LISTA DE MEDICAMENTOS CUBIERTOS

Community Care Plus FIDA-MMP 2015

1.877.ICS.2525 www.icsny.org

ICS_15412000_A2TC_G_EFF01012015_ 08042014_174025_Comprehensive_R11 3 14_Approved

ICS Community Care Plus FIDA-MMP | 2015 Lista de medicamentos cubiertos (Formulario) Ésta es una lista de medicamentos que los participantes pueden obtener en ICS Community Care Plus FIDA-MMP.  ICS Community Care Plus FIDA-MMP es un plan de salud administrado que tiene un contrato con Medicare y el Departamento de salud del estado de New York (Medicaid) proporcionar los beneficios de los dos programas a los participantes a través de un programa FIDA (Fully Integrated Duals Advantage o Organización integral para personas elegibles para ambos programas).  Los beneficios, la Lista de medicamentos cubiertos y las redes de proveedores pueden cambiar durante el año y el 1º de enero de cada año.  Usted siempre puede revisar la Lista de medicamentos cubiertos actualizada de ICS Community Care Plus FIDA-MMP en internet en www.icsny.org/care-plus o llamar a Servicios al participante de ICS Community Care Plus FIDA-MMP al 1.887.ICS.2525.  Se pueden aplicar limitaciones y restricciones. Para obtener más información, llame a Servicios al participante de ICS Community Care Plus FIDA-MMP o lea el Manual del participante de ICS Community Care Plus FIDA-MMP.  No hay copagos para los medicamentos cubiertos.  Usted puede pedir esta información en otros formatos, como Braille o letra grande, de manera gratuita. Llame al 1.877.ICS.2525. La llamada es gratuita.  Usted puede obtener esta información en otros idiomas, de manera gratuita. Llame al 1.877.ICS.2525 y 1.855.ICS.4TTY durante el horario de 8 a. m. a 8 p. m., de lunes a viernes. La llamada es gratuita.  You can get this information for free in other languages. Call 1.877.ICS.2525 and TTY 1.855.ICS.4TTY during the hours of 8 a.m. to 8 p.m., Monday through Friday. The call is free.

Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 1

 Вы можете бесплатно получить всю эту информацию на других языках. Звоните в ICS по телефону 1.877.ICS.2525 и телетайпу 1.855.ICS.4TTY с понедельника по пятницу с 8:00 до 20:00. Звонок бесплатный.  您可免费获得所有这些信息的其他语言版本。请在周一至周五上午 8 点至晚上 8 点致 电 ICS，电话号码为 1.877.ICS.2525，听障专线 (TTY) 为 1.855.ICS.4TTY。此为免 费电话。  Ou kapab jwenn tout enfòmasyon sa a gratis nan lòt lang. Rele ICS nan 1.877.ICS.2525 ak TTY 1.855.ICS.4TTY, ant 8 a.m. ak 8 p.m., lendi jiska vandredi. Apèl la gratis.  이 모든 정보는 타 언어로 무료로 제공됩니다. 월요일~금요일, 오전 8시~오후 8시 사이에 1.877.ICS.2525 및 TTY(청각 장애인용 전화) 1.855.ICS.4TTY로 ICS에 전화해 주십시오. 이 전화는 무료입니다.  Le informazioni in questione sono disponibili gratuitamente anche in altre lingue. Chiamare ICS ai numeri 1.877.ICS.2525 e TTY 1.855.ICS.4TTY tra le 8:00 e le 20.00 dal lunedì al venerdì. La chiamata è gratuita.  El estado de New York creó un Programa Ombudsman para los participantes llamado Red Independiente de Defensoría del Consumidor (Independent Consumer Advocacy Network, ICAN) para proporcionarles a los Participantes asistencia gratuita, confidencial para los servicios que ofrece ICS Community Care Plus FIDAMMP. Para comunicarse con ICAN llame al 1.844.614.8800 o vaya a www.icannys.org.

Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 2

Preguntas frecuentes (FAQ) Encuentre aquí las respuestas a las preguntas que usted tenga sobre esta Lista de medicamentos cubiertos. Usted puede leer todas las Preguntas frecuentes para saber más o buscar preguntas y respuestas.

1. ¿Qué medicamentos de receta se encuentran en la Lista de medicamentos cubiertos? (Llamamos “Lista de medicamentos” a la Lista de medicamentos cubiertos, para abreviar.) Los medicamentos de la Lista de medicamentos cubiertos que comienza en la página 14 son los medicamentos cubiertos por ICS Community Care Plus FIDA-MMP. Los medicamentos están disponibles en las farmacias dentro de nuestra red. Una farmacia está en nuestra red si tenemos un acuerdo con ellos, para trabajar con nosotros y proporcionarle servicios a usted. Nos referimos a estas farmacias como “farmacias de la red”. ICS Community Care Plus FIDA-MMP cubrirá todos los medicamentos de la Lista, si:

 Su médico u otro proveedor de la red dice que usted los necesita para mejorar o para seguir sano,

 El medicamento es médicamente necesario para su enfermedad, y  Usted surte la receta en una farmacia de la red de ICS Community Care Plus FIDA-MMP.

 ICS Community Care Plus FIDA-MMP podría tener pasos adicionales para tener acceso a ciertos tipos de medicamentos (lea en el pregunta #5 de abajo). En algunos casos es probable que usted tenga que hacer algo antes de obtener un medicamento, por ejemplo: primero probar otros medicamentos. Usted puede también leer una lista actualizada de los medicamentos que cubrimos en nuestro sitio web en www.icsny.org/care-plus/pharmacy-benefits o llame a Servicios al participante al 1.877.ICS.2525.

2. ¿La Lista de medicamentos cambia alguna vez? Sí. ICS Community Care Plus FIDA-MMP podría agregar o quitar medicamentos de la Lista de medicamentos durante el año. De manera general, la Lista de medicamentos sólo cambiará si:

Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 3

 Aparece un nuevo medicamento, que funcione tan bien como algún medicamento que se encuentre actualmente en la Lista de medicamentos o

 Nos enteramos que algún medicamento no es seguro. También podemos cambiar nuestras reglas sobre algunos medicamentos. Por ejemplo, podríamos:

 Decidir si exigir o no aprobación previa para algún medicamento. (Aprobación previa es el permiso de ICS Community Care Plus FIDA-MMP o su Equipo interdisciplinario (IDT) antes que usted puede obtener un medicamento.)

 Aumentar o cambiar la cantidad de un medicamento que usted puede obtener (llamado "límite de cantidad”).

 Agregar o cambiar restricciones de tratamiento progresivo de un medicamento. (Terapia progresiva significa que usted podría tener que probar un medicamento antes que cubramos otro medicamento.) (Para obtener más información acerca de estas reglas para los medicamentos, lea la página 5.) Le avisaremos cuando quitemos de la Lista de Medicamento algún medicamento que usted esté tomando. También le diremos cuando cambiemos nuestras reglas para cubrir algún medicamento. Las preguntas 3, 4 y 7 de abajo tienen más información sobre lo que sucederá cuando cambie la Lista de medicamentos.

 Usted siempre puede leer la Lista de medicamentos actualizada de ICS Community Care Plus FIDA-MMP en internet, en www.icsny.org/care-plus/druglist. También puede llamar a Servicios al participante para revisar la Lista de medicamentos actual, al 1.877.ICS.2525.

3. ¿Qué sucederá cuando aparezca un medicamento más barato que funcione tan bien como algún medicamento que se encuentre actualmente en la Lista de medicamentos? Si aparece un medicamento más barato que funcione tan bien como algún medicamento que se encuentre actualmente en la Lista de medicamentos:

 Es probable que su farmacéutico le dé un medicamento más barato la próxima vez que surta su receta. Si usted y su proveedor deciden que el medicamento más barato no es el correcto para usted, su proveedor puede indicarle al farmacéutico que continúe surtiéndole el medicamento que toma ahora.

Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 4

 Es probable que ICS Community Care Plus FIDA-MMP decida quitar el medicamento más caro de la Lista de medicamentos. Si usted está tomando un medicamento que quitamos de la Lista de medicamentos, porque aparece un medicamento más barato que funcione tan bien, le avisaremos con 60 días de anticipación antes de quitarlo de la Lista de medicamentos o cuando pida que surtamos nuevamente el medicamento. En ese momento, usted podrá obtener un suministro de 60 días del medicamento antes de que se haga el cambio en la Lista de medicamentos.

 El plan Community Care Plus FIDA-MMP de ICS informará estos cambios a los miembros por correo e incluirá información sobre cómo presentar una queja, apelación o solicitud de excepción. El plan Community Care Plus FIDA-MMP de ICS también publicará esta información en nuestro sitio web, el cual puede encontrarse en www.icsny.org/care-plus y notificará a los miembros todos los años sobre nuestro formulario actualizado. Esta información puede proporcionarse en formatos alternativos.

4. ¿Qué sucederá cuándo averigüemos que algún medicamento no es seguro? Si la Administración de alimentos y medicamentos (FDA) dice que algún medicamento no es seguro, lo quitaremos inmediatamente de la Lista de medicamentos. También le enviaremos una carta y lo llamaremos para avistarle que el medicamento que no es seguro fue quitado de la Lista de medicamentos. Se le indicará que se comunique con el médico que emite sus recetas lo antes posible para recibir instrucciones a fin de reemplazar el medicamento discontinuado. También puede ponerse en contacto con su gerente de atención para obtener ayuda.

5. ¿La cobertura de medicamentos tiene alguna restricción o límite? ¿O hay que hacer algo en particular para poder obtener ciertos medicamentos? Sí, algunos medicamentos tienen reglas de cobertura o tienen límites en la cantidad que usted puede obtener. En algunos casos, tendrá que hacer algo antes de poder obtener el medicamento. Por ejemplo:

 Aprobación previa (o autorización previa): Para algunos medicamentos, usted o su médico deben obtener una aprobación de ICS Community Care Plus FIDAMMP o su Equipo interdisciplinario (IDT) antes de surtir su receta. Y si usted no

Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 5

consigue la aprobación, ICS Community Care Plus FIDA-MMP podría no cubrir el medicamento.

 Límites de cantidad: A veces ICS Community Care Plus FIDA-MMP limita la cantidad de un medicamento que usted puede obtener.

 Tratamiento progresivo: A veces ICS Community Care Plus FIDA-MMP exige que usted siga un tratamiento progresivo. Esto significa que usted tendrá que probar los medicamentos en un cierto orden para su enfermedad. Usted podría tener que probar un medicamento antes de que cubramos otro medicamento. Si a su médico le parece que el primer medicamento no funciona para usted, entonces cubriremos el segundo. Usted puede averiguar si su medicamento tiene algún requisito o límite adicional, leyendo los cuadros de las páginas 15. Usted también puede obtener más información en nuestro sitio web en www.icsny.org/care-plus/pharmacy-benefits. Hemos publicado documentos en línea que explican nuestra autorización previa y las restricciones de la terapia escalonada. Usted puede pedirnos que le enviemos una copia. Usted también puede pedir una "excepción" a esos límites. Por favor lea en la pregunta 11 más información sobre las excepciones. Si usted está en un hogar para personas de la tercera edad u otra institución de cuidados a largo plazo y necesita algún medicamento que no esté en la Lista de medicamentos o si no puede obtener el medicamento que necesite fácilmente, podemos ayudarle. Cubriremos un suministro de emergencia de 31 días del medicamento que usted necesite (a menos que tenga una receta para menos días), sin importar que usted sea o no un participante nuevo de ICS Community Care Plus FIDA-MMP. Esto le dará tiempo para hablar con su médico u otro proveedor médico. Ellos podrán ayudarle a decidir si hay algún otro medicamento similar en la Lista de medicamentos que usted pueda tomar en su lugar o si tiene que pedir una excepción. Por favor lea en la pregunta 11 más información sobre las excepciones.

6. ¿Cómo sabrá si el medicamento que usted quiere tiene limitaciones o si tiene que hacer algo para obtenerlo? La Lista de medicamentos cubiertos de la página 15 tiene una columna llamada "Medidas necesarias, restricciones o límites de uso".

Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 6

7. ¿Qué sucederá si cambiamos nuestras reglas sobre cómo cubrimos algunos medicamentos? Por ejemplo, si agregamos requisitos de autorización (aprobación) previa, límites de cantidad y/o restricciones de tratamiento progresivo a algún medicamento. Le avisaremos si agregamos requisitos de aprobación previa, límites de cantidad y/o restricciones de tratamiento progresivo a un medicamento. Le avisaremos por lo menos 60 días antes de agregar la restricción o cuando pida su siguiente resurtido. En ese momento, usted podrá obtener un suministro de 60 días del medicamento antes de que se haga el cambio en la Lista de medicamentos. Esto le dará tiempo para hablar con su médico u otra persona que prescribe sobre qué hacer después.

8. ¿Cómo puede encontrar un medicamento en la Lista de medicamentos? Hay dos maneras de encontrar un medicamento:

 Puede buscar por orden alfabético (si usted sabe cómo se escribe el nombre del medicamento), o

 Puede buscar por enfermedad. Para buscar por orden alfabético, vaya a la sección alfabética de la lista en la página l-1 Luego busque el nombre en la Lista de medicamentos. Para buscar por enfermedad, busque la sección titulada “Lista de medicamentos por enfermedad” de la página 15. Luego, busque su enfermedad. Por ejemplo, si usted tiene una enfermedad del corazón, usted debe buscar en esa categoría. Ahí encontrará los medicamentos que traten enfermedades del corazón.

9. ¿Qué pasará si el medicamento que usted quiere tomar no está en la Lista de medicamentos? Si usted no encuentra su medicamento en la Lista de medicamentos, llame a Servicios al participante al 1.855.ICS.2525 y pregunte por él. Si se entera que ICS Community Care Plus FIDA-MMP no cubrirá el medicamento, usted puede hacer algo de lo siguiente:

Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 7

 Pida a Servicios al participante una lista de medicamentos similar al que quiera tomar. Luego, muestre la lista a su médico u otro proveedor médico. Éste podrá recetarle un medicamento similar al de la Lista de medicamentos que usted quiere tomar. O,

 Usted también puede pedir al plan o a su Equipo interdisciplinario (IDT) que haga una excepción para cubrir su medicamento. Por favor lea en la pregunta 11 más información sobre las excepciones.

10. ¿Qué pasará si usted es un participante nuevo de ICS Community Care Plus FIDA-MMP y no puede encontrar su medicamento en la Lista o tiene problemas para obtener su medicamento? Podemos ayudarle. Debemos cubrir un suministro temporario de hasta 90 días de su medicamento, cuando sea necesario, durante los primeros 90 días que usted sea participante de ICS Community Care Plus FIDA-MMP. Esto le dará tiempo para hablar con su médico u otro proveedor médico. Ellos podrán ayudarle a decidir si hay algún otro medicamento similar en la Lista de medicamentos que usted pueda tomar en su lugar o si tiene que pedir una excepción. Cubriremos un suministro de hasta 90 días de su medicamento si:

 Usted está tomando algún medicamento que no esté en nuestra Lista de medicamentos o  Las reglas del plan de salud no le permiten obtener la cantidad recetada por su proveedor médico o  El medicamento requiere aprobación previa de ICS Community Care Plus FIDA-MMP o de su Equipo interdisciplinario (IDT) o  Usted toma algún medicamento que forme parte de una restricción de tratamiento progresivo. Si usted vive en un hogar para personas de la tercera edad u otra institución de cuidados a largo plazo, usted puede resurtir su receta hasta por días por tanto tiempo como 98 días. Usted podrá resurtir el medicamento varias veces durante los 98 días. Esto le dará tiempo a su proveedor médico para cambiar su medicamento por alguno que esté en la Lista de medicamentos o para pedir una excepción. Si es un participante actual que experimenta un cambio en el nivel de atención de un tratamiento por otro, es probable que reúna los requisitos para obtener el suministro para 90 días de un medicamento que no se encuentre en la Lista de medicamentos, a fin de darle tiempo a su médico o a la persona que le emite las recetas para que localice un medicamento

Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 8

en la lista o para que presente una excepción. Es probable que usted reúna los requisitos para obtener el suministro de transición de nivel de atención si:    

 

ingresa a un centro de atención a largo plazo (Long-Term Care, LTC) de un hospital u otro establecimiento abandona un centro de LTC y regresa a la comunidad le dan de alta de un hospital y regresa a un hogar finalizó su internación en un centro de enfermería especializada cubierto por la Parte A de Medicare (incluidos los cargos de farmacia) y regresa a la cobertura de la Parte D vuelve del estado de cuidados paliativos a los beneficios estándar de la Parte A y B de Medicare o le dan de alta de un hospital psiquiátrico con regímenes de medicamentos que son altamente individualizados.

11. ¿Puede pedir al plan que haga una excepción para cubrir su medicamento? Sí. Usted puede pedirle a ICS Community Care Plus FIDA-MMP o a su Equipo interdisciplinario (IDT) que haga una excepción para cubrir su medicamento si éste no está en la Lista de medicamentos. Usted también puede pedirle a ICS Community Care Plus FIDA-MMP o a su IDT un cambio a las reglas de su medicamento.

 Por ejemplo, ICS Community Care Plus FIDA-MMP podría limitar la cantidad que cubriremos de un medicamento. Si su medicamento tiene un límite, usted puede pedirnos a nosotros o a su IDT que cambiemos el límite y que cubramos más.  Otros ejemplos: Usted puede pedirnos a nosotros o a su IDT que quitemos las restricciones de tratamiento progresivo o los requisitos de aprobación previa.

12. ¿Cuánto tiempo toma obtener una excepción? Primero, ICS Community Care Plus FIDA-MMP o su Equipo interdisciplinario (IDT) recibir una declaración de su proveedor médico apoyando su pedido de una excepción. Después de recibir la declaración, le daremos una decisión sobre su pedido de excepción a más tardar en 72 horas.

Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 9

Si usted o su proveedor médico piensan que su salud podría deteriorarse si tiene que esperar 72 horas para obtener una decisión, entonces usted puede pedir una excepción acelerada. Ésta es una decisión más rápida. Si su proveedor médico apoya su pedido, le daremos una decisión dentro de las 24 horas después de recibir la declaración de apoyo de su proveedor médico.

13. ¿Cómo puede pedir una excepción? Para pedir una excepción, llame a su Administrador de cuidados. Su Administrador de cuidados trabajará con usted y su proveedor para ayudarle a pedir una excepción.

14. ¿Qué son los medicamentos genéricos? Los medicamentos genéricos están hechos con los mismos ingredientes que los medicamentos de marca. Generalmente cuestan menos que los medicamentos de marca y no tienen marcas tan conocidas. Los medicamentos genéricos son aprobados por la Administración de alimentos y medicamentos (FDA). ICS Community Care Plus FIDA-MMP cubre tanto medicamentos de marca como medicamentos genéricos.

15. ¿Qué son los medicamentos de venta libre (OTC)? OTC quiere decir "medicamentos que se venden sin receta". ICS Community Care Plus FIDAMMP cubre algunos medicamentos de venta libre cuando su proveedor escribe una receta para ellos. Usted puede leer la Lista de medicamentos de ICS Community Care Plus FIDA-MMP para ver qué medicamentos de venta libre están cubiertos.

16. ¿El plan Community Care Plus FIDA-MMP de ICS cubre algún producto de venta libre que no sea un medicamento? El plan Community Care Plus FIDA-MMP de ICS cubre algunos productos de venta libre como vendas de gasa, algodones/almohadillas con alcohol, agujas y jeringas para la insulina, etc., cuando los receta por escrito su proveedor.

Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 10

Usted puede leer la Lista de medicamentos de ICS Community Care Plus FIDA-MMP para ver qué productos de venta libre, que no son medicamentos, están cubiertos.

17. ¿Cuánto es su copago? A usted no le cobrarán un copago por los medicamentos de la Lista de medicamentos.

18. ¿Qué son los niveles de medicamentos? Los niveles son grupos de medicamentos. Todo medicamento de la Lista de medicamentos del plan se encuentra en uno de los 4 niveles. Usted no tiene que pagar nada por los medicamentos de cualquiera de los niveles.

 Nivel 1: Medicamentos genéricos cubiertos por Medicare  Nivel 2: Medicamentos de marca y especialidad cubiertos por Medicare  Nivel 3: Medicamentos genéricos y de marca no pertenecientes a la Parte D cubiertos por Medicaid

 Nivel 4: Medicamentos de venta libre (over-the-counter, OTC) cubiertos por Medicaid

Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 11

Lista de medicamentos cubiertos La lista de medicamentos cubiertos que comienza en la próxima página le brinda información sobre los medicamentos cubiertos por el plan Community Care Plus FIDA-MMP de ICS. Si usted tiene problemas para encontrar su medicamento en la lista, lea el Índice que comienza en la página I-1. La primera columna del cuadro contiene el nombre del medicamento. Los medicamentos de marca están escritos en mayúsculas (p.ej.: AVONEX) y los medicamentos genéricos están escritos en cursivas minúsculas (p.ej.: amoxicillin). La información de la columna titulada "Medidas necesarias, restricciones o límites de uso", le indica si ICS Community Care Plus FIDA-MMP tiene alguna regla para cubrir su medicamento.

Abreviaturas y símbolos Dentro del cuerpo de este documento, encontrará las siguientes abreviaturas ABREVIATURA

DESCRIPCIÓN

EXPLICACIÓN

Restricción de administración de uso

PA

PA BvD

Restricción de la autorización previa

Restricción de la autorización previa para determinar la Parte B frente a la Parte D

Usted (o su médico) debe recibir la autorización previa de parte del plan Community Care Plus FIDA-MMP de ICS para surtir su receta a fin de obtener este medicamento. Sin la autorización previa, es probable que el plan Community Care Plus FIDA-MMP de ICS no cubra este medicamento. Este medicamento puede ser elegible para ser pagado por la Parte B o Parte D de Medicare. Usted (o su médico) debe obtener la autorización previa de parte del plan Community Care Plus FIDAMMP de ICS para determinar que este medicamento está cubierto por la Parte D de Medicare, a fin de surtir su receta para obtener este medicamento. Sin la autorización previa, es probable que FIDA Care Complete no cubra este medicamento.

Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 12

ABREVIATURA

PA NSO

QL

ST

*

LA

DESCRIPCIÓN

EXPLICACIÓN

Restricción de autorización previa solo para nuevos miembros

Si es miembro nuevo o no ha tomado antes este medicamento, usted (o su médico) debe recibir la autorización previa de parte del plan Community Care Plus FIDA-MMP de ICS para surtir su receta a fin de obtener este medicamento. Sin la autorización previa, es probable que FIDA Care Complete no cubra este medicamento.

Restricción de límite de cantidad

El plan Community Care Plus FIDAMMP de ICS limita la cantidad de este medicamento que está cubierto por la receta o dentro de un período específico.

Restricción de la terapia escalonada

Antes de que el plan Community Care Plus FIDA-MMP de ICS brinde cobertura para este medicamento, usted debe probar primero otros medicamentos para tratar su afección médica. Este medicamento solo puede cubrirse si otro(s) medicamento(s) no le funciona(n) a usted.

Otras abreviaturas de la cobertura Medicamento que no Este medicamento es un medicamento pertenece a la Parte que no pertenece a la Parte D cubierto por Medicaid. D

Medicamento con acceso limitado

Es posible que este medicamento se encuentre disponible solamente en ciertas farmacias. Para obtener más información, consulte su Directorio de farmacias o llame al plan Community Care Plus FIDA-MMP de ICS al 1.877.ICS.2525, de lunes a viernes, de 8 a. m. a 8 p. m. La llamada es gratuita.

Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 13

ABREVIATURA

GC

DESCRIPCIÓN

EXPLICACIÓN

Cobertura durante el período de carencia

Para obtener más información, visite www.icsny.org/care-plus. Ofrecemos cobertura de este medicamento recetado durante el período de carencia de la cobertura. Consulte nuestra Evidencia de cobertura para obtener más información sobre esta cobertura.

Nota: El símbolo (*) junto a un medicamento significa que el medicamento no es un “medicamento Parte D”. Estos medicamentos tienen reglas diferentes para las apelaciones. Una apelación es una manera formal de pedirnos que revisemos alguna decisión de cobertura y que la cambiemos, si le parece que hemos cometido un error. Por ejemplo, ICS Community Care Plus FIDA-MMP o su Equipo interdisciplinario (IDT) podría decidir que un medicamento que usted quiere ya no está cubierto por Medicare o Medicaid. Si usted o su médico no están de acuerdo con nuestra decisión, usted puede apelar. Para pedir instrucciones sobre cómo apelar, llame a Servicios al participante, al 1.877.ICS.2525 o a la Red Independiente de Defensoría del Consumidor (Independent Consumer Advocacy Network, ICAN) al 1.844.614.8800. Usted también puede enterarse de cómo apelar una decisión leyendo el Manual del participante.

Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 14

If you have questions, please call ICS Community Care Plus FIDA-MMP at 1.877.ICS.2525, Monday to Friday, 8 a.m. to 8 p.m. The call is free. For more information, visit www.icsny.org/care-plus. 15

Tier level

What the drug will cost you

(Acetaminophen) (Acetaminophen) (Tylenol 8 Hour)

4 4 4

$0 $0 $0

(Acetaminophen)

4

$0

1

$0

1

$0

1

$0

1

$0

1

$0

1

$0

(Tencon)

1

$0

(Esgic)

1

$0

(Fiorinal)

1

$0

(Butorphanol Tartrate)

1

$0

Name of Drug

Necessary Actions, Restrictions, or Limits on Use

Analgesics Analgesics, Miscellaneous acephen * acetaminophen * oral acetaminophen * oral acetaminophen * rectal suppository 120 mg, 650 mg acetaminophen-codeine oral solution acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg acetaminophen-codeine oral tablet 300-60 mg buprenorphine hcl injection

(Acetaminophen with Codeine) (Tylenol-Codeine No.3) (Tylenol-Codeine No.3) (Buprenorphine HCl)

butalb-acetaminophen-caffeine oral (Esgic) capsule 50-325-40 mg (Fioricet with butalbital-acetaminop-caf-cod Codeine) butalbital-acetaminophen butalbital-acetaminophen-caff oral tablet 50-325-40 mg butalbital-aspirin-caffeine oral capsule butorphanol tartrate nasal

QL (2700 per 30 days) QL (360 per 30 days) QL (180 per 30 days)

PA-HRM; QL (180 per 30 days) PA-HRM; QL (180 per 30 days) PA-HRM; QL (180 per 30 days) PA-HRM; QL (180 per 30 days) PA-HRM; QL (180 per 30 days) QL (5 per 28 days)

BUTRANS 2 $0 QL (4 per 28 days) children's mapap * (Acetaminophen) 4 $0 children's non-aspirin * oral (Acetaminophen) 4 $0 children's non-aspirin * oral (Acetaminophen) 4 $0 children's pain & fever relief * oral (Infants' Tylenol) 4 $0 children's pain reliever * oral (Acetaminophen) 4 $0 children's pain reliever * oral (Acetaminophen) 4 $0 You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 16

Tier level

What the drug will cost you

4

$0

1

$0

1

$0

2

$0

(Actiq)

1

$0

(Duragesic)

1

$0

(Duragesic)

1

$0

(Acetaminophen)

4

$0

(Hycet)

1

$0

Name of Drug children's silapap * codeine sulfate oral tablet codeine-butalbital-asa-caffein oral capsule 30-50-325-40 mg DURAMORPH (PF) fentanyl citrate fentanyl transdermal patch 72 hour 100 mcg/hr fentanyl transdermal patch 72 hour 12 mcg/hr, 25 mcg/hr, 37.5 mcg/hour, 50 mcg/hr, 62.5 mcg/hour, 75 mcg/hr, 87.5 mcg/hour feverall * rectal suppository 120 mg, 325 mg, 650 mg hydrocodone-acetaminophen oral solution hydrocodone-acetaminophen oral tablet 10-300 mg, 5-300 mg, 7.5300 mg hydrocodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5325 mg, 7.5-325 mg hydrocodone-ibuprofen hydromorphone (pf) injection solution 10 mg/ml hydromorphone (pf) injection solution 4 mg/ml

(Tylenol Sore Throat) (Codeine Sulfate) (Fiorinal with Codeine #3)

(Norco)

1

$0

(Norco)

1

$0

(Ibudone) (Hydromorphone HCl/PF)

1

$0

1

$0

(Dilaudid)

1

$0

Necessary Actions, Restrictions, or Limits on Use

QL (180 per 30 days) PA-HRM; QL (180 per 30 days) PA; QL (120 per 30 days) PA; QL (20 per 30 days) PA; QL (10 per 30 days)

QL (2700 per 30 days) (includes Vicodin, Vicodin ES and Vicodin HP); QL (390 per 30 days) QL (360 per 30 days) QL (150 per 30 days)

(Hydromorphone 1 $0 HCl) hydromorphone injection syringe 2 (Hydromorphone 1 $0 mg/ml HCl) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. hydromorphone injection solution

Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 17

Tier level

What the drug will cost you

Necessary Actions, Restrictions, or Limits on Use

(Dilaudid)

1

$0

(Dilaudid)

1

$0

QL (1200 per 30 days) QL (180 per 30 days)

(Dilaudid) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen) (Acetaminophen)

1 4 4 4 4 4

$0 $0 $0 $0 $0 $0

2

$0

1

$0

Name of Drug hydromorphone oral liquid hydromorphone oral tablet 2 mg, 4 mg hydromorphone oral tablet 8 mg infant acetaminophen * infantaire * infant's pain reliever * jr. acetaminophen * junior mapap * LAZANDA levorphanol tartrate

(Levorphanol Tartrate)

QL (240 per 30 days)

PA; QL (30 per 30 days) QL (180 per 30 days)

mapap (acetaminophen) * oral (Acetaminophen) 4 $0 capsule mapap (acetaminophen) * oral (Acetaminophen) 4 $0 elixir mapap (acetaminophen) * oral (Tylenol Sore 4 $0 liquid 500 mg/15 ml Throat) mapap (acetaminophen) * oral (Infants' Tylenol) 4 $0 suspension mapap (acetaminophen) * oral (Tylenol) 4 $0 tablet mapap (acetaminophen) * oral (Acetaminophen) 4 $0 tablet,chewable mapap arthritis pain * (Tylenol 8 Hour) 4 $0 mapap extra strength * (Tylenol) 4 $0 methadone hcl oral tablet,soluble QL (90 per 30 days) (Diskets) 1 $0 40 mg methadone injection (Methadone HCl) 1 $0 methadone oral (Methadone HCl) 1 $0 QL (1800 per 30 days) methadone oral (Diskets) 1 $0 QL (360 per 30 days) morphine concentrate oral solution (Msir) 1 $0 QL (200 per 30 days) morphine concentrate oral syringe (Morphine Sulfate) 1 $0 You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 18

Tier level

What the drug will cost you

(Morphine Sulfate)

1

$0

(Morphine Sulfate)

1

$0

(Morphine Sulfate) (Morphine Sulfate)

1 1

$0 $0

(Morphine Sulfate)

1

$0

(Morphine Sulfate) (Msir) (Msir)

1 1 1 1

$0 $0 $0 $0

(MS Contin)

1

$0

(MS Contin)

1

$0

(Morphine Sulfate) (Acetaminophen) (Tylenol Sore Throat)

1 4

$0 $0

4

$0

(Tylenol)

4

$0

(Acetaminophen) (Acetaminophen)

4 4 2 2

$0 $0 $0 $0

1

$0

Name of Drug morphine injection solution 15 mg/ml, 8 mg/ml morphine injection syringe 10 mg/ml, 2 mg/ml morphine intramuscular morphine intravenous morphine intravenous solution 25 mg/ml, 50 mg/ml morphine intravenous morphine oral solution 10 mg/5 ml morphine oral solution 20 mg/5 ml MORPHINE ORAL TABLET morphine oral tablet extended release 100 mg, 30 mg, 60 mg morphine oral tablet extended release 15 mg, 200 mg morphine rectal non-aspirin extra strength * oral non-aspirin extra strength * oral non-aspirin extra strength * oral tablet non-aspirin jr strength * nortemp * oral NUCYNTA NUCYNTA ER oxycodone hcl-acetaminophen oral solution 5-325 mg/5 ml oxycodone hcl-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5325 mg, 7.5-325 mg oxycodone hcl-aspirin oxycodone oral concentrate

(Oxycodone HCl/Acetaminophe n)

Necessary Actions, Restrictions, or Limits on Use

QL (700 per 30 days) QL (300 per 30 days) QL (180 per 30 days) QL (120 per 30 days) QL (180 per 30 days)

QL (181 per 30 days) QL (60 per 30 days) QL (1800 per 30 days) QL (360 per 30 days)

(Xolox)

1

$0

(Percodan) (Oxycodone HCl)

1 1

$0 $0

QL (360 per 30 days) QL (180 per 30 days)

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 19

Tier level

What the drug will cost you

Necessary Actions, Restrictions, or Limits on Use

(Oxycodone HCl) (Percolone)

1 1

$0 $0

QL (1300 per 30 days) QL (180 per 30 days) QL (360 per 30 days)

(Xolox)

1

$0

(Xolox)

1

$0

(Xolox)

1

$0

(Percodan)

1

$0

2

$0

Name of Drug oxycodone oral solution oxycodone oral tablet oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5325 mg, 7.5-325 mg oxycodone-acetaminophen oral tablet 10-650 mg oxycodone-acetaminophen oral tablet 7.5-500 mg oxycodone-aspirin OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 80 MG oxymorphone oral tablet oxymorphone oral tablet extended release 12 hr 10 mg, 15 mg, 20 mg, 5 mg, 7.5 mg oxymorphone oral tablet extended release 12 hr 30 mg, 40 mg pain relief adult * pain relief * oral capsule pain relief * oral tablet extended release pain reliever jr strength * pain reliever * oral pharbetol * q-pap extra strength * q-pap * oral drops

QL (180 per 30 days) QL (240 per 30 days) QL (360 per 30 days) QL (60 per 30 days)

QL (120 per 30 days) 2

$0

(Opana)

1

$0

(Opana ER)

1

$0

(Opana ER)

1

$0

4

$0

4

$0

(Tylenol 8 Hour)

4

$0

(Acetaminophen) (Acetaminophen) (Tylenol) (Tylenol) (Acetaminophen)

4 4 4 4 4

$0 $0 $0 $0 $0

(Tylenol Sore Throat) (Acetaminophen)

QL (180 per 30 days) QL (60 per 30 days) QL (120 per 30 days)

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 20

Name of Drug

Tier level

What the drug will cost you

Necessary Actions, Restrictions, or Limits on Use

(Tylenol Sore 4 $0 Throat) q-pap * oral tablet (Tylenol) 4 $0 silapap * (Acetaminophen) 4 $0 tactinal * (Tylenol) 4 $0 tactinal extra strength * (Tylenol) 4 $0 tramadol oral tablet (Ultram) 1 $0 QL (240 per 30 days) tramadol-acetaminophen (Ultracet) 1 $0 QL (240 per 30 days) xylon 10 (Ibudone) 1 $0 QL (150 per 30 days) Nonsteroidal Anti-Inflammatory Agents advil * oral tablet (Motrin Ib) 4 $0 advil * oral tablet,chewable (Ibuprofen) 4 $0 aspirin * oral tablet (Ecotrin) 4 $0 (Bayer Chewable aspirin * oral tablet,chewable 4 $0 Aspirin) aspirin * oral tablet,delayed release (Ecotrin) 4 $0 (dr/ec) 325 mg, 500 mg, 81 mg aspirin * rectal (Aspirin) 4 $0 (Aspirin/Calcium aspirin, buffered * 4 $0 Carbonate/Mag) aspir-low * (Ecotrin) 4 $0 (Aspirin/Calcium bufferin * oral tablet 325 mg 4 $0 Carbonate/Mag) CALDOLOR INTRAVENOUS 2 $0 RECON SOLN celecoxib (Celebrex) 1 $0 QL (60 per 30 days) (Children'S children's advil * 4 $0 Motrin) (Choline Sal/Mag choline,magnesium salicylate 1 $0 Salicylate) COMFORT PAC-IBUPROFEN 1 $0 COMFORT PAC-MELOXICAM 1 $0 COMFORT PAC-NAPROXEN 1 $0 diclofenac potassium (Cataflam) 1 $0 You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. q-pap * oral liquid

Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 21

Tier level

What the drug will cost you

1

$0

1

$0

1 1 1 4 1

$0 $0 $0 $0 $0

1

$0

2 1

$0 $0

4

$0

4 4

$0 $0

(Ibuprofen)

1

$0

(Motrin Ib)

4

$0

(Ibuprofen)

1

$0

indomethacin oral capsule 25 mg

(Indomethacin)

1

$0

indomethacin oral capsule 50 mg

(Indomethacin)

1

$0

(Indomethacin)

1

$0

(Indocin I.V.) (Infants' Motrin)

1 4 3 1

$0 $0 $0 $0

Name of Drug diclofenac sodium oral tablet extended release 24 hr diclofenac sodium oral tablet,delayed release (dr/ec) diclofenac sodium topical gel diclofenac-misoprostol diflunisal e.c. prin * etodolac fenoprofen oral tablet FLECTOR flurbiprofen ibuprofen * 100 mg/5 ml susp children's (otc) ibuprofen jr strength * ibuprofen * oral ibuprofen oral suspension 100 mg/5 ml ibuprofen * oral tablet 100 mg, 200 mg ibuprofen oral tablet 400 mg, 600 mg, 800 mg

indomethacin oral capsule, extended release indomethacin sodium infant's ibuprofen * INFANT'S MOTRIN * ketoprofen oral capsule

(Voltaren-XR) (Diclofenac Sodium) (Solaraze) (Arthrotec 50) (Diflunisal) (Ecotrin) (Etodolac) (Fenoprofen Calcium) (Ansaid) (Children'S Motrin) (Ibuprofen) (Advil)

(Ketoprofen)

Necessary Actions, Restrictions, or Limits on Use

PA

PA-HRM; QL (240 per 30 days) PA-HRM; QL (120 per 30 days) PA-HRM; QL (60 per 30 days) PA-HRM

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 22

Tier level

What the drug will cost you

(Ketoprofen)

1

$0

(Toradol)

1

$0

(Toradol)

1

$0

1

$0

1

$0

1

$0

1

$0

1 1 1 1 1

$0 $0 $0 $0 $0

(Ec-Naprosyn)

1

$0

(Anaprox)

1

$0

(Feldene) (Salsalate)

1 1

$0 $0

4

$0

4

$0

4 1 1

$0 $0 $0

4

$0

Name of Drug ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg ketorolac injection cartridge 15 mg/ml ketorolac injection cartridge 30 mg/ml ketorolac injection solution 15 mg/ml ketorolac injection solution 30 mg/ml (1 ml) ketorolac intramuscular solution ketorolac oral mefenamic acid meloxicam nabumetone naproxen oral suspension naproxen oral tablet naproxen oral tablet,delayed release (dr/ec) naproxen sodium oral tablet 275 mg, 550 mg piroxicam salsalate sb aspirin * 325 mg tablet na/f, caffeine-free st joseph aspirin * st. joseph aspirin * sulindac oral tolmetin tri-buffered aspirin *

(Ketorolac Tromethamine) (Ketorolac Tromethamine) (Ketorolac Tromethamine) (Ketorolac Tromethamine) (Ponstel) (Mobic) (Nabumetone) (Naprosyn) (Naprosyn)

(Bayer Chewable Aspirin) (Ecotrin) (Sulindac) (Tolmetin Sodium) (Aspirin/Calcium Carbonate/Mag)

Necessary Actions, Restrictions, or Limits on Use

QL (40 per 30 days) QL (20 per 30 days) QL (40 per 30 days) QL (20 per 30 days) QL (20 per 30 days) QL (20 per 30 days)

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 23

Tier level

What the drug will cost you

(Advil)

2 4

$0 $0

glydo

(Lidocaine HCl)

1

$0

lidocaine (pf) injection solution

(Xylocaine-MPF)

1

$0

lidocaine hcl injection solution

(Xylocaine)

1

$0

lidocaine hcl laryngotracheal lidocaine hcl mucous membrane gel lidocaine hcl mucous membrane jelly in applicator lidocaine hcl mucous membrane solution lidocaine hcl urethral lidocaine topical adhesive patch,medicated

(Xylocaine) (Lidocaine HCl)

1 1

$0 $0

(Lidocaine HCl)

1

$0

(Xylocaine)

1

$0

(Lidocaine HCl)

1

$0

(Lidoderm)

1

$0

lidocaine topical ointment

(Lidocaine)

1

$0

lidocaine-prilocaine topical

(EMLA)

1

$0

lidocaine-prilocaine topical kit RELADOR PAK

(Relador Pak)

1 1

$0 $0

Anti-Addiction/Substance Abuse Treatment Agents acamprosate (Campral)

1

$0

buprenorphine hcl sublingual

1

$0

1

$0

1

$0

Name of Drug VOLTAREN TOPICAL wal-profen * oral

Necessary Actions, Restrictions, or Limits on Use

Anesthetics Local Anesthetics PA BvD; (PA for ESRD Only) PA BvD; (PA for ESRD Only)

PA PA BvD; (PA for ESRD Only) PA BvD; (PA for ESRD Only) PA BvD PA BvD

Anti-Addiction/Substance Abuse Treatment Agents

buprenorphine-naloxone bupropion hcl sr 150 mg tablet f/c

(Subutex) (Buprenorphine HCl/Naloxone HCl) (Zyban)

PA; QL (90 per 30 days) PA; QL (90 per 30 days)

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 24

Name of Drug CHANTIX CHANTIX CONTINUING MONTH BOX CHANTIX CONTINUING MONTH PAK CHANTIX STARTING MONTH BOX disulfiram naloxone naltrexone hcl naltrexone NICODERM CQ * TRANSDERMAL PATCH 24 HOUR 14 MG/24 HR, 21 MG/24 HR NICODERM CQ * TRANSDERMAL PATCH 24 HOUR 7 MG/24 HR nicorelief * buccal gum nicorette * buccal gum 2 mg nicotine (polacrilex) * nicotine * transdermal patch 24 hour 14 mg/24 hr, 7 mg/24 hr nicotine * transdermal patch 24 hour 21 mg/24 hr, 22 mg/24 hr NICOTROL ZUBSOLV SUBLINGUAL TABLET 1.4-0.36 MG ZUBSOLV SUBLINGUAL TABLET 11.4-2.9 MG ZUBSOLV SUBLINGUAL TABLET 2.9-0.71 MG, 8.6-2.1 MG ZUBSOLV SUBLINGUAL TABLET 5.7-1.4 MG

(Antabuse) (Naloxone HCl) (Revia) (Revia)

Tier level

What the drug will cost you

2

$0

2

$0

2

$0

2

$0

1 1 1 1

$0 $0 $0 $0

Necessary Actions, Restrictions, or Limits on Use QL (168 per 84 days) QL (56 per 28 days) QL (56 per 28 days) QL (53 per 28 days)

QL (168 per 365 days) 4

$0

4

$0

(Nicorette) (Nicorette) (Nicorette)

4 4 4

$0 $0 $0

(Nicoderm Cq)

4

$0

(Nicoderm Cq)

4

$0

2

$0

2

$0

2

$0

2

$0

2

$0

QL (180 per 365 days) QL (168 per 365 days)

PA; QL (120 per 30 days) PA; QL (30 per 30 days) PA; QL (60 per 30 days) PA; QL (90 per 30 days)

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 25

Tier level

What the drug will cost you

(Xanax)

1

$0

(Xanax XR)

1

$0

(Xanax XR)

1

$0

(Alprazolam)

1

$0

(Chlordiazepoxide HCl)

1

$0

(Klonopin)

1

$0

(Klonopin)

1

$0

(Clonazepam)

1

$0

(Clonazepam)

1

$0

(Tranxene T-Tab)

1

$0

(Tranxene T-Tab)

1

$0

2

$0

1 1 1 1 1

$0 $0 $0 $0 $0

Name of Drug

Necessary Actions, Restrictions, or Limits on Use

Antianxiety Agents Benzodiazepines alprazolam oral tablet alprazolam oral tablet extended release 24 hr 0.5 mg alprazolam oral tablet extended release 24 hr 1 mg, 2 mg, 3 mg alprazolam oral tablet,disintegrating chlordiazepoxide hcl clonazepam oral tablet 0.5 mg, 1 mg clonazepam oral tablet 2 mg clonazepam oral tablet,disintegrating 0.125 mg, 0.25 mg, 0.5 mg, 1 mg clonazepam oral tablet,disintegrating 2 mg clorazepate dipotassium oral tablet 15 mg clorazepate dipotassium oral tablet 3.75 mg, 7.5 mg DIASTAT ACUDIAL RECTAL KIT 12.5-15-17.5-20 MG diazepam injection diazepam intensol diazepam oral solution diazepam oral tablet diazepam rectal

(Diazepam) (Diazepam) (Diazepam) (Valium) (Diastat Acudial)

QL (90 per 30 days) QL (90 per 30 days) QL (60 per 30 days) QL (90 per 30 days) QL (120 per 30 days) QL (90 per 30 days) QL (300 per 30 days) QL (90 per 30 days) QL (300 per 30 days) QL (120 per 30 days) QL (60 per 30 days)

QL (10 per 28 days) QL (1200 per 30 days) QL (1200 per 30 days) QL (120 per 30 days)

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 26

Name of Drug

Tier level

What the drug will cost you

estazolam oral tablet 1 mg

(Estazolam)

1

$0

estazolam oral tablet 2 mg

(Estazolam)

1

$0

flurazepam oral capsule 15 mg

(Flurazepam HCl)

1

$0

Necessary Actions, Restrictions, or Limits on Use PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (60 per 30 days) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (30 per 30 days) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (60 per 30 days)

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 27

Name of Drug

Tier level

What the drug will cost you

flurazepam oral capsule 30 mg

(Flurazepam HCl)

1

$0

lorazepam oral solution lorazepam injection solution lorazepam injection syringe lorazepam oral tablet

(Ativan) (Ativan) (Ativan) (Ativan) (Midazolam HCl/PF) (Midazolam HCl/PF) (Midazolam HCl)

