qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo...

89
Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos Cubiertos) POR FAVOR LEA: ESTE DOCUMENTO CONTIENE INFORMACIÓN SOBRE LOS MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN Nota a los miembros actuales: Este formulario ha cambiado desde el año pasado. Por favor revise este documento para asegurarse de que todavía contiene los medicamentos que usted toma. Los beneficiarios deben utilizar las farmacias de la red para tener acceso a su beneficio de medicamentos con receta médica. Los beneficios, el formulario, la red de farmacias, la prima y/o los copagos/coseguro pueden cambiar el 1 de enero de 2013. QualityHealthPlans es una organización de Medicare Advantage con un contrato con Medicare. Llame al 1-877-233-7058 para recibir materiales en otro idioma o formato. H2773_QHPNY0467S File & Use 08302011 HPMS Approved Formulary File Submission ID: 00012472, Version Number: V26 Last Updated 10/31/2012

Transcript of qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo...

Page 1: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Formulario Completo de la Parte D

i

Advantage Platinum NY (HMO)

Formulario del 2012

(Lista de Medicamentos Cubiertos)

POR FAVOR LEA: ESTE DOCUMENTO CONTIENE INFORMACIÓN SOBRE LOS MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN

Nota a los miembros actuales: Este formulario ha cambiado desde el año pasado. Por favor revise este documento para asegurarse de que todavía contiene los medicamentos que usted toma. Los beneficiarios deben utilizar las farmacias de la red para tener acceso a su beneficio de medicamentos con receta médica. Los beneficios, el formulario, la red de farmacias, la prima y/o los copagos/coseguro pueden cambiar el 1 de enero de 2013. QualityHealthPlans es una organización de Medicare Advantage con un contrato con Medicare. Llame al 1-877-233-7058 para recibir materiales en otro idioma o formato. H2773_QHPNY0467S File & Use 08302011

HPMS Approved Formulary File Submission ID: 00012472, Version Number: V26

Last Updated 10/31/2012

Page 2: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Formulario Completo de la Parte D

ii

¿Quées el Formulario de Quality Health Plans?

Un formulario es una lista de medicamentos cubiertos seleccionados por QualityHealthPlans en consulta con un equipo de proveedores del cuidado de la salud, que representa los tratamientos recetados considerados una parte necesaria de un programa de tratamiento de calidad. QualityHealthPlans por lo general cubrirá los medicamentos incluidos en nuestro formulario, siempre y cuando el medicamento sea médicamente necesario, la receta se surta en una farmacia de la red de QualityHealthPlans y se cumplan otras normas del plan. Para obtener más información sobre cómo surtir sus recetas, por favor revise su Evidencia de Cobertura.

¿Puede cambiar el Formulario?

En general, si usted está tomando un medicamento que se encuentra en nuestro formulario del 2012 y que estaba cubierto a principios del año, no descontinuaremos ni reduciremos la cobertura de dicho medicamento durante el año de cobertura 2012, excepto si un medicamento genérico nuevo y menos costoso llega a estar disponible o cuando se dé a conocer nueva información adversa sobre la seguridad o eficacia de un fármaco. Otros tipos de cambios en el formulario, tales como la eliminación de un medicamento de nuestro formulario, no afectarán a los miembros que estén tomando actualmente el fármaco. Dicho medicamento permanecerá disponible al mismo costo compartido para aquellos miembros que lo sigan tomando durante el resto del año de cobertura. Consideramos que es importante que usted siga teniendo acceso durante el resto del año de la cobertura a los medicamentos del formulario, que estaban disponibles cuando eligió nuestro plan, excepto en los casos en los que pueda ahorrar más dinero o cuando podamos garantizar su seguridad.

Si eliminamos medicamentos de nuestro formulario o si añadimos una autorización previa, límites de cantidad y/o restricciones de tratamiento escalonado para un medicamento o si pasamos un medicamento a un nivel más alto de costo compartido, debemos avisar del cambio a los miembros afectados, al menos 60 días antes de que el cambio entre en efecto o cuando el miembro solicite volver a surtir el medicamento, en cuyo momento el miembro recibirá un suministro del medicamento para 60 días. Si la Administración de Alimentos y Medicamentos (FDA, por sus siglas en inglés) considera que un medicamento de nuestro formulario no es seguro o si el fabricante del fármaco lo retira del mercado, lo quitaremos de inmediato de nuestro formulario y avisaremos a los miembros que toman el medicamento. El formulario adjunto está vigente a partir de 11/01/2012. Para obtener información actualizada acerca de los medicamentos cubiertos por Quality Health Plans, por favor visite nuestro sitio Web en www.qualityhealthplansny.com, o llame a Servicios al Cliente al 1-877-233-7058, lunes a viernes, de 8:00AM a 8:00PM. Los usuarios de TTY/TDD deben llamar al 711.

Si se hace algún cambio a la cobertura del medicamento que usted utiliza, el plan le enviará una notificación para comunicárselo. Habitualmente, se lo haremos saber por lo menos con 60 días de antelación. Cada cierto tiempo, algún medicamento es rápidamente retirado del mercado porque se ha conocido que no es seguro o por otras razones. Si esto sucede, el plan lo retirará inmediatamente de la Lista de Medicamentos.Le comunicaremos el cambio inmediatamente. Su doctor también se enterará del cambio y puede trabajar con usted en la búsqueda de otro medicamento para su afección.

Page 3: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Formulario Completo de la Parte D

iii

¿Cómo utilizo el Formulario?

Hay dos maneras de buscar su medicamento en el formulario:

Afección Médica

El formulario comienza en la página 1. Los medicamentos que aparecen en este formulario se agrupan en categorías según el tipo de afecciones médicas para las que se utilizan. Por ejemplo, los medicamentos usados para tratar una afección cardíaca se enumeran en la categoría: Agentes Cardiovasculares. Si usted sabe para qué se utiliza su medicamento, busque el nombre de la categoría en la lista que comienzaen la página 1. Luego, busque su medicamento bajo el nombre de la categoría.

Orden Alfabético

Si no está seguro en qué categoría buscar, deberá buscar su medicamento en el Índice que comienza en la página 60. El Índice proporciona una lista por orden alfabético de todos los medicamentos incluidos en este documento. En el Índice aparecen tanto los medicamentos de marca como los genéricos. Busque en el Índice hasta que encuentre su medicamento. Junto a su medicamento verá el número de la página en la que puede encontrar información sobre la cobertura. Pase a la página que se indica en el Índice y busque el nombre de su medicamento en la primera columna de la lista.

¿Qué son los medicamentos genéricos?

QualityHealthPlans cubre tanto los medicamentos de marca como los medicamentos genéricos. Un medicamento genérico es aprobado por la FDA por contener el mismo ingrediente activo que un medicamento de marca. En general, los medicamentos genéricos cuestan menos que los medicamentos de marca.

¿Hay algunas restricciones en mi cobertura?

Algunos medicamentos cubiertos pueden tener requisitos o límites adicionales de cobertura. Entre estos requisitos y límites se pueden incluir:

Autorización previa: QualityHealthPlans requiere que usted o su médico obtenga una autorización previa para ciertos medicamentos. Esto significa que usted deberá obtener la aprobación de QualityHealthPlans antes de surtir sus recetas. Si no obtiene la aprobación, es posible que QualityHealthPlans no cubra el medicamento.

Límites de Cantidad: Para ciertos medicamentos, QualityHealthPlans limita la cantidad del medicamento que cubrirá QualityHealthPlans. Por ejemplo, QualityHealthPlans provee 62 cápsulas de Celebrex por receta. Esto puede ser adicional a un suministro estándar para un mes o tres meses.

Tratamiento Escalonado: En algunos casos, QualityHealthPlans requiere que usted primero pruebe

ciertos medicamentos para tratar su afección médica antes de que podamos cubrir otro medicamento

Page 4: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Formulario Completo de la Parte D

iv

para ese mismo padecimiento. Por ejemplo, si tanto el Medicamento A como el Medicamento B sirven para el tratamiento de su afección médica, es posible que QualityHealthPlans no cubra el Medicamento B, a menos que usted primero pruebe el Medicamento A. Si el Medicamento A no funciona para usted, QualityHealthPlans cubrirá entonces el Medicamento B.

Usted puede averiguar si su medicamento tiene requisitos o límites adicionales consultando el formulario que comienza en la página 1. También puede obtener más información sobre las restricciones que se aplican a determinados medicamentos que cubrimos, si visita nuestro sitio Web en www.qualityhealthplansny.com.

Usted puede pedirle a QualityHealthPlans que haga una excepción a estas restricciones o límites. Consulte la sección, “¿Cómo solicito una excepción al formulario de QualityHealthPlans?” en la página vii para obtener información acerca de cómo solicitar una excepción.

¿Qué son los medicamentos sin receta (OTC)?

Los medicamentos sin receta (OTC, por sus siglas en inglés) son medicamentos sin receta médica que normalmente no están cubiertos por un plan de medicamentos con receta de Medicare. QualityHealthPlans paga por ciertos medicamentos OTC. QualityHealthPlans proporcionará estos medicamentos OTC sin costo alguno para usted. Para QualityHealthPlans, los costos de estos medicamentos OTC no contarán para sus costos totales de medicamentos.

Item # Product Description Size Price Quantity $ Total

First Aid

001 Ace Bandage 1 $5.39

002 Muscle Rub 85 $5.19

003 Calamine Lotion (Medica) 120 $3.19

004 Hydrocortisone Cream 1% 28.4 $2.69

005 Triple Antibiotic Oint. 28.4 $4.89

006 Bandage Strips 20 $1.89

006-01 Gauze Sterile Pads 25 $3.67

006-02 Alcohol Prep Pads 100 $2.49

Laxatives

007 Bisacodyl 5mg 100 $5.39

008 Stool Softener (Docusate Sodium) 100 $5.99

009 Natural Laxative plus Doss (Sennosides) 60 $5.09

010 Fiber Capsules ( Psyllium husk) 160 $7.79

Anti-Fungals

012 Tolnaftate Cream 30 $2.29

Page 5: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Formulario Completo de la Parte D

v

Item # Product Description Size Price Quantity $ Total

013 Clotrimazole Cream 28 $1.99

Digestive Aids

014 Loperamide Tablets 24 $3.69

015 Pink Bismuth Tablets(Bismuth subsalicylate) 30 $2.29

016 Gas Relief Extra Strength (Simethicone) 30 $3.79

Eye Care

017 Artificial Tears (Polyvinyl alcohol) 15 $1.99

018 Eye Drops (Tetrahydrozoline hydrochloride) 15 $3.09

Cough/Cold/Allergy

019 Oxymetazolone Nasal Spray 30 $2.39

020 Diphenhydramine 25mg 24 $1.49

021 Vicks Vaporub 100 $2.89

022 Digital Thermometer 1 $5.69

023 Loratadine 10mg 30 $4.69

024 Tussin Liquid 240 $2.79

025 Tussin DM Liquid 240 $3.09

025-01 Mucinex Tablet 600mg 20 $10.99

025-02 Mucinex DM Tablet 600mg 20 $11.99

025-03 Cetirizine Allergy 10mg 30 $15.99

025-04 Cough Drops Methol 30 $1.99

025-05 Cough Drops Methol-Diab 25 $2.39

Anti-Hemorrhoidal

026 Hemorrhoidal Pads 100 $6.49

027 Hemorrhoidal Oint. 1% 28 $3.49

028 Hemorrhoidal Suppository 24 $5.69

Vitamins

029 B-Complex (100% RDA) 100 $5.59

030 Vitamin C 500mg 100 $2.39

031 Calcium Carbonate + D 250mg 100 $3.99

032 Daily Multivitamin 100 $4.79

Page 6: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Formulario Completo de la Parte D

vi

Item # Product Description Size Price Quantity $ Total

033 Complete Senior Vitamin 100 $6.09

034 Echinacea 400mg 100 $5.09

035 Ginkgo Biloba 60mg 120 $6.09

Vitamins (continued)

036 Glucosamine/Chondroitin 60 $9.09

037 Calcium 500mg + D 60 $2.49

038 Vitamin A 10,000 IU 100 $2.59

039 Chewable Multivitamin 100 $4.29

040 Vitamin E 400 IU 100 $4.99

041 Folic Acid 800mcg 100 $2.59

042 Iron 325mg 100 $4.59

043 Fish Oil 1,000mg - Omega (300mg) 120 $6.78

044 Garlic Odorless 100 $3.99

044-01 Niacin 500mg 100 $4.68

Pain Relievers

045 Ibuprofen 200mg 100 $2.79

046 Aspirin 325mg 100 $0.99

047 Aspirin 325mg EC 100 $1.99

048 Aspirin 81mg EC 120 $2.39

049 Acetaminophen 500mg 100 $3.99

051 Aspirin 81mg Chewable 36 $3.09

053 Icy Hot Patch 5 $4.49

053-01 Acetaminophen 325mg 100 $3.30

Antacids

054 Effervescent Pain Relief 36 $3.69

055 Calcium Antacid Tablet 150 $2.89

056 Ranitidine 75mg 60 $10.49

057 Prilosec OTC 14 $12.99

058 Omeprazole 20mg 14 $9.99

Page 7: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Formulario Completo de la Parte D

vii

¿Qué sucede si mi medicamento no está en el Formulario?

Si su medicamento no está incluido en este formulario, debe comunicarse primero con Servicios al Cliente y confirmar que su medicamento no está cubierto. Si se entera de que QualityHealthPlans no cubre su medicamento, usted tiene dos opciones:

Puede solicitarle a Servicios al Cliente una lista de medicamentos similares que están cubiertos por QualityHealthPlans. Cuando reciba la lista, muéstresela a su médico y pídale que le recete un medicamento similar que esté cubierto por QualityHealthPlans.

Puede solicitarle a QualityHealthPlans que haga una excepción y cubra su medicamento. A

continuación, encontrará información sobre cómo solicitar una excepción.

¿Cómo solicito una excepción al Formulario de QualityHealthPlans?

Usted puede solicitarle a QualityHealthPlans que haga una excepción a nuestras reglas de cobertura. Existen varios tipos de excepciones que puede pedirnos que hagamos.

Puede pedirnos que cubramos su medicamento aunque no esté incluido en nuestro formulario.

Puede pedirnos que renunciemos a las restricciones o límites de cobertura de su medicamento. Por ejemplo, para ciertos medicamentos QualityHealthPlans limita la cantidad del medicamento que vamos a cubrir. Si su medicamento tiene un límite de cantidad, puede pedirnos que no apliquemos el límite y que cubramos más.

Puede pedirnos que proporcionemos un mayor nivel de cobertura de su medicamento. Si su

medicamento se encuentra en nuestro nivel de no preferidos, puede pedirnos que lo cubramos con la cantidad del costo compartido que se aplica a los medicamentos en el nivel 2 en su lugar. Esto disminuiría la cantidad que debe pagar por su medicamento. Por favor tenga en cuenta que si aceptamos su solicitud para cubrir un medicamento que no está en nuestro formulario, usted no puede pedirnos que le proporcionemos un nivel más alto de cobertura para el medicamento. Además, no puede pedirnos que proporcionemos un nivel más alto de cobertura para los medicamentos que están en el nivel 4.

Page 8: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Formulario Completo de la Parte D

viii

En general, QualityHealthPlans aprobará su solicitud de excepción sólo si los medicamentos alternativos incluidos en el formulario del plan, el medicamento de nivel más bajo o las restricciones adicionales de utilización no fueran tan eficaces en el tratamiento de su afección y/o pueden causarle efectos médicos adversos.

Debe comunicarse con nosotros para solicitarnos una decisión de cobertura inicial para una excepción de formulario, nivel o restricción de utilización. Cuando solicite una excepción de formulario, nivel o restricción de utilización, debe presentar una declaración de su médico que respalde su solicitud. Por lo general, debemos tomar nuestra decisión dentro de 72 horas, después de recibir la declaración de respaldo de su médico que receta o de la persona autorizada a recetar. Puede solicitar una excepción acelerada (rápida), si usted o su médico consideran que su salud podría verse seriamente perjudicada si espera hasta 72 horas por una decisión. Si se concede su solicitud de excepción acelerada, debemos darle una decisión en un máximo de 24 horas, después de haber recibido la declaración de respaldo de la persona autorizada a recetar o de su médico que prescribe.

¿Qué debo hacer antes de poder hablar con mi médico sobre cambiar mis medicamentos o solicitar una excepción?

Como un miembro nuevo o que continúa en nuestro plan, usted puede estar tomando medicamentos que no se encuentren en nuestro formulario. O bien, puede estar tomando un medicamento que está en nuestro formulario, pero su capacidad para conseguirlo es limitada. Por ejemplo, es posible que necesite una autorización previa de nosotros antes de que pueda surtir su receta. Debe hablar con su médico para decidir si debe cambiarse a un medicamento apropiado que cubrimos o solicitar una excepción al formulario, para que cubramos el medicamento que usted toma. Mientras habla con su médico para determinar el rumbo correcto de acción para usted, podemos cubrir su medicamento en ciertos casos durante los primeros 90 días que esté inscrito en nuestro plan.

Por cada uno de sus medicamentos que no se encuentre en nuestro formulario o si su capacidad para obtener sus medicamentos es limitada, cubriremos un suministro temporal para 30 días (a menos que tenga una receta que indique para menos días) cuando acuda a una farmacia de la red. Después de su primer suministro para 30 días, no vamos a pagar por estos medicamentos, incluso si usted ha sido un miembro del plan menos de 90 días.

Si usted es un residente de un centro de cuidado a largo plazo, le permitiremos resurtir su receta hasta que le hayamos entregado un suministro de transición por 90 días, consistente con el aumento de entrega (a menos que tenga una receta que indique para menos días). Cubriremos más de una repetición de estos medicamentos durante los primeros 90 días que usted esté inscrito en nuestro plan. Si necesita un medicamento que no se encuentra en nuestro formulario o si su capacidad para obtener estos medicamentos está limitada, pero ya pasaron los primeros 90 días de estar inscrito en nuestro plan, cubriremos un suministro de emergencia de ese medicamento para 31 días (a menos que tenga una receta que indique para menos días), mientras trata de obtener una excepción al formulario.

Page 9: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Formulario Completo de la Parte D

ix

Es posible que haya un cambio en el entorno de tratamiento de un miembro actual debido al nivel de atención requerido. Entre estas transiciones se incluyen:

1. Los miembros dados de alta de un hospital para regresar a su hogar;

2. Los miembros que finalizan su estadía de la Parte A de Medicare en un centro de atención de enfermería especializada (en donde los pagos incluyen todos los gastos de farmacia) y que, en la actualidad, necesitan utilizar su plan de la Parte D;

3. Los miembros que abandonan su estado de hospicio y vuelven a la cobertura estándar de la Parte A y B de Medicare;

4. Miembros dados de alta de hospitales psiquiátricos crónicos con regímenes de medicamentos altamente individualizados;

En el caso de estas transiciones no planificadas, es posible que los miembros deban solicitar una excepción o presentar una apelación para continuar con la cobertura de su medicamento. Además, QualityHealthPlans deberá revisar las solicitudes para la continuación de tratamientos caso por caso para aquellos miembros que hayan experimentado un cambio en el nivel de atención y se encuentren estables en regímenes de medicamentos que, si se modifican, pueden suponer un riesgo.

QualityHealthPlans puede proporcionar una receta de transición para obtener un suministro único de un mes (31 días), de manera que el miembro tenga tiempo suficiente para cambiar a tratamientos alternativos del formulario o para completar los procesos de excepción y determinación de cobertura.

Para más información

Para obtener más información acerca de la cobertura de medicamentos con receta médica de QualityHealthPlans, por favor revise su Evidencia de Cobertura y otros materiales del plan.

Si tienepreguntasacerca de Quality Health Plans, por favor llame a Servicios al Cliente al 1-877-233-7058, lunes a viernes, 8:00AM to 8:00PM. Los usuarios de TTY/TDD deben llamar al 711. O bien, visite www.qualityhealthplansny.com.

Si tiene preguntas generales acerca de la cobertura de medicamentos con receta médica de Medicare, por favor llame a Medicare al 1-800-MEDICARE (1-800-633-4227), las 24 horas del día/los 7 días de la semana. Los usuarios de TTY/TDD deben llamar al 1-877-486-2048. O bien, visite www.medicare.gov.

Formulario de QualityHealthPlans

El siguiente formulario proporciona información sobre la cobertura de algunos medicamentos cubiertos por QualityHealthPlans. Si tiene problemas para encontrar su medicamento en la lista, regrese al Índice que comienza en la página 60.

La primera columna de la tabla enumera el nombre del medicamento. Los medicamentos de marca están escritos en mayúsculas (por ejemplo, MOTRIN) y los medicamentos genéricos están escritos en cursivas minúsculas (por ejemplo, ibuprofen).

Page 10: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Formulario Completo de la Parte D

x

La información en la columna Requisitos/Límites le dice si QualityHealthPlans tiene algunos requisitos especiales para la cobertura de su medicamento.

Abreviaturas:

ED: Este medicamento con receta no está cubierto normalmente en un plan de medicamentos con receta de Medicare. La cantidad que usted paga cuando surte una receta de este fármaco no cuenta para sus costos totales de medicamentos (es decir, la cantidad que paga no le ayuda a calificar para la cobertura catastrófica). Además, si usted está recibiendo ayuda adicional para pagar sus recetas médicas, usted no recibirá ninguna ayuda adicional para pagar por este medicamento. GC: Período sin Cobertura. Ofrecemos una cobertura adicional de este medicamento con receta durante el período sin cobertura. Por favor consulte nuestra Evidencia de Cobertura para obtener más información acerca de esta cobertura. LA: Disponibilidad Limitada. Esta receta puede estar disponible sólo en ciertas farmacias. Para más información consulte su Directorio de Farmacias o llame a Servicios al Cliente al 1-877-233-7058, de lunes a viernes, de 8 a.m. a 8 p.m. Los usuarios de TTY/TDD deben llamar al 711. MO: Medicamentos por Correo. Este medicamento con receta está disponible a través del servicio de órdenes por correo. PA: Autorización Previa. QualityHealthPlans requiere que usted o su médico obtenga una autorización previa para ciertos medicamentos. Esto significa que usted deberá obtener la aprobación de QualityHealthPlans antes de surtir sus recetas. Si no obtiene la aprobación, es posible que QualityHealthPlans no cubra el medicamento. QL: Límite de Cantidad. Para ciertos medicamentos, QualityHealthPlans limita la cantidad del medicamento que cubrirá. Por ejemplo, QualityHealthPlans provee 93 cápsulas para 31 días de 100mg de Celebrex. Esto puede ser además de un suministro estándar de un mes o tres meses. ST: Tratamiento Escalonado. En algunos casos, QualityHealthPlans requiere que usted primero pruebe ciertos medicamentos para tratar su afección médica antes de que podamos cubrir otro medicamento para ese mismo padecimiento. Por ejemplo, si tanto el Medicamento A como el Medicamento B sirven para el tratamiento de su afección, es posible que QualityHealthPlans no cubra el Medicamento B, a menos que usted primero pruebe el Medicamento A. Si el Medicamento A no funciona para usted, QualityHealthPlans cubrirá entonces el Medicamento B.

