Drugs Covered Under Medicaid 3-9-12 Appendix A
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AMENDED Appendix 5101:3-9-12
Appendix A
DRUG NAME A1A-DIGITALIS GLYCOSIDES DIGOXIN 0.05MG/ML PED ELIXIR DIGOXIN 0.125MG, 0.25MG, 0.5MG DIGOXIN 0.25MG/ML INJ LANOXICAPS 0.1MG, 0.2MG LANOXIN 0.05MG/ML PED ELIXIR LANOXIN 0.125MG, 0.25MG LANOXIN 0.25MG/ML INJ A1B-XANTHINES AMINOPHYLLINE 100MG, 200MG TAB AMINOPHYLLINE 105MG/5ML LIQUID AMINOPHYLLINE 500MG/20ML INJ CAFCIT 20MG/ML CAFFEINE CITRATE 20MG/ML DILOR 200MG, 400MG DYPHYLLINE 100MG/15ML ELIXOPHYLLIN ELIXIR 80MG/15ML THEO-24 100MG, 200MG, 300MG, 400MG THEOPHYLLINE ANHYDROUS CAPS 100MG, 125MG, 200MG, 300MG THEOPHYLLINE LIQUID 80MG/15ML THEOPHYLLINE SR TAB 100MG, 200MG, 300MG, 450MG UNIPHYL 400MG, 600MG A1D-GENERAL BRONCHODILATOR AGENTS ATROVENT HFA ATROVENT INH, REF 18MCG IPRATROPIUM 0.2MG/ML KIE LIQUID SPIRIVA INHALER 18MCG A2A-ANTIARRHYTHMICS AMIODARONE 200MG CORDARONE IV 50MG/ML DISOPYRAMIDE CR 150MG DISOPYRAMIDE PHOSPHATE 100MG, 150MG ETHMOZINE 200MG, 250MG, 300MG FLECAINIDE ACETATE 50MG, 100MG, 150MG MEXILITENE HCL 150MG, 200MG, 250MG NORPACE CR 100MG, 150MG PACERONE 200MG PROCAINAMIDE HCL 250MG, 500MG PROCAINAMIDE HCL INJ 100MG/ML, 500MG/ML PROCAINAMIDE HCL SR 500MG PROCAINAMIDE HCL SR 750MG, 1000MG PROCANBID 500MG, 1000MG PRONESTYL 250MG, 500MG PROPAFENONE 150MG, 225MG QUINIDINE GLUCONATE 324MG
0 0 0 2 2 2 2
ELIGIBLE COVERED FOR DUAL
AMEND
Page 1 of 61 CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N N N N N
0 0 0 2 0 2 2 2 2 0 0 0 2
N N N N N N N N N N N N N
2 2 0 2 2
N N N N N
0 2 0 0 2 0 0 2 0 0 0 0 0 2 2 0 0
N N N N N N N N N N N N N N N N N
Effective October 1, 2007 March 20, 2008 APPENDIX p(31979) pa(40321) d(168211) ra(140269)
print date: 02/19/2008 10:36 AM
Appendix A
DRUG NAME QUINIDINE SULFATE 200MG, 300MG QUINIDINE SULFATE SR 300MG RYTHMOL 150MG, 225MG RYTHMOL 300MG RYTHMOL SR 225MG, 325MG, 425MG TAMBOCOR 50MG, 100MG, 150MG TIKOSYN 0.125MG, 0.25MG, 0.5MG A2C-ANTI-ANGINAL AND ANTI-ISCHEMIC AGENTS, NON-HEMODYNAMIC RANEXA 500MG A4A-HYPOTENSIVES, VASODILATORS DOXAZOSIN MESYLATE 1MG, 2MG, 4MG, 8MG HYDRALAZINE HCL 10MG, 25MG, 50MG, 100MG HYDRALAZINE INJ 20MG/ML HYDRALAZINE/HCTZ 25/25, 50/50, 100/50 HYDRALAZINE/HCTZ/RESERPINE 25-0.1-15 MINOXIDIL 2.5MG, 10MG PRAZOSIN HCL 1MG, 2MG, 5MG TERAZOSIN HCL 1MG, 2MG, 5MG, 10MG A4B-HYPOTENSIVES, SYMPATHOLYTIC CATAPRES-TTS 0.1MG, 0.2MG, 0.3MG CLONIDINE HCL 0.1MG, 0.2MG, 0.3MG CLORPRES 0.1/15, 0.2/15, 0.3/15 ENDURONYL FORTE 0.5/5 GUANABENZ 4MG, 8MG GUANFACINE 1MG, 2MG HYDROCHLOROTHIAZIDE/RESERPINE 50/0.125 ISMELIN 10MG, 25MG METHYLDOPA 250MG, 500MG METHYLDOPA/HCTZ 250/15, 250/25, 500/30 RESERPINE 0.1MG, 0.25MG SALUTENSIN 0.125MG/50MG SALUTENSIN-DEMI 0.125MG/25MG A4C-HYPOTENSIVES, GANGLIONIC