1 1 1 1

$0 $0 $0 $0

1

$0

1

$0

1

$0

ONFI ORAL SUSPENSION

2

$0

ONFI ORAL TABLET 10 MG, 20 MG

2

$0

1

$0

midazolam (pf) injection midazolam (pf) injection syringe 2 mg/2 ml (1 mg/ml) midazolam oral syrup 2 mg/ml

temazepam oral capsule 15 mg, 22.5 mg, 30 mg

(Restoril)

Necessary Actions, Restrictions, or Limits on Use PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (30 per 30 days) QL (150 per 30 days) QL (2 per 30 days) QL (2 per 30 days) QL (90 per 30 days) QL (2 per 30 days) QL (2 per 30 days) QL (10 per 30 days) PA NSO; QL (480 per 30 days) PA NSO; QL (60 per 30 days) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (30 per 30 days)

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 28

Name of Drug

Tier level

What the drug will cost you

temazepam oral capsule 7.5 mg

(Restoril)

1

$0

triazolam oral tablet 0.125 mg

(Halcion)

1

$0

triazolam oral tablet 0.25 mg

(Halcion)

1

$0

2

$0

1

$0

Necessary Actions, Restrictions, or Limits on Use PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (120 per 30 days) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (120 per 30 days) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (60 per 30 days)

Antibacterials Aminoglycosides BETHKIS gentamicin in nacl (iso-osm) intravenous piggyback

(Gentamicin In Nacl, Iso-Osm)

PA BvD

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 29

Tier level

What the drug will cost you

(Garamycin) (Gentamicin Sulfate/PF) (Gentamicin Sulfate/PF) (Neomycin Sulfate) (Streptomycin Sulfate)

1

$0

1

$0

1

$0

1

$0

1

$0

TOBI PODHALER INHALATION tobramycin in 0.225 % nacl (Tobi) (Tobramycin/Sodiu tobramycin in 0.9 % nacl m Chloride) tobramycin sulfate injection (Nebcin) solution Antibacterials, Miscellaneous bacitracin intramuscular (Bacitracin) (Chloramphenicol chloramphenicol sod succinate Sod Succ) clindamycin hcl (Cleocin HCl) (Cleocin Phosphate clindamycin in 5 % dextrose In D5w) clindamycin palmitate hcl (Cleocin Palmitate) (Cleocin clindamycin phosphate injection Phosphate) clindamycin phosphate intravenous (Cleocin solution Phosphate) (Coly-Mycin M colistin (colistimethate na) Parenteral) CUBICIN linezolid (Zyvox) methenamine hippurate (Hiprex) methenamine mandelate oral tablet (Methenamine 1 gram Mandelate)

2 1

$0 $0

1

$0

1

$0

1

$0

1

$0

1

$0

1

$0

1

$0

1

$0

1

$0

1

$0

2 1 1

$0 $0 $0

1

$0

Name of Drug gentamicin injection solution gentamicin sulfate (ped) (pf) gentamicin sulfate (pf) intravenous solution neomycin streptomycin intramuscular

Necessary Actions, Restrictions, or Limits on Use

QL (224 per 28 days) PA BvD

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 30

Name of Drug

Tier level

What the drug will cost you

nitrofurantoin macrocrystal oral capsule 100 mg

(Macrodantin)

1

$0

nitrofurantoin macrocrystal oral capsule

(Macrodantin)

1

$0

nitrofurantoin monohyd/m-cryst

(Macrobid)

1

$0

2 1

$0 $0

1

$0

1

$0

1

$0

1

$0

2

$0

2

$0

2

$0

1

$0

SYNERCID trimethoprim vancomycin in d5w intravenous piggyback vancomycin intravenous recon soln 1,000 mg, 10 gram, 750 mg vancomycin intravenous recon soln 500 mg vancomycin oral capsule XIFAXAN ORAL TABLET 200 MG XIFAXAN ORAL TABLET 550 MG ZYVOX ORAL Cephalosporins cefaclor oral capsule

(Trimethoprim) (Vancomycin HCl/D5W) (Vancomycin HCl) (Vancomycin HCl/D5W) (Vancocin HCl)

(Cefaclor)

Necessary Actions, Restrictions, or Limits on Use PA-HRM; QL (120 per 30 days) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (120 per 30 days) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use of nitrofurantoin drugs); QL (120 per 30 days)

PA; QL (9 per 30 days) ST; QL (60 per 30 days)

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 31

Tier level

What the drug will cost you

(Cefaclor)

1

$0

(Cefadroxil)

1

$0

(Cefadroxil)

1

$0

(Cefadroxil)

1

$0

(Cefazolin Sodium)

1

$0

1

$0

1

$0

(Cefazolin Sodium)

1

$0

(Cefazolin Sodium) (Cefdinir) (Spectracef) (Maxipime)

1 1 1 1 2

$0 $0 $0 $0 $0

2

$0

1 1

$0 $0

1

$0

1

$0

1 1

$0 $0

Name of Drug cefaclor oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml cefadroxil oral capsule cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml cefadroxil oral tablet cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml cefazolin in dextrose (iso-os) intravenous piggyback 2 gram/50 ml cefazolin injection recon soln cefazolin injection recon soln 100 gram, 300 g cefazolin intravenous cefdinir cefditoren pivoxil cefepime CEFEPIME IN DEXTROSE 5 % CEFEPIME IN DEXTROSE,ISOOSM INTRAVENOUS PIGGYBACK cefotaxime cefoxitin cefoxitin in dextrose, iso-osm intravenous piggyback 2 gram/50 ml cefpodoxime cefprozil ceftazidime

(Cefazolin Sodium/Dextrose, Iso) (Ancef)

(Claforan) (Mefoxin) (Cefoxitin Sodium/Dextrose, Iso) (Cefpodoxime Proxetil) (Cefprozil) (Fortaz)

Necessary Actions, Restrictions, or Limits on Use

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 32

Tier level

What the drug will cost you

(Fortaz)

1

$0

(Cedax)

1

$0

(Ceftriaxone Na/Dextrose, Iso)

1

$0

1

$0

1

$0

1

$0

1

$0

(Ceftin)

1

$0

(Zinacef)

1

$0

(Zinacef) (Cefuroxime Sodium/Dextrose, Iso) (Keflex)

1

$0

1

$0

1

$0

(Cephalexin)

1

$0

(Cephalexin)

1

$0

2

$0

2

$0

2

$0

2

$0

1

$0

Name of Drug ceftazidime injection recon soln 2 gram, 6 gram ceftibuten ceftriaxone in dextrose,iso-os intravenous piggyback 1 gram/50 ml CEFTRIAXONE IN DEXTROSE,ISO-OS INTRAVENOUS PIGGYBACK 2 GRAM/50 ML ceftriaxone injection recon soln ceftriaxone intravenous recon soln 1 gram CEFTRIAXONE INTRAVENOUS RECON SOLN 2 GRAM cefuroxime axetil oral tablet cefuroxime sodium injection recon soln 1.5 gram, 750 mg cefuroxime sodium intravenous cefuroxime-dextrose (iso-osm) cephalexin oral capsule cephalexin oral suspension for reconstitution cephalexin oral tablet MEFOXIN IN DEXTROSE (ISOOSM) SUPRAX ORAL TABLET SUPRAX ORAL TABLET,CHEWABLE TEFLARO Macrolides azithromycin

(Rocephin) (Ceftriaxone Na/Dextrose, Iso)

(Zithromax)

Necessary Actions, Restrictions, or Limits on Use

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 33

Tier level

What the drug will cost you

(Biaxin)

1

$0

(Biaxin)

1

$0

(Biaxin XL)

1

$0

2 2

$0 $0

1

$0

1

$0

1

$0

1

$0

1

$0

1

$0

1

$0

1 2 1 2 1

$0 $0 $0 $0 $0

1

$0

1

$0

Name of Drug clarithromycin oral suspension for reconstitution clarithromycin oral tablet clarithromycin oral tablet extended release 24 hr DIFICID ERYTHROCIN erythromycin base oral tablet,delayed release (dr/ec) 250 mg, 500 mg ERYTHROMYCIN BASE ORAL TABLET,DELAYED RELEASE (DR/EC) 333 MG erythromycin ethylsuccinate oral suspension for reconstitution 200 mg/5 ml erythromycin ethylsuccinate oral tablet 400 mg erythromycin oral capsule,delayed release(dr/ec)

(Erythromycin Base)

(Eryped 200)

(Erythromycin Ethylsuccinate) (Erythromycin Base) (Erythromycin erythromycin oral tablet Base) erythromycin stearate oral tablet (Erythromycin 250 mg Stearate) Miscellaneous B-Lactam Antibiotics aztreonam (Azactam) CAYSTON imipenem-cilastatin (Primaxin) INVANZ meropenem (Merrem) Penicillins amoxicillin oral capsule (Amoxicillin) amoxicillin oral suspension for (Amoxil) reconstitution

Necessary Actions, Restrictions, or Limits on Use

QL (20 per 10 days)

LA

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 34

Tier level

What the drug will cost you

(Amoxicillin)

1

$0

(Amoxicillin)

1

$0

(Augmentin)

1

$0

(Augmentin)

1

$0

(Augmentin XR)

1

$0

1

$0

1

$0

(Totacillin-N)

1

$0

(Totacillin-N)

1

$0

(Unasyn)

1

$0

(Unasyn)

1

$0

2 2

$0 $0

1

$0

2

$0

1 1

$0 $0

1

$0

1 1

$0 $0

Name of Drug amoxicillin oral tablet amoxicillin oral tablet,chewable 125 mg, 250 mg amoxicillin-pot clavulanate oral suspension for reconstitution amoxicillin-pot clavulanate oral tablet amoxicillin-pot clavulanate oral tablet extended release 12 hr amoxicillin-pot clavulanate oral tablet,chewable ampicillin ampicillin sodium injection recon soln ampicillin sodium intravenous recon soln ampicillin-sulbactam injection ampicillin-sulbactam intravenous recon soln BICILLIN C-R BICILLIN L-A dicloxacillin nafcillin in dextrose iso-osm nafcillin injection nafcillin intravenous recon soln oxacillin in dextrose(iso-osm) oxacillin injection recon soln oxacillin intravenous recon soln

(Amoxicillin/Potas sium Clav) (Ampicillin Trihydrate)

(Dicloxacillin Sodium) (Nafcillin In Dextrose,Iso-Osm) (Unipen) (Nallpen) (Oxacillin Sodium/Dextrose, Iso) (Oxacillin Sodium) (Oxacillin Sodium)

Necessary Actions, Restrictions, or Limits on Use

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 35

Tier level

What the drug will cost you

1

$0

1

$0

1

$0

1

$0

1

$0

(Cipro) (Cipro) (Cipro I.V.)

1 1 1

$0 $0 $0

(Cipro I.V.)

1

$0

(Levaquin)

1

$0

(Levofloxacin) (Levaquin) (Avelox) (Ofloxacin)

1 1 1 1

$0 $0 $0 $0

(Sulfadiazine) (Sulfamethoxazole/ Trimethoprim) (Sulfamethoxazole/ Trimethoprim)

1

$0

1

$0

1

$0

(Bactrim)

1

$0

(Azulfidine) (Sulfamethoxazole/ Trimethoprim) (Azulfidine)

1

$0

1

$0

1

$0

Name of Drug

penicillin g pot in dextrose penicillin g potassium penicillin g procaine penicillin v potassium piperacillin-tazobactam Quinolones ciprofloxacin ciprofloxacin hcl oral ciprofloxacin in 5 % dextrose ciprofloxacin lactate intravenous solution 400 mg/40 ml levofloxacin in d5w intravenous piggyback levofloxacin intravenous levofloxacin oral moxifloxacin ofloxacin oral Sulfonamides sulfadiazine oral sulfamethoxazole-trimethoprim intravenous sulfamethoxazole-trimethoprim oral suspension sulfamethoxazole-trimethoprim oral tablet sulfasalazine sulfatrim sulfazine

(Pen G Pot/DextroseWater) (Penicillin G Potassium) (Penicillin G Procaine) (Penicillin V Potassium) (Zosyn)

Necessary Actions, Restrictions, or Limits on Use

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 36

Tier level

What the drug will cost you

(Azulfidine)

1

$0

(Morgidox)

1

$0

(Doryx) (Doxycycline Hyclate)

1

$0

1

$0

(Adoxa)

1

$0

(Morgidox)

1

$0

(Adoxa)

1

$0

(Doryx)

1

$0

(Adoxa)

1

$0

(Vibramycin)

1

$0

(Adoxa)

1

$0

(Minocin) (Minocycline HCl) (Ala-Tet)

1 1 1 2

$0 $0 $0 $0

2

$0

Name of Drug sulfazine ec Tetracyclines doxycycline hyclate oral capsule 100 mg doxycycline hyclate 100 mg tab f/c doxycycline hyclate intravenous doxycycline hyclate oral capsule 100 mg doxycycline hyclate oral capsule 50 mg doxycycline hyclate oral tablet 100 mg, 50 mg doxycycline hyclate oral tablet 20 mg doxycycline monohydrate oral capsule doxycycline monohydrate oral suspension for reconstitution doxycycline monohydrate oral tablet minocycline oral capsule minocycline oral tablet tetracycline TYGACIL

Necessary Actions, Restrictions, or Limits on Use

Anticancer Agents Anticancer Agents ABRAXANE

PA NSO; QL (4 per 21 days) PA NSO; QL (112 per AFINITOR DISPERZ 2 $0 28 days) AFINITOR ORAL TABLET 10 PA NSO; QL (56 per 2 $0 MG 28 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. ADCETRIS

2

$0

Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 37

Name of Drug AFINITOR ORAL TABLET 2.5 MG, 5 MG, 7.5 MG ALIMTA INTRAVENOUS RECON SOLN anastrozole ARRANON ARZERRA AVASTIN azacitidine BELEODAQ

(Arimidex)

(Vidaza)

Tier level

What the drug will cost you

2

$0

2

$0

1 2 2 2 1 2

$0 $0 $0 $0 $0 $0

bexarotene

(Targretin)

1

$0

bicalutamide

(Casodex) (Bleomycin Sulfate)

1

$0

1

$0

2

$0

2

$0

2

$0

2

$0

2

$0

1 1

$0 $0

2

$0

1

$0

2

$0

bleomycin BLINCYTO BOSULIF ORAL TABLET 100 MG BOSULIF ORAL TABLET 500 MG CAPRELSA ORAL TABLET 100 MG CAPRELSA ORAL TABLET 300 MG carboplatin intravenous solution cisplatin

(Carboplatin) (Cisplatin)

COMETRIQ cyclophosphamide intravenous recon soln CYCLOPHOSPHAMIDE ORAL CAPSULE

(Cyclophosphamid e)

Necessary Actions, Restrictions, or Limits on Use PA NSO; QL (28 per 28 days)

PA NSO PA NSO PA NSO PA NSO; QL (420 per 30 days) PA BvD PA NSO; QL (140 per 365 days) PA NSO; QL (120 per 30 days) PA NSO; QL (30 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (30 per 30 days)

PA NSO; QL (112 per 28 days) PA BvD PA BvD; ST

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 38

Tier level

What the drug will cost you

1

$0

(Cytarabine) (Cytarabine/PF) (Cytarabine/PF) (Dtic-Dome IV) (Dactinomycin) (Dacogen)

2 1 1 1 1 1 1

$0 $0 $0 $0 $0 $0 $0

(Doxorubicin HCl)

1

$0

(Doxil)

1

$0

(Doxil)

1 2

$0 $0

2

$0

2

$0

2

$0

2

$0

2

$0

1

$0

2

$0

ERIVEDGE

2

$0

ETOPOPHOS etoposide intravenous exemestane FARESTON

2 1 1 2

$0 $0 $0 $0

Name of Drug cyclophosphamide oral tablet CYRAMZA cytarabine cytarabine (pf) injection recon soln cytarabine (pf) injection solution dacarbazine intravenous recon soln dactinomycin decitabine doxorubicin hcl intravenous recon soln 10 mg doxorubicin hcl peg-liposomal intravenous suspension 2 mg/ml doxorubicin, peg-liposomal DROXIA ELIGARD SUBCUTANEOUS SYRINGE 22.5 MG (3 MONTH) ELIGARD SUBCUTANEOUS SYRINGE 30 MG (4 MONTH) ELIGARD SUBCUTANEOUS SYRINGE 45 MG (6 MONTH) ELIGARD SUBCUTANEOUS SYRINGE 7.5 MG (1 MONTH) EMCYT epirubicin intravenous solution 50 mg/25 ml ERBITUX

(Cyclophosphamid e)

(Ellence)

(Etoposide) (Aromasin)

Necessary Actions, Restrictions, or Limits on Use PA BvD; ST PA NSO PA BvD PA BvD PA BvD

PA BvD PA BvD PA BvD QL (1 per 84 days) QL (1 per 112 days) QL (1 per 168 days) QL (1 per 28 days)

PA NSO PA NSO; QL (30 per 30 days)

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 39

Tier level

What the drug will cost you

Necessary Actions, Restrictions, or Limits on Use

FARYDAK

2

$0

PA NSO; QL (6 per 21 days)

FASLODEX FIRMAGON KIT W DILUENT SYRINGE floxuridine fludarabine fluorouracil intravenous solution 2.5 gram/50 ml, 5 gram/100 ml, 500 mg/10 ml flutamide

2

$0

2

$0

(FUDR) (Fludara)

1 1

$0 $0

(Fluorouracil)

1

$0

(Flutamide)

1

$0

GAZYVA

2

$0

gemcitabine intravenous recon soln (Gemzar) 1 gram

1

$0

GILOTRIF

2

$0

2

$0

2

$0

HALAVEN

2

$0

HERCEPTIN HEXALEN hydroxyurea

2 2 1

$0 $0 $0

IBRANCE

2

$0

ICLUSIG ORAL TABLET 15 MG

2

$0

ICLUSIG ORAL TABLET 45 MG

2

$0

1 1

$0 $0

Name of Drug

PA BvD

GLEEVEC ORAL TABLET 100 MG GLEEVEC ORAL TABLET 400 MG

ifosfamide intravenous recon soln ifosfamide intravenous solution

PA BvD

(Hydrea)

(Ifex) (Ifex)

PA NSO; QL (40 per 28 days)

PA NSO; QL (30 per 30 days) PA NSO; QL (90 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (24 per 28 days) PA NSO

PA NSO; QL (21 per 28 days) PA NSO; QL (60 per 30 days) PA NSO; QL (30 per 30 days) PA BvD PA BvD

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 40

Tier level

What the drug will cost you

1

$0

IMBRUVICA

2

$0

INLYTA ORAL TABLET 1 MG

2

$0

INLYTA ORAL TABLET 5 MG

2

$0

IRESSA

2

$0

ISTODAX IXEMPRA

2 2

$0 $0

JAKAFI

2

$0

JEVTANA KADCYLA KEYTRUDA

2 2 2

$0 $0 $0

KYPROLIS

2

$0

LENVIMA letrozole LEUKERAN

2 1 2

$0 $0 $0

1

$0

1 2 2 2 2 2

$0 $0 $0 $0 $0 $0

2

$0

Name of Drug ifosfamide-mesna

leuprolide lomustine LUPRON DEPOT LUPRON DEPOT (3 MONTH) LUPRON DEPOT (4 MONTH) LUPRON DEPOT (6 MONTH) LUPRON DEPOT-PED LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT

(Ifosfamide/Mesna )

(Femara) (Leuprolide Acetate) (Gleostine)

Necessary Actions, Restrictions, or Limits on Use PA BvD PA NSO; QL (120 per 30 days) PA NSO; QL (180 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (60 per 30 days) PA NSO PA NSO; QL (60 per 30 days) PA NSO PA NSO PA NSO; QL (6 per 28 days) PA NSO

QL (1 per 28 days) QL (1 per 84 days) QL (1 per 84 days) QL (1 per 168 days) QL (1 per 28 days) QL (1 per 84 days)

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 41

Tier level

What the drug will cost you

LYNPARZA

2

$0

LYSODREN

2

$0

MARQIBO

2

$0

MATULANE MEGACE ES megestrol oral suspension 400 mg/10 ml (40 mg/ml), 625 mg/5 ml

2 2

$0 $0

(Megace Es)

1

$0

(Megestrol Acetate)

1

$0

MEKINIST ORAL TABLET 0.5 MG

2

$0

MEKINIST ORAL TABLET 2 MG

2

$0

1 1

$0 $0

1

$0

1

$0

1

$0

1

$0

1

$0

1

$0

MUSTARGEN

2

$0

NEXAVAR

2

$0

NILANDRON ONCASPAR

2 2

$0 $0

Name of Drug

megestrol oral tablet

melphalan hcl intravenous mercaptopurine methotrexate sodium (pf) injection recon soln methotrexate sodium (pf) injection solution methotrexate sodium injection methotrexate sodium oral mitomycin intravenous recon soln mitoxantrone

(Alkeran) (Purinethol) (Methotrexate Sodium/PF) (Methotrexate Sodium) (Methotrexate Sodium) (Methotrexate Sodium) (Mitomycin) (Mitoxantrone HCl)

Necessary Actions, Restrictions, or Limits on Use PA NSO; QL (480 per 30 days) PA NSO; QL (4 per 28 days)

PA NSO; QL (90 per 30 days) PA NSO; QL (30 per 30 days)

PA BvD PA BvD PA BvD PA BvD; ST PA BvD

PA NSO; QL (120 per 30 days) PA NSO

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 42

Tier level

What the drug will cost you

2

$0

1

$0

1 2

$0 $0

POMALYST

2

$0

PROLEUKIN PURIXAN

2 2

$0 $0

REVLIMID

2

$0

RITUXAN SOLTAMOX SPRYCEL ORAL TABLET 100 MG, 140 MG, 50 MG, 70 MG, 80 MG

2 2

$0 $0

2

$0

SPRYCEL ORAL TABLET 20 MG

2

$0

STIVARGA

2

$0

SUTENT

2

$0

SYLVANT

2

$0

SYNRIBO

2

$0

TABLOID

2

$0

TAFINLAR

2

$0

1

$0

2

$0

Name of Drug OPDIVO INTRAVENOUS SOLUTION 40 MG/4 ML oxaliplatin intravenous solution 100 (Eloxatin) mg/20 ml paclitaxel (Paclitaxel) PERJETA

(Tamoxifen Citrate)

tamoxifen TARCEVA ORAL TABLET 100 MG, 25 MG

Necessary Actions, Restrictions, or Limits on Use PA NSO

PA NSO PA NSO; QL (21 per 28 days)

PA NSO; LA; QL (21 per 28 days) PA NSO PA NSO; QL (30 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (84 per 28 days) PA NSO; QL (30 per 30 days) PA NSO PA NSO; QL (28 per 28 days) PA NSO; QL (120 per 30 days)

PA NSO; QL (60 per 30 days)

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 43

Tier level

What the drug will cost you

TARCEVA ORAL TABLET 150 MG

2

$0

TARGRETIN TOPICAL

2

$0

TASIGNA

2

$0

TEMODAR INTRAVENOUS toposar intravenous topotecan intravenous

2 1 1

$0 $0 $0

2

$0

2

$0

2

$0

Name of Drug

(Etoposide) (Hycamtin)

TORISEL TREANDA INTRAVENOUS RECON SOLN TREANDA INTRAVENOUS SOLUTION TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION TRELSTAR INTRAMUSCULAR SYRINGE 11.25 MG/2 ML TRELSTAR INTRAMUSCULAR SYRINGE 22.5 MG/2 ML TRELSTAR INTRAMUSCULAR SYRINGE 3.75 MG/2 ML tretinoin (chemotherapy) TREXALL TYKERB UNITUXIN VALSTAR VECTIBIX VELCADE vinblastine intravenous

Necessary Actions, Restrictions, or Limits on Use PA NSO; QL (90 per 30 days) PA NSO; QL (60 per 28 days) PA NSO; QL (112 per 28 days) PA NSO; (vial only)

PA BvD; QL (4 per 28 days)

QL (1 per 168 days)

(Tretinoin)

(Vinblastine Sulfate)

2

$0

2

$0

2

$0

2

$0

1 2 2 2 2 2 2

$0 $0 $0 $0 $0 $0 $0

1

$0

QL (1 per 84 days) QL (1 per 168 days) QL (1 per 28 days) (capsule: 10mg) PA BvD; ST PA NSO PA NSO PA NSO PA BvD

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 44

Tier level

What the drug will cost you

1

$0

1

$0

1

$0

VOTRIENT

2

$0

XALKORI

2

$0

XTANDI

2

$0

YERVOY ZALTRAP INTRAVENOUS SOLUTION

2

$0

2

$0

ZELBORAF

2

$0

2

$0

2

$0

2

$0

ZYDELIG

2

$0

ZYKADIA

2

$0

ZYTIGA

2

$0

1

$0

1

$0

Name of Drug vincristine vincristine sulfate intravenous solution 1 mg/ml vinorelbine intravenous solution

(Vincristine Sulfate) (Vincristine Sulfate) (Navelbine)

ZOLADEX SUBCUTANEOUS IMPLANT 10.8 MG ZOLADEX SUBCUTANEOUS IMPLANT 3.6 MG ZOLINZA

Necessary Actions, Restrictions, or Limits on Use PA BvD PA BvD

PA NSO; QL (120 per 30 days) PA NSO; QL (60 per 30 days) PA NSO; QL (120 per 30 days) PA NSO PA NSO PA NSO; QL (240 per 30 days) QL (1 per 84 days) QL (1 per 28 days)

PA NSO; QL (60 per 30 days) PA NSO; QL (140 per 28 days) PA NSO; QL (120 per 30 days)

Anticholinergic Agents Antimuscarinics/Antispasmodics atropine injection solution 0.4 (Atropine Sulfate) mg/ml atropine injection syringe 0.05 (Atropine Sulfate) mg/ml, 0.1 mg/ml

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 45

Tier level

What the drug will cost you

1

$0

(Tegretol)

2 2 1

$0 $0 $0

(Carbatrol)

1

$0

(Tegretol)

1

$0

(Tegretol XR)

1

$0

(Carbamazepine)

1

$0

2

$0

Name of Drug propantheline

(Propantheline Bromide)

Necessary Actions, Restrictions, or Limits on Use

Anticonvulsants Anticonvulsants APTIOM BANZEL carbamazepine carbamazepine oral capsule, er multiphase 12 hr carbamazepine oral suspension carbamazepine oral tablet extended release 12 hr carbamazepine oral tablet,chewable CELONTIN ORAL CAPSULE 300 MG DILANTIN CAPSULE 30 MG divalproex oral capsule, sprinkle divalproex oral tablet extended release 24 hr divalproex oral tablet,delayed release (dr/ec) ethosuximide felbamate fosphenytoin FYCOMPA ORAL TABLET gabapentin oral capsule gabapentin oral solution gabapentin oral tablet 600 mg, 800 mg GABITRIL ORAL TABLET 12 MG, 16 MG

2

$0

(Depakote Sprinkle)

1

$0

(Depakote ER)

1

$0

(Depakote)

1

$0

(Zarontin) (Felbatol) (Cerebyx) (Neurontin) (Neurontin)

1 1 1 2 1 1

$0 $0 $0 $0 $0 $0

(Neurontin)

1

$0

2

$0

ST ST

ST

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 46

Tier level

What the drug will cost you

2

$0

(Lamictal)

1

$0

(Lamictal XR)

1

$0

(Lamictal)

1

$0

(Lamictal (Blue))

1

$0

(Keppra) (Keppra) (Keppra)

1 1 1

$0 $0 $0

(Keppra XR)

1

$0

(Phenobarbital)

2 2 1 2 2 1

$0 $0 $0 $0 $0 $0

(Phenobarbital)

1

$0

(Phenobarbital) (Phenobarbital Sodium)

1

$0

1

$0

(Dilantin-125)

1

$0

(Dilantin) (Phenytoin Sodium) (Dilantin)

1

$0

1

$0

1

$0

Name of Drug LAMICTAL ORAL TABLET, CHEWABLE DISPERSIBLE 2 MG lamotrigine oral tablet lamotrigine oral tablet extended release 24hr lamotrigine oral tablet, chewable dispersible lamotrigine oral tablets,dose pack 25 mg (35) levetiracetam intravenous levetiracetam oral solution levetiracetam oral tablet levetiracetam oral tablet extended release 24 hr LYRICA ORAL CAPSULE LYRICA ORAL SOLUTION oxcarbazepine OXTELLAR XR PEGANONE phenobarbital oral elixir phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg phenobarbital oral tablet 30 mg phenobarbital sodium injection solution phenytoin oral suspension 125 mg/5 ml phenytoin oral phenytoin sodium phenytoin sodium extended

(Trileptal)

Necessary Actions, Restrictions, or Limits on Use

QL (90 per 30 days) QL (900 per 30 days) ST QL (1500 per 30 days) QL (90 per 30 days) QL (200 per 30 days) QL (2 per 30 days)

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 47

Tier level

What the drug will cost you

POTIGA ORAL TABLET 200 MG, 300 MG, 400 MG

2

$0

POTIGA ORAL TABLET 50 MG

2

$0

(Gabitril) (Topamax)

1 2 2 1 1

$0 $0 $0 $0 $0

(Qudexy XR)

1

$0

2

$0

(Depacon) (Depakene)

2 1 1

$0 $0 $0

(Depakene)

1

$0

VIMPAT INTRAVENOUS

2

$0

VIMPAT ORAL SOLUTION

2

$0

VIMPAT ORAL TABLET

2

$0

(Zonegran)

1

$0

(Aricept) (Aricept Odt)

1 1 1

$0 $0 $0

(Razadyne ER)

1

$0

(Razadyne)

1

$0

Name of Drug

primidone QUDEXY XR SABRIL tiagabine topiramate oral capsule, sprinkle topiramate oral capsule,sprinkle,er 24hr TRILEPTAL ORAL SUSPENSION TROKENDI XR valproate sodium valproic acid valproic acid (as sodium salt) oral solution 250 mg/5 ml

zonisamide

(Mysoline)

Necessary Actions, Restrictions, or Limits on Use ST; QL (90 per 30 days) ST; QL (270 per 30 days) ST

ST

ST; QL (200 per 5 days) ST; QL (1200 per 30 days) ST; QL (60 per 30 days)

Antidementia Agents Antidementia Agents donepezil oral tablet donepezil oral tablet,disintegrating EXELON TRANSDERMAL galantamine oral capsule,ext rel. pellets 24 hr galantamine oral solution

QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (200 per 30 days)

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 48

Tier level

What the drug will cost you

1 1 1 2 2 2

$0 $0 $0 $0 $0 $0

2

$0

2

$0

2 1

$0 $0

1

$0

(Wellbutrin)

1 2 1

$0 $0 $0

(Wellbutrin SR)

1

$0

(Wellbutrin XL)

1

$0

1

$0

1 1 1 1

$0 $0 $0 $0

1

$0

Name of Drug galantamine oral tablet memantine oral tablet memantine oral tablets,dose pack NAMENDA ORAL SOLUTION NAMENDA ORAL TABLET NAMENDA TITRATION PAK NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE PACK NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 24HR NAMZARIC rivastigmine tartrate

(Razadyne) (Namenda) (Namenda)

(Exelon)

Necessary Actions, Restrictions, or Limits on Use QL (60 per 30 days) QL (60 per 30 days) QL (49 per 28 days) QL (360 per 30 days) QL (60 per 30 days) QL (49 per 28 days) QL (28 per 28 days) QL (30 per 30 days)

QL (60 per 30 days)

Antidepressants Antidepressants amitriptyline amoxapine BRINTELLIX bupropion hcl oral tablet bupropion hcl oral tablet extended release , 150 mg bupropion hcl oral tablet extended release 24 hr citalopram oral solution citalopram oral tablet clomipramine desipramine oral doxepin oral duloxetine oral capsule,delayed release(dr/ec) 20 mg, 60 mg

(Amitriptyline HCl) (Amoxapine)

(Citalopram Hydrobromide) (Celexa) (Anafranil) (Norpramin) (Doxepin HCl) (Irenka)

PA NSO-HRM

ST

QL (30 per 30 days) PA NSO-HRM PA NSO-HRM QL (60 per 30 days)

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 49

Tier level

What the drug will cost you

(Irenka)

1

$0

(Irenka)

2

$0

(Prozac)

2 1 2 1

$0 $0 $0 $0

(Prozac Weekly)

1

$0

(Fluoxetine HCl) (Fluoxetine HCl)

1 1

$0 $0

1

$0

1

$0

1

$0

1 1 2

$0 $0 $0

2

$0

Name of Drug duloxetine oral capsule,delayed release(dr/ec) 30 mg duloxetine oral capsule,delayed release(dr/ec) 40 mg EMSAM escitalopram oxalate FETZIMA fluoxetine oral capsule fluoxetine oral capsule,delayed release(dr/ec) fluoxetine oral solution fluoxetine oral tablet 10 mg, 20 mg FLUOXETINE ORAL TABLET 60 MG fluvoxamine oral capsule,extended release 24hr fluvoxamine oral tablet imipramine hcl imipramine pamoate IRENKA

(Lexapro)

(Luvox CR) (Fluvoxamine Maleate) (Tofranil) (Tofranil-Pm)

KHEDEZLA

Necessary Actions, Restrictions, or Limits on Use QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days) ST

PA NSO-HRM PA NSO-HRM QL (30 per 30 days) ST; QL (30 per 30 days)

maprotiline (Maprotiline HCl) 1 $0 MARPLAN 2 $0 mirtazapine (Remeron) 1 $0 nefazodone (Nefazodone HCl) 1 $0 nortriptyline oral capsule (Pamelor) 1 $0 nortriptyline oral solution (Nortriptyline HCl) 1 $0 olanzapine-fluoxetine (Symbyax) 1 $0 paroxetine hcl oral tablet (Paxil) 1 $0 paroxetine hcl oral tablet extended (Paxil CR) 1 $0 release 24 hr PAXIL ORAL SUSPENSION 2 $0 You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 50

Tier level

What the drug will cost you

1

$0

1

$0

2

$0

ST; QL (30 per 30 days)

$0 $0 $0 $0 $0 $0

QL (30 per 30 days) PA NSO-HRM

(Parnate) (Trazodone HCl)

1 1 2 2 1 1

(Effexor XR)

1

$0

(Venlafaxine HCl)

1

$0

(Venlafaxine HCl)

1

$0

2

$0

1 2

$0 $0

2

$0

2

$0

2 2

$0 $0

2

$0

Name of Drug perphenazine-amitriptyline phenelzine

(Perphenazine/Ami triptyline HCl) (Nardil)

PRISTIQ protriptyline sertraline SILENOR SURMONTIL tranylcypromine trazodone venlafaxine oral capsule,extended release 24hr venlafaxine oral tablet venlafaxine oral tablet extended release 24hr 150 mg, 37.5 mg, 75 mg VIIBRYD

(Vivactil) (Zoloft)

Necessary Actions, Restrictions, or Limits on Use PA NSO-HRM

Antidiabetic Agents Antidiabetic Agents, Miscellaneous acarbose (Precose) BYDUREON BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/DOSE (250 MCG/ML) 1.2 ML CYCLOSET GLYXAMBI INVOKAMET ORAL TABLET 150-1,000 MG, 150-500 MG, 501,000 MG

QL (90 per 30 days) QL (4 per 28 days) QL (2.4 per 28 days) QL (1.2 per 28 days) QL (180 per 30 days) QL (30 per 30 days) ST; QL (60 per 30 days)

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 51

Name of Drug INVOKAMET ORAL TABLET 50-500 MG INVOKANA ORAL TABLET 100 MG INVOKANA ORAL TABLET 300 MG JANUMET JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 1001,000 MG, 50-500 MG JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 501,000 MG JANUVIA

Tier level

What the drug will cost you

2

$0

2

$0

2

$0

2

$0

2

$0

ST; QL (120 per 30 days) ST; QL (60 per 30 days) ST; QL (30 per 30 days) QL (60 per 30 days) QL (30 per 30 days) QL (60 per 30 days)

2

$0

2

$0

JARDIANCE

2

$0

JENTADUETO

2

$0

KORLYM

2

$0

(Glucophage) (Glucophage) (Glucophage)

1 1 1

$0 $0 $0

(Glucophage XR)

1

$0

(Glucophage XR)

1

$0

(Fortamet)

1

$0

(Starlix) (Actos) (Duetact) (Actoplus Met)

1 1 1 1 2 1

$0 $0 $0 $0 $0 $0

metformin oral tablet 1,000 mg metformin oral tablet 500 mg metformin oral tablet 850 mg metformin oral tablet extended release 24 hr 500 mg metformin oral tablet extended release 24 hr 750 mg metformin oral tablet extended release 24hr nateglinide pioglitazone pioglitazone-glimepiride pioglitazone-metformin PRANDIMET repaglinide

Necessary Actions, Restrictions, or Limits on Use

(Prandin)

QL (30 per 30 days) ST; QL (30 per 30 days) QL (60 per 30 days) PA; QL (112 per 28 days) QL (60 per 30 days) QL (120 per 30 days) QL (90 per 30 days) QL (120 per 30 days) QL (90 per 30 days) QL (60 per 30 days) QL (90 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (90 per 30 days) QL (150 per 30 days) QL (240 per 30 days)

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 52

Name of Drug SYMLINPEN 120

Tier level

What the drug will cost you

2

$0

Necessary Actions, Restrictions, or Limits on Use PA; QL (10.8 per 28 days) PA; QL (6 per 28 days) QL (30 per 30 days) QL (4 per 28 days) PA; QL (9 per 28 days)

SYMLINPEN 60 2 $0 TRADJENTA 2 $0 TRULICITY 2 $0 VICTOZA 2 $0 Insulins HUMALOG KWIKPEN QL (30 per 28 days) SUBCUTANEOUS INSULIN PEN 2 $0 100 UNIT/ML HUMALOG KWIKPEN QL (12 per 28 days) SUBCUTANEOUS INSULIN PEN 2 $0 200 UNIT/ML (3 ML) HUMALOG MIX 50-50 2 $0 QL (40 per 28 days) HUMALOG MIX 50-50 QL (30 per 28 days) 2 $0 KWIKPEN HUMALOG MIX 75-25 2 $0 QL (40 per 28 days) HUMALOG MIX 75-25 QL (30 per 28 days) 2 $0 KWIKPEN HUMALOG SUBCUTANEOUS QL (30 per 28 days) 2 $0 CARTRIDGE HUMALOG SUBCUTANEOUS 2 $0 QL (40 per 28 days) HUMULIN 70/30 2 $0 QL (40 per 28 days) HUMULIN 70/30 KWIKPEN 2 $0 QL (30 per 28 days) HUMULIN N 2 $0 QL (40 per 28 days) HUMULIN N KWIKPEN 2 $0 QL (30 per 28 days) HUMULIN R 2 $0 QL (40 per 28 days) HUMULIN R U-500 QL (40 per 28 days) 2 $0 (CONCENTRATED) LANTUS 2 $0 QL (40 per 28 days) LANTUS SOLOSTAR 2 $0 QL (30 per 28 days) NOVOLIN 70/30 2 $0 QL (40 per 28 days) NOVOLIN N 2 $0 QL (40 per 28 days) NOVOLIN R 2 $0 QL (40 per 28 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document.

Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 53

Tier level

What the drug will cost you

2 2 2 2 2 2

$0 $0 $0 $0 $0 $0

QL (40 per 28 days) QL (30 per 28 days) QL (40 per 28 days) QL (30 per 28 days) QL (30 per 28 days) QL (7.5 per 28 days)

(Amaryl) (Amaryl) (Glucotrol) (Glucotrol)

1 1 1 1

$0 $0 $0 $0

(Glucotrol XL)

1

$0

QL (30 per 30 days) QL (60 per 30 days) QL (120 per 30 days) QL (60 per 30 days) QL (60 per 30 days)

(Glucotrol XL)

1

$0

1

$0

1

$0

(Glynase)

1

$0

(Glynase)

1

$0

(Glynase)

1

$0

glyburide oral tablet 1.25 mg

(Glyburide)

1

$0

glyburide oral tablet 2.5 mg

(Glyburide)

1

$0

glyburide oral tablet 5 mg

(Glyburide)

1

$0

glyburide-metformin oral tablet 1.25-250 mg

(Glucovance)

1

$0

Name of Drug NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX 70-30 NOVOLOG MIX 70-30 FLEXPEN NOVOLOG PENFILL TOUJEO SOLOSTAR Sulfonylureas glimepiride oral tablet 1 mg, 2 mg glimepiride oral tablet 4 mg glipizide oral tablet 10 mg glipizide oral tablet 5 mg glipizide oral tablet extended release 24hr 10 mg glipizide oral tablet extended release 24hr 2.5 mg, 5 mg glipizide-metformin oral tablet 2.5250 mg glipizide-metformin oral tablet 2.5500 mg, 5-500 mg glyburide micronized oral tablet 1.5 mg glyburide micronized oral tablet 3 mg glyburide micronized oral tablet 6 mg

(Glipizide/Metform in HCl) (Glipizide/Metform in HCl)

Necessary Actions, Restrictions, or Limits on Use

QL (30 per 30 days) QL (60 per 30 days) QL (120 per 30 days) PA-HRM; QL (400 per 30 days) PA-HRM; QL (180 per 30 days) PA-HRM; QL (120 per 30 days) PA-HRM; QL (280 per 30 days) PA-HRM; QL (240 per 30 days) PA-HRM; QL (120 per 30 days) PA-HRM; QL (240 per 30 days)

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 54

Tier level

What the drug will cost you

(Glucovance)

1

$0

(Tolazamide) (Tolazamide) (Tolbutamide)

1 1 1

$0 $0 $0

(Miconazole Nitrate)

4

$0

2 4

$0 $0

4

$0

2 1 4 4 4 4 4 2 1 1 1 1

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

1

$0

1 4 4 4 1 1

$0 $0 $0 $0 $0 $0

Name of Drug glyburide-metformin oral tablet 2.5500 mg, 5-500 mg tolazamide oral tablet 250 mg tolazamide oral tablet 500 mg tolbutamide

Necessary Actions, Restrictions, or Limits on Use PA-HRM; QL (120 per 30 days) QL (120 per 30 days) QL (60 per 30 days) QL (180 per 30 days)

Antifungals Antifungals 3 day vaginal * ABELCET af * aloe vesta * topical ointment 2 % AMBISOME amphotericin b antifungal (tolnaftate) * topical antifungal (tolnaftate) * topical antifungal * topical solution baza antifungal * blis-to-sol (tolnaftate) * CANCIDAS ciclopirox topical cream ciclopirox topical gel ciclopirox topical shampoo ciclopirox topical solution ciclopirox topical suspension ciclopirox-ure-camph-menth-euc clotrimazole * 1% cream (otc) clotrimazole * 1% solution (otc) clotrimazole 3 day * clotrimazole mucous membrane clotrimazole topical cream 1 %

(Tinactin) (Miconazole Nitrate) (Amphotericin B) (Tolnaftate) (Tolnaftate) (Undecylenic Acid) (Nuzole) (Tolnaftate) (Ciclodan) (Loprox) (Loprox) (Penlac) (Ciclopirox Olamine) (Ciclodan) (Lotrimin AF) (Clotrimazole) (Gyne-Lotrimin) (Clotrimazole) (Clotrimazole)

PA BvD

PA BvD PA BvD

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 55

Tier level

What the drug will cost you

(Lotrimin) (Gyne-Lotrimin) (Clotrimazole) (Gyne-Lotrimin) (Gyne-Lotrimin)

1 4 4 4 4

$0 $0 $0 $0 $0

(Lotrisone)

1

$0

1

$0

4

$0

4

$0

4 1 4 1

$0 $0 $0 $0

1

$0

1

$0

1 4 4 4 4 1 4 1 1 1 1 4

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

Name of Drug clotrimazole topical solution 1 % clotrimazole * vaginal cream clotrimazole * vaginal tablet clotrimazole-3 * clotrimazole-7 * clotrimazole-betamethasone topical cream clotrimazole-betamethasone topical lotion critic-aid clear af * dermafungal * desenex (clotrimazole) * econazole topical elon dual defense * fluconazole fluconazole in dextrose(iso-o) intravenous piggyback fluconazole in nacl (iso-osm) intravenous piggyback flucytosine foot odor control * fungi cure * FUNGI-NAIL * TOPICAL fungoid-d * griseofulvin microsize oral tablet inzo antifungal * itraconazole ketoconazole oral ketoconazole topical cream ketoconazole topical shampoo LAMISIL (AEROSOL) *

(Clotrimazole/Beta methasone Dip) (Miconazole Nitrate) (Miconazole Nitrate) (Lotrimin AF) (Econazole Nitrate) (Undecylenic Acid) (Diflucan) (Fluconazole In Nacl,Iso-Osm) (Fluconazole In Nacl,Iso-Osm) (Ancobon) (Tinactin) (Clotrimazole) (Tinactin) (Grifulvin V) (Nuzole) (Sporanox) (Ketoconazole) (Ketoconazole) (Nizoral)

Necessary Actions, Restrictions, or Limits on Use

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 56

Name of Drug lamisil af * topical aerosol powder lamisil af * topical powder LAMISIL AT * TOPICAL LOTRIMIN ULTRA * micatin * miconazole 7 * vaginal suppository miconazole nitrate * topical cream miconazole nitrate * vaginal miconazole nitrate * vaginal

(Tinactin) (Tolnaftate)

(Nuzole) (Miconazole Nitrate) (Nuzole) (Miconazole Nitrate) (Miconazole Nitrate)

miconazole nitrate * vaginal kit 200 (Monistat 3) mg- 2 % (9 gram) miconazole nitrate vaginal (Monistat 3) suppository 200 mg MONISTAT 3 * VAGINAL COMB PACK,PREFILL APPL & CREAM MONISTAT 3 * VAGINAL KIT (Miconazole monistat 7 * vaginal Nitrate) myco nail a * (Undecylenic Acid) NOXAFIL ORAL NYSTATIN (BULK) POWDER 1 BILLION UNIT nystatin oral (Nystatin) nystatin oral (Nystatin) nystatin topical (Nystatin) (Nystatin/Triamcin nystatin-triamcinolone ) podactin * (Tolnaftate) remedy phytoplex antifungal * (Miconazole topical ointment Nitrate)

