drugs? - vnsny choice

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VNSNY CHOICE Medicare
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1-866-783-1444 (TTY for the hearing impaired 711)
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2016 FORMULARY OF COVERED PRESCRIPTION DRUGS
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN
This formulary was updated on 08/29/2015. For more recent information or other questions, please contact
VNSNY CHOICE Medicare Member Services at 1-866-783-1444 or, for TTY users, 711, Monday through Friday
from 8:00 AM to 8:00 PM or visit www.vnsnychoice.org
A Medicare Advantage Plan
2016 FORMULARY
OF COVERED
PRESCRIPTION DRUGS
VNSNY CHOICE Medicare
Approved Formulary Submission
ID Number: 16492.001, Version 7
VNSNY CHOICE Medicare Preferred (HMO SNP)
VNSNY CHOICE Total (HMO SNP)
VNSNY CHOICE Medicare Maximum (HMO SNP)
VNSNY CHOICE Medicare Classic (HMO)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN
This formulary was updated on 08/29/2015. For more recent information or other questions, please contact
VNSNY CHOICE Medicare Member Services at 1-866-783-1444 or, for TTY users, 711, Monday through Friday
from 8:00 AM to 8:00 PM or visit www.vnsnychoice.org
H5549_2016 Formulary_1085_DSB_rv_Accepted 09192015
VNSNY CHOICE Medicare and
VNSNY CHOICE Total
2016 Formulary
(List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION
ABOUT THE DRUGS WE COVER IN THIS PLAN
Includes members enrolled in VNSNY CHOICE Medicare Preferred (HMO SNP), VNSNY
CHOICE Medicare Classic (HMO), VNSNY CHOICE Medicare Maximum (HMO SNP)
and VNSNY CHOICE Total (HMO SNP)
Approved Formulary Submission ID Number: 16492.001, Version: 7
This formulary was updated on August 29, 2015. For more recent information or
other questions, please contact VNSNY CHOICE Medicare Member Services at
1-866-783-1444 or, for TTY users, 711, Monday through Friday from 8:00 AM to
8:00 PM or visit www.vnsnychoice.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 VNSNY
CHOICE Medicare. When it refers to “plan” or “our plan,” it means our VNSNY
CHOICE Medicare Preferred (HMO SNP), VNSNY CHOICE Medicare Classic
(HMO), VNSNY CHOICE Medicare Maximum (HMO SNP) and VNSNY
CHOICE Total (HMO SNP).
This document includes a list of the drugs (formulary) for our plan, which is current
as of August 29, 2015. For an updated formulary, please contact us. Our contact
information, along with the date we last updated the formulary, appears on the front
cover 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, 2017, and from time to time during the year.
VNSNY CHOICE Medicare is an HMO plan with a Medicare contract.
Enrollment in VNSNY CHOICE Medicare depends on contract renewal.
Last updated: 08/29/2015
H5549_2016 Formulary_1085_DSB
1
What is the VNSNY CHOICE Medicare Formulary?
A formulary is a list of covered drugs selected by VNSNY CHOICE Medicare 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. VNSNY
CHOICE Medicare will generally cover the drugs listed in our formulary as long as the
drug is medically necessary, the prescription is filled at a VNSNY CHOICE Medicare
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 2016 formulary that was covered at the
beginning of the year, we will not discontinue or reduce coverage of the drug during
the 2016 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 August 29, 2015. To get updated information
about the drugs covered by VNSNY CHOICE Medicare, please contact us. Our
contact information appears on the front cover and back cover pages. If we update
our printed formulary with non-maintenance formulary changes, we will send you a
notice that includes this information.
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How do I use the Formulary?
There are two ways to find your drug within the formulary:
Medical Condition
The formulary begins on page 49. 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 on page 49. 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 I-1. 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?
VNSNY CHOICE Medicare 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: VNSNY CHOICE Medicare requires you or your
physician to get prior authorization for certain drugs. This means that you
will need to get approval from VNSNY CHOICE Medicare before you fill
your prescriptions. If you don’t get approval, VNSNY CHOICE Medicare
may not cover the drug.
• Quantity Limits: For certain drugs, VNSNY CHOICE Medicare limits the
amount of the drug that VNSNY CHOICE Medicare will cover. For example,
VNSNY CHOICE Medicare provides 60 capsules per prescription for Celebrex.
This may be in addition to a standard one-month or three-month supply.
• Step Therapy: In some cases, VNSNY CHOICE Medicare requires you to
first try certain drugs to treat\RXUPHGLFDOFRQGLWLRQEHIRUHZHZLOO
3
cover another drug for that condition. For example, if Drug A and Drug B
both treat your medical condition, VNSNY CHOICE Medicare may not cover
Drug B unless you try Drug A first. If Drug A does not work for you,
VNSNY CHOICE Medicare 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 49. 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
cover and back cover pages.
You can ask VNSNY CHOICE Medicare 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 VNSNY CHOICE Medicare’s
formulary?” on page 5 for information about how to request an exception.
What are over-the counter (OTC) drugs?
OTC drugs are non-prescription drugs that are not normally covered by a Medicare
Prescription Drug Plan. VNSNY CHOICE Medicare pays for certain OTC drugs.
COVERED OVER-THE-COUNTER (OTC) DRUGS
DRUG
Dosage Form
Generic Name
(Reference Brand
Name)
cetirizine hydrochloride
(Zyrtec)
Chewable Tablets, Solution,
Tablets
(Zyrtec-D)
12 Hour Tablets
(Claritin)
Solution, Tablets
12 Hour Tablets
24 Hour Tablets
Drops
cetirizine hydrochloride/
pseudoephedrine
hydrochloride
loratadine
loratadine/
pseudoephedrine sulfate
ketotifen fumarate
(Claritin-D)
(Zaditor)
VNSNY CHOICE Medicare will provide these OTC drugs at no cost to you. The cost
to VNSNY CHOICE Medicare of these OTC drugs will not count toward your total
Part D drug costs (that is, the amount you pay does not count for the coverage gap.)
4
What if my drug is not on the Formulary?
If your drug is not included in this formulary (list of covered drugs), you should first
contact Member Services and ask if your drug is covered.
If you learn that VNSNY CHOICE Medicare does not cover your drug, you have
two options:
• You can ask Member Services for a list of similar drugs that are covered by
VNSNY CHOICE Medicare. When you receive the list, show it to your
doctor and ask him or her to prescribe a similar drug that is covered by
VNSNY CHOICE Medicare.
• You can ask VNSNY CHOICE Medicare 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 VNSNY CHOICE Medicare
Formulary?
You can ask VNSNY CHOICE Medicare 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 this
drug is not on the specialty tier. If approved this would lower the amount you
must pay for your drug.
• You can ask us to waive coverage restrictions or limits on your drug. For
example, for certain drugs, VNSNY CHOICE Medicare 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, VNSNY CHOICE Medicare will only approve your request for an
exception if the alternative drugs included on the plan’s formulary, the lower costsharing 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.
5
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 a 91-day transition supply, consistent
with dispensing increment, (unless you have a prescription written for fewer days).
We will cover more than one refill of these drugs for the first 90 days 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.
A transition fill is provided to current members that are in need of a one-time
Emergency Fill or that are prescribed a non-formulary drug as a result of a level of
care change.
6
For more information
For more detailed information about your VNSNY CHOICE Medicare prescription
drug coverage, please review your Evidence of Coverage and other plan materials.
If you have questions about VNSNY CHOICE Medicare, please contact us. Our
contact information, along with the date we last updated the formulary, appears on
the front cover 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.
This information is available for free in other languages. Please call Member
Services at 1-866-783-1444 for additional information. (TTY users should call 711
Toll-free) Monday through Friday from 8:00 AM to 8:00 PM. Member Services also
has free language interpreter services available for non-English speakers.
VNSNY CHOICE Medicare is an HMO with a Medicare contract.
Enrollment in VNSNY CHOICE Medicare depends on contract renewal.
7
VNSNY CHOICE Medicare’s Formulary
The formulary that begins on page 49 provides coverage information about the drugs
covered by VNSNY CHOICE Medicare. If you have trouble finding your drug in
the list, turn to the Index that begins on page I-1.
The first column of the chart lists the drug name. Brand name drugs are capitalized
(e.g., CELEBREX) and generic drugs are listed in lower-case italics (e.g., naproxen).
The information in the Requirements/Limits column tells you if VNSNY CHOICE
Medicare has any special requirements for coverage of your drug.
The following Utilization Management abbreviations may be found
within the body of this document
COVERAGE NOTES ABBREVIATIONS
ABBREVIATION
DESCRIPTION
EXPLANATION
Utilization Management Restrictions
PA
PA BvD
Prior Authorization
Restriction
You (or your physician) are required to
get prior authorization from VNSNY
CHOICE Medicare before you fill your
prescription for this drug. Without prior
approval, VNSNY CHOICE Medicare
may not cover this drug.
Prior Authorization
Restriction for
Part B vs Part D
Determination
This drug may be eligible for payment
under Medicare Part B or Part D. You
(or your physician) are required to get
prior authorization from VNSNY
CHOICE Medicare to determine that this
drug is covered under Medicare Part D
before you fill your prescription for this
drug. Without prior approval, VNSNY
CHOICE Medicare may not cover this
drug.
8
ABBREVIATION
PA-HRM
PA NSO
QL
ST
DESCRIPTION
EXPLANATION
This drug has been deemed by CMS to
be potentially harmful and therefore, a
High Risk Medication for Medicare
beneficiaries 65 years or older. Members
Prior Authorization
age 65 yrs or older are required to get
Restriction for
prior authorization from VNSNY
High Risk Medications
CHOICE Medicare before you fill your
prescription for this drug. Without prior
approval, VNSNY CHOICE Medicare
may not cover this drug
Prior Authorization
Restriction for
New Starts Only
Quantity Limit
Restriction
Step Therapy
Restriction
9
If you are a new member, you (or your
physician) are required to get prior
authorization from VNSNY CHOICE
Medicare before you fill your
prescription for this drug. Without prior
approval, VNSNY CHOICE Medicare
may not cover this drug.
VNSNY CHOICE Medicare limits the
amount of this drug that is covered per
prescription, or within a specific time
frame.
Before VNSNY CHOICE Medicare will
provide coverage for this drug, you must
first try another drug(s) to treat your
medical condition. This drug may only
be covered if the other drug(s) does not
work for you.
The following additional coverage note abbreviations may be found
within the body of this document
OTHER SPECIAL REQUIREMENTS FOR COVERAGE
ABBREVIATION
LA
NM
DESCRIPTION
EXPLANATION
Limited Access Drug
This prescription may be available
only at certain pharmacies. For more
information consult your Provider and
Pharmacy Directory or call Member
Services at 1-866-783-1444, Monday
through Friday from 8:00 am to 8:00
pm. TTY/TDD users should call 711.
Non-Mail Order Drug
You may be able to receive greater
than a 1-month supply of most of the
drugs on your formulary via mail
order at a reduced cost share. Drugs
not available via your mail order
benefit are noted with “NM” in the
Requirements/Limits column of your
formulary.
10
STRENGTH AND DOSAGE FORM ABBREVIATIONS
ABBREVIATION
adh. patch
aer br act
aer pow
aer pow ba
aer refill
aer w/adap
ampul
blkbaginj
cap dr mp
cap ds pk
cap er 12h
cap er 24h
cap er deg
cap er pel
cap mphase
cap.sa 24h
cap.sr 12h
cap.sr 24h
cap24h pct
cap24h pel
cap sprink
cap sr pel
cap w/dev
capsule dr
capsule er
capsule sa
cmb cappad
cmb ont fm
cmb ont lt
cmb tabpad
combo. pkg
cpmp 12hr
cpmp 24hr
cpmp 30-70
DESCRIPTION
adhesive patch
aerosol, breath activated
aerosol, powder
aerosol powder, breath activated
aerosol refill
aerosol with adapter
ampule
bulk bag injection
capsule, delayed release multiphasic
capsule, dose pack
capsule, 12 hour extended release
capsule, 24 hour extended release
capsule, extended release degradable
capsule, extended release pellets
capsule, multiphasic
capsule, 24 hour sustained action
capsule, 12 hour sustained release
capsule, 24 hour sustained release
capsule, 24 hour controlled-onset pellets
capsule, 24 hour sustained release pellets
capsule, sprinkle
capsule sustained release pellets
capsule with device
capsule, delayed release
capsule, extended release
capsule, sustained action
combination: capsule, pad
combination: ointment, foam
combination: ointment, lotion
combination: tablet, pad
combination package
capsule, 12 hour multiphasic
capsule, 24 hour multiphasic
capsule, multiphasic, 30%-70%
11
ABBREVIATION
cpmp 50-50
cream(g), cream(gm)
cream(ml)
cream/appl
cream, er (g)
cream pack
dehp fr bg
dis needle
disk w/dev
disp syrin
drops susp
drps hpvis
emul adhes
emul packt
emulsn(g)
foam/appl.
froz.piggy
g
gel/pf app
gel (gm)
gel (ml)
gel md pmp
gel w/appl
gel w/pump
gran pack
hfa aer ad
infus. btl
insuln pen
ip soln
irrig soln
iv soln.
jel
jelly/app
jel/pf app
kit cl&crm
kt crm le
DESCRIPTION
capsule, multiphasic, 50%-50%
cream (grams)
cream (milliliters)
cream with applicator
cream, extended release (grams)
cream, package
di(2-ethylhexyl)phthalate free bag
disposable needle
disk with inhalation device
disposable syringe
drops, suspension
drops, hyperviscous
emulsion adhesive
emulsion packet
emulsion (grams)
foam with applicator
frozen piggyback
gram
gel with prefilled applicator
gel (grams)
gel (milliliters)
gel in metered dose pump
gel with applicator
gel with pump
granule pack
hfa aerosol adapter
infusion bottle
insulin pen
intraperitoneal solution
irrigating solution
intravenous solution
jelly
jelly with applicator
jelly with pre-filled applicator
kit: cleanser and cream
kit: cream, lotion emollient
12
ABBREVIATION
kt lotn ce
kt oint le
lotion, er
lozenge hd
m.ht patch
ma buc tab
mcg
med. pad
med. swab
med. tape
mg
ml
muc er 12h
ndl fr inj
nl fm susp
oint. (g), oint.(gm)
oral conc
oral susp
paste (g)
patch td24
patch td72
patch tdsw
patch tdwk
pca syring
pca vial
pellet(ea)
pen ij kit
pen injctr
pggybk btl
plast. bag
powd pack
sol md pmp
sol w/appl
sol/pf app
sol-gel
soln recon
DESCRIPTION
kit: lotion, cream emollient
kit: ointment, lotion emollient
lotion, extended release
lozenge handle
medicated heated patch
mucoadhesive buccal tablet
microgram
medicated pad
medicated swab
medicated tape
milligram
milliliter
mucoadhesive system, 12 hour extended release
needle for injection
nail film suspension
ointment (grams)
oral concentrate
oral suspension
paste (grams)
patch, 24 hour transdermal
patch, 72 hour transdermal
patch, biweekly transdermal
patch, weekly transdermal
patient-controlled analgesic syringe
patient-controlled analgesic vial
pellet (each)
pen injector kit
pen injector
piggyback bottle
plastic bag
powder pack
solution with multi-dose pump
solution with applicator
solution with pre-filled applicator
solution, gel-forming
solution, reconstituted
13
ABBREVIATION
soln(gram)
spray susp
spray/pump
stick(ea)
supp.rect
supp.vag
suppos.
sus er 24h
sus er rec
sus mc rec
suspdr pkt
susp recon
syringekit
tab chew
tab er 12h
tab er 24h
tab er prt
tab er seq
tab disper
tab ds pk
tab er 24
tab mphase
tab part
tab rap dr
tab rapdis
tab subl
tab.sr 12h
tab.sr 24h
tabergr24hr
tablet dr
tablet, er
tablet eff
tablet sa
tablet sol
tb er dspk
tb mp dspk
DESCRIPTION
solution (grams)
spray, suspension
spray with pump
stick (each)
suppository, rectal
suppository, vaginal
suppository
suspension, 24 hour extended release
suspension, extended release reconstituted
suspension, microcapsule reconstituted
suspension, delayed release packet
suspension, reconstituted
syringe kit
tablet, chewable
tablet, 12 hour extended release
tablet, 24 hour extended release
tablet, extended release particles
tablet, extended release sequels
tablet, dispersible
tablet, dose pack
tablet, 24 hour extended release
tablet, multiphasic
tablet, particles
tablet, rapid disintegrating delayed release
tablet, rapid disintegrating
tablet, sublingual
tablet, 12 hour sustained release
tablet, 24 hour sustained release
tablet, 24 hour gradual extended release
tablet, delayed release
tablet, extended release
tablet, effervescent
tablet, sustained action
tablet, soluble
tablet, extended release dose pack
tablet, multiphasic dose pack
14
ABBREVIATION
tb rd dspk
tbdspk 3mo
tbmp 12hr
tbmp 24hr
u
vag ring
DESCRIPTION
tablet, rapid disintegrating dose pack
tablet, 3-month dose pack
tablet, 12 hour multiphasic
tablet, 24 hour multiphasic
unit
vaginal ring
15
VNSNY CHOICE Medicare y
VNSNY CHOICE Total
Formulario de Medicamentos 201
(Listado de Medicamentos Cubiertos)
Incluye miembros inscritos en VNSNY CHOICE Medicare Preferred (HMO SNP), VNSNY
CHOICE Medicare Classic (HMO), VNSNY CHOICE Medicare Maximum (HMO SNP)
and VNSNY CHOICE Total (HMO SNP)
Aprobado Formulario Número de la petición: 16492.001, Versión
Este formulario de medicamentos fue actualizado 08/29/2015. Para recibir información
más reciente o si tiene alguna otra duda, sírvase llamar al Servicio para Miembros de
Medicare de VNSNY CHOICE al 1-866-783-1444 o, para aquellos que utilizan TTY,
al 711, de lunes a viernes, de 8:00 AM a 8:00 PM o visite www.vnsnychoice.org.
Aviso para miembros existentes: Este formulario de medicamentos ha cambiado
desde el año pasado. Por favor, revise este documento para asegurar que aún
contiene los medicamentos que usted toma.
Cuando esta relación de medicamentos (formulario de medicamentos) hace
referencia a “nos,” “nosotros”, o “nuestro,” se refiere a VNSNY CHOICE Medicare.
Cuando hace referencia al “plan” o “nuestro plan,” se refiere a nuestro VNSNY
CHOICE Medicare Preferred (HMO SNP), VNSNY CHOICE Medicare Classic
(HMO), VNSNY CHOICE Medicare Maximum (HMO SNP) and VNSNY
CHOICE Total (HMO SNP).
Este documento incluye una relación de los medicamentos (formulario de
medicamentos) para nuestro plan, que se encuentra actualizado a partir del 08/29/2015.
Para recibir un formulario de medicamentos actualizado, sírvase comunicarse con
nosotros. Nuestra información de contacto, al igual que la fecha en que actualizamos el
formulario de medicamentos, aparece en la portada y contraportada.
Por lo general, debe utilizar las farmacias dentro de la red para poder utilizar su
beneficio de medicamentos con receta. Los beneficios, el formulario de
medicamentos, la red de farmacias, las primas y/o copagos/coaseguro pueden
cambiar el 1 de enero de 2017.
VNSNY CHOICE Medicare es un plan de HMO con contrato de Medicare.
La inscripción en VNSNY CHOICE Medicare depende de la renovación del contrato.
16
¿Qué es el formulario de medicamentos de VNSNY CHOICE
Medicare?
Un formulario de medicamentos es una relación de medicamentos cubiertos
seleccionados por VNSNY CHOICE Medicare en consulta con un equipo de
proveedores de servicios médicos, que representan los tratamientos con receta que se
piensan ser una parte necesaria de un programa de tratamiento de calidad. VNSNY
CHOICE Medicare, por lo general, cubrirá los medicamentos que aparecen en nuestro
formulario de medicamentos siempre que dicho medicamento es médicamente
necesario, la receta se llena en una farmacia de la red de VNSNY CHOICE Medicare,
y se siguen otros reglamentos del plan. Para más información sobre cómo llenar sus
recetas, sírvase revisar su Evidencia de Cobertura.
¿Puede cambiar el formulario de medicamentos (relación de
medicamentos)?
Generalmente, si está tomando un medicamento que se encuentra en nuestro
formulario de medicamentos de 2016 que fue cubierto al comienzo del año, no
descontinuaremos ni reduciremos la cobertura de ese medicamento durante el año de
cobertura de 2016 con la excepción de que se haga disponible un medicamento
genérico nuevo y más económico o si se difunde nueva información adversa sobre la
seguridad o efectividad de un medicamento. Otros tipos de cambios al formulario de
medicamentos, tal como eliminar un medicamento del mismo, no afectará a los
miembros que están tomando el medicamento actualmente. Permanecerá disponible al
mismo costo compartido para aquellos miembros que lo toman durante lo que resta del
año de cobertura. Pensamos que es importante que usted tenga acceso continuado a los
medicamentos del formulario de medicamentos que tenía disponible cuando escogió
nuestro plan, para lo que resta del año de cobertura, con excepción de los casos en los
cuales puede ahorrar dinero adicional o podemos asegurar su seguridad.
Si eliminamos medicamentos de nuestro formulario de medicamentos, o añadimos
restricciones de autorización previa, límites de cantidad y/o terapias escalonadas
para un medicamento o si cambiamos un medicamento a un nivel de costo
compartido más alto, debemos notificar a los miembros afectados de dicho cambio
un mínimo de 60 días antes de que tome vigencia, o cuando el miembro pide una
reposición del medicamento, en cuyo momento el miembro recibirá un suministro de
60 días de dicho medicamento. Si el Organismo para el Control de Alimentos y
Fármacos (FDA, por sus siglas en inglés) considera que un medicamento que se
encuentra en nuestro formulario de medicamentos no es seguro o el fabricante del
medicamento lo retira del mercado, nosotros eliminaremos el mismo de nuestro
formulario de medicamentos de inmediato y le daremos aviso a aquellos miembros
que toman ese medicamento. El formulario de medicamentos adjunto se encuentra
actualizado a partir 08/29/2015. Para recibir información actualizada sobre los
17
medicamentos cubiertos por VNSNY CHOICE Medicare, sírvase comunicarse con
nosotros. Nuestra información de contacto aparece en la portada y contraportada. Si
actualizamos nuestro formulario de medicamentos impreso con cambios que no son
de mantenimiento, le enviaremos una notificación que contiene esta información.
¿Cómo utilizo el formulario de medicamentos?
Existen dos formas de encontrar su medicamento dentro del formulario de
medicamentos:
Condición médica
El formulario de medicamentos comienza en la página 49. Los medicamentos en
este formulario de medicamentos están agrupados en categorías de acuerdo a los
tipos de condiciones médicas para los cuales son utilizados. Por ejemplo, los
medicamentos utilizados para tratar una condición cardíaca se encuentran bajo la
categoría, “Cardiovascular Agents”. Si sabe para qué se utiliza el medicamento,
busque el nombre de la categoría en la relación que comienza en la página 49.
Luego, mire bajo el nombre de categoría para buscar ese medicamento.
Relación alfabética
Si no está seguro en qué categoría buscar, debe buscar el medicamento en el
Índice que comienza en la página I-1. El Índice ofrece una relación alfabética de
todos los medicamentos incluidos en este documento. Los medicamentos de
marca, al igual que los medicamentos genéricos, se encuentran en el Índice.
Busque en el Índice y encuentre el medicamento. Al lado del medicamento, verá
el número de la página en la cual puede encontrar la información de cobertura.
Vaya a la página mencionada en el Índice y encuentre el nombre del
medicamento en la primera columna de la relación.
¿Qué son los medicamentos genéricos?
VNSNY CHOICE Medicare cubre los medicamentos de marca al igual que los
medicamentos genéricos. Un medicamento genérico es aprobado por la FDA como
teniendo el mismo ingrediente activo que el de marca. Por lo general, los
medicamentos genéricos cuestan menos que los de marca.
18
¿Existe alguna restricción sobre mi cobertura?
Algunos medicamentos cubiertos pueden tener requerimientos o limitaciones
adicionales sobre su cobertura. Estos requerimientos y limitaciones pueden incluir:
• Autorización previa: VNSNY CHOICE Medicare exige que usted o su
médico reciba autorización previa para ciertos medicamentos. Esto implica
que deberá recibir aprobación de VNSNY CHOICE Medicare antes de llenar
sus recetas. Si no consigue aprobación, es posible que VNSNY CHOICE
Medicare no cubra el medicamento.
• Limitaciones de cantidad: Para ciertos medicamentos, VNSNY CHOICE
Medicare limita la cantidad del medicamento que VNSNY CHOICE Medicare
cubrirá. Por ejemplo, VNSNY CHOICE Medicare suministra 60 cápsulas por
cada receta para el medicamento Celebrex. Esto puede ser además de un
suministro estándar de un mes o tres meses.
• Tratamiento escalonado: En algunos casos, VNSNY CHOICE Medicare
exige que pruebe ciertos medicamentos primero, para tratar su condición
médica, antes que cubriremos otro medicamento para tratar esa condición.
Por ejemplo, si Medicamento A y Medicamento B pueden tratar su condición
médica, es posible que VNSNY CHOICE Medicare no cubra el Medicamento
B al menos que primero pruebe con el Medicamento A. Si no le funciona el
Medicamento A, entonces VNSNY CHOICE Medicare cubrirá el
medicamento B.
Usted puede determinar si su medicamento tiene algún requerimiento adicional o
limitación con buscar en el formulario de medicamentos que comienza en la página
49. También puede recibir más información sobre las restricciones que aplican a
ciertos medicamentos cubiertos con visitar nuestro sitio Web. Nuestra información
de contacto, al igual que la fecha en que actualizamos el formulario de
medicamentos, aparece en la portada y contraportada.
Puede pedirle a VNSNY CHOICE Medicare para hacer una excepción a estas
restricciones o limitaciones o para una relación de otros medicamentos similares que
pueden tratar su condición de salud. Véase la sección, “Cómo pido una excepción al
formulario de medicamentos de VNSNY CHOICE Medicare?” que se encuentra en
la página 20 para obtener más información sobre cómo solicitar una excepción.
19
MEDICAMENTOS DE VENTA LIBRE (OTC) CON COBERTURA
MEDICAMENTOS
Nombre genérico
(Nombre de marca
de referencia)
hidrocloruro de
(Zyrtec)
cetirizina
hidrocloruro de
cetirizina/
(Zyrtec-D)
hidrocloruro de
pseudoefedrina
loratadina
(Claritin)
loratadina/
sulfato de
(Claritin-D)
pseudoefedrina
fumarato de cetotifeno
(Zaditor)
Presentación
Tabletas masticables,
solución, tabletas
Tabletas de 12 horas
Solución, tabletas
Tabletas de 12 horas
Tabletas de 24 horas
Gotas
Y ¿Si mi medicamento no se encuentra en el formulario de
medicamentos?
Si su medicamento no se incluye en este formulario de medicamentos (relación de
medicamentos cubiertos), debe primero comunicarse con Servicios para Miembros
para consultar si su medicamento se encuentra cubierto.
Si descubre que VNSNY CHOICE Medicare no cubre su medicamento, usted tiene
dos opciones:
• Puede pedirle a Servicios para Miembros para una relación de medicamentos
similares que están cubiertos por VNSNY CHOICE Medicare. Cuando recibe
la relación, muéstrela a su médico y pídale que recete un medicamento similar
que sea cubierto por VNSNY CHOICE Medicare.
• Puede pedirle a VNSNY CHOICE Medicare para que haga una excepción y
cubra su medicamento. Véase a continuación para obtener información sobre
cómo solicitar una excepción.
20
¿Cómo pido una excepción al Vademécum de VNSNY CHOICE
Medicare?
Puede pedirle a VNSNY CHOICE Medicare de hacer una excepción a los
reglamentos de cobertura. Existen varios tipos de excepciones que nos puede pedir.
• Nos puede pedir cubrir un medicamento, aunque no se encuentra en nuestro
formulario de medicamentos. Si es aprobado, este medicamento será cubierto
en un nivel de costo compartido predeterminado, y no podrá pedirnos ofrecer
el medicamento a un nivel de costo compartido inferior.
• Nos puede pedir cubrir un medicamento que se encuentra en el formulario de
medicamentos a un nivel de costo compartido inferior si el medicamento no se
encuentra en el nivel especializado. Si es aprobado, esto reduciría el monto
que debe pagar para su medicamento.
•
Nos puede pedir eliminar las restricciones o limitaciones de cobertura sobre
su medicamento. Por ejemplo, para ciertos medicamentos, VNSNY CHOICE
Medicare limita la cantidad de medicamento que cubrirá. Si su medicamento
tiene un límite de cantidad, nos puede pedir eliminar ese límite y cubrir una
cantidad mayor.
Por lo general, VNSNY CHOICE Medicare solamente aprobará su solicitud para
una excepción si los medicamentos alternativos incluidos en el formulario de
medicamentos del plan, el medicamento de costo compartido inferior o las
restricciones de utilización adicionales no serían tan eficaces en tratar su condición
y/o le causaría tener efectos médicos adversos.
Debe comunicarse con nosotros para pedirnos una decisión de cobertura inicial para
una excepción de restricción al formulario de medicamentos, escalonamiento o
utilización.
Cuando solicita una excepción de restricción al formulario de medicamentos,
escalonamiento o utilización, debe presentar una declaración del prescriptor o
médico apoyando su petición. Por lo general, debemos tomar nuestra decisión
dentro de 72 horas de recibir la declaración de apoyo de su prescriptor. Puede pedir
una excepción acelerada (rápida) si usted o su médico piensa que su salud puede ser
seriamente perjudicada si espera hasta 72 horas para recibir una decisión. Si se le
otorga su petición para acelerar, le debemos dar una decisión no menos de 24 horas
después de recibir la declaración de apoyo de su médico u otro prescriptor.
21
¿Qué debo hacer antes de hablar con mi médico sobre cambiar mis
medicamentos o pedir una excepción?
Como un miembro nuevo o continuado de nuestro plan, es posible que usted está
tomando medicamentos que no se encuentran en nuestro formulario de
medicamentos. También es posible que esté tomando un medicamento que se
encuentra en nuestro formulario de medicamentos pero su habilidad de conseguirlo
es limitada. Por ejemplo, usted puede necesitar una autorización previa de nosotros
antes de poder llenar su receta. Debe consultar con su médico para determinar si
debe cambiar a un medicamento apropiado que cubrimos o pedir una excepción al
formulario de medicamentos para poder cubrirle el medicamento que toma. Mientras
consulta con su médico para determinar el curso apropiado para usted, es posible
que cubriremos su medicamentos en ciertos casos durante los primeros 90 días que
usted es un miembro de nuestro plan.
Por cada uno de los medicamentos que no se encuentran en nuestro formulario de
medicamentos o si tiene habilidad limitada de conseguir sus medicamentos,
cubriremos un suministro provisional de 30 días (al menos que tiene una receta
escrita para menos días) cuando vaya a una farmacia dentro de la red. Después de su
primer suministro de 30 días, no pagaremos por estos medicamentos, aunque ha sido
un miembro del plan menos de 90 días.
Si es residente de una centro de atención a largo plazo, le permitiremos reposicionar
su receta hasta que le hayamos proveído con un suministro de 91 días, consistente
con el incremento de dispensación (al menos que tiene una receta escrita por menos
días). Cubriremos más de una reposición de estos medicamentos para los primeros
90 días si es un miembro de nuestro plan. Si necesita de un medicamento que no se
encuentra en nuestro formulario de medicamentos o si tiene habilidad limitada en
conseguir sus medicamentos, pero se encuentran pasados los primeros 90 días de
membresía en nuestro plan, cubriremos un suministro de emergencia de 31 días para
ese medicamento (al menos que tiene una receta para menos días) mientras solicita
una excepción al formulario de medicamentos.
Un resurtido de transición sera proporcionado, por una vez, a los miembros actuales
que están en necesidad de un resurtido de emergencia o que han sido recetado un
medicamento fuera del formulario debido a un cambio de nivel de atención.
22
Para más información
Para obtener más información sobre su cobertura de medicamentos con receta de
VNSNY CHOICE Medicare, sírvase revisar la Evidencia de Cobertura y demás
materiales del plan.
Si tiene alguna duda sobre VNSNY CHOICE Medicare, sírvase comunicarse con
nosotros. Nuestra información de contacto, al igual que la fecha en que actualizamos
el formulario de medicamentos, aparece en la portada y contraportada.
Si tiene alguna duda en general sobre la cobertura de medicamentos con receta de
Medicare sírvase llamar al 1-800-MEDICARE (1-800-633-4227) las 24 horas del
día/7 días a la semana. Los usuarios de TTY deben llamar al 1-877-486-2048. O,
visite www.medicare.gov.
Esta información está disponible gratis en otros idiomas. Comuníquese con nuestros
Servicios al miembro al número 1-866-783-1444 para obtener información adicional.
(Los usuarios de TTY deben llamar al 711.) Horario de atención de lunes a viernes de
8:00 a.m. a 8:00 p.m. Los Servicios al miembro también tienen disponibles servicios
gratis de intérpretes de idiomas para personas que no hablan ingles
VNSNY CHOICE Medicare es un plan de HMO con contrato de Medicare.
La inscripción en VNSNY CHOICE Medicare depende de la renovación del contrato.
23
Formulario de Medicamentos de
VNSNY CHOICE Medicare
El formulario de medicamentos que comienza en la página 49 ofrece información de
cobertura sobre los medicamentos cubiertos por VNSNY CHOICE Medicare. Si tiene
dificultad en encontrar su medicamento en esta relación, sírvase consultar el Índice
que comienza en la página I-1.
En la primera columna de la tabla aparece el nombre del medicamento. Los
medicamentos de marca aparecen con letras mayúsculas (por ejemplo, CELEBREX) y
los medicamentos genéricos aparecen con letras minúsculas y en bastardilla (por
ejemplo, naproxen).
La información que se encuentra en la columna de Requerimientos/Limitaciones le
informa si VNSNY CHOICE Medicare tiene algún requerimiento especial para la
cobertura de su medicamento.
24
Las siguientes abreviaturas de Gestión de Uso se pueden encontrar
en el cuerpo de este documento
ABREVIATURAS DE LOS AVISOS DE COBERTURA
ABREVIATURA
DESCRIPCIÓN
EXPLICACIÓN
Restricciones en la Gestión de Uso
PA
PA BvD
PA-HRM
Se requiere que usted (o su médico)
obtenga autorización previa de
VNSNY CHOICE Medicare para
Restricciones de la
poder surtir este medicamento con
receta médica. Sin autorización
Autorización previa
previa, es posible que VNSNY
CHOICE Medicare no cubra este
medicamento.
Es posible que este medicamento sea
elegible para pago según la Parte B o
la Parte D de Medicare. Usted (o su
médico) deben obtener autorización
Restricciones de
previa de VNSNY CHOICE Medicare
Autorización previa para para determinar si este medicamento
determinación de la Parte está cubierto por la Parte D de
Medicare antes de que se surta este
B frente a la Parte D
medicamento con receta médica. Sin
autorización previa, es posible que
VNSNY CHOICE Medicare no cubra
este medicamento.
Restricciones de
autorización previa para
Medicamentos de alto
riesgo
25
CMS considera que este medicamento
es potencialmente dañino y, por
consiguiente, se clasifica como
medicamento de alto riesgo para los
beneficiarios de Medicare de 65 años de
edad o mayores. Se requiere que los
afiliados de 65 años de edad o mayores
obtengan autorización previa de
VNSNY CHOICE Medicare antes de
que se surta este medicamento con
receta médica. Sin autorización previa,
es posible que VNSNY CHOICE
Medicare no cubra este medicamento.
ABREVIATURA
PA NSO
QL
ST
DESCRIPCIÓN
EXPLICACIÓN
Restricciones de
autorización previa para
nuevos afiliados
únicamente
Si es un afiliado nuevo, se requiere que
usted (o su médico) obtenga
autorización previa de VNSNY
CHOICE Medicare antes de que se
surta este medicamento con receta
médica. Sin autorización previa, es
posible que VNSNY CHOICE
Medicare no cubra este medicamento.
Restricciones para los
límites de cantidad
VNSNY CHOICE Medicare limita la
cantidad de este medicamentos que es
cubierto por receta médica, o dentro de
un marco de tiempo específico.
Restricción en la terapia
de pasos
Antes de que VNSNY CHOICE
Medicare le proporcione cobertura
para este medicamento, primero debe
intentar usar otro medicamento o
medicamentos para tratar su condición
médica. Este medicamente se cubrirá
únicamente si los otros medicamentos
no funcionan para usted.
