2015
DRUG FORMULARY
FORMULARIO DE MEDICAMENTOS
Counties/Condados:
Alameda, El Paso, Fresno, Los Angeles, Merced
Orange, Riverside, San Bernardino, San Diego, San Francisco, San Joaquin, Santa Clara & Stanislaus
Care1st Health Plan is an HMO and an HMO SNP plan with a Medicare contract and a contract with the California State Medicaid
Program. Enrollment in Care1st Health Plan depends on contract renewal. This formulary was updated August 2014. For more recent
information or other questions, please contact Care1st Health Plan at 1-800-544-0088 or, for TTY users, 711, from 8 a.m. to 8 p.m.,
seven days a week from October 1 through February 14, except Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through
Friday, from February 15 through September 30, except holidays, or visit www.care1stmedicare.com.
H5928_15_031_PD Accepted
H5928_15_031_PD_SPA Accepted
Care1st Health Plan
2015 Formulary (List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE
COVER IN THIS PLAN
Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take.
Care1st Health Plan is an HMO and an HMO SNP plan with a Medicare contract and a contract with the California State Medicaid Program. Enrollment in Care1st Health Plan depends on contract renewal.
This information is available for free in other languages. Please contact Member Services,
1-800-544-0088 (TTY 711), 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday from February 15 through September 30, except holidays.
Esta información está disponible gratuitamente en otros idiomas. Comuníquese con Servicios para los
Miembros: 1-800-544-0088 (TTY 711), de 8 a.m. a 8 p.m., los siete días de la semana del 1° de octubre al 14
de febrero, excepto el Día de Acción de Gracias y Navidad, y de 8 a.m. a 8 p.m., de lunes a viernes del 15 de
febrero al 30 de septiembre, excepto los días festivos. 1-800-544-0088
(
711)
HPMS Approved Formulary 00015370 Version: 7
H5928_15_031_PD Accepted
1
When this drug list (formulary) refers to “we,” “us”, or “our,” it means Care1st Health Plan. When it
refers to “plan” or “our plan,” it means Care1st AdvantageOptimum Plan (HMO), or Coordinated Choice
Plan (HMO), or Care1st TotalDual Plan (HMO SNP).
This document includes a list of the drugs (formulary) for our plan which is current as of August 2014. For
an updated formulary, please contact us. Our contact information, along with the date we last updated the
formulary, appears on the front and back cover pages.
You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary,
pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2016, and from time
to time during the year.
2
What is the Care1st Health Plan Formulary?
A formulary is a list of covered drugs selected by Care1st Health Plan in consultation with a team of health
care providers, which represents the prescription therapies believed to be a necessary part of a quality
treatment program. Care1st Health Plan will generally cover the drugs listed in our formulary as long as the
drug is medically necessary, the prescription is filled at a Care1st Health Plan network pharmacy, and other
plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence
of Coverage.
Can the Formulary (drug list) change?
Generally, if you are taking a drug on our 2015 formulary that was covered at the beginning of the year,
we will not discontinue or reduce coverage of the drug during the 2015 coverage year except when a
new, less expensive generic drug becomes available or when new adverse information about the safety
or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from
our formulary, will not affect members who are currently taking the drug. It will remain available at
the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is
important that you have continued access for the remainder of the coverage year to the formulary drugs
that were available when you chose our plan, except for cases in which you can save additional money
or we can ensure your safety.
If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy
restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of
the change at least 60 days before the change becomes effective, or at the time the member requests a
refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and
Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes
the drug from the market, we will immediately remove the drug from our formulary and provide notice
to members who take the drug. The enclosed formulary is current as of August 2014. To get updated
information about the drugs covered by Care1st Health Plan, please contact us. Our contact information
appears on the front and back cover pages.
How does Care1st Health Plan let me know about changes to the Formulary?
Every month Care1st Health Plan mails you a report called the “Explanation of Benefits,” or “EOB.” The
EOB tells you the total amount you have spent on your prescription drugs and the total amount we have paid
for each of your prescription drugs during the month. Along with your EOB, we will send you a “Formulary
Change Insert” if there have been any recent changes to our formulary. Even if you have not recently filled
any prescriptions, please carefully review this document when you receive it so you know if the formulary
has changed.
Please keep your Formulary Change Inserts. Filing them with your formulary will make sure you
always have current information at hand about your covered drugs. In addition, copies of the formulary
change inserts will be posted on our web site at www.care1stmedicare.com under Notice of Formulary
Change.
3
How do I use the Formulary?
There are two ways to find your drug within the formulary:
Medical Condition
The formulary begins on page 23. The drugs in this formulary are grouped into categories depending on
the type of medical conditions that they are used to treat. For example, drugs used to treat a heart
condition are listed under the category, “Cardiac drugs”. If you know what your drug is used for, look
for the category name in the list that begins page 23. Then look under the category name for your drug.
Alphabetical Listing
If you are not sure what category to look under, you should look for your drug in the Index that begins on
page 155. The Index provides an alphabetical list of all of the drugs included in this document. Both
brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next
to your drug, you will see the page number where you can find coverage information. Turn to the page
listed in the Index and find the name of your drug in the first column of the list.
What are generic drugs?
Care1st Health Plan covers both brand name drugs and generic drugs. A generic drug is approved by the
FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less
than brand name drugs.
Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements and limits
may include:
• Prior Authorization: Care1st Health Plan requires you or your physician to get prior authorization
for certain drugs. This means that you will need to get approval from Care1st Health Plan before you
fill your prescriptions. If you don’t get approval, Care1st Health Plan may not cover the drug.
• Quantity Limits: For certain drugs, Care1st Health Plan limits the amount of the drug that Care1st
Health Plan will cover. For example, Care1st Health Plan provides one inhaler per prescription for
QVAR. This may be in addition to a standard one-month or three-month supply.
• Step Therapy: In some cases, Care1st Health Plan requires you to first try certain drugs to treat your
medical condition before we will cover another drug for that condition. For example, if Drug A and
Drug B both treat your medical condition, Care1st Health Plan may not cover Drug B unless you try
Drug A first. If Drug A does not work for you, Care1st Health Plan will then cover Drug B.
4
You can find out if your drug has any additional requirements or limits by looking in the formulary that
begins on page 23. You can also get more information about the restrictions applied to specific covered
drugs by visiting our Web site. We have posted on line documents that explain our authorization and
step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with
the date we last updated the formulary, appears on the front and back cover pages.
You can ask Care1st Health Plan to make an exception to these restrictions or limits or for a list of other,
silimar drugs that may treat you health condition. See the section, “How do I request an exception to the
Care1st Health Plan’s formulary?” on page 5 for information about how to request an exception.
5
What are over-the counter (OTC) drugs?
OTC drugs are non-prescription drugs that are not normally covered by a Medicare Prescription Drug Plan.
Care1st Health Plan pays for certain OTC drugs. Care1st Health Plan will provide these OTC drugs at no
cost to you. The cost to Care1st Health Plan of these OTC drugs will not count toward your total Part D drug
costs (that is, the amount you pay does not count for the coverage gap).
BRAND NAME
STRENGTH
GENERIC NAME
DOSAGE FORM
LORATADINE
10 MG
LORATADINE
TABLET
LORATADINE
5 MG/5ML
LORATADINE
ORAL SOLUTION
LORATADINE
10 MG
LORATADINE
TAB RAPDIS
FEXOFENADINE
30 MG
FEXOFENADINE
TABLET
FEXOFENADINE
60 MG
FEXOFENADINE
TABLET
FEXOFENADINE
180 MG
FEXOFENADINE
TABLET
What if my drug is not on the Formulary?
If your drug is not included in this formulary (list of covered drugs), you should first contact Member
Services and ask if your drug is not covered. If you learn that Care1st Health Plan does not cover your drug,
you have two options:
• You can ask Member Services for a list of similar drugs that are covered by Care1st Health Plan.
When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is
covered by Care1st Health Plan.
• You can ask Care1st Health Plan to make an exception and cover your drug. See below for
information about how to request an exception. How do I request an exception to the Care1st Health Plan’s Formulary?
You can ask Care1st Health Plan to make an exception to our coverage rules. There are several types of
exceptions that you can ask us to make.
6
• You can ask us to cover your drug even if it is not on our formulary. If approved, this drug will be
covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the
drug at a lower cost-sharing level.
• You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the
specialty tier. If approved, this would lower the amount you must pay for your drug.
• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs,
Care1st Health Plan limits the amount of the drug that we will cover. If your drug has a quantity
limit, you can ask us to waive the limit and cover a greater amount.
Generally, Care1st Health Plan will only approve your request for an exception if the alternative drugs
included on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would not
be as effective in treating your condition and/or would cause you to have adverse medical effects.
You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization
restriction exception. When you request a formulary, tiering or utilization restriction exception you
should submit a statement from your prescriber or physician supporting your request. Generally, we
must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request
an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by
waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no
later than 24 hours after we get a supporting statement from your doctor or other prescriber.
What do I do before I can talk to my doctor about changing my drugs or requesting an
exception?
As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you
may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need
a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide
if you should switch to an appropriate drug that we cover or request a formulary exception so that we will
cover the drug you take. While you talk to your doctor to determine the right course of action for you, we
may cover your drug in certain cases during the first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will
cover a temporary 30-day supplies (unless you have a prescription written for fewer days) when you go to a
network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a
member of the plan less than 90 days.
If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have
provided you with a 91 day transition supply, consistent with dispensing increment, (unless you have a
prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days
7
you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your
drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day
emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary
exception.
In circumstances where a beneficiary is changing from one treatment setting to another, Care1st Health Plan
will ensure a fast process for approving non-formulary Part D drugs. This process shall also apply to
formulary Part D drugs that require prior authorization or step-therapy. Examples of level of care changes
are: beneficiaries who are discharged from a hospital to a home; beneficiaries who end their skilled nursing
facility Medicare Part A stay and who need to revert to their Part D plan formulary; beneficiaries who end a
long-term care facility stay and return to the community; and, beneficiaries who are discharged from
psychiatric hospitals with medication regimens that are highly individualized.
Care1st Health Plan’s After Hours Service will provide pharmacies with access to representatives of the plan
who have the ability to override pharmacy claims processing issues. This access will allow pharmacies to
obtain prescription claims overrides at the point-of-sale and ensure that beneficiaries receive reliable access
to medications.
For more information
For more detailed information about your Care1st Health Plan prescription drug coverage, please review
your Evidence of Coverage and other plan materials.
If you have questions about Care1st Health Plan, please contact us. Our contact information, along with the
date we last updated the formulary, appears on the front and back cover pages.
If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800­
MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY/TDD users should call 1-877-486-2048.
Or, visit http://www.mediacare.gov.
Care1st Health Plan’s Formulary
The formulary provides coverage information about some of the drugs covered by Care1st Health Plan. If
you have trouble finding your drug in the list, turn to the Index that begins on page 155.
The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., IMITREX) and
generic drugs are listed in lower-case italics (e.g., simvastatin).
The information in the Requirements/Limits column tells you if Care1st Health Plan has any special
requirements for coverage of your drug.
8
Copayments/Coinsurance for members of Care1st AdvantageOptimum Plan (HMO) in Los Angeles, Orange,
Santa Clara, San Joaquin and Merced Counties:
Tier
Tier 1
Tier 2
Description
30 day supply
$0 Copay
Preferred Generic Drugs
Non-Preferred Generic
Drugs
Preferred Brand Drugs
Tier 3
Tier 4
Non-Preferred Brand
Drugs
Specialty Tier Drugs
Tier 5
Copayment/Coinsurance
90 day supply
$0 Copay
$5 Copay
$10 Copay
$30 Copay
$60 Copay
$50 Copay
$100 Copay
33% coinsurance
33% coinsurance
Copayments/Coinsurance for members of Care1st AdvantageOptimum Plan (HMO) in San Diego:
Tier
Tier 1
Tier 2
Description
30 day supply
$0 Copay
Preferred Generic Drugs
Non-Preferred Generic
Drugs
Preferred Brand Drugs
Tier 3
Tier 4
Non-Preferred Brand
Drugs
Specialty Tier Drugs
Tier 5
Copayment/Coinsurance
90 day supply
$0 Copay
$7 Copay
$14 Copay
$35 Copay
$70 Copay
$60 Copay
$120 Copay
33% coinsurance
33% coinsurance
Copayments/Coinsurance for members of Care1st AdvantageOptimum Plan (HMO) in Riverside, San
Bernardino, Stanislaus, Alameda, San Francisco and Fresno Counties:
Tier
Tier 1
Tier 2
Tier 3
Tier 4
Tier 5
Copayment/Coinsurance
30 day supply
90 day supply
$0 Copay
$0 Copay
Description
Preferred Generic Drugs
Non-Preferred Generic
Drugs
Preferred Brand Drugs
Non-Preferred Brand
Drugs
Specialty Tier Drugs
9
$5 Copay
$10 Copay
$40 Copay
$80 Copay
$80 Copay
$160 Copay
33% coinsurance
33% coinsurance
Copayments/Coinsurance for members of Care1st AdvantageOptimum Plan (HMO) in El Paso County:
Tier
Tier 1
Tier 2
Description
Preferred Generic Drugs
Non-Preferred Generic
Drugs
Preferred Brand Drugs
Tier 3
Tier 4
Non-Preferred Brand
Drugs
Specialty Tier Drugs
Tier 5
30 day supply
$0 Copay
Copayment/Coinsurance
90 day supply
$0 Copay
$4 Copay
$8 Copay
$30 Copay
$60 Copay
$50 Copay
$100 Copay
33% coinsurance
33% coinsurance
Copayments/Coinsurance for members of Coordinated Choice Plan (HMO):
Tier
Tier 1
Tier 2
Description
Preferred Generic Drugs
Non-Preferred Generic
Drugs
Preferred Brand Drugs
Tier 3
Tier 4
Non-Preferred Brand
Drugs
Specialty Tier Drugs
Tier 5
30 day supply
$0 copay
Copayment/Coinsurance
90 day supply
$0 copay
25% coinsurance
25% coinsurance
25% coinsurance
25% coinsurance
25% coinsurance
25% coinsurance
25% coinsurance
25% coinsurance
Copayments/Coinsurance for members of Care1st TotalDual Plan (HMO SNP) in Los Angeles, Orange, San
Bernardino, Alameda, Santa Clara and San Francisco Counties*:
Tier
Tier 1
Tier 2
Tier 3
Tier 4
Tier 5
Description
Preferred Generic Drugs
Non-Preferred Generic
Drugs
Preferred Brand Drugs
Non-Preferred Brand
Drugs
Specialty Tier Drugs
Copayment/Coinsurance
30 day supply
90 day supply
$0.00
$0.00
$0.00 to $2.65 copay,
$0.00 to $2.65 copay,
OR 15% coinsurance
OR 15% coinsurance
$0.00 to $6.60 copay,
$0.00 to $6.60 copay,
OR 15% coinsurance
OR 15% coinsurance
$0.00 to $6.60 copay,
$0.00 to $6.60 copay,
OR 15% coinsurance
OR 15% coinsurance
$0.00 to $6.60 copay,
$0.00 to $6.60 copay,
OR 15% coinsurance
OR 15% coinsurance
* Please refer to your Low Income Subsidy rider for the exact cost that applies to you.
10
Copayments/Coinsurance for members of Care1st TotalDual Plan (HMO SNP) in San Diego County*:
Tier
Description
Tier 1
Preferred Generic Drugs
Tier 2
Non-Preferred Generic
Drugs
Preferred Brand Drugs
Tier 3
Tier 4
Tier 5
Non-Preferred Brand
Drugs
Specialty Tier Drugs
Copayment/Coinsurance
30 day supply
90 day supply
$0.00 to $2.65 copay,
$0.00 to $2.65 copay,
OR 15% coinsurance
OR 15% coinsurance
$0.00 to $2.65 copay,
$0.00 to $2.65 copay,
OR 15% coinsurance
OR 15% coinsurance
$0.00 to $6.60 copay,
$0.00 to $6.60 copay,
OR 15% coinsurance
OR 15% coinsurance
$0.00 to $6.60 copay,
$0.00 to $6.60 copay,
OR 15% coinsurance
OR 15% coinsurance
$0.00 to $6.60 copay,
$0.00 to $6.60 copay,
OR 15% coinsurance
OR 15% coinsurance
* Please refer to your Low Income Subsidy rider for the exact cost that applies to you.
Requirements/Limits Legend
Abbreviation
PA
QL
ST
BvD
PA>65
Description
Prior authorization required.
Quantity limit
Step therapy
Requires a prior authorization to perform a Part B vs. Part D coverage determination.
Requires a Prior Authorization for members greater than 65 years old
Footnote Legend
Symbol
~
*
+
Note
This prescription may be available only at certain pharmacies. For more information
consult your Provider Directory or call Member Services at {1-800-544-0088}.
TTY/TDD users should call {711}.
We provide additional coverage of this prescription drug in the coverage gap. Please
refer to our Evidence of Coverage for more information about this coverage.
Maintenance drug. Up to a 90-day supply of this drug is available through our
network mail-order pharmacy, and through some of our network retail pharmacies.
For more information call Member Services.
11
Care1st Health Plan
Formulario para 2015
(Lista de medicamentos cubiertos)
LEA LO SIGUIENTE: ESTE DOCUMENTO CONTIENE INFORMACIÓN ACERCA DE LOS
MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN
Nota para los miembros actuales: Este formulario ha cambiado con respecto al año pasado. Revise
este documento para asegurarse de que aún contiene los medicamentos que usted toma. Care1st Health Plan es un plan HMO/HMO SNP que tiene contratos con Medicare y con el programa Medicaid del estado de California. La inscripción en el Plan de salud de Care1st depende de la renovación del contrato.
Esta información está disponible gratuitamente en otros idiomas. Comuníquese con Servicios para los
Miembros: 1-800-544-0088 (TTY 711), de 8 a.m. a 8 p.m., los siete días de la semana del 1° de octubre al 14 de febrero, excepto el Día de Acción de Gracias y Navidad, y de 8 a.m. a 8 p.m., de lunes a viernes del 15 de
febrero al 30 de septiembre, excepto los días festivos. This information is available for free in other languages. Please contact Member Services,
1-800-544-0088 (TTY 711), 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday from February 15 through September 30, except holidays.
HPMS Approved Formulary 00015370 Version: 7
H5928_15_031_PD_SPA Accepted
12 Cuando en esta lista de medicamentos (formulario) dice “nosotros”, “nos” o “nuestro”, se hace referencia a
Care1st Health Plan. Cuando dice “plan” o “nuestro plan”, se hace referencia a Care1st AdvantageOptimum
Plan (HMO) o Coordinated Choice Plan (HMO) o Care1st TotalDual Plan (HMO SNP).
Este documento incluye una lista de medicamentos (formulario) de nuestro plan, la cual estará en vigencia
desde el Augosto 2014 Para obtener el formulario actualizado, comuníquese con nosotros. Nuestra
información de contacto, junto con la fecha de la última actualización del formulario, aparece en las páginas
de la portada y la contraportada.
Generalmente, debe concurrir a las farmacias de la red para usar el beneficio de medicamentos con receta.
Los beneficios, el formulario, la red de farmacias, la prima y/o los copagos o el coseguro pueden cambiar el
1 de enero de 2016 y de vez en cuando durante el año.
¿En qué consiste el formulario de Care1st Health Plan?
Un formulario es una lista de medicamentos cubiertos seleccionados por Care1st Health Plan con la
colaboración de un equipo de proveedores de atención médica, que representa los tratamientos con receta
que se consideran parte necesaria de un programa de tratamiento de calidad. Normalmente, Care1st Health
Plan cubrirá los medicamentos incluidos en el formulario siempre que el medicamento sea necesario desde el
punto de vista médico, el medicamento con receta se obtenga en una farmacia de la red de Care1st Health
Plan y se cumpla con otras normas del plan. Para obtener más información sobre cómo obtener sus
medicamentos con receta, consulte la Evidencia de cobertura.
¿El formulario (lista de medicamentos) puede modificarse?
En general, si usted está tomando un medicamento de nuestro formulario para 2015 que estaba cubierto
al comienzo del año, no discontinuaremos ni reduciremos la cobertura del medicamento durante el año
de cobertura 2015, excepto cuando esté disponible un nuevo medicamento genérico de menor costo o
cuando se dé a conocer nueva información adversa acerca de la seguridad o eficacia del medicamento.
Otros tipos de cambios en nuestro formulario, como la eliminación de un medicamento, no afectarán a
los miembros que estén actualmente tomando ese medicamento. Continuará disponible al mismo costo
compartido para aquellos miembros que deban tomarlo por el resto del año de cobertura. Consideramos
que es importante que tenga acceso continuo, durante el resto del año de cobertura, a los medicamentos
del formulario que estaban disponibles cuando eligió nuestro plan, salvo en los casos en los que usted
podría ahorrar más dinero o en que nosotros podríamos garantizarle mayor seguridad.
Si retiramos medicamentos de nuestro formulario, agregamos autorizaciones previas, límites de
cantidad o restricciones en tratamientos escalonados en relación con un medicamento, o si pasamos un
medicamento a un nivel superior de costo compartido, debemos notificar sobre el cambio a los
miembros afectados al menos 60 días antes de que entre en vigencia dicho cambio o cuando el miembro
solicite una reposición del medicamento, momento en el cual el miembro recibirá un suministro del
13 medicamento para 60 días. Si la Administración de Drogas y Alimentos considera que un medicamento
de nuestro formulario es inseguro o si el fabricante del medicamento lo retira del mercado,
eliminaremos de inmediato dicho medicamento de nuestro formulario y notificaremos a los miembros
que toman el medicamento en cuestión. El formulario adjunto estará vigente desde el Augosto 2014
Para recibir información actualizada sobre los medicamentos cubiertos por Care1st Health Plan,
comuníquese con nosotros. Nuestra información de contacto aparece en las páginas de la portada y la
contraportada.
¿Cómo me notifica Care1st Health Plan sobre los cambios en el formulario?
Todos los meses, Care1st Health Plan le envía por correo un informe mensual llamado “Explicación de
beneficios” o “EOB”, por sus siglas en inglés. La Explicación de beneficios le informa la cantidad total que
gastó en medicamentos con receta y la cantidad total que nosotros pagamos por cada uno de los
medicamentos con receta durante el mes. Junto con la Explicación de beneficios, le enviaremos un “Encarte
de cambios en formularios” en caso de que haya habido cambios recientes en el formulario. Aunque no haya
obtenido ninguna receta, revise con atención este documento cuando lo reciba para saber si el formulario ha
cambiado.
Conserve sus encartes de cambios en formularios. Al archivarlos con su formulario, siempre tendrá a
mano información actualizada sobre sus medicamentos cubiertos. Además, se publicarán copias de los
encartes de cambios de formularios en nuestro sitio web en www.care1stmedicare.com, en la sección
Aviso de cambios en formularios.
¿Cómo utilizo el formulario?
Hay dos formas de encontrar su medicamento dentro del formulario:
Afección médica
El formulario empieza en la página 23. Los medicamentos de este formulario están agrupados en
categorías según el tipo de enfermedad para cuyo tratamiento se los emplea. Por ejemplo, los
medicamentos utilizados para tratar una enfermedad cardíaca se agrupan en la categoría “Medicamentos
cardíacos”. Si sabe para qué se utiliza su medicamento, busque el nombre de la categoría en la lista que
comienza 23. Después busque el medicamento debajo del nombre de esa categoría.
Listado alfabético
Si no está seguro de qué categoría debe consultar, busque su medicamento en el índice que comienza en
la página 155. El índice proporciona una lista alfabética de todos los medicamentos incluidos en este
documento. En el índice se incluyen tanto los medicamentos de marca como los genéricos. Busque su
medicamento en el índice. Junto a su medicamento, verá el número de página donde puede encontrar
información acerca de la cobertura. Vaya a la página que figura en el índice y busque el nombre de su
medicamento en la primera columna de la lista.
14 ¿Qué son los medicamentos genéricos?
Care1st Health Plan cubre tanto los medicamentos de marca como los genéricos. Un medicamento
genérico está aprobado por la Administración de Drogas y Alimentos (FDA, por sus siglas en inglés)
dado que se considera que tiene el mismo ingrediente activo que el medicamento de marca.
Normalmente, los medicamentos genéricos cuestan menos que los de marca.
¿Hay alguna restricción en mi cobertura?
Algunos medicamentos cubiertos pueden tener requisitos o límites adicionales de cobertura. Estos requisitos
y límites pueden incluir:
• Autorización previa (PA, por sus siglas en inglés): Care1st Health Plan exige que usted o su
médico obtengan una autorización previa para determinados medicamentos. Esto significa que
necesitará contar con la aprobación de Care1st Health Plan antes de obtener sus medicamentos con
receta. Si no consigue la autorización, es posible que Care1st Health Plan no cubra el medicamento.
• Límites de cantidad (QL, por sus siglas en inglés): Para ciertos medicamentos, Care1st Health Plan
limita la cantidad del medicamento que cubrirá Care1st Health Plan. Por ejemplo, Care1st Health
Plan proporciona un inhalador por receta de QVAR. Esto puede ser complementario a un suministro
estándar para un mes o tres meses.
• Tratamiento escalonado (ST, por sus siglas en inglés): En algunos casos, Care1st Health Plan
requiere que usted primero pruebe ciertos medicamentos para tratar su enfermedad antes de que
cubramos otro medicamento para esa enfermedad. Por ejemplo, si tanto el medicamento A como el
medicamento B se utilizan para tratar su enfermedad, es posible que Care1st Health Plan no cubra el
medicamento B si usted no prueba primero el medicamento A. Si el medicamento A no funciona
para usted, entonces Care1st Health Plan cubrirá el medicamento B.
Puede consultar el formulario que comienza en la página 23 para averiguar si su medicamento tiene
algún otro requisito o límite. También puede obtener más información sobre las restricciones que se
aplican a medicamentos cubiertos específicos en nuestro sitio web. Hemos publicado documentos en
línea que explican nuestras restricciones en autorizaciones y tratamientos escalonados. También puede
pedir que le enviemos una copia. Nuestra información de contacto, junto con la fecha de la última
actualización del formulario, aparece en las páginas de la portada y la contraportada.
Puede solicitar a Care1st Health Plan que haga una excepción a estas restricciones o límites o puede
solicitarle una lista de otros medicamentos similares que puedan tratar su afección médica. Consulte la
sección “¿Cómo solicito una excepción al formulario de Care1st Health Plan?” en la página 17 para obtener
información acerca de cómo solicitar una excepción.
15 ¿Qué son los medicamentos de venta libre?
Los medicamentos de venta libre (OTC, por sus siglas en inglés) son medicamentos sin receta que,
normalmente, no están cubiertos por un plan de medicamentos con receta de Medicare. Care1st Health Plan
paga por ciertos medicamentos de venta libre. Care1st Health Plan le proporcionará estos medicamentos de
venta libre sin costo alguno para usted. El costo para Care1st Health Plan de estos medicamentos de venta
libre no se tendrá en cuenta en los costos totales de medicamentos de la parte D (es decir, el monto que usted
paga no se tiene en cuenta para el período sin cobertura).
NOMBRE DE MARCA
CONCENTRACIÓN
NOMBRE GENÉRICO
FORMA DE
DOSIFICACIÓN
LORATADINA
10mg
LORATADINA
COMPRIMIDO
LORATADINA
5mg/5ml
LORATADINA
SOLUCIÓN ORAL
LORATADINA
10mg
LORATADINA
COMP. DIS. RÁP.
FEXOFENADINA
30mg
FEXOFENADINA
COMPRIMIDO
FEXOFENADINA
60mg
FEXOFENADINA
COMPRIMIDO
FEXOFENADINA
180mg
FEXOFENADINA
COMPRIMIDO
¿Qué debo hacer si mi medicamento no está en el formulario?
Si su medicamento no está incluido en este formulario (lista de medicamentos cubiertos), primero debe
ponerse en contacto con el Servicio para los miembros y preguntar si su medicamento está cubierto. Si
resulta que Care1st Health Plan no cubre su medicamento, tiene dos alternativas:
• Puede solicitar al Servicio para los miembros una lista de medicamentos similares cubiertos por
Care1st Health Plan. Cuando reciba la lista, muéstresela a su médico y pídale que le recete un
medicamento similar que esté cubierto por Care1st Health Plan.
• Puede solicitar a Care1st Health Plan que haga una excepción y cubra el medicamento. Consulte más
abajo para obtener información sobre cómo solicitar una excepción.
¿Cómo puedo solicitar que se haga una excepción al formulario de Care1st Health
Plan?
16 Puede solicitar a Care1st Health Plan que haga una excepción a nuestras normas de cobertura. Hay varios
tipos de excepciones que puede solicitarnos.
• Puede pedirnos que cubramos su medicamento, incluso si no está en nuestro formulario. Si se
aprueba, el medicamento quedará cubierto a un nivel de costo compartido predeterminado y usted no
podrá pedirnos que proporcionemos el medicamento a un nivel de costo compartido menor.
• Puede pedirnos que cubramos un medicamento del formulario a un nivel de costo compartido menor
si este medicamento no está incluido en el nivel de medicamentos especializados. Si se aprueba, esto
reduciría el monto que usted debe pagar por su medicamento.
• Puede pedirnos que no apliquemos restricciones o límites de cobertura para su medicamento. Por
ejemplo: para ciertos medicamentos, Care1st Health Plan limita la cantidad del medicamento que
cubriremos. Si su medicamento tiene un límite de cantidad, puede pedirnos que hagamos una
excepción al límite y cubramos una cantidad mayor.
Por lo general, Care1st Health Plan solo aprobará su pedido de excepción si los demás medicamentos
incluidos en el formulario del plan, el medicamento de menor costo compartido o las restricciones de uso
adicionales no fueran tan efectivos para tratar su enfermedad o pudieran causarle efectos médicos adversos.
Debe ponerse en contacto con nosotros para solicitarnos una decisión inicial de cobertura respecto de una
excepción al formulario, al nivel o a la restricción de uso. Cuando solicita una excepción al formulario, al
nivel o a la restricción de uso, debe presentar una declaración de su médico o de la persona que emite
la receta que respalde su solicitud. Por lo general, debemos tomar una decisión dentro de las 72 horas a
partir de la fecha en que recibimos la declaración que respalda su solicitud por parte de la persona que emite
la receta. Puede solicitar una excepción acelerada (rápida) si usted o su médico consideran que esperar 72
horas para tomar la decisión podría perjudicar gravemente su salud. Si se le concede el trámite rápido de la
excepción, debemos comunicarle nuestra decisión a más tardar dentro de las 24 horas después de haber
recibido la declaración de respaldo de la persona autorizada para dar recetas.
¿Qué debo hacer antes de hablar con mi médico sobre el cambio de los medicamentos
que tomo o la solicitud de una excepción?
Como miembro nuevo o permanente de nuestro plan, es posible que esté tomando medicamentos que no
están incluidos en el formulario. También es posible que esté tomando un medicamento incluido en el
formulario pero su capacidad de conseguirlo esté limitada. Por ejemplo, puede necesitar nuestra autorización
previa para obtener su medicamento con receta. Debe consultar con su médico para decidir si debe cambiar
su medicamento por uno apropiado que nosotros cubramos o solicitar una excepción al formulario para que
le cubramos su medicamento. Mientras evalúa con su médico el procedimiento adecuado para su caso,
podemos cubrir su medicamento en ciertos casos durante los primeros 90 días en que usted es miembro de
nuestro plan.
17 Para cada uno de los medicamentos que no están incluidos en el formulario o si su capacidad para conseguir
los medicamentos es limitada, cubriremos suministros temporales para 30 días (a menos que tenga una receta
para menos días) cuando acuda a una farmacia de la red. Después del primer suministro para 30 días, no
seguiremos pagando estos medicamentos, aunque haga menos de 90 días que usted es miembro del plan.
Si reside en un centro de atención a largo plazo, le permitiremos volver a obtener su receta hasta que le
hayamos provisto un suministro de transición de 91 días, conforme al incremento de provisión (a menos que
tenga una receta para menos días). Cubriremos más de resurtido de estos medicamentos durante los primeros
90 días en que usted sea miembro del plan. Si necesita un medicamento que no está en el formulario o si su
capacidad para conseguir los medicamentos es limitada, pero ya pasaron los primeros 90 días de membresía
en nuestro plan, cubriremos un suministro de emergencia del medicamento para 31 días (a menos que tenga
una receta para menos días) mientras solicita la excepción al formulario.
En circunstancias donde un beneficiario pasa de un entorno de tratamiento a otro, Care1st Health Plan
garantizará un proceso acelerado para aprobar los medicamentos no incluidos en la parte D del formulario.
Este proceso también se aplicará a los medicamentos incluidos en la parte D del formulario que necesiten
autorización previa o tratamiento escalonado. Algunos ejemplos de cambios en su nivel de atención son:
beneficiarios que son dados de alta de un hospital para regresar a su hogar; beneficiarios que finalizan su
estadía de la parte A de Medicare en un centro de atención de enfermería especializada y que deben volver a
su formulario del plan de la parte D; beneficiarios que finalizan una estadía en un centro de atención a largo
plazo y regresan a la comunidad; y beneficiarios que son dados de alta de hospitales psiquiátricos con
regímenes de medicamentos sumamente individualizados.
El Servicio fuera del horario de Care1st Health Plan proveerá farmacias con acceso para representantes del
plan que puedan sortear inconvenientes de procesamiento de reclamos de farmacia. Este acceso permitirá a
las farmacias obtener la invalidación de los reclamos de medicamentos con receta en el punto de venta y
garantizar que los beneficiarios tengan un acceso confiable a los medicamentos.
Para obtener más información
Para obtener información más detallada sobre la cobertura de medicamentos con receta de Care1st Health
Plan, consulte la Evidencia de cobertura y la demás documentación del plan.
Si tiene alguna pregunta sobre Care1st Health Plan, comuníquese con nosotros. Nuestra información de
contacto, junto con la fecha de la última actualización del formulario, aparece en las páginas de la portada y
la contraportada.
Si tiene preguntas generales sobre su cobertura de medicamentos con receta de Medicare, llame a Medicare
al 1-800-MEDICARE (1-800-633-4227), durante las 24 horas, los 7 días de la semana. Los usuarios de
TTY/TDD deben llamar al 1-877-486-2048. O visite http://www.mediacare.gov.
Formulario de Care1st Health Plan
18 El formulario proporciona información sobre la cobertura de algunos de los medicamentos que cubre Care1st
Health Plan. Si tiene alguna dificultad para encontrar su medicamento en la lista, consulte el índice que
comienza en la página 155.
En la primera columna de la tabla figura el nombre del medicamento. Los medicamentos de marca están en
letra mayúscula (por ejemplo, IMITREX) y los medicamentos genéricos están en letra minúscula y cursiva
(por ejemplo, simvastatin).
La información de la columna de Requisitos/límites indica si Care1st Health Plan tiene algún requisito
especial para la cobertura del medicamento.
Copagos/coseguros para miembros de Care1st AdvantageOptimum Plan (HMO) en los condados de Los
Angeles, Orange, Santa Clara, San Joaquin y Merced:
Nivel
Nivel 1
Descripción
Medicamentos genéricos
preferidos
Medicamentos genéricos
no preferidos
Medicamentos de marca
preferidos
Medicamentos de marca
no preferidos
Medicamentos de nivel
especializado
Nivel 2
Nivel 3
Nivel 4
Nivel 5
Copago/coseguro
Suministro para 30 días
Suministro para 90 días
$0 Copago
$0 Copago
$5 Copago
$10 Copago
$30 Copago
$60 Copago
$50 Copago
$100 Copago
33% coseguro
33% coseguro
Copagos/coseguros para miembros de Care1st AdvantageOptimum Plan (HMO) en San Diego:
Nivel
Nivel 1
Nivel 2
Nivel 3
Nivel 4
Nivel 5
Descripción
Medicamentos genéricos
preferidos
Medicamentos genéricos
no preferidos
Medicamentos de marca
preferidos
Medicamentos de marca
no preferidos
Medicamentos de nivel
especializado
Copago/coseguro
Suministro para 30 días
Suministro para 90 días
$0 Copago
$0 Copago
$7 Copago
$14 Copago
$35 Copago
$70 Copago
$60 Copago
$120 Copago
33% coseguro
33% coseguro
19
Copagos/coseguros para miembros de Care1st AdvantageOptimum Plan (HMO) en los condados de
Riverside, San Bernardino, Stanislaus, Alameda, San Francisco y Fresno:
Nivel
Nivel 1
Descripción
Medicamentos genéricos
preferidos
Medicamentos genéricos
no preferidos
Medicamentos de marca
preferidos
Medicamentos de marca
no preferidos
Medicamentos de nivel
especializado
Nivel 2
Nivel 3
Nivel 4
Nivel 5
Copago/coseguro
Suministro para 30 días
Suministro para 90 días
$0 Copago
$0 Copago
$5 Copago
$10 Copago
$40 Copago
$80 Copago
$80 Copago
$160 Copago
33% coseguro
33% coseguro
Copagos/coseguros para miembros de Care1st AdvantageOptimum Plan (HMO) en el condado de El Paso:
Nivel
Nivel 1
Descripción
Medicamentos genéricos
preferidos
Medicamentos genéricos
no preferidos
Medicamentos de marca
preferidos
Medicamentos de marca
no preferidos
Medicamentos de nivel
especializado
Nivel 2
Nivel 3
Nivel 4
Nivel 5
Copago/coseguro
Suministro para 30 días
Suministro para 90 días
$0 Copago
$0 Copago
$4 Copago
$8 Copago
$30 Copago
$60 Copago
$50 Copago
$100 Copago
33% coseguro
33% coseguro
Copagos/coseguros para miembros de Coordinated Choice Plan (HMO):
Nivel
Nivel 1
Nivel 2
Nivel 3
Nivel 4
Nivel 5
Descripción
Medicamentos genéricos
preferidos
Medicamentos genéricos
no preferidos
Medicamentos de marca
preferidos
Medicamentos de marca
no preferidos
Medicamentos de nivel
especializado
Copago/coseguro
Suministro para 30 días
Suministro para 90 días
$0 Copago
$0 Copago
25% coseguro
25% coseguro
25% coseguro
25% coseguro
25% coseguro
25% coseguro
25% coseguro
25% coseguro
20
Copagos/coseguros para miembros de Care1st TotalDual Plan (HMO SNP) en los condados* de Los
Angeles, Orange, San Bernardino, Alameda, Santa Clara y San Francisco:
Nivel
Nivel 1
Descripción
Medicamentos genéricos
preferidos
Medicamentos genéricos
no preferidos
Medicamentos de marca
preferidos
Medicamentos de marca
no preferidos
Medicamentos de nivel
especializado
Nivel 2
Nivel 3
Nivel 4
Nivel 5
Copago/coseguro
Suministro para 30 días
Suministro para 90 días
$0.00
$0.00
Copago de $0.00 a $2.65
o coseguro del 15 %
Copago de $0.00 a $6.60
o coseguro del 15 %
Copago de $0.00 a $6.60
o coseguro del 15 %
Copago de $0.00 a $6.60
o coseguro del 15 %
Copago de $0.00 a $2.65
o coseguro del 15 %
Copago de $0.00 a $6.60
o coseguro del 15 %
Copago de $0.00 a $6.60
o coseguro del 15 %
Copago de $0.00 a $6.60
o coseguro del 15 %
Consulte la Cláusula adicional para subsidio por bajos ingresos para saber el costo exacto le corresponde.
Copagos/coseguros para miembros de Care1st TotalDual Plan (HMO SNP) en el condado de San Diego*:
Nivel
Nivel 1
Nivel 2
Nivel 3
Nivel 4
Nivel 5
Descripción
Medicamentos genéricos
preferidos
Medicamentos genéricos
no preferidos
Medicamentos de marca
preferidos
Medicamentos de marca
no preferidos
Medicamentos de nivel
especializado
Copago/coseguro
Suministro para 30 días
Suministro para 90 días
Copago de $0.00 a $2.65 Copago de $0.00 a $2.65
o coseguro del 15 %
o coseguro del 15 %
Copago de $0.00 a $2.65 Copago de $0.00 a $2.65
o coseguro del 15 %
o coseguro del 15 %
Copago de $0.00 a $6.60 Copago de $0.00 a
o coseguro del 15 %
$6.60 o coseguro del
15 %
Copago de $0.00 a $6.60 Copago de $0.00 a $6.60
o coseguro del 15 %
o coseguro del 15 %
Copago de $0.00 a $6.60 Copago de $0.00 a $6.60
o coseguro del 15 %
o coseguro del 15 %
Consulte la Cláusula adicional para subsidio por bajos ingresos para saber el costo exacto le corresponde.
21
Leyenda de requisitos/límites
Abreviatura
PA
QL
ST
BvD
PA>65
Descripción
Se requiere autorización previa.
Límites de cantidad
Tratamiento escalonado
Se requiere una autorización previa para realizar una determinación de cobertura de
la parte B en comparación con la parte D.
Se requiere una autorización previa para miembros mayores de 65 años de edad.
