1250 Broadway, 11th floor, New York, NY 10001 www.vnsnychoice.org VNSNY CHOICE Medicare Any questions? Call toll free 1-866-783-1444 (TTY for the hearing impaired 711) 8 am – 8 pm, Monday – Friday 2016 FORMULARY OF COVERED PRESCRIPTION DRUGS PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on 08/29/2015. For more recent information or other questions, please contact VNSNY CHOICE Medicare Member Services at 1-866-783-1444 or, for TTY users, 711, Monday through Friday from 8:00 AM to 8:00 PM or visit www.vnsnychoice.org A Medicare Advantage Plan 2016 FORMULARY OF COVERED PRESCRIPTION DRUGS VNSNY CHOICE Medicare Approved Formulary Submission ID Number: 16492.001, Version 7 VNSNY CHOICE Medicare Preferred (HMO SNP) VNSNY CHOICE Total (HMO SNP) VNSNY CHOICE Medicare Maximum (HMO SNP) VNSNY CHOICE Medicare Classic (HMO) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on 08/29/2015. For more recent information or other questions, please contact VNSNY CHOICE Medicare Member Services at 1-866-783-1444 or, for TTY users, 711, Monday through Friday from 8:00 AM to 8:00 PM or visit www.vnsnychoice.org H5549_2016 Formulary_1085_DSB_rv_Accepted 09192015 VNSNY CHOICE Medicare and VNSNY CHOICE Total 2016 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Includes members enrolled in VNSNY CHOICE Medicare Preferred (HMO SNP), VNSNY CHOICE Medicare Classic (HMO), VNSNY CHOICE Medicare Maximum (HMO SNP) and VNSNY CHOICE Total (HMO SNP) Approved Formulary Submission ID Number: 16492.001, Version: 7 This formulary was updated on August 29, 2015. For more recent information or other questions, please contact VNSNY CHOICE Medicare Member Services at 1-866-783-1444 or, for TTY users, 711, Monday through Friday from 8:00 AM to 8:00 PM or visit www.vnsnychoice.org. Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to “we,” “us”, or “our,” it means VNSNY CHOICE Medicare. When it refers to “plan” or “our plan,” it means our VNSNY CHOICE Medicare Preferred (HMO SNP), VNSNY CHOICE Medicare Classic (HMO), VNSNY CHOICE Medicare Maximum (HMO SNP) and VNSNY CHOICE Total (HMO SNP). This document includes a list of the drugs (formulary) for our plan, which is current as of August 29, 2015. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front cover and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2017, and from time to time during the year. VNSNY CHOICE Medicare is an HMO plan with a Medicare contract. Enrollment in VNSNY CHOICE Medicare depends on contract renewal. Last updated: 08/29/2015 H5549_2016 Formulary_1085_DSB 1 What is the VNSNY CHOICE Medicare Formulary? A formulary is a list of covered drugs selected by VNSNY CHOICE Medicare in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. VNSNY CHOICE Medicare will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a VNSNY CHOICE Medicare network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 2016 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2016 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of August 29, 2015. To get updated information about the drugs covered by VNSNY CHOICE Medicare, please contact us. Our contact information appears on the front cover and back cover pages. If we update our printed formulary with non-maintenance formulary changes, we will send you a notice that includes this information. 2 How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 49. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “Cardiovascular”. If you know what your drug is used for, look for the category name in the list that begins on page 49. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on I-1. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? VNSNY CHOICE Medicare covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: • Prior Authorization: VNSNY CHOICE Medicare requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from VNSNY CHOICE Medicare before you fill your prescriptions. If you don’t get approval, VNSNY CHOICE Medicare may not cover the drug. • Quantity Limits: For certain drugs, VNSNY CHOICE Medicare limits the amount of the drug that VNSNY CHOICE Medicare will cover. For example, VNSNY CHOICE Medicare provides 60 capsules per prescription for Celebrex. This may be in addition to a standard one-month or three-month supply. • Step Therapy: In some cases, VNSNY CHOICE Medicare requires you to first try certain drugs to treat\RXUPHGLFDOFRQGLWLRQEHIRUHZHZLOO 3 cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, VNSNY CHOICE Medicare may not cover Drug B unless you try Drug A first. If Drug A does not work for you, VNSNY CHOICE Medicare will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 49. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. Our contact information, along with the date we last updated the formulary, appears on the front cover and back cover pages. You can ask VNSNY CHOICE Medicare to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the VNSNY CHOICE Medicare’s formulary?” on page 5 for information about how to request an exception. What are over-the counter (OTC) drugs? OTC drugs are non-prescription drugs that are not normally covered by a Medicare Prescription Drug Plan. VNSNY CHOICE Medicare pays for certain OTC drugs. COVERED OVER-THE-COUNTER (OTC) DRUGS DRUG Dosage Form Generic Name (Reference Brand Name) cetirizine hydrochloride (Zyrtec) Chewable Tablets, Solution, Tablets (Zyrtec-D) 12 Hour Tablets (Claritin) Solution, Tablets 12 Hour Tablets 24 Hour Tablets Drops cetirizine hydrochloride/ pseudoephedrine hydrochloride loratadine loratadine/ pseudoephedrine sulfate ketotifen fumarate (Claritin-D) (Zaditor) VNSNY CHOICE Medicare will provide these OTC drugs at no cost to you. The cost to VNSNY CHOICE Medicare of these OTC drugs will not count toward your total Part D drug costs (that is, the amount you pay does not count for the coverage gap.) 4 What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. If you learn that VNSNY CHOICE Medicare does not cover your drug, you have two options: • You can ask Member Services for a list of similar drugs that are covered by VNSNY CHOICE Medicare. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by VNSNY CHOICE Medicare. • You can ask VNSNY CHOICE Medicare to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the VNSNY CHOICE Medicare Formulary? You can ask VNSNY CHOICE Medicare to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. • You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. • You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. • You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, VNSNY CHOICE Medicare limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, VNSNY CHOICE Medicare will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower costsharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. 5 When you request a formulary, tiering or utilization restriction exception, you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 91-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. A transition fill is provided to current members that are in need of a one-time Emergency Fill or that are prescribed a non-formulary drug as a result of a level of care change. 6 For more information For more detailed information about your VNSNY CHOICE Medicare prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about VNSNY CHOICE Medicare, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front cover and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or, visit www.medicare.gov. This information is available for free in other languages. Please call Member Services at 1-866-783-1444 for additional information. (TTY users should call 711 Toll-free) Monday through Friday from 8:00 AM to 8:00 PM. Member Services also has free language interpreter services available for non-English speakers. VNSNY CHOICE Medicare is an HMO with a Medicare contract. Enrollment in VNSNY CHOICE Medicare depends on contract renewal. 7 VNSNY CHOICE Medicare’s Formulary The formulary that begins on page 49 provides coverage information about the drugs covered by VNSNY CHOICE Medicare. If you have trouble finding your drug in the list, turn to the Index that begins on page I-1. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., CELEBREX) and generic drugs are listed in lower-case italics (e.g., naproxen). The information in the Requirements/Limits column tells you if VNSNY CHOICE Medicare has any special requirements for coverage of your drug. The following Utilization Management abbreviations may be found within the body of this document COVERAGE NOTES ABBREVIATIONS ABBREVIATION DESCRIPTION EXPLANATION Utilization Management Restrictions PA PA BvD Prior Authorization Restriction You (or your physician) are required to get prior authorization from VNSNY CHOICE Medicare before you fill your prescription for this drug. Without prior approval, VNSNY CHOICE Medicare may not cover this drug. Prior Authorization Restriction for Part B vs Part D Determination This drug may be eligible for payment under Medicare Part B or Part D. You (or your physician) are required to get prior authorization from VNSNY CHOICE Medicare to determine that this drug is covered under Medicare Part D before you fill your prescription for this drug. Without prior approval, VNSNY CHOICE Medicare may not cover this drug. 8 ABBREVIATION PA-HRM PA NSO QL ST DESCRIPTION EXPLANATION This drug has been deemed by CMS to be potentially harmful and therefore, a High Risk Medication for Medicare beneficiaries 65 years or older. Members Prior Authorization age 65 yrs or older are required to get Restriction for prior authorization from VNSNY High Risk Medications CHOICE Medicare before you fill your prescription for this drug. Without prior approval, VNSNY CHOICE Medicare may not cover this drug Prior Authorization Restriction for New Starts Only Quantity Limit Restriction Step Therapy Restriction 9 If you are a new member, you (or your physician) are required to get prior authorization from VNSNY CHOICE Medicare before you fill your prescription for this drug. Without prior approval, VNSNY CHOICE Medicare may not cover this drug. VNSNY CHOICE Medicare limits the amount of this drug that is covered per prescription, or within a specific time frame. Before VNSNY CHOICE Medicare will provide coverage for this drug, you must first try another drug(s) to treat your medical condition. This drug may only be covered if the other drug(s) does not work for you. The following additional coverage note abbreviations may be found within the body of this document OTHER SPECIAL REQUIREMENTS FOR COVERAGE ABBREVIATION LA NM DESCRIPTION EXPLANATION Limited Access Drug This prescription may be available only at certain pharmacies. For more information consult your Provider and Pharmacy Directory or call Member Services at 1-866-783-1444, Monday through Friday from 8:00 am to 8:00 pm. TTY/TDD users should call 711. Non-Mail Order Drug You may be able to receive greater than a 1-month supply of most of the drugs on your formulary via mail order at a reduced cost share. Drugs not available via your mail order benefit are noted with “NM” in the Requirements/Limits column of your formulary. 10 STRENGTH AND DOSAGE FORM ABBREVIATIONS ABBREVIATION adh. patch aer br act aer pow aer pow ba aer refill aer w/adap ampul blkbaginj cap dr mp cap ds pk cap er 12h cap er 24h cap er deg cap er pel cap mphase cap.sa 24h cap.sr 12h cap.sr 24h cap24h pct cap24h pel cap sprink cap sr pel cap w/dev capsule dr capsule er capsule sa cmb cappad cmb ont fm cmb ont lt cmb tabpad combo. pkg cpmp 12hr cpmp 24hr cpmp 30-70 DESCRIPTION adhesive patch aerosol, breath activated aerosol, powder aerosol powder, breath activated aerosol refill aerosol with adapter ampule bulk bag injection capsule, delayed release multiphasic capsule, dose pack capsule, 12 hour extended release capsule, 24 hour extended release capsule, extended release degradable capsule, extended release pellets capsule, multiphasic capsule, 24 hour sustained action capsule, 12 hour sustained release capsule, 24 hour sustained release capsule, 24 hour controlled-onset pellets capsule, 24 hour sustained release pellets capsule, sprinkle capsule sustained release pellets capsule with device capsule, delayed release capsule, extended release capsule, sustained action combination: capsule, pad combination: ointment, foam combination: ointment, lotion combination: tablet, pad combination package capsule, 12 hour multiphasic capsule, 24 hour multiphasic capsule, multiphasic, 30%-70% 11 ABBREVIATION cpmp 50-50 cream(g), cream(gm) cream(ml) cream/appl cream, er (g) cream pack dehp fr bg dis needle disk w/dev disp syrin drops susp drps hpvis emul adhes emul packt emulsn(g) foam/appl. froz.piggy g gel/pf app gel (gm) gel (ml) gel md pmp gel w/appl gel w/pump gran pack hfa aer ad infus. btl insuln pen ip soln irrig soln iv soln. jel jelly/app jel/pf app kit cl&crm kt crm le DESCRIPTION capsule, multiphasic, 50%-50% cream (grams) cream (milliliters) cream with applicator cream, extended release (grams) cream, package di(2-ethylhexyl)phthalate free bag disposable needle disk with inhalation device disposable syringe drops, suspension drops, hyperviscous emulsion adhesive emulsion packet emulsion (grams) foam with applicator frozen piggyback gram gel with prefilled applicator gel (grams) gel (milliliters) gel in metered dose pump gel with applicator gel with pump granule pack hfa aerosol adapter infusion bottle insulin pen intraperitoneal solution irrigating solution intravenous solution jelly jelly with applicator jelly with pre-filled applicator kit: cleanser and cream kit: cream, lotion emollient 12 ABBREVIATION kt lotn ce kt oint le lotion, er lozenge hd m.ht patch ma buc tab mcg med. pad med. swab med. tape mg ml muc er 12h ndl fr inj nl fm susp oint. (g), oint.(gm) oral conc oral susp paste (g) patch td24 patch td72 patch tdsw patch tdwk pca syring pca vial pellet(ea) pen ij kit pen injctr pggybk btl plast. bag powd pack sol md pmp sol w/appl sol/pf app sol-gel soln recon DESCRIPTION kit: lotion, cream emollient kit: ointment, lotion emollient lotion, extended release lozenge handle medicated heated patch mucoadhesive buccal tablet microgram medicated pad medicated swab medicated tape milligram milliliter mucoadhesive system, 12 hour extended release needle for injection nail film suspension ointment (grams) oral concentrate oral suspension paste (grams) patch, 24 hour transdermal patch, 72 hour transdermal patch, biweekly transdermal patch, weekly transdermal patient-controlled analgesic syringe patient-controlled analgesic vial pellet (each) pen injector kit pen injector piggyback bottle plastic bag powder pack solution with multi-dose pump solution with applicator solution with pre-filled applicator solution, gel-forming solution, reconstituted 13 ABBREVIATION soln(gram) spray susp spray/pump stick(ea) supp.rect supp.vag suppos. sus er 24h sus er rec sus mc rec suspdr pkt susp recon syringekit tab chew tab er 12h tab er 24h tab er prt tab er seq tab disper tab ds pk tab er 24 tab mphase tab part tab rap dr tab rapdis tab subl tab.sr 12h tab.sr 24h tabergr24hr tablet dr tablet, er tablet eff tablet sa tablet sol tb er dspk tb mp dspk DESCRIPTION solution (grams) spray, suspension spray with pump stick (each) suppository, rectal suppository, vaginal suppository suspension, 24 hour extended release suspension, extended release reconstituted suspension, microcapsule reconstituted suspension, delayed release packet suspension, reconstituted syringe kit tablet, chewable tablet, 12 hour extended release tablet, 24 hour extended release tablet, extended release particles tablet, extended release sequels tablet, dispersible tablet, dose pack tablet, 24 hour extended release tablet, multiphasic tablet, particles tablet, rapid disintegrating delayed release tablet, rapid disintegrating tablet, sublingual tablet, 12 hour sustained release tablet, 24 hour sustained release tablet, 24 hour gradual extended release tablet, delayed release tablet, extended release tablet, effervescent tablet, sustained action tablet, soluble tablet, extended release dose pack tablet, multiphasic dose pack 14 ABBREVIATION tb rd dspk tbdspk 3mo tbmp 12hr tbmp 24hr u vag ring DESCRIPTION tablet, rapid disintegrating dose pack tablet, 3-month dose pack tablet, 12 hour multiphasic tablet, 24 hour multiphasic unit vaginal ring 15 VNSNY CHOICE Medicare y VNSNY CHOICE Total Formulario de Medicamentos 201 (Listado de Medicamentos Cubiertos) Incluye miembros inscritos en VNSNY CHOICE Medicare Preferred (HMO SNP), VNSNY CHOICE Medicare Classic (HMO), VNSNY CHOICE Medicare Maximum (HMO SNP) and VNSNY CHOICE Total (HMO SNP) Aprobado Formulario Número de la petición: 16492.001, Versión Este formulario de medicamentos fue actualizado 08/29/2015. Para recibir información más reciente o si tiene alguna otra duda, sírvase llamar al Servicio para Miembros de Medicare de VNSNY CHOICE al 1-866-783-1444 o, para aquellos que utilizan TTY, al 711, de lunes a viernes, de 8:00 AM a 8:00 PM o visite www.vnsnychoice.org. Aviso para miembros existentes: Este formulario de medicamentos ha cambiado desde el año pasado. Por favor, revise este documento para asegurar que aún contiene los medicamentos que usted toma. Cuando esta relación de medicamentos (formulario de medicamentos) hace referencia a “nos,” “nosotros”, o “nuestro,” se refiere a VNSNY CHOICE Medicare. Cuando hace referencia al “plan” o “nuestro plan,” se refiere a nuestro VNSNY CHOICE Medicare Preferred (HMO SNP), VNSNY CHOICE Medicare Classic (HMO), VNSNY CHOICE Medicare Maximum (HMO SNP) and VNSNY CHOICE Total (HMO SNP). Este documento incluye una relación de los medicamentos (formulario de medicamentos) para nuestro plan, que se encuentra actualizado a partir del 08/29/2015. Para recibir un formulario de medicamentos actualizado, sírvase comunicarse con nosotros. Nuestra información de contacto, al igual que la fecha en que actualizamos el formulario de medicamentos, aparece en la portada y contraportada. Por lo general, debe utilizar las farmacias dentro de la red para poder utilizar su beneficio de medicamentos con receta. Los beneficios, el formulario de medicamentos, la red de farmacias, las primas y/o copagos/coaseguro pueden cambiar el 1 de enero de 2017. VNSNY CHOICE Medicare es un plan de HMO con contrato de Medicare. La inscripción en VNSNY CHOICE Medicare depende de la renovación del contrato. 16 ¿Qué es el formulario de medicamentos de VNSNY CHOICE Medicare? Un formulario de medicamentos es una relación de medicamentos cubiertos seleccionados por VNSNY CHOICE Medicare en consulta con un equipo de proveedores de servicios médicos, que representan los tratamientos con receta que se piensan ser una parte necesaria de un programa de tratamiento de calidad. VNSNY CHOICE Medicare, por lo general, cubrirá los medicamentos que aparecen en nuestro formulario de medicamentos siempre que dicho medicamento es médicamente necesario, la receta se llena en una farmacia de la red de VNSNY CHOICE Medicare, y se siguen otros reglamentos del plan. Para más información sobre cómo llenar sus recetas, sírvase revisar su Evidencia de Cobertura. ¿Puede cambiar el formulario de medicamentos (relación de medicamentos)? Generalmente, si está tomando un medicamento que se encuentra en nuestro formulario de medicamentos de 2016 que fue cubierto al comienzo del año, no descontinuaremos ni reduciremos la cobertura de ese medicamento durante el año de cobertura de 2016 con la excepción de que se haga disponible un medicamento genérico nuevo y más económico o si se difunde nueva información adversa sobre la seguridad o efectividad de un medicamento. Otros tipos de cambios al formulario de medicamentos, tal como eliminar un medicamento del mismo, no afectará a los miembros que están tomando el medicamento actualmente. Permanecerá disponible al mismo costo compartido para aquellos miembros que lo toman durante lo que resta del año de cobertura. Pensamos que es importante que usted tenga acceso continuado a los medicamentos del formulario de medicamentos que tenía disponible cuando escogió nuestro plan, para lo que resta del año de cobertura, con excepción de los casos en los cuales puede ahorrar dinero adicional o podemos asegurar su seguridad. Si eliminamos medicamentos de nuestro formulario de medicamentos, o añadimos restricciones de autorización previa, límites de cantidad y/o terapias escalonadas para un medicamento o si cambiamos un medicamento a un nivel de costo compartido más alto, debemos notificar a los miembros afectados de dicho cambio un mínimo de 60 días antes de que tome vigencia, o cuando el miembro pide una reposición del medicamento, en cuyo momento el miembro recibirá un suministro de 60 días de dicho medicamento. Si el Organismo para el Control de Alimentos y Fármacos (FDA, por sus siglas en inglés) considera que un medicamento que se encuentra en nuestro formulario de medicamentos no es seguro o el fabricante del medicamento lo retira del mercado, nosotros eliminaremos el mismo de nuestro formulario de medicamentos de inmediato y le daremos aviso a aquellos miembros que toman ese medicamento. El formulario de medicamentos adjunto se encuentra actualizado a partir 08/29/2015. Para recibir información actualizada sobre los 17 medicamentos cubiertos por VNSNY CHOICE Medicare, sírvase comunicarse con nosotros. Nuestra información de contacto aparece en la portada y contraportada. Si actualizamos nuestro formulario de medicamentos impreso con cambios que no son de mantenimiento, le enviaremos una notificación que contiene esta información. ¿Cómo utilizo el formulario de medicamentos? Existen dos formas de encontrar su medicamento dentro del formulario de medicamentos: Condición médica El formulario de medicamentos comienza en la página 49. Los medicamentos en este formulario de medicamentos están agrupados en categorías de acuerdo a los tipos de condiciones médicas para los cuales son utilizados. Por ejemplo, los medicamentos utilizados para tratar una condición cardíaca se encuentran bajo la categoría, “Cardiovascular Agents”. Si sabe para qué se utiliza el medicamento, busque el nombre de la categoría en la relación que comienza en la página 49. Luego, mire bajo el nombre de categoría para buscar ese medicamento. Relación alfabética Si no está seguro en qué categoría buscar, debe buscar el medicamento en el Índice que comienza en la página I-1. El Índice ofrece una relación alfabética de todos los medicamentos incluidos en este documento. Los medicamentos de marca, al igual que los medicamentos genéricos, se encuentran en el Índice. Busque en el Índice y encuentre el medicamento. Al lado del medicamento, verá el número de la página en la cual puede encontrar la información de cobertura. Vaya a la página mencionada en el Índice y encuentre el nombre del medicamento en la primera columna de la relación. ¿Qué son los medicamentos genéricos? VNSNY CHOICE Medicare cubre los medicamentos de marca al igual que los medicamentos genéricos. Un medicamento genérico es aprobado por la FDA como teniendo el mismo ingrediente activo que el de marca. Por lo general, los medicamentos genéricos cuestan menos que los de marca. 18 ¿Existe alguna restricción sobre mi cobertura? Algunos medicamentos cubiertos pueden tener requerimientos o limitaciones adicionales sobre su cobertura. Estos requerimientos y limitaciones pueden incluir: • Autorización previa: VNSNY CHOICE Medicare exige que usted o su médico reciba autorización previa para ciertos medicamentos. Esto implica que deberá recibir aprobación de VNSNY CHOICE Medicare antes de llenar sus recetas. Si no consigue aprobación, es posible que VNSNY CHOICE Medicare no cubra el medicamento. • Limitaciones de cantidad: Para ciertos medicamentos, VNSNY CHOICE Medicare limita la cantidad del medicamento que VNSNY CHOICE Medicare cubrirá. Por ejemplo, VNSNY CHOICE Medicare suministra 60 cápsulas por cada receta para el medicamento Celebrex. Esto puede ser además de un suministro estándar de un mes o tres meses. • Tratamiento escalonado: En algunos casos, VNSNY CHOICE Medicare exige que pruebe ciertos medicamentos primero, para tratar su condición médica, antes que cubriremos otro medicamento para tratar esa condición. Por ejemplo, si Medicamento A y Medicamento B pueden tratar su condición médica, es posible que VNSNY CHOICE Medicare no cubra el Medicamento B al menos que primero pruebe con el Medicamento A. Si no le funciona el Medicamento A, entonces VNSNY CHOICE Medicare cubrirá el medicamento B. Usted puede determinar si su medicamento tiene algún requerimiento adicional o limitación con buscar en el formulario de medicamentos que comienza en la página 49. También puede recibir más información sobre las restricciones que aplican a ciertos medicamentos cubiertos con visitar nuestro sitio Web. Nuestra información de contacto, al igual que la fecha en que actualizamos el formulario de medicamentos, aparece en la portada y contraportada. Puede pedirle a VNSNY CHOICE Medicare para hacer una excepción a estas restricciones o limitaciones o para una relación de otros medicamentos similares que pueden tratar su condición de salud. Véase la sección, “Cómo pido una excepción al formulario de medicamentos de VNSNY CHOICE Medicare?” que se encuentra en la página 20 para obtener más información sobre cómo solicitar una excepción. 19 MEDICAMENTOS DE VENTA LIBRE (OTC) CON COBERTURA MEDICAMENTOS Nombre genérico (Nombre de marca de referencia) hidrocloruro de (Zyrtec) cetirizina hidrocloruro de cetirizina/ (Zyrtec-D) hidrocloruro de pseudoefedrina loratadina (Claritin) loratadina/ sulfato de (Claritin-D) pseudoefedrina fumarato de cetotifeno (Zaditor) Presentación Tabletas masticables, solución, tabletas Tabletas de 12 horas Solución, tabletas Tabletas de 12 horas Tabletas de 24 horas Gotas Y ¿Si mi medicamento no se encuentra en el formulario de medicamentos? Si su medicamento no se incluye en este formulario de medicamentos (relación de medicamentos cubiertos), debe primero comunicarse con Servicios para Miembros para consultar si su medicamento se encuentra cubierto. Si descubre que VNSNY CHOICE Medicare no cubre su medicamento, usted tiene dos opciones: • Puede pedirle a Servicios para Miembros para una relación de medicamentos similares que están cubiertos por VNSNY CHOICE Medicare. Cuando recibe la relación, muéstrela a su médico y pídale que recete un medicamento similar que sea cubierto por VNSNY CHOICE Medicare. • Puede pedirle a VNSNY CHOICE Medicare para que haga una excepción y cubra su medicamento. Véase a continuación para obtener información sobre cómo solicitar una excepción. 20 ¿Cómo pido una excepción al Vademécum de VNSNY CHOICE Medicare? Puede pedirle a VNSNY CHOICE Medicare de hacer una excepción a los reglamentos de cobertura. Existen varios tipos de excepciones que nos puede pedir. • Nos puede pedir cubrir un medicamento, aunque no se encuentra en nuestro formulario de medicamentos. Si es aprobado, este medicamento será cubierto en un nivel de costo compartido predeterminado, y no podrá pedirnos ofrecer el medicamento a un nivel de costo compartido inferior. • Nos puede pedir cubrir un medicamento que se encuentra en el formulario de medicamentos a un nivel de costo compartido inferior si el medicamento no se encuentra en el nivel especializado. Si es aprobado, esto reduciría el monto que debe pagar para su medicamento. • Nos puede pedir eliminar las restricciones o limitaciones de cobertura sobre su medicamento. Por ejemplo, para ciertos medicamentos, VNSNY CHOICE Medicare limita la cantidad de medicamento que cubrirá. Si su medicamento tiene un límite de cantidad, nos puede pedir eliminar ese límite y cubrir una cantidad mayor. Por lo general, VNSNY CHOICE Medicare solamente aprobará su solicitud para una excepción si los medicamentos alternativos incluidos en el formulario de medicamentos del plan, el medicamento de costo compartido inferior o las restricciones de utilización adicionales no serían tan eficaces en tratar su condición y/o le causaría tener efectos médicos adversos. Debe comunicarse con nosotros para pedirnos una decisión de cobertura inicial para una excepción de restricción al formulario de medicamentos, escalonamiento o utilización. Cuando solicita una excepción de restricción al formulario de medicamentos, escalonamiento o utilización, debe presentar una declaración del prescriptor o médico apoyando su petición. Por lo general, debemos tomar nuestra decisión dentro de 72 horas de recibir la declaración de apoyo de su prescriptor. Puede pedir una excepción acelerada (rápida) si usted o su médico piensa que su salud puede ser seriamente perjudicada si espera hasta 72 horas para recibir una decisión. Si se le otorga su petición para acelerar, le debemos dar una decisión no menos de 24 horas después de recibir la declaración de apoyo de su médico u otro prescriptor. 