26
Las siguientes abreviaturas de aviso de cobertura adicional se pueden
encontrar en el cuerpo de este documento
OTROS REQUERIMIENTOS ESPECIALES PARA LA COBERTURA
ABREVIATURA
DESCRIPCIÓN
EXPLICACIÓN
LA
Estos medicamentos con receta
médica podrían estar disponibles
únicamente en ciertas farmacias. Para
obtener más información, consulte
Medicamentos de acceso con el Directorio de proveedores y
farmacias o llame a Servicios al
limitado
afiliado al 1-866-783-1444, de lunes a
viernes, de 8:00 a.m. a 8:00 p.m. Los
usuarios de TTY/TDD deben llamar al
711.
NM
Es posible que pueda recibir por
correo más de un mes de suministros
para la mayoría de los medicamentos
en su formulario, con un costo
compartido reducido. Los
Medicamentos que no se
medicamentos que no están
pueden enviar por correo
disponibles mediante el beneficio de
pedido por correo, se identifican con
las iniciales «NM» en la columna de
Requerimientos/Límites de su
formulario.
27
ABREVIATURAS DE POTENCIA Y PRESENTACIÓN
ABREVIATURA
adh. patch
aer br act
aer pow
aer pow ba
aer refill
aer w/adap
ampul
blkbaginj
cap dr mp
cap ds pk
cap er 12h
cap er 24h
cap er deg
cap er pel
cap mphase
cap.sa 24h
cap.sr 12h
cap.sr 24h
cap24h pct
cap24h pel
cap sprink
cap sr pel
cap w/dev
capsule dr
capsule er
capsule sa
cmb cappad
cmb ont fm
cmb ont lt
cmb tabpad
combo. pkg
cpmp 12hr
cpmp 24hr
DESCRIPCIÓN
parche adhesivo
aerosol, activado por la respiración
aerosol, polvo
aerosol en polvo, activado por la respiración
recarga de aerosol
aerosol con adaptador
ampolleta
inyecciones de bolsa a granel
cápsula, liberación retardada multifásica
cápsula, paquete de dosis
cápsula, 12 horas de acción prolongada
cápsula, 24 horas de acción prolongada
cápsula, liberación prolongada degradable
cápsula, gránulos de liberación prolongada
cápsula, multifásica
cápsula, 24 horas de acción sostenida
cápsula, 12 horas de liberación sostenida
cápsula, 24 horas de liberación sostenida
cápsula, gránulos de 24 horas de acción local
controlada
cápsula, gránulos de 24 horas de liberación sostenida
cápsula, dispersable
cápsula de gránulos de liberación sostenida
cápsula con dispositivo
cápsula de liberación prolongada
cápsula de liberación extendida
cápsula de acción sostenida
combinación: cápsula, almohadilla
combinación: ungüento, espuma
combinación: ungüento, loción
combinación: tableta, almohadilla
paquete combinado
cápsula, 12 horas multifásica
cápsula, 24 horas multifásica
28
ABREVIATURA
cpmp 30-70
cpmp 50-50
cream(g), cream(gm)
cream(ml)
cream/appl
cream, er (g)
cream pack
dehp fr bg
dis needle
disk w/dev
disp syrin
drops susp
drps hpvis
emul adhes
emul packt
emulsn(g)
foam/appl.
froz.piggy
g
gel/pf app
gel (gm)
gel (ml)
gel md pmp
gel w/appl
gel w/pump
gran pack
hfa aer ad
infus. btl
insuln pen
ip soln
irrig soln
iv soln.
jel
jelly/app
jel/pf app
kit cl&crm
DESCRIPCIÓN
cápsula, multifásicas, 30%-70%
cápsula, multifásicas, 50%-50%
crema (gramos)
crema (mililitros)
crema con aplicador
crema, liberación prolongada (gramos)
crema, paquete
di(2-etilhexil)ftalato bolsa libre
aguja desechable
disco con dispositivo de inhalación
jeringa desechable
gotas, suspensión
gotas, hiperviscosas
emulsión adhesiva
emulsión en paquete
emulsión (gramos)
espuma con aplicador
solución premezclada congelada
gramo
gel con aplicador llenado previamente
gel (gramos)
gel (mililitros)
gel en bomba de dosis medida
gel con aplicador
gel con bomba
paquete de gránulos
adaptador de aerosoles hfa
frasco de infusión
pluma de insulina
solución intraperitoneal
solución de irrigación
solución intravenosa
gel
gel con aplicador
gel con aplicador llenado previamente
kit: limpiador y crema
29
ABREVIATURA
kt crm le
kt lotn ce
kt oint le
lotion, er
lozenge hd
m.ht patch
ma buc tab
mcg
med. pad
med. swab
med. tape
mg
ml
muc er 12h
ndl fr inj
nl fm susp
oint. (g), oint.(gm)
oral conc
oral susp
paste (g)
patch td24
patch td72
patch tdsw
patch tdwk
pca syring
pca vial
pellet(ea)
pen ij kit
pen injctr
pggybk btl
plast. bag
powd pack
sol md pmp
sol w/appl
sol/pf app
DESCRIPCIÓN
kit: crema, loción emoliente
kit: loción, crema emoliente
kit: ungüento, loción emoliente
loción, liberación prolongada
controlador de comprimidos
parche de calor medicado
tableta bucal mucoadhesiva
microgramo
almohadilla medicada
hisopo medicado
cinta adhesiva medicada
miligramo
mililitro
sistema mucoadhesivo, 12 horas de liberación
prolongada
aguja para inyección
suspensión en película para uñas
ungüento (gramos)
concentrado oral
suspensión oral
pasta (gramos)
parche, 24 horas transdérmico
parche, 72 horas transdérmico
parche, transdérmico quincenal
parche, transdérmico semanal
jeringa de analgésico controlado por el paciente
vial de analgésico controlado por el paciente
gránulos (cada uno)
kit de pluma de inyección
pluma de inyección
frasco de solución premezclada
bolsa de plástico
paquete de polvo
solución con bomba multidosificadora
solución con aplicador
solución con aplicador llenado previamente
30
ABREVIATURA
sol-gel
soln recon
soln(gram)
spray susp
spray/pump
stick(ea)
supp.rect
supp.vag
suppos.
sus er 24h
sus er rec
sus mc rec
suspdr pkt
susp recon
syringekit
tab chew
tab er 12h
tab er 24h
tab er prt
tab er seq
tab disper
tab ds pk
tab er 24
tab mphase
tab part
tab rap dr
tab rapdis
tab subl
tab.sr 12h
tab.sr 24h
tabergr24hr
tablet dr
tablet, er
tablet eff
tablet sa
tablet sol
DESCRIPCIÓN
solución formadora de gel
solución, reconstituida
solución (gramos)
atomizador, suspensión
atomizador con bomba
barra (cada una)
supositorio, rectal
supositorio, vaginal
supositorio
suspensión, 24 horas de liberación prolongada
suspensión, liberación prolongada reconstituida
suspensión, microcápsula reconstituida
suspensión, paquete de liberación prolongada
suspensión, reconstituida
kit de jeringas
tableta, masticable
tableta, 12 horas liberación prolongada
tableta, 24 horas liberación prolongada
tableta, partículas de liberación prolongada
tableta, hora liberación prolongada
tableta, dispersable
tableta, paquete de dosis
tableta, 24 horas liberación prolongada
tableta, multifásica
tableta, partículas
tableta, liberación prolongada de desintegración rápida
tableta, desintegración rápida
tableta, sublingual
tableta, 12 horas liberación sostenida
tableta, 24 horas liberación sostenida
tableta, 24 horas liberación prolongada gradual
tableta, liberación prolongada
tableta, liberación prolongada
tableta, efervescente
tableta, acción sostenida
tableta, soluble
31
ABREVIATURA
tb er dspk
tb mp dspk
tb rd dspk
tbdspk 3mo
tbmp 12hr
tbmp 24hr
u
vag ring
DESCRIPCIÓN
tableta, paquete de dosis de liberación prolongada
tableta, paquete de dosis multifásica
tableta, paquete de dosis de desintegración rápida
tableta, paquete de dosis para 3 meses
tableta, 12 horas multifásica
tableta, 24 horas multifásica
unidad
anillo vaginal
32
VNSNY CHOICE Medicare 㠷
VNSNY CHOICE Total
2016 㲅ᯩ䳶
˄㎖Ԉ㰕૱␵௞˅
वਜ਼VNSNY CHOICE Medicare Preferred (HMO SNP),
VNSNY CHOICE Medicare Classic (HMO),
VNSNY CHOICE Medicare Maximum (HMO SNP) and
VNSNY CHOICE Total (HMO SNP)
Ṩ߶Ⲵ㲅ᯩ䳶ᨀӔ ID 㲏⻬˖16492.001,ㅜ 7 ⡸
Ṉ⹦᪉㞟᭦᪂᪊ 2015 ᖺ 08 ᭶ 29 ᪥傏 ዴ㟂᭦ከ᭱᪂ⓗ㈨イᡈ᭷඼௚ၥ㢟凞 ㄳ⫃⤡ VNSNY
CHOICE Medicare ᭳ဨ᭹ົ㒊凞 㟁ヰ凬 1-866-783-1444凞 TTY ౑⏝⪅ㄳ᧕
711凞 㐌୍฿㐌஬凞 ᪩ୖ 8:00 ฿᫽ୖ 8:00凞 ᡈ㐀ゼ www.vnsnychoice.org傏
⌧᭷᭳ဨὀព஦㡯凬 Ṉ⹦᪉㞟ᕬ᪊ཤᖺㆰ᭦傏 ㄳᷙ教Ṉᩥ௳௨☜ᐃ඼୰௔↛ໟྵᝍ᭹⏝ⓗ⸩ရ傏
Ṉ⸩ရΎႝ凚 ⹦᪉㞟凛 ᡤ㏙ⓗ傘 ᡃ಼備 傎 傘 ᡃ᪉備 ᡈ傘 ᡃ಼ⓗ備 ᆒ௦⾲ VNSNY CHOICE
Medicare傏 ᅾᥦ฿傘 ィ␓備 ᡈ傘 ᡃ಼ⓗィ␓備 ᫬凞 ពᣦᡃ಼ⓗVNSNY CHOICE Medicare
Preferred (HMO SNP), VNSNY CHOICE Medicare Classic (HMO), VNSNY CHOICE
Medicare Maximum (HMO SNP) and VNSNY CHOICE Total (HMO SNP)傏
Ṉᩥ௳ໟྵᡃ಼ィ␓ⓗ⸩ရΎႝ凚 ⹦᪉㞟凛 凞 ᫝ᡖ⮳ 2015 ᖺ 8 ᭶ 29
᪥ⓗ᭱᪂∧傏 ᝿せ⋓ᚓ᭦᪂∧ⓗ⹦᪉㞟凞 ㄳ⯅ᡃ಼⫃⤡傏 ᡃ಼ⓗ⫃⤡㈨イ凞 ௨ཬ᭱ᚋ᭦᪂⹦᪉㞟ⓗ᪥
ᮇ凞 ぢᑒ㠃⯅ᑒᗏ㡫傏
ᝍᚲ㡲౑⏝㐃⥙ⓗ⸩ᡣ凞 ᡯ⬟౑⏝ᝍⓗ⹦᪉⸩⚟฼傏 ⚟฼傎 ⹦᪉㞟傎 㐃⥙⸩ᡣ傎 ಖ㈝࿴/ᡈඹྠ㈇᧴
㈝⏝/ඹಖ㈝ྍ⬟᪊ 2017 ᖺ 1 ᭶ 1 ᪥ㆰ᭦傏
VNSNY CHOICE Medicare ᫝ᦚ㓄 Medicare ྜ⣙ⓗ HMO ィ␓傏 ト෉ VNSNY
CHOICE Medicare ྲྀỴ᪊ྜ⣙⧰ゞ傏
ᴰᖼᴤᯠ˖ 08/29/2015
33
VNSNY CHOICE Medicare ⹦᪉㞟᫝⏒㯟㸽
⹦᪉㞟᫝ VNSNY CHOICE Medicare ㅎュ㓾⒪ಖ೺ᥦ౪⪅ᅰ㝲ྡྷᡤᣮ㑅ⓗ⤥௜⸩ရΎႝ
㸪௦⾲᧸ಙ㧗ရ㉁἞⒪᪉᱌ᡤ㟂ⓗ⹦᪉⒪ἲࠋྈせヱ⸩ရ᫝㓾⒪ୖᚲ㡲ⓗ㸪୪ୟᅾ
VNSNY CHOICE Medicare 㐃⥙ⓗ⸩ᡣ㡿ྲྀ⹦᪉⸩ရ㸪ୟ㑂Ᏺ඼௚ⓗィ␓つ๎㸪㑣㯟
VNSNY CHOICE Medicare ᑘ඲㠃⤥௜ᡃ಼⹦᪉㞟ᡤิⓗ⸩ရࠋᑞ᪊ዴఱㄪກ⹦᪉ⓗ᭦
ከ㈨イ㸪ㄳᷙどᝍⓗࠕಖ㞋⌮㈺㡯┠婒᫂᭩ࠖࠋ
⹦᪉㞟㸦⸩ရΎႝ㸧ྍ௨᭦ᨵႫ㸽
୍⯡⪋ゝ㸪ዴᯝᝍᅾᖺึ᭹⏝ᡃ಼ 2016 ᖺ⹦᪉㞟ᡤ⤥௜ⓗ⸩ရ㸪㝖㠀᭷㍑౽ᐅⓗ᪂Ꮵྡ
⸩ྍ⏝㸪ᡈ᫝᪂ⓐథ㜝᪊ヱ⸩ရᏳ඲ᛶᡈຌᩀⓗ㈇㠃㈨イ௨እ㸪ᅾ 2016 ᖺ⤥௜ᖺᗘᮇ㛫
㸪ᡃ಼୙᭳୰Ṇᡈῶᑡ⸩ရⓗ⤥௜ࠋ඼௚㢮ᆺⓗ⹦᪉㞟ㆰ᭦㸦౛ዴᑘ୍✀⸩ရᚘ⹦᪉㞟
⛣㝖㸧㸪୪୙᭳ᙳ㡪┠๓᭹⏝ヱ⸩ရⓗ᭳ဨࠋ᭹⏝ヱ⸩ရⓗ᭳ဨᅾ⤥௜ᖺᗘⓗ๦㣾ᮇ㛫
㸪௔↛ྍ௨┦ྠⓗ㈝⏝ศᨦྲྀᚓࠋᡃ಼┦ಙ㸪ᝍᅾ⤥௜ᖺᗘⓗ๦㣾ᮇ㛫㸪௔↛⧤⧰ྲྀᚓ
ᝍᅾ㑅᧪ᡃ಼ィ␓᫬ྍ⏝ⓗ⹦᪉㞟⸩ရ᫝㠀ᖖ㔜せⓗ㸪㝖㠀ᝍྍ௨⠇┬㢠እⓗ㈝⏝ᡈ᫝
ᡃ಼ྍ௨☜ಖᝍⓗᏳ඲ࠋ
ዴᯝᡃ಼ᚘ⹦᪉㞟⛣㝖⸩ရᡈ᫝᪂ቔ⸩ရⓗ஦ඛ᰾Ὶࠊᩝ㔞㝈ไ࿴/ᡈศ㝵ẁ⒪ἲ㝈ไ㸪
ᡈ᫝ᑘ୍✀⸩ရ㎈฿㍑㧗ⓗ㈝⏝ศᨦᒙ⣭㸪ᡃ಼ᚲ㡲ᅾㆰ᭦⏕ᩀⓗ⮳ᑡ 60 ኳ๓㸪ᡈ᫝᭳
ဨせồ⿵඘⸩ရ᫬㸪㏻▱ཷᙳ㡪ⓗ᭳ဨ㸪ᒄ᫬᭳ဨᑘ ᨲ฿ 60 ኳⓗ⸩ရࠋ ዴᯝ⨾ᅧ㣗ရ
࿴⸩ရ⟶⌮ᒁㄆⅭᡃ಼⹦᪉㞟ⓗ⸩ရ୙Ᏻ඲㸪ᡈ᫝⸩ရⓗ〇㐀ၟᚘᕷሙ᧔㝖ヱ⸩ရ㸪ᡃ
಼ᑘ❧༶ᚘ⹦᪉㞟୰⛣㝖ヱ⸩ရ㸪୪㏻▱᭹⏝ヱ⸩ရⓗ᭳ဨࠋᡤ㝃ⓗ⹦᪉㞟᫝ᡖ⮳ 2016
ᖺ 1 ᭶ 1 ᪥ⓗ᭱᪂∧ࠋዴせྲྀᚓ㜝᪊ VNSNY CHOICE Medicare ⤥௜⸩ရⓗ᭱᪂㈨イ㸪
ㄳ⯅ᡃ಼⫃⤡ࠋᡃ಼ⓗ⫃⤡㈨イฟ⌧᪊ᑒ㠃⯅ᑒᗏ㡫ࠋዴᯝᡃ಼௨ᮍ⥔ㆤⓗ⹦᪉㞟ㆰ᭦
᭦᪂ᡃ಼ⓗ༳ๅ⹦᪉㞟㸪ᡃ಼ᑘᐤ⤥ᝍໟྵṈ㈨イⓗ㏻▱ࠋ
34
ᡃせዴఱ౑⏝⹦᪉㞟㸽
᭷ඳ⛇᪉ἲྍᢍฟ⹦᪉㞟ℏᝍ㟂せⓗ⸩ရ㸸
㓾⒪᝟ἣ
⹦᪉㞟ᚘ➨ 49 㡫㛤ጞࠋṈ⹦᪉㞟ℏⓗ⸩ရ᫝ᣨ↷Ꮽ಼⏝᪊἞⒪ⓗ㓾 ⒪᝟ἣ㢮ᆺ౗ศ
㢮ⓗࠋ ౛ዴ㸪⏝᪊἞⒪ᚰ⮤᝟ἣⓗ⸩ရᲄิ᪊ࠕᚰ⾑⟶ࠖ 㢮ูࠋዴᯝᝍ▱㐨ᝍⓗ⸩
ရ⏝㏵㸪ᅾ➨ 49 㡫㛤ጞⓗΎႝୖᦏᑜ㢮ูྡ✃ࠋ ↛ᚋᅾ㢮ูྡ✃ୗ᪉ᦏᑜᝍⓗ⸩ရࠋ
ᣨᏐẕ᤼ิⓗ⸩ရΎႝ
ዴᯝᝍ୙☜ᐃせᦏᑜⓗ㢮ู㸪᠕ヱᅾ I-1 㛤ጞⓗࠕ⣴ᘬ (Index)ࠖ ᦏᑜᝍⓗ⸩ရࠋࠕ⣴
ᘬࠖᥦ౪Ṉᩥ௳඲㒊ⓗᣨᏐẕ᤼ิⓗ⸩ရΎႝࠋࠕ⣴ᘬࠖྠ᫬ᲄิᑙ฼⸩⯅Ꮵྡ⸩ࠋ
ᚘࠕ⣴ᘬࠖ୰㞍ᢍᝍⓗ⸩ရࠋᅾᝍⓗ⸩ရ᪍㑔㸪᭳┳฿ྍ௨ᢍ฿⤥௜㈨イⓗ㡫☞ࠋ⩻
฿ࠕ⣴ᘬࠖᡤิⓗ㡫☞㸪୪᪊Ύႝⓗ➨୍ḍ㞍ᢍ⸩ရⓗྡ✃ࠋ
⏒㯟᫝Ꮵྡ⸩㸽
VNSNY CHOICE Medicare ྠ᫬⤥௜ᑙ฼⸩࿴Ꮵྡ⸩ࠋᏥྡ⸩᫝ FDA ᰾෸࿴ᑙ฼⸩ල
᭷┦ྠάᛶᡂศⓗ⸩ရࠋ୍⯡⪋ゝ㸪Ꮵྡ⸩ẚᑙ฼⸩౽ᐅࠋ
ᡃⓗ⤥௜᫝ྰ᭷௵ఱ㝈ไ㸽
᭷ல⤥௜⸩ရᑞ⤥௜⠊ᅩྍ⬟᭷඼௚せồᡈ㝈ไࠋ㏺லせồ⯅㝈ไྍ⬟ໟᣓ㸸
• ஦ඛᤵḒ㸸VNSNY CHOICE Medicare せồᝍᡈᝍⓗ㓾ᖌ㔪ᑞ≉ᐃ⸩ရྲྀᚓ஦ඛᤵ
Ḓࠋ㏺⾲♧ᅾ౫↷ᝍⓗ⹦᪉㡿⸩அ๓㸪ᚲ㡲ྲྀᚓ VNSNY CHOICE Medicare ⓗ᰾෸
ࠋ ⱝᮍ⥂᰾Ὶ㸪VNSNY CHOICE Medicare ྍ⬟↓ἲ⤥௜⸩ရࠋ
• ᩝ㔞㝈ไ㸸VNSNY CHOICE Medicare ᭳㔪ᑞ≉ᐃ⸩ရ㝈ไ VNSNY CHOICE
Medicare ᑘ⤥௜ⓗ౪᠕㔞ࠋ౛ዴ㸪VNSNY CHOICE Medicare 㔪ᑞẗᙇ⹦᪉ᥦ౪ 60
㢛 Celebrex ⭺ᄷࠋ㏺ྍ⬟᫝㝃ຍ᪊ᶆ‽ⓗ୍ಶ᭶ᡈ୕ಶ᭶⸩㔞ࠋ
• ศ㝵ẁ⒪ἲ㸸ᅾ᯾ல᝟ἣୗ㸪VNSNY CHOICE Medicare ᭳ᅾ⤥௜⏝᪊ヱ⑓᝟ⓗ྄
୍✀⸩ရஅ๓㸪せồᝍඛაヨ≉ᐃⓗ⸩ရ௨἞⒪ᝍⓗ㓾⒪᝟ἣࠋ౛ዴ㸪ዴᯝ A ⸩
ရ⯅ B ⸩ရ㒔⬟἞⒪ᝍⓗ㓾⒪᝟ἣ㸪VNSNY CHOICE Medicare ྍ⬟ᅾᝍඛაヨ A
⸩ရஅᚋ㸪ᡯ⤥௜ B ⸩ရࠋዴᯝ A ⸩ရᑞᝍ↓ᩀ㸪๎ VNSNY CHOICE Medicare
ᑘ⤥௜ B ⸩ရࠋ
35
㞍ᢍᚘ➨ 49 㡫㛤ጞⓗ⹦᪉㞟㸪ྍ௨஢ゎᝍⓗ⸩ရ᫝ྰ᭷඼௚せồᡈ㝈ไࠋ
㐀ゼᡃ಼ⓗ⥙❰ஓྍ௨ྲྀᚓ㜝᪊≉ᐃ⤥௜⸩ရ㝈ไⓗ᭦ከ㈨イࠋᡃ಼ⓗ⫃⤡㈨イ㸪௨ཬ
᭱ᚋ᭦᪂⹦᪉㞟ⓗ᪥ᮇ㸪ฟ⌧᪊ᑒ㠃⯅ᑒᗏ㡫ࠋ
ᝍྍ௨せồ VNSNY CHOICE Medicare ᑞ㏺ல㝈ไ㐍⾜౛እ⹦⌮㸪 ᡈ᫝せồྍ௨἞⒪ᝍ
ⓗ೺ᗣ᝟ἣⓗ඼௚㢮ఝ⸩ရΎႝࠋㄳཨ教➨ 5 㡫ࠕᡃዴఱせồᑞ VNSNY CHOICE
Medicare ⹦᪉㞟㐍⾜౛እ⹦⌮ࠖ❶⠇㸪 ⋓ᚓ㜝᪊ዴఱせồ౛እ⹦⌮ⓗ㈨イࠋ
ᡂ⸩ (OTC) ᫝⏒㯟㸽
OTC ⸩ရ᫝ Medicare ⹦᪉⸩ရィ␓୍⯡୙⤥௜ⓗ㠀⹦᪉⸩ࠋVNSNY CHOICE Medicare
⤥௜≉ᐃⓗ OTC ⸩ရࠋ
⤥௜ⓗ㠀⹦᪉⸩ (OTC)
⸩ရ
Ꮵྡ
㮴㓟す᭰฼▒ (cetirizine
hydrochloride)
㮴㓟す᭰฼▒ (cetirizine
hydrochloride)/
ഇ㯞㯣ሞ㮴㓟㮴
(pseudoephedrine
hydrochloride)
㯗㞾௚ᐃ (loratadine)
㯗㞾௚ᐃ (loratadine)/
ഇ㯞㯣ሞ◲㓟㮴
(pseudoephedrine sulfate)
ᐩ㤿㓟愖᭰ⰷ (ketotifen
fumarate)
(ࠕཨ⪃ᑙ฼⸩ࠖ)
ກ㔞⾲
(Zyrtec)
ᄮ㘄ࠊ⸩Ỉࠊ⸩㘄
(Zyrtec-D)
12 ᑠ᫬⸩㘄
(Claritin)
⸩Ỉࠊ⸩㘄
(Claritin-D)
12 ᑠ᫬⸩㘄
24 ᑠ᫬⸩㘄
(Zaditor)
⁲ກ
VNSNY CHOICE Medicare ᑘච㈝ྥᝍᥦ౪㏺ல OTC ⸩ရࠋ VNSNY CHOICE Medicare
ᡤᨭ௜ⓗ㏺ல OTC ⸩ရᡂᮏ୪୙᭳ィධᝍⓗ Part D ⸩ရ⦻ᡂᮏ㸦஼༶ᝍᨭ௜ⓗ㔠㢠୪
ᮍィධ⤥௜⠊ᅩ⨃ཱྀࠋ
36
ዴᯝᡃⓗ⸩ရ୙ᅾ⹦᪉㞟ℏ㸪ᛠ㯟㎨㸽
ዴᯝᝍⓗ⸩ရ୪୙ᅾ⹦᪉㞟㸦⤥௜⸩ရΎႝ㸧ℏ㸪ᝍ᠕ヱඛ⫃⤡᭳ဨ᭹ົ㒊㸪ュၥᝍⓗ
⸩ရ᫝ྰ⤥௜ࠋ
ዴᯝᝍᚓ▱ VNSNY CHOICE Medicare ୪ᮍ⤥௜ᝍⓗ⸩ရ㸪ᝍ᭷஧✀㑅᧪㸸
ᝍྍ௨せồ᭳ဨ᭹ົ㒊ᥦ౪ VNSNY CHOICE Medicare ⤥௜ⓗ㢮ఝ⸩ရΎႝࠋᅾᨲ฿Ύ
ႝ᫬㸪ฟ♧⤥ᝍⓗ㓾⏕㸪୪せồ㛤 VNSNY CHOICE Medicare ⤥௜ⓗ㢮ఝ⸩ရ⹦᪉ࠋ
ᝍྍ௨せồ VNSNY CHOICE Medicare 㐍⾜౛እ⹦⌮௨⤥௜ᝍⓗ⸩ရࠋㄳཨ教௨ୗዴ
ఱせồ౛እ⹦⌮ⓗ㈨イࠋ
ᡃせዴఱせồ VNSNY CHOICE Medicare ⹦᪉㞟ⓗ౛እ⹦⌮凱
ᝍྍ௨せồ VNSNY CHOICE Medicare 㔪ᑞᡃ಼ⓗ⤥௜つ๎㐍⾜౛እ⹦⌮ࠋᝍྍ௨せồ
ᡃ಼㐍⾜౛እ⹦⌮ⓗ㢮ᆺ᭷チከ✀ࠋ
•
༶౑୙ᅾᡃ಼ⓗ⹦᪉㞟ℏ㸪ᝍ㑏᫝ྍ௨せồᡃ಼⤥௜⸩ရࠋዴᯝ⥂᰾෸㸪
Ṉ⸩ရᑘ౫↷㡸ඛ☜ᐃⓗ㈝⏝ศᨦ➼⣭⤥௜㸪ᝍ୙⬟せồᡃ಼௨㍑పⓗ㈝
⏝ศᨦ➼⣭ᥦ౪⸩ရࠋ
•
ዴᯝヱ⸩ရ୙ᒞ᪊ᑙ㛛ᒙ⣭㸪ᝍྍ௨せồᡃ಼௨㍑పⓗ㈝⏝ศᨦ➼⣭⤥௜Ṉ⹦᪉㞟
⸩ရࠋዴᯝ⥂᰾෸㸪㏺ᑘ᭳㝆పᝍᚲ㡲ᨭ௜ⓗ⸩ရ㔠㢠ࠋ
•
ᝍྍ௨せồᡃ಼ྲྀᾘᑞᝍ⸩ရⓗ⤥௜⠊ᅩ㝈ไࠋ౛ዴ㸪VNSNY CHOICE Medicare
᭳㔪ᑞᡃ಼ᑘ⤥௜ⓗ⸩ရ㸪㝈ไᡃ಼ᑘ⤥௜ⓗ⸩ရ㔠㢠ࠋ ዴᯝᝍⓗ⸩ရ᭷ᩝ㔞㝈
ไ㸪ᝍྍ௨せồᡃ಼ྲྀᾘヱ㝈ไ㸪୪⤥௜㍑㧗ⓗ㔠㢠ࠋ
୍⯡⪋ゝ㸪ྈ᭷␜ィ␓ⓗ⹦᪉㞟ໟྵⓗ᭰௦⸩ရࠊ㈝⏝ศᨦ㍑పⓗ⸩ရᡈ඼௚ⓗ౑⏝㝈
ไᑞᝍⓗ἞⒪᝟ἣ↓ᩀ㸪ᡈ᫝᭳ᑞᝍ㐀ᡂ୙Ⰻⓗ㓾⒪ᙳ㡪᫬㸪VNSNY CHOICE Medicare
ᡯ᭳᰾෸ᝍᑞ౛እ⹦⌮ⓗせồࠋ
ᝍ᠕ヱ⯅ᡃ಼⫃⤡㸪せồᡃ಼㔪ᑞ⹦᪉㞟ࠊศ⣭ᡈ౑⏝㝈ไ౛እ೴ฟึṉⓗ⤥௜Ỵᐃࠋ
37
ᅾᝍせồ⹦᪉㞟ࠊศ⣭ᡈ౑⏝⋡౛እ᫬㸪ᝍ᠕ヱᥦ஺㛤❧⹦᪉⪅ᡈ㓾ᖌᨭᣢᝍせồⓗ⫆
᫂ࠋ ୍⯡᝟ἣୗ㸪ᡃ಼ᚲ㡲ᅾྲྀᚓᝍⓗ㛤❧⹦᪉⪅ᡈ㓾ᖌᨭᣢ⫆ ᫂ⓗ 72 ᑠ᫬ℏ೴ฟỴ
ᐃࠋዴᯝᝍᡈᝍⓗ㓾ᖌㄆⅭᝍⓗ೺ᗣ᝟ἣ᭳ᅉⅭ➼ᚅỴ ᐃ㛗㐩 72 ᑠ᫬⪋ཷ฿ᄫ㔜ⓗയ
ᐖ㸪ᝍྍ௨せồຍ㏿㸦ᛌ㏿㸧ⓗ౛እ⹦⌮ࠋዴᯝᡃ಼᰾෸ᝍせồຍ㏿ⓗせồ㸪ᡃ಼ᚲ㡲
ᅾྲྀᚓᝍⓗ㛤❧⹦᪉⪅ᡈ㓾ᖌᨭᣢ⫆᫂ⓗ 24 ᑠ᫬ℏ೴ฟỴᐃࠋ
ᅾᡃ࿴㓾ᖌウㄽㆰ᭦ᡃⓗ⸩ရᡈせồ౛እ⹦⌮அ๓㸪ᡃせ೴⏒㯟㸽
㌟Ⅽᡃ಼ィ␓ⓗ᪂᭳ဨᡈ⧰⣙᭳ဨ㸪ᝍྍ⬟ṇ᭹⏝ᡃ಼⹦᪉㞟௨እⓗ⸩ရࠋᡈ⪅㸪ᝍ᭹
⏝ⓗ᫝⹦᪉㞟ℏⓗ⸩ရ㸪ణ᫝ᝍྲྀᚓ⸩ရⓗ⬟ຊཷ฿㝈ไࠋ౛ዴ㸪ᝍᅾ౫⹦᪉㡿⸩அ๓,
ྍ⬟㟂せ஦ඛ᰾෸ࠋᝍ᠕ヱ࿴㓾ᖌウㄽ௨Ỵᐃ᫝ྰ᠕ヱษ᥮฿ᡃ಼⤥௜ⓗ㐺␜⸩ရ㸪ᡈ
᫝せồ⹦᪉㞟౛እ㸪௨౽ᡃ಼⤥௜ᝍᡤ᭹⏝ⓗ⸩ရࠋ⯅㓾ᖌウㄽỴᐃ㐺ྜᝍⓗ⾜ື᪉㔪
᫬㸪ᅾ≉ᐃⓗ᝟ἣୗ㸪ᡃ಼ྍ⬟᪊ᝍᡂⅭᡃ಼᭳ဨⓗ๓ 90 ኳ⤥௜ᝍⓗ⸩≀ࠋ
ᑞ᪊ᝍᡤ᭹⏝୙ᅾᡃ಼⹦᪉㞟ℏⓗẗ✀⸩ရ㸪ᡈ᫝ዴᯝᝍྲྀᚓ⸩ရⓗ⬟ຊཷ㝈㸪ᅾᝍ๓
㐃⥙⸩ᒁ᫬㸪ᡃ಼ᑘ⤥௜⮫᫬ⓗ 30 ኳ౪᠕㔞㸦㝖㠀ᝍⓗ⹦᪉㛤❧ⓗ ᫝㍑ᑡⓗኳᩝ㸧
ࠋᅾ๓ 30 ኳ౪᠕㔞அᚋ㸪༶౑ᝍᡂⅭィ␓᭳ဨⓗ᫬㛫୙฿ 90 ኳ㸪ᡃ಼ᑘ୙᭳෌⤥௜㏺
ல⸩ရࠋ
ዴᯝᝍ᫝㛗ᮇ↷ㆤᶵᵓⓗఫẸ㸪ᡃ಼ᑘඔチᝍ෌ḟᣨ⹦᪉㡿⸩㸪㓄ྜ㓄⸩ቔ㔞㸪┤฿ᡃ
಼ᥦ౪ᝍ 91 ኳⓗ㎈᥮౪᠕㔞㸦㝖㠀ᝍⓗ⹦᪉㛤❧ⓗ᫝㍑ᑡⓗኳᩝ㸧ࠋᅾᝍᡂⅭᡃ಼᭳ဨ
ⓗ➨୍ಶ 90 ኳ⿬㸪ᡃ಼ᑘ⤥௜㏺ல⸩ရ୍ḟ௨ୖⓗ⿵඘㔞ࠋ ዴᯝᝍ㟂せᡃ಼⹦᪉㞟௨
እⓗ⸩ရ㸪ᡈ᫝ᝍྲྀᚓ⸩ရⓗ⬟ຊཷ㝈㸪ణ᫝ᝍᡂⅭᡃ಼ィ␓ⓗ᭳ဨᕬ⥂㉸㐣 90 ኳ㸪ᅾ
ᝍせồ⹦᪉㞟౛እ⹦⌮᫬㸪ᡃ಼ᑘᨭ௜ヱ⸩ရⓗ 31 ኳ⥭ᛴ౪᠕㔞㸦㝖㠀ᝍⓗ⹦᪉㛤❧ⓗ
᫝㍑ᑡⓗኳᩝ㸧ࠋ
㚱暨天ᶨ㫉⿏䵲⿍惵喍㚵⊁ㆾ暨天惵朆嗽㕡喍⚈䁢嬟䎮䳂⇍㚜㓡䘬㚫⒉⎗ẍ⼿⇘ᶨ㫉廱
㎃ὃㅱ慷ˤġġġ
38
ዴ㟂᭦ከ㈨イ
ዴ㟂㜝᪊ VNSNY CHOICE Medicare ⹦᪉⸩⤥௜ⓗ᭦ከヲ⣽㈨イ㸪ㄳᷙどᝍⓗࠕಖ㞋⌮
㈺㡯┠婒᫂᭩ࠖ⯅඼௚ィ␓㈨ᩱࠋ
ዴᯝᝍ᭷㜝᪊ VNSNY CHOICE Medicare ⓗၥ㢟㸪ㄳ⯅ᡃ಼⫃⤡ࠋ ᡃ಼ⓗ⫃⤡㈨イ㸪௨
ཬ᭱ᚋ᭦᪂⹦᪉㞟ⓗ᪥ᮇ㸪ฟ⌧᪊ᑒ㠃⯅ᑒᗏ㡫ࠋ
ዴᯝᝍ᭷㜝᪊ Medicare ⹦᪉⸩⤥௜ⓗ୍⯡ၥ㢟㸪ㄳ᧕ᡴ㸸1-800-MEDICARE (1-800-6334227) ⯅ Medicare ⫃⤡㸪Ṉᑙ⥺ 24 ᑠ᫬඲ኳೃᥦ౪᭹ົࠋTTY ౑⏝⪅ㄳ᧕㸸1-877-4862048ࠋᡈ㐀ゼ www.medicare.govࠋ
㏺௷㈨イྠ᫬ᥦ౪඼௚ㄒゝ∧ᮏ㸪᏶඲ච㈝ࠋㄳ᧕ᡴ 1-866-783-1444 ⯅᭳ဨ᭹ົ㒊⫃⤡
௨ྲྀᚓ඼௚㈨イࠋ(TTY ౑⏝⪅᠕᧕ᡴ 711 ච㈝㟁ヰ) ᭹ົ᫬㛫Ⅽ㐌୍฿㐌஬᪩ୖ 8 ᫬⮳
᫽㛫 8 ᫬ࠋ᭳ဨ᭹ົ㒊ஓⅭ㠀ⱥㄒ⣔ ᅧᐙேኈᥦ౪ච㈝ⓗㄒゝཱྀ㆞᭹ົࠋ
VNSNY CHOICE Medicare ᫝ᦚ㓄 Medicare ྜ⣙ⓗ HMO ィ␓ࠋᢞಖ VNSNY CHOICE
Medicare ྲྀỴ᪊⧰⣙ࠋ
39
VNSNY CHOICE Medicare ⓗ⹦᪉㞟
ᚘ➨ 49 㡫㛤ጞⓗ⹦᪉㞟ᥦ౪㜝᪊ VNSNY CHOICE Medicare ⤥௜⸩≀ⓗ┦㜝⤥௜㈨イࠋ
ዴᯝᝍᅾΎႝ୰ᢍ୙฿ᝍⓗ⸩ရ㸪ㄳ⩻฿ᚘ➨ I-1 㡫㛤ጞⓗࠕ⣴ᘬࠖࠋ
ᅯ⾲ⓗ➨୍ḍ᭳ิฟ⸩ရⓗྡ✃ࠋᑙ฼⸩ྡ✃᫝኱ᑃ㸦౛ዴ CELEBREX㸧⪋Ꮵྡ⸩๎᫝
ᑠᑃⓗᩳ㧓Ꮠ㸦౛ዴ naproxen㸧ࠋ
ࠕせồ㸭㝈ไ (Requirements/Limits)ࠖḍⓗ㈨イ婒᫂ VNSNY CHOICE Medicare 㔪ᑞᝍⓗ
⸩ရ⤥௜᫝ྰ᭷௵ఱ≉Ṧⓗせồࠋ
௨ୗⓗ౑⏝⟶⌮⦰ᑃྍ⬟ฟ⌧᪊
ᮏᩥ௳ⓗṇᩥ
ಖ㞋⤥௜ὀព஦㡯⦰ᑃ
⦰ᑃ
婒᫂
ゎ㔚
౑⏝⟶⌮㝈ไ
PA
ᅾᣨṈ⹦᪉㡿ྲྀ⸩ရஅ๓㸪ᝍᡈ (ᝍⓗ㓾⏕) ᚲ㡲ඛᚘ
஦ඛᤵḒ㝈ไ VNSNY CHOICE Medicare ྲྀᚓ஦ඛᤵḒࠋዴᮍ஦ඛ᰾
෸㸪VNSNY CHOICE Medicare ྍ⬟↓ἲ⤥௜Ṉ⸩ရࠋ
PA BvD
Ṉ⸩ရྍ⬟➢ྜ Medicare Part B ᡈ Part D ⓗ⤥௜㈨᱁ࠋ
Part B ⯅ Part ᅾᣨṈ⹦᪉㡿ྲྀ⸩ရஅ๓㸪ᝍ (ᡈᝍⓗ㓾⏕) ᚲ㡲ඛᚘ
D ุᐃⓗ
VNSNY CHOICE Medicare ྲྀᚓ஦ඛᤵḒ㸪௨ุᐃ᫝ྰ
஦ඛᤵḒ㝈ไ ᰿᧸ Medicare Part D ⤥௜Ṉ⸩ရࠋዴᮍ஦ඛ᰾෸㸪
VNSNY CHOICE Medicare ྍ⬟↓ἲ⤥௜Ṉ⸩ရࠋ
40
⦰ᑃ
婒᫂
ゎ㔚
PA-HRM
CMS ㄆⅭṈ⸩ရල᭷₮ᅾⓗയᐖᛶ㸪ᅉṈ᫝ᖺ⁹ 65 荅
அ Medicare ཷ┈ேⓗ㧗㢼㞋⸩≀ࠋᖺ⁹ 65 荅ⓗ᭳ဨᅾ
㧗㢼㞋⸩≀ⓗ
ᣨṈ⹦᪉㡿ྲྀ⸩ရஅ๓㸪ᚲ㡲ඛᚘ VNSNY CHOICE
஦ඛᤵḒ㝈ไ
Medicare ྲྀᚓ஦ඛᤵḒࠋዴᮍ஦ඛ᰾෸㸪VNSNY
CHOICE Medicare ྍ⬟↓ἲ⤥௜Ṉ⸩ရ
PA NSO
ዴᯝᝍ᫝᪂᭳ဨ㸪ᅾᣨṈ⹦᪉㡿ྲྀ⸩ရஅ๓㸪ᝍᡈ (ᝍⓗ
ഹ㝈᪂᭳ဨⓗ 㓾⏕) ᚲ㡲ඛᚘ VNSNY CHOICE Medicare ྲྀᚓ஦ඛᤵḒ
஦ඛᤵḒ㝈ไ ࠋዴᮍ஦ඛ᰾෸㸪VNSNY CHOICE Medicare ྍ⬟↓ἲ
⤥௜Ṉ⸩ရࠋ
QL
ᩝ㔞㝈ไ
VNSNY CHOICE Medicare 㝈ไẗᙇ⹦᪉⡗ᡈ᫝ᅾ≉ᐃ
᫬㛫ℏ⤥௜Ṉ⸩ရⓗᩝ㔞ࠋ
ST
ศ㝵ẁ⒪ἲ㝈
ไ
ᅾ VNSNY CHOICE Medicare ᥦ౪Ṉ⸩ရⓗ⤥௜அ๓㸪
ᝍᚲ㡲ඛაヨ඼௚⸩ရ௨἞⒪ᝍⓗ⑓⑕ࠋዴᯝ඼௚⸩ရ
ᑞᝍἄ᭷ຌᩀ㸪ᡯ᭳⤥௜Ṉ⸩ရࠋ
41
௨ୗⓗ඼௚⤥௜ὀព஦㡯⦰ᑃྍ⬟ฟ⌧᪊
ᮏᩥ௳ⓗṇᩥ
ಖ㞋⤥௜ⓗ඼௚≉Ṧせồ
⦰ᑃ
婒᫂
ゎ㔚
Ṉ⹦᪉ྍ⬟ྈᥦ౪᪊≉ᐃⓗ⸩ᒁࠋዴ㟂᭦ከ㈨イ㸪ㄳ㞍
LA
ྲྀᚓཷ㝈ⓗ⸩ရ
教ᝍⓗࠕᥦ౪⪅ཬ⸩ᡣ┠㗴ࠖᡈ⮴㟁᭳ဨ᭹ົ㒊㸪㟁ヰ
1-866-783-1444㸪㐌୍⮳㐌஬㸪᪩ୖ 8:00 ⮳᫽ୖ 8:00ࠋ
TTY/TDD ౑⏝⪅ㄳ᧕ᡴ 711ࠋ
㏱㐣㒑㉎㸪ᝍྍ⬟௨᭦పⓗศᨦ㈝⏝㡿ྲྀ⹦᪉㞟኱㒊ศ
NM
㠀㒑㉎⸩ရ
⸩ရ 1 ಶ᭶௨ୖⓗ⸩㔞ࠋ↓ἲ㏱㐣㒑㉎⚟฼ᥦ౪ⓗ⸩ရ
㸪ᅾ⹦᪉㞟ⓗࠕせồ/㝈ไ(Requirements/Limits) ḍᶆ♧Ⅽ
"NM"ࠋ
42
ᙉᗘ⯅ກ㔞⾲⦰ᑃ
⦰ᑃ
婒᫂
adh. patch
㈞ᕸ
aer br act
ᄇ㟝ກ㸪㠁྾Ềᘬື
aer pow
ᄇ㟝ກ㸪⢊≪
aer pow ba
ᄇ㟝ກ⢊ᮎ㸪㠁྾Ềᘬື
aer refill
ᄇ㟝⿵඘ກ
aer w/adap
㝃㎈᥋㢌ⓗᄇ㟝ກ
ampul
Ᏻ⏂
blkbaginj
ᩓ⿶⿄ὀᑕ
cap dr mp
⭺ᄷ㸪ከẁᘧ⦆㔚⸩ᩀ
cap ds pk
⭺ᄷ㸪ກ㔞ໟ
cap er 12h
⭺ᄷ㸪12 ᑠ᫬⦆㔚⸩ᩀ
cap er 24h
⭺ᄷ㸪24 ᑠ᫬⦆㔚⸩ᩀ
cap er deg
⭺ᄷ㸪⦆㔚⸩ᩀ㸪ྍ㝆ゎ
cap er pel
⭺ᄷ㸪⦆㔚⸩ᩀ⸩୸
cap mphase
⭺ᄷ㸪ከẁᘧ
cap.sa 24h
⭺ᄷ㸪24 ᑠ᫬ᣢ⧰⸩ᩀ
cap.sr 12h
⭺ᄷ㸪12 ᑠ᫬ᣢ⧰ᛶ⸩ᩀ
cap.sr 24h
⭺ᄷ㸪24 ᑠ᫬ᣢ⧰ᛶ⸩ᩀ
cap24h pct
⭺ᄷ㸪24 ᑠ᫬᥍ไⓐస⸩୸
cap24h pel
⭺ᄷ㸪24 ᑠ᫬ᣢ⧰ᛶ⸩ᩀ⸩୸
cap sprink
⭺ᄷ㸪ศᩓᆺ
cap sr pel
⭺ᄷ㸪⦆㔚⸩ᩀ⸩୸
cap w/dev
㝃⿶⨨ⓗ⭺ᄷ
capsule dr
⭺ᄷ㸪⦆㔚⸩ᩀ
capsule er
⭺ᄷ㸪⦆㔚⸩ᩀ
capsule sa
⭺ᄷ㸪㛗ᩀ
cmb cappad
ᩚྜ㸸⭺ᄷ㸪ቈ
cmb ont fm
ᩚྜ㸸⸩⭯㸪Ἳἓᆺ
cmb ont lt
ᩚྜ㸸⸩⭯㸪ஙᾮᆺ
43
⦰ᑃ
婒᫂
cmb tabpad
ᩚྜ㸸⸩㘄㸪ቈ
combo. pkg
ᩚྜໟ⿶
cpmp 12hr
⭺ᄷ㸪12 ᑠ᫬ከẁᘧ
cpmp 24hr
⭺ᄷ㸪24 ᑠ᫬ከẁᘧ
cpmp 30-70
⭺ᄷ㸪ከẁᘧ㸪30%-70%
cpmp 50-50
⭺ᄷ㸪ከẁᘧ㸪50%-50%
cream(g), cream(gm)
ங㟖 (බඞ)
cream(ml)
ங㟖 (ấ⡿)
cream/appl
㝃ሬ᢯ჾⓗங㟖
cream, er (g)
ங㟖㸪㛗ᩀᆺ (බඞ)
cream pack
ங㟖㸪ໟ⿶
dehp fr bg
dis needle
୙ྵ㒲Ɽ஧⏥㓟஧(2-எᇶᕫᇶ)愗 (di(2ethylhexyl)phthalate) ⓗ⿄Ꮚ
㉳Რᘧ㔪㢌
disp syrin
㝃྾ධᘧ⿶⨨ⓗᅭ┙
㉳Რᘧ㔪⟄
drops susp
⁲ກ㸪ᠱᾋ
drps hpvis
⁲ກ㸪㉸㯫ᛶ
emul adhes
ங໬ກ㯫⭺
emul packt
ங໬ກໟ
emulsn(g)
ங໬ກ (බඞ)
foam/appl.
㝃ሬ᢯ჾⓗἻἓ
froz.piggy
෦ᩜ⫼ᖔ
g
බඞ
gel/pf app
㝃㡸඘ሸሬ᢯ჾⓗจ⭺
gel (gm)
จ⭺ (බඞ)
gel (ml)
จ⭺ (ấ⡿)
gel md pmp
᭷้ᗘກ㔞ᖳᾆⓗจ⭺
gel w/appl
㝃ሬ᢯ჾⓗจ⭺
gel w/pump
㝃ᖳᾆⓗจ⭺
disk w/dev
44
⦰ᑃ
婒᫂
gran pack
㢛⢏ໟ
hfa aer ad
hfa ᄇ㟝ກ㎈᥋㢌
infus. btl
㍺ᾮ⎼
insuln pen
ip soln
⬓ᓥ⣲➹
⭡⭷ℏ⁐ᾮ
irrig soln
℺ὀ⁐ᾮ
iv soln.
㟿⬦⁐ᾮ
jel
⭺≪≀
jelly/app
㝃ሬ᢯ჾⓗ⭺≪≀
jel/pf app
㝃㡸඘ሸሬ᢯ჾⓗ⭺≪≀
kit cl&crm
⤌௳㸸Ύ₩ກ⯅ங㟖
kt crm le
⤌௳㸸ங㟖ࠊஙᾮ₶⭵ກ
kt lotn ce
⤌௳㸸ஙᾮࠊங㟖₶⭵ກ
kt oint le
⤌௳㸸⸩⭯㸪ஙᾮ₶⭵ກ
lotion, er
ஙᾮ㸪⦆㔚⸩ᩀ
lozenge hd
⳻ᙧᥱᢕ
m.ht patch
ྵ⸩≀ⓗ⇕ᩜ㈞∦
ma buc tab
㯫⭷྾㝃ᛶཱྀ㢏㘄
mcg
ᚤඞ
med. pad
ྵ⸩ቈ
med. swab
ྵ⸩ᲤⰼᲬ
med. tape
ྵ⸩⭺ᖔ
mg
ấඞ
ml
ấ⡿
muc er 12h
㯫⭷྾㝃ᛶ⣔⤫㸪12 ᑠ᫬⦆㔚⸩ᩀ
ndl fr inj
ὀᑕ㔪
nl fm susp
ᣦ⏥⭷ᠱᾋᾮ
oint. (g), oint.(gm)
⸩⭯ (බඞ)
oral conc
ཱྀ᭹⃰⦰ກ
oral susp
ཱྀ᭹ᠱᾋກ
45
⦰ᑃ
婒᫂
paste (g)
⭯ (බඞ)
patch td24
㈞ᕸ㸪24 ᑠ᫬⥂⓶⭵
patch td72
㈞ᕸ㸪72 ᑠ᫬⥂⓶⭵
patch tdsw
㈞ᕸ㸪㞬㐌⥂⓶⭵
patch tdwk
㈞ᕸ㸪ẗ㐌⥂⓶⭵
pca syring
⏤⑓ᝈ᥍ไⓗṆ③㔪⟄
pca vial
⏤⑓ᝈ᥍ไⓗṆ③ᑠ⎼
pellet(ea)
⸩୸ (ẗ㢛)
pen ij kit
➹ᆺὀᑕჾ⤌௳
pen injctr
➹ᆺὀᑕჾ
pggybk btl
⫪⫼⎼
plast. bag
ረ⭺⿄
powd pack
⢊ᮎໟ
sol md pmp
㝃ከກᖳᾆⓗ⁐ᾮ
sol w/appl
㝃ሬ᢯ჾⓗ⁐ᾮ
sol/pf app
㝃㡸඘ሸሬ᢯ჾⓗ⁐ᾮ
sol-gel
⁐ᾮ㸪จ⭺≪
soln recon
⁐ᾮ㸪㔜⤌ⓗ
soln(gram)
⁐ᾮ (බඞ)
spray susp
ᄇ㟝㸪ᠱᾋᾮ
spray/pump
㝃ᖳᾆⓗᄇ㟝
stick(ea)
ᲄ≪ (ẗ᰿)
supp.rect
ᰦກ㸪⫠㛛
supp.vag
ᰦກ㸪㝜㐨
suppos.
ᰦກ
sus er 24h
ᠱᾋᾮ㸪24 ᑠ᫬⦆㔚⸩ᩀ
sus er rec
ᠱᾋᾮ㸪⦆㔚⸩ᩀ㔜⤌
sus mc rec
ᠱᾋᾮ㸪㔜⤌ⓗᚤ⭺ᄷ
suspdr pkt
ᠱᾋᾮ㸪⦆㔚⸩ᩀໟ
susp recon
ᠱᾋᾮ㸪㔜⤌ⓗ
46
⦰ᑃ
婒᫂
syringekit
㔪⟄⤌௳
tab chew
⸩㘄㸪ྍᄮ
tab er 12h
⸩㘄㸪12 ᑠ᫬⦆㔚⸩ᩀ
tab er 24h
⸩㘄㸪24 ᑠ᫬⦆㔚⸩ᩀ
tab er prt
⸩㘄㸪⦆㔚⸩ᩀ⢏Ꮚ
tab er seq
⸩㘄㸪⦆㔚⸩ᩀ
tab disper
⸩㘄㸪ྍศᩓ
tab ds pk
⸩㘄㸪ກ㔞ໟ
tab er 24
⸩㘄㸪24 ᑠ᫬⦆㔚⸩ᩀ
tab mphase
⸩㘄㸪ከẁᘧ
tab part
⸩㘄㸪⢏Ꮚ
tab rap dr
⸩㘄㸪ᛌ㏿ᔂゎ⦆㔚⸩ᩀ
tab rapdis
⸩㘄㸪ᛌ㏿ᔂゎ
tab subl
⸩㘄㸪⯉ୗ
tab.sr 12h
⸩㘄㸪12 ᑠ᫬ᣢ⧰ᛶ⸩ᩀ
tab.sr 24h
⸩㘄㸪24 ᑠ᫬ᣢ⧰ᛶ⸩ᩀ
tabergr24hr
⸩㘄㸪24 ᑠ᫬₞㐍⦆㔚⸩ᩀ
tablet dr
⸩㘄㸪⦆㔚⸩ᩀ
tablet, er
⸩㘄㸪⦆㔚⸩ᩀ
tablet eff
⸩㘄㸪ⓐἻກ
tablet sa
⸩㘄㸪㛗ᩀ
tablet sol
⸩㘄㸪ྍ⁐ゎ
tb er dspk
⸩㘄㸪⦆㔚ກ㔞ໟ
tb mp dspk
⸩㘄㸪ከẁᘧກ㔞ໟ
tb rd dspk
⸩㘄㸪ᛌ㏿ᔂゎກ㔞ໟ
tbdspk 3mo
⸩㘄㸪3 ಶ᭶ກ㔞ໟ
tbmp 12hr
⸩㘄㸪12 ᑠ᫬ከẁᘧ
tbmp 24hr
