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Microsoft word - 2014h5640current_memberformulary2014

IEHP Medicare DualChoice (HMO SNP)
2014 Formulary
(List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION
ABOUT THE DRUGS WE COVER IN THIS PLAN
HPMS Approved Formulary File Submission ID 00014392, Version Number 23 This formulary was updated on November 22, 2013. For more recent information or other questions, please contact us IEHP Medicare DualChoice (HMO SNP) Member Services, at 1-877-273-IEHP (4347), 8 a.m. – 8 p.m. (PST), 7 days a week, including holidays or, for TTY users, 1-800-718-4347, or visit www.iehp.org. Note to existing members: This formulary has changed since last year. Please review this document to
make sure that it still contains the drugs you take.
When this drug list (formulary) refers to “we,” “us”, or “our,” it means IEHP Health Access. When it refers to “plan” or “our plan,” it means IEHP Medicare DualChoice (HMO SNP). This document includes list of the drugs (formulary) for our plan which is current as of November 22, 2013. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary,
pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2015.


What is the IEHP Medicare DualChoice (HMO SNP) Formulary?
A formulary is a list of covered drugs selected by IEHP Medicare DualChoice (HMO SNP) in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. IEHP Medicare DualChoice (HMO SNP) will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a IEHP Medicare DualChoice (HMO SNP) network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.
Can the Formulary (drug list) change?
Generally, if you are taking a drug on our 2014 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2014 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of November 22, 2013. To get updated information about the drugs covered by IEHP Medicare DualChoice (HMO SNP), please contact us. In the event of mid-year non-maintenance formulary changes, we will mail you an errata sheet notifying you of the change. Our contact information appears on the front and back cover pages.
How do I use the Formulary?
There are two ways to find your drug within the formulary:

Medical Condition
The formulary begins on page 7. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular. If you know what your drug is used for, look for the category name in the list that begins 7. Then look under the category name for your drug. Alphabetical Listing
If you are not sure what category to look under, you should look for your drug in the Index that begins on page 42. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs?
IEHP Medicare DualChoice (HMO SNP) covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.
Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:  Prior Authorization: IEHP Medicare DualChoice (HMO SNP) requires you to get prior
authorization for certain drugs. This means that you will need to get approval from IEHP Medicare DualChoice (HMO SNP) before you fill your prescriptions. If you don’t get approval, IEHP Medicare DualChoice (HMO SNP) may not cover the drug.  Quantity Limits: For certain drugs, IEHP Medicare DualChoice (HMO SNP) limits the amount of
the drug that IEHP Medicare DualChoice (HMO SNP) will cover. For example, IEHP Medicare DualChoice (HMO SNP) provides 31 pills per prescription for Januvia. This may be in addition to a standard one-month or three-month supply.  Step Therapy: In some cases, IEHP Medicare DualChoice (HMO SNP) requires you to first try
certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, IEHP Medicare DualChoice (HMO SNP) may not cover Drug B unless you try Drug A first. If Drug A does not work for you, IEHP Medicare DualChoice (HMO SNP) will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 7. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask IEHP Medicare DualChoice (HMO SNP) to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the IEHP Medicare DualChoice (HMO SNP) formulary?” on page 4 for information about how to request an exception. What if my drug is not on the Formulary?
If your drug is not included in this formulary (list of covered drugs), you should first contact IEHP Member Services and ask if your drug is covered. If you learn that IEHP Medicare DualChoice (HMO SNP) does not cover your drug, you have two options:  You can ask Member Services for a list of similar drugs that are covered by IEHP Medicare DualChoice (HMO SNP). When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by IEHP Medicare DualChoice (HMO SNP).  You can ask IEHP Medicare DualChoice (HMO SNP) to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the IEHP Medicare DualChoice (HMO SNP) Formulary?
You can ask IEHP Medicare DualChoice (HMO SNP) to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.  You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.  You can ask us to cover a formulary drug at a lower cost-sharing level. If approved this would lower  You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, IEHP Medicare DualChoice (HMO SNP) limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, IEHP Medicare DualChoice (HMO SNP) will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization
restriction exception. When you request a formulary, tiering or utilization restriction exception you
should submit a statement from your prescriber or physician supporting your request. Generally, we
must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request
an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by
waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no
later than 24 hours after we get a supporting statement from your doctor or other prescriber.
