DEXTROSE W/ELECTROLYTE A 57
DEXTROSE W/ELECTROLYTE B 57
DIASTAT ACUDIAL................. 13
diazepam ................................. 13
diclofenac potassium ............... 12
diclofenac sodium.............. 12, 46
diclofenac sodium/misoprostol 12
dicloxacillin sodium.................. 16
dicyclomine hcl ........................ 47
didanosine ............................... 30
DIFICID ................................... 15
diflorasone diacetate ............... 44
diflunisal .................................. 12
digoxin ..................................... 39
DIGOXIN ................................. 39
dihydroergotamine mesylate ... 27
DILANTIN ................................ 21
diltiazem hcl....................... 38, 39
dimenhydrinate ........................ 28
DIOVAN .................................. 37
DIPENTUM.............................. 54
diphenhydramine hcl ............... 27
diphenoxylate hcl/atropine ....... 47
DIPHTHERIA-TETANUS TOXOIDSPED .................................... 53
disopyramide phosphate ......... 38
disulfiram ................................. 13
divalproex sodium ................... 21
dobutamine hcl ........................ 39
dobutamine hcl/d5w ................ 39
DOCEFREZ............................. 18
docetaxel .................................18
donepezil hcl ............................22
dopamine hcl............................39
dopamine hcl/d5w ....................39
dopamine hcl/dextrose 5%-water39
dorzolamide hcl ........................57
dorzolamide hcl/timolol maleat .57
doxazosin mesylate .................36
doxepin hcl ...............................23
doxercalciferol ..........................54
doxorubicin hcl .........................18
doxorubicin hcl peg-liposomal ..18
doxycycline hyclate ..................17
doxycycline monohydrate.........17
dronabinol ................................28
droperidol .................................55
DROXIA ...................................18
DUAVEE ..................................49
DULERA ..................................59
duloxetine hcl ...........................23
DUODOTE ...............................55
DUREZOL ................................46
DUTOPROL .............................38
DYRENIUM ..............................40
DYSPORT................................55
econazole nitrate......................26
edetate disodium......................48
EDURANT................................31
EFFIENT ..................................33
ELAPRASE ..............................45
electrolyte-48 solution/d5w.......57
electrolyte-48/fructose 10%......57
electrolyte-48/fructose 5%........57
electrolyte-75 solution/d5w.......57
electrolyte-75/fructose 5%........57
ELELYSO ................................45
ELIDEL ....................................44
ELIGARD .................................18
ELIQUIS...................................32
ELITEK ....................................45
ELMIRON ................................55
ELSPAR ...................................18
EMCYT ....................................18
EMEND ....................................28
EMSAM ....................................23
EMTRIVA .................................31
enalapril maleate......................37
enalapril/hydrochlorothiazide ...37
enalaprilat dihydrate.................37
ENBREL ..................................52
ENGERIX-B ADULT ................53
ENGERIX-B PEDIATRICADOLESCENT .................... 53
enoxaparin sodium .................. 32
entacapone .............................. 29
entecavir .................................. 32
ephedrine sulfate ..................... 39
epinastine hcl........................... 46
epinephrine .............................. 39
EPIPEN 2-PAK ........................ 39
EPIPEN JR 2-PAK ................... 39
epirubicin hcl............................ 18
EPIVIR ..................................... 31
EPIVIR HBV ............................ 31
eplerenone............................... 41
EPOGEN ................................. 33
epoprostenol sodium (glycine) . 61
eprosartan mesylate ................ 37
EPZICOM ................................ 31
ERAXIS WATER DILUENT ..... 26
ERBITUX ................................. 18
ERGOMAR .............................. 27
ERIVEDGE .............................. 18
ERWINAZE.............................. 18
ery e-succ/sulfisoxazole........... 15
ERY-TAB ................................. 15
ERYTHROCIN LACTOBIONATE15
erythromycin base ............. 15, 45
erythromycin base/ethanol....... 43
erythromycin ethylsuccinate .... 16
erythromycin stearate .............. 16
erythromycin/benzoyl peroxide 43
escitalopram oxalate ................ 23
esmolol hcl............................... 38
esomeprazole sodium.............. 47
estazolam ................................ 13
ESTRACE................................ 49
estradiol ................................... 49
estradiol valerate ..................... 49
estradiol/norethindrone acet .... 49
ESTRASORB .......................... 49
estropipate ............................... 49
ethambutol hcl ......................... 27
ethanolamine oleate ................ 39
ethinyl estradiol/drospirenone .. 42
ethosuximide ........................... 21
ethynodiol d-ethinyl estradiol ... 42
etidronate disodium ................. 54
etodolac ................................... 12
ETOPOPHOS .......................... 18
etoposide ................................. 18
EURAX .................................... 44
EXELDERM ............................. 26
I-4
EXELON.................................. 22
exemestane ............................. 18
EXFORGE ............................... 40
EXFORGE HCT ...................... 40
EXJADE .................................. 48
EXTAVIA ................................. 55
FABRAZYME .......................... 45
famciclovir ............................... 32
famotidine ................................ 47
famotidine in nacl,iso-osm/pf ... 47
FANAPT .................................. 29
FARESTON ............................. 18
FASLODEX ............................. 18
FAZACLO ................................ 29
felbamate ................................ 21
felodipine ................................. 40
FEMRING ................................ 49
fenofibrate ............................... 40
fenofibrate nanocrystallized ..... 40
fenofibrate,micronized ............. 40