Tier level

What the drug will cost you

4 4 4 4 4

$0 $0 $0 $0 $0

4

$0

4

$0

4

$0

4

$0

4

$0

1

$0

4

$0

4

$0

4

$0

4 2

$0 $0

1

$0

1 1 1

$0 $0 $0

1

$0

4

$0

4

$0

Necessary Actions, Restrictions, or Limits on Use

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 57

Name of Drug terbinafine hcl oral terbinafine hcl * topical tolnaftate * topical tolnaftate * topical triple paste af * voriconazole intravenous voriconazole oral

(Lamisil) (Desenex) (Tinactin) (Tolnaftate) (Miconazole Nitrate) (Vfend IV) (Vfend)

Tier level

What the drug will cost you

1 4 4 4

$0 $0 $0 $0

4

$0

1 1

$0 $0

4

$0

4

$0

4

$0

4

$0

4

$0

4 4 4 4 4

$0 $0 $0 $0 $0

4

$0

4

$0

4 4

$0 $0

4

$0

Necessary Actions, Restrictions, or Limits on Use

Antihistamines Antihistamines alavert d-12 allergy-sinus * aller-chlor * oral syrup aller-chlor * oral tablet allerclear d-12hr * allerclear d-24hr * allergy (chlorpheniramine) * allergy relief (cetirizine) * oral allergy relief (loratadine) * oral allerhist-1 * aller-tec d * ambi 60pse-4cpm * aprodine * banophen allergy * banophen * oral capsule 25 mg banophen * oral

(Claritin-D 12 Hour) (Chlorpheniramine Maleate) (Chlor-Trimeton) (Claritin-D 12 Hour) (Claritin-D 24 Hour) (Chlor-Trimeton) (Zyrtec) (Claritin) (Tavist-1) (Zyrtec-D) (Pseudoephed/Chlo rpheniramine) (Pseudoephedrine/ Triprolidine) (Zzzquil) (Benadryl) (Diphenhydramine HCl)

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 58

Name of Drug benadryl allergy * oral tablet

(Diphenhydramine HCl) (Children'S Zyrtec) (Zyrtec) (Zyrtec) (Zyrtec-D) (Dimetapp) (Dimetapp) (Children'S Zyrtec)

Tier level

What the drug will cost you

4

$0

Necessary Actions, Restrictions, or Limits on Use

cetirizine * oral solution 4 $0 cetirizine * oral tablet 4 $0 cetirizine * oral tablet,chewable 4 $0 cetirizine-pseudoephedrine * 4 $0 child triaminic cold & allergy * 4 $0 child wal-tap cold-allergy * 4 $0 children's aller-tec * 4 $0 children's cetirizine * oral (Zyrtec) 4 $0 tablet,chewable 5 mg CHILDREN'S CLARITIN * ORAL 4 $0 children's wal-dryl allergy * oral (Zzzquil) 4 $0 children's wal-zyr * oral (Zyrtec) 4 $0 CHILDREN'S ZYRTEC 4 $0 ALLERGY * CLARITIN * 4 $0 CLARITIN LIQUI-GEL * 4 $0 CLARITIN REDITABS * 4 $0 CLARITIN-D 12 HOUR * 4 $0 CLARITIN-D 24 HOUR * 4 $0 (Clemastine PA-HRM clemastine oral syrup 1 $0 Fumarate) clemastine * oral tablet 1.34 mg (Tavist-1) 4 $0 (Clemastine PA-HRM clemastine oral tablet 2.68 mg 1 $0 Fumarate) (Triaminic Cold cold & cough * oral liquid 4 $0 and Cough) (Diphenhydramine compoz * 4 $0 HCl) (Cyproheptadine PA-HRM cyproheptadine 1 $0 HCl) dailyhist-1 * (Tavist-1) 4 $0 dayhist allergy * (Tavist-1) 4 $0 You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 59

Name of Drug

Tier level

What the drug will cost you

(Dimetapp) (Triaminic Cold dimetapp cold-congestion * and Cough) diphenhist * oral capsule (Benadryl) diphenhist * oral (Zzzquil) (Diphenhydramine diphenhist * oral tablet 25 mg HCl) diphenhydramine hcl injection (Diphenhydramine solution 50 mg/ml HCl) diphenhydramine hcl injection (Diphenhydramine syringe HCl) diphenhydramine hcl * oral capsule (Benadryl) diphenhydramine hcl * oral tablet (Diphenhydramine 50 mg HCl) (Chlorpheniramine ed chlorped jr * Maleate) geri-dryl * oral capsule (Benadryl) levocetirizine (Xyzal) loradamed * (Claritin) loratadine * oral (Claritin) loratadine * oral (Claritin) loratadine-d * oral tablet extended (Claritin-D 12 release 12 hr Hour) loratadine-d * oral tablet extended (Claritin-D 24 release 24 hr Hour) (Diphenhydramine nyt-time sleep * HCl) phenylephrine-chlorpheniramine * (Phenylephrine/Chl oral tablet 4-10 mg orpheniramine) (Promethazine promethazine oral syrup HCl) q-dryl * oral liquid (Zzzquil) (Pseudoephedrine/ q-tapp * Brompheniramin)

4

$0

4

$0

4 4

$0 $0

4

$0

1

$0

1

$0

4

$0

4

$0

4

$0

4 1 4 4 4

$0 $0 $0 $0 $0

4

$0

4

$0

4

$0

4

$0

1

$0

4

$0

4

$0

dimaphen (pe) *

Necessary Actions, Restrictions, or Limits on Use

PA-HRM

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 60

Name of Drug siladryl sa * simply sleep * sinus & allergy (pseudoephed) * sleep aid (diphenhydramine) * oral sleep-tabs * sudogest cold & allergy *

(Zzzquil) (Diphenhydramine HCl) (Pseudoephed/Chlo rpheniramine) (Zzzquil) (Diphenhydramine HCl) (Pseudoephed/Chlo rpheniramine)

TRIAMINIC COLD & COUGH NT (PE) * ultra sleep (doxylamine succ) * unisom sleepgels * wal-act d cold & allergy * wal-dryl allergy * oral wal-dryl allergy * oral wal-finate * wal-finate-d * wal-itin * wal-itin d * wal-itin d 12 hour * wal-phed * oral tablet 4-60 mg wal-phed pe sinus & allergy * wal-sleep z * oral capsule wal-sleep z * oral liquid

(Doxylamine Succinate) (Benadryl) (Pseudoephedrine/ Triprolidine) (Benadryl) (Diphenhydramine HCl) (Chlor-Trimeton) (Pseudoephed/Chlo rpheniramine) (Claritin) (Claritin-D 24 Hour) (Claritin-D 12 Hour) (Pseudoephed/Chlo rpheniramine) (Phenylephrine/Chl orpheniramine) (Benadryl) (Zzzquil)

Tier level

What the drug will cost you

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4 4

$0 $0

Necessary Actions, Restrictions, or Limits on Use

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 61

Tier level

What the drug will cost you

(Unisom Sleepmelts)

4

$0

(Benadryl)

4

$0

(Dimetapp) (Children'S Zyrtec) (Zyrtec) (Zyrtec-D) (Benadryl) (Zzzquil)

4 4 4 4 4 4 4 4

$0 $0 $0 $0 $0 $0 $0 $0

4

$0

4 2 1 1 1 1

$0 $0 $0 $0 $0 $0

Name of Drug wal-sleep z * oral tablet,disintegrating wal-som (diphenhydramine) * oral capsule wal-tap * wal-zyr (cetirizine) * oral wal-zyr (cetirizine) * oral wal-zyr d * z-sleep * oral capsule z-sleep * oral liquid ZYRTEC * ORAL CAPSULE ZYRTEC * ORAL TABLET ZYRTEC * ORAL TABLET,DISINTEGRATING

Necessary Actions, Restrictions, or Limits on Use

Anti-Infectives (Skin And Mucous Membrane) Anti-Infectives (Skin And Mucous Membrane) ABREVA * AVC VAGINAL clindamycin phosphate vaginal (Cleocin) metronidazole vaginal (Metrogel-Vaginal) terconazole vaginal cream (Terazol 7) terconazole vaginal suppository (Terconazole)

Antimigraine Agents Antimigraine Agents dihydroergotamine injection (D.H.E.45) 1 $0 QL (30 per 28 days) dihydroergotamine nasal (Migranal) 1 $0 QL (4 per 28 days) ERGOMAR 2 $0 QL (40 per 28 days) naratriptan (Amerge) 1 $0 QL (18 per 28 days) rizatriptan oral tablet (Maxalt) 1 $0 QL (18 per 28 days) rizatriptan oral QL (18 per 28 days) (Maxalt Mlt) 1 $0 tablet,disintegrating sumatriptan nasal spray (Imitrex) 1 $0 QL (12 per 28 days) sumatriptan oral tablet (Imitrex) 1 $0 QL (18 per 28 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 62

Tier level

What the drug will cost you

(Imitrex)

1

$0

(Imitrex)

1

$0

(Imitrex)

1

$0

(Zomig)

1

$0

(Zomig Zmt)

1

$0

2 1 1 1 2 2 1 1 1 1 2

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

SIRTURO

2

$0

TRECATOR

2

$0

4 1 4 4 1 2

$0 $0 $0 $0 $0 $0

Name of Drug sumatriptan succinate subcutaneous cartridge sumatriptan succinate subcutaneous pen injector sumatriptan succinate subcutaneous solution zolmitriptan oral tablet zolmitriptan oral tablet,disintegrating

Necessary Actions, Restrictions, or Limits on Use QL (4 per 28 days) QL (4 per 28 days) QL (4 per 28 days) QL (12 per 28 days) QL (12 per 28 days)

Antimycobacterials Antimycobacterials CAPASTAT dapsone ethambutol isoniazid oral PASER PRIFTIN pyrazinamide rifabutin rifampin rifampin RIFATER

(Dapsone) (Myambutol) (Isoniazid)

(Pyrazinamide) (Mycobutin) (Rifadin) (Rifadin)

PA; QL (188 per 168 days)

Antinausea Agents Antinausea Agents ambizine * dimenhydrinate injection solution dramamine * oral tablet driminate * dronabinol EMEND INTRAVENOUS

(Meclizine HCl) (Dimenhydrinate) (Dimenhydrinate) (Dimenhydrinate) (Marinol)

QL (2 per 28 days)

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 63

Tier level

What the drug will cost you

2

$0

2

$0

2

$0

2

$0

(Granisetron HCl/PF)

1

$0

(Kytril)

1

$0

(Granisetron HCl)

1

$0

(Meclizine HCl)

4

$0

(Meclizine HCl)

4

$0

(Antivert)

1

$0

(Dimenhydrinate) (Meclizine HCl) (Zofran Odt) (Ondansetron HCl/PF) (Zofran) (Compazine)

4 4 1

$0 $0 $0

1

$0

1 1

$0 $0

(Compazine)

1

$0

(Compazine) (Compazine) (Phenergan) (Promethazine HCl) (Phenergan)

1 1 1

$0 $0 $0

1

$0

Name of Drug EMEND ORAL CAPSULE 125 MG EMEND ORAL CAPSULE 40 MG EMEND ORAL CAPSULE 80 MG EMEND ORAL CAPSULE,DOSE PACK granisetron (pf) intravenous solution granisetron hcl intravenous solution 1 mg/ml (1 ml) granisetron hcl oral meclizine * 12.5 mg caplet caplet (otc) meclizine * 25 mg tablet (otc) meclizine oral tablet 12.5 mg, 25 mg motion sickness * motion sickness (meclizine) * ondansetron ondansetron hcl (pf) ondansetron hcl oral prochlorperazine prochlorperazine edisylate injection solution prochlorperazine maleate prochlorperazine maleate oral promethazine hcl promethazine oral tablet

Necessary Actions, Restrictions, or Limits on Use PA BvD; QL (1 per 1 day) QL (1 per 1 day) PA BvD; QL (2 per 1 day) PA BvD; QL (3 per 1 day)

PA BvD

PA BvD

PA BvD

PA-HRM PA-HRM

promethazine rectal 1 $0 PA-HRM TRANSDERM-SCOP 2 $0 QL (10 per 30 days) travel sickness (meclizine) * (Bonine) 4 $0 You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 64

Name of Drug wal-dram *

(Dimenhydrinate)

Tier level

What the drug will cost you

4

$0

2 2 1 1 2 1 2 2 1 1 1

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

1

$0

1 2

$0 $0

1

$0

2 2 1

$0 $0 $0

1 2 2

$0 $0 $0

Necessary Actions, Restrictions, or Limits on Use

Antiparasite Agents Antiparasite Agents ALBENZA ALINIA atovaquone atovaquone-proguanil BILTRICIDE chloroquine phosphate oral COARTEM DARAPRIM hydroxychloroquine oral ivermectin oral mefloquine metronidazole in nacl (iso-os) metronidazole oral NEBUPENT paromomycin PENTAM PRIMAQUINE quinine sulfate

(Mepron) (Malarone) (Aralen Phosphate)

(Plaquenil) (Stromectol) (Mefloquine HCl) (Metronidazole/So dium Chloride) (Flagyl) (Paromomycin Sulfate)

(Qualaquin)

PA BvD

QL (90 per 30 days) PA; QL (42 per 7 days)

Antiparkinsonian Agents Antiparkinsonian Agents amantadine hcl APOKYN AZILECT

(Amantadine HCl)

QL (60 per 30 days)

(Benztropine PA-HRM 1 $0 Mesylate) bromocriptine (Parlodel) 1 $0 cabergoline (Cabergoline) 1 $0 carbidopa (Lodosyn) 1 $0 You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. benztropine oral

Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 65

Tier level

What the drug will cost you

(Sinemet CR)

1

$0

(Sinemet CR)

1

$0

(Stalevo 50) (Comtan)

1 1

$0 $0

2

$0

(Mirapex) (Requip)

1 1

$0 $0

(Requip XL)

1

$0

(Eldepryl) (Selegiline HCl) (Trihexyphenidyl HCl)

1 1

$0 $0

1

$0

Name of Drug carbidopa-levodopa oral tablet carbidopa-levodopa oral tablet extended release carbidopa-levodopa-entacapone entacapone NEUPRO pramipexole oral tablet ropinirole oral tablet ropinirole oral tablet extended release 24 hr selegiline hcl oral capsule selegiline hcl oral tablet trihexyphenidyl

Necessary Actions, Restrictions, or Limits on Use

ST; QL (30 per 30 days)

PA-HRM

Antipsychotic Agents Antipsychotic Agents ABILIFY DISCMELT ORAL TABLET,DISINTEGRATING 10 MG ABILIFY DISCMELT ORAL TABLET,DISINTEGRATING 15 MG ABILIFY INTRAMUSCULAR ABILIFY MAINTENA ABILIFY ORAL SOLUTION aripiprazole oral solution aripiprazole oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 5 mg aripiprazole oral tablet 2 mg chlorpromazine clozapine oral tablet 100 mg

QL (90 per 30 days) 2

$0

2

$0

(Abilify)

2 2 2 1

$0 $0 $0 $0

(Abilify)

1

$0

(Abilify) (Chlorpromazine HCl) (Clozaril)

1

$0

1

$0

1

$0

QL (60 per 30 days) QL (161.2 per 28 days) QL (1 per 28 days) QL (900 per 30 days) QL (900 per 30 days) QL (30 per 30 days) QL (60 per 30 days)

QL (270 per 30 days)

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 66

Tier level

What the drug will cost you

Necessary Actions, Restrictions, or Limits on Use

(Clozaril) (Clozaril)

1 1

$0 $0

(Fazaclo)

1

$0

(Fazaclo)

1

$0

(Fazaclo)

1

$0

FANAPT ORAL TABLET

2

$0

FANAPT ORAL TABLETS,DOSE PACK

2

$0

QL (135 per 30 days) QL (90 per 30 days) ST; QL (90 per 30 days) ST; QL (180 per 30 days) ST; QL (120 per 30 days) ST; QL (60 per 30 days) ST; QL (8 per 28 days)

1

$0

1

$0

2 1

$0 $0

1

$0

1

$0

1

$0

2

$0

ST; QL (30 per 30 days)

2

$0

ST; QL (60 per 30 days)

Name of Drug clozapine oral tablet 200 mg clozapine oral tablet 25 mg, 50 mg clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 25 mg clozapine oral tablet,disintegrating 150 mg clozapine oral tablet,disintegrating 200 mg

fluphenazine decanoate fluphenazine hcl GEODON INTRAMUSCULAR haloperidol haloperidol decanoate intramuscular solution 100 mg/ml haloperidol decanoate intramuscular solution 50 mg/ml haloperidol lactate

(Fluphenazine Decanoate) (Fluphenazine HCl) (Haloperidol) (Haloperidol Decanoate) (Haldol Decanoate 50) (Haloperidol Lactate)

INVEGA ORAL TABLET EXTENDED RELEASE 24HR 1.5 MG, 3 MG, 9 MG INVEGA ORAL TABLET EXTENDED RELEASE 24HR 6 MG INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.75 ML

QL (6 per 28 days)

QL (0.75 per 28 days) 2

$0

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 67

Name of Drug INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 156 MG/ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 234 MG/1.5 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 39 MG/0.25 ML INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 78 MG/0.5 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.875 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 410 MG/1.315 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 546 MG/1.75 ML INVEGA TRINZA INTRAMUSCULAR SYRINGE 819 MG/2.625 ML LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG

2

$0

2

$0

Necessary Actions, Restrictions, or Limits on Use QL (1 per 28 days) QL (1.5 per 28 days) QL (0.25 per 28 days)

2

$0 QL (0.5 per 28 days)

2

$0

2

$0

2

$0

QL (0.875 per 84 days) QL (1.315 per 84 days) QL (1.75 per 84 days) 2

$0

2

$0

2

$0

2

$0

(Loxitane) (Zyprexa) (Zyprexa)

1 1 1

$0 $0 $0

(Zyprexa Zydis)

1

$0

QL (2.625 per 84 days)

LATUDA ORAL TABLET 80 MG loxapine succinate olanzapine intramuscular olanzapine oral tablet olanzapine oral tablet,disintegrating 10 mg, 15 mg, 5 mg

Tier level

What the drug will cost you

ST; QL (30 per 30 days) ST; QL (60 per 30 days) QL (30 per 30 days) QL (30 per 30 days) QL (30 per 30 days)

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 68

Tier level

What the drug will cost you

1

$0

2

$0

(Invega)

1

$0

(Invega)

1

$0

(Perphenazine) (Orap) (Seroquel)

1 1 1

$0 $0 $0

2

$0

2

$0

2

$0

(Risperdal) (Risperdal)

2 1 1

$0 $0 $0

(Risperdal M-Tab)

1

$0

(Risperdal M-Tab)

1

$0

2

$0

2

$0

ST; QL (60 per 30 days) ST; QL (60 per 30 days)

2

$0

ST; QL (30 per 30 days)

1 1

$0 $0

Name of Drug olanzapine oral tablet,disintegrating 20 mg ORAP paliperidone oral tablet extended release 24hr 1.5 mg, 3 mg, 9 mg paliperidone oral tablet extended release 24hr 6 mg perphenazine pimozide quetiapine REXULTI ORAL TABLET 0.25 MG REXULTI ORAL TABLET 0.5 MG REXULTI ORAL TABLET 1 MG, 2 MG, 3 MG, 4 MG RISPERDAL CONSTA risperidone oral solution risperidone oral tablet risperidone oral tablet,disintegrating 0.25 mg, 0.5 mg, 1 mg, 2 mg risperidone oral tablet,disintegrating 3 mg, 4 mg

(Zyprexa Zydis)

SAPHRIS (BLACK CHERRY) SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 150 MG, 300 MG, 400 MG, 50 MG SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR 200 MG thioridazine (Thioridazine HCl) thiothixene (Thiothixene)

Necessary Actions, Restrictions, or Limits on Use QL (31 per 30 days)

QL (30 per 30 days) QL (60 per 30 days)

QL (90 per 30 days) ST; QL (120 per 30 days) ST; QL (60 per 30 days) ST; QL (30 per 30 days) QL (4 per 28 days) QL (480 per 30 days) QL (60 per 30 days) QL (60 per 30 days) QL (120 per 30 days)

PA NSO-HRM

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 69

Name of Drug trifluoperazine

(Trifluoperazine HCl)

VERSACLOZ ziprasidone hcl ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG, 405 MG

(Geodon)

Tier level

What the drug will cost you

1

$0

2

$0

1

$0

2

$0

1 1 2 2 2

$0 $0 $0 $0 $0

2

$0

1 2 2 2 2 2 2 2 2 2 2 1 1 2

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

Necessary Actions, Restrictions, or Limits on Use

ST; QL (540 per 30 days) QL (60 per 30 days) QL (2 per 28 days)

Antivirals (Systemic) Antiretrovirals abacavir abacavir-lamivudine-zidovudine APTIVUS ATRIPLA COMPLERA CRIXIVAN ORAL CAPSULE 200 MG, 400 MG didanosine EDURANT EMTRIVA EPIVIR HBV ORAL SOLUTION EPZICOM EVOTAZ FUZEON SUBCUTANEOUS INTELENCE INVIRASE ISENTRESS KALETRA lamivudine lamivudine-zidovudine LEXIVA

(Ziagen) (Trizivir)

(Videx EC)

(Epivir) (Combivir)

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 70

Tier level

What the drug will cost you

(Viramune) (Viramune)

1 1

$0 $0

(Viramune XR)

1

$0

2 2 2 2 2

$0 $0 $0 $0 $0

2

$0

2

$0

2 1 2 2 2 2 2 2 2 2

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0

2

$0

2 2 2 1 1 1

$0 $0 $0 $0 $0 $0

Name of Drug nevirapine oral suspension nevirapine oral tablet nevirapine oral tablet extended release 24 hr NORVIR PREZCOBIX PREZISTA RESCRIPTOR RETROVIR INTRAVENOUS REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG REYATAZ ORAL POWDER IN PACKET SELZENTRY stavudine STRIBILD SUSTIVA TIVICAY TRIUMEQ TRUVADA VIDEX 2 GRAM PEDIATRIC VIDEX 4 GRAM PEDIATRIC VIRACEPT ORAL TABLET VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR 100 MG VIREAD VITEKTA ZIAGEN ORAL SOLUTION zidovudine oral capsule zidovudine oral syrup zidovudine oral tablet Antivirals, Miscellaneous

(Zerit)

(Retrovir) (Retrovir) (Zidovudine)

Necessary Actions, Restrictions, or Limits on Use

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 71

Tier level

What the drug will cost you

1 2 1 2

$0 $0 $0 $0

2

$0

2

$0

2

$0

2

$0

DAKLINZA

2

$0

HARVONI

2

$0

OLYSIO

2

$0

SOVALDI

2

$0

TECHNIVIE

2

$0

VIEKIRA PAK

2

$0

Interferons INTRON A INJECTION PEGASYS PEGASYS PROCLICK PEGINTRON PEGINTRON REDIPEN

2 2 2 2 2

$0 $0 $0 $0 $0

SYLATRON

2

$0

Name of Drug foscarnet RELENZA DISKHALER rimantadine SYNAGIS TAMIFLU ORAL CAPSULE 30 MG TAMIFLU ORAL CAPSULE 45 MG TAMIFLU ORAL CAPSULE 75 MG TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION Hcv Antivirals

(Foscavir) (Flumadine)

Necessary Actions, Restrictions, or Limits on Use PA BvD

QL (84 per 180 days) QL (48 per 180 days) QL (42 per 180 days) QL (540 per 180 days)

PA; QL (28 per 28 days) PA; QL (30 per 30 days) PA; QL (28 per 28 days) PA; QL (28 per 28 days) PA; QL (56 per 28 days) PA; QL (112 per 28 days) PA NSO PA PA PA PA PA NSO; QL (4 per 28 days)

Nucleosides And Nucleotides You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 72

Tier level

What the drug will cost you

(Zovirax)

1

$0

(Zovirax)

1

$0

(Zovirax) (Acyclovir Sodium) (Acyclovir Sodium) (Hepsera) (Baraclude) (Famvir) (Cytovene) (Rebetol)

1

$0

1

$0

1

$0

1 1 1 1 1

$0 $0 $0 $0 $0

(Copegus)

1

$0

(Valtrex) (Valcyte)

2 1 1 2

$0 $0 $0 $0

(Lovenox)

2 2 1

$0 $0 $0

(Lovenox)

1

$0

(Lovenox)

1

$0

(Lovenox)

1

$0

(Lovenox)

1

$0

Name of Drug acyclovir oral capsule acyclovir oral suspension 200 mg/5 ml acyclovir oral tablet acyclovir sodium intravenous recon soln acyclovir sodium intravenous solution adefovir entecavir famciclovir ganciclovir sodium ribavirin oral capsule 200 mg ribavirin oral tablet 200 mg, 400 mg, 600 mg TYZEKA valacyclovir valganciclovir VIRAZOLE

Necessary Actions, Restrictions, or Limits on Use

PA BvD PA BvD

PA BvD

PA BvD

Blood Products/Modifiers/Volume Expanders Anticoagulants CEPROTIN (BLUE BAR) ELIQUIS enoxaparin subcutaneous solution enoxaparin subcutaneous syringe 100 mg/ml enoxaparin subcutaneous syringe 120 mg/0.8 ml, 80 mg/0.8 ml enoxaparin subcutaneous syringe 150 mg/ml enoxaparin subcutaneous syringe 30 mg/0.3 ml

QL (36 per 30 days) QL (36 per 30 days) QL (27.2 per 30 days) QL (34 per 30 days) QL (18 per 30 days)

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 73

Tier level

What the drug will cost you

(Lovenox)

1

$0

(Lovenox)

1

$0

(Arixtra)

1

$0

(Arixtra)

1

$0

(Arixtra)

1

$0

(Arixtra)

1

$0

(Heparin Sodium in 5% Dextrose)

1

$0

1

$0

1

$0

1

$0

1

$0

1

$0

1

$0

Name of Drug enoxaparin subcutaneous syringe 40 mg/0.4 ml enoxaparin subcutaneous syringe 60 mg/0.6 ml fondaparinux subcutaneous syringe 10 mg/0.8 ml fondaparinux subcutaneous syringe 2.5 mg/0.5 ml fondaparinux subcutaneous syringe 5 mg/0.4 ml fondaparinux subcutaneous syringe 7.5 mg/0.6 ml heparin (porcine) in 5 % dex intravenous parenteral solution 12,500 unit/250 ml, 20,000 unit/500 ml (40 unit/ml) HEPARIN (PORCINE) IN 5 % DEX INTRAVENOUS PARENTERAL SOLUTION 25,000 UNIT/250 ML(100 UNIT/ML), 25,000 UNIT/500 ML (50 UNIT/ML) heparin (porcine) in nacl (pf) intravenous parenteral solution 1,000 unit/500 ml heparin (porcine) injection heparin, porcine (pf) injection solution 5,000 unit/0.5 ml heparin, porcine (pf) injection heparin, porcine (pf) intravenous syringe 100 unit/ml

(Heparin Sodium,Porcine/Ns /PF) (Heparin Sodium,Porcine) (Heparin Sodium,Porcine/PF ) (Monoject Prefill Advanced) (Monoject Prefill Advanced)

Necessary Actions, Restrictions, or Limits on Use QL (13.6 per 30 days) QL (20.4 per 30 days) QL (24 per 30 days) QL (15 per 30 days) QL (12 per 30 days) QL (18 per 30 days)

PA BvD; (PA for ESRD Only) PA BvD PA BvD; (PA for ESRD Only)

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 74

Tier level

What the drug will cost you

1

$0

1

$0

1

$0

1

$0

IPRIVASK

2

$0

jantoven (Coumadin) PRADAXA warfarin (Coumadin) XARELTO Blood Formation Modifiers EPOGEN INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML GRANIX LEUKINE INJECTION RECON SOLN

1 2 1 2

$0 $0 $0 $0

Name of Drug HEPARIN-0.45% NACL 25,000 UNITS/250 ML (100 UNITS/ML) BAG LATEX-FREE, OUTER HEPARIN-0.45% NACL 25,000 UNITS/500 ML (50 UNITS/ML) BAG LATEX-FREE, OUTER heparin-d5w 25,000 units/250 ml (100 units/ml) bag excel container heparin-d5w 25,000 units/500 ml (50 units/ml) bag excel container

(Heparin Sodium in 5% Dextrose) (Heparin Sodium in 5% Dextrose)

Necessary Actions, Restrictions, or Limits on Use

PA; QL (24 per 28 days) QL (60 per 30 days)

PA; QL (12 per 28 days) 2

$0

2

$0

2

$0

MIRCERA

2

$0

MOZOBIL NEULASTA SUBCUTANEOUS SYRINGE NEUMEGA NEUPOGEN

2

$0

2

$0

2 2

$0 $0

PA; QL (0.6 per 28 days)

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 75

Name of Drug

Tier level

PROCRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML PROCRIT INJECTION SOLUTION 40,000 UNIT/ML

What the drug will cost you

Necessary Actions, Restrictions, or Limits on Use PA; QL (12 per 28 days)

2

$0

2

$0

PROMACTA

2

$0

ZARXIO Hematologic Agents, Miscellaneous (Aminocaproic aminocaproic acid oral solution Acid) aminocaproic acid oral tablet (Amicar) anagrelide (Agrylin)

2

$0

1

$0

1 1

$0 $0

protamine

1

$0

(Protamine Sulfate)

PA; QL (6 per 28 days) PA; QL (30 per 30 days) ST

PA BvD; (PA for ESRD Only)

tranexamic acid intravenous (Tranexamic Acid) 1 $0 tranexamic acid oral (Lysteda) 1 $0 QL (30 per 30 days) Platelet-Aggregation Inhibitors AGGRENOX 2 $0 QL (60 per 30 days) aspirin-dipyridamole (Aggrenox) 1 $0 BRILINTA 2 $0 cilostazol (Pletal) 1 $0 clopidogrel (Plavix) 1 $0 EFFIENT 2 $0 QL (30 per 30 days) pentoxifylline (Pentoxifylline) 1 $0 Volume Expanders ALBUKED-25 2 $0 ALBUKED-5 2 $0 ALBUMIN, HUMAN 25 % 2 $0 ALBUMIN, HUMAN 5 % 2 $0 ALBUMINAR 25 % 2 $0 ALBUMINAR 5 % 2 $0 You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 76

Name of Drug ALBURX (HUMAN) 5 % ALBUTEIN 25 % ALBUTEIN 5 % BUMINATE 25 % BUMINATE 5 % FLEXBUMIN 25 % FLEXBUMIN 5 % KEDBUMIN PLASBUMIN 25 % PLASBUMIN 5 %

Tier level

What the drug will cost you

2 2 2 2 2 2 2 2 2 2

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0

2 2 2 2

$0 $0 $0 $0

2

$0

2

$0

2

$0

2 2 2 2

$0 $0 $0 $0

2

$0

2 2 2

$0 $0 $0

2

$0

2

$0

Necessary Actions, Restrictions, or Limits on Use

Caloric Agents Caloric Agents AMINO ACIDS 15 % AMINOSYN 10 % AMINOSYN 3.5 % AMINOSYN 7 % AMINOSYN 7 % WITH ELECTROLYTES AMINOSYN 8.5 % AMINOSYN 8.5 %ELECTROLYTES AMINOSYN II 10 % AMINOSYN II 15 % AMINOSYN II 7 % AMINOSYN II 8.5 % AMINOSYN II 8.5 %ELECTROLYTES AMINOSYN M 3.5 % AMINOSYN-HBC 7% AMINOSYN-PF 10 % AMINOSYN-PF 7 % (SULFITEFREE) AMINOSYN-RF 5.2 %

PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 77

Name of Drug CLINIMIX 5%/D15W SULFITE FREE CLINIMIX 5%/D25W SULFITEFREE CLINIMIX 2.75%/D5W SULFIT FREE CLINIMIX 4.25%/D10W SULF FREE CLINIMIX 4.25%/D5W SULFIT FREE CLINIMIX 4.25%-D20W SULFFREE CLINIMIX 4.25%-D25W SULFFREE CLINIMIX 5%-D20W(SULFITEFREE) CLINIMIX E 2.75%/D10W SUL FREE CLINIMIX E 2.75%/D5W SULF FREE CLINIMIX E 4.25%/D10W SUL FREE CLINIMIX E 4.25%/D25W SUL FREE CLINIMIX E 4.25%/D5W SULF FREE CLINIMIX E 5%/D15W SULFIT FREE CLINIMIX E 5%/D20W SULFIT FREE CLINIMIX E 5%/D25W SULFIT FREE CLINISOL SF 15 %

Tier level

What the drug will cost you

2

$0

2

$0

2

$0

2

$0

2

$0

2

$0

2

$0

2

$0

2

$0

2

$0

2

$0

2

$0

2

$0

2

$0

2

$0

2

$0

2

$0

Necessary Actions, Restrictions, or Limits on Use PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 78

Name of Drug cysteine (l-cysteine) intravenous solution

(Cysteine HCl)

(Dextrose 10 % and 0.45 % NaCl) (Dextrose 10 % d10 %-0.9 % sodium chloride and 0.9 % NaCl) (Dextrose 2.5 % d2.5 %-0.45 % sodium chloride and 0.45 % NaCl) (Dextrose 5 % and d5 % and 0.9 % sodium chloride 0.9 % NaCl) (Dextrose 5 %-0.45 d5 %-0.45 % sodium chloride % NaCl) dex4 glucose * oral tablet,chewable (Dextrose) (Dextrose 10 % dextrose 10 % and 0.2 % nacl and 0.2 % NaCl) dextrose 10 % in water (d10w) (Dextrose 10 % in intravenous Water) (Dextrose 2.5 % in dextrose 2.5 % in water(d2.5w) Water) (Dextrose 20 % in dextrose 20 % in water (d20w) Water) (Dextrose 25 % in dextrose 25 % in water (d25w) Water) (Dextrose 40 % in dextrose 40 % in water (d40w) Water) (Dextrose 5% In dextrose 5 % in ringers Ringers) dextrose 5 % in water (d5w) (Dextrose 5 % in intravenous Water) (Dextrose 5%dextrose 5 %-lactated ringers Lactated Ringers) (Dextrose 5 %-0.2 dextrose 5%-0.2 % sod chloride % NaCl) d10 % & 0.45 % sodium chloride

Tier level

What the drug will cost you

1

$0

1

$0

1

$0

1

$0

1

$0

1

$0

4

$0

1

$0

1

$0

1

$0

1

$0

1

$0

1

$0

1

$0

1

$0

1

$0

1

$0

Necessary Actions, Restrictions, or Limits on Use PA BvD

PA BvD PA BvD PA BvD PA BvD PA BvD

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 79

Name of Drug dextrose 5%-0.3 % sod.chloride dextrose 50 % in water (d50w) dextrose 70 % in water (d70w) dextrose with sodium chloride

(Dextrose 5 % and 0.3 % NaCl) (Dextrose 50 % in Water) (Dextrose 70 % in Water) (Dextrose 5 %-0.2 % NaCl)

FREAMINE HBC 6.9 % FREAMINE III 10 % gluco burst * glucose gel * glucose * oral tablet,chewable glutose 15 * HEPATAMINE 8% HEPATASOL 8 %

(Dextrose) (Dextrose) (Dextrose) (Dextrose)

insta-glucose *

(Dextrose/Dextrin/ Maltose)

INTRALIPID INTRAVENOUS EMULSION 20 %, 30 % KABIVEN LIPOSYN II LIPOSYN III NEPHRAMINE 5.4 % NUTRILIPID PERIKABIVEN potassium chloride in lr-d5 intravenous parenteral solution PREMASOL 10 % PREMASOL 6 % PROCALAMINE 3% PROSOL 20 % TRAVASOL 10 %

(Potassium Chloride In Lr-D5)

Tier level

What the drug will cost you

1

$0

1

$0

1

$0

1

$0

2 2 4 4 4 4 2 2

$0 $0 $0 $0 $0 $0 $0 $0

4

$0

2

$0

2 2 2 2 2 2

$0 $0 $0 $0 $0 $0

1

$0

2 2 2 2 2

$0 $0 $0 $0 $0

Necessary Actions, Restrictions, or Limits on Use

PA BvD PA BvD

PA BvD PA BvD

PA BvD PA BvD

PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD

PA BvD PA BvD PA BvD PA BvD PA BvD

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 80

Tier level

What the drug will cost you

2 2

$0 $0

(Catapres) (Clonidine HCl/Chlorthalidon e)

1

$0

1

$0

(Catapres-Tts 1)

1

$0

(Catapres-Tts 1)

1

$0

(Cardura) (Tenex) (Midodrine HCl)

1 1 1

$0 $0 $0

(Medi-Phenyl)

4

$0

NORTHERA

2

$0

phenylephrine hcl injection (Vazculep) prazosin oral (Minipress) sudogest pe * (Medi-Phenyl) wal-phed pe * (Medi-Phenyl) Angiotensin Ii Receptor Antagonists BENICAR BENICAR HCT candesartan (Atacand) candesartan-hydrochlorothiazid (Atacand HCT)

1 1 4 4

$0 $0 $0 $0

2 2 1 1

$0 $0 $0 $0

ENTRESTO

2

$0

1 1 1

$0 $0 $0

Name of Drug TROPHAMINE 10 % TROPHAMINE 6%

Necessary Actions, Restrictions, or Limits on Use PA BvD PA BvD

Cardiovascular Agents Alpha-Adrenergic Agents clonidine hcl oral tablet clonidine hcl-chlorthalidone clonidine transdermal patch weekly 0.1 mg/24 hr, 0.2 mg/24 hr clonidine transdermal patch weekly 0.3 mg/24 hr doxazosin guanfacine oral tablet midodrine nasal decongestant (pe) * oral tablet 10 mg

irbesartan irbesartan-hydrochlorothiazide losartan

(Avapro) (Avalide) (Cozaar)

QL (4 per 28 days) QL (8 per 28 days)

PA-HRM

PA; QL (180 per 30 days)

ST ST

PA; QL (60 per 30 days)

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 81

Name of Drug

Tier level

What the drug will cost you

losartan-hydrochlorothiazide (Hyzaar) telmisartan (Micardis) telmisartan-hydrochlorothiazid (Micardis HCT) TRIBENZOR valsartan (Diovan) valsartan-hydrochlorothiazide (Diovan HCT) Angiotensin-Converting Enzyme Inhibitors benazepril (Lotensin) benazepril-hydrochlorothiazide (Lotensin HCT) captopril (Captopril) (Captopril/Hydroch captopril-hydrochlorothiazide lorothiazide) enalapril maleate (Vasotec) (Enalaprilat enalaprilat intravenous injectable Dihydrate) enalapril-hydrochlorothiazide (Vaseretic) (Fosinopril fosinopril Sodium) (Fosinopril/Hydroc fosinopril-hydrochlorothiazide hlorothiazide) lisinopril (Zestril) lisinopril-hydrochlorothiazide (Zestoretic) moexipril (Univasc) moexipril-hydrochlorothiazide (Uniretic) perindopril erbumine (Aceon) quinapril (Accupril) quinapril-hydrochlorothiazide (Accuretic) ramipril (Altace) trandolapril (Mavik) Antiarrhythmic Agents amiodarone hcl oral tablet 100 mg, (Cordarone) 200 mg, 400 mg amiodarone oral (Cordarone)

1 1 1 2 1 1

$0 $0 $0 $0 $0 $0

1 1 1

$0 $0 $0

1

$0

1

$0

1

$0

1

$0

1

$0

1

$0

1 1 1 1 1 1 1 1 1

$0 $0 $0 $0 $0 $0 $0 $0 $0

1

$0

1

$0

Necessary Actions, Restrictions, or Limits on Use

ST

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 82

Tier level

What the drug will cost you

1

$0

1

$0

1

$0

1

$0

1 2

$0 $0

(Procainamide HCl)

1

$0

(Rythmol SR)

1

$0

(Rythmol) (Quinidine Gluconate) (Quinidine Sulfate)

1

$0

1

$0

Name of Drug disopyramide phosphate oral capsule flecainide lidocaine (pf) intravenous syringe 50 mg/5 ml (1 %) lidocaine in 5 % dextrose (pf) intravenous parenteral solution 8 mg/ml (0.8 %) mexiletine MULTAQ procainamide injection propafenone oral capsule,extended release 12 hr propafenone oral tablet quinidine gluconate oral

(Norpace) (Flecainide Acetate) (Lidocaine HCl/PF) (Lidocaine HCl/D5w/PF) (Mexiletine HCl)

Necessary Actions, Restrictions, or Limits on Use

quinidine sulfate 1 $0 TIKOSYN 2 $0 Beta-Adrenergic Blocking Agents acebutolol (Sectral) 1 $0 atenolol (Tenormin) 1 $0 atenolol-chlorthalidone (Tenoretic 50) 1 $0 betaxolol oral (Kerlone) 1 $0 bisoprolol fumarate (Zebeta) 1 $0 bisoprolol-hydrochlorothiazide (Ziac) 1 $0 BYSTOLIC 2 $0 carvedilol (Coreg) 1 $0 esmolol intravenous (Esmolol HCl) 1 $0 PA BvD labetalol intravenous solution (Trandate) 1 $0 labetalol oral (Trandate) 1 $0 metoprolol succinate (Toprol XL) 1 $0 metoprolol ta-hydrochlorothiaz (Lopressor HCT) 1 $0 You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 83

Tier level

What the drug will cost you

1

$0

1 1 1 1

$0 $0 $0 $0

(Inderal LA)

1

$0

(Propranolol HCl) (Propranolol HCl) (Propranolol/Hydro chlorothiazid)

1 1

$0 $0

1

$0

Name of Drug metoprolol tartrate intravenous metoprolol tartrate oral nadolol pindolol propranolol intravenous propranolol oral capsule,extended release 24 hr propranolol oral solution propranolol oral tablet propranolol-hydrochlorothiazid

(Metoprolol Tartrate) (Lopressor) (Corgard) (Pindolol) (Propranolol HCl)

Necessary Actions, Restrictions, or Limits on Use

sotalol hcl oral tablet 120 mg, 160 (Betapace) 1 $0 mg, 240 mg, 80 mg sotalol oral (Betapace) 1 $0 timolol maleate oral (Timolol Maleate) 1 $0 Calcium-Channel Blocking Agents cartia xt (Cardizem CD) 1 $0 diltiazem hcl intravenous (Cardizem CD) 1 $0 diltiazem hcl oral capsule, extended (Cardizem CD) 1 $0 release 180 mg, 360 mg, 420 mg diltiazem hcl oral capsule,extended (Cardizem CD) 1 $0 release 12 hr diltiazem hcl oral capsule,extended (Cardizem CD) 1 $0 release 24hr diltiazem hcl oral tablet (Cardizem CD) 1 $0 diltiazem hcl oral tablet extended (Cardizem LA) 1 $0 release 24 hr dilt-xr (Cardizem CD) 1 $0 matzim la (Cardizem CD) 1 $0 taztia xt (Cardizem CD) 1 $0 verapamil intravenous syringe (Verapamil HCl) 1 $0 verapamil oral capsule, 24 hr er (Verelan Pm) 1 $0 pellet ct You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 84

Name of Drug verapamil oral capsule,ext rel. (Verelan) pellets 24 hr verapamil oral tablet (Calan) verapamil oral tablet extended (Calan SR) release Cardiovascular Agents, Miscellaneous ADRENALIN 1 MG/ML VIAL SUV ADRENALIN INJECTION SOLUTION 1 MG/ML (1:1,000) adrenalin injection solution 1 (Epinephrine) mg/ml (1:1,000) (1ml) CORLANOR DEMSER

Tier level

What the drug will cost you

1

$0

1

$0

1

$0

1

$0

1

$0

1

$0

2 2

$0 $0

digitek oral tablet 125 mcg

(Lanoxin)

1

$0

digitek oral tablet 250 mcg

(Lanoxin)

1

$0

digoxin injection

(Digoxin)

1

$0

2

$0

1

$0

DIGOXIN ORAL SOLUTION

digoxin oral tablet

(Lanoxin)

Necessary Actions, Restrictions, or Limits on Use

ST PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); QL (30 per 30 days) PA-HRM; QL (30 per 30 days) PA-HRM PA-HRM; QL (300 per 30 days) PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); QL (30 per 30 days)

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 85

Name of Drug dobutamine in d5w intravenous parenteral solution 1,000 mg/250 ml (4,000 mcg/ml), 250 mg/250 ml (1 mg/ml), 500 mg/250 ml (2,000 mcg/ml) dobutamine intravenous solution dopamine in 5 % dextrose intravenous solution dopamine intravenous solution ephedrine sulfate injection solution epinephrine 1 mg/ml ampul latexfree epinephrine hcl (pf) intravenous epinephrine injection auto-injector epinephrine injection syringe 0.1 mg/ml (1:10,000) EPIPEN 2-PAK EPIPEN JR 2-PAK

Tier level

FIRAZYR hydralazine

(Dobutamine HCl/D5W)

1

$0

(Dobutamine HCl) (Dopamine HCl/D5W) (Dopamine HCl) (Ephedrine Sulfate)

1

$0

1

$0

1 1

$0 $0

(Epinephrine)

1

$0

1

$0

1

$0

1

$0

2 2

$0 $0

1

$0

2 1

$0 $0

(Epinephrine HCl/PF) (Adrenaclick) (Epinephrine)

(Hydralazine HCl)

LANOXIN ORAL TABLET 187.5 MCG, 62.5 MCG milrinone milrinone in 5 % dextrose intravenous piggyback 40 mg/200 ml (200 mcg/ml)

Necessary Actions, Restrictions, or Limits on Use PA BvD

(Ethanolamine Oleate)

ethamolin

What the drug will cost you

2

$0

(Milrinone Lactate)

1

$0

(Milrinone Lactate/D5W)

1

$0

PA BvD PA BvD PA BvD

PA-HRM; (High Risk Med for Ages 65 and Older and Dose is Greater Than 125mcg Per Day); QL (30 per 30 days) PA BvD PA BvD

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 86

Tier level

What the drug will cost you

1

$0

1 1 2

$0 $0 $0

1 1 1 1 2

$0 $0 $0 $0 $0

2

$0

(Felodipine) (Isradipine) (Nicardipine HCl)

1 1 1

$0 $0 $0

(Procardia XL)

1

$0

(Adalat CC)

