Story Transcript
PLANES TUFTS MEDICARE PREFERRED HMO | 2016
Formulario Tufts Medicare Preferred HMO para 2016 (Lista de medicamentos cubiertos)
IMPORTANTE: Este documento contiene información sobre los medicamentos cubiertos por este plan. Este formulario fue actualizado el 1 de enero de 2016. Si necesita información más reciente o si tiene otras preguntas, llámenos al 1-800-701-9000 o al 1-800-208-9562 para usuarios de TTY, de lunes a viernes de 8:00 a. m. a 8:00 p. m. (Del 1 de octubre al 14 de febrero los representantes están disponibles los 7 días de la semana, de 8:00 a. m. a 8:00 p. m.). Después del horario de atención y los días feriados, deje un mensaje y un representante lo llamará el siguiente día hábil. O visite tuftsmedicarepreferred.org. Para miembros existentes: Para miembros existentes: Este formulario ha sido modificado desde el año pasado. Revise este documento para asegurarse de que aún incluye los medicamentos que usted toma.
16408 Version 5 H2256_2016_14SPA Accepted
TUFTS MEDICARE PREFERRED HMO _
Formulario 2016 (Lista de medicamentos cubiertos) Cuando en la lista de medicamentos (formulario) se mencionan las palabras “nosotros”, “nuestro” o “nuestra”, se refieren a Tufts Health Plan Medicare Preferred. Cuando se menciona “plan” o “nuestro plan”, se refiere a Tufts Medicare Preferred HMO. Este documento incluye una lista de medicamentos (formulario) de nuestro plan, que tiene vigencia desde el 1 de enero de 2016. Para solicitar un formulario actualizado, comuníquese con nosotros. Nuestra información de contacto, junto con la fecha de la última actualización del formulario, figura en el frente y en la contratapa. Por lo general, debe usar farmacias de la red para obtener su beneficio de medicamentos recetados. Los beneficios, el formulario, la red de farmacias y/o los copagos/coseguros pueden cambiar el 1 de enero de 2017, y de vez en cuando durante el año.
¿Qué es el Formulario de Tufts Medicare Preferred HMO? Un formulario es una lista de medicamentos cubiertos que selecciona Tufts Medicare Preferred HMO en colaboración con un equipo de proveedores de atención médica, que representa los tratamientos recetados que se consideran necesarios como parte del programa de tratamientos de calidad. Tufts Medicare Preferred HMO generalmente cubrirá los medicamentos que se incluyen en el formulario siempre que el medicamento sea necesario desde el punto de vista médico, se adquiera el medicamento recetado en una farmacia de la red de Tufts Medicare Preferred HMO y se cumplan otras reglas del plan. Para obtener más información sobre cómo adquirir medicamentos recetados, revise su Evidencia de cobertura.
¿El Formulario (lista de medicamentos) puede cambiar? Por lo general, si está tomando un medicamento de nuestro formulario de 2016 que estaba cubierto a principio de año, no suspenderemos ni reduciremos la cobertura del medicamento durante el año de cobertura 2016 a menos que aparezca a la venta un nuevo medicamento genérico más económico o que se publique nueva información negativa sobre la seguridad o eficacia del medicamento. Otros tipos de cambios en el formulario, como el retiro de un medicamento del formulario, no afectarán a los miembros que estén en ese momento tomando el medicamento. Continuará disponible con la misma participación en los costos para los miembros que lo estén tomando durante el resto del año de cobertura. Creemos 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, excepto en los casos en que usted pueda ahorrar dinero adicional o nosotros podamos garantizar su seguridad. Si retiramos medicamentos de nuestro formulario o agregamos autorización previa, límites de cantidad o restricciones a la terapia escalonada para un medicamento o cambiamos un medicamento a un nivel más alto de participación en los costos, debemos notificar dicho cambio a los miembros afectados al menos 60 días antes de que entre en vigencia el cambio, o en el momento en que el miembro solicite una reposición del medicamento, momento en el cual el miembro recibirá un suministro del medicamento para 60 días. Si la Administración de Medicamentos y Alimentos (Food and Drug Administration, FDA) considera que un medicamento de nuestro formulario es inseguro o el fabricante del medicamento retira el medicamento del mercado, nosotros retiraremos inmediatamente el medicamento de nuestro formulario y notificaremos a los miembros que toman el medicamento. El formulario que se adjunta entra en vigencia a partir del 1 de enero de 2016. Para obtener información actualizada sobre los medicamentos cubiertos por Tufts Medicare Preferred HMO, comuníquese con nosotros. Nuestra información de contacto aparece en el frente y la contratapa. Si durante el año se realiza alguna modificación en el formulario que no sea por razones de mantenimiento, le avisaremos mediante una fe de erratas. -I-
¿Cómo uso el Formulario? Hay dos maneras de buscar un medicamento en el formulario: Afección médica El formulario comienza en la página 1. Los medicamentos de este formulario están agrupados en categorías según la clase de afecciones médicas para las cuales se usan. Por ejemplo, los medicamentos que se usan para tratar una afección del corazón se enumeran bajo la categoría “Agentes cardiovasculares”. Si conoce para qué se usa su medicamento, busque el nombre de la categoría en la lista que comienza en la página 1. Luego mire debajo del nombre de la categoría para encontrar su medicamento. Lista por orden alfabético Si no está seguro de la categoría en la que debe mirar, entonces debe buscar su medicamento en el Índice que comienza en la página 68. El Índice brinda una lista por orden alfabético de todos los medicamentos incluidos en este documento. El Índice incluye tanto medicamentos de marca como medicamentos genéricos. Mire en el Índice y encuentre su medicamento. Al lado del medicamento, verá el número de página donde puede encontrar información sobre la cobertura. Vaya a la página que se enumera en el Índice y busque el nombre de su medicamento en la primera columna de la lista.
¿Qué son los medicamentos genéricos? Tufts Medicare Preferred HMO cubre medicamentos de marca y medicamentos genéricos. Un medicamento genérico está aprobado por la FDA y tiene los mismos principios activos que el medicamento de marca. Por lo general, los medicamentos genéricos cuestan menos que los medicamentos de marca.
¿Hay restricciones en mi cobertura? Algunos medicamentos cubiertos pueden tener requisitos adicionales o limitaciones en la cobertura. Estos requisitos y límites pueden incluir: • Autorización previa: Tufts Medicare Preferred HMO requiere que usted (o su médico) obtenga autorización previa para ciertos medicamentos. Esto significa que deberá obtener aprobación de Tufts Medicare Preferred HMO antes de adquirir sus medicamentos recetados. Si no consigue la aprobación, Tufts Medicare Preferred HMO no podrá cubrir el medicamento. • Límites de cantidad: Tufts Medicare Preferred HMO limita la cantidad de ciertos medicamentos que cubre. Por ejemplo, Tufts Medicare Preferred HMO brinda 30 comprimidos por receta para ROZEREM. Esto puede sumarse a un suministro estándar de un mes o tres meses. • Terapia escalonada: En algunos casos, Tufts Medicare Preferred HMO requiere que primero pruebe ciertos medicamentos para tratar su afección médica antes de cubrir otro medicamento para esa afección. Por ejemplo, si tanto el medicamento A como el medicamento B tratan su afección médica, Tufts Medicare Preferred HMO podrá no cubrir el medicamento B a menos que pruebe primero el medicamento A. Si el medicamento A no es eficaz en su caso, Tufts Medicare Preferred HMO cubrirá el medicamento B. Consulte el formulario que comienza en la página 1 para averiguar si su medicamento tiene límites o requisitos adicionales. También puede obtener más información sobre las restricciones que se aplican a determinados medicamentos cubiertos si visita nuestro sitio web. Hemos publicado un documento en línea que explica nuestra restricción de autorización previa y nuestras restricciones de terapia escalonada. También puede solicitar que le enviemos un ejemplar. Nuestra información de contacto, junto con la fecha de la última actualización del formulario, figura en el frente y en la contratapa. - II -
Puede pedir que Tufts Medicare Preferred HMO haga una excepción a estas restricciones o límites o solicitar una lista de otros medicamentos similares que puedan tratar su afección médica. Consulte la sección “¿Cómo solicito una excepción al formulario de Tufts Medicare Preferred HMO?” en la siguiente página para obtener información sobre cómo solicitar una excepción.
¿Qué sucede si mi medicamento no está en el Formulario? Si su medicamento no está incluido en este formulario (lista de medicamentos cubiertos), primero debe comunicarse con Servicios al cliente y preguntar si su medicamento está cubierto. Si le informan que Tufts Medicare Preferred HMO no cubre su medicamento, tiene dos opciones: • En Servicios al cliente, puede pedir una lista de medicamentos similares que estén cubiertos por Tufts Medicare Preferred HMO. Cuando reciba la lista, muéstresela a su médico y pídale que le recete un medicamento similar que esté cubierto por Tufts Medicare Preferred HMO. • Puede pedir que Tufts Medicare Preferred HMO haga una excepción y cubra su medicamento. Lea a continuación para obtener información sobre cómo solicitar una excepción.
¿Cómo solicito una excepción al formulario de Tufts Medicare Preferred HMO? Puede pedir que Tufts Medicare Preferred HMO haga una excepción a las reglas de la cobertura. Hay varias clases de excepciones que nos puede pedir que hagamos. • Puede pedir que cubramos su medicamento aunque no esté en nuestro formulario. Si se aprueba, el medicamento será cubierto a un nivel predeterminado de participación en los costos, y usted no podrá solicitar que se cubra el medicamento en un nivel de participación en los costos más bajo. • Puede solicitar que se cubra un medicamento del formulario a un nivel de participación en los costos más bajo si este medicamento no figura en el nivel de especialidad. Si se aprueba, esto reduciría el monto que debe pagar por su medicamento. • Puede pedir que anulemos límites o restricciones de cobertura a su medicamento. Por ejemplo, Tufts Medicare Preferred HMO limita la cantidad de ciertos medicamentos que cubre. Si su medicamento tiene un límite de cantidad, puede pedirnos que anulemos el límite y cubramos una cantidad mayor. Por lo general, Tufts Medicare Preferred HMO solo aprobará su solicitud de excepción en caso de que los medicamentos alternativos incluidos en el formulario del plan, el medicamento de menor participación en los costos o las restricciones adicionales de uso no fueran tan efectivas para tratar su afección o le causaran efectos médicos adversos. Debe comunicarse con nosotros para pedir una decisión de cobertura inicial respecto de la excepción sobre el formulario, el nivel o la restricción de uso. Cuando solicita una excepción sobre el formulario, el nivel o la restricción de uso, debe presentar un informe de su médico o persona que receta que respalde su solicitud. Por lo general, debemos tomar una decisión dentro de las 72 horas de haber recibido el informe de respaldo de la persona que recete. Puede solicitar una excepción acelerada (rápida) si usted o su médico creen que esperar 72 horas para conocer la decisión puede perjudicar gravemente su salud. Si se acepta su solicitud para una respuesta acelerada, debemos comunicarle la decisión antes de las 24 horas de haber recibido el informe de respaldo de su médico o persona que recete.
- III -
¿Qué hago hasta que pueda hablar con mi médico sobre el cambio de medicamentos o la solicitud de excepción? Como miembro nuevo o permanente de nuestro plan puede estar tomando medicamentos que no estén en nuestro formulario. O, es posible que esté tomando un medicamento incluido en nuestro formulario pero que su posibilidad de obtenerlo sea limitada. Por ejemplo, quizás necesite una autorización previa de parte nuestra antes de que pueda adquirir su medicamento recetado. Debe hablar con su médico para decidir si debe cambiar a un medicamento adecuado cubierto por nosotros o solicitar una excepción al formulario para que cubramos el medicamento que toma. Mientras habla con su médico para determinar la decisión que más le convenga, nosotros podremos cubrir su medicamento en ciertos casos durante los primeros 90 días si usted es miembro de nuestro plan. Para cada uno de los medicamentos que no esté en nuestro formulario o en caso de que sea limitada su posibilidad de conseguir los medicamentos, cubriremos un suministro temporal de 30 días (salvo que tenga una receta por menos días) cuando vaya a una farmacia de la red. Después del primer suministro de 30 días, no pagaremos estos medicamentos, aunque haga menos de 90 días que es miembro de este plan. Si es residente de un centro de cuidados a largo plazo, le permitiremos reponer su medicamento hasta que hayamos proporcionado un suministro de transición de 98 días, de acuerdo con el incremento del despacho (salvo que la receta sea por menos días). Cubriremos más de una reposición de estos medicamentos durante los primeros 90 días que sea miembro de nuestro plan. Si necesita un medicamento que no está en nuestro formulario o si es limitada su posibilidad de conseguir los medicamentos, pero ya pasaron los primeros 90 días de membrecía en nuestro plan, cubriremos un suministro de emergencia de 31 días para ese medicamento (salvo que tenga una receta por menos días) mientras intenta conseguir una excepción al formulario. Como miembro actual, si lo internan en un centro de cuidados a largo plazo o lo dan de alta, y sufre un cambio inesperado de medicamentos, puede solicitar que aprobemos una reposición temporal del medicamento no cubierto por única vez para darle tiempo de conversar con su médico sobre un plan de transición. Su médico también puede solicitar una excepción de cobertura para el medicamento no cubierto a partir de la revisión de necesidad médica. Para ello, debe seguir el proceso de excepción estándar señalado anteriormente. La “primera reposición” temporal, por lo general, será un suministro de 31 días, pero se puede extender para darle tiempo a usted y a su médico de manejar las complejidades de los distintos medicamentos o cuando lo ameriten circunstancias especiales. Puede solicitar una reposición temporal del medicamento recetado llamando al Departamento de Servicios al Cliente de Tufts Health Plan Medicare Preferred HMO.
- IV -
Para obtener más información Para obtener información más detallada sobre la cobertura de medicamentos recetados que brinda Tufts Medicare Preferred HMO, revise su Evidencia de cobertura y otros materiales del plan. Si tiene alguna pregunta sobre Tufts Medicare Preferred HMO, comuníquese con nosotros. Nuestra información de contacto, junto con la fecha de la última actualización del formulario, figura en el frente y en la contratapa. Si tiene preguntas generales sobre la cobertura de medicamentos recetados de Medicare, comuníquese con Medicare llamado al 1-800-MEDICARE (1-800-633-4227) las 24 horas del día, los 7 días de la semana. Los usuarios de TTY/TDD deben llamar al 1-877-486-2048. O visite www.medicare.gov. Formulario de Tufts Medicare Preferred HMO El formulario que comienza en la página 1 brinda información de cobertura sobre algunos medicamentos cubiertos por Tufts Medicare Preferred HMO. Si tiene problemas para encontrar su medicamento en la lista, consulte el Índice que comienza en la página 68. La primera columna del cuadro muestra el nombre del medicamento. Los medicamentos de marca aparecen en mayúsculas (por ej., PROAIR HFA) y los medicamentos genéricos se mencionan en minúsculas (por ej., omeprazol). La información en la columna Requisitos/Límites detalla si Tufts Health Plan Medicare Preferred HMO tiene requisitos especiales para cubrir su medicamento. B/D: Medicare Parte B o D Estos medicamentos requieren autorización previa para determinar la cobertura adecuada según la Parte B o la Parte D de Medicare. QL: Se aplica límite de cantidad. Debido a posibles inquietudes sobre el uso y la seguridad, Tufts Medicare Preferred HMO ha establecido limitaciones de despacho para un pequeño número de medicamentos recetados. Esto significa que la farmacia solo entregará una cierta cantidad de un medicamento en un período de tiempo determinado. Estas cantidades se basan en normas de atención médica reconocidas, por ejemplo las recomendaciones de uso de la Administración de Medicamentos y Alimentos de los EE. UU. Si su médico cree que usted necesita una cantidad superior a la limitación del programa, el médico puede enviar una solicitud de cobertura según el Proceso de revisión médica. Mediante el Proceso de revisión médica, su médico puede solicitarle a Tufts Medicare Preferred HMO que haga una excepción a las normas de cobertura. Consulte la sección “¿Cómo solicito una excepción al formulario de Tufts Medicare Preferred HMO?” en la página III para ver cómo solicitar una excepción. ID: Medicamento para terapia de infusión domiciliaria. Este medicamento puede estar cubierto conforme a su beneficio de la Parte B de Medicare. Los medicamentos de infusión domiciliaria que no están cubiertos por la Parte B de Medicare serán cubiertos por la Parte D de Medicare. Para obtener más información, llame a Servicios al Cliente al 1-800-701-9000, de lunes a viernes, de 8:00 a. m. a 8:00 p. m. (del 1 de octubre al 14 de febrero, los representantes están disponibles los 7 días de la semana, de 8:00 a. m. a 8:00 p. m.). Después del horario de atención y los días feriados, deje un mensaje y un representante lo llamará el siguiente día hábil. Los usuarios de TTY deben llamar al 1-800-208-9562.
-V-
LA: Medicamento de acceso limitado. Este medicamento puede estar disponible solo en ciertas farmacias. Para obtener más información, consulte el Directorio de farmacias o llame a Servicios al Cliente al 1-800-701-9000, de lunes a viernes, de 8:00 a. m. a 8:00 p. m. (del 1 de octubre al 14 de febrero, los representantes están disponibles los 7 días de la semana, de 8:00 a. m. a 8:00 p. m.). Después del horario de atención y los días feriados, deje un mensaje y un representante lo llamará el siguiente día hábil. Los usuarios de TTY deben llamar al 1-800-208-9562. PA: Se requiere autorización previa. El proceso de autorización previa alienta la indicación racional de productos farmacéuticos que presentan importantes inquietudes de seguridad y/o económicas. Un proveedor puede presentar una solicitud de cobertura según la necesidad médica que tenga un miembro en relación con ese medicamento en particular. Si se aprueba, el miembro paga el copago del nivel designado. Existe un proceso de apelación en caso de que se rechace la solicitud. STPA: Se aplica autorización previa para terapia escalonada. La Terapia escalonada es un formulario automatizado de Autorización previa, en el que se utilizan antecedentes de reclamos para la aprobación de un medicamento en el punto de venta. Los Programas de terapia escalonada alientan el uso clínicamente comprobado de medicamentos de primera línea y están diseñados para asegurar la utilización de los agentes terapéuticos más adecuados y económicos en primer lugar, antes de cubrir otros tratamientos. Los miembros que actualmente estén tomando medicamentos que cumplan con los criterios de la Terapia escalonada inicial automáticamente podrán adquirir sus medicamentos recetados de terapia escalonada. Si un miembro no cumple con los criterios de la Terapia escalonada inicial, la receta se rechazará en el punto de venta con un mensaje en el que se indica que es necesario obtener Autorización previa (AP). Los médicos pueden presentar solicitudes de Autorización previa a Tufts Medicare Preferred HMO para miembros que no cumplan con los criterios de la Terapia escalonada en el punto de venta según el proceso de Revisión médica. Mediante el Proceso de revisión médica, usted o su médico pueden solicitarle a Tufts Medicare Preferred HMO que haga una excepción a las normas de cobertura. Consulte la sección “¿Cómo solicito una excepción al formulario de Tufts Medicare Preferred HMO?” en la página III para ver cómo solicitar una excepción. Trasplante: Este medicamento se cubre por la Parte B cuando se usa para un trasplante de órganos cubierto por Medicare. Período sin cobertura: Para los miembros de Tufts Medicare Preferred HMO Prime Rx Plus, brindamos cobertura para los medicamentos del Nivel 1 y Nivel 2 en el Período sin cobertura. Consulte nuestra Evidencia de cobertura para obtener más información sobre esta cobertura. Medicamentos de la Parte B: No se requiere copago y el costo del medicamento no se aplica al beneficio de la Parte D.
- VI -
Sus costos de medicamentos recetados HMO Saver Rx Condados de Barnstable, Bristol, Essex, Middlesex, Norfolk, Plymouth, Suffolk, y Worcester Deducible
$300 (para sus medicamentos de Nivel 3, Nivel 4 y Nivel 5)
HMO Basic Rx Condados de Barnstable, Bristol, Essex, Hampden, Hampshire, Middlesex, Norfolk, Plymouth y Suffolk $250 (para sus medicamentos de Nivel 3, Nivel 4 y Nivel 5)
HMO Value Rx Condados de Barnstable, Bristol, Essex, Hampden, Hampshire, Middlesex, Norfolk, Plymouth y Suffolk $200 (para sus medicamentos de Nivel 3, Nivel 4 y Nivel 5)
Copagos
Farmacia Pedido Farmacia Pedido Farmacia Pedido Suministro de por correo Suministro de por correo Suministro de por correo 30 días Suministro de 30 días Suministro de 30 días Suministro de 90 días 90 días 90 días Nivel 1 $6 $15 $4 $10 $4 $10 Nivel 2 $12 $30 $8 $21 $8 $21 Nivel 3 $47 $141 $47 $141 $47 $141 Nivel 4 $100 $300 $100 $300 $100 $300 Nivel 5 26 % 26 % 27 % 27 % 28 % 28 % Etapa de período sin cobertura Después de alcanzar $3,310 por el costo total de medicamentos recetados, y hasta que sus pagos lleguen a $4,850, usted paga: • 58 % por costos de medicamentos genéricos de la Parte D • 45 % por costos de medicamentos de marca de la Parte D
Etapa de cobertura en situación catastrófica Después del período sin cobertura, cuando sus pagos de todo el año superen $4, 850, usted pagará el mayor de los siguientes montos: 5 % por medicamento, o $2.95 por medicamento para medicamentos genéricos de la Parte D y 7.40 por medicamento para medicamentos de marca de la Parte D.
- VII -
Sus costos de medicamentos recetados HMO Prime Rx Barnstable, Bristol, Essex, Hampden, Hampshire, Middlesex, Norfolk, Plymouth, y Suffolk Deducible
Copagos
HMO Prime Rx Plus Barnstable, Bristol, Essex, Hampden, Hampshire, Middlesex, Norfolk, Plymouth, y Suffolk
$0
Farmacia Suministro de 30 días
$0
Pedido por correo Suministro de 90 días
Farmacia Suministro de 30 días
Pedido por correo Suministro de 90 días
Nivel 1 $4 $10 $2 $5 Nivel 2 $8 $21 $4 $10 Nivel 3 $47 $141 $30 $90 Nivel 4 $100 $300 $80 $240 Nivel 5 33 % 33 % 33 % 33 % Etapa de período sin cobertura Después de alcanzar $3,310 por el costo total de medicamentos recetados, y hasta que sus pagos lleguen a $4,850; usted paga: • 5 8 % por costos de medicamentos genéricos • Copagos de nivel 1 por medicamentos de la Parte D genéricos del nivel 1 • 4 5 % por costos de medicamentos de marca • Copagos de nivel 2 por medicamentos de la Parte D genéricos del nivel 2 • 58 % por costos del resto de los medicamentos genéricos de la Parte D • 45 % por costos de medicamentos de marca de la Parte D
Etapa de cobertura en situación catastrófica Después del período sin cobertura, cuando sus pagos de todo el año superen $4,850, usted pagará el mayor de los siguientes montos: 5 % por medicamento, o $2.95 por medicamento para medicamentos genéricos de la Parte D y $7.40 por medicamento para medicamentos de marca de la Parte D.
- VIII -
Sus costos de medicamentos recetados (continuación) HMO Basic Rx Condado de Worcester Deducible
Copagos
HMO Value Rx Condado de Worcester
HMO Prime Rx Condado de Worcester
$250 $200 $0 (para sus medicamentos de (para sus medicamentos de Nivel 3, Nivel 4 y Nivel 5) Nivel 3, Nivel 4 y Nivel 5) Farmacia Pedido Farmacia Pedido Farmacia Pedido Suministro de por correo Suministro de por correo Suministro de por correo 30 días Suministro de 30 días Suministro de 30 días Suministro de 90 días 90 días 90 días
Nivel 1 $4 $10 $4 $10 $4 $10 Nivel 2 $6 $15 $6 $15 $6 $15 Nivel 3 $47 $141 $47 $141 $47 $141 Nivel 4 $75 $225 $75 $225 $75 $225 Nivel 5 27 % 27 % 28 % 28 % 33 % 33 % Etapa de período sin cobertura Después de alcanzar $3,310 por el costo total de medicamentos recetados, y hasta que sus pagos lleguen a $4,850; usted paga: • 58 % por costos de medicamentos genéricos de la Parte D • 45 % por costos de medicamentos de marca de la Parte D
Etapa de cobertura en situación catastrófica Después del período sin cobertura, cuando sus pagos de todo el año superen $4,850, usted pagará el mayor 5 % por medicamento, o $2.95 por medicamento para medicamentos genéricos de la Parte D y $7.40 por medicamento para medicamentos de marca de la Parte D.