What do I do before I can talk to my doctor about changing my drugs or requesting an
exception?
As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with 91-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. For more information
For more detailed information about your IEHP Medicare DualChoice (HMO SNP) prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about IEHP Medicare DualChoice (HMO SNP), please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or, visit www.medicare.gov. IEHP Medicare DualChoice (HMO SNP) Formulary
The formulary that begins on page 7 provides coverage information about the drugs covered by IEHP Medicare DualChoice (HMO SNP). If you have trouble finding your drug in the list, turn to the Index that begins on page 42. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., PLAVIX) and generic drugs are listed in lower-case italics (e.g., cephalexin). The information in the Requirements/Limits column tells you if IEHP Medicare DualChoice (HMO SNP) has any special requirements for coverage of your drug. List of Abbreviations
B/D: This prescription drug has a Part B versus D administrative prior authorization requirement. This drug
may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be
submitted describing the use and setting of the drug to make the determination.
CB: This prescription drug has a capped benefit limit.
ED: This prescription drug is not normally covered in a Medicare Prescription Drug Plan. The amount you
pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the
amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra
help to pay for your prescriptions, you will not get any extra help to pay for this drug.
FF: Free First Fill. This prescription drug will be provided at zero cost-sharing the first time you fill it.
GC: Gap Coverage. We provide additional coverage of this prescription drug in the coverage gap. Please
refer to our Evidence of Coverage for more information about this coverage.
HI: Home Infusion. This prescription drug may be covered under our medical benefit. For more information,
call IEHP Member Services at 1-877-273-IEHP (4347), 8 a.m. – 8 p.m. (PST), 7 days a week, including
holidays. TTY/TDD users should call 1-800-718-4347.
LA: Limited Availability. This prescription may be available only at certain pharmacies. For more
information consult your Provider and Pharmacy Directory or call IEHP Member Services at 1-877-273-
IEHP (4347), 8 a.m. – 8 p.m. (PST), 7 days a week, including holidays. TTY/TDD users should call 1-
800-718-4347.
MO: Mail Order Drug. This prescription drug is available through a mail-order service.
PA: Prior Authorization. IEHP Medicare DualChoice (HMO SNP) requires you or your physician to get
prior authorization for certain drugs. This means that you will need to get approval from IEHP Medicare
DualChoice (HMO SNP) before you fill your prescriptions. If you don't get approval, IEHP Medicare
DualChoice (HMO SNP) may not cover the drug.
QL: Quantity Limit. For certain drugs, IEHP Medicare DualChoice (HMO SNP) limits the amount of the
drug that IEHP Medicare DualChoice (HMO SNP) will cover. For example, IEHP Medicare DualChoice
(HMO SNP) provides 31 pills per prescription for Januvia. This may be in addition to a standard one month
or three month supply.
ST: Step Therapy. In some cases, IEHP Medicare DualChoice (HMO SNP) requires you to first try certain
drugs to treat your medical condition before we will cover another drug for that condition. For example, if
Drug A and Drug B both treat your medical condition, IEHP Medicare DualChoice (HMO SNP) may not
cover drug B unless you try Drug A first. If Drug A does not work for you, IEHP Medicare DualChoice
(HMO SNP) will then cover Drug B.
