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Medicare HMO Blue and Pharmacy Medicare PPO Blue Medical ... · e esgic plus® flexeril® e.e.s....
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• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • © 2006 Blue Cross and Blue Shield of Massachusetts, Inc. All rights reserved. Blue Cross and Blue Shield of Massachusetts, Inc. is an Independent Licensee of the Blue Cross and Blue Shield Association. 023 Posted: 1/9/06 Page 1 of 19 Medicare HMO Blue and Medicare PPO Blue Non-covered Drug List For Formulary Exception form see # 434 Pharmacy Medical Policy • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • BCBSMA maintains a formulary, or a list of covered drugs. This BCBSMA formulary applies to members of group and individual HMO and PPO Medicare Advantage plans with drug benefit. For a complete list of covered Medicare HMO Blue and Medicare PPO Blue medications, please visit our internet site at: http://www.bluecrossma.com/forSeniors/. If a patient has a medical basis for a non-covered drug In order to promote clinically appropriate and cost-effective prescription drug use, BCBSMA may require the use of a BCBSMA formulary drug prior to allowing benefit coverage for a non-formulary drug. Pharmacy benefits and coverage are generally not provided for non-formulary drugs because safe and effective prescription alternatives generally are available on the BCBSMA formulary. The BCBSMA formulary drugs are used and accepted by regulatory, medical and pharmacy communities. If allowed with Formulary Exception request, the non- formulary drug coverage will be at the highest copayment level and terms as the Plan allows. The non-formulary drug would also be ineligible for co-pay appeal. Clinical coverage criteria BCBSMA may authorize coverage for non-formulary prescription medications for a member who meets one of the following clinical criteria: • The member has documented treatment failure with a covered formulary drugs If the therapeutic class in which the non formulary drug belongs to has only one covered formulary drug, then documented treatment failure with only one covered formulary drug will be required; or • The member has documented adverse effects to a covered formulary drug, significant enough to preclude use of the covered formulary drug; or • There is some other specified clinical basis. You can request continued coverage of a non-covered drug through our formulary exception program for members when there is a medical basis for the member not being able to take any of the covered drugs from the same therapeutic class. You can obtain the Formulary Exception Form in one of three ways: • Call BCBSMA’s Fax-on-Demand service at 1-888-633-7654 and request document 434. • Visit our internet site, http://www.bluecrossma.com and click on “Pharmacy Program.” • Call us at 1-800-366-7778 and leave a message with your name and fax number. Then fax or mail the completed form to BCBSMA. We will respond to your request within two business days of receipt. Once we approve a formulary exception, you will not need to submit another exception form for the same therapy for that patient.
Transcript of Medicare HMO Blue and Pharmacy Medicare PPO Blue Medical ... · e esgic plus® flexeril® e.e.s....
• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • © 2006 Blue Cross and Blue Shield of Massachusetts, Inc. All rights reserved. Blue Cross and Blue Shield of Massachusetts, Inc. is an Independent Licensee of the Blue Cross and Blue Shield Association.
023 Posted: 1/9/06 Page 1 of 19
Medicare HMO Blue and Medicare PPO Blue Non-covered Drug List For Formulary Exception form see # 434
Pharmacy Medical Policy
• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •
BCBSMA maintains a formulary, or a list of covered drugs. This BCBSMA formulary applies to members of group and individual HMO and PPO Medicare Advantage plans with drug benefit. For a complete list of covered Medicare HMO Blue and Medicare PPO Blue medications, please visit our internet site at: http://www.bluecrossma.com/forSeniors/.
If a patient has a medical basis for a non-covered drug In order to promote clinically appropriate and cost-effective prescription drug use, BCBSMA may require the use of a BCBSMA formulary drug prior to allowing benefit coverage for a non-formulary drug. Pharmacy benefits and coverage are generally not provided for non-formulary drugs because safe and effective prescription alternatives generally are available on the BCBSMA formulary. The BCBSMA formulary drugs are used and accepted by regulatory, medical and pharmacy communities. If allowed with Formulary Exception request, the non-formulary drug coverage will be at the highest copayment level and terms as the Plan allows. The non-formulary drug would also be ineligible for co-pay appeal.