Page 11: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Formulario Completo de la Parte D

xi

La tabla a continuación muestra sus copagos/coseguro de acuerdo al nivel del medicamento antes de entrar al período sin cobertura de cada plan:

Advantage Platinum NY

Drug Tier Retail 30-day

Retail 90-day

Long Term Care 31-day

Mail Order 30-day

Mail Order 90-day

Out of Network 30-day

Tier 1

Preferred Generic

$4 $12 $4 $4 $8 $4

Tier 2

Preferred Brand

$30 $90 $30 $30 $60 $30

Tier 3

Non-Preferred

Brand

$55 $165 $55 N/A N/A $55

Tier 4

Specialty Tier

33% NA 33% N/A N/A 33%

Page 12: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 1 of 78

Drug Name Drug Tier Requirements/Limits

Analgesics Analgesics

SAVELLA 2 QL (62 EA per 31 days) SAVELLA TITRATION PACK 2 QL (55 EA per 31 days)

Nonsteroidal Anti-inflammatory Drugs ARTHROTEC 50 3 ARTHROTEC 75 3 CELEBREX CAPSULE 200MG, 400MG, 50MG 3 QL (62 EA per 31 days) CELEBREX CAPSULE 100MG 3 QL (93 EA per 31 days) diclofenac sodium dr 1 GC diclofenac sodium xr 1 GC diflunisal 1 GC etodolac 1 GC etodolac er 1 GC fenoprofen calcium 1 GC flurbiprofen 1 GC ibuprofen suspension 1 GC ibuprofen tablet 400mg, 600mg, 800mg 1 GC INDOCIN SUSPENSION 3 indomethacin er 1 GC indomethacin capsule 1 GC ketoprofen 1 GC ketoprofen er 1 GC ketorolac tromethamine tablet 1 QL (20 EA per 5 days) GC ketorolac tromethamine injection 30mg/ml 1 QL (20 ML per 31 days) GC ketorolac tromethamine injection 15mg/ml 1 QL (40 ML per 31 days) GC meclofenamate sodium 1 GC mefenamic acid 3 meloxicam suspension 3 QL (310 ML per 31 days) meloxicam tablet 15mg 1 QL (31 EA per 31 days) GC meloxicam tablet 7.5mg 1 QL (62 EA per 31 days) GC nabumetone 1 GC NALFON 3 naproxen 1 GC naproxen dr 1 GC oxaprozin 1 GC PENNSAID 2 piroxicam 1 GC sulindac 1 GC tolmetin sodium 1 GC VIMOVO 2 QL (62 EA per 31 days) VOLTAREN 2

Opioid Analgesics ABSTRAL 4 QL (124 EA per 31 days) PA

(Fentanyl (Brand)) acetaminophen/caffeine/dihydrocodeine bitartrate 1 QL (155 EA per 31 days) GC acetaminophen/codeine #3 1 QL (372 EA per 31 days) GC acetaminophen/codeine solution 1 QL (4650 ML per 31 days) GC acetaminophen/codeine tablet 300mg; 60mg 1 QL (186 EA per 31 days) GC acetaminophen/codeine tablet 300mg; 15mg 1 QL (403 EA per 31 days) GC

Page 13: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 2 of 78

Drug Name Drug Tier Requirements/Limits

ascomp/codeine 1 QL (186 EA per 31 days) GC astramorph 1 GC buprenorphine hcl injection 3 buprenorphine hcl tablet sublingual 2mg 3 QL (16 EA per 31 days) PA

(Buprenorphine) buprenorphine hcl tablet sublingual 8mg 3 QL (8 EA per 31 days) PA

(Buprenorphine) butalbital/acetaminophen/caffeine/codeine 1 QL (186 EA per 31 days) GC butorphanol tartrate injection 1 GC butorphanol tartrate nasal solution 1 QL (5 ML per 1 days) GC CAPITAL/CODEINE 2 QL (4650 ML per 31 days) co-gesic 1 QL (248 EA per 31 days) GC codeine sulfate tablet 1 GC DILAUDID-5 3 QL (4940 ML per 31 days) duramorph 1 PA (ANALGESICS - INJECTION,

new starts only) GC endocet tablet 650mg; 10mg 1 QL (186 EA per 31 days) GC endocet tablet 500mg; 7.5mg 1 QL (248 EA per 31 days) GC endocet tablet 325mg; 10mg, 325mg; 5mg, 325mg; 7.5mg

1 QL (372 EA per 31 days) GC

endodan 1 QL (372 EA per 31 days) GC fentanyl citrate 1 PA (ANALGESICS - INJECTION,

new starts only) GC fentanyl citrate oral transmucosal 4 QL (124 EA per 31 days) PA

(Fentanyl) fentanyl patch 72 hour 12mcg/hr, 25mcg/hr, 50mcg/hr 3 QL (15 EA per 31 days) fentanyl patch 72 hour 100mcg/hr, 75mcg/hr 3 QL (31 EA per 31 days) HYCET 3 QL (5735 ML per 31 days) hydrocodone bitartrate/acetaminophen solution 3 QL (5735 ML per 31 days) hydrocodone bitartrate/acetaminophen tablet 300mg; 10mg, 300mg; 5mg, 300mg; 7.5mg

3 QL (403 EA per 31 days)

hydrocodone bitartrate/acetaminophen tablet 750mg; 10mg

1 QL (155 EA per 31 days) GC

hydrocodone/acetaminophen solution 1 QL (3720 ML per 31 days) GC hydrocodone/acetaminophen tablet 750mg; 7.5mg 1 QL (155 EA per 31 days) GC hydrocodone/acetaminophen tablet 650mg; 10mg, 650mg; 7.5mg, 660mg; 10mg

1 QL (186 EA per 31 days) GC

hydrocodone/acetaminophen tablet 500mg; 10mg, 500mg; 2.5mg, 500mg; 5mg, 500mg; 7.5mg

1 QL (248 EA per 31 days) GC

hydrocodone/acetaminophen tablet 325mg; 10mg, 325mg; 5mg, 325mg; 7.5mg

1 QL (372 EA per 31 days) GC

hydrocodone/ibuprofen tablet 7.5mg; 200mg 1 QL (155 EA per 31 days) GC hydromorphone hcl tablet 1 QL (372 EA per 31 days) GC hydromorphone hcl injection 500mg/50ml 3 INFUMORPH 200 3 PA (ANALGESICS - INJECTION,

new starts only) INFUMORPH 500 3 KADIAN CAPSULE EXTENDED RELEASE 24 HOUR 10MG, 20MG, 30MG, 50MG, 60MG, 80MG

2 QL (124 EA per 31 days)

Page 14: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 3 of 78

Drug Name Drug Tier Requirements/Limits

KADIAN CAPSULE EXTENDED RELEASE 24 HOUR 100MG, 200MG

2 QL (186 EA per 31 days)

LAZANDA 4 QL (164.3 EA per 31 days) PA (Fentanyl (Brand))

levorphanol tartrate 3 QL (496 EA per 31 days) margesic-h 1 QL (248 EA per 31 days) GC METHADONE HCL INJECTION 3 methadone hcl oral solution 1 QL (1860 ML per 31 days) GC methadone hcl tablet 1 QL (372 EA per 31 days) GC methadone hcl concentrate 1 QL (744 ML per 31 days) GC methadose tablet 1 QL (372 EA per 31 days) GC morphine sulfate er capsule extended release 24 hour 20mg, 30mg, 50mg, 60mg, 80mg

2 QL (124 EA per 31 days)

morphine sulfate er capsule extended release 24 hour 100mg

2 QL (186 EA per 31 days)

morphine sulfate er tablet extended release 12 hour 15mg, 30mg, 60mg

1 QL (124 EA per 31 days) GC

morphine sulfate er tablet extended release 12 hour 100mg, 200mg

1 QL (186 EA per 31 days) GC

morphine sulfate oral solution 1 GC morphine sulfate tablet 1 QL (372 EA per 31 days) GC morphine sulfate injection 1mg/ml 1 GC morphine sulfate injection 0.5mg/ml 1 PA (ANALGESICS - INJECTION,

new starts only) GC nalbuphine hcl 1 PA (ANALGESICS - INJECTION,

new starts only) GC NUCYNTA ER 2 QL (62 EA per 31 days) OPANA ER (CRUSH RESISTANT) 2 QL (124 EA per 31 days) oxycodone hcl concentrate 1 GC oxycodone hcl capsule 1 QL (496 EA per 31 days) GC oxycodone hcl tablet 15mg, 30mg, 5mg 1 QL (496 EA per 31 days) GC oxycodone/acetaminophen capsule 1 QL (248 EA per 31 days) GC oxycodone/acetaminophen tablet 650mg; 10mg 1 QL (186 EA per 31 days) GC oxycodone/acetaminophen tablet 500mg; 7.5mg 1 QL (248 EA per 31 days) GC oxycodone/acetaminophen tablet 325mg; 10mg, 325mg; 2.5mg, 325mg; 5mg, 325mg; 7.5mg

1 QL (372 EA per 31 days) GC

oxycodone/aspirin 1 QL (372 EA per 31 days) GC oxycodone/ibuprofen 1 QL (124 EA per 31 days) GC OXYCONTIN TABLET EXTENDED RELEASE 12 HOUR 10MG, 15MG, 20MG, 30MG, 40MG, 60MG

3 QL (124 EA per 31 days)

OXYCONTIN TABLET EXTENDED RELEASE 12 HOUR 80MG

3 QL (186 EA per 31 days)

oxymorphone hydrochloride 3 QL (186 EA per 31 days) oxymorphone hydrochloride er 2 QL (124 EA per 31 days) ROXICET SOLUTION 3 QL (1922 ML per 31 days) roxicet tablet 500mg; 5mg 1 QL (248 EA per 31 days) GC roxicet tablet 325mg; 5mg 1 QL (372 EA per 31 days) GC stagesic 1 QL (248 EA per 31 days) GC SYNALGOS-DC 3 QL (372 EA per 31 days) tramadol hcl 1 QL (248 EA per 31 days) GC

Page 15: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 4 of 78

Drug Name Drug Tier Requirements/Limits

tramadol hcl er tablet extended release 24 hour 1 QL (31 EA per 31 days) GC tramadol hydrochloride/acetaminophen 1 QL (248 EA per 31 days) GC ULTRAM ER TABLET EXTENDED RELEASE 24 HOUR 300MG

3 QL (31 EA per 31 days)

zerlor 1 QL (155 EA per 31 days) GC ZYDONE 3 QL (310 EA per 31 days)

Anesthetics Local Anesthetics

lidocaine hcl jelly 1 GC lidocaine hcl external solution 1 GC lidocaine hcl injection 0.5%, 1% 1 PA GC lidocaine viscous 1 GC lidocaine/prilocaine cream 1 PA GC lidocaine ointment 1 PA GC LIDODERM 2 QL (93 EA per 31 days) PA

(LIDODERM, new starts only) Anti-inflammatory Agents

Nonsteroidal Anti-inflammatory Drugs diclofenac potassium 1 GC naproxen sodium tablet 275mg, 550mg 1 GC ZIPSOR 3 QL (124 EA per 31 days)

Antibacterials Aminoglycosides

amikacin sulfate injection 500mg/2ml, 50mg/ml 1 GC gentak ointment 1 GC gentamicin sulfate/0.9% sodium chloride injection 0.9mg/ml; 0.9%, 1.4mg/ml; 0.9%, 1.6mg/ml; 0.9%, 1mg/ml; 0.9%

1 GC

gentamicin sulfate/sodium chloride injection 1.2mg/ml; 0.9%

1 GC

gentamicin sulfate cream, injection, ointment, ophthalmic solution

1 GC

gentasol 1 GC isotonic gentamicin injection 0.6mg/ml; 0.9%, 0.8mg/ml; 0.9%

1 GC

kanamycin sulfate 1 GC neomycin sulfate 1 GC paromomycin sulfate 1 GC STREPTOMYCIN SULFATE 3 TOBI 4 PA tobramycin sulfate/sodium chloride 1 GC tobramycin sulfate ophthalmic solution 1 GC tobramycin sulfate injection 10mg/ml, 80mg/2ml 1 GC tobrasol 1 GC TOBREX OINTMENT 3

Antibacterials, Other alcohol preps pad 1 GC baciim 1 GC bacitracin 1 GC bacitracin/polymyxin b 1 GC

Page 16: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 5 of 78

Drug Name Drug Tier Requirements/Limits

BACTROBAN NASAL 2 BACTROBAN CREAM 2 chloramphenicol sodium succinate 1 GC CLEOCIN GALAXY 3 PA (ANTIBIOTICS, new starts

only) CLEOCIN IN D5W 3 PA (ANTIBIOTICS, new starts

only) CLEOCIN SUPPOSITORY 3 CLEOCIN CAPSULE 75MG 3 CLINDAGEL 3 clindamycin hcl capsule 150mg, 300mg 1 GC clindamycin phosphate add-vantage 1 GC clindamycin phosphate foam 3 clindamycin phosphate cream, gel, lotion, solution, swab 1 GC CLINDESSE 3 colistimethate sodium 4 CORTISPORIN CREAM 2 CUBICIN 4 PA (ANTIBIOTICS, new starts

only) FLAGYL ER 3 methenamine hippurate 1 GC METROGEL 3 metronidazole 1 GC metronidazole in nacl 0.79% 1 GC metronidazole vaginal 1 GC MONUROL 3 mupirocin 1 GC neomycin/bacitracin/polymyxin 1 GC neomycin/polymyxin b sulfates 1 GC neomycin/polymyxin/gramicidin 1 GC nitrofurantoin 3 nitrofurantoin macrocrystalline capsule 50mg 1 GC nitrofurantoin monohydrate 1 GC NORITATE 3 polymyxin b sulfate 1 GC PRIMSOL 3 silver sulfadiazine 1 GC ssd 1 GC SULFAMYLON PACKET 3 SULFAMYLON CREAM 2 SYNERCID 4 PA (ANTIBIOTICS, new starts

only) thermazene 1 GC trimethoprim 1 GC TYGACIL 3 PA (ANTIBIOTICS) VANCOCIN HCL 4 PA (Vancocin) vancomycin hcl capsule 4 PA (Vancocin) vancomycin hcl injection 500mg 1 PA GC vancomycin hcl injection 1000mg, 10gm 1 PA (ANTIBIOTICS) GC vandazole 1 GC

Page 17: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 6 of 78

Drug Name Drug Tier Requirements/Limits

XIFAXAN TABLET 550MG 4 XIFAXAN TABLET 200MG 3 PA (XIFAXAN) ZYVOX INJECTION 4 PA (Zyvox (IV)) ZYVOX SUSPENSION RECONSTITUTED, TABLET 4 PA (Zyvox (Oral))

Beta-lactam, Cephalosporins CEDAX CAPSULE 3 cefaclor 1 GC cefaclor er 1 GC cefadroxil 1 GC cefazolin sodium injection 10gm, 1gm; 5%, 1gm, 500mg 1 GC cefdinir 1 GC cefepime injection 1gm, 2gm 3 cefotaxime sodium 1 GC cefoxitin sodium injection 10gm, 1gm, 2gm 3 cefpodoxime proxetil 1 GC cefprozil 1 GC ceftazidime injection 1gm, 2gm, 6gm 1 GC ceftriaxone sodium injection 1gm, 2gm 3 ceftriaxone sodium injection 10gm, 250mg, 500mg 1 GC cefuroxime axetil 1 GC cefuroxime sodium injection 1.5gm, 7.5gm, 750mg 1 GC cephalexin 1 GC CLAFORAN INJECTION 1GM 3 PA (ANTIBIOTICS, new starts

only) FORTAZ INJECTION 1GM/50ML; 5%, 2GM/50ML; 5% 3 KEFLEX CAPSULE 750MG 3 SUPRAX SUSPENSION RECONSTITUTED, TABLET 2 tazicef injection 1gm, 2gm, 6gm 1 GC ZINACEF IN ISO-OSMOTIC DEXTROSE 3 ZINACEF IN ISO-OSMOTIC DILUENT 3 PA (ANTIBIOTICS, new starts

only) ZINACEF INJECTION 750MG 3

Beta-lactam, Other aztreonam injection 1gm 1 GC CAYSTON 4 imipenem/cilastatin 3 PA (ANTIBIOTICS, new starts

only) INVANZ 2 PA (ANTIBIOTICS, new starts

only) meropenem injection 500mg 3 PA (ANTIBIOTICS, new starts

only) PRIMAXIN I.M. 3

Beta-lactam, Penicillins amoxicillin 1 GC amoxicillin/clavulanate potassium er 1 GC amoxicillin/clavulanate potassium tablet chewable, suspension reconstituted

1 GC

amoxicillin/clavulanate potassium tablet 250mg; 125mg 1 GC amoxicillin/potassium clavulanate tablet 1 GC ampicillin 1 GC

Page 18: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 7 of 78

Drug Name Drug Tier Requirements/Limits

ampicillin sodium injection 10gm, 125mg, 1gm 1 GC ampicillin-sulbactam injection 10gm; 5gm, 2gm; 1gm 1 GC BACTOCILL IN DEXTROSE INJECTION 0; 2GM/50ML 4 PA (ANTIBIOTICS, new starts

only) BACTOCILL IN DEXTROSE INJECTION 0; 1GM/50ML 3 PA (ANTIBIOTICS, new starts

only) BICILLIN C-R 3 BICILLIN L-A 3 dicloxacillin sodium 1 GC nafcillin sodium injection 10gm, 1gm 3 NALLPEN/DEXTROSE 3 OXACILLIN SODIUM INJECTION 10GM, 1GM 3 penicillin g potassium in iso-osmotic dextrose injection 0; 40000unit/ml, 0; 60000unit/ml

3

penicillin g potassium injection 5mu 3 penicillin g sodium 3 penicillin v potassium 1 GC PIPERACILLIN SODIUM 3 piperacillin sodium/tazobactam sodium injection 4gm; 0.5gm

3

piperacillin sodium/tazobactam sodium injection 3gm; 0.375gm

3 PA (ANTIBIOTICS, new starts only)

TIMENTIN INJECTION 0.1GM; 3GM 2 PA (ANTIBIOTICS, new starts only)

ZOSYN INJECTION 5%; 2GM/50ML; 0.25GM/50ML, 5%; 3GM/50ML; 0.375GM/50ML

2 PA (ANTIBIOTICS, new starts only)

Macrolides AKNE-MYCIN 3 AZASITE 2 azithromycin suspension reconstituted, tablet 1 GC azithromycin injection 500mg 1 GC clarithromycin 1 GC clarithromycin er 1 GC DIFICID 4 PA (DIFICID) e.e.s. 400 1 GC E.E.S. GRANULES 2 ery 1 GC ERY-TAB 2 ERYPED 200 2 ERYPED 400 2 ERYTHROCIN LACTOBIONATE INJECTION 500MG 2 ERYTHROCIN STEARATE 3 erythromycin base 1 GC erythromycin ethylsuccinate 1 GC erythromycin/sulfisoxazole 1 GC erythromycin gel, ointment, solution 1 GC KETEK 3 PA (Ketek) PCE 3 romycin 1 GC ZMAX 3

Page 19: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 8 of 78

Drug Name Drug Tier Requirements/Limits

Quinolones AVELOX ABC PACK 2 AVELOX INJECTION 3 AVELOX TABLET 2 BESIVANCE 2 CILOXAN OINTMENT 2 CIPRO SUSPENSION RECONSTITUTED 3 ciprofloxacin er 1 GC ciprofloxacin hcl 1 GC ciprofloxacin injection 400mg/40ml 1 GC levofloxacin in d5w injection 5%; 500mg/100ml 1 GC levofloxacin injection 3 levofloxacin ophthalmic solution, oral solution, tablet 1 GC MOXEZA 2 NOROXIN 3 ofloxacin 1 GC PROQUIN XR 3 VIGAMOX 2 ZYMAR 2 ZYMAXID 2

Sulfonamides sodium sulfacetamide 1 GC sulfacetamide sodium ointment 1 GC sulfadiazine 3 sulfamethoxazole/trimethoprim 1 GC sulfamethoxazole/trimethoprim ds 1 GC trimethoprim sulfate/polymyxin b sulfate 1 GC

Tetracyclines demeclocycline hcl 3 DORYX TABLET DELAYED RELEASE 150MG 3 doxycycline hyclate injection, tablet delayed release 3 doxycycline hyclate capsule, capsule delayed release particles, tablet

1 GC

doxycycline monohydrate tablet 150mg, 50mg, 75mg 3 doxycycline capsule 75mg 3 minocycline hcl er 3 minocycline hcl tablet 3 minocycline hcl capsule 1 GC ORACEA 2 tetracycline hcl 1 GC VIBRAMYCIN SYRUP 3

Anticonvulsants Anticonvulsants, Other

BANZEL 3 levetiracetam er tablet extended release 24 hour 750mg 3 QL (124 EA per 31 days) levetiracetam er tablet extended release 24 hour 500mg 3 QL (186 EA per 31 days) levetiracetam oral solution 3 levetiracetam tablet 1 GC levetiracetam injection 500mg/5ml 3 PA (ANTICONVULSANTS, new

starts only)

Page 20: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 9 of 78

Drug Name Drug Tier Requirements/Limits

POTIGA TABLET 50MG 3 QL (279 EA per 31 days) POTIGA TABLET 200MG, 300MG, 400MG 3 QL (93 EA per 31 days) VIMPAT 3

Calcium Channel Modifying Agents CELONTIN 3 ethosuximide 1 GC LYRICA CAPSULE 3 PA (Lyrica, new starts only) zonisamide 1 GC

Gamma-aminobutyric Acid (GABA) Augmenting Agents divalproex sodium 1 GC divalproex sodium dr 1 GC divalproex sodium er 1 GC gabapentin solution 3 gabapentin capsule, tablet 1 GC GABITRIL 3 primidone 1 GC SABRIL 4 PA (Sabril, new starts only) STAVZOR 3 valproate sodium 3 valproic acid 1 GC

Glutamate Reducing Agents felbamate suspension 4 felbamate tablet 3 FELBATOL SUSPENSION 4 FELBATOL TABLET 3 LAMICTAL STARTER/NOT TAKING CARBAMAZEPINE2 LAMICTAL STARTER/TAKING CARBAMAZEPINE/NOT TAKING VALPROATE

2

LAMICTAL STARTER/TAKING VALPROATE 2 lamotrigine tablet chewable 3 lamotrigine tablet 1 GC topiramate 1 GC

Sodium Channel Inhibitors carbamazepine 1 GC carbamazepine er 1 GC CARBATROL 2 DILANTIN INFATABS 2 DILANTIN CAPSULE 30MG 2 epitol 1 GC fosphenytoin sodium injection 500mg pe/10ml 1 GC oxcarbazepine suspension 3 oxcarbazepine tablet 1 GC PEGANONE 3 phenytoin 1 GC phenytoin sodium 1 GC phenytoin sodium extended 1 GC TEGRETOL-XR TABLET EXTENDED RELEASE 12 HOUR 100MG

2

Antidementia Agents Cholinesterase Inhibitors

Page 21: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 10 of 78

Drug Name Drug Tier Requirements/Limits

ARICEPT TABLET 23MG 2 ST (Aricept Therapy - PS PART D #2)

donepezil hcl 1 GC EXELON SOLUTION 3 EXELON PATCH 24 HOUR 4.6MG/24HR, 9.5MG/24HR 3 galantamine hydrobromide 3 rivastigmine tartrate 3

Glutamate Pathway Modifiers NAMENDA 2 NAMENDA TITRATION PAK 2

Antidepressants Antidepressants, Other

budeprion sr tablet extended release 12 hour 100mg 1 QL (124 EA per 31 days) GC budeprion sr tablet extended release 12 hour 150mg 1 QL (62 EA per 31 days) GC budeprion xl tablet extended release 24 hour 300mg 1 QL (31 EA per 31 days) GC budeprion xl tablet extended release 24 hour 150mg 1 QL (93 EA per 31 days) GC bupropion hcl sr tablet extended release 12 hour 100mg 1 QL (124 EA per 31 days) GC bupropion hcl sr tablet extended release 12 hour 150mg, 200mg

1 QL (62 EA per 31 days) GC

bupropion hcl tablet 100mg 1 QL (124 EA per 31 days) GC bupropion hcl tablet 75mg 1 QL (186 EA per 31 days) GC maprotiline hcl 1 GC mirtazapine 1 QL (31 EA per 31 days) GC mirtazapine odt tablet dispersible 30mg, 45mg 1 QL (31 EA per 31 days) GC nefazodone hcl 1 GC trazodone hcl 1 GC

Monoamine Oxidase Inhibitors EMSAM 3 QL (31 EA per 31 days) ST

(Antidepressant Therapy - PS PART D #2, new starts only)

MARPLAN 3 phenelzine sulfate 1 GC tranylcypromine sulfate 1 GC

Serotonin/ Norepinephrine Reuptake Inhibitors citalopram hydrobromide 1 GC CYMBALTA CAPSULE DELAYED RELEASE PARTICLES 60MG

2 QL (31 EA per 31 days) PA (CYMBALTA, new starts only)

CYMBALTA CAPSULE DELAYED RELEASE PARTICLES 20MG, 30MG

2 QL (62 EA per 31 days) PA (CYMBALTA, new starts only)

escitalopram oxalate solution 3 QL (620 ML per 31 days) escitalopram oxalate tablet 1 QL (31 EA per 31 days) GC fluoxetine dr 3 QL (5 EA per 31 days) ST

(Antidepressant Therapy - PS PART D #2, new starts only)

fluoxetine hcl capsule 20mg 1 QL (124 EA per 31 days) GC fluoxetine hcl capsule 40mg 1 QL (62 EA per 31 days) GC fluoxetine hcl capsule 10mg 1 QL (93 EA per 31 days) GC fluoxetine hcl solution 1 QL (620 ML per 31 days) GC fluoxetine hcl tablet 20mg 1 QL (124 EA per 31 days) GC fluoxetine hcl tablet 10mg 1 QL (93 EA per 31 days) GC

Page 22: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 11 of 78

Drug Name Drug Tier Requirements/Limits

fluvoxamine maleate 1 QL (93 EA per 31 days) GC paroxetine hcl er tablet extended release 24 hour 12.5mg

3 QL (186 EA per 31 days)

paroxetine hcl er tablet extended release 24 hour 25mg 3 QL (93 EA per 31 days) paroxetine hcl er tablet extended release 24 hour 37.5mg

1 QL (62 EA per 31 days) GC

paroxetine hcl suspension 3 QL (930 ML per 31 days) paroxetine hcl tablet 10mg 1 QL (31 EA per 31 days) GC paroxetine hcl tablet 40mg 1 QL (45 EA per 31 days) GC paroxetine hcl tablet 30mg 1 QL (62 EA per 31 days) GC paroxetine hcl tablet 20mg 1 QL (93 EA per 31 days) GC PEXEVA TABLET 10MG, 20MG 3 QL (31 EA per 31 days) ST

(Antidepressant Therapy - PS PART D #2, new starts only)

PEXEVA TABLET 40MG 3 QL (45 EA per 30 days) ST (Antidepressant Therapy - PS PART D #2, new starts only)

PEXEVA TABLET 30MG 3 QL (62 EA per 31 days) ST (Antidepressant Therapy - PS PART D #2, new starts only)

PRISTIQ 2 QL (31 EA per 31 days) selfemra 3 ST (PMDD Therapy- PS PART D

#2, new starts only) sertraline hcl concentrate 1 QL (310 ML per 31 days) GC sertraline hcl tablet 50mg 1 QL (31 EA per 31 days) GC sertraline hcl tablet 25mg 1 QL (45 EA per 31 days) GC sertraline hcl tablet 100mg 1 QL (62 EA per 31 days) GC venlafaxine hcl er capsule extended release 24 hour 150mg

1 QL (62 EA per 31 days) GC

venlafaxine hcl er capsule extended release 24 hour 37.5mg, 75mg

1 QL (93 EA per 31 days) GC

venlafaxine hcl er tablet extended release 24 hour 225mg

3 QL (31 EA per 31 days)

venlafaxine hcl er tablet extended release 24 hour 150mg

3 QL (62 EA per 31 days)

venlafaxine hcl er tablet extended release 24 hour 37.5mg, 75mg

3 QL (93 EA per 31 days)

venlafaxine hcl tablet 50mg 1 QL (217 EA per 31 days) GC venlafaxine hcl tablet 100mg, 25mg, 37.5mg, 75mg 1 QL (93 EA per 31 days) GC VIIBRYD KIT 3 QL (30 EA per 30 days) PA

(VIIBRYD, new starts only) VIIBRYD TABLET 3 QL (31 EA per 31 days) PA

(VIIBRYD, new starts only) Tricyclics

amitriptyline hcl 1 GC amoxapine 1 GC clomipramine hcl 1 GC desipramine hcl 1 GC doxepin hcl 1 GC imipramine hcl 1 GC

Page 23: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 12 of 78

Drug Name Drug Tier Requirements/Limits

imipramine pamoate 3 nortriptyline hcl solution 3 nortriptyline hcl capsule 1 GC protriptyline hcl 3 SURMONTIL 3 trimipramine maleate 1 GC

Antidotes, Deterrents, and Toxicologic Agents Antidotes

CUPRIMINE 2 DEPEN TITRATABS 3 EXJADE TABLET SOLUBLE 250MG, 500MG 4 PA (ANTIDOTES,

DETERRENTS, AND TOXICOLOGIC AGENTS)

EXJADE TABLET SOLUBLE 125MG 3 PA (ANTIDOTES, DETERRENTS, AND TOXICOLOGIC AGENTS)

kionex powder 1 GC RELISTOR 3 PA (Relistor) sodium polystyrene sulfonate suspension 1 GC SYPRINE 3