Drug Name
Requirements/Limits
Analgesics
Analgesics
butalbital/acetaminophen/caffeine caps butalbital/acetaminophen/caffeine tabs 500mg; 50mg; Nonsteroidal Anti-inflammatory Drugs
diclofenac sodium dr tbec 25mg, 75mg Opioid Analgesics, Long-acting
morphine sulfate er cp24 100mg, 20mg, 30mg, 50mg, 60mg, 80mg morphine sulfate er tbcr 100mg morphine sulfate er tbcr 15mg, 30mg, 60mg tramadol hcl er tb24 100mg, 200mg Opioid Analgesics, Short-acting
acetaminophen/codeine tabs 300mg; 60mg acetaminophen/codeine tabs 300mg; 15mg fentanyl citrate oral transmucosal hydrocodone bitartrate/acetaminophen tabs 750mg; 10mg hydrocodone/acetaminophen soln hydrocodone/acetaminophen tabs 750mg; 7.5mg hydrocodone/acetaminophen tabs 650mg; 7.5mg hydrocodone/acetaminophen tabs 660mg; 10mg hydrocodone/acetaminophen tabs 650mg; 10mg hydrocodone/acetaminophen tabs 500mg; 10mg, 500mg; 2.5mg, 500mg; 5mg, 500mg; 7.5mg hydrocodone/acetaminophen tabs 325mg; 10mg, 325mg; 5mg, 325mg; 7.5mg hydrocodone/ibuprofen tabs 7.5mg; 200mg Drug Name
Requirements/Limits
morphine sulfate soln 10mg/5ml, 20mg/5ml, 20mg/ml oxycodone/acetaminophen tabs 650mg; 10mg oxycodone/acetaminophen tabs 325mg; 5mg tramadol hydrochloride/acetaminophen Anesthetics
Local Anesthetics
Anti-Addiction/Substance Abuse Treatment Agents
Alcohol Deterrents/Anti-craving
Opioid Antagonists
buprenorphine hcl/naloxone hcl subl 2mg; 0.5mg buprenorphine hcl/naloxone hcl subl 8mg; 2mg Smoking Cessation Agents
Anti-inflammatory Agents
Nonsteroidal Anti-inflammatory Drugs
Drug Name
Requirements/Limits
Antibacterials
Aminoglycosides
amikacin sulfate inj 1gm/4ml, 50mg/ml gentamicin sulfate/0.9% sodium chloride inj 0.9mg/ml; 0.9%, 1.4mg/ml; 0.9%, 1.6mg/ml; 0.9%, 1mg/ml; 0.9% gentamicin sulfate crea, inj, oint, ophthalmic soln Antibacterials, Other
clindamycin hcl caps 150mg, 300mg clindamycin phosphate add-vantage neomycin/polymyxin/bacitracin/hydrocortisone neomycin/polymyxin/hydrocortisone ophthalmic susp 1%; 3.5mg/ml; 10000unit/ml nitrofurantoin nitrofurantoin macrocrystalline caps 50mg trimethoprim sulfate/polymyxin b sulfate Drug Name
Requirements/Limits
vancomycin hcl inj 1000mg, 10gm, 500mg Beta-lactam, Cephalosporins
cefazolin sodium inj 10gm, 1gm; 5%, 1gm, 500mg cefoxitin sodium inj 10gm, 1gm, 2gm cefuroxime sodium inj 1.5gm, 7.5gm, 750mg Beta-lactam, Other
Beta-lactam, Penicillins
amoxicillin/clavulanate potassium er amoxicillin/clavulanate potassium chew amoxicillin/clavulanate potassium susr 250mg/5ml; 62.5mg/5ml, 400mg/5ml; 57mg/5ml, 600mg/5ml; 42.9mg/5ml amoxicillin/clavulanate potassium tabs 250mg; 125mg amoxicillin/potassium clavulanate tabs amoxicillin/potassium clavulanate susr 200mg/5ml; ampicillin sodium inj 10gm, 125mg, 1gm ampicillin-sulbactam inj 10gm; 5gm, 2gm; 1gm Drug Name
Requirements/Limits
piperacillin sodium/tazobactam sodium inj 3gm; 0.375gm, 4gm; 0.5gm TIMENTIN INJ 0.1GM; 3GM Macrolides
erythrocin lactobionate inj 500mg Quinolones
ciprofloxacin i.v.-in d5w inj 200mg/100ml; 5% levofloxacin inj, ophthalmic soln, oral soln Sulfonamides
Tetracyclines
doxycycline hyclate caps, inj, tabs doxycycline monohydrate tabs 150mg, 50mg, 75mg Anticonvulsants
Anticonvulsants, Other
phenobarbital tabs 100mg, 15mg, 60mg Drug Name