fenofibric acid .......................... 40
fenofibric acid (choline) ........... 40
fenoprofen calcium .................. 12
fentanyl.................................... 10
fentanyl citrate ......................... 10
FERRIPROX ........................... 48
FETZIMA ................................. 23
finasteride ................................ 55
FIRAZYR ................................. 39
FIRMAGON ............................. 18
flavoxate hcl ............................ 48
FLEBOGAMMA ....................... 52
FLEBOGAMMA DIF ................ 52
flecainide acetate .................... 38
FLECTOR ............................... 12
FLEXBUMIN ............................ 34
floxuridine ................................ 18
fluconazole .............................. 26
fluconazole in nacl,iso-osm ..... 26
flucytosine ............................... 26
fludarabine phosphate ............. 18
fludrocortisone acetate ............ 50
flumazenil ................................ 41
flunisolide ................................ 59
fluocinonide ............................. 44
fluorometholone....................... 46
FLUOROPLEX ........................ 43
fluorouracil ......................... 18, 43
fluoxetine hcl ........................... 23
fluoxymesterone ...................... 49
fluphenazine decanoate .......... 29
fluphenazine hcl ...................... 29
flurazepam hcl..........................13
flurbiprofen ...............................12
flurbiprofen sodium ..................46
flutamide ..................................18
fluticasone propionate ..............44
fluvastatin sodium ....................40
fluvoxamine maleate ................23
FOLOTYN ................................18
fomepizole ...............................55
fondaparinux sodium..........32, 33
FORADIL .................................59
FORTEO ..................................54
FORTICAL ...............................54
foscarnet sodium......................31
fosinopril sodium ......................37
fosinopril/hydrochlorothiazide...37
fosphenytoin sodium ................21
FREAMINE HBC ......................35
FREAMINE III ..........................35
fructose 10% ............................35
FULYZAQ ................................47
furosemide ...............................40
FUROXONE.............................14
FUSILEV ..................................55
FUZEON ..................................31
FYCOMPA ...............................21
gabapentin ...............................21
GABITRIL ................................21
galantamine hbr .......................22
GALZIN ....................................48
GAMASTAN S-D......................52
GAMMAGARD LIQUID ............52
GAMMAPLEX ..........................52
GAMUNEX-C ...........................52
ganciclovir sodium ...................32
GARDASIL ...............................53
gatifloxacin ...............................45
gauze bandage ........................55
GAZYVA ..................................18
gemcitabine hcl ........................18
gemfibrozil ...............................40
GENOTROPIN .........................50
gentamicin in nacl, iso-osm ......14
gentamicin sulfate ........14, 43, 45
gentamicin sulfate/pf ................14
GEODON .................................29
GILENYA .................................55
GILOTRIF ................................18
GLEEVEC ................................18
glimepiride ...............................25
glipizide ....................................25
glipizide/metformin hcl .............25
GLUCAGEN ............................ 55
GLUCAGON EMERGENCY KIT55
glutethimide ............................. 55
glyburide .................................. 25
glyburide,micronized ................ 25
glyburide/metformin hcl............ 25
GLYCINE ................................. 54
glycopyrrolate .......................... 47
GLYSET .................................. 24
granisetron hcl ......................... 28
granisetron hcl/pf ..................... 28
GRANIX ................................... 33
griseofulvin ultramicrosize ....... 26
griseofulvin, microsize ............. 26
guanfacine hcl ......................... 36
guanidine hcl ........................... 55
H.P. ACTHAR .......................... 55
HALAVEN ................................ 19
HALFAN .................................. 28
halobetasol propionate ............ 44
haloperidol ............................... 30
haloperidol decanoate ............. 29
haloperidol lactate ................... 30
HAVRIX ................................... 53
heparin sod,pork in 0.45% nacl 33
heparin sodium,porcine ........... 33
heparin sodium,porcine/d5w .... 33
heparin sodium,porcine/ns/pf... 33
heparin sodium,porcine/pf ....... 33
HEPATAMINE ......................... 35
HEPATASOL ........................... 35
HERCEPTIN ............................ 19
HEXALEN ................................ 19
homatropine hbr ...................... 46
HUMALOG .............................. 25
HUMALOG MIX 50-50 ............. 24
HUMALOG MIX 75-25 ............. 24
HUMATROPE .......................... 50
HUMIRA .................................. 52
HUMULIN 70-30 ...................... 25
HUMULIN N............................. 25
HUMULIN R............................. 25
hydralazine hcl......................... 39
hydralazine/hydrochlorothiazid 39
hydrochlorothiazide.................. 40
hydrocodone/acetaminophen .. 10
hydrocodone/ibuprofen ............ 10
hydrocortisone ................... 44, 50
hydrocortisone acetate ............ 44
hydrocortisone acetate/aloe v .. 44
hydrocortisone acetate/urea .... 44
hydrocortisone butyrate ........... 44
I-5
hydrocortisone sod succinate .. 50
hydrocortisone valerate ........... 44
hydromorphone hcl.................. 10
hydromorphone hcl/pf.............. 10
hydroxychloroquine sulfate ...... 28
hydroxyurea............................. 19
hydroxyzine hcl........................ 55
hydroxyzine pamoate .............. 55
HYPERLYTE CR ..................... 57
HYPERLYTE R ....................... 57
HYPERRAB S-D ..................... 52
HYPERRHO S-D ..................... 52
ibandronate sodium ................. 54
ibuprofen ................................. 12
ibuprofen/oxycodone hcl ......... 10
ICLUSIG .................................. 19
idarubicin hcl ........................... 19