BLOCKERS INVERSINE 2.5MG A4D-HYPOTENSIVES, ACE INHIBITORS BENAZEPRIL 5MG, 10MG, 20MG, 40MG BENAZEPRIL/HCTZ 5-6.25MG, 10-12.5MG, 20-12.5MG, 20-25MG CAPTOPRIL 12.5MG, 25MG, 50MG, 100MG CAPTOPRIL/HCTZ 25/15, 25/25, 50/15, 50/25 ENALAPRIL 2.5MG, 5MG, 10MG, 20MG ENALAPRIL/HCTZ 5/12.5, 10/25 LISINOPRIL 2.5MG, 5MG, 10MG, 20MG, 30MG, 40MG LISINOPRIL/HCTZ 10/12.5, 20/12.5, 20/25 A4F-HYPOTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONIST AVALIDE 12.5-150, 12.5-300, 300-25 AVAPRO 75MG, 150MG, 300MG
Effective October 1, 2007 March 20, 2008
0 0 2 0 2 2 2
ELIGIBLE COVERED FOR DUAL
AMEND
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DRUG CLASS
5101:3-9-12
N N N N N N N
2
N
0 0 0 0 0 0 0 0
N N N N N N N N
2 0 2 2 0 0 0 2 0 0 0 2 2
N N N N N N N N N N N N N
2
N
0 0 0 0 0 0 0 0
N N N N N N N N
2 2
N N
Appendix A
ELIGIBLE COVERED FOR DUAL
AMEND
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5101:3-9-12
DRUG NAME BENICAR 5MG, 20MG, 40MG 2 BENICAR HCT 20/12.5, 40/12.5, 40/25 2 COZAAR 25MG, 50MG, 100MG 2 DIOVAN 40MG, 80MG, 160MG, 320MG 2 DIOVAN HCT 80/12.5, 160/12.5, 160/25, 320/12.5, 320/25 2 HYZAAR 50/12.5, 100/12.5, 100/25 2 MICARDIS 20MG, 40MG, 80MG 2 MICARDIS HCT 40-12.5, 80-12.5, 80-25 2 A4H-ANGIOTENSIN RECEPTOR ANTAGONIST & CALCIUM CHANNEL BLOCKER COMBINATION EXFORGE TABLET 5MG-160MG, 10MG-160MG, 5MG-320MG, 10MG-320MG 2 A4K-ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATION LOTREL 10/2.5, 10/5, 10/20, 20/5, 40/5, 40/10 2 TARKA 2/180, 1/240, 2/240, 4/240 2 A4Y-HYPOTENSIVES,MISC ATENOLOL/CHLORTHALIDONE 25/50, 25/100 0 BISOPROLOL FUMARATE/HCTZ 6.25/2.5, 6.25/5, 6.25/10 0 DEMSER 250MG 2 PROPRANOL/HCTZ 25/40, 25/80 0 TIMOLIDE 10/25 2 A7B-CORONARY VASODILATORS DILATRATE SR 40MG 2 DIPYRIDAMOLE 25MG, 50MG, 75MG 0 IMDUR 120MG 0 ISOSORBIDE DINITRATE ORAL 5MG, 10MG, 20MG, 30MG 0 ISOSORBIDE DINITRATE SL 2.5MG, 5MG 0 ISOSORBIDE DINITRATE SR 40MG 0 ISOSORBIDE MONONITRATE 10MG, 20MG, 30MG, 60MG 0 MINITRAN 0.1MG/HR, 0.2MG/HR, 0.4MG/HR, 0.6MG/HR 2 NITROBID OINT 2% 2 NITRO-DUR 0.1MG/HR, 0.3MG/HR, 0.8MG/HR 2 NITRO-DUR II 0.1MG/HR, 0.2MG/HR, 0.3MG/HR 2 NITRO-DUR II 0.4MG/HR, 0.6MG/HR 2 NITROGLYCERIN ORAL 2.5MG, 6.5MG, 9MG 0 NITROGLYCERIN PATCHES 0.1MG/HR, 0.2MG/HR, 0.4MG/HR, 0.6MG/HR 0 NITROGLYCERIN SL 0.3, 0.4, 0.6 0 NITROLINGUAL SPRAY 0.4MG/DOSE 2 NITROQUICK 0.3MG, 0.4MG, 0.6MG 0 NITROSTAT 0.3MG, 0.4MG, 0.6MG 2 A7C-PERIPHERAL VASODILATORS ERGOT ALKALOIDS ORAL 1MG 0 PAPAVERINE HCL 150MG 0 A9A-CALCIUM CHANNEL BLOCKERS AMLODIPINE 2.5MG, 5MG, 10MG 0 DILTIAZEM 30MG, 60MG, 90MG, 120MG 0 DILTIAZEM CD 120MG, 180MG, 240MG, 300MG, 360MG 0 DILTIAZEM INJ 5MG/ML 0
Effective October 1, 2007 March 20, 2008
N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N
Appendix A
