List of Covered Drugs by lnd15050

VIEWS: 374 PAGES: 66

									               2010 Formulary
               List of Covered Drugs




               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.




<H2323, H5575, H5980> 10_07 MRT                                    Formulary ID 10296, Version 5
CMS File & Use 9/23/2009                                              Last Updated: August 2009
                          A Health Plan with a Medicare Contract
THIS PAge HAS been InTenTIonALLy LeFT bLAnk.
What is the Fidelis SecureCare Formulary?
A formulary is a list of covered drugs selected by Fidelis SecureCare 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. Fidelis SecureCare will generally cover the drugs listed in our formulary
as long as the drug is medically necessary, the prescription is filled at a Fidelis SecureCare 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 2010 formulary that was covered at the beginning of the
year, we will not discontinue or reduce coverage of the drug during the 2010 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 2009. To get updated information about the drugs
covered by Fidelis SecureCare, please visit our website at www.fidelissc.com or call Member
Services at 1.877.372.7948, Monday through Friday from 8:00 a.m. to 6:00 p.m. TTy/TDD users
should call 1.888.844.5530.

In the event of mid-year non-maintenance formulary changes, Fidelis SecureCare will provide
all members notice of those changes in a manner consistent with Medicare requirements.
examples of communications may include formulary errata sheets or formulary update letters
mailed to beneficiaries.




                                                   1
How do i use the Formulary?
There are two ways to find your drug within the formulary:

medical Condition
The formulary begins on page seven (7). 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 — Drugs to Treat Heart
and Circulation Conditions”. If you know what your drug is used for, look for the category name in the
list that begins on page seven (7). Then look under the category name for your drug.

alphabetical listing
If you are not sure what category to look under, you should look for your drug in the index that begins
on page 45. 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?
Fidelis SecureCare 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: Fidelis SecureCare requires you or your physician to get prior authorization
   for certain drugs. This means that you will need to get approval from Fidelis SecureCare before
   you fill your prescriptions. If you don’t get approval, Fidelis SecureCare may not cover the drug.

 • Quantity limits: For certain drugs, Fidelis SecureCare limits the amount of the drug that Fidelis
   SecureCare will cover. For example, Fidelis SecureCare provides nine (9) pills per prescription
   for Zomig. This may be in addition to a standard one month or three month supply.

 • Step therapy: In some cases, Fidelis SecureCare 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, Fidelis SecureCare may not cover drug b unless
   you try Drug A first. If Drug A does not work for you, Fidelis SecureCare 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 seven (7). You can also get more information about the restrictions applied to specific
covered drugs by visiting our website at www.fidelissc.com.


                                                   2
you can ask Fidelis SecureCare to make an exception to these restrictions or limits. See the section,
“How do I request an exception to the Fidelis SecureCare formulary?” below for information about
how to request an exception.


What if my drug is not on the Formulary?
If your drug is not included in this formulary, you should first contact Member Services and confirm
that your drug is not covered. If you learn that Fidelis SecureCare does not cover your drug, you
have two options:

 • You can ask Member Services for a list of similar drugs that are covered by Fidelis SecureCare.
   When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that
   is covered by Fidelis SecureCare.

 • You can ask Fidelis SecureCare 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 Fidelis SecureCare Formulary?
you can ask Fidelis SecureCare 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, Fidelis SecureCare limit 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 tier (Tier 3), you can ask us to cover it at the cost-sharing amount that applies
   to drugs in the preferred tier (Tier 2, if the drug is a brand drug) or the generic tier (Tier 1, if the
   drug is a generic drug) instead. This would lower the amount you must pay for your drug. Please
   note, if we grant your request to cover a drug that is not on our formulary, you may not ask us to
   provide a higher level of coverage for the drug. Also, you may not ask us to provide a higher
   level of coverage for drugs that are in the Specialty tier (Tier 4).

generally, Fidelis SecureCare will only approve your request for an exception if the alternative
drugs included on the plan’s formulary, preferred brand or generic tiers, or additional utilization
restrictions would not be as effective in treating your condition and/or would cause you to have
adverse medical effects.




                                                     3
you should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization
restriction exception. When you are requesting a formulary, tiering or utilization restriction exception
you should submit a statement from your 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 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 31-day supply (unless you have a prescription written for fewer days) when you
go to a network pharmacy. After your first 31-day supply, we will not pay for these drugs, even if you
have been a member of the plan less than 90 days.

If you are a resident of a long-term care facility, we will 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.

If you are moving from one level of care to another as defined by one of the following situations:
members transitioning from hospital to home, long term care facility, assisted living, group home
(discharge medications), members transitioning from a skilled nursing benefit and reverting to the
Part D benefit; members terminating a hospice election and reverting to a Part D benefit, or members
discharged from a chronic psychiatric hospital to home, long term care facility, assisted living, group
home (discharge medications), a temporary, one time up to 31-day supply prescription fill for Part D
eligible non-formulary drugs will be provided at a non-preferred Tier 3 copay. The authorization will be
granted through an exception process at or prior to the transition pharmacy transaction.




                                                     4
For more information
For more detailed information about your Fidelis SecureCare prescription drug coverage, please
review your Evidence of Coverage and other plan materials.

If you have questions about Fidelis SecureCare, please call Member Services at 1.877.372.7948,
Monday through Friday from 8:00 a.m. to 6:00 p.m. TTy/TDD users should call 1.888.844.5530.
Or visit www.fidelissc.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.


Fidelis SecureCare’s Formulary
The formulary that begins on page seven (7) provides coverage information about some of the drugs
covered by Fidelis SecureCare. If you have trouble finding your drug in the list, turn to the index that
begins on page 45.

The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., LIPITOR®)
and generic drugs are listed in lower-case italics (e.g., simvastatin).

All drugs on our “Drug List” are available from our mail order pharmacy except if designated as limited
access. Limited access means that prescription drug may be available only at certain pharmacies.

The second column indicates the tier level. After you have paid your deductible and before your yearly
prescription drug costs reach $2830, the drug tier levels are as follows:


                                                                                 Non-
                                                                 Preferred     preferred     Specialty
                                                   generics        brand         Drugs         Drugs
                                    Deductible     tier “1”       tier “2”      tier “3”      tier “4”
Fidelis Secure Comfort
                                       $310             25%        25%           25%           25%
(HMo)

For Fidelis Secure Comfort (HMo), after your total yearly drug costs reach $2830, you pay 100% of
the discounted cost of your drugs until your yearly out-of-pocket drug costs reach $4550.




                                                    5
                                                                               Non-
                                                               Preferred     preferred     Specialty
                                                  generics       brand         Drugs         Drugs
                                   Deductible     tier “1”      tier “2”      tier “3”      tier “4”
Fidelis Secure Comfort Plus
                                      $0.00         $5.00        $30.00       $65.00           33%
(HMo)
Fidelis Secure Independence
                                      $0.00         $5.00        $30.00       $65.00           33%
(HMo)
Fidelis Secure At Home
                                      $0.00         $5.00        $30.00       $65.00           33%
(HMo)

For all of the other plans above, after your total yearly drug costs reach $2830, you pay 100% of the
discounted cost of your drugs until your yearly out-of-pocket drug costs reach $4550. However, you
will continue to pay only a copay for all Tier 1 drugs on the formulary. This is because we provide
coverage for Tier 1 generic drugs in the gap for these plans.

Please refer to our Evidence of Coverage for more information about your plan coverage.

After your yearly out-of-pocket drug costs reach $4550, you pay the greater of $2.50 copay
for generics (including brand drugs treated as generic) and $6.30 copay for all other drugs,
or 5% coinsurance.

The third column, the “notes” column tells you if Fidelis SecureCare has any special requirements
for coverage of your drug.

 b/D — Indicates Authorization is required to identify if the use of the drug is for a
       Medicare Part b or Part D indication. This determines coverage status and
       impact on Part D drug benefit.

 LA   — Indicates Limited Access. These prescriptions may be available only at certain
        pharmacies. For more information consult your Pharmacy Directory or call
        Customer Service at 1.877.372.7948, Monday through Friday from 8:00 a.m.
        to 6:00 p.m. TTy/TDD users should call 1.888.844.5530.

 PA — Indicates Prior Authorization is Required

 QL — Indicates Quantity Limits

 ST — Indicates Step Therapy




                                                  6
Covered medications by therapeutic Category

Drug Name                    tier   Notes       Drug Name                     tier     Notes



AnAlgEsiCs —                                    oxaprozin                      1
Drugs to Treat Pain, Inflammation,              piroxicam                      1
and Muscle and Joint Conditions                 sulindac                       1
                                                tolmetin sodium                1
analgesics, other —
  miscellaneous Pain relievers                  opioid analgesics — opioid Pain relievers
eQUAgeSIC®                    3                 acetaminophen/codeine            1
                                                ascomp/codeine                   1
Nonsteroidal Anti-Inflammatory Drugs —          astramorph                       1
    Pain/Anti-Inflammatory Drugs                AVInZA®                          2  QL
ARTHRoTeC®                      3               balacet 325                      3
CeLebRex     ®
                                3   QL          buprenorphine HCl                3
diclofenac potassium            1               butalbital/acetaminophen/        1
diclofenac sodium               1                  caffeine/codeine
diclofenac sodium EC            1               butorphanol tartrate (injection) 3
diclofenac sodium XR            1               butorphanol tartrate             3  QL
diflunisal                      1                  (nasal spray)
etodolac                        1               CAPITAL®/CoDeIne                 2
etodolac ER                     1               co-gesic                         1
fenoprofen calcium              1               DARVon-n®                        3  QL
flurbiprofen                    1               DILAUDID-5    ®
                                                                                 3  QL
IBU                             1               duramorph                        1
ibuprofen                       1               endocet                          1
InDoCIn    ®
                                3               endodan                          1
indomethacin                    1               fentanyl (patch)                 3  QL
indomethacin ER                 1               fentanyl citrate (injection)     1
ketoprofen                      1               fentanyl citrate oral            4 PA,QL
ketoprofen ER                   1                  transmucosal
ketorolac tromethamine          1   QL          HyCeT®                           3
meclofenamate sodium            1               hydrocodone/acetaminophen        1
meloxicam (oral suspension)     3
meloxicam (tablet)              1
nabumetone                      1               b/D – Authorization required to
nALFon     ®
                                3                     identify Medicare D coverage
nAPReLAn     ®
                                3               LA – Limited Access; drugs available
    (375mg CR 24-hour tablet)                         only at certain pharmacies
                                                PA – Prior Authorization required
naproxen                        1
                                                QL – Quantity Limits apply
naproxen DR                     1               ST – Step Therapy required
                                            7
Drug Name                       tier   Notes       Drug Name                       tier   Notes


hydrocodone/Ibuprofen           1                  ULTRAM® eR                      3      QL
hydromorphone HCl (injection)   3                     (100mg 24-hour tablet,
hydromorphone HCl (tablet)      1      QL             200mg 24-hour tablet)
InFUMoRPH®                      3                  ULTRAM® eR                      3
kADIAn®                         2      QL             (300mg 24-hour tablet)
levorphanol tartrate            3      QL          vanacet                         1
margesic-H                      1                  xoDoL®                          3
meperidine HCl (injection)      1                  ZyDone®                         3
meperidine HCl                  1      QL
   (oral solution, tablet)                         AnEstHEtiCs —
methadone HCl (concentrate,     1      QL          Drugs for Numbing
   oral solution, tablet)
methadone HCl (injection)       3                  local anesthetics
methadose                       1      QL          anestacon                       1
morphine sulfate                1                  lidocaine                       1
   (injection, oral solution)                      lidocaine HCl                   1
morphine sulfate (tablet)       1      QL          lidocaine HCl jelly             1
morphine sulfate ER             1      QL          lidocaine viscous               1
nalbuphine HCl                  3                  lidocaine/prilocaine            1
oPAnA®                          2      QL          LIDoDeRM®                       2      QL
oPAnA® eR                       2      QL
oxycodone HCl                   1      QL          AntibACtEriAls —
oxycodone HCl ER                3      QL          Drugs to treat bacterial infections
oxycodone/acetaminophen         1
oxycodone/aspirin               1                  aminoglycosides — antibiotics
oxycodone/ibuprofen             1                  ak-tob (ophthalmic)             1
oxyConTIn®                      3      QL          amikacin sulfate                1
pentazocine/acetaminophen       1                  genoptic (ophthalmic)           1
pentazocine/naloxone HCl        1                  gentak (ophthalmic)             1
propoxyphene HCl                1      QL          gentamicin sulfate              1
propoxyphene/acetaminophen      1                  gentasol (ophthalmic)           1
propoxyphene-N/                 1                  isotonic gentamicin             1
   acetaminophen
RoxICeT® (oral solution)        3
roxicet (tablet)                1
stagesic                        1                  b/D – Authorization required to
SUboxone®                       3      QL                identify Medicare D coverage
SUbUTex®                        3      QL          LA – Limited Access; drugs available
                                                         only at certain pharmacies
tramadol HCl                    1
                                                   PA – Prior Authorization required
tramadol HCl/acetaminophen      1                  QL – Quantity Limits apply
                                                   ST – Step Therapy required
                                               8
Drug Name                       tier   Notes       Drug Name                         tier   Notes


kanamycin sulfate               1                  MonURoL®                          3
neo-FRADIn®                     3                  mupirocin                         1
neomycin sulfate                1                  neomycin/polymyxin B sulfates     1
paromomycin sulfate             1                  neomycin/polymyxin/gramicidin     1
STRePToMyCIn® SULFATe           3                  neomycin/polymyxin/               1
tobramycin sulfate              1                      hydrocortisone
tobrasol (ophthalmic)           1                  nitrofurantoin macrocrystalline   1
TobRex® (ointment)              3                  nitrofurantoin monohydrate        1
                                                   noRITATe®                         3
antibacterials, other — antibiotics                polycin B (ophthalmic)            1
ak-poly-bac (ophthalmic)         1                 polymyxin B sulfate               1
BACiiM                           1                 PRIMSoL®                          3
bacitracin (ointment)            1                 silver sulfadiazine               1
bacitracin/neomycin/polymyxin    1                 SSD                               1
bacitracin/polymyxin B           1                 SULFAMyLon® (cream)               2
bacitracin/polymyxin/neomycin/ 1                   SULFAMyLon®                       3
    hydrocortisone                                     (topical solution pack)
bACTRobAn® (cream)               2                 SyneRCID®                         4
bACTRobAn® nASAL                 2                 thermazene                        1
CLeoCIn (75mg capsule,
           ®
                                 3                 trimethoprim                      1
    vaginal suppository)                           trimethoprim sulfate/             1
CLeoCIn® gALAxy                  3                     polymyxin B sulfate
CLeoCIn    ®
                                 3                 TygACIL®                          3
    PeDIATRIC gRAnULeS                             VAnCoCIn® HCL                     4      PA
CLInDAgeL® (topical gel)         3                 vancomycin HCl (injection)        1
clindamycin HCl                  1                 vancomycin HCl                    3
clindamycin phosphate            1                     iso-osmotic dextrose
CLInDeSSe (vaginal cream)
              ®
                                 3                 vandazole (vaginal)               1
colistimethate sodium            4                 xIFAxAn®                          3
CoRTISPoRIn (ointment)
                  ®
                                 3                 ZyVox® (injection)                4
CUbICIn   ®
                                 4                 ZyVox®                            4      PA
eVoCLIn    ®
                                 3                     (oral suspension, tablet)
FLAgyL eR®
                                 3
FURADAnTIn      ®
                                 3
MACRoDAnTIn®                     3
    (25mg capsule)                                 b/D – Authorization required to
methenamine hippurate            1                       identify Medicare D coverage
MeTRogeL      ®
                                 3                 LA – Limited Access; drugs available
                                                         only at certain pharmacies
metronidazole                    1
                                                   PA – Prior Authorization required
metronidazole in NaCl 0.79%      1                 QL – Quantity Limits apply
metronidazole vaginal            1                 ST – Step Therapy required
                                               9
Drug Name                      tier   Notes        Drug Name                      tier      Notes


beta-lactam, Cephalosporins —                      beta-lactam, other — antibiotics
    antibiotics                                    AZACTAM®                       2
CeDAx®                          3                  InVAnZ ®
                                                                                  3
cefaclor                        1                  MeRReM   ®
                                                                                  3
cefaclor ER                     1                  PRIMAxIn  ®
                                                                                  3
cefadroxil                      1
cefazolin Sodium                1                  beta-lactam, Penicillins — antibiotics
cefdinir                        1                  amoxicillin                      1
cefepime (injection)            3                  amoxicillin/potassium            1
CeFIZox in Dextrose 5%
            ®
                                3                      clavulanate
cefotaxime sodium               3                  amoxil (250mg/5ml oral           1
cefoxitin sodium                3                      suspension, capsule)
cefoxitin sodium/dextrose       3                  ampicillin                       1
cefpodoxime proxetil            1                  ampicillin sodium                1
cefprozil                       1                  ampicillin-sulbactam             3
ceftazidime                     3                  AUgMenTIn® (125mg/5ml            3
ceftriaxone sodium              3                      oral suspension,
ceftriaxone/dextrose            3                      250mg/5ml oral suspension,
                                                       chewable tablet)
cefuroxime axetil (oral)        1
                                                   AUgMenTIn® xR                    3
cefuroxime sodium (injection)   1
                                                   bACToCILL in Dextrose
                                                                   ®
                                                                                    4
cefuroxime/dextrose (injection) 1
                                                   bICILLIn C-R
                                                              ®
                                                                                    3
cephalexin                      1
                                                   bICILLIn® L-A                    3
CLAFoRAn (1gm injection)
                ®
                                3
                                                   dicloxacillin sodium             1
CLAFoRAn /D5W   ®
                                3
                                                   nafcillin sodium                 3
FoRTAZ® /D5W                    3
                                                   nALLPen /DexTRoSe
                                                                ®
                                                                                    3
keFLex (750mg capsule)
          ®
                                3
                                                   oxACILLIn SoDIUM
                                                                  ®
                                                                                    3
MAxIPIMe (2gm injection)
              ®
                                2
                                                       (10gm injection)
MeFoxIn in Dextrose
             ®
                                3
                                                   oxacillin sodium (1gm injection) 3
SPeCTRACeF        ®
                                2
                                                   penicillin G potassium           3
SUPRAx®                         3
                                                   penicillin G potassium in        3
tazicef                         3
                                                       iso-osmotic dextrose
ZInACeF (750mg injection)
            ®
                                3
ZInACeF     ®
                                3
    in Iso-osmotic Dextrose
ZInACeF®                        3
    in Iso-osmotic Diluent                         b/D – Authorization required to
                                                         identify Medicare D coverage
                                                   LA – Limited Access; drugs available
                                                         only at certain pharmacies
                                                   PA – Prior Authorization required
                                                   QL – Quantity Limits apply
                                                   ST – Step Therapy required
                                              10
Drug Name                       tier   Notes        Drug Name                         tier   Notes


penicillin G sodium             3                   ciprofloxacin ER                  1
penicillin V potassium          1                       (1000mg 24-hour tablet)
PIPeRACILLIn® SoDIUM            3                   ciprofloxacin HCl                 1
TIMenTIn®                       2                   FACTIVe®                          2
trimox                          1                   LeVAQUIn®                         2
veetids                         1                   LeVAQUIn® PReMIx                  2
ZoSyn® (3-0.375g injection)     2                   noRoxIn®                          3
ZoSyn® In DexTRoSe              3                   ofloxacin                         1
    (2-0.25gm injection,                            PRoQUIn® xR                       3
    3-0.375g injection)                             QUIxIn® (ophthalmic)              3
                                                    VIgAMox® (ophthalmic)             2
macrolides — antibiotics                            ZyMAR® (ophthalmic)               2
Akne-MyCIn®                     3
azithromycin (injection)        3                   Sulfonamides — antibiotics
azithromycin                    1                   gAnTRISIn® PeDIATRIC              2
    (oral suspension, tablet)                       ocusulf-10 (ophthalmic)           1
clarithromycin                  1                   sulfacetamide sodium              1
clarithromycin ER               1                   sulfadiazine                      3
E.E.S. 400                      1                   sulfamethoxazole/trimethoprim     1
e.e.S.® gRAnULeS                2                   sulfatrim                         1
ery                             1
eRyPeD®                         2                   tetracyclines — antibiotics
eRy-TAb®                        2                   demeclocycline HCl                3
eRyTHRoCIn®                     2                   DoRyx®                            3
    LACTobIonATe                                    doxy-caps                         1
eRyTHRoCIn® STeARATe            3                   doxycycline hyclate               1
erythromycin                    1                      (capsule, extended release
erythromycin base               1                      capsule, tablet)
erythromycin/sulfisoxazole      1                   doxycycline hyclate (injection)   3
keTek®                          3      PA           doxycycline monohydrate           3
PCe®                            3                      (50mg tablet, 75mg tablet)
romycin (ophthalmic)            1                   doxycycline monohydrate           1
ZMAx®                           3                      (oral suspension)

Quinolones — antibiotics
AVeLox®                         3                   b/D – Authorization required to
AVeLox® AbC Pack                3                         identify Medicare D coverage
CILoxAn® (ointment)             2                   LA – Limited Access; drugs available
                                                          only at certain pharmacies
CIPRo® (oral suspension)        3
                                                    PA – Prior Authorization required
ciprofloxacin                   1                   QL – Quantity Limits apply
                                                    ST – Step Therapy required
                                               11
Drug Name                   tier   Notes        Drug Name                      tier    Notes


minocycline HCl (capsule)    1                  glutamate reducing agents —
minocycline HCl (tablet)     3                     Seizure Control Drugs
myrac                        3                  FeLbAToL®                      3
oRACeA®                      2                  LAMICTAL® STARTeR kIT          2
tetracycline HCl             1                  lamotrigine                    3
VIbRAMyCIn® (syrup)          3                  topiramate                     1       PA
                                                topiramate sprinkle            3       PA
AntiConvulsAnts —
Drugs to treat seizures                         Sodium Channel inhibitors —
                                                    Seizure Control Drugs
anticonvulsants, other —                        carbamazepine                  1
   Seizure Control Drugs                        carbamazepine ER               1
bAnZeL®                      3                  CARbATRoL®                     2
kePPRA® (injection)          3                  DILAnTIn®                      2
kePPRA® xR                   2     QL           DILAnTIn® InFATAbS             2
levetiracetam                3                  epitol                         1
VIMPAT®                      3                  fosphenytoin sodium            3
                                                oxcarbazepine                  3
Calcium Channel modifying agents —              PegAnone®                      3
   Seizure Control Drugs                        PHenyTek®                      2
CeLonTIn®                    3                  phenytoin                      1
ethosuximide (capsule)       3                  phenytoin sodium               1
ethosuximide (oral solution) 1                  phenytoin sodium extended      1
LyRICA ®
                             3     PA           TegReToL®                      2
zonisamide                   1                  TegReToL-xR®                   2
                                                TRILePTAL® (oral suspension)   3
gamma-aminobutyric acid
   (gaba) augmenting agents —
   Seizure Control Drugs
divalproex sodium (24-hour   3
   tablet, sprinkle capsule)
divalproex sodium            1
   (delayed release tablet)
gabapentin                   1
gAbITRIL®                    3
neURonTIn (oral solution)
              ®
                             3                  b/D – Authorization required to
primidone                    1                        identify Medicare D coverage
STAVZoR    ®
                             3                  LA – Limited Access; drugs available
valproate sodium             3                        only at certain pharmacies
                                                PA – Prior Authorization required
valproic acid                1
                                                QL – Quantity Limits apply
                                                ST – Step Therapy required
                                           12
Drug Name                     tier    Notes        Drug Name                        tier   Notes


AntiDEMEntiA AgEnts —                              Serotonin/Norepinephrine reuptake
Drugs to Treat Alzheimer’s                             inhibitors — antidepressants
Disease and Dementia                               citalopram hydrobromide         1
                                                   CyMbALTA       ®
                                                                                   2
Cholinesterase inhibitors — alzheimer’s            eFFexoR xR   ®
                                                                                   2  QL
   Disease and Dementia Drugs                      fluoxetine HCl                  1
ARICePT®                        2                  fluvoxamine maleate             1
ARICePT® oDT                    2                  LexAPRo®                        2
exeLon  ®
                                3                  paroxetine HCl                  3
galantamine hydrobromide        3                      (oral suspension)
galantamine hydrobromide ER     3                  paroxetine HCl (tablet)         1
RAZADyne (oral solution)
           ®
                                2                  paroxetine HCl ER               3  QL
                                                   PexeVA    ®
                                                                                   3  ST
Glutamate Pathway Modifiers —                      PRISTIQ   ®
                                                                                   2  QL
   alzheimer’s Disease                             PRoZAC WeekLy
                                                              ®
                                                                                   3 QL,ST
   and Dementia Drugs                              selfemra                        3 QL,ST
nAMenDA®                      2                    sertraline HCl                  1
nAMenDA® TITRATIon PAk        2                    venlafaxine HCl                 1  QL