- IX -
2016 Formulario para miembros individuales de Tufts Health Plan Medicare Preferred HMO Índice
ANTI-INFECTIVES AND INFECTIOUS DISEASE_______________________________________________ 2 BLOOD THINNERS AND BLOOD MODIFYING AGENTS _______________________________________ 8 CANCER DRUGS _________________________________________________________________________ 10 CARDIOVASCULAR AGENTS _____________________________________________________________ 14 DIABETES MELLITUS ____________________________________________________________________ 20 EAR, NOSE AND THROAT ________________________________________________________________ 22 EYE ____________________________________________________________________________________ 23 GASTROINTESTINAL DRUGS _____________________________________________________________ 26 HOME INFUSION THERAPY _______________________________________________________________ 29 HORMONES _____________________________________________________________________________ 35 IMMUNOLOGIC AGENTS _________________________________________________________________ 37 MISCELLANEOUS DRUGS ________________________________________________________________ 39 NEUROLOGICAL DRUGS _________________________________________________________________ 44 PAIN AND INFLAMMATORY DISEASES ____________________________________________________ 47 PSYCHIATRIC ___________________________________________________________________________ 51 RESPIRATORY DRUGS ___________________________________________________________________ 55 SKIN____________________________________________________________________________________ 58 WOMENS HEALTH _______________________________________________________________________ 63 INDEX __________________________________________________________________________________ 68
1
Drug Name
Drug Tier
Requirements/Limits
ANTI-INFECTIVES AND INFECTIOUS DISEASE ANTIFUNGALS, SYSTEMIC AND ORAL TOPICAL clotrimazole mucous membrane
Tier-2
CRESEMBA ORAL
Tier-5
fluconazole oral suspension
Tier-2
fluconazole oral tablet
Tier-1
flucytosine
Tier-5
griseofulvin microsize
Tier-2
griseofulvin ultramicrosize
Tier-2
itraconazole
Tier-2
ketoconazole oral
Tier-2
LAMISIL ORAL GRANULES 125 MG
Tier-4
QL (56 EA per 28 days)
LAMISIL ORAL GRANULES 187.5 MG
Tier-4
QL (28 EA per 28 days)
NOXAFIL ORAL
Tier-5
nystatin oral tablet
Tier-2
terbinafine hcl oral
Tier-1
voriconazole oral suspension
Tier-5
voriconazole oral tablet 200 mg
Tier-5
QL (28 EA per 14 days)
voriconazole oral tablet 50 mg
Tier-5
QL (56 EA per 14 days)
PA
QL (42 EA per 42 days)
ANTI-INFECTIVES, MISCELLANEOUS ALBENZA
Tier-5
ALINIA
Tier-4
BILTRICIDE
Tier-3
ivermectin oral
Tier-2
linezolid oral
Tier-2
methenamine hippurate
Tier-2
metronidazole oral
Tier-2
MONUROL
Tier-4
neomycin
Tier-2
nitrofurantoin macrocrystal
Tier-2
PA; QL (90 EA per 365 days)
nitrofurantoin monohyd/m-cryst
Tier-2
PA; QL (90 EA per 365 days)
PRIMSOL
Tier-3
STROMECTOL
Tier-3
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 2
Drug Name
Drug Tier
Requirements/Limits
trimethoprim
Tier-2
vancomycin oral capsule
Tier-2
XIFAXAN ORAL TABLET 200 MG
Tier-5
QL (9 EA per 30 days)
XIFAXAN ORAL TABLET 550 MG
Tier-5
PA; QL (60 EA per 30 days)
ZYVOX ORAL SUSPENSION
Tier-5
ANTIMALARIALS AND ANTIPROTOZOALS atovaquone
Tier-5
atovaquone-proguanil
Tier-2
chloroquine phosphate oral
Tier-2
COARTEM
Tier-3
dapsone
Tier-2
DARAPRIM
Tier-3
hydroxychloroquine oral
Tier-2
mefloquine
Tier-2
NEBUPENT
Tier-4
paromomycin
Tier-2
PENTAM
Tier-3
primaquine
Tier-2
quinine sulfate
Tier-2
tinidazole
Tier-2
QL (24 EA per 3 days)
B/D
ANTIVIRALS abacavir
Tier-2
abacavir-lamivudine-zidovudine
Tier-5
acyclovir oral capsule
Tier-1
acyclovir oral suspension
Tier-2
acyclovir oral tablet
Tier-2
adefovir
Tier-5
amantadine hcl oral
Tier-2
APTIVUS
Tier-5
ATRIPLA
Tier-5
COMPLERA
Tier-5
COPEGUS
Tier-5
CRIXIVAN
Tier-3
didanosine
Tier-2
EDURANT
Tier-5
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 3
Drug Name
Drug Tier
Requirements/Limits
EMTRIVA
Tier-3
entecavir
Tier-5
EPIVIR ORAL SOLUTION
Tier-3
EPZICOM
Tier-5
EVOTAZ
Tier-5
famciclovir
Tier-2
FUZEON SUBCUTANEOUS RECON SOLN
Tier-5
HARVONI
Tier-5
INTELENCE ORAL TABLET 100 MG, 25 MG
Tier-3
INTELENCE ORAL TABLET 200 MG
Tier-5
INTRON A INJECTION SOLUTION
Tier-3
INVIRASE
Tier-5
ISENTRESS CHEWABLE TABLET 25 MG
Tier-3
QL (720 EA per 30 days)
ISENTRESS CHEWABLE TABLET 100 MG
Tier-5
QL (180 EA per 30 days)
ISENTRESS ORAL POWDER IN PACKET
Tier-3
ISENTRESS ORAL TABLET
Tier-5
KALETRA ORAL SOLUTION
Tier-5
KALETRA ORAL TABLET 100-25 MG
Tier-3
KALETRA ORAL TABLET 200-50 MG
Tier-5
lamivudine
Tier-2
lamivudine-zidovudine
Tier-2
LEXIVA ORAL SUSPENSION
Tier-3
LEXIVA ORAL TABLET
Tier-5
nevirapine
Tier-2
NORVIR
Tier-3
PEGASYS
Tier-5
PA; QL (4 ML per 28 days)
PEGASYS PROCLICK
Tier-5
PA; QL (4 ML per 28 days)
PEGINTRON
Tier-5
PA; QL (4 EA per 28 days)
PEGINTRON REDIPEN
Tier-5
PA; QL (4 EA per 28 days)
PREZCOBIX
Tier-5
PREZISTA
Tier-5
REBETOL ORAL SOLUTION
Tier-3
RELENZA DISKHALER
Tier-3
RESCRIPTOR
Tier-3
REYATAZ
Tier-5
PA
QL (360 EA per 90 days)
QL (60 EA per 180 days)
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 4
Drug Name
Drug Tier
Requirements/Limits
ribasphere
Tier-2
ribasphere ribapak
Tier-5
ribavirin
Tier-2
rimantadine
Tier-2
SELZENTRY ORAL TABLET 150 MG
Tier-5
QL (60 EA per 30 days)
SELZENTRY ORAL TABLET 300 MG
Tier-5
QL (120 EA per 30 days)
SOVALDI
Tier-5
PA
stavudine
Tier-2
STRIBILD
Tier-5
SUSTIVA ORAL CAPSULE 200 MG
Tier-5
SUSTIVA ORAL CAPSULE 50 MG
Tier-3
SUSTIVA ORAL TABLET
Tier-5
TAMIFLU ORAL CAPSULE 30 MG
Tier-3
QL (56 EA per 180 days)
TAMIFLU ORAL CAPSULE 45 MG, 75 MG
Tier-3
QL (28 EA per 180 days)
TAMIFLU ORAL SUSPENSION
Tier-3
QL (360 ML per 180 days)
TIVICAY
Tier-5
TRIUMEQ
Tier-5
TRUVADA
Tier-5
TYBOST
Tier-3
TYZEKA
Tier-5
valacyclovir
Tier-3
VALCYTE ORAL SOLUTION
Tier-5
valganciclovir
Tier-2
VIDEX 2 GRAM PEDIATRIC
Tier-3
VIRACEPT ORAL TABLET 250 MG
Tier-3
VIRACEPT ORAL TABLET 625 MG
Tier-5
VIRAMUNE XR TABLET EXTENDEDRELEASE 24 HR 100 MG
Tier-3
VIREAD
Tier-5
VITEKTA
Tier-5
ZIAGEN
Tier-3
zidovudine
Tier-2
BETA-LACTAM ANTIBIOTICS amoxicillin oral capsule
Tier-1
amoxicillin oral suspension for reconstitution
Tier-1
QL (30 EA per 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 5
Drug Name
Drug Tier
amoxicillin oral tablet
Tier-1
amoxicillin oral tablet,chewable
Tier-1
amoxicillin-pot clavulanate
Tier-2
ampicillin oral capsule
Tier-1
ampicillin oral suspension
Tier-2
BICILLIN C-R
Tier-3
BICILLIN L-A
Tier-3
CEDAX
Tier-4
cefaclor
Tier-2
cefadroxil
Tier-2
cefdinir
Tier-2
cefditoren pivoxil
Tier-2
cefixime
Tier-2
cefpodoxime
Tier-2
cefprozil
Tier-2
cefuroxime axetil oral tablet
Tier-2
cephalexin
Tier-2
dicloxacillin
Tier-2
penicillin v potassium
Tier-1
SUPRAX ORAL CAPSULE
Tier-4
SUPRAX ORAL SUSPENSION
Tier-4
SUPRAX ORAL TABLET, CHEWABLE
Tier-4
Requirements/Limits
KETOLIDES KETEK
Tier-3
MACROLIDES AND CLINDAMYCIN azithromycin oral
Tier-2
clarithromycin
Tier-2
clindamycin hcl
Tier-2
clindamycin pediatric
Tier-2
DIFICID
Tier-5
e.e.s. 400 oral tablet
Tier-2
E.E.S. GRANULES
Tier-4
eryped 200
Tier-2
eryped 400
Tier-2
ERY-TAB
Tier-4
PA
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 6
Drug Name
Drug Tier
erythrocin (as stearate)
Tier-2
erythromycin ethylsuccinate oral tablet
Tier-2
erythromycin oral tablet
Tier-2
PCE
Tier-4
ZMAX
Tier-4
Requirements/Limits
MYCOBACTERIAL INFECTIONS-TUBERCULOSIS AND MYCOBACTERIUM AVIUM COMPLEX ethambutol
Tier-2
isoniazid oral solution
Tier-2
isoniazid oral tablet
Tier-1
PASER
Tier-4
PRIFTIN
Tier-3
pyrazinamide
Tier-2
rifabutin
Tier-2
RIFAMATE
Tier-4
rifampin oral
Tier-2
RIFATER
Tier-4
SIRTURO
Tier-3
TRECATOR
Tier-4
PA
QUINOLONES ciprofloxacin
Tier-2
ciprofloxacin (mixture)
Tier-2
ciprofloxacin hcl oral
Tier-1
levofloxacin oral
Tier-3
moxifloxacin
Tier-3
ofloxacin oral
Tier-2
SULFONAMIDES sulfadiazine oral
Tier-2
sulfamethoxazole-trimethoprim oral suspension
Tier-2
sulfamethoxazole-trimethoprim oral tablet
Tier-1
TETRACYCLINES demeclocycline oral
Tier-2
doxycycline hyclate oral capsule
Tier-1
doxycycline hyclate oral tablet
Tier-1
doxycycline hyclate oral tablet, delayed release
Tier-1
doxycycline monohydrate oral capsule
Tier-1
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 7
Drug Name
Drug Tier
doxycycline monohydrate oral suspension
Tier-2
doxycycline monohydrate oral tablet
Tier-1
minocycline oral
Tier-2
tetracycline
Tier-1
VIBRAMYCIN ORAL SYRUP
Tier-4
Requirements/Limits
BLOOD THINNERS AND BLOOD MODIFYING AGENTS ANTIPLATELET THERAPY AGGRENOX
Tier-4
BRILINTA
Tier-4
clopidogrel
Tier-2
dipyridamole oral
Tier-2
EFFIENT
Tier-4
ZONTIVITY
Tier-4
PA
BLOOD MODIFYING AGENTS ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCG/ML, 200 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML
Tier-5
QL (4 ML per 28 days)
ARANESP (IN POLYSORBATE) INJECTION SOLUTION 25 MCG/ML
Tier-3
QL (4 ML per 28 days)
ARANESP (IN POLYSORBATE) INJECTION SYRINGE 10 MCG/0.4 ML, 25 MCG/0.42 ML, 40 MCG/0.4 ML
Tier-3
QL (4 ML per 28 days)
ARANESP (IN POLYSORBATE) INJECTION SYRINGE 100 MCG/0.5 ML, 150 MCG/0.3 ML, 200 MCG/0.4 ML, 300 MCG/0.6 ML, 500 MCG/ML, 60 MCG/0.3 ML
Tier-5
QL (4 ML per 28 days)
EPOGEN INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 3,000 UNIT/ML, 4,000 UNIT/ML
Tier-3
QL (10 ML per 14 days)
EPOGEN INJECTION SOLUTION 20,000 UNIT/ML
Tier-5
QL (10 ML per 14 days)
FRAGMIN SUBCUTANEOUS SOLUTION
Tier-5
FRAGMIN SUBCUTANEOUS SYRINGE 7,500 ANTI-XA UNIT/0.3 ML
Tier-5
GRANIX
Tier-5
LEUKINE INJECTION RECON SOLN
Tier-5
QL (10 ML per 14 Days)
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 8
Drug Name
Drug Tier
Requirements/Limits
MIRCERA INJECTION SYRINGE 100 MCG/0.3 ML, 50 MCG/0.3 ML, 75 MCG/0.3 ML
Tier-3
QL (0.3 ML per 14 days)
MIRCERA INJECTION SYRINGE 200 MCG/0.3 ML
Tier-5
QL (0.3 ML per 14 days)
MOZOBIL
Tier-5
NEULASTA SUBCUTANEOUS SYRINGE
Tier-5
NEUMEGA
Tier-5
NEUPOGEN
Tier-5
QL (10 ML per 14 days)
PROCRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 3,000 UNIT/ML, 4,000 UNIT/ML
Tier-3
QL (10 ML per 14 days)
PROCRIT INJECTION SOLUTION 20,000 UNIT/ML, 40,000 UNIT/ML
Tier-5
QL (10 ML per 14 days)
PROMACTA
Tier-5
PA; QL (30 EA per 30 days)
QL (1 ML per 14 days)
BLOOD THINNERS COUMADIN ORAL
Tier-4
ELIQUIS
Tier-3
enoxaparin subcutaneous solution
Tier-5
enoxaparin subcutaneous syringe 100 mg/ml, 120 mg/0.8 ml, 30 mg/0.3 ml, 40 mg/0.4 ml, 60 mg/0.6 ml, 80 mg/0.8 ml
Tier-2
enoxaparin subcutaneous syringe 150 mg/ml
Tier-5
fondaparinux subcutaneous syringe 10 mg/0.8 ml, 5 mg/0.4 ml, 7.5 mg/0.6 ml
Tier-5
fondaparinux subcutaneous syringe 2.5 mg/0.5 ml
Tier-2
FRAGMIN SUBCUTANEOUS SYRINGE 10,000 ANTI-XA UNIT/ML, 12,500 ANTI-XA UNIT/0.5 ML, 15,000 ANTI-XA UNIT/0.6 ML, 18,000 ANTI-XA UNIT/0.72 ML
Tier-5
FRAGMIN SUBCUTANEOUS SYRINGE 2,500 ANTI-XA UNIT/0.2 ML, 5,000 ANTI-XA UNIT/0.2 ML
Tier-3
jantoven
Tier-1
PRADAXA
Tier-3
SAVAYSA
Tier-4
warfarin
Tier-1
XARELTO ORAL TABLET 10 MG
Tier-3
QL (60 EA per 30 days)
QL (60 EA per 30 days)
QL (35 EA per 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 9
Drug Name
Drug Tier
XARELTO ORAL TABLET 15 MG, 20 MG
Tier-3
XARELTO ORAL TABLETS, DOSE PACK
Tier-3
BLOOD, MISCELLANEOUS anagrelide
Tier-2
cilostazol
Tier-2
pentoxifylline
Tier-2
STIMATE
Tier-4
tranexamic acid
Tier-2
Requirements/Limits
CANCER DRUGS INJECTABLE AGENTS ABRAXANE
Tier-5
ALIMTA
Tier-5
ALKERAN INTRAVENOUS
Tier-5
ARRANON
Tier-5
ARZERRA
Tier-5
AVASTIN
Tier-5
azacitidine
Tier-5
BELEODAQ
Tier-5
BICNU
Tier-5
bleomycin
Tier-2
BUSULFEX
Tier-5
carboplatin intravenous solution
Tier-2
cisplatin
Tier-2
cladribine
Tier-2
CLOLAR
Tier-5
COSMEGEN
Tier-5
cytarabine
Tier-2
cytarabine (pf) injection solution
Tier-2
dacarbazine
Tier-2
DACOGEN
Tier-5
daunorubicin intravenous solution
Tier-2
DAUNOXOME
Tier-5
decitabine
Tier-2
dexrazoxane hcl
Tier-2
DOCEFREZ
Tier-5
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 10
Drug Name
Drug Tier
docetaxel
Tier-2
doxorubicin
Tier-2
doxorubicin, peg-liposomal
Tier-2
ELITEK
Tier-5
ELLENCE
Tier-5
epirubicin
Tier-2
ERBITUX
Tier-5
ERWINAZE
Tier-5
ETOPOPHOS
Tier-5
etoposide intravenous
Tier-2
FASLODEX
Tier-5
fludarabine intravenous solution
Tier-2
fluorouracil intravenous
Tier-2
ganciclovir sodium
Tier-2
gemcitabine
Tier-2
HALAVEN
Tier-5
HERCEPTIN
Tier-5
idarubicin
Tier-2
ifosfamide
Tier-2
irinotecan
Tier-2
ISTODAX
Tier-5
IXEMPRA
Tier-5
JEVTANA
Tier-5
KADCYLA
Tier-5
KEYTRUDA INTRAVENOUS SOLUTION
Tier-5
leuprolide
Tier-2
melphalan hcl
Tier-2
mitomycin
Tier-2
mitoxantrone
Tier-2
MUSTARGEN
Tier-5
ONCASPAR
Tier-5
OPDIVO
Tier-5
oxaliplatin
Tier-2
paclitaxel
Tier-2
PERJETA
Tier-5
Requirements/Limits
PA
PA
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 11
Drug Name
Drug Tier
Requirements/Limits
PROLEUKIN
Tier-5
RITUXAN
Tier-5
PA
SYLATRON
Tier-5
PA; QL (4 EA per 28 days)
SYNRIBO
Tier-5
topotecan intravenous solution
Tier-2
TORISEL
Tier-5
TREANDA
Tier-5
TRISENOX
Tier-5
UVADEX
Tier-3
VECTIBIX
Tier-5
VELCADE
Tier-5
vinblastine intravenous solution
Tier-2
vincasar pfs
Tier-2
vincristine
Tier-2
vinorelbine
Tier-2
YERVOY
Tier-5
ZALTRAP
Tier-5
ZANOSAR
Tier-5
ORAL AGENTS 8-MOP
Tier-3
AFINITOR
Tier-5
PA; QL (30 EA per 30 days)
AFINITOR DISPERZ
Tier-5
PA; QL (60 EA per 30 days)
ALKERAN ORAL
Tier-3
Part B
anastrozole
Tier-2
bicalutamide
Tier-2
BOSULIF ORAL TABLET 100 MG
Tier-5
PA; QL (120 EA per 30 days)
BOSULIF ORAL TABLET 500 MG
Tier-5
PA; QL (30 EA per 30 days)
capecitabine
Tier-2
Part B
CAPRELSA ORAL TABLET 100 MG
Tier-5
PA; QL (60 EA per 30 days)
CAPRELSA ORAL TABLET 300 MG
Tier-5
PA; QL (30 EA per 30 days)
COMETRIQ
Tier-5
PA
CYCLOPHOSPHAMIDE ORAL CAPSULE
Tier-3
B/D
DROXIA
Tier-3
EMCYT
Tier-3
ERIVEDGE
Tier-5
PA
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 12
Drug Name
Drug Tier
Requirements/Limits
exemestane
Tier-2
FARESTON
Tier-3
FARYDAK
Tier-5
flutamide
Tier-2
GILOTRIF
Tier-5
GLEEVEC
Tier-5
GLEOSTINE
Tier-4
HEXALEN
Tier-5
HYCAMTIN ORAL
Tier-3
hydroxyurea
Tier-2
IBRANCE
Tier-5
PA
ICLUSIG
Tier-5
PA
IMBRUVICA
Tier-5
PA
INLYTA
Tier-5
PA
JAKAFI
Tier-5
PA
LENVIMA
Tier-5
PA
letrozole
Tier-2
LEUKERAN
Tier-3
lomustine
Tier-2
LYNPARZA
Tier-5
LYSODREN
Tier-3
MATULANE
Tier-5
megestrol oral tablet
Tier-1
PA
MEKINIST
Tier-5
PA
mercaptopurine
Tier-2
MYLERAN
Tier-3
Part B
NEXAVAR
Tier-5
PA; QL (220 EA per 30 days)
NILANDRON
Tier-5
POMALYST
Tier-5
PURIXAN
Tier-3
REVLIMID
Tier-5
SOLTAMOX
Tier-3
SPRYCEL ORAL TABLET 100 & 140 MG
Tier-5
PA; QL (30 EA per 30 days)
SPRYCEL ORAL TABLET 20, 50, 70 & 80 MG
Tier-5
PA; QL (60 EA per 30 days)
STIVARGA
Tier-5
PA; QL (90 EA per 30 Days)
PA PA
Part B
PA
PA PA; LA
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 13
Drug Name
Drug Tier
Requirements/Limits
SUTENT
Tier-5
PA
TABLOID
Tier-3
TAFINLAR
Tier-5
tamoxifen
Tier-2
TARCEVA ORAL TABLET 100 MG
Tier-5
QL (90 EA per 30 days)
TARCEVA ORAL TABLET 150 MG, 25 MG
Tier-5
QL (30 EA per 30 days)
TARGRETIN ORAL
Tier-5
TASIGNA
Tier-5
PA
temozolomide
Tier-2
Part B
THALOMID
Tier-5
tretinoin (chemotherapy)
Tier-2
TYKERB
Tier-5
PA; QL (180 EA per 30 days)
VOTRIENT
Tier-5
PA; QL (120 EA per 30 days)
XALKORI
Tier-5
PA
XTANDI
Tier-5
PA; QL (120 EA per 30 days)
ZELBORAF
Tier-5
PA
ZOLINZA
Tier-5
PA
ZYDELIG
Tier-5
PA
ZYKADIA
Tier-5
PA
ZYTIGA
Tier-5
PA; QL (120 EA per 30 days)
PA
PROTECTIVE AGENTS amifostine crystalline
Tier-2
FUSILEV
Tier-3
leucovorin calcium injection solution
Tier-2
leucovorin calcium oral
Tier-2
LEVOLEUCOVORIN CALCIUM
Tier-3
mesna
Tier-2
MESNEX ORAL
Tier-4
ZINECARD (AS HCL)
Tier-3
CARDIOVASCULAR AGENTS ACE INHIBITORS benazepril
Tier-1
captopril
Tier-1
enalapril maleate
Tier-1
EPANED
Tier-4
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 14
Drug Name
Drug Tier
fosinopril
Tier-1
lisinopril
Tier-1
moexipril
Tier-1
perindopril erbumine
Tier-1
quinapril
Tier-1
ramipril
Tier-1
trandolapril
Tier-1
Requirements/Limits
ALPHA1 BLOCKERS CARDURA XL
Tier-4
doxazosin
Tier-1
prazosin oral
Tier-1
terazosin
Tier-1
ANGINA CORLANOR
Tier-4
isosorbide dinitrate oral
Tier-1
isosorbide mononitrate
Tier-2
NITRO-BID
Tier-4
nitroglycerin intravenous
Tier-2
nitroglycerin transdermal patch 24 hour
Tier-2
nitroglycerin translingual spray, non-aerosol
Tier-2
NITROMIST
Tier-4
NITROSTAT
Tier-3
RANEXA
Tier-3
ANGIOTENSIN II RECEPTOR BLOCKERS BENICAR
Tier-3
candesartan
Tier-1
eprosartan
Tier-1
irbesartan
Tier-1
losartan
Tier-1
telmisartan
Tier-3
valsartan
Tier-3
PA
ANTI-ARRHYTHMICS AND CARDIAC GLYCOSIDES amiodarone oral Tier-2 digitek
Tier-1
digoxin injection solution
Tier-1
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 15
Drug Name
Drug Tier
Requirements/Limits
digoxin oral solution 50 mcg/ml
Tier-1
digoxin oral tablet 125 mcg
Tier-1
digoxin oral tablet 250 mcg
Tier-1
PA
disopyramide phosphate oral capsule
Tier-2
PA
flecainide
Tier-2
LANOXIN TABLET 62.5 & 125 MCG
Tier-4
LANOXIN ORAL TABLET 187.5 & 250 MCG
Tier-4
mexiletine
Tier-2
MULTAQ
Tier-4
NORPACE CR
Tier-4
propafenone
Tier-2
quinidine gluconate oral
Tier-2
quinidine sulfate oral tablet
Tier-2
sorine
Tier-2
sotalol af
Tier-1
sotalol oral
Tier-1
SOTYLIZE
Tier-4
TIKOSYN
Tier-3
PA
PA
PA
ANTIHYPERTENSIVE FIXED-DOSE COMBINATION PRODUCTS amlodipine-atorvastatin
Tier-3
amlodipine-benazepril
Tier-3
amlodipine-valsartan
Tier-3
amlodipine-valsartan- hydrochlorothiazide
Tier-3
atenolol-chlorthalidone
Tier-1
AZOR
Tier-3
benazepril-hydrochlorothiazide
Tier-1
BENICAR HCT
Tier-3
bisoprolol-hydrochlorothiazide
Tier-1
candesartan-hydrochlorothiazide
Tier-1
captopril-hydrochlorothiazide
Tier-1
clorpres
Tier-2
DUTOPROL
Tier-4
enalapril-hydrochlorothiazide
Tier-1
fosinopril-hydrochlorothiazide
Tier-1
irbesartan-hydrochlorothiazide
Tier-1
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 16
Drug Name
Drug Tier
lisinopril-hydrochlorothiazide
Tier-1
losartan-hydrochlorothiazide
Tier-1
metoprolol ta-hydrochlorothiazide
Tier-2
moexipril-hydrochlorothiazide
Tier-1
nadolol-bendroflumethiazide
Tier-2
propranolol-hydrochlorothiazide
Tier-2
quinapril-hydrochlorothiazide
Tier-1
TEKTURNA HCT
Tier-3
telmisartan-amlodipine
Tier-1
telmisartan-hydrochlorothiazide
Tier-3
trandolapril-verapamil
Tier-2
valsartan-hydrochlorothiazide
Tier-1
BETA AND ALPHA BLOCKERS carvedilol
Tier-1
COREG CR
Tier-4
labetalol oral
Tier-2
BETA BLOCKERS acebutolol oral
Tier-2
atenolol
Tier-1
betaxolol oral
Tier-2
bisoprolol fumarate
Tier-2
metoprolol succinate
Tier-2
metoprolol tartrate oral
Tier-1
nadolol
Tier-1
pindolol
Tier-2
propranolol oral capsule,extended release 24 hr
Tier-2
propranolol oral solution
Tier-2
propranolol oral tablet
Tier-1
timolol maleate oral
Tier-2
CALCIUM CHANNEL BLOCKERS afeditab cr
Tier-2
amlodipine
Tier-2
cartia xt
Tier-2
diltiazem hcl oral capsule, extended release
Tier-2
diltiazem hcl oral capsule,ext release degradable
Tier-2
Requirements/Limits
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 17
Drug Name
Drug Tier
diltiazem hcl oral capsule,extended release 12 hr
Tier-2
diltiazem hcl oral capsule,extended release 24hr
Tier-2
diltiazem hcl oral tablet
Tier-1
diltiazem hcl oral tablet extended release 24 hr
Tier-2
dilt-xr
Tier-2
felodipine
Tier-2
isradipine
Tier-2
matzim la
Tier-2
nicardipine oral
Tier-2
nifedical xl
Tier-2
nifedipine oral capsule
Tier-2
nifedipine oral tablet extended release 24hr
Tier-2
nimodipine
Tier-2
nisoldipine
Tier-2
taztia xt
Tier-2
verapamil oral
Tier-1
CENTRALLY ACTING AGENTS clonidine
Tier-2
clonidine hcl oral tablet
Tier-1
NORTHERA
Tier-5
reserpine oral tablet 0.1 mg
Tier-2
reserpine oral tablet 0.25 mg
Tier-2
Requirements/Limits
PA
PA PA
DIRECT RENIN INHIBITORS TEKTURNA
Tier-3
DIURETICS amiloride oral
Tier-2
amiloride-hydrochlorothiazide
Tier-1
bumetanide oral
Tier-1
chlorothiazide
Tier-2
chlorthalidone
Tier-1
EDECRIN
Tier-3
eplerenone
Tier-2
furosemide oral solution
Tier-2
furosemide oral tablet
Tier-1
hydrochlorothiazide
Tier-1
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 18
Drug Name
Drug Tier
indapamide
Tier-1
methyclothiazide
Tier-2
metolazone
Tier-2
spironolactone
Tier-1
spironolacton-hydrochlorothiazide
Tier-2
torsemide oral
Tier-2
triamterene-hydrochlorothiazide
Tier-1
Requirements/Limits
LIPID LOWERING AGENTS atorvastatin
Tier-2
cholestyramine light oral powder in packet
Tier-2
colestipol oral granules
Tier-2
colestipol oral tablet
Tier-2
CRESTOR
Tier-4
fenofibrate
Tier-2
fenofibrate micronized
Tier-2
fenofibrate nanocrystallized
Tier-2
fenofibric acid (choline)
Tier-2
fluvastatin
Tier-3
gemfibrozil oral
Tier-2
JUXTAPID
Tier-5
PA
KYNAMRO
Tier-5
PA
lovastatin
Tier-1
niacin oral tablet extended release 24 hr
Tier-3
niacor
Tier-2
omega-3 acid ethyl esters
Tier-3
pravastatin
Tier-1
PREVALITE ORAL POWDER
Tier-4
SIMCOR
Tier-3
simvastatin
Tier-1
VASCEPA
Tier-3
VYTORIN 10-10
Tier-4
VYTORIN 10-20
Tier-4
VYTORIN 10-40
Tier-4
VYTORIN 10-80
Tier-4
WELCHOL
Tier-4
PA
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 19
Drug Name
Drug Tier
ZETIA
Requirements/Limits
Tier-3
POTASSIUM REPLACEMENT klor-con 10
Tier-2
klor-con 8
Tier-2
KLOR-CON M15
Tier-4
klor-con m20
Tier-2
K-TAB ORAL TABLET EXTENDED RELEASE 10 MEQ, 8 MEQ
Tier-4
potassium chloride cap, extended release 10 meq
Tier-1
potassium chloride cap, extended release 8 meq
Tier-2
potassium chloride oral liquid
Tier-2
potassium chloride oral tablet extended release 8 meq
Tier-2
potassium chloride oral tablet,er particles/crystals
Tier-2
VASODILATORS BIDIL
Tier-3
hydralazine oral
Tier-1
minoxidil oral
Tier-2
DIABETES MELLITUS DIABETIC SUPPLIES gauze pad topical bandage
Tier-2
INSULIN PEN NEEDLE
Tier-3
INSULIN SYRINGE-NEEDLE
Tier-3
insulin syringe-needle
Tier-2
isopropyl alcohol-benzocaine
Tier-2
lancets
Tier-2
Part B
ONETOUCH ULTRA TEST
Tier-3
Part B
ONETOUCH VERIO
Tier-3
Part B
safety needles
Tier-2
GLUCOSE ELEVATING GLUCAGEN HYPOKIT
Tier-3
GLUCAGON EMERGENCY KIT (HUMAN)
Tier-3
PROGLYCEM
Tier-4
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 20
Drug Name
Drug Tier
INSULINS HUMALOG
Tier-3
HUMALOG KWIKPEN
Tier-3
HUMALOG MIX 50-50
Tier-3
HUMALOG MIX 50-50 KWIKPEN