DRUG NAME DILTIAZEM SR 60MG, 90MG, 120MG DILTIAZEM XR 120MG, 180MG, 240MG, DYNACIRC 2.5MG, 5MG DYNACIRC CR 5MG, 10MG FELODIPINE ER 2.5MG, 5MG, 10MG NICARDIPINE HCL 20MG, 30MG NIPEDIPINE ER 30MG, 60MG, 90MG SULAR 10MG, 20MG, 30MG, 40MG TAZTIA XT 120MG, 180MG, 240MG, 300MG, 360MG VERAPAMIL HCL 40MG, 80MG, 120MG VERAPAMIL SR 120MG, 180MG, 240MG, 360MG B0A-GENERAL INHALATION AGENTS DEY-PAK 10% DEY-PAK 3% SODIUM CHLORIDE FOR INHALATION 0.9% B3A-MUCOLYTICS ACETYLCYSTEINE SOLN 10%, 20% PULMOZYME 2.5MG B3J-EXPECTORANTS (cough suppressants may be covered for dual eligible) BRONTEX LIQUID BRONTEX TABS DE-CHLOR G 100-10-2/5ML GDP-EX 200-300-10 GUAIFENESIN 200MG, 400MG, 600MG, 1200MG GUAIFENESIN CODEINE 300/10MG TABS, 150-5/10ML GUAIFENESIN CODEINE SYRUP 100-10/5 ML, 150-5/10ML GUAIFENESIN DM 600/30 TABS GUAIFENESIN DM SYRUP 100-10/5ML, 100-15/5ML, 200-10/5ML, 200-30/5ML GUAIFENESIN PE SYRUP 100-30/5ML GUAIFENESIN PE/HC SYRUP 50-7.5-2.5/5ML GUAIFENESIN SYRUP 100MG/5ML GUAIFENESIN/DM/PE 200-30-10/5ML GUAIFENESIN/PHENYLEPH/HCOD 100-10-2MG/5ML GUAIFENESIN/PSEUDOEPHEDRINE 100-30/5ML GUAIFENESIN/PSEUDOEPHEDRINE 250/120, 300/60 GUAIFENESIN/PSEUDOEPHEDRINE 50-15/5ML GUAIFENESIN/PSEUDOEPHEDRINE 600/120, 600/60 GUAIFENESIN/PSEUDOEPHEDRINE/CODEINE 100-30-10/5 GUAIFENESIN/PSEUDOEPHEDRINE/DEXTROMETHORPHANLIQ 100-10-30/5ML GUAIFENESIN/PSEUDOEPHEDRINE/DEXTROMETHORPHANTAB 600-60-30 GUAITUSS CF (GUAIFENESIN/DEXTROMETHORPHAN/PSE 100-10-30) HCA COUGH FORMULA 200-30/5ML HUMIBID LA 600-300 HYDROCODONE/GUAI/PSEUDO 5-200-60/5ML, 100-15-3/5ML HYDROCODONE/GUAIFENESIN SYRUP 5MG-100MG/5ML HYDRON EX 120-2.5MG/5ML
Effective October 1, 2007 March 20, 2008
0 0 0 2 0 0 0 2 0 0 0
ELIGIBLE COVERED FOR DUAL
AMEND
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DRUG CLASS
5101:3-9-12
N N N N N N N N N N N
2 0 0
N N N
0 2
N N
0 0 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 2 0 0 2
Y Y Y Y N Y Y Y Y N Y Y Y Y N N N N Y Y Y Y Y N Y Y Y
Appendix A
ELIGIBLE COVERED FOR DUAL
AMEND
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5101:3-9-12
DRUG NAME HYDRO-TUSSIN XP 2 Y INTENSE COUGH RELIEVER SYRUP 2 Y MINTUSS G 100-10-2/5ML 2 Y MUCINEX TABLET 600MG, 1200MG 2 Y POT GUAIACO-HYDROCOD 120-2.5MG/5ML 0 Y PRO-CLEAR 350-3MG/5ML 2 Y PRO-COF 300MG-5MG/5ML 2 Y ROBITUSSIN DM 200-10MG/5ML 2 Y ROBITUSSIN DM INFANT DROPS 100-5/2.5ML 2 Y B3K-COUGH AND/OR COLD PREPARATIONS (cough suppressants may be covered for dual eligible) AMERITUSS AD 15-10-3/5ML 2 Y ATUSS HC 10-2.5-2MG/5ML 2 Y BROMAXEFED RF 45-4/5ML 0 N BROMODIPHENHYDRAMINE/CODEINE 12.5-10/5ML 0 Y BROMPLEX DM 30-60-4MG/5ML 2 Y CARBINOXAMINE/PSEUDO 4MG/60MG, 8MG/120MG 0 N CARBINOXAMINE/PSEUDO DROPS, SYRUP 15-1/1ML, 15-2/1ML, 60-4/5ML 0 N CARBINOXAMINE/PSEUDO/DM DROPS, SYRUP 4-15-1/1ML, 4-15-2/1ML 0 Y