⸩㘄㸪24 ᑠ᫬ከẁᘧ
u
ႝ఩
vag ring
㝜㐨⎔
47
48
Drug Name
Drug Tier Requirements/Limits
Analgesics
Analgesics, Miscellaneous
acetaminophen-codeine oral solution
(Acetaminophen with
Codeine)
acetaminophen-codeine oral tablet 300-15 (Tylenol-Codeine No.3)
mg, 300-30 mg
acetaminophen-codeine oral tablet 300-60 (Tylenol-Codeine No.3)
mg
(Buprenorphine HCl)
buprenorphine hcl injection
(Esgic)
butalb-acetaminophen-caffeine oral
capsule 50-325-40 mg
(Fioricet with Codeine)
butalbital-acetaminop-caf-cod
1
QL (2700 per 30 days)
1
QL (360 per 30 days)
1
QL (180 per 30 days)
1
1
1
butalbital-acetaminophen
(Tencon)
1
butalbital-acetaminophen-caff oral tablet
50-325-40 mg
butalbital-aspirin-caffeine oral capsule
(Esgic)
1
(Fiorinal)
1
BUTRANS
codeine sulfate oral tablet
codeine-butalbital-asa-caffein oral
capsule 30-50-325-40 mg
EMBEDA ORAL CAPSULE,ORAL
ONLY,EXT.REL PELL
fentanyl
fentanyl citrate
(Codeine Sulfate)
(Fiorinal with Codeine
#3)
1
1
1
1
(Duragesic)
(Actiq)
1
1
hydrocodone-acetaminophen oral solution (Hycet)
(Norco)
hydrocodone-acetaminophen oral tablet
10-300 mg, 5-300 mg, 7.5-300 mg
1
1
(Norco)
1
(Ibudone)
(Hydromorphone
HCl/PF)
1
1
hydrocodone-acetaminophen oral tablet
10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325
mg
hydrocodone-ibuprofen
hydromorphone (pf) injection solution 10
mg/ml
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 (4 per 28 days)
QL (180 per 30 days)
PA-HRM; QL (180 per
30 days)
QL (60 per 30 days)
PA; QL (10 per 30 days)
PA; QL (120 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)
You can find information on what the symbols and abbreviations in this table mean by going
to the introduction pages of this document
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
49
Effective: January 01, 2016
Drug Name
hydromorphone (pf) injection solution 4
mg/ml
hydromorphone injection solution
hydromorphone injection syringe 2 mg/ml
hydromorphone oral liquid
hydromorphone oral tablet 2 mg, 4 mg
hydromorphone oral tablet 8 mg
LAZANDA
methadone hcl oral tablet,soluble 40 mg
methadone injection
methadone oral
methadone oral
morphine concentrate oral solution
morphine concentrate oral syringe
morphine injection solution 10 mg/ml, 15
mg/ml, 8 mg/ml
morphine injection syringe
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
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, 5-325 mg, 7.5-325
mg
oxycodone hcl-aspirin
oxycodone oral concentrate
Drug Tier Requirements/Limits
(Dilaudid)
1
(Hydromorphone HCl)
(Hydromorphone HCl)
(Dilaudid)
(Dilaudid)
(Dilaudid)
(Diskets)
(Methadone HCl)
(Methadone HCl)
(Diskets)
(Morphine Sulfate)
(Morphine Sulfate)
(Morphine Sulfate)
1
1
1
1
1
1
1
1
1
1
1
1
1
(Morphine Sulfate)
(Morphine Sulfate)
(Morphine Sulfate)
(Morphine Sulfate)
1
1
1
1
(Morphine Sulfate)
(Morphine Sulfate)
(Morphine Sulfate)
(MS Contin)
1
1
1
1
1
QL (700 per 30 days)
QL (300 per 30 days)
QL (180 per 30 days)
QL (120 per 30 days)
(MS Contin)
1
QL (180 per 30 days)
(Morphine Sulfate)
1
1
1
1
QL (181 per 30 days)
QL (60 per 30 days)
QL (1800 per 30 days)
1
QL (360 per 30 days)
1
1
QL (360 per 30 days)
QL (180 per 30 days)
(Oxycodone
HCl/Acetaminophen)
(Xolox)
(Percodan)
(Oxycodone HCl)
QL (1200 per 30 days)
QL (180 per 30 days)
QL (240 per 30 days)
PA; QL (30 per 30 days)
QL (90 per 30 days)
QL (1800 per 30 days)
QL (360 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
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
50
Effective: January 01, 2016
Drug Name
oxycodone oral solution
oxycodone oral tablet
oxycodone-acetaminophen oral tablet 10325 mg, 2.5-325 mg, 5-325 mg, 7.5-325
mg
oxycodone-acetaminophen oral tablet 10650 mg
oxycodone-acetaminophen oral tablet 7.5500 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
tramadol oral tablet
tramadol-acetaminophen
XARTEMIS XR
xylon 10
Drug Tier Requirements/Limits
(Oxycodone HCl)
(Roxicodone)
(Xolox)
1
1
1
QL (1300 per 30 days)
QL (180 per 30 days)
QL (360 per 30 days)
(Xolox)
1
QL (180 per 30 days)
(Xolox)
1
QL (240 per 30 days)
(Percodan)
1
1
QL (360 per 30 days)
QL (60 per 30 days)
1
QL (120 per 30 days)
(Opana)
(Opana ER)
1
1
QL (180 per 30 days)
QL (60 per 30 days)
(Opana ER)
1
QL (120 per 30 days)
(Ultram)
(Ultracet)
1
1
1
1
QL (240 per 30 days)
QL (240 per 30 days)
QL (360 per 30 days)
QL (150 per 30 days)
(Ibudone)
Nonsteroidal Anti-Inflammatory Agents
CALDOLOR INTRAVENOUS RECON
SOLN
celecoxib
choline,magnesium salicylate
diclofenac potassium
diclofenac sodium oral tablet extended
release 24 hr
diclofenac sodium oral tablet,delayed
release (dr/ec)
diclofenac sodium topical gel
diclofenac-misoprostol
diflunisal
etodolac
1
(Celebrex)
(Choline Sal/Mag
Salicylate)
(Diclofenac Potassium)
(Voltaren-XR)
1
1
1
1
(Diclofenac Sodium)
1
(Solaraze)
(Arthrotec 50)
(Diflunisal)
(Etodolac)
1
1
1
1
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
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
51
Effective: January 01, 2016
Drug Name
Drug Tier Requirements/Limits
fenoprofen oral tablet
FLECTOR
flurbiprofen
ibuprofen oral
ibuprofen oral tablet 400 mg, 600 mg, 800
mg
indomethacin oral capsule 25 mg
(Fenoprofen Calcium)
(Flurbiprofen)
(Ibuprofen)
(Ibuprofen)
1
1
1
1
1
(Indomethacin)
1
indomethacin oral capsule 50 mg
(Indomethacin)
1
indomethacin oral capsule, extended
release
indomethacin sodium
ketoprofen oral capsule
ketoprofen oral capsule,ext rel. pellets 24
hr 200 mg
ketorolac injection cartridge 15 mg/ml
(Indomethacin)
1
(Indomethacin Sodium)
(Ketoprofen)
(Ketoprofen)
1
1
1
(Ketorolac
Tromethamine)
(Ketorolac
Tromethamine)
(Ketorolac
Tromethamine)
(Ketorolac
Tromethamine)
(Ketorolac
Tromethamine)
(Ketorolac
Tromethamine)
(Ponstel)
(Mobic)
(Mobic)
(Nabumetone)
(Naprosyn)
(Naprosyn)
(Ec-Naprosyn)
1
QL (40 per 30 days)
1
QL (20 per 30 days)
1
QL (40 per 30 days)
1
QL (20 per 30 days)
1
QL (20 per 30 days)
1
QL (20 per 30 days)
1
1
1
1
1
1
1
(Anaprox)
1
(Feldene)
1
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 oral suspension
meloxicam oral tablet
nabumetone
naproxen oral suspension
naproxen oral tablet
naproxen oral tablet,delayed release
(dr/ec)
naproxen sodium oral tablet 275 mg, 550
mg
piroxicam
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
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
52
Effective: January 01, 2016
Drug Name
salsalate
sulindac oral
tolmetin
VOLTAREN TOPICAL
Drug Tier Requirements/Limits
(Salsalate)
(Sulindac)
(Tolmetin Sodium)
1
1
1
1
glydo
lidocaine (pf) injection solution
(Lidocaine HCl)
(Xylocaine-MPF)
1
1
lidocaine (pf) intravenous syringe 100
mg/5 ml (2 %)
lidocaine hcl injection solution
(Lidocaine HCl/PF)
1
(Xylocaine)
1
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
lidocaine topical ointment
(Xylocaine)
(Lidocaine HCl)
(Lidocaine HCl)
1
1
1
(Xylocaine)
(Lidocaine HCl)
(Lidoderm)
1
1
1
(Lidocaine)
1
lidocaine-prilocaine topical
(EMLA)
1
lidocaine-prilocaine topical kit
(Lidocaine/Prilocaine)
1
PA BvD; (PA for ESRD
Only)
PA BvD; (PA for ESRD
Only)
PA BvD
1
1
1
PA; QL (90 per 30 days)
PA; QL (90 per 30 days)
1
1
1
QL (168 per 84 days)
QL (56 per 28 days)
1
1
QL (56 per 28 days)
QL (53 per 28 days)
Anesthetics
Local Anesthetics
PA BvD; (PA for ESRD
Only)
PA BvD; (PA for ESRD
Only)
PA
Anti-Addiction/Substance Abuse Treatment Agents
Anti-Addiction/Substance Abuse Treatment Agents
acamprosate
buprenorphine hcl sublingual
buprenorphine-naloxone
bupropion hcl sr 150 mg tablet f/c
CHANTIX
CHANTIX CONTINUING MONTH
BOX
CHANTIX CONTINUING MONTH PAK
CHANTIX STARTING MONTH BOX
(Acamprosate Calcium)
(Subutex)
(Buprenorphine
HCl/Naloxone HCl)
(Zyban)
You can find information on what the symbols and abbreviations in this table mean by going
to the introduction pages of this document
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
53
Effective: January 01, 2016
Drug Name
disulfiram
naloxone
naltrexone hcl
naltrexone
NICOTROL
ZUBSOLV
Drug Tier Requirements/Limits
(Antabuse)
(Naloxone HCl)
(Revia)
(Revia)
1
1
1
1
1
1
QL (1008 per 90 days)
PA; QL (90 per 30 days)
(Xanax)
(Xanax XR)
1
1
QL (120 per 30 days)
QL (120 per 30 days)
(Xanax XR)
1
QL (90 per 30 days)
(Chlordiazepoxide HCl)
(Klonopin)
(Klonopin)
(Clonazepam)
1
1
1
1
QL (120 per 30 days)
QL (90 per 30 days)
QL (300 per 30 days)
QL (90 per 30 days)
(Clonazepam)
1
QL (300 per 30 days)
(Tranxene T-Tab)
(Tranxene T-Tab)
1
1
QL (120 per 30 days)
QL (60 per 30 days)
(Diazepam)
(Diazepam)
(Diazepam)
(Valium)
(Diastat)
(Estazolam)
1
1
1
1
1
1
QL (10 per 28 days)
QL (1200 per 30 days)
QL (1200 per 30 days)
QL (120 per 30 days)
Antianxiety Agents
Benzodiazepines
alprazolam oral tablet
alprazolam oral tablet extended release 24
hr 0.5 mg, 1 mg, 2 mg
alprazolam oral tablet extended release 24
hr 3 mg
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
diazepam injection
diazepam intensol
diazepam oral solution
diazepam oral tablet
diazepam rectal
estazolam oral tablet 1 mg
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
non-benzodiazepine
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
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
54
Effective: January 01, 2016
Drug Name
Drug Tier Requirements/Limits
estazolam oral tablet 2 mg
(Estazolam)
1
flurazepam oral capsule 15 mg
(Flurazepam HCl)
1
flurazepam oral capsule 30 mg
(Flurazepam HCl)
1
lorazepam oral tablet
midazolam oral syrup 2 mg/ml
temazepam oral capsule 15 mg, 22.5 mg,
30 mg
(Ativan)
(Midazolam HCl)
(Restoril)
1
1
1
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
non-benzodiazepine
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
non-benzodiazepine
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
non-benzodiazepine
hypnotic drug); QL (30
per 30 days)
QL (90 per 30 days)
QL (10 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
non-benzodiazepine
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
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
55
Effective: January 01, 2016
Drug Name
Drug Tier Requirements/Limits
temazepam oral capsule 7.5 mg
(Restoril)
1
triazolam oral tablet 0.125 mg
(Halcion)
1
triazolam oral tablet 0.25 mg
(Halcion)
1
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
non-benzodiazepine
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
non-benzodiazepine
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
non-benzodiazepine
hypnotic drug); QL (60
per 30 days)
Antibacterials
Aminoglycosides
BETHKIS
gentamicin in nacl (iso-osm) intravenous
piggyback
gentamicin injection solution
gentamicin sulfate (ped) (pf)
gentamicin sulfate (pf) intravenous
solution
neomycin
streptomycin intramuscular
TOBI PODHALER INHALATION
tobramycin in 0.225 % nacl
(Gentamicin In Nacl,
Iso-Osm)
(Gentamicin Sulfate)
(Gentamicin Sulfate/PF)
(Gentamicin Sulfate/PF)
(Neomycin Sulfate)
(Streptomycin Sulfate)
(Tobi)
1
1
PA BvD
1
1
1
1
1
1
1
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
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
56
Effective: January 01, 2016
Drug Name
tobramycin in 0.9 % nacl
tobramycin sulfate injection solution
Drug Tier Requirements/Limits
(Tobramycin/Sodium
Chloride)
(Tobramycin Sulfate)
1
(Bacitracin)
(Chloramphenicol Sod
Succ)
(Cleocin HCl)
(Cleocin Phosphate In
D5w)
(Cleocin Palmitate)
(Cleocin Phosphate)
(Cleocin Phosphate)
1
1
1
Antibacterials, Miscellaneous
bacitracin intramuscular
chloramphenicol sod succinate
clindamycin hcl
clindamycin in 5 % dextrose
clindamycin palmitate hcl
clindamycin phosphate injection
clindamycin phosphate intravenous
solution
colistin (colistimethate na)
CUBICIN
linezolid
methenamine hippurate
methenamine mandelate
metronidazole in nacl (iso-os)
metronidazole oral
nitrofurantoin macrocrystal oral capsule
100 mg
nitrofurantoin macrocrystal oral capsule
(Coly-Mycin M
Parenteral)
1
1
1
1
1
1
1
1
1
1
(Zyvox)
(Hiprex)
(Methenamine
Mandelate)
(Metronidazole/Sodium
Chloride)
(Flagyl)
(Macrodantin/Macrobid)
1
1
(Macrodantin/Macrobid)
1
1
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)
You can find information on what the symbols and abbreviations in this table mean by going
to the introduction pages of this document
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
57
Effective: January 01, 2016
Drug Name
nitrofurantoin monohyd/m-cryst
Drug Tier Requirements/Limits
(Macrobid)
(Polymyxin B Sulfate)
polymyxin b sulfate
SYNERCID
(Trimethoprim)
trimethoprim
vancomycin in d5w intravenous piggyback (Vancomycin
HCl/D5W)
vancomycin intravenous recon soln 1,000 (Vancomycin HCl)
mg, 10 gram, 750 mg
(Vancomycin
vancomycin intravenous recon soln 500
HCl/D5W)
mg
(Vancocin HCl)
vancomycin oral capsule
XIFAXAN ORAL TABLET 200 MG
ZYVOX ORAL SUSPENSION FOR
RECONSTITUTION
1
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)
1
1
1
1
1
1
1
1
1
PA; QL (9 per 30 days)
Cephalosporins
cefaclor oral capsule
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, 2 gram/50 ml
cefazolin injection recon soln 1 gram, 10
gram, 100 gram, 300 g, 500 mg
cefdinir
cefditoren pivoxil
cefepime
CEFEPIME IN DEXTROSE 5 %
CEFEPIME IN DEXTROSE,ISO-OSM
INTRAVENOUS PIGGYBACK
(Cefaclor)
(Cefaclor)
1
1
(Cefadroxil)
(Cefadroxil)
1
1
(Cefadroxil)
(Cefazolin
Sodium/Dextrose, Iso)
(Cefazolin Sodium)
1
1
(Cefdinir)
(Spectracef)
(Maxipime)
1
1
1
1
1
1
You can find information on what the symbols and abbreviations in this table mean by going
to the introduction pages of this document
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
58
Effective: January 01, 2016
Drug Name
cefotaxime
cefoxitin
cefoxitin in dextrose, iso-osm intravenous
piggyback 2 gram/50 ml
cefpodoxime
cefprozil
ceftazidime intravenous recon soln 1
gram, 2 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 (ISO-OSM)
SUPRAX ORAL SUSPENSION FOR
RECONSTITUTION 500 MG/5 ML
SUPRAX ORAL TABLET,CHEWABLE
TEFLARO
Drug Tier Requirements/Limits
(Claforan)
(Cefoxitin Sodium)
(Cefoxitin
Sodium/Dextrose, Iso)
(Cefpodoxime Proxetil)
(Cefprozil)
(Ceftazidime)
(Cedax)
(Ceftriaxone
Na/Dextrose, Iso)
1
1
1
1
1
1
1
1
1
(Rocephin)
(Ceftriaxone
Na/Dextrose, Iso)
1
1
1
(Ceftin)
(Zinacef)
1
1
(Zinacef)
(Cefuroxime
Sodium/Dextrose, Iso)
(Keflex)
(Cephalexin)
1
1
(Cephalexin)
1
1
1
1
1
1
1
Macrolides
azithromycin
clarithromycin oral suspension for
reconstitution
clarithromycin oral tablet
(Zithromax)
(Biaxin)
1
1
(Biaxin)
1
You can find information on what the symbols and abbreviations in this table mean by going
to the introduction pages of this document
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
59
Effective: January 01, 2016
Drug Name
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
erythromycin ethylsuccinate oral tablet
erythromycin oral capsule,delayed
release(dr/ec)
erythromycin oral tablet
erythromycin stearate oral tablet 250 mg
Drug Tier Requirements/Limits
(Clarithromycin)
1
(Erythromycin Base)
1
1
1
QL (20 per 10 days)
1
(Eryped 200)
1
(Erythromycin
Ethylsuccinate)
(Erythromycin Base)
1
1
(Erythromycin Base)
(Erythromycin Stearate)
1
1
Miscellaneous B-Lactam Antibiotics
aztreonam injection recon soln 1 gram
CAYSTON
imipenem-cilastatin
INVANZ
meropenem
(Azactam)
(Merrem)
1
1
1
1
1
(Amoxicillin)
(Amoxicillin)
1
1
(Amoxicillin)
(Amoxicillin)
1
1
(Augmentin)
1
(Augmentin)
(Augmentin XR)
1
1
(Amoxicillin/Potassium
Clav)
(Ampicillin Trihydrate)
(Ampicillin Sodium)
1
(Primaxin)
LA
Penicillins
amoxicillin oral capsule
amoxicillin oral suspension for
reconstitution
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
1
1
You can find information on what the symbols and abbreviations in this table mean by going
to the introduction pages of this document
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
60
Effective: January 01, 2016
Drug Name
ampicillin sodium intravenous recon soln
ampicillin-sulbactam injection recon soln
ampicillin-sulbactam intravenous
BICILLIN C-R
BICILLIN L-A
dicloxacillin
nafcillin injection
nafcillin intravenous recon soln
oxacillin in dextrose(iso-osm)
Drug Tier Requirements/Limits
(Ampicillin Sodium)
(Unasyn)
(Unasyn)
(Dicloxacillin Sodium)
(Nafcillin Sodium)
(Nafcillin Sodium)
(Oxacillin
Sodium/Dextrose, Iso)
(Oxacillin Sodium)
oxacillin injection recon soln 10 gram
(Oxacillin Sodium)
oxacillin intravenous
(Pen G Pot/Dextrosepenicillin g pot in dextrose
Water)
(Penicillin G Potassium)
penicillin g potassium
(Penicillin G Procaine)
penicillin g procaine
(Penicillin V Potassium)
penicillin v potassium
piperacillin-tazobactam intravenous recon (Zosyn)
soln
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Quinolones
ciprofloxacin
ciprofloxacin hcl oral
ciprofloxacin in 5 % dextrose
ciprofloxacin lactate
levofloxacin in d5w intravenous piggyback
levofloxacin intravenous
levofloxacin oral solution
levofloxacin oral tablet
moxifloxacin
ofloxacin oral tablet 400 mg
(Cipro)
(Cipro)
(Cipro I.V.)