AntiDEPrEssAnts —                                  tricyclics — antidepressants
Drugs to treat Depression                          amitriptyline HCl                1
                                                   amoxapine                        1
antidepressants, other — antidepressants           chlordiazepoxide/amitriptyline   1
budeprion SR                  1     QL             clomipramine HCl                 1
budeprion XL                  3     QL             desipramine HCl                  1
bupropion HCl                 1     QL             doxepin HCl                      1
bupropion HCl SR              1     QL             imipramine HCl                   1
maprotiline HCl               1                    imipramine pamoate               3
mirtazapine                   1                    nortriptyline HCl                1
mirtazapine ODT               1                    perphenazine/amitriptyline       1
nefazodone HCl                1                    protriptyline HCl                3
trazodone HCl                 1                    SURMonTIL® (100mg capsule)       3
                                                   trimipramine maleate             3
monoamine oxidase inhibitors —
    antidepressants
eMSAM®                        3      QL,ST         b/D – Authorization required to
MARPLAn    ®
                              3                          identify Medicare D coverage
nARDIL  ®
                              2                    LA – Limited Access; drugs available
                                                         only at certain pharmacies
tranylcypromine sulfate       1                    PA – Prior Authorization required
                                                   QL – Quantity Limits apply
                                                   ST – Step Therapy required
                                              13
Drug Name                      tier    Notes        Drug Name                     tier     Notes


AntiDotEs, DEtErrEnts,                              granisetron HCl (injection)    3
AnD toxiCologiC AgEnts —                            granisetron HCl (tablet)       3     b/D,QL
Drugs for overdose or Deterrants                    granisol                       3     b/D,QL
                                                    hydroxyzine pamoate            1
antidotes — antidotes/Protectants                   meclizine HCl                  1
ACeTADoTe®                     3                    metoclopramide HCl             1
acetylcysteine                 1       b/D          ondansetron HCl (injection)    3
CUPRIMIne     ®
                               2                    ondansetron HCl                3     b/D,QL
DePen TITRATAbS
        ®
                               3                        (oral solution, tablet)
exjADe    ®
                               4                    ondansetron ODT                1     b/D,QL
kionex                         1                    TRAnSDeRM-SCoP®                3
leucovorin calcium             1                    trimethobenzamide HCl          1
sodium polystyrene sulfonate   1
SyPRIne     ®
                               3                    AntifungAls — Drugs to treat
                                                    fungal infections
Deterrents — antidotes/Protectants
AnTAbUSe®                      2                    antifungals — Fungal infection Drugs
bupropion HCl SR               1       QL           amphotericin B                 3    b/D
CAMPRAL    ®
                               3                    AnCobon (250mg capsule)
                                                                 ®
                                                                                   3
CHAnTIx  ®
                               3       QL           AnCobon (500mg capsule)
                                                                 ®
                                                                                   4
nICoTRoL InHALeR
            ®
                               3                    CAnCIDAS     ®
                                                                                   4
nICoTRoL® nS                   3                    ciclopirox (gel)               3
                                                    ciclopirox (suspension)        1
toxicologic agents —                                ciclopirox nail lacquer        1
   antidotes/Protectants                            ciclopirox olamine             1
depade                         3                    clotrimazole                   1
naloxone HCl                   1                    clotrimazole/betamethasone     1
naltrexone HCl                 3                        dipropionate
                                                    econazole nitrate              1
antiemetics — Drugs to treat                        eRAxIS   ®
                                                                                   3
   Nausea and Vomiting                              eRTACZo®                       3
ALoxI®                         4                    exeLDeRM       ®
                                                                                   3
AnTIVeRT® (50mg tablet)        3                    fluconazole (oral suspension)  3
AnZeMeT® (injection)           3
AnZeMeT® (tablet)              3      b/D,QL
dronabinol (10mg capsule,      4       b/D,         b/D – Authorization required to
   5mg capsule)                       PA,QL               identify Medicare D coverage
                                                    LA – Limited Access; drugs available
dronabinol                     3       b/D,               only at certain pharmacies
   (2.5mg capsule)                    PA,QL         PA – Prior Authorization required
eMenD®                         2       b/D,         QL – Quantity Limits apply
                                      PA,QL         ST – Step Therapy required
                                               14
Drug Name                      tier   Notes        Drug Name                        tier    Notes


fluconazole (tablet)           1                   AntiMigrAinE AgEnts —
fluconazole in dextrose        3                   Drugs to treat Migraines
gRIFULVIn® V                   2
griseofulvin microsize         1                   abortive — migraine Drugs
gRIS-Peg®                      3                   acetaminophen/caffeine/          1
gynAZoLe-1® (vaginal)          2                       dihydrocodeine bitartrate
itraconazole                   3                   AMeRge®                          3      QL,ST
ketoconazole                   1                   AxeRT®                           3      QL,ST
kuric                          1                   dihydroergotamine mesylate       3
LAMISIL® (solution)            3                   ergoloid mesylates               3
LoPRox® Shampoo                3                   eRgoMAR®                         2
MenTAx®                        3                   ergotamine tartrate/caffeine     1
miconazole 3 (vaginal)         1                   FRoVA®                           3      QL,ST
nAFTIn®                        2                   IMITRex® (nasal spray)           2       QL
nATACyn® (ophthalmic)          2                   IMITRex® Statdose Refill         2       QL
noxAFIL®                       4                       (4mg/0.5 injection)
nystatin                       1                   MAxALT®                          2       QL
nystatin/triamcinolone         1                   MAxALT-MLT®                      2       QL
nystop                         1                   migergot                         3
oxISTAT®                       3                   MIgRAnAL®                        3       QL
pedi-dri                       1                   orphenadrine/aspirin/caffeine    1
SPoRAnox® (oral solution)      3      PA           PAnLoR® DC                       3
terbinafine HCl                1                   ReLPAx®                          3      QL,ST
terconazole (vaginal)          1                   sumatriptan succinate            1       QL
VFenD®                         4                       (injection)
xoLegeL®                       3                   sumatriptan succinate (tablet)   3       QL
zazole (vaginal)               1                   SynALgoS-DC®                     3
                                                   trezix                           1
Antigout AgEnts —                                  zerlor                           1
Drugs to treat gout                                ZoMIg®                           3       QL
                                                   ZoMIg® ZMT                       3       QL
antigout agents — gout Drugs
allopurinol                    1
allopurinol sodium             1
colchicine                     1
                                                   b/D – Authorization required to
probenecid                     1
                                                         identify Medicare D coverage
probenecid/colchicine          1                   LA – Limited Access; drugs available
                                                         only at certain pharmacies
                                                   PA – Prior Authorization required
                                                   QL – Quantity Limits apply
                                                   ST – Step Therapy required
                                              15
Drug Name                      tier   Notes        Drug Name                     tier     Notes


AntiMyAstHEniC AgEnts —                            AntinEoPlAstiCs —
Drugs to treat Myasthenia gravis                   Drugs to treat Cancer and Cancer
                                                   Treatment Side Effects
Parasympathomimetics —
   myasthenia gravis Drugs                         alkylating agents — Chemotherapy agents
gUAnIDIne® HCL                 3                   ALkeRAn®                     4
MeSTInon® (syrup)              2                   bICnU  ®
                                                                                3
MeSTInon® TIMeSPAn             2                   bUSULFex     ®
                                                                                4
MyTeLASe®                      3                   CeenU   ®
                                                                                2
pyridostigmine bromide         1                   cyclophosphamide (injection) 1
regonol                        3                   cyclophosphamide (tablet)    3    b/D
                                                   dacarbazine                  3
AntiMyCobACtEriAls —                               HexALen    ®
                                                                                4    PA
Drugs to treat infections                          ifosfamide                   3
                                                   ifosfamide/mesna             4
antimycobacterials, other —                        LeUkeRAn      ®
                                                                                2
   miscellaneous anti-infectives                   MATULAne®                    4
DAPSone®                        2                  MUSTARgen       ®
                                                                                3
MyCobUTIn   ®
                                3                  THIoTePA    ®
                                                                                3
                                                   TReAnDA    ®
                                                                                4    PA
antituberculars — tuberculosis Drugs               ZAnoSAR    ®
                                                                                3
CAPASTAT® SULFATe              4
ethambutol HCl                 1                   antiangiogenic agents —
isonarif                       3                      Chemotherapy agents
isoniazid                      1                   ReVLIMID®                      4     PA,LA
PASeR    ®
                               3                   THALoMID®                      4      PA
PRIFTIn    ®
                               3
pyrazinamide                   1                   Antiestrogens/Modifiers —
rifampin (capsule)             1                      Chemotherapy agents
tifampin (injection)           4                   eMCyT®                         2
RIFATeR     ®
                               3                   FAReSTon®                      3
SeRoMyCIn       ®
                               3                   FASLoDex®                      4
TReCAToR      ®
                               3                   tamoxifen citrate              1


                                                   b/D – Authorization required to
                                                         identify Medicare D coverage
                                                   LA – Limited Access; drugs available
                                                         only at certain pharmacies
                                                   PA – Prior Authorization required
                                                   QL – Quantity Limits apply
                                                   ST – Step Therapy required
                                              16
Drug Name                      tier   Notes        Drug Name                       tier   Notes


antimetabolites — Chemotherapy agents              mitoxantrone HCl               3
ALIMTA®                      4    PA               onCASPAR         ®
                                                                                  4
cytarabine                   1                     onTAk    ®
                                                                                  4
cytarabine aqueous           1                     onxol                          4
DRoxIA   ®
                             2                     paclitaxel                     3
eLITek®                      4                     PHoToFRIn®                     4
geMZAR     ®
                             4                     PRoLeUkIn         ®
                                                                                  4     PA
hydroxyurea                  1                     TAxoTeRe        ®
                                                                                  4
mercaptopurine               1                     toposar                        1
pentostatin                  4                     ToRISeL     ®
                                                                                  4
TAbLoID®                     3                     TRISenox®                      3
                                                   VeLCADe       ®
                                                                                  4
antineoplastics, other —                           VIDAZA    ®
                                                                                  4
    Chemotherapy agents                            vinblastine sulfate            1
AbRAxAne®                      4                   vincasar PFS                   1
ARRAnon®                       4                   vincristine sulfate            1
bleomycin sulfate              3                   vinorelbine tartrate           3
carboplatin                    3                   ZoLInZA     ®
                                                                                  4     PA
cisplatin                      1                   aromatase inhibitors, 3rd generation —
cladribine                     4                      Chemotherapy agents
CLoLAR®                        4                   ARIMIDex®                      2
CoSMegen®                      3                   ARoMASIn        ®
                                                                                  3
DACogen®                       4                   FeMARA      ®
                                                                                  2
daunorubicin HCl               3
DAUnoxoMe®                     3                   molecular target inhibitors —
DegAReLIx® (120mg injection)   4      PA             Chemotherapy agents
DegAReLIx® (80mg injection)    3      PA           gLeeVeC®                        4      PA
DoxIL®                         4      b/D          nexAVAR®                        4      PA
doxorubicin HCl                3      b/D          SPRyCeL®                        4      PA
eLoxATIn®                      4                   SUTenT®                         4      PA
eLSPAR®                        3                   TARCeVA®                        4      PA
epirubicin HCl                 3                   TASIgnA®                        4      PA
eToPoPHoS®                     4                   TykeRb®                         4      PA
etoposide                      1
fludarabine phosphate          4
HyCAMTIn®                      4                   b/D – Authorization required to
                                                         identify Medicare D coverage
idarubicin HCl                 4
                                                   LA – Limited Access; drugs available
irinotecan                     3                         only at certain pharmacies
IxeMPRA® kIT                   4                   PA – Prior Authorization required
mitomycin                      3                   QL – Quantity Limits apply
                                                   ST – Step Therapy required
                                              17
Drug Name                   tier   Notes        Drug Name                       tier   Notes


monoclonal antibodies —                         Pediculicides/Scabicides —
   Chemotherapy agents                              Scabies and lice Drugs
AVASTIn®                     4     PA           acticin                         1
CAMPATH®                     4                  eURAx®                          3
eRbITUx®                     4     PA           lindane                         3
HeRCePTIn®                   4                  oVIDe®                          3
MyLoTARg®                    4                  permethrin                      1
RITUxAn®                     4     PA
VeCTIbIx®                    4     PA           AntiPArkinson AgEnts —
                                                Drugs to Treat Parkinson’s Disease
retinoids — Chemotherapy agents
PAnReTIn®                    4                  antiparkinson agents —
TARgReTIn® (capsule)         4     PA               Parkinson’s Disease Drugs
TARgReTIn® (gel)             4                  amantadine HCl                  1
tretinoin (capsule)          4                  APokyn®                         4      PA
                                                atamet                          1
                                                AZILeCT®                        2
AntiPArAsitiCs — Drugs to treat
Parasitic infections                            benztropine mesylate            1
                                                bromocriptine mesylate          3
anthelmintics — Worm infection Drugs            carbidopa/levodopa              1
ALbenZA®                      2                 carbidopa/levodopa CR           1
bILTRICIDe   ®
                              2                 carbidopa/levodopa ODT          3
mebendazole                   1                 CogenTIn®                       2
STRoMeCToL®                   2                 CoMTAn®                         2
antiprotozoals —                                LoDoSyn®                        3
   Protozoal infection Drugs                    MIRAPex®                        2
ALInIA®                       3                 ropinirole HCl                  1
chloroquine phosphate         1                 selegiline HCl                  1
DARAPRIM    ®
                              2                 STALeVo®                        3      ST
hydroxychloroquine sulfate    1                 trihexyphenidyl HCl             1
MALARone      ®
                              3                 ZeLAPAR®                        3      ST
mefloquine HCl                1
MePRon    ®
                              4
PRIMAQUIne Phosphate
                 ®
                              2
QUALAQUIn      ®
                              3    PA
                                                b/D – Authorization required to
TInDAMAx    ®
                              2
                                                      identify Medicare D coverage
                                                LA – Limited Access; drugs available
                                                      only at certain pharmacies
                                                PA – Prior Authorization required
                                                QL – Quantity Limits apply
                                                ST – Step Therapy required
                                           18
Drug Name                   tier     Notes        Drug Name                     tier     Notes


AntiPsyCHotiCs —                                  AntisPAstiCity AgEnts —
Drugs to treat Mood Disorders                     Drugs to Treat Spasms

atypicals — mood Disorder Drugs                   antispasticity agents —
AbILIFy®                      3                       muscle Spasm Drugs
AbILIFy DISCMeLT
         ®
                              3                   baclofen                       1
clozapine                     3                   dantrolene sodium              3
FAZACLo    ®
                              3                   tizanidine HCl                 1
InVegA   ®
                              3                   ZAnAFLex® (capsule)            3
RISPeRDAL® ConSTA             3
    (12.5mg injection,                            AntivirAls —
    25mg injection)                               Drugs to treat viral infections
RISPeRDAL® ConSTA             4
    (37.5mg injection,                            anti-Cytomegalovirus (CmV) agents —
    50mg injection)                                  miscellaneous antiviral Drugs
RISPeRDAL® M-TAb              3                   foscarnet sodium               1  b/D
risperidone                   3                   ganciclovir                    4
SeRoQUeL     ®
                              2                   VALCyTe   ®
                                                                                 4
SeRoQUeL xR  ®
                              2
ZyPRexA®                      2                   antihepatitis agents — Hepatitis Drugs
ZyPRexA ZyDIS
           ®
                              2                   bARACLUDe®                      3
                                                  HePSeRA     ®
                                                                                  4
Conventional — mood Disorder Drugs                RebeToL (oral solution)
                                                              ®
                                                                                  4    PA
chlorpromazine HCl           1                    ribasphere                      1    PA
compro                       1                    ribavirin                       1    PA
fluphenazinedecanoate        1                    TyZekA    ®
                                                                                  3
fluphenazine HCl             1
haloperidol                  1                    antiherpetic agents — Herpes Drugs
haloperidol decanoate        1                    acyclovir                     1
haloperidol lactate          1                    acyclovir sodium              3    b/D
loxapine succinate           1                    DenAVIR   ®
                                                                                2
MobAn     ®
                             3                    famciclovir                   3
nAVAne (20mg capsule)
           ®
                             3
oRAP    ®
                             2
perphenazine                 1
prochlorperazine             1                    b/D – Authorization required to
prochlorperazine edisylate   1                          identify Medicare D coverage
prochlorperazine maleate     1                    LA – Limited Access; drugs available
                                                        only at certain pharmacies
thioridazine HCl             1                    PA – Prior Authorization required
thiothixene                  1                    QL – Quantity Limits apply
trifluoperazine HCl          1                    ST – Step Therapy required
                                             19
Drug Name                     tier    Notes        Drug Name                     tier     Notes


trifluridine                  3                    anti-HiV agents,
VALTRex®                      3                       Protease inhibitors — HiV Drugs
ZoVIRAx® (cream, ointment)    2                    APTIVUS®                       4
                                                   CRIxIVAn     ®
                                                                                  2
anti-HiV agents, Nonnucleoside reverse             InVIRASe     ®
                                                                                  4
   transcriptase inhibitors — HiV Drugs            kALeTRA (100-25mg tablet)
                                                               ®
                                                                                  3
ReSCRIPToR®                     3                  kALeTRA (200-50mg tablet,
                                                               ®
                                                                                  4
SUSTIVA®                        3                     oral solution)
VIRAMUne (oral suspension) 3
           ®                                       LexIVA® (oral suspension)      3
VIRAMUne® (tablet)              2                  LexIVA (tablet)
                                                           ®
                                                                                  4
                                                   noRVIR®                        3
anti-HiV agents, Nucleoside and                    noRVIR (oral solution)
                                                             ®
                                                                                  4
   Nucleotide reverse transcriptase                PReZISTA (400mg tablet,
                                                                ®
                                                                                  4
   inhibitors — HiV Drugs                             600mg tablet)
ATRIPLA®                       4                   PReZISTA® (75mg tablet)        3
CoMbIVIR     ®
                               4                   ReyATAZ     ®
                                                                                  4
didanosine                     3                   VIRACePT (powder)
                                                                 ®
                                                                                  3
eMTRIVA®                       3                   VIRACePT® (tablet)             4
ePIVIR  ®
                               2
ePIVIR HbV
        ®
                               2                   Anti-Influenza Agents — Flu Drugs
ePZICoM     ®
                               4                   ReLenZA® Diskhaler             3
ReTRoVIR IV Infusion
              ®
                               3                   rimantadine HCl                1
stavudine                      3                   TAMIFLU   ®
                                                                                  2
TRIZIVIR®                      4
TRUVADA     ®
                               4                   AnxiolytiCs —
VIDex eC (125mg delayed
       ®
                               3                   Drugs to treat Anxiety
   release capsule)
VIDex® Pediatric               3                   anxiolytics, other — anxiety Drugs
VIReAD    ®
                               3                   buspirone HCl                   1
ZIAgen    ®
                               2                   meprobamate                     1
zidovudine                     3

anti-HiV agents, other — HiV Drugs
FUZeon®                        4
InTeLenCe  ®
                               4
ISenTReSS  ®
                               4                   b/D – Authorization required to
SeLZenTRy®                     4                         identify Medicare D coverage
                                                   LA – Limited Access; drugs available
                                                         only at certain pharmacies
                                                   PA – Prior Authorization required
                                                   QL – Quantity Limits apply
                                                   ST – Step Therapy required
                                              20
Drug Name                     tier   Notes        Drug Name                     tier     Notes


biPolAr AgEnts —                                  metformin HCl ER               1
Drugs to treat Mood Disorders                     PRAnDIn®                       3     QL,ST
                                                  RIoMeT®                        3
bipolar agents — mood Disorder Drugs              STARLIx®                       2     QL,ST
eQUeTRo®                     2                    SyMLIn®                        3      PA
geoDon      ®
                             3                    tolazamide                     1
lithium carbonate            1                    tolbutamide                    1
lithium carbonate ER         1
lithium citrate              1                    glycemic agents — Diabetic Drugs
LITHobID®                    2                    gLUCAgen® Hypokit             3
SyMbyAx      ®
                             3                    gLUCAgon® emergency kit       2
                                                  PRogLyCeM   ®
                                                                                3
blooD gluCosE rEgulAtors —
Drugs to regulate blood sugar                     insulins — Diabetic Drugs
                                                  HUMALog®                       2
antidiabetic agents — Diabetic Drugs              HUMALog® Mix                   2
acarbose                       1     ST           HUMULIn®                       2
ACToPLUS Met   ®
                               2     ST           LAnTUS®                        2
ACToS    ®
                               2     ST           LeVeMIR®                       2
AVAnDAMeT®                     3     ST           noVoLIn®                       2
AVAnDARyL        ®
                               3     ST           noVoLog®                       2
AVAnDIA    ®
                               3     ST           noVoLog® Mix                   2
byeTTA    ®
                               2     ST
chlorpropamide                 1                  blooD ProDuCts/MoDifiErs/
DUeTACT     ®
                               2     ST           voluME ExPAnDErs —
FoRTAMeT®                      3                  Drugs to treat blood Disorders
glimepiride                    1
glipizide                      1                  anticoagulants — blood thinners
glipizide ER                   1                  ARIxTRA®                      3
glipizide/metformin HCl        1                  CoUMADIn (injection)
                                                             ®
                                                                                3
gLUMeTZA®                      3                  CoUMADIn (tablet)
                                                             ®
                                                                                2
glyburide                      1
glyburide micronized           1
glyburide/metformin HCl        1
glycron (1.5mg tablet, 3mg     1
                                                  b/D – Authorization required to
    tablet, 6mg tablet)
                                                        identify Medicare D coverage
gLySeT®                        3     ST           LA – Limited Access; drugs available
jAnUMeT      ®
                               3     ST                 only at certain pharmacies
jAnUVIA®                       3     ST           PA – Prior Authorization required
metformin HCl                  1                  QL – Quantity Limits apply
                                                  ST – Step Therapy required
                                             21
Drug Name                          tier    Notes        Drug Name                       tier    Notes