CHILDS ALLERGY 5-15-1MG/5ML 2 Y CHLORPHEN/P-EPH/HC 2-2-5/5 0 Y CHLORPHEN/P-EPH/PHENYLTOX 4/20/50 0 N CHLORPHEN/PSEUDO 4MG/60MG, 8MG/120MG 0 N CHLORPHEN/PSEUDO SYRUP 2MG-30MG/5ML, 1-15/5ML 0 N CHLORPHEN/PSEUDO/ACETA 4/60/650 0 N CLORFED 60-4MG 2 N COLDCOUGH HC 15-3-2/5ML 2 Y DEXBROMPHENIRAMINE/PSEUDO 6/120 0 N DEXTROMETHORPHAN/PSEUDOEPHEDRINE/CHRLORPHENIRAMINE5-15-1/5ML 0 Y DIHISTINE DH (PSEUDO/CPM/COD) 0 Y DM TAN/P-EPH TAN-CP TAN 25MG-75MG-4.5MG/5ML 0 Y DM/PE/CHLORPHEN 15-10-2MG/5ML, 15-6-2/5ML 0 Y DUOTAN PD 75-2.5MG/5ML 2 N HISTADE 120MG-12MG 2 N HYDROCODONE/HOMATRO 5/1.5 TAB, SYRUP 0 Y HYDROCODONE/PSEUDO LIQUID 5MG-60MG/5ML 0 Y HYDRON CP 10-5-2MG/5ML 2 Y NOVAHISTINE DH 2 Y PEDIA COUGH-COLD 5-15-1MG/5ML 2 Y PEDIACARE 7.5-15MG CHEW 2 Y PHENYLEPH/HCOD BT/CP 5-2.5-2/5ML, 10-5-2/5ML, 5-5-2/5ML, 10-2.5-2/5ML 0 Y PHENYLEPH/PYRIL/DM 5-8.33-10/5ML 0 Y PHENYLEPH/PYRIL/HCOD 7.5-15/5 0 Y PHENYLEPHRINE/PYRILAMINE TANNATE 5-30/5ML 0 N PROMETHAZINE CODEINE SYRUP 10-6.25/5ML 0 Y PROMETHAZINE VC CODEINE SYRUP 0 Y PROMETHAZINE VC SYRUP 0 N
Effective October 1, 2007 March 20, 2008
Appendix A
ELIGIBLE COVERED FOR DUAL
AMEND
Page 6 of 61 CO-PAYMENT
DRUG CLASS
5101:3-9-12
DRUG NAME PRO-RED 5-2-8.33/5ML 2 PSE-BROM 30-60-4/5ML 2 PSEUDO/BROM MAL 15-1/5ML,60-4/5ML 0 PSEUDO/BROM MAL DM 15-1-5/ML,60-4-15/5ML 0 PSEUDO/BROMPHEN/DM 45-4-15/5ML, 10-30-2/5ML, 30-60-4/5 0 PSEUDO/CARB MAL 15-2/ML 0 PSEUDO/HC/CTM 15-3-2/5ML 0 PSEUDOEPHEDRINE/CHLORPHENIRAMINE/CODEINE 30-10-2/5ML 0 RELACON HC 10-3.5-2.5MG/5ML 2 ROBITUSSIN 10MG-30MG-2MG/5ML 0 ROBITUSSIN PM 7.5MG-15MG-1MG/5ML 2 R-TANNIC-S 5-30MG/ML 0 RU-TUSS A 15-10-2MG/5ML 0 TRIACTING COLD & ALLERGY 0 TRIACTING COLD/COUGH 5-15-1/5ML 0 TRIACTING SORE THROAT 7.5-15-160MG/5ML 2 TRIAMINIC COUGH 5-15 MG/5ML 2 TRIAMINIC COUGH/SORE THROAT 7.5-15-160/5ML 2 TRIPROLIDINE/PSEUDO 2.5/60 TAB 0 TRIPROLIDINE/PSEUDO LIQUID 1.25-30/5ML 0 TRIPROLIDINE/PSEUDO/CODEINE SYRUP 0 TUSSIN PEDIATRIC COUGH-COLD 7.5-15MG/5ML 2 UNI-TUSS DM 15-5-2/5 2 B3P-NON-NARC ANTITUS-1ST GEN ANTIHIST-DECON-ANALGES CB (cough suppressants may be covered for dual eligible) DIMETAPP 5-15-160-1 2 TRIAMINIC COLD/COUGH/FEVER 2 B3Q-NARCOTIC ANTITUSS-1ST GEN. ANTIHISTAMINE-DECONGEST (cough suppressants may be covered for dual eligible) BROMPHENIRAMINE-HYDROCOD-PSE 30-2.5-3MG/5ML 0 BROVEX HC 2 HYDRO-TUSSIN HC 15-3-2/5ML 2 PHENYLEPHRINE-HYDROCODONE-CP 5-5-2MG/5ML 0 B3R-NON-NARC ANTITUSS-1ST GEN. ANTIHISTAMINE-DECONGEST (cough suppressants may be covered for dual eligible) CODIMAL DM SYRUP 2 DEXTROMETHORPHAN/PHENYLEPHRIN/BROMPHENIRAMINE5-2.5-1/5 0 DEXTROMETHORPHAN/PHENYLEPHRINE/CHLORPHENIRAMINE15-12.5-4, 3-3.51/ML, 15-10-2/5ML 0 DIMETAPP DM 2 PE-HIST DM 15-5-2MG/5ML 2 RESCON DM 10MG-30MG, 10-30-2/5 2 TANACOF-DM 25-75-2.5/5ML 2 TRIAMINIC COLD & COUGH 5-15-1MG/5ML 2 TRIAMINIC NIGHT TIME 2