Tier-3
HUMALOG MIX 75-25
Tier-3
HUMALOG MIX 75-25 KWIKPEN
Tier-3
HUMULIN 70/30
Tier-3
HUMULIN N
Tier-3
HUMULIN R
Tier-3
HUMULIN R U-500 "CONCENTRATED"
Tier-3
LANTUS
Tier-3
LANTUS SOLOSTAR
Tier-3
Requirements/Limits
NON-INSULIN INJECTABLES BYDUREON
Tier-3
SYMLINPEN 120
Tier-3
SYMLINPEN 60
Tier-3
TRULICITY
Tier-3
ORAL AGENTS acarbose
Tier-1
ACTOPLUS MET XR
Tier-4
chlorpropamide
Tier-1
FARXIGA
Tier-3
glimepiride
Tier-1
glipizide
Tier-1
glipizide-metformin
Tier-1
glyburide
Tier-1
PA
glyburide micronized
Tier-1
PA
glyburide-metformin
Tier-1
PA
GLYXAMBI
Tier-4
INVOKAMET
Tier-3
INVOKANA
Tier-3
JANUMET
Tier-3
JANUMET XR
Tier-3
JANUVIA
Tier-3
PA
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 21
Drug Name
Drug Tier
JENTADUETO
Tier-3
metformin
Tier-1
nateglinide
Tier-1
pioglitazone
Tier-3
pioglitazone-glimepiride
Tier-2
pioglitazone-metformin
Tier-3
PRANDIMET
Tier-4
repaglinide
Tier-1
RIOMET
Tier-3
tolazamide
Tier-1
tolbutamide
Tier-1
TRADJENTA
Tier-3
XIGDUO XR
Tier-3
Requirements/Limits
EAR, NOSE AND THROAT EAR acetasol hc
Tier-2
acetic acid otic
Tier-2
CIPRO HC
Tier-3
CIPRODEX
Tier-3
fluocinolone acetonide oil
Tier-2
hydrocortisone-acetic acid
Tier-2
ofloxacin otic
Tier-2
MOUTH AND THROAT cevimeline
Tier-2
chlorhexidine gluconate mucous membrane
Tier-1
periogard
Tier-1
pilocarpine hcl oral
Tier-2
triamcinolone acetonide dental
Tier-2
NOSE azelastine nasal
Tier-2
BACTROBAN NASAL
Tier-4
budesonide nasal
Tier-2
cyproheptadine
Tier-2
desloratadine
Tier-2
flunisolide nasal spray,non-aerosol 25 mcg
Tier-2
QL (120 ML per 90 days)
PA QL (150 ML per 90 Days)
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 22
Drug Name
Drug Tier
Requirements/Limits
fluticasone nasal
Tier-2
QL (48 GM per 90 days)
hydroxyzine hcl oral
Tier-2
PA
hydroxyzine pamoate
Tier-2
PA
ipratropium nasal spray,non-aerosol 0.03 %
Tier-2
QL (180 ML per 90 days)
ipratropium nasal spray,non-aerosol 0.06 %
Tier-2
QL (90 ML per 90 days)
levocetirizine
Tier-2
NASONEX
Tier-3
QL (102 GM per 90 days)
olopatadine
Tier-2
QL (91.5 GM per 90 days)
triamcinolone acetonide nasal
Tier-3
QL (49.5 GM per 90 days)
TYZINE NASAL DROPS
Tier-4
EYE ALLERGY ALOCRIL
Tier-4
ALOMIDE
Tier-4
azelastine ophthalmic
Tier-2
cromolyn ophthalmic
Tier-2
EMADINE
Tier-4
epinastine
Tier-2
LASTACAFT
Tier-4
naphazoline
Tier-2
ANTI-INFECTIVES AZASITE
Tier-4
bacitracin ophthalmic
Tier-2
bacitracin-polymyxin b ophthalmic
Tier-2
BESIVANCE
Tier-4
BLEPHAMIDE
Tier-4
BLEPHAMIDE S.O.P.
Tier-4
ciprofloxacin hcl ophthalmic
Tier-2
erythromycin ophthalmic
Tier-2
GARAMYCIN OPHTHALMIC DROPS
Tier-4
gatifloxacin
Tier-2
gentak ophthalmic ointment
Tier-1
gentamicin ophthalmic
Tier-1
levofloxacin ophthalmic
Tier-2
MOXEZA
Tier-4
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 23
Drug Name
Drug Tier
neomycin-bacitracin-poly-hc
Tier-2
neomycin-bacitracin-polymyxin
Tier-2
neomycin-polymyxin-hc drops,suspension
Tier-2
ofloxacin ophthalmic
Tier-2
polymyxin b sulf-trimethoprim
Tier-1
sulfacetamide sodium ophthalmic
Tier-2
sulfacetamide-prednisolone
Tier-2
TOBRADEX OPHTHALMIC OINTMENT
Tier-4
TOBRADEX ST
Tier-4
tobramycin
Tier-2
tobramycin-dexamethasone
Tier-2
VIGAMOX
Tier-4
ANTI-INFLAMMATORIES ALREX
Tier-4
bromfenac
Tier-2
dexamethasone sodium phosphate ophthalmic
Tier-2
diclofenac sodium ophthalmic
Tier-2
DUREZOL
Tier-4
FLAREX
Tier-4
fluorometholone
Tier-2
flurbiprofen sodium
Tier-2
FML FORTE
Tier-4
FML S.O.P.
Tier-3
ILEVRO
Tier-4
ketorolac ophthalmic
Tier-2
LOTEMAX
Tier-4
MAXIDEX
Tier-4
neomycin-polymyxin b-dexamethasone
Tier-2
neomycin-polymyxin-gramicidin
Tier-2
neomycin-polymyxin-hc ophthalmic
Tier-2
neomycin-polymyxin-hc solution
Tier-2
NEVANAC
Tier-4
PRED MILD
Tier-3
PRED-G
Tier-3
PRED-G S.O.P.
Tier-3
Requirements/Limits
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 24
Drug Name
Drug Tier
prednisolone acetate
Tier-2
PROLENSA
Tier-4
VEXOL
Tier-3
ZYLET
Tier-4
ANTIVIRALS trifluridine
Tier-2
ZIRGAN
Tier-4
Requirements/Limits
GLAUCOMA acetazolamide oral
Tier-2
ALPHAGAN P OPHTHALMIC DROPS 0.1 %
Tier-4
apraclonidine
Tier-2
AZOPT
Tier-3
betaxolol ophthalmic
Tier-2
BETIMOL OPHTHALMIC DROPS 0.5 %
Tier-3
BETOPTIC S
Tier-4
bimatoprost
Tier-2
brimonidine
Tier-2
carteolol
Tier-2
COMBIGAN
Tier-4
dorzolamide
Tier-2
dorzolamide-timolol
Tier-2
IOPIDINE OPHTHALMIC DROPPERETTE
Tier-4
latanoprost
Tier-2
levobunolol ophthalmic drops 0.5 %
Tier-1
LUMIGAN OPHTHALMIC DROPS 0.01 %
Tier-4
methazolamide oral
Tier-2
metipranolol
Tier-2
PHOSPHOLINE IODIDE
Tier-3
pilocarpine hcl ophthalmic
Tier-2
SIMBRINZA
Tier-4
timolol maleate ophthalmic drops
Tier-1
timolol maleate ophthalmic gel forming solution
Tier-2
TRAVATAN Z
Tier-4
travoprost (benzalkonium)
Tier-2
ZIOPTAN (PF)
Tier-4
STPA
STPA STPA
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 25
Drug Name
Drug Tier
Requirements/Limits
OPHTHALMIC DRUGS, MISCELLANEOUS ALCAINE
Tier-4
atropine ophthalmic drops
Tier-2
NATACYN
Tier-4
proparacaine
Tier-2
RESTASIS
Tier-3
PA
ALOXI
Tier-5
B/D
ANZEMET ORAL
Tier-3
B/D
CESAMET
Tier-3
B/D
compro
Tier-2
dronabinol
Tier-2
B/D
EMEND ORAL
Tier-3
B/D
granisetron hcl oral
Tier-2
B/D
meclizine oral tablet
Tier-2
metoclopramide hcl oral
Tier-2
ondansetron
Tier-2
B/D
ondansetron hcl oral
Tier-2
B/D
prochlorperazine
Tier-2
prochlorperazine maleate oral
Tier-2
promethazine oral
Tier-2
promethazine rectal
Tier-2
SANCUSO
Tier-4
TRANSDERM-SCOP
Tier-4
GASTROINTESTINAL DRUGS EMESIS
PA B/D; QL (1 EA per 7 days)
ENZYMES CARBAGLU
Tier-3
CREON
Tier-3
CYSTAGON
Tier-4
PANCREAZE
Tier-4
PERTZYE
Tier-4
ULTRESA
Tier-4
VIOKACE
Tier-4
PA
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 26
Drug Name
Drug Tier
ZENPEP
Requirements/Limits
Tier-4
GASTROINTESTINAL DRUGS, MISCELLANEOUS alosetron
Tier-2
CANTIL
Tier-4
constulose
Tier-2
cromolyn oral
Tier-2
dicyclomine oral capsule
Tier-1
dicyclomine oral solution
Tier-1
dicyclomine oral tablet
Tier-1
enulose
Tier-2
FULYZAQ
Tier-3
PA
GATTEX ONE-VIAL
Tier-5
PA
generlac
Tier-2
glycopyrrolate oral
Tier-2
KRISTALOSE
Tier-3
lactulose
Tier-2
levocarnitine (with sugar)
Tier-2
levocarnitine oral tablet
Tier-2
loperamide oral capsule
Tier-2
megestrol oral suspension
Tier-2
MOVIPREP
Tier-4
OSMOPREP
Tier-4
peg 3350-electrolytes
Tier-2
peg-3350 with flavor packs
Tier-2
peg-electrolyte solution
Tier-2
polyethylene glycol 3350 oral powder
Tier-2
propantheline
Tier-2
RELISTOR SUBCUTANEOUS SOLUTION
Tier-5
RELISTOR SUBCUTANEOUS SYRINGE
Tier-5
SUCLEAR
Tier-4
SUPREP BOWEL PREP KIT
Tier-4
trilyte with flavor packets
Tier-2
ursodiol
Tier-2
PA
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 27
Drug Name
Drug Tier
Requirements/Limits
GASTROINTESTINAL DRUGS, PEPTIC ULCER TREATMENT, REFLUX (GERD) amoxicil-clarithromy-lansoprazole Tier-2 CARAFATE ORAL SUSPENSION
Tier-4
cimetidine
Tier-1
cimetidine hcl oral
Tier-2
DEXILANT
Tier-4
PA
esomeprazole magnesium
Tier-3
PA
famotidine oral suspension
Tier-2
famotidine oral tablet 20 mg, 40 mg
Tier-1
lansoprazole oral capsule, delayed release(dr/ec)
Tier-3
methscopolamine oral
Tier-2
misoprostol
Tier-2
nizatidine
Tier-2
omeprazole oral capsule, delayed release(dr/ec)
Tier-2
omeprazole-sodium bicarbonate
Tier-2
pantoprazole oral
Tier-2
PYLERA
Tier-3
rabeprazole
Tier-3
ranitidine hcl oral capsule
Tier-1
ranitidine hcl oral syrup
Tier-2
ranitidine hcl oral tablet 150 mg, 300 mg
Tier-1
sucralfate oral tablet
Tier-2
INFLAMMATORY BOWEL DISEASE AMITIZA
Tier-3
APRISO
Tier-3
ASACOL HD
Tier-3
balsalazide
Tier-2
budesonide oral
Tier-2
CANASA
Tier-3
colocort
Tier-2
DELZICOL
Tier-3
DIPENTUM
Tier-3
hydrocortisone rectal enema
Tier-2
LIALDA
Tier-3
LINZESS
Tier-3
QL (30 EA per 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 28
Drug Name
Drug Tier
mesalamine with cleansing wipe
Tier-2
PENTASA
Tier-3
SFROWASA
Tier-4
sulfasalazine oral tablet
Tier-2
sulfazine ec
Tier-2
UCERIS ORAL
Tier-5
Requirements/Limits
HOME INFUSION THERAPY ACUTE CARE DRUGS ABELCET
Tier-3
HI
acetazolamide sodium
Tier-2
HI
acyclovir sodium intravenous solution
Tier-2
HI
AMBISOME
Tier-3
HI
amikacin injection
Tier-2
HI; Part B
aminophylline intravenous
Tier-2
HI
amphotericin b
Tier-2
HI
ampicillin sodium
Tier-2
HI; Part B
ampicillin-sulbactam
Tier-2
HI; Part B
ANZEMET INTRAVENOUS
Tier-3
B/D; HI
ARGATROBAN
Tier-4
HI
ARGATROBAN IN 0.9 % NACL SOLUTION
Tier-4
HI
atropine injection
Tier-2
HI
atropine intravenous
Tier-2
HI
AVELOX IN NACL (ISO-OSMOTIC)
Tier-3
HI; Part B
azithromycin intravenous
Tier-2
HI; Part B
aztreonam
Tier-2
HI; Part B
benztropine injection
Tier-2
HI
bumetanide injection
Tier-2
HI
buprenorphine hcl injection syringe
Tier-2
HI
butorphanol tartrate injection
Tier-2
HI
calcitriol intravenous
Tier-2
HI
CANCIDAS
Tier-5
HI
CAPASTAT
Tier-3
HI
CARDENE IV IN SODIUM CHLORIDE
Tier-4
HI
cefazolin
Tier-2
HI; Part B
cefazolin in 0.9% nacl intravenous solution
Tier-2
HI; Part B
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 29
Drug Name
Drug Tier
Requirements/Limits
cefazolin in 0.9% nacl intravenous syringe
Tier-2
HI; Part B
cefazolin in dextrose (iso-os)
Tier-2
HI; Part B
cefazolin in dextrose 5 %
Tier-2
HI; Part B
cefazolin in sterile water
Tier-2
HI; Part B
cefepime
Tier-2
HI; Part B
cefepime in dextrose 5 %
Tier-2
HI; Part B
cefotaxime
Tier-2
HI; Part B
cefotetan
Tier-2
HI; Part B
cefoxitin
Tier-2
HI; Part B
cefoxitin in dextrose, iso-osm
Tier-2
HI; Part B
ceftazidime
Tier-2
HI; Part B
ceftazidime in d5w
Tier-2
HI; Part B
ceftriaxone injection
Tier-2
HI; Part B
ceftriaxone intravenous solution
Tier-2
HI; Part B
cefuroxime sodium
Tier-2
HI; Part B
chloramphenicol sod succinate
Tier-2
HI; Part B
cidofovir
Tier-2
HI
ciprofloxacin in 5 % dextrose
Tier-2
HI; Part B
ciprofloxacin lactate
Tier-2
HI; Part B
clindamycin in 5 % dextrose
Tier-2
HI; Part B
clindamycin phosphate injection
Tier-2
HI; Part B
clindamycin phosphate intravenous
Tier-2
HI; Part B
colistin (colistimethate na)
Tier-2
HI; Part B
CRESEMBA INTRAVENOUS
Tier-5
HI
CUBICIN
Tier-5
HI; Part B
cyclosporine intravenous
Tier-2
B/D; HI
CYKLOKAPRON
Tier-3
HI
DALVANCE
Tier-3
HI; Part B
dexamethasone sodium phos (pf)
Tier-2
HI
dexamethasone sodium phosphate injection
Tier-2
HI
diltiazem hcl intravenous
Tier-2
HI
diphenhydramine hcl injection
Tier-2
HI
DORIBAX
Tier-3
HI; Part B
DOXY-100
Tier-4
HI; Part B
duramorph (pf)
Tier-2
HI
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 30
Drug Name
Drug Tier
Requirements/Limits
ERAXIS(WATER DILUENT)
Tier-3
HI
ERYTHROCIN
Tier-3
HI; Part B
esomeprazole sodium
Tier-2
HI
fluconazole in dextrose (iso-o)
Tier-2
HI
foscarnet
Tier-2
HI
gentamicin in nacl (iso-osm)
Tier-2
HI; Part B
gentamicin injection
Tier-2
HI; Part B
gentamicin sulfate (ped) (pf)
Tier-2
HI; Part B
gentamicin sulfate (pf)
Tier-2
HI; Part B
granisetron (pf)
Tier-2
B/D; HI
granisetron hcl intravenous
Tier-2
B/D; HI
heparin (porcine) injection solution
Tier-2
HI
imipenem-cilastatin
Tier-2
HI; Part B
INVANZ INJECTION
Tier-3
HI; Part B
isoniazid injection
Tier-2
HI
labetalol intravenous solution
Tier-2
HI
lactated ringers intravenous
Tier-2
HI
levetiracetam in nacl (iso-os)
Tier-2
HI
levocarnitine intravenous
Tier-2
HI
levofloxacin in d5w
Tier-2
HI; Part B
levofloxacin intravenous
Tier-2
HI; Part B
levothyroxine intravenous
Tier-2
HI
LINCOCIN
Tier-3
HI; Part B
linezolid intravenous
Tier-2
HI; Part B
meropenem
Tier-2
HI; Part B
methadone injection
Tier-2
HI
methotrexate sodium (pf)
Tier-2
HI
metoclopramide hcl injection solution
Tier-2
HI
metoprolol tartrate intravenous solution
Tier-2
HI
metronidazole in nacl (iso-os)
Tier-2
HI; Part B
morphine intravenous syringe
Tier-2
HI
MYCAMINE
Tier-3
HI
nafcillin
Tier-2
HI; Part B
nafcillin in dextrose iso-osm
Tier-2
HI; Part B
ondansetron hcl (pf)
Tier-2
B/D; HI
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 31
Drug Name
Drug Tier
Requirements/Limits
oxacillin
Tier-2
HI; Part B
oxacillin in dextrose(iso-osm)
Tier-2
HI; Part B
penicillin g pot in dextrose
Tier-2
HI; Part B
penicillin g potassium
Tier-2
HI; Part B
penicillin g sodium
Tier-2
HI; Part B
piperacillin-tazobactam
Tier-2
HI; Part B
polymyxin b sulfate
Tier-2
HI; Part B
prochlorperazine edisylate
Tier-2
HI
PROGRAF INTRAVENOUS
Tier-3
B/D; HI
promethazine injection solution
Tier-2
HI
ranitidine hcl injection solution
Tier-2
HI
RETROVIR INTRAVENOUS
Tier-3
HI
rifampin intravenous
Tier-2
HI; Part B
streptomycin intramuscular
Tier-2
HI; Part B
sulfamethoxazole-trimethoprim intravenous
Tier-2
HI; Part B
SYNERCID
Tier-3
HI; Part B
TEFLARO
Tier-3
HI; Part B
tobramycin sulfate injection solution
Tier-2
HI; Part B
TYGACIL
Tier-3
HI; Part B
valproate sodium
Tier-2
HI
vancomycin intravenous
Tier-2
HI; Part B
VISTIDE
Tier-3
HI
voriconazole intravenous
Tier-2
HI
ZERBAXA
Tier-5
HI; Part B
ammonium chloride
Tier-2
HI
d10 % & 0.45 % sodium chloride
Tier-2
HI
d10 %-0.9 % sodium chloride
Tier-2
HI
d2.5 %-0.45 % sodium chloride
Tier-2
HI
d5 % and 0.9 % sodium chloride
Tier-2
HI
d5 %-0.45 % sodium chloride
Tier-2
HI
dextrose 10 % and 0.2 % nacl
Tier-2
HI
dextrose 10 % in water (d10w) intravenous parenteral solution
Tier-2
HI
ELECTROLYTES
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 32
Drug Name
Drug Tier
Requirements/Limits
dextrose 5 % in water (d5w) intravenous parenteral solution
Tier-2
HI
dextrose 5 %-lactated ringers
Tier-2
HI
dextrose 5%-0.2 % sod chloride
Tier-2
HI
dextrose 5%-0.3 % sod.chloride
Tier-2
HI
IONOSOL-B IN D5W
Tier-3
HI
IONOSOL-MB IN D5W
Tier-3
HI
ISOLYTE-P IN 5 % DEXTROSE
Tier-3
HI
ISOLYTE-S
Tier-3
HI
magnesium sulfate injection
Tier-2
HI
NORMOSOL-M IN 5 % DEXTROSE
Tier-3
HI
NORMOSOL-R IN 5 % DEXTROSE
Tier-3
HI
NORMOSOL-R PH 7.4
Tier-3
HI
PLASMA-LYTE 148
Tier-3
HI
PLASMA-LYTE A
Tier-3
HI
PLASMA-LYTE-56 IN 5 % DEXTROSE
Tier-3
HI
potassium chlorid-d5-0.45%nacl
Tier-2
HI
potassium chloride in 0.9%nacl
Tier-2
HI
potassium chloride in 5 % dex
Tier-2
HI
potassium chloride in lr-d5
Tier-2
HI
potassium chloride intravenous
Tier-2
HI
potassium chloride-0.45 % nacl
Tier-2
HI
potassium chloride-d5-0.2%nacl
Tier-2
HI
potassium chloride-d5-0.3%nacl
Tier-2
HI
potassium chloride-d5-0.9%nacl
Tier-2
HI
potassium cl in d10-0.2 % nacl
Tier-2
HI
ringers intravenous
Tier-2
HI
sodium chloride 0.45 % iv parenteral solution
Tier-2
HI
sodium chloride 0.9 % iv parenteral solution
Tier-2
HI
sodium chloride 3 %
Tier-2
HI
sodium chloride 5 %
Tier-2
HI
sodium lactate intravenous solution
Tier-2
HI
IV NUTRITION AMINOSYN 7 % WITH ELECTROLYTES
Tier-3
B/D; HI
AMINOSYN 8.5 %-ELECTROLYTES
Tier-3
B/D; HI
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 33
Drug Name
Drug Tier
Requirements/Limits
AMINOSYN II 10 %
Tier-3
B/D; HI
AMINOSYN II 15 %
Tier-3
B/D; HI
AMINOSYN II 7 %
Tier-3
B/D; HI
AMINOSYN II 8.5 %
Tier-3
B/D; HI
AMINOSYN II 8.5 %-ELECTROLYTES
Tier-3
B/D; HI
AMINOSYN M 3.5 %
Tier-3
B/D; HI
AMINOSYN-HBC 7%
Tier-3
B/D; HI
AMINOSYN-PF 10 %
Tier-3
B/D; HI
AMINOSYN-PF 7 % (SULFITE-FREE)
Tier-3
B/D; HI
AMINOSYN-RF 5.2 %
Tier-3
B/D; HI
CLINIMIX 5%/D15W SULFITE FREE
Tier-3
B/D; HI
CLINIMIX 5%/D25W SULFITE-FREE
Tier-3
B/D; HI
CLINIMIX 2.75%/D5W SULFIT FREE
Tier-3
B/D; HI
CLINIMIX 4.25%/D10W SULF FREE
Tier-3
B/D; HI
CLINIMIX 4.25%/D5W SULFIT FREE
Tier-3
B/D; HI
CLINIMIX 4.25%-D20W SULF-FREE
Tier-3
B/D; HI
CLINIMIX 4.25%-D25W SULF-FREE
Tier-3
B/D; HI
CLINIMIX 5%-D20W(SULFITE-FREE)
Tier-3
B/D; HI
CLINIMIX E 2.75%/D10W SUL FREE
Tier-3
B/D; HI
CLINIMIX E 2.75%/D5W SULF FREE
Tier-3
B/D; HI
CLINIMIX E 4.25%/D10W SUL FREE
Tier-3
B/D; HI
CLINIMIX E 4.25%/D25W SUL FREE
Tier-3
B/D; HI
CLINIMIX E 4.25%/D5W SULF FREE
Tier-3
B/D; HI
CLINIMIX E 5%/D15W SULFIT FREE
Tier-3
B/D; HI
CLINIMIX E 5%/D20W SULFIT FREE
Tier-3
B/D; HI
CLINIMIX E 5%/D25W SULFIT FREE
Tier-3
B/D; HI
CLINISOL SF 15 %
Tier-3
B/D; HI
FREAMINE HBC 6.9 %
Tier-3
B/D; HI
HEPATAMINE 8%
Tier-3
B/D; HI
INTRALIPID
Tier-3
B/D; HI
LIPOSYN II
Tier-3
B/D; HI
NEPHRAMINE 5.4 %
Tier-3
B/D; HI
NUTRILIPID
Tier-3
B/D; HI
PREMASOL 10 %
Tier-3
B/D; HI
PREMASOL 6 %
Tier-3
B/D; HI
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 34
Drug Name
Drug Tier
Requirements/Limits
PROCALAMINE 3%
Tier-3
B/D; HI
PROSOL 20 %
Tier-3
B/D; HI
tpn electrolytes
Tier-2
B/D; HI
TRAVASOL 10 %
Tier-3
B/D; HI
TROPHAMINE 10 %
Tier-3
B/D; HI
TROPHAMINE 6%
Tier-3
B/D; HI
HORMONES ADRENAL CORTICOSTEROIDS a-hydrocort
Tier-2
cortisone
Tier-2
DEPO-MEDROL
Tier-3
dexamethasone intensol
Tier-2
dexamethasone oral elixir
Tier-2
dexamethasone oral tablet
Tier-1
dexpak 13 day
Tier-2
fludrocortisone
Tier-2
hydrocortisone oral
Tier-2
MEDROL ORAL TABLET 2 MG
Tier-4
methylprednisolone
Tier-2
methylprednisolone acetate
Tier-2
methylprednisolone sodium succ
Tier-2
MILLIPRED
Tier-4
Transplant
ORAPRED ODT
Tier-4
Transplant
prednisolone sodium phosphate
Tier-2
prednisolone sodium phosphate oral
Tier-2
Transplant
PREDNISONE INTENSOL
Tier-4
Transplant
prednisone oral solution
Tier-2
Transplant
prednisone oral tablet
Tier-1
Transplant
SOLU-CORTEF
Tier-4
SOLU-CORTEF (PF)
Tier-4
SOLU-MEDROL
Tier-4
SOLU-MEDROL (PF)
Tier-4
VERIPRED 20
Tier-4
ANDROGENS AVEED
Tier-4
Transplant
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 35
Drug Name
Drug Tier
danazol oral
Tier-2
DEPO-TESTOSTERONE
Tier-4
METHITEST
Tier-4
oxandrolone
Tier-2
testosterone cypionate
Tier-2
testosterone enanthate
Tier-2
testosterone transderm gel in metered-dose pump
Tier-2
testosterone transdermal gel in packet
Tier-2
TESTRED
Tier-5
Requirements/Limits
GONADOTROPIN RELEASING AGONISTS ELIGARD
Tier-3
FIRMAGON RECON SOLN 120 MG
Tier-5
FIRMAGON RECON SOLN 80 MG
Tier-3
LUPRON DEPOT
Tier-5
LUPRON DEPOT (3 MONTH)
Tier-5
LUPRON DEPOT (4 MONTH)
Tier-5
LUPRON DEPOT (6 MONTH)
Tier-5
LUPRON DEPOT-PED
Tier-5
SYNAREL
Tier-3
TRELSTAR
Tier-3
TRELSTAR DEPOT
Tier-3
TRELSTAR LA
Tier-3
THYROID REPLACEMENT AND ANTITHYROID AGENTS ARMOUR THYROID
Tier-4
levothyroxine oral
Tier-1
levoxyl
Tier-1
liothyronine oral
Tier-2
methimazole
Tier-2
propylthiouracil
Tier-2
SYNTHROID
Tier-4
THYROLAR-1
Tier-4
THYROLAR-1/2
Tier-4
THYROLAR-1/4
Tier-4
THYROLAR-2
Tier-4
THYROLAR-3
Tier-4
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 36
Drug Name
Drug Tier
TIROSINT
Tier-4
TRIOSTAT
Tier-3
unithroid
Tier-1
Requirements/Limits
IMMUNOLOGIC AGENTS IMMUNE STIMULANTS ACTHIB (PF)
Tier-3
ACTIMMUNE
Tier-5
ADACEL (TDAP ADOLESN/ADULT)(PF)
Tier-3
ADAGEN
Tier-5
bcg vaccine, live (pf)
Tier-2
BEXSERO (PF)
Tier-3
BIVIGAM
Tier-5
BOOSTRIX TDAP
Tier-3
CARIMUNE NF NANOFILTERED
Tier-5
CERVARIX VACCINE (PF)
Tier-3
COMVAX (PF)
Tier-3
DAPTACEL (DTAP PEDIATRIC) (PF)
Tier-3
ENGERIX-B (PF) IM SYRINGE
Tier-3
B/D
ENGERIX-B PEDIATRIC (PF)
Tier-3
B/D
FLEBOGAMMA DIF
Tier-5
PA; Part B
GAMASTAN S/D
Tier-3
PA; Part B
GAMMAGARD LIQUID
Tier-5
PA; Part B
GAMMAKED
Tier-5
PA; Part B
GAMMAPLEX
Tier-5
PA; Part B
GAMUNEX-C
Tier-5
PA; Part B
GARDASIL (PF)
Tier-3
GARDASIL 9 (PF)
Tier-3
HAVRIX (PF)
Tier-3
HYPERRAB S/D (PF)
Tier-3
IMOVAX RABIES VACCINE (PF)
Tier-3
INFANRIX (DTAP) (PF) IM SUSPENSION
Tier-3
IPOL
Tier-3
IXIARO (PF)
Tier-3
MENACTRA (PF) IM SOLUTION
Tier-3
MENOMUNE - A/C/Y/W-135 (PF)
Tier-3
Part B
PA; Part B PA; Part B
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 37
Drug Name
Drug Tier
Requirements/Limits
MENVEO A-C-Y-W-135-DIP (PF)
Tier-3
M-M-R II (PF)
Tier-3
OCTAGAM
Tier-3
PEDVAX HIB (PF)
Tier-3
PNEUMOVAX 23 INJECTION SOLUTION
Tier-3
Part B
PREVNAR 13 (PF)
Tier-3
Part B
PRIVIGEN
Tier-5
PA; Part B
PROQUAD (PF)
Tier-3
QUADRACEL (PF)
Tier-3
RABAVERT (PF)
Tier-3
RECOMBIVAX HB (PF)
Tier-3
ROTARIX
Tier-3
ROTATEQ VACCINE
Tier-3
TENIVAC (PF) INTRAMUSCULAR SYRINGE
Tier-3
tetanus,diphtheria tox ped(pf)
Tier-2
tetanus-diphtheria toxoids-td
Tier-2
TRUMENBA
Tier-3
TWINRIX (PF) INTRAMUSCULAR SUSPENSION
Tier-3
TYPHIM VI
Tier-3
VAQTA (PF) INTRAMUSCULAR SYRINGE
Tier-3
VARIVAX (PF)
Tier-3
VARIZIG INTRAMUSCULAR SOLUTION
Tier-3
VIVOTIF BERNA VACCINE
Tier-3
YF-VAX (PF)
Tier-3
ZOSTAVAX (PF)
Tier-3
IMMUNOSUPPRESSIVES ASTAGRAF XL
Tier-4
B/D
ATGAM
Tier-3
B/D
BENLYSTA
Tier-3
PA
CELLCEPT ORAL SUSPENSION
Tier-5
B/D
cyclosporine modified
Tier-2
B/D
cyclosporine oral capsule
Tier-2
B/D
gengraf
Tier-2
B/D
mycophenolate mofetil
Tier-2
B/D
PA; Part B
B/D
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 38
Drug Name
Drug Tier
Requirements/Limits
mycophenolate sodium
Tier-2
B/D
NULOJIX
Tier-5
B/D
RAPAMUNE ORAL SOLUTION
Tier-3
B/D
SIMULECT
Tier-5
B/D
sirolimus
Tier-2
B/D
tacrolimus oral capsule 0.5 mg, 1 mg
Tier-2
B/D
tacrolimus oral capsule 5 mg
Tier-5
B/D
THYMOGLOBULIN
Tier-3
B/D
ZORTRESS
Tier-3
B/D; QL (180 EA per 90 days)
MISCELLANEOUS DRUGS ACROMEGALY octreotide acetate injection solution
Tier-2
SANDOSTATIN LAR DEPOT KIT
Tier-5
SIGNIFOR LAR
Tier-5
SOMATULINE DEPOT
Tier-5
SOMAVERT
Tier-5
PA; QL (2 EA per 28 days) PA
AMYOTROPHIC LATERAL SCLEROSIS riluzole
Tier-3
ANAPHYLAXIS EMERGENCY AUVI-Q
Tier-3
QL (2 EA per 1 day)
epinephrine injection auto-injector
Tier-2
QL (2 EA per 1 day)
EPIPEN 2-PAK
Tier-3
QL (2 EA per 1 day)
EPIPEN JR 2-PAK
Tier-3
QL (2 EA per 1 day)
midodrine
Tier-2
BOTULINUM TOXINS BOTOX
Tier-3
PA
DYSPORT
Tier-3
PA
XEOMIN
Tier-3
PA
Tier-5
PA
CASTLEMAN DISEASE SYLVANT
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 39
Drug Name
Drug Tier
Requirements/Limits
CRYOPYRIN-ASSOCIATED PERIODIC SYNDROMES ARCALYST Tier-5
PA
ILARIS (PF)
Tier-5
PA
KORLYM
Tier-5
PA; QL (120 EA per 30 days)
SIGNIFOR
Tier-5
PA; QL (60 ML per 30 days)
CYSTIC FIBROSIS BETHKIS
Tier-5
B/D
CAYSTON
Tier-5
KALYDECO
Tier-5
PA; QL (60 EA per 30 days)
PULMOZYME
Tier-5
B/D
TOBI PODHALER
Tier-5
tobramycin in 0.225 % nacl
Tier-5
CUSHING DISEASE
B/D
CYSTINURIA CYSTADANE
Tier-3
DETOXIFICATION AGENTS CHEMET
Tier-4
EXJADE
Tier-5
FERRIPROX
Tier-3
JADENU
Tier-5
FABRY DISEASE FABRAZYME
Tier-5
PA
CERDELGA
Tier-5
PA
CEREZYME
Tier-5
PA
ELELYSO
Tier-5
PA
VPRIV
Tier-5
PA
ZAVESCA
Tier-5
PA
EGRIFTA
Tier-5
PA
GENOTROPIN
Tier-3
PA
GENOTROPIN MINIQUICK
Tier-3
PA
HUMATROPE
Tier-3
PA
INCRELEX
Tier-5
PA
NORDITROPIN FLEXPRO
Tier-5
PA
GAUCHER DISEASE
GROWTH HORMONE DEFICIENCY
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 40
Drug Name