(Ciprofloxacin Lactate)
(Levaquin)
(Levofloxacin)
(Levaquin)
(Levaquin)
(Avelox)
(Ofloxacin)
1
1
1
1
1
1
1
1
1
1
(Sulfadiazine)
(Sulfamethoxazole/Trim
ethoprim)
(Sulfamethoxazole/Trim
ethoprim)
(Bactrim)
(Azulfidine)
1
1
Sulfonamides
sulfadiazine oral
sulfamethoxazole-trimethoprim
intravenous
sulfamethoxazole-trimethoprim oral
suspension
sulfamethoxazole-trimethoprim oral tablet
sulfasalazine
1
1
1
You can find information on what the symbols and abbreviations in this table mean by going
to the introduction pages of this document
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
61
Effective: January 01, 2016
Drug Name
sulfatrim
sulfazine
sulfazine ec
Drug Tier Requirements/Limits
(Sulfamethoxazole/Trim
ethoprim)
(Azulfidine)
(Azulfidine)
1
1
1
(Morgidox)
(Doryx)
(Doxycycline Hyclate)
(Adoxa)
(Morgidox)
(Avidoxy)
1
1
1
1
1
1
(Doryx)
(Adoxa)
(Vibramycin)
1
1
1
(Avidoxy)
1
1
1
1
1
1
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
MINOCIN INTRAVENOUS
minocycline oral capsule
minocycline oral tablet
tetracycline
TYGACIL
(Minocin)
(Minocycline HCl)
(Tetracycline HCl)
Anticancer Agents
Anticancer Agents
ABRAXANE
ADCETRIS
1
1
AFINITOR DISPERZ
1
AFINITOR ORAL TABLET 10 MG
1
AFINITOR ORAL TABLET 2.5 MG, 5
MG, 7.5 MG
ALIMTA INTRAVENOUS RECON
SOLN
(Arimidex)
anastrozole
AVASTIN INTRAVENOUS SOLUTION
25 MG/ML
1
PA NSO; QL (4 per 21
days)
PA NSO; QL (112 per 28
days)
PA NSO; QL (56 per 28
days)
PA NSO; QL (28 per 28
days)
1
1
1
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
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
62
Effective: January 01, 2016
Drug Name
azacitidine
BELEODAQ
bicalutamide
bleomycin
BLINCYTO
Drug Tier Requirements/Limits
(Vidaza)
(Casodex)
(Bleomycin Sulfate)
1
1
1
1
1
BOSULIF ORAL TABLET 100 MG
1
BOSULIF ORAL TABLET 500 MG
1
CAPRELSA ORAL TABLET 100 MG
1
CAPRELSA ORAL TABLET 300 MG
1
COMETRIQ
1
PA NSO
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
1
cyclophosphamide intravenous recon soln (Cyclophosphamide)
CYCLOPHOSPHAMIDE ORAL
1
CAPSULE
(Cyclophosphamide)
1
PA BvD; ST
cyclophosphamide oral tablet
CYRAMZA INTRAVENOUS
1
PA NSO
SOLUTION 10 MG/ML
(Dactinomycin)
1
dactinomycin
DAUNOXOME
1
(Dacogen)
1
decitabine
1
docetaxel intravenous solution 160 mg/16 (Taxotere)
ml (10 mg/ml), 20 mg/2 ml (final), 80 mg/4
ml (20 mg/ml), 80 mg/8 ml (10 mg/ml)
1
PA BvD
doxorubicin hcl intravenous recon soln 10 (Doxorubicin HCl)
mg
1
PA BvD
doxorubicin hcl peg-liposomal intravenous (Doxil)
suspension 2 mg/ml
(Doxil)
1
PA BvD
doxorubicin, peg-liposomal
DROXIA
1
ELIGARD SUBCUTANEOUS SYRINGE
1
QL (1 per 84 days)
22.5 MG (3 MONTH)
ELIGARD SUBCUTANEOUS SYRINGE
1
QL (1 per 112 days)
30 MG (4 MONTH)
ELIGARD SUBCUTANEOUS SYRINGE
1
QL (1 per 168 days)
45 MG (6 MONTH)
You can find information on what the symbols and abbreviations in this table mean by going
to the introduction pages of this document
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
63
Effective: January 01, 2016
Drug Name
Drug Tier Requirements/Limits
ELIGARD SUBCUTANEOUS SYRINGE
7.5 MG (1 MONTH)
EMCYT
ERIVEDGE
1
ETOPOPHOS
etoposide intravenous
exemestane
FARESTON
FARYDAK
FASLODEX
floxuridine
fluorouracil intravenous solution 2.5
gram/50 ml, 5 gram/100 ml, 500 mg/10 ml
flutamide
GAZYVA
gemcitabine intravenous recon soln 1
gram
GILOTRIF
1
1
1
1
1
1
1
1
1
1
(Etoposide)
(Aromasin)
(Floxuridine)
(Fluorouracil)
(Flutamide)
(Gemzar)
1
1
1
1
GLEEVEC ORAL TABLET 100 MG
1
GLEEVEC ORAL TABLET 400 MG
1
HERCEPTIN
HEXALEN
hydroxyurea
IBRANCE
1
1
1
1
(Hydrea)
ICLUSIG ORAL TABLET 15 MG
1
ICLUSIG ORAL TABLET 45 MG
1
ifosfamide intravenous recon soln
ifosfamide intravenous solution
ifosfamide-mesna
IMBRUVICA
INLYTA ORAL TABLET 1 MG
(Ifex)
(Ifex)
(Ifosfamide/Mesna)
1
1
1
1
1
PA NSO; QL (30 per 30
days)
PA NSO
PA BvD
PA BvD
PA NSO
PA NSO; QL (30 per 30
days)
PA NSO; QL (90 per 30
days)
PA NSO; QL (60 per 30
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
PA BvD
PA NSO
PA NSO; 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
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
64
Effective: January 01, 2016
Drug Name
Drug Tier Requirements/Limits
INLYTA ORAL TABLET 5 MG
1
IXEMPRA
JAKAFI
1
1
KEYTRUDA
KYPROLIS
1
1
LENVIMA
letrozole
LEUKERAN
leuprolide
lomustine
LUPRON DEPOT
LUPRON DEPOT (3 MONTH)
LUPRON DEPOT (4 MONTH)
LUPRON DEPOT (6 MONTH)
LYNPARZA
1
1
1
1
1
1
1
1
1
1
(Femara)
(Leuprolide Acetate)
(Gleostine)
LYSODREN
MARQIBO
1
1
MATULANE
megestrol oral tablet
MEKINIST ORAL TABLET 0.5 MG
1
1
1
(Megestrol Acetate)
MEKINIST ORAL TABLET 2 MG
melphalan hcl intravenous
mercaptopurine
methotrexate sodium (pf) injection recon
soln
methotrexate sodium (pf) injection
solution
methotrexate sodium injection
methotrexate sodium oral
mitoxantrone
NEXAVAR
1
PA NSO; QL (60 per 30
days)
PA NSO; QL (60 per 30
days)
PA NSO
PA NSO; QL (6 per 28
days)
PA NSO
QL (1 per 84 days)
QL (1 per 84 days)
QL (1 per 168 days)
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)
(Alkeran)
(Mercaptopurine)
(Methotrexate
Sodium/PF)
(Methotrexate Sodium)
1
1
1
PA BvD
1
PA BvD
(Methotrexate Sodium)
(Methotrexate Sodium)
(Mitoxantrone HCl)
1
1
1
1
PA BvD
PA BvD; ST
PA NSO; 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
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
65
Effective: January 01, 2016
Drug Name
NILANDRON
ONCASPAR
OPDIVO INTRAVENOUS SOLUTION
40 MG/4 ML
oxaliplatin intravenous solution 100
mg/20 ml
PERJETA
POMALYST
Drug Tier Requirements/Limits
1
1
1
(Eloxatin)
1
1
1
PROLEUKIN
PURIXAN
REVLIMID
RITUXAN
SOLTAMOX
SPRYCEL ORAL TABLET 100 MG, 140
MG, 50 MG, 70 MG, 80 MG
SPRYCEL ORAL TABLET 20 MG
1
1
1
1
1
1
STIVARGA
1
SUTENT
1
SYLVANT
SYNRIBO
1
1
TABLOID
TAFINLAR
1
1
tamoxifen
TARCEVA ORAL TABLET 100 MG, 25
MG
TARCEVA ORAL TABLET 150 MG
PA NSO
PA NSO
1
(Tamoxifen Citrate)
1
1
1
TARGRETIN ORAL
1
TARGRETIN TOPICAL
1
TASIGNA
1
PA NSO
PA NSO; QL (21 per 28
days)
PA NSO; LA
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)
PA NSO; QL (90 per 30
days)
PA NSO; QL (420 per 30
days)
PA NSO; QL (60 per 28
days)
PA NSO; 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
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
66
Effective: January 01, 2016
Drug Name
TEMODAR INTRAVENOUS
teniposide
toposar intravenous
topotecan intravenous
TORISEL
TREANDA
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
VALSTAR
VECTIBIX INTRAVENOUS
SOLUTION
VELCADE
vincristine
vincristine sulfate
vinorelbine intravenous solution
VOTRIENT
Drug Tier Requirements/Limits
(Teniposide)
(Etoposide)
(Hycamtin)
1
1
1
1
1
PA NSO; (vial only)
PA BvD; QL (4 per 28
days)
1
1
QL (1 per 168 days)
1
QL (1 per 84 days)
1
QL (1 per 168 days)
1
(Tretinoin)
(Vincristine Sulfate)
(Vincristine Sulfate)
(Navelbine)
1
1
1
1
1
1
1
1
1
1
(capsule: 10mg)
PA BvD; ST
PA NSO
PA NSO
PA BvD
PA BvD
XALKORI
1
XTANDI
1
YERVOY INTRAVENOUS SOLUTION
ZALTRAP INTRAVENOUS SOLUTION
ZELBORAF
1
1
1
ZOLADEX SUBCUTANEOUS
IMPLANT 10.8 MG
ZOLADEX SUBCUTANEOUS
IMPLANT 3.6 MG
1
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)
1
QL (1 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
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
67
Effective: January 01, 2016
Drug Name
Drug Tier Requirements/Limits
ZOLINZA
ZYDELIG
1
1
ZYKADIA
1
ZYTIGA
1
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 0.1 mg/ml syringe luer-jet syr
atropine injection solution
atropine injection syringe 0.05 mg/ml, 0.1
mg/ml
propantheline
(Atropine Sulfate)
(Atropine Sulfate)
(Atropine Sulfate)
1
1
1
(Propantheline Bromide)
1
(Carbatrol)
1
1
1
(Tegretol)
(Tegretol XR)
1
1
(Carbamazepine)
(Depakote Sprinkle)
(Depakote ER)
1
1
1
1
1
(Depakote)
1
(Zarontin)
(Felbatol)
(Cerebyx)
1
1
1
1
1
1
1
Anticonvulsants
Anticonvulsants
APTIOM
BANZEL
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
divalproex oral capsule, sprinkle
divalproex oral tablet extended release 24
hr
divalproex oral tablet,delayed release
(dr/ec)
ethosuximide
felbamate
fosphenytoin
FYCOMPA
gabapentin oral capsule
gabapentin oral solution
gabapentin oral tablet 600 mg, 800 mg
(Neurontin)
(Neurontin)
(Neurontin)
You can find information on what the symbols and abbreviations in this table mean by going
to the introduction pages of this document
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
68
Effective: January 01, 2016
Drug Name
GABITRIL ORAL TABLET 12 MG, 16
MG
GRALISE
GRALISE 30-DAY STARTER PACK
LAMICTAL ODT STARTER (BLUE)
LAMICTAL ODT STARTER (GREEN)
LAMICTAL ODT STARTER (ORANGE)
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 in nacl (iso-os)
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
Drug Tier Requirements/Limits
1
1
1
1
1
1
1
(Lamictal)
(Lamictal XR)
1
1
(Lamictal)
1
(Lamictal (Blue))
1
(Levetiracetam In Nacl
(Iso-Os))
(Keppra)
(Keppra)
(Keppra)
(Keppra XR)
1
1
1
1
1
(Phenobarbital)
(Phenobarbital)
1
1
1
1
1
1
1
(Phenobarbital)
(Phenobarbital Sodium)
(Dilantin-125)
(Dilantin)
(Phenytoin Sodium)
(Dilantin)
1
1
1
1
1
1
(Trileptal)
ST; QL (90 per 30 days)
ST; QL (78 per 30 days)
QL (90 per 30 days)
QL (900 per 30 days)
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
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
69
Effective: January 01, 2016
Drug Name
POTIGA ORAL TABLET 200 MG, 300
MG, 400 MG
POTIGA ORAL TABLET 50 MG
primidone
SABRIL
TEGRETOL XR ORAL TABLET
EXTENDED RELEASE 12 HR 100 MG
tiagabine
topiramate oral capsule, sprinkle
topiramate oral capsule,sprinkle,er 24hr
topiramate oral tablet
TROKENDI XR
valproate sodium
valproic acid
valproic acid (as sodium salt) oral
solution 250 mg/5 ml
VIMPAT INTRAVENOUS
VIMPAT ORAL SOLUTION
VIMPAT ORAL TABLET
zonisamide
Drug Tier Requirements/Limits
(Mysoline)
(Gabitril)
(Topamax)
(Qudexy XR)
(Topamax)
1
QL (90 per 30 days)
1
1
1
1
QL (270 per 30 days)
(Depacon)
(Depakene)
(Depakene)
1
1
1
1
1
1
1
1
QL (200 per 5 days)
QL (1200 per 30 days)
QL (60 per 30 days)
(Zonegran)
1
1
1
1
(Aricept)
(Donepezil HCl)
(Razadyne ER)
1
1
1
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
(Galantamine Hbr)
(Razadyne)
1
1
1
QL (200 per 30 days)
QL (60 per 30 days)
QL (28 per 28 days)
1
QL (30 per 30 days)
(Exelon)
1
1
QL (60 per 30 days)
(Amitriptyline HCl)
(Amoxapine)
1
1
Antidementia Agents
Antidementia Agents
donepezil oral tablet
donepezil oral tablet,disintegrating
galantamine oral capsule,ext rel. pellets
24 hr
galantamine oral solution
galantamine oral tablet
NAMENDA XR ORAL
CAP,SPRINKLE,ER 24HR DOSE PACK
NAMENDA XR ORAL
CAPSULE,SPRINKLE,ER 24HR
NAMZARIC
rivastigmine tartrate
Antidepressants
Antidepressants
amitriptyline
amoxapine
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
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
70
Effective: January 01, 2016
Drug Name
BRINTELLIX
bupropion hcl oral tablet
bupropion hcl oral tablet extended release
bupropion hcl oral tablet extended release
24 hr
citalopram oral solution
Drug Tier Requirements/Limits
(Wellbutrin)
(Wellbutrin SR)
(Wellbutrin XL)
(Citalopram
Hydrobromide)
(Celexa)
(Anafranil)
(Norpramin)
1
1
1
1
1
1
QL (30 per 30 days)
citalopram oral tablet
1
PA NSO-HRM
clomipramine
1
desipramine oral
DESVENLAFAXINE FUMARATE
1
QL (30 per 30 days)
(Doxepin HCl)
1
PA NSO-HRM
doxepin oral
(Irenka)
1
QL (60 per 30 days)
duloxetine oral capsule,delayed
release(dr/ec) 20 mg, 60 mg
(Irenka)
1
QL (30 per 30 days)
duloxetine oral capsule,delayed
release(dr/ec) 30 mg, 40 mg
EMSAM
1
QL (30 per 30 days)
(Lexapro)
1
escitalopram oxalate
FETZIMA
1
(Prozac)
1
fluoxetine oral capsule
(Prozac Weekly)
1
fluoxetine oral capsule,delayed
release(dr/ec)
(Fluoxetine HCl)
1
fluoxetine oral solution
(Fluoxetine HCl)
1
fluoxetine oral tablet 10 mg, 20 mg
FLUOXETINE ORAL TABLET 60 MG
1
(Fluvoxamine Maleate)
1
fluvoxamine
(Tofranil)
1
PA NSO-HRM
imipramine hcl
(Tofranil-Pm)
1
PA NSO-HRM
imipramine pamoate
(Maprotiline HCl)
1
maprotiline
MARPLAN
1
(Remeron)
1
mirtazapine
(Nefazodone HCl)
1
nefazodone
(Pamelor)
1
nortriptyline oral capsule
(Nortriptyline HCl)
1
nortriptyline oral solution
(Symbyax)
1
olanzapine-fluoxetine
(Paxil)
1
paroxetine hcl oral tablet
1
paroxetine hcl oral tablet extended release (Paxil CR)
24 hr
PAXIL ORAL SUSPENSION
1
You can find information on what the symbols and abbreviations in this table mean by going
to the introduction pages of this document
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
71
Effective: January 01, 2016
Drug Name
perphenazine-amitriptyline
phenelzine
PRISTIQ
protriptyline
sertraline oral concentrate
sertraline oral tablet
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
venlafaxine oral tablet extended release
24hr 225 mg
VIIBRYD
Drug Tier Requirements/Limits
(Perphenazine/Amitripty
line HCl)
(Nardil)
1
(Parnate)
(Trazodone HCl)
(Effexor XR)
1
1
1
1
1
1
1
1
1
1
(Venlafaxine HCl)
(Venlafaxine HCl)
1
1
(Venlafaxine HCl)
1
(Protriptyline HCl)
(Zoloft)
(Zoloft)
PA NSO-HRM
QL (30 per 30 days)
QL (30 per 30 days)
PA NSO-HRM
1
Antidiabetic Agents
Antidiabetic Agents, Miscellaneous
(Precose)
1
QL (90 per 30 days)
acarbose
ACTOPLUS MET XR
1
QL (60 per 30 days)
CYCLOSET
1
QL (180 per 30 days)
GLYSET
1
QL (90 per 30 days)
GLYXAMBI
1
ST; QL (30 per 30 days)
INVOKAMET ORAL TABLET 1501
ST; QL (60 per 30 days)
1,000 MG, 150-500 MG, 50-1,000 MG
INVOKAMET ORAL TABLET 50-500
1
ST; QL (120 per 30
MG
days)
INVOKANA ORAL TABLET 100 MG
1
ST; QL (60 per 30 days)
INVOKANA ORAL TABLET 300 MG
1
ST; QL (30 per 30 days)
JANUMET
1
QL (60 per 30 days)
JANUMET XR ORAL TABLET, ER
1
QL (30 per 30 days)
MULTIPHASE 24 HR 100-1,000 MG, 50500 MG
JANUMET XR ORAL TABLET, ER
1
QL (60 per 30 days)
MULTIPHASE 24 HR 50-1,000 MG
JANUVIA
1
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
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
72
Effective: January 01, 2016
Drug Name
Drug Tier Requirements/Limits
JARDIANCE
JENTADUETO
KAZANO
KORLYM
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
NESINA
OSENI
pioglitazone
pioglitazone-glimepiride
pioglitazone-metformin
PRANDIMET
repaglinide
SYMLINPEN 120
SYMLINPEN 60
TRADJENTA
TRULICITY
VICTOZA
1
1
1
1
(Glucophage)
(Glucophage)
(Glucophage)
(Glucophage XR)
1
1
1
1
ST; QL (30 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
PA; QL (112 per 28
days)
QL (60 per 30 days)
QL (150 per 30 days)
QL (90 per 30 days)
QL (120 per 30 days)
(Glucophage XR)
1
QL (90 per 30 days)
(Fortamet)
1
QL (60 per 30 days)
(Starlix)
1
1
1
1
1
1
1
1
1
1
1
1
1
QL (90 per 30 days)
QL (30 per 30 days)
QL (30 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)
QL (10.8 per 28 days)
QL (6 per 28 days)
QL (30 per 30 days)
ST; QL (4 per 28 days)
ST; QL (9 per 28 days)
1
QL (40 per 28 days)
1
1
1
1
1
1
1
1
QL (40 per 28 days)
QL (30 per 28 days)
QL (40 per 28 days)
QL (40 per 28 days)
QL (40 per 28 days)
QL (40 per 28 days)
QL (30 per 28 days)
QL (40 per 28 days)
(Actos)
(Duetact)
(Actoplus Met)
(Prandin)
Insulins
HUMULIN R U-500
"CONCENTRATED"
LANTUS
LANTUS SOLOSTAR
NOVOLIN 70/30
NOVOLIN N
NOVOLIN R
NOVOLOG
NOVOLOG FLEXPEN
NOVOLOG MIX 70-30
You can find information on what the symbols and abbreviations in this table mean by going
to the introduction pages of this document
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
73
Effective: January 01, 2016
Drug Name
Drug Tier Requirements/Limits
NOVOLOG MIX 70-30 FLEXPEN
NOVOLOG PENFILL
TOUJEO SOLOSTAR
1
1
1
QL (30 per 28 days)
QL (30 per 28 days)
(Amaryl)
(Amaryl)
(Glucotrol)
(Glucotrol)
(Glucotrol XL)
1
1
1
1
1
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
QL (30 per 30 days)
1
QL (240 per 30 days)
glipizide-metformin oral tablet 2.5-500
mg, 5-500 mg
glyburide micronized oral tablet 1.5 mg
(Glipizide/Metformin
HCl)
(Glipizide/Metformin
HCl)
(Glynase)
1
QL (120 per 30 days)
1
glyburide micronized oral tablet 3 mg
(Glynase)
1
glyburide micronized oral tablet 6 mg
(Glynase)
1
glyburide oral tablet 1.25 mg
(Glyburide)
1
glyburide oral tablet 2.5 mg
(Glyburide)
1
glyburide oral tablet 5 mg
(Glyburide)
1
glyburide-metformin oral tablet 1.25-250
mg
glyburide-metformin oral tablet 2.5-500
mg, 5-500 mg
tolazamide oral tablet 250 mg
tolazamide oral tablet 500 mg
tolbutamide
(Glucovance)
1
(Glucovance)
1
(Tolazamide)
(Tolazamide)
(Tolbutamide)
1
1
1
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)
PA-HRM; QL (120 per
30 days)
QL (120 per 30 days)
QL (60 per 30 days)
QL (180 per 30 days)
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 2.5-250 mg
Antifungals
Antifungals
ABELCET
1
PA BvD
AMBISOME
1
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
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
74
Effective: January 01, 2016
Drug Name
amphotericin b
CANCIDAS
ciclopirox topical cream
ciclopirox topical gel
ciclopirox topical shampoo
ciclopirox topical solution
ciclopirox topical suspension
ciclopirox-ure-camph-menth-euc
clotrimazole mucous membrane
clotrimazole topical cream
clotrimazole topical solution
clotrimazole-betamethasone topical cream
clotrimazole-betamethasone topical lotion
Drug Tier Requirements/Limits
(Amphotericin B)
(Ciclodan)
(Loprox)
(Loprox)
(Penlac)
(Ciclopirox Olamine)
(Ciclodan)
(Clotrimazole)
(Clotrimazole)
(Lotrimin)
(Lotrisone)
(Clotrimazole/Betameth
asone Dip)
(Econazole Nitrate)
1
1
1
1
1
1
1
1
1
1
1
1
1
PA BvD
1
econazole topical
EXELDERM
1
(Diflucan)
1
fluconazole
1
fluconazole in dextrose(iso-o) intravenous (Fluconazole In
Nacl,Iso-Osm)
piggyback
1
fluconazole in nacl (iso-osm) intravenous (Fluconazole In
Nacl,Iso-Osm)
piggyback 400 mg/200 ml
(Ancobon)
1
flucytosine
(Grifulvin V)
1
griseofulvin microsize oral tablet
(Sporanox)
1
itraconazole
(Ketoconazole)
1
ketoconazole oral
(Ketoconazole)
1
ketoconazole topical cream
(Nizoral)
1
ketoconazole topical shampoo
(Monistat 3)
1
miconazole nitrate vaginal suppository
200 mg
NOXAFIL
1
NYSTATIN (BULK) POWDER 1
1
BILLION UNIT, 10 BILLION UNIT
(Nystatin)
1
nystatin oral
(Nystatin)
1
nystatin oral
(Nystatin)
1
nystatin topical
(Nystatin/Triamcin)
1
nystatin-triamcinolone
SPORANOX ORAL SOLUTION
1
(Lamisil)
1
terbinafine hcl oral
(Vfend IV)
1
voriconazole intravenous
You can find information on what the symbols and abbreviations in this table mean by going
to the introduction pages of this document
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
75
Effective: January 01, 2016
Drug Name
voriconazole oral
Drug Tier Requirements/Limits
(Vfend)
1
Antihistamines
Antihistamines
carbinoxamine maleate
(Carbinoxamine
Maleate)
(Clemastine Fumarate)
clemastine oral tablet 2.68 mg
(Cyproheptadine HCl)
cyproheptadine
diphenhydramine hcl injection solution 50 (Diphenhydramine HCl)
mg/ml
(Diphenhydramine HCl)
diphenhydramine hcl injection syringe
(Xyzal)
levocetirizine
(Promethazine HCl)
promethazine oral syrup
1
PA-HRM
1
1
1
PA-HRM
PA-HRM
1
1
1
PA-HRM
Anti-Infectives (Skin And Mucous Membrane)
Anti-Infectives (Skin And Mucous Membrane)
AVC VAGINAL
clindamycin phosphate vaginal
metronidazole vaginal
terconazole vaginal cream
terconazole vaginal suppository
(Cleocin)
(Metrogel-Vaginal)
(Terazol 7)
(Terconazole)
1
1
1
1
1
Antimigraine Agents
Antimigraine Agents
(D.H.E.45)
1
QL (30 per 28 days)
dihydroergotamine injection
(Migranal)
1
QL (8 per 28 days)
dihydroergotamine nasal
ERGOMAR
1
QL (40 per 28 days)
(Amerge)
1
QL (18 per 28 days)
naratriptan
(Maxalt)
1
QL (18 per 28 days)
rizatriptan oral tablet
(Maxalt Mlt)
1
QL (18 per 28 days)
rizatriptan oral tablet,disintegrating
(Imitrex)
1
QL (12 per 28 days)
sumatriptan nasal spray
(Imitrex)
1
QL (18 per 28 days)
sumatriptan oral tablet
(Imitrex)
1
QL (4 per 28 days)
sumatriptan succinate subcutaneous
cartridge 6 mg/0.5 ml
(Sumatriptan Succinate)
1
QL (4 per 28 days)
sumatriptan succinate subcutaneous pen
injector 4 mg/0.5 ml
(Imitrex)
1
QL (4 per 28 days)
sumatriptan succinate subcutaneous pen
injector 6 mg/0.5 ml
(Imitrex)
1
QL (4 per 28 days)
sumatriptan succinate subcutaneous
solution
(Zomig)
1
QL (12 per 28 days)
zolmitriptan oral tablet
You can find information on what the symbols and abbreviations in this table mean by going
to the introduction pages of this document
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
76
Effective: January 01, 2016
Drug Name
zolmitriptan oral tablet,disintegrating
Drug Tier Requirements/Limits
(Zomig Zmt)
1
QL (12 per 28 days)
Antimycobacterials
Antimycobacterials
CAPASTAT
dapsone
ethambutol
isoniazid oral solution
isoniazid oral tablet
PASER
PRIFTIN
pyrazinamide
rifabutin
rifampin
rifampin
RIFATER
SIRTURO
(Dapsone)
(Myambutol)
(Isoniazid)
(Isoniazid)
(Pyrazinamide)
(Mycobutin)
(Rifadin)
(Rifadin)
TRECATOR
1
1
1
1
1
1
1
1
1
1
1
1
1
PA; QL (188 per 168
days)
1
Antinausea Agents
Antinausea Agents
(Dimenhydrinate)
1
dimenhydrinate injection solution
(Marinol)
1
dronabinol
EMEND INTRAVENOUS
1
QL (2 per 28 days)
EMEND ORAL
1
PA BvD
(Granisetron HCl/PF)
1
granisetron (pf) intravenous solution
(Granisetron HCl)
1
granisetron hcl intravenous solution 1
mg/ml (1 ml)
(Granisetron HCl)
1
PA BvD
granisetron hcl oral
(Antivert)
1
meclizine oral tablet 12.5 mg, 25 mg
(Zofran Odt)
1
PA BvD
ondansetron
(Ondansetron HCl/PF)
1
ondansetron hcl (pf) injection
(Zofran)
1
PA BvD
ondansetron hcl oral
(Compazine)
1
prochlorperazine
(Prochlorperazine
1
prochlorperazine edisylate injection
Edisylate)
solution
(Compazine)
1
prochlorperazine maleate oral
(Phenergan)
1
PA-HRM
promethazine hcl
(Promethazine HCl)
1
PA-HRM
promethazine oral tablet
You can find information on what the symbols and abbreviations in this table mean by going
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VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
77
Effective: January 01, 2016
Drug Name
promethazine rectal
TRANSDERM-SCOP
Drug Tier Requirements/Limits
(Phenergan)
1
1
PA-HRM
QL (10 per 30 days)
Antiparasite Agents
Antiparasite Agents
ALBENZA
ALINIA
atovaquone
atovaquone-proguanil
chloroquine phosphate oral
COARTEM
DARAPRIM
hydroxychloroquine oral
ivermectin oral
mefloquine
NEBUPENT
paromomycin
PENTAM
PRIMAQUINE
quinine sulfate
(Mepron)
(Malarone)
(Chloroquine Phosphate)
(Plaquenil)
(Stromectol)
(Mefloquine HCl)
(Paromomycin Sulfate)
(Qualaquin)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
PA BvD
QL (90 per 30 days)
PA; QL (42 per 7 days)
Antiparkinsonian Agents
Antiparkinsonian Agents
(Amantadine HCl)
1
amantadine hcl oral
APOKYN
1
QL (60 per 30 days)
AZILECT
1
(Benztropine Mesylate)
1
PA-HRM
benztropine oral
(Parlodel)
1
bromocriptine
(Cabergoline)
1
cabergoline
(Lodosyn)
1
carbidopa
(Sinemet CR)
1
carbidopa-levodopa oral tablet
(Sinemet CR)
1
carbidopa-levodopa oral tablet extended
release
(Stalevo 50)
1
carbidopa-levodopa-entacapone
(Comtan)
1
entacapone
NEUPRO
1
ST; QL (30 per 30 days)
(Mirapex)
1
pramipexole oral tablet
(Requip)
1
ropinirole oral tablet
1
ropinirole oral tablet extended release 24 (Requip XL)
hr
You can find information on what the symbols and abbreviations in this table mean by going
to the introduction pages of this document
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
78
Effective: January 01, 2016
Drug Name
selegiline hcl oral capsule
selegiline hcl oral tablet
trihexyphenidyl
Drug Tier Requirements/Limits
(Eldepryl)
(Selegiline HCl)
(Trihexyphenidyl HCl)
1
1
1
PA-HRM
1
QL (90 per 30 days)
Antipsychotic Agents
Antipsychotic Agents
ABILIFY DISCMELT ORAL
TABLET,DISINTEGRATING 10 MG
ABILIFY MAINTENA
INTRAMUSCULAR
SUSPENSION,EXTENDED REL
RECON
ABILIFY MAINTENA
INTRAMUSCULAR
SUSPENSION,EXTENDED REL
SYRING
aripiprazole oral tablet 10 mg, 15 mg, 20
mg, 30 mg, 5 mg
aripiprazole oral tablet 2 mg
chlorpromazine
clozapine oral tablet 100 mg
clozapine oral tablet 200 mg
clozapine oral tablet 25 mg, 50 mg
clozapine oral tablet,disintegrating
FANAPT ORAL TABLET
FANAPT ORAL TABLETS,DOSE
PACK
fluphenazine decanoate
fluphenazine hcl
GEODON INTRAMUSCULAR
haloperidol
haloperidol decanoate intramuscular
solution 100 mg/ml
haloperidol decanoate intramuscular
solution 50 mg/ml
haloperidol lactate
INVEGA ORAL TABLET EXTENDED
RELEASE 24HR 1.5 MG, 3 MG, 9 MG
1
1
QL (1 per 28 days)
(Abilify)
1
QL (30 per 30 days)
(Abilify)
(Chlorpromazine HCl)
(Clozaril)
(Clozaril)
(Clozaril)
(Fazaclo)
1
1
1
1
1
1
1
1
QL (60 per 30 days)
(Fluphenazine
Decanoate)
(Fluphenazine HCl)
1
(Haloperidol)
(Haloperidol Decanoate)
1
1
1
1
(Haldol Decanoate 50)
1
(Haloperidol Lactate)
1
1
QL (270 per 30 days)
QL (135 per 30 days)
QL (90 per 30 days)
ST
ST; QL (60 per 30 days)
ST; QL (8 per 28 days)
QL (6 per 28 days)
ST; 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
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
79
Effective: January 01, 2016
Drug Name
INVEGA ORAL TABLET EXTENDED
RELEASE 24HR 6 MG
INVEGA SUSTENNA
INTRAMUSCULAR SYRINGE 117
MG/0.75 ML
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
LATUDA ORAL TABLET 80 MG
loxapine succinate
olanzapine intramuscular
olanzapine oral tablet
olanzapine oral tablet,disintegrating 10
mg, 15 mg, 5 mg
olanzapine oral tablet,disintegrating 20
mg
ORAP
perphenazine
quetiapine
RISPERDAL CONSTA
risperidone oral solution
Drug Tier Requirements/Limits
1
ST; QL (60 per 30 days)
1
QL (0.75 per 28 days)
1
QL (1 per 28 days)
1
QL (1.5 per 28 days)
1
QL (0.25 per 28 days)
1
QL (0.5 per 28 days)
1
QL (0.875 per 84 days)
1
QL (1.315 per 84 days)
1
QL (1.75 per 84 days)
1
QL (2.625 per 84 days)
1
ST; QL (30 per 30 days)
ST; QL (60 per 30 days)
(Loxapine Succinate)
(Zyprexa)
(Zyprexa)
(Zyprexa Zydis)
1
1
1
1
1
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
(Zyprexa Zydis)
1
QL (31 per 30 days)
1
1
1
1
1
QL (90 per 30 days)
QL (4 per 28 days)
QL (480 per 30 days)
(Perphenazine)
(Seroquel)
(Risperdal)
You can find information on what the symbols and abbreviations in this table mean by going
to the introduction pages of this document
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
80
Effective: January 01, 2016
Drug Name
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
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
thiothixene
trifluoperazine
VERSACLOZ
Drug Tier Requirements/Limits
(Risperdal)
(Risperdal M-Tab)
1
1
QL (60 per 30 days)
QL (60 per 30 days)
(Risperdal M-Tab)
1
QL (120 per 30 days)
1
1
ST; QL (60 per 30 days)
ST; QL (60 per 30 days)
1
ST; QL (30 per 30 days)
1
1
1
1
PA NSO-HRM
(Thioridazine HCl)
(Thiothixene)
(Trifluoperazine HCl)
(Geodon)
ziprasidone hcl
ZYPREXA RELPREVV
INTRAMUSCULAR SUSPENSION FOR
RECONSTITUTION 210 MG, 405 MG
1
1
ST; QL (540 per 30
days)
QL (60 per 30 days)
Antivirals (Systemic)
Antiretrovirals
(Ziagen)
1
abacavir
(Trizivir)
1
abacavir-lamivudine-zidovudine
APTIVUS ORAL CAPSULE
1
APTIVUS ORAL SOLUTION
1
ATRIPLA
1
COMPLERA
1
CRIXIVAN ORAL CAPSULE 200 MG,
1
400 MG
(Videx EC)
1
didanosine
EDURANT
1
EMTRIVA
1
EPIVIR HBV ORAL SOLUTION
1
EPZICOM
1
EVOTAZ
1
FUZEON SUBCUTANEOUS
1
INTELENCE ORAL TABLET 100 MG,
1
200 MG
You can find information on what the symbols and abbreviations in this table mean by going
to the introduction pages of this document
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
81
Effective: January 01, 2016
Drug Name
INTELENCE ORAL TABLET 25 MG
INVIRASE
ISENTRESS ORAL POWDER IN
PACKET
ISENTRESS ORAL TABLET
ISENTRESS ORAL
TABLET,CHEWABLE
KALETRA ORAL SOLUTION
KALETRA ORAL TABLET 100-25 MG
KALETRA ORAL TABLET 200-50 MG
lamivudine
lamivudine-zidovudine
LEXIVA ORAL SUSPENSION
LEXIVA ORAL TABLET
nevirapine oral suspension
nevirapine oral tablet
nevirapine oral tablet extended release 24
hr
NORVIR
PREZCOBIX
PREZISTA ORAL SUSPENSION
PREZISTA ORAL TABLET 150 MG, 75
MG
PREZISTA ORAL TABLET 400 MG,
600 MG, 800 MG
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
Drug Tier Requirements/Limits
1
1
1
1
1
(Epivir)
(Combivir)
(Viramune)
(Viramune)
(Viramune XR)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
(Zerit)
You can find information on what the symbols and abbreviations in this table mean by going
to the introduction pages of this document
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
82
Effective: January 01, 2016
Drug Name
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
Drug Tier Requirements/Limits
1
1
1
(Retrovir)
(Retrovir)
(Zidovudine)
1
1
1
1
1
1
Antivirals, Miscellaneous
foscarnet
RELENZA DISKHALER
rimantadine
SYNAGIS
TAMIFLU
(Foscavir)
(Flumadine)
1
1
1
1
1
PA BvD
1
1
1
PA; QL (30 per 30 days)
PA; QL (28 per 28 days)
PA; QL (28 per 28 days)
1
1
1
1
1
PA NSO
PA
PA
PA
PA NSO; QL (4 per 28
days)
Hcv Antivirals
HARVONI
OLYSIO
SOVALDI
Interferons
INTRON A INJECTION
PEGASYS
PEGASYS PROCLICK
PEGINTRON
SYLATRON
Nucleosides And Nucleotides
(Zovirax)
1
acyclovir oral capsule
(Zovirax)
1
acyclovir oral suspension 200 mg/5 ml
(Zovirax)
1
acyclovir oral tablet
(Acyclovir Sodium)
1
PA BvD
acyclovir sodium intravenous solution
(Hepsera)
1
adefovir
BARACLUDE ORAL SOLUTION
1
(Vistide)
1
cidofovir
(Baraclude)
1
entecavir
(Famvir)
1
famciclovir
(Cytovene)