21 ¿Qué debo hacer antes de hablar con mi médico sobre cambiar mis medicamentos o pedir una excepción? Como un miembro nuevo o continuado de nuestro plan, es posible que usted está tomando medicamentos que no se encuentran en nuestro formulario de medicamentos. También es posible que esté tomando un medicamento que se encuentra en nuestro formulario de medicamentos pero su habilidad de conseguirlo es limitada. Por ejemplo, usted puede necesitar una autorización previa de nosotros antes de poder llenar su receta. Debe consultar con su médico para determinar si debe cambiar a un medicamento apropiado que cubrimos o pedir una excepción al formulario de medicamentos para poder cubrirle el medicamento que toma. Mientras consulta con su médico para determinar el curso apropiado para usted, es posible que cubriremos su medicamentos en ciertos casos durante los primeros 90 días que usted es un miembro de nuestro plan. Por cada uno de los medicamentos que no se encuentran en nuestro formulario de medicamentos o si tiene habilidad limitada de conseguir sus medicamentos, cubriremos un suministro provisional de 30 días (al menos que tiene una receta escrita para menos días) cuando vaya a una farmacia dentro de la red. Después de su primer suministro de 30 días, no pagaremos por estos medicamentos, aunque ha sido un miembro del plan menos de 90 días. Si es residente de una centro de atención a largo plazo, le permitiremos reposicionar su receta hasta que le hayamos proveído con un suministro de 91 días, consistente con el incremento de dispensación (al menos que tiene una receta escrita por menos días). Cubriremos más de una reposición de estos medicamentos para los primeros 90 días si es un miembro de nuestro plan. Si necesita de un medicamento que no se encuentra en nuestro formulario de medicamentos o si tiene habilidad limitada en conseguir sus medicamentos, pero se encuentran pasados los primeros 90 días de membresía en nuestro plan, cubriremos un suministro de emergencia de 31 días para ese medicamento (al menos que tiene una receta para menos días) mientras solicita una excepción al formulario de medicamentos. Un resurtido de transición sera proporcionado, por una vez, a los miembros actuales que están en necesidad de un resurtido de emergencia o que han sido recetado un medicamento fuera del formulario debido a un cambio de nivel de atención. 22 Para más información Para obtener más información sobre su cobertura de medicamentos con receta de VNSNY CHOICE Medicare, sírvase revisar la Evidencia de Cobertura y demás materiales del plan. Si tiene alguna duda sobre VNSNY CHOICE Medicare, sírvase comunicarse con nosotros. Nuestra información de contacto, al igual que la fecha en que actualizamos el formulario de medicamentos, aparece en la portada y contraportada. Si tiene alguna duda en general sobre la cobertura de medicamentos con receta de Medicare sírvase llamar al 1-800-MEDICARE (1-800-633-4227) las 24 horas del día/7 días a la semana. Los usuarios de TTY deben llamar al 1-877-486-2048. O, visite www.medicare.gov. Esta información está disponible gratis en otros idiomas. Comuníquese con nuestros Servicios al miembro al número 1-866-783-1444 para obtener información adicional. (Los usuarios de TTY deben llamar al 711.) Horario de atención de lunes a viernes de 8:00 a.m. a 8:00 p.m. Los Servicios al miembro también tienen disponibles servicios gratis de intérpretes de idiomas para personas que no hablan ingles VNSNY CHOICE Medicare es un plan de HMO con contrato de Medicare. La inscripción en VNSNY CHOICE Medicare depende de la renovación del contrato. 23 Formulario de Medicamentos de VNSNY CHOICE Medicare El formulario de medicamentos que comienza en la página 49 ofrece información de cobertura sobre los medicamentos cubiertos por VNSNY CHOICE Medicare. Si tiene dificultad en encontrar su medicamento en esta relación, sírvase consultar el Índice que comienza en la página I-1. En la primera columna de la tabla aparece el nombre del medicamento. Los medicamentos de marca aparecen con letras mayúsculas (por ejemplo, CELEBREX) y los medicamentos genéricos aparecen con letras minúsculas y en bastardilla (por ejemplo, naproxen). La información que se encuentra en la columna de Requerimientos/Limitaciones le informa si VNSNY CHOICE Medicare tiene algún requerimiento especial para la cobertura de su medicamento. 24 Las siguientes abreviaturas de Gestión de Uso se pueden encontrar en el cuerpo de este documento ABREVIATURAS DE LOS AVISOS DE COBERTURA ABREVIATURA DESCRIPCIÓN EXPLICACIÓN Restricciones en la Gestión de Uso PA PA BvD PA-HRM Se requiere que usted (o su médico) obtenga autorización previa de VNSNY CHOICE Medicare para Restricciones de la poder surtir este medicamento con receta médica. Sin autorización Autorización previa previa, es posible que VNSNY CHOICE Medicare no cubra este medicamento. Es posible que este medicamento sea elegible para pago según la Parte B o la Parte D de Medicare. Usted (o su médico) deben obtener autorización Restricciones de previa de VNSNY CHOICE Medicare Autorización previa para para determinar si este medicamento determinación de la Parte está cubierto por la Parte D de Medicare antes de que se surta este B frente a la Parte D medicamento con receta médica. Sin autorización previa, es posible que VNSNY CHOICE Medicare no cubra este medicamento. Restricciones de autorización previa para Medicamentos de alto riesgo 25 CMS considera que este medicamento es potencialmente dañino y, por consiguiente, se clasifica como medicamento de alto riesgo para los beneficiarios de Medicare de 65 años de edad o mayores. Se requiere que los afiliados de 65 años de edad o mayores obtengan autorización previa de VNSNY CHOICE Medicare antes de que se surta este medicamento con receta médica. Sin autorización previa, es posible que VNSNY CHOICE Medicare no cubra este medicamento. ABREVIATURA PA NSO QL ST DESCRIPCIÓN EXPLICACIÓN Restricciones de autorización previa para nuevos afiliados únicamente Si es un afiliado nuevo, se requiere que usted (o su médico) obtenga autorización previa de VNSNY CHOICE Medicare antes de que se surta este medicamento con receta médica. Sin autorización previa, es posible que VNSNY CHOICE Medicare no cubra este medicamento. Restricciones para los límites de cantidad VNSNY CHOICE Medicare limita la cantidad de este medicamentos que es cubierto por receta médica, o dentro de un marco de tiempo específico. Restricción en la terapia de pasos Antes de que VNSNY CHOICE Medicare le proporcione cobertura para este medicamento, primero debe intentar usar otro medicamento o medicamentos para tratar su condición médica. Este medicamente se cubrirá únicamente si los otros medicamentos no funcionan para usted. 26 Las siguientes abreviaturas de aviso de cobertura adicional se pueden encontrar en el cuerpo de este documento OTROS REQUERIMIENTOS ESPECIALES PARA LA COBERTURA ABREVIATURA DESCRIPCIÓN EXPLICACIÓN LA Estos medicamentos con receta médica podrían estar disponibles únicamente en ciertas farmacias. Para obtener más información, consulte Medicamentos de acceso con el Directorio de proveedores y farmacias o llame a Servicios al limitado afiliado al 1-866-783-1444, de lunes a viernes, de 8:00 a.m. a 8:00 p.m. Los usuarios de TTY/TDD deben llamar al 711. NM Es posible que pueda recibir por correo más de un mes de suministros para la mayoría de los medicamentos en su formulario, con un costo compartido reducido. Los Medicamentos que no se medicamentos que no están pueden enviar por correo disponibles mediante el beneficio de pedido por correo, se identifican con las iniciales «NM» en la columna de Requerimientos/Límites de su formulario. 27 ABREVIATURAS DE POTENCIA Y PRESENTACIÓN ABREVIATURA adh. patch aer br act aer pow aer pow ba aer refill aer w/adap ampul blkbaginj cap dr mp cap ds pk cap er 12h cap er 24h cap er deg cap er pel cap mphase cap.sa 24h cap.sr 12h cap.sr 24h cap24h pct cap24h pel cap sprink cap sr pel cap w/dev capsule dr capsule er capsule sa cmb cappad cmb ont fm cmb ont lt cmb tabpad combo. pkg cpmp 12hr cpmp 24hr DESCRIPCIÓN parche adhesivo aerosol, activado por la respiración aerosol, polvo aerosol en polvo, activado por la respiración recarga de aerosol aerosol con adaptador ampolleta inyecciones de bolsa a granel cápsula, liberación retardada multifásica cápsula, paquete de dosis cápsula, 12 horas de acción prolongada cápsula, 24 horas de acción prolongada cápsula, liberación prolongada degradable cápsula, gránulos de liberación prolongada cápsula, multifásica cápsula, 24 horas de acción sostenida cápsula, 12 horas de liberación sostenida cápsula, 24 horas de liberación sostenida cápsula, gránulos de 24 horas de acción local controlada cápsula, gránulos de 24 horas de liberación sostenida cápsula, dispersable cápsula de gránulos de liberación sostenida cápsula con dispositivo cápsula de liberación prolongada cápsula de liberación extendida cápsula de acción sostenida combinación: cápsula, almohadilla combinación: ungüento, espuma combinación: ungüento, loción combinación: tableta, almohadilla paquete combinado cápsula, 12 horas multifásica cápsula, 24 horas multifásica 28 ABREVIATURA cpmp 30-70 cpmp 50-50 cream(g), cream(gm) cream(ml) cream/appl cream, er (g) cream pack dehp fr bg dis needle disk w/dev disp syrin drops susp drps hpvis emul adhes emul packt emulsn(g) foam/appl. froz.piggy g gel/pf app gel (gm) gel (ml) gel md pmp gel w/appl gel w/pump gran pack hfa aer ad infus. btl insuln pen ip soln irrig soln iv soln. jel jelly/app jel/pf app kit cl&crm DESCRIPCIÓN cápsula, multifásicas, 30%-70% cápsula, multifásicas, 50%-50% crema (gramos) crema (mililitros) crema con aplicador crema, liberación prolongada (gramos) crema, paquete di(2-etilhexil)ftalato bolsa libre aguja desechable disco con dispositivo de inhalación jeringa desechable gotas, suspensión gotas, hiperviscosas emulsión adhesiva emulsión en paquete emulsión (gramos) espuma con aplicador solución premezclada congelada gramo gel con aplicador llenado previamente gel (gramos) gel (mililitros) gel en bomba de dosis medida gel con aplicador gel con bomba paquete de gránulos adaptador de aerosoles hfa frasco de infusión pluma de insulina solución intraperitoneal solución de irrigación solución intravenosa gel gel con aplicador gel con aplicador llenado previamente kit: limpiador y crema 29 ABREVIATURA kt crm le kt lotn ce kt oint le lotion, er lozenge hd m.ht patch ma buc tab mcg med. pad med. swab med. tape mg ml muc er 12h ndl fr inj nl fm susp oint. (g), oint.(gm) oral conc oral susp paste (g) patch td24 patch td72 patch tdsw patch tdwk pca syring pca vial pellet(ea) pen ij kit pen injctr pggybk btl plast. bag powd pack sol md pmp sol w/appl sol/pf app DESCRIPCIÓN kit: crema, loción emoliente kit: loción, crema emoliente kit: ungüento, loción emoliente loción, liberación prolongada controlador de comprimidos parche de calor medicado tableta bucal mucoadhesiva microgramo almohadilla medicada hisopo medicado cinta adhesiva medicada miligramo mililitro sistema mucoadhesivo, 12 horas de liberación prolongada aguja para inyección suspensión en película para uñas ungüento (gramos) concentrado oral suspensión oral pasta (gramos) parche, 24 horas transdérmico parche, 72 horas transdérmico parche, transdérmico quincenal parche, transdérmico semanal jeringa de analgésico controlado por el paciente vial de analgésico controlado por el paciente gránulos (cada uno) kit de pluma de inyección pluma de inyección frasco de solución premezclada bolsa de plástico paquete de polvo solución con bomba multidosificadora solución con aplicador solución con aplicador llenado previamente 30 ABREVIATURA sol-gel soln recon soln(gram) spray susp spray/pump stick(ea) supp.rect supp.vag suppos. sus er 24h sus er rec sus mc rec suspdr pkt susp recon syringekit tab chew tab er 12h tab er 24h tab er prt tab er seq tab disper tab ds pk tab er 24 tab mphase tab part tab rap dr tab rapdis tab subl tab.sr 12h tab.sr 24h tabergr24hr tablet dr tablet, er tablet eff tablet sa tablet sol DESCRIPCIÓN solución formadora de gel solución, reconstituida solución (gramos) atomizador, suspensión atomizador con bomba barra (cada una) supositorio, rectal supositorio, vaginal supositorio suspensión, 24 horas de liberación prolongada suspensión, liberación prolongada reconstituida suspensión, microcápsula reconstituida suspensión, paquete de liberación prolongada suspensión, reconstituida kit de jeringas tableta, masticable tableta, 12 horas liberación prolongada tableta, 24 horas liberación prolongada tableta, partículas de liberación prolongada tableta, hora liberación prolongada tableta, dispersable tableta, paquete de dosis tableta, 24 horas liberación prolongada tableta, multifásica tableta, partículas tableta, liberación prolongada de desintegración rápida tableta, desintegración rápida tableta, sublingual tableta, 12 horas liberación sostenida tableta, 24 horas liberación sostenida tableta, 24 horas liberación prolongada gradual tableta, liberación prolongada tableta, liberación prolongada tableta, efervescente tableta, acción sostenida tableta, soluble 31 ABREVIATURA tb er dspk tb mp dspk tb rd dspk tbdspk 3mo tbmp 12hr tbmp 24hr u vag ring DESCRIPCIÓN tableta, paquete de dosis de liberación prolongada tableta, paquete de dosis multifásica tableta, paquete de dosis de desintegración rápida tableta, paquete de dosis para 3 meses tableta, 12 horas multifásica tableta, 24 horas multifásica unidad anillo vaginal 32 VNSNY CHOICE Medicare 㠷 VNSNY CHOICE Total 2016 㲅ᯩ䳶 ˄㎖Ԉ㰕૱˅ वਜ਼VNSNY CHOICE Medicare Preferred (HMO SNP), VNSNY CHOICE Medicare Classic (HMO), VNSNY CHOICE Medicare Maximum (HMO SNP) and VNSNY CHOICE Total (HMO SNP) Ṩ߶Ⲵ㲅ᯩ䳶ᨀӔ ID 㲏⻬˖16492.001,ㅜ 7 ⡸ Ṉ᪉㞟᭦᪂ 2015 ᖺ 08 ᭶ 29 ᪥傏 ዴ㟂᭦ከ᭱᪂ⓗ㈨イᡈ᭷ၥ㢟凞 ㄳ⫃⤡ VNSNY CHOICE Medicare ᭳ဨ᭹ົ㒊凞 㟁ヰ凬 1-866-783-1444凞 TTY ⏝⪅ㄳ᧕ 711凞 㐌୍฿㐌凞 ᪩ୖ 8:00 ฿ୖ 8:00凞 ᡈ㐀ゼ www.vnsnychoice.org傏 ⌧᭷᭳ဨὀព㡯凬 Ṉ᪉㞟ᕬཤᖺㆰ᭦傏 ㄳᷙ教Ṉᩥ௳௨☜ᐃ୰↛ໟྵᝍ᭹⏝ⓗ⸩ရ傏 Ṉ⸩ရΎႝ凚 ᪉㞟凛 ᡤ㏙ⓗ傘 ᡃ಼備 傎 傘 ᡃ᪉備 ᡈ傘 ᡃ಼ⓗ備 ᆒ௦⾲ VNSNY CHOICE Medicare傏 ᅾᥦ฿傘 ィ␓備 ᡈ傘 ᡃ಼ⓗィ␓備 凞 ពᣦᡃ಼ⓗVNSNY CHOICE Medicare Preferred (HMO SNP), VNSNY CHOICE Medicare Classic (HMO), VNSNY CHOICE Medicare Maximum (HMO SNP) and VNSNY CHOICE Total (HMO SNP)傏 Ṉᩥ௳ໟྵᡃ಼ィ␓ⓗ⸩ရΎႝ凚 ᪉㞟凛 凞 ᡖ⮳ 2015 ᖺ 8 ᭶ 29 ᪥ⓗ᭱᪂∧傏 せ⋓ᚓ᭦᪂∧ⓗ᪉㞟凞 ㄳ⯅ᡃ಼⫃⤡傏 ᡃ಼ⓗ⫃⤡㈨イ凞 ௨ཬ᭱ᚋ᭦᪂᪉㞟ⓗ᪥ ᮇ凞 ぢᑒ㠃⯅ᑒᗏ㡫傏 ᝍᚲ㡲⏝㐃⥙ⓗ⸩ᡣ凞 ᡯ⬟⏝ᝍⓗ᪉⸩⚟傏 ⚟傎 ᪉㞟傎 㐃⥙⸩ᡣ傎 ಖ㈝/ᡈඹྠ㈇᧴ ㈝⏝/ඹಖ㈝ྍ⬟ 2017 ᖺ 1 ᭶ 1 ᪥ㆰ᭦傏 VNSNY CHOICE Medicare ᦚ㓄 Medicare ྜ⣙ⓗ HMO ィ␓傏 ト VNSNY CHOICE Medicare ྲྀỴྜ⣙⧰ゞ傏 ᴰᖼᴤᯠ˖ 08/29/2015 33 VNSNY CHOICE Medicare ᪉㞟⏒㯟㸽 ᪉㞟 VNSNY CHOICE Medicare ㅎュ㓾⒪ಖᥦ౪⪅ᅰ㝲ྡྷᡤᣮ㑅ⓗ⤥⸩ရΎႝ 㸪௦⾲᧸ಙ㧗ရ㉁⒪᪉ᡤ㟂ⓗ᪉⒪ἲࠋྈせヱ⸩ရ㓾⒪ୖᚲ㡲ⓗ㸪୪ୟᅾ VNSNY CHOICE Medicare 㐃⥙ⓗ⸩ᡣ㡿ྲྀ᪉⸩ရ㸪ୟ㑂Ᏺⓗィ␓つ๎㸪㑣㯟 VNSNY CHOICE Medicare ᑘ㠃⤥ᡃ಼᪉㞟ᡤิⓗ⸩ရࠋᑞዴఱㄪກ᪉ⓗ᭦ ከ㈨イ㸪ㄳᷙどᝍⓗࠕಖ㞋⌮㈺㡯┠婒᫂᭩ࠖࠋ ᪉㞟㸦⸩ရΎႝ㸧ྍ௨᭦ᨵႫ㸽 ୍⯡⪋ゝ㸪ዴᯝᝍᅾᖺึ᭹⏝ᡃ಼ 2016 ᖺ᪉㞟ᡤ⤥ⓗ⸩ရ㸪㝖㠀᭷㍑౽ᐅⓗ᪂Ꮵྡ ⸩ྍ⏝㸪ᡈ᪂ⓐథ㜝ヱ⸩ရᏳᛶᡈຌᩀⓗ㈇㠃㈨イ௨እ㸪ᅾ 2016 ᖺ⤥ᖺᗘᮇ㛫 㸪ᡃ಼᭳୰Ṇᡈῶᑡ⸩ရⓗ⤥ࠋ㢮ᆺⓗ᪉㞟ㆰ᭦㸦ዴᑘ୍✀⸩ရᚘ᪉㞟 ⛣㝖㸧㸪୪᭳ᙳ㡪┠๓᭹⏝ヱ⸩ရⓗ᭳ဨࠋ᭹⏝ヱ⸩ရⓗ᭳ဨᅾ⤥ᖺᗘⓗ㣾ᮇ㛫 㸪↛ྍ௨┦ྠⓗ㈝⏝ศᨦྲྀᚓࠋᡃ಼┦ಙ㸪ᝍᅾ⤥ᖺᗘⓗ㣾ᮇ㛫㸪↛⧤⧰ྲྀᚓ ᝍᅾ㑅᧪ᡃ಼ィ␓ྍ⏝ⓗ᪉㞟⸩ရ㠀ᖖ㔜せⓗ㸪㝖㠀ᝍྍ௨⠇┬㢠እⓗ㈝⏝ᡈ ᡃ಼ྍ௨☜ಖᝍⓗᏳࠋ ዴᯝᡃ಼ᚘ᪉㞟⛣㝖⸩ရᡈ᪂ቔ⸩ရⓗඛ᰾Ὶࠊᩝ㔞㝈ไ/ᡈศ㝵ẁ⒪ἲ㝈ไ㸪 ᡈᑘ୍✀⸩ရ㎈฿㍑㧗ⓗ㈝⏝ศᨦᒙ⣭㸪ᡃ಼ᚲ㡲ᅾㆰ᭦⏕ᩀⓗ⮳ᑡ 60 ኳ๓㸪ᡈ᭳ ဨせồ⿵⸩ရ㸪㏻▱ཷᙳ㡪ⓗ᭳ဨ㸪ᒄ᭳ဨᑘ ᨲ฿ 60 ኳⓗ⸩ရࠋ ዴᯝ⨾ᅧ㣗ရ ⸩ရ⟶⌮ᒁㄆⅭᡃ಼᪉㞟ⓗ⸩ရᏳ㸪ᡈ⸩ရⓗ〇㐀ၟᚘᕷሙ᧔㝖ヱ⸩ရ㸪ᡃ ಼ᑘ❧༶ᚘ᪉㞟୰⛣㝖ヱ⸩ရ㸪୪㏻▱᭹⏝ヱ⸩ရⓗ᭳ဨࠋᡤ㝃ⓗ᪉㞟ᡖ⮳ 2016 ᖺ 1 ᭶ 1 ᪥ⓗ᭱᪂∧ࠋዴせྲྀᚓ㜝 VNSNY CHOICE Medicare ⤥⸩ရⓗ᭱᪂㈨イ㸪 ㄳ⯅ᡃ಼⫃⤡ࠋᡃ಼ⓗ⫃⤡㈨イฟ⌧ᑒ㠃⯅ᑒᗏ㡫ࠋዴᯝᡃ಼௨ᮍ⥔ㆤⓗ᪉㞟ㆰ᭦ ᭦᪂ᡃ಼ⓗ༳ๅ᪉㞟㸪ᡃ಼ᑘᐤ⤥ᝍໟྵṈ㈨イⓗ㏻▱ࠋ 34 ᡃせዴఱ⏝᪉㞟㸽 ᭷ඳ⛇᪉ἲྍᢍฟ᪉㞟ℏᝍ㟂せⓗ⸩ရ㸸 㓾⒪ἣ ᪉㞟ᚘ➨ 49 㡫㛤ጞࠋṈ᪉㞟ℏⓗ⸩ရᣨ↷Ꮽ಼⏝⒪ⓗ㓾 ⒪ἣ㢮ᆺศ 㢮ⓗࠋ ዴ㸪⏝⒪ᚰ⮤ἣⓗ⸩ရᲄิࠕᚰ⾑⟶ࠖ 㢮ูࠋዴᯝᝍ▱㐨ᝍⓗ⸩ ရ⏝㏵㸪ᅾ➨ 49 㡫㛤ጞⓗΎႝୖᦏᑜ㢮ูྡ✃ࠋ ↛ᚋᅾ㢮ูྡ✃ୗ᪉ᦏᑜᝍⓗ⸩ရࠋ ᣨᏐẕิⓗ⸩ရΎႝ ዴᯝᝍ☜ᐃせᦏᑜⓗ㢮ู㸪᠕ヱᅾ I-1 㛤ጞⓗࠕ⣴ᘬ (Index)ࠖ ᦏᑜᝍⓗ⸩ရࠋࠕ⣴ ᘬࠖᥦ౪Ṉᩥ௳㒊ⓗᣨᏐẕิⓗ⸩ရΎႝࠋࠕ⣴ᘬࠖྠᲄิᑙ⸩⯅Ꮵྡ⸩ࠋ ᚘࠕ⣴ᘬࠖ୰㞍ᢍᝍⓗ⸩ရࠋᅾᝍⓗ⸩ရ㑔㸪᭳┳฿ྍ௨ᢍ฿⤥㈨イⓗ㡫☞ࠋ⩻ ฿ࠕ⣴ᘬࠖᡤิⓗ㡫☞㸪୪Ύႝⓗ➨୍ḍ㞍ᢍ⸩ရⓗྡ✃ࠋ ⏒㯟Ꮵྡ⸩㸽 VNSNY CHOICE Medicare ྠ⤥ᑙ⸩Ꮵྡ⸩ࠋᏥྡ⸩ FDA ᰾ᑙ⸩ල ᭷┦ྠάᛶᡂศⓗ⸩ရࠋ୍⯡⪋ゝ㸪Ꮵྡ⸩ẚᑙ⸩౽ᐅࠋ ᡃⓗ⤥ྰ᭷௵ఱ㝈ไ㸽 ᭷ல⤥⸩ရᑞ⤥⠊ᅩྍ⬟᭷せồᡈ㝈ไࠋ㏺லせồ⯅㝈ไྍ⬟ໟᣓ㸸 • ඛᤵḒ㸸VNSNY CHOICE Medicare せồᝍᡈᝍⓗ㓾ᖌ㔪ᑞ≉ᐃ⸩ရྲྀᚓඛᤵ Ḓࠋ㏺⾲♧ᅾ౫↷ᝍⓗ᪉㡿⸩அ๓㸪ᚲ㡲ྲྀᚓ VNSNY CHOICE Medicare ⓗ᰾ ࠋ ⱝᮍ⥂᰾Ὶ㸪VNSNY CHOICE Medicare ྍ⬟↓ἲ⤥⸩ရࠋ • ᩝ㔞㝈ไ㸸VNSNY CHOICE Medicare ᭳㔪ᑞ≉ᐃ⸩ရ㝈ไ VNSNY CHOICE Medicare ᑘ⤥ⓗ౪᠕㔞ࠋዴ㸪VNSNY CHOICE Medicare 㔪ᑞẗᙇ᪉ᥦ౪ 60 㢛 Celebrex ⭺ᄷࠋ㏺ྍ⬟㝃ຍᶆ‽ⓗ୍ಶ᭶ᡈ୕ಶ᭶⸩㔞ࠋ • ศ㝵ẁ⒪ἲ㸸ᅾ᯾லἣୗ㸪VNSNY CHOICE Medicare ᭳ᅾ⤥⏝ヱⓗ྄ ୍✀⸩ရஅ๓㸪せồᝍඛაヨ≉ᐃⓗ⸩ရ௨⒪ᝍⓗ㓾⒪ἣࠋዴ㸪ዴᯝ A ⸩ ရ⯅ B ⸩ရ㒔⬟⒪ᝍⓗ㓾⒪ἣ㸪VNSNY CHOICE Medicare ྍ⬟ᅾᝍඛაヨ A ⸩ရஅᚋ㸪ᡯ⤥ B ⸩ရࠋዴᯝ A ⸩ရᑞᝍ↓ᩀ㸪๎ VNSNY CHOICE Medicare ᑘ⤥ B ⸩ရࠋ 35 㞍ᢍᚘ➨ 49 㡫㛤ጞⓗ᪉㞟㸪ྍ௨ゎᝍⓗ⸩ရྰ᭷せồᡈ㝈ไࠋ 㐀ゼᡃ಼ⓗ⥙❰ஓྍ௨ྲྀᚓ㜝≉ᐃ⤥⸩ရ㝈ไⓗ᭦ከ㈨イࠋᡃ಼ⓗ⫃⤡㈨イ㸪௨ཬ ᭱ᚋ᭦᪂᪉㞟ⓗ᪥ᮇ㸪ฟ⌧ᑒ㠃⯅ᑒᗏ㡫ࠋ ᝍྍ௨せồ VNSNY CHOICE Medicare ᑞ㏺ல㝈ไ㐍⾜እ⌮㸪 ᡈせồྍ௨⒪ᝍ ⓗᗣἣⓗ㢮ఝ⸩ရΎႝࠋㄳཨ教➨ 5 㡫ࠕᡃዴఱせồᑞ VNSNY CHOICE Medicare ᪉㞟㐍⾜እ⌮ࠖ❶⠇㸪 ⋓ᚓ㜝ዴఱせồእ⌮ⓗ㈨イࠋ ᡂ⸩ (OTC) ⏒㯟㸽 OTC ⸩ရ Medicare ᪉⸩ရィ␓୍⯡⤥ⓗ㠀᪉⸩ࠋVNSNY CHOICE Medicare ⤥≉ᐃⓗ OTC ⸩ရࠋ ⤥ⓗ㠀᪉⸩ (OTC) ⸩ရ Ꮵྡ 㮴㓟す᭰▒ (cetirizine hydrochloride) 㮴㓟す᭰▒ (cetirizine hydrochloride)/ ഇ㯞㯣ሞ㮴㓟㮴 (pseudoephedrine hydrochloride) 㯗㞾ᐃ (loratadine) 㯗㞾ᐃ (loratadine)/ ഇ㯞㯣ሞ◲㓟㮴 (pseudoephedrine sulfate) ᐩ㤿㓟愖᭰ⰷ (ketotifen fumarate) (ࠕཨ⪃ᑙ⸩ࠖ) ກ㔞⾲ (Zyrtec) ᄮ㘄ࠊ⸩Ỉࠊ⸩㘄 (Zyrtec-D) 12 ᑠ⸩㘄 (Claritin) ⸩Ỉࠊ⸩㘄 (Claritin-D) 12 ᑠ⸩㘄 24 ᑠ⸩㘄 (Zaditor) ກ VNSNY CHOICE Medicare ᑘච㈝ྥᝍᥦ౪㏺ல OTC ⸩ရࠋ VNSNY CHOICE Medicare ᡤᨭⓗ㏺ல OTC ⸩ရᡂᮏ୪᭳ィධᝍⓗ Part D ⸩ရ⦻ᡂᮏ㸦༶ᝍᨭⓗ㔠㢠୪ ᮍィධ⤥⠊ᅩ⨃ཱྀࠋ 36 ዴᯝᡃⓗ⸩ရᅾ᪉㞟ℏ㸪ᛠ㯟㎨㸽 ዴᯝᝍⓗ⸩ရ୪ᅾ᪉㞟㸦⤥⸩ရΎႝ㸧ℏ㸪ᝍ᠕ヱඛ⫃⤡᭳ဨ᭹ົ㒊㸪ュၥᝍⓗ ⸩ရྰ⤥ࠋ ዴᯝᝍᚓ▱ VNSNY CHOICE Medicare ୪ᮍ⤥ᝍⓗ⸩ရ㸪ᝍ᭷✀㑅᧪㸸 ᝍྍ௨せồ᭳ဨ᭹ົ㒊ᥦ౪ VNSNY CHOICE Medicare ⤥ⓗ㢮ఝ⸩ရΎႝࠋᅾᨲ฿Ύ ႝ㸪ฟ♧⤥ᝍⓗ㓾⏕㸪୪せồ㛤 VNSNY CHOICE Medicare ⤥ⓗ㢮ఝ⸩ရ᪉ࠋ ᝍྍ௨せồ VNSNY CHOICE Medicare 㐍⾜እ⌮௨⤥ᝍⓗ⸩ရࠋㄳཨ教௨ୗዴ ఱせồእ⌮ⓗ㈨イࠋ ᡃせዴఱせồ VNSNY CHOICE Medicare ᪉㞟ⓗእ⌮凱 ᝍྍ௨せồ VNSNY CHOICE Medicare 㔪ᑞᡃ಼ⓗ⤥つ๎㐍⾜እ⌮ࠋᝍྍ௨せồ ᡃ಼㐍⾜እ⌮ⓗ㢮ᆺ᭷チከ✀ࠋ • ༶ᅾᡃ಼ⓗ᪉㞟ℏ㸪ᝍ㑏ྍ௨せồᡃ಼⤥⸩ရࠋዴᯝ⥂᰾㸪 Ṉ⸩ရᑘ౫↷㡸ඛ☜ᐃⓗ㈝⏝ศᨦ➼⣭⤥㸪ᝍ⬟せồᡃ಼௨㍑పⓗ㈝ ⏝ศᨦ➼⣭ᥦ౪⸩ရࠋ • ዴᯝヱ⸩ရᒞᑙ㛛ᒙ⣭㸪ᝍྍ௨せồᡃ಼௨㍑పⓗ㈝⏝ศᨦ➼⣭⤥Ṉ᪉㞟 ⸩ရࠋዴᯝ⥂᰾㸪㏺ᑘ᭳㝆పᝍᚲ㡲ᨭⓗ⸩ရ㔠㢠ࠋ • ᝍྍ௨せồᡃ಼ྲྀᾘᑞᝍ⸩ရⓗ⤥⠊ᅩ㝈ไࠋዴ㸪VNSNY CHOICE Medicare ᭳㔪ᑞᡃ಼ᑘ⤥ⓗ⸩ရ㸪㝈ไᡃ಼ᑘ⤥ⓗ⸩ရ㔠㢠ࠋ ዴᯝᝍⓗ⸩ရ᭷ᩝ㔞㝈 ไ㸪ᝍྍ௨せồᡃ಼ྲྀᾘヱ㝈ไ㸪୪⤥㍑㧗ⓗ㔠㢠ࠋ ୍⯡⪋ゝ㸪ྈ᭷␜ィ␓ⓗ᪉㞟ໟྵⓗ᭰௦⸩ရࠊ㈝⏝ศᨦ㍑పⓗ⸩ရᡈⓗ⏝㝈 ไᑞᝍⓗ⒪ἣ↓ᩀ㸪ᡈ᭳ᑞᝍ㐀ᡂⰋⓗ㓾⒪ᙳ㡪㸪VNSNY CHOICE Medicare ᡯ᭳᰾ᝍᑞእ⌮ⓗせồࠋ ᝍ᠕ヱ⯅ᡃ಼⫃⤡㸪せồᡃ಼㔪ᑞ᪉㞟ࠊศ⣭ᡈ⏝㝈ไእฟึṉⓗ⤥Ỵᐃࠋ 37 ᅾᝍせồ᪉㞟ࠊศ⣭ᡈ⏝⋡እ㸪ᝍ᠕ヱᥦ㛤❧᪉⪅ᡈ㓾ᖌᨭᣢᝍせồⓗ⫆ ᫂ࠋ ୍⯡ἣୗ㸪ᡃ಼ᚲ㡲ᅾྲྀᚓᝍⓗ㛤❧᪉⪅ᡈ㓾ᖌᨭᣢ⫆ ᫂ⓗ 72 ᑠℏฟỴ ᐃࠋዴᯝᝍᡈᝍⓗ㓾ᖌㄆⅭᝍⓗᗣἣ᭳ᅉⅭ➼ᚅỴ ᐃ㛗㐩 72 ᑠ⪋ཷ฿ᄫ㔜ⓗയ ᐖ㸪ᝍྍ௨せồຍ㏿㸦ᛌ㏿㸧ⓗእ⌮ࠋዴᯝᡃ಼᰾ᝍせồຍ㏿ⓗせồ㸪ᡃ಼ᚲ㡲 ᅾྲྀᚓᝍⓗ㛤❧᪉⪅ᡈ㓾ᖌᨭᣢ⫆᫂ⓗ 24 ᑠℏฟỴᐃࠋ ᅾᡃ㓾ᖌウㄽㆰ᭦ᡃⓗ⸩ရᡈせồእ⌮அ๓㸪ᡃせ⏒㯟㸽 ㌟Ⅽᡃ಼ィ␓ⓗ᪂᭳ဨᡈ⧰⣙᭳ဨ㸪ᝍྍ⬟ṇ᭹⏝ᡃ಼᪉㞟௨እⓗ⸩ရࠋᡈ⪅㸪ᝍ᭹ ⏝ⓗ᪉㞟ℏⓗ⸩ရ㸪ణᝍྲྀᚓ⸩ရⓗ⬟ຊཷ฿㝈ไࠋዴ㸪ᝍᅾ౫᪉㡿⸩அ๓, ྍ⬟㟂せඛ᰾ࠋᝍ᠕ヱ㓾ᖌウㄽ௨Ỵᐃྰ᠕ヱษ฿ᡃ಼⤥ⓗ㐺␜⸩ရ㸪ᡈ せồ᪉㞟እ㸪௨౽ᡃ಼⤥ᝍᡤ᭹⏝ⓗ⸩ရࠋ⯅㓾ᖌウㄽỴᐃ㐺ྜᝍⓗ⾜ື᪉㔪 㸪ᅾ≉ᐃⓗἣୗ㸪ᡃ಼ྍ⬟ᝍᡂⅭᡃ಼᭳ဨⓗ๓ 90 ኳ⤥ᝍⓗ⸩≀ࠋ ᑞᝍᡤ᭹⏝ᅾᡃ಼᪉㞟ℏⓗẗ✀⸩ရ㸪ᡈዴᯝᝍྲྀᚓ⸩ရⓗ⬟ຊཷ㝈㸪ᅾᝍ๓ 㐃⥙⸩ᒁ㸪ᡃ಼ᑘ⤥⮫ⓗ 30 ኳ౪᠕㔞㸦㝖㠀ᝍⓗ᪉㛤❧ⓗ ㍑ᑡⓗኳᩝ㸧 ࠋᅾ๓ 30 ኳ౪᠕㔞அᚋ㸪༶ᝍᡂⅭィ␓᭳ဨⓗ㛫฿ 90 ኳ㸪ᡃ಼ᑘ᭳⤥㏺ ல⸩ရࠋ ዴᯝᝍ㛗ᮇ↷ㆤᶵᵓⓗఫẸ㸪ᡃ಼ᑘඔチᝍḟᣨ᪉㡿⸩㸪㓄ྜ㓄⸩ቔ㔞㸪┤฿ᡃ ಼ᥦ౪ᝍ 91 ኳⓗ㎈౪᠕㔞㸦㝖㠀ᝍⓗ᪉㛤❧ⓗ㍑ᑡⓗኳᩝ㸧ࠋᅾᝍᡂⅭᡃ಼᭳ဨ ⓗ➨୍ಶ 90 ኳ㸪ᡃ಼ᑘ⤥㏺ல⸩ရ୍ḟ௨ୖⓗ⿵㔞ࠋ ዴᯝᝍ㟂せᡃ಼᪉㞟௨ እⓗ⸩ရ㸪ᡈᝍྲྀᚓ⸩ရⓗ⬟ຊཷ㝈㸪ణᝍᡂⅭᡃ಼ィ␓ⓗ᭳ဨᕬ⥂㉸㐣 90 ኳ㸪ᅾ ᝍせồ᪉㞟እ⌮㸪ᡃ಼ᑘᨭヱ⸩ရⓗ 31 ኳ⥭ᛴ౪᠕㔞㸦㝖㠀ᝍⓗ᪉㛤❧ⓗ ㍑ᑡⓗኳᩝ㸧ࠋ 㚱暨天ᶨ㫉⿏䵲⿍惵喍㚵⊁ㆾ暨天惵朆嗽㕡喍⚈䁢嬟䎮䳂⇍㚜㓡䘬㚫⒉⎗ẍ⼿⇘ᶨ㫉廱 ㎃ὃㅱ慷ˤġġġ 38 ዴ㟂᭦ከ㈨イ ዴ㟂㜝 VNSNY CHOICE Medicare ᪉⸩⤥ⓗ᭦ከヲ⣽㈨イ㸪ㄳᷙどᝍⓗࠕಖ㞋⌮ ㈺㡯┠婒᫂᭩ࠖ⯅ィ␓㈨ᩱࠋ ዴᯝᝍ᭷㜝 VNSNY CHOICE Medicare ⓗၥ㢟㸪ㄳ⯅ᡃ಼⫃⤡ࠋ ᡃ಼ⓗ⫃⤡㈨イ㸪௨ ཬ᭱ᚋ᭦᪂᪉㞟ⓗ᪥ᮇ㸪ฟ⌧ᑒ㠃⯅ᑒᗏ㡫ࠋ ዴᯝᝍ᭷㜝 Medicare ᪉⸩⤥ⓗ୍⯡ၥ㢟㸪ㄳ᧕ᡴ㸸1-800-MEDICARE (1-800-6334227) ⯅ Medicare ⫃⤡㸪Ṉᑙ⥺ 24 ᑠኳೃᥦ౪᭹ົࠋTTY ⏝⪅ㄳ᧕㸸1-877-4862048ࠋᡈ㐀ゼ www.medicare.govࠋ ㏺௷㈨イྠᥦ౪ㄒゝ∧ᮏ㸪ච㈝ࠋㄳ᧕ᡴ 1-866-783-1444 ⯅᭳ဨ᭹ົ㒊⫃⤡ ௨ྲྀᚓ㈨イࠋ(TTY ⏝⪅᠕᧕ᡴ 711 ච㈝㟁ヰ) ᭹ົ㛫Ⅽ㐌୍฿㐌᪩ୖ 8 ⮳ 㛫 8 ࠋ᭳ဨ᭹ົ㒊ஓⅭ㠀ⱥㄒ⣔ ᅧᐙேኈᥦ౪ච㈝ⓗㄒゝཱྀ㆞᭹ົࠋ VNSNY CHOICE Medicare ᦚ㓄 Medicare ྜ⣙ⓗ HMO ィ␓ࠋᢞಖ VNSNY CHOICE Medicare ྲྀỴ⧰⣙ࠋ 39 VNSNY CHOICE Medicare ⓗ᪉㞟 ᚘ➨ 49 㡫㛤ጞⓗ᪉㞟ᥦ౪㜝 VNSNY CHOICE Medicare ⤥⸩≀ⓗ┦㜝⤥㈨イࠋ ዴᯝᝍᅾΎႝ୰ᢍ฿ᝍⓗ⸩ရ㸪ㄳ⩻฿ᚘ➨ I-1 㡫㛤ጞⓗࠕ⣴ᘬࠖࠋ ᅯ⾲ⓗ➨୍ḍ᭳ิฟ⸩ရⓗྡ✃ࠋᑙ⸩ྡ✃ᑃ㸦ዴ CELEBREX㸧⪋Ꮵྡ⸩๎ ᑠᑃⓗᩳ㧓Ꮠ㸦ዴ naproxen㸧ࠋ ࠕせồ㸭㝈ไ (Requirements/Limits)ࠖḍⓗ㈨イ婒᫂ VNSNY CHOICE Medicare 㔪ᑞᝍⓗ ⸩ရ⤥ྰ᭷௵ఱ≉Ṧⓗせồࠋ ௨ୗⓗ⏝⟶⌮⦰ᑃྍ⬟ฟ⌧ ᮏᩥ௳ⓗṇᩥ ಖ㞋⤥ὀព㡯⦰ᑃ ⦰ᑃ 婒᫂ ゎ㔚 ⏝⟶⌮㝈ไ PA ᅾᣨṈ᪉㡿ྲྀ⸩ရஅ๓㸪ᝍᡈ (ᝍⓗ㓾⏕) ᚲ㡲ඛᚘ ඛᤵḒ㝈ไ VNSNY CHOICE Medicare ྲྀᚓඛᤵḒࠋዴᮍඛ᰾ 㸪VNSNY CHOICE Medicare ྍ⬟↓ἲ⤥Ṉ⸩ရࠋ PA BvD Ṉ⸩ရྍ⬟➢ྜ Medicare Part B ᡈ Part D ⓗ⤥㈨᱁ࠋ Part B ⯅ Part ᅾᣨṈ᪉㡿ྲྀ⸩ရஅ๓㸪ᝍ (ᡈᝍⓗ㓾⏕) ᚲ㡲ඛᚘ D ุᐃⓗ VNSNY CHOICE Medicare ྲྀᚓඛᤵḒ㸪௨ุᐃྰ ඛᤵḒ㝈ไ ᰿᧸ Medicare Part D ⤥Ṉ⸩ရࠋዴᮍඛ᰾㸪 VNSNY CHOICE Medicare ྍ⬟↓ἲ⤥Ṉ⸩ရࠋ 40 ⦰ᑃ 婒᫂ ゎ㔚 PA-HRM CMS ㄆⅭṈ⸩ရල᭷₮ᅾⓗയᐖᛶ㸪ᅉṈᖺ⁹ 65 荅 அ Medicare ཷ┈ேⓗ㧗㢼㞋⸩≀ࠋᖺ⁹ 65 荅ⓗ᭳ဨᅾ 㧗㢼㞋⸩≀ⓗ ᣨṈ᪉㡿ྲྀ⸩ရஅ๓㸪ᚲ㡲ඛᚘ VNSNY CHOICE ඛᤵḒ㝈ไ Medicare ྲྀᚓඛᤵḒࠋዴᮍඛ᰾㸪VNSNY CHOICE Medicare ྍ⬟↓ἲ⤥Ṉ⸩ရ PA NSO ዴᯝᝍ᪂᭳ဨ㸪ᅾᣨṈ᪉㡿ྲྀ⸩ရஅ๓㸪ᝍᡈ (ᝍⓗ ഹ㝈᪂᭳ဨⓗ 㓾⏕) ᚲ㡲ඛᚘ VNSNY CHOICE Medicare ྲྀᚓඛᤵḒ ඛᤵḒ㝈ไ ࠋዴᮍඛ᰾㸪VNSNY CHOICE Medicare ྍ⬟↓ἲ ⤥Ṉ⸩ရࠋ QL ᩝ㔞㝈ไ VNSNY CHOICE Medicare 㝈ไẗᙇ᪉⡗ᡈᅾ≉ᐃ 㛫ℏ⤥Ṉ⸩ရⓗᩝ㔞ࠋ ST ศ㝵ẁ⒪ἲ㝈 ไ ᅾ VNSNY CHOICE Medicare ᥦ౪Ṉ⸩ရⓗ⤥அ๓㸪 ᝍᚲ㡲ඛაヨ⸩ရ௨⒪ᝍⓗࠋዴᯝ⸩ရ ᑞᝍἄ᭷ຌᩀ㸪ᡯ᭳⤥Ṉ⸩ရࠋ 41 ௨ୗⓗ⤥ὀព㡯⦰ᑃྍ⬟ฟ⌧ ᮏᩥ௳ⓗṇᩥ ಖ㞋⤥ⓗ≉Ṧせồ ⦰ᑃ 婒᫂ ゎ㔚 Ṉ᪉ྍ⬟ྈᥦ౪≉ᐃⓗ⸩ᒁࠋዴ㟂᭦ከ㈨イ㸪ㄳ㞍 LA ྲྀᚓཷ㝈ⓗ⸩ရ 教ᝍⓗࠕᥦ౪⪅ཬ⸩ᡣ┠㗴ࠖᡈ⮴㟁᭳ဨ᭹ົ㒊㸪㟁ヰ 1-866-783-1444㸪㐌୍⮳㐌㸪᪩ୖ 8:00 ⮳ୖ 8:00ࠋ TTY/TDD ⏝⪅ㄳ᧕ᡴ 711ࠋ ㏱㐣㒑㉎㸪ᝍྍ⬟௨᭦పⓗศᨦ㈝⏝㡿ྲྀ᪉㞟㒊ศ NM 㠀㒑㉎⸩ရ ⸩ရ 1 ಶ᭶௨ୖⓗ⸩㔞ࠋ↓ἲ㏱㐣㒑㉎⚟ᥦ౪ⓗ⸩ရ 㸪ᅾ᪉㞟ⓗࠕせồ/㝈ไ(Requirements/Limits) ḍᶆ♧Ⅽ "NM"ࠋ 42 ᙉᗘ⯅ກ㔞⾲⦰ᑃ ⦰ᑃ 婒᫂ adh. patch ㈞ᕸ aer br act ᄇ㟝ກ㸪㠁྾Ềᘬື aer pow ᄇ㟝ກ㸪⢊≪ aer pow ba ᄇ㟝ກ⢊ᮎ㸪㠁྾Ềᘬື aer refill ᄇ㟝⿵ກ aer w/adap 㝃㎈᥋㢌ⓗᄇ㟝ກ ampul Ᏻ⏂ blkbaginj ᩓ⿶⿄ὀᑕ cap dr mp ⭺ᄷ㸪ከẁᘧ⦆㔚⸩ᩀ cap ds pk ⭺ᄷ㸪ກ㔞ໟ cap er 12h ⭺ᄷ㸪12 ᑠ⦆㔚⸩ᩀ cap er 24h ⭺ᄷ㸪24 ᑠ⦆㔚⸩ᩀ cap er deg ⭺ᄷ㸪⦆㔚⸩ᩀ㸪ྍ㝆ゎ cap er pel ⭺ᄷ㸪⦆㔚⸩ᩀ⸩ cap mphase ⭺ᄷ㸪ከẁᘧ cap.sa 24h ⭺ᄷ㸪24 ᑠᣢ⧰⸩ᩀ cap.sr 12h ⭺ᄷ㸪12 ᑠᣢ⧰ᛶ⸩ᩀ cap.sr 24h ⭺ᄷ㸪24 ᑠᣢ⧰ᛶ⸩ᩀ cap24h pct ⭺ᄷ㸪24 ᑠ᥍ไⓐస⸩ cap24h pel ⭺ᄷ㸪24 ᑠᣢ⧰ᛶ⸩ᩀ⸩ cap sprink ⭺ᄷ㸪ศᩓᆺ cap sr pel ⭺ᄷ㸪⦆㔚⸩ᩀ⸩ cap w/dev 㝃⿶⨨ⓗ⭺ᄷ capsule dr ⭺ᄷ㸪⦆㔚⸩ᩀ capsule er ⭺ᄷ㸪⦆㔚⸩ᩀ capsule sa ⭺ᄷ㸪㛗ᩀ cmb cappad ᩚྜ㸸⭺ᄷ㸪ቈ cmb ont fm ᩚྜ㸸⸩⭯㸪Ἳἓᆺ cmb ont lt ᩚྜ㸸⸩⭯㸪ஙᾮᆺ 43 ⦰ᑃ 婒᫂ cmb tabpad ᩚྜ㸸⸩㘄㸪ቈ combo. pkg ᩚྜໟ⿶ cpmp 12hr ⭺ᄷ㸪12 ᑠከẁᘧ cpmp 24hr ⭺ᄷ㸪24 ᑠከẁᘧ cpmp 30-70 ⭺ᄷ㸪ከẁᘧ㸪30%-70% cpmp 50-50 ⭺ᄷ㸪ከẁᘧ㸪50%-50% cream(g), cream(gm) ங㟖 (බඞ) cream(ml) ங㟖 (ấ⡿) cream/appl 㝃ሬჾⓗங㟖 cream, er (g) ங㟖㸪㛗ᩀᆺ (බඞ) cream pack ங㟖㸪ໟ⿶ dehp fr bg dis needle ྵ㒲Ɽ⏥㓟(2-எᇶᕫᇶ)愗 (di(2ethylhexyl)phthalate) ⓗ⿄Ꮚ ㉳Რᘧ㔪㢌 disp syrin 㝃྾ධᘧ⿶⨨ⓗᅭ┙ ㉳Რᘧ㔪⟄ drops susp ກ㸪ᠱᾋ drps hpvis ກ㸪㉸㯫ᛶ emul adhes ஙກ㯫⭺ emul packt ஙກໟ emulsn(g) ஙກ (බඞ) foam/appl. 㝃ሬჾⓗἻἓ froz.piggy ෦ᩜ⫼ᖔ g බඞ gel/pf app 㝃㡸ሸሬჾⓗจ⭺ gel (gm) จ⭺ (බඞ) gel (ml) จ⭺ (ấ⡿) gel md pmp ᭷้ᗘກ㔞ᖳᾆⓗจ⭺ gel w/appl 㝃ሬჾⓗจ⭺ gel w/pump 㝃ᖳᾆⓗจ⭺ disk w/dev 44 ⦰ᑃ 婒᫂ gran pack 㢛⢏ໟ hfa aer ad hfa ᄇ㟝ກ㎈᥋㢌 infus. btl ㍺ᾮ⎼ insuln pen ip soln ⬓ᓥ⣲➹ ⭡⭷ℏ⁐ᾮ irrig soln ℺ὀ⁐ᾮ iv soln. 㟿⬦⁐ᾮ jel ⭺≪≀ jelly/app 㝃ሬჾⓗ⭺≪≀ jel/pf app 㝃㡸ሸሬჾⓗ⭺≪≀ kit cl&crm ⤌௳㸸Ύ₩ກ⯅ங㟖 kt crm le ⤌௳㸸ங㟖ࠊஙᾮ₶ກ kt lotn ce ⤌௳㸸ஙᾮࠊங㟖₶ກ kt oint le ⤌௳㸸⸩⭯㸪ஙᾮ₶ກ lotion, er ஙᾮ㸪⦆㔚⸩ᩀ lozenge hd ⳻ᙧᥱᢕ m.ht patch ྵ⸩≀ⓗ⇕ᩜ㈞∦ ma buc tab 㯫⭷྾㝃ᛶཱྀ㢏㘄 mcg ᚤඞ med. pad ྵ⸩ቈ med. swab ྵ⸩ᲤⰼᲬ med. tape ྵ⸩⭺ᖔ mg ấඞ ml ấ⡿ muc er 12h 㯫⭷྾㝃ᛶ⣔⤫㸪12 ᑠ⦆㔚⸩ᩀ ndl fr inj ὀᑕ㔪 nl fm susp ᣦ⏥⭷ᠱᾋᾮ oint. (g), oint.(gm) ⸩⭯ (බඞ) oral conc ཱྀ᭹⃰⦰ກ oral susp ཱྀ᭹ᠱᾋກ 45 ⦰ᑃ 婒᫂ paste (g) ⭯ (බඞ) patch td24 ㈞ᕸ㸪24 ᑠ⥂⓶ patch td72 ㈞ᕸ㸪72 ᑠ⥂⓶ patch tdsw ㈞ᕸ㸪㞬㐌⥂⓶ patch tdwk ㈞ᕸ㸪ẗ㐌⥂⓶ pca syring ⏤ᝈ᥍ไⓗṆ③㔪⟄ pca vial ⏤ᝈ᥍ไⓗṆ③ᑠ⎼ pellet(ea) ⸩ (ẗ㢛) pen ij kit ➹ᆺὀᑕჾ⤌௳ pen injctr ➹ᆺὀᑕჾ pggybk btl ⫪⫼⎼ plast. bag ረ⭺⿄ powd pack ⢊ᮎໟ sol md pmp 㝃ከກᖳᾆⓗ⁐ᾮ sol w/appl 㝃ሬჾⓗ⁐ᾮ sol/pf app 㝃㡸ሸሬჾⓗ⁐ᾮ sol-gel ⁐ᾮ㸪จ⭺≪ soln recon ⁐ᾮ㸪㔜⤌ⓗ soln(gram) ⁐ᾮ (බඞ) spray susp ᄇ㟝㸪ᠱᾋᾮ spray/pump 㝃ᖳᾆⓗᄇ㟝 stick(ea) ᲄ≪ (ẗ᰿) supp.rect ᰦກ㸪⫠㛛 supp.vag ᰦກ㸪㝜㐨 suppos. ᰦກ sus er 24h ᠱᾋᾮ㸪24 ᑠ⦆㔚⸩ᩀ sus er rec ᠱᾋᾮ㸪⦆㔚⸩ᩀ㔜⤌ sus mc rec ᠱᾋᾮ㸪㔜⤌ⓗᚤ⭺ᄷ suspdr pkt ᠱᾋᾮ㸪⦆㔚⸩ᩀໟ susp recon ᠱᾋᾮ㸪㔜⤌ⓗ 46 ⦰ᑃ 婒᫂ syringekit 㔪⟄⤌௳ tab chew ⸩㘄㸪ྍᄮ tab er 12h ⸩㘄㸪12 ᑠ⦆㔚⸩ᩀ tab er 24h ⸩㘄㸪24 ᑠ⦆㔚⸩ᩀ tab er prt ⸩㘄㸪⦆㔚⸩ᩀ⢏Ꮚ tab er seq ⸩㘄㸪⦆㔚⸩ᩀ tab disper ⸩㘄㸪ྍศᩓ tab ds pk ⸩㘄㸪ກ㔞ໟ tab er 24 ⸩㘄㸪24 ᑠ⦆㔚⸩ᩀ tab mphase ⸩㘄㸪ከẁᘧ tab part ⸩㘄㸪⢏Ꮚ tab rap dr ⸩㘄㸪ᛌ㏿ᔂゎ⦆㔚⸩ᩀ tab rapdis ⸩㘄㸪ᛌ㏿ᔂゎ tab subl ⸩㘄㸪⯉ୗ tab.sr 12h ⸩㘄㸪12 ᑠᣢ⧰ᛶ⸩ᩀ tab.sr 24h ⸩㘄㸪24 ᑠᣢ⧰ᛶ⸩ᩀ tabergr24hr ⸩㘄㸪24 ᑠ㐍⦆㔚⸩ᩀ tablet dr ⸩㘄㸪⦆㔚⸩ᩀ tablet, er ⸩㘄㸪⦆㔚⸩ᩀ tablet eff ⸩㘄㸪ⓐἻກ tablet sa ⸩㘄㸪㛗ᩀ tablet sol ⸩㘄㸪ྍ⁐ゎ tb er dspk ⸩㘄㸪⦆㔚ກ㔞ໟ tb mp dspk ⸩㘄㸪ከẁᘧກ㔞ໟ tb rd dspk ⸩㘄㸪ᛌ㏿ᔂゎກ㔞ໟ tbdspk 3mo ⸩㘄㸪3 ಶ᭶ກ㔞ໟ tbmp 12hr ⸩㘄㸪12 ᑠከẁᘧ tbmp 24hr ⸩㘄㸪24 ᑠከẁᘧ u ႝ vag ring 㝜㐨⎔ 47 48 Drug Name Drug Tier Requirements/Limits Analgesics Analgesics, Miscellaneous acetaminophen-codeine oral solution (Acetaminophen with Codeine) acetaminophen-codeine oral tablet 300-15 (Tylenol-Codeine No.3) mg, 300-30 mg acetaminophen-codeine oral tablet 300-60 (Tylenol-Codeine No.3) mg (Buprenorphine HCl) buprenorphine hcl injection (Esgic) butalb-acetaminophen-caffeine oral capsule 50-325-40 mg (Fioricet with Codeine) butalbital-acetaminop-caf-cod 1 QL (2700 per 30 days) 1 QL (360 per 30 days) 1 QL (180 per 30 days) 1 1 1 butalbital-acetaminophen (Tencon) 1 butalbital-acetaminophen-caff oral tablet 50-325-40 mg butalbital-aspirin-caffeine oral capsule (Esgic) 1 (Fiorinal) 1 BUTRANS codeine sulfate oral tablet codeine-butalbital-asa-caffein oral capsule 30-50-325-40 mg EMBEDA ORAL CAPSULE,ORAL ONLY,EXT.REL PELL fentanyl fentanyl citrate (Codeine Sulfate) (Fiorinal with Codeine #3) 1 1 1 1 (Duragesic) (Actiq) 1 1 hydrocodone-acetaminophen oral solution (Hycet) (Norco) hydrocodone-acetaminophen oral tablet 10-300 mg, 5-300 mg, 7.5-300 mg 1 1 (Norco) 1 (Ibudone) (Hydromorphone HCl/PF) 1 1 hydrocodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg hydrocodone-ibuprofen hydromorphone (pf) injection solution 10 mg/ml PA-HRM; QL (180 per 30 days) PA-HRM; QL (180 per 30 days) PA-HRM; QL (180 per 30 days) PA-HRM; QL (180 per 30 days) PA-HRM; QL (180 per 30 days) QL (4 per 28 days) QL (180 per 30 days) PA-HRM; QL (180 per 30 days) QL (60 per 30 days) PA; QL (10 per 30 days) PA; QL (120 per 30 days) QL (2700 per 30 days) (includes Vicodin, Vicodin ES and Vicodin HP); QL (390 per 30 days) QL (360 per 30 days) QL (150 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 49 Effective: January 01, 2016 Drug Name hydromorphone (pf) injection solution 4 mg/ml hydromorphone injection solution hydromorphone injection syringe 2 mg/ml hydromorphone oral liquid hydromorphone oral tablet 2 mg, 4 mg hydromorphone oral tablet 8 mg LAZANDA methadone hcl oral tablet,soluble 40 mg methadone injection methadone oral methadone oral morphine concentrate oral solution morphine concentrate oral syringe morphine injection solution 10 mg/ml, 15 mg/ml, 8 mg/ml morphine injection syringe morphine intramuscular morphine intravenous morphine intravenous solution 25 mg/ml, 50 mg/ml morphine intravenous morphine oral solution 10 mg/5 ml morphine oral solution 20 mg/5 ml MORPHINE ORAL TABLET morphine oral tablet extended release 100 mg, 30 mg, 60 mg morphine oral tablet extended release 15 mg, 200 mg morphine rectal NUCYNTA NUCYNTA ER oxycodone hcl-acetaminophen oral solution 5-325 mg/5 ml oxycodone hcl-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg oxycodone hcl-aspirin oxycodone oral concentrate Drug Tier Requirements/Limits (Dilaudid) 1 (Hydromorphone HCl) (Hydromorphone HCl) (Dilaudid) (Dilaudid) (Dilaudid) (Diskets) (Methadone HCl) (Methadone HCl) (Diskets) (Morphine Sulfate) (Morphine Sulfate) (Morphine Sulfate) 1 1 1 1 1 1 1 1 1 1 1 1 1 (Morphine Sulfate) (Morphine Sulfate) (Morphine Sulfate) (Morphine Sulfate) 1 1 1 1 (Morphine Sulfate) (Morphine Sulfate) (Morphine Sulfate) (MS Contin) 1 1 1 1 1 QL (700 per 30 days) QL (300 per 30 days) QL (180 per 30 days) QL (120 per 30 days) (MS Contin) 1 QL (180 per 30 days) (Morphine Sulfate) 1 1 1 1 QL (181 per 30 days) QL (60 per 30 days) QL (1800 per 30 days) 1 QL (360 per 30 days) 1 1 QL (360 per 30 days) QL (180 per 30 days) (Oxycodone HCl/Acetaminophen) (Xolox) (Percodan) (Oxycodone HCl) QL (1200 per 30 days) QL (180 per 30 days) QL (240 per 30 days) PA; QL (30 per 30 days) QL (90 per 30 days) QL (1800 per 30 days) QL (360 per 30 days) QL (200 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 50 Effective: January 01, 2016 Drug Name oxycodone oral solution oxycodone oral tablet oxycodone-acetaminophen oral tablet 10325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg oxycodone-acetaminophen oral tablet 10650 mg oxycodone-acetaminophen oral tablet 7.5500 mg oxycodone-aspirin OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 80 MG oxymorphone oral tablet oxymorphone oral tablet extended release 12 hr 10 mg, 15 mg, 20 mg, 5 mg, 7.5 mg oxymorphone oral tablet extended release 12 hr 30 mg, 40 mg tramadol oral tablet tramadol-acetaminophen XARTEMIS XR xylon 10 Drug Tier Requirements/Limits (Oxycodone HCl) (Roxicodone) (Xolox) 1 1 1 QL (1300 per 30 days) QL (180 per 30 days) QL (360 per 30 days) (Xolox) 1 QL (180 per 30 days) (Xolox) 1 QL (240 per 30 days) (Percodan) 1 1 QL (360 per 30 days) QL (60 per 30 days) 1 QL (120 per 30 days) (Opana) (Opana ER) 1 1 QL (180 per 30 days) QL (60 per 30 days) (Opana ER) 1 QL (120 per 30 days) (Ultram) (Ultracet) 1 1 1 1 QL (240 per 30 days) QL (240 per 30 days) QL (360 per 30 days) QL (150 per 30 days) (Ibudone) Nonsteroidal Anti-Inflammatory Agents CALDOLOR INTRAVENOUS RECON SOLN celecoxib choline,magnesium salicylate diclofenac potassium diclofenac sodium oral tablet extended release 24 hr diclofenac sodium oral tablet,delayed release (dr/ec) diclofenac sodium topical gel diclofenac-misoprostol diflunisal etodolac 1 (Celebrex) (Choline Sal/Mag Salicylate) (Diclofenac Potassium) (Voltaren-XR) 1 1 1 1 (Diclofenac Sodium) 1 (Solaraze) (Arthrotec 50) (Diflunisal) (Etodolac) 1 1 1 1 QL (60 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 51 Effective: January 01, 2016 Drug Name Drug Tier Requirements/Limits fenoprofen oral tablet FLECTOR flurbiprofen ibuprofen oral ibuprofen oral tablet 400 mg, 600 mg, 800 mg indomethacin oral capsule 25 mg (Fenoprofen Calcium) (Flurbiprofen) (Ibuprofen) (Ibuprofen) 1 1 1 1 1 (Indomethacin) 1 indomethacin oral capsule 50 mg (Indomethacin) 1 indomethacin oral capsule, extended release indomethacin sodium ketoprofen oral capsule ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg ketorolac injection cartridge 15 mg/ml (Indomethacin) 1 (Indomethacin Sodium) (Ketoprofen) (Ketoprofen) 1 1 1 (Ketorolac Tromethamine) (Ketorolac Tromethamine) (Ketorolac Tromethamine) (Ketorolac Tromethamine) (Ketorolac Tromethamine) (Ketorolac Tromethamine) (Ponstel) (Mobic) (Mobic) (Nabumetone) (Naprosyn) (Naprosyn) (Ec-Naprosyn) 1 QL (40 per 30 days) 1 QL (20 per 30 days) 1 QL (40 per 30 days) 1 QL (20 per 30 days) 1 QL (20 per 30 days) 1 QL (20 per 30 days) 1 1 1 1 1 1 1 (Anaprox) 1 (Feldene) 1 ketorolac injection cartridge 30 mg/ml ketorolac injection solution 15 mg/ml ketorolac injection solution 30 mg/ml (1 ml) ketorolac intramuscular solution ketorolac oral mefenamic acid meloxicam oral suspension meloxicam oral tablet nabumetone naproxen oral suspension naproxen oral tablet naproxen oral tablet,delayed release (dr/ec) naproxen sodium oral tablet 275 mg, 550 mg piroxicam PA PA-HRM; QL (240 per 30 days) PA-HRM; QL (120 per 30 days) PA-HRM; QL (60 per 30 days) PA-HRM You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 52 Effective: January 01, 2016 Drug Name salsalate sulindac oral tolmetin VOLTAREN TOPICAL Drug Tier Requirements/Limits (Salsalate) (Sulindac) (Tolmetin Sodium) 1 1 1 1 glydo lidocaine (pf) injection solution (Lidocaine HCl) (Xylocaine-MPF) 1 1 lidocaine (pf) intravenous syringe 100 mg/5 ml (2 %) lidocaine hcl injection solution (Lidocaine HCl/PF) 1 (Xylocaine) 1 lidocaine hcl laryngotracheal lidocaine hcl mucous membrane gel lidocaine hcl mucous membrane jelly in