Marys Medicine

Peach state health plan


Advantage by Buckeye Community
Health Plan (HMO SNP)
2011 Comprehensive Formulary
(List of Covered Drugs)
Approved July 2011
Effective August 2011
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE
DRUGS WE COVER IN THIS PLAN

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.
Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits,
formulary, pharmacy network, premium and/or copayments/ coinsurance may change on
January 1, 2012.
Advantage by Buckeye Community Health Plan is a Medicare Advantage Special Needs Plan
for Dual Eligible Members with a Medicare Contract.
This document is available in alternative formats and languages. To request information in
alternative formats or languages please call our Member Services Department at 866-389-7690 (TTY
800-750-0750) 8:00AM to 8:00PM, 7 days a week.
H0908_RX011_008 File and Use 08/01/2011 What is the Advantage by Buckeye Community Health Plan Formulary?
A formulary is a list of covered drugs selected by Advantage by Buckeye Community Health Plan 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. Advantage by Buckeye Community Health Plan will
generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription
is filled at a Advantage by Buckeye Community Health Plan 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 change?
Generally, if you are taking a drug on our 2011 formulary that was covered at the beginning of the year,
we will not discontinue or reduce coverage of the drug during the 2011 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 January 1, 2011. To get updated
information about the drugs covered by Advantage by Buckeye Community Health Plan please visit our
Web site at www.bchpohio.com or call Member Services at 866-389-7690, 8:00AM to 8:00PM, 7 days a
week. TTY/TDD users should call 800-750-0750.
Advantage by Buckeye Community Health Plan reviews the formulary each month. Formulary changes
will be included in your monthly Part D explanation of benefits. Updated formularies are also uploaded
on the plan's website month and are available in print form upon request. Please contact our Member
Services department for more information.
How do I use the Formulary?
There are two ways to find your drug within the formulary:
1. Medical Condition The formulary begins on page 14. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins on page 14. Then look under the category name for your drug. 2. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 52. 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?
Advantage by Buckeye Community Health Plan 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: Advantage by Buckeye Community Health Plan requires you [or your physician] to get prior authorization for certain drugs. This means that you will need to get approval from Advantage by Buckeye Community Health Plan before you fill your prescriptions. If you don't get approval, Advantage by Buckeye Community Health Plan may not cover the drug. • Quantity Limits: For certain drugs, Advantage by Buckeye Community Health Plan limits the amount of the drug that Advantage by Buckeye Community Health Plan will cover. For example, Advantage by Buckeye Community Health Plan provides 60 tablets per prescription for Exelon. This may be in addition to a standard one month or three month supply. You can find out if your drug has any additional requirements or limits by looking in the formulary that
begins on page 14. You can also get more information about the restrictions applied to specific covered
drugs by visiting our Web site at <plan website>.
You can ask Advantage by Buckeye Community Health Plan to make an exception to these restrictions or
limits. See the section, "How do I request an exception to the Advantage by Buckeye Community Health
Plan formulary?" on page 4 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. Advantage by Buckeye Community Health Plan pays for certain OTC drugs. Advantage by Buckeye
Community Health Plan will provide these OTC drugs at no cost to you. The cost to Advantage by
Buckeye Community Health Plan of these OTC drugs will not count toward your total drug costs. The list
of OTC items and ordering instructions is available on the Advantage by Buckeye Community Health Plan
website, and also available in hard copy in the new member welcome packet and Annual Notice of Change
mailing.
What if my drug is not on the Formulary?
If your drug is not included in this list of covered drugs, you should first contact Member Services and ask
if your drug is covered. This document includes only a partial list of covered drugs, so Advantage by
Buckeye Community Health Plan may cover your drug. You can contact Member Services at 866-389-
7690, 8:00AM to 8:00PM, 7 days a week. TTY/TDD users should call 800-750-0750.
If you learn that Advantage by Buckeye Community Health Plan does not cover your drug, you have two
options:
1. You can ask Member Services for a list of similar drugs that are covered by Advantage by Buckeye Community Health Plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Advantage by Buckeye Community Health Plan. 2. You can ask Advantage by Buckeye Community Health Plan 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 Advantage by Buckeye Community Health
Plan Formulary?
You can ask Advantage by Buckeye Community Health Plan 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 your drug even if it is not on our formulary. • You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs Advantage by Buckeye Community Health Plan 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 more. • You can ask us to provide a higher level of coverage for your drug. If your drug is contained in our non-preferred/ highest tier subject to the tiering exceptions process tier, you can ask us to cover it at the cost sharing amount that applies to drugs in the preferred/lowest tier subject to the tiering exceptions process instead. This would lower the amount you must pay for your drug. Please note, if we grant your request to coverage a drug that is not on our formulary, you may not ask us to provider a higher level of coverage for the drug.
Generally, Advantage by Buckeye Community Health Plan will only approve your request for an exception
if the alternative drugs included on the plan's formulary, the lower-tiered drug or additional utilization
restrictions would not be as effective in treating your condition and/or would cause you to have adverse
medical effects.
You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization
restriction exception. When you are requesting a formulary, tiering or utilization restriction
exception you should submit a statement from your prescriber's or physician supporting your
request.
Generally, we must make our decision within 72 hours of getting your prescribing physician'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 your prescriber's or prescribing
physician's supporting statement.
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 cover a temporary 31 day transition supply (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.
For current enrollees whose drugs are no longer on the Advantage by Buckeye Community Health Plan
formulary, Advantage by Buckeye Community Health Plan covers 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.

For more information
For more detailed information about your Advantage by Buckeye Community Health Plan prescription
drug coverage, please review your Evidence of Coverage and other plan materials.
If you have questions about Advantage by Buckeye Community Health Plan, please call Member Services
at 866-389-7690 from 8:00AM to 8:00PM, 7 days a week. TTY/TDD users should call 800-750-0750, or
visit www.bchpohio.com.
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/TDD users should call 1-877-486-
2048. Or, visit www.medicare.gov.


Advantage by Buckeye Community
Health Plan (HMO SNP)
Formulario de 2011
(Lista de medicamentos cubiertos)
aprobado julio 2011 – eficaz Agosto 2011
POR FAVOR LEA: ESTE DOCUMENTO CONTIENE INFORMACIÓN SOBRE LOS
MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN

Nota a los miembros existentes: Este formulario ha cambiado desde el año pasado. Sírvase
revisarlo para asegurarse de que todavía contenga los medicamentos que usted recibe.
Los beneficiarios deben usar farmacias de la red para acceder a su beneficio de medicamentos
recetados. Los beneficios, el formulario, la red de farmacias, las primas y/o
copagos/coseguros pueden cambiar el 1 de enero de 2012.
Advantage by Buckeye Community Health Plan (HMO) es un Plan de necesidades especiales
de Medicare Advantage para miembros con elegibilidad doble que tiene contrato de Medicare.
Este documento está disponible en formatos e idiomas diferentes. Comuníquese con nuestro
Departamento de Servicios para los Miembros llamando al 866-389-7690 (TTY 800-750-0750) de 8
a.m. a 8 p.m., los 7 días de la semana, para obtener información en otros formatos o idiomas.
H0908_RX011_008SP File and Use 08/01/2011


Advantage by Buckeye Community
Health Plan (HMO SNP)
Formulario de 2011
(Lista de medicamentos cubiertos)
aprobado julio 2011 – eficaz Agosto 2011
POR FAVOR LEA: ESTE DOCUMENTO CONTIENE INFORMACIÓN SOBRE LOS
MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN

Nota a los miembros existentes: Este formulario ha cambiado desde el año pasado. Sírvase
revisarlo para asegurarse de que todavía contenga los medicamentos que usted recibe.
Los beneficiarios deben usar farmacias de la red para acceder a su beneficio de medicamentos
recetados. Los beneficios, el formulario, la red de farmacias, las primas y/o
copagos/coseguros pueden cambiar el 1 de enero de 2012.
Advantage by Buckeye Community Health Plan (HMO) es un Plan de necesidades especiales
de Medicare Advantage para miembros con elegibilidad doble que tiene contrato de Medicare.
Este documento está disponible en formatos e idiomas diferentes. Comuníquese con nuestro
Departamento de Servicios para los Miembros llamando al 866-389-7690 (TTY 800-750-0750) de 8
a.m. a 8 p.m., los 7 días de la semana, para obtener información en otros formatos o idiomas.
H0908_RX011_008SP File and Use MMDDYYYY ¿Qué es el Formulario de Advantage by Buckeye Community Health Plan?
Un formulario es una lista de medicamentos cubiertos seleccionados por Advantage by Buckeye
Community Health Plan en consulta con un equipo de proveedores de atención médica, que representa las
terapias recetadas que se cree son una parte necesaria de un programa de tratamiento de calidad.
Advantage by Buckeye Community Health Plan generalmente cubrirá los medicamentos que aparecen en
nuestro formulario siempre y cuando el medicamento sea necesario desde el punto de vista médico, la
receta se surta en una farmacia de la red de Advantage by Buckeye Community Health Plan y se sigan otras
reglas del plan. Para obtener más información sobre cómo surtir sus recetas, revise su Evidencia de
Cobertura.
¿Puede cambiar el Formulario?
Generalmente, si usted recibe un medicamento de nuestro formulario de 2011 que estaba cubierto al
comienzo del año, no discontinuaremos ni reduciremos la cobertura del medicamento durante el año de
cobertura 2011 excepto cuando un medicamento genérico nuevo y más barato se encuentre disponible o
cuando se publique nueva información adversa sobre la seguridad o eficacia de un medicamento. Otros
tipos de cambios en el formulario, como retirar un medicamento de nuestro formulario, no afectarán a los
miembros que reciben actualmente el medicamento. Permanecerá disponible al mismo costo compartido
para los miembros que lo reciben, por lo que queda del año de cobertura. Creemos que es importante que
tenga acceso continuo por lo que queda del año de cobertura a los medicamentos del formulario que
estaban disponibles cuando usted eligió nuestro plan, excepto por casos en los que puede ahorrar dinero
adicional o nosotros podemos garantizar su seguridad.
Si retiramos medicamentos de nuestro formulario, o añadimos autorización previa, límites de cantidad y/o
restricciones de terapia escalonada a un medicamento o movemos un medicamento a un nivel de costo
compartido más alto, debemos notificar a los miembros afectados sobre el cambio al menos 60 días antes
de que el cambio entre en efecto, o en el momento en que el miembro solicite una renovación de la receta,
momento en el cual el miembro recibirá un suministro de 60 días del medicamento. Si la Administración
de Alimentos y Medicamentos considera que un medicamento de nuestro formulario no es seguro o el
fabricante del medicamento retira el medicamento del mercado, nosotros lo retiraremos inmediatamente
de nuestro formulario e informaremos a los miembros que lo reciben. El formulario adjunto está
actualizado a partir del 1º de Enero de 2011. Para obtener información actualizada sobre los medicamentos
cubiertos por Advantage by Buckeye Community Health Plan, visite nuestro sitio Web en
www.bchpohio.com o llame a Servicios para los Miembros al 1-866-389-7690, de 8 a.m. a 8 p.m, los 7 días
de la semana. Los usuarios de TTY/TDD deben llamar al 1-800-750-0750.
Advantage by Buckeye Community Health Plan revisa el formulario cada mes. Los cambios al formulario se incluirán en su explicación de beneficios mensual de la Parte D. Además se cargan en el sitio web del plan formularios actualizados todos los meses y están disponibles en forma impresa al solicitarlos. Llame al departamento de Servicios para los miembros para obtener más información. ¿Cómo uso el Formulario?