Requirements/Limits
Calcium Channel Modifying Agents
Gamma-aminobutyric Acid (GABA) Augmenting Agents
Glutamate Reducing Agents
topiramate tabs 100mg, 200mg, 50mg Sodium Channel Agents
carbamazepine er cp12 100mg, 200mg fosphenytoin sodium inj 100mg pe/2ml Drug Name
Requirements/Limits
Antidementia Agents
Antidementia Agents, Other
Cholinesterase Inhibitors
galantamine hydrobromide cp24 16mg, 8mg galantamine hydrobromide cp24 24mg N-methyl-D-aspartate (NMDA) Receptor Antagonist
Antidepressants
Antidepressants, Other
Monoamine Oxidase Inhibitors
Serotonin/Norepinephrine Reuptake Inhibitors
Drug Name
Requirements/Limits
paroxetine hcl er tb24 12.5mg, 37.5mg Tricyclics
Antiemetics
Antiemetics, Other
Emetogenic Therapy Adjuncts
granisetron hcl inj 0.1mg/ml, 1mg/ml Antifungals
Antifungals
clotrimazole/betamethasone dipropionate fluconazole in dextrose inj 56mg/ml; 400mg/200ml Drug Name
Requirements/Limits
nystatin crea, oint, powd, susp, tabs Antigout Agents
Antigout Agents
Antimigraine Agents
Ergot Alkaloids
Serotonin (5-HT) 1b/1d Receptor Agonists
sumatriptan succinate inj 6mg/0.5ml Antimyasthenic Agents
Parasympathomimetics
Antimycobacterials
Antimycobacterials, Other
Antituberculars
Drug Name
Requirements/Limits
Antineoplastics
Alkylating Agents
Antiangiogenic Agents
Antiestrogens/Modifiers
Antimetabolites
Antineoplastics, Other
Drug Name
Requirements/Limits
leucovorin calcium inj 100mg, 350mg Drug Name
Requirements/Limits
vinorelbine tartrate inj 50mg/5ml Antineoplastics
Aromatase Inhibitors, 3rd Generation
Enzyme Inhibitors
Molecular Target Inhibitors
Monoclonal Antibodies
Retinoids
Antiparasitics
Drug Name
Requirements/Limits
Anthelmintics
Antiprotozoals
atovaquone/proguanil hcl tabs 250mg; 100mg Pediculicides/Scabicides
Antiparkinson Agents
Anticholinergics
Antiparkinson Agents, Other
Dopamine Agonists
Dopamine Precursors/L- Amino Acid Decarboxylase
Inhibitors
Monoamine Oxidase B (MAO-B) Inhibitors
Antipsychotics
1st Generation/Typical
Drug Name
Requirements/Limits
2nd Generation/Atypical
Treatment-Resistant
Antispasticity Agents
Antispasticity Agents
Antivirals
Anti-cytomegalovirus (CMV) Agents
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase
Inhibitors
Drug Name
Requirements/Limits
Anti-HIV Agents, Nucleoside and Nucleotide Reverse
Transcriptase Inhibitors
Anti-HIV Agents, Other
Anti-HIV Agents, Protease Inhibitors
Anti-influenza Agents
Drug Name
Requirements/Limits
Antihepatitis Agents
Antiherpetic Agents
Anxiolytics
Anxiolytics, Other
buspirone hcl tabs 10mg, 15mg, 30mg, 7.5mg Bipolar Agents
Mood Stabilizers
lithium carbonate caps 300mg, 600mg Blood Glucose Regulators
Antidiabetic Agents
Drug Name
Requirements/Limits
glipizide/metformin hcl tabs 2.5mg; 500mg, 5mg; 500mg 1 glipizide/metformin hcl tabs 2.5mg; 250mg glyburide/metformin hcl tabs 2.5mg; 500mg, 5mg; 500mg glyburide/metformin hcl tabs 1.25mg; 250mg metformin hcl er tb24 500mg, 750mg Glycemic Agents
dextrose 2.5%/sodium chloride 0.45% potassium chloride 0.15% d5w/nacl 0.33% potassium chloride 0.15% d5w/nacl 0.45% viaflex potassium chloride 0.22% d5w/nacl 0.45% Insulins
Drug Name
Requirements/Limits
Blood Products/Modifiers/Volume Expanders
Anticoagulants