Leyenda de nota al pie
Símbolo
~
*
+
Nota
Este medicamento con receta puede estar disponible solamente en determinadas
farmacias. Para obtener más información, consulte su Directorio de proveedores y
farmacias o llame al Servicio para los miembros al {1-800-544-0088}. Los usuarios
de TTY/TDD deben llamar al {711}.
Proporcionamos cobertura adicional para este medicamento con receta durante el
período sin cobertura. Consulte la Evidencia de cobertura para obtener más
información sobre esta cobertura.
Medicamento de mantenimiento. Hay suministro de este medicamento para un
máximo de 90 días a través de pedidos por correo a nuestra farmacia de la red y a
través de algunas de nuestras farmacias minoristas de la red. Para obtener más
información, comuníquese con el Servicio para los miembros.
22 Table of Contents
Tabla de Contenidos
QUANTITY LIMITS TABLE ............................................................................................... 29
QUANTITY LIMITS TABLE ........................................................................................................... 29 ANALGESICS .................................................................................................................. 39
ANALGESICS, MISCELLANEOUS ................................................................................................ 39
NONSTEROIDAL ANTI-INFLAMMATORY AGENTS ...................................................................... 41
ANESTHETICS ................................................................................................................. 44
LOCAL ANESTHETICS ............................................................................................................... 44 ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS ........................................ 44
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS ..................................................... 44
ANTIANXIETY AGENTS .................................................................................................. 45
BENZODIAZEPINES ................................................................................................................... 45
ANTIBACTERIALS ........................................................................................................... 46
AMINOGLYCOSIDES ................................................................................................................ 46
ANTIBACTERIALS, MISCELLANEOUS .......................................................................................... 46
CEPHALOSPORINS ................................................................................................................... 47
MACROLIDES ........................................................................................................................... 49
MISCELLANEOUS B-LACTAM ANTIBIOTICS ................................................................................ 50
PENICILLINS ............................................................................................................................. 51
QUINOLONES ......................................................................................................................... 52
SULFONAMIDES ....................................................................................................................... 53
TETRACYCLINES ....................................................................................................................... 54
ANTICANCER AGENTS .................................................................................................... 55
ANTICANCER AGENTS .............................................................................................................. 55
ANTICONVULSANTS ...................................................................................................... 61
ANTICONVULSANTS ................................................................................................................. 61 ANTIDEMENTIA AGENTS ............................................................................................... 65
ANTIDEMENTIA AGENTS ........................................................................................................... 65
ANTIDEPRESSANTS ........................................................................................................ 66
ANTIDEPRESSANTS ................................................................................................................... 66
ANTIDIABETIC AGENTS .................................................................................................. 69
ANTIDIABETIC AGENTS, MISCELLANEOUS ................................................................................ 69
INSULINS .................................................................................................................................. 70
SULFONYLUREAS ...................................................................................................................... 71
ANTIFUNGALS ............................................................................................................... 72
ANTIFUNGALS .......................................................................................................................... 72
2015 CARE1ST MEDICARE DRUG FORMULARY
23
Table of Contents
Tabla de Contenidos
ANTIHISTAMINES .......................................................................................................... 75
ANTIHISTAMINES ...................................................................................................................... 75
ANTI-INFECTIVES (SKIN AND MUCOUS MEMBRANE) .................................................... 75
ANTI-INFECTIVES (SKIN AND MUCOUS MEMBRANE) ................................................................. 75
ANTIMIGRAINE AGENTS ................................................................................................ 76
ANTIMIGRAINE AGENTS ........................................................................................................... 76
ANTIMYCOBACTERIALS .................................................................................................. 76
ANTIMYCOBACTERIALS ............................................................................................................ 76
ANTINAUSEA AGENTS ................................................................................................... 77
ANTINAUSEA AGENTS .............................................................................................................. 77
ANTIPARASITE AGENTS ................................................................................................. 79
ANTIPARASITE AGENTS ............................................................................................................. 79 ANTIPARKINSONIAN AGENTS ......................................................................................80
ANTIPARKINSONIAN AGENTS ................................................................................................... 80
ANTIPSYCHOTIC AGENTS .............................................................................................. 81
ANTIPSYCHOTIC AGENTS ........................................................................................................ 81
ANTIVIRALS (SYSTEMIC) ................................................................................................. 84
ANTIRETROVIRALS .................................................................................................................... 84
ANTIVIRALS, MISCELLANEOUS .................................................................................................. 88
HCV ANTIVIRALS ....................................................................................................................... 88
INTERFERONS .......................................................................................................................... 88
NUCLEOSIDES AND NUCLEOTIDES .......................................................................................... 89
BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS ................................................. 90
ANTICOAGULANTS .................................................................................................................. 90 BLOOD FORMATION MODIFIERS ............................................................................................. 91
HEMATOLOGIC AGENTS, MISCELLANEOUS ............................................................................. 92
PLATELET-AGGREGATION INHIBITORS ...................................................................................... 93
CALORIC AGENTS .......................................................................................................... 93
CALORIC AGENTS .................................................................................................................... 93
CARDIOVASCULAR AGENTS ........................................................................................... 95
ALPHA-ADRENERGIC AGENTS ................................................................................................... 95
ANGIOTENSIN II RECEPTOR ANTAGONISTS ............................................................................. 95
ANGIOTENSIN-CONVERTING ENZYME INHIBITORS .................................................................. 95
ANTIARRHYTHMIC AGENTS ...................................................................................................... 96
BETA-ADRENERGIC BLOCKING AGENTS ................................................................................... 97
CALCIUM-CHANNEL BLOCKING AGENTS ................................................................................. 99
2015 CARE1ST MEDICARE DRUG FORMULARY
24
Table of Contents
Tabla de Contenidos
CARDIOVASCULAR AGENTS, MISCELLANEOUS ......................................................................... 99
DIHYDROPYRIDINES ............................................................................................................... 101
DIURETICS .............................................................................................................................. 101
DYSLIPIDEMICS ....................................................................................................................... 102
RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS .................................................... 103
VASODILATORS ...................................................................................................................... 104
CENTRAL NERVOUS SYSTEM AGENTS .......................................................................... 105
CENTRAL NERVOUS SYSTEM AGENTS ..................................................................................... 105
CONTRACEPTIVES ........................................................................................................ 106
CONTRACEPTIVES .................................................................................................................. 106
DENTAL AND ORAL AGENTS ....................................................................................... 111
DENTAL AND ORAL AGENTS .................................................................................................. 111
DERMATOLOGICAL AGENTS ........................................................................................ 112
DERMATOLOGICAL AGENTS, OTHER ..................................................................................... 112
DERMATOLOGICAL ANTIBACTERIALS ...................................................................................... 113
DERMATOLOGICAL ANTI-INFLAMMATORY AGENTS ................................................................ 114
DERMATOLOGICAL RETINOIDS .............................................................................................. 118
SCABICIDES AND PEDICULICIDES ........................................................................................... 119
DEVICES ....................................................................................................................... 119
DEVICES ................................................................................................................................. 119
ENZYME REPLACEMENT/MODIFIERS ............................................................................ 120
ENZYME REPLACEMENT/MODIFIERS ....................................................................................... 120
EYE, EAR, NOSE, THROAT AGENTS .............................................................................. 121
EYE, EAR, NOSE, THROAT AGENTS, MISCELLANEOUS ............................................................. 121
EYE, EAR, NOSE, THROAT ANTI-INFECTIVES AGENTS .............................................................. 122
EYE, EAR, NOSE, THROAT ANTI-INFLAMMATORY AGENTS ...................................................... 124
GASTROINTESTINAL AGENTS ...................................................................................... 125
ANTIULCER AGENTS AND ACID SUPPRESSANTS ...................................................................... 125
GASTROINTESTINAL AGENTS, OTHER ..................................................................................... 126
LAXATIVES .............................................................................................................................. 127
PHOSPHATE BINDERS ............................................................................................................. 127
GENITOURINARY AGENTS ........................................................................................... 128
ANTISPASMODICS, URINARY .................................................................................................. 128
GENITOURINARY AGENTS, MISCELLANEOUS ......................................................................... 129
HEAVY METAL ANTAGONISTS ..................................................................................... 129
HEAVY METAL ANTAGONISTS ................................................................................................. 129
2015 CARE1ST MEDICARE DRUG FORMULARY
25
Table of Contents
Tabla de Contenidos
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING ................................ 129
ANDROGENS ......................................................................................................................... 129
ESTROGENS AND ANTIESTROGENS ....................................................................................... 130
GLUCOCORTICOIDS/MINERALOCORTICOIDS ....................................................................... 131
PITUITARY ............................................................................................................................... 132
PROGESTINS .......................................................................................................................... 133
THYROID AND ANTITHYROID AGENTS ................................................................................... 134
IMMUNOLOGICAL AGENTS ......................................................................................... 135
IMMUNOLOGICAL AGENTS ................................................................................................... 135
VACCINES .............................................................................................................................. 138
INFLAMMATORY BOWEL DISEASE AGENTS .................................................................141
INFLAMMATORY BOWEL DISEASE AGENTS ............................................................................. 141
IRRIGATING SOLUTIONS ............................................................................................. 141
IRRIGATING SOLUTIONS ........................................................................................................ 141
METABOLIC BONE DISEASE AGENTS ........................................................................... 141
METABOLIC BONE DISEASE AGENTS ...................................................................................... 141
MISCELLANEOUS THERAPEUTIC AGENTS .................................................................... 143
MISCELLANEOUS THERAPEUTIC AGENTS ................................................................................ 143
OPHTHALMIC AGENTS ................................................................................................. 146
ANTIGLAUCOMA AGENTS ...................................................................................................... 146
REPLACEMENT PREPARATIONS ....................................................................................147
REPLACEMENT PREPARATIONS ................................................................................................ 147
RESPIRATORY TRACT AGENTS ...................................................................................... 149
ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS ........................................................... 149
ANTILEUKOTRIENES ................................................................................................................ 150
BRONCHODILATORS ............................................................................................................. 150
RESPIRATORY TRACT AGENTS, OTHER .................................................................................... 152
SKELETAL MUSCLE RELAXANTS ....................................................................................152
SKELETAL MUSCLE RELAXANTS ................................................................................................ 152
SLEEP DISORDER AGENTS ............................................................................................ 153
SLEEP DISORDER AGENTS ....................................................................................................... 153
VASODILATING AGENTS ............................................................................................. 153
VASODILATING AGENTS ........................................................................................................ 153
VITAMINS AND MINERALS .......................................................................................... 154
VITAMINS AND MINERALS ....................................................................................................... 154
2015 CARE1ST MEDICARE DRUG FORMULARY
26
Table of Contents
Tabla de Contenidos
INDEX OF DRUGS ........................................................................................................ 155
INDEX OF DRUGS .................................................................................................................. 155
2015 CARE1ST MEDICARE DRUG FORMULARY
27
QUANTITY LIMITS TABLE / TABLA DE LIMITE DE CANTIDAD
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA FARMACEUTICA
QUANTITY LIMIT
LIMITE DE CANTIDAD
ARIPIPRAZOLE
TABLET
30 TABS IN 30 DAYS
ABILIFY
ARIPIPRAZOLE
ORAL SOLUTION
900 ML IN 30 DAYS
ABILIFY DISCMELT 10 MG
ARIPIPRAZOLE
TAB RAPDIS
30 TABS IN 30 DAYS
ABILIFY DISCMELT 15 MG
ARIPIPRAZOLE
TAB RAPDIS
60 TABS IN 30 DAYS
ACARBOSE 100 MG
ACARBOSE
TABLET
90 TABS IN 30 DAYS
ACARBOSE 25 MG
ACARBOSE
TABLET
360 TABS IN 30 DAYS
ACARBOSE 50 MG
ACARBOSE
TABLET
180 TABS IN 30 DAYS
ACETAMINOPHEN WITH CODEINE
ACETAMINOPHEN WITH CODEINE ORAL SOLUTION 1800 ML IN 30 DAYS
ACETAMINOPHEN WITH CODEINE
ACETAMINOPHEN WITH CODEINETABLET
120 TABS IN 30 DAYS
ACTONEL 35 MG
RISEDRONATE SODIUM
TABLET
4 TABS IN 28 DAYS
ACTONEL 5 MG
RISEDRONATE SODIUM
TABLET
30 TABS IN 30 DAYS
ACYCLOVIR
ACYCLOVIR
TOPICAL OINT.
30 GM IN 30 DAYS
ADVAIR DISKUS
FLUTICASONE/SALMETEROL INHALATION DISK
60 CAPS IN 30 DAYS
ADVAIR HFA 120 ACTU
FLUTICASONE/SALMETEROL AEROSOL
12 GM IN 30 DAYS
ADVAIR HFA 60 ACTU
FLUTICASONE/SALMETEROL AEROSOL
8 GM IN 30 DAYS
ALENDRONATE 35 MG, 70MG
ALENDRONATE SODIUM
TABLET
4 TABS IN 28 DAYS
ALENDRONATE 5MG, 10MG, 40MG
ALENDRONATE SODIUM
TABLET
30 TABS IN 30 DAYS
ALFUZOSIN HCL ER
ALFUZOSIN HCL
TAB ER 24H
30 TABS IN 30 DAYS
ALPRAZOLAM .25 MG, .5MG, 1MG
ALPRAZOLAM
TABLET
120 TABS IN 30 DAYS
ALPRAZOLAM 2 MG
ALPRAZOLAM
TABLET
60 TABS IN 30 DAYS
AMLODIPINE-BENAZEPRIL
AMLODIPINE BESYLATE/BENAZEPRIL CAPSULE
ANORO ELLIPTA
UMECLIDINIUM BRM/VILANTEROL TR INHALATION DISK60 CAPS IN 30 DAYS
APTIOM 200 MG, 400MG
ESLICARBAZEPINE ACETATE TABLET
30 TABS IN 30 DAYS
APTIOM 600 MG
ESLICARBAZEPINE ACETATE TABLET
60 TABS IN 30 DAYS
ASCOMP WITH CODEINE
CODEINE/BUTALBITAL/ASA/CAFFEIN CAPSULE
180 CAPS IN 30 DAYS
ATELVIA
RISEDRONATE SODIUM
4 TABS IN 28 DAYS
2015 CARE1ST MEDICARE DRUG FORMULARY
TABLET DR
30 CAPS IN 30 DAYS
29
QUANTITY LIMITS TABLE
ABILIFY
QUANTITY LIMITS TABLE / TABLA DE LIMITE DE CANTIDAD
QUANTITY LIMITS TABLE
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA FARMACEUTICA
QUANTITY LIMIT
LIMITE DE CANTIDAD
AVODART
DUTASTERIDE
CAPSULE
30 CAPS IN 30 DAYS
AZELASTINE HCL
AZELASTINE HCL
NASAL SPRAY
30 ML IN 30 DAYS
AZILECT
RASAGILINE MESYLATE
TABLET
30 TABS IN 30 DAYS
AZITHROMYCIN
AZITHROMYCIN
ORAL PACKETS
2 GM IN 30 DAYS
AZITHROMYCIN 100 MG/5ML
AZITHROMYCIN
ORAL SUSP
2 ML IN 30 DAYS
AZITHROMYCIN 200 MG/5ML
AZITHROMYCIN
ORAL SUSP
67.5 ML IN 30 DAYS
AZITHROMYCIN 250 MG, 500MG
AZITHROMYCIN
TABLET
6 TABS IN 30 DAYS
AZITHROMYCIN 600 MG
AZITHROMYCIN
TABLET
8 TABS IN 30 DAYS
AZOPT
BRINZOLAMIDE
OPHT SUSP
15 ML IN 30 DAYS
BUPROPION XL
BUPROPION HCL
TAB ER 24H
30 TABS IN 30 DAYS
BUTALB-CAFF-APAP-CODEIN
BUTALBIT/ACETAMIN/CAFF/CODEINE CAPSULE
180 CAPS IN 30 DAYS
BUTALBITAL COMP-CODEINE
CODEINE/BUTALBITAL/ASA/CAFFEIN CAPSULE
120 CAPS IN 30 DAYS
CALCIPOTRIENE
CALCIPOTRIENE
TOPICAL CREAM
60 GM IN 30 DAYS
CALCIPOTRIENE
CALCIPOTRIENE
TOPICAL SOLUTION
60 ML IN 30 DAYS
CARISOPRODOL
CARISOPRODOL
TABLET
90 TABS IN 30 DAYS
CHLORZOXAZONE
CHLORZOXAZONE
TABLET
180 TABS IN 30 DAYS
CLORAZEPATE 15 MG
CLORAZEPATE DIPOTASSIUM TABLET
180 TABS IN 30 DAYS
CLORAZEPATE 3.75 MG, 7.5MG
CLORAZEPATE DIPOTASSIUM TABLET
120 TABS IN 30 DAYS
CODEINE SULFATE
CODEINE SULFATE
120 TABS IN 30 DAYS
COMBIVENT RESPIMAT
IPRATROPIUM/ALBUTEROL SULFATE AEROSOL
8 GM IN 30 DAYS
COMFORT PAC-CYCLOBENZAPRINE
CYCLOBENZ HCL/IRR CNTR-IRR CB2 KIT
90 TABS IN 30 DAYS
CYCLOBENZAPRINE HCL
CYCLOBENZAPRINE HCL
TABLET
90 TABS IN 30 DAYS
DIAZEPAM
DIAZEPAM
KIT
5 SUPP IN 30 DAYS
DIAZEPAM
DIAZEPAM
ORAL SOLUTION
1200 ML IN 30 DAYS
DIAZEPAM
DIAZEPAM
TABLET
120 TABS IN 30 DAYS
DIFFERIN
ADAPALENE
MED. SWAB
45 GM IN 30 DAYS
30
TABLET
2015 CARE1ST MEDICARE DRUG FORMULARY
QUANTITY LIMITS TABLE / TABLA DE LIMITE DE CANTIDAD
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA FARMACEUTICA
QUANTITY LIMIT
LIMITE DE CANTIDAD
DIGOXIN
TABLET
30 TABS IN 30 DAYS
DORZOLAMIDE HCL
DORZOLAMIDE HCL
OPHT DROPS
10 ML IN 30 DAYS
DORZOLAMIDE-TIMOLOL
DORZOLAMIDE HCL/TIMOLOL MALEAT OPHT DROPS10 ML IN 30 DAYS
DOXERCALCIFEROL 0.5 MCG
DOXERCALCIFEROL
CAPSULE
30 CAPS IN 30 DAYS
DOXERCALCIFEROL 1 MCG
DOXERCALCIFEROL
CAPSULE
90 CAPS IN 30 DAYS
EDURANT
RILPIVIRINE HCL
TABLET
30 TABS IN 30 DAYS
ELIDEL
PIMECROLIMUS
TOPICAL CREAM
30 GM IN 30 DAYS
ELLA
ULIPRISTAL ACETATE
TABLET
1 TABS IN 30 DAYS
ENDOCET
OXYCODONE HCL/ACETAMINOPHEN TABLET
120 TABS IN 30 DAYS
ENDODAN
OXYCODONE HCL/ASPIRIN TABLET
120 TABS IN 30 DAYS
FENTANYL
FENTANYL
PATCH
10 PATCH IN 30 DAYS
FENTANYL CITRATE
FENTANYL CITRATE
LOZENGE HD
120 LOZ IN 30 DAYS
FINASTERIDE
FINASTERIDE
TABLET
30 TABS IN 30 DAYS
FORTEO
TERIPARATIDE
INJECTION KIT
3 UNIT IN 28 DAYS
FYCOMPA 10MG, 12MG
PERAMPANEL
TABLET
30 TABS IN 30 DAYS
FYCOMPA 2MG, 4MG, 8MG
PERAMPANEL
TABLET
30 TABS IN 30 DAYS
FYCOMPA 6MG
PERAMPANEL
TABLET
60 TABS IN 30 DAYS
GLIMEPIRIDE 1 MG
GLIMEPIRIDE
TABLET
240 TABS IN 30 DAYS
GLIMEPIRIDE 2 MG
GLIMEPIRIDE
TABLET
120 TABS IN 30 DAYS
GLIMEPIRIDE 4 MG
GLIMEPIRIDE
TABLET
60 TABS IN 30 DAYS
GLIP/METFORMIN 2.5-250 MG
GLIPIZIDE/METFORMIN HCL TABLET
240 TABS IN 30 DAYS
GLIP/METFORMIN 2.5-500MG
GLIPIZIDE/METFORMIN HCL TABLET
120 TABS IN 30 DAYS
GLIP/METFORMIN 5-500MG
GLIPIZIDE/METFORMIN HCL TABLET
120 TABS IN 30 DAYS
GLIPIZIDE 10 MG
GLIPIZIDE
TABLET
120 TABS IN 30 DAYS
GLIPIZIDE 5 MG
GLIPIZIDE
TABLET
60 TABS IN 30 DAYS
GLIPIZIDE ER 10 MG
GLIPIZIDE
TAB ER 24
60 TABS IN 30 DAYS
2015 CARE1ST MEDICARE DRUG FORMULARY
31
QUANTITY LIMITS TABLE
DIGOX
QUANTITY LIMITS TABLE / TABLA DE LIMITE DE CANTIDAD
QUANTITY LIMITS TABLE
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA FARMACEUTICA
QUANTITY LIMIT
LIMITE DE CANTIDAD
GLIPIZIDE ER 2.5 MG
GLIPIZIDE
TAB ER 24
240 TABS IN 30 DAYS
GLIPIZIDE ER 5 MG
GLIPIZIDE
TAB ER 24
120 TABS IN 30 DAYS
GLUCAGON EMERGENCY KIT
GLUCAGON,HUMAN RECOMBINANT INJECTION KIT 2 UNIT IN 30 DAYS
GLYBURIDE 1.25 MG
GLYBURIDE
TABLET
480 TABS IN 30 DAYS
GLYBURIDE 2.5 MG
GLYBURIDE
TABLET
240 TABS IN 30 DAYS
GLYBURIDE 5 MG
GLYBURIDE
TABLET
120 TABS IN 30 DAYS
GLYBURIDE MICRONIZED 1.5 MG
GLYBURIDE,MICRONIZED
TABLET
240 TABS IN 30 DAYS
GLYBURIDE MICRONIZED 3 MG
GLYBURIDE,MICRONIZED
TABLET
120 TABS IN 30 DAYS
GLYBURIDE MICRONIZED 6 MG
GLYBURIDE,MICRONIZED
TABLET
60 TABS IN 30 DAYS
GLYBURIDE-METFORMIN 1.25-250MG GLYBURIDE/METFORMIN
TABLET
240 TABS IN 30 DAYS
GLYBURIDE-METFORMIN 2.5-500MG GLYBURIDE/METFORMIN
TABLET
120 TABS IN 30 DAYS
GLYBURIDE-METFORMIN 5-500MG
GLYBURIDE/METFORMIN
TABLET
120 TABS IN 30 DAYS
GLYSET 100 MG
MIGLITOL
TABLET
90 TABS IN 30 DAYS
GLYSET 25 MG
MIGLITOL
TABLET
360 TABS IN 30 DAYS
GLYSET 50 MG
MIGLITOL
TABLET
180 TABS IN 30 DAYS
HOMATROPINE HYDROBROMIDE
HOMATROPINE HBR
OPHT DROPS
5 ML IN 30 DAYS
HYDROCODONE BIT-IBUPROFEN
HYDROCODONE/IBUPROFEN TABLET
HYDROCODONE-APAP
HYDROCODONE/ACETAMINOPHEN ORAL SOLUTION 1800 ML IN 30 DAYS
HYDROCODONE-APAP
HYDROCODONE/ACETAMINOPHENTABLET
120 TABS IN 30 DAYS
HYDROCODONE-IBUPROFEN
HYDROCODONE/IBUPROFEN TABLET
120 TABS IN 30 DAYS
HYDROMORPHONE HCL
HYDROMORPHONE HCL
TABLET
120 TABS IN 30 DAYS
IBANDRONATE SODIUM
IBANDRONATE SODIUM
TABLET
1 TABS IN 30 DAYS
IMIQUIMOD
IMIQUIMOD
TOPICAL CREAM
12 GM IN 30 DAYS
INVEGA
PALIPERIDONE
TAB ER 24
30 TABS IN 30 DAYS
INVIRASE
SAQUINAVIR MESYLATE
CAPSULE
300 CAPS IN 30 DAYS
ISENTRESS
RALTEGRAVIR POTASSIUM ORAL POWD PACK
32
120 TABS IN 30 DAYS
60 GM IN 30 DAYS
2015 CARE1ST MEDICARE DRUG FORMULARY
QUANTITY LIMITS TABLE / TABLA DE LIMITE DE CANTIDAD
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA FARMACEUTICA
QUANTITY LIMIT
LIMITE DE CANTIDAD
RALTEGRAVIR POTASSIUM TAB CHEW
180 TABS IN 30 DAYS
ISENTRESS 25 MG
RALTEGRAVIR POTASSIUM TAB CHEW
120 TABS IN 30 DAYS
JANUMET
SITAGLIPTIN PHOS/METFORMIN HCL TABLET
60 TABS IN 30 DAYS
JANUMET XR 100-1000MG
SITAGLIPTIN PHOS/METFORMIN HCL TBMP 24HR
60 TABS IN 30 DAYS
JANUMET XR 50-1000 MG
SITAGLIPTIN PHOS/METFORMIN HCL TBMP 24HR
60 TABS IN 30 DAYS
JANUMET XR 50MG-500MG
SITAGLIPTIN PHOS/METFORMIN HCL TBMP 24HR
30 TABS IN 30 DAYS
JANUVIA
SITAGLIPTIN PHOSPHATE
30 TABS IN 30 DAYS
JENTADUETO
LINAGLIPTIN/METFORMIN HCL TABLET
60 TABS IN 30 DAYS
KETOROLAC TROMETHAMINE
KETOROLAC TROMETHAMINE INJECTION
20 ML IN 30 DAYS
KETOROLAC TROMETHAMINE
KETOROLAC TROMETHAMINEINJECTION CART
20 ML IN 30 DAYS
KETOROLAC TROMETHAMINE
KETOROLAC TROMETHAMINETABLET
20 TABS IN 30 DAYS
LAZANDA
FENTANYL CITRATE
NASAL SPRAY
75 ML IN 30 DAYS
LEVETIRACETAM ER 500 MG
LEVETIRACETAM
TAB ER 24H
180 TABS IN 30 DAYS
LEVETIRACETAM ER 750 MG
LEVETIRACETAM
TAB ER 24H
120 TABS IN 30 DAYS
LEVOBUNOLOL HCL
LEVOBUNOLOL HCL
OPHT DROPS
15 ML IN 30 DAYS
LORAZEPAM
LORAZEPAM
TABLET
120 TABS IN 30 DAYS
LORCET
HYDROCODONE/ACETAMINOPHEN TABLET
120 TABS IN 30 DAYS
LORCET HD
HYDROCODONE/ACETAMINOPHEN TABLET
120 TABS IN 30 DAYS
LORCET PLUS
HYDROCODONE/ACETAMINOPHEN TABLET
120 TABS IN 30 DAYS
MEPERIDINE HCL
MEPERIDINE HCL
ORAL SOLUTION
600 ML IN 30 DAYS
MEPERIDINE HCL
MEPERIDINE HCL
TABLET
120 TABS IN 30 DAYS
METFORMIN ER 1000 MG, 750 MG
METFORMIN HCL
TAB ER 24
60 TABS IN 30 DAYS
METFORMIN HCL 1000 MG
METFORMIN HCL
TABLET
60 TABS IN 30 DAYS
METFORMIN HCL 500 MG
METFORMIN HCL
TABLET
150 TABS IN 30 DAYS
METFORMIN HCL 850 MG
METFORMIN HCL
TABLET
90 TABS IN 30 DAYS
METFORMIN HCL ER 500 MG
METFORMIN HCL
TAB ER 24H
120 TABS IN 30 DAYS
2015 CARE1ST MEDICARE DRUG FORMULARY
TABLET
33
QUANTITY LIMITS TABLE
ISENTRESS 100 MG
QUANTITY LIMITS TABLE / TABLA DE LIMITE DE CANTIDAD
QUANTITY LIMITS TABLE
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA FARMACEUTICA
QUANTITY LIMIT
LIMITE DE CANTIDAD
METHADONE HCL
METHADONE HCL
ORAL SOLUTION
1800 ML IN 30 DAYS
METHADONE HCL
METHADONE HCL
TABLET
120 TABS IN 30 DAYS
METHADONE INTENSOL
METHADONE HCL
ORAL CONC
1800 ML IN 30 DAYS
METHADOSE
METHADONE HCL
TABLET SOL
120 TABS IN 30 DAYS
METHOCARBAMOL 500 MG
METHOCARBAMOL
TABLET
240 TABS IN 30 DAYS
METHOCARBAMOL 750 MG
METHOCARBAMOL
TABLET
180 TABS IN 30 DAYS
METOPROLOL SUCCINATE 100 MG
METOPROLOL SUCCINATE TAB ER 24H
30 TABS IN 30 DAYS
METOPROLOL SUCCINATE 200 MG
METOPROLOL SUCCINATE TAB ER 24H
60 TABS IN 30 DAYS
METOPROLOL SUCCINATE 25 MG
METOPROLOL SUCCINATE TAB ER 24H
30 TABS IN 30 DAYS
METOPROLOL SUCCINATE 50 MG
METOPROLOL SUCCINATE TAB ER 24H
30 TABS IN 30 DAYS
MORPHINE SULFATE
MORPHINE SULFATE
ORAL SOLUTION
1800 ML IN 30 DAYS
MORPHINE SULFATE
MORPHINE SULFATE
RECTAL SUPP
120 SUPP IN 30 DAYS
MORPHINE SULFATE
MORPHINE SULFATE
TABLET
120 TABS IN 30 DAYS
MORPHINE SULFATE ER
MORPHINE SULFATE
TABLET ER
90 TABS IN 30 DAYS
MUPIROCIN
MUPIROCIN
TOPICAL OINT.
22 GM IN 30 DAYS
NAPHAZOLINE W/ANTAZOLINE
NAPHAZOLINE HCL/ANTAZOLINE OPHT DROPS
15 ML IN 30 DAYS
NEOMYCIN W/DEXAMETHASONE
NEOMYCIN SULFATE/DEX NA PH OPHT DROPS
5 ML IN 30 DAYS
OLANZAPINE
OLANZAPINE
TABLET
30 TABS IN 30 DAYS
OLANZAPINE ODT
OLANZAPINE
TAB RAPDIS
30 TABS IN 30 DAYS
OMEPRAZOLE 10 MG, 20 MG
OMEPRAZOLE
CAPSULE DR
60 CAPS IN 30 DAYS
OMEPRAZOLE 40MG
OMEPRAZOLE
CAPSULE DR
30 CAPS IN 30 DAYS
OXYCODONE HCL
OXYCODONE HCL
CAPSULE
120 CAPS IN 30 DAYS
OXYCODONE HCL
OXYCODONE HCL
ORAL CONC
250 ML IN 30 DAYS
OXYCODONE HCL
OXYCODONE HCL
ORAL SOLUTION
250 ML IN 30 DAYS
OXYCODONE HCL
OXYCODONE HCL
TABLET
120 TABS IN 30 DAYS
OXYCODONE HCL-APAP
OXYCODONE HCL/ACETAMINOPHEN TABLET
34
120 TABS IN 30 DAYS
2015 CARE1ST MEDICARE DRUG FORMULARY
QUANTITY LIMITS TABLE / TABLA DE LIMITE DE CANTIDAD
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA FARMACEUTICA
QUANTITY LIMIT
LIMITE DE CANTIDAD
OXYCODONE HCL/ASPIRIN TABLET
120 TABS IN 30 DAYS
OXYCODONE-ACETAMINOPHEN
OXYCODONE HCL/ACETAMINOPHEN TABLET
120 TABS IN 30 DAYS
OXYCONTIN
OXYCODONE HCL
TAB ER 12H
60 TABS IN 30 DAYS
PATANOL
OLOPATADINE HCL
OPHT DROPS
5 ML IN 30 DAYS
PEG 3350-ELECTROLYTE
PEG 3350/NA SULF,BICARB,CL/KCL ORAL SOLUTION 4000 ML IN 30 DAYS
PENTASA
MESALAMINE
CAPSULE ER
480 CAPS IN 30 DAYS
PHENYLEPHRINE HCL
PHENYLEPHRINE HCL
OPHT DROPS
15 ML IN 30 DAYS
PILOCARPINE HCL
PILOCARPINE HCL
OPHT DROPS
15 ML IN 30 DAYS
PIOGLITAZONE HCL
PIOGLITAZONE HCL
TABLET
30 TABS IN 30 DAYS
POTIGA
EZOGABINE
TABLET
270 TABS IN 30 DAYS
PREZISTA
DARUNAVIR ETHANOLATE
ORAL SUSP
360 ML IN 30 DAYS
PREZISTA
DARUNAVIR ETHANOLATE
TABLET
60 TABS IN 30 DAYS
PROAIR HFA
ALBUTEROL SULFATE
AEROSOL
17 GM IN 30 DAYS
QUETIAPINE FUMARATE
QUETIAPINE FUMARATE
TABLET
90 TABS IN 30 DAYS
RALOXIFENE HCL
RALOXIFENE HCL
TABLET
30 TABS IN 30 DAYS
REGRANEX
BECAPLERMIN
TOPICAL GEL
15 GM IN 30 DAYS
RELENZA
ZANAMIVIR
INHALATION DISK
56 CAPS IN 180 DAYS
REPREXAIN
HYDROCODONE/IBUPROFEN TABLET
120 TABS IN 30 DAYS
RESTASIS
CYCLOSPORINE
OPHT DROPS
64 ML IN 30 DAYS
RISEDRONATE SODIUM 150 MG
RISEDRONATE SODIUM
TABLET
1 TABS IN 30 DAYS
RISPERIDONE
RISPERIDONE
ORAL SOLUTION
240 ML IN 30 DAYS
RISPERIDONE
RISPERIDONE
TABLET
60 TABS IN 30 DAYS
RISPERIDONE ODT
RISPERIDONE
TAB RAPDIS
60 TABS IN 30 DAYS
RIZATRIPTAN
RIZATRIPTAN BENZOATE
TAB RAPDIS
12 TABS IN 30 DAYS
RIZATRIPTAN
RIZATRIPTAN BENZOATE
TABLET
12 TABS IN 30 DAYS
ROXICET
OXYCODONE HCL/ACETAMINOPHEN TABLET
2015 CARE1ST MEDICARE DRUG FORMULARY
120 TABS IN 30 DAYS
35
QUANTITY LIMITS TABLE
OXYCODONE HCL-ASPIRIN
QUANTITY LIMITS TABLE / TABLA DE LIMITE DE CANTIDAD
QUANTITY LIMITS TABLE
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA FARMACEUTICA
QUANTITY LIMIT
LIMITE DE CANTIDAD
SENSIPAR
CINACALCET HCL
TABLET
30 TABS IN 30 DAYS
SIROLIMUS
SIROLIMUS
TABLET
30 TABS IN 30 DAYS
SPIRIVA
TIOTROPIUM BROMIDE
INHALATION CAPSULE 30 CAPS IN 30 DAYS
SUMATRIPTAN
SUMATRIPTAN
NASAL SPRAY
SUMATRIPTAN SUCCINATE
SUMATRIPTAN SUCCINATE TABLET
9 TABS IN 30 DAYS
SUMATRIPTAN SUCCINATE
SUMATRIPTAN SUCCINATE INJECTION CART
4 ML IN 30 DAYS
TAMIFLU
OSELTAMIVIR PHOSPHATE ORAL SUSP
360 ML IN 180 DAYS
TAMIFLU 30MG
OSELTAMIVIR PHOSPHATE CAPSULE
56 CAPS IN 180 DAYS
TAMIFLU 45MG, 75MG
OSELTAMIVIR PHOSPHATE CAPSULE
28 CAPS IN 180 DAYS
TAMSULOSIN HCL
TAMSULOSIN HCL
CAP ER 24H
60 CAPS IN 30 DAYS
TEMAZEPAM
TEMAZEPAM
CAPSULE
30 CAPS IN 30 DAYS
TOLAZAMIDE
TOLAZAMIDE
TABLET
60 TABS IN 30 DAYS
TOLBUTAMIDE
TOLBUTAMIDE
TABLET
180 TABS IN 30 DAYS
TOLTERODINE TARTRATE
TOLTERODINE TARTRATE
TABLET
60 TABS IN 30 DAYS
TOLTERODINE TARTRATE ER
TOLTERODINE TARTRATE
CAP ER 24H
30 CAPS IN 30 DAYS
TRADJENTA
LINAGLIPTIN
TABLET
30 TABS IN 30 DAYS
TRAMADOL HCL
TRAMADOL HCL
TABLET
240 TABS IN 30 DAYS
TRAMADOL-ACETAMINOPHEN
TRAMADOL HCL/ACETAMINOPHEN TABLET
240 TABS IN 30 DAYS
TRAVATAN Z
TRAVOPROST
5 ML IN 30 DAYS
TRAVOPROST
TRAVOPROST (BENZALKONIUM) OPHT DROPS
5 ML IN 30 DAYS
TRIAZOLAM
TRIAZOLAM
TABLET
30 TABS IN 30 DAYS
TROKENDI XR 100MG
TOPIRAMATE
CAP ER 24H
90 CAPS IN 30 DAYS
TROKENDI XR 200MG
TOPIRAMATE
CAP ER 24H
240 CAPS IN 30 DAYS
TROKENDI XR 25MG
TOPIRAMATE
CAP ER 24H
90 CAPS IN 30 DAYS
TROKENDI XR 50MG
TOPIRAMATE
CAP ER 24H
90 CAPS IN 30 DAYS
VENTOLIN HFA
ALBUTEROL SULFATE
AEROSOL
36 GM IN 30 DAYS
36
OPHT DROPS
9 ML IN 30 DAYS
2015 CARE1ST MEDICARE DRUG FORMULARY
QUANTITY LIMITS TABLE / TABLA DE LIMITE DE CANTIDAD
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA FARMACEUTICA
QUANTITY LIMIT
LIMITE DE CANTIDAD
LACOSAMIDE
INTRAVENOUS (IV)
200 ML IN 5 DAYS
ZAFIRLUKAST
ZAFIRLUKAST
TABLET
60 TABS IN 30 DAYS
ZIPRASIDONE HCL 20 MG, 40 MG
ZIPRASIDONE HCL
CAPSULE
60 CAPS IN 30 DAYS
ZIPRASIDONE HCL 60 MG, 80 MG
ZIPRASIDONE HCL
CAPSULE
120 CAPS IN 30 DAYS
ZMAX
AZITHROMYCIN
ORAL SUS ER REC
60 ML IN 30 DAYS
ZOLPIDEM TARTRATE
ZOLPIDEM TARTRATE
TABLET
30 TABS IN 30 DAYS
ZOVIRAX
ACYCLOVIR
TOPICAL CREAM
10 GM IN 30 DAYS
2015 CARE1ST MEDICARE DRUG FORMULARY
37
QUANTITY LIMITS TABLE
VIMPAT
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
ANALGESICS
ANALGESICS, MISCELLANEOUS
Acetaminophen With Codeine TABLET
2
QL
*Acetaminophen-Codeine
Acetaminophen With Codeine ORAL SOLUTION
2
QL
*Ascomp With Codeine
Codeine/Butalbital/Asa/Caffein CAPSULE
2
QL
ASTRAMORPH-PF
Morphine Sulfate/Pf
INJECTION
3
BvD
*Astramorph-Pf
Morphine Sulfate/Pf
INJECTION
2
BvD
*Butalb-Caff-Acetaminoph-Codein
Butalbit/Acetamin/Caff/Codeine CAPSULE
2
QL, PA>65 y/o
*Butalbital Compound-Codeine
Codeine/Butalbital/Asa/Caffein CAPSULE
2
QL
*Codeine Sulfate
Codeine Sulfate
TABLET
2
QL
*Diskets
Methadone Hcl
TAB DISPER
2
QL
*Endocet
Oxycodone Hcl/Acetaminophen TABLET
2
QL
*Endodan
Oxycodone Hcl/Aspirin
TABLET
2
QL
*Fentanyl
Fentanyl
PATCH
2
QL, ST
FENTANYL CITRATE
Fentanyl Citrate
LOZENGE
4
PA, QL
*Hydrocodone Bit-Ibuprofen
Hydrocodone/Ibuprofen
TABLET
2
QL
*Hydrocodone-Acetaminophen
Hydrocodone/Acetaminophen TABLET
2
QL
*Hydrocodone-Acetaminophen
Hydrocodone/Acetaminophen ORAL SOLUTION
2
QL
*Hydrocodone-Ibuprofen
Hydrocodone/Ibuprofen
TABLET
2
QL
*Hydromorphone Hcl
Hydromorphone Hcl
TABLET
2
QL
ANALGESICS
*Acetaminophen-Codeine
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
39
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
ANALGESICS (continued)
ANALGESICS
ANALGESICS, MISCELLANEOUS (continued)
*Hydromorphone Hcl
Hydromorphone Hcl/Pf
INJECTION
2
BvD
*Hydromorphone Hcl
Hydromorphone Hcl
INJECTION
2
BvD
LAZANDA
Fentanyl Citrate
NASAL SPRAY
5
PA, QL
*Lorcet
Hydrocodone/Acetaminophen TABLET
2
QL
*Lorcet Hd
Hydrocodone/Acetaminophen TABLET
2
QL
*Lorcet Plus
Hydrocodone/Acetaminophen TABLET
2
QL
*Meperidine Hcl
Meperidine Hcl
ORAL SOLUTION
2
QL, PA>65 y/o
*Meperidine Hcl
Meperidine Hcl
TABLET
2
QL, PA>65 y/o
*Meperitab
Meperidine Hcl
TABLET
2
QL, PA>65 y/o
*Methadone Hcl
Methadone Hcl
INJECTION
2
BvD
*Methadone Hcl
Methadone Hcl
TABLET
2
QL
*Methadone Hcl
Methadone Hcl
ORAL SOLUTION
2
QL
*Methadone Intensol
Methadone Hcl
ORAL CONC
2
QL
*Methadose
Methadone Hcl
TAB DISPER
2
QL
*Morphine Sulfate
Morphine Sulfate
INJECTION
2
BvD
*Morphine Sulfate
Morphine Sulfate
TABLET
2
QL
*Morphine Sulfate
Morphine Sulfate
ORAL SOLUTION
2
QL
*Morphine Sulfate
Morphine Sulfate
TABLET ER
2
QL
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
40
2015 CARE1ST MEDICARE DRUG FORMULARY
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
ANALGESICS (continued)
ANALGESICS, MISCELLANEOUS (continued)
Morphine Sulfate
RECTAL SUPP
2
QL
*Morphine Sulfate Er
Morphine Sulfate
TABLET ER
2
QL
*Oxycodone Hcl
Oxycodone Hcl
CAPSULE
2
QL
*Oxycodone Hcl
Oxycodone Hcl
ORAL CONC
2
QL
*Oxycodone Hcl
Oxycodone Hcl
ORAL SOLUTION
2
QL
*Oxycodone Hcl
Oxycodone Hcl
TABLET
2
QL
*Oxycodone Hcl-Acetaminophen
Oxycodone Hcl/Acetaminophen TABLET
2
QL
*Oxycodone Hcl-Aspirin
Oxycodone Hcl/Aspirin
2
QL
*Oxycodone-Acetaminophen
Oxycodone Hcl/Acetaminophen TABLET
2
QL
OXYCONTIN
Oxycodone Hcl
TAB ER 12H
4
PA, QL
*Reprexain
Hydrocodone/Ibuprofen
TABLET
2
QL
*Roxicet
Oxycodone Hcl/Acetaminophen TABLET
2
QL
*Tramadol Hcl
Tramadol Hcl
TABLET
2
QL
*Tramadol Hcl-Acetaminophen
Tramadol Hcl/Acetaminophen TABLET
2
QL
PA
TABLET
ANALGESICS
*Morphine Sulfate
NONSTEROIDAL ANTI-INFLAMMATORY AGENTS
+CELEBREX
Celecoxib
CAPSULE
4
*+Choline Mag Trisalicylate
Choline Sal/Mag Salicylate
ORAL SOLUTION
2
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
41
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
ANALGESICS (continued)
ANALGESICS
NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (continued)
*Comfort Pac-Ibuprofen
Ibuprofen/Irr Cnt-Irrit Cmb #2
KIT
2
*Comfort Pac-Meloxicam
Meloxicam/Irr Cntr-Irr Cmb #2 KIT
2
*Comfort Pac-Naproxen
Naproxen/Irr Cntr-Irrit Cmb #2 KIT
2
*Diclofenac Potassium
Diclofenac Potassium
TABLET
2
*+Diclofenac Sodium
Diclofenac Sodium
TABLET DR
2
+DICLOFENAC SODIUM
Diclofenac Sodium
TOPICAL GEL
5
*+Diclofenac Sodium Er
Diclofenac Sodium
TAB ER 24H
2
*+Diflunisal
Diflunisal
TABLET
2
*+Etodolac
Etodolac
CAPSULE
2
*+Etodolac
Etodolac
TABLET
2
*+Etodolac Er
Etodolac
TAB ER 24H
2
*+Fenoprofen Calcium
Fenoprofen Calcium
TABLET
2
*+Flurbiprofen
Flurbiprofen
TABLET
2
*+Ibuprofen
Ibuprofen
TABLET
2
*Indomethacin
Indomethacin
CAPSULE
2
PA>65 y/o
*Indomethacin
Indomethacin
CAPSULE ER
2
PA>65 y/o
*+Ketoprofen
Ketoprofen
CAP24H PEL
2
*+Ketoprofen
Ketoprofen
CAPSULE
2
PA
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
42
2015 CARE1ST MEDICARE DRUG FORMULARY
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
ANALGESICS (continued)
NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (continued)
Ketorolac Tromethamine
INJECTION
2
BvD, QL
*Ketorolac Tromethamine
Ketorolac Tromethamine
INJECTION
2
BvD, QL
*Ketorolac Tromethamine
Ketorolac Tromethamine
TABLET
2
QL, PA>65 y/o
*+Meclofenamate Sodium
Meclofenamate Sodium
CAPSULE
2
*+Meloxicam
Meloxicam
TABLET
2
*+Nabumetone
Nabumetone
TABLET
2
*+Naproxen
Naproxen
ORAL SUSP
2
*+Naproxen
Naproxen
TABLET
2
*+Naproxen
Naproxen
TABLET DR
2
*+Naproxen Sodium
Naproxen Sodium
TABLET
2
*+Oxaprozin
Oxaprozin
TABLET
2
*+Piroxicam
Piroxicam
CAPSULE
2
*+Salsalate
Salsalate
TABLET
2
*+Sulindac
Sulindac
TABLET
2
*+Tolmetin Sodium
Tolmetin Sodium
CAPSULE
2
*+Tolmetin Sodium
Tolmetin Sodium
TABLET
2
+VOLTAREN
Diclofenac Sodium
TOPICAL GEL
3
ANALGESICS
*Ketorolac Tromethamine
PA
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
43
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
ANESTHETICS
ANESTHETICS
LOCAL ANESTHETICS
LIDOCAINE
Lidocaine
PATCH
4
PA
*Lidocaine
Lidocaine
TOPICAL OINT.