FRAgMIn®                           4                    PRoCRIT® (10,000units/          3      b/D,PA
    (10,000units/ml injection,                            ml, 20,000units/ml &
    25,000units/ml injection,                             40,000units/ml injection)
    7,500units/0.3ml injection)                         PRoCRIT®                        3       b/D,
FRAgMIn®                           3       QL             (2,000units/ml injection,            PA,QL
    (2,500units/0.2ml injection,                          3,000units/ml Injection,
    5,000units/0.2ml injection)                           4,000units/ml injection)
heparin sodium                     1
heparin sodium DCU                 1                    Coagulants — blood Clotting Drugs
heparin sodium/D5W                 1                    CykLokAPRon®                  2
    (20,000units injection,
    25,000units injection)                              Platelet aggregation inhibitors —
heparin sodium/NaCl                1                        blood thinners
InnoHeP®                           3                    AggRenox®                        2      QL
jantoven                           1                    anagrelide HCl                   1
LoVenox®                           4                    cilostazol                       1
    (100mg/1ml , 120mg/0.8ml,                           dipyridamole                     1
    300mg/3ml, 60mg/0.6ml, &                            pentopak                         1
    80mg/0.8ml injection)
                                                        pentoxifylline ER                1
Lovenox (150mg/1ml, &              3
                                                        pentoxil                         1
    30mg/0.3ml Injection)
                                                        PLAVIx   ®
                                                                                         2      QL
LoVenox®                           3       QL
                                                        ticlopidine HCl                  1
    (40mg/0.4ml injection)
warfarin sodium                    1
                                                        CArDiovAsCulAr AgEnts —
blood Formation Products —                              Drugs to treat Heart
   blood Formation Drugs                                and Circulation Conditions
ARAneSP® Albumin Free              3      b/D,PA
   (100mcg/0.5ml,                                       alpha-adrenergic agonists —
   100mcg/1ml, 150mcg/0.3ml,                               blood Pressure Drugs
   200mcg/0.4ml, 200mcg/1ml,                            CATAPReS-TTS®                   2       QL
   300mcg/0.6ml, 300mcg/1ml,                            clonidine HCl                   1
   40mcg/0.4ml, 40mcg/1ml,                              guanabenz acetate               1
   500mcg/1ml, 60mcg/0.3ml,                             guanfacine HCl                  1
   60mcg/1ml injection)
ARAneSP® Albumin Free              3       b/D,
   (25mcg/0.42ml &                        PA,QL
   25mcg/1ml injection)                                 b/D – Authorization required to
LeUkIne®                           4       PA                 identify Medicare D coverage
                                                        LA – Limited Access; drugs available
neULASTA®                          4       PA
                                                              only at certain pharmacies
neUMegA®                           2       PA           PA – Prior Authorization required
neUPogen®                          4       PA           QL – Quantity Limits apply
                                                        ST – Step Therapy required
                                                   22
Drug Name                    tier    Notes        Drug Name                         tier   Notes


methyldopa                    1                   carvedilol                        1
midodrine HCl                 3                   InnoPRAn® xL                      3
                                                  labetalol HCl                     1
alpha-adrenergic blocking agents —                LeVAToL®                          3
    blood Pressure Drugs                          metoprolol succinate ER           1
DIbenZyLIne®                  3                   metoprolol tartrate               1
doxazosin mesylate            1                   metoprolol/hydrochlorothiazide    1
prazosin HCl                  1                   nadolol                           1
terazosin HCl                 1                   nadolol/bendroflumethiazide       1
                                                  pindolol                          1
antiarrhythmics — Heart regulation Drugs          propranolol HCl                   1
amiodarone HCl                1                   propranolol HCl ER                1
disopyramide phosphate        1                   propranolol/hydrochlorothiazide   1
flecainide acetate            1                   TIMoLIDe® 10/25                   3
mexiletine HCl                1                   timolol maleate                   1
noRPACe CR (100mg cr
             ®
                              3
    12-hour capsule)                              Calcium Channel blocking agents —
PACeRone® (100mg tablet,      3                        blood Pressure Drugs
    300mg tablet)                                 afeditab CR                     1
pacerone (200mg tablet)       1                   amlodipine besylate             1
procainamide HCl (injection)  1                   CARDene SR  ®
                                                                                  3  QL
propafenone HCl               1                   CARDIZeM CD  ®
                                                                                  3
quinidine gluconate           3                        (360mg/24 24-hour capsule)
quinidine gluconate CR        1                   CARDIZeM® LA                    2  QL
quinidine sulfate             1                   cartia XT                       1
quinidine sulfate ER          1                   CoVeRA-HS      ®
                                                                                  3  QL
RyTHMoL SR   ®
                              3                   dilt-CD                         1
sorine                        1                   diltiazem CD                    1
sotalol HCl                   1                   diltiazem HCl                   1
TIkoSyn    ®
                              3                   diltiazem HCl ER                1
                                                  dilt-XR                         1
beta-adrenergic blocking agents —                 DynACIRC® CR                    3  QL
   blood Pressure Drugs                           exFoRge     ®
                                                                                  2 QL,ST
acebutolol HCl                1
atenolol                      1
atenolol/chlorthalidone       1                   b/D – Authorization required to
betaxolol HCl                 1                         identify Medicare D coverage
bisoprolol fumarate           1                   LA – Limited Access; drugs available
                                                        only at certain pharmacies
bisoprolol fumarate/          1
                                                  PA – Prior Authorization required
   hydrochlorothiazide                            QL – Quantity Limits apply
bySToLIC®                     2 QL,ST             ST – Step Therapy required
                                             23
Drug Name                      tier    Notes        Drug Name                         tier    Notes


exFoRge® HCT                   2      QL,ST         InSPRA® (25mg tablet)             3
felodipine ER                  1                    methyclothiazide                  1
isradipine                     1                    methyldopa/hydrochlorothiazide    1
nicardipine HCl                1                    metolazone                        1
nifediac CC                    1                    spironolactone                    1
nifedical XL                   1                    spironolactone/                   1
nifedipine                     1                        hydrochlorothiazide
nifedipine ER                  1                    THALITone®                        3
nimodipine                     4                    torsemide                         1
nisoldipine                    1                    triamterene/hydrochlorothiazide   1
taztia XT                      1
verapamil HCl                  1                    Dyslipidemics —
verapamil HCl ER               1                       Cholesterol Control Drugs
                                                    ADVICoR®                          2       QL
Cardiovascular agents, other —                      ALToPReV®                         3      QL,ST
   miscellaneous Cardiac Drugs                      AnTARA®                           2
DeMSeR®                         4                   CADUeT®                           3       QL
digoxin                         1                   cholestyramine                    1
LAnoxIn   ®
                                2                   cholestyramine light              1
   (0.1mg/ml injection, tablet)                     colestipol HCl                    1
RAnexA®                         2      ST           CReSToR®                          2       QL
reserpine                       1                   fenofibrate                       1
                                                    fenofibrate micronized            1
Diuretics — blood Pressure Drugs                    gemfibrozil                       1
acetazolamide sodium          3                     LeSCoL®                           3      QL,ST
ALDACTAZIDe® (50/50 tablet)   3                     LeSCoL® xL                        3      QL,ST
amiloride HCl                 1                     LIPIToR®                          2       QL
amiloride/hydrochlorothiazide 1                     lovastatin                        1
bumetanide                    1                     LoVAZA®                           3
chlorothiazide                1                     niacor                            1
chlorthalidone                1                     nIASPAn®                          2
CLoRPReS      ®
                              3                     pravastatin sodium                1
DeMADex (injection)
            ®
                              3                     prevalite                         1
DIURIL  ®
                              2
DIURIL IV
        ®
                              3
DyRenIUM     ®
                              3                     b/D – Authorization required to
                                                          identify Medicare D coverage
eDeCRIn®                      3
                                                    LA – Limited Access; drugs available
eplerenone                    3                           only at certain pharmacies
furosemide                    1                     PA – Prior Authorization required
hydrochlorothiazide           1                     QL – Quantity Limits apply
indapamide                    1                     ST – Step Therapy required
                                               24
Drug Name                    tier    Notes        Drug Name                       tier    Notes


SIMCoR®                       2     QL,ST         moexipril HCl                   1
simvastatin                   1                   moexipril/hydrochlorothiazide   1
TRICoR®                       2                   quinapril HCl                   1
TRIgLIDe® (50mg tablet)       3                   quinapril/hydrochlorothiazide   1
TRILIPIx®                     2                   quinaretic                      1
VyToRIn®                      3     QL,ST         ramipril                        1
WeLCHoL®                      2                   TARkA®                          3       ST
ZeTIA®                        2      QL           TekTURnA®                       2      QL,ST
                                                  TekTURnA® HCT                   2      QL,ST
renin-angiotensin-aldosterone System              TeVeTen®                        3      QL,ST
     inhibitors — blood Pressure Drugs            TeVeTen® HCT                    3      QL,ST
ACeon®                           3                trandolapril                    1
amlodipine besylate/             1
     benazepril HCl                               Vasodilators — Chest Pain Drugs
ATACAnD®                         3 QL,ST          bIDIL®                        2
ATACAnD® HCT                     3 QL,ST          DILATRATe SR ®
                                                                                3
AVALIDe     ®
                                 3 QL,ST          hydralazine HCl (injection)   3
AVAPRo      ®
                                 3 QL,ST          hydralazine HCl (tablet)      1
AZoR    ®
                                 2 QL,ST          isochron                      1
benazepril HCl                   1                ISoRDIL TITRADoSe
                                                            ®
                                                                                3
benazepril HCl/                  1                    (40mg tablet)
     hydrochlorothiazide                          isosorbide dinitrate          1
benICAR®                         2 QL,ST          isosorbide dinitrate ER       1
benICAR® HCT                     2 QL,ST          isosorbide mononitrate        1
captopril                        1                isosorbide mononitrate ER     1
captopril/hydrochlorothiazide    1                minitran                      1
CoZAAR      ®
                                 3 QL,ST          minoxidil                     1
DIoVAn     ®
                                 2 QL,ST          nITRo-DUR     ®
                                                                                3
DIoVAn® HCT                      2 QL,ST              (0.3mg/hr 24-hour patch,
enalapril maleate                1                    0.8mg/hr 24-hour patch)
enalapril maleate/               1                nitroglycerin                 1
     hydrochlorothiazide                          nITRoLIngUAL PUMPSPRAy 3
                                                                    ®

fosinopril sodium                1                VenTAVIS®                     4        b/D,PA
fosinopril sodium/               1
     hydrochlorothiazide
HyZAAR®                          3 QL,ST          b/D – Authorization required to
lisinopril                       1                      identify Medicare D coverage
lisinopril/hydrochlorothiazide   1                LA – Limited Access; drugs available
                                                        only at certain pharmacies
LoTReL® (10-40mg capsule,        3    QL
                                                  PA – Prior Authorization required
     5-40mg capsule)
                                                  QL – Quantity Limits apply
MICARDIS®                        3 QL,ST          ST – Step Therapy required
MICARDIS® HCT                    3 QL,ST     25
Drug Name                  tier   Notes        Drug Name                     tier     Notes


CEntrAl nErvous                                periogard                      1
systEM AgEnts —                                pilocarpine HCl                3
Drugs to treat nerve Conditions                triamcinolone in orabase       1

amphetamines, aDHD — aDHD Drugs                DErMAtologiCAl AgEnts —
ADDeRALL® xR                 3 QL              Drugs to treat skin Conditions
amphetamine salt combo       1 QL
dextroamphetamine sulfate    1 QL              Dermatological agents — Skin agents
dextroamphetamine sulfate ER 3 QL              ALDARA®                        2
                                               ammonium lactate               1
Non-amphetamines, aDHD — aDHD Drugs            amnesteem                      3
ConCeRTA®                   3  QL              avita                          1    PA
DAyTRAnA     ®
                            3  QL              AZeLex    ®
                                                                              3
dexmethylphenidate HCl      1  QL              benZACLIn       ®
                                                                              2
FoCALIn xR ®
                            3  QL              calcipotriene                  3
MeTADATe CD  ®
                            3  QL              CARAC®                         2
MeTHyLIn® (chewable tablet, 3  QL              claravis                       3
   oral solution)                              ConDyLox geL (gel)
                                                               ®
                                                                              3
methylin (tablet)           1  QL              DIFFeRIn     ®
                                                                              3
methylin ER                 1  QL              DoVonex (cream)
                                                             ®
                                                                              2
methylphenidate HCl         1  QL              eLIDeL®                        3   ST
methylphenidate HCl ER      1  QL              ePIDUo    ®
                                                                              3
RITALIn LA
         ®
                            3  QL              erythromycin/benzoyl peroxide  1
STRATTeRA      ®
                            3 QL,ST            FInACeA     ®
                                                                              2
                                               FLUoRoPLex          ®
                                                                              2
Non-amphetamines, other —                      fluorouracil (cream, solution) 3
   miscellaneous Nervous System Drugs          fluorouracil (injection)       1
PRoVIgIL®                     2 PA,QL          laclotion                      1
RILUTek  ®
                              4                oxSoRALen         ®
                                                                              3
xyReM  ®
                              4 QL,LA          oxSoRALen ULTRA   ®
                                                                              4
                                               podofilox                      1
DEntAl AnD orAl AgEnts —                       PRoToPIC®                      3   ST
Drugs to treat Mouth and                       RegRAnex        ®
                                                                              4 PA,QL
throat Conditions

Dental and oral agents                         b/D – Authorization required to
APHTHASoL®                  2                        identify Medicare D coverage
                                               LA – Limited Access; drugs available
chlorhexadine               1                        only at certain pharmacies
   gluconate oral rinse                        PA – Prior Authorization required
eVoxAC®                     3     ST           QL – Quantity Limits apply
kePIVAnCe®                  4                  ST – Step Therapy required
                                          26
Drug Name                   tier   Notes        Drug Name                     tier     Notes


ReTIn-A MICRo®              2      PA           gAstrointEstinAl AgEnts —
SAnTyL®                     3                   Drugs to treat bowel, intestine
selenium sulfide            1                   and Stomach Conditions
SoLARAZe®                   3
SoRIATAne® Ck               3                   antispasmodics, gastrointestinal —
sotret (10mg, 20mg, 40mg)   3                       bowel treatment Drugs
SoTReT® (30mg)              3                   atropine sulfate               3
TAZoRAC®                    3                   dicyclomine HCl                1
tretinoin (cream, gel)      1      PA           glycopyrrolate                 1
u-cort                      1                   methscopolamine bromide        3
                                                propantheline bromide          1
EnzyME rEPlACEMEnts/
MoDifiErs — Drugs to treat                      gastrointestinal agents, other —
Enzyme Deficiency                                   miscellaneous gastrointestinal Drugs
                                                AMITIZA®                        3 PA,QL
Enzyme Replacements/Modifiers —                 constulose                      1
  Enzyme Deficiency Drugs                       diphenoxylate/atropine          1
ADAgen®                      4                  enulose                         1
ALDURAZyMe®                  4                  gavilyte-G                      1     QL
bUPHenyL   ®
                             4                  generlac                        1
CeReZyMe    ®
                             4                  HALFLyTeLy bowel Prep
                                                              ®
                                                                                2     QL
CReon ®
                             2                  kRISTALoSe®                     2
CySTADAne     ®
                             3                  lactulose                       1
CySTAgon    ®
                             3                  lonox                           1
eLAPRASe®                    4                  loperamide HCl                  1
FAbRAZyMe     ®
                             4                  MoToFen     ®
                                                                                3
kUVAn®
                             4                  MoVIPReP®                       2
MyoZyMe   ®
                             4                  nULyTeLy    ®
                                                                                2     QL
nAgLAZyMe     ®
                             4                  PEG 3350/electrolytes           1     QL
oRFADIn®                     4                  TRILyTe   ®
                                                                                2     QL
SUCRAID ®
                             4                  ursodiol                        3
ULTRASe ®
                             2
ULTRASe MT
        ®
                             2
ZAVeSCA ®
                             4

                                                b/D – Authorization required to
                                                      identify Medicare D coverage
                                                LA – Limited Access; drugs available
                                                      only at certain pharmacies
                                                PA – Prior Authorization required
                                                QL – Quantity Limits apply
                                                ST – Step Therapy required
                                           27
Drug Name                    tier   Notes        Drug Name                      tier    Notes


Histamine2 (H2) blocking agents —                gEnitourinAry AgEnts —
   ulcer and Stomach acid Drugs                  Drugs to treat bladder,
AxID® (oral solution)         3                  genital and kidney Conditions
cimetidine                    1
cimetidine HCl                1                  antispasmodics, urinary —
famotidine                    1                      bladder Control Drugs
nizatidine                    1                  DeTRoL®                        2       QL
PePCID® (oral suspension)     3                  DeTRoL® LA                     2       QL
ranitidine HCl (capsule,      1                  enAbLex®                       2       QL
   injection, tablet)                            flavoxate HCl                  1
ranitidine HCl (syrup)        3                  oxybutynin chloride (tablet)   1
ZAnTAC (50/50ml injection,
          ®
                              3                  oxybutynin chloride ER         1
   effervescent tablet, pack)                    oxyTRoL®                       2       QL
                                                 SAnCTURA®                      3       QL
irritable bowel Syndrome agents — bowel          SAnCTURA® xR                   3       QL
     treatment Drugs                             VeSICARe®                      3      QL,ST
LoTRonex®                     2 PA,QL
                                                 benign Prostatic Hypertrophy agents —
Protectants —                                        Prostate Enlargement Drugs
   ulcer and Stomach acid Drugs                  AVoDART®                       2 QL,ST
CARAFATe® (oral suspension)   3                  CARDURA xL  ®
                                                                                3
misoprostol                   1                  finasteride (5mg tablet)       1
sucralfate                    1                  FLoMAx    ®
                                                                                2    QL
                                                 URoxATRAL     ®
                                                                                3    QL
Proton Pump inhibitors —
   ulcer and Stomach acid Drugs
                                                 genitourinary agents, other —
ACIPHex®                      3     ST              miscellaneous bladder, genital,
HeLIDAC   ®
                              3     QL              and Kidney Conditions Drugs
nexIUM  ®
                              2                  bethanechol chloride           1
nexIUM I.V.
        ®
                              3                  eLMIRon  ®
                                                                                3
omeprazole                    1                  LITHoSTAT  ®
                                                                                3
pantoprazole sodium           3     ST           MeTHeRgIne®                    2
PReVACID    ®
                              2                  THIoLA ®
                                                                                3
PReVACID nAPRAPAC
            ®
                              3     QL
PReVACID SoLUTAb
            ®
                              2
PReVPAC®                      3     QL           b/D – Authorization required to
PRoTonIx (delayed
            ®
                              2                        identify Medicare D coverage
   release tablet, pack)                         LA – Limited Access; drugs available
PRoTonIx® (injection)         3                        only at certain pharmacies
ZegeRID   ®
                              3     ST           PA – Prior Authorization required
                                                 QL – Quantity Limits apply
                                                 ST – Step Therapy required
                                            28
Drug Name                     tier     Notes        Drug Name                          tier   Notes


Phosphate binders —                                 cormax (cream)                     1
   Phosphate-removing agents                        CoRTIFoAM® (foam)                  3
calcium acetate             3                       cortisone acetate                  1
FoSRenoL    ®
                            3                       CoRTISPoRIn® (cream)               2
RenVeLA   ®
                            2                       CUTIVATe® (lotion)                 3
                                                    del-beta (lotion)                  1
HorMonAl AgEnts, stiMulAnt/                         DePo-MeDRoL®                       2
rEPlACEMEnt/MoDifying                                    (20mg/ml injection)
(ADrEnAl) — Drugs to regulate                       DeRMA-SMooTHeR/FS®                 3
Hormones and Treat Diabetes and                     desonide                           1
bone Conditions                                          (cream, lotion, ointment)
                                                    desoximetasone (cream, gel)        1
glucocorticoids/mineralocorticoids —                desoximetasone (ointment)          3
    Anti-Inflammatory Drugs                         dexamethasone                      1
a-hydrocort                    1                    dexamethasone intensol             1
ala-cort (cream, lotion)       1                    dexamethasone                      1
ALA-SCALP (lotion)
               ®
                               2                         sodium phosphate
alclometasone dipropionate     1                    DexPAk®                            3
    (cream, ointment)                               diflorasone diacetate              1
amcinonide (cream, lotion,     1                         (cream, ointment)
    ointment)                                       enToCoRT® eC                       3
a-methapred                    1                    fludrocortisone acetate            1
augmented betamethasone        1                    fluocinolone acetonide             1
    dipropionate (gel)                                   (cream, ointment, solution)
betamethasone dipropionate     1                    fluocinonide                       1
    (cream, ointment)                                    (gel, ointment, solution)
betamethasone valerate         1                    fluocinonide-E                     1
    (cream, lotion, ointment)                       fluticasone propionate             1
beta-val (cream, lotion)       1                         (cream, ointment)
CAPex® (shampoo)               3                    halobetasol propionate             1
CeLeSTone        ®
                               3                         (cream, ointment)
clobetasol propionate (foam)   3                    HALog® (cream, ointment)           3
clobetasol propionate          1                    hydrocortisone (cream, lotion,     1
    (ointment, solution)                                 ointment, tablet)
clobetasol propionate E        1
CLobex    ®
                               3
                                                    b/D – Authorization required to
    (shampoo, lotion, spray)
                                                          identify Medicare D coverage
CLoDeRM® (cream)               3                    LA – Limited Access; drugs available
colocort                       3                          only at certain pharmacies
CoRDRAn® (cream, lotion)       3                    PA – Prior Authorization required
CoRDRAn SP (cream)
             ®
                               3                    QL – Quantity Limits apply
CoRDRAn TAPe ®
                               3                    ST – Step Therapy required
                                               29
Drug Name                         tier   Notes        Drug Name                     tier     Notes


hydrocortisone (enema)            3                   HorMonAl AgEnts, stiMulAnt/
hydrocortisone butyrate           1                   rEPlACEMEnt/MoDifying
    (cream, ointment, solution)                       (PituitAry) — Drugs to regulate
hydrocortisone in absorbase       1                   Hormones and Treat Diabetes and
    (ointment)                                        bone Conditions
hydrocortisone valerate           1
    (cream, ointment)                                 Hormonal agents, Stimulant/replacement/
isovate (cream)                   1                      modifying (Pituitary) — Hormone
kenALog® (spray)                  2                      replacement/modifying Drugs
LoCoID® LIPoCReAM (cream)         3                   chorionic gonadotropin         3   PA
lokara (lotion)                   1                   desmopressin acetate           3
LUxIQ® (foam)                     3                   genoTRoPIn       ®
                                                                                     4   PA
MeDRoL® (2mg tablet)              3                   genoTRoPIn® Miniquick          3 PA,QL
methylprednisolone                1                      (0.2mg injection)
methylprednisolone acetate        1                   genoTRoPIn® Miniquick          4   PA
methylprednisolone                1                      (0.4mg injection, 0.6mg
    sodium succinate                                     injection, 0.8mg injection,
MILLIPReD® (tablet)               3                      1.2mg injection, 1.4mg
                                                         injection, 1.6mg injection,
mometasone furoate (cream,        1
                                                         1.8mg injection, 1mg
    lotion, ointment)
                                                         injection, 2mg injection)
oLUx-e®                           3
                                                      HUMATRoPe®                     4   PA
PAnDeL® (cream)                   3
                                                      noRDITRoPIn       ®
                                                                                     4   PA
prednicarbate (cream, ointment)   1
                                                      novarel                        3   PA
prednisolone sodium phosphate     1
                                                      nUTRoPIn    ®
                                                                                     4   PA
prednisone                        1
                                                      nUTRoPIn AQ ®
                                                                                     4   PA
prednisone intensol               1
                                                      oMnITRoPe      ®
                                                                                     4   PA
proctocream-HC (cream)            1
                                                      pregnyl w/diluent benzyl       1   PA
procto-pak (cream)                1
                                                         alcohol/NaCl
proctosol HC (cream)              1
                                                      SAIZen®                        4   PA
proctozone-HC (cream)             1
                                                      STIMATe   ®
                                                                                     3
SoLU-CoRTeF®                      2
                                                      TeV-TRoPIn®                    4   PA
    (250mg injection)
SoLU-MeDRoL®                      2
    (2gm injection)
texacort (1% solution)            1
texacort (2.5% solution)          3                   b/D – Authorization required to
triamcinolone acetonide           1                         identify Medicare D coverage
    (cream, lotion, ointment)                         LA – Limited Access; drugs available
triamcinolone acetonide           1                         only at certain pharmacies
    in absorbase                                      PA – Prior Authorization required
triderm (cream, ointment)         1                   QL – Quantity Limits apply
                                                      ST – Step Therapy required
VAnoS® (cream)                    3
                                                 30
Drug Name                   tier   Notes        Drug Name                         tier   Notes