applicator lidocaine hcl mucous membrane solution lidocaine hcl urethral lidocaine topical adhesive patch,medicated lidocaine topical ointment (Xylocaine) (Lidocaine HCl) (Lidocaine HCl) 1 1 1 (Xylocaine) (Lidocaine HCl) (Lidoderm) 1 1 1 (Lidocaine) 1 lidocaine-prilocaine topical (EMLA) 1 lidocaine-prilocaine topical kit (Lidocaine/Prilocaine) 1 PA BvD; (PA for ESRD Only) PA BvD; (PA for ESRD Only) PA BvD 1 1 1 PA; QL (90 per 30 days) PA; QL (90 per 30 days) 1 1 1 QL (168 per 84 days) QL (56 per 28 days) 1 1 QL (56 per 28 days) QL (53 per 28 days) Anesthetics Local Anesthetics PA BvD; (PA for ESRD Only) PA BvD; (PA for ESRD Only) PA Anti-Addiction/Substance Abuse Treatment Agents Anti-Addiction/Substance Abuse Treatment Agents acamprosate buprenorphine hcl sublingual buprenorphine-naloxone bupropion hcl sr 150 mg tablet f/c CHANTIX CHANTIX CONTINUING MONTH BOX CHANTIX CONTINUING MONTH PAK CHANTIX STARTING MONTH BOX (Acamprosate Calcium) (Subutex) (Buprenorphine HCl/Naloxone HCl) (Zyban) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 53 Effective: January 01, 2016 Drug Name disulfiram naloxone naltrexone hcl naltrexone NICOTROL ZUBSOLV Drug Tier Requirements/Limits (Antabuse) (Naloxone HCl) (Revia) (Revia) 1 1 1 1 1 1 QL (1008 per 90 days) PA; QL (90 per 30 days) (Xanax) (Xanax XR) 1 1 QL (120 per 30 days) QL (120 per 30 days) (Xanax XR) 1 QL (90 per 30 days) (Chlordiazepoxide HCl) (Klonopin) (Klonopin) (Clonazepam) 1 1 1 1 QL (120 per 30 days) QL (90 per 30 days) QL (300 per 30 days) QL (90 per 30 days) (Clonazepam) 1 QL (300 per 30 days) (Tranxene T-Tab) (Tranxene T-Tab) 1 1 QL (120 per 30 days) QL (60 per 30 days) (Diazepam) (Diazepam) (Diazepam) (Valium) (Diastat) (Estazolam) 1 1 1 1 1 1 QL (10 per 28 days) QL (1200 per 30 days) QL (1200 per 30 days) QL (120 per 30 days) Antianxiety Agents Benzodiazepines alprazolam oral tablet alprazolam oral tablet extended release 24 hr 0.5 mg, 1 mg, 2 mg alprazolam oral tablet extended release 24 hr 3 mg chlordiazepoxide hcl clonazepam oral tablet 0.5 mg, 1 mg clonazepam oral tablet 2 mg clonazepam oral tablet,disintegrating 0.125 mg, 0.25 mg, 0.5 mg, 1 mg clonazepam oral tablet,disintegrating 2 mg clorazepate dipotassium oral tablet 15 mg clorazepate dipotassium oral tablet 3.75 mg, 7.5 mg diazepam injection diazepam intensol diazepam oral solution diazepam oral tablet diazepam rectal estazolam oral tablet 1 mg PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (60 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 54 Effective: January 01, 2016 Drug Name Drug Tier Requirements/Limits estazolam oral tablet 2 mg (Estazolam) 1 flurazepam oral capsule 15 mg (Flurazepam HCl) 1 flurazepam oral capsule 30 mg (Flurazepam HCl) 1 lorazepam oral tablet midazolam oral syrup 2 mg/ml temazepam oral capsule 15 mg, 22.5 mg, 30 mg (Ativan) (Midazolam HCl) (Restoril) 1 1 1 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (30 per 30 days) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (60 per 30 days) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (30 per 30 days) QL (90 per 30 days) QL (10 per 30 days) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (30 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 55 Effective: January 01, 2016 Drug Name Drug Tier Requirements/Limits temazepam oral capsule 7.5 mg (Restoril) 1 triazolam oral tablet 0.125 mg (Halcion) 1 triazolam oral tablet 0.25 mg (Halcion) 1 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (120 per 30 days) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (120 per 30 days) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (60 per 30 days) Antibacterials Aminoglycosides BETHKIS gentamicin in nacl (iso-osm) intravenous piggyback gentamicin injection solution gentamicin sulfate (ped) (pf) gentamicin sulfate (pf) intravenous solution neomycin streptomycin intramuscular TOBI PODHALER INHALATION tobramycin in 0.225 % nacl (Gentamicin In Nacl, Iso-Osm) (Gentamicin Sulfate) (Gentamicin Sulfate/PF) (Gentamicin Sulfate/PF) (Neomycin Sulfate) (Streptomycin Sulfate) (Tobi) 1 1 PA BvD 1 1 1 1 1 1 1 QL (224 per 28 days) PA BvD You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 56 Effective: January 01, 2016 Drug Name tobramycin in 0.9 % nacl tobramycin sulfate injection solution Drug Tier Requirements/Limits (Tobramycin/Sodium Chloride) (Tobramycin Sulfate) 1 (Bacitracin) (Chloramphenicol Sod Succ) (Cleocin HCl) (Cleocin Phosphate In D5w) (Cleocin Palmitate) (Cleocin Phosphate) (Cleocin Phosphate) 1 1 1 Antibacterials, Miscellaneous bacitracin intramuscular chloramphenicol sod succinate clindamycin hcl clindamycin in 5 % dextrose clindamycin palmitate hcl clindamycin phosphate injection clindamycin phosphate intravenous solution colistin (colistimethate na) CUBICIN linezolid methenamine hippurate methenamine mandelate metronidazole in nacl (iso-os) metronidazole oral nitrofurantoin macrocrystal oral capsule 100 mg nitrofurantoin macrocrystal oral capsule (Coly-Mycin M Parenteral) 1 1 1 1 1 1 1 1 1 1 (Zyvox) (Hiprex) (Methenamine Mandelate) (Metronidazole/Sodium Chloride) (Flagyl) (Macrodantin/Macrobid) 1 1 (Macrodantin/Macrobid) 1 1 PA-HRM; QL (120 per 30 days) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (120 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 57 Effective: January 01, 2016 Drug Name nitrofurantoin monohyd/m-cryst Drug Tier Requirements/Limits (Macrobid) (Polymyxin B Sulfate) polymyxin b sulfate SYNERCID (Trimethoprim) trimethoprim vancomycin in d5w intravenous piggyback (Vancomycin HCl/D5W) vancomycin intravenous recon soln 1,000 (Vancomycin HCl) mg, 10 gram, 750 mg (Vancomycin vancomycin intravenous recon soln 500 HCl/D5W) mg (Vancocin HCl) vancomycin oral capsule XIFAXAN ORAL TABLET 200 MG ZYVOX ORAL SUSPENSION FOR RECONSTITUTION 1 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (120 per 30 days) 1 1 1 1 1 1 1 1 1 PA; QL (9 per 30 days) Cephalosporins cefaclor oral capsule cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml cefadroxil oral capsule cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml cefazolin injection recon soln 1 gram, 10 gram, 100 gram, 300 g, 500 mg cefdinir cefditoren pivoxil cefepime CEFEPIME IN DEXTROSE 5 % CEFEPIME IN DEXTROSE,ISO-OSM INTRAVENOUS PIGGYBACK (Cefaclor) (Cefaclor) 1 1 (Cefadroxil) (Cefadroxil) 1 1 (Cefadroxil) (Cefazolin Sodium/Dextrose, Iso) (Cefazolin Sodium) 1 1 (Cefdinir) (Spectracef) (Maxipime) 1 1 1 1 1 1 You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 58 Effective: January 01, 2016 Drug Name cefotaxime cefoxitin cefoxitin in dextrose, iso-osm intravenous piggyback 2 gram/50 ml cefpodoxime cefprozil ceftazidime intravenous recon soln 1 gram, 2 gram ceftibuten ceftriaxone in dextrose,iso-os intravenous piggyback 1 gram/50 ml CEFTRIAXONE IN DEXTROSE,ISO-OS INTRAVENOUS PIGGYBACK 2 GRAM/50 ML ceftriaxone injection recon soln ceftriaxone intravenous recon soln 1 gram CEFTRIAXONE INTRAVENOUS RECON SOLN 2 GRAM cefuroxime axetil oral tablet cefuroxime sodium injection recon soln 1.5 gram, 750 mg cefuroxime sodium intravenous cefuroxime-dextrose (iso-osm) cephalexin oral capsule cephalexin oral suspension for reconstitution cephalexin oral tablet MEFOXIN IN DEXTROSE (ISO-OSM) SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 500 MG/5 ML SUPRAX ORAL TABLET,CHEWABLE TEFLARO Drug Tier Requirements/Limits (Claforan) (Cefoxitin Sodium) (Cefoxitin Sodium/Dextrose, Iso) (Cefpodoxime Proxetil) (Cefprozil) (Ceftazidime) (Cedax) (Ceftriaxone Na/Dextrose, Iso) 1 1 1 1 1 1 1 1 1 (Rocephin) (Ceftriaxone Na/Dextrose, Iso) 1 1 1 (Ceftin) (Zinacef) 1 1 (Zinacef) (Cefuroxime Sodium/Dextrose, Iso) (Keflex) (Cephalexin) 1 1 (Cephalexin) 1 1 1 1 1 1 1 Macrolides azithromycin clarithromycin oral suspension for reconstitution clarithromycin oral tablet (Zithromax) (Biaxin) 1 1 (Biaxin) 1 You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 59 Effective: January 01, 2016 Drug Name clarithromycin oral tablet extended release 24 hr DIFICID ERYTHROCIN erythromycin base oral tablet,delayed release (dr/ec) 250 mg, 500 mg ERYTHROMYCIN BASE ORAL TABLET,DELAYED RELEASE (DR/EC) 333 MG erythromycin ethylsuccinate oral suspension for reconstitution erythromycin ethylsuccinate oral tablet erythromycin oral capsule,delayed release(dr/ec) erythromycin oral tablet erythromycin stearate oral tablet 250 mg Drug Tier Requirements/Limits (Clarithromycin) 1 (Erythromycin Base) 1 1 1 QL (20 per 10 days) 1 (Eryped 200) 1 (Erythromycin Ethylsuccinate) (Erythromycin Base) 1 1 (Erythromycin Base) (Erythromycin Stearate) 1 1 Miscellaneous B-Lactam Antibiotics aztreonam injection recon soln 1 gram CAYSTON imipenem-cilastatin INVANZ meropenem (Azactam) (Merrem) 1 1 1 1 1 (Amoxicillin) (Amoxicillin) 1 1 (Amoxicillin) (Amoxicillin) 1 1 (Augmentin) 1 (Augmentin) (Augmentin XR) 1 1 (Amoxicillin/Potassium Clav) (Ampicillin Trihydrate) (Ampicillin Sodium) 1 (Primaxin) LA Penicillins amoxicillin oral capsule amoxicillin oral suspension for reconstitution amoxicillin oral tablet amoxicillin oral tablet,chewable 125 mg, 250 mg amoxicillin-pot clavulanate oral suspension for reconstitution amoxicillin-pot clavulanate oral tablet amoxicillin-pot clavulanate oral tablet extended release 12 hr amoxicillin-pot clavulanate oral tablet,chewable ampicillin ampicillin sodium injection recon soln 1 1 You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 60 Effective: January 01, 2016 Drug Name ampicillin sodium intravenous recon soln ampicillin-sulbactam injection recon soln ampicillin-sulbactam intravenous BICILLIN C-R BICILLIN L-A dicloxacillin nafcillin injection nafcillin intravenous recon soln oxacillin in dextrose(iso-osm) Drug Tier Requirements/Limits (Ampicillin Sodium) (Unasyn) (Unasyn) (Dicloxacillin Sodium) (Nafcillin Sodium) (Nafcillin Sodium) (Oxacillin Sodium/Dextrose, Iso) (Oxacillin Sodium) oxacillin injection recon soln 10 gram (Oxacillin Sodium) oxacillin intravenous (Pen G Pot/Dextrosepenicillin g pot in dextrose Water) (Penicillin G Potassium) penicillin g potassium (Penicillin G Procaine) penicillin g procaine (Penicillin V Potassium) penicillin v potassium piperacillin-tazobactam intravenous recon (Zosyn) soln 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Quinolones ciprofloxacin ciprofloxacin hcl oral ciprofloxacin in 5 % dextrose ciprofloxacin lactate levofloxacin in d5w intravenous piggyback levofloxacin intravenous levofloxacin oral solution levofloxacin oral tablet moxifloxacin ofloxacin oral tablet 400 mg (Cipro) (Cipro) (Cipro I.V.) (Ciprofloxacin Lactate) (Levaquin) (Levofloxacin) (Levaquin) (Levaquin) (Avelox) (Ofloxacin) 1 1 1 1 1 1 1 1 1 1 (Sulfadiazine) (Sulfamethoxazole/Trim ethoprim) (Sulfamethoxazole/Trim ethoprim) (Bactrim) (Azulfidine) 1 1 Sulfonamides sulfadiazine oral sulfamethoxazole-trimethoprim intravenous sulfamethoxazole-trimethoprim oral suspension sulfamethoxazole-trimethoprim oral tablet sulfasalazine 1 1 1 You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 61 Effective: January 01, 2016 Drug Name sulfatrim sulfazine sulfazine ec Drug Tier Requirements/Limits (Sulfamethoxazole/Trim ethoprim) (Azulfidine) (Azulfidine) 1 1 1 (Morgidox) (Doryx) (Doxycycline Hyclate) (Adoxa) (Morgidox) (Avidoxy) 1 1 1 1 1 1 (Doryx) (Adoxa) (Vibramycin) 1 1 1 (Avidoxy) 1 1 1 1 1 1 Tetracyclines doxycycline hyclate oral capsule 100 mg doxycycline hyclate 100 mg tab f/c doxycycline hyclate intravenous doxycycline hyclate oral capsule 100 mg doxycycline hyclate oral capsule 50 mg doxycycline hyclate oral tablet 100 mg, 50 mg doxycycline hyclate oral tablet 20 mg doxycycline monohydrate oral capsule doxycycline monohydrate oral suspension for reconstitution doxycycline monohydrate oral tablet MINOCIN INTRAVENOUS minocycline oral capsule minocycline oral tablet tetracycline TYGACIL (Minocin) (Minocycline HCl) (Tetracycline HCl) Anticancer Agents Anticancer Agents ABRAXANE ADCETRIS 1 1 AFINITOR DISPERZ 1 AFINITOR ORAL TABLET 10 MG 1 AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 MG ALIMTA INTRAVENOUS RECON SOLN (Arimidex) anastrozole AVASTIN INTRAVENOUS SOLUTION 25 MG/ML 1 PA NSO; QL (4 per 21 days) PA NSO; QL (112 per 28 days) PA NSO; QL (56 per 28 days) PA NSO; QL (28 per 28 days) 1 1 1 PA NSO You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 62 Effective: January 01, 2016 Drug Name azacitidine BELEODAQ bicalutamide bleomycin BLINCYTO Drug Tier Requirements/Limits (Vidaza) (Casodex) (Bleomycin Sulfate) 1 1 1 1 1 BOSULIF ORAL TABLET 100 MG 1 BOSULIF ORAL TABLET 500 MG 1 CAPRELSA ORAL TABLET 100 MG 1 CAPRELSA ORAL TABLET 300 MG 1 COMETRIQ 1 PA NSO PA BvD PA NSO; QL (140 per 365 days) PA NSO; QL (120 per 30 days) PA NSO; QL (30 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (30 per 30 days) PA NSO; QL (112 per 28 days) PA BvD PA BvD; ST 1 cyclophosphamide intravenous recon soln (Cyclophosphamide) CYCLOPHOSPHAMIDE ORAL 1 CAPSULE (Cyclophosphamide) 1 PA BvD; ST cyclophosphamide oral tablet CYRAMZA INTRAVENOUS 1 PA NSO SOLUTION 10 MG/ML (Dactinomycin) 1 dactinomycin DAUNOXOME 1 (Dacogen) 1 decitabine 1 docetaxel intravenous solution 160 mg/16 (Taxotere) ml (10 mg/ml), 20 mg/2 ml (final), 80 mg/4 ml (20 mg/ml), 80 mg/8 ml (10 mg/ml) 1 PA BvD doxorubicin hcl intravenous recon soln 10 (Doxorubicin HCl) mg 1 PA BvD doxorubicin hcl peg-liposomal intravenous (Doxil) suspension 2 mg/ml (Doxil) 1 PA BvD doxorubicin, peg-liposomal DROXIA 1 ELIGARD SUBCUTANEOUS SYRINGE 1 QL (1 per 84 days) 22.5 MG (3 MONTH) ELIGARD SUBCUTANEOUS SYRINGE 1 QL (1 per 112 days) 30 MG (4 MONTH) ELIGARD SUBCUTANEOUS SYRINGE 1 QL (1 per 168 days) 45 MG (6 MONTH) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 63 Effective: January 01, 2016 Drug Name Drug Tier Requirements/Limits ELIGARD SUBCUTANEOUS SYRINGE 7.5 MG (1 MONTH) EMCYT ERIVEDGE 1 ETOPOPHOS etoposide intravenous exemestane FARESTON FARYDAK FASLODEX floxuridine fluorouracil intravenous solution 2.5 gram/50 ml, 5 gram/100 ml, 500 mg/10 ml flutamide GAZYVA gemcitabine intravenous recon soln 1 gram GILOTRIF 1 1 1 1 1 1 1 1 1 1 (Etoposide) (Aromasin) (Floxuridine) (Fluorouracil) (Flutamide) (Gemzar) 1 1 1 1 GLEEVEC ORAL TABLET 100 MG 1 GLEEVEC ORAL TABLET 400 MG 1 HERCEPTIN HEXALEN hydroxyurea IBRANCE 1 1 1 1 (Hydrea) ICLUSIG ORAL TABLET 15 MG 1 ICLUSIG ORAL TABLET 45 MG 1 ifosfamide intravenous recon soln ifosfamide intravenous solution ifosfamide-mesna IMBRUVICA INLYTA ORAL TABLET 1 MG (Ifex) (Ifex) (Ifosfamide/Mesna) 1 1 1 1 1 PA NSO; QL (30 per 30 days) PA NSO PA BvD PA BvD PA NSO PA NSO; QL (30 per 30 days) PA NSO; QL (90 per 30 days) PA NSO; QL (60 per 30 days) PA NSO PA NSO; QL (21 per 28 days) PA NSO; QL (60 per 30 days) PA NSO; QL (30 per 30 days) PA BvD PA BvD PA BvD PA NSO PA NSO; QL (180 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 64 Effective: January 01, 2016 Drug Name Drug Tier Requirements/Limits INLYTA ORAL TABLET 5 MG 1 IXEMPRA JAKAFI 1 1 KEYTRUDA KYPROLIS 1 1 LENVIMA letrozole LEUKERAN leuprolide lomustine LUPRON DEPOT LUPRON DEPOT (3 MONTH) LUPRON DEPOT (4 MONTH) LUPRON DEPOT (6 MONTH) LYNPARZA 1 1 1 1 1 1 1 1 1 1 (Femara) (Leuprolide Acetate) (Gleostine) LYSODREN MARQIBO 1 1 MATULANE megestrol oral tablet MEKINIST ORAL TABLET 0.5 MG 1 1 1 (Megestrol Acetate) MEKINIST ORAL TABLET 2 MG melphalan hcl intravenous mercaptopurine methotrexate sodium (pf) injection recon soln methotrexate sodium (pf) injection solution methotrexate sodium injection methotrexate sodium oral mitoxantrone NEXAVAR 1 PA NSO; QL (60 per 30 days) PA NSO; QL (60 per 30 days) PA NSO PA NSO; QL (6 per 28 days) PA NSO QL (1 per 84 days) QL (1 per 84 days) QL (1 per 168 days) PA NSO; QL (480 per 30 days) PA NSO; QL (4 per 28 days) PA NSO; QL (90 per 30 days) PA NSO; QL (30 per 30 days) (Alkeran) (Mercaptopurine) (Methotrexate Sodium/PF) (Methotrexate Sodium) 1 1 1 PA BvD 1 PA BvD (Methotrexate Sodium) (Methotrexate Sodium) (Mitoxantrone HCl) 1 1 1 1 PA BvD PA BvD; ST PA NSO; QL (120 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 65 Effective: January 01, 2016 Drug Name NILANDRON ONCASPAR OPDIVO INTRAVENOUS SOLUTION 40 MG/4 ML oxaliplatin intravenous solution 100 mg/20 ml PERJETA POMALYST Drug Tier Requirements/Limits 1 1 1 (Eloxatin) 1 1 1 PROLEUKIN PURIXAN REVLIMID RITUXAN SOLTAMOX SPRYCEL ORAL TABLET 100 MG, 140 MG, 50 MG, 70 MG, 80 MG SPRYCEL ORAL TABLET 20 MG 1 1 1 1 1 1 STIVARGA 1 SUTENT 1 SYLVANT SYNRIBO 1 1 TABLOID TAFINLAR 1 1 tamoxifen TARCEVA ORAL TABLET 100 MG, 25 MG TARCEVA ORAL TABLET 150 MG PA NSO PA NSO 1 (Tamoxifen Citrate) 1 1 1 TARGRETIN ORAL 1 TARGRETIN TOPICAL 1 TASIGNA 1 PA NSO PA NSO; QL (21 per 28 days) PA NSO; LA PA NSO PA NSO; QL (30 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (84 per 28 days) PA NSO; QL (30 per 30 days) PA NSO PA NSO; QL (28 per 28 days) PA NSO; QL (120 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (90 per 30 days) PA NSO; QL (420 per 30 days) PA NSO; QL (60 per 28 days) PA NSO; QL (112 per 28 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 66 Effective: January 01, 2016 Drug Name TEMODAR INTRAVENOUS teniposide toposar intravenous topotecan intravenous TORISEL TREANDA TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION TRELSTAR INTRAMUSCULAR SYRINGE 11.25 MG/2 ML TRELSTAR INTRAMUSCULAR SYRINGE 22.5 MG/2 ML TRELSTAR INTRAMUSCULAR SYRINGE 3.75 MG/2 ML tretinoin (chemotherapy) TREXALL TYKERB VALSTAR VECTIBIX INTRAVENOUS SOLUTION VELCADE vincristine vincristine sulfate vinorelbine intravenous solution VOTRIENT Drug Tier Requirements/Limits (Teniposide) (Etoposide) (Hycamtin) 1 1 1 1 1 PA NSO; (vial only) PA BvD; QL (4 per 28 days) 1 1 QL (1 per 168 days) 1 QL (1 per 84 days) 1 QL (1 per 168 days) 1 (Tretinoin) (Vincristine Sulfate) (Vincristine Sulfate) (Navelbine) 1 1 1 1 1 1 1 1 1 1 (capsule: 10mg) PA BvD; ST PA NSO PA NSO PA BvD PA BvD XALKORI 1 XTANDI 1 YERVOY INTRAVENOUS SOLUTION ZALTRAP INTRAVENOUS SOLUTION ZELBORAF 1 1 1 ZOLADEX SUBCUTANEOUS IMPLANT 10.8 MG ZOLADEX SUBCUTANEOUS IMPLANT 3.6 MG 1 PA NSO; QL (120 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (120 per 30 days) PA NSO PA NSO PA NSO; QL (240 per 30 days) QL (1 per 84 days) 1 QL (1 per 28 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 67 Effective: January 01, 2016 Drug Name Drug Tier Requirements/Limits ZOLINZA ZYDELIG 1 1 ZYKADIA 1 ZYTIGA 1 PA NSO; QL (60 per 30 days) PA NSO; QL (140 per 28 days) PA NSO; QL (120 per 30 days) Anticholinergic Agents Antimuscarinics/Antispasmodics atropine 0.1 mg/ml syringe luer-jet syr atropine injection solution atropine injection syringe 0.05 mg/ml, 0.1 mg/ml propantheline (Atropine Sulfate) (Atropine Sulfate) (Atropine Sulfate) 1 1 1 (Propantheline Bromide) 1 (Carbatrol) 1 1 1 (Tegretol) (Tegretol XR) 1 1 (Carbamazepine) (Depakote Sprinkle) (Depakote ER) 1 1 1 1 1 (Depakote) 1 (Zarontin) (Felbatol) (Cerebyx) 1 1 1 1 1 1 1 Anticonvulsants Anticonvulsants APTIOM BANZEL carbamazepine oral capsule, er multiphase 12 hr carbamazepine oral suspension carbamazepine oral tablet extended release 12 hr carbamazepine oral tablet,chewable CELONTIN ORAL CAPSULE 300 MG DILANTIN divalproex oral capsule, sprinkle divalproex oral tablet extended release 24 hr divalproex oral tablet,delayed release (dr/ec) ethosuximide felbamate fosphenytoin FYCOMPA gabapentin oral capsule gabapentin oral solution gabapentin oral tablet 600 mg, 800 mg (Neurontin) (Neurontin) (Neurontin) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 68 Effective: January 01, 2016 Drug Name GABITRIL ORAL TABLET 12 MG, 16 MG GRALISE GRALISE 30-DAY STARTER PACK LAMICTAL ODT STARTER (BLUE) LAMICTAL ODT STARTER (GREEN) LAMICTAL ODT STARTER (ORANGE) LAMICTAL ORAL TABLET, CHEWABLE DISPERSIBLE 2 MG lamotrigine oral tablet lamotrigine oral tablet extended release 24hr lamotrigine oral tablet, chewable dispersible lamotrigine oral tablets,dose pack 25 mg (35) levetiracetam in nacl (iso-os) levetiracetam intravenous levetiracetam oral solution levetiracetam oral tablet levetiracetam oral tablet extended release 24 hr LYRICA ORAL CAPSULE LYRICA ORAL SOLUTION oxcarbazepine OXTELLAR XR PEGANONE phenobarbital oral elixir phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg phenobarbital oral tablet 30 mg phenobarbital sodium injection solution phenytoin oral suspension 125 mg/5 ml phenytoin oral phenytoin sodium phenytoin sodium extended Drug Tier Requirements/Limits 1 1 1 1 1 1 1 (Lamictal) (Lamictal XR) 1 1 (Lamictal) 1 (Lamictal (Blue)) 1 (Levetiracetam In Nacl (Iso-Os)) (Keppra) (Keppra) (Keppra) (Keppra XR) 1 1 1 1 1 (Phenobarbital) (Phenobarbital) 1 1 1 1 1 1 1 (Phenobarbital) (Phenobarbital Sodium) (Dilantin-125) (Dilantin) (Phenytoin Sodium) (Dilantin) 1 1 1 1 1 1 (Trileptal) ST; QL (90 per 30 days) ST; QL (78 per 30 days) QL (90 per 30 days) QL (900 per 30 days) QL (1500 per 30 days) QL (90 per 30 days) QL (200 per 30 days) QL (2 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 69 Effective: January 01, 2016 Drug Name POTIGA ORAL TABLET 200 MG, 300 MG, 400 MG POTIGA ORAL TABLET 50 MG primidone SABRIL TEGRETOL XR ORAL TABLET EXTENDED RELEASE 12 HR 100 MG tiagabine topiramate oral capsule, sprinkle topiramate oral capsule,sprinkle,er 24hr topiramate oral tablet TROKENDI XR valproate sodium valproic acid valproic acid (as sodium salt) oral solution 250 mg/5 ml VIMPAT INTRAVENOUS VIMPAT ORAL SOLUTION VIMPAT ORAL TABLET zonisamide Drug Tier Requirements/Limits (Mysoline) (Gabitril) (Topamax) (Qudexy XR) (Topamax) 1 QL (90 per 30 days) 1 1 1 1 QL (270 per 30 days) (Depacon) (Depakene) (Depakene) 1 1 1 1 1 1 1 1 QL (200 per 5 days) QL (1200 per 30 days) QL (60 per 30 days) (Zonegran) 1 1 1 1 (Aricept) (Donepezil HCl) (Razadyne ER) 1 1 1 QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) (Galantamine Hbr) (Razadyne) 1 1 1 QL (200 per 30 days) QL (60 per 30 days) QL (28 per 28 days) 1 QL (30 per 30 days) (Exelon) 1 1 QL (60 per 30 days) (Amitriptyline HCl) (Amoxapine) 1 1 Antidementia Agents Antidementia Agents donepezil oral tablet donepezil oral tablet,disintegrating galantamine oral capsule,ext rel. pellets 24 hr galantamine oral solution galantamine oral tablet NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE PACK NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 24HR NAMZARIC rivastigmine tartrate Antidepressants Antidepressants amitriptyline amoxapine PA NSO-HRM You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 70 Effective: January 01, 2016 Drug Name BRINTELLIX bupropion hcl oral tablet bupropion hcl oral tablet extended release bupropion hcl oral tablet extended release 24 hr citalopram oral solution Drug Tier Requirements/Limits (Wellbutrin) (Wellbutrin SR) (Wellbutrin XL) (Citalopram Hydrobromide) (Celexa) (Anafranil) (Norpramin) 1 1 1 1 1 1 QL (30 per 30 days) citalopram oral tablet 1 PA NSO-HRM clomipramine 1 desipramine oral DESVENLAFAXINE FUMARATE 1 QL (30 per 30 days) (Doxepin HCl) 1 PA NSO-HRM doxepin oral (Irenka) 1 QL (60 per 30 days) duloxetine oral capsule,delayed release(dr/ec) 20 mg, 60 mg (Irenka) 1 QL (30 per 30 days) duloxetine oral capsule,delayed release(dr/ec) 30 mg, 40 mg EMSAM 1 QL (30 per 30 days) (Lexapro) 1 escitalopram oxalate FETZIMA 1 (Prozac) 1 fluoxetine oral capsule (Prozac Weekly) 1 fluoxetine oral capsule,delayed release(dr/ec) (Fluoxetine HCl) 1 fluoxetine oral solution (Fluoxetine HCl) 1 fluoxetine oral tablet 10 mg, 20 mg FLUOXETINE ORAL TABLET 60 MG 1 (Fluvoxamine Maleate) 1 fluvoxamine (Tofranil) 1 PA NSO-HRM imipramine hcl (Tofranil-Pm) 1 PA NSO-HRM imipramine pamoate (Maprotiline HCl) 1 maprotiline MARPLAN 1 (Remeron) 1 mirtazapine (Nefazodone HCl) 1 nefazodone (Pamelor) 1 nortriptyline oral capsule (Nortriptyline HCl) 1 nortriptyline oral solution (Symbyax) 1 olanzapine-fluoxetine (Paxil) 1 paroxetine hcl oral tablet 1 paroxetine hcl oral tablet extended release (Paxil CR) 24 hr PAXIL ORAL SUSPENSION 1 You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 71 Effective: January 01, 2016 Drug Name perphenazine-amitriptyline phenelzine PRISTIQ protriptyline sertraline oral concentrate sertraline oral tablet SILENOR SURMONTIL tranylcypromine trazodone venlafaxine oral capsule,extended release 24hr venlafaxine oral tablet venlafaxine oral tablet extended release 24hr 150 mg, 37.5 mg, 75 mg venlafaxine oral tablet extended release 24hr 225 mg VIIBRYD Drug Tier Requirements/Limits (Perphenazine/Amitripty line HCl) (Nardil) 1 (Parnate) (Trazodone HCl) (Effexor XR) 1 1 1 1 1 1 1 1 1 1 (Venlafaxine HCl) (Venlafaxine HCl) 1 1 (Venlafaxine HCl) 1 (Protriptyline HCl) (Zoloft) (Zoloft) PA NSO-HRM QL (30 per 30 days) QL (30 per 30 days) PA NSO-HRM 1 Antidiabetic Agents Antidiabetic Agents, Miscellaneous (Precose) 1 QL (90 per 30 days) acarbose ACTOPLUS MET XR 1 QL (60 per 30 days) CYCLOSET 1 QL (180 per 30 days) GLYSET 1 QL (90 per 30 days) GLYXAMBI 1 ST; QL (30 per 30 days) INVOKAMET ORAL TABLET 1501 ST; QL (60 per 30 days) 1,000 MG, 150-500 MG, 50-1,000 MG INVOKAMET ORAL TABLET 50-500 1 ST; QL (120 per 30 MG days) INVOKANA ORAL TABLET 100 MG 1 ST; QL (60 per 30 days) INVOKANA ORAL TABLET 300 MG 1 ST; QL (30 per 30 days) JANUMET 1 QL (60 per 30 days) JANUMET XR ORAL TABLET, ER 1 QL (30 per 30 days) MULTIPHASE 24 HR 100-1,000 MG, 50500 MG JANUMET XR ORAL TABLET, ER 1 QL (60 per 30 days) MULTIPHASE 24 HR 50-1,000 MG JANUVIA 1 QL (30 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 72 Effective: January 01, 2016 Drug Name Drug Tier Requirements/Limits JARDIANCE JENTADUETO KAZANO KORLYM metformin oral tablet 1,000 mg metformin oral tablet 500 mg metformin oral tablet 850 mg metformin oral tablet extended release 24 hr 500 mg metformin oral tablet extended release 24 hr 750 mg metformin oral tablet extended release 24hr nateglinide NESINA OSENI pioglitazone pioglitazone-glimepiride pioglitazone-metformin PRANDIMET repaglinide SYMLINPEN 120 SYMLINPEN 60 TRADJENTA TRULICITY VICTOZA 1 1 1 1 (Glucophage) (Glucophage) (Glucophage) (Glucophage XR) 1 1 1 1 ST; QL (30 per 30 days) QL (60 per 30 days) QL (60 per 30 days) PA; QL (112 per 28 days) QL (60 per 30 days) QL (150 per 30 days) QL (90 per 30 days) QL (120 per 30 days) (Glucophage XR) 1 QL (90 per 30 days) (Fortamet) 1 QL (60 per 30 days) (Starlix) 1 1 1 1 1 1 1 1 1 1 1 1 1 QL (90 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (90 per 30 days) QL (150 per 30 days) QL (240 per 30 days) QL (10.8 per 28 days) QL (6 per 28 days) QL (30 per 30 days) ST; QL (4 per 28 days) ST; QL (9 per 28 days) 1 QL (40 per 28 days) 1 1 1 1 1 1 1 1 QL (40 per 28 days) QL (30 per 28 days) QL (40 per 28 days) QL (40 per 28 days) QL (40 per 28 days) QL (40 per 28 days) QL (30 per 28 days) QL (40 per 28 days) (Actos) (Duetact) (Actoplus Met) (Prandin) Insulins HUMULIN R U-500 "CONCENTRATED" LANTUS LANTUS SOLOSTAR NOVOLIN 70/30 NOVOLIN N NOVOLIN R NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX 70-30 You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 73 Effective: January 01, 2016 Drug Name Drug Tier Requirements/Limits NOVOLOG MIX 70-30 FLEXPEN NOVOLOG PENFILL TOUJEO SOLOSTAR 1 1 1 QL (30 per 28 days) QL (30 per 28 days) (Amaryl) (Amaryl) (Glucotrol) (Glucotrol) (Glucotrol XL) 1 1 1 1 1 QL (30 per 30 days) QL (60 per 30 days) QL (120 per 30 days) QL (60 per 30 days) QL (60 per 30 days) (Glucotrol XL) 1 QL (30 per 30 days) 1 QL (240 per 30 days) glipizide-metformin oral tablet 2.5-500 mg, 5-500 mg glyburide micronized oral tablet 1.5 mg (Glipizide/Metformin HCl) (Glipizide/Metformin HCl) (Glynase) 1 QL (120 per 30 days) 1 glyburide micronized oral tablet 3 mg (Glynase) 1 glyburide micronized oral tablet 6 mg (Glynase) 1 glyburide oral tablet 1.25 mg (Glyburide) 1 glyburide oral tablet 2.5 mg (Glyburide) 1 glyburide oral tablet 5 mg (Glyburide) 1 glyburide-metformin oral tablet 1.25-250 mg glyburide-metformin oral tablet 2.5-500 mg, 5-500 mg tolazamide oral tablet 250 mg tolazamide oral tablet 500 mg tolbutamide (Glucovance) 1 (Glucovance) 1 (Tolazamide) (Tolazamide) (Tolbutamide) 1 1 1 PA-HRM; QL (400 per 30 days) PA-HRM; QL (180 per 30 days) PA-HRM; QL (120 per 30 days) PA-HRM; QL (280 per 30 days) PA-HRM; QL (240 per 30 days) PA-HRM; QL (120 per 30 days) PA-HRM; QL (240 per 30 days) PA-HRM; QL (120 per 30 days) QL (120 per 30 days) QL (60 per 30 days) QL (180 per 30 days) Sulfonylureas glimepiride oral tablet 1 mg, 2 mg glimepiride oral tablet 4 mg glipizide oral tablet 10 mg glipizide oral tablet 5 mg glipizide oral tablet extended release 24hr 10 mg glipizide oral tablet extended release 24hr 2.5 mg, 5 mg glipizide-metformin oral tablet 2.5-250 mg Antifungals Antifungals ABELCET 1 PA BvD AMBISOME 1 PA BvD You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 74 Effective: January 01, 2016 Drug Name amphotericin b CANCIDAS ciclopirox topical cream ciclopirox topical gel ciclopirox topical shampoo ciclopirox topical solution ciclopirox topical suspension ciclopirox-ure-camph-menth-euc clotrimazole mucous membrane clotrimazole topical cream clotrimazole topical solution clotrimazole-betamethasone topical cream clotrimazole-betamethasone topical lotion Drug Tier Requirements/Limits (Amphotericin B) (Ciclodan) (Loprox) (Loprox) (Penlac) (Ciclopirox Olamine) (Ciclodan) (Clotrimazole) (Clotrimazole) (Lotrimin) (Lotrisone) (Clotrimazole/Betameth asone Dip) (Econazole Nitrate) 1 1 1 1 1 1 1 1 1 1 1 1 1 PA BvD 1 econazole topical EXELDERM 1 (Diflucan) 1 fluconazole 1 fluconazole in dextrose(iso-o) intravenous (Fluconazole In Nacl,Iso-Osm) piggyback 1 fluconazole in nacl (iso-osm) intravenous (Fluconazole In Nacl,Iso-Osm) piggyback 400 mg/200 ml (Ancobon) 1 flucytosine (Grifulvin V) 1 griseofulvin microsize oral tablet (Sporanox) 1 itraconazole (Ketoconazole) 1 ketoconazole oral (Ketoconazole) 1 ketoconazole topical cream (Nizoral) 1 ketoconazole topical shampoo (Monistat 3) 1 miconazole nitrate vaginal suppository 200 mg NOXAFIL 1 NYSTATIN (BULK) POWDER 1 1 BILLION UNIT, 10 BILLION UNIT (Nystatin) 1 nystatin oral (Nystatin) 1 nystatin oral (Nystatin) 1 nystatin topical (Nystatin/Triamcin) 1 nystatin-triamcinolone SPORANOX ORAL SOLUTION 1 (Lamisil) 1 terbinafine hcl oral (Vfend IV) 1 voriconazole intravenous You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 75 Effective: January 01, 2016 Drug Name voriconazole oral Drug Tier Requirements/Limits (Vfend) 1 Antihistamines Antihistamines carbinoxamine maleate (Carbinoxamine Maleate) (Clemastine Fumarate) clemastine oral tablet 2.68 mg (Cyproheptadine HCl) cyproheptadine diphenhydramine hcl injection solution 50 (Diphenhydramine HCl) mg/ml (Diphenhydramine HCl) diphenhydramine hcl injection syringe (Xyzal) levocetirizine (Promethazine HCl) promethazine oral syrup 1 PA-HRM 1 1 1 PA-HRM PA-HRM 1 1 1 PA-HRM Anti-Infectives (Skin And Mucous Membrane) Anti-Infectives (Skin And Mucous Membrane) AVC VAGINAL clindamycin phosphate vaginal metronidazole vaginal terconazole vaginal cream terconazole vaginal suppository (Cleocin) (Metrogel-Vaginal) (Terazol 7) (Terconazole) 1 1 1 1 1 Antimigraine Agents Antimigraine Agents (D.H.E.45) 1 QL (30 per 28 days) dihydroergotamine injection (Migranal) 1 QL (8 per 28 days) dihydroergotamine nasal ERGOMAR 1 QL (40 per 28 days) (Amerge) 1 QL (18 per 28 days) naratriptan (Maxalt) 1 QL (18 per 28 days) rizatriptan oral tablet (Maxalt Mlt) 1 QL (18 per 28 days) rizatriptan oral tablet,disintegrating (Imitrex) 1 QL (12 per 28 days) sumatriptan nasal spray (Imitrex) 1 QL (18 per 28 days) sumatriptan oral tablet (Imitrex) 1 QL (4 per 28 days) sumatriptan succinate subcutaneous cartridge 6 mg/0.5 ml (Sumatriptan Succinate) 1 QL (4 per 28 days) sumatriptan succinate subcutaneous pen injector 4 mg/0.5 ml (Imitrex) 1 QL (4 per 28 days) sumatriptan succinate subcutaneous pen injector 6 mg/0.5 ml (Imitrex) 1 QL (4 per 28 days) sumatriptan succinate subcutaneous solution (Zomig) 1 QL (12 per 28 days) zolmitriptan oral tablet You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 76 Effective: January 01, 2016 Drug Name zolmitriptan oral tablet,disintegrating Drug Tier Requirements/Limits (Zomig Zmt) 1 QL (12 per 28 days) Antimycobacterials Antimycobacterials CAPASTAT dapsone ethambutol isoniazid oral solution isoniazid oral tablet PASER PRIFTIN pyrazinamide rifabutin rifampin rifampin RIFATER SIRTURO (Dapsone) (Myambutol) (Isoniazid) (Isoniazid) (Pyrazinamide) (Mycobutin) (Rifadin) (Rifadin) TRECATOR 1 1 1 1 1 1 1 1 1 1 1 1 1 PA; QL (188 per 168 days) 1 Antinausea Agents Antinausea Agents (Dimenhydrinate) 1 dimenhydrinate injection solution (Marinol) 1 dronabinol EMEND INTRAVENOUS 1 QL (2 per 28 days) EMEND ORAL 1 PA BvD (Granisetron HCl/PF) 1 granisetron (pf) intravenous solution (Granisetron HCl) 1 granisetron hcl intravenous solution 1 mg/ml (1 ml) (Granisetron HCl) 1 PA BvD granisetron hcl oral (Antivert) 1 meclizine oral tablet 12.5 mg, 25 mg (Zofran Odt) 1 PA BvD ondansetron (Ondansetron HCl/PF) 1 ondansetron hcl (pf) injection (Zofran) 1 PA BvD ondansetron hcl oral (Compazine) 1 prochlorperazine (Prochlorperazine 1 prochlorperazine edisylate injection Edisylate) solution (Compazine) 1 prochlorperazine maleate oral (Phenergan) 1 PA-HRM promethazine hcl (Promethazine HCl) 1 PA-HRM promethazine oral tablet You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 77 Effective: January 01, 2016 Drug Name promethazine rectal TRANSDERM-SCOP Drug Tier Requirements/Limits (Phenergan) 1 1 PA-HRM QL (10 per 30 days) Antiparasite Agents Antiparasite Agents ALBENZA ALINIA atovaquone atovaquone-proguanil chloroquine phosphate oral COARTEM DARAPRIM hydroxychloroquine oral ivermectin oral mefloquine NEBUPENT paromomycin PENTAM PRIMAQUINE quinine sulfate (Mepron) (Malarone) (Chloroquine Phosphate) (Plaquenil) (Stromectol) (Mefloquine HCl) (Paromomycin Sulfate) (Qualaquin) 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 PA BvD QL (90 per 30 days) PA; QL (42 per 7 days) Antiparkinsonian Agents Antiparkinsonian Agents (Amantadine HCl) 1 amantadine hcl oral APOKYN 1 QL (60 per 30 days) AZILECT 1 (Benztropine Mesylate) 1 PA-HRM benztropine oral (Parlodel) 1 bromocriptine (Cabergoline) 1 cabergoline (Lodosyn) 1 carbidopa (Sinemet CR) 1 carbidopa-levodopa oral tablet (Sinemet CR) 1 carbidopa-levodopa oral tablet extended release (Stalevo 50) 1 carbidopa-levodopa-entacapone (Comtan) 1 entacapone NEUPRO 1 ST; QL (30 per 30 days) (Mirapex) 1 pramipexole oral tablet (Requip) 1 ropinirole oral tablet 1 ropinirole oral tablet extended release 24 (Requip XL) hr You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 78 Effective: January 01, 2016 Drug Name selegiline hcl oral capsule selegiline hcl oral tablet trihexyphenidyl Drug Tier Requirements/Limits (Eldepryl) (Selegiline HCl) (Trihexyphenidyl HCl) 1 1 1 PA-HRM 1 QL (90 per 30 days) Antipsychotic Agents Antipsychotic Agents ABILIFY DISCMELT ORAL TABLET,DISINTEGRATING 10 MG ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING aripiprazole oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 5 mg aripiprazole oral tablet 2 mg chlorpromazine clozapine oral tablet 100 mg clozapine oral tablet 200 mg clozapine oral tablet 25 mg, 50 mg clozapine oral tablet,disintegrating FANAPT ORAL TABLET FANAPT ORAL TABLETS,DOSE PACK fluphenazine decanoate fluphenazine hcl GEODON INTRAMUSCULAR haloperidol haloperidol decanoate intramuscular solution 100 mg/ml haloperidol decanoate intramuscular solution 50 mg/ml haloperidol lactate INVEGA ORAL TABLET EXTENDED RELEASE 24HR 1.5 MG, 3 MG, 9 MG 1 1 QL (1 per 28 days) (Abilify) 1 QL (30 per 30 days) (Abilify) (Chlorpromazine HCl) (Clozaril) (Clozaril) (Clozaril) (Fazaclo) 1 1 1 1 1 1 1 1 QL (60 per 30 days) (Fluphenazine Decanoate) (Fluphenazine HCl) 1 (Haloperidol) (Haloperidol Decanoate) 1 1 1 1 (Haldol Decanoate 50) 1 (Haloperidol Lactate) 1 1 QL (270 per 30 days) QL (135 per 30 days) QL (90 per 30 days) ST ST; QL (60 per 30 days) ST; QL (8 per 28 days) QL (6 per 28 days) ST; QL (30 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 79 Effective: January 01, 2016 Drug Name INVEGA ORAL TABLET EXTENDED RELEASE 24HR 6 MG INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.75 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 156 MG/ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 234 MG/1.5 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 39 MG/0.25 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 78 MG/0.5 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 410 MG/1.315 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 546 MG/1.75 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 819 MG/2.625 ML LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG LATUDA ORAL TABLET 80 MG loxapine succinate olanzapine intramuscular olanzapine oral tablet olanzapine oral tablet,disintegrating 10 mg, 15 mg, 5 mg olanzapine oral tablet,disintegrating 20 mg ORAP perphenazine quetiapine RISPERDAL CONSTA risperidone oral solution Drug Tier Requirements/Limits 1 ST; QL (60 per 30 days) 1 QL (0.75 per 28 days) 1 QL (1 per 28 days) 1 QL (1.5 per 28 days) 1 QL (0.25 per 28 days) 1 QL (0.5 per 28 days) 1 QL (0.875 per 84 days) 1 QL (1.315 per 84 days) 1 QL (1.75 per 84 days) 1 QL (2.625 per 84 days) 1 ST; QL (30 per 30 days) ST; QL (60 per 30 days) (Loxapine Succinate) (Zyprexa) (Zyprexa) (Zyprexa Zydis) 1 1 1 1 1 QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) (Zyprexa Zydis) 1 QL (31 per 30 days) 1 1 1 1 1 QL (90 per 30 days) QL (4 per 28 days) QL (480 per 30 days) (Perphenazine) (Seroquel) (Risperdal) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 80 Effective: January 01, 2016 Drug Name risperidone oral tablet risperidone oral tablet,disintegrating 0.25 mg, 0.5 mg, 1 mg, 2 mg risperidone oral tablet,disintegrating 3 mg, 4 mg SAPHRIS (BLACK CHERRY) SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG, 300 MG, 400 MG, 50 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 200 MG thioridazine thiothixene trifluoperazine VERSACLOZ Drug Tier Requirements/Limits (Risperdal) (Risperdal M-Tab) 1 1 QL (60 per 30 days) QL (60 per 30 days) (Risperdal M-Tab) 1 QL (120 per 30 days) 1 1 ST; QL (60 per 30 days) ST; QL (60 per 30 days) 1 ST; QL (30 per 30 days) 1 1 1 1 PA NSO-HRM (Thioridazine HCl) (Thiothixene) (Trifluoperazine HCl) (Geodon) ziprasidone hcl ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG, 405 MG 1 1 ST; QL (540 per 30 days) QL (60 per 30 days) Antivirals (Systemic) Antiretrovirals (Ziagen) 1 abacavir (Trizivir) 1 abacavir-lamivudine-zidovudine APTIVUS ORAL CAPSULE 1 APTIVUS ORAL SOLUTION 1 ATRIPLA 1 COMPLERA 1 CRIXIVAN ORAL CAPSULE 200 MG, 1 400 MG (Videx EC) 1 didanosine EDURANT 1 EMTRIVA 1 EPIVIR HBV ORAL SOLUTION 1 EPZICOM 1 EVOTAZ 1 FUZEON SUBCUTANEOUS 1 INTELENCE ORAL TABLET 100 MG, 1 200 MG You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 81 Effective: January 01, 2016 Drug Name INTELENCE ORAL TABLET 25 MG INVIRASE ISENTRESS ORAL POWDER IN PACKET ISENTRESS ORAL TABLET ISENTRESS ORAL TABLET,CHEWABLE KALETRA ORAL SOLUTION KALETRA ORAL TABLET 100-25 MG KALETRA ORAL TABLET 200-50 MG lamivudine lamivudine-zidovudine LEXIVA ORAL SUSPENSION LEXIVA ORAL TABLET nevirapine oral suspension nevirapine oral tablet nevirapine oral tablet extended release 24 hr NORVIR PREZCOBIX PREZISTA ORAL SUSPENSION PREZISTA ORAL TABLET 150 MG, 75 MG PREZISTA ORAL TABLET 400 MG, 600 MG, 800 MG RESCRIPTOR RETROVIR INTRAVENOUS REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG REYATAZ ORAL POWDER IN PACKET SELZENTRY stavudine STRIBILD SUSTIVA TIVICAY TRIUMEQ TRUVADA VIDEX 2 GRAM PEDIATRIC Drug Tier Requirements/Limits 1 1 1 1 1 (Epivir) (Combivir) (Viramune) (Viramune) (Viramune XR) 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 (Zerit) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 82 Effective: January 01, 2016 Drug Name VIDEX 4 GRAM PEDIATRIC VIRACEPT ORAL TABLET VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 100 MG VIREAD VITEKTA ZIAGEN ORAL SOLUTION zidovudine oral capsule zidovudine oral syrup zidovudine oral tablet Drug Tier Requirements/Limits 1 1 1 (Retrovir) (Retrovir) (Zidovudine) 1 1 1 1 1 1 Antivirals, Miscellaneous foscarnet RELENZA DISKHALER rimantadine SYNAGIS TAMIFLU (Foscavir) (Flumadine) 1 1 1 1 1 PA BvD 1 1 1 PA; QL (30 per 30 days) PA; QL (28 per 28 days) PA; QL (28 per 28 days) 1 1 1 1 1 PA NSO PA PA PA PA NSO; QL (4 per 28 days) Hcv Antivirals HARVONI OLYSIO SOVALDI Interferons INTRON A INJECTION PEGASYS PEGASYS PROCLICK PEGINTRON SYLATRON Nucleosides And Nucleotides (Zovirax) 1 acyclovir oral capsule (Zovirax) 1 acyclovir oral suspension 200 mg/5 ml (Zovirax) 1 acyclovir oral tablet (Acyclovir Sodium) 1 PA BvD acyclovir sodium intravenous solution (Hepsera) 1 adefovir BARACLUDE ORAL SOLUTION 1 (Vistide) 1 cidofovir (Baraclude) 1 entecavir (Famvir) 1 famciclovir (Cytovene) 1 PA BvD ganciclovir sodium You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 83 Effective: January 01, 2016 Drug Name ribavirin oral capsule 200 mg ribavirin oral tablet 200 mg, 400 mg, 600 mg ribavirin oral tablets,dose pack 200 mg (7)- 400 mg (7), 400-400 mg (28)-mg (28), 600-400 mg (28)-mg (28) TYZEKA valacyclovir VALCYTE ORAL RECON SOLN valganciclovir VIRAZOLE Drug Tier Requirements/Limits (Rebetol) (Copegus) 1 1 (Ribatab) 1 1 1 1 1 1 PA BvD (Lovenox) (Lovenox) 1 1 1 1 QL (36 per 30 days) QL (36 per 30 days) (Lovenox) 1 QL (27.2 per 30 days) (Lovenox) 1 QL (34 per 30 days) (Lovenox) 1 QL (18 per 30 days) (Lovenox) 1 QL (13.6 per 30 days) (Lovenox) 1 QL (20.4 per 30 days) (Lovenox) 1 QL (27.2 per 30 days) (Arixtra) 1 QL (24 per 30 days) (Arixtra) 1 QL (15 per 30 days) (Arixtra) 1 QL (12 per 30 days) (Arixtra) 1 QL (18 per 30 days) (Valtrex) (Valcyte) Blood Products/Modifiers/Volume Expanders Anticoagulants CEPROTIN (BLUE BAR) ELIQUIS enoxaparin subcutaneous solution enoxaparin subcutaneous syringe 100 mg/ml enoxaparin subcutaneous syringe 120 mg/0.8 ml enoxaparin subcutaneous syringe 150 mg/ml enoxaparin subcutaneous syringe 30 mg/0.3 ml enoxaparin subcutaneous syringe 40 mg/0.4 ml enoxaparin subcutaneous syringe 60 mg/0.6 ml enoxaparin subcutaneous syringe 80 mg/0.8 ml fondaparinux subcutaneous syringe 10 mg/0.8 ml fondaparinux subcutaneous syringe 2.5 mg/0.5 ml fondaparinux subcutaneous syringe 5 mg/0.4 ml fondaparinux subcutaneous syringe 7.5 mg/0.6 ml You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 84 Effective: January 01, 2016 Drug Name heparin (porcine) in 5 % dex intravenous parenteral solution 12,500 unit/250 ml, 20,000 unit/500 ml (40 unit/ml), 25,000 unit/500 ml (50 unit/ml) heparin (porcine) in 5 % dex intravenous parenteral solution 25,000 unit/250 ml(100 unit/ml) heparin (porcine) in nacl (pf) intravenous parenteral solution 1,000 unit/500 ml heparin (porcine) injection solution 1,000 unit/ml, 20,000 unit/ml, 5,000 unit/ml heparin (porcine) injection solution 10,000 unit/ml heparin sodium,porcine-pf intravenous syringe 10 unit/ml heparin, porcine (pf) injection heparin, porcine (pf) intravenous syringe heparin-0.45% nacl 25,000 units/250 ml (100 units/ml) bag latex-free, inner heparin-d5w 25,000 units/250 ml (100 units/ml) bag excel container IPRIVASK jantoven PRADAXA SAVAYSA warfarin XARELTO Drug Tier Requirements/Limits (Heparin Sodium,Porcine/D5W) 1 (Heparin Sod,Pork In 0.45% NaCl) 1 (Heparin Sodium,Porcine/Ns/PF) (Heparin Sodium,Porcine) (Heparin Sodium,Porcine) (Monoject Prefill Advanced) (Monoject Prefill Advanced) (Monoject Prefill Advanced) (Heparin Sod,Pork In 0.45% NaCl) (Heparin Sodium,Porcine/D5W) 1 (Coumadin) (Coumadin) 1 1 PA BvD; (PA for ESRD Only) PA BvD 1 1 PA BvD; (PA for ESRD Only) 1 1 1 1 1 1 1 1 1 PA; QL (24 per 28 days) ST; QL (60 per 30 days) ST Blood Formation Modifiers CINRYZE 1 PA EPOGEN INJECTION SOLUTION 1 PA; QL (12 per 28 days) 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML GRANIX 1 LEUKINE INJECTION RECON SOLN 1 MIRCERA INJECTION SYRINGE 100 1 PA; QL (0.6 per 28 days) MCG/0.3 ML, 50 MCG/0.3 ML, 75 MCG/0.3 ML You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 85 Effective: January 01, 2016 Drug Name Drug Tier Requirements/Limits MOZOBIL NEULASTA SUBCUTANEOUS SYRINGE NEUMEGA NEUPOGEN PROCRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 3,000 UNIT/ML, 4,000 UNIT/ML PROCRIT INJECTION SOLUTION 20,000 UNIT/ML PROCRIT INJECTION SOLUTION 40,000 UNIT/ML PROMACTA 1 1 1 1 1 PA; QL (12 per 28 days) 1 PA; QL (12 per 28 days) 1 PA; QL (6 per 28 days) 1 PA; QL (30 per 30 days) Hematologic Agents, Miscellaneous aminocaproic acid oral solution aminocaproic acid oral tablet anagrelide protamine (Aminocaproic Acid) (Amicar) (Agrylin) (Protamine Sulfate) 1 1 1 1 tranexamic acid intravenous tranexamic acid oral (Tranexamic Acid) (Lysteda) 1 1 PA BvD; (PA for ESRD Only) QL (30 per 30 days) Platelet-Aggregation Inhibitors AGGRENOX BRILINTA cilostazol clopidogrel EFFIENT pentoxifylline (Pletal) (Plavix) (Pentoxifylline) 1 1 1 1 1 1 QL (60 per 30 days) QL (30 per 30 days) Volume Expanders ALBUKED-25 ALBUKED-5 ALBUMIN, HUMAN 25 % ALBUMIN, HUMAN 5 % ALBUMINAR 25 % ALBUMINAR 5 % ALBURX (HUMAN) 5 % ALBUTEIN 25 % 1 1 1 1 1 1 1 1 You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 86 Effective: January 01, 2016 Drug Name Drug Tier Requirements/Limits ALBUTEIN 5 % BUMINATE 25 % BUMINATE 5 % FLEXBUMIN 25 % FLEXBUMIN 5 % KEDBUMIN PLASBUMIN 25 % PLASBUMIN 5 % 1 1 1 1 1 1 1 1 Caloric Agents Caloric Agents AMINO ACIDS 15 % AMINOSYN 10 % AMINOSYN 3.5 % AMINOSYN 7 % AMINOSYN 7 % WITH ELECTROLYTES AMINOSYN 8.5 % AMINOSYN 8.5 %-ELECTROLYTES AMINOSYN II 10 % AMINOSYN II 15 % AMINOSYN II 7 % AMINOSYN II 8.5 % AMINOSYN II 8.5 %-ELECTROLYTES AMINOSYN M 3.5 % AMINOSYN-HBC 7% AMINOSYN-PF 10 % AMINOSYN-PF 7 % (SULFITE-FREE) AMINOSYN-RF 5.2 % CLINIMIX 5%/D15W SULFITE FREE CLINIMIX 5%/D25W SULFITE-FREE CLINIMIX 2.75%/D5W SULFIT FREE CLINIMIX 4.25%/D10W SULF FREE CLINIMIX 4.25%/D5W SULFIT FREE CLINIMIX 4.25%-D20W SULF-FREE CLINIMIX 4.25%-D25W SULF-FREE CLINIMIX 5%-D20W(SULFITE-FREE) CLINIMIX E 2.75%/D10W SUL FREE CLINIMIX E 2.75%/D5W SULF FREE 1 1 1 1 1 PA BvD PA BvD PA BvD PA BvD PA BvD 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 87 Effective: January 01, 2016 Drug Name CLINIMIX E 4.25%/D10W SUL FREE CLINIMIX E 4.25%/D25W SUL FREE CLINIMIX E 4.25%/D5W SULF FREE CLINIMIX E 5%/D15W SULFIT FREE CLINIMIX E 5%/D20W SULFIT FREE CLINIMIX E 5%/D25W SULFIT FREE CLINISOL SF 15 % cysteine (l-cysteine) intravenous solution d10 %-0.9 % sodium chloride dextrose 10 % in water (d10w) intravenous dextrose 2.5 % in water(d2.5w) dextrose 20 % in water (d20w) dextrose 25 % in water (d25w) dextrose 40 % in water (d40w) dextrose 5 % in ringers dextrose 5 % in water (d5w) intravenous dextrose 50 % in water (d50w) dextrose 70 % in water (d70w) Drug Tier Requirements/Limits (Cysteine HCl) (Dextrose 10 % and 0.9 % NaCl) (Dextrose 10 % in Water) (Dextrose 2.5 % in Water) (Dextrose 20 % in Water) (Dextrose 25 % in Water) (Dextrose 40 % in Water) (Dextrose 5% In Ringers) (Dextrose 5 % in Water) (Dextrose 50 % in Water) (Dextrose 70 % in Water) FREAMINE HBC 6.9 % FREAMINE III 10 % HEPATAMINE 8% HEPATASOL 8 % INTRALIPID INTRAVENOUS EMULSION 20 %, 30 % KABIVEN LIPOSYN II LIPOSYN III NEPHRAMINE 5.4 % NUTRILIPID PERIKABIVEN 1 1 1 1 1 1 1 1 1 PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD 1 PA BvD 1 PA BvD 1 PA BvD 1 PA BvD 1 PA BvD 1 1 1 PA BvD 1 PA BvD 1 1 1 1 1 PA BvD PA BvD PA BvD PA BvD PA BvD 1 1 1 1 1 1 PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 88 Effective: January 01, 2016 Drug Name Drug Tier Requirements/Limits PREMASOL 10 % PREMASOL 6 % PROCALAMINE 3% PROSOL 20 % TRAVASOL 10 % TROPHAMINE 10 % TROPHAMINE 6% 1 1 1 1 1 1 1 PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD Cardiovascular Agents Alpha-Adrenergic Agents clonidine hcl oral tablet clonidine hcl-chlorthalidone clonidine transdermal patch weekly 0.1 mg/24 hr, 0.2 mg/24 hr clonidine transdermal patch weekly 0.3 mg/24 hr doxazosin guanfacine oral tablet midodrine NORTHERA phenylephrine hcl injection prazosin oral (Catapres) (Clonidine HCl/Chlorthalidone) (Catapres-Tts 1) 1 1 1 QL (4 per 28 days) (Catapres-Tts 1) 1 QL (8 per 28 days) (Cardura) (Tenex) (Midodrine HCl) 1 1 1 1 (Vazculep) (Minipress) PA-HRM PA; QL (180 per 30 days) 1 1 Angiotensin Ii Receptor Antagonists BENICAR BENICAR HCT candesartan candesartan-hydrochlorothiazid EDARBI EDARBYCLOR irbesartan irbesartan-hydrochlorothiazide losartan losartan-hydrochlorothiazide telmisartan telmisartan-hydrochlorothiazid TEVETEN HCT TRIBENZOR (Atacand) (Atacand HCT) (Avapro) (Avalide) (Cozaar) (Hyzaar) (Micardis) (Micardis HCT) 1 1 1 1 1 1 1 1 1 1 1 1 1 1 ST ST ST ST ST ST You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 89 Effective: January 01, 2016 Drug Name valsartan valsartan-hydrochlorothiazide Drug Tier Requirements/Limits (Diovan) (Diovan HCT) 1 1 Angiotensin-Converting Enzyme Inhibitors benazepril benazepril-hydrochlorothiazide captopril captopril-hydrochlorothiazide enalapril maleate enalaprilat intravenous injectable enalapril-hydrochlorothiazide fosinopril fosinopril-hydrochlorothiazide lisinopril lisinopril-hydrochlorothiazide moexipril moexipril-hydrochlorothiazide perindopril erbumine quinapril quinapril-hydrochlorothiazide ramipril trandolapril (Lotensin) (Lotensin HCT) (Captopril) (Captopril/Hydrochlorot hiazide) (Vasotec) (Enalaprilat Dihydrate) (Vaseretic) (Fosinopril Sodium) (Fosinopril/Hydrochloro thiazide) (Zestril) (Zestoretic) (Moexipril HCl) (Moexipril/Hydrochlorot hiazide) (Aceon) (Accupril) (Accuretic) (Altace) (Mavik) 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Antiarrhythmic Agents amiodarone hcl oral tablet 100 mg, 200 mg, 400 mg amiodarone intravenous amiodarone oral disopyramide phosphate oral capsule flecainide lidocaine (pf) intravenous syringe 50 mg/5 ml (1 %) lidocaine in 5 % dextrose (pf) intravenous parenteral solution 8 mg/ml (0.8 %) mexiletine MULTAQ procainamide injection (Cordarone) 1 (Amiodarone HCl) (Cordarone) (Norpace) (Tambocor) (Lidocaine HCl/PF) 1 1 1 1 1 (Lidocaine HCl/D5w/PF) (Mexiletine HCl) 1 (Procainamide HCl) 1 1 1 You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 90 Effective: January 01, 2016 Drug Name propafenone oral capsule,extended release 12 hr propafenone oral tablet quinidine gluconate oral quinidine sulfate TIKOSYN Drug Tier Requirements/Limits (Rythmol SR) 1 (Rythmol) (Quinidine Gluconate) (Quinidine Sulfate) 1 1 1 1 Beta-Adrenergic Blocking Agents acebutolol oral atenolol atenolol-chlorthalidone betaxolol oral bisoprolol fumarate bisoprolol-hydrochlorothiazide BYSTOLIC carvedilol esmolol intravenous labetalol intravenous solution labetalol oral metoprolol succinate metoprolol ta-hydrochlorothiaz metoprolol tartrate intravenous metoprolol tartrate oral nadolol pindolol propranolol intravenous propranolol oral capsule,extended release 24 hr propranolol oral solution propranolol oral tablet propranolol-hydrochlorothiazid sotalol hcl oral tablet 120 mg, 160 mg, 240 mg, 80 mg sotalol oral timolol maleate oral (Sectral) (Tenormin) (Tenoretic 50) (Kerlone) (Zebeta) (Ziac) (Coreg) (Esmolol HCl) (Labetalol HCl) (Trandate) (Toprol XL) (Lopressor HCT) (Lopressor) (Lopressor) (Corgard) (Pindolol) (Propranolol HCl) (Inderal LA) 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 (Propranolol HCl) (Propranolol HCl) (Propranolol/Hydrochlor othiazid) (Betapace) 1 1 1 (Betapace) (Timolol Maleate) 1 1 PA BvD 1 Calcium-Channel Blocking Agents cartia xt diltiazem hcl intravenous (Cardizem CD) (Cardizem CD) 1 1 You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 91 Effective: January 01, 2016 Drug Name diltiazem hcl oral capsule, extended release 180 mg, 360 mg, 420 mg diltiazem hcl oral capsule,extended release 12 hr diltiazem hcl oral capsule,extended release 24hr diltiazem hcl oral tablet diltiazem hcl oral tablet extended release 24 hr dilt-xr matzim la taztia xt verapamil intravenous syringe verapamil oral capsule, 24 hr er pellet ct verapamil oral capsule,ext rel. pellets 24 hr verapamil oral tablet verapamil oral tablet extended release Drug Tier Requirements/Limits (Cardizem CD) 1 (Cardizem CD) 1 (Cardizem CD) 1 (Cardizem CD) (Cardizem LA) 1 1 (Cardizem CD) (Cardizem CD) (Cardizem CD) (Verapamil HCl) (Verelan Pm) (Verelan) 1 1 1 1 1 1 (Calan) (Calan SR) 1 1 Cardiovascular Agents, Miscellaneous DEMSER digitek oral tablet 125 mcg (Lanoxin) 1 1 digitek oral tablet 250 mcg (Lanoxin) 1 digoxin injection DIGOXIN ORAL SOLUTION (Digoxin) 1 1 digoxin oral tablet (Lanoxin) 1 PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); QL (30 per 30 days) PA-HRM; QL (30 per 30 days) PA-HRM PA-HRM; QL (300 per 30 days) PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); QL (30 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 92 Effective: January 01, 2016 Drug Name Drug Tier Requirements/Limits dobutamine in d5w intravenous parenteral solution 1,000 mg/250 ml (4,000 mcg/ml), 250 mg/250 ml (1 mg/ml), 500 mg/250 ml (2,000 mcg/ml) dobutamine intravenous solution dopamine in 5 % dextrose intravenous solution dopamine intravenous solution ephedrine sulfate injection solution epinephrine injection auto-injector epinephrine injection solution epinephrine injection syringe 0.1 mg/ml (1:10,000) EPIPEN 2-PAK EPIPEN JR 2-PAK ethamolin FIRAZYR hydralazine LANOXIN ORAL TABLET 187.5 MCG, 62.5 MCG (Dobutamine HCl/D5W) 1 PA BvD (Dobutamine HCl) (Dopamine HCl/D5W) 1 1 PA BvD PA BvD (Dopamine HCl) (Ephedrine Sulfate) (Adrenaclick) (Epinephrine) (Epinephrine) 1 1 1 1 1 PA BvD milrinone milrinone in 5 % dextrose intravenous piggyback 40 mg/200 ml (200 mcg/ml) norepinephrine bitartrate papaverine injection solution papaverine oral RANEXA (Milrinone Lactate) (Milrinone Lactate/D5W) (Levophed Bitartrate) (Papaverine HCl) (Papaverine HCl) 1 1 (Norvasc) (Lotrel) (Exforge) (Exforge HCT) 1 1 1 1 1 1 (Ethanolamine Oleate) (Hydralazine HCl) 1 1 1 1 1 1 1 1 1 1 PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); QL (30 per 30 days) PA BvD PA BvD PA BvD PA PA Dihydropyridines amlodipine amlodipine-benazepril amlodipine-valsartan amlodipine-valsartan-hcthiazid AZOR CLEVIPREX INTRAVENOUS EMULSION ST You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 93 Effective: January 01, 2016 Drug Name felodipine isradipine nicardipine oral nifedipine oral tablet extended release 24hr 30 mg nifedipine oral tablet extended release 24hr 60 mg, 90 mg nifedipine oral tablet extended release 30 mg, 60 mg Drug Tier Requirements/Limits (Felodipine) (Isradipine) (Nicardipine HCl) (Adalat CC) 1 1 1 1 (Procardia XL) 1 (Adalat CC) 1 (Midamor) (Amiloride/Hydrochloro thiazide) (Bumetanide) (Chlorothiazide) (Sodium Diuril) (Chlorthalidone) 1 1 Diuretics amiloride oral amiloride-hydrochlorothiazide bumetanide chlorothiazide chlorothiazide sodium chlorthalidone oral tablet 25 mg, 50 mg DYRENIUM furosemide injection furosemide oral solution furosemide oral tablet hydrochlorothiazide oral capsule hydrochlorothiazide oral tablet indapamide methyclothiazide metolazone torsemide oral triamterene-hydrochlorothiazid oral capsule triamterene-hydrochlorothiazid oral tablet (Furosemide) (Furosemide) (Lasix) (Microzide) (Hydrochlorothiazide) (Indapamide) (Methyclothiazide) (Zaroxolyn) (Demadex) (Dyazide) 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 (Maxzide) 1 Dyslipidemics ALTOPREV amlodipine-atorvastatin atorvastatin cholestyramine (with sugar) oral cholestyramine-aspartame oral powder 4 gram (Caduet) (Lipitor) (Questran) (Cholestyramine/Asparta me) 1 1 1 1 1 You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 94 Effective: January 01, 2016 Drug Name cholestyramine-aspartame oral powder in packet 4 gram colestipol CRESTOR fenofibrate micronized fenofibrate nanocrystallized fenofibrate oral tablet fenofibric acid fenofibric acid (choline) gemfibrozil oral JUXTAPID ORAL CAPSULE 10 MG, 30 MG, 40 MG, 60 MG JUXTAPID ORAL CAPSULE 20 MG JUXTAPID ORAL CAPSULE 5 MG KYNAMRO lovastatin niacin oral tablet extended release 24 hr omega-3 acid ethyl esters pravastatin simvastatin VASCEPA VYTORIN 10-10 VYTORIN 10-20 VYTORIN 10-40 VYTORIN 10-80 ZETIA Drug Tier Requirements/Limits (Cholestyramine/Asparta me) (Colestid) (Lofibra) (Tricor) (Lofibra) (Fibricor) (Trilipix) (Lopid) (Mevacor) (Niaspan) (Lovaza) (Pravachol) (Zocor) 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 ST PA; QL (30 per 30 days) PA; QL (90 per 30 days) PA; QL (45 per 30 days) PA; QL (4 per 28 days) QL (30 per 30 days) Renin-Angiotensin-Aldosterone System Inhibitors eplerenone spironolactone spironolacton-hydrochlorothiaz (Inspra) (Aldactone) (Aldactazide) 1 1 1 (Isochron) (Isosorbide Dinitrate) (Isosorbide Mononitrate) (Imdur) 1 1 1 1 (Nitro-Dur) 1 Vasodilators isosorbide dinitrate oral isosorbide dinitrate sublingual isosorbide mononitrate oral tablet isosorbide mononitrate oral tablet extended release 24 hr minitran transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.6 mg/hr QL (30 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 95 Effective: January 01, 2016 Drug Name minitran transdermal patch 24 hour 0.4 mg/hr minoxidil oral NITRO-BID nitroglycerin in 5 % dextrose intravenous solution nitroglycerin intravenous nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.6 mg/hr nitroglycerin transdermal patch 24 hour 0.4 mg/hr NITROSTAT PROGLYCEM Drug Tier Requirements/Limits (Nitro-Dur) 1 QL (60 per 30 days) (Minoxidil) (Nitroglycerin/D5W) 1 1 1 (Nitroglycerin) (Nitro-Dur) 1 1 QL (30 per 30 days) (Nitro-Dur) 1 QL (60 per 30 days) 1 1 Central Nervous System Agents Central Nervous System Agents amphetamine salt combo AMPYRA caffeine citrated intravenous caffeine citrated oral caffeine-sodium benzoate clonidine hcl oral tablet extended release 12 hr dexmethylphenidate oral tablet dextroamphetamine oral capsule, extended release dextroamphetamine oral tablet dextroamphetamine-amphetamine oral capsule,extended release 24hr 10 mg, 15 mg, 5 mg dextroamphetamine-amphetamine oral capsule,extended release 24hr 20 mg, 25 mg, 30 mg flumazenil guanfacine oral tablet extended release 24 hr lithium carbonate oral capsule lithium carbonate oral tablet (Adderall) (Cafcit) (Cafcit) (Caffeine/Sodium Benzoate) (Kapvay) 1 1 1 1 1 QL (60 per 30 days) PA; QL (60 per 30 days) 1 (Focalin) (Dexedrine) 1 1 QL (60 per 30 days) QL (120 per 30 days) (Dexedrine) (Adderall XR) 1 1 QL (180 per 30 days) QL (30 per 30 days) (Adderall XR) 1 QL (60 per 30 days) (Romazicon) (Intuniv) 1 1 (Lithium Carbonate) (Lithobid) 1 1 You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 96 Effective: January 01, 2016 Drug Name lithium carbonate oral tablet extended release lithium citrate oral solution methylphenidate oral capsule, er biphasic 30-70 10 mg, 20 mg, 40 mg, 50 mg, 60 mg methylphenidate oral capsule, er biphasic 30-70 30 mg methylphenidate oral capsule,er biphasic 50-50 20 mg, 40 mg methylphenidate oral capsule,er biphasic 50-50 30 mg methylphenidate oral solution methylphenidate oral tablet methylphenidate oral tablet extended release methylphenidate oral tablet extended release 24hr 18 mg, 27 mg, 54 mg methylphenidate oral tablet extended release 24hr 36 mg NUEDEXTA QUILLIVANT XR riluzole SAVELLA STRATTERA XENAZINE Drug Tier Requirements/Limits (Lithobid) 1 (Lithium Citrate) (Metadate Cd) 1 1 QL (30 per 30 days) (Metadate Cd) 1 QL (60 per 30 days) (Metadate Cd) 1 QL (30 per 30 days) (Metadate Cd) 1 QL (60 per 30 days) (Methylin) (Ritalin) (Methylphenidate HCl) 1 1 1 QL (900 per 30 days) QL (90 per 30 days) QL (90 per 30 days) (Concerta) 1 QL (30 per 30 days) (Concerta) 1 QL (60 per 30 days) 1 1 1 1 1 1 QL (60 per 30 days) (Rilutek) QL (60 per 30 days) PA; QL (112 per 28 days) Contraceptives Contraceptives ashlyna deblitane desog-e.estradiol/e.estradiol desogestrel-ethinyl estradiol oral tablet 0.1/.125/.15-25 mg-mcg, 0.15-0.03 mg drospirenone-ethinyl estradiol ELLA ethinyl estradiol/drospirenone ethynodiol d-ethinyl estradiol gildess 24 fe (Seasonique) (Nor-Q-D) (Mircette) (Desogen) 1 1 1 1 (Yaz) 1 1 1 1 (Yaz) (Ethynodiol D-Ethinyl Estradiol) (Loestrin Fe) QL (6 per 365 days) 1 You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 97 Effective: January 01, 2016 Drug Name junel fe 24 l norgest/e.estradiol-e.estrad larin 24 fe levonorgestrel oral tablet 0.75 mg levonorgestrel oral tablet 1.5 mg levonorgestrel-ethin estradiol oral tablet 0.1-20 mg-mcg, 0.15-0.03 mg, 50-30 (6)/75-40 (5)/125-30(10) levonorgestrel-ethin estradiol oral tablets,dose pack,3 month 0.15-30 mg-mcg levonorgestrel-ethinyl estrad oral tablet levonorgestrel-ethinyl estrad oral tablet 0.15-0.03 mg levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month l-norgest-eth estr/ethin estra norelgestromin/ethin.estradiol norethindrone norethindrone (contraceptive) norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg, 1.5-30 mg-mcg norethindrone-e.estradiol-iron oral tablet 1 mg-20 mcg (21)/75 mg (7), 1 mg-20 mcg (24)/75 mg (4), 1-20(5)/1-30(7) /1mg35mcg (9), 1.5 mg-30 mcg (21)/75 mg (7) norethindrone-ethinyl estrad oral tablet 0.4-35 mg-mcg, 0.5-35 mg-mcg, 0.5-35/135 mg-mcg/mg-mcg, 0.5/0.75/1 mg- 35 mcg, 0.5/1/0.5-35 mg-mcg, 1-35 mg-mcg norethindrone-mestranol norgestimate-ethinyl estradiol norgestrel-ethinyl estradiol NUVARING tarina fe Drug Tier Requirements/Limits (Loestrin Fe) (Seasonique) (Loestrin Fe) (Plan B One-Step) (Plan B One-Step) (Amethyst) 1 1 1 1 1 1 (Levonorgestrel-Ethin Estradiol) (Amethyst) (Amethyst) 1 QL (91 per 84 days) 1 1 QL (91 per 84 days) (Amethyst) 1 QL (91 per 84 days) (Seasonique) (Ortho Evra) (Nor-Q-D) (Nor-Q-D) (Loestrin) 1 1 1 1 1 QL (91 per 84 days) QL (3 per 28 days) (Loestrin Fe) 1 (Modicon) 1 (Norinyl 1+50) (Ortho-Cyclen) (Norgestrel-Ethinyl Estradiol) 1 1 1 (Loestrin Fe) 1 1 (Evoxac) 1 QL (91 per 84 days) QL (12 per 365 days) QL (6 per 365 days) QL (1 per 28 days) Dental And Oral Agents Dental And Oral Agents cevimeline You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 98 Effective: January 01, 2016 Drug Name chlorhexidine gluconate mucous membrane mouthwash 0.12 % pilocarpine hcl oral sodium fluoride oral tablet,chewable 0.25 mg fluorid (0.55 mg) triamcinolone acetonide dental Drug Tier Requirements/Limits (Peridex) 1 (Salagen) (Sodium Fluoride) 1 1 (Triamcinolone Acetonide) 1 Dermatological Agents Dermatological Agents, Other 8-MOP acitretin acyclovir topical ALCOHOL PADS ALCOHOL PREP PADS ammonium lactate ANACAINE calcipotriene topical cream calcipotriene topical solution calcitriol topical CONDYLOX TOPICAL GEL COSENTYX (2 SYRINGES) COSENTYX PEN COSENTYX PEN (2 PENS) DENAVIR FLUOROPLEX fluorouracil topical cream fluorouracil topical solution imiquimod isotretinoin oral capsule 10 mg, 20 mg, 30 mg, 40 mg methoxsalen rapid PANRETIN PICATO TOPICAL GEL 0.015 % PICATO TOPICAL GEL 0.05 % podofilox podophyllum resin potassium hydroxide (Carac) (Fluorouracil) (Aldara) 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 (Isotretinoin) 1 (Oxsoralen-Ultra) 1 1 1 1 1 1 1 (Soriatane) (Zovirax) (Lac-Hydrin) (Dovonex) (Calcipotriene) (Vectical) (Condylox) (Podophyllum Resin) (Potassium Hydroxide) QL (30 per 30 days) PA PA PA PA NSO; QL (24 per 30 days) QL (3 per 56 days) QL (2 per 56 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 99 Effective: January 01, 2016 Drug Name Drug Tier Requirements/Limits REGRANEX SANTYL VALCHLOR VEREGEN ZOVIRAX TOPICAL CREAM 1 1 1 1 1 PA; QL (30 per 30 days) QL (15 per 30 days) Dermatological Antibacterials clindamycin phosphate topical gel clindamycin phosphate topical lotion clindamycin phosphate topical solution clindamycin phosphate topical swab erythromycin base-ethanol (Cleocin T) (Cleocin T) (Cleocin T) (Cleocin T) (Erythromycin Base/Ethanol) (Emgel) erythromycin with ethanol topical gel erythromycin with ethanol topical solution (Erythromycin Base/Ethanol) (Erythromycin erythromycin with ethanol topical swab Base/Ethanol) (Benzamycin) erythromycin-benzoyl peroxide (Gentamicin Sulfate) gentamicin topical (Metrocream) metronidazole topical (Rosadan) metronidazole topical (Metrolotion) metronidazole topical (Centany) mupirocin (Bactroban) mupirocin calcium (Neosporin G.U. neomycin-polymyxin b gu Irrigant) (Selenium Sulfide) selenium sulfide (Silver Nitrate silver nitrate applicators Applicator) (Silver Nitrate) silver nitrate topical (Silvadene) silver sulfadiazine topical cream 1 % (Klaron) sulfacetamide sodium (acne) 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Dermatological Anti-Inflammatory Agents (Alclometasone 1 Dipropionate) (Betamethasone 1 betamethasone dipropionate Dipropionate) (Betamethasone 1 betamethasone valerate topical cream Valerate) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document alclometasone VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 100 Effective: January 01, 2016 Drug Name betamethasone valerate topical foam betamethasone valerate topical lotion betamethasone valerate topical ointment betamethasone, augmented topical cream betamethasone, augmented topical gel betamethasone, augmented topical lotion betamethasone, augmented topical ointment clobetasol propionate topical solution 0.05 % clobetasol topical cream clobetasol topical foam clobetasol topical gel clobetasol topical lotion clobetasol topical ointment clobetasol topical shampoo clobetasol topical solution clobetasol-emollient topical clocortolone pivalate desonide topical cream desonide topical ointment desoximetasone ELIDEL fluocinonide topical cream 0.05 % fluocinonide topical gel fluocinonide topical ointment fluocinonide topical solution fluocinonide-emollient base fluticasone topical cream fluticasone topical ointment halobetasol propionate hydrocortisone 1% ointment carton (otc) hydrocortisone acet-aloe vera topical gel hydrocortisone acetate-urea Drug Tier Requirements/Limits (Luxiq) (Betamethasone Valerate) (Betamethasone Valerate) (Diprolene AF) (Betamethasone Dipropionate) (Diprolene) (Diprolene) 1 1 (Clobetasol Propionate) 1 (Temovate) (Olux) (Clobetasol Propionate) (Clobex) (Temovate) (Clobex) (Clobetasol Propionate) (Temovate) (Cloderm) (Desowen) (Desonide) (Topicort) 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 (Vanos) (Fluocinonide) (Fluocinonide) (Fluocinonide) (Vanos) (Cutivate) (Fluticasone Propionate) (Ultravate) (Hydrocortisone) (Hydrocortisone Acetate/Aloe V) (Hydrocortisone Acetate/Urea) 1 1 1 1 1 1 You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 101 Effective: January 01, 2016 Drug Name Drug Tier Requirements/Limits hydrocortisone butyrate topical cream (Hydrocortisone Butyrate) (Locoid) hydrocortisone butyrate topical ointment (Locoid) hydrocortisone butyrate topical solution (Hydrocortisone hydrocortisone butyr-emollient Butyrate) (Anusol-HC) hydrocortisone rectal cream 1 % (Hydrocortisone) hydrocortisone rectal cream 2.5 % hydrocortisone rectal enema 100 mg/60 ml (Cortenema) hydrocortisone topical cream 1 %, 2.5 % (Anusol-HC) (Scalacort) hydrocortisone topical lotion 2 %, 2.5 % (Hydrocortisone) hydrocortisone topical ointment 1 %, 2.5 % (Hydrocortisone hydrocortisone valerate topical cream Valerate) (Westcort) hydrocortisone valerate topical ointment (Elocon) mometasone ONFI ORAL SUSPENSION 1 1 1 1 1 1 ONFI ORAL TABLET 10 MG, 20 MG 1 prednicarbate tacrolimus topical triamcinolone acetonide topical cream triamcinolone acetonide topical lotion triamcinolone acetonide topical ointment 0.025 %, 0.1 %, 0.5 % 1 1 1 1 1 1 1 1 (Dermatop) (Protopic) (Triamcinolone Acetonide) (Triamcinolone Acetonide) (Triamcinolone Acetonide) 1 1 1 (Differin) (Differin) 1 1 1 1 1 PA NSO; QL (480 per 30 days) PA NSO; QL (60 per 30 days) 1 1 Dermatological Retinoids adapalene topical cream adapalene topical gel 0.1 % TAZORAC TOPICAL CREAM tretinoin microspheres tretinoin topical (Retin-A Micro) (Retin-A) PA PA Scabicides And Pediculicides EURAX 1 (Ovide) 1 malathion (Elimite) 1 permethrin topical cream You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 102 Effective: January 01, 2016 Drug Name Drug Tier Requirements/Limits Devices Devices ASSURE ID INSULIN SAFETY SYRINGE BD ECLIPSE LUER-LOK SYRINGE 1 ML 27 X 1/2" BD INSULIN PEN NEEDLE UF SHORT BD INSULIN SYRINGE ULTRA-FINE SYRINGE 0.3 ML 31 X 5/16", 1 ML 31 X 5/16", 1/2 ML 31 X 5/16" INSULIN PEN NEEDLE NEEDLE 29 GAUGE X 1/2 " INSULIN SYRINGE-NEEDLE U-100 SYRINGE 0.3 ML 29, 1 ML 29 X 1/2", 1/2 ML 28 VGO 40 1 1 1 1 1 1 1 Enzyme Replacement/Modifiers Enzyme Replacement/Modifiers ADAGEN ALDURAZYME CEREZYME INTRAVENOUS RECON SOLN 400 UNIT CREON ELAPRASE ELITEK INTRAVENOUS RECON SOLN FABRAZYME INTRAVENOUS RECON SOLN KRYSTEXXA KUVAN ORAL TABLET,SOLUBLE (Zenpep) lipase-protease-amylase MYOZYME NAGLAZYME ORFADIN PERTZYE PULMOZYME VIMIZIM VPRIV 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 PA BvD PA You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 103 Effective: January 01, 2016 Drug Name Drug Tier Requirements/Limits ZAVESCA ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,000-34,000 55,000 UNIT, 15,000-51,000 -82,000 UNIT, 20,000-68,000 -109,000 UNIT, 25,000-85,000- 136,000 UNIT, 3,00010,000- 16,000 UNIT, 40,000-136,000218,000 UNIT 1 1 QL (90 per 30 days) Eye, Ear, Nose, Throat Agents Eye, Ear, Nose, Throat Agents, Miscellaneous AKTEN (PF) altacaine apraclonidine atropine ophthalmic drops atropine ophthalmic ointment azelastine nasal aerosol,spray azelastine ophthalmic BEPREVE carteolol cromolyn ophthalmic CYCLOGYL OPHTHALMIC DROPS 0.5 % cyclopentolate CYSTARAN epinastine homatropine hbr ipratropium bromide nasal spray,nonaerosol 0.03 % ipratropium bromide nasal spray,nonaerosol 0.06 % LACRISERT naphazoline phenylephrine hcl ophthalmic proparacaine proparacaine hcl ophthalmic drops 0.5 % proparacaine-fluorescein sod (Tetcaine) (Iopidine) (Isopto Atropine) (Atropine Sulfate) (Astepro) (Azelastine HCl) (Carteolol HCl) (Cromolyn Sodium) (Cyclogyl) 1 1 1 1 1 1 1 1 1 1 1 QL (30 per 25 days) ST (Elestat) (Isopto Homatropine) (Atrovent) 1 1 1 1 1 QL (30 per 28 days) (Atrovent) 1 QL (15 per 10 days) (Naphazoline HCl) (Mydfrin) (Proparacaine HCl) (Proparacaine HCl) (Proparacaine/Fluorescei n Sod) (Tetracaine HCl/PF) 1 1 1 1 1 1 1 tetracaine hcl (pf) ophthalmic TYZINE NASAL DROPS 0.1 % 1 You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 104 Effective: January 01, 2016 Drug Name Drug Tier Requirements/Limits TYZINE NASAL SPRAY,NONAEROSOL 1 Eye, Ear, Nose, Throat Anti-Infectives Agents acetic acid otic bacitracin ophthalmic bacitracin-polymyxin b ophthalmic BLEPHAMIDE BLEPHAMIDE S.O.P. CILOXAN OPHTHALMIC OINTMENT CIPRODEX ciprofloxacin hcl ophthalmic ciprofloxacin hcl otic COLY-MYCIN S CORTISPORIN-TC erythromycin ophthalmic gatifloxacin gentamicin ophthalmic gentamicin sulfate ophthalmic ointment 0.3 % (3 mg/gram) levofloxacin ophthalmic MOXEZA NATACYN neomy sulf-bacitrac zn-poly-hc neomycin-bacitracin-poly-hc neomycin-bacitracin-polymyxin neomycin-polymyxin b-dexameth neomycin-polymyxin-gramicidin neomycin-polymyxin-hc ophthalmic neomycin-polymyxin-hc otic drops,suspension neomycin-polymyxin-hc otic solution neo-polycin ofloxacin ophthalmic (Acetic Acid) (Bacitracin) (Bacitracin/Polymyxin B Sulfate) (Ciloxan) (Cetraxal) (Ilotycin) (Zymaxid) (Garamycin) (Garamycin) (Levofloxacin) (Neomycin Su/Baci Zn/Poly/HC) (Neomycin Su/Baci Zn/Poly/HC) (Neomycin Su/Bacitra/Polymyxin) (Maxitrol) (Neosporin) (Neomycin/Polymyxin B Sulf/HC) (Neomycin/Polymyxin B Sulf/HC) (Cortisporin) (Neomycin Su/Bacitra/Polymyxin) (Ocuflox) 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 105 Effective: January 01, 2016 Drug Name ofloxacin otic polymyxin b sulf-trimethoprim sulfacetamide sodium sulfacetamide-prednisolone TOBRADEX OPHTHALMIC OINTMENT TOBRADEX ST tobramycin trifluridine VIGAMOX ZIRGAN ZYLET Drug Tier Requirements/Limits (Ocuflox) (Polytrim) (Sulfacetamide Sodium) (Sulfacetamide/Predniso lone Sp) 1 1 1 1 1 (Tobrex) (Viroptic) 1 1 1 1 1 1 Eye, Ear, Nose, Throat Anti-Inflammatory Agents ALREX bromfenac dexamethasone sodium phosphate ophthalmic diclofenac sodium ophthalmic DUREZOL flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) fluorometholone flurbiprofen sodium fluticasone nasal ILEVRO ketorolac ophthalmic LOTEMAX NEVANAC prednisolone acetate prednisolone sodium phosphate ophthalmic PROLENSA RESTASIS (Bromfenac Sodium) (Dexasol) (Diclofenac Sodium) (Flunisolide) (FML) (Ocufen) (Fluticasone Propionate) (Acular) (Omnipred) (Prednisolone Sod Phosphate) 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 ST QL (50 per 25 days) QL (16 per 30 days) QL (60 per 30 days) Gastrointestinal Agents Antiulcer Agents And Acid Suppressants amoxicil-clarithromy-lansopraz CARAFATE ORAL SUSPENSION (Prevpac) 1 1 You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 106 Effective: January 01, 2016 Drug Name cimetidine cimetidine hcl oral DEXILANT esomeprazole sodium famotidine (pf) famotidine (pf)-nacl (iso-os) famotidine intravenous famotidine oral tablet 20 mg, 40 mg lansoprazole oral capsule,delayed release(dr/ec) misoprostol nizatidine omeprazole oral capsule,delayed release(dr/ec) pantoprazole oral ranitidine hcl injection ranitidine hcl oral capsule ranitidine hcl oral syrup ranitidine hcl oral tablet 150 mg, 300 mg sucralfate oral suspension sucralfate oral tablet Drug Tier Requirements/Limits (Cimetidine) (Cimetidine HCl) (Nexium I.V.) (Famotidine) (Famotidine In Nacl,IsoOsm/PF) (Famotidine) (Pepcid) (Prevacid) 1 1 1 1 1 1 1 1 1 (Cytotec) (Nizatidine) (Prilosec) 1 1 1 (Protonix) (Zantac) (Ranitidine HCl) (Ranitidine HCl) (Zantac) (Sucralfate) (Carafate) 1 1 1 1 1 1 1 (Rx Product Only) ST (Rx Product Only) (Rx Product Only) (Rx Product Only) (Rx Product Only) (Rx Product Only) (Rx Product Only) Gastrointestinal Agents, Other AMITIZA BUPHENYL ORAL TABLET CARBAGLU cromolyn oral dicyclomine oral capsule dicyclomine oral solution dicyclomine oral tablet diphenoxylate-atropine oral liquid diphenoxylate-atropine oral tablet GATTEX 30-VIAL GATTEX ONE-VIAL glycopyrrolate glycopyrrolate lactulose (Gastrocrom) (Bentyl) (Dicyclomine HCl) (Bentyl) (Diphenoxylate HCl/Atropine) (Lomotil) (Robinul) (Robinul) (Lactulose) 1 1 1 1 1 1 1 1 1 1 1 1 1 1 QL (60 per 30 days) PA PA You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 107 Effective: January 01, 2016 Drug Name LINZESS loperamide oral LOTRONEX methscopolamine oral metoclopramide hcl injection metoclopramide hcl oral metoclopramide hcl oral MOVANTIK NUTRESTORE RAVICTI RELISTOR SUBCUTANEOUS RELISTOR SUBCUTANEOUS SYRINGE 8 MG/0.4 ML sodium polystyrene sulfonate oral powder Drug Tier Requirements/Limits (Loperamide HCl) (Methscopolamine Bromide) (Metoclopramide HCl) (Metoclopramide HCl) (Reglan) (Sodium Polystyrene Sulfonate) (Sodium Polystyrene sodium polystyrene sulfonate oral Sulfonate) suspension 15 gram/60 ml sodium polystyrene sulfonate rectal enema (Sodium Polystyrene Sulfonate) 30 gram/120 ml (Actigall) ursodiol oral capsule (Urso) ursodiol oral tablet VELPHORO 1 1 1 1 1 1 1 1 1 1 1 1 QL (30 per 30 days) PA PA; QL (28 per 28 days) PA; QL (28 per 28 days) 1 1 1 1 1 1 Laxatives MOVIPREP peg 3350-electrolytes PEG 3350-GRX peg 3350-na sulf,bicarb,cl-kcl peg-electrolyte soln polyethylene glycol 3350 oral PREPOPIK sodium chloride-nahco3-kcl-peg oral recon soln 420 gram (Golytely) (Golytely) (Nulytely with Flavor Packs) (Gavilyte-N) (Nulytely with Flavor Packs) 1 1 1 1 1 1 1 1 Phosphate Binders AURYXIA calcium acetate oral capsule calcium carbonate-mag carb-fa 1 1 1 (Phoslo) (Calcium Carbonate/Mag Carb/Fa) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 108 Effective: January 01, 2016 Drug Name Drug Tier Requirements/Limits FOSRENOL PHOSLYRA RENAGEL RENVELA 1 1 1 1 Genitourinary Agents Antispasmodics, Urinary MYRBETRIQ oxybutynin chloride oral tablet oxybutynin chloride oral tablet extended release 24hr tolterodine oral capsule,extended release 24hr tolterodine oral tablet TOVIAZ trospium VESICARE (Oxybutynin Chloride) (Ditropan XL) 1 1 1 (Detrol LA) 1 (Detrol) 1 1 1 1 (Trospium Chloride) Genitourinary Agents, Miscellaneous alfuzosin tamsulosin terazosin (Uroxatral) (Flomax) (Terazosin HCl) 1 1 1 Heavy Metal Antagonists Heavy Metal Antagonists (Desferal) deferoxamine injection recon soln DEPEN TITRATABS EXJADE ORAL TABLET, DISPERSIBLE 125 MG EXJADE ORAL TABLET, DISPERSIBLE 250 MG, 500 MG FERRIPROX sodium thiosulfate intravenous solution 1 (Sodium Thiosulfate) gram/10 ml (100 mg/ml), 12.5 gram/50 ml (250 mg/ml) SYPRINE 1 1 1 PA BvD 1 1 1 1 Hormonal Agents, Stimulant/Replacement/Modifying Androgens ANDRODERM 1 PA; QL (30 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 109 Effective: January 01, 2016 Drug Name Drug Tier Requirements/Limits ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 20.25 MG/1.25 GRAM (1.62 %) ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62 % (40.5 MG/2.5 GRAM) AXIRON danazol oral fluoxymesterone oxandrolone testosterone cypionate testosterone enanthate testosterone transdermal gel in packet 1 % (25 mg/2.5gram) (Danazol) (Fluoxymesterone) (Oxandrin) (Depo-Testosterone) (Delatestryl) (Androgel) 1 PA; QL (150 per 30 days) 1 PA; QL (150 per 30 days) 1 PA; QL (180 per 28 days) 1 1 1 1 1 1 PA PA; QL (5 per 28 days) PA; QL (300 per 30 days) Estrogens And Antiestrogens COMBIPATCH 1 DUAVEE ESTRACE VAGINAL estradiol oral estradiol transdermal patch semiweekly (Estrace) (Vivelle-Dot) 1 1 1 1 estradiol transdermal patch weekly (Climara) 1 estradiol valerate estradiol/norethindrone acet estradiol-norethindrone acet ESTRING estropipate FEMRING MENEST PREMARIN INJECTION PREMARIN ORAL PREMARIN VAGINAL PREMPHASE PREMPRO raloxifene VAGIFEM (Delestrogen) (Activella) (Activella) 1 1 1 1 1 1 1 1 1 1 1 1 1 1 (Estropipate) (Evista) PA-HRM; QL (8 per 28 days) PA-HRM PA-HRM PA-HRM; QL (8 per 28 days) PA-HRM; QL (4 per 28 days) PA-HRM PA-HRM QL (1 per 84 days) PA-HRM QL (1 per 84 days) PA-HRM PA-HRM PA-HRM PA-HRM QL (18 per 28 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 110 Effective: January 01, 2016 Drug Name Drug Tier Requirements/Limits Glucocorticoids/Mineralocorticoids betamethasone acet,sod phos cortisone dexamethasone oral dexamethasone oral dexamethasone sodium phosphate injection fludrocortisone hydrocortisone oral hydrocortisone sod succinate methylprednisolone methylprednisolone acetate methylprednisolone sodium succ injection recon soln 125 mg, 40 mg methylprednisolone sodium succ intravenous prednisolone sodium phosphate oral solution PREDNISONE INTENSOL prednisone oral solution prednisone oral tablet prednisone oral tablets,dose pack SOLU-CORTEF (PF) INJECTION RECON SOLN triamcinolone acetonide injection (Celestone) (Cortisone Acetate) (Dexamethasone) (Dexamethasone) (Dexamethasone Sod Phosphate) (Fludrocortisone Acetate) (Cortef) (Hydrocortisone Sod Succinate) (Medrol) (Depo-Medrol) (A-Methapred) 1 1 1 1 1 PA BvD PA BvD PA BvD PA BvD PA BvD 1 1 PA BvD PA BvD 1 1 1 PA BvD PA BvD PA BvD (A-Methapred) 1 PA BvD (Pediapred) 1 PA BvD (Prednisone) (Prednisone) (Prednisone) 1 1 1 1 1 PA BvD PA BvD PA BvD PA BvD PA BvD 1 (Triamcinolone Acetonide) 1 (Desmopressin Acetate) (DDAVP) (Desmopressin Acetate) (DDAVP) 1 1 1 1 1 1 Pituitary desmopressin injection desmopressin nasal desmopressin nasal desmopressin oral GENOTROPIN GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.2 MG/0.25 ML QL (15 per 30 days) QL (15 per 30 days) PA PA You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 111 Effective: January 01, 2016 Drug Name GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.4 MG/0.25 ML, 0.6 MG/0.25 ML, 0.8 MG/0.25 ML, 1 MG/0.25 ML, 1.2 MG/0.25 ML, 1.4 MG/0.25 ML, 1.6 MG/0.25 ML, 1.8 MG/0.25 ML, 2 MG/0.25 ML INCRELEX LUPRON DEPOT-PED LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT NORDITROPIN FLEXPRO NORDITROPIN NORDIFLEX octreotide acetate injection solution 1,000 mcg/ml octreotide acetate injection solution 100 mcg/ml, 200 mcg/ml, 500 mcg/ml octreotide acetate injection solution 50 mcg/ml octreotide acetate injection syringe SAIZEN SAIZEN CLICK.EASY SANDOSTATIN LAR DEPOT INTRAMUSCULAR KIT SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG, 5 MG, 6 MG SOMATULINE DEPOT SOMAVERT STIMATE SUPPRELIN LA Drug Tier Requirements/Limits 1 PA 1 1 1 QL (1 per 84 days) (Sandostatin) 1 1 1 PA PA (Sandostatin) 1 (Octreotide Acetate) 1 (Octreotide Acetate) 1 1 1 1 PA PA 1 PA 1 1 1 1 QL (1 per 28 days) 1 QL (10 per 28 days) 1 1 1 1 1 1 QL (1 per 84 days) QL (1 per 360 days) Progestins DEPO-PROVERA INTRAMUSCULAR SOLUTION medroxyprogesterone intramuscular medroxyprogesterone oral MEGACE ES megestrol oral suspension norethindrone acetate progesterone (Depo-Provera) (Provera) (Megace Es) (Aygestin) (Progesterone) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 112 Effective: January 01, 2016 Drug Name progesterone micronized capsules Drug Tier Requirements/Limits (Prometrium) 1 Thyroid And Antithyroid Agents levothyroxine intravenous levothyroxine oral liothyronine oral methimazole oral tablet 10 mg, 5 mg propylthiouracil (Levothyroxine Sodium) (Levoxyl) (Cytomel) (Tapazole) (Propylthiouracil) 1 1 1 1 1 Immunological Agents Immunological Agents ARCALYST ASTAGRAF XL AUBAGIO azathioprine azathioprine sodium CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN CELLCEPT INTRAVENOUS CIMZIA CIMZIA POWDER FOR RECONST cyclosporine intravenous cyclosporine modified cyclosporine oral capsule cyclosporine, modified ENBREL ENBREL SURECLICK FLEBOGAMMA DIF GAMASTAN S/D GAMMAGARD LIQUID GAMMAPLEX GAMUNEX-C INJECTION SOLUTION HUMIRA HUMIRA CROHN'S DIS START PCK HUMIRA PEN HYQVIA ILARIS (PF) IMOGAM RABIES-HT (PF) KINERET (Imuran) (Azathioprine Sodium) (Sandimmune) (Neoral) (Sandimmune) (Neoral) 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 PA BvD PA; QL (28 per 28 days) PA BvD PA BvD PA BvD PA BvD PA PA PA BvD PA BvD PA BvD PA BvD PA PA PA BvD PA BvD PA BvD PA BvD PA BvD PA PA PA PA BvD PA PA; QL (18.76 per 28 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 113 Effective: January 01, 2016 Drug Name leflunomide mycophenolate mofetil oral capsule mycophenolate mofetil oral suspension for reconstitution mycophenolate mofetil oral tablet mycophenolate sodium NULOJIX OCTAGAM ORENCIA ORENCIA (WITH MALTOSE) PRIVIGEN PROGRAF INTRAVENOUS RAPAMUNE ORAL SOLUTION RIDAURA sirolimus oral tablet 0.5 mg, 1 mg sirolimus oral tablet 2 mg tacrolimus oral TYSABRI Drug Tier Requirements/Limits (Arava) (Cellcept) (Cellcept) 1 1 1 (Cellcept) (Myfortic) 1 1 1 1 1 1 1 1 1 1 1 1 1 1 (Rapamune) (Rapamune) (Hecoria) ZORTRESS ORAL TABLET 0.25 MG 1 ZORTRESS ORAL TABLET 0.5 MG, 0.75 MG 1 PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA PA PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA; LA; QL (15 per 28 days) PA BvD; QL (120 per 30 days) PA BvD; QL (120 per 30 days) Vaccines ACTHIB (PF) ADACEL(TDAP ADOLESN/ADULT)(PF) BCG VACCINE, LIVE (PF) BEXSERO (PF) BOOSTRIX TDAP CERVARIX VACCINE (PF) COMVAX (PF) DAPTACEL (DTAP PEDIATRIC) (PF) ENGERIX-B (PF) 1 1 1 1 1 1 1 1 1 PA BvD PA BvD; QL (3 per 365 days) ENGERIX-B PEDIATRIC (PF) 1 PA BvD; QL (3 per 365 days) GARDASIL (PF) 1 QL (1.5 per 365 days) GARDASIL 9 (PF) 1 QL (1.5 per 365 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 114 Effective: January 01, 2016 Drug Name Drug Tier Requirements/Limits HAVRIX (PF) INTRAMUSCULAR SUSPENSION HAVRIX (PF) INTRAMUSCULAR SYRINGE IMOVAX RABIES VACCINE (PF) INFANRIX (DTAP) (PF) INTRAMUSCULAR IPOL IXIARO (PF) KINRIX (PF) MENACTRA (PF) INTRAMUSCULAR SOLUTION MENHIBRIX (PF) MENOMUNE - A/C/Y/W-135 (PF) MENVEO A-C-Y-W-135-DIP (PF) MENVEO MENA COMPONENT (PF) MENVEO MENCYW-135 COMPNT (PF) M-M-R II (PF) PEDIARIX (PF) PEDVAX HIB (PF) PENTACEL (PF) PENTACEL ACTHIB COMPONENT (PF) PENTACEL DTAP-IPV COMPNT (PF) PROQUAD (PF) QUADRACEL (PF) RABAVERT (PF) RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCG/ML, 40 MCG/ML RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE ROTARIX ROTATEQ VACCINE TENIVAC (PF) INTRAMUSCULAR TETANUS TOXOID,ADSORBED (PF) TETANUS,DIPHTHERIA TOX PED(PF) TETANUS-DIPHTHERIA TOXOIDS-TD 1 1 1 1 PA BvD 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 QL (2 per 365 days) QL (2 per 365 days) PA BvD PA BvD; QL (3 per 365 days) PA BvD; QL (3 per 365 days) PA BvD You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 115 Effective: January 01, 2016 Drug Name Drug Tier Requirements/Limits TICE BCG TRUMENBA TWINRIX (PF) TYPHIM VI INTRAMUSCULAR VAQTA (PF) VARIVAX (PF) YF-VAX (PF) ZOSTAVAX (PF) 1 1 1 1 1 1 1 1 PA BvD QL (2 per 365 days) QL (1 per 365 days) Inflammatory Bowel Disease Agents Inflammatory Bowel Disease Agents APRISO ASACOL HD balsalazide budesonide oral DELZICOL DIPENTUM (Colazal) (Entocort EC) 1 1 1 1 1 1 ST Irrigating Solutions Irrigating Solutions acetic acid irrigation LACTATED RINGERS IRRIGATION ringers irrigation sodium chloride irrigation sorbitol irrigation sorbitol-mannitol water for irrigation, sterile (Acetic Acid) (Ringers Solution) (Sodium Chloride Irrig Solution) (Sorbitol Solution) (Mannitol/Sorbitol Solution) (Water For Irrigation,Sterile) 1 1 1 1 1 1 1 Metabolic Bone Disease Agents Metabolic Bone Disease Agents ACTONEL ORAL TABLET 35 MG alendronate oral solution alendronate oral tablet 10 mg, 40 mg, 5 mg alendronate oral tablet 35 mg, 70 mg calcitonin (salmon) (Alendronate Sodium) (Fosamax) 1 1 1 QL (4 per 28 days) QL (300 per 28 days) (Fosamax) (Miacalcin) 1 1 QL (4 per 28 days) QL (3.7 per 28 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 116 Effective: January 01, 2016 Drug Name Drug Tier Requirements/Limits calcitriol intravenous solution 1 mcg/ml (Calcitriol) 1 calcitriol oral (Rocaltrol) 1 doxercalciferol intravenous (Doxercalciferol) 1 doxercalciferol oral (Hectorol) 1 (Ibandronate Sodium) 1 1 1 FORTEO FORTICAL ibandronate intravenous solution ibandronate oral MIACALCIN INJECTION (Boniva) 1 1 NATPARA pamidronate intravenous (Pamidronate Disodium) 1 1 paricalcitol oral (Zemplar) 1 PROLIA risedronate oral tablet 150 mg risedronate oral tablet 30 mg, 5 mg XGEVA ZEMPLAR INTRAVENOUS zoledronic acid intravenous zoledronic acid-mannitol-water intravenous piggyback zoledronic acid-mannitol-water intravenous solution ZOMETA INTRAVENOUS SOLUTION 4 MG/100 ML (Actonel) (Actonel) (Zometa) (Zoledronic Acid/Mannitol and Water) (Reclast) 1 1 1 1 1 PA BvD; (PA for ESRD Only) PA BvD; (PA for ESRD Only) PA BvD; (PA for ESRD Only) PA BvD; (PA for ESRD Only) QL (2.4 per 28 days) QL (3.7 per 28 days) PA BvD; (PA for ESRD Only); QL (3 per 84 days) QL (1 per 28 days) PA BvD; (PA for ESRD Only) PA; QL (2 per 28 days) PA BvD; (PA for ESRD Only) PA BvD; (PA for ESRD Only) QL (1 per 180 days) QL (1 per 28 days) QL (30 per 28 days) PA PA BvD; (PA for ESRD Only) 1 1 1 QL (100 per 300 days) 1 PA BvD 1 PA Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents ACTEMRA INTRAVENOUS SOLUTION 200 MG/10 ML (20 MG/ML) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 117 Effective: January 01, 2016 Drug Name ACTEMRA SUBCUTANEOUS ACTIMMUNE allopurinol amifostine crystalline ammonium chloride anticoag citrate phos dextrose AVONEX (WITH ALBUMIN) AVONEX INTRAMUSCULAR AVONEX INTRAMUSCULAR BENLYSTA INTRAVENOUS RECON SOLN BETASERON SUBCUTANEOUS bethanechol chloride BOTOX INJECTION RECON SOLN 100 UNIT BOTOX INJECTION RECON SOLN 200 UNIT buspirone CERDELGA colchicine oral tablet colchicine-probenecid COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML CYSTADANE dexrazoxane hcl intravenous recon soln droperidol injection solution ELMIRON ergoloid EXTAVIA SUBCUTANEOUS finasteride oral tablet 5 mg fomepizole FUSILEV GAUZE PAD TOPICAL BANDAGE 2 X 2" GILENYA GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) Drug Tier Requirements/Limits (Zyloprim) (Ethyol) (Ammonium Chloride) (Citrate Phosphate Dextros Soln) (Urecholine) (Buspirone HCl) (Colcrys) (Colchicine/Probenecid) (Totect) (Droperidol) (Ergoloid Mesylates) (Proscar) (Fomepizole) 1 1 1 1 1 1 PA 1 1 1 1 ST ST ST PA 1 1 1 ST 1 PA; QL (1 per 90 days) 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 PA; QL (4 per 90 days) PA ST PA; QL (28 per 28 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 118 Effective: January 01, 2016 Drug Name guanidine hydroxyzine hcl intramuscular hydroxyzine hcl oral solution 10 mg/5 ml hydroxyzine hcl oral tablet hydroxyzine pamoate JALYN LEMTRADA leucovorin calcium injection recon soln 100 mg, 200 mg, 350 mg leucovorin calcium oral levocarnitine (with sugar) levocarnitine oral mesna MESNEX ORAL MESTINON ORAL SYRUP MESTINON TIMESPAN methylergonovine injection morrhuate sodium MYOBLOC INTRAMUSCULAR SOLUTION 5,000 UNIT/ML NPLATE SUBCUTANEOUS RECON SOLN OTEZLA OTEZLA STARTER OTREXUP (PF) PLEGRIDY probenecid PROCYSBI pyridostigmine bromide oral tablet RASUVO (PF) REBIF (WITH ALBUMIN) REBIF REBIDOSE REBIF TITRATION PACK REMICADE SENSIPAR ORAL TABLET 30 MG Drug Tier Requirements/Limits (Guanidine HCl) (Hydroxyzine HCl) (Hydroxyzine HCl) (Hydroxyzine HCl) (Vistaril) (Leucovorin Calcium) 1 1 1 1 1 1 1 1 (Leucovorin Calcium) (Levocarnitine (With Sugar)) (Carnitor) 1 1 (Mesnex) 1 1 1 1 1 (Methylergonovine Maleate) (Sodium Morrhuate) (Probenecid) (Mestinon) 1 PA-HRM PA-HRM PA-HRM PA-HRM QL (30 per 30 days) PA PA BvD; (PA for ESRD Only) PA BvD; (PA for ESRD Only) 1 1 QL (1 per 90 days) 1 PA; QL (8 per 28 days) 1 1 1 1 1 1 1 1 1 1 1 1 1 PA; QL (60 per 30 days) PA; QL (60 