1

$0

(Midamor) (Amiloride/Hydroc hlorothiazide) (Bumetanide) (Chlorothiazide) (Sodium Diuril)

1

$0

1

$0

1 1 1

$0 $0 $0

(Chlorthalidone)

1

$0

(Furosemide) (Furosemide) (Lasix)

2 1 1 1

$0 $0 $0 $0

Name of Drug norepinephrine bitartrate papaverine injection solution papaverine oral RANEXA Dihydropyridines amlodipine amlodipine-benazepril amlodipine-valsartan amlodipine-valsartan-hcthiazid AZOR CLEVIPREX INTRAVENOUS EMULSION felodipine isradipine nicardipine oral nifedipine oral tablet extended release 24hr 30 mg, 60 mg, 90 mg nifedipine oral tablet extended release 30 mg, 60 mg Diuretics amiloride oral amiloride-hydrochlorothiazide bumetanide chlorothiazide chlorothiazide sodium chlorthalidone oral tablet 25 mg, 50 mg DYRENIUM furosemide injection furosemide oral solution furosemide oral tablet

(Levophed Bitartrate) (Papaverine HCl) (Papaverine HCl)

(Norvasc) (Lotrel) (Exforge) (Exforge HCT)

Necessary Actions, Restrictions, or Limits on Use PA BvD PA PA

ST

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 87

Tier level

What the drug will cost you

(Microzide) (Hydrochlorothiazi de) (Indapamide) (Methyclothiazide) (Zaroxolyn) (Demadex)

1

$0

1

$0

1 1 1 1

$0 $0 $0 $0

(Dyazide)

1

$0

(Maxzide)

1

$0

(Caduet) (Lipitor) (Questran) (Cholestyramine/A spartame) (Cholestyramine/A spartame) (Colestid)

1 1 1

$0 $0 $0

1

$0

1

$0

1 2

$0 $0

(Slo-Niacin)

4

$0

(Antara) (Tricor) (Lofibra) (Fibricor) (Trilipix) (Lopid) (Inositol/Choline/V it B Comp) (Mevacor)

1 1 1 1 1 1

$0 $0 $0 $0 $0 $0

4

$0

Name of Drug hydrochlorothiazide oral capsule hydrochlorothiazide oral tablet indapamide methyclothiazide metolazone torsemide oral triamterene-hydrochlorothiazid oral capsule triamterene-hydrochlorothiazid oral tablet Dyslipidemics amlodipine-atorvastatin atorvastatin cholestyramine (with sugar) oral cholestyramine-aspartame oral powder 4 gram cholestyramine-aspartame oral powder in packet 4 gram colestipol CRESTOR endur-acin * oral tablet extended release 500 mg fenofibrate micronized fenofibrate nanocrystallized fenofibrate oral tablet fenofibric acid fenofibric acid (choline) gemfibrozil oral lipogen *

Necessary Actions, Restrictions, or Limits on Use

lovastatin 1 $0 niacin * oral capsule, extended (Niacin) 4 $0 release 500 mg You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 88

Name of Drug

Tier level

What the drug will cost you

Necessary Actions, Restrictions, or Limits on Use

niacin * oral tablet 100 mg, 50 mg, (Slo-Niacin) 4 $0 500 mg niacin oral tablet extended release (Niaspan) 1 $0 24 hr niacin * oral tablet extended (Slo-Niacin) 4 $0 release 500 mg niacinamide * oral tablet 500 mg (Niacinamide) 4 $0 omega-3 acid ethyl esters (Lovaza) 1 $0 PRALUENT PEN 2 $0 PA; QL (2 per 28 days) PRALUENT SYRINGE 2 $0 PA; QL (2 per 28 days) pravastatin (Pravachol) 1 $0 REPATHA SURECLICK 2 $0 PA; QL (3 per 28 days) REPATHA SYRINGE 2 $0 PA; QL (3 per 28 days) simvastatin (Zocor) 1 $0 QL (30 per 30 days) VASCEPA 2 $0 WELCHOL 2 $0 ZETIA 2 $0 Renin-Angiotensin-Aldosterone System Inhibitors eplerenone (Inspra) 1 $0 spironolactone (Aldactone) 1 $0 spironolacton-hydrochlorothiaz (Aldactazide) 1 $0 Vasodilators BIDIL 2 $0 isosorbide dinitrate oral (Isochron) 1 $0 (Isosorbide isosorbide dinitrate sublingual 1 $0 Dinitrate) (Isosorbide isosorbide mononitrate oral tablet 1 $0 Mononitrate) isosorbide mononitrate oral tablet (Imdur) 1 $0 extended release 24 hr minitran transdermal patch 24 hour QL (30 per 30 days) (Nitro-Dur) 1 $0 0.1 mg/hr, 0.2 mg/hr, 0.6 mg/hr minitran transdermal patch 24 hour QL (60 per 30 days) (Nitro-Dur) 1 $0 0.4 mg/hr You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 89

Tier level

What the drug will cost you

1 2

$0 $0

1

$0

1

$0

(Nitro-Dur)

1

$0

(Nitro-Dur)

1

$0

2 2

$0 $0

Central Nervous System Agents amphetamine salt combo (Adderall)

1

$0

AMPYRA

2

$0

1 1

$0 $0

1

$0

Name of Drug minoxidil oral NITRO-BID nitroglycerin in 5 % dextrose intravenous solution nitroglycerin intravenous nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.6 mg/hr nitroglycerin transdermal patch 24 hour 0.4 mg/hr NITROSTAT PROGLYCEM

(Minoxidil) (Nitroglycerin/D5 W) (Nitroglycerin)

Necessary Actions, Restrictions, or Limits on Use

QL (30 per 30 days) QL (60 per 30 days)

Central Nervous System Agents

caffeine citrated intravenous caffeine citrated oral caffeine-sodium benzoate

(Cafcit) (Cafcit) (Caffeine/Sodium Benzoate)

QL (60 per 30 days) PA; QL (60 per 30 days)

clonidine hcl oral tablet extended (Kapvay) 1 $0 release 12 hr dexmethylphenidate oral tablet (Focalin) 1 $0 QL (60 per 30 days) dextroamphetamine oral capsule, QL (120 per 30 days) (Dexedrine) 1 $0 extended release dextroamphetamine oral tablet (Dexedrine) 1 $0 QL (180 per 30 days) dextroamphetamine-amphetamine QL (30 per 30 days) oral capsule,extended release 24hr (Adderall XR) 1 $0 10 mg, 15 mg, 5 mg dextroamphetamine-amphetamine QL (60 per 30 days) oral capsule,extended release 24hr (Adderall XR) 1 $0 20 mg, 25 mg, 30 mg flumazenil (Romazicon) 1 $0 You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 90

Tier level

What the drug will cost you

(Intuniv)

1

$0

(Eskalith) (Lithobid)

1 1

$0 $0

(Lithobid)

1

$0

(Lithium Citrate)

1

$0

(Metadate Cd)

1

$0

(Metadate Cd)

1

$0

(Metadate Cd)

1

$0

(Metadate Cd)

1

$0

(Ritalin LA)

1

$0

(Methylin) (Ritalin)

1 1

$0 $0

(Ritalin-SR)

1

$0

(Concerta)

1

$0

(Concerta)

1

$0

(Rilutek)

2 2 1 2 2

$0 $0 $0 $0 $0

1

$0

Name of Drug guanfacine oral tablet extended release 24 hr lithium carbonate oral capsule lithium carbonate oral tablet lithium carbonate oral tablet extended release lithium citrate oral solution methylphenidate oral capsule, er biphasic 30-70 10 mg, 20 mg, 50 mg, 60 mg methylphenidate oral capsule, er biphasic 30-70 30 mg methylphenidate oral capsule,er biphasic 50-50 20 mg methylphenidate oral capsule,er biphasic 50-50 30 mg methylphenidate oral capsule,er biphasic 50-50 40 mg methylphenidate oral solution methylphenidate oral tablet methylphenidate oral tablet extended release methylphenidate oral tablet extended release 24hr 18 mg, 27 mg, 54 mg methylphenidate oral tablet extended release 24hr 36 mg NUEDEXTA QUILLIVANT XR riluzole SAVELLA STRATTERA tetrabenazine

Necessary Actions, Restrictions, or Limits on Use

QL (30 per 30 days) QL (60 per 30 days) QL (30 per 30 days) QL (60 per 30 days) QL (30 per 30 days) QL (900 per 30 days) QL (90 per 30 days) QL (90 per 30 days) QL (30 per 30 days)

(Xenazine)

QL (60 per 30 days) QL (60 per 30 days)

QL (60 per 30 days) PA; QL (112 per 28 days)

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 91

Tier level

What the drug will cost you

2

$0

(Seasonique) (Desogen) (Nor-Q-D) (Mircette)

1 1 1 1

$0 $0 $0 $0

(Desogen)

1

$0

(Yaz)

1 2 1

$0 $0 $0

1

$0

1 1 1 1 1 4 1 1 4

$0 $0 $0 $0 $0 $0 $0 $0 $0

(Amethyst)

1

$0

(LevonorgestrelEthin Estradiol)

1

$0

(Amethyst)

1

$0

Name of Drug XENAZINE

Necessary Actions, Restrictions, or Limits on Use PA; QL (112 per 28 days)

Contraceptives Contraceptives ashlyna cyred deblitane desog-e.estradiol/e.estradiol desogestrel-ethinyl estradiol oral tablet 0.1/.125/.15-25 mg-mcg, 0.15-0.03 mg drospirenone-ethinyl estradiol ELLA ethinyl estradiol/drospirenone ethynodiol d-ethinyl estradiol gildess 24 fe junel fe 24 kimidess (28) l norgest/e.estradiol-e.estrad larin 24 fe levonorgestrel * 1.5 mg tablet (otc) levonorgestrel oral tablet 0.75 mg levonorgestrel oral tablet 1.5 mg levonorgestrel * oral tablet 1.5 mg levonorgestrel-ethin estradiol oral tablet 0.1-20 mg-mcg, 0.15-0.03 mg, 50-30 (6)/75-40 (5)/125-30(10) levonorgestrel-ethin estradiol oral tablets,dose pack,3 month 0.15-30 mg-mcg levonorgestrel-ethinyl estrad oral tablet

(Yaz) (Ethynodiol DEthinyl Estradiol) (Loestrin Fe) (Loestrin Fe) (Mircette) (Seasonique) (Loestrin Fe) (Plan B One-Step) (Plan B One-Step) (Plan B One-Step) (Plan B One-Step)

QL (91 per 84 days)

QL (91 per 84 days) QL (6 per 365 days) QL (6 per 365 days) QL (6 per 365 days)

QL (91 per 84 days)

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 92

Tier level

What the drug will cost you

1

$0

1

$0

(Plan B One-Step)

1

$0

(Ortho Evra) (Femcon Fe) (Nor-Q-D) (Nor-Q-D)

1 1 1 1

$0 $0 $0 $0

(Loestrin)

1

$0

(Loestrin Fe)

1

$0

(Loestrin Fe)

1

$0

(Modicon)

1

$0

(Norinyl 1+50) (Ortho-Cyclen) (Norgestrel-Ethinyl Estradiol)

1 1

$0 $0

1

$0

2 4 3

$0 $0 $0

1

$0

1

$0

Name of Drug levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month l-norgest-eth estr/ethin estra next choice one dose 1.5 mg tb (rx) 1.5 mg norelgestromin/ethin.estradiol noreth-ethinyl estradiol/iron norethindrone norethindrone (contraceptive) norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg, 1.5-30 mg-mcg norethindrone-e.estradiol-iron norethindrone-e.estradiol-iron oral tablet 1-20(5)/1-30(7) /1mg-35mcg (9), 1.5 mg-30 mcg (21)/75 mg (7) norethindrone-ethinyl estrad oral tablet 0.4-35 mg-mcg, 0.5-35 mgmcg, 0.5-35/1-35 mg-mcg/mg-mcg, 0.5/0.75/1 mg- 35 mcg, 0.5/1/0.5-35 mg-mcg, 1-35 mg-mcg norethindrone-mestranol norgestimate-ethinyl estradiol norgestrel-ethinyl estradiol NUVARING opcicon one-step * PLAN B ONE-STEP * setlakin tarina fe

(LevonorgestrelEthin Estradiol) (Seasonique)

(Plan B One-Step) (LevonorgestrelEthin Estradiol) (Loestrin Fe)

Necessary Actions, Restrictions, or Limits on Use QL (91 per 84 days) QL (91 per 84 days) QL (6 per 365 days) QL (3 per 28 days)

ST; QL (1 per 28 days) QL (6 per 365 days) QL (6 per 365 days) QL (91 per 84 days)

Cough And Cold Products Cough And Cold Products 30pse-150gfn-15dm * (Trispec Pse) 4 $0 adt robitussin peak cld dm max * (G-Zyncof) 4 $0 You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 93

Name of Drug adult nasal decongestant * adult robitussin lingering cld * adult robitussin peak cold dm * adult wal-tussin * adult wal-tussin dm max * alka-seltzer plus mucus-conges * alka-seltzer plus sinus-cough * ambi 10peh-4cpm-20dm * ambi 20dm-4cpm * ambi 40pse-400gfn-20dm * ambi 60pse-4cpm-20dm * benzonatate * bio-dtuss dmx * bionel * bionel pediatric * biospec dmx * bromphenex dm *

(Pseudoephedrine HCl) (Dextromethorphan Hbr) (G-Zyncof) (Robitussin Mucus-Chest Congest) (G-Zyncof) (Guaifenesin/Dextr omethorphan) (DMethorphan/Pe/Ac etaminophen) (Dm/Phenyleph/Ch lorpheniramine) (Coricidin Hbp) (Poly-Vent Dm) (D-Methorphan Hb/P-Ephed HCl/Cp) (Zonatuss) (D-Methorphan Hb/P-Epd HCl/Bpm) (Guaifenesin/Dm/P seudoephedrine) (Trispec Pse) (G-Zyncof) (D-Methorphan Hb/P-Epd HCl/Bpm)

Tier level

What the drug will cost you

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4 4

$0 $0

4

$0

3

$0

4

$0

4

$0

4 4

$0 $0

4

$0

Necessary Actions, Restrictions, or Limits on Use

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 94

Name of Drug (D-Methorphan Hb/P-Epd HCl/Bpm) brompheniram-phenylephrine-dm * (Ala-Hist Dm) broncotron-s * (G-Zyncof) cardec dm (phenyleph-chlorphn) * (Accuhist Pdx) cheratussin ac * (M-Clear Wc) cheratussin dac * (Tusnel C) chest congestion relief + dm * (Allfen Dm) chest congestion relief d * (Poly-Vent Ir) chest congestion relief pe * (Maxiphen) (D-Methorphan child cough & sore throat * Hb/Acetaminophen ) (Robitussin child mucinex chest congestion * Mucus-Chest Congest) child mucus relief cough * (G-Zyncof) (Dextromethorphn/ child plus cough & runny nose * Acetaminoph/Cp) (Cough Formula child triaminic cough-congest * Dm) (Dextromethorphan child wal-tussin cough relief * Hbr) (Robitussin children's chest congestion * Mucus-Chest Congest) CHILDREN'S DIMETAPP COLD &FLU * (Childrens Tylenol children's flu relief * Plus Cold) children's mucinex cough * (G-Zyncof) (Pseudoephedrine children's silfedrine * HCl) brompheniramine-pseudoeph-dm *

Tier level

What the drug will cost you

4

$0

3 4 4 4 4 4 4 4

$0 $0 $0 $0 $0 $0 $0 $0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

Necessary Actions, Restrictions, or Limits on Use

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 95

Name of Drug (Pseudoephedrine HCl) (Dextromethorphan children's sudafed pe cough * /Phenylephrine) chlophedianol-guaifenesin * (Vanacof G) (Dm/Phenyleph/Ch chlorpheniramine-phenyleph-dm * lorpheniramine) (Pyrilamine/Pe/De codituss dm * xtromethorphan) (Comtrex Cold and cold multi-symptom * Cough) (Dm cold multi-symptom day/night * Hb/Pe/Acetaminop hen/Chlorph) (Dm/Pe/Acetamino cold multi-symptom nighttime * phen/Doxylamine) (Dm cold relief m/s day/night * Hb/Pe/Acetaminop hen/Chlorph) (Dcold-flu relief * oral liquid 12.5-30Methorphan/Aceta 1,000 mg/30 ml min/Doxylamn) (Vicks Dayquilcold-flu relief, day/night * Nyquil) congestac * (Poly-Vent Ir) (Guaifenesin/Dextr coricidin hbp * oral capsule omethorphan) cough & cold * oral (Coricidin Hbp) cough & runny nose * oral liquid 1- (Vicks Children'S 5 mg/5 ml Nyquil) (Cough Formula creo-terpin (dm-guaifenesin) * Dm) daytime cold & cough * (Triaminic) children's sudafed *

Tier level

What the drug will cost you

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

Necessary Actions, Restrictions, or Limits on Use

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 96

Tier level

What the drug will cost you

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4 4

$0 $0

(Poly-Vent Dm)

4

$0

(Panatuss Ped) (Delsym) (Robitussin Mucus-Chest Congest) (G-Zyncof) (Robitussin Mucus-Chest Congest) (Brompheniram/Ph enylephrine/Dm) (D-Methorphan Hb/P-Epd HCl/Bpm) (Dm/Phenyleph/Ch lorpheniramine) (Despec) (Trispec Pse)

4 4

$0 $0

4

$0

4

$0

4

$0

4

$0

3

$0

4

$0

4 4

$0 $0

Name of Drug

daytime cold-flu * day-time cough * daytime mucus relief dm * daytime-nighttime * daytime-nighttime cold-flu * daytime-nighttime cough * decongestant cough * delsym cough+chest congest dm * despec-dm (pseudoeph-dm-guaif) * oral tablet 30-10-200 mg dexchlorphen-pse-chlophedianol * dextromethorphan polistirex * diabetic siltussin das-na * diabetic tussin dm * diabetic tussin ex * oral dimaphen dm * d-methorphan hb-p-epd hcl-bpm * oral syrup 2-30-10 mg/5 ml dm-phenyleph-chlorpheniramine * oral drops 1-2-3 mg/ml ed bron gp * entre-cough *

(DMethorphan/Pe/Ac etaminophen) (Dextromethorphan Hbr) (G-Zyncof) (Vicks DayquilNyquil) (Dm/Pe/Acetamino phen/Doxylamine) (Dextromethorphan Hb/Doxylamine) (Trispec Pse) (G-Zyncof)

Necessary Actions, Restrictions, or Limits on Use

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 97

Tier level

What the drug will cost you

(Poly-Vent Dm) (G-Zyncof) (Dextromethorphan /Pseudoephed) (Robitussin Mucus-Chest Congest) (Dm/Pe/Acetamino ph/Diphenhydram) (Theraflu) (Cough Formula Dm) (M-Clear Wc) (Tusnel C) (Allfen)

4 4

$0 $0

4

$0

4

$0

4

$0

4

$0

4

$0

4 4 4

$0 $0 $0

(Mucinex)

4

$0

4

$0

3

$0

3

$0

3

$0

3

$0

4

$0

4

$0

Name of Drug exefen dmx * expectorant dm * oral liquid expectorant max strength * expectorant * oral flu formula daytime-nighttime * flu severe cold-congestion * geri-tussin dm * guaiatussin ac * guaifenesin dac * guaifenesin * oral tablet 200 mg guaifenesin * oral tablet extended release 12hr head congestion day-night * hydrocodone bit-homatrop me-br * oral syrup 5-1.5 mg/5 ml hydrocodone-chlorpheniramine * hydrocodone-homatropine * oral syrup 5-1.5 mg/5 ml hydrocodone-homatropine * oral tablet infants' non-aspirin cold * intense cough reliever * oral liquid

(Dm Hb/Pe/Acetaminop hen/Chlorph) (Hydrocodone Bit/Homatrop MeBr) (Hydrocodone/Chl orphen P-Stirex) (Hydrocodone Bit/Homatrop MeBr) (Tussigon) (Dm/Pseudoephed/ Acetaminophen) (G-Zyncof)

Necessary Actions, Restrictions, or Limits on Use

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 98

Name of Drug

kidkare cough/cold * liquibid d-r * lohist peb dm * lortuss ex * oral syrup mar-cof bp * mar-cof cg * maximum strength flu * medi-brom * mesehist dm * mucinex fast-max dm max * mucus dm * mucus dm max * mucus relief * oral tablet 400 mg multi-symptom cold night time * multi-symptom cold-cough * nasal & sinus decongestant * neo-tuss * NEXAFED * night time cold-flu * oral night time cold-flu relief * oral liquid

(D-Methorphan Hb/P-Ephed HCl/Cp) (Maxiphen) (Ala-Hist Dm) (Tusnel C) (Bromphenira/Pseu doephed/Codein) (M-Clear Wc) (Coricidin Hbp) (D-Methorphan Hb/P-Epd HCl/Bpm) (D-Methorphan Hb/P-Ephed HCl/Cp) (G-Zyncof) (Mucinex Dm) (Mucinex Dm) (Allfen) (Theraflu) (Dm Hb/Pseudoephed/A cetamin/Cp) (Sudafed 12-Hour) (G-Zyncof) (Dm/PEphed/Acetaminop h/Doxylam) (Dm/PEphed/Acetaminop h/Doxylam)

Tier level

What the drug will cost you

4

$0

4 4 4

$0 $0 $0

3

$0

3 4

$0 $0

4

$0

4

$0

4 4 4 4 4

$0 $0 $0 $0 $0

4

$0

4 4 4

$0 $0 $0

4

$0

4

$0

Necessary Actions, Restrictions, or Limits on Use

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 99

Name of Drug

night time * oral capsule nighttime cold-flu * nighttime cough * nite time cold-flu * nite time-d cold-flu relief * nohist-dm * non-aspirin cold * non-aspirin flu * oral tablet 30-15500 mg pecgen dmx * oral liquid 15-125 mg/5 ml pedia relief * pedia relief infant * pediacare multi-symptom cold * phenylhistine dh * poly-tussin *

(Dm/PEphed/Acetaminop h/Doxylam) (DMethorphan/Aceta min/Doxylamn) (Dextromethorphan Hb/Doxylamine) (DMethorphan/Aceta min/Doxylamn) (Dm/PEphed/Acetaminop h/Doxylam) (Dm/Phenyleph/Ch lorpheniramine) (Dm Hb/Pseudoephed/A cetamin/Cp) (Dm/Pseudoephed/ Acetaminophen) (G-Zyncof) (D-Methorphan Hb/P-Ephed HCl/Cp) (Dextromethorphan /Pseudoephed) (Dextromethorphan /Phenylephrine) (P-Ephed HCl/Cod/Chlorphe nir) (Chlorcyclizine/Co deine)

Tier level

What the drug will cost you

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

Necessary Actions, Restrictions, or Limits on Use

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 100

Name of Drug promethazine-codeine * promethazine-dm * promethazine-phenyleph-codeine * pseudoephedrine hcl * oral pseudoephedrine hcl * oral q-tapp dm * q-tussin * q-tussin dm * refenesen * refenesen pe * relcof c * REZIRA * robafen * robafen cough * robafen dm * robitussin cough-chest-cong dm *

(Promethazine HCl/Codeine) (Promethazine/Dex tromethorphan) (Promethazine/Phe nyleph/Codeine) (Pseudoephedrine HCl) (Sudafed 12-Hour) (D-Methorphan Hb/P-Epd HCl/Bpm) (Robitussin Mucus-Chest Congest) (Cough Formula Dm) (Allfen) (Maxiphen) (M-Clear Wc) (Robitussin Mucus-Chest Congest) (Dextromethorphan Hbr) (Cough Formula Dm) (Guaifenesin/Dextr omethorphan)

ROBITUSSIN LONG-ACTING * robitussin pediatric *

(Dextromethorphan Hbr)

Tier level

What the drug will cost you

3

$0

3

$0

3

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4 4 3 3

$0 $0 $0 $0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

Necessary Actions, Restrictions, or Limits on Use

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 101

Name of Drug rydex * safe tussin dm * scot-tussin dm * scot-tussin expectorant * siltussin dm das * siltussin sa * sudogest * suphedrin * oral suphedrine pe day-night * suphedrine severe cold max str *

(Bromphenira/Pseu doephed/Codein) (G-Zyncof) (Vicks Children'S Nyquil) (Robitussin Mucus-Chest Congest) (G-Zyncof) (Robitussin Mucus-Chest Congest) (Sudafed 12-Hour) (Pseudoephedrine HCl) (Diphenhydram/Pe/ Dm/Acetamin/Gg) (Dm/Pseudoephed/ Acetaminophen)

THERAFLU DAYTIME COLDCOUGH * THERAFLU NIGHTTIME SEVERE COLD * THERAFLU SEVERE COLDCOUGH * triacting m-sym cold/cough * triaminic cold & cough (pe) * triaminic cough-nasal congesti *

(D-Methorphan Hb/P-Ephed HCl/Cp) (Dextromethorphan /Phenylephrine) (Dextromethorphan /Pseudoephed)

TRIAMINIC COUGH-SORE THROAT *

Tier level

What the drug will cost you

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

Necessary Actions, Restrictions, or Limits on Use

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 102

Tier level

What the drug will cost you

4

$0

4 4 4

$0 $0 $0

4

$0

(Giltuss) (Guaifenesin/Dm/P seudoephedrine) (Guaifenesin/Dm/P seudoephedrine) (Dextromethorphan Hbr)

4

$0

4

$0

4

$0

4

$0

(G-Zyncof)

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4 4

$0 $0

4

$0

4

$0

Name of Drug tri-dex pe * trigofen dm * trymine cg * tusnel diabetic * TUSNEL PEDIATRIC * ORAL LIQUID tussin cf cough-cold * tussin cf * oral tussin cold-congestion * tussin cough (dm only) * oral tussin dm cough & chest * oral liquid 10-200 mg/5 ml tussin dm * oral tussin maximum strength cough * tussin pe * oral liquid valu-tapp dm * vicks dayquil cough * vicks nature fusion cough * virdec dm * wal-phed * oral tablet 30 mg wal-phed pe day-night * wal-tussin cough *

(Dm/Phenyleph/Ch lorpheniramine) (Accuhist Pdx) (M-Clear Wc) (G-Zyncof)

(Cough Formula Dm) (Dextromethorphan Hbr) (Despec) (D-Methorphan Hb/P-Epd HCl/Bpm) (Dextromethorphan Hbr) (Dextromethorphan Hbr) (Accuhist Pdx) (Sudafed 12-Hour) (Diphenhydram/Pe/ Dm/Acetamin/Gg) (Dextromethorphan Hbr)

Necessary Actions, Restrictions, or Limits on Use

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 103

Tier level

What the drug will cost you

4

$0

4

$0

(G-Zyncof)

4 3 4

$0 $0 $0

(Evoxac)

1

$0

(Peridex)

1

$0

4

$0

1 3

$0 $0

1

$0

(Soriatane) (Benzoyl Peroxide)

2 1 4

$0 $0 $0

(Benzoyl Peroxide)

4

$0

4

$0

4 1 1 1 1

$0 $0 $0 $0 $0

1

$0

Name of Drug wal-tussin cough & cold cf * wal-tussin dm * zephrex-d * ZONATUSS * zyncof * oral liquid

(Giltuss) (Cough Formula Dm) (Sudafed 12-Hour)

Necessary Actions, Restrictions, or Limits on Use

Dental And Oral Agents Dental And Oral Agents cevimeline chlorhexidine gluconate mucous membrane PHOS-FLUR * DENTAL SOLUTION pilocarpine hcl oral PREVIDENT 5000 SENSITIVE * triamcinolone acetonide dental

(Salagen) (Triamcinolone Acetonide)

Dermatological Agents Dermatological Agents, Other 8-MOP acitretin acne medication * topical gel 10 % acne medication * topical lotion 10 % ACNE MEDICATION * TOPICAL LOTION 5 % acne-clear * acyclovir topical ALCOHOL PADS ALCOHOL PREP PADS ALCOH-WIPE aluminum chloride

(Benzoyl Peroxide) (Zovirax)

(Aluminum Chloride)

QL (30 per 30 days)

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 104

Tier level

What the drug will cost you

4

$0

4

$0

4

$0

(Lac-Hydrin)

1

$0

(Lac-Hydrin)

1

$0

2

$0

(Benzac Ac)

3

$0

(Benzoyl Peroxide)

4

$0

(Dovonex) (Calcipotriene) (Calcipotriene) (Vectical)

4 1 1 1 1

$0 $0 $0 $0 $0

4

$0

2 2 2 2 2 2 1 1

$0 $0 $0 $0 $0 $0 $0 $0

4

$0

Name of Drug amlactin * topical lotion ammonium lactate * 12% cream fragrance free (otc) ammonium lactate * 12% lotion (otc) ammonium lactate topical cream 12 % ammonium lactate topical lotion 12 % ANACAINE benzoyl peroxide * 10% gel aqueous (rx) benzoyl peroxide * topical gel 10 %, 5 % BETADINE SPRAY * calcipotriene topical cream calcipotriene topical ointment calcipotriene topical solution calcitriol topical CASTELLANI PAINT MODIFIED * CONDYLOX TOPICAL GEL COSENTYX (2 SYRINGES) COSENTYX PEN COSENTYX PEN (2 PENS) DRYSOL DAB-O-MATIC FLUOROPLEX fluorouracil topical cream fluorouracil topical solution geri-hydrolac * topical imiquimod

(Lac-Hydrin Twelve) (Ammonium Lactate) (Lac-Hydrin Twelve)

(Carac) (Fluorouracil) (Lac-Hydrin Twelve)

Necessary Actions, Restrictions, or Limits on Use

PA NSO PA NSO PA NSO

PA NSO; QL (24 per 30 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. (Aldara)

1

$0

Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 105

Name of Drug isotretinoin oral capsule 10 mg, 20 mg, 30 mg, 40 mg LACTINOL HX * lobana bath * mafenide acetate methoxsalen rapid PANRETIN persa-gel * PICATO TOPICAL GEL 0.015 % PICATO TOPICAL GEL 0.05 % podofilox podophyllum resin potassium hydroxide

(Isotretinoin) (Mineral Oil) (Mafenide Acetate) (Oxsoralen-Ultra) (Benzoyl Peroxide)

(Condylox) (Podophyllum Resin) (Potassium Hydroxide)

SANTYL silver nitrate applicators skin treatment *

(Silver Nitrate Applicator) (Lac-Hydrin Twelve)

VALCHLOR zinc oxide * topical ointment (Boudreauxs) ZOVIRAX TOPICAL CREAM Dermatological Antibacterials bacitracin * topical (Bacitracin) bacitraycin plus * topical ointment (Bacitracin) 500 unit/gram clindamycin phosphate topical gel (Cleocin T) clindamycin phosphate topical (Cleocin T) lotion clindamycin phosphate topical (Cleocin T) solution clindamycin phosphate topical swab (Cleocin T)

Tier level

What the drug will cost you

1

$0

4 4 1 1 2 4 2 2 1

$0 $0 $0 $0 $0 $0 $0 $0 $0

1

$0

1

$0

2

$0

1

$0

4

$0

2 4 2

$0 $0 $0

4

$0

4

$0

1

$0

1

$0

1

$0

1

$0

Necessary Actions, Restrictions, or Limits on Use

QL (3 per 56 days) QL (2 per 56 days)

QL (15 per 30 days)

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 106

Tier level

What the drug will cost you

(Erythromycin Base/Ethanol)

1

$0

(Emgel)

1

$0

1

$0

1

$0

1

$0

1 1 1 1 1

$0 $0 $0 $0 $0

1

$0

1 1

$0 $0

1

$0

1

$0

1

$0

1

$0

4 4

$0 $0

1

$0

1

$0

1

$0

Name of Drug erythromycin base-ethanol erythromycin with ethanol topical gel erythromycin with ethanol topical solution erythromycin with ethanol topical swab gentamicin topical metronidazole topical metronidazole topical metronidazole topical mupirocin mupirocin calcium neomycin-polymyxin b gu

(Erythromycin Base/Ethanol) (Erythromycin Base/Ethanol) (Gentamicin Sulfate) (Metrocream) (Nydamax) (Metrolotion) (Centany) (Bactroban) (Neosporin G.U. Irrigant) (Selenium Sulfide) (Silver Nitrate)

selenium sulfide silver nitrate topical silver sulfadiazine topical cream 1 (Silvadene) % sulfacetamide sodium (acne) (Klaron) Dermatological Anti-Inflammatory Agents alclometasone topical cream (Aclovate) (Alclometasone alclometasone topical ointment Dipropionate) aquanil hc * (Cortizone-10) beta-hc * (Cortizone-10) betamethasone dipropionate topical (Diprosone) cream betamethasone dipropionate topical (Betamethasone lotion Dipropionate) betamethasone dipropionate topical (Betamethasone ointment Dipropionate)

Necessary Actions, Restrictions, or Limits on Use

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 107

Tier level

What the drug will cost you

(Betamethasone Valerate)

1

$0

(Luxiq)

1

$0

1

$0

1

$0

(Diprolene AF)

1

$0

(Betamethasone Dipropionate)

1

$0

(Diprolene)

1

$0

(Diprolene)

1

$0

1

$0

1 1 1 1 1 1

$0 $0 $0 $0 $0 $0

1

$0

1 1

$0 $0

2

$0

4

$0

4

$0

4

$0

Name of Drug betamethasone valerate topical cream betamethasone valerate topical foam betamethasone valerate topical lotion betamethasone valerate topical ointment betamethasone, augmented topical cream betamethasone, augmented topical gel betamethasone, augmented topical lotion betamethasone, augmented topical ointment clobetasol propionate topical solution 0.05 % clobetasol topical cream clobetasol topical foam clobetasol topical gel clobetasol topical lotion clobetasol topical ointment clobetasol topical shampoo clobetasol topical solution clobetasol-emollient topical clocortolone pivalate CORDRAN TOPICAL OINTMENT cortizone-10 * topical cream CORTIZONE-10 * TOPICAL LOTION cortizone-10 * topical ointment

(Betamethasone Valerate) (Betamethasone Valerate)

(Clobetasol Propionate) (Temovate) (Olux) (Temovate) (Clobex) (Temovate) (Clobex) (Clobetasol Propionate) (Temovate) (Cloderm)

(Hydrocortisone)

(Hydrocortisone)

Necessary Actions, Restrictions, or Limits on Use

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 108

Tier level

What the drug will cost you

4 1 1 1

$0 $0 $0 $0

2

$0

(Vanos) (Fluocinonide) (Fluocinonide) (Fluocinonide) (Vanos) (Cutivate) (Fluticasone Propionate) (Ultravate)

1 1 1 1 1 1

$0 $0 $0 $0 $0 $0

1

$0

1

$0

(Hydrocortisone)

4

$0

(Rederm)

3

$0

(Hydrocortisone)

4

$0

1

$0

4

$0

4

$0

1

$0

Name of Drug dermarest eczema (hydrocort) * desonide topical cream desonide topical ointment desoximetasone

(Cortizone-10) (Desowen) (Tridesilon) (Topicort)

ELIDEL fluocinonide topical cream 0.05 % fluocinonide topical gel fluocinonide topical ointment fluocinonide topical solution fluocinonide-emollient base fluticasone topical cream fluticasone topical ointment halobetasol propionate hydrocortisone * 1% cream maximum strength (otc) hydrocortisone * 1% lotion (rx) hydrocortisone * 1% ointment carton (otc) hydrocortisone acet-aloe vera topical gel hydrocortisone acetate * topical cream 1 % hydrocortisone acetate-aloe * hydrocortisone acetate-urea

(Hydrocortisone Acetate/Aloe V) (Hydrocortisone Acetate) (Hydrocortisone Acetate/Aloe V) (Hydrocortisone Acetate/Urea) (Locoid) (Locoid) (Anusol-HC) (Hydrocortisone)

Necessary Actions, Restrictions, or Limits on Use

PA; AGE (Min 2 Years)

hydrocortisone butyrate 1 $0 hydrocortisone butyr-emollient 1 $0 hydrocortisone rectal cream 1 % 1 $0 hydrocortisone rectal cream 2.5 % 1 $0 hydrocortisone rectal enema 100 (Cortenema) 1 $0 mg/60 ml You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 109

Tier level

What the drug will cost you

(Hydrocortisone)

4

$0

(Anusol-HC)

1

$0

(Cortizone-10)

3

$0

(Rederm)

1

$0

(Hydrocortisone)

4

$0

(Hydrocortisone)

1

$0

(Hydrocortisone Valerate)

1

$0

(Westcort)

1

$0

(Cortizone-10) (Elocon) (Hydrocortisone) (Dermatop) (Hydrocortisone) (Hydrocortisone) (Protopic) (Triamcinolone Acetonide)

4 1 4 1 4 4 1

$0 $0 $0 $0 $0 $0 $0

1

$0

(Kenalog)

1

$0

(Triderm)

1

$0

(Triamcinolone Acetonide)

1

$0

(Differin) (Differin)

1 1

$0 $0

Name of Drug hydrocortisone * topical cream 0.5 % hydrocortisone topical cream 1 %, 2.5 % hydrocortisone * topical lotion 1 % hydrocortisone topical lotion 2 %, 2.5 % hydrocortisone * topical ointment 0.5 % hydrocortisone topical ointment 1 %, 2.5 % hydrocortisone valerate topical cream hydrocortisone valerate topical ointment hydroskin * topical lotion mometasone neosporin anti-itch * prednicarbate preparation h hydrocortisone * recort plus * tacrolimus topical triamcinolone acetonide topical cream triamcinolone acetonide topical lotion triamcinolone acetonide topical ointment 0.025 %, 0.05 %, 0.1 %, 0.5 % triderm topical cream Dermatological Retinoids adapalene topical cream adapalene topical gel 0.1 %

Necessary Actions, Restrictions, or Limits on Use

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 110

Name of Drug

Tier level

What the drug will cost you

TAZORAC TOPICAL CREAM tretinoin microspheres (Retin-A Micro) tretinoin topical cream (Retin-A) tretinoin topical gel 0.01 %, 0.025 (Retin-A) % Scabicides And Pediculicides lice cream rinse * (Nix) (Piperonyl lice killing * Butoxide/Pyrethrin s) lice treatment (permethrin) * (Nix) lice treatment * topical liquid 1 % (Nix) malathion (Ovide) permethrin topical cream (Elimite) permethrin * topical liquid (Nix)

2 1 1

$0 $0 $0

1

$0

4

$0

4

$0

4 4 1 1 4

$0 $0 $0 $0 $0

Necessary Actions, Restrictions, or Limits on Use PA PA PA

Devices Devices ASSURE ID INSULIN SAFETY 1 $0 SYRINGE BD INSULIN PEN NEEDLE UF 1 $0 SHORT BD INSULIN SYRINGE ULTRAFINE SYRINGE 0.3 ML 31 X 1 $0 5/16", 1 ML 31 X 5/16", 1/2 ML 31 X 5/16" INSULIN SYRINGE 1 $0 NEEDLELESS INSULIN SYRINGE SYRINGE 1 $0 INSULIN SYRINGE-NEEDLE U1 $0 100 SYRINGE PEN NEEDLE, DIABETIC 1 $0 NEEDLE 31 SURE COMFORT INS. SYR. U1 $0 100 You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 111

Name of Drug

Tier level

What the drug will cost you

4

$0

2 2

$0 $0

2

$0

2

$0

2

$0

2 2

$0 $0

2

$0

2

$0

2 2 2 1 2 2 2 2 2 2 2 2 2 2

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

Necessary Actions, Restrictions, or Limits on Use

Disinfectants (For Non-Dermatologic Use) Disinfectants (For Non-Dermatologic Use) iodine * (Iodine)

Enzyme Replacement/Modifiers Enzyme Replacement/Modifiers ADAGEN ALDURAZYME CEREZYME INTRAVENOUS RECON SOLN 400 UNIT CIMZIA CIMZIA POWDER FOR RECONST CREON ELAPRASE ELITEK INTRAVENOUS RECON SOLN FABRAZYME INTRAVENOUS RECON SOLN KRYSTEXXA KUVAN LINZESS lipase-protease-amylase (Zenpep) LOTRONEX LUMIZYME MYOZYME NAGLAZYME ORFADIN PULMOZYME VIMIZIM VPRIV ZAVESCA ZENPEP

PA PA

QL (30 per 30 days)

PA BvD PA QL (90 per 30 days)

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 112

Name of Drug

Tier level

What the drug will cost you

2 4 1 4 1 4

$0 $0 $0 $0 $0 $0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

1 1 4 4 1 1

$0 $0 $0 $0 $0 $0

4

$0

1

$0

1

$0

Necessary Actions, Restrictions, or Limits on Use

Eye, Ear, Nose, Throat Agents Eye, Ear, Nose, Throat Agents, Miscellaneous AKTEN (PF) alaway * (Zaditor) altacaine (Tetcaine) altamist * (Little Remedies) apraclonidine (Iopidine) artificial tears (petro/min) * (Genteal Pm) (Dextran artificial tears (pf) * ophthalmic 70/Hypromellose/P dropperette 0.1-0.3 % F) artificial tears * ophthalmic drops (Tears Naturale) 0.1-0.3 % artificial tears * ophthalmic drops (Polyvinyl 0.5-0.6 % Alcohol/Povidone) artificial tears * ophthalmic (Petrolat,Wht/Min ointment Oil/Sod Chl) (Glycerin/Propylen artificial tears(glycerin-peg) * e Glycol) (Genteal Mild To artificial tears(hypromellose) * Moderate) atropine ophthalmic drops (Isopto Atropine) atropine ophthalmic ointment (Atropine Sulfate) ayr saline * nasal aerosol,spray (Little Remedies) ayr saline * nasal drops (Sodium Chloride) azelastine nasal (Astepro) azelastine ophthalmic (Optivar) (Dextran bion tears (pf) * 70/Hypromellose/P F) carteolol (Carteolol HCl) (Cromolyn cromolyn ophthalmic Sodium)

QL (30 per 25 days)

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 113

Tier level

What the drug will cost you

2

$0

1 2 4

$0 $0 $0

4

$0

1

$0

4

$0

4

$0

4 4 4

$0 $0 $0

(Isopto Homatropine)

1

$0

(Atrovent)

1

$0

(Atrovent)

1

$0

4

$0

4 2

$0 $0

4

$0

4

$0

4

$0

4

$0

4

$0

Name of Drug CYCLOGYL OPHTHALMIC DROPS 0.5 % cyclopentolate CYSTARAN deep sea nasal * dristan long lasting * epinastine eq gentle *

(Cyclogyl) (Little Remedies) (Oxymetazoline HCl) (Elestat) (Genteal Mild To Moderate)

GENTEAL MILD TO MODERATE * GENTEAL GEL * GENTEAL MILD * GENTEAL SEVERE * homatropine hbr ipratropium bromide nasal spray,non-aerosol 0.03 % ipratropium bromide nasal spray,non-aerosol 0.06 % isopto tears * ketotifen fumarate * LACRISERT liquitears * lubricant dry eye relief * lubricant eye (cmc-glycer)(pf) * lubricant eye (cmc-glycerin) * lubricant eye (polyv alcohol) *

(Genteal Mild To Moderate) (Zaditor) (Polyvinyl Alcohol) (Carboxymethylcel lulose Sodium) (Carboxymethylcel l/Glycerin/PF) (Refresh Optive) (Polyvinyl Alcohol)

Necessary Actions, Restrictions, or Limits on Use

QL (30 per 28 days) QL (15 per 10 days)

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 114

Tier level

What the drug will cost you

(Propylene Glycol) (Carboxymethylcel lulose Sodium)

4

$0

4

$0

(Refresh Tears)

4

$0

4

$0

4 4 4 1 4

$0 $0 $0 $0 $0

4

$0

4

$0

4

$0

4

$0

4

$0

(Mydfrin) (Proparacaine HCl)

4 1 2 2 1 1

$0 $0 $0 $0 $0 $0

(Proparacaine HCl)

1

$0

(Proparacaine/Fluo rescein Sod)

1

$0

Name of Drug lubricant eye (propyl glycol) * lubricant eye drops * ophthalmic dropperette lubricant eye drops * ophthalmic drops lubricant gel * lubricating drops * lubrifresh pm * muro 128 * naphazoline nasal decongestant (oxymetazl) * natural balance * natural tears (pf) * nature's tears * neo-synephrine 12 h spr (oxym) * nighttime relief eye * ocean nasal * olopatadine PATADAY PATANOL phenylephrine hcl ophthalmic proparacaine proparacaine hcl ophthalmic drops 0.5 % proparacaine-fluorescein sod

(Carboxymethylcel l/Hypromellose) (Refresh Optive) (Genteal Pm) (Sodium Chloride) (Naphazoline HCl) (Afrin) (Genteal Mild To Moderate) (Dextran 70/Hypromellose/P F) (Genteal Mild To Moderate) (Oxymetazoline HCl) (Petrolat,Wht/Min Oil/Sod Chl) (Little Remedies) (Patanase)

Necessary Actions, Restrictions, or Limits on Use

QL (30.5 per 30 days) ST ST

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 115

Name of Drug pure & gentle eye *

(Genteal Mild To Moderate)

REFRESH CLASSIC (PF) * REFRESH LACRI-LUBE * REFRESH LIQUIGEL * REFRESH OPTIVE * retaine cmc * saline mist * sea soft nasal mist * sochlor * ophthalmic sodium chloride * ophthalmic STERILE LUBRICANT * tears again * ophthalmic drops tears again * ophthalmic ointment

(Carboxymethylcel lulose Sodium) (Little Remedies) (Little Remedies) (Sodium Chloride) (Sodium Chloride) (Polyvinyl Alcohol) (Lanolin/Min Oil/Petrolat, Wht)

TEARS NATURALE II * tetracaine hcl

(Tetcaine) (Lanolin/Min ultra fresh pm * Oil/Petrolat, Wht) (Oxymetazoline vicks qlearquil(oxymetazoline) * HCl) vicks sinex 12-hour * (Afrin) wal-zyr (ketotifen) * (Zaditor) zyrtec itchy eye drops (keto) * (Zaditor) Eye, Ear, Nose, Throat Anti-Infectives Agents acetic acid otic (Acetic Acid) bacitracin ophthalmic (Bacitracin) (Bacitracin/Polymy bacitracin-polymyxin b ophthalmic xin B Sulfate) CIPRODEX ciprofloxacin hcl ophthalmic (Ciloxan)