Clinical coverage criteria BCBSMA may authorize coverage for non-formulary prescription medications for a member who meets one of the following clinical criteria:
• The member has documented treatment failure with a covered formulary drugs If the therapeutic class in which the non formulary drug belongs to has only one covered formulary drug, then documented treatment failure with only one covered formulary drug will be required; or
• The member has documented adverse effects to a covered formulary drug, significant enough to preclude use of the covered formulary drug; or
• There is some other specified clinical basis.
You can request continued coverage of a non-covered drug through our formulary exception program for members when there is a medical basis for the member not being able to take any of the covered drugs from the same therapeutic class. You can obtain the Formulary Exception Form in one of three ways:
• Call BCBSMA’s Fax-on-Demand service at 1-888-633-7654 and request
document 434. • Visit our internet site, http://www.bluecrossma.com and click on
“Pharmacy Program.” • Call us at 1-800-366-7778 and leave a message with your name and fax
number.
Then fax or mail the completed form to BCBSMA. We will respond to your request within two business days of receipt. Once we approve a formulary exception, you will not need to submit another exception form for the same therapy for that patient.
Medicare Part D Non-covered Drug List, 023 (continued) Page 2 • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •
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Blue Cross Blue Shield of Massachusetts Clinical Pharmacy Department 1030 Hingham Street Rockland, MA 02370 Tel: 1-800-366-7778 Fax: 1-866-463-7700
Medicare HMO Blue and Medicare PPO Blue Non-Covered Drug List
A AEROKID™ ALFENTA® ABBOKINASE® AGGRASTAT® ALIMTA® ABELCET® AGGRENOX™ ALLCLENZ® ABRAXANE® AGRYLIN ® ALLEGRA® ACCUHIST DM® AGRYLIN® ALLEGRA-D 12 HOUR® ACCUHIST LA® AH-CHEW D® ALLEGRA-D 24 HOUR® ACCUHIST PDX® AH-CHEW II® ALLERX-D™ ACCUHIST® AH-CHEW® ALLERX™ ACCUPRIL® AHIST® ALLFEN C® ACCURETIC™ A-HYDROCORT® ALLFEN JR® ACCUTANE® AIRET® ALLFEN® ACCUZYME™ AK-CIDE® ALLFEN-DM® ACD-A® AKINETON® ALOCRIL™ ACEON® AKNE-MYCIN® ALOMIDE® ACID JELLY® ALACOL® ALORA® ACIPHEX® ALA-CORT® ALOXI® ACLOVATE® ALAMAST® ALPHAGAN P® ACTHAR H.P.® ALA-QUIN® ALPHANATE® ACTHREL® ALA-SCALP HP® ALPHANINE SD® ACTIGALL® ALA-TET® ALPHATREX® ACTIMMUNE® ALBA-3® ALREX® ACTIVASE® ALBALON® ALTACE® ACTIVELLA™ ALBATUSSIN CF® ALTAFLUOR® ACTOPLUS MET® ALBATUSSIN DM® ALTOPREV® ACTOS® ALBATUSSIN NN® ALUPENT® ACUFLEX® ALBATUSSIN PEDIATRIC® AMARYL® ACULAR LS™ ALBATUSSIN SR F® AMBI 5/15/100® ACULAR PF® ALBATUSSIN SR SENIOR® AMBI 60/580/30® ACULAR® ALBATUSSIN SR® AMBI 60-580® ACUNOL® ALBATUSSIN® AMBI 80/700® ADAGEN® ALBATUSSIN-NN® AMBIFED-G DM® ADALAT CC® ALBUMINAR-25® AMBIFED-G® ADDERALL XR® ALBUMINAR-5® AMBISOME® ADDERALL® ALCAINE® AMERGE® ADENOCARD IV® ALCORTIN™ AMERIFED DM® ADENOCARD® ALDACTAZIDE® AMERIFED® ADENOSCAN® ALDACTONE® AMERITUSS AD™ ADIPEX-P® ALDEX G® A-METHAPRED® ADOXA PAK® ALDEX™ AMEVIVE® ADOXA® ALDOCLOR-250® AMICAR® ADRENALIN CHLORIDE NASAL® ALDOMET® AMIDAL®
Medicare Part D Non-covered Drug List, 023 (continued) Page 3 • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •
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ADRENALIN CHLORIDE® ALDORIL-25® AMIKIN PEDIATRIC® ADRIAMYCIN RDF® ALDORIL-D50® AMIKIN® ADVATE® AHIST® AMINESS® ADVICOR™ A-HYDROCORT® AMINO-CERV®
AEROBID® AIRET® AMINOSYN II 3.5%/DEXTROSE 5%®
AEROBID-M® AK-CIDE® AMINOSYN II® AEROHIST™ ALESSE-28® AMINOSYN M® AMINOSYN® ARGATROBAN® BACTRIM DS® AMINOSYN-HBC® ARISTOCORT A® BACTRIM® AMINOSYN-PF® ARISTOCORT FORTE® BACTROBAN NASAL® AMINOSYN-RF® ARISTOCORT HP® BACTROBAN® AMMONUL® ARISTOCORT® BAL IN OIL®
AMOXIL® ARISTOSPAN PARENTERAL® BALACET 325®
AMPHOCIN® ARISTOSPAN® BALAMINE DM® AMPHOTEC® ARMOUR THYROID™ BALTUSSIN™ AMVISC PLUS® ARTHROTEC 50® BANCAP HC™ AMVISC® ARTHROTEC 75® BARBIDONNA® AMYTAL SODIUM® ASTRAMORPH® BAROS GRANULES® ANADROL-50® ASTRAMORPH-PF® BAYGAM® ANAFRANIL® ASTRINGYN® BAYHEP B® ANALPRAM-HC® ATABEX® BAYHEP B® ANAMANTLE HC FORTE® ATACAND HCT® BAYRAB® ANAMANTLE HC® ATACAND® BEBULIN VH IMMUNO® ANANA FORTE® ATGAM® BECONASE AQ® ANAPLEX DM® ATIVAN® BECONASE® ANAPLEX DMX® ATROVENT SOLUTION® BENADRYL STERI-DOSE® ANAPLEX HD® ATROVENT SPRAY® BENADRYL®
ANAPROX DS® ATTENUVAX VACCINE W/DILUENT® BENEFIX®