per 30 days) ST PA You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 119 Effective: January 01, 2016 Drug Name Drug Tier Requirements/Limits SENSIPAR ORAL TABLET 60 MG, 90 MG SIGNIFOR SIMPONI ARIA SIMPONI SUBCUTANEOUS SYRINGE STELARA SUBCUTANEOUS SYRINGE STERILE PADS TOPICAL BANDAGE 2 X2" SYNAREL TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG (14)- 240 MG (46), 240 MG THALOMID 1 1 1 1 1 QL (60 per 30 days) PA PA PA 1 TYBOST ULORIC XELJANZ 1 1 PA; QL (14 per 30 days) 1 PA; QL (60 per 30 days) 1 PA NSO; QL (60 per 30 days) QL (30 per 30 days) ST; QL (30 per 30 days) PA; QL (60 per 30 days) 1 1 1 Non-Frf Non-Frf ibandronate intravenous syringe (Ibandronate Sodium) 1 megestrol oral suspension 625 mg/5 ml (Megestrol Acetate) 1 (Diamox Sequels) 1 (Acetazolamide) (Acetazolamide Sodium) 1 1 1 PA BvD; QL (3 per 84 days) Ophthalmic Agents Antiglaucoma Agents acetazolamide oral capsule, extended release acetazolamide oral tablet acetazolamide sodium ALPHAGAN P OPHTHALMIC DROPS 0.1 % AZOPT betaxolol ophthalmic BETOPTIC S (Betaxolol HCl) 1 1 1 You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 120 Effective: January 01, 2016 Drug Name brimonidine COMBIGAN dorzolamide dorzolamide-timolol latanoprost levobunolol LUMIGAN OPHTHALMIC DROPS 0.01 % methazolamide oral metipranolol PHOSPHOLINE IODIDE pilocarpine hcl ophthalmic drops 1 %, 2 %, 4 % SIMBRINZA timolol maleate ophthalmic drops timolol maleate ophthalmic gel forming solution TRAVATAN Z travoprost (benzalkonium) Drug Tier Requirements/Limits (Alphagan P) (Trusopt) (Cosopt) (Xalatan) (Betagan) (Neptazane) (Metipranolol) 1 1 1 1 1 1 1 (Isopto Carpine) 1 1 1 1 (Timolol Maleate) (Timoptic-Xe) 1 1 1 (Travoprost (Benzalkonium)) ZIOPTAN (PF) (drops: 0.15%, 0.20%) QL (2.5 per 25 days) 1 1 QL (2.5 per 25 days) QL (2.5 per 25 days) 1 QL (30 per 30 days) Replacement Preparations Replacement Preparations calcium chloride intravenous calcium gluconate intravenous (Calcium Chloride) (Calcium Gluconate) 1 1 citric acid-sodium citrate (Citric Acid/Sodium Citrate) (Dextrose 10 % and 0.45 % NaCl) (Dextrose 2.5 % and 0.45 % NaCl) (Dextrose 5 % and 0.9 % NaCl) (Dextrose 5 %-0.45 % NaCl) (Dextrose 10 % and 0.2 % NaCl) 1 d10 % & 0.45 % sodium chloride d2.5 %-0.45 % sodium chloride d5 % and 0.9 % sodium chloride d5 %-0.45 % sodium chloride dextrose 10 % and 0.2 % nacl PA BvD; (PA for ESRD Only) 1 1 1 1 1 You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 121 Effective: January 01, 2016 Drug Name dextrose 5 %-lactated ringers dextrose 5%-0.2 % sod chloride dextrose 5%-0.3 % sod.chloride dextrose with sodium chloride electrolyte-48 in d5w HYPERLYTE CR IONOSOL-B IN D5W IONOSOL-MB IN D5W ISOLYTE M IN 5 % DEXTROSE ISOLYTE-H IN 5 % DEXTROSE ISOLYTE-P IN 5 % DEXTROSE ISOLYTE-S klor-con 10 klor-con m10 klor-con m15 klor-con m20 magnesium chloride injection magnesium sulfate in d5w intravenous piggyback 1 gram/100 ml magnesium sulfate in water intravenous piggyback 4 gram/100 ml (4 %), 4 gram/50 ml (8 %) magnesium sulfate injection NORMOSOL-M IN 5 % DEXTROSE NORMOSOL-R PH 7.4 NUTRILYTE NUTRILYTE II phosphorus #1 PLASMA-LYTE 148 PLASMA-LYTE A PLASMA-LYTE-56 IN 5 % DEXTROSE potassium acetate intravenous potassium bicarb and chloride Drug Tier Requirements/Limits (Dextrose 5%-Lactated Ringers) (Dextrose 5 %-0.2 % NaCl) (Dextrose 5 % and 0.3 % NaCl) (Dextrose 5 %-0.2 % NaCl) (Electrolyte-48 Solution/D5W) (Potassium Chloride) (Potassium Chloride) (Potassium Chloride) (Potassium Chloride) (Magnesium Chloride) (Magnesium Sulfate/D5W) (Magnesium Sulfate in Water) (Magnesium Sulfate) (K-Phos Neutral) (Potassium Acetate) (Pot Chloride/Pot Bicarb/Cit Ac) 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 122 Effective: January 01, 2016 Drug Name potassium bicarb-citric acid potassium bicarbonate-cit ac oral tablet, effervescent 25 meq potassium chlorid-d5-0.45%nacl potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 30 meq/l, 40 meq/l potassium chloride in lr-d5 intravenous parenteral solution potassium chloride intravenous potassium chloride oral capsule, extended release potassium chloride oral liquid potassium chloride oral packet potassium chloride oral tablet extended release potassium chloride oral tablet,er particles/crystals 10 meq potassium chloride oral tablet,er particles/crystals 20 meq potassium chloride-0.45 % nacl potassium chloride-d5-0.2%nacl potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 meq/l potassium chloride-d5-0.9%nacl potassium citrate potassium citrate-citric acid oral packet potassium phosphate dibasic ringers intravenous sodium acetate intravenous Drug Tier Requirements/Limits (Klor-Con-Ef) (Klor-Con-Ef) 1 1 (Potassium Chloride/D50.45nacl) (Potassium Chloride In 0.9%NaCl) 1 (Potassium Chloride In D5w) 1 (Potassium Chloride In Lr-D5) (Potassium Chloride) (Micro-K) 1 (Potassium Chloride) (Klor-Con) (K-Tab ER) 1 1 1 (K-Tab ER) 1 (Potassium Chloride) 1 (Potassium Chloride0.45% NaCl) (Potassium Chloride/D50.2%NaCl) (Potassium Chloride/D50.3%NaCl) (Potassium Chloride/D50.9%NaCl) (Urocit-K) (Potassium Citrate/Citric Acid) (Potassium Phos,MBasic-D-Basic) (Ringers Solution) (Sodium Acetate) 1 1 1 1 1 1 1 1 1 1 1 1 You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 123 Effective: January 01, 2016 Drug Name Drug Tier Requirements/Limits sodium bicarbonate intravenous solution 1 (Sodium Bicarbonate) meq/ml (8.4 %) (Sodium Bicarbonate) sodium bicarbonate intravenous syringe (Sodium Chloride 0.45 sodium chloride 0.45 % intravenous %) (0.9 % Sodium sodium chloride 0.9 % injection solution Chloride) (0.9 % Sodium sodium chloride 0.9 % intravenous Chloride) (Sodium Chloride 3 %) sodium chloride 3 % (Sodium Chloride 5 %) sodium chloride 5 % (Sodium Chloride) sodium chloride intravenous (Citric Acid/Sodium sodium citrate-citric acid Citrate) (Sodium Lactate) sodium lactate intravenous (Sodium Phos,M-Basicsodium phosphate D-Basic) (Sod/Pot/K Cit/Sod sod-pot-k cit-sod cit-cit acid Cit/Cit Acid) TPN ELECTROLYTES TPN ELECTROLYTES II 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Respiratory Tract Agents Anti-Inflammatories, Inhaled Corticosteroids ADVAIR DISKUS ADVAIR HFA BREO ELLIPTA INHALATION BLISTER WITH DEVICE 100-25 MCG/DOSE DULERA FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 50 MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION 1 1 1 QL (60 per 30 days) QL (12 per 28 days) QL (60 per 30 days) 1 1 QL (13 per 28 days) QL (60 per 30 days) 1 QL (120 per 30 days) 1 QL (12 per 28 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 124 Effective: January 01, 2016 Drug Name Drug Tier Requirements/Limits FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION QVAR 1 QL (24 per 28 days) 1 QL (21.2 per 28 days) 1 QL (17.4 per 25 days) Antileukotrienes montelukast zafirlukast (Singulair) (Accolate) 1 1 (Albuterol Sulfate) 1 (Albuterol Sulfate) (Albuterol Sulfate) (Vospire ER) 1 1 1 Bronchodilators albuterol sulfate inhalation solution for nebulization albuterol sulfate oral syrup albuterol sulfate oral tablet albuterol sulfate oral tablet extended release 12 hr ATROVENT HFA COMBIVENT RESPIMAT FORADIL AEROLIZER metaproterenol oral PROAIR HFA PROAIR RESPICLICK SEREVENT DISKUS SPIRIVA RESPIMAT SPIRIVA WITH HANDIHALER STRIVERDI RESPIMAT terbutaline oral terbutaline subcutaneous theophylline anhydrous oral elixir 80 mg/15 ml theophylline anhydrous oral tablet extended release 12 hr 100 mg, 200 mg, 300 mg theophylline in dextrose 5 % intravenous parenteral solution 200 mg/100 ml, 200 mg/50 ml, 400 mg/250 ml, 400 mg/500 ml, 800 mg/250 ml (Metaproterenol Sulfate) (Terbutaline Sulfate) (Terbutaline Sulfate) (Theophylline Anhydrous) (Theophylline Anhydrous) (Theophylline/D5W) 1 1 1 1 1 1 1 1 1 1 1 1 1 PA BvD QL (25.8 per 28 days) QL (8 per 30 days) QL (60 per 30 days) QL (17 per 25 days) QL (2 per 30 days) QL (60 per 30 days) QL (4 per 30 days) QL (30 per 30 days) QL (4 per 28 days) 1 1 You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 125 Effective: January 01, 2016 Drug Name theophylline oral theophylline oral theophylline oral Drug Tier Requirements/Limits (Theophylline Anhydrous) (Theophylline Anhydrous) (Theophylline Anhydrous) TUDORZA PRESSAIR VENTOLIN HFA 1 1 1 1 1 QL (1 per 28 days) QL (36 per 25 days) 1 1 1 1 1 PA BvD PA BvD PA BvD QL (30 per 30 days) PA; QL (270 per 30 days) PA; QL (60 per 30 days) PA; QL (60 per 30 days) Respiratory Tract Agents, Other acetylcysteine acetylcysteine solution cromolyn inhalation DALIRESP ESBRIET (Acetadote) (Acetadote) (Cromolyn Sodium) KALYDECO OFEV PROLASTIN-C XOLAIR 1 1 1 1 PA Skeletal Muscle Relaxants Skeletal Muscle Relaxants baclofen carisoprodol (Baclofen) (Soma) 1 1 chlorzoxazone cyclobenzaprine oral tablet 10 mg, 5 mg dantrolene dantrolene sodium metaxalone methocarbamol oral tizanidine (Parafon Forte DSC) (Fexmid) (Dantrium) (Dantrium) (Skelaxin) (Robaxin) (Zanaflex) 1 1 1 1 1 1 1 PA-HRM; QL (120 per 30 days) PA-HRM PA-HRM PA-HRM PA-HRM Sleep Disorder Agents Sleep Disorder Agents HETLIOZ NUVIGIL ROZEREM XYREM 1 1 1 1 PA; QL (30 per 30 days) PA LA You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 126 Effective: January 01, 2016 Drug Name Drug Tier Requirements/Limits zaleplon (Sonata) 1 zolpidem oral tablet (Ambien) 1 zolpidem oral tablet,ext release multiphase (Ambien CR) 1 PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (60 per 30 days) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (30 per 30 days) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any non-benzodiazepine hypnotic drug); QL (30 per 30 days) Vasodilating Agents Vasodilating Agents ADCIRCA ADEMPAS CIALIS ORAL TABLET 2.5 MG, 5 MG epoprostenol (glycine) intravenous recon soln 0.5 mg epoprostenol (glycine) intravenous recon soln 1.5 mg LETAIRIS OPSUMIT ORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 MG (Flolan) 1 1 1 1 PA; QL (60 per 30 days) PA; QL (90 per 30 days) PA; QL (30 per 30 days) PA BvD (Flolan) 1 PA BvD 1 1 1 PA; QL (30 per 30 days) PA; QL (30 per 30 days) PA You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 127 Effective: January 01, 2016 Drug Name Drug Tier Requirements/Limits ORENITRAM ORAL TABLET EXTENDED RELEASE 0.25 MG, 1 MG, 2.5 MG REMODULIN (Revatio) sildenafil intravenous (Revatio) sildenafil oral TRACLEER 1 PA 1 1 1 1 TYVASO TYVASO REFILL KIT TYVASO STARTER KIT 1 1 1 PA BvD PA; QL (37.5 per 1 day) PA; QL (90 per 30 days) PA; LA; QL (60 per 30 days) PA BvD PA BvD PA BvD Vitamins And Minerals Vitamins And Minerals pedi m.vit no.17 with fluoride oral tablet,chewable 0.5 mg prenatal vitamins oral tablet 27 mg iron- 1 mg sodium fluoride oral tablet (Pedi M.Vit No.17 with Fluoride) (Pnv with Ca,No.72/Iron/Fa) (Pedi M.Vit No.17 with Fluoride) 1 1 (All Rx Prenatal Vitamins Covered) 1 You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 128 Effective: January 01, 2016 INDEX 8 8-MOP .................................... 99 A abacavir .................................. 81 abacavir-lamivudine-zidovudine ............................................ 81 ABELCET .............................. 74 ABILIFY DISCMELT ........... 79 ABILIFY MAINTENA .......... 79 ABRAXANE .......................... 62 acamprosate ............................ 53 acarbose .................................. 72 acebutolol ............................... 91 acetaminophen-codeine .......... 49 acetazolamide ....................... 120 acetazolamide sodium .......... 120 acetic acid ..................... 105, 116 acetylcysteine ....................... 126 acitretin ................................... 99 ACTEMRA .................. 117, 118 ACTHIB (PF) ....................... 114 ACTIMMUNE ..................... 118 ACTONEL ........................... 116 ACTOPLUS MET XR ........... 72 acyclovir ........................... 83, 99 acyclovir sodium .................... 83 ADACEL(TDAP ADOLESN/ADULT)(PF) 114 ADAGEN ............................. 103 adapalene .............................. 102 ADCETRIS ............................ 62 ADCIRCA ............................ 127 adefovir................................... 83 ADEMPAS ........................... 127 ADVAIR DISKUS ............... 124 ADVAIR HFA ..................... 124 AFINITOR ............................. 62 AFINITOR DISPERZ ........... 62 AGGRENOX ......................... 86 AKTEN (PF) ....................... 104 ALBENZA............................. 78 ALBUKED-25 ....................... 86 ALBUKED-5 ......................... 86 ALBUMIN, HUMAN 25 % .. 86 ALBUMIN, HUMAN 5 % .... 86 ALBUMINAR 25 %.............. 86 ALBUMINAR 5 %................ 86 ALBURX (HUMAN) 5 %..... 86 ALBUTEIN 25 % .................. 86 ALBUTEIN 5 % .................... 87 albuterol sulfate ................... 125 alclometasone ...................... 100 ALCOHOL PADS ................. 99 ALCOHOL PREP PADS ...... 99 ALDURAZYME ................. 103 alendronate........................... 116 alfuzosin............................... 109 ALIMTA................................ 62 ALINIA ................................. 78 allopurinol............................ 118 ALPHAGAN P .................... 120 alprazolam ............................. 54 ALREX ................................ 106 altacaine ............................... 104 ALTOPREV .......................... 94 amantadine hcl ....................... 78 AMBISOME.......................... 74 amifostine crystalline ........... 118 amiloride ................................ 94 amiloride-hydrochlorothiazide ........................................... 94 AMINO ACIDS 15 % ........... 87 aminocaproic acid .................. 86 AMINOSYN 10 % ................ 87 AMINOSYN 3.5 % ................ 87 AMINOSYN 7 % ................... 87 AMINOSYN 7 % WITH ELECTROLYTES ............. 87 AMINOSYN 8.5 % ................ 87 AMINOSYN 8.5 %ELECTROLYTES ............. 87 AMINOSYN II 10 % ............. 87 AMINOSYN II 15 % ............. 87 AMINOSYN II 7 % ............... 87 AMINOSYN II 8.5 % ............ 87 AMINOSYN II 8.5 %ELECTROLYTES ............. 87 AMINOSYN M 3.5 % ........... 87 AMINOSYN-HBC 7% .......... 87 AMINOSYN-PF 10 % ........... 87 AMINOSYN-PF 7 % (SULFITE-FREE) .............. 87 AMINOSYN-RF 5.2 % ......... 87 amiodarone ............................. 90 amiodarone hcl ....................... 90 AMITIZA............................. 107 amitriptyline ........................... 70 amlodipine.............................. 93 amlodipine-atorvastatin.......... 94 amlodipine-benazepril............ 93 amlodipine-valsartan .............. 93 amlodipine-valsartan-hcthiazid ............................................ 93 ammonium chloride ............. 118 ammonium lactate .................. 99 amoxapine .............................. 70 amoxicil-clarithromy-lansopraz .......................................... 106 amoxicillin ............................. 60 amoxicillin-pot clavulanate .... 60 amphetamine salt combo........ 96 I-1 VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 Effective: January 01, 2016 amphotericin b ........................ 75 ampicillin................................ 60 ampicillin sodium ............. 60, 61 ampicillin-sulbactam .............. 61 AMPYRA ............................... 96 ANACAINE ........................... 99 anagrelide ............................... 86 anastrozole .............................. 62 ANDRODERM .................... 109 ANDROGEL ........................ 110 anticoag citrate phos dextrose .......................................... 118 APOKYN ............................... 78 apraclonidine ........................ 104 APRISO ................................ 116 APTIOM................................. 68 APTIVUS ............................... 81 ARCALYST ......................... 113 aripiprazole ............................. 79 ASACOL HD ....................... 116 ashlyna .................................... 97 ASSURE ID INSULIN SAFETY ........................... 103 ASTAGRAF XL .................. 113 atenolol ................................... 91 atenolol-chlorthalidone........... 91 atorvastatin ............................. 94 atovaquone ............................. 78 atovaquone-proguanil ............. 78 ATRIPLA ............................... 81 atropine ........................... 68, 104 ATROVENT HFA ............... 125 AUBAGIO ........................... 113 AURYXIA ........................... 108 AVASTIN .............................. 62 AVC VAGINAL .................... 76 AVONEX ............................. 118 AVONEX (WITH ALBUMIN) .......................................... 118 AXIRON .............................. 110 azacitidine............................... 63 azathioprine .......................... 113 azathioprine sodium ............. 113 azelastine ............................. 104 AZILECT............................... 78 azithromycin .......................... 59 AZOPT ................................ 120 AZOR .................................... 93 aztreonam............................... 60 B bacitracin ....................... 57, 105 bacitracin-polymyxin b ........ 105 baclofen ............................... 126 balsalazide ........................... 116 BANZEL ............................... 68 BARACLUDE ....................... 83 BCG VACCINE, LIVE (PF) 114 BD ECLIPSE LUER-LOK .. 103 BD INSULIN PEN NEEDLE UF SHORT ...................... 103 BD INSULIN SYRINGE ULTRA-FINE.................. 103 BELEODAQ.......................... 63 benazepril............................... 90 benazepril-hydrochlorothiazide ........................................... 90 BENICAR.............................. 89 BENICAR HCT..................... 89 BENLYSTA ........................ 118 benztropine ............................ 78 BEPREVE ........................... 104 betamethasone acet,sod phos 111 betamethasone dipropionate 100 betamethasone valerate 100, 101 betamethasone, augmented .. 101 BETASERON...................... 118 betaxolol ........................ 91, 120 bethanechol chloride ............ 118 BETHKIS .............................. 56 BETOPTIC S ....................... 120 BEXSERO (PF) ................... 114 bicalutamide........................... 63 BICILLIN C-R ...................... 61 BICILLIN L-A ...................... 61 bisoprolol fumarate ................ 91 bisoprolol-hydrochlorothiazide ............................................ 91 bleomycin ............................... 63 BLEPHAMIDE .................... 105 BLEPHAMIDE S.O.P. ........ 105 BLINCYTO ........................... 63 BOOSTRIX TDAP .............. 114 BOSULIF ............................... 63 BOTOX ................................ 118 BREO ELLIPTA.................. 124 BRILINTA ............................. 86 brimonidine .......................... 121 BRINTELLIX ........................ 71 bromfenac ............................ 106 bromocriptine ......................... 78 budesonide ........................... 116 bumetanide ............................. 94 BUMINATE 25 % ................. 87 BUMINATE 5 % ................... 87 BUPHENYL ........................ 107 buprenorphine hcl ............ 49, 53 buprenorphine-naloxone ........ 53 bupropion hcl ................... 53, 71 buspirone .............................. 118 butalb-acetaminophen-caffeine ............................................ 49 butalbital-acetaminop-caf-cod 49 butalbital-acetaminophen ....... 49 butalbital-acetaminophen-caff 49 butalbital-aspirin-caffeine ...... 49 BUTRANS ............................. 49 BYSTOLIC ............................ 91 C cabergoline ............................. 78 caffeine citrated ...................... 96 caffeine-sodium benzoate ...... 96 calcipotriene ........................... 99 calcitonin (salmon)............... 116 calcitriol ......................... 99, 117 calcium acetate ..................... 108 I-2 VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 Effective: January 01, 2016 calcium carbonate-mag carb-fa .......................................... 108 calcium chloride ................... 121 calcium gluconate ................. 121 CALDOLOR .......................... 51 CANCIDAS ........................... 75 candesartan ............................. 89 candesartan-hydrochlorothiazid ............................................ 89 CAPASTAT ........................... 77 CAPRELSA ........................... 63 captopril.................................. 90 captopril-hydrochlorothiazide 90 CARAFATE ......................... 106 CARBAGLU ........................ 107 carbamazepine ........................ 68 carbidopa ................................ 78 carbidopa-levodopa ................ 78 carbidopa-levodopa-entacapone ............................................ 78 carbinoxamine maleate ........... 76 CARIMUNE NF NANOFILTERED ........... 113 carisoprodol .......................... 126 carteolol ................................ 104 cartia xt ................................... 91 carvedilol ................................ 91 CAYSTON ............................. 60 cefaclor ................................... 58 cefadroxil................................ 58 cefazolin ................................. 58 cefazolin in dextrose (iso-os) . 58 cefdinir ................................... 58 cefditoren pivoxil ................... 58 cefepime ................................. 58 CEFEPIME IN DEXTROSE 5 %......................................... 58 CEFEPIME IN DEXTROSE,ISO-OSM...... 58 cefotaxime .............................. 59 cefoxitin.................................. 59 cefoxitin in dextrose, iso-osm 59 cefpodoxime .......................... 59 cefprozil ................................. 59 ceftazidime............................. 59 ceftibuten ............................... 59 ceftriaxone ............................. 59 CEFTRIAXONE ................... 59 ceftriaxone in dextrose,iso-os 59 CEFTRIAXONE IN DEXTROSE,ISO-OS ........ 59 cefuroxime axetil ................... 59 cefuroxime sodium ................ 59 cefuroxime-dextrose (iso-osm) ........................................... 59 celecoxib ................................ 51 CELLCEPT INTRAVENOUS ......................................... 113 CELONTIN ........................... 68 cephalexin .............................. 59 CEPROTIN (BLUE BAR) .... 84 CERDELGA ........................ 118 CEREZYME........................ 103 CERVARIX VACCINE (PF) ......................................... 114 cevimeline .............................. 98 CHANTIX ............................. 53 CHANTIX CONTINUING MONTH BOX ................... 53 CHANTIX CONTINUING MONTH PAK.................... 53 CHANTIX STARTING MONTH BOX ................... 53 chloramphenicol sod succinate ........................................... 57 chlordiazepoxide hcl .............. 54 chlorhexidine gluconate ......... 99 chloroquine phosphate ........... 78 chlorothiazide ........................ 94 chlorothiazide sodium............ 94 chlorpromazine ...................... 79 chlorthalidone ........................ 94 chlorzoxazone ...................... 126 cholestyramine (with sugar) .. 94 cholestyramine-aspartame 94, 95 choline,magnesium salicylate 51 CIALIS................................. 127 ciclopirox ............................... 75 ciclopirox-ure-camph-mentheuc ...................................... 75 cidofovir ................................. 83 cilostazol ................................ 86 CILOXAN............................ 105 cimetidine ............................. 107 cimetidine hcl ....................... 107 CIMZIA ............................... 113 CIMZIA POWDER FOR RECONST ....................... 113 CINRYZE .............................. 85 CIPRODEX.......................... 105 ciprofloxacin .......................... 61 ciprofloxacin hcl ............ 61, 105 ciprofloxacin in 5 % dextrose 61 ciprofloxacin lactate ............... 61 citalopram .............................. 71 citric acid-sodium citrate...... 121 clarithromycin .................. 59, 60 clemastine .............................. 76 CLEVIPREX.......................... 93 clindamycin hcl ...................... 57 clindamycin in 5 % dextrose .. 57 clindamycin palmitate hcl ...... 57 clindamycin phosphate.... 57, 76, 100 CLINIMIX 5%/D15W SULFITE FREE ................. 87 CLINIMIX 5%/D25W SULFITE-FREE ................ 87 CLINIMIX 2.75%/D5W SULFIT FREE ................... 87 CLINIMIX 4.25%/D10W SULF FREE .................................. 87 CLINIMIX 4.25%/D5W SULFIT FREE ................... 87 CLINIMIX 4.25%-D20W SULF-FREE....................... 87 I-3 VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 Effective: January 01, 2016 CLINIMIX 4.25%-D25W SULF-FREE ....................... 87 CLINIMIX 5%D20W(SULFITE-FREE) ... 87 CLINIMIX E 2.75%/D10W SUL FREE.......................... 87 CLINIMIX E 2.75%/D5W SULF FREE ....................... 87 CLINIMIX E 4.25%/D10W SUL FREE.......................... 88 CLINIMIX E 4.25%/D25W SUL FREE.......................... 88 CLINIMIX E 4.25%/D5W SULF FREE ....................... 88 CLINIMIX E 5%/D15W SULFIT FREE.................... 88 CLINIMIX E 5%/D20W SULFIT FREE.................... 88 CLINIMIX E 5%/D25W SULFIT FREE.................... 88 CLINISOL SF 15 % ............... 88 clobetasol .............................. 101 clobetasol propionate............ 101 clobetasol-emollient ............. 101 clocortolone pivalate ............ 101 clomipramine .......................... 71 clonazepam ............................. 54 clonidine ................................. 89 clonidine hcl ..................... 89, 96 clonidine hcl-chlorthalidone ... 89 clopidogrel .............................. 86 clorazepate dipotassium ......... 54 clotrimazole ............................ 75 clotrimazole-betamethasone ... 75 clozapine................................. 79 COARTEM ............................ 78 codeine sulfate ........................ 49 codeine-butalbital-asa-caffein 49 colchicine ............................. 118 colchicine-probenecid .......... 118 colestipol ................................ 95 colistin (colistimethate na) ..... 57 COLY-MYCIN S ................ 105 COMBIGAN ....................... 121 COMBIPATCH ................... 110 COMBIVENT RESPIMAT. 125 COMETRIQ .......................... 63 COMPLERA ......................... 81 COMVAX (PF) ................... 114 CONDYLOX ......................... 99 COPAXONE ....................... 118 cortisone............................... 111 CORTISPORIN-TC ............ 105 COSENTYX (2 SYRINGES) 99 COSENTYX PEN ................. 99 COSENTYX PEN (2 PENS) . 99 CREON................................ 103 CRESTOR ............................. 95 CRIXIVAN............................ 81 cromolyn .............. 104, 107, 126 CUBICIN ............................... 57 cyclobenzaprine ................... 126 CYCLOGYL ....................... 104 cyclopentolate ...................... 104 cyclophosphamide ................. 63 CYCLOPHOSPHAMIDE ..... 63 CYCLOSET........................... 72 cyclosporine ......................... 113 cyclosporine modified ......... 113 cyclosporine, modified ........ 113 cyproheptadine....................... 76 CYRAMZA ........................... 63 CYSTADANE ..................... 118 CYSTARAN........................ 104 cysteine (l-cysteine) ............... 88 D d10 % & 0.45 % sodium chloride ............................ 121 d10 %-0.9 % sodium chloride 88 d2.5 %-0.45 % sodium chloride ......................................... 121 d5 % and 0.9 % sodium chloride ......................................... 121 d5 %-0.45 % sodium chloride .......................................... 121 dactinomycin .......................... 63 DALIRESP .......................... 126 danazol ................................. 110 dantrolene ............................. 126 dantrolene sodium ................ 126 dapsone .................................. 77 DAPTACEL (DTAP PEDIATRIC) (PF) ........... 114 DARAPRIM .......................... 78 DAUNOXOME ..................... 63 deblitane ................................. 97 decitabine ............................... 63 deferoxamine........................ 109 DELZICOL .......................... 116 DEMSER ............................... 92 DENAVIR.............................. 99 DEPEN TITRATABS.......... 109 DEPO-PROVERA ............... 112 desipramine ............................ 71 desmopressin ........................ 111 desog-e.estradiol/e.estradiol ... 97 desogestrel-ethinyl estradiol .. 97 desonide ............................... 101 desoximetasone .................... 101 DESVENLAFAXINE FUMARATE...................... 71 dexamethasone ..................... 111 dexamethasone sodium phosphate ................. 106, 111 DEXILANT ......................... 107 dexmethylphenidate ............... 96 dexrazoxane hcl ................... 118 dextroamphetamine ................ 96 dextroamphetamineamphetamine ...................... 96 dextrose 10 % and 0.2 % nacl .......................................... 121 dextrose 10 % in water (d10w) ............................................ 88 I-4 VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 Effective: January 01, 2016 dextrose 2.5 % in water(d2.5w) ............................................ 88 dextrose 20 % in water (d20w) ............................................ 88 dextrose 25 % in water (d25w) ............................................ 88 dextrose 40 % in water (d40w) ............................................ 88 dextrose 5 % in ringers ........... 88 dextrose 5 % in water (d5w) .. 88 dextrose 5 %-lactated ringers .......................................... 