Hay dos maneras de encontrar su medicamento dentro del formulario:
1. Condición médica El formulario comienza en la pàgina 14. Los medicamentos de este formulario están agrupados en categorías dependiendo del tipo de condiciones médicas para las que se usan. Por ejemplo, los medicamentos usados para tratar una condición cardiaca aparecen bajo la categoría, Agentes cardiovasculares. Si usted sabe para qué se usa su medicamento, busque el nombre de la categoría en la lista que comienza en la pàgina 14. Luego busque su medicamento bajo el nombre de la categoría. 2. Lista alfabética Si no está seguro(a) bajo qué categoría buscar, debe buscar su medicamento en el Índice que comienza en la pàgina 52. El Índice presenta una lista alfabética de todos los medicamentos que incluye este documento. En el Índice aparecen tanto medicamentos de marca como genéricos. Busque en el Índice y encuentre su medicamento. Junto a su medicamento, usted verá el número de página en el que puede encontrar información sobre la cobertura. Pase a la página que aparece en el Índice y encuentre el nombre de su medicamento en la primera columna de la lista. ¿Qué son medicamentos genéricos?
Advantage by Buckeye Community Health Plan cubre tanto medicamentos de marca como medicamentos
genéricos. Un medicamento genérico tiene la aprobación de la FDA como uno que tiene el mismo
ingrediente activo que el medicamento de marca. Generalmente, los medicamentos genéricos cuestan
menos que los medicamentos de marca.
¿Tiene restricciones mi cobertura?
Algunos medicamentos cubiertos pueden tener requisitos o límites adicionales en la cobertura. Estos
requisitos y límites pueden incluir:
• Autorización Previa: Advantage by Buckeye Community Health Plan requiere que usted [o su médico] obtenga autorización previa para ciertos medicamentos. Esto significa que usted necesitará obtener aprobación de Advantage by Buckeye Community Health Plan antes de surtir sus recetas. Si no obtiene aprobación, es posible que Advantage by Buckeye Community Health Plan no cubra el medicamento. • Límites de Cantidad: Para ciertos medicamentos, Advantage by Buckeye Community Health Plan limita la cantidad de medicamento que Advantage by Buckeye Community Health Plan cubrirá. Por ejemplo, Advantage by Buckeye Community Health Plan proporciona 60 pastillas por receta para Exelon. Esto puede ser en adición a un suministro estándar de un mes o tres meses. Usted puede determinar si su medicamento tiene requisitos o límites adicionales buscando en el formulario que comienza en la pàgina 14. Además puede obtener más información sobre las restricciones aplicadas a medicamentos específicos cubiertos visitando nuestro sitio Web en www.bchpohio.com.
Puede pedir a Advantage by Buckeye Community Health Plan que haga una excepción a estas restricciones
o límites. Consulte la sección, "¿Cómo solicito una excepción al formulario de Advantage by Buckeye
Community Health Plan?" en la página 11 para obtener información sobre cómo solicitar una excepción.
¿Qué son medicamentos de venta sin receta (OTC)?
Los medicamentos OTC son medicamentos que no necesitan receta, que normalmente no están cubiertos
por un plan de medicamentos recetados de Medicare. Advantage by Buckeye Community Health Plan
paga por ciertos medicamentos de venta sin receta. Advantage by Buckeye Community Health Plan le
proporcionará estos medicamentos de venta sin receta sin costo para usted. El costo para Advantage by
Buckeye Community Health Plan de estos medicamentos de venta sin receta no contará para sus costos
totales de medicamentos.
Una lista de medicamentos de venta sin receta cubiertos por Advantage by Buckeye Community Health
Plan se encuentra en el sitio web del plan y también disponible en copia dura en el nuevo paquete de la
recepción del miembro y el aviso anual del correo del cambio.
¿Qué pasa si mi medicamento no está en el Formulario?
Si su medicamento no está incluido en esta lista de medicamentos cubiertos, debe comunicarse primero
con Servicios para los Miembros y preguntar si su medicamento está cubierto. Este documento incluye
sólo una lista parcial de los medicamentos cubiertos, así que es posible que Advantage by Buckeye
Community Health Plan cubra su medicamento. Puede comunicarse con Servicios a los Miembros al 1-
866-389-7690. Advantage by Buckeye Community Health Plan, de 8 a.m. a 8 p.m, los 7 días de la semana.
Los usuarios de TTY/TDD deben llamar al 1-800-750-0750.
Si se entera que Advantage by Buckeye Community Health Plan no cubre su medicamento, usted tiene dos opciones: 1. Puede pedir a Servicios para los Miembros una lista de medicamentos similares que están cubiertos por Advantage by Buckeye Community Health Plan. Cuando usted reciba la lista, muéstrela a su médico y pídale que prescriba un medicamento similar que esté cubierto por Advantage by Buckeye Community Health Plan. 2. Puede pedir a Advantage by Buckeye Community Health Plan que haga una excepción y cubra su medicamento. Consulte abajo para obtener información sobre cómo solicitar una excepción.
¿Cómo solicito una excepción al Formulario de Advantage by Buckeye Community
Health Plan?
Puede pedir a Advantage by Buckeye Community Health Plan que haga una excepción a las reglas de
cobertura. Hay varios tipos de excepciones que nos puede pedir que hagamos.
• Nos puede pedir que cubramos su medicamento incluso si no está en nuestro formulario. • Nos puede pedir que exoneremos restricciones o límites en la cobertura para su medicamento. Por ejemplo, para ciertos medicamentos, Advantage by Buckeye Community Health Plan limita la cantidad de medicamento que cubriremos. Si su medicamento tiene un límite de cantidad, nos puede pedir que exoneremos el límite y cubramos más. • Puede pedirnos que demos un nivel más alto de cobertura para su medicamento. Si su medicamento está en nuestro nivel no preferido/ más alto sujeto al proceso de excepciones de los niveles, puede pedirnos que más bien lo cubramos a la cantidad de costo compartido que se aplica a los medicamentos en el nivel preferido/más bajo sujeto al proceso de excepciones de los niveles. Esto disminuiría la cantidad que usted debe pagar por su medicamento. Sírvase notar, si otorgamos su solicitud de cubrir un medicamento que no está en nuestro formulario, no nos puede pedir que demos un nivel más alto de cobertura para el medicamento.
Generalmente, Advantage by Buckeye Community Health Plan sólo aprobará su solicitud como una
excepción si los medicamentos alternativos incluidos en el formulario del plan, el medicamento del nivel
más bajo o las restricciones adicionales en la utilización no serían tan eficaces en el tratamiento de su
condición y/o causarían que usted tuviera efectos médicos adversos.
Debe comunicarse con nosotros para pedirnos una decisión inicial de cobertura para una excepción al
formulario, los niveles o de restricción de la utilización. Cuando usted solicita una excepción al
formulario, de los niveles o de la restricción de la utilización debe presentar una declaración de su
médico respaldando su solicitud.
Generalmente, debemos tomar nuestra decisión dentro de un plazo
de 72 horas de obtener la declaración de respaldo del médico que le recetó. Usted puede solicitar una
excepción acelerada (rápida) si usted o su médico cree que su salud podría ser gravemente dañada si
esperara hasta 72 horas por una decisión. Si se acepta su solicitud de acelerar, debemos darle una decisión a
más tardar 24 horas después de que obtengamos la declaración de respaldo del médico que le recetó.
¿Qué hago antes de que pueda hablar con mi médico sobre cambiar mis
medicamentos o solicitar una excepción?
Como miembro nuevo o continuo en nuestro plan, puede que usted tome medicamentos que no están en
nuestro formulario. O, es posible que esté recibiendo un medicamento que está en nuestro formulario pero
su capacidad de obtenerlo es limitada. Por ejemplo, usted puede necesitar nuestra autorización previa antes
de que pueda surtir su receta. Debe conversar con su médico para decidir si debe cambiar a un
medicamento apropiado que cubrimos o solicitar una excepción al formulario para que cubramos el
medicamento que recibe. Mientras usted conversa con su médico para determinar el curso correcto de
acción para usted, podemos cubrir su medicamento en ciertos casos durante los primeros 90 días que sea
miembro de nuestro plan.
Para cada uno de sus medicamentos que no esté en nuestro formulario o si su capacidad de obtener sus
medicamentos es limitada, cubriremos un suministro temporal de 30 días (a menos que su receta sea por
menos días) cuando vaya a una farmacia de la red. Después de su primer suministro de 30 días, no
pagaremos por estos medicamentos, incluso si ha sido miembro del plan por menos de 90 días.
Si usted es un residente de un centro de cuidado a largo plazo, cubriremos un suministro temporal
transitorio de 31 días (a menos que su receta sea por menos días). Cubriremos más de una renovación de
estos medicamentos durante los primeros 90 días que es miembro de nuestro plan. Si necesita un
medicamento que no está en nuestro formulario o si su capacidad de obtener sus medicamentos es
limitada, pero usted ha pasado los primeros 90 días de su afiliación a nuestro plan, cubriremos un
suministro de emergencia de 31 días de ese medicamento (a menos que tenga una receta por menos días)
mientras busca una excepción al formulario.
Para los afiliados actuales cuyos medicamentos ya no están en el formulario de Advantage by Buckeye
Community Health Plan, Advantage by Buckeye Community Health Plan cubre un suministro temporal de
30 días (a menos que tengan una receta por menos días) cuando van a una farmacia de la red. Después de
su primer suministro de 30 días, no pagaremos por estos medicamentos.
Para obtener más información
Para obtener más información detallada sobre su cobertura de medicamentos recetados de Advantage by Buckeye Community Health Plan, revise su Evidencia de cobertura y otros materiales del plan. Si tiene preguntas sobre Advantage by Buckeye Community Health Plan, llame a Servicios para los Miembros al 1-866-389-7690, de 8 a.m. a 8 p.m., los 7 días de la semana. Los usuarios de TTY/TDD deben llamar al 1-800-750-0750, o visite www.bchpohio.com. Si tiene preguntas generales sobre la cobertura de medicamentos recetados de Medicare, llame a Medicare al 1-800-MEDICARE (1-800-633-4227) las 24 horas del día, los 7 días de la semana. Los usuarios de TTY/TDD deben llamar al 1-877-486-2048. O, visite .
Formulario de Advantage by Buckeye Community Health Plan
El formulario que comienza en la página siguiente presenta información de cobertura acerca de algunos de
los medicamentos cubiertos por Advantage by Buckeye Community Health Plan. Si tiene problemas para
encontrar su medicamento en la lista, pase al Índice.
La primera columna de la tabla muestra el nombre del medicamento. Los medicamentos de marca están en
mayúsculas (por ejemplo, LEVAQUIN) y los medicamentos genéricos aparecen en minúsculas y cursiva
(por ejemplo., ciprofloxacin).
La información de la columna de Notas le dice si Advantage by Buckeye Community Health Plan tiene
requisitos especiales para la cobertura de su medicamento.


Formulary: 2011 Medicare D SNIP Formulary
Date generated: June 30, 2011
List of Abbreviations
B/D: This prescription drug has a Part B versus D administrative prior authorization requirement. This drug may be
covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted
describing the use and setting of the drug to make the determination.
CB: This prescription drug has a capped benefit limit.
ED: This prescription drug is not normally covered in a Medicare Prescription Drug Plan. The amount you pay when
you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not
help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you
will not get any extra help to pay for this drug.
FF: Free First Fill. This prescription drug will be provided at zero or reduced cost-sharing the first time you fill it.
GC: Gap Coverage. We provide additional coverage of this prescription drug in the coverage gap. Please refer to our
Evidence of Coverage for more information about this coverage.
HI: Home Infusion. This prescription drug may be covered under our medical benefit. For more information, call
Member Services at 866-389-7690 8 a.m. to 8 p.m. 7 days per week. TTY/TDD users should call 800-750-0750.
LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information consult
your Pharmacy Directory or call Member Services at 866-389-7690 8 a.m. to 8 p.m. 7 days per week. TTY/TDD users
should call 800-750-0750.
MO: Mail Order Drug. This prescription drug is available through a mail-order service.
PA: Prior Authorization. Advantage by Buckeye Community Health Plan requires you (or your physician) to get prior
authorization for certain drugs. This means that you will need to get approval from Buckeye before you fill your
prescriptions. If you don't get approval, Buckeye may not cover the drug.
QL: Quantity Limit. For certain drugs, Advantage by Buckeye Community Health Plan limits the amount of the drug
that Buckeye will cover. For example, Buckeye provides 390 per prescription for acetaminophen. This may be in
addition to a standard one month or three month supply.
ST: Step Therapy. In some cases, Advantage by Buckeye Community Health Plan requires you to first try certain drugs
to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug
B both treat your medical condition, Buckeye may not cover drug B unless you try Drug A first. If Drug A does not
work for you, Buckeye will then cover Drug B.
Drug Name
Analgesics
Nonsteroidal Anti-inflammatory Drugs
piroxicam Opioid Analgesics
acetaminophen/codeine #3 QL (390 per 30 days) acetaminophen/codeine #4 QL (390 per 30 days) acetaminophen/codeine tablet QL (390 per 30 days) ascomp/codeine BUPRENORPHINE HCL INJECTION buprenorphine hcl tablet sublingual BUTORPHANOL TARTRATE INJECTION butorphanol tartrate nasal solution QL (240 per 30 days) DEMEROL INJECTION endocet tablet 650mg; 10mg QL (180 per 30 days) endocet tablet 500mg; 7.5mg QL (240 per 30 days) endocet tablet 325mg; 10mg, 325mg; 5mg, 325mg; 7.5mg QL (360 per 30 days) FENTANYL CITRATE hydrocodone bitartrate/acetaminophen tablet 750mg; 10mg QL (150 per 30 days) hydrocodone/acetaminophen tablet 650mg; 10mg hydrocodone/acetaminophen tablet 750mg; 7.5mg QL (150 per 30 days) hydrocodone/acetaminophen tablet 650mg; 7.5mg, 660mg; 10mg QL (180 per 30 days) hydrocodone/acetaminophen tablet 500mg; 10mg, 500mg; 2.5mg, 500mg; 1 QL (240 per 30 days) 5mg, 500mg; 7.5mg hydrocodone/acetaminophen tablet 325mg; 10mg, 325mg; 5mg, 325mg; 1 QL (360 per 30 days) 7.5mg HYDROMORPHONE HCL INJECTION hydromorphone hcl tablet levorphanol tartrate margesic-h QL (240 per 30 days) meperidine hcl oral solution, tablet MEPERIDINE HCL INJECTION 10MG/ML, 25MG/ML, 4 50MG/ML, 75MG/ML METHADONE HCL INJECTION methadone hcl concentrate, oral solution, tablet methadose morphine sulfate er tablet extended release 12 hour 15mg, 200mg, 30mg, 1 QL (120 per 30 days) 60mg morphine sulfate er tablet extended release 12 hour 100mg QL (180 per 30 days) MORPHINE SULFATE INJECTION morphine sulfate tablet morphine sulfate oral solution 10mg/5ml, 20mg/5ml oramorph sr tablet extended release 12 hour 15mg, 30mg QL (120 per 30 days) Drug Name
oramorph sr tablet extended release 12 hour 100mg QL (180 per 30 days) oxycodone hcl tablet oxycodone/acetaminophen tablet 500mg; 7.5mg QL (240 per 30 days) oxycodone/acetaminophen tablet 325mg; 10mg, 325mg; 5mg, 325mg; QL (360 per 30 days) 7.5mg oxycodone/aspirin tablet 325mg; 4.5mg; 0.38mg QL (360 per 30 days) pentazocine/naloxone hcl roxicet tablet 325mg; 5mg QL (360 per 30 days) QL (240 per 30 days) tramadol hcl QL (240 per 30 days) tramadol hydrochloride/acetaminophen QL (240 per 30 days) Anesthetics
Local Anesthetics
lidocaine lidocaine hcl jelly LIDOCAINE HCL INJECTION lidocaine hcl gel, external solution QL (30 per 30 days) XYLOCAINE INJECTION Anti-inflammatory Agents
Nonsteroidal Anti-inflammatory Drugs
diclofenac potassium diclofenac sodium diclofenac sodium ec diclofenac sodium xr diflunisal etodolac er fenoprofen calcium flurbiprofen ibuprofen indomethacin indomethacin er ketoprofen ketoprofen er QL (30 per 30 days) KETOROLAC TROMETHAMINE INJECTION ketorolac tromethamine tablet QL (30 per 30 days) meclofenamate sodium meloxicam suspension meloxicam tablet 7.5mg meloxicam tablet 15mg QL (30 per 30 days) nabumetone naproxen dr oxaprozin piroxicam Drug Name
tolmetin sodium AMIKACIN SULFATE gentak solution GENTAMICIN SULFATE/0.9% SODIUM CHLORIDE GENTAMICIN SULFATE/SODIUM CHLORIDE GENTAMICIN SULFATE INJECTION gentamicin sulfate cream, ointment, ophthalmic solution ISOTONIC GENTAMICIN KANAMYCIN SULFATE neomycin sulfate STREPTOMYCIN SULFATE TOBRAMYCIN SULFATE/SODIUM CHLORIDE TOBRAMYCIN SULFATE INJECTION tobramycin sulfate ophthalmic solution Antibacterials, Other
bacitracin/polymyxin b BACITRACIN INJECTION bacitracin ointment CHLORAMPHENICOL SODIUM SUCCINATE clindamycin hcl CLINDAMYCIN PHOSPHATE ADD-VANTAGE clindamycin phosphate cream, gel, lotion, solution, swab COLISTIMETHATE SODIUM methenamine hippurate METRONIDAZOLE IN NACL 0.79% metronidazole vaginal metronidazole cream, gel, lotion, tablet mupirocin NEOMYCIN/POLYMYXIN B SULFATES nitrofurantoin macrocrystalline nitrofurantoin monohydrate polycin b POLYMYXIN B SULFATE silver sulfadiazine thermazene Drug Name
trimethoprim XIFAXAN TABLET 200MG QL (20 per 10 days) ZYVOX SUSPENSION RECONSTITUTED QL (600 per 10 days) Beta-lactam, Cephalosporins
cefaclor er cefadroxil CEFAZOLIN SODIUM CEFOTAXIME SODIUM CEFOXITIN SODIUM INJECTION 10GM, 1GM, 2GM cefpodoxime proxetil tablet cefprozil suspension reconstituted cefprozil tablet 250mg CEFTRIAXONE SODIUM cefuroxime axetil tablet CEFUROXIME SODIUM CEFUROXIME/DEXTROSE 4 cephalexin FORTAZ INJECTION 1GM/50ML; 5%, 1GM, 2GM/50ML; 4 5% MAXIPIME 4 TAZICEF INJECTION 2GM, 6GM ZINACEF IN ISO-OSMOTIC DEXTROSE ZINACEF IN ISO-OSMOTIC DILUENT Beta-lactam, Other
AZACTAM IN ISO-OSMOTIC DEXTROSE Beta-lactam, Penicillins
amoxicillin amoxicillin/clavulanate potassium amoxicillin/clavulanate potassium er amoxicillin/potassium clavulanate ampicillin AMPICILLIN SODIUM AMPICILLIN-SULBACTAM 4 BACTOCILL IN DEXTROSE Drug Name
dicloxacillin sodium NAFCILLIN SODIUM NALLPEN/DEXTROSE 4 OXACILLIN SODIUM PENICILLIN G POTASSIUM PENICILLIN G POTASSIUM IN ISO-OSMOTIC DEXTROSE PENICILLIN G PROCAINE PENICILLIN G SODIUM penicillin v potassium PIPERACILLIN SODIUM UNASYN BULK PACK Macrolides
AZITHROMYCIN INJECTION azithromycin suspension reconstituted 100mg/5ml QL (15 per 5 days) azithromycin suspension reconstituted 200mg/5ml QL (22.5 per 5 days) azithromycin tablet 500mg QL (3 per 3 days) azithromycin tablet 250mg QL (6 per 5 days) azithromycin tablet 600mg QL (8 per 28 days) clarithromycin suspension reconstituted clarithromycin tablet 250mg QL (28 per 14 days) clarithromycin tablet 500mg QL (42 per 21 days) e.e.s. 400 e.e.s. granules ERYTHROCIN LACTOBIONATE erythrocin stearate erythromycin base erythromycin ointment, solution KETEK TABLET 300MG KETEK TABLET 400MG QL (20 per 10 days) ZITHROMAX INJECTION Quinolones
AVELOX INJECTION CIPRO I.V.-IN D5W ciprofloxacin ciprofloxacin hcl LEVAQUIN ORAL SOLUTION LEVAQUIN INJECTION LEVAQUIN TABLET 250MG QL (10 per 10 days) LEVAQUIN TABLET 500MG, 750MG QL (14 per 14 days) ofloxacin otic solution, tablet Drug Name
ofloxacin ophthalmic solution QL (30 per 30 days) sodium sulfacetamide sulfadiazine sulfamethoxazole/trimethoprim ds SULFAMETHOXAZOLE/TRIMETHOPRIM INJECTION 4 sulfamethoxazole/trimethoprim suspension, tablet sulfatrim trimethoprim sulfate/polymyxin b sulfate demeclocycline hcl doxycycline hyclate capsule delayed release particles 75mg doxycycline hyclate capsule, tablet DOXYCYCLINE HYCLATE INJECTION 100MG doxycycline monohydrate tablet 50mg, 75mg minocycline hcl capsule tetracycline hcl Anticonvulsants, Other
KEPPRA INJECTION levetiracetam solution, tablet VIMPAT ORAL SOLUTION, TABLET VIMPAT INJECTION Calcium Channel Modifying Agents
ethosuximide LYRICA CAPSULE 150MG, 200MG, 225MG, 300MG QL (60 per 30 days) LYRICA CAPSULE 100MG, 25MG, 50MG, 75MG QL (90 per 30 days) zonisamide Gamma-aminobutyric Acid (GABA) Augmenting Agents
DEPAKOTE SPRINKLES divalproex sodium gabapentin GABITRIL TABLET 4MG GABITRIL TABLET 12MG, 16MG, 2MG QL (90 per 30 days) MYSOLINE TABLET 50MG NEURONTIN SOLUTION primidone VALPROATE SODIUM valproic acid Glutamate Reducing Agents
LAMICTAL STARTER/NOT TAKING CARBAMAZEPINE 2 LAMICTAL STARTER/TAKING CARBAMAZEPINE/NOT TAKING VALPROATE LAMICTAL STARTER/TAKING VALPROATE lamotrigine Drug Name
topiramate Sodium Channel Inhibitors
carbamazepine carbamazepine er DILANTIN INFATABS oxcarbazepine phenytoin PHENYTOIN SODIUM phenytoin sodium extended Antidementia Agents
Cholinesterase Inhibitors