Effective October 1, 2007 March 20, 2008
Y Y N Y Y N Y Y Y Y Y N Y N Y Y Y Y N N Y Y Y
Y Y
Y Y Y Y
Y Y Y Y Y Y Y Y Y
Appendix A
ELIGIBLE COVERED FOR DUAL
AMEND
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DRUG CLASS
5101:3-9-12
DRUG NAME B3T-NON-NARCOTIC ANTITUSSIVE AND EXPECTORANT COMB (cough suppressants may be covered for dual eligible) GUAIFENESIN/DEXTROMETHORPHAN 100-5MG/5, 400-20MG TAB 0 Y HCA COUGH FORMULA (WALSH) 300-20/5ML 2 Y B4A-NON-NARCOTIC ANTITUSSIVE-ANALGESIC COMBINATIONS (cough suppressants may be covered for dual eligible) DEXTROMETHORPHAN/ACETAMINOPHEN 30-1000/30, 7.5-160/5 0 Y B4D-NARCOTIC ANTITUSSIVE-1ST GENERATION ANTIHISTAMINE COTAB AX 4-20MG 2 Y B4E-NON-NARC ANTITUSSIVE-1ST GEN ANTIHISTAMINE COMB (cough suppressants may be covered for dual eligible) DEXTROMETHORPHAN/CHLORPHENIRAMINE 7.5-1MG/5ML 0 Y PROMETHAZINE DM SYRUP 15-6.25/5 0 Y ROBITUSSIN COUGH-COLD LIQUID 7.5MG-1MG/5ML 0 Y B4K-NARCOTIC ANTITUSSIVE-DECONGESTANT COMBINATIONS (cough suppressants may be covered for dual eligible) HISTUSSIN D 60-5MG/5ML 2 Y PANCOF HC 15-3/5ML 2 Y B4M-NON-NARCOTIC ANTITUSSIVE-DECONGESTANT-ANALGESIC CB (cough suppressants may be covered for dual eligible) D-METHORPHAN/PE/ACETAMINOPHEN 5-325MG/15 0 Y B4P-NON-NARC ANTITUSS-DECONGESTANT-ANALGESIC-EXPECT CB (cough suppressants may be covered for dual eligible) HCA COUGH AND COLD RELIEVER (WALSH) 10-5-325/5ML 2 Y B4Q-NARCOTIC ANTITUSS-DECONGESTANT-EXPECTORANT COMB (cough suppressants may be covered for dual eligible) DONATUSSIN DC SYR 2 Y B4R-NON-NARCOTIC ANTITUSS-DECONGESTANT-EXPECTORANT CMB (cough suppressants may be covered for dual eligible) GUAIFENISEN/DEXTROMETHORPHAN/PHENYLEPHRINE 100-10-5/5ML 0 Y TUSNEL PEDIATRIC LIQUID 50-5-15/5ML 2 Y B4S-NARCOTIC ANTITUSSIVE-EXPECTORANT COMBINATION (cough suppressants may be covered for dual eligible) EXECOF-XP 90-3/5ML 2 Y GUAIFENESIN W/CODEINE SYRUP 100-10MG/5 0 Y M-CLEAR 400-5/5ML 2 Y PANCOF XP 90-3/5ML 2 Y B4W-DECONGESTANT-EXPECTORANT COMBINATIONS MARDROPS-EX 50-15/1ML 2 N RESCON GG 100-5/5ML 2 N RESPAIRE SR 200/60 2 N ROBITUSSIN PE 2 N TRIACTING CHEST CONGESTION 0 N TRIAMINIC CHEST CONGESTION 50-15MG/5ML 2 N
Effective October 1, 2007 March 20, 2008
Appendix A
DRUG NAME C0B-WATER STERILE WATER FOR INHALATION STERILE WATER FOR INJECTION C0C-DRUGS USED TO TREAT ACIDOSIS LACTATED RINGERS SOLN C0D-ANTI-ALCOHOLIC PREPARATIONS ANTABUSE 250MG, 500MG CAMPRAL 333MG C0K-BICARBONATE PRODUCING/CONTAINING AGENTS SODIUM ACETATE 2MEQ/ML, 4MEQ/ML SODIUM LACTATE 5MEQ/ML C1A-ELECTROLYTE DEPLETERS FOSRENOL 250MG, 500MG, 750MG, 1000MG KAYEXALATE POWDER KIONEX PDR MAGNEBIND 450/200, 300/300, 200/400 PHOSLO 667MG RENAGEL 400MG, 800MG