Tier level

What the drug will cost you

4

$0

4 4 4 4

$0 $0 $0 $0

4

$0

4 4 4 4 4

$0 $0 $0 $0 $0

4

$0

4

$0

4 1

$0 $0

4

$0

4

$0

4 4 4

$0 $0 $0

1 1

$0 $0

1

$0

2 1

$0 $0

Necessary Actions, Restrictions, or Limits on Use

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 116

Tier level

What the drug will cost you

(Ilotycin) (Zymaxid) (Garamycin)

1 2 1 1 1

$0 $0 $0 $0 $0

(Garamycin)

1

$0

(Quixin)

1 2 2

$0 $0 $0

1

$0

1

$0

1

$0

1 1 1 1 1 1

$0 $0 $0 $0 $0 $0

4

$0

1

$0

1

$0

1

$0

Name of Drug ciprofloxacin hcl otic COLY-MYCIN S erythromycin ophthalmic gatifloxacin gentamicin ophthalmic gentamicin sulfate ophthalmic ointment 0.3 % (3 mg/gram) levofloxacin ophthalmic MOXEZA NATACYN neomy sulf-bacitrac zn-poly-hc neomycin-bacitracin-poly-hc neomycin-bacitracin-polymyxin neomycin-polymyxin b-dexameth neomycin-polymyxin-gramicidin neomycin-polymyxin-hc ofloxacin ophthalmic ofloxacin otic polymyxin b sulf-trimethoprim REFRESH OPTIVE ADVANCED * sulfacetamide sodium sulfacetamide sodium ophthalmic drops 10 % sulfacetamide-prednisolone

(Cetraxal)

(Neomycin Su/Baci Zn/Poly/HC) (Neomycin Su/Baci Zn/Poly/HC) (Neomycin Su/Bacitra/Polymy xin) (Maxitrol) (Neosporin) (Oticin HC) (Ocuflox) (Ocuflox) (Polytrim)

(Sulfacetamide Sodium) (Sulfacetamide Sodium) (Sulfacetamide/Pre dnisolone Sp)

Necessary Actions, Restrictions, or Limits on Use

TOBRADEX ST 2 $0 tobramycin (Tobrex) 1 $0 trifluridine (Viroptic) 1 $0 You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 117

Name of Drug

Tier level

VIGAMOX ZYLET Eye, Ear, Nose, Throat Anti-Inflammatory Agents ALREX (Bromfenac bromfenac Sodium) dexamethasone sodium phosphate (Dexasol) ophthalmic (Diclofenac diclofenac sodium ophthalmic Sodium) DUREZOL fluorometholone (FML) flurbiprofen sodium (Ocufen) fluticasone nasal (Flonase) ILEVRO ketorolac ophthalmic (Acular) LOTEMAX NASONEX NEVANAC prednisolone acetate (Omnipred) prednisolone sodium phosphate (Prednisolone Sod ophthalmic Phosphate) PROLENSA RESTASIS

What the drug will cost you

2 2

$0 $0

2

$0

1

$0

1

$0

1

$0

2 1 1 1 2 1 2 2 2 1

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0

1

$0

2 2

$0 $0

4 4 4 4 4 4 4

$0 $0 $0 $0 $0 $0 $0

Necessary Actions, Restrictions, or Limits on Use

QL (16 per 30 days)

QL (34 per 28 days)

QL (60 per 30 days)

Gastrointestinal Agents Antiflatulents anti-gas maximum strength * bicarsim forte * gas free extra strength * gas relief 80 * gas relief extra strength * oral gas relief * oral gas-x ultra-strength *

(Gas-X) (Simethicone) (Gas-X) (Gas-X) (Gas-X) (Gas-X) (Gas-X)

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 118

Name of Drug mi-acid gas relief * (Gas-X) mylanta gas * (Gas-X) mytab gas * (Gas-X) mytab gas maximum strength * (Gas-X) simethicone * oral capsule 180 mg (Gas-X) simethicone * oral (Infants' Mylicon) Antiulcer Agents And Acid Suppressants acid reducer (famotidine) * (Pepcid Ac) acid relief (cimetidine) * (Tagamet Hb) amoxicil-clarithromy-lansopraz (Prevpac) CARAFATE ORAL SUSPENSION cimetidine hcl oral (Cimetidine HCl) cimetidine oral tablet 200 mg, 300 (Tagamet) mg, 400 mg, 800 mg cvs cimetidine * 200 mg tablet (otc) (Tagamet Hb) esomeprazole sodium (Nexium I.V.) famotidine (pf) (Famotidine/PF) (Famotidine In famotidine (pf)-nacl (iso-os) Nacl,Iso-Osm/PF) famotidine oral tablet 20 mg, 40 mg (Pepcid) lansoprazole * dr 15 mg capsule (Prevacid 24hr) 2x14 day course (otc) lansoprazole oral capsule,delayed (Prevacid) release(dr/ec) 15 mg, 30 mg misoprostol (Cytotec) (Omeprazole omeprazole magnesium * Magnesium) omeprazole oral capsule,delayed (Prilosec) release(dr/ec) omeprazole * oral tablet,delayed (Omeprazole) release (dr/ec) omeprazole-sodium bicarbonate (Zegerid) oral capsule 20-1.1 mg-gram

Tier level

What the drug will cost you

4 4 4 4 4 4

$0 $0 $0 $0 $0 $0

4 4 1 2 1

$0 $0 $0 $0 $0

1

$0

4 1 1

$0 $0 $0

1

$0

1

$0

4

$0

1

$0

1

$0

4

$0

1

$0

4

$0

3

$0

Necessary Actions, Restrictions, or Limits on Use

(Rx Product Only)

(Rx Product Only)

(Rx Product Only)

(Rx Product Only)

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 119

Name of Drug pantoprazole intravenous

(Pantoprazole Sodium) (Protonix)

pantoprazole oral PRILOSEC OTC * pub famotidine * 20 mg tablet max (Pepcid Ac) strength (otc) ra omepraz-bicarb 20-1,100 cap (Zegerid Otc) 3x14 day course (otc) ranitidine 150 mg tablet maximum (Zantac) strength (otc) ranitidine hcl injection (Zantac) ranitidine hcl oral syrup (Ranitidine HCl) ranitidine hcl oral tablet 150 mg, (Zantac) 300 mg ranitidine hcl * oral tablet 75 mg (Zantac) sucralfate oral suspension (Sucralfate) sucralfate oral tablet (Carafate) wal-zan 75 * (Zantac) zantac 75 * (Zantac) Gastrointestinal Agents, Other acid gone antacid * (Gaviscon) (Maalox Maximum almacone * oral suspension Strength) (Maalox Maximum almacone-2 * Strength) aluminum hydroxide gel * oral (Aluminum suspension 320 mg/5 ml Hydroxide) AMITIZA (Calcium antacid anti-gas * oral Carbonate/Simethi cone) antacid extra-strength * oral (Tums) tablet,chewable 300 mg (750 mg) antacid * oral (Tums)

Tier level

What the drug will cost you

1

$0

1 4

$0 $0

4

$0

4

$0

4

$0

1 1

$0 $0

1

$0

4 1 1 4 4

$0 $0 $0 $0 $0

4

$0

4

$0

4

$0

4

$0

2

$0

4

$0

4

$0

4

$0

Necessary Actions, Restrictions, or Limits on Use

(Rx Product Only) (Rx Product Only) (Rx Product Only)

QL (60 per 30 days)

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 120

Tier level

What the drug will cost you

4

$0

4

$0

(Loperamide HCl)

4

$0

(Imodium A-D)

4

$0

(Pepto-Bismol)

4

$0

(Pepto-Bismol) (Tums)

4 2 4

$0 $0 $0

(Tums)

4

$0

4

$0

4 4 2

$0 $0 $0

4

$0

1 4 1 1 1

$0 $0 $0 $0 $0

1

$0

1

$0

4

$0

4

$0

Name of Drug antacid plus anti-gas * oral suspension anti-diarrheal * anti-diarrheal (loperamide) * oral capsule anti-diarrheal (loperamide) * oral bismatrol * oral suspension 262 mg/15 ml bismatrol * oral tablet,chewable BUPHENYL ORAL TABLET calci-chew * calcium carbonate * oral tablet,chewable 500 mg calcium (1,250 mg) CALCIUM CARBONATEVITAMIN D3 * ORAL TABLET,CHEWABLE 500-100 MG-UNIT cal-gest antacid * children's soothe * CHOLBAM comfort gel extra strength * cromolyn oral diamode * dicyclomine oral capsule dicyclomine oral solution dicyclomine oral tablet diphenoxylate-atropine oral liquid diphenoxylate-atropine oral tablet flanax antacid * foaming antacid *

(Maalox Maximum Strength) (Pepto-Bismol)

(Tums) (Tums) (Maalox Maximum Strength) (Gastrocrom) (Imodium A-D) (Bentyl) (Dicyclomine HCl) (Bentyl) (Diphenoxylate HCl/Atropine) (Lomotil) (Maalox Maximum Strength) (Gaviscon)

Necessary Actions, Restrictions, or Limits on Use

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 121

Tier level

What the drug will cost you

(Maalox Maximum Strength)

4

$0

(Almacone)

4

$0

(Robinul) (Robinul) (Loperamide HCl)

1 1 4 4 4 1 1 4

$0 $0 $0 $0 $0 $0 $0 $0

Name of Drug gelusil antacid & anti-gas * oral suspension gelusil antacid & anti-gas * oral tablet,chewable glycopyrrolate glycopyrrolate imodium a-d * oral liquid IMODIUM A-D * ORAL TABLET kaopectate (bismuth subsalicy) * lactulose oral solution loperamide oral loperamide * oral

Necessary Actions, Restrictions, or Limits on Use

(Pepto-Bismol) (Lactulose) (Loperamide HCl) (Loperamide HCl) (Maalox Maximum maalox advanced * oral suspension 4 $0 Strength) MAGNEBIND 300 * 4 $0 magnesium oxide * oral capsule (Uromag) 4 $0 500 mg magnesium oxide * oral tablet 250 (Magox 400) 4 $0 mg, 400 mg, 500 mg (Maalox Maximum masanti double strength * 4 $0 Strength) methscopolamine oral (Pamine) 1 $0 metoclopramide hcl injection (Reglan) 1 $0 (Metoclopramide metoclopramide hcl oral 1 $0 HCl) metoclopramide hcl oral (Reglan) 1 $0 mgo * (Magox 400) 4 $0 (Maalox Maximum mi-acid * oral suspension 4 $0 Strength) mi-acid * oral tablet,chewable (Rolaids) 4 $0 (Maalox Maximum mintox * 4 $0 Strength) (Maalox Maximum mintox maximum strength * 4 $0 Strength) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 122

Tier level

What the drug will cost you

4 2 2 4 4

$0 $0 $0 $0 $0

RELISTOR SUBCUTANEOUS

2

$0

RELISTOR SUBCUTANEOUS

2

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4 1 1

$0 $0 $0

4 4 4 4 4 4 4 4 4

$0 $0 $0 $0 $0 $0 $0 $0 $0

Name of Drug mintox plus * MOVANTIK NUTRESTORE pep-t-med * phillips *

ri-gel ii * ri-mox * sodium bicarbonate * oral tablet 650 mg soothe (bismuth subsalicylate) * oral soothe regular strength * stomach relief * oral ultra strength antacid * ursodiol oral capsule ursodiol oral tablet Laxatives alophen * bisac-evac * bisacodyl * oral bisacodyl * rectal biscolax * clearlax * oral colace * oral capsule 100 mg doc-q-lace * docu *

(Almacone)

(Pepto-Bismol) (Magox 400)

(Maalox Maximum Strength) (Maalox Maximum Strength) (Sodium Bicarbonate) (Bismuth Subsalicylate) (Pepto-Bismol) (Bismuth Subsalicylate) (Tums) (Actigall) (Urso) (Dulcolax) (Dulcolax) (Dulcolax) (Dulcolax) (Dulcolax) (Gavilax) (Sof-Lax) (Sof-Lax) (Docusate Sodium)

Necessary Actions, Restrictions, or Limits on Use QL (30 per 30 days)

PA; QL (28 per 28 days) PA; QL (28 per 28 days)

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 123

Tier level

What the drug will cost you

(Docusate Sodium) (Docusate Sodium) (Sof-Lax) (Docusate Sodium) (Sof-Lax) (Enema)

4 4 4 4 4 4

$0 $0 $0 $0 $0 $0

(Enema)

4

$0

(Docusate Sodium) (Docusol Plus) (Calcium Polycarbophil) (Fibercon) (Citrucel) (Psyllium Seed) (Psyllium Seed (With Sugar))

4 4

$0 $0

4

$0

4 4 4

$0 $0 $0

4

$0

(Citrucel)

4

$0

(Citrucel) (Fibercon) (Gavilax) (Gavilax) (Miralax) (Psyllium Seed) (Metamucil) (Fibercon)

4 4 4 4 3 4 4 4 4

$0 $0 $0 $0 $0 $0 $0 $0 $0

(Psyllium Husk)

4

$0

(Gavilax)

4

$0

(Miralax)

4

$0

Name of Drug docusate sodium * oral docusol * dok * oral capsule dok * oral tablet dulcolax stool softener (dss) * enema disposable * enema * rectal enema * 19-7 gram/118 ml enemeez * enemeez plus * equalactin * fiber (calcium polycarbophil) * fiber laxative (methylcellulo) * fiber smooth * fiber therapy (psyllium/sugar) * fiber therapy * oral powder 2 gram/19 gram fiber therapy * oral tablet fiber-lax * FLEET BISACODYL * gentlelax * glycolax * oral powder healthylax * hydrocil instant * konsyl (sugar) * oral konsyl fiber * konsyl sugar-free * oral powder in packet laxative peg 3350 * oral powder laxative peg 3350 * oral powder in packet

Necessary Actions, Restrictions, or Limits on Use

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 124

Tier level

What the drug will cost you

4

$0

4 2

$0 $0

4

$0

4

$0

1 1 1

$0 $0 $0

1

$0

4

$0

4

$0

4

$0

1

$0

(Miralax)

4

$0

(Docusate Sodium) (Gavilax) (Miralax) (Psyllium Seed (With Sugar)) (Sennosides) (Senokot) (Senokot) (Senokot) (Sennosides) (Sennosides)

4 4 4

$0 $0 $0

4

$0

4 4 4 4 4 4

$0 $0 $0 $0 $0 $0

Name of Drug milk of magnesia * mineral oil laxative * MOVIPREP natural fiber laxative therapy * oral saline laxative * oral peg 3350-electrolytes PEG 3350-GRX peg 3350-na sulf,bicarb,cl-kcl peg-electrolyte soln peri-colace * phillips liqui-gels * phosphate laxative * oral polyethylene glycol 3350 oral powder polyethylene glycol 3350 * oral powder in packet promolaxin * purelax * oral powder purelax * oral powder in packet reguloid * oral powder senexon * oral syrup senexon * oral tablet senna lax * senna laxative * oral tablet 8.6 mg senna * oral capsule senna * oral syrup 8.8 mg/5 ml

(Milk Of Magnesia) (Mineral Oil) (Psyllium Seed (With Sugar)) (Na Phos,M-B/Na Phos,Di-Ba) (Golytely) (Golytely) (Nulytely with Flavor Packs) (Sennosides/Docus ate Sodium) (Sof-Lax) (Na Phos,M-B/Na Phos,Di-Ba) (Polyethylene Glycol 3350)

Necessary Actions, Restrictions, or Limits on Use

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 125

Tier level

What the drug will cost you

4

$0

4

$0

4 4 4

$0 $0 $0

1

$0

(Surfak)

4

$0

(Dulcolax)

4

$0

(Phoslo) (Calcium Acetate)

1 1

$0 $0

4

$0

1

$0

4 2 2 2

$0 $0 $0 $0

1

$0

1

$0

1

$0

Name of Drug senna with docusate sodium * senokot-s * silace * oral liquid silace * oral syrup smoothlax * oral sodium chloride-nahco3-kcl-peg oral recon soln 420 gram stool softener * oral capsule 240 mg the magic bullet * Phosphate Binders calcium acetate oral capsule calcium acetate oral tablet 667 mg CALCIUM ACETATE * ORAL TABLET 668 MG (169 MG CALCIUM) calcium carbonate-mag carb-fa calphron * PHOSLYRA RENAGEL RENVELA sodium polystyrene sulfonate oral powder sodium polystyrene sulfonate oral suspension 15 gram/60 ml sodium polystyrene sulfonate rectal enema 30 gram/120 ml

(Sennosides/Docus ate Sodium) (Sennosides/Docus ate Sodium) (Docusate Sodium) (Colace) (Miralax) (Nulytely with Flavor Packs)

(Calcium Carbonate/Mag Carb/Fa) (Calcium Acetate)

(Sodium Polystyrene Sulfonate) (Sodium Polystyrene Sulfonate) (Sodium Polystyrene Sulfonate)

Necessary Actions, Restrictions, or Limits on Use

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 126

Name of Drug

Tier level

What the drug will cost you

1

$0

1

$0

1

$0

1 2

$0 $0

1

$0

1

$0

1 1 1

$0 $0 $0

1 2 2 2 2

$0 $0 $0 $0 $0

1

$0

2

$0

Necessary Actions, Restrictions, or Limits on Use

Genitourinary Agents Antispasmodics, Urinary oxybutynin chloride oral tablet

(Oxybutynin Chloride)

oxybutynin chloride oral tablet (Ditropan XL) extended release 24hr tolterodine oral capsule,extended (Detrol LA) release 24hr tolterodine oral tablet (Detrol) TOVIAZ trospium oral capsule,extended (Sanctura XR) release 24hr trospium oral tablet (Sanctura) Genitourinary Agents, Miscellaneous alfuzosin (Uroxatral) tamsulosin (Flomax) terazosin (Terazosin HCl)

Heavy Metal Antagonists Heavy Metal Antagonists deferoxamine injection recon soln (Desferal) DEPEN TITRATABS EXJADE FERRIPROX JADENU sodium thiosulfate intravenous (Sodium solution 1 gram/10 ml (100 mg/ml), Thiosulfate) 12.5 gram/50 ml (250 mg/ml) SYPRINE

PA BvD

Hormonal Agents, Stimulant/Replacement/Modifying Androgens ANDRODERM

2

$0

PA; QL (30 per 30 days)

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 127

Name of Drug ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 1.25 GRAM/ ACTUATION (1 %) ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 20.25 MG/1.25 GRAM (1.62 %) ANDROGEL TRANSDERMAL GEL IN PACKET 1 % (25 MG/2.5GRAM), 1 % (50 MG/5 GRAM) ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62 % (40.5 MG/2.5 GRAM) danazol oral fluoxymesterone oxandrolone

Tier level

What the drug will cost you

2

$0

PA; QL (300 per 30 days)

2

$0

PA; QL (150 per 30 days)

2

$0

2

$0

1 1 1

$0 $0 $0

1

$0

testosterone enanthate testosterone transdermal gel in (Androgel) packet 1 % (25 mg/2.5gram) Estrogens And Antiestrogens

1

$0

1

$0

COMBIPATCH

2

$0

DUAVEE ESTRACE VAGINAL estradiol oral estradiol transdermal patch semiweekly

(Estrace)

2 2 1

$0 $0 $0

(Vivelle-Dot)

1

$0

estradiol transdermal patch weekly

(Climara)

1

$0

estradiol valerate estradiol/norethindrone acet

(Delestrogen) (Activella)

1 1

$0 $0

testosterone cypionate

(Danazol) (Fluoxymesterone) (Oxandrin) (DepoTestosterone) (Delatestryl)

Necessary Actions, Restrictions, or Limits on Use

PA; QL (300 per 30 days) PA; QL (150 per 30 days)

PA PA; QL (5 per 28 days) PA; QL (150 per 30 days) PA-HRM; QL (8 per 28 days) PA-HRM PA-HRM PA-HRM; QL (8 per 28 days) PA-HRM; QL (4 per 28 days) PA-HRM

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 128

Tier level

What the drug will cost you

1

$0

ESTRASORB

2

$0

estropipate (Ogen) FEMRING MENEST norethindrone ac-eth estradiol oral (Femhrt) tablet 1-5 mg-mcg PREMARIN INJECTION PREMARIN ORAL PREMARIN VAGINAL PREMPHASE PREMPRO raloxifene (Evista) VAGIFEM Glucocorticoids/Mineralocorticoids betamethasone acet,sod phos (Celestone) cortisone (Cortisone Acetate) dexamethasone oral (Dexamethasone) dexamethasone oral (Dexamethasone) dexamethasone sodium phosphate (Dexamethasone injection Sod Phosphate) (Fludrocortisone fludrocortisone Acetate) hydrocortisone oral (Cortef) (Hydrocortisone hydrocortisone sod succinate Sod Succinate) methylprednisolone (Medrol) methylprednisolone acetate (Depo-Medrol) methylprednisolone sodium succ (A-Methapred) injection recon soln 125 mg, 40 mg methylprednisolone sodium succ (A-Methapred) intravenous

1 2 2

$0 $0 $0

1

$0

2 2 2 2 2 1 2

$0 $0 $0 $0 $0 $0 $0

1 1 1 1

$0 $0 $0 $0

1

$0

1

$0

1

$0

1

$0

1 1

$0 $0

1

$0

1

$0

Name of Drug estradiol-norethindrone acet

(Activella)

Necessary Actions, Restrictions, or Limits on Use PA-HRM PA-HRM; QL (97.44 per 28 days) PA-HRM QL (1 per 84 days) PA-HRM PA-HRM

PA-HRM PA-HRM PA-HRM QL (18 per 28 days) PA BvD PA BvD PA BvD PA BvD PA BvD

PA BvD PA BvD PA BvD PA BvD PA BvD PA BvD

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 129

Tier level

What the drug will cost you

(Orapred)

1

$0

(Prednisone)

1

$0

2

$0

1

$0

1

$0

1

$0

1

$0

Name of Drug prednisolone sodium phosphate oral solution prednisone SOLU-CORTEF (PF) INJECTION RECON SOLN 100 MG/2 ML triamcinolone acetonide injection

(Triamcinolone Acetonide)

Necessary Actions, Restrictions, or Limits on Use PA BvD PA BvD PA BvD

Pituitary desmopressin injection desmopressin nasal desmopressin nasal

(Desmopressin Acetate) (DDAVP) (Desmopressin Acetate) (DDAVP)

QL (15 per 30 days) QL (15 per 30 days)

desmopressin oral 1 $0 GENOTROPIN 2 $0 PA GENOTROPIN MINIQUICK 2 $0 PA HUMATROPE 2 $0 PA INCRELEX 2 $0 NORDITROPIN FLEXPRO 2 $0 PA NUTROPIN 2 $0 PA NUTROPIN AQ NUSPIN 2 $0 PA NUTROPIN AQ PA 2 $0 SUBCUTANEOUS octreotide acetate injection solution 1,000 mcg/ml, 100 mcg/ml, 200 (Sandostatin) 1 $0 mcg/ml, 500 mcg/ml octreotide acetate injection solution (Octreotide 1 $0 50 mcg/ml Acetate) (Octreotide octreotide acetate injection syringe 1 $0 Acetate) OMNITROPE 2 $0 PA PREGNYL 2 $0 SAIZEN 2 $0 PA SAIZEN CLICK.EASY 2 $0 PA You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 130

Name of Drug SANDOSTATIN LAR DEPOT INTRAMUSCULAR KIT SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG, 5 MG, 6 MG SOMATULINE DEPOT SOMAVERT SUPPRELIN LA TEV-TROPIN vasopressin (Pitressin) ZOMACTON Progestins DEPO-PROVERA INTRAMUSCULAR SOLUTION medroxyprogesterone (Depo-Provera) intramuscular suspension medroxyprogesterone (Medroxyprogester intramuscular syringe one Acetate) medroxyprogesterone oral (Provera) norethindrone acetate (Aygestin) progesterone (Progesterone) progesterone micronized capsules (Prometrium) Thyroid And Antithyroid Agents (Levothyroxine levothyroxine intravenous Sodium) levothyroxine oral (Levoxyl) liothyronine oral (Cytomel) methimazole oral tablet 10 mg, 5 (Tapazole) mg propylthiouracil (Propylthiouracil)

Tier level

What the drug will cost you

2

$0

Necessary Actions, Restrictions, or Limits on Use

PA 2

$0

2 2 2 2 1 2

$0 $0 $0 $0 $0 $0

2

$0

1

$0

1

$0

1 1 1 1

$0 $0 $0 $0

1

$0

1 1

$0 $0

1

$0

1

$0

2

$0

QL (1 per 28 days) QL (1 per 360 days) PA PA QL (10 per 28 days) QL (1 per 84 days) QL (1 per 84 days)

Immunological Agents Immunological Agents ARCALYST

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 131

Tier level

What the drug will cost you

ASTAGRAF XL

2

$0

AUBAGIO

2

$0

1

$0

1

$0

Name of Drug

azathioprine azathioprine sodium CARIMUNE NF NANOFILTERED INTRAVENOUS RECON SOLN CELLCEPT INTRAVENOUS cyclosporine intravenous cyclosporine modified cyclosporine oral capsule cyclosporine, modified ENBREL ENBREL SURECLICK FLEBOGAMMA DIF GAMASTAN S/D GAMMAGARD LIQUID GAMMAPLEX GAMUNEX-C INJECTION SOLUTION HUMIRA HUMIRA PEN HUMIRA PEN CROHN'S-UC-HS START HYPERRAB S/D (PF) HYQVIA ILARIS (PF) IMOGAM RABIES-HT (PF)

(Imuran) (Azathioprine Sodium)

PA BvD PA; QL (28 per 28 days) PA BvD PA BvD PA BvD

(Sandimmune) (Neoral) (Sandimmune) (Neoral)

KINERET leflunomide

Necessary Actions, Restrictions, or Limits on Use

(Arava)

2

$0

2 1 1 1 1 2 2 2 2 2 2

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

2

$0

2 2

$0 $0

2

$0

2 2 2 2

$0 $0 $0 $0

PA BvD PA

2

$0

PA; QL (18.76 per 28 days)

1

$0

PA BvD PA BvD PA BvD PA BvD PA BvD PA PA PA BvD PA BvD PA BvD PA BvD PA BvD PA PA PA

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 132

Tier level

What the drug will cost you

Necessary Actions, Restrictions, or Limits on Use

1 1 2 2 2 2 2 2 2

$0 $0 $0 $0 $0 $0 $0 $0 $0

2

$0

PA BvD PA BvD PA BvD PA BvD PA; QL (4 per 28 days) PA PA BvD PA BvD PA BvD PA BvD

2 1 1

$0 $0 $0

TYSABRI

2

$0

ZORTRESS

2

$0

2

$0

2

$0

2 2 2 2 2

$0 $0 $0 $0 $0

2

$0

2 2 2 2

$0 $0 $0 $0

Name of Drug mycophenolate mofetil mycophenolate sodium NULOJIX OCTAGAM ORENCIA ORENCIA (WITH MALTOSE) PRIVIGEN PROGRAF INTRAVENOUS RAPAMUNE ORAL SOLUTION RAPAMUNE ORAL TABLET 1 MG, 2 MG RIDAURA sirolimus tacrolimus oral

(Cellcept) (Myfortic)

(Rapamune) (Hecoria)

Vaccines ACTHIB (PF) ADACEL(TDAP ADOLESN/ADULT)(PF) BCG VACCINE, LIVE (PF) BEXSERO (PF) BOOSTRIX TDAP CERVARIX VACCINE (PF) COMVAX (PF) DAPTACEL (DTAP PEDIATRIC) (PF) ENGERIX-B (PF) ENGERIX-B PEDIATRIC (PF) GARDASIL (PF) GARDASIL 9 (PF)

PA BvD PA BvD PA; LA; QL (15 per 28 days) PA BvD; QL (120 per 30 days)

PA BvD

PA BvD PA BvD

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 133

Name of Drug HAVRIX (PF) INTRAMUSCULAR SUSPENSION HAVRIX (PF) INTRAMUSCULAR SYRINGE IMOVAX RABIES VACCINE (PF) INFANRIX (DTAP) (PF) INTRAMUSCULAR IPOL INJECTION SUSPENSION IXIARO (PF) KINRIX (PF) MENACTRA (PF) INTRAMUSCULAR SOLUTION MENHIBRIX (PF) MENOMUNE - A/C/Y/W-135 (PF) MENVEO A-C-Y-W-135-DIP (PF) MENVEO MENA COMPONENT (PF) MENVEO MENCYW-135 COMPNT (PF) M-M-R II (PF) PEDIARIX (PF) PEDVAX HIB (PF) PENTACEL (PF) PENTACEL ACTHIB COMPONENT (PF) PROQUAD (PF) QUADRACEL (PF) RABAVERT (PF) RECOMBIVAX HB (PF) ROTARIX ROTATEQ VACCINE

Tier level

What the drug will cost you

2

$0

2

$0

2

$0

2

$0

2 2 2

$0 $0 $0

2

$0

2 2 2

$0 $0 $0

2

$0

2

$0

2 2 2 2

$0 $0 $0 $0

2

$0

2 2 2 2 2 2

$0 $0 $0 $0 $0 $0

Necessary Actions, Restrictions, or Limits on Use

PA BvD

PA BvD PA BvD

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 134

Name of Drug TENIVAC (PF) INTRAMUSCULAR TETANUS TOXOID,ADSORBED (PF) TETANUS,DIPHTHERIA TOX PED(PF) TETANUS-DIPHTHERIA TOXOIDS-TD TICE BCG TRUMENBA TWINRIX (PF) TYPHIM VI VAQTA (PF) VARIVAX (PF) YF-VAX (PF) ZOSTAVAX (PF)

Tier level

What the drug will cost you

2

$0

2

$0

2

$0

2

$0

2 2 2 2 2 2 2 2

$0 $0 $0 $0 $0 $0 $0 $0

1 2 2 1 1 2 2

$0 $0 $0 $0 $0 $0 $0

1 1

$0 $0

2

$0

1

$0

Necessary Actions, Restrictions, or Limits on Use

PA BvD

PA BvD

QL (1 per 365 days)

Inflammatory Bowel Disease Agents Inflammatory Bowel Disease Agents alosetron (Alosetron HCl) APRISO ASACOL HD balsalazide (Colazal) budesonide oral (Entocort EC) DELZICOL DIPENTUM

ST

Irrigating Solutions Irrigating Solutions acetic acid irrigation GLYCINE IRRIGATION LACTATED RINGERS IRRIGATION ringers irrigation

(Acetic Acid)

(Tis-U-Sol)

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 135

Name of Drug sodium chloride irrigation sorbitol irrigation sorbitol-mannitol water for irrigation, sterile

(Sodium Chloride Irrig Solution) (Sorbitol Solution) (Mannitol/Sorbitol Solution) (Water For Irrigation,Sterile)

Tier level

What the drug will cost you

1

$0

1

$0

1

$0

1

$0

1

$0

1

$0

1

$0

1

$0

1

$0

Necessary Actions, Restrictions, or Limits on Use

Metabolic Bone Disease Agents Metabolic Bone Disease Agents (Alendronate alendronate oral solution Sodium) alendronate oral tablet 10 mg, 40 (Fosamax) mg, 5 mg alendronate oral tablet 35 mg, 70 (Fosamax) mg calcitonin (salmon) (Miacalcin) calcitriol intravenous solution 1 (Calcitriol) mcg/ml calcitriol oral

(Rocaltrol)

1

$0

doxercalciferol intravenous

(Doxercalciferol)

1

$0

doxercalciferol oral

(Hectorol)

1

$0

etidronate disodium

(Etidronate Disodium)

1

$0

FORTEO

2

$0

FORTICAL

2

$0

ibandronate intravenous solution

(Ibandronate Sodium)

1

$0

ibandronate intravenous syringe

(Boniva)

1

$0

QL (300 per 28 days)

QL (4 per 28 days) QL (3.7 per 28 days) PA BvD; (PA for ESRD Only) PA BvD; (PA for ESRD Only) PA BvD; (PA for ESRD Only) PA BvD; (PA for ESRD Only)

PA; QL (2.4 per 28 days) QL (3.7 per 28 days) PA BvD; (PA for ESRD Only); QL (3 per 84 days) PA BvD; QL (3 per 84 days)

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 136

Tier level

What the drug will cost you

Necessary Actions, Restrictions, or Limits on Use

1

$0

MIACALCIN INJECTION

2

$0

NATPARA

2

$0

(Zemplar)

1

$0

(Actonel)

2 1

$0 $0

XGEVA

2

$0

ZEMPLAR INTRAVENOUS

2

$0

QL (1 per 28 days) PA BvD; (PA for ESRD Only) PA; QL (2 per 28 days) PA BvD; (PA for ESRD Only) QL (1 per 180 days) QL (1 per 28 days) PA; QL (1.7 per 28 days) PA BvD; (PA for ESRD Only)

(Zometa) (Zoledronic Acid/Mannitol and Water)

1

$0

1

$0

(Reclast)

1

$0

2

$0

ACTEMRA INTRAVENOUS

2

$0

ACTEMRA SUBCUTANEOUS

2

$0

ACTIMMUNE allopurinol

2 1

$0 $0

1

$0

1

$0

Name of Drug ibandronate oral

paricalcitol oral PROLIA risedronate oral tablet 150 mg

zoledronic acid intravenous zoledronic acid-mannitol-water intravenous piggyback zoledronic acid-mannitol-water intravenous solution ZOMETA INTRAVENOUS SOLUTION 4 MG/100 ML

(Boniva)

QL (100 per 300 days)

Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents

amifostine crystalline anticoag citrate phos dextrose

(Zyloprim) (Amifostine Crystalline) (Citrate Phosphate Dextros Soln)

PA; QL (40 per 30 days) PA; QL (3.6 per 28 days)

AVODART 2 $0 AVONEX (WITH ALBUMIN) 2 $0 ST You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 137

Tier level

What the drug will cost you

2 2

$0 $0

2

$0

2 1

$0 $0

2

$0

2

$0

1 2 1

$0 $0 $0

1

$0

2

$0

2

$0

1

$0

(Acetic Acid) (Droperidol)

2 4 1 2

$0 $0 $0 $0

(Ergoloid Mesylates)

1

$0

(Acetic Acid) (Acetic Acid) (Proscar) (Fomepizole)

2 4 4 1 1 2

$0 $0 $0 $0 $0 $0

Name of Drug AVONEX INTRAMUSCULAR AVONEX INTRAMUSCULAR BENLYSTA INTRAVENOUS RECON SOLN BETASERON SUBCUTANEOUS bethanechol chloride BOTOX INJECTION RECON SOLN 100 UNIT BOTOX INJECTION RECON SOLN 200 UNIT buspirone CERDELGA colchicine oral tablet colchicine-probenecid COLCRYS COPAXONE SUBCUTANEOUS SYRINGE CURITY GAUZE TOPICAL BANDAGE 2 X 2 " CYSTADANE douche vinegar & water extra * droperidol injection solution ELMIRON ergoloid EXTAVIA SUBCUTANEOUS extra cleansing douche * feminine care douche * finasteride oral tablet 5 mg fomepizole FUSILEV

(Urecholine)

(Buspirone HCl) (Colcrys) (Colchicine/Proben ecid)

Necessary Actions, Restrictions, or Limits on Use ST ST PA ST PA; QL (4 per 90 days) PA; QL (1 per 90 days)

PA

ST

PA; QL (28 per 28 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document.

GILENYA

2

$0

Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 138

Tier level

What the drug will cost you

2

$0

2

$0

(Guanidine HCl) (Hydroxyzine HCl)

1 1

$0 $0

(Hydroxyzine HCl)

1

$0

(Hydroxyzine HCl) (Vistaril)

1 1 2

$0 $0 $0

2

$0

1

$0

1

$0

1

$0

1

$0

1

$0

1 2 2 4 4

$0 $0 $0 $0 $0

1

$0

OTEZLA

2

$0

OTEZLA STARTER

2

$0

PLEGRIDY

2

$0

Name of Drug GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT (HUMAN) guanidine hydroxyzine hcl intramuscular hydroxyzine hcl oral solution 10 mg/5 ml hydroxyzine hcl oral tablet hydroxyzine pamoate JALYN LEMTRADA leucovorin calcium injection recon soln 100 mg, 200 mg, 350 mg leucovorin calcium oral levocarnitine (with sugar) levocarnitine oral levoleucovorin calcium mesna MESNEX ORAL MESTINON ORAL SYRUP MINERAL OIL * mineral oil light * morrhuate sodium

(Leucovorin Calcium) (Leucovorin Calcium) (Levocarnitine (With Sugar)) (Carnitor) (Levoleucovorin Calcium) (Mesnex)

(Mineral Oil) (Sodium Morrhuate)

Necessary Actions, Restrictions, or Limits on Use

PA-HRM PA-HRM PA-HRM PA-HRM QL (30 per 30 days) PA; QL (9.6 per 365 days)

PA BvD; (PA for ESRD Only) PA BvD; (PA for ESRD Only)

PA; QL (60 per 30 days) PA; QL (60 per 30 days) ST

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 139

Name of Drug probenecid PROCYSBI pyridostigmine bromide REBIF (WITH ALBUMIN) REBIF REBIDOSE REBIF TITRATION PACK REMICADE SENSIPAR

(Probenecid) (Mestinon)

SIMPONI ARIA SIMPONI SUBCUTANEOUS PEN INJECTOR 100 MG/ML SIMPONI SUBCUTANEOUS PEN INJECTOR 50 MG/0.5 ML SIMPONI SUBCUTANEOUS SYRINGE 100 MG/ML SIMPONI SUBCUTANEOUS SYRINGE 50 MG/0.5 ML SOLIRIS STELARA SUBCUTANEOUS SYRINGE STERILE PADS TOPICAL BANDAGE 2 X 2 " summer's eve disposable douche * (Acetic Acid) vaginal solution summers eve extra cleansing * (Acetic Acid) SUSPENDOL-S * SYNAREL TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG

Tier level

What the drug will cost you

1 2 1 2 2 2 2 2

$0 $0 $0 $0 $0 $0 $0 $0

2

$0

2

$0

2

$0

2

$0

2

$0

2

$0

2

$0

1

$0

4

$0

4 4 2

$0 $0 $0

2

$0

Necessary Actions, Restrictions, or Limits on Use

PA PA; QL (12 per 28 days) PA; QL (3 per 28 days) PA; QL (0.5 per 28 days) PA; QL (3 per 28 days) PA; QL (0.5 per 28 days) PA

PA; QL (14 per 30 days)

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 140

Name of Drug

Tier level

What the drug will cost you

TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG (14)240 MG (46), 240 MG

2

$0

THALOMID

2

$0

TYBOST

2

$0

ULORIC

2

$0

XELJANZ

2

$0

(Diamox Sequels)

1

$0

(Acetazolamide) (Acetazolamide Sodium)

1

$0

1

$0

2

$0

2 1 1 1 2 1 1 1 1

$0 $0 $0 $0 $0 $0 $0 $0 $0

2

$0

1 1

$0 $0

Necessary Actions, Restrictions, or Limits on Use PA; QL (60 per 30 days) PA NSO; QL (60 per 30 days) QL (30 per 30 days) ST; QL (30 per 30 days) PA; QL (60 per 30 days)

Ophthalmic Agents Antiglaucoma Agents acetazolamide oral capsule, extended release acetazolamide oral tablet acetazolamide sodium ALPHAGAN P OPHTHALMIC DROPS 0.1 % AZOPT betaxolol ophthalmic bimatoprost brimonidine COMBIGAN dorzolamide dorzolamide-timolol latanoprost levobunolol LUMIGAN OPHTHALMIC DROPS 0.01 % methazolamide oral metipranolol

(Betaxolol HCl) (Bimatoprost) (Alphagan P) (Trusopt) (Cosopt) (Xalatan) (Betagan)

(Neptazane) (Metipranolol)

(drops: 0.15%, 0.20%)

QL (2.5 per 25 days)

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 141

Tier level

What the drug will cost you

2

$0

(Isopto Carpine)

1

$0

(Timolol Maleate)

2 1

$0 $0

(Timoptic-Xe)

1

$0

2

$0

1

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4 4

$0 $0

4

$0

4

$0

4

$0

4

$0

Name of Drug PHOSPHOLINE IODIDE pilocarpine hcl ophthalmic drops 1 %, 2 %, 4 % SIMBRINZA timolol maleate ophthalmic drops timolol maleate ophthalmic gel forming solution TRAVATAN Z travoprost (benzalkonium)

(Travoprost (Benzalkonium))

Necessary Actions, Restrictions, or Limits on Use

QL (2.5 per 25 days) QL (2.5 per 25 days)

Replacement Preparations Replacement Preparations (Ca/D3/Mag ca-d3-mag ox-zinc-cop-mang-bor * Ox/Zinc/Cop/Mang oral tablet,chewable /Bor) (Calcium calcionate * Glubionate) calcitrate * (Calcium Citrate) (Citracal-Vitamin calcitrate-vitamin d * D) calcium 500 + d (d3) * (Os-Cal 500+D) calcium 500 + d * oral tablet 500 (Os-Cal 500+D) mg(1,250mg) -400 unit calcium 500 with d * (Os-Cal 500+D) calcium 600 * (Caltrate 600) (Calcium calcium 600 + d(3) * oral capsule Carbonate/Vitamin D3) calcium 600 + d(3) * oral tablet (Os-Cal 500+D) (Calcium calcium 600 with vitamin d3 * oral Carbonate/Vitamin D3) (Calcium calcium carbonate * oral Carbonate)

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 142

Name of Drug calcium carbonate * oral tablet 260 (Caltrate 600) mg calcium (648 mg) (Calcium calcium carbonate-vitamin d2 * Carbonate/Vitamin D2) calcium carbonate-vitamin d3 * (Calcium oral capsule 600 mg(1,500mg) -100 Carbonate/Vitamin unit, 600 mg(1,500mg) -400 unit, D3) 600 mg(1,500mg) -500 unit calcium carbonate-vitamin d3 * (Os-Cal 500+D) oral tablet calcium carbonate-vitamin d3 * oral tablet,chewable 500 (Os-Cal 500+D) mg(1,250mg) -400 unit calcium chloride intravenous (Calcium Chloride) calcium citrate-vitamin d3 * oral (Citracal-Vitamin tablet 315-250 mg-unit D) (Calcium calcium gluconate intravenous Gluconate) calcium gluconate * oral tablet 45 (Calcium mg (500 mg) Gluconate) calcium lactate * oral tablet 84 mg (Calcium Lactate) (648 mg), 84 mg (650 mg) calcium+d * oral tablet (Os-Cal 500+D) CALTRATE 600 + D * CALTRATE-600 + D VIT D3 (800) * CENTRUM PRO NUTRIENTS * (Citracal-Vitamin citracal + d maximum * D) (Citric citric acid-sodium citrate Acid/Sodium Citrate)

Tier level

What the drug will cost you

4

$0

4

$0

4

$0

4

$0

4

$0

1

$0

4

$0

1

$0

4

$0

4

$0

4 4

$0 $0

4

$0

4

$0

4

$0

1

$0

Necessary Actions, Restrictions, or Limits on Use

PA BvD; (PA for ESRD Only)

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 143

Name of Drug citrus calcium * oral tablet coral calcium * oral tablet electrolyte-48 in d5w enfalyte * hi-cal plus vit d * HYPERLYTE CR IONOSOL-B IN D5W IONOSOL-MB IN D5W ISOLYTE M IN 5 % DEXTROSE ISOLYTE-H IN 5 % DEXTROSE ISOLYTE-P IN 5 % DEXTROSE ISOLYTE-S KELP (IODINE) * KLOR-CON klor-con 10

(Citracal-Vitamin D) (Caltrate 600) (Electrolyte-48 Solution/D5W) (Pedialyte) (Os-Cal 500+D)

(Potassium Chloride)

KLOR-CON 8 klor-con m10 klor-con m15 klor-con m20 klor-con sprinkle KLOR-CON/EF

(Potassium Chloride) (Potassium Chloride) (Potassium Chloride) (Micro-K)

Tier level

What the drug will cost you

4

$0

4

$0

1

$0

4 4 2 2 2 2 2 2 2 4 1

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

1

$0

1

$0

1

$0

1

$0

1

$0

1 1

$0 $0

Necessary Actions, Restrictions, or Limits on Use

(Calcium Carbonate/Vitamin 4 $0 D3) (Magnesium mag 64 * 4 $0 Chloride) (Magnesium mag-delay * 4 $0 Chloride) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. liquid calcium with vitamin d *

Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 144

Name of Drug mag-g * magnesium (oxide/aa chelate) * magnesium chloride injection magnesium gluconate * oral tablet magnesium * oral tablet 250 mg magnesium sulf in 0.45% nacl magnesium sulfate in d5w intravenous piggyback 1 gram/100 ml, 4 gram/100 ml magnesium sulfate in water magnesium sulfate injection natural calcium * NORMOSOL-M IN 5 % DEXTROSE NORMOSOL-R NORMOSOL-R PH 7.4 NUTRILYTE NUTRILYTE II oralyte * oysco 500/d * oral tablet oysco d * oysco-500 * oyster shell calcium 500 * oyster shell calcium with d * oyster shell calcium-vit d3 * oystercal-d *

(Magonate) (Magnesium Oxide/Mag Aa Chelate) (Magnesium Chloride) (Magonate) (Magnesium) (Magnesium Sulf In 0.45% NaCl) (Magnesium Sulfate/D5W) (Magnesium Sulfate in Water) (Magnesium Sulfate) (Caltrate 600)

(Pedialyte) (Os-Cal 500+D) (Os-Cal 500+D) (Caltrate 600) (Caltrate 600) (Calcium Carbonate/Vitamin D2) (Os-Cal 500+D) (Os-Cal 500+D)

Tier level

What the drug will cost you

4

$0

4

$0

1

$0

4 4

$0 $0

1

$0

1

$0

1

$0

1

$0

4

$0

2

$0

2 2 2 2 4 4 4 4 4

$0 $0 $0 $0 $0 $0 $0 $0 $0

4

$0

4 4

$0 $0

Necessary Actions, Restrictions, or Limits on Use

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 145

Tier level

What the drug will cost you

4 4 4 1 2 2

$0 $0 $0 $0 $0 $0

2

$0

1

$0

1

$0

1

$0

1

$0

1

$0

1

$0

(Potassium Chloride In D5w)