Deterrents ANTABUSE 2 buproban 1 QL (62 EA per 31 days) GC CAMPRAL 3 CHANTIX 3 QL (62 EA per 31 days) PA

(CHANTIX) CHANTIX STARTING MONTH PAK 3 QL (53 EA per 31 days) PA

(CHANTIX) disulfiram 1 GC NICOTROL INHALER 3 QL (3024 EA per 180 days) NICOTROL NS 3 QL (720 ML per 180 days)

Toxicologic Agents depade 1 GC FERRIPROX 4 PA (FERRIPROX) naloxone hcl 1 GC naltrexone hcl 1 GC SUBOXONE 3 QL (93 EA per 31 days) PA

(Buprenorphine) Antiemetics

Antiemetics ALOXI 3 PA ANTIVERT TABLET 50MG 3 ANZEMET INJECTION 3 PA ANZEMET TABLET 100MG 4 QL (3 EA per 3 days) PA ANZEMET TABLET 50MG 3 QL (6 EA per 3 days) PA compro 1 GC dronabinol capsule 10mg 4 PA (Marinol) dronabinol capsule 2.5mg, 5mg 3 QL (186 EA per 31 days) PA

(Marinol) EMEND 2 PA (Emend)

Page 24: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 13 of 78

Drug Name Drug Tier Requirements/Limits

granisetron hcl tablet 3 QL (6 EA per 3 days) PA granisetron hcl injection 0.1mg/ml, 1mg/ml 3 PA granisol 3 QL (30 ML per 3 days) PA hydroxyzine pamoate 1 GC meclizine hcl 1 GC metoclopramide hcl 1 GC ondansetron hcl oral solution 3 PA ondansetron hcl tablet 1 PA GC ondansetron hcl injection 4mg/2ml 3 PA ondansetron odt 1 PA GC prochlorperazine 1 GC SANCUSO 4 QL (2 EA per 28 days) PA

(SANCUSO) TRANSDERM-SCOP 3 QL (10 EA per 30 days) ZUPLENZ FILM 4MG 3 QL (18 EA per 28 days) PA ZUPLENZ FILM 8MG 3 QL (60 EA per 28 days) PA

Antifungals Antifungals

ABELCET 4 PA AMBISOME 4 PA amphotericin b 3 PA ANCOBON 4 CANCIDAS 4 ciclopirox nail lacquer 1 GC ciclopirox olamine 1 GC ciclopirox gel, shampoo 3 ciclopirox suspension 1 GC clotrimazole 1 GC clotrimazole/betamethasone dipropionate 1 GC econazole nitrate 1 GC ERAXIS INJECTION 100MG 4 ERTACZO 3 EXELDERM 3 fluconazole 1 GC fluconazole in dextrose injection 56mg/ml; 400mg/200ml 3 PA (ANTIFUNGALS - INJ, new

starts only) flucytosine 4 GRIFULVIN V 2 GRIS-PEG 3 griseofulvin microsize 1 GC GYNAZOLE-1 2 itraconazole 3 QL (130 EA per 31 days) PA

(Sporanox (capsules)) ketoconazole foam 3 ketoconazole cream, shampoo, tablet 1 GC MENTAX 3 miconazole 3 1 GC NATACYN 2 NOXAFIL 4 nyamyc 1 GC

Page 25: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 14 of 78

Drug Name Drug Tier Requirements/Limits

nystatin/triamcinolone 1 GC nystatin cream, ointment, powder, suspension, tablet 1 GC nystop 1 GC ORAVIG 3 QL (14 EA per 31 days) OXISTAT 3 pedi-dri 1 GC SPORANOX SOLUTION 3 QL (1240 ML per 31 days) PA

(Sporanox (solution)) terbinafine hcl tablet 1 GC terconazole 1 GC VFEND IV 3 PA (ANTIFUNGALS - INJ, new

starts only) VFEND SUSPENSION RECONSTITUTED 4 PA (ANTIFUNGALS - INJ, new

starts only) voriconazole tablet 4 PA (VORICONAZOLE, new

starts only) voriconazole injection 3 PA (ANTIFUNGALS - INJ, new

starts only) zazole cream 1 GC

Antigout Agents Antigout Agents

allopurinol 1 GC allopurinol sodium 3 COLCRYS 3 QL (62 EA per 31 days) probenecid 1 GC probenecid/colchicine 1 GC ULORIC 2 ST (Uloric Therapy - PS PART D

#2) Antimigraine Agents

Abortive ALSUMA 3 QL (4 ML per 30 days) AXERT 3 QL (12 EA per 30 days) ST

(Triptan Therapy - PS PART D #2)

ergotamine tartrate/caffeine 1 QL (40 EA per 28 days) GC FROVA 3 QL (18 EA per 30 days) ST

(Triptan Therapy - PS PART D #2)

IMITREX SOLUTION 2 QL (6 EA per 30 days) MAXALT 2 QL (12 EA per 30 days) MAXALT-MLT 2 QL (12 EA per 30 days) migergot 3 QL (20 EA per 28 days) naratriptan hcl 1 QL (9 EA per 30 days) GC RELPAX 3 QL (6 EA per 30 days) ST

(Triptan Therapy - PS PART D #2)

sumatriptan succinate tablet 1 QL (9 EA per 30 days) GC sumatriptan succinate injection 6mg/0.5ml 3 QL (4 ML per 30 days) sumatriptan succinate injection 4mg/0.5ml 3 QL (4 ML per 31 days) ZOMIG ZMT 3 QL (9 EA per 30 days)

Page 26: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 15 of 78

Drug Name Drug Tier Requirements/Limits

ZOMIG SOLUTION 3 QL (6 EA per 30 days) ZOMIG TABLET 3 QL (9 EA per 30 days)

Antimyasthenic Agents Parasympathomimetics

GUANIDINE HCL 3 MESTINON TIMESPAN 2 MESTINON SYRUP 2 MYTELASE 3 pyridostigmine bromide 1 GC regonol 1 GC

Antimycobacterials Antimycobacterials, Other

DAPSONE 2 MYCOBUTIN 3

Antituberculars CAPASTAT SULFATE 3 ethambutol hcl 1 GC isonarif 3 isoniazid injection 3 isoniazid syrup, tablet 1 GC PASER 3 PRIFTIN 3 pyrazinamide 1 GC rifampin injection 4 PA (RIFAMPIN INJ) rifampin capsule 1 GC RIFATER 3 TRECATOR 3

Antineoplastics Alkylating Agents

BICNU 3 PA (ANTINEOPLASTICS, new starts only)

BUSULFEX 4 PA (ANTINEOPLASTICS, new starts only)

CEENU 2 cyclophosphamide tablet 3 PA dacarbazine injection 200mg 1 GC HEXALEN 4 PA (Hexalen, new starts only) ifosfamide/mesna 4 PA (ANTINEOPLASTICS, new

starts only) ifosfamide injection 1gm 3 LEUKERAN 2 MATULANE 4 melphalan hydrochloride 4 PA (ANTINEOPLASTICS, new

starts only) MUSTARGEN 4 PA (ANTINEOPLASTICS, new

starts only) THIOTEPA 3 PA (ANTINEOPLASTICS, new

starts only) TREANDA INJECTION 100MG 4 PA (Treanda, new starts only)

Page 27: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 16 of 78

Drug Name Drug Tier Requirements/Limits

ZANOSAR 4 PA (ANTINEOPLASTICS, new starts only)

Antiangiogenic Agents CAPRELSA 4 PA (VANDETANIB, new starts

only) REVLIMID CAPSULE 10MG, 15MG, 25MG, 5MG 4 PA (Revlimid, new starts only) LATHALOMID 4 PA (Thalomid, new starts only) VANDETANIB 4 PA (VANDETANIB, new starts

only) VOTRIENT 4 PA (VOTRIENT, new starts only)

Antiestrogens/Modifiers EMCYT 2 PA (EMCYT, new starts only) FARESTON 3 FASLODEX 4 PA (ANTINEOPLASTICS, new

starts only) tamoxifen citrate 1 GC

Antimetabolites cladribine 4 PA CLOLAR 4 PA (ANTINEOPLASTICS, new

starts only) cytarabine aqueous injection 100mg/ml 3 PA cytarabine aqueous injection 20mg/ml 1 PA GC cytarabine injection 500mg 1 PA GC DROXIA 2 ELITEK INJECTION 1.5MG 4 PA (ANTINEOPLASTICS, new

starts only) fluorouracil injection 500mg/10ml 1 PA GC FOLOTYN INJECTION 40MG/2ML 4 PA (FOLOTYN, new starts only) gemcitabine hcl injection 1gm 4 PA (ANTINEOPLASTICS, new

starts only) gemcitabine injection 1gm/26.3ml 4 PA (ANTINEOPLASTICS, new

starts only) GEMZAR INJECTION 1GM 4 PA (ANTINEOPLASTICS, new

starts only) hydroxyurea 1 GC mercaptopurine 1 GC pentostatin 4 PA (ANTINEOPLASTICS, new

starts only) TABLOID 3 PA (TABLOID, new starts only)

Antineoplastics, Other ABRAXANE 4 PA (ANTINEOPLASTICS, new

starts only) adriamycin injection 2mg/ml 3 PA ALIMTA 4 PA (Alimta, new starts only) amifostine 4 ARRANON 4 PA (ANTINEOPLASTICS, new

starts only) bleomycin sulfate injection 30unit 3 PA carboplatin injection 150mg/15ml 1 GC cisplatin injection 100mg/100ml 1 GC

Page 28: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 17 of 78

Drug Name Drug Tier Requirements/Limits

DACOGEN 4 daunorubicin hcl injection 5mg/ml 3 DAUNOXOME 3 dexrazoxane injection 500mg 4 PA (ANTINEOPLASTICS, new

starts only) DOCEFREZ 4 DOCETAXEL INJECTION 80MG/8ML 4 PA docetaxel injection 80mg/4ml 4 PA (ANTINEOPLASTICS, new

starts only) DOXIL 4 PA doxorubicin hcl injection 2mg/ml 3 PA ELSPAR 3 PA (ANTINEOPLASTICS, new

starts only) epirubicin hcl injection 50mg/25ml 3 PA (ANTINEOPLASTICS, new

starts only) ERIVEDGE 4 QL (31 EA per 31 days) PA

(ERIVEDGE, new starts only) ETOPOPHOS 4 PA (ANTINEOPLASTICS, new

starts only) etoposide injection 1 GC FIRMAGON INJECTION 120MG 4 QL (2 EA per 365 days) PA

(Degarelix, new starts only) FIRMAGON INJECTION 80MG 3 QL (4 EA per 28 days) PA

(Degarelix, new starts only) fludarabine phosphate injection 50mg 4 PA (ANTINEOPLASTICS, new

starts only) HALAVEN 4 PA (Halaven, new starts only) idarubicin hcl injection 10mg/10ml 4 PA (ANTINEOPLASTICS, new

starts only) irinotecan injection 100mg/5ml 3 ISTODAX 4 PA (ISTODAX, new starts only) IXEMPRA KIT INJECTION 45MG 4 JAKAFI 4 QL (62 EA per 31 days) PA

(JAKAFI, new starts only) JEVTANA 4 PA (Jevtana, new starts only) mesna 3 MESNEX TABLET 3 PA (ANTINEOPLASTICS, new

starts only) mitomycin injection 20mg 3 mitoxantrone hcl 3 NOVANTRONE 4 ST (Novantrone Therapy - PS

PART D #2, new starts only) ONTAK 4 PA (ONTAK, new starts only) oxaliplatin injection 100mg/20ml 4 PA (ANTINEOPLASTICS, new

starts only) paclitaxel injection 300mg/50ml 3 PA (ANTINEOPLASTICS, new

starts only) PICATO 3 PROLEUKIN 4 PA (Proleukin, new starts only) SYLATRON INJECTION 296MCG, 444MCG, 888MCG 4 PA (SYLATRON, new starts only)

Page 29: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 18 of 78

Drug Name Drug Tier Requirements/Limits

TAXOTERE INJECTION 80MG/2ML, 80MG/4ML 4 PA (ANTINEOPLASTICS, new starts only)

toposar 1 GC topotecan hcl injection 4mg 4 PA (ANTINEOPLASTICS, new

starts only) TORISEL 4 TRISENOX 3 PA (TRISENOX, new starts only)VELCADE 4 PA (VELCADE, new starts only) VIDAZA 4 PA (VIDAZA, new starts only) vinblastine sulfate injection 10mg 1 PA GC vincasar pfs 1 PA GC vincristine sulfate 1 PA GC vinorelbine tartrate injection 50mg/5ml 3 ZOLINZA 4 PA (Zolinza, new starts only) ZYTIGA 4 PA (ZYTIGA, new starts only)

Aromatase Inhibitors, 3rd Generation anastrozole 1 GC exemestane 3 letrozole 1 GC

Molecular Target Inhibitors AFINITOR 4 PA (Afinitor, new starts only) GLEEVEC 4 PA (Gleevec, new starts only) INLYTA TABLET 5MG 4 QL (124 EA per 31 days) PA

(INLYTA, new starts only) INLYTA TABLET 1MG 4 QL (248 EA per 31 days) PA

(INLYTA, new starts only) NEXAVAR 4 PA (Nexavar, new starts only) SPRYCEL 4 PA (Sprycel, new starts only) SUTENT 4 PA (Sutent, new starts only) TARCEVA 4 PA (Tarceva, new starts only) TASIGNA 4 PA (Tasigna, new starts only) TYKERB 4 PA (Tykerb, new starts only) XALKORI 4 PA (XALKORI, new starts only) ZELBORAF 4 PA (ZELBORAF, new starts only)

Monoclonal Antibodies ARZERRA INJECTION 100MG/5ML 4 PA (Arzerra, new starts only) AVASTIN INJECTION 100MG/4ML 4 PA (Avastin, new starts only) CAMPATH 4 PA (CAMPATH, new starts only) ERBITUX INJECTION 100MG/50ML 4 PA (Erbitux, new starts only) HERCEPTIN 4 PA (ANTINEOPLASTICS, new

starts only) RITUXAN 4 PA (Rituxan, new starts only) VECTIBIX INJECTION 100MG/5ML 4 PA (Vectibix, new starts only) YERVOY INJECTION 50MG/10ML 4 PA (YERVOY, new starts only)

Retinoids PANRETIN 4 PA (PANRETIN, new starts only)TARGRETIN 4 PA (TARGRETIN, new starts

only) tretinoin 4

Antiparasitics

Page 30: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 19 of 78

Drug Name Drug Tier Requirements/Limits

Anthelmintics ALBENZA 2 BILTRICIDE 2 mebendazole 1 GC STROMECTOL 2

Antiprotozoals ALINIA 3 atovaquone/proguanil hcl tablet 250mg; 100mg 3 chloroquine phosphate 1 GC DARAPRIM 2 hydroxychloroquine sulfate 1 GC MALARONE 3 mefloquine hcl 1 GC MEPRON 4 PRIMAQUINE PHOSPHATE 2 QUALAQUIN 3 PA (Qualaquin) tinidazole 1 GC

Pediculicides/ Scabicides acticin 1 GC EURAX 3 lindane 3 malathion 3 permethrin cream 1 GC

Antiparkinson Agents Antiparkinson Agents

APOKYN 4 QL (60 ML per 31 days) AZILECT 2 benztropine mesylate injection 3 benztropine mesylate tablet 1 GC bromocriptine mesylate capsule 3 bromocriptine mesylate tablet 1 GC carbidopa/levodopa 1 GC carbidopa/levodopa cr 1 GC carbidopa/levodopa er tablet extended release 50mg; 200mg

1 GC

carbidopa/levodopa odt 1 GC COMTAN 2 LODOSYN 3 pramipexole dihydrochloride 3 ropinirole er 3 ropinirole hcl 1 GC selegiline hcl 1 GC STALEVO 100 3 STALEVO 125 3 STALEVO 150 3 STALEVO 200 3 STALEVO 50 3 STALEVO 75 3 trihexyphenidyl hcl 1 GC

Page 31: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 20 of 78

Drug Name Drug Tier Requirements/Limits

ZELAPAR 3 ST (Zelapar Therapy - PS PART D #2)

Antipsychotics Atypicals

ABILIFY DISCMELT 3 QL (62 EA per 31 days) ABILIFY INJECTION 3 ABILIFY TABLET 3 QL (31 EA per 31 days) ABILIFY ORAL SOLUTION 3 QL (775 ML per 31 days) clozapine 1 GC FANAPT 3 QL (62 EA per 31 days) ST

(Fanapt Therapy - PS PART D #2; Fanapt Therapy - PS PART D 2 #2, new starts only)

FANAPT TITRATION PACK 3 QL (8 EA per 31 days) ST (Fanapt Therapy - PS PART D #2; Fanapt Therapy - PS PART D 2 #2, new starts only)

FAZACLO 3 GEODON INJECTION 3 PA (ANTIPSYCHOTICS - IM,

new starts only) GEODON CAPSULE 3 PA (ANTIPSYCHOTICS - ORAL,

new starts only) INVEGA 3 PA (ANTIPSYCHOTICS - ORAL,

new starts only) INVEGA SUSTENNA INJECTION 117MG/0.75ML 4 QL (0.75 ML per 28 days) PA

(ANTIPSYCHOTICS - IM, new starts only)

INVEGA SUSTENNA INJECTION 156MG/ML 4 QL (1 ML per 28 days) PA (ANTIPSYCHOTICS - IM, new starts only)

INVEGA SUSTENNA INJECTION 234MG/1.5ML 4 QL (1.5 ML per 28 days) PA (ANTIPSYCHOTICS - IM, new starts only)

INVEGA SUSTENNA INJECTION 39MG/0.25ML 3 QL (0.25 ML per 28 days) PA (ANTIPSYCHOTICS - IM, new starts only)

INVEGA SUSTENNA INJECTION 78MG/0.5ML 3 QL (0.5 ML per 28 days) PA (ANTIPSYCHOTICS - IM, new starts only)

LATUDA TABLET 20MG, 40MG, 80MG 3 QL (31 EA per 31 days) olanzapine odt 3 QL (31 EA per 31 days) olanzapine tablet 3 QL (31 EA per 31 days) olanzapine injection 1 GC RISPERDAL CONSTA INJECTION 37.5MG, 50MG 4 QL (4 EA per 28 days) PA

(ANTIPSYCHOTICS - IM, new starts only)

RISPERDAL CONSTA INJECTION 12.5MG, 25MG 3 QL (4 EA per 28 days) PA (ANTIPSYCHOTICS - IM, new starts only)

risperidone odt 3

Page 32: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 21 of 78

Drug Name Drug Tier Requirements/Limits

risperidone solution 3 risperidone tablet 1 GC ziprasidone hcl 3 PA (ANTIPSYCHOTICS - ORAL,

new starts only) ZYPREXA ZYDIS 3 QL (31 EA per 31 days) ZYPREXA INJECTION 3 ZYPREXA TABLET 10MG, 2.5MG, 20MG, 5MG, 7.5MG 3 QL (31 EA per 31 days) ZYPREXA TABLET 15MG 3 QL (31 EA per 31 days)

Conventional chlorpromazine hcl 1 GC fluphenazine decanoate 1 GC fluphenazine hcl 1 GC haloperidol 1 GC haloperidol decanoate 1 GC haloperidol lactate 1 GC loxapine succinate 1 GC ORAP 2 perphenazine 1 GC perphenazine/amitriptyline 1 GC prochlorperazine edisylate 1 GC prochlorperazine maleate 1 GC thioridazine hcl 1 GC thiothixene 1 GC trifluoperazine hcl 1 GC

Antispasticity Agents Antispasticity Agents

baclofen 1 GC dantrolene sodium capsule 1 GC GABLOFEN INJECTION 40000MCG/20ML 4 PA (GABLOFEN) GABLOFEN INJECTION 10000MCG/20ML, 50MCG/ML 2 PA (GABLOFEN) LIORESAL INTRATHECAL INJECTION 10MG/5ML 4 PA (LIORESAL) LIORESAL INTRATHECAL INJECTION 0.05MG/ML, 10MG/20ML

2 PA (LIORESAL)

tizanidine hcl capsule 2 tizanidine hcl tablet 1 GC ZANAFLEX CAPSULE 3

Antivirals Anti-cytomegalovirus (CMV) Agents

FOSCARNET SODIUM 2 PA GANCICLOVIR CAPSULE 250MG 3 ganciclovir capsule 500mg 4 ganciclovir injection 3 PA VALCYTE 4 ZIRGAN 2

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors

ATRIPLA 4 COMPLERA 4 EDURANT 4 INTELENCE TABLET 100MG, 200MG 4

Page 33: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 22 of 78

Drug Name Drug Tier Requirements/Limits

nevirapine tablet 2 RESCRIPTOR 3 STRIBILD 4 SUSTIVA 3 VIRAMUNE XR 2 VIRAMUNE SUSPENSION 3 VIRAMUNE TABLET 2

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors

abacavir 2 COMBIVIR 4 didanosine 3 EMTRIVA 3 EPIVIR HBV 2 EPIVIR SOLUTION 2 EPZICOM 4 lamivudine 2 lamivudine/zidovudine 4 RETROVIR IV INFUSION 3 stavudine 3 TRIZIVIR 4 TRUVADA 4 VIDEX PEDIATRIC SOLUTION RECONSTITUTED 2GM

3

VIREAD 4 ZIAGEN 2 zidovudine capsule, syrup 3 zidovudine tablet 1 GC

Anti-HIV Agents, Other FUZEON INJECTION 90MG 4 ISENTRESS TABLET 4 SELZENTRY 4

Anti-HIV Agents, Protease Inhibitors APTIVUS 4 CRIXIVAN 2 INVIRASE TABLET 4 INVIRASE CAPSULE 3 KALETRA SOLUTION 4 KALETRA TABLET 200MG; 50MG 4 KALETRA TABLET 100MG; 25MG 3 LEXIVA TABLET 4 LEXIVA SUSPENSION 3 NORVIR TABLET 3 NORVIR CAPSULE, SOLUTION 3 PREZISTA TABLET 400MG, 600MG 4 QL (62 EA per 31 days) PREZISTA TABLET 150MG 3 QL (186 EA per 31 days) PREZISTA TABLET 75MG 3 QL (62 EA per 31 days) REYATAZ CAPSULE 150MG, 300MG 4 QL (31 EA per 31 days) REYATAZ CAPSULE 200MG 4 QL (62 EA per 31 days) REYATAZ CAPSULE 100MG 3 QL (31 EA per 31 days)

Page 34: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 23 of 78

Drug Name Drug Tier Requirements/Limits

VICTRELIS 4 QL (372 EA per 31 days) PA (VICTRELIS)

VIRACEPT TABLET 4 VIRACEPT POWDER 3

Anti-influenza Agents amantadine hcl 1 GC RELENZA DISKHALER 3 QL (62 EA per 31 days) rimantadine hcl 1 GC TAMIFLU CAPSULE 45MG, 75MG 2 QL (31 EA per 31 days) TAMIFLU CAPSULE 30MG 2 QL (62 EA per 31 days) TAMIFLU SUSPENSION RECONSTITUTED 12MG/ML 2 QL (194 ML per 31 days) TAMIFLU SUSPENSION RECONSTITUTED 6MG/ML 2 QL (388 ML per 31 days)

Antihepatitis Agents BARACLUDE TABLET 4 PA (BARACLUDE) BARACLUDE SOLUTION 3 PA (BARACLUDE) HEPSERA 4 PA (HEPSERA, new starts only) INCIVEK 4 QL (186 EA per 31 days) PA

(INCIVEK) REBETOL SOLUTION 3 PA (Ribavirin) ribasphere capsule 1 QL (217 EA per 31 days) PA

(Ribavirin) GC RIBASPHERE TABLET 400MG, 600MG 4 QL (56 EA per 28 days) PA

(Ribavirin) ribasphere tablet 200mg 1 QL (93 EA per 31 days) PA

(Ribavirin) GC ribavirin 1 QL (155 EA per 31 days) PA

(Ribavirin) GC TYZEKA 4

Antiherpetic Agents acyclovir 1 GC acyclovir sodium injection 500mg 3 PA DENAVIR 2 famciclovir 3 trifluridine 3 valacyclovir hcl 3 ZOVIRAX CREAM, OINTMENT 2

Anxiolytics Anxiolytics, Other

alprazolam tablet 0.25mg, 0.5mg, 1mg 1 QL (90 EA per 30 days) ED GC alprazolam tablet 2mg 1 QL (120 EA per 30 days) ED GCbuspirone hcl 1 GC chlordiazepoxide/amitriptyline 1 GC clonazepam tablet 0.5mg, 1mg, 2mg 1 QL (90 EA per 30 days) ED GC clorazepate dipotassium tablet 7.5mg, 15mg 1 QL (90 EA per 30 days) ED GC diazepam tablet 2mg, 5mg, 10mg 1 QL (90 EA per 30 days) ED GC lorazepam tablet 0.5mg, 1mg 1 QL (90 EA per 30 days) ED GC lorazepam tablet 2mg 1 QL (60 EA per 30 days) ED GC meprobamate 1 GC

Bipolar Agents Bipolar Agents

Page 35: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 24 of 78

Drug Name Drug Tier Requirements/Limits

EQUETRO 2 lithium carbonate 1 GC lithium carbonate er 1 GC lithium citrate 1 GC LITHOBID 2 olanzapine/fluoxetine 3 quetiapine fumarate 1 GC SAPHRIS 2 PA (ANTIPSYCHOTICS - ORAL,

new starts only) SEROQUEL 3 SEROQUEL XR 2 SYMBYAX 3

Blood Glucose Regulators Antidiabetic Agents

acarbose tablet 50mg 1 QL (186 EA per 31 days) ST (Alpha Glucosidase Inhibitor Therapy - PS PART D #2) GC

acarbose tablet 25mg 1 QL (372 EA per 31 days) ST (Alpha Glucosidase Inhibitor Therapy - PS PART D #2) GC

acarbose tablet 100mg 1 QL (93 EA per 31 days) ST (Alpha Glucosidase Inhibitor Therapy - PS PART D #2) GC

ACTOPLUS MET 2 QL (93 EA per 31 days) ACTOS TABLET 30MG, 45MG 2 QL (31 EA per 31 days) ST

(Actos Therapy - PS PART D #2)ACTOS TABLET 15MG 2 QL (93 EA per 31 days) ST

(Actos Therapy - PS PART D #2)AVANDAMET TABLET 500MG; 2MG 3 QL (124 EA per 31 days) PA