Drug Tier
Requirements/Limits
NORDITROPIN NORDIFLEX
Tier-5
PA
NUTROPIN AQ NUSPIN
Tier-5
PA
NUTROPIN AQ SQ CARTRIDGE
Tier-5
PA
OMNITROPE
Tier-3
PA
SAIZEN
Tier-5
PA
SAIZEN CLICK.EASY
Tier-5
PA
SEROSTIM
Tier-5
PA
ZOMACTON
Tier-3
PA
ZORBTIVE
Tier-5
PA
HEREDITARY ANGIOEDEMA BERINERT INTRAVENOUS KIT
Tier-3
CINRYZE
Tier-5
PA
FIRAZYR
Tier-5
PA; QL (3 ML per 7 days)
RUCONEST
Tier-5
HEREDITARY TYROSINEMIA TYPE 1 ORFADIN
Tier-5
PA
HUNTINGTON DISEASE XENAZINE ORAL TABLET 12.5 MG
Tier-5
PA; QL (90 EA per 30 days)
XENAZINE ORAL TABLET 25 MG
Tier-5
PA; QL (120 EA per 30 days)
HYPERCALCEMIA SENSIPAR ORAL TABLET 30 MG
Tier-3
SENSIPAR ORAL TABLET 60 MG, 90 MG
Tier-5
HYPERPARATHYROIDISM calcitriol oral
Tier-2
doxercalciferol
Tier-2
paricalcitol
Tier-2
HYPOPARATHYROIDISM NATPARA
Tier-5
PA; QL (2 EA per 28 days)
MUCOPOLYSACCHARIDOSIS ALDURAZYME
Tier-5
ELAPRASE
Tier-5
LUMIZYME
Tier-5
NAGLAZYME
Tier-5
MULTIPLE SCLEROSIS AMPYRA
Tier-5
PA; QL (60 EA per 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 41
Drug Name
Drug Tier
Requirements/Limits
AUBAGIO
Tier-5
PA; QL (30 EA per 30 Days)
AVONEX (WITH ALBUMIN)
Tier-5
QL (4 EA per 28 days)
AVONEX INTRAMUSCULAR PEN
Tier-5
QL (4 EA per 28 days)
AVONEX INTRAMUSCULAR SYRINGE KIT
Tier-5
QL (4 EA per 28 days)
BETASERON SUBCUTANEOUS KIT
Tier-5
QL (15 EA per 30 days)
COPAXONE SQ SYRINGE 20 MG/ML
Tier-5
QL (30 ML per 30 days)
COPAXONE SQ SYRINGE 40 MG/ML
Tier-5
QL (12 ML per 28 days)
EXTAVIA SUBCUTANEOUS KIT
Tier-5
QL (15 EA per 30 days)
GILENYA
Tier-5
PA; QL (30 EA per 30 Days)
PLEGRIDY SUBCUTANEOUS PEN INJECTOR 63 MCG/0.5 ML- 94 MCG/0.5 ML
Tier-5
PLEGRIDY SUBCUTANEOUS SYRINGE 125 MCG/0.5 ML
Tier-5
QL (1 ML per 28 days)
REBIF (WITH ALBUMIN)
Tier-5
QL (12 ML per 28 days)
REBIF REBIDOSE
Tier-5
QL (12 ML per 28 days)
REBIF TITRATION PACK
Tier-5
QL (12 ML per 28 days)
TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG (14)- 240 MG (46)
Tier-5
PA
TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG, 240 MG
Tier-5
PA; QL (60 EA per 30 Days)
TYSABRI
Tier-5
PA; LA
MYASTHENIA GRAVIS guanidine
Tier-2
MESTINON ORAL SYRUP
Tier-4
MESTINON TIMESPAN
Tier-3
pyridostigmine bromide oral tablet
Tier-2
PAGET'S DISEASE etidronate disodium
Tier-2
PHENYLKETONURIA KUVAN ORAL POWDER
Tier-5
PA
KUVAN ORAL TABLET,SOLUBLE
Tier-5
PA
PHEOCHROMOCYTOMA DEMSER
Tier-5
PHOSPHATE BINDERS AURYXIA
Tier-4
calcium acetate oral capsule
Tier-2
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 42
Drug Name
Drug Tier
FOSRENOL
Tier-3
PHOSLYRA
Tier-3
RENAGEL
Tier-3
RENVELA ORAL POWDER IN PACKET
Tier-5
RENVELA ORAL TABLET
Tier-3
VELPHORO
Tier-5
POMPE DISEASE MYOZYME
Tier-5
POTASSIUM BINDER kionex oral powder
Tier-2
sodium polystyrene (sorb free)
Tier-2
Requirements/Limits
RESPIRATORY SYNCYTIAL VIRUS SYNAGIS
Tier-5
VIRAZOLE
Tier-5
SMOKING CESSATION buproban
Tier-2
CHANTIX
Tier-4
QL (60 EA per 30 days)
CHANTIX CONTINUING MONTH BOX
Tier-4
QL (56 EA per 28 days)
CHANTIX STARTING MONTH BOX
Tier-4
QL (53 EA per 28 days)
NICOTROL
Tier-3
NICOTROL NS
Tier-4
SYMPTOMATIC BENIGN PROSTATIC HYPERPLASIA alfuzosin Tier-2 AVODART
Tier-3
CIALIS ORAL TABLET 2.5 MG, 5 MG
Tier-4
finasteride oral tablet 5 mg
Tier-2
JALYN
Tier-3
tamsulosin
Tier-2
PA; QL (30 EA per 30 days)
UREA CYCLE DISORDERS RAVICTI
Tier-5
PA
UROLOGIC DISORDERS bethanechol chloride
Tier-2
desmopressin injection
Tier-2
desmopressin nasal solution
Tier-2
desmopressin nasal spray,non-aerosol
Tier-2
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 43
Drug Name
Drug Tier
desmopressin oral
Tier-2
ELMIRON
Tier-4
ENABLEX
Tier-4
flavoxate
Tier-2
GELNIQUE
Tier-3
MYRBETRIQ
Tier-4
oxybutynin chloride oral syrup
Tier-2
oxybutynin chloride oral tablet
Tier-1
oxybutynin chloride tablet extended release 24hr
Tier-2
potassium citrate
Tier-2
SAMSCA
Tier-4
tolterodine
Tier-3
trospium
Tier-2
UROCIT-K 10
Tier-4
UROCIT-K 15
Tier-4
UROCIT-K 5
Tier-4
VESICARE
Tier-3
WILSON'S DISEASE CUPRIMINE
Tier-5
DEPEN TITRATABS
Tier-3
SYPRINE
Tier-3
Requirements/Limits
STPA
STPA
NEUROLOGICAL DRUGS ALZHEIMERS DISEASE donepezil
Tier-2
ergoloid
Tier-2
EXELON TRANSDERMAL
Tier-4
galantamine
Tier-2
NAMENDA XR
Tier-3
rivastigmine tartrate
Tier-2
MIGRAINE THERAPY dihydroergotamine injection
Tier-2
PA
dihydroergotamine nasal
Tier-2
PA
MIGERGOT
Tier-3
MIGRANAL
Tier-4
naratriptan
Tier-2
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 44
Drug Name
Drug Tier
Requirements/Limits
rizatriptan
Tier-2
sumatriptan
Tier-2
sumatriptan succinate oral
Tier-2
sumatriptan succinate subcutaneous pen injector
Tier-2
sumatriptan succinate subcutaneous solution
Tier-2
zolmitriptan
Tier-2
PARKINSONS DISEASE APOKYN
Tier-5
AZILECT
Tier-3
benztropine oral
Tier-1
bromocriptine
Tier-2
cabergoline
Tier-2
carbidopa
Tier-2
carbidopa-levodopa
Tier-2
carbidopa-levodopa-entacapone
Tier-2
CYCLOSET
Tier-3
DUOPA
Tier-4
entacapone
Tier-2
NEUPRO
Tier-4
pramipexole oral tablet
Tier-2
pramipexole tablet ext-rel 24 hr 0.75 mg, 1.5 mg
Tier-2
ropinirole
Tier-2
RYTARY
Tier-4
selegiline hcl
Tier-2
TASMAR
Tier-3
tolcapone
Tier-2
trihexyphenidyl
Tier-1
PA
PSEUDOBULBAR AFFECT NUEDEXTA
Tier-3
PA
SEIZURES APTIOM
Tier-4
PA
BANZEL
Tier-3
carbamazepine oral capsule, er multiphase 12 hr
Tier-2
carbamazepine oral suspension
Tier-2
carbamazepine oral tablet
Tier-1
PA
QL (30 EA per 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 45
Drug Name
Drug Tier
carbamazepine oral tablet extended release 12 hr
Tier-2
carbamazepine oral tablet,chewable
Tier-2
CELONTIN
Tier-4
CEREBYX
Tier-4
clonazepam
Tier-2
diazepam intensol
Tier-2
diazepam oral solution
Tier-2
diazepam oral tablet
Tier-2
diazepam rectal
Tier-2
DILANTIN
Tier-3
DILANTIN EXTENDED
Tier-3
DILANTIN INFATABS
Tier-3
DILANTIN-125
Tier-3
divalproex
Tier-2
epitol
Tier-1
ethosuximide
Tier-2
felbamate
Tier-2
FYCOMPA
Tier-4
gabapentin
Tier-2
GABITRIL
Tier-3
HORIZANT
Tier-4
lamotrigine oral tablet
Tier-2
lamotrigine oral tablet extended release 24hr
Tier-3
lamotrigine oral tablet, chewable dispersible
Tier-2
lamotrigine oral tablet,disintegrating
Tier-2
levetiracetam
Tier-2
LYRICA
Tier-4
ONFI ORAL SUSPENSION
Tier-4
ONFI ORAL TABLET
Tier-4
oxcarbazepine
Tier-2
OXTELLAR XR
Tier-4
PEGANONE
Tier-4
phenobarbital
Tier-2
phenytoin oral suspension
Tier-2
phenytoin oral tablet,chewable
Tier-2
Requirements/Limits
PA
QL (60 EA per 30 Days)
STPA QL (60 EA per 30 days)
PA
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 46
Drug Name
Drug Tier
Requirements/Limits
phenytoin sodium extended
Tier-2
phenytoin sodium intravenous solution
Tier-2
POTIGA
Tier-4
primidone
Tier-2
QUDEXY XR
Tier-4
SABRIL
Tier-5
SAVELLA ORAL TABLET
Tier-3
TEGRETOL XR TAB EXT-REL 12 HR 100 MG
Tier-3
tiagabine
Tier-2
topiramate
Tier-2
TROKENDI XR
Tier-4
valproic acid
Tier-2
valproic acid (as sodium salt) oral solution
Tier-2
VIMPAT INTRAVENOUS
Tier-4
VIMPAT ORAL SOLUTION
Tier-4
PA
VIMPAT ORAL TABLET
Tier-4
PA; QL (180 EA per 90 days)
zonisamide
Tier-2
SPASTICITY baclofen
Tier-1
cyclobenzaprine oral tablet
Tier-1
dantrolene
Tier-2
tizanidine
Tier-2
PA
STPA; QL (180 EA per 90 days)
PA
PAIN AND INFLAMMATORY DISEASES ARTHRITIS ACTEMRA
Tier-3
PA
AZASAN
Tier-4
B/D
azathioprine
Tier-2
B/D
CIMZIA
Tier-5
PA; QL (2 EA per 30 days)
CIMZIA POWDER FOR RECONST
Tier-3
PA
diclofenac sodium topical
Tier-2
ENBREL SQ SOLUTION
Tier-5
PA; QL (8 EA per 28 Days)
ENBREL SQ SYRINGE 25 MG/0.5ML (0.51)
Tier-5
PA; QL (8.16 ML per 28 Days)
ENBREL SQ SYRINGE 50 MG/ML (0.98 ML)
Tier-5
PA; QL (7.84 ML per 28 Days)
ENBREL SURECLICK
Tier-5
PA; QL (7.84 ML per 28 days)
HUMIRA
Tier-5
PA; QL (6 EA per 28 days)
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 47
Drug Name
Drug Tier
Requirements/Limits
HUMIRA CROHN'S STARTER PACK
Tier-5
PA
KINERET
Tier-5
PA; QL (20.1 ML per 28 days)
leflunomide
Tier-2
methotrexate sodium oral
Tier-2
B/D
ORENCIA
Tier-5
PA; QL (4 ML per 28 Days)
ORENCIA (WITH MALTOSE)
Tier-3
PA
OTREXUP (PF)
Tier-4
REMICADE
Tier-5
RIDAURA
Tier-5
SIMPONI ARIA
Tier-5
PA
SIMPONI SQ PEN INJECTOR 100 MG/ML
Tier-5
PA; QL (1 ML per 28 days)
SIMPONI SQ PEN INJECTOR 50 MG/0.5 ML
Tier-5
PA; QL (0.5 ML per 28 days)
SIMPONI SQ SYRINGE 100 MG/ML
Tier-5
PA; QL (4 ML per 28 days)
SIMPONI SQ SYRINGE 50 MG/0.5 ML
Tier-5
PA; QL (0.5 ML per 28 Days)
TREXALL
Tier-4
B/D
VOLTAREN TOPICAL
Tier-4
XELJANZ
Tier-5
GOUT allopurinol
Tier-1
colchicine oral
Tier-2
colchicine-probenecid
Tier-2
probenecid
Tier-2
ULORIC
Tier-4
STPA
PAIN, NSAID ANALGESICS celecoxib
Tier-3
PA
diclofenac potassium
Tier-1
diclofenac sodium oral
Tier-1
diclofenac-misoprostol
Tier-2
diflunisal
Tier-2
etodolac
Tier-2
fenoprofen oral tablet
Tier-2
flurbiprofen
Tier-2
ibuprofen oral suspension
Tier-2
ibuprofen oral tablet 400 mg, 600 mg, 800 mg
Tier-1
INDOCIN ORAL
Tier-4
PA
PA; QL (60 EA per 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 48
Drug Name
Drug Tier
indomethacin oral
Tier-1
ketoprofen
Tier-2
meclofenamate oral
Tier-2
mefenamic acid
Tier-2
meloxicam oral suspension
Tier-2
meloxicam oral tablet
Tier-1
nabumetone
Tier-2
naproxen oral suspension
Tier-2
naproxen oral tablet
Tier-1
oxaprozin
Tier-2
piroxicam
Tier-2
sulindac oral
Tier-2
tolmetin
Tier-2
Requirements/Limits PA
PAIN, OPIOID AND OTHER ANALGESICS ABSTRAL
Tier-5
PA; QL (120 EA per 30 days)
acetaminophen-codeine oral solution 300 mg-30 mg /12.5 ml
Tier-2
QL (5000 ML per 30 days)
acetaminophen-codeine oral tablet 300-15 mg
Tier-2
QL (300 EA per 30 days)
acetaminophen-codein tab 300-30 mg, 300-60 mg
Tier-2
QL (400 EA per 30 days)
ACTIQ
Tier-5
PA; QL (120 EA per 30 days)
butorphanol tartrate nasal
Tier-2
QL (7.5 ML per 30 days)
BUTRANS
Tier-4
QL (4 EA per 28 Days)
codeine sulfate oral tablet
Tier-2
QL (180 EA per 30 days)
DILAUDID ORAL LIQUID
Tier-4
QL (1440 ML per 30 days)
EMBEDA ORAL CAPSULE EXT.REL PELL
Tier-4
QL (60 EA per 30 days)
endocet tablet 10-325 mg, 5-325 mg, 7.5-325 mg
Tier-2
QL (360 EA per 30 days)
fentanyl citrate
Tier-5
PA; QL (120 EA per 30 days)
fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr
Tier-2
QL (10 EA per 30 days)
FENTORA
Tier-5
PA; QL (120 EA per 30 days)
hydrocodone-acetaminophen oral solution 7.5325 mg/15 ml
Tier-2
QL (5540 ML per 30 days)
hydrocodone-acetaminophen oral tablet 10-300 mg, 5-300 mg, 7.5-300 mg
Tier-2
QL (400 EA per 30 days)
hydrocodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg
Tier-2
QL (360 EA per 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 49
Drug Name
Drug Tier
Requirements/Limits
hydrocodone-ibuprofen oral tablet 7.5-200 mg
Tier-2
QL (480 EA per 30 days)
hydromorphone oral liquid
Tier-2
QL (1350 ML per 30 days)
hydromorphone oral tablet
Tier-2
QL (360 EA per 30 days)
hydromorphone oral tablet extended release 24 hr
Tier-2
QL (30 EA per 30 days)
HYSINGLA ER
Tier-4
QL (60 EA per 30 days)
ibuprofen-oxycodone
Tier-2
QL (240 EA per 30 days)
LAZANDA
Tier-5
PA; QL (30 EA per 30 days)
levorphanol tartrate
Tier-2
QL (240 EA per 30 days)
methadone oral solution 10 mg/5 ml
Tier-2
QL (1800 ML per 30 days)
methadone oral solution 5 mg/5 ml
Tier-2
QL (3600 ML per 30 days)
methadone oral tablet
Tier-2
QL (120 EA per 30 days)
morphine concentrate oral solution
Tier-2
QL (540 ML per 30 days)
morphine oral capsule, er multiphase 24 hr
Tier-2
QL (60 EA per 30 days)
morphine oral capsule,extend.release pellets
Tier-2
QL (60 EA per 30 days)
morphine oral solution
Tier-2
QL (960 ML per 30 days)
morphine oral tablet
Tier-2
QL (180 EA per 30 days)
morphine oral tablet extended release
Tier-2
QL (60 EA per 30 days)
oxycodone oral capsule
Tier-2
QL (360 EA per 30 days)
oxycodone oral concentrate
Tier-2
QL (120 ML per 30 days)
oxycodone oral solution
Tier-2
QL (2400 ML per 30 Days)
oxycodone tablet 10 mg, 15 mg, 20 mg, 30 mg
Tier-2
QL (180 EA per 30 days)
oxycodone oral tablet 5 mg
Tier-2
QL (360 EA per 30 days)
oxycodone oral tablet,oral only,ext.rel.12 hr
Tier-2
QL (120 EA per 30 days)
oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg
Tier-2
QL (360 EA per 30 days)
oxycodone-aspirin
Tier-2
QL (360 EA per 30 days)
OXYCONTIN ORAL TABLET
Tier-3
QL (120 EA per 30 days)
oxymorphone oral tablet
Tier-2
QL (180 EA per 30 days)
oxymorphone oral tablet extended release 12 hr
Tier-2
QL (60 EA per 30 Days)
SUBSYS
Tier-5
PA; QL (120 EA per 30 days)
tramadol oral capsule,er biphase 24 hr 17-83
Tier-2
tramadol oral capsule,er biphase 24 hr 25-75
Tier-2
tramadol oral tablet
Tier-2
tramadol oral tablet extended release 24 hr
Tier-2
tramadol-acetaminophen
Tier-2
QL (360 EA per 30 days)
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 50
Drug Name
Drug Tier
Requirements/Limits
PSYCHIATRIC ALCOHOL DETERRENTS acamprosate
Tier-2
disulfiram
Tier-2
naltrexone oral
Tier-2
ANXIETY alprazolam
Tier-2
alprazolam intensol
Tier-2
amitriptyline-chlordiazepoxide
Tier-2
buspirone
Tier-1
clorazepate dipotassium
Tier-2
lorazepam intensol
Tier-2
lorazepam oral tablet
Tier-2
oxazepam
Tier-2
ATTENTION DEFICIT DISORDER ADDERALL XR
Tier-4
amphetamine salt combo
Tier-2
clonidine hcl oral tablet extended release 12 hr
Tier-2
DESOXYN
Tier-4
DEXEDRINE SPANSULE
Tier-4
dexmethylphenidate
Tier-2
dextroamphetamine oral capsule, extended release
Tier-2
dextroamphetamine oral tablet
Tier-2
dextroamphetamine-amphetamine oral capsule,extended release 24hr
Tier-2
FOCALIN XR
Tier-3
STPA
guanfacine oral tablet extended release 24 hr
Tier-2
PA; QL (90 EA per 90 days)
KAPVAY
Tier-4
METADATE CD
Tier-4
METADATE ER
Tier-4
methamphetamine
Tier-2
METHYLIN ORAL SOLUTION
Tier-3
METHYLIN ORAL TABLET,CHEWABLE
Tier-3
methylphenidate oral
Tier-2
STPA
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 51
Drug Name
Drug Tier
Requirements/Limits
QUILLIVANT XR
Tier-4
STPA
STRATTERA ORAL CAPSULE 10 MG, 18 MG, 25 MG, 40 MG, 60 MG
Tier-3
QL (60 EA per 30 days)
STRATTERA ORAL CAPSULE 100 MG, 80 MG
Tier-3
QL (30 EA per 30 days)
VYVANSE
Tier-4
STPA
BIPOLAR DISORDER EQUETRO
Tier-4
lithium carbonate
Tier-1
lithium citrate
Tier-1
olanzapine-fluoxetine
Tier-2
RISPERDAL CONSTA
Tier-3
risperidone oral solution
Tier-2
risperidone oral tablet
Tier-2
risperidone oral tablet,disintegrating
Tier-2
STPA
DEPRESSION amitriptyline
Tier-1
amoxapine
Tier-2
APLENZIN ORAL TABLET EXTENDED RELEASE 24 HR 174 MG, 348 MG
Tier-4
STPA
APLENZIN ORAL TABLET EXTENDED RELEASE 24 HR 522 MG
Tier-5
STPA
BRINTELLIX
Tier-4
STPA
bupropion hcl
Tier-2
citalopram
Tier-1
clomipramine
Tier-2
desipramine oral
Tier-2
desvenlafaxine oral tablet extended release 24 hr
Tier-2
doxepin oral capsule
Tier-1
PA
doxepin oral concentrate
Tier-2
PA
duloxetine capsule, delayed release 20 & 60 mg
Tier-3
QL (60 EA per 30 Days)
duloxetine capsule, delayed release 30 mg
Tier-3
QL (90 EA per 30 days)
DULOXETINE ORAL CAPSULE,DELAYED RELEASE(DR/EC) 40 MG
Tier-4
STPA; QL (60 EA per 30 days)
EMSAM
Tier-5
STPA
escitalopram oxalate
Tier-2
PA
PA
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 52
Drug Name
Drug Tier
Requirements/Limits
FETZIMA
Tier-4
STPA
fluoxetine oral capsule
Tier-1
fluoxetine oral capsule,delayed release(dr/ec)
Tier-1
fluoxetine oral solution
Tier-2
fluoxetine oral tablet 10 mg, 20 mg
Tier-1
fluoxetine oral tablet 60 mg
Tier-2
fluvoxamine
Tier-2
imipramine hcl
Tier-2
PA
imipramine pamoate
Tier-2
PA
IRENKA
Tier-4
STPA; QL (60 EA per 30 days)
KHEDEZLA
Tier-4
STPA
maprotiline
Tier-2
MARPLAN
Tier-4
mirtazapine
Tier-2
nefazodone
Tier-2
nortriptyline
Tier-1
paroxetine hcl oral tablet
Tier-1
paroxetine hcl oral tablet extended release 24 hr
Tier-1
PAXIL ORAL SUSPENSION
Tier-4
PEXEVA
Tier-4
phenelzine
Tier-2
PRISTIQ
Tier-4
protriptyline
Tier-2
sertraline
Tier-2
SURMONTIL
Tier-3
tranylcypromine
Tier-2
trazodone
Tier-1
venlafaxine
Tier-2
VIIBRYD ORAL TABLET
Tier-4
STPA
VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)-20 MG (7)-40 MG (16)
Tier-4
STPA
STPA STPA
PA
INSOMNIA estazolam
Tier-2
eszopiclone
Tier-3
flurazepam
Tier-2
PA; QL (90 EA per 365 days)
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 53
Drug Name
Drug Tier
Requirements/Limits
HETLIOZ
Tier-4
PA
ROZEREM
Tier-4
QL (30 EA per 30 days)
SILENOR
Tier-4
QL (30 EA per 30 days)
temazepam
Tier-2
triazolam
Tier-2
zaleplon
Tier-2
PA; QL (90 EA per 365 days)
zolpidem
Tier-2
PA; QL (90 EA per 365 days)
modafinil
Tier-2
PA
NUVIGIL
Tier-4
PA
XYREM
Tier-5
LA
BUNAVAIL
Tier-4
PA; QL (90 EA per 30 days)
buprenorphine hcl sublingual
Tier-2
PA; QL (90 EA per 30 days)
buprenorphine-naloxone
Tier-2
PA; QL (90 EA per 30 days)
naloxone
Tier-2
SUBOXONE SUBLINGUAL FILM
Tier-4
PA; QL (90 EA per 30 days)
ZUBSOLV
Tier-4
PA; QL (90 EA per 30 days)
ABILIFY DISCMELT 10 MG
Tier-4
STPA
ABILIFY MAINTENA
Tier-5
aripiprazole
Tier-3
chlorpromazine
Tier-2
clozapine
Tier-2
FANAPT
Tier-4
FAZACLO
Tier-3
fluphenazine decanoate
Tier-2
fluphenazine hcl
Tier-2
GEODON INTRAMUSCULAR
Tier-4
haloperidol
Tier-1
haloperidol decanoate
Tier-2
haloperidol lactate
Tier-2
INVEGA ORAL TABLET EXTENDED RELEASE 24HR 1.5 MG
Tier-4
NARCOLEPSY
OPIOID ANTAGONISTS
PSYCHOSES
STPA
STPA
STPA
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 54
Drug Name
Drug Tier
Requirements/Limits
INVEGA ORAL TABLET EXTENDED RELEASE 24HR 3 MG, 6 MG, 9 MG
Tier-5
INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.75 ML, 156 MG/ML, 234 MG/1.5 ML, 78 MG/0.5 ML
Tier-5
INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 39 MG/0.25 ML
Tier-3
LATUDA ORAL TABLET 120 MG
Tier-5
STPA; QL (30 EA per 30 days)
LATUDA ORAL TABLET 20 MG, 40 MG, 60 MG
Tier-4
STPA; QL (30 EA per 30 days)
LATUDA ORAL TABLET 80 MG
Tier-4
STPA; QL (60 EA per 30 Days)
loxapine succinate
Tier-2
olanzapine intramuscular
Tier-2
olanzapine oral
Tier-2
ORAP
Tier-3
perphenazine
Tier-2
perphenazine-amitriptyline
Tier-2
quetiapine oral tablet 100 mg, 200 mg, 300 mg, 400 mg
Tier-2
STPA
quetiapine oral tablet 25 mg, 50 mg
Tier-2
STPA; QL (60 EA per 30 days)
SAPHRIS
Tier-4
STPA
SAPHRIS (BLACK CHERRY)
Tier-4
STPA
SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR
Tier-3
STPA
thioridazine
Tier-1
PA
thiothixene
Tier-1
trifluoperazine
Tier-2
VERSACLOZ
Tier-4
ziprasidone hcl
Tier-2
ZYPREXA INTRAMUSCULAR
Tier-3
ZYPREXA RELPREVV
Tier-3
STPA
STPA
STPA
RESPIRATORY DRUGS ASTHMA ADVAIR DISKUS
Tier-3
QL (180 EA per 90 days)
ADVAIR HFA
Tier-3
QL (72 GM per 90 days)
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 55
Drug Name
Drug Tier
Requirements/Limits
albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %)
Tier-2
B/D; QL (1080 ML per 90 days)
albuterol sulfate inhalation solution for nebulization 5 mg/ml
Tier-2
B/D; QL (180 ML per 90 days)
albuterol sulfate oral
Tier-1
ALVESCO INHALATION HFA AEROSOL INHALER 160 MCG/ACTUATION
Tier-4
QL (36.6 GM per 90 days)
ALVESCO INHALATION HFA AEROSOL INHALER 80 MCG/ACTUATION
Tier-4
QL (18.3 GM per 90 days)
ANORO ELLIPTA
Tier-3
QL (180 EA per 90 days)
ARCAPTA NEOHALER
Tier-4
QL (90 EA per 90 days)
ASMANEX TWISTHALER
Tier-3
QL (360 EA per 90 Days)
ATROVENT HFA
Tier-3
QL (77.4 GM per 90 days)
BREO ELLIPTA INHALATION BLISTER WITH DEVICE 100-25 MCG/DOSE
Tier-3
QL (180 EA per 90 days)
BREO ELLIPTA INHALATION BLISTER WITH DEVICE 200-25 MCG/DOSE
Tier-3
QL (90 EA per 90 days)
BROVANA
Tier-4
B/D; QL (360 ML per 90 days)
budesonide inhalation
Tier-2
B/D; QL (720 ML per 90 days)
COMBIVENT RESPIMAT
Tier-3
QL (24 GM per 90 days)
cromolyn inhalation
Tier-2
B/D; QL (720 ML per 90 days)
elixophyllin
Tier-2
FLOVENT DISKUS
Tier-3
QL (360 EA per 90 days)
FLOVENT HFA
Tier-3
QL (72 GM per 90 days)
FORADIL AEROLIZER
Tier-4
QL (180 EA per 90 Days)
ipratropium bromide inhalation
Tier-2
B/D; QL (900 ML per 90 days)
ipratropium-albuterol
Tier-2
B/D; QL (1620 ML per 90 days)
levalbuterol hcl inhalation solution for nebulization 0.31 mg/3 ml
Tier-2
B/D; QL (3240 ML per 90 days)
levalbuterol hcl inhalation solution for nebulization 0.63 mg/3 ml
Tier-2
B/D; QL (1620 ML per 90 days)
levalbuterol hcl inhalation solution for nebulization 1.25 mg/0.5 ml
Tier-2
B/D; QL (810 EA per 90 days)
metaproterenol oral
Tier-2
montelukast
Tier-2
PERFOROMIST
Tier-3
B/D; QL (360 ML per 90 Days)
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 56
Drug Name
Drug Tier
Requirements/Limits
PROAIR HFA
Tier-3
QL (51 GM per 90 days)
PROAIR RESPICLICK
Tier-3
QL (6 EA per 90 days)
PROVENTIL HFA
Tier-4
QL (40.2 GM per 90 days)
PULMICORT FLEXHALER
Tier-4
QL (6 EA per 90 days)
PULMICORT SUSPENSION 1 MG/2 ML
Tier-4
QL (720 ML per 90 days)
QVAR
Tier-3
QL (52.2 GM per 90 days)
SEREVENT DISKUS
Tier-3
QL (180 EA per 90 days)
SPIRIVA WITH HANDIHALER
Tier-3
QL (90 EA per 90 days)
STRIVERDI RESPIMAT
Tier-4
QL (180 GM per 90 days)
SYMBICORT
Tier-3
QL (30.6 GM per 90 Days)
terbutaline oral
Tier-2
theophylline oral solution
Tier-2
theophylline oral tablet extended release
Tier-2
theophylline oral tablet extended release 12 hr
Tier-2
TUDORZA PRESSAIR
Tier-4
QL (3 EA per 90 days)
VENTOLIN HFA
Tier-4
QL (108 GM per 90 days)
XOPENEX HFA
Tier-4
QL (90 GM per 90 days)
zafirlukast
Tier-2
IDIOPATHIC PULMONARY FIBROSIS ESBRIET
Tier-5
PA; QL (270 EA per 30 days)
OFEV
Tier-5
PA; QL (60 EA per 30 days)
PULMONARY HYPERTENSION ADCIRCA
Tier-5
PA
ADEMPAS
Tier-5
PA
epoprostenol (glycine)
Tier-2
PA
FLOLAN
Tier-3
PA
LETAIRIS
Tier-5
PA
OPSUMIT
Tier-5
PA
ORENITRAM
Tier-4
PA
REMODULIN
Tier-5
PA
REVATIO ORAL SUSPENSION
Tier-3
PA
sildenafil intravenous
Tier-2
PA
sildenafil oral
Tier-3
PA
TRACLEER
Tier-5
PA; LA
TYVASO
Tier-3
PA
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 57
Drug Name
Drug Tier
Requirements/Limits
VELETRI
Tier-3
PA
VENTAVIS
Tier-3
PA
RESPIRATORY DRUGS, MISCELLANEOUS acetylcysteine solution
Tier-2
B/D
ARALAST NP
Tier-5
DALIRESP
Tier-4
GLASSIA
Tier-3
GRASTEK
Tier-4
PROLASTIN-C
Tier-5
RAGWITEK
Tier-4
PA
XOLAIR
Tier-5
PA
ZEMAIRA
Tier-3
PA
SKIN ACNE ROSACEA FINACEA
Tier-3
metronidazole topical cream
Tier-2
metronidazole topical gel
Tier-2
metronidazole topical lotion
Tier-2
NORITATE
Tier-4
SOOLANTRA
Tier-4
ACNE VULGARIS ABSORICA ORAL CAPSULE
Tier-4
adapalene topical cream
Tier-2
PA
adapalene topical gel
Tier-2
PA
amnesteem
Tier-2
ATRALIN
Tier-4
PA
avita
Tier-2
PA
AZELEX
Tier-4
claravis