ifosfamide ................................ 19
ifosfamide/mesna .................... 19
ILARIS ..................................... 52
ILEVRO ................................... 46
IMBRUVICA ............................ 19
imipenem/cilastatin sodium ..... 16
imipramine hcl ......................... 23
imipramine pamoate ................ 23
imiquimod ................................ 43
IMOGAM RABIES-HT ............. 52
IMOVAX RABIES VACCINE ... 53
INCIVEK .................................. 32
INCRELEX .............................. 50
indapamide .............................. 40
indomethacin ........................... 12
indomethacin sodium .............. 12
INFANRIX DTAP ..................... 53
INFANRIX PF .......................... 53
INLYTA.................................... 19
INTELENCE ............................ 31
INTRALIPID............................. 35
INTRON A ............................... 32
INTUNIV .................................. 41
INVANZ ................................... 16
INVEGA................................... 30
INVEGA SUSTENNA .............. 30
INVIRASE ............................... 31
INVOKAMET ........................... 24
INVOKANA .............................. 24
IONOSOL B with DEXTROSE 5% 57
IONOSOL MB-DEXTROSE 5%57
IONOSOL T-DEXTROSE 5% .. 57
IPOL ........................................ 53
ipratropium bromide ................ 59
IPRIVASK ................................ 33
irbesartan .................................37
irbesartan/hydrochlorothiazide .37
irinotecan hcl ............................19
ISENTRESS.............................31
ISOLYTE E ..............................57
ISOLYTE H W/DEXTROSE .....57
ISOLYTE M W/DEXTROSE .....57
ISOLYTE P with DEXTROSE ..57
ISOLYTE R W/DEXTROSE .....57
ISOLYTE S ..............................58
ISOLYTE S with DEXTROSE ..57
isoniazid ...................................27
isopropamide/prochlorperazine 47
ISOPTO CARPINE ..................57
ISOPTO HOMATROPINE ........46
isosorbide dinitrate ...................41
isosorbide mononitrate.............41
ISOVEX ...................................61
isradipine .................................40
ISTALOL ..................................57
ISTODAX .................................19
itraconazole..............................26
IXEMPRA .................................19
IXIARO.....................................53
JAKAFI.....................................19
JANUMET ................................24
JANUMET XR ..........................24
JANUVIA ..................................24
JENTADUETO .........................24
JE-VAX ....................................53
JEVTANA .................................19
JUVISYNC ...............................24
KABIVEN .................................35
KADCYLA ................................19
KALBITOR ...............................55
KALETRA ................................31
KALYDECO .............................60
kanamycin sulfate ....................14
KEDBUMIN ..............................34
KEPIVANCE ............................42
KETEK .....................................16
ketoconazole ............................26
ketoprofen ................................12
ketorolac tromethamine .....12, 46
KHEDEZLA ..............................23
KINERET .................................52
KINRIX .....................................53
KORLYM ..................................24
K-PHOS NO.2 ..........................58
KRYSTEXXA ...........................45
KUVAN ....................................45
KYNAMRO ...............................40
KYPROLIS............................... 19
labetalol hcl.............................. 38
LACRISERT ............................ 47
LACTATED RINGERS............. 54
lactulose .................................. 47
LAMICTAL ............................... 21
lamivudine ............................... 31
lamivudine/zidovudine ............. 31
lamotrigine ............................... 21
LANOXIN ................................. 39
lansoprazole ............................ 47
lansoprazole/amoxiciln/clarith .. 47
LANTUS .................................. 25
LANTUS SOLOSTAR .............. 25
latanoprost ............................... 57
LATUDA .................................. 30
LAZANDA ................................ 10
leflunomide .............................. 52
LETAIRIS................................. 61
letrozole ................................... 19
leucovorin calcium ................... 55
LEUKERAN ............................. 19
LEUKINE ................................. 33
leuprolide acetate .................... 19
LEVEMIR ................................. 25
LEVEMIR FLEXPEN................ 25
levetiracetam ........................... 21
levetiracetam in nacl (iso-os) ... 21
levobunolol hcl ......................... 57
levocarnitine ............................ 55
levocarnitine (with sugar) ......... 55
levocetirizine dihydrochloride ... 27
levofloxacin .................. 16, 17, 45
levofloxacin/d5w ...................... 16
levonorgestrel .......................... 42
levonorgestrel-ethin estradiol ... 42
levorphanol tartrate .................. 11
levothyroxine sodium ............... 51
LEVULAN ................................ 43
LEXIVA .................................... 31
lidocaine .................................. 13
lidocaine hcl ............................. 12
lidocaine hcl/d5w/pf ................. 38
lidocaine hcl/pf ................... 12, 38
lidocaine/prilocaine .................. 12
LIDODERM.............................. 13
LINZESS.................................. 45
liothyronine sodium .................. 51
lipase/protease/amylase .......... 45
LIPOSYN II .............................. 36
LIPOSYN III ............................. 36
lisinopril.................................... 37
I-6
lisinopril/hydrochlorothiazide ... 37
lithium carbonate ..................... 41
lithium citrate ........................... 41
LITHOSTAT............................. 56
l-norgest-eth estr/ethin estra.... 42
LOCOID .................................. 44
lomustine ................................. 19
loperamide hcl ......................... 48
lorazepam ............................... 13
losartan potassium .................. 37
losartan/hydrochlorothiazide.... 37
LOTEMAX ............................... 46
LOTRONEX............................. 45