ANAPROX® ATUSS DR® BENSAL HP® ANASPAZ® ATUSS G® BENTYL® ANCEF® ATUSS HC® BENZAC AC® ANDEHIST DM® ATUSS HX® BENZAC W 10® ANDRODERM® ATUSS MR® BENZAC W 2.5® ANDROGEL® ATUSS MS® BENZAC W WASH® ANDROID® ATUSS NX® BENZACLIN® ANECTINE® ATUSS-12 DM® BENZAGEL WASH® ANEMAGEN OB® ATUSS-12 DX® BENZAGEL-10® ANERGAN 50® AUGMENTIN ES-600® BENZAGEL-5® ANESTACON® AUGMENTIN XR® BENZAMYCIN® ANGIOMAX® AUGMENTIN® BENZAMYCINPAK® ANSAID® AUTOPLEX T® BENZASHAVE® ANTARA® AVAGE® BENZOTIC™ ANTIBIOTIC HC® AVAR® BETAGAN® ANTIVENIN POLYVALENT® AVAR-E® BETAPACE AF™ ANTIVERT/25® AVASTIN® BETAPACE® ANTIVERT® AVC™ BETATAN® ANTIZOL® AVELOX ABC PACK® BETAVENT® ANUSOL-HC® AVELOX IV® BETIMOL® ANZEMET® AVELOX® BETOPTIC S®
Medicare Part D Non-covered Drug List, 023 (continued) Page 4 • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •
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APEXICON E® AVENTYL HCL® BEXXAR® APEXICON® AVINZA® BIAFINE RE® APHRODYNE® AVITA® BIAFINE® APHTHASOL™ AVODART® BIAXIN XL® APLISOL® AXERT® BIAXIN® APOKYN® AXID® BICHLORACETIC ACID® APRESOLINE® AXOCET® BICILLIN C-R® AQUACHLORAL® AYGESTIN® BICILLIN L-A®
AQUA-MEPHYTON® AZACTAM/ISO-OSMOTIC DEXTROSE® BICITRA®
AQUAPHILIC W/TRIAMCINOLONE® AZACTAM® BICNU® AQUATAB C® AZASAN® BIDEX DM™ AQUATAB D® AZELEX® BIDEX™ AQUATAB DM® AZMACORT® BIDIL® ARALEN PHOSPHATE® AZOPT® BILTRICIDE® ARAMINE® AZULFIDINE® BIOHIST-LA®
ARAVA™ B BIONECT® AREDIA® B & O SUPPRETTES ® BIO-STATIN® ARESTIN® BACTOCILL® BIO-THROID® BLENOXANE® CANCIDAS® CERUMENEX® BLEPH-10® CANTIL® CERVIDIL™ BLEPHAMIDE S.O.P.® CAPASTAT SULFATE® CETACAINE® BLEPHAMIDE® CAPEX SHAMPOO® CETACORT® BLOCADREN® CAPHOSOL® CETAPRED® BONIVA® CAPITAL W-CODEINE® CETROTIDE® BOOSTRIX® CAPITROL® CHLORDEX GP® BRANCHAMIN® CAPOTEN® CHLOROMYCETIN® BRETHINE® CAPOZIDE® CHOLEODORON® BREVITAL SODIUM® CARAC® CHROMIUM CHLORIDE® BREVOXYL-4® CARAFATE TABLET® CILOXAN® BREVOXYL-8® CARBAPHEN 12 PED® CINNABAR 20X/PYRITE 3X® BRIGHT BEGINNINGS PRENATAL® CARBAPHEN 12® CIPRO XR® BROFED® CARBATROL® CIPRO® BROMFED® CARBATUSS-CL® CIPRO® BROMFED-DM® CARBA-XP® CIPRODEX® BROMFED-PD® CARBOCAINE® CITRACAL PRENATAL RX®
BROMHIST® CARBOXINE-PSE® CITRATE PHOSPHATE DEXTROSE®
BROMPHED-PD® CARDENE I.V.® CITROLITH® BRONCAP® CARDENE SR® CLAFORAN GALAXY® BRONCHOLATE® CARDENE® CLAFORAN® BRONCODUR™ CARDIODORON® CLARINEX® BRONCOMAR GG® CARDIZEM CD® CLARINEX-D 24 HOUR® BRONCOMAR-1® CARDIZEM LA® CLEOCIN CAPSULE® BRONCOPECTOL® CARDIZEM SR® CLEOCIN T® BRONCOTRON-D™ CARDIZEM® CLEOCIN TABLET® BRONDIL® CARDURA® CLIMARA PRO™
BRONKOPHYLLINE GG® CARIMUNE NF NANOFILTERED® CLIMARA®
BRONKOSOL® CARIMUNE® CLINAC BPO®
Medicare Part D Non-covered Drug List, 023 (continued) Page 5 • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •
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BRONTEX® CARMOL 40® CLINDAGEL™ BRONTUSS SF® CARMOL HC® CLINDAMAX™ BROVEX CT™ CARMOL SCALP® CLINDESSE® BROVEX HC™ CARNITOR® CLINDETS™ BROVEX SR® CATAFLAM® CLINISOL® BROVEX-D® CATAPRES® CLINORIL® BROVEX™ CATAPRES-TTS 1® CLOBEVATE™ BUCALCIDE® CATAPRES-TTS 2® CLOBEX® BUCALSEP® CATAPRES-TTS 3® CLODERM® BUMEX® CATHFLO ACTIVASE® CLOMID® BUMINATE W/ADMINISTRATION SET® CAVIRINSE® CLORFED® BUMINATE® CEBOCAP #1® CLORPRES™ BUPRENEX® CEBOCAP #2® CLOZARIL® BUPRENORPHINE HCL® CEBOCAP #3® CODICLEAR DH® BUSPAR® CECLOR® CODIMAL DH® BUSULFEX® CEDAX® CODIMAL LA® BUTISOL SODIUM® CEFIZOX® CODIMAL-A® C CEFOTAN® COGENTIN® CADUET® CEFTIN TABLET® COGNEX® CAFERGOT TABLET® CEFTRIAXONE SODIUM® COLAZAL™ CALAN SR® CEFZIL® COLDAMINE® CALAN® CELESTONE® COLDEC DS™ CALCIBIND® CELEXA® COLESTID® CALCIJEX® CENESTIN™ COLOCORT™ CALCIUM DISODIUM VERSENATE® CENOCORT A-40® COLREX COMPOUND®
CALCON 1® CENOCORT FORTE SUSPENSION® COLY-MYCIN M PARENTERAL®
CALPHOSAN® CENOLATE® COLY-MYCIN S®
CAMPATH® CENTANY™ COLYTE WITH FLAVOR PACKETS®
CAMPTOSAR® CERTUSS® COLYTE® CANASA® CERTUSS-D® COMBIPATCH® COMBUNOX® DALMANE® DEXACEN LA-8® COMHIST® DANOCRINE® DEXACIDIN® COMPAZINE® DANTRIUM® DEXEDRINE® CONDYLOX SOLUTION® DAPTACEL® DEXPAK™ CONEX® DARVOCET A500™ DEXTROSE 10%-1/4NS-KCL®
CONPEC L.A.® DARVOCET-N 100® DEXTROSE 5%-ELECTROLYTE #48®
CONPEC® DARVOCET-N 50® DEXTROSE 5%-ELECTROLYTE #75®
CONTROL RX® DARVON COMPOUND-65® DEXTROSTAT® COPHENE-B® DARVON® D-FEDA II® CORDARONE I.V.® DARVON-N® DIABETA® CORDARONE® DAUNOXOME® DIABINESE® CORDRAN SP® DAYPRO® DIALYTE LM W/DEXTROSE 1.5%® CORDRAN® DAYTO-HIMBIN® DIAMOX SEQUELS® CORDRON-D® DAYTO-SULF® DIANEAL W/1.5% DEXTROSE®
CORDRON-DM® DDAVP TABS, SOL., NASAL SPRAY® DIFFERIN®
Medicare Part D Non-covered Drug List, 023 (continued) Page 6 • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •
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CORDRON-HC® DECADRON® DIFIL-G FORTE® CORGARD® DECAHIST-DM® DIFIL-G® CORLOPAM® DECAVAC® DIFLUCAN IN DEXTROSE® CORMAX® DECLOMYCIN® DIFLUCAN IN SALINE® CORTEF® DECONAMINE CX® DIFLUCAN® CORTIFOAM® DECONAMINE SR® DIGEX® CORTISPORIN® DECONAMINE® DIGIBIND® CORTISPORIN-TC® DECONEX™ DILACOR XR® CORTROSYN® DECON-G® DILATRATE-SR® CORVERT® DECONSAL II® DILAUDID® CORZIDE® DEKA® DILAUDID-5® COSMEGEN® DELATESTRYL® DILAUDID-HP® COTAZYM® DELESTROGEN® DILEX-G 200®
COVERA-HS® DELFLEX W/2.5% DEXTROSE® DILEX-G 400®
COZAAR® DELFLEX W/4.25% DEXTROSE® DILEX-G®
CRATAEGUS® DEL-MYCIN® DIPRIVAN® CREON 10® DELTUSS DMX® DIPROLENE AF® CREON 20® DEMADEX® DIPROLENE® CREON 5® DEMULEN 1/35-28® DIPROSONE® CRESTOR® DEMULEN 1/50-21® DISALCID® CRESYLATE® DEMULEN 1/50-28® DISPERMOX™ CRINONE® DEPACON® DITROPAN XL® CROFAB® DEPAKENE® DITROPAN® CROLOM® DEPEN® DIURIL SODIUM® CUBICIN® DEPOCYT® DIURIL® CUPRIC SULFATE® DEPO-ESTRADIOL® DMAX® CUTIVATE® DEPO-MEDROL® DOBUTREX® CYCLESSA® DEPO-PROVERA® DOLGIC LQ® CYCLOCORT® DEPO-TESTOSTERONE® DOLGIC PLUS® CYCLOGYL® DERMA-CAS® DOLOBID® CYCLOMYDRIL™ DERMA-SMOOTHE/FS® DOMEBORO® CYKLOKAPRON® DERMATOP® DOMETUSS DM™ CYLERT® DESFERAL MESYLATE® DONATUSSIN DC® CYSTOSPAZ® DESFERAL® DONATUSSIN® CYSTOSPAZ-M® DESOGEN® DONNAMAR® CYTOGAM® DESOWEN® DONNATAL®
CYTOTEC® DESPEC DM® DOPAMINE HCL ADDITIVE SYRINGE®
CYTOVENE® DESPEC SR® DORAL® CYTOXAN LYOPHILIZED® DESPEC® DORYX® CYTOXAN® DESQUAM-E® DOSTINEX® D DESQUAM-X 10® DRISDOL® D.H.E.45® DESQUAM-X 5® DRITHO-SCALP® DALLERGY® DESQUAM-X® DRIZE-R® DALLERGY-JR® DESYREL® DROCON-CS® DROXIA® ELIXOPHYLLIN-KI® EVOCLIN® DRYSOL DAB-O-MATIC® ELLENCE™ EVOXAC™ DRYSOL® ELMIRON® EXACTACAIN® DTIC-DOME IV® ELOCON® EXCOF® DUAC™ ELOXATIN™ EXCOF-SF®
Medicare Part D Non-covered Drug List, 023 (continued) Page 7 • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •
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DUET DHA STUARTNATAL® ELSPAR® EXELDERM® DUET DHA® EMADINE® EXODERM® DUET STUART NATAL® EMCIN CLEAR® EXTENDRYL JR® DUET STUARTNATAL® EMERSAL® EZOL™
DUOTAN® EMGEL® F DURABAC® EMLA® FACTIVE® DURACLON® E-MYCIN® FACTREL® DURADEX® ENABLEX® FAMVIR® DURAFLU™ ENDAGEN HD™ FANSIDAR® DURAGESIC® ENDAL HD® FAZACLO™ DURAHIST PE™ ENDAL-HD PLUS® FEIBA VH IMMUNO® DURAHIST™ ENDO-AVITENE® FELDENE® DURAMORPH® ENDRATE® FEMHRT® DURAPHEN DM™ ENDURON® FEMRING™ DURAPHEN FORTE® ENDURONYL FORTE® FEMTRACE® DURAPHEN II DM® ENLON® FENESIN® DURAPHEN II® ENTEX ER® FERTINEX™ DURATAN DM® ENTEX HC® FETRIN® DURATUSS DM® ENTEX LA® FINACEA™ DURATUSS GP® ENTEX PSE® FIORICET W/CODEINE® DURATUSS HD® ENTEX® FIORICET® DURATUSS® EPIFOAM® FIORINAL W/CODEINE #3® DURAXIN® EQUAGESIC® FIORINAL® DURICEF® ERBITUX® FIRST-HYDROCORTISONE® DYAZIDE® ERGOMAR® FIRST-MOUTHWASH BLM® DYNABAC® ERTACZO™ FIRST-PROGESTERONE MC 10® DYNACIN® ERYC® FIRST-PROGESTERONE MC 5®
DYNACIRC CR® ERYCETTE® FIRST-PROGESTERONE VGS 100®
DYNACIRC® ERYDERM® FIRST-PROGESTERONE VGS 200®
DYNAPEN® ERYGEL® FIRST-PROGESTERONE VGS 50® DYNATUSS HCG® ERYPED 200® FIRST-TESTOSTERONE MC® DYNEX HD® ERYPED 400® FIRST-TESTOSTERONE® DYNEX™ ERYPED® FLAGYL 375® DYRENIUM® ERYSIDORON 1® FLAGYL ER® DYTAN® ERYSIDORON 2® FLAGYL®
DYTAN-CS® ERYTHROCIN LACTOBIONATE® FLAREX®
DYTAN-D® ESCLIM® FLEBOGAMMA® E ESGIC PLUS® FLEXERIL® E.E.S. 200® ESGIC® FLEXTRA® E.E.S. 400® ESGIC-PLUS® FLEXTRA-650® EASPRIN® ESTRACE TABLET® FLEXTRA-DS® EC-NAPROSYN® ESTRADERM® FLOLAN® ECONOPRED PLUS® ESTRASORB® FLONASE® ED-A-HIST DM® ESTRATEST H.S.® FLOR-DAC® ED-DM® ESTRATEST® FLORINEF ACETATE® EDECRIN SODIUM® ESTRING® FLOXIN I.V.® EDECRIN® ESTRO-5® FLOXIN TABLET® EFUDEX SOLUTION® ESTROGEL® FLUARIX®
Medicare Part D Non-covered Drug List, 023 (continued) Page 8 • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •
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ELDEPRYL® ESTROSTEP FE® FLUCAINE® ELESTAT™ ETHAMOLIN® FLUDARA® ELIMITE® ETHYOL® FLUMADINE® ELITEK® EUDAL-SR® FLUMIST® ELIXOPHYLLIN GG® EUFLEXXA® FLUORABON BASIC™ ELIXOPHYLLIN® EULEXIN® FLUORABON™ FLUORACAINE® GENTAFAIR® HISTEX CT™ FLUORETS® GENTEX LA® HISTEX HC™ FLUORI-METHANE® GENTEX LQ® HISTEX IE™ FLUOR-OP® GEREF DIAGNOSTIC® HISTEX PD 12™ FLURA-DROPS® GFN 1000/DM 50® HISTEX PD™ FLURA-TAB® GFN 550/PSE 60/DM 30® HISTEX SR™ FLURATE® GFN 550/PSE 60® HISTEX® FLURESS® GILCHEW IR® HISTOR-D® FLURO-ETHYL® GILPHEX TR™ HISTUSSIN D® FLUTUSS HC® GILTUSS HC™ HISTUSSIN HC® FML FORTE® GILTUSS PED-C™ HMS®
FML S.O.P.® GILTUSS PEDIATRIC™ HONEY BEE VENOM TREATMENT KIT®
FML® GILTUSS TR™ HONEY BEE VENOM® FML-S® GILTUSS™ HUMATE-P® FOCALIN® GLUCAGEN® HUMATIN® FORADIL® GLUCOPHAGE XR® HUMATROPE® FORMADON® GLUCOPHAGE® HUMIBID DM® FORMALYDE-10® GLUCOTROL XL® HUMIBID L.A.® FORMA-RAY® GLUCOTROL® HUMORSOL® FORTAMET® GLUCOVANCE® HYALGAN® FORTAZ IN ISO-OSMOTIC DEXTROSE® GLYNASE® HYATE:C® FORTAZ® GLYSET® HYCAMTIN® FORTAZ® GOLYTELY® HYCET™ FOSCAVIR® GONAL-F RFF® HYCODAN® FRAGMIN® GONAL-F® HYCOMINE COMPOUND® FREAMINE III® GONIOSOL® HYCOTUSS® FRENADOL® GORDOFILM® HYDREA® FROVA™ GORDO-UREA® HYDRO PC II™ FRUCTOSE IV® GRANULEX® HYDRO PRO® FULVICIN U/F® GRIFULVIN V® HYDROCET® FURACIN® GUAIFED® HYDRO-TUSSIN DM ™ FUROXONE® GUAIFED-PD® HYPERHEP S/D® G GUAIMAX-D® HYPERLYTE CR® GABARONE® GYNAZOLE-1® HYPERLYTE R®