1
PA BvD
ganciclovir sodium
You can find information on what the symbols and abbreviations in this table mean by going
to the introduction pages of this document
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
83
Effective: January 01, 2016
Drug Name
ribavirin oral capsule 200 mg
ribavirin oral tablet 200 mg, 400 mg, 600
mg
ribavirin oral tablets,dose pack 200 mg
(7)- 400 mg (7), 400-400 mg (28)-mg (28),
600-400 mg (28)-mg (28)
TYZEKA
valacyclovir
VALCYTE ORAL RECON SOLN
valganciclovir
VIRAZOLE
Drug Tier Requirements/Limits
(Rebetol)
(Copegus)
1
1
(Ribatab)
1
1
1
1
1
1
PA BvD
(Lovenox)
(Lovenox)
1
1
1
1
QL (36 per 30 days)
QL (36 per 30 days)
(Lovenox)
1
QL (27.2 per 30 days)
(Lovenox)
1
QL (34 per 30 days)
(Lovenox)
1
QL (18 per 30 days)
(Lovenox)
1
QL (13.6 per 30 days)
(Lovenox)
1
QL (20.4 per 30 days)
(Lovenox)
1
QL (27.2 per 30 days)
(Arixtra)
1
QL (24 per 30 days)
(Arixtra)
1
QL (15 per 30 days)
(Arixtra)
1
QL (12 per 30 days)
(Arixtra)
1
QL (18 per 30 days)
(Valtrex)
(Valcyte)
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
enoxaparin subcutaneous syringe 150
mg/ml
enoxaparin subcutaneous syringe 30
mg/0.3 ml
enoxaparin subcutaneous syringe 40
mg/0.4 ml
enoxaparin subcutaneous syringe 60
mg/0.6 ml
enoxaparin subcutaneous syringe 80
mg/0.8 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
You can find information on what the symbols and abbreviations in this table mean by going
to the introduction pages of this document
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
84
Effective: January 01, 2016
Drug Name
heparin (porcine) in 5 % dex intravenous
parenteral solution 12,500 unit/250 ml,
20,000 unit/500 ml (40 unit/ml), 25,000
unit/500 ml (50 unit/ml)
heparin (porcine) in 5 % dex intravenous
parenteral solution 25,000 unit/250
ml(100 unit/ml)
heparin (porcine) in nacl (pf) intravenous
parenteral solution 1,000 unit/500 ml
heparin (porcine) injection solution 1,000
unit/ml, 20,000 unit/ml, 5,000 unit/ml
heparin (porcine) injection solution
10,000 unit/ml
heparin sodium,porcine-pf intravenous
syringe 10 unit/ml
heparin, porcine (pf) injection
heparin, porcine (pf) intravenous syringe
heparin-0.45% nacl 25,000 units/250 ml
(100 units/ml) bag latex-free, inner
heparin-d5w 25,000 units/250 ml (100
units/ml) bag excel container
IPRIVASK
jantoven
PRADAXA
SAVAYSA
warfarin
XARELTO
Drug Tier Requirements/Limits
(Heparin
Sodium,Porcine/D5W)
1
(Heparin Sod,Pork In
0.45% NaCl)
1
(Heparin
Sodium,Porcine/Ns/PF)
(Heparin
Sodium,Porcine)
(Heparin
Sodium,Porcine)
(Monoject Prefill
Advanced)
(Monoject Prefill
Advanced)
(Monoject Prefill
Advanced)
(Heparin Sod,Pork In
0.45% NaCl)
(Heparin
Sodium,Porcine/D5W)
1
(Coumadin)
(Coumadin)
1
1
PA BvD; (PA for ESRD
Only)
PA BvD
1
1
PA BvD; (PA for ESRD
Only)
1
1
1
1
1
1
1
1
1
PA; QL (24 per 28 days)
ST; QL (60 per 30 days)
ST
Blood Formation Modifiers
CINRYZE
1
PA
EPOGEN INJECTION SOLUTION
1
PA; QL (12 per 28 days)
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
1
LEUKINE INJECTION RECON SOLN
1
MIRCERA INJECTION SYRINGE 100
1
PA; QL (0.6 per 28 days)
MCG/0.3 ML, 50 MCG/0.3 ML, 75
MCG/0.3 ML
You can find information on what the symbols and abbreviations in this table mean by going
to the introduction pages of this document
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
85
Effective: January 01, 2016
Drug Name
Drug Tier Requirements/Limits
MOZOBIL
NEULASTA SUBCUTANEOUS
SYRINGE
NEUMEGA
NEUPOGEN
PROCRIT INJECTION SOLUTION
10,000 UNIT/ML, 2,000 UNIT/ML,
20,000 UNIT/2 ML, 3,000 UNIT/ML,
4,000 UNIT/ML
PROCRIT INJECTION SOLUTION
20,000 UNIT/ML
PROCRIT INJECTION SOLUTION
40,000 UNIT/ML
PROMACTA
1
1
1
1
1
PA; QL (12 per 28 days)
1
PA; QL (12 per 28 days)
1
PA; QL (6 per 28 days)
1
PA; QL (30 per 30 days)
Hematologic Agents, Miscellaneous
aminocaproic acid oral solution
aminocaproic acid oral tablet
anagrelide
protamine
(Aminocaproic Acid)
(Amicar)
(Agrylin)
(Protamine Sulfate)
1
1
1
1
tranexamic acid intravenous
tranexamic acid oral
(Tranexamic Acid)
(Lysteda)
1
1
PA BvD; (PA for ESRD
Only)
QL (30 per 30 days)
Platelet-Aggregation Inhibitors
AGGRENOX
BRILINTA
cilostazol
clopidogrel
EFFIENT
pentoxifylline
(Pletal)
(Plavix)
(Pentoxifylline)
1
1
1
1
1
1
QL (60 per 30 days)
QL (30 per 30 days)
Volume Expanders
ALBUKED-25
ALBUKED-5
ALBUMIN, HUMAN 25 %
ALBUMIN, HUMAN 5 %
ALBUMINAR 25 %
ALBUMINAR 5 %
ALBURX (HUMAN) 5 %
ALBUTEIN 25 %
1
1
1
1
1
1
1
1
You can find information on what the symbols and abbreviations in this table mean by going
to the introduction pages of this document
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
86
Effective: January 01, 2016
Drug Name
Drug Tier Requirements/Limits
ALBUTEIN 5 %
BUMINATE 25 %
BUMINATE 5 %
FLEXBUMIN 25 %
FLEXBUMIN 5 %
KEDBUMIN
PLASBUMIN 25 %
PLASBUMIN 5 %
1
1
1
1
1
1
1
1
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 % (SULFITE-FREE)
AMINOSYN-RF 5.2 %
CLINIMIX 5%/D15W SULFITE FREE
CLINIMIX 5%/D25W SULFITE-FREE
CLINIMIX 2.75%/D5W SULFIT FREE
CLINIMIX 4.25%/D10W SULF FREE
CLINIMIX 4.25%/D5W SULFIT FREE
CLINIMIX 4.25%-D20W SULF-FREE
CLINIMIX 4.25%-D25W SULF-FREE
CLINIMIX 5%-D20W(SULFITE-FREE)
CLINIMIX E 2.75%/D10W SUL FREE
CLINIMIX E 2.75%/D5W SULF FREE
1
1
1
1
1
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
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
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
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
87
Effective: January 01, 2016
Drug Name
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 %
cysteine (l-cysteine) intravenous solution
d10 %-0.9 % sodium chloride
dextrose 10 % in water (d10w)
intravenous
dextrose 2.5 % in water(d2.5w)
dextrose 20 % in water (d20w)
dextrose 25 % in water (d25w)
dextrose 40 % in water (d40w)
dextrose 5 % in ringers
dextrose 5 % in water (d5w) intravenous
dextrose 50 % in water (d50w)
dextrose 70 % in water (d70w)
Drug Tier Requirements/Limits
(Cysteine HCl)
(Dextrose 10 % and 0.9
% NaCl)
(Dextrose 10 % in
Water)
(Dextrose 2.5 % in
Water)
(Dextrose 20 % in
Water)
(Dextrose 25 % in
Water)
(Dextrose 40 % in
Water)
(Dextrose 5% In
Ringers)
(Dextrose 5 % in Water)
(Dextrose 50 % in
Water)
(Dextrose 70 % in
Water)
FREAMINE HBC 6.9 %
FREAMINE III 10 %
HEPATAMINE 8%
HEPATASOL 8 %
INTRALIPID INTRAVENOUS
EMULSION 20 %, 30 %
KABIVEN
LIPOSYN II
LIPOSYN III
NEPHRAMINE 5.4 %
NUTRILIPID
PERIKABIVEN
1
1
1
1
1
1
1
1
1
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
1
PA BvD
1
PA BvD
1
PA BvD
1
PA BvD
1
PA BvD
1
1
1
PA BvD
1
PA BvD
1
1
1
1
1
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
1
1
1
1
1
1
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
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
88
Effective: January 01, 2016
Drug Name
Drug Tier Requirements/Limits
PREMASOL 10 %
PREMASOL 6 %
PROCALAMINE 3%
PROSOL 20 %
TRAVASOL 10 %
TROPHAMINE 10 %
TROPHAMINE 6%
1
1
1
1
1
1
1
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
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
NORTHERA
phenylephrine hcl injection
prazosin oral
(Catapres)
(Clonidine
HCl/Chlorthalidone)
(Catapres-Tts 1)
1
1
1
QL (4 per 28 days)
(Catapres-Tts 1)
1
QL (8 per 28 days)
(Cardura)
(Tenex)
(Midodrine HCl)
1
1
1
1
(Vazculep)
(Minipress)
PA-HRM
PA; QL (180 per 30
days)
1
1
Angiotensin Ii Receptor Antagonists
BENICAR
BENICAR HCT
candesartan
candesartan-hydrochlorothiazid
EDARBI
EDARBYCLOR
irbesartan
irbesartan-hydrochlorothiazide
losartan
losartan-hydrochlorothiazide
telmisartan
telmisartan-hydrochlorothiazid
TEVETEN HCT
TRIBENZOR
(Atacand)
(Atacand HCT)
(Avapro)
(Avalide)
(Cozaar)
(Hyzaar)
(Micardis)
(Micardis HCT)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
ST
ST
ST
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
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
89
Effective: January 01, 2016
Drug Name
valsartan
valsartan-hydrochlorothiazide
Drug Tier Requirements/Limits
(Diovan)
(Diovan HCT)
1
1
Angiotensin-Converting Enzyme Inhibitors
benazepril
benazepril-hydrochlorothiazide
captopril
captopril-hydrochlorothiazide
enalapril maleate
enalaprilat intravenous injectable
enalapril-hydrochlorothiazide
fosinopril
fosinopril-hydrochlorothiazide
lisinopril
lisinopril-hydrochlorothiazide
moexipril
moexipril-hydrochlorothiazide
perindopril erbumine
quinapril
quinapril-hydrochlorothiazide
ramipril
trandolapril
(Lotensin)
(Lotensin HCT)
(Captopril)
(Captopril/Hydrochlorot
hiazide)
(Vasotec)
(Enalaprilat Dihydrate)
(Vaseretic)
(Fosinopril Sodium)
(Fosinopril/Hydrochloro
thiazide)
(Zestril)
(Zestoretic)
(Moexipril HCl)
(Moexipril/Hydrochlorot
hiazide)
(Aceon)
(Accupril)
(Accuretic)
(Altace)
(Mavik)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Antiarrhythmic Agents
amiodarone hcl oral tablet 100 mg, 200
mg, 400 mg
amiodarone intravenous
amiodarone oral
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
(Cordarone)
1
(Amiodarone HCl)
(Cordarone)
(Norpace)
(Tambocor)
(Lidocaine HCl/PF)
1
1
1
1
1
(Lidocaine
HCl/D5w/PF)
(Mexiletine HCl)
1
(Procainamide HCl)
1
1
1
You can find information on what the symbols and abbreviations in this table mean by going
to the introduction pages of this document
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
90
Effective: January 01, 2016
Drug Name
propafenone oral capsule,extended release
12 hr
propafenone oral tablet
quinidine gluconate oral
quinidine sulfate
TIKOSYN
Drug Tier Requirements/Limits
(Rythmol SR)
1
(Rythmol)
(Quinidine Gluconate)
(Quinidine Sulfate)
1
1
1
1
Beta-Adrenergic Blocking Agents
acebutolol oral
atenolol
atenolol-chlorthalidone
betaxolol oral
bisoprolol fumarate
bisoprolol-hydrochlorothiazide
BYSTOLIC
carvedilol
esmolol intravenous
labetalol intravenous solution
labetalol oral
metoprolol succinate
metoprolol ta-hydrochlorothiaz
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
sotalol hcl oral tablet 120 mg, 160 mg,
240 mg, 80 mg
sotalol oral
timolol maleate oral
(Sectral)
(Tenormin)
(Tenoretic 50)
(Kerlone)
(Zebeta)
(Ziac)
(Coreg)
(Esmolol HCl)
(Labetalol HCl)
(Trandate)
(Toprol XL)
(Lopressor HCT)
(Lopressor)
(Lopressor)
(Corgard)
(Pindolol)
(Propranolol HCl)
(Inderal LA)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
(Propranolol HCl)
(Propranolol HCl)
(Propranolol/Hydrochlor
othiazid)
(Betapace)
1
1
1
(Betapace)
(Timolol Maleate)
1
1
PA BvD
1
Calcium-Channel Blocking Agents
cartia xt
diltiazem hcl intravenous
(Cardizem CD)
(Cardizem CD)
1
1
You can find information on what the symbols and abbreviations in this table mean by going
to the introduction pages of this document
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
91
Effective: January 01, 2016
Drug Name
diltiazem hcl oral capsule, extended
release 180 mg, 360 mg, 420 mg
diltiazem hcl oral capsule,extended
release 12 hr
diltiazem hcl oral capsule,extended
release 24hr
diltiazem hcl oral tablet
diltiazem hcl oral tablet extended release
24 hr
dilt-xr
matzim la
taztia xt
verapamil intravenous syringe
verapamil oral capsule, 24 hr er pellet ct
verapamil oral capsule,ext rel. pellets 24
hr
verapamil oral tablet
verapamil oral tablet extended release
Drug Tier Requirements/Limits
(Cardizem CD)
1
(Cardizem CD)
1
(Cardizem CD)
1
(Cardizem CD)
(Cardizem LA)
1
1
(Cardizem CD)
(Cardizem CD)
(Cardizem CD)
(Verapamil HCl)
(Verelan Pm)
(Verelan)
1
1
1
1
1
1
(Calan)
(Calan SR)
1
1
Cardiovascular Agents, Miscellaneous
DEMSER
digitek oral tablet 125 mcg
(Lanoxin)
1
1
digitek oral tablet 250 mcg
(Lanoxin)
1
digoxin injection
DIGOXIN ORAL SOLUTION
(Digoxin)
1
1
digoxin oral tablet
(Lanoxin)
1
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
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
92
Effective: January 01, 2016
Drug Name
Drug Tier Requirements/Limits
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 injection auto-injector
epinephrine injection solution
epinephrine injection syringe 0.1 mg/ml
(1:10,000)
EPIPEN 2-PAK
EPIPEN JR 2-PAK
ethamolin
FIRAZYR
hydralazine
LANOXIN ORAL TABLET 187.5 MCG,
62.5 MCG
(Dobutamine HCl/D5W)
1
PA BvD
(Dobutamine HCl)
(Dopamine HCl/D5W)
1
1
PA BvD
PA BvD
(Dopamine HCl)
(Ephedrine Sulfate)
(Adrenaclick)
(Epinephrine)
(Epinephrine)
1
1
1
1
1
PA BvD
milrinone
milrinone in 5 % dextrose intravenous
piggyback 40 mg/200 ml (200 mcg/ml)
norepinephrine bitartrate
papaverine injection solution
papaverine oral
RANEXA
(Milrinone Lactate)
(Milrinone
Lactate/D5W)
(Levophed Bitartrate)
(Papaverine HCl)
(Papaverine HCl)
1
1
(Norvasc)
(Lotrel)
(Exforge)
(Exforge HCT)
1
1
1
1
1
1
(Ethanolamine Oleate)
(Hydralazine HCl)
1
1
1
1
1
1
1
1
1
1
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
PA BvD
PA
PA
Dihydropyridines
amlodipine
amlodipine-benazepril
amlodipine-valsartan
amlodipine-valsartan-hcthiazid
AZOR
CLEVIPREX INTRAVENOUS
EMULSION
ST
You can find information on what the symbols and abbreviations in this table mean by going
to the introduction pages of this document
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
93
Effective: January 01, 2016
Drug Name
felodipine
isradipine
nicardipine oral
nifedipine oral tablet extended release
24hr 30 mg
nifedipine oral tablet extended release
24hr 60 mg, 90 mg
nifedipine oral tablet extended release 30
mg, 60 mg
Drug Tier Requirements/Limits
(Felodipine)
(Isradipine)
(Nicardipine HCl)
(Adalat CC)
1
1
1
1
(Procardia XL)
1
(Adalat CC)
1
(Midamor)
(Amiloride/Hydrochloro
thiazide)
(Bumetanide)
(Chlorothiazide)
(Sodium Diuril)
(Chlorthalidone)
1
1
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
hydrochlorothiazide oral capsule
hydrochlorothiazide oral tablet
indapamide
methyclothiazide
metolazone
torsemide oral
triamterene-hydrochlorothiazid oral
capsule
triamterene-hydrochlorothiazid oral tablet
(Furosemide)
(Furosemide)
(Lasix)
(Microzide)
(Hydrochlorothiazide)
(Indapamide)
(Methyclothiazide)
(Zaroxolyn)
(Demadex)
(Dyazide)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
(Maxzide)
1
Dyslipidemics
ALTOPREV
amlodipine-atorvastatin
atorvastatin
cholestyramine (with sugar) oral
cholestyramine-aspartame oral powder 4
gram
(Caduet)
(Lipitor)
(Questran)
(Cholestyramine/Asparta
me)
1
1
1
1
1
You can find information on what the symbols and abbreviations in this table mean by going
to the introduction pages of this document
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
94
Effective: January 01, 2016
Drug Name
cholestyramine-aspartame oral powder in
packet 4 gram
colestipol
CRESTOR
fenofibrate micronized
fenofibrate nanocrystallized
fenofibrate oral tablet
fenofibric acid
fenofibric acid (choline)
gemfibrozil oral
JUXTAPID ORAL CAPSULE 10 MG, 30
MG, 40 MG, 60 MG
JUXTAPID ORAL CAPSULE 20 MG
JUXTAPID ORAL CAPSULE 5 MG
KYNAMRO
lovastatin
niacin oral tablet extended release 24 hr
omega-3 acid ethyl esters
pravastatin
simvastatin
VASCEPA
VYTORIN 10-10
VYTORIN 10-20
VYTORIN 10-40
VYTORIN 10-80
ZETIA
Drug Tier Requirements/Limits
(Cholestyramine/Asparta
me)
(Colestid)
(Lofibra)
(Tricor)
(Lofibra)
(Fibricor)
(Trilipix)
(Lopid)
(Mevacor)
(Niaspan)
(Lovaza)
(Pravachol)
(Zocor)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
ST
PA; QL (30 per 30 days)
PA; QL (90 per 30 days)
PA; QL (45 per 30 days)
PA; QL (4 per 28 days)
QL (30 per 30 days)
Renin-Angiotensin-Aldosterone System Inhibitors
eplerenone
spironolactone
spironolacton-hydrochlorothiaz
(Inspra)
(Aldactone)
(Aldactazide)
1
1
1
(Isochron)
(Isosorbide Dinitrate)
(Isosorbide Mononitrate)
(Imdur)
1
1
1
1
(Nitro-Dur)
1
Vasodilators
isosorbide dinitrate oral
isosorbide dinitrate sublingual
isosorbide mononitrate oral tablet
isosorbide mononitrate oral tablet
extended release 24 hr
minitran transdermal patch 24 hour 0.1
mg/hr, 0.2 mg/hr, 0.6 mg/hr
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
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
95
Effective: January 01, 2016
Drug Name
minitran transdermal patch 24 hour 0.4
mg/hr
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
Drug Tier Requirements/Limits
(Nitro-Dur)
1
QL (60 per 30 days)
(Minoxidil)
(Nitroglycerin/D5W)
1
1
1
(Nitroglycerin)
(Nitro-Dur)
1
1
QL (30 per 30 days)
(Nitro-Dur)
1
QL (60 per 30 days)
1
1
Central Nervous System Agents
Central Nervous System Agents
amphetamine salt combo
AMPYRA
caffeine citrated intravenous
caffeine citrated oral
caffeine-sodium benzoate
clonidine hcl oral tablet extended release
12 hr
dexmethylphenidate oral tablet
dextroamphetamine oral capsule, extended
release
dextroamphetamine oral tablet
dextroamphetamine-amphetamine oral
capsule,extended release 24hr 10 mg, 15
mg, 5 mg
dextroamphetamine-amphetamine oral
capsule,extended release 24hr 20 mg, 25
mg, 30 mg
flumazenil
guanfacine oral tablet extended release 24
hr
lithium carbonate oral capsule
lithium carbonate oral tablet
(Adderall)
(Cafcit)
(Cafcit)
(Caffeine/Sodium
Benzoate)
(Kapvay)
1
1
1
1
1
QL (60 per 30 days)
PA; QL (60 per 30 days)
1
(Focalin)
(Dexedrine)
1
1
QL (60 per 30 days)
QL (120 per 30 days)
(Dexedrine)
(Adderall XR)
1
1
QL (180 per 30 days)
QL (30 per 30 days)
(Adderall XR)
1
QL (60 per 30 days)
(Romazicon)
(Intuniv)
1
1
(Lithium Carbonate)
(Lithobid)
1
1
You can find information on what the symbols and abbreviations in this table mean by going
to the introduction pages of this document
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
96
Effective: January 01, 2016
Drug Name
lithium carbonate oral tablet extended
release
lithium citrate oral solution
methylphenidate oral capsule, er biphasic
30-70 10 mg, 20 mg, 40 mg, 50 mg, 60 mg
methylphenidate oral capsule, er biphasic
30-70 30 mg
methylphenidate oral capsule,er biphasic
50-50 20 mg, 40 mg
methylphenidate oral capsule,er biphasic
50-50 30 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
XENAZINE
Drug Tier Requirements/Limits
(Lithobid)
1
(Lithium Citrate)
(Metadate Cd)
1
1
QL (30 per 30 days)
(Metadate Cd)
1
QL (60 per 30 days)
(Metadate Cd)
1
QL (30 per 30 days)
(Metadate Cd)
1
QL (60 per 30 days)
(Methylin)
(Ritalin)
(Methylphenidate HCl)
1
1
1
QL (900 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
(Concerta)
1
QL (30 per 30 days)
(Concerta)
1
QL (60 per 30 days)
1
1
1
1
1
1
QL (60 per 30 days)
(Rilutek)
QL (60 per 30 days)
PA; QL (112 per 28
days)
Contraceptives
Contraceptives
ashlyna
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
(Seasonique)
(Nor-Q-D)
(Mircette)
(Desogen)
1
1
1
1
(Yaz)
1
1
1
1
(Yaz)
(Ethynodiol D-Ethinyl
Estradiol)
(Loestrin Fe)
QL (6 per 365 days)
1
You can find information on what the symbols and abbreviations in this table mean by going
to the introduction pages of this document
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
97
Effective: January 01, 2016
Drug Name
junel fe 24
l norgest/e.estradiol-e.estrad
larin 24 fe
levonorgestrel oral tablet 0.75 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
levonorgestrel-ethinyl estrad oral tablet
0.15-0.03 mg
levonorgestrel-ethinyl estrad oral
tablets,dose pack,3 month
l-norgest-eth estr/ethin estra
norelgestromin/ethin.estradiol
norethindrone
norethindrone (contraceptive)
norethindrone ac-eth estradiol oral tablet
1-20 mg-mcg, 1.5-30 mg-mcg
norethindrone-e.estradiol-iron oral tablet
1 mg-20 mcg (21)/75 mg (7), 1 mg-20 mcg
(24)/75 mg (4), 1-20(5)/1-30(7) /1mg35mcg (9), 1.5 mg-30 mcg (21)/75 mg (7)
norethindrone-ethinyl estrad oral tablet
0.4-35 mg-mcg, 0.5-35 mg-mcg, 0.5-35/135 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
tarina fe
Drug Tier Requirements/Limits
(Loestrin Fe)
(Seasonique)
(Loestrin Fe)
(Plan B One-Step)
(Plan B One-Step)
(Amethyst)
1
1
1
1
1
1
(Levonorgestrel-Ethin
Estradiol)
(Amethyst)
(Amethyst)
1
QL (91 per 84 days)
1
1
QL (91 per 84 days)
(Amethyst)
1
QL (91 per 84 days)
(Seasonique)
(Ortho Evra)
(Nor-Q-D)
(Nor-Q-D)
(Loestrin)
1
1
1
1
1
QL (91 per 84 days)
QL (3 per 28 days)
(Loestrin Fe)
1
(Modicon)
1
(Norinyl 1+50)
(Ortho-Cyclen)
(Norgestrel-Ethinyl
Estradiol)
1
1
1
(Loestrin Fe)
1
1
(Evoxac)
1
QL (91 per 84 days)
QL (12 per 365 days)
QL (6 per 365 days)
QL (1 per 28 days)
Dental And Oral Agents
Dental And Oral Agents
cevimeline
You can find information on what the symbols and abbreviations in this table mean by going
to the introduction pages of this document
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
98
Effective: January 01, 2016
Drug Name
chlorhexidine gluconate mucous
membrane mouthwash 0.12 %
pilocarpine hcl oral
sodium fluoride oral tablet,chewable 0.25
mg fluorid (0.55 mg)
triamcinolone acetonide dental
Drug Tier Requirements/Limits
(Peridex)
1
(Salagen)
(Sodium Fluoride)
1
1
(Triamcinolone
Acetonide)
1
Dermatological Agents
Dermatological Agents, Other
8-MOP
acitretin
acyclovir topical
ALCOHOL PADS
ALCOHOL PREP PADS
ammonium lactate
ANACAINE
calcipotriene topical cream
calcipotriene topical solution
calcitriol topical
CONDYLOX TOPICAL GEL
COSENTYX (2 SYRINGES)
COSENTYX PEN
COSENTYX PEN (2 PENS)
DENAVIR
FLUOROPLEX
fluorouracil topical cream
fluorouracil topical solution
imiquimod
isotretinoin oral capsule 10 mg, 20 mg, 30
mg, 40 mg
methoxsalen rapid
PANRETIN
PICATO TOPICAL GEL 0.015 %
PICATO TOPICAL GEL 0.05 %
podofilox
podophyllum resin
potassium hydroxide
(Carac)
(Fluorouracil)
(Aldara)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
(Isotretinoin)
1
(Oxsoralen-Ultra)
1
1
1
1
1
1
1
(Soriatane)
(Zovirax)
(Lac-Hydrin)
(Dovonex)
(Calcipotriene)
(Vectical)
(Condylox)
(Podophyllum Resin)
(Potassium Hydroxide)
QL (30 per 30 days)
PA
PA
PA
PA NSO; QL (24 per 30
days)
QL (3 per 56 days)
QL (2 per 56 days)
You can find information on what the symbols and abbreviations in this table mean by going
to the introduction pages of this document
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
99
Effective: January 01, 2016
Drug Name
Drug Tier Requirements/Limits
REGRANEX
SANTYL
VALCHLOR
VEREGEN
ZOVIRAX TOPICAL CREAM
1
1
1
1
1
PA; QL (30 per 30 days)
QL (15 per 30 days)
Dermatological Antibacterials
clindamycin phosphate topical gel
clindamycin phosphate topical lotion
clindamycin phosphate topical solution
clindamycin phosphate topical swab
erythromycin base-ethanol
(Cleocin T)
(Cleocin T)
(Cleocin T)
(Cleocin T)
(Erythromycin
Base/Ethanol)
(Emgel)
erythromycin with ethanol topical gel
erythromycin with ethanol topical solution (Erythromycin
Base/Ethanol)
(Erythromycin
erythromycin with ethanol topical swab
Base/Ethanol)
(Benzamycin)
erythromycin-benzoyl peroxide
(Gentamicin Sulfate)
gentamicin topical
(Metrocream)
metronidazole topical
(Rosadan)
metronidazole topical
(Metrolotion)
metronidazole topical
(Centany)
mupirocin
(Bactroban)
mupirocin calcium
(Neosporin G.U.
neomycin-polymyxin b gu
Irrigant)
(Selenium Sulfide)
selenium sulfide
(Silver Nitrate
silver nitrate applicators
Applicator)
(Silver Nitrate)
silver nitrate topical
(Silvadene)
silver sulfadiazine topical cream 1 %
(Klaron)
sulfacetamide sodium (acne)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Dermatological Anti-Inflammatory Agents
(Alclometasone
1
Dipropionate)
(Betamethasone
1
betamethasone dipropionate
Dipropionate)
(Betamethasone
1
betamethasone valerate topical cream
Valerate)
You can find information on what the symbols and abbreviations in this table mean by going
to the introduction pages of this document
alclometasone
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
100
Effective: January 01, 2016
Drug Name
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
desonide topical cream
desonide topical ointment
desoximetasone
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% ointment carton (otc)
hydrocortisone acet-aloe vera topical gel
hydrocortisone acetate-urea
Drug Tier Requirements/Limits
(Luxiq)
(Betamethasone
Valerate)
(Betamethasone
Valerate)
(Diprolene AF)
(Betamethasone
Dipropionate)
(Diprolene)
(Diprolene)
1
1
(Clobetasol Propionate)
1
(Temovate)
(Olux)
(Clobetasol Propionate)
(Clobex)
(Temovate)
(Clobex)
(Clobetasol Propionate)
(Temovate)
(Cloderm)
(Desowen)
(Desonide)
(Topicort)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
(Vanos)
(Fluocinonide)
(Fluocinonide)
(Fluocinonide)
(Vanos)
(Cutivate)
(Fluticasone Propionate)
(Ultravate)
(Hydrocortisone)
(Hydrocortisone
Acetate/Aloe V)
(Hydrocortisone
Acetate/Urea)
1
1
1
1
1
1
You can find information on what the symbols and abbreviations in this table mean by going
to the introduction pages of this document
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
101
Effective: January 01, 2016
Drug Name
Drug Tier Requirements/Limits
hydrocortisone butyrate topical cream
(Hydrocortisone
Butyrate)
(Locoid)
hydrocortisone butyrate topical ointment
(Locoid)
hydrocortisone butyrate topical solution
(Hydrocortisone
hydrocortisone butyr-emollient
Butyrate)
(Anusol-HC)
hydrocortisone rectal cream 1 %
(Hydrocortisone)
hydrocortisone rectal cream 2.5 %
hydrocortisone rectal enema 100 mg/60 ml (Cortenema)
hydrocortisone topical cream 1 %, 2.5 % (Anusol-HC)
(Scalacort)
hydrocortisone topical lotion 2 %, 2.5 %
(Hydrocortisone)
hydrocortisone topical ointment 1 %, 2.5
%
(Hydrocortisone
hydrocortisone valerate topical cream
Valerate)
(Westcort)
hydrocortisone valerate topical ointment
(Elocon)
mometasone
ONFI ORAL SUSPENSION
1
1
1
1
1
1
ONFI ORAL TABLET 10 MG, 20 MG
1
prednicarbate
tacrolimus topical
triamcinolone acetonide topical cream
triamcinolone acetonide topical lotion
triamcinolone acetonide topical ointment
0.025 %, 0.1 %, 0.5 %
1
1
1
1
1
1
1
1
(Dermatop)
(Protopic)
(Triamcinolone
Acetonide)
(Triamcinolone
Acetonide)
(Triamcinolone
Acetonide)
1
1
1
(Differin)
(Differin)
1
1
1
1
1
PA NSO; QL (480 per 30
days)
PA NSO; QL (60 per 30
days)
1
1
Dermatological Retinoids
adapalene topical cream
adapalene topical gel 0.1 %
TAZORAC TOPICAL CREAM
tretinoin microspheres
tretinoin topical
(Retin-A Micro)
(Retin-A)
PA
PA
Scabicides And Pediculicides
EURAX
1
(Ovide)
1
malathion
(Elimite)
1
permethrin topical cream
You can find information on what the symbols and abbreviations in this table mean by going
to the introduction pages of this document
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
102
Effective: January 01, 2016
Drug Name
Drug Tier Requirements/Limits
Devices
Devices
ASSURE ID INSULIN SAFETY
SYRINGE
BD ECLIPSE LUER-LOK SYRINGE 1
ML 27 X 1/2"
BD INSULIN PEN NEEDLE UF SHORT
BD INSULIN SYRINGE ULTRA-FINE
SYRINGE 0.3 ML 31 X 5/16", 1 ML 31 X
5/16", 1/2 ML 31 X 5/16"
INSULIN PEN NEEDLE NEEDLE 29
GAUGE X 1/2 "
INSULIN SYRINGE-NEEDLE U-100
SYRINGE 0.3 ML 29, 1 ML 29 X 1/2",
1/2 ML 28
VGO 40
1
1
1
1
1
1
1
Enzyme Replacement/Modifiers
Enzyme Replacement/Modifiers
ADAGEN
ALDURAZYME
CEREZYME INTRAVENOUS RECON
SOLN 400 UNIT
CREON
ELAPRASE
ELITEK INTRAVENOUS RECON
SOLN
FABRAZYME INTRAVENOUS RECON
SOLN
KRYSTEXXA
KUVAN ORAL TABLET,SOLUBLE
(Zenpep)
lipase-protease-amylase
MYOZYME
NAGLAZYME
ORFADIN
PERTZYE
PULMOZYME
VIMIZIM
VPRIV
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
PA BvD
PA
You can find information on what the symbols and abbreviations in this table mean by going
to the introduction pages of this document
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
103
Effective: January 01, 2016
Drug Name
Drug Tier Requirements/Limits
ZAVESCA
ZENPEP ORAL CAPSULE,DELAYED
RELEASE(DR/EC) 10,000-34,000 55,000 UNIT, 15,000-51,000 -82,000
UNIT, 20,000-68,000 -109,000 UNIT,
25,000-85,000- 136,000 UNIT, 3,00010,000- 16,000 UNIT, 40,000-136,000218,000 UNIT
1
1
QL (90 per 30 days)
Eye, Ear, Nose, Throat Agents
Eye, Ear, Nose, Throat Agents, Miscellaneous
AKTEN (PF)
altacaine
apraclonidine
atropine ophthalmic drops
atropine ophthalmic ointment
azelastine nasal aerosol,spray
azelastine ophthalmic
BEPREVE
carteolol
cromolyn ophthalmic
CYCLOGYL OPHTHALMIC DROPS 0.5
%
cyclopentolate
CYSTARAN
epinastine
homatropine hbr
ipratropium bromide nasal spray,nonaerosol 0.03 %
ipratropium bromide nasal spray,nonaerosol 0.06 %
LACRISERT
naphazoline
phenylephrine hcl ophthalmic
proparacaine
proparacaine hcl ophthalmic drops 0.5 %
proparacaine-fluorescein sod
(Tetcaine)
(Iopidine)
(Isopto Atropine)
(Atropine Sulfate)
(Astepro)
(Azelastine HCl)
(Carteolol HCl)
(Cromolyn Sodium)
(Cyclogyl)
1
1
1
1
1
1
1
1
1
1
1
QL (30 per 25 days)
ST
(Elestat)
(Isopto Homatropine)
(Atrovent)
1
1
1
1
1
QL (30 per 28 days)
(Atrovent)
1
QL (15 per 10 days)
(Naphazoline HCl)
(Mydfrin)
(Proparacaine HCl)
(Proparacaine HCl)
(Proparacaine/Fluorescei
n Sod)
(Tetracaine HCl/PF)
1
1
1
1
1
1
1
tetracaine hcl (pf) ophthalmic
TYZINE NASAL DROPS 0.1 %
1
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VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
104
Effective: January 01, 2016
Drug Name
Drug Tier Requirements/Limits
TYZINE NASAL SPRAY,NONAEROSOL
1
Eye, Ear, Nose, Throat Anti-Infectives Agents
acetic acid otic
bacitracin ophthalmic
bacitracin-polymyxin b ophthalmic
BLEPHAMIDE
BLEPHAMIDE S.O.P.