Tier-2
CLINDAGEL
Tier-4
clindamax topical gel
Tier-2
clindamycin phosphate topical
Tier-2
clindamycin-benzoyl peroxide
Tier-2
DIFFERIN TOPICAL LOTION
Tier-4
ery pads
Tier-2
PA
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 58
Drug Name
Drug Tier
Requirements/Limits
erythromycin with ethanol topical gel
Tier-2
erythromycin with ethanol topical solution
Tier-2
erythromycin-benzoyl peroxide
Tier-2
EVOCLIN
Tier-4
FABIOR
Tier-4
PA
RETIN-A
Tier-4
PA
RETIN-A MICRO
Tier-4
PA
tretinoin microspheres topical gel with pump
Tier-2
PA
tretinoin topical
Tier-2
PA
BACTERIAL INFECTIONS, TOPICAL ALTABAX
Tier-4
CORTISPORIN TOPICAL
Tier-4
gentamicin topical
Tier-1
mupirocin
Tier-2
mupirocin calcium
Tier-2
silver sulfadiazine
Tier-2
ssd
Tier-2
CORTICOSTEROIDS, TOPICAL ala-cort topical cream
Tier-1
ALA-SCALP
Tier-4
alclometasone
Tier-2
amcinonide
Tier-2
apexicon e
Tier-2
betamethasone dipropionate
Tier-2
betamethasone valerate
Tier-2
betamethasone, augmented
Tier-2
CAPEX
Tier-4
clobetasol topical foam
Tier-2
clobetasol topical gel
Tier-2
clobetasol topical lotion
Tier-2
clobetasol topical ointment
Tier-2
clobetasol topical shampoo
Tier-2
clobetasol topical solution
Tier-2
clobetasol topical spray,non-aerosol
Tier-2
clobetasol-emollient topical cream
Tier-2
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 59
Drug Name
Drug Tier
clodan
Tier-2
CLODERM
Tier-4
CORDRAN TAPE LARGE ROLL
Tier-4
CORDRAN TOPICAL LOTION
Tier-4
cormax topical solution
Tier-2
desonide
Tier-2
desoximetasone
Tier-2
diflorasone
Tier-2
fluocinolone
Tier-1
fluocinonide
Tier-1
fluocinonide-e
Tier-1
fluticasone topical
Tier-2
halobetasol propionate
Tier-2
HALOG
Tier-4
hydrocortisone butyrate topical ointment
Tier-1
hydrocortisone butyrate topical solution
Tier-1
hydrocortisone butyr-emollient
Tier-1
hydrocortisone topical cream
Tier-1
hydrocortisone topical lotion
Tier-1
hydrocortisone topical ointment
Tier-1
hydrocortisone valerate
Tier-3
KENALOG TOPICAL
Tier-4
mometasone
Tier-2
PANDEL
Tier-4
prednicarbate
Tier-2
triamcinolone acetonide topical
Tier-2
TRIANEX
Tier-4
triderm topical cream
Tier-2
Requirements/Limits
FUNGAL INFECTIONS, TOPICAL ciclopirox
Tier-2
clotrimazole topical
Tier-2
clotrimazole-betamethasone
Tier-2
econazole topical
Tier-2
ERTACZO
Tier-4
EXELDERM
Tier-4
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 60
Drug Name
Drug Tier
Requirements/Limits
ketoconazole topical cream
Tier-2
ketoconazole topical shampoo
Tier-2
MENTAX
Tier-4
naftifine
Tier-2
NAFTIN TOPICAL CREAM 2 %
Tier-3
NAFTIN TOPICAL GEL
Tier-3
nyamyc
Tier-2
nystatin oral suspension
Tier-2
nystatin topical cream
Tier-1
nystatin topical ointment
Tier-2
nystatin topical powder
Tier-2
nystatin-triamcinolone
Tier-3
nystop
Tier-2
OXISTAT
Tier-3
PSORIASIS AND SEBORRHEA acitretin oral capsule 10 mg
Tier-2
acitretin oral capsule 17.5 mg, 25 mg
Tier-5
calcipotriene
Tier-2
calcipotriene-betamethasone
Tier-2
calcitriol topical
Tier-2
COSENTYX PEN
Tier-5
methoxsalen rapid
Tier-5
OTEZLA
Tier-5
PA
OTEZLA STARTER
Tier-5
PA
STELARA SUBCUTANEOUS SYRINGE
Tier-3
PA
TAZORAC
Tier-4
PA
PA; QL (2 ML per 28 days)
SCABIES AND PEDICULOSIS EURAX
Tier-3
lindane
Tier-2
malathion
Tier-2
permethrin topical cream
Tier-2
SKLICE
Tier-4
ULESFIA
Tier-4
TOPICAL, MISCELLANEOUS ammonium lactate topical
Tier-2
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 61
Drug Name
Drug Tier
ANUSOL-HC RECTAL CREAM
Tier-4
diclofenac sodium topical gel
Tier-2
ELIDEL
Tier-4
FLUOROPLEX
Tier-3
fluorouracil topical
Tier-2
lidocaine hcl mucous membrane gel
Tier-2
lidocaine hcl mucous membrane solution
Tier-2
lidocaine topical adhesive patch,medicated
Tier-3
lidocaine topical ointment
Tier-2
lidocaine-prilocaine topical cream
Tier-2
neomycin-polymyxin b gu
Tier-2
PANRETIN
Tier-5
PICATO
Tier-4
proctosol hc
Tier-2
prudoxin
Tier-2
REGRANEX
Tier-3
SANTYL
Tier-3
selenium sulfide topical suspension
Tier-2
sodium chloride irrigation
Tier-2
sulfacetamide sodium
Tier-2
SULFAMYLON
Tier-4
tacrolimus topical
Tier-2
TARGRETIN TOPICAL
Tier-5
UCERIS RECTAL
Tier-3
VALCHLOR
Tier-5
water for irrigation, sterile
Tier-2
ZONALON
Tier-4
Requirements/Limits
STPA
PA; QL (90 EA per 30 Days)
VIRAL INFECTIONS, TOPICAL acyclovir topical
Tier-2
CONDYLOX TOPICAL GEL
Tier-4
DENAVIR
Tier-4
imiquimod
Tier-2
podofilox
Tier-2
ZOVIRAX TOPICAL CREAM
Tier-3
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 62
Drug Name
Drug Tier
Requirements/Limits
WOMENS HEALTH CONTRACEPTIVES amethia
Tier-2
amethyst
Tier-2
apri
Tier-2
aranelle (28)
Tier-2
ashlyna
Tier-2
aubra
Tier-2
aviane
Tier-2
balziva (28)
Tier-2
BEYAZ
Tier-4
briellyn
Tier-2
camila
Tier-2
deblitane
Tier-2
delyla (28)
Tier-2
desog-e.estradiol/e.estradiol
Tier-2
drospirenone-ethinyl estradiol
Tier-2
emoquette
Tier-2
errin
Tier-2
estradiol-norethindrone acet
Tier-2
falmina (28)
Tier-2
GENERESS FE
Tier-4
gildagia
Tier-2
gildess 24 fe
Tier-2
gildess oral tablet 1.5-30 mg-mcg
Tier-2
introvale
Tier-2
jinteli
Tier-2
junel 1.5/30 (21)
Tier-2
junel 1/20 (21)
Tier-2
junel fe 1.5/30 (28)
Tier-2
junel fe 1/20 (28)
Tier-2
junel fe 24
Tier-2
kariva (28)
Tier-2
kelnor 1/35 (28)
Tier-2
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 63
Drug Name
Drug Tier
l norgest&e estradiol-e estrad oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (7)
Tier-2
larin 1.5/30 (21)
Tier-2
larin 1/20 (21)
Tier-2
larin fe
Tier-2
lessina
Tier-2
levonest (28)
Tier-2
levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 90-20 mcg
Tier-2
levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month
Tier-2
levora-28
Tier-2
LO LOESTRIN FE
Tier-4
lopreeza
Tier-2
marlissa oral tablet 0.15-0.03 mg
Tier-2
microgestin 1.5/30 (21)
Tier-2
microgestin 1/20 (21)
Tier-2
microgestin fe 1.5/30 (28)
Tier-2
microgestin fe 1/20 (28)
Tier-2
MINASTRIN 24 FE
Tier-3
necon 0.5/35 (28)
Tier-2
necon 1/35 (28)
Tier-2
NECON 10/11 (28)
Tier-3
necon 7/7/7 (28)
Tier-2
nikki (28)
Tier-2
noreth-ethinyl estradiol-iron oral tablet,chewable 0.8mg-25mcg(24) and 75 mg (4)
Tier-2
norethindrone ac-eth estradiol oral tablet 0.5-2.5 mg-mcg, 1-5 mg-mcg
Tier-2
norethindrone-e.estradiol-iron oral tablet 1 mg20 mcg (24)/75 mg (4)
Tier-2
norlyroc
Tier-2
nortrel 0.5/35 (28)
Tier-2
nortrel 1/35 (21)
Tier-2
nortrel 1/35 (28)
Tier-2
nortrel 7/7/7 (28)
Tier-2
Requirements/Limits
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 64
Drug Name
Drug Tier
NUVARING
Tier-3
orsythia
Tier-2
ORTHO TRI-CYCLEN (28)
Tier-4
portia
Tier-2
quasense
Tier-2
SAFYRAL
Tier-4
sharobel
Tier-2
tarina fe
Tier-2
trinessa (28)
Tier-2
tri-previfem (28)
Tier-2
tri-sprintec (28)
Tier-2
trivora (28)
Tier-2
velivet triphasic regimen (28)
Tier-2
vyfemla (28)
Tier-2
ZENCHENT (28)
Tier-4
ZENCHENT FE
Tier-4
zeosa
Tier-2
zovia 1/35e (28)
Tier-2
zovia 1/50e (28)
Tier-2
MENOPAUSAL SYMPTOMS/OSTEOPOROSIS alendronate
Tier-2
ALORA
Tier-4
ANGELIQ
Tier-4
calcitonin (salmon)
Tier-2
COMBIPATCH
Tier-4
CRINONE
Tier-3
DELESTROGEN
Tier-4
DEPO-ESTRADIOL
Tier-3
DEPO-PROVERA IM SOLUTION
Tier-3
DEPO-PROVERA IM SUSPENSION
Tier-3
DEPO-SUBQ PROVERA 104
Tier-3
DIVIGEL
Tier-4
DUAVEE
Tier-4
ELESTRIN
Tier-4
ENJUVIA
Tier-4
Requirements/Limits
PA
PA
PA PA
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 65
Drug Name
Drug Tier
Requirements/Limits
ESTRACE VAGINAL
Tier-3
estradiol oral
Tier-1
PA
estradiol transdermal
Tier-2
PA
estradiol valerate
Tier-2
ESTRING
Tier-3
estropipate
Tier-2
EVAMIST
Tier-4
FEMHRT LOW DOSE
Tier-4
FEMRING
Tier-3
FORTEO
Tier-5
ibandronate intravenous solution
Tier-2
ibandronate oral
Tier-3
medroxyprogesterone oral
Tier-1
MENEST
Tier-4
PA
MENOSTAR
Tier-4
PA
methylergonovine oral
Tier-2
MIACALCIN INJECTION
Tier-3
norethindrone acetate
Tier-2
pamidronate intravenous solution
Tier-2
PREMARIN INJECTION
Tier-4
PREMARIN ORAL
Tier-4
PREMARIN VAGINAL
Tier-4
PREMPHASE
Tier-4
PA
PREMPRO
Tier-4
PA
progesterone micronized
Tier-2
PROLIA
Tier-3
raloxifene
Tier-2
RECLAST
Tier-3
risedronate
Tier-3
VAGIFEM
Tier-3
XGEVA
Tier-5
zoledronic acid intravenous solution
Tier-2
zoledronic acid-mannitol-water intravenous
Tier-2
PRENATAL VITAMINS prenatal vitamins low iron
Tier-2
PA PA PA
PA
PA
PA
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 66
Drug Name
Drug Tier
VAGINAL INFECTIONS AVC VAGINAL
Tier-4
CLEOCIN VAGINAL SUPPOSITORY
Tier-4
clindamycin phosphate vaginal
Tier-2
GYNAZOLE-1 VAGINAL CREAM
Tier-4
metronidazole vaginal
Tier-2
miconazole-3 vaginal suppository
Tier-2
NUVESSA
Tier-4
terconazole
Tier-2
vandazole
Tier-2
Requirements/Limits
You can find information on what the symbols and abbreviations on this table mean by going to page V. For Tufts Medicare Preferred HMO Prime Rx Plus members we provide coverage for Tier-1 and Tier-2 drugs through the Coverage Gap. 67
Index 8-MOP .................................... 12 abacavir .................................... 3 abacavir-lamivudine-zidovudine .............................................. 3 ABELCET .............................. 29 ABILIFY DISCMELT ........... 54 ABILIFY MAINTENA .......... 54 ABRAXANE.......................... 10 ABSORICA............................ 58 ABSTRAL.............................. 49 acamprosate ............................ 51 acarbose .................................. 21 acebutolol ............................... 17 acetaminophen-codeine .......... 49 acetasol hc .............................. 22 acetazolamide ......................... 25 acetazolamide sodium ............ 29 acetic acid ............................... 22 acetylcysteine ......................... 58 acitretin ................................... 61 ACTEMRA ............................ 47 ACTHIB (PF) ......................... 37 ACTIMMUNE ....................... 37 ACTIQ.................................... 49 ACTOPLUS MET XR ........... 21 acyclovir ............................. 3, 62 acyclovir sodium .................... 29 ADACEL(TDAP ADOLESN/ADULT)(PF) .. 37 ADAGEN ............................... 37 adapalene ................................ 58 ADCIRCA .............................. 57 ADDERALL XR .................... 51 adefovir..................................... 3 ADEMPAS ............................. 57 ADVAIR DISKUS ................. 55 ADVAIR HFA ....................... 55 afeditab cr ............................... 17 AFINITOR ............................. 12 AFINITOR DISPERZ ............ 12 AGGRENOX ........................... 8 a-hydrocort ............................. 35 ala-cort .................................... 59 ALA-SCALP .......................... 59 ALBENZA ............................... 2 albuterol sulfate ...................... 56 ALCAINE .............................. 26 alclometasone ......................... 59
ALDURAZYME .................... 41 alendronate ............................. 65 alfuzosin ................................. 43 ALIMTA ................................ 10 ALINIA .................................... 2 ALKERAN ....................... 10, 12 allopurinol .............................. 48 ALOCRIL............................... 23 ALOMIDE.............................. 23 ALORA .................................. 65 alosetron ................................. 27 ALOXI.................................... 26 ALPHAGAN P ....................... 25 alprazolam .............................. 51 alprazolam intensol................. 51 ALREX ................................... 24 ALTABAX ............................. 59 ALVESCO.............................. 56 amantadine hcl .......................... 3 AMBISOME .......................... 29 amcinonide ............................. 59 amethia ................................... 63 amethyst.................................. 63 amifostine crystalline ............. 14 amikacin ................................. 29 amiloride................................. 18 amiloride-hydrochlorothiazide18 aminophylline ......................... 29 AMINOSYN 7 % WITH ELECTROLYTES.............. 33 AMINOSYN 8.5 %ELECTROLYTES.............. 33 AMINOSYN II 10 % ............. 34 AMINOSYN II 15 % ............. 34 AMINOSYN II 7 % ............... 34 AMINOSYN II 8.5 % ............ 34 AMINOSYN II 8.5 %ELECTROLYTES.............. 34 AMINOSYN M 3.5 %............ 34 AMINOSYN-HBC 7%........... 34 AMINOSYN-PF 10 % ........... 34 AMINOSYN-PF 7 % (SULFITE-FREE) .............. 34 AMINOSYN-RF 5.2 % .......... 34 amiodarone ............................. 15 AMITIZA ............................... 28 amitriptyline ........................... 52
68
amitriptyline-chlordiazepoxide ............................................ 51 amlodipine .............................. 17 amlodipine-atorvastatin .......... 16 amlodipine-benazepril ............ 16 amlodipine-valsartan .............. 16 amlodipine-valsartan-hcthiazid ............................................ 16 ammonium chloride ................ 32 ammonium lactate .................. 61 amnesteem .............................. 58 amoxapine............................... 52 amoxicil-clarithromy-lansopraz ............................................ 28 amoxicillin ............................ 5, 6 amoxicillin-pot clavulanate ...... 6 amphetamine salt combo ........ 51 amphotericin b ........................ 29 ampicillin .................................. 6 ampicillin sodium ................... 29 ampicillin-sulbactam .............. 29 AMPYRA ............................... 41 anagrelide ............................... 10 anastrozole .............................. 12 ANGELIQ .............................. 65 ANORO ELLIPTA ................. 56 ANUSOL-HC ......................... 62 ANZEMET ....................... 26, 29 apexicon e ............................... 59 APLENZIN............................. 52 APOKYN ............................... 45 apraclonidine .......................... 25 apri .......................................... 63 APRISO .................................. 28 APTIOM ................................. 45 APTIVUS ................................. 3 ARALAST NP........................ 58 aranelle (28) ............................ 63 ARANESP (IN POLYSORBATE) ................ 8 ARCALYST ........................... 40 ARCAPTA NEOHALER ....... 56 ARGATROBAN .................... 29 ARGATROBAN IN 0.9 % SOD CHLOR............................... 29 aripiprazole ............................. 54 ARMOUR THYROID............ 36 ARRANON ............................ 10
ARZERRA ............................. 10 ASACOL HD ......................... 28 ashlyna .................................... 63 ASMANEX TWISTHALER.. 56 ASTAGRAF XL .................... 38 atenolol ................................... 17 atenolol-chlorthalidone........... 16 ATGAM ................................. 38 atorvastatin ............................. 19 atovaquone ............................... 3 atovaquone-proguanil ............... 3 ATRALIN .............................. 58 ATRIPLA ................................. 3 atropine ............................. 26, 29 ATROVENT HFA ................. 56 AUBAGIO ............................. 42 aubra ....................................... 63 AURYXIA ............................. 42 AUVI-Q .................................. 39 AVASTIN .............................. 10 AVC VAGINAL .................... 67 AVEED .................................. 35 AVELOX IN NACL (ISOOSMOTIC)......................... 29 aviane ..................................... 63 avita ........................................ 58 AVODART ............................ 43 AVONEX ............................... 42 AVONEX (WITH ALBUMIN) ............................................ 42 azacitidine............................... 10 AZASAN................................ 47 AZASITE ............................... 23 azathioprine ............................ 47 azelastine .......................... 22, 23 AZELEX ................................ 58 AZILECT ............................... 45 azithromycin ....................... 6, 29 AZOPT ................................... 25 AZOR ..................................... 16 aztreonam ............................... 29 bacitracin ................................ 23 bacitracin-polymyxin b .......... 23 baclofen .................................. 47 BACTROBAN NASAL ......... 22 balsalazide .............................. 28 balziva (28)............................. 63 BANZEL ................................ 45 bcg vaccine, live (pf) .............. 37 BELEODAQ .......................... 10
benazepril ............................... 14 benazepril-hydrochlorothiazide ............................................ 16 BENICAR .............................. 15 BENICAR HCT ..................... 16 BENLYSTA ........................... 38 benztropine ....................... 29, 45 BERINERT ............................ 41 BESIVANCE.......................... 23 betamethasone dipropionate ... 59 betamethasone valerate........... 59 betamethasone, augmented ..... 59 BETASERON ........................ 42 betaxolol ........................... 17, 25 bethanechol chloride............... 43 BETHKIS ............................... 40 BETIMOL .............................. 25 BETOPTIC S .......................... 25 BEXSERO (PF) ...................... 37 BEYAZ................................... 63 bicalutamide ........................... 12 BICILLIN C-R ......................... 6 BICILLIN L-A ......................... 6 BICNU.................................... 10 BIDIL ..................................... 20 BILTRICIDE ............................ 2 bimatoprost ............................. 25 bisoprolol fumarate................. 17 bisoprolol-hydrochlorothiazide ............................................ 16 BIVIGAM .............................. 37 bleomycin ............................... 10 BLEPHAMIDE ...................... 23 BLEPHAMIDE S.O.P. ........... 23 BOOSTRIX TDAP................. 37 BOSULIF ............................... 12 BOTOX .................................. 39 BREO ELLIPTA .................... 56 briellyn.................................... 63 BRILINTA ............................... 8 brimonidine ............................ 25 BRINTELLIX ........................ 52 bromfenac ............................... 24 bromocriptine ......................... 45 BROVANA ............................ 56 budesonide .................. 22, 28, 56 bumetanide ....................... 18, 29 BUNAVAIL ........................... 54 buprenorphine hcl ............. 29, 54 buprenorphine-naloxone......... 54
69
buproban ................................. 43 bupropion hcl .......................... 52 buspirone ................................ 51 BUSULFEX ........................... 10 butorphanol tartrate .......... 29, 49 BUTRANS ............................. 49 BYDUREON .......................... 21 cabergoline ............................. 45 calcipotriene ........................... 61 calcipotriene-betamethasone .. 61 calcitonin (salmon) ................. 65 calcitriol ...................... 29, 41, 61 calcium acetate ....................... 42 camila ..................................... 63 CANASA................................ 28 CANCIDAS ............................ 29 candesartan ............................. 15 candesartan-hydrochlorothiazid ............................................ 16 CANTIL ................................. 27 CAPASTAT ........................... 29 capecitabine ............................ 12 CAPEX ................................... 59 CAPRELSA ............................ 12 captopril .................................. 14 captopril-hydrochlorothiazide 16 CARAFATE ........................... 28 CARBAGLU .......................... 26 carbamazepine .................. 45, 46 carbidopa ................................ 45 carbidopa-levodopa ................ 45 carbidopa-levodopa-entacapone ............................................ 45 carboplatin .............................. 10 CARDENE IV IN SODIUM CHLORIDE ........................ 29 CARDURA XL ...................... 15 CARIMUNE NF NANOFILTERED .............. 37 carteolol .................................. 25 cartia xt ................................... 17 carvedilol ................................ 17 CAYSTON ............................. 40 CEDAX .................................... 6 cefaclor ..................................... 6 cefadroxil .................................. 6 cefazolin ................................. 29 cefazolin in 0.9% sod chloride ...................................... 29, 30 cefazolin in dextrose (iso-os).. 30
cefazolin in dextrose 5 % ....... 30 cefazolin in sterile water ........ 30 cefdinir ..................................... 6 cefditoren pivoxil ..................... 6 cefepime ................................. 30 cefepime in dextrose 5 % ....... 30 cefixime .................................... 6 cefotaxime .............................. 30 cefotetan ................................. 30 cefoxitin.................................. 30 cefoxitin in dextrose, iso-osm 30 cefpodoxime ............................. 6 cefprozil .................................... 6 ceftazidime ............................. 30 ceftazidime in d5w ................. 30 ceftriaxone .............................. 30 cefuroxime axetil ...................... 6 cefuroxime sodium ................. 30 celecoxib................................. 48 CELLCEPT ............................ 38 CELONTIN ............................ 46 cephalexin................................. 6 CERDELGA........................... 40 CEREBYX ............................. 46 CEREZYME .......................... 40 CERVARIX VACCINE (PF) 37 CESAMET ............................. 26 cevimeline .............................. 22 CHANTIX .............................. 43 CHANTIX CONTINUING MONTH BOX .................... 43 CHANTIX STARTING MONTH BOX .................... 43 CHEMET ............................... 40 chloramphenicol sod succinate ............................................ 30 chlorhexidine gluconate ......... 22 chloroquine phosphate.............. 3 chlorothiazide ......................... 18 chlorpromazine ....................... 54 chlorpropamide....................... 21 chlorthalidone ......................... 18 cholestyramine light ............... 19 CIALIS ................................... 43 ciclopirox................................ 60 cidofovir ................................. 30 cilostazol................................. 10 cimetidine ............................... 28 cimetidine hcl ......................... 28 CIMZIA .................................. 47