2
BvD
*Lidocaine Hcl
Lidocaine Hcl
INJECTION
2
BvD
*Lidocaine Hcl
Lidocaine Hcl
ORAL JEL
2
*Lidocaine Hcl
Lidocaine Hcl
ORAL JEL
2
*Lidocaine Hcl
Lidocaine Hcl
ORAL SOLUTION
2
*Lidocaine Hcl
Lidocaine Hcl/Pf
INJECTION
2
BvD
*Lidocaine Hcl
Lidocaine Hcl
INJECTION
2
BvD
*Lidocaine Hcl Viscous
Lidocaine Hcl
ORAL SOLUTION
2
*Lidocaine-Prilocaine
Lidocaine/Prilocaine
CREAM
2
PA
*Lidocaine-Prilocaine
Lidocaine/Prilocaine
CREAM
2
PA
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS
+ACAMPROSATE CALCIUM
Acamprosate Calcium
TABLET DR
4
BUPRENORPHINE HCL
Buprenorphine Hcl
TAB SUBL
4
PA
BUPRENORPHINE-NALOXONE
Buprenorphine Hcl/Naloxone Hcl TAB SUBL
4
PA
CHANTIX
Varenicline Tartrate
4
PA
TABLET
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
44
2015 CARE1ST MEDICARE DRUG FORMULARY
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS (continued)
ANTI-ADDICTION/SUBSTANCE ABUSE TREATMENT AGENTS (continued)
Naltrexone Hcl
TABLET
2
*+Disulfiram
Disulfiram
TABLET
2
NALOXONE HCL
Naloxone Hcl
SYRINGES
3
NALOXONE HCL
Naloxone Hcl
INJECTION
3
*Naltrexone Hcl
Naltrexone Hcl
TABLET
2
NICOTROL
Nicotine
INHALATION CARTRIDGE 3
PA
NICOTROL NS
Nicotine
NASAL SPRAY
3
PA
SUBOXONE
Buprenorphine Hcl/Naloxone Hcl SUBLINGUAL FILM 4
PA
ANTI-ADDICTION/SUBSTANCE ABUSE
*Depade
ANTIANXIETY AGENTS
BENZODIAZEPINES
*Alprazolam
Alprazolam
TABLET
2
QL
*+Clonazepam
Clonazepam
TAB RAPDIS
2
*+Clonazepam
Clonazepam
TABLET
2
*Clorazepate Dipotassium
Clorazepate Dipotassium
TABLET
2
QL
*Diazepam
Diazepam
ORAL SOLUTION
2
QL
*Diazepam
Diazepam
TABLET
2
QL
*Diazepam
Diazepam
RECTAL
2
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
45
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
ANTIANXIETY AGENTS (continued)
ANTIANXIETY AGENTS
BENZODIAZEPINES (continued)
*Diazepam
Diazepam
RECTAL
2
QL
*Lorazepam
Lorazepam
TABLET
2
QL
+ONFI
Clobazam
TABLET
4
PA
+ONFI
Clobazam
ORAL SUSP
4
PA
*Temazepam
Temazepam
CAPSULE
2
QL
*Triazolam
Triazolam
TABLET
2
QL
*Amikacin Sulfate
Amikacin Sulfate
INJECTION
2
BvD
*Gentamicin Sulfate
Gentamicin Sulfate
INJECTION
2
BvD
*Neomycin Sulfate
Neomycin Sulfate
TABLET
2
*Streptomycin Sulfate
Streptomycin Sulfate
INJECTION
2
BvD
TOBI
Tobramycin In 0.225% Nacl
INHALATION SOLN
5
PA
*Tobramycin Sulfate
Tobramycin Sulfate
INJECTION
2
BvD
CHLORAMPHENICOL SOD SUCCINATE Chloramphenicol Sod Succ INTRAVENOUS (IV) 4
BvD
ANTIBACTERIALS
AMINOGLYCOSIDES
ANTIBACTERIALS, MISCELLANEOUS
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
46
2015 CARE1ST MEDICARE DRUG FORMULARY
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
ANTIBACTERIALS (continued)
ANTIBACTERIALS, MISCELLANEOUS (continued)
*Clindamycin Hcl
Clindamycin Hcl
CAPSULE
2
*Clindamycin Phosphate
Clindamycin Phosphate
INTRAVENOUS (IV)
2
*Colistimethate Sodium
Colistin (Colistimethate Na)
INJECTION
2
CUBICIN
Daptomycin
INTRAVENOUS (IV)
5
*Methenamine Hippurate
Methenamine Hippurate
TABLET
2
*Methenamine Mandelate
Methenamine Mandelate
TABLET
2
*Nitrofurantoin
Nitrofurantoin Macrocrystal
CAPSULE
2
PA>65 y/o
SYNERCID
Quinupristin/Dalfopristin
INTRAVENOUS (IV)
5
BvD
*Trimethoprim
Trimethoprim
TABLET
2
VANCOMYCIN HCL
Vancomycin Hcl
CAPSULE
5
*Vancomycin Hcl
Vancomycin Hcl
INTRAVENOUS (IV)
2
BvD
ZYVOX
Linezolid
TABLET
5
PA
ZYVOX
Linezolid
ORAL SUSP
5
PA
ZYVOX
Linezolid
INTRAVENOUS (IV)
5
BvD
*Cefaclor
Cefaclor
CAPSULE
2
*Cefaclor
Cefaclor
ORAL SUSP
2
BvD
PA
ANTIBACTERIALS
CEPHALOSPORINS
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
47
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
ANTIBACTERIALS (continued)
ANTIBACTERIALS
CEPHALOSPORINS (continued)
*Cefaclor ER
Cefaclor
TAB ER 12H
2
*Cefadroxil
Cefadroxil
TABLET
2
*Cefadroxil
Cefadroxil
ORAL SUSP
2
*Cefadroxil
Cefadroxil
CAPSULE
2
*Cefazolin
Cefazolin Sodium/Dextrose,Iso INTRAVENOUS (IV)
*Cefazolin Sodium
Cefazolin Sodium
*Cefazolin Sodium
2
BvD
INJECTION
2
BvD
Cefazolin Sodium
INJECTION
2
BvD
*Cefdinir
Cefdinir
CAPSULE
2
*Cefepime Hcl
Cefepime Hcl
INJECTION
2
BvD
*Cefotaxime Sodium
Cefotaxime Sodium
INJECTION
2
BvD
*Cefpodoxime Proxetil
Cefpodoxime Proxetil
TABLET
2
*Cefpodoxime Proxetil
Cefpodoxime Proxetil
ORAL SUSP
2
*Cefprozil
Cefprozil
ORAL SUSP
2
*Cefprozil
Cefprozil
TABLET
2
*Ceftazidime
Ceftazidime Pentahydrate
INJECTION
2
BvD
CEFTAZIDIME
Ceftazidime Pentahydrate/D5W INTRAVENOUS (IV)
3
BvD
*Ceftriaxone
Ceftriaxone Sodium
INJECTION
2
BvD
*Ceftriaxone
Ceftriaxone Sodium
INTRAVENOUS (IV)
2
BvD
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
48
2015 CARE1ST MEDICARE DRUG FORMULARY
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
ANTIBACTERIALS (continued)
CEPHALOSPORINS (continued)
Ceftriaxone Na/Dextrose,Iso
INTRAVENOUS (IV)
2
*Cefuroxime
Cefuroxime Axetil
TABLET
2
*Cefuroxime Sodium
Cefuroxime Sodium
INJECTION
2
*Cephalexin
Cephalexin
CAPSULE
2
*Cephalexin
Cephalexin
ORAL SUSP
2
*Cephalexin
Cephalexin
TABLET
2
FORTAZ IN ISO-OSMOTIC DEXTROSE Ceftazidime Na/Dextrose,Iso INTRAVENOUS (IV) 3
BvD
BvD
ANTIBACTERIALS
*Ceftriaxone
BvD
SUPRAX
Cefixime
TABLET
3
*Tazicef
Ceftazidime Pentahydrate
INTRAVENOUS (IV)
2
BvD
*Tazicef
Ceftazidime Pentahydrate
INJECTION
2
BvD
*Tazicef In Dextrose
Ceftazidime P-Hyd/Dextrose,Iso INTRAVENOUS (IV) 2
BvD
TEFLARO
Ceftaroline Fosamil Acetate
INTRAVENOUS (IV)
5
BvD
*Azithromycin
Azithromycin
TABLET
2
QL
*Azithromycin
Azithromycin
ORAL SUSP
2
QL
*Azithromycin
Azithromycin
INTRAVENOUS (IV)
2
BvD
*Azithromycin
Azithromycin
ORAL PACKETS
2
QL
MACROLIDES
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
49
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
ANTIBACTERIALS (continued)
ANTIBACTERIALS
MACROLIDES (continued)
*Clarithromycin
Clarithromycin
ORAL SUSP
2
*Clarithromycin
Clarithromycin
TABLET
2
*Clarithromycin ER
Clarithromycin
TAB ER 24H
2
*E.E.S. 400
Erythromycin Ethylsuccinate
TABLET
2
ERYTHROCIN LACTOBIONATE
Erythromycin Lactobionate
INTRAVENOUS (IV)
4
*Erythrocin Stearate
Erythromycin Stearate
TABLET
2
*Erythromycin
Erythromycin Base
CAPSULE DR
2
*Erythromycin
Erythromycin Base
TABLET
2
*Erythromycin Ethylsuccinate
Erythromycin Ethylsuccinate
TABLET
2
*Erythromycin-Sulfisoxazole
Ery E-Succ/Sulfisoxazole
ORAL SUSP
2
KETEK
Telithromycin
TABLET
4
ST
ZMAX
Azithromycin
ORAL SUSP
3
QL
BvD
MISCELLANEOUS B-LACTAM ANTIBIOTICS
*Aztreonam
Aztreonam
INJECTION
2
BvD
CAYSTON
Aztreonam Lysine
INHALATION SOLN
5
PA
*Imipenem-Cilastatin Sodium
Imipenem/Cilastatin Sodium
INTRAVENOUS (IV)
2
BvD
INVANZ
Ertapenem Sodium
INJECTION
4
BvD
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
50
2015 CARE1ST MEDICARE DRUG FORMULARY
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
ANTIBACTERIALS (continued)
MISCELLANEOUS B-LACTAM ANTIBIOTICS (continued)
MEROPENEM
Meropenem
INTRAVENOUS (IV)
4
BvD
PRIMAXIN I.M.
Imipenem/Cilastatin Sodium
INJECTION
3
*Amox Tr-Potassium Clavulanate
Amoxicillin/Potassium Clav
ORAL SUSP
2
*Amox Tr-Potassium Clavulanate
Amoxicillin/Potassium Clav
TAB CHEW
2
*Amox Tr-Potassium Clavulanate
Amoxicillin/Potassium Clav
TABLET
2
*Amoxicillin
Amoxicillin
CAPSULE
2
*Amoxicillin
Amoxicillin
ORAL SUSP
2
*Amoxicillin
Amoxicillin
TAB CHEW
2
*Amoxicillin
Amoxicillin
TABLET
2
AMPICILLIN SODIUM
Ampicillin Sodium
INJECTION
3
*Ampicillin Trihydrate
Ampicillin Trihydrate
ORAL SUSP
2
*Ampicillin Trihydrate
Ampicillin Trihydrate
CAPSULE
2
*Ampicillin-Sulbactam
Ampicillin Sodium/Sulbactam Na INTRAVENOUS (IV) 2
BvD
*Ampicillin-Sulbactam
Ampicillin Sodium/Sulbactam Na INJECTION
2
BvD
BICILLIN C-R
Pen G Benz/Pen G Procaine
INJECTION
3
BvD
BICILLIN L-A
Penicillin G Benzathine
INJECTION
3
BvD
PENICILLINS
ANTIBACTERIALS
BvD
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
51
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
ANTIBACTERIALS (continued)
ANTIBACTERIALS
PENICILLINS (continued)
*Dicloxacillin Sodium
Dicloxacillin Sodium
CAPSULE
2
*Nafcillin Sodium
Nafcillin Sodium
INJECTION
2
BvD
*Nafcillin Sodium
Nafcillin Sodium
INTRAVENOUS (IV)
2
BvD
*Nallpen-Iso-Osmotic Dextrose
Nafcillin In Dextrose,Iso-Osm INTRAVENOUS (IV)
2
BvD
*Penicillin G Potassium
Penicillin G Potassium
INJECTION
2
BvD
*Penicillin G Sodium
Penicillin G Sodium
INJECTION
2
BvD
*Penicillin Gk-Iso-Osm Dextrose
Pen G Pot/Dextrose-Water
INTRAVENOUS (IV)
2
BvD
*Penicillin V Potassium
Penicillin V Potassium
ORAL SOLUTION
2
*Penicillin V Potassium
Penicillin V Potassium
TABLET
2
*Pfizerpen
Penicillin G Potassium
INJECTION
2
BvD
PIPERACILLIN-TAZOBACTAM
Piperacillin Sodium/Tazobactam INTRAVENOUS (IV) 3
BvD
TICAR
Ticarcillin Disodium
INJECTION
3
BvD
TICAR
Ticarcillin Disodium
INTRAVENOUS (IV)
3
BvD
TICAR IN DEXTROSE
Ticarcillin Disodium/D5W
INTRAVENOUS (IV)
3
BvD
TIMENTIN
Ticarcillin/K Clavulanate
INTRAVENOUS (IV)
3
BvD
Ciprofloxacin
ORAL SUSP
2
QUINOLONES
*Ciprofloxacin
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
52
2015 CARE1ST MEDICARE DRUG FORMULARY
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
ANTIBACTERIALS (continued)
QUINOLONES (continued)
Ciprofloxacin Lactate
INTRAVENOUS (IV)
2
*Ciprofloxacin Er
Ciprofloxacin/Ciprofloxa Hcl
TAB SR 24H
2
*Ciprofloxacin Hcl
Ciprofloxacin Hcl
TABLET
2
*Levofloxacin
Levofloxacin
ORAL SOLUTION
2
*Levofloxacin
Levofloxacin
TABLET
2
*Levofloxacin-D5W
Levofloxacin/D5W
INTRAVENOUS (IV)
2
MOXIFLOXACIN HCL
Moxifloxacin Hcl
TABLET
4
*Nalidixic Acid
Nalidixic Acid
TABLET
2
NEGGRAM
Nalidixic Acid
TABLET
3
*Ofloxacin
Ofloxacin
TABLET
2
*Sulfadiazine
Sulfadiazine
TABLET
2
*Sulfamethoxazole/Trimethoprim
Sulfamethoxazole/Trimethoprim TABLET
2
*Sulfamethoxazole-Trimethoprim
Sulfamethoxazole/Trimethoprim TABLET
2
*Sulfamethoxazole-Trimethoprim
Sulfamethoxazole/Trimethoprim INTRAVENOUS (IV)
2
*Sulfamethoxazole-Trimethoprim
Sulfamethoxazole/Trimethoprim ORAL SUSP
2
*Sulfasalazine
Sulfasalazine
BvD
ANTIBACTERIALS
*Ciprofloxacin
BvD
SULFONAMIDES
TABLET
BvD
2
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
53
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
ANTIBACTERIALS (continued)
SULFONAMIDES (continued)
*Sulfasalazine Dr
Sulfasalazine
TABLET DR
2
*Sulfatrim
Sulfamethoxazole/Trimethoprim ORAL SUSP
*Sulfazine
Sulfasalazine
TABLET
2
*Demeclocycline Hcl
Demeclocycline Hcl
TABLET
2
*Doxy 100
Doxycycline Hyclate
INTRAVENOUS (IV)
2
*Doxycycline Hyclate
Doxycycline Hyclate
CAPSULE DR
2
*Doxycycline Hyclate
Doxycycline Hyclate
TABLET
2
*Doxycycline Hyclate
Doxycycline Hyclate
CAPSULE
2
*Doxycycline Monohydrate
Doxycycline Monohydrate
TABLET
2
*Doxycycline Monohydrate
Doxycycline Monohydrate
CAPSULE
2
*Doxy-Lemmon
Doxycycline Hyclate
TABLET
2
*Doxy-Lemmon
Doxycycline Hyclate
CAPSULE
2
*Ed Doxy-Caps
Doxycycline Hyclate
CAPSULE
2
*Minocycline Hcl
Minocycline Hcl
CAPSULE
2
*Minocycline Hcl
Minocycline Hcl
TABLET
2
*Tetracycline Hcl
Tetracycline Hcl
CAPSULE
2
2
ANTIBACTERIALS
TETRACYCLINES
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
54
2015 CARE1ST MEDICARE DRUG FORMULARY
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
ANTIBACTERIALS (continued)
TETRACYCLINES (continued)
TYGACIL
Tigecycline
INTRAVENOUS (IV)
3
BvD
ADCETRIS
Brentuximab Vedotin
INTRAVENOUS (IV)
5
BvD
+AFINITOR
Everolimus
TABLET
5
PA
AFINITOR DISPERZ
Everolimus
TAB SUSP
5
PA
ALIMTA
Pemetrexed Disodium
INTRAVENOUS (IV)
5
BvD
*+Anastrozole
Anastrozole
TABLET
2
ARZERRA
Ofatumumab
INTRAVENOUS (IV)
5
BvD
AVASTIN
Bevacizumab
INTRAVENOUS (IV)
5
BvD
AZACITIDINE
Azacitidine
INJECTION
5
PA
*+Bicalutamide
Bicalutamide
TABLET
2
*Bleomycin Sulfate
Bleomycin Sulfate
INJECTION
2
BvD
+BOSULIF
Bosutinib
TABLET
5
PA
CAPRELSA
Vandetanib
TABLET
5
PA
COMETRIQ
Cabozantinib S-Malate
CAPSULE
5
PA
*Cyclophosphamide
Cyclophosphamide
TABLET
2
BvD
ANTICANCER AGENTS
ANTICANCER AGENTS
ANTIBACTERIALS
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
55
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
ANTICANCER AGENTS (continued)
ANTICANCER AGENTS
ANTICANCER AGENTS (continued)
CYCLOPHOSPHAMIDE
Cyclophosphamide
CAPSULE
4
BvD
CYRAMZA
Ramucirumab
INTRAVENOUS (IV)
5
PA
DECITABINE
Decitabine
INTRAVENOUS (IV)
5
PA
DOCETAXEL
Docetaxel
INTRAVENOUS (IV)
5
PA
+DROXIA
Hydroxyurea
CAPSULE
3
ELIGARD
Leuprolide Acetate
INJECTION
3
PA
EMCYT
Estramustine Phosphate Sodium CAPSULE
3
PA
+ERIVEDGE
Vismodegib
5
PA
ERWINAZE
Asparaginase (Erwinia Chrysan) INJECTION
5
PA
*+Exemestane
Exemestane
TABLET
2
+FARESTON
Toremifene Citrate
TABLET
3
FASLODEX
Fulvestrant
INJECTION
4
BvD
FIRMAGON
Degarelix Acetate
INJECTION
5
PA
FIRMAGON
Degarelix Acetate
INJECTION
4
PA
*+Flutamide
Flutamide
CAPSULE
2
FOLOTYN
Pralatrexate
INTRAVENOUS (IV)
5
BvD
GAZYVA
Obinutuzumab
INTRAVENOUS (IV)
5
PA
GEMCITABINE HCL
Gemcitabine Hcl
INTRAVENOUS (IV)
5
PA
CAPSULE
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
56
2015 CARE1ST MEDICARE DRUG FORMULARY
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
ANTICANCER AGENTS (continued)
ANTICANCER AGENTS (continued)
Afatinib Dimaleate
TABLET
5
PA
+GLEEVEC
Imatinib Mesylate
TABLET
5
PA
HALAVEN
Eribulin Mesylate
INTRAVENOUS (IV)
5
PA
HEXALEN
Altretamine
CAPSULE
5
PA
*+Hydroxyurea
Hydroxyurea
CAPSULE
2
+ICLUSIG
Ponatinib Hcl
TABLET
5
PA
IMBRUVICA
Ibrutinib
CAPSULE
5
PA
INLYTA
Axitinib
TABLET
5
PA
ISTODAX
Romidepsin
INTRAVENOUS (IV)
5
BvD
+JAKAFI
Ruxolitinib Phosphate
TABLET
5
PA
JEVTANA
Cabazitaxel
INTRAVENOUS (IV)
5
BvD
KADCYLA
Ado-Trastuzumab Emtansine INTRAVENOUS (IV)
5
PA
KYPROLIS
Carfilzomib
INTRAVENOUS (IV)
5
PA
*+Letrozole
Letrozole
TABLET
2
LEUKERAN
Chlorambucil
TABLET
3
LEUPROLIDE ACETATE
Leuprolide Acetate
INJECTION
3
PA
LIPODOX
Doxorubicin Hcl Peg-Liposomal INTRAVENOUS (IV)
5
BvD
LOMUSTINE
Lomustine
3
PA
CAPSULE
ANTICANCER AGENTS
GILOTRIF
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
57
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
ANTICANCER AGENTS (continued)
ANTICANCER AGENTS
ANTICANCER AGENTS (continued)
LUPRON DEPOT
Leuprolide Acetate
INJECTION
5
PA
LUPRON DEPOT
Leuprolide Acetate
INJECTION
3
PA
LUPRON DEPOT-PED
Leuprolide Acetate
INJECTION
5
PA
LUPRON DEPOT-PED
Leuprolide Acetate
INJECTION
5
PA
LYSODREN
Mitotane
TABLET
3
MARQIBO
Vincristine Sulfate Liposomal
INTRAVENOUS (IV)
5
+MATULANE
Procarbazine Hcl
CAPSULE
5
*Megestrol Acetate
Megestrol Acetate
ORAL SUSP
2
PA>65 y/o
*Megestrol Acetate
Megestrol Acetate
TABLET
2
PA>65 y/o
+MEKINIST
Trametinib Dimethyl Sulfoxide TABLET
5
PA
MELPHALAN HCL
Melphalan Hcl
INTRAVENOUS (IV)
5
BvD
*Mercaptopurine
Mercaptopurine
TABLET
2
*+Methotrexate
Methotrexate Sodium
TABLET
2
*Mitoxantrone Hcl
Mitoxantrone Hcl
INTRAVENOUS (IV)
2
BvD
+NEXAVAR
Sorafenib Tosylate
TABLET
5
PA
+NILANDRON
Nilutamide
TABLET
3
PA
ONCASPAR
Pegaspargase
INJECTION
5
BvD
ONTAK
Denileukin Diftitox
INTRAVENOUS (IV)
3
PA
PA
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
58
2015 CARE1ST MEDICARE DRUG FORMULARY
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
ANTICANCER AGENTS (continued)
ANTICANCER AGENTS (continued)
Oxaliplatin
INTRAVENOUS (IV)
5
BvD
PERJETA
Pertuzumab
INTRAVENOUS (IV)
5
PA
+POMALYST
Pomalidomide
CAPSULE
5
PA
PROLEUKIN
Aldesleukin
INTRAVENOUS (IV)
5
BvD
~+REVLIMID
Lenalidomide
CAPSULE
5
PA
RITUXAN
Rituximab
INTRAVENOUS (IV)
5
BvD
+SOLTAMOX
Tamoxifen Citrate
ORAL SOLUTION
4
PA
+SPRYCEL
Dasatinib
TABLET
5
PA
+STIVARGA
Regorafenib
TABLET
5
PA
+SUTENT
Sunitinib Malate
CAPSULE
5
PA
SYLVANT
Siltuximab
INTRAVENOUS (IV)
5
BvD
SYNRIBO
Omacetaxine Mepesuccinate INJECTION
5
PA
TABLOID
Thioguanine
TABLET
3
PA
TAFINLAR
Dabrafenib Mesylate
CAPSULE
5
PA
*+Tamoxifen Citrate
Tamoxifen Citrate
TABLET
2
+TARCEVA
Erlotinib Hcl
TABLET
5
+TARGRETIN
Bexarotene
CAPSULE
5
+TARGRETIN
Bexarotene
TOPICAL GEL
5
ANTICANCER AGENTS
OXALIPLATIN
PA
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
59
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
ANTICANCER AGENTS (continued)
ANTICANCER AGENTS
ANTICANCER AGENTS (continued)
+TASIGNA
Nilotinib Hcl
CAPSULE
5
PA
TEMODAR
Temozolomide
INTRAVENOUS (IV)
5
BvD
TENIPOSIDE
Teniposide
INTRAVENOUS (IV)
5
PA
TOPOTECAN HCL
Topotecan Hcl
INTRAVENOUS (IV)
3
PA
TRELSTAR
Triptorelin Pamoate
INJECTION
5
PA
TRETINOIN
Tretinoin
CAPSULE
5
PA
TRISENOX
Arsenic Trioxide
INTRAVENOUS (IV)
3
PA
+TYKERB
Lapatinib Ditosylate
TABLET
5
PA
VELCADE
Bortezomib
INJECTION
5
PA
VOTRIENT
Pazopanib Hcl
TABLET
5
PA
+XALKORI
Crizotinib
CAPSULE
5
PA
+XTANDI
Enzalutamide
CAPSULE
5
PA
YERVOY
Ipilimumab
INTRAVENOUS (IV)
5
BvD
ZALTRAP
Ziv-Aflibercept
INTRAVENOUS (IV)
5
BvD
+ZELBORAF
Vemurafenib
TABLET
5
PA
ZOLADEX
Goserelin Acetate
INJECTION
5
PA
ZOLINZA
Vorinostat
CAPSULE
5
PA
ZYKADIA
Ceritinib
CAPSULE
5
PA
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
60
2015 CARE1ST MEDICARE DRUG FORMULARY
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
ANTICANCER AGENTS (continued)
ANTICANCER AGENTS (continued)
+ZYTIGA
Abiraterone Acetate
TABLET
5
PA +APTIOM
Eslicarbazepine Acetate
TABLET
5
PA
+APTIOM
Eslicarbazepine Acetate
TABLET
5
PA, QL
+APTIOM
Eslicarbazepine Acetate
TABLET
4
PA, QL
+BANZEL
Rufinamide
ORAL SUSP
4
PA
+BANZEL
Rufinamide
TABLET
5
PA
+BANZEL
Rufinamide
TABLET
4
PA
*+Carbamazepine
Carbamazepine
ORAL SUSP
2
*+Carbamazepine
Carbamazepine
CAPSULE
2
*+Carbamazepine
Carbamazepine
TAB CHEW
2
*+Carbamazepine
Carbamazepine
TABLET
2
*+Carbamazepine Er
Carbamazepine
TAB ER 12H
2
*+Carbamazepine Xr
Carbamazepine
TAB ER 12H
2
+CELONTIN
Methsuximide
CAPSULE
3
+DILANTIN
Phenytoin Sodium Extended
CAPSULE
3
ANTICONVULSANTS
ANTICONVULSANTS
ANTICANCER AGENTS
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
61
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
ANTICONVULSANTS (continued)
ANTICONVULSANTS
ANTICONVULSANTS (continued)
+DILANTIN
Phenytoin
TAB CHEW
3
+DILANTIN-125
Phenytoin
ORAL SUSP
3
*+Divalproex Sodium
Divalproex Sodium
CAP SPRINK
2
*+Divalproex Sodium
Divalproex Sodium
TABLET DR
2
*+Divalproex Sodium Er
Divalproex Sodium
TAB ER 24H
2
*+Epitol
Carbamazepine
TABLET
2
*+Ethosuximide
Ethosuximide
ORAL SOLUTION
2
*+Ethosuximide
Ethosuximide
CAPSULE
2
+FELBAMATE
Felbamate
ORAL SUSP
4
PA
+FELBAMATE
Felbamate
TABLET
4
PA
+FYCOMPA
Perampanel
TABLET
4
PA, QL
*+Gabapentin
Gabapentin
CAPSULE
2
*+Gabapentin
Gabapentin
ORAL SOLUTION
2
*+Gabapentin
Gabapentin
TABLET
2
+GABITRIL
Tiagabine Hcl
TABLET
4
*+Lamotrigine
Lamotrigine
TAB CHW DSP
2
*+Lamotrigine
Lamotrigine
TAB DS PK
2
*+Lamotrigine
Lamotrigine
TABLET
2
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
62
2015 CARE1ST MEDICARE DRUG FORMULARY
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
ANTICONVULSANTS (continued)
ANTICONVULSANTS (continued)
*Levetiracetam
Levetiracetam
TABLET
2
*Levetiracetam
Levetiracetam
INTRAVENOUS (IV)
2
*Levetiracetam
Levetiracetam
ORAL SOLUTION
2
*Levetiracetam Er
Levetiracetam
TAB ER 24H
2
QL
*Levetiracetam-Nacl
Levetiracetam In Nacl (Iso-Os) INTRAVENOUS (IV)
2
PA
+LYRICA
Pregabalin
CAPSULE
4
+LYRICA
Pregabalin
ORAL SOLUTION
4
*+Oxcarbazepine
Oxcarbazepine
ORAL SUSP
2
*+Oxcarbazepine
Oxcarbazepine
TABLET
2
+OXTELLAR XR
Oxcarbazepine
TAB ER 24H
4
+PEGANONE
Ethotoin
TABLET
3
*+Phenobarbital
Phenobarbital
ORAL SOLUTION
2
PA>65 y/o
*+Phenobarbital
Phenobarbital
TABLET
2
PA>65 y/o
+PHENYTEK
Phenytoin Sodium Extended
CAPSULE
3
*+Phenytoin
Phenytoin
ORAL SUSP
2
*+Phenytoin
Phenytoin
TAB CHEW
2
*Phenytoin Sodium
Phenytoin Sodium
INTRAVENOUS (IV)
2
PA
*Phenytoin Sodium
Phenytoin Sodium
INTRAVENOUS (IV)
2
PA
PA
ANTICONVULSANTS
PA
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
63
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
ANTICONVULSANTS (continued)
ANTICONVULSANTS
ANTICONVULSANTS (continued)
*+Phenytoin Sodium Extended
Phenytoin Sodium Extended
CAPSULE
2
+POTIGA
Ezogabine
TABLET
5
PA
+POTIGA
Ezogabine
TABLET
4
PA, QL
+POTIGA
Ezogabine
TABLET
4
PA
*+Primidone
Primidone
TABLET
2
QUDEXY XR
Topiramate
CAP SPR 24
4
PA
+SABRIL
Vigabatrin
TABLET
5
PA
+SABRIL
Vigabatrin
ORAL PACKETS
5
PA
+TEGRETOL XR
Carbamazepine
TAB ER 12H
3
+TIAGABINE HCL
Tiagabine Hcl
TABLET
4
*+Topiragen
Topiramate
TABLET
2
*+Topiramate
Topiramate
CAP SPRINK
2
*+Topiramate
Topiramate
TABLET
2
+TRILEPTAL
Oxcarbazepine
ORAL SUSP
3
+TROKENDI XR
Topiramate
CAP ER 24H
4
PA, QL
*+Valproate Sodium
Valproic Acid (As Sodium Salt) INTRAVENOUS (IV)
2
BvD
*+Valproic Acid
Valproic Acid
*+Valproic Acid
Valproic Acid (As Sodium Salt) ORAL SOLUTION
CAPSULE
2
2
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
64
2015 CARE1ST MEDICARE DRUG FORMULARY
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
ANTICONVULSANTS (continued)
ANTICONVULSANTS (continued)
VIMPAT
Lacosamide
INTRAVENOUS (IV)
4
PA, QL
+VIMPAT
Lacosamide
ORAL SOLUTION
4
PA
+VIMPAT
Lacosamide
TABLET
4
PA
*+Zonisamide
Zonisamide
CAPSULE
2
ANTICONVULSANTS
ANTIDEMENTIA AGENTS
ANTIDEMENTIA AGENTS
*+Donepezil Hcl
Donepezil Hcl
TABLET
2
+DONEPEZIL HCL
Donepezil Hcl
TABLET
3
*+Donepezil Hcl Odt
Donepezil Hcl
TAB RAPDIS
2
+EXELON
Rivastigmine
PATCH
4
+EXELON
Rivastigmine Tartrate
ORAL SOLUTION
3
+NAMENDA
Memantine Hcl
ORAL SOLUTION
3
+NAMENDA XR
Memantine Hcl
CAPSULES DOSEPACK 3
+NAMENDA XR
Memantine Hcl
CAP SPR 24
3
*+Rivastigmine
Rivastigmine Tartrate
CAPSULE
2
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
65
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
ANTIDEPRESSANTS
ANTIDEPRESSANTS
ANTIDEPRESSANTS
*+Amitriptyline Hcl
Amitriptyline Hcl
TABLET
2
PA>65 y/o
*+Amoxapine
Amoxapine
TABLET
2
+BRINTELLIX
Vortioxetine Hydrobromide
TABLET
4
*+Buproban
Bupropion Hcl
TABLET ER
2
*+Bupropion Hcl
Bupropion Hcl
TABLET
2
*+Bupropion Hcl Sr
Bupropion Hcl
TABLET ER
2
*+Bupropion Xl
Bupropion Hcl
TAB ER 24H
2
*+Bupropion Xl
Bupropion Hcl
TAB ER 24H
2
*+Chlordiazepoxide-Amitriptyline
Amitrip Hcl/Chlordiazepoxide
TABLET
2
*+Citalopram Hbr
Citalopram Hydrobromide
ORAL SOLUTION
2
*+Citalopram Hbr
Citalopram Hydrobromide
TABLET
2
*+Clomipramine Hcl
Clomipramine Hcl
CAPSULE
2
*+Desipramine Hcl
Desipramine Hcl
TABLET
2
+DESVENLAFAXINE ER
Desvenlafaxine
TAB ER 24
4
PA
+DESVENLAFAXINE ER
Desvenlafaxine
TAB ER 24H
4
PA
*+Doxepin Hcl
Doxepin Hcl
CAPSULE
2
PA>65 y/o
*+Doxepin Hcl
Doxepin Hcl
ORAL CONC
2
PA>65 y/o
+DULOXETINE HCL
Duloxetine Hcl
CAPSULE DR
4
PA
QL
PA>65 y/o
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
66
2015 CARE1ST MEDICARE DRUG FORMULARY
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
ANTIDEPRESSANTS (continued)
ANTIDEPRESSANTS (continued)
Selegiline
PATCH
4
*+Escitalopram Oxalate
Escitalopram Oxalate
TABLET
2
*+Escitalopram Oxalate
Escitalopram Oxalate
ORAL SOLUTION
2
+FETZIMA
Levomilnacipran Hydrochloride CAPSULES DOSEPACK 4
PA
+FETZIMA
Levomilnacipran Hydrochloride CAP SA 24H
PA
*+Fluoxetine Dr
Fluoxetine Hcl
CAPSULE DR
2
*+Fluoxetine Hcl
Fluoxetine Hcl
TABLET
2
*+Fluoxetine Hcl
Fluoxetine Hcl
CAPSULE
2
*+Fluoxetine Hcl
Fluoxetine Hcl
ORAL SOLUTION
2
*+Fluvoxamine Maleate
Fluvoxamine Maleate
TABLET
2
*+Imipramine Hcl
Imipramine Hcl
TABLET
2
PA>65 y/o
*+Imipramine Pamoate
Imipramine Pamoate
CAPSULE
2
PA>65 y/o
+KHEDEZLA
Desvenlafaxine
TAB ER 24
4
PA
*+Maprotiline Hcl
Maprotiline Hcl
TABLET
2
+MARPLAN
Isocarboxazid
TABLET
3
*+Mirtazapine
Mirtazapine
TAB RAPDIS
2
*+Mirtazapine
Mirtazapine
TABLET
2
*+Nefazodone Hcl
Nefazodone Hcl
TABLET
2
4
PA
ANTIDEPRESSANTS
+EMSAM
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
67
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
ANTIDEPRESSANTS (continued)
ANTIDEPRESSANTS
ANTIDEPRESSANTS (continued)
*+Nortriptyline Hcl
Nortriptyline Hcl
CAPSULE
2
*+Nortriptyline Hcl
Nortriptyline Hcl
ORAL SOLUTION
2
*+Paroxetine Hcl
Paroxetine Hcl
TABLET
2
+PAXIL
Paroxetine Hcl
ORAL SUSP
3
*+Perphenazine-Amitriptyline
Perphenazine/Amitriptyline Hcl TABLET
2
*+Phenelzine Sulfate
Phenelzine Sulfate
TABLET
2
+PRISTIQ ER
Desvenlafaxine Succinate
TAB ER 24H
4
*+Protriptyline Hcl
Protriptyline Hcl
TABLET
2
*+Sertraline Hcl
Sertraline Hcl
ORAL CONC
2
*+Sertraline Hcl
Sertraline Hcl
TABLET
2
+SURMONTIL
Trimipramine Maleate
CAPSULE
3
*+Tranylcypromine Sulfate
Tranylcypromine Sulfate
TABLET
2
*+Trazodone Hcl
Trazodone Hcl
TABLET
2
*+Venlafaxine Hcl
Venlafaxine Hcl
TABLET
2
+VENLAFAXINE HCL ER
Venlafaxine Hcl
TAB ER 24
4
*+Venlafaxine Hcl Er
Venlafaxine Hcl
CAP ER 24H
2
+VIIBRYD
Vilazodone Hydrochloride
TABLET
4
PA
+VIIBRYD
Vilazodone Hydrochloride
TAB DS PK
4
PA
PA>65 y/o
PA
PA
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
68
2015 CARE1ST MEDICARE DRUG FORMULARY
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
ANTIDIABETIC AGENTS
ANTIDIABETIC AGENTS, MISCELLANEOUS
Acarbose
TABLET
2
QL
+AVANDIA
Rosiglitazone Maleate
TABLET
3
PA
BYDUREON
Exenatide Microspheres
INJECTION
4
PA
BYDUREON PEN
Exenatide Microspheres
INJECTION
4
PA
BYETTA
Exenatide
INJECTION
4
PA
+CYCLOSET
Bromocriptine Mesylate
TABLET
4
PA
+GLYSET
Miglitol
TABLET
3
QL
+INVOKANA
Canagliflozin
TABLET
4
PA
+JANUMET
Sitagliptin Phos/Metformin Hcl TABLET
3
QL
+JANUMET XR
Sitagliptin Phos/Metformin Hcl TAB SR 24H
3
QL
+JANUVIA
Sitagliptin Phosphate
TABLET
3
QL
+JENTADUETO
Linagliptin/Metformin Hcl
TABLET
3
QL
*+Metformin Hcl
Metformin Hcl
TABLET
1
QL
*+Metformin Hcl ER
Metformin Hcl
TAB ER 24
1
QL
*+Metformin Hcl ER
Metformin Hcl
TAB ER 24H
1
QL
*+Nateglinide
Nateglinide
TABLET
2
*+Pioglitazone Hcl
Pioglitazone Hcl
TABLET
2
*+Repaglinide
Repaglinide
TABLET
2
ANTIDIABETIC AGENTS
*+Acarbose
QL
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
69
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
ANTIDIABETIC AGENTS (continued)
ANTIDIABETIC AGENTS
ANTIDIABETIC AGENTS, MISCELLANEOUS (continued)
+SYMLINPEN 120
Pramlintide Acetate
INJECTION
4
PA
+SYMLINPEN 60
Pramlintide Acetate
INJECTION
4
PA
+TRADJENTA
Linagliptin
TABLET
3
QL
VICTOZA 3-PAK
Liraglutide
INJECTION
4
PA
+HUMALOG
Insulin Lispro
INSULN PEN
3
+HUMALOG
Insulin Lispro
INJECTION
3
+HUMALOG MIX 50-50
Insulin Npl/Insulin Lispro
INJECTION
3
+HUMALOG MIX 50-50
Insulin Npl/Insulin Lispro
INSULN PEN
3
+HUMALOG MIX 75-25
Insulin Npl/Insulin Lispro
INSULN PEN
3
+HUMALOG MIX 75-25
Insulin Npl/Insulin Lispro
INJECTION
3
+HUMULIN 70/30 KWIKPEN
Hum Insulin Nph/Reg Insulin Hm INSULN PEN
3
+HUMULIN 70-30
Hum Insulin Nph/Reg Insulin Hm INJECTION
3
+HUMULIN N
Nph, Human Insulin Isophane INJECTION
3
+HUMULIN N KWIKPEN
Nph, Human Insulin Isophane INSULN PEN
3
+HUMULIN R
Insulin Regular, Human
INJECTION
3
+HUMULIN R
Insulin Regular, Human
INJECTION
5
INSULINS
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
70
2015 CARE1ST MEDICARE DRUG FORMULARY
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
ANTIDIABETIC AGENTS (continued)
INSULINS (continued)
Insulin Glargine,Hum.Rec.Anlog INJECTION
3
+LANTUS SOLOSTAR
Insulin Glargine,Hum.Rec.Anlog INSULN PEN
3
+NOVOLIN 70-30
Hum Insulin Nph/Reg Insulin Hm INJECTION
3
+NOVOLIN 70-30
Hum Insulin Nph/Reg Insulin Hm INJECTION
3
+NOVOLIN N
Nph, Human Insulin Isophane INJECTION
3
+NOVOLIN N
Nph, Human Insulin Isophane INJECTION
3
+NOVOLIN R
Insulin Regular, Human
INJECTION
3
+NOVOLIN R
Insulin Regular, Human
INJECTION
3
+NOVOLOG
Insulin Aspart
INJECTION
3
+NOVOLOG FLEXPEN
Insulin Aspart
INSULN PEN
3
+NOVOLOG MIX 70-30
Insuln Asp Prt/Insulin Aspart
INJECTION
3
+NOVOLOG MIX 70-30 FLEXPEN
Insuln Asp Prt/Insulin Aspart
INSULN PEN
3
*+Glimepiride
Glimepiride
TABLET
1
QL
*+Glipizide
Glipizide
TABLET
1
QL
*+Glipizide ER
Glipizide
TAB ER 24
1
QL
*+Glipizide-Metformin
Glipizide/Metformin Hcl
TABLET
1
QL
ANTIDIABETIC AGENTS
+LANTUS
SULFONYLUREAS
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
71
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
ANTIDIABETIC AGENTS (continued)
ANTIDIABETIC AGENTS
SULFONYLUREAS (continued)
*+Glyburide
o
Glyburide
TABLET
1
QL, PA>65 y/
*+Glyburide Micronized
o
Glyburide,Micronized
TABLET
1
QL, PA>65 y/
*+Glyburide-Metformin Hcl
o
Glyburide/Metformin Hcl
TABLET
1
QL, PA>65 y/
*+Tolazamide
Tolazamide
TABLET
2
QL
*+Tolbutamide
Tolbutamide
TABLET
2
QL
ANTIFUNGALS
ANTIFUNGALS
ABELCET
Amphotericin B Lipid Complex INTRAVENOUS (IV)
3
BvD
AMBISOME
Amphotericin B Liposome
INTRAVENOUS (IV)
3
BvD
*Amphotericin B
Amphotericin B
INJECTION
2
BvD
CANCIDAS
Caspofungin Acetate
INTRAVENOUS (IV)
5
*Ciclopirox
Ciclopirox
TOPICAL GEL
2
*Ciclopirox
Ciclopirox/Ure/Camph/Menth/Euc TOPICAL SOLUTION2
*Ciclopirox
Ciclopirox Olamine
CREAM
2
*Ciclopirox
Ciclopirox Olamine
ORAL SUSP
2
PA
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
72
2015 CARE1ST MEDICARE DRUG FORMULARY
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
ANTIFUNGALS (continued)
ANTIFUNGALS (continued)
Clotrimazole
CREAM
2
*Clotrimazole
Clotrimazole
ORAL TROCHE
2
*Clotrimazole
Clotrimazole
TOPICAL SOLUTION
2
*Clotrimazole-Betamethasone
Clotrimazole/Betamethasone Dip CREAM
2
*Clotrimazole-Betamethasone
Clotrimazole/Betamethasone Dip TOPICAL LOTION
2
*Econazole Nitrate
Econazole Nitrate
CREAM
2
ERAXIS (WATER DILUENT)
Anidulafungin
INTRAVENOUS (IV)
5
*Fluconazole
Fluconazole
ORAL SUSP
2
*Fluconazole
Fluconazole
TABLET
2
*Fluconazole In Saline
Fluconazole In Nacl,Iso-Osm
INTRAVENOUS (IV)
2
*Flucytosine
Flucytosine
CAPSULE
2
FULVICIN U/F
Griseofulvin, Microsize
TABLET
3
*+Griseofulvin
Griseofulvin, Microsize
TABLET
2
*+Griseofulvin
Griseofulvin, Microsize
ORAL SUSP
2
*+Griseofulvin Ultramicrosize
Griseofulvin Ultramicrosize
TABLET
2
*Itraconazole
Itraconazole
CAPSULE
2
*Ketoconazole
Ketoconazole
CREAM
2
*Ketoconazole
Ketoconazole
SHAMPOO
2
ANTIFUNGALS
*Clotrimazole
BvD
PA
PA
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
73
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
ANTIFUNGALS (continued)
ANTIFUNGALS
ANTIFUNGALS (continued)
*Ketoconazole
Ketoconazole
TABLET
2
*Miconazole 3
Miconazole Nitrate
VAGINAL SUPP
2
*Myconel
Nystatin/Triamcin
CREAM
2
*Nyamyc
Nystatin
TOPICAL POWDER
2
*Nystatin
Nystatin
TOPICAL POWDER
2
*Nystatin
Nystatin
TOPICAL POWDER
2
*Nystatin
Nystatin
ORAL SUSP
2
*Nystatin
Nystatin
TABLET
2
*Nystatin
Nystatin
CREAM
2
*Nystatin
Nystatin
TOPICAL OINT.