QL (30 per 30 days) ARICEPT TABLET 10MG, 5MG QL (30 per 30 days) donepezil hcl QL (60 per 30 days) galantamine hydrobromide solution galantamine hydrobromide capsule extended release 24 hour QL (30 per 30 days) galantamine hydrobromide tablet 4mg QL (180 per 30 days) galantamine hydrobromide tablet 12mg QL (60 per 30 days) galantamine hydrobromide tablet 8mg QL (90 per 30 days) rivastigmine tartrate QL (60 per 30 days) Glutamate Pathway Modifiers
NAMENDA TITRATION PAK NAMENDA SOLUTION QL (360 per 30 days) QL (60 per 30 days) Antidepressants, Other
budeprion sr budeprion xl tablet extended release 24 hour 300mg budeprion xl tablet extended release 24 hour 150mg QL (30 per 30 days) bupropion hcl bupropion hcl sr maprotiline hcl mirtazapine mirtazapine odt nefazodone hcl trazodone hcl Monoamine Oxidase Inhibitors
Drug Name
phenelzine sulfate tranylcypromine sulfate Serotonin/ Norepinephrine Reuptake Inhibitors
citalopram hydrobromide CYMBALTA CAPSULE DELAYED RELEASE PARTICLES 2 QL (30 per 30 days) 60MG CYMBALTA CAPSULE DELAYED RELEASE PARTICLES 2 QL (60 per 30 days) 20MG, 30MG EFFEXOR XR fluoxetine hcl capsule, solution fluvoxamine maleate LEXAPRO SOLUTION QL (30 per 30 days) paroxetine hcl paroxetine hcl er tablet extended release 24 hour 37.5mg sertraline hcl venlafaxine hcl QL (90 per 30 days) venlafaxine hcl er Tricyclics
amitriptyline hcl amoxapine clomipramine hcl desipramine hcl doxepin hcl capsule 100mg, 10mg, 25mg, 50mg, 75mg doxepin hcl concentrate imipramine hcl imipramine pamoate nortriptyline hcl protriptyline hcl Antidotes, Deterrents, and Toxicologic Agents
Antidotes
sodium polystyrene sulfonate Deterrents
bupropion hcl sr Toxicologic Agents
Drug Name
naltrexone hcl SUBOXONE TABLET SUBLINGUAL Antiemetics
Antiemetics
dronabinol EMEND CAPSULE 40MG QL (1 per 14 days) QL (3 per 14 days) granisetron hcl injection hydroxyzine pamoate meclizine hcl METOCLOPRAMIDE HCL INJECTION metoclopramide hcl oral solution, tablet ondansetron hcl oral solution, tablet ondansetron hcl injection ondansetron odt PROMETHAZINE HCL INJECTION promethazine hcl syrup, tablet promethegan REGLAN INJECTION TRIMETHOBENZAMIDE HCL INJECTION trimethobenzamide hcl capsule Antifungals
Antifungals
ciclopirox olamine ciclopirox suspension clotrimazole clotrimazole/betamethasone dipropionate DIFLUCAN IN NACL econazole nitrate FLUCONAZOLE IN DEXTROSE fluconazole suspension reconstituted fluconazole tablet 100mg, 200mg, 50mg fluconazole tablet 150mg QL (1 per 10 days) itraconazole ketoconazole miconazole 3 QL (12 per 30 days) Drug Name
nystatin cream, powder, suspension, tablet SPORANOX SOLUTION terbinafine hcl terconazole cream 0.8% QL (40 per 30 days) terconazole cream 0.4% QL (90 per 30 days) terconazole suppository zazole cream 0.8% QL (40 per 30 days) zazole cream 0.4% QL (90 per 30 days) zazole suppository Antigout Agents
Antigout Agents
allopurinol ALLOPURINOL SODIUM probenecid Antimigraine Agents
Abortive
DIHYDROERGOTAMINE MESYLATE ergotamine tartrate/caffeine IMITREX STATDOSE REFILL IMITREX SOLUTION QL (12 per 30 days) sumatriptan succinate tablet sumatriptan succinate injection 6mg/0.5ml Antimyasthenic Agents
guanidine hcl MESTINON TIMESPAN pyridostigmine bromide Antimycobacterials, Other
CAPASTAT SULFATE ethambutol hcl ISONIAZID INJECTION isoniazid syrup, tablet Drug Name
pyrazinamide RIFADIN INJECTION RIFAMPIN INJECTION rifampin capsule Alkylating Agents
cyclophosphamide IFOSFAMIDE/MESNA 4 melphalan hydrochloride Antiangiogenic Agents
tamoxifen citrate CYTARABINE AQUEOUS INJECTION 100MG/ML cytarabine aqueous injection 20mg/ml FLUDARABINE PHOSPHATE fluorouracil gemcitabine hcl hydroxyurea Drug Name
mercaptopurine pentostatin Antineoplastics, Other
amifostine BLEOMYCIN SULFATE carboplatin DAUNORUBICIN HCL docetaxel epirubicin hcl irinotecan MITOXANTRONE HCL oxaliplatin topotecan hcl Drug Name
VINBLASTINE SULFATE vincristine sulfate VINORELBINE TARTRATE Aromatase Inhibitors, 3rd Generation
anastrozole QL (30 per 30 days) QL (30 per 30 days) exemestane QL (30 per 30 days) letrozole Molecular Target Inhibitors
Monoclonal Antibodies
Retinoids
tretinoin mebendazole chloroquine phosphate hydroxychloroquine sulfate mefloquine hcl Drug Name
PRIMAQUINE PHOSPHATE Pediculicides/ Scabicides
lindane lotion permethrin Antiparkinson Agents
Antiparkinson Agents
QL (30 per 30 days) benztropine mesylate tablet bromocriptine mesylate carbidopa/levodopa cr carbidopa/levodopa odt carbidopa/levodopa sr QL (240 per 30 days) pramipexole dihydrochloride ropinirole hcl selegiline hcl trihexyphenidyl hcl Atypicals
ABILIFY DISCMELT QL (30 per 30 days) ABILIFY INJECTION clozapine FANAPT TITRATION PACK FAZACLO TABLET DISPERSIBLE 100MG, 12.5MG, 25MG 2 GEODON INJECTION RISPERDAL CONSTA risperidone risperidone odt Drug Name
ZYPREXA INJECTION CHLORPROMAZINE HCL INJECTION chlorpromazine hcl tablet FLUPHENAZINE DECANOATE FLUPHENAZINE HCL INJECTION fluphenazine hcl concentrate, elixir, tablet haloperidol HALOPERIDOL DECANOATE HALOPERIDOL LACTATE loxapine succinate perphenazine PROCHLORPERAZINE EDISYLATE prochlorperazine maleate thioridazine hcl thiothixene trifluoperazine hcl Antispasticity Agents
Antispasticity Agents
dantrolene sodium tizanidine hcl Antivirals
Anti-cytomegalovirus (CMV) Agents
FOSCARNET SODIUM ganciclovir capsule Anti-HIV Agents, Non-nucleoside Reverse Transcriptase
Inhibitors
Anti-HIV Agents, Nucleoside and Nucleotide Reverse
Transcriptase Inhibitors
didanosine RETROVIR IV INFUSION stavudine Drug Name
ZERIT SOLUTION RECONSTITUTED zidovudine Anti-HIV Agents, Other
Anti-HIV Agents, Protease Inhibitors
Anti-influenza Agents
amantadine hcl capsule, tablet RELENZA DISKHALER QL (56 per 180 days) rimantadine hcl TAMIFLU SUSPENSION RECONSTITUTED TAMIFLU CAPSULE 30MG, 45MG TAMIFLU CAPSULE 75MG QL (28 per 180 days) Antihepatitis Agents
REBETOL SOLUTION ribasphere tablet ribavirin Antiherpetic Agents
acyclovir ACYCLOVIR SODIUM famciclovir QL (60 per 30 days) trifluridine valacyclovir hcl QL (30 per 30 days) ZOVIRAX CREAM, OINTMENT QL (30 per 30 days) Anxiolytics
Anxiolytics, Other
Drug Name
buspirone hcl meprobamate Bipolar Agents
Bipolar Agents
divalproex sodium divalproex sodium er lithium carbonate lithium carbonate er lithium citrate QL (30 per 30 days) Blood Glucose Regulators
Antidiabetic Agents
QL (90 per 30 days) QL (90 per 30 days) QL (30 per 30 days) AVANDAMET TABLET 500MG; 2MG QL (120 per 30 days) AVANDAMET TABLET 1000MG; 2MG, 1000MG; 4MG, QL (60 per 30 days) 500MG; 4MG AVANDARYL TABLET 2MG; 8MG, 4MG; 8MG AVANDARYL TABLET 4MG; 4MG QL (30 per 30 days) AVANDARYL TABLET 1MG; 4MG, 2MG; 4MG QL (60 per 30 days) AVANDIA TABLET 8MG QL (30 per 30 days) AVANDIA TABLET 2MG, 4MG QL (60 per 30 days) BYETTA INJECTION 5MCG/0.02ML PA (Blood Glucose Regulators) BYETTA INJECTION 10MCG/0.04ML QL (2.4 per 30 days) PA (Blood Glucose Regulators) chlorpropamide QL (30 per 30 days) glimepiride glipizide glipizide er glipizide/metformin hcl QL (120 per 30 days) glyburide glyburide micronized QL (60 per 30 days) glyburide/metformin hcl QL (120 per 30 days) glycron tablet 1.5mg, 3mg, 6mg QL (90 per 30 days) QL (30 per 30 days) metformin hcl er tablet extended release 24 hour 500mg QL (120 per 30 days) metformin hcl er tablet extended release 24 hour 750mg QL (90 per 30 days) metformin hcl tablet 500mg QL (120 per 30 days) metformin hcl tablet 1000mg QL (60 per 30 days) metformin hcl tablet 850mg QL (90 per 30 days) nateglinide PA (Blood Glucose Regulators - Drug Name
Notes
Amylinomimetics)
PA (Blood Glucose Regulators - Amylinomimetics) PA (Blood Glucose Regulators - Amylinomimetics) tolbutamide Glycemic Agents
GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT Insulins
QL (40 per 30 days) QL (40 per 30 days) QL (40 per 30 days) HUMALOG MIX 50/50 QL (40 per 30 days) HUMALOG MIX 50/50 KWIKPEN QL (40 per 30 days) HUMALOG MIX 75/25 QL (40 per 30 days) HUMALOG MIX 75/25 KWIKPEN QL (40 per 30 days) QL (40 per 30 days) HUMULIN 70/30 PEN QL (40 per 30 days) QL (40 per 30 days) HUMULIN N U-100 PEN QL (40 per 30 days) QL (40 per 30 days) HUMULIN R U-500 (CONCENTRATED) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (40 per 30 days) NOVOLIN 70/30 INNOLET QL (40 per 30 days) QL (40 per 30 days) NOVOLIN N INNOLET QL (40 per 30 days) QL (40 per 30 days) QL (40 per 30 days) QL (40 per 30 days) NOVOLOG MIX 70/30 QL (40 per 30 days) NOVOLOG MIX 70/30 PREFILLED FLEXPEN QL (40 per 30 days) QL (40 per 30 days) Blood Products/Modifiers/ Volume Expanders
COUMADIN INJECTION enoxaparin sodium FRAGMIN INJECTION 10000UNIT/ML, 25000UNIT/ML, 4 2500UNIT/0.2ML, 5000UNIT/0.2ML, 7500UNIT/0.3ML HEPARIN SODIUM HEPARIN SODIUM/D5W HEPARIN SODIUM/NACL 0.45% HEPARIN SODIUM/SODIUM CHLORIDE 0.9% PREMIX 4 Drug Name