1

$0

(Potassium Chloride)

1

$0

(Micro-K)

1

$0

(Kaochlor) (Klor-Con)

1 1

$0 $0

(Klor-Con 8)

1

$0

(Klor-Con 8)

1

$0

Name of Drug pediatric electrolyte * oral solution pediatric freezer pops * PHOS-NAK * phosphorus #1 PLASMA-LYTE 148 PLASMA-LYTE A PLASMA-LYTE-56 IN 5 % DEXTROSE potassium acetate intravenous potassium bicarb and chloride potassium bicarb-citric acid potassium bicarbonate-cit ac oral tablet, effervescent 25 meq potassium chlorid-d5-0.45%nacl potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 30 meq/l, 40 meq/l potassium chloride intravenous potassium chloride oral capsule, extended release potassium chloride oral liquid potassium chloride oral packet potassium chloride oral tablet extended release potassium chloride oral tablet,er particles/crystals 10 meq

(Pedialyte) (Pedialyte) (K-Phos Neutral)

(Potassium Acetate) (Pot Chloride/Pot Bicarb/Cit Ac) (Klor-Con-Ef) (Klor-Con-Ef) (Potassium Chloride/D50.45nacl) (Potassium Chloride In 0.9%NaCl)

Necessary Actions, Restrictions, or Limits on Use

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 146

Name of Drug

Tier level

What the drug will cost you

Necessary Actions, Restrictions, or Limits on Use

potassium chloride oral tablet,er particles/crystals 20 meq

(Potassium 1 $0 Chloride) (Potassium potassium chloride-0.45 % nacl Chloride-0.45% 1 $0 NaCl) (Potassium potassium chloride-d5-0.2%nacl Chloride/D51 $0 0.2%NaCl) potassium chloride-d5-0.3%nacl (Potassium intravenous parenteral solution 20 Chloride/D51 $0 meq/l 0.3%NaCl) (Potassium potassium chloride-d5-0.9%nacl Chloride/D51 $0 0.9%NaCl) potassium citrate-citric acid oral (Potassium 1 $0 packet 3,300-1,002 mg Citrate/Citric Acid) potassium citrate-citric acid oral (Potassium 1 $0 solution 1,100-334 mg/5 ml Citrate/Citric Acid) (Potassium potassium phosphate m-/d-basic Phos,M-Basic-D1 $0 Basic) ringers intravenous (Ringers Solution) 1 $0 sodium acetate intravenous (Sodium Acetate) 1 $0 (Sodium sodium bicarbonate intravenous 1 $0 Bicarbonate) (Sodium Chloride sodium chloride 0.45 % intravenous 1 $0 0.45 %) sodium chloride 0.9 % injection (0.9 % Sodium 1 $0 solution Chloride) (0.9 % Sodium sodium chloride 0.9 % intravenous 1 $0 Chloride) (Sodium Chloride sodium chloride 3 % 1 $0 3 %) (Sodium Chloride sodium chloride 5 % 1 $0 5 %) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 147

Name of Drug sodium chloride intravenous sodium citrate-citric acid sodium lactate intravenous sodium phosphate sod-pot-k cit-sod cit-cit acid

(Sodium Chloride) (Citric Acid/Sodium Citrate) (Sodium Lactate) (Sodium Phos,MBasic-D-Basic) (Sod/Pot/K Cit/Sod Cit/Cit Acid)

TPN ELECTROLYTES TPN ELECTROLYTES II

Tier level

What the drug will cost you

1

$0

1

$0

1

$0

1

$0

1

$0

2 2

$0 $0

2 2 2 2

$0 $0 $0 $0

2

$0

Necessary Actions, Restrictions, or Limits on Use

Respiratory Tract Agents Anti-Inflammatories, Inhaled Corticosteroids ADVAIR DISKUS ADVAIR HFA BREO ELLIPTA DULERA FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 50 MCG/ACTUATION FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCG/ACTUATION FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION QVAR

QL (60 per 30 days) QL (12 per 28 days) QL (60 per 30 days) QL (13 per 28 days) QL (60 per 30 days)

QL (120 per 30 days) 2

$0 QL (12 per 28 days)

2

$0

2

$0

2

$0

2

$0

QL (24 per 28 days) QL (21.2 per 28 days) QL (17.4 per 25 days)

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 148

Tier level

What the drug will cost you

(Singulair) (Accolate)

1 1

$0 $0

(Albuterol Sulfate)

1

$0

(Albuterol Sulfate) (Albuterol Sulfate)

1 1

$0 $0

(Vospire ER)

1

$0

2 2 2

$0 $0 $0

1

$0

2 2 2 2 2 2 2

$0 $0 $0 $0 $0 $0 $0

1

$0

1

$0

(Theophylline Anhydrous)

1

$0

(Theophylline/D5 W)

1

$0

Name of Drug Antileukotrienes montelukast zafirlukast Bronchodilators albuterol sulfate inhalation solution for nebulization albuterol sulfate oral syrup albuterol sulfate oral tablet albuterol sulfate oral tablet extended release 12 hr ANORO ELLIPTA ATROVENT HFA COMBIVENT RESPIMAT metaproterenol oral

(Metaproterenol Sulfate)

PROAIR HFA PROAIR RESPICLICK SEREVENT DISKUS SPIRIVA RESPIMAT SPIRIVA WITH HANDIHALER STIOLTO RESPIMAT STRIVERDI RESPIMAT terbutaline oral terbutaline subcutaneous theophylline anhydrous oral tablet extended release 12 hr 100 mg, 200 mg, 300 mg theophylline in dextrose 5 % intravenous parenteral solution 200 mg/100 ml, 200 mg/50 ml, 400 mg/250 ml, 400 mg/500 ml, 800 mg/250 ml

(Terbutaline Sulfate) (Terbutaline Sulfate)

Necessary Actions, Restrictions, or Limits on Use

PA BvD

QL (60 per 30 days) QL (25.8 per 28 days) QL (8 per 30 days)

QL (17 per 25 days) QL (2 per 25 days) QL (60 per 30 days) QL (4 per 30 days) QL (30 per 30 days) QL (4 per 28 days)

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 149

Tier level

What the drug will cost you

1

$0

1

$0

1

$0

TUDORZA PRESSAIR Respiratory Tract Agents, Other acetylcysteine (Acetadote) acetylcysteine (Acetadote) ARALAST NP (Cromolyn cromolyn inhalation Sodium) cromolyn * nasal (Nasalcrom) DALIRESP

2

$0

QL (1 per 28 days)

1 1 2

$0 $0 $0

PA BvD PA BvD

1

$0

4 2

$0 $0

ESBRIET

2

$0

KALYDECO

2

$0

OFEV

2

$0

ORKAMBI

2

$0

3

$0

2 2

$0 $0

Name of Drug theophylline oral theophylline oral theophylline oral

sodium chloride * inhalation solution for nebulization 0.9 % XOLAIR ZEMAIRA

(Theophylline Anhydrous) (Theophylline Anhydrous) (Theophylline Anhydrous)

(Pulmosal)

Necessary Actions, Restrictions, or Limits on Use

PA BvD

QL (30 per 30 days) PA; QL (270 per 30 days) PA; QL (60 per 30 days) PA; QL (60 per 30 days) PA; QL (120 per 30 days)

PA; QL (6 per 28 days)

Skeletal Muscle Relaxants Skeletal Muscle Relaxants baclofen

(Baclofen)

1

$0

carisoprodol

(Soma)

1

$0

PA-HRM; QL (120 per 30 days) PA-HRM

(Parafon Forte 1 $0 DSC) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document.

chlorzoxazone

Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 150

Tier level

What the drug will cost you

1

$0

1

$0

(Fexmid)

1

$0

(Dantrium) (Dantrium) (Skelaxin) (Robaxin) (Zanaflex)

1 1 1 1 1

$0 $0 $0 $0 $0

2 2 2

$0 $0 $0

1

$0

Name of Drug COMFORT PACCYCLOBENZAPRINE COMFORT PAC-TIZANIDINE cyclobenzaprine oral tablet 10 mg, 5 mg dantrolene dantrolene sodium metaxalone methocarbamol oral tizanidine

Necessary Actions, Restrictions, or Limits on Use PA-HRM

PA-HRM

PA-HRM PA-HRM

Sleep Disorder Agents Sleep Disorder Agents NUVIGIL ROZEREM XYREM

zaleplon

(Sonata)

PA LA PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (60 per 30 days)

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 151

Name of Drug

Tier level

What the drug will cost you

zolpidem oral tablet

(Ambien)

1

$0

zolpidem oral tablet,ext release multiphase

(Ambien CR)

1

$0

1

$0

Necessary Actions, Restrictions, or Limits on Use PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (30 per 30 days) PA-HRM; (High Risk Med. QL applies to all members; PA required for 65 years and older with over 90 days cumulative use with any nonbenzodiazepine hypnotic drug); QL (30 per 30 days)

Sympatholytic Adrenergic Blocking Agents Alpha-Adrenergic Blocking Agents (Phentolamine phentolamine injection Mesylate)

PA

Vasodilating Agents Vasodilating Agents PA; QL (60 per 30 days) PA; QL (90 per 30 ADEMPAS 2 $0 days) epoprostenol (glycine) (Flolan) 1 $0 PA BvD PA; QL (30 per 30 LETAIRIS 2 $0 days) PA; QL (30 per 30 OPSUMIT 2 $0 days) You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. ADCIRCA

2

$0

Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 152

Name of Drug ORENITRAM REMODULIN

Tier level

What the drug will cost you

Necessary Actions, Restrictions, or Limits on Use

2 2

$0 $0

PA PA BvD PA; QL (37.5 per 1 day) PA; QL (90 per 30 days) PA; LA; QL (60 per 30 days) PA BvD PA BvD PA BvD PA BvD

sildenafil intravenous

(Revatio)

1

$0

sildenafil oral

(Revatio)

1

$0

TRACLEER

2

$0

TYVASO TYVASO REFILL KIT TYVASO STARTER KIT VENTAVIS

2 2 2 2

$0 $0 $0 $0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

Vitamins And Minerals Vitamins And Minerals a thru z advanced formula * a thru z high potency * oral tablet a thru z select 50+ formula * a thru z select * oral tablet a thru z select * oral tablet 300600-300 mcg, 500-300-250 mcg a thru z select women's * abc plus * adult multivitamin gummies * adult one daily gummies * adults 50+ daily formula * adults' daily formula *

(Multivitamin/Iron/ Folic Acid) (Multivitamin WMinerals/Lutein) (Biocel) (Multivitamin WMinerals/Lutein) (Biocel) (Multivits WFe,Other Min/Lut) (Biocel) (One-A-Day Vitacraves) (One-A-Day Vitacraves) (Biocel) (Multivitamin/Iron/ Folic Acid)

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 153

Name of Drug airshield * oral tablet, effervescent 5,000-1000-30 unit-mg-unit animal chews * animal shape vitamins * animal shapes plus iron * antioxidant * antioxidant formula * antioxidant vitamins * oral tablet antioxidant vitamins * oral tablet 1,000 unit-200 mg-60 unit-2 mg apatate forte *

(Vit A,C, and E/Dietary Supp No.12) (Multivitamin) (Multivitamin) (Multivitamins with Iron) (Beta-Carotene(A) W-C and E/Min) (Beta-Carotene(A) W-C and E/Min) (Multivitamin with Minerals) (Ocuvite with Lutein) (Multivitamin with Minerals)

ascorbic acid * oral tablet extended (Ascorbic Acid) release 1,500 mg ascorbic acid * oral (Ascorbic Acid) (Vitamin B b complete * Complex) (Vitamin B b complex 1 * Complex) (Vitamin B b complex-vitamin b12 * Complex) b complex-vitamin c-folic acid * (Dialyvite 800) (Vitamin B b-100 complex * oral tablet Complex) b-12 dots * (B-12) (Vitamin B b-50 complex * oral tablet Complex) (Vitamin B bal b-100 * Complex)

Tier level

What the drug will cost you

4

$0

4 4

$0 $0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

Necessary Actions, Restrictions, or Limits on Use

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 154

Name of Drug bal b-50 * balance b-100 * balance b-50 * balanced b-100 * oral balanced b-100 * oral tablet 100 mg balanced b-150 * balanced b-50 * oral tablet b-complex * oral tablet b-complex with vitamin c * oral capsule b-complex with vitamin c * oral tablet bee-zee * biosupp * biotin * oral tablet 300 mcg biovol * c complex * calcidol * centamin * central vite with lutein *

(Vitamin B Complex) (Vitamin B Complex) (Vitamin B Complex) (Vitamin B Complex) (Vit B Complex 100 Cmb #3/Herbs) (Vitamin B Complex) (Vitamin B Complex) (Vitamin B Complex) (B Complex with Vitamin C) (Vita-Bee with C) (Multivitamin with Minerals) (Multivitamin with Minerals) (Biotin) (Multivitamin with Minerals) (Ascorbic Acid) (Drisdol) (Multivits WMin/Ferrous Gluc) (Biocel)

Tier level

What the drug will cost you

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4 4

$0 $0

4

$0

4

$0

Necessary Actions, Restrictions, or Limits on Use

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 155

Name of Drug central-vite for seniors * central-vite * oral tablet 18-400 mg-mcg central-vite select * oral tablet central-vite senior * centram-care * centravites 50 plus * centrum complete * centrum * oral liquid centrum silver * oral tablet centrum ultra women's * century adults 50+ * century advanced formula * century mature * oral tablet century mature * oral tablet 0.4300-250 mg-mcg-mcg, 500-300-250 mcg century * oral tablet 18-400 mgmcg century ultimate women's * oral tablet 18-400 mg-mcg cerovite * cerovite advanced formula *

(Multivitamin W/Iron, Minerals) (Multivitamin/Iron/ Folic Acid) (Multivitamin WMinerals/Lutein) (Biocel) (Multivits WMin/Ferrous Gluc) (Multivitamin W/Iron, Minerals) (Multivitamin/Iron/ Folic Acid) (Multivits WMin/Ferrous Gluc) (Biocel) (Multivitamin/Iron/ Folic Acid) (Biocel) (Multivits WFe,Other Min/Lut) (Multivitamin WMinerals/Lutein) (Biocel) (Multivitamin/Iron/ Folic Acid) (Multivitamin/Iron/ Folic Acid) (Multivits WMin/Ferrous Gluc) (Multivitamin/Iron/ Folic Acid)

Tier level

What the drug will cost you

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

Necessary Actions, Restrictions, or Limits on Use

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 156

Name of Drug (Multivitamin W/Iron, Minerals) (Multivitamin Wcerovite senior * Minerals/Lutein) certavite senior-antioxidant * (Biocel) certavite-antioxid (iron gluc) * oral (Multivits Wliquid 9 mg iron/15 ml Min/Ferrous Gluc) (Multivitamin/Iron/ certavite-antioxidant * Folic Acid) chewable multi vitamin * (Multivitamin) chewable-vite * (Multivitamin) (Multivitamins chewable-vite with iron * with Iron) (Pedi Mv child complete multivitamin * No.58/Ferrous Fumarate) (Multivitamin child vitamin with minerals * W/Iron, Minerals) children's chewable * (Multivitamin) children's chewable complete * oral (Multivitamin) tablet,chewable children's chewable vitamin * (Multivitamin) (Multivitamin children's chewable w/minerals * W/Iron, Minerals) (Pedi Mv children's complete vitamin * No.67/Ferrous Fumarate) children's multivit w/extra c * (Multivitamin) (Multivitamins children's vitamin with iron * with Iron) childs chew vite * (Multivitamin) child's chewable vitamins/iron * (Multivitamins oral tablet,chewable with Iron) cerovite jr *

Tier level

What the drug will cost you

4

$0

4

$0

4

$0

4

$0

4

$0

4 4

$0 $0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

Necessary Actions, Restrictions, or Limits on Use

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 157

Name of Drug child's vitamin with iron * child's vitamin with vitamin c * childs/iron * compete * complete 50+ * complete multi 50+ * complete multivitamin * oral tablet complete multivitamin * oral tablet 0.4-300-250 mg-mcg-mcg complete multivitamin-mineral * oral tablet complete senior * oral tablet complete senior * oral tablet 0.4300-250 mg-mcg-mcg cyanocobalamin (vitamin b-12) * injection cyanocobalamin (vitamin b-12) * oral drops 1,000 mcg/ml cyanocobalamin (vitamin b-12) * oral tablet 1,000 mcg, 100 mcg, 250 mcg, 500 mcg daily gummies * daily multiple * oral tablet daily multiple * oral tablet 18-400 mg-mcg daily multi-vitamin * daily multivitamin with iron *

(Multivitamins with Iron) (Multivitamin) (Multivitamins with Iron) (Multivitamin W/Iron, Minerals) (Biocel) (Biocel) (Multivits,Th WFe,Other Min) (Biocel) (Multivitamin/Iron/ Folic Acid) (Multivitamin W/Iron, Minerals) (Biocel) (Cyanocobalamin (Vitamin B-12)) (Cyanocobalamin (Vitamin B-12)) (B-12) (One-A-Day Vitacraves) (Multivitamin) (Multivitamin/Iron/ Folic Acid) (Multivitamin) (Multivitamin/Iron/ Folic Acid)

Tier level

What the drug will cost you

4

$0

4

$0

4

$0

4

$0

4 4

$0 $0

4

$0

4

$0

4

$0

4

$0

4

$0

3

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

Necessary Actions, Restrictions, or Limits on Use

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 158

Tier level

What the drug will cost you

4

$0

4

$0

4

$0

4 4 4

$0 $0 $0

4

$0

4

$0

4

$0

4

$0

4 4 4

$0 $0 $0

4

$0

4

$0

4

$0

4

$0

4

$0

(Drisdol)

3

$0

(Drisdol)

4

$0

Name of Drug daily multivitamin-minerals * daily multi-vitamins/iron * daily teen multi-vitamin * daily value * daily vitamin * daily vitamin formula * daily vitamin formula + iron * daily vitamin formula-minerals * daily vitamin with iron * daily vites/iron * daily-vite * dino-life * dino-life with extra c * dino-life with iron-zinc *

(Multivitamin with Minerals) (Multivitamins with Iron) (Multivitamin/Iron/ Folic Acid) (Multivitamin) (Multivitamin) (Multivitamin) (Multivitamin/Iron/ Folic Acid) (Multivitamin with Minerals) (Multivitamins with Iron) (Multivitamins with Iron) (Multivitamin) (Multivitamin) (Multivitamin) (Multivitamin W/Iron, Minerals)

ECEE PLUS * eldertonic * ellis tonic * eql central-vite select * tablet ergocalciferol (vitamin d2) * oral capsule ergocalciferol (vitamin d2) * oral drops

(B1,B2,B3,B6,B12 /Dexpan/Zn/Mang) (Multivitamin with Minerals) (Multivitamin WMinerals/Lutein)

Necessary Actions, Restrictions, or Limits on Use

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 159

Tier level

What the drug will cost you

4

$0

4

$0

4 4 4

$0 $0 $0

3

$0

3

$0

4

$0

3

$0

4 4

$0 $0

4

$0

4

$0

(Ferrous Fumarate)

4

$0

(Fergon) (Fer-In-Sol) (Ferrous Sulfate) (Ferrous Sulfate)

4 4 4 4

$0 $0 $0 $0

(Ferrous Sulfate)

4

$0

(Ferrous Sulfate)

4

$0

(Multivitamin W/Iron, Minerals)

4

$0

(Multivitamin)

4

$0

Name of Drug essentia * essential balance with lutein * essential daily * essential one daily * fa-8 * fe fumarate-doss-fa-bcomp and c * fe fumarate-vit c-b12-if-fa * oral capsule 110-0.5 mg ferate * oral tablet ferotrinsic * ferretts * ferrex 150 * ferrex 150 plus * ferrocite * ferrous fumarate * oral tablet 324 mg (106 mg iron) ferrous gluconate * oral tablet ferrous sulfate * oral ferrous sulfate * oral ferrous sulfate * oral ferrous sulfate * oral tablet 325 mg (65 mg iron) ferrous sulfate * oral tablet,delayed release (dr/ec) 324 mg (65 mg iron) flintstones complete (iron) * oral tablet,chewable flintstones multivitamin * oral tablet,chewable

(Multivitamin/Iron/ Folic Acid) (Multivits WFe,Other Min/Lut) (Tab A Vite) (Multivitamin) (Folic Acid) (Fe Fumarate/Doss/Fa/ Bcomp and C) (Fe Fumarate/Vit C/B12-If/Fa) (Fergon) (Fe Fumarate/Vit C/B12-If/Fa) (Ferrous Fumarate) (Pic 200) (Iron Aspgly and Ps Cmplx/C/Sucac) (Ferrous Fumarate)

Necessary Actions, Restrictions, or Limits on Use

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 160

Tier level

What the drug will cost you

(Pedi Mv No.79/Ferrous Fumarate)

4

$0

(Multivitamin)

4

$0

(Folic Acid)

4

$0

4

$0

(Folic Acid)

3

$0

(Folic Acid)

4

$0

4

$0

4 4 4

$0 $0 $0

4

$0

4 4

$0 $0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

Name of Drug

flintstones with iron * flintstones/extra c * oral tablet,chewable folic acid * 1,000 mcg tablet p/f,s/f (otc) FOLIC ACID * ORAL CAPSULE 20 MG folic acid * oral tablet 1 mg folic acid * oral tablet 400 mcg, 800 mcg fosfree * fruity chews * geravim * geriaton * germ defense * gummi bear multivitamin * gummy swirls * hair vitamins * hair,skin & nails * oral tablet hair,skin & nails * oral tablet 1 mg iron-66.7 mcg-1,000 mcg healthy eyes * hemocyte * hi-b complex *

(Calcium/Multivita mins W-Iron) (Multivitamin) (Pediavit) (Pediavit) (Vit A,C, and E/Dietary Supp No.12) (Multivitamin) (Multivitamin) (Multivitamins with Iron) (Multivitamin with Minerals) (Mv,Ca,Min/Iron Gluc/Fa/Biotin) (Ocuvite with Lutein) (Ferrous Fumarate) (Vitamin B Complex)

Necessary Actions, Restrictions, or Limits on Use

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 161

Name of Drug high potency multivit-multimin * honey bears * honey bears with iron-zinc * icaps plus * iferex 150 * iron high potency * i-vite * kid's vitamins + extra c * kids vitamins + iron * kid's vitamins + iron *

(Multivitamin WMinerals/Lutein) (Multivitamin) (Multivitamin W/Iron, Minerals) (Multivitamin with Minerals) (Pic 200) (Fergon) (Ocuvite with Lutein) (Multivitamin) (Ped Multivit #17/Iron Fumarate) (Multivitamins with Iron)

Tier level

What the drug will cost you

4

$0

4

$0

4

$0

4

$0

4 4

$0 $0

4

$0

4

$0

4

$0

4

$0

kid's vitamins * oral tablet,chewable

(Multivitamin)

4

$0

life-pack women's *

(Multivitamin W/Iron, Minerals)

4

$0

4 4

$0 $0

4

$0

4 4 4 4

$0 $0 $0 $0

4

$0

4

$0

4

$0

LIQUI-E * little animals * little animals-iron * oral tablet,chewable lysiplex plus * oral liquid MACUVITE * MACUVITE EYE CARE * maximum daily multivitamin * mega multiple/chelated mineral * mega multivitamin with mineral * oral tablet men's daily gummies *

(Multivitamin) (Multivitamins with Iron) (Pediavit)

(Tab A Vite) (Multivitamin with Minerals) (Multivitamin with Minerals) (One-A-Day Vitacraves)

Necessary Actions, Restrictions, or Limits on Use

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 162

Name of Drug men's multi-vitamin * men's multivitamin gummies * men's one daily * oral tablet

(Multivitamin) (One-A-Day Vitacraves) (Multivitamin with Minerals)

MEPHYTON * milltrium senior * multi complete with iron * multi-day with iron * multi-delyn * multi-delyn with iron * multilex * multilex-t&m * multiple vitamin-minerals * multiple vitamins * multiple vitamins with iron * multivital platinum * oral tablet multivital platinum * oral tablet 500-300-250 mcg multivitamin 50 plus * multi-vitamin hp/minerals * multivitamin * oral tablet

(Multivitamin WMinerals/Lutein) (Multivitamin/Iron/ Folic Acid) (Multivitamin/Iron/ Folic Acid) (Multivitamin) (Multivitamin/Ferr ous Gluconate) (Multivitamin W/Iron, Minerals) (Multivits,Th WFe,Other Min) (Multivitamin with Minerals) (Multivitamin) (Multivitamins with Iron) (Multivitamin WMinerals/Lutein) (Biocel) (Multivitamin WMinerals/Lutein) (Multivitamins,The r W-Minerals) (Multivitamin)

Tier level

What the drug will cost you

4

$0

4

$0

4

$0

3

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

Necessary Actions, Restrictions, or Limits on Use

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 163

Tier level

What the drug will cost you

4

$0

4

$0

4

$0

3

$0

4

$0

4

$0

1

$0

4

$0

4

$0

3

$0

4

$0

4

$0

4

$0

(Niacinamide)

4

$0

(Pic 200) (Beta-Carotene(A) W-C and E/Min) (Multivitamin) (Multivitamins,The rapeutic) (Multivitamin with Minerals)

4

$0

4

$0

4

$0

4

$0

4

$0

Name of Drug multivitamin with iron * multivitamin with minerals * oral liquid multivitamin with minerals * oral tablet multivitamins with min no.7-fa * oral capsule 1 mg multi-vite * multi-vite 50 & over * multivit-fluor 0.25 mg/ml drop 0.25 mg/ml my favorite multiple * my-vitalife *

(Multivitamins with Iron) (Multivits WMin/Ferrous Gluc) (Multivitamin with Minerals) (Multivitamins with Min No.7/Fa) (Multivitamin/Iron/ Folic Acid) (Multivitamin WMinerals/Lutein) (Pedi Mvi No.82 with Fluoride) (Multivitamin) (Multivitamin with Minerals)

NASCOBAL * natural b-100 * natural b-100 complex * nephro-vite * niacinamide * oral tablet extended release nu-iron * ocutabs * once daily * oncovite * one daily 50 plus *

(Vitamin B Complex) (Vit B Complex 100 Cmb #2/Herbs) (Dialyvite 800)

Necessary Actions, Restrictions, or Limits on Use

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 164

Name of Drug one daily complete * oral tablet one daily energy * oral tablet one daily essential * oral tablet one daily gummy vites * one daily maximum (with ca) * one daily men's 50+ * oral tablet one daily multi-vit w-mineral * one daily multivitamin * oral tablet one daily multivitamin * oral tablet 400 mcg

(Multivitamin with Minerals) (Multivitamin with Minerals) (Multivitamin) (One-A-Day Vitacraves) (Tab A Vite) (Multivitamin with Minerals) (Multivitamins with Iron) (Multivitamin) (Quintabs)

(Multivitamin/Iron/ Folic Acid) one daily * oral tablet (Multivitamin) (Multivitamins one daily plus iron * oral tablet with Iron) one daily plus iron * oral tablet 18- (Multivitamin/Iron/ 400 mg-mcg Folic Acid) (Multivitamin with one daily plus minerals * Minerals) (Multivitamins one daily with iron * with Iron) one-a-day essential * (Multivitamin) (Multivitamin with one-a-day maximum formula * Minerals) one-a-day teen advantage * oral (Multivitamin/Iron/ tablet 18-400 mg-mcg Folic Acid) one-a-day teen advantage * oral (Multivits,Ca,Mine tablet 9 mg iron-400 mcg rals/Iron/Fa) one daily multivit-iron(folic) *

Tier level

What the drug will cost you

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

Necessary Actions, Restrictions, or Limits on Use

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 165

Name of Drug (Beta-Carotene(A) W-C and E/Min) opti-vitamins * oral tablet 1,000 (Ocuvite with unit-200 mg-60 unit-2 mg Lutein) pediatric multivitamin * (Multivitamin) pharmacist favorite multi-vit * (Multivitamin) phytonadione * oral tablet 100 mcg (Phytonadione) poly-iron * (Pic 200) (Pediatric Multivit poly-vita * Comb No.20) (Ped Multivit poly-vita (iron) * #46/Iron Sulfate) (Pediatric Multivit poly-vitamin * Comb No.20) (Ped Multivit poly-vitamin with iron * #46/Iron Sulfate) (Multivitamin polyvitamin/iron * W/Iron, Minerals) poly-vitamins * (Multivitamin) prenatal formula * oral tablet 28(Classic Prenatal) 0.8 mg prenatal * oral tablet 28-0.8 mg (Classic Prenatal) (Prenatal prenatal vit#96-ferrous fum-fa * Vit#96/Ferrous Fum/Fa) prenatal vitamin with minerals * (Classic Prenatal) prenatal vitamins oral tablet 27 mg (Pnv with iron- 1 mg Ca,No.72/Iron/Fa) PRENATAL VITAMINS ORAL TABLET 29 MG IRON- 1 MG-25 MG prenatal vit-iron fumarate-fa * (Classic Prenatal) (A/C/E/Zinc/Sod prosight * Selenate/Copper) opti-vitamins * oral tablet

Tier level

What the drug will cost you

4

$0

4

$0

4 4 4 4

$0 $0 $0 $0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

2

$0

2

$0

4

$0

4

$0

Necessary Actions, Restrictions, or Limits on Use

(All Rx Prenatal Vitamins Covered)

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 166

Tier level

What the drug will cost you

(Pyridoxine HCl) (Multivitamin W/Iron, Minerals) (Multivitamin W/Iron, Minerals) (Biocel) (Multivitamin/Iron/ Folic Acid) (Biocel) (Sodium Fluoride) (Pedi Mvi No.82 with Fluoride)

3

$0

4

$0

4

$0

4

$0

4

$0

4 1

$0 $0

1

$0

(Sodium Fluoride)

3

$0

(Biocel) (Multivitamin/Iron/ Folic Acid) (Pediavit) (Multivitamins with Iron) (Multivitamin W/Iron, Minerals) (Multivitamin WMinerals/Lutein) (Multivitamin/Iron/ Folic Acid) (Multivits,Stress Formula/Zinc) (Multivits,Stress Formula/Zinc) (Vitamin B Complex)

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

Name of Drug pyridoxine * injection ra central-vite select * tab p/f scooby-doo one a day * senior tabs * sentry * oral tablet 18-400 mg-mcg sentry senior * sodium fluoride 1 mg (2.2 mg) sodium fluoride oral tablet 1 mg fluoride (2.2 mg) sodium fluoride * oral tablet,chewable 0.25 mg fluorid (0.55 mg) spectravite adult 50+ * oral tablet spectravite advanced formula * oral tablet spectravite * oral liquid spectravite * oral tablet,chewable spectravite senior * oral tablet spectravite senior w-lycopene * spectravite ultra women * stress 500 plus zinc * stress b with zinc * stress b-biotin *

Necessary Actions, Restrictions, or Limits on Use

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 167

Name of Drug stress formula * stress formula plus iron * stress formula with iron * stress formula with zinc * stuart prenatal * sunvite * super b complex-vitamin c * super b/c * super b-50 complex * super b-50 complex plus * super multiple * oral tablet super multivitamin * super quints b-50 * super thera vite m * superior 35 * superplex-t * support * support-500 *

(Multivits,Stress Formula) (Iron/Multivits,Stre ss Formula) (Vit B Comp/C/Fa/Iron/Vi t E) (Multivits,Stress Formula/Zinc) (Classic Prenatal) (Mv-Min/Iron Fum/Fa/K/Lyco/Lu tn) (Vita-Bee with C) (B Complex with Vitamin C) (Vitamin B Complex) (Vitamin B Complex) (Multivitamin W/Iron, Minerals) (Multivitamin) (Vitamin B Complex) (Multivitamins,The r W-Minerals) (Multivitamin W/Iron, Minerals) (Vita-Bee with C) (Multivitamin with Minerals) (B Complex with Vitamin C)

Tier level

What the drug will cost you

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

3

$0

Necessary Actions, Restrictions, or Limits on Use

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 168

Name of Drug

Tier level

What the drug will cost you

(Multivitamin) (Multivitamins tab-a-vite/iron * with Iron) (Multivitamin with tab-a-vite-minerals * Minerals) (Multivits,Ca,Mine thera m plus (ferrous fumarat) * rals/Iron/Fa) (Multivitamins,The thera vitamin * rapeutic) (Multivit,Ther theradex m * Iron,Ca,Fa and Min) (Multivits,Th Wthera-m * oral tablet Fe,Other Min) (Multivit,Ther thera-m * oral tablet 27-0.4 mg Iron,Ca,Fa and Min) thera-m * oral tablet 9 mg iron-400 (Multivits,Ca,Mine mcg rals/Iron/Fa) (Multivitamin with theramill forte * oral capsule Minerals) (Multivitamins,The therapeutic liquid * rapeutic) therapeutic m + beta-carotene * (Tab A Vite) (Multivitamins,The therapeutic vitamin & mineral * r W-Minerals) (Multivitamins therapeutic vitamins/minerals * with Min No.7/Fa) therapeutic-m * oral tablet 9 mg (Multivits,Ca,Mine iron-400 mcg rals/Iron/Fa) (Multivit,Ther therapeutic-m vitamin/minerals * Iron,Ca,Fa and oral tablet 27-0.4 mg Min)

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

3

$0

4

$0

4

$0

tab-a-vite *

Necessary Actions, Restrictions, or Limits on Use

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 169

Name of Drug thera-tabs * theratrum complete 50 plus * theratrum complete 50 plus/lut * therems * therems-h * therems-m * thiamine hcl * injection thiamine hcl * oral tablet 500 mg total b/c * totalday multiple * tri-vi-sol * tri-vita * tri-vitamin * ultra b-100 complex * oral tablet unicomplex-m * vision * vision formula *

(Multivitamins,The rapeutic) (Multivitamin W/Iron, Minerals) (Multivitamin WMinerals/Lutein) (Multivitamins,The rapeutic) (Multivits,Th WFe,Other Min) (Multivits,Th WFe,Other Min) (Thiamine HCl) (Thiamine HCl) (Vita-Bee with C) (Multivitamin with Minerals) (Vit A Palmitate/Vit C/Vit D3) (Pedi Multivits A,C, and D3 No.21) (Pedi Multivits A,C, and D3 No.21) (Vitamin B Complex) (Multivitamin W/Iron, Minerals) (Beta-Carotene(A) W-C and E/Min) (Beta-Carotene(A) W-C and E/Min)

Tier level

What the drug will cost you

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

3 4 4

$0 $0 $0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

Necessary Actions, Restrictions, or Limits on Use

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 170

Tier level

What the drug will cost you

4

$0

4

$0

3

$0

3

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

(Pyridoxine HCl)

4

$0

(Ascorbic Acid)

4

$0

(Ascorbic Acid)

4

$0

(Ascorbic Acid)

4

$0

(Ascorbic Acid)

4

$0

(Ascorbic Acid)

4

$0

Name of Drug vision formula (with lutein) * vision plus lutein * vit b cmplx 3-fa-vit c-biotin * oral tablet 1-60-300 mg-mg-mcg vit b cmplx no3-fa-c-biot-zinc * vitabee/c * vitalets * oral tablet,chewable vitamin a * oral capsule 10,000 unit, 25,000 unit vitamin b complex * vitamin b complex with c * vitamin b-1 * oral tablet vitamin b-100 complex * vitamin b12-folic acid * oral vitamin b-6 * oral tablet 100 mg, 25 mg, 250 mg, 50 mg vitamin c * oral capsule, extended release vitamin c * oral syrup vitamin c * oral tablet 1,000 mg, 250 mg, 500 mg vitamin c * oral tablet extended release vitamin c * oral tablet,chewable 250 mg, 500 mg

(Ocuvite with Lutein) (Multivitamin WMinerals/Lutein) (Vit B Cmplx 3/Fa/Vit C/Biotin) (Vit B Cmplx No3/Fa/C/Biot/Zin c) (Vita-Bee with C) (Multivitamins with Iron) (Vitamin A) (Vitamin B Complex) (B Complex with Vitamin C) (Thiamine HCl) (Vitamin B Complex) (Cyanocobalamin/ Folic Acid)

Necessary Actions, Restrictions, or Limits on Use

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 171

Name of Drug vitamins & minerals * vitamins b complex * oral capsule vitamins b complex * oral tablet vitamins b complex * oral tablet 500 mg-400 mcg- 18 mg iron vitamins for hair * oral tablet vitrum senior * oral tablet

(Multivitamins,The r W-Minerals) (Vitamin B Complex) (Vitamin B Complex) (Vit B Comp/C/Fa/Iron/Vi t E) (Multivitamin) (Multivitamin WMinerals/Lutein)

vitrum senior * oral tablet 500-300(Biocel) 250 mcg (One-A-Day womens daily gummies * Vitacraves) women's daily multivitamin * (Tab A Vite) (Multivitamin/Iron/ yelets * Folic Acid) zoo chews * (Multivitamin)

Tier level

What the drug will cost you

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

4

$0

Necessary Actions, Restrictions, or Limits on Use

You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document. Si tiene alguna pregunta, por favor llame a ICS Community Care Plus FIDA-MMP al 1.877.ICS.2525, de lunes a viernes, de 8 a.m. to 8 p.m. La llamada es gratuita. Para obtener más información, vaya a www.icsny.org/care-plus. 172

INDEX

3 3 day vaginal .......................... 55 30pse-150gfn-15dm ............... 93 8 8-MOP.................................. 104 A a thru z advanced formula .... 153 a thru z high potency ............ 153 a thru z select ....................... 153 a thru z select 50+ formula... 153 a thru z select women's ........ 153 abacavir .................................. 70 abacavir-lamivudine-zidovudine ............................................ 70 abc plus ................................ 153 ABELCET.............................. 55 ABILIFY ................................ 66 ABILIFY DISCMELT ........... 66 ABILIFY MAINTENA ......... 66 ABRAXANE ......................... 37 ABREVA ............................... 62 acamprosate............................ 24 acarbose.................................. 51 acebutolol ............................... 83 acephen .................................. 16 acetaminophen ....................... 16 acetaminophen-codeine.......... 16 acetazolamide ....................... 141 acetazolamide sodium .......... 141 acetic acid..................... 116, 135 acetylcysteine ....................... 150 acid gone antacid.................. 120 acid reducer (famotidine) ..... 119 acid relief (cimetidine) ......... 119 acitretin ................................ 104 acne medication ................... 104 ACNE MEDICATION ........ 104

acne-clear ............................. 104 ACTEMRA .......................... 137 ACTHIB (PF) ....................... 133 ACTIMMUNE ..................... 137 acyclovir ................... 72, 73, 104 acyclovir sodium .................... 73 ADACEL(TDAP ADOLESN/ADULT)(PF) 133 ADAGEN ............................. 112 adapalene .............................. 110 ADCETRIS ............................ 37 ADCIRCA ............................ 152 adefovir .................................. 73 ADEMPAS........................... 152 adrenalin ................................. 85 ADRENALIN ........................ 85 adt robitussin peak cld dm max ............................................ 93 adult multivitamin gummies 153 adult nasal decongestant......... 94 adult one daily gummies ...... 153 adult robitussin lingering cld.. 94 adult robitussin peak cold dm 94 adult wal-tussin ...................... 94 adult wal-tussin dm max ........ 94 adults 50+ daily formula ...... 153 adults' daily formula ............. 153 ADVAIR DISKUS ............... 148 ADVAIR HFA ..................... 148 advil ........................................ 21 af 55 AFINITOR ....................... 37, 38 AFINITOR DISPERZ ............ 37 AGGRENOX ......................... 76 airshield ................................ 154 AKTEN (PF) ........................ 113 alavert d-12 allergy-sinus ....... 58

I-1 Formulario del plan Community Care Plus 2015 de Medicare-Medicaid de ventaja doble completamente integrado (Fully Integrated Duals Advantage Medicare-Medicaid Plan, FIDA MMP) de ICS Identificación del formulario: 15412.000, Versión: 16

alaway .................................. 113 ALBENZA ............................. 65 ALBUKED-25 ....................... 76 ALBUKED-5 ......................... 76 ALBUMIN, HUMAN 25 % ... 76 ALBUMIN, HUMAN 5 % ..... 76 ALBUMINAR 25 % .............. 76 ALBUMINAR 5 % ................ 76 ALBURX (HUMAN) 5 % ..... 77 ALBUTEIN 25 % .................. 77 ALBUTEIN 5 % .................... 77 albuterol sulfate .................... 149 alclometasone ....................... 107 ALCOHOL PADS ............... 104 ALCOHOL PREP PADS ..... 104 ALCOH-WIPE ..................... 104 ALDURAZYME .................. 112 alendronate ........................... 136 alfuzosin ............................... 127 ALIMTA ................................ 38 ALINIA .................................. 65 alka-seltzer plus mucus-conges ............................................ 94 alka-seltzer plus sinus-cough . 94 aller-chlor ............................... 58 allerclear d-12hr ..................... 58 allerclear d-24hr ..................... 58 allergy (chlorpheniramine) ..... 58 allergy relief (cetirizine) ......... 58 allergy relief (loratadine)........ 58 allerhist-1................................ 58 aller-tec d ................................ 58 allopurinol ............................ 137 almacone .............................. 120 almacone-2 ........................... 120 aloe vesta ................................ 55 alophen ................................. 123

Fecha de entrada en vigencia: 01 de diciembre 2015

alosetron ............................... 135 ALPHAGAN P .................... 141 alprazolam .............................. 26 ALREX ................................ 118 altacaine ............................... 113 altamist ................................. 113 aluminum chloride ............... 104 aluminum hydroxide gel ...... 120 amantadine hcl ....................... 65 ambi 10peh-4cpm-20dm ........ 94 ambi 20dm-4cpm ................... 94 ambi 40pse-400gfn-20dm ...... 94 ambi 60pse-4cpm ................... 58 ambi 60pse-4cpm-20dm......... 94 AMBISOME .......................... 55 ambizine ................................. 63 amifostine crystalline ........... 137 amiloride ................................ 87 amiloride-hydrochlorothiazide87 AMINO ACIDS 15 % ............ 77 aminocaproic acid .................. 76 AMINOSYN 10 % ................. 77 AMINOSYN 3.5 % ................ 77 AMINOSYN 7 % ................... 77 AMINOSYN 7 % WITH ELECTROLYTES ............. 77 AMINOSYN 8.5 % ................ 77 AMINOSYN 8.5 %ELECTROLYTES ............. 77 AMINOSYN II 10 % ............. 77 AMINOSYN II 15 % ............. 77 AMINOSYN II 7 % ............... 77 AMINOSYN II 8.5 % ............ 77 AMINOSYN II 8.5 %ELECTROLYTES ............. 77 AMINOSYN M 3.5 % ........... 77 AMINOSYN-HBC 7% .......... 77 AMINOSYN-PF 10 % ........... 77 AMINOSYN-PF 7 % (SULFITE-FREE) .............. 77 AMINOSYN-RF 5.2 % ......... 77 amiodarone ............................. 82

amiodarone hcl ....................... 82 AMITIZA ............................. 120 amitriptyline ........................... 49 amlactin ................................ 105 amlodipine.............................. 87 amlodipine-atorvastatin .......... 88 amlodipine-benazepril ............ 87 amlodipine-valsartan .............. 87 amlodipine-valsartan-hcthiazid ............................................ 87 ammonium lactate ................ 105 amoxapine .............................. 49 amoxicil-clarithromy-lansopraz .......................................... 119 amoxicillin ....................... 34, 35 amoxicillin-pot clavulanate .... 35 amphetamine salt combo ........ 90 amphotericin b........................ 55 ampicillin ............................... 35 ampicillin sodium................... 35 ampicillin-sulbactam .............. 35 AMPYRA............................... 90 ANACAINE ......................... 105 anagrelide ............................... 76 anastrozole ............................. 38 ANDRODERM .................... 127 ANDROGEL ........................ 128 animal chews ........................ 154 animal shape vitamins .......... 154 animal shapes plus iron ........ 154 ANORO ELLIPTA .............. 149 antacid .................................. 120 antacid anti-gas .................... 120 antacid extra-strength ........... 120 antacid plus anti-gas ............. 121 anticoag citrate phos dextrose .......................................... 137 anti-diarrheal ........................ 121 anti-diarrheal (loperamide) .. 121 antifungal ............................... 55 antifungal (tolnaftate) ............. 55 anti-gas maximum strength .. 118

I-2 Formulario del plan Community Care Plus 2015 de Medicare-Medicaid de ventaja doble completamente integrado (Fully Integrated Duals Advantage Medicare-Medicaid Plan, FIDA MMP) de ICS Identificación del formulario: 15412.000, Versión: 16

antioxidant ............................ 154 antioxidant formula .............. 154 antioxidant vitamins ............. 154 apatate forte .......................... 154 APOKYN ............................... 65 apraclonidine ........................ 113 APRISO................................ 135 aprodine .................................. 58 APTIOM ................................ 46 APTIVUS ............................... 70 aquanil hc ............................. 107 ARALAST NP ..................... 150 ARCALYST ......................... 131 aripiprazole ............................. 66 ARRANON ............................ 38 artificial tears ........................ 113 artificial tears (petro/min) .... 113 artificial tears (pf) ................. 113 artificial tears(glycerin-peg) . 113 artificial tears(hypromellose) 113 ARZERRA ............................. 38 ASACOL HD ....................... 135 ascorbic acid ......................... 154 ashlyna.................................... 92 aspirin ............................... 21, 23 aspirin, buffered ..................... 21 aspirin-dipyridamole .............. 76 aspir-low ................................. 21 ASSURE ID INSULIN SAFETY ........................... 111 ASTAGRAF XL .................. 132 atenolol ................................... 83 atenolol-chlorthalidone .......... 83 atorvastatin ............................. 88 atovaquone ............................. 65 atovaquone-proguanil ............. 65 ATRIPLA ............................... 70 atropine ........................... 45, 113 ATROVENT HFA ............... 149 AUBAGIO ........................... 132 AVASTIN .............................. 38 AVC VAGINAL .................... 62