GAMASTAN S/D® H HYPERLYTE® GAMASTAN S/D® H 9600 SR® HYPERRAB S/D® GAMMAGARD LIQUID® HALCION® HYPERRHO S/D®
GAMMAGARD S/D® HALDOL DECANOATE 100® HYPERSTAT I.V.®
GAMMAR-P I.V.® HALDOL DECANOATE 50® HYPERTETS/D® GAMUNEX® HALDOL® HYTONE®
GANIRELIX ACETATE® HALFLYTELY WITH FLAVOR PACKS® HYTRIN®
GARAMYCIN® HALFLYTELY® HYZAAR®
Medicare Part D Non-covered Drug List, 023 (continued) Page 9 • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •
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GARYLIN® HALOG® I GASTRINEX® HEALON GV® IB-STAT® GELCLAIR® HEALON® ICAR PRENATAL® GELFILM® HELIDAC® ICAR-C PLUS® GELFOAM COMPRESSED® HELIXATE FS® IDAMYCIN PFS® GELFOAM PACKS® HEMABATE® IFEX/MESNEX® GELFOAM PROSTATECTOMY CONES® HEMOFIL-M® IFEX® GELFOAM® HEPATAMINE® ILOPAN INJECTION® GEMZAR® HEPATASOL® IMDUR® GENARC® HERCEPTIN® IMODIUM® GENELAN® HEXAFED® IMOGAM RABIES-HT® GENEPATUSS® HEXAFLU® IMOVAX RABIES VACCINE® GENEXPECT DM™ HIPREX® IMOVAX RABIES VACCINE® GENEXPECT-PE™ HISTADE MX® IMURAN® GENEXPECT-SF™ HISTALET® INDERAL® GENOPTIC S.O.P.® HISTATAB PLUS® INDERIDE-40/25®
GENOPTIC® HISTATROL INTRADERMAL® INDERIDE-80/25®
INDOCIN I.V.® KEMADRIN™ LEVACET® INDOCIN SR® KENALOG IN ORABASE® LEVALL G® INDOCIN® KENALOG® LEVALL® INFANRIX® KENALOG-10® LEVALL-12® INFLAMASE FORTE® KENALOG-40® LEVATOL® INFLAMASE MILD® KERALAC® LEVBID® INFLUDO® KERLONE® LEVLEN 28® INFUMORPH® KETALAR® LEVLITE-28™ INNOHEP® KETEK PAK® LEVO-DROMORAN® INNOPRAN XL® KETEK™ LEVOPHED BITARTRATE® INPERSOL W/4.25% DEXTROSE® KEY-PRED 25® LEVSIN/SL® INTAL SOLUTION® KEY-PRED® LEVSIN® INTEGRILIN® KIONEX® LEVSINEX® INTROL® KLARON® LEVULAN® INVANZ® KLONOPIN® LEXAPRO® INVERSINE® K-LOR® LEXXEL® IODOFLEX® KLOR-CON/25® LIBRAX® IODOPEN® KLOTRIX® LIBRIUM® IODOSORB® K-LYTE DS® LIDAMANTLE HC™ IOPIDINE® K-LYTE/CL® LIDAMANTLE™ IRRIGATING SOLUTION G® K-LYTE® LIDEX® ISMO™ KOATE-DVI® LIDEX-E® ISOCHRON® KOGENATE FS® LIMBITROL DS® ISOLYTE E® KOVIA® LIMBITROL® ISOLYTE G W/DEXTROSE® K-PHOS NEUTRAL® LIMBREL® ISOLYTE H W/DEXTROSE® KRISTALOSE™ LINCOCIN® ISOLYTE S® KRONOFED-A® LIORESAL INTRATHECAL® ISOPTIN SR® KRONOFED-A-JR® LIORESAL®
Medicare Part D Non-covered Drug List, 023 (continued) Page 10 • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •
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ISOPTO ATROPINE® K-TAB® LIQUIBID® ISOPTO CARBACHOL® KURIC® LIQUIBID-D 1200® ISOPTO CARPINE® KUTRASE® LIQUIBID-D® ISOPTO HOMATROPINE® KU-ZYME HP® LIQUIBID-PD® ISOPTO HYOSCINE® KU-ZYME® LIQUID PRENATAL VITAMIN® ISORDIL® KWELCOF® LITHOSTAT® ISOVEX® KYTRIL® LIVOSTIN®
ISTALOL™ L LO/OVRAL-21® ISUPREL® LAC-HYDRIN® LO/OVRAL-28® IVEEGAM EN® LACLOTION® LO/OVRAL-8® J LACRISERT® LOCOID® JAYCOF-HC™ LACTICARE-HC® LODINE XL® JAYCOF™ LACTINOL® LODINE® JAYCOF-XP™ LACTINOL-E® LODRANE 24® JE-VAX® LACTOCAL-F® LODRANE D® J-MAX® LAGESIC® LODRANE XR®
J-TAN D® LAMISIL CREAM, SOLUTION® LODRANE®
J-TAN® LAMPRENE® LOESTRIN FE® JUST FOR KIDS® LANOXICAPS® LOESTRIN® K LANOXIN PEDIATRIC® LOFIBRA™ KADIAN® LANOXIN® LOKARA™ KAOCHLOR® LANZATUSS-N.F® LOMOTIL® KAOCHLOR-EFF® LARIAM® LONITEN® KAON® LARTUS® LOPID® KAON-CL® LASIX® LOPRESSOR HCT® KAY CIEL® LAZERFORMALYDE® LOPRESSOR® KAYEXALATE® LEMOHIST PLUS® LOPROX® K-DUR® LEMOTUSSIN-DM® LORCET 10/650® KEFLEX® LESCOL XL® LORCET HD® KEFTAB® LESCOL® LORCET PLUS® KEFZOL® LEUSTATIN® LORCET-HD®
LORTAB® MAXI-TUSS DM® MINTUSS MR ™ LORTUSS DM™ MAXI-TUSS HC® MIRALAX® LORTUSS HC™ MAXI-TUSS HCG® MIRCETTE® LOTEMAX™ MAXI-TUSS HCX™ MIRENA® LOTENSIN HCT® MAXZIDE® MITHRACIN®
LOTENSIN® MAXZIDE-25MG® MIXED VESPID VENOM PROTEIN KIT®
LOTRIMIN® M-CLEAR JR® MIXED VESPID VENOM PROTEIN®
LOTRISONE® MEBARAL® M-M-R II VACCINE W/DILUENT® LOXITANE® MEDENT DM™ M-M-R II VACCINE W/DILUENT® LOZOL® MEDENT LD™ M-M-R II® LUFYLLIN® MEDROL® MOBIC® LUFYLLIN-400® MEFOXIN® MODICON® LUFYLLIN-GG® MEGACE® MODURETIC® LUMINAL SODIUM® MENACTRA® MONARC-M® LUNELLE® M-END DM® MONISTAT DUAL-PAK® LUPRON® M-END MAX® MONISTAT®
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LUSONAL® MENOMUNE-A/C/Y/W W/DILUENT VL® MONISTAT-DERM®
LUSONEX™ MENOMUNE-A/C/Y/W-135® MONOCLATE-P®
LUTREPULSE® MENOSTAR™ MONODOX® LUXIQ® MENTAX® MONOKET®
LYRICA® MEPROBAMATE W/ASPIRIN® MONONINE®
M MERREM® MONOPRIL HCT®
M.T.E.-4® MERUVAX II VACCINE W/DILUENT® MONOPRIL®