(Rosiglitazone) AVANDAMET TABLET 1000MG; 2MG, 1000MG; 4MG, 500MG; 4MG

3 QL (62 EA per 31 days) PA (Rosiglitazone)

AVANDARYL 3 QL (31 EA per 31 days) PA (Rosiglitazone)

BYDUREON 2 QL (4 EA per 28 days) ST (Bydureon Therapy - QHP #2)

BYETTA INJECTION 5MCG/0.02ML 2 QL (1.2 ML per 30 days) ST (Incretin Mimetic Therapy - PS PART D #2; Incretin Mimetic Therapy - PS PART D 2 #2)

BYETTA INJECTION 10MCG/0.04ML 2 QL (2.4 ML per 30 days) ST (Incretin Mimetic Therapy - PS PART D #2; Incretin Mimetic Therapy - PS PART D 2 #2)

DUETACT 2 QL (31 EA per 31 days) ST (Duetact Therapy - PS PART D #2)

FORTAMET TABLET EXTENDED RELEASE 24 HOUR 500MG

3 QL (155 EA per 31 days)

Page 36: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 25 of 78

Drug Name Drug Tier Requirements/Limits

FORTAMET TABLET EXTENDED RELEASE 24 HOUR 1000MG

3 QL (62 EA per 31 days)

glimepiride tablet 2mg 1 QL (124 EA per 31 days) GC glimepiride tablet 1mg 1 QL (248 EA per 31 days) GC glimepiride tablet 4mg 1 QL (62 EA per 31 days) GC glipizide er tablet extended release 24 hour 5mg 1 QL (124 EA per 31 days) GC glipizide er tablet extended release 24 hour 2.5mg 1 QL (248 EA per 31 days) GC glipizide er tablet extended release 24 hour 10mg 1 QL (62 EA per 31 days) GC glipizide/metformin hcl tablet 2.5mg; 500mg, 5mg; 500mg

1 QL (124 EA per 31 days) GC

glipizide/metformin hcl tablet 2.5mg; 250mg 1 QL (248 EA per 31 days) GC glipizide tablet 10mg 1 QL (124 EA per 31 days) GC glipizide tablet 5mg 1 QL (248 EA per 31 days) GC GLUMETZA TABLET EXTENDED RELEASE 24 HOUR 500MG

3 QL (124 EA per 31 days)

GLUMETZA TABLET EXTENDED RELEASE 24 HOUR 1000MG

3 QL (62 EA per 31 days)

glyburide micronized tablet 3mg 1 QL (124 EA per 31 days) GC glyburide micronized tablet 1.5mg 1 QL (248 EA per 31 days) GC glyburide micronized tablet 6mg 1 QL (62 EA per 31 days) GC glyburide/metformin hcl tablet 2.5mg; 500mg, 5mg; 500mg

1 QL (124 EA per 31 days) GC

glyburide/metformin hcl tablet 1.25mg; 250mg 1 QL (248 EA per 31 days) GC glyburide tablet 5mg 1 QL (124 EA per 31 days) GC glyburide tablet 2.5mg 1 QL (248 EA per 31 days) GC glyburide tablet 1.25mg 1 QL (496 EA per 31 days) GC glycron tablet 3mg 1 QL (124 EA per 31 days) GC glycron tablet 1.5mg 1 QL (248 EA per 31 days) GC glycron tablet 6mg 1 QL (62 EA per 31 days) GC GLYSET TABLET 50MG 3 QL (186 EA per 31 days) ST

(Alpha Glucosidase Inhibitor Therapy - PS PART D #2)

GLYSET TABLET 25MG 3 QL (372 EA per 31 days) ST (Alpha Glucosidase Inhibitor Therapy - PS PART D #2)

GLYSET TABLET 100MG 3 QL (93 EA per 31 days) ST (Alpha Glucosidase Inhibitor Therapy - PS PART D #2)

JANUMET 2 QL (62 EA per 31 days) ST (Dipeptidyl Peptidase-4 Inhibitor/ Metformin Combination Therapy -PS PART D #2)

JANUMET XR TABLET EXTENDED RELEASE 24 HOUR 1000MG; 100MG, 500MG; 50MG

2 QL (31 EA per 31 days) ST (Janumet XR Therapy - QHP #2)

JANUMET XR TABLET EXTENDED RELEASE 24 HOUR 1000MG; 50MG

2 QL (62 EA per 31 days) ST (Janumet XR Therapy - QHP #2)

JANUVIA TABLET 25MG 2 QL (124 EA per 31 days) ST (Dipeptidyl Peptidase-4 Inhibitor Therapy - PS PART D #2)

Page 37: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 26 of 78

Drug Name Drug Tier Requirements/Limits

JANUVIA TABLET 100MG 2 QL (31 EA per 31 days) ST (Dipeptidyl Peptidase-4 Inhibitor Therapy - PS PART D #2)

JANUVIA TABLET 50MG 2 QL (62 EA per 31 days) ST (Dipeptidyl Peptidase-4 Inhibitor Therapy - PS PART D #2)

KOMBIGLYZE XR TABLET EXTENDED RELEASE 24 HOUR 1000MG; 5MG, 500MG; 5MG

2 QL (31 EA per 31 days) ST (Dipeptidyl Peptidase-4 Inhibitor/ Metformin Combination Therapy -PS PART D #2)

KOMBIGLYZE XR TABLET EXTENDED RELEASE 24 HOUR 1000MG; 2.5MG

2 QL (62 EA per 31 days) ST (Dipeptidyl Peptidase-4 Inhibitor/ Metformin Combination Therapy -PS PART D #2)

metformin hcl er tablet extended release 24 hour 500mg 1 QL (124 EA per 31 days) GC metformin hcl er tablet extended release 24 hour 750mg 1 QL (62 EA per 31 days) GC metformin hcl tablet 500mg 1 QL (155 EA per 31 days) GC metformin hcl tablet 1000mg 1 QL (77.5 EA per 31 days) GC metformin hcl tablet 850mg 1 QL (93 EA per 31 days) GC nateglinide tablet 60mg 1 QL (186 EA per 31 days) GC nateglinide tablet 120mg 1 QL (93 EA per 31 days) GC ONGLYZA TABLET 5MG 2 QL (31 EA per 31 days) ST

(Dipeptidyl Peptidase-4 Inhibitor Therapy - PS PART D #2)

ONGLYZA TABLET 2.5MG 2 QL (62 EA per 31 days) ST (Dipeptidyl Peptidase-4 Inhibitor Therapy - PS PART D #2)

pioglitazone hcl/metformin hcl 1 QL (93 EA per 31 days) GC PRANDIN TABLET 2MG 3 QL (248 EA per 31 days) ST

(Meglitinide Therapy - PS PART D #2)

PRANDIN TABLET 1MG 3 QL (496 EA per 31 days) ST (Meglitinide Therapy - PS PART D #2)

PRANDIN TABLET 0.5MG 3 QL (992 EA per 31 days) ST (Meglitinide Therapy - PS PART D #2)

RIOMET 3 QL (791 ML per 31 days) SYMLIN 3 QL (20 ML per 31 days) SYMLINPEN 120 3 QL (10.8 ML per 30 days) SYMLINPEN 60 3 QL (6 ML per 31 days) tolazamide tablet 250mg 1 QL (124 EA per 31 days) GC tolazamide tablet 500mg 1 QL (62 EA per 31 days) GC tolbutamide 1 QL (186 EA per 31 days) GC VICTOZA 2 QL (9 ML per 30 days) ST

(Incretin Mimetic Therapy - PS PART D 2 #2)

Glycemic Agents GLUCAGEN HYPOKIT 3 GLUCAGON EMERGENCY KIT 2

Page 38: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 27 of 78

Drug Name Drug Tier Requirements/Limits

PROGLYCEM 3 Insulins

HUMALOG 2 HUMALOG KWIKPEN 2 HUMALOG MIX 50/50 2 HUMALOG MIX 50/50 KWIKPEN 2 HUMALOG MIX 75/25 2 HUMALOG MIX 75/25 KWIKPEN 2 HUMULIN 70/30 2 HUMULIN 70/30 PEN 2 HUMULIN N 2 HUMULIN N U-100 PEN 2 HUMULIN R 2 HUMULIN R U-500 (CONCENTRATED) 2 PA LANTUS 2 LANTUS SOLOSTAR 2 LEVEMIR 2 LEVEMIR FLEXPEN 2 NOVOLIN 70/30 2 NOVOLIN N 2 NOVOLIN R 2 NOVOLOG 2 NOVOLOG FLEXPEN 2 NOVOLOG MIX 70/30 2 NOVOLOG MIX 70/30 PREFILLED FLEXPEN 2

Blood Products/Modifiers/ Volume Expanders Anticoagulants

ARGATROBAN INJECTION 100MG/ML 4 argatroban injection 125mg/125ml; 0.9% 4 ARIXTRA INJECTION 5MG/0.4ML 4 QL (12.4 ML per 31 days) PA

(ANTICOAGULANTS = INJ, new starts only)

ARIXTRA INJECTION 7.5MG/0.6ML 4 QL (18.6 ML per 31 days) PA (ANTICOAGULANTS = INJ, new starts only)

ARIXTRA INJECTION 10MG/0.8ML 4 QL (24.8 ML per 31 days) PA (ANTICOAGULANTS = INJ, new starts only)

ARIXTRA INJECTION 2.5MG/0.5ML 3 QL (15.5 ML per 31 days) PA (ANTICOAGULANTS = INJ, new starts only)

COUMADIN INJECTION 3 COUMADIN TABLET 2 enoxaparin sodium injection 120mg/0.8ml 4 QL (49.6 ML per 31 days) enoxaparin sodium injection 100mg/ml, 150mg/ml 4 QL (62 ML per 31 days) enoxaparin sodium injection 30mg/0.3ml 3 QL (18.6 ML per 31 days) enoxaparin sodium injection 40mg/0.4ml 3 QL (24.8 ML per 31 days) enoxaparin sodium injection 60mg/0.6ml 3 QL (37.2 ML per 31 days) enoxaparin sodium injection 80mg/0.8ml 3 QL (49.6 ML per 31 days)

Page 39: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 28 of 78

Drug Name Drug Tier Requirements/Limits

fondaparinux sodium injection 5mg/0.4ml 3 QL (12.4 ML per 31 days) PA (ANTICOAGULANTS = INJ, new starts only)

fondaparinux sodium injection 2.5mg/0.5ml 3 QL (15.5 ML per 31 days) PA (ANTICOAGULANTS = INJ, new starts only)

fondaparinux sodium injection 7.5mg/0.6ml 3 QL (18.6 ML per 31 days) PA (ANTICOAGULANTS = INJ, new starts only)

fondaparinux sodium injection 10mg/0.8ml 3 QL (24.8 ML per 31 days) PA (ANTICOAGULANTS = INJ, new starts only)

FRAGMIN INJECTION 12500UNIT/0.5ML 4 QL (15.5 ML per 31 days) PA (FRAGMIN, new starts only)

FRAGMIN INJECTION 15000UNIT/0.6ML 4 QL (18.6 ML per 31 days) PA (FRAGMIN, new starts only)

FRAGMIN INJECTION 18000UNT/0.72ML 4 QL (22.32 ML per 31 days) PA (FRAGMIN, new starts only)

FRAGMIN INJECTION 10000UNIT/ML 4 QL (31 ML per 31 days) PA (ANTICOAGULANTS = INJ, new starts only)

FRAGMIN INJECTION 7500UNIT/0.3ML 4 QL (9.3 ML per 31 days) PA (ANTICOAGULANTS = INJ, new starts only)

FRAGMIN INJECTION 2500UNIT/0.2ML, 5000UNIT/0.2ML

3 QL (12.4 ML per 31 days) PA (ANTICOAGULANTS = INJ, new starts only)

FRAGMIN INJECTION 25000UNIT/ML 3 QL (31 ML per 31 days) PA (ANTICOAGULANTS = INJ, new starts only)

heparin sodium/d5w injection 5%; 40unit/ml 1 PA (ANTICOAGULANTS = INJ, new starts only) GC

heparin sodium/nacl 0.45% 1 PA (ANTICOAGULANTS = INJ, new starts only) GC

heparin sodium/sodium chloride 0.9% premix 1 GC heparin sodium injection 10000unit/ml, 1000unit/ml, 20000unit/ml, 5000unit/ml

1 GC

heparin sodium injection 2000unit/ml 1 PA (ANTICOAGULANTS = INJ, new starts only) GC

jantoven 1 GC LOVENOX INJECTION 300MG/3ML 3 QL (93 ML per 31 days) PRADAXA 2 QL (62 EA per 31 days) PA

(PRADAXA) warfarin sodium 1 GC XARELTO 2 PA (XARELTO)

Blood Formation Products ARANESP ALBUMIN FREE INJECTION 500MCG/ML 4 QL (1 ML per 21 days) PA

(Aranesp) ARANESP ALBUMIN FREE INJECTION 150MCG/0.3ML

4 QL (1.2 ML per 28 days) PA (Aranesp)

Page 40: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 29 of 78

Drug Name Drug Tier Requirements/Limits

ARANESP ALBUMIN FREE INJECTION 200MCG/0.4ML

4 QL (1.6 ML per 28 days) PA (Aranesp)

ARANESP ALBUMIN FREE INJECTION 300MCG/0.6ML

4 QL (2.4 ML per 28 days) PA (Aranesp)

ARANESP ALBUMIN FREE INJECTION 200MCG/ML, 300MCG/ML

4 QL (4 ML per 28 days) PA (Aranesp)

ARANESP ALBUMIN FREE INJECTION 60MCG/0.3ML 3 QL (1.2 ML per 28 days) PA (Aranesp)

ARANESP ALBUMIN FREE INJECTION 40MCG/0.4ML 3 QL (1.6 ML per 28 days) PA (Aranesp)

ARANESP ALBUMIN FREE INJECTION 25MCG/0.42ML

3 QL (1.7 ML per 28 days) PA (Aranesp)

ARANESP ALBUMIN FREE INJECTION 100MCG/0.5ML

3 QL (2 ML per 28 days) PA (Aranesp)

ARANESP ALBUMIN FREE INJECTION 100MCG/ML, 25MCG/ML, 40MCG/ML, 60MCG/ML

3 QL (4 ML per 28 days) PA (Aranesp)

LEUKINE 4 PA (Leukine) NEULASTA 4 PA (Neulasta) NEUMEGA 2 PA (Neumega) NEUPOGEN INJECTION 300MCG/0.5ML, 480MCG/0.8ML, 480MCG/1.6ML

4 PA (Neupogen)

PROCRIT INJECTION 40000UNIT/ML 4 PA (Epoetin alfa) PROCRIT INJECTION 20000UNIT/ML 4 QL (12 ML per 28 days) PA

(Epoetin alfa) PROCRIT INJECTION 10000UNIT/ML 3 QL (12 ML per 28 days) PA

(Epoetin alfa) PROCRIT INJECTION 2000UNIT/ML 3 QL (15 ML per 31 days) PA

(Epoetin alfa) PROCRIT INJECTION 3000UNIT/ML, 4000UNIT/ML 3 QL (30 ML per 31 days) PA

(Epoetin alfa) PROMACTA 4 PA (Promacta)

Blood Products/Modifiers/ Volume Expanders CINRYZE 4 PA (CINRYZE) MOZOBIL 4 PA (Mozobil) pentopak 1 GC pentoxifylline er 1 GC PROMACTA 4 PA (Promacta)

Coagulants BRILINTA 3 QL (62 EA per 31 days) CYKLOKAPRON 2 tranexamic acid 2

Platelet Aggregation Inhibitors AGGRENOX 2 QL (62 EA per 31 days) cilostazol 1 GC clopidogrel tablet 300mg 1 QL (3 EA per 31 days) GC clopidogrel tablet 75mg 1 QL (31 EA per 31 days) GC EFFIENT 2 QL (31 EA per 31 days) PLAVIX TABLET 300MG 2 QL (3 EA per 31 days) PLAVIX TABLET 75MG 2 QL (31 EA per 31 days) ticlopidine hcl 1 QL (62 EA per 31 days) GC

Page 41: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 30 of 78

Drug Name Drug Tier Requirements/Limits

Cardiovascular Agents Alpha-adrenergic Agonists

clonidine hcl tablet 1 GC clonidine hcl patch weekly 0.2mg/24hr, 0.3mg/24hr 3 QL (10 EA per 31 days) clonidine hcl patch weekly 0.1mg/24hr 3 QL (5 EA per 31 days) CLORPRES 3 guanabenz acetate 1 GC guanfacine hcl 1 GC KAPVAY 2 QL (62 EA per 31 days) methyldopa 1 GC methyldopa/hydrochlorothiazide 1 GC midodrine hcl 1 GC

Alpha-adrenergic Blocking Agents DIBENZYLINE 3 prazosin hcl 1 GC reserpine 1 GC

Antiarrhythmics amiodarone hcl tablet 1 GC amiodarone hcl injection 50mg/ml 1 GC disopyramide phosphate 1 GC flecainide acetate 1 GC mexiletine hcl 1 GC MULTAQ 3 PA (Multaq, new starts only) PACERONE TABLET 100MG 3 pacerone tablet 200mg 1 GC procainamide hcl 1 GC propafenone hcl 1 GC propafenone hcl er 3 QUINIDINE GLUCONATE 3 quinidine gluconate er 1 GC quinidine sulfate 1 GC quinidine sulfate er 1 GC sorine 1 GC sotalol hcl 1 GC sotalol hydrochloride 3 TIKOSYN 3

Beta-adrenergic Blocking Agents acebutolol hcl 1 GC atenolol 1 GC atenolol/chlorthalidone 1 GC betaxolol hcl 1 GC bisoprolol fumarate 1 GC bisoprolol fumarate/hydrochlorothiazide 1 GC BYSTOLIC TABLET 2.5MG 2 QL (31 EA per 31 days) BYSTOLIC TABLET 20MG 2 QL (62 EA per 31 days) BYSTOLIC TABLET 10MG, 5MG 2 QL (93 EA per 31 days) carvedilol 1 GC INNOPRAN XL 3 labetalol hcl 1 GC LEVATOL 3

Page 42: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 31 of 78

Drug Name Drug Tier Requirements/Limits

metoprolol succinate er 1 GC metoprolol tartrate 1 GC metoprolol/hydrochlorothiazide 1 GC nadolol 1 GC nadolol/bendroflumethiazide 1 GC pindolol 1 GC propranolol hcl 1 GC propranolol hcl er 1 GC propranolol/hydrochlorothiazide 1 GC timolol maleate 1 GC

Calcium Channel Blocking Agents afeditab cr 1 GC amlodipine besylate 1 GC amlodipine besylate/benazepril hcl 1 GC amlodipine besylate/benazepril hydrochloride 1 GC AZOR 2 QL (31 EA per 31 days) ST (Azor

Therapy - PS PART D #2) CARDIZEM CD CAPSULE EXTENDED RELEASE 24 HOUR 360MG

3

cartia xt 1 GC COVERA-HS TABLET EXTENDED RELEASE 24 HOUR 240MG

3 QL (62 EA per 31 days)

COVERA-HS TABLET EXTENDED RELEASE 24 HOUR 180MG

3 QL (93 EA per 31 days)

dilt-cd capsule extended release 24 hour 120mg, 300mg 1 GC dilt-xr capsule extended release 24 hour 180mg, 240mg 1 GC diltiazem cd capsule extended release 24 hour 120mg, 240mg, 300mg

1 GC

diltiazem hcl er capsule extended release 24 hour 180mg, 360mg, 420mg

1 GC

diltiazem hcl er capsule extended release 12 hour 1 GC diltiazem hcl tablet 1 GC diltiazem hcl injection 100mg, 25mg/5ml 1 GC diltzac capsule extended release 24 hour 120mg, 180mg, 240mg, 300mg

1 GC

DYNACIRC CR TABLET EXTENDED RELEASE 24 HOUR 10MG

3 QL (62 EA per 31 days)

DYNACIRC CR TABLET EXTENDED RELEASE 24 HOUR 5MG

3 QL (93 EA per 31 days)

felodipine er 1 GC isradipine 1 GC matzim la 1 GC nicardipine hcl 1 GC nifediac cc 1 GC nifedical xl 1 GC nifedipine er 1 GC nimodipine 3 nisoldipine er 3 QL (31 EA per 31 days) nisoldipine tablet extended release 24 hour 20mg, 30mg, 40mg

3

Page 43: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 32 of 78

Drug Name Drug Tier Requirements/Limits

nisoldipine tablet extended release 24 hour 17mg, 34mg, 8.5mg

3 QL (31 EA per 31 days)

taztia xt 1 GC TRIBENZOR 2 QL (31 EA per 31 days) ST

(Tribenzor Therapy - PS PART D #2)

TWYNSTA 3 QL (31 EA per 31 days) ST (Twynsta Therapy - PS PART D #2)

verapamil hcl 1 GC verapamil hcl er 1 GC

Cardiovascular Agents, Other DEMSER 4 digoxin 1 GC LANOXIN INJECTION 0.1MG/ML 2 LANOXIN TABLET 0.125MG 2 RANEXA 2 ST (Ranexa Therapy - PS PART

D #2) Diuretics

acetazolamide sodium 1 GC ALDACTAZIDE TABLET 50MG; 50MG 3 amiloride hcl 1 GC amiloride/hydrochlorothiazide 1 GC bumetanide 1 GC chlorothiazide 1 GC chlorothiazide sodium 3 PA (CARDIOVASCULAR

AGENTS, new starts only) chlorthalidone tablet 25mg, 50mg 1 GC DIURIL 2 DYRENIUM 3 EDECRIN 3 eplerenone 3 furosemide 1 GC hydrochlorothiazide 1 GC indapamide 1 GC methyclothiazide 1 GC metolazone 1 GC SAMSCA TABLET 15MG 4 QL (31 EA per 31 days) PA

(Samsca) SAMSCA TABLET 30MG 4 QL (62 EA per 31 days) PA

(Samsca) spironolactone 1 GC spironolactone/hydrochlorothiazide 1 GC THALITONE 3 torsemide tablet 1 GC torsemide injection 20mg/2ml 1 GC triamterene/hydrochlorothiazide 1 GC

Dyslipidemics ADVICOR TABLET EXTENDED RELEASE 24 HOUR 40MG; 1000MG

3 QL (31 EA per 31 days)

Page 44: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 33 of 78

Drug Name Drug Tier Requirements/Limits

ADVICOR TABLET EXTENDED RELEASE 24 HOUR 20MG; 1000MG, 20MG; 500MG, 20MG; 750MG

3 QL (62 EA per 31 days)

ALTOPREV 3 QL (31 EA per 31 days) ST (Statin Therapy: Group 1 - PS PART D #2; Statin Therapy: Group 1 - PS PART D 2 #2)

ANTARA 2 atorvastatin calcium 2 QL (31 EA per 31 days) cholestyramine light packet 1 GC colestipol hcl 1 GC CRESTOR 2 QL (31 EA per 31 days) fenofibrate 1 GC fenofibrate micronized 1 GC fluvastatin capsule 20mg 1 QL (31 EA per 31 days) GC fluvastatin capsule 40mg 1 QL (62 EA per 31 days) GC gemfibrozil 1 GC LESCOL XL 3 QL (31 EA per 31 days) ST

(Statin Therapy: Group 1 - PS PART D #2; Statin Therapy: Group 1 - PS PART D 2 #2)

LESCOL CAPSULE 20MG 3 QL (31 EA per 31 days) LESCOL CAPSULE 40MG 3 QL (62 EA per 31 days) lovastatin 1 GC LOVAZA 3 niacor 1 GC NIASPAN 2 pravastatin sodium 1 GC prevalite powder 1 GC SIMCOR TABLET EXTENDED RELEASE 24 HOUR 1000MG; 40MG, 500MG; 40MG

2 QL (31 EA per 31 days)

SIMCOR TABLET EXTENDED RELEASE 24 HOUR 500MG; 20MG, 750MG; 20MG

2 QL (62 EA per 31 days)

simvastatin tablet 10mg, 20mg, 40mg, 5mg 1 GC simvastatin tablet 80mg 1 PA (SIMVASTATIN, new starts

only) GC TRICOR 2 TRILIPIX 2 VYTORIN TABLET 10MG; 80MG 3 QL (31 EA per 31 days) PA

(SIMVASTATIN, new starts only)VYTORIN TABLET 10MG; 10MG, 10MG; 20MG, 10MG; 40MG

3 QL (31 EA per 31 days) ST (Statin Therapy: Group 2 - PS PART D #2; Statin Therapy: Group 2 - PS PART D 2 #2)

WELCHOL 2 ZETIA 2 QL (31 EA per 31 days) ST (Zetia

Therapy - PS PART D #2) Renin-angiotensin-aldosterone System Inhibitors

benazepril hcl 1 GC benazepril hcl/hydrochlorothiazide 1 GC

Page 45: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 34 of 78

Drug Name Drug Tier Requirements/Limits

BENICAR 2 QL (31 EA per 31 days) ST (Angiotensin Receptor Blocker: Group 2 - PS PART D #2)

BENICAR HCT 2 QL (31 EA per 31 days) ST (Angiotensin Receptor Blocker: Group 2 - PS PART D #2)

captopril 1 GC captopril/hydrochlorothiazide 1 GC DIOVAN HCT TABLET 12.5MG; 320MG, 25MG; 320MG 2 QL (31 EA per 31 days) ST

(Angiotensin Receptor Blocker: Group 2 - PS PART D #2)

DIOVAN HCT TABLET 12.5MG; 160MG, 12.5MG; 80MG, 25MG; 160MG

2 QL (62 EA per 31 days) ST (Angiotensin Receptor Blocker: Group 2 - PS PART D #2)

DIOVAN TABLET 320MG 2 QL (31 EA per 31 days) ST (Angiotensin Receptor Blocker: Group 2 - PS PART D #2)

DIOVAN TABLET 160MG, 40MG, 80MG 2 QL (62 EA per 31 days) ST (Angiotensin Receptor Blocker: Group 2 - PS PART D #2)

EDARBI 3 QL (31 EA per 31 days) EDARBYCLOR 3 QL (31 EA per 31 days) enalapril maleate 1 GC enalapril maleate/hydrochlorothiazide 1 GC eprosartan mesylate 1 QL (31 EA per 31 days) GC fosinopril sodium 1 GC fosinopril sodium/hydrochlorothiazide 1 GC irbesartan/hydrochlorothiazide tablet 12.5mg; 300mg 1 QL (31 EA per 31 days) GC irbesartan/hydrochlorothiazide tablet 12.5mg; 150mg 1 QL (62 EA per 31 days) GC irbesartan tablet 300mg 1 QL (31 EA per 31 days) GC irbesartan tablet 150mg 1 QL (62 EA per 31 days) GC irbesartan tablet 75mg 1 QL (93 EA per 31 days) GC lisinopril 1 GC lisinopril/hydrochlorothiazide 1 GC losartan potassium/hydrochlorothiazide tablet 12.5mg; 100mg, 25mg; 100mg