lovastatin ................................. 40
loxapine succinate ................... 30
LOZI-FLUR .............................. 61
LUMINAL SODIUM ................. 21
LUMIZYME .............................. 45
LUPRON DEPOT .................... 19
LUPRON DEPOT-PED ........... 19
LYRICA ................................... 21
LYSODREN............................. 19
mafenide acetate ..................... 43
magnesium chloride ................ 58
magnesium sulfate .................. 58
magnesium sulfate in water ..... 58
magnesium sulfate/d5w........... 58
malathion................................. 44
mannitol/sorbitol solution ......... 54
maprotiline hcl ......................... 23
MARPLAN ............................... 23
MARQIBO ............................... 19
MATULANE ............................. 19
meclizine hcl ............................ 28
medroxyprogesterone acet ...... 51
medroxyprogesterone acetate . 51
mefenamic acid ....................... 12
mefloquine hcl ......................... 28
MEGACE ES ........................... 19
megestrol acetate .................... 19
MEKINIST ............................... 19
meloxicam ............................... 12
melphalan hcl .......................... 19
MENACTRA ............................ 53
MENEST ................................. 49
MENHIBRIX ............................ 53
MENOMUNE-A-C-Y-W-135 .... 53
MENVEO A-C-Y-W-135-DIP ... 53
mercaptopurine ....................... 19
meropenem ............................. 16
mesna ..................................... 56
MESNEX ................................. 56
MESTINON ..............................56
metaproterenol sulfate .............59
metaxalone ..............................60
metformin hcl ...........................24
methadone hcl .........................11
methazolamide.........................57
methenamine hippurate ...........14
methimazole.............................51
methocarbamol ........................60
methotrexate sodium ...............19
methotrexate sodium/pf ...........19
methoxsalen, rapid...................43
methscopolamine bromide .......48
methyclothiazide ......................40
methylene blue.........................56
methylergonovine maleate .......56
methylphenidate hcl ...........41, 42
methylprednisolone ..................50
methylprednisolone acetate .....50
methylprednisolone sod succ ...50
metipranolol .............................57
metoclopramide hcl ..................48
metolazone ..............................40
metoprolol succinate ................38
metoprolol tartrate ....................38
metoprolol/hydrochlorothiazide 38
metronidazole ..............27, 28, 43
metronidazole/sodium chloride 28
METVIXIA ................................43
mexiletine hcl ...........................38
MIACALCIN .............................54
miconazole nitrate ....................27
MICRHOGAM ULTRA-FILTERED
PLUS ...................................52
midazolam hcl ..........................13
midazolam hcl/pf ......................13
midodrine hcl............................36
milrinone lactate .......................39
milrinone lactate/d5w ...............39
MINOCIN .................................17
minocycline hcl.........................17
minoxidil ...................................41
mirtazapine ..............................23
misoprostol...............................47
mitomycin .................................19
mitoxantrone hcl.......................19
M-M-R II VACCINE ..................53
MOBAN ....................................30
modafinil ..................................60
moexipril hcl .............................37
moexipril/hydrochlorothiazide...37
mometasone furoate ................44
montelukast sodium ................. 59
morphine sulfate ...................... 11
MORPHINE SULFATE ............ 11
morphine sulfate/0.9% nacl/pf . 11
morphine sulfate/pf .................. 11
MOVIPREP.............................. 48
MOXEZA ................................. 46
moxifloxacin hcl ....................... 17
MOZOBIL ................................ 33
MULTAQ.................................. 38
mupirocin ................................. 43
mupirocin calcium .................... 43
MUSTARGEN.......................... 19
mycophenolate mofetil ............. 52
mycophenolate sodium ............ 52
MYOBLOC............................... 56
MYOZYME .............................. 45
MYTELASE ............................. 56
na nitrite/na thiosul/amyl nit ..... 48
nabumetone............................. 12
nadolol ..................................... 38
NAFCILL IN DEXTROSE......... 16
nafcillin sodium ........................ 16
NAGLAZYME .......................... 45
nalbuphine hcl ......................... 11
nalidixic acid ............................ 17
naloxone hcl ............................ 13
naltrexone hcl .......................... 13
NAMENDA............................... 22
NAMENDA XR ......................... 22
naphazoline hcl/antazoline ...... 47
naproxen.................................. 12
naproxen sodium ..................... 12
naratriptan hcl .......................... 27
NASONEX ............................... 59
NATACYN ............................... 46
nateglinide ............................... 24
NEBUPENT ............................. 28
needles, insulin disposable ...... 44
nefazodone hcl ........................ 23
neo/polymyx b sulf/dexameth .. 46
neomy sulf/bacitra/polymyxin b 46
neomy sulf/bacitrac zn/poly/hc . 46
neomy sulf/polymyxin b sulfate 43
neomycin sulfate ...................... 14
neomycin sulfate/dex na ph ..... 46
neomycin/polymyxin b sulf/hc .. 46
neomycin/polymyxn b/gramicidin46
neostigmine methylsulfate ....... 56
NEPHRAMINE ......................... 36
NEULASTA.............................. 33
NEUMEGA .............................. 33
I-7
NEUPOGEN ............................ 33
NEUPRO ................................. 29
NEVANAC ............................... 46
nevirapine ................................ 31
NEXAVAR ............................... 19
niacin ....................................... 40
nicardipine hcl ......................... 40
NICOTROL .............................. 13
nifedipine ................................. 40
NILANDRON ........................... 19
NITRO-BID .............................. 41
nitrofurantoin ........................... 14