MACROBID® MESCOLOR® MONUROL® MACRODANTIN® MESNA® MOTOFEN® MACUGEN® MESTINON TABLETS® MOTRIN® MAGAN® METAGLIP® M-R-VAX II VACCINE W/DILUENT® MANDELAMINE HAFGRAMS® METOPIRONE® MS CONTIN® MANDELAMINE® METRO IV® MSIR® MANDOL® METROCREAM® MUCOMYST® MARCAINE SPINAL® METROGEL® MUCOMYST-10® MARCAINE W/EPINEPHRINE® METROGEL-VAGINAL® MULTILYTE-20® MARCAINE® METROLOTION® MULTILYTE-40®
MARINOL® MEVACOR® MUMPSVAX VACCINE W/DILUENT®
MARNATAL F® MEXITIL® MUROCOLL-2® MARNATAL-F PLUS® MICARDIS HCT® MUSE® MAR-SPAS® MICARDIS® MUSTARGEN® MATERNA® MICRHOGAM® MUTAMYCIN® MAVIK® MICRO-K 10® M-VIT® MAX HC® MICRO-K® MYAMBUTOL® MAXAIR AUTOHALER® MICRONASE® MYCELEX® MAXALT MLT™ MICRONOR® MYCOLOG II® MAXALT® MICROZIDE® MYCOSTATIN® MAXAQUIN® MIDAMOR® MYDFRIN® MAXIDEX® MIDRIN® MYDRIACYL® MAXIDONE™ MIGRALAM® MYLOCEL® MAXIFED DM® MIGRANAL® MYLOTARG® MAXIFED DMX® MIGRATEN® MYOBLOC™ MAXIFED® MILTOWN® MYSOLINE® MAXIFED-G® MILTUSS-EX™ MYTELASE® MAXIFLOR® MIMYX® MYTREX®
MAXINATE® MINDAL® N MAXIPHEN ADT® MINIPRESS® NABI-HB® MAXIPHEN DM® MINIRIN® NABI-HB® MAXIPHEN G® MINITRAN® NAFCILL IN DEXTROSE® MAXIPHEN® MINIZIDE 1® NAFTIN® MAXIPHEN-G DM® MINIZIDE 2® NAGLAZYME® MAXIPIME® MINIZIDE 5® NALEX DH® MAXITROL® MINOCIN® NALFON® NALLPEN IN DEXTROSE® NORDETTE-28® OGEN® NALLPEN/ISO-OSMOTIC NORDETTE-8® OLUX®
Medicare Part D Non-covered Drug List, 023 (continued) Page 12 • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •
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DEXTROSE® NALLPEN® NOREL LA® OMNICEF® NAPRELAN® NOREL SD® OMNIHIST II LA® NAPROSYN® NOREL SR® OMNII MED® NARCAN MULTIPLE DOSE® NORFLEX™ ONCASPAR® NARCAN® NORGESIC FORTE™ ONTAK® NAROPIN® NORGESIC™ OPHTHETIC® NASACORT AQ® NORINYL 1+35® OPIUM® NASACORT® NORINYL 1+50® OPTINATE® NASAREL® NORITATE® OPTIPRANOLOL® NASCOBAL® NORMODYNE® OPTIVAR®
NASOP® NORMOSOL-M AND DEXTROSE® ORACIT®
NATACHEW™ NORMOSOL-R PH 7.4® ORAGRAFIN SODIUM® NATAFORT® NORMOSOL-R® ORAMAGICRX™ NATALCARE RX® NOROXIN® ORAPRED® NATALVIT® NORPACE CR® ORATUSS® NATELLE C® NORPACE® ORGANIDIN NR® NATELLE PREFER® NORPRAMIN® ORTHO MICRONOR® NATELLE® NOR-QD® ORTHO TRI-CYCLEN LO® NATELLE-EZ® NOTUSS PD® ORTHO TRI-CYCLEN® NATRECOR® NOTUSS® ORTHO-CEPT® NATURETIN-5® NOVAMINE® ORTHOCLONE OKT-3® NAVANE® NOVANATAL® ORTHO-CYCLEN® NAVELBINE® NOVANTRONE® ORTHO-EST® ND-GESIC® NOVASAL® ORTHO-NOVUM® NEBCIN IN DEXTROSE® NOVASTART® ORTHO-PREFEST® NEGGRAM® NOVOCAIN® ORTHOVISC® NEMBUTAL SODIUM® NOVOSEVEN® ORUDIS® NEO-FRADIN® NUBAIN® ORUVAIL® NEORAL® NUCOFED® OSMOGLYN® NEOSAR® NUHIST® OTILAM® NEOSAR® NULEV® OTN PAMIDRONATE® NEOSPORIN G.U. IRRIGANT®
NULYTELY WITH FLAVOR PACKS® OTOCAIN®
NEOSPORIN® NULYTELY™ OTOGESIC® NEO-SYNEPHRINE® NUMOBID DX® OVACE™ NEOTUSS-D® NUMOBID® OVCON-35® NEPTAZANE® NUMONYL DX® OVCON-50® NESACAINE® NUMONYL PEDIATRIC® OVIDE® NESACAINE-MPF® NUMONYL SR® OVIDREL® NESTABS CBF® NUMONYL® OVRAL-21® NESTABS FA® NUMORPHAN® OVRAL-28® NEURONTIN® NUOX® OVRAL-4® NEUT® NUTRACARE® OVRETTE® NEUTREXIN® NUTRACORT® OXALIS® NEXAVIR® NUVARING® OXANDRIN® NEXIUM® NUZON® OXISTAT® NIACOR® NYDRAZID® OXSORALEN®
NICOTROL NS® O OXSORALEN-ULTRA® NICOTROL® OB COMPLETE® OXYCEL®
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NIFEREX-PN FORTE® OBSTETRIX EC® OXYCONTIN® NIPENT® OBSTETRIX-100® OXYFAST® NITRO-DUR® OBTREX® OXYIR® NITROLINGUAL® O-CAL FA® OXYTROL™
NITROSTAT® O-CAL PRENATAL® P NIZORAL® OCL® P.T.E.-5® NOLVADEX® OCUFEN® PAIN EASE® NORCO® OCUFLOX® PALGIC DS® NORDETTE-21® OCUTRICIN® PALGIC® PAMELOR® PEPCID RPD® PODOCON-25® PAMINE FORTE® PEPCID® POLOCAINE® PAMINE® PERCOCET® POLY HIST DM® PANAFIL® PERCODAN® POLY HIST FORTE® PANAFIL-WHITE® PERCOLONE® POLY HIST PD® PANATUSS DXP® PERIDEX® POLYCITRA® PANATUSS DX™ PERIOSTAT® POLYCITRA-K® PANATUSS™ PERMAX® POLYCITRA-LC®
PANCOF EXP® PERRY PRENATAL TABLET® POLYGAM S/D®
PANCOF® PERSANTINE® POLY-HISTINE® PANCOF® PEXEVA™ POLY-PRED® PANCREASE MT 10® PFIZERPEN® POLYSPORIN® PANCREASE MT 16® PHANASIN® POLYTRIM™ PANCREASE MT 20® PHANATUSS HC® POLY-TUSSIN DM™ PANCREASE MT 4® PHENABID DM® POLY-TUSSIN HD™ PANCREASE® PHENABID® POLY-TUSSIN XP™ PANCRECARB MS-16® PHENA-HC® POLY-TUSSIN™ PANCRECARB MS-4® PHENA-PLUS® POLY-VENT® PANCRECARB MS-8® PHENA-S® POLY-VI-FLOR W/IRON®
PANDEL® PHENERGAN VC W/CODEINE® POLY-VI-FLOR®
PANGLOBULIN NF® PHENERGAN W/CODEINE® POLY-VITAMIN/FLUORIDE/IRON®
PANHEMATIN® PHENERGAN® PONTOCAINE®
PANIXINE™ PHENTOLAMINE MESYLATE® PRAMOTIC™
PANLOR DC® PHENYDEX® PRAVIGARD PAC™ PANLOR SS® PHENYTEK® PRECARE CONCEIVE® PANNAZ S® PHISOHEX® PRECARE PRENATAL® PANNAZ® PHOSPHOLINE IODIDE® PRECARE® PANOXYL AQ 10® PHOTOFRIN® PRED FORTE® PANOXYL AQ 2.5® PHRENILIN FORTE® PRED-G®
PANOXYL AQ 5® PHRENILIN W/CAFFEINE & CODEINE® PREDNISONE INTENSOL®
PANOXYL® PHRENILIN® PREFEST® PANRETIN® PHYSIOSOL® PREGNYL® PARAFON FORTE DSC® PHYTONADIONE® PREHIST® PARAPLATIN® PILOCAR® PREKUNIL® PARCOPA® PILOPINE HS® PRELONE® PARLODEL™ PIMA® PREMASOL® PASER® PIPERACILLIN SODIUM® PREMESIS RX™ PATANOL® PIPERACILLIN® PREMPHASE™