warfarin sodium Blood Formation Products
ARANESP ALBUMIN FREE INJECTION 100MCG/ML, PA (Blood Products/Modifiers/ 150MCG/0.3ML, 200MCG/0.4ML, 200MCG/ML, Volume Expanders) 25MCG/0.42ML, 25MCG/ML, 300MCG/ML, 40MCG/0.4ML, 40MCG/ML, 500MCG/ML, 60MCG/ML LEUKINE 4 PROCRIT INJECTION 10000UNIT/ML, 2000UNIT/ML, PA (Blood Products/Modifiers/ 3000UNIT/ML, 40000UNIT/ML, 4000UNIT/ML Volume Expanders) Blood Products/Modifiers/ Volume Expanders
Coagulants
Platelet Aggregation Inhibitors
QL (60 per 30 days) cilostazol dipyridamole PLAVIX TABLET 75MG QL (30 per 30 days) ticlopidine hcl QL (60 per 30 days) Cardiovascular Agents
Alpha-adrenergic Agonists
clonidine hcl tablet guanabenz acetate guanfacine hcl methyldopa METHYLDOPATE HCL midodrine hcl Alpha-adrenergic Blocking Agents
prazosin hcl reserpine tablet 0.25mg AMIODARONE HCL INJECTION amiodarone hcl tablet QL (30 per 30 days) disopyramide phosphate flecainide acetate mexiletine hcl PACERONE TABLET 100MG, 400MG pacerone tablet 200mg PROCAINAMIDE HCL propafenone hcl QUINIDINE GLUCONATE quinidine gluconate er Drug Name
quinidine sulfate quinidine sulfate er sotalol hcl verapamil hcl er Beta-adrenergic Blocking Agents
acebutolol hcl betaxolol hcl bisoprolol fumarate bisoprolol fumarate/hydrochlorothiazide carvedilol QL (60 per 30 days) LABETALOL HCL INJECTION labetalol hcl tablet LOPRESSOR INJECTION metoprolol succinate er METOPROLOL TARTRATE INJECTION metoprolol tartrate tablet propranolol hcl er PROPRANOLOL HCL INJECTION propranolol hcl oral solution, tablet timolol maleate Calcium Channel Blocking Agents
afeditab cr QL (30 per 30 days) amlodipine besylate QL (30 per 30 days) amlodipine besylate/benazepril hydrochloride QL (30 per 30 days) cartia xt QL (30 per 30 days) QL (30 per 30 days) diltiazem cd QL (30 per 30 days) diltiazem hcl er capsule extended release 12 hour diltiazem hcl er capsule extended release 24 hour QL (30 per 30 days) DILTIAZEM HCL INJECTION diltiazem hcl tablet felodipine er tablet extended release 24 hour 2.5mg, 5mg felodipine er tablet extended release 24 hour 10mg QL (30 per 30 days) isradipine nifediac cc QL (30 per 30 days) nifedical xl QL (30 per 30 days) nifedipine nifedipine er QL (30 per 30 days) taztia xt QL (30 per 30 days) verapamil hcl er VERAPAMIL HCL INJECTION Drug Name
verapamil hcl tablet Cardiovascular Agents, Other
DIGOXIN INJECTION digoxin oral solution, tablet LANOXIN INJECTION RANEXA TABLET EXTENDED RELEASE 12 HOUR QL (120 per 30 days) Diuretics
ACETAZOLAMIDE SODIUM BUMETANIDE INJECTION bumetanide tablet chlorothiazide chlorthalidone FUROSEMIDE INJECTION furosemide oral solution, tablet indapamide methyclothiazide metolazone torsemide tablet torsemide injection cholestyramine light colestipol hcl fenofibrate QL (30 per 30 days) fenofibrate micronized QL (30 per 30 days) gemfibrozil QL (60 per 30 days) QL (30 per 30 days) lovastatin tablet 10mg, 20mg QL (30 per 30 days) lovastatin tablet 40mg QL (60 per 30 days) pravastatin sodium tablet 10mg, 80mg pravastatin sodium tablet 20mg, 40mg QL (30 per 30 days) prevalite simvastatin QL (30 per 30 days) QL (30 per 30 days) Renin-angiotensin-aldosterone System Inhibitors
benazepril hcl benazepril hcl/hydrochlorothiazide tablet 5mg; 6.25mg benazepril hcl/hydrochlorothiazide tablet 10mg; 12.5mg, 20mg; 12.5mg, 1 QL (30 per 30 days) 20mg; 25mg captopril Drug Name
QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) enalapril maleate enalapril maleate/hydrochlorothiazide fosinopril sodium fosinopril sodium/hydrochlorothiazide QL (30 per 30 days) lisinopril QL (30 per 30 days) losartan potassium losartan potassium/hydrochlorothiazide spironolactone QL (30 per 30 days) QL (30 per 30 days) trandolapril QL (180 per 30 days) HYDRALAZINE HCL INJECTION hydralazine hcl tablet isosorbide dinitrate isosorbide dinitrate er isosorbide mononitrate isosorbide mononitrate er minoxidil nitroglycerin transdermal NITROGLYCERIN INJECTION nitroglycerin patch 24 hour Central Nervous System Agents
Amphetamines, ADHD
amphetamine/dextroamphetamine tablet 5mg; 5mg; 5mg; 5mg, 7.5mg; QL (60 per 30 days) 7.5mg; 7.5mg; 7.5mg amphetamine/dextroamphetamine tablet 1.25mg; 1.25mg; 1.25mg; QL (90 per 30 days) 1.25mg, 1.875mg; 1.875mg; 1.875mg; 1.875mg, 2.5mg; 2.5mg; 2.5mg; 2.5mg, 3.125mg; 3.125mg; 3.125mg; 3.125mg, 3.75mg; 3.75mg; 3.75mg; 3.75mg dextroamphetamine sulfate Non-amphetamines, ADHD
QL (30 per 30 days) metadate er methylin er METHYLIN TABLET CHEWABLE, SOLUTION methylin tablet QL (90 per 30 days) methylphenidate hcl QL (90 per 30 days) methylphenidate hcl sr QL (60 per 30 days) Non-amphetamines, Other
Drug Name
PROVIGIL TABLET 200MG QL (30 per 30 days) PA (Central Nervous System Agents) PROVIGIL TABLET 100MG QL (60 per 30 days) PA (Central Nervous System Agents) QL (540 per 30 days) LA Dental and Oral Agents
Dental and Oral Agents
chlorhexidine gluconate oral rinse periogard pilocarpine hcl triamcinolone in orabase Dermatological Agents
Dermatological Agents
QL (24 per 30 days) PA (Dermatological Agents - IV psoriasis) ammonium lactate amnesteem avita gel QL (90 per 30 days) calcipotriene solution QL (60 per 30 days) QL (200 per 30 days) QL (60 per 30 days) PA (Dermatological Agents) erythromycin/benzoyl peroxide fluorouracil imiquimod laclotion podofilox QL (60 per 30 days) PA (Dermatological Agents) QL (15 per 30 days) selenium sulfide QL (120 per 30 days) sodium sulfacetamide tretinoin cream tretinoin gel QL (90 per 30 days) QL (15 per 30 days) Enzyme Replacements/ Modifiers
Enzyme Replacements/ Modifiers
Drug Name
Gastrointestinal Agents
Antispasmodics, Gastrointestinal
ATROPINE SULFATE BENTYL INJECTION DICYCLOMINE HCL INJECTION dicyclomine hcl capsule, oral solution, tablet GLYCOPYRROLATE INJECTION glycopyrrolate tablet methscopolamine bromide tablet 2.5mg ROBINUL INJECTION Gastrointestinal Agents, Other
constulose diphenoxylate/atropine tablet HALFLYTELY BOWEL PREP lactulose loperamide hcl NULYTELY/FLAVOR PACKS polyethylene glycol 3350 ursodiol capsule Histamine2 (H2) Blocking Agents
axid solution cimetidine CIMETIDINE HCL INJECTION cimetidine hcl oral solution FAMOTIDINE PREMIXED FAMOTIDINE INJECTION famotidine tablet nizatidine capsule RANITIDINE HCL INJECTION ranitidine hcl capsule, syrup, tablet ZANTAC INJECTION Drug Name
Irritable Bowel Syndrome Agents
Protectants
misoprostol sucralfate Proton Pump Inhibitors
omeprazole pantoprazole sodium PROTONIX INJECTION Genitourinary Agents
Antispasmodics, Urinary
QL (60 per 30 days) QL (30 per 30 days) flavoxate hcl oxybutynin chloride er oxybutynin chloride tablet Benign Prostatic Hypertrophy Agents
QL (30 per 30 days) doxazosin mesylate finasteride QL (30 per 30 days) QL (60 per 30 days) tamsulosin hcl terazosin hcl Genitourinary Agents, Other
bethanechol chloride Phosphate Binders
calcium acetate Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal)
Glucocorticoids/ Mineralocorticoids
alclometasone dipropionate amcinonide augmented betamethasone dipropionate cream, gel, ointment betamethasone dipropionate cream, ointment betamethasone valerate clobetasol propionate e clobetasol propionate ointment, solution CORTEF TABLET 5MG cortisone acetate desoximetasone dexamethasone DEXAMETHASONE SODIUM PHOSPHATE diflorasone diacetate Drug Name
fludrocortisone acetate fluocinolone acetonide fluocinonide fluocinonide emollient base fluticasone propionate halobetasol propionate hydrocortisone hydrocortisone butyrate hydrocortisone valerate LOCOID OINTMENT, SOLUTION METHYLPREDNISOLONE ACETATE METHYLPREDNISOLONE SODIUMSUCCINATE methylprednisolone tablet 4mg, 8mg mometasone furoate prednicarbate cream prednisolone sodium phosphate prednisone procto-pak proctocream hc proctosol hc proctozone-hc triamcinolone acetonide TRIAMCINOLONE ACETONIDE IN ABSORBASE Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary)
Hormonal Agents, Stimulant/ Replacement/ Modifying
(Pituitary)
chorionic gonadotropin desmopressin acetate tablet desmopressin acetate injection desmopressin acetate nasal solution 0.01% QL (28 per 28 days) PA (Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary)) HUMATROPE COMBO PACK QL (28 per 28 days) PA (Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary)) NORDITROPIN FLEXPRO INJECTION 15MG/1.5ML, PA (Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary)) QL (28 per 28 days) PA (Hormonal Agents, Stimulant/ Replacement/ Drug Name
Notes
Modifying (Pituitary))