1 QL (31 EA per 31 days) GC

losartan potassium/hydrochlorothiazide tablet 12.5mg; 50mg

1 QL (62 EA per 31 days) GC

losartan potassium tablet 100mg 1 QL (31 EA per 31 days) GC losartan potassium tablet 25mg, 50mg 1 QL (62 EA per 31 days) GC MICARDIS 3 QL (31 EA per 31 days) ST

(Angiotensin Receptor Blocker: Group 1 - PS PART D #2)

MICARDIS HCT 3 QL (31 EA per 31 days) ST (Angiotensin Receptor Blocker: Group 1 - PS PART D #2)

moexipril hcl 1 GC moexipril/hydrochlorothiazide 1 GC perindopril erbumine 1 GC quinapril hcl 1 GC

Page 46: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 35 of 78

Drug Name Drug Tier Requirements/Limits

quinapril/hydrochlorothiazide 1 GC ramipril 1 GC TEKTURNA 2 QL (31 EA per 31 days) ST

(Tekturna Therapy - PS PART D #2)

TEKTURNA HCT 2 QL (31 EA per 31 days) ST (Tekturna Therapy - PS PART D #2)

trandolapril 1 GC Vasodilators

BIDIL 2 DILATRATE SR 3 hydralazine hcl injection 3 hydralazine hcl tablet 1 GC isochron 1 GC ISORDIL TITRADOSE TABLET 40MG 3 isosorbide dinitrate 1 GC isosorbide dinitrate er 1 GC isosorbide mononitrate 1 GC isosorbide mononitrate er 1 GC minitran 1 GC minoxidil 1 GC NITRO-DUR PATCH 24 HOUR 0.3MG/HR, 0.8MG/HR 3 nitroglycerin 1 GC nitroglycerin transdermal patch 24 hour 0.1mg/hr 1 GC NITROLINGUAL PUMPSPRAY 3 NITROMIST 3 NITROSTAT 2

Central Nervous System Agents Amphetamines, ADHD

ADDERALL XR 3 QL (62 EA per 31 days) amphetamine/dextroamphetamine capsule extended release 24 hour

3 QL (62 EA per 31 days)

amphetamine/dextroamphetamine tablet 1 QL (62 EA per 31 days) GC dextroamphetamine sulfate er capsule extended release 24 hour 15mg

3 QL (124 EA per 31 days)

dextroamphetamine sulfate er capsule extended release 24 hour 10mg

3 QL (155 EA per 31 days)

dextroamphetamine sulfate er capsule extended release 24 hour 5mg

3 QL (62 EA per 31 days)

dextroamphetamine sulfate tablet 10mg 1 QL (186 EA per 31 days) GC dextroamphetamine sulfate tablet 5mg 1 QL (62 EA per 31 days) GC

Non-amphetamines, ADHD CONCERTA TABLET EXTENDED RELEASE 18MG, 27MG, 54MG

3 QL (31 EA per 31 days)

CONCERTA TABLET EXTENDED RELEASE 36MG 3 QL (62 EA per 31 days) DAYTRANA 3 QL (31 EA per 31 days) dexmethylphenidate hcl 1 QL (62 EA per 31 days) GC FOCALIN XR CAPSULE EXTENDED RELEASE 24 HOUR 10MG, 15MG, 30MG, 35MG, 40MG, 5MG

3 QL (31 EA per 31 days)

Page 47: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 36 of 78

Drug Name Drug Tier Requirements/Limits

FOCALIN XR CAPSULE EXTENDED RELEASE 24 HOUR 20MG

3 QL (62 EA per 31 days)

focalin xr capsule extended release 24 hour 25mg 3 QL (31 EA per 31 days) METADATE CD 3 QL (31 EA per 31 days) methylin er 1 QL (93 EA per 31 days) GC methylin tablet 1 QL (93 EA per 31 days) GC METHYLIN TABLET CHEWABLE 10MG 3 QL (186 EA per 31 days) METHYLIN TABLET CHEWABLE 2.5MG, 5MG 3 QL (93 EA per 31 days) methylphenidate hcl 1 QL (93 EA per 31 days) GC methylphenidate hcl er capsule extended release 24 hour 40mg

3 QL (31 EA per 31 days)

methylphenidate hcl er capsule extended release 24 hour 30mg

3 QL (62 EA per 31 days)

methylphenidate hcl er capsule extended release 24 hour 20mg

3 QL (93 EA per 31 days)

methylphenidate hcl sr 1 QL (93 EA per 31 days) GC methylphenidate hydrochloride solution 5mg/5ml 3 QL (1860 ML per 31 days) methylphenidate hydrochloride solution 10mg/5ml 3 QL (930 ML per 31 days) RITALIN LA CAPSULE EXTENDED RELEASE 24 HOUR 10MG

3 QL (31 EA per 31 days)

STRATTERA CAPSULE 100MG, 60MG, 80MG 3 QL (31 EA per 31 days) ST (CNS Stimulant Therapy - PS PART D #2; CNS Stimulant Therapy - PS PART D 2 #2)

STRATTERA CAPSULE 10MG, 18MG, 25MG, 40MG 3 QL (62 EA per 31 days) ST (CNS Stimulant Therapy - PS PART D #2; CNS Stimulant Therapy - PS PART D 2 #2)

Non-amphetamines, Other AMPYRA 4 QL (62 EA per 31 days) PA

(AMPYRA) modafinil tablet 100mg 3 QL (31 EA per 31 days) PA

(Provigil) modafinil tablet 200mg 3 QL (62 EA per 31 days) PA

(Provigil) PROVIGIL TABLET 100MG 3 QL (31 EA per 31 days) PA

(Provigil) PROVIGIL TABLET 200MG 3 QL (62 EA per 31 days) PA

(Provigil) RILUTEK 4 XYREM 2 QL (540 ML per 30 days) PA

(XYREM) LA Dental and Oral Agents

Dental and Oral Agents chlorhexidine gluconate oral rinse 1 GC EVOXAC 3 ST (Cholinergic Agonist Therapy

- PS PART D #2) KEPIVANCE 4 periogard 1 GC pilocarpine hcl 3

Page 48: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 37 of 78

Drug Name Drug Tier Requirements/Limits

pilocarpine hydrochloride 3 triamcinolone in orabase 1 GC

Dermatological Agents Dermatological Agents

adapalene cream 3 adapalene gel 1 GC ammonium lactate 1 GC amnesteem 3 avita 1 PA (Topical Retinoids) GC AZELEX 3 BENZACLIN WITH PUMP 2 calcipotriene cream 2 calcipotriene ointment, solution 3 CARAC 2 claravis capsule 30mg 3 claravis capsule 10mg, 20mg, 40mg 3 PA (ISOTRETINOIN) clindamycin/benzoyl peroxide gel 5%; 1% 3 CONDYLOX GEL 3 DIFFERIN LOTION 3 DOVONEX 2 ELIDEL 3 ST (Topical Immunomodulator

Therapy - PS PART D #2) EPIDUO 3 erythromycin/benzoyl peroxide 1 GC FINACEA 2 FLUOROPLEX 2 fluorouracil cream 3 fluorouracil external solution 1 GC imiquimod 3 PA (ALDARA, new starts only) laclotion 1 GC OXSORALEN 3 PA (OXSORALEN) OXSORALEN ULTRA 4 PA (OXSORALEN) podofilox 1 GC PROTOPIC 3 ST (Topical Immunomodulator

Therapy - PS PART D #2) REGRANEX 4 PA (Regranex) RETIN-A MICRO 2 PA (Topical Retinoids) SANTYL 3 selenium sulfide lotion 1 GC SOLARAZE 3 SORIATANE 4 SOTRET CAPSULE 30MG 3 sotret capsule 20mg 3 sotret capsule 10mg, 40mg 3 PA (ISOTRETINOIN) sulfacetamide sodium 1 GC TAZORAC GEL 3 PA (Topical Retinoids) tretinoin 1 PA (Topical Retinoids) GC VELTIN 3 PA (Topical Retinoids) ZYCLARA 2

Enzyme Replacements/ Modifiers

Page 49: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 38 of 78

Drug Name Drug Tier Requirements/Limits

Enzyme Replacements/ Modifiers ADAGEN 4 PA (ENZYME REPLACEMENTS/

MODIFIERS, new starts only) ALDURAZYME 4 PA (ENZYME REPLACEMENTS/

MODIFIERS, new starts only) BUPHENYL 4 CARBAGLU 4 CEREZYME INJECTION 200UNIT 4 CREON 2 CYSTADANE 4 CYSTAGON 3 ELAPRASE 4 PA (ENZYME REPLACEMENTS/

MODIFIERS, new starts only) FABRAZYME INJECTION 35MG 4 PA (ENZYME REPLACEMENTS/

MODIFIERS, new starts only) KUVAN 4 LUMIZYME 4 MYOZYME 4 NAGLAZYME 4 PA (ENZYME REPLACEMENTS/

MODIFIERS, new starts only) ORFADIN 4 SUCRAID 4 VPRIV 4 PA (VPRIV) ZAVESCA 4 PA (ENZYME REPLACEMENTS/

MODIFIERS) ZENPEP 2

Gastrointestinal Agents Antispasmodics, Gastrointestinal

CUVPOSA 3 dicyclomine hcl 1 PA (Drugs to Avoid in the Elderly)

GC glycopyrrolate 1 GC HELIDAC 3 QL (56 EA per 180 days) methscopolamine bromide 1 GC propantheline bromide 1 GC

Gastrointestinal Agents, Other AMITIZA 2 QL (62 EA per 31 days) ST

(Amitiza Therapy - PS PART D #2)

constulose 1 GC enulose 1 GC GASTROCROM 3 gavilyte-g 1 QL (4000 ML per 31 days) GC gavilyte-n/flavor pack 1 QL (4000 ML per 31 days) GC HALFLYTELY BOWEL PREP/FLAVOR PACKS 2 QL (1 EA per 31 days) KRISTALOSE 2 lactulose 1 GC loperamide hcl capsule 1 GC MOVIPREP 2 NULYTELY/FLAVOR PACKS 2 QL (4000 ML per 31 days)

Page 50: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 39 of 78

Drug Name Drug Tier Requirements/Limits

OSMOPREP 2 polyethylene glycol 3350 powder 1 GC SUPREP BOWEL PREP 3 QL (354 ML per 31 days) ursodiol tablet 3 ursodiol capsule 1 GC VISICOL 2

Histamine2 (H2) Blocking Agents cimetidine 1 GC cimetidine hcl 1 GC famotidine premixed 1 GC famotidine suspension reconstituted 3 famotidine injection 1 GC famotidine tablet 20mg, 40mg 1 GC nizatidine solution 3 nizatidine capsule 1 GC ranitidine hcl syrup 3 ranitidine hcl capsule, tablet 1 GC ranitidine hcl injection 150mg/6ml 1 GC ZANTAC TABLET EFFERVESCENT 3 ZANTAC INJECTION 50MG/50ML; 0.45% 3

Irritable Bowel Syndrome Agents LOTRONEX 4 QL (62 EA per 31 days) PA

(Lotronex) Protectants

CARAFATE SUSPENSION 3 misoprostol 1 GC sucralfate 1 GC

Proton Pump Inhibitors DEXILANT 3 QL (62 EA per 31 days) lansoprazole 1 QL (62 EA per 31 days) GC lansoprazole odt 3 QL (62 EA per 31 days) ST

(Lansoprazole Therapy - PS PART D #2)

NEXIUM I.V. 3 NEXIUM CAPSULE DELAYED RELEASE 2 QL (62 EA per 31 days) NEXIUM PACKET 10MG, 20MG, 40MG 2 QL (62 EA per 31 days) omeprazole/sodium bicarbonate 3 QL (62 EA per 31 days) omeprazole capsule delayed release 1 QL (62 EA per 31 days) GC pantoprazole sodium 1 QL (62 EA per 31 days) GC PREVPAC 3 QL (112 EA per 180 days) PROTONIX INJECTION 3

Genitourinary Agents Antispasmodics, Urinary

ENABLEX 2 QL (31 EA per 31 days) flavoxate hcl 1 GC GELNIQUE GEL 10% 2 QL (30 GM per 30 days) oxybutynin chloride er 1 GC oxybutynin chloride tablet 1 GC OXYTROL 2 QL (8 EA per 28 days) SANCTURA XR 3 QL (31 EA per 31 days)

Page 51: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 40 of 78

Drug Name Drug Tier Requirements/Limits

trospium chloride 3 QL (62 EA per 31 days) VESICARE 2 QL (31 EA per 31 days)

Benign Prostatic Hypertrophy Agents alfuzosin hcl er 1 QL (31 EA per 31 days) GC AVODART 2 QL (31 EA per 31 days) CARDURA XL 3 QL (31 EA per 31 days) doxazosin mesylate 1 GC finasteride 1 QL (31 EA per 31 days) GC RAPAFLO 2 QL (31 EA per 31 days) tamsulosin hcl 1 QL (62 EA per 31 days) GC terazosin hcl 1 GC

Genitourinary Agents, Other bethanechol chloride 1 GC CIALIS TABLET 5MG, 10MG, 20MG 3 QL (6 EA per 30 days) ED ELMIRON 3 LEVITRA TABLET 2.5MG, 5MG, 10MG, 20MG 3 QL (6 EA per 30 days) ED VIAGRA TABLET 25MG, 50MG, 100MG 3 QL (6 EA per 30 days) ED

Phosphate Binders calcium acetate capsule 3 calcium acetate tablet 667mg 1 GC eliphos 1 GC FOSRENOL 2 PHOSLYRA 3 ST (Phoslyra Therapy - QHP #2)RENAGEL 2 ST (Renagel Therapy- PS PART

D #2) RENVELA 2

Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal)

Glucocorticoids/ Mineralocorticoids betamethasone dipropionate 1 GC clobetasol propionate lotion, shampoo 3 DEXPAK 13 DAY 3 fluocinolone acetonide 1 GC fluocinolone acetonide body 1 GC fluticasone propionate 3 RAYOS 3 PA u-cort 1 GC

Hormonal Agents, Stimulant/ Replacement/ Modifying (Sex Hormones/ Modifiers)

Anabolic Steroids ANADROL-50 4 PA (Anadrol-50) oxandrolone tablet 10mg 4 QL (62 EA per 31 days) PA

(Oxandrin) oxandrolone tablet 2.5mg 1 QL (124 EA per 31 days) PA

(Oxandrin) GC Androgens

ANDRODERM 2 QL (30 EA per 30 days) PA (Testosterone (topical))

ANDROGEL PUMP GEL 1.62% 2 QL (150 GM per 30 days)

Page 52: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 41 of 78

Drug Name Drug Tier Requirements/Limits

ANDROGEL GEL 50MG/5GM 2 QL (300 GM per 30 days) PA (Testosterone (topical))

androxy 3 PA (ANDROXY, new starts only)danazol 3 STRIANT 3 QL (60 EA per 30 days) PA

(Striant) testosterone cypionate 1 PA (Testosterone (injectable) GCtestosterone enanthate 1 PA (Testosterone (injectable) GC

Estrogens ACTIVELLA TABLET 0.5MG; 0.1MG 3 ALORA PATCH BIWEEKLY 0.025MG/24HR 2 amethyst 1 GC ANGELIQ TABLET 0.5MG; 1MG 3 apri 1 GC aranelle 1 GC aviane 1 GC balziva 1 GC briellyn 1 GC CENESTIN 2 cesia 1 GC CLIMARA PRO 3 COMBIPATCH 3 cryselle-28 1 GC cyclafem 1/35 1 GC cyclafem 7/7/7 1 GC DEPO-ESTRADIOL 3 DIVIGEL GEL 1MG/GM 3 QL (60 GM per 31 days) emoquette 1 GC ENJUVIA 2 enpresse-28 1 GC ESTRACE CREAM 3 ESTRADERM 2 estradiol 1 GC estradiol valerate 1 GC estradiol/norethindrone acetate tablet 1mg; 0.5mg 1 GC ESTRING 2 QL (1 EA per 90 days) estropipate 1 GC FEMHRT LOW DOSE 2 FEMRING 3 QL (1 EA per 90 days) FEMTRACE 3 gianvi 1 GC introvale 1 GC jinteli 1 GC junel 1.5/30 1 GC junel 1/20 1 GC junel fe 1.5/30 1 GC junel fe 1/20 1 GC kariva 1 GC kelnor 1/35 1 GC leena 1 GC

Page 53: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 42 of 78

Drug Name Drug Tier Requirements/Limits

lessina-28 1 GC levora 0.15/30-28 1 GC LOESTRIN 24 FE 3 LOSEASONIQUE 3 low-ogestrel 1 GC lutera 1 GC marlissa 1 GC MENEST 2 MENOSTAR 3 microgestin 1.5/30 1 GC microgestin 1/20 1 GC microgestin fe 1 GC microgestin fe 1.5/30 1 GC mononessa 1 GC necon 0.5/35-28 1 GC necon 1/35-28 1 GC necon 10/11-28 1 GC necon 7/7/7 1 GC nortrel 0.5/35 (28) 1 GC nortrel 1/35 (21) 1 GC nortrel 1/35 (28) 1 GC nortrel 7/7/7 1 GC NUVARING 2 ocella 1 GC ogestrel 1 GC orsythia 1 GC ORTHO EVRA 2 ORTHO TRI-CYCLEN LO 3 ortho-est 1 GC OVCON-50 28 3 portia-28 1 GC PREFEST 3 PREMARIN CREAM, TABLET 2 PREMPHASE 2 PREMPRO 2 previfem 1 GC quasense 1 GC reclipsen 1 GC SEASONIQUE 3 solia 1 GC sprintec 28 1 GC sronyx 1 GC tri-legest fe 1 GC tri-previfem 1 GC tri-sprintec 1 GC trinessa 1 GC trivora-28 1 GC velivet 1 GC vestura 1 GC VIVELLE-DOT 2

Page 54: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 43 of 78

Drug Name Drug Tier Requirements/Limits

zeosa 1 GC zovia 1/35e 1 GC zovia 1/50e 1 GC

Progestins camila 1 GC CRINONE 3 DEPO-PROVERA 3 ELLA 3 errin 1 GC jolivette 1 GC medroxyprogesterone acetate 1 GC MEGACE ES 3 PA (MEGACE, new starts only) megestrol acetate tablet 1 GC megestrol acetate suspension 1 PA (MEGACE, new starts only)

GC next choice 1 GC nora-be 1 GC norethindrone acetate 1 GC progesterone capsule 1 GC PROMETRIUM 2

Selective Estrogen Receptor Modifying Agents EVISTA 2 QL (31 EA per 31 days)

Hormonal Agents, Stimulant/ Replacement/ Modifying (Thyroid)

Hormonal Agents, Stimulant/ Replacement/ Modifying (Thyroid)

LEVOTHROID 2 levothyroxine sodium tablet 1 GC levoxyl 1 GC liothyronine sodium injection 3 liothyronine sodium tablet 1 GC SYNTHROID 2 THYROLAR-1 2 THYROLAR-1/4 2 THYROLAR-2 2 THYROLAR-3 2 unithroid tablet 100mcg, 112mcg, 125mcg, 150mcg, 175mcg, 200mcg, 25mcg, 300mcg, 50mcg, 75mcg, 88mcg

1 GC

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)

Glucocorticoids/Mineralocorticoids a-hydrocort 1 GC a-methapred 1 GC ala cort 1 GC ala-cort 1 GC alclometasone dipropionate 1 GC amcinonide 1 GC augmented betamethasone dipropionate 1 GC betamethasone dipropionate 1 GC

Page 55: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 44 of 78

Drug Name Drug Tier Requirements/Limits

betamethasone valerate 1 GC CAPEX 3 CELESTONE 3 clobetasol propionate e 1 GC clobetasol propionate foam 3 clobetasol propionate gel, ointment, solution 1 GC CLOBEX 3 CLODERM 3 CORDRAN 3 CORDRAN SP 3 CORDRAN TAPE 3 cortisone acetate 1 GC CUTIVATE 3 DEPO-MEDROL 2 PA (STEROID INJ, new starts

only) DERMA-SMOOTHE/FS BODY OIL 3 desonide 1 GC desoximetasone 1 GC dexamethasone 1 GC dexamethasone intensol 1 GC dexamethasone sodium phosphate 1 GC diflorasone diacetate 1 GC fludrocortisone acetate 1 GC fluocinolone acetonide 1 GC fluocinonide 1 GC fluocinonide-e 1 GC fluticasone propionate 1 GC halobetasol propionate 1 GC HALOG 3 hydrocortisone butyrate 1 GC hydrocortisone valerate 1 GC hydrocortisone enema 3 hydrocortisone cream, lotion, ointment, tablet 1 GC KENALOG 2 LOCOID LIPOCREAM 3 lokara 1 GC LUXIQ 3 methylprednisolone 1 GC methylprednisolone acetate 1 GC methylprednisolone dose pack 1 GC methylprednisolone sodiumsuccinate 1 GC mometasone furoate 1 GC OLUX-E 3 PANDEL 3 prednicarbate 1 GC prednisolone sodium phosphate 1 GC prednisone 1 GC prednisone intensol 1 GC procto-pak 1 GC proctocream hc 1 GC

Page 56: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 45 of 78

Drug Name Drug Tier Requirements/Limits

proctosol hc 1 GC proctozone-hc 1 GC SOLU-CORTEF 2 SOLU-MEDROL 2 PA (STEROID INJ, new starts

only) triamcinolone acetonide 1 GC triamcinolone acetonide in absorbase 1 GC triderm 1 GC VANOS 3

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)

chorionic gonadotropin 3 PA (Chorionic Gonadotropin) desmopressin acetate nasal solution 3 desmopressin acetate injection 3 PA (DDAVP, new starts only) desmopressin acetate tablet 1 GC EGRIFTA 4 QL (60 EA per 30 days) PA

(EGRIFTA) GENOTROPIN 4 PA (Growth Hormones) GENOTROPIN MINIQUICK INJECTION 0.4MG, 0.6MG, 0.8MG, 1.2MG, 1.4MG, 1.6MG, 1.8MG, 1MG, 2MG

4 QL (28 EA per 28 days) PA (Growth Hormones)

GENOTROPIN MINIQUICK INJECTION 0.2MG 3 QL (28 EA per 28 days) PA (Growth Hormones)

HUMATROPE 4 PA (Growth Hormones) HUMATROPE COMBO PACK 4 PA (Growth Hormones) INCRELEX 4 PA (Insulin-like Growth Factor) NORDITROPIN FLEXPRO 4 PA (Growth Hormones) NORDITROPIN NORDIFLEX PEN 4 PA (Growth Hormones) novarel 3 PA (Chorionic Gonadotropin) NUTROPIN 4 PA (Growth Hormones) NUTROPIN AQ NUSPIN 5 4 PA (Growth Hormones) NUTROPIN AQ PEN 4 PA (Growth Hormones) OMNITROPE INJECTION 5.8MG, 5MG/1.5ML 4 PA (Growth Hormones) OMNITROPE INJECTION 10MG/1.5ML 3 PA (Growth Hormones) pregnyl w/diluent benzyl alcohol/nacl 3 PA (Chorionic Gonadotropin) SAIZEN 4 PA (Growth Hormones) SAIZEN CLICK.EASY 4 PA (Growth Hormones) STIMATE 3 TEV-TROPIN 3 PA (Growth Hormones)

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)

Progestins CRINONE 3 DEPO-SUBQ PROVERA 104 3

Hormonal Agents, Suppressant (Adrenal) Hormonal Agents, Suppressant (Adrenal)

LYSODREN 2 Hormonal Agents, Suppressant (Parathyroid)

Hormonal Agents, Suppressant (Parathyroid)

Page 57: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 46 of 78

Drug Name Drug Tier Requirements/Limits

SENSIPAR TABLET 90MG 4 QL (124 EA per 31 days) SENSIPAR TABLET 60MG 4 QL (62 EA per 31 days) SENSIPAR TABLET 30MG 2 QL (62 EA per 31 days)

Hormonal Agents, Suppressant (Pituitary) Hormonal Agents, Suppressant (Pituitary)

cabergoline 3 ELIGARD INJECTION 45MG 4 QL (1 EA per 168 days) PA

(LUPRON, ELIGARD,TRELSTAR, new starts only)

ELIGARD INJECTION 30MG 3 QL (1 EA per 112 days) PA (LUPRON, ELIGARD,TRELSTAR, new starts only)

ELIGARD INJECTION 7.5MG 3 QL (1 EA per 28 days) PA (LUPRON, ELIGARD,TRELSTAR, new starts only)

ELIGARD INJECTION 22.5MG 3 QL (1 EA per 84 days) PA (LUPRON, ELIGARD,TRELSTAR, new starts only)

leuprolide acetate 3 PA (LUPRON, ELIGARD,TRELSTAR, new starts only)

LUPRON DEPOT-PED INJECTION 11.25MG, 15MG 4 PA (LUPRON, ELIGARD,TRELSTAR, new starts only)

LUPRON DEPOT INJECTION 30MG 4 QL (1 EA per 112 days) PA (LUPRON, ELIGARD,TRELSTAR, new starts only)

LUPRON DEPOT INJECTION 45MG 4 QL (1 EA per 168 days) PA (LUPRON, ELIGARD,TRELSTAR, new starts only)

LUPRON DEPOT INJECTION 11.25MG, 22.5MG 4 QL (1 EA per 84 days) PA (LUPRON, ELIGARD,TRELSTAR, new starts only)

LUPRON DEPOT INJECTION 3.75MG, 7.5MG 2 QL (1 EA per 28 days) PA (LUPRON, ELIGARD,TRELSTAR, new starts only)

octreotide acetate injection 1000mcg/ml 4 PA (Sandostatin) octreotide acetate injection 200mcg/ml 4 QL (120 ML per 30 days) PA

(Sandostatin) octreotide acetate injection 500mcg/ml 4 QL (93 ML per 31 days) PA

(Sandostatin)

Page 58: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 47 of 78

Drug Name Drug Tier Requirements/Limits

octreotide acetate injection 100mcg/ml, 50mcg/ml 3 QL (124 ML per 31 days) PA (Sandostatin)