2500UNIT/0.2ML, 5000UNIT/0.2ML, 7500UNIT/0.3ML heparin sodium/d5w inj 5%; 40unit/ml heparin sodium inj 10000unit/ml, 20000unit/ml Blood Formation Modifiers
NEUPOGEN INJ 300MCG/0.5ML, 480MCG/0.8ML, Coagulants
Platelet Modifying Agents
Cardiovascular Agents
Alpha-adrenergic Agonists
Drug Name
Requirements/Limits
Alpha-adrenergic Blocking Agents
Angiotensin II Receptor Antagonists
losartan potassium/hydrochlorothiazide Angiotensin-converting Enzyme (ACE) Inhibitors
benazepril hcl/hydrochlorothiazide enalapril maleate/hydrochlorothiazide fosinopril sodium/hydrochlorothiazide Antiarrhythmics
sotalol hcl tabs 160mg, 240mg, 80mg Beta-adrenergic Blocking Agents
Drug Name
Requirements/Limits
bisoprolol fumarate/hydrochlorothiazide metoprolol succinate er tb24 100mg, 25mg, 50mg metoprolol succinate er tb24 200mg timolol maleate tabs 10mg, 20mg, 5mg Calcium Channel Blocking Agents
amlodipine besylate/benazepril hcl amlodipine besylate/benazepril hydrochloride diltiazem cd cp24 120mg, 240mg, 300mg verapamil hcl er tbcr 180mg, 240mg Cardiovascular Agents, Other
Diuretics, Carbonic Anhydrase Inhibitors
Diuretics, Loop
Drug Name
Requirements/Limits
Diuretics, Potassium-sparing
spironolactone/hydrochlorothiazide triamterene/hydrochlorothiazide caps 25mg; 37.5mg triamterene/hydrochlorothiazide tabs Diuretics, Thiazide
hydrochlorothiazide tabs 25mg, 50mg Dyslipidemics, Fibric Acid Derivatives
Dyslipidemics, HMG CoA Reductase Inhibitors
pravastatin sodium tabs 10mg, 20mg, 40mg simvastatin tabs 10mg, 20mg, 40mg, 5mg Dyslipidemics, Other
VYTORIN TABS 10MG; 10MG, 10MG; 20MG, 10MG; Vasodilators, Direct-acting Arterial/Venous
nitroglycerin transdermal pt24 0.1mg/hr Vasodilators, Direct-acting Arterial
Drug Name
Requirements/Limits
Central Nervous System Agents
Attention Deficit Hyperactivity Disorder Agents,
Amphetamines
amphetamine/dextroamphetamine tabs Attention Deficit Hyperactivity Disorder Agents,
Non-amphetamines
Central Nervous System Agents
Central Nervous System, Other
butalbital/acetaminophen/caffeine/codeine caps 325mg; 1 Multiple Sclerosis Agents
Dental and Oral Agents
Dental and Oral Agents
Dermatological Agents
Dermatological Agents
clindamycin/benzoyl peroxide gel 5%; 1% Drug Name
Requirements/Limits
fluorouracil external soln 2%, 5% tretinoin crea 0.025%, 0.05%, 0.1% Enzyme Replacement/Modifiers
Enzyme Replacement/Modifiers
ZENPEP CPEP 109000UNIT; 20000UNIT; 68000UNIT, 2 27000UNIT; 5000UNIT; 17000UNIT, 55000UNIT; 10000UNIT; 34000UNIT, 82000UNIT; 15000UNIT; 51000UNIT Gastrointestinal Agents
Antispasmodics, Gastrointestinal
Gastrointestinal Agents, Other
Drug Name
Requirements/Limits
Histamine2 (H2) receptor Antagonists
Irritable Bowel Syndrome Agents
Laxatives
Protectants
Proton Pump Inhibitors
Genitourinary Agents
Antispasmodics, Urinary
Benign Prostatic Hypertrophy Agents
Genitourinary Agents, Other
Phosphate Binders
Drug Name
Requirements/Limits
Hormonal Agents, Stimulant/Replacement/Modifying
(Adrenal)
Glucocorticoids/Mineralocorticoids