122 dextrose 5%-0.2 % sod chloride .......................................... 122 dextrose 5%-0.3 % sod.chloride .......................................... 122 dextrose 50 % in water (d50w) ............................................ 88 dextrose 70 % in water (d70w) ............................................ 88 dextrose with sodium chloride .......................................... 122 diazepam................................. 54 diazepam intensol ................... 54 diclofenac potassium .............. 51 diclofenac sodium .......... 51, 106 diclofenac-misoprostol ........... 51 dicloxacillin ............................ 61 dicyclomine .......................... 107 didanosine............................... 81 DIFICID ................................. 60 diflunisal ................................. 51 digitek ..................................... 92 digoxin.................................... 92 DIGOXIN ............................... 92 dihydroergotamine ................. 76 DILANTIN ............................. 68 diltiazem hcl ..................... 91, 92 dilt-xr ...................................... 92 dimenhydrinate ....................... 77 DIPENTUM ......................... 116 diphenhydramine hcl .............. 76 diphenoxylate-atropine ........ 107 disopyramide phosphate ........ 90 disulfiram ............................... 54 divalproex .............................. 68 dobutamine ............................ 93 dobutamine in d5w ................ 93 docetaxel ................................ 63 donepezil................................ 70 dopamine ............................... 93 dopamine in 5 % dextrose ..... 93 dorzolamide ......................... 121 dorzolamide-timolol ............ 121 doxazosin ............................... 89 doxepin .................................. 71 doxercalciferol ..................... 117 doxorubicin hcl ...................... 63 doxorubicin hcl peg-liposomal ........................................... 63 doxorubicin, peg-liposomal ... 63 doxycycline hyclate ............... 62 doxycycline monohydrate...... 62 dronabinol .............................. 77 droperidol............................. 118 drospirenone-ethinyl estradiol 97 DROXIA................................ 63 DUAVEE ............................. 110 DULERA ............................. 124 duloxetine .............................. 71 DUREZOL........................... 106 DYRENIUM.......................... 94 E econazole ............................... 75 EDARBI ................................ 89 EDARBYCLOR .................... 89 EDURANT ............................ 81 EFFIENT ............................... 86 ELAPRASE ......................... 103 electrolyte-48 in d5w ........... 122 ELIDEL ............................... 101 ELIGARD........................ 63, 64 ELIQUIS................................ 84 ELITEK ............................... 103 ELLA ..................................... 97 ELMIRON ........................... 118 EMBEDA............................... 49 EMCYT.................................. 64 EMEND ................................. 77 EMSAM ................................. 71 EMTRIVA ............................. 81 enalapril maleate .................... 90 enalaprilat ............................... 90 enalapril-hydrochlorothiazide 90 ENBREL .............................. 113 ENBREL SURECLICK ....... 113 ENGERIX-B (PF) ................ 114 ENGERIX-B PEDIATRIC (PF) .......................................... 114 enoxaparin .............................. 84 entacapone.............................. 78 entecavir ................................. 83 ephedrine sulfate .................... 93 epinastine ............................. 104 epinephrine............................. 93 EPIPEN 2-PAK...................... 93 EPIPEN JR 2-PAK ................ 93 EPIVIR HBV ......................... 81 eplerenone .............................. 95 EPOGEN ................................ 85 epoprostenol (glycine) ......... 127 EPZICOM .............................. 81 ergoloid ................................ 118 ERGOMAR............................ 76 ERIVEDGE............................ 64 ERYTHROCIN ...................... 60 erythromycin .................. 60, 105 erythromycin base .................. 60 ERYTHROMYCIN BASE .... 60 erythromycin base-ethanol ... 100 erythromycin ethylsuccinate .. 60 erythromycin stearate ............. 60 erythromycin with ethanol ... 100 erythromycin-benzoyl peroxide .......................................... 100 ESBRIET ............................. 126 I-5 VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 Effective: January 01, 2016 escitalopram oxalate ............... 71 esmolol ................................... 91 esomeprazole sodium ........... 107 estazolam .......................... 54, 55 ESTRACE ............................ 110 estradiol ................................ 110 estradiol valerate .................. 110 estradiol/norethindrone acet . 110 estradiol-norethindrone acet . 110 ESTRING ............................. 110 estropipate ............................ 110 ethambutol .............................. 77 ethamolin ................................ 93 ethinyl estradiol/drospirenone 97 ethosuximide .......................... 68 ethynodiol d-ethinyl estradiol. 97 etodolac .................................. 51 ETOPOPHOS ......................... 64 etoposide................................. 64 EURAX ................................ 102 EVOTAZ ................................ 81 EXELDERM .......................... 75 exemestane ............................. 64 EXJADE ............................... 109 EXTAVIA ............................ 118 F FABRAZYME ..................... 103 famciclovir ............................. 83 famotidine............................. 107 famotidine (pf)...................... 107 famotidine (pf)-nacl (iso-os)107 FANAPT ................................ 79 FARESTON ........................... 64 FARYDAK............................. 64 FASLODEX ........................... 64 felbamate ................................ 68 felodipine ................................ 94 FEMRING ............................ 110 fenofibrate .............................. 95 fenofibrate micronized ........... 95 fenofibrate nanocrystallized ... 95 fenofibric acid ........................ 95 fenofibric acid (choline) ........ 95 fenoprofen .............................. 52 fentanyl .................................. 49 fentanyl citrate ....................... 49 FERRIPROX ....................... 109 FETZIMA .............................. 71 finasteride ............................ 118 FIRAZYR .............................. 93 FLEBOGAMMA DIF ......... 113 flecainide ............................... 90 FLECTOR ............................. 52 FLEXBUMIN 25 %............... 87 FLEXBUMIN 5 %................. 87 FLOVENT DISKUS............ 124 FLOVENT HFA .......... 124, 125 floxuridine ............................. 64 fluconazole............................. 75 fluconazole in dextrose(iso-o) 75 fluconazole in nacl (iso-osm) 75 flucytosine ............................. 75 fludrocortisone ..................... 111 flumazenil .............................. 96 flunisolide ............................ 106 fluocinonide ......................... 101 fluocinonide-emollient base 101 fluorometholone................... 106 FLUOROPLEX ..................... 99 fluorouracil ...................... 64, 99 fluoxetine ............................... 71 FLUOXETINE ...................... 71 fluoxymesterone .................. 110 fluphenazine decanoate.......... 79 fluphenazine hcl..................... 79 flurazepam ............................. 55 flurbiprofen ............................ 52 flurbiprofen sodium ............. 106 flutamide ................................ 64 fluticasone.................... 101, 106 fluvoxamine ........................... 71 fomepizole ........................... 118 fondaparinux .......................... 84 FORADIL AEROLIZER..... 125 FORTEO .............................. 117 FORTICAL .......................... 117 foscarnet ................................. 83 fosinopril ................................ 90 fosinopril-hydrochlorothiazide ............................................ 90 fosphenytoin ........................... 68 FOSRENOL ......................... 109 FREAMINE HBC 6.9 %........ 88 FREAMINE III 10 % ............. 88 furosemide.............................. 94 FUSILEV ............................. 118 FUZEON ................................ 81 FYCOMPA ............................ 68 G gabapentin .............................. 68 GABITRIL ............................. 69 galantamine ............................ 70 GAMASTAN S/D................ 113 GAMMAGARD LIQUID .... 113 GAMMAPLEX .................... 113 GAMUNEX-C ..................... 113 ganciclovir sodium ................. 83 GARDASIL (PF) ................. 114 GARDASIL 9 (PF) .............. 114 gatifloxacin .......................... 105 GATTEX 30-VIAL.............. 107 GATTEX ONE-VIAL ......... 107 GAUZE PAD ....................... 118 GAZYVA ............................... 64 gemcitabine ............................ 64 gemfibrozil ............................. 95 GENOTROPIN .................... 111 GENOTROPIN MINIQUICK .................................. 111, 112 gentamicin .............. 56, 100, 105 gentamicin in nacl (iso-osm) .. 56 gentamicin sulfate ................ 105 gentamicin sulfate (ped) (pf) .. 56 gentamicin sulfate (pf) ........... 56 GEODON ............................... 79 gildess 24 fe ........................... 97 I-6 VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 Effective: January 01, 2016 GILENYA ............................ 118 GILOTRIF.............................. 64 GLEEVEC.............................. 64 glimepiride ............................. 74 glipizide .................................. 74 glipizide-metformin ................ 74 GLUCAGEN HYPOKIT ..... 118 GLUCAGON EMERGENCY KIT (HUMAN) ................ 118 glyburide................................. 74 glyburide micronized.............. 74 glyburide-metformin .............. 74 glycopyrrolate....................... 107 glydo ....................................... 53 GLYSET................................. 72 GLYXAMBI .......................... 72 GRALISE ............................... 69 GRALISE 30-DAY STARTER PACK ................................. 69 granisetron (pf) ....................... 77 granisetron hcl ........................ 77 GRANIX ................................ 85 griseofulvin microsize ............ 75 guanfacine ........................ 89, 96 guanidine .............................. 119 H halobetasol propionate.......... 101 haloperidol .............................. 79 haloperidol decanoate ............. 79 haloperidol lactate .................. 79 HARVONI ............................. 83 HAVRIX (PF) ...................... 115 heparin (porcine) .................... 85 heparin (porcine) in 5 % dex .. 85 heparin (porcine) in nacl (pf) . 85 heparin sodium,porcine-pf ..... 85 heparin(porcine) in 0.45% nacl ............................................ 85 heparin, porcine (pf) ............... 85 HEPATAMINE 8%................ 88 HEPATASOL 8 % ................. 88 HERCEPTIN .......................... 64 HETLIOZ ............................ 126 HEXALEN ............................ 64 homatropine hbr................... 104 HUMIRA ............................. 113 HUMIRA CROHN'S DIS START PCK .................... 113 HUMIRA PEN .................... 113 HUMULIN R U-500 ............. 73 hydralazine............................. 93 hydrochlorothiazide ............... 94 hydrocodone-acetaminophen . 49 hydrocodone-ibuprofen ......... 49 hydrocortisone ..... 101, 102, 111 hydrocortisone acet-aloe vera ......................................... 101 hydrocortisone acetate-urea . 101 hydrocortisone butyrate ....... 102 hydrocortisone butyr-emollient ......................................... 102 hydrocortisone sod succinate111 hydrocortisone valerate........ 102 hydromorphone...................... 50 hydromorphone (pf)......... 49, 50 hydroxychloroquine ............... 78 hydroxyurea ........................... 64 hydroxyzine hcl ................... 119 hydroxyzine pamoate ........... 119 HYPERLYTE CR................ 122 HYQVIA ............................. 113 I ibandronate .................. 117, 120 IBRANCE.............................. 64 ibuprofen................................ 52 ICLUSIG ............................... 64 ifosfamide .............................. 64 ifosfamide-mesna................... 64 ILARIS (PF) ........................ 113 ILEVRO............................... 106 IMBRUVICA ........................ 64 imipenem-cilastatin ............... 60 imipramine hcl ....................... 71 imipramine pamoate .............. 71 imiquimod .............................. 99 IMOGAM RABIES-HT (PF) .......................................... 113 IMOVAX RABIES VACCINE (PF) .................................. 115 INCRELEX .......................... 112 indapamide ............................. 94 indomethacin .......................... 52 indomethacin sodium ............. 52 INFANRIX (DTAP) (PF) .... 115 INLYTA ........................... 64, 65 INSULIN PEN NEEDLE .... 103 INSULIN SYRINGE-NEEDLE U-100 ............................... 103 INTELENCE.................... 81, 82 INTRALIPID ......................... 88 INTRON A............................. 83 INVANZ ................................ 60 INVEGA .......................... 79, 80 INVEGA SUSTENNA .......... 80 INVEGA TRINZA................. 80 INVIRASE ............................. 82 INVOKAMET ....................... 72 INVOKANA .......................... 72 IONOSOL-B IN D5W ......... 122 IONOSOL-MB IN D5W...... 122 IPOL ..................................... 115 ipratropium bromide ............ 104 IPRIVASK ............................. 85 irbesartan ................................ 89 irbesartan-hydrochlorothiazide ............................................ 89 ISENTRESS........................... 82 ISOLYTE M IN 5 % DEXTROSE..................... 122 ISOLYTE-H IN 5 % DEXTROSE..................... 122 ISOLYTE-P IN 5 % DEXTROSE..................... 122 ISOLYTE-S ......................... 122 isoniazid ................................. 77 isosorbide dinitrate ................. 95 I-7 VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 Effective: January 01, 2016 isosorbide mononitrate ........... 95 isotretinoin.............................. 99 isradipine ................................ 94 itraconazole ............................ 75 ivermectin ............................... 78 IXEMPRA .............................. 65 IXIARO (PF) ........................ 115 J JAKAFI .................................. 65 JALYN ................................. 119 jantoven .................................. 85 JANUMET ............................. 72 JANUMET XR....................... 72 JANUVIA............................... 72 JARDIANCE .......................... 73 JENTADUETO ...................... 73 junel fe 24 ............................... 98 JUXTAPID ............................. 95 K KABIVEN .............................. 88 KALETRA ............................. 82 KALYDECO ........................ 126 KAZANO ............................... 73 KEDBUMIN .......................... 87 ketoconazole ........................... 75 ketoprofen............................... 52 ketorolac ......................... 52, 106 KEYTRUDA .......................... 65 KINERET ............................. 113 KINRIX (PF) ........................ 115 klor-con 10 ........................... 122 klor-con m10 ........................ 122 klor-con m15 ........................ 122 klor-con m20 ........................ 122 KORLYM............................... 73 KRYSTEXXA ...................... 103 KUVAN ............................... 103 KYNAMRO ........................... 95 KYPROLIS ............................ 65 L l norgest/e.estradiol-e.estrad ... 98 labetalol .................................. 91 LACRISERT ....................... 104 LACTATED RINGERS ...... 116 lactulose ............................... 107 LAMICTAL........................... 69 LAMICTAL ODT STARTER (BLUE) .............................. 69 LAMICTAL ODT STARTER (GREEN) ........................... 69 LAMICTAL ODT STARTER (ORANGE) ........................ 69 lamivudine ............................. 82 lamivudine-zidovudine .......... 82 lamotrigine ............................. 69 LANOXIN ............................. 93 lansoprazole ......................... 107 LANTUS ............................... 73 LANTUS SOLOSTAR .......... 73 larin 24 fe ............................... 98 latanoprost ........................... 121 LATUDA ............................... 80 LAZANDA ............................ 50 leflunomide .......................... 114 LEMTRADA ....................... 119 LENVIMA ............................. 65 LETAIRIS ........................... 127 letrozole ................................. 65 leucovorin calcium .............. 119 LEUKERAN.......................... 65 LEUKINE .............................. 85 leuprolide ............................... 65 levetiracetam .......................... 69 levetiracetam in nacl (iso-os) . 69 levobunolol .......................... 121 levocarnitine ........................ 119 levocarnitine (with sugar) .... 119 levocetirizine ......................... 76 levofloxacin ................... 61, 105 levofloxacin in d5w ............... 61 levonorgestrel ........................ 98 levonorgestrel-ethin estradiol 98 levonorgestrel-ethinyl estrad . 98 levothyroxine ....................... 113 LEXIVA ................................. 82 lidocaine ................................. 53 lidocaine (pf) .................... 53, 90 lidocaine hcl ........................... 53 lidocaine in 5 % dextrose (pf) 90 lidocaine-prilocaine................ 53 linezolid.................................. 57 LINZESS.............................. 108 liothyronine .......................... 113 lipase-protease-amylase ....... 103 LIPOSYN II ........................... 88 LIPOSYN III.......................... 88 lisinopril ................................. 90 lisinopril-hydrochlorothiazide 90 lithium carbonate ............. 96, 97 lithium citrate ......................... 97 l-norgest-eth estr/ethin estra ... 98 lomustine ................................ 65 loperamide............................ 108 lorazepam oral solution .......... 55 losartan ................................... 89 losartan-hydrochlorothiazide . 89 LOTEMAX .......................... 106 LOTRONEX ........................ 108 lovastatin ................................ 95 loxapine succinate .................. 80 LUMIGAN ........................... 121 LUPRON DEPOT .................. 65 LUPRON DEPOT (3 MONTH) ............................................ 65 LUPRON DEPOT (4 MONTH) ............................................ 65 LUPRON DEPOT (6 MONTH) ............................................ 65 LUPRON DEPOT-PED ....... 112 LUPRON DEPOT-PED (3 MONTH).......................... 112 LYNPARZA .......................... 65 LYRICA................................. 69 LYSODREN .......................... 65 M magnesium chloride ............. 122 I-8 VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 Effective: January 01, 2016 magnesium sulfate ................ 122 magnesium sulfate in d5w .... 122 magnesium sulfate in water .. 122 malathion .............................. 102 maprotiline ............................. 71 MARPLAN ............................ 71 MARQIBO ............................. 65 MATULANE ......................... 65 matzim la ................................ 92 meclizine ................................ 77 medroxyprogesterone ........... 112 mefenamic acid ...................... 52 mefloquine .............................. 78 MEFOXIN IN DEXTROSE (ISO-OSM) ......................... 59 MEGACE ES ....................... 112 megestrol ................ 65, 112, 120 MEKINIST ............................. 65 meloxicam .............................. 52 melphalan hcl intravenous ...... 65 MENACTRA (PF) ............... 115 MENEST .............................. 110 MENHIBRIX (PF) ............... 115 MENOMUNE - A/C/Y/W-135 (PF) ................................... 115 MENVEO A-C-Y-W-135-DIP (PF) ................................... 115 MENVEO MENA COMPONENT (PF) ......... 115 MENVEO MENCYW-135 COMPNT (PF) ................. 115 mercaptopurine ....................... 65 meropenem ............................. 60 mesna .................................... 119 MESNEX ............................. 119 MESTINON ......................... 119 MESTINON TIMESPAN .... 119 metaproterenol ...................... 125 metaxalone ........................... 126 metformin ............................... 73 methadone .............................. 50 methadone hcl ........................ 50 methazolamide ..................... 121 methenamine hippurate.......... 57 methenamine mandelate ........ 57 methimazole......................... 113 methocarbamol .................... 126 methotrexate sodium.............. 65 methotrexate sodium (pf)....... 65 methoxsalen rapid .................. 99 methscopolamine ................. 108 methyclothiazide .................... 94 methylergonovine ................ 119 methylphenidate..................... 97 methylprednisolone ............. 111 methylprednisolone acetate . 111 methylprednisolone sodium succ ......................................... 111 metipranolol ......................... 121 metoclopramide hcl ............. 108 metolazone ............................. 94 metoprolol succinate .............. 91 metoprolol ta-hydrochlorothiaz ........................................... 91 metoprolol tartrate ................. 91 metronidazole .......... 57, 76, 100 metronidazole in nacl (iso-os) 57 mexiletine .............................. 90 MIACALCIN....................... 117 miconazole nitrate.................. 75 midazolam ............................. 55 midodrine ............................... 89 milrinone................................ 93 milrinone in 5 % dextrose ...... 93 minitran............................ 95, 96 MINOCIN.............................. 62 minocycline ........................... 62 minoxidil................................ 96 MIRCERA ............................. 85 mirtazapine ............................ 71 misoprostol .......................... 107 mitoxantrone .......................... 65 M-M-R II (PF) ..................... 115 moexipril................................ 90 moexipril-hydrochlorothiazide ............................................ 90 mometasone ......................... 102 montelukast .......................... 125 morphine ................................ 50 MORPHINE........................... 50 morphine concentrate ............. 50 morrhuate sodium ................ 119 MOVANTIK ........................ 108 MOVIPREP ......................... 108 MOXEZA ............................ 105 moxifloxacin .......................... 61 MOZOBIL ............................. 86 MULTAQ .............................. 90 mupirocin ............................. 100 mupirocin calcium ............... 100 mycophenolate mofetil......... 114 mycophenolate sodium ........ 114 MYOBLOC.......................... 119 MYOZYME ......................... 103 MYRBETRIQ ...................... 109 N nabumetone ............................ 52 nadolol.................................... 91 nafcillin .................................. 61 NAGLAZYME .................... 103 naloxone ................................. 54 naltrexone ............................... 54 naltrexone hcl ......................... 54 NAMENDA XR..................... 70 NAMZARIC .......................... 70 naphazoline .......................... 104 naproxen................................. 52 naproxen sodium .................... 52 naratriptan .............................. 76 NATACYN .......................... 105 nateglinide .............................. 73 NATPARA........................... 117 NEBUPENT........................... 78 nefazodone ............................. 71 neomy sulf-bacitrac zn-poly-hc .......................................... 105 I-9 VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 Effective: January 01, 2016 neomycin ................................ 56 neomycin-bacitracin-poly-hc105 neomycin-bacitracin-polymyxin .......................................... 105 neomycin-polymyxin b gu ... 100 neomycin-polymyxin bdexameth .......................... 105 neomycin-polymyxingramicidin......................... 105 neomycin-polymyxin-hc ...... 105 neo-polycin ........................... 105 NEPHRAMINE 5.4 % ........... 88 NESINA ................................. 73 NEULASTA ........................... 86 NEUMEGA ............................ 86 NEUPOGEN .......................... 86 NEUPRO ................................ 78 NEVANAC .......................... 106 nevirapine ............................... 82 NEXAVAR ............................ 65 niacin ...................................... 95 nicardipine .............................. 94 NICOTROL ............................ 54 nifedipine ................................ 94 NILANDRON ........................ 66 NITRO-BID ........................... 96 nitrofurantoin macrocrystal .... 57 nitrofurantoin monohyd/m-cryst ............................................ 58 nitroglycerin ........................... 96 nitroglycerin in 5 % dextrose . 96 NITROSTAT .......................... 96 nizatidine .............................. 107 NORDITROPIN FLEXPRO 112 NORDITROPIN NORDIFLEX .......................................... 112 norelgestromin/ethin.estradiol 98 norepinephrine bitartrate ........ 93 norethindrone ......................... 98 norethindrone (contraceptive) 98 norethindrone acetate ........... 112 norethindrone ac-eth estradiol 98 norethindrone-e.estradiol-iron 98 norethindrone-ethinyl estrad .. 98 norethindrone-mestranol ........ 98 norgestimate-ethinyl estradiol 98 norgestrel-ethinyl estradiol .... 98 NORMOSOL-M IN 5 % DEXTROSE .................... 122 NORMOSOL-R PH 7.4....... 122 NORTHERA ......................... 89 nortriptyline ........................... 71 NORVIR ................................ 82 NOVOLIN 70/30 ................... 73 NOVOLIN N ......................... 73 NOVOLIN R ......................... 73 NOVOLOG ........................... 73 NOVOLOG FLEXPEN ......... 73 NOVOLOG MIX 70-30 ........ 73 NOVOLOG MIX 70-30 FLEXPEN.......................... 74 NOVOLOG PENFILL .......... 74 NOXAFIL.............................. 75 NPLATE .............................. 119 NUCYNTA............................ 50 NUCYNTA ER ..................... 50 NUEDEXTA ......................... 97 NULOJIX ............................ 114 NUTRESTORE ................... 108 NUTRILIPID ......................... 88 NUTRILYTE ....................... 122 NUTRILYTE II ................... 122 NUVARING .......................... 98 NUVIGIL............................. 126 nystatin................................... 75 NYSTATIN (BULK) ............. 75 nystatin-triamcinolone ........... 75 O OCTAGAM ......................... 114 octreotide acetate ................. 112 OFEV ................................... 126 ofloxacin ................ 61, 105, 106 olanzapine .............................. 80 olanzapine-fluoxetine ............ 71 OLYSIO ................................. 83 omega-3 acid ethyl esters ....... 95 omeprazole ........................... 107 ONCASPAR .......................... 66 ondansetron ............................ 77 ondansetron hcl ...................... 77 ondansetron hcl (pf) ............... 77 ONFI .................................... 102 OPDIVO ................................ 66 OPSUMIT ............................ 127 ORAP ..................................... 80 ORENCIA ............................ 114 ORENCIA (WITH MALTOSE) .......................................... 114 ORENITRAM .............. 127, 128 ORFADIN ............................ 103 OSENI .................................... 73 OTEZLA .............................. 119 OTEZLA STARTER ........... 119 OTREXUP (PF) ................... 119 oxacillin.................................. 61 oxacillin in dextrose(iso-osm) 61 oxaliplatin .............................. 66 oxandrolone.......................... 110 oxcarbazepine ........................ 69 OXTELLAR XR .................... 69 oxybutynin chloride ............. 109 oxycodone ........................ 50, 51 oxycodone hcl-acetaminophen ............................................ 50 oxycodone hcl-aspirin ............ 50 oxycodone-acetaminophen .... 51 oxycodone-aspirin .................. 51 OXYCONTIN ........................ 51 oxymorphone ......................... 51 P pamidronate.......................... 117 PANRETIN ............................ 99 pantoprazole ......................... 107 papaverine .............................. 93 paricalcitol............................ 117 paromomycin ......................... 78 I-10 VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 Effective: January 01, 2016 paroxetine hcl ......................... 71 PASER ................................... 77 PAXIL .................................... 71 pedi m.vit no.17 with fluoride .......................................... 