2
*Nystatin-Triamcinolone
Nystatin/Triamcin
CREAM
2
*Nystatin-Triamcinolone
Nystatin/Triamcin
TOPICAL OINT.
2
*Nystop
Nystatin
TOPICAL POWDER
2
*Pedi-Dri
Nystatin
TOPICAL POWDER
2
*Terbinafine Hcl
Terbinafine Hcl
TABLET
2
VORICONAZOLE
Voriconazole
INTRAVENOUS (IV)
4
BvD
VORICONAZOLE
Voriconazole
TABLET
5
PA
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
74
2015 CARE1ST MEDICARE DRUG FORMULARY
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
ANTIHISTAMINES
ANTIHISTAMINES
Clemastine Fumarate
ORAL SYRUP
2
PA>65 y/o
*Clemastine Fumarate
Clemastine Fumarate
TABLET
2
PA>65 y/o
*+Cyproheptadine Hcl
Cyproheptadine Hcl
TABLET
2
PA>65 y/o
*+Desloratadine
Desloratadine
TAB RAPDIS
2
ST
*+Desloratadine
Desloratadine
TABLET
2
ST
*Diphenhydramine Hcl
Diphenhydramine Hcl
INJECTION
2
BvD
*Promethazine Hcl
Promethazine Hcl
ORAL SYRUP
2
PA>65 y/o
ANTIHISTAMINES
*Clemastine Fumarate
ANTI-INFECTIVES (SKIN AND MUCOUS MEMBRANE)
ANTI-INFECTIVES (SKIN AND MUCOUS MEMBRANE)
*Clindamycin Phosphate
Clindamycin Phosphate
VAGINAL CREAM
2
*Metronidazole
Metronidazole
VAGINAL GEL
2
*Terconazole
Terconazole
VAGINAL CREAM
2
*Terconazole
Terconazole
VAGINAL SUPP
2
*Zazole
Terconazole
VAGINAL CREAM
2
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
75
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
ANTIMIGRAINE AGENTS
ANTIMIGRAINE AGENTS
ANTIMIGRAINE AGENTS
*Dihydroergotamine Mesylate
Dihydroergotamine Mesylate
INJECTION
2
BvD
ERGOMAR
Ergotamine Tartrate
TAB SUBL
3
*Ergotamine-Caffeine
Ergotamine Tartrate/Caffeine TABLET
2
*Migergot
Ergotamine Tartrate/Caffeine RECTAL SUPP
2
*Rizatriptan
Rizatriptan Benzoate
TABLET
2
QL
*Rizatriptan
Rizatriptan Benzoate
TAB RAPDIS
2
QL
*Sumatriptan
Sumatriptan
NASAL SPRAY
2
QL
*Sumatriptan Succinate
Sumatriptan Succinate
INJECTION
2
QL
*Sumatriptan Succinate
Sumatriptan Succinate
TABLET
2
QL
*Sumatriptan Succinate
Sumatriptan Succinate
INJECTION
2
QL
PA
ANTIMYCOBACTERIALS
ANTIMYCOBACTERIALS
CAPASTAT SULFATE
Capreomycin Sulfate
INJECTION
3
CYCLOSERINE
Cycloserine
CAPSULE
3
+DAPSONE
Dapsone
TABLET
3
*+Ethambutol Hcl
Ethambutol Hcl
TABLET
2
*+Isoniazid
Isoniazid
ORAL SOLUTION
2
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
76
2015 CARE1ST MEDICARE DRUG FORMULARY
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
ANTIMYCOBACTERIALS (continued)
ANTIMYCOBACTERIALS (continued)
Isoniazid
TABLET
2
+PASER
Aminosalicylic Acid
ORAL PACKETS
4
PRIFTIN
Rifapentine
TABLET
3
*+Pyrazinamide
Pyrazinamide
TABLET
2
*Rifabutin
Rifabutin
CAPSULE
2
RIFAMPIN
Rifampin
INTRAVENOUS (IV)
4
*Rifampin
Rifampin
CAPSULE
2
+RIFATER
Rifamp/Isoniazid/Pyrazinamide TABLET
3
+TRECATOR
Ethionamide
TABLET
3
*Anergan 50
Promethazine Hcl
INJECTION
2
*Compro
Prochlorperazine Maleate
RECTAL SUPP
2
DRONABINOL
Dronabinol
CAPSULE
4
PA
EMEND
Aprepitant
CAP DS PK
3
BvD
EMEND
Aprepitant
CAPSULE
3
BvD
EMEND
Fosaprepitant Dimeglumine
INTRAVENOUS (IV)
3
BvD
ANTIMYCOBACTERIALS
*+Isoniazid
BvD
ANTINAUSEA AGENTS
ANTINAUSEA AGENTS
BvD
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
77
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
ANTINAUSEA AGENTS (continued)
ANTINAUSEA AGENTS
ANTINAUSEA AGENTS (continued)
*Granisetron Hcl
Granisetron Hcl
INTRAVENOUS (IV)
2
BvD
*Granisetron Hcl
Granisetron Hcl
TABLET
2
BvD
GRANISETRON HCL
Granisetron Hcl/Pf
INTRAVENOUS (IV)
4
BvD
*Meclizine Hcl
Meclizine Hcl
TABLET
2
*Ondansetron Hcl
Ondansetron Hcl
ORAL SOLUTION
2
BvD
*Ondansetron Hcl
Ondansetron Hcl/Pf
INJECTION
2
BvD
*Ondansetron Hcl
Ondansetron Hcl
TABLET
2
BvD
*Ondansetron Odt
Ondansetron
TAB RAPDIS
2
BvD
*Phenadoz
Promethazine Hcl
RECTAL SUPP
2
PA>65 y/o
*Prochlorperazine Edisylate
Prochlorperazine Edisylate
INJECTION
2
BvD
*Prochlorperazine Maleate
Prochlorperazine Maleate
RECTAL SUPP
2
*Prochlorperazine Maleate
Prochlorperazine Maleate
TABLET
2
*Promethazine Hcl
Promethazine Hcl
INJECTION
2
BvD
*Promethazine Hcl
Promethazine Hcl
RECTAL SUPP
2
PA>65 y/o
*Promethazine Hcl
Promethazine Hcl
TABLET
2
PA>65 y/o
*Promethegan
Promethazine Hcl
RECTAL SUPP
2
PA>65 y/o
TRANSDERM-SCOP
Scopolamine
PATCH
3
PA
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
78
2015 CARE1ST MEDICARE DRUG FORMULARY
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
ANTIPARASITE AGENTS
ANTIPARASITE AGENTS
ALBENZA
Albendazole
TABLET
3
ALINIA
Nitazoxanide
TABLET
4
ATOVAQUONE
Atovaquone
ORAL SUSP
5
ATOVAQUONE-PROGUANIL HCL
Atovaquone/Proguanil Hcl
TABLET
3
BILTRICIDE
Praziquantel
TABLET
3
*+Chloroquine Phosphate
Chloroquine Phosphate
TABLET
2
DARAPRIM
Pyrimethamine
TABLET
3
*+Hydroxychloroquine Sulfate
Hydroxychloroquine Sulfate
TABLET
2
*+Mefloquine Hcl
Mefloquine Hcl
TABLET
2
*Metronidazole
Metronidazole
TABLET
2
*Metronidazole
Metronidazole/Sodium Chloride INTRAVENOUS (IV)
*Metryl
Metronidazole
TABLET
2
NEBUPENT
Pentamidine Isethionate
INHALATION SOLN
4
*Paromomycin Sulfate
Paromomycin Sulfate
CAPSULE
2
PENTAM 300
Pentamidine Isethionate
INJECTION
4
PA
PENTAMIDINE ISETHIONATE
Pentamidine Isethionate
INJECTION
4
PA
PRIMAQUINE
Primaquine Phosphate
TABLET
3
STROMECTOL
Ivermectin
TABLET
3
ANTIPARASITE AGENTS
2
PA
BvD
PA
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
79
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
ANTIPARASITE AGENTS (continued)
ANTIPARASITE AGENTS (continued)
*Yodoxin
Iodoquinol
TABLET
2
ANTIPARKINSONIAN AGENTS
ANTIPARASITE AGENTS
ANTIPARKINSONIAN AGENTS
*+Amantadine
Amantadine Hcl
CAPSULE
2
*+Amantadine
Amantadine Hcl
ORAL SYRUP
2
*+Amantadine
Amantadine Hcl
TABLET
2
APOKYN
Apomorphine Hcl
INJECTION
5
PA
+AZILECT
Rasagiline Mesylate
TABLET
4
PA, QL
+AZILECT
Rasagiline Mesylate
TABLET
4
PA
*+Benztropine Mesylate
Benztropine Mesylate
TABLET
2
PA>65 y/o
*+Bromocriptine Mesylate
Bromocriptine Mesylate
CAPSULE
2
*+Bromocriptine Mesylate
Bromocriptine Mesylate
TABLET
2
*+Cabergoline
Cabergoline
TABLET
2
*+Carbidopa-Levodopa
Carbidopa/Levodopa
TABLET
2
*+Carbidopa-Levodopa Er
Carbidopa/Levodopa
TABLET ER
2
*+Carbidopa-Levodopa-Entacapone Carbidopa/Levodopa/Entacapone TABLET
2
ST
+ENTACAPONE
3
ST
Entacapone
TABLET
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
80
2015 CARE1ST MEDICARE DRUG FORMULARY
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
ANTIPARKINSONIAN AGENTS (continued)
ANTIPARKINSONIAN AGENTS (continued)
Pramipexole Di-Hcl
TABLET
2
*+Ropinirole Hcl
Ropinirole Hcl
TABLET
2
*+Selegiline Hcl
Selegiline Hcl
CAPSULE
2
*+Selegiline Hcl
Selegiline Hcl
TABLET
2
+TASMAR
Tolcapone
TABLET
3
ST
*+Trihexyphenidyl Hcl
Trihexyphenidyl Hcl
ORAL SOLUTION
2
PA>65 y/o
*+Trihexyphenidyl Hcl
Trihexyphenidyl Hcl
TABLET
2
PA>65 y/o
ANTIPARKINSONIAN AGENTS
*+Pramipexole Dihydrochloride
ANTIPSYCHOTIC AGENTS
ANTIPSYCHOTIC AGENTS
ABILIFY
Aripiprazole
INJECTION
3
PA
+ABILIFY
Aripiprazole
ORAL SOLUTION
3
QL, ST
+ABILIFY 2MG, 10MG
Aripiprazole
TABLET
3
QL, ST
+ABILIFY 5MG, 15MG, 20MG, 30MG Aripiprazole
TABLET
5
QL, ST
+ABILIFY DISCMELT
Aripiprazole
TAB RAPDIS
5
QL, ST
ABILIFY MAINTENA
Aripiprazole
SUSER VIAL
5
PA
+ADASUVE
Loxapine
AEROSOL
4
BvD
*Chlorpromazine Hcl
Chlorpromazine Hcl
INJECTION
2
BvD
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
81
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
ANTIPSYCHOTIC AGENTS (continued)
ANTIPSYCHOTIC AGENTS
ANTIPSYCHOTIC AGENTS (continued)
*+Chlorpromazine Hcl
Chlorpromazine Hcl
ORAL CONC.
2
*+Chlorpromazine Hcl
Chlorpromazine Hcl
TABLET
2
*+Clozapine
Clozapine
TABLET
2
+CLOZAPINE ODT
Clozapine
TAB RAPDIS
3
+FANAPT
Iloperidone
TABLET
4
PA
+FANAPT
Iloperidone
TAB DS PK
4
PA
+FAZACLO
Clozapine
TAB RAPDIS
3
*Fluphenazine Decanoate
Fluphenazine Decanoate
INJECTION
2
*Fluphenazine Hcl
Fluphenazine Hcl
ORAL CONC
2
*Fluphenazine Hcl
Fluphenazine Hcl
ORAL SOLUTION
2
*Fluphenazine Hcl
Fluphenazine Hcl
INJECTION
2
*+Fluphenazine Hcl
Fluphenazine Hcl
TABLET
2
GEODON
Ziprasidone Mesylate
INJECTION
3
*+Haloperidol
Haloperidol
TABLET
2
*Haloperidol Decanoate
Haloperidol Decanoate
INJECTION
2
PA
*Haloperidol Lactate
Haloperidol Lactate
INJECTION
2
BvD
*+Haloperidol Lactate
Haloperidol Lactate
ORAL CONC
2
+INVEGA 1.5 MG, 3 MG
Paliperidone
TAB ER 24
4
BvD
BvD
PA
PA, QL
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
82
2015 CARE1ST MEDICARE DRUG FORMULARY
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
ANTIPSYCHOTIC AGENTS (continued)
ANTIPSYCHOTIC AGENTS (continued)
+INVEGA 6 MG, 9 MG
Paliperidone
TAB ER 24
5
PA, QL INVEGA SUSTENNA 117MG/0.75ML, 156 MG/ML, 234MG/1.5ML Paliperidone Palmitate INJECTION 5 PA
4
PA
+LATUDA
Lurasidone Hcl
TABLET
4
PA *+Loxapine
Loxapine Succinate
CAPSULE
2
*+Olanzapine
Olanzapine
TABLET
2
QL
*Olanzapine
Olanzapine
INJECTION
2
PA
+OLANZAPINE
Olanzapine
TABLET
3
QL *+Olanzapine Odt
Olanzapine
TAB RAPDIS
2
QL
+ORAP
Pimozide
TABLET
4
*+Perphenazine
Perphenazine
TABLET
2
*+Quetiapine Fumarate
Quetiapine Fumarate
TABLET
2
QL
RISPERDAL CONSTA
Risperidone Microspheres
INJECTION
3
PA
*+Risperidone
Risperidone
TAB RAPDIS
2
QL
*+Risperidone
Risperidone
TABLET
2
QL
*+Risperidone
Risperidone
ORAL SOLUTION
2
QL
*+Risperidone Odt
Risperidone
TAB RAPDIS
2
QL
+SAPHRIS
Asenapine Maleate
TAB SUBL
4
PA ANTIPSYCHOTIC AGENTS
INVEGA SUSTENNA 39MG/0.25, 78MG/0.5ML Paliperidone Palmitate INJECTION
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
83
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
ANTIPSYCHOTIC AGENTS (continued)
ANTIPSYCHOTIC AGENTS
ANTIPSYCHOTIC AGENTS (continued)
*+Thioridazine Hcl
Thioridazine Hcl
ORAL CONC.
2
PA>65 y/o
*+Thioridazine Hcl
Thioridazine Hcl
TABLET
2
PA>65 y/o
*+Thiothixene
Thiothixene
CAPSULE
2
*+Trifluoperazine Hcl
Trifluoperazine Hcl
TABLET
2
+VERSACLOZ
Clozapine
ORAL SUSP
4
PA
*+Ziprasidone Hcl
Ziprasidone Hcl
CAPSULE
2
QL
TABLET
2
ANTIVIRALS (SYSTEMIC)
ANTIRETROVIRALS
*+Abacavir
Abacavir Sulfate
+ABACAVIR-LAMIVUDINE-ZIDOVUDINE Abacavir/Lamivudine/Zidovudine TABLET
5
+APTIVUS
Tipranavir/Vitamin E Tpgs
ORAL SOLUTION
5
+APTIVUS
Tipranavir
CAPSULE
5
+ATRIPLA
Efavirenz/Emtricitab/Tenofovir TABLET
5
+COMPLERA
Emtricitab/Rilpivirine/Tenofov TABLET
5
+CRIXIVAN
Indinavir Sulfate
CAPSULE
3
*+Didanosine
Didanosine
CAPSULE DR
2
+EDURANT
Rilpivirine Hcl
TABLET
5
QL
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
84
2015 CARE1ST MEDICARE DRUG FORMULARY
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
ANTIVIRALS (SYSTEMIC) (continued)
ANTIRETROVIRALS (continued)
+EMTRIVA
Emtricitabine
ORAL SOLUTION
3
+EMTRIVA
Emtricitabine
CAPSULE
3
+EPIVIR
Lamivudine
ORAL SOLUTION
3
+EPIVIR HBV
Lamivudine
ORAL SOLUTION
3
+EPZICOM
Abacavir Sulfate/Lamivudine
TABLET
5
FUZEON
Enfuvirtide
INJECTION
5
+INTELENCE
Etravirine
TABLET
5
+INTELENCE
Etravirine
TABLET
3
+INVIRASE
Saquinavir Mesylate
TABLET
5
+INVIRASE
Saquinavir Mesylate
CAPSULE
3
QL
+ISENTRESS
Raltegravir Potassium
ORAL PACKETS
3
QL
+ISENTRESS
Raltegravir Potassium
TAB CHEW
3
QL
+ISENTRESS
Raltegravir Potassium
TABLET
5
+KALETRA
Lopinavir/Ritonavir
ORAL SOLUTION
5
+KALETRA
Lopinavir/Ritonavir
TABLET
3
+KALETRA
Lopinavir/Ritonavir
TABLET
5
*+Lamivudine
Lamivudine
TABLET
2
*+Lamivudine Hbv
Lamivudine
TABLET
2
PA
ANTIVIRALS (SYSTEMIC)
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
85
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
ANTIVIRALS (SYSTEMIC) (continued)
ANTIVIRALS (SYSTEMIC)
ANTIRETROVIRALS (continued)
+LAMIVUDINE-ZIDOVUDINE
Lamivudine/Zidovudine
TABLET
5
+LEXIVA
Fosamprenavir Calcium
TABLET
5
+LEXIVA
Fosamprenavir Calcium
ORAL SUSP
3
*+Nevirapine
Nevirapine
ORAL SUSP
2
*+Nevirapine
Nevirapine
TABLET
2
*+Nevirapine Er
Nevirapine
TAB ER 24H
2
+NORVIR
Ritonavir
TABLET
3
+NORVIR
Ritonavir
ORAL SOLUTION
3
+NORVIR
Ritonavir
CAPSULE
3
+PREZISTA
Darunavir Ethanolate
TABLET
3
+PREZISTA
Darunavir Ethanolate
TABLET
5
+PREZISTA
Darunavir Ethanolate
TABLET
3
+PREZISTA
Darunavir Ethanolate
ORAL SUSP
3
+RESCRIPTOR
Delavirdine Mesylate
TABLET
3
+RESCRIPTOR
Delavirdine Mesylate
TAB DISPER
3
RETROVIR
Zidovudine
INTRAVENOUS (IV)
3
+REYATAZ
Atazanavir Sulfate
CAPSULE
5
+SELZENTRY
Maraviroc
TABLET
5
QL
QL
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
86
2015 CARE1ST MEDICARE DRUG FORMULARY
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
ANTIVIRALS (SYSTEMIC) (continued)
ANTIRETROVIRALS (continued)
Stavudine
ORAL SOLUTION
2
*+Stavudine
Stavudine
CAPSULE
2
+STRIBILD
Elvitegr/Cobicist/Emtric/Tenof TABLET
5
+SUSTIVA
Efavirenz
TABLET
3
+SUSTIVA
Efavirenz
CAPSULE
3
+TIVICAY
Dolutegravir Sodium
TABLET
5
+TRUVADA
Emtricitabine/Tenofovir
TABLET
5
+VIDEX
Didanosine
ORAL SOLUTION
3
+VIRACEPT
Nelfinavir Mesylate
TABLET
5
+VIRAMUNE XR
Nevirapine
TAB ER 24H
3
+VIREAD
Tenofovir Disoproxil Fumarate ORAL POWDER
5
+VIREAD
Tenofovir Disoproxil Fumarate TABLET
5
+ZIAGEN
Abacavir Sulfate
ORAL SOLUTION
3
*+Zidovudine
Zidovudine
TABLET
2
*+Zidovudine
Zidovudine
CAPSULE
2
*+Zidovudine
Zidovudine
ORAL SYRUP
2
ANTIVIRALS (SYSTEMIC)
*+Stavudine
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
87
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
ANTIVIRALS (SYSTEMIC) (continued)
ANTIVIRALS (SYSTEMIC)
ANTIVIRALS, MISCELLANEOUS
RELENZA
Zanamivir
INHALATION DISK
4
QL
*Rimantadine Hcl
Rimantadine Hcl
TABLET
2
SYNAGIS
Palivizumab
INJECTION
5
PA
TAMIFLU
Oseltamivir Phosphate
CAPSULE
4
QL
TAMIFLU
Oseltamivir Phosphate
ORAL SUSP
4
QL
INCIVEK
Telaprevir
TABLET
5
PA
OLYSIO
Simeprevir Sodium
CAPSULE
5
PA
SOVALDI
Sofosbuvir
TABLET
5
PA
VICTRELIS
Boceprevir
CAPSULE
5
PA
INFERGEN
Interferon Alfacon-1
INJECTION
5
PA
INTRON A
Interferon Alfa-2B,Recomb.
INJECTION
3
PA
INTRON A
Interferon Alfa-2B,Recomb.
INJECTION
5
PA
INTRON A
Interferon Alfa-2B,Recomb.