augmented betamethasone dipropionate betamethasone valerate crea, lotn, oint clobetasol propionate foam, gel, lotn, oint, sham, soln dexamethasone sodium phosphate inj 4mg/ml fluocinolone acetonide crea, oint, soln fluticasone propionate crea 0.05% fluticasone propionate oint 0.005% hydrocortisone tabs 10mg, 20mg, 5mg methylprednisolone tabs 16mg, 32mg, 8mg prednisolone sodium phosphate oral soln 15mg/5ml, Hormonal Agents, Stimulant/Replacement/Modifying
(Pituitary)
Hormonal Agents, Stimulant/Replacement/Modifying
(Pituitary)
Drug Name
Requirements/Limits
Hormonal Agents, Stimulant/Replacement/Modifying (Sex
Hormones/Modifiers)
Anabolic Steroids
Androgens
testosterone cypionate inj 100mg/ml Estrogens
Drug Name
Requirements/Limits
Progestins
Selective Estrogen Receptor Modifying Agents
Hormonal Agents, Stimulant/Replacement/Modifying
(Thyroid)
Hormonal Agents, Stimulant/Replacement/Modifying
(Thyroid)
unithroid tabs 100mcg, 112mcg, 125mcg, 150mcg, 175mcg, 200mcg, 25mcg, 300mcg, 50mcg, 75mcg, 88mcg Hormonal Agents, Suppressant (Adrenal)
Hormonal Agents, Suppressant (Adrenal)
Hormonal Agents, Suppressant (Parathyroid)
Hormonal Agents, Suppressant (Parathyroid)
Hormonal Agents, Suppressant (Pituitary)
Hormonal Agents, Suppressant (Pituitary)
LUPRON DEPOT INJ 22.5MG, 3.75MG, 30MG, 45MG, 2 PA 7.5MG octreotide acetate Drug Name
Requirements/Limits
Hormonal Agents, Suppressant (Sex Hormones/Modifiers)
Antiandrogens
Hormonal Agents, Suppressant (Thyroid)
Antithyroid Agents
Immunological Agents
Immune Suppressants
Immunizing Agents, Passive
Immunomodulators
Drug Name
Requirements/Limits
Vaccines
Inflammatory Bowel Disease Agents
Aminosalicylates
Drug Name
Requirements/Limits
Glucocorticoids
Sulfonamides
Metabolic Bone Disease Agents
Metabolic Bone Disease Agents
alendronate sodium tabs 10mg, 40mg, 5mg alendronate sodium tabs 35mg, 70mg pamidronate disodium inj 30mg/10ml, 6mg/ml, zoledronic acid inj 4mg/5ml, 5mg/100ml Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
BD INSULIN SYRINGE SAFETYGLIDE/1ML/29G X 1/2" 2 BD INSULIN SYRINGE ULTRAFINE/0.3ML/31G X 5/16" 2 BD INSULIN SYRINGE ULTRAFINE/0.5ML/30G X 1/2" 2 BD INSULIN SYRINGE ULTRAFINE/1ML/31G X 5/16" 2 Ophthalmic Agents
Ophthalmic Prostaglandin and Prostamide Analogs
Ophthalmic Agents, Other
Drug Name
Requirements/Limits
Ophthalmic Anti-allergy Agents
azelastine hcl ophthalmic soln 0.05% Ophthalmic Anti-inflammatories
dexamethasone sodium phosphate ophthalmic soln prednisolone sodium phosphate ophthalmic soln 1% sulfacetamide sodium/prednisolone sodium phosphate 1 TOBRADEX OINT Ophthalmic Antiglaucoma Agents
timolol maleate ophthalmic gel forming Otic Agents
Otic Agents
neomycin/polymyxin/hydrocortisone otic susp 1%; Respiratory Tract Agents
Anti-inflammatories, Inhaled Corticosteroids
Drug Name
Requirements/Limits
budesonide susp 0.25mg/2ml, 0.5mg/2ml fluticasone propionate susp 50mcg/act Antihistamines
azelastine hcl nasal soln 137mcg/spray Antileukotrienes
Bronchodilators, Anticholinergic
ipratropium bromide/albuterol sulfate ipratropium bromide inhalation soln Bronchodilators, Phosphodiesterase Inhibitors
(Xanthines)
theophylline er tb12 300mg, 450mg Bronchodilators, Sympathomimetic
albuterol sulfate nebu 0.083%, 0.5%, 0.63mg/3ml albuterol sulfate nebu 1.25mg/3ml Drug Name
Requirements/Limits
Mast Cell Stabilizers
Pulmonary Antihypertensives
Respiratory Tract Agents, Other
Skeletal Muscle Relaxants