128 PEDIARIX (PF) ................... 115 PEDVAX HIB (PF).............. 115 peg 3350-electrolytes ........... 108 PEG 3350-GRX.................... 108 peg 3350-na sulf,bicarb,cl-kcl .......................................... 108 PEGANONE .......................... 69 PEGASYS .............................. 83 PEGASYS PROCLICK ......... 83 peg-electrolyte soln .............. 108 PEGINTRON ......................... 83 penicillin g pot in dextrose ..... 61 penicillin g potassium............. 61 penicillin g procaine ............... 61 penicillin v potassium............. 61 PENTACEL (PF) ................. 115 PENTACEL ACTHIB COMPONENT (PF) ......... 115 PENTACEL DTAP-IPV COMPNT (PF) ................. 115 PENTAM ............................... 78 pentoxifylline ......................... 86 PERIKABIVEN ..................... 88 perindopril erbumine .............. 90 PERJETA ............................... 66 permethrin ............................ 102 perphenazine........................... 80 perphenazine-amitriptyline..... 72 PERTZYE ............................ 103 phenelzine............................... 72 phenobarbital .......................... 69 phenobarbital sodium ............. 69 phenylephrine hcl ........... 89, 104 phenytoin ................................ 69 phenytoin sodium ................... 69 phenytoin sodium extended .... 69 PHOSLYRA ......................... 109 PHOSPHOLINE IODIDE ... 121 phosphorus #1 ...................... 122 PICATO ................................. 99 pilocarpine hcl ............... 99, 121 pindolol .................................. 91 pioglitazone ........................... 73 pioglitazone-glimepiride........ 73 pioglitazone-metformin ......... 73 piperacillin-tazobactam ......... 61 piroxicam ............................... 52 PLASBUMIN 25 % ............... 87 PLASBUMIN 5 % ................. 87 PLASMA-LYTE 148 .......... 122 PLASMA-LYTE A.............. 122 PLASMA-LYTE-56 IN 5 % DEXTROSE .................... 122 PLEGRIDY ......................... 119 podofilox................................ 99 podophyllum resin ................. 99 polyethylene glycol 3350..... 108 polymyxin b sulfate ............... 58 polymyxin b sulf-trimethoprim ......................................... 106 POMALYST.......................... 66 potassium acetate ................. 122 potassium bicarb and chloride ......................................... 122 potassium bicarb-citric acid . 123 potassium bicarbonate-cit ac 123 potassium chlorid-d5-0.45%nacl ......................................... 123 potassium chloride ............... 123 potassium chloride in 0.9%nacl ......................................... 123 potassium chloride in 5 % dex ......................................... 123 potassium chloride in lr-d5 .. 123 potassium chloride-0.45 % nacl ......................................... 123 potassium chloride-d5-0.2%nacl ......................................... 123 potassium chloride-d5-0.3%nacl .......................................... 123 potassium chloride-d5-0.9%nacl .......................................... 123 potassium citrate .................. 123 potassium citrate-citric acid . 123 potassium hydroxide .............. 99 potassium phosphate dibasic 123 POTIGA ................................. 70 PRADAXA ............................ 85 pramipexole............................ 78 PRANDIMET ........................ 73 pravastatin .............................. 95 prazosin .................................. 89 prednicarbate ........................ 102 prednisolone acetate ............. 106 prednisolone sodium phosphate .................................. 106, 111 prednisone ............................ 111 PREDNISONE INTENSOL 111 PREMARIN ......................... 110 PREMASOL 10 % ................. 89 PREMASOL 6 % ................... 89 PREMPHASE ...................... 110 PREMPRO ........................... 110 prenatal vitamins .................. 128 PREPOPIK........................... 108 PREZCOBIX ......................... 82 PREZISTA ............................. 82 PRIFTIN ................................ 77 PRIMAQUINE ...................... 78 primidone ............................... 70 PRISTIQ ................................ 72 PRIVIGEN ........................... 114 PROAIR HFA ...................... 125 PROAIR RESPICLICK ....... 125 probenecid ............................ 119 procainamide .......................... 90 PROCALAMINE 3% ............ 89 prochlorperazine .................... 77 prochlorperazine edisylate ..... 77 prochlorperazine maleate ....... 77 I-11 VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 Effective: January 01, 2016 PROCRIT ............................... 86 PROCYSBI .......................... 119 progesterone ......................... 112 progesterone micronized capsules ............................ 113 PROGLYCEM ....................... 96 PROGRAF ........................... 114 PROLASTIN-C .................... 126 PROLENSA ......................... 106 PROLEUKIN ......................... 66 PROLIA ............................... 117 PROMACTA .......................... 86 promethazine .............. 76, 77, 78 promethazine hcl .................... 77 propafenone ............................ 91 propantheline .......................... 68 proparacaine ......................... 104 proparacaine hcl ................... 104 proparacaine-fluorescein sod 104 propranolol ............................. 91 propranolol-hydrochlorothiazid ............................................ 91 propylthiouracil .................... 113 PROQUAD (PF) .................. 115 PROSOL 20 % ....................... 89 protamine ................................ 86 protriptyline ............................ 72 PULMOZYME..................... 103 PURIXAN .............................. 66 pyrazinamide .......................... 77 pyridostigmine bromide ....... 119 Q QUADRACEL (PF) ............. 115 quetiapine ............................... 80 QUILLIVANT XR ................. 97 quinapril ................................. 90 quinapril-hydrochlorothiazide 90 quinidine gluconate ................ 91 quinidine sulfate ..................... 91 quinine sulfate ........................ 78 QVAR................................... 125 R RABAVERT (PF) ............... 115 raloxifene ............................. 110 ramipril .................................. 90 RANEXA............................... 93 ranitidine hcl ........................ 107 RAPAMUNE ....................... 114 RASUVO (PF)..................... 119 RAVICTI ............................. 108 REBIF (WITH ALBUMIN) 119 REBIF REBIDOSE ............. 119 REBIF TITRATION PACK 119 RECOMBIVAX HB (PF).... 115 REGRANEX ....................... 100 RELENZA DISKHALER ..... 83 RELISTOR .......................... 108 REMICADE ........................ 119 REMODULIN ..................... 128 RENAGEL........................... 109 RENVELA........................... 109 repaglinide ............................. 73 RESCRIPTOR ....................... 82 RESTASIS ........................... 106 RETROVIR ........................... 82 REVLIMID............................ 66 REYATAZ............................. 82 ribavirin ................................. 84 RIDAURA ........................... 114 rifabutin ................................. 77 rifampin ................................. 77 RIFATER............................... 77 riluzole ................................... 97 rimantadine ............................ 83 ringers .......................... 116, 123 risedronate ........................... 117 RISPERDAL CONSTA ........ 80 risperidone ....................... 80, 81 RITUXAN ............................. 66 rivastigmine tartrate ............... 70 rizatriptan ............................... 76 ropinirole ............................... 78 ROTARIX ........................... 115 ROTATEQ VACCINE ........ 115 ROZEREM .......................... 126 S SABRIL ................................. 70 SAIZEN ............................... 112 SAIZEN CLICK.EASY ....... 112 salsalate .................................. 53 SANDOSTATIN LAR DEPOT .......................................... 112 SANTYL .............................. 100 SAPHRIS (BLACK CHERRY) ............................................ 81 SAVAYSA............................. 85 SAVELLA ............................. 97 selegiline hcl .......................... 79 selenium sulfide ................... 100 SELZENTRY......................... 82 SENSIPAR................... 119, 120 SEREVENT DISKUS.......... 125 SEROQUEL XR .................... 81 SEROSTIM .......................... 112 sertraline ................................. 72 SIGNIFOR ........................... 120 sildenafil oral tablet 20 mg .. 128 SILENOR............................... 72 silver nitrate ......................... 100 silver nitrate applicators ....... 100 silver sulfadiazine ................ 100 SIMBRINZA........................ 121 SIMPONI ............................. 120 SIMPONI ARIA .................. 120 simvastatin ............................. 95 sirolimus ............................... 114 SIRTURO .............................. 77 sodium acetate ...................... 123 sodium bicarbonate .............. 124 sodium chloride ............ 116, 124 sodium chloride 0.45 % ....... 124 sodium chloride 0.9 % ......... 124 sodium chloride 3 % ............ 124 sodium chloride 5 % ............ 124 I-12 VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 Effective: January 01, 2016 sodium chloride-nahco3-kcl-peg .......................................... 108 sodium citrate-citric acid ...... 124 sodium fluoride .............. 99, 128 sodium lactate ....................... 124 sodium phosphate ................. 124 sodium polystyrene sulfonate .......................................... 108 sodium thiosulfate ................ 109 sod-pot-k cit-sod cit-cit acid . 124 SOLTAMOX.......................... 66 SOLU-CORTEF (PF)........... 111 SOMATULINE DEPOT ...... 112 SOMAVERT ........................ 112 sorbitol.................................. 116 sorbitol-mannitol .................. 116 sotalol ..................................... 91 sotalol hcl ............................... 91 SOVALDI .............................. 83 SPIRIVA RESPIMAT.......... 125 SPIRIVA WITH HANDIHALER ................ 125 spironolactone ........................ 95 spironolacton-hydrochlorothiaz ............................................ 95 SPORANOX .......................... 75 SPRYCEL .............................. 66 stavudine................................. 82 STELARA ............................ 120 STERILE PADS................... 120 STIMATE............................. 112 STIVARGA ............................ 66 STRATTERA ......................... 97 streptomycin ........................... 56 STRIBILD .............................. 82 STRIVERDI RESPIMAT .... 125 sucralfate .............................. 107 sulfacetamide sodium ........... 106 sulfacetamide sodium (acne) 100 sulfacetamide-prednisolone .. 106 sulfadiazine............................. 61 sulfamethoxazole-trimethoprim ........................................... 61 sulfasalazine........................... 61 sulfatrim ................................. 62 sulfazine ................................. 62 sulfazine ec ............................ 62 sulindac .................................. 53 sumatriptan nasal spray ......... 76 sumatriptan succinate ............ 76 SUPPRELIN LA.................. 112 SUPRAX ............................... 59 SURMONTIL ........................ 72 SUSTIVA .............................. 82 SUTENT ................................ 66 SYLATRON .......................... 83 SYLVANT............................. 66 SYMLINPEN 120 ................. 73 SYMLINPEN 60 ................... 73 SYNAGIS .............................. 83 SYNAREL ........................... 120 SYNERCID ........................... 58 SYNRIBO.............................. 66 SYPRINE............................. 109 T TABLOID.............................. 66 tacrolimus .................... 102, 114 TAFINLAR ........................... 66 TAMIFLU ............................. 83 tamoxifen ............................... 66 tamsulosin ............................ 109 TARCEVA ............................ 66 TARGRETIN......................... 66 tarina fe .................................. 98 TASIGNA.............................. 66 TAZORAC .......................... 102 taztia xt .................................. 92 TECFIDERA ....................... 120 TEFLARO ............................. 59 TEGRETOL XR .................... 70 telmisartan ............................. 89 telmisartan-hydrochlorothiazid ........................................... 89 temazepam ....................... 55, 56 TEMODAR ............................ 67 teniposide ............................... 67 TENIVAC (PF) .................... 115 terazosin ............................... 109 terbinafine hcl ........................ 75 terbutaline ............................ 125 terconazole ............................. 76 testosterone .......................... 110 testosterone cypionate .......... 110 testosterone enanthate .......... 110 TETANUS TOXOID,ADSORBED (PF) .......................................... 115 TETANUS,DIPHTHERIA TOX PED(PF) ........................... 115 TETANUS-DIPHTHERIA TOXOIDS-TD ................. 115 tetracaine hcl (pf) ................. 104 tetracycline ............................. 62 TEVETEN HCT..................... 89 THALOMID ........................ 120 theophylline.......................... 126 theophylline anhydrous ........ 125 theophylline in dextrose 5 % 125 thioridazine ............................ 81 thiothixene.............................. 81 tiagabine ................................. 70 TICE BCG ........................... 116 TIKOSYN .............................. 91 timolol maleate............... 91, 121 TIVICAY ............................... 82 tizanidine .............................. 126 TOBI PODHALER ................ 56 TOBRADEX ........................ 106 TOBRADEX ST .................. 106 tobramycin ........................... 106 tobramycin in 0.225 % nacl ... 56 tobramycin in 0.9 % nacl ....... 57 tobramycin sulfate .................. 57 tolazamide .............................. 74 tolbutamide ............................ 74 I-13 VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 Effective: January 01, 2016 tolmetin................................... 53 tolterodine............................. 109 topiramate ............................... 70 toposar intravenous ................ 67 topotecan ................................ 67 TORISEL ............................... 67 torsemide ................................ 94 TOUJEO SOLOSTAR ........... 74 TOVIAZ ............................... 109 TPN ELECTROLYTES ....... 124 TPN ELECTROLYTES II ... 124 TRACLEER ......................... 128 TRADJENTA ......................... 73 tramadol .................................. 51 tramadol-acetaminophen ........ 51 trandolapril ............................. 90 tranexamic acid ...................... 86 TRANSDERM-SCOP ............ 78 tranylcypromine ..................... 72 TRAVASOL 10 % ................. 89 TRAVATAN Z .................... 121 travoprost (benzalkonium) ... 121 trazodone ................................ 72 TREANDA ............................. 67 TRECATOR ........................... 77 TRELSTAR ............................ 67 tretinoin ................................ 102 tretinoin (chemotherapy) ........ 67 tretinoin microspheres .......... 102 TREXALL .............................. 67 triamcinolone acetonide 99, 102, 111 triamterene-hydrochlorothiazid ............................................ 94 triazolam ................................. 56 TRIBENZOR ......................... 89 trifluoperazine ........................ 81 trifluridine............................. 106 trihexyphenidyl....................... 79 trimethoprim ........................... 58 TRIUMEQ .............................. 82 TROKENDI XR ..................... 70 TROPHAMINE 10 %............ 89 TROPHAMINE 6%............... 89 trospium ............................... 109 TRULICITY .......................... 73 TRUMENBA ....................... 116 TRUVADA............................ 82 TUDORZA PRESSAIR ...... 126 TWINRIX (PF) .................... 116 TYBOST.............................. 120 TYGACIL.............................. 62 TYKERB ............................... 67 TYPHIM VI......................... 116 TYSABRI ............................ 114 TYVASO ............................. 128 TYVASO REFILL KIT ....... 128 TYVASO STARTER KIT... 128 TYZEKA ............................... 84 TYZINE ....................... 104, 105 U ULORIC .............................. 120 ursodiol ................................ 108 V VAGIFEM ........................... 110 valacyclovir ........................... 84 VALCHLOR ....................... 100 VALCYTE............................. 84 valganciclovir ........................ 84 valproate sodium.................... 70 valproic acid .......................... 70 valproic acid (as sodium salt) 70 valsartan ................................. 90 valsartan-hydrochlorothiazide 90 VALSTAR ............................. 67 vancomycin ............................ 58 vancomycin in d5w ................ 58 VAQTA (PF) ....................... 116 VARIVAX (PF)................... 116 VASCEPA ............................. 95 VECTIBIX............................. 67 VELCADE............................. 67 VELPHORO ........................ 108 venlafaxine............................. 72 VENTOLIN HFA ................ 126 verapamil................................ 92 VEREGEN ........................... 100 VERSACLOZ ........................ 81 VESICARE .......................... 109 VGO 40 ................................ 103 VICTOZA .............................. 73 VIDEX 2 GRAM PEDIATRIC ............................................ 82 VIDEX 4 GRAM PEDIATRIC ............................................ 83 VIGAMOX .......................... 106 VIIBRYD ............................... 72 VIMIZIM ............................. 103 VIMPAT ................................ 70 vincristine............................... 67 vincristine sulfate ................... 67 vinorelbine ............................. 67 VIRACEPT ............................ 83 VIRAMUNE XR ................... 83 VIRAZOLE............................ 84 VIREAD ................................ 83 VITEKTA .............................. 83 VOLTAREN .......................... 53 voriconazole ..................... 75, 76 VOTRIENT............................ 67 VPRIV.................................. 103 VYTORIN 10-10 ................... 95 VYTORIN 10-20 ................... 95 VYTORIN 10-40 ................... 95 VYTORIN 10-80 ................... 95 W warfarin .................................. 85 water for irrigation, sterile ... 116 X XALKORI.............................. 67 XARELTO ............................. 85 XARTEMIS XR..................... 51 XELJANZ ............................ 120 XENAZINE ........................... 97 XGEVA................................ 117 XIFAXAN.............................. 58 I-14 VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 Effective: January 01, 2016 XOLAIR ............................... 126 XTANDI................................. 67 xylon 10 .................................. 51 XYREM ............................... 126 Y YERVOY ............................... 67 YF-VAX (PF) ....................... 116 Z zafirlukast ............................. 125 zaleplon ................................ 127 ZALTRAP .............................. 67 ZAVESCA ........................... 104 ZELBORAF ........................... 67 ZEMPLAR ........................... 117 ZENPEP............................... 104 ZETIA.................................... 95 ZIAGEN ................................ 83 zidovudine ............................. 83 ZIOPTAN (PF) .................... 121 ziprasidone hcl ....................... 81 ZIRGAN .............................. 106 ZOLADEX ............................ 67 zoledronic acid ..................... 117 zoledronic acid-mannitol-water ......................................... 117 ZOLINZA .............................. 68 zolmitriptan...................... 76, 77 zolpidem .............................. 127 ZOMETA ............................. 117 zonisamide ............................. 70 ZORTRESS.......................... 114 ZOSTAVAX (PF) ................ 116 ZOVIRAX............................ 100 ZUBSOLV ............................. 54 ZYDELIG .............................. 68 ZYKADIA ............................. 68 ZYLET ................................. 106 ZYPREXA RELPREVV ....... 81 ZYTIGA ................................. 68 ZYVOX.................................. 58 I-15 VNSNY CHOICE Medicare Formulary ID: 16492.001, Version: 7 Effective: January 01, 2016 tolmetin................................. 53 tolterodine ........................... 111 topiramate ............................. 70 toposar intravenous ............... 67 topotecan .............................. 67 TORISEL.............................. 67 torsemide .............................. 96 TOUJEO SOLOSTAR .......... 74 TOVIAZ ............................. 111 TPN ELECTROLYTES ...... 126 TPN ELECTROLYTES II .. 126 TRACLEER........................ 130 TRADJENTA ....................... 74 tramadol................................ 51 tramadol-acetaminophen ....... 51 trandolapril ........................... 91 tranexamic acid ..................... 87 TRANSDERM-SCOP ........... 78 tranylcypromine .................... 72 TRAVASOL 10 % ................ 90 TRAVATAN Z ................... 123 travoprost (benzalkonium) .. 123 trazodone .............................. 72 TREANDA ........................... 67 TRECATOR ......................... 78 TRELSTAR .......................... 67 tretinoin .............................. 104 tretinoin (chemotherapy) ....... 67 tretinoin microspheres ......... 104 TREXALL ............................ 67 triamcinolone acetonide ..... 100, 104, 113 triamterene-hydrochlorothiazid .......................................... 96 triazolam ............................... 56 TRIBENZOR ........................ 91 trifluoperazine ....................... 82 trifluridine ........................... 107 trihexyphenidyl ..................... 80 trimethoprim ......................... 58 TRIUMEQ ............................ 84 TROKENDI XR ................... 70 TROPHAMINE 10 % ............90 TROPHAMINE 6% ...............90 trospium .............................. 111 TRULICITY ..........................74 TRUMENBA....................... 117 TRUVADA ...........................84 TUDORZA PRESSAIR ....... 128 TWINRIX (PF) .................... 117 TYBOST ............................. 122 TYGACIL .............................62 TYKERB ...............................68 TYPHIM VI ........................ 118 TYSABRI ............................ 116 TYVASO............................. 130 TYVASO REFILL KIT .......130 TYVASO STARTER KIT ...130 TYZEKA ...............................85 TYZINE .............................. 106 U ULORIC .............................. 122 ursodiol................................ 110 V VAGIFEM........................... 112 valacyclovir ...........................85 VALCHLOR ....................... 101 VALCYTE ............................85 valganciclovir ........................85 valproate sodium....................70 valproic acid ..........................70 valproic acid (as sodium salt) .71 valsartan ................................91 valsartan-hydrochlorothiazide 91 VALSTAR ............................68 vancomycin ...........................58 vancomycin in d5w ................58 VAQTA (PF) ....................... 118 VARIVAX (PF)................... 118 VASCEPA.............................96 VECTIBIX ............................68 VELCADE ............................68 VELPHORO ........................ 110 venlafaxine ............................73 VENTOLIN HFA ................ 128 verapamil............................... 93 VEREGEN .......................... 101 VERSACLOZ ....................... 82 VESICARE ......................... 111 VGO 40 ............................... 104 VICTOZA ............................. 74 VIDEX 2 GRAM PEDIATRIC .......................................... 84 VIDEX 4 GRAM PEDIATRIC .......................................... 84 VIGAMOX ......................... 107 VIIBRYD .............................. 73 VIMIZIM ............................ 105 VIMPAT ............................... 71 vincristine .............................. 68 vincristine sulfate................... 68 vinorelbine ............................ 68 VIRACEPT ........................... 84 VIRAMUNE XR ................... 84 VIRAZOLE ........................... 85 VIREAD ............................... 84 VITEKTA ............................. 84 VOLTAREN ......................... 53 voriconazole .......................... 76 VOTRIENT ........................... 68 VPRIV ................................ 105 VYTORIN 10-10 ................... 96 VYTORIN 10-20 ................... 96 VYTORIN 10-40 ................... 96 VYTORIN 10-80 ................... 96 W warfarin ................................. 86 water for irrigation, sterile ... 118 X XALKORI ............................. 68 XARELTO ............................ 86 XARTEMIS XR .................... 51 XELJANZ ........................... 122 XENAZINE........................... 99 XGEVA............................... 119 XIFAXAN ............................. 58 I-14 VNS Choice Medicare Formulary ID: 16492.001, Version: 7 Effective: January 01, 2016 XOLAIR ............................. 128 XTANDI ............................... 68 xylon 10 ................................ 51 XYREM ............................. 129 Y YERVOY ............................. 68 YF-VAX (PF) ..................... 118 Z zafirlukast ........................... 127 zaleplon .............................. 129 ZALTRAP ............................ 68 ZAVESCA.......................... 105 ZELBORAF.......................... 68 ZEMPLAR ......................... 119 ZENPEP .............................. 105 ZETIA ...................................96 ZIAGEN ................................84 zidovudine .............................84 ZIOPTAN (PF) .................... 123 ziprasidone hcl .......................82 ZIRGAN .............................. 107 ZOLADEX ............................68 zoledronic acid..................... 119 zoledronic acid-mannitol-water ........................................ 119 ZOLINZA .............................68 zolmitriptan ...........................77 zolpidem .............................. 129 ZOMETA ............................ 119 zonisamide ............................ 71 ZORTRESS ......................... 116 ZOSTAVAX (PF) ............... 118 ZOVIRAX ........................... 101 ZUBSOLV ............................ 54 ZYDELIG ............................. 68 ZYKADIA ............................ 68 ZYLET ................................ 107 ZYPREXA RELPREVV ....... 82 ZYTIGA ................................ 68 ZYVOX................................. 58 I-15 VNS Choice Medicare Formulary ID: 16492.001, Version: 7 Effective: January 01, 2016 This formulary was updated on 08/29/2015. For more recent information or other questions, please contact VNSNY CHOICE Medicare Member Services at 1-866-783-1444 or, for TTY users, 711, Monday through Friday from 8:00 AM to 8:00 PM or visit www.vnsnychoice.org. Este formulario de medicamentos fue actualizado 08/29/2015. Para recibir información más reciente o si tiene alguna otra duda, sírvase llamar al Servicio para Miembros de Medicare de VNSNY CHOICE al 1-866-783-1444 o, para aquellos que utilizan TTY, al 711, de lunes a viernes, de 8:00 AM a 8:00 PM o visite www.vnsnychoice.org. Ṉ᪉㞟᭦᪂ 2015 ᖺ 08᭶ 29 ᪥傏 ዴ㟂᭦ከ᭱᪂ⓗ㈨イᡈ᭷ၥ㢟凞 ㄳ⫃⤡ VNSNY CHOICE Medicare ᭳ဨ᭹ົ㒊凞 㟁ヰ凬 1-866-783-1444凞 TTY ⏝⪅ㄳ᧕ 711凞 㐌୍฿㐌凞 ᪩ୖ 8:00 ฿ୖ 8:00凞 ᡈ㐀ゼ www.vnsnychoice.org傏 1250 Broadway, 11th floor, New York, NY 10001 www.vnsnychoice.org VNSNY CHOICE Medicare Any questions? Call toll free 1-866-783-1444 (TTY for the hearing impaired 711) 8 am – 8 pm, Monday – Friday 2016 FORMULARY OF COVERED PRESCRIPTION DRUGS PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on 08/29/2015. For more recent information or other questions, please contact VNSNY CHOICE Medicare Member Services at 1-866-783-1444 or, for TTY users, 711, Monday through Friday from 8:00 AM to 8:00 PM or visit www.vnsnychoice.org A Medicare Advantage Plan 2016 FORMULARY OF COVERED PRESCRIPTION DRUGS VNSNY CHOICE Medicare Approved Formulary Submission ID Number: 16492.001, Version 7 VNSNY CHOICE Medicare Preferred (HMO SNP) VNSNY CHOICE Total (HMO SNP) VNSNY CHOICE Medicare Maximum (HMO SNP) VNSNY CHOICE Medicare Classic (HMO) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN This formulary was updated on 08/29/2015. For more recent information or other questions, please contact VNSNY CHOICE Medicare Member Services at 1-866-783-1444 or, for TTY users, 711, Monday through Friday from 8:00 AM to 8:00 PM or visit www.vnsnychoice.org H5549_2016 Formulary_1085_DSB_rv_Accepted 09192015
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