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PAXIL CR™ PIROSAL® PREMPRO™ PAXIL™ PITOCIN® PRENA-CAP® PAXIPAM® PITRESSIN® PRENATE ELITE® PCE® PLAQUENIL® PRENATE GT® PEDAMETH® PLASBUMIN-20® PRE-PEN® PEDIACOF® PLASBUMIN-25® PREPIDIL® PEDIAFLOR® PLASMA-LYTE 148® PREVACID IV®
PEDIAPRED® PLASMA-LYTE 56 IN DEXTROSE® PREVACID NAPRAPAC™
PEDIATEX 12 D® PLASMA-LYTE 56® PREVACID® PEDIATEX 12 DM™ PLASMA-LYTE A PH 7.4® PREVIDENT 5000 PLUS® PEDIATEX 12® PLASMA-LYTE R® PREVIDENT® PEDIATEX DM® PLATINOL-AQ® PREVNAR® PEDIATEX-D® PLENAXIS® PRIALT® PEDIAZOLE® PLENDIL® PRILOSEC® PEDIOTIC® PLETAL® PRIMACARE ONE® PEDIOX™ PLEXION SCT® PRIMACARE® PENICILLIN G POTASSIUM IN D5W® PLEXION TS® PRIMACOR IN 5% DEXTROSE® PENICILLIN G PROCAINE® PLEXION® PRIMACOR® PENICILLIN GK/ISO-OSM DEXTROSE® PNEUMOTUSSIN® PRIMAQUINE® PENLAC™ PNU-IMUNE 23® PRIMAXIN I.M.® PENTOTHAL® PODOBEN RESIN® PRIMAXIN I.V.® PRIMAXIN® PRUDOXIN® RE-TANN® PRIMSOL® PSEUDO-G® RETAVASE® PRINCIPEN 125® PSORCON E® RETIN-A MICRO® PRINCIPEN 250® PSORCON® RETIN-A® PRINCIPEN® PSORIATEC® RETROVIR 300 MG TABLET® PRINIVIL® PULEXN DM® RETROVIR SOLUTION® PRINZIDE® PURINETHOL® REVEX® PROAMATINE® P-V-TUSSIN® REV-EYES® PRO-BANTHINE® PYRIDIUM PLUS® REVIA® PROCALAMINE® PYRIDIUM® R-GENE 10®
PROCANBID® Q RHEUMATREX® PROCARDIA XL® QDALL AR® RHINOCORT AQUA™ PROCARDIA® QDALL® RHINOCORT® PROCHIEVE® QUESTRAN LIGHT® RHOGAM® PROCHIEVE® QUESTRAN® RHOPHYLAC® PRO-CLEAR® QUIBRON® RICOBID® PROCTOCORT® QUIBRON-300® RICOBID-H® PROCTOCREAM-HC® QUIBRON-T/SR® RICOTUSS® PROCTOFOAM-HC® QUIBRON-T® RIFADIN IV® PROCTOSOL-HC® QUINIDEX® RIFADIN® PROFASI® QUIXIN® RIFAMATE®
PRO-FAST HS® R RIFATER® PRO-FAST SA® RABAVERT® RIMSO-50® PROFEN FORTE DM® RADIAPLEXRX™ RINGERS IRRIGATION® PROFEN FORTE® RANICLOR™ RIOMET™ PROFEN II DM® RAPIFLUX® RITALIN LA® PROFEN II® REBETOL® RITALIN® PROFILNINE SD® RECOMBINATE® RITALIN-SR®
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PROLEX D® REFACTO® RITUXAN® PROLEX DM® REFLUDAN® ROBAXIN® PROLEX PD® REGENECARE® ROBAXIN-750® PROLIXIN DECANOATE® REGLAN® ROBAXISAL® PROLIXIN® REGONOL® ROBINUL FORTE® PROLOPRIM® RELACON-DM® ROBINUL® PROMETRIUM® RELACON-HC® ROCALTROL®
PROMIT® RELAFEN® ROCEPHIN/ISO-OSMOTIC DEXTROSE®
PRONESTYL® RELAGARD® ROCEPHIN® PRONESTYL-SR® RELAGESIC® ROMAZICON® PROPINE® RELENZA® ROMILAR AC® PROPLEX T® RELPAX® RONDEC® PROQUAD® REMERON® RONDEC-DM® PROQUIN XR® REMULAR-S® RONDEC-TR® PRO-RED™ RENACIDIN® ROSAC® PROSED EC® RENAMIN® ROSANIL™ PROSOM™ RENOQUID® ROSULA NS® PROSTIN E2 VAGINAL SUPPOSITORY® REOPRO® ROSULA® PROSTIN VR PEDIATRIC® REPLIVA 21/7® ROWASA® PROTID® REPREXAIN™ ROXANOL 100® PROTONIX IV® RESCON-JR® ROXANOL® PROTOPAM CHLORIDE® RESCON-MX® ROXANOL-T® PROTOPIC® RESECTISOL® ROXICODONE INTENSOL® PROTUSS® RESPA A.R.® ROXICODONE® PROVENTIL HFA® RESPAIRE-120® RUM-K® PROVENTIL® RESPAIRE-60® RU-TUSS 800 DM® PROVERA® RESPA-PE® RU-TUSS A® PROVISC® RESPIGAM® RU-TUSS DM® PROVOCHOLINE® RESPI-TANN PD® RYNA-12 S® PROZAC WEEKLY® RESPI-TANN™ RYNA-12® PROZAC® RESTORIL® RYNA-12X®
RYNATAN PEDIATRIC® SOLU-MEDROL W/DILUENT® SYNERCID®
RYNATAN® SOLU-MEDROL® SYPRINE®
RYNATUSS® SOMA COMPOUND W/CODEINE® T
RYNEZE® SOMA COMPOUND® TAGAMET® RYTHMOL SR® SOMA® TALACEN® RYTHMOL® SOMNOTE® TALWIN NX® S SONATA® TALWIN® SALAGEN® SOTRADECOL® TAMBOCOR™ SALEX® SPACOL T/S® TAMIFLU® SALFLEX® SPACOL® TANAFED DMX™ SALICEPT™ SPECTAZOLE® TANAFED DP™ SAL-TROPINE® SPECTRACEF® TANAFED® SALURON® SPORANOX® TAPAZOLE® SANCTURA® SPRAY AND STRETCH® TARABINE PFS® SANDIMMUNE® SSKI® TARKA® SANDOSTATIN (except LAR)® S-T FORTE 2® TAXOL®
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SANTUSS® STA-D® TAXOTERE® SANTYL® STADOL® TAZICEF IN DEXTROSE® SARAFEM® STAFLEX® TAZICEF® SCLEROMATE® STAGESIC-10® TAZORAC® SCOPACE™ STAHIST® TEMOVATE EMOLLIENT® SCOPOLAMINE HYDROBROMIDE® STALEVO 100™ TEMOVATE® SEASONALE® STALEVO 150™ TENEX® SEBIZON® STALEVO 50™ TENORETIC 100®
SEB-PREV® STAPHAGE LYSATE (SPL)® TENORETIC 50®
SECONAL SODIUM® STARLIX® TENORMIN® SECTRAL® STATUSS GREEN® TENUATE® SELECT-OB® STERAPRED DS® TEQUIN® SELEPEN® STERAPRED® TERAZOL 3® SEL-PEN® STRATTERA® TERAZOL 7® SELSEB® STREPTASE® TERRAMYCIN IM®
SEMPREX-D® STREPTOMYCIN SULFATE® TERRAMYCIN W/POLYMYXIN®
SENSORCAINE W/DEXTROSE® STRIANT™ TERRAMYCIN® SENSORCAINE W/EPINEPHRINE® STRONGSTART® TESSALON PERLE® SENSORCAINE® STUARTNATAL PLUS 3® TESSALON® SEPTRA DS® SUBLIMAZE® TESTOPEL® SEPTRA® SUCRAID® TESTRED® SERAX® SUDAL 12® TETANUS TOXOID (FLUID)® SERENTIL® SUDAL DM® TETANUS TOXOID®
SEROMYCIN® SUDAL SR® TETANUS/DIPHTHERIA TOXOIDS®