SANDOSTATIN LAR DEPOT 4 PA (Sandostatin LAR) SOMATULINE DEPOT 4 PA (Somatuline) SOMAVERT 4 PA (Somavert) SYNAREL 4 PA (SYNAREL) TRELSTAR DEPOT MIXJECT 4 PA (LUPRON,

ELIGARD,TRELSTAR, new starts only)

TRELSTAR LA MIXJECT 4 PA (LUPRON, ELIGARD,TRELSTAR, new starts only)

TRELSTAR MIXJECT 4 PA (LUPRON, ELIGARD,TRELSTAR, new starts only)

Hormonal Agents, Suppressant (Sex Hormones/ Modifiers) Antiandrogens

bicalutamide 1 GC flutamide 3 NILANDRON 3 PA (NILANDRON, new starts

only) Hormonal Agents, Suppressant (Thyroid)

Antithyroid Agents methimazole 1 GC propylthiouracil 1 GC

Immunological Agents Immune Suppressants

ACTEMRA INJECTION 200MG/10ML 4 PA (ACTEMRA) AZASAN 2 azathioprine 1 GC azathioprine sodium 3 BENLYSTA INJECTION 120MG 4 PA (BENLYSTA) CELLCEPT INTRAVENOUS 3 PA (Cellcept (IV), new starts

only) CELLCEPT SUSPENSION RECONSTITUTED 4 PA (Cellcept (oral), new starts

only) CIMZIA 4 PA (Cimzia) cyclosporine 3 PA cyclosporine modified capsule 100mg, 50mg 3 PA cyclosporine modified solution 3 PA ENBREL INJECTION 25MG/0.5ML, 50MG/ML 4 QL (7.84 ML per 28 days) PA

(Enbrel) ENBREL INJECTION 25MG 4 QL (8 EA per 28 days) PA

(Enbrel) gengraf 3 PA HUMIRA PEN-CROHNS DISEASESTARTER 4 QL (1 EA per 28 days) PA

(Humira) HUMIRA INJECTION 20MG/0.4ML 4 QL (1 EA per 28 days) PA

(Humira)

Page 59: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 48 of 78

Drug Name Drug Tier Requirements/Limits

HUMIRA INJECTION 40MG/0.8ML 4 QL (2 EA per 28 days) PA (Humira)

methotrexate 1 PA GC methotrexate sodium injection 1gm, 25mg/ml 1 PA GC mycophenolate mofetil 3 PA (Cellcept (oral), new starts

only) MYFORTIC 3 PA NULOJIX 4 PA (NULOJIX, new starts only) ORENCIA INJECTION 250MG 4 QL (4 EA per 28 days) PA

(Orencia) ORENCIA INJECTION 125MG/1ML 4 QL (4 ML per 28 days) PA

(Orencia) PROGRAF INJECTION 3 PA (Prograf (IV), new starts only)RAPAMUNE SOLUTION 4 PA RAPAMUNE TABLET 1MG 4 QL (31 EA per 31 days) PA RAPAMUNE TABLET 2MG 4 QL (620 EA per 31 days) PA RAPAMUNE TABLET 0.5MG 3 QL (31 EA per 31 days) PA tacrolimus capsule 5mg 4 PA (Prograf (oral), new starts

only) tacrolimus capsule 1mg 3 QL (248 EA per 31 days) PA

(Prograf (oral), new starts only) tacrolimus capsule 0.5mg 3 QL (62 EA per 31 days) PA

(Prograf (oral), new starts only) TREXALL 3 PA ZORTRESS TABLET 0.75MG 4 PA (ZORTRESS, new starts only)ZORTRESS TABLET 0.5MG 4 QL (62 EA per 31 days) PA

(ZORTRESS, new starts only) ZORTRESS TABLET 0.25MG 3 QL (62 EA per 31 days) PA

(ZORTRESS, new starts only) Immunizing Agents, Passive

CARIMUNE NANOFILTERED INJECTION 3GM 4 PA (Immune Globulin) GAMASTAN S/D 2 PA (Gamastan) GAMMAGARD LIQUID 4 PA (Immune Globulin) GAMMAPLEX INJECTION 10GM/200ML 4 PA (Immune Globulin) GAMUNEX-C INJECTION 1GM/10ML 4 PA (Immune Globulin) HIZENTRA INJECTION 1GM/5ML 4 QL (20 ML per 28 days) PA

(Immune Globulin) PRIVIGEN INJECTION 20GM/200ML 4 PA (Immune Globulin)

Immunomodulators ACTIMMUNE 4 PA (ACTIMMUNE, new starts

only) ARCALYST 4 PA (Arcalyst) AVONEX INJECTION 30MCG/0.5ML 4 QL (2 EA per 28 days) AVONEX INJECTION 30MCG/VIAL 4 QL (4 EA per 28 days) BETASERON 4 QL (14 EA per 28 days) COPAXONE 4 QL (30 EA per 30 days) PA

(Copaxone, new starts only) GILENYA 4 QL (28 EA per 28 days) PA

(GILENYA) ILARIS 4 PA (ILARIS)

Page 60: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 49 of 78

Drug Name Drug Tier Requirements/Limits

INFERGEN INJECTION 15MCG/0.5ML 4 PA (Infergen) INTRON-A W/DILUENT INJECTION 10MU 4 PA (Intron-A, new starts only) INTRON-A INJECTION 10MU/0.2ML, 5MU/0.2ML 4 PA (Intron-A, new starts only) INTRON-A INJECTION 3MU/0.2ML 4 QL (6 EA per 28 days) PA

(Intron-A, new starts only) INTRON-A INJECTION 6000000UNIT/ML 3 PA (Intron-A, new starts only) KINERET 4 QL (20.77 ML per 31 days) PA

(Kineret) leflunomide 1 GC PEG-INTRON REDIPEN 4 PA (PEG-Intron) PEG-INTRON INJECTION 50MCG/0.5ML 4 PA (PEG-Intron) PEGASYS PROCLICK INJECTION 135MCG/0.5ML 4 PA (Pegasys) PEGASYS INJECTION 180MCG/0.5ML, 180MCG/ML 4 PA (Pegasys) REBIF 4 QL (6 ML per 28 days) REBIF TITRATION PACK 4 QL (4.2 ML per 28 days) REMICADE 4 PA (Remicade) RIDAURA 3 SYNAGIS INJECTION 50MG/0.5ML 4 TYSABRI 4 PA (Tysabri) LA

Vaccines ACTHIB 2 ADACEL 2 BOOSTRIX 2 CERVARIX 2 COMVAX 2 DAPTACEL 2 DECAVAC 2 DIPHTHERIA/TETANUS TOXOID PEDIATRIC 2 ENGERIX-B INJECTION 10MCG/0.5ML, 20MCG/ML 2 PA GARDASIL 2 PA (VACCINES) HAVRIX 2 IMOVAX RABIES (H.D.C.V.) 2 PA INFANRIX 2 IPOL INACTIVATED IPV 2 IXIARO 2 JE-VAX 2 M-M-R II W/DILUENT 10 DOSE 2 MENACTRA 2 MENOMUNE-A/C/Y/W-135 2 MENVEO 2 PEDVAX HIB 2 PROQUAD 2 RABAVERT 2 RECOMBIVAX HB INJECTION 10MCG/ML, 40MCG/ML 2 PA ROTATEQ 2 TETANUS TOXOID ADSORBED 2 TETANUS/DIPHTHERIA TOXOIDS-ADSORBED ADULT

2

TRIPEDIA 2 TWINRIX 2 PA (VACCINES)

Page 61: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 50 of 78

Drug Name Drug Tier Requirements/Limits

TYPHIM VI 2 VAQTA INJECTION 25UNIT/0.5ML 2 VARIVAX 2 YF-VAX 2 ZOSTAVAX 2

Inflammatory Bowel Disease Agents Glucocorticoids

budesonide 3 colocort 3 CORTIFOAM 3 ENTOCORT EC 3 methylprednisolone 1 GC MILLIPRED TABLET 3

Salicylates APRISO 2 ASACOL 2 ASACOL HD 2 balsalazide disodium 3 CANASA 2 DIPENTUM 3 mesalamine enema 3 PENTASA 3

Sulfonamides sulfasalazine tablet 1 GC sulfazine ec 1 GC

Metabolic Bone Disease Agents Metabolic Bone Disease Agents

ACTONEL TABLET 150MG 2 QL (1 EA per 28 days) ACTONEL TABLET 30MG, 5MG 2 QL (31 EA per 31 days) ACTONEL TABLET 35MG 2 QL (4 EA per 28 days) alendronate sodium 1 GC calcitonin-salmon 1 QL (3.8 ML per 31 days) GC calcitriol injection, oral solution 3 PA calcitriol capsule 1 PA GC etidronate disodium 1 GC FORTEO 4 PA (Forteo) FOSAMAX PLUS D 3 QL (4 EA per 28 days) FOSAMAX SOLUTION 3 QL (375 ML per 31 days) HECTOROL 2 PA ibandronate sodium 1 QL (1 EA per 28 days) GC MIACALCIN INJECTION 3 PA (Miacalcin) pamidronate disodium injection 30mg/10ml, 6mg/ml, 90mg/10ml

1 PA (METABOLIC BONE DISEASE AGENTS, new starts only) GC

PROLIA 3 QL (1 ML per 180 days) PA (PROLIA)

XGEVA 4 QL (1.7 ML per 28 days) PA (XGEVA)

Page 62: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 51 of 78

Drug Name Drug Tier Requirements/Limits

ZEMPLAR CAPSULE 2 PA (METABOLIC BONE DISEASE AGENTS, new starts only)

ZEMPLAR INJECTION 2MCG/ML 2 PA ZEMPLAR INJECTION 5MCG/ML 2 PA (METABOLIC BONE

DISEASE AGENTS, new starts only)

ZOMETA INJECTION 4MG/100ML 4 ZOMETA INJECTION 4MG/5ML 4 PA (METABOLIC BONE

DISEASE AGENTS, new starts only)

Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents

anagrelide hydrochloride 1 PA (ANAGRELIDE) GC BD INSULIN SYRINGE SAFETYGLIDE/1ML/29G X 1/2" 2 BD INSULIN SYRINGE ULTRAFINE/0.3ML/31G X 5/16" 2 BD INSULIN SYRINGE ULTRAFINE/0.5ML/30G X 1/2" 2 BD INSULIN SYRINGE ULTRAFINE/1ML/31G X 5/16" 2 BD PEN NEEDLE/ULTRAFINE/29G X 12.7MM 2 BOTOX INJECTION 100UNIT 3 PA (Botox) CURITY GAUZE PADS 2"X2" 2 dextrose 10% flex container 1 GC dextrose 5% 1 GC FIRAZYR 4 PA (FIRAZYR) intralipid injection 2.25%; 20% 3 PA leucovorin calcium tablet 1 GC leucovorin calcium injection 100mg, 350mg 1 PA (ANTINEOPLASTICS, new

starts only) GC levocarnitine oral solution 3 PA levocarnitine injection 3 PA (ENZYME REPLACEMENTS/

MODIFIERS, new starts only) levocarnitine tablet 1 PA GC METHERGINE 2 methylergonovine maleate tablet 1 GC sterile water irrigation 1 GC XENAZINE 4 PA (Xenazine)

Ophthalmic Agents Ophthalmic Agents, Other

ak-con 1 GC LACRISERT 2 parcaine 1 GC proparacaine hcl 1 GC RESTASIS 2 QL (24 EA per 30 days) tropicamide 1 GC

Ophthalmic Anti-allergy Agents ALAMAST 3 ALOCRIL 3 ALOMIDE 3 azelastine hcl 1 GC BEPREVE 3

Page 63: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 52 of 78

Drug Name Drug Tier Requirements/Limits

cromolyn sodium 1 GC EMADINE 3 ST (Ophthalmic Antihistamine

Therapy - PS PART D #2) epinastine hcl 1 GC LASTACAFT 2 PATADAY 2 PATANOL 2

Ophthalmic Anti-inflammatories ACUVAIL 3 ALREX 3 BLEPHAMIDE 2 BLEPHAMIDE S.O.P. 2 BROMDAY 3 BROMFENAC 3 CORTISPORIN 3 dexamethasone sodium phosphate 1 GC diclofenac sodium 1 GC DUREZOL 3 FLAREX 2 fluorometholone 1 GC flurbiprofen sodium 1 GC FML 2 FML FORTE 2 ST (Ophthalmic Steroid Therapy -

PS PART D #2) ketorolac tromethamine 1 GC LOTEMAX 3 MAXIDEX 2 neomycin/polymyxin/bacitracin/hydrocortisone 1 GC neomycin/polymyxin/dexamethasone 1 GC NEVANAC 2 poly-dex 1 GC POLY-PRED 2 PRED MILD 2 PRED-G 3 PRED-G S.O.P. 2 prednisolone acetate 1 GC prednisolone sodium phosphate 1 GC sulfacetamide sodium/prednisolone sodium phosphate 1 GC TOBRADEX OINTMENT 2 tobramycin/dexamethasone 1 GC VEXOL 2 ST (Ophthalmic Steroid Therapy -

PS PART D #2) ZYLET 2

Ophthalmic Antiglaucoma Agents acetazolamide 1 GC acetazolamide er 3 ALPHAGAN P SOLUTION 0.1% 2 apraclonidine 1 GC AZOPT 2 betaxolol hcl 1 GC

Page 64: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 53 of 78

Drug Name Drug Tier Requirements/Limits

BETIMOL 3 brimonidine tartrate 1 GC carteolol hcl 1 GC COMBIGAN 2 dorzolamide hcl 1 GC dorzolamide hcl/timolol maleate 1 GC IOPIDINE SOLUTION 1% 3 ISOPTO CARPINE 2 ISTALOL 3 levobunolol hcl 1 GC methazolamide 1 GC metipranolol 1 GC PHOSPHOLINE IODIDE 2 PILOPINE HS 2 timolol maleate 1 GC

Ophthalmic Prostaglandin and Prostamide Analogs latanoprost 1 GC LUMIGAN 2 TRAVATAN Z 2

Otic Agents Otic Agents

acetic acid 1 GC CIPRO HC 2 COLY-MYCIN S 3 CORTISPORIN-TC 3 cortomycin 1 GC DERMOTIC 2 hydrocortisone/acetic acid 3 neomycin/polymyxin/hc 1 GC neomycin/polymyxin/hydrocortisone ophthalmic suspension, otic suspension

1 GC

Respiratory Tract Agents Anti-inflammatories, Inhaled Corticosteroids

ADVAIR DISKUS 2 QL (60 EA per 30 days) ST (Advair Therapy - PS PART D #2)

ADVAIR HFA 2 QL (12M per 30 days) ST (Advair Therapy - PS PART D #2)

ALVESCO 3 QL (12.2M per 30 days) ST (Inhaled Corticosteroid Therapy - PS PART D #2)

ASMANEX 120 METERED DOSES 3 QL (0.48 EA per 30 days) ASMANEX 14 METERED DOSES 3 QL (0.27 EA per 30 days) ASMANEX 30 METERED DOSES 3 QL (0.27 EA per 30 days) ASMANEX 60 METERED DOSES 3 QL (0.48 EA per 30 days) BECONASE AQ 3 QL (50 GM per 31 days) budesonide 3 PA DULERA 3 QL (13 GM per 30 days) FLOVENT DISKUS 2 QL (120 EA per 30 days) FLOVENT HFA AEROSOL 44MCG/ACT 2 QL (21.2M per 30 days)

Page 65: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 54 of 78

Drug Name Drug Tier Requirements/Limits

FLOVENT HFA AEROSOL 110MCG/ACT, 220MCG/ACT

2 QL (24M per 30 days)

flunisolide solution 0.025% 1 GC fluticasone propionate 1 GC NASONEX 2 QL (34M per 30 days) PULMICORT FLEXHALER 2 QL (2 EA per 30 days) PULMICORT SUSPENSION 1MG/2ML 3 PA QVAR AEROSOL SOLUTION 40MCG/ACT 2 QL (17.4M per 30 days) QVAR AEROSOL SOLUTION 80MCG/ACT 2 QL (26.1 GM per 30 days) SYMBICORT 2 QL (10.2M per 30 days) ST

(Symbicort Therapy - PS PART D #2)

triamcinolone acetonide 1 QL (16.5 GM per 30 days) GC Antihistamines

ALLEGRA 3 QL (310 ML per 31 days) ST (Allegra Suspension Therapy - PS PART D #2)

ASTEPRO 2 QL (60 ML per 31 days) azelastine hcl 1 QL (60 ML per 31 days) GC cetirizine hcl syrup 1 GC CLARINEX-D 12 HOUR 3 QL (62 EA per 31 days) ST

(Clarinex Tablet Therapy - PS PART D #2)

CLARINEX-D 24 HOUR 3 QL (31 EA per 31 days) ST (Clarinex Tablet Therapy - PS PART D #2)

clemastine fumarate syrup 1 GC clemastine fumarate tablet 2.68mg 1 GC desloratadine 3 QL (31 EA per 31 days) hydroxyzine hcl 1 GC levocetirizine dihydrochloride solution 3 QL (310 ML per 31 days) levocetirizine dihydrochloride tablet 1 QL (31 EA per 31 days) GC PATANASE 2 QL (30.5 GM per 31 days) phenadoz 1 GC promethazine hcl 1 GC promethegan suppository 25mg, 50mg 1 GC SEMPREX-D 3

Antileukotrienes montelukast sodium tablet chewable, tablet 1 QL (31 EA per 31 days) GC SINGULAIR 2 QL (31 EA per 31 days) zafirlukast 1 QL (62 EA per 31 days) GC ZYFLO 4 QL (124 EA per 31 days) ST

(Zyflo Therapy - PS PART D #2) ZYFLO CR 3 QL (124 EA per 31 days) ST

(Leukotriene Modifier Asthma Therapy - PS PART D #2)

Bronchodilators, Anticholinergic ATROVENT HFA 2 QL (25.8 GM per 31 days) COMBIVENT 2 QL (29.4M per 31 days) COMBIVENT RESPIMAT 2 QL (8 GM per 31 days)

Page 66: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 55 of 78

Drug Name Drug Tier Requirements/Limits

ipratropium bromide/albuterol sulfate 1 PA GC ipratropium bromide nasal solution 1 GC ipratropium bromide inhalation solution 1 PA GC SPIRIVA HANDIHALER 2 QL (30 EA per 30 days)

Bronchodilators, Phosphodiesterase Inhibitors (Xanthines)

aminophylline 1 GC ELIXOPHYLLIN 2 THEO-24 2 theochron tablet extended release 12 hour 100mg, 300mg

1 GC

theophylline cr tablet extended release 12 hour 100mg 1 GC theophylline er tablet extended release 24 hour 1 GC theophylline er tablet extended release 12 hour 200mg, 300mg, 450mg

1 GC

Bronchodilators, Sympathomimetic albuterol sulfate syrup, tablet 1 GC albuterol sulfate nebulization solution 1 PA GC BROVANA 3 PA epinephrine hcl injection 0.1mg/ml 1 GC EPIPEN 2-PAK 2 EPIPEN-JR 2-PAK 2 FORADIL AEROLIZER 2 QL (60 EA per 30 days) ST (Long

Acting Beta Agonist Therapy - PS PART D #2)

levalbuterol 3 ST (Xopenex Nebulizer Therapy -PS PART D #2) PA

MAXAIR AUTOHALER 3 QL (14M per 31 days) metaproterenol sulfate 1 GC PERFOROMIST 3 PA PROAIR HFA 2 QL (25.5 GM per 31 days) PROVENTIL HFA 2 QL (25.5 GM per 31 days) SEREVENT DISKUS 2 QL (60 EA per 30 days) ST (Long

Acting Beta Agonist Therapy - PS PART D #2)

terbutaline sulfate injection 4 terbutaline sulfate tablet 1 GC TWINJECT 3 VENTOLIN HFA 2 QL (54M per 31 days) XOPENEX 3 ST (Xopenex Nebulizer Therapy -

PS PART D #2) PA XOPENEX HFA 3 QL (30 GM per 31 days)

Mast Cell Stabilizers cromolyn sodium concentrate 3 cromolyn sodium nebulization solution 1 PA GC

Pulmonary Antihypertensives ADCIRCA 4 QL (62 EA per 31 days) LETAIRIS 4 QL (31 EA per 31 days) REMODULIN 4 PA (Remodulin) REVATIO INJECTION 4

Page 67: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 56 of 78

Drug Name Drug Tier Requirements/Limits

REVATIO TABLET 4 QL (93 EA per 31 days) TRACLEER 4 QL (62 EA per 31 days) LA VENTAVIS SOLUTION 10MCG/ML 4 PA (Ventavis)

Respiratory Tract Agents, Other acetylcysteine 1 PA GC ARALAST NP INJECTION 400MG 4 PA (Alpha-1 Proteinase

Inhibitors) GLASSIA 4 PA (Alpha-1 Proteinase

Inhibitors) KALYDECO 4 QL (62 EA per 31 days) PA

(KALYDECO) PROLASTIN-C 4 PA (Alpha-1 Proteinase

Inhibitors) PROLASTIN INJECTION 500MG 4 PA (Alpha-1 Proteinase

Inhibitors) PULMOZYME 4 PA TYZINE 2 TYZINE PEDIATRIC NASAL DROPS 2 XOLAIR 4 PA (Xolair) ZEMAIRA 4 PA (Alpha-1 Proteinase

Inhibitors) Sedatives/Hypnotics

Sedatives/Hypnotics LUNESTA 2 QL (31 EA per 31 days) ROZEREM 3 QL (31 EA per 31 days) temazepam capsule 15mg, 30mg 1 QL (30 EA per 30 days) ED GC zaleplon capsule 5mg 1 QL (31 EA per 31 days) GC zaleplon capsule 10mg 1 QL (62 EA per 31 days) GC zolpidem tartrate 1 QL (31 EA per 31 days) GC zolpidem tartrate er 3 QL (31 EA per 31 days)

Skeletal Muscle Relaxants Skeletal Muscle Relaxants

carisoprodol tablet 350mg 1 QL (124 EA per 31 days) GC chlorzoxazone 1 QL (186 EA per 31 days) GC cyclobenzaprine hcl tablet 7.5mg 3 QL (93 EA per 31 days) cyclobenzaprine hcl tablet 10mg, 5mg 1 QL (93 EA per 31 days) GC metaxalone 3 QL (124 EA per 31 days) methocarbamol tablet 750mg 1 QL (186 EA per 31 days) GC methocarbamol tablet 500mg 1 QL (279 EA per 31 days) GC

Therapeutic Nutrients/Minerals/ Electrolytes Electrolytes/Minerals

AMINOSYN 3 PA AMINOSYN II 3.5/DEXTROSE 25% 3 PA AMINOSYN II 4.25/DEXTROSE10% 3 PA

Page 68: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 57 of 78

Drug Name Drug Tier Requirements/Limits

AMINOSYN II INJECTION 61.1MEQ/L; 844MG/100ML; 865MG/100ML; 595MG/100ML; 627MG/100ML; 425MG/100ML; 255MG/100ML; 561MG/100ML; 850MG/100ML; 893MG/100ML; 146MG/100ML; 253MG/100ML; 614MG/100ML; 450MG/100ML; 33.3MEQ/L; 340MG/100ML; 170MG/100ML; 230MG/100ML; 425MG/100ML

3 PA

AMINOSYN-PF 7% 3 PA clinimix 4.25%/dextrose 10% 3 PA CLINIMIX 5%/DEXTROSE 25% 3 PA CLINIMIX E 2.75%/DEXTROSE 5% 3 PA CLINIMIX E 5%/DEXTROSE 15% 3 PA dextrose 5%/potassium chloride 0.075% 1 GC hepatamine 3 PA IONOSOL-PAEXTROSE 5% 3 ISOLYTE-P/DEXTROSE 5% 3 kcl 0.15%/d5w/nacl 0.9% 1 GC kcl 0.3%/d5w/nacl 0.9% 1 GC klor-con 10 1 GC magnesium sulfate in d5w injection 5%; 10mg/ml 1 GC NEPHRAMINE 3 PA PHYSIOSOL IRRIGATION 3 PLASMA-LYTE A 3 PLASMA-LYTE-148/D5W 3 plasma-lyte-r 1 GC potassium chloride 0.224%/d5w 1 GC potassium chloride 0.3%/ nacl 0.9% 1 GC PREMASOL 3 PA sodium chloride injection 3% 1 GC sodium lactate 1 GC

Vitamins FUSILEV 4 prenatabs obn 1 GC

Therapeutic Nutrients/Minerals/Electrolytes Electrolytes/Minerals

AMINOSYN 3 PA aminosyn 8.5%/electrolytes 1 PA GC AMINOSYN II 3 PA AMINOSYN II 3.5%/DEXTROSE25% 3 PA AMINOSYN II 3.5%/DEXTROSE5% 3 PA AMINOSYN II 4.25/DEXTROSE20% 3 PA AMINOSYN II 4.25/DEXTROSE25% 3 PA AMINOSYN II 5/DEXTROSE 25 3 PA aminosyn ii 8.5%/electrolytes 1 PA GC AMINOSYN II M 3.5%/DEXTROSE 5% 3 PA AMINOSYN M 3 PA AMINOSYN-HBC 3 PA aminosyn-hf 3 PA AMINOSYN-PF 3 PA CLINIMIX 2.75%/DEXTROSE 5% 3 PA

