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Formulario (Lista de medicamentos) Anthem HealthKeepers Medicare-Medicaid Plan (MMP), a Commonwealth Coordinated Care Plan Virginia Servicios al Miembro: 1-855-817-5787 (TTY 711) Lunes a viernes de 8 a.m. a 8 p.m. hora local mss.anthem.com/ccc H0147_16_24596_T_SP CMS Approved 09/18/2015 ID del Formulario: 16234 Versión: 7 Publicado 01/01/2016 H0147_16_24596_T_SP CMS Approved 09/18/2015 Anthem HealthKeepers Medicare-Medicaid Plan (MMP), a Commonwealth Coordinated Care Plan | 2016 Lista de medicamentos cubiertos (Formulario) Esta es una lista de los medicamentos que los miembros pueden obtener en Anthem HealthKeepers Medicare-Medicaid Plan (MMP), a Commonwealth Coordinated Care plan ofrecido por HealthKeepers, Inc. HealthKeepers, Inc. es un plan de salud que tiene contrato con ambos Medicare y el Virginia Department of Medical Assistance Services para ofrecer beneficios de ambos programas a los inscritos. La lista de medicamentos cubiertos y/o las redes de farmacias y proveedores pueden cambiar a lo largo del año. Le enviaremos una notificación antes de hacer un cambio que le afecte. Los beneficios y/o los copagos pueden cambiar el 1 de enero de cada año. Siempre puede revisar la lista actualizada de medicamentos cubiertos en línea de Anthem HealthKeepers MMP en mss.anthem.com/ccc. Puede obtener esta información gratuitamente en otros formatos, tales como letras grandes, braille o audio. Llame al 1-855-817-5787 (TTY 711). La llamada es gratuita. Pueden aplicarse limitaciones, copagos y restricciones. Para obtener más información, llame a Anthem HealthKeepers MMP Member Services o lea el manual del miembro de Anthem HealthKeepers MMP. Los copagos para medicamentos recetados pueden variar con base en el nivel de Ayuda adicional (Extra Help) que usted recibe. Póngase en contacto con el plan para mayores detalles. You can get this information for free in other languages. Call 1-855-817-5787 (TTY 711). The call is free. Puede recibir esta información sin cargo en otros idiomas. Llame al 1-855-817-5787 (TTY 711). La llamada es gratuita. HealthKeepers, Inc. es un plan de salud que tiene contrato con ambos Medicare y el Virginia Department of Medical Assistance Services para ofrecer beneficios de ambos programas a los inscritos. HealthKeepers, Inc. es un licenciatario independiente de Blue Cross and Blue Shield Association. ANTHEM es una marca comercial registrada de Anthem Insurance Companies, Inc. Los nombres y símbolos de Blue Cross and Blue Shield son marcas registradas de Blue Cross and Blue Shield Association. ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 1 Preguntas frecuentes (FAQ) Encuentre aquí respuestas a las preguntas que tenga sobre esta Lista de medicamentos cubiertos. Puede leer todas las preguntas frecuentes para aprender más o buscar una pregunta y respuesta. ¿Qué medicamentos recetados se encuentran en la lista de medicamentos cubiertos? (Llamamos a la lista de medicamentos cubiertos la “lista de medicamentos” para abreviar). 1. Los medicamentos en la Lista de medicamentos cubiertos que comienza en la página 11 son los medicamentos cubiertos por HealthKeepers, Inc. Estos medicamentos están disponibles en farmacias de nuestra red. Una farmacia se encuentra en nuestra red si tiene un acuerdo para trabajar con nosotros y proporcionarle sus servicios. Nos referimos a estas farmacias como “farmacias de la red”. → HealthKeepers, Inc. cubrirá todos los medicamentos necesarios por motivos médicos en la Lista de medicamentos si: • su doctor u otro recetante afirma que los necesita para estar mejor o para estar sano, y • usted abastece la receta en una farmacia de la red de Anthem HealthKeepers MMP. → Es posible que HealthKeepers, Inc. tenga pasos adicionales para acceder a ciertos medicamentos (ver pregunta #5 más adelante). Puede ver una lista actualizada de los medicamentos que cubrimos en nuestro sitio web en mss.anthem.com/ccc o llamar a Member Services al 1-855-817-5787 (TTY 711). ¿Cambia alguna vez la lista de medicamentos? 2. Sí. Anthem HealthKeepers MMP puede agregar o eliminar medicamentos de la Lista de medicamentos durante el año. Por lo general, la lista de medicamentos solo cambiará si: • surge un medicamento más barato que funciona tan bien como el medicamento en la lista de medicamentos ahora, o • nos enteramos de que un medicamento no es seguro. También podemos cambiar nuestras reglas sobre medicamentos. Por ejemplo, podríamos: ? • Decidir la exigencia o no de aprobación previa para un medicamento. (Aprobación previa es permiso de HealthKeepers, Inc. antes de recibir un medicamento). • Agregar o cambiar la cantidad de un medicamento que puede recibir (llamado “límites de cantidad”). Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 2 • Agregar o cambiar restricciones de terapia escalonada para un medicamento. (Terapia escalonada significa que debe probar un medicamento antes de que cubramos otro medicamento). (Para obtener más información sobre estas reglas de medicamentos, vea la página 4). Le informaremos cuando un medicamento que usted toma es retirado de la Lista de medicamentos. También le avisaremos cuando cambiemos nuestras reglas para cubrir un medicamento. Las preguntas 3, 4 y 7 a continuación tienen más información sobre lo que ocurre cuando cambia la lista de medicamentos. → Siempre puede revisar la lista actualizada de medicamentos en línea de Anthem HealthKeepers MMP en mss.anthem.com/ccc. → También puede llamar a Member Services para revisar la Lista de medicamentos actual al 1-855-817-5787 (TTY 711). 3. ¿Qué ocurre cuando surge un medicamento más barato que funciona tan bien como un medicamento en la lista de medicamentos ahora? Si toma un medicamento que es retirado debido a la aparición de un medicamento más económico que funciona bien, le informaremos. Le avisaremos al menos 60 días antes de retirarlo de la lista de medicamentos o cuando usted solicita un reabastecimiento. Luego puede recibir un suministro de 60 días del medicamento antes de que se realice el cambio a la lista de medicamentos. En el caso de cambios a la lista de medicamentos durante el año, le enviaremos una carta sobre estos cambios 60 días antes de su entrada en vigencia. También publicaremos una copia de la carta en nuestro sitio web en mss.anthem.com/ccc. 4. ¿Qué ocurre cuando averiguamos que un medicamento no es seguro? Si la Administración de Alimentos y Medicamentos (Food and Drug Administration (FDA)) informa que un medicamento que usted está tomando no es seguro, lo eliminaremos de la lista de medicamentos de inmediato. También le enviaremos una carta informándole esta situación. Si recibe un aviso acerca de un medicamento poco seguro, llame de inmediato a su doctor. Su doctor puede ayudarle a encontrar otro medicamento que le sea de utilidad. También puede llamar a Member Services o a su encargado de cuidado quien puede ayudar a encontrar un medicamento similar o ayudar a contactar a su proveedor. Llámenos al 1-855-817-5787 (TTY 711). ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 3 ¿Hay alguna restricción o límite en la cobertura de medicamentos? ¿O existen acciones requeridas que se deben realizar para obtener ciertos medicamentos? 5. Sí, algunos medicamentos tienen reglas de cobertura o límites en la cantidad que puede recibir. En algunos casos usted o su doctor u otro recetante debe realizar algo antes de poder recibir el medicamento. Por ejemplo: • Aprobación previa (o autorización previa): Para algunos medicamentos, usted o su doctor u otro recetante deben obtener la aprobación de HealthKeepers, Inc. antes de completar su receta. Si no obtiene aprobación, puede que HealthKeepers, Inc. no cubra el medicamento. • Límites de cantidad: En ocasiones HealthKeepers, Inc. limita la cantidad de un medicamento que usted puede recibir. • Terapia escalonada: En ocasiones HealthKeepers, Inc. requiere que usted realice una terapia escalonada. Esto significa que tendrá que probar los medicamentos en un cierto orden para su condición médica. Es posible que deba probar un medicamento antes de que cubramos otro medicamento. Si su doctor cree que el primer medicamento no funciona en su caso, entonces cubriremos el segundo. Usted puede saber si su medicamento tiene requisitos adicionales o límites buscando en las tablas en las páginas 11-145. Hemos publicado en línea documentos que explican nuestras restricciones de autorización previa y terapia escalonada. También puede obtener información al visitar nuestro sitio web en mss.anthem.com/ccc. También puede pedirnos que le enviemos una copia. Puede pedir una “excepción” de estos límites. Vea la pregunta 11 para obtener más información sobre las excepciones. → Si se encuentra en un asilo de ancianos u otro centro de cuidado a largo plazo y necesita un medicamento que no está en la Lista de medicamentos o si no puede obtener con facilidad el medicamento que necesita, podemos ayudarlo. Cubriremos un suministro de emergencia de 31 días del medicamento que necesite (a menos que tenga una receta por menos días), aunque sea un nuevo miembro de Anthem HealthKeepers MMP o no. Esto le dará tiempo para conversar con su doctor u otro recetante. Este profesional puede ayudarle a decidir si existe un medicamento similar en la lista de medicamentos que usted puede tomar o si solicita una excepción. Vea la pregunta 11 para obtener más información sobre las excepciones. ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 4 ¿Cómo sabrá si el medicamento que desea tiene limitaciones o si existen acciones requeridas que realizar para obtener el medicamento? 6. La Lista de medicamentos cubiertos en la página 11 tiene una columna llamada “Acciones necesarias, restricciones o límites de uso”. ¿Qué ocurre si cambiamos nuestras reglas sobre cómo cubrimos algunos medicamentos? Por ejemplo, si agregamos autorización (aprobación) previa, límites de cantidad y/o restricciones de terapia escalonada a un medicamento. 7. Le informaremos si agregamos aprobación previa, límites de cantidad y/o restricciones de terapia escalonada a un medicamento. Le indicaremos al menos 60 días antes de incluir la restricción o cuando solicite reabastecimiento. Luego, puede recibir un suministro de 60 días del medicamento antes de que se realice el cambio a la lista de medicamentos. Esto le permitirá contar con tiempo para conversar con su doctor u otro recetante acerca de lo que debe hacer a continuación. ¿Cómo puede encontrar un medicamento en la lista de medicamentos? 8. Hay dos formas de encontrar un medicamento: • Puede buscar en forma alfabética (si sabe cómo deletrear el medicamento) o • Puede buscar por condición médica. Para buscar en forma alfabética, vaya a la sección Listado alfabético. Puede encontrarlo al buscar en el índice de medicamentos, desde la página 146. Para buscar por condición médica, busque la sección llamada “Lista de medicamentos por condición médica” en la página 11. Los medicamentos en esta sección están agrupados en categorías, dependiendo del tipo de condiciones médicas para los que se utilizan. Por ejemplo, si tiene una condición cardiaca, debe buscar en la categoría Cardiovascular/hipertensión/lípidos. Es donde encontrará medicamentos para tratar condiciones cardiacas. ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 5 ¿Qué pasa si el medicamento que desea tomar no está en la lista de medicamentos? 9. Si no encuentra su medicamento en la Lista de medicamentos, llame a Member Services al 1-855-817-5787 (TTY 711) y pregunte por el mismo. Si se entera que HealthKeepers, Inc. no cubrirá el medicamento, puede seguir uno de estos dos pasos: • Pida a Member Services una lista de los medicamentos similares al que desea tomar. Luego muestre la lista a su doctor u otro recetante. Él o ella puede recetar un medicamento de la lista de medicamentos que sea similar al que usted desea tomar. O • Puede pedirle al plan de salud que haga una excepción y cubra su medicamento. Vea la pregunta 11 para obtener más información sobre las excepciones. 10. ¿Qué ocurre si usted es un nuevo miembro de Anthem HealthKeepers MMP y no puede encontrar su medicamento en la Lista de medicamentos o tiene un problema para obtener su medicamento? Podemos ayudar. Podemos cubrir un suministro temporal de 31 días de su medicamento durante los primeros 90 días en que usted es miembro de Anthem HealthKeepers MMP. Esto le dará tiempo para conversar con su doctor u otro recetante. Este profesional puede ayudarle a decidir si existe un medicamento similar en la lista de medicamentos que usted puede tomar o si solicita una excepción. Cubriremos un suministro de 31 días de su medicamento si: • usted toma un medicamento que no está en nuestra Lista de medicamentos, o • las reglas del plan de salud no le permiten recibir la cantidad establecida por su recetante, o • el medicamento requiere aprobación previa de Anthem HealthKeepers MMP, o • usted toma un medicamento que es parte de una restricción de terapia escalonada. Si vive en un asilo de ancianos u otro centro de cuidado a largo plazo, puede reabastecer su receta hasta por 98 días. Puede reabastecer el medicamento múltiples veces durante sus primeros 90 días en el plan. Esto le brinda a su recetante tiempo para cambiar sus medicamentos a los que están en la lista de medicamentos o pedir una excepción. Si experimenta un cambio en el nivel de cuidado que recibe, que le exige pasar de una instalación o centro de tratamiento a otro, puede ser elegible para un reabastecimiento temporal único de la receta que tiene actualmente. Por ejemplo, si recibe el alta del hospital y se le entrega una lista de medicamentos basada en el formulario del hospital, es posible que reciba un reabastecimiento único del medicamento. Puede recibir la excepción temporal única sin importar si se encuentra ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 6 o no en sus primeros 90 días de afiliación al programa. Pida a su recetante que nos llame para indicarnos los detalles. Si tiene alguna pregunta, llame a su encargado de cuidado al 1-855-817-5787 (TTY 711). 11. ¿Puede pedir una excepción para cubrir su medicamento? Sí. Puede solicitar a HealthKeepers, Inc. que realice una excepción para cubrir un medicamento que no esté en la Lista de medicamentos. También nos puede pedir que cambiemos las reglas sobre su medicamento. • Por ejemplo, HealthKeepers, Inc. puede limitar la cantidad del medicamento que cubriremos. Si su medicamento tiene un límite, puede pedirnos que cambiemos el límite y cubramos más. • Otros ejemplos: Puede pedirnos que eliminemos las restricciones de terapia escalonada o requisitos de aprobación previa. 12. ¿Cuánto tiempo toma obtener una excepción? Primero, debemos recibir una declaración de su recetante que apoye su solicitud para una excepción. Después de recibir la declaración, le daremos una decisión sobre su solicitud de excepción dentro de 72 horas. Si usted o su recetante piensan que su salud se puede ver afectada si tiene que esperar 72 horas para recibir una decisión, puede solicitar una excepción acelerada. Esta es una decisión más rápida. Si su recetante apoya su solicitud, le daremos una decisión dentro de 24 horas de recibir la declaración de apoyo de su recetante. 13. ¿Cómo puede pedir una excepción? Para pedir una excepción, llame a Member Services al 1-855-817-5787 (TTY 711). Un representante de Member Services trabajará con usted y su proveedor para ayudarlo a pedir una excepción. 14. ¿Qué son medicamentos genéricos? Los medicamentos genéricos están elaborados con los mismos ingredientes activos que los medicamentos de marca. Por lo general tienen un menor valor que el medicamento de marca y no tienen nombres muy conocidos. Los medicamentos genéricos son aprobados por la Administración de Alimentos y Medicamentos (Food and Drug Administration (FDA)). HealthKeepers, Inc. cubre medicamentos tanto de marca como genéricos. ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 7 15. ¿Qué son medicamentos OTC? OTC significa “de venta libre”. HealthKeepers, Inc. cubre algunos medicamentos de venta libre, cuando están escritos como recetas por parte de su proveedor. Puede leer la Lista de medicamentos de Anthem HealthKeepers MMP para ver qué medicamentos de venta libre están cubiertos. 16. ¿Cubre HealthKeepers, Inc. productos de venta libre que no son medicamentos? HealthKeepers, Inc. cubre algunos productos de venta libre que no son medicamentos, cuando están escritos como recetas por parte de su proveedor. Puede leer la Lista de medicamentos de Anthem HealthKeepers MMP para ver qué productos de venta libre, que no son medicamentos, están cubiertos. 17. ¿Cuál es su copago? Puede leer la Lista de medicamentos de Anthem HealthKeepers MMP para conocer el copago de cada medicamento. Los miembros de Anthem HealthKeepers MMP que viven en asilos de ancianos u otros centros de cuidado a largo plazo no tendrán copagos. Algunos miembros que reciben cuidado a largo plazo en la comunidad tampoco tendrán copago. Los copagos se enumeran por niveles. Los niveles son grupos de medicamentos con el mismo copago. • Nivel 1 – Medicamentos preferidos de Medicare Part D. Este nivel tiene medicamentos de marca y genéricos. El copago es $0. • Nivel 2 – Medicamentos preferidos y no preferidos de Medicare Part D. Este nivel tiene medicamentos de marca y genéricos. El copago es de $0 a $7.40 dependiendo de sus ingresos. • Nivel 3 – Medicamentos recetados aprobados por Medicaid (estado). Este nivel tiene medicamentos de marca y genéricos. Estos son medicamentos cubiertos por Medicaid, no son medicamentos de Part D. Tienen un copago de $0. • Nivel 4 – Medicamentos de venta libre (OTC) aprobados por Medicaid (estado). Estos son medicamentos cubiertos por Medicaid, no son medicamentos de Part D. Tienen un copago de $0. Necesita una receta de su proveedor para obtener medicamentos en este nivel. ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 8 Lista de medicamentos cubiertos La lista de medicamentos cubiertos que comienza en la siguiente página le da información sobre los medicamentos cubiertos por HealthKeepers, Inc. Si tiene problemas para encontrar su medicamento en la lista, consulte el índice que comienza en la página 146. La primera columna del cuadro lista el nombre del medicamento. Los medicamentos de marca están en mayúsculas (por ejemplo: AZOPT) y los medicamentos genéricos están listados en minúsculas cursivas (por ejemplo: amoxicilina). La información en la columna sobre las acciones necesarias, restricciones y límites de uso le indica si Anthem HealthKeepers MMP tiene alguna regla que cubre su medicamento. Lista de abreviaturas • B/D: Este medicamento recetado puede estar cubierto bajo Medicare Part B o D dependiendo de las circunstancias. Tal vez se tenga que presentar información que describa el uso y entorno del medicamento para tomar la determinación. • HI: Infusión en el hogar. Este medicamento recetado puede ser cubierto bajo nuestro beneficio médico. Para obtener más información, llame a Member Services al 1-855-817-5787 (TTY 711). • LA: Disponibilidad limitada. Esta receta puede estar disponible solamente en ciertas farmacias. Para obtener más información, llame a Member Services al 1-855-817-5787 (TTY 711). • MO: Medicamento de pedido por correo. Este medicamento recetado está disponible a través de nuestro servicio de pedido por correo, como también a través de nuestras farmacias minoristas de la red. Considere el uso del pedido por correo para sus medicamentos a largo plazo (mantenimiento) (como medicamentos para la presión arterial alta). Las farmacias minoristas de la red pueden ser más adecuadas para recetas de corto plazo (como antibióticos). • PAR: Se requiere autorización previa. El plan requiere que usted o su médico obtengan autorización previa para ciertos medicamentos. Esto significa que usted tendrá que obtener aprobación antes de abastecer sus recetas. Si no obtiene aprobación, puede que no cubramos el medicamento. • QLL: Límite de cantidad. Para ciertos medicamentos, el plan limita la cantidad del medicamento que cubriremos. • ST: Terapia escalonada. En algunos casos, el plan requiere que usted intente primero tomar ciertos medicamentos para tratar su condición médica antes de que cubramos otro medicamento para esa condición. Por ejemplo, si los Medicamentos A y B tratan su condición médica, puede que no cubramos el Medicamento B a menos que intente primero con el Medicamento A. Si el Medicamento A no funciona para usted, entonces cubriremos el Medicamento B. ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 9 Nota: El (*) junto a un medicamento significa que el medicamento no es un “Medicamento de la Parte D”. El monto que paga al abastecer una receta para este medicamento no cuenta para sus costos totales de medicamentos (o sea, el monto que usted paga no lo ayuda para calificar para cobertura catastrófica). Además, si usted está recibiendo ayuda adicional para pagar sus recetas, no recibirá ninguna ayuda adicional para pagar por estos medicamentos. Estos medicamentos también tienen reglas diferentes para las apelaciones. Una apelación es una manera formal de pedirnos que revisemos una decisión de cobertura y que la cambiemos si usted cree que cometimos un error. Por ejemplo, podríamos decidir que un medicamento que usted desea no está cubierto o ya no está cubierto por Medicare o Commonwealth Coordinated Care. Si usted o su doctor están en desacuerdo con nuestra decisión, puede apelar. Para pedir instrucciones sobre cómo apelar, llame a Member Services al 1-855-817-5787 (TTY 711). También puede leer el manual del miembro para aprender cómo apelar a una decisión. ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 10 Lista de medicamentos por condición médica Los medicamentos en esta sección están agrupados en categorías, dependiendo del tipo de condiciones médicas para los que se utilizan. Por ejemplo, si tiene una condición cardiaca, debe buscar en la categoría Cardiovascular/hipertensión/lípidos. Es donde encontrará medicamentos para tratar condiciones cardiacas. Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso ABELCET $0-$7.40 (Tier 2) B/D PAR; MO AMBISOME $0-$7.40 (Tier 2) B/D PAR; MO amphotericin b $0-$7.40 (Tier 2) B/D PAR; MO CANCIDAS $0-$7.40 (Tier 2) B/D PAR; MO clotrimazole mucous membrane $0-$7.40 (Tier 2) MO ERAXIS(WATER DILUENT) $0-$7.40 (Tier 2) PAR; MO fluconazole $0-$7.40 (Tier 2) MO fluconazole in dextrose(iso-o) $0-$7.40 (Tier 2) fluconazole in nacl (iso-osm) intravenous piggyback 100 mg/50 ml, 400 mg/200 ml $0-$7.40 (Tier 2) fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/100 ml $0-$7.40 (Tier 2) MO flucytosine $0-$7.40 (Tier 2) MO griseofulvin microsize oral suspension $0-$7.40 (Tier 2) MO griseofulvin ultramicrosize $0-$7.40 (Tier 2) MO itraconazole $0-$7.40 (Tier 2) PAR; MO ketoconazole oral $0-$7.40 (Tier 2) MO NOXAFIL ORAL SUSPENSION $0-$7.40 (Tier 2) PAR; MO; QLL (630 per 30 days) nystatin oral suspension $0-$7.40 (Tier 2) MO nystatin oral tablet $0-$7.40 (Tier 2) MO terbinafine hcl oral $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) voriconazole intravenous $0-$7.40 (Tier 2) MO ANTI - INFECTIVES 0B ANTIFUNGAL AGENTS 16B ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 11 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso voriconazole oral suspension for reconstitution $0-$7.40 (Tier 2) PAR; MO; QLL (300 per 30 days) voriconazole oral tablet 200 mg $0-$7.40 (Tier 2) PAR; MO; QLL (60 per 30 days) voriconazole oral tablet 50 mg $0-$7.40 (Tier 2) PAR; MO; QLL (120 per 30 days) abacavir $0-$7.40 (Tier 2) MO; QLL (60 per 30 days) abacavir-lamivudine-zidovudine $0-$7.40 (Tier 2) MO; QLL (60 per 30 days) acyclovir oral capsule $0-$7.40 (Tier 2) MO acyclovir oral suspension 200 mg/5 ml $0-$7.40 (Tier 2) MO acyclovir oral tablet $0-$7.40 (Tier 2) MO acyclovir sodium intravenous recon soln 500 mg $0-$7.40 (Tier 2) B/D PAR acyclovir sodium intravenous solution $0-$7.40 (Tier 2) B/D PAR; MO adefovir $0-$7.40 (Tier 2) MO amantadine hcl oral capsule $0-$7.40 (Tier 2) MO amantadine hcl oral tablet $0-$7.40 (Tier 2) MO APTIVUS ORAL CAPSULE $0-$7.40 (Tier 2) MO; QLL (120 per 30 days) APTIVUS ORAL SOLUTION $0-$7.40 (Tier 2) QLL (380 per 30 days) ATRIPLA $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) BARACLUDE ORAL SOLUTION $0-$7.40 (Tier 2) PAR; MO cidofovir $0-$7.40 (Tier 2) B/D PAR; MO COMPLERA $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) CRIXIVAN ORAL CAPSULE 200 MG $0-$7.40 (Tier 2) MO; QLL (360 per 30 days) CRIXIVAN ORAL CAPSULE 400 MG $0-$7.40 (Tier 2) MO; QLL (180 per 30 days) didanosine oral capsule,delayed release(dr/ec) 125 mg $0-$7.40 (Tier 2) MO; QLL (90 per 30 days) didanosine oral capsule,delayed release(dr/ec) 200 mg $0-$7.40 (Tier 2) MO; QLL (60 per 30 days) didanosine oral capsule,delayed release(dr/ec) 250 mg, 400 mg $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) EDURANT $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) ANTIVIRALS 17B B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 12 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso EMTRIVA ORAL CAPSULE $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) EMTRIVA ORAL SOLUTION $0-$7.40 (Tier 2) MO; QLL (850 per 30 days) entecavir $0-$7.40 (Tier 2) PAR; MO EPIVIR HBV ORAL SOLUTION $0-$7.40 (Tier 2) MO EPIVIR ORAL SOLUTION $0-$7.40 (Tier 2) MO; QLL (900 per 30 days) EPZICOM $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) EVOTAZ $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) famciclovir oral tablet 125 mg, 250 mg $0-$7.40 (Tier 2) MO; QLL (60 per 30 days) famciclovir oral tablet 500 mg $0-$7.40 (Tier 2) MO; QLL (21 per 7 days) foscarnet $0-$7.40 (Tier 2) B/D PAR; MO FUZEON SUBCUTANEOUS RECON SOLN $0-$7.40 (Tier 2) MO; QLL (60 per 30 days) ganciclovir sodium $0-$7.40 (Tier 2) MO HARVONI $0-$7.40 (Tier 2) PAR; MO; QLL (28 per 28 days) INTELENCE ORAL TABLET 100 MG $0-$7.40 (Tier 2) MO; QLL (120 per 30 days) INTELENCE ORAL TABLET 200 MG $0-$7.40 (Tier 2) MO; QLL (60 per 30 days) INTELENCE ORAL TABLET 25 MG $0-$7.40 (Tier 2) QLL (480 per 30 days) INVIRASE ORAL CAPSULE $0-$7.40 (Tier 2) MO; QLL (300 per 30 days) INVIRASE ORAL TABLET $0-$7.40 (Tier 2) MO; QLL (120 per 30 days) ISENTRESS ORAL POWDER IN PACKET $0-$7.40 (Tier 2) ISENTRESS ORAL TABLET $0-$7.40 (Tier 2) MO; QLL (120 per 30 days) ISENTRESS ORAL TABLET,CHEWABLE 100 MG $0-$7.40 (Tier 2) MO; QLL (180 per 30 days) ISENTRESS ORAL TABLET,CHEWABLE 25 MG $0-$7.40 (Tier 2) MO; QLL (720 per 30 days) KALETRA ORAL SOLUTION $0-$7.40 (Tier 2) MO; QLL (480 per 30 days) KALETRA ORAL TABLET 100-25 MG $0-$7.40 (Tier 2) MO; QLL (300 per 30 days) KALETRA ORAL TABLET 200-50 MG $0-$7.40 (Tier 2) MO; QLL (120 per 30 days) lamivudine oral solution $0-$7.40 (Tier 2) MO; QLL (900 per 30 days) lamivudine oral tablet 100 mg $0-$7.40 (Tier 2) MO lamivudine oral tablet 150 mg $0-$7.40 (Tier 2) MO; QLL (60 per 30 days) ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 13 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso lamivudine oral tablet 300 mg $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) lamivudine-zidovudine $0-$7.40 (Tier 2) MO; QLL (60 per 30 days) LEXIVA ORAL SUSPENSION $0-$7.40 (Tier 2) MO; QLL (1800 per 30 days) LEXIVA ORAL TABLET $0-$7.40 (Tier 2) MO; QLL (120 per 30 days) nevirapine oral suspension $0-$7.40 (Tier 2) MO; QLL (1200 per 30 days) nevirapine oral tablet $0-$7.40 (Tier 2) MO; QLL (60 per 30 days) nevirapine oral tablet extended release 24 hr $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) NORVIR ORAL CAPSULE $0-$7.40 (Tier 2) MO; QLL (360 per 30 days) NORVIR ORAL SOLUTION $0-$7.40 (Tier 2) MO; QLL (480 per 30 days) NORVIR ORAL TABLET $0-$7.40 (Tier 2) MO; QLL (360 per 30 days) OLYSIO $0-$7.40 (Tier 2) PAR; MO PREZCOBIX $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) PREZISTA ORAL SUSPENSION $0-$7.40 (Tier 2) MO; QLL (400 per 30 days) PREZISTA ORAL TABLET 150 MG $0-$7.40 (Tier 2) MO; QLL (180 per 30 days) PREZISTA ORAL TABLET 600 MG, 800 MG $0-$7.40 (Tier 2) MO; QLL (60 per 30 days) PREZISTA ORAL TABLET 75 MG $0-$7.40 (Tier 2) MO; QLL (300 per 30 days) RELENZA DISKHALER $0-$7.40 (Tier 2) MO; QLL (60 per 180 days) RESCRIPTOR ORAL TABLET $0-$7.40 (Tier 2) MO; QLL (180 per 30 days) RESCRIPTOR ORAL TABLET, DISPERSIBLE $0-$7.40 (Tier 2) MO; QLL (360 per 30 days) RETROVIR INTRAVENOUS $0-$7.40 (Tier 2) MO REYATAZ ORAL CAPSULE 150 MG, 200 MG $0-$7.40 (Tier 2) MO; QLL (60 per 30 days) REYATAZ ORAL CAPSULE 300 MG $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) REYATAZ ORAL POWDER IN PACKET $0-$7.40 (Tier 2) MO; QLL (240 per 30 days) ribasphere oral capsule $0-$7.40 (Tier 2) PAR; MO ribasphere oral tablet 200 mg $0-$7.40 (Tier 2) PAR; MO ribavirin oral capsule $0-$7.40 (Tier 2) PAR; MO ribavirin oral tablet 200 mg $0-$7.40 (Tier 2) PAR; MO rimantadine $0-$7.40 (Tier 2) MO B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 14 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso SELZENTRY $0-$7.40 (Tier 2) MO; QLL (120 per 30 days) SOVALDI $0-$7.40 (Tier 2) PAR; MO stavudine oral capsule 15 mg, 20 mg $0-$7.40 (Tier 2) MO; QLL (120 per 30 days) stavudine oral capsule 30 mg, 40 mg $0-$7.40 (Tier 2) MO; QLL (60 per 30 days) stavudine oral recon soln $0-$7.40 (Tier 2) MO; QLL (2400 per 30 days) STRIBILD $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) SUSTIVA ORAL CAPSULE 200 MG $0-$7.40 (Tier 2) MO; QLL (120 per 30 days) SUSTIVA ORAL CAPSULE 50 MG $0-$7.40 (Tier 2) MO; QLL (360 per 30 days) SUSTIVA ORAL TABLET $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) SYNAGIS $0-$7.40 (Tier 2) PAR; MO; LA TAMIFLU $0-$7.40 (Tier 2) MO TIVICAY $0-$7.40 (Tier 2) MO; QLL (60 per 30 days) TRIUMEQ $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) TRUVADA $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) TYBOST $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) TYZEKA $0-$7.40 (Tier 2) PAR; MO valacyclovir $0-$7.40 (Tier 2) MO; QLL (30 per 2 days) valganciclovir $0-$7.40 (Tier 2) MO VIDEX 2 GRAM PEDIATRIC $0-$7.40 (Tier 2) MO; QLL (1200 per 30 days) VIDEX 4 GRAM PEDIATRIC $0-$7.40 (Tier 2) MO; QLL (1200 per 30 days) VIEKIRA PAK $0-$7.40 (Tier 2) PAR; MO VIRACEPT ORAL TABLET 250 MG $0-$7.40 (Tier 2) MO; QLL (300 per 30 days) VIRACEPT ORAL TABLET 625 MG $0-$7.40 (Tier 2) MO; QLL (120 per 30 days) VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 100 MG $0-$7.40 (Tier 2) MO VIRAZOLE $0-$7.40 (Tier 2) PAR; MO VIREAD ORAL POWDER $0-$7.40 (Tier 2) MO; QLL (240 per 30 days) VIREAD ORAL TABLET $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) VITEKTA $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) ZIAGEN ORAL SOLUTION $0-$7.40 (Tier 2) MO; QLL (960 per 30 days) ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 15 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso zidovudine oral capsule $0-$7.40 (Tier 2) MO; QLL (180 per 30 days) zidovudine oral syrup $0-$7.40 (Tier 2) MO; QLL (1920 per 30 days) zidovudine oral tablet $0-$7.40 (Tier 2) MO; QLL (60 per 30 days) cefaclor oral capsule $0-$7.40 (Tier 2) MO cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml $0-$7.40 (Tier 2) MO cefaclor oral tablet extended release 12 hr $0-$7.40 (Tier 2) MO cefadroxil oral capsule $0-$7.40 (Tier 2) MO cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml $0-$7.40 (Tier 2) MO cefadroxil oral tablet $0-$7.40 (Tier 2) MO cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml $0-$7.40 (Tier 2) MO cefazolin injection recon soln 1 gram, 500 mg $0-$7.40 (Tier 2) MO cefazolin injection recon soln 10 gram, 100 gram, 20 gram, 300 g $0-$7.40 (Tier 2) cefazolin intravenous $0-$7.40 (Tier 2) cefdinir $0-$7.40 (Tier 2) MO cefepime $0-$7.40 (Tier 2) MO cefoxitin in dextrose, iso-osm $0-$7.40 (Tier 2) cefoxitin intravenous recon soln 1 gram $0-$7.40 (Tier 2) cefoxitin intravenous recon soln 10 gram, 2 gram $0-$7.40 (Tier 2) cefpodoxime $0-$7.40 (Tier 2) MO cefprozil $0-$7.40 (Tier 2) MO ceftazidime injection recon soln 1 gram, 2 gram $0-$7.40 (Tier 2) MO ceftazidime injection recon soln 6 gram $0-$7.40 (Tier 2) ceftriaxone in dextrose,iso-os $0-$7.40 (Tier 2) CEPHALOSPORINS 18B MO MO B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 16 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso ceftriaxone injection recon soln 1 gram, 2 gram, 250 mg, 500 mg $0-$7.40 (Tier 2) MO ceftriaxone injection recon soln 10 gram $0-$7.40 (Tier 2) ceftriaxone intravenous recon soln $0-$7.40 (Tier 2) MO cefuroxime axetil oral tablet $0-$7.40 (Tier 2) MO cefuroxime sodium injection recon soln 1.5 gram, 750 mg $0-$7.40 (Tier 2) MO cefuroxime sodium intravenous vial $0-$7.40 (Tier 2) cephalexin oral capsule 250 mg, 500 mg $0-$7.40 (Tier 2) MO cephalexin oral suspension for reconstitution $0-$7.40 (Tier 2) MO cephalexin oral tablet $0-$7.40 (Tier 2) MO TEFLARO $0-$7.40 (Tier 2) MO azithromycin intravenous recon soln 500 mg $0-$7.40 (Tier 2) MO azithromycin intravenous recon soln 500 mg (2 mg/ml) $0-$7.40 (Tier 2) azithromycin oral suspension for reconstitution $0-$7.40 (Tier 2) MO azithromycin oral tablet $0-$7.40 (Tier 2) MO clarithromycin oral suspension for reconstitution $0-$7.40 (Tier 2) MO clarithromycin oral tablet $0-$7.40 (Tier 2) MO clarithromycin oral tablet extended release 24 hr $0-$7.40 (Tier 2) MO; QLL (28 per 2 days) e.e.s. 400 oral tablet $0-$7.40 (Tier 2) MO ery-tab $0-$7.40 (Tier 2) MO erythrocin (as stearate) oral tablet 250 mg $0-$7.40 (Tier 2) MO ERYTHROCIN INTRAVENOUS RECON SOLN 500 MG $0-$7.40 (Tier 2) erythromycin ethylsuccinate oral tablet $0-$7.40 (Tier 2) MO erythromycin oral tablet $0-$7.40 (Tier 2) MO $0-$7.40 (Tier 2) MO ERYTHROMYCINS / OTHER MACROLIDES 19B MISCELLANEOUS ANTIINFECTIVES 20B ALBENZA ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 17 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso ALINIA ORAL SUSPENSION FOR RECONSTITUTION $0-$7.40 (Tier 2) MO; QLL (180 per 3 days) ALINIA ORAL TABLET $0-$7.40 (Tier 2) MO amikacin injection solution 1,000 mg/4 ml, 500 mg/2 ml $0-$7.40 (Tier 2) MO atovaquone $0-$7.40 (Tier 2) PAR; MO atovaquone-proguanil $0-$7.40 (Tier 2) MO AZACTAM IN DEXTROSE (ISO-OSM) $0-$7.40 (Tier 2) aztreonam $0-$7.40 (Tier 2) baciim $0-$7.40 (Tier 2) BILTRICIDE $0-$7.40 (Tier 2) CAPASTAT $0-$7.40 (Tier 2) CAYSTON $0-$7.40 (Tier 2) chloramphenicol sod succinate $0-$7.40 (Tier 2) chloroquine phosphate oral $0-$7.40 (Tier 2) MO clindamycin hcl $0-$7.40 (Tier 2) MO clindamycin phosphate injection $0-$7.40 (Tier 2) MO clindamycin phosphate intravenous solution 300 mg/2 ml, 900 mg/6 ml $0-$7.40 (Tier 2) clindamycin phosphate intravenous solution 600 mg/4 ml $0-$7.40 (Tier 2) MO colistin (colistimethate na) $0-$7.40 (Tier 2) MO DAPSONE $0-$7.40 (Tier 2) MO DARAPRIM $0-$7.40 (Tier 2) MO ethambutol $0-$7.40 (Tier 2) MO gentamicin injection $0-$7.40 (Tier 2) MO gentamicin sulfate (ped) (pf) $0-$7.40 (Tier 2) MO gentamicin sulfate (pf) intravenous solution 100 mg/10 ml $0-$7.40 (Tier 2) MO MO MO PAR; MO; LA B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 18 Nombre del medicamento Qué le costará el medicamento (nivel de clase) GENTAMICIN SULFATE (PF) INTRAVENOUS SOLUTION 60 MG/6 ML $0-$7.40 (Tier 2) gentamicin sulfate (pf) intravenous solution 80 mg/8 ml $0-$7.40 (Tier 2) hydroxychloroquine oral $0-$7.40 (Tier 2) MO imipenem-cilastatin $0-$7.40 (Tier 2) MO INVANZ INJECTION $0-$7.40 (Tier 2) MO isoniazid oral $0-$7.40 (Tier 2) MO ivermectin oral $0-$7.40 (Tier 2) MO linezolid intravenous $0-$7.40 (Tier 2) linezolid oral $0-$7.40 (Tier 2) linezolid-0.9% sodium chloride $0-$7.40 (Tier 2) mefloquine $0-$7.40 (Tier 2) MO meropenem $0-$7.40 (Tier 2) MO metro i.v. $0-$7.40 (Tier 2) MO metronidazole in nacl (iso-os) $0-$7.40 (Tier 2) MO metronidazole oral capsule $0-$7.40 (Tier 2) metronidazole oral tablet $0-$7.40 (Tier 2) MO NEBUPENT $0-$7.40 (Tier 2) B/D PAR; MO neomycin $0-$7.40 (Tier 2) MO paromomycin $0-$7.40 (Tier 2) MO PASER $0-$7.40 (Tier 2) MO PENTAM $0-$7.40 (Tier 2) MO PRIFTIN $0-$7.40 (Tier 2) MO PRIMAQUINE $0-$7.40 (Tier 2) MO pyrazinamide $0-$7.40 (Tier 2) MO rifabutin $0-$7.40 (Tier 2) MO rifampin intravenous $0-$7.40 (Tier 2) MO rifampin oral $0-$7.40 (Tier 2) MO RIFATER $0-$7.40 (Tier 2) MO ? Acciones necesarias, restricciones, o límites sobre el uso PAR; MO; QLL (28 per 2 days) Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 19 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso SIRTURO $0-$7.40 (Tier 2) PAR; MO; LA STREPTOMYCIN INTRAMUSCULAR $0-$7.40 (Tier 2) MO SYNERCID $0-$7.40 (Tier 2) tobramycin in 0.225 % nacl $0-$7.40 (Tier 2) tobramycin sulfate injection recon soln $0-$7.40 (Tier 2) tobramycin sulfate injection solution $0-$7.40 (Tier 2) MO TRECATOR $0-$7.40 (Tier 2) MO TYGACIL $0-$7.40 (Tier 2) MO ZYVOX INTRAVENOUS PARENTERAL SOLUTION 200 MG/100 ML $0-$7.40 (Tier 2) ZYVOX INTRAVENOUS PARENTERAL SOLUTION 600 MG/300 ML $0-$7.40 (Tier 2) MO ZYVOX ORAL SUSPENSION FOR RECONSTITUTION $0-$7.40 (Tier 2) PAR; MO; QLL (1800 per 2 days) amoxicillin oral capsule $0-$7.40 (Tier 2) MO amoxicillin oral suspension for reconstitution $0-$7.40 (Tier 2) MO amoxicillin oral tablet $0-$7.40 (Tier 2) MO amoxicillin oral tablet,chewable 125 mg, 250 mg $0-$7.40 (Tier 2) MO amoxicillin-pot clavulanate $0-$7.40 (Tier 2) MO ampicillin $0-$7.40 (Tier 2) MO ampicillin sodium injection $0-$7.40 (Tier 2) MO ampicillin sodium intravenous $0-$7.40 (Tier 2) ampicillin-sulbactam injection recon soln 1.5 gram, 3 gram $0-$7.40 (Tier 2) ampicillin-sulbactam injection recon soln 15 gram $0-$7.40 (Tier 2) ampicillin-sulbactam intravenous recon soln 1.5 gram $0-$7.40 (Tier 2) B/D PAR; MO; QLL (280 per 28 days) PENICILLINS 21B MO B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 20 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso ampicillin-sulbactam intravenous recon soln 3 gram $0-$7.40 (Tier 2) MO BICILLIN C-R $0-$7.40 (Tier 2) MO BICILLIN L-A $0-$7.40 (Tier 2) MO dicloxacillin $0-$7.40 (Tier 2) MO nafcillin injection $0-$7.40 (Tier 2) MO nafcillin intravenous recon soln 2 gram $0-$7.40 (Tier 2) MO oxacillin injection $0-$7.40 (Tier 2) MO oxacillin intravenous $0-$7.40 (Tier 2) PENICILLIN G POT IN DEXTROSE $0-$7.40 (Tier 2) penicillin g potassium $0-$7.40 (Tier 2) MO penicillin g procaine intramuscular syringe 1.2 million unit/2 ml $0-$7.40 (Tier 2) MO penicillin g procaine intramuscular syringe 600,000 unit/ml $0-$7.40 (Tier 2) penicillin g sodium $0-$7.40 (Tier 2) MO penicillin v potassium $0-$7.40 (Tier 2) MO piperacillin-tazobactam $0-$7.40 (Tier 2) MO TIMENTIN INTRAVENOUS RECON SOLN 31 GRAM $0-$7.40 (Tier 2) QUINOLONES 2B ciprofloxacin $0-$7.40 (Tier 2) ciprofloxacin (mixture) oral tablet, er multiphase 24 hr 1,000 mg $0-$7.40 (Tier 2) MO; QLL (14 per 2 days) ciprofloxacin (mixture) oral tablet, er multiphase 24 hr 500 mg $0-$7.40 (Tier 2) MO; QLL (3 per 2 days) ciprofloxacin hcl oral tablet $0-$7.40 (Tier 2) MO ciprofloxacin lactate intravenous solution 200 mg/20 ml $0-$7.40 (Tier 2) MO ciprofloxacin lactate intravenous solution 400 mg/40 ml $0-$7.40 (Tier 2) ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 21 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso levofloxacin intravenous $0-$7.40 (Tier 2) MO levofloxacin oral tablet $0-$7.40 (Tier 2) MO; QLL (14 per 2 days) moxifloxacin $0-$7.40 (Tier 2) MO; QLL (21 per 2 days) ofloxacin oral tablet 400 mg $0-$7.40 (Tier 2) MO sulfadiazine oral $0-$7.40 (Tier 2) MO sulfamethoxazole-trimethoprim $0-$7.40 (Tier 2) MO demeclocycline oral $0-$7.40 (Tier 2) MO DOXY-100 $0-$7.40 (Tier 2) MO doxycycline hyclate intravenous $0-$7.40 (Tier 2) doxycycline hyclate oral capsule $0-$7.40 (Tier 2) MO doxycycline hyclate oral tablet 100 mg, 20 mg $0-$7.40 (Tier 2) MO doxycycline hyclate oral tablet 50 mg $0-$7.40 (Tier 2) doxycycline hyclate oral tablet,delayed release (dr/ec) $0-$7.40 (Tier 2) MO doxycycline monohydrate oral capsule $0-$7.40 (Tier 2) MO doxycycline monohydrate oral tablet $0-$7.40 (Tier 2) MO minocycline oral capsule $0-$7.40 (Tier 2) MO minocycline oral tablet $0-$7.40 (Tier 2) MO tetracycline $0-$7.40 (Tier 2) MO methenamine hippurate $0-$7.40 (Tier 2) MO nitrofurantoin macrocrystal oral capsule 50 mg $0-$7.40 (Tier 2) PAR; MO trimethoprim $0-$7.40 (Tier 2) MO SULFA'S / RELATED AGENTS 23B TETRACYCLINES 24B URINARY TRACT AGENTS 25B B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 22 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso VANCOMYCIN IN D5W INTRAVENOUS