CILOXAN OPHTHALMIC OINTMENT
CIPRODEX
ciprofloxacin hcl ophthalmic
ciprofloxacin hcl otic
COLY-MYCIN S
CORTISPORIN-TC
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 ophthalmic
neomycin-polymyxin-hc otic
drops,suspension
neomycin-polymyxin-hc otic solution
neo-polycin
ofloxacin ophthalmic
(Acetic Acid)
(Bacitracin)
(Bacitracin/Polymyxin B
Sulfate)
(Ciloxan)
(Cetraxal)
(Ilotycin)
(Zymaxid)
(Garamycin)
(Garamycin)
(Levofloxacin)
(Neomycin Su/Baci
Zn/Poly/HC)
(Neomycin Su/Baci
Zn/Poly/HC)
(Neomycin
Su/Bacitra/Polymyxin)
(Maxitrol)
(Neosporin)
(Neomycin/Polymyxin B
Sulf/HC)
(Neomycin/Polymyxin B
Sulf/HC)
(Cortisporin)
(Neomycin
Su/Bacitra/Polymyxin)
(Ocuflox)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
You can find information on what the symbols and abbreviations in this table mean by going
to the introduction pages of this document
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
105
Effective: January 01, 2016
Drug Name
ofloxacin otic
polymyxin b sulf-trimethoprim
sulfacetamide sodium
sulfacetamide-prednisolone
TOBRADEX OPHTHALMIC
OINTMENT
TOBRADEX ST
tobramycin
trifluridine
VIGAMOX
ZIRGAN
ZYLET
Drug Tier Requirements/Limits
(Ocuflox)
(Polytrim)
(Sulfacetamide Sodium)
(Sulfacetamide/Predniso
lone Sp)
1
1
1
1
1
(Tobrex)
(Viroptic)
1
1
1
1
1
1
Eye, Ear, Nose, Throat Anti-Inflammatory Agents
ALREX
bromfenac
dexamethasone sodium phosphate
ophthalmic
diclofenac sodium ophthalmic
DUREZOL
flunisolide nasal spray,non-aerosol 25
mcg (0.025 %)
fluorometholone
flurbiprofen sodium
fluticasone nasal
ILEVRO
ketorolac ophthalmic
LOTEMAX
NEVANAC
prednisolone acetate
prednisolone sodium phosphate
ophthalmic
PROLENSA
RESTASIS
(Bromfenac Sodium)
(Dexasol)
(Diclofenac Sodium)
(Flunisolide)
(FML)
(Ocufen)
(Fluticasone Propionate)
(Acular)
(Omnipred)
(Prednisolone Sod
Phosphate)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
ST
QL (50 per 25 days)
QL (16 per 30 days)
QL (60 per 30 days)
Gastrointestinal Agents
Antiulcer Agents And Acid Suppressants
amoxicil-clarithromy-lansopraz
CARAFATE ORAL SUSPENSION
(Prevpac)
1
1
You can find information on what the symbols and abbreviations in this table mean by going
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VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
106
Effective: January 01, 2016
Drug Name
cimetidine
cimetidine hcl oral
DEXILANT
esomeprazole sodium
famotidine (pf)
famotidine (pf)-nacl (iso-os)
famotidine intravenous
famotidine oral tablet 20 mg, 40 mg
lansoprazole oral capsule,delayed
release(dr/ec)
misoprostol
nizatidine
omeprazole oral capsule,delayed
release(dr/ec)
pantoprazole oral
ranitidine hcl injection
ranitidine hcl oral capsule
ranitidine hcl oral syrup
ranitidine hcl oral tablet 150 mg, 300 mg
sucralfate oral suspension
sucralfate oral tablet
Drug Tier Requirements/Limits
(Cimetidine)
(Cimetidine HCl)
(Nexium I.V.)
(Famotidine)
(Famotidine In Nacl,IsoOsm/PF)
(Famotidine)
(Pepcid)
(Prevacid)
1
1
1
1
1
1
1
1
1
(Cytotec)
(Nizatidine)
(Prilosec)
1
1
1
(Protonix)
(Zantac)
(Ranitidine HCl)
(Ranitidine HCl)
(Zantac)
(Sucralfate)
(Carafate)
1
1
1
1
1
1
1
(Rx Product Only)
ST
(Rx Product Only)
(Rx Product Only)
(Rx Product Only)
(Rx Product Only)
(Rx Product Only)
(Rx Product Only)
Gastrointestinal Agents, Other
AMITIZA
BUPHENYL ORAL TABLET
CARBAGLU
cromolyn oral
dicyclomine oral capsule
dicyclomine oral solution
dicyclomine oral tablet
diphenoxylate-atropine oral liquid
diphenoxylate-atropine oral tablet
GATTEX 30-VIAL
GATTEX ONE-VIAL
glycopyrrolate
glycopyrrolate
lactulose
(Gastrocrom)
(Bentyl)
(Dicyclomine HCl)
(Bentyl)
(Diphenoxylate
HCl/Atropine)
(Lomotil)
(Robinul)
(Robinul)
(Lactulose)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
QL (60 per 30 days)
PA
PA
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VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
107
Effective: January 01, 2016
Drug Name
LINZESS
loperamide oral
LOTRONEX
methscopolamine oral
metoclopramide hcl injection
metoclopramide hcl oral
metoclopramide hcl oral
MOVANTIK
NUTRESTORE
RAVICTI
RELISTOR SUBCUTANEOUS
RELISTOR SUBCUTANEOUS
SYRINGE 8 MG/0.4 ML
sodium polystyrene sulfonate oral powder
Drug Tier Requirements/Limits
(Loperamide HCl)
(Methscopolamine
Bromide)
(Metoclopramide HCl)
(Metoclopramide HCl)
(Reglan)
(Sodium Polystyrene
Sulfonate)
(Sodium Polystyrene
sodium polystyrene sulfonate oral
Sulfonate)
suspension 15 gram/60 ml
sodium polystyrene sulfonate rectal enema (Sodium Polystyrene
Sulfonate)
30 gram/120 ml
(Actigall)
ursodiol oral capsule
(Urso)
ursodiol oral tablet
VELPHORO
1
1
1
1
1
1
1
1
1
1
1
1
QL (30 per 30 days)
PA
PA; QL (28 per 28 days)
PA; QL (28 per 28 days)
1
1
1
1
1
1
Laxatives
MOVIPREP
peg 3350-electrolytes
PEG 3350-GRX
peg 3350-na sulf,bicarb,cl-kcl
peg-electrolyte soln
polyethylene glycol 3350 oral
PREPOPIK
sodium chloride-nahco3-kcl-peg oral
recon soln 420 gram
(Golytely)
(Golytely)
(Nulytely with Flavor
Packs)
(Gavilyte-N)
(Nulytely with Flavor
Packs)
1
1
1
1
1
1
1
1
Phosphate Binders
AURYXIA
calcium acetate oral capsule
calcium carbonate-mag carb-fa
1
1
1
(Phoslo)
(Calcium
Carbonate/Mag Carb/Fa)
You can find information on what the symbols and abbreviations in this table mean by going
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VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
108
Effective: January 01, 2016
Drug Name
Drug Tier Requirements/Limits
FOSRENOL
PHOSLYRA
RENAGEL
RENVELA
1
1
1
1
Genitourinary Agents
Antispasmodics, Urinary
MYRBETRIQ
oxybutynin chloride oral tablet
oxybutynin chloride oral tablet extended
release 24hr
tolterodine oral capsule,extended release
24hr
tolterodine oral tablet
TOVIAZ
trospium
VESICARE
(Oxybutynin Chloride)
(Ditropan XL)
1
1
1
(Detrol LA)
1
(Detrol)
1
1
1
1
(Trospium Chloride)
Genitourinary Agents, Miscellaneous
alfuzosin
tamsulosin
terazosin
(Uroxatral)
(Flomax)
(Terazosin HCl)
1
1
1
Heavy Metal Antagonists
Heavy Metal Antagonists
(Desferal)
deferoxamine injection recon soln
DEPEN TITRATABS
EXJADE ORAL TABLET,
DISPERSIBLE 125 MG
EXJADE ORAL TABLET,
DISPERSIBLE 250 MG, 500 MG
FERRIPROX
sodium thiosulfate intravenous solution 1 (Sodium Thiosulfate)
gram/10 ml (100 mg/ml), 12.5 gram/50 ml
(250 mg/ml)
SYPRINE
1
1
1
PA BvD
1
1
1
1
Hormonal Agents, Stimulant/Replacement/Modifying
Androgens
ANDRODERM
1
PA; QL (30 per 30 days)
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VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
109
Effective: January 01, 2016
Drug Name
Drug Tier Requirements/Limits
ANDROGEL TRANSDERMAL GEL IN
METERED-DOSE PUMP 20.25 MG/1.25
GRAM (1.62 %)
ANDROGEL TRANSDERMAL GEL IN
PACKET 1.62 % (20.25 MG/1.25
GRAM), 1.62 % (40.5 MG/2.5 GRAM)
AXIRON
danazol oral
fluoxymesterone
oxandrolone
testosterone cypionate
testosterone enanthate
testosterone transdermal gel in packet 1 %
(25 mg/2.5gram)
(Danazol)
(Fluoxymesterone)
(Oxandrin)
(Depo-Testosterone)
(Delatestryl)
(Androgel)
1
PA; QL (150 per 30
days)
1
PA; QL (150 per 30
days)
1
PA; QL (180 per 28
days)
1
1
1
1
1
1
PA
PA; QL (5 per 28 days)
PA; QL (300 per 30
days)
Estrogens And Antiestrogens
COMBIPATCH
1
DUAVEE
ESTRACE VAGINAL
estradiol oral
estradiol transdermal patch semiweekly
(Estrace)
(Vivelle-Dot)
1
1
1
1
estradiol transdermal patch weekly
(Climara)
1
estradiol valerate
estradiol/norethindrone acet
estradiol-norethindrone acet
ESTRING
estropipate
FEMRING
MENEST
PREMARIN INJECTION
PREMARIN ORAL
PREMARIN VAGINAL
PREMPHASE
PREMPRO
raloxifene
VAGIFEM
(Delestrogen)
(Activella)
(Activella)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
(Estropipate)
(Evista)
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
PA-HRM
QL (1 per 84 days)
PA-HRM
QL (1 per 84 days)
PA-HRM
PA-HRM
PA-HRM
PA-HRM
QL (18 per 28 days)
You can find information on what the symbols and abbreviations in this table mean by going
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VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
110
Effective: January 01, 2016
Drug Name
Drug Tier Requirements/Limits
Glucocorticoids/Mineralocorticoids
betamethasone acet,sod phos
cortisone
dexamethasone oral
dexamethasone oral
dexamethasone sodium phosphate
injection
fludrocortisone
hydrocortisone oral
hydrocortisone sod succinate
methylprednisolone
methylprednisolone acetate
methylprednisolone sodium succ injection
recon soln 125 mg, 40 mg
methylprednisolone sodium succ
intravenous
prednisolone sodium phosphate oral
solution
PREDNISONE INTENSOL
prednisone oral solution
prednisone oral tablet
prednisone oral tablets,dose pack
SOLU-CORTEF (PF) INJECTION
RECON SOLN
triamcinolone acetonide injection
(Celestone)
(Cortisone Acetate)
(Dexamethasone)
(Dexamethasone)
(Dexamethasone Sod
Phosphate)
(Fludrocortisone
Acetate)
(Cortef)
(Hydrocortisone Sod
Succinate)
(Medrol)
(Depo-Medrol)
(A-Methapred)
1
1
1
1
1
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
1
1
PA BvD
PA BvD
1
1
1
PA BvD
PA BvD
PA BvD
(A-Methapred)
1
PA BvD
(Pediapred)
1
PA BvD
(Prednisone)
(Prednisone)
(Prednisone)
1
1
1
1
1
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
1
(Triamcinolone
Acetonide)
1
(Desmopressin Acetate)
(DDAVP)
(Desmopressin Acetate)
(DDAVP)
1
1
1
1
1
1
Pituitary
desmopressin injection
desmopressin nasal
desmopressin nasal
desmopressin oral
GENOTROPIN
GENOTROPIN MINIQUICK
SUBCUTANEOUS SYRINGE 0.2
MG/0.25 ML
QL (15 per 30 days)
QL (15 per 30 days)
PA
PA
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VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
111
Effective: January 01, 2016
Drug Name
GENOTROPIN MINIQUICK
SUBCUTANEOUS SYRINGE 0.4
MG/0.25 ML, 0.6 MG/0.25 ML, 0.8
MG/0.25 ML, 1 MG/0.25 ML, 1.2
MG/0.25 ML, 1.4 MG/0.25 ML, 1.6
MG/0.25 ML, 1.8 MG/0.25 ML, 2
MG/0.25 ML
INCRELEX
LUPRON DEPOT-PED
LUPRON DEPOT-PED (3 MONTH)
INTRAMUSCULAR SYRINGE KIT
NORDITROPIN FLEXPRO
NORDITROPIN NORDIFLEX
octreotide acetate injection solution 1,000
mcg/ml
octreotide acetate injection solution 100
mcg/ml, 200 mcg/ml, 500 mcg/ml
octreotide acetate injection solution 50
mcg/ml
octreotide acetate injection syringe
SAIZEN
SAIZEN CLICK.EASY
SANDOSTATIN LAR DEPOT
INTRAMUSCULAR KIT
SEROSTIM SUBCUTANEOUS RECON
SOLN 4 MG, 5 MG, 6 MG
SOMATULINE DEPOT
SOMAVERT
STIMATE
SUPPRELIN LA
Drug Tier Requirements/Limits
1
PA
1
1
1
QL (1 per 84 days)
(Sandostatin)
1
1
1
PA
PA
(Sandostatin)
1
(Octreotide Acetate)
1
(Octreotide Acetate)
1
1
1
1
PA
PA
1
PA
1
1
1
1
QL (1 per 28 days)
1
QL (10 per 28 days)
1
1
1
1
1
1
QL (1 per 84 days)
QL (1 per 360 days)
Progestins
DEPO-PROVERA INTRAMUSCULAR
SOLUTION
medroxyprogesterone intramuscular
medroxyprogesterone oral
MEGACE ES
megestrol oral suspension
norethindrone acetate
progesterone
(Depo-Provera)
(Provera)
(Megace Es)
(Aygestin)
(Progesterone)
You can find information on what the symbols and abbreviations in this table mean by going
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VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
112
Effective: January 01, 2016
Drug Name
progesterone micronized capsules
Drug Tier Requirements/Limits
(Prometrium)
1
Thyroid And Antithyroid Agents
levothyroxine intravenous
levothyroxine oral
liothyronine oral
methimazole oral tablet 10 mg, 5 mg
propylthiouracil
(Levothyroxine Sodium)
(Levoxyl)
(Cytomel)
(Tapazole)
(Propylthiouracil)
1
1
1
1
1
Immunological Agents
Immunological Agents
ARCALYST
ASTAGRAF XL
AUBAGIO
azathioprine
azathioprine sodium
CARIMUNE NF NANOFILTERED
INTRAVENOUS RECON SOLN
CELLCEPT INTRAVENOUS
CIMZIA
CIMZIA POWDER FOR RECONST
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 CROHN'S DIS START PCK
HUMIRA PEN
HYQVIA
ILARIS (PF)
IMOGAM RABIES-HT (PF)
KINERET
(Imuran)
(Azathioprine Sodium)
(Sandimmune)
(Neoral)
(Sandimmune)
(Neoral)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
PA BvD
PA; QL (28 per 28 days)
PA BvD
PA BvD
PA BvD
PA BvD
PA
PA
PA BvD
PA BvD
PA BvD
PA BvD
PA
PA
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA
PA
PA
PA BvD
PA
PA; QL (18.76 per 28
days)
You can find information on what the symbols and abbreviations in this table mean by going
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VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
113
Effective: January 01, 2016
Drug Name
leflunomide
mycophenolate mofetil oral capsule
mycophenolate mofetil oral suspension for
reconstitution
mycophenolate mofetil oral tablet
mycophenolate sodium
NULOJIX
OCTAGAM
ORENCIA
ORENCIA (WITH MALTOSE)
PRIVIGEN
PROGRAF INTRAVENOUS
RAPAMUNE ORAL SOLUTION
RIDAURA
sirolimus oral tablet 0.5 mg, 1 mg
sirolimus oral tablet 2 mg
tacrolimus oral
TYSABRI
Drug Tier Requirements/Limits
(Arava)
(Cellcept)
(Cellcept)
1
1
1
(Cellcept)
(Myfortic)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
(Rapamune)
(Rapamune)
(Hecoria)
ZORTRESS ORAL TABLET 0.25 MG
1
ZORTRESS ORAL TABLET 0.5 MG,
0.75 MG
1
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA
PA
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA; LA; QL (15 per 28
days)
PA BvD; QL (120 per 30
days)
PA BvD; QL (120 per 30
days)
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)
1
1
1
1
1
1
1
1
1
PA BvD
PA BvD; QL (3 per 365
days)
ENGERIX-B PEDIATRIC (PF)
1
PA BvD; QL (3 per 365
days)
GARDASIL (PF)
1
QL (1.5 per 365 days)
GARDASIL 9 (PF)
1
QL (1.5 per 365 days)
You can find information on what the symbols and abbreviations in this table mean by going
to the introduction pages of this document
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
114
Effective: January 01, 2016
Drug Name
Drug Tier Requirements/Limits
HAVRIX (PF) INTRAMUSCULAR
SUSPENSION
HAVRIX (PF) INTRAMUSCULAR
SYRINGE
IMOVAX RABIES VACCINE (PF)
INFANRIX (DTAP) (PF)
INTRAMUSCULAR
IPOL
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)
PENTACEL DTAP-IPV COMPNT (PF)
PROQUAD (PF)
QUADRACEL (PF)
RABAVERT (PF)
RECOMBIVAX HB (PF)
INTRAMUSCULAR SUSPENSION 10
MCG/ML, 40 MCG/ML
RECOMBIVAX HB (PF)
INTRAMUSCULAR SYRINGE
ROTARIX
ROTATEQ VACCINE
TENIVAC (PF) INTRAMUSCULAR
TETANUS TOXOID,ADSORBED (PF)
TETANUS,DIPHTHERIA TOX PED(PF)
TETANUS-DIPHTHERIA TOXOIDS-TD
1
1
1
1
PA BvD
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
QL (2 per 365 days)
QL (2 per 365 days)
PA BvD
PA BvD; QL (3 per 365
days)
PA BvD; QL (3 per 365
days)
PA BvD
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VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
115
Effective: January 01, 2016
Drug Name
Drug Tier Requirements/Limits
TICE BCG
TRUMENBA
TWINRIX (PF)
TYPHIM VI INTRAMUSCULAR
VAQTA (PF)
VARIVAX (PF)
YF-VAX (PF)
ZOSTAVAX (PF)
1
1
1
1
1
1
1
1
PA BvD
QL (2 per 365 days)
QL (1 per 365 days)
Inflammatory Bowel Disease Agents
Inflammatory Bowel Disease Agents
APRISO
ASACOL HD
balsalazide
budesonide oral
DELZICOL
DIPENTUM
(Colazal)
(Entocort EC)
1
1
1
1
1
1
ST
Irrigating Solutions
Irrigating Solutions
acetic acid irrigation
LACTATED RINGERS IRRIGATION
ringers irrigation
sodium chloride irrigation
sorbitol irrigation
sorbitol-mannitol
water for irrigation, sterile
(Acetic Acid)
(Ringers Solution)
(Sodium Chloride Irrig
Solution)
(Sorbitol Solution)
(Mannitol/Sorbitol
Solution)
(Water For
Irrigation,Sterile)
1
1
1
1
1
1
1
Metabolic Bone Disease Agents
Metabolic Bone Disease Agents
ACTONEL ORAL TABLET 35 MG
alendronate oral solution
alendronate oral tablet 10 mg, 40 mg, 5
mg
alendronate oral tablet 35 mg, 70 mg
calcitonin (salmon)
(Alendronate Sodium)
(Fosamax)
1
1
1
QL (4 per 28 days)
QL (300 per 28 days)
(Fosamax)
(Miacalcin)
1
1
QL (4 per 28 days)
QL (3.7 per 28 days)
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VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
116
Effective: January 01, 2016
Drug Name
Drug Tier Requirements/Limits
calcitriol intravenous solution 1 mcg/ml
(Calcitriol)
1
calcitriol oral
(Rocaltrol)
1
doxercalciferol intravenous
(Doxercalciferol)
1
doxercalciferol oral
(Hectorol)
1
(Ibandronate Sodium)
1
1
1
FORTEO
FORTICAL
ibandronate intravenous solution
ibandronate oral
MIACALCIN INJECTION
(Boniva)
1
1
NATPARA
pamidronate intravenous
(Pamidronate Disodium)
1
1
paricalcitol oral
(Zemplar)
1
PROLIA
risedronate oral tablet 150 mg
risedronate oral tablet 30 mg, 5 mg
XGEVA
ZEMPLAR INTRAVENOUS
zoledronic acid intravenous
zoledronic acid-mannitol-water
intravenous piggyback
zoledronic acid-mannitol-water
intravenous solution
ZOMETA INTRAVENOUS SOLUTION
4 MG/100 ML
(Actonel)
(Actonel)
(Zometa)
(Zoledronic
Acid/Mannitol and
Water)
(Reclast)
1
1
1
1
1
PA BvD; (PA for ESRD
Only)
PA BvD; (PA for ESRD
Only)
PA BvD; (PA for ESRD
Only)
PA BvD; (PA for ESRD
Only)
QL (2.4 per 28 days)
QL (3.7 per 28 days)
PA BvD; (PA for ESRD
Only); QL (3 per 84
days)
QL (1 per 28 days)
PA BvD; (PA for ESRD
Only)
PA; QL (2 per 28 days)
PA BvD; (PA for ESRD
Only)
PA BvD; (PA for ESRD
Only)
QL (1 per 180 days)
QL (1 per 28 days)
QL (30 per 28 days)
PA
PA BvD; (PA for ESRD
Only)
1
1
1
QL (100 per 300 days)
1
PA BvD
1
PA
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
ACTEMRA INTRAVENOUS
SOLUTION 200 MG/10 ML (20 MG/ML)
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VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
117
Effective: January 01, 2016
Drug Name
ACTEMRA SUBCUTANEOUS
ACTIMMUNE
allopurinol
amifostine crystalline
ammonium chloride
anticoag citrate phos dextrose
AVONEX (WITH ALBUMIN)
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
COPAXONE SUBCUTANEOUS
SYRINGE 40 MG/ML
CYSTADANE
dexrazoxane hcl intravenous recon soln
droperidol injection solution
ELMIRON
ergoloid
EXTAVIA SUBCUTANEOUS
finasteride oral tablet 5 mg
fomepizole
FUSILEV
GAUZE PAD TOPICAL BANDAGE 2 X
2"
GILENYA
GLUCAGEN HYPOKIT
GLUCAGON EMERGENCY KIT
(HUMAN)
Drug Tier Requirements/Limits
(Zyloprim)
(Ethyol)
(Ammonium Chloride)
(Citrate Phosphate
Dextros Soln)
(Urecholine)
(Buspirone HCl)
(Colcrys)
(Colchicine/Probenecid)
(Totect)
(Droperidol)
(Ergoloid Mesylates)
(Proscar)
(Fomepizole)
1
1
1
1
1
1
PA
1
1
1
1
ST
ST
ST
PA
1
1
1
ST
1
PA; QL (1 per 90 days)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
PA; QL (4 per 90 days)
PA
ST
PA; QL (28 per 28 days)
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VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
118
Effective: January 01, 2016
Drug Name
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
mesna
MESNEX ORAL
MESTINON ORAL SYRUP
MESTINON TIMESPAN
methylergonovine injection
morrhuate sodium
MYOBLOC INTRAMUSCULAR
SOLUTION 5,000 UNIT/ML
NPLATE SUBCUTANEOUS RECON
SOLN
OTEZLA
OTEZLA STARTER
OTREXUP (PF)
PLEGRIDY
probenecid
PROCYSBI
pyridostigmine bromide oral tablet
RASUVO (PF)
REBIF (WITH ALBUMIN)
REBIF REBIDOSE
REBIF TITRATION PACK
REMICADE
SENSIPAR ORAL TABLET 30 MG
Drug Tier Requirements/Limits
(Guanidine HCl)
(Hydroxyzine HCl)
(Hydroxyzine HCl)
(Hydroxyzine HCl)
(Vistaril)
(Leucovorin Calcium)
1
1
1
1
1
1
1
1
(Leucovorin Calcium)
(Levocarnitine (With
Sugar))
(Carnitor)
1
1
(Mesnex)
1
1
1
1
1
(Methylergonovine
Maleate)
(Sodium Morrhuate)
(Probenecid)
(Mestinon)
1
PA-HRM
PA-HRM
PA-HRM
PA-HRM
QL (30 per 30 days)
PA
PA BvD; (PA for ESRD
Only)
PA BvD; (PA for ESRD
Only)
1
1
QL (1 per 90 days)
1
PA; QL (8 per 28 days)
1
1
1
1
1
1
1
1
1
1
1
1
1
PA; QL (60 per 30 days)
PA; QL (60 per 30 days)
ST
PA
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VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
119
Effective: January 01, 2016
Drug Name
Drug Tier Requirements/Limits
SENSIPAR ORAL TABLET 60 MG, 90
MG
SIGNIFOR
SIMPONI ARIA
SIMPONI SUBCUTANEOUS SYRINGE
STELARA SUBCUTANEOUS
SYRINGE
STERILE PADS TOPICAL BANDAGE 2
X2"
SYNAREL
TECFIDERA ORAL
CAPSULE,DELAYED
RELEASE(DR/EC) 120 MG
TECFIDERA ORAL
CAPSULE,DELAYED
RELEASE(DR/EC) 120 MG (14)- 240
MG (46), 240 MG
THALOMID
1
1
1
1
1
QL (60 per 30 days)
PA
PA
PA
1
TYBOST
ULORIC
XELJANZ
1
1
PA; QL (14 per 30 days)
1
PA; QL (60 per 30 days)
1
PA NSO; QL (60 per 30
days)
QL (30 per 30 days)
ST; QL (30 per 30 days)
PA; QL (60 per 30 days)
1
1
1
Non-Frf
Non-Frf
ibandronate intravenous syringe
(Ibandronate Sodium)
1
megestrol oral suspension 625 mg/5 ml
(Megestrol Acetate)
1
(Diamox Sequels)
1
(Acetazolamide)
(Acetazolamide Sodium)
1
1
1
PA BvD; QL (3 per 84
days)
Ophthalmic Agents
Antiglaucoma Agents
acetazolamide oral capsule, extended
release
acetazolamide oral tablet
acetazolamide sodium
ALPHAGAN P OPHTHALMIC DROPS
0.1 %
AZOPT
betaxolol ophthalmic
BETOPTIC S
(Betaxolol HCl)
1
1
1
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VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
120
Effective: January 01, 2016
Drug Name
brimonidine
COMBIGAN
dorzolamide
dorzolamide-timolol
latanoprost
levobunolol
LUMIGAN OPHTHALMIC DROPS 0.01
%
methazolamide oral
metipranolol
PHOSPHOLINE IODIDE
pilocarpine hcl ophthalmic drops 1 %, 2
%, 4 %
SIMBRINZA
timolol maleate ophthalmic drops
timolol maleate ophthalmic gel forming
solution
TRAVATAN Z
travoprost (benzalkonium)
Drug Tier Requirements/Limits
(Alphagan P)
(Trusopt)
(Cosopt)
(Xalatan)
(Betagan)
(Neptazane)
(Metipranolol)
1
1
1
1
1
1
1
(Isopto Carpine)
1
1
1
1
(Timolol Maleate)
(Timoptic-Xe)
1
1
1
(Travoprost
(Benzalkonium))
ZIOPTAN (PF)
(drops: 0.15%, 0.20%)
QL (2.5 per 25 days)
1
1
QL (2.5 per 25 days)
QL (2.5 per 25 days)
1
QL (30 per 30 days)
Replacement Preparations
Replacement Preparations
calcium chloride intravenous
calcium gluconate intravenous
(Calcium Chloride)
(Calcium Gluconate)
1
1
citric acid-sodium citrate
(Citric Acid/Sodium
Citrate)
(Dextrose 10 % and 0.45
% NaCl)
(Dextrose 2.5 % and
0.45 % NaCl)
(Dextrose 5 % and 0.9 %
NaCl)
(Dextrose 5 %-0.45 %
NaCl)
(Dextrose 10 % and 0.2
% NaCl)
1
d10 % & 0.45 % sodium chloride
d2.5 %-0.45 % sodium chloride
d5 % and 0.9 % sodium chloride
d5 %-0.45 % sodium chloride
dextrose 10 % and 0.2 % nacl
PA BvD; (PA for ESRD
Only)
1
1
1
1
1
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VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
121
Effective: January 01, 2016
Drug Name
dextrose 5 %-lactated ringers
dextrose 5%-0.2 % sod chloride
dextrose 5%-0.3 % sod.chloride
dextrose with sodium chloride
electrolyte-48 in d5w
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
klor-con 10
klor-con m10
klor-con m15
klor-con m20
magnesium chloride injection
magnesium sulfate in d5w intravenous
piggyback 1 gram/100 ml
magnesium sulfate in water intravenous
piggyback 4 gram/100 ml (4 %), 4
gram/50 ml (8 %)
magnesium sulfate injection
NORMOSOL-M IN 5 % DEXTROSE
NORMOSOL-R PH 7.4
NUTRILYTE
NUTRILYTE II
phosphorus #1
PLASMA-LYTE 148
PLASMA-LYTE A
PLASMA-LYTE-56 IN 5 % DEXTROSE
potassium acetate intravenous
potassium bicarb and chloride
Drug Tier Requirements/Limits
(Dextrose 5%-Lactated
Ringers)
(Dextrose 5 %-0.2 %
NaCl)
(Dextrose 5 % and 0.3 %
NaCl)
(Dextrose 5 %-0.2 %
NaCl)
(Electrolyte-48
Solution/D5W)
(Potassium Chloride)
(Potassium Chloride)
(Potassium Chloride)
(Potassium Chloride)
(Magnesium Chloride)
(Magnesium
Sulfate/D5W)
(Magnesium Sulfate in
Water)
(Magnesium Sulfate)
(K-Phos Neutral)
(Potassium Acetate)
(Pot Chloride/Pot
Bicarb/Cit Ac)
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
You can find information on what the symbols and abbreviations in this table mean by going
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VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
122
Effective: January 01, 2016
Drug Name
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 in lr-d5 intravenous
parenteral solution
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
potassium chloride oral tablet,er
particles/crystals 20 meq
potassium chloride-0.45 % nacl
potassium chloride-d5-0.2%nacl
potassium chloride-d5-0.3%nacl
intravenous parenteral solution 20 meq/l
potassium chloride-d5-0.9%nacl
potassium citrate
potassium citrate-citric acid oral packet
potassium phosphate dibasic
ringers intravenous
sodium acetate intravenous
Drug Tier Requirements/Limits
(Klor-Con-Ef)
(Klor-Con-Ef)
1
1
(Potassium Chloride/D50.45nacl)
(Potassium Chloride In
0.9%NaCl)
1
(Potassium Chloride In
D5w)
1
(Potassium Chloride In
Lr-D5)
(Potassium Chloride)
(Micro-K)
1
(Potassium Chloride)
(Klor-Con)
(K-Tab ER)
1
1
1
(K-Tab ER)
1
(Potassium Chloride)
1
(Potassium Chloride0.45% NaCl)
(Potassium Chloride/D50.2%NaCl)
(Potassium Chloride/D50.3%NaCl)
(Potassium Chloride/D50.9%NaCl)
(Urocit-K)
(Potassium Citrate/Citric
Acid)
(Potassium Phos,MBasic-D-Basic)
(Ringers Solution)
(Sodium Acetate)
1
1
1
1
1
1
1
1
1
1
1
1
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VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
123
Effective: January 01, 2016
Drug Name
Drug Tier Requirements/Limits
sodium bicarbonate intravenous solution 1 (Sodium Bicarbonate)
meq/ml (8.4 %)
(Sodium Bicarbonate)
sodium bicarbonate intravenous syringe
(Sodium Chloride 0.45
sodium chloride 0.45 % intravenous
%)
(0.9 % Sodium
sodium chloride 0.9 % injection solution
Chloride)
(0.9 % Sodium
sodium chloride 0.9 % intravenous
Chloride)
(Sodium Chloride 3 %)
sodium chloride 3 %
(Sodium Chloride 5 %)
sodium chloride 5 %
(Sodium Chloride)
sodium chloride intravenous
(Citric Acid/Sodium
sodium citrate-citric acid
Citrate)
(Sodium Lactate)
sodium lactate intravenous
(Sodium Phos,M-Basicsodium phosphate
D-Basic)
(Sod/Pot/K Cit/Sod
sod-pot-k cit-sod cit-cit acid
Cit/Cit Acid)
TPN ELECTROLYTES
TPN ELECTROLYTES II
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Respiratory Tract Agents
Anti-Inflammatories, Inhaled Corticosteroids
ADVAIR DISKUS
ADVAIR HFA
BREO ELLIPTA INHALATION
BLISTER WITH DEVICE 100-25
MCG/DOSE
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
1
1
1
QL (60 per 30 days)
QL (12 per 28 days)
QL (60 per 30 days)
1
1
QL (13 per 28 days)
QL (60 per 30 days)
1
QL (120 per 30 days)
1
QL (12 per 28 days)
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VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
124
Effective: January 01, 2016
Drug Name
Drug Tier Requirements/Limits
FLOVENT HFA INHALATION HFA
AEROSOL INHALER 220
MCG/ACTUATION
FLOVENT HFA INHALATION HFA
AEROSOL INHALER 44
MCG/ACTUATION
QVAR
1
QL (24 per 28 days)
1
QL (21.2 per 28 days)
1
QL (17.4 per 25 days)
Antileukotrienes
montelukast
zafirlukast
(Singulair)
(Accolate)
1
1
(Albuterol Sulfate)
1
(Albuterol Sulfate)
(Albuterol Sulfate)
(Vospire ER)
1
1
1
Bronchodilators
albuterol sulfate inhalation solution for
nebulization
albuterol sulfate oral syrup
albuterol sulfate oral tablet
albuterol sulfate oral tablet extended
release 12 hr
ATROVENT HFA
COMBIVENT RESPIMAT
FORADIL AEROLIZER
metaproterenol oral
PROAIR HFA
PROAIR RESPICLICK
SEREVENT DISKUS
SPIRIVA RESPIMAT
SPIRIVA WITH HANDIHALER
STRIVERDI RESPIMAT
terbutaline oral
terbutaline subcutaneous
theophylline anhydrous oral elixir 80
mg/15 ml
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
(Metaproterenol Sulfate)
(Terbutaline Sulfate)
(Terbutaline Sulfate)
(Theophylline
Anhydrous)
(Theophylline
Anhydrous)
(Theophylline/D5W)
1
1
1
1
1
1
1
1
1
1
1
1
1
PA BvD
QL (25.8 per 28 days)
QL (8 per 30 days)
QL (60 per 30 days)
QL (17 per 25 days)
QL (2 per 30 days)
QL (60 per 30 days)
QL (4 per 30 days)
QL (30 per 30 days)
QL (4 per 28 days)
1
1
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VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
125
Effective: January 01, 2016
Drug Name
theophylline oral
theophylline oral
theophylline oral
Drug Tier Requirements/Limits
(Theophylline
Anhydrous)
(Theophylline
Anhydrous)
(Theophylline
Anhydrous)
TUDORZA PRESSAIR
VENTOLIN HFA
1
1
1
1
1
QL (1 per 28 days)
QL (36 per 25 days)
1
1
1
1
1
PA BvD
PA BvD
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)
Respiratory Tract Agents, Other
acetylcysteine
acetylcysteine solution
cromolyn inhalation
DALIRESP
ESBRIET
(Acetadote)
(Acetadote)
(Cromolyn Sodium)
KALYDECO
OFEV
PROLASTIN-C
XOLAIR
1
1
1
1
PA
Skeletal Muscle Relaxants
Skeletal Muscle Relaxants
baclofen
carisoprodol
(Baclofen)
(Soma)
1
1
chlorzoxazone
cyclobenzaprine oral tablet 10 mg, 5 mg
dantrolene
dantrolene sodium
metaxalone
methocarbamol oral
tizanidine
(Parafon Forte DSC)
(Fexmid)
(Dantrium)
(Dantrium)
(Skelaxin)
(Robaxin)
(Zanaflex)
1
1
1
1
1
1
1
PA-HRM; QL (120 per
30 days)
PA-HRM
PA-HRM
PA-HRM
PA-HRM
Sleep Disorder Agents
Sleep Disorder Agents
HETLIOZ
NUVIGIL
ROZEREM
XYREM
1
1
1
1
PA; QL (30 per 30 days)
PA
LA
You can find information on what the symbols and abbreviations in this table mean by going
to the introduction pages of this document
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
126
Effective: January 01, 2016
Drug Name
Drug Tier Requirements/Limits
zaleplon
(Sonata)
1
zolpidem oral tablet
(Ambien)
1
zolpidem oral tablet,ext release multiphase (Ambien CR)
1
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
non-benzodiazepine
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
non-benzodiazepine
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
non-benzodiazepine
hypnotic drug); QL (30
per 30 days)
Vasodilating Agents
Vasodilating Agents
ADCIRCA
ADEMPAS
CIALIS ORAL TABLET 2.5 MG, 5 MG
epoprostenol (glycine) intravenous recon
soln 0.5 mg
epoprostenol (glycine) intravenous recon
soln 1.5 mg
LETAIRIS
OPSUMIT
ORENITRAM ORAL TABLET
EXTENDED RELEASE 0.125 MG
(Flolan)
1
1
1
1
PA; QL (60 per 30 days)
PA; QL (90 per 30 days)
PA; QL (30 per 30 days)
PA BvD
(Flolan)
1
PA BvD
1
1
1
PA; QL (30 per 30 days)
PA; QL (30 per 30 days)
PA
You can find information on what the symbols and abbreviations in this table mean by going
to the introduction pages of this document
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
127
Effective: January 01, 2016
Drug Name
Drug Tier Requirements/Limits
ORENITRAM ORAL TABLET
EXTENDED RELEASE 0.25 MG, 1 MG,
2.5 MG
REMODULIN
(Revatio)
sildenafil intravenous
(Revatio)
sildenafil oral
TRACLEER
1
PA
1
1
1
1
TYVASO
TYVASO REFILL KIT
TYVASO STARTER KIT
1
1
1
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
Vitamins And Minerals
Vitamins And Minerals
pedi m.vit no.17 with fluoride oral
tablet,chewable 0.5 mg
prenatal vitamins oral tablet 27 mg iron- 1
mg
sodium fluoride oral tablet
(Pedi M.Vit No.17 with
Fluoride)
(Pnv with
Ca,No.72/Iron/Fa)
(Pedi M.Vit No.17 with
Fluoride)
1
1
(All Rx Prenatal
Vitamins Covered)
1
You can find information on what the symbols and abbreviations in this table mean by going
to the introduction pages of this document
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
128
Effective: January 01, 2016
INDEX
8
8-MOP .................................... 99
A
abacavir .................................. 81
abacavir-lamivudine-zidovudine
............................................ 81
ABELCET .............................. 74
ABILIFY DISCMELT ........... 79
ABILIFY MAINTENA .......... 79
ABRAXANE .......................... 62
acamprosate ............................ 53
acarbose .................................. 72
acebutolol ............................... 91
acetaminophen-codeine .......... 49
acetazolamide ....................... 120
acetazolamide sodium .......... 120
acetic acid ..................... 105, 116
acetylcysteine ....................... 126
acitretin ................................... 99
ACTEMRA .................. 117, 118
ACTHIB (PF) ....................... 114
ACTIMMUNE ..................... 118
ACTONEL ........................... 116
ACTOPLUS MET XR ........... 72
acyclovir ........................... 83, 99
acyclovir sodium .................... 83
ADACEL(TDAP
ADOLESN/ADULT)(PF) 114
ADAGEN ............................. 103
adapalene .............................. 102
ADCETRIS ............................ 62
ADCIRCA ............................ 127
adefovir................................... 83
ADEMPAS ........................... 127
ADVAIR DISKUS ............... 124
ADVAIR HFA ..................... 124
AFINITOR ............................. 62
AFINITOR DISPERZ ........... 62
AGGRENOX ......................... 86
AKTEN (PF) ....................... 104
ALBENZA............................. 78
ALBUKED-25 ....................... 86
ALBUKED-5 ......................... 86
ALBUMIN, HUMAN 25 % .. 86
ALBUMIN, HUMAN 5 % .... 86
ALBUMINAR 25 %.............. 86
ALBUMINAR 5 %................ 86
ALBURX (HUMAN) 5 %..... 86
ALBUTEIN 25 % .................. 86
ALBUTEIN 5 % .................... 87
albuterol sulfate ................... 125
alclometasone ...................... 100
ALCOHOL PADS ................. 99
ALCOHOL PREP PADS ...... 99
ALDURAZYME ................. 103
alendronate........................... 116
alfuzosin............................... 109
ALIMTA................................ 62
ALINIA ................................. 78
allopurinol............................ 118
ALPHAGAN P .................... 120
alprazolam ............................. 54
ALREX ................................ 106
altacaine ............................... 104
ALTOPREV .......................... 94
amantadine hcl ....................... 78
AMBISOME.......................... 74
amifostine crystalline ........... 118
amiloride ................................ 94
amiloride-hydrochlorothiazide
........................................... 94
AMINO ACIDS 15 % ........... 87
aminocaproic acid .................. 86
AMINOSYN 10 % ................ 87
AMINOSYN 3.5 % ................ 87
AMINOSYN 7 % ................... 87
AMINOSYN 7 % WITH
ELECTROLYTES ............. 87
AMINOSYN 8.5 % ................ 87
AMINOSYN 8.5 %ELECTROLYTES ............. 87
AMINOSYN II 10 % ............. 87
AMINOSYN II 15 % ............. 87
AMINOSYN II 7 % ............... 87
AMINOSYN II 8.5 % ............ 87
AMINOSYN II 8.5 %ELECTROLYTES ............. 87
AMINOSYN M 3.5 % ........... 87
AMINOSYN-HBC 7% .......... 87
AMINOSYN-PF 10 % ........... 87
AMINOSYN-PF 7 %
(SULFITE-FREE) .............. 87
AMINOSYN-RF 5.2 % ......... 87
amiodarone ............................. 90
amiodarone hcl ....................... 90
AMITIZA............................. 107
amitriptyline ........................... 70
amlodipine.............................. 93
amlodipine-atorvastatin.......... 94
amlodipine-benazepril............ 93
amlodipine-valsartan .............. 93
amlodipine-valsartan-hcthiazid
............................................ 93
ammonium chloride ............. 118
ammonium lactate .................. 99
amoxapine .............................. 70
amoxicil-clarithromy-lansopraz
.......................................... 106
amoxicillin ............................. 60
amoxicillin-pot clavulanate .... 60
amphetamine salt combo........ 96
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VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
Effective: January 01, 2016
amphotericin b ........................ 75
ampicillin................................ 60
ampicillin sodium ............. 60, 61
ampicillin-sulbactam .............. 61
AMPYRA ............................... 96
ANACAINE ........................... 99
anagrelide ............................... 86
anastrozole .............................. 62
ANDRODERM .................... 109
ANDROGEL ........................ 110
anticoag citrate phos dextrose
.......................................... 118
APOKYN ............................... 78
apraclonidine ........................ 104
APRISO ................................ 116
APTIOM................................. 68
APTIVUS ............................... 81
ARCALYST ......................... 113
aripiprazole ............................. 79
ASACOL HD ....................... 116
ashlyna .................................... 97
ASSURE ID INSULIN
SAFETY ........................... 103
ASTAGRAF XL .................. 113
atenolol ................................... 91
atenolol-chlorthalidone........... 91
atorvastatin ............................. 94
atovaquone ............................. 78
atovaquone-proguanil ............. 78
ATRIPLA ............................... 81
atropine ........................... 68, 104
ATROVENT HFA ............... 125
AUBAGIO ........................... 113
AURYXIA ........................... 108
AVASTIN .............................. 62
AVC VAGINAL .................... 76
AVONEX ............................. 118
AVONEX (WITH ALBUMIN)
.......................................... 118
AXIRON .............................. 110
azacitidine............................... 63
azathioprine .......................... 113
azathioprine sodium ............. 113
azelastine ............................. 104
AZILECT............................... 78