QL (28 per 28 days) PA (Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary)) NUTROPIN AQ PEN INJECTION 10MG/2ML QL (28 per 28 days) PA (Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary)) PREGNYL W/DILUENT BENZYL ALCOHOL/NACL PA (Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary)) SAIZEN CLICK.EASY PA (Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary)) QL (28 per 28 days) PA (Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary) - Serostim) QL (28 per 28 days) PA (Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary)) PA (Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary) - Zorbtive) Hormonal Agents, Stimulant/ Replacement/ Modifying (Sex
Hormones/ Modifiers)
Anabolic Steroids
oxandrolone Androgens
ANDRODERM PATCH 24 HOUR 5MG/24HR QL (30 per 30 days) ANDRODERM PATCH 24 HOUR 2.5MG/24HR QL (60 per 30 days) TESTOSTERONE CYPIONATE TESTOSTERONE ENANTHATE Estrogens
QL (8 per 28 days) QL (28 per 28 days) QL (28 per 28 days) QL (28 per 28 days) QL (28 per 28 days) QL (28 per 28 days) QL (4 per 28 days) QL (4 per 28 days) cryselle-28 DEPO-ESTRADIOL 4 enpresse-28 QL (28 per 28 days) estradiol valerate estradiol tablet Drug Name
estradiol patch weekly QL (4 per 28 days) estropipate junel 1.5/30 junel 1/20 junel fe 1.5/30 QL (28 per 28 days) junel fe 1/20 QL (28 per 28 days) QL (28 per 28 days) kelnor 1/35 QL (28 per 28 days) QL (28 per 28 days) lessina-28 QL (28 per 28 days) levora 0.15/30-28 QL (28 per 28 days) loestrin 24 fe QL (28 per 28 days) low-ogestrel QL (28 per 28 days) microgestin 1.5/30 QL (21 per 21 days) microgestin 1/20 QL (21 per 21 days) microgestin fe QL (28 per 28 days) microgestin fe 1.5/30 QL (28 per 28 days) mononessa necon 0.5/35-28 QL (28 per 28 days) necon 1/35-28 QL (28 per 28 days) necon 10/11-28 necon 7/7/7 QL (28 per 28 days) nortrel 0.5/35 (28) QL (28 per 28 days) nortrel 1/35 (21) QL (28 per 28 days) nortrel 1/35 (28) QL (28 per 28 days) nortrel 7/7/7 QL (28 per 28 days) QL (3 per 28 days) portia-28 QL (28 per 28 days) PREMARIN W/APPLICATOR PREMARIN INJECTION PREMARIN TABLET 0.3MG, 0.625MG PREMARIN TABLET 0.45MG, 0.9MG, 1.25MG QL (30 per 30 days) QL (30 per 30 days) QL (91 per 91 days) reclipsen QL (28 per 28 days) QL (28 per 28 days) sprintec 28 QL (28 per 28 days) tri-previfem QL (28 per 28 days) tri-sprintec QL (28 per 28 days) QL (28 per 28 days) trivora-28 QL (28 per 28 days) QL (28 per 28 days) zovia 1/35e QL (28 per 28 days) zovia 1/50e QL (28 per 28 days) Progestins
Drug Name
QL (28 per 28 days) DEPO-PROVERA CONTRACEPTIVE DEPO-SUBQ PROVERA 104 QL (28 per 28 days) jolivette QL (28 per 28 days) MEDROXYPROGESTERONE ACETATE INJECTION medroxyprogesterone acetate tablet megestrol acetate QL (28 per 28 days) norethindrone acetate Selective Estrogen Receptor Modifying Agents
Hormonal Agents, Stimulant/ Replacement/ Modifying (Thyroid)
Hormonal Agents, Stimulant/ Replacement/ Modifying
(Thyroid)
levothroid levothyroxine sodium LIOTHYRONINE SODIUM INJECTION liothyronine sodium tablet unithroid Hormonal Agents, Suppressant (Adrenal)
Hormonal Agents, Suppressant (Adrenal)
Hormonal Agents, Suppressant (Parathyroid)
Hormonal Agents, Suppressant (Parathyroid)
Hormonal Agents, Suppressant (Pituitary)
Hormonal Agents, Suppressant (Pituitary)
cabergoline LEUPROLIDE ACETATE LUPRON DEPOT-PED OCTREOTIDE ACETATE INJECTION 200MCG/ML octreotide acetate injection 1000mcg/ml, 100mcg/ml, 500mcg/ml, 50mcg/ml SANDOSTATIN LAR DEPOT SOMATULINE DEPOT INJECTION 120MG/0.5ML, 90MG/0.3ML SOMAVERT PA (Hormonal Agents, Suppressant (Pituitary) - Somavert) TRELSTAR DEPOT MIXJECT Drug Name
TRELSTAR LA MIXJECT Hormonal Agents, Suppressant (Sex Hormones/ Modifiers)
bicalutamide flutamide Hormonal Agents, Suppressant (Thyroid)
Antithyroid Agents
methimazole propylthiouracil Immunological Agents
Immune Suppressants
azathioprine AZATHIOPRINE SODIUM CELLCEPT INTRAVENOUS CELLCEPT SUSPENSION RECONSTITUTED cyclosporine modified CYCLOSPORINE INJECTION cyclosporine capsule PA (Immunological Agents) PA (Immunological Agents) HUMIRA PEN-CROHNS DISEASESTARTER PA (Immunological Agents) methotrexate METHOTREXATE SODIUM mycophenolate mofetil PROGRAF INJECTION PA (Immunological Agents) tacrolimus Immunizing Agents, Passive
CARIMUNE NANOFILTERED GAMMAGARD LIQUID PA (Immunological Agents - Infergen) INTRON-A W/DILUENT Drug Name
QL (28 per 28 days) PA (Immunological Agents) leflunomide QL (30 per 30 days) PA (Immunological Agents - Peg-Intron, Pegasys) PEG-INTRON REDIPEN PA (Immunological Agents - Peg-Intron, Pegasys) PA (Immunological Agents - Peg-Intron, Pegasys) REBIF TITRATION PACK Vaccines
DIPHTHERIA/TETANUS TOXOID PEDIATRIC IMOVAX RABIES (H.D.C.V.) IPOL INACTIVATED IPV M-M-R II W/DILUENT 10 DOSE MENOMUNE-A/C/Y/W-135 4 MERUVAX II W/DILUENT 10 DOSE TETANUS TOXOID ADSORBED TETANUS/DIPHTHERIA TOXOIDS-ADSORBED ADULT TRIHIBIT 4 Drug Name
Inflammatory Bowel Disease Agents
hydrocortisone methylprednisolone tablet 4mg Salicylates
QL (180 per 30 days) mesalamine PENTASA CAPSULE EXTENDED RELEASE 500MG QL (240 per 30 days) PENTASA CAPSULE EXTENDED RELEASE 250MG QL (480 per 30 days) sulfasalazine sulfazine ec Metabolic Bone Disease Agents
Metabolic Bone Disease Agents
ACTONEL TABLET 30MG, 5MG QL (30 per 30 days) ACTONEL TABLET 35MG QL (4 per 28 days) alendronate sodium tablet 35mg, 70mg alendronate sodium tablet 10mg, 40mg, 5mg QL (30 per 30 days) QL (4 per 30 days) CALCITRIOL INJECTION calcitriol capsule, oral solution etidronate disodium tablet 400mg PA (metabolic bone disease agents - IV osteoporosis) QL (4 per 30 days) FOSAMAX SOLUTION HECTOROL INJECTION HECTOROL CAPSULE 0.5MCG, 2.5MCG MIACALCIN INJECTION PAMIDRONATE DISODIUM Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
alcohol preps anagrelide hydrochloride BD INSULIN SYRINGE SAFETYGLIDE/1ML/29G X 1/2" 2 BD INSULIN SYRINGE ULTRAFINE/0.3ML/31G X 5/16" 2 QL (200 per 30 days) BD INSULIN SYRINGE ULTRAFINE/0.5ML/30G X 1/2" 2 QL (200 per 30 days) BD INSULIN SYRINGE ULTRAFINE/1ML/31G X 5/16" 2 QL (200 per 30 days) BD PEN NEEDLE/ULTRAFINE/29G X 12.7MM QL (200 per 30 days) PA (Miscellaneous Therapeutic Agents) curity gauze pads 2"x2" QL (204 per 30 days) DEXTROSE 10% FLEX CONTAINER Drug Name
lactated ringers irrigation LEUCOVORIN CALCIUM INJECTION leucovorin calcium tablet LEVOCARNITINE INJECTION levocarnitine oral solution, tablet pentoxifylline er Ophthalmic Agents
Ophthalmic Agents, Other
QL (120 per 30 days) naphazoline hcl tropicamide Ophthalmic Anti-allergy Agents
cromolyn sodium Ophthalmic Anti-inflammatories
QL (5 per 15 days) QL (5 per 15 days) dexamethasone sodium phosphate dexasporin diclofenac sodium QL (5 per 15 days) fluorometholone flurbiprofen sodium ketorolac tromethamine ophthalmic solution 0.4% QL (5 per 15 days) prednisolone acetate prednisolone sodium phosphate sulfacetamide sodium/prednisolone sodium phosphate TOBRADEX OINTMENT QL (3.5 per 10 days) TOBRADEX SUSPENSION QL (5 per 10 days) Ophthalmic Antiglaucoma Agents
acetazolamide tablet betaxolol hcl QL (30 per 30 days) brimonidine tartrate carteolol hcl dorzolamide hcl QL (20 per 30 days) Drug Name
dorzolamide hcl/timolol maleate QL (20 per 30 days) levobunolol hcl QL (30 per 30 days) methazolamide metipranolol PHOSPHOLINE IODIDE timolol maleate QL (30 per 30 days) Ophthalmic Prostaglandin and Prostamide Analogs
latanoprost LUMIGAN SOLUTION 0.03% Otic Agents
Otic Agents
acetasol hc acetic acid acetic acid/hydrocortisone cortomycin Respiratory Tract Agents
Anti-inflammatories, Inhaled Corticosteroids
QL (60 per 30 days) ADVAIR HFA AEROSOL 115MCG/ACT; 21MCG/ACT, 45MCG/ACT; 21MCG/ACT ADVAIR HFA AEROSOL 230MCG/ACT; 21MCG/ACT QL (12 per 30 days) ASMANEX 120 METERED DOSES ASMANEX 14 METERED DOSES ASMANEX 30 METERED DOSES ASMANEX 60 METERED DOSES FLOVENT HFA AEROSOL 44MCG/ACT QL (21.2 per 30 days) FLOVENT HFA AEROSOL 110MCG/ACT, 220MCG/ACT 2 QL (24 per 30 days) flunisolide QL (50 per 30 days) fluticasone propionate QL (32 per 30 days) QL (34 per 30 days) QL (30 per 30 days) clemastine fumarate cyproheptadine hcl dexchlorpheniramine maleate DIPHENHYDRAMINE HCL INJECTION diphenhydramine hcl capsule fexofenadine hcl tablet 180mg QL (30 per 30 days) fexofenadine hcl tablet 30mg, 60mg QL (60 per 30 days) HYDROXYZINE HCL INJECTION hydroxyzine hcl syrup, tablet Drug Name
promethazine hcl promethazine vc QL (60 per 30 days) QL (30 per 30 days) zafirlukast QL (60 per 30 days) QL (120 per 30 days) Bronchodilators, Anticholinergic