PIGGYBACK 1 GRAM/200 ML $0-$7.40 (Tier 2) B/D PAR; MO VANCOMYCIN IN D5W INTRAVENOUS PIGGYBACK 500 MG/100 ML $0-$7.40 (Tier 2) B/D PAR VANCOMYCIN IN DEXTROSE ISO-OSM $0-$7.40 (Tier 2) B/D PAR vancomycin intravenous $0-$7.40 (Tier 2) B/D PAR; MO VANCOMYCIN INTRAVENOUS 750 MG $0-$7.40 (Tier 2) B/D PAR; MO vancomycin oral capsule 125 mg $0-$7.40 (Tier 2) PAR; MO; QLL (40 per 2 days) vancomycin oral capsule 250 mg $0-$7.40 (Tier 2) PAR; MO; QLL (80 per 2 days) VANCOMYCIN 26B ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS 1B ADJUNCTIVE AGENTS 27B amifostine crystalline $0-$7.40 (Tier 2) PAR; MO dexrazoxane hcl intravenous recon soln 250 mg $0-$7.40 (Tier 2) B/D PAR dexrazoxane hcl intravenous recon soln 500 mg $0-$7.40 (Tier 2) B/D PAR; MO ELITEK $0-$7.40 (Tier 2) PAR FUSILEV $0-$7.40 (Tier 2) B/D PAR; MO KEPIVANCE $0-$7.40 (Tier 2) leucovorin calcium injection recon soln 100 mg, 350 mg $0-$7.40 (Tier 2) B/D PAR; MO leucovorin calcium injection recon soln 200 mg, 50 mg $0-$7.40 (Tier 2) MO leucovorin calcium injection recon soln 500 mg $0-$7.40 (Tier 2) B/D PAR leucovorin calcium oral $0-$7.40 (Tier 2) MO mesna $0-$7.40 (Tier 2) B/D PAR; MO MESNEX ORAL $0-$7.40 (Tier 2) MO XGEVA $0-$7.40 (Tier 2) PAR; MO; QLL (1.7 per 28 days) ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 23 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS 28B ABRAXANE $0-$7.40 (Tier 2) B/D PAR; MO AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, 5 MG $0-$7.40 (Tier 2) PAR; MO; QLL (60 per 30 days) AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 3 MG $0-$7.40 (Tier 2) PAR; MO; QLL (90 per 30 days) AFINITOR ORAL TABLET 10 MG $0-$7.40 (Tier 2) PAR; MO; QLL (30 per 30 days) AFINITOR ORAL TABLET 2.5 MG $0-$7.40 (Tier 2) PAR; MO; QLL (120 per 30 days) AFINITOR ORAL TABLET 5 MG $0-$7.40 (Tier 2) PAR; MO; QLL (60 per 30 days) AFINITOR ORAL TABLET 7.5 MG $0-$7.40 (Tier 2) PAR; MO; QLL (40 per 30 days) ALIMTA $0-$7.40 (Tier 2) PAR; MO anastrozole $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) ARRANON $0-$7.40 (Tier 2) B/D PAR ARZERRA $0-$7.40 (Tier 2) PAR; MO AVASTIN $0-$7.40 (Tier 2) PAR; MO azacitidine $0-$7.40 (Tier 2) PAR; MO azathioprine $0-$7.40 (Tier 2) B/D PAR; MO BELEODAQ $0-$7.40 (Tier 2) PAR; MO bicalutamide $0-$7.40 (Tier 2) MO BICNU $0-$7.40 (Tier 2) B/D PAR; MO bleomycin $0-$7.40 (Tier 2) B/D PAR; MO BLINCYTO $0-$7.40 (Tier 2) PAR; MO BOSULIF ORAL TABLET 100 MG $0-$7.40 (Tier 2) PAR; MO; QLL (120 per 30 days) BOSULIF ORAL TABLET 500 MG $0-$7.40 (Tier 2) PAR; MO; QLL (30 per 30 days) BUSULFEX $0-$7.40 (Tier 2) B/D PAR CAPRELSA ORAL TABLET 100 MG $0-$7.40 (Tier 2) PAR; MO; LA; QLL (90 per 30 days) CAPRELSA ORAL TABLET 300 MG $0-$7.40 (Tier 2) PAR; MO; LA; QLL (30 per 30 days) carboplatin intravenous solution $0-$7.40 (Tier 2) B/D PAR; MO B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 24 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso CELLCEPT INTRAVENOUS $0-$7.40 (Tier 2) B/D PAR; MO cisplatin $0-$7.40 (Tier 2) B/D PAR; MO cladribine $0-$7.40 (Tier 2) B/D PAR; MO CLOLAR $0-$7.40 (Tier 2) B/D PAR; MO COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG[1]-20 MG[1]) $0-$7.40 (Tier 2) PAR; MO; QLL (56 per 28 days) COMETRIQ ORAL CAPSULE 140 MG/DAY(80 MG[1]-20 MG[3]) $0-$7.40 (Tier 2) PAR; MO; QLL (112 per 28 days) COMETRIQ ORAL CAPSULE 60 MG/DAY (20 MG [3]/DAY) $0-$7.40 (Tier 2) PAR; MO; QLL (84 per 28 days) cyclophosphamide oral capsule $0-$7.40 (Tier 2) B/D PAR; MO cyclosporine intravenous $0-$7.40 (Tier 2) B/D PAR cyclosporine modified $0-$7.40 (Tier 2) B/D PAR; MO cyclosporine oral capsule $0-$7.40 (Tier 2) B/D PAR; MO CYRAMZA $0-$7.40 (Tier 2) PAR; MO cytarabine $0-$7.40 (Tier 2) B/D PAR; MO cytarabine (pf) injection solution 100 mg/5 ml (20 mg/ml), 2 gram/20 ml (100 mg/ml) $0-$7.40 (Tier 2) B/D PAR; MO cytarabine (pf) injection solution 20 mg/ml $0-$7.40 (Tier 2) B/D PAR dacarbazine $0-$7.40 (Tier 2) B/D PAR; MO daunorubicin intravenous solution $0-$7.40 (Tier 2) B/D PAR decitabine $0-$7.40 (Tier 2) B/D PAR; MO DOCEFREZ INTRAVENOUS RECON SOLN 20 MG $0-$7.40 (Tier 2) B/D PAR docetaxel intravenous solution 10 mg/ml, 140 mg/7 ml (20 mg/ml), 160 mg/16 ml (10 mg/ml), 20 mg/2 ml (10 mg/ml) $0-$7.40 (Tier 2) B/D PAR docetaxel intravenous solution 20 mg/ml (1 ml), 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ml) $0-$7.40 (Tier 2) B/D PAR; MO doxorubicin intravenous recon soln $0-$7.40 (Tier 2) B/D PAR doxorubicin intravenous solution $0-$7.40 (Tier 2) B/D PAR; MO DROXIA $0-$7.40 (Tier 2) MO ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 25 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso EMCYT $0-$7.40 (Tier 2) MO epirubicin intravenous solution 200 mg/100 ml $0-$7.40 (Tier 2) B/D PAR epirubicin intravenous solution 50 mg/25 ml $0-$7.40 (Tier 2) B/D PAR; MO ERBITUX $0-$7.40 (Tier 2) PAR; MO ERIVEDGE $0-$7.40 (Tier 2) PAR; MO; QLL (30 per 30 days) ERWINAZE $0-$7.40 (Tier 2) PAR; MO ETOPOPHOS $0-$7.40 (Tier 2) B/D PAR; MO etoposide intravenous $0-$7.40 (Tier 2) B/D PAR; MO exemestane $0-$7.40 (Tier 2) MO; QLL (60 per 30 days) FARESTON $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) FARYDAK ORAL CAPSULE 10 MG $0-$7.40 (Tier 2) PAR; MO; QLL (60 per 30 days) FARYDAK ORAL CAPSULE 15 MG, 20 MG $0-$7.40 (Tier 2) PAR; MO; QLL (30 per 30 days) FASLODEX $0-$7.40 (Tier 2) PAR; MO FIRMAGON KIT W DILUENT SYRINGE $0-$7.40 (Tier 2) PAR; MO fludarabine intravenous recon soln $0-$7.40 (Tier 2) B/D PAR; MO fludarabine intravenous solution $0-$7.40 (Tier 2) B/D PAR fluorouracil intravenous $0-$7.40 (Tier 2) B/D PAR; MO flutamide $0-$7.40 (Tier 2) MO FOLOTYN $0-$7.40 (Tier 2) B/D PAR; MO GAZYVA $0-$7.40 (Tier 2) PAR; MO gemcitabine intravenous recon soln 1 gram, 200 mg $0-$7.40 (Tier 2) B/D PAR; MO gemcitabine intravenous recon soln 2 gram $0-$7.40 (Tier 2) B/D PAR gemcitabine intravenous solution $0-$7.40 (Tier 2) B/D PAR gengraf $0-$7.40 (Tier 2) B/D PAR; MO GILOTRIF $0-$7.40 (Tier 2) PAR; MO; QLL (30 per 30 days) GLEEVEC ORAL TABLET 100 MG $0-$7.40 (Tier 2) PAR; MO; QLL (240 per 30 days) GLEEVEC ORAL TABLET 400 MG $0-$7.40 (Tier 2) PAR; MO; QLL (60 per 30 days) GLEOSTINE $0-$7.40 (Tier 2) MO B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 26 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso HALAVEN $0-$7.40 (Tier 2) PAR; MO HERCEPTIN $0-$7.40 (Tier 2) PAR; MO HEXALEN $0-$7.40 (Tier 2) MO hydroxyurea $0-$7.40 (Tier 2) MO IBRANCE $0-$7.40 (Tier 2) PAR; MO; QLL (30 per 30 days) ICLUSIG ORAL TABLET 15 MG $0-$7.40 (Tier 2) PAR; MO; QLL (60 per 30 days) ICLUSIG ORAL TABLET 45 MG $0-$7.40 (Tier 2) PAR; MO; QLL (30 per 30 days) idarubicin $0-$7.40 (Tier 2) B/D PAR ifosfamide intravenous recon soln 1 gram $0-$7.40 (Tier 2) B/D PAR; MO ifosfamide intravenous recon soln 3 gram $0-$7.40 (Tier 2) B/D PAR ifosfamide intravenous solution $0-$7.40 (Tier 2) B/D PAR IMBRUVICA $0-$7.40 (Tier 2) PAR; MO; QLL (120 per 30 days) INLYTA ORAL TABLET 1 MG $0-$7.40 (Tier 2) PAR; MO; QLL (240 per 30 days) INLYTA ORAL TABLET 5 MG $0-$7.40 (Tier 2) PAR; MO; QLL (120 per 30 days) irinotecan intravenous solution 100 mg/5 ml, 40 mg/2 ml $0-$7.40 (Tier 2) B/D PAR; MO irinotecan intravenous solution 500 mg/25 ml $0-$7.40 (Tier 2) B/D PAR ISTODAX $0-$7.40 (Tier 2) PAR; MO IXEMPRA $0-$7.40 (Tier 2) B/D PAR; MO JAKAFI ORAL TABLET 10 MG $0-$7.40 (Tier 2) PAR; MO; QLL (150 per 30 days) JAKAFI ORAL TABLET 15 MG $0-$7.40 (Tier 2) PAR; MO; QLL (100 per 30 days) JAKAFI ORAL TABLET 20 MG $0-$7.40 (Tier 2) PAR; MO; QLL (75 per 30 days) JAKAFI ORAL TABLET 25 MG $0-$7.40 (Tier 2) PAR; MO; QLL (60 per 30 days) JAKAFI ORAL TABLET 5 MG $0-$7.40 (Tier 2) PAR; MO; QLL (300 per 30 days) JEVTANA $0-$7.40 (Tier 2) B/D PAR; MO KADCYLA $0-$7.40 (Tier 2) PAR; MO KEYTRUDA $0-$7.40 (Tier 2) PAR; MO LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG [1]/DAY) $0-$7.40 (Tier 2) PAR; MO; QLL (30 per 30 days) ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 27 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso LENVIMA ORAL CAPSULE 14 MG (10 MG[1] -4 MG[1])/DAY, 20 MG/DAY (10 MG [2]/DAY) $0-$7.40 (Tier 2) PAR; MO; QLL (60 per 30 days) LENVIMA ORAL CAPSULE 24 MG (10 MG[2] -4 MG[1])/DAY $0-$7.40 (Tier 2) PAR; MO; QLL (90 per 30 days) letrozole $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) LEUKERAN $0-$7.40 (Tier 2) MO leuprolide $0-$7.40 (Tier 2) PAR; MO LOMUSTINE $0-$7.40 (Tier 2) MO LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG $0-$7.40 (Tier 2) PAR; MO; QLL (1 per 28 days) LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 7.5 MG $0-$7.40 (Tier 2) PAR; MO LUPRON DEPOT-PED INTRAMUSCULAR KIT 7.5 MG (PED) $0-$7.40 (Tier 2) PAR; MO; QLL (1 per 28 days) LYNPARZA $0-$7.40 (Tier 2) PAR; MO; QLL (480 per 30 days) LYSODREN $0-$7.40 (Tier 2) MO MATULANE $0-$7.40 (Tier 2) MO megestrol oral suspension 400 mg/10 ml (10 ml) $0-$7.40 (Tier 2) PAR megestrol oral suspension 400 mg/10 ml (40 mg/ml) $0-$7.40 (Tier 2) PAR; MO megestrol oral tablet $0-$7.40 (Tier 2) PAR; MO MEKINIST ORAL TABLET 0.5 MG $0-$7.40 (Tier 2) PAR; MO; QLL (90 per 30 days) MEKINIST ORAL TABLET 2 MG $0-$7.40 (Tier 2) PAR; MO; QLL (30 per 30 days) melphalan hcl $0-$7.40 (Tier 2) B/D PAR mercaptopurine $0-$7.40 (Tier 2) MO methotrexate sodium (pf) injection recon soln $0-$7.40 (Tier 2) B/D PAR methotrexate sodium (pf) injection solution $0-$7.40 (Tier 2) B/D PAR; MO methotrexate sodium injection $0-$7.40 (Tier 2) B/D PAR; MO methotrexate sodium oral $0-$7.40 (Tier 2) MO mitomycin $0-$7.40 (Tier 2) B/D PAR; MO B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 28 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso mitoxantrone $0-$7.40 (Tier 2) MO MUSTARGEN $0-$7.40 (Tier 2) B/D PAR; MO mycophenolate mofetil $0-$7.40 (Tier 2) B/D PAR; MO mycophenolate sodium $0-$7.40 (Tier 2) B/D PAR; MO NEXAVAR $0-$7.40 (Tier 2) PAR; MO; LA; QLL (120 per 30 days) NILANDRON $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) NIPENT $0-$7.40 (Tier 2) B/D PAR; MO NULOJIX $0-$7.40 (Tier 2) PAR; MO octreotide acetate $0-$7.40 (Tier 2) PAR; MO ONCASPAR $0-$7.40 (Tier 2) PAR; MO OPDIVO $0-$7.40 (Tier 2) PAR; MO oxaliplatin intravenous recon soln 100 mg $0-$7.40 (Tier 2) B/D PAR; MO oxaliplatin intravenous recon soln 50 mg $0-$7.40 (Tier 2) B/D PAR oxaliplatin intravenous solution $0-$7.40 (Tier 2) B/D PAR; MO paclitaxel $0-$7.40 (Tier 2) B/D PAR; MO PERJETA $0-$7.40 (Tier 2) PAR; MO POMALYST ORAL CAPSULE 1 MG $0-$7.40 (Tier 2) PAR; MO; QLL (120 per 30 days) POMALYST ORAL CAPSULE 2 MG $0-$7.40 (Tier 2) PAR; MO; QLL (60 per 30 days) POMALYST ORAL CAPSULE 3 MG, 4 MG $0-$7.40 (Tier 2) PAR; MO; QLL (30 per 30 days) PROGRAF INTRAVENOUS $0-$7.40 (Tier 2) B/D PAR; MO PURIXAN $0-$7.40 (Tier 2) PAR; MO RAPAMUNE ORAL SOLUTION $0-$7.40 (Tier 2) B/D PAR; MO REVLIMID ORAL CAPSULE 10 MG $0-$7.40 (Tier 2) PAR; MO; LA; QLL (60 per 30 days) REVLIMID ORAL CAPSULE 15 MG, 2.5 MG, 20 MG, 25 MG $0-$7.40 (Tier 2) PAR; MO; LA; QLL (30 per 30 days) REVLIMID ORAL CAPSULE 5 MG $0-$7.40 (Tier 2) PAR; MO; LA; QLL (150 per 30 days) RITUXAN $0-$7.40 (Tier 2) PAR; MO SIGNIFOR $0-$7.40 (Tier 2) MO ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 29 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso SIMULECT INTRAVENOUS RECON SOLN 10 MG $0-$7.40 (Tier 2) B/D PAR SIMULECT INTRAVENOUS RECON SOLN 20 MG $0-$7.40 (Tier 2) B/D PAR; MO sirolimus $0-$7.40 (Tier 2) B/D PAR; MO SOLTAMOX $0-$7.40 (Tier 2) MO SOMATULINE DEPOT $0-$7.40 (Tier 2) PAR; MO SPRYCEL $0-$7.40 (Tier 2) PAR; MO; QLL (30 per 30 days) STIVARGA $0-$7.40 (Tier 2) PAR; MO; QLL (120 per 30 days) SUTENT ORAL CAPSULE 12.5 MG $0-$7.40 (Tier 2) PAR; MO; QLL (90 per 30 days) SUTENT ORAL CAPSULE 25 MG, 37.5 MG, 50 MG $0-$7.40 (Tier 2) PAR; MO; QLL (30 per 30 days) SYNRIBO $0-$7.40 (Tier 2) PAR; MO TABLOID $0-$7.40 (Tier 2) MO tacrolimus oral $0-$7.40 (Tier 2) B/D PAR; MO TAFINLAR $0-$7.40 (Tier 2) PAR; MO; QLL (120 per 30 days) tamoxifen $0-$7.40 (Tier 2) MO TARCEVA ORAL TABLET 100 MG, 150 MG $0-$7.40 (Tier 2) PAR; MO; QLL (30 per 30 days) TARCEVA ORAL TABLET 25 MG $0-$7.40 (Tier 2) PAR; MO; QLL (90 per 30 days) TARGRETIN ORAL $0-$7.40 (Tier 2) PAR; MO; QLL (300 per 30 days) TARGRETIN TOPICAL $0-$7.40 (Tier 2) PAR; MO TASIGNA $0-$7.40 (Tier 2) PAR; MO; QLL (120 per 30 days) THALOMID ORAL CAPSULE 100 MG, 50 MG $0-$7.40 (Tier 2) PAR; MO; QLL (30 per 30 days) THALOMID ORAL CAPSULE 150 MG, 200 MG $0-$7.40 (Tier 2) PAR; MO; QLL (60 per 30 days) toposar $0-$7.40 (Tier 2) B/D PAR; MO topotecan $0-$7.40 (Tier 2) B/D PAR; MO TORISEL $0-$7.40 (Tier 2) B/D PAR; MO TREANDA $0-$7.40 (Tier 2) B/D PAR; MO TRELSTAR DEPOT $0-$7.40 (Tier 2) B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 30 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION $0-$7.40 (Tier 2) MO; QLL (1 per 168 days) TRELSTAR INTRAMUSCULAR SYRINGE 11.25 MG/2 ML, 3.75 MG/2 ML $0-$7.40 (Tier 2) MO TRELSTAR INTRAMUSCULAR SYRINGE 22.5 MG/2 ML $0-$7.40 (Tier 2) MO; QLL (1 per 168 days) TRELSTAR LA $0-$7.40 (Tier 2) tretinoin (chemotherapy) $0-$7.40 (Tier 2) MO TREXALL $0-$7.40 (Tier 2) MO TRISENOX $0-$7.40 (Tier 2) B/D PAR; MO TYKERB $0-$7.40 (Tier 2) PAR; MO; LA; QLL (180 per 30 days) VECTIBIX $0-$7.40 (Tier 2) PAR; MO VELCADE $0-$7.40 (Tier 2) PAR; MO vinblastine intravenous solution $0-$7.40 (Tier 2) B/D PAR; MO VINCASAR PFS INTRAVENOUS SOLUTION 1 MG/ML $0-$7.40 (Tier 2) B/D PAR vincasar pfs intravenous solution 2 mg/2 ml $0-$7.40 (Tier 2) B/D PAR; MO vincristine $0-$7.40 (Tier 2) B/D PAR; MO vinorelbine $0-$7.40 (Tier 2) B/D PAR; MO VOTRIENT $0-$7.40 (Tier 2) PAR; MO; QLL (120 per 30 days) XALKORI $0-$7.40 (Tier 2) PAR; MO; QLL (60 per 30 days) XTANDI $0-$7.40 (Tier 2) PAR; MO; QLL (120 per 30 days) YERVOY $0-$7.40 (Tier 2) PAR; MO ZALTRAP $0-$7.40 (Tier 2) PAR; MO ZANOSAR $0-$7.40 (Tier 2) B/D PAR; MO ZELBORAF $0-$7.40 (Tier 2) PAR; MO; QLL (240 per 30 days) ZOLINZA $0-$7.40 (Tier 2) PAR; MO; QLL (120 per 30 days) ZORTRESS $0-$7.40 (Tier 2) B/D PAR; MO ZYDELIG $0-$7.40 (Tier 2) PAR; MO; QLL (60 per 30 days) ZYKADIA $0-$7.40 (Tier 2) PAR; MO; QLL (150 per 30 days) ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 31 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso ZYTIGA $0-$7.40 (Tier 2) PAR; MO; QLL (120 per 30 days) AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH 2B ANTICONVULSANTS 29B APTIOM $0-$7.40 (Tier 2) ST; MO BANZEL ORAL SUSPENSION $0-$7.40 (Tier 2) PAR; MO; QLL (2400 per 30 days) BANZEL ORAL TABLET 200 MG $0-$7.40 (Tier 2) PAR; MO; QLL (480 per 30 days) BANZEL ORAL TABLET 400 MG $0-$7.40 (Tier 2) PAR; MO; QLL (240 per 30 days) carbamazepine oral capsule, er multiphase 12 hr $0-$7.40 (Tier 2) MO carbamazepine oral suspension 100 mg/5 ml $0-$7.40 (Tier 2) MO carbamazepine oral tablet $0-$7.40 (Tier 2) MO carbamazepine oral tablet extended release 12 hr $0-$7.40 (Tier 2) MO carbamazepine oral tablet,chewable $0-$7.40 (Tier 2) MO CELONTIN ORAL CAPSULE 300 MG $0-$7.40 (Tier 2) MO clonazepam oral tablet 0.5 mg $0-$7.40 (Tier 2) PAR; MO; QLL (1200 per 30 days) clonazepam oral tablet 1 mg $0-$7.40 (Tier 2) PAR; MO; QLL (600 per 30 days) clonazepam oral tablet 2 mg $0-$7.40 (Tier 2) PAR; MO; QLL (300 per 30 days) clonazepam oral tablet,disintegrating 0.125 mg $0-$7.40 (Tier 2) PAR; MO; QLL (4800 per 30 days) clonazepam oral tablet,disintegrating 0.25 mg $0-$7.40 (Tier 2) PAR; MO; QLL (2400 per 30 days) clonazepam oral tablet,disintegrating 0.5 mg $0-$7.40 (Tier 2) PAR; MO; QLL (1200 per 30 days) clonazepam oral tablet,disintegrating 1 mg $0-$7.40 (Tier 2) PAR; MO; QLL (600 per 30 days) clonazepam oral tablet,disintegrating 2 mg $0-$7.40 (Tier 2) PAR; MO; QLL (300 per 30 days) diazepam rectal kit 12.5-15-17.5-20 mg $0-$7.40 (Tier 2) MO diazepam rectal kit 2.5 mg, 5-7.5-10 mg $0-$7.40 (Tier 2) MO; QLL (2 per 2 days) DILANTIN CAPSULES $0-$7.40 (Tier 2) MO DILANTIN EXTENDED CAPSULES $0-$7.40 (Tier 2) MO DILANTIN INFATABS $0-$7.40 (Tier 2) MO B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 32 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso divalproex $0-$7.40 (Tier 2) MO epitol $0-$7.40 (Tier 2) MO EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 100 MG $0-$7.40 (Tier 2) MO; QLL (480 per 30 days) EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 200 MG $0-$7.40 (Tier 2) MO; QLL (240 per 30 days) EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 300 MG $0-$7.40 (Tier 2) MO; QLL (180 per 30 days) ethosuximide $0-$7.40 (Tier 2) MO felbamate $0-$7.40 (Tier 2) MO fosphenytoin $0-$7.40 (Tier 2) B/D PAR; MO FYCOMPA ORAL TABLET 10 MG, 12 MG $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) FYCOMPA ORAL TABLET 2 MG $0-$7.40 (Tier 2) MO; QLL (180 per 30 days) FYCOMPA ORAL TABLET 4 MG $0-$7.40 (Tier 2) MO; QLL (90 per 30 days) FYCOMPA ORAL TABLET 6 MG $0-$7.40 (Tier 2) MO; QLL (60 per 30 days) FYCOMPA ORAL TABLET 8 MG $0-$7.40 (Tier 2) MO; QLL (45 per 30 days) gabapentin oral capsule 100 mg $0 (Tier 1) MO; QLL (1080 per 30 days) gabapentin oral capsule 300 mg $0 (Tier 1) MO; QLL (360 per 30 days) gabapentin oral capsule 400 mg $0 (Tier 1) MO; QLL (270 per 30 days) gabapentin oral solution 250 mg/5 ml $0-$7.40 (Tier 2) MO; QLL (2160 per 30 days) gabapentin oral solution 250 mg/5 ml (5 ml), 300 mg/6 ml (6 ml) $0-$7.40 (Tier 2) QLL (2160 per 30 days) gabapentin oral tablet 600 mg $0 (Tier 1) MO; QLL (180 per 30 days) gabapentin oral tablet 800 mg $0 (Tier 1) MO; QLL (135 per 30 days) GABITRIL ORAL TABLET 12 MG, 16 MG $0-$7.40 (Tier 2) MO lamotrigine oral tablet $0-$7.40 (Tier 2) MO lamotrigine oral tablet, chewable dispersible $0-$7.40 (Tier 2) MO levetiracetam in nacl (iso-os) $0-$7.40 (Tier 2) B/D PAR levetiracetam intravenous $0-$7.40 (Tier 2) B/D PAR; MO levetiracetam oral solution 100 mg/ml $0-$7.40 (Tier 2) MO levetiracetam oral solution 500 mg/5 ml (5 ml) $0-$7.40 (Tier 2) ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 33 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso levetiracetam oral tablet $0-$7.40 (Tier 2) MO levetiracetam oral tablet extended release 24 hr 500 mg $0-$7.40 (Tier 2) MO; QLL (180 per 30 days) levetiracetam oral tablet extended release 24 hr 750 mg $0-$7.40 (Tier 2) MO; QLL (120 per 30 days) LYRICA ORAL CAPSULE 100 MG $0-$7.40 (Tier 2) PAR; MO; QLL (180 per 30 days) LYRICA ORAL CAPSULE 150 MG $0-$7.40 (Tier 2) PAR; MO; QLL (120 per 30 days) LYRICA ORAL CAPSULE 200 MG $0-$7.40 (Tier 2) PAR; MO; QLL (90 per 30 days) LYRICA ORAL CAPSULE 225 MG, 300 MG $0-$7.40 (Tier 2) PAR; MO; QLL (60 per 30 days) LYRICA ORAL CAPSULE 25 MG $0-$7.40 (Tier 2) PAR; MO; QLL (720 per 30 days) LYRICA ORAL CAPSULE 50 MG $0-$7.40 (Tier 2) PAR; MO; QLL (360 per 30 days) LYRICA ORAL CAPSULE 75 MG $0-$7.40 (Tier 2) PAR; MO; QLL (240 per 30 days) LYRICA ORAL SOLUTION $0-$7.40 (Tier 2) PAR; MO; QLL (900 per 30 days) ONFI ORAL SUSPENSION $0-$7.40 (Tier 2) PAR; MO; QLL (480 per 30 days) ONFI ORAL TABLET 10 MG $0-$7.40 (Tier 2) PAR; MO; QLL (120 per 30 days) ONFI ORAL TABLET 20 MG $0-$7.40 (Tier 2) PAR; MO; QLL (60 per 30 days) oxcarbazepine $0-$7.40 (Tier 2) MO OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG $0-$7.40 (Tier 2) MO; QLL (480 per 30 days) OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 300 MG $0-$7.40 (Tier 2) MO; QLL (240 per 30 days) OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR 600 MG $0-$7.40 (Tier 2) MO; QLL (120 per 30 days) PEGANONE $0-$7.40 (Tier 2) MO phenobarbital oral elixir $0-$7.40 (Tier 2) PAR; MO; QLL (3000 per 30 days) phenobarbital oral tablet 100 mg $0-$7.40 (Tier 2) PAR; QLL (120 per 30 days) phenobarbital oral tablet 15 mg $0-$7.40 (Tier 2) PAR; MO; QLL (800 per 30 days) phenobarbital oral tablet 16.2 mg $0-$7.40 (Tier 2) PAR; MO; QLL (741 per 30 days) phenobarbital oral tablet 30 mg $0-$7.40 (Tier 2) PAR; MO; QLL (400 per 30 days) phenobarbital oral tablet 32.4 mg $0-$7.40 (Tier 2) PAR; MO; QLL (370 per 30 days) B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 34 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso phenobarbital oral tablet 60 mg $0-$7.40 (Tier 2) PAR; MO; QLL (200 per 30 days) phenobarbital oral tablet 64.8 mg $0-$7.40 (Tier 2) PAR; MO; QLL (185 per 30 days) phenobarbital oral tablet 97.2 mg $0-$7.40 (Tier 2) PAR; MO; QLL (123 per 30 days) phenytoin oral suspension 100 mg/4 ml $0-$7.40 (Tier 2) phenytoin oral suspension 125 mg/5 ml $0-$7.40 (Tier 2) MO phenytoin oral tablet,chewable $0-$7.40 (Tier 2) MO phenytoin sodium extended $0-$7.40 (Tier 2) MO phenytoin sodium intravenous solution $0-$7.40 (Tier 2) B/D PAR; MO phenytoin sodium intravenous syringe $0-$7.40 (Tier 2) B/D PAR POTIGA ORAL TABLET 200 MG, 300 MG, 400 MG $0-$7.40 (Tier 2) MO; QLL (90 per 30 days) POTIGA ORAL TABLET 50 MG $0-$7.40 (Tier 2) MO; QLL (270 per 30 days) primidone $0-$7.40 (Tier 2) MO SABRIL $0-$7.40 (Tier 2) PAR; MO; LA; QLL (180 per 30 days) tiagabine $0-$7.40 (Tier 2) MO topiramate oral capsule, sprinkle $0-$7.40 (Tier 2) PAR; MO topiramate oral tablet 100 mg $0-$7.40 (Tier 2) PAR; MO; QLL (480 per 30 days) topiramate oral tablet 200 mg $0-$7.40 (Tier 2) PAR; MO; QLL (240 per 30 days) topiramate oral tablet 25 mg $0-$7.40 (Tier 2) PAR; MO; QLL (1920 per 30 days) topiramate oral tablet 50 mg $0-$7.40 (Tier 2) PAR; MO; QLL (960 per 30 days) valproate sodium $0-$7.40 (Tier 2) B/D PAR; MO valproic acid $0-$7.40 (Tier 2) MO valproic acid (as sodium salt) oral solution 250 mg/5 ml $0-$7.40 (Tier 2) MO valproic acid (as sodium salt) oral solution 250 mg/5 ml (5 ml), 500 mg/10 ml (10 ml) $0-$7.40 (Tier 2) VIMPAT INTRAVENOUS $0-$7.40 (Tier 2) B/D PAR; QLL (1200 per 30 days) VIMPAT ORAL SOLUTION $0-$7.40 (Tier 2) MO; QLL (1200 per 30 days) VIMPAT ORAL TABLET 100 MG $0-$7.40 (Tier 2) MO; QLL (120 per 30 days) VIMPAT ORAL TABLET 150 MG $0-$7.40 (Tier 2) MO; QLL (80 per 30 days) ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 35 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso VIMPAT ORAL TABLET 200 MG $0-$7.40 (Tier 2) MO; QLL (60 per 30 days) VIMPAT ORAL TABLET 50 MG $0-$7.40 (Tier 2) MO; QLL (240 per 30 days) zonisamide $0-$7.40 (Tier 2) MO APOKYN $0-$7.40 (Tier 2) PAR; MO; LA AZILECT $0-$7.40 (Tier 2) MO benztropine oral $0-$7.40 (Tier 2) PAR; MO bromocriptine $0-$7.40 (Tier 2) MO carbidopa-levodopa $0-$7.40 (Tier 2) MO entacapone $0-$7.40 (Tier 2) MO NEUPRO $0-$7.40 (Tier 2) PAR; MO; QLL (30 per 30 days) pramipexole oral tablet $0-$7.40 (Tier 2) MO ropinirole oral tablet $0-$7.40 (Tier 2) MO selegiline hcl $0-$7.40 (Tier 2) MO tolcapone $0-$7.40 (Tier 2) MO dihydroergotamine injection $0-$7.40 (Tier 2) PAR; MO ERGOMAR $0-$7.40 (Tier 2) MO rizatriptan $0-$7.40 (Tier 2) MO; QLL (12 per 30 days) sumatriptan succinate oral $0-$7.40 (Tier 2) MO; QLL (9 per 30 days) sumatriptan succinate subcutaneous cartridge $0-$7.40 (Tier 2) MO; QLL (4 per 30 days) sumatriptan succinate subcutaneous pen injector $0-$7.40 (Tier 2) MO; QLL (4 per 30 days) sumatriptan succinate subcutaneous solution $0-$7.40 (Tier 2) MO; QLL (4 per 30 days) sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml $0-$7.40 (Tier 2) QLL (4 per 30 days) zolmitriptan $0-$7.40 (Tier 2) MO; QLL (9 per 30 days) ZOMIG NASAL $0-$7.40 (Tier 2) MO; QLL (6 per 30 days) ANTIPARKINSONISM AGENTS 30B MIGRAINE / CLUSTER HEADACHE THERAPY 31B B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 36 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso MISCELLANEOUS NEUROLOGICAL THERAPY 32B AMPYRA $0-$7.40 (Tier 2) PAR; MO; LA; QLL (60 per 30 days) COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML $0-$7.40 (Tier 2) PAR; MO; QLL (30 per 30 days) COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML $0-$7.40 (Tier 2) PAR; MO; QLL (12 per 28 days) donepezil oral tablet 10 mg, 5 mg $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) donepezil oral tablet,disintegrating $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) galantamine oral capsule,ext rel. pellets 24 hr $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) galantamine oral solution $0-$7.40 (Tier 2) MO; QLL (180 per 30 days) galantamine oral tablet $0-$7.40 (Tier 2) MO; QLL (60 per 30 days) GILENYA $0-$7.40 (Tier 2) PAR; MO; QLL (30 per 30 days) GLATOPA $0-$7.40 (Tier 2) PAR; MO; QLL (30 per 30 days) NAMENDA ORAL SOLUTION $0-$7.40 (Tier 2) MO; QLL (300 per 30 days) NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE PACK $0-$7.40 (Tier 2) MO; QLL (56 per 365 days) NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 24HR $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) NUEDEXTA $0-$7.40 (Tier 2) MO; QLL (60 per 30 days) rivastigmine tartrate $0-$7.40 (Tier 2) MO; QLL (60 per 30 days) TECFIDERA $0-$7.40 (Tier 2) PAR; MO TYSABRI $0-$7.40 (Tier 2) PAR; MO; LA XENAZINE ORAL TABLET 12.5 MG $0-$7.40 (Tier 2) PAR; MO; LA; QLL (240 per 30 days) XENAZINE ORAL TABLET 25 MG $0-$7.40 (Tier 2) PAR; MO; LA; QLL (120 per 30 days) MUSCLE RELAXANTS / ANTISPASMODIC THERAPY 3B baclofen $0-$7.40 (Tier 2) MO cyclobenzaprine oral tablet $0-$7.40 (Tier 2) PAR; MO dantrolene $0-$7.40 (Tier 2) MO ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 37 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso MESTINON ORAL SYRUP $0-$7.40 (Tier 2) MO MESTINON TIMESPAN $0-$7.40 (Tier 2) MO pyridostigmine bromide oral tablet $0-$7.40 (Tier 2) MO tizanidine oral tablet $0-$7.40 (Tier 2) MO acetaminophen-codeine oral solution 120 mg-12 mg /5 ml (5 ml), 240 mg-24 mg /10 ml (10 ml), 300 mg-30 mg /12.5 ml $0-$7.40 (Tier 2) QLL (4500 per 30 days) acetaminophen-codeine oral solution 120-12 mg/5 ml $0-$7.40 (Tier 2) MO; QLL (4500 per 30 days) acetaminophen-codeine oral tablet 300-15 mg $0-$7.40 (Tier 2) MO; QLL (390 per 30 days) acetaminophen-codeine oral tablet 300-30 mg $0-$7.40 (Tier 2) MO; QLL (360 per 30 days) acetaminophen-codeine oral tablet 300-60 mg $0-$7.40 (Tier 2) MO; QLL (180 per 30 days) buprenorphine hcl injection syringe $0-$7.40 (Tier 2) QLL (150 per 30 days) buprenorphine hcl sublingual tablet 2 mg $0-$7.40 (Tier 2) PAR; MO; QLL (240 per 30 days) buprenorphine hcl sublingual tablet 8 mg $0-$7.40 (Tier 2) PAR; MO; QLL (60 per 30 days) butalbital compound w/codeine $0-$7.40 (Tier 2) PAR; MO; QLL (180 per 30 days) duramorph (pf) injection solution 0.5 mg/ml $0-$7.40 (Tier 2) B/D PAR; MO; QLL (180 per 30 days) duramorph (pf) injection solution 1 mg/ml $0-$7.40 (Tier 2) B/D PAR; QLL (180 per 30 days) endocet oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg $0-$7.40 (Tier 2) MO; QLL (360 per 30 days) fentanyl citrate $0-$7.40 (Tier 2) PAR; MO; QLL (120 per 30 days) fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr $0-$7.40 (Tier 2) ST; MO; QLL (15 per 30 days) hydrocodone-acetaminophen oral solution 2.5-167 mg/5 ml $0-$7.40 (Tier 2) QLL (2700 per 30 days) hydrocodone-acetaminophen oral solution 7.5-325 mg/15 ml $0-$7.40 (Tier 2) MO; QLL (2700 per 30 days) hydrocodone-acetaminophen oral tablet 10-300 mg, 5-300 mg, 7.5-300 mg $0-$7.40 (Tier 2) MO; QLL (390 per 30 days) NARCOTIC ANALGESICS 34B B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 38 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg $0-$7.40 (Tier 2) MO; QLL (360 per 30 days) hydrocodone-ibuprofen $0-$7.40 (Tier 2) MO; QLL (480 per 30 days) hydromorphone oral tablet 2 mg, 4 mg $0-$7.40 (Tier 2) MO; QLL (360 per 30 days) hydromorphone oral tablet 8 mg $0-$7.40 (Tier 2) MO; QLL (180 per 30 days) levorphanol tartrate $0-$7.40 (Tier 2) MO; QLL (180 per 30 days) methadone injection $0-$7.40 (Tier 2) QLL (150 per 30 days) methadone intensol $0-$7.40 (Tier 2) MO; QLL (180 per 30 days) methadone oral concentrate $0-$7.40 (Tier 2) QLL (180 per 30 days) methadone oral solution 10 mg/5 ml $0-$7.40 (Tier 2) MO; QLL (900 per 30 days) methadone oral solution 5 mg/5 ml $0-$7.40 (Tier 2) MO; QLL (1800 per 30 days) methadone oral tablet 10 mg $0-$7.40 (Tier 2) MO; QLL (180 per 30 days) methadone oral tablet 5 mg $0-$7.40 (Tier 2) MO; QLL (360 per 30 days) methadose oral concentrate $0-$7.40 (Tier 2) MO; QLL (180 per 30 days) morphine (pf) injection solution 0.5 mg/ml $0-$7.40 (Tier 2) B/D PAR morphine (pf) injection solution 1 mg/ml $0-$7.40 (Tier 2) B/D PAR; MO; QLL (180 per 30 days) morphine (pf) intravenous patient control.analgesia soln 150 mg/30 ml $0-$7.40 (Tier 2) MO; QLL (120 per 30 days) morphine (pf) intravenous patient control.analgesia soln 30 mg/30 ml $0-$7.40 (Tier 2) B/D PAR; QLL (180 per 30 days) morphine concentrate oral solution $0-$7.40 (Tier 2) MO; QLL (270 per 30 days) morphine intravenous cartridge $0-$7.40 (Tier 2) QLL (120 per 30 days) MORPHINE INTRAVENOUS CARTRIDGE $0-$7.40 (Tier 2) QLL (120 per 30 days) morphine intravenous pt controlled analgesia syring $0-$7.40 (Tier 2) B/D PAR; QLL (180 per 30 days) morphine intravenous solution 100 mg/4 ml, 25 mg/ml, 250 mg/10 ml $0-$7.40 (Tier 2) QLL (120 per 30 days) morphine intravenous solution 50 mg/ml $0-$7.40 (Tier 2) MO; QLL (120 per 30 days) morphine intravenous syringe 2 mg/ml, 4 mg/ml $0-$7.40 (Tier 2) QLL (120 per 30 days) morphine oral capsule, er multiphase 24 hr 120 mg, 75 mg, 90 mg $0-$7.40 (Tier 2) MO; QLL (60 per 30 days) ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 39 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso morphine oral capsule, er multiphase 24 hr 30 mg, 45 mg, 60 mg $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) morphine oral capsule,extend.release pellets 100 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg $0-$7.40 (Tier 2) MO; QLL (60 per 30 days) morphine oral solution 20 mg/5 ml $0-$7.40 (Tier 2) MO; QLL (1350 per 30 days) morphine oral tablet 15 mg $0-$7.40 (Tier 2) MO; QLL (360 per 30 days) morphine oral tablet 30 mg $0-$7.40 (Tier 2) MO; QLL (180 per 30 days) morphine oral tablet extended release 100 mg, 15 mg, 30 mg, 60 mg $0-$7.40 (Tier 2) MO; QLL (90 per 30 days) morphine oral tablet extended release 200 mg $0-$7.40 (Tier 2) MO; QLL (60 per 30 days) oxycodone oral capsule $0-$7.40 (Tier 2) MO; QLL (360 per 30 days) oxycodone oral concentrate $0-$7.40 (Tier 2) MO; QLL (360 per 30 days) oxycodone oral tablet 10 mg, 5 mg $0-$7.40 (Tier 2) MO; QLL (360 per 30 days) oxycodone oral tablet 15 mg $0-$7.40 (Tier 2) MO; QLL (540 per 30 days) oxycodone oral tablet 20 mg, 30 mg $0-$7.40 (Tier 2) MO; QLL (180 per 30 days) oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg $0-$7.40 (Tier 2) MO; QLL (360 per 30 days) oxycodone-aspirin $0-$7.40 (Tier 2) MO; QLL (360 per 30 days) ROXICET ORAL SOLUTION $0-$7.40 (Tier 2) MO; QLL (1800 per 30 days) NON-NARCOTIC ANALGESICS 35B 8 hour pain reliever $0 (Tier 4) MO; [*] acephen rectal suppository 120 mg, 650 mg $0 (Tier 4) MO; [*] acephen rectal suppository 325 mg $0 (Tier 4) [*] acetadryl $0 (Tier 4) [*] aceta-gesic $0 (Tier 4) [*] acetaminophen extra strength $0 (Tier 4) [*] acetaminophen oral drops,suspension $0 (Tier 4) [*] acetaminophen oral elixir $0 (Tier 4) [*] acetaminophen oral solution 160 mg/5 ml (5 ml) $0 (Tier 4) MO; [*] B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 40 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso acetaminophen oral solution 325 mg/10.15 ml $0 (Tier 4) [*] acetaminophen oral suspension 160 mg/5 ml $0 (Tier 4) [*] acetaminophen oral tablet $0 (Tier 4) MO; [*] acetaminophen oral tablet extended release $0 (Tier 4) [*] acetaminophen oral tablet,disintegrating $0 (Tier 4) [*] acetaminophen pain relief $0 (Tier 4) [*] acetaminophen pm $0 (Tier 4) [*] acetaminophen pm extra str $0 (Tier 4) [*] acetaminophen rectal suppository 120 mg, 650 mg $0 (Tier 4) [*] added strength headache relief $0 (Tier 4) [*] added strength pain reliever $0 (Tier 4) [*] adult low dose aspirin $0 (Tier 4) MO; [*] ADVIL LIQUI-GEL $0 (Tier 4) MO; [*] ADVIL MIGRAINE $0 (Tier 4) [*] advil oral tablet $0 (Tier 4) MO; [*] ADVIL ORAL TABLET $0 (Tier 4) MO; [*] advil oral tablet,chewable $0 (Tier 4) [*] ADVIL PM $0 (Tier 4) MO; [*] ADVIL PM LIQUI-GELS $0 (Tier 4) [*] alka-seltzer original $0 (Tier 4) [*] all day pain relief $0 (Tier 4) [*] all day relief $0 (Tier 4) MO; [*] antacid & pain relief $0 (Tier 4) [*] arthritis pain relief (acetam) $0 (Tier 4) [*] arthritis pain reliever $0 (Tier 4) [*] aspir-81 $0 (Tier 4) [*] aspirin childrens $0 (Tier 4) [*] aspirin low dose $0 (Tier 4) MO; [*] aspirin low-strength $0 (Tier 4) [*] ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 41 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso aspirin oral tablet 325 mg $0 (Tier 4) MO; [*] aspirin oral tablet,chewable $0 (Tier 4) MO; [*] aspirin oral tablet,delayed release (dr/ec) 325 mg, 81 mg $0 (Tier 4) MO; [*] aspir-low $0 (Tier 4) MO; [*] aspir-trin $0 (Tier 4) MO; [*] athenol $0 (Tier 4) [*] bayer aspirin $0 (Tier 4) MO; [*] betatemp $0 (Tier 4) [*] buprenorphine-naloxone sublingual tablet 2-0.5 mg $0-$7.40 (Tier 2) PAR; MO; QLL (360 per 30 days) buprenorphine-naloxone sublingual tablet 8-2 mg $0-$7.40 (Tier 2) PAR; MO; QLL (90 per 30 days) butorphanol tartrate injection solution 1 mg/ml $0-$7.40 (Tier 2) MO; QLL (240 per 30 days) butorphanol tartrate injection solution 2 mg/ml $0-$7.40 (Tier 2) MO; QLL (120 per 30 days) butorphanol tartrate nasal $0-$7.40 (Tier 2) MO; QLL (5 per 28 days) child aspirin $0 (Tier 4) [*] child ibuprofen $0 (Tier 4) [*] child non-aspirin quick melts $0 (Tier 4) [*] child pain rel-fever reducer $0 (Tier 4) [*] children's acetaminophen oral suspension 160 mg/5 ml, 160 mg/5 ml (5 ml) $0 (Tier 4) [*] children's acetaminophen oral tablet,chewable $0 (Tier 4) [*] children's advil $0 (Tier 4) MO; [*] children's aspirin $0 (Tier 4) MO; [*] children's easy-melts $0 (Tier 4) [*] children's fever reducing $0 (Tier 4) [*] children's ibuprofen $0 (Tier 4) MO; [*] children's mapap $0 (Tier 4) [*] children's medi-profen $0 (Tier 4) [*] B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 42 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso children's medi-tabs $0 (Tier 4) [*] CHILDREN'S MOTRIN $0 (Tier 4) [*] children's non-aspirin oral elixir $0 (Tier 4) [*] children's non-aspirin oral suspension $0 (Tier 4) [*] children's non-aspirin oral tablet,chewable $0 (Tier 4) [*] children's non-aspirin pain $0 (Tier 4) [*] children's pain & fever relief $0 (Tier 4) MO; [*] children's pain relief $0 (Tier 4) [*] children's pain reliever oral suspension $0 (Tier 4) [*] children's pain reliever oral tablet,disintegrating $0 (Tier 4) [*] children's profen ib $0 (Tier 4) [*] children's q-pap $0 (Tier 4) MO; [*] children's silapap $0 (Tier 4) [*] children's tactinal $0 (Tier 4) [*] diclofenac potassium $0-$7.40 (Tier 2) MO diclofenac sodium oral $0-$7.40 (Tier 2) MO diflunisal $0-$7.40 (Tier 2) MO diphenhydramine-acetaminophen $0 (Tier 4) [*] e.c. prin $0 (Tier 4) [*] ecotrin $0 (Tier 4) MO; [*] ecotrin low strength $0 (Tier 4) MO; [*] ed-apap $0 (Tier 4) [*] efferves pain relief antacid $0 (Tier 4) [*] effervescent pain relief oral tablet, effervescent 325-1,916-1,000 mg $0 (Tier 4) [*] enteric coated aspirin $0 (Tier 4) [*] etodolac oral capsule 200 mg $0-$7.40 (Tier 2) MO etodolac oral tablet $0-$7.40 (Tier 2) MO etodolac oral tablet extended release 24 hr $0-$7.40 (Tier 2) MO EXCEDRIN EXTRA STRENGTH ? $0 (Tier 4) MO; [*] Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 43 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso EXCEDRIN MIGRAINE $0 (Tier 4) MO; [*] EXCEDRIN TENSION HEADACHE $0 (Tier 4) [*] ex-strength medi-tabs $0 (Tier 4) [*] ex-strength medi-tabs pm $0 (Tier 4) [*] $0-$7.40 (Tier 2) MO fever reducer $0 (Tier 4) [*] fever reducer & pain reliever $0 (Tier 4) [*] FEVERALL $0 (Tier 4) [*] flanax (naproxen) $0 (Tier 4) [*] $0-$7.40 (Tier 2) MO headache formula $0 (Tier 4) [*] headache formula added str $0 (Tier 4) [*] headache pm $0 (Tier 4) [*] headache relief (asa-acet-caf) $0 (Tier 4) [*] ibu-drops $0 (Tier 4) [*] ibuprofen ib $0 (Tier 4) [*] ibuprofen jr strength $0 (Tier 4) [*] ibuprofen oral capsule $0 (Tier 4) [*] ibuprofen oral drops,suspension $0 (Tier 4) [*] $0-$7.40 (Tier 2) MO ibuprofen oral tablet 100 mg $0 (Tier 4) [*] ibuprofen oral tablet 200 mg $0 (Tier 4) MO; [*] fenoprofen oral tablet flurbiprofen ibuprofen oral suspension ibuprofen oral tablet 400 mg, 600 mg, 800 mg $0-$7.40 (Tier 2) MO ibuprofen pm oral tablet $0 (Tier 4) [*] ibuprofen-diphenhydramine cit $0 (Tier 4) [*] ibuprofen-diphenhydramine hcl $0 (Tier 4) [*] infant fever reducer-pain relf $0 (Tier 4) [*] infant pain reliever $0 (Tier 4) [*] B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 44 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso infants ibu-drops $0 (Tier 4) [*] infant's ibuprofen $0 (Tier 4) [*] infant's medi-profen $0 (Tier 4) [*] infant's non-aspirin $0 (Tier 4) [*] infants' pain & fever $0 (Tier 4) [*] infants' pain relief $0 (Tier 4) [*] infant's pain relief oral drops,suspension 80 mg/0.8 ml $0 (Tier 4) [*] infant's pain relief oral suspension $0 (Tier 4) [*] infant's pain reliever $0 (Tier 4) [*] infants profenib $0 (Tier 4) [*] i-prin $0 (Tier 4) [*] jr. acetaminophen $0 (Tier 4) [*] jr. str non-aspirin pain $0 (Tier 4) [*] jr. strength pain reliever $0 (Tier 4) [*] junior mapap $0 (Tier 4) MO; [*] lite coat aspirin $0 (Tier 4) [*] little remedies fever & pain $0 (Tier 4) [*] lo-dose aspirin $0 (Tier 4) [*] mapap (acetaminophen) oral capsule $0 (Tier 4) MO; [*] mapap (acetaminophen) oral elixir $0 (Tier 4) MO; [*] mapap (acetaminophen) oral liquid 160 mg/5 ml $0 (Tier 4) [*] mapap (acetaminophen) oral liquid 500 mg/15 ml $0 (Tier 4) MO; [*] mapap (acetaminophen) oral suspension $0 (Tier 4) [*] mapap (acetaminophen) oral tablet $0 (Tier 4) MO; [*] mapap (acetaminophen) oral tablet,chewable $0 (Tier 4) MO; [*] mapap arthritis pain $0 (Tier 4) MO; [*] mapap extra strength $0 (Tier 4) MO; [*] mapap pm $0 (Tier 4) MO; [*] masophen $0 (Tier 4) [*] ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 45 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso meclofenamate oral $0-$7.40 (Tier 2) MO medi-profen $0 (Tier 4) [*] mediproxen $0 (Tier 4) [*] medi-tabs $0 (Tier 4) [*] medi-tabs pain reliever $0 (Tier 4) [*] medi-tabs pm $0 (Tier 4) [*] meloxicam oral suspension $0-$7.40 (Tier 2) MO; QLL (300 per 30 days) meloxicam oral tablet $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) migraine formula $0 (Tier 4) [*] migraine pain reliever $0 (Tier 4) [*] migraine relief $0 (Tier 4) [*] MOTRIN IB $0 (Tier 4) MO; [*] motrin pm $0 (Tier 4) [*] nabumetone $0-$7.40 (Tier 2) MO nalbuphine injection solution 10 mg/ml $0-$7.40 (Tier 2) MO; QLL (180 per 30 days) nalbuphine injection solution 20 mg/ml $0-$7.40 (Tier 2) MO; QLL (90 per 30 days) naloxone injection solution $0-$7.40 (Tier 2) MO naloxone injection syringe 0.4 mg/ml $0-$7.40 (Tier 2) naloxone injection syringe 1 mg/ml $0-$7.40 (Tier 2) MO naltrexone oral $0-$7.40 (Tier 2) MO naproxen $0-$7.40 (Tier 2) MO naproxen sodium oral capsule $0 (Tier 4) [*] naproxen sodium oral tablet 220 mg $0 (Tier 4) MO; [*] naproxen sodium oral tablet 275 mg, 550 mg $0-$7.40 (Tier 2) MO non-aspirin 8 hour $0 (Tier 4) [*] non-aspirin childrens $0 (Tier 4) [*] non-aspirin children's $0 (Tier 4) [*] non-aspirin extra strength $0 (Tier 4) [*] B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 46 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso non-aspirin nightime $0 (Tier 4) [*] non-aspirin oral elixir $0 (Tier 4) [*] non-aspirin oral suspension $0 (Tier 4) [*] non-aspirin oral tablet $0 (Tier 4) [*] non-aspirin oral tablet,chewable 80 mg $0 (Tier 4) [*] non-aspirin pain relief oral tablet 500 mg $0 (Tier 4) [*] non-aspirin pain relief pm $0 (Tier 4) [*] non-aspirin pm $0 (Tier 4) [*] nortemp $0 (Tier 4) [*] $0-$7.40 (Tier 2) MO oxaprozin pain & fever $0 (Tier 4) MO; [*] pain relief adult $0 (Tier 4) [*] pain relief extra strength $0 (Tier 4) [*] pain relief oral capsule $0 (Tier 4) [*] pain relief oral liquid $0 (Tier 4) [*] pain relief oral tablet 500 mg $0 (Tier 4) [*] pain relief oral tablet extended release $0 (Tier 4) [*] pain relief pm $0 (Tier 4) [*] pain relief pm rapid release $0 (Tier 4) [*] pain relief regular strength $0 (Tier 4) [*] pain reliever (acetam-aspirin) $0 (Tier 4) [*] pain reliever extra strength $0 (Tier 4) [*] pain reliever oral capsule $0 (Tier 4) [*] pain reliever oral tablet $0 (Tier 4) [*] pain reliever plus $0 (Tier 4) MO; [*] pain reliever pm ex-strength $0 (Tier 4) [*] pain reliever pm oral tablet 25-500 mg $0 (Tier 4) [*] pain-off $0 (Tier 4) [*] pamprin max $0 (Tier 4) [*] ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 47 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso pediacare fever reducer $0 (Tier 4) [*] percogesic $0 (Tier 4) [*] pharbetol $0 (Tier 4) [*] piroxicam $0-$7.40 (Tier 2) MO provil $0 (Tier 4) [*] q-pap extra strength $0 (Tier 4) MO; [*] q-pap oral drops $0 (Tier 4) MO; [*] q-pap oral liquid $0 (Tier 4) MO; [*] q-pap oral tablet 325 mg $0 (Tier 4) [*] q-pap oral tablet 500 mg $0 (Tier 4) MO; [*] silapap $0 (Tier 4) [*] SUBOXONE SUBLINGUAL FILM 12-3 MG $0-$7.40 (Tier 2) PAR; MO; QLL (60 per 30 days) SUBOXONE SUBLINGUAL FILM 2-0.5 MG $0-$7.40 (Tier 2) PAR; MO; QLL (360 per 30 days) SUBOXONE SUBLINGUAL FILM 4-1 MG $0-$7.40 (Tier 2) PAR; MO; QLL (180 per 30 days) SUBOXONE SUBLINGUAL FILM 8-2 MG $0-$7.40 (Tier 2) PAR; MO; QLL (90 per 30 days) sulindac oral $0-$7.40 (Tier 2) MO super pain relief $0 (Tier 4) [*] tactinal $0 (Tier 4) [*] tactinal extra strength $0 (Tier 4) [*] TENSION HEADACHE $0 (Tier 4) [*] TENSION HEADACHE PAIN RELIEVER $0 (Tier 4) [*] TENSION HEADACHE RELIEF $0 (Tier 4) [*] tolmetin $0-$7.40 (Tier 2) MO tramadol oral tablet $0-$7.40 (Tier 2) MO; QLL (240 per 30 days) tramadol-acetaminophen $0-$7.40 (Tier 2) MO; QLL (240 per 30 days) tylophen VOLTAREN GEL TOPICAL GEL 1 % wal-profen $0 (Tier 4) $0-$7.40 (Tier 2) $0 (Tier 4) [*] MO; QLL (1000 per 30 days) [*] B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 48 Nombre del medicamento wal-proxen Qué le costará el medicamento (nivel de clase) $0 (Tier 4) Acciones necesarias, restricciones, o límites sobre el uso [*] PSYCHOTHERAPEUTIC DRUGS 36B ABILIFY DISCMELT ORAL TABLET,DISINTEGRATING 10 MG $0-$7.40 (Tier 2) PAR; MO; QLL (90 per 30 days) ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON $0-$7.40 (Tier 2) MO; QLL (1 per 28 days) ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING $0-$7.40 (Tier 2) QLL (1 per 28 days) ADASUVE $0-$7.40 (Tier 2) alprazolam oral tablet $0-$7.40 (Tier 2) MO; QLL (90 per 30 days) amitriptyline $0-$7.40 (Tier 2) PAR; MO amoxapine $0-$7.40 (Tier 2) MO amphetamine salt combo oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 5 mg, 7.5 mg $0-$7.40 (Tier 2) PAR; MO; QLL (90 per 30 days) amphetamine salt combo oral tablet 30 mg $0-$7.40 (Tier 2) PAR; MO; QLL (60 per 30 days) aripiprazole oral tablet 10 mg $0-$7.40 (Tier 2) PAR; MO; QLL (90 per 30 days) aripiprazole oral tablet 15 mg $0-$7.40 (Tier 2) PAR; MO; QLL (60 per 30 days) aripiprazole oral tablet 2 mg $0-$7.40 (Tier 2) PAR; MO; QLL (450 per 30 days) aripiprazole oral tablet 20 mg, 30 mg $0-$7.40 (Tier 2) PAR; MO; QLL (30 per 30 days) aripiprazole oral tablet 5 mg $0-$7.40 (Tier 2) PAR; MO; QLL (180 per 30 days) BRINTELLIX ORAL TABLET 10 MG $0-$7.40 (Tier 2) ST; MO; QLL (60 per 30 days) BRINTELLIX ORAL TABLET 20 MG $0-$7.40 (Tier 2) ST; MO; QLL (30 per 30 days) BRINTELLIX ORAL TABLET 5 MG $0-$7.40 (Tier 2) ST; MO; QLL (120 per 30 days) bupropion hcl oral tablet 100 mg $0-$7.40 (Tier 2) MO; QLL (135 per 30 days) bupropion hcl oral tablet 75 mg $0-$7.40 (Tier 2) MO; QLL (180 per 30 days) bupropion hcl oral tablet extended release 100 mg $0-$7.40 (Tier 2) MO; QLL (120 per 30 days) bupropion hcl oral tablet extended release 150 mg, 200 mg $0-$7.40 (Tier 2) MO; QLL (60 per 30 days) bupropion hcl oral tablet extended release 24 hr 150 mg $0-$7.40 (Tier 2) MO; QLL (90 per 30 days) ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 49 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso bupropion hcl oral tablet extended release 24 hr 300 mg $0-$7.40 (Tier 2) MO; QLL (45 per 30 days) buspirone $0-$7.40 (Tier 2) MO chlorpromazine $0-$7.40 (Tier 2) PAR; MO citalopram oral solution $0-$7.40 (Tier 2) MO; QLL (600 per 30 days) citalopram oral tablet 10 mg $0 (Tier 1) MO; QLL (120 per 30 days) citalopram oral tablet 20 mg $0 (Tier 1) MO; QLL (60 per 30 days) citalopram oral tablet 40 mg $0 (Tier 1) MO; QLL (30 per 30 days) clomipramine $0-$7.40 (Tier 2) PAR; MO clorazepate dipotassium $0-$7.40 (Tier 2) MO; QLL (120 per 30 days) clozapine oral tablet 100 mg $0 (Tier 1) MO; QLL (270 per 30 days) clozapine oral tablet 200 mg $0 (Tier 1) QLL (135 per 30 days) clozapine oral tablet 25 mg $0 (Tier 1) MO; QLL (1080 per 30 days) clozapine oral tablet 50 mg $0 (Tier 1) MO; QLL (540 per 30 days) clozapine oral tablet,disintegrating 100 mg $0 (Tier 1) QLL (270 per 30 days) clozapine oral tablet,disintegrating 12.5 mg $0 (Tier 1) QLL (2160 per 30 days) clozapine oral tablet,disintegrating 150 mg $0-$7.40 (Tier 2) QLL (180 per 30 days) clozapine oral tablet,disintegrating 200 mg $0-$7.40 (Tier 2) QLL (135 per 30 days) clozapine oral tablet,disintegrating 25 mg $0 (Tier 1) QLL (1080 per 30 days) desipramine oral $0-$7.40 (Tier 2) MO DESVENLAFAXINE FUMARATE ORAL TABLET EXTENDED RELEASE 24HR 100 MG $0-$7.40 (Tier 2) MO; QLL (120 per 30 days) DESVENLAFAXINE FUMARATE ORAL TABLET EXTENDED RELEASE 24HR 50 MG $0-$7.40 (Tier 2) MO; QLL (240 per 30 days) DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR 100 MG $0-$7.40 (Tier 2) MO; QLL (120 per 30 days) DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24 HR 50 MG $0-$7.40 (Tier 2) MO; QLL (240 per 30 days) DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 100 MG $0-$7.40 (Tier 2) QLL (120 per 30 days) B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 50 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso DESVENLAFAXINE ORAL TABLET EXTENDED RELEASE 24HR 50 MG $0-$7.40 (Tier 2) QLL (240 per 30 days) dextroamphetamine oral capsule, extended release 10 mg, 5 mg $0-$7.40 (Tier 2) MO; QLL (60 per 30 days) dextroamphetamine oral capsule, extended release 15 mg $0-$7.40 (Tier 2) MO; QLL (120 per 30 days) dextroamphetamine oral tablet 10 mg $0-$7.40 (Tier 2) MO; QLL (180 per 30 days) dextroamphetamine oral tablet 5 mg $0-$7.40 (Tier 2) MO; QLL (90 per 30 days) diazepam injection solution $0-$7.40 (Tier 2) diazepam injection syringe $0-$7.40 (Tier 2) MO diazepam intensol $0-$7.40 (Tier 2) PAR; MO; QLL (240 per 30 days) diazepam oral concentrate $0-$7.40 (Tier 2) PAR; QLL (240 per 30 days) diazepam oral solution 5 mg/5 ml $0-$7.40 (Tier 2) PAR; MO; QLL (1200 per 30 days) diazepam oral tablet 10 mg $0-$7.40 (Tier 2) PAR; MO; QLL (120 per 30 days) diazepam oral tablet 2 mg $0-$7.40 (Tier 2) PAR; MO; QLL (600 per 30 days) diazepam oral tablet 5 mg $0-$7.40 (Tier 2) PAR; MO; QLL (240 per 30 days) diphenhydramine hcl oral tablet 50 mg $0 (Tier 4) [*] doxepin oral $0-$7.40 (Tier 2) PAR; MO duloxetine oral capsule,delayed release(dr/ec) 20 mg $0-$7.40 (Tier 2) MO; QLL (180 per 30 days) duloxetine oral capsule,delayed release(dr/ec) 30 mg $0-$7.40 (Tier 2) MO; QLL (120 per 30 days) duloxetine oral capsule,delayed release(dr/ec) 40 mg $0-$7.40 (Tier 2) QLL (90 per 30 days) duloxetine oral capsule,delayed release(dr/ec) 60 mg $0-$7.40 (Tier 2) MO; QLL (60 per 30 days) EMSAM $0-$7.40 (Tier 2) PAR; MO; QLL (30 per 30 days) ergoloid $0-$7.40 (Tier 2) PAR; MO escitalopram oxalate oral solution $0-$7.40 (Tier 2) MO; QLL (600 per 30 days) escitalopram oxalate oral tablet 10 mg $0-$7.40 (Tier 2) MO; QLL (60 per 30 days) escitalopram oxalate oral tablet 20 mg $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) escitalopram oxalate oral tablet 5 mg $0-$7.40 (Tier 2) MO; QLL (120 per 30 days) ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 51 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso FANAPT ORAL TABLET 1 MG $0-$7.40 (Tier 2) ST; MO; QLL (720 per 30 days) FANAPT ORAL TABLET 10 MG $0-$7.40 (Tier 2) ST; MO; QLL (72 per 30 days) FANAPT ORAL TABLET 12 MG $0-$7.40 (Tier 2) ST; MO; QLL (60 per 30 days) FANAPT ORAL TABLET 2 MG $0-$7.40 (Tier 2) ST; MO; QLL (360 per 30 days) FANAPT ORAL TABLET 4 MG $0-$7.40 (Tier 2) ST; MO; QLL (180 per 30 days) FANAPT ORAL TABLET 6 MG $0-$7.40 (Tier 2) ST; MO; QLL (120 per 30 days) FANAPT ORAL TABLET 8 MG $0-$7.40 (Tier 2) ST; MO; QLL (90 per 30 days) FANAPT ORAL TABLETS,DOSE PACK $0-$7.40 (Tier 2) ST; MO; QLL (16 per 365 days) FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK $0-$7.40 (Tier 2) PAR; MO; QLL (56 per 365 days) FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 80 MG $0-$7.40 (Tier 2) PAR; MO; QLL (30 per 30 days) FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 20 MG $0-$7.40 (Tier 2) PAR; MO; QLL (180 per 30 days) FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 40 MG $0-$7.40 (Tier 2) PAR; MO; QLL (90 per 30 days) fluoxetine oral capsule 10 mg $0-$7.40 (Tier 2) MO; QLL (240 per 30 days) fluoxetine oral capsule 20 mg $0-$7.40 (Tier 2) MO; QLL (120 per 30 days) fluoxetine oral capsule 40 mg $0-$7.40 (Tier 2) MO; QLL (60 per 30 days) fluoxetine oral solution $0-$7.40 (Tier 2) MO; QLL (600 per 30 days) fluoxetine oral tablet 10 mg $0-$7.40 (Tier 2) MO; QLL (240 per 30 days) fluoxetine oral tablet 20 mg $0-$7.40 (Tier 2) MO; QLL (120 per 30 days) fluphenazine decanoate $0 (Tier 1) MO fluphenazine hcl $0 (Tier 1) MO fluvoxamine oral tablet 100 mg $0-$7.40 (Tier 2) MO; QLL (90 per 30 days) fluvoxamine oral tablet 25 mg $0-$7.40 (Tier 2) MO; QLL (360 per 30 days) fluvoxamine oral tablet 50 mg $0-$7.40 (Tier 2) MO; QLL (180 per 30 days) GEODON INTRAMUSCULAR $0-$7.40 (Tier 2) MO guanfacine oral tablet extended release 24 hr $0-$7.40 (Tier 2) PAR; MO; QLL (30 per 30 days) guanidine $0-$7.40 (Tier 2) MO B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 52 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso haloperidol $0 (Tier 1) MO haloperidol decanoate $0 (Tier 1) MO haloperidol lactate $0 (Tier 1) MO HETLIOZ $0-$7.40 (Tier 2) PAR; MO; QLL (30 per 30 days) imipramine hcl $0-$7.40 (Tier 2) PAR; MO INVEGA ORAL TABLET EXTENDED RELEASE 24HR 1.5 MG $0-$7.40 (Tier 2) PAR; MO; QLL (240 per 30 days) INVEGA ORAL TABLET EXTENDED RELEASE 24HR 3 MG $0-$7.40 (Tier 2) PAR; MO; QLL (120 per 30 days) INVEGA ORAL TABLET EXTENDED RELEASE 24HR 6 MG $0-$7.40 (Tier 2) PAR; MO; QLL (60 per 30 days) INVEGA ORAL TABLET EXTENDED RELEASE 24HR 9 MG $0-$7.40 (Tier 2) PAR; MO; QLL (30 per 30 days) INVEGA SUSTENNA $0-$7.40 (Tier 2) MO; QLL (2 per 28 days) INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML $0-$7.40 (Tier 2) QLL (0.875 per 90 days) INVEGA TRINZA INTRAMUSCULAR SYRINGE 410 MG/1.315 ML $0-$7.40 (Tier 2) QLL (1.315 per 90 days) INVEGA TRINZA INTRAMUSCULAR SYRINGE 546 MG/1.75 ML $0-$7.40 (Tier 2) QLL (1.75 per 90 days) INVEGA TRINZA INTRAMUSCULAR SYRINGE 819 MG/2.625 ML $0-$7.40 (Tier 2) QLL (2.625 per 90 days) KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 100 MG $0-$7.40 (Tier 2) MO; QLL (120 per 30 days) KHEDEZLA ORAL TABLET EXTENDED RELEASE 24HR 50 MG $0-$7.40 (Tier 2) MO; QLL (240 per 30 days) LATUDA ORAL TABLET 120 MG $0-$7.40 (Tier 2) PAR; MO; QLL (30 per 30 days) LATUDA ORAL TABLET 20 MG $0-$7.40 (Tier 2) PAR; MO; QLL (240 per 30 days) LATUDA ORAL TABLET 40 MG $0-$7.40 (Tier 2) PAR; MO; QLL (120 per 30 days) LATUDA ORAL TABLET 60 MG $0-$7.40 (Tier 2) PAR; MO; QLL (75 per 30 days) LATUDA ORAL TABLET 80 MG $0-$7.40 (Tier 2) PAR; MO; QLL (60 per 30 days) lithium carbonate ? $0 (Tier 1) MO Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 53 Nombre del medicamento lithium citrate oral solution 8 meq/5 ml Qué le costará el medicamento (nivel de clase) $0 (Tier 1) Acciones necesarias, restricciones, o límites sobre el uso MO lorazepam oral tablet $0-$7.40 (Tier 2) MO; QLL (90 per 30 days) loxapine succinate $0-$7.40 (Tier 2) MO maprotiline oral tablet 25 mg $0-$7.40 (Tier 2) MO; QLL (270 per 30 days) maprotiline oral tablet 50 mg $0-$7.40 (Tier 2) MO; QLL (135 per 30 days) maprotiline oral tablet 75 mg $0-$7.40 (Tier 2) MO MARPLAN $0-$7.40 (Tier 2) MO methylphenidate oral tablet $0-$7.40 (Tier 2) MO; QLL (90 per 30 days) mirtazapine oral tablet 15 mg $0-$7.40 (Tier 2) MO; QLL (90 per 30 days) mirtazapine oral tablet 30 mg $0-$7.40 (Tier 2) MO; QLL (45 per 30 days) mirtazapine oral tablet 45 mg $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) mirtazapine oral tablet 7.5 mg $0-$7.40 (Tier 2) MO; QLL (180 per 30 days) mirtazapine oral tablet,disintegrating 15 mg $0-$7.40 (Tier 2) MO; QLL (90 per 30 days) mirtazapine oral tablet,disintegrating 30 mg $0-$7.40 (Tier 2) MO; QLL (45 per 30 days) mirtazapine oral tablet,disintegrating 45 mg $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) modafinil oral tablet 100 mg $0-$7.40 (Tier 2) PAR; MO; QLL (30 per 30 days) modafinil oral tablet 200 mg $0-$7.40 (Tier 2) PAR; MO; QLL (60 per 30 days) nefazodone oral tablet 100 mg $0-$7.40 (Tier 2) MO; QLL (180 per 30 days) nefazodone oral tablet 150 mg $0-$7.40 (Tier 2) MO; QLL (120 per 30 days) nefazodone oral tablet 200 mg $0-$7.40 (Tier 2) MO; QLL (90 per 30 days) nefazodone oral tablet 250 mg $0-$7.40 (Tier 2) MO; QLL (72 per 30 days) nefazodone oral tablet 50 mg $0-$7.40 (Tier 2) MO; QLL (360 per 30 days) nortriptyline $0-$7.40 (Tier 2) MO olanzapine intramuscular $0 (Tier 1) MO; QLL (60 per 30 days) olanzapine oral tablet 10 mg $0 (Tier 1) MO; QLL (60 per 30 days) olanzapine oral tablet 15 mg $0 (Tier 1) MO; QLL (40 per 30 days) olanzapine oral tablet 2.5 mg $0 (Tier 1) MO; QLL (240 per 30 days) olanzapine oral tablet 20 mg $0 (Tier 1) MO; QLL (30 per 30 days) B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 54 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso olanzapine oral tablet 5 mg $0 (Tier 1) MO; QLL (120 per 30 days) olanzapine oral tablet 7.5 mg $0 (Tier 1) MO; QLL (80 per 30 days) olanzapine oral tablet,disintegrating 10 mg $0 (Tier 1) MO; QLL (60 per 30 days) olanzapine oral tablet,disintegrating 15 mg $0 (Tier 1) MO; QLL (40 per 30 days) olanzapine oral tablet,disintegrating 20 mg $0 (Tier 1) MO; QLL (30 per 30 days) olanzapine oral tablet,disintegrating 5 mg $0 (Tier 1) MO; QLL (120 per 30 days) ORAP $0-$7.40 (Tier 2) MO paroxetine hcl oral tablet 10 mg $0-$7.40 (Tier 2) MO; QLL (180 per 30 days) paroxetine hcl oral tablet 20 mg $0-$7.40 (Tier 2) MO; QLL (90 per 30 days) paroxetine hcl oral tablet 30 mg $0-$7.40 (Tier 2) MO; QLL (60 per 30 days) paroxetine hcl oral tablet 40 mg $0-$7.40 (Tier 2) MO; QLL (45 per 30 days) paroxetine hcl oral tablet extended release 24 hr 12.5 mg $0-$7.40 (Tier 2) MO; QLL (180 per 30 days) paroxetine hcl oral tablet extended release 24 hr 25 mg $0-$7.40 (Tier 2) MO; QLL (90 per 30 days) paroxetine hcl oral tablet extended release 24 hr 37.5 mg $0-$7.40 (Tier 2) MO; QLL (60 per 30 days) PAXIL ORAL SUSPENSION $0-$7.40 (Tier 2) MO; QLL (900 per 30 days) perphenazine $0 (Tier 1) MO phenelzine $0 (Tier 1) MO $0-$7.40 (Tier 2) MO protriptyline quetiapine oral tablet 100 mg $0 (Tier 1) PAR; MO; QLL (240 per 30 days) quetiapine oral tablet 200 mg $0 (Tier 1) PAR; MO; QLL (120 per 30 days) quetiapine oral tablet 25 mg $0 (Tier 1) PAR; MO; QLL (960 per 30 days) quetiapine oral tablet 300 mg $0 (Tier 1) PAR; MO; QLL (80 per 30 days) quetiapine oral tablet 400 mg $0 (Tier 1) PAR; MO; QLL (60 per 30 days) quetiapine oral tablet 50 mg $0 (Tier 1) PAR; MO; QLL (480 per 30 days) RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 12.5 MG/2 ML, 25 MG/2 ML, 37.5 MG/2 ML ? $0-$7.40 (Tier 2) MO; QLL (2 per 28 days) Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 55 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 50 MG/2 ML $0-$7.40 (Tier 2) MO risperidone oral solution $0 (Tier 1) MO; QLL (480 per 30 days) risperidone oral tablet 0.25 mg $0 (Tier 1) MO; QLL (1920 per 30 days) risperidone oral tablet 0.5 mg $0 (Tier 1) MO; QLL (960 per 30 days) risperidone oral tablet 1 mg $0 (Tier 1) MO; QLL (480 per 30 days) risperidone oral tablet 2 mg $0 (Tier 1) MO; QLL (240 per 30 days) risperidone oral tablet 3 mg $0 (Tier 1) MO; QLL (150 per 30 days) risperidone oral tablet 4 mg $0 (Tier 1) MO; QLL (120 per 30 days) risperidone oral tablet,disintegrating 0.25 mg $0 (Tier 1) MO; QLL (1920 per 30 days) risperidone oral tablet,disintegrating 0.5 mg $0 (Tier 1) MO; QLL (960 per 30 days) risperidone oral tablet,disintegrating 1 mg $0 (Tier 1) MO; QLL (480 per 30 days) risperidone oral tablet,disintegrating 2 mg $0 (Tier 1) MO; QLL (240 per 30 days) risperidone oral tablet,disintegrating 3 mg $0 (Tier 1) MO; QLL (150 per 30 days) risperidone oral tablet,disintegrating 4 mg $0 (Tier 1) MO; QLL (120 per 30 days) ROZEREM $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 10 MG $0-$7.40 (Tier 2) PAR; MO; QLL (60 per 30 days) SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 2.5 MG $0-$7.40 (Tier 2) PAR; QLL (240 per 30 days) SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET 5 MG $0-$7.40 (Tier 2) PAR; MO; QLL (120 per 30 days) SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG $0-$7.40 (Tier 2) PAR; MO; QLL (150 per 30 days) SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 200 MG $0-$7.40 (Tier 2) PAR; MO; QLL (120 per 30 days) SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 300 MG $0-$7.40 (Tier 2) PAR; MO; QLL (80 per 30 days) SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 400 MG $0-$7.40 (Tier 2) PAR; MO; QLL (60 per 30 days) B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 56 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 50 MG $0-$7.40 (Tier 2) PAR; MO; QLL (480 per 30 days) sertraline oral concentrate $0-$7.40 (Tier 2) MO; QLL (300 per 30 days) sertraline oral tablet 100 mg $0 (Tier 1) MO; QLL (60 per 30 days) sertraline oral tablet 25 mg $0 (Tier 1) MO; QLL (240 per 30 days) sertraline oral tablet 50 mg $0 (Tier 1) MO; QLL (120 per 30 days) STRATTERA ORAL CAPSULE 10 MG, 18 MG, 25 MG, 40 MG $0-$7.40 (Tier 2) PAR; MO; QLL (60 per 30 days) STRATTERA ORAL CAPSULE 100 MG, 60 MG, 80 MG $0-$7.40 (Tier 2) PAR; MO; QLL (30 per 30 days) SURMONTIL $0-$7.40 (Tier 2) PAR; MO temazepam oral capsule 15 mg, 22.5 mg, 30 mg $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) thioridazine $0 (Tier 1) PAR; MO thiothixene $0 (Tier 1) MO tranylcypromine $0-$7.40 (Tier 2) MO trazodone $0-$7.40 (Tier 2) MO $0 (Tier 1) MO trifluoperazine venlafaxine oral capsule,extended release 24hr 150 mg $0-$7.40 (Tier 2) MO; QLL (60 per 30 days) venlafaxine oral capsule,extended release 24hr 37.5 mg $0-$7.40 (Tier 2) MO; QLL (180 per 30 days) venlafaxine oral capsule,extended release 24hr 75 mg $0-$7.40 (Tier 2) MO; QLL (90 per 30 days) venlafaxine oral tablet 100 mg $0-$7.40 (Tier 2) MO; QLL (113 per 30 days) venlafaxine oral tablet 25 mg $0-$7.40 (Tier 2) MO; QLL (450 per 30 days) venlafaxine oral tablet 37.5 mg $0-$7.40 (Tier 2) MO; QLL (300 per 30 days) venlafaxine oral tablet 50 mg $0-$7.40 (Tier 2) MO; QLL (225 per 30 days) venlafaxine oral tablet 75 mg $0-$7.40 (Tier 2) MO; QLL (150 per 30 days) venlafaxine oral tablet extended release 24hr 150 mg $0-$7.40 (Tier 2) MO; QLL (60 per 30 days) venlafaxine oral tablet extended release 24hr 37.5 mg $0-$7.40 (Tier 2) MO; QLL (180 per 30 days) ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 57 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso venlafaxine oral tablet extended release 24hr 75 mg $0-$7.40 (Tier 2) MO; QLL (90 per 30 days) VERSACLOZ $0-$7.40 (Tier 2) LA; QLL (600 per 30 days) VIIBRYD ORAL TABLET 10 MG $0-$7.40 (Tier 2) ST; MO; QLL (120 per 30 days) VIIBRYD ORAL TABLET 20 MG $0-$7.40 (Tier 2) ST; MO; QLL (60 per 30 days) VIIBRYD ORAL TABLET 40 MG $0-$7.40 (Tier 2) ST; MO; QLL (30 per 30 days) VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)-20 MG (7)-40 MG (16) $0-$7.40 (Tier 2) ST; MO; QLL (30 per 30 days) XYREM $0-$7.40 (Tier 2) PAR; MO; LA; QLL (540 per 30 days) zaleplon oral capsule 10 mg $0-$7.40 (Tier 2) PAR; MO; QLL (60 per 30 days) zaleplon oral capsule 5 mg $0-$7.40 (Tier 2) PAR; MO; QLL (30 per 30 days) zenzedi oral tablet 10 mg $0-$7.40 (Tier 2) PAR; MO; QLL (180 per 30 days) zenzedi oral tablet 5 mg $0-$7.40 (Tier 2) PAR; MO; QLL (90 per 30 days) ziprasidone hcl oral capsule 20 mg $0 (Tier 1) MO; QLL (240 per 30 days) ziprasidone hcl oral capsule 40 mg $0 (Tier 1) MO; QLL (120 per 30 days) ziprasidone hcl oral capsule 60 mg, 80 mg $0 (Tier 1) MO; QLL (60 per 30 days) zolpidem oral tablet $0-$7.40 (Tier 2) PAR; MO; QLL (30 per 30 days) ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG, 405 MG $0-$7.40 (Tier 2) PAR; LA; QLL (2 per 28 days) ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 300 MG $0-$7.40 (Tier 2) PAR; MO; LA; QLL (2 per 28 days) CARDIOVASCULAR, HYPERTENSION / LIPIDS 3B ANTIARRHYTHMIC AGENTS 37B amiodarone intravenous solution $0-$7.40 (Tier 2) B/D PAR; MO amiodarone intravenous syringe $0-$7.40 (Tier 2) B/D PAR amiodarone oral $0-$7.40 (Tier 2) MO B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 58 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso flecainide $0-$7.40 (Tier 2) MO lidocaine (pf) intravenous solution $0-$7.40 (Tier 2) MO lidocaine (pf) intravenous syringe 100 mg/5 ml (2 %), 50 mg/5 ml (1 %) $0-$7.40 (Tier 2) mexiletine $0-$7.40 (Tier 2) MO MULTAQ $0-$7.40 (Tier 2) MO; QLL (60 per 30 days) pacerone oral tablet 100 mg, 200 mg, 400 mg $0-$7.40 (Tier 2) MO procainamide injection solution 100 mg/ml $0-$7.40 (Tier 2) MO procainamide injection solution 500 mg/ml $0-$7.40 (Tier 2) propafenone oral tablet $0-$7.40 (Tier 2) MO quinidine sulfate tablets $0-$7.40 (Tier 2) MO sorine oral tablet 120 mg, 160 mg, 80 mg $0-$7.40 (Tier 2) MO sorine oral tablet 240 mg $0-$7.40 (Tier 2) sotalol af $0-$7.40 (Tier 2) MO sotalol oral $0-$7.40 (Tier 2) MO TIKOSYN $0-$7.40 (Tier 2) MO acebutolol oral $0-$7.40 (Tier 2) MO afeditab cr $0-$7.40 (Tier 2) MO amiloride oral $0-$7.40 (Tier 2) MO amiloride-hydrochlorothiazide $0-$7.40 (Tier 2) MO ANTIHYPERTENSIVE THERAPY 38B amlodipine oral tablet 10 mg, 2.5 mg $0 (Tier 1) MO; QLL (30 per 30 days) amlodipine oral tablet 5 mg $0 (Tier 1) MO; QLL (45 per 30 days) amlodipine-benazepril $0 (Tier 1) MO amlodipine-valsartan $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) amlodipine-valsartan-hcthiazid $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) atenolol $0-$7.40 (Tier 2) MO atenolol-chlorthalidone $0-$7.40 (Tier 2) MO AZOR $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 59 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso benazepril $0 (Tier 1) MO benazepril-hydrochlorothiazide $0 (Tier 1) MO betaxolol oral $0-$7.40 (Tier 2) MO bisoprolol fumarate $0-$7.40 (Tier 2) MO bisoprolol-hydrochlorothiazide $0-$7.40 (Tier 2) MO bumetanide $0-$7.40 (Tier 2) MO BYSTOLIC $0-$7.40 (Tier 2) MO candesartan oral tablet 16 mg, 4 mg, 8 mg $0 (Tier 1) MO; QLL (60 per 30 days) candesartan oral tablet 32 mg $0 (Tier 1) MO; QLL (30 per 30 days) candesartan-hydrochlorothiazid oral tablet 1612.5 mg $0 (Tier 1) MO; QLL (60 per 30 days) candesartan-hydrochlorothiazid oral tablet 3212.5 mg, 32-25 mg $0 (Tier 1) MO; QLL (30 per 30 days) captopril $0 (Tier 1) MO captopril-hydrochlorothiazide $0 (Tier 1) MO $0-$7.40 (Tier 2) MO $0 (Tier 1) MO chlorothiazide $0-$7.40 (Tier 2) MO chlorothiazide sodium $0-$7.40 (Tier 2) MO chlorthalidone oral tablet 25 mg, 50 mg $0-$7.40 (Tier 2) MO clonidine hcl oral tablet $0-$7.40 (Tier 2) MO clonidine patches $0-$7.40 (Tier 2) MO; QLL (4 per 28 days) COREG CR $0-$7.40 (Tier 2) ST; MO DEMSER $0-$7.40 (Tier 2) MO diltiazem hcl intravenous recon soln $0-$7.40 (Tier 2) B/D PAR diltiazem hcl intravenous solution $0-$7.40 (Tier 2) diltiazem hcl oral capsule, extended release $0-$7.40 (Tier 2) MO diltiazem hcl oral capsule,ext release degradable $0-$7.40 (Tier 2) MO diltiazem hcl oral capsule,extended release 12 hr $0-$7.40 (Tier 2) MO cartia xt carvedilol B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 60 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso diltiazem hcl oral capsule,extended release 24hr $0-$7.40 (Tier 2) MO diltiazem hcl oral tablet $0-$7.40 (Tier 2) MO diltiazem hcl oral tablet extended release 24 hr 180 mg, 300 mg, 420 mg $0-$7.40 (Tier 2) diltiazem hcl oral tablet extended release 24 hr 240 mg, 360 mg $0-$7.40 (Tier 2) MO dilt-xr $0-$7.40 (Tier 2) MO doxazosin $0-$7.40 (Tier 2) MO enalapril maleate $0 (Tier 1) MO enalapril-hydrochlorothiazide $0 (Tier 1) MO eplerenone $0-$7.40 (Tier 2) MO eprosartan $0 (Tier 1) felodipine er MO; QLL (30 per 30 days) $0-$7.40 (Tier 2) MO fosinopril $0 (Tier 1) MO fosinopril-hydrochlorothiazide $0 (Tier 1) MO furosemide injection $0-$7.40 (Tier 2) MO furosemide oral solution 10 mg/ml, 40 mg/5 ml $0-$7.40 (Tier 2) MO $0 (Tier 1) MO $0-$7.40 (Tier 2) MO $0 (Tier 1) MO indapamide $0-$7.40 (Tier 2) MO irbesartan $0 (Tier 1) MO; QLL (30 per 30 days) irbesartan-hydrochlorothiazide oral tablet 15012.5 mg $0 (Tier 1) MO; QLL (60 per 30 days) irbesartan-hydrochlorothiazide oral tablet 30012.5 mg $0 (Tier 1) MO; QLL (30 per 30 days) furosemide oral tablet hydralazine hydrochlorothiazide isradipine $0-$7.40 (Tier 2) MO labetalol intravenous solution $0-$7.40 (Tier 2) MO labetalol oral $0-$7.40 (Tier 2) MO lisinopril $0 (Tier 1) MO lisinopril-hydrochlorothiazide $0 (Tier 1) MO ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 61 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso losartan oral tablet 100 mg $0 (Tier 1) MO; QLL (30 per 30 days) losartan oral tablet 25 mg, 50 mg $0 (Tier 1) MO; QLL (60 per 30 days) losartan-hydrochlorothiazide $0 (Tier 1) MO; QLL (30 per 30 days) methyclothiazide $0-$7.40 (Tier 2) MO metolazone $0-$7.40 (Tier 2) MO $0 (Tier 1) MO metoprolol ta-hydrochlorothiaz $0-$7.40 (Tier 2) MO metoprolol tartrate intravenous solution $0-$7.40 (Tier 2) MO metoprolol tartrate intravenous syringe $0-$7.40 (Tier 2) metoprolol succinate metoprolol tartrate oral $0 (Tier 1) MO $0-$7.40 (Tier 2) MO moexipril $0 (Tier 1) MO moexipril-hydrochlorothiazide $0 (Tier 1) MO nadolol $0-$7.40 (Tier 2) MO nadolol-bendroflumethiazide $0-$7.40 (Tier 2) MO nicardipine $0-$7.40 (Tier 2) MO nifedical xl $0-$7.40 (Tier 2) MO nifedipine oral tablet extended release $0-$7.40 (Tier 2) MO nifedipine oral tablet extended release 24hr $0-$7.40 (Tier 2) MO nimodipine $0-$7.40 (Tier 2) MO $0 (Tier 1) MO pindolol $0-$7.40 (Tier 2) MO prazosin oral $0-$7.40 (Tier 2) MO propranolol intravenous $0-$7.40 (Tier 2) propranolol oral $0-$7.40 (Tier 2) MO propranolol-hydrochlorothiazid $0-$7.40 (Tier 2) MO quinapril $0 (Tier 1) MO quinapril-hydrochlorothiazide $0 (Tier 1) MO minoxidil oral perindopril erbumine B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 62 Nombre del medicamento ramipril Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso $0 (Tier 1) MO spironolactone $0-$7.40 (Tier 2) MO spironolacton-hydrochlorothiaz $0-$7.40 (Tier 2) MO taztia xt $0-$7.40 (Tier 2) MO TEKTURNA $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) TEKTURNA HCT $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) telmisartan oral tablet 20 mg, 40 mg $0 (Tier 1) MO; QLL (30 per 30 days) telmisartan oral tablet 80 mg $0 (Tier 1) MO; QLL (60 per 30 days) telmisartan-amlodipine $0 (Tier 1) MO; QLL (30 per 30 days) telmisartan-hydrochlorothiazid oral tablet 40-12.5 mg, 80-25 mg $0 (Tier 1) MO; QLL (30 per 30 days) telmisartan-hydrochlorothiazid oral tablet 80-12.5 mg $0 (Tier 1) MO; QLL (60 per 30 days) terazosin $0-$7.40 (Tier 2) MO timolol maleate oral $0-$7.40 (Tier 2) MO torsemide oral $0-$7.40 (Tier 2) MO $0 (Tier 1) MO triamterene-hydrochlorothiazid oral capsule 37.525 mg $0-$7.40 (Tier 2) MO triamterene-hydrochlorothiazid oral tablet $0-$7.40 (Tier 2) MO TRIBENZOR $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) valsartan oral tablet 160 mg $0-$7.40 (Tier 2) MO; QLL (60 per 30 days) valsartan oral tablet 320 mg $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) valsartan oral tablet 40 mg, 80 mg $0-$7.40 (Tier 2) MO; QLL (90 per 30 days) valsartan-hydrochlorothiazide $0 (Tier 1) MO; QLL (30 per 30 days) verapamil intravenous solution $0-$7.40 (Tier 2) verapamil intravenous syringe $0-$7.40 (Tier 2) verapamil oral $0-$7.40 (Tier 2) MO $0-$7.40 (Tier 2) MO trandolapril MO CARDIAC GLYCOSIDES 39B DIGITEK ORAL TABLET 125 MCG ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 63 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso digox oral tablet 125 mcg $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) digoxin oral solution 50 mcg/ml $0-$7.40 (Tier 2) MO digoxin oral tablet 125 mcg $0-$7.40 (Tier 2) MO LANOXIN ORAL TABLET 125 MCG $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) LANOXIN ORAL TABLET 62.5 MCG $0-$7.40 (Tier 2) MO AGGRENOX $0-$7.40 (Tier 2) ST; MO; QLL (60 per 30 days) BRILINTA $0-$7.40 (Tier 2) MO; QLL (60 per 30 days) cilostazol $0-$7.40 (Tier 2) MO COAGULATION THERAPY 40B clopidogrel oral tablet 300 mg $0 (Tier 1) MO; QLL (1 per 30 days) clopidogrel oral tablet 75 mg $0 (Tier 1) MO; QLL (30 per 30 days) COUMADIN ORAL $0-$7.40 (Tier 2) MO EFFIENT $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) ELIQUIS $0-$7.40 (Tier 2) MO; QLL (60 per 30 days) enoxaparin subcutaneous solution $0-$7.40 (Tier 2) MO; QLL (84 per 30 days) enoxaparin subcutaneous syringe 100 mg/ml, 150 mg/ml $0-$7.40 (Tier 2) MO; QLL (28 per 30 days) enoxaparin subcutaneous syringe 120 mg/0.8 ml, 80 mg/0.8 ml $0-$7.40 (Tier 2) MO; QLL (22.4 per 30 days) enoxaparin subcutaneous syringe 30 mg/0.3 ml $0-$7.40 (Tier 2) MO; QLL (8.4 per 30 days) enoxaparin subcutaneous syringe 40 mg/0.4 ml $0-$7.40 (Tier 2) MO; QLL (11.2 per 30 days) enoxaparin subcutaneous syringe 60 mg/0.6 ml $0-$7.40 (Tier 2) MO; QLL (16.8 per 30 days) fondaparinux subcutaneous syringe 10 mg/0.8 ml $0-$7.40 (Tier 2) MO; QLL (24 per 30 days) fondaparinux subcutaneous syringe 2.5 mg/0.5 ml $0-$7.40 (Tier 2) MO; QLL (15 per 30 days) fondaparinux subcutaneous syringe 5 mg/0.4 ml $0-$7.40 (Tier 2) MO; QLL (12 per 30 days) fondaparinux subcutaneous syringe 7.5 mg/0.6 ml $0-$7.40 (Tier 2) MO; QLL (18 per 30 days) heparin (porcine) in 5 % dex intravenous parenteral solution 12,500 unit/250 ml, 25,000 unit/250 ml(100 unit/ml) $0-$7.40 (Tier 2) B/D PAR B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 64 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso heparin (porcine) in 5 % dex intravenous parenteral solution 25,000 unit/500 ml (50 unit/ml) $0-$7.40 (Tier 2) B/D PAR; MO heparin (porcine) in nacl (pf) intravenous parenteral solution 1,000 unit/500 ml, 2,000 unit/1,000 ml $0-$7.40 (Tier 2) B/D PAR heparin (porcine) injection cartridge $0-$7.40 (Tier 2) B/D PAR; MO heparin (porcine) injection solution $0-$7.40 (Tier 2) B/D PAR; MO HEPARIN(PORCINE) IN 0.45% NACL INTRAVENOUS PARENTERAL SOLUTION 12,500 UNIT/250 ML $0-$7.40 (Tier 2) B/D PAR heparin(porcine) in 0.45% nacl intravenous parenteral solution 25,000 unit/250 ml, 25,000 unit/500 ml $0-$7.40 (Tier 2) B/D PAR heparin, porcine (pf) injection $0-$7.40 (Tier 2) B/D PAR; MO jantoven $0-$7.40 (Tier 2) MO MEPHYTON $0 (Tier 3) MO; [*] pentoxifylline $0-$7.40 (Tier 2) MO PRADAXA $0-$7.40 (Tier 2) MO; QLL (60 per 30 days) PROMACTA ORAL TABLET 12.5 MG, 25 MG, 75 MG $0-$7.40 (Tier 2) PAR; MO; LA; QLL (30 per 30 days) PROMACTA ORAL TABLET 50 MG $0-$7.40 (Tier 2) PAR; MO; LA; QLL (60 per 30 days) tranexamic acid intravenous $0-$7.40 (Tier 2) MO vitamin k injection $0 (Tier 3) MO; [*] vitamin k1 injection $0 (Tier 3) MO; [*] warfarin $0 (Tier 1) MO XARELTO ORAL TABLET 10 MG, 20 MG $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) XARELTO ORAL TABLET 15 MG $0-$7.40 (Tier 2) MO; QLL (42 per 30 days) XARELTO ORAL TABLETS,DOSE PACK $0-$7.40 (Tier 2) MO; QLL (102 per 365 days) $0-$7.40 (Tier 2) PAR; MO; QLL (30 per 30 days) LIPID/CHOLESTEROL LOWERING AGENTS 41B ALTOPREV amlodipine-atorvastatin ? $0 (Tier 1) MO; QLL (30 per 30 days) Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 65 Nombre del medicamento Qué le costará el medicamento (nivel de clase) atorvastatin $0 (Tier 1) Acciones necesarias, restricciones, o límites sobre el uso MO; QLL (30 per 30 days) cholestyramine (with sugar) $0-$7.40 (Tier 2) MO cholestyramine light $0-$7.40 (Tier 2) MO colestipol $0-$7.40 (Tier 2) MO CRESTOR $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) fenofibrate nanocrystallized 48 mg, 145 mg $0-$7.40 (Tier 2) MO fenofibrate oral tablet 160 mg, 54 mg $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) gemfibrozil oral $0-$7.40 (Tier 2) MO JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 5 MG $0-$7.40 (Tier 2) PAR; MO; LA lovastatin oral tablet 10 mg, 20 mg $0 (Tier 1) MO; QLL (30 per 30 days) lovastatin oral tablet 40 mg $0 (Tier 1) MO; QLL (60 per 30 days) niacin oral tablet extended release 24 hr 1,000 mg, 750 mg $0-$7.40 (Tier 2) MO; QLL (60 per 30 days) niacin oral tablet extended release 24 hr 500 mg $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) NIACOR $0-$7.40 (Tier 2) MO omega-3 acid ethyl esters $0-$7.40 (Tier 2) PAR; MO pravastatin prevalite $0 (Tier 1) $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) MO simvastatin $0 (Tier 1) WELCHOL $0-$7.40 (Tier 2) MO ZETIA $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) MO; QLL (30 per 30 days) MISCELLANEOUS CARDIOVASCULAR AGENTS 42B RANEXA $0-$7.40 (Tier 2) VECAMYL $0-$7.40 (Tier 2) PAR; MO B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 66 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso isosorbide dinitrate oral $0-$7.40 (Tier 2) MO isosorbide mononitrate $0-$7.40 (Tier 2) MO nitro-bid $0-$7.40 (Tier 2) MO nitroglycerin intravenous $0-$7.40 (Tier 2) B/D PAR nitroglycerin transdermal patch 24 hour $0-$7.40 (Tier 2) MO NITROSTAT $0-$7.40 (Tier 2) MO acitretin $0-$7.40 (Tier 2) MO calcipotriene topical cream $0-$7.40 (Tier 2) MO; QLL (120 per 30 days) calcipotriene topical ointment $0-$7.40 (Tier 2) MO; QLL (120 per 30 days) calcipotriene topical solution $0-$7.40 (Tier 2) MO; QLL (60 per 30 days) selenium sulfide topical suspension $0-$7.40 (Tier 2) MO silver sulfadiazine $0-$7.40 (Tier 2) MO ssd $0-$7.40 (Tier 2) MO callus remover $0 (Tier 4) [*] callus removers $0 (Tier 4) [*] corn remover $0 (Tier 4) [*] dr scholl's clear away $0 (Tier 4) [*] mediplast corn-callus-wart $0 (Tier 4) MO; [*] mosco corn remover $0 (Tier 4) [*] one-step plantar wart remover $0 (Tier 4) [*] one-step wart remover $0 (Tier 4) [*] NITRATES 43B DERMATOLOGICALS/TOPICAL THERAPY 4B ANTIPSORIATIC / ANTISEBORRHEIC 4B BURN THERAPY 45B KERATOLYTICS 46B ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 67 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso plantar wart remover $0 (Tier 4) [*] wart remover topical adhesive patch,medicated $0 (Tier 4) [*] $0 (Tier 4) MO; [*] MISCELLANEOUS DERMATOLOGICALS 47B a + d (lan, pet) ammonium lactate topical $0-$7.40 (Tier 2) MO ARCTIC RELIEF $0 (Tier 4) [*] CHEST RUB $0 (Tier 4) [*] ELIDEL $0-$7.40 (Tier 2) PAR; MO; QLL (100 per 90 days) fluorouracil topical cream 5 % $0-$7.40 (Tier 2) MO fluorouracil topical solution $0-$7.40 (Tier 2) MO imiquimod $0-$7.40 (Tier 2) MO methoxsalen rapid $0-$7.40 (Tier 2) PAR; MO OXSORALEN $0-$7.40 (Tier 2) MO PANRETIN $0-$7.40 (Tier 2) MO podofilox $0-$7.40 (Tier 2) MO tacrolimus topical $0-$7.40 (Tier 2) PAR; MO; QLL (100 per 90 days) U-CORT $0-$7.40 (Tier 2) MO UVADEX $0-$7.40 (Tier 2) VALCHLOR $0-$7.40 (Tier 2) MO VAPORX BALM $0 (Tier 4) [*] vitamin a & d diaper rash $0 (Tier 4) [*] vitamin a and d $0 (Tier 4) [*] vits a and d-white pet-lanolin topical ointment $0 (Tier 4) MO; [*] ZIKS ARTHRITIS PAIN RELIEF $0 (Tier 4) [*] zinc oxide topical ointment 20 % $0 (Tier 4) MO; [*] $0 (Tier 4) [*] THERAPY FOR ACNE 48B acne control cleanser B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 68 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso acne cream $0 (Tier 4) [*] acne foaming wash $0 (Tier 4) [*] acne treatment (benzoyl perox) $0 (Tier 4) [*] acne-clear $0 (Tier 4) [*] adapalene topical gel 0.3 % $0-$7.40 (Tier 2) MO adapalene topical gel with pump $0-$7.40 (Tier 2) MO amnesteem $0-$7.40 (Tier 2) MO benzoyl peroxide topical cleanser 10 %, 5 %, 6 % $0 (Tier 4) MO; [*] benzoyl peroxide topical gel 10 %, 2.5 %, 5 % $0 (Tier 4) MO; [*] benzoyl peroxide topical lotion 10 % $0 (Tier 4) MO; [*] bp topical gel $0 (Tier 4) [*] bp wash topical cleanser 10 %, 5 % $0 (Tier 4) MO; [*] bpo-10 $0 (Tier 4) [*] bpo-5 $0 (Tier 4) [*] clindamycin phosphate topical $0-$7.40 (Tier 2) MO ery pads $0-$7.40 (Tier 2) MO erythromycin with ethanol $0-$7.40 (Tier 2) MO erythromycin-benzoyl peroxide $0-$7.40 (Tier 2) MO foaming acne face wash $0 (Tier 4) [*] invisible acne $0 (Tier 4) [*] metronidazole topical cream $0-$7.40 (Tier 2) MO metronidazole topical gel 0.75 % $0-$7.40 (Tier 2) MO metronidazole topical lotion $0-$7.40 (Tier 2) MO panoxyl topical cleanser $0 (Tier 4) MO; [*] panoxyl-4 $0 (Tier 4) MO; [*] persa-gel $0 (Tier 4) [*] rosadan topical cream $0-$7.40 (Tier 2) MO TAZORAC $0-$7.40 (Tier 2) PAR; MO tretinoin topical $0-$7.40 (Tier 2) MO; QLL (45 per 30 days) ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 69 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso TRETIN-X CREAM KIT $0-$7.40 (Tier 2) MO; QLL (1 per 30 days) TOPICAL ANESTHETICS 49B lidocaine (pf) injection solution 15 mg/ml (1.5 %) $0-$7.40 (Tier 2) LIDOCAINE (PF) INJECTION SOLUTION 20 MG/ML (2 %) $0-$7.40 (Tier 2) MO lidocaine (pf) injection solution 40 mg/ml (4 %), 5 mg/ml (0.5 %) $0-$7.40 (Tier 2) MO lidocaine hcl injection solution 20 mg/ml (2 %) $0-$7.40 (Tier 2) MO lidocaine hcl laryngotracheal $0-$7.40 (Tier 2) MO lidocaine hcl mucous membrane gel $0-$7.40 (Tier 2) MO lidocaine hcl mucous membrane jelly in applicator $0-$7.40 (Tier 2) MO lidocaine hcl mucous membrane solution 2 % $0-$7.40 (Tier 2) lidocaine hcl mucous membrane solution 4 % (40 mg/ml) $0-$7.40 (Tier 2) lidocaine hcl urethral $0-$7.40 (Tier 2) lidocaine topical adhesive patch,medicated $0-$7.40 (Tier 2) PAR; MO; QLL (90 per 30 days) lidocaine topical ointment $0-$7.40 (Tier 2) MO lidocaine viscous $0-$7.40 (Tier 2) MO lidocaine-prilocaine $0-$7.40 (Tier 2) MO antibiotic (neomy-bacit-polym) $0 (Tier 4) [*] antibiotic + pain relief topical ointment $0 (Tier 4) [*] gentamicin topical $0-$7.40 (Tier 2) MO mupirocin calcium $0-$7.40 (Tier 2) MO mupirocin ointment $0-$7.40 (Tier 2) MO neosporin + pain relief (bac) $0 (Tier 4) [*] sulfacetamide sodium (acne) $0-$7.40 (Tier 2) MO SULFAMYLON TOPICAL CREAM $0-$7.40 (Tier 2) MO MO TOPICAL ANTIBACTERIALS 50B B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 70 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso tri-biozene $0 (Tier 4) [*] triple antibiotic (pram) extra $0 (Tier 4) [*] triple antibiotic plus $0 (Tier 4) [*] triple antibiotic topical ointment $0 (Tier 4) MO; [*] triple antibiotic topical ointment in packet $0 (Tier 4) MO; [*] triple antibiotic-pain relief $0 (Tier 4) [*] af $0 (Tier 4) [*] aloe vesta topical ointment 2 % $0 (Tier 4) [*] anti-fungal $0 (Tier 4) [*] antifungal (clotrimazole) $0 (Tier 4) [*] antifungal (tolnaftate) topical aerosol,spray $0 (Tier 4) [*] antifungal (tolnaftate) topical cream $0 (Tier 4) [*] antifungal (tolnaftate) topical powder $0 (Tier 4) MO; [*] antifungal cream $0 (Tier 4) [*] antifungal spray $0 (Tier 4) [*] ANTIFUNGAL TOPICAL SOLUTION $0 (Tier 4) [*] athlete's foot (clotrimazole) $0 (Tier 4) [*] athlete's foot (terbinafine) $0 (Tier 4) [*] athlete's foot (tolnaftate) $0 (Tier 4) [*] athlete's foot af $0 (Tier 4) [*] athlete's foot topical aerosol powder $0 (Tier 4) [*] athletic foot cream $0 (Tier 4) [*] azolen tincture $0 (Tier 4) [*] baza antifungal $0 (Tier 4) MO; [*] TOPICAL ANTIFUNGALS 51B ciclodan topical solution $0-$7.40 (Tier 2) PAR; MO ciclopirox topical cream $0-$7.40 (Tier 2) MO ciclopirox topical gel $0-$7.40 (Tier 2) MO ciclopirox topical shampoo $0-$7.40 (Tier 2) MO ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 71 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso ciclopirox topical solution $0-$7.40 (Tier 2) PAR; MO ciclopirox topical suspension $0-$7.40 (Tier 2) MO clotrim antifungal $0 (Tier 4) [*] clotrimazole af $0 (Tier 4) [*] clotrimazole foot $0 (Tier 4) [*] clotrimazole topical $0-$7.40 (Tier 2) MO clotrimazole-betamethasone $0-$7.40 (Tier 2) MO critic-aid clear af $0 (Tier 4) MO; [*] desenex spray $0 (Tier 4) [*] DESENEX TOPICAL AEROSOL,SPRAY $0 (Tier 4) [*] desenex topical powder $0 (Tier 4) MO; [*] econazole topical $0-$7.40 (Tier 2) MO ELON DUAL DEFENSE $0 (Tier 4) [*] foot & sneaker $0 (Tier 4) [*] FUNGI-NAIL TOPICAL SOLUTION $0 (Tier 4) [*] fungoid tincture $0 (Tier 4) MO; [*] fungoid-d $0 (Tier 4) [*] inzo antifungal $0 (Tier 4) [*] jock itch $0 (Tier 4) [*] jock itch (clotrimazole) $0 (Tier 4) [*] jock itch (terbinafine) $0 (Tier 4) [*] ketoconazole topical $0-$7.40 (Tier 2) MO LAMISIL (AEROSOL) $0 (Tier 4) MO; [*] lamisil af topical aerosol powder $0 (Tier 4) MO; [*] lamisil af topical powder $0 (Tier 4) [*] lamisil at $0 (Tier 4) MO; [*] lotrimin af jock itch powder $0 (Tier 4) [*] lotrimin af powder $0 (Tier 4) MO; [*] B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 72 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso LOTRIMIN AF TOPICAL AEROSOL,SPRAY $0 (Tier 4) [*] LOTRIMIN AF TOPICAL CREAM $0 (Tier 4) MO; [*] LOTRIMIN AF TOPICAL POWDER $0 (Tier 4) MO; [*] lotrimin ultra $0 (Tier 4) MO; [*] micatin $0 (Tier 4) [*] miconazole nitrate topical aerosol powder $0 (Tier 4) [*] miconazole nitrate topical cream $0 (Tier 4) MO; [*] miconazorb af $0 (Tier 4) [*] micro-guard $0 (Tier 4) MO; [*] MYCO NAIL A $0 (Tier 4) [*] nuzole $0 (Tier 4) [*] nystatin topical $0-$7.40 (Tier 2) MO nystatin-triamcinolone $0-$7.40 (Tier 2) MO nystop $0-$7.40 (Tier 2) MO odor control foot-sneaker $0 (Tier 4) [*] podactin $0 (Tier 4) [*] remedy antifungal $0 (Tier 4) [*] ringworm $0 (Tier 4) [*] secura antifungal $0 (Tier 4) MO; [*] secura antifungal extra thick $0 (Tier 4) [*] terbinafine hcl topical $0 (Tier 4) MO; [*] tinactin topical aerosol powder $0 (Tier 4) MO; [*] TINACTIN TOPICAL AEROSOL,SPRAY $0 (Tier 4) [*] TINACTIN TOPICAL CREAM $0 (Tier 4) MO; [*] tinactin topical powder $0 (Tier 4) MO; [*] tolnaftate topical aerosol powder $0 (Tier 4) [*] tolnaftate topical cream $0 (Tier 4) [*] tolnaftate topical powder $0 (Tier 4) [*] triple paste af $0 (Tier 4) MO; [*] ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 73 Nombre del medicamento zeasorb (miconazole) Qué le costará el medicamento (nivel de clase) $0 (Tier 4) Acciones necesarias, restricciones, o límites sobre el uso MO; [*] TOPICAL ANTIVIRALS 52B acyclovir topical $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) DENAVIR $0-$7.40 (Tier 2) MO; QLL (5 per 2 days) ala-cort topical cream $0-$7.40 (Tier 2) MO alclometasone $0-$7.40 (Tier 2) MO amcinonide $0-$7.40 (Tier 2) MO anti-itch (hc) topical cream $0 (Tier 4) [*] betamethasone dipropionate $0-$7.40 (Tier 2) MO betamethasone valerate topical cream $0-$7.40 (Tier 2) MO betamethasone valerate topical lotion $0-$7.40 (Tier 2) MO betamethasone valerate topical ointment $0-$7.40 (Tier 2) MO betamethasone, augmented $0-$7.40 (Tier 2) MO CAPEX $0-$7.40 (Tier 2) MO clobetasol topical cream $0-$7.40 (Tier 2) MO clobetasol topical foam $0-$7.40 (Tier 2) MO clobetasol topical gel $0-$7.40 (Tier 2) MO clobetasol topical ointment $0-$7.40 (Tier 2) MO clobetasol topical solution $0-$7.40 (Tier 2) MO clobetasol-emollient topical cream $0-$7.40 (Tier 2) MO cormax topical solution $0-$7.40 (Tier 2) MO TOPICAL CORTICOSTEROIDS 53B cortaid topical cream $0 (Tier 4) MO; [*] cortisone (hydrocortisone) topical cream $0 (Tier 4) [*] cortizone-10 plus $0 (Tier 4) [*] cortizone-10 topical cream $0 (Tier 4) [*] $0-$7.40 (Tier 2) MO DERMATOP TOPICAL OINTMENT B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 74 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso desonide $0-$7.40 (Tier 2) MO desoximetasone $0-$7.40 (Tier 2) MO diflorasone $0-$7.40 (Tier 2) MO $0 (Tier 4) [*] fluocinolone $0-$7.40 (Tier 2) MO fluocinolone-shower cap $0-$7.40 (Tier 2) MO fluocinonide topical cream 0.05 % $0-$7.40 (Tier 2) MO fluocinonide topical gel $0-$7.40 (Tier 2) MO fluocinonide topical ointment $0-$7.40 (Tier 2) MO fluocinonide topical solution $0-$7.40 (Tier 2) MO fluocinonide-e $0-$7.40 (Tier 2) MO fluocinonide-emollient $0-$7.40 (Tier 2) MO fluticasone topical $0-$7.40 (Tier 2) MO halobetasol propionate $0-$7.40 (Tier 2) MO HALOG $0-$7.40 (Tier 2) MO hydro skin topical cream $0 (Tier 4) [*] hydrocortisone acetate topical cream 0.5 % $0 (Tier 4) [*] hydrocortisone plus $0 (Tier 4) [*] hydrocortisone topical cream 0.5 % $0 (Tier 4) MO; [*] eczema anti-itch hydrocortisone topical cream 1 %, 2.5 % $0-$7.40 (Tier 2) MO hydrocortisone topical lotion 2.5 % $0-$7.40 (Tier 2) MO hydrocortisone topical ointment 0.5 % $0 (Tier 4) MO; [*] hydrocortisone topical ointment 1 %, 2.5 % $0-$7.40 (Tier 2) MO hydrocortisone valerate $0-$7.40 (Tier 2) MO hydrocortisone-min oil-wht pet $0-$7.40 (Tier 2) MO hydrocream $0 (Tier 4) [*] mometasone $0-$7.40 (Tier 2) MO neosporin anti-itch $0 (Tier 4) [*] noble formula hc topical cream $0 (Tier 4) [*] ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 75 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso PREPARATION H HYDROCORTISONE $0 (Tier 4) MO; [*] recort plus $0 (Tier 4) [*] soothing care (hydrocortisone) $0 (Tier 4) [*] triamcinolone acetonide topical cream $0-$7.40 (Tier 2) MO triamcinolone acetonide topical lotion $0-$7.40 (Tier 2) MO triamcinolone acetonide topical ointment 0.025 %, 0.1 %, 0.5 % $0-$7.40 (Tier 2) MO trianex $0-$7.40 (Tier 2) MO triderm topical cream $0-$7.40 (Tier 2) MO $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) TOPICAL ENZYMES 54B SANTYL TOPICAL SCABICIDES / PEDICULICIDES 5B complete lice treatment $0 (Tier 4) [*] lice complete kit 1-2-3 $0 (Tier 4) [*] lice cream rinse $0 (Tier 4) [*] lice killing $0 (Tier 4) [*] lice killing (permethrin) $0 (Tier 4) [*] lice pyrinyl shampoo $0 (Tier 4) [*] lice solution $0 (Tier 4) [*] lice treatment (permethrin) $0 (Tier 4) [*] lice treatment topical liquid 1 % $0 (Tier 4) [*] lice treatment topical shampoo $0 (Tier 4) [*] lindane $0-$7.40 (Tier 2) MO permethrin topical cream $0-$7.40 (Tier 2) MO permethrin topical liquid $0 (Tier 4) MO; [*] pyrethrin lice treatment m $0 (Tier 4) [*] rid complete lice elim kit topical $0 (Tier 4) [*] B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 76 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso DIAGNOSTICS / MISCELLANEOUS AGENTS 5B ANOREXIANTS 56B ADIPEX-P $0 (Tier 3) MO; [*] benzphetamine $0 (Tier 3) MO; [*] diethylpropion $0 (Tier 3) MO; [*] phendimetrazine tartrate $0 (Tier 3) MO; [*] phentermine $0 (Tier 3) MO; [*] QSYMIA $0 (Tier 3) MO; [*] SUPRENZA $0 (Tier 3) MO; [*] XENICAL $0 (Tier 3) MO; [*] ANTIDOTES 57B acetylcysteine intravenous $0-$7.40 (Tier 2) B/D PAR; MO lactated ringers irrigation $0-$7.40 (Tier 2) B/D PAR; MO neomycin-polymyxin b gu $0-$7.40 (Tier 2) MO ringers irrigation $0-$7.40 (Tier 2) B/D PAR; MO acamprosate $0-$7.40 (Tier 2) MO ADAGEN $0-$7.40 (Tier 2) MO alendronate oral tablet 40 mg $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) anagrelide $0-$7.40 (Tier 2) MO ARALAST NP $0-$7.40 (Tier 2) PAR; MO; LA BUPHENYL ORAL TABLET $0-$7.40 (Tier 2) PAR; MO CARBAGLU $0-$7.40 (Tier 2) PAR; MO; LA CLINIMIX 4.25%/D5W SULFIT FREE $0-$7.40 (Tier 2) B/D PAR CLINIMIX E 2.75%/D10W SUL FREE $0-$7.40 (Tier 2) B/D PAR IRRIGATING SOLUTIONS 58B MISCELLANEOUS AGENTS 59B ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 77 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso CLINIMIX E 2.75%/D5W SULF FREE $0-$7.40 (Tier 2) B/D PAR d10 % & 0.45 % sodium chloride $0-$7.40 (Tier 2) B/D PAR d2.5 %-0.45 % sodium chloride $0-$7.40 (Tier 2) B/D PAR d5 % and 0.9 % sodium chloride $0-$7.40 (Tier 2) B/D PAR; MO d5 %-0.45 % sodium chloride $0-$7.40 (Tier 2) B/D PAR; MO dextrose 10 % and 0.2 % nacl $0-$7.40 (Tier 2) B/D PAR dextrose 10 % in water (d10w) intravenous parenteral solution $0-$7.40 (Tier 2) B/D PAR; MO dextrose 25 % in water (d25w) $0-$7.40 (Tier 2) B/D PAR dextrose 30 % in water (d30w) $0-$7.40 (Tier 2) B/D PAR dextrose 40 % in water (d40w) $0-$7.40 (Tier 2) B/D PAR dextrose 5 % in water (d5w) $0-$7.40 (Tier 2) B/D PAR; MO dextrose 5 %-lactated ringers $0-$7.40 (Tier 2) B/D PAR; MO dextrose 5%-0.2 % sod chloride $0-$7.40 (Tier 2) B/D PAR dextrose 5%-0.3 % sod.chloride $0-$7.40 (Tier 2) B/D PAR dextrose 50 % in water (d50w) intravenous parenteral solution $0-$7.40 (Tier 2) B/D PAR; MO dextrose 50 % in water (d50w) intravenous syringe $0-$7.40 (Tier 2) B/D PAR dextrose 70 % in water (d70w) $0-$7.40 (Tier 2) B/D PAR; MO dextrose with sodium chloride $0-$7.40 (Tier 2) B/D PAR disulfiram $0-$7.40 (Tier 2) MO EXJADE $0-$7.40 (Tier 2) PAR; MO; LA INCRELEX $0-$7.40 (Tier 2) PAR; MO; LA kionex $0-$7.40 (Tier 2) MO levocarnitine (with sugar) $0-$7.40 (Tier 2) B/D PAR; MO levocarnitine oral tablet $0-$7.40 (Tier 2) MO midodrine $0-$7.40 (Tier 2) MO ORFADIN ORAL CAPSULE 10 MG, 5 MG $0-$7.40 (Tier 2) LA B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 78 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso ORFADIN ORAL CAPSULE 2 MG $0-$7.40 (Tier 2) MO; LA pilocarpine hcl oral $0-$7.40 (Tier 2) MO RAVICTI $0-$7.40 (Tier 2) PAR; MO; QLL (525 per 30 days) RENAGEL $0-$7.40 (Tier 2) ST; MO RENVELA ORAL POWDER IN PACKET 0.8 GRAM $0-$7.40 (Tier 2) MO; QLL (180 per 30 days) RENVELA ORAL POWDER IN PACKET 2.4 GRAM $0-$7.40 (Tier 2) MO; QLL (90 per 30 days) RENVELA ORAL TABLET $0-$7.40 (Tier 2) MO; QLL (270 per 30 days) riluzole $0-$7.40 (Tier 2) MO sodium chloride 0.9 % intravenous $0-$7.40 (Tier 2) MO sodium chloride irrigation $0-$7.40 (Tier 2) MO sodium polystyrene (sorb free) $0-$7.40 (Tier 2) sodium polystyrene sulfonate oral powder $0-$7.40 (Tier 2) sodium polystyrene sulfonate oral suspension $0-$7.40 (Tier 2) sodium polystyrene sulfonate rectal $0-$7.40 (Tier 2) SODIUM POLYSTYRENE SULFONATE RECTAL $0-$7.40 (Tier 2) sps oral $0-$7.40 (Tier 2) sps rectal $0-$7.40 (Tier 2) SYPRINE $0-$7.40 (Tier 2) MO water for irrigation, sterile $0-$7.40 (Tier 2) B/D PAR; MO MO MO MISCELLANEOUS DEVICES 60B alcohol, rubbing $0 (Tier 4) [*] isopropyl alcohol solution 70 % $0 (Tier 4) MO; [*] isopropyl alcohol, rubbing $0 (Tier 4) MO; [*] SMOKING DETERRENTS 61B buproban $0-$7.40 (Tier 2) MO; QLL (60 per 30 days) CHANTIX $0-$7.40 (Tier 2) PAR; MO; QLL (60 per 30 days) ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 79 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso CHANTIX CONTINUING MONTH BOX $0-$7.40 (Tier 2) PAR; MO; QLL (56 per 28 days) CHANTIX STARTING MONTH BOX $0-$7.40 (Tier 2) PAR; MO; QLL (106 per 365 days) nicorelief buccal gum $0 (Tier 4) MO; [*] nicotine (polacrilex) buccal gum $0 (Tier 4) MO; [*] nicotine (polacrilex) buccal lozenge $0 (Tier 4) MO; [*]; QLL (20 per 1 day) nicotine transdermal patch 24 hour 14 mg/24 hr, 21 mg/24 hr, 7 mg/24 hr $0 (Tier 4) MO; [*]; QLL (30 per 30 days) NICOTROL NS $0-$7.40 (Tier 2) MO; QLL (120 per 30 days) nts step 1 $0 (Tier 4) [*]; QLL (30 per 30 days) quit 2 buccal gum $0 (Tier 4) [*] quit 4 buccal gum $0 (Tier 4) [*] stop smoking aid buccal lozenge $0 (Tier 4) [*]; QLL (20 per 1 day) 12 hour nasal relief spray $0 (Tier 4) [*] 12 hour nasal spray $0 (Tier 4) [*] AFRIN (OXYMETAZOLINE) $0 (Tier 4) MO; [*] AFRIN SINUS (OXYMETAZOLINE) $0 (Tier 4) [*] anefrin nasal spray,non-aerosol $0 (Tier 4) [*] EAR, NOSE / THROAT MEDICATIONS 6B MISCELLANEOUS AGENTS 62B azelastine nasal $0-$7.40 (Tier 2) MO; QLL (30 per 25 days) chlorhexidine gluconate mucous membrane $0-$7.40 (Tier 2) MO ipratropium bromide nasal $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) nasal decongestant (oxymetazl) $0 (Tier 4) [*] nasal relief $0 (Tier 4) [*] nasal spray (oxymetazoline) $0 (Tier 4) [*] nasal spray 12 hour $0 (Tier 4) [*] nasal spray 12 hour sinus $0 (Tier 4) [*] B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 80 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso nasal spray extra moisturizing $0 (Tier 4) [*] nasal spray long acting $0 (Tier 4) [*] nasal spray sinus $0 (Tier 4) [*] nasal spray x-moist $0 (Tier 4) [*] no drip $0 (Tier 4) [*] nrs nasal relief $0 (Tier 4) [*] original nasal spray $0 (Tier 4) [*] oxymetazoline $0 (Tier 4) [*] paroex oral rinse $0-$7.40 (Tier 2) MO periogard $0-$7.40 (Tier 2) MO severe congestion $0 (Tier 4) [*] sinus nasal spray $0 (Tier 4) [*] sinus relief (oxymetazoline) nasal spray,nonaerosol $0 (Tier 4) [*] triamcinolone acetonide dental $0-$7.40 (Tier 2) MO TYZINE NASAL DROPS 0.05 % $0-$7.40 (Tier 2) MO $0 (Tier 4) [*] acetic acid otic $0-$7.40 (Tier 2) MO acetic acid-aluminum acetate $0-$7.40 (Tier 2) MO carbamoxide ear drops $0 (Tier 4) [*] ear drops (carbamide peroxide) $0 (Tier 4) [*] ear drops otc $0 (Tier 4) [*] ear wax removal drops $0 (Tier 4) [*] ear wax removal kit $0 (Tier 4) [*] ear wax removal system otic drops $0 (Tier 4) [*] ear wax treatment $0 (Tier 4) [*] fluocinolone acetonide oil $0-$7.40 (Tier 2) MO hydrocortisone-acetic acid $0-$7.40 (Tier 2) MO vicks sinex 12-hour MISCELLANEOUS OTIC PREPARATIONS 63B ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 81 Nombre del medicamento murine ear wax removal system ofloxacin otic Qué le costará el medicamento (nivel de clase) $0 (Tier 4) Acciones necesarias, restricciones, o límites sobre el uso MO; [*] $0-$7.40 (Tier 2) MO CIPRODEX $0-$7.40 (Tier 2) MO COLY-MYCIN S $0-$7.40 (Tier 2) MO neomycin-polymyxin-hc otic $0-$7.40 (Tier 2) MO cortisone $0-$7.40 (Tier 2) MO dexamethasone $0-$7.40 (Tier 2) MO dexamethasone sodium phos (pf) $0-$7.40 (Tier 2) MO dexamethasone sodium phosphate injection $0-$7.40 (Tier 2) MO fludrocortisone $0-$7.40 (Tier 2) MO hydrocortisone oral $0-$7.40 (Tier 2) MO methylprednisolone acetate $0-$7.40 (Tier 2) MO methylprednisolone sodium succ injection recon soln 125 mg, 40 mg $0-$7.40 (Tier 2) MO methylprednisolone sodium succ intravenous $0-$7.40 (Tier 2) MO methylprednisolone tablets $0-$7.40 (Tier 2) MO prednisolone oral solution 15 mg/5 ml $0-$7.40 (Tier 2) MO prednisolone sodium phosphate oral solution 15 mg/5 ml, 5 mg base/5 ml (6.7 mg/5 ml) $0-$7.40 (Tier 2) MO prednisolone sodium phosphate oral tablet,disintegrating $0-$7.40 (Tier 2) MO prednisone intensol $0-$7.40 (Tier 2) MO prednisone oral $0-$7.40 (Tier 2) MO OTIC STEROID / ANTIBIOTIC 64B ENDOCRINE/DIABETES 7B ADRENAL HORMONES 65B B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 82 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso triamcinolone acetonide injection suspension 10 mg/ml $0-$7.40 (Tier 2) MO triamcinolone acetonide injection suspension 40 mg/ml $0-$7.40 (Tier 2) ANTITHYROID AGENTS 6B methimazole oral tablet 10 mg, 5 mg $0-$7.40 (Tier 2) MO propylthiouracil $0-$7.40 (Tier 2) MO DIABETES THERAPY 67B acarbose oral tablet 100 mg $0 (Tier 1) MO; QLL (90 per 30 days) acarbose oral tablet 25 mg $0 (Tier 1) MO; QLL (360 per 30 days) acarbose oral tablet 50 mg $0 (Tier 1) MO; QLL (180 per 30 days) alcohol pads $0 (Tier 1) BYDUREON $0-$7.40 (Tier 2) MO; QLL (4 per 28 days) BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML $0-$7.40 (Tier 2) MO; QLL (2.4 per 30 days) BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/DOSE (250 MCG/ML) 1.2 ML $0-$7.40 (Tier 2) MO; QLL (1.2 per 30 days) CYCLOSET $0-$7.40 (Tier 2) ST; MO; QLL (180 per 30 days) GAUZE PADS 2 X 2 $0 (Tier 1) QLL (200 per 30 days) glimepiride oral tablet 1 mg $0 (Tier 1) MO; QLL (240 per 30 days) glimepiride oral tablet 2 mg $0 (Tier 1) MO; QLL (120 per 30 days) glimepiride oral tablet 4 mg $0 (Tier 1) MO; QLL (60 per 30 days) glipizide oral tablet 10 mg $0 (Tier 1) MO; QLL (120 per 30 days) glipizide oral tablet 5 mg $0 (Tier 1) MO; QLL (240 per 30 days) glipizide oral tablet extended release 24hr 10 mg $0 (Tier 1) MO; QLL (60 per 30 days) glipizide oral tablet extended release 24hr 2.5 mg $0 (Tier 1) MO; QLL (240 per 30 days) glipizide oral tablet extended release 24hr 5 mg $0 (Tier 1) MO; QLL (120 per 30 days) glipizide-metformin oral tablet 2.5-250 mg $0 (Tier 1) MO; QLL (240 per 30 days) glipizide-metformin oral tablet 2.5-500 mg, 5-500 mg $0 (Tier 1) MO; QLL (120 per 30 days) ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 83 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso GLUCAGEN HYPOKIT $0 (Tier 1) MO GLUCAGON EMERGENCY KIT (HUMAN) $0 (Tier 1) MO HUMALOG KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML $0 (Tier 1) MO HUMALOG KWIKPEN SUBCUTANEOUS INSULIN PEN 200 UNIT/ML (3 ML) $0 (Tier 1) HUMALOG MIX 50-50 $0 (Tier 1) MO HUMALOG MIX 50-50 KWIKPEN $0 (Tier 1) MO HUMALOG MIX 75-25 $0 (Tier 1) MO HUMALOG MIX 75-25 KWIKPEN $0 (Tier 1) MO HUMALOG SUBCUTANEOUS CARTRIDGE $0 (Tier 1) MO HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML $0 (Tier 1) MO HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML (PREFILLED SYRINGE) $0 (Tier 1) HUMULIN 70/30 $0 (Tier 1) MO HUMULIN 70/30 KWIKPEN $0 (Tier 1) MO HUMULIN N $0 (Tier 1) MO HUMULIN N KWIKPEN $0 (Tier 1) MO HUMULIN R $0 (Tier 1) MO HUMULIN R U-500 "CONCENTRATED" $0 (Tier 1) MO insulin pen needle $0 (Tier 1) MO; QLL (200 per 30 days) INSULIN SYRINGE (DISP) U-100 0.3 ML, 1/2 ML $0 (Tier 1) QLL (200 per 30 days) INSULIN SYRINGE (DISP) U-100 1 ML $0 (Tier 1) MO; QLL (200 per 30 days) JANUMET $0-$7.40 (Tier 2) MO; QLL (60 per 30 days) JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 50-1,000 MG, 50-500 MG $0-$7.40 (Tier 2) MO; QLL (60 per 30 days) JANUVIA ORAL TABLET 100 MG $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 84 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso JANUVIA ORAL TABLET 25 MG $0-$7.40 (Tier 2) MO; QLL (120 per 30 days) JANUVIA ORAL TABLET 50 MG $0-$7.40 (Tier 2) MO; QLL (60 per 30 days) JARDIANCE $0-$7.40 (Tier 2) PAR; MO; QLL (30 per 30 days) JENTADUETO $0-$7.40 (Tier 2) MO; QLL (60 per 30 days) LANTUS $0 (Tier 1) MO LANTUS SOLOSTAR $0 (Tier 1) MO LEVEMIR $0 (Tier 1) MO LEVEMIR FLEXTOUCH $0 (Tier 1) MO metformin oral tablet 1,000 mg $0 (Tier 1) MO; QLL (76 per 30 days) metformin oral tablet 500 mg $0 (Tier 1) MO; QLL (153 per 30 days) metformin oral tablet 850 mg $0 (Tier 1) MO; QLL (90 per 30 days) metformin oral tablet extended release 24 hr 500 mg $0 (Tier 1) MO; QLL (120 per 30 days) metformin oral tablet extended release 24 hr 750 mg $0 (Tier 1) MO; QLL (80 per 30 days) metformin oral tablet extended release 24hr 1,000 mg $0 (Tier 1) MO; QLL (75 per 30 days) metformin oral tablet extended release 24hr 500 mg $0 (Tier 1) MO; QLL (150 per 30 days) nateglinide oral tablet 120 mg $0 (Tier 1) MO; QLL (90 per 30 days) nateglinide oral tablet 60 mg $0 (Tier 1) MO; QLL (180 per 30 days) needles, insulin disp.,safety $0 (Tier 1) QLL (200 per 30 days) pioglitazone oral tablet 15 mg $0 (Tier 1) MO; QLL (90 per 30 days) pioglitazone oral tablet 30 mg $0 (Tier 1) MO; QLL (45 per 30 days) pioglitazone oral tablet 45 mg $0 (Tier 1) MO; QLL (30 per 30 days) pioglitazone-glimepiride $0 (Tier 1) MO; QLL (30 per 30 days) pioglitazone-metformin $0 (Tier 1) MO; QLL (90 per 30 days) PRANDIMET $0-$7.40 (Tier 2) MO; QLL (150 per 30 days) PROGLYCEM $0-$7.40 (Tier 2) MO SYMLINPEN 120 $0-$7.40 (Tier 2) PAR; MO; QLL (11 per 30 days) SYMLINPEN 60 $0-$7.40 (Tier 2) PAR; MO; QLL (6 per 30 days) ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 85 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso TANZEUM $0-$7.40 (Tier 2) MO; QLL (4 per 28 days) tolazamide oral tablet 250 mg $0 (Tier 1) MO; QLL (120 per 30 days) tolazamide oral tablet 500 mg $0 (Tier 1) MO; QLL (60 per 30 days) tolbutamide $0 (Tier 1) MO; QLL (180 per 30 days) TOUJEO SOLOSTAR $0-$7.40 (Tier 2) MO TRADJENTA $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) TRULICITY $0-$7.40 (Tier 2) MO; QLL (2 per 28 days) VICTOZA 2-PAK $0-$7.40 (Tier 2) MO; QLL (9 per 30 days) VICTOZA 3-PAK $0-$7.40 (Tier 2) MO; QLL (9 per 30 days) ALDURAZYME $0-$7.40 (Tier 2) PAR; MO ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 20.25 MG/1.25 GRAM (1.62 %) $0-$7.40 (Tier 2) PAR; MO; QLL (150 per 30 days) ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM) $0-$7.40 (Tier 2) PAR; MO; QLL (112.5 per 30 days) ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (40.5 MG/2.5 GRAM) $0-$7.40 (Tier 2) PAR; MO; QLL (150 per 30 days) androxy $0-$7.40 (Tier 2) PAR; MO cabergoline $0-$7.40 (Tier 2) MO calcitonin (salmon) $0-$7.40 (Tier 2) MO; QLL (4 per 30 days) calcitriol intravenous solution 1 mcg/ml $0-$7.40 (Tier 2) B/D PAR; MO calcitriol oral $0-$7.40 (Tier 2) B/D PAR; MO CEREZYME INTRAVENOUS RECON SOLN 400 UNIT $0-$7.40 (Tier 2) PAR; MO danazol oral $0-$7.40 (Tier 2) MO desmopressin injection $0-$7.40 (Tier 2) MO desmopressin nasal $0-$7.40 (Tier 2) MO desmopressin oral $0-$7.40 (Tier 2) MO MISCELLANEOUS HORMONES 68B B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 86 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso doxercalciferol intravenous $0-$7.40 (Tier 2) B/D PAR doxercalciferol oral $0-$7.40 (Tier 2) B/D PAR; MO ELAPRASE $0-$7.40 (Tier 2) PAR; MO FABRAZYME $0-$7.40 (Tier 2) PAR; MO KORLYM $0-$7.40 (Tier 2) PAR; MO KUVAN ORAL TABLET,SOLUBLE $0-$7.40 (Tier 2) PAR; MO; LA MIACALCIN INJECTION $0-$7.40 (Tier 2) B/D PAR; MO MYOZYME $0-$7.40 (Tier 2) PAR; MO NAGLAZYME $0-$7.40 (Tier 2) PAR; MO; LA NATPARA $0-$7.40 (Tier 2) PAR; MO; LA; QLL (2 per 28 days) oxandrolone oral tablet 10 mg $0-$7.40 (Tier 2) PAR; MO; QLL (60 per 30 days) oxandrolone oral tablet 2.5 mg $0-$7.40 (Tier 2) PAR; MO; QLL (120 per 30 days) pamidronate $0-$7.40 (Tier 2) B/D PAR; MO paricalcitol oral $0-$7.40 (Tier 2) B/D PAR; MO SENSIPAR ORAL TABLET 30 MG, 60 MG $0-$7.40 (Tier 2) MO; QLL (60 per 30 days) SENSIPAR ORAL TABLET 90 MG $0-$7.40 (Tier 2) MO; QLL (120 per 30 days) SOMAVERT $0-$7.40 (Tier 2) PAR; MO STIMATE $0-$7.40 (Tier 2) MO SYNAREL $0-$7.40 (Tier 2) PAR; MO testosterone cypionate $0-$7.40 (Tier 2) MO testosterone enanthate $0-$7.40 (Tier 2) MO VPRIV $0-$7.40 (Tier 2) PAR; MO ZAVESCA $0-$7.40 (Tier 2) PAR; MO; LA ZEMPLAR INTRAVENOUS $0-$7.40 (Tier 2) B/D PAR; MO zoledronic acid intravenous recon soln 4 mg $0-$7.40 (Tier 2) PAR zoledronic acid intravenous solution 4 mg/5 ml $0-$7.40 (Tier 2) PAR; MO ZOMETA INTRAVENOUS SOLUTION 4 MG/100 ML $0-$7.40 (Tier 2) PAR; MO ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 87 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso THYROID HORMONES 69B levothyroxine oral $0 (Tier 1) MO levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg $0-$7.40 (Tier 2) MO liothyronine oral $0-$7.40 (Tier 2) MO SYNTHROID $0-$7.40 (Tier 2) MO UNITHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG $0-$7.40 (Tier 2) MO anti-diarrhea $0 (Tier 4) [*] anti-diarrheal $0 (Tier 4) [*] anti-diarrheal (loperamide) oral capsule $0 (Tier 4) [*] anti-diarrheal (loperamide) oral liquid $0 (Tier 4) [*] anti-diarrheal (loperamide) oral tablet $0 (Tier 4) MO; [*] GASTROENTEROLOGY 8B ANTIDIARRHEALS / ANTISPASMODICS 70B atropine injection syringe 0.05 mg/ml, 0.1 mg/ml $0-$7.40 (Tier 2) bismatrol oral suspension 262 mg/15 ml $0 (Tier 4) MO; [*] bismatrol oral suspension 525 mg/15 ml $0 (Tier 4) [*] bismatrol oral tablet,chewable $0 (Tier 4) [*] bismuth $0 (Tier 4) [*] bismuth maximum strength $0 (Tier 4) [*] diamode $0 (Tier 4) [*] diarrhea relief (bismuth subs) $0 (Tier 4) [*] dicyclomine oral capsule $0-$7.40 (Tier 2) MO dicyclomine oral solution $0-$7.40 (Tier 2) MO B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 88 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso dicyclomine oral tablet $0-$7.40 (Tier 2) MO $0 (Tier 4) [*] diphenoxylate-atropine $0-$7.40 (Tier 2) MO glycopyrrolate oral $0-$7.40 (Tier 2) MO diotame IMODIUM A-D ORAL LIQUID $0 (Tier 4) MO; [*] kaopectate (bismuth subsalicy) $0 (Tier 4) MO; [*] kaopectate ex str (bismuth ss) $0 (Tier 4) [*] kao-tin (bismuth subsalicylat) $0 (Tier 4) [*] k-pec antidiarrheal (bism sub) $0 (Tier 4) [*] $0-$7.40 (Tier 2) MO loperamide oral capsule loperamide oral liquid 1 mg/5 ml $0 (Tier 4) MO; [*] loperamide oral liquid 1 mg/7.5 ml $0 (Tier 4) [*] loperamide oral tablet $0 (Tier 4) [*] medi-bismuth $0 (Tier 4) [*] $0-$7.40 (Tier 2) MO peptic relief $0 (Tier 4) [*] PEPTO-BISMOL $0 (Tier 4) MO; [*] PEPTO-BISMOL MAX ST $0 (Tier 4) MO; [*] pepto-bismol to-go $0 (Tier 4) [*] pink bismuth maximum strength $0 (Tier 4) [*] pink bismuth oral suspension $0 (Tier 4) [*] pink bismuth oral tablet $0 (Tier 4) [*] pink bismuth oral tablet,chewable $0 (Tier 4) MO; [*] soothe (bismuth subsalicylate) $0 (Tier 4) [*] soothe regular strength $0 (Tier 4) [*] stomach relief $0 (Tier 4) [*] stomach relief max strength $0 (Tier 4) [*] stomach relief original $0 (Tier 4) [*] opium tincture oral tincture ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 89 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso MISCELLANEOUS GASTROINTESTINAL AGENTS 71B acid gone $0 (Tier 4) [*] acid gone antacid $0 (Tier 4) [*] advanced antacid-antigas $0 (Tier 4) [*] almacone oral suspension $0 (Tier 4) [*] almacone-2 $0 (Tier 4) [*] alosetron $0-$7.40 (Tier 2) PAR; MO; QLL (60 per 30 days) aluminum hydroxide gel oral suspension 320 mg/5 ml $0 (Tier 4) MO; [*] aluminum hydroxide gel oral suspension 600 mg/5 ml $0 (Tier 4) [*] $0-$7.40 (Tier 2) MO antacid anti-gas double str $0 (Tier 4) [*] antacid anti-gas oral suspension $0 (Tier 4) [*] antacid exst (mag carb-al hyd) $0 (Tier 4) [*] antacid extra-strength oral suspension $0 (Tier 4) [*] antacid liquid $0 (Tier 4) [*] antacid m $0 (Tier 4) [*] antacid maximum strength oral suspension $0 (Tier 4) [*] antacid oral suspension $0 (Tier 4) [*] antacid plus anti-gas $0 (Tier 4) [*] antacid regular strength $0 (Tier 4) [*] antacid with simethicone oral suspension $0 (Tier 4) [*] antacid-antigas $0 (Tier 4) [*] antacid-simethicone $0 (Tier 4) [*] antacid-simethicone ds $0 (Tier 4) [*] anti-gas ultra strength $0 (Tier 4) [*] $0-$7.40 (Tier 2) MO AMITIZA APRISO B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 90 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso ASACOL HD $0-$7.40 (Tier 2) MO balsalazide $0-$7.40 (Tier 2) MO bisac-evac $0 (Tier 4) MO; [*] bisacodyl rectal $0 (Tier 4) MO; [*] biscolax $0 (Tier 4) MO; [*] budesonide oral $0-$7.40 (Tier 2) MO CANASA $0-$7.40 (Tier 2) MO child suppository $0 (Tier 4) [*] children's pepto $0 (Tier 4) [*] children's soothe $0 (Tier 4) [*] CIMZIA $0-$7.40 (Tier 2) PAR; MO; QLL (6 per 28 days) CIMZIA POWDER FOR RECONST $0-$7.40 (Tier 2) PAR; MO; QLL (6 per 28 days) CIMZIA STARTER KIT $0-$7.40 (Tier 2) PAR; MO; QLL (6 per 28 days) citrate of magnesia $0 (Tier 4) [*] citroma $0 (Tier 4) [*] citrucel oral tablet $0 (Tier 4) MO; [*] clearlax oral powder $0 (Tier 4) MO; [*] colocort $0-$7.40 (Tier 2) MO comfort gel $0 (Tier 4) [*] comfort gel extra strength $0 (Tier 4) [*] compro $0-$7.40 (Tier 2) PAR; MO constulose $0-$7.40 (Tier 2) MO CREON $0-$7.40 (Tier 2) MO CYSTADANE $0-$7.40 (Tier 2) MO DELZICOL $0-$7.40 (Tier 2) MO DIPENTUM $0-$7.40 (Tier 2) MO dronabinol $0-$7.40 (Tier 2) B/D PAR; MO; QLL (120 per 30 days) EMEND ORAL CAPSULE 125 MG $0-$7.40 (Tier 2) B/D PAR; MO; QLL (5 per 30 days) EMEND ORAL CAPSULE 40 MG $0-$7.40 (Tier 2) B/D PAR; MO; QLL (1 per 2 days) ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 91 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso EMEND ORAL CAPSULE 80 MG $0-$7.40 (Tier 2) B/D PAR; MO; QLL (10 per 30 days) EMEND ORAL CAPSULE,DOSE PACK $0-$7.40 (Tier 2) B/D PAR; MO; QLL (15 per 30 days) enulose $0-$7.40 (Tier 2) MO fiber (calcium polycarbophil) $0 (Tier 4) MO; [*] fiber (psyllium husk) $0 (Tier 4) [*] fiber laxative (ca polycarbo) $0 (Tier 4) [*] fiber laxative (methylcellulo) $0 (Tier 4) [*] fiber laxative (psyllium husk) $0 (Tier 4) [*] fiber therapy (ca polycarboph) $0 (Tier 4) [*] fiber therapy laxative (husk) $0 (Tier 4) [*] fiber therapy oral tablet $0 (Tier 4) [*] fiber-caps $0 (Tier 4) [*] fiber-lax $0 (Tier 4) MO; [*] fiber-tabs $0 (Tier 4) [*] flanax antacid $0 (Tier 4) [*] fleet glycerin (adult) $0 (Tier 4) [*] foaming antacid extra strength $0 (Tier 4) [*] foaming antacid oral suspension $0 (Tier 4) [*] gas free extra strength $0 (Tier 4) MO; [*] gas relief 80 $0 (Tier 4) [*] gas relief extra strength $0 (Tier 4) [*] gas relief oral capsule $0 (Tier 4) [*] gas relief oral drops,suspension $0 (Tier 4) [*] gas relief oral tablet,chewable $0 (Tier 4) MO; [*] gas relief ultra strength $0 (Tier 4) [*] GAS-X EXTRA STRENGTH $0 (Tier 4) MO; [*] GAS-X ORAL TABLET,CHEWABLE $0 (Tier 4) MO; [*] GAS-X ULTRA-STRENGTH $0 (Tier 4) [*] B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 92 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso GATTEX 30-VIAL $0-$7.40 (Tier 2) MO GATTEX ONE-VIAL $0-$7.40 (Tier 2) MO gavilax oral powder $0 (Tier 4) MO; [*] gavilyte-c $0-$7.40 (Tier 2) MO gavilyte-g $0-$7.40 (Tier 2) MO gavilyte-n $0-$7.40 (Tier 2) MO GAVISCON EXTRA STRENGTH $0 (Tier 4) MO; [*] GAVISCON ORAL SUSPENSION $0 (Tier 4) MO; [*] generlac $0-$7.40 (Tier 2) MO gentle laxative rectal $0 (Tier 4) [*] gentlelax $0 (Tier 4) [*] geri-kot $0 (Tier 4) [*] geri-lanta $0 (Tier 4) [*] geri-mox antacid-antigas $0 (Tier 4) [*] glycerin (adult) $0 (Tier 4) [*] glycerin (child) $0 (Tier 4) [*] glycolax oral powder $0 (Tier 4) [*] healthylax $0 (Tier 4) [*] heartburn antacid $0 (Tier 4) [*] heartburn relief $0 (Tier 4) [*] $0-$7.40 (Tier 2) MO infants gas relief $0 (Tier 4) [*] konsyl fiber $0 (Tier 4) [*] konsyl sugar-free oral capsule $0 (Tier 4) [*] hydrocortisone rectal enema lactulose oral solution 10 gram/15 ml (15 ml) $0-$7.40 (Tier 2) lactulose oral solution 10 gram/15 ml, 20 gram/30 ml $0-$7.40 (Tier 2) MO laxa clear $0 (Tier 4) [*] laxative (glycerin-pediatric) $0 (Tier 4) [*] laxative peg 3350 oral powder $0 (Tier 4) [*] ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 93 Nombre del medicamento laxative rectal Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso $0 (Tier 4) [*] LIALDA $0-$7.40 (Tier 2) MO LINZESS $0-$7.40 (Tier 2) MO liquid antacid $0 (Tier 4) [*] MAALOX ADVANCED ORAL SUSPENSION $0 (Tier 4) [*] maalox maximum strength $0 (Tier 4) MO; [*] mag-al plus $0 (Tier 4) [*] mag-al plus extra strength $0 (Tier 4) [*] magnesium citrate oral solution $0 (Tier 4) MO; [*] masanti double strength $0 (Tier 4) [*] $0-$7.40 (Tier 2) MO meclizine oral tablet 12.5 mg, 25 mg meclizine oral tablet,chewable $0 (Tier 4) MO; [*] medi-mucil $0 (Tier 4) [*] medi-natural $0 (Tier 4) [*] mesalamine rectal $0-$7.40 (Tier 2) MO mesalamine with cleansing wipe $0-$7.40 (Tier 2) MO metoclopramide hcl injection solution $0-$7.40 (Tier 2) MO metoclopramide hcl injection syringe $0-$7.40 (Tier 2) metoclopramide hcl oral solution $0-$7.40 (Tier 2) MO metoclopramide hcl oral tablet $0-$7.40 (Tier 2) MO mi-acid gas relief $0 (Tier 4) [*] mi-acid oral suspension $0 (Tier 4) MO; [*] mi-acid oral tablet,chewable $0 (Tier 4) [*] milk of magnesia $0 (Tier 4) MO; [*] mintox $0 (Tier 4) MO; [*] mintox maximum strength $0 (Tier 4) MO; [*] mintox plus $0 (Tier 4) MO; [*] miralax oral powder in packet $0 (Tier 4) MO; [*] B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 94 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso motion sickness relief(mecliz) oral tablet,chewable $0 (Tier 4) [*] mytab gas $0 (Tier 4) [*] mytab gas maximum strength $0 (Tier 4) [*] natural fiber laxative oral capsule $0 (Tier 4) [*] natural veg laxative(sennosid) $0 (Tier 4) [*] ondansetron hcl (pf) injection solution $0-$7.40 (Tier 2) MO ondansetron hcl (pf) injection syringe $0-$7.40 (Tier 2) ondansetron hcl intravenous solution $0-$7.40 (Tier 2) MO ondansetron hcl oral solution $0-$7.40 (Tier 2) B/D PAR; MO; QLL (450 per 30 days) ondansetron hcl oral tablet 24 mg $0-$7.40 (Tier 2) B/D PAR; QLL (30 per 30 days) ondansetron hcl oral tablet 4 mg, 8 mg $0-$7.40 (Tier 2) B/D PAR; MO; QLL (90 per 30 days) ondansetron odt $0-$7.40 (Tier 2) B/D PAR; MO; QLL (90 per 30 days) peg 3350-electrolytes oral recon soln 236-22.746.74 -5.86 gram $0-$7.40 (Tier 2) MO peg 3350-electrolytes oral recon soln 240-22.726.72 -5.84 gram $0-$7.40 (Tier 2) peg3350 $0 (Tier 4) peg-3350 with flavor packs $0-$7.40 (Tier 2) peg-electrolyte soln $0-$7.40 (Tier 2) PENTASA $0-$7.40 (Tier 2) [*] MO PHAZYME ORAL CAPSULE 180 MG $0 (Tier 4) MO; [*] polyethylene glycol 3350 $0 (Tier 4) MO; [*] polyethylene glycol 3350 oral powderlax $0-$7.40 (Tier 2) MO $0 (Tier 4) [*] prochlorperazine edisylate $0-$7.40 (Tier 2) PAR; MO prochlorperazine maleate oral $0-$7.40 (Tier 2) PAR; MO prochlorperazine maleate rectal $0-$7.40 (Tier 2) PAR; MO procto-pak $0-$7.40 (Tier 2) MO proctosol hc $0-$7.40 (Tier 2) MO ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 95 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso proctozone-hc $0-$7.40 (Tier 2) MO psyllium husk oral capsule $0 (Tier 4) [*] purelax $0 (Tier 4) [*] reguloid oral capsule $0 (Tier 4) [*] RELISTOR SUBCUTANEOUS SOLUTION $0-$7.40 (Tier 2) PAR; MO RELISTOR SUBCUTANEOUS SYRINGE $0-$7.40 (Tier 2) PAR; MO REMICADE $0-$7.40 (Tier 2) PAR; MO ri-gel $0 (Tier 4) [*] ri-gel ii $0 (Tier 4) [*] ri-mox $0 (Tier 4) [*] ri-mox plus $0 (Tier 4) [*] RULOX $0 (Tier 4) [*] sani-supp (adult) $0 (Tier 4) MO; [*] sani-supp (infant) $0 (Tier 4) MO; [*] senexon oral tablet $0 (Tier 4) MO; [*] senna lax $0 (Tier 4) MO; [*] senna laxative oral tablet 8.6 mg $0 (Tier 4) [*] senna oral tablet $0 (Tier 4) [*] senna-gen $0 (Tier 4) MO; [*] senno $0 (Tier 4) [*] sen-o-tab $0 (Tier 4) [*] simethicone oral capsule 180 mg $0 (Tier 4) [*] simethicone oral drops,suspension $0 (Tier 4) MO; [*] simethicone oral tablet,chewable $0 (Tier 4) [*] smoothlax $0 (Tier 4) [*] sodium bicarbonate oral $0 (Tier 4) MO; [*] soluble fiber $0 (Tier 4) [*] sulfasalazine $0-$7.40 (Tier 2) MO B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 96 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso sulfazine $0-$7.40 (Tier 2) MO sulfazine ec $0-$7.40 (Tier 2) MO suppository adult $0 (Tier 4) [*] the magic bullet $0 (Tier 4) MO; [*] travel sickness (meclizine) $0 (Tier 4) MO; [*] ursodiol $0-$7.40 (Tier 2) MO vegetable laxative $0 (Tier 4) [*] wal-mucil fiber $0 (Tier 4) [*] acid controller complete $0 (Tier 4) [*] acid controller oral tablet 10 mg $0 (Tier 4) [*] acid reducer (famotidine) oral tablet 10 mg $0 (Tier 4) [*] acid reducer (ranitidine) oral tablet 75 mg $0 (Tier 4) [*] acid reducer complete (famot) $0 (Tier 4) [*] complete oral tablet,chewable $0 (Tier 4) [*] ULCER THERAPY 72B DEXILANT dual action complete $0-$7.40 (Tier 2) ST; MO; QLL (30 per 30 days) $0 (Tier 4) [*] famotidine (pf) $0-$7.40 (Tier 2) MO famotidine (pf)-nacl (iso-os) $0-$7.40 (Tier 2) famotidine intravenous $0-$7.40 (Tier 2) MO famotidine oral suspension $0-$7.40 (Tier 2) MO famotidine oral tablet 10 mg famotidine oral tablet 20 mg, 40 mg $0 (Tier 4) MO; [*] $0-$7.40 (Tier 2) MO heartburn prevention oral tablet 10 mg $0 (Tier 4) [*] heartburn relief (famotidine) oral tablet 10 mg $0 (Tier 4) [*] heartburn relief (ranitidine) oral tablet 75 mg $0 (Tier 4) [*] lansoprazole oral capsule,delayed release(dr/ec) $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) misoprostol $0-$7.40 (Tier 2) MO omeprazole oral capsule,delayed release(dr/ec) ? $0 (Tier 1) MO; QLL (30 per 30 days) Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 97 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso omeprazole oral tablet,delayed release (dr/ec) $0 (Tier 4) MO; [*] pantoprazole oral $0 (Tier 1) MO; QLL (30 per 30 days) PROTONIX INTRAVENOUS $0-$7.40 (Tier 2) MO ranitidine hcl injection $0-$7.40 (Tier 2) MO ranitidine hcl oral syrup $0-$7.40 (Tier 2) MO ranitidine hcl oral tablet 150 mg, 300 mg $0-$7.40 (Tier 2) MO ranitidine hcl oral tablet 75 mg sucralfate oral tablet $0 (Tier 4) MO; [*] $0-$7.40 (Tier 2) MO tums dual action (famotidine) $0 (Tier 4) [*] wal-zan 75 $0 (Tier 4) [*] IMMUNOLOGY, VACCINES / BIOTECHNOLOGY 9B BIOTECHNOLOGY DRUGS 73B ACTIMMUNE $0-$7.40 (Tier 2) PAR; MO ARANESP (IN POLYSORBATE) $0-$7.40 (Tier 2) PAR; MO ARCALYST $0-$7.40 (Tier 2) PAR; MO AVONEX (WITH ALBUMIN) $0-$7.40 (Tier 2) PAR; MO; QLL (4 per 28 days) AVONEX INTRAMUSCULAR PEN INJECTOR KIT $0-$7.40 (Tier 2) PAR; MO; QLL (4 per 28 days) AVONEX INTRAMUSCULAR SYRINGE $0-$7.40 (Tier 2) PAR; MO; QLL (4 per 28 days) AVONEX INTRAMUSCULAR SYRINGE KIT $0-$7.40 (Tier 2) PAR; MO; QLL (4 per 28 days) EXTAVIA SUBCUTANEOUS KIT $0-$7.40 (Tier 2) PAR; MO EXTAVIA SUBCUTANEOUS RECON SOLN $0-$7.40 (Tier 2) PAR ILARIS (PF) $0-$7.40 (Tier 2) PAR; MO; LA INTRON A INJECTION $0-$7.40 (Tier 2) PAR; MO NEUMEGA $0-$7.40 (Tier 2) PAR; MO; QLL (21 per 21 days) NEUPOGEN $0-$7.40 (Tier 2) PAR; MO NORDITROPIN FLEXPRO $0-$7.40 (Tier 2) PAR; MO B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 98 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso NORDITROPIN NORDIFLEX $0-$7.40 (Tier 2) PAR; MO OMNITROPE $0-$7.40 (Tier 2) PAR; MO PEGASYS $0-$7.40 (Tier 2) PAR; MO PEGASYS PROCLICK $0-$7.40 (Tier 2) PAR; MO PEGINTRON $0-$7.40 (Tier 2) PAR; MO PEGINTRON REDIPEN $0-$7.40 (Tier 2) PAR; MO PROCRIT $0-$7.40 (Tier 2) PAR; MO; QLL (12 per 28 days) PROLEUKIN $0-$7.40 (Tier 2) B/D PAR; MO REBIF (WITH ALBUMIN) $0-$7.40 (Tier 2) PAR; MO REBIF REBIDOSE $0-$7.40 (Tier 2) PAR; MO REBIF TITRATION PACK $0-$7.40 (Tier 2) PAR; MO SYLATRON $0-$7.40 (Tier 2) PAR; MO VACCINES / MISCELLANEOUS IMMUNOLOGICALS 74B ACTHIB (PF) $0 (Tier 1) MO ADACEL(TDAP ADOLESN/ADULT)(PF) $0 (Tier 1) MO ATGAM $0-$7.40 (Tier 2) BCG VACCINE, LIVE (PF) $0-$7.40 (Tier 2) BEXSERO (PF) $0-$7.40 (Tier 2) BOOSTRIX TDAP CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN 12 GRAM, 6 GRAM $0 (Tier 1) $0-$7.40 (Tier 2) B/D PAR MO PAR; MO CERVARIX VACCINE (PF) $0 (Tier 1) MO COMVAX (PF) $0 (Tier 1) MO DAPTACEL (DTAP PEDIATRIC) (PF) $0 (Tier 1) MO ENGERIX-B (PF) $0 (Tier 1) B/D PAR; MO ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SUSPENSION $0 (Tier 1) B/D PAR; MO ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE $0 (Tier 1) B/D PAR ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 99 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso GAMASTAN S/D $0-$7.40 (Tier 2) PAR; MO GAMMAGARD LIQUID $0-$7.40 (Tier 2) PAR; MO GAMMAGARD S-D (IGA 1 MCG/ML) $0-$7.40 (Tier 2) PAR; MO GAMMAPLEX $0-$7.40 (Tier 2) PAR; MO GAMUNEX-C $0-$7.40 (Tier 2) PAR; MO GARDASIL (PF) $0-$7.40 (Tier 2) MO GARDASIL 9 (PF) $0-$7.40 (Tier 2) MO HAVRIX (PF) INTRAMUSCULAR SUSPENSION $0 (Tier 1) MO HAVRIX (PF) INTRAMUSCULAR SYRINGE 1,440 ELISA UNIT/ML $0 (Tier 1) MO HAVRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT/0.5 ML $0 (Tier 1) IMOVAX RABIES VACCINE (PF) $0-$7.40 (Tier 2) MO INFANRIX (DTAP) (PF) $0-$7.40 (Tier 2) MO $0 (Tier 1) MO IXIARO (PF) $0-$7.40 (Tier 2) MO MENACTRA (PF) INTRAMUSCULAR SOLUTION $0-$7.40 (Tier 2) MO MENOMUNE - A/C/Y/W-135 $0-$7.40 (Tier 2) MENOMUNE - A/C/Y/W-135 (PF) $0-$7.40 (Tier 2) MO MENVEO A-C-Y-W-135-DIP (PF) $0-$7.40 (Tier 2) MO $0 (Tier 1) MO IPOL M-M-R II (PF) OCTAGAM PEDVAX HIB (PF) $0-$7.40 (Tier 2) $0 (Tier 1) PRIVIGEN $0-$7.40 (Tier 2) PROQUAD (PF) $0-$7.40 (Tier 2) QUADRACEL (PF) $0-$7.40 (Tier 2) RABAVERT (PF) $0-$7.40 (Tier 2) PAR; MO MO PAR; MO MO B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 100 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION $0 (Tier 1) B/D PAR; MO RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCG/ML $0 (Tier 1) MO RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 5 MCG/0.5 ML $0 (Tier 1) ROTARIX ROTATEQ VACCINE $0-$7.40 (Tier 2) $0 (Tier 1) tetanus toxoid,adsorbed (pf) $0-$7.40 (Tier 2) MO tetanus,diphtheria tox ped(pf) $0-$7.40 (Tier 2) MO $0 (Tier 1) MO TETANUS-DIPHTHERIA TOXOIDS-TD THYMOGLOBULIN $0-$7.40 (Tier 2) B/D PAR TICE BCG $0-$7.40 (Tier 2) MO TRUMENBA $0-$7.40 (Tier 2) TWINRIX (PF) $0 (Tier 1) MO TYPHIM VI INTRAMUSCULAR SOLUTION $0-$7.40 (Tier 2) TYPHIM VI INTRAMUSCULAR SYRINGE $0-$7.40 (Tier 2) MO VAQTA (PF) INTRAMUSCULAR SUSPENSION $0-$7.40 (Tier 2) MO VAQTA (PF) INTRAMUSCULAR SYRINGE $0-$7.40 (Tier 2) VARIVAX (PF) $0-$7.40 (Tier 2) MO VARIZIG INTRAMUSCULAR RECON SOLN $0-$7.40 (Tier 2) MO VARIZIG INTRAMUSCULAR SOLUTION $0-$7.40 (Tier 2) YF-VAX (PF) $0-$7.40 (Tier 2) MO ZOSTAVAX (PF) $0-$7.40 (Tier 2) MO allopurinol $0-$7.40 (Tier 2) MO colchicine-probenecid $0-$7.40 (Tier 2) MO MUSCULOSKELETAL / RHEUMATOLOGY 10B GOUT THERAPY 75B ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 101 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso COLCRYS $0-$7.40 (Tier 2) MO probenecid $0-$7.40 (Tier 2) MO ULORIC $0-$7.40 (Tier 2) ST; MO alendronate oral solution $0-$7.40 (Tier 2) MO; QLL (300 per 28 days) alendronate oral tablet 10 mg, 5 mg $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) alendronate oral tablet 35 mg, 70 mg $0-$7.40 (Tier 2) MO; QLL (4 per 28 days) BONIVA INTRAVENOUS $0-$7.40 (Tier 2) B/D PAR; MO FORTEO $0-$7.40 (Tier 2) PAR; MO; QLL (3 per 28 days) ibandronate intravenous solution $0-$7.40 (Tier 2) B/D PAR; MO ibandronate intravenous syringe $0-$7.40 (Tier 2) MO ibandronate oral $0-$7.40 (Tier 2) MO; QLL (1 per 28 days) PROLIA $0-$7.40 (Tier 2) PAR; MO; QLL (2 per 365 days) raloxifene $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) ACTEMRA INTRAVENOUS VIAL $0-$7.40 (Tier 2) PAR; MO BENLYSTA $0-$7.40 (Tier 2) PAR; MO DEPEN TITRATABS $0-$7.40 (Tier 2) MO ENBREL SUBCUTANEOUS RECON SOLN $0-$7.40 (Tier 2) PAR; MO; QLL (8 per 28 days) ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5ML (0.51) $0-$7.40 (Tier 2) PAR; MO; QLL (4.08 per 28 days) ENBREL SUBCUTANEOUS SYRINGE 50 MG/ML (0.98 ML) $0-$7.40 (Tier 2) PAR; MO; QLL (8 per 28 days) ENBREL SURECLICK $0-$7.40 (Tier 2) PAR; MO; QLL (8 per 28 days) HUMIRA CROHN'S DIS START PCK $0-$7.40 (Tier 2) PAR; MO; QLL (9.6 per 365 days) HUMIRA PED CROHN'S STARTER PK $0-$7.40 (Tier 2) PAR; MO; QLL (4.8 per 365 days) HUMIRA PEN $0-$7.40 (Tier 2) PAR; MO; QLL (3.2 per 28 days) HUMIRA PSORIASIS STARTER PACK $0-$7.40 (Tier 2) PAR; MO; QLL (3.2 per 28 days) OSTEOPOROSIS THERAPY 76B OTHER RHEUMATOLOGICALS 7B B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 102 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML, 20 MG/0.4 ML $0-$7.40 (Tier 2) PAR; MO; QLL (2 per 28 days) HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML $0-$7.40 (Tier 2) PAR; MO; QLL (3.2 per 28 days) KINERET $0-$7.40 (Tier 2) PAR; MO; QLL (28 per 28 days) leflunomide $0-$7.40 (Tier 2) MO ORENCIA $0-$7.40 (Tier 2) PAR; MO; QLL (4 per 28 days) ORENCIA (WITH MALTOSE) $0-$7.40 (Tier 2) PAR; MO RIDAURA $0-$7.40 (Tier 2) MO SAVELLA ORAL TABLET 100 MG $0-$7.40 (Tier 2) MO; QLL (60 per 30 days) SAVELLA ORAL TABLET 12.5 MG $0-$7.40 (Tier 2) MO; QLL (480 per 30 days) SAVELLA ORAL TABLET 25 MG $0-$7.40 (Tier 2) MO; QLL (240 per 30 days) SAVELLA ORAL TABLET 50 MG $0-$7.40 (Tier 2) MO; QLL (120 per 30 days) SAVELLA ORAL TABLETS,DOSE PACK $0-$7.40 (Tier 2) MO; QLL (110 per 365 days) SIMPONI $0-$7.40 (Tier 2) PAR; MO; QLL (1 per 28 days) camila $0-$7.40 (Tier 2) MO DEPO-PROVERA INTRAMUSCULAR SOLUTION 400 MG/ML $0-$7.40 (Tier 2) MO errin $0-$7.40 (Tier 2) MO estradiol oral $0-$7.40 (Tier 2) PAR; MO estradiol transdermal patch weekly $0-$7.40 (Tier 2) PAR; MO; QLL (4 per 28 days) lyza $0-$7.40 (Tier 2) medroxyprogesterone $0-$7.40 (Tier 2) MO MENEST $0-$7.40 (Tier 2) PAR; MO nora-be $0-$7.40 (Tier 2) MO norethindrone (contraceptive) $0-$7.40 (Tier 2) MO OBSTETRICS / GYNECOLOGY 1B ESTROGENS / PROGESTINS 78B ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 103 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso norethindrone acetate $0-$7.40 (Tier 2) MO ORTHO MICRONOR $0-$7.40 (Tier 2) MO PREMARIN ORAL $0-$7.40 (Tier 2) PAR; MO PREMARIN VAGINAL $0-$7.40 (Tier 2) MO PREMPRO $0-$7.40 (Tier 2) PAR; MO progesterone micronized $0-$7.40 (Tier 2) ST; MO MISCELLANEOUS OB/GYN 79B 3 day vaginal $0 (Tier 4) [*] 3-day vaginal $0 (Tier 4) [*] $0-$7.40 (Tier 2) MO clindamycin phosphate vaginal clotrimazole 3 day $0 (Tier 4) MO; [*] clotrimazole vaginal cream $0 (Tier 4) MO; [*] clotrimazole-3 $0 (Tier 4) [*] clotrimazole-7 $0 (Tier 4) [*] GYNE-LOTRIMIN 7 $0 (Tier 4) [*] GYNE-LOTRIMIN VAGINAL CREAM 2 % $0 (Tier 4) MO; [*] metronidazole vaginal $0-$7.40 (Tier 2) MO miconazole 7 $0 (Tier 4) MO; [*] miconazole nitrate vaginal comb pack,prefill appl & cream $0 (Tier 4) [*] miconazole nitrate vaginal cream $0 (Tier 4) MO; [*] miconazole nitrate vaginal kit 1,200-2 mg-% $0 (Tier 4) [*] miconazole nitrate vaginal suppository $0 (Tier 4) [*] miconazole-3 vaginal kit $0 (Tier 4) [*] miconazole-3 vaginal suppository $0-$7.40 (Tier 2) MO; QLL (6 per 30 days) NUVARING $0-$7.40 (Tier 2) MO ORTHO EVRA $0-$7.40 (Tier 2) MO terconazole $0-$7.40 (Tier 2) MO B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 104 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso tioconazole $0 (Tier 4) [*] tioconazole-1 $0 (Tier 4) [*] tranexamic acid oral $0-$7.40 (Tier 2) MO XULANE $0-$7.40 (Tier 2) MO ORAL CONTRACEPTIVES / RELATED AGENTS 80B AFTERA $0 (Tier 4) [*] altavera (28) $0-$7.40 (Tier 2) MO alyacen 1/35 (28) $0-$7.40 (Tier 2) MO alyacen 7/7/7 (28) $0-$7.40 (Tier 2) MO apri $0-$7.40 (Tier 2) MO aranelle (28) $0-$7.40 (Tier 2) MO aviane $0-$7.40 (Tier 2) MO azurette (28) $0-$7.40 (Tier 2) MO caziant (28) $0-$7.40 (Tier 2) MO cryselle (28) $0-$7.40 (Tier 2) MO cyclafem 1/35 (28) $0-$7.40 (Tier 2) MO cyclafem 7/7/7 (28) $0-$7.40 (Tier 2) MO drospirenone-ethinyl estradiol $0-$7.40 (Tier 2) MO $0 (Tier 4) [*] elinest $0-$7.40 (Tier 2) MO ELLA $0-$7.40 (Tier 2) MO enpresse $0-$7.40 (Tier 2) MO fallback solo $0 (Tier 4) [*] falmina (28) $0-$7.40 (Tier 2) MO gildagia $0-$7.40 (Tier 2) MO gildess fe $0-$7.40 (Tier 2) MO junel 1.5/30 (21) $0-$7.40 (Tier 2) MO junel 1/20 (21) $0-$7.40 (Tier 2) MO junel fe 1.5/30 (28) $0-$7.40 (Tier 2) MO econtra ez ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 105 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso junel fe 1/20 (28) $0-$7.40 (Tier 2) MO kariva (28) $0-$7.40 (Tier 2) MO kelnor 1/35 (28) $0-$7.40 (Tier 2) MO LARIN 1/20 (21) $0-$7.40 (Tier 2) MO LARIN FE $0-$7.40 (Tier 2) MO lessina $0-$7.40 (Tier 2) MO levonest (28) $0-$7.40 (Tier 2) MO $0 (Tier 4) [*] levonorgestrel-ethinyl estrad oral tablet 0.15-0.03 mg $0-$7.40 (Tier 2) MO levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month $0-$7.40 (Tier 2) MO low-ogestrel (28) $0-$7.40 (Tier 2) MO lutera (28) $0-$7.40 (Tier 2) MO marlissa $0-$7.40 (Tier 2) MO MICROGESTIN 1.5/30 (21) $0-$7.40 (Tier 2) MO MICROGESTIN 1/20 (21) $0-$7.40 (Tier 2) MO MICROGESTIN FE 1.5/30 (28) $0-$7.40 (Tier 2) MO MICROGESTIN FE 1/20 (28) $0-$7.40 (Tier 2) MO mono-linyah $0-$7.40 (Tier 2) MO mononessa (28) $0-$7.40 (Tier 2) MO my way $0 (Tier 4) [*] myzilra $0-$7.40 (Tier 2) MO necon 0.5/35 (28) $0-$7.40 (Tier 2) MO necon 1/35 (28) $0-$7.40 (Tier 2) MO necon 1/50 (28) $0-$7.40 (Tier 2) MO necon 10/11 (28) $0-$7.40 (Tier 2) MO necon 7/7/7 (28) $0-$7.40 (Tier 2) MO $0 (Tier 4) [*] levonorgestrel oral tablet 1.5 mg next choice one dose B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 106 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso norgestimate-ethinyl estradiol $0-$7.40 (Tier 2) MO nortrel 0.5/35 (28) $0-$7.40 (Tier 2) MO nortrel 1/35 (21) $0-$7.40 (Tier 2) MO nortrel 1/35 (28) $0-$7.40 (Tier 2) MO nortrel 7/7/7 (28) $0-$7.40 (Tier 2) MO ocella $0-$7.40 (Tier 2) MO ogestrel (28) $0-$7.40 (Tier 2) MO PLAN B ONE-STEP $0 (Tier 4) MO; [*] portia $0-$7.40 (Tier 2) MO previfem $0-$7.40 (Tier 2) MO reclipsen (28) $0-$7.40 (Tier 2) MO sprintec (28) $0-$7.40 (Tier 2) MO syeda $0-$7.40 (Tier 2) MO TAKE ACTION $0 (Tier 4) [*] tri-previfem (28) $0-$7.40 (Tier 2) MO tri-sprintec (28) $0-$7.40 (Tier 2) MO trivora (28) $0-$7.40 (Tier 2) MO velivet triphasic regimen (28) $0-$7.40 (Tier 2) MO viorele (28) $0-$7.40 (Tier 2) MO zarah $0-$7.40 (Tier 2) MO zenchent (28) $0-$7.40 (Tier 2) MO zovia 1/35e (28) $0-$7.40 (Tier 2) MO zovia 1/50e (28) $0-$7.40 (Tier 2) MO $0-$7.40 (Tier 2) MO OXYTOCICS 81B methylergonovine oral ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 107 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso ak-poly-bac $0-$7.40 (Tier 2) MO bacitracin ophthalmic $0-$7.40 (Tier 2) MO bacitracin-polymyxin b ophthalmic $0-$7.40 (Tier 2) MO BESIVANCE $0-$7.40 (Tier 2) MO ciprofloxacin hcl ophthalmic $0-$7.40 (Tier 2) MO erythromycin ophthalmic $0-$7.40 (Tier 2) MO gentak ophthalmic ointment $0-$7.40 (Tier 2) MO gentamicin ophthalmic $0-$7.40 (Tier 2) MO neomycin-bacitracin-polymyxin $0-$7.40 (Tier 2) MO neomycin-polymyxin-gramicidin $0-$7.40 (Tier 2) MO neo-polycin $0-$7.40 (Tier 2) ofloxacin ophthalmic $0-$7.40 (Tier 2) polycin $0-$7.40 (Tier 2) polymyxin b sulf-trimethoprim $0-$7.40 (Tier 2) MO tobramycin $0-$7.40 (Tier 2) MO VIGAMOX $0-$7.40 (Tier 2) MO trifluridine $0-$7.40 (Tier 2) MO ZIRGAN $0-$7.40 (Tier 2) MO betaxolol ophthalmic $0-$7.40 (Tier 2) MO carteolol $0-$7.40 (Tier 2) MO levobunolol ophthalmic drops 0.5 % $0-$7.40 (Tier 2) MO OPHTHALMOLOGY 12B ANTIBIOTICS 82B MO ANTIVIRALS 83B BETA-BLOCKERS 84B B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 108 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso metipranolol $0-$7.40 (Tier 2) MO timolol maleate ophthalmic $0-$7.40 (Tier 2) MO TIMOPTIC OCUDOSE (PF) $0-$7.40 (Tier 2) MO $0-$7.40 (Tier 2) MO CHOLINESTERASE INHIBITOR MIOTICS 85B PHOSPHOLINE IODIDE MISCELLANEOUS OPHTHALMOLOGICS 86B advanced eye relief $0 (Tier 4) MO; [*] akwa tears $0 (Tier 4) MO; [*] akwa tears (polyvinyl alcohol) $0 (Tier 4) MO; [*] alaway $0 (Tier 4) MO; [*] allergy eye (ketotifen) $0 (Tier 4) [*] altachlore ophthalmic ointment $0 (Tier 4) [*] artificial tears (polyvin alc) $0 (Tier 4) MO; [*] artificial tears ophthalmic drops , 0.5-0.6 % $0 (Tier 4) [*] artificial tears(glycerin-peg) $0 (Tier 4) [*] artificial tears(hypromellose) $0 (Tier 4) [*] $0-$7.40 (Tier 2) MO $0 (Tier 4) [*] $0-$7.40 (Tier 2) MO eye itch relief $0 (Tier 4) [*] itchy eye drops $0 (Tier 4) [*] ketotifen fumarate $0 (Tier 4) MO; [*] liquitears $0 (Tier 4) MO; [*] lubricant eye (pg-peg 400) $0 (Tier 4) [*] lubricant eye (polyv alcohol) $0 (Tier 4) [*] lubricant eye drops $0 (Tier 4) [*] lubricant eye drops (glyc-pg) $0 (Tier 4) [*] lubricating plus $0 (Tier 4) [*] azelastine ophthalmic children's alaway cromolyn ophthalmic ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 109 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso moisture drops $0 (Tier 4) [*] MOISTURIZING LUBRICANT $0 (Tier 4) [*] MURO 128 OPHTHALMIC DROPS 2 % $0 (Tier 4) MO; [*] MURO 128 OPHTHALMIC OINTMENT $0 (Tier 4) MO; [*] natural balance $0 (Tier 4) MO; [*] nature's tears $0 (Tier 4) [*] PATADAY $0-$7.40 (Tier 2) MO PAZEO $0-$7.40 (Tier 2) MO polyvinyl alcohol $0 (Tier 4) [*] REFRESH CLASSIC (PF) $0 (Tier 4) MO; [*] REFRESH LACRI-LUBE $0 (Tier 4) MO; [*] REFRESH TEARS $0 (Tier 4) MO; [*] RESTASIS $0-$7.40 (Tier 2) MO retaine cmc $0 (Tier 4) [*] revive plus $0 (Tier 4) [*] sochlor ophthalmic ointment $0 (Tier 4) [*] sodium chloride ophthalmic ointment $0 (Tier 4) MO; [*] SYSTANE $0 (Tier 4) MO; [*] SYSTANE (PF) $0 (Tier 4) MO; [*] SYSTANE ULTRA $0 (Tier 4) MO; [*] SYSTANE ULTRA (PF) $0 (Tier 4) MO; [*] tears again $0 (Tier 4) MO; [*] TEARS NATURALE II $0 (Tier 4) MO; [*] tears pure $0 (Tier 4) [*] ultra fresh $0 (Tier 4) [*] ULTRA LUBRICANT EYE $0 (Tier 4) [*] wal-zyr (ketotifen) $0 (Tier 4) [*] ZADITOR $0 (Tier 4) MO; [*] B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 110 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso NON-STEROIDAL ANTI-INFLAMMATORY AGENTS 87B flurbiprofen sodium drops $0-$7.40 (Tier 2) MO ILEVRO $0-$7.40 (Tier 2) MO ketorolac ophthalmic $0-$7.40 (Tier 2) MO NEVANAC $0-$7.40 (Tier 2) MO acetazolamide oral $0-$7.40 (Tier 2) MO acetazolamide sodium $0-$7.40 (Tier 2) MO methazolamide oral $0-$7.40 (Tier 2) MO AZOPT $0-$7.40 (Tier 2) MO bimatoprost $0-$7.40 (Tier 2) MO COMBIGAN $0-$7.40 (Tier 2) MO dorzolamide $0-$7.40 (Tier 2) MO dorzolamide-timolol $0-$7.40 (Tier 2) MO latanoprost $0-$7.40 (Tier 2) MO LUMIGAN OPHTHALMIC DROPS 0.01 % $0-$7.40 (Tier 2) MO TRAVATAN Z $0-$7.40 (Tier 2) MO; QLL (5 per 30 days) neomycin-bacitracin-poly-hc $0-$7.40 (Tier 2) MO neomycin-polymyxin b-dexameth $0-$7.40 (Tier 2) MO neomycin-polymyxin-hc ophthalmic $0-$7.40 (Tier 2) MO neo-polycin hc $0-$7.40 (Tier 2) tobramycin-dexamethasone opth susp $0-$7.40 (Tier 2) MO dexamethasone sodium phosphate ophthalmic $0-$7.40 (Tier 2) MO fluorometholone $0-$7.40 (Tier 2) MO ORAL DRUGS FOR GLAUCOMA 8B OTHER GLAUCOMA DRUGS 89B STEROID-ANTIBIOTIC COMBINATIONS 90B STEROIDS 91B ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 111 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso prednisolone acetate $0-$7.40 (Tier 2) MO prednisolone sodium phosphate ophthalmic $0-$7.40 (Tier 2) MO BLEPHAMIDE S.O.P. $0-$7.40 (Tier 2) MO sulfacetamide-prednisolone $0-$7.40 (Tier 2) MO $0-$7.40 (Tier 2) MO ALPHAGAN P OPHTHALMIC DROPS 0.1 % $0-$7.40 (Tier 2) MO apraclonidine $0-$7.40 (Tier 2) MO brimonidine $0-$7.40 (Tier 2) MO $0-$7.40 (Tier 2) MO STEROID-SULFONAMIDE COMBINATIONS 92B SULFONAMIDES 93B sulfacetamide sodium ophthalmic drops SYMPATHOMIMETICS 94B VASOCONSTRICTOR DECONGESTANTS 95B naphazoline RESPIRATORY AND ALLERGY 13B ANTIHISTAMINE / ANTIALLERGENIC AGENTS 96B 12 hour cold relief $0 (Tier 4) [*] 12 hour decongestant $0 (Tier 4) [*] adt robitussin peak cld dm max $0 (Tier 4) MO; [*] adult cough formula dm max $0 (Tier 4) [*] adult robitussin lingering cld $0 (Tier 4) [*] adult robitussin m-s cold $0 (Tier 4) [*] ADULT ROBITUSSIN NIGHT M-S CLD $0 (Tier 4) [*] adult robitussin peak cold dm $0 (Tier 4) MO; [*] adult robitussin peak cold m-s $0 (Tier 4) [*] B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 112 Nombre del medicamento Qué le costará el medicamento (nivel de clase) adult tussin chest congestion $0 (Tier 4) [*] adult tussin cough congest dm $0 (Tier 4) [*] adult tussin dm $0 (Tier 4) [*] adult tussin multi-symp cold $0 (Tier 4) [*] adult wal-tussin $0 (Tier 4) [*] adult wal-tussin dm max $0 (Tier 4) [*] ADVIL ALLERGY SINUS $0 (Tier 4) [*] ADVIL ALLERGY-CONGESTION RLF $0 (Tier 4) [*] ADVIL COLD & SINUS ORAL CAPSULE $0 (Tier 4) MO; [*] advil cold & sinus oral tablet $0 (Tier 4) [*] ALA-HIST DM $0 (Tier 4) MO; [*] ala-hist ir $0 (Tier 4) MO; [*] alavert d-12 allergy-sinus $0 (Tier 4) MO; [*] alavert oral tablet,disintegrating $0 (Tier 4) MO; [*]; QLL (30 per 30 days) ALDEX GS $0 (Tier 4) [*] aler-cap $0 (Tier 4) [*] aler-tab $0 (Tier 4) [*] ALEVE COLD & SINUS $0 (Tier 4) [*] ALEVE SINUS & HEADACHE $0 (Tier 4) [*] ALEVE-D SINUS & COLD $0 (Tier 4) [*] ALEVE-D SINUS & HEADACHE $0 (Tier 4) [*] alka-seltzer plus allergy $0 (Tier 4) [*] ALKA-SELTZER PLUS DAY $0 (Tier 4) [*] ALKA-SELTZER PLUS SINUS-COUGH $0 (Tier 4) [*] all day allergy (cetirizine) oral tablet $0 (Tier 4) MO; [*]; QLL (30 per 30 days) all day allergy (cetirizine) oral tablet,chewable 10 mg $0 (Tier 4) MO; [*] all day allergy relief(cetir) $0 (Tier 4) [*]; QLL (30 per 30 days) all day allergy-d $0 (Tier 4) MO; [*] ALL DAY PAIN RELIEF SINUS & CO $0 (Tier 4) [*] ? Acciones necesarias, restricciones, o límites sobre el uso Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 113 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso ALLER-CHLOR ORAL SYRUP $0 (Tier 4) [*] aller-chlor oral tablet $0 (Tier 4) MO; [*] allerclear $0 (Tier 4) [*]; QLL (30 per 30 days) allerclear d-12hr $0 (Tier 4) [*] allerclear d-24hr $0 (Tier 4) MO; [*] aller-ease $0 (Tier 4) [*] aller-fex $0 (Tier 4) [*] aller-g-time $0 (Tier 4) [*] allergy & congestion relief $0 (Tier 4) [*] allergy (chlorpheniramine) $0 (Tier 4) MO; [*] allergy (diphenhydramine) $0 (Tier 4) [*] allergy 4-hour $0 (Tier 4) [*] allergy complete-d $0 (Tier 4) [*] allergy d-12 $0 (Tier 4) [*] allergy medication $0 (Tier 4) [*] allergy medicine $0 (Tier 4) [*] allergy m-s nighttime $0 (Tier 4) [*] allergy multi-symptom $0 (Tier 4) [*] allergy plus severe sinus ha $0 (Tier 4) [*] allergy relief & nasal deconge $0 (Tier 4) MO; [*] allergy relief (cetirizine) oral tablet $0 (Tier 4) [*]; QLL (30 per 30 days) allergy relief (clemastine) $0 (Tier 4) MO; [*] allergy relief (fexofenadine) $0 (Tier 4) [*] allergy relief (loratadine) oral solution $0 (Tier 4) [*] allergy relief (loratadine) oral tablet $0 (Tier 4) MO; [*]; QLL (30 per 30 days) allergy relief (loratadine) oral tablet,disintegrating $0 (Tier 4) [*]; QLL (30 per 30 days) allergy relief d12 $0 (Tier 4) [*] allergy relief d-24 $0 (Tier 4) [*] B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 114 Nombre del medicamento Qué le costará el medicamento (nivel de clase) allergy relief multi-symptom $0 (Tier 4) [*] allergy relief(chlorpheniramn) $0 (Tier 4) [*] allergy relief(diphenhydramin) $0 (Tier 4) [*] allergy relief-d (cetirizine) $0 (Tier 4) [*] allergy relief-d (loratadine) $0 (Tier 4) [*] allergy relief-d(fexofenadine) $0 (Tier 4) [*] ALLERGY RELIEF-SINUS HEADACHE $0 (Tier 4) [*] allergy sinus pe $0 (Tier 4) [*] allergy-congestion relief-d $0 (Tier 4) [*] allergy-time $0 (Tier 4) [*] allerhist-1 $0 (Tier 4) [*] aller-tec $0 (Tier 4) [*]; QLL (30 per 30 days) aller-tec d $0 (Tier 4) [*] allfen $0 (Tier 4) [*] allfen dm $0 (Tier 4) MO; [*] ALL-NITE COLD-FLU ORAL LIQUID 6.25-15325 MG/15 ML $0 (Tier 4) [*] ambi 60pse-400gfn $0 (Tier 4) MO; [*] antitussive dm $0 (Tier 4) [*] ap-hist dm $0 (Tier 4) [*] arbinoxa $0-$7.40 (Tier 2) Acciones necesarias, restricciones, o límites sobre el uso PAR; MO BALAMINE DM (CHLOR-PE) $0 (Tier 4) [*] banophen allergy $0 (Tier 4) MO; [*] banophen oral capsule 25 mg $0 (Tier 4) MO; [*] banophen oral capsule 50 mg $0 (Tier 4) [*] banophen oral liquid $0 (Tier 4) MO; [*] banophen oral tablet $0 (Tier 4) [*] benzonatate oral capsule 100 mg $0 (Tier 3) MO; [*] biocotron $0 (Tier 4) [*] bionel $0 (Tier 4) [*] ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 115 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso BIONEL PEDIATRIC $0 (Tier 4) [*] bp 8 cough $0 (Tier 4) [*] brompheniramine-pseudoeph-dm oral syrup $0 (Tier 3) MO; [*] bronchial asthma relief $0 (Tier 4) [*] brotapp dm $0 (Tier 4) [*] BROVEX PEB DM $0 (Tier 4) [*] CAPCOF $0 (Tier 3) MO; [*] CAPMIST DM ORAL TABLET 60-15-400 MG $0 (Tier 4) MO; [*] CAPRON DM $0 (Tier 4) [*] cetiri-d $0 (Tier 4) [*] cetirizine oral tablet $0 (Tier 4) MO; [*]; QLL (30 per 30 days) cetirizine oral tablet,chewable $0 (Tier 4) MO; [*] cetirizine-pseudoephedrine $0 (Tier 4) MO; [*] cheratussin ac $0 (Tier 3) MO; [*] cheratussin dac $0 (Tier 3) MO; [*] chest congestion relief + dm $0 (Tier 4) [*] chest congestion relief d $0 (Tier 4) [*] chest congestion relief oral tablet $0 (Tier 4) [*] chest congestion relief pe $0 (Tier 4) [*] chest congestion-cough relief $0 (Tier 4) [*] chest-sinus congestion relief $0 (Tier 4) [*] child allergy relf(cetirizine) oral tablet,chewable 10 mg $0 (Tier 4) [*] child chest congestion + cough $0 (Tier 4) [*] child delsym cough+chest dm $0 (Tier 4) [*] CHILD DELSYM COUGH+COLD $0 (Tier 4) [*] child mucinex chest congestion $0 (Tier 4) [*] CHILD MUCINEX CONGESTION-COUGH $0 (Tier 4) [*] CHILD MUCINEX STUFFY NOSE-COLD $0 (Tier 4) MO; [*] B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 116 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso child mucus relief cough $0 (Tier 4) [*] child mucus relief expectorant $0 (Tier 4) [*] child multi-symptom cold/cough $0 (Tier 4) [*] children night time cold-cough $0 (Tier 4) [*] children's allergy (diphenhyd) oral elixir $0 (Tier 4) [*] children's allergy (diphenhyd) oral liquid $0 (Tier 4) [*] children's allergy relief(lor) $0 (Tier 4) [*] children's cetirizine oral tablet,chewable $0 (Tier 4) MO; [*] children's chest congestion $0 (Tier 4) [*] CHILDREN'S CLARITIN $0 (Tier 4) MO; [*] children's cold & cough $0 (Tier 4) [*] children's cold & cough dm $0 (Tier 4) [*] CHILDREN'S COLD-COUGH-SORE $0 (Tier 4) [*] children's cough $0 (Tier 4) [*] children's dibromm dm cold & c $0 (Tier 4) [*] children's flu relief $0 (Tier 4) [*] CHILDREN'S MUCINEX COLD-FEVER $0 (Tier 4) [*] children's mucinex cough $0 (Tier 4) [*] CHILDREN'S MUCINEX MULTI-SYMP $0 (Tier 4) [*] CHILDREN'S MUCINEX NIGHT TIME $0 (Tier 4) [*] childrens plus cold oral suspension 1-2.5-5-160 mg/5 ml $0 (Tier 4) [*] children's plus flu $0 (Tier 4) [*] children's silfedrine $0 (Tier 4) [*] children's sudafed pe cough $0 (Tier 4) [*] children's wal-dryl allergy oral liquid $0 (Tier 4) [*] children's wal-dryl allergy oral prefilled spoon $0 (Tier 4) [*] children's wal-zyr oral tablet,chewable $0 (Tier 4) [*] CHILD'S MUCUS RELIEF M-S COLD $0 (Tier 4) [*] childs triacting cold & cough $0 (Tier 4) [*] ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 117 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso CHLO TUSS EX $0 (Tier 4) [*] chlorhist $0 (Tier 4) [*] chlorpheniramine maleate oral tablet $0 (Tier 4) [*] chlorpheniramine maleate oral tablet extended release $0 (Tier 4) MO; [*] chlortabs $0 (Tier 4) [*] CLARITIN LIQUI-GEL $0 (Tier 4) MO; [*] CLARITIN ORAL SOLUTION $0 (Tier 4) [*] CLARITIN ORAL TABLET $0 (Tier 4) MO; [*]; QLL (30 per 30 days) CLARITIN REDITABS ORAL TABLET,DISINTEGRATING 10 MG $0 (Tier 4) MO; [*]; QLL (30 per 30 days) CLARITIN REDITABS ORAL TABLET,DISINTEGRATING 5 MG $0 (Tier 4) MO; [*] CLARITIN-D 12 HOUR $0 (Tier 4) MO; [*] CLARITIN-D 24 HOUR $0 (Tier 4) MO; [*] clemastine oral tablet 1.34 mg $0 (Tier 4) MO; [*] clemastine oral tablet 2.68 mg $0-$7.40 (Tier 2) PAR; MO codeine-guaifenesin $0 (Tier 3) MO; [*] codituss dm $0 (Tier 4) MO; [*] cold & cough dm $0 (Tier 4) [*] cold & cough elixir $0 (Tier 4) [*] cold & cough oral liquid 6.25-2.5 mg/5 ml $0 (Tier 4) [*] COLD & FLU RELIEF $0 (Tier 4) [*] cold & flu severe $0 (Tier 4) [*] cold & sinus pain relief $0 (Tier 4) [*] cold head congestion day/nite $0 (Tier 4) [*] COLD HEAD CONGESTION DAYTIME $0 (Tier 4) [*] cold head congestion nighttime $0 (Tier 4) [*] cold head congestion sever day $0 (Tier 4) [*] B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 118 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso cold multi-symptom $0 (Tier 4) [*] cold multi-symptom (chlorphen) $0 (Tier 4) [*] COLD MULTI-SYMPTOM DAY/NIGHT $0 (Tier 4) [*] cold multi-symptom nighttime $0 (Tier 4) [*] cold relief m/s day/night $0 (Tier 4) [*] cold relief plus $0 (Tier 4) [*] cold severe congestion $0 (Tier 4) [*] cold-flu relief $0 (Tier 4) [*] cold-flu relief, day/night $0 (Tier 4) [*] cold-sinus relief $0 (Tier 4) [*] complete allergy $0 (Tier 4) [*] complete allergy medicine $0 (Tier 4) [*] congestac $0 (Tier 4) [*] CONTAC COLD-FLU NIGHT $0 (Tier 4) [*] CORICIDIN HBP COLD-MULTI SYMPT $0 (Tier 4) [*] CORICIDIN HBP COUGH & COLD $0 (Tier 4) MO; [*] CORICIDIN HBP ORAL CAPSULE $0 (Tier 4) [*] COUGH & COLD BP $0 (Tier 4) [*] cough & cold mucus relief cf $0 (Tier 4) [*] cough & cold oral liquid $0 (Tier 4) [*] cough & cold oral tablet $0 (Tier 4) [*] COUGH & SEVERE COLD $0 (Tier 4) [*] cough control (dextromethorph) $0 (Tier 4) [*] cough control (guaifenesin) $0 (Tier 4) [*] cough control cf (pe) $0 (Tier 4) [*] cough control dm $0 (Tier 4) [*] cough control dm max $0 (Tier 4) [*] cough dm er $0 (Tier 4) [*] cough formula dm $0 (Tier 4) [*] ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 119 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso cough relief $0 (Tier 4) [*] cough suppressant-expectorant $0 (Tier 4) [*] cough syrup $0 (Tier 4) [*] cough syrup dm $0 (Tier 4) [*] cough-sore throat night $0 (Tier 4) [*] coughtab $0 (Tier 4) [*] day time pe $0 (Tier 4) [*] dayhist allergy $0 (Tier 4) [*] daytime $0 (Tier 4) [*] daytime & nighttime cold $0 (Tier 4) [*] DAYTIME COLD & COUGH $0 (Tier 4) [*] daytime cold & flu relief (pe) $0 (Tier 4) [*] daytime cold-flu $0 (Tier 4) [*] day-time cough $0 (Tier 4) [*] day-time oral capsule 30-15-325 mg $0 (Tier 4) [*] DAYTIME SINUS $0 (Tier 4) [*] DAYTIME SINUS-CONGESTION $0 (Tier 4) [*] daytime-nighttime $0 (Tier 4) [*] DECONEX DMX $0 (Tier 4) MO; [*] DECONEX IR $0 (Tier 4) MO; [*] DELSYM 12 HOUR $0 (Tier 4) MO; [*] delsym cough+chest congest dm $0 (Tier 4) [*] DELSYM COUGH+COLD DAYTIME $0 (Tier 4) [*] DELSYM COUGH+COLD NIGHTTIME $0 (Tier 4) [*] DESPEC $0 (Tier 4) [*] DEXCHLORPHEN-PSE-CHLOPHEDIANOL $0 (Tier 4) [*] dextromethorphan polistirex $0 (Tier 4) [*] dextromethorphan-guaifenesin $0 (Tier 4) [*] B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 120 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso diabetic siltussin das-na $0 (Tier 4) [*] diabetic siltussin-dm $0 (Tier 4) [*] diabetic siltussin-dm max str $0 (Tier 4) [*] diabetic tussin dm oral liquid 10-100 mg/5 ml $0 (Tier 4) MO; [*] diabetic tussin dm oral liquid 10-200 mg/5 ml $0 (Tier 4) [*] diabetic tussin ex oral liquid $0 (Tier 4) MO; [*] diabetic tussin max st $0 (Tier 4) MO; [*] dimaphen dm $0 (Tier 4) MO; [*] dimetapp cold-congestion $0 (Tier 4) [*] dimetapp dm cold-cough (pe) $0 (Tier 4) [*] DIMETAPP LONG-ACTING (CPM-DM) $0 (Tier 4) [*] diphedryl allergy $0 (Tier 4) [*] diphedryl oral capsule $0 (Tier 4) [*] diphedryl oral liquid $0 (Tier 4) MO; [*] diphedryl oral tablet $0 (Tier 4) MO; [*] diphenhist oral capsule $0 (Tier 4) [*] diphenhist oral liquid $0 (Tier 4) MO; [*] diphenhist oral tablet 25 mg $0 (Tier 4) MO; [*] diphenhydramine hcl injection solution 50 mg/ml $0-$7.40 (Tier 2) PAR; MO diphenhydramine hcl injection syringe $0-$7.40 (Tier 2) PAR; MO diphenhydramine hcl oral capsule $0 (Tier 4) MO; [*] diphenhydramine hcl oral elixir $0 (Tier 4) [*] diphenhydramine hcl oral liquid $0 (Tier 4) [*] diphenhydramine hcl oral syrup $0 (Tier 4) [*] diphenhydramine hcl oral tablet 25 mg $0 (Tier 4) [*] dm max $0 (Tier 4) [*] DONATUSSIN $0 (Tier 4) MO; [*] dristan cold $0 (Tier 4) [*] DURAFLU $0 (Tier 4) MO; [*] ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 121 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso ed a-hist dm oral liquid $0 (Tier 4) MO; [*] ed bron gp $0 (Tier 4) [*] ed chlorped jr $0 (Tier 4) [*] ED-CHLORPED $0 (Tier 4) [*] ed-chlortan $0 (Tier 4) MO; [*] endacof - dm $0 (Tier 4) [*] endacof-c $0 (Tier 3) MO; [*] ENTEX T $0 (Tier 4) MO; [*] entre-cough $0 (Tier 4) [*] epinephrine injection solution 1 mg/ml (1:1,000) $0-$7.40 (Tier 2) MO epinephrine injection syringe 0.1 mg/ml (1:10,000) $0-$7.40 (Tier 2) MO EPIPEN 2-PAK $0-$7.40 (Tier 2) MO; QLL (2 per 2 days) EPIPEN JR 2-PAK $0-$7.40 (Tier 2) MO; QLL (2 per 2 days) expectorant cough syrup $0 (Tier 4) [*] expectorant oral liquid $0 (Tier 4) [*] fenesin ir $0 (Tier 4) [*] fenesin pe ir $0 (Tier 4) [*] fexofenadine oral tablet 180 mg, 60 mg $0 (Tier 4) MO; [*] FLU & SEVERE COLD-DAYTIME $0 (Tier 4) [*] flu relief therapy daytime $0 (Tier 4) [*] FLU-SEVERE COLD-COUGH DAYTIME $0 (Tier 4) [*] FLU-SEVERE COLD-COUGH NIGHT $0 (Tier 4) [*] geri-tussin $0 (Tier 4) [*] GILPHEX TR $0 (Tier 4) [*] g-tron $0 (Tier 4) [*] guaiatussin ac $0 (Tier 3) [*] guaifenesin ac $0 (Tier 3) [*] guaifenesin dac $0 (Tier 3) MO; [*] B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 122 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso guaifenesin oral liquid $0 (Tier 4) [*] guaifenesin oral tablet 200 mg $0 (Tier 4) MO; [*] guaifenesin oral tablet extended release 12hr $0 (Tier 4) MO; [*] guaifenesin-dm $0 (Tier 4) [*] HEAD CONGESTION COLD RELIEF $0 (Tier 4) [*] hot steam liquid $0 (Tier 4) [*] hydrocodone-chlorpheniramine $0 (Tier 3) MO; [*] hydrocodone-homatropine oral syrup 5-1.5 mg/5 ml $0 (Tier 3) MO; [*] HYDROCODONE-HOMATROPINE ORAL SYRUP 5-1.5 MG/5 ML (5 ML) $0 (Tier 3) [*] hydrocodone-homatropine oral tablet $0 (Tier 3) MO; [*] hydromet $0 (Tier 3) MO; [*] ibuprofen cold $0 (Tier 4) [*] ibuprofen cold-sinus(with pse) $0 (Tier 4) [*] INTENSE COUGH $0 (Tier 4) [*] INTENSE COUGH RELIEVER $0 (Tier 4) [*] iophen c-nr $0 (Tier 3) MO; [*] iophen dm-nr $0 (Tier 4) MO; [*] iophen-nr $0 (Tier 4) MO; [*] J-MAX $0 (Tier 4) MO; [*] J-TAN PD $0 (Tier 4) MO; [*] kidkare cough/cold $0 (Tier 4) [*] levocetirizine oral tablet $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) LIQUITUSS GG $0 (Tier 4) [*] lohist peb dm $0 (Tier 4) [*] loradamed $0 (Tier 4) MO; [*]; QLL (30 per 30 days) lorata-d $0 (Tier 4) [*] lorata-dine d $0 (Tier 4) [*] loratadine oral solution $0 (Tier 4) MO; [*] ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 123 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso loratadine oral tablet $0 (Tier 4) MO; [*]; QLL (30 per 30 days) loratadine oral tablet,disintegrating $0 (Tier 4) MO; [*]; QLL (30 per 30 days) loratadine-d $0 (Tier 4) MO; [*] LORTUSS DM $0 (Tier 4) MO; [*] mapap cold formula $0 (Tier 4) [*] mapap sinus max strength (pe) $0 (Tier 4) [*] MAR-COF BP $0 (Tier 3) [*] MAR-COF CG $0 (Tier 3) MO; [*] maxiphen $0 (Tier 4) MO; [*] MAXIPHEN DM $0 (Tier 4) [*] m-clear wc $0 (Tier 3) MO; [*] medicidin-d $0 (Tier 4) [*] medifin expectorant mucus rlf $0 (Tier 4) [*] medi-phedrine $0 (Tier 4) [*] medi-phedryl $0 (Tier 4) [*] medi-tussin $0 (Tier 4) [*] medi-tussin dm $0 (Tier 4) [*] medi-tussin dm diabetic $0 (Tier 4) [*] M-END DMX $0 (Tier 4) [*] M-END MAX D $0 (Tier 3) MO; [*] M-END PE $0 (Tier 3) MO; [*] mucaphed $0 (Tier 4) [*] MUCINEX COLD-FLU & SORE THROAT $0 (Tier 4) [*] MUCINEX FAST-MAX COLD-FLU-THRT ORAL TABLET $0 (Tier 4) [*] MUCINEX FAST-MAX COLD-SINUS $0 (Tier 4) [*] MUCINEX FAST-MAX CONGEST-COUGH ORAL LIQUID $0 (Tier 4) MO; [*] B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 124 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso MUCINEX FAST-MAX CONGEST-COUGH ORAL TABLET $0 (Tier 4) [*] mucinex fast-max dm max $0 (Tier 4) [*] MUCINEX FAST-MAX NITE COLD-FLU $0 (Tier 4) [*] MUCINEX FAST-MAX SEVERE COLD $0 (Tier 4) [*] MUCINEX MINI-MELTS ORAL GRANULES IN PACKET 100 MG $0 (Tier 4) MO; [*] MUCINEX SINUS-MAX PRESSUR-PAIN ORAL TABLET $0 (Tier 4) [*] MUCINEX SINUS-MAX SEV CONGESTN ORAL TABLET $0 (Tier 4) [*] mucosa $0 (Tier 4) [*] mucosa dm $0 (Tier 4) [*] mucus and cough relief $0 (Tier 4) [*] mucus relief chest $0 (Tier 4) [*] MUCUS RELIEF COLD & SINUS ORAL TABLET $0 (Tier 4) [*] MUCUS RELIEF COLD-FLU-SORE THR ORAL TABLET $0 (Tier 4) [*] MUCUS RELIEF CONGESTION-COUGH $0 (Tier 4) [*] mucus relief cough $0 (Tier 4) [*] mucus relief d (phenylephrine) $0 (Tier 4) [*] mucus relief dm $0 (Tier 4) MO; [*] mucus relief dm max $0 (Tier 4) [*] mucus relief er oral tablet extended release 12hr $0 (Tier 4) [*] mucus relief oral tablet 200 mg $0 (Tier 4) [*] mucus relief oral tablet 400 mg $0 (Tier 4) MO; [*] mucus relief pe $0 (Tier 4) [*] mucus relief plus $0 (Tier 4) [*] MUCUS RELIEF SEV CONGEST-COLD $0 (Tier 4) [*] mucus relief sinus $0 (Tier 4) [*] ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 125 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso MUCUS RLF SEVERE SINUS CONGEST $0 (Tier 4) [*] multi-symptom cold (pe & cpm) $0 (Tier 4) [*] multi-symptom cold (pe) $0 (Tier 4) [*] multi-symptom cold daytime $0 (Tier 4) [*] multi-symptom cold night time $0 (Tier 4) [*] nasal decongestant (pe) oral tablet 10 mg $0 (Tier 4) [*] nasal decongestant (pseudoeph) $0 (Tier 4) [*] night time cold & flu relief $0 (Tier 4) [*] night time cold oral tablet $0 (Tier 4) [*] NIGHT TIME COLD-FLU ORAL LIQUID $0 (Tier 4) [*] NIGHT TIME COLD-FLU RELIEF ORAL LIQUID 12.5-30-1,000 MG/30 ML $0 (Tier 4) [*] night time cough & sore throat $0 (Tier 4) [*] night time oral capsule 6.25-15-325 mg $0 (Tier 4) [*] nightime sleep $0 (Tier 4) [*] nighttime cold-flu $0 (Tier 4) [*] nighttime cold-flu relief $0 (Tier 4) [*] nighttime cough $0 (Tier 4) [*] nighttime cough-cold $0 (Tier 4) [*] nighttime sinus $0 (Tier 4) [*] nighttime sleep aid (diphen) $0 (Tier 4) [*] nite time cold-flu formula $0 (Tier 4) [*] NITE TIME COLD-FLU ORAL LIQUID $0 (Tier 4) [*] NITE TIME COLD-FLU RELIEF $0 (Tier 4) [*] nite time cough $0 (Tier 4) [*] nite time-d cold-flu relief $0 (Tier 4) [*] nite-time $0 (Tier 4) [*] nite-time cold-flu $0 (Tier 4) [*] nitetime cough $0 (Tier 4) [*] B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 126 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso nitetime multi-symptom $0 (Tier 4) [*] nohist-dm $0 (Tier 4) [*] non-aspirin severe congest m-s $0 (Tier 4) [*] non-drowsy allergy $0 (Tier 4) [*]; QLL (30 per 30 days) NOREL AD $0 (Tier 4) MO; [*] nyquil d $0 (Tier 4) [*] organ-i nr $0 (Tier 4) MO; [*] ormir $0 (Tier 4) [*] pain relief allergy sinus $0 (Tier 4) [*] pain relief cold $0 (Tier 4) [*] PAIN RELIEF COLD & COUGH $0 (Tier 4) [*] PAIN RELIEF SINUS PE $0 (Tier 4) [*] pedia relief cough-cold $0 (Tier 4) [*] pediacare multi-symptom cold $0 (Tier 4) [*] PEDIATEX TDM $0 (Tier 4) [*] pediatric cough & cold oral liquid 1-15-5 mg/5 ml $0 (Tier 4) [*] pharbechlor $0 (Tier 4) [*] pharbedryl $0 (Tier 4) [*] phenylhistine dh $0 (Tier 3) MO; [*] POLY HIST PD $0 (Tier 4) [*] POLY-HIST DM (THONZYLAMINE) $0 (Tier 4) [*] poly-tussin $0 (Tier 3) [*] poly-tussin d $0 (Tier 3) [*] pres gen $0 (Tier 4) [*] PRESGEN B $0 (Tier 4) [*] PRESSURE & PAIN $0 (Tier 4) [*] PRIMATENE ASTHMA $0 (Tier 4) MO; [*] PRO-CHLO $0 (Tier 4) [*] PRO-CLEAR AC $0 (Tier 3) MO; [*] ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 127 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso promethazine injection solution $0-$7.40 (Tier 2) PAR; MO promethazine oral tablet 12.5 mg, 25 mg $0-$7.40 (Tier 2) PAR; MO promethazine vc-codeine $0 (Tier 3) MO; [*] promethazine-codeine $0 (Tier 3) MO; [*] promethazine-dm $0 (Tier 3) MO; [*] promethazine-phenyleph-codeine $0 (Tier 3) [*] promethegan rectal suppository 12.5 mg $0-$7.40 (Tier 2) PAR; MO PRO-RED AC (W/ DEXCHLORPHENIR) $0 (Tier 3) [*] pseudoephedrine hcl oral liquid $0 (Tier 4) MO; [*] pseudoephedrine hcl oral tablet 30 mg $0 (Tier 4) MO; [*] pseudoephedrine hcl oral tablet 60 mg $0 (Tier 4) [*] pseudoephedrine hcl oral tablet extended release $0 (Tier 4) MO; [*] q-dryl oral capsule $0 (Tier 4) [*] q-dryl oral liquid $0 (Tier 4) MO; [*] q-tapp dm $0 (Tier 4) MO; [*] q-tussin $0 (Tier 4) [*] q-tussin dm $0 (Tier 4) [*] quenalin $0 (Tier 4) [*] refenesen $0 (Tier 4) [*] refenesen dm $0 (Tier 4) [*] refenesen pe $0 (Tier 4) [*] relcof c $0 (Tier 3) [*] RESCON-DM $0 (Tier 4) MO; [*] rescon-gg $0 (Tier 4) MO; [*] RESPAIRE-30 $0 (Tier 4) MO; [*] rest simply nighttime sleep $0 (Tier 4) [*] restfully sleep $0 (Tier 4) [*] ri-tussin $0 (Tier 4) [*] B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 128 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso ri-tussin dm $0 (Tier 4) [*] robafen $0 (Tier 4) MO; [*] robafen cf oral liquid $0 (Tier 4) [*] robafen cough $0 (Tier 4) MO; [*] robafen dm $0 (Tier 4) MO; [*] robafen dm cough $0 (Tier 4) [*] robitussin cold-flu day $0 (Tier 4) MO; [*] robitussin cough & cold cf $0 (Tier 4) [*] ROBITUSSIN LONG-ACTING $0 (Tier 4) [*] robitussin pediatric $0 (Tier 4) MO; [*] RYCONTUSS $0 (Tier 4) [*] rydex $0 (Tier 3) [*] rynex dm $0 (Tier 4) [*] SCOT-TUSSIN DIABETES CF $0 (Tier 4) [*] scot-tussin dm $0 (Tier 4) [*] scot-tussin expectorant $0 (Tier 4) [*] SCOT-TUSSIN SENIOR $0 (Tier 4) [*] SEVERE ALLERGY-SINUS HEADACHE $0 (Tier 4) [*] severe cold $0 (Tier 4) [*] SEVERE COLD & FLU NIGHTTIME $0 (Tier 4) [*] severe cold multi-symptom $0 (Tier 4) [*] SEVERE CONGESTION & COUGH MAX $0 (Tier 4) [*] SEVERE SINUS $0 (Tier 4) [*] siladryl sa $0 (Tier 4) [*] silphen cough $0 (Tier 4) [*] siltussin dm das $0 (Tier 4) [*] siltussin sa $0 (Tier 4) MO; [*] siltussin-dm $0 (Tier 4) [*] simply sleep $0 (Tier 4) [*] ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 129 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso sinus & allergy non-drowsy $0 (Tier 4) [*] SINUS & COLD-D $0 (Tier 4) [*] sinus 12 hour $0 (Tier 4) [*] sinus cong & pain day-night $0 (Tier 4) [*] sinus congestion & pain $0 (Tier 4) [*] sinus congestion & pain(guaif) $0 (Tier 4) [*] sinus congestion&pain(chlorph) $0 (Tier 4) [*] sinus decongestant (pe) $0 (Tier 4) [*] sinus headache pe $0 (Tier 4) [*] sinus pain relief $0 (Tier 4) [*] sinus relief (non-drowsy) $0 (Tier 4) [*] sleep $0 (Tier 4) [*] sleep aid (diphenhydramine) oral capsule 50 mg $0 (Tier 4) [*] sleep aid (diphenhydramine) oral tablet $0 (Tier 4) [*] sleep aid max str (diphenhydr) $0 (Tier 4) [*] sleep ii $0 (Tier 4) [*] sleep tablet (diphenhydramine) $0 (Tier 4) [*] sleep-tabs $0 (Tier 4) [*] sorbugen nr $0 (Tier 4) [*] SUDAFED PE PRESSURE+PAIN+COUGH $0 (Tier 4) [*] sudogest $0 (Tier 4) MO; [*] sudogest 12-hour $0 (Tier 4) MO; [*] sudogest pe $0 (Tier 4) MO; [*] suphedrin $0 (Tier 4) [*] suphedrin 12 hour $0 (Tier 4) [*] suphedrine $0 (Tier 4) [*] suphedrine 12 hour $0 (Tier 4) [*] suphedrine pe $0 (Tier 4) [*] B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 130 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso suphedrine pe sinus headache $0 (Tier 4) [*] TESSALON PERLES $0 (Tier 3) MO; [*] TG 10PEH-380GFN $0 (Tier 4) [*] tg 10peh-380gfn-15dm $0 (Tier 4) [*] THERAFLU DAYTIME COLD-COUGH $0 (Tier 4) [*] THERAFLU FLU-SORE THROAT $0 (Tier 4) [*] THERAFLU MULTI-SYMPTOM COLD $0 (Tier 4) [*] THERAFLU NIGHT SEVERE COLD-CGH $0 (Tier 4) [*] TRIAMINIC CHEST &NASAL CONGEST $0 (Tier 4) [*] TRIAMINIC COLD & COUGH (PE) $0 (Tier 4) [*] TRIAMINIC COLD & COUGH NT (PE) $0 (Tier 4) [*] triaminic cough-sore throat $0 (Tier 4) [*] trymine cg $0 (Tier 3) [*] TUSICOF ORAL TABLET $0 (Tier 4) [*] tusnel c $0 (Tier 3) [*] tusnel diabetic $0 (Tier 4) [*] TUSNEL NEW FORMULA $0 (Tier 4) [*] TUSNEL PEDIATRIC $0 (Tier 4) [*] TUSNEL-DM PEDIATRIC $0 (Tier 4) [*] tussi pres-b oral liquid 4-10-20 mg/5 ml $0 (Tier 4) [*] TUSSICAPS $0 (Tier 3) MO; [*] tussigon $0 (Tier 3) MO; [*] tussin $0 (Tier 4) [*] tussin cf cough-cold $0 (Tier 4) [*] tussin cf max $0 (Tier 4) [*] tussin cf oral liquid $0 (Tier 4) MO; [*] tussin chest congestion $0 (Tier 4) [*] tussin cough &chest congestion $0 (Tier 4) [*] tussin cough (dm only) $0 (Tier 4) [*] ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 131 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso tussin cough dm $0 (Tier 4) [*] tussin dm clear $0 (Tier 4) [*] tussin dm cough $0 (Tier 4) [*] tussin dm cough & chest $0 (Tier 4) [*] tussin dm max oral liquid 10-200 mg/5 ml $0 (Tier 4) [*] tussin dm oral liquid $0 (Tier 4) [*] tussin dm oral syrup 10-100 mg/5 ml $0 (Tier 4) [*] tussin dm oral tablet $0 (Tier 4) [*] tussin expectorant $0 (Tier 4) [*] tussin honey $0 (Tier 4) [*] tussin maximum strength $0 (Tier 4) [*] tussin maximum strength cough $0 (Tier 4) [*] tussin pe oral liquid $0 (Tier 4) [*] tussinmax $0 (Tier 4) [*] tussi-pres oral liquid $0 (Tier 4) [*] TYLENOL COLD MULTI-SYMPT NIGHT ORAL LIQUID $0 (Tier 4) [*] TYLENOL COLD MULTI-SYMPTOM DAY $0 (Tier 4) [*] TYLENOL SINUS CONGESTION PAIN ORAL TABLET 5-325-200 MG $0 (Tier 4) [*] unisom sleepgels $0 (Tier 4) [*] valu-dryl allergy oral capsule $0 (Tier 4) [*] VANACOF $0 (Tier 4) MO; [*] VANAHIST PD $0 (Tier 4) [*] vaporizing steam $0 (Tier 4) [*] VICKS CHILDREN'S NYQUIL COLD&C $0 (Tier 4) [*] vicks dayquil cold&flu relief $0 (Tier 4) [*] vicks dayquil cough $0 (Tier 4) [*] VICKS DAYQUIL MUCUS CONTROL DM $0 (Tier 4) [*] B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 132 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso VICKS DAYQUIL SEVERE COLD-FLU $0 (Tier 4) [*] VICKS DAYQUIL SINEX $0 (Tier 4) [*] VICKS NATURE FUSION $0 (Tier 4) [*] vicks nature fusion cough $0 (Tier 4) [*] VICKS NYQUIL COLD/FLU (CPM) $0 (Tier 4) [*] vicks nyquil cold/flu liquicap $0 (Tier 4) [*] VICKS NYQUIL COUGH $0 (Tier 4) [*] VICKS NYQUIL NIGHTTIME RELIEF $0 (Tier 4) [*] VICKS NYQUIL SEVERE COLD-FLU $0 (Tier 4) [*] vicks qlearquil allergy $0 (Tier 4) [*]; QLL (30 per 30 days) VICKS QLEARQUIL DAYTIME SINUS $0 (Tier 4) [*] vicks qlearquil nighttime rlf $0 (Tier 4) [*] vicks vaposteam $0 (Tier 4) [*] virtussin ac $0 (Tier 3) MO; [*] wal-dryl allergy $0 (Tier 4) [*] wal-dryl severe allergy-sinus $0 (Tier 4) [*] wal-fex allergy $0 (Tier 4) [*] wal-finate $0 (Tier 4) [*] WAL-FLU NIGHT TIME $0 (Tier 4) [*] wal-flu severe cold $0 (Tier 4) [*] WAL-FLU SEVERE COLD & COUGH $0 (Tier 4) [*] WAL-FLU SEVERE COLD-COUGH $0 (Tier 4) [*] wal-itin d $0 (Tier 4) [*] wal-itin d 12 hour $0 (Tier 4) [*] wal-itin oral solution $0 (Tier 4) [*] wal-itin oral tablet $0 (Tier 4) [*]; QLL (30 per 30 days) wal-itin oral tablet,disintegrating $0 (Tier 4) [*]; QLL (30 per 30 days) wal-phed 12 hour $0 (Tier 4) [*] wal-phed oral tablet 30 mg $0 (Tier 4) [*] ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 133 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso wal-phed pe $0 (Tier 4) [*] wal-phed pe nighttime cold $0 (Tier 4) [*] WAL-PHED PE TRIPLE RELIEF $0 (Tier 4) [*] wal-profen cold-sinus $0 (Tier 4) [*] wal-profen d cold & sinus $0 (Tier 4) [*] wal-som oral capsule $0 (Tier 4) [*] wal-tap dm $0 (Tier 4) [*] wal-tussin cough $0 (Tier 4) [*] wal-tussin cough & cold cf $0 (Tier 4) [*] wal-tussin dm $0 (Tier 4) [*] wal-tussin max strength cough $0 (Tier 4) [*] wal-zyr (cetirizine) oral tablet $0 (Tier 4) [*]; QLL (30 per 30 days) wal-zyr d $0 (Tier 4) [*] ZODRYL AC 25 $0 (Tier 3) [*] ZODRYL AC 30 $0 (Tier 3) [*] ZODRYL AC 40 $0 (Tier 3) [*] ZODRYL AC 50 $0 (Tier 3) [*] ZODRYL AC 60 $0 (Tier 3) [*] ZODRYL AC 80 $0 (Tier 3) [*] ZODRYL DEC 25 $0 (Tier 3) [*] ZODRYL DEC 30 $0 (Tier 3) [*] ZODRYL DEC 40 $0 (Tier 3) [*] ZODRYL DEC 50 $0 (Tier 3) [*] ZODRYL DEC 60 $0 (Tier 3) [*] ZODRYL DEC 80 $0 (Tier 3) [*] Z-TUSS AC $0 (Tier 3) MO; [*] ZYRTEC ORAL TABLET $0 (Tier 4) MO; [*]; QLL (30 per 30 days) B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 134 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso PULMONARY AGENTS 97B acetylcysteine solution $0 (Tier 1) B/D PAR; MO ADEMPAS $0-$7.40 (Tier 2) PAR; MO; LA ADVAIR DISKUS $0-$7.40 (Tier 2) MO; QLL (60 per 30 days) ADVAIR HFA $0-$7.40 (Tier 2) MO; QLL (12 per 30 days) AEROSPAN $0-$7.40 (Tier 2) MO; QLL (18 per 30 days) albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %) $0 (Tier 1) B/D PAR; MO; QLL (360 per 30 days) albuterol sulfate inhalation solution for nebulization 2.5 mg/0.5 ml, 5 mg/ml $0 (Tier 1) B/D PAR; MO; QLL (60 per 30 days) albuterol sulfate oral $0 (Tier 1) MO ANORO ELLIPTA $0-$7.40 (Tier 2) MO; QLL (60 per 30 days) ARNUITY ELLIPTA $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) ASMANEX HFA $0-$7.40 (Tier 2) MO; QLL (13 per 30 days) ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (30 DOSES) $0-$7.40 (Tier 2) MO; QLL (0.14 per 30 days) ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG (7 DOSES), 220 MCG (14 DOSES) $0-$7.40 (Tier 2) ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 