SODIUM POLYSTYRENE SULFONATE 15GM/60ML C1B-SODIUM/SALINE PREPARATIONS SODIUM CHLORIDE SOLUTION 0.45%, 0.9%, 5%, 2.5 MEQ/ML, 4MEQ/ML C1D POTASSIUM REPLACEMENT DEXTROSE 10% - 1/4NS-KCL DEXTROSE 5% - 1/4NS-KCL DEXTROSE 5% - 1/2NS-KCL DEXTROSE 5% - KCL DEXTROSE 5% - LACT RING-KCL EFFER-K TABLETS 10MEQ, 20MEQ KAON 20MEQ/15ML KAON-CL 10MEQ KLOR-CON 10, 10MEQ KLOR-CON 25 EFFERVESCENT KLOR-CON 25, 25MEQ KLOTRIX 10MEQ K-TAB 10MEQ MICRO-K EXTENCAPS 8MEQ POTASSIUM CHLORIDE 10 MEQ, 20MEQ POTASSIUM CHLORIDE 8MEQ, 10MEQ POTASSIUM CHLORIDE EFF PKTS 25MEQ POTASSIUM CHLORIDE INJ 20MEQ, 40MEQ POTASSIUM CHLORIDE ORAL LIQ 10%, 20% POTASSIUM CHLORIDE PACKETS 20MEQ POTASSIUM GLUCONATE ELIXIR 4.68GM/15ML TRAVERT 10%-1/2NS KCL 40MEQ
Effective October 1, 2007 March 20, 2008
0 0
ELIGIBLE COVERED FOR DUAL
AMEND
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DRUG CLASS
5101:3-9-12
N N
0
N
2 2
N N
0 0
N N
2 2 0 2 2 2 0
N N N N N N N
0
N
0 1 2 0 0 2 2 2 2 0 2 2 2 2 0 0 0 0 0 0 0 2
N N N N N N N N N N N N N N N N N N N N N N
Appendix A
DRUG NAME C1F-CALCIUM REPLACEMENT (may be covered for dual eligible) CALCI-MIX 1.25GM CALCIUM CARBONATE 1.25 GM CALCIUM CARBONATE 10GR CALCIUM CITRATE 950MG, 1040MG CALCIUM GLUBIONATE 1.8GM/5ML CALCIUM GLUCONATE 10% CALCIUM GLUCONATE 10GR CALCIUM LACTATE 10GR CITRACAL 950MG NEPHRO CALCI 1500MG OYSTER SHELL CALC W/D 250MG/125U, 500MG/125U, 500MG/200U OYSTER SHELL CALCIUM 500MG C1H-MAGNESIUM SALTS REPLACEMENT (may be covered for dual eligible) MAG DELAY 64MG MAGNESIUM GLUCONATE 500MG MAGNESIUM OXIDE 400MG MAGNESIUM SULFATE 4MEQ/ML MAGNESIUM SULFATE/DEX 1%, 2% MAGONATE 1GM/5ML ORAL MAGTAB SR 84MG SLOW MAG 64MG URO-MAG 140MG C1P-PHOSPHATE REPLACEMENT (may be covered for dual eligible) NEUTRA-PHOS NEUTRA-PHOS-K PHOS-NAK POTASSIUM PHOS 3MM/ML SODIUM PHOS 3MM/ML C1W-ELECTROLYTE MAINTENANCE DEXTROSE 10% - ELECTROLYE #48 DEXTROSE 5% - ELECTROLYE #48, #75 FRUCTOSE 10% ELECTROLYTE #48 FRUCTOSE 5% ELECTROLYTE #48, #75 M.T.E. M.T.E. -4, -5, -6, -7 MULTITRACE-4, -5 P.T.E. -4, -5 PEDTRACE-4 PLASMA-LYTE TRAVERT - ELECTROLYTES #1, #2, #3, #4 C1Z-ELECTROLYTE REPLACEMENT NORMOSOL-M AND DEXTROSE 5% ORAL ELECTROLYTES PARENTERAL ELECTROLYTES
Effective October 1, 2007 March 20, 2008
2 0 0 0 0 0 0 0 2 2 0 0
ELIGIBLE COVERED FOR DUAL
AMEND
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DRUG CLASS
5101:3-9-12
Y Y Y Y Y Y Y Y Y Y Y Y
0 0 0 0 2 2 2 2 2
Y Y Y Y Y Y Y Y Y
2 2 2 0 0
Y Y Y Y Y
2 2 2 2 2 2 2 2 2 2 2
N N N N N N N N N N N
2 0 2
N Y N
AMEND