HorMonAl AgEnts, stiMulAnt/                     DIVIgeL®                          3      QL
rEPlACEMEnt/MoDifying (sEx                      enjUVIA®                          2
HorMonEs/MoDifiErs) — Drugs                     enpresse                          1
to Regulate Hormones and Treat                  eSTRACe® (cream)                  3
Diabetes and Bone Conditions                    eSTRADeRM®                        2
                                                estradiol                         1
anabolic Steroids — Hormone                     estradiol valerate                1
   replacement/modifying Drugs                  estradiol/norethindrone acetate   1
AnADRoL-50®                  4     PA           eSTRASoRb®                        3
oxandrolone (10mg tablet)    4     PA           eSTRIng®                          2      QL
oxandrolone (2.5mg tablet)   1     PA           eSTRogeL®                         3      QL
                                                estropipate                       1
androgens — Hormone replacement/                FeMHRT®                           2
    modifying Drugs                             FeMRIng®                          3      QL
AnDRoDeRM®                 2     PA             FeMTRACe®                         3
AnDRogeL     ®
                           2     PA             gynodiol (0.5mg tablet, 1mg       1
AnDRoID    ®
                           3                        tablet, 2mg tablet)
androxy                    3                    gynoDIoL® (1.5mg tablet)          2
danazol                    3                    junel                             1
MeTHITeST    ®
                           3                    junel Fe                          1
STRIAnT   ®
                           3     PA             kariva                            1
TeSTIM  ®
                           3     PA             kelnor                            1
testosterone cypionate     1     PA             leena                             1
testosterone enanthate     1     PA             lessina                           1
TeSTReD    ®
                           3                    levora                            1
                                                LoeSTRIn 24 Fe®                   3
Estrogens — Hormone replacement/                low-ogestrel                      1
   modifying Drugs                              lutera                            1
ACTIVeLLA® (0.5-0.1 tablet) 3                   MeneST®                           2
ALoRA    ®
                            2                   MenoSTAR®                         3
AngeLIQ®                    3                   microgestin                       1
apri                        1                   microgestin Fe                    1
aranelle                    1                   mononessa                         1
aviane                      1
balziva                     1
CeneSTIn     ®
                            2                   b/D – Authorization required to
cesia                       1                         identify Medicare D coverage
CLIMARA PRo®
                            3                   LA – Limited Access; drugs available
                                                      only at certain pharmacies
CoMbIPATCH     ®
                            3                   PA – Prior Authorization required
cryselle                    1                   QL – Quantity Limits apply
DePo-eSTRADIoL   ®
                            3                   ST – Step Therapy required
                                           31
Drug Name                  tier     Notes        Drug Name                     tier     Notes


necon                       1                    jolivette                      1
nortrel                     1                    medroxyprogesterone acetate    1
nUVARIng®                   2                    MegACe® eS                     3
ocella                      1                    megestrol acetate              1
ogestrel                    1                    nora-BE                        1
oRTHo eVRA®                 2                    norethindroneacetate           1
oRTHo TRI-CyCLen Lo®        3                    PLAn b®                        3
ortho-est                   1                    PRoCHIeVe®                     3
oVCon-50®                   3                    PRoMeTRIUM®                    2
portia                      1
PReFeST®                    3                    Selective Estrogen receptor
PReMARIn®                   2                       modifying agents — Hormone
PReMPHASe®                  2                       replacement/modifying Drugs
PReMPRo®                    2                    eVISTA®                      2         QL
previfem                    1
quasense                    1                    HorMonAl AgEnts, stiMulAnt/
reclipsen                   1                    rEPlACEMEnt/MoDifying
SeASonALe®                  3                    (tHyroiD) — Drugs to replace
SeASonIQUe®                 3                    Thyroid Hormones
solia                       1
sprintec                    1                    Hormonal agents, Stimulant/
sronyx                      1                        replacement/modifying (thyroid) —
                                                     thyroid replacement Drugs
tri-legest Fe               1
                                                 LeVoTHRoID®                    2
trinessa                    1
                                                 levothyroxine sodium           1
tri-previfem                1
                                                 levoxyl                        1
tri-sprintec                1
                                                 liothyronine sodium            1
trivora                     1
                                                 SynTHRoID      ®
                                                                                2
VAgIFeM®                    2
                                                 THyRoLAR     ®
                                                                                2
velivet                     1
                                                 unithroid                      1
VIVeLLe-DoT®                2
yAZ®                        2
zovia                       1

Progestins — Hormone replacement/
    modifying Drugs
camila                      1                    b/D – Authorization required to
                                                       identify Medicare D coverage
CRInone   ®
                            3
                                                 LA – Limited Access; drugs available
DePo-PRoVeRA        ®
                            3                          only at certain pharmacies
    (400/ml injection)                           PA – Prior Authorization required
DePo-SUbQ PRoVeRA® 104      3                    QL – Quantity Limits apply
errin                       1                    ST – Step Therapy required
                                            32
Drug Name                   tier   Notes        Drug Name                     tier     Notes


HorMonAl AgEnts,                                HorMonAl AgEnts,
suPPrEssAnt (ADrEnAl) —                         suPPrEssAnt (sEx HorMonEs/
Drugs to Regulate Hormones and                  MoDifiErs) — Drugs to regulate
Treat Diabetes and Bone Conditions              Hormones and Treat Diabetes and
                                                bone Conditions
Hormonal agents, Suppressant
   (adrenal) — Hormone Suppressants             antiandrogens — Hormone Suppressants
LySoDRen®                    2                  bicalutamide               3
                                                flutamide                  3
HorMonAl AgEnts,                                nILAnDRon    ®
                                                                           3
suPPrEssAnt (PArAtHyroiD) –
Drugs to Regulate Hormones and                  HorMonAl AgEnts,
Treat Diabetes and Bone Conditions              suPPrEssAnt (tHyroiD) — Drugs
                                                to Suppress Thyroid Hormones
Hormonal agents, Suppressant
  (Parathyroid) — Hormone Suppressants          antithyroid agents —
SenSIPAR®                    2                     thyroid Suppresing Drugs
                                                methimazole                    1
HorMonAl AgEnts,                                propylthiouracil               1
suPPrEssAnt (PituitAry) —
Drugs to Regulate Hormones and                  iMMunologiCAl AgEnts —
Treat Diabetes and Bone Conditions              Drugs that Stimulate or Suppress
                                                the Immune System
Hormonal agents, Suppressant
   (Pituitary) — Hormone Suppressants           immune Suppressants —
cabergoline                   3                    immune System Drugs
eLIgARD®                      3                 AZASAn®                        2
leuprolide acetate            1                 azathioprine                   1
LUPRon DePoT-PeD
          ®
                              4                 azathioprine sodium            3
LUPRon DePoT
          ®
                              3                 CeLLCePT® (oral suspension)    4     b/D,PA
octreotide acetate            3    PA           CeLLCePT® Intravenous          3     b/D,PA
SAnDoSTATIn® LAR DePoT        4    PA           CIMZIA®                        4       PA
SoMATULIne DePoT ®
                              4    PA           cyclosporine                   3      b/D
SoMAVeRT       ®
                              4    PA
SynAReL     ®
                              4
TReLSTAR DePoT®
                              3                 b/D – Authorization required to
TReLSTAR LA   ®
                              3                       identify Medicare D coverage
                                                LA – Limited Access; drugs available
                                                      only at certain pharmacies
                                                PA – Prior Authorization required
                                                QL – Quantity Limits apply
                                                ST – Step Therapy required
                                           33
Drug Name                          tier    Notes        Drug Name                     tier     Notes


cyclosporine modified              3       b/D          leflunomide                    1
enbReL®                            4       PA           PegASyS®                       4       PA
gengraf                            3       b/D          Peg-InTRon®                    4       PA
HUMIRA®                            4       PA           RebIF®                         4       ST
kIneReT®                           4       PA           RebIF® TITRATIon PACk          4       ST
methotrexate                       1                    ReMICADe®                      4       PA
methotrexate sodium                1                    RIDAURA®                       3
mycophenolate                      3      b/D,PA        TySAbRI®                       4     PA,LA
MyFoRTIC®                          3       b/D
PRogRAF® (0.5mg capsule,           3       b/D,         Vaccines
   1mg capsule)                           PA,QL         ACTHIb®                        2
PRogRAF®                           3      b/D,PA        ADACeL®                        2
   (5mg capsule, injection)                             ATTenUVAx®                     2
RAPAMUne® (oral solution)          3       b/D          booSTRIx®                      2
RAPAMUne® (tablet)                 4       b/D          CoMVAx®                        2
TRexALL®                           3                    DAPTACeL®                      2
                                                        DeCAVAC®                       2
immunizing agents, Passive —                            DIPTHeRIA/TeTAnUS              2
  immune System Drugs                                      ToxoID PeDIATRIC
CARIMUne® Nanofiltered             4      b/D,PA        engeRIx-b®                     2       b/D
FLebogAMMA®                        4      b/D,PA        gARDASIL®                      2
gAMASTAn® S/D                      2      b/D,PA        HAVRIx®                        2
gAMMAgARD® Liquid                  4      b/D,PA        HIbTITeR®                      2
gAMUnex®                           4      b/D,PA        IMoVAx® RAbIeS (H.D.C.V.)      2
oCTAgAM®                           4      b/D,PA        InFAnRIx®                      2
PoLygAM® S/D                       3      b/D,PA        IPoL® InACTIVATeD IPV          2
SynAgIS®                           4                    je-VAx®                        2
                                                        MenACTRA®                      2
immunomodulators —                                      MenoMUne-A/C/y/W-135®          2
   immune System Drugs                                  MeRUVAx II®                    2
ACTIMMUne®                         4                    M-M-R II®                      2
ALFeRon® n                         3                    PeDIARIx®                      2
ARCALyST®                          4       PA           PeDVAx® HIb                    2
AVonex®                            4
beTASeRon®                         4
CoPAxone®                          4                    b/D – Authorization required to
InFeRgen®                          4       PA                 identify Medicare D coverage
InTRon-A® (10mu injection,         3       PA           LA – Limited Access; drugs available
                                                              only at certain pharmacies
   10mu pen injection, 18mu
                                                        PA – Prior Authorization required
   injection, 5mu pen injection)
                                                        QL – Quantity Limits apply
InTRon-A® (3mu pen injection)      3      PA,QL         ST – Step Therapy required
                                                   34
Drug Name                    tier   Notes        Drug Name                         tier   Notes


PRoQUAD®                      2                  MEtAboliC bonE DisEAsE
RAbAVeRT®                     2                  AgEnts — Drugs to regulate
ReCoMbIVAx® Hb                2     b/D          Hormones and Treat Diabetes
RoTATeQ®                      2                  and bone Conditions
TeTAnUS ToxoID                2
   ADSoRbeD                                      metabolic bone Disease agents —
TeTAnUS/DIPHTHeRIA            2                      osteoporosis (bone loss) Drugs
   ToxoIDS-ADSoRbeD                              ACToneL®                              2   QL
   ADULT                                         ACToneL® with Calcium                 2   QL
TRIHIbIT®                     2                  alendronate sodium                    1
TRIPeDIA®                     2                  bonIVA (injection)
                                                           ®
                                                                                       3
TWInRIx®                      2                  bonIVA (tablet)
                                                           ®
                                                                                       2   QL
TyPHIM® VI                    2                  calcitonin-salmon (nasal spray) 1         QL
VAQTA®                        2                  calcitriol (capsule)                  1
VARIVAx®                      2                  calcitriol (injection, oral solution) 3
VIVoTIF® beRnA                2                  DIDRoneL® (400mg tablet)              3
yF-VAx®                       2                  etidronate disodium                   1
ZoSTAVAx®                     2                  FoRTeo      ®
                                                                                       3 b/D,PA
                                                 FoRTICAL      ®
                                                                                       2   QL
inflAMMAtory bowEl DisEAsE                       FoSAMAx® (oral solution)              3   QL
AgEnts — Drugs to treat                          FoSAMAx Plus D®
                                                                                       3   QL
Inflammatory Bowel Disease                       HeCToRoL        ®
                                                                                       2
                                                 MIACALCIn (injection)
                                                                 ®
                                                                                       3 b/D,PA
Salicylates —                                    MIACALCIn (nasal spray)
                                                                 ®
                                                                                       3   QL
   Inflammatory Bowel Disease Drugs              pamidronate disodium                  3
ASACoL®                       2                  ZeMPLAR® (2mcg/ml injection) 3
balsalazide disodium          3                  ZeMPLAR®                              2
CAnASA   ®
                              2                      (5mcg/ml injection, capsule)
DIPenTUM     ®
                              3                  ZoMeTA®                               4
mesalamine                    3
PenTASA    ®
                              3

Sulfonamides —
    Inflammatory Bowel Disease Drugs
sulfasalazine                  1
sulfazine                      1                 b/D – Authorization required to
sulfazine EC                   1                       identify Medicare D coverage
                                                 LA – Limited Access; drugs available
                                                       only at certain pharmacies
                                                 PA – Prior Authorization required
                                                 QL – Quantity Limits apply
                                                 ST – Step Therapy required
                                            35
Drug Name                     tier   Notes        Drug Name                     tier     Notes


MisCEllAnEous AgEnts — Drugs                      ophthalmic antiglaucoma agents —
to treat Miscellaneous Conditions                     glaucoma Drugs
                                                  acetazolamide                3
Cytoprotective agents —                               (12-hour capsule)
   ulcer and Stomach acid Drugs                   acetazolamide (tablet)       1
amifostine                    4                   ALPHAgAn P   ®
                                                                               2
dexrazoxane                   4                   AZoPT   ®
                                                                               2
mesna                         3                   betaxolol HCl                1
MeSnex (tablet)
         ®
                              4                   beTIMoL    ®
                                                                               3
                                                  beToPTIC-S     ®
                                                                               2
Diabetic Supplies                                 brimonidine tartrate         1
alcohol preps            1                        carteolol HCl                1
gAUZe PADS               2                        CoMbIgAn     ®
                                                                               2
InSULIn SyRIngeS,neeDLeS 2                        dipivefrin HCl               1
                                                  dorzolamide HCl              1
oPHtHAlMiC AgEnts —                               dorzolamide HCl/             1
Drugs to treat Eye Conditions                         timolol maleate
                                                  IoPIDIne®                    3
ophthalmic agents, other —                        ISTALoL   ®
                                                                               3
    miscellaneous Eye Drugs                       levobunolol HCl              1
ak-con                         1                  methazolamide                1
LACRISeRT®                     2                  metipranolol                 1
mydral                         1                  PHoSPHoLIne Iodide
                                                                   ®
                                                                               2
naphazoline HCl                1                  PILoPIne® HS                 2
parcaine                       1                  timolol maleate              1
proparacaine HCl               1
ReSTASIS®                      3                  ophthalmic Prostaglandin and Prostamide
tropicacyl                     1                    analogs — glaucoma Drugs
tropicamide                    1                  LUMIgAn®                      2    QL
                                                  TRAVATAn ®
                                                                                2    QL
ophthalmic anti-allergy agents — allergy,         TRAVATAn Z
                                                           ®
                                                                                2    QL
   Infection and Inflammation Drugs               xALATAn®                      3 QL,ST
ALAMAST®                       3
ALoCRIL   ®
                               3
ALoMIDe    ®
                               3
cromolyn sodium (solution)     1                  b/D – Authorization required to
eLeSTAT   ®
                               3     ST                 identify Medicare D coverage
                                                  LA – Limited Access; drugs available
eMADIne®                       3     ST                 only at certain pharmacies
oPTIVAR   ®
                               2                  PA – Prior Authorization required
PATADAy   ®
                               2                  QL – Quantity Limits apply
PATAnoL   ®
                               2                  ST – Step Therapy required
                                             36
Drug Name                     tier   Notes        Drug Name                      tier    Notes


Ophthalmic Anti-Inflammatories — Allergy,         otiC AgEnts —
    Infection and Inflammation Drugs              Drugs to treat Ear Conditions
ACULAR®                         2
ACULAR LS  ®
                                2                 otic agents — Ear Drugs
ALRex   ®
                                3                 acetasol HC                    1
bLePHAMIDe        ®
                                2                 acetic acid                    1
bLePHAMIDe S.o.P. ®
                                2                 acetic acid/aluminum acetate   1
dexamethasone sodium            1                 acetic acid/hydrocortisone     1
    phosphate                                     borofair                       1
dexasporin                      1                 CIPRo® HC                      2
diclofenac sodium               1                 CIPRoDex®                      2
FLARex     ®
                                2                 CoLy-MyCIn® S                  3
fluorometholone                 1                 CoRTISPoRIn-TC®                3
fluor-op                        1                 cortomycin                     1
flurbiprofen sodium             1                 DeRMoTIC®                      2
FML®                            2                 neomycin/polymyxin/            1
FML FoRTe
     ®
                                2    ST              hydrocortisone
LoTeMAx       ®
                                3
MAxIDex      ®
                                2                 rEsPirAtory trACt AgEnts —
neomycin/polymyxin/             1                 Drugs to treat Allergies, Cough,
    dexamethasone                                 Cold and lung Conditions
neVAnAC®                        3
poly-dex                        1                 antihistamines — allergy Drugs
PoLy-PReD®                      2                 ALLegRA® (oral suspension)     3      QL,ST
PReD MILD       ®
                                2                 ALLegRA -D   ®
                                                                                 3      QL,ST
PReD-g     ®
                                3                 ASTeLIn    ®
                                                                                 2       QL
PReD-g S.o.P.
           ®
                                2                 ASTePRo      ®
                                                                                 2       QL
prednisolone acetate            1                 cetirizine HCl                 1       QL
prednisolone sodium phosphate 1                   CLARInex®                      3      QL,ST
sulfacetamide sodium/           1                 CLARInex Reditabs
                                                                ®
                                                                                 3      QL,ST
    prednisolone sodium                           CLARInex -D   ®
                                                                                 3      QL,ST
    phosphate
                                                  clemastine fumarate            1
TobRADex®                       2
tobramycin/dexamethasone        1
VexoL    ®
                                2    ST
xIbRoM     ®
                                3                 b/D – Authorization required to
ZyLeT   ®
                                3                       identify Medicare D coverage
                                                  LA – Limited Access; drugs available
                                                        only at certain pharmacies
                                                  PA – Prior Authorization required
                                                  QL – Quantity Limits apply
                                                  ST – Step Therapy required
                                             37
Drug Name                     tier   Notes        Drug Name                     tier     Notes


cyproheptadine HCl            1                   bronchodilators, anticholinergic —
dexchlorpheniramine maleate   1                       asthma/lung Drugs
diphenhydramine HCl           1                   ATRoVenT® HFA                   2
fexofenadine HCl              1                   ipratropium bromide             1
hydroxyzine HCl               1                       (nasal spray)
PATAnASe®                     2      QL           ipratropium bromide             1      b/D
phenadoz                      1                       (nebulizer solution)
promethazine HCl              1                   SPIRIVA® HAnDIHALeR             2
promethazine VC               1
promethegan                   1                   bronchodilators, Phosphodiesterase
                                                     inhibitors (xanthines) —
SeMPRex®-D                    3
                                                     asthma/lung Drugs
                                                  aminophylline                 1
Anti-Inflammatories, Inhaled
                                                  eLIxoPHyLLIn    ®
                                                                                2
     Corticosteroids — asthma/lung Drugs
                                                  THeo-24   ®
                                                                                2
ADVAIR® Diskus                  2 QL,ST
                                                  theochron                     1
ADVAIR HFA®
                                2 QL,ST
                                                  theophylline ER               1
AeRobID     ®
                                3 QL,ST
AeRobID-M      ®
                                3 QL,ST
                                                  bronchodilators, Sympathomimetic —
ALVeSCo®                        3 QL,ST
                                                      asthma/lung Drugs
ASMAnex      ®
                                3 QL,ST
                                                  albuterol sulfate                 1 b/D
AZMACoRT       ®
                                3 QL,ST
                                                      (nebulizer solution)
beConASe AQ    ®
                                3    QL
                                                  albuterol sulfate (syrup, tablet) 1
FLoVenT HFA ®
                                2    QL
                                                  CoMbIVenT       ®
                                                                                    2
flunisolide                     1
                                                  epinephrine HCl                   1
fluticasone propionate          1
                                                  ePIPen   ®
                                                                                    2
nASACoRT AQ    ®
                                3    QL
                                                  ePIPen -jR
                                                           ®
                                                                                    2
nASonex      ®
                                2    QL
                                                  FoRADIL® AeRoLIZeR                2 PA
PULMICoRT       ®
                                2   b/D
                                                  ipratropium bromide/albuterol     1 b/D
     (nebulizer suspension)
                                                      sulfate (nebulizer solution)
PULMICoRT® FLexHALeR            2    QL
                                                  metaproterenol sulfate            1
QVAR    ®
                                2    QL
                                                  PRoAIR HFA®
                                                                                    2
RHInoCoRT® AQUA                 2    QL
                                                  PRoVenTIL HFA  ®
                                                                                    3
                                                  SeReVenT Diskus
                                                                ®
                                                                                    3 PA
antileukotrienes – asthma/lung Drugs
ACCoLATe®                     3 QL,ST
SIngULAIR   ®
                              2 QL,ST             b/D – Authorization required to
ZyFLo CR
       ®
                              3 QL,ST                   identify Medicare D coverage
                                                  LA – Limited Access; drugs available
                                                        only at certain pharmacies
                                                  PA – Prior Authorization required
                                                  QL – Quantity Limits apply
                                                  ST – Step Therapy required
                                             38
Drug Name                         tier    Notes        Drug Name                        tier   Notes


SyMbICoRT®                        2      QL,ST         skElEtAl MusClE rElAxAnts —
terbutaline sulfate (injection)   3                    Drugs to Treat Pain, Inflammation,
terbutaline sulfate (tablet)      1                    and Muscle and Joint Conditions
TWInjeCT®                         3
VenToLIn® HFA                     2                    Skeletal muscle relaxants —
xoPenex® (nebulizer solution)     3      b/D,ST            Pain/Swelling management Drugs
xoPenex® HFA                      3                    carisoprodol                  1
                                                       carisoprodol/aspirin          1
mast Cell Stabilizers —                                carisoprodol/aspirin/codeine  3    QL
   asthma/lung Drugs                                   chlorzoxazone                 1
cromolyn sodium                   1       b/D          cyclobenzaprine HCl           1
   (nebulizer solution)                                methocarbamol                 1
gASTRoCRoM®                       3                    orphenadrine citrate          3
InTAL® InHALeR                    2                    orphenadrine citrate ER       1
                                                       RobAxIn (injection)
                                                                 ®
                                                                                     3
Pulmonary antihypertensives —                          SkeLAxIn   ®
                                                                                     3
   asthma/lung Drugs
LeTAIRIS®                     4            PA          tHErAPEutiC nutriEnts/
ReMoDULIn   ®
                              4          b/D,PA        MinErAls/ElECtrolytEs —
ReVATIo ®
                              4            PA          Drugs to Treat Vitamin, Mineral
TRACLeeR  ®
                              4          PA,LA         and Body Fluid Deficiencies

respiratory tract agents, other —                      Electrolytes/minerals —
  asthma/lung Drugs                                       Electrolytes and minerals
ARALAST®                        4                      AMIneSS®                         3      b/D
PRoLASTIn®                      4                      AMInoSyn®                        3      b/D
TyZIne ®
                                2                      AMInoSyn® 7%/electrolytes        3      b/D
xoLAIR ®
                                4         PA           aminosyn 8.5%/electrolytes       3      b/D
ZeMAIRA  ®
                                4                      AMInoSyn® II (10% Inj, 7% Inj,   3      b/D
                                                          8.5% injection)
sEDAtivEs/HyPnotiCs —                                  AMInoSyn® II 3.5%/               3      b/D
Drugs for sedation and sleep                              Dextrose 25%

Sedatives/Hypnotics —
   Sedation and Sleep Drugs
AMbIen® CR                        2      QL,ST         b/D – Authorization required to
LUneSTA®                          2      QL,ST               identify Medicare D coverage
RoZeReM®                          3       QL           LA – Limited Access; drugs available
                                                             only at certain pharmacies
zaleplon                          1       QL
                                                       PA – Prior Authorization required
zolpidem tartrate                 1       QL           QL – Quantity Limits apply
                                                       ST – Step Therapy required
                                                  39
Drug Name                       tier   Notes        Drug Name                       tier   Notes