nitrofurantoin macrocrystal ...... 14
nitroglycerin ............................. 41
nitroglycerin/d5w ..................... 41
NITROSTAT ............................ 41
nizatidine ................................. 47
NORDITROPIN ....................... 50
NORDITROPIN FLEXPRO...... 50
NORDITROPIN NORDIFLEX .. 50
norelgestromin/ethin.estradiol . 42
norepinephrine bitartrate ......... 39
noreth-ethinyl estradiol/iron ..... 42
norethindrone .......................... 42
norethindrone acetate ............. 51
norethindrone ac-eth estradiol42, 49
norethindrone-e.estradiol-iron . 42
norethindrone-ethinyl estrad .... 42
norethindrone-mestranol ......... 42
norgestimate-ethinyl estradiol.. 42
norgestrel-ethinyl estradiol ...... 42
NORMOSOL-M and DEXTROSE58
NORMOSOL-R PH 7.4 ............ 58
nortriptyline hcl ........................ 23
NORVIR .................................. 31
NOVAMINE ............................. 36
NOVAREL ............................... 50
NOVOLIN 70-30 ...................... 25
NOVOLIN N............................. 25
NOVOLIN R............................. 25
NOVOLOG .............................. 25
NOVOLOG FLEXPEN ............. 25
NOVOLOG MIX 70-30............. 25
NOVOLOG MIX 70-30 FLEXPEN25
NOXAFIL ................................. 26
NPLATE .................................. 56
NUCYNTA ............................... 11
NUCYNTA ER ......................... 11
NUEDEXTA ............................. 42
NULOJIX ................................. 52
NUTRESTORE........................ 48
NUTRILYTE ............................ 58
NUTRILYTE II ..........................58
NUTROPIN ..............................50
NUTROPIN AQ ........................50
NUTROPIN AQ NUSPIN..........50
NUVARING ..............................42
nylidrin hcl ................................41
nystatin ....................................26
nystatin/triamcin .......................26
OCTAGAM ...............................52
octreotide acetate ....................51
OFIRMEV ................................11
ofloxacin.............................17, 46
olanzapine ...............................30
olanzapine/fluoxetine hcl ..........23
OLYSIO ...................................32
omega-3 acid ethyl esters ........40
omeprazole ..............................47
OMNITROPE ...........................51
ONCASPAR .............................19
ondansetron .............................28
ondansetron hcl .......................28
ONFI ..................................13, 14
ONTAK ....................................19
OPSUMIT ................................61
ORAP.......................................30
ORENCIA ................................52
ORENITRAM ER .....................39
ORFADIN .................................45
ORTHO EVRA .........................42
OTEZLA ...................................56
oxacillin sodium........................16
oxacillin sodium/dextrose,iso ...16
oxaliplatin .................................20
oxandrolone .............................49
oxcarbazepine..........................21
OXSORALEN-ULTRA ..............43
OXTELLAR XR ........................21
oxybutynin chloride ..................48
oxycodone hcl ..........................11
oxycodone hcl/acetaminophen.11
oxycodone hcl/aspirin ..............11
OXYCONTIN............................11
oxymorphone hcl......................11
paclitaxel ..................................20
pamidronate disodium..............54
PANRETIN ...............................43
pantoprazole sodium................47
papaverine hcl..........................39
paregoric ..................................48
paricalcitol ................................54
paromomycin sulfate ................28
paroxetine hcl...........................23
PASER .................................... 27
PATADAY ................................ 47
PATANOL ................................ 47
PAXIL ...................................... 23
pedi m.vit no.17 with fluoride ... 61
pedi mvi no.12/sodium fluoride 61
PEDIARIX ................................ 53
PEDVAXHIB ............................ 53
peg 3350/na sulf,bicarb,cl/kcl .. 48
PEGANONE ............................ 21
PEGASYS ............................... 32
PEGASYS PROCLICK ............ 32
PEGINTRON ........................... 32
PEGINTRON REDIPEN .......... 32
pen g pot/dextrose-water ......... 16
penicillin g potassium............... 16
penicillin g potassium/d5w ....... 16
penicillin g procaine ................. 16
penicillin v potassium ............... 16
PENTACEL.............................. 53
PENTACEL ACTHIB COMPONENT
............................................ 53
PENTACEL DTAP-IPV COMPONENT
............................................ 53
PENTAM 300........................... 28
pentamidine isethionate ........... 28
pentostatin ............................... 20
pentoxifylline ............................ 33
p-epd tan/chlor-tan................... 27
PERIKABIVEN......................... 36
perindopril erbumine ................ 37
PERJETA ................................ 20
permethrin ............................... 44
perphenazine ........................... 30
perphenazine/amitriptyline hcl . 23
phenelzine sulfate .................... 23
phenobarbital ........................... 22
phenobarbital sodium .............. 21
phentolamine mesylate ............ 61
phenylephrine hcl .............. 37, 47
PHENYTEK ............................. 22
phenytoin ................................. 22
phenytoin sodium .................... 22
phenytoin sodium extended ..... 22
PHOSLYRA ............................. 48
PHOSPHOLINE IODIDE ......... 57
phosphorus #1 ......................... 58
physostigmine salicylate .......... 56
PICATO ................................... 43
pilocarpine hcl.................... 42, 57
PILOPINE HS .......................... 57
pindolol .................................... 38
I-8
pioglitazone hcl........................ 26
pioglitazone hcl/glimepiride ..... 26
pioglitazone hcl/metformin hcl . 26
piperacillin sodium/tazobactam 16
piroxicam ................................. 12
PLASBUMIN-25 ...................... 34
PLASBUMIN-5 ........................ 34
PLASMA-LYTE 148................. 58
PLASMA-LYTE 56 IN DEXTROSE58
PLASMA-LYTE A PH 7.4 ........ 58
PLASMA-LYTE M IN DEXTROSE 58
pnv with ca,no.72/iron/fa ......... 61
podofilox .................................. 43