INJECTION
3
PA
PEGASYS
Peginterferon Alfa-2A
INJECTION
5
PA
PEGASYS
Peginterferon Alfa-2A
INJECTION
5
PA
HCV ANTIVIRALS
INTERFERONS
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
88
2015 CARE1ST MEDICARE DRUG FORMULARY
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
ANTIVIRALS (SYSTEMIC) (continued)
INTERFERONS (continued)
PEGASYS PROCLICK
Peginterferon Alfa-2A
INJECTION
5
PA
PEGINTRON
Peginterferon Alfa-2B
INJECTION
5
PA
PEGINTRON REDIPEN
Peginterferon Alfa-2B
INJECTION
5
PA
SYLATRON 4-PACK
Peginterferon Alfa-2B
INJECTION
5
PA
ANTIVIRALS (SYSTEMIC)
NUCLEOSIDES AND NUCLEOTIDES
*+Acyclovir
Acyclovir
CAPSULE
2
*+Acyclovir
Acyclovir
ORAL SUSP
2
*+Acyclovir
Acyclovir
TABLET
2
*Acyclovir Sodium
Acyclovir Sodium
INTRAVENOUS (IV)
2
BvD
ADEFOVIR DIPIVOXIL
Adefovir Dipivoxil
TABLET
5
PA
+BARACLUDE
Entecavir
TABLET
5
PA
+BARACLUDE
Entecavir
ORAL SOLUTION
3
PA
GANCICLOVIR SODIUM
Ganciclovir Sodium
INTRAVENOUS (IV)
3
BvD
*Ribasphere
Ribavirin
CAPSULE
2
PA
*Ribasphere
Ribavirin
TABLET
2
PA
*Ribavirin
Ribavirin
CAPSULE
2
PA
*Ribavirin
Ribavirin
TABLET
2
PA
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
89
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
ANTIVIRALS (SYSTEMIC) (continued)
ANTIVIRALS (SYSTEMIC)
NUCLEOSIDES AND NUCLEOTIDES (continued)
+TYZEKA
Telbivudine
TABLET
5
PA
*+Valacyclovir
Valacyclovir Hcl
TABLET
2
+VALCYTE
Valganciclovir Hcl
TABLET
5
+VIRAZOLE
Ribavirin
INHALATION SOLN
5
BvD
BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS
ANTICOAGULANTS
+COUMADIN
Warfarin Sodium
TABLET
3
+ELIQUIS
Apixaban
TABLET
4
PA ENOXAPARIN SODIUM
Enoxaparin Sodium
INJECTION
3
PA
ENOXAPARIN SODIUM 30MG/0.3ML, 40MG/0.4ML, 60MG/0.6ML Enoxaparin Sodium INJECTION 3 PA
ENOXAPARIN SODIUM 80MG/0.8ML, 100 MG/ML, 120MG/.8ML, 150 MG/ML Enoxaparin Sodium INJECTION 5 PA
FONDAPARINUX SODIUM
Fondaparinux Sodium
INJECTION
3
PA
FRAGMIN
Dalteparin Sodium,Porcine
INJECTION
4
PA
FRAGMIN
Dalteparin Sodium,Porcine
INJECTION
4
PA
*Heparin Flush
Heparin Sodium,Porcine/Pf
INTRAVENOUS (IV)
2
BvD *Heparin Sodium
Heparin Sodium,Porcine
INJECTION
2
BvD *Heparin Sodium
Heparin Sodium,Porcine/Pf
SYRINGES
2
BvD
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
90
2015 CARE1ST MEDICARE DRUG FORMULARY
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS (continued)
ANTICOAGULANTS (continued)
*Heparin Sodium-D5W
Heparin Sodium,Porcine/D5W INTRAVENOUS (IV)
2
BvD
*Heparin Sodium-Ns
Heparin Sodium,Porcine/Ns/Pf INTRAVENOUS (IV)
2
BvD
*+Jantoven
Warfarin Sodium
+PRADAXA
Dabigatran Etexilate Mesylate CAPSULE
*+Warfarin Sodium
Warfarin Sodium
TABLET
1
+XARELTO
Rivaroxaban
TABLET
4
PA
ARANESP 150MCG/0.3, 200MCG/0.4 Darbepoetin Alfa In Polysorbat SYRINGES
5
PA
ARANESP 200 MCG/ML, 300 MCG/ML Darbepoetin Alfa In Polysorbat INJECTION
5
PA
ARANESP 25 MCG/ML, 40 MCG/ML Darbepoetin Alfa In Polysorbat INJECTION
3
PA
ARANESP 25MCG/0.42, 40 MCG/0.4 Darbepoetin Alfa In Polysorbat SYRINGES
3
PA
ARANESP 300MCG/0.6, 500 MCG/ML Darbepoetin Alfa In Polysorbat SYRINGES
5
PA
ARANESP 60MCG/0.3, 100MCG/0.5 Darbepoetin Alfa In Polysorbat SYRINGES
3
PA
ARANESP 60MCG/ML, 100 MCG/ML Darbepoetin Alfa In Polysorbat INJECTION
3
PA
EPOGEN
INJECTION
5
PA
EPOGEN 2000/ML, 3000/ML, 4000/ML, 10000/ML Epoetin Alfa
INJECTION
3
PA
GRANIX
INJECTION
5
PA
1
4
BLOOD PRODUCTS/MODIFIERS/VOLUME
TABLET
PA
BLOOD FORMATION MODIFIERS
Epoetin Alfa
Tbo-Filgrastim
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
91
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS (continued)
BLOOD PRODUCTS/MODIFIERS/VOLUME
BLOOD FORMATION MODIFIERS (continued)
LEUKINE
Sargramostim
INJECTION
5
PA
MOZOBIL
Plerixafor
INJECTION
5
PA
NEULASTA
Pegfilgrastim
INJECTION
5
PA
NEUMEGA
Oprelvekin
INJECTION
5
PA
NEUPOGEN
Filgrastim
INJECTION
5
PA
NEUPOGEN
Filgrastim
SYRINGES
5
PA
PROCRIT 2000/ML, 3000/ML, 4000/ML Epoetin Alfa
INJECTION
3
PA
PROCRIT 20000/2ML, 20000/ML, 40000/ML Epoetin Alfa
INJECTION
5
PA
+PROMACTA
TABLET
5
PA
Eltrombopag Olamine
HEMATOLOGIC AGENTS, MISCELLANEOUS
*Aminocaproic Acid
Aminocaproic Acid
TABLET
2
PA
*Aminocaproic Acid
Aminocaproic Acid
INTRAVENOUS (IV)
2
BvD
*Aminocaproic Acid
Aminocaproic Acid
ORAL SOLUTION
2
PA
*+Anagrelide Hcl
Anagrelide Hcl
CAPSULE
2
TRANEXAMIC ACID
Tranexamic Acid
INTRAVENOUS (IV)
3
PA
TRANEXAMIC ACID
Tranexamic Acid
TABLET
4
PA
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
92
2015 CARE1ST MEDICARE DRUG FORMULARY
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
BLOOD PRODUCTS/MODIFIERS/VOLUME EXPANDERS (continued)
PLATELET-AGGREGATION INHIBITORS
Aspirin/Dipyridamole
CAPSULE
4
+BRILINTA
Ticagrelor
TABLET
4
*+Cilostazol
Cilostazol
TABLET
2
*+Clopidogrel
Clopidogrel Bisulfate
TABLET
1
*+Dipyridamole
Dipyridamole
TABLET
2
*+Pentoxifylline
Pentoxifylline
TABLET ER
2
*+Ticlopidine Hcl
Ticlopidine Hcl
TABLET
2
BLOOD PRODUCTS/MODIFIERS/VOLUME
+AGGRENOX
PA>65 y/o
PA>65 y/o
CALORIC AGENTS
CALORIC AGENTS
AMINOSYN
Parenteral Amino Acid 3.5% No1 INTRAVENOUS (IV) 3
BvD
*Aminosyn Ii
Parenteral Amino Acid 15% No.2 INTRAVENOUS (IV) 2
BvD
AMINOSYN II
Amino Acids 7 %
INTRAVENOUS (IV)
3
BvD
AMINOSYN-HBC
Amino Acids 7 %
INTRAVENOUS (IV)
3
BvD
AMINOSYN-PF
Parent. Amino Acid 7 % #1(Ped) INTRAVENOUS (IV) 3
BvD
*Dextrose In Lactated Ringers
Dextrose 5%-Lactated Ringers INTRAVENOUS (IV)
2
BvD
*Dextrose In Ringers Injection
Dextrose 5% In Ringers
INTRAVENOUS (IV)
2
*Dextrose In Water
Dextrose 5 % In Water
INTRAVENOUS (IV)
2
BvD
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
93
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
CALORIC AGENTS (continued)
CALORIC AGENTS
CALORIC AGENTS (continued)
*Dextrose In Water
Dextrose 50 % In Water
INTRAVENOUS (IV)
2
BvD
*Dextrose In Water
Dextrose 50 % In Water
INTRAVENOUS (IV)
2
BvD
*Dextrose In Water
Dextrose 10 % In Water
INTRAVENOUS (IV)
2
BvD
*Dextrose In Water 40%
Dextrose 40%-Water
INTRAVENOUS (IV)
2
BvD
*Dextrose In Water 70%
Dextrose 70%-Water
INTRAVENOUS (IV)
2
*Dextrose With Sodium Chloride
Dextrose 2.5%-0.5Normal Saline INTRAVENOUS (IV) 2
BvD
*Dextrose With Sodium Chloride
Dextrose 5 % And 0.3 % Nacl INTRAVENOUS (IV)
2
BvD
FREAMINE HBC
Amino Acids 6.9%
INTRAVENOUS (IV)
3
BvD
FRUCTOSE
Fructose 10%
INTRAVENOUS (IV)
3
BvD
*Glucose
Dextrose
TAB CHEW
2
*Hepatasol
Amino Acids 8%
INTRAVENOUS (IV)
2
BvD
INTRALIPID
Fat Emulsions
INTRAVENOUS (IV)
3
BvD
NEPHRAMINE
Amino Acids 5.4%
INTRAVENOUS (IV)
3
BvD
*Potassium Chloride In D5Lr
Potassium Chloride In Lr-D5
INTRAVENOUS (IV)
2
BvD
*Premasol
Parenteral Amino Acid 6% No.1 INTRAVENOUS (IV)
2
BvD
TRAVAMULSION
Fat Emulsions
INTRAVENOUS (IV)
3
BvD
*Travasol
Amino Acids 8.5 %
INTRAVENOUS (IV)
2
BvD
*Trophamine
Amino Acids 10 %
INTRAVENOUS (IV)
2
BvD
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
94
2015 CARE1ST MEDICARE DRUG FORMULARY
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
CARDIOVASCULAR AGENTS
ALPHA-ADRENERGIC AGENTS
Clonidine Hcl
TABLET
1
*+Doxazosin Mesylate
Doxazosin Mesylate
TABLET
1
*+Guanfacine Hcl
Guanfacine Hcl
TABLET
2
PA>65 y/o
*+Methyldopa
Methyldopa
TABLET
2
PA>65 y/o
*+Methyldopa/Hydrochlorothiazide
Methyldopa/Hydrochlorothiazide TABLET
2
PA>65 y/o
*+Methyldopa-Hydrochlorothiazide
Methyldopa/Hydrochlorothiazide TABLET
2
PA>65 y/o
*+Midodrine Hcl
Midodrine Hcl
TABLET
2
*+Prazosin Hcl
Prazosin Hcl
CAPSULE
2
CARDIOVASCULAR AGENTS
*+Clonidine Hcl
ANGIOTENSIN II RECEPTOR ANTAGONISTS
+DIOVAN
Valsartan
TABLET
3
*+Losartan Potassium
Losartan Potassium
TABLET
1
*+Losartan-Hydrochlorothiazide
Losartan/Hydrochlorothiazide TABLET
1
*+Valsartan-Hydrochlorothiazide
Valsartan/Hydrochlorothiazide TABLET
2
ANGIOTENSIN-CONVERTING ENZYME INHIBITORS
*+Benazepril Hcl
Benazepril Hcl
TABLET
1
*+Benazepril-Hydrochlorothiazide
Benazepril/Hydrochlorothiazide TABLET
1
*+Captopril
Captopril
TABLET
1
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
95
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
CARDIOVASCULAR AGENTS (continued)
CARDIOVASCULAR AGENTS
ANGIOTENSIN-CONVERTING ENZYME INHIBITORS (continued)
*+Captopril-Hydrochlorothiazide
Captopril/Hydrochlorothiazide TABLET
1
*+Enalapril Maleate
Enalapril Maleate
TABLET
1
*+Enalapril-Hydrochlorothiazide
Enalapril/Hydrochlorothiazide TABLET
1
*+Fosinopril Sodium
Fosinopril Sodium
TABLET
2
*+Fosinopril-Hydrochlorothiazide
Fosinopril/Hydrochlorothiazide TABLET
2
*+Lisinopril
Lisinopril
TABLET
1
*+Lisinopril-Hydrochlorothiazide
Lisinopril/Hydrochlorothiazide TABLET
1
*+Moexipril Hcl
Moexipril Hcl
TABLET
2
*+Quinapril Hcl
Quinapril Hcl
TABLET
2
*+Quinapril-Hydrochlorothiazide
Quinapril/Hydrochlorothiazide TABLET
2
*+Ramipril
Ramipril
CAPSULE
2
*+Trandolapril
Trandolapril
TABLET
2
*+Amiodarone Hcl
Amiodarone Hcl
TABLET
2
*+Disopyramide Phosphate
Disopyramide Phosphate
CAPSULE
2
*+Flecainide Acetate
Flecainide Acetate
TABLET
2
*Lidocaine Hcl In 5% Dextrose
Lidocaine Hcl/D5W/Pf
INTRAVENOUS (IV)
2
ANTIARRHYTHMIC AGENTS
PA>65 y/o
BvD
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
96
2015 CARE1ST MEDICARE DRUG FORMULARY
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
CARDIOVASCULAR AGENTS (continued)
ANTIARRHYTHMIC AGENTS (continued)
Mexiletine Hcl
CAPSULE
2
+MULTAQ
Dronedarone Hcl
TABLET
4
*+Pacerone
Amiodarone Hcl
TABLET
2
*+Procainamide Hcl
Procainamide Hcl
CAPSULE
2
*+Procainamide Hcl
Procainamide Hcl
TABLET SA
2
+PRONESTYL
Procainamide Hcl
CAPSULE
3
*+Propafenone Hcl
Propafenone Hcl
TABLET
2
*+Quinidine Gluconate
Quinidine Gluconate
TABLET ER
2
*+Quinidine Sulfate
Quinidine Sulfate
TABLET
2
*+Quinidine Sulfate
Quinidine Sulfate
TABLET ER
2
+TIKOSYN
Dofetilide
CAPSULE
4
PA
CARDIOVASCULAR AGENTS
*+Mexiletine Hcl
PA
BETA-ADRENERGIC BLOCKING AGENTS
*+Acebutolol Hcl
Acebutolol Hcl
CAPSULE
2
*+Atenolol
Atenolol
TABLET
1
*+Atenolol-Chlorthalidone
Atenolol/Chlorthalidone
TABLET
1
*+Betaxolol Hcl
Betaxolol Hcl
TABLET
2
*+Bisoprolol Fumarate
Bisoprolol Fumarate
TABLET
2
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
97
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
CARDIOVASCULAR AGENTS (continued)
CARDIOVASCULAR AGENTS
BETA-ADRENERGIC BLOCKING AGENTS (continued)
*+Bisoprolol-Hydrochlorothiazide
Bisoprolol Fumarate/Hctz
TABLET
2
BREVIBLOC
Esmolol In Sodium Chloride,Iso INTRAVENOUS (IV)
*+Carvedilol
Carvedilol
TABLET
1
*Esmolol Hcl
Esmolol Hcl
INTRAVENOUS (IV)
2
*+Labetalol Hcl
Labetalol Hcl
TABLET
2
*+Metoprolol Succinate
Metoprolol Succinate
TAB ER 24H
2
*+Metoprolol Tartrate
Metoprolol Tartrate
TABLET
1
*+Metoprolol-Hydrochlorothiazide
Metoprolol/Hydrochlorothiazide TABLET
1
*+Nadolol
Nadolol
TABLET
1
*+Pindolol
Pindolol
TABLET
1
*+Propranolol Hcl
Propranolol Hcl
CAP SA 24H
2
*+Propranolol Hcl
Propranolol Hcl
TABLET
2
*+Propranolol-Hydrochlorothiazid
Propranolol/Hydrochlorothiazid TABLET
2
*+Sorine
Sotalol Hcl
TABLET
2
*+Sotalol
Sotalol Hcl
TABLET
2
*+Sotalol Af
Sotalol Hcl
TABLET
2
*+Timolol Maleate
Timolol Maleate
TABLET
2
3
BvD
BvD
QL
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
98
2015 CARE1ST MEDICARE DRUG FORMULARY
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
CARDIOVASCULAR AGENTS (continued)
CALCIUM-CHANNEL BLOCKING AGENTS
Diltiazem Hcl
CAP ER 24H
2
*+Diltiazem 24Hr Er
Diltiazem Hcl
CAP ER 24H
2
*+Diltiazem Er
Diltiazem Hcl
CAP ER DEG
2
*+Diltiazem Er
Diltiazem Hcl
CAPSULE ER
2
*+Diltiazem Er
Diltiazem Hcl
CAP ER 12H
2
*+Diltiazem Hcl
Diltiazem Hcl
TABLET
2
*+Dilt-Xr
Diltiazem Hcl
CAP ER DEG
2
*+Taztia Xt
Diltiazem Hcl
CAPSULE ER
2
*+Verapamil Er
Verapamil Hcl
CAP24H PEL
2
*+Verapamil Er
Verapamil Hcl
TABLET ER
2
*+Verapamil Er Pm
Verapamil Hcl
CAP24H PCT
2
*+Verapamil Hcl
Verapamil Hcl
TABLET
2
*+Verapamil Hcl
Verapamil Hcl
CAP24H PEL
2
CARDIOVASCULAR AGENTS
*+Cartia Xt
CARDIOVASCULAR AGENTS, MISCELLANEOUS
+DEMSER
Metyrosine
CAPSULE
5
PA
DIGIFAB
Digoxin Immune Fab
INTRAVENOUS (IV)
5
BvD
*+Digox
Digoxin
TABLET
1
PA>65 y/o
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
99
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
CARDIOVASCULAR AGENTS (continued)
CARDIOVASCULAR AGENTS
CARDIOVASCULAR AGENTS, MISCELLANEOUS (continued)
*+Digox
Digoxin
TABLET
1
QL
+DIGOXIN
Digoxin
ORAL SOLUTION
3
*+Digoxin
Digoxin
SYRINGES
2
*Epinephrine
Epinephrine
PEN INJCTR
2
*Epinephrine
Epinephrine
SYRINGES
2
+EPIPEN 2-PAK
Epinephrine
PEN INJCTR
3
FIRAZYR
Icatibant Acetate
INJECTION
5
*+Hctz/Reserpine/Hydralazine
Hydralazine/Reserpin/Hctz
TABLET
2
*+Hydralazine Hcl
Hydralazine Hcl
TABLET
2
*+Hydralazine W/Hctz
Hydralazine/Hydrochlorothiazid CAPSULE
2
*+Hydrochlorothiazide/Reserpine
Reserpine/Hydrochlorothiazide TABLET
2
+LANOXIN
Digoxin
TABLET
3
LANOXIN PEDIATRIC
Digoxin
INJECTION
3
BvD
*Milrinone In 5% Dextrose
Milrinone Lactate/D5W
INTRAVENOUS (IV)
2
BvD
+RANEXA
Ranolazine
TAB ER 12H
3
*+Reserpine
Reserpine
TABLET
2
BvD
PA
PA>65 y/o
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
100
2015 CARE1ST MEDICARE DRUG FORMULARY
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
CARDIOVASCULAR AGENTS (continued)
DIHYDROPYRIDINES
*+Afeditab Cr
Nifedipine
TABLET ER
2
*+Amlodipine Besylate
Amlodipine Besylate
TABLET
1
*+Amlodipine Besylate-Benazepril 2.5Mg-10Mg, 5 Mg-10 Mg Amlodipine Besylate/Benazepril CAPSULE 1 QL
*+Amlodipine Besylate-Benazepril 5 Mg-20 Mg, 10 Mg-20Mg Amlodipine Besylate/Benazepril CAPSULE 1 QL
CARDIOVASCULAR AGENTS
*+Amlodipine Besylate-Benazepril 5 Mg-40 Mg, 10 Mg-40Mg Amlodipine Besylate/Benazepril CAPSULE 2 QL
*+Felodipine Er
Felodipine
TAB ER 24H
2
*+Isradipine
Isradipine
CAPSULE
2
*+Nicardipine Hcl
Nicardipine Hcl
CAPSULE
2
*+Nifedical Xl
Nifedipine
TAB ER 24
2
*+Nifedipine Er
Nifedipine
TAB ER 24
2
*+Nifedipine Er
Nifedipine
TABLET ER
2
*+Amiloride Hcl
Amiloride Hcl
TABLET
2
*+Amiloride-Hydrochlorothiazide
Amiloride/Hydrochlorothiazide TABLET
2
*Bumetanide
Bumetanide
INJECTION
2
*+Bumetanide
Bumetanide
TABLET
2
*+Chlorothiazide
Chlorothiazide
TABLET
2
DIURETICS
BvD
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
101
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
CARDIOVASCULAR AGENTS (continued)
CARDIOVASCULAR AGENTS
DIURETICS (continued)
*+Chlorthalidone
Chlorthalidone
TABLET
2
*Furosemide
Furosemide
INJECTION
2
*+Furosemide
Furosemide
ORAL SOLUTION
1
*+Furosemide
Furosemide
SYRINGES
2
*+Furosemide
Furosemide
TABLET
1
*+Hydrochlorothiazide
Hydrochlorothiazide
CAPSULE
1
*+Hydrochlorothiazide
Hydrochlorothiazide
TABLET
1
*+Indapamide
Indapamide
TABLET
2
*+Methyclothiazide
Methyclothiazide
TABLET
2
*+Metolazone
Metolazone
TABLET
2
*+Torsemide
Torsemide
TABLET
2
*+Triamterene-Hctz
Triamterene/Hydrochlorothiazid TABLET
1
*+Triamterene-Hctz
Triamterene/Hydrochlorothiazid CAPSULE
1
*+Triamterene-Hydrochlorothiazid
Triamterene/Hydrochlorothiazid TABLET
1
BvD
BvD
DYSLIPIDEMICS
*+Atorvastatin Calcium
Atorvastatin Calcium
TABLET
1
*+Cholestyramine
Cholestyramine (With Sugar)
ORAL PACKETS
2
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
102
2015 CARE1ST MEDICARE DRUG FORMULARY
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
CARDIOVASCULAR AGENTS (continued)
DYSLIPIDEMICS (continued)
Colestipol Hcl
ORAL PACKETS
2
*+Colestipol Hcl
Colestipol Hcl
TABLET
2
*+Fenofibrate
Fenofibrate,Micronized
CAPSULE
2
*+Fenofibrate
Fenofibrate Nanocrystallized
TABLET
2
*+Gemfibrozil
Gemfibrozil
TABLET
2
*+Lovastatin
Lovastatin
TABLET
1
+NIACIN ER
Niacin
TAB ER 24H
4
+OMEGA-3 ACID ETHYL ESTERS
Omega-3 Acid Ethyl Esters
CAPSULE
4
*+Pravastatin Sodium
Pravastatin Sodium
TABLET
2
*+Prevalite
Cholestyramine/Aspartame
ORAL POWDER
2
*+Simvastatin
Simvastatin
TABLET
1
+VASCEPA
Icosapent Ethyl
CAPSULE
4
PA
+WELCHOL
Colesevelam Hcl
TABLET
4
PA
+WELCHOL
Colesevelam Hcl
ORAL PACKETS
4
PA
+ZETIA
Ezetimibe
TABLET
3
PA
4
PA CARDIOVASCULAR AGENTS
*+Colestipol Hcl
PA
RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS
+EPLERENONE
Eplerenone
TABLET
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
103
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
CARDIOVASCULAR AGENTS (continued)
CARDIOVASCULAR AGENTS
RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS (continued)
*+Spironolactone
Spironolactone
TABLET
2
*+Spironolactone-Hctz
Spironolact/Hydrochlorothiazid TABLET
2
+TEKTURNA
Aliskiren Hemifumarate
TABLET
3
PA
+TEKTURNA HCT
Aliskiren/Hydrochlorothiazide TABLET
3
PA
VASODILATORS
*+Isoditrate
Isosorbide Dinitrate
TABLET ER
1
*+Isosorbide Dinitrate
Isosorbide Dinitrate
TAB SUBL
1
*+Isosorbide Dinitrate
Isosorbide Dinitrate
TABLET
1
*+Isosorbide Mononitrate
Isosorbide Mononitrate
TABLET
2
*+Isosorbide Mononitrate Er
Isosorbide Mononitrate
TAB ER 24H
2
*+Minitran
Nitroglycerin
PATCH
2
*+Minoxidil
Minoxidil
TABLET
2
*+Nitroglycerin Patch
Nitroglycerin
PATCH
2
+NITROSTAT
Nitroglycerin
TAB SUBL
3
+PROGLYCEM
Diazoxide
ORAL SUSP
3
PA
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
104
2015 CARE1ST MEDICARE DRUG FORMULARY
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
CENTRAL NERVOUS SYSTEM AGENTS
CENTRAL NERVOUS SYSTEM AGENTS
Dextroamphetamine/Amphetamine TABLET
2
+AMPYRA
Dalfampridine
TAB ER 12H
5
PA
+CLONIDINE HCL ER
Clonidine Hcl
TAB ER 12H
3
PA
*+Dexmethylphenidate Hcl
Dexmethylphenidate Hcl
TABLET
2
ST
+DEXMETHYLPHENIDATE HCL ER Dexmethylphenidate Hcl
CAPSULE
4
ST
*+Dextroamphetamine Sulfate
Dextroamphetamine Sulfate
TABLET
2
*+Dextroamphetamine Sulfate Er
Dextroamphetamine Sulfate
CAPSULE ER
2
*+Dextroamphetamine-Amphetamine Dextroamphetamine/Amphetamine CAP ER 24H
2
+FOCALIN XR
Dexmethylphenidate Hcl
CAPSULE
4
ST
+INTUNIV
Guanfacine Hcl
TAB ER 24H
3
PA
*+Lithium
Lithium Citrate
ORAL SOLUTION
2
*+Lithium Carbonate
Lithium Carbonate
CAPSULE
2
*+Lithium Carbonate
Lithium Carbonate
TABLET
2
*+Lithium Carbonate
Lithium Carbonate
TABLET ER
2
*+Methylphenidate Er
Methylphenidate Hcl
TABLET ER
2
+METHYLPHENIDATE ER
Methylphenidate Hcl
TAB ER 24
3
*+Methylphenidate Hcl
Methylphenidate Hcl
TABLET
2
*+Methylphenidate Sr
Methylphenidate Hcl
TABLET ER
2
CENTRAL NERVOUS SYSTEM AGENTS
*+Amphetamine Salt Combo
ST
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
105
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
CENTRAL NERVOUS SYSTEM AGENTS (continued)
CENTRAL NERVOUS SYSTEM AGENTS
CENTRAL NERVOUS SYSTEM AGENTS (continued)
+NUEDEXTA
Dextromethorphan Hbr/Quinidine CAPSULE
3
PA
*+Riluzole
Riluzole
TABLET
2
PA
+SAVELLA
Milnacipran Hcl
TAB DS PK
3
PA
+SAVELLA
Milnacipran Hcl
TABLET
3
PA
+STRATTERA
Atomoxetine Hcl
CAPSULE
3
PA
+XENAZINE
Tetrabenazine
TABLET
5
*+Altavera
Levonorgestrel-Ethin Estradiol TABLET
2
*+Alyacen
Norethindrone-Ethinyl Estrad
TABLET
2
*+Apri
Desogestrel-Ethinyl Estradiol
TABLET
2
*+Aranelle
Norethindrone-Ethinyl Estrad
TABLET
2
*+Aubra
Levonorgestrel-Ethin Estradiol TABLET
2
*+Aviane
Levonorgestrel-Ethin Estradiol TABLET
2
*+Azurette
Desog-E.Estradiol/E.Estradiol TABLET
2
*+Balziva
Norethindrone-Ethinyl Estrad
TABLET
2
*+Briellyn
Norethindrone-Ethinyl Estrad
TABLET
2
CONTRACEPTIVES
CONTRACEPTIVES
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
106
2015 CARE1ST MEDICARE DRUG FORMULARY
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
CONTRACEPTIVES (continued)
CONTRACEPTIVES (continued)
Norethindrone
TABLET
2
*+Caziant
Desogestrel-Ethinyl Estradiol
TABLET
2
*+Cryselle
Norgestrel-Ethinyl Estradiol
TABLET
2
*+Cyclafem
Norethindrone-Ethinyl Estrad
TABLET
2
*+Dasetta
Norethindrone-Ethinyl Estrad
TABLET
2
*+Desogestrel-Ethinyl Estradiol
Desogestrel-Ethinyl Estradiol
TABLET
2
*+Drospirenone-Ethinyl Estradiol
Ethinyl Estradiol/Drospirenone TABLET
2
ELLA
Ulipristal Acetate
TABLET
3
*+Emoquette
Desogestrel-Ethinyl Estradiol
TABLET
2
*+Enpresse
Levonorgestrel-Ethin Estradiol TABLET
2
*+Enskyce
Desogestrel-Ethinyl Estradiol
TABLET
2
*+Errin
Norethindrone
TABLET
2
*+Falmina
Levonorgestrel-Ethin Estradiol TABLET
2
*+Gildagia
Norethindrone-Ethinyl Estrad
TABLET
2
*+Gildess
Norethindrone Ac-Eth Estradiol TABLET
2
*+Gildess Fe
Norethindrone-E.Estradiol-Iron TABLET
2
*+Heather
Norethindrone
TABLET
2
*+Introvale
Levonorgestrel-Ethin Estradiol TABLET
2
CONTRACEPTIVES
*+Camila
QL
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
107
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
CONTRACEPTIVES (continued)
CONTRACEPTIVES
CONTRACEPTIVES (continued)
*+Jolessa
Levonorgestrel-Ethin Estradiol TABLET
2
*+Jolivette
Norethindrone
TABLET
2
*+Junel
Norethindrone Ac-Eth Estradiol TABLET
2
*+Junel Fe
Norethindrone-E.Estradiol-Iron TABLET
2
*+Kariva
Desog-E.Estradiol/E.Estradiol TABLET
2
*+Kelnor 1-35
Ethynodiol D-Ethinyl Estradiol TABLET
2
*+Kurvelo
Levonorgestrel-Ethin Estradiol TABLET
2
*+Larin Fe
Norethindrone-E.Estradiol-Iron TABLET
2
*+Leena
Norethindrone-Ethinyl Estrad
TABLET
2
*+Lessina
Levonorgestrel-Ethin Estradiol TABLET
2
*+Levlen 28
Levonorgestrel-Ethin Estradiol TABLET
2
*+Levonest
Levonorgestrel-Ethin Estradiol TABLET
2
*+Levonorgestrel
Levonorgestrel
TABLET
2
*+Levonorgestrel-Eth Estradiol
Levonorgestrel-Ethin Estradiol TABLET
2
*+Levonorgestrel-Eth Estradiol
Levonorgestrel-Ethin Estradiol TABLET
2
*+Levora-28
Levonorgestrel-Ethin Estradiol TABLET
2
*+Low-Ogestrel
Norgestrel-Ethinyl Estradiol
TABLET
2
*+Lutera
Levonorgestrel-Ethin Estradiol TABLET
2
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
108
2015 CARE1ST MEDICARE DRUG FORMULARY
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
CONTRACEPTIVES (continued)
CONTRACEPTIVES (continued)
Levonorgestrel-Ethin Estradiol TABLET
2
*+Microgestin
Norethindrone Ac-Eth Estradiol TABLET
2
*+Microgestin Fe
Norethindrone-E.Estradiol-Iron TABLET
2
*+Mono-Linyah
Norgestimate-Ethinyl Estradiol TABLET
2
*+Mononessa
Norgestimate-Ethinyl Estradiol TABLET
2
*+Myzilra
Levonorgestrel-Ethin Estradiol TABLET
2
*+Necon
Norethindrone-Ethinyl Estrad
TABLET
2
*+Next Choice One Dose
Levonorgestrel
TABLET
2
*+Nora-Be
Norethindrone
TABLET
2
*+Norethindrone
Norethindrone
TABLET
2
*+Norethindron-Ethinyl Estradiol
Norethindrone Ac-Eth Estradiol TABLET
2
*+Norethin-Eth Estra Ferrous Fum
Norethindrone-E.Estradiol-Iron TABLET
2
*+Norgestimate-Ethinyl Estradiol
Norgestimate-Ethinyl Estradiol TABLET
2
*+Norlyroc
Norethindrone
TABLET
2
*+Nortrel
Norethindrone-Ethinyl Estrad
TABLET
2
*+Ogestrel
Norgestrel-Ethinyl Estradiol
TABLET
2
*+Orsythia
Levonorgestrel-Ethin Estradiol TABLET
2
*+Philith
Norethindrone-Ethinyl Estrad
TABLET
2
CONTRACEPTIVES
*+Marlissa
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
109
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
CONTRACEPTIVES (continued)
CONTRACEPTIVES
CONTRACEPTIVES (continued)
*+Pirmella
Norethindrone-Ethinyl Estrad
TABLET
2
*+Portia
Levonorgestrel-Ethin Estradiol TABLET
2
*+Previfem
Norgestimate-Ethinyl Estradiol TABLET
2
*+Quasense
Levonorgestrel-Ethin Estradiol TABLET
2
*+Reclipsen
Desogestrel-Ethinyl Estradiol
TABLET
2
*+Sprintec
Norgestimate-Ethinyl Estradiol TABLET
2
*+Sronyx
Levonorgestrel-Ethin Estradiol TABLET
2
*+Tilia Fe
Norethindrone-E.Estradiol-Iron TABLET
2
*+Tri-Legest Fe
Norethindrone-E.Estradiol-Iron TABLET
2
*+Tri-Linyah
Norgestimate-Ethinyl Estradiol TABLET
2
*+Trinessa
Norgestimate-Ethinyl Estradiol TABLET
2
*+Tri-Previfem
Norgestimate-Ethinyl Estradiol TABLET
2
*+Tri-Sprintec
Norgestimate-Ethinyl Estradiol TABLET
2
*+Trivora-28
Levonorgestrel-Ethin Estradiol TABLET
2
*+Velivet
Desogestrel-Ethinyl Estradiol
TABLET
2
*+Viorele
Desog-E.Estradiol/E.Estradiol TABLET
2
*+Vyfemla
Norethindrone-Ethinyl Estrad
TABLET
2
*+Wera
Norethindrone-Ethinyl Estrad
TABLET
2
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
110
2015 CARE1ST MEDICARE DRUG FORMULARY
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
CONTRACEPTIVES (continued)
CONTRACEPTIVES (continued)
*+Zenchent
Norethindrone-Ethinyl Estrad
TABLET
2
*+Zenchent Fe
Noreth-Ethinyl Estradiol/Iron
TAB CHEW
2
*+Zovia 1-35E
Ethynodiol D-Ethinyl Estradiol TABLET
2
*+Zovia 1-50E
Ethynodiol D-Ethinyl Estradiol TABLET
2
CONTRACEPTIVES
DENTAL AND ORAL AGENTS
DENTAL AND ORAL AGENTS
*Chlorhexidine Gluconate
Chlorhexidine Gluconate
ORAL SOLUTION
2
*+Denta 5000 Plus
Sodium Fluoride
DENTAL CREAM
2
*+Dentagel
Sodium Fluoride
DENTAL GEL
2
*Oralone
Triamcinolone Acetonide
DENTAL PASTE
2
*Periogard
Chlorhexidine Gluconate
ORAL SOLUTION
2
*+Pilocarpine Hcl
Pilocarpine Hcl
TABLET
2
*+Sf 5000 Plus
Sodium Fluoride
DENTAL CREAM
2
*+Sodium Fluoride
Sodium Fluoride
DENTAL SOLN
2
*+Stannous Fluoride
Stannous Fluoride
DENTAL SOLN
2
*Triamcinolone Acetonide
Triamcinolone Acetonide
DENTAL PASTE
2
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
111
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
DERMATOLOGICAL AGENTS
DERMATOLOGICAL AGENTS
DERMATOLOGICAL AGENTS, OTHER
8-MOP
Methoxsalen
CAPSULE
3
PA
ACITRETIN
Acitretin
CAPSULE
5
ACYCLOVIR
Acyclovir
TOPICAL OINT.
3
*Alcohol Pads
Alcohol Antiseptic Pads
TOPICAL MED. PAD
2
*Ammonium Lactate
Ammonium Lactate
TOPICAL LOTION
2
AMNESTEEM
Isotretinoin
CAPSULE
4
*Anacaine
Benzocaine
TOPICAL OINT.
2
*Calcipotriene
Calcipotriene
CREAM
2
PA, QL
*Calcipotriene
Calcipotriene
TOPICAL SOLUTION
2
PA, QL
CLARAVIS
Isotretinoin
CAPSULE
4
PA
DENAVIR
Penciclovir
CREAM
3
PA
*Fluorouracil
Fluorouracil
CREAM
2
*Fluorouracil
Fluorouracil
TOPICAL SOLUTION
2
*Imiquimod
Imiquimod
CREAM
2
PA, QL
LEVULAN
Aminolevulinic Acid Hcl
TOPICAL SOLUTION
3
PA
METHOXSALEN
Methoxsalen, Rapid
CAPSULE
3
PA
OXSORALEN
Methoxsalen
TOPICAL LOTION
3
PA
OXSORALEN-ULTRA
Methoxsalen, Rapid
CAPSULE
3
PA
QL
PA
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
112
2015 CARE1ST MEDICARE DRUG FORMULARY
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
DERMATOLOGICAL AGENTS (continued)
DERMATOLOGICAL AGENTS, OTHER (continued)
Alitretinoin
TOPICAL GEL
5
PA
PICATO
Ingenol Mebutate
TOPICAL GEL
5
PA
PODOCON-25
Podophyllum Resin
TOPICAL LIQUID
3
*Podofilox
Podofilox
TOPICAL SOLUTION
2
REGRANEX
Becaplermin
TOPICAL GEL
5
SANTYL
Collagenase Clostridium Hist. TOPICAL OINT.
SOTRET
Isotretinoin
CAPSULE
4
PA
VALCHLOR
Mechlorethamine Hcl
TOPICAL GEL
5
PA
+ZONALON
Doxepin Hcl
CREAM
3
ZOVIRAX
Acyclovir
CREAM
3
QL
+ZYCLARA
Imiquimod
CREAM
4
PA
DERMATOLOGICAL AGENTS
PANRETIN
PA, QL
3
DERMATOLOGICAL ANTIBACTERIALS
*Clindamax
Clindamycin Phosphate
TOPICAL GEL
2
*Clindamax
Clindamycin Phosphate
TOPICAL LOTION
2
*Clindamycin Phosphate
Clindamycin Phosphate
TOPICAL LOTION
2
*Clindamycin Phosphate
Clindamycin Phosphate
TOPICAL MED. SWAB 2
*Clindamycin Phosphate
Clindamycin Phosphate
TOPICAL GEL
2
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
113
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
DERMATOLOGICAL AGENTS (continued)
DERMATOLOGICAL AGENTS
DERMATOLOGICAL ANTIBACTERIALS (continued)
*Clindamycin Phosphate
Clindamycin Phosphate
TOPICAL SOLUTION
2
*Ery
Erythromycin Base/Ethanol
TOPICAL MED. SWAB 2
*Erythromycin
Erythromycin Base/Ethanol
TOPICAL GEL
*Erythromycin
Erythromycin Base/Ethanol
TOPICAL MED. SWAB 2
*Erythromycin
Erythromycin Base/Ethanol
TOPICAL SOLUTION
*Erythromycin-Benzoyl Peroxide
Erythromycin/Benzoyl Peroxide TOPICAL GEL
*Metronidazole
Metronidazole
CREAM
2
*Metronidazole
Metronidazole
TOPICAL GEL
2
*Metronidazole
Metronidazole
TOPICAL LOTION
2
*Mupirocin
Mupirocin
TOPICAL OINT.
2
*Selenium Sulfide
Selenium Sulfide
ORAL SUSP
2
*Selenium Sulfide
Selenium Sulfide
SHAMPOO
2
*Silver Sulfadiazine
Silver Sulfadiazine
CREAM
2
*Ssd
Silver Sulfadiazine
CREAM
2
*Thermazene
Silver Sulfadiazine
CREAM
2
2
2
2
QL
DERMATOLOGICAL ANTI-INFLAMMATORY AGENTS
*Ala-Cort
Hydrocortisone
CREAM
2
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
114
2015 CARE1ST MEDICARE DRUG FORMULARY
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
DERMATOLOGICAL AGENTS (continued)
DERMATOLOGICAL ANTI-INFLAMMATORY AGENTS (continued)
Hydrocortisone
TOPICAL LOTION
2
*Alclometasone Dipropionate
Alclometasone Dipropionate
CREAM
2
*Alclometasone Dipropionate
Alclometasone Dipropionate
TOPICAL OINT.
2
*Amcinonide
Amcinonide
CREAM
2
*Amcinonide
Amcinonide
TOPICAL LOTION
2
*Amcinonide
Amcinonide
TOPICAL OINT.
2
*Apexicon E
Diflorasone Diacetate/Emoll
CREAM
2
*Betamethasone Dipropionate
Betamethasone Dipropionate TOPICAL LOTION
2
*Betamethasone Dipropionate
Betamethasone Dipropionate TOPICAL OINT.
2
*Betamethasone Dipropionate
Betamethasone Dipropionate TOPICAL GEL
2
*Betamethasone Dipropionate
Betamethasone Dipropionate CREAM
2
*Betamethasone Valerate
Betamethasone Valerate
TOPICAL LOTION
2
*Betamethasone Valerate
Betamethasone Valerate
TOPICAL OINT.
2
*Betamethasone Valerate
Betamethasone Valerate
CREAM
2
*Clobetasol Propionate
Clobetasol Propionate
CREAM
2
*Clobetasol Propionate
Clobetasol Propionate
TOPICAL FOAM
2
*Clobetasol Propionate
Clobetasol Propionate
TOPICAL GEL
2
*Clobetasol Propionate
Clobetasol Propionate
TOPICAL OINT.
2
DERMATOLOGICAL AGENTS
*Ala-Scalp
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
115
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
DERMATOLOGICAL AGENTS (continued)
DERMATOLOGICAL AGENTS
DERMATOLOGICAL ANTI-INFLAMMATORY AGENTS (continued)
*Clobetasol Propionate
Clobetasol Propionate
TOPICAL SOLUTION
2
*Colocort
Hydrocortisone
RECTAL ENEMA
2
*Cormax
Clobetasol Propionate
TOPICAL SOLUTION
2
DESONATE
Desonide
TOPICAL GEL
4
*Desonide
Desonide
CREAM
2
*Desonide
Desonide
TOPICAL OINT.
2
*Desonide
Desonide
TOPICAL LOTION
2
*Desoximetasone
Desoximetasone
CREAM
2
*Desoximetasone
Desoximetasone
TOPICAL GEL
2
*Desoximetasone
Desoximetasone
TOPICAL OINT.
2
*Diflorasone Diacetate
Diflorasone Diacetate
CREAM
2
*Diflorasone Diacetate
Diflorasone Diacetate
TOPICAL OINT.
2
ELIDEL
Pimecrolimus
CREAM
3
*Fluocinolone Acetonide
Fluocinolone Acetonide
CREAM
2
*Fluocinolone Acetonide
Fluocinolone Acetonide
TOPICAL OINT.
2
*Fluocinolone Acetonide
Fluocinolone Acetonide
TOPICAL SOLUTION
2
*Fluocinonide
Fluocinonide
TOPICAL GEL
2
*Fluocinonide
Fluocinonide
TOPICAL OINT.
2
PA, QL
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
116
2015 CARE1ST MEDICARE DRUG FORMULARY
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
DERMATOLOGICAL AGENTS (continued)
DERMATOLOGICAL ANTI-INFLAMMATORY AGENTS (continued)
Fluocinonide
CREAM
2
*Fluocinonide
Fluocinonide
TOPICAL SOLUTION
2
*Fluticasone Propionate
Fluticasone Propionate
CREAM
2
*Fluticasone Propionate
Fluticasone Propionate
TOPICAL OINT.
2
*Halobetasol Propionate
Halobetasol Propionate
CREAM
2
*Halobetasol Propionate
Halobetasol Propionate
TOPICAL OINT.
2
*Hycort
Hydrocortisone
TOPICAL OINT.
2
*Hydrocortisone
Hydrocortisone
CREAM
2
*Hydrocortisone
Hydrocortisone
TOPICAL OINT.
2
*Hydrocortisone
Hydrocortisone
TOPICAL LOTION
2
*Hydrocortisone
Hydrocortisone
RECTAL ENEMA
2
*Hydrocortisone Butyrate
Hydrocortisone Butyrate
CREAM
2
*Hydrocortisone Butyrate
Hydrocortisone Butyrate
TOPICAL OINT.
2
*Hydrocortisone Butyrate
Hydrocortisone Butyrate
TOPICAL SOLUTION
2
*Hydrocortisone Plus
Hydrocortisone
CREAM
2
*Hydrocortisone Valerate
Hydrocortisone Valerate
TOPICAL OINT.
2
*Hydrocortisone Valerate
Hydrocortisone Valerate
CREAM
2
*Lokara
Desonide
TOPICAL LOTION
2
DERMATOLOGICAL AGENTS
*Fluocinonide
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
117
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
DERMATOLOGICAL AGENTS (continued)
DERMATOLOGICAL AGENTS
DERMATOLOGICAL ANTI-INFLAMMATORY AGENTS (continued)
*Mometasone Furoate
Mometasone Furoate
CREAM
2
*Mometasone Furoate
Mometasone Furoate
TOPICAL OINT.
2
*Mometasone Furoate
Mometasone Furoate
TOPICAL SOLUTION
2
*Procto-Pak
Hydrocortisone
RECTAL CREAM
2
*Proctosol-Hc
Hydrocortisone
RECTAL CREAM
2
*Proctozone-Hc
Hydrocortisone
RECTAL CREAM
2
*Triamcinolone Acetonide
Triamcinolone Acetonide
CREAM
2
*Triamcinolone Acetonide
Triamcinolone Acetonide
TOPICAL LOTION
2
*Triamcinolone Acetonide
Triamcinolone Acetonide
TOPICAL OINT.