Page 69: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 58 of 78

Drug Name Drug Tier Requirements/Limits

clinimix 4.25%/dextrose 20% 3 PA clinimix 4.25%/dextrose 25% 3 PA CLINIMIX 4.25%/DEXTROSE 5% 3 PA CLINIMIX 5%/DEXTROSE 15% 3 PA CLINIMIX 5%/DEXTROSE 20% 3 PA CLINIMIX E 2.75%/DEXTROSE 10% 3 PA CLINIMIX E 4.25%/DEXTROSE 25% 3 PA CLINIMIX E 4.25%/DEXTROSE 5% 3 PA CLINIMIX E 5%/DEXTROSE 20% 3 PA CLINIMIX E 5%/DEXTROSE 25% 3 PA clinisol sf 15% 3 PA dextrose 10%/nacl 0.45% 1 GC DEXTROSE 5% /ELECTROLYTE #48 VIAFLEX 3 dextrose 10%/nacl 0.2% 1 GC dextrose 2.5%/sodium chloride 0.45% 1 GC dextrose 5%/lactated ringers 1 GC dextrose 5%/nacl 0.2% 1 GC dextrose 5%/nacl 0.225% 1 GC dextrose 5%/nacl 0.33% 1 GC dextrose 5%/nacl 0.45% 1 GC dextrose 5%/nacl 0.9% 1 GC ed k+10 1 GC FREAMINE III 3 PA FREAMINE III 3% 3 PA HEPATASOL 3 PA IONOSOL-MPAEXTROSE 5% 3 IONOSOL-T/DEXTROSE 5% 3 ISOLYTE-H/DEXTROSE 5% 3 isolyte-m/dextrose 5% 1 GC ISOLYTE-S 3 ISOLYTE-S/DEXTROSE 5% 3 kcl 0.075%/d5w/nacl 0.45% 1 GC kcl 0.15%/d10w/nacl 0.2% 1 GC kcl 0.15%/d5w/lr 1 GC kcl 0.15%/d5w/nacl 0.2% 1 GC kcl 0.15%/d5w/nacl 0.225% 1 GC kcl 0.3%/d5w/nacl 0.2% 1 GC kcl 0.3%/d5w/nacl 0.45% 1 GC klor-con 8 1 GC KLOR-CON M15 2 klor-con m20 1 GC lactated ringers 1 GC lactated ringers irrigation 1 GC magnesium sulfate 1 GC normosol-m in d5w 1 GC NORMOSOL-R 3 normosol-r in d5w 1 GC physiolyte 3 PLASMA-LYTE 56 3 PLASMA-LYTE-148 3

Page 70: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 59 of 78

Drug Name Drug Tier Requirements/Limits

PLASMA-LYTE-56/D5W 3 potassium chloride 1 GC potassium chloride 0.075%/d5w/nacl 0.225% 1 GC potassium chloride 0.15% /nacl 0.45% viaflex 1 GC potassium chloride 0.15% d5w/nacl 0.33% 1 GC potassium chloride 0.15% d5w/nacl 0.45% viaflex 1 GC potassium chloride 0.15% nacl 0.9% 1 GC potassium chloride 0.15%/d5w 1 GC potassium chloride 0.22% d5w/nacl 0.45% 1 GC potassium chloride 0.224%d5w/nacl 0.33% 1 GC potassium chloride 0.3%/d5w 1 GC potassium chloride er 1 GC potassium citrate er 1 GC premasol 3 PA PROCALAMINE 3 PA PROSOL 3 PA ringers injection 1 GC ringers irrigation 1 GC sodium bicarbonate 1 GC sodium chloride 1 GC sodium chloride 0.45% viaflex 1 GC sodium chloride 0.9% 1 GC sodium fluoride 1 GC sodium lactate 1 GC tis-u-sol 1 GC tpn electrolytes 1 GC TRAVASOL 3 PA TROPHAMINE 3 PA

Page 71: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 60 of 78

Index Drug Name Page #

abacavir 22ABELCET 13

ABILIFY 20ABILIFY DISCMELT 20

ABRAXANE 16ABSTRAL 1acarbose 24

acebutolol hcl 30acetaminophen/caffeine/dihydrocodeine

bitartrate 1

acetaminophen/codeine 1acetaminophen/codeine #3 1

acetazolamide 52acetazolamide er 52

acetazolamide sodium 32acetic acid 53

acetylcysteine 56ACTEMRA 47

ACTHIB 49acticin 19

ACTIMMUNE 48ACTIVELLA 41

ACTONEL 50ACTOPLUS MET 24

ACTOS 24ACUVAIL 52acyclovir 23

acyclovir sodium 23ADACEL 49ADAGEN 38

adapalene 37ADCIRCA 55

ADDERALL XR 35adriamycin 16

ADVAIR DISKUS 53ADVAIR HFA 53

ADVICOR 32afeditab cr 31AFINITOR 18

AGGRENOX 29a-hydrocort 43

ak-con 51AKNE-MYCIN 7

ala cort 43ala-cort 43

ALAMAST 51ALBENZA 19

Drug Name Page #albuterol sulfate 55

alclometasone dipropionate 43alcohol preps 4

ALDACTAZIDE 32ALDURAZYME 38

alendronate sodium 50alfuzosin hcl er 40

ALIMTA 16ALINIA 19

ALLEGRA 54allopurinol 14

allopurinol sodium 14ALOCRIL 51ALOMIDE 51

ALORA 41ALOXI 12

ALPHAGAN P 52alprazolam

ALREX 52ALSUMA 14

ALTOPREV 33ALVESCO 53

amantadine hcl 23AMBISOME 13amcinonide 43

a-methapred 43amethyst 41

amifostine 16amikacin sulfate 4

amiloride hcl 32amiloride/hydrochlorothiazide 32

aminophylline 55AMINOSYN 56AMINOSYN 57

aminosyn 8.5%/electrolytes 57AMINOSYN II 57AMINOSYN II 57

AMINOSYN II 3.5%/DEXTROSE25% 57AMINOSYN II 3.5%/DEXTROSE5% 57AMINOSYN II 3.5/DEXTROSE 25% 56

AMINOSYN II 4.25/DEXTROSE10% 56AMINOSYN II 4.25/DEXTROSE20% 57AMINOSYN II 4.25/DEXTROSE25% 57

AMINOSYN II 5/DEXTROSE 25 57aminosyn ii 8.5%/electrolytes 57

AMINOSYN II M 3.5%/DEXTROSE 5% 57AMINOSYN M 57

AMINOSYN-HBC 57aminosyn-hf 57

AMINOSYN-PF 57AMINOSYN-PF 7% 57

mworley
Text Box
23
Page 72: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 61 of 78

Drug Name Page #amiodarone hcl 30

AMITIZA 38amitriptyline hcl 11

amlodipine besylate 31amlodipine besylate/benazepril hcl 31

amlodipine besylate/benazepril hydrochloride

31

ammonium lactate 37amnesteem 37amoxapine 11amoxicillin 6

amoxicillin/clavulanate potassium 6amoxicillin/clavulanate potassium er 6

amoxicillin/potassium clavulanate 6amphetamine/dextroamphetamine 35

amphotericin b 13ampicillin 6

ampicillin sodium 7ampicillin-sulbactam 7

AMPYRA 36ANADROL-50 40

anagrelide hydrochloride 51anastrozole 18ANCOBON 13

ANDRODERM 40ANDROGEL 41

ANDROGEL PUMP 40androxy 41

ANGELIQ 41ANTABUSE 12

ANTARA 33ANTIVERT 12ANZEMET 12

APOKYN 19apraclonidine 52

apri 41APRISO 50

APTIVUS 22ARALAST NP 56

aranelle 41ARANESP ALBUMIN FREE 28

ARCALYST 48ARGATROBAN 27

ARICEPT 10ARIXTRA 27

ARRANON 16ARTHROTEC 50 1ARTHROTEC 75 1

ARZERRA 18ASACOL 50

ASACOL HD 50

Drug Name Page #ascomp/codeine 2

ASMANEX 120 METERED DOSES 53ASMANEX 14 METERED DOSES 53ASMANEX 30 METERED DOSES 53ASMANEX 60 METERED DOSES 53

ASTEPRO 54astramorph 2

atenolol 30atenolol/chlorthalidone 30

atorvastatin calcium 33atovaquone/proguanil hcl 19

ATRIPLA 21ATROVENT HFA 54

augmented betamethasone dipropionate

43

AVANDAMET 24AVANDARYL 24

AVASTIN 18AVELOX 8

AVELOX ABC PACK 8aviane 41

avita 37AVODART 40

AVONEX 48AXERT 14

AZASAN 47AZASITE 7

azathioprine 47azathioprine sodium 47

azelastine hcl 51azelastine hcl 54

AZELEX 37AZILECT 19

azithromycin 7AZOPT 52AZOR 31

aztreonam 6baciim 4

bacitracin 4bacitracin/polymyxin b 4

baclofen 21BACTOCILL IN DEXTROSE 7

BACTROBAN 5BACTROBAN NASAL 5balsalazide disodium 50

balziva 41BANZEL 8

BARACLUDE 23BD INSULIN SYRINGE

SAFETYGLIDE/1ML/29G X 1/2"51

Page 73: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 62 of 78

Drug Name Page #BD INSULIN SYRINGE

ULTRAFINE/0.3ML/31G X 5/16" 51

BD INSULIN SYRINGE ULTRAFINE/0.5ML/30G X 1/2"

51

BD INSULIN SYRINGE ULTRAFINE/1ML/31G X 5/16"

51

BD PEN NEEDLE/ULTRAFINE/29G X 12.7MM

51

BECONASE AQ 53benazepril hcl 33

benazepril hcl/hydrochlorothiazide 33BENICAR 34

BENICAR HCT 34BENLYSTA 47

BENZACLIN WITH PUMP 37benztropine mesylate 19

BEPREVE 51BESIVANCE 8

betamethasone dipropionate 40betamethasone dipropionate 43

betamethasone valerate 44BETASERON 48

betaxolol hcl 30betaxolol hcl 52

bethanechol chloride 40BETIMOL 53

bicalutamide 47BICILLIN C-R 7BICILLIN L-A 7

BICNU 15BIDIL 35

BILTRICIDE 19bisoprolol fumarate 30

bisoprolol fumarate/hydrochlorothiazide 30bleomycin sulfate 16

BLEPHAMIDE 52BLEPHAMIDE S.O.P. 52

BOOSTRIX 49BOTOX 51briellyn 41

BRILINTA 29brimonidine tartrate 53

BROMDAY 52BROMFENAC 52

bromocriptine mesylate 19BROVANA 55

budeprion sr 10budeprion xl 10budesonide 50budesonide 53bumetanide 32

Drug Name Page #BUPHENYL 38

buprenorphine hcl 2buproban 12

bupropion hcl 10bupropion hcl sr 10

buspirone hcl 23BUSULFEX 15

butalbital/acetaminophen/caffeine/codeine

2

butorphanol tartrate 2BYDUREON 24

BYETTA 24BYSTOLIC 30cabergoline 46

calcipotriene 37calcitonin-salmon 50

calcitriol 50calcium acetate 40

camila 43CAMPATH 18CAMPRAL 12

CANASA 50CANCIDAS 13

CAPASTAT SULFATE 15CAPEX 44

CAPITAL/CODEINE 2CAPRELSA 16

captopril 34captopril/hydrochlorothiazide 34

CARAC 37CARAFATE 39CARBAGLU 38

carbamazepine 9carbamazepine er 9

CARBATROL 9carbidopa/levodopa 19

carbidopa/levodopa cr 19carbidopa/levodopa er 19

carbidopa/levodopa odt 19carboplatin 16

CARDIZEM CD 31CARDURA XL 40

CARIMUNE NANOFILTERED 48carisoprodol 56carteolol hcl 53

cartia xt 31carvedilol 30

CAYSTON 6CEDAX 6CEENU 15cefaclor 6

Page 74: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 63 of 78

Drug Name Page #cefaclor er 6cefadroxil 6

cefazolin sodium 6cefdinir 6

cefepime 6cefotaxime sodium 6

cefoxitin sodium 6cefpodoxime proxetil 6

cefprozil 6ceftazidime 6

ceftriaxone sodium 6cefuroxime axetil 6

cefuroxime sodium 6CELEBREX 1

CELESTONE 44CELLCEPT 47

CELLCEPT INTRAVENOUS 47CELONTIN 9CENESTIN 41cephalexin 6

CEREZYME 38CERVARIX 49

cesia 41cetirizine hcl 54

CHANTIX 12CHANTIX STARTING MONTH PAK 12

chloramphenicol sodium succinate 5chlordiazepoxide/amitriptyline 23

chlorhexidine gluconate oral rinse 36chloroquine phosphate 19

chlorothiazide 32chlorothiazide sodium 32

chlorpromazine hcl 21chlorthalidone 32chlorzoxazone 56

cholestyramine light 33chorionic gonadotropin 45

CIALIS 40ciclopirox 13

ciclopirox nail lacquer 13ciclopirox olamine 13

cilostazol 29CILOXAN 8cimetidine 39

cimetidine hcl 39CIMZIA 47

CINRYZE 29CIPRO 8

CIPRO HC 53ciprofloxacin 8

ciprofloxacin er 8

Drug Name Page #ciprofloxacin hcl 8

cisplatin 16citalopram hydrobromide 10

cladribine 16CLAFORAN 6

claravis 37CLARINEX-D 12 HOUR 54CLARINEX-D 24 HOUR 54

clarithromycin 7clarithromycin er 7

clemastine fumarate 54CLEOCIN 5

CLEOCIN GALAXY 5CLEOCIN IN D5W 5

CLIMARA PRO 41CLINDAGEL 5

clindamycin hcl 5clindamycin phosphate 5

clindamycin phosphate add-vantage 5clindamycin/benzoyl peroxide 37

CLINDESSE 5CLINIMIX 2.75%/DEXTROSE 5% 57

clinimix 4.25%/dextrose 10% 57clinimix 4.25%/dextrose 20% 58clinimix 4.25%/dextrose 25% 58

CLINIMIX 4.25%/DEXTROSE 5% 58CLINIMIX 5%/DEXTROSE 15% 58CLINIMIX 5%/DEXTROSE 20% 58CLINIMIX 5%/DEXTROSE 25% 57

CLINIMIX E 2.75%/DEXTROSE 10% 58CLINIMIX E 2.75%/DEXTROSE 5% 57

CLINIMIX E 4.25%/DEXTROSE 25% 58CLINIMIX E 4.25%/DEXTROSE 5% 58

CLINIMIX E 5%/DEXTROSE 15% 57CLINIMIX E 5%/DEXTROSE 20% 58CLINIMIX E 5%/DEXTROSE 25% 58

clinisol sf 15% 58clobetasol propionate 40clobetasol propionate 44

clobetasol propionate e 44CLOBEX 44

CLODERM 44CLOLAR 16

clomipramine hcl 11clonazepam 23clonidine hcl 30

clopidogrel 29clorazepate dipotassium 23

CLORPRES 30clotrimazole 13

Page 75: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 64 of 78

Drug Name Page #clotrimazole/betamethasone

dipropionate 13

clozapine 20codeine sulfate 2

co-gesic 2COLCRYS 14

colestipol hcl 33colistimethate sodium 5

colocort 50COLY-MYCIN S 53

COMBIGAN 53COMBIPATCH 41

COMBIVENT 54COMBIVENT RESPIMAT 54

COMBIVIR 22COMPLERA 21

compro 12COMTAN 19COMVAX 49

CONCERTA 35CONDYLOX 37

constulose 38COPAXONE 48

CORDRAN 44CORDRAN SP 44

CORDRAN TAPE 44CORTIFOAM 50

cortisone acetate 44CORTISPORIN 5CORTISPORIN 52

CORTISPORIN-TC 53cortomycin 53

COUMADIN 27COVERA-HS 31

CREON 38CRESTOR 33CRINONE 43CRINONE 45CRIXIVAN 22

cromolyn sodium 52cromolyn sodium 55

cryselle-28 41CUBICIN 5

CUPRIMINE 12CURITY GAUZE PADS 2"X2" 51

CUTIVATE 44CUVPOSA 38

cyclafem 1/35 41cyclafem 7/7/7 41

cyclobenzaprine hcl 56cyclophosphamide 15

Drug Name Page #cyclosporine 47

cyclosporine modified 47CYKLOKAPRON 29

CYMBALTA 10CYSTADANE 38CYSTAGON 38

cytarabine 16cytarabine aqueous 16

dacarbazine 15DACOGEN 17

danazol 41dantrolene sodium 21

DAPSONE 15DAPTACEL 49DARAPRIM 19

daunorubicin hcl 17DAUNOXOME 17

DAYTRANA 35DECAVAC 49

demeclocycline hcl 8DEMSER 32DENAVIR 23

depade 12DEPEN TITRATABS 12DEPO-ESTRADIOL 41

DEPO-MEDROL 44DEPO-PROVERA 43

DEPO-SUBQ PROVERA 104 45DERMA-SMOOTHE/FS BODY OIL 44

DERMOTIC 53desipramine hcl 11

desloratadine 54desmopressin acetate 45

desonide 44desoximetasone 44dexamethasone 44

dexamethasone intensol 44dexamethasone sodium phosphate 44dexamethasone sodium phosphate 52

DEXILANT 39dexmethylphenidate hcl 35

DEXPAK 13 DAY 40dexrazoxane 17

dextroamphetamine sulfate 35dextroamphetamine sulfate er 35

dextrose 10%/nacl 0.45% 58DEXTROSE 5% /ELECTROLYTE #48

VIAFLEX58

dextrose 10% flex container 51dextrose 10%/nacl 0.2% 58

dextrose 2.5%/sodium chloride 0.45% 58

Page 76: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 65 of 78

Drug Name Page #dextrose 5% 51

dextrose 5%/lactated ringers 58dextrose 5%/nacl 0.2% 58

dextrose 5%/nacl 0.225% 58dextrose 5%/nacl 0.33% 58dextrose 5%/nacl 0.45% 58dextrose 5%/nacl 0.9% 58