220 MCG (120 DOSES), 220 MCG (30 DOSES), 220 MCG (60 DOSES) $0-$7.40 (Tier 2) MO; QLL (0.24 per 30 days) ATROVENT HFA $0-$7.40 (Tier 2) MO; QLL (26 per 30 days) BREO ELLIPTA $0-$7.40 (Tier 2) MO; QLL (60 per 30 days) CINRYZE $0-$7.40 (Tier 2) PAR; MO COMBIVENT RESPIMAT $0-$7.40 (Tier 2) MO; QLL (8 per 30 days) cromolyn inhalation DALIRESP ? $0 (Tier 1) B/D PAR; MO; QLL (240 per 30 days) $0-$7.40 (Tier 2) PAR; MO; QLL (30 per 30 days) Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 135 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso DULERA $0-$7.40 (Tier 2) MO; QLL (13 per 30 days) ESBRIET $0-$7.40 (Tier 2) PAR; MO; QLL (270 per 30 days) FIRAZYR $0-$7.40 (Tier 2) PAR; MO FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION $0-$7.40 (Tier 2) MO; QLL (60 per 30 days) FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION, 50 MCG/ACTUATION $0-$7.40 (Tier 2) MO; QLL (240 per 30 days) FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION $0-$7.40 (Tier 2) MO; QLL (12 per 30 days) FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCG/ACTUATION $0-$7.40 (Tier 2) MO; QLL (24 per 30 days) FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION $0-$7.40 (Tier 2) MO; QLL (11 per 30 days) flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) $0 (Tier 1) MO; QLL (75 per 30 days) fluticasone nasal $0 (Tier 1) MO; QLL (16 per 30 days) $0-$7.40 (Tier 2) MO; QLL (60 per 30 days) FORADIL AEROLIZER ipratropium bromide inhalation $0 (Tier 1) B/D PAR; MO ipratropium-albuterol $0-$7.40 (Tier 2) B/D PAR; MO; QLL (540 per 30 days) KALYDECO ORAL TABLET $0-$7.40 (Tier 2) PAR; MO; QLL (60 per 30 days) LETAIRIS $0-$7.40 (Tier 2) PAR; MO; LA; QLL (30 per 30 days) levalbuterol hcl inhalation solution for nebulization 0.31 mg/3 ml, 1.25 mg/0.5 ml, 1.25 mg/3 ml $0 (Tier 1) B/D PAR; MO; QLL (270 per 30 days) levalbuterol hcl inhalation solution for nebulization 0.63 mg/3 ml $0 (Tier 1) B/D PAR; MO; QLL (540 per 30 days) metaproterenol oral $0 (Tier 1) MO montelukast $0 (Tier 1) MO; QLL (30 per 30 days) NASONEX $0-$7.40 (Tier 2) MO; QLL (17 per 30 days) OFEV ORAL CAPSULE 150 MG $0-$7.40 (Tier 2) PAR; MO; QLL (60 per 30 days) B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 136 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso PERFOROMIST $0-$7.40 (Tier 2) B/D PAR; MO; QLL (120 per 30 days) PROAIR HFA $0-$7.40 (Tier 2) MO; QLL (18 per 30 days) PULMOZYME $0-$7.40 (Tier 2) B/D PAR; MO QVAR INHALATION AEROSOL 40 MCG/ACTUATION $0-$7.40 (Tier 2) MO; QLL (9 per 30 days) QVAR INHALATION AEROSOL 80 MCG/ACTUATION $0-$7.40 (Tier 2) MO; QLL (18 per 30 days) SEREVENT DISKUS $0-$7.40 (Tier 2) MO; QLL (60 per 30 days) sildenafil oral $0-$7.40 (Tier 2) PAR; MO; QLL (90 per 30 days) SPIRIVA RESPIMAT $0-$7.40 (Tier 2) MO; QLL (4 per 30 days) SPIRIVA WITH HANDIHALER $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) terbutaline oral $0 (Tier 1) MO terbutaline subcutaneous $0 (Tier 1) MO theophylline oral tablet extended release $0 (Tier 1) MO theophylline oral tablet extended release 12 hr $0 (Tier 1) MO TRACLEER $0-$7.40 (Tier 2) PAR; MO; LA; QLL (60 per 30 days) VENTAVIS $0-$7.40 (Tier 2) PAR; MO XOLAIR $0-$7.40 (Tier 2) PAR; MO; LA; QLL (6 per 28 days) zafirlukast $0 (Tier 1) MO; QLL (60 per 30 days) MYRBETRIQ $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) oxybutynin chloride oral syrup $0-$7.40 (Tier 2) MO; QLL (600 per 30 days) oxybutynin chloride oral tablet $0-$7.40 (Tier 2) MO; QLL (120 per 30 days) oxybutynin chloride oral tablet extended release 24hr 10 mg, 15 mg $0-$7.40 (Tier 2) MO; QLL (60 per 30 days) oxybutynin chloride oral tablet extended release 24hr 5 mg $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) UROLOGICALS 14B ANTICHOLINERGICS / ANTISPASMODICS 98B ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 137 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso tolterodine oral capsule,extended release 24hr $0-$7.40 (Tier 2) MO; QLL (30 per 30 days) tolterodine oral tablet $0-$7.40 (Tier 2) MO; QLL (60 per 30 days) trospium oral tablet $0-$7.40 (Tier 2) MO; QLL (60 per 30 days) BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY 9B alfuzosin $0-$7.40 (Tier 2) MO finasteride oral tablet 5 mg $0-$7.40 (Tier 2) MO tamsulosin $0-$7.40 (Tier 2) MO $0-$7.40 (Tier 2) MO CIALIS ORAL TABLET 2.5 MG, 5 MG $0-$7.40 (Tier 2) PAR; MO; QLL (30 per 30 days) CYSTAGON $0-$7.40 (Tier 2) MO; LA potassium citrate oral tablet extended release 10 meq (1,080 mg), 5 meq (540 mg) $0-$7.40 (Tier 2) MO CHOLINERGIC STIMULANTS 10B bethanechol chloride MISCELLANEOUS UROLOGICALS 10B VITAMINS, HEMATINICS / ELECTROLYTES 15B ELECTROLYTES 102B ANTACID CALCIUM ORAL TABLET,CHEWABLE 215 MG CALCIUM (500 MG) $0 (Tier 4) [*] antacid ext str (calcium carb) $0 (Tier 4) [*] antacid extra-strength oral tablet,chewable 200 mg calcium (500 mg), 300 mg (750 mg) $0 (Tier 4) [*] antacid oral tablet,chewable 200 mg calcium (500 mg) $0 (Tier 4) [*] antacid ultra strength oral tablet,chewable 400 mg (1,000 mg) $0 (Tier 4) [*] calcium 500 oral tablet $0 (Tier 4) [*] B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 138 Nombre del medicamento calcium 600 calcium acetate oral capsule Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso $0 (Tier 4) [*] $0-$7.40 (Tier 2) MO calcium antacid oral tablet,chewable 200 mg calcium (500 mg) $0 (Tier 4) MO; [*] calcium antacid oral tablet,chewable 300 mg (750 mg), 320 mg (750 mg), 400 mg (1,000 mg) $0 (Tier 4) [*] calcium antacid tropical $0 (Tier 4) [*] calcium antacid ultra max st $0 (Tier 4) [*] calcium carbonate oral suspension $0 (Tier 4) MO; [*] calcium carbonate oral tablet 260 mg calcium (648 mg), 500 mg calcium (1,250 mg), 600 mg (1,500 mg) $0 (Tier 4) MO; [*] calcium carbonate oral tablet,chewable 200 mg calcium (500 mg), 400 mg (1,000 mg) $0 (Tier 4) [*] cal-gest antacid $0 (Tier 4) MO; [*] chromium chloride $0 (Tier 3) MO; [*] copper chloride $0 (Tier 3) MO; [*] dextrose-kcl-nacl $0-$7.40 (Tier 2) B/D PAR high potency calcium $0 (Tier 4) [*] KLOR-CON 10 $0-$7.40 (Tier 2) MO KLOR-CON 8 $0-$7.40 (Tier 2) MO klor-con m10 $0-$7.40 (Tier 2) MO KLOR-CON M15 $0-$7.40 (Tier 2) MO KLOR-CON M20 $0-$7.40 (Tier 2) MO K-TAB ORAL TABLET EXTENDED RELEASE 8 MEQ $0-$7.40 (Tier 2) lactated ringers intravenous $0-$7.40 (Tier 2) magnesium oxide oral tablet 400 mg, 420 mg $0 (Tier 4) magnesium sulfate in water $0-$7.40 (Tier 2) magnesium sulfate injection solution $0-$7.40 (Tier 2) magnesium sulfate injection syringe $0-$7.40 (Tier 2) ? B/D PAR; MO MO; [*] MO Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 139 Nombre del medicamento manganese chloride Qué le costará el medicamento (nivel de clase) $0 (Tier 3) Acciones necesarias, restricciones, o límites sobre el uso [*] NORMOSOL-R $0-$7.40 (Tier 2) B/D PAR NORMOSOL-R IN 5 % DEXTROSE $0-$7.40 (Tier 2) B/D PAR oysco d $0 (Tier 4) MO; [*] oysco-500 $0 (Tier 4) MO; [*] oyst-cal-500 $0 (Tier 4) MO; [*] oyster shell + d3 $0 (Tier 4) [*] oyster shell calcium $0 (Tier 4) MO; [*] oyster shell calcium 500 $0 (Tier 4) MO; [*] oyster shell calcium-vit d3 oral tablet 250-125 mgunit $0 (Tier 4) MO; [*] potassium chlorid-d5-0.45%nacl intravenous parenteral solution 10 meq/l, 30 meq/l, 40 meq/l $0-$7.40 (Tier 2) B/D PAR potassium chlorid-d5-0.45%nacl intravenous parenteral solution 20 meq/l $0-$7.40 (Tier 2) B/D PAR; MO potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l $0-$7.40 (Tier 2) B/D PAR potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 30 meq/l, 40 meq/l $0-$7.40 (Tier 2) B/D PAR potassium chloride in lr-d5 intravenous parenteral solution 20 meq/l $0-$7.40 (Tier 2) B/D PAR; MO potassium chloride in lr-d5 intravenous parenteral solution 40 meq/l $0-$7.40 (Tier 2) B/D PAR potassium chloride intravenous piggyback 10 meq/100 ml, 20 meq/100 ml, 20 meq/50 ml, 30 meq/100 ml, 40 meq/100 ml $0-$7.40 (Tier 2) B/D PAR potassium chloride intravenous piggyback 10 meq/50 ml $0-$7.40 (Tier 2) B/D PAR; MO potassium chloride intravenous solution $0-$7.40 (Tier 2) B/D PAR; MO potassium chloride oral capsule, extended release $0 (Tier 1) MO potassium chloride oral tablet extended release $0 (Tier 1) MO potassium chloride oral tablet,er particles/crystals $0 (Tier 1) MO B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 140 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso potassium chloride-0.45 % nacl $0-$7.40 (Tier 2) B/D PAR potassium chloride-d5-0.2%nacl intravenous parenteral solution 20 meq/l $0-$7.40 (Tier 2) B/D PAR; MO potassium chloride-d5-0.2%nacl intravenous parenteral solution 30 meq/l, 40 meq/l $0-$7.40 (Tier 2) B/D PAR potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 meq/l $0-$7.40 (Tier 2) B/D PAR potassium chloride-d5-0.9%nacl intravenous parenteral solution 20 meq/l $0-$7.40 (Tier 2) B/D PAR; MO potassium chloride-d5-0.9%nacl intravenous parenteral solution 40 meq/l $0-$7.40 (Tier 2) B/D PAR ringers intravenous $0-$7.40 (Tier 2) B/D PAR smooth antacid $0 (Tier 4) [*] sodium chloride 0.45 % intravenous parenteral solution $0-$7.40 (Tier 2) MO sodium chloride 0.45 % intravenous piggyback $0-$7.40 (Tier 2) sodium chloride 3 % $0-$7.40 (Tier 2) sodium chloride 5 % $0-$7.40 (Tier 2) sodium chloride intravenous $0-$7.40 (Tier 2) MO B/D PAR; MO super calcium $0 (Tier 4) [*] TUMS $0 (Tier 4) MO; [*] TUMS E-X $0 (Tier 4) MO; [*] TUMS EXTRA STRENGTH SMOOTHIES $0 (Tier 4) [*] TUMS FRESHERS $0 (Tier 4) [*] tums ultra oral tablet,chewable 400 mg (1,000 mg) $0 (Tier 4) MO; [*] ultra strength antacid $0 (Tier 4) [*] ultra strength calcium antacid $0 (Tier 4) [*] zinc chloride intraveneous solution $0 (Tier 3) MO; [*] AMINOSYN 8.5 % $0-$7.40 (Tier 2) B/D PAR AMINOSYN 8.5 %-ELECTROLYTES $0-$7.40 (Tier 2) B/D PAR MISCELLANEOUS NUTRITION PRODUCTS 103B ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 141 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso AMINOSYN II 10 % $0-$7.40 (Tier 2) B/D PAR AMINOSYN II 7 % $0-$7.40 (Tier 2) B/D PAR AMINOSYN II 8.5 % $0-$7.40 (Tier 2) B/D PAR AMINOSYN II 8.5 %-ELECTROLYTES $0-$7.40 (Tier 2) B/D PAR AMINOSYN M 3.5 % $0-$7.40 (Tier 2) B/D PAR AMINOSYN-HBC 7% $0-$7.40 (Tier 2) B/D PAR AMINOSYN-PF 10 % $0-$7.40 (Tier 2) B/D PAR AMINOSYN-PF 7 % (SULFITE-FREE) $0-$7.40 (Tier 2) B/D PAR CLINIMIX 5%/D15W SULFITE FREE $0-$7.40 (Tier 2) B/D PAR CLINIMIX 5%/D25W SULFITE-FREE $0-$7.40 (Tier 2) B/D PAR CLINIMIX 2.75%/D5W SULFIT FREE $0-$7.40 (Tier 2) B/D PAR CLINIMIX 4.25%/D10W SULF FREE $0-$7.40 (Tier 2) B/D PAR CLINIMIX 4.25%-D20W SULF-FREE $0-$7.40 (Tier 2) B/D PAR CLINIMIX 4.25%-D25W SULF-FREE $0-$7.40 (Tier 2) B/D PAR CLINIMIX 5%-D20W(SULFITE-FREE) $0-$7.40 (Tier 2) B/D PAR CLINIMIX E 4.25%/D10W SUL FREE $0-$7.40 (Tier 2) B/D PAR CLINIMIX E 4.25%/D25W SUL FREE $0-$7.40 (Tier 2) B/D PAR CLINIMIX E 4.25%/D5W SULF FREE $0-$7.40 (Tier 2) B/D PAR CLINIMIX E 5%/D15W SULFIT FREE $0-$7.40 (Tier 2) B/D PAR CLINIMIX E 5%/D20W SULFIT FREE $0-$7.40 (Tier 2) B/D PAR CLINIMIX E 5%/D25W SULFIT FREE $0-$7.40 (Tier 2) B/D PAR freamine iii 10 % $0-$7.40 (Tier 2) B/D PAR HEPATAMINE 8% $0-$7.40 (Tier 2) B/D PAR intralipid intravenous emulsion 20 % $0-$7.40 (Tier 2) B/D PAR; MO ISOLYTE-P IN 5 % DEXTROSE $0-$7.40 (Tier 2) B/D PAR NORMOSOL-M IN 5 % DEXTROSE $0-$7.40 (Tier 2) B/D PAR NORMOSOL-R PH 7.4 $0-$7.40 (Tier 2) B/D PAR PLASMA-LYTE 148 $0-$7.40 (Tier 2) B/D PAR B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 142 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso PLASMA-LYTE-56 IN 5 % DEXTROSE $0-$7.40 (Tier 2) B/D PAR THERAFLU COLD-SORE THROAT (PE) $0 (Tier 4) [*] THERAFLU SINUS & COLD $0 (Tier 4) [*] travasol 10 % $0-$7.40 (Tier 2) B/D PAR; MO TROPHAMINE 10 % $0-$7.40 (Tier 2) B/D PAR; MO TROPHAMINE 6% $0-$7.40 (Tier 2) B/D PAR WAL-FLU COLD & SORE THROAT $0 (Tier 4) [*] a thru z advanced formula $0 (Tier 4) [*] adults' daily formula $0 (Tier 4) [*] AQUASOL A $0 (Tier 3) MO; [*] ascorbic acid oral tablet 250 mg $0 (Tier 4) [*] c-250 $0 (Tier 4) [*] calcium carbonate-vit d3-min oral tablet,chewable 600 mg (1,500 mg)-400 unit $0 (Tier 4) [*] central-vite oral tablet 18-400 mg-mcg $0 (Tier 4) [*] century oral tablet 18-400 mg-mcg $0 (Tier 4) [*] century ultimate women's oral tablet 18-400 mgmcg $0 (Tier 4) [*] cerovite advanced formula $0 (Tier 4) MO; [*] certavite-antioxidant $0 (Tier 4) MO; [*] complete multivitamin-mineral oral tablet $0 (Tier 4) [*] cyanocobalamin (vitamin b-12) injection $0 (Tier 3) MO; [*] daily multiple oral tablet 18-400 mg-mcg $0 (Tier 4) [*] daily multiple vitamins/iron $0 (Tier 4) [*] daily multivitamin with iron $0 (Tier 4) [*] daily multi-vitamins/iron $0 (Tier 4) [*] daily vitamin formula + iron $0 (Tier 4) [*] daily vitamin with iron $0 (Tier 4) [*] VITAMINS / HEMATINICS 104B ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 143 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso daily vites/iron $0 (Tier 4) MO; [*] DRISDOL ORAL CAPSULE $0 (Tier 3) MO; [*] ergocalciferol (vitamin d2) oral capsule $0 (Tier 3) MO; [*] essentia $0 (Tier 4) [*] FERAHEME $0 (Tier 3) MO; [*] fluoritab oral tablet,chewable 1 mg fluoride (2.2 mg) $0-$7.40 (Tier 2) MO folic acid injection $0 (Tier 3) MO; [*] folic acid oral tablet 1 mg $0 (Tier 3) MO; [*] hair vitamins $0 (Tier 4) [*] hydroxocobalamin $0 (Tier 3) MO; [*] infed $0 (Tier 3) MO; [*] INFUVITE ADULT $0 (Tier 3) MO; [*] INFUVITE PEDIATRIC $0 (Tier 3) MO; [*] m.v.i. adult $0 (Tier 3) [*] M.V.I. PEDIATRIC $0 (Tier 3) [*] multi complete with iron $0 (Tier 4) [*] multi-day with iron $0 (Tier 4) [*] multivitamin with iron $0 (Tier 4) [*] multi-vite $0 (Tier 4) [*] NASCOBAL $0 (Tier 3) MO; [*] one daily multi-vit w-mineral $0 (Tier 4) [*] one daily plus iron $0 (Tier 4) [*] one daily with iron $0 (Tier 4) [*] one-a-day teen advantage oral tablet 18-400 mgmcg $0 (Tier 4) [*] prenatal vitamin oral tablet $0-$7.40 (Tier 2) pyridoxine injection $0 (Tier 3) MO; [*] sentry oral tablet 18-400 mg-mcg $0 (Tier 4) [*] B/D - Autorización previa requerida, solo determinación de Parte D vs. Parte B LA - Disponibilidad limitada MO - Pedido por correo PAR - Requiere autorización previa QLL - Límite de nivel de cantidad ST - Terapia escalonada [*] - Medicamentos no de la Parte D o artículos OTC que están cubiertos por Medicaid 144 Nombre del medicamento Qué le costará el medicamento (nivel de clase) Acciones necesarias, restricciones, o límites sobre el uso sodium fluoride oral tablet,chewable 0.5 mg fluoride (1.1 mg), 1 mg fluoride (2.2 mg) $0-$7.40 (Tier 2) MO spectravite advanced formula oral tablet 18-400 mg-mcg $0 (Tier 4) [*] spectravite ultra women $0 (Tier 4) [*] tab-a-vite/iron $0 (Tier 4) MO; [*] thiamine hcl injection $0 (Tier 3) MO; [*] VENOFER INTRAVENOUS SOLUTION 100 MG/5 ML IRON, 200 MG/10 ML IRON $0 (Tier 3) MO; [*] VENOFER INTRAVENOUS SOLUTION 50 MG/2.5 ML IRON $0 (Tier 3) [*] vitamin c oral tablet 250 mg $0 (Tier 4) MO; [*] vitamin d2 $0 (Tier 3) MO; [*] VITAMIN E (DL, ACETATE) ORAL CAPSULE 1,000 UNIT $0 (Tier 4) [*] vitamin e mixed oral capsule 1,000 unit $0 (Tier 4) [*] vitamin e natural blend $0 (Tier 4) [*] vitamin e oral capsule 1,000 unit $0 (Tier 4) MO; [*] yelets $0 (Tier 4) [*] ? Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 145 H0147_16_24596_T_SP CMS Approved 09/18/2015 Índice 1 12 hour cold relief........ 112 12 hour decongestant ... 112 12 hour nasal relief spray80 12 hour nasal spray ........ 80 3 3 day vaginal ................ 104 3-day vaginal................ 104 8 8 hour pain reliever ........ 40 A a + d (lan, pet) ................ 68 a thru z advanced formula .................................. 143 abacavir .......................... 12 abacavir-lamivudinezidovudine.................. 12 ABELCET...................... 11 ABILIFY DISCMELT... 49 ABILIFY MAINTENA . 49 ABRAXANE ................. 24 acamprosate.................... 77 acarbose.......................... 83 acebutolol....................... 59 acephen .......................... 40 acetadryl......................... 40 aceta-gesic...................... 40 acetaminophen ......... 40, 41 acetaminophen extra strength....................... 40 acetaminophen pain relief .................................... 41 acetaminophen pm ......... 41 acetaminophen pm extra str .................................... 41 acetaminophen-codeine.. 38 acetazolamide............... 111 acetazolamide sodium.. 111 acetic acid....................... 81 acetic acid-aluminum acetate ........................ 81 acetylcysteine......... 77, 135 acid controller ................ 97 acid controller complete. 97 ? acid gone ........................ 90 acid gone antacid............ 90 acid reducer (famotidine)97 acid reducer (ranitidine). 97 acid reducer complete (famot)........................ 97 acitretin .......................... 67 acne control cleanser...... 68 acne cream ..................... 69 acne foaming wash......... 69 acne treatment (benzoyl perox) ......................... 69 acne-clear ....................... 69 ACTEMRA .................. 102 ACTHIB (PF)................. 99 ACTIMMUNE............... 98 acyclovir................... 12, 74 acyclovir sodium............ 12 ADACEL(TDAP ADOLESN/ADULT)(PF ) .................................. 99 ADAGEN....................... 77 adapalene........................ 69 ADASUVE .................... 49 added strength headache relief ........................... 41 added strength pain reliever .................................... 41 adefovir .......................... 12 ADEMPAS .................. 135 ADIPEX-P ..................... 77 adt robitussin peak cld dm max........................... 112 adult cough formula dm max........................... 112 adult low dose aspirin .... 41 adult robitussin lingering cld............................. 112 adult robitussin m-s cold .................................. 112 ADULT ROBITUSSIN NIGHT M-S CLD .... 112 adult robitussin peak cold dm ............................ 112 adult robitussin peak cold m-s............................ 112 adult tussin chest congestion ................ 113 adult tussin cough congest dm ............................ 113 adult tussin dm ............. 113 adult tussin multi-symp cold........................... 113 adult wal-tussin ............ 113 adult wal-tussin dm max .................................. 113 adults' daily formula..... 143 ADVAIR DISKUS....... 135 ADVAIR HFA ............. 135 advanced antacid-antigas 90 advanced eye relief....... 109 advil................................ 41 ADVIL ........................... 41 ADVIL ALLERGY SINUS .................................. 113 ADVIL ALLERGYCONGESTION RLF 113 advil cold & sinus ........ 113 ADVIL COLD & SINUS .................................. 113 ADVIL LIQUI-GEL ...... 41 ADVIL MIGRAINE ...... 41 ADVIL PM .................... 41 ADVIL PM LIQUI-GELS .................................... 41 AEROSPAN................. 135 af 71 afeditab cr....................... 59 AFINITOR ..................... 24 AFINITOR DISPERZ.... 24 AFRIN (OXYMETAZOLINE) .................................... 80 AFRIN SINUS (OXYMETAZOLINE) .................................... 80 AFTERA ...................... 105 AGGRENOX ................. 64 Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 146 ak-poly-bac .................. 108 akwa tears..................... 109 akwa tears (polyvinyl alcohol) .................... 109 ala-cort ........................... 74 ALA-HIST DM............ 113 ala-hist ir ...................... 113 alavert........................... 113 alavert d-12 allergy-sinus .................................. 113 alaway .......................... 109 ALBENZA..................... 17 albuterol sulfate............ 135 alclometasone................. 74 alcohol pads ................... 83 alcohol, rubbing ............. 79 ALDEX GS.................. 113 ALDURAZYME............ 86 alendronate............. 77, 102 aler-cap......................... 113 aler-tab ......................... 113 ALEVE COLD & SINUS .................................. 113 ALEVE SINUS & HEADACHE............ 113 ALEVE-D SINUS & COLD....................... 113 ALEVE-D SINUS & HEADACHE............ 113 alfuzosin....................... 138 ALIMTA ........................ 24 ALINIA.......................... 18 alka-seltzer original........ 41 alka-seltzer plus allergy 113 ALKA-SELTZER PLUS DAY......................... 113 ALKA-SELTZER PLUS SINUS-COUGH ...... 113 all day allergy (cetirizine) .................................. 113 all day allergy relief(cetir) .................................. 113 all day allergy-d ........... 113 all day pain relief ........... 41 ALL DAY PAIN RELIEF SINUS & CO ........... 113 all day relief ................... 41 ? aller-chlor..................... 114 ALLER-CHLOR.......... 114 allerclear....................... 114 allerclear d-12hr ........... 114 allerclear d-24hr ........... 114 aller-ease ...................... 114 aller-fex ........................ 114 aller-g-time................... 114 allergy & congestion relief .................................. 114 allergy (chlorpheniramine) .................................. 114 allergy (diphenhydramine) .................................. 114 allergy 4-hour............... 114 allergy complete-d ....... 114 allergy d-12 .................. 114 allergy eye (ketotifen) .. 109 allergy medication........ 114 allergy medicine........... 114 allergy m-s nighttime ... 114 allergy multi-symptom. 114 allergy plus severe sinus ha .................................. 114 allergy relief & nasal deconge .................... 114 allergy relief (cetirizine) .................................. 114 allergy relief (clemastine) .................................. 114 allergy relief (fexofenadine) .......... 114 allergy relief (loratadine) .................................. 114 allergy relief d12 .......... 114 allergy relief d-24 ......... 114 allergy relief multi- symptom................... 115 allergy relief(chlorpheniramn) .................................. 115 allergy relief(diphenhydramin) .................................. 115 allergy relief-d (cetirizine) .................................. 115 allergy relief-d (loratadine) .................................. 115 allergy relief- d(fexofenadine) ........ 115 ALLERGY RELIEFSINUS HEADACHE115 allergy sinus pe............. 115 allergy-congestion relief-d .................................. 115 allergy-time .................. 115 allerhist-1 ..................... 115 aller-tec......................... 115 aller-tec d...................... 115 allfen............................. 115 allfen dm ...................... 115 ALL-NITE COLD-FLU .................................. 115 allopurinol .................... 101 almacone ........................ 90 almacone-2 ..................... 90 aloe vesta........................ 71 alosetron ......................... 90 ALPHAGAN P ............ 112 alprazolam...................... 49 altachlore...................... 109 altavera (28) ................. 105 ALTOPREV................... 65 aluminum hydroxide gel 90 alyacen 1/35 (28).......... 105 alyacen 7/7/7 (28)......... 105 amantadine hcl ............... 12 ambi 60pse-400gfn....... 115 AMBISOME .................. 11 amcinonide ..................... 74 amifostine crystalline ..... 23 amikacin ......................... 18 amiloride ........................ 59 amiloridehydrochlorothiazide ... 59 AMINOSYN 8.5 %...... 141 AMINOSYN 8.5 %ELECTROLYTES ... 141 AMINOSYN II 10 % ... 142 AMINOSYN II 7 % ..... 142 AMINOSYN II 8.5 % .. 142 AMINOSYN II 8.5 %ELECTROLYTES ... 142 Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 147 AMINOSYN M 3.5 % . 142 AMINOSYN-HBC 7% 142 AMINOSYN-PF 10 %. 142 AMINOSYN-PF 7 % (SULFITE-FREE).... 142 amiodarone..................... 58 AMITIZA....................... 90 amitriptyline................... 49 amlodipine...................... 59 amlodipine-atorvastatin.. 65 amlodipine-benazepril.... 59 amlodipine-valsartan...... 59 amlodipine-valsartanhcthiazid..................... 59 ammonium lactate.......... 68 amnesteem...................... 69 amoxapine ...................... 49 amoxicillin ..................... 20 amoxicillin-pot clavulanate .................................... 20 amphetamine salt combo 49 amphotericin b ............... 11 ampicillin ....................... 20 ampicillin sodium........... 20 ampicillin-sulbactam 20, 21 AMPYRA ...................... 37 anagrelide....................... 77 anastrozole ..................... 24 ANDROGEL.................. 86 androxy .......................... 86 anefrin ............................ 80 ANORO ELLIPTA ...... 135 antacid .................... 90, 138 antacid & pain relief....... 41 antacid anti-gas .............. 90 antacid anti-gas double str .................................... 90 ANTACID CALCIUM 138 antacid exst (mag carb-al hyd) ............................ 90 antacid ext str (calcium carb) ......................... 138 antacid extra-strength.... 90, 138 antacid liquid.................. 90 antacid m........................ 90 ? antacid maximum strength .................................... 90 antacid plus anti-gas....... 90 antacid regular strength.. 90 antacid ultra strength.... 138 antacid with simethicone 90 antacid-antigas ............... 90 antacid-simethicone ....... 90 antacid-simethicone ds... 90 antibiotic (neomy-bacitpolym) ........................ 70 antibiotic + pain relief.... 70 anti-diarrhea ................... 88 anti-diarrheal .................. 88 anti-diarrheal (loperamide) .................................... 88 anti-fungal ...................... 71 ANTIFUNGAL.............. 71 antifungal (clotrimazole) 71 antifungal (tolnaftate)..... 71 antifungal cream............. 71 antifungal spray.............. 71 anti-gas ultra strength..... 90 anti-itch (hc)................... 74 antitussive dm .............. 115 ap-hist dm..................... 115 APOKYN....................... 36 apraclonidine................ 112 apri ............................... 105 APRISO ......................... 90 APTIOM ........................ 32 APTIVUS....................... 12 AQUASOL A............... 143 ARALAST NP ............... 77 aranelle (28) ................. 105 ARANESP (IN POLYSORBATE)...... 98 arbinoxa........................ 115 ARCALYST .................. 98 ARCTIC RELIEF .......... 68 aripiprazole .................... 49 ARNUITY ELLIPTA .. 135 ARRANON.................... 24 arthritis pain relief (acetam) .................................... 41 arthritis pain reliever ...... 41 artificial tears ............... 109 artificial tears (polyvin alc) .................................. 109 artificial tears(glycerinpeg)........................... 109 artificial tears(hypromellose).. 109 ARZERRA ..................... 24 ASACOL HD................. 91 ascorbic acid................. 143 ASMANEX HFA......... 135 ASMANEX TWISTHALER ........ 135 aspir-81........................... 41 aspirin............................. 42 aspirin childrens ............. 41 aspirin low dose ............. 41 aspirin low-strength........ 41 aspir-low......................... 42 aspir-trin ......................... 42 atenolol........................... 59 atenolol-chlorthalidone .. 59 ATGAM ......................... 99 athenol............................ 42 athlete's foot ................... 71 athlete's foot (clotrimazole) .................................... 71 athlete's foot (terbinafine) .................................... 71 athlete's foot (tolnaftate) 71 athlete's foot af ............... 71 athletic foot cream.......... 71 atorvastatin ..................... 66 atovaquone ..................... 18 atovaquone-proguanil..... 18 ATRIPLA....................... 12 atropine........................... 88 ATROVENT HFA ....... 135 AVASTIN ...................... 24 aviane ........................... 105 AVONEX....................... 98 AVONEX (WITH ALBUMIN)................ 98 azacitidine ...................... 24 AZACTAM IN DEXTROSE (ISOOSM).......................... 18 azathioprine.................... 24 Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. 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Para obtener más información, visite mss.anthem.com/ccc. 148 azelastine................ 80, 109 AZILECT....................... 36 azithromycin .................. 17 azolen tincture................ 71 AZOPT......................... 111 AZOR............................. 59 aztreonam....................... 18 azurette (28) ................. 105 B baciim............................. 18 bacitracin...................... 108 bacitracin-polymyxin b 108 baclofen.......................... 37 BALAMINE DM (CHLOR-PE) ........... 115 balsalazide...................... 91 banophen ...................... 115 banophen allergy.......... 115 BANZEL........................ 32 BARACLUDE ............... 12 bayer aspirin................... 42 baza antifungal ............... 71 BCG VACCINE, LIVE (PF) ............................ 99 BELEODAQ .................. 24 benazepril....................... 60 benazeprilhydrochlorothiazide ... 60 BENLYSTA................. 102 benzonatate .................. 115 benzoyl peroxide............ 69 benzphetamine ............... 77 benztropine..................... 36 BESIVANCE ............... 108 betamethasone dipropionate ............... 74 betamethasone valerate .. 74 betamethasone, augmented .................................... 74 betatemp......................... 42 betaxolol................. 60, 108 bethanechol chloride .... 138 BEXSERO (PF) ............. 99 bicalutamide................... 24 BICILLIN C-R............... 21 BICILLIN L-A............... 21 BICNU ........................... 24 ? BILTRICIDE ................. 18 bimatoprost .................. 111 biocotron ...................... 115 bionel............................ 115 BIONEL PEDIATRIC . 116 bisac-evac....................... 91 bisacodyl ........................ 91 biscolax .......................... 91 bismatrol ........................ 88 bismuth........................... 88 bismuth maximum strength .................................... 88 bisoprolol fumarate ........ 60 bisoprololhydrochlorothiazide ... 60 bleomycin ....................... 24 BLEPHAMIDE S.O.P. 112 BLINCYTO ................... 24 BONIVA ...................... 102 BOOSTRIX TDAP ........ 99 BOSULIF....................... 24 bp.................................... 69 bp 8 cough .................... 116 bp wash .......................... 69 bpo-10 ............................ 69 bpo-5 .............................. 69 BREO ELLIPTA.......... 135 BRILINTA..................... 64 brimonidine .................. 112 BRINTELLIX ................ 49 bromocriptine................. 36 brompheniraminepseudoeph-dm .......... 116 bronchial asthma relief. 116 brotapp dm ................... 116 BROVEX PEB DM ..... 116 budesonide ..................... 91 bumetanide..................... 60 BUPHENYL .................. 77 buprenorphine hcl .......... 38 buprenorphine-naloxone 42 buproban ........................ 79 bupropion hcl ........... 49, 50 buspirone........................ 50 BUSULFEX................... 24 butalbital compound w/codeine ................... 38 butorphanol tartrate ........ 42 BYDUREON ................. 83 BYETTA........................ 83 BYSTOLIC .................... 60 C c-250............................. 143 cabergoline ..................... 86 calcipotriene ................... 67 calcitonin (salmon)......... 86 calcitriol ......................... 86 calcium 500 .................. 138 calcium 600 .................. 139 calcium acetate............. 139 calcium antacid ............ 139 calcium antacid tropical139 calcium antacid ultra max st ............................... 139 calcium carbonate ........ 139 calcium carbonate-vit d3min ........................... 143 cal-gest antacid............. 139 callus remover ................ 67 callus removers .............. 67 camila ........................... 103 CANASA ....................... 91 CANCIDAS ................... 11 candesartan..................... 60 candesartanhydrochlorothiazid ..... 60 CAPASTAT ................... 18 CAPCOF ...................... 116 CAPEX .......................... 74 CAPMIST DM............. 116 CAPRELSA ................... 24 CAPRON DM .............. 116 captopril ......................... 60 captoprilhydrochlorothiazide ... 60 CARBAGLU.................. 77 carbamazepine................ 32 carbamoxide ear drops ... 81 carbidopa-levodopa........ 36 carboplatin...................... 24 CARIMUNE NF NANOFILTERED ..... 99 carteolol........................ 108 cartia xt........................... 60 Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. 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Para obtener más información, visite mss.anthem.com/ccc. 149 carvedilol........................ 60 CAYSTON..................... 18 caziant (28)................... 105 cefaclor........................... 16 cefadroxil ....................... 16 cefazolin......................... 16 cefazolin in dextrose (isoos)............................... 16 cefdinir ........................... 16 cefepime......................... 16 cefoxitin ......................... 16 cefoxitin in dextrose, isoosm............................. 16 cefpodoxime................... 16 cefprozil ......................... 16 ceftazidime..................... 16 ceftriaxone...................... 17 ceftriaxone in dextrose,isoos ................................ 16 cefuroxime axetil ........... 17 cefuroxime sodium......... 17 CELLCEPT INTRAVENOUS ....... 25 CELONTIN.................... 32 central-vite ................... 143 century.......................... 143 century ultimate women's .................................. 143 cephalexin ...................... 17 CEREZYME .................. 86 cerovite advanced formula .................................. 143 certavite-antioxidant .... 143 CERVARIX VACCINE (PF) ............................ 99 cetiri-d .......................... 116 cetirizine....................... 116 cetirizine-pseudoephedrine .................................. 116 CHANTIX...................... 79 CHANTIX CONTINUING MONTH BOX ........... 80 CHANTIX STARTING MONTH BOX ........... 80 cheratussin ac ............... 116 cheratussin dac ............. 116 chest congestion relief.. 116 ? chest congestion relief + dm ............................ 116 chest congestion relief d .................................. 116 chest congestion relief pe .................................. 116 chest congestion-cough relief ......................... 116 CHEST RUB.................. 68 chest-sinus congestion relief ......................... 116 child allergy relf(cetirizine) .................................. 116 child aspirin.................... 42 child chest congestion + cough ........................ 116 child delsym cough+chest dm ............................ 116 CHILD DELSYM COUGH+COLD ...... 116 child ibuprofen ............... 42 child mucinex chest congestion ................ 116 CHILD MUCINEX CONGESTIONCOUGH ................... 116 CHILD MUCINEX STUFFY NOSE-COLD .................................. 116 child mucus relief cough .................................. 117 child mucus relief expectorant............... 117 child multi-symptom cold/cough................ 117 child non-aspirin quick melts........................... 42 child pain rel-fever reducer .................................... 42 child suppository............ 91 children night time cold- cough ........................ 117 children's acetaminophen42 children's advil ............... 42 children's alaway.......... 109 children's allergy (diphenhyd) .............. 117 children's allergy relief(lor) .................................. 117 children's aspirin ............ 42 children's cetirizine ...... 117 children's chest congestion .................................. 117 CHILDREN'S CLARITIN .................................. 117 children's cold & cough 117 children's cold & cough dm .................................. 117 CHILDREN'S COLDCOUGH-SORE........ 117 children's cough ........... 117 children's dibromm dm cold & c.................... 117 children's easy-melts ...... 42 children's fever reducing 42 children's flu relief ....... 117 children's ibuprofen ........ 42 children's mapap............. 42 children's medi-profen ... 42 children's medi-tabs ....... 43 CHILDREN'S MOTRIN 43 CHILDREN'S MUCINEX COLD-FEVER......... 117 children's mucinex cough .................................. 117 CHILDREN'S MUCINEX MULTI-SYMP......... 117 CHILDREN'S MUCINEX NIGHT TIME .......... 117 children's non-aspirin ..... 43 children's non-aspirin pain .................................... 43 children's pain & fever relief ........................... 43 children's pain relief....... 43 children's pain reliever ... 43 children's pepto .............. 91 childrens plus cold ....... 117 children's plus flu ......... 117 children's profen ib ......... 43 children's q-pap .............. 43 children's silapap............ 43 children's silfedrine ...... 117 children's soothe............. 91 Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. 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Para obtener más información, visite mss.anthem.com/ccc. 150 children's sudafed pe cough .................................. 117 children's tactinal ........... 43 children's wal-dryl allergy .................................. 117 children's wal-zyr......... 117 CHILD'S MUCUS RELIEF M-S COLD............... 117 childs triacting cold & cough ........................ 117 CHLO TUSS EX.......... 118 chloramphenicol sod succinate..................... 18 chlorhexidine gluconate . 80 chlorhist........................ 118 chloroquine phosphate ... 18 chlorothiazide................. 60 chlorothiazide sodium.... 60 chlorpheniramine maleate .................................. 118 chlorpromazine .............. 50 chlortabs....................... 118 chlorthalidone ................ 60 cholestyramine (with sugar) .................................... 66 cholestyramine light....... 66 chromium chloride ....... 139 CIALIS......................... 138 ciclodan .......................... 71 ciclopirox ................. 71, 72 cidofovir......................... 12 cilostazol ........................ 64 CIMZIA ......................... 91 CIMZIA POWDER FOR RECONST ................. 91 CIMZIA STARTER KIT91 CINRYZE .................... 135 CIPRODEX.................... 82 ciprofloxacin .................. 21 ciprofloxacin (mixture) .. 21 ciprofloxacin hcl .... 21, 108 ciprofloxacin lactate....... 21 cisplatin .......................... 25 citalopram ...................... 50 citrate of magnesia ......... 91 citroma ........................... 91 citrucel............................ 91 ? cladribine........................ 25 clarithromycin ................ 17 CLARITIN................... 118 CLARITIN LIQUI-GEL .................................. 118 CLARITIN REDITABS .................................. 118 CLARITIN-D 12 HOUR .................................. 118 CLARITIN-D 24 HOUR .................................. 118 clearlax........................... 91 clemastine .................... 118 clindamycin hcl.............. 18 clindamycin phosphate.. 18, 69, 104 CLINIMIX 5%/D15W SULFITE FREE....... 142 CLINIMIX 5%/D25W SULFITE-FREE ...... 142 CLINIMIX 2.75%/D5W SULFIT FREE ......... 142 CLINIMIX 4.25%/D10W SULF FREE ............. 142 CLINIMIX 4.25%/D5W SULFIT FREE ........... 77 CLINIMIX 4.25%-D20W SULF-FREE............. 142 CLINIMIX 4.25%-D25W SULF-FREE............. 142 CLINIMIX 5%D20W(SULFITE-FREE) .................................. 142 CLINIMIX E 2.75%/D10W SUL FREE.......................... 77 CLINIMIX E 2.75%/D5W SULF FREE ............... 78 CLINIMIX E 4.25%/D10W SUL FREE........................ 142 CLINIMIX E 4.25%/D25W SUL FREE........................ 142 CLINIMIX E 4.25%/D5W SULF FREE ............. 142 CLINIMIX E 5%/D15W SULFIT FREE ......... 142 CLINIMIX E 5%/D20W SULFIT FREE ......... 142 CLINIMIX E 5%/D25W SULFIT FREE ......... 142 clobetasol ....................... 74 clobetasol-emollient ....... 74 CLOLAR........................ 25 clomipramine ................. 50 clonazepam..................... 32 clonidine hcl................... 60 clonidine patches............ 60 clopidogrel ..................... 64 clorazepate dipotassium . 50 clotrim antifungal........... 72 clotrimazole...... 11, 72, 104 clotrimazole 3 day ........ 104 clotrimazole af................ 72 clotrimazole foot ............ 72 clotrimazole-3 .............. 