DRUG NAME PARENTERAL ELECTROLYTES W/DEXTROSE PEDIAPOP C3B-IRON REPLACEMENT (may be covered for dual eligible) B-COMPLEX PLUS IRON CHROMAGEN FA 70-150-1 CHROMAGEN FORTE 151-60-1 CORVITE 150 CORVITE FREE DEXFERRUM 50MG/ML FEFUM/C/B12/IF/FA 0.5MG FEOGEN FORTE 460/60MG FERROGELS FORTE 460/60MG FERROUS FUM/C/B-12 FERROUS FUM/C/B-12/FA FERROUS FUMARATE 325MG FERROUS GLUCONATE EC 5GR, 240MG FERROUS SULFATE 5GR FERROUS SULFATE DROPS, ELIXIR 75MG/0.6ML, 220MG/5ML FERROUS/FA/B&C HEMATOGEN HEMATOGEN FA 200-250MG HEMATOGEN FORTE 460-60MG INFED INJ 100MG/2ML MYKIDZ IRON 10 SUSPENSION 15MG/1.5ML NEPHRON FA NIFEREX 100MG/5ML ELIXIR NIFEREX 150 FORTE POLYSACCARIDE 150 FORTE POLYSACCARIDE FORTE ELIXIR POLYSACCARIDE IRON 150MG RE DUALVIT F 106-1MG RE DUALVIT PLUS 106-1MG REOCYTE PLUS 106-1MG STRESS FORMULA + IRON C3C-ZINC REPLACEMENT (may be covered for dual eligible) ZINC SULFATE 220MG C3H-IODINE CONTAINING AGENTS (may be covered for dual eligible) POTASSIUM IODIDE 1GM/ML C3M-MISC MINERAL REPLACEMENT (may be covered for dual eligible) MOLYPEN 25MCG/ML C4F-ANTIHYPERGLY, (DPP-4) INHIBITOR & BIGUANIDE COMB. JANUMET 50-500, 50-1000 C4G-INSULINS LANTUS 100U/ML NOVOLIN 70/30 100U/ML, 150U/1.5ML, 70-30U/ML NOVOLIN N
Effective October 1, 2007 March 20, 2008
Page 10 of 61
2 0
ELIGIBLE COVERED FOR DUAL
Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N Y
0 2 2 2 2 2 0 0 0 0 0 0 0 0 0 0 0 0 0 2 0 2 2 2 0 0 0 2 2 2 0
Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y
2
Y
0
Y
2
Y
2
N
2 2 2
N N N
AMEND
DRUG NAME NOVOLIN R NOVOLOG 100U/ML NOVOLOG MIX 70/30 C4H-ANTIHYPERGLYCEMIC, AMYLIN ANALOG-TYPE SYMLIN 0.6MG/ML C4I-ANTIHYPERGLYCEMIC, INCRETIN MIMETIC(GLP-1 RECEPTOR AGONIST) BYETTA 5MCG/0.02, 10MCG/0.04 C4J-ANTIHYPERGLYCEMIC, DPP-4 INHIBITORS JANUVIA 25MG, 50MG, 100MG C4K-HYPOGLYCEMICS, INSULIN-RELEASE STIMULANT TYPE ACETOHEXAMIDE 250MG,500MG CHLORPROPAMIDE 100MG, 250MG GLIMEPIRIDE 1MG, 2MG, 4MG GLIPIZIDE 5MG,10MG GLIPIZIDE ER 2.5MG,5MG,10MG GLYBURIDE 1.25MG,2.5MG,5MG GLYBURIDE MICRONIZED 1.5MG,3MG,6MG STARLIX 60MG,120MG TOLAZAMIDE 100MG,250MG,500MG TOLBUTAMIDE 500MG TOLINASE 100MG C4L-HYPOGLYCEMICS, BIGUANIDE TYPE (NON-SULFONYLUREAS) METFORMIN 500MG, 850MG, 1000MG METFORMIN HCL ER 500MG, 750MG C4M-HYPOGLYCEM, ALPHA-GLUCOSIDASE INHIB TYPE (N-S) GLYSET 25MG,50MG,100MG PRECOSE 25MG,50MG,100MG C4N-HYPOGLYCEMICS, INSULIN-RESPONSE ENHANCER (N-S) ACTOPLUS MET 15-500, 15-850 ACTOS 15MG, 30MG, 45MG AVANDIA 2MG,4MG,8MG C4R-HYPOGLYCEMICS, INSULIN-RESPONSE & INSULIN RELEASE COMBINATION AVANDARYL 4-1, 4-2, 4-4, 8-2, 8-4 DUETACT 30-2, 30-4 C4S-HYPOGLY, INSULIN-REL STIM. & BIGUANIDE (N-S) COMB. GLYBURIDE-METFORMIN 1.25-250, 2.5-500, 5-500 C4T-HYPOGLY, INSUL-RESP. ENHANCER & BIGUANIDE COMB. AVANDAMET 1-500, 2-500, 4-500, 2-1000, 4-1000 C5A-CARBOHYDRATES TRAVERT IN NORMAL SALINE C5B-PROTEIN REPLACEMENT NOVAMINE 15% PREMASOL 6%, 10% PROSOL 20% INJECTION
Effective October 1, 2007 March 20, 2008
Page 11 of 61
2 2 2
ELIGIBLE COVERED FOR DUAL
Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N