AMInoSyn® II 4.25%/             3      b/D          IonoSoL-T® /Dextrose 5%         3
    Dextrose 10%, 20%, & 25%                        ISoLyTe-H® /Dextrose 5%         3
AMInoSyn® II 5%/                3      b/D          isolyte-M/dextrose 5%           3
    Dextrose 25%                                    ISoLyTe-P® /Dextrose 5%         3
aminosyn II 8.5%/electrolytes   3      b/D          ISoLyTe-S®                      3
AMInoSyn® II M 3.5%/            3      b/D          ISoLyTe-S® /Dextrose 5%         3
    Dextrose 5%                                     kaon-Cl-10                      1
AMInoSyn® M                     3      b/D          KCl                             1
AMInoSyn®-HbC                   3      b/D          KCl 0.075%/D5W/                 1
aminosyn-HF                     3      b/D              NaCl 0.225%, & 0.45%
AMInoSyn®-PF                    3      b/D          KCl 0.15% /NaCl 0.45% viaflex   1
CLInIMIx® 2.75%/Dextrose 5%     3      b/D          KCl 0.15% D5W/NaCl 0.33%        1
clinimix 4.25%/dextrose 10%     1      b/D          KCl 0.15% D5W/NaCl 0.45%        1
clinimix 4.25%/dextrose 20%,    3      b/D              viaflex
    & 25%                                           KCl 0.15% NaCl 0.9%             1
CLInIMIx® 4.25%/Dextrose 5%     3      b/D          KCl 0.15%/D10W/NaCl 0.2%        1
CLInIMIx® 5%/                   3      b/D          KCl 0.15%/D5W                   1
    Dextrose 15%, 20%, & 25%                        KCl 0.15%/D5W/LR                1
CLInIMIx® e 2.75%/              3      b/D          KCl 0.15%/D5W/                  1
    Dextrose 5% & 10%                                   NaCl 0.2%, 0.225%, & 0.9%
CLInIMIx® e 4.25%/              3      b/D          KCl 0.22% D5W/NaCl 0.45%        1
    Dextrose 5% & 25%
                                                    KCl 0.224%/D5W                  1
CLInIMIx® e 5%/Dextrose 15%,    3      b/D
                                                    KCl 0.224%/D5W/                 1
    20%, 25% & 35%
                                                        NaCl 0.2% & 0.33%
clinisol SF 15%                 3      b/D
                                                    KCl 0.3%/D5W                    1
dextrose 10% /                  1
                                                    KCl 0.3%/D5W/LR IV LAC ring     1
    NaCl 0.2%, & 0.45%
                                                    KCl 0.3%/D5W/                   1
dextrose 2.5%/NaCl 0.45%        1
                                                        NaCl 0.2%, 0.45%, & 0.9%
DexTRoSe 5%/                    2
                                                    KCl ER                          1
    eLeCTRoLyTe #48
                                                    klor-con 8 & 10                 1
    VIAFLex®
                                                    kLoR-Con® M15                   2
dextrose 5%/KCl 0.075%          1
                                                    klor-con M20                    1
dextrose 5% /NaCl 0.2%,         1
    0.22%, 0.33%, 0.45%, 0.9%                       lactated ringer’s irrigation    1
ED K+10                         1
FReAMIne® HbC                   3      b/D
FReAMIne® III                   3      b/D          b/D – Authorization required to
hepatamine                      3      b/D                identify Medicare D coverage
                                                    LA – Limited Access; drugs available
HePATASoL®                      3      b/D
                                                          only at certain pharmacies
intralipid (20% injection)      1      b/D          PA – Prior Authorization required
IonoSoL-b® /Dextrose 5%         3                   QL – Quantity Limits apply
IonoSoL-Mb® /Dextrose 5%        3                   ST – Step Therapy required
                                               40
Drug Name                     tier   Notes        Drug Name                       tier     Notes


lactated ringer’s viaflex     1                   therapeutic Nutrients/minerals/
levocarnitine                 1                      Electrolytes, other — Electrolytes,
magnesium sulfate             1                      minerals, and Nutrients
magnesium sulfate in D5W      1                   alcohol 5%/dextrose 5%          1
NaCl                          1                   dextrose 10%                    1
NaCl 0.45% viaflex            1                   dextrose 5%                     1
NaCl 0.9%                     1                   sterile water irrigation        1
nePHRAMIne®                   3      b/D
normosol-M in D5W             3                   Vitamins
noRMoSoL-R®                   3                   prenatal vitamins               1
normosol-R in D5W             3
novamine                      3      b/D
oSMoPReP®                     2
physiolyte                    3
PHySIoSoL® IRRIgATIon         3
PLASMA-LyTe®                  3
PLASMA-LyTe®/D5W              3
plasma-lyte-R                 3
potassium citrate             1
    extended-release
premasol                      3      b/D
PRoCALAMIne®                  3      b/D
PRoSoL®                       3      b/D
RenAMIn®                      3      b/D
ringer’s injection            1
ringer’s irrigation           1
sodium bicarbonate            1
sodium fluoride               1
sodium lactate                1
tis-u-sol                     1
TPN electrolytes FTV          3
TRAVASoL®                     3      b/D
TRAVASoL®                     3      b/D
    2.75%/Dextrose 5%, &10%
travasol 3.5%/electrolytes    3      b/D
TRAVASoL® 8.5%/DexTRoSe       3      b/D          b/D – Authorization required to
    10%, 20%, & 50%                                     identify Medicare D coverage
                                                  LA – Limited Access; drugs available
travasol 8.5%/electrolytes    3      b/D
                                                        only at certain pharmacies
TRoPHAMIne® (10% injection)   3      b/D          PA – Prior Authorization required
VISICoL®                      2                   QL – Quantity Limits apply
                                                  ST – Step Therapy required
                                             41
THIS PAge HAS been InTenTIonALLy LeFT bLAnk.
index of Drugs

              A                    acyclovir sodium . . . . . 19        ALkeRAn®      . . . . . . . 16

AbILIFy® . . . . . . . . . 19      ADACeL® . . . . . . . . 34           ALLegRA®-D. . . . . . . 37

AbILIFy® DISCMeLT. . . 19          ADAgen® . . . . . . . . 27           ALLegRA®
                                   ADDeRALL® xR . . . . . 26               (oral suspension) . . . 37
AbRAxAne®         . . . . . . 17
                                   ADVAIR® Diskus . . . . . 38          allopurinol . . . . . . . . 15
acarbose . . . . . . . . . 21
                                   ADVAIR® HFA . . . . . . 38           allopurinol sodium . . . . 15
ACCoLATe® . . . . . . . 38
                                   ADVICoR® . . . . . . . . 24          ALoCRIL® . . . . . . . . 36
acebutolol HCl . . . . . . 23
                                   AeRobID® . . . . . . . . 38          ALoMIDe® . . . . . . . . 36
ACeon® . . . . . . . . . 25
                                   AeRobID-M® . . . . . . 38            ALoRA® . . . . . . . . . 31
ACeTADoTe® . . . . . . 14
                                   afeditab CR. . . . . . . . 23        ALoxI®    . . . . . . . . . 14
acetaminophen/caffeine/
   dihydrocodeine                  AggRenox® . . . . . . 22             ALPHAgAn® P . . . . . . 36
   bitartrate . . . . . . . 15     a-hydrocort . . . . . . . . 29       ALRex® . . . . . . . . . 37
acetaminophen/codeine . . 7        ak-con . . . . . . . . . . 36        ALToPReV® . . . . . . . 24
acetasol HC . . . . . . . 37       Akne-MyCIn®           . . . . . 11   ALVeSCo®      . . . . . . . 38
acetazolamide                      ak-poly-bac (ophthalmic) . . 9       amantadine HCl . . . . . 18
   (12-hour capsule) . . . 36                                           AMbIen® CR . . . . . . . 39
                                   ak-tob (ophthalmic). . . . . 8
acetazolamide sodium . . 24                                             amcinonide (cream,
                                   ala-cort (cream, lotion) . . 29
acetazolamide (tablet) . . 36                                             lotion, ointment). . . . 29
                                   ALAMAST®         . . . . . . . 36
acetic acid . . . . . . . . 37                                          AMeRge® . . . . . . . . 15
                                   ALA-SCALP (lotion) . . . 29
                                                ®

acetic acid/                                                            a-methapred . . . . . . . 29
   aluminum acetate. . . 37        ALbenZA® . . . . . . . . 18
                                                                        amifostine . . . . . . . . 36
acetic acid/hydrocortisone 37      albuterol sulfate
                                      (nebulizer solution) . . 38       amikacin sulfate . . . . . . 8
acetylcysteine . . . . . . 14                                           amiloride HCl . . . . . . . 24
                                   albuterol sulfate
ACIPHex® . . . . . . . . 28           (syrup, tablet) . . . . . 38      amiloride/
ACTHIb® . . . . . . . . . 34       alclometasone dipropionate              hydrochlorothiazide . . 24
acticin . . . . . . . . . . 18         (cream, ointment) . . . 29       AMIneSS® . . . . . . . . 39
ACTIMMUne® . . . . . . 34          alcohol 5%/dextrose 5% . 41          aminophylline. . . . . . . 38
ACTIVeLLA®                         alcohol preps . . . . . . . 36       AMInoSyn® . . . . . . . 39
  (0.5-0.1 tablet) . . . . 31      ALDACTAZIDe®                         AMInoSyn® 7%/
ACToneL® . . . . . . . 35            (50/50 tablet) . . . . . 24          electrolytes . . . . . . 39
ACToneL® with Calcium 35           ALDARA® . . . . . . . . 26           aminosyn 8.5%/
ACToPLUS® Met. . . . . 21          ALDURAZyMe® . . . . . 27                electrolytes . . . . . . 39

ACToS® . . . . . . . . . 21        alendronate sodium . . . 35          AMInoSyn®-HbC . . . . 40

ACULAR® . . . . . . . . 37         ALFeRon® n . . . . . . 34            aminosyn-HF . . . . . . . 40

ACULAR® LS . . . . . . . 37        ALIMTA® . . . . . . . . . 17         AMInoSyn® II 3.5%/
                                                                          DexTRoSe 25% . . . 39
acyclovir . . . . . . . . . 19     ALInIA® . . . . . . . . . 18
                                                    43
AMInoSyn® II 4.25%/                 AnDRoID®      . . . . . . . 31    ASMAnex® . . . . . . . 38
  Dextrose 10%, 20%,                androxy. . . . . . . . . . 31     ASTeLIn® . . . . . . . . 37
  & 25%. . . . . . . . . 40
                                    anestacon . . . . . . . . . 8     ASTePRo® . . . . . . . 37
AMInoSyn II 5%/
             ®
                                    AngeLIQ® . . . . . . . . 31       astramorph . . . . . . . . . 7
  Dextrose 25%. . . . . 40
                                    AnTAbUSe® . . . . . . . 14        ATACAnD®      . . . . . . . 25
aminosyn II 8.5%/
   electrolytes . . . . . . 40      AnTARA® . . . . . . . . 24        ATACAnD® HCT . . . . . 25
AMInoSyn® II (10% Inj,              AnTIVeRT® (50mg tablet) 14        atamet . . . . . . . . . . 18
  7% Inj, 8.5% injection) 39        AnZeMeT® (injection) . . 14       atenolol . . . . . . . . . . 23
AMInoSyn II M 3.5%/
             ®
                                    AnZeMeT® (tablet). . . . 14       atenolol/chlorthalidone . . 23
  Dextrose 5% . . . . . 40
                                    APHTHASoL® . . . . . . 26         ATRIPLA® . . . . . . . . 20
AMInoSyn M. . . . . . 40
             ®
                                    APokyn® . . . . . . . . 18        atropine sulfate . . . . . . 27
AMInoSyn -PF . . . . . 40
             ®
                                    apri . . . . . . . . . . . . 31   ATRoVenT® HFA . . . . 38
amiodarone HCl . . . . . 23
                                    APTIVUS® . . . . . . . . 20       ATTenUVAx® . . . . . . 34
AMITIZA  ®
             . . . . . . . . 27
                                    ARALAST® . . . . . . . . 39       augmented betamethasone
amitriptyline HCl . . . . . 13                                           dipropionate (gel) . . . 29
                                    aranelle. . . . . . . . . . 31
amlodipine besylate . . . 23                                          AUgMenTIn®
                                    ARAneSP® ALbUMIn FRee
amlodipine besylate/                  (25mcg/0.42ml &                   (125mg/5ml oral
   benazepril HCl . . . . 25          25mcg/1ml injection) . 22         suspension, 250mg/5ml
                                                                        oral suspension,
ammonium lactate . . . . 26         ARAneSP® ALbUMIn FRee               chewable tablet) . . . 10
amnesteem. . . . . . . . 26           (100mcg/0.5ml,
                                      100mcg/1ml,                     AUgMenTIn® xR . . . . 10
amoxapine . . . . . . . . 13
                                      150mcg/0.3ml,                   AVALIDe® . . . . . . . . 25
amoxicillin . . . . . . . . 10        200mcg/0.4ml,                   AVAnDAMeT® . . . . . . 21
amoxicillin/potassium                 200mcg/1ml,
                                                                      AVAnDARyL® . . . . . . 21
  clavulanate . . . . . . 10          300mcg/0.6ml,
                                      300mcg/1ml,                     AVAnDIA® . . . . . . . . 21
amoxil (250mg/5ml oral
  suspension, capsule) 10             40mcg/0.4ml,                    AVAPRo® . . . . . . . . 25
                                      40mcg/1ml, 500mcg/1ml,
amphetamine salt combo 26                                             AVASTIn® . . . . . . . . 18
                                      60mcg/0.3ml, 60mcg/1ml
amphotericin B . . . . . . 14         injection) . . . . . . . 22     AVeLox® . . . . . . . . 11
ampicillin . . . . . . . . . 10     ARCALyST® . . . . . . . 34        AVeLox® AbC Pack . . . 11
ampicillin sodium . . . . . 10      ARICePT® . . . . . . . . 13       aviane . . . . . . . . . . 31
ampicillin-sulbactam . . . 10       ARICePT® oDT . . . . . 13         AVInZA® . . . . . . . . . . 7
AnADRoL-50®          . . . . . 31   ARIMIDex® . . . . . . . 17        avita . . . . . . . . . . . 26
anagrelide HCl . . . . . . 22       ARIxTRA® . . . . . . . . 21       AVoDART® . . . . . . . 28
AnCobon®                            ARoMASIn® . . . . . . . 17        AVonex® . . . . . . . . 34
  (250mg capsule) . . . 14                                            AxeRT® . . . . . . . . . 15
                                    ARRAnon® . . . . . . . 17
AnCobon®                                                              AxID® (oral solution) . . . 28
                                    ARTHRoTeC® . . . . . . . 7
  (500mg capsule) . . . 14
                                    ASACoL® . . . . . . . . 35        AZACTAM® . . . . . . . 10
AnDRoDeRM        ®
                     . . . . . 31
                                    ascomp/codeine . . . . . . 7      AZASAn® . . . . . . . . 33
AnDRogeL     ®
                 . . . . . . 31
                                               44
azathioprine . . . . . . . 33     betamethasone dipropionate               buspirone HCl . . . . . . 20
azathioprine sodium . . . 33         (cream, ointment) . . . 29            bUSULFex® . . . . . . . 16
AZeLex®     . . . . . . . . 26    betamethasone valerate                   butalbital/acetaminophen/
                                     (cream, lotion,                          caffeine/codeine . . . . 7
AZILeCT® . . . . . . . . 18          ointment) . . . . . . . 29
azithromycin (injection). . 11                                             butorphanol tartrate
                                  beTASeRon® . . . . . . 34                   (injection) . . . . . . . . 7
azithromycin (oral                beta-val (cream, lotion). . 29           butorphanol tartrate
    suspension, tablet) . . 11
                                  betaxolol HCl . . . . . . . 23              (nasal spray) . . . . . . 7
AZMACoRT® . . . . . . 38
                                  betaxolol HCl . . . . . . . 36           byeTTA®      . . . . . . . . 21
AZoPT  ®
           . . . . . . . . . 36
                                  bethanechol chloride . . . 28            bySToLIC® . . . . . . . 23
AZoR® . . . . . . . . . . 25
                                  beTIMoL® . . . . . . . . 36
                                  beToPTIC-S® . . . . . . 36                              C
               b
                                  bicalutamide . . . . . . . 33            cabergoline . . . . . . . . 33
BACiiM . . . . . . . . . . . 9
                                  bICILLIn® C-R . . . . . . 10             CADUeT® . . . . . . . . 24
bacitracin/neomycin/
                                  bICILLIn® L-A . . . . . . 10             calcipotriene . . . . . . . 26
   polymyxin . . . . . . . . 9
                                  bICnU       ®
                                                   . . . . . . . . . 16    calcitonin-salmon
bacitracin (ointment) . . . . 9
                                  bIDIL   ®
                                                  . . . . . . . . . . 25      (nasal spray) . . . . . 35
bacitracin/polymyxin B . . . 9
                                  bILTRICIDe®            . . . . . . 18    calcitriol (capsule) . . . . 35
bacitracin/polymyxin/
   neomycin/                      bisoprolol fumarate . . . . 23           calcitriol (injection, oral
   hydrocortisone . . . . . 9                                                 solution). . . . . . . . 35
                                  bisoprolol fumarate/
baclofen . . . . . . . . . 19        hydrochlorothiazide . . 23            calcium acetate. . . . . . 29

bACToCILL® In                     bleomycin sulfate. . . . . 17            camila . . . . . . . . . . 32
  DexTRoSe . . . . . 10           bLePHAMIDe® . . . . . 37                 CAMPATH® . . . . . . . 18
bACTRobAn® (cream) . . 9          bLePHAMIDe® S.o.P. . . 37                CAMPRAL® . . . . . . . 14
bACTRobAn® nASAL. . . 9           bonIVA® (injection) . . . 35             CAnASA® . . . . . . . . 35
balacet 325 . . . . . . . . . 7   bonIVA® (tablet) . . . . . 35            CAnCIDAS® . . . . . . . 14
balsalazide disodium . . . 35     booSTRIx® . . . . . . . 34               CAPASTAT® SULFATe . . 16
balziva . . . . . . . . . . 31    borofair . . . . . . . . . . 37          CAPex® (shampoo) . . . 29
bAnZeL® . . . . . . . . 12        brimonidine tartrate. . . . 36           CAPITAL®/CoDeIne. . . . 7
bARACLUDe® . . . . . . 19         bromocriptine mesylate . 18              captopril . . . . . . . . . 25
beConASe® AQ . . . . . 38         budeprion SR. . . . . . . 13             captopril/
benazepril HCl . . . . . . 25                                                 hydrochlorothiazide . . 25
                                  budeprion XL . . . . . . . 13
benazepril HCl/                                                            CARAC® . . . . . . . . . 26
                                  bumetanide. . . . . . . . 24
   hydrochlorothiazide . . 25                                              CARAFATe®
                                  bUPHenyL® . . . . . . . 27
benICAR® . . . . . . . . 25                                                  (oral suspension) . . . 28
                                  buprenorphine HCl . . . . . 7
benICAR® HCT . . . . . 25                                                  carbamazepine . . . . . . 12
                                  bupropion HCl . . . . . . 13
benZACLIn® . . . . . . 26                                                  carbamazepine ER . . . . 12
                                  bupropion HCl SR . . . . 13
benztropine mesylate . . 18                                                CARbATRoL® . . . . . . 12
                                  bupropion HCl SR . . . . 14
                                              45
carbidopa/levodopa . . . 18          (injection) . . . . . . . 10   CIPRoDex® . . . . . . . 37
carbidopa/levodopa CR . 18        cefuroxime sodium                 ciprofloxacin . . . . . . . 11
carbidopa/levodopa ODT 18            (injection) . . . . . . . 10   ciprofloxacin ER (1000mg
carboplatin . . . . . . . . 17    CeLebRex . . . . . . . . 7
                                              ®
                                                                        24-hour tablet) . . . . 11

CARDene® SR . . . . . 23          CeLeSTone® . . . . . . 29         ciprofloxacin HCl . . . . . 11

CARDIZeM® CD (360mg/              CeLLCePT® Intravenous 33          CIPRo® HC . . . . . . . 37
  24 24-hour capsule) . 23        CeLLCePT®                         CIPRo® (oral suspension) 11
CARDIZeM® LA . . . . . 23           (oral suspension) . . . 33      cisplatin. . . . . . . . . . 17
CARDURA® xL. . . . . . 28         CeLonTIn® . . . . . . . 12        citalopram hydrobromide 13
CARIMUne Nanofiltered 34
            ®                     CeneSTIn® . . . . . . . 31        cladribine . . . . . . . . . 17
carisoprodol . . . . . . . 39     cephalexin . . . . . . . . 10     CLAFoRAn®
carisoprodol/aspirin . . . 39     CeReZyMe® . . . . . . 27            (1gm injection) . . . . 10

carisoprodol/                     cesia . . . . . . . . . . . 31    CLAFoRAn® /D5W . . . 10
    aspirin/codeine . . . . 39    cetirizine HCl . . . . . . . 37   claravis . . . . . . . . . . 26
carteolol HCl . . . . . . . 36    CHAnTIx® . . . . . . . . 14       CLARInex® . . . . . . . 37
cartia XT . . . . . . . . . 23    chlordiazepoxide/                 CLARInex®-D . . . . . . 37
carvedilol . . . . . . . . . 23      amitriptyline . . . . . . 13   CLARInex® Reditabs . . 37
CATAPReS-TTS® . . . . 22          chlorhexadine                     clarithromycin . . . . . . 11
                                     gluconate oral rinse. . 26
CeDAx® . . . . . . . . . 10                                         clarithromycin ER . . . . 11
                                  chloroquine phosphate . . 18
CeenU® . . . . . . . . . 16                                         clemastine fumarate . . . 37
                                  chlorothiazide . . . . . . 24
cefaclor . . . . . . . . . . 10                                     CLeoCIn® (75mg capsule,
                                  chlorpromazine HCl . . . 19         vaginal suppository) . . 9
cefaclor ER . . . . . . . . 10
                                  chlorpropamide. . . . . . 21      CLeoCIn® gALAxy . . . . 9
cefadroxil . . . . . . . . . 10
                                  chlorthalidone . . . . . . 24     CLeoCIn® PeDIATRIC
cefazolin Sodium . . . . . 10
                                  chlorzoxazone . . . . . . 39        gRAnULeS . . . . . . 9
cefdinir . . . . . . . . . . 10
                                  cholestyramine . . . . . . 24     CLIMARA® PRo . . . . . 31
cefepime (injection) . . . 10
                                  cholestyramine light . . . 24     CLInDAgeL® (topical gel) . 9
CeFIZox®
  In DexTRoSe 5% . . 10           chorionic gonadotropin . . 30     clindamycin HCl . . . . . . 9

cefotaxime sodium . . . . 10      ciclopirox (gel) . . . . . . 14   clindamycin phosphate . . . 9

cefoxitin sodium . . . . . 10     ciclopirox nail lacquer . . 14    CLInDeSSe®
                                  ciclopirox olamine . . . . 14        (vaginal cream) . . . . . 9
cefoxitin sodium/dextrose 10
                                  ciclopirox (suspension) . . 14    CLInIMIx® 2.75%/
cefpodoxime proxetil . . . 10                                          Dextrose 5% . . . . . 40
cefprozil . . . . . . . . . 10    cilostazol . . . . . . . . . 22
                                                                    CLInIMIx® 4.25%/
ceftazidime . . . . . . . . 10    CILoxAn® (ointment) . . 11           Dextrose 5% . . . . . 40
ceftriaxone/dextrose . . . 10     cimetidine . . . . . . . . 28     clinimix 4.25%/
ceftriaxone sodium . . . . 10     cimetidine HCl . . . . . . 28         dextrose 10% . . . . . 40
cefuroxime axetil (oral) . . 10   CIMZIA® . . . . . . . . . 33      clinimix 4.25%/dextrose
                                                                        20%, & 25% . . . . . 40
cefuroxime/dextrose
                                                  46
CLInIMIx® 5%/DexTRoSe                      ConCeRTA® . . . . . . 26                     cyclosporine modified . . 34
   15%, 20%, & 25% . . 40                  ConDyLox® geL (gel) . 26                     CykLokAPRon® . . . . 22
CLInIMIx e 2.75%/
          ®
                                           constulose . . . . . . . . 27                CyMbALTA® . . . . . . . 13
   Dextrose 5% & 10% . 40
                                           CoPAxone® . . . . . . 34                     cyproheptadine HCl . . . 38
CLInIMIx e 4.25%/
          ®
                                           CoRDRAn®                                     CySTADAne® . . . . . . 27
   Dextrose 5% & 25% . 40
                                             (cream, lotion) . . . . 29                 CySTAgon® . . . . . . 27
CLInIMIx® e 5%/Dextrose
                                           CoRDRAn® SP (cream) . 29                     cytarabine . . . . . . . . 17
   15%, 20%, 25% & 35% 40
                                           CoRDRAn TAPe . . . . 29
                                                               ®
                                                                                        cytarabine aqueous . . . 17
clinisol SF 15% . . . . . . 40
                                           cormax (cream) . . . . . 29
clobetasol propionate E . 29
                                           CoRTIFoAM® (foam) . . 29                                   D
clobetasol propionate
   (foam). . . . . . . . . 29              cortisone acetate . . . . . 29
                                                                                        dacarbazine . . . . . . . 16
clobetasol propionate                      CoRTISPoRIn® (cream) 29
                                                                                        DACogen® . . . . . . . 17
   (ointment, solution) . . 29             CoRTISPoRIn (ointment) 9    ®
                                                                                        danazol . . . . . . . . . . 31
CLobex (shampoo,
         ®
                                           CoRTISPoRIn-TC® . . . 37
  lotion, spray) . . . . . 29                                                           dantrolene sodium . . . . 19
                                           cortomycin . . . . . . . . 37
CLoDeRM® (cream) . . . 29                                                               DAPSone® . . . . . . . 16
                                           CoSMegen® . . . . . . 17
CLoLAR   ®
              . . . . . . . . 17                                                        DAPTACeL® . . . . . . . 34
                                           CoUMADIn® (injection) . 21
clomipramine HCl . . . . 13                                                             DARAPRIM® . . . . . . . 18
                                           CoUMADIn (tablet) . . . 21
                                                               ®