azithromycin .......................... 59
AZOPT ................................ 120
AZOR .................................... 93
aztreonam............................... 60
B
bacitracin ....................... 57, 105
bacitracin-polymyxin b ........ 105
baclofen ............................... 126
balsalazide ........................... 116
BANZEL ............................... 68
BARACLUDE ....................... 83
BCG VACCINE, LIVE (PF) 114
BD ECLIPSE LUER-LOK .. 103
BD INSULIN PEN NEEDLE
UF SHORT ...................... 103
BD INSULIN SYRINGE
ULTRA-FINE.................. 103
BELEODAQ.......................... 63
benazepril............................... 90
benazepril-hydrochlorothiazide
........................................... 90
BENICAR.............................. 89
BENICAR HCT..................... 89
BENLYSTA ........................ 118
benztropine ............................ 78
BEPREVE ........................... 104
betamethasone acet,sod phos 111
betamethasone dipropionate 100
betamethasone valerate 100, 101
betamethasone, augmented .. 101
BETASERON...................... 118
betaxolol ........................ 91, 120
bethanechol chloride ............ 118
BETHKIS .............................. 56
BETOPTIC S ....................... 120
BEXSERO (PF) ................... 114
bicalutamide........................... 63
BICILLIN C-R ...................... 61
BICILLIN L-A ...................... 61
bisoprolol fumarate ................ 91
bisoprolol-hydrochlorothiazide
............................................ 91
bleomycin ............................... 63
BLEPHAMIDE .................... 105
BLEPHAMIDE S.O.P. ........ 105
BLINCYTO ........................... 63
BOOSTRIX TDAP .............. 114
BOSULIF ............................... 63
BOTOX ................................ 118
BREO ELLIPTA.................. 124
BRILINTA ............................. 86
brimonidine .......................... 121
BRINTELLIX ........................ 71
bromfenac ............................ 106
bromocriptine ......................... 78
budesonide ........................... 116
bumetanide ............................. 94
BUMINATE 25 % ................. 87
BUMINATE 5 % ................... 87
BUPHENYL ........................ 107
buprenorphine hcl ............ 49, 53
buprenorphine-naloxone ........ 53
bupropion hcl ................... 53, 71
buspirone .............................. 118
butalb-acetaminophen-caffeine
............................................ 49
butalbital-acetaminop-caf-cod 49
butalbital-acetaminophen ....... 49
butalbital-acetaminophen-caff 49
butalbital-aspirin-caffeine ...... 49
BUTRANS ............................. 49
BYSTOLIC ............................ 91
C
cabergoline ............................. 78
caffeine citrated ...................... 96
caffeine-sodium benzoate ...... 96
calcipotriene ........................... 99
calcitonin (salmon)............... 116
calcitriol ......................... 99, 117
calcium acetate ..................... 108
I-2
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
Effective: January 01, 2016
calcium carbonate-mag carb-fa
.......................................... 108
calcium chloride ................... 121
calcium gluconate ................. 121
CALDOLOR .......................... 51
CANCIDAS ........................... 75
candesartan ............................. 89
candesartan-hydrochlorothiazid
............................................ 89
CAPASTAT ........................... 77
CAPRELSA ........................... 63
captopril.................................. 90
captopril-hydrochlorothiazide 90
CARAFATE ......................... 106
CARBAGLU ........................ 107
carbamazepine ........................ 68
carbidopa ................................ 78
carbidopa-levodopa ................ 78
carbidopa-levodopa-entacapone
............................................ 78
carbinoxamine maleate ........... 76
CARIMUNE NF
NANOFILTERED ........... 113
carisoprodol .......................... 126
carteolol ................................ 104
cartia xt ................................... 91
carvedilol ................................ 91
CAYSTON ............................. 60
cefaclor ................................... 58
cefadroxil................................ 58
cefazolin ................................. 58
cefazolin in dextrose (iso-os) . 58
cefdinir ................................... 58
cefditoren pivoxil ................... 58
cefepime ................................. 58
CEFEPIME IN DEXTROSE 5
%......................................... 58
CEFEPIME IN
DEXTROSE,ISO-OSM...... 58
cefotaxime .............................. 59
cefoxitin.................................. 59
cefoxitin in dextrose, iso-osm 59
cefpodoxime .......................... 59
cefprozil ................................. 59
ceftazidime............................. 59
ceftibuten ............................... 59
ceftriaxone ............................. 59
CEFTRIAXONE ................... 59
ceftriaxone in dextrose,iso-os 59
CEFTRIAXONE IN
DEXTROSE,ISO-OS ........ 59
cefuroxime axetil ................... 59
cefuroxime sodium ................ 59
cefuroxime-dextrose (iso-osm)
........................................... 59
celecoxib ................................ 51
CELLCEPT INTRAVENOUS
......................................... 113
CELONTIN ........................... 68
cephalexin .............................. 59
CEPROTIN (BLUE BAR) .... 84
CERDELGA ........................ 118
CEREZYME........................ 103
CERVARIX VACCINE (PF)
......................................... 114
cevimeline .............................. 98
CHANTIX ............................. 53
CHANTIX CONTINUING
MONTH BOX ................... 53
CHANTIX CONTINUING
MONTH PAK.................... 53
CHANTIX STARTING
MONTH BOX ................... 53
chloramphenicol sod succinate
........................................... 57
chlordiazepoxide hcl .............. 54
chlorhexidine gluconate ......... 99
chloroquine phosphate ........... 78
chlorothiazide ........................ 94
chlorothiazide sodium............ 94
chlorpromazine ...................... 79
chlorthalidone ........................ 94
chlorzoxazone ...................... 126
cholestyramine (with sugar) .. 94
cholestyramine-aspartame 94, 95
choline,magnesium salicylate 51
CIALIS................................. 127
ciclopirox ............................... 75
ciclopirox-ure-camph-mentheuc ...................................... 75
cidofovir ................................. 83
cilostazol ................................ 86
CILOXAN............................ 105
cimetidine ............................. 107
cimetidine hcl ....................... 107
CIMZIA ............................... 113
CIMZIA POWDER FOR
RECONST ....................... 113
CINRYZE .............................. 85
CIPRODEX.......................... 105
ciprofloxacin .......................... 61
ciprofloxacin hcl ............ 61, 105
ciprofloxacin in 5 % dextrose 61
ciprofloxacin lactate ............... 61
citalopram .............................. 71
citric acid-sodium citrate...... 121
clarithromycin .................. 59, 60
clemastine .............................. 76
CLEVIPREX.......................... 93
clindamycin hcl ...................... 57
clindamycin in 5 % dextrose .. 57
clindamycin palmitate hcl ...... 57
clindamycin phosphate.... 57, 76,
100
CLINIMIX 5%/D15W
SULFITE FREE ................. 87
CLINIMIX 5%/D25W
SULFITE-FREE ................ 87
CLINIMIX 2.75%/D5W
SULFIT FREE ................... 87
CLINIMIX 4.25%/D10W SULF
FREE .................................. 87
CLINIMIX 4.25%/D5W
SULFIT FREE ................... 87
CLINIMIX 4.25%-D20W
SULF-FREE....................... 87
I-3
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
Effective: January 01, 2016
CLINIMIX 4.25%-D25W
SULF-FREE ....................... 87
CLINIMIX 5%D20W(SULFITE-FREE) ... 87
CLINIMIX E 2.75%/D10W
SUL FREE.......................... 87
CLINIMIX E 2.75%/D5W
SULF FREE ....................... 87
CLINIMIX E 4.25%/D10W
SUL FREE.......................... 88
CLINIMIX E 4.25%/D25W
SUL FREE.......................... 88
CLINIMIX E 4.25%/D5W
SULF FREE ....................... 88
CLINIMIX E 5%/D15W
SULFIT FREE.................... 88
CLINIMIX E 5%/D20W
SULFIT FREE.................... 88
CLINIMIX E 5%/D25W
SULFIT FREE.................... 88
CLINISOL SF 15 % ............... 88
clobetasol .............................. 101
clobetasol propionate............ 101
clobetasol-emollient ............. 101
clocortolone pivalate ............ 101
clomipramine .......................... 71
clonazepam ............................. 54
clonidine ................................. 89
clonidine hcl ..................... 89, 96
clonidine hcl-chlorthalidone ... 89
clopidogrel .............................. 86
clorazepate dipotassium ......... 54
clotrimazole ............................ 75
clotrimazole-betamethasone ... 75
clozapine................................. 79
COARTEM ............................ 78
codeine sulfate ........................ 49
codeine-butalbital-asa-caffein 49
colchicine ............................. 118
colchicine-probenecid .......... 118
colestipol ................................ 95
colistin (colistimethate na) ..... 57
COLY-MYCIN S ................ 105
COMBIGAN ....................... 121
COMBIPATCH ................... 110
COMBIVENT RESPIMAT. 125
COMETRIQ .......................... 63
COMPLERA ......................... 81
COMVAX (PF) ................... 114
CONDYLOX ......................... 99
COPAXONE ....................... 118
cortisone............................... 111
CORTISPORIN-TC ............ 105
COSENTYX (2 SYRINGES) 99
COSENTYX PEN ................. 99
COSENTYX PEN (2 PENS) . 99
CREON................................ 103
CRESTOR ............................. 95
CRIXIVAN............................ 81
cromolyn .............. 104, 107, 126
CUBICIN ............................... 57
cyclobenzaprine ................... 126
CYCLOGYL ....................... 104
cyclopentolate ...................... 104
cyclophosphamide ................. 63
CYCLOPHOSPHAMIDE ..... 63
CYCLOSET........................... 72
cyclosporine ......................... 113
cyclosporine modified ......... 113
cyclosporine, modified ........ 113
cyproheptadine....................... 76
CYRAMZA ........................... 63
CYSTADANE ..................... 118
CYSTARAN........................ 104
cysteine (l-cysteine) ............... 88
D
d10 % & 0.45 % sodium
chloride ............................ 121
d10 %-0.9 % sodium chloride 88
d2.5 %-0.45 % sodium chloride
......................................... 121
d5 % and 0.9 % sodium chloride
......................................... 121
d5 %-0.45 % sodium chloride
.......................................... 121
dactinomycin .......................... 63
DALIRESP .......................... 126
danazol ................................. 110
dantrolene ............................. 126
dantrolene sodium ................ 126
dapsone .................................. 77
DAPTACEL (DTAP
PEDIATRIC) (PF) ........... 114
DARAPRIM .......................... 78
DAUNOXOME ..................... 63
deblitane ................................. 97
decitabine ............................... 63
deferoxamine........................ 109
DELZICOL .......................... 116
DEMSER ............................... 92
DENAVIR.............................. 99
DEPEN TITRATABS.......... 109
DEPO-PROVERA ............... 112
desipramine ............................ 71
desmopressin ........................ 111
desog-e.estradiol/e.estradiol ... 97
desogestrel-ethinyl estradiol .. 97
desonide ............................... 101
desoximetasone .................... 101
DESVENLAFAXINE
FUMARATE...................... 71
dexamethasone ..................... 111
dexamethasone sodium
phosphate ................. 106, 111
DEXILANT ......................... 107
dexmethylphenidate ............... 96
dexrazoxane hcl ................... 118
dextroamphetamine ................ 96
dextroamphetamineamphetamine ...................... 96
dextrose 10 % and 0.2 % nacl
.......................................... 121
dextrose 10 % in water (d10w)
............................................ 88
I-4
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
Effective: January 01, 2016
dextrose 2.5 % in water(d2.5w)
............................................ 88
dextrose 20 % in water (d20w)
............................................ 88
dextrose 25 % in water (d25w)
............................................ 88
dextrose 40 % in water (d40w)
............................................ 88
dextrose 5 % in ringers ........... 88
dextrose 5 % in water (d5w) .. 88
dextrose 5 %-lactated ringers
.......................................... 122
dextrose 5%-0.2 % sod chloride
.......................................... 122
dextrose 5%-0.3 % sod.chloride
.......................................... 122
dextrose 50 % in water (d50w)
............................................ 88
dextrose 70 % in water (d70w)
............................................ 88
dextrose with sodium chloride
.......................................... 122
diazepam................................. 54
diazepam intensol ................... 54
diclofenac potassium .............. 51
diclofenac sodium .......... 51, 106
diclofenac-misoprostol ........... 51
dicloxacillin ............................ 61
dicyclomine .......................... 107
didanosine............................... 81
DIFICID ................................. 60
diflunisal ................................. 51
digitek ..................................... 92
digoxin.................................... 92
DIGOXIN ............................... 92
dihydroergotamine ................. 76
DILANTIN ............................. 68
diltiazem hcl ..................... 91, 92
dilt-xr ...................................... 92
dimenhydrinate ....................... 77
DIPENTUM ......................... 116
diphenhydramine hcl .............. 76
diphenoxylate-atropine ........ 107
disopyramide phosphate ........ 90
disulfiram ............................... 54
divalproex .............................. 68
dobutamine ............................ 93
dobutamine in d5w ................ 93
docetaxel ................................ 63
donepezil................................ 70
dopamine ............................... 93
dopamine in 5 % dextrose ..... 93
dorzolamide ......................... 121
dorzolamide-timolol ............ 121
doxazosin ............................... 89
doxepin .................................. 71
doxercalciferol ..................... 117
doxorubicin hcl ...................... 63
doxorubicin hcl peg-liposomal
........................................... 63
doxorubicin, peg-liposomal ... 63
doxycycline hyclate ............... 62
doxycycline monohydrate...... 62
dronabinol .............................. 77
droperidol............................. 118
drospirenone-ethinyl estradiol 97
DROXIA................................ 63
DUAVEE ............................. 110
DULERA ............................. 124
duloxetine .............................. 71
DUREZOL........................... 106
DYRENIUM.......................... 94
E
econazole ............................... 75
EDARBI ................................ 89
EDARBYCLOR .................... 89
EDURANT ............................ 81
EFFIENT ............................... 86
ELAPRASE ......................... 103
electrolyte-48 in d5w ........... 122
ELIDEL ............................... 101
ELIGARD........................ 63, 64
ELIQUIS................................ 84
ELITEK ............................... 103
ELLA ..................................... 97
ELMIRON ........................... 118
EMBEDA............................... 49
EMCYT.................................. 64
EMEND ................................. 77
EMSAM ................................. 71
EMTRIVA ............................. 81
enalapril maleate .................... 90
enalaprilat ............................... 90
enalapril-hydrochlorothiazide 90
ENBREL .............................. 113
ENBREL SURECLICK ....... 113
ENGERIX-B (PF) ................ 114
ENGERIX-B PEDIATRIC (PF)
.......................................... 114
enoxaparin .............................. 84
entacapone.............................. 78
entecavir ................................. 83
ephedrine sulfate .................... 93
epinastine ............................. 104
epinephrine............................. 93
EPIPEN 2-PAK...................... 93
EPIPEN JR 2-PAK ................ 93
EPIVIR HBV ......................... 81
eplerenone .............................. 95
EPOGEN ................................ 85
epoprostenol (glycine) ......... 127
EPZICOM .............................. 81
ergoloid ................................ 118
ERGOMAR............................ 76
ERIVEDGE............................ 64
ERYTHROCIN ...................... 60
erythromycin .................. 60, 105
erythromycin base .................. 60
ERYTHROMYCIN BASE .... 60
erythromycin base-ethanol ... 100
erythromycin ethylsuccinate .. 60
erythromycin stearate ............. 60
erythromycin with ethanol ... 100
erythromycin-benzoyl peroxide
.......................................... 100
ESBRIET ............................. 126
I-5
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
Effective: January 01, 2016
escitalopram oxalate ............... 71
esmolol ................................... 91
esomeprazole sodium ........... 107
estazolam .......................... 54, 55
ESTRACE ............................ 110
estradiol ................................ 110
estradiol valerate .................. 110
estradiol/norethindrone acet . 110
estradiol-norethindrone acet . 110
ESTRING ............................. 110
estropipate ............................ 110
ethambutol .............................. 77
ethamolin ................................ 93
ethinyl estradiol/drospirenone 97
ethosuximide .......................... 68
ethynodiol d-ethinyl estradiol. 97
etodolac .................................. 51
ETOPOPHOS ......................... 64
etoposide................................. 64
EURAX ................................ 102
EVOTAZ ................................ 81
EXELDERM .......................... 75
exemestane ............................. 64
EXJADE ............................... 109
EXTAVIA ............................ 118
F
FABRAZYME ..................... 103
famciclovir ............................. 83
famotidine............................. 107
famotidine (pf)...................... 107
famotidine (pf)-nacl (iso-os)107
FANAPT ................................ 79
FARESTON ........................... 64
FARYDAK............................. 64
FASLODEX ........................... 64
felbamate ................................ 68
felodipine ................................ 94
FEMRING ............................ 110
fenofibrate .............................. 95
fenofibrate micronized ........... 95
fenofibrate nanocrystallized ... 95
fenofibric acid ........................ 95
fenofibric acid (choline) ........ 95
fenoprofen .............................. 52
fentanyl .................................. 49
fentanyl citrate ....................... 49
FERRIPROX ....................... 109
FETZIMA .............................. 71
finasteride ............................ 118
FIRAZYR .............................. 93
FLEBOGAMMA DIF ......... 113
flecainide ............................... 90
FLECTOR ............................. 52
FLEXBUMIN 25 %............... 87
FLEXBUMIN 5 %................. 87
FLOVENT DISKUS............ 124
FLOVENT HFA .......... 124, 125
floxuridine ............................. 64
fluconazole............................. 75
fluconazole in dextrose(iso-o) 75
fluconazole in nacl (iso-osm) 75
flucytosine ............................. 75
fludrocortisone ..................... 111
flumazenil .............................. 96
flunisolide ............................ 106
fluocinonide ......................... 101
fluocinonide-emollient base 101
fluorometholone................... 106
FLUOROPLEX ..................... 99
fluorouracil ...................... 64, 99
fluoxetine ............................... 71
FLUOXETINE ...................... 71
fluoxymesterone .................. 110
fluphenazine decanoate.......... 79
fluphenazine hcl..................... 79
flurazepam ............................. 55
flurbiprofen ............................ 52
flurbiprofen sodium ............. 106
flutamide ................................ 64
fluticasone.................... 101, 106
fluvoxamine ........................... 71
fomepizole ........................... 118
fondaparinux .......................... 84
FORADIL AEROLIZER..... 125
FORTEO .............................. 117
FORTICAL .......................... 117
foscarnet ................................. 83
fosinopril ................................ 90
fosinopril-hydrochlorothiazide
............................................ 90
fosphenytoin ........................... 68
FOSRENOL ......................... 109
FREAMINE HBC 6.9 %........ 88
FREAMINE III 10 % ............. 88
furosemide.............................. 94
FUSILEV ............................. 118
FUZEON ................................ 81
FYCOMPA ............................ 68
G
gabapentin .............................. 68
GABITRIL ............................. 69
galantamine ............................ 70
GAMASTAN S/D................ 113
GAMMAGARD LIQUID .... 113
GAMMAPLEX .................... 113
GAMUNEX-C ..................... 113
ganciclovir sodium ................. 83
GARDASIL (PF) ................. 114
GARDASIL 9 (PF) .............. 114
gatifloxacin .......................... 105
GATTEX 30-VIAL.............. 107
GATTEX ONE-VIAL ......... 107
GAUZE PAD ....................... 118
GAZYVA ............................... 64
gemcitabine ............................ 64
gemfibrozil ............................. 95
GENOTROPIN .................... 111
GENOTROPIN MINIQUICK
.................................. 111, 112
gentamicin .............. 56, 100, 105
gentamicin in nacl (iso-osm) .. 56
gentamicin sulfate ................ 105
gentamicin sulfate (ped) (pf) .. 56
gentamicin sulfate (pf) ........... 56
GEODON ............................... 79
gildess 24 fe ........................... 97
I-6
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
Effective: January 01, 2016
GILENYA ............................ 118
GILOTRIF.............................. 64
GLEEVEC.............................. 64
glimepiride ............................. 74
glipizide .................................. 74
glipizide-metformin ................ 74
GLUCAGEN HYPOKIT ..... 118
GLUCAGON EMERGENCY
KIT (HUMAN) ................ 118
glyburide................................. 74
glyburide micronized.............. 74
glyburide-metformin .............. 74
glycopyrrolate....................... 107
glydo ....................................... 53
GLYSET................................. 72
GLYXAMBI .......................... 72
GRALISE ............................... 69
GRALISE 30-DAY STARTER
PACK ................................. 69
granisetron (pf) ....................... 77
granisetron hcl ........................ 77
GRANIX ................................ 85
griseofulvin microsize ............ 75
guanfacine ........................ 89, 96
guanidine .............................. 119
H
halobetasol propionate.......... 101
haloperidol .............................. 79
haloperidol decanoate ............. 79
haloperidol lactate .................. 79
HARVONI ............................. 83
HAVRIX (PF) ...................... 115
heparin (porcine) .................... 85
heparin (porcine) in 5 % dex .. 85
heparin (porcine) in nacl (pf) . 85
heparin sodium,porcine-pf ..... 85
heparin(porcine) in 0.45% nacl
............................................ 85
heparin, porcine (pf) ............... 85
HEPATAMINE 8%................ 88
HEPATASOL 8 % ................. 88
HERCEPTIN .......................... 64
HETLIOZ ............................ 126
HEXALEN ............................ 64
homatropine hbr................... 104
HUMIRA ............................. 113
HUMIRA CROHN'S DIS
START PCK .................... 113
HUMIRA PEN .................... 113
HUMULIN R U-500 ............. 73
hydralazine............................. 93
hydrochlorothiazide ............... 94
hydrocodone-acetaminophen . 49
hydrocodone-ibuprofen ......... 49
hydrocortisone ..... 101, 102, 111
hydrocortisone acet-aloe vera
......................................... 101
hydrocortisone acetate-urea . 101
hydrocortisone butyrate ....... 102
hydrocortisone butyr-emollient
......................................... 102
hydrocortisone sod succinate111
hydrocortisone valerate........ 102
hydromorphone...................... 50
hydromorphone (pf)......... 49, 50
hydroxychloroquine ............... 78
hydroxyurea ........................... 64
hydroxyzine hcl ................... 119
hydroxyzine pamoate ........... 119
HYPERLYTE CR................ 122
HYQVIA ............................. 113
I
ibandronate .................. 117, 120
IBRANCE.............................. 64
ibuprofen................................ 52
ICLUSIG ............................... 64
ifosfamide .............................. 64
ifosfamide-mesna................... 64
ILARIS (PF) ........................ 113
ILEVRO............................... 106
IMBRUVICA ........................ 64
imipenem-cilastatin ............... 60
imipramine hcl ....................... 71
imipramine pamoate .............. 71
imiquimod .............................. 99
IMOGAM RABIES-HT (PF)
.......................................... 113
IMOVAX RABIES VACCINE
(PF) .................................. 115
INCRELEX .......................... 112
indapamide ............................. 94
indomethacin .......................... 52
indomethacin sodium ............. 52
INFANRIX (DTAP) (PF) .... 115
INLYTA ........................... 64, 65
INSULIN PEN NEEDLE .... 103
INSULIN SYRINGE-NEEDLE
U-100 ............................... 103
INTELENCE.................... 81, 82
INTRALIPID ......................... 88
INTRON A............................. 83
INVANZ ................................ 60
INVEGA .......................... 79, 80
INVEGA SUSTENNA .......... 80
INVEGA TRINZA................. 80
INVIRASE ............................. 82
INVOKAMET ....................... 72
INVOKANA .......................... 72
IONOSOL-B IN D5W ......... 122
IONOSOL-MB IN D5W...... 122
IPOL ..................................... 115
ipratropium bromide ............ 104
IPRIVASK ............................. 85
irbesartan ................................ 89
irbesartan-hydrochlorothiazide
............................................ 89
ISENTRESS........................... 82
ISOLYTE M IN 5 %
DEXTROSE..................... 122
ISOLYTE-H IN 5 %
DEXTROSE..................... 122
ISOLYTE-P IN 5 %
DEXTROSE..................... 122
ISOLYTE-S ......................... 122
isoniazid ................................. 77
isosorbide dinitrate ................. 95
I-7
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
Effective: January 01, 2016
isosorbide mononitrate ........... 95
isotretinoin.............................. 99
isradipine ................................ 94
itraconazole ............................ 75
ivermectin ............................... 78
IXEMPRA .............................. 65
IXIARO (PF) ........................ 115
J
JAKAFI .................................. 65
JALYN ................................. 119
jantoven .................................. 85
JANUMET ............................. 72
JANUMET XR....................... 72
JANUVIA............................... 72
JARDIANCE .......................... 73
JENTADUETO ...................... 73
junel fe 24 ............................... 98
JUXTAPID ............................. 95
K
KABIVEN .............................. 88
KALETRA ............................. 82
KALYDECO ........................ 126
KAZANO ............................... 73
KEDBUMIN .......................... 87
ketoconazole ........................... 75
ketoprofen............................... 52
ketorolac ......................... 52, 106
KEYTRUDA .......................... 65
KINERET ............................. 113
KINRIX (PF) ........................ 115
klor-con 10 ........................... 122
klor-con m10 ........................ 122
klor-con m15 ........................ 122
klor-con m20 ........................ 122
KORLYM............................... 73
KRYSTEXXA ...................... 103
KUVAN ............................... 103
KYNAMRO ........................... 95
KYPROLIS ............................ 65
L
l norgest/e.estradiol-e.estrad ... 98
labetalol .................................. 91
LACRISERT ....................... 104
LACTATED RINGERS ...... 116
lactulose ............................... 107
LAMICTAL........................... 69
LAMICTAL ODT STARTER
(BLUE) .............................. 69
LAMICTAL ODT STARTER
(GREEN) ........................... 69
LAMICTAL ODT STARTER
(ORANGE) ........................ 69
lamivudine ............................. 82
lamivudine-zidovudine .......... 82
lamotrigine ............................. 69
LANOXIN ............................. 93
lansoprazole ......................... 107
LANTUS ............................... 73
LANTUS SOLOSTAR .......... 73
larin 24 fe ............................... 98
latanoprost ........................... 121
LATUDA ............................... 80
LAZANDA ............................ 50
leflunomide .......................... 114
LEMTRADA ....................... 119
LENVIMA ............................. 65
LETAIRIS ........................... 127
letrozole ................................. 65
leucovorin calcium .............. 119
LEUKERAN.......................... 65
LEUKINE .............................. 85
leuprolide ............................... 65
levetiracetam .......................... 69
levetiracetam in nacl (iso-os) . 69
levobunolol .......................... 121
levocarnitine ........................ 119
levocarnitine (with sugar) .... 119
levocetirizine ......................... 76
levofloxacin ................... 61, 105
levofloxacin in d5w ............... 61
levonorgestrel ........................ 98
levonorgestrel-ethin estradiol 98
levonorgestrel-ethinyl estrad . 98
levothyroxine ....................... 113
LEXIVA ................................. 82
lidocaine ................................. 53
lidocaine (pf) .................... 53, 90
lidocaine hcl ........................... 53
lidocaine in 5 % dextrose (pf) 90
lidocaine-prilocaine................ 53
linezolid.................................. 57
LINZESS.............................. 108
liothyronine .......................... 113
lipase-protease-amylase ....... 103
LIPOSYN II ........................... 88
LIPOSYN III.......................... 88
lisinopril ................................. 90
lisinopril-hydrochlorothiazide 90
lithium carbonate ............. 96, 97
lithium citrate ......................... 97
l-norgest-eth estr/ethin estra ... 98
lomustine ................................ 65
loperamide............................ 108
lorazepam oral solution .......... 55
losartan ................................... 89
losartan-hydrochlorothiazide . 89
LOTEMAX .......................... 106
LOTRONEX ........................ 108
lovastatin ................................ 95
loxapine succinate .................. 80
LUMIGAN ........................... 121
LUPRON DEPOT .................. 65
LUPRON DEPOT (3 MONTH)
............................................ 65
LUPRON DEPOT (4 MONTH)
............................................ 65
LUPRON DEPOT (6 MONTH)
............................................ 65
LUPRON DEPOT-PED ....... 112
LUPRON DEPOT-PED (3
MONTH).......................... 112
LYNPARZA .......................... 65
LYRICA................................. 69
LYSODREN .......................... 65
M
magnesium chloride ............. 122
I-8
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
Effective: January 01, 2016
magnesium sulfate ................ 122
magnesium sulfate in d5w .... 122
magnesium sulfate in water .. 122
malathion .............................. 102
maprotiline ............................. 71
MARPLAN ............................ 71
MARQIBO ............................. 65
MATULANE ......................... 65
matzim la ................................ 92
meclizine ................................ 77
medroxyprogesterone ........... 112
mefenamic acid ...................... 52
mefloquine .............................. 78
MEFOXIN IN DEXTROSE
(ISO-OSM) ......................... 59
MEGACE ES ....................... 112
megestrol ................ 65, 112, 120
MEKINIST ............................. 65
meloxicam .............................. 52
melphalan hcl intravenous ...... 65
MENACTRA (PF) ............... 115
MENEST .............................. 110
MENHIBRIX (PF) ............... 115
MENOMUNE - A/C/Y/W-135
(PF) ................................... 115
MENVEO A-C-Y-W-135-DIP
(PF) ................................... 115
MENVEO MENA
COMPONENT (PF) ......... 115
MENVEO MENCYW-135
COMPNT (PF) ................. 115
mercaptopurine ....................... 65
meropenem ............................. 60
mesna .................................... 119
MESNEX ............................. 119
MESTINON ......................... 119
MESTINON TIMESPAN .... 119
metaproterenol ...................... 125
metaxalone ........................... 126
metformin ............................... 73
methadone .............................. 50
methadone hcl ........................ 50
methazolamide ..................... 121
methenamine hippurate.......... 57
methenamine mandelate ........ 57
methimazole......................... 113
methocarbamol .................... 126
methotrexate sodium.............. 65
methotrexate sodium (pf)....... 65
methoxsalen rapid .................. 99
methscopolamine ................. 108
methyclothiazide .................... 94
methylergonovine ................ 119
methylphenidate..................... 97
methylprednisolone ............. 111
methylprednisolone acetate . 111
methylprednisolone sodium succ
......................................... 111
metipranolol ......................... 121
metoclopramide hcl ............. 108
metolazone ............................. 94
metoprolol succinate .............. 91
metoprolol ta-hydrochlorothiaz
........................................... 91
metoprolol tartrate ................. 91
metronidazole .......... 57, 76, 100
metronidazole in nacl (iso-os) 57
mexiletine .............................. 90
MIACALCIN....................... 117
miconazole nitrate.................. 75
midazolam ............................. 55
midodrine ............................... 89
milrinone................................ 93
milrinone in 5 % dextrose ...... 93
minitran............................ 95, 96
MINOCIN.............................. 62
minocycline ........................... 62
minoxidil................................ 96
MIRCERA ............................. 85
mirtazapine ............................ 71
misoprostol .......................... 107
mitoxantrone .......................... 65
M-M-R II (PF) ..................... 115
moexipril................................ 90
moexipril-hydrochlorothiazide
............................................ 90
mometasone ......................... 102
montelukast .......................... 125
morphine ................................ 50
MORPHINE........................... 50
morphine concentrate ............. 50
morrhuate sodium ................ 119
MOVANTIK ........................ 108
MOVIPREP ......................... 108