104 clotrimazole-7 .............. 104 clotrimazolebetamethasone............ 72 clozapine ........................ 50 codeine-guaifenesin ..... 118 codituss dm .................. 118 colchicine-probenecid .. 101 COLCRYS ................... 102 cold & cough ................ 118 cold & cough dm.......... 118 cold & cough elixir ...... 118 COLD & FLU RELIEF 118 cold & flu severe .......... 118 cold & sinus pain relief 118 cold head congestion day/nite..................... 118 COLD HEAD CONGESTION DAYTIME ............... 118 cold head congestion nighttime .................. 118 cold head congestion sever day ............................ 118 cold multi-symptom ..... 119 cold multi-symptom (chlorphen) ............... 119 Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. 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Para obtener más información, visite mss.anthem.com/ccc. 151 COLD MULTISYMPTOM DAY/NIGHT ........... 119 cold multi-symptom nighttime .................. 119 cold relief m/s day/night .................................. 119 cold relief plus.............. 119 cold severe congestion . 119 cold-flu relief ............... 119 cold-flu relief, day/night .................................. 119 cold-sinus relief............ 119 colestipol ........................ 66 colistin (colistimethate na) .................................... 18 colocort .......................... 91 COLY-MYCIN S........... 82 COMBIGAN................ 111 COMBIVENT RESPIMAT .................................. 135 COMETRIQ................... 25 comfort gel ..................... 91 comfort gel extra strength .................................... 91 COMPLERA.................. 12 complete......................... 97 complete allergy........... 119 complete allergy medicine .................................. 119 complete lice treatment .. 76 complete multivitamin- mineral ..................... 143 compro ........................... 91 COMVAX (PF).............. 99 congestac...................... 119 constulose....................... 91 CONTAC COLD-FLU NIGHT ..................... 119 COPAXONE 20 MG/ML .................................... 37 copper chloride............. 139 COREG CR.................... 60 CORICIDIN HBP ........ 119 CORICIDIN HBP COLDMULTI SYMPT....... 119 ? CORICIDIN HBP COUGH & COLD................... 119 cormax............................ 74 corn remover .................. 67 cortaid ............................ 74 cortisone......................... 82 cortisone (hydrocortisone) .................................... 74 cortizone-10 ................... 74 cortizone-10 plus............ 74 cough & cold ................ 119 COUGH & COLD BP . 119 cough & cold mucus relief cf .............................. 119 COUGH & SEVERE COLD....................... 119 cough control (dextromethorph) ..... 119 cough control (guaifenesin) .................................. 119 cough control cf (pe).... 119 cough control dm ......... 119 cough control dm max . 119 cough dm er.................. 119 cough formula dm ........ 119 cough relief .................. 120 cough suppressant- expectorant............... 120 cough syrup.................. 120 cough syrup dm............ 120 cough-sore throat night 120 coughtab....................... 120 COUMADIN.................. 64 CREON .......................... 91 CRESTOR...................... 66 critic-aid clear af ............ 72 CRIXIVAN .................... 12 cromolyn .............. 109, 135 cryselle (28) ................. 105 cyanocobalamin (vitamin b-12)......................... 143 cyclafem 1/35 (28) ....... 105 cyclafem 7/7/7 (28) ...... 105 cyclobenzaprine ............. 37 cyclophosphamide.......... 25 CYCLOSET................... 83 cyclosporine ................... 25 cyclosporine modified.... 25 CYRAMZA.................... 25 CYSTADANE ............... 91 CYSTAGON................ 138 cytarabine ....................... 25 cytarabine (pf) ................ 25 D d10 % & 0.45 % sodium chloride....................... 78 d2.5 %-0.45 % sodium chloride....................... 78 d5 % and 0.9 % sodium chloride....................... 78 d5 %-0.45 % sodium chloride....................... 78 dacarbazine..................... 25 daily multiple ............... 143 daily multiple vitamins/iron .................................. 143 daily multivitamin with iron ........................... 143 daily multi-vitamins/iron .................................. 143 daily vitamin formula + iron ........................... 143 daily vitamin with iron. 143 daily vites/iron.............. 144 DALIRESP .................. 135 danazol ........................... 86 dantrolene....................... 37 DAPSONE ..................... 18 DAPTACEL (DTAP PEDIATRIC) (PF) ..... 99 DARAPRIM .................. 18 daunorubicin................... 25 day time pe ................... 120 dayhist allergy .............. 120 daytime......................... 120 day-time ....................... 120 daytime & nighttime cold .................................. 120 DAYTIME COLD & COUGH ................... 120 daytime cold & flu relief (pe) ........................... 120 daytime cold-flu ........... 120 day-time cough............. 120 Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. 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Para obtener más información, visite mss.anthem.com/ccc. 152 DAYTIME SINUS....... 120 DAYTIME SINUSCONGESTION ........ 120 daytime-nighttime ........ 120 decitabine ....................... 25 DECONEX DMX ........ 120 DECONEX IR ............. 120 DELSYM 12 HOUR.... 120 delsym cough+chest congest dm ............... 120 DELSYM COUGH+COLD DAYTIME ............... 120 DELSYM COUGH+COLD NIGHTTIME ........... 120 DELZICOL .................... 91 demeclocycline .............. 22 DEMSER ....................... 60 DENAVIR...................... 74 DEPEN TITRATABS.. 102 DEPO-PROVERA 400 MG/ML .................... 103 DERMATOP.................. 74 desenex........................... 72 DESENEX ..................... 72 desenex spray ................. 72 desipramine .................... 50 desmopressin.................. 86 desonide ......................... 75 desoximetasone .............. 75 DESPEC....................... 120 DESVENLAFAXINE... 50, 51 DESVENLAFAXINE FUMARATE.............. 50 dexamethasone............... 82 dexamethasone sodium phos (pf) ..................... 82 dexamethasone sodium phosphate ........... 82, 111 DEXCHLORPHEN-PSECHLOPHEDIANOL 120 DEXILANT ................... 97 dexrazoxane hcl ............. 23 dextroamphetamine........ 51 dextromethorphan polistirex .................. 120 ? dextromethorphanguaifenesin ............... 120 dextrose 10 % and 0.2 % nacl............................. 78 dextrose 10 % in water (d10w) ........................ 78 dextrose 25 % in water (d25w) ........................ 78 dextrose 30 % in water (d30w) ........................ 78 dextrose 40 % in water (d40w) ........................ 78 dextrose 5 % in water (d5w) .......................... 78 dextrose 5 %-lactated ringers ........................ 78 dextrose 5%-0.2 % sod chloride ...................... 78 dextrose 5%-0.3 % sod.chloride................ 78 dextrose 50 % in water (d50w) ........................ 78 dextrose 70 % in water (d70w) ........................ 78 dextrose with sodium chloride ...................... 78 dextrose-kcl-nacl.......... 139 diabetic siltussin das-na 121 diabetic siltussin-dm .... 121 diabetic siltussin-dm max str.............................. 121 diabetic tussin dm ........ 121 diabetic tussin ex.......... 121 diabetic tussin max st ... 121 diamode.......................... 88 diarrhea relief (bismuth subs) ........................... 88 diazepam .................. 32, 51 diazepam intensol........... 51 diclofenac potassium...... 43 diclofenac sodium .......... 43 dicloxacillin.................... 21 dicyclomine.............. 88, 89 didanosine ...................... 12 diethylpropion ................ 77 diflorasone...................... 75 diflunisal ........................ 43 DIGITEK ....................... 63 digox .............................. 64 digoxin ........................... 64 dihydroergotamine ......... 36 DILANTIN CAPSULES 32 DILANTIN EXTENDED CAPSULES................ 32 DILANTIN INFATABS 32 diltiazem hcl............. 60, 61 dilt-xr.............................. 61 dimaphen dm................ 121 dimetapp cold-congestion .................................. 121 dimetapp dm cold-cough (pe) ........................... 121 DIMETAPP LONGACTING (CPM-DM) .................................. 121 diotame........................... 89 DIPENTUM ................... 91 diphedryl ...................... 121 diphedryl allergy .......... 121 diphenhist ..................... 121 diphenhydramine hcl..... 51, 121 diphenhydramineacetaminophen ........... 43 diphenoxylate-atropine... 89 disulfiram ....................... 78 divalproex....................... 33 dm max......................... 121 DOCEFREZ ................... 25 docetaxel ........................ 25 DONATUSSIN ............ 121 donepezil ........................ 37 dorzolamide.................. 111 dorzolamide-timolol..... 111 doxazosin ....................... 61 doxepin........................... 51 doxercalciferol ............... 87 doxorubicin .................... 25 DOXY-100 ..................... 22 doxycycline hyclate........ 22 doxycycline monohydrate .................................... 22 dr scholl's clear away ..... 67 DRISDOL .................... 144 Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. 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Para obtener más información, visite mss.anthem.com/ccc. 153 dristan cold................... 121 dronabinol ...................... 91 drospirenone-ethinyl estradiol.................... 105 DROXIA ........................ 25 dual action complete ...... 97 DULERA ..................... 136 duloxetine....................... 51 DURAFLU................... 121 duramorph (pf) ............... 38 E e.c. prin........................... 43 e.e.s. 400 ........................ 17 ear drops (carbamide peroxide) .................... 81 ear drops otc................... 81 ear wax removal drops ... 81 ear wax removal kit........ 81 ear wax removal system. 81 ear wax treatment........... 81 econazole........................ 72 econtra ez ..................... 105 ecotrin ............................ 43 ecotrin low strength........ 43 eczema anti-itch ............. 75 ed a-hist dm.................. 122 ed bron gp .................... 122 ed chlorped jr ............... 122 ed-apap........................... 43 ED-CHLORPED.......... 122 ed-chlortan ................... 122 EDURANT .................... 12 efferves pain relief antacid .................................... 43 effervescent pain relief... 43 EFFIENT........................ 64 ELAPRASE ................... 87 ELIDEL.......................... 68 elinest ........................... 105 ELIQUIS ........................ 64 ELITEK.......................... 23 ELLA ........................... 105 ELON DUAL DEFENSE .................................... 72 EMCYT.......................... 26 EMEND ................... 91, 92 EMSAM......................... 51 ? EMTRIVA ..................... 13 enalapril maleate ............ 61 enalaprilhydrochlorothiazide ... 61 ENBREL ...................... 102 ENBREL SURECLICK102 endacof - dm ................ 122 endacof-c...................... 122 endocet ........................... 38 ENGERIX-B (PF).......... 99 ENGERIX-B PEDIATRIC (PF) ............................ 99 enoxaparin...................... 64 enpresse........................ 105 entacapone...................... 36 entecavir......................... 13 enteric coated aspirin ..... 43 ENTEX T ..................... 122 entre-cough .................. 122 enulose ........................... 92 epinephrine................... 122 EPIPEN 2-PAK............ 122 EPIPEN JR 2-PAK ...... 122 epirubicin ....................... 26 epitol .............................. 33 EPIVIR........................... 13 EPIVIR HBV ................. 13 eplerenone ...................... 61 eprosartan....................... 61 EPZICOM ...................... 13 EQUETRO..................... 33 ERAXIS(WATER DILUENT) ................. 11 ERBITUX ...................... 26 ergocalciferol (vitamin d2) .................................. 144 ergoloid .......................... 51 ERGOMAR.................... 36 ERIVEDGE.................... 26 errin .............................. 103 ERWINAZE................... 26 ery pads .......................... 69 ery-tab ............................ 17 ERYTHROCIN.............. 17 erythrocin (as stearate)... 17 erythromycin .......... 17, 108 erythromycin ethylsuccinate............. 17 erythromycin with ethanol .................................... 69 erythromycin-benzoyl peroxide...................... 69 ESBRIET ..................... 136 escitalopram oxalate....... 51 essentia ......................... 144 estradiol........................ 103 ethambutol...................... 18 ethosuximide .................. 33 etodolac .......................... 43 ETOPOPHOS ................ 26 etoposide ........................ 26 EVOTAZ........................ 13 EXCEDRIN EXTRA STRENGTH............... 43 EXCEDRIN MIGRAINE .................................... 44 EXCEDRIN TENSION HEADACHE.............. 44 exemestane ..................... 26 EXJADE......................... 78 expectorant ................... 122 expectorant cough syrup .................................. 122 ex-strength medi-tabs..... 44 ex-strength medi-tabs pm44 EXTAVIA...................... 98 eye itch relief................ 109 F FABRAZYME ............... 87 fallback solo ................. 105 falmina (28).................. 105 famciclovir ..................... 13 famotidine ...................... 97 famotidine (pf) ............... 97 famotidine (pf)-nacl (isoos)............................... 97 FANAPT ........................ 52 FARESTON ................... 26 FARYDAK .................... 26 FASLODEX................... 26 felbamate........................ 33 felodipine er ................... 61 fenesin ir....................... 122 Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. 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Para obtener más información, visite mss.anthem.com/ccc. 154 fenesin pe ir.................. 122 fenofibrate ...................... 66 fenofibrate micronized ... 66 fenofibrate nanocrystallized 48 mg, 145 mg ........... 66 fenoprofen ...................... 44 fentanyl .......................... 38 fentanyl citrate ............... 38 FERAHEME ................ 144 FETZIMA ...................... 52 fever reducer .................. 44 fever reducer & pain reliever ....................... 44 FEVERALL ................... 44 fexofenadine................. 122 fiber (calcium polycarbophil) ............ 92 fiber (psyllium husk)...... 92 fiber laxative (ca polycarbo) .................. 92 fiber laxative (methylcellulo)........... 92 fiber laxative (psyllium husk)........................... 92 fiber therapy ................... 92 fiber therapy (ca polycarboph) .............. 92 fiber therapy laxative (husk) ......................... 92 fiber-caps........................ 92 fiber-lax.......................... 92 fiber-tabs ........................ 92 finasteride..................... 138 FIRAZYR .................... 136 FIRMAGON KIT W DILUENT SYRINGE 26 flanax (naproxen) ........... 44 flanax antacid ................. 92 flecainide........................ 59 fleet glycerin (adult)....... 92 FLOVENT DISKUS.... 136 FLOVENT HFA .......... 136 FLU & SEVERE COLDDAYTIME ............... 122 flu relief therapy daytime .................................. 122 fluconazole..................... 11 ? fluconazole in dextrose(isoo) ................................ 11 fluconazole in nacl (isoosm)............................ 11 flucytosine...................... 11 fludarabine ..................... 26 fludrocortisone ............... 82 flunisolide .................... 136 fluocinolone ................... 75 fluocinolone acetonide oil .................................... 81 fluocinolone-shower cap 75 fluocinonide ................... 75 fluocinonide-e ................ 75 fluocinonide-emollient... 75 fluoritab........................ 144 fluorometholone........... 111 fluorouracil............... 26, 68 fluoxetine ....................... 52 fluphenazine decanoate.. 52 fluphenazine hcl ............. 52 flurbiprofen .................... 44 flurbiprofen sodium drops .................................. 111 FLU-SEVERE COLDCOUGH DAYTIME 122 FLU-SEVERE COLDCOUGH NIGHT...... 122 flutamide ........................ 26 fluticasone .............. 75, 136 fluvoxamine ................... 52 foaming acne face wash . 69 foaming antacid.............. 92 foaming antacid extra strength....................... 92 folic acid....................... 144 FOLOTYN..................... 26 fondaparinux .................. 64 foot & sneaker................ 72 FORADIL AEROLIZER .................................. 136 FORTEO ...................... 102 foscarnet......................... 13 fosinopril ........................ 61 fosinoprilhydrochlorothiazide ... 61 fosphenytoin ................... 33 freamine iii 10 %.......... 142 FUNGI-NAIL ................ 72 fungoid tincture .............. 72 fungoid-d ........................ 72 furosemide...................... 61 FUSILEV ....................... 23 FUZEON........................ 13 FYCOMPA .................... 33 G gabapentin ...................... 33 GABITRIL ..................... 33 galantamine .................... 37 GAMASTAN S/D........ 100 GAMMAGARD LIQUID .................................. 100 GAMMAGARD S-D (IGA < 1 MCG/ML).......... 100 GAMMAPLEX............ 100 GAMUNEX-C ............. 100 ganciclovir sodium......... 13 GARDASIL (PF) ......... 100 GARDASIL 9 (PF) ...... 100 gas free extra strength .... 92 gas relief......................... 92 gas relief 80.................... 92 gas relief extra strength .. 92 gas relief ultra strength... 92 GAS-X ........................... 92 GAS-X EXTRA STRENGTH............... 92 GAS-X ULTRASTRENGTH............... 92 GATTEX 30-VIAL........ 93 GATTEX ONE-VIAL.... 93 GAUZE PAD ................. 83 gavilax............................ 93 gavilyte-c........................ 93 gavilyte-g ....................... 93 gavilyte-n ....................... 93 GAVISCON ................... 93 GAVISCON EXTRA STRENGTH............... 93 GAZYVA....................... 26 gemcitabine .................... 26 gemfibrozil ..................... 66 generlac .......................... 93 gengraf ........................... 26 Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. 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Para obtener más información, visite mss.anthem.com/ccc. 155 gentak........................... 108 gentamicin........ 18, 70, 108 gentamicin sulfate (ped) (pf).............................. 18 gentamicin sulfate (pf) .. 18, 19 GENTAMICIN SULFATE (PF) ............................ 19 gentle laxative ................ 93 gentlelax......................... 93 GEODON....................... 52 geri-kot........................... 93 geri-lanta ........................ 93 geri-mox antacid-antigas 93 geri-tussin..................... 122 gildagia......................... 105 gildess fe ...................... 105 GILENYA...................... 37 GILOTRIF ..................... 26 GILPHEX TR .............. 122 GLATOPA..................... 37 GLEEVEC ..................... 26 GLEOSTINE.................. 26 glimepiride ..................... 83 glipizide.......................... 83 glipizide-metformin ....... 83 GLUCAGEN HYPOKIT84 GLUCAGON EMERGENCY KIT (HUMAN).................. 84 glycerin (adult)............... 93 glycerin (child)............... 93 glycolax.......................... 93 glycopyrrolate ................ 89 griseofulvin microsize.... 11 griseofulvin ultramicrosize .................................... 11 g-tron............................ 122 guaiatussin ac ............... 122 guaifenesin ................... 123 guaifenesin ac............... 122 guaifenesin dac............. 122 guaifenesin-dm............. 123 guanfacine ...................... 52 guanidine........................ 52 GYNE-LOTRIMIN...... 104 GYNE-LOTRIMIN 7... 104 ? H hair vitamins................. 144 HALAVEN .................... 27 halobetasol propionate ... 75 HALOG.......................... 75 haloperidol ..................... 53 haloperidol decanoate .... 53 haloperidol lactate.......... 53 HARVONI ..................... 13 HAVRIX (PF).............. 100 HEAD CONGESTION COLD RELIEF ........ 123 headache formula ........... 44 headache formula added str .................................... 44 headache pm................... 44 headache relief (asa-acetcaf) ............................. 44 healthylax....................... 93 heartburn antacid............ 93 heartburn prevention ...... 97 heartburn relief............... 93 heartburn relief (famotidine)................ 97 heartburn relief (ranitidine) .................................... 97 heparin (porcine)............ 65 heparin (porcine) in 5 % dex ........................ 64, 65 heparin (porcine) in nacl (pf).............................. 65 heparin(porcine) in 0.45% nacl............................. 65 HEPARIN(PORCINE) IN 0.45% NACL ............. 65 heparin, porcine (pf)....... 65 HEPATAMINE 8% ..... 142 HERCEPTIN.................. 27 HETLIOZ....................... 53 HEXALEN..................... 27 high potency calcium ... 139 hot steam liquid............ 123 HUMALOG ................... 84 HUMALOG KWIKPEN 84 HUMALOG MIX 50-50 84 HUMALOG MIX 50-50 KWIKPEN ................. 84 HUMALOG MIX 75-25 84 HUMALOG MIX 75-25 KWIKPEN ................. 84 HUMIRA ..................... 103 HUMIRA CROHN'S DIS START PCK ............ 102 HUMIRA PED CROHN'S STARTER PK.......... 102 HUMIRA PEN............. 102 HUMIRA PSORIASIS STARTER PACK .... 102 HUMULIN 70/30........... 84 HUMULIN 70/30 KWIKPEN ................. 84 HUMULIN N................. 84 HUMULIN N KWIKPEN .................................... 84 HUMULIN R ................. 84 HUMULIN R U-500 ...... 84 hydralazine ..................... 61 hydro skin....................... 75 hydrochlorothiazide ....... 61 hydrocodoneacetaminophen ..... 38, 39 hydrocodonechlorpheniramine ..... 123 hydrocodone-homatropine .................................. 123 HYDROCODONEHOMATROPINE..... 123 hydrocodone-ibuprofen.. 39 hydrocortisone.... 75, 82, 93 hydrocortisone acetate.... 75 hydrocortisone plus ........ 75 hydrocortisone valerate .. 75 hydrocortisone-acetic acid .................................... 81 hydrocortisone-min oil-wht pet............................... 75 hydrocream..................... 75 hydromet ...................... 123 hydromorphone .............. 39 hydroxocobalamin ........ 144 hydroxychloroquine ....... 19 hydroxyurea ................... 27 I ibandronate................... 102 Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. 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Para obtener más información, visite mss.anthem.com/ccc. 156 IBRANCE ...................... 27 ibu-drops ........................ 44 ibuprofen ........................ 44 ibuprofen cold .............. 123 ibuprofen cold-sinus(with pse)........................... 123 ibuprofen ib.................... 44 ibuprofen jr strength....... 44 ibuprofen pm.................. 44 ibuprofen-diphenhydramine cit................................ 44 ibuprofen-diphenhydramine hcl............................... 44 ICLUSIG........................ 27 idarubicin ....................... 27 ifosfamide ...................... 27 ILARIS (PF)................... 98 ILEVRO....................... 111 IMBRUVICA................. 27 imipenem-cilastatin........ 19 imipramine hcl ............... 53 imiquimod ...................... 68 IMODIUM A-D ............. 89 IMOVAX RABIES VACCINE (PF)........ 100 INCRELEX.................... 78 indapamide..................... 61 INFANRIX (DTAP) (PF) .................................. 100 infant fever reducer-pain relf .............................. 44 infant pain reliever ......... 44 infants gas relief............. 93 infants ibu-drops ............ 45 infant's ibuprofen ........... 45 infant's medi-profen ....... 45 infant's non-aspirin......... 45 infants' pain & fever....... 45 infants' pain relief........... 45 infant's pain relief........... 45 infant's pain reliever....... 45 infants profenib .............. 45 infed ............................. 144 INFUVITE ADULT..... 144 INFUVITE PEDIATRIC .................................. 144 INLYTA......................... 27 ? insulin pen needle .......... 84 INSULIN SYRINGE (DISP) U-100 0.3 ML 84 INTELENCE.................. 13 INTENSE COUGH...... 123 INTENSE COUGH RELIEVER .............. 123 intralipid....................... 142 INTRON A..................... 98 INVANZ ........................ 19 INVEGA ........................ 53 INVEGA SUSTENNA .. 53 INVEGA TRINZA......... 53 INVIRASE..................... 13 invisible acne ................. 69 inzo antifungal ............... 72 iophen c-nr ................... 123 iophen dm-nr................ 123 iophen-nr ...................... 123 IPOL............................. 100 ipratropium bromide ..... 80, 136 ipratropium-albuterol ... 136 i-prin............................... 45 irbesartan........................ 61 irbesartanhydrochlorothiazide ... 61 irinotecan........................ 27 ISENTRESS................... 13 ISOLYTE-P IN 5 % DEXTROSE............. 142 isoniazid ......................... 19 isopropyl alcohol............ 79 isopropyl alcohol, rubbing .................................... 79 isosorbide dinitrate......... 67 isosorbide mononitrate... 67 isradipine........................ 61 ISTODAX ...................... 27 itchy eye drops ............. 109 itraconazole .................... 11 ivermectin ...................... 19 IXEMPRA...................... 27 IXIARO (PF) ............... 100 J JAKAFI.......................... 27 jantoven.......................... 65 JANUMET ..................... 84 JANUMET XR .............. 84 JANUVIA ................ 84, 85 JARDIANCE ................. 85 JENTADUETO.............. 85 JEVTANA...................... 27 J-MAX ......................... 123 jock itch.......................... 72 jock itch (clotrimazole) .. 72 jock itch (terbinafine)..... 72 jr. acetaminophen ........... 45 jr. str non-aspirin pain .... 45 jr. strength pain reliever . 45 J-TAN PD .................... 123 junel 1.5/30 (21)........... 105 junel 1/20 (21).............. 105 junel fe 1.5/30 (28)....... 105 junel fe 1/20 (28).......... 106 junior mapap .................. 45 JUXTAPID .................... 66 K KADCYLA .................... 27 KALETRA ..................... 13 KALYDECO................ 136 kaopectate (bismuth subsalicy) ................... 89 kaopectate ex str (bismuth ss) ............................... 89 kao-tin (bismuth subsalicylat) ............... 89 kariva (28) .................... 106 kelnor 1/35 (28)............ 106 KEPIVANCE ................. 23 ketoconazole............. 11, 72 ketorolac....................... 111 ketotifen fumarate ........ 109 KEYTRUDA.................. 27 KHEDEZLA .................. 53 kidkare cough/cold....... 123 KINERET..................... 103 kionex............................. 78 KLOR-CON 10 ............ 139 KLOR-CON 8 .............. 139 klor-con m10 ................ 139 KLOR-CON M15 ........ 139 KLOR-CON M20 ........ 139 konsyl fiber .................... 93 Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. 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Para obtener más información, visite mss.anthem.com/ccc. 157 konsyl sugar-free............ 93 KORLYM ...................... 87 k-pec antidiarrheal (bism sub)............................. 89 K-TAB ......................... 139 KUVAN ......................... 87 L labetalol.......................... 61 lactated ringers ....... 77, 139 lactulose ......................... 93 LAMISIL (AEROSOL) . 72 lamisil af......................... 72 lamisil at......................... 72 lamivudine................ 13, 14 lamivudine-zidovudine .. 14 lamotrigine ..................... 33 LANOXIN ..................... 64 lansoprazole ................... 97 LANTUS........................ 85 LANTUS SOLOSTAR .. 85 LARIN 1/20 (21).......... 106 LARIN FE.................... 106 latanoprost.................... 111 LATUDA ....................... 53 laxa clear ........................ 93 laxative........................... 94 laxative (glycerin-pediatric) .................................... 93 laxative peg 3350 ........... 93 leflunomide .................. 103 LENVIMA ............... 27, 28 lessina........................... 106 LETAIRIS.................... 136 letrozole.......................... 28 leucovorin calcium......... 23 LEUKERAN .................. 28 leuprolide ....................... 28 levalbuterol hcl............. 136 LEVEMIR...................... 85 LEVEMIR FLEXTOUCH .................................... 85 levetiracetam ............ 33, 34 levetiracetam in nacl (isoos)............................... 33 levobunolol .................. 108 levocarnitine................... 78 ? levocarnitine (with sugar) .................................... 78 levocetirizine................ 123 levofloxacin.................... 22 levonest (28)................. 106 levonorgestrel............... 106 levonorgestrel-ethinyl estrad ........................ 106 levorphanol tartrate ........ 39 levothyroxine ................. 88 levoxyl............................ 88 LEXIVA......................... 14 LIALDA......................... 94 lice complete kit 1-2-3 ... 76 lice cream rinse .............. 76 lice killing ...................... 76 lice killing (permethrin) . 76 lice pyrinyl shampoo...... 76 lice solution.................... 76 lice treatment.................. 76 lice treatment (permethrin) .................................... 76 lidocaine......................... 70 lidocaine (pf)............ 59, 70 LIDOCAINE (PF).......... 70 lidocaine hcl ................... 70 lidocaine viscous............ 70 lidocaine-prilocaine........ 70 lindane............................ 76 linezolid.......................... 19 linezolid-0.9% sodium chloride ...................... 19 LINZESS........................ 94 liothyronine .................... 88 liquid antacid.................. 94 liquitears....................... 109 LIQUITUSS GG .......... 123 lisinopril ......................... 61 lisinoprilhydrochlorothiazide ... 61 lite coat aspirin............... 45 lithium carbonate ........... 53 lithium citrate ................. 54 little remedies fever & pain .................................... 45 lo-dose aspirin................ 45 lohist peb dm................ 123 LOMUSTINE ................ 28 loperamide...................... 89 loradamed..................... 123 lorata-d ......................... 123 loratadine.............. 123, 124 lorata-dine d ................. 123 loratadine-d .................. 124 lorazepam ....................... 54 LORTUSS DM ............ 124 losartan ........................... 62 losartanhydrochlorothiazide ... 62 LOTRIMIN AF .............. 73 lotrimin af jock itch powder .................................... 72 lotrimin af powder.......... 72 lotrimin ultra .................. 73 lovastatin ........................ 66 low-ogestrel (28) .......... 106 loxapine succinate .......... 54 lubricant eye (pg-peg 400) .................................. 109 lubricant eye (polyv alcohol)..................... 109 lubricant eye drops ....... 109 lubricant eye drops (glycpg) ............................ 109 lubricating plus............. 109 LUMIGAN................... 111 LUPRON DEPOT.......... 28 LUPRON DEPOT-PED. 28 lutera (28)..................... 106 LYNPARZA .................. 28 LYRICA......................... 34 LYSODREN .................. 28 lyza ............................... 103 M m.v.i. adult ................... 144 M.V.I. PEDIATRIC ..... 144 MAALOX ADVANCED .................................... 94 maalox maximum strength .................................... 94 mag-al plus..................... 94 mag-al plus extra strength .................................... 94 magnesium citrate .......... 94 Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 158 magnesium oxide ......... 139 magnesium sulfate ....... 139 magnesium sulfate in water .................................. 139 manganese chloride...... 140 mapap (acetaminophen) . 45 mapap arthritis pain........ 45 mapap cold formula ..... 124 mapap extra strength ...... 45 mapap pm....................... 45 mapap sinus max strength (pe) ........................... 124 maprotiline ..................... 54 MAR-COF BP ............. 124 MAR-COF CG............. 124 marlissa ........................ 106 MARPLAN .................... 54 masanti double strength . 94 masophen ....................... 45 MATULANE ................. 28 maxiphen...................... 124 MAXIPHEN DM ......... 124 m-clear wc.................... 124 meclizine ........................ 94 meclofenamate ............... 46 medi-bismuth ................. 89 medicidin-d .................. 124 medifin expectorant mucus rlf.............................. 124 medi-mucil ..................... 94 medi-natural ................... 94 medi-phedrine .............. 124 medi-phedryl ................ 124 mediplast corn-callus-wart .................................... 67 medi-profen .................... 46 mediproxen .................... 46 medi-tabs........................ 46 medi-tabs pain reliever... 46 medi-tabs pm.................. 46 medi-tussin................... 124 medi-tussin dm............. 124 medi-tussin dm diabetic124 medroxyprogesterone... 103 mefloquine ..................... 19 megestrol........................ 28 MEKINIST .................... 28 ? meloxicam...................... 46 melphalan hcl ................. 28 MENACTRA (PF) ....... 100 M-END DMX .............. 124 M-END MAX D .......... 124 M-END PE................... 124 MENEST...................... 103 MENOMUNE - A/C/Y/W135............................ 100 MENOMUNE - A/C/Y/W135 (PF) ................... 100 MENVEO A-C-Y-W-135DIP (PF) ................... 100 MEPHYTON ................. 65 mercaptopurine .............. 28 meropenem..................... 19 mesalamine .................... 94 mesalamine with cleansing wipe............................ 94 mesna ............................. 23 MESNEX ....................... 23 MESTINON................... 38 MESTINON TIMESPAN .................................... 38 metaproterenol ............. 136 metformin....................... 85 methadone ...................... 39 methadone intensol ........ 39 methadose ...................... 39 methazolamide ............. 111 methenamine hippurate.. 22 methimazole................... 83 methotrexate sodium...... 28 methotrexate sodium (pf)28 methoxsalen rapid .......... 68 methyclothiazide ............ 62 methylergonovine ........ 107 methylphenidate............. 54 methylprednisolone acetate .................................... 82 methylprednisolone sodium succ ............................ 82 methylprednisolone tablets .................................... 82 metipranolol ................. 109 metoclopramide hcl........ 94 metolazone ..................... 62 metoprolol succinate ...... 62 metoprolol tahydrochlorothiaz ........ 62 metoprolol tartrate.......... 62 metro i.v. ........................ 19 metronidazole... 19, 69, 104 metronidazole in nacl (isoos)............................... 19 mexiletine....................... 59 MIACALCIN ................. 87 mi-acid ........................... 94 mi-acid gas relief............ 94 micatin............................ 73 miconazole 7 ................ 104 miconazole nitrate .. 73, 104 miconazole-3 ................ 104 miconazorb af................. 73 MICROGESTIN 1.5/30 (21) ........................... 106 MICROGESTIN 1/20 (21) .................................. 106 MICROGESTIN FE 1.5/30 (28) ........................... 106 MICROGESTIN FE 1/20 (28) ........................... 106 micro-guard.................... 73 midodrine ....................... 78 migraine formula............ 46 migraine pain reliever .... 46 migraine relief ................ 46 milk of magnesia............ 94 minocycline.................... 22 minoxidil ........................ 62 mintox ............................ 94 mintox maximum strength .................................... 94 mintox plus..................... 94 miralax ........................... 94 mirtazapine..................... 54 misoprostol..................... 97 mitomycin ...................... 28 mitoxantrone .................. 29 M-M-R II (PF) ............. 100 modafinil ........................ 54 moexipril ........................ 62 moexiprilhydrochlorothiazide ... 62 Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. 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Para obtener más información, visite mss.anthem.com/ccc. 159 moisture drops.............. 110 MOISTURIZING LUBRICANT........... 110 mometasone ................... 75 mono-linyah ................. 106 mononessa (28) ............ 106 montelukast .................. 136 morphine .................. 39, 40 MORPHINE................... 39 morphine (pf) ................. 39 morphine concentrate..... 39 mosco corn remover....... 67 motion sickness relief(mecliz).............. 95 MOTRIN IB................... 46 motrin pm....................... 46 moxifloxacin .................. 22 mucaphed ..................... 124 MUCINEX COLD-FLU & SORE THROAT ...... 124 MUCINEX FAST-MAX COLD-FLU-THRT .. 124 MUCINEX FAST-MAX COLD-SINUS.......... 124 MUCINEX FAST-MAX CONGEST-COUGH .......................... 124, 125 mucinex fast-max dm max .................................. 125 MUCINEX FAST-MAX NITE COLD-FLU.... 125 MUCINEX FAST-MAX SEVERE COLD....... 125 MUCINEX MINI-MELTS .................................. 125 MUCINEX SINUS-MAX PRESSUR-PAIN ..... 125 MUCINEX SINUS-MAX SEV CONGESTN.... 125 mucosa ......................... 125 mucosa dm ................... 125 mucus and cough relief 125 mucus relief.................. 125 mucus relief chest ........ 125 MUCUS RELIEF COLD & SINUS ...................... 125 ? MUCUS RELIEF COLDFLU-SORE THR ..... 125 MUCUS RELIEF CONGESTIONCOUGH ................... 125 mucus relief cough ....... 125 mucus relief d (phenylephrine) ........ 125 mucus relief dm............ 125 mucus relief dm max.... 125 mucus relief er.............. 125 mucus relief pe............. 125 mucus relief plus .......... 125 MUCUS RELIEF SEV CONGEST-COLD... 125 mucus relief sinus ........ 125 MUCUS RLF SEVERE SINUS CONGEST... 126 MULTAQ ...................... 59 multi complete with iron .................................. 144 multi-day with iron ...... 144 multi-symptom cold (pe & cpm) ......................... 126 multi-symptom cold (pe) .................................. 126 multi-symptom cold daytime..................... 126 multi-symptom cold night time .......................... 126 multivitamin with iron . 144 multi-vite...................... 144 mupirocin calcium ......... 70 mupirocin ointment........ 70 murine ear wax removal system ........................ 82 MURO 128................... 110 MUSTARGEN............... 29 my way......................... 106 MYCO NAIL A ............. 73 mycophenolate mofetil... 29 mycophenolate sodium .. 29 MYOZYME................... 87 MYRBETRIQ .............. 137 mytab gas ....................... 95 mytab gas maximum strength....................... 95 myzilra ......................... 106 N nabumetone .................... 46 nadolol............................ 62 nadololbendroflumethiazide... 62 nafcillin .......................... 21 NAGLAZYME .............. 87 nalbuphine...................... 46 naloxone ......................... 46 naltrexone....................... 46 NAMENDA ................... 37 NAMENDA XR............. 37 naphazoline .................. 112 naproxen......................... 46 naproxen sodium ............ 46 nasal decongestant (oxymetazl) ................ 80 nasal decongestant (pe) 126 nasal decongestant (pseudoeph).............. 126 nasal relief ...................... 80 nasal spray (oxymetazoline) ......... 80 nasal spray 12 hour ........ 80 nasal spray 12 hour sinus80 nasal spray extra moisturizing ............... 