clonidine HCl . . . . . . . 22                                                          DARVon-n® . . . . . . . . 7
                                           CoVeRA-HS               ®
                                                                       . . . . . . 23
CLoRPReS®                 . . . . . . 24                                                daunorubicin HCl . . . . . 17
                                           CoZAAR® . . . . . . . . 25
clotrimazole . . . . . . . 14                                                           DAUnoxoMe® . . . . . 17
                                           CReon . . . . . . . . . 27
                                                   ®

clotrimazole/betamethasone                                                              DAyTRAnA® . . . . . . . 26
                                           CReSToR         ®
                                                                   . . . . . . . 24
    dipropionate . . . . . 14                                                           DeCAVAC® . . . . . . . 34
                                           CRInone         ®
                                                                   . . . . . . . 32
clozapine . . . . . . . . . 19                                                          DegAReLIx®
                                           CRIxIVAn®               . . . . . . . 20       (80mg injection). . . . 17
CogenTIn® . . . . . . . 18
                                           cromolyn sodium                              DegAReLIx®
co-gesic . . . . . . . . . . 7
                                              (nebulizer solution) . . 39                 (120mg injection) . . . 17
colchicine. . . . . . . . . 15
                                           cromolyn sodium                              del-beta (lotion). . . . . . 29
colestipol HCl. . . . . . . 24                (solution) . . . . . . . 36
                                                                                        DeMADex® (injection) . . 24
colistimethate sodium . . . 9              cryselle . . . . . . . . . . 31
                                                                                        demeclocycline HCl . . . 11
colocort . . . . . . . . . . 29            CUbICIn     ®
                                                               . . . . . . . . .9
                                                                                        DeMSeR® . . . . . . . . 24
CoLy-MyCIn S . . . . . 37
                      ®
                                           CUPRIMIne® . . . . . . 14
                                                                                        DenAVIR® . . . . . . . . 19
CoMbIgAn          ®
                          . . . . . . 36   CUTIVATe (lotion). . . . 29
                                                           ®
                                                                                        depade . . . . . . . . . . 14
CoMbIPATCH® . . . . . 31                   cyclobenzaprine HCl . . . 39
                                                                                        DePen® TITRATAbS . . 14
CoMbIVenT® . . . . . . 38                  cyclophosphamide
                                                                                        DePo-eSTRADIoL®         . . 31
CoMbIVIR      ®
                      . . . . . . . 20        (injection) . . . . . . . 16
                                                                                        DePo-MeDRoL®
compro . . . . . . . . . . 19              cyclophosphamide (tablet) 16
                                                                                          (20mg/ml injection) . . 29
CoMTAn® . . . . . . . . 18                 cyclosporine . . . . . . . 33
                                                                                        DePo-PRoVeRA®
CoMVAx® . . . . . . . . 34                                                                (400/ml injection) . . . 32
                                                                   47
DePo-SUbQ                           0.33%, 0.45%, 0.9% . 40             ToxoID PeDIATRIC         34
  PRoVeRA® 104 . . . 32          dextrose 10%. . . . . . . 41        dipyridamole . . . . . . . 22
DeRMA-                           dextrose 10% /                      disopyramide phosphate 23
  SMooTHeR/FS®         . . 29       NaCl 0.2%, & 0.45% 40            DIURIL® . . . . . . . . . 24
DeRMoTIC . . . . . . . 37
            ®
                                 DIbenZyLIne® . . . . . 23           DIURIL® IV . . . . . . . . 24
desipramine HCl . . . . . 13     diclofenac potassium . . . . 7      divalproex sodium
desmopressin acetate . . 30      diclofenac sodium . . . . . 7          (24-hour tablet, sprinkle
desonide (cream, lotion,         diclofenac sodium . . . . 37           capsule). . . . . . . . 12
   ointment) . . . . . . . 29                                        divalproex sodium (delayed
                                 diclofenac sodium EC . . . 7
desoximetasone                                                          release tablet) . . . . 12
                                 diclofenac sodium XR . . . 7
   (cream, gel) . . . . . . 29                                       DIVIgeL® . . . . . . . . 31
                                 dicloxacillin sodium. . . . 10
desoximetasone                                                       DoRyx® . . . . . . . . . 11
   (ointment) . . . . . . . 29   dicyclomine HCl . . . . . 27
                                                                     dorzolamide HCl . . . . . 36
DeTRoL® . . . . . . . . 28       didanosine . . . . . . . . 20
                                                                     dorzolamide HCl/timolol
DeTRoL® LA . . . . . . . 28      DIDRoneL®                              maleate . . . . . . . . 36
                                    (400mg tablet) . . . . 35
dexamethasone . . . . . 29                                           DoVonex® (cream) . . . 26
                                 DIFFeRIn   ®
                                                 . . . . . . . 26
dexamethasone intensol     29                                        doxazosin mesylate . . . 23
                                 diflorasone diacetate
dexamethasone sodium                                                 doxepin HCl . . . . . . . 13
                                     (cream, ointment) . . . 29
   phosphate . . . . . . 29
                                 diflunisal . . . . . . . . . . 7    DoxIL®    . . . . . . . . . 17
dexamethasone sodium
                                 digoxin . . . . . . . . . . 24      doxorubicin HCl . . . . . 17
   phosphate . . . . . . 37
                                 dihydroergotamine                   doxy-caps . . . . . . . . 11
dexasporin . . . . . . . . 37
                                    mesylate . . . . . . . 15        doxycycline hyclate (capsule,
dexchlorpheniramine
                                 DILAnTIn . . . . . . . . 12
                                            ®                           extended release
   maleate . . . . . . . . 38
                                                                        capsule, tablet) . . . . 11
dexmethylphenidate HCl 26        DILAnTIn® InFATAbS . . 12
                                                                     doxycycline hyclate
DexPAk® . . . . . . . . 29       DILATRATe® SR . . . . . 25             (injection) . . . . . . . 11
dexrazoxane . . . . . . . 36     DILAUDID-5® . . . . . . . 7         doxycycline monohydrate
dextroamphetamine sulfate        dilt-CD . . . . . . . . . . 23         (50mg tablet, 75mg
   26                            diltiazem CD . . . . . . . 23          tablet) . . . . . . . . . 11
dextroamphetamine sulfate        diltiazem HCl . . . . . . . 23      doxycycline monohydrate
   ER . . . . . . . . . . 26                                            (oral suspension) . . . 11
                                 diltiazem HCl ER . . . . . 23
dextrose 2.5%/                                                       dronabinol
                                 dilt-XR . . . . . . . . . . 23
   NaCl 0.45% . . . . . . 40                                            (2.5mg capsule) . . . 14
                                 DIoVAn®        . . . . . . . . 25
dextrose 5% . . . . . . . 41                                         dronabinol (10mg capsule,
                                 DIoVAn® HCT . . . . . . 25             5mg capsule) . . . . . 14
DexTRoSe 5%/
  eLeCTRoLyTe #48                DIPenTUM® . . . . . . . 35          DRoxIA®     . . . . . . . . 17
  VIAFLex® . . . . . . 40        diphenhydramine HCl . . 38          DUeTACT®      . . . . . . . 21
dextrose 5%/KCl 0.075% 40        diphenoxylate/atropine . . 27       duramorph . . . . . . . . . 7
dextrose 5% /                    dipivefrin HCl . . . . . . . 36     DynACIRC® CR . . . . . 23
   NaCl 0.2%, 0.22%,             DIPTHeRIA/TeTAnUS                   DyRenIUM® . . . . . . . 24
                                            48
                  e                    epirubicin HCl . . . . . . 17       ethambutol HCl. . . . . . 16

econazole nitrate . . . . . 14         epitol . . . . . . . . . . . 12     ethosuximide (capsule). . 12

eDeCRIn® . . . . . . . . 24            ePIVIR   ®
                                                    . . . . . . . . . 20   ethosuximide
                                       ePIVIR® HbV. . . . . . . 20            (oral solution) . . . . . 12
ED K+10 . . . . . . . . . 40
                                       eplerenone . . . . . . . . 24       etidronate disodium . . . 35
E.E.S. 400 . . . . . . . . 11
                                       ePZICoM® . . . . . . . . 20         etodolac . . . . . . . . . . 7
e.e.S.® gRAnULeS . . . 11
                                       eQUAgeSIC® . . . . . . . 7          etodolac ER . . . . . . . . 7
eFFexoR® xR . . . . . . 13
                                       eQUeTRo® . . . . . . . 21           eToPoPHoS®          . . . . . 17
eLAPRASe® . . . . . . . 27
                                       eRAxIS® . . . . . . . . . 14        etoposide . . . . . . . . . 17
eLeSTAT® . . . . . . . . 36
                                       eRbITUx® . . . . . . . . 18         eURAx® . . . . . . . . . 18
eLIDeL . . . . . . . . . 26
       ®

                                       ergoloid mesylates . . . . 15       eVISTA® . . . . . . . . . 32
eLIgARD . . . . . . . . 33
            ®

                                       eRgoMAR® . . . . . . . 15           eVoCLIn®       . . . . . . . .9
eLITek® . . . . . . . . . 17
                                       ergotamine tartrate/                eVoxAC® . . . . . . . . 26
eLIxoPHyLLIn®            . . . . 38
                                          caffeine . . . . . . . . 15      exeLDeRM®          . . . . . . 14
eLMIRon® . . . . . . . . 28
                                       errin . . . . . . . . . . . 32      exeLon® . . . . . . . . 13
eLoxATIn® . . . . . . . 17
                                       eRTACZo® . . . . . . . 14           exFoRge® . . . . . . . 23
eLSPAR® . . . . . . . . 17
                                       ery 11                              exFoRge® HCT . . . . . 24
eMADIne® . . . . . . . . 36
                                       eRyPeD® . . . . . . . . 11          exjADe® . . . . . . . . 14
eMCyT . . . . . . . . . 16
        ®

                                       eRy-TAb® . . . . . . . . 11
eMenD . . . . . . . . . 14
        ®

                                       eRyTHRoCIn®                                        F
eMSAM® . . . . . . . . . 13              LACTobIonATe . . . 11
                                                                           FAbRAZyMe® . . . . . . 27
eMTRIVA® . . . . . . . . 20            eRyTHRoCIn®
                                                                           FACTIVe® . . . . . . . . 11
enAbLex®         . . . . . . . 28        STeARATe . . . . . . 11
                                                                           famciclovir . . . . . . . . 19
enalapril maleate . . . . . 25         erythromycin . . . . . . . 11
                                                                           famotidine . . . . . . . . 28
enalapril maleate/                     erythromycin base . . . . 11
   hydrochlorothiazide . . 25                                              FAReSTon® . . . . . . . 16
                                       erythromycin/benzoyl
enbReL® . . . . . . . . 34                peroxide . . . . . . . 26        FASLoDex® . . . . . . . 16
endocet. . . . . . . . . . . 7         erythromycin/sulfisoxazole 11       FAZACLo® . . . . . . . . 19
endodan . . . . . . . . . . 7          eSTRACe® (cream) . . . 31           FeLbAToL® . . . . . . . 12
engeRIx-b®            . . . . . . 34   eSTRADeRM®           . . . . . 31   felodipine ER . . . . . . . 24
enjUVIA® . . . . . . . . 31            estradiol . . . . . . . . . 31      FeMARA® . . . . . . . . 17
enpresse . . . . . . . . . 31          estradiol/norethindrone             FeMHRT® . . . . . . . . 31
enToCoRT® eC . . . . . 29                 acetate . . . . . . . . 31       FeMRIng®       . . . . . . . 31
enulose . . . . . . . . . . 27         estradiol valerate . . . . . 31     FeMTRACe®          . . . . . . 31
ePIDUo®         . . . . . . . . 26     eSTRASoRb® . . . . . . 31           fenofibrate . . . . . . . . 24
epinephrine HCl . . . . . 38           eSTRIng® . . . . . . . . 31         fenofibrate micronized . . 24
ePIPen® . . . . . . . . . 38           eSTRogeL®         . . . . . . 31    fenoprofen calcium . . . . . 7
ePIPen®-jR . . . . . . . 38            estropipate . . . . . . . . 31      fentanyl citrate (injection). . 7
                                                       49
fentanyl citrate oral              fluticasone propionate . . 38       galantamine hydrobromide 13
   transmucosal . . . . . . 7      fluticasone propionate              galantamine
fentanyl (patch). . . . . . . 7         (cream, ointment) . . . 29        hydrobromide ER . . . 13
fexofenadine HCl . . . . . 38      fluvoxamine maleate . . . 13        gAMASTAn® S/D . . . . 34
FInACeA® . . . . . . . . 26        FML® . . . . . . . . . . . 37       gAMMAgARD® Liquid . . 34
finasteride (5mg tablet). . 28     FML® FoRTe. . . . . . . 37          gAMUnex® . . . . . . . 34
FLAgyL® eR . . . . . . . . 9       FoCALIn® xR . . . . . . 26          ganciclovir . . . . . . . . 19
FLARex® . . . . . . . . 37         FoRADIL® AeRoLIZeR . 38             gAnTRISIn® PeDIATRIC 11
flavoxate HCl . . . . . . . 28     FoRTAMeT® . . . . . . . 21          gARDASIL® . . . . . . . 34
FLebogAMMA® . . . . . 34           FoRTAZ® /D5W . . . . . 10           gASTRoCRoM® . . . . 39
flecainide acetate. . . . . 23     FoRTeo® . . . . . . . . 35          gAUZe PADS . . . . . . 36
FLoMAx® . . . . . . . . 28         FoRTICAL® . . . . . . . 35          gavilyte-G . . . . . . . . 27
FLoVenT® HFA . . . . . 38          FoSAMAx® (oral solution) 35         gemfibrozil . . . . . . . . 24
fluconazole in dextrose. . 15      FoSAMAx® Plus D. . . . 35           geMZAR® . . . . . . . . 17
fluconazole                        foscarnet sodium . . . . . 19       generlac . . . . . . . . . 27
    (oral suspension) . . . 14     fosinopril sodium . . . . . 25      gengraf . . . . . . . . . . 34
fluconazole (tablet) . . . . 15    fosinopril sodium/                  genoptic (ophthalmic) . . . 8
fludarabine phosphate . . 17           hydrochlorothiazide . . 25      genoTRoPIn® . . . . . 30
fludrocortisone acetate . . 29     fosphenytoin sodium . . . 12        genoTRoPIn® MInIQUICk
flunisolide. . . . . . . . . 38    FoSRenoL®          . . . . . . 29     (0.2mg injection) . . . 30
fluocinolone acetonide             FRAgMIn®                            genoTRoPIn® MInIQUICk
    (cream, ointment,                (2,500units/0.2ml                   (0.4mg injection,
    solution). . . . . . . . 29      injection, 5,000units/0.2ml         0.6mg injection,
fluocinonide-E . . . . . . 29        injection) . . . . . . . 22         0.8mg injection,
                                   FRAgMIn® (10,000units/ml              1.2mg injection,
fluocinonide (gel,
                                     injection, 25,000units/ml           1.4mg injection,
    ointment, solution) . . 29
                                     injection, 7,500units/0.3ml         1.6mg injection,
fluorometholone . . . . . 37                                             1.8mg injection,
                                     injection) . . . . . . . 22
fluor-op . . . . . . . . . . 37                                          1mg injection,
                                   FReAMIne® HbC . . . . 40              2mg injection). . . . . 30
FLUoRoPLex® . . . . . 26
                                   FReAMIne® III . . . . . . 40        gentak (ophthalmic) . . . . 8
fluorouracil                       FRoVA® . . . . . . . . . 15
    (cream, solution) . . . 26                                         gentamicin sulfate . . . . . 8
                                   FURADAnTIn     ®
                                                       . . . . . .9
fluorouracil (injection) . . 26                                        gentasol (ophthalmic) . . . 8
                                   furosemide . . . . . . . . 24
fluoxetine HCl . . . . . . 13                                          geoDon® . . . . . . . . 21
                                   FUZeon® . . . . . . . . 20
fluphenazinedecanoate . 19                                             gLeeVeC® . . . . . . . 17
fluphenazine HCl . . . . . 19                                          glimepiride . . . . . . . . 21
                                                 g
flurbiprofen . . . . . . . . . 7                                       glipizide. . . . . . . . . . 21
                                   gabapentin . . . . . . . . 12       glipizide ER. . . . . . . . 21
flurbiprofen sodium . . . . 37
                                   gAbITRIL . . . . . . . . 12
                                             ®
                                                                       glipizide/metformin HCl. . 21
flutamide . . . . . . . . . 33

                                                 50
gLUCAgen® HyPokIT . 21               HeLIDAC® . . . . . . . . 28                   hydroxychloroquine
gLUCAgon®                            heparin sodium . . . . . . 22                    sulfate. . . . . . . . . 18
  emergency kit . . . . 21           heparin sodium/D5W                            hydroxyurea . . . . . . . 17
gLUMeTZA®           . . . . . . 21      (20,000units injection,                    hydroxyzine HCl . . . . . 38
glyburide . . . . . . . . . 21          25,000units injection) 22                  hydroxyzine pamoate . . 14
glyburide/metformin HCl . 21         heparin sodium DCU . . . 22                   HyZAAR® . . . . . . . . 25
glyburide micronized . . . 21        heparin sodium/NaCl . . . 22

glycopyrrolate . . . . . . 27        hepatamine. . . . . . . . 40                                 I
glycron (1.5mg tablet,               HePATASoL            ®
                                                                  . . . . . . 40
                                                                                   IBU . . . . . . . . . . . . . 7
   3mg tablet, 6mg tablet) 21        HePSeRA® . . . . . . . 19
                                                                                   ibuprofen . . . . . . . . . . 7
gLySeT® . . . . . . . . 21           HeRCePTIn® . . . . . . 18
                                                                                   idarubicin HCl . . . . . . 17
granisetron HCl (injection) 14       HexALen®             . . . . . . . 16
                                                                                   ifosfamide . . . . . . . . 16
granisetron HCl (tablet) . 14        HIbTITeR® . . . . . . . . 34
                                                                                   ifosfamide/mesna . . . . 16
granisol . . . . . . . . . . 14      HUMALog® . . . . . . . 21
                                                                                   imipramine HCl . . . . . . 13
gRIFULVIn V . . . . . . 15
            ®
                                     HUMALog Mix . . . . . 21
                                                      ®
                                                                                   imipramine pamoate . . . 13
griseofulvin microsize . . 15        HUMATRoPe                ®
                                                                   . . . . . 30
                                                                                   IMITRex® (nasal spray) . 15
gRIS-Peg   ®
                . . . . . . . 15     HUMIRA   ®
                                                      . . . . . . . . 34
                                                                                   IMITRex® Statdose Refill
guanabenz acetate . . . . 22         HUMULIn . . . . . . . . 21
                                                  ®
                                                                                      (4mg/0.5 injection) . . 15
guanfacine HCl . . . . . . 22        HyCAMTIn® . . . . . . . 17                    IMoVAx® RAbIeS
gUAnIDIne® HCL . . . . 16            HyCeT® . . . . . . . . . . 7                    (H.D.C.V.). . . . . . . 34
gynAZoLe-1® (vaginal)          15    hydralazine HCl (injection) 25                indapamide . . . . . . . . 24
gynodiol (0.5mg tablet, 1mg          hydralazine HCl (tablet) . 25                 InDoCIn® . . . . . . . . . 7
   tablet, 2mg tablet) . . 31        hydrochlorothiazide . . . 24                  indomethacin . . . . . . . . 7
gynoDIoL    ®
                                     hydrocodone/                                  indomethacin ER . . . . . . 7
  (1.5mg tablet) . . . . . 31           acetaminophen . . . . . 7                  InFAnRIx®     . . . . . . . 34
                                     hydrocodone/Ibuprofen. . . 8                  InFeRgen® . . . . . . . 34
                H
                                     hydrocortisone butyrate                       InFUMoRPH® . . . . . . . 8
HALFLyTeLy      ®                       (cream, ointment,
                                                                                   InnoHeP® . . . . . . . . 22
  bowel Prep . . . . . . 27             solution). . . . . . . . 30
                                                                                   InnoPRAn® xL . . . . . 23
halobetasol propionate               hydrocortisone (cream,
                                        lotion, ointment, tablet) 29               InSPRA® (25mg tablet) . 24
   (cream, ointment) . . . 29
                                     hydrocortisone (enema) . 30                   InSULIn SyRIngeS,
HALog®
                                                                                      neeDLeS . . . . . . 36
  (cream, ointment) . . . 29         hydrocortisone in absorbase
                                        (ointment) . . . . . . . 30                InTAL® InHALeR . . . . 39
haloperidol . . . . . . . . 19
                                     hydrocortisone valerate                       InTeLenCe® . . . . . . 20
haloperidol decanoate . . 19
                                        (cream, ointment) . . . 30                 intralipid (20% injection) . 40
haloperidol lactate . . . . 19
                                     hydromorphone HCl                             InTRon-A®
HAVRIx® . . . . . . . . . 34
                                        (injection) . . . . . . . . 8                 (3mu pen injection) . . 34
HeCToRoL® . . . . . . 35
                                     hydromorphone HCl (tablet) 8
                                                          51
InTRon-A® (10mu injection,          isosorbide mononitrate ER 25       KCl 0.15% D5W/
   10mu pen injection,              isotonic gentamicin . . . . . 8       NaCl 0.33% . . . . . . 40
   18mu injection, 5mu pen                                             KCl 0.15% D5W/
                                    isovate (cream). . . . . . 30
   injection) . . . . . . . 34                                            NaCl 0.45% viaflex . . 40
                                    isradipine . . . . . . . . . 24
InVAnZ® . . . . . . . . . 10                                           KCl 0.15%/D10W/
                                    ISTALoL® . . . . . . . . 36
InVegA   ®
             . . . . . . . . 19                                           NaCl 0.2% . . . . . . 40
                                    itraconazole . . . . . . . 15
InVIRASe®        . . . . . . . 20                                      KCl 0.15% NaCl 0.9% . . 40
                                    IxeMPRA® kIT . . . . . . 17
IonoSoL-b /  ®
                                                                       KCl 0.15% /NaCl 0.45%
   Dextrose 5% . . . . . 40                                               viaflex . . . . . . . . . 40
IonoSoL-Mb® /                                      j                   KCl 0.22% D5W/
   Dextrose 5% . . . . . 40         jantoven . . . . . . . . . 22         NaCl 0.45% . . . . . . 40
IonoSoL-T /  ®
                                    jAnUMeT® . . . . . . . 21          KCl 0.075%/D5W/NaCl
   Dextrose 5% . . . . . 40                                               0.225%, & 0.45% . . . 40
                                    jAnUVIA® . . . . . . . . 21
IoPIDIne® . . . . . . . . 36                                           KCl 0.224%/D5W. . . . . 40
                                    je-VAx® . . . . . . . . . 34
IPoL® InACTIVATeD IPV 34                                               KCl 0.224%/D5W/
                                    jolivette . . . . . . . . . . 32      NaCl 0.2% & 0.33% . 40
ipratropium bromide/
    albuterol sulfate               junel . . . . . . . . . . . 31     KCl ER . . . . . . . . . . 40
    (nebulizer solution) . . 38     junel Fe. . . . . . . . . . 31     keFLex®
ipratropium bromide                                                      (750mg capsule) . . . 10
    (nasal spray) . . . . . 38                     k                   kelnor. . . . . . . . . . . 31
ipratropium bromide                 kADIAn® . . . . . . . . . . 8      kenALog® (spray) . . . 30
    (nebulizer solution) . . 38
                                    kALeTRA®                           kePIVAnCe® . . . . . . 26
irinotecan . . . . . . . . . 17       (100-25mg tablet). . . 20        kePPRA® (injection) . . . 12
ISenTReSS    ®
                  . . . . . . 20    kALeTRA® (200-50mg                 kePPRA® xR . . . . . . 12
isochron . . . . . . . . . 25         tablet, oral solution). . 20
                                                                       keTek® . . . . . . . . . 11
ISoLyTe-H® /                        kanamycin sulfate . . . . . 9
                                                                       ketoconazole . . . . . . . 15
   DexTRoSe 5% . . . 40             kaon-Cl-10 . . . . . . . . 40
                                                                       ketoprofen . . . . . . . . . 7
isolyte-M/dextrose 5% . . 40        kariva . . . . . . . . . . . 31
                                                                       ketoprofen ER . . . . . . . 7
ISoLyTe-P® /                        KCl . . . . . . . . . . . . 40
   DexTRoSe 5% . . . 40                                                ketorolac tromethamine . . 7
                                    KCl 0.3%/D5W . . . . . . 40
ISoLyTe-S® . . . . . . . 40                                            kIneReT® . . . . . . . . 34
                                    KCl 0.3%/D5W/
ISoLyTe-S® /Dextrose 5%40                                              kionex . . . . . . . . . . 14
                                       LR IV LAC ring . . . . 40
isonarif . . . . . . . . . . 16                                        klor-con 8 & 10 . . . . . 40
                                    KCl 0.3%/D5W/NaCl 0.2%,
isoniazid . . . . . . . . . 16         0.45%, & 0.9% . . . . 40        kLoR-Con® M15 . . . . 40
ISoRDIL® TITRADoSe                  KCl 0.15%/D5W . . . . . 40         klor-con M20 . . . . . . . 40
   (40mg tablet) . . . . . 25       KCl 0.15%/D5W/LR . . . 40          kRISTALoSe® . . . . . . 27
isosorbide dinitrate . . . . 25     KCl 0.15%/D5W/NaCl 0.2%,           kuric . . . . . . . . . . . 15
isosorbide dinitrate ER . . 25         0.225%, & 0.9% . . . 40         kUVAn® . . . . . . . . . 27
isosorbide mononitrate . . 25