MOXEZA ............................ 105
moxifloxacin .......................... 61
MOZOBIL ............................. 86
MULTAQ .............................. 90
mupirocin ............................. 100
mupirocin calcium ............... 100
mycophenolate mofetil......... 114
mycophenolate sodium ........ 114
MYOBLOC.......................... 119
MYOZYME ......................... 103
MYRBETRIQ ...................... 109
N
nabumetone ............................ 52
nadolol.................................... 91
nafcillin .................................. 61
NAGLAZYME .................... 103
naloxone ................................. 54
naltrexone ............................... 54
naltrexone hcl ......................... 54
NAMENDA XR..................... 70
NAMZARIC .......................... 70
naphazoline .......................... 104
naproxen................................. 52
naproxen sodium .................... 52
naratriptan .............................. 76
NATACYN .......................... 105
nateglinide .............................. 73
NATPARA........................... 117
NEBUPENT........................... 78
nefazodone ............................. 71
neomy sulf-bacitrac zn-poly-hc
.......................................... 105
I-9
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
Effective: January 01, 2016
neomycin ................................ 56
neomycin-bacitracin-poly-hc105
neomycin-bacitracin-polymyxin
.......................................... 105
neomycin-polymyxin b gu ... 100
neomycin-polymyxin bdexameth .......................... 105
neomycin-polymyxingramicidin......................... 105
neomycin-polymyxin-hc ...... 105
neo-polycin ........................... 105
NEPHRAMINE 5.4 % ........... 88
NESINA ................................. 73
NEULASTA ........................... 86
NEUMEGA ............................ 86
NEUPOGEN .......................... 86
NEUPRO ................................ 78
NEVANAC .......................... 106
nevirapine ............................... 82
NEXAVAR ............................ 65
niacin ...................................... 95
nicardipine .............................. 94
NICOTROL ............................ 54
nifedipine ................................ 94
NILANDRON ........................ 66
NITRO-BID ........................... 96
nitrofurantoin macrocrystal .... 57
nitrofurantoin monohyd/m-cryst
............................................ 58
nitroglycerin ........................... 96
nitroglycerin in 5 % dextrose . 96
NITROSTAT .......................... 96
nizatidine .............................. 107
NORDITROPIN FLEXPRO 112
NORDITROPIN NORDIFLEX
.......................................... 112
norelgestromin/ethin.estradiol 98
norepinephrine bitartrate ........ 93
norethindrone ......................... 98
norethindrone (contraceptive) 98
norethindrone acetate ........... 112
norethindrone ac-eth estradiol 98
norethindrone-e.estradiol-iron 98
norethindrone-ethinyl estrad .. 98
norethindrone-mestranol ........ 98
norgestimate-ethinyl estradiol 98
norgestrel-ethinyl estradiol .... 98
NORMOSOL-M IN 5 %
DEXTROSE .................... 122
NORMOSOL-R PH 7.4....... 122
NORTHERA ......................... 89
nortriptyline ........................... 71
NORVIR ................................ 82
NOVOLIN 70/30 ................... 73
NOVOLIN N ......................... 73
NOVOLIN R ......................... 73
NOVOLOG ........................... 73
NOVOLOG FLEXPEN ......... 73
NOVOLOG MIX 70-30 ........ 73
NOVOLOG MIX 70-30
FLEXPEN.......................... 74
NOVOLOG PENFILL .......... 74
NOXAFIL.............................. 75
NPLATE .............................. 119
NUCYNTA............................ 50
NUCYNTA ER ..................... 50
NUEDEXTA ......................... 97
NULOJIX ............................ 114
NUTRESTORE ................... 108
NUTRILIPID ......................... 88
NUTRILYTE ....................... 122
NUTRILYTE II ................... 122
NUVARING .......................... 98
NUVIGIL............................. 126
nystatin................................... 75
NYSTATIN (BULK) ............. 75
nystatin-triamcinolone ........... 75
O
OCTAGAM ......................... 114
octreotide acetate ................. 112
OFEV ................................... 126
ofloxacin ................ 61, 105, 106
olanzapine .............................. 80
olanzapine-fluoxetine ............ 71
OLYSIO ................................. 83
omega-3 acid ethyl esters ....... 95
omeprazole ........................... 107
ONCASPAR .......................... 66
ondansetron ............................ 77
ondansetron hcl ...................... 77
ondansetron hcl (pf) ............... 77
ONFI .................................... 102
OPDIVO ................................ 66
OPSUMIT ............................ 127
ORAP ..................................... 80
ORENCIA ............................ 114
ORENCIA (WITH MALTOSE)
.......................................... 114
ORENITRAM .............. 127, 128
ORFADIN ............................ 103
OSENI .................................... 73
OTEZLA .............................. 119
OTEZLA STARTER ........... 119
OTREXUP (PF) ................... 119
oxacillin.................................. 61
oxacillin in dextrose(iso-osm) 61
oxaliplatin .............................. 66
oxandrolone.......................... 110
oxcarbazepine ........................ 69
OXTELLAR XR .................... 69
oxybutynin chloride ............. 109
oxycodone ........................ 50, 51
oxycodone hcl-acetaminophen
............................................ 50
oxycodone hcl-aspirin ............ 50
oxycodone-acetaminophen .... 51
oxycodone-aspirin .................. 51
OXYCONTIN ........................ 51
oxymorphone ......................... 51
P
pamidronate.......................... 117
PANRETIN ............................ 99
pantoprazole ......................... 107
papaverine .............................. 93
paricalcitol............................ 117
paromomycin ......................... 78
I-10
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
Effective: January 01, 2016
paroxetine hcl ......................... 71
PASER ................................... 77
PAXIL .................................... 71
pedi m.vit no.17 with fluoride
.......................................... 128
PEDIARIX (PF) ................... 115
PEDVAX HIB (PF).............. 115
peg 3350-electrolytes ........... 108
PEG 3350-GRX.................... 108
peg 3350-na sulf,bicarb,cl-kcl
.......................................... 108
PEGANONE .......................... 69
PEGASYS .............................. 83
PEGASYS PROCLICK ......... 83
peg-electrolyte soln .............. 108
PEGINTRON ......................... 83
penicillin g pot in dextrose ..... 61
penicillin g potassium............. 61
penicillin g procaine ............... 61
penicillin v potassium............. 61
PENTACEL (PF) ................. 115
PENTACEL ACTHIB
COMPONENT (PF) ......... 115
PENTACEL DTAP-IPV
COMPNT (PF) ................. 115
PENTAM ............................... 78
pentoxifylline ......................... 86
PERIKABIVEN ..................... 88
perindopril erbumine .............. 90
PERJETA ............................... 66
permethrin ............................ 102
perphenazine........................... 80
perphenazine-amitriptyline..... 72
PERTZYE ............................ 103
phenelzine............................... 72
phenobarbital .......................... 69
phenobarbital sodium ............. 69
phenylephrine hcl ........... 89, 104
phenytoin ................................ 69
phenytoin sodium ................... 69
phenytoin sodium extended .... 69
PHOSLYRA ......................... 109
PHOSPHOLINE IODIDE ... 121
phosphorus #1 ...................... 122
PICATO ................................. 99
pilocarpine hcl ............... 99, 121
pindolol .................................. 91
pioglitazone ........................... 73
pioglitazone-glimepiride........ 73
pioglitazone-metformin ......... 73
piperacillin-tazobactam ......... 61
piroxicam ............................... 52
PLASBUMIN 25 % ............... 87
PLASBUMIN 5 % ................. 87
PLASMA-LYTE 148 .......... 122
PLASMA-LYTE A.............. 122
PLASMA-LYTE-56 IN 5 %
DEXTROSE .................... 122
PLEGRIDY ......................... 119
podofilox................................ 99
podophyllum resin ................. 99
polyethylene glycol 3350..... 108
polymyxin b sulfate ............... 58
polymyxin b sulf-trimethoprim
......................................... 106
POMALYST.......................... 66
potassium acetate ................. 122
potassium bicarb and chloride
......................................... 122
potassium bicarb-citric acid . 123
potassium bicarbonate-cit ac 123
potassium chlorid-d5-0.45%nacl
......................................... 123
potassium chloride ............... 123
potassium chloride in 0.9%nacl
......................................... 123
potassium chloride in 5 % dex
......................................... 123
potassium chloride in lr-d5 .. 123
potassium chloride-0.45 % nacl
......................................... 123
potassium chloride-d5-0.2%nacl
......................................... 123
potassium chloride-d5-0.3%nacl
.......................................... 123
potassium chloride-d5-0.9%nacl
.......................................... 123
potassium citrate .................. 123
potassium citrate-citric acid . 123
potassium hydroxide .............. 99
potassium phosphate dibasic 123
POTIGA ................................. 70
PRADAXA ............................ 85
pramipexole............................ 78
PRANDIMET ........................ 73
pravastatin .............................. 95
prazosin .................................. 89
prednicarbate ........................ 102
prednisolone acetate ............. 106
prednisolone sodium phosphate
.................................. 106, 111
prednisone ............................ 111
PREDNISONE INTENSOL 111
PREMARIN ......................... 110
PREMASOL 10 % ................. 89
PREMASOL 6 % ................... 89
PREMPHASE ...................... 110
PREMPRO ........................... 110
prenatal vitamins .................. 128
PREPOPIK........................... 108
PREZCOBIX ......................... 82
PREZISTA ............................. 82
PRIFTIN ................................ 77
PRIMAQUINE ...................... 78
primidone ............................... 70
PRISTIQ ................................ 72
PRIVIGEN ........................... 114
PROAIR HFA ...................... 125
PROAIR RESPICLICK ....... 125
probenecid ............................ 119
procainamide .......................... 90
PROCALAMINE 3% ............ 89
prochlorperazine .................... 77
prochlorperazine edisylate ..... 77
prochlorperazine maleate ....... 77
I-11
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
Effective: January 01, 2016
PROCRIT ............................... 86
PROCYSBI .......................... 119
progesterone ......................... 112
progesterone micronized
capsules ............................ 113
PROGLYCEM ....................... 96
PROGRAF ........................... 114
PROLASTIN-C .................... 126
PROLENSA ......................... 106
PROLEUKIN ......................... 66
PROLIA ............................... 117
PROMACTA .......................... 86
promethazine .............. 76, 77, 78
promethazine hcl .................... 77
propafenone ............................ 91
propantheline .......................... 68
proparacaine ......................... 104
proparacaine hcl ................... 104
proparacaine-fluorescein sod 104
propranolol ............................. 91
propranolol-hydrochlorothiazid
............................................ 91
propylthiouracil .................... 113
PROQUAD (PF) .................. 115
PROSOL 20 % ....................... 89
protamine ................................ 86
protriptyline ............................ 72
PULMOZYME..................... 103
PURIXAN .............................. 66
pyrazinamide .......................... 77
pyridostigmine bromide ....... 119
Q
QUADRACEL (PF) ............. 115
quetiapine ............................... 80
QUILLIVANT XR ................. 97
quinapril ................................. 90
quinapril-hydrochlorothiazide 90
quinidine gluconate ................ 91
quinidine sulfate ..................... 91
quinine sulfate ........................ 78
QVAR................................... 125
R
RABAVERT (PF) ............... 115
raloxifene ............................. 110
ramipril .................................. 90
RANEXA............................... 93
ranitidine hcl ........................ 107
RAPAMUNE ....................... 114
RASUVO (PF)..................... 119
RAVICTI ............................. 108
REBIF (WITH ALBUMIN) 119
REBIF REBIDOSE ............. 119
REBIF TITRATION PACK 119
RECOMBIVAX HB (PF).... 115
REGRANEX ....................... 100
RELENZA DISKHALER ..... 83
RELISTOR .......................... 108
REMICADE ........................ 119
REMODULIN ..................... 128
RENAGEL........................... 109
RENVELA........................... 109
repaglinide ............................. 73
RESCRIPTOR ....................... 82
RESTASIS ........................... 106
RETROVIR ........................... 82
REVLIMID............................ 66
REYATAZ............................. 82
ribavirin ................................. 84
RIDAURA ........................... 114
rifabutin ................................. 77
rifampin ................................. 77
RIFATER............................... 77
riluzole ................................... 97
rimantadine ............................ 83
ringers .......................... 116, 123
risedronate ........................... 117
RISPERDAL CONSTA ........ 80
risperidone ....................... 80, 81
RITUXAN ............................. 66
rivastigmine tartrate ............... 70
rizatriptan ............................... 76
ropinirole ............................... 78
ROTARIX ........................... 115
ROTATEQ VACCINE ........ 115
ROZEREM .......................... 126
S
SABRIL ................................. 70
SAIZEN ............................... 112
SAIZEN CLICK.EASY ....... 112
salsalate .................................. 53
SANDOSTATIN LAR DEPOT
.......................................... 112
SANTYL .............................. 100
SAPHRIS (BLACK CHERRY)
............................................ 81
SAVAYSA............................. 85
SAVELLA ............................. 97
selegiline hcl .......................... 79
selenium sulfide ................... 100
SELZENTRY......................... 82
SENSIPAR................... 119, 120
SEREVENT DISKUS.......... 125
SEROQUEL XR .................... 81
SEROSTIM .......................... 112
sertraline ................................. 72
SIGNIFOR ........................... 120
sildenafil oral tablet 20 mg .. 128
SILENOR............................... 72
silver nitrate ......................... 100
silver nitrate applicators ....... 100
silver sulfadiazine ................ 100
SIMBRINZA........................ 121
SIMPONI ............................. 120
SIMPONI ARIA .................. 120
simvastatin ............................. 95
sirolimus ............................... 114
SIRTURO .............................. 77
sodium acetate ...................... 123
sodium bicarbonate .............. 124
sodium chloride ............ 116, 124
sodium chloride 0.45 % ....... 124
sodium chloride 0.9 % ......... 124
sodium chloride 3 % ............ 124
sodium chloride 5 % ............ 124
I-12
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
Effective: January 01, 2016
sodium chloride-nahco3-kcl-peg
.......................................... 108
sodium citrate-citric acid ...... 124
sodium fluoride .............. 99, 128
sodium lactate ....................... 124
sodium phosphate ................. 124
sodium polystyrene sulfonate
.......................................... 108
sodium thiosulfate ................ 109
sod-pot-k cit-sod cit-cit acid . 124
SOLTAMOX.......................... 66
SOLU-CORTEF (PF)........... 111
SOMATULINE DEPOT ...... 112
SOMAVERT ........................ 112
sorbitol.................................. 116
sorbitol-mannitol .................. 116
sotalol ..................................... 91
sotalol hcl ............................... 91
SOVALDI .............................. 83
SPIRIVA RESPIMAT.......... 125
SPIRIVA WITH
HANDIHALER ................ 125
spironolactone ........................ 95
spironolacton-hydrochlorothiaz
............................................ 95
SPORANOX .......................... 75
SPRYCEL .............................. 66
stavudine................................. 82
STELARA ............................ 120
STERILE PADS................... 120
STIMATE............................. 112
STIVARGA ............................ 66
STRATTERA ......................... 97
streptomycin ........................... 56
STRIBILD .............................. 82
STRIVERDI RESPIMAT .... 125
sucralfate .............................. 107
sulfacetamide sodium ........... 106
sulfacetamide sodium (acne) 100
sulfacetamide-prednisolone .. 106
sulfadiazine............................. 61
sulfamethoxazole-trimethoprim
........................................... 61
sulfasalazine........................... 61
sulfatrim ................................. 62
sulfazine ................................. 62
sulfazine ec ............................ 62
sulindac .................................. 53
sumatriptan nasal spray ......... 76
sumatriptan succinate ............ 76
SUPPRELIN LA.................. 112
SUPRAX ............................... 59
SURMONTIL ........................ 72
SUSTIVA .............................. 82
SUTENT ................................ 66
SYLATRON .......................... 83
SYLVANT............................. 66
SYMLINPEN 120 ................. 73
SYMLINPEN 60 ................... 73
SYNAGIS .............................. 83
SYNAREL ........................... 120
SYNERCID ........................... 58
SYNRIBO.............................. 66
SYPRINE............................. 109
T
TABLOID.............................. 66
tacrolimus .................... 102, 114
TAFINLAR ........................... 66
TAMIFLU ............................. 83
tamoxifen ............................... 66
tamsulosin ............................ 109
TARCEVA ............................ 66
TARGRETIN......................... 66
tarina fe .................................. 98
TASIGNA.............................. 66
TAZORAC .......................... 102
taztia xt .................................. 92
TECFIDERA ....................... 120
TEFLARO ............................. 59
TEGRETOL XR .................... 70
telmisartan ............................. 89
telmisartan-hydrochlorothiazid
........................................... 89
temazepam ....................... 55, 56
TEMODAR ............................ 67
teniposide ............................... 67
TENIVAC (PF) .................... 115
terazosin ............................... 109
terbinafine hcl ........................ 75
terbutaline ............................ 125
terconazole ............................. 76
testosterone .......................... 110
testosterone cypionate .......... 110
testosterone enanthate .......... 110
TETANUS
TOXOID,ADSORBED (PF)
.......................................... 115
TETANUS,DIPHTHERIA TOX
PED(PF) ........................... 115
TETANUS-DIPHTHERIA
TOXOIDS-TD ................. 115
tetracaine hcl (pf) ................. 104
tetracycline ............................. 62
TEVETEN HCT..................... 89
THALOMID ........................ 120
theophylline.......................... 126
theophylline anhydrous ........ 125
theophylline in dextrose 5 % 125
thioridazine ............................ 81
thiothixene.............................. 81
tiagabine ................................. 70
TICE BCG ........................... 116
TIKOSYN .............................. 91
timolol maleate............... 91, 121
TIVICAY ............................... 82
tizanidine .............................. 126
TOBI PODHALER ................ 56
TOBRADEX ........................ 106
TOBRADEX ST .................. 106
tobramycin ........................... 106
tobramycin in 0.225 % nacl ... 56
tobramycin in 0.9 % nacl ....... 57
tobramycin sulfate .................. 57
tolazamide .............................. 74
tolbutamide ............................ 74
I-13
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
Effective: January 01, 2016
tolmetin................................... 53
tolterodine............................. 109
topiramate ............................... 70
toposar intravenous ................ 67
topotecan ................................ 67
TORISEL ............................... 67
torsemide ................................ 94
TOUJEO SOLOSTAR ........... 74
TOVIAZ ............................... 109
TPN ELECTROLYTES ....... 124
TPN ELECTROLYTES II ... 124
TRACLEER ......................... 128
TRADJENTA ......................... 73
tramadol .................................. 51
tramadol-acetaminophen ........ 51
trandolapril ............................. 90
tranexamic acid ...................... 86
TRANSDERM-SCOP ............ 78
tranylcypromine ..................... 72
TRAVASOL 10 % ................. 89
TRAVATAN Z .................... 121
travoprost (benzalkonium) ... 121
trazodone ................................ 72
TREANDA ............................. 67
TRECATOR ........................... 77
TRELSTAR ............................ 67
tretinoin ................................ 102
tretinoin (chemotherapy) ........ 67
tretinoin microspheres .......... 102
TREXALL .............................. 67
triamcinolone acetonide 99, 102,
111
triamterene-hydrochlorothiazid
............................................ 94
triazolam ................................. 56
TRIBENZOR ......................... 89
trifluoperazine ........................ 81
trifluridine............................. 106
trihexyphenidyl....................... 79
trimethoprim ........................... 58
TRIUMEQ .............................. 82
TROKENDI XR ..................... 70
TROPHAMINE 10 %............ 89
TROPHAMINE 6%............... 89
trospium ............................... 109
TRULICITY .......................... 73
TRUMENBA ....................... 116
TRUVADA............................ 82
TUDORZA PRESSAIR ...... 126
TWINRIX (PF) .................... 116
TYBOST.............................. 120
TYGACIL.............................. 62
TYKERB ............................... 67
TYPHIM VI......................... 116
TYSABRI ............................ 114
TYVASO ............................. 128
TYVASO REFILL KIT ....... 128
TYVASO STARTER KIT... 128
TYZEKA ............................... 84
TYZINE ....................... 104, 105
U
ULORIC .............................. 120
ursodiol ................................ 108
V
VAGIFEM ........................... 110
valacyclovir ........................... 84
VALCHLOR ....................... 100
VALCYTE............................. 84
valganciclovir ........................ 84
valproate sodium.................... 70
valproic acid .......................... 70
valproic acid (as sodium salt) 70
valsartan ................................. 90
valsartan-hydrochlorothiazide 90
VALSTAR ............................. 67
vancomycin ............................ 58
vancomycin in d5w ................ 58
VAQTA (PF) ....................... 116
VARIVAX (PF)................... 116
VASCEPA ............................. 95
VECTIBIX............................. 67
VELCADE............................. 67
VELPHORO ........................ 108
venlafaxine............................. 72
VENTOLIN HFA ................ 126
verapamil................................ 92
VEREGEN ........................... 100
VERSACLOZ ........................ 81
VESICARE .......................... 109
VGO 40 ................................ 103
VICTOZA .............................. 73
VIDEX 2 GRAM PEDIATRIC
............................................ 82
VIDEX 4 GRAM PEDIATRIC
............................................ 83
VIGAMOX .......................... 106
VIIBRYD ............................... 72
VIMIZIM ............................. 103
VIMPAT ................................ 70
vincristine............................... 67
vincristine sulfate ................... 67
vinorelbine ............................. 67
VIRACEPT ............................ 83
VIRAMUNE XR ................... 83
VIRAZOLE............................ 84
VIREAD ................................ 83
VITEKTA .............................. 83
VOLTAREN .......................... 53
voriconazole ..................... 75, 76
VOTRIENT............................ 67
VPRIV.................................. 103
VYTORIN 10-10 ................... 95
VYTORIN 10-20 ................... 95
VYTORIN 10-40 ................... 95
VYTORIN 10-80 ................... 95
W
warfarin .................................. 85
water for irrigation, sterile ... 116
X
XALKORI.............................. 67
XARELTO ............................. 85
XARTEMIS XR..................... 51
XELJANZ ............................ 120
XENAZINE ........................... 97
XGEVA................................ 117
XIFAXAN.............................. 58
I-14
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
Effective: January 01, 2016
XOLAIR ............................... 126
XTANDI................................. 67
xylon 10 .................................. 51
XYREM ............................... 126
Y
YERVOY ............................... 67
YF-VAX (PF) ....................... 116
Z
zafirlukast ............................. 125
zaleplon ................................ 127
ZALTRAP .............................. 67
ZAVESCA ........................... 104
ZELBORAF ........................... 67
ZEMPLAR ........................... 117
ZENPEP............................... 104
ZETIA.................................... 95
ZIAGEN ................................ 83
zidovudine ............................. 83
ZIOPTAN (PF) .................... 121
ziprasidone hcl ....................... 81
ZIRGAN .............................. 106
ZOLADEX ............................ 67
zoledronic acid ..................... 117
zoledronic acid-mannitol-water
......................................... 117
ZOLINZA .............................. 68
zolmitriptan...................... 76, 77
zolpidem .............................. 127
ZOMETA ............................. 117
zonisamide ............................. 70
ZORTRESS.......................... 114
ZOSTAVAX (PF) ................ 116
ZOVIRAX............................ 100
ZUBSOLV ............................. 54
ZYDELIG .............................. 68
ZYKADIA ............................. 68
ZYLET ................................. 106
ZYPREXA RELPREVV ....... 81
ZYTIGA ................................. 68
ZYVOX.................................. 58
I-15
VNSNY CHOICE Medicare
Formulary ID: 16492.001, Version: 7
Effective: January 01, 2016
tolmetin................................. 53
tolterodine ........................... 111
topiramate ............................. 70
toposar intravenous ............... 67
topotecan .............................. 67
TORISEL.............................. 67
torsemide .............................. 96
TOUJEO SOLOSTAR .......... 74
TOVIAZ ............................. 111
TPN ELECTROLYTES ...... 126
TPN ELECTROLYTES II .. 126
TRACLEER........................ 130
TRADJENTA ....................... 74
tramadol................................ 51
tramadol-acetaminophen ....... 51
trandolapril ........................... 91
tranexamic acid ..................... 87
TRANSDERM-SCOP ........... 78
tranylcypromine .................... 72
TRAVASOL 10 % ................ 90
TRAVATAN Z ................... 123
travoprost (benzalkonium) .. 123
trazodone .............................. 72
TREANDA ........................... 67
TRECATOR ......................... 78
TRELSTAR .......................... 67
tretinoin .............................. 104
tretinoin (chemotherapy) ....... 67
tretinoin microspheres ......... 104
TREXALL ............................ 67
triamcinolone acetonide ..... 100,
104, 113
triamterene-hydrochlorothiazid
.......................................... 96
triazolam ............................... 56
TRIBENZOR ........................ 91
trifluoperazine ....................... 82
trifluridine ........................... 107
trihexyphenidyl ..................... 80
trimethoprim ......................... 58
TRIUMEQ ............................ 84
TROKENDI XR ................... 70
TROPHAMINE 10 % ............90
TROPHAMINE 6% ...............90
trospium .............................. 111
TRULICITY ..........................74
TRUMENBA....................... 117
TRUVADA ...........................84
TUDORZA PRESSAIR ....... 128
TWINRIX (PF) .................... 117
TYBOST ............................. 122
TYGACIL .............................62
TYKERB ...............................68
TYPHIM VI ........................ 118
TYSABRI ............................ 116
TYVASO............................. 130
TYVASO REFILL KIT .......130
TYVASO STARTER KIT ...130
TYZEKA ...............................85
TYZINE .............................. 106
U
ULORIC .............................. 122
ursodiol................................ 110
V
VAGIFEM........................... 112
valacyclovir ...........................85
VALCHLOR ....................... 101
VALCYTE ............................85
valganciclovir ........................85
valproate sodium....................70
valproic acid ..........................70
valproic acid (as sodium salt) .71
valsartan ................................91
valsartan-hydrochlorothiazide 91
VALSTAR ............................68
vancomycin ...........................58
vancomycin in d5w ................58
VAQTA (PF) ....................... 118
VARIVAX (PF)................... 118
VASCEPA.............................96
VECTIBIX ............................68
VELCADE ............................68
VELPHORO ........................ 110
venlafaxine ............................73
VENTOLIN HFA ................ 128
verapamil............................... 93
VEREGEN .......................... 101
VERSACLOZ ....................... 82
VESICARE ......................... 111
VGO 40 ............................... 104
VICTOZA ............................. 74
VIDEX 2 GRAM PEDIATRIC
.......................................... 84
VIDEX 4 GRAM PEDIATRIC
.......................................... 84
VIGAMOX ......................... 107
VIIBRYD .............................. 73
VIMIZIM ............................ 105
VIMPAT ............................... 71
vincristine .............................. 68
vincristine sulfate................... 68
vinorelbine ............................ 68
VIRACEPT ........................... 84
VIRAMUNE XR ................... 84
VIRAZOLE ........................... 85
VIREAD ............................... 84
VITEKTA ............................. 84
VOLTAREN ......................... 53
voriconazole .......................... 76
VOTRIENT ........................... 68
VPRIV ................................ 105
VYTORIN 10-10 ................... 96
VYTORIN 10-20 ................... 96
VYTORIN 10-40 ................... 96
VYTORIN 10-80 ................... 96
W
warfarin ................................. 86
water for irrigation, sterile ... 118
X
XALKORI ............................. 68
XARELTO ............................ 86
XARTEMIS XR .................... 51
XELJANZ ........................... 122
XENAZINE........................... 99
XGEVA............................... 119
XIFAXAN ............................. 58
I-14
VNS Choice Medicare
Formulary ID: 16492.001, Version: 7
Effective: January 01, 2016
XOLAIR ............................. 128
XTANDI ............................... 68
xylon 10 ................................ 51
XYREM ............................. 129
Y
YERVOY ............................. 68
YF-VAX (PF) ..................... 118
Z
zafirlukast ........................... 127
zaleplon .............................. 129
ZALTRAP ............................ 68
ZAVESCA.......................... 105
ZELBORAF.......................... 68
ZEMPLAR ......................... 119
ZENPEP .............................. 105
ZETIA ...................................96
ZIAGEN ................................84
zidovudine .............................84
ZIOPTAN (PF) .................... 123
ziprasidone hcl .......................82
ZIRGAN .............................. 107
ZOLADEX ............................68
zoledronic acid..................... 119
zoledronic acid-mannitol-water
........................................ 119
ZOLINZA .............................68
zolmitriptan ...........................77
zolpidem .............................. 129
ZOMETA ............................ 119
zonisamide ............................ 71
ZORTRESS ......................... 116
ZOSTAVAX (PF) ............... 118
ZOVIRAX ........................... 101
ZUBSOLV ............................ 54
ZYDELIG ............................. 68
ZYKADIA ............................ 68
ZYLET ................................ 107
ZYPREXA RELPREVV ....... 82
ZYTIGA ................................ 68
ZYVOX................................. 58
I-15
VNS Choice Medicare
Formulary ID: 16492.001, Version: 7
Effective: January 01, 2016
This formulary was updated on 08/29/2015. For more recent information or other
questions, please contact VNSNY CHOICE Medicare Member Services at
1-866-783-1444 or, for TTY users, 711, Monday through Friday from 8:00 AM to
8:00 PM or visit www.vnsnychoice.org.
Este formulario de medicamentos fue actualizado 08/29/2015. Para recibir
información más reciente o si tiene alguna otra duda, sírvase llamar al Servicio
para Miembros de Medicare de VNSNY CHOICE al 1-866-783-1444 o, para
aquellos que utilizan TTY, al 711, de lunes a viernes, de 8:00 AM a 8:00 PM o
visite www.vnsnychoice.org.
Ṉ⹦᪉㞟᭦᪂᪊ 2015 ᖺ 08᭶ 29 ᪥傏 ዴ㟂᭦ከ᭱᪂ⓗ㈨イᡈ᭷඼௚ၥ㢟凞 ㄳ⫃⤡ VNSNY
CHOICE Medicare ᭳ဨ᭹ົ㒊凞 㟁ヰ凬 1-866-783-1444凞 TTY ౑⏝⪅ㄳ᧕
711凞 㐌୍฿㐌஬凞 ᪩ୖ 8:00 ฿᫽ୖ 8:00凞 ᡈ㐀ゼ www.vnsnychoice.org傏
1250 Broadway, 11th floor, New York, NY 10001
www.vnsnychoice.org
VNSNY CHOICE Medicare
Any questions? Call toll free
1-866-783-1444 (TTY for the hearing impaired 711)
8 am – 8 pm, Monday – Friday
2016 FORMULARY OF COVERED PRESCRIPTION DRUGS
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN
This formulary was updated on 08/29/2015. For more recent information or other questions, please contact
VNSNY CHOICE Medicare Member Services at 1-866-783-1444 or, for TTY users, 711, Monday through Friday
from 8:00 AM to 8:00 PM or visit www.vnsnychoice.org
A Medicare Advantage Plan
2016 FORMULARY
OF COVERED
PRESCRIPTION DRUGS
VNSNY CHOICE Medicare
Approved Formulary Submission
ID Number: 16492.001, Version 7
VNSNY CHOICE Medicare Preferred (HMO SNP)
VNSNY CHOICE Total (HMO SNP)
VNSNY CHOICE Medicare Maximum (HMO SNP)
VNSNY CHOICE Medicare Classic (HMO)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN
This formulary was updated on 08/29/2015. For more recent information or other questions, please contact
VNSNY CHOICE Medicare Member Services at 1-866-783-1444 or, for TTY users, 711, Monday through Friday
from 8:00 AM to 8:00 PM or visit www.vnsnychoice.org
H5549_2016 Formulary_1085_DSB_rv_Accepted 09192015