podophyllum resin ................... 43
polyethylene glycol 3350 ......... 48
polymyxin b sulf/trimethoprim .. 46
polymyxin b sulfate .................. 14
POMALYST ............................. 20
pot chloride/pot bicarb/cit ac .... 58
potassium acetate ................... 58
potassium bicarbonate/cit ac ... 58
potassium chlorid/d10-0.2%nacl58
potassium chloride .................. 58
potassium chloride in 0.9%nacl58
potassium chloride in d5w ....... 58
potassium chloride in lr-d5....... 58
potassium chloride/d5-0.2%nacl58
potassium chloride/d5-0.25ns.. 58
potassium chloride/d5-0.3%nacl58
potassium chloride/d5-0.45nacl58
potassium chloride/d5-0.9%nacl58
potassium chloride-0.45% nacl 58
potassium citrate/citric acid ..... 58
potassium gluconate ............... 58
potassium hydroxide ............... 43
potassium phos,m-basic-d-basic58
POTIGA................................... 22
PRADAXA ............................... 33
PRALIDOXIME CHLORIDE .... 56
pramipexole di-hcl ................... 29
PRANDIMET ........................... 24
pravastatin sodium .................. 40
prazosin hcl ............................. 37
prednicarbate .......................... 44
prednisolone ............................ 50
prednisolone acetate ......... 46, 50
prednisolone sod phosphate46, 50
prednisone .............................. 50
PREDNISONE INTENSOL ...... 50
PREMARIN ............................. 49
PREMASOL ............................ 36
PREMPHASE .......................... 49
PREMPRO ...............................49
PREZISTA ...............................31
PRIFTIN ...................................27
PRIMAQUINE ..........................28
primidone .................................22
PRISTIQ ER.............................23
PRIVIGEN ................................52
PROAIR HFA ...........................59
probenecid ...............................56
procainamide hcl ......................38
PROCALAMINE .......................36
prochlorperazine edisylate .......28
prochlorperazine maleate.........28
PROCRIT .................................33
PROCYSBI ..............................56
progesterone ............................51
progesterone,micronized .........51
PROGLYCEM ..........................41
PROGRAF ...............................52
PROLENSA .............................46
PROLEUKIN ............................20
PROLIA....................................54
PROMACTA.............................33
promethazine hcl................27, 28
PRONESTYL ...........................38
propafenone hcl .......................38
propantheline bromide .............21
proparacaine hcl ......................47
proparacaine/fluorescein sod ...47
propranolol hcl .........................38
propranolol/hydrochlorothiazid .38
propylthiouracil .........................51
PROQUAD ...............................53
PROSOL ..................................36
PROSTIGMIN ..........................56
protamine sulfate .....................33
PROTOPAM CHLORIDE .........56
PROTOPIC ..............................44
protriptyline hcl .........................23
PULMOZYME ..........................45
PURIXAN .................................20
pyridostigmine bromide ............56
QNASL.....................................59
QUDEXY XR ............................22
quetiapine fumarate .................30
QUICK MIX with LYTES ..........36
QUILLIVANT XR ......................42
quinapril hcl ..............................37
quinapril/hydrochlorothiazide ...37
quinidine gluconate ..................38
quinidine sulfate .......................38
quinine sulfate ..........................28
QVAR ...................................... 59
RABAVERT ............................. 53
raloxifene hcl ........................... 49
ramipril ..................................... 37
RANEXA .................................. 39
ranitidine hcl ............................ 47
RAPAMUNE ............................ 52
RAVICTI .................................. 48
REBIF ...................................... 56
REBIF REBIDOSE................... 56
RECOMBIVAX HB ................... 53
REGONOL............................... 56
RELENZA ................................ 31
RELISTOR............................... 48
REMICADE.............................. 56
REMODULIN ........................... 61
RENAGEL ............................... 48
RENVELA ................................ 48
repaglinide ............................... 24
RESCRIPTOR ......................... 31
RETROVIR .............................. 31
REVATIO ................................. 61
REVLIMID................................ 20
REYATAZ ................................ 31
RHOGAM ULTRA-FILTERED PLUS
............................................ 52
RHOPHYLAC .......................... 52
ribavirin .................................... 32
RIDAURA ................................ 52
rifabutin .................................... 27
rifampin .................................... 27
RIFATER ................................. 27
riluzole ..................................... 42
rimantadine hcl ........................ 31
ringers solution .................. 54, 58
risedronate sodium .................. 54
RISPERDAL CONSTA ............ 30
risperidone ............................... 30
RITUXAN ................................. 20
rivastigmine tartrate ................. 22
rizatriptan benzoate ................. 27
ropinirole hcl ............................ 29
ROTARIX................................. 53
ROTATEQ ............................... 53
ROZEREM............................... 60
SABRIL .................................... 22
SAIZEN.................................... 51
salsalate .................................. 12
SANDOSTATIN LAR ............... 51
SANTYL................................... 43
SAPHRIS ................................. 30
SAVELLA................................. 42
I-9
selegiline hcl ............................ 29
selenium sulfide....................... 43
SELZENTRY ........................... 31
SENSIPAR .............................. 56
SEREVENT DISKUS............... 59
SEROMYCIN........................... 27
SEROQUEL XR ...................... 30
SEROSTIM.............................. 51
sertraline hcl ............................ 23
SHOHL'S MODIFIED .............. 58
SIGNIFOR ............................... 56
sildenafil citrate........................ 61