Fecha de entrada en vigencia: 01 de diciembre 2015

AVODART .......................... 137 AVONEX ............................. 138 AVONEX (WITH ALBUMIN) .......................................... 137 ayr saline .............................. 113 azacitidine .............................. 38 azathioprine .......................... 132 azathioprine sodium ............. 132 azelastine .............................. 113 AZILECT ............................... 65 azithromycin .......................... 33 AZOPT ................................. 141 AZOR ..................................... 87 aztreonam ............................... 34 B b complete ............................ 154 b complex 1 .......................... 154 b complex-vitamin b12 ........ 154 b complex-vitamin c-folic acid .......................................... 154 b-100 complex ..................... 154 b-12 dots............................... 154 b-50 complex ....................... 154 bacitracin ................ 30, 106, 116 bacitracin-polymyxin b ........ 116 bacitraycin plus .................... 106 baclofen ................................ 150 bal b-100 .............................. 154 bal b-50 ................................ 155 balance b-100 ....................... 155 balance b-50 ......................... 155 balanced b-100 ..................... 155 balanced b-150 ..................... 155 balanced b-50 ....................... 155 balsalazide ............................ 135 banophen ................................ 58 banophen allergy .................... 58 BANZEL ................................ 46 baza antifungal ....................... 55 BCG VACCINE, LIVE (PF) 133 b-complex ............................ 155 b-complex with vitamin c .... 155

BD INSULIN PEN NEEDLE UF SHORT ...................... 111 BD INSULIN SYRINGE ULTRA-FINE .................. 111 bee-zee ................................. 155 BELEODAQ .......................... 38 benadryl allergy...................... 59 benazepril ............................... 82 benazepril-hydrochlorothiazide ............................................ 82 BENICAR .............................. 81 BENICAR HCT ..................... 81 BENLYSTA ......................... 138 benzonatate............................. 94 benzoyl peroxide .................. 105 benztropine ............................. 65 BETADINE SPRAY ............ 105 beta-hc .................................. 107 betamethasone acet,sod phos 129 betamethasone dipropionate . 107 betamethasone valerate ........ 108 betamethasone, augmented .. 108 BETASERON ...................... 138 betaxolol ......................... 83, 141 bethanechol chloride ............ 138 BETHKIS ............................... 29 bexarotene .............................. 38 BEXSERO (PF) ................... 133 bicalutamide ........................... 38 bicarsim forte ....................... 118 BICILLIN C-R ....................... 35 BICILLIN L-A ....................... 35 BIDIL ..................................... 89 BILTRICIDE ......................... 65 bimatoprost........................... 141 bio-dtuss dmx ......................... 94 bion tears (pf) ....................... 113 bionel ...................................... 94 bionel pediatric ....................... 94 biospec dmx ........................... 94 biosupp ................................. 155 biotin .................................... 155

I-3 Formulario del plan Community Care Plus 2015 de Medicare-Medicaid de ventaja doble completamente integrado (Fully Integrated Duals Advantage Medicare-Medicaid Plan, FIDA MMP) de ICS Identificación del formulario: 15412.000, Versión: 16

biovol.................................... 155 bisac-evac ............................. 123 bisacodyl .............................. 123 biscolax ................................ 123 bismatrol ............................... 121 bisoprolol fumarate ................ 83 bisoprolol-hydrochlorothiazide ............................................ 83 bleomycin ............................... 38 BLINCYTO............................ 38 blis-to-sol (tolnaftate) ............. 55 BOOSTRIX TDAP .............. 133 BOSULIF ............................... 38 BOTOX ................................ 138 BREO ELLIPTA .................. 148 BRILINTA ............................. 76 brimonidine .......................... 141 BRINTELLIX ........................ 49 bromfenac ............................. 118 bromocriptine ......................... 65 bromphenex dm ...................... 94 brompheniramine-pseudoephdm ....................................... 95 brompheniram-phenylephrinedm ....................................... 95 broncotron-s ........................... 95 budesonide............................ 135 bufferin ................................... 21 bumetanide ............................. 87 BUMINATE 25 % ................. 77 BUMINATE 5 % ................... 77 BUPHENYL ........................ 121 buprenorphine hcl............. 16, 24 buprenorphine-naloxone ........ 24 bupropion hcl ................... 24, 49 buspirone .............................. 138 butalb-acetaminophen-caffeine ............................................ 16 butalbital-acetaminop-caf-cod 16 butalbital-acetaminophen ....... 16 butalbital-acetaminophen-caff 16 butalbital-aspirin-caffeine ...... 16

Fecha de entrada en vigencia: 01 de diciembre 2015

butorphanol tartrate ................ 16 BUTRANS ............................. 16 BYDUREON ......................... 51 BYETTA ................................ 51 BYSTOLIC ............................ 83 C c complex ............................. 155 cabergoline ............................. 65 ca-d3-mag ox-zinc-cop-mangbor .................................... 142 caffeine citrated ...................... 90 caffeine-sodium benzoate ...... 90 calci-chew ............................ 121 calcidol ................................. 155 calcionate ............................. 142 calcipotriene ......................... 105 calcitonin (salmon)............... 136 calcitrate ............................... 142 calcitrate-vitamin d .............. 142 calcitriol ....................... 105, 136 calcium 500 + d.................... 142 calcium 500 + d (d3) ............ 142 calcium 500 with d ............... 142 calcium 600 .......................... 142 calcium 600 + d(3) ............... 142 calcium 600 with vitamin d3 142 calcium acetate ..................... 126 CALCIUM ACETATE ........ 126 calcium carbonate 121, 142, 143 calcium carbonate-mag carb-fa .......................................... 126 calcium carbonate-vitamin d2 .......................................... 143 calcium carbonate-vitamin d3 .......................................... 143 CALCIUM CARBONATEVITAMIN D3 .................. 121 calcium chloride ................... 143 calcium citrate-vitamin d3 ... 143 calcium gluconate ................ 143 calcium lactate ..................... 143 calcium+d............................. 143

CALDOLOR .......................... 21 cal-gest antacid ..................... 121 calphron ................................ 126 CALTRATE 600 + D ........... 143 CALTRATE-600 + D VIT D3 (800) ................................. 143 CANCIDAS ........................... 55 candesartan ............................. 81 candesartan-hydrochlorothiazid ............................................ 81 CAPASTAT ........................... 63 CAPRELSA ........................... 38 captopril ................................. 82 captopril-hydrochlorothiazide 82 CARAFATE......................... 119 carbamazepine ........................ 46 carbidopa ................................ 65 carbidopa-levodopa ................ 66 carbidopa-levodopa-entacapone ............................................ 66 carboplatin .............................. 38 cardec dm (phenyleph-chlorphn) ............................................ 95 CARIMUNE NF NANOFILTERED ........... 132 carisoprodol .......................... 150 carteolol ................................ 113 cartia xt ................................... 84 carvedilol ................................ 83 CASTELLANI PAINT MODIFIED ...................... 105 CAYSTON ............................. 34 cefaclor ............................. 31, 32 cefadroxil ............................... 32 cefazolin ................................. 32 cefazolin in dextrose (iso-os) . 32 cefdinir ................................... 32 cefditoren pivoxil ................... 32 cefepime ................................. 32 CEFEPIME IN DEXTROSE 5 % ........................................ 32

I-4 Formulario del plan Community Care Plus 2015 de Medicare-Medicaid de ventaja doble completamente integrado (Fully Integrated Duals Advantage Medicare-Medicaid Plan, FIDA MMP) de ICS Identificación del formulario: 15412.000, Versión: 16

CEFEPIME IN DEXTROSE,ISO-OSM ..... 32 cefotaxime .............................. 32 cefoxitin.................................. 32 cefoxitin in dextrose, iso-osm 32 cefpodoxime ........................... 32 cefprozil.................................. 32 ceftazidime ....................... 32, 33 ceftibuten ................................ 33 ceftriaxone .............................. 33 CEFTRIAXONE .................... 33 ceftriaxone in dextrose,iso-os. 33 CEFTRIAXONE IN DEXTROSE,ISO-OS ......... 33 cefuroxime axetil .................... 33 cefuroxime sodium ................. 33 cefuroxime-dextrose (iso-osm) ............................................ 33 celecoxib ................................ 21 CELLCEPT INTRAVENOUS .......................................... 132 CELONTIN ............................ 46 centamin ............................... 155 central vite with lutein .......... 155 central-vite............................ 156 central-vite for seniors.......... 156 central-vite select . 156, 159, 167 central-vite senior ................. 156 centram-care ......................... 156 centravites 50 plus ................ 156 centrum ................................. 156 centrum complete ................. 156 CENTRUM PRO NUTRIENTS .......................................... 143 centrum silver ....................... 156 centrum ultra women's ......... 156 century .................................. 156 century adults 50+ ................ 156 century advanced formula .... 156 century mature ...................... 156 century ultimate women's..... 156 cephalexin .............................. 33

Fecha de entrada en vigencia: 01 de diciembre 2015

CEPROTIN (BLUE BAR) ..... 73 CERDELGA ........................ 138 CEREZYME ........................ 112 cerovite ................................. 156 cerovite advanced formula ... 156 cerovite jr ............................. 157 cerovite senior ...................... 157 certavite senior-antioxidant .. 157 certavite-antioxid (iron gluc) 157 certavite-antioxidant ............ 157 CERVARIX VACCINE (PF) .......................................... 133 cetirizine ................................. 59 cetirizine-pseudoephedrine .... 59 cevimeline ............................ 104 CHANTIX.............................. 25 CHANTIX CONTINUING MONTH BOX ................... 25 CHANTIX CONTINUING MONTH PAK .................... 25 CHANTIX STARTING MONTH BOX ................... 25 cheratussin ac ......................... 95 cheratussin dac ....................... 95 chest congestion relief + dm .. 95 chest congestion relief d......... 95 chest congestion relief pe ....... 95 chewable multi vitamin ........ 157 chewable-vite ....................... 157 chewable-vite with iron........ 157 child complete multivitamin 157 child cough & sore throat ....... 95 child mucinex chest congestion ............................................ 95 child mucus relief cough ........ 95 child plus cough & runny nose ............................................ 95 child triaminic cold & allergy 59 child triaminic cough-congest 95 child vitamin with minerals . 157 child wal-tap cold-allergy ...... 59 child wal-tussin cough relief .. 95

children's advil ....................... 21 children's aller-tec .................. 59 children's cetirizine ................ 59 children's chest congestion ..... 95 children's chewable .............. 157 children's chewable complete .......................................... 157 children's chewable vitamin . 157 children's chewable w/minerals .......................................... 157 CHILDREN'S CLARITIN ..... 59 children's complete vitamin . 157 CHILDREN'S DIMETAPP COLD &FLU ..................... 95 children's flu relief ................. 95 children's mapap ..................... 16 children's mucinex cough ....... 95 children's multivit w/extra c . 157 children's non-aspirin ............. 16 children's pain & fever relief.. 16 children's pain reliever ........... 16 children's silapap .................... 17 children's silfedrine ................ 95 children's soothe ................... 121 children's sudafed ................... 96 children's sudafed pe cough ... 96 children's vitamin with iron . 157 children's wal-dryl allergy...... 59 children's wal-zyr ................... 59 CHILDREN'S ZYRTEC ALLERGY ......................... 59 childs chew vite .................... 157 child's chewable vitamins/iron .......................................... 157 child's vitamin with iron....... 158 child's vitamin with vitamin c .......................................... 158 childs/iron............................. 158 chlophedianol-guaifenesin ..... 96 chloramphenicol sod succinate ............................................ 30 chlordiazepoxide hcl .............. 26

I-5 Formulario del plan Community Care Plus 2015 de Medicare-Medicaid de ventaja doble completamente integrado (Fully Integrated Duals Advantage Medicare-Medicaid Plan, FIDA MMP) de ICS Identificación del formulario: 15412.000, Versión: 16

chlorhexidine gluconate ....... 104 chloroquine phosphate ........... 65 chlorothiazide ......................... 87 chlorothiazide sodium ............ 87 chlorpheniramine-phenyleph-dm ............................................ 96 chlorpromazine ....................... 66 chlorthalidone ......................... 87 chlorzoxazone ...................... 150 CHOLBAM .......................... 121 cholestyramine (with sugar) ... 88 cholestyramine-aspartame ...... 88 choline,magnesium salicylate 21 ciclopirox................................ 55 ciclopirox-ure-camph-menth-euc ............................................ 55 cilostazol ................................ 76 cimetidine ............................. 119 cimetidine hcl ....................... 119 CIMZIA................................ 112 CIMZIA POWDER FOR RECONST........................ 112 CIPRODEX .......................... 116 ciprofloxacin .......................... 36 ciprofloxacin hcl..... 36, 116, 117 ciprofloxacin in 5 % dextrose 36 ciprofloxacin lactate ............... 36 cisplatin .................................. 38 citalopram ............................... 49 citracal + d maximum........... 143 citric acid-sodium citrate ...... 143 citrus calcium ....................... 144 clarithromycin ........................ 34 CLARITIN ............................. 59 CLARITIN LIQUI-GEL ........ 59 CLARITIN REDITABS......... 59 CLARITIN-D 12 HOUR........ 59 CLARITIN-D 24 HOUR........ 59 clearlax ................................. 123 clemastine ............................... 59 CLEVIPREX .......................... 87 clindamycin hcl ...................... 30

Fecha de entrada en vigencia: 01 de diciembre 2015

clindamycin in 5 % dextrose .. 30 clindamycin palmitate hcl ...... 30 clindamycin phosphate.... 30, 62, 106 CLINIMIX 5%/D15W SULFITE FREE ................. 78 CLINIMIX 5%/D25W SULFITE-FREE ................ 78 CLINIMIX 2.75%/D5W SULFIT FREE ................... 78 CLINIMIX 4.25%/D10W SULF FREE .................................. 78 CLINIMIX 4.25%/D5W SULFIT FREE ................... 78 CLINIMIX 4.25%-D20W SULF-FREE ....................... 78 CLINIMIX 4.25%-D25W SULF-FREE ....................... 78 CLINIMIX 5%D20W(SULFITE-FREE) ... 78 CLINIMIX E 2.75%/D10W SUL FREE ......................... 78 CLINIMIX E 2.75%/D5W SULF FREE ....................... 78 CLINIMIX E 4.25%/D10W SUL FREE ......................... 78 CLINIMIX E 4.25%/D25W SUL FREE ......................... 78 CLINIMIX E 4.25%/D5W SULF FREE ....................... 78 CLINIMIX E 5%/D15W SULFIT FREE ................... 78 CLINIMIX E 5%/D20W SULFIT FREE ................... 78 CLINIMIX E 5%/D25W SULFIT FREE ................... 78 CLINISOL SF 15 %............... 78 clobetasol ............................. 108 clobetasol propionate ........... 108 clobetasol-emollient ............. 108 clocortolone pivalate ............ 108 clomipramine ......................... 49

clonazepam............................. 26 clonidine ................................. 81 clonidine hcl ..................... 81, 90 clonidine hcl-chlorthalidone .. 81 clopidogrel ............................. 76 clorazepate dipotassium ......... 26 clotrimazole ...................... 55, 56 clotrimazole 3 day .................. 55 clotrimazole-3 ........................ 56 clotrimazole-7 ........................ 56 clotrimazole-betamethasone... 56 clozapine .......................... 66, 67 COARTEM ............................ 65 codeine sulfate........................ 17 codeine-butalbital-asa-caffein 17 codituss dm ............................ 96 colace ................................... 123 colchicine ............................. 138 colchicine-probenecid .......... 138 COLCRYS ........................... 138 cold & cough .......................... 59 cold multi-symptom ............... 96 cold multi-symptom day/night96 cold multi-symptom nighttime ............................................ 96 cold relief m/s day/night ........ 96 cold-flu relief.......................... 96 cold-flu relief, day/night ........ 96 colestipol ................................ 88 colistin (colistimethate na) ..... 30 COLY-MYCIN S ................. 117 COMBIGAN ........................ 141 COMBIPATCH ................... 128 COMBIVENT RESPIMAT . 149 COMETRIQ ........................... 38 comfort gel extra strength .... 121 COMFORT PACCYCLOBENZAPRINE ... 151 COMFORT PAC-IBUPROFEN ............................................ 21 COMFORT PACMELOXICAM ................... 21

I-6 Formulario del plan Community Care Plus 2015 de Medicare-Medicaid de ventaja doble completamente integrado (Fully Integrated Duals Advantage Medicare-Medicaid Plan, FIDA MMP) de ICS Identificación del formulario: 15412.000, Versión: 16

COMFORT PAC-NAPROXEN ............................................ 21 COMFORT PAC-TIZANIDINE .......................................... 151 compete ................................ 158 COMPLERA .......................... 70 complete 50+ ........................ 158 complete multi 50+ .............. 158 complete multivitamin ......... 158 complete multivitamin-mineral .......................................... 158 complete senior .................... 158 compoz ................................... 59 COMVAX (PF) .................... 133 CONDYLOX ....................... 105 congestac ................................ 96 COPAXONE ........................ 138 coral calcium ........................ 144 CORDRAN .......................... 108 coricidin hbp........................... 96 CORLANOR .......................... 85 cortisone ............................... 129 cortizone-10.......................... 108 CORTIZONE-10 .................. 108 COSENTYX (2 SYRINGES) .......................................... 105 COSENTYX PEN ................ 105 COSENTYX PEN (2 PENS) 105 cough & cold .......................... 96 cough & runny nose ............... 96 CREON ................................ 112 creo-terpin (dm-guaifenesin) .. 96 CRESTOR .............................. 88 critic-aid clear af .................... 56 CRIXIVAN ............................ 70 cromolyn .............. 113, 121, 150 CUBICIN ............................... 30 CURITY GAUZE ................ 138 cyanocobalamin (vitamin b-12) .......................................... 158 cyclobenzaprine.................... 151 CYCLOGYL ........................ 114

Fecha de entrada en vigencia: 01 de diciembre 2015

cyclopentolate ...................... 114 cyclophosphamide............ 38, 39 CYCLOPHOSPHAMIDE...... 38 CYCLOSET ........................... 51 cyclosporine ......................... 132 cyclosporine modified .......... 132 cyclosporine, modified ......... 132 cyproheptadine ....................... 59 CYRAMZA............................ 39 cyred ....................................... 92 CYSTADANE ..................... 138 CYSTARAN ........................ 114 cysteine (l-cysteine) ............... 79 cytarabine ............................... 39 cytarabine (pf) ........................ 39 D d10 % & 0.45 % sodium chloride .............................. 79 d10 %-0.9 % sodium chloride 79 d2.5 %-0.45 % sodium chloride ............................................ 79 d5 % and 0.9 % sodium chloride ............................................ 79 d5 %-0.45 % sodium chloride 79 dacarbazine ............................ 39 dactinomycin .......................... 39 daily gummies ...................... 158 daily multiple ....................... 158 daily multi-vitamin............... 158 daily multivitamin with iron 158 daily multivitamin-minerals . 159 daily multi-vitamins/iron ..... 159 daily teen multi-vitamin ....... 159 daily value ............................ 159 daily vitamin ........................ 159 daily vitamin formula ........... 159 daily vitamin formula + iron 159 daily vitamin formula-minerals .......................................... 159 daily vitamin with iron ......... 159 daily vites/iron ..................... 159 dailyhist-1 .............................. 59

daily-vite .............................. 159 DAKLINZA ........................... 72 DALIRESP........................... 150 danazol ................................. 128 dantrolene ............................. 151 dantrolene sodium ................ 151 dapsone................................... 63 DAPTACEL (DTAP PEDIATRIC) (PF) ........... 133 DARAPRIM........................... 65 dayhist allergy ........................ 59 daytime cold & cough ............ 96 daytime cold-flu ..................... 97 day-time cough ....................... 97 daytime mucus relief dm ........ 97 daytime-nighttime .................. 97 daytime-nighttime cold-flu .... 97 daytime-nighttime cough ....... 97 deblitane ................................. 92 decitabine ............................... 39 decongestant cough ................ 97 deep sea nasal ....................... 114 deferoxamine ........................ 127 delsym cough+chest congest dm ............................................ 97 DELZICOL .......................... 135 DEMSER ............................... 85 DEPEN TITRATABS .......... 127 DEPO-PROVERA ............... 131 dermafungal ........................... 56 dermarest eczema (hydrocort) .......................................... 109 desenex (clotrimazole) ........... 56 desipramine ............................ 49 desmopressin ........................ 130 desog-e.estradiol/e.estradiol ... 92 desogestrel-ethinyl estradiol .. 92 desonide ............................... 109 desoximetasone .................... 109 despec-dm (pseudoeph-dmguaif) .................................. 97 dex4 glucose ........................... 79

I-7 Formulario del plan Community Care Plus 2015 de Medicare-Medicaid de ventaja doble completamente integrado (Fully Integrated Duals Advantage Medicare-Medicaid Plan, FIDA MMP) de ICS Identificación del formulario: 15412.000, Versión: 16

dexamethasone ..................... 129 dexamethasone sodium phosphate.................. 118, 129 dexchlorphen-pse-chlophedianol ............................................ 97 dexmethylphenidate ............... 90 dextroamphetamine ................ 90 dextroamphetamineamphetamine ...................... 90 dextromethorphan polistirex .. 97 dextrose 10 % and 0.2 % nacl 79 dextrose 10 % in water (d10w) ............................................ 79 dextrose 2.5 % in water(d2.5w) ............................................ 79 dextrose 20 % in water (d20w) ............................................ 79 dextrose 25 % in water (d25w) ............................................ 79 dextrose 40 % in water (d40w) ............................................ 79 dextrose 5 % in ringers ........... 79 dextrose 5 % in water (d5w) .. 79 dextrose 5 %-lactated ringers . 79 dextrose 5%-0.2 % sod chloride ............................................ 79 dextrose 5%-0.3 % sod.chloride ............................................ 80 dextrose 50 % in water (d50w) ............................................ 80 dextrose 70 % in water (d70w) ............................................ 80 dextrose with sodium chloride 80 diabetic siltussin das-na.......... 97 diabetic tussin dm ................... 97 diabetic tussin ex .................... 97 diamode ................................ 121 DIASTAT ACUDIAL ............ 26 diazepam ................................ 26 diazepam intensol ................... 26 diclofenac potassium .............. 21 diclofenac sodium .......... 22, 118

Fecha de entrada en vigencia: 01 de diciembre 2015

diclofenac-misoprostol ........... 22 dicloxacillin............................ 35 dicyclomine .......................... 121 didanosine .............................. 70 DIFICID ................................. 34 diflunisal ................................ 22 digitek .................................... 85 digoxin ................................... 85 DIGOXIN .............................. 85 dihydroergotamine ................. 62 DILANTIN CAPSULE 30 MG ............................................ 46 diltiazem hcl ........................... 84 dilt-xr...................................... 84 dimaphen (pe) ........................ 60 dimaphen dm .......................... 97 dimenhydrinate ...................... 63 dimetapp cold-congestion ...... 60 dino-life ................................ 159 dino-life with extra c ............ 159 dino-life with iron-zinc ........ 159 DIPENTUM ......................... 135 diphenhist ............................... 60 diphenhydramine hcl .............. 60 diphenoxylate-atropine ........ 121 disopyramide phosphate......... 83 disulfiram ............................... 25 divalproex .............................. 46 d-methorphan hb-p-epd hcl-bpm ............................................ 97 dm-phenyleph-chlorpheniramine ............................................ 97 dobutamine............................. 86 dobutamine in d5w................. 86 doc-q-lace ............................. 123 docu ...................................... 123 docusate sodium ................... 124 docusol ................................. 124 dok........................................ 124 donepezil ................................ 48 dopamine ................................ 86 dopamine in 5 % dextrose ...... 86

dorzolamide.......................... 141 dorzolamide-timolol ............. 141 douche vinegar & water extra .......................................... 138 doxazosin ............................... 81 doxepin ................................... 49 doxercalciferol ..................... 136 doxorubicin hcl ...................... 39 doxorubicin hcl peg-liposomal ............................................ 39 doxorubicin, peg-liposomal ... 39 doxycycline hyclate................ 37 doxycycline monohydrate ...... 37 dramamine .............................. 63 driminate ................................ 63 dristan long lasting ............... 114 dronabinol .............................. 63 droperidol ............................. 138 drospirenone-ethinyl estradiol 92 DROXIA ................................ 39 DRYSOL DAB-O-MATIC .. 105 DUAVEE ............................. 128 dulcolax stool softener (dss) 124 DULERA ............................. 148 duloxetine ......................... 49, 50 DURAMORPH (PF) .............. 17 DUREZOL ........................... 118 DYRENIUM .......................... 87 E e.c. prin ................................... 22 ECEE PLUS ......................... 159 econazole ................................ 56 ed bron gp............................... 97 ed chlorped jr ......................... 60 EDURANT............................. 70 EFFIENT ................................ 76 ELAPRASE ......................... 112 eldertonic .............................. 159 electrolyte-48 in d5w ........... 144 ELIDEL ................................ 109 ELIGARD .............................. 39 ELIQUIS ................................ 73

I-8 Formulario del plan Community Care Plus 2015 de Medicare-Medicaid de ventaja doble completamente integrado (Fully Integrated Duals Advantage Medicare-Medicaid Plan, FIDA MMP) de ICS Identificación del formulario: 15412.000, Versión: 16

ELITEK ................................ 112 ELLA...................................... 92 ellis tonic .............................. 159 ELMIRON............................ 138 elon dual defense .................... 56 EMCYT .................................. 39 EMEND............................ 63, 64 EMSAM ................................. 50 EMTRIVA.............................. 70 enalapril maleate .................... 82 enalaprilat ............................... 82 enalapril-hydrochlorothiazide 82 ENBREL .............................. 132 ENBREL SURECLICK ....... 132 endur-acin ............................... 88 enema ................................... 124 enema disposable ................. 124 enemeez ................................ 124 enemeez plus ........................ 124 enfalyte ................................. 144 ENGERIX-B (PF) ................ 133 ENGERIX-B PEDIATRIC (PF) .......................................... 133 enoxaparin ........................ 73, 74 entacapone .............................. 66 entecavir ................................. 73 entre-cough ............................. 97 ENTRESTO ........................... 81 ephedrine sulfate .................... 86 epinastine.............................. 114 epinephrine ............................. 86 epinephrine hcl (pf) ................ 86 EPIPEN 2-PAK ...................... 86 EPIPEN JR 2-PAK................. 86 epirubicin................................ 39 EPIVIR HBV ......................... 70 eplerenone .............................. 89 EPOGEN ................................ 75 epoprostenol (glycine) .......... 152 EPZICOM .............................. 70 eq gentle ............................... 114 equalactin ............................. 124

Fecha de entrada en vigencia: 01 de diciembre 2015

ERBITUX .............................. 39 ergocalciferol (vitamin d2) .. 159 ergoloid ................................ 138 ERGOMAR............................ 62 ERIVEDGE............................ 39 ERYTHROCIN ...................... 34 erythromycin .................. 34, 117 erythromycin base .................. 34 ERYTHROMYCIN BASE .... 34 erythromycin base-ethanol ... 107 erythromycin ethylsuccinate .. 34 erythromycin stearate ............. 34 erythromycin with ethanol ... 107 ESBRIET ............................. 150 escitalopram oxalate............... 50 esmolol ................................... 83 esomeprazole sodium ........... 119 essentia ................................. 160 essential balance with lutein 160 essential daily ....................... 160 essential one daily ................ 160 estazolam................................ 27 ESTRACE ............................ 128 estradiol ................................ 128 estradiol valerate .................. 128 estradiol/norethindrone acet . 128 estradiol-norethindrone acet. 129 ESTRASORB ...................... 129 estropipate ............................ 129 ethambutol.............................. 63 ethamolin................................ 86 ethinyl estradiol/drospirenone 92 ethosuximide .......................... 46 ethynodiol d-ethinyl estradiol 92 etidronate disodium .............. 136 etodolac .................................. 22 ETOPOPHOS ........................ 39 etoposide ................................ 39 EVOTAZ................................ 70 exefen dmx ............................. 98 EXELON................................ 48 exemestane ............................. 39

EXJADE............................... 127 expectorant ............................. 98 expectorant dm ....................... 98 expectorant max strength ....... 98 EXTAVIA ............................ 138 extra cleansing douche ......... 138 F fa-8 ....................................... 160 FABRAZYME ..................... 112 famciclovir ............................. 73 famotidine .................... 119, 120 famotidine (pf) ..................... 119 famotidine (pf)-nacl (iso-os) 119 FANAPT ................................ 67 FARESTON ........................... 39 FARYDAK ............................ 40 FASLODEX ........................... 40 fe fumarate-doss-fa-bcomp and c ........................................ 160 fe fumarate-vit c-b12-if-fa ... 160 felbamate ................................ 46 felodipine ............................... 87 feminine care douche ........... 138 FEMRING ............................ 129 fenofibrate .............................. 88 fenofibrate micronized ........... 88 fenofibrate nanocrystallized ... 88 fenofibric acid ........................ 88 fenofibric acid (choline) ......... 88 fenoprofen .............................. 22 fentanyl................................... 17 fentanyl citrate........................ 17 ferate..................................... 160 ferotrinsic ............................. 160 ferretts .................................. 160 ferrex 150 ............................. 160 ferrex 150 plus ..................... 160 FERRIPROX ........................ 127 ferrocite ................................ 160 ferrous fumarate ................... 160 ferrous gluconate .................. 160 ferrous sulfate ....................... 160

I-9 Formulario del plan Community Care Plus 2015 de Medicare-Medicaid de ventaja doble completamente integrado (Fully Integrated Duals Advantage Medicare-Medicaid Plan, FIDA MMP) de ICS Identificación del formulario: 15412.000, Versión: 16

FETZIMA .............................. 50 feverall.................................... 17 fiber (calcium polycarbophil) .......................................... 124 fiber laxative (methylcellulo)124 fiber smooth ......................... 124 fiber therapy ......................... 124 fiber therapy (psyllium/sugar) .......................................... 124 fiber-lax ................................ 124 finasteride ............................. 138 FIRAZYR ............................... 86 FIRMAGON KIT W DILUENT SYRINGE .......................... 40 flanax antacid ....................... 121 FLEBOGAMMA DIF .......... 132 flecainide ................................ 83 FLECTOR .............................. 22 FLEET BISACODYL .......... 124 FLEXBUMIN 25 % ............... 77 FLEXBUMIN 5 % ................. 77 flintstones complete (iron) ... 160 flintstones multivitamin ....... 160 flintstones with iron.............. 161 flintstones/extra c ................. 161 FLOVENT DISKUS ............ 148 FLOVENT HFA................... 148 floxuridine .............................. 40 flu formula daytime-nighttime98 flu severe cold-congestion...... 98 fluconazole ............................. 56 fluconazole in dextrose(iso-o) 56 fluconazole in nacl (iso-osm) . 56 flucytosine .............................. 56 fludarabine.............................. 40 fludrocortisone ..................... 129 flumazenil ............................... 90 fluocinonide.......................... 109 fluocinonide-emollient base . 109 fluorometholone ................... 118 FLUOROPLEX .................... 105 fluorouracil ..................... 40, 105

Fecha de entrada en vigencia: 01 de diciembre 2015

fluoxetine ............................... 50 FLUOXETINE ....................... 50 fluoxymesterone ................... 128 fluphenazine decanoate .......... 67 fluphenazine hcl ..................... 67 flurazepam........................ 27, 28 flurbiprofen ............................ 22 flurbiprofen sodium ............. 118 flutamide ................................ 40 fluticasone .................... 109, 118 fluvoxamine ........................... 50 foaming antacid .................... 121 folic acid............................... 161 FOLIC ACID ....................... 161 fomepizole............................ 138 fondaparinux .......................... 74 foot odor control .................... 56 FORTEO .............................. 136 FORTICAL .......................... 136 foscarnet ........................... 71, 72 fosfree .................................. 161 fosinopril ................................ 82 fosinopril-hydrochlorothiazide ............................................ 82 fosphenytoin ........................... 46 FREAMINE HBC 6.9 %........ 80 FREAMINE III 10 % ............. 80 fruity chews .......................... 161 fungi cure ............................... 56 FUNGI-NAIL ........................ 56 fungoid-d ................................ 56 furosemide.............................. 87 FUSILEV ............................. 138 FUZEON ................................ 70 FYCOMPA ............................ 46 G gabapentin .............................. 46 GABITRIL ............................. 46 galantamine ...................... 48, 49 GAMASTAN S/D ................ 132 GAMMAGARD LIQUID .... 132 GAMMAPLEX .................... 132

GAMUNEX-C ..................... 132 ganciclovir sodium ................. 73 GARDASIL (PF) ................. 133 GARDASIL 9 (PF) .............. 133 gas free extra strength .......... 118 gas relief ............................... 118 gas relief 80 .......................... 118 gas relief extra strength ........ 118 gas-x ultra-strength .............. 118 gatifloxacin........................... 117 GAZYVA ............................... 40 gelusil antacid & anti-gas ..... 122 gemcitabine ............................ 40 gemfibrozil ............................. 88 GENOTROPIN .................... 130 GENOTROPIN MINIQUICK .......................................... 130 gentamicin .............. 30, 107, 117 gentamicin in nacl (iso-osm) .. 29 gentamicin sulfate ................ 117 gentamicin sulfate (ped) (pf) .. 30 gentamicin sulfate (pf) ........... 30 GENTEAL MILD TO MODERATE ................... 114 GENTEAL GEL .................. 114 GENTEAL MILD ................ 114 GENTEAL SEVERE ........... 114 gentlelax ............................... 124 GEODON ............................... 67 geravim................................. 161 geriaton................................. 161 geri-dryl .................................. 60 geri-hydrolac ........................ 105 geri-tussin dm ......................... 98 germ defense ........................ 161 gildess 24 fe ........................... 92 GILENYA ............................ 138 GILOTRIF ............................. 40 GLEEVEC ............................. 40 glimepiride ............................. 54 glipizide .................................. 54 glipizide-metformin ............... 54

I-10 Formulario del plan Community Care Plus 2015 de Medicare-Medicaid de ventaja doble completamente integrado (Fully Integrated Duals Advantage Medicare-Medicaid Plan, FIDA MMP) de ICS Identificación del formulario: 15412.000, Versión: 16

GLUCAGEN HYPOKIT ..... 139 GLUCAGON EMERGENCY KIT (HUMAN) ................ 139 gluco burst .............................. 80 glucose.................................... 80 glucose gel .............................. 80 glutose 15 ............................... 80 glyburide ................................ 54 glyburide micronized ............. 54 glyburide-metformin ........ 54, 55 GLYCINE ............................ 135 glycolax ................................ 124 glycopyrrolate ...................... 122 glydo ....................................... 24 GLYXAMBI .......................... 51 granisetron (pf) ....................... 64 granisetron hcl ........................ 64 GRANIX ................................ 75 griseofulvin microsize ............ 56 guaiatussin ac ......................... 98 guaifenesin ............................. 98 guaifenesin dac ....................... 98 guanfacine ........................ 81, 91 guanidine .............................. 139 gummi bear multivitamin ..... 161 gummy swirls ....................... 161 H hair vitamins ......................... 161 hair,skin & nails ................... 161 HALAVEN ............................ 40 halobetasol propionate ......... 109 haloperidol.............................. 67 haloperidol decanoate............. 67 haloperidol lactate .................. 67 HARVONI ............................. 72 HAVRIX (PF) ...................... 134 head congestion day-night...... 98 healthy eyes .......................... 161 healthylax ............................. 124 hemocyte .............................. 161 heparin (porcine) .................... 74

Fecha de entrada en vigencia: 01 de diciembre 2015

heparin (porcine) in 5 % dex . 74, 75 HEPARIN (PORCINE) IN 5 % DEX ................................... 74 heparin (porcine) in nacl (pf) . 74 HEPARIN(PORCINE) IN 0.45% NACL ..................... 75 heparin, porcine (pf)............... 74 HEPATAMINE 8% ............... 80 HEPATASOL 8 % ................. 80 HERCEPTIN.......................... 40 HEXALEN ............................. 40 hi-b complex ........................ 161 hi-cal plus vit d..................... 144 high potency multivit-multimin .......................................... 162 homatropine hbr ................... 114 honey bears .......................... 162 honey bears with iron-zinc ... 162 HUMALOG ........................... 53 HUMALOG KWIKPEN ........ 53 HUMALOG MIX 50-50 ........ 53 HUMALOG MIX 50-50 KWIKPEN ......................... 53 HUMALOG MIX 75-25 ........ 53 HUMALOG MIX 75-25 KWIKPEN ......................... 53 HUMATROPE ..................... 130 HUMIRA ............................. 132 HUMIRA PEN ..................... 132 HUMIRA PEN CROHN'S-UCHS START ....................... 132 HUMULIN 70/30................... 53 HUMULIN 70/30 KWIKPEN 53 HUMULIN N ......................... 53 HUMULIN N KWIKPEN ..... 53 HUMULIN R ......................... 53 HUMULIN R U-500 (CONCENTRATED) ......... 53 hydralazine ............................. 86 hydrochlorothiazide ............... 88 hydrocil instant..................... 124

hydrocodone bit-homatrop mebr ........................................ 98 hydrocodone-acetaminophen . 17 hydrocodone-chlorpheniramine ............................................ 98 hydrocodone-homatropine ..... 98 hydrocodone-ibuprofen .......... 17 hydrocortisone ...... 109, 110, 129 hydrocortisone acet-aloe vera .......................................... 109 hydrocortisone acetate.......... 109 hydrocortisone acetate-aloe.. 109 hydrocortisone acetate-urea . 109 hydrocortisone butyrate........ 109 hydrocortisone butyr-emollient .......................................... 109 hydrocortisone sod succinate 129 hydrocortisone valerate ........ 110 hydromorphone ................ 17, 18 hydromorphone (pf) ............... 17 hydroskin .............................. 110 hydroxychloroquine ............... 65 hydroxyurea ........................... 40 hydroxyzine hcl .................... 139 hydroxyzine pamoate ........... 139 HYPERLYTE CR ................ 144 HYPERRAB S/D (PF) ......... 132 HYQVIA .............................. 132 I ibandronate ................... 136, 137 IBRANCE .............................. 40 ibuprofen ................................ 22 ibuprofen jr strength ............... 22 icaps plus .............................. 162 ICLUSIG ................................ 40 iferex 150 ............................. 162 ifosfamide............................... 40 ifosfamide-mesna ................... 41 ILARIS (PF) ......................... 132 ILEVRO ............................... 118 IMBRUVICA ......................... 41 imipenem-cilastatin ................ 34

I-11 Formulario del plan Community Care Plus 2015 de Medicare-Medicaid de ventaja doble completamente integrado (Fully Integrated Duals Advantage Medicare-Medicaid Plan, FIDA MMP) de ICS Identificación del formulario: 15412.000, Versión: 16

imipramine hcl ....................... 50 imipramine pamoate ............... 50 imiquimod ............................ 105 imodium a-d ......................... 122 IMODIUM A-D ................... 122 IMOGAM RABIES-HT (PF) .......................................... 132 IMOVAX RABIES VACCINE (PF) ................................... 134 INCRELEX .......................... 130 indapamide ............................. 88 indomethacin .......................... 22 indomethacin sodium ............. 22 INFANRIX (DTAP) (PF) .... 134 infant acetaminophen ............. 18 infantaire ................................ 18 infant's ibuprofen .................... 22 INFANT'S MOTRIN ............. 22 infants' non-aspirin cold ......... 98 infant's pain reliever ............... 18 INLYTA ................................. 41 insta-glucose ........................... 80 INSULIN SYRINGE ........... 111 INSULIN SYRINGE NEEDLELESS ................. 111 INSULIN SYRINGE-NEEDLE U-100................................ 111 INTELENCE .......................... 70 intense cough reliever ............ 98 INTRALIPID ......................... 80 INTRON A ............................. 72 INVANZ ................................ 34 INVEGA ................................ 67 INVEGA SUSTENNA..... 67, 68 INVEGA TRINZA ................. 68 INVIRASE ............................. 70 INVOKAMET.................. 51, 52 INVOKANA .......................... 52 inzo antifungal ........................ 56 iodine .................................... 112 IONOSOL-B IN D5W ......... 144 IONOSOL-MB IN D5W ...... 144

Fecha de entrada en vigencia: 01 de diciembre 2015

IPOL ..................................... 134 ipratropium bromide ............ 114 IPRIVASK ............................. 75 irbesartan ................................ 81 irbesartan-hydrochlorothiazide ............................................ 81 IRENKA ................................ 50 IRESSA .................................. 41 iron high potency ................. 162 ISENTRESS ........................... 70 ISOLYTE M IN 5 % DEXTROSE ..................... 144 ISOLYTE-H IN 5 % DEXTROSE ..................... 144 ISOLYTE-P IN 5 % DEXTROSE ..................... 144 ISOLYTE-S ......................... 144 isoniazid ................................. 63 isopto tears ........................... 114 isosorbide dinitrate ................. 89 isosorbide mononitrate ........... 89 isotretinoin ........................... 106 isradipine ................................ 87 ISTODAX .............................. 41 itraconazole ............................ 56 ivermectin .............................. 65 i-vite ..................................... 162 IXEMPRA.............................. 41 IXIARO (PF) ....................... 134 J JADENU .............................. 127 JAKAFI .................................. 41 JALYN ................................. 139 jantoven .................................. 75 JANUMET ............................. 52 JANUMET XR ...................... 52 JANUVIA .............................. 52 JARDIANCE ......................... 52 JENTADUETO ...................... 52 JEVTANA.............................. 41 jr. acetaminophen ................... 18 junel fe 24 .............................. 92

junior mapap .......................... 18 K KABIVEN .............................. 80 KADCYLA ............................ 41 KALETRA ............................. 70 KALYDECO ........................ 150 kaopectate (bismuth subsalicy) .......................................... 122 KEDBUMIN .......................... 77 KELP (IODINE) .................. 144 ketoconazole........................... 56 ketoprofen ........................ 22, 23 ketorolac ......................... 23, 118 ketotifen fumarate ................ 114 KEYTRUDA .......................... 41 KHEDEZLA .......................... 50 kidkare cough/cold ................. 99 kid's vitamins ....................... 162 kid's vitamins + extra c ........ 162 kids vitamins + iron ............. 162 kid's vitamins + iron ............. 162 kimidess (28) .......................... 92 KINERET............................. 132 KINRIX (PF)........................ 134 KLOR-CON ......................... 144 klor-con 10 ........................... 144 KLOR-CON 8 ...................... 144 klor-con m10 ........................ 144 klor-con m15 ........................ 144 klor-con m20 ........................ 144 klor-con sprinkle .................. 144 KLOR-CON/EF ................... 144 konsyl (sugar) ....................... 124 konsyl fiber .......................... 124 konsyl sugar-free .................. 124 KORLYM .............................. 52 KRYSTEXXA ..................... 112 KUVAN ............................... 112 KYPROLIS ............................ 41 L l norgest/e.estradiol-e.estrad .. 92 labetalol .................................. 83

I-12 Formulario del plan Community Care Plus 2015 de Medicare-Medicaid de ventaja doble completamente integrado (Fully Integrated Duals Advantage Medicare-Medicaid Plan, FIDA MMP) de ICS Identificación del formulario: 15412.000, Versión: 16

LACRISERT ........................ 114 LACTATED RINGERS....... 135 LACTINOL HX ................... 106 lactulose................................ 122 LAMICTAL ........................... 47 LAMISIL (AEROSOL) ......... 56 lamisil af ................................. 57 LAMISIL AT ......................... 57 lamivudine .............................. 70 lamivudine-zidovudine........... 70 lamotrigine ............................. 47 LANOXIN.............................. 86 lansoprazole.......................... 119 LANTUS ................................ 53 LANTUS SOLOSTAR .......... 53 larin 24 fe ............................... 92 latanoprost ............................ 141 LATUDA ............................... 68 laxative peg 3350 ................. 124 LAZANDA ............................ 18 leflunomide .......................... 132 LEMTRADA........................ 139 LENVIMA ............................. 41 LETAIRIS ............................ 152 letrozole .................................. 41 leucovorin calcium ............... 139 LEUKERAN .......................... 41 LEUKINE .............................. 75 leuprolide................................ 41 levetiracetam .......................... 47 levobunolol ........................... 141 levocarnitine ......................... 139 levocarnitine (with sugar) .... 139 levocetirizine .......................... 60 levofloxacin .................... 36, 117 levofloxacin in d5w ................ 36 levoleucovorin calcium ........ 139 levonorgestrel ................... 92, 93 levonorgestrel-ethin estradiol . 92 levonorgestrel-ethinyl estrad . 92, 93 levorphanol tartrate ................ 18

Fecha de entrada en vigencia: 01 de diciembre 2015

levothyroxine ....................... 131 LEXIVA ................................. 70 lice cream rinse .................... 111 lice killing ............................ 111 lice treatment ........................ 111 lice treatment (permethrin) .. 111 lidocaine ................................. 24 lidocaine (pf) .................... 24, 83 lidocaine hcl ........................... 24 lidocaine in 5 % dextrose (pf) 83 lidocaine-prilocaine................ 24 life-pack women's ................ 162 linezolid.................................. 30 LINZESS.............................. 112 liothyronine .......................... 131 lipase-protease-amylase ....... 112 lipogen.................................... 88 LIPOSYN II ........................... 80 LIPOSYN III .......................... 80 liquibid d-r ............................. 99 liquid calcium with vitamin d .......................................... 144 LIQUI-E ............................... 162 liquitears ............................... 114 lisinopril ................................. 82 lisinopril-hydrochlorothiazide 82 lithium carbonate ................... 91 lithium citrate ......................... 91 little animals ......................... 162 little animals-iron ................. 162 l-norgest-eth estr/ethin estra ... 93 lobana bath ........................... 106 lohist peb dm .......................... 99 lomustine ................................ 41 loperamide............................ 122 loradamed ............................... 60 loratadine................................ 60 loratadine-d ............................ 60 lorazepam oral solution .......... 28 lortuss ex ................................ 99 losartan ................................... 81 losartan-hydrochlorothiazide . 82