QL (39 per 30 days) QL (45 per 30 days) ipratropium bromide/albuterol sulfate ipratropium bromide inhalation solution ipratropium bromide nasal solution 0.06% QL (15 per 30 days) ipratropium bromide nasal solution 0.03% QL (30 per 30 days) SPIRIVA HANDIHALER QL (30 per 30 days) Bronchodilators, Phosphodiesterase Inhibitors (Xanthines)
AMINOPHYLLINE INJECTION aminophylline tablet QL (30 per 30 days) theochron theophylline er Bronchodilators, Sympathomimetic
albuterol sulfate syrup, tablet albuterol sulfate nebulization solution QL (2 per 10 days) QL (2 per 10 days) metaproterenol sulfate QL (36 per 30 days) QL (60 per 30 days) TERBUTALINE SULFATE INJECTION terbutaline sulfate tablet QL (36 per 30 days) QL (45 per 30 days) Mast Cell Stabilizers
cromolyn sodium Pulmonary Antihypertensives
QL (90 per 30 days) QL (60 per 30 days) LA Respiratory Tract Agents, Other
acetylcysteine Drug Name
TYZINE PEDIATRIC NASAL DROPS PA (Respiratory Tract Agents) QL (30 per 30 days) hydroxyzine hcl QL (30 per 30 days) zolpidem tartrate QL (30 per 30 days) zolpidem tartrate er tablet extended release 12.5mg zolpidem tartrate er tablet extended release 6.25mg QL (30 per 30 days) Skeletal Muscle Relaxants
Skeletal Muscle Relaxants
carisoprodol chlorzoxazone cyclobenzaprine hcl methocarbamol ORPHENADRINE CITRATE orphenadrine citrate er ROBAXIN INJECTION Therapeutic Nutrients/Minerals/ Electrolytes
AMINOSYN 7%/ELECTROLYTES AMINOSYN 8.5%/ELECTROLYTES AMINOSYN II 3.5%/DEXTROSE25% AMINOSYN II 3.5/DEXTROSE 25% AMINOSYN II 4.25/DEXTROSE10% AMINOSYN II 4.25/DEXTROSE20% AMINOSYN II 4.25/DEXTROSE25% AMINOSYN II 5/DEXTROSE 25 AMINOSYN II 8.5%/ELECTROLYTES AMMONIUM CHLORIDE CLINIMIX 2.75%/DEXTROSE 5% CLINIMIX 4.25%/DEXTROSE 10% CLINIMIX 4.25%/DEXTROSE 20% CLINIMIX 4.25%/DEXTROSE 25% CLINIMIX 5%/DEXTROSE 20% CLINIMIX 5%/DEXTROSE 25% CLINIMIX E 2.75%/DEXTROSE 5% CLINIMIX E 4.25%/DEXTROSE 25% Drug Name
CLINIMIX E 4.25%/DEXTROSE 5% CLINIMIX E 5%/DEXTROSE 15% CLINIMIX E 5%/DEXTROSE 25% DEXTROSE 10%/NACL 0.45% DEXTROSE 5% /ELECTROLYTE #48 VIAFLEX DEXTROSE 10%/NACL 0.2% DEXTROSE 2.5%/SODIUM CHLORIDE 0.45% DEXTROSE 5%/NACL 0.2% DEXTROSE 5%/NACL 0.225% DEXTROSE 5%/NACL 0.33% DEXTROSE 5%/NACL 0.45% DEXTROSE 5%/NACL 0.9% DEXTROSE 5%/POTASSIUM CHLORIDE 0.075% FREAMINE HBC 6.9% IONOSOL-B/DEXTROSE 5% IONOSOL-MB/DEXTROSE 5% IONOSOL-T/DEXTROSE 5% ISOLYTE-H/DEXTROSE 5% ISOLYTE-M/DEXTROSE 5% ISOLYTE-P/DEXTROSE 5% ISOLYTE-S/DEXTROSE 5% kaon-cl-10 KCL 0.075%/D5W/NACL 0.45% KCL 0.15%/D10W/NACL 0.2% KCL 0.15%/D5W/LR KCL 0.15%/D5W/NACL 0.2% KCL 0.15%/D5W/NACL 0.225% KCL 0.15%/D5W/NACL 0.9% KCL 0.3%/D5W/LR IV LAC RING KCL 0.3%/D5W/NACL 0.2% KCL 0.3%/D5W/NACL 0.45% KCL 0.3%/D5W/NACL 0.9% klor-con 10 klor-con 8 klor-con m15 klor-con m20 MAGNESIUM SULFATE MAGNESIUM SULFATE IN D5W NORMOSOL-M IN D5W NORMOSOL-R IN D5W Drug Name
physiolyte physiosol irrigation PLASMA-LYTE-148 4 PLASMA-LYTE-148/D5W 4 PLASMA-LYTE-56/D5W 4 POTASSIUM CHLORIDE POTASSIUM CHLORIDE 0.075%/D5W/NACL 0.225% POTASSIUM CHLORIDE 0.15% /NACL 0.45% VIAFLEX 4 POTASSIUM CHLORIDE 0.15% D5W/NACL 0.33% POTASSIUM CHLORIDE 0.15% D5W/NACL 0.45% VIAFLEX POTASSIUM CHLORIDE 0.15% NACL 0.9% POTASSIUM CHLORIDE 0.15%/D5W POTASSIUM CHLORIDE 0.22% D5W/NACL 0.45% POTASSIUM CHLORIDE 0.224%/D5W POTASSIUM CHLORIDE 0.224%D5W/NACL 0.33% POTASSIUM CHLORIDE 0.3%/ NACL 0.9% POTASSIUM CHLORIDE 0.3%/D5W potassium chloride er tablet extended release potassium chloride sr potassium citrate extended-release RINGERS INJECTION ringers irrigation SODIUM BICARBONATE sodium chloride 0.9% SODIUM CHLORIDE 0.45% VIAFLEX sodium fluoride tis-u-sol TPN ELECTROLYTES FTV Therapeutic Nutrients/Minerals/ Electrolytes
ALCOHOL 5%/DEXTROSE 5% AMINOSYN II 3.5%/DEXTROSE5% CLINIMIX 4.25%/DEXTROSE 5% CLINIMIX 5%/DEXTROSE 15% CLINIMIX E 2.75%/DEXTROSE 10% CLINIMIX E 5%/DEXTROSE 20% Vitamins
ROCALTROL SOLUTION OTC products
Drug Name
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
1st choice pen needles 31gx8mm bd insulin syringe ultrafine/1ml/30g x 1/2" bd insulin syringe/detachable needle/u-100/1ml/25g x 5/8" bd pen needle/mini/ultrafine/31g x 3/16" bd pen needle/short/ultrafine/31g x 5/16" bd pen needles short/ultrafine/31g x 5/16" easy touch pen needles 31gx5/16" easy touch pen needles/31g x 3/16" exel insulin pen needles 31gx1/3" insupen ultrafin 31gx8mm lite touch pen needles/31g x 3/16" monoject insulin syringe/softpack/1ml/25g x 58" novofine 32gx6mm prodigy insulin mini pen needles/31g x 3/16" prodigy insulin short penneedles/31g x 5/16" sure comfort pen needles 31gx3/16" (5mm) sure comfort pen needles 31gx5/16" (8mm) sure-fine pen needles 31gx3/16" 5mm sure-fine pen needles 31gx5/16" 8mm ulticare short pen needles 31gx8mm ulticare short pen needles ulti-fine iv ultra-thin ii pen needle/short/31g x 5/16" Drug Name
Drug Name
ALLOPURINOL SODIUM 1st choice pen needles 31gx8mm amantadine hcl ABILIFY DISCMELT acebutolol hcl acetaminophen/codeine #3 acetaminophen/codeine #4 acetasol hc acetazolamide AMINOSYN 7%/ELECTROLYTES ACETAZOLAMIDE SODIUM acetic acid acetic acid/hydrocortisone AMINOSYN II 3.5%/DEXTROSE25% acetylcysteine AMINOSYN II 3.5%/DEXTROSE5% AMINOSYN II 3.5/DEXTROSE 25% AMINOSYN II 4.25/DEXTROSE10% AMINOSYN II 4.25/DEXTROSE20% AMINOSYN II 4.25/DEXTROSE25% AMINOSYN II 5/DEXTROSE 25 AMINOSYN II 8.5%/ELECTROLYTES acyclovir ACYCLOVIR SODIUM amitriptyline hcl afeditab cr AMMONIUM CHLORIDE ammonium lactate albuterol sulfate amoxicillin/clavulanate potassium er alclometasone dipropionate ALCOHOL 5%/DEXTROSE 5% alcohol preps alendronate sodium AMPICILLIN SODIUM Drug Name
Drug Name
anagrelide hydrochloride anastrozole AZATHIOPRINE SODIUM BACTOCILL IN DEXTROSE BD INSULIN SYRINGE ARANESP ALBUMIN FREE SAFETYGLIDE/1ML/29G X 1/2" BD INSULIN SYRINGE ULTRAFINE/0.3ML/31G X 5/16" BD INSULIN SYRINGE ULTRAFINE/0.5ML/30G X 1/2" bd insulin syringe ultrafine/1ml/30g x 1/2" BD INSULIN SYRINGE ULTRAFINE/1ML/31G X 5/16" bd insulin syringe/detachable needle/u- 100/1ml/25g x 5/8" bd pen needle/mini/ultrafine/31g x 3/16" ascomp/codeine bd pen needle/short/ultrafine/31g x 5/16" ASMANEX 120 METERED DOSES BD PEN NEEDLE/ULTRAFINE/29G X ASMANEX 14 METERED DOSES ASMANEX 30 METERED DOSES bd pen needles short/ultrafine/31g x 5/16" ASMANEX 60 METERED DOSES benazepril hcl ATROPINE SULFATE betaxolol hcl betaxolol hcl augmented betamethasone dipropionate BLEOMYCIN SULFATE AZACTAM IN ISO-OSMOTIC Drug Name
Drug Name
budeprion sr budeprion xl CEFTRIAXONE SODIUM cefuroxime axetil CEFUROXIME SODIUM BUPRENORPHINE HCL bupropion hcl CELLCEPT INTRAVENOUS bupropion hcl sr bupropion hcl sr buspirone hcl BUTORPHANOL TARTRATE cabergoline calcipotriene CHLORAMPHENICOL SODIUM calcium acetate chlorhexidine gluconate oral rinse CHLORPROMAZINE HCL CAPASTAT SULFATE captopril carbamazepine carbamazepine er carbidopa/levodopa cr carbidopa/levodopa odt CIPRO I.V.-IN D5W carbidopa/levodopa sr carboplatin CARIMUNE NANOFILTERED ciprofloxacin hcl carisoprodol carteolol hcl cartia xt carvedilol cefaclor er cefadroxil CEFAZOLIN SODIUM clindamycin hcl CEFOTAXIME SODIUM CEFOXITIN SODIUM CLINDAMYCIN PHOSPHATE ADD- Drug Name
Drug Name
CLINIMIX 2.75%/DEXTROSE 5% CLINIMIX 4.25%/DEXTROSE 10% curity gauze pads 2"x2" CLINIMIX 4.25%/DEXTROSE 20% CLINIMIX 4.25%/DEXTROSE 25% CLINIMIX 4.25%/DEXTROSE 5% CLINIMIX 5%/DEXTROSE 15% CLINIMIX 5%/DEXTROSE 20% CLINIMIX 5%/DEXTROSE 25% CLINIMIX E 2.75%/DEXTROSE 10% CLINIMIX E 2.75%/DEXTROSE 5% CLINIMIX E 4.25%/DEXTROSE 25% CLINIMIX E 4.25%/DEXTROSE 5% CLINIMIX E 5%/DEXTROSE 15% CYTARABINE AQUEOUS CLINIMIX E 5%/DEXTROSE 20% CLINIMIX E 5%/DEXTROSE 25% clobetasol propionate clobetasol propionate e dantrolene sodium clomipramine hcl clonidine hcl clotrimazole clotrimazole/betamethasone dipropionate clozapine colestipol hcl COLISTIMETHATE SODIUM DEPAKOTE SPRINKLES constulose DEPO-SUBQ PROVERA 104 cortisone acetate desipramine hcl cortomycin cromolyn sodium DEXAMETHASONE SODIUM cromolyn sodium cryselle-28 dexamethasone sodium phosphate Drug Name
Drug Name
dexasporin divalproex sodium er dexchlorpheniramine maleate donepezil hcl dextroamphetamine sulfate dorzolamide hcl DEXTROSE 10%/NACL 0.45% dorzolamide hcl/timolol maleate DEXTROSE 5% /ELECTROLYTE #48 DEXTROSE 10% FLEX CONTAINER doxepin hcl DEXTROSE 10%/NACL 0.2% DEXTROSE 2.5%/SODIUM CHLORIDE DEXTROSE 5%/NACL 0.2% DEXTROSE 5%/NACL 0.225% DEXTROSE 5%/NACL 0.33% DEXTROSE 5%/NACL 0.45% DEXTROSE 5%/NACL 0.9% DEXTROSE 5%/POTASSIUM e.e.s. 400 e.e.s. granules diclofenac potassium easy touch pen needles 31gx5/16" diclofenac sodium easy touch pen needles/31g x 3/16" diclofenac sodium econazole nitrate diclofenac sodium ec diclofenac sodium xr dicloxacillin sodium didanosine diflorasone diacetate DIFLUCAN IN NACL diflunisal DIHYDROERGOTAMINE MESYLATE DILANTIN INFATABS diltiazem cd diltiazem hcl er enalapril maleate DIPHENHYDRAMINE HCL enoxaparin sodium DIPHTHERIA/TETANUS TOXOID dipyridamole disopyramide phosphate divalproex sodium divalproex sodium epirubicin hcl Drug Name