                                                  52
              L                   LexIVA® (oral suspension) 20        LoVenox® (100mg/1ml,
                                  LexIVA® (tablet) . . . . . 20         120mg/0.8ml,
labetalol HCl . . . . . . . 23                                          300mg/3ml,
laclotion . . . . . . . . . 26    lidocaine . . . . . . . . . . 8       60mg/0.6ml, &
LACRISeRT® . . . . . . 36         lidocaine HCl . . . . . . . . 8       80mg/0.8ml injection) 22
lactated ringer’s irrigation 40   lidocaine HCl jelly . . . . . 8     Lovenox (150mg/1ml, &
                                  lidocaine/prilocaine . . . . . 8       30mg/0.3ml Injection) 22
lactated ringer’s viaflex. . 41
                                  lidocaine viscous . . . . . . 8     low-ogestrel . . . . . . . 31
lactulose . . . . . . . . . 27
                                  LIDoDeRM® . . . . . . . . 8         loxapine succinate . . . . 19
LAMICTAL®
  STARTeR kIT . . . . 12          lindane . . . . . . . . . . 18      LUMIgAn® . . . . . . . . 36
LAMISIL® (solution) . . . 15      liothyronine sodium. . . . 32       LUneSTA® . . . . . . . . 39
lamotrigine . . . . . . . . 12    LIPIToR® . . . . . . . . 24         LUPRon® DePoT . . . . 33
LAnoxIn® (0.1mg/ml                lisinopril. . . . . . . . . . 25    LUPRon® DePoT-PeD . 33
  injection, tablet) . . . . 24   lisinopril/                         lutera . . . . . . . . . . . 31
LAnTUS® . . . . . . . . 21             hydrochlorothiazide . . 25     LUxIQ® (FoAM) . . . . . 30
leena . . . . . . . . . . . 31    lithium carbonate . . . . . 21      LyRICA® . . . . . . . . . 12
leflunomide . . . . . . . . 34    lithium carbonate ER . . . 21       LySoDRen®         . . . . . . 33
LeSCoL® . . . . . . . . 24        lithium citrate . . . . . . . 21
LeSCoL xL . . . . . . . 24
         ®
                                  LITHobID®       . . . . . . . 21                  M
lessina . . . . . . . . . . 31    LITHoSTAT® . . . . . . . 28         MACRoDAnTIn®
LeTAIRIS® . . . . . . . . 39      LoCoID® LIPoCReAM                     (25mg capsule) . . . . . 9
leucovorin calcium . . . . 14       (cream) . . . . . . . . 30        magnesium sulfate . . . . 41
LeUkeRAn® . . . . . . . 16        LoDoSyn     ®
                                                  . . . . . . . 18    magnesium sulfate
LeUkIne® . . . . . . . . 22       LoeSTRIn 24 Fe       ®
                                                           . . . 31     in D5W . . . . . . . . 41

leuprolide acetate . . . . 33     lokara (lotion). . . . . . . 30     MALARone® . . . . . . 18

LeVAQUIn® . . . . . . . 11        lonox . . . . . . . . . . . 27      maprotiline HCl . . . . . . 13

LeVAQUIn® PReMIx . . 11           loperamide HCl. . . . . . 27        margesic-H . . . . . . . . . 8

LeVAToL® . . . . . . . . 23       LoPRox® SHAMPoo . . 15              MARPLAn® . . . . . . . 13

LeVeMIR® . . . . . . . . 21       LoTeMAx® . . . . . . . 37           MATULAne® . . . . . . . 16

levetiracetam . . . . . . . 12    LoTReL® (10-40mg capsule,           MAxALT® . . . . . . . . 15
                                    5-40mg capsule) . . . 25          MAxALT-MLT® . . . . . . 15
levobunolol HCl . . . . . 36
                                  LoTRonex®        . . . . . . 28     MAxIDex® . . . . . . . . 37
levocarnitine . . . . . . . 41
                                  lovastatin . . . . . . . . . 24     MAxIPIMe®
levora. . . . . . . . . . . 31
                                  LoVAZA® . . . . . . . . 24            (2gm injection) . . . . 10
levorphanol tartrate. . . . . 8
                                  LoVenox® (40mg/                     mebendazole . . . . . . . 18
LeVoTHRoID® . . . . . 32            0.4ml injection) . . . . 22       meclizine HCl. . . . . . . 14
levothyroxine sodium. . . 32
                                                                      meclofenamate sodium . . 7
levoxyl . . . . . . . . . . 32
                                                                      MeDRoL® (2mg tablet) . 30
LexAPRo® . . . . . . . 13
                                                  53
medroxyprogesterone                methenamine hippurate . . 9      MIACALCIn®
  acetate . . . . . . . . 32       MeTHeRgIne® . . . . . 28            (nasal spray) . . . . . 35
mefloquine HCl . . . . . . 18      methimazole . . . . . . . 33     MICARDIS® . . . . . . . 25
MeFoxIn® In                        MeTHITeST® . . . . . . 31        MICARDIS® HCT . . . . . 25
  DexTRoSe . . . . . 10                                             miconazole 3 (vaginal) . . 15
                                   methocarbamol. . . . . . 39
MegACe eS . . . . . . 32
          ®
                                                                    microgestin . . . . . . . . 31
                                   methotrexate . . . . . . . 34
megestrol acetate . . . . 32                                        microgestin Fe . . . . . . 31
                                   methotrexate sodium . . . 34
meloxicam                                                           midodrine HCl . . . . . . 23
                                   methscopolamine bromide 27
   (oral suspension) . . . . 7
                                   methyclothiazide . . . . . 24    migergot . . . . . . . . . 15
meloxicam (tablet) . . . . . 7
                                   methyldopa . . . . . . . . 23    MIgRAnAL® . . . . . . . 15
MenACTRA      ®
                  . . . . . . 34
                                   methyldopa/                      MILLIPReD® (tablet) . . . 30
MeneST   ®
              . . . . . . . . 31
                                     hydrochlorothiazide . . 24     minitran. . . . . . . . . . 25
MenoMUne-
                                   MeTHyLIn® (chewable              minocycline HCl (capsule) 12
  A/C/y/W-135® . . . . 34
                                     tablet, oral solution). . 26   minocycline HCl (tablet) . 12
MenoSTAR® . . . . . . 31
                                   methylin ER . . . . . . . 26     minoxidil . . . . . . . . . 25
MenTAx® . . . . . . . . 15
                                   methylin (tablet) . . . . . 26   MIRAPex® . . . . . . . . 18
meperidine HCl (injection) . 8
                                   methylphenidate HCl . . . 26     mirtazapine . . . . . . . . 13
meperidine HCl
                                   methylphenidate HCl ER 26        mirtazapine ODT . . . . . 13
  (oral solution, tablet) . . 8
                                   methylprednisolone . . . 30      misoprostol . . . . . . . . 28
meprobamate . . . . . . 20
                                   methylprednisolone               mitomycin . . . . . . . . 17
MePRon® . . . . . . . . 18
                                     acetate . . . . . . . . 30
mercaptopurine. . . . . . 17                                        mitoxantrone HCl. . . . . 17
                                   methylprednisolone sodium
MeRReM® . . . . . . . . 10           succinate . . . . . . . 30     M-M-R II® . . . . . . . . 34
MeRUVAx II® . . . . . . 34         metipranolol . . . . . . . 36    MobAn® . . . . . . . . . 19
mesalamine . . . . . . . 35        metoclopramide HCl . . . 14      moexipril HCl . . . . . . . 25
mesna . . . . . . . . . . 36       metolazone . . . . . . . . 24    moexipril/
                                                                      hydrochlorothiazide . . 25
MeSnex® (tablet) . . . . 36        metoprolol/
                                                                    mometasone furoate (cream,
MeSTInon (syrup) . . . 16
              ®
                                     hydrochlorothiazide . . 23
                                                                      lotion, ointment). . . . 30
MeSTInon® TIMeSPAn 16              metoprolol succinate ER    23
                                                                    mononessa . . . . . . . . 31
MeTADATe CD . . . . . 26
              ®
                                   metoprolol tartrate . . . . 23
                                                                    MonURoL® . . . . . . . . 9
metaproterenol sulfate . . 38      MeTRogeL® . . . . . . . 9
                                                                    morphine sulfate ER . . . . 8
metformin HCl . . . . . . 21       metronidazole . . . . . . . 9
                                                                    morphine sulfate
metformin HCl ER . . . . 21        metronidazole                      (injection, oral solution) 8
methadone HCl (concentrate,          in NaCl 0.79% . . . . . 9
                                                                    morphine sulfate (tablet) . . 8
  oral solution, tablet). . . 8    metronidazole vaginal . . . 9
                                                                    MoToFen® . . . . . . . 27
methadone HCl (injection) . 8      mexiletine HCl . . . . . . 23
                                                                    MoVIPReP® . . . . . . . 27
methadose . . . . . . . . . 8      MIACALCIn® (injection) . 35
                                                                    mupirocin . . . . . . . . . . 9
methazolamide . . . . . . 36
                                                                    MUSTARgen®        . . . . . 16
                                                54
MyCobUTIn® . . . . . . 16         nAVAne® (20mg capsule) 19                 nITRo-DUR® (0.3mg/hr
mycophenolate . . . . . . 34      necon. . . . . . . . . . . 32                24-hour patch, 0.8mg/hr
                                                                               24-hour patch) . . . . 25
mydral . . . . . . . . . . 36     nefazodone HCl . . . . . 13
                                                                            nitrofurantoin
MyFoRTIC® . . . . . . . 34        neo-FRADIn® . . . . . . . 9                   macrocrystalline . . . . 9
MyLoTARg® . . . . . . 18          neomycin/polymyxin B                      nitrofurantoin monohydrate 9
MyoZyMe® . . . . . . . 27            sulfates . . . . . . . . . 9
                                                                            nitroglycerin . . . . . . . 25
myrac. . . . . . . . . . . 12     neomycin/polymyxin/
                                     dexamethasone. . . . 37                nITRoLIngUAL®
MyTeLASe® . . . . . . . 16                                                     PUMPSPRAy. . . . . 25
                                  neomycin/polymyxin/
                                     gramicidin. . . . . . . . 9            nizatidine . . . . . . . . . 28
              n                                                             nora-BE . . . . . . . . . 32
                                  neomycin/polymyxin/
nabumetone . . . . . . . . 7         hydrocortisone . . . . . 9             noRDITRoPIn® . . . . . 30
NaCl . . . . . . . . . . . 41     neomycin/polymyxin/                       norethindroneacetate. . . 32
NaCl 0.9% . . . . . . . . 41         hydrocortisone . . . . 37              noRITATe® . . . . . . . . 9
NaCl 0.45% viaflex . . . . 41     neomycin sulfate . . . . . . 9            normosol-M in D5W . . . 41
nadolol . . . . . . . . . . 23    nePHRAMIne             ®
                                                             . . . . . 41   noRMoSoL-R® . . . . . 41
nadolol/                          neULASTA® . . . . . . . 22                normosol-R in D5W . . . 41
   bendroflumethiazide . 23       neUMegA       ®
                                                     . . . . . . . 22       noRoxIn®        . . . . . . . 11
nafcillin sodium . . . . . . 10   neUPogen           ®
                                                         . . . . . . 22     noRPACe® CR (100mg cr
nAFTIn® . . . . . . . . . 15      neURonTIn®                                  12-hour capsule) . . . 23
nAgLAZyMe® . . . . . . 27           (oral solution) . . . . . 12            nortrel . . . . . . . . . . 32
nalbuphine HCl . . . . . . . 8    neVAnAC® . . . . . . . 37                 nortriptyline HCl . . . . . 13
nALFon® . . . . . . . . . 7       nexAVAR    ®
                                                     . . . . . . . 17       noRVIR® .   . . . . . . . . . . . . . . . 20


nALLPen®/DexTRoSe . 10            nexIUM® . . . . . . . . 28                noRVIR® (oral solution) . 20
naloxone HCl . . . . . . . 14     nexIUM® I.V. . . . . . . . 28             novamine . . . . . . . . . 41
naltrexone HCl . . . . . . 14     niacor. . . . . . . . . . . 24            novarel . . . . . . . . . . 30
nAMenDA® . . . . . . . 13         nIASPAn . . . . . . . . 24
                                            ®
                                                                            noVoLIn® . . . . . . . . 21
nAMenDA® TITRATIon                nicardipine HCl . . . . . . 24            noVoLog® . . . . . . . 21
  PAk . . . . . . . . . . 13      nICoTRoL InHALeR. . 14
                                                 ®
                                                                            noVoLog® Mix . . . . . 21
naphazoline HCl . . . . . 36      nICoTRoL nS . . . . . 14
                                                 ®
                                                                            noxAFIL® . . . . . . . . 15
nAPReLAn® (375mg                  nifediac CC . . . . . . . . 24            nULyTeLy® . . . . . . . 27
  CR 24-hour tablet) . . . 7      nifedical XL . . . . . . . . 24           nUTRoPIn® . . . . . . . 30
naproxen . . . . . . . . . . 7    nifedipine . . . . . . . . . 24           nUTRoPIn® AQ . . . . . 30
naproxen DR . . . . . . . . 7     nifedipine ER . . . . . . . 24            nUVARIng® . . . . . . . 32
nARDIL . . . . . . . . . 13
        ®
                                  nILAnDRon® . . . . . . 33                 nystatin . . . . . . . . . . 15
nASACoRT® AQ . . . . . 38         nimodipine . . . . . . . . 24             nystatin/triamcinolone . . 15
nASonex® . . . . . . . 38         nisoldipine . . . . . . . . 24            nystop . . . . . . . . . . 15
nATACyn® (ophthalmic)       15

                                                     55
              o                   oxACILLIn® SoDIUM                         PASeR® . . . . . . . . . 16
                                    (10gm injection). . . . 10              PATADAy® . . . . . . . . 36
ocella . . . . . . . . . . . 32
                                  oxandrolone                               PATAnASe® . . . . . . . 38
oCTAgAM® . . . . . . . 34            (2.5mg tablet) . . . . . 31
octreotide acetate . . . . 33                                               PATAnoL® . . . . . . . . 36
                                  oxandrolone (10mg tablet) 31
ocusulf-10 (ophthalmic) . 11                                                PCe® . . . . . . . . . . . 11
                                  oxaprozin . . . . . . . . . . 7
ofloxacin . . . . . . . . . 11                                              PeDIARIx®     . . . . . . . 34
                                  oxcarbazepine . . . . . . 12
ogestrel. . . . . . . . . . 32                                              pedi-dri . . . . . . . . . . 15
                                  oxISTAT® . . . . . . . . 15
oLUx-e® . . . . . . . . . 30                                                PeDVAx® HIb . . . . . . 34
                                  oxSoRALen® . . . . . . 26
omeprazole. . . . . . . . 28                                                PEG 3350/electrolytes . . 27
                                  oxSoRALen® ULTRA . . 26
oMnITRoPe® . . . . . . 30                                                   PegAnone® . . . . . . 12
                                  oxybutynin chloride ER. . 28
onCASPAR® . . . . . . 17                                                    PegASyS® . . . . . . . 34
                                  oxybutynin chloride
ondansetron HCl                                                             Peg-InTRon®       . . . . . 34
                                     (tablet) . . . . . . . . 28
   (injection) . . . . . . . 14                                             penicillin G potassium . . 10
                                  oxycodone/acetaminophen 8
ondansetron HCl (oral                                                       penicillin G potassium in iso-
                                  oxycodone/aspirin . . . . . 8
   solution, tablet) . . . . 14                                                osmotic dextrose . . . 10
                                  oxycodone HCl . . . . . . . 8
ondansetron ODT . . . . 14                                                  penicillin G sodium . . . . 11
                                  oxycodone HCl ER . . . . . 8
onTAk® . . . . . . . . . 17                                                 penicillin V potassium . . 11
                                  oxycodone/ibuprofen . . . . 8
onxol . . . . . . . . . . . 17                                              PenTASA®      . . . . . . . 35
                                  oxyConTIn        ®
                                                           . . . . . . .8
oPAnA® . . . . . . . . . . 8                                                pentazocine/
                                  oxyTRoL® . . . . . . . 28                    acetaminophen . . . . . 8
oPAnA® eR . . . . . . . . 8
oPTIVAR® . . . . . . . . 36                                                 pentazocine/naloxone HCl 8
                                                       P
oRACeA® . . . . . . . . 12                                                  pentopak . . . . . . . . . 22
                                  PACeRone (100mg tablet,
                                                   ®
                                                                            pentostatin . . . . . . . . 17
oRAP® . . . . . . . . . . 19
                                    300mg tablet) . . . . . 23
oRFADIn® . . . . . . . . 27                                                 pentoxifylline ER . . . . . 22
                                  pacerone (200mg tablet) 23
orphenadrine/aspirin/                                                       pentoxil . . . . . . . . . . 22
                                  paclitaxel . . . . . . . . . 17
   caffeine . . . . . . . . 15                                              PePCID®
                                  pamidronate disodium . . 35                 (oral suspension) . . . 28
orphenadrine citrate . . . 39
                                  PAnDeL® (cream) . . . . 30                periogard . . . . . . . . . 26
orphenadrine citrate ER . 39
                                  PAnLoR DC . . . . . . 15
                                           ®
                                                                            permethrin . . . . . . . . 18
ortho-est . . . . . . . . . 32
                                  PAnReTIn     ®
                                                       . . . . . . . 18     perphenazine. . . . . . . 19
oRTHo eVRA® . . . . . 32
                                  pantoprazole sodium . . . 28              perphenazine/amitriptyline 13
oRTHo
  TRI-CyCLen Lo® . . 32           parcaine . . . . . . . . . 36             PexeVA® . . . . . . . . 13
oSMoPReP® . . . . . . 41          paromomycin sulfate . . . . 9             phenadoz. . . . . . . . . 38
oVCon-50® . . . . . . . 32        paroxetine HCl ER . . . . 13              PHenyTek® . . . . . . . 12
oVIDe® . . . . . . . . . 18       paroxetine HCl (oral                      phenytoin . . . . . . . . . 12
                                     suspension). . . . . . 13
oxacillin sodium                                                            phenytoin sodium . . . . 12
   (1gm injection) . . . . 10     paroxetine HCl (tablet) . . 13
                                                                            phenytoin sodium
                                                                               extended . . . . . . . 12
                                                   56
PHoSPHoLIne® IoDIDe 36            prednisone . . . . . . . . 30      PRoCRIT®
PHoToFRIn® . . . . . . 17         prednisone intensol . . . 30         (2,000units/ml injection,
                                                                       3,000units/ml Injection,
physiolyte. . . . . . . . . 41    PReFeST®       . . . . . . . 32      4,000units/ml injection) 22
PHySIoSoL®                        pregnyl w/diluent benzyl           PRoCRIT® (10,000units/
  IRRIgATIon . . . . . 41            alcohol/NaCl . . . . . 30         ml, 20,000units/ml &
pilocarpine HCl . . . . . . 26    PReMARIn® . . . . . . . 32           40,000units/ml
PILoPIne® HS . . . . . . 36       premasol . . . . . . . . . 41        injection) . . . . . . . 22
pindolol . . . . . . . . . . 23   PReMPHASe®          . . . . . 32   proctocream-HC (cream) 30
PIPeRACILLIn® SoDIUM 11           PReMPRo® . . . . . . . 32          procto-pak (cream) . . . . 30
piroxicam . . . . . . . . . . 7   prenatal vitamins . . . . . 41     proctosol HC (cream) . . 30
PLAn b® . . . . . . . . . 32      PReVACID® . . . . . . . 28         proctozone-HC (cream) . 30
PLASMA-LyTe® . . . . . 41         PReVACID® nAPRAPAC 28              PRogLyCeM®        . . . . . 21
PLASMA-LyTe®/D5W . . 41           PReVACID® SoLUTAb . 28             PRogRAF® (0.5mg capsule,
                                                                       1mg capsule) . . . . . 34
plasma-lyte-R . . . . . . 41      prevalite . . . . . . . . . 24
                                                                     PRogRAF® (5mg capsule,
PLAVIx® . . . . . . . . . 22      previfem . . . . . . . . . 32
                                                                       injection) . . . . . . . 34
podofilox . . . . . . . . . 26    PReVPAC® . . . . . . . 28
                                                                     PRoLASTIn® . . . . . . 39
polycin B (ophthalmic) . . . 9    PReZISTA (75mg tablet) 20
                                             ®
                                                                     PRoLeUkIn® . . . . . . 17
poly-dex . . . . . . . . . 37     PReZISTA (400mg tablet,
                                             ®
                                                                     promethazine HCl . . . . 38
PoLygAM® S/D . . . . . 34           600mg tablet) . . . . . 20
                                                                     promethazine VC. . . . . 38
polymyxin B sulfate. . . . . 9    PRIFTIn® . . . . . . . . 16
                                                                     promethegan . . . . . . . 38
PoLy-PReD® . . . . . . 37         PRIMAQUIne®
                                    PHoSPHATe . . . . . 18           PRoMeTRIUM® . . . . . 32
portia . . . . . . . . . . . 32
                                  PRIMAxIn® . . . . . . . 10         propafenone HCl . . . . . 23
potassium citrate
                                  primidone. . . . . . . . . 12      propantheline bromide . . 27
   extended-release . . . 41
                                  PRIMSoL® . . . . . . . . . 9       proparacaine HCl. . . . . 36
PRAnDIn® . . . . . . . . 21
                                  PRISTIQ® . . . . . . . . 13        propoxyphene/
pravastatin sodium . . . . 24
                                                                        acetaminophen . . . . . 8
prazosin HCl . . . . . . . 23     PRoAIR® HFA . . . . . . 38
                                                                     propoxyphene HCl . . . . . 8
PReD-g® . . . . . . . . 37        probenecid . . . . . . . . 15
                                                                     propoxyphene-N/
PReD-g® S.o.P. . . . . . 37       probenecid/colchicine . . 15
                                                                        acetaminophen . . . . . 8
PReD MILD®      . . . . . . 37    procainamide HCl
                                                                     propranolol HCl. . . . . . 23
                                     (injection) . . . . . . . 23
prednicarbate                                                        propranolol HCl ER. . . . 23
   (cream, ointment) . . . 30     PRoCALAMIne® . . . . 41
                                                                     propranolol/
prednisolone acetate . . . 37     PRoCHIeVe® . . . . . . 32
                                                                        hydrochlorothiazide . . 23
prednisolone sodium               prochlorperazine . . . . . 19
                                                                     propylthiouracil . . . . . . 33
   phosphate . . . . . . 30       prochlorperazine edisylate 19
                                                                     PRoQUAD® . . . . . . . 35
prednisolone sodium               prochlorperazine maleate 19
                                                                     PRoQUIn® xR . . . . . . 11
   phosphate . . . . . . 37
                                                                     PRoSoL® . . . . . . . . 41