2
*Triderm
Triamcinolone Acetonide
CREAM
2
*U-Cort
Hydrocortisone Acetate/Urea
CREAM
2
VERDESO
Desonide
TOPICAL FOAM
4
DERMATOLOGICAL RETINOIDS
*Adapalene
Adapalene
TOPICAL GEL
2
*Adapalene
Adapalene
CREAM
2
*Adapalene
Adapalene
TOPICAL GEL
2
*Avita
Tretinoin
TOPICAL GEL
2
PA
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
118
2015 CARE1ST MEDICARE DRUG FORMULARY
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
DERMATOLOGICAL AGENTS (continued)
DERMATOLOGICAL RETINOIDS (continued)
Adapalene
TOPICAL LOTION
3
DIFFERIN
Adapalene
TOPICAL MED. SWAB 3
QL
TAZORAC
Tazarotene
CREAM
4
PA
TAZORAC
Tazarotene
TOPICAL GEL
4
PA
*Tretinoin
Tretinoin
TOPICAL GEL
2
PA
*Tretinoin
Tretinoin/Emollient Base
CREAM
2
PA
DERMATOLOGICAL AGENTS
DIFFERIN
SCABICIDES AND PEDICULICIDES
*Lindane
Lindane
SHAMPOO
2
*Lindane
Lindane
TOPICAL LOTION
2
*Permethrin
Permethrin
CREAM
2
DEVICES
DEVICES
*Eclipse Luer-Lok Syringe
Syringe W-Needle,Disposab,1Ml SYRINGES
2
*+Insulin Syringe
Syring W-Ndl,Disp,Insul,0.5Ml SYRINGES
2
PEN NEEDLE
Needles, Insulin Disposable
*+Sure Comfort
Syring W-Ndl,Disp,Insul,0.5Ml SYRINGES
PEN NEEDLE
3
2
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
119
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
ENZYME REPLACEMENT/MODIFIERS
ENZYME REPLACEMENT/MODIFIERS
ENZYME REPLACEMENT/MODIFIERS
ADAGEN
Pegademase Bovine
INJECTION
5
BvD
ALDURAZYME
Laronidase
INTRAVENOUS (IV)
5
BvD
CEREZYME
Imiglucerase
INTRAVENOUS (IV)
5
BvD
+CREON
Lipase/Protease/Amylase
CAPSULE DR
3
+CYSTAGON
Cysteamine Bitartrate
CAPSULE
3
PA
ELAPRASE
Idursulfase
INTRAVENOUS (IV)
5
PA
ELELYSO
Taliglucerase Alfa
INTRAVENOUS (IV)
5
BvD
ELITEK
Rasburicase
INTRAVENOUS (IV)
5
BvD
FABRAZYME
Agalsidase Beta
INTRAVENOUS (IV)
5
BvD
+KUVAN
Sapropterin Dihydrochloride
TAB DISPER
5
PA
+LOTRONEX
Alosetron Hcl
TABLET
5
PA
MYOZYME
Alglucosidase Alfa
INTRAVENOUS (IV)
5
BvD
NAGLAZYME
Galsulfase
INTRAVENOUS (IV)
5
BvD
+ORFADIN
Nitisinone
CAPSULE
3
PA
+PANCRELIPASE 5,000
Lipase/Protease/Amylase
CAPSULE DR
3
+PULMOZYME
Dornase Alfa
INHALATION SOLN
5
BvD
+SUCRAID
Sacrosidase
ORAL SOLUTION
3
PA
VPRIV
Velaglucerase Alfa
INTRAVENOUS (IV)
5
BvD
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
120
2015 CARE1ST MEDICARE DRUG FORMULARY
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
ENZYME REPLACEMENT/MODIFIERS (continued)
ENZYME REPLACEMENT/MODIFIERS (continued)
+ZAVESCA
Miglustat
CAPSULE
5
PA +ZENPEP
Lipase/Protease/Amylase
CAPSULE DR
3
ENZYME REPLACEMENT/MODIFIERS
EYE, EAR, NOSE, THROAT AGENTS
EYE, EAR, NOSE, THROAT AGENTS, MISCELLANEOUS
*Alcaine
Proparacaine Hcl
OPHT DROPS
2
*Azelastine Hcl
Azelastine Hcl
NASAL SPRAY
2
*Azelastine Hcl
Azelastine Hcl
OPHT DROPS
2
*Carteolol Hcl
Carteolol Hcl
OPHT DROPS
2
*Cromolyn Sodium
Cromolyn Sodium
OPHT DROPS
2
*Cyclopentolate Hcl
Cyclopentolate Hcl
OPHT DROPS
2
*Homatropaire
Homatropine Hbr
OPHT DROPS
2
QL
*Homatropine Hydrobromide
Homatropine Hbr
OPHT DROPS
2
QL
*+Ipratropium Bromide
Ipratropium Bromide
NASAL SPRAY
2
LACRISERT
Hydroxypropyl Cellulose
OPHT INSERT
3
*Naphazoline Hcl
Naphazoline Hcl
OPHT DROPS
2
*Naphazoline Hcl W/Antazoline
Naphazoline Hcl/Antazoline
OPHT DROPS
2
QL
*Neofrin
Phenylephrine Hcl
OPHT DROPS
2
QL
QL
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
121
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
EYE, EAR, NOSE, THROAT AGENTS (continued)
EYE, EAR, NOSE, THROAT AGENTS
EYE, EAR, NOSE, THROAT AGENTS, MISCELLANEOUS (continued)
PATANOL
Olopatadine Hcl
OPHT DROPS
3
QL
*Phenylephrine Hcl
Phenylephrine Hcl
OPHT DROPS
2
QL
*Proparacaine Hcl
Proparacaine Hcl
OPHT DROPS
2
*Tetcaine
Tetracaine Hcl
OPHT DROPS
2
*Tetracaine Hcl
Tetracaine Hcl
OPHT DROPS
2
*Tropicamide
Tropicamide
OPHT DROPS
2
TYZINE
Tetrahydrozoline Hcl
NASAL SPRAY
3
TYZINE
Tetrahydrozoline Hcl
NASAL SPRAY
3
EYE, EAR, NOSE, THROAT ANTI-INFECTIVES AGENTS
*Acetasol Hc
Acetic Acid/Hydrocortisone
OTIC DROPS
2
*Bacitracin
Bacitracin
OPHT OINTMENT
2
*Bacitracin-Polymyxin
Bacitracin/Polymyxin B Sulfate OPHT OINTMENT
2
*Bleph-10
Sulfacetamide Sodium
OPHT DROPS
2
*Ciprofloxacin Hcl
Ciprofloxacin Hcl
OPHT DROPS
2
*Ciprofloxacin Hcl
Ciprofloxacin Hcl
OTIC DROPS
2
*Erythromycin
Erythromycin Base
OPHT OINTMENT
2
*Gentak
Gentamicin Sulfate
OPHT OINTMENT
2
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
122
2015 CARE1ST MEDICARE DRUG FORMULARY
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
EYE, EAR, NOSE, THROAT AGENTS (continued)
EYE, EAR, NOSE, THROAT ANTI-INFECTIVES AGENTS (continued)
Gentamicin Sulfate
OPHT DROPS
2
*Gentamicin Sulfate
Gentamicin Sulfate
OPHT OINTMENT
2
*Neomycin W/Dexamethasone
Neomycin Sulfate/Dex Na Ph OPHT DROPS
2
*Neomycin-Bacitracin-Poly-Hc
Neomy Sulf/Bacitrac Zn/Poly/Hc OPHT OINTMENT
2
*Neomycin-Bacitracin-Polymyxin
Neomy Sulf/Bacitra/Polymyxin B OPHT OINTMENT
2
*Neomycin-Polymyxin-Dexameth
Neo/Polymyx B Sulf/Dexameth OPHT OINTMENT
2
*Neomycin-Polymyxin-Dexameth
Neo/Polymyx B Sulf/Dexameth OPHT SUSP
2
*Neomycin-Polymyxin-Gramicidin
Neomycin/Polymyxn B/Gramicidin OPHT DROPS
2
*Neomycin-Polymyxin-Hc
Neomycin/Polymyxin B Sulf/Hc OPHT SUSP
2
*Neomycin-Polymyxin-Hydrocort
Neomycin/Polymyxin B Sulf/Hc OTIC SOLUTION
2
*Ofloxacin
Ofloxacin
*Otimar
Neomycin/Polymyxin B Sulf/Hc OTIC SUSP
2
*Otimar
Neomycin/Polymyxin B Sulf/Hc OTIC SOLUTION
2
*Otomycet-Hc
Acetic Acid/Hydrocortisone
*Polymyxin B Sul-Trimethoprim
Polymyxin B Sulf/Trimethoprim OPHT DROPS
*Sulfacetamide Sodium
Sulfacetamide Sodium
OPHT OINTMENT
2
*Sulfacetamide Sodium
Sulfacetamide Sodium
OPHT DROPS
2
*Sulfacetamide-Prednisolone
Sulfacetamide/Prednisolone Sp OPHT DROPS
OTIC DROPS
OTIC DROPS
QL
EYE, EAR, NOSE, THROAT AGENTS
*Gentamicin Sulfate
2
2
2
2
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
123
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
EYE, EAR, NOSE, THROAT AGENTS (continued)
EYE, EAR, NOSE, THROAT AGENTS
EYE, EAR, NOSE, THROAT ANTI-INFECTIVES AGENTS (continued)
*Tobramycin Sulfate
Tobramycin Sulfate
OPHT DROPS
2
*Tobramycin-Dexamethasone
Tobramycin/Dexamethasone
OPHT SUSP
2
*Trifluridine
Trifluridine
OPHT DROPS
2
VIGAMOX
Moxifloxacin Hcl
OPHT DROPS
4
EYE, EAR, NOSE, THROAT ANTI-INFLAMMATORY AGENTS
BROMFENAC SODIUM
Bromfenac Sodium
OPHT DROPS
4
*Dexamethasone Sodium Phosphate Dexamethasone Sod Phosphate OPHT DROPS
2
*+Diclofenac Sodium
Diclofenac Sodium
OPHT DROPS
2
*+Flunisolide
Flunisolide
NASAL SPRAY
2
FLUOCINOLONE ACETONIDE OIL Fluocinolone Acetonide Oil
OTIC DROPS
3
FLUOROMETHOLONE
Fluorometholone
OPHT SUSP
3
*Flurbiprofen Sodium
Flurbiprofen Sodium
OPHT DROPS
2
*Fluticasone Propionate
Fluticasone Propionate
NASAL SPRAY
2
*Ketorolac Tromethamine
Ketorolac Tromethamine
OPHT DROPS
2
LOTEMAX
Loteprednol Etabonate
OPHT SUSP
3
MAXIDEX
Dexamethasone
OPHT SUSP
3
*Prednisolone Acetate
Prednisolone Acetate
OPHT SUSP
2
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
124
2015 CARE1ST MEDICARE DRUG FORMULARY
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
EYE, EAR, NOSE, THROAT AGENTS (continued)
EYE, EAR, NOSE, THROAT ANTI-INFLAMMATORY AGENTS (continued)
*Prednisolone Sodium Phosphate
Prednisolone Sod Phosphate OPHT DROPS
2
RESTASIS
Cyclosporine
OPHT DROPS
4
PA, QL
EYE, EAR, NOSE, THROAT AGENTS
GASTROINTESTINAL AGENTS
ANTIULCER AGENTS AND ACID SUPPRESSANTS
*+Cimetidine
Cimetidine
TABLET
2
*Cimetidine Hcl
Cimetidine Hcl
ORAL SOLUTION
2
*+Famotidine
Famotidine
TABLET
2
*Famotidine
Famotidine In Nacl,Iso-Osm/Pf INTRAVENOUS (IV)
2
BvD
*Famotidine
Famotidine/Pf
INTRAVENOUS (IV)
2
BvD
*+Lansoprazole
Lansoprazole
CAPSULE DR
2
*+Misoprostol
Misoprostol
TABLET
2
*+Nizatidine
Nizatidine
CAPSULE
2
*+Omeprazole
Omeprazole
CAPSULE DR
2
QL
PANTOPRAZOLE SODIUM
Pantoprazole Sodium
INTRAVENOUS (IV)
4
BvD
*+Pantoprazole Sodium
Pantoprazole Sodium
TABLET DR
2
*+Ranitidine Hcl
Ranitidine Hcl
ORAL SYRUP
2
*+Ranitidine Hcl
Ranitidine Hcl
TABLET
2
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
125
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
GASTROINTESTINAL AGENTS (continued)
GASTROINTESTINAL AGENTS
ANTIULCER AGENTS AND ACID SUPPRESSANTS (continued)
*Ranitidine Hcl
Ranitidine Hcl
INJECTION
2
*+Ranitidine Hcl
Ranitidine Hcl
CAPSULE
2
*+Sucralfate
Sucralfate
TABLET
2
*+Sucralfate
Sucralfate
ORAL SUSP
2
BvD
GASTROINTESTINAL AGENTS, OTHER
AMITIZA
Lubiprostone
CAPSULE
3
PA
BUPHENYL
Sodium Phenylbutyrate
TABLET
3
PA
*+Constulose
Lactulose
ORAL SOLUTION
2
CROMOLYN SODIUM
Cromolyn Sodium
ORAL SOLUTION
3
*Dicyclomine Hcl
Dicyclomine Hcl
CAPSULE
2
*Dicyclomine Hcl
Dicyclomine Hcl
TABLET
2
*Diphenoxylate-Atropine
Diphenoxylate Hcl/Atropine
TABLET
2
*Diphenoxylate-Atropine
Diphenoxylate Hcl/Atropine
ORAL SOLUTION
2
*+Generlac
Lactulose
ORAL SOLUTION
2
*Glycopyrrolate
Glycopyrrolate
TABLET
2
*+Lactulose
Lactulose
ORAL SOLUTION
2
*+Lactulose
Lactulose
ORAL SYRUP
2
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
126
2015 CARE1ST MEDICARE DRUG FORMULARY
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
GASTROINTESTINAL AGENTS (continued)
GASTROINTESTINAL AGENTS, OTHER (continued)
Loperamide Hcl
CAPSULE
2
*Metoclopramide Hcl
Metoclopramide Hcl
INJECTION
2
*Metoclopramide Hcl
Metoclopramide Hcl
ORAL SOLUTION
2
*Metoclopramide Hcl
Metoclopramide Hcl
TABLET
2
RELISTOR
Methylnaltrexone Bromide
INJECTION
4
*+Ursodiol
Ursodiol
CAPSULE
2
BvD
GASTROINTESTINAL AGENTS
*Loperamide
PA
LAXATIVES
*Gavilyte-C
Peg 3350/Na Sulf,Bicarb,Cl/Kcl ORAL SOLUTION
2
*Gavilyte-N
Sodium Chloride/Nahco3/Kcl/Peg ORAL SOLUTION
2
*Peg 3350-Electrolyte
Peg 3350/Na Sulf,Bicarb,Cl/Kcl ORAL SOLUTION
2
*Peg 3350-Grx
Polyethylene Glycol 3350
*Peg-3350
Sodium Chloride/Nahco3/Kcl/Peg ORAL SOLUTION
2
*Peg-3350 And Electrolytes
Peg 3350/Na Sulf,Bicarb,Cl/Kcl ORAL SOLUTION
2
*Polyethylene Glycol 3350
Polyethylene Glycol 3350
*Trilyte With Flavor Packets
Sodium Chloride/Nahco3/Kcl/Peg ORAL SOLUTION
ORAL POWDER
ORAL POWDER
QL
2
QL
2
2
PHOSPHATE BINDERS
*+Calcium Acetate
Calcium Acetate
CAPSULE
2
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
127
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
GASTROINTESTINAL AGENTS (continued)
GASTROINTESTINAL AGENTS
PHOSPHATE BINDERS (continued)
*+Calcium Acetate
Calcium Acetate
TABLET
2
*+Eliphos
Calcium Acetate
TABLET
2
*Kionex
Sodium Polystyrene Sulfonate ORAL SUSP
+RENAGEL
Sevelamer Hcl
TABLET
4
+RENVELA
Sevelamer Carbonate
TABLET
4
+SEVELAMER CARBONATE
Sevelamer Carbonate
TABLET
4
*Sps
Sodium Polystyrene Sulfonate ORAL SUSP
2
2
GENITOURINARY AGENTS
ANTISPASMODICS, URINARY
+MYRBETRIQ
Mirabegron
TAB ER 24H
4
PA
*+Oxybutynin Chloride
Oxybutynin Chloride
ORAL SYRUP
2
*+Oxybutynin Chloride
Oxybutynin Chloride
TABLET
2
*+Oxybutynin Chloride Er
Oxybutynin Chloride
TAB ER 24
2
*+Tolterodine Tartrate
Tolterodine Tartrate
TABLET
2
QL, ST
*+Tolterodine Tartrate Er
Tolterodine Tartrate
CAP ER 24H
2
QL, ST
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
128
2015 CARE1ST MEDICARE DRUG FORMULARY
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
GENITOURINARY AGENTS (continued)
GENITOURINARY AGENTS, MISCELLANEOUS
*+Alfuzosin Hcl Er
Alfuzosin Hcl
TAB ER 24H
2
QL
*+Tamsulosin Hcl
Tamsulosin Hcl
CAP ER 24H
2
QL
*+Terazosin Hcl
Terazosin Hcl
CAPSULE
2
GENITOURINARY AGENTS
HEAVY METAL ANTAGONISTS
HEAVY METAL ANTAGONISTS
+CUPRIMINE
Penicillamine
CAPSULE
3
PA
*Deferoxamine Mesylate
Deferoxamine Mesylate
INJECTION
2
BvD
+DEPEN
Penicillamine
TABLET
3
+EXJADE
Deferasirox
TAB DISPER
3
PA
+EXJADE
Deferasirox
TAB DISPER
5
PA
+SYPRINE
Trientine Hcl
CAPSULE
5
PA
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING
ANDROGENS
+ANADROL-50
Oxymetholone
TABLET
5
PA
+ANDRODERM
Testosterone
PATCH
3
PA
*+Android
Methyltestosterone
CAPSULE
2
PA
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
129
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (continued)
HORMONAL AGENTS, STIMULANT/
ANDROGENS (continued)
*+Androxy
Fluoxymesterone
TABLET
2
PA
AVEED
Testosterone Undecanoate
INJECTION
4
PA
*Danazol
Danazol
CAPSULE
2
*+Oxandrolone
Oxandrolone
TABLET
2
PA
*Testosterone Cypionate
Testosterone Cypionate
INJECTION
2
PA
ESTROGENS AND ANTIESTROGENS
+ALORA
Estradiol
PATCH
3
+CENESTIN
Estrogens,Conj.,Synthetic A
TABLET
4
+COMBIPATCH
Estradiol/Norethindrone Acet
PATCH
3
*+Estradiol
Estradiol
PATCH
2
PA>65 y/o
*+Estradiol
Estradiol
TABLET
2
PA>65 y/o
*+Estradiol-Norethindrone Acetat
Estradiol/Norethindrone Acet
TABLET
2
*+Estropipate
Estropipate
TABLET
2
PA>65 y/o
+MENEST
Estrogens,Esterified
TABLET
4
PA>65 y/o
*+Mimvey
Estradiol/Norethindrone Acet
TABLET
2
+PREMARIN
Estrogens, Conjugated
TABLET
3
+PREMARIN
Estrogens, Conjugated
VAGINAL CREAM
3
PA>65 y/o
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
130
2015 CARE1ST MEDICARE DRUG FORMULARY
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (continued)
ESTROGENS AND ANTIESTROGENS (continued)
+PREMPHASE
Estrogen,Con/M-Progest Acet TABLET
3
PA>65 y/o
+PREMPRO
Estrogen,Con/M-Progest Acet TABLET
3
PA>65 y/o
*+Raloxifene Hcl
Raloxifene Hcl
TABLET
2
QL
HORMONAL AGENTS, STIMULANT/
GLUCOCORTICOIDS/MINERALOCORTICOIDS
*A-Hydrocort
Hydrocortisone Sod Succinate INJECTION
2
BvD
*A-Methapred
Methylprednisolone Sod Succ INJECTION
2
BvD
*Cortisone Acetate
Cortisone Acetate
TABLET
2
BvD
DEPO-MEDROL
Methylprednisolone Acetate
INJECTION
4
BvD
*Dexamethasone
Dexamethasone
ORAL SOLUTION
2
BvD
*Dexamethasone
Dexamethasone
TABLET
2
BvD
*Dexamethasone Acetate
Dexamethasone Acetate
INJECTION
2
BvD
*Dexamethasone Sodium Phosphate Dexamethasone Sod Phosphate INJECTION
2
BvD
*Fludrocortisone Acetate
Fludrocortisone Acetate
TABLET
2
*Hydrocortisone
Hydrocortisone
TABLET
2
BvD
*Methylprednisolone
Methylprednisolone
TAB DS PK
2
BvD
*Methylprednisolone
Methylprednisolone
TABLET
2
BvD
*Methylprednisolone Acetate
Methylprednisolone Acetate
INJECTION
2
BvD
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
131
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (continued)
HORMONAL AGENTS, STIMULANT/
GLUCOCORTICOIDS/MINERALOCORTICOIDS (continued)
*Methylprednisolone Sod Succ
Methylprednisolone Sod Succ INTRAVENOUS (IV)
2
BvD
*Prednisolone Sodium Phosphate
Prednisolone Sod Phosphate ORAL SOLUTION
2
BvD
*Prednisone
Prednisone
TABLET
2
BvD
*Prednisone
Prednisone
TAB DS PK
2
*Veripred 20
Prednisolone Sod Phosphate ORAL SOLUTION
2
BvD
*Chorionic Gonadotropin
Chorionic Gonadotropin, Human INJECTION
2
PA
*Desmopressin Acetate
Desmopressin Acetate
INJECTION
2
PA
*+Desmopressin Acetate
Desmopressin Acetate
NASAL SPRAY
2
*+Desmopressin Acetate
Desmopressin Acetate
NASAL SPRAY
2
*+Desmopressin Acetate
Desmopressin Acetate
TABLET
2
GENOTROPIN
Somatropin
INJECTION
5
PA
GENOTROPIN
Somatropin
INJECTION
5
PA
GENOTROPIN
Somatropin
INJECTION
3
PA
HUMATROPE
Somatropin
INJECTION
3
PA
HUMATROPE
Somatropin
INJECTION
5
PA
HUMATROPE
Somatropin
INJECTION
5
PA
PITUITARY
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
132
2015 CARE1ST MEDICARE DRUG FORMULARY
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (continued)
PITUITARY (continued)
Mecasermin
INJECTION
5
PA
NORDITROPIN FLEXPRO
Somatropin
INJECTION
5
PA
NORDITROPIN NORDIFLEX
Somatropin
INJECTION
5
PA
NUTROPIN
Somatropin
INJECTION
5
PA
NUTROPIN AQ NUSPIN
Somatropin
INJECTION
5
PA
SAIZEN
Somatropin
INJECTION
5
PA
SAIZEN
Somatropin
INJECTION
5
PA
SANDOSTATIN LAR
Octreotide Acetate
INJECTION
5
BvD
SEROSTIM
Somatropin
INJECTION
5
PA
SOMATULINE DEPOT
Lanreotide Acetate
INJECTION
5
PA
SOMAVERT
Pegvisomant
INJECTION
5
PA
ZORBTIVE
Somatropin
INJECTION
5
PA
DEPO-PROVERA
Medroxyprogesterone Acetate INJECTION
3
BvD
*+Medroxyprogesterone Acetate
Medroxyprogesterone Acetate TABLET
2
*Medroxyprogesterone Acetate
Medroxyprogesterone Acetate INJECTION
2
BvD
*Medroxyprogesterone Acetate
Medroxyprogesterone Acetate INJECTION
2
BvD
HORMONAL AGENTS, STIMULANT/
INCRELEX
PROGESTINS
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
133
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (continued)
PROGESTINS (continued)
*+Norethindrone Acetate
Norethindrone Acetate
TABLET
2
*+Progesterone
Progesterone,Micronized
CAPSULE
2
HORMONAL AGENTS, STIMULANT/
THYROID AND ANTITHYROID AGENTS
*+Levothyroxine Sodium
Levothyroxine Sodium
TABLET
2
+LEVOXYL
Levothyroxine Sodium
TABLET
3
*+Liothyronine Sodium
Liothyronine Sodium
TABLET
2
*+Methimazole
Methimazole
TABLET
2
*+Propylthiouracil
Propylthiouracil
TABLET
2
+SYNTHROID
Levothyroxine Sodium
TABLET
3
+THYROLAR-1
Liotrix
TABLET
3
+THYROLAR-1/2
Liotrix
TABLET
3
+THYROLAR-1/4
Liotrix
TABLET
3
+THYROLAR-2
Liotrix
TABLET
3
+THYROLAR-3
Liotrix
TABLET
3
+TIROSINT
Levothyroxine Sodium
CAPSULE
4
+UNITHROID
Levothyroxine Sodium
TABLET
3
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
134
2015 CARE1ST MEDICARE DRUG FORMULARY
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
IMMUNOLOGICAL AGENTS
IMMUNOLOGICAL AGENTS
5
BvD
ANTIVENIN MICRURUS FULVIUS
Antivenin,Micrurus Fulvius
INJECTION
5
BvD
ARCALYST
Rilonacept
INJECTION
5
PA
+ASTAGRAF XL
Tacrolimus
CAP ER 24H
4
PA
ATGAM
Lymphocyte Immune Globulin INTRAVENOUS (IV)
3
BvD
+AUBAGIO
Teriflunomide
TABLET
5
PA
*+Azathioprine
Azathioprine
TABLET
2
BvD
BIVIGAM
Immune Globulin,Gamma(Igg) INTRAVENOUS (IV)
5
BvD
CARIMUNE NF NANOFILTERED
Immune Globulin,Gamma(Igg) INTRAVENOUS (IV)
5
BvD
+CELLCEPT
Mycophenolate Mofetil
ORAL SUSP
5
BvD
CROFAB
Antivenin,Crotalidae Fab(Ovin) INJECTION
5
BvD
*+Cyclosporine
Cyclosporine
CAPSULE
2
BvD
*+Cyclosporine
Cyclosporine, Modified
ORAL SOLUTION
2
BvD
*Cyclosporine
Cyclosporine
INTRAVENOUS (IV)
2
BvD
*+Cyclosporine Modified
Cyclosporine, Modified
CAPSULE
2
BvD
CYTOGAM
Cytomegalovirus Immune Glob INTRAVENOUS (IV)
5
BvD
+ENBREL
Etanercept
INJECTION
5
PA
+ENBREL
Etanercept
INJECTION
5
PA
IMMUNOLOGICAL AGENTS
ANTIVENIN LATRODECTUS MACTANS Antivenin,Latrodectus Mactans INJECTION
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
135
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
IMMUNOLOGICAL AGENTS (continued)
IMMUNOLOGICAL AGENTS
IMMUNOLOGICAL AGENTS (continued)
+ENBREL
Etanercept
5
PA
GAMUNEX-C
Immune Glob,Gam Caprylate(Igg) INJECTION
3
BvD
*+Gengraf
Cyclosporine, Modified
ORAL SOLUTION
2
BvD
*+Gengraf
Cyclosporine, Modified
CAPSULE
2
BvD
HEPAGAM B
Hepatitis B Immun Glob/Maltose INJECTION
5
BvD
+HUMIRA
Adalimumab
INJECTION
5
PA
+HUMIRA
Adalimumab
INJECTION
5
PA
HYPERHEP B S-D
Hepatitis B Immune Globulin
INJECTION
5
BvD
HYPERHEP B S-D
Hepatitis B Immune Globulin
INJECTION
5
BvD
HYPERRAB S-D
Rabies Immune Globulin/Pf
INJECTION
5
BvD
HYPERRHO S-D
Rho(D) Immune Globulin
INJECTION
5
BvD
HYPERRHO S-D
Rho(D) Immune Globulin
INJECTION
4
BvD
HYPERTET S-D
Tetanus Immune Globulin/Pf
INJECTION
5
BvD
IMOGAM RABIES-HT
Rabies Immune Globulin/Pf
INJECTION
5
BvD
KINERET
Anakinra
INJECTION
5
PA
*+Leflunomide
Leflunomide
TABLET
2
MICRHOGAM ULTRA-FILTERED PLUS Rho(D) Immune Globulin
INJECTION
3
BvD
*+Mycophenolate Mofetil
CAPSULE
2
BvD
Mycophenolate Mofetil
INJECTION
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
136
2015 CARE1ST MEDICARE DRUG FORMULARY
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
IMMUNOLOGICAL AGENTS (continued)
IMMUNOLOGICAL AGENTS (continued)
Mycophenolate Mofetil
TABLET
2
BvD
*+Mycophenolic Acid
Mycophenolate Sodium
TABLET DR
2
BvD
NABI-HB
Hepatitis B Immune Globulin
INJECTION
5
BvD
NULOJIX
Belatacept
INTRAVENOUS (IV)
5
PA
ORENCIA
Abatacept/Maltose
INTRAVENOUS (IV)
5
BvD
PROGRAF
Tacrolimus
INTRAVENOUS (IV)
3
BvD
+RAPAMUNE
Sirolimus
TABLET
5
BvD
+RAPAMUNE
Sirolimus
ORAL SOLUTION
3
BvD
RHOGAM ULTRA-FILTERED PLUS Rho(D) Immune Globulin
INJECTION
3
BvD
RHOPHYLAC
Rho(D) Immune Globulin
SYRINGES
4
BvD
+RIDAURA
Auranofin
CAPSULE
3
*+Sirolimus
Sirolimus
TABLET
2
BvD, QL
+TACROLIMUS
Tacrolimus
CAPSULE
5
BvD
*+Tacrolimus
Tacrolimus
CAPSULE
2
BvD
TYSABRI
Natalizumab
INTRAVENOUS (IV)
5
PA
WINRHO SDF
Rho(D) Immune Globulin/Maltose INJECTION
5
BvD
+ZORTRESS
Everolimus
TABLET
5
PA
+ZORTRESS
Everolimus
TABLET
4
PA
IMMUNOLOGICAL AGENTS
*+Mycophenolate Mofetil
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
137
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
IMMUNOLOGICAL AGENTS (continued)
IMMUNOLOGICAL AGENTS
VACCINES
ACTHIB
Haemoph B Poly Conj-Tet Tox/Pf INJECTION
3
ADACEL TDAP
Diph,Pertuss(Acell),Tet Vac/Pf INJECTION
3
ADACEL TDAP
Diph,Pertuss(Acell),Tet Vac/Pf INJECTION
3
BCG VACCINE (TICE STRAIN)
Bcg Live
INJECTION
3
BOOSTRIX TDAP
Diphth,Pertuss(Acell),Tet Vac INJECTION
3
BOOSTRIX TDAP
Diphth,Pertuss(Acell),Tet Vac INJECTION
3
CERVARIX
Human Papillomav Vacc Bival/Pf INJECTION
3
COMVAX
Hep B Vaccine/Hib Conj-Meng/Pf INJECTION
3
DAPTACEL DTAP
Diph,Pertuss(Acell),Tet Ped/Pf INJECTION
3
DIPHTHERIA-TETANUS TOXOIDS-PED Tetanus,Diphtheria Toxd Ped/Pf INJECTION
3
ENGERIX-B ADULT
Hepatitis B Virus Vaccine/Pf
INJECTION
3
BvD
ENGERIX-B ADULT
Hepatitis B Virus Vaccine/Pf
INJECTION
3
BvD
ENGERIX-B PEDIATRIC-ADOLESCENT Hepatitis B Virus Vaccine/Pf INJECTION
3
BvD
GARDASIL
Human Papilomvirus Vac,Qval/Pf INJECTION
3
GARDASIL
Human Papilomvirus Vac,Qval/Pf INJECTION
3
HAVRIX
Hepatitis A Virus Vaccine
INJECTION
3
HAVRIX
Hepatitis A Virus Vaccine/Pf
INJECTION
3
IMOVAX RABIES VACCINE
Rabies Vacc, Human Diploid/Pf INJECTION
3
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
138
2015 CARE1ST MEDICARE DRUG FORMULARY
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
IMMUNOLOGICAL AGENTS (continued)
VACCINES (continued)
Diph,Pertuss(Acell),Tet Ped/Pf INJECTION
3
IPOL
Poliomyelitis Vaccine, Killed
INJECTION
3
IXIARO
Japanese Encephalitis Vacc/Pf INJECTION
4
KINRIX
Diph,Pertus(Acel),Tet,Polio/Pf INJECTION
3
KINRIX
Diph,Pertus(Acel),Tet,Polio/Pf INJECTION
3
MENACTRA
Mening Vac A,C,Y,W-135 Dip/Pf INJECTION
3
MENHIBRIX
Meningococcal Vac C,Y/Hib/Pf INJECTION
3
MENOMUNE-A-C-Y-W-135
Meningococ Vac A,C,Y,W-135/Pf INJECTION
3
MENVEO A-C-Y-W-135-DIP
Mening Vac A,C,Y,W-135 Dip/Pf INJECTION
3
M-M-R II VACCINE
Measles,Mumps&Rubella Vacc/Pf INJECTION
3
PEDIARIX
Hep B Vaccine/Dp(A)T-Polio/Pf INJECTION
3
PEDVAXHIB
Haemph B Polysac Conj-Menin/Pf INJECTION
3
PENTACEL ACTHIB COMPONENT Haemoph B Poly Conj-Tet Tox/Pf INJECTION
3
PENTACEL DTAP-IPV COMPONENT Diph,Pertus(Acel),Tet,Polio/Pf INJECTION
3
PROQUAD
Measles,Mumps,Rub,Varicella/Pf INJECTION
3
RABAVERT
Rabies Vaccine (Pcec)/Pf
INJECTION
3
RECOMBIVAX HB
Hepatitis B Virus Vaccine/Pf
INJECTION
3
BvD
RECOMBIVAX HB
Hepatitis B Virus Vaccine/Pf
INJECTION
3
BvD
IMMUNOLOGICAL AGENTS
INFANRIX DTAP
BvD
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
139
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
IMMUNOLOGICAL AGENTS (continued)
IMMUNOLOGICAL AGENTS
VACCINES (continued)
ROTARIX
Rotavirus Vac,Live Att, 89-12 ORAL SUSP
3
ROTATEQ
Rotavirus Vaccine,Live Oral Pv ORAL SUSP
3
TE ANATOXAL BERNA
Tetanus Toxoid, Adsorbed
INJECTION
3
TENIVAC
Tetanus And Diphtheria Tox/Pf INJECTION
3
TETANUS DIPHTHERIA TOXOIDS
Tetanus & Diphtheria Tox,Adult INJECTION
3
*Tetanus Toxoid Adsorbed
Tetanus Toxoid, Adsorbed/Pf INJECTION
2
THERACYS
Bcg Live
INJECTION
3
TWINRIX
Hepatitis A & B Vaccine/Pf
INJECTION
3
BvD
TWINRIX
Hepatitis A & B Vaccine/Pf
INJECTION
3
BvD
TYPHIM VI
Typhoid Vacc Vi Capsulr Polys INJECTION
3
VAQTA
Hepatitis A Virus Vaccine/Pf
INJECTION
3
VAQTA
Hepatitis A Virus Vaccine/Pf
INJECTION
3
VARIVAX VACCINE
Varicella Vaccine Live/Pf
INJECTION
3
VIVOTIF BERNA
Typhoid Vacc,Live,Attenuated CAPSULE DR
3
YF-VAX
Yellow Fever Vaccine Live/Pf INJECTION
3
ZOSTAVAX
Zoster Vaccine Live/Pf
INJECTION
3
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
140
2015 CARE1ST MEDICARE DRUG FORMULARY
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
INFLAMMATORY BOWEL DISEASE AGENTS
INFLAMMATORY BOWEL DISEASE AGENTS
Balsalazide Disodium
CAPSULE
2
+BUDESONIDE EC
Budesonide
CAPSULE
5
+CANASA
Mesalamine
RECTAL SUPP
3
+DELZICOL
Mesalamine
CAPSULE DR
3
+DIPENTUM
Olsalazine Sodium
CAPSULE
3
*+Mesalamine
Mesalamine W/Cleansing Wipes RECTAL ENEMA
+PENTASA
Mesalamine
CAPSULE ER
INFLAMMATORY BOWEL DISEASE AGENTS
*+Balsalazide Disodium
2
4
QL
IRRIGATING SOLUTIONS
IRRIGATING SOLUTIONS
*Sodium Chloride
Sodium Chloride Irrig Solution IRRIGATION
2
BvD *Water
Water For Irrigation,Sterile
IRRIGATION
2
BvD METABOLIC BONE DISEASE AGENTS
METABOLIC BONE DISEASE AGENTS
+ACTONEL
Risedronate Sodium
TABLET
4
QL
*+Alendronate Sodium
Alendronate Sodium
TABLET
1
QL
+ATELVIA
Risedronate Sodium
TABLET DR
4
PA,QL
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
141
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
METABOLIC BONE DISEASE AGENTS (continued)
METABOLIC BONE DISEASE AGENTS
METABOLIC BONE DISEASE AGENTS (continued)
+CALCITONIN-SALMON
Calcitonin,Salmon,Synthetic
NASAL SPRAY
4
PA
*+Calcitriol
Calcitriol
CAPSULE
2
BvD
+DOXERCALCIFEROL
Doxercalciferol
CAPSULE
3
BvD
+DOXERCALCIFEROL
Doxercalciferol
CAPSULE
3
BvD, QL
DOXERCALCIFEROL
Doxercalciferol
INTRAVENOUS (IV)
3
BvD
*+Etidronate Disodium
Etidronate Disodium
TABLET
2
FORTEO
Teriparatide
INJECTION
5
PA, QL
+FORTICAL
Calcitonin,Salmon,Synthetic
NASAL SPRAY
4
PA
HECTOROL
Doxercalciferol
INTRAVENOUS (IV)
3
BvD
+IBANDRONATE SODIUM
Ibandronate Sodium
TABLET
4
QL
MIACALCIN
Calcitonin,Salmon,Synthetic
INJECTION
4
PA
*Pamidronate Disodium
Pamidronate Disodium
INTRAVENOUS (IV)
2
BvD
+PARICALCITOL
Paricalcitol
CAPSULE
3
BvD
PROLIA
Denosumab
INJECTION
4
PA
+RISEDRONATE SODIUM
Risedronate Sodium
TABLET
4
QL
XGEVA
Denosumab
INJECTION
5
PA
ZEMPLAR
Paricalcitol
INTRAVENOUS (IV)
3
BvD
ZOLEDRONIC ACID
Zoledronic Acid
INTRAVENOUS (IV)
4
BvD
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
142
2015 CARE1ST MEDICARE DRUG FORMULARY
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
METABOLIC BONE DISEASE AGENTS (continued)
METABOLIC BONE DISEASE AGENTS (continued)
ZOLEDRONIC ACID
Zoledronic Acid/Mannitol&Water INTRAVENOUS (IV) 3
BvD
ZOLEDRONIC ACID
Zoledronic Acid/Mannitol&Water INTRAVENOUS (IV) 4
BvD
ZOMETA
Zoledronic Acid/Mannitol&Water INTRAVENOUS (IV) 5
BvD
METABOLIC BONE DISEASE AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS
ACTIMMUNE
Interferon Gamma-1B,Recomb. INJECTION
5
PA
*+Allopurinol
Allopurinol
TABLET
2
AMIFOSTINE
Amifostine Crystalline
INTRAVENOUS (IV)
5
PA
+AVODART
Dutasteride
CAPSULE
4
QL
AVONEX
Interferon Beta-1A
INJECTION
5
PA
AVONEX ADMINISTRATION PACK Interferon Beta-1A/Albumin
INJECTION
5
PA
+BETASERON
Interferon Beta-1B
INJECTION
5
*Bethanechol Chloride
Bethanechol Chloride
TABLET
2
*+Buspirone Hcl
Buspirone Hcl
TABLET
2
+COLCRYS
Colchicine
TABLET
3
COPAXONE
Glatiramer Acetate
INJECTION
5
PA
COPAXONE
Glatiramer Acetate
INJECTION
5
PA
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
143
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
MISCELLANEOUS THERAPEUTIC AGENTS (continued)
MISCELLANEOUS THERAPEUTIC AGENTS
MISCELLANEOUS THERAPEUTIC AGENTS (continued)
CYSTADANE
Betaine
ORAL POWDER
3
*Ergoloid Mesylates
Ergoloid Mesylates
TABLET
2
PA
+EXTAVIA
Interferon Beta-1B
INJECTION
5
PA
*+Finasteride
Finasteride
TABLET
2
QL
FOMEPIZOLE
Fomepizole
INTRAVENOUS (IV)
5
BvD
+GILENYA
Fingolimod Hcl
CAPSULE
5
PA
GLUCAGEN
Glucagon,Human Recombinant INJECTION
3
GLUCAGON EMERGENCY KIT
Glucagon,Human Recombinant INJECTION
3
*+Guanidine Hcl
Guanidine Hcl
TABLET
2
*Hydroxyzine Hcl
Hydroxyzine Hcl
ORAL SYRUP
2
PA>65 y/o
*Hydroxyzine Hcl
Hydroxyzine Hcl
TABLET
2
PA>65 y/o
KEPIVANCE
Palifermin
INTRAVENOUS (IV)
5
BvD
*Leucovorin Calcium
Leucovorin Calcium
TABLET
2
*Leucovorin Calcium
Leucovorin Calcium
INJECTION
2
MESNEX
Mesna
TABLET
3
MIFEPREX
Mifepristone
TABLET
3
OTEZLA
Apremilast
TAB DS PK
5
PA
OTEZLA
Apremilast
TABLET
5
PA
QL
BvD
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
144
2015 CARE1ST MEDICARE DRUG FORMULARY
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
MISCELLANEOUS THERAPEUTIC AGENTS (continued)
MISCELLANEOUS THERAPEUTIC AGENTS (continued)
Probenecid
TABLET
2
*+Probenecid-Colchicine
Colchicine/Probenecid
TABLET
2
*+Pyridostigmine Bromide
Pyridostigmine Bromide
TABLET
2
REBIF
Interferon Beta-1A/Albumin
INJECTION
5
PA
REBIF REBIDOSE
Interferon Beta-1A/Albumin
INJECTION
5
PA
REMICADE
Infliximab
INTRAVENOUS (IV)
5
PA
+SENSIPAR
Cinacalcet Hcl
TABLET
5
PA
+SENSIPAR
Cinacalcet Hcl
TABLET
3
PA, QL
SIMULECT
Basiliximab
INTRAVENOUS (IV)
4
BvD
SYNAREL
Nafarelin Acetate
NASAL SPRAY
5
PA
+TECFIDERA
Dimethyl Fumarate
CAPSULE DR
5
PA
+THALOMID
Thalidomide
CAPSULE
5
PA
THIOLA
Tiopronin
TABLET
3
*+Valsartan
Valsartan
TABLET
2
*Versalon
Gauze Bandage
SPONGE
2
VORAXAZE
Glucarpidase
INTRAVENOUS (IV)
5
BvD
+XELJANZ
Tofacitinib Citrate
TABLET
5
PA
MISCELLANEOUS THERAPEUTIC AGENTS
*+Probenecid
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
145
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
OPHTHALMIC AGENTS
OPHTHALMIC AGENTS
ANTIGLAUCOMA AGENTS
+ACETAZOLAMIDE
Acetazolamide
CAPSULE ER
4
*+Acetazolamide
Acetazolamide
TABLET
2
+ALPHAGAN P
Brimonidine Tartrate
OPHT DROPS
3
+AZOPT
Brinzolamide
OPHT SUSP
3
*+Betaxolol Hcl
Betaxolol Hcl
OPHT DROPS
2
*+Brimonidine Tartrate
Brimonidine Tartrate
OPHT DROPS
2
*+Dorzolamide Hcl
Dorzolamide Hcl
OPHT DROPS
2
QL
*+Dorzolamide-Timolol
Dorzolamide Hcl/Timolol Maleat OPHT DROPS
2
QL
+HUMORSOL
Demecarium Bromide
OPHT DROPS
3
*+Latanoprost
Latanoprost
OPHT DROPS
2
*+Levobunolol Hcl
Levobunolol Hcl
OPHT DROPS
1
*+Levobunolol Hcl
Levobunolol Hcl
OPHT DROPS
1
*+Methazolamide
Methazolamide
TABLET
2
*+Metipranolol
Metipranolol
OPHT DROPS
2
+PHOSPHOLINE IODIDE
Echothiophate Iodide
OPHT DROPS
3
*+Pilocarpine Hcl
Pilocarpine Hcl
OPHT DROPS
2
*+Timolol Maleate
Timolol Maleate
OPHT DROPS
1
*+Timolol Maleate
Timolol Maleate
OPHT GEL
2
QL
QL
QL
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
146
2015 CARE1ST MEDICARE DRUG FORMULARY
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
OPHTHALMIC AGENTS (continued)
ANTIGLAUCOMA AGENTS (continued)
+TRAVATAN Z
Travoprost
OPHT DROPS
3
QL +TRAVOPROST
Travoprost (Benzalkonium)
OPHT DROPS
3
QL REPLACEMENT PREPARATIONS
REPLACEMENT PREPARATIONS
Citric Acid/Sodium Citrate
ORAL SOLUTION
2
*Cytra-3
Sod/Pot/K Cit/Sod Cit/Cit Acid ORAL SOLUTION
2
*+Cytra-K
Potassium Citrate/Citric Acid
ORAL SOLUTION
2
*Dextrose 5%-0.2% Nacl-Kcl
Potassium Chloride/D5-0.2%Nacl INTRAVENOUS (IV) 2
BvD
*Dextrose 5%-0.3% Nacl-Kcl
Potassium Chloride/D5-0.3%Nacl INTRAVENOUS (IV) 2
BvD
*Dextrose 5%-0.33% Nacl-Kcl
Potassium Chloride/D5-0.3%Nacl INTRAVENOUS (IV) 2
BvD
*Dextrose 5%-0.45% Nacl-Kcl
Potassium Chloride/D5-0.45Nacl INTRAVENOUS (IV) 2
BvD
*Dextrose 5%-1/2Ns-Kcl
Potassium Chloride/D5-0.45Nacl INTRAVENOUS (IV) 2
BvD
*Dextrose 5%-1/4Ns-Kcl
Potassium Chloride/D5-0.25Ns INTRAVENOUS (IV)
2
BvD
*Dextrose 5%-Ns-Kcl
Potassium Chloride/D5-0.9%Nacl INTRAVENOUS (IV) 2
BvD
*Dextrose 5%-Potassium Chloride
Potassium Chloride In D5W
INTRAVENOUS (IV)
2
*+Ed K+10
Potassium Chloride
TABLET SA
2
*+Effer-K
Potassium Bicarbonate/Cit Ac TABLET EFF
OPHTHALMIC AGENTS
*Cytra-2
BvD
2
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
147
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
REPLACEMENT PREPARATIONS (continued)
REPLACEMENT PREPARATIONS
REPLACEMENT PREPARATIONS (continued)
HYPERLYTE CR
Sodium/K+/Mag/Ca/Chlor/Acetate INTRAVENOUS (IV) 3
HYPERLYTE R
Electrolyte Solution,Inj
*+K Effervescent
Potassium Bicarbonate/Cit Ac TABLET EFF
*+Klor-Con
Potassium Chloride
ORAL PACKETS
2
*+Klor-Con 10
Potassium Chloride
TABLET ER
2
*+Klor-Con 8
Potassium Chloride
TABLET ER
2
*+Klor-Con M15
Potassium Chloride
TAB ER PRT
2
*+Klor-Con M20
Potassium Chloride
TAB ER PRT
2
*+Klor-Con-Ef
Potassium Bicarbonate/Cit Ac TABLET EFF
2
LACTATED RINGERS
Ringers Solution,Lactated
4
BvD
NUTRILYTE II
Sodium/K+/Mag/Ca/Chlor/Acetate INTRAVENOUS (IV) 3
BvD
*Phospha 250 Neutral
Phosphorus #1
*+Potassium Bicarbonate
Potassium Bicarbonate/Cit Ac TABLET EFF
*Potassium Chl-Normal Saline
Potassium Chloride In 0.9%Nacl INTRAVENOUS (IV) 2
*+Potassium Chloride
Potassium Chloride
TAB ER PRT
2
*+Potassium Chloride
Potassium Chloride
ORAL PACKETS
2
*+Potassium Chloride
Potassium Chloride
CAPSULE ER
2
*+Potassium Chloride
Pot Chloride/Pot Bicarb/Cit Ac TABLET EFF
INTRAVENOUS (IV)
INTRAVENOUS (IV)
TABLET
3
BvD
BvD
2
2
2
BvD
2
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
148
2015 CARE1ST MEDICARE DRUG FORMULARY
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
REPLACEMENT PREPARATIONS (continued)
REPLACEMENT PREPARATIONS (continued)
*+Potassium Chloride
Potassium Chloride
TABLET ER
2
*+Potassium Chloride
Potassium Chloride
ORAL SOLUTION
2
*+Potassium Citrate
Potassium Citrate
TABLET ER
2
*Ringers Injection
Ringers Solution
INTRAVENOUS (IV)
2
*Shohl'S Modified
Citric Acid/Sodium Citrate
ORAL SOLUTION
2
*Sodium Bicarbonate
Sodium Bicarbonate
INTRAVENOUS (IV)
2
*Sodium Bicarbonate
Sodium Bicarbonate
INTRAVENOUS (IV)
2
*Sodium Chloride
0.9 % Sodium Chloride
INJECTION
2
BvD
*Sodium Chloride
0.9 % Sodium Chloride
INTRAVENOUS (IV)
2
BvD
*Sodium Citrate & Citric Acid
Citric Acid/Sodium Citrate
ORAL SOLUTION
2
TPN ELECTROLYTES II
Sodium/K+/Mag/Ca/Chlor/Acetate INTRAVENOUS (IV) 3
*Tricitrates
Sod/Pot/K Cit/Sod Cit/Cit Acid ORAL SOLUTION
REPLACEMENT PREPARATIONS
BvD
BvD
2
RESPIRATORY TRACT AGENTS
ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS
+ADVAIR DISKUS
Fluticasone/Salmeterol
INHALATION DISK
3
QL, ST
+ADVAIR HFA
Fluticasone/Salmeterol
AEROSOL
3
QL, ST
+ASMANEX
Mometasone Furoate
AEROSOL
4
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
149
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
RESPIRATORY TRACT AGENTS (continued)
RESPIRATORY TRACT AGENTS
ANTI-INFLAMMATORIES, INHALED CORTICOSTEROIDS (continued)
+FLOVENT HFA
Fluticasone Propionate
AEROSOL
3
+PULMICORT FLEXHALER
Budesonide
AEROSOL
4
+QVAR
Beclomethasone Dipropionate AEROSOL
3
ANTILEUKOTRIENES
*+Montelukast Sodium
Montelukast Sodium
TAB CHEW
2
*+Montelukast Sodium
Montelukast Sodium
TABLET
2
*+Zafirlukast
Zafirlukast
TABLET
2
*+Albuterol Sulfate
Albuterol Sulfate
ORAL SYRUP
2
*+Albuterol Sulfate
Albuterol Sulfate
TAB ER 12H
2
*+Albuterol Sulfate
Albuterol Sulfate
INHALATION SOLN
2
*+Albuterol Sulfate
Albuterol Sulfate
TABLET
2
*+Aminophylline
Aminophylline
ORAL SOLUTION
2
+ANORO ELLIPTA
Umeclidinium Brm/Vilanterol Tr INHALATION DISK
+ATROVENT HFA
Ipratropium Bromide
AEROSOL
3
+COMBIVENT RESPIMAT
Ipratropium/Albuterol Sulfate
AEROSOL
3
*+Elixophyllin
Theophylline Anhydrous
ORAL SOLUTION
2
QL
BRONCHODILATORS
3
BvD
PA,QL
QL
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
150
2015 CARE1ST MEDICARE DRUG FORMULARY
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
RESPIRATORY TRACT AGENTS (continued)
BRONCHODILATORS (continued)
Ipratropium Bromide
INHALATION SOLN
2
BvD
*+Ipratropium-Albuterol
Ipratropium/Albuterol Sulfate
INHALATION SOLN
2
BvD
*+Metaproterenol Sulfate
Metaproterenol Sulfate
ORAL SYRUP
2
*+Metaproterenol Sulfate
Metaproterenol Sulfate
TABLET
2
+PROAIR HFA
Albuterol Sulfate
AEROSOL
3
QL
+SEREVENT DISKUS
Salmeterol Xinafoate
INHALATION DISK
3
PA
+SPIRIVA
Tiotropium Bromide
INHALATION CAPSULE 3
QL
*Terbutaline Sulfate
Terbutaline Sulfate
INJECTION
2
*+Terbutaline Sulfate
Terbutaline Sulfate
TABLET
2
+THEO-24
Theophylline Anhydrous
CAP ER 24H
3
*+Theochron
Theophylline Anhydrous
TAB ER 12H
2
*+Theophylline
Theophylline Anhydrous
ORAL SOLUTION
2
*+Theophylline
Theophylline Anhydrous
TABLET ER
2
*+Theophylline Anhydrous
Theophylline Anhydrous
TAB ER 12H
2
*Theophylline In 5% Dextrose
Theophylline/D5W
INTRAVENOUS (IV)
2
BvD
+TUDORZA PRESSAIR
Aclidinium Bromide
AEROSOL
4
ST
+VENTOLIN HFA
Albuterol Sulfate
AEROSOL
3
QL
RESPIRATORY TRACT AGENTS
*+Ipratropium Bromide
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
151
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
RESPIRATORY TRACT AGENTS (continued)
RESPIRATORY TRACT AGENTS
RESPIRATORY TRACT AGENTS, OTHER
*Cromolyn Sodium
Cromolyn Sodium
INHALATION SOLN
2
BvD
+DALIRESP
Roflumilast
TABLET
4
PA
XOLAIR
Omalizumab
INJECTION
5
PA
ZEMAIRA
Alpha-1-Proteinase Inhibitor
INTRAVENOUS (IV)
5
PA
SKELETAL MUSCLE RELAXANTS
SKELETAL MUSCLE RELAXANTS
*+Baclofen
Baclofen
TABLET
2
*Carisoprodol
Carisoprodol
TABLET
2
QL, PA>65 y/o
*Chlorzoxazone
Chlorzoxazone
TABLET
2
QL, PA>65 y/o
*Comfort Pac-Cyclobenzaprine
Cyclobenz Hcl/Irr Cntr-Irr Cb2 KIT
2
QL, PA>65 y/o
*Comfort Pac-Tizanidine
Tizanidine/Irr Cntr-Irr Cmb #2 KIT
2
*Cyclobenzaprine Hcl
Cyclobenzaprine Hcl
TABLET
2
*+Dantrolene Sodium
Dantrolene Sodium
CAPSULE
2
*Methocarbamol
Methocarbamol
TABLET
2
*+Tizanidine Hcl
Tizanidine Hcl
TABLET
2
QL, PA>65 y/o
QL, PA>65 y/o
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
152
2015 CARE1ST MEDICARE DRUG FORMULARY
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
SLEEP DISORDER AGENTS
SLEEP DISORDER AGENTS
Modafinil
TABLET
3
PA
ROZEREM
Ramelteon
TABLET
3
PA
~XYREM
Sodium Oxybate
ORAL SOLUTION
5
PA
*Zaleplon
Zaleplon
CAPSULE
2
PA>65 y/o
*Zolpidem Tartrate
Zolpidem Tartrate
TABLET
2
QL, PA>65 y/o
VASODILATING AGENTS
VASODILATING AGENTS
+ADCIRCA
Tadalafil
TABLET
5
PA
+ADEMPAS
Riociguat
TABLET
5
PA
EPOPROSTENOL SODIUM
Epoprostenol Sodium (Glycine) INTRAVENOUS (IV)
5
BvD
LETAIRIS
Ambrisentan
TABLET
5
PA
REMODULIN
Treprostinil Sodium
INJECTION
5
PA
REVATIO
Sildenafil Citrate
INTRAVENOUS (IV)
5
PA
*+Sildenafil
Sildenafil Citrate
TABLET
2
PA
~+TRACLEER
Bosentan
TABLET
5
PA
VELETRI
Epoprostenol Sodium (Arginine) INTRAVENOUS (IV)
5
BvD
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
2015 CARE1ST MEDICARE DRUG FORMULARY
153
SLEEP DISORDER AGENTS
+MODAFINIL
BRAND DRUG NAME
NOMBRE DE MARCA
GENERIC DRUG NAME
NOMBRE GENERICO
FORMULATION
FORMA
FARMACEUTICA
REQUIREMENTS/
LIMITS
DRUG TIER
NIVEL DEL
REQUISITOS/
MEDICAMENTO LIMITES
VITAMINS AND MINERALS
VITAMINS AND MINERALS
Pnv119/Iron Fumarate/Fa/Dss TABLET
2
*+Prenatal Plus
Pnv With Ca,No.72/Iron/Fa
TABLET
2
VITAMINS AND MINERALS
*+Prenatal 19
* We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage
for more information about this coverage.