CIMZIA POWDER FOR RECONST .......................... 47 CINRYZE ............................... 41 CIPRO HC .............................. 22 CIPRODEX ............................ 22 ciprofloxacin ............................. 7 ciprofloxacin (mixture)............. 7 ciprofloxacin hcl ................. 7, 23 ciprofloxacin in 5 % dextrose . 30 ciprofloxacin lactate ............... 30 cisplatin .................................. 10 citalopram ............................... 52 cladribine ................................ 10 claravis.................................... 58 clarithromycin .......................... 6 CLEOCIN ............................... 67 CLINDAGEL ......................... 58 clindamax ............................... 58 clindamycin hcl ........................ 6 clindamycin in 5 % dextrose .. 30 clindamycin pediatric ............... 6 clindamycin phosphate .... 30, 58, 67 clindamycin-benzoyl peroxide58 CLINIMIX 5%/D15W SULFITE FREE ................. 34 CLINIMIX 5%/D25W SULFITE-FREE ................. 34 CLINIMIX 2.75%/D5W SULFIT FREE.................... 34 CLINIMIX 4.25%/D10W SULF FREE .................................. 34 CLINIMIX 4.25%/D5W SULFIT FREE.................... 34 CLINIMIX 4.25%-D20W SULF-FREE ....................... 34 CLINIMIX 4.25%-D25W SULF-FREE ....................... 34 CLINIMIX 5%D20W(SULFITE-FREE).... 34 CLINIMIX E 2.75%/D10W SUL FREE.......................... 34 CLINIMIX E 2.75%/D5W SULF FREE ....................... 34 CLINIMIX E 4.25%/D10W SUL FREE.......................... 34 CLINIMIX E 4.25%/D25W SUL FREE.......................... 34 CLINIMIX E 4.25%/D5W SULF FREE ....................... 34
70
CLINIMIX E 5%/D15W SULFIT FREE .................... 34 CLINIMIX E 5%/D20W SULFIT FREE .................... 34 CLINIMIX E 5%/D25W SULFIT FREE .................... 34 CLINISOL SF 15 % ............... 34 clobetasol ................................ 59 clobetasol-emollient ............... 59 clodan ..................................... 60 CLODERM............................. 60 CLOLAR ................................ 10 clomipramine .......................... 52 clonazepam ............................. 46 clonidine ................................. 18 clonidine hcl ..................... 18, 51 clopidogrel ................................ 8 clorazepate dipotassium.......... 51 clorpres ................................... 16 clotrimazole ........................ 2, 60 clotrimazole-betamethasone ... 60 clozapine ................................. 54 COARTEM............................... 3 codeine sulfate ........................ 49 colchicine ................................ 48 colchicine-probenecid............. 48 colestipol................................. 19 colistin (colistimethate na) ..... 30 colocort ................................... 28 COMBIGAN .......................... 25 COMBIPATCH ...................... 65 COMBIVENT RESPIMAT.... 56 COMETRIQ ........................... 12 COMPLERA ............................ 3 compro .................................... 26 COMVAX (PF) ...................... 37 CONDYLOX .......................... 62 constulose ............................... 27 COPAXONE .......................... 42 COPEGUS ................................ 3 CORDRAN............................. 60 CORDRAN TAPE LARGE ROLL.................................. 60 COREG CR ............................ 17 CORLANOR .......................... 15 cormax .................................... 60 cortisone ................................. 35 CORTISPORIN ...................... 59 COSENTYX PEN .................. 61 COSMEGEN .......................... 10
COUMADIN ............................ 9 CREON .................................. 26 CRESEMBA ...................... 2, 30 CRESTOR .............................. 19 CRINONE .............................. 65 CRIXIVAN .............................. 3 cromolyn..................... 23, 27, 56 CUBICIN ............................... 30 CUPRIMINE .......................... 44 cyclobenzaprine ...................... 47 CYCLOPHOSPHAMIDE ...... 12 CYCLOSET ........................... 45 cyclosporine ..................... 30, 38 cyclosporine modified ............ 38 CYKLOKAPRON.................. 30 cyproheptadine ....................... 22 CYSTADANE........................ 40 CYSTAGON .......................... 26 cytarabine ............................... 10 cytarabine (pf) ........................ 10 d10 % & 0.45 % sodium chloride ............................... 32 d10 %-0.9 % sodium chloride 32 d2.5 %-0.45 % sodium chloride ............................................ 32 d5 % and 0.9 % sodium chloride ............................................ 32 d5 %-0.45 % sodium chloride 32 dacarbazine ............................. 10 DACOGEN ............................ 10 DALIRESP ............................. 58 DALVANCE .......................... 30 danazol ................................... 36 dantrolene ............................... 47 dapsone ..................................... 3 DAPTACEL (DTAP PEDIATRIC) (PF).............. 37 DARAPRIM ............................. 3 daunorubicin ........................... 10 DAUNOXOME...................... 10 deblitane ................................. 63 decitabine ............................... 10 DECITABINE ........................ 10 DELESTROGEN ................... 65 delyla (28) .............................. 63 DELZICOL ............................ 28 demeclocycline ......................... 7 DEMSER................................ 42 DENAVIR .............................. 62 DEPEN TITRATABS ............ 44
DEPO-ESTRADIOL .............. 65 DEPO-MEDROL ................... 35 DEPO-PROVERA.................. 65 DEPO-SUBQ PROVERA 104 ............................................ 65 DEPO-TESTOSTERONE ...... 36 desipramine ............................ 52 desloratadine ........................... 22 desmopressin .................... 43, 44 desog-e.estradiol/e.estradiol ... 63 desonide .................................. 60 desoximetasone ...................... 60 DESOXYN ............................. 51 desvenlafaxine ........................ 52 dexamethasone ....................... 35 dexamethasone intensol .......... 35 dexamethasone sodium phos (pf) ...................................... 30 dexamethasone sodium phosphate ...................... 24, 30 DEXEDRINE SPANSULE .... 51 DEXILANT ............................ 28 dexmethylphenidate................ 51 dexpak 13 day......................... 35 dexrazoxane hcl ...................... 10 dextroamphetamine ................ 51 dextroamphetamineamphetamine ...................... 51 dextrose 10 % and 0.2 % nacl 32 dextrose 10 % in water (d10w) ............................................ 32 dextrose 5 % in water (d5w)... 33 dextrose 5 %-lactated ringers . 33 dextrose 5%-0.2 % sod chloride ............................................ 33 dextrose 5%-0.3 % sod.chloride ............................................ 33 diazepam ................................. 46 diazepam intensol ................... 46 diclofenac potassium .............. 48 diclofenac sodium. 24, 47, 48, 62 diclofenac-misoprostol ........... 48 dicloxacillin .............................. 6 dicyclomine ............................ 27 didanosine................................. 3 DIFFERIN .............................. 58 DIFICID ................................... 6 diflorasone .............................. 60 diflunisal ................................. 48 digitek ..................................... 15
71
digoxin .............................. 15, 16 dihydroergotamine .................. 44 DILANTIN ............................. 46 DILANTIN EXTENDED....... 46 DILANTIN INFATABS ........ 46 DILANTIN-125 ...................... 46 DILAUDID............................. 49 diltiazem hcl ............... 17, 18, 30 dilt-xr ...................................... 18 DIPENTUM ........................... 28 diphenhydramine hcl .............. 30 dipyridamole ............................. 8 disopyramide phosphate ......... 16 disulfiram ................................ 51 divalproex ............................... 46 DIVIGEL ................................ 65 DOCEFREZ ........................... 10 docetaxel ................................. 11 donepezil................................. 44 DORIBAX .............................. 30 dorzolamide ............................ 25 dorzolamide-timolol ............... 25 doxazosin ................................ 15 doxepin ................................... 52 doxercalciferol ........................ 41 doxorubicin ............................. 11 doxorubicin, peg-liposomal .... 11 DOXY-100 ............................. 30 doxycycline hyclate .................. 7 doxycycline monohydrate .... 7, 8 dronabinol ............................... 26 drospirenone-ethinyl estradiol 63 DROXIA................................. 12 DUAVEE ................................ 65 duloxetine ............................... 52 DULOXETINE....................... 52 DUOPA .................................. 45 duramorph (pf)........................ 30 DUREZOL ............................. 24 DUTOPROL ........................... 16 DYSPORT .............................. 39 e.e.s. 400 ................................... 6 E.E.S. GRANULES .................. 6 econazole ................................ 60 EDECRIN ............................... 18 EDURANT ............................... 3 EFFIENT .................................. 8 EGRIFTA ............................... 40 ELAPRASE ............................ 41 ELELYSO .............................. 40
ELESTRIN ............................. 65 ELIDEL .................................. 62 ELIGARD .............................. 36 ELIQUIS .................................. 9 ELITEK .................................. 11 elixophyllin............................. 56 ELLENCE .............................. 11 ELMIRON.............................. 44 EMADINE ............................. 23 EMBEDA ............................... 49 EMCYT .................................. 12 EMEND.................................. 26 emoquette ............................... 63 EMSAM ................................. 52 EMTRIVA................................ 4 ENABLEX ............................. 44 enalapril maleate .................... 14 enalapril-hydrochlorothiazide 16 ENBREL ................................ 47 ENBREL SURECLICK ......... 47 endocet ................................... 49 ENGERIX-B (PF) .................. 37 ENGERIX-B PEDIATRIC (PF) ............................................ 37 ENJUVIA ............................... 65 enoxaparin ................................ 9 entacapone .............................. 45 entecavir ................................... 4 enulose.................................... 27 EPANED ................................ 14 epinastine................................ 23 epinephrine ............................. 39 EPIPEN 2-PAK ...................... 39 EPIPEN JR 2-PAK ................. 39 epirubicin................................ 11 epitol ....................................... 46 EPIVIR ..................................... 4 eplerenone .............................. 18 EPOGEN .................................. 8 epoprostenol (glycine) ............ 57 eprosartan ............................... 15 EPZICOM ................................ 4 EQUETRO ............................. 52 ERAXIS(WATER DILUENT) ............................................ 31 ERBITUX............................... 11 ergoloid................................... 44 ERIVEDGE ............................ 12 errin ........................................ 63 ERTACZO ............................. 60
ERWINAZE ........................... 11 ery pads................................... 58 eryped 200 ................................ 6 eryped 400 ................................ 6 ERY-TAB ................................. 6 ERYTHROCIN ...................... 31 erythrocin (as stearate) ............. 7 erythromycin ...................... 7, 23 erythromycin ethylsuccinate..... 7 erythromycin with ethanol...... 59 erythromycin-benzoyl peroxide ............................................ 59 ESBRIET ................................ 57 escitalopram oxalate ............... 52 esomeprazole magnesium....... 28 esomeprazole sodium ............. 31 estazolam ................................ 53 ESTRACE .............................. 66 estradiol .................................. 66 estradiol valerate..................... 66 estradiol-norethindrone acet ... 63 ESTRING ............................... 66 estropipate .............................. 66 eszopiclone ............................. 53 ethambutol ................................ 7 ethosuximide .......................... 46 etidronate disodium ................ 42 etodolac .................................. 48 ETOPOPHOS ......................... 11 etoposide................................. 11 EURAX .................................. 61 EVAMIST .............................. 66 EVOCLIN .............................. 59 EVOTAZ .................................. 4 EXELDERM .......................... 60 EXELON ................................ 44 exemestane ............................. 13 EXJADE ................................. 40 EXTAVIA .............................. 42 FABIOR ................................. 59 FABRAZYME ....................... 40 falmina (28) ............................ 63 famciclovir................................ 4 famotidine............................... 28 FANAPT ................................ 54 FARESTON ........................... 13 FARXIGA .............................. 21 FARYDAK ............................. 13 FASLODEX ........................... 11 FAZACLO.............................. 54
72
felbamate ................................ 46 felodipine ................................ 18 FEMHRT LOW DOSE .......... 66 FEMRING .............................. 66 fenofibrate............................... 19 fenofibrate micronized............ 19 fenofibrate nanocrystallized ... 19 fenofibric acid (choline) ......... 19 fenoprofen............................... 48 fentanyl ................................... 49 fentanyl citrate ........................ 49 FENTORA .............................. 49 FERRIPROX .......................... 40 FETZIMA ............................... 53 FINACEA ............................... 58 finasteride ............................... 43 FIRAZYR ............................... 41 FIRMAGON KIT W DILUENT SYRINGE ........................... 36 FLAREX................................. 24 flavoxate ................................. 44 FLEBOGAMMA DIF ............ 37 flecainide ................................ 16 FLOLAN ................................ 57 FLOVENT DISKUS .............. 56 FLOVENT HFA ..................... 56 fluconazole ............................... 2 fluconazole in dextrose(iso-o) 31 flucytosine ................................ 2 fludarabine .............................. 11 fludrocortisone ........................ 35 flunisolide ............................... 22 fluocinolone ............................ 60 fluocinolone acetonide oil ...... 22 fluocinonide ............................ 60 fluocinonide-e ......................... 60 fluorometholone ..................... 24 FLUOROPLEX ...................... 62 fluorouracil ....................... 11, 62 fluoxetine ................................ 53 fluphenazine decanoate .......... 54 fluphenazine hcl...................... 54 flurazepam .............................. 53 flurbiprofen ............................. 48 flurbiprofen sodium ................ 24 flutamide ................................. 13 fluticasone......................... 23, 60 fluvastatin ............................... 19 fluvoxamine ............................ 53 FML FORTE .......................... 24
FML S.O.P. ............................ 24 FOCALIN XR ........................ 51 fondaparinux............................. 9 FORADIL AEROLIZER ....... 56 FORTEO ................................ 66 foscarnet ................................. 31 fosinopril ................................ 15 fosinopril-hydrochlorothiazide ............................................ 16 FOSRENOL ........................... 43 FRAGMIN ........................... 8, 9 FREAMINE HBC 6.9 % ........ 34 FULYZAQ ............................. 27 furosemide .............................. 18 FUSILEV ............................... 14 FUZEON .................................. 4 FYCOMPA ............................ 46 gabapentin .............................. 46 GABITRIL ............................. 46 galantamine ............................ 44 GAMASTAN S/D .................. 37 GAMMAGARD LIQUID ...... 37 GAMMAKED ........................ 37 GAMMAPLEX ...................... 37 GAMUNEX-C ....................... 37 ganciclovir sodium ................. 11 GARAMYCIN ....................... 23 GARDASIL (PF).................... 37 GARDASIL 9 (PF)................. 37 gatifloxacin ............................. 23 GATTEX ONE-VIAL ............ 27 gauze pad ................................ 20 GELNIQUE ............................ 44 gemcitabine ............................ 11 gemfibrozil.............................. 19 GENERESS FE ...................... 63 generlac .................................. 27 gengraf .................................... 38 GENOTROPIN ...................... 40 GENOTROPIN MINIQUICK 40 gentak ..................................... 23 gentamicin .................. 23, 31, 59 gentamicin in nacl (iso-osm) .. 31 gentamicin sulfate (ped) (pf) .. 31 gentamicin sulfate (pf) ........... 31 GEODON ............................... 54 gildagia ................................... 63 gildess ..................................... 63 gildess 24 fe............................ 63 GILENYA .............................. 42
GILOTRIF .............................. 13 GLASSIA ............................... 58 GLEEVEC .............................. 13 GLEOSTINE .......................... 13 glimepiride.............................. 21 glipizide .................................. 21 glipizide-metformin ................ 21 GLUCAGEN HYPOKIT ....... 20 GLUCAGON EMERGENCY KIT (HUMAN)................... 20 glyburide ................................. 21 glyburide micronized .............. 21 glyburide-metformin .............. 21 glycopyrrolate ......................... 27 GLYXAMBI .......................... 21 granisetron (pf) ....................... 31 granisetron hcl .................. 26, 31 GRANIX .................................. 8 GRASTEK.............................. 58 griseofulvin microsize .............. 2 griseofulvin ultramicrosize ....... 2 guanfacine .............................. 51 guanidine ................................ 42 GYNAZOLE-1 ....................... 67 HALAVEN ............................. 11 halobetasol propionate ............ 60 HALOG .................................. 60 haloperidol .............................. 54 haloperidol decanoate ............. 54 haloperidol lactate .................. 54 HARVONI................................ 4 HAVRIX (PF) ........................ 37 heparin (porcine) .................... 31 HEPATAMINE 8% ................ 34 HERCEPTIN .......................... 11 HETLIOZ ............................... 54 HEXALEN ............................. 13 HORIZANT............................ 46 HUMALOG............................ 21 HUMALOG KWIKPEN ........ 21 HUMALOG MIX 50-50 ........ 21 HUMALOG MIX 50-50 KWIKPEN.......................... 21 HUMALOG MIX 75-25 ........ 21 HUMALOG MIX 75-25 KWIKPEN.......................... 21 HUMATROPE ....................... 40 HUMIRA ................................ 47 HUMIRA CROHN'S DIS START PCK....................... 48
73
HUMULIN 70/30 ................... 21 HUMULIN N ......................... 21 HUMULIN R.......................... 21 HUMULIN R U-500 .............. 21 HYCAMTIN........................... 13 hydralazine ............................. 20 hydrochlorothiazide ................ 18 hydrocodone-acetaminophen .. 49 hydrocodone-ibuprofen .......... 50 hydrocortisone ............ 28, 35, 60 hydrocortisone butyrate .......... 60 hydrocortisone butyr-emollient ............................................ 60 hydrocortisone valerate .......... 60 hydrocortisone-acetic acid ...... 22 hydromorphone....................... 50 hydroxychloroquine .................. 3 hydroxyurea ............................ 13 hydroxyzine hcl ...................... 23 hydroxyzine pamoate.............. 23 HYPERRAB S/D (PF) ........... 37 HYSINGLA ER...................... 50 ibandronate ............................. 66 IBRANCE............................... 13 ibuprofen................................. 48 ibuprofen-oxycodone .............. 50 ICLUSIG ................................ 13 idarubicin ................................ 11 ifosfamide ............................... 11 ILARIS (PF) ........................... 40 ILEVRO ................................. 24 IMBRUVICA ......................... 13 imipenem-cilastatin ................ 31 imipramine hcl ........................ 53 imipramine pamoate ............... 53 imiquimod............................... 62 IMOVAX RABIES VACCINE (PF) ..................................... 37 INCRELEX ............................ 40 indapamide ............................. 19 INDOCIN ............................... 48 indomethacin .......................... 49 INFANRIX (DTAP) (PF) ....... 37 INLYTA ................................. 13 INSULIN PEN NEEDLE ....... 20 insulin syringe-needle u-100 .. 20 INSULIN SYRINGE-NEEDLE U-100 .................................. 20 INTELENCE ............................ 4 INTRALIPID .......................... 34