SILENOR ................................ 23
silver nitrate ............................. 43
silver nitrate applicator ............ 43
silver sulfadiazine .................... 43
SIMBRINZA ............................. 57
SIMPONI ................................. 56
SIMPONI ARIA ........................ 56
SIMULECT .............................. 56
simvastatin .............................. 40
sirolimus .................................. 52
SIRTURO ................................ 27
sod propion/inositol/aa14/urea 27
sod/pot/k cit/sod cit/cit acid ...... 58
sodium acetate ........................ 58
sodium bicarbonate ................. 58
sodium chloride ....................... 58
sodium chloride 0.45 % ........... 58
sodium chloride 3% ................. 58
sodium chloride 5% ................. 58
sodium chloride irrig solution ... 54
sodium chloride/nahco3/kcl/peg48
sodium lactate ......................... 59
SODIUM LACTATE ................. 59
sodium morrhuate ................... 56
sodium phenylbutyrate ............ 48
sodium phos,m-basic-d-basic .. 59
sodium polystyrene sulfonate .. 48
sodium tetradecyl sulfate ......... 56
sodium thiosulfate ................... 48
SOLIRIS .................................. 56
SOLTAMOX ............................ 20
SOLU-CORTEF....................... 50
SOLU-MEDROL ...................... 50
SOMATULINE DEPOT ............ 51
SOMAVERT ............................ 51
sorbitol solution ....................... 54
sotalol hcl ................................ 38
SOTALOL HCL........................ 38
SOVALDI ................................. 32
spinosad .................................. 44
SPIRIVA...................................59
spironolact/hydrochlorothiazid..41
spironolactone..........................41
SPORANOX.............................26
SPRYCEL ................................20
stavudine .................................31
STELARA ................................56
STERILE DILUENT..................34
STIVARGA ...............................20
STRATTERA............................42
streptomycin sulfate .................14
STRIBILD .................................31
STROMECTOL ........................28
SUBOXONE.............................13
sucralfate .................................47
sulfacetamide sodium ........43, 46
sulfacetamide/prednisolone sp.46
sulfadiazine ..............................17
sulfamethoxazole/trimethoprim 17
sulfasalazine ............................17
sulindac....................................12
sumatriptan ..............................27
sumatriptan succinate ..............27
SUPPRELIN LA .......................51
SUPRAX ..................................15
SUSTIVA .................................31
SUTENT ..................................20
SYLATRON 4-PACK................32
SYLVANT ................................20
SYMLIN ...................................24
SYMLINPEN 120 .....................24
SYMLINPEN 60 .......................24
SYNAGIS .................................31
SYNAREL ................................56
SYNERCID ..............................14
SYNRIBO .................................20
SYPRINE .................................48
syring w-ndl,disp,insul,0.3ml ....44
syring w-ndl,disp,insul,0.5ml ....45
syring w-o ndl,disp,insul, 1ml ...45
TABLOID .................................20
tacrolimus ................................52
TAFINLAR................................20
TAMIFLU ...........................31, 32
tamoxifen citrate.......................20
tamsulosin hcl ..........................61
TANZEUM................................24
TARCEVA ................................20
TARGRETIN ......................20, 44
TASIGNA .................................20
TAZICEF IN DEXTROSE .........15
TAZORAC ................................44
TE ANATOXAL BERNA........... 53
tea tree oil ................................ 15
TECFIDERA ............................ 56
TEGRETOL XR ....................... 22
telmisartan ............................... 37
telmisartan/hydrochlorothiazid . 37
temazepam .............................. 14
TEMODAR............................... 20
teniposide ................................ 20
TENIVAC ................................. 53
terazosin hcl ............................ 61
terbinafine hcl .......................... 26
terbutaline sulfate .................... 59
terconazole .............................. 27
testosterone cypionate............. 49
testosterone enanthate ............ 49
TETANUS DIPHTHERIA TOXOIDS53
TETANUS TOXOID ADSORBED53
tetracaine hcl/pf ....................... 47
tetracycline hcl ......................... 17
TEV-TROPIN ........................... 51
THALOMID .............................. 56
theophylline anhydrous ............ 59
theophylline/d5w ...................... 59
THERACYS ............................. 53
THERMAZENE ........................ 43
thioridazine hcl......................... 30
thiotepa .................................... 20
thiothixene ............................... 30
tiagabine hcl ............................ 22
TIKOSYN ................................. 38
timolol maleate .................. 38, 57
tinidazole ................................. 28
TIVICAY................................... 31
tizanidine hcl ............................ 60
TOBI PODHALER.................... 14
tobramycin in 0.225% nacl ....... 14
tobramycin sulfate ............. 14, 46
tobramycin/dexamethasone..... 46
tobramycin/sodium chloride ..... 14
tolazamide ............................... 25
tolbutamide .............................. 25
tolmetin sodium ....................... 12
tolterodine tartrate ................... 48
topiramate................................ 22
topotecan hcl ........................... 20
TORISEL ................................. 20
torsemide ................................. 40
TPN ELECTROLYTES ............ 59
TRACLEER ............................. 61
TRADJENTA ........................... 24
tramadol hcl ............................. 11
I-10
tramadol hcl/acetaminophen ... 11
trandolapril .............................. 37
tranexamic acid ....................... 33
tranylcypromine sulfate ........... 23
TRAVAMULSION .................... 36
TRAVASOL ............................. 36
TRAVASOL W/DEXTROSE .... 36
TRAVASOL W/ELECTROLYTES36
TRAVASOL with DEXTROSE . 36
TRAVASOL with ELECTROLYTES36
TRAVATAN Z .......................... 57