+ Maintenance drug. Up to a 90-day supply of this drug is available through our network mail-order pharmacy, and
through some of our network retail pharmacies. For more information call Member Services.
~This prescription may be available only at certain pharmacies. For more information consult your Provider Directory or
call Member Services at 1-800-544-0088, 8 a.m. to 8 p.m., seven days a week from October 1 through February 14, except
Thanksgiving and Christmas, and 8 a.m. to 8 p.m., Monday through Friday, from February 15 through September 30,
except holidays. TTY/TDD users should call 711.
(You can find information on what the abbreviations in this table mean by going to pages 11-12).
154
2015 CARE1ST MEDICARE DRUG FORMULARY
Index of Drugs
Indice de Medicamentos
8
8-MOP ................................................................... 112
A
ABACAVIR ..............................................................84
ABACAVIR-LAMIVUDINEZIDOVUDINE ..........................................................84
ABELCET ................................................................72
ABILIFY ...................................................................81
ABILIFY 2MG, 10MG ..............................................81
ABILIFY 5MG, 15MG, 20MG, 30MG .......................81
ABILIFY DISCMELT ................................................81
ABILIFY MAINTENA ...............................................81
ACAMPROSATE CALCIUM ....................................44
ACARBOSE ............................................................69
ACEBUTOLOL HCL ................................................97
ACETAMINOPHEN-CODEINE ...............................39
ACETASOL HC .....................................................122
ACETAZOLAMIDE ................................................146
ACITRETIN ........................................................... 112
ACTHIB .................................................................138
ACTIMMUNE .........................................................143
ACTONEL .............................................................141
ACYCLOVIR ............................................................89
ACYCLOVIR .......................................................... 112
ACYCLOVIR SODIUM ............................................89
ADACEL TDAP .....................................................138
ADAGEN ...............................................................120
ADAPALENE ......................................................... 118
ADASUVE ...............................................................81
ADCETRIS ..............................................................55
ADCIRCA ..............................................................153
ADEFOVIR DIPIVOXIL ........................................... 89
ADEMPAS ............................................................. 153
ADVAIR DISKUS .................................................. 149
ADVAIR HFA ......................................................... 149
AFEDITAB CR ...................................................... 101
AFINITOR ............................................................... 55
AFINITOR DISPERZ ............................................... 55
AGGRENOX ........................................................... 93
A-HYDROCORT ................................................... 131
ALA-CORT ............................................................ 114
ALA-SCALP .......................................................... 115
ALBENZA ................................................................ 79
ALBUTEROL SULFATE ........................................ 150
ALCAINE ............................................................... 121
ALCLOMETASONE DIPROPIONATE .................. 115
ALCOHOL PADS .................................................. 112
ALDURAZYME ...................................................... 120
ALENDRONATE SODIUM .................................... 141
ALFUZOSIN HCL ER ............................................ 129
ALIMTA ................................................................... 55
ALINIA ..................................................................... 79
ALLOPURINOL ..................................................... 143
ALORA .................................................................. 130
ALPHAGAN P ....................................................... 146
ALPRAZOLAM ........................................................ 45
ALTAVERA ........................................................... 106
ALYACEN ............................................................. 106
AMANTADINE ......................................................... 80
AMBISOME ............................................................. 72
AMCINONIDE ....................................................... 115
A-METHAPRED .................................................... 131
AMIFOSTINE ........................................................ 143
2015 CARE1ST MEDICARE DRUG FORMULARY
155
Index of Drugs
Indice de Medicamentos
AMIKACIN SULFATE .............................................. 46
AMILORIDE HCL .................................................. 101
AMILORIDEHYDROCHLOROTHIAZIDE .................................. 101
AMINOCAPROIC ACID ........................................... 92
AMINOPHYLLINE ................................................. 150
AMINOSYN ............................................................. 93
AMINOSYN II .......................................................... 93
AMINOSYN-HBC .................................................... 93
AMINOSYN-PF ....................................................... 93
AMIODARONE HCL ................................................ 96
AMITIZA ................................................................ 126
AMITRIPTYLINE HCL ............................................. 66
AMLODIPINE BESYLATE ..................................... 101
AMLODIPINE BESYLATEBENAZEPRIL 2.5MG-10MG, 5 MG-10
MG ......................................................................... 101
AMLODIPINE BESYLATEBENAZEPRIL 5 MG-20 MG, 10 MG20MG ..................................................................... 101
AMLODIPINE BESYLATEBENAZEPRIL 5 MG-40 MG, 10 MG40MG ..................................................................... 101
AMMONIUM LACTATE ......................................... 112
AMNESTEEM ........................................................ 112
AMOX TR-POTASSIUM
CLAVULANATE ...................................................... 51
AMOXAPINE ........................................................... 66
AMOXICILLIN .......................................................... 51
AMPHETAMINE SALT COMBO ........................... 105
AMPHOTERICIN B ................................................. 72
AMPICILLIN SODIUM ............................................. 51
AMPICILLIN TRIHYDRATE .................................... 51
AMPICILLIN-SULBACTAM ..................................... 51
AMPYRA ............................................................... 105
ANACAINE ............................................................ 112
ANADROL-50 ........................................................ 129
ANAGRELIDE HCL ................................................. 92
ANASTROZOLE ..................................................... 55
ANDRODERM ....................................................... 129
ANDROID .............................................................. 129
ANDROXY ............................................................ 130
ANERGAN 50 ......................................................... 77
ANORO ELLIPTA .................................................. 150
ANTIVENIN LATRODECTUS
MACTANS ............................................................. 135
ANTIVENIN MICRURUS FULVIUS ...................... 135
APEXICON E ........................................................ 115
APOKYN ................................................................. 80
APRI ...................................................................... 106
APTIOM .................................................................. 61
APTIVUS ................................................................. 84
ARANELLE ........................................................... 106
ARANESP 150MCG/0.3, 200MCG/0.4 ................... 91
ARANESP 200 MCG/ML, 300 MCG/ML ................. 91
ARANESP 25 MCG/ML, 40 MCG/ML ..................... 91
ARANESP 25MCG/0.42, 40 MCG/0.4 .................... 91
ARANESP 300MCG/0.6, 500 MCG/ML .................. 91
ARANESP 60MCG/0.3, 100MCG/0.5 ..................... 91
ARANESP 60MCG/ML, 100 MCG/ML .................... 91
ARCALYST ........................................................... 135
ARZERRA ............................................................... 55
ASCOMP WITH CODEINE ..................................... 39
ASMANEX ............................................................. 149
ASTAGRAF XL ..................................................... 135
ASTRAMORPH-PF ................................................. 39
2015 CARE1ST MEDICARE DRUG FORMULARY
156
Index of Drugs
Indice de Medicamentos
ATELVIA ................................................................ 141
ATENOLOL ............................................................. 97
ATENOLOL-CHLORTHALIDONE ........................... 97
ATGAM .................................................................. 135
ATORVASTATIN CALCIUM .................................. 102
ATOVAQUONE ....................................................... 79
ATOVAQUONE-PROGUANIL HCL ........................ 79
ATRIPLA ................................................................. 84
ATROVENT HFA ................................................... 150
AUBAGIO .............................................................. 135
AUBRA .................................................................. 106
AVANDIA ................................................................. 69
AVASTIN ................................................................. 55
AVEED .................................................................. 130
AVIANE ................................................................. 106
AVITA .................................................................... 118
AVODART ............................................................. 143
AVONEX ............................................................... 143
AVONEX ADMINISTRATION PACK ..................... 143
AZACITIDINE .......................................................... 55
AZATHIOPRINE .................................................... 135
AZELASTINE HCL ................................................ 121
AZILECT .................................................................. 80
AZITHROMYCIN ..................................................... 49
AZOPT .................................................................. 146
AZTREONAM .......................................................... 50
AZURETTE ........................................................... 106
B
BACITRACIN ......................................................... 122
BACITRACIN-POLYMYXIN .................................. 122
BACLOFEN ........................................................... 152
BALSALAZIDE DISODIUM ................................... 141
BALZIVA ............................................................... 106
BANZEL .................................................................. 61
BARACLUDE .......................................................... 89
BCG VACCINE (TICE STRAIN) ............................ 138
BENAZEPRIL HCL .................................................. 95
BENAZEPRILHYDROCHLOROTHIAZIDE ................................... 95
BENZTROPINE MESYLATE .................................. 80
BETAMETHASONE DIPROPIONATE .................. 115
BETAMETHASONE VALERATE .......................... 115
BETASERON ........................................................ 143
BETAXOLOL HCL ........................................... 97, 146
BETHANECHOL CHLORIDE ................................ 143
BICALUTAMIDE ...................................................... 55
BICILLIN C-R .......................................................... 51
BICILLIN L-A ........................................................... 51
BILTRICIDE ............................................................ 79
BISOPROLOL FUMARATE .................................... 97
BISOPROLOLHYDROCHLOROTHIAZIDE ................................... 98
BIVIGAM ............................................................... 135
BLEOMYCIN SULFATE .......................................... 55
BLEPH-10 ............................................................. 122
BOOSTRIX TDAP ................................................. 138
BOSULIF ................................................................. 55
BREVIBLOC ............................................................ 98
BRIELLYN ............................................................. 106
BRILINTA ................................................................ 93
BRIMONIDINE TARTRATE .................................. 146
BRINTELLIX ............................................................ 66
BROMFENAC SODIUM ........................................ 124
BROMOCRIPTINE MESYLATE .............................. 80
BUDESONIDE EC ................................................ 141
2015 CARE1ST MEDICARE DRUG FORMULARY
157
Index of Drugs
Indice de Medicamentos
BUMETANIDE .......................................................101
BUPHENYL ...........................................................126
BUPRENORPHINE HCL .........................................44
BUPRENORPHINE-NALOXONE ............................44
BUPROBAN ............................................................66
BUPROPION HCL ...................................................66
BUPROPION HCL SR .............................................66
BUPROPION XL .....................................................66
BUSPIRONE HCL .................................................143
BUTALB-CAFF-ACETAMINOPHCODEIN ..................................................................39
BUTALBITAL COMPOUND-CODEINE ...................39
BYDUREON ............................................................69
BYDUREON PEN ....................................................69
BYETTA ..................................................................69
C
CABERGOLINE ......................................................80
CALCIPOTRIENE ................................................. 112
CALCITONIN-SALMON ........................................142
CALCITRIOL .........................................................142
CALCIUM ACETATE .............................................127
CAMILA .................................................................107
CANASA ................................................................141
CANCIDAS ..............................................................72
CAPASTAT SULFATE ............................................76
CAPRELSA .............................................................55
CAPTOPRIL ............................................................95
CAPTOPRILHYDROCHLOROTHIAZIDE ....................................96
CARBAMAZEPINE ..................................................61
CARBAMAZEPINE ER ............................................61
CARBAMAZEPINE XR ............................................61
CARBIDOPA-LEVODOPA ...................................... 80
CARBIDOPA-LEVODOPA ER ................................ 80
CARBIDOPA-LEVODOPAENTACAPONE ....................................................... 80
CARIMUNE NF NANOFILTERED ........................ 135
CARISOPRODOL ................................................. 152
CARTEOLOL HCL ................................................ 121
CARTIA XT ............................................................. 99
CARVEDILOL ......................................................... 98
CAYSTON ............................................................... 50
CAZIANT ............................................................... 107
CEFACLOR ............................................................. 47
CEFACLOR ER ....................................................... 48
CEFADROXIL ......................................................... 48
CEFAZOLIN ............................................................ 48
CEFAZOLIN SODIUM ............................................. 48
CEFDINIR ............................................................... 48
CEFEPIME HCL ...................................................... 48
CEFOTAXIME SODIUM ......................................... 48
CEFPODOXIME PROXETIL ................................... 48
CEFPROZIL ............................................................ 48
CEFTAZIDIME ........................................................ 48
CEFTRIAXONE ....................................................... 48
CEFUROXIME ........................................................ 49
CEFUROXIME SODIUM ......................................... 49
CELEBREX ............................................................. 41
CELLCEPT ............................................................ 135
CELONTIN .............................................................. 61
CENESTIN ............................................................ 130
CEPHALEXIN ......................................................... 49
CEREZYME .......................................................... 120
CERVARIX ............................................................ 138
2015 CARE1ST MEDICARE DRUG FORMULARY
158
Index of Drugs
Indice de Medicamentos
CHANTIX .................................................................44
CHLORAMPHENICOL SOD
SUCCINATE ............................................................46
CHLORDIAZEPOXIDEAMITRIPTYLINE .....................................................66
CHLORHEXIDINE GLUCONATE ......................... 111
CHLOROQUINE PHOSPHATE ..............................79
CHLOROTHIAZIDE ...............................................101
CHLORPROMAZINE HCL ......................................81
CHLORTHALIDONE .............................................102
CHLORZOXAZONE ..............................................152
CHOLESTYRAMINE .............................................102
CHOLINE MAG TRISALICYLATE ...........................41
CHORIONIC GONADOTROPIN ...........................132
CICLOPIROX ..........................................................72
CILOSTAZOL ..........................................................93
CIMETIDINE ..........................................................125
CIMETIDINE HCL .................................................125
CIPROFLOXACIN ...................................................52
CIPROFLOXACIN ER .............................................53
CIPROFLOXACIN HCL ...................................53, 122
CITALOPRAM HBR ................................................66
CLARAVIS ............................................................. 112
CLARITHROMYCIN ................................................50
CLARITHROMYCIN ER ..........................................50
CLEMASTINE FUMARATE .....................................75
CLINDAMAX ......................................................... 113
CLINDAMYCIN HCL ...............................................47
CLINDAMYCIN PHOSPHATE .................. 47, 75, 113
CLOBETASOL PROPIONATE .............................. 115
CLOMIPRAMINE HCL ............................................66
CLONAZEPAM ........................................................45
CLONIDINE HCL .....................................................95
CLONIDINE HCL ER ............................................ 105
CLOPIDOGREL ...................................................... 93
CLORAZEPATE DIPOTASSIUM ............................ 45
CLOTRIMAZOLE .................................................... 73
CLOTRIMAZOLE-BETAMETHASONE ................... 73
CLOZAPINE ............................................................ 82
CLOZAPINE ODT ................................................... 82
CODEINE SULFATE ............................................... 39
COLCRYS ............................................................. 143
COLESTIPOL HCL ............................................... 103
COLISTIMETHATE SODIUM .................................. 47
COLOCORT .......................................................... 116
COMBIPATCH ...................................................... 130
COMBIVENT RESPIMAT ..................................... 150
COMETRIQ ............................................................. 55
COMFORT PAC-CYCLOBENZAPRINE ............... 152
COMFORT PAC-IBUPROFEN ............................... 42
COMFORT PAC-MELOXICAM ............................... 42
COMFORT PAC-NAPROXEN ................................ 42
COMFORT PAC-TIZANIDINE .............................. 152
COMPLERA ............................................................ 84
COMPRO ................................................................ 77
COMVAX ............................................................... 138
CONSTULOSE ..................................................... 126
COPAXONE .......................................................... 143
CORMAX .............................................................. 116
CORTISONE ACETATE ....................................... 131
COUMADIN ............................................................. 90
CREON ................................................................. 120
CRIXIVAN ............................................................... 84
CROFAB ............................................................... 135
CROMOLYN SODIUM .......................................... 121
2015 CARE1ST MEDICARE DRUG FORMULARY
159
Index of Drugs
Indice de Medicamentos
CROMOLYN SODIUM ..........................................126
CROMOLYN SODIUM ..........................................152
CRYSELLE ............................................................107
CUBICIN ..................................................................47
CUPRIMINE ..........................................................129
CYCLAFEM ...........................................................107
CYCLOBENZAPRINE HCL ...................................152
CYCLOPENTOLATE HCL ....................................121
CYCLOPHOSPHAMIDE .........................................55
CYCLOPHOSPHAMIDE .........................................56
CYCLOSERINE .......................................................76
CYCLOSET .............................................................69
CYCLOSPORINE ..................................................135
CYCLOSPORINE MODIFIED ...............................135
CYPROHEPTADINE HCL .......................................75
CYRAMZA ...............................................................56
CYSTADANE ........................................................144
CYSTAGON ..........................................................120
CYTOGAM ............................................................135
CYTRA-2 ...............................................................147
CYTRA-3 ...............................................................147
CYTRA-K ...............................................................147
D
DALIRESP .............................................................152
DANAZOL .............................................................130
DANTROLENE SODIUM ......................................152
DAPSONE ...............................................................76
DAPTACEL DTAP .................................................138
DARAPRIM .............................................................79
DASETTA ..............................................................107
DECITABINE ...........................................................56
DEFEROXAMINE MESYLATE .............................129
DELZICOL ............................................................. 141
DEMECLOCYCLINE HCL ....................................... 54
DEMSER ................................................................. 99
DENAVIR .............................................................. 112
DENTA 5000 PLUS ................................................111
DENTAGEL ............................................................111
DEPADE ................................................................. 45
DEPEN .................................................................. 129
DEPO-MEDROL ................................................... 131
DEPO-PROVERA ................................................. 133
DESIPRAMINE HCL ............................................... 66
DESLORATADINE .................................................. 75
DESMOPRESSIN ACETATE ................................ 132
DESOGESTREL-ETHINYL
ESTRADIOL .......................................................... 107
DESONATE .......................................................... 116
DESONIDE ........................................................... 116
DESOXIMETASONE ............................................ 116
DESVENLAFAXINE ER .......................................... 66
DEXAMETHASONE .............................................. 131
DEXAMETHASONE ACETATE ............................ 131
DEXAMETHASONE SODIUM
PHOSPHATE ................................................ 124, 131
DEXMETHYLPHENIDATE HCL ........................... 105
DEXMETHYLPHENIDATE HCL ER ..................... 105
DEXTROAMPHETAMINE SULFATE .................... 105
DEXTROAMPHETAMINE SULFATE
ER ......................................................................... 105
DEXTROAMPHETAMINEAMPHETAMINE .................................................... 105
DEXTROSE 5%-0.2% NACL-KCL ........................ 147
DEXTROSE 5%-0.3% NACL-KCL ........................ 147
DEXTROSE 5%-0.33% NACL-KCL ...................... 147
2015 CARE1ST MEDICARE DRUG FORMULARY
160
Index of Drugs
Indice de Medicamentos
DEXTROSE 5%-0.45% NACL-KCL ......................147
DEXTROSE 5%-1/2NS-KCL .................................147
DEXTROSE 5%-1/4NS-KCL .................................147
DEXTROSE 5%-NS-KCL ......................................147
DEXTROSE 5%-POTASSIUM
CHLORIDE ............................................................147
DEXTROSE IN LACTATED RINGERS ...................93
DEXTROSE IN RINGERS INJECTION ...................93
DEXTROSE IN WATER ..........................................93
DEXTROSE IN WATER 40% ..................................94
DEXTROSE IN WATER 70% ..................................94
DEXTROSE WITH SODIUM
CHLORIDE ..............................................................94
DIAZEPAM ..............................................................45
DICLOFENAC POTASSIUM ...................................42
DICLOFENAC SODIUM ..........................................42
DICLOFENAC SODIUM ........................................124
DICLOFENAC SODIUM ER ....................................42
DICLOXACILLIN SODIUM ......................................52
DICYCLOMINE HCL .............................................126
DIDANOSINE ..........................................................84
DIFFERIN .............................................................. 119
DIFLORASONE DIACETATE ............................... 116
DIFLUNISAL ............................................................42
DIGIFAB ..................................................................99
DIGOX .....................................................................99
DIGOXIN ...............................................................100
DIHYDROERGOTAMINE MESYLATE ...................76
DILANTIN ................................................................61
DILANTIN-125 .........................................................62
DILTIAZEM 24HR ER .............................................99
DILTIAZEM ER ........................................................99
DILTIAZEM HCL .....................................................99
DILT-XR .................................................................. 99
DIOVAN .................................................................. 95
DIPENTUM ........................................................... 141
DIPHENHYDRAMINE HCL ..................................... 75
DIPHENOXYLATE-ATROPINE ............................ 126
DIPHTHERIA-TETANUS TOXOIDSPED ....................................................................... 138
DIPYRIDAMOLE ..................................................... 93
DISKETS ................................................................. 39
DISOPYRAMIDE PHOSPHATE ............................. 96
DISULFIRAM .......................................................... 45
DIVALPROEX SODIUM .......................................... 62
DIVALPROEX SODIUM ER .................................... 62
DOCETAXEL .......................................................... 56
DONEPEZIL HCL .................................................... 65
DONEPEZIL HCL ODT ........................................... 65
DORZOLAMIDE HCL ............................................ 146
DORZOLAMIDE-TIMOLOL ................................... 146
DOXAZOSIN MESYLATE ....................................... 95
DOXEPIN HCL ........................................................ 66
DOXERCALCIFEROL ........................................... 142
DOXY 100 ............................................................... 54
DOXYCYCLINE HYCLATE ..................................... 54
DOXYCYCLINE MONOHYDRATE ......................... 54
DOXY-LEMMON ..................................................... 54
DRONABINOL ........................................................ 77
DROSPIRENONE-ETHINYL
ESTRADIOL .......................................................... 107
DROXIA .................................................................. 56
DULOXETINE HCL ................................................. 66
E
E.E.S. 400 ............................................................... 50
2015 CARE1ST MEDICARE DRUG FORMULARY
161
Index of Drugs
Indice de Medicamentos
ECLIPSE LUER-LOK SYRINGE ........................... 119
ECONAZOLE NITRATE ..........................................73
ED DOXY-CAPS .....................................................54
ED K+10 ................................................................147
EDURANT ...............................................................84
EFFER-K ...............................................................147
ELAPRASE ...........................................................120
ELELYSO ..............................................................120
ELIDEL .................................................................. 116
ELIGARD .................................................................56
ELIPHOS ...............................................................128
ELIQUIS ..................................................................90
ELITEK ..................................................................120
ELIXOPHYLLIN .....................................................150
ELLA ......................................................................107
EMCYT ....................................................................56
EMEND ...................................................................77
EMOQUETTE ........................................................107
EMSAM ...................................................................67
EMTRIVA ................................................................85
ENALAPRIL MALEATE ...........................................96
ENALAPRILHYDROCHLOROTHIAZIDE ....................................96
ENBREL ................................................................135
ENDOCET ...............................................................39
ENDODAN ..............................................................39
ENGERIX-B ADULT ..............................................138
ENGERIX-B PEDIATRICADOLESCENT ......................................................138
ENOXAPARIN SODIUM .........................................90
ENOXAPARIN SODIUM 30MG/0.3ML,
40MG/0.4ML, 60MG/0.6ML .....................................90
ENOXAPARIN SODIUM 80MG/0.8ML,
100 MG/ML, 120MG/.8ML, 150 MG/ML .................. 90
ENPRESSE ........................................................... 107
ENSKYCE ............................................................. 107
ENTACAPONE ....................................................... 80
EPINEPHRINE ...................................................... 100
EPIPEN 2-PAK ...................................................... 100
EPITOL ................................................................... 62
EPIVIR .................................................................... 85
EPIVIR HBV ............................................................ 85
EPLERENONE ...................................................... 103
EPOGEN ................................................................. 91
EPOGEN 2000/ML, 3000/ML, 4000/ML,
10000/ML ................................................................ 91
EPOPROSTENOL SODIUM ................................. 153
EPZICOM ................................................................ 85
ERAXIS (WATER DILUENT) .................................. 73
ERGOLOID MESYLATES ..................................... 144
ERGOMAR .............................................................. 76
ERGOTAMINE-CAFFEINE ..................................... 76
ERIVEDGE .............................................................. 56
ERRIN ................................................................... 107
ERWINAZE ............................................................. 56
ERY ....................................................................... 114
ERYTHROCIN LACTOBIONATE ............................ 50
ERYTHROCIN STEARATE .................................... 50
ERYTHROMYCIN ................................... 50, 114, 122
ERYTHROMYCIN ETHYLSUCCINATE .................. 50
ERYTHROMYCIN-BENZOYL
PEROXIDE ............................................................ 114
ERYTHROMYCIN-SULFISOXAZOLE .................... 50
ESCITALOPRAM OXALATE .................................. 67
ESMOLOL HCL ....................................................... 98
2015 CARE1ST MEDICARE DRUG FORMULARY
162
Index of Drugs
Indice de Medicamentos
ESTRADIOL ..........................................................130
ESTRADIOL-NORETHINDRONE
ACETAT ................................................................130
ESTROPIPATE .....................................................130
ETHAMBUTOL HCL ................................................76
ETHOSUXIMIDE .....................................................62
ETIDRONATE DISODIUM ....................................142
ETODOLAC .............................................................42
ETODOLAC ER .......................................................42
EXELON ..................................................................65
EXEMESTANE ........................................................56
EXJADE ................................................................129
EXTAVIA ...............................................................144
F
FABRAZYME ........................................................120
FALMINA ...............................................................107
FAMOTIDINE ........................................................125
FANAPT ..................................................................82
FARESTON .............................................................56
FASLODEX .............................................................56
FAZACLO ................................................................82
FELBAMATE ...........................................................62
FELODIPINE ER ...................................................101
FENOFIBRATE .....................................................103
FENOPROFEN CALCIUM ......................................42
FENTANYL ..............................................................39
FENTANYL CITRATE .............................................39
FETZIMA .................................................................67
FINASTERIDE .......................................................144
FIRAZYR ...............................................................100
FIRMAGON .............................................................56
FLECAINIDE ACETATE ..........................................96
FLOVENT HFA ..................................................... 150
FLUCONAZOLE ...................................................... 73
FLUCONAZOLE IN SALINE ................................... 73
FLUCYTOSINE ....................................................... 73
FLUDROCORTISONE ACETATE ........................ 131
FLUNISOLIDE ....................................................... 124
FLUOCINOLONE ACETONIDE ............................ 116
FLUOCINOLONE ACETONIDE OIL ..................... 124
FLUOCINONIDE ................................................... 116
FLUOROMETHOLONE ........................................ 124
FLUOROURACIL .................................................. 112
FLUOXETINE DR ................................................... 67
FLUOXETINE HCL ................................................. 67
FLUPHENAZINE DECANOATE ............................. 82
FLUPHENAZINE HCL ............................................. 82
FLURBIPROFEN .................................................... 42
FLURBIPROFEN SODIUM ................................... 124
FLUTAMIDE ............................................................ 56
FLUTICASONE PROPIONATE .................... 117, 124
FLUVOXAMINE MALEATE ..................................... 67
FOCALIN XR ......................................................... 105
FOLOTYN ............................................................... 56
FOMEPIZOLE ....................................................... 144
FONDAPARINUX SODIUM .................................... 90
FORTAZ IN ISO-OSMOTIC
DEXTROSE ............................................................ 49
FORTEO ............................................................... 142
FORTICAL ............................................................ 142
FOSINOPRIL SODIUM ........................................... 96
FOSINOPRILHYDROCHLOROTHIAZIDE ................................... 96
FRAGMIN ................................................................ 90
FREAMINE HBC ..................................................... 94
2015 CARE1ST MEDICARE DRUG FORMULARY
163
Index of Drugs
Indice de Medicamentos
FRUCTOSE .............................................................94
FULVICIN U/F .........................................................73
FUROSEMIDE ......................................................102
FUZEON ..................................................................85
FYCOMPA ...............................................................62
G
GABAPENTIN .........................................................62
GABITRIL ................................................................62
GAMUNEX-C ........................................................136
GANCICLOVIR SODIUM ........................................89
GARDASIL ............................................................138
GAVILYTE-C .........................................................127
GAVILYTE-N .........................................................127
GAZYVA ..................................................................56
GEMCITABINE HCL ...............................................56
GEMFIBROZIL ......................................................103
GENERLAC ...........................................................126
GENGRAF .............................................................136
GENOTROPIN ......................................................132
GENTAK ................................................................122
GENTAMICIN SULFATE .................................46, 123
GEODON ................................................................82
GILDAGIA .............................................................107
GILDESS ...............................................................107
GILDESS FE .........................................................107
GILENYA ...............................................................144
GILOTRIF ................................................................57
GLEEVEC ...............................................................57
GLIMEPIRIDE .........................................................71
GLIPIZIDE ...............................................................71
GLIPIZIDE ER .........................................................71
GLIPIZIDE-METFORMIN ........................................71
GLUCAGEN .......................................................... 144
GLUCAGON EMERGENCY KIT ........................... 144
GLUCOSE ............................................................... 94
GLYBURIDE ........................................................... 72
GLYBURIDE MICRONIZED .................................... 72
GLYBURIDE-METFORMIN HCL ............................ 72
GLYCOPYRROLATE ............................................ 126
GLYSET .................................................................. 69
GRANISETRON HCL .............................................. 78
GRANIX .................................................................. 91
GRISEOFULVIN ..................................................... 73
GRISEOFULVIN ULTRAMICROSIZE ..................... 73
GUANFACINE HCL ................................................ 95
GUANIDINE HCL .................................................. 144
H
HALAVEN ............................................................... 57
HALOBETASOL PROPIONATE ........................... 117
HALOPERIDOL ....................................................... 82
HALOPERIDOL DECANOATE ............................... 82
HALOPERIDOL LACTATE ..................................... 82
HAVRIX ................................................................. 138
HCTZ/RESERPINE/HYDRALAZINE ..................... 100
HEATHER ............................................................. 107
HECTOROL .......................................................... 142
HEPAGAM B ......................................................... 136
HEPARIN FLUSH ................................................... 90
HEPARIN SODIUM ................................................. 90
HEPARIN SODIUM-D5W ........................................ 91
HEPARIN SODIUM-NS ........................................... 91
HEPATASOL ........................................................... 94
HEXALEN ............................................................... 57
HOMATROPAIRE ................................................. 121
2015 CARE1ST MEDICARE DRUG FORMULARY
164
Index of Drugs
Indice de Medicamentos
HOMATROPINE HYDROBROMIDE .....................121
HUMALOG ..............................................................70
HUMALOG MIX 50-50 .............................................70
HUMALOG MIX 75-25 .............................................70
HUMATROPE .......................................................132
HUMIRA ................................................................136
HUMORSOL ..........................................................146
HUMULIN 70/30 KWIKPEN ....................................70
HUMULIN 70-30 ......................................................70
HUMULIN N ............................................................70
HUMULIN N KWIKPEN ...........................................70
HUMULIN R ............................................................70
HYCORT ............................................................... 117
HYDRALAZINE HCL .............................................100
HYDRALAZINE W/HCTZ ......................................100
HYDROCHLOROTHIAZIDE ..................................102
HYDROCHLOROTHIAZIDE/
RESERPINE ..........................................................100
HYDROCODONE BIT-IBUPROFEN .......................39
HYDROCODONE-ACETAMINOPHEN ...................39
HYDROCODONE-IBUPROFEN .............................39
HYDROCORTISONE .................................... 117, 131
HYDROCORTISONE BUTYRATE ........................ 117
HYDROCORTISONE PLUS .................................. 117
HYDROCORTISONE VALERATE ........................ 117
HYDROMORPHONE HCL ......................................39
HYDROXYCHLOROQUINE SULFATE ...................79
HYDROXYUREA .....................................................57
HYDROXYZINE HCL ............................................144
HYPERHEP B S-D ................................................136
HYPERLYTE CR ...................................................148
HYPERLYTE R .....................................................148
HYPERRAB S-D ................................................... 136
HYPERRHO S-D ................................................... 136
HYPERTET S-D .................................................... 136
I
IBANDRONATE SODIUM ..................................... 142
IBUPROFEN ........................................................... 42
ICLUSIG .................................................................. 57
IMBRUVICA ............................................................ 57
IMIPENEM-CILASTATIN SODIUM ......................... 50
IMIPRAMINE HCL ................................................... 67
IMIPRAMINE PAMOATE ........................................ 67
IMIQUIMOD .......................................................... 112
IMOGAM RABIES-HT ........................................... 136
IMOVAX RABIES VACCINE ................................. 138
INCIVEK .................................................................. 88
INCRELEX ............................................................ 133
INDAPAMIDE ........................................................ 102
INDOMETHACIN .................................................... 42
INFANRIX DTAP ................................................... 139
INFERGEN .............................................................. 88
INLYTA .................................................................... 57
INSULIN SYRINGE ............................................... 119
INTELENCE ............................................................ 85
INTRALIPID ............................................................ 94
INTRON A ............................................................... 88
INTROVALE .......................................................... 107
INTUNIV ................................................................ 105
INVANZ ................................................................... 50
INVEGA 1.5 MG, 3 MG ........................................... 82
INVEGA 6 MG, 9 MG .............................................. 83
INVEGA SUSTENNA 117MG/0.75ML,
156 MG/ML, 234MG/1.5ML ..................................... 83
2015 CARE1ST MEDICARE DRUG FORMULARY
165
Index of Drugs
Indice de Medicamentos
INVEGA SUSTENNA 39MG/0.25,
78MG/0.5ML ............................................................83
INVIRASE ................................................................85
INVOKANA ..............................................................69
IPOL ......................................................................139
IPRATROPIUM BROMIDE ............................121, 151
IPRATROPIUM-ALBUTEROL ...............................151
ISENTRESS ............................................................85
ISODITRATE .........................................................104
ISONIAZID ..............................................................76
ISOSORBIDE DINITRATE ....................................104
ISOSORBIDE MONONITRATE ............................104
ISOSORBIDE MONONITRATE ER ......................104
ISRADIPINE ..........................................................101
ISTODAX .................................................................57
ITRACONAZOLE ....................................................73
IXIARO ..................................................................139
J
JAKAFI ....................................................................57
JANTOVEN .............................................................91
JANUMET ...............................................................69
JANUMET XR .........................................................69
JANUVIA .................................................................69
JENTADUETO ........................................................69
JEVTANA ................................................................57
JOLESSA ..............................................................108
JOLIVETTE ...........................................................108
JUNEL ...................................................................108
JUNEL FE .............................................................108
K
K EFFERVESCENT ..............................................148
KADCYLA ............................................................... 57
KALETRA ................................................................ 85
KARIVA ................................................................. 108
KELNOR 1-35 ....................................................... 108
KEPIVANCE .......................................................... 144
KETEK .................................................................... 50
KETOCONAZOLE ................................................... 73
KETOPROFEN ....................................................... 42
KETOROLAC TROMETHAMINE .................... 43, 124
KHEDEZLA ............................................................. 67
KINERET ............................................................... 136
KINRIX .................................................................. 139
KIONEX ................................................................. 128
KLOR-CON ........................................................... 148
KLOR-CON 10 ...................................................... 148
KLOR-CON 8 ........................................................ 148
KLOR-CON M15 ................................................... 148
KLOR-CON M20 ................................................... 148
KLOR-CON-EF ..................................................... 148
KURVELO ............................................................. 108
KUVAN .................................................................. 120
KYPROLIS .............................................................. 57
L
LABETALOL HCL ................................................... 98
LACRISERT .......................................................... 121
LACTATED RINGERS .......................................... 148
LACTULOSE ......................................................... 126
LAMIVUDINE .......................................................... 85
LAMIVUDINE HBV .................................................. 85
LAMIVUDINE-ZIDOVUDINE ................................... 86
LAMOTRIGINE ....................................................... 62
LANOXIN .............................................................. 100
2015 CARE1ST MEDICARE DRUG FORMULARY
166
Index of Drugs
Indice de Medicamentos
LANOXIN PEDIATRIC ..........................................100
LANSOPRAZOLE .................................................125
LANTUS ..................................................................71
LANTUS SOLOSTAR ..............................................71
LARIN FE ..............................................................108
LATANOPROST ....................................................146
LATUDA ..................................................................83
LAZANDA ................................................................40
LEENA ...................................................................108
LEFLUNOMIDE .....................................................136
LESSINA ...............................................................108
LETAIRIS ..............................................................153
LETROZOLE ...........................................................57
LEUCOVORIN CALCIUM .....................................144
LEUKERAN .............................................................57
LEUKINE .................................................................92