LOTEMAX .......................... 118 LOTRIMIN ULTRA .............. 57 LOTRONEX ........................ 112 lovastatin ................................ 88 loxapine succinate .................. 68 lubricant dry eye relief ......... 114 lubricant eye (cmc-glycer)(pf) .......................................... 114 lubricant eye (cmc-glycerin) 114 lubricant eye (polyv alcohol) 114 lubricant eye (propyl glycol) 115 lubricant eye drops ............... 115 lubricant gel.......................... 115 lubricating drops .................. 115 lubrifresh pm ........................ 115 LUMIGAN ........................... 141 LUMIZYME ........................ 112 LUPRON DEPOT .................. 41 LUPRON DEPOT (3 MONTH) ............................................ 41 LUPRON DEPOT (4 MONTH) ............................................ 41 LUPRON DEPOT (6 MONTH) ............................................ 41 LUPRON DEPOT-PED ......... 41 LUPRON DEPOT-PED (3 MONTH) ............................ 41 LYNPARZA .......................... 42 LYRICA ................................. 47 lysiplex plus ......................... 162 LYSODREN .......................... 42 M maalox advanced .................. 122 MACUVITE......................... 162 MACUVITE EYE CARE .... 162 mafenide acetate ................... 106 mag 64 .................................. 144 mag-delay ............................. 144 mag-g ................................... 145 MAGNEBIND 300 .............. 122 magnesium ........................... 145

I-13 Formulario del plan Community Care Plus 2015 de Medicare-Medicaid de ventaja doble completamente integrado (Fully Integrated Duals Advantage Medicare-Medicaid Plan, FIDA MMP) de ICS Identificación del formulario: 15412.000, Versión: 16

magnesium (oxide/aa chelate) .......................................... 145 magnesium chloride ............. 145 magnesium gluconate ........... 145 magnesium oxide ................. 122 magnesium sulf in 0.45% nacl .......................................... 145 magnesium sulfate ................ 145 magnesium sulfate in d5w .... 145 magnesium sulfate in water .. 145 malathion .............................. 111 mapap (acetaminophen) ......... 18 mapap arthritis pain ................ 18 mapap extra strength .............. 18 maprotiline ............................. 50 mar-cof bp .............................. 99 mar-cof cg .............................. 99 MARPLAN ............................ 50 MARQIBO ............................. 42 masanti double strength........ 122 MATULANE ......................... 42 matzim la ................................ 84 maximum daily multivitamin .......................................... 162 maximum strength flu ............ 99 meclizine ................................ 64 medi-brom .............................. 99 medroxyprogesterone ........... 131 mefenamic acid ...................... 23 mefloquine.............................. 65 MEFOXIN IN DEXTROSE (ISO-OSM) ......................... 33 mega multiple/chelated mineral .......................................... 162 mega multivitamin with mineral .......................................... 162 MEGACE ES ......................... 42 megestrol ................................ 42 MEKINIST ............................. 42 meloxicam .............................. 23 melphalan hcl intravenous...... 42 memantine .............................. 49

Fecha de entrada en vigencia: 01 de diciembre 2015

MENACTRA (PF) ............... 134 MENEST.............................. 129 MENHIBRIX (PF) ............... 134 MENOMUNE - A/C/Y/W-135 (PF) .................................. 134 men's daily gummies ............ 162 men's multi-vitamin ............. 163 men's multivitamin gummies 163 men's one daily..................... 163 MENVEO A-C-Y-W-135-DIP (PF) .................................. 134 MENVEO MENA COMPONENT (PF)......... 134 MENVEO MENCYW-135 COMPNT (PF) ................. 134 MEPHYTON ....................... 163 mercaptopurine ...................... 42 meropenem ............................. 34 mesehist dm ........................... 99 mesna ................................... 139 MESNEX ............................. 139 MESTINON ......................... 139 metaproterenol ..................... 149 metaxalone ........................... 151 metformin ............................... 52 methadone .............................. 18 methadone hcl ........................ 18 methazolamide ..................... 141 methenamine hippurate .......... 30 methenamine mandelate......... 30 methimazole ......................... 131 methocarbamol ..................... 151 methotrexate sodium .............. 42 methotrexate sodium (pf) ....... 42 methoxsalen rapid ................ 106 methscopolamine ................. 122 methyclothiazide .................... 88 methylphenidate ..................... 91 methylprednisolone .............. 129 methylprednisolone acetate .. 129 methylprednisolone sodium succ .......................................... 129

metipranolol ......................... 141 metoclopramide hcl .............. 122 metolazone ............................. 88 metoprolol succinate .............. 83 metoprolol ta-hydrochlorothiaz ............................................ 83 metoprolol tartrate .................. 84 metronidazole ........... 62, 65, 107 metronidazole in nacl (iso-os) 65 mexiletine ............................... 83 mgo....................................... 122 MIACALCIN ....................... 137 mi-acid ................................. 122 mi-acid gas relief .................. 119 micatin .................................... 57 miconazole 7 .......................... 57 miconazole nitrate .................. 57 midazolam .............................. 28 midazolam (pf) ....................... 28 midodrine ............................... 81 milk of magnesia .................. 125 milltrium senior .................... 163 milrinone ................................ 86 milrinone in 5 % dextrose ...... 86 MINERAL OIL .................... 139 mineral oil laxative............... 125 mineral oil light .................... 139 minitran .................................. 89 minocycline ............................ 37 minoxidil ................................ 90 mintox .................................. 122 mintox maximum strength ... 122 mintox plus........................... 123 MIRCERA ............................. 75 mirtazapine ............................. 50 misoprostol ........................... 119 mitomycin .............................. 42 mitoxantrone .......................... 42 M-M-R II (PF) ..................... 134 moexipril ................................ 82 moexipril-hydrochlorothiazide ............................................ 82

I-14 Formulario del plan Community Care Plus 2015 de Medicare-Medicaid de ventaja doble completamente integrado (Fully Integrated Duals Advantage Medicare-Medicaid Plan, FIDA MMP) de ICS Identificación del formulario: 15412.000, Versión: 16

mometasone.......................... 110 MONISTAT 3 ........................ 57 monistat 7 ............................... 57 montelukast .......................... 149 morphine ................................ 19 MORPHINE ........................... 19 morphine concentrate ............. 18 morrhuate sodium................. 139 motion sickness ...................... 64 motion sickness (meclizine) ... 64 MOVANTIK ........................ 123 MOVIPREP.......................... 125 MOXEZA ............................. 117 moxifloxacin .......................... 36 MOZOBIL.............................. 75 mucinex fast-max dm max ..... 99 mucus dm ............................... 99 mucus dm max ....................... 99 mucus relief ............................ 99 MULTAQ ............................... 83 multi complete with iron ...... 163 multi-day with iron ............... 163 multi-delyn ........................... 163 multi-delyn with iron............ 163 multilex ................................ 163 multilex-t&m ........................ 163 multiple vitamin-minerals .... 163 multiple vitamins.................. 163 multiple vitamins with iron .. 163 multi-symptom cold night time ............................................ 99 multi-symptom cold-cough .... 99 multivital platinum ............... 163 multivitamin ......................... 163 multivitamin 50 plus ............ 163 multi-vitamin hp/minerals .... 163 multivitamin with iron.......... 164 multivitamin with minerals .. 164 multivitamins with min no.7-fa .......................................... 164 multi-vite .............................. 164 multi-vite 50 & over ............. 164

Fecha de entrada en vigencia: 01 de diciembre 2015

mupirocin ............................. 107 mupirocin calcium ............... 107 muro 128 .............................. 115 MUSTARGEN....................... 42 my favorite multiple ............. 164 myco nail a ............................. 57 mycophenolate mofetil......... 133 mycophenolate sodium ........ 133 mylanta gas .......................... 119 MYOZYME ......................... 112 mytab gas ............................. 119 mytab gas maximum strength .......................................... 119 my-vitalife ............................ 164 N nabumetone ............................ 23 nadolol.................................... 84 nafcillin .................................. 35 nafcillin in dextrose iso-osm .. 35 NAGLAZYME .................... 112 naloxone ................................. 25 naltrexone............................... 25 naltrexone hcl ......................... 25 NAMENDA ........................... 49 NAMENDA TITRATION PAK ............................................ 49 NAMENDA XR..................... 49 NAMZARIC .......................... 49 naphazoline .......................... 115 naproxen ................................. 23 naproxen sodium .................... 23 naratriptan .............................. 62 nasal & sinus decongestant .... 99 nasal decongestant (oxymetazl) .......................................... 115 nasal decongestant (pe) .......... 81 NASCOBAL ........................ 164 NASONEX .......................... 118 NATACYN .......................... 117 nateglinide .............................. 52 NATPARA ........................... 137 natural b-100 ........................ 164

natural b-100 complex ......... 164 natural balance ..................... 115 natural calcium ..................... 145 natural fiber laxative therapy 125 natural tears (pf) ................... 115 nature's tears ......................... 115 NEBUPENT ........................... 65 nefazodone ............................. 50 neomy sulf-bacitrac zn-poly-hc .......................................... 117 neomycin ................................ 30 neomycin-bacitracin-poly-hc 117 neomycin-bacitracin-polymyxin .......................................... 117 neomycin-polymyxin b gu ... 107 neomycin-polymyxin bdexameth .......................... 117 neomycin-polymyxingramicidin ........................ 117 neomycin-polymyxin-hc ...... 117 neosporin anti-itch................ 110 neo-synephrine 12 h spr (oxym) .......................................... 115 neo-tuss .................................. 99 NEPHRAMINE 5.4 % ........... 80 nephro-vite ........................... 164 NEULASTA........................... 75 NEUMEGA ............................ 75 NEUPOGEN .......................... 75 NEUPRO................................ 66 NEVANAC .......................... 118 nevirapine ............................... 71 NEXAFED ............................. 99 NEXAVAR ............................ 42 niacin ................................ 88, 89 niacinamide .................... 89, 164 nicardipine .............................. 87 NICODERM CQ .................... 25 nicorelief ................................ 25 nicorette .................................. 25 nicotine ................................... 25 nicotine (polacrilex) ............... 25

I-15 Formulario del plan Community Care Plus 2015 de Medicare-Medicaid de ventaja doble completamente integrado (Fully Integrated Duals Advantage Medicare-Medicaid Plan, FIDA MMP) de ICS Identificación del formulario: 15412.000, Versión: 16

NICOTROL............................ 25 nifedipine................................ 87 night time ............................. 100 night time cold-flu .................. 99 night time cold-flu relief ........ 99 nighttime cold-flu ................. 100 nighttime cough .................... 100 nighttime relief eye .............. 115 NILANDRON ........................ 42 nite time cold-flu .................. 100 nite time-d cold-flu relief ..... 100 NITRO-BID ........................... 90 nitrofurantoin macrocrystal .... 31 nitrofurantoin monohyd/m-cryst ............................................ 31 nitroglycerin ........................... 90 nitroglycerin in 5 % dextrose . 90 NITROSTAT.......................... 90 nohist-dm.............................. 100 non-aspirin cold .................... 100 non-aspirin extra strength ....... 19 non-aspirin flu ...................... 100 non-aspirin jr strength ............ 19 NORDITROPIN FLEXPRO 130 norelgestromin/ethin.estradiol 93 norepinephrine bitartrate ........ 87 noreth-ethinyl estradiol/iron ... 93 norethindrone ......................... 93 norethindrone (contraceptive) 93 norethindrone acetate ........... 131 norethindrone ac-eth estradiol .................................... 93, 129 norethindrone-e.estradiol-iron 93 norethindrone-ethinyl estrad .. 93 norethindrone-mestranol ........ 93 norgestimate-ethinyl estradiol 93 norgestrel-ethinyl estradiol..... 93 NORMOSOL-M IN 5 % DEXTROSE ..................... 145 NORMOSOL-R ................... 145 NORMOSOL-R PH 7.4 ....... 145 nortemp .................................. 19

Fecha de entrada en vigencia: 01 de diciembre 2015

NORTHERA .......................... 81 nortriptyline............................ 50 NORVIR ................................ 71 NOVOLIN 70/30 ................... 53 NOVOLIN N ......................... 53 NOVOLIN R .......................... 53 NOVOLOG ............................ 54 NOVOLOG FLEXPEN ......... 54 NOVOLOG MIX 70-30 ......... 54 NOVOLOG MIX 70-30 FLEXPEN .......................... 54 NOVOLOG PENFILL ........... 54 NOXAFIL .............................. 57 NUCYNTA ............................ 19 NUCYNTA ER ...................... 19 NUEDEXTA .......................... 91 nu-iron .................................. 164 NULOJIX ............................. 133 NUTRESTORE.................... 123 NUTRILIPID ......................... 80 NUTRILYTE ....................... 145 NUTRILYTE II ................... 145 NUTROPIN ......................... 130 NUTROPIN AQ................... 130 NUTROPIN AQ NUSPIN ... 130 NUVARING .......................... 93 NUVIGIL ............................. 151 nystatin ................................... 57 NYSTATIN (BULK) ............. 57 nystatin-triamcinolone ........... 57 nyt-time sleep ......................... 60 O ocean nasal ........................... 115 OCTAGAM ......................... 133 octreotide acetate ................. 130 ocutabs ................................. 164 OFEV ................................... 150 ofloxacin ........................ 36, 117 olanzapine ........................ 68, 69 olanzapine-fluoxetine............. 50 olopatadine ........................... 115 OLYSIO ................................. 72

omega-3 acid ethyl esters ....... 89 omeprazole ........................... 119 omeprazole magnesium........ 119 omeprazole-sodium bicarbonate .................................. 119, 120 OMNITROPE ...................... 130 ONCASPAR .......................... 42 once daily ............................. 164 oncovite ................................ 164 ondansetron ............................ 64 ondansetron hcl ...................... 64 ondansetron hcl (pf) ............... 64 one daily ............................... 165 one daily 50 plus .................. 164 one daily complete ............... 165 one daily energy ................... 165 one daily essential ................ 165 one daily gummy vites ......... 165 one daily maximum (with ca) .......................................... 165 one daily men's 50+ ............. 165 one daily multi-vit w-mineral .......................................... 165 one daily multivitamin ......... 165 one daily multivit-iron(folic) 165 one daily plus iron ................ 165 one daily plus minerals ........ 165 one daily with iron ............... 165 one-a-day essential ............... 165 one-a-day maximum formula165 one-a-day teen advantage ..... 165 ONFI ...................................... 28 opcicon one-step .................... 93 OPDIVO................................. 43 OPSUMIT ............................ 152 opti-vitamins ........................ 166 oral saline laxative ............... 125 oralyte................................... 145 ORAP ..................................... 69 ORENCIA ............................ 133 ORENCIA (WITH MALTOSE) .......................................... 133

I-16 Formulario del plan Community Care Plus 2015 de Medicare-Medicaid de ventaja doble completamente integrado (Fully Integrated Duals Advantage Medicare-Medicaid Plan, FIDA MMP) de ICS Identificación del formulario: 15412.000, Versión: 16

ORENITRAM ...................... 153 ORFADIN ............................ 112 ORKAMBI ........................... 150 OTEZLA .............................. 139 OTEZLA STARTER ........... 139 oxacillin .................................. 35 oxacillin in dextrose(iso-osm) 35 oxaliplatin............................... 43 oxandrolone .......................... 128 oxcarbazepine ......................... 47 OXTELLAR XR .................... 47 oxybutynin chloride ............. 127 oxycodone ........................ 19, 20 oxycodone hcl-acetaminophen ............................................ 19 oxycodone hcl-aspirin ............ 19 oxycodone-acetaminophen ..... 20 oxycodone-aspirin .................. 20 OXYCONTIN ........................ 20 oxymorphone.......................... 20 oysco 500/d .......................... 145 oysco d ................................. 145 oysco-500 ............................. 145 oyster shell calcium 500 ....... 145 oyster shell calcium with d ... 145 oyster shell calcium-vit d3 ... 145 oystercal-d ............................ 145 P paclitaxel ................................ 43 pain relief ............................... 20 pain relief adult ...................... 20 pain reliever ............................ 20 pain reliever jr strength .......... 20 paliperidone ............................ 69 PANRETIN .......................... 106 pantoprazole ......................... 120 papaverine .............................. 87 paricalcitol ............................ 137 paromomycin.......................... 65 paroxetine hcl ......................... 50 PASER ................................... 63 PATADAY ........................... 115

Fecha de entrada en vigencia: 01 de diciembre 2015

PATANOL ........................... 115 PAXIL .................................... 50 pecgen dmx .......................... 100 pedi m.vit no.17 with fluoride .......................................... 164 pedia relief ........................... 100 pedia relief infant ................. 100 pediacare multi-symptom cold .......................................... 100 PEDIARIX (PF) ................... 134 pediatric electrolyte .............. 146 pediatric freezer pops ........... 146 pediatric multivitamin .......... 166 PEDVAX HIB (PF) ............. 134 peg 3350-electrolytes ........... 125 PEG 3350-GRX ................... 125 peg 3350-na sulf,bicarb,cl-kcl .......................................... 125 PEGANONE .......................... 47 PEGASYS .............................. 72 PEGASYS PROCLICK ......... 72 peg-electrolyte soln .............. 125 PEGINTRON ......................... 72 PEGINTRON REDIPEN ....... 72 PEN NEEDLE, DIABETIC . 111 penicillin g pot in dextrose ..... 36 penicillin g potassium ............ 36 penicillin g procaine ............... 36 penicillin v potassium ............ 36 PENTACEL (PF) ................. 134 PENTACEL ACTHIB COMPONENT (PF)......... 134 PENTAM ............................... 65 pentoxifylline ......................... 76 pep-t-med ............................. 123 peri-colace ............................ 125 PERIKABIVEN ..................... 80 perindopril erbumine .............. 82 PERJETA ............................... 43 permethrin ............................ 111 perphenazine .......................... 69 perphenazine-amitriptyline .... 51

persa-gel ............................... 106 pharbetol................................. 20 pharmacist favorite multi-vit 166 phenelzine .............................. 51 phenobarbital .......................... 47 phenobarbital sodium ............. 47 phentolamine ........................ 152 phenylephrine hcl ........... 81, 115 phenylephrine-chlorpheniramine ............................................ 60 phenylhistine dh ................... 100 phenytoin ................................ 47 phenytoin sodium ................... 47 phenytoin sodium extended ... 47 phillips.................................. 123 phillips liqui-gels.................. 125 PHOS-FLUR ........................ 104 PHOSLYRA......................... 126 PHOS-NAK ......................... 146 phosphate laxative ................ 125 PHOSPHOLINE IODIDE.... 142 phosphorus #1 ...................... 146 phytonadione ........................ 166 PICATO ............................... 106 pilocarpine hcl .............. 104, 142 pimozide ................................. 69 pindolol .................................. 84 pioglitazone ............................ 52 pioglitazone-glimepiride ........ 52 pioglitazone-metformin .......... 52 piperacillin-tazobactam .......... 36 piroxicam ............................... 23 PLAN B ONE-STEP .............. 93 PLASBUMIN 25 % ............... 77 PLASBUMIN 5 % ................. 77 PLASMA-LYTE 148 ........... 146 PLASMA-LYTE A .............. 146 PLASMA-LYTE-56 IN 5 % DEXTROSE ..................... 146 PLEGRIDY .......................... 139 podactin .................................. 57 podofilox .............................. 106

I-17 Formulario del plan Community Care Plus 2015 de Medicare-Medicaid de ventaja doble completamente integrado (Fully Integrated Duals Advantage Medicare-Medicaid Plan, FIDA MMP) de ICS Identificación del formulario: 15412.000, Versión: 16

podophyllum resin ................ 106 polyethylene glycol 3350 ..... 125 poly-iron ............................... 166 polymyxin b sulf-trimethoprim .......................................... 117 poly-tussin ............................ 100 poly-vita ............................... 166 poly-vita (iron) ..................... 166 poly-vitamin ......................... 166 poly-vitamin with iron.......... 166 polyvitamin/iron ................... 166 poly-vitamins........................ 166 POMALYST .......................... 43 potassium acetate ................. 146 potassium bicarb and chloride .......................................... 146 potassium bicarb-citric acid . 146 potassium bicarbonate-cit ac 146 potassium chlorid-d5-0.45%nacl .......................................... 146 potassium chloride ....... 146, 147 potassium chloride in 0.9%nacl .......................................... 146 potassium chloride in 5 % dex .......................................... 146 potassium chloride in lr-d5..... 80 potassium chloride-0.45 % nacl .......................................... 147 potassium chloride-d5-0.2%nacl .......................................... 147 potassium chloride-d5-0.3%nacl .......................................... 147 potassium chloride-d5-0.9%nacl .......................................... 147 potassium citrate-citric acid . 147 potassium hydroxide ............ 106 potassium phosphate m-/d-basic .......................................... 147 POTIGA ................................. 48 PRADAXA ............................ 75 PRALUENT PEN .................. 89 PRALUENT SYRINGE......... 89

Fecha de entrada en vigencia: 01 de diciembre 2015

pramipexole............................ 66 PRANDIMET ........................ 52 pravastatin .............................. 89 prazosin .................................. 81 prednicarbate ........................ 110 prednisolone acetate ............. 118 prednisolone sodium phosphate .................................. 118, 130 prednisone ............................ 130 PREGNYL ........................... 130 PREMARIN ......................... 129 PREMASOL 10 % ................. 80 PREMASOL 6 % ................... 80 PREMPHASE ...................... 129 PREMPRO ........................... 129 prenatal ................................. 166 prenatal formula ................... 166 prenatal vit#96-ferrous fum-fa .......................................... 166 prenatal vitamin with minerals .......................................... 166 prenatal vitamins .................. 166 PRENATAL VITAMINS .... 166 prenatal vit-iron fumarate-fa 166 preparation h hydrocortisone 110 PREVIDENT 5000 SENSITIVE .......................................... 104 PREZCOBIX ......................... 71 PREZISTA ............................. 71 PRIFTIN ................................ 63 PRILOSEC OTC .................. 120 PRIMAQUINE ...................... 65 primidone ............................... 48 PRISTIQ ................................ 51 PRIVIGEN ........................... 133 PROAIR HFA ...................... 149 PROAIR RESPICLICK ....... 149 probenecid ............................ 140 procainamide .......................... 83 PROCALAMINE 3% ............ 80 prochlorperazine .................... 64 prochlorperazine edisylate ..... 64

prochlorperazine maleate ....... 64 PROCRIT ............................... 76 PROCYSBI .......................... 140 progesterone ......................... 131 progesterone micronized capsules ............................ 131 PROGLYCEM ....................... 90 PROGRAF ........................... 133 PROLENSA ......................... 118 PROLEUKIN ......................... 43 PROLIA ............................... 137 PROMACTA ......................... 76 promethazine .................... 60, 64 promethazine hcl .................... 64 promethazine-codeine .......... 101 promethazine-dm ................. 101 promethazine-phenylephcodeine ............................. 101 promolaxin ........................... 125 propafenone ............................ 83 propantheline .......................... 46 proparacaine ......................... 115 proparacaine hcl ................... 115 proparacaine-fluorescein sod 115 propranolol ............................. 84 propranolol-hydrochlorothiazid ............................................ 84 propylthiouracil .................... 131 PROQUAD (PF) .................. 134 prosight................................. 166 PROSOL 20 % ....................... 80 protamine ............................... 76 protriptyline ............................ 51 pseudoephedrine hcl ............. 101 PULMOZYME .................... 112 pure & gentle eye ................. 116 purelax .................................. 125 PURIXAN .............................. 43 pyrazinamide .......................... 63 pyridostigmine bromide ....... 140 pyridoxine ............................ 167

I-18 Formulario del plan Community Care Plus 2015 de Medicare-Medicaid de ventaja doble completamente integrado (Fully Integrated Duals Advantage Medicare-Medicaid Plan, FIDA MMP) de ICS Identificación del formulario: 15412.000, Versión: 16

Q q-dryl ...................................... 60 q-pap ................................. 20, 21 q-pap extra strength ................ 20 q-tapp...................................... 60 q-tapp dm ............................. 101 q-tussin ................................. 101 q-tussin dm ........................... 101 QUADRACEL (PF) ............. 134 QUDEXY XR ........................ 48 quetiapine ............................... 69 QUILLIVANT XR ................. 91 quinapril ................................. 82 quinapril-hydrochlorothiazide 82 quinidine gluconate ................ 83 quinidine sulfate ..................... 83 quinine sulfate ........................ 65 QVAR .................................. 148 R RABAVERT (PF) ................ 134 raloxifene.............................. 129 ramipril ................................... 82 RANEXA ............................... 87 ranitidine hcl......................... 120 RAPAMUNE ....................... 133 REBIF (WITH ALBUMIN) . 140 REBIF REBIDOSE .............. 140 REBIF TITRATION PACK 140 RECOMBIVAX HB (PF) .... 134 recort plus ............................. 110 refenesen .............................. 101 refenesen pe .......................... 101 REFRESH CLASSIC (PF) ... 116 REFRESH LACRI-LUBE ... 116 REFRESH LIQUIGEL......... 116 REFRESH OPTIVE ............. 116 REFRESH OPTIVE ADVANCED ................... 117 reguloid ................................ 125 RELADOR PAK .................... 24 relcof c .................................. 101 RELENZA DISKHALER ...... 72

Fecha de entrada en vigencia: 01 de diciembre 2015

RELISTOR .......................... 123 remedy phytoplex antifungal . 57 REMICADE ......................... 140 REMODULIN...................... 153 RENAGEL ........................... 126 RENVELA ........................... 126 repaglinide.............................. 52 REPATHA SURECLICK ...... 89 REPATHA SYRINGE ........... 89 RESCRIPTOR ....................... 71 RESTASIS ........................... 118 retaine cmc ........................... 116 RETROVIR............................ 71 REVLIMID ............................ 43 REXULTI .............................. 69 REYATAZ ............................. 71 REZIRA ............................... 101 ribavirin .................................. 73 RIDAURA ........................... 133 rifabutin .................................. 63 rifampin .................................. 63 RIFATER ............................... 63 ri-gel ii .................................. 123 riluzole ................................... 91 rimantadine ............................ 72 ri-mox ................................... 123 ringers .......................... 135, 147 risedronate ............................ 137 RISPERDAL CONSTA ......... 69 risperidone.............................. 69 RITUXAN.............................. 43 rivastigmine tartrate ............... 49 rizatriptan ............................... 62 robafen ................................. 101 robafen cough....................... 101 robafen dm ........................... 101 robitussin cough-chest-cong dm .......................................... 101 ROBITUSSIN LONG-ACTING .......................................... 101 robitussin pediatric ............... 101 ropinirole ................................ 66

ROTARIX ............................ 134 ROTATEQ VACCINE ........ 134 ROZEREM........................... 151 rydex..................................... 102 S SABRIL ................................. 48 safe tussin dm ....................... 102 SAIZEN ............................... 130 SAIZEN CLICK.EASY ....... 130 saline mist ............................ 116 salsalate .................................. 23 SANDOSTATIN LAR DEPOT .......................................... 131 SANTYL .............................. 106 SAPHRIS (BLACK CHERRY) ............................................ 69 SAVELLA ............................. 91 scooby-doo one a day........... 167 scot-tussin dm ...................... 102 scot-tussin expectorant ......... 102 sea soft nasal mist ................ 116 selegiline hcl .......................... 66 selenium sulfide ................... 107 SELZENTRY ......................... 71 senexon................................. 125 senior tabs ............................ 167 senna..................................... 125 senna lax ............................... 125 senna laxative ....................... 125 senna with docusate sodium . 126 senokot-s .............................. 126 SENSIPAR ........................... 140 sentry .................................... 167 sentry senior ......................... 167 SEREVENT DISKUS .......... 149 SEROQUEL XR .................... 69 SEROSTIM .......................... 131 sertraline ................................. 51 setlakin ................................... 93 silace..................................... 126 siladryl sa ............................... 61 silapap .................................... 21

I-19 Formulario del plan Community Care Plus 2015 de Medicare-Medicaid de ventaja doble completamente integrado (Fully Integrated Duals Advantage Medicare-Medicaid Plan, FIDA MMP) de ICS Identificación del formulario: 15412.000, Versión: 16

sildenafil oral tablet 20 mg ... 153 SILENOR ............................... 51 siltussin dm das .................... 102 siltussin sa ............................ 102 silver nitrate .......................... 107 silver nitrate applicators ....... 106 silver sulfadiazine................. 107 SIMBRINZA ........................ 142 simethicone .......................... 119 simply sleep ............................ 61 SIMPONI ............................. 140 SIMPONI ARIA................... 140 simvastatin.............................. 89 sinus & allergy (pseudoephed) ............................................ 61 sirolimus ............................... 133 SIRTURO ............................... 63 skin treatment ....................... 106 sleep aid (diphenhydramine) .. 61 sleep-tabs ................................ 61 smoothlax ............................. 126 sochlor .................................. 116 sodium acetate ...................... 147 sodium bicarbonate ...... 123, 147 sodium chloride ... 116, 136, 148, 150 sodium chloride 0.45 %........ 147 sodium chloride 0.9 %.......... 147 sodium chloride 3 %............. 147 sodium chloride 5 %............. 147 sodium chloride-nahco3-kcl-peg .......................................... 126 sodium citrate-citric acid ...... 148 sodium fluoride .................... 167 sodium lactate....................... 148 sodium phosphate ................. 148 sodium polystyrene sulfonate .......................................... 126 sodium thiosulfate ................ 127 sod-pot-k cit-sod cit-cit acid. 148 SOLIRIS ............................... 140 SOLTAMOX.......................... 43

Fecha de entrada en vigencia: 01 de diciembre 2015

SOLU-CORTEF (PF) .......... 130 SOMATULINE DEPOT ...... 131 SOMAVERT........................ 131 soothe (bismuth subsalicylate) .......................................... 123 soothe regular strength ......... 123 sorbitol ................................. 136 sorbitol-mannitol .................. 136 sotalol ..................................... 84 sotalol hcl ............................... 84 SOVALDI .............................. 72 spectravite ............................ 167 spectravite adult 50+ ............ 167 spectravite advanced formula .......................................... 167 spectravite senior ................. 167 spectravite senior w-lycopene .......................................... 167 spectravite ultra women ....... 167 SPIRIVA RESPIMAT ......... 149 SPIRIVA WITH HANDIHALER ............... 149 spironolactone ........................ 89 spironolacton-hydrochlorothiaz ............................................ 89 SPRYCEL .............................. 43 st joseph aspirin...................... 23 st. joseph aspirin..................... 23 stavudine ................................ 71 STELARA............................ 140 STERILE LUBRICANT ...... 116 STERILE PADS .................. 140 STIOLTO RESPIMAT ........ 149 STIVARGA ........................... 43 stomach relief ....................... 123 stool softener ........................ 126 STRATTERA ........................ 91 streptomycin ........................... 30 stress 500 plus zinc .............. 167 stress b with zinc .................. 167 stress b-biotin ....................... 167 stress formula ....................... 168

stress formula plus iron ........ 168 stress formula with iron........ 168 stress formula with zinc ....... 168 STRIBILD .............................. 71 STRIVERDI RESPIMAT .... 149 stuart prenatal ....................... 168 sucralfate .............................. 120 sudogest ................................ 102 sudogest cold & allergy.......... 61 sudogest pe ............................. 81 sulfacetamide sodium ........... 117 sulfacetamide sodium (acne) 107 sulfacetamide-prednisolone . 117 sulfadiazine ............................ 36 sulfamethoxazole-trimethoprim ............................................ 36 sulfasalazine ........................... 36 sulfatrim ................................. 36 sulfazine ................................. 36 sulfazine ec ............................. 37 sulindac .................................. 23 sumatriptan nasal spray .......... 62 sumatriptan succinate ....... 62, 63 summer's eve disposable douche .......................................... 140 summers eve extra cleansing 140 sunvite .................................. 168 super b complex-vitamin c ... 168 super b/c ............................... 168 super b-50 complex .............. 168 super b-50 complex plus ...... 168 super multiple....................... 168 super multivitamin ............... 168 super quints b-50 .................. 168 super thera vite m ................. 168 superior 35............................ 168 superplex-t ............................ 168 suphedrin .............................. 102 suphedrine pe day-night ....... 102 suphedrine severe cold max str .......................................... 102 support .................................. 168

I-20 Formulario del plan Community Care Plus 2015 de Medicare-Medicaid de ventaja doble completamente integrado (Fully Integrated Duals Advantage Medicare-Medicaid Plan, FIDA MMP) de ICS Identificación del formulario: 15412.000, Versión: 16

support-500 .......................... 168 SUPPRELIN LA .................. 131 SUPRAX ................................ 33 SURE COMFORT INS. SYR. U-100................................ 111 SURMONTIL ........................ 51 SUSPENDOL-S ................... 140 SUSTIVA ............................... 71 SUTENT ................................ 43 SYLATRON .......................... 72 SYLVANT ............................. 43 SYMLINPEN 120 .................. 53 SYMLINPEN 60 .................... 53 SYNAGIS .............................. 72 SYNAREL ........................... 140 SYNERCID ............................ 31 SYNRIBO .............................. 43 SYPRINE ............................. 127 T tab-a-vite .............................. 169 tab-a-vite/iron ....................... 169 tab-a-vite-minerals ............... 169 TABLOID .............................. 43 tacrolimus ..................... 110, 133 tactinal .................................... 21 tactinal extra strength ............. 21 TAFINLAR ............................ 43 TAMIFLU .............................. 72 tamoxifen................................ 43 tamsulosin ............................ 127 TARCEVA ....................... 43, 44 TARGRETIN ......................... 44 tarina fe................................... 93 TASIGNA .............................. 44 TAZORAC ........................... 111 taztia xt ................................... 84 tears again............................. 116 TEARS NATURALE II ....... 116 TECFIDERA ................ 140, 141 TECHNIVIE .......................... 72 TEFLARO .............................. 33 telmisartan .............................. 82

Fecha de entrada en vigencia: 01 de diciembre 2015

telmisartan-hydrochlorothiazid ............................................ 82 temazepam ....................... 28, 29 TEMODAR ............................ 44 TENIVAC (PF) .................... 135 terazosin ............................... 127 terbinafine hcl ........................ 58 terbutaline ............................ 149 terconazole ............................. 62 testosterone .......................... 128 testosterone cypionate .......... 128 testosterone enanthate .......... 128 TETANUS TOXOID,ADSORBED (PF) .......................................... 135 TETANUS,DIPHTHERIA TOX PED(PF) ........................... 135 TETANUS-DIPHTHERIA TOXOIDS-TD ................. 135 tetrabenazine .......................... 91 tetracaine hcl ........................ 116 tetracycline ............................. 37 TEV-TROPIN ...................... 131 THALOMID ........................ 141 the magic bullet .................... 126 theophylline.......................... 150 theophylline anhydrous ........ 149 theophylline in dextrose 5 % 149 thera m plus (ferrous fumarat) .......................................... 169 thera vitamin ........................ 169 theradex m ............................ 169 THERAFLU DAYTIME COLD-COUGH ............... 102 THERAFLU NIGHTTIME SEVERE COLD............... 102 THERAFLU SEVERE COLDCOUGH ........................... 102 thera-m ................................. 169 theramill forte....................... 169 therapeutic liquid ................. 169

therapeutic m + beta-carotene .......................................... 169 therapeutic vitamin & mineral .......................................... 169 therapeutic vitamins/minerals .......................................... 169 therapeutic-m ....................... 169 therapeutic-m vitamin/minerals .......................................... 169 thera-tabs .............................. 170 theratrum complete 50 plus .. 170 theratrum complete 50 plus/lut .......................................... 170 therems ................................. 170 therems-h .............................. 170 therems-m............................. 170 thiamine hcl .......................... 170 thioridazine............................. 69 thiothixene.............................. 69 tiagabine ................................. 48 TICE BCG............................ 135 TIKOSYN .............................. 83 timolol maleate ............... 84, 142 TIVICAY ............................... 71 tizanidine .............................. 151 TOBI PODHALER ................ 30 TOBRADEX ST .................. 117 tobramycin ........................... 117 tobramycin in 0.225 % nacl ... 30 tobramycin in 0.9 % nacl ....... 30 tobramycin sulfate .................. 30 tolazamide .............................. 55 tolbutamide............................. 55 tolmetin .................................. 23 tolnaftate................................. 58 tolterodine ............................ 127 topiramate............................... 48 toposar intravenous ................ 44 topotecan ................................ 44 TORISEL ............................... 44 torsemide ................................ 88 total b/c................................. 170

I-21 Formulario del plan Community Care Plus 2015 de Medicare-Medicaid de ventaja doble completamente integrado (Fully Integrated Duals Advantage Medicare-Medicaid Plan, FIDA MMP) de ICS Identificación del formulario: 15412.000, Versión: 16

totalday multiple................... 170 TOUJEO SOLOSTAR ........... 54 TOVIAZ ............................... 127 TPN ELECTROLYTES ....... 148 TPN ELECTROLYTES II ... 148 TRACLEER ......................... 153 TRADJENTA ......................... 53 tramadol.................................. 21 tramadol-acetaminophen ........ 21 trandolapril ............................. 82 tranexamic acid ...................... 76 TRANSDERM-SCOP ............ 64 tranylcypromine ..................... 51 TRAVASOL 10 % ................. 80 TRAVATAN Z .................... 142 travel sickness (meclizine) ..... 64 travoprost (benzalkonium) ... 142 trazodone ................................ 51 TREANDA ............................. 44 TRECATOR ........................... 63 TRELSTAR............................ 44 tretinoin ................................ 111 tretinoin (chemotherapy) ........ 44 tretinoin microspheres .......... 111 TREXALL.............................. 44 triacting m-sym cold/cough.. 102 triamcinolone acetonide ...... 104, 110, 130 triaminic cold & cough (pe) . 102 TRIAMINIC COLD & COUGH NT (PE) .............................. 61 triaminic cough-nasal congesti .......................................... 102 TRIAMINIC COUGH-SORE THROAT.......................... 102 triamterene-hydrochlorothiazid ............................................ 88 triazolam ................................. 29 TRIBENZOR ......................... 82 tri-buffered aspirin ................. 23 triderm .................................. 110 tri-dex pe .............................. 103

Fecha de entrada en vigencia: 01 de diciembre 2015

trifluoperazine ........................ 70 trifluridine ............................ 117 trigofen dm ........................... 103 trihexyphenidyl ...................... 66 TRILEPTAL .......................... 48 trimethoprim .......................... 31 triple paste af .......................... 58 TRIUMEQ ............................. 71 tri-vi-sol................................ 170 tri-vita................................... 170 tri-vitamin ............................ 170 TROKENDI XR..................... 48 TROPHAMINE 10 % ............ 81 TROPHAMINE 6% ............... 81 trospium ............................... 127 TRULICITY .......................... 53 TRUMENBA ....................... 135 TRUVADA ............................ 71 trymine cg ............................ 103 TUDORZA PRESSAIR ....... 150 tusnel diabetic ...................... 103 TUSNEL PEDIATRIC ........ 103 tussin cf ................................ 103 tussin cf cough-cold ............. 103 tussin cold-congestion .......... 103 tussin cough (dm only)......... 103 tussin dm .............................. 103 tussin dm cough & chest ...... 103 tussin maximum strength cough .......................................... 103 tussin pe ............................... 103 TWINRIX (PF) .................... 135 TYBOST .............................. 141 TYGACIL .............................. 37 TYKERB................................ 44 TYPHIM VI ......................... 135 TYSABRI ............................ 133 TYVASO ............................. 153 TYVASO REFILL KIT ....... 153 TYVASO STARTER KIT ... 153 TYZEKA................................ 73

U ULORIC ............................... 141 ultra b-100 complex ............. 170 ultra fresh pm ....................... 116 ultra sleep (doxylamine succ) 61 ultra strength antacid ............ 123 unicomplex-m ...................... 170 unisom sleepgels .................... 61 UNITUXIN ............................ 44 ursodiol................................. 123 V VAGIFEM ........................... 129 valacyclovir ............................ 73 VALCHLOR ........................ 106 valganciclovir ......................... 73 valproate sodium .................... 48 valproic acid ........................... 48 valproic acid (as sodium salt). 48 valsartan ................................. 82 valsartan-hydrochlorothiazide 82 VALSTAR ............................. 44 valu-tapp dm ........................ 103 vancomycin ............................ 31 vancomycin in d5w ................ 31 VAQTA (PF)........................ 135 VARIVAX (PF) ................... 135 VASCEPA ............................. 89 vasopressin ........................... 131 VECTIBIX ............................. 44 VELCADE ............................. 44 venlafaxine ............................. 51 VENTAVIS .......................... 153 verapamil .......................... 84, 85 VERSACLOZ ........................ 70 vicks dayquil cough ............. 103 vicks nature fusion cough .... 103 vicks qlearquil(oxymetazoline) .......................................... 116 vicks sinex 12-hour .............. 116 VICTOZA .............................. 53 VIDEX 2 GRAM PEDIATRIC ............................................ 71

I-22 Formulario del plan Community Care Plus 2015 de Medicare-Medicaid de ventaja doble completamente integrado (Fully Integrated Duals Advantage Medicare-Medicaid Plan, FIDA MMP) de ICS Identificación del formulario: 15412.000, Versión: 16

VIDEX 4 GRAM PEDIATRIC ............................................ 71 VIEKIRA PAK ...................... 72 VIGAMOX .......................... 118 VIIBRYD ............................... 51 VIMIZIM ............................. 112 VIMPAT ................................ 48 vinblastine .............................. 44 vincristine ............................... 45 vincristine sulfate ................... 45 vinorelbine.............................. 45 VIRACEPT ............................ 71 VIRAMUNE XR .................... 71 VIRAZOLE ............................ 73 virdec dm .............................. 103 VIREAD ................................. 71 vision .................................... 170 vision formula ...................... 170 vision formula (with lutein) . 171 vision plus lutein .................. 171 vit b cmplx 3-fa-vit c-biotin . 171 vit b cmplx no3-fa-c-biot-zinc .......................................... 171 vitabee/c ............................... 171 vitalets .................................. 171 vitamin a ............................... 171 vitamin b complex ................ 171 vitamin b complex with c ..... 171 vitamin b-1 ........................... 171 vitamin b-100 complex ........ 171 vitamin b12-folic acid .......... 171 vitamin b-6 ........................... 171 vitamin c ............................... 171 vitamins & minerals ............. 172 vitamins b complex .............. 172 vitamins for hair ................... 172 VITEKTA .............................. 71 vitrum senior ........................ 172 VOLTAREN .......................... 24 voriconazole ........................... 58 VOTRIENT ............................ 45 VPRIV .................................. 112

Fecha de entrada en vigencia: 01 de diciembre 2015

W wal-act d cold & allergy......... 61 wal-dram ................................ 65 wal-dryl allergy ...................... 61 wal-finate ............................... 61 wal-finate-d ............................ 61 wal-itin ................................... 61 wal-itin d ................................ 61 wal-itin d 12 hour ................... 61 wal-phed ......................... 61, 103 wal-phed pe ............................ 81 wal-phed pe day-night.......... 103 wal-phed pe sinus & allergy .. 61 wal-profen .............................. 24 wal-sleep z ....................... 61, 62 wal-som (diphenhydramine) .. 62 wal-tap.................................... 62 wal-tussin cough .................. 103 wal-tussin cough & cold cf .. 104 wal-tussin dm ....................... 104 wal-zan 75 ............................ 120 wal-zyr (cetirizine) ................. 62 wal-zyr (ketotifen) ............... 116 wal-zyr d ................................ 62 warfarin .................................. 75 water for irrigation, sterile ... 136 WELCHOL ............................ 89 womens daily gummies........ 172 women's daily multivitamin . 172

X XALKORI.............................. 45 XARELTO ............................. 75 XELJANZ ............................ 141 XENAZINE ........................... 92 XGEVA ................................ 137 XIFAXAN .............................. 31 XOLAIR............................... 150 XTANDI ................................ 45 xylon 10.................................. 21 XYREM ............................... 151 Y yelets .................................... 172 YERVOY ............................... 45 YF-VAX (PF) ...................... 135 Z zafirlukast ............................. 149 zaleplon ................................ 151 ZALTRAP .............................. 45 zantac 75 .............................. 120 ZARXIO................................. 76 ZAVESCA ........................... 112 ZELBORAF ........................... 45 ZEMAIRA ........................... 150 ZEMPLAR ........................... 137 ZENPEP ............................... 112 zephrex-d .............................. 104 ZETIA .................................... 89 ZIAGEN ................................. 71

I-23 Formulario del plan Community Care Plus 2015 de Medicare-Medicaid de ventaja doble completamente integrado (Fully Integrated Duals Advantage Medicare-Medicaid Plan, FIDA MMP) de ICS Identificación del formulario: 15412.000, Versión: 16

zidovudine .............................. 71 zinc oxide ............................. 106 ziprasidone hcl ....................... 70 ZOLADEX ............................. 45 zoledronic acid ..................... 137 zoledronic acid-mannitol-water .......................................... 137 ZOLINZA .............................. 45 zolmitriptan ............................ 63 zolpidem ............................... 152 ZOMACTON ....................... 131 ZOMETA ............................. 137 ZONATUSS ......................... 104 zonisamide.............................. 48 zoo chews ............................. 172 ZORTRESS .......................... 133 ZOSTAVAX (PF) ................ 135 ZOVIRAX ............................ 106 z-sleep .................................... 62 ZUBSOLV ............................. 25 ZYDELIG .............................. 45 ZYKADIA.............................. 45 ZYLET ................................. 118 zyncof ................................... 104 ZYPREXA RELPREVV ........ 70 ZYRTEC ................................ 62 zyrtec itchy eye drops (keto) 116 ZYTIGA ................................. 45 ZYVOX .................................. 31

Fecha de entrada en vigencia: 01 de diciembre 2015

1.877.ICS.2525 www.icsny.org Oficina Administrativa Independence Care System 257 Park Ave. South 2nd Floor New York, NY 10010 Centros de Atención al Paciente 400 East Fordham Road 10th floor Bronx, New York 10458 25 Elm Place 5th Floor Brooklyn, NY 11201

Este formulario se actualizó el 12/1/2015. Si tiene preguntas, llame al plan Community Care Plus FIDA-MMP de ICS al 1.877.ICS.2525, de lunes a viernes, de 8 a. m. a 8 p. m. La llamada es gratuita. Para obtener más información, visite www.icsny.org/care-plus.