TRAVERT ............................... 36
TRAVERT IN NORMAL SALINE36
TRAVERT-ELECTROLYTE NO.159
TRAVERT-ELECTROLYTE NO.259
TRAVERT-ELECTROLYTE NO.359
TRAVERT-ELECTROLYTE NO.459
travoprost (benzalkonium) ....... 57
trazodone hcl ........................... 23
TREANDA ............................... 20
TRECATOR............................. 27
TRELSTAR.............................. 20
tretinoin ............................. 20, 44
tretinoin microspheres ............. 44
TREXALL ................................ 20
triamcinolone acetonide42, 44, 50, 59
triamterene/hydrochlorothiazid 40
triazolam.................................. 14
TRIBENZOR............................ 37
trifluoperazine hcl .................... 30
trifluridine ................................. 46
trihexyphenidyl hcl ................... 29
TRILEPTAL ............................. 22
trimethoprim ............................ 14
trimipramine maleate ............... 24
tripelennamine hcl ................... 27
TRISENOX .............................. 20
TRIUMEQ ................................ 31
TROKENDI XR ........................ 22
TROPHAMINE ........................ 36
trospium chloride ..................... 48
TRUVADA ............................... 31
TWINRIX ................................. 53
TYGACIL ................................. 17
TYKERB .................................. 20
TYPHIM VI .............................. 53
TYSABRI ................................. 52
TYVASO.................................. 61
TYZEKA .................................. 32
TYZINE ................................... 47
UCERIS ................................... 50
urologic solution-g ................... 54
ursodiol ....................................48
UVADEX ..................................43
VAGIFEM .................................49
valacyclovir hcl .........................32
VALCHLOR..............................43
VALCYTE ................................32
valproic acid .............................22
valproic acid (as sodium salt) ...22
valsartan/hydrochlorothiazide ..37
VALSTAR ................................20
vancomycin hcl ..................14, 15
VANCOMYCIN HCL ................15
vancomycin hcl/d5w .................14
VANTAS ..................................51
VAQTA.....................................53
VARIVAX VACCINE ................53
VASCEPA ................................40
vasopressin ..............................51
VECAMYL ................................39
VECTIBIX ................................20
VELCADE ................................20
venlafaxine hcl .........................24
VENLAFAXINE HCL ER ..........24
VENTAVIS ...............................61
VENTOLIN HFA .......................59
verapamil hcl ............................39
VERSACLOZ ...........................30
VESICARE ...............................48
VICTRELIS ..............................32
VIDEX ......................................31
VIGAMOX ................................46
VIIBRYD ..................................24
VIMIZIM ................................... 45
VIMPAT ................................... 22
vinblastine sulfate .................... 20
vincristine sulfate ..................... 20
vinorelbine tartrate ................... 20
VIRACEPT............................... 31
VIRAMUNE XR ........................ 31
VIREAD ................................... 31
VIVELLE-DOT ......................... 50
VOLTAREN ............................. 12
VORAXAZE ............................. 56
voriconazole ............................ 26
VOTRIENT .............................. 20
VPRIV ...................................... 45
VUMON ................................... 20
warfarin sodium ....................... 33
water for irrigation,sterile ......... 54
WELCHOL ............................... 40
WINRHO SDF ......................... 52
XALKORI ................................. 20
XARELTO ................................ 33
XARTEMIS XR ........................ 11
XELJANZ ................................. 56
XENAZINE............................... 42
XERAC AC .............................. 43
XGEVA .................................... 54
XOLAIR ................................... 60
XTANDI ................................... 20
XYLOCAINE ............................ 38
XYREM .................................... 60
YERVOY.................................. 20
YF-VAX.................................... 53
I-11
zafirlukast ................................ 59
zaleplon ................................... 60
ZALTRAP ................................ 21
ZANOSAR ............................... 21
ZAVESCA ............................... 45
ZELBORAF ............................. 21
ZEMAIRA ................................ 60
ZEMPLAR ............................... 54
ZENPEP .................................. 45
ZETIA ...................................... 41
ZIAGEN ................................... 31
zidovudine ............................... 31
ziprasidone hcl ........................ 30
ZOLADEX ............................... 21
zoledronic acid ........................ 54
zoledronic acid/mannitol&water54
ZOLINZA ................................. 21
zolmitriptan .............................. 27
zolpidem tartrate...................... 60
ZOMETA ................................. 54
zonisamide .............................. 22
ZORBTIVE .............................. 51
ZORTRESS ............................. 52
ZOSTAVAX ............................. 54
ZOVIRAX ................................ 43
ZUBSOLV ............................... 13
ZYDELIG ................................. 21
ZYKADIA ................................. 21
ZYLET ..................................... 46
ZYPREXA RELPREVV ........... 30
ZYTIGA ................................... 21
ZYVOX .................................... 15
Este formulario se actualizó el 11/01/2014. Para obtener información más reciente o hacer otras preguntas, comuníquese
con Servicios para Miembros de Transamerica MedicareRx Choice (PDP) al teléfono 1-888-672-7206 o, los usuarios de
TTY deben llamar al 711, 24 horas al día, 365 días al año, o visite www.transamericamedicarerx.com.
Stonebridge Life Insurance Company (una compañía de Transamerica) es un patrocinador del plan PDP con un contrato
de Medicare. La inscripción en este plan depende de la renovación del contrato.