2
N
2
N
2
N
0 0 0 0 0 0 0 2 0 0 2
N N N N N N N N N N N
0 0
N N
2 2
N N
2 2 2
N N N
2 2
N N
0
N
2
N
2
N
2 2 2
N N N
AMEND
DRUG NAME C5F-DIETARY SUPPLEMENTS, MISC (may be covered for dual eligible) CO ENZYME Q10 LIQ10 50MG/5ML Q-GEL MEGA 100MG C5H-VITAMINS INJ (may be covered for dual eligible) M.V.I. PED, 12 C5J-IV SOLNS DEXTROSE/WATER DEXTROSE 5% W/POTASSIUM CHLORIDE 10MEQ/L, 20MEQ/L, 30MEQ/L, 40MEQ/L DEXTROSE/WATER 5%, 10%, 50%, 70% C5K-IV SOLNS DEXTROSE/SALINE/KCL DEXTROSE 5%/0.25%NS/KCL 10MEQ/L, 20MEQ/L, 30MEQ/L, 40MEQ/L DEXTROSE 5%/0.33%NS/KCL 10MEQ/L, 20MEQ/L, 30MEQ/L, 40MEQ/L DEXTROSE 5%/0.45%NS/KCL 10MEQ/L, 20MEQ/L, 30MEQ/L, 40MEQ/L DEXTROSE/NACL 2%/0.45%, 5%/0.2%, 5%/0.33%, 5%/0.45%, 5%/0.9% DEXTROSE/NS/KCL 10MEQ/L, 20MEQ/L,30MEQ/L,40MEQ/L C5M-IV SOLNS DEXTROSE/LACT RINGERS DEXTROSE 5%/LACTATED RINGERS C5N-PROTEIN REPLACEMENT AMINESS 5.2% AMINOSYN 5%, 5.2%, 7%, 8.5%, 10% AMINOSYN II 4.25%, 5%, 7%, 8.5%, 10% AMINOSYN-HBC 7% AMINOSYN-HF 8% AMINOSYN-PF 7%, 10% CLINIMIX 2.75%,4.25%,5% CLINIMIX-E 2.75/5, 2.75/10, 4.25/5, 4.25/10, 4.25/25, 5/15, 5/20, 5/25 CLINISOL 15% FREAMINE III 8.5%, 10% FREAMINE HBC 6.9% HEPATAMINE 8% HEPATASOL 8% PROCALAMINE 3% QUICK MIX W/LYTES 2.75%, 4.25% RENAMIN 6.5% TRAVASOL 5.5%, 8.5%, 10% TRAVASOL/DEXTROSE 5.5%, 8.5% TRAVASOL/ELECTROLYTES 5.5%, 8.5% TROPHAMINE 6%, 10% C5O-SOLNS MISCELLANEOUS DILUENT ELLIOTTS B C6B-VITAMIN B PREPARATIONS (may be covered for dual eligible) ALLANTEX CEREFOLIN 1-5-50-5MG CEREFOLIN NAC DEXFOL 5MG
Effective October 1, 2007 March 20, 2008
Page 12 of 61
0 0 0
ELIGIBLE COVERED FOR DUAL
Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
Y Y Y
2
Y
0 0
N N
0 0 0 0 0
N N N N N
0
N
2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2
N N N N N N N N N N N N N N N N N N N N
2 2
N N
2 2 2 2
Y Y Y Y
AMEND
DRUG NAME DIALYVITE 3000 DIATX DIATX ZN 5-1.5-25MG FOLAMIN 2-2.5-25MG FOLBALIN 1-2.5-25MG FOLBALIN PLUS 2-2.5-25 FOLBEE 1-2.5-25MG FOLBEE PLUS FOLBIC 2-2.5-25MG FOLEVE TABLET FOLGARD RX 0.5-2.2-25, 1-2.2-25 FOLNATE TABLET FOLNATE PLUS TABLET FOLTX 2-2.5-25 METANX 2-2.8-25MG NEPHPLEX RX NEPHROCAPS NEPHRONEX 1MG NEPHRO-VITE RX RENAL CAPS 1MG RENAPHRO 1MG RENA-VITE RENA-VITE RX C6D-VITAMIN D PREPARATIONS (may be covered for dual eligible) CALCIFEROL LIQ 8,000U/ML CALCITRIOL 0.25MCG, 0.5MCG DHT 0.125MG, 0.2MG, 0.4MG DHT INTENSOL 0.2MG/ML DRISDOL 8000 IU/ML ROCALTROL 0.25MCG, 0.5MCG ROCALTROL 1MCG/ML VITAMIN D 50,000U C6E-VITAMIN E PREPARATIONS (may be covered for dual eligible) AQUAVIT-E 50U/ML C6F-PRENATAL VITAMINS (family planning) ANEMAGEN OB CARENATE 600 CENOGEN OB CENOGEN ULTRA CHROMAGEN OB CITRACAL PRENATAL RX 27-1-50MG CITRANATAL RX 27-1-50 CO-NATAL FA DUET DUET DHA STUARTNATAL DUET DHA EC STUARTNATAL 29-1-