INTRON A ............................... 4 introvale.................................. 63 INVANZ................................. 31 INVEGA........................... 54, 55 INVEGA SUSTENNA........... 55 INVIRASE ............................... 4 INVOKAMET........................ 21 INVOKANA .......................... 21 IONOSOL-B IN D5W ........... 33 IONOSOL-MB IN D5W ........ 33 IOPIDINE............................... 25 IPOL ....................................... 37 ipratropium bromide......... 23, 56 ipratropium-albuterol ............. 56 irbesartan ................................ 15 irbesartan-hydrochlorothiazide ............................................ 16 IRENKA ................................. 53 irinotecan ................................ 11 ISENTRESS ............................. 4 ISOLYTE-P IN 5 % DEXTROSE ....................... 33 ISOLYTE-S ............................ 33 isoniazid ............................. 7, 31 isopropyl alcohol-benzocaine. 20 isosorbide dinitrate ................. 15 isosorbide mononitrate ........... 15 isradipine ................................ 18 ISTODAX .............................. 11 itraconazole .............................. 2 ivermectin ................................. 2 IXEMPRA .............................. 11 IXIARO (PF) .......................... 37 JADENU ................................ 40 JAKAFI .................................. 13 JALYN ................................... 43 jantoven .................................... 9 JANUMET ............................. 21 JANUMET XR....................... 21 JANUVIA............................... 21 JENTADUETO ...................... 22 JEVTANA .............................. 11 jinteli....................................... 63 junel 1.5/30 (21) ..................... 63 junel 1/20 (21) ........................ 63 junel fe 1.5/30 (28) ................. 63 junel fe 1/20 (28) .................... 63 junel fe 24 ............................... 63 JUXTAPID ............................. 19 KADCYLA ............................ 11
KALETRA ............................... 4 KALYDECO .......................... 40 KAPVAY ............................... 51 kariva (28) .............................. 63 kelnor 1/35 (28) ...................... 63 KENALOG ............................. 60 KETEK ..................................... 6 ketoconazole ....................... 2, 61 ketoprofen ............................... 49 ketorolac ................................. 24 KEYTRUDA .......................... 11 KHEDEZLA ........................... 53 KINERET ............................... 48 kionex..................................... 43 klor-con 10 ............................. 20 klor-con 8 ............................... 20 KLOR-CON M15 ................... 20 klor-con m20 .......................... 20 KORLYM ............................... 40 KRISTALOSE........................ 27 K-TAB .................................... 20 KUVAN.................................. 42 KYNAMRO ........................... 19 l norgest&e estradiol-e estrad . 64 labetalol ............................ 17, 31 lactated ringers ....................... 31 lactulose .................................. 27 LAMISIL .................................. 2 lamivudine ................................ 4 lamivudine-zidovudine ............. 4 lamotrigine.............................. 46 lancets ..................................... 20 LANOXIN .............................. 16 lansoprazole ............................ 28 LANTUS ................................ 21 LANTUS SOLOSTAR........... 21 larin 1.5/30 (21) ...................... 64 larin 1/20 (21) ......................... 64 larin fe..................................... 64 LASTACAFT ......................... 23 latanoprost .............................. 25 LATUDA................................ 55 LAZANDA ............................. 50 leflunomide............................. 48 LENVIMA.............................. 13 lessina ..................................... 64 LETAIRIS .............................. 57 letrozole .................................. 13 leucovorin calcium ................. 14 LEUKERAN .......................... 13
74
LEUKINE ................................. 8 leuprolide ................................ 11 levalbuterol hcl ....................... 56 levetiracetam........................... 46 levetiracetam in nacl (iso-os).. 31 levobunolol ............................. 25 levocarnitine ..................... 27, 31 levocarnitine (with sugar) ....... 27 levocetirizine .......................... 23 levofloxacin .................. 7, 23, 31 levofloxacin in d5w ................ 31 LEVOLEUCOVORIN CALCIUM .......................... 14 levonest (28) ........................... 64 levonorgestrel-ethinyl estrad .. 64 levora-28 ................................. 64 levorphanol tartrate ................. 50 levothyroxine .................... 31, 36 levoxyl .................................... 36 LEXIVA ................................... 4 LIALDA ................................. 28 lidocaine ................................. 62 lidocaine hcl............................ 62 lidocaine-prilocaine ................ 62 LINCOCIN ............................. 31 lindane .................................... 61 linezolid .............................. 2, 31 LINZESS ................................ 28 liothyronine............................. 36 LIPOSYN II............................ 34 lisinopril.................................. 15 lisinopril-hydrochlorothiazide 17 lithium carbonate .................... 52 lithium citrate.......................... 52 LO LOESTRIN FE ................. 64 lomustine ................................ 13 loperamide .............................. 27 lopreeza................................... 64 lorazepam ............................... 51 lorazepam intensol .................. 51 losartan ................................... 15 losartan-hydrochlorothiazide .. 17 LOTEMAX............................. 24 lovastatin................................. 19 loxapine succinate .................. 55 LUMIGAN ............................. 25 LUMIZYME........................... 41 LUPRON DEPOT .................. 36 LUPRON DEPOT (3 MONTH) ............................................ 36
LUPRON DEPOT (4 MONTH) ............................................ 36 LUPRON DEPOT (6 MONTH) ............................................ 36 LUPRON DEPOT-PED ......... 36 LYNPARZA........................... 13 LYRICA ................................. 46 LYSODREN........................... 13 magnesium sulfate .................. 33 malathion ................................ 61 maprotiline ............................. 53 marlissa................................... 64 MARPLAN ............................ 53 MATULANE ......................... 13 matzim la ................................ 18 MAXIDEX ............................. 24 meclizine ................................ 26 meclofenamate ....................... 49 MEDROL ............................... 35 medroxyprogesterone ............. 66 mefenamic acid ...................... 49 mefloquine................................ 3 megestrol .......................... 13, 27 MEKINIST ............................. 13 meloxicam .............................. 49 melphalan hcl ......................... 11 MENACTRA (PF) ................. 37 MENEST ................................ 66 MENOMUNE - A/C/Y/W-135 (PF) ..................................... 37 MENOSTAR .......................... 66 MENTAX ............................... 61 MENVEO A-C-Y-W-135-DIP (PF) ..................................... 38 mercaptopurine ....................... 13 meropenem ............................. 31 mesalamine with cleansing wipe ............................................ 29 mesna...................................... 14 MESNEX ............................... 14 MESTINON ........................... 42 MESTINON TIMESPAN ...... 42 METADATE CD ................... 51 METADATE ER .................... 51 metaproterenol ........................ 56 metformin ............................... 22 methadone ........................ 31, 50 methamphetamine .................. 51 methazolamide ....................... 25 methenamine hippurate ............ 2
methimazole ........................... 36 METHITEST .......................... 36 methotrexate sodium .............. 48 methotrexate sodium (pf) ....... 31 methoxsalen rapid................... 61 methscopolamine .................... 28 methyclothiazide .................... 19 methylergonovine ................... 66 METHYLIN ........................... 51 methylphenidate ..................... 51 methylprednisolone ................ 35 methylprednisolone acetate .... 35 methylprednisolone sodium succ ............................................ 35 metipranolol............................ 25 metoclopramide hcl .......... 26, 31 metolazone.............................. 19 metoprolol succinate............... 17 metoprolol ta-hydrochlorothiaz ............................................ 17 metoprolol tartrate ............ 17, 31 metronidazole ............... 2, 58, 67 metronidazole in nacl (iso-os) 31 mexiletine ............................... 16 MIACALCIN ......................... 66 miconazole-3 .......................... 67 microgestin 1.5/30 (21) .......... 64 microgestin 1/20 (21) ............. 64 microgestin fe 1.5/30 (28) ...... 64 microgestin fe 1/20 (28) ......... 64 midodrine................................ 39 MIGERGOT ........................... 44 MIGRANAL .......................... 44 MILLIPRED ........................... 35 MINASTRIN 24 FE ............... 64 minocycline .............................. 8 minoxidil ................................ 20 MIRCERA ................................ 9 mirtazapine ............................. 53 misoprostol ............................. 28 mitomycin............................... 11 mitoxantrone........................... 11 M-M-R II (PF) ........................ 38 modafinil ................................ 54 moexipril ................................ 15 moexipril-hydrochlorothiazide ............................................ 17 mometasone ............................ 60 montelukast ............................ 56 MONUROL .............................. 2
75
morphine ........................... 31, 50 morphine concentrate ............. 50 MOVIPREP ............................ 27 MOXEZA ............................... 23 moxifloxacin ............................. 7 MOZOBIL ................................ 9 MULTAQ ............................... 16 mupirocin ................................ 59 mupirocin calcium .................. 59 MUSTARGEN ....................... 11 MYCAMINE .......................... 31 mycophenolate mofetil ........... 38 mycophenolate sodium ........... 39 MYLERAN ............................ 13 MYOZYME .......................... 43 MYRBETRIQ......................... 44 nabumetone............................. 49 nadolol .................................... 17 nadolol-bendroflumethiazide.. 17 nafcillin ................................... 31 nafcillin in dextrose iso-osm .. 31 naftifine................................... 61 NAFTIN ................................. 61 NAGLAZYME ....................... 41 naloxone ................................. 54 naltrexone ............................... 51 NAMENDA XR ..................... 44 naphazoline ............................. 23 naproxen ................................. 49 naratriptan ............................... 44 NASONEX ............................. 23 NATACYN............................. 26 nateglinide .............................. 22 NATPARA ............................. 41 NEBUPENT ............................. 3 necon 0.5/35 (28) .................... 64 necon 1/35 (28) ....................... 64 NECON 10/11 (28)................. 64 necon 7/7/7 (28) ...................... 64 nefazodone .............................. 53 neomycin .................................. 2 neomycin-bacitracin-poly-hc .. 24 neomycin-bacitracin-polymyxin ............................................ 24 neomycin-polymyxin b gu ...... 62 neomycin-polymyxin bdexameth............................. 24 neomycin-polymyxingramicidin ........................... 24 neomycin-polymyxin-hc......... 24
NEPHRAMINE 5.4 % ........... 34 NEULASTA ............................. 9 NEUMEGA .............................. 9 NEUPOGEN ............................ 9 NEUPRO ................................ 45 NEVANAC ............................ 24 nevirapine ................................. 4 NEXAVAR ............................ 13 niacin ...................................... 19 niacor ...................................... 19 nicardipine .............................. 18 NICOTROL............................ 43 NICOTROL NS...................... 43 nifedical xl .............................. 18 nifedipine................................ 18 nikki (28) ................................ 64 NILANDRON ........................ 13 nimodipine.............................. 18 nisoldipine .............................. 18 NITRO-BID ........................... 15 nitrofurantoin macrocrystal ...... 2 nitrofurantoin monohyd/m-cryst .............................................. 2 nitroglycerin ........................... 15 NITROMIST .......................... 15 NITROSTAT.......................... 15 nizatidine ................................ 28 NORDITROPIN FLEXPRO .. 40 NORDITROPIN NORDIFLEX ............................................ 41 noreth-ethinyl estradiol-iron ... 64 norethindrone acetate ............. 66 norethindrone ac-eth estradiol 64 norethindrone-e.estradiol-iron 64 NORITATE ............................ 58 norlyroc .................................. 64 NORMOSOL-M IN 5 % DEXTROSE ....................... 33 NORMOSOL-R IN 5 % DEXTROSE ....................... 33 NORMOSOL-R PH 7.4 ......... 33 NORPACE CR ....................... 16 NORTHERA .......................... 18 nortrel 0.5/35 (28) .................. 64 nortrel 1/35 (21) ..................... 64 nortrel 1/35 (28) ..................... 64 nortrel 7/7/7 (28) .................... 64 nortriptyline ............................ 53 NORVIR................................... 4 NOXAFIL ................................ 2
NUEDEXTA .......................... 45 NULOJIX ............................... 39 NUTRILIPID.......................... 34 NUTROPIN AQ ..................... 41 NUTROPIN AQ NUSPIN...... 41 NUVARING ........................... 65 NUVESSA.............................. 67 NUVIGIL ............................... 54 nyamyc ................................... 61 nystatin ............................... 2, 61 nystatin-triamcinolone ............ 61 nystop ..................................... 61 OCTAGAM ............................ 38 octreotide acetate .................... 39 OFEV...................................... 57 ofloxacin ....................... 7, 22, 24 olanzapine............................... 55 olanzapine-fluoxetine ............. 52 olopatadine ............................. 23 omega-3 acid ethyl esters ....... 19 omeprazole ............................. 28 omeprazole-sodium bicarbonate ............................................ 28 OMNITROPE......................... 41 ONCASPAR........................... 11 ondansetron ............................ 26 ondansetron hcl....................... 26 ondansetron hcl (pf)................ 31 ONETOUCH ULTRA TEST . 20 ONETOUCH VERIO ............. 20 ONFI....................................... 46 OPDIVO ................................. 11 OPSUMIT .............................. 57 ORAP ..................................... 55 ORAPRED ODT .................... 35 ORENCIA .............................. 48 ORENCIA (WITH MALTOSE) ............................................ 48 ORENITRAM ........................ 57 ORFADIN .............................. 41 orsythia ................................... 65 ORTHO TRI-CYCLEN (28) .. 65 OSMOPREP ........................... 27 OTEZLA ................................ 61 OTEZLA STARTER .............. 61 OTREXUP (PF) ..................... 48 oxacillin .................................. 32 oxacillin in dextrose(iso-osm) 32 oxaliplatin ............................... 11 oxandrolone ............................ 36
76
oxaprozin ................................ 49 oxazepam ................................ 51 oxcarbazepine ......................... 46 OXISTAT ............................... 61 OXTELLAR XR .................... 46 oxybutynin chloride ................ 44 oxycodone............................... 50 oxycodone-acetaminophen ..... 50 oxycodone-aspirin .................. 50 OXYCONTIN ........................ 50 oxymorphone .......................... 50 paclitaxel................................. 11 pamidronate ............................ 66 PANCREAZE......................... 26 PANDEL ................................ 60 PANRETIN ............................ 62 pantoprazole ........................... 28 paricalcitol .............................. 41 paromomycin ............................ 3 paroxetine hcl ......................... 53 PASER...................................... 7 PAXIL .................................... 53 PCE ........................................... 7 PEDVAX HIB (PF) ................ 38 peg 3350-electrolytes.............. 27 peg-3350 with flavor packs .... 27 PEGANONE........................... 46 PEGASYS ................................ 4 PEGASYS PROCLICK............ 4 peg-electrolyte soln ................ 27 PEGINTRON ........................... 4 PEGINTRON REDIPEN.......... 4 penicillin g pot in dextrose ..... 32 penicillin g potassium ............. 32 penicillin g sodium ................. 32 penicillin v potassium ............... 6 PENTAM .................................. 3 PENTASA .............................. 29 pentoxifylline .......................... 10 PERFOROMIST..................... 56 perindopril erbumine .............. 15 periogard ................................. 22 PERJETA ............................... 11 permethrin............................... 61 perphenazine ........................... 55 perphenazine-amitriptyline ..... 55 PERTZYE............................... 26 PEXEVA ................................ 53 phenelzine ............................... 53 phenobarbital .......................... 46
phenytoin ................................ 46 phenytoin sodium ................... 47 phenytoin sodium extended .... 47 PHOSLYRA ........................... 43 PHOSPHOLINE IODIDE ...... 25 PICATO ................................. 62 pilocarpine hcl .................. 22, 25 pindolol................................... 17 pioglitazone ............................ 22 pioglitazone-glimepiride ........ 22 pioglitazone-metformin .......... 22 piperacillin-tazobactam .......... 32 piroxicam................................ 49 PLASMA-LYTE 148 ............. 33 PLASMA-LYTE A ................ 33 PLASMA-LYTE-56 IN 5 % DEXTROSE ....................... 33 PLEGRIDY ............................ 42 PNEUMOVAX 23 ................. 38 podofilox ................................ 62 polyethylene glycol 3350 ....... 27 polymyxin b sulfate ................ 32 polymyxin b sulf-trimethoprim ............................................ 24 POMALYST .......................... 13 portia....................................... 65 potassium chlorid-d5-0.45%nacl ............................................ 33 potassium chloride............ 20, 33 potassium chloride in 0.9%nacl ............................................ 33 potassium chloride in 5 % dex 33 potassium chloride in lr-d5 ..... 33 potassium chloride-0.45 % nacl ............................................ 33 potassium chloride-d5-0.2%nacl ............................................ 33 potassium chloride-d5-0.3%nacl ............................................ 33 potassium chloride-d5-0.9%nacl ............................................ 33 potassium citrate..................... 44 potassium cl in d10-0.2 % nacl ............................................ 33 POTIGA ................................. 47 PRADAXA............................... 9 pramipexole ............................ 45 PRANDIMET......................... 22 pravastatin .............................. 19 prazosin .................................. 15