dextrose 5%/potassium chloride 0.075% 57diazepam 23

DIBENZYLINE 30diclofenac potassium 4

diclofenac sodium 52diclofenac sodium dr 1diclofenac sodium xr 1

dicloxacillin sodium 7dicyclomine hcl 38

didanosine 22DIFFERIN 37

DIFICID 7diflorasone diacetate 44

diflunisal 1digoxin 32

DILANTIN 9DILANTIN INFATABS 9

DILATRATE SR 35DILAUDID-5 2

dilt-cd 31diltiazem cd 31diltiazem hcl 31

diltiazem hcl er 31dilt-xr 31

diltzac 31DIOVAN 34

DIOVAN HCT 34DIPENTUM 50

DIPHTHERIA/TETANUS TOXOID PEDIATRIC

49

disopyramide phosphate 30disulfiram 12

DIURIL 32divalproex sodium 9

divalproex sodium dr 9divalproex sodium er 9

DIVIGEL 41DOCEFREZ 17

DOCETAXEL 17donepezil hcl 10

DORYX 8dorzolamide hcl 53

dorzolamide hcl/timolol maleate 53DOVONEX 37

Drug Name Page #doxazosin mesylate 40

doxepin hcl 11DOXIL 17

doxorubicin hcl 17doxycycline 8

doxycycline hyclate 8doxycycline monohydrate 8

dronabinol 12DROXIA 16

DUETACT 24DULERA 53

duramorph 2DUREZOL 52

DYNACIRC CR 31DYRENIUM 32

e.e.s. 400 7E.E.S. GRANULES 7

econazole nitrate 13ed k+10 58EDARBI 34

EDARBYCLOR 34EDECRIN 32

EDURANT 21EFFIENT 29EGRIFTA 45

ELAPRASE 38ELIDEL 37

ELIGARD 46eliphos 40ELITEK 16

ELIXOPHYLLIN 55ELLA 43

ELMIRON 40ELSPAR 17

EMADINE 52EMCYT 16EMEND 12

emoquette 41EMSAM 10

EMTRIVA 22ENABLEX 39

enalapril maleate 34enalapril maleate/hydrochlorothiazide 34

ENBREL 47endocet 2

endodan 2ENGERIX-B 49

ENJUVIA 41enoxaparin sodium 27

enpresse-28 41ENTOCORT EC 50

Page 77: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 66 of 78

Drug Name Page #enulose 38

EPIDUO 37epinastine hcl 52

epinephrine hcl 55EPIPEN 2-PAK 55

EPIPEN-JR 2-PAK 55epirubicin hcl 17

epitol 9EPIVIR 22

EPIVIR HBV 22eplerenone 32

eprosartan mesylate 34EPZICOM 22

EQUETRO 24ERAXIS 13

ERBITUX 18ergotamine tartrate/caffeine 14

ERIVEDGE 17errin 43

ERTACZO 13ery 7

ERYPED 200 7ERYPED 400 7

ERY-TAB 7ERYTHROCIN LACTOBIONATE 7

ERYTHROCIN STEARATE 7erythromycin 7

erythromycin base 7erythromycin ethylsuccinate 7

erythromycin/benzoyl peroxide 37erythromycin/sulfisoxazole 7

escitalopram oxalate 10ESTRACE 41

ESTRADERM 41estradiol 41

estradiol valerate 41estradiol/norethindrone acetate 41

ESTRING 41estropipate 41

ethambutol hcl 15ethosuximide 9

etidronate disodium 50etodolac 1

etodolac er 1ETOPOPHOS 17

etoposide 17EURAX 19EVISTA 43

EVOXAC 36EXELDERM 13

EXELON 10

Drug Name Page #exemestane 18

EXJADE 12FABRAZYME 38

famciclovir 23famotidine 39

famotidine premixed 39FANAPT 20

FANAPT TITRATION PACK 20FARESTON 16FASLODEX 16

FAZACLO 20felbamate 9

FELBATOL 9felodipine er 31

FEMHRT LOW DOSE 41FEMRING 41

FEMTRACE 41fenofibrate 33

fenofibrate micronized 33fenoprofen calcium 1

fentanyl 2fentanyl citrate 2

fentanyl citrate oral transmucosal 2FERRIPROX 12

FINACEA 37finasteride 40FIRAZYR 51

FIRMAGON 17FLAGYL ER 5

FLAREX 52flavoxate hcl 39

flecainide acetate 30FLOVENT DISKUS 53

FLOVENT HFA 53fluconazole 13

fluconazole in dextrose 13flucytosine 13

fludarabine phosphate 17fludrocortisone acetate 44

flunisolide 54fluocinolone acetonide 40fluocinolone acetonide 44

fluocinolone acetonide body 40fluocinonide 44

fluocinonide-e 44fluorometholone 52FLUOROPLEX 37

fluorouracil 16fluorouracil 37

fluoxetine dr 10fluoxetine hcl 10

Page 78: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 67 of 78

Drug Name Page #fluphenazine decanoate 21

fluphenazine hcl 21flurbiprofen 1

flurbiprofen sodium 52flutamide 47

fluticasone propionate 40fluticasone propionate 44fluticasone propionate 54

fluvastatin 33fluvoxamine maleate 11

FML 52FML FORTE 52

FOCALIN XR 35FOLOTYN 16

fondaparinux sodium 28FORADIL AEROLIZER 55

FORTAMET 24FORTAZ 6FORTEO 50

FOSAMAX 50FOSAMAX PLUS D 50

FOSCARNET SODIUM 21fosinopril sodium 34

fosinopril sodium/hydrochlorothiazide 34fosphenytoin sodium 9

FOSRENOL 40FRAGMIN 28

FREAMINE III 58FREAMINE III 3% 58

FROVA 14furosemide 32

FUSILEV 57FUZEON 22

gabapentin 9GABITRIL 9

GABLOFEN 21galantamine hydrobromide 10

GAMASTAN S/D 48GAMMAGARD LIQUID 48

GAMMAPLEX 48GAMUNEX-C 48

GANCICLOVIR 21GARDASIL 49

GASTROCROM 38gavilyte-g 38

gavilyte-n/flavor pack 38GELNIQUE 39gemcitabine 16

gemcitabine hcl 16gemfibrozil 33GEMZAR 16

Drug Name Page #gengraf 47

GENOTROPIN 45GENOTROPIN MINIQUICK 45

gentak 4gentamicin sulfate 4

gentamicin sulfate/0.9% sodium chloride 4gentamicin sulfate/sodium chloride 4

gentasol 4GEODON 20

gianvi 41GILENYA 48GLASSIA 56

GLEEVEC 18glimepiride 25

glipizide 25glipizide er 25

glipizide/metformin hcl 25GLUCAGEN HYPOKIT 26

GLUCAGON EMERGENCY KIT 26GLUMETZA 25

glyburide 25glyburide micronized 25

glyburide/metformin hcl 25glycopyrrolate 38

glycron 25GLYSET 25

granisetron hcl 13granisol 13

GRIFULVIN V 13griseofulvin microsize 13

GRIS-PEG 13guanabenz acetate 30

guanfacine hcl 30GUANIDINE HCL 15

GYNAZOLE-1 13HALAVEN 17

HALFLYTELY BOWEL PREP/FLAVOR PACKS

38

halobetasol propionate 44HALOG 44

haloperidol 21haloperidol decanoate 21

haloperidol lactate 21HAVRIX 49

HECTOROL 50HELIDAC 38

heparin sodium 28heparin sodium/d5w 28

heparin sodium/nacl 0.45% 28heparin sodium/sodium chloride 0.9%

premix28

Page 79: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 68 of 78

Drug Name Page #hepatamine 57

HEPATASOL 58HEPSERA 23

HERCEPTIN 18HEXALEN 15

HIZENTRA 48HUMALOG 27

HUMALOG KWIKPEN 27HUMALOG MIX 50/50 27

HUMALOG MIX 50/50 KWIKPEN 27HUMALOG MIX 75/25 27

HUMALOG MIX 75/25 KWIKPEN 27HUMATROPE 45

HUMATROPE COMBO PACK 45HUMIRA 47

HUMIRA PEN-CROHNS DISEASESTARTER

47

HUMULIN 70/30 27HUMULIN 70/30 PEN 27

HUMULIN N 27HUMULIN N U-100 PEN 27

HUMULIN R 27HUMULIN R U-500 (CONCENTRATED) 27

HYCET 2hydralazine hcl 35

hydrochlorothiazide 32hydrocodone bitartrate/acetaminophen 2

hydrocodone/acetaminophen 2hydrocodone/ibuprofen 2

hydrocortisone 44hydrocortisone butyrate 44hydrocortisone valerate 44

hydrocortisone/acetic acid 53hydromorphone hcl 2

hydroxychloroquine sulfate 19hydroxyurea 16

hydroxyzine hcl 54hydroxyzine pamoate 13

ibandronate sodium 50ibuprofen 1

idarubicin hcl 17ifosfamide 15

ifosfamide/mesna 15ILARIS 48

imipenem/cilastatin 6imipramine hcl 11

imipramine pamoate 12imiquimod 37IMITREX 14

IMOVAX RABIES (H.D.C.V.) 49INCIVEK 23

Drug Name Page #INCRELEX 45indapamide 32

INDOCIN 1indomethacin 1

indomethacin er 1INFANRIX 49

INFERGEN 49INFUMORPH 200 2INFUMORPH 500 2

INLYTA 18INNOPRAN XL 30

INTELENCE 21intralipid 51

INTRON-A 49INTRON-A W/DILUENT 49

introvale 41INVANZ 6INVEGA 20

INVEGA SUSTENNA 20INVIRASE 22

IONOSOL-PAEXTROSE 5% 57IONOSOL-MPAEXTROSE 5% 58

IONOSOL-T/DEXTROSE 5% 58IOPIDINE 53

IPOL INACTIVATED IPV 49ipratropium bromide 55

ipratropium bromide/albuterol sulfate 55irbesartan 34

irbesartan/hydrochlorothiazide 34irinotecan 17

ISENTRESS 22isochron 35

ISOLYTE-H/DEXTROSE 5% 58isolyte-m/dextrose 5% 58

ISOLYTE-P/DEXTROSE 5% 57ISOLYTE-S 58

ISOLYTE-S/DEXTROSE 5% 58isonarif 15

isoniazid 15ISOPTO CARPINE 53

ISORDIL TITRADOSE 35isosorbide dinitrate 35

isosorbide dinitrate er 35isosorbide mononitrate 35

isosorbide mononitrate er 35isotonic gentamicin 4

isradipine 31ISTALOL 53ISTODAX 17

itraconazole 13IXEMPRA KIT 17

Page 80: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 69 of 78

Drug Name Page #IXIARO 49JAKAFI 17

jantoven 28JANUMET 25

JANUMET XR 25JANUVIA 25

JE-VAX 49JEVTANA 17

jinteli 41jolivette 43

junel 1.5/30 41junel 1/20 41

junel fe 1.5/30 41junel fe 1/20 41

KADIAN 2KALETRA 22

KALYDECO 56kanamycin sulfate 4

KAPVAY 30kariva 41

kcl 0.075%/d5w/nacl 0.45% 58kcl 0.15%/d10w/nacl 0.2% 58

kcl 0.15%/d5w/lr 58kcl 0.15%/d5w/nacl 0.2% 58

kcl 0.15%/d5w/nacl 0.225% 58kcl 0.15%/d5w/nacl 0.9% 57kcl 0.3%/d5w/nacl 0.2% 58

kcl 0.3%/d5w/nacl 0.45% 58kcl 0.3%/d5w/nacl 0.9% 57

KEFLEX 6kelnor 1/35 41KENALOG 44

KEPIVANCE 36KETEK 7

ketoconazole 13ketoprofen 1

ketoprofen er 1ketorolac tromethamine 1ketorolac tromethamine 52

KINERET 49kionex 12

klor-con 10 57klor-con 8 58

KLOR-CON M15 58klor-con m20 58

KOMBIGLYZE XR 26KRISTALOSE 38

KUVAN 38labetalol hcl 30

laclotion 37LACRISERT 51

Drug Name Page #lactated ringers 58

lactated ringers irrigation 58lactulose 38

LAMICTAL STARTER/NOT TAKING CARBAMAZEPINE

9

LAMICTAL STARTER/TAKING CARBAMAZEPINE/NOT TAKING

VALPROATE

9

LAMICTAL STARTER/TAKING VALPROATE

9

lamivudine 22lamivudine/zidovudine 22

lamotrigine 9LANOXIN 32

lansoprazole 39lansoprazole odt 39

LANTUS 27LANTUS SOLOSTAR 27

LASTACAFT 52latanoprost 53

LATUDA 20LAZANDA 3

leena 41leflunomide 49

LESCOL 33LESCOL XL 33

lessina-28 42LETAIRIS 55

letrozole 18leucovorin calcium 51

LEUKERAN 15LEUKINE 29

leuprolide acetate 46levalbuterol 55

LEVATOL 30LEVEMIR 27

LEVEMIR FLEXPEN 27levetiracetam 8

levetiracetam er 8LEVITRA 40

levobunolol hcl 53levocarnitine 51

levocetirizine dihydrochloride 54levofloxacin 8

levofloxacin in d5w 8levora 0.15/30-28 42

levorphanol tartrate 3LEVOTHROID 43

levothyroxine sodium 43levoxyl 43

LEXIVA 22

Page 81: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 70 of 78

Drug Name Page #lidocaine 4

lidocaine hcl 4lidocaine hcl jelly 4lidocaine viscous 4

lidocaine/prilocaine 4LIDODERM 4

lindane 19LIORESAL INTRATHECAL 21

liothyronine sodium 43lisinopril 34

lisinopril/hydrochlorothiazide 34lithium carbonate 24

lithium carbonate er 24lithium citrate 24

LITHOBID 24LOCOID LIPOCREAM 44

LODOSYN 19LOESTRIN 24 FE 42

lokara 44loperamide hcl 38

lorazepam 23losartan potassium 34

losartan potassium/hydrochlorothiazide 34LOSEASONIQUE 42

LOTEMAX 52LOTRONEX 39

lovastatin 33LOVAZA 33

LOVENOX 28low-ogestrel 42

loxapine succinate 21LUMIGAN 53

LUMIZYME 38LUNESTA 56

LUPRON DEPOT 46LUPRON DEPOT-PED 46

lutera 42LUXIQ 44

LYRICA 9LYSODREN 45

magnesium sulfate 58magnesium sulfate in d5w 57

MALARONE 19malathion 19

maprotiline hcl 10margesic-h 3

marlissa 42MARPLAN 10

MATULANE 15matzim la 31

MAXAIR AUTOHALER 55

Drug Name Page #MAXALT 14

MAXALT-MLT 14MAXIDEX 52

mebendazole 19meclizine hcl 13

meclofenamate sodium 1medroxyprogesterone acetate 43

mefenamic acid 1mefloquine hcl 19MEGACE ES 43

megestrol acetate 43meloxicam 1

melphalan hydrochloride 15MENACTRA 49

MENEST 42MENOMUNE-A/C/Y/W-135 49

MENOSTAR 42MENTAX 13MENVEO 49

meprobamate 23MEPRON 19

mercaptopurine 16meropenem 6mesalamine 50

mesna 17MESNEX 17

MESTINON 15MESTINON TIMESPAN 15

METADATE CD 36metaproterenol sulfate 55

metaxalone 56metformin hcl 26

metformin hcl er 26METHADONE HCL 3

methadose 3methazolamide 53

methenamine hippurate 5METHERGINE 51

methimazole 47methocarbamol 56

methotrexate 48methotrexate sodium 48

methscopolamine bromide 38methyclothiazide 32

methyldopa 30methyldopa/hydrochlorothiazide 30

methylergonovine maleate 51methylin 36

methylin er 36methylphenidate hcl 36

methylphenidate hcl er 36

Page 82: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 71 of 78

Drug Name Page #methylphenidate hcl sr 36

methylphenidate hydrochloride 36methylprednisolone 44methylprednisolone 50

methylprednisolone acetate 44methylprednisolone dose pack 44

methylprednisolone sodiumsuccinate 44metipranolol 53

metoclopramide hcl 13metolazone 32

metoprolol succinate er 31metoprolol tartrate 31

metoprolol/hydrochlorothiazide 31METROGEL 5

metronidazole 5metronidazole in nacl 0.79% 5

metronidazole vaginal 5mexiletine hcl 30

MIACALCIN 50MICARDIS 34

MICARDIS HCT 34miconazole 3 13

microgestin 1.5/30 42microgestin 1/20 42

microgestin fe 42microgestin fe 1.5/30 42

midodrine hcl 30migergot 14

MILLIPRED 50minitran 35

minocycline hcl 8minocycline hcl er 8

minoxidil 35mirtazapine 10

mirtazapine odt 10misoprostol 39

mitomycin 17mitoxantrone hcl 17

M-M-R II W/DILUENT 10 DOSE 49modafinil 36

moexipril hcl 34moexipril/hydrochlorothiazide 34

mometasone furoate 44mononessa 42

montelukast sodium 54MONUROL 5

morphine sulfate 3morphine sulfate er 3

MOVIPREP 38MOXEZA 8

MOZOBIL 29

Drug Name Page #MULTAQ 30mupirocin 5

MUSTARGEN 15MYCOBUTIN 15

mycophenolate mofetil 48MYFORTIC 48MYOZYME 38

MYTELASE 15nabumetone 1

nadolol 31nadolol/bendroflumethiazide 31

nafcillin sodium 7NAGLAZYME 38

nalbuphine hcl 3NALFON 1

NALLPEN/DEXTROSE 7naloxone hcl 12

naltrexone hcl 12NAMENDA 10

NAMENDA TITRATION PAK 10naproxen 1

naproxen dr 1naproxen sodium 4

naratriptan hcl 14NASONEX 54NATACYN 13nateglinide 26

necon 0.5/35-28 42necon 1/35-28 42

necon 10/11-28 42necon 7/7/7 42

nefazodone hcl 10neomycin sulfate 4

neomycin/bacitracin/polymyxin 5neomycin/polymyxin b sulfates 5

neomycin/polymyxin/bacitracin/hydrocortisone

52

neomycin/polymyxin/dexamethasone 52neomycin/polymyxin/gramicidin 5

neomycin/polymyxin/hc 53neomycin/polymyxin/hydrocortisone 53

NEPHRAMINE 57NEULASTA 29NEUMEGA 29

NEUPOGEN 29NEVANAC 52nevirapine 22NEXAVAR 18

NEXIUM 39NEXIUM I.V. 39

next choice 43

Page 83: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 72 of 78

Drug Name Page #niacor 33

NIASPAN 33nicardipine hcl 31

NICOTROL INHALER 12NICOTROL NS 12

nifediac cc 31nifedical xl 31

nifedipine er 31NILANDRON 47

nimodipine 31nisoldipine 31

nisoldipine er 31NITRO-DUR 35nitrofurantoin 5

nitrofurantoin macrocrystalline 5nitrofurantoin monohydrate 5

nitroglycerin 35nitroglycerin transdermal 35

NITROLINGUAL PUMPSPRAY 35NITROMIST 35NITROSTAT 35

nizatidine 39nora-be 43

NORDITROPIN FLEXPRO 45NORDITROPIN NORDIFLEX PEN 45

norethindrone acetate 43NORITATE 5

normosol-m in d5w 58NORMOSOL-R 58

normosol-r in d5w 58NOROXIN 8

nortrel 0.5/35 (28) 42nortrel 1/35 (21) 42nortrel 1/35 (28) 42

nortrel 7/7/7 42nortriptyline hcl 12

NORVIR 22NOVANTRONE 17

novarel 45NOVOLIN 70/30 27

NOVOLIN N 27NOVOLIN R 27NOVOLOG 27

NOVOLOG FLEXPEN 27NOVOLOG MIX 70/30 27

NOVOLOG MIX 70/30 PREFILLED FLEXPEN

27

NOXAFIL 13NUCYNTA ER 3

NULOJIX 48NULYTELY/FLAVOR PACKS 38

Drug Name Page #NUTROPIN 45

NUTROPIN AQ NUSPIN 5 45NUTROPIN AQ PEN 45

NUVARING 42nyamyc 13nystatin 14

nystatin/triamcinolone 14nystop 14ocella 42

octreotide acetate 46ofloxacin 8ogestrel 42

olanzapine 20olanzapine odt 20

olanzapine/fluoxetine 24OLUX-E 44

omeprazole 39omeprazole/sodium bicarbonate 39

OMNITROPE 45ondansetron hcl 13ondansetron odt 13

ONGLYZA 26ONTAK 17

OPANA ER (CRUSH RESISTANT) 3ORACEA 8

ORAP 21ORAVIG 14

ORENCIA 48ORFADIN 38

orsythia 42ORTHO EVRA 42

ORTHO TRI-CYCLEN LO 42ortho-est 42

OSMOPREP 39OVCON-50 28 42

OXACILLIN SODIUM 7oxaliplatin 17

oxandrolone 40oxaprozin 1

oxcarbazepine 9OXISTAT 14

OXSORALEN 37OXSORALEN ULTRA 37

oxybutynin chloride 39oxybutynin chloride er 39

oxycodone hcl 3oxycodone/acetaminophen 3

oxycodone/aspirin 3oxycodone/ibuprofen 3

OXYCONTIN 3oxymorphone hydrochloride 3

Page 84: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 73 of 78

Drug Name Page #oxymorphone hydrochloride er 3

OXYTROL 39PACERONE 30

paclitaxel 17pamidronate disodium 50

PANDEL 44PANRETIN 18

pantoprazole sodium 39parcaine 51

paromomycin sulfate 4paroxetine hcl 11

paroxetine hcl er 11PASER 15

PATADAY 52PATANASE 54

PATANOL 52PCE 7

pedi-dri 14PEDVAX HIB 49PEGANONE 9

PEGASYS 49PEGASYS PROCLICK 49

PEG-INTRON 49PEG-INTRON REDIPEN 49

penicillin g potassium 7penicillin g potassium in iso-osmotic

dextrose 7

penicillin g sodium 7penicillin v potassium 7

PENNSAID 1PENTASA 50pentopak 29

pentostatin 16pentoxifylline er 29

PERFOROMIST 55perindopril erbumine 34

periogard 36permethrin 19

perphenazine 21perphenazine/amitriptyline 21

PEXEVA 11phenadoz 54

phenelzine sulfate 10phenytoin 9

phenytoin sodium 9phenytoin sodium extended 9

PHOSLYRA 40PHOSPHOLINE IODIDE 53

physiolyte 58PHYSIOSOL IRRIGATION 57

PICATO 17

Drug Name Page #pilocarpine hcl 36

pilocarpine hydrochloride 37PILOPINE HS 53

pindolol 31pioglitazone hcl/metformin hcl 26

PIPERACILLIN SODIUM 7piperacillin sodium/tazobactam sodium 7

piroxicam 1PLASMA-LYTE 56 58PLASMA-LYTE A 57

PLASMA-LYTE-148 58PLASMA-LYTE-148/D5W 57PLASMA-LYTE-56/D5W 59

plasma-lyte-r 57PLAVIX 29

podofilox 37poly-dex 52

polyethylene glycol 3350 39polymyxin b sulfate 5

POLY-PRED 52portia-28 42

potassium chloride 59potassium chloride 0.075%/d5w/nacl

0.225%59

potassium chloride 0.15% /nacl 0.45% viaflex

59

potassium chloride 0.15% d5w/nacl 0.33%

59

potassium chloride 0.15% d5w/nacl 0.45% viaflex

59

potassium chloride 0.15% nacl 0.9% 59potassium chloride 0.15%/d5w 59

potassium chloride 0.22% d5w/nacl 0.45%

59

potassium chloride 0.224%/d5w 57potassium chloride 0.224%d5w/nacl

0.33%59

potassium chloride 0.3%/ nacl 0.9% 57potassium chloride 0.3%/d5w 59

potassium chloride er 59potassium citrate er 59

POTIGA 9PRADAXA 28

pramipexole dihydrochloride 19PRANDIN 26

pravastatin sodium 33prazosin hcl 30PRED MILD 52

PRED-G 52PRED-G S.O.P. 52

prednicarbate 44

Page 85: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 74 of 78

Drug Name Page #prednisolone acetate 52

prednisolone sodium phosphate 44prednisolone sodium phosphate 52

prednisone 44prednisone intensol 44

PREFEST 42pregnyl w/diluent benzyl alcohol/nacl 45

PREMARIN 42PREMASOL 57

premasol 59PREMPHASE 42

PREMPRO 42prenatabs obn 57

prevalite 33previfem 42

PREVPAC 39PREZISTA 22

PRIFTIN 15PRIMAQUINE PHOSPHATE 19

PRIMAXIN I.M. 6primidone 9PRIMSOL 5PRISTIQ 11

PRIVIGEN 48PROAIR HFA 55

probenecid 14probenecid/colchicine 14

procainamide hcl 30PROCALAMINE 59prochlorperazine 13

prochlorperazine edisylate 21prochlorperazine maleate 21

PROCRIT 29proctocream hc 44

procto-pak 44proctosol hc 45

proctozone-hc 45progesterone 43

PROGLYCEM 27PROGRAF 48

PROLASTIN 56PROLASTIN-C 56

PROLEUKIN 17PROLIA 50

PROMACTA 29PROMACTA 29

promethazine hcl 54promethegan 54

PROMETRIUM 43propafenone hcl 30

propafenone hcl er 30

Drug Name Page #propantheline bromide 38

proparacaine hcl 51propranolol hcl 31

propranolol hcl er 31propranolol/hydrochlorothiazide 31

propylthiouracil 47PROQUAD 49

PROQUIN XR 8PROSOL 59

PROTONIX 39PROTOPIC 37

protriptyline hcl 12PROVENTIL HFA 55

PROVIGIL 36PULMICORT 54

PULMICORT FLEXHALER 54PULMOZYME 56pyrazinamide 15

pyridostigmine bromide 15QUALAQUIN 19

quasense 42quetiapine fumarate 24

quinapril hcl 34quinapril/hydrochlorothiazide 35

QUINIDINE GLUCONATE 30quinidine gluconate er 30

quinidine sulfate 30quinidine sulfate er 30

QVAR 54RABAVERT 49

ramipril 35RANEXA 32

ranitidine hcl 39RAPAFLO 40

RAPAMUNE 48RAYOS 40

REBETOL 23REBIF 49

REBIF TITRATION PACK 49reclipsen 42

RECOMBIVAX HB 49regonol 15

REGRANEX 37RELENZA DISKHALER 23

RELISTOR 12RELPAX 14

REMICADE 49REMODULIN 55

RENAGEL 40RENVELA 40

RESCRIPTOR 22

Page 86: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 75 of 78

Drug Name Page #reserpine 30

RESTASIS 51RETIN-A MICRO 37

RETROVIR IV INFUSION 22REVATIO 55

REVLIMID 16REYATAZ 22ribasphere 23

ribavirin 23RIDAURA 49

rifampin 15RIFATER 15RILUTEK 36

rimantadine hcl 23ringers injection 59ringers irrigation 59

RIOMET 26RISPERDAL CONSTA 20

risperidone 21risperidone odt 20

RITALIN LA 36RITUXAN 18

rivastigmine tartrate 10romycin 7

ropinirole er 19ropinirole hcl 19

ROTATEQ 49ROXICET 3

ROZEREM 56SABRIL 9SAIZEN 45

SAIZEN CLICK.EASY 45SAMSCA 32

SANCTURA XR 39SANCUSO 13

SANDOSTATIN LAR DEPOT 47SANTYL 37

SAPHRIS 24SAVELLA 1

SAVELLA TITRATION PACK 1SEASONIQUE 42

selegiline hcl 19selenium sulfide 37

selfemra 11SELZENTRY 22SEMPREX-D 54

SENSIPAR 46SEREVENT DISKUS 55

SEROQUEL 24SEROQUEL XR 24

sertraline hcl 11

Drug Name Page #silver sulfadiazine 5

SIMCOR 33simvastatin 33

SINGULAIR 54sodium bicarbonate 59

sodium chloride 57sodium chloride 59

sodium chloride 0.45% viaflex 59sodium chloride 0.9% 59

sodium fluoride 59sodium lactate 57sodium lactate 59

sodium polystyrene sulfonate 12sodium sulfacetamide 8

SOLARAZE 37solia 42

SOLU-CORTEF 45SOLU-MEDROL 45

SOMATULINE DEPOT 47SOMAVERT 47SORIATANE 37

sorine 30sotalol hcl 30

sotalol hydrochloride 30SOTRET 37

SPIRIVA HANDIHALER 55spironolactone 32

spironolactone/hydrochlorothiazide 32SPORANOX 14

sprintec 28 42SPRYCEL 18

sronyx 42ssd 5

stagesic 3STALEVO 100 19STALEVO 125 19STALEVO 150 19STALEVO 200 19

STALEVO 50 19STALEVO 75 19

stavudine 22STAVZOR 9

sterile water irrigation 51STIMATE 45

STRATTERA 36STREPTOMYCIN SULFATE 4

STRIANT 41STRIBILD 22

STROMECTOL 19SUBOXONE 12

SUCRAID 38

Page 87: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 76 of 78

Drug Name Page #sucralfate 39

sulfacetamide sodium 8sulfacetamide sodium 37

sulfacetamide sodium/prednisolone sodium phosphate

52

sulfadiazine 8sulfamethoxazole/trimethoprim 8

sulfamethoxazole/trimethoprim ds 8SULFAMYLON 5

sulfasalazine 50sulfazine ec 50

sulindac 1sumatriptan succinate 14

SUPRAX 6SUPREP BOWEL PREP 39

SURMONTIL 12SUSTIVA 22SUTENT 18

SYLATRON 17SYMBICORT 54

SYMBYAX 24SYMLIN 26

SYMLINPEN 120 26SYMLINPEN 60 26

SYNAGIS 49SYNALGOS-DC 3

SYNAREL 47SYNERCID 5

SYNTHROID 43SYPRINE 12TABLOID 16tacrolimus 48TAMIFLU 23

tamoxifen citrate 16tamsulosin hcl 40

TARCEVA 18TARGRETIN 18

TASIGNA 18TAXOTERE 18

tazicef 6TAZORAC 37

taztia xt 32TEGRETOL-XR 9

TEKTURNA 35TEKTURNA HCT 35

temazepam 56terazosin hcl 40

terbinafine hcl 14terbutaline sulfate 55

terconazole 14testosterone cypionate 41

Drug Name Page #testosterone enanthate 41

TETANUS TOXOID ADSORBED 49TETANUS/DIPHTHERIA TOXOIDS-

ADSORBED ADULT49

tetracycline hcl 8TEV-TROPIN 45THALITONE 32THALOMID 16

THEO-24 55theochron 55

theophylline cr 55theophylline er 55

thermazene 5thioridazine hcl 21

THIOTEPA 15thiothixene 21

THYROLAR-1 43THYROLAR-1/4 43

THYROLAR-2 43THYROLAR-3 43ticlopidine hcl 29

TIKOSYN 30TIMENTIN 7

timolol maleate 31timolol maleate 53

tinidazole 19tis-u-sol 59

tizanidine hcl 21TOBI 4

TOBRADEX 52tobramycin sulfate 4

tobramycin sulfate/sodium chloride 4tobramycin/dexamethasone 52

tobrasol 4TOBREX 4

tolazamide 26tolbutamide 26

tolmetin sodium 1topiramate 9

toposar 18topotecan hcl 18

TORISEL 18torsemide 32

tpn electrolytes 59TRACLEER 56tramadol hcl 3

tramadol hcl er 4tramadol hydrochloride/acetaminophen 4

trandolapril 35tranexamic acid 29

TRANSDERM-SCOP 13

Page 88: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 77 of 78

Drug Name Page #tranylcypromine sulfate 10

TRAVASOL 59TRAVATAN Z 53trazodone hcl 10

TREANDA 15TRECATOR 15

TRELSTAR DEPOT MIXJECT 47TRELSTAR LA MIXJECT 47

TRELSTAR MIXJECT 47tretinoin 18tretinoin 37

TREXALL 48triamcinolone acetonide 45triamcinolone acetonide 54

triamcinolone acetonide in absorbase 45triamcinolone in orabase 37

triamterene/hydrochlorothiazide 32TRIBENZOR 32

TRICOR 33triderm 45

trifluoperazine hcl 21trifluridine 23

trihexyphenidyl hcl 19tri-legest fe 42

TRILIPIX 33trimethoprim 5

trimethoprim sulfate/polymyxin b sulfate 8trimipramine maleate 12

trinessa 42TRIPEDIA 49

tri-previfem 42TRISENOX 18tri-sprintec 42trivora-28 42TRIZIVIR 22

TROPHAMINE 59tropicamide 51

trospium chloride 40TRUVADA 22TWINJECT 55

TWINRIX 49TWYNSTA 32

TYGACIL 5TYKERB 18

TYPHIM VI 50TYSABRI 49TYZEKA 23TYZINE 56

TYZINE PEDIATRIC NASAL DROPS 56u-cort 40

ULORIC 14

Drug Name Page #ULTRAM ER 4

unithroid 43ursodiol 39

valacyclovir hcl 23VALCYTE 21

valproate sodium 9valproic acid 9

VANCOCIN HCL 5vancomycin hcl 5

vandazole 5VANDETANIB 16

VANOS 45VAQTA 50

VARIVAX 50VECTIBIX 18VELCADE 18

velivet 42VELTIN 37

venlafaxine hcl 11venlafaxine hcl er 11

VENTAVIS 56VENTOLIN HFA 55

verapamil hcl 32verapamil hcl er 32

VESICARE 40vestura 42VEXOL 52VFEND 14

VFEND IV 14VIAGRA 40

VIBRAMYCIN 8VICTOZA 26

VICTRELIS 23VIDAZA 18

VIDEX PEDIATRIC 22VIGAMOX 8

VIIBRYD 11VIMOVO 1VIMPAT 9

vinblastine sulfate 18vincasar pfs 18

vincristine sulfate 18vinorelbine tartrate 18

VIRACEPT 23VIRAMUNE 22

VIRAMUNE XR 22VIREAD 22VISICOL 39

VIVELLE-DOT 42VOLTAREN 1voriconazole 14

Page 89: qualityhealthplansny.comqualityhealthplansny.com/files/platinum_spanish.pdf · Formulario Completo de la Parte D i Advantage Platinum NY (HMO) Formulario del 2012 (Lista de Medicamentos

Page 78 of 78

Drug Name Page #VOTRIENT 16

VPRIV 38VYTORIN 33

warfarin sodium 28WELCHOL 33

XALKORI 18XARELTO 28

XENAZINE 51XGEVA 50

XIFAXAN 6XOLAIR 56

XOPENEX 55XOPENEX HFA 55

XYREM 36YERVOY 18

YF-VAX 50zafirlukast 54

zaleplon 56ZANAFLEX 21ZANOSAR 16

ZANTAC 39ZAVESCA 38

zazole 14ZELAPAR 20

ZELBORAF 18ZEMAIRA 56

ZEMPLAR 51ZENPEP 38

zeosa 43zerlor 4

ZETIA 33ZIAGEN 22

zidovudine 22ZINACEF 6

ZINACEF IN ISO-OSMOTIC DEXTROSE

6

ZINACEF IN ISO-OSMOTIC DILUENT 6ziprasidone hcl 21

ZIPSOR 4ZIRGAN 21

ZMAX 7ZOLINZA 18

zolpidem tartrate 56zolpidem tartrate er 56

ZOMETA 51ZOMIG 15

ZOMIG ZMT 14zonisamide 9

ZORTRESS 48ZOSTAVAX 50

ZOSYN 7

Drug Name Page #zovia 1/35e 43zovia 1/50e 43

ZOVIRAX 23ZUPLENZ 13ZYCLARA 37ZYDONE 4

ZYFLO 54ZYFLO CR 54

ZYLET 52ZYMAR 8

ZYMAXID 8ZYPREXA 21

ZYPREXA ZYDIS 21ZYTIGA 18ZYVOX 6