                                                 57
PRoTonIx® (delayed                    RAZADyne®                          RISPeRDAL® ConSTA
  release tablet, pack) . 28            (oral solution) . . . . . 13        (37.5mg injection,
PRoTonIx® (injection). . 28           RebeToL® (oral solution) 19           50mg injection) . . . . 19

PRoToPIC® . . . . . . . 26            RebIF®    . . . . . . . . . 34     RISPeRDAL® M-TAb. . . 19

protriptyline HCl . . . . . 13        RebIF® TITRATIon PACk 34           risperidone . . . . . . . . 19

PRoVenTIL® HFA . . . . 38             reclipsen . . . . . . . . . 32     RITALIn® LA . . . . . . . 26

PRoVIgIL® . . . . . . . 26            ReCoMbIVAx® Hb . . . 35            RITUxAn® . . . . . . . . 18

PRoZAC® WeekLy . . . 13               regonol . . . . . . . . . . 16     RobAxIn® (injection) . . 39

PULMICoRT®                            RegRAnex® . . . . . . 26           romycin (ophthalmic) . . . 11
  FLexHALeR . . . . . 38              ReLenZA® Diskhaler . . 20          ropinirole HCl. . . . . . . 18
PULMICoRT® (nebulizer                 ReLPAx® . . . . . . . . 15         RoTATeQ® . . . . . . . 35
  suspension). . . . . . 38                                              RoxICeT® (oral solution) . 8
                                      ReMICADe® . . . . . . . 34
pyrazinamide . . . . . . . 16                                            roxicet (tablet) . . . . . . . 8
                                      ReMoDULIn® . . . . . . 39
pyridostigmine bromide . 16                                              RoZeReM® . . . . . . . 39
                                      RenAMIn®       . . . . . . . 41
                                      RenVeLA®       . . . . . . . 29    RyTHMoL® SR . . . . . 23
                 Q
                                      ReSCRIPToR® . . . . . 20
QUALAQUIn     ®
                     . . . . . . 18                                                     S
                                      reserpine . . . . . . . . . 24
quasense . . . . . . . . . 32                                            SAIZen® . . . . . . . . . 30
                                      ReSTASIS® . . . . . . . 36
quinapril HCl . . . . . . . 25                                           SAnCTURA®          . . . . . . 28
                                      ReTIn-A MICRo® . . . . 27
quinapril/                                                               SAnCTURA® xR . . . . . 28
                                      ReTRoVIR® IV Infusion . 20
   hydrochlorothiazide . . 25
                                      ReVATIo® . . . . . . . . 39        SAnDoSTATIn® LAR
quinaretic . . . . . . . . . 25                                            DePoT . . . . . . . . 33
                                      ReVLIMID® . . . . . . . 16
quinidine gluconate. . . . 23                                            SAnTyL® . . . . . . . . 27
                                      ReyATAZ® . . . . . . . . 20
quinidine gluconate CR . 23                                              SeASonALe® . . . . . . 32
                                      RHInoCoRT® AQUA . . 38
quinidine sulfate . . . . . 23                                           SeASonIQUe® . . . . . 32
                                      ribasphere . . . . . . . . 19
quinidine sulfate ER . . . 23                                            selegiline HCl. . . . . . . 18
                                      ribavirin . . . . . . . . . . 19
QUIxIn® (ophthalmic) . . 11                                              selenium sulfide . . . . . 27
                                      RIDAURA® . . . . . . . . 34
QVAR® . . . . . . . . . . 38                                             selfemra . . . . . . . . . 13
                                      rifampin (capsule) . . . . 16
                                                                         SeLZenTRy® . . . . . . 20
                 R                    RIFATeR® . . . . . . . . 16
                                                                         SeMPRex®-D . . . . . . 38
                                      RILUTek® . . . . . . . . 26
RAbAVeRT® . . . . . . . 35                                               SenSIPAR® . . . . . . . 33
                                      rimantadine HCl . . . . . 20
ramipril . . . . . . . . . . 25                                          SeReVenT® Diskus . . . 38
                                      ringer’s injection . . . . . 41
RAnexA® . . . . . . . . 24                                               SeRoMyCIn® . . . . . . 16
                                      ringer’s irrigation . . . . . 41
ranitidine HCl (capsule,                                                 SeRoQUeL® . . . . . . 19
   injection, tablet) . . . . 28      RIoMeT® . . . . . . . . 21
                                                                         SeRoQUeL® xR . . . . . 19
ranitidine HCl (syrup). . . 28        RISPeRDAL® ConSTA
                                         (12.5mg injection,              sertraline HCl. . . . . . . 13
RAPAMUne     ®
                                         25mg injection) . . . . 19      silver sulfadiazine . . . . . 9
  (oral solution) . . . . . 34
RAPAMUne® (tablet). . . 34                          58
SIMCoR® . . . . . . . . 25              sterile water irrigation . . 41    SynALgoS-DC® . . . . 15
simvastatin . . . . . . . . 25          STIMATe® . . . . . . . . 30        SynAReL®        . . . . . . . 33
SIngULAIR . . . . . . . 38
                 ®
                                        STRATTeRA     ®
                                                          . . . . . . 26   SyneRCID . . . . . . . . 9
                                                                                       ®


SkeLAxIn® . . . . . . . 39              STRePToMyCIn®                      SynTHRoID® . . . . . . 32
sodium bicarbonate . . . 41               SULFATe . . . . . . . . 9        SyPRIne® . . . . . . . . 14
sodium fluoride . . . . . . 41          STRIAnT® . . . . . . . . 31

sodium lactate . . . . . . 41           STRoMeCToL® . . . . . 18                           T
sodium polystyrene                      SUboxone® . . . . . . . 8
                                                                           TAbLoID® . . . . . . . . 17
   sulfonate . . . . . . . 14           SUbUTex® . . . . . . . . 8
                                                                           TAMIFLU® . . . . . . . . 20
SoLARAZe . . . . . . . 27
                 ®
                                        SUCRAID . . . . . . . . 27
                                                  ®
                                                                           tamoxifen citrate . . . . . 16
solia . . . . . . . . . . . 32          sucralfate . . . . . . . . . 28
                                                                           TARCeVA® . . . . . . . . 17
SoLU-CoRTeF            ®
                                        sulfacetamide sodium . . 11
                                                                           TARgReTIn® (capsule) . 18
  (250mg injection) . . . 30            sulfacetamide sodium/
                                                                           TARgReTIn® (gel) . . . . 18
SoLU-MeDRoL            ®
                                            prednisolone sodium
  (2gm injection) . . . . 30                phosphate . . . . . . 37       TARkA® . . . . . . . . . 25
SoMATULIne® DePoT . 33                  sulfadiazine. . . . . . . . 11     TASIgnA® . . . . . . . . 17
SoMAVeRT® . . . . . . 33                sulfamethoxazole/                  TAxoTeRe® . . . . . . . 17
SoRIATAne® Ck. . . . . 27                   trimethoprim . . . . . 11      tazicef . . . . . . . . . . 10
sorine. . . . . . . . . . . 23          SULFAMyLon® (cream) . . 9          TAZoRAC® . . . . . . . 27
sotalol HCl . . . . . . . . 23          SULFAMyLon® (topical               taztia XT . . . . . . . . . 24
                                          solution pack) . . . . . . 9     TegReToL® . . . . . . . 12
sotret
   (10mg, 20mg, 40mg) . 27              sulfasalazine . . . . . . . 35     TegReToL-xR®         . . . . 12
SoTReT (30mg) . . . . 27
         ®                              sulfatrim . . . . . . . . . 11     TekTURnA® . . . . . . . 25
SPeCTRACeF® . . . . . 10                sulfazine . . . . . . . . . 35     TekTURnA® HCT . . . . 25
SPIRIVA® HAnDIHALeR 38                  sulfazine EC . . . . . . . 35      terazosin HCl . . . . . . . 23
spironolactone . . . . . . 24           sulindac . . . . . . . . . . 7     terbinafine HCl . . . . . . 15
spironolactone/                         sumatriptan succinate              terbutaline sulfate
    hydrochlorothiazide . . 24             (injection) . . . . . . . 15        (injection) . . . . . . . 39
SPoRAnox®                               sumatriptan succinate              terbutaline sulfate (tablet) 39
  (oral solution) . . . . . 15             (tablet) . . . . . . . . 15
                                                                           terconazole (vaginal) . . . 15
sprintec . . . . . . . . . . 32         SUPRAx® . . . . . . . . 10
                                                                           TeSTIM® . . . . . . . . . 31
SPRyCeL®             . . . . . . . 17   SURMonTIL     ®

                                          (100mg capsule) . . . 13         testosterone cypionate . . 31
sronyx . . . . . . . . . . 32                                              testosterone enanthate. . 31
                                        SUSTIVA® . . . . . . . . 20
SSD . . . . . . . . . . . . 9                                              TeSTReD®        . . . . . . . 31
                                        SUTenT® . . . . . . . . 17
stagesic . . . . . . . . . . 8                                             TeTAnUS/DIPHTHeRIA
                                        SyMbICoRT® . . . . . . 39
STALeVo . . . . . . . . 18
             ®
                                                                             ToxoIDS-ADSoRbeD
                                        SyMbyAx® . . . . . . . 21            ADULT . . . . . . . . 35
STARLIx® . . . . . . . . 21
                                        SyMLIn® . . . . . . . . . 21       TeTAnUS ToxoID
stavudine . . . . . . . . . 20
                                        SynAgIS . . . . . . . . 34
                                                  ®
                                                                             ADSoRbeD . . . . . 35
STAVZoR® . . . . . . . . 12                       59
tetracycline HCl . . . . . 12            topiramate sprinkle . . . . 12       TRICoR®      . . . . . . . . 25
TeVeTen®              . . . . . . . 25   toposar . . . . . . . . . . 17       triderm (cream, ointment) 30
TeVeTen HCT . . . . . 25
              ®
                                         ToRISeL   ®
                                                       . . . . . . . . 17     trifluoperazine HCl . . . . 19
TeV-TRoPIn® . . . . . . 30               torsemide. . . . . . . . . 24        trifluridine . . . . . . . . . 20
texacort (1% solution) . . 30            TPN electrolytes FTV . . 41          TRIgLIDe® (50mg tablet) 25
texacort (2.5% solution) . 30            TRACLeeR® . . . . . . . 39           trihexyphenidyl HCl. . . . 18
THALITone® . . . . . . 24                tramadol HCl . . . . . . . . 8       TRIHIbIT® . . . . . . . . 35
THALoMID® . . . . . . . 16               tramadol HCl/                        tri-legest Fe. . . . . . . . 32
THeo-24® . . . . . . . . 38                 acetaminophen . . . . . 8         TRILePTAL®
theochron. . . . . . . . . 38            trandolapril . . . . . . . . 25         (oral suspension) . . . 12

theophylline ER . . . . . 38             TRAnSDeRM-SCoP® . . 14               TRILIPIx® . . . . . . . . 25

thermazene. . . . . . . . . 9            tranylcypromine sulfate. . 13        TRILyTe® . . . . . . . . 27

THIoLA® . . . . . . . . . 28             TRAVASoL® . . . . . . . 41           trimethobenzamide HCl . 14

thioridazine HCl . . . . . 19            TRAVASoL® 2.75%/                     trimethoprim . . . . . . . . 9
                                           Dextrose 5%, &10% . 41             trimethoprim sulfate/
THIoTePA® . . . . . . . 16
                                         travasol 3.5%/electrolytes 41            polymyxin B sulfate . . . 9
thiothixene . . . . . . . . 19
                                         TRAVASoL® 8.5%/                      trimipramine maleate . . . 13
THyRoLAR          ®
                       . . . . . . 32      DexTRoSe 10%,                      trimox. . . . . . . . . . . 11
ticlopidine HCl . . . . . . 22             20%, & 50% . . . . . 41
                                                                              trinessa . . . . . . . . . . 32
tifampin (injection) . . . . 16          travasol 8.5%/electrolytes 41
                                                                              TRIPeDIA®      . . . . . . . 35
TIkoSyn® . . . . . . . . 23              TRAVATAn      ®
                                                           . . . . . . . 36
                                                                              tri-previfem . . . . . . . . 32
TIMenTIn® . . . . . . . 11               TRAVATAn® Z . . . . . . 36
                                                                              TRISenox® . . . . . . . 17
TIMoLIDe® 10/25 . . . . 23               trazodone HCl . . . . . . 13
                                                                              tri-sprintec . . . . . . . . 32
timolol maleate . . . . . . 23           TReAnDA® . . . . . . . 16
                                                                              trivora. . . . . . . . . . . 32
timolol maleate . . . . . . 36           TReCAToR® . . . . . . . 16
                                                                              TRIZIVIR® . . . . . . . . 20
TInDAMAx . . . . . . . 18
                  ®
                                         TReLSTAR DePoT . . . 33
                                                       ®
                                                                              TRoPHAMIne®
tis-u-sol . . . . . . . . . . 41         TReLSTAR LA . . . . . 33
                                                       ®
                                                                                (10% injection) . . . . 41
tizanidine HCl . . . . . . 19            tretinoin (capsule) . . . . 18       tropicacyl . . . . . . . . . 36
TobRADex          ®
                       . . . . . . 37    tretinoin (cream, gel) . . . 27      tropicamide . . . . . . . . 36
tobramycin/                              TRexALL . . . . . . . . 34
                                                   ®
                                                                              TRUVADA® . . . . . . . 20
   dexamethasone. . . . 37               trezix . . . . . . . . . . . 15      TWInjeCT® . . . . . . . 39
tobramycin sulfate . . . . . 9           triamcinolone acetonide              TWInRIx® . . . . . . . . 35
tobrasol (ophthalmic) . . . . 9              (cream, lotion,
                                                                              TygACIL® . . . . . . . . . 9
TobRex (ointment) . . . . 9
          ®                                  ointment) . . . . . . . 30
                                                                              TykeRb® . . . . . . . . 17
tolazamide . . . . . . . . 21            triamcinolone acetonide in
                                             absorbase . . . . . . 30         TyPHIM® VI . . . . . . . 35
tolbutamide . . . . . . . . 21
                                         triamcinolone in orabase 26          TySAbRI® . . . . . . . . 34
tolmetin sodium . . . . . . 7
                                         triamterene/                         TyZekA® . . . . . . . . 19
topiramate . . . . . . . . 12
                                             hydrochlorothiazide . . 24       TyZIne® . . . . . . . . . 39
                                                      60
                 U                  VeSICARe® . . . . . . . 28         xoPenex®
                                    VexoL® . . . . . . . . . 37          (nebulizer solution) . . 39
u-cort . . . . . . . . . . . 27
                                    VFenD® . . . . . . . . . 15        xyReM® . . . . . . . . . 26
ULTRAM eR®

  (100mg 24-hour tablet,            VIbRAMyCIn® (syrup) . . 12
  200mg 24-hour tablet) . 8                                                          y
                                    VIDAZA® . . . . . . . . . 17
ULTRAM® eR                          VIDex® eC (125mg delayed           yAZ® . . . . . . . . . . . 32
  (300mg 24-hour tablet) 8             release capsule) . . . 20       yF-VAx® . . . . . . . . . 35
ULTRASe® . . . . . . . . 27         VIDex® Pediatric . . . . . 20
ULTRASe MT . . . . . . 27
             ®
                                    VIgAMox® (ophthalmic) . 11                       Z
unithroid . . . . . . . . . 32      VIMPAT® . . . . . . . . . 12       zaleplon . . . . . . . . . 39
URoxATRAL® . . . . . . 28           vinblastine sulfate . . . . 17     ZAnAFLex® (capsule) . . 19
ursodiol . . . . . . . . . . 27     vincasar PFS . . . . . . . 17      ZAnoSAR® . . . . . . . 16
                                    vincristine sulfate . . . . . 17   ZAnTAC® (50/50ml injection,
                 V
                                    vinorelbine tartrate . . . . 17      effervescent tablet,
VAgIFeM . . . . . . . . 32
          ®
                                    VIRACePT® (PoWDeR)           20      pack) . . . . . . . . . 28
VALCyTe . . . . . . . . 19
             ®
                                    VIRACePT® (tablet) . . . 20        ZAVeSCA®      . . . . . . . 27
valproate sodium . . . . . 12       VIRAMUne® (oral                    zazole (vaginal) . . . . . 15
valproic acid . . . . . . . 12         suspension). . . . . . 20       ZegeRID® . . . . . . . . 28
VALTRex® . . . . . . . . 20         VIRAMUne® (tablet) . . . 20        ZeLAPAR® . . . . . . . . 18
vanacet . . . . . . . . . . . 8     VIReAD® . . . . . . . . . 20       ZeMAIRA® . . . . . . . . 39
VAnCoCIn® HCL . . . . . 9           VISICoL® . . . . . . . . 41        ZeMPLAR®
                                    VIVeLLe-DoT® . . . . . 32            (2mcg/ml injection) . . 35
vancomycin HCl (injection) 9
                                    VIVoTIF® beRnA . . . . 35          ZeMPLAR® (5mcg/ml
vancomycin HCl
                                                                         injection, capsule) . . 35
   iso-osmotic dextrose . . 9       VyToRIn® . . . . . . . . 25
                                                                       zerlor . . . . . . . . . . . 15
vandazole (vaginal) . . . . 9
                                                                       ZeTIA® . . . . . . . . . . 25
VAnoS® (cream) . . . . . 30                       W
                                                                       ZIAgen® . . . . . . . . . 20
VAQTA® . . . . . . . . . 35         warfarin sodium . . . . . 22
                                                                       zidovudine . . . . . . . . 20
VARIVAx® . . . . . . . . 35         WeLCHoL® . . . . . . . 25
                                                                       ZInACeF®
VeCTIbIx® . . . . . . . . 18
                                                                          (750mg injection) . . . 10
veetids . . . . . . . . . . 11                     x                   ZInACeF® in Iso-osmotic
VeLCADe      ®
                 . . . . . . . 17                                         Dextrose . . . . . . . 10
                                    xALATAn® . . . . . . . . 36
velivet . . . . . . . . . . 32                                         ZInACeF® in Iso-osmotic
                                    xIbRoM® . . . . . . . . 37
venlafaxine HCl . . . . . 13                                              Diluent . . . . . . . . 10
                                    xIFAxAn® . . . . . . . . . 9
VenTAVIS® . . . . . . . 25                                             ZMAx® . . . . . . . . . . 11
                                    xoDoL® . . . . . . . . . . 8
VenToLIn® HFA . . . . . 39                                             ZoLInZA® . . . . . . . . 17
                                    xoLAIR® . . . . . . . . . 39
verapamil HCl . . . . . . 24                                           zolpidem tartrate . . . . . 39
                                    xoLegeL®       . . . . . . . 15
verapamil HCl ER . . . . 24                                            ZoMeTA® . . . . . . . . 35
                                    xoPenex® HFA . . . . . 39
                                                  61
ZoMIg® . . . . . . . . . 15     ZoSyn® In DexTRoSe               ZyLeT® . . . . . . . . . 37
ZoMIg® ZMT. . . . . . . 15        (2-0.25gm injection,           ZyMAR® (ophthalmic) . . 11
                                  3-0.375g injection) . . 11
zonisamide . . . . . . . . 12                                    ZyPRexA®      . . . . . . . 19
                                zovia . . . . . . . . . . . 32
ZoSTAVAx® . . . . . . . 35                                       ZyPRexA® ZyDIS . . . . 19
                                ZoVIRAx   ®
ZoSyn®                                                           ZyVox® (injection) . . . . 9
                                  (cream, ointment) . . . 20
  (3-0.375g injection) . . 11                                    ZyVox® (oral suspension,
                                ZyDone® . . . . . . . . . 8
                                                                   tablet) . . . . . . . . . . 9
                                ZyFLo® CR . . . . . . . 38
                                                                 Frequently Asked Questions


Q:   What is Fidelis SecureCare?
A:   Fidelis SecureCare is a Health Plan with a Medicare contract. The Fidelis SecureCare contract with
     CMS is renewed annually and coverage availability beyond the end of the current contract year is not
     guaranteed. By law, Fidelis SecureCare can choose not to renew its contract with CMS and CMS may
     refuse to renew the contract, thus resulting in a termination or non-renewal. This may result in
     termination of the beneficiaries’ enrollment in the plan. In addition, Fidelis SecureCare may reduce its
     service area and no longer offer services in the area where the beneficiary resides.

Q:   What number do I call if I have questions?
A:   If you have questions, please call Fidelis SecureCare Customer Service at 1-877-372-8085. TTY users
     should call 1-888-844-5530. We are open Monday through Friday from 8:00 AM to 6:00 PM. During
     Medicare’s Open Enrollment Election Period, Customer Service is open seven days a week, from 8:00
     AM to 8:00 PM.

     You may also contact 1-800-MEDICARE (1-800-633-4227), or visit http://www.medicare.gov for more
     information about Medicare benefits and services including general information regarding the health or
     Part D benefit.

Q:   Am I eligible to join Fidelis Secure Care?
A:   You are eligible to join Fidelis SecureCare (HMO) if:
        You are covered by Medicare Parts A and B.
        You live in our service area.
        You have not been diagnosed with End-Stage Renal Disease (ESRD, which is permanent kidney
        failure) and require regular dialysis at the time of your enrollment.
        You meet certain clinical criteria necessary to meet the Medicare Special Needs Plan for Institutional
        Beneficiaries, and/or you permanently reside in a nursing facility or assisted living facility for at
        least 90 days.

Q:   If I join Fidelis, do I have to pay my Medicare Part B premium?
A:   If you enroll with Fidelis SecureCare you must continue to pay your Medicare Part B premium. For
     those full dual eligible members whose premium is paid by the State, the Part B premium will continue
     to be covered by the State.

Q:   Can I have my plan premium taken out of my Social Security Check automatically?
A:   If you have a premium and decide to switch to premium withhold or moved from premium withhold to
     direct bill, it could take up to three months for it to take effect, and you will ultimately be held
     responsible for the premium.

Q:   Can I join Fidelis SecureCare and keep another Part D Plan?
A:   You can be in only one Medicare Advantage plan at a time. Enrollment in this plan will automatically
     end your enrollment in another Medicare health plan or prescription drug plan.


                                 A Health Plan with a Medicare Contract
                                                                   Frequently Asked Questions

Q:     Am I automatically a member of Fidelis SecureCare when I sign up?
A:     Your enrollment with Fidelis SecureCare is subject to approval by the Centers for Medicare & Medicaid
       Services (CMS). If your enrollment is not accepted by CMS we will notify you immediately.

Q:     When can I join or leave Fidelis SecureCare?
A:     Beneficiaries who qualify for "extra help"/ Low Income Subsidy (LIS) or meet the criteria for an
       institutional individual can change plans in any month of the year if they wish. This is known as the
       Special Enrollment Period.

Q:     Can I get help with my prescription drug costs?
A:     People with limited incomes may qualify for extra help to pay for their prescription drug costs. If
       eligible, Medicare could pay for seventy five (75) percent of drug costs including monthly prescription
       drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be
       subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and
       don’t even know it. For more information about this Extra Help, contact your local Social Security
       office or call 1-800-MEDICARE (1-800-633-4227), 24 hours per day, 7 days per week. TTY users
       should call 1-877-486-2048

Q:     Where can I read about Fidelis SecureCare’s performance?
A:     The Medicare program rates how well plan sponsors perform in different categories (for example,
       detecting and preventing illness, ratings from patients, patient safety and customer service). Information
       about Fidelis SecureCare’s ratings can be found at http://www.medicare.gov.

Q:     Do I have to use the Fidelis SecureCare network of doctors?
A:     You must use plan providers except in emergent or urgent care situation, or for out-of-area renal
       dialysis. If you obtain routine care from out-of-network providers neither Medicare nor Fidelis
       SecureCare will be responsible for these costs.

Q:     Can I get plan materials in another format?
A:     Please call Fidelis SecureCare Customer Service at 1-877-372-8085 for alternative formats of plan
       materials. TTY users should call 1-888-844-5530. We are open Monday through Friday from 8:00 AM
       to 6:00 PM. During Medicare’s Open Enrollment Election Period, Customer Service is open seven days
       a week, from 8:00 AM to 8:00 PM.


For full information on Fidelis SecureCare benefits, please call Fidelis SecureCare Customer Service at 1-877-
372-8085. TTY users should call 1-888-844-5530. We are open Monday through Friday from 8:00 AM to 6:00
PM. During Medicare’s Open Enrollment Election Period, Customer Service is open seven days a week, from
8:00 AM to 8:00 PM.




                                   A Health Plan with a Medicare Contract

								
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