SEROSTIM® SULAR® TEVETEN HCT® SHOHL'S MODIFIED® SULFACET-R® TEVETEN® SILVADENE® SULFOXYL REGULAR® TEXACORT® SIMETYL® SULFOXYL STRONG® THEO-24® SIMULECT® SUMYCIN 250® THEOCAP® SINA-12X® SUMYCIN 500® THEOMAR GG® SINEMET CR® SUMYCIN® THERACYS® SINEMET-10/100® SUPPRELIN® THERA-FLUR-N® SINEMET-25/100® SUPRAX® THIOCYL® SINEMET-25/250® SUTTAR-2® THROMBIN-JMI® SINEQUAN® SUTTAR-SF® THYMOGLOBULIN® SINUTUSS DM® SYMAX DUOTAB® THYROLAR-1/2® SITREX® SYMBYAX® THYROLAR-1/4® SKELID® SYMMETREL® THYROLAR-1® SLO-BID 50® SYMTAN® THYROLAR-2® SLOFED 60® SYNAGIS® THYROLAR-3® SOLAGE® SYNALAR® TIAZAC® SOLGANAL SUSPENSION® SYNALGOS-DC® TICAR IN DEXTROSE® SOLU-CORTEF® SYNAREL® TICAR® TICE BCG® TRISENOX® ULTRALYTIC 2® TICLID® TRISPEC DMX® ULTRAM® TIGAN THERA-JECT® TRISPEC PSE® ULTRASE MT 12®
Medicare Part D Non-covered Drug List, 023 (continued) Page 17 • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •
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TIGAN® TRISPEC SFX® ULTRASE MT 18® TIKOSYN® TRISPEC-DM® ULTRASE MT 20® TIMENTIN ISO-OSMOTIC® TRISPEC-PE® ULTRASE® TIMENTIN® TRISPEC-SF® ULTRAVATE™ TIMOLIDE® TRITAL DM® UMECTA™ TIMOPTIC® TRITON X-100® UNASYN® TIMOPTIC-XE® TRITUSS® UNGUENTUM BOSSI® TINDAMAX™ TRITUSS-A® UNIRETIC® TISSEEL VH® TRITUSS-ER® UNIVASC® TOBRADEX® TRI-VI-FLOR W/IRON® URECHOLINE® TOBREX® TRI-VI-FLOR® URELLE® TOFRANIL® TROBICIN ® URETRON D/S® TOFRANIL-PM® TRYCET® UREX® TOLECTIN 600® TUBERSOL® URIMAX® TOLINASE® TUSNEL PED-C® URISED® TOPICORT LP® TUSNEL® URISPAS® TOPICORT® TUSNEL-DM® URISYM® TOPOSAR™ TUSNEL-HC® URO BLUE® TORADOL® TUSSAFED-HCG® URODOL® TORECAN® TUSSALL® UROLENE BLUE® TOTACILLIN-N® TUSSALL-ER® UROQID-ACID NO.2® TOURO ALLERGY® TUSS-DA NR® URSO FORTE® TOURO CC® TUSS-DA® URSO® TOURO CC-LD® TUSSEND® UTA® TOURO DM® TUSSI-12 S® UVADEX®
TOURO HC® TUSSI-12® V TOURO LA® TUSSI-12D S® VALIUM® TOURO LA-LD® TUSSI-12D® VANACET® TRAC 2X® TUSSIDEX® VANAMIDE™ TRACE ELEMENTS-4® TUSSIGON® VANCENASE® TRANDATE® TUSSILAN N.F.® VANEX HD® TRANXENE SD® TUSSINATE® VANOXIDE-HC® TRANXENE T-TAB® TUSSIONEX® VANSPAR®
TRAVATAN® TUSSI-ORGANIDIN DM NR® VANTIN®
TRECATOR® TUSSI-ORGANIDIN DM-S NR® VASERETIC®
TRECATOR-SC® TUSSI-ORGANIDIN NR® VASOCIDIN® TRELSTAR DEPOT® TUSSI-ORGANIDIN-S NR® VASODILAN® TRELSTAR LA® TUSSI-PRES® VASOTEC® TRENTAL® TUSSIREX® VAZOL® TREXALL® TUSS-MINE D.M.® VAZOL-D® TRIANT-HC® TUSSO-DF® VEETIDS 500® TRIAZ® TUSSO-HC® VEHICLE/N MILD® TRICARE® TWINJECT® VEHICLE/N® TRI-CHLOR® TYGACIL® VELCADE®
TRICHOPHYTON® TYLENOL W/CODEINE NO.3® VELOSEF®
TRICOR® TYLENOL W/CODEINE NO.4® VENOGLOBULIN-S®
TRICOSAL® TYLOX® VENOMIL MIXED VESPID VENOM®
Medicare Part D Non-covered Drug List, 023 (continued) Page 18 • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •
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TRIDAL® TYMPAGESIC® VENTOLIN HFA® TRIDESILON® TYSABRI® VENTOLIN® TRI-K® TYZINE® VEPESID®
TRI-LEVLEN 28® U VERELAN PM® TRILISATE® U-CORT™ VERELAN® TRILYTE WITH FLAVOR PACKETS® ULTIVA® VERMOX® TRI-NORINYL® ULTRABROM PD® VERSED® TRIPEDIA® ULTRABROM® VERSICLEAR™ TRIPHASIL-28® ULTRACET® VERTIN-32® VESICARE® VEXOL® XIRAHISTDM® ZOTEX GPX®
VIADUR® X ZOTEX LAX® VIBRAMYCIN® XODOL™ ZOTEX® VIBRA-TABS® XOLAIR® ZOTEX-G® VICODIN ES® XOPENEX HFA® ZOTEX-GP® VICODIN HP® XPECT-AT® ZOTEX-LA® VICODIN® XPECT-HC® ZOTO-HC®
VICOPROFEN® XYLOCAINE IM FOR CARDIAC®
ZOVIRAX TABS, CAPS, SUSPENSION®
VI-DAYLIN F ADC® XYLOCAINE IV FOR CARDIAC® ZTUSS®
VI-DAYLIN/F + IRON® XYLOCAINE VISCOUS® ZYBAN® VI-DAYLIN/F ADC PLUS IRON®
XYLOCAINE W/DEXTROSE® ZYDONE®
VI-DAYLIN/F® XYLOCAINE W/EPINEPHRINE® ZYFLO®
VIDAZA® XYLOCAINE® ZYLET® VIDEX EC® XYLOCAINE-MPF® ZYLOPRIM®
VIGAMOX® Y ZYMAR® VINATAL 600® YASMIN 28® ZYMINE HC®
VINATE GOOD START® YELLOW JACKET VENOM PROTEIN KT® ZYMINE®
VIOKASE® YELLOW JACKET VENOM PROTEIN® ZYMINE-D®
VIRAVAN DM® YELLOW JACKET VENOM PROTEIN® ZYRTEC®
VIRAVAN-S® YOCON® ZYRTEC-D® VIRAVAN-T® YODEFAN® VIRAZOLE® YODEFAN-NF® VIROPTIC® YODOXIN® VISCOAT® YOHIMAR®
VISICOL™ Z VISTARIL® ZADITOR® VISTIDE® ZANAFLEX® VISUDYNE® ZANOSAR® VITA-NUMONYL EX® ZANTAC 25®
VITRASERT® ZANTAC CAPSULES, TABLETS®
VIVELLE® ZARONTIN® VIVELLE-DOT™ ZAROXOLYN®
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VIVOTIF BERNA® ZAZOLE® VOLMAX® Z-CLINZ 10® VOLTAREN TABLETS® Z-CLINZ 5® VOLTAREN-XR® Z-COF DM® VOPAC® Z-COF DMX® VOSPIRE ER® Z-COF HC® VUMON® Z-COF LA® VYTONE® Z-COF LAX® W ZEBETA® WASP VENOM PROTEIN TREATMEN KT® ZEBUTAL® WASP VENOM PROTEIN® ZEGERID® WELCHOL™ ZEMAIRA® WELLBUTRIN SR® ZEPHREX® WELLBUTRIN XL™ ZEPHREX-LA® WELLBUTRIN® ZESTORETIC® WESTCORT® ZESTRIL® WINRHO SD® ZETACET® WINRHO SDF® ZIAC®
WINRHO SDF® ZINACEF IN ISO-OSMOTIC WATER®
WINSTROL® ZINACEF/ISO-OSMOTIC DEXTROSE®
X ZINACEF® XANAX XR® ZINECARD® XANAX® ZITHROMAX TABLETS® XENADERM™ ZODERM® XERAC AC® ZOFRAN IN DEXTROSE® XIFAXAN® ZOMETA® XIRAHIST® ZORPRIN®