81 nasal spray long acting... 81 nasal spray sinus............. 81 nasal spray x-moist......... 81 NASCOBAL ................ 144 NASONEX .................. 136 nateglinide...................... 85 NATPARA..................... 87 natural balance ............. 110 natural fiber laxative ...... 95 natural veg laxative(sennosid) ...... 95 nature's tears................. 110 NEBUPENT................... 19 necon 0.5/35 (28) ......... 106 necon 1/35 (28) ............ 106 necon 1/50 (28) ............ 106 necon 10/11 (28) .......... 106 necon 7/7/7 (28) ........... 106 Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. 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Para obtener más información, visite mss.anthem.com/ccc. 160 needles, insulin disp.,safety .................................... 85 nefazodone ..................... 54 neomycin........................ 19 neomycin-bacitracin-polyhc.............................. 111 neomycin-bacitracinpolymyxin ................ 108 neomycin-polymyxin b gu .................................... 77 neomycin-polymyxin bdexameth .................. 111 neomycin-polymyxingramicidin ................ 108 neomycin-polymyxin-hc82, 111 neo-polycin .................. 108 neo-polycin hc.............. 111 neosporin + pain relief (bac) ........................... 70 neosporin anti-itch ......... 75 NEUMEGA.................... 98 NEUPOGEN .................. 98 NEUPRO........................ 36 NEVANAC .................. 111 nevirapine....................... 14 NEXAVAR .................... 29 next choice one dose .... 106 niacin.............................. 66 NIACOR ........................ 66 nicardipine...................... 62 nicorelief ........................ 80 nicotine........................... 80 nicotine (polacrilex) ....... 80 NICOTROL NS ............. 80 nifedical xl ..................... 62 nifedipine ....................... 62 night time ..................... 126 night time cold ............. 126 night time cold & flu relief .................................. 126 NIGHT TIME COLD-FLU .................................. 126 NIGHT TIME COLD-FLU RELIEF .................... 126 night time cough & sore throat ........................ 126 ? nightime sleep .............. 126 nighttime cold-flu......... 126 nighttime cold-flu relief126 nighttime cough ........... 126 nighttime cough-cold ... 126 nighttime sinus ............. 126 nighttime sleep aid (diphen) .................... 126 NILANDRON................ 29 nimodipine ..................... 62 NIPENT ......................... 29 NITE TIME COLD-FLU .................................. 126 nite time cold-flu formula .................................. 126 NITE TIME COLD-FLU RELIEF .................... 126 nite time cough............. 126 nite time-d cold-flu relief .................................. 126 nite-time ....................... 126 nite-time cold-flu ......... 126 nitetime cough .............. 126 nitetime multi-symptom127 nitro-bid.......................... 67 nitrofurantoin macrocrystal .................................... 22 nitroglycerin................... 67 NITROSTAT ................. 67 no drip ............................ 81 noble formula hc ............ 75 nohist-dm ..................... 127 non-aspirin ..................... 47 non-aspirin 8 hour .......... 46 non-aspirin childrens...... 46 non-aspirin children's ..... 46 non-aspirin extra strength .................................... 46 non-aspirin nightime ...... 47 non-aspirin pain relief .... 47 non-aspirin pain relief pm .................................... 47 non-aspirin pm ............... 47 non-aspirin severe congest m-s............................ 127 non-drowsy allergy ...... 127 nora-be ......................... 103 NORDITROPIN FLEXPRO.................. 98 NORDITROPIN NORDIFLEX ............. 99 NOREL AD.................. 127 norethindrone (contraceptive) ......... 103 norethindrone acetate ... 104 norgestimate-ethinyl estradiol.................... 107 NORMOSOL-M IN 5 % DEXTROSE............. 142 NORMOSOL-R ........... 140 NORMOSOL-R IN 5 % DEXTROSE............. 140 NORMOSOL-R PH 7.4142 nortemp .......................... 47 nortrel 0.5/35 (28) ........ 107 nortrel 1/35 (21) ........... 107 nortrel 1/35 (28) ........... 107 nortrel 7/7/7 (28) .......... 107 nortriptyline.................... 54 NORVIR ........................ 14 NOXAFIL ...................... 11 nrs nasal relief ................ 81 nts step 1 ........................ 80 NUEDEXTA.................. 37 NULOJIX....................... 29 NUVARING ................ 104 nuzole ............................. 73 nyquil d ........................ 127 nystatin ..................... 11, 73 nystatin-triamcinolone ... 73 nystop ............................. 73 O ocella ............................ 107 OCTAGAM ................. 100 octreotide acetate............ 29 odor control foot-sneaker73 OFEV ........................... 136 ofloxacin........... 22, 82, 108 ogestrel (28) ................. 107 olanzapine ................ 54, 55 OLYSIO ......................... 14 omega-3 acid ethyl esters66 omeprazole ............... 97, 98 OMNITROPE ................ 99 Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. 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Para obtener más información, visite mss.anthem.com/ccc. 161 ONCASPAR .................. 29 ondansetron hcl .............. 95 ondansetron hcl (pf) ....... 95 ondansetron odt.............. 95 one daily multi-vit w- mineral ..................... 144 one daily plus iron........ 144 one daily with iron ....... 144 one-a-day teen advantage .................................. 144 one-step plantar wart remover ...................... 67 one-step wart remover.... 67 ONFI .............................. 34 OPDIVO ........................ 29 opium tincture ................ 89 ORAP............................. 55 ORENCIA.................... 103 ORENCIA (WITH MALTOSE) ............. 103 ORFADIN................ 78, 79 organ-i nr...................... 127 original nasal spray ........ 81 ormir............................. 127 ORTHO EVRA............ 104 ORTHO MICRONOR . 104 oxacillin.......................... 21 oxaliplatin ...................... 29 oxandrolone.................... 87 oxaprozin........................ 47 oxcarbazepine ................ 34 OXSORALEN ............... 68 OXTELLAR XR............ 34 oxybutynin chloride ..... 137 oxycodone ...................... 40 oxycodone-acetaminophen .................................... 40 oxycodone-aspirin.......... 40 oxymetazoline ................ 81 oysco d ......................... 140 oysco-500..................... 140 oyst-cal-500.................. 140 oyster shell + d3 ........... 140 oyster shell calcium...... 140 oyster shell calcium 500 .................................. 140 ? oyster shell calcium-vit d3 .................................. 140 P pacerone ......................... 59 paclitaxel ........................ 29 pain & fever ................... 47 pain relief ....................... 47 pain relief adult .............. 47 pain relief allergy sinus 127 pain relief cold ............. 127 PAIN RELIEF COLD & COUGH ................... 127 pain relief extra strength 47 pain relief pm ................. 47 pain relief pm rapid release .................................... 47 pain relief regular strength .................................... 47 PAIN RELIEF SINUS PE .................................. 127 pain reliever ................... 47 pain reliever (acetamaspirin) ....................... 47 pain reliever extra strength .................................... 47 pain reliever plus............ 47 pain reliever pm ............. 47 pain reliever pm ex- strength....................... 47 pain-off........................... 47 pamidronate.................... 87 pamprin max .................. 47 panoxyl........................... 69 panoxyl-4 ....................... 69 PANRETIN.................... 68 pantoprazole................... 98 paricalcitol...................... 87 paroex oral rinse............. 81 paromomycin ................. 19 paroxetine hcl................. 55 PASER ........................... 19 PATADAY .................. 110 PAXIL............................ 55 PAZEO......................... 110 pedia relief cough-cold 127 pediacare fever reducer .. 48 pediacare multi-symptom cold........................... 127 PEDIATEX TDM ........ 127 pediatric cough & cold. 127 PEDVAX HIB (PF) ..... 100 peg 3350-electrolytes ..... 95 peg3350 .......................... 95 peg-3350 with flavor packs .................................... 95 PEGANONE .................. 34 PEGASYS...................... 99 PEGASYS PROCLICK . 99 peg-electrolyte soln ........ 95 PEGINTRON ................. 99 PEGINTRON REDIPEN99 PENICILLIN G POT IN DEXTROSE............... 21 penicillin g potassium .... 21 penicillin g procaine....... 21 penicillin g sodium......... 21 penicillin v potassium .... 21 PENTAM ....................... 19 PENTASA...................... 95 pentoxifylline ................. 65 peptic relief .................... 89 PEPTO-BISMOL ........... 89 PEPTO-BISMOL MAX ST .................................... 89 pepto-bismol to-go ......... 89 percogesic....................... 48 PERFOROMIST .......... 137 perindopril erbumine...... 62 periogard ........................ 81 PERJETA ....................... 29 permethrin ...................... 76 perphenazine .................. 55 persa-gel ......................... 69 pharbechlor................... 127 pharbedryl .................... 127 pharbetol......................... 48 PHAZYME .................... 95 phendimetrazine tartrate. 77 phenelzine ...................... 55 phenobarbital............ 34, 35 phentermine.................... 77 phenylhistine dh ........... 127 phenytoin........................ 35 Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. 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Para obtener más información, visite mss.anthem.com/ccc. 162 phenytoin sodium........... 35 phenytoin sodium extended .................................... 35 PHOSPHOLINE IODIDE .................................. 109 pilocarpine hcl................ 79 pindolol .......................... 62 pink bismuth................... 89 pink bismuth maximum strength....................... 89 pioglitazone.................... 85 pioglitazone-glimepiride 85 pioglitazone-metformin.. 85 piperacillin-tazobactam.. 21 piroxicam ....................... 48 PLAN B ONE-STEP.... 107 plantar wart remover ...... 68 PLASMA-LYTE 148... 142 PLASMA-LYTE-56 IN 5 % DEXTROSE ........ 143 podactin.......................... 73 podofilox ........................ 68 POLY HIST PD ........... 127 polycin.......................... 108 polyethylene glycol 3350 95 POLY-HIST DM (THONZYLAMINE)127 polymyxin b sulftrimethoprim ............ 108 poly-tussin.................... 127 poly-tussin d................. 127 polyvinyl alcohol ......... 110 POMALYST .................. 29 portia ............................ 107 potassium chlorid-d50.45%nacl................. 140 potassium chloride ....... 140 potassium chloride in 0.9%nacl................... 140 potassium chloride in 5 % dex ............................ 140 potassium chloride in lr-d5 .................................. 140 potassium chloride-0.45 % nacl........................... 141 potassium chloride-d50.2%nacl................... 141 ? potassium chloride-d50.3%nacl................... 141 potassium chloride-d50.9%nacl................... 141 potassium citrate .......... 138 POTIGA......................... 35 powderlax....................... 95 PRADAXA .................... 65 pramipexole.................... 36 PRANDIMET ................ 85 pravastatin ...................... 66 prazosin .......................... 62 prednisolone................... 82 prednisolone acetate..... 112 prednisolone sodium phosphate ........... 82, 112 prednisone ...................... 82 prednisone intensol ........ 82 PREMARIN................. 104 PREMPRO................... 104 prenatal vitamin oral tablet .................................. 144 PREPARATION H HYDROCORTISONE76 pres gen ........................ 127 PRESGEN B ................ 127 PRESSURE & PAIN ... 127 prevalite.......................... 66 previfem ....................... 107 PREZCOBIX ................. 14 PREZISTA..................... 14 PRIFTIN ........................ 19 PRIMAQUINE .............. 19 PRIMATENE ASTHMA .................................. 127 primidone ....................... 35 PRIVIGEN................... 100 PROAIR HFA.............. 137 probenecid.................... 102 procainamide.................. 59 PRO-CHLO.................. 127 prochlorperazine edisylate .................................... 95 prochlorperazine maleate95 prochlorperazine maleate rectal........................... 95 PRO-CLEAR AC......... 127 PROCRIT....................... 99 procto-pak ...................... 95 proctosol hc .................... 95 proctozone-hc................. 96 progesterone micronized .................................. 104 PROGLYCEM ............... 85 PROGRAF ..................... 29 PROLEUKIN ................. 99 PROLIA ....................... 102 PROMACTA ................. 65 promethazine................ 128 promethazine vc-codeine .................................. 128 promethazine-codeine .. 128 promethazine-dm ......... 128 promethazine-phenylephcodeine ..................... 128 promethegan ................. 128 propafenone.................... 59 propranolol ..................... 62 propranololhydrochlorothiazid ..... 62 propylthiouracil.............. 83 PROQUAD (PF) .......... 100 PRO-RED AC (W/ DEXCHLORPHENIR) .................................. 128 PROTONIX ................... 98 protriptyline.................... 55 provil .............................. 48 pseudoephedrine hcl..... 128 psyllium husk ................. 96 PULMOZYME ............ 137 purelax............................ 96 PURIXAN...................... 29 pyrazinamide.................. 19 pyrethrin lice treatment m .................................... 76 pyridostigmine bromide . 38 pyridoxine .................... 144 Q q-dryl............................ 128 q-pap............................... 48 q-pap extra strength........ 48 QSYMIA........................ 77 q-tapp dm ..................... 128 Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. 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Para obtener más información, visite mss.anthem.com/ccc. 163 q-tussin......................... 128 q-tussin dm................... 128 QUADRACEL (PF)..... 100 quenalin........................ 128 quetiapine....................... 55 quinapril ......................... 62 quinaprilhydrochlorothiazide ... 62 quinidine sulfate tablets . 59 quit 2 .............................. 80 quit 4 .............................. 80 QVAR .......................... 137 R RABAVERT (PF)........ 100 raloxifene ..................... 102 ramipril........................... 63 RANEXA....................... 66 ranitidine hcl .................. 98 RAPAMUNE ................. 29 RAVICTI ....................... 79 REBIF (WITH ALBUMIN)................ 99 REBIF REBIDOSE........ 99 REBIF TITRATION PACK......................... 99 reclipsen (28) ............... 107 RECOMBIVAX HB (PF) .................................. 101 recort plus....................... 76 refenesen ...................... 128 refenesen dm ................ 128 refenesen pe ................. 128 REFRESH CLASSIC (PF) .................................. 110 REFRESH LACRI-LUBE .................................. 110 REFRESH TEARS ...... 110 reguloid .......................... 96 relcof c ......................... 128 RELENZA DISKHALER .................................... 14 RELISTOR .................... 96 remedy antifungal .......... 73 REMICADE................... 96 RENAGEL..................... 79 RENVELA..................... 79 RESCON-DM .............. 128 ? rescon-gg...................... 128 RESCRIPTOR ............... 14 RESPAIRE-30 ............. 128 rest simply nighttime sleep .................................. 128 RESTASIS ................... 110 restfully sleep ............... 128 retaine cmc ................... 110 RETROVIR.................... 14 revive plus.................... 110 REVLIMID .................... 29 REYATAZ..................... 14 ribasphere....................... 14 ribavirin.......................... 14 rid complete lice elim kit 76 RIDAURA ................... 103 rifabutin.......................... 19 rifampin.......................... 19 RIFATER....................... 19 ri-gel............................... 96 ri-gel ii............................ 96 riluzole ........................... 79 rimantadine .................... 14 ri-mox............................. 96 ri-mox plus ..................... 96 ringers .................... 77, 141 ringworm........................ 73 RISPERDAL CONSTA 55, 56 risperidone...................... 56 ri-tussin ........................ 128 ri-tussin dm .................. 129 RITUXAN...................... 29 rivastigmine tartrate ....... 37 rizatriptan ....................... 36 robafen ......................... 129 robafen cf ..................... 129 robafen cough............... 129 robafen dm ................... 129 robafen dm cough ........ 129 robitussin cold-flu day . 129 robitussin cough & cold cf .................................. 129 ROBITUSSIN LONGACTING .................. 129 robitussin pediatric....... 129 ropinirole........................ 36 rosadan ........................... 69 ROTARIX.................... 101 ROTATEQ VACCINE 101 ROXICET ...................... 40 ROZEREM .................... 56 RULOX.......................... 96 RYCONTUSS.............. 129 rydex............................. 129 rynex dm ...................... 129 S SABRIL ......................... 35 sani-supp (adult)............. 96 sani-supp (infant) ........... 96 SANTYL........................ 76 SAPHRIS (BLACK CHERRY) .................. 56 SAVELLA ................... 103 SCOT-TUSSIN DIABETES CF ........ 129 scot-tussin dm .............. 129 scot-tussin expectorant. 129 SCOT-TUSSIN SENIOR .................................. 129 secura antifungal ............ 73 secura antifungal extra thick............................ 73 selegiline hcl .................. 36 selenium sulfide ............. 67 SELZENTRY................. 15 senexon........................... 96 senna............................... 96 senna lax......................... 96 senna laxative................. 96 senna-gen ....................... 96 senno .............................. 96 sen-o-tab......................... 96 SENSIPAR..................... 87 sentry............................ 144 SEREVENT DISKUS.. 137 SEROQUEL XR ...... 56, 57 sertraline......................... 57 SEVERE ALLERGYSINUS HEADACHE129 severe cold.................... 129 SEVERE COLD & FLU NIGHTTIME ........... 129 Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. 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Para obtener más información, visite mss.anthem.com/ccc. 164 severe cold multi-symptom .................................. 129 severe congestion ........... 81 SEVERE CONGESTION & COUGH MAX..... 129 SEVERE SINUS.......... 129 SIGNIFOR ..................... 29 siladryl sa ..................... 129 silapap ............................ 48 sildenafil....................... 137 silphen cough ............... 129 siltussin dm das ............ 129 siltussin sa .................... 129 siltussin-dm .................. 129 silver sulfadiazine .......... 67 simethicone .................... 96 simply sleep ................. 129 SIMPONI ..................... 103 SIMULECT.................... 30 simvastatin ..................... 66 sinus & allergy non-drowsy .................................. 130 SINUS & COLD-D...... 130 sinus 12 hour ................ 130 sinus cong & pain day- night ......................... 130 sinus congestion & pain130 sinus congestion & pain(guaif)................ 130 sinus congestion&pain(chlorph ) ................................ 130 sinus decongestant (pe) 130 sinus headache pe......... 130 sinus nasal spray ............ 81 sinus pain relief ............ 130 sinus relief (non-drowsy) .................................. 130 sinus relief (oxymetazoline) .................................... 81 sirolimus......................... 30 SIRTURO ...................... 20 sleep ............................. 130 sleep aid (diphenhydramine)... 130 sleep aid max str (diphenhydr)............. 130 ? sleep ii .......................... 130 sleep tablet (diphenhydramine)... 130 sleep-tabs...................... 130 smooth antacid ............. 141 smoothlax ....................... 96 sochlor.......................... 110 sodium bicarbonate ........ 96 sodium chloride..... 79, 110, 141 sodium chloride 0.45 % 141 sodium chloride 0.9 % ... 79 sodium chloride 3 % .... 141 sodium chloride 5 % .... 141 sodium fluoride ............ 145 sodium polystyrene (sorb free) ............................ 79 sodium polystyrene sulfonate..................... 79 SODIUM POLYSTYRENE SULFONATE ............ 79 SOLTAMOX ................. 30 soluble fiber ................... 96 SOMATULINE DEPOT 30 SOMAVERT.................. 87 soothe (bismuth subsalicylate).............. 89 soothe regular strength... 89 soothing care (hydrocortisone)......... 76 sorbugen nr................... 130 sorine.............................. 59 sotalol............................. 59 sotalol af......................... 59 SOVALDI ...................... 15 spectravite advanced formula..................... 145 spectravite ultra women145 SPIRIVA RESPIMAT . 137 SPIRIVA WITH HANDIHALER ....... 137 spironolactone ................ 63 spironolactonhydrochlorothiaz ........ 63 sprintec (28) ................. 107 SPRYCEL ...................... 30 sps .................................. 79 ssd .................................. 67 stavudine ........................ 15 STIMATE ...................... 87 STIVARGA ................... 30 stomach relief................. 89 stomach relief max strength .................................... 89 stomach relief original ... 89 stop smoking aid ............ 80 STRATTERA................. 57 STREPTOMYCIN ......... 20 STRIBILD...................... 15 SUBOXONE.................. 48 sucralfate ........................ 98 SUDAFED PE PRESSURE+PAIN+CO UGH ......................... 130 sudogest........................ 130 sudogest 12-hour .......... 130 sudogest pe................... 130 sulfacetamide sodium... 112 sulfacetamide sodium (acne).......................... 70 sulfacetamide-prednisolone .................................. 112 sulfadiazine .................... 22 sulfamethoxazoletrimethoprim .............. 22 SULFAMYLON ............ 70 sulfasalazine ................... 96 sulfazine ......................... 97 sulfazine ec..................... 97 sulindac .......................... 48 sumatriptan succinate..... 36 super calcium ............... 141 super pain relief.............. 48 suphedrin...................... 130 suphedrin 12 hour ........ 130 suphedrine .................... 130 suphedrine 12 hour....... 130 suphedrine pe ............... 130 suphedrine pe sinus headache................... 131 suppository adult ............ 97 SUPRENZA ................... 77 SURMONTIL ................ 57 Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. 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Para obtener más información, visite mss.anthem.com/ccc. 165 SUSTIVA....................... 15 SUTENT ........................ 30 syeda ............................ 107 SYLATRON .................. 99 SYMLINPEN 120.......... 85 SYMLINPEN 60............ 85 SYNAGIS ...................... 15 SYNAREL ..................... 87 SYNERCID.................... 20 SYNRIBO ...................... 30 SYNTHROID ................ 88 SYPRINE....................... 79 SYSTANE.................... 110 SYSTANE (PF) ........... 110 SYSTANE ULTRA ..... 110 SYSTANE ULTRA (PF) .................................. 110 T tab-a-vite/iron............... 145 TABLOID ...................... 30 tacrolimus................. 30, 68 tactinal............................ 48 tactinal extra strength..... 48 TAFINLAR.................... 30 TAKE ACTION........... 107 TAMIFLU...................... 15 tamoxifen ....................... 30 tamsulosin .................... 138 TANZEUM .................... 86 TARCEVA..................... 30 TARGRETIN................. 30 TASIGNA ...................... 30 TAZORAC..................... 69 taztia xt........................... 63 tears again .................... 110 TEARS NATURALE II110 tears pure...................... 110 TECFIDERA.................. 37 TEFLARO...................... 17 TEKTURNA .................. 63 TEKTURNA HCT ......... 63 telmisartan...................... 63 telmisartan-amlodipine .. 63 telmisartanhydrochlorothiazid ..... 63 temazepam ..................... 57 TENSION HEADACHE 48 ? TENSION HEADACHE PAIN RELIEVER...... 48 TENSION HEADACHE RELIEF ...................... 48 terazosin ......................... 63 terbinafine hcl .......... 11, 73 terbutaline .................... 137 terconazole ................... 104 TESSALON PERLES.. 131 testosterone cypionate.... 87 testosterone enanthate .... 87 tetanus toxoid,adsorbed (pf)............................ 101 tetanus,diphtheria tox ped(pf)...................... 101 TETANUS-DIPHTHERIA TOXOIDS-TD ......... 101 tetracycline..................... 22 TG 10PEH-380GFN .... 131 tg 10peh-380gfn-15dm. 131 THALOMID .................. 30 the magic bullet.............. 97 theophylline.................. 137 THERAFLU COLD-SORE THROAT (PE) ......... 143 THERAFLU DAYTIME COLD-COUGH ....... 131 THERAFLU FLU-SORE THROAT ................. 131 THERAFLU MULTISYMPTOM COLD.. 131 THERAFLU NIGHT SEVERE COLD-CGH .................................. 131 THERAFLU SINUS & COLD....................... 143 thiamine hcl.................. 145 thioridazine .................... 57 thiothixene...................... 57 THYMOGLOBULIN .. 101 tiagabine......................... 35 TICE BCG ................... 101 TIKOSYN ...................... 59 TIMENTIN .................... 21 timolol maleate....... 63, 109 TIMOPTIC OCUDOSE (PF) .......................... 109 tinactin............................ 73 TINACTIN..................... 73 tioconazole ................... 105 tioconazole-1 ................ 105 TIVICAY ....................... 15 tizanidine........................ 38 tobramycin ................... 108 tobramycin in 0.225 % nacl .................................... 20 tobramycin sulfate.......... 20 tobramycin-dexamethasone opth susp .................. 111 tolazamide ...................... 86 tolbutamide..................... 86 tolcapone ........................ 36 tolmetin .......................... 48 tolnaftate......................... 73 tolterodine .................... 138 topiramate....................... 35 toposar............................ 30 topotecan ........................ 30 TORISEL ....................... 30 torsemide........................ 63 TOUJEO SOLOSTAR... 86 TRACLEER ................. 137 TRADJENTA................. 86 tramadol ......................... 48 tramadol-acetaminophen 48 trandolapril ..................... 63 tranexamic acid ...... 65, 105 tranylcypromine ............. 57 travasol 10 %................ 143 TRAVATAN Z ............ 111 travel sickness (meclizine) .................................... 97 trazodone........................ 57 TREANDA..................... 30 TRECATOR................... 20 TRELSTAR ................... 31 TRELSTAR DEPOT...... 30 TRELSTAR LA ............. 31 tretinoin .......................... 69 tretinoin (chemotherapy) 31 TRETIN-X CREAM KIT .................................... 70 TREXALL ..................... 31 Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. 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Para obtener más información, visite mss.anthem.com/ccc. 166 triamcinolone acetonide 76, 81, 83 TRIAMINIC CHEST &NASAL CONGEST .................................. 131 TRIAMINIC COLD & COUGH (PE) ........... 131 TRIAMINIC COLD & COUGH NT (PE)..... 131 triaminic cough-sore throat .................................. 131 triamterenehydrochlorothiazid ..... 63 trianex ............................ 76 TRIBENZOR ................. 63 tri-biozene ...................... 71 triderm............................ 76 trifluoperazine ................ 57 trifluridine .................... 108 trimethoprim .................. 22 triple antibiotic ............... 71 triple antibiotic (pram) extra............................ 71 triple antibiotic plus ....... 71 triple antibiotic-pain relief .................................... 71 triple paste af.................. 73 tri-previfem (28)........... 107 TRISENOX.................... 31 tri-sprintec (28) ............ 107 TRIUMEQ ..................... 15 trivora (28) ................... 107 TROPHAMINE 10 % .. 143 TROPHAMINE 6% ..... 143 trospium ....................... 138 TRULICITY .................. 86 TRUMENBA ............... 101 TRUVADA .................... 15 trymine cg .................... 131 TUMS .......................... 141 tums dual action (famotidine)................ 98 TUMS E-X................... 141 TUMS EXTRA STRENGTH SMOOTHIES........... 141 TUMS FRESHERS...... 141 ? tums ultra ..................... 141 TUSICOF..................... 131 tusnel c ......................... 131 tusnel diabetic .............. 131 TUSNEL NEW FORMULA .............. 131 TUSNEL PEDIATRIC 131 TUSNEL-DM PEDIATRIC............. 131 tussi pres-b ................... 131 TUSSICAPS ................ 131 tussigon ........................ 131 tussin ............................ 131 tussin cf ........................ 131 tussin cf cough-cold ..... 131 tussin cf max ................ 131 tussin chest congestion. 131 tussin cough &chest congestion ................ 131 tussin cough (dm only). 131 tussin cough dm ........... 132 tussin dm ...................... 132 tussin dm clear ............. 132 tussin dm cough ........... 132 tussin dm cough & chest .................................. 132 tussin dm max .............. 132 tussin expectorant......... 132 tussin honey ................. 132 tussin maximum strength .................................. 132 tussin maximum strength cough ........................ 132 tussin pe ....................... 132 tussinmax ..................... 132 tussi-pres ...................... 132 TWINRIX (PF) ............ 101 TYBOST ........................ 15 TYGACIL ...................... 20 TYKERB........................ 31 TYLENOL COLD MULTI-SYMPT NIGHT .................................. 132 TYLENOL COLD MULTI-SYMPTOM DAY......................... 132 TYLENOL SINUS CONGESTION PAIN .................................. 132 tylophen.......................... 48 TYPHIM VI ................. 101 TYSABRI ...................... 37 TYZEKA........................ 15 TYZINE ......................... 81 U U-CORT......................... 68 ULORIC....................... 102 ultra fresh ..................... 110 ULTRA LUBRICANT EYE.......................... 110 ultra strength antacid.... 141 ultra strength calcium antacid ...................... 141 unisom sleepgels .......... 132 UNITHROID ................. 88 ursodiol .......................... 97 UVADEX....................... 68 V valacyclovir.................... 15 VALCHLOR.................. 68 valganciclovir................. 15 valproate sodium ............ 35 valproic acid................... 35 valproic acid (as sodium salt)............................. 35 valsartan ......................... 63 valsartanhydrochlorothiazide ... 63 valu-dryl allergy........... 132 VANACOF .................. 132 VANAHIST PD ........... 132 vancomycin .................... 23 VANCOMYCIN ............ 23 VANCOMYCIN IN D5W .................................... 23 VANCOMYCIN IN DEXTROSE ISO-OSM .................................... 23 vaporizing steam .......... 132 VAPORX BALM........... 68 VAQTA (PF) ............... 101 VARIVAX (PF) ........... 101 VARIZIG ..................... 101 Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. 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Para obtener más información, visite mss.anthem.com/ccc. 167 VECAMYL.................... 66 VECTIBIX..................... 31 vegetable laxative........... 97 VELCADE..................... 31 velivet triphasic regimen (28)........................... 107 venlafaxine............... 57, 58 VENOFER ................... 145 VENTAVIS.................. 137 verapamil........................ 63 VERSACLOZ ................ 58 VICKS CHILDREN'S NYQUIL COLD&C. 132 vicks dayquil cold&flu relief ......................... 132 vicks dayquil cough ..... 132 VICKS DAYQUIL MUCUS CONTROL DM ........................... 132 VICKS DAYQUIL SEVERE COLD-FLU .................................. 133 VICKS DAYQUIL SINEX .................................. 133 VICKS NATURE FUSION .................................. 133 vicks nature fusion cough .................................. 133 VICKS NYQUIL COLD/FLU (CPM).. 133 vicks nyquil cold/flu liquicap..................... 133 VICKS NYQUIL COUGH .................................. 133 VICKS NYQUIL NIGHTTIME RELIEF .................................. 133 VICKS NYQUIL SEVERE COLD-FLU.............. 133 vicks qlearquil allergy.. 133 VICKS QLEARQUIL DAYTIME SINUS... 133 vicks qlearquil nighttime rlf .................................. 133 vicks sinex 12-hour ........ 81 vicks vaposteam ........... 133 VICTOZA 2-PAK.......... 86 ? VICTOZA 3-PAK.......... 86 VIDEX 2 GRAM PEDIATRIC............... 15 VIDEX 4 GRAM PEDIATRIC............... 15 VIEKIRA PAK .............. 15 VIGAMOX .................. 108 VIIBRYD....................... 58 VIMPAT .................. 35, 36 vinblastine ...................... 31 vincasar pfs .................... 31 VINCASAR PFS ........... 31 vincristine....................... 31 vinorelbine ..................... 31 viorele (28)................... 107 VIRACEPT .................... 15 VIRAMUNE XR ........... 15 VIRAZOLE.................... 15 VIREAD ........................ 15 virtussin ac ................... 133 vitamin a & d diaper rash68 vitamin a and d ............... 68 vitamin c....................... 145 vitamin d2 .................... 145 vitamin e....................... 145 VITAMIN E (DL, ACETATE) .............. 145 vitamin e mixed............ 145 vitamin e natural blend. 145 vitamin k ........................ 65 vitamin k1 ...................... 65 VITEKTA ...................... 15 vits a and d-white pet- lanolin ........................ 68 VOLTAREN GEL ......... 48 voriconazole............. 11, 12 VOTRIENT.................... 31 VPRIV............................ 87 W wal-dryl allergy............ 133 wal-dryl severe allergy- sinus ......................... 133 wal-fex allergy ............. 133 wal-finate ..................... 133 WAL-FLU COLD & SORE THROAT ...... 143 WAL-FLU NIGHT TIME .................................. 133 wal-flu severe cold ....... 133 WAL-FLU SEVERE COLD & COUGH ... 133 WAL-FLU SEVERE COLD-COUGH ....... 133 wal-itin ......................... 133 wal-itin d ...................... 133 wal-itin d 12 hour......... 133 wal-mucil fiber............... 97 wal-phed....................... 133 wal-phed 12 hour ......... 133 wal-phed pe .................. 134 wal-phed pe nighttime cold .................................. 134 WAL-PHED PE TRIPLE RELIEF .................... 134 wal-profen ...................... 48 wal-profen cold-sinus... 134 wal-profen d cold & sinus .................................. 134 wal-proxen ..................... 49 wal-som........................ 134 wal-tap dm.................... 134 wal-tussin cough .......... 134 wal-tussin cough & cold cf .................................. 134 wal-tussin dm ............... 134 wal-tussin max strength cough ........................ 134 wal-zan 75 ...................... 98 wal-zyr (cetirizine)....... 134 wal-zyr (ketotifen)........ 110 wal-zyr d ...................... 134 warfarin .......................... 65 wart remover .................. 68 water for irrigation, sterile .................................... 79 WELCHOL .................... 66 X XALKORI...................... 31 XARELTO ..................... 65 XENAZINE ................... 37 XENICAL ...................... 77 XGEVA.......................... 23 XOLAIR....................... 137 Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 168 XTANDI ........................ 31 XULANE ..................... 105 XYREM ......................... 58 Y yelets ............................ 145 YERVOY....................... 31 YF-VAX (PF) .............. 101 Z ZADITOR .................... 110 zafirlukast..................... 137 zaleplon .......................... 58 ZALTRAP...................... 31 ZANOSAR..................... 31 zarah............................. 107 ZAVESCA ..................... 87 zeasorb (miconazole) ..... 74 ZELBORAF................... 31 ZEMPLAR..................... 87 zenchent (28)................ 107 zenzedi ........................... 58 ? ZETIA ............................ 66 ZIAGEN......................... 15 zidovudine...................... 16 ZIKS ARTHRITIS PAIN RELIEF ...................... 68 zinc chloride intraveneous solution..................... 141 zinc oxide ....................... 68 ziprasidone hcl ............... 58 ZIRGAN ...................... 108 ZODRYL AC 25.......... 134 ZODRYL AC 30.......... 134 ZODRYL AC 40.......... 134 ZODRYL AC 50.......... 134 ZODRYL AC 60.......... 134 ZODRYL AC 80.......... 134 ZODRYL DEC 25 ....... 134 ZODRYL DEC 30 ....... 134 ZODRYL DEC 40 ....... 134 ZODRYL DEC 50 ....... 134 ZODRYL DEC 60 ....... 134 ZODRYL DEC 80 ....... 134 zoledronic acid ............... 87 ZOLINZA ...................... 31 zolmitriptan .................... 36 zolpidem......................... 58 ZOMETA ....................... 87 ZOMIG........................... 36 zonisamide ..................... 36 ZORTRESS.................... 31 ZOSTAVAX (PF) ........ 101 zovia 1/35e (28) ........... 107 zovia 1/50e (28) ........... 107 Z-TUSS AC ................. 134 ZYDELIG ...................... 31 ZYKADIA ..................... 31 ZYPREXA RELPREVV 58 ZYRTEC ...................... 134 ZYTIGA......................... 32 ZYVOX.......................... 20 Si tiene preguntas, llame a Anthem HealthKeepers MMP al 1-855-817-5787 (TTY 711), de lunes a viernes de 8 a.m. a 8 p.m. local time. La llamada es gratuita. Para obtener más información, visite mss.anthem.com/ccc. 169 ¿Tiene alguna pregunta? Llámenos a la línea gratuita al 1-855-817-5787 (TTY 711) de lunes a viernes de 8 a.m. a 8 p.m. hora local. O visite mss.anthem.com/ccc. Los copagos por medicamentos recetados pueden variar según el nivel de Ayuda adicional que reciba. Contacte al plan para obtener más detalles. La Lista de medicamentos cubiertos o las redes de farmacias y prestadores pueden cambiar durante el año. Le enviaremos una notificación antes de hacer algún cambio que afecte su caso. Los beneficios o copagos pueden cambiar el 1 de enero de cada año. Pueden aplicarse limitaciones, copagos y restricciones. Para obtener más información, llame a Anthem HealthKeepers MMP Member Services o lea el Manual del miembro de Anthem HealthKeepers MMP. You can get this information for free in other languages. Call 1-855-817-5787 (TTY 711). The call is free. Puede recibir esta información sin cargo en otros idiomas. Llame al 1-855-817-5787 (TTY 711). La llamada es gratuita. Puede obtener esta información de forma gratuita en otros formatos, como letra grande, Braille o audio. Llame al 1-855-817-5787 (TTY 711). La llamada es gratuita. HealthKeepers, Inc. es un plan de salud que posee contratos con Medicare y el Virginia Department of Medical Assistance Services para proporcionar los beneficios de ambos programas a los inscritos. HealthKeepers, Inc. es un licenciatario independiente de Blue Cross and Blue Shield Association. ANTHEM es una marca comercial registrada de Anthem Insurance Companies, Inc. Los nombres y símbolos de Blue Cross and Blue Shield son marcas registradas de Blue Cross and Blue Shield Association. H0147_16_24596_T_SP CMS Approved 09/18/2015 ID del Formulario: 16234 Versión: 7 Publicado 01/01/2016 AVADMKT-0092-15 01/16 Form SP
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