Skeletal Muscle Relaxants
cyclobenzaprine hcl tabs 10mg, 5mg Sleep Disorder Agents
GABA Receptor Modulators
Sleep Disorders, Other
phenobarbital tabs 16.2mg, 30mg, 32.4mg, 64.8mg, Therapeutic Nutrients/Minerals/Electrolytes
Electrolyte/Mineral Modifiers
sodium polystyrene sulfonate susp Electrolyte/Mineral Replacement
dextrose 5%/potassium chloride 0.15% Drug Name
Requirements/Limits
potassium chloride er tbcr 10meq, 20meq potassium chloride inj 10meq/100ml, 2meq/ml, 30meq/100ml, 40meq/100ml ringers injection sodium chloride inj 2.5meq/ml, 5% Vitamins
OTC products
Drug Name
Requirements/Limits
Dermatological Agents
Dermatological Agents
gauze sponges 4"x4" 12 ply Unclassified
No Classification
Drug Name
Drug Name
amlodipine besylate/benazepril hcl amoxicillin/clavulanate potassium er Drug Name
Drug Name
bisoprolol fumarate/hydrochlorothiazide butalbital/acetaminophen/caffeine/codei benazepril hcl/hydrochlorothiazide Drug Name
Drug Name
Drug Name
Drug Name
dextrose 2.5%/sodium chloride 0.45% dextrose 5%/potassium chloride 0.15% Drug Name
Drug Name
enalapril maleate/hydrochlorothiazide fentanyl citrate oral transmucosal fosinopril sodium/hydrochlorothiazide Drug Name
Drug Name
gauze sponges 4"x4" 12 ply hydrocodone bitartrate/acetaminophen gentamicin sulfate/0.9% sodium chloride Drug Name
Drug Name
ipratropium bromide/albuterol sulfate losartan potassium/hydrochlorothiazide Drug Name
Drug Name
Drug Name
Drug Name
neomycin/polymyxin/bacitracin/hydrocor neomycin/polymyxin/hydrocortisone neomycin/polymyxin/hydrocortisone Drug Name
Drug Name
piperacillin sodium/tazobactam sodium potassium chloride 0.15% d5w/nacl potassium chloride 0.15% d5w/nacl potassium chloride 0.22% d5w/nacl Drug Name
Drug Name
spironolactone/hydrochlorothiazide sulfacetamide sodium/prednisolone Drug Name
Drug Name
tramadol hydrochloride/acetaminophen trimethoprim sulfate/polymyxin b sulfate timolol maleate ophthalmic gel forming Drug Name
Drug Name
This formulary was updated on November 22, 2013. For more recent information or other questions, please contact, IEHP Medicare DualChoice (HMO SNP) Member Services, at 1-877-273-IEHP (4347), 8 a.m. – 8 p.m. (PST), 7 days a week, including holidays or, for TTY users, 1-800-718-4347, or visit www.iehp.org. IEHP Medicare DualChoice (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid Program. Enrollment in IEHP Medicare DualChoice (HMO SNP) depends on contract renewal. This information is available for free in other languages. Please call IEHP Member Services for additional information at 1-877-273-IEHP (4347), 8 a.m. – 8 p.m. (PST), 7 days a week, including holidays. TTY/TDD users should call 1-800-718-4347. Esta información está disponible de manera gratuita en otros idiomas. Para obtener detalles adicionales, por favor comuníquese a Servicios para Miembros de IEHP al 1-877-273-IEHP (4347), de 8 a.m. – 8 p.m. (Hora del Pacífico), los 7 días de la semana, incluidos días festivos. Los usuarios de TTY/TDD deben llamar al 1-800-718-4347. H5640_001_MDC_14_00147_Final_2 CMS Approved

Source: https://ww2.iehp.org/en/providers/pharmaceutical-services/formulary/medicare-formulary/~/media/Pharmacy/Formulary/2014%20Medicare%20Formulary%20Book.pdf