PRED MILD........................... 24 PRED-G.................................. 24 PRED-G S.O.P. ...................... 24 prednicarbate .......................... 60 prednisolone acetate ............... 25 prednisolone sodium phosphate ............................................ 35 prednisone .............................. 35 PREDNISONE INTENSOL... 35 PREMARIN ........................... 66 PREMASOL 10 % ................. 34 PREMASOL 6 % ................... 34 PREMPHASE ........................ 66 PREMPRO ............................. 66 prenatal vitamins low iron ...... 66 PREVALITE .......................... 19 PREVNAR 13 (PF) ................ 38 PREZCOBIX ............................ 4 PREZISTA ............................... 4 PRIFTIN ................................... 7 primaquine ................................ 3 primidone................................ 47 PRIMSOL................................. 2 PRISTIQ ................................. 53 PRIVIGEN ............................. 38 PROAIR HFA ........................ 57 PROAIR RESPICLICK ......... 57 probenecid .............................. 48 PROCALAMINE 3% ............. 35 prochlorperazine ..................... 26 prochlorperazine edisylate...... 32 prochlorperazine maleate ....... 26 PROCRIT ................................. 9 proctosol hc ............................ 62 progesterone micronized ........ 66 PROGLYCEM ....................... 20 PROGRAF.............................. 32 PROLASTIN-C ...................... 58 PROLENSA ........................... 25 PROLEUKIN ......................... 12 PROLIA.................................. 66 PROMACTA ............................ 9 promethazine .................... 26, 32 propafenone ............................ 16 propantheline .......................... 27 proparacaine ........................... 26 propranolol ............................. 17 propranolol-hydrochlorothiazid ............................................ 17 propylthiouracil ...................... 36
77
PROQUAD (PF) ..................... 38 PROSOL 20 % ....................... 35 protriptyline ............................ 53 PROVENTIL HFA ................. 57 prudoxin.................................. 62 PULMICORT ......................... 57 PULMICORT FLEXHALER . 57 PULMOZYME ....................... 40 PURIXAN .............................. 13 PYLERA................................. 28 pyrazinamide ............................ 7 pyridostigmine bromide.......... 42 QUADRACEL (PF) ............... 38 quasense .................................. 65 QUDEXY XR ......................... 47 quetiapine ............................... 55 QUILLIVANT XR ................. 52 quinapril .................................. 15 quinapril-hydrochlorothiazide 17 quinidine gluconate ................ 16 quinidine sulfate ..................... 16 quinine sulfate .......................... 3 QVAR ..................................... 57 RABAVERT (PF) .................. 38 rabeprazole ............................. 28 RAGWITEK ........................... 58 raloxifene ................................ 66 ramipril ................................... 15 RANEXA ............................... 15 ranitidine hcl ..................... 28, 32 RAPAMUNE.......................... 39 RAVICTI ................................ 43 REBETOL ................................ 4 REBIF (WITH ALBUMIN) ... 42 REBIF REBIDOSE ................ 42 REBIF TITRATION PACK ... 42 RECLAST .............................. 66 RECOMBIVAX HB (PF)....... 38 REGRANEX .......................... 62 RELENZA DISKHALER ........ 4 RELISTOR ............................. 27 REMICADE ........................... 48 REMODULIN ........................ 57 RENAGEL ............................. 43 RENVELA ............................. 43 repaglinide .............................. 22 RESCRIPTOR .......................... 4 reserpine ................................. 18 RESTASIS .............................. 26 RETIN-A ................................ 59
RETIN-A MICRO .................. 59 RETROVIR ............................ 32 REVATIO .............................. 57 REVLIMID ............................ 13 REYATAZ ............................... 4 ribasphere ................................. 5 ribasphere ribapak .................... 5 ribavirin .................................... 5 RIDAURA.............................. 48 rifabutin .................................... 7 RIFAMATE ............................. 7 rifampin .............................. 7, 32 RIFATER ................................. 7 riluzole.................................... 39 rimantadine ............................... 5 ringers ..................................... 33 RIOMET................................. 22 risedronate .............................. 66 RISPERDAL CONSTA ......... 52 risperidone .............................. 52 RITUXAN .............................. 12 rivastigmine tartrate................ 44 rizatriptan ............................... 45 ropinirole ................................ 45 ROTARIX .............................. 38 ROTATEQ VACCINE .......... 38 ROZEREM ............................. 54 RUCONEST ........................... 41 RYTARY ............................... 45 SABRIL.................................. 47 safety needles ......................... 20 SAFYRAL.............................. 65 SAIZEN.................................. 41 SAIZEN CLICK.EASY ......... 41 SAMSCA ............................... 44 SANCUSO ............................. 26 SANDOSTATIN LAR DEPOT ............................................ 39 SANTYL ................................ 62 SAPHRIS ............................... 55 SAPHRIS (BLACK CHERRY) ............................................ 55 SAVAYSA ............................... 9 SAVELLA .............................. 47 selegiline hcl ........................... 45 selenium sulfide...................... 62 SELZENTRY ........................... 5 SENSIPAR ............................. 41 SEREVENT DISKUS ............ 57 SEROQUEL XR .................... 55
SEROSTIM ............................ 41 sertraline ................................. 53 SFROWASA .......................... 29 sharobel .................................. 65 SIGNIFOR.............................. 40 SIGNIFOR LAR..................... 39 sildenafil ................................. 57 SILENOR ............................... 54 silver sulfadiazine ................... 59 SIMBRINZA .......................... 25 SIMCOR ................................. 19 SIMPONI................................ 48 SIMPONI ARIA ..................... 48 SIMULECT ............................ 39 simvastatin .............................. 19 sirolimus ................................. 39 SIRTURO ................................. 7 SKLICE .................................. 61 sodium chloride ...................... 62 sodium chloride 0.45 % .......... 33 sodium chloride 0.9 % ............ 33 sodium chloride 3 % ............... 33 sodium chloride 5 % ............... 33 sodium lactate ......................... 33 sodium polystyrene (sorb free) ............................................ 43 SOLTAMOX .......................... 13 SOLU-CORTEF ..................... 35 SOLU-CORTEF (PF) ............. 35 SOLU-MEDROL ................... 35 SOLU-MEDROL (PF) ........... 35 SOMATULINE DEPOT ........ 39 SOMAVERT .......................... 39 SOOLANTRA ........................ 58 sorine ...................................... 16 sotalol ..................................... 16 sotalol af ................................. 16 SOTYLIZE ............................. 16 SOVALDI ................................ 5 SPIRIVA WITH HANDIHALER .................. 57 spironolactone ........................ 19 spironolacton-hydrochlorothiaz ............................................ 19 SPRYCEL .............................. 13 ssd ........................................... 59 stavudine................................... 5 STELARA .............................. 61 STIMATE ............................... 10 STIVARGA ............................ 13
78
STRATTERA ......................... 52 streptomycin ........................... 32 STRIBILD ................................ 5 STRIVERDI RESPIMAT ...... 57 STROMECTOL ....................... 2 SUBOXONE .......................... 54 SUBSYS ................................. 50 SUCLEAR .............................. 27 sucralfate................................. 28 sulfacetamide sodium ............. 24 sulfacetamide sodium (acne) .. 62 sulfacetamide-prednisolone .... 24 sulfadiazine ............................... 7 sulfamethoxazole-trimethoprim ........................................ 7, 32 SULFAMYLON ..................... 62 sulfasalazine ........................... 29 sulfazine ec ............................. 29 sulindac ................................... 49 sumatriptan ............................. 45 sumatriptan succinate ............. 45 SUPRAX .................................. 6 SUPREP BOWEL PREP KIT 27 SURMONTIL ......................... 53 SUSTIVA ................................. 5 SUTENT ................................. 14 SYLATRON ........................... 12 SYLVANT ............................. 39 SYMBICORT ......................... 57 SYMLINPEN 120 .................. 21 SYMLINPEN 60 .................... 21 SYNAGIS .............................. 43 SYNAREL.............................. 36 SYNERCID ............................ 32 SYNRIBO............................... 12 SYNTHROID ......................... 36 SYPRINE ............................... 44 TABLOID............................... 14 tacrolimus ......................... 39, 62 TAFINLAR ............................ 14 TAMIFLU ................................ 5 tamoxifen ................................ 14 tamsulosin ............................... 43 TARCEVA ............................. 14 TARGRETIN ................... 14, 62 tarina fe ................................... 65 TASIGNA............................... 14 TASMAR ............................... 45 TAZORAC ............................. 61 taztia xt ................................... 18
TECFIDERA .......................... 42 TEFLARO .............................. 32 TEGRETOL XR ..................... 47 TEKTURNA .......................... 18 TEKTURNA HCT ................. 17 telmisartan .............................. 15 telmisartan-amlodipine ........... 17 telmisartan-hydrochlorothiazid ............................................ 17 temazepam .............................. 54 temozolomide ......................... 14 TENIVAC (PF) ...................... 38 terazosin ................................. 15 terbinafine hcl ........................... 2 terbutaline ............................... 57 terconazole ............................. 67 testosterone ............................. 36 testosterone cypionate ............ 36 testosterone enanthate ............ 36 TESTRED .............................. 36 tetanus,diphtheria tox ped(pf) 38 tetanus-diphtheria toxoids-td .. 38 tetracycline ............................... 8 THALOMID........................... 14 theophylline ............................ 57 thioridazine ............................. 55 thiothixene .............................. 55 THYMOGLOBULIN ............. 39 THYROLAR-1 ....................... 36 THYROLAR-1/2.................... 36 THYROLAR-1/4.................... 36 THYROLAR-2 ....................... 36 THYROLAR-3 ....................... 36 tiagabine ................................. 47 TIKOSYN .............................. 16 timolol maleate ................. 17, 25 tinidazole .................................. 3 TIROSINT.............................. 37 TIVICAY ................................. 5 tizanidine ................................ 47 TOBI PODHALER ................ 40 TOBRADEX .......................... 24 TOBRADEX ST .................... 24 tobramycin .............................. 24 tobramycin in 0.225 % nacl ... 40 tobramycin sulfate .................. 32 tobramycin-dexamethasone.... 24 tolazamide .............................. 22 tolbutamide ............................. 22 tolcapone ................................ 45
tolmetin................................... 49 tolterodine............................... 44 topiramate ............................... 47 topotecan ................................ 12 TORISEL................................ 12 torsemide ................................ 19 tpn electrolytes ....................... 35 TRACLEER ........................... 57 TRADJENTA ......................... 22 tramadol .................................. 50 tramadol-acetaminophen ........ 50 trandolapril ............................. 15 trandolapril-verapamil ............ 17 tranexamic acid....................... 10 TRANSDERM-SCOP ............ 26 tranylcypromine...................... 53 TRAVASOL 10 % ................. 35 TRAVATAN Z....................... 25 travoprost (benzalkonium) ..... 25 trazodone ................................ 53 TREANDA ............................. 12 TRECATOR ............................. 7 TRELSTAR ............................ 36 TRELSTAR DEPOT .............. 36 TRELSTAR LA ..................... 36 tretinoin .................................. 59 tretinoin (chemotherapy) ........ 14 tretinoin microspheres ............ 59 TREXALL .............................. 48 triamcinolone acetonide .. 22, 23, 60 triamterene-hydrochlorothiazid ............................................ 19 TRIANEX .............................. 60 triazolam ................................. 54 triderm .................................... 60 trifluoperazine ........................ 55 trifluridine............................... 25 trihexyphenidyl ....................... 45 trilyte with flavor packets ....... 27 trimethoprim ............................. 3 trinessa (28) ............................ 65 TRIOSTAT ............................. 37 tri-previfem (28) ..................... 65 TRISENOX ............................ 12 tri-sprintec (28) ....................... 65 TRIUMEQ ................................ 5 trivora (28) .............................. 65 TROKENDI XR ..................... 47 TROPHAMINE 10 % ............ 35
79
TROPHAMINE 6%................ 35 trospium .................................. 44 TRULICITY ........................... 21 TRUMENBA .......................... 38 TRUVADA............................... 5 TUDORZA PRESSAIR ......... 57 TWINRIX (PF) ....................... 38 TYBOST................................... 5 TYGACIL............................... 32 TYKERB ................................ 14 TYPHIM VI............................ 38 TYSABRI ............................... 42 TYVASO ................................ 57 TYZEKA .................................. 5 TYZINE .................................. 23 UCERIS ............................ 29, 62 ULESFIA ................................ 61 ULORIC ................................. 48 ULTRESA .............................. 26 unithroid ................................. 37 UROCIT-K 10 ........................ 44 UROCIT-K 15 ........................ 44 UROCIT-K 5 .......................... 44 ursodiol ................................... 27 UVADEX ............................... 12 VAGIFEM .............................. 66 valacyclovir .............................. 5 VALCHLOR .......................... 62 VALCYTE ............................... 5 valganciclovir ........................... 5 valproate sodium .................... 32 valproic acid ........................... 47 valproic acid (as sodium salt) . 47 valsartan .................................. 15 valsartan-hydrochlorothiazide 17 vancomycin......................... 3, 32 vandazole ................................ 67 VAQTA (PF) .......................... 38 VARIVAX (PF)...................... 38 VARIZIG ................................ 38 VASCEPA .............................. 19 VECTIBIX ............................. 12 VELCADE ............................. 12 VELETRI ............................... 58 velivet triphasic regimen (28) . 65 VELPHORO ........................... 43 venlafaxine ............................. 53 VENTAVIS ............................ 58 VENTOLIN HFA ................... 57 verapamil ................................ 18
VERIPRED 20 ....................... 35 VERSACLOZ ........................ 55 VESICARE ............................ 44 VEXOL .................................. 25 VIBRAMYCIN ........................ 8 VIDEX 2 GRAM PEDIATRIC 5 VIGAMOX............................. 24 VIIBRYD ............................... 53 VIMPAT................................. 47 vinblastine .............................. 12 vincasar pfs ............................. 12 vincristine ............................... 12 vinorelbine.............................. 12 VIOKACE .............................. 26 VIRACEPT .............................. 5 VIRAMUNE XR ...................... 5 VIRAZOLE ............................ 43 VIREAD ................................... 5 VISTIDE ................................ 32 VITEKTA................................. 5 VIVOTIF BERNA VACCINE ............................................ 38 VOLTAREN .......................... 48 voriconazole ....................... 2, 32 VOTRIENT ............................ 14 VPRIV .................................... 40 vyfemla (28) ........................... 65 VYTORIN 10-10.................... 19 VYTORIN 10-20.................... 19 VYTORIN 10-40.................... 19 VYTORIN 10-80.................... 19
VYVANSE ............................. 52 warfarin .................................... 9 water for irrigation, sterile ...... 62 WELCHOL ............................ 19 XALKORI .............................. 14 XARELTO ......................... 9, 10 XELJANZ .............................. 48 XENAZINE ............................ 41 XEOMIN ................................ 39 XGEVA .................................. 66 XIFAXAN ................................ 3 XIGDUO XR .......................... 22 XOLAIR ................................. 58 XOPENEX HFA .................... 57 XTANDI................................. 14 XYREM.................................. 54 YERVOY ............................... 12 YF-VAX (PF) ......................... 38 zafirlukast ............................... 57 zaleplon .................................. 54 ZALTRAP .............................. 12 ZANOSAR ............................. 12 ZAVESCA.............................. 40 ZELBORAF ........................... 14 ZEMAIRA .............................. 58 ZENCHENT (28) ................... 65 ZENCHENT FE ..................... 65 ZENPEP ................................. 27 zeosa ....................................... 65 ZERBAXA ............................. 32 ZETIA .................................... 20
80
ZIAGEN ................................... 5 zidovudine ................................ 5 ZINECARD (AS HCL) .......... 14 ZIOPTAN (PF) ....................... 25 ziprasidone hcl ........................ 55 ZIRGAN ................................. 25 ZMAX ...................................... 7 zoledronic acid........................ 66 zoledronic acid-mannitol-water ............................................ 66 ZOLINZA ............................... 14 zolmitriptan............................. 45 zolpidem ................................. 54 ZOMACTON ......................... 41 ZONALON ............................. 62 zonisamide .............................. 47 ZONTIVITY............................. 8 ZORBTIVE ............................ 41 ZORTRESS ............................ 39 ZOSTAVAX (PF) .................. 38 zovia 1/35e (28) ...................... 65 zovia 1/50e (28) ...................... 65 ZOVIRAX .............................. 62 ZUBSOLV .............................. 54 ZYDELIG ............................... 14 ZYKADIA .............................. 14 ZYLET ................................... 25 ZYPREXA .............................. 55 ZYPREXA RELPREVV ........ 55 ZYTIGA ................................. 14 ZYVOX .................................... 3
Este formulario fue actualizado el 1 de enero de 2016. Si necesita información más reciente o si tiene otras preguntas, llámenos al 1-800-701-9000 o al 1-800-208-9562 para usuarios de TTY, de lunes a viernes de 8:00 a. m. a 8:00 p. m. (Del 1 de octubre al 14 de febrero los representantes están disponibles los 7 días de la semana, de 8:00 a. m. a 8:00 p. m.). Después del horario de atención y los días feriados, deje un mensaje y un representante lo llamará el siguiente día hábil. O visite tuftsmedicarepreferred.org.
Tufts Health Plan Medicare Preferred es un plan HMO con un contrato de Medicare. La inscripción en Tufts Health Plan Medicare Preferred depende de la renovación del contrato. El formulario puede ser modificado en cualquier momento. Le enviaremos un aviso cuando sea necesario. This information is available for free in other languages. Please call our Customer Relations number at 1-800-701-9000 or, for TTY users, 1-800-208-9562, Monday - Friday 8:00 a.m. - 8:00 p.m. (from Oct. 1 - Feb. 14 representatives are available 7 days a week, 8:00 a.m. - 8:00 p.m.). After hours and on holidays, please leave a message and a representative will return your call on the next business day. Esta información está disponible de forma gratuita en otros idiomas. Comuníquese con nuestro número de Servicios al cliente al 1-800-701-9000 o, para usuarios con problemas auditivos (TTY), al 1-800-208-9562, de lunes a viernes, de 8 a. m. a 8 p. m. (Del 1 de octubre al 14 de febrero, los representantes están disponibles los 7 días de la semana, de 8 a. m. a 8 p. m.). Después del horario de atención y en días feriados, deje un mensaje y un representante lo llamará el siguiente día hábil.
705 Mount Auburn Street, Watertown, MA 02472