Drug Name
flavoxate hcl ergotamine tartrate/caffeine FLUCONAZOLE IN DEXTROSE FLUDARABINE PHOSPHATE ERYTHROCIN LACTOBIONATE erythrocin stearate erythromycin erythromycin base erythromycin/benzoyl peroxide fluocinonide emollient base estradiol estradiol valerate fluoxetine hcl estropipate FLUPHENAZINE DECANOATE ethambutol hcl ethosuximide etidronate disodium etodolac er exel insulin pen needles 31gx1/3" exemestane fosinopril sodium famciclovir FREAMINE HBC 6.9% FAMOTIDINE PREMIXED FANAPT TITRATION PACK felodipine er fenofibrate fenofibrate micronized fenoprofen calcium FENTANYL CITRATE gemcitabine hcl fexofenadine hcl Drug Name
Drug Name
HUMATROPE COMBO PACK GENTAMICIN SULFATE HUMIRA PEN-CROHNS GENTAMICIN SULFATE/0.9% SODIUM GENTAMICIN SULFATE/SODIUM HUMULIN 70/30 PEN HUMULIN N U-100 PEN HUMULIN R U-500 (CONCENTRATED) glimepiride glipizide glipizide er glipizide/metformin hcl GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT glyburide glyburide micronized glyburide/metformin hcl HYDROMORPHONE HCL granisetron hcl hydroxyzine hcl guanabenz acetate guanfacine hcl guanidine hcl HALFLYTELY BOWEL PREP halobetasol propionate haloperidol HALOPERIDOL DECANOATE HALOPERIDOL LACTATE imipramine hcl HEPARIN SODIUM/D5W IMITREX STATDOSE REFILL HEPARIN SODIUM/NACL 0.45% IMOVAX RABIES (H.D.C.V.) HEPARIN SODIUM/SODIUM CHLORIDE 0.9% PREMIX indomethacin er insupen ultrafin 31gx8mm HUMALOG MIX 50/50 HUMALOG MIX 50/50 KWIKPEN HUMALOG MIX 75/25 HUMALOG MIX 75/25 KWIKPEN INTRON-A W/DILUENT Drug Name
Drug Name
KCL 0.3%/D5W/NACL 0.9% kelnor 1/35 IONOSOL-B/DEXTROSE 5% IONOSOL-MB/DEXTROSE 5% IONOSOL-T/DEXTROSE 5% IPOL INACTIVATED IPV ketoprofen er ipratropium bromide KETOROLAC TROMETHAMINE ipratropium bromide/albuterol sulfate irinotecan klor-con 10 ISOLYTE-H/DEXTROSE 5% klor-con 8 ISOLYTE-M/DEXTROSE 5% klor-con m15 ISOLYTE-P/DEXTROSE 5% klor-con m20 ISOLYTE-S/DEXTROSE 5% isosorbide dinitrate isosorbide dinitrate er lactated ringers irrigation isosorbide mononitrate isosorbide mononitrate er LAMICTAL STARTER/NOT TAKING ISOTONIC GENTAMICIN LAMICTAL STARTER/TAKING isradipine CARBAMAZEPINE/NOT TAKING itraconazole LAMICTAL STARTER/TAKING jolivette junel 1.5/30 junel 1/20 junel fe 1.5/30 junel fe 1/20 KANAMYCIN SULFATE kaon-cl-10 LEUCOVORIN CALCIUM KCL 0.075%/D5W/NACL 0.45% KCL 0.15%/D10W/NACL 0.2% LEUPROLIDE ACETATE KCL 0.15%/D5W/LR KCL 0.15%/D5W/NACL 0.2% KCL 0.15%/D5W/NACL 0.225% KCL 0.15%/D5W/NACL 0.9% KCL 0.3%/D5W/LR IV LAC RING KCL 0.3%/D5W/NACL 0.2% levobunolol hcl KCL 0.3%/D5W/NACL 0.45% Drug Name
Drug Name
levora 0.15/30-28 levorphanol tartrate levothroid levothyroxine sodium meclizine hcl mefloquine hcl lidocaine megestrol acetate lidocaine hcl jelly meperidine hcl LIOTHYRONINE SODIUM lisinopril MERUVAX II W/DILUENT 10 DOSE lite touch pen needles/31g x 3/16" lithium carbonate lithium carbonate er lithium citrate MESTINON TIMESPAN loestrin 24 fe metadate er loperamide hcl metformin hcl metformin hcl er losartan potassium losartan potassium/hydrochlorothiazide lovastatin low-ogestrel loxapine succinate METHOTREXATE SODIUM LUPRON DEPOT-PED MAGNESIUM SULFATE methylin er MAGNESIUM SULFATE IN D5W maprotiline hcl methylphenidate hcl sr margesic-h METHYLPREDNISOLONE Drug Name
Drug Name
metipranolol METOCLOPRAMIDE HCL metolazone naproxen dr metoprolol succinate er METOPROLOL TARTRATE metronidazole METRONIDAZOLE IN NACL 0.79% metronidazole vaginal necon 0.5/35-28 mexiletine hcl necon 1/35-28 necon 10/11-28 miconazole 3 necon 7/7/7 microgestin 1.5/30 nefazodone hcl microgestin 1/20 neomycin sulfate microgestin fe microgestin fe 1.5/30 NEOMYCIN/POLYMYXIN B SULFATES midodrine hcl minocycline hcl minoxidil mirtazapine mirtazapine odt misoprostol MITOXANTRONE HCL M-M-R II W/DILUENT 10 DOSE mometasone furoate monoject insulin syringe/softpack/1ml/25g x 58" mononessa MORPHINE SULFATE morphine sulfate er mupirocin nifediac cc nifedical xl nifedipine er mycophenolate mofetil nabumetone NAFCILLIN SODIUM NORDITROPIN FLEXPRO NALLPEN/DEXTROSE NORMOSOL-M IN D5W naltrexone hcl NORMOSOL-R IN D5W NAMENDA TITRATION PAK nortrel 0.5/35 (28) naphazoline hcl nortrel 1/35 (21) Drug Name
Drug Name
nortrel 1/35 (28) nortrel 7/7/7 nortriptyline hcl PAMIDRONATE DISODIUM novofine 32gx6mm NOVOLIN 70/30 INNOLET paroxetine hcl NOVOLIN N INNOLET paroxetine hcl er NOVOLOG MIX 70/30 NOVOLOG MIX 70/30 PREFILLED NULYTELY/FLAVOR PACKS PEG-INTRON REDIPEN PENICILLIN G POTASSIUM PENICILLIN G POTASSIUM IN ISO- PENICILLIN G PROCAINE PENICILLIN G SODIUM OCTREOTIDE ACETATE penicillin v potassium ofloxacin omeprazole ondansetron hcl ondansetron odt pentoxifylline er oramorph sr ORPHENADRINE CITRATE orphenadrine citrate er OXACILLIN SODIUM oxaliplatin oxandrolone oxaprozin oxcarbazepine phenytoin sodium extended PHOSPHOLINE IODIDE oxybutynin chloride oxybutynin chloride er oxycodone hcl pilocarpine hcl Drug Name
Drug Name
PREGNYL W/DILUENT BENZYL PIPERACILLIN SODIUM piroxicam PREMARIN W/APPLICATOR piroxicam PLASMA-LYTE-148/D5W PLASMA-LYTE-56/D5W podofilox PRIMAQUINE PHOSPHATE polycin b PRIMAXIN I.M.
polyethylene glycol 3350 POLYMYXIN B SULFATE portia-28 POTASSIUM CHLORIDE POTASSIUM CHLORIDE 0.075%/D5W/NACL 0.225% POTASSIUM CHLORIDE 0.15% /NACL POTASSIUM CHLORIDE 0.15% POTASSIUM CHLORIDE 0.15% D5W/NACL 0.45% VIAFLEX proctocream hc POTASSIUM CHLORIDE 0.15% NACL proctosol hc POTASSIUM CHLORIDE 0.15%/D5W POTASSIUM CHLORIDE 0.22% prodigy insulin mini pen needles/31g x 3/16" prodigy insulin short penneedles/31g x 5/16" POTASSIUM CHLORIDE 0.224%/D5W POTASSIUM CHLORIDE 0.224%D5W/NACL 0.33% POTASSIUM CHLORIDE 0.3%/ NACL POTASSIUM CHLORIDE 0.3%/D5W potassium chloride er potassium chloride sr promethazine hcl potassium citrate extended-release promethazine vc pramipexole dihydrochloride pravastatin sodium propafenone hcl prazosin hcl propranolol hcl er prednicarbate prednisolone acetate prednisolone sodium phosphate prednisolone sodium phosphate prednisone Drug Name
Drug Name
protriptyline hcl pyrazinamide pyridostigmine bromide ropinirole hcl QUINIDINE GLUCONATE quinidine gluconate er quinidine sulfate quinidine sulfate er SAIZEN CLICK.EASY SANDOSTATIN LAR DEPOT selegiline hcl selenium sulfide REBIF TITRATION PACK reclipsen RELENZA DISKHALER sertraline hcl SODIUM BICARBONATE reserpine sodium chloride 0.9% RETROVIR IV INFUSION SODIUM CHLORIDE 0.45% VIAFLEX sodium fluoride sodium polystyrene sulfonate ribasphere ribavirin rimantadine hcl RINGERS INJECTION sotalol hcl ringers irrigation RISPERDAL CONSTA SPIRIVA HANDIHALER risperidone risperidone odt rivastigmine tartrate sprintec 28 Drug Name
Drug Name
terazosin hcl terbinafine hcl stavudine TERBUTALINE SULFATE TESTOSTERONE CYPIONATE STREPTOMYCIN SULFATE TESTOSTERONE ENANTHATE TETANUS TOXOID ADSORBED sucralfate sulfacetamide sodium/prednisolone sodium phosphate tetracycline hcl sulfadiazine sulfamethoxazole/trimethoprim ds sulfasalazine sulfatrim theophylline er sulfazine ec thioridazine hcl sumatriptan succinate sure comfort pen needles 31gx3/16" (5mm) sure comfort pen needles 31gx5/16" (8mm) sure-fine pen needles 31gx3/16" 5mm sure-fine pen needles 31gx5/16" 8mm ticlopidine hcl timolol maleate timolol maleate tizanidine hcl TOBRAMYCIN SULFATE TOBRAMYCIN SULFATE/SODIUM tacrolimus tamoxifen citrate tamsulosin hcl tolmetin sodium topotecan hcl Drug Name
Drug Name
torsemide TPN ELECTROLYTES FTV tramadol hcl tramadol hydrochloride/acetaminophen valacyclovir hcl trandolapril tranylcypromine sulfate valproic acid trazodone hcl TRELSTAR DEPOT MIXJECT TRELSTAR LA MIXJECT tretinoin tretinoin triamcinolone acetonide TRIAMCINOLONE ACETONIDE IN venlafaxine hcl triamcinolone in orabase venlafaxine hcl er trifluoperazine hcl verapamil hcl er trifluridine verapamil hcl er trihexyphenidyl hcl TRIMETHOBENZAMIDE HCL trimethoprim trimethoprim sulfate/polymyxin b sulfate tri-previfem VINBLASTINE SULFATE tri-sprintec trivora-28 VINORELBINE TARTRATE tropicamide TYZINE PEDIATRIC NASAL DROPS warfarin sodium ulticare short pen needles 31gx8mm ulticare short pen needles ulti-fine iv ultra-thin ii pen needle/short/31g x 5/16" Drug Name
zafirlukast zidovudine ZINACEF IN ISO-OSMOTIC DEXTROSE ZINACEF IN ISO-OSMOTIC DILUENT zolpidem tartrate zolpidem tartrate er zonisamide zovia 1/35e zovia 1/50e

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