LEUPROLIDE ACETATE ........................................57
LEVETIRACETAM ..................................................63
LEVETIRACETAM ER ............................................63
LEVETIRACETAM-NACL ........................................63
LEVLEN 28 ............................................................108
LEVOBUNOLOL HCL ...........................................146
LEVOFLOXACIN .....................................................53
LEVOFLOXACIN-D5W ............................................53
LEVONEST ...........................................................108
LEVONORGESTREL ............................................108
LEVONORGESTREL-ETH
ESTRADIOL ..........................................................108
LEVORA-28 ...........................................................108
LEVOTHYROXINE SODIUM ................................134
LEVOXYL ..............................................................134
LEVULAN .............................................................. 112
LEXIVA .................................................................... 86
LIDOCAINE ............................................................. 44
LIDOCAINE HCL ..................................................... 44
LIDOCAINE HCL IN 5% DEXTROSE ..................... 96
LIDOCAINE HCL VISCOUS ................................... 44
LIDOCAINE-PRILOCAINE ...................................... 44
LINDANE ............................................................... 119
LIOTHYRONINE SODIUM .................................... 134
LIPODOX ................................................................ 57
LISINOPRIL ............................................................ 96
LISINOPRILHYDROCHLOROTHIAZIDE ................................... 96
LITHIUM ................................................................ 105
LITHIUM CARBONATE ........................................ 105
LOKARA ................................................................ 117
LOMUSTINE ........................................................... 57
LOPERAMIDE ....................................................... 127
LORAZEPAM .......................................................... 46
LORCET .................................................................. 40
LORCET HD ........................................................... 40
LORCET PLUS ....................................................... 40
LOSARTAN POTASSIUM ....................................... 95
LOSARTANHYDROCHLOROTHIAZIDE ................................... 95
LOTEMAX ............................................................. 124
LOTRONEX .......................................................... 120
LOVASTATIN ........................................................ 103
LOW-OGESTREL ................................................. 108
LOXAPINE .............................................................. 83
LUPRON DEPOT .................................................... 58
LUPRON DEPOT-PED ........................................... 58
LUTERA ................................................................ 108
LYRICA ................................................................... 63
2015 CARE1ST MEDICARE DRUG FORMULARY
167
Index of Drugs
Indice de Medicamentos
LYSODREN .............................................................58
M
MAPROTILINE HCL ................................................67
MARLISSA ............................................................109
MARPLAN ...............................................................67
MARQIBO ...............................................................58
MATULANE .............................................................58
MAXIDEX ..............................................................124
MECLIZINE HCL .....................................................78
MECLOFENAMATE SODIUM .................................43
MEDROXYPROGESTERONE
ACETATE ..............................................................133
MEFLOQUINE HCL ................................................79
MEGESTROL ACETATE ........................................58
MEKINIST ...............................................................58
MELOXICAM ...........................................................43
MELPHALAN HCL ..................................................58
MENACTRA ..........................................................139
MENEST ...............................................................130
MENHIBRIX ..........................................................139
MENOMUNE-A-C-Y-W-135 ..................................139
MENVEO A-C-Y-W-135-DIP .................................139
MEPERIDINE HCL ..................................................40
MEPERITAB ............................................................40
MERCAPTOPURINE ..............................................58
MEROPENEM .........................................................51
MESALAMINE .......................................................141
MESNEX ...............................................................144
METAPROTERENOL SULFATE ..........................151
METFORMIN HCL ..................................................69
METFORMIN HCL ER ............................................69
METHADONE HCL .................................................40
METHADONE INTENSOL ...................................... 40
METHADOSE ......................................................... 40
METHAZOLAMIDE ............................................... 146
METHENAMINE HIPPURATE ................................ 47
METHENAMINE MANDELATE ............................... 47
METHIMAZOLE .................................................... 134
METHOCARBAMOL ............................................. 152
METHOTREXATE ................................................... 58
METHOXSALEN ................................................... 112
METHYCLOTHIAZIDE .......................................... 102
METHYLDOPA ....................................................... 95
METHYLDOPA/
HYDROCHLOROTHIAZIDE ................................... 95
METHYLDOPAHYDROCHLOROTHIAZIDE ................................... 95
METHYLPHENIDATE ER ..................................... 105
METHYLPHENIDATE HCL ................................... 105
METHYLPHENIDATE SR ..................................... 105
METHYLPREDNISOLONE ................................... 131
METHYLPREDNISOLONE ACETATE ................. 131
METHYLPREDNISOLONE SOD SUCC ............... 132
METIPRANOLOL .................................................. 146
METOCLOPRAMIDE HCL .................................... 127
METOLAZONE ..................................................... 102
METOPROLOL SUCCINATE ................................. 98
METOPROLOL TARTRATE ................................... 98
METOPROLOLHYDROCHLOROTHIAZIDE ................................... 98
METRONIDAZOLE ................................... 75, 79, 114
METRYL .................................................................. 79
MEXILETINE HCL ................................................... 97
MIACALCIN ........................................................... 142
MICONAZOLE 3 ..................................................... 74
2015 CARE1ST MEDICARE DRUG FORMULARY
168
Index of Drugs
Indice de Medicamentos
MICRHOGAM ULTRA-FILTERED
PLUS .....................................................................136
MICROGESTIN .....................................................109
MICROGESTIN FE ...............................................109
MIDODRINE HCL ....................................................95
MIFEPREX ............................................................144
MIGERGOT .............................................................76
MILRINONE IN 5% DEXTROSE ...........................100
MIMVEY ................................................................130
MINITRAN .............................................................104
MINOCYCLINE HCL ...............................................54
MINOXIDIL ............................................................104
MIRTAZAPINE ........................................................67
MISOPROSTOL ....................................................125
MITOXANTRONE HCL ...........................................58
M-M-R II VACCINE ...............................................139
MODAFINIL ...........................................................153
MOEXIPRIL HCL .....................................................96
MOMETASONE FUROATE .................................. 118
MONO-LINYAH .....................................................109
MONONESSA .......................................................109
MONTELUKAST SODIUM ....................................150
MORPHINE SULFATE ............................................40
MORPHINE SULFATE ER ......................................41
MOXIFLOXACIN HCL .............................................53
MOZOBIL ................................................................92
MULTAQ .................................................................97
MUPIROCIN .......................................................... 114
MYCONEL ...............................................................74
MYCOPHENOLATE MOFETIL .............................136
MYCOPHENOLIC ACID ........................................137
MYOZYME ............................................................120
MYRBETRIQ ......................................................... 128
MYZILRA ............................................................... 109
N
NABI-HB ................................................................ 137
NABUMETONE ....................................................... 43
NADOLOL ............................................................... 98
NAFCILLIN SODIUM .............................................. 52
NAGLAZYME ........................................................ 120
NALIDIXIC ACID ..................................................... 53
NALLPEN-ISO-OSMOTIC DEXTROSE .................. 52
NALOXONE HCL .................................................... 45
NALTREXONE HCL ................................................ 45
NAMENDA .............................................................. 65
NAMENDA XR ........................................................ 65
NAPHAZOLINE HCL ............................................. 121
NAPHAZOLINE HCL W/ANTAZOLINE ................. 121
NAPROXEN ............................................................ 43
NAPROXEN SODIUM ............................................. 43
NATEGLINIDE ........................................................ 69
NEBUPENT ............................................................. 79
NECON ................................................................. 109
NEFAZODONE HCL ............................................... 67
NEGGRAM .............................................................. 53
NEOFRIN .............................................................. 121
NEOMYCIN SULFATE ............................................ 46
NEOMYCIN W/DEXAMETHASONE ..................... 123
NEOMYCIN-BACITRACIN-POLY-HC ................... 123
NEOMYCIN-BACITRACINPOLYMYXIN ......................................................... 123
NEOMYCIN-POLYMYXIN-DEXAMETH ............... 123
NEOMYCIN-POLYMYXINGRAMICIDIN ......................................................... 123
2015 CARE1ST MEDICARE DRUG FORMULARY
169
Index of Drugs
Indice de Medicamentos
NEOMYCIN-POLYMYXIN-HC ..............................123
NEOMYCIN-POLYMYXINHYDROCORT .......................................................123
NEPHRAMINE ........................................................94
NEULASTA .............................................................92
NEUMEGA ..............................................................92
NEUPOGEN ............................................................92
NEVIRAPINE ...........................................................86
NEVIRAPINE ER .....................................................86
NEXAVAR ...............................................................58
NEXT CHOICE ONE DOSE ..................................109
NIACIN ER ............................................................103
NICARDIPINE HCL ...............................................101
NICOTROL ..............................................................45
NICOTROL NS ........................................................45
NIFEDICAL XL ......................................................101
NIFEDIPINE ER ....................................................101
NILANDRON ...........................................................58
NITROFURANTOIN ................................................47
NITROGLYCERIN PATCH ....................................104
NITROSTAT ..........................................................104
NIZATIDINE ..........................................................125
NORA-BE ..............................................................109
NORDITROPIN FLEXPRO ...................................133
NORDITROPIN NORDIFLEX ................................133
NORETHINDRONE ...............................................109
NORETHINDRONE ACETATE .............................134
NORETHINDRON-ETHINYL
ESTRADIOL ..........................................................109
NORETHIN-ETH ESTRA FERROUS
FUM .......................................................................109
NORGESTIMATE-ETHINYL
ESTRADIOL ..........................................................109
NORLYROC .......................................................... 109
NORTREL ............................................................. 109
NORTRIPTYLINE HCL ........................................... 68
NORVIR .................................................................. 86
NOVOLIN 70-30 ...................................................... 71
NOVOLIN N ............................................................ 71
NOVOLIN R ............................................................ 71
NOVOLOG .............................................................. 71
NOVOLOG FLEXPEN ............................................. 71
NOVOLOG MIX 70-30 ............................................ 71
NOVOLOG MIX 70-30 FLEXPEN ........................... 71
NUEDEXTA ........................................................... 106
NULOJIX ............................................................... 137
NUTRILYTE II ....................................................... 148
NUTROPIN ........................................................... 133
NUTROPIN AQ NUSPIN ....................................... 133
NYAMYC ................................................................. 74
NYSTATIN .............................................................. 74
NYSTATIN-TRIAMCINOLONE ............................... 74
NYSTOP ................................................................. 74
O
OFLOXACIN ................................................... 53, 123
OGESTREL ........................................................... 109
OLANZAPINE ......................................................... 83
OLANZAPINE ODT ................................................. 83
OLYSIO ................................................................... 88
OMEGA-3 ACID ETHYL ESTERS ........................ 103
OMEPRAZOLE ..................................................... 125
ONCASPAR ............................................................ 58
ONDANSETRON HCL ............................................ 78
ONDANSETRON ODT ............................................ 78
ONFI ........................................................................ 46
2015 CARE1ST MEDICARE DRUG FORMULARY
170
Index of Drugs
Indice de Medicamentos
ONTAK ....................................................................58
ORALONE ............................................................. 111
ORAP ......................................................................83
ORENCIA ..............................................................137
ORFADIN ..............................................................120
ORSYTHIA ............................................................109
OTEZLA ................................................................144
OTIMAR ................................................................123
OTOMYCET-HC ....................................................123
OXALIPLATIN .........................................................59
OXANDROLONE ..................................................130
OXAPROZIN ...........................................................43
OXCARBAZEPINE ..................................................63
OXSORALEN ........................................................ 112
OXSORALEN-ULTRA ........................................... 112
OXTELLAR XR ........................................................63
OXYBUTYNIN CHLORIDE ...................................128
OXYBUTYNIN CHLORIDE ER .............................128
OXYCODONE HCL .................................................41
OXYCODONE HCLACETAMINOPHEN .................................................41
OXYCODONE HCL-ASPIRIN .................................41
OXYCODONE-ACETAMINOPHEN ........................41
OXYCONTIN ...........................................................41
P
PACERONE ............................................................97
PAMIDRONATE DISODIUM .................................142
PANCRELIPASE 5,000 .........................................120
PANRETIN ............................................................ 113
PANTOPRAZOLE SODIUM ..................................125
PARICALCITOL ....................................................142
PAROMOMYCIN SULFATE ....................................79
PAROXETINE HCL ................................................. 68
PASER .................................................................... 77
PATANOL ............................................................. 122
PAXIL ...................................................................... 68
PEDIARIX ............................................................. 139
PEDI-DRI ................................................................ 74
PEDVAXHIB .......................................................... 139
PEG 3350-ELECTROLYTE .................................. 127
PEG 3350-GRX ..................................................... 127
PEG-3350 ............................................................. 127
PEG-3350 AND ELECTROLYTES ....................... 127
PEGANONE ............................................................ 63
PEGASYS ............................................................... 88
PEGASYS PROCLICK ............................................ 89
PEGINTRON ........................................................... 89
PEGINTRON REDIPEN .......................................... 89
PEN NEEDLE ....................................................... 119
PENICILLIN G POTASSIUM ................................... 52
PENICILLIN G SODIUM ......................................... 52
PENICILLIN GK-ISO-OSM DEXTROSE ................. 52
PENICILLIN V POTASSIUM ................................... 52
PENTACEL ACTHIB COMPONENT ..................... 139
PENTACEL DTAP-IPV COMPONENT ................. 139
PENTAM 300 .......................................................... 79
PENTAMIDINE ISETHIONATE ............................... 79
PENTASA ............................................................. 141
PENTOXIFYLLINE .................................................. 93
PERIOGARD ..........................................................111
PERJETA ................................................................ 59
PERMETHRIN ...................................................... 119
PERPHENAZINE .................................................... 83
PERPHENAZINE-AMITRIPTYLINE ........................ 68
2015 CARE1ST MEDICARE DRUG FORMULARY
171
Index of Drugs
Indice de Medicamentos
PFIZERPEN ............................................................52
PHENADOZ ............................................................78
PHENELZINE SULFATE .........................................68
PHENOBARBITAL ..................................................63
PHENYLEPHRINE HCL ........................................122
PHENYTEK .............................................................63
PHENYTOIN ...........................................................63
PHENYTOIN SODIUM ............................................63
PHENYTOIN SODIUM EXTENDED .......................64
PHILITH .................................................................109
PHOSPHA 250 NEUTRAL ....................................148
PHOSPHOLINE IODIDE .......................................146
PICATO ................................................................. 113
PILOCARPINE HCL ...................................... 111, 146
PINDOLOL ..............................................................98
PIOGLITAZONE HCL ..............................................69
PIPERACILLIN-TAZOBACTAM ..............................52
PIRMELLA ............................................................. 110
PIROXICAM ............................................................43
PODOCON-25 ....................................................... 113
PODOFILOX ......................................................... 113
POLYETHYLENE GLYCOL 3350 .........................127
POLYMYXIN B SUL-TRIMETHOPRIM .................123
POMALYST .............................................................59
PORTIA ................................................................. 110
POTASSIUM BICARBONATE ..............................148
POTASSIUM CHL-NORMAL SALINE ...................148
POTASSIUM CHLORIDE ......................................148
POTASSIUM CHLORIDE IN D5LR .........................94
POTASSIUM CITRATE .........................................149
POTIGA ...................................................................64
PRADAXA ...............................................................91
PRAMIPEXOLE DIHYDROCHLORIDE .................. 81
PRAVASTATIN SODIUM ...................................... 103
PRAZOSIN HCL ...................................................... 95
PREDNISOLONE ACETATE ................................ 124
PREDNISOLONE SODIUM
PHOSPHATE ................................................ 125, 132
PREDNISONE ...................................................... 132
PREMARIN ........................................................... 130
PREMASOL ............................................................ 94
PREMPHASE ........................................................ 131
PREMPRO ............................................................ 131
PRENATAL 19 ...................................................... 154
PRENATAL PLUS ................................................. 154
PREVALITE .......................................................... 103
PREVIFEM ............................................................ 110
PREZISTA ............................................................... 86
PRIFTIN .................................................................. 77
PRIMAQUINE ......................................................... 79
PRIMAXIN I.M. ........................................................ 51
PRIMIDONE ............................................................ 64
PRISTIQ ER ............................................................ 68
PROAIR HFA ........................................................ 151
PROBENECID ...................................................... 145
PROBENECID-COLCHICINE ............................... 145
PROCAINAMIDE HCL ............................................ 97
PROCHLORPERAZINE EDISYLATE ..................... 78
PROCHLORPERAZINE MALEATE ........................ 78
PROCRIT 2000/ML, 3000/ML, 4000/ML ................. 92
PROCRIT 20000/2ML, 20000/ML,
40000/ML ................................................................ 92
PROCTO-PAK ...................................................... 118
PROCTOSOL-HC ................................................. 118
PROCTOZONE-HC .............................................. 118
2015 CARE1ST MEDICARE DRUG FORMULARY
172
Index of Drugs
Indice de Medicamentos
PROGESTERONE ................................................134
PROGLYCEM .......................................................104
PROGRAF .............................................................137
PROLEUKIN ............................................................59
PROLIA .................................................................142
PROMACTA ............................................................92
PROMETHAZINE HCL ......................................75, 78
PROMETHEGAN ....................................................78
PRONESTYL ...........................................................97
PROPAFENONE HCL .............................................97
PROPARACAINE HCL ..........................................122
PROPRANOLOL HCL .............................................98
PROPRANOLOLHYDROCHLOROTHIAZID ......................................98
PROPYLTHIOURACIL ..........................................134
PROQUAD ............................................................139
PROTRIPTYLINE HCL ............................................68
PULMICORT FLEXHALER ...................................150
PULMOZYME ........................................................120
PYRAZINAMIDE .....................................................77
PYRIDOSTIGMINE BROMIDE .............................145
Q
QUASENSE .......................................................... 110
QUDEXY XR ...........................................................64
QUETIAPINE FUMARATE ......................................83
QUINAPRIL HCL .....................................................96
QUINAPRILHYDROCHLOROTHIAZIDE ....................................96
QUINIDINE GLUCONATE ......................................97
QUINIDINE SULFATE .............................................97
QVAR ....................................................................150
R
RABAVERT ........................................................... 139
RALOXIFENE HCL ............................................... 131
RAMIPRIL ............................................................... 96
RANEXA ............................................................... 100
RANITIDINE HCL .................................................. 125
RAPAMUNE .......................................................... 137
REBIF .................................................................... 145
REBIF REBIDOSE ................................................ 145
RECLIPSEN .......................................................... 110
RECOMBIVAX HB ................................................ 139
REGRANEX .......................................................... 113
RELENZA ................................................................ 88
RELISTOR ............................................................ 127
REMICADE ........................................................... 145
REMODULIN ......................................................... 153
RENAGEL ............................................................. 128
RENVELA ............................................................. 128
REPAGLINIDE ........................................................ 69
REPREXAIN ........................................................... 41
RESCRIPTOR ......................................................... 86
RESERPINE ......................................................... 100
RESTASIS ............................................................ 125
RETROVIR .............................................................. 86
REVATIO .............................................................. 153
REVLIMID ............................................................... 59
REYATAZ ................................................................ 86
RHOGAM ULTRA-FILTERED PLUS .................... 137
RHOPHYLAC ........................................................ 137
RIBASPHERE ......................................................... 89
RIBAVIRIN .............................................................. 89
2015 CARE1ST MEDICARE DRUG FORMULARY
173
Index of Drugs
Indice de Medicamentos
RIDAURA ..............................................................137
RIFABUTIN .............................................................77
RIFAMPIN ...............................................................77
RIFATER .................................................................77
RILUZOLE .............................................................106
RIMANTADINE HCL ...............................................88
RINGERS INJECTION ..........................................149
RISEDRONATE SODIUM .....................................142
RISPERDAL CONSTA ............................................83
RISPERIDONE ........................................................83
RISPERIDONE ODT ...............................................83
RITUXAN .................................................................59
RIVASTIGMINE .......................................................65
RIZATRIPTAN .........................................................76
ROPINIROLE HCL ..................................................81
ROTARIX ..............................................................140
ROTATEQ .............................................................140
ROXICET ................................................................41
ROZEREM ............................................................153
S
SABRIL ....................................................................64
SAIZEN .................................................................133
SALSALATE ............................................................43
SANDOSTATIN LAR .............................................133
SANTYL ................................................................ 113
SAPHRIS .................................................................83
SAVELLA ..............................................................106
SELEGILINE HCL ...................................................81
SELENIUM SULFIDE ............................................ 114
SELZENTRY ...........................................................86
SENSIPAR ............................................................145
SEREVENT DISKUS .............................................151
SEROSTIM ........................................................... 133
SERTRALINE HCL ................................................. 68
SEVELAMER CARBONATE ................................. 128
SF 5000 PLUS .......................................................111
SHOHL'S MODIFIED ............................................ 149
SILDENAFIL .......................................................... 153
SILVER SULFADIAZINE ....................................... 114
SIMULECT ............................................................ 145
SIMVASTATIN ...................................................... 103
SIROLIMUS .......................................................... 137
SODIUM BICARBONATE ..................................... 149
SODIUM CHLORIDE .................................... 141, 149
SODIUM CITRATE & CITRIC ACID ..................... 149
SODIUM FLUORIDE ..............................................111
SOLTAMOX ............................................................ 59
SOMATULINE DEPOT ......................................... 133
SOMAVERT .......................................................... 133
SORINE .................................................................. 98
SOTALOL ................................................................ 98
SOTALOL AF .......................................................... 98
SOTRET ................................................................ 113
SOVALDI ................................................................. 88
SPIRIVA ................................................................ 151
SPIRONOLACTONE ............................................. 104
SPIRONOLACTONE-HCTZ .................................. 104
SPRINTEC ............................................................ 110
SPRYCEL ............................................................... 59
SPS ....................................................................... 128
SRONYX ............................................................... 110
SSD ....................................................................... 114
STANNOUS FLUORIDE ........................................111
STAVUDINE ............................................................ 87
2015 CARE1ST MEDICARE DRUG FORMULARY
174
Index of Drugs
Indice de Medicamentos
STIVARGA ..............................................................59
STRATTERA .........................................................106
STREPTOMYCIN SULFATE ...................................46
STRIBILD ................................................................87
STROMECTOL .......................................................79
SUBOXONE ............................................................45
SUCRAID ..............................................................120
SUCRALFATE .......................................................126
SULFACETAMIDE SODIUM .................................123
SULFACETAMIDE-PREDNISOLONE ..................123
SULFADIAZINE .......................................................53
SULFAMETHOXAZOLE/
TRIMETHOPRIM .....................................................53
SULFAMETHOXAZOLETRIMETHOPRIM .....................................................53
SULFASALAZINE ...................................................53
SULFASALAZINE DR .............................................54
SULFATRIM ............................................................54
SULFAZINE .............................................................54
SULINDAC ..............................................................43
SUMATRIPTAN .......................................................76
SUMATRIPTAN SUCCINATE .................................76
SUPRAX ..................................................................49
SURE COMFORT ................................................. 119
SURMONTIL ...........................................................68
SUSTIVA .................................................................87
SUTENT ..................................................................59
SYLATRON 4-PACK ...............................................89
SYLVANT ................................................................59
SYMLINPEN 120 .....................................................70
SYMLINPEN 60 .......................................................70
SYNAGIS ................................................................88
SYNAREL ..............................................................145
SYNERCID .............................................................. 47
SYNRIBO ................................................................ 59
SYNTHROID ......................................................... 134
SYPRINE .............................................................. 129
T
TABLOID ................................................................. 59
TACROLIMUS ....................................................... 137
TAFINLAR ............................................................... 59
TAMIFLU ................................................................. 88
TAMOXIFEN CITRATE ........................................... 59
TAMSULOSIN HCL ............................................... 129
TARCEVA ............................................................... 59
TARGRETIN ........................................................... 59
TASIGNA ................................................................ 60
TASMAR ................................................................. 81
TAZICEF ................................................................. 49
TAZICEF IN DEXTROSE ........................................ 49
TAZORAC ............................................................. 119
TAZTIA XT .............................................................. 99
TE ANATOXAL BERNA ........................................ 140
TECFIDERA .......................................................... 145
TEFLARO ................................................................ 49
TEGRETOL XR ....................................................... 64
TEKTURNA ........................................................... 104
TEKTURNA HCT .................................................. 104
TEMAZEPAM .......................................................... 46
TEMODAR .............................................................. 60
TENIPOSIDE .......................................................... 60
TENIVAC ............................................................... 140
TERAZOSIN HCL ................................................. 129
TERBINAFINE HCL ................................................ 74
TERBUTALINE SULFATE .................................... 151
2015 CARE1ST MEDICARE DRUG FORMULARY
175
Index of Drugs
Indice de Medicamentos
TERCONAZOLE .....................................................75
TESTOSTERONE CYPIONATE ...........................130
TETANUS DIPHTHERIA TOXOIDS ......................140
TETANUS TOXOID ADSORBED ..........................140
TETCAINE .............................................................122
TETRACAINE HCL ...............................................122
TETRACYCLINE HCL .............................................54
THALOMID ............................................................145
THEO-24 ...............................................................151
THEOCHRON .......................................................151
THEOPHYLLINE ...................................................151
THEOPHYLLINE ANHYDROUS ...........................151
THEOPHYLLINE IN 5% DEXTROSE ...................151
THERACYS ...........................................................140
THERMAZENE ...................................................... 114
THIOLA .................................................................145
THIORIDAZINE HCL ...............................................84
THIOTHIXENE ........................................................84
THYROLAR-1 ........................................................134
THYROLAR-1/2 .....................................................134
THYROLAR-1/4 .....................................................134
THYROLAR-2 ........................................................134
THYROLAR-3 ........................................................134
TIAGABINE HCL .....................................................64
TICAR ......................................................................52
TICAR IN DEXTROSE ............................................52
TICLOPIDINE HCL ..................................................93
TIKOSYN .................................................................97
TILIA FE ................................................................ 110
TIMENTIN ...............................................................52
TIMOLOL MALEATE .......................................98, 146
TIROSINT ..............................................................134
TIVICAY .................................................................. 87
TIZANIDINE HCL .................................................. 152
TOBI ........................................................................ 46
TOBRAMYCIN SULFATE ............................... 46, 124
TOBRAMYCIN-DEXAMETHASONE .................... 124
TOLAZAMIDE ......................................................... 72
TOLBUTAMIDE ....................................................... 72
TOLMETIN SODIUM ............................................... 43
TOLTERODINE TARTRATE ................................. 128
TOLTERODINE TARTRATE ER ........................... 128
TOPIRAGEN ........................................................... 64
TOPIRAMATE ......................................................... 64
TOPOTECAN HCL .................................................. 60
TORSEMIDE ......................................................... 102
TPN ELECTROLYTES II ....................................... 149
TRACLEER ........................................................... 153
TRADJENTA ........................................................... 70
TRAMADOL HCL .................................................... 41
TRAMADOL HCL-ACETAMINOPHEN ................... 41
TRANDOLAPRIL ..................................................... 96
TRANEXAMIC ACID ............................................... 92
TRANSDERM-SCOP .............................................. 78
TRANYLCYPROMINE SULFATE ........................... 68
TRAVAMULSION .................................................... 94
TRAVASOL ............................................................. 94
TRAVATAN Z ........................................................ 147
TRAVOPROST ..................................................... 147
TRAZODONE HCL ................................................. 68
TRECATOR ............................................................ 77
TRELSTAR ............................................................. 60
TRETINOIN ............................................................. 60
TRETINOIN ........................................................... 119
2015 CARE1ST MEDICARE DRUG FORMULARY
176
Index of Drugs
Indice de Medicamentos
TRIAMCINOLONE ACETONIDE ...................111, 118
TRIAMTERENE-HCTZ ..........................................102
TRIAMTERENEHYDROCHLOROTHIAZID ....................................102
TRIAZOLAM ............................................................46
TRICITRATES .......................................................149
TRIDERM .............................................................. 118
TRIFLUOPERAZINE HCL .......................................84
TRIFLURIDINE ......................................................124
TRIHEXYPHENIDYL HCL .......................................81
TRI-LEGEST FE .................................................... 110
TRILEPTAL .............................................................64
TRI-LINYAH .......................................................... 110
TRILYTE WITH FLAVOR PACKETS ....................127
TRIMETHOPRIM .....................................................47
TRINESSA ............................................................ 110
TRI-PREVIFEM ..................................................... 110
TRISENOX ..............................................................60
TRI-SPRINTEC ..................................................... 110
TRIVORA-28 ......................................................... 110
TROKENDI XR ........................................................64
TROPHAMINE ........................................................94
TROPICAMIDE .....................................................122
TRUVADA ...............................................................87
TUDORZA PRESSAIR ..........................................151
TWINRIX ...............................................................140
TYGACIL .................................................................55
TYKERB ..................................................................60
TYPHIM VI ............................................................140
TYSABRI ...............................................................137
TYZEKA ..................................................................90
TYZINE ..................................................................122
U
U-CORT ................................................................ 118
UNITHROID .......................................................... 134
URSODIOL ........................................................... 127
V
VALACYCLOVIR ..................................................... 90
VALCHLOR ........................................................... 113
VALCYTE ................................................................ 90
VALPROATE SODIUM ........................................... 64
VALPROIC ACID .................................................... 64
VALSARTAN ......................................................... 145
VALSARTANHYDROCHLOROTHIAZIDE ................................... 95
VANCOMYCIN HCL ................................................ 47
VAQTA .................................................................. 140
VARIVAX VACCINE .............................................. 140
VASCEPA ............................................................. 103
VELCADE ............................................................... 60
VELETRI ............................................................... 153
VELIVET ............................................................... 110
VENLAFAXINE HCL ............................................... 68
VENLAFAXINE HCL ER ......................................... 68
VENTOLIN HFA .................................................... 151
VERAPAMIL ER ...................................................... 99
VERAPAMIL ER PM ............................................... 99
VERAPAMIL HCL ................................................... 99
VERDESO ............................................................. 118
VERIPRED 20 ....................................................... 132
VERSACLOZ .......................................................... 84
VERSALON ........................................................... 145
VICTOZA 3-PAK ..................................................... 70
2015 CARE1ST MEDICARE DRUG FORMULARY
177
Index of Drugs
Indice de Medicamentos
VICTRELIS ..............................................................88
VIDEX ......................................................................87
VIGAMOX ..............................................................124
VIIBRYD ..................................................................68
VIMPAT ...................................................................65
VIORELE ............................................................... 110
VIRACEPT ..............................................................87
VIRAMUNE XR .......................................................87
VIRAZOLE ...............................................................90
VIREAD ...................................................................87
VIVOTIF BERNA ...................................................140
VOLTAREN .............................................................43
VORAXAZE ...........................................................145
VORICONAZOLE ....................................................74
VOTRIENT ..............................................................60
VPRIV ....................................................................120
VYFEMLA .............................................................. 110
W
WARFARIN SODIUM ..............................................91
WATER .................................................................141
WELCHOL .............................................................103
WERA .................................................................... 110
WINRHO SDF .......................................................137
X
XALKORI .................................................................60
XARELTO ................................................................91
XELJANZ ...............................................................145
XENAZINE ............................................................106
XGEVA ..................................................................142
XOLAIR .................................................................152
XTANDI ...................................................................60
XYREM ................................................................. 153
Y
YERVOY ................................................................. 60
YF-VAX ................................................................. 140
YODOXIN ................................................................ 80
Z
ZAFIRLUKAST ...................................................... 150
ZALEPLON ........................................................... 153
ZALTRAP ................................................................ 60
ZAVESCA ............................................................. 121
ZAZOLE .................................................................. 75
ZELBORAF ............................................................. 60
ZEMAIRA .............................................................. 152
ZEMPLAR ............................................................. 142
ZENCHENT ............................................................111
ZENCHENT FE ......................................................111
ZENPEP ................................................................ 121
ZETIA .................................................................... 103
ZIAGEN ................................................................... 87
ZIDOVUDINE .......................................................... 87
ZIPRASIDONE HCL ................................................ 84
ZMAX ...................................................................... 50
ZOLADEX ............................................................... 60
ZOLEDRONIC ACID ............................................. 142
ZOLINZA ................................................................. 60
ZOLPIDEM TARTRATE ........................................ 153
ZOMETA ............................................................... 143
ZONALON ............................................................. 113
ZONISAMIDE .......................................................... 65
ZORBTIVE ............................................................ 133
ZORTRESS ........................................................... 137
2015 CARE1ST MEDICARE DRUG FORMULARY
178
Index of Drugs
Indice de Medicamentos
ZOSTAVAX ...........................................................140
ZOVIA 1-35E ......................................................... 111
ZOVIA 1-50E ......................................................... 111
ZOVIRAX ............................................................... 113
ZYCLARA .............................................................. 113
ZYKADIA .................................................................60
ZYTIGA ...................................................................61
ZYVOX ....................................................................47
2015 CARE1ST MEDICARE DRUG FORMULARY
179
2015
DRUG FORMULARY
FORMULARIO DE MEDICAMENTOS
Counties/Condados:
Alameda, El Paso, Fresno, Los Angeles, Merced
Orange, Riverside, San Bernardino, San Diego, San
Francisco, San Joaquin, Santa Clara & Stanislaus
Care1st Health Plan
601 Potrero Grande Dr., Monterey Park, CA 91755
Member Services
1-800-544-0088 (TTY users should call 711)
From October 1 through February 14, Member Services representatives will
be available to answer your call from 8 a.m. to 8 p.m., seven days a week,
except Thanksgiving and Christmas. From February 15 through September
30, Member Services representatives will be available to answer your call
from 8 a.m. to 8 p.m., Monday through Friday, except holidays. Del 1° de
octubre al 14 de febrero, los representantes de Servicios para los Miembros
estarán disponibles para recibir su llamada de 8 a. m. a 8 p. m., los 7 días de
la semana, excepto el Día de Acción de Gracias y Navidad. Del 15 de febrero
al 30 de septiembre, los representantes de Servicios para los Miembros
estarán disponibles para recibir su llamada de 8 a. m. a 8 p. m., de lunes a
viernes, excepto los días festivos.
Care1stMedicare.com
Care1st Health Plan es un plan HMO y HMO SNP con un contrato con Medicare y un contrato con el programa de Medicaid estatal
en California. La inscripción en Care1st Health Plan depende de la renovación del contrato. Este formulario de medicamentos se
actualizó Augusto 2014. Para obtener información más reciente o si tiene preguntas, por favor llame a Care1st Health Plan al 1-800544-0088 o, para usuarios del TTY, 711, de 8 a.m. a 8 p.m., los siete días de la semana del 1° de octubre al 14 de febrero, excepto el Día de
Acción de Gracias y Navidad, y de 8 a.m. a 8 p.m., de lunes a viernes, del 15 de febrero al 30 de septiembre, excepto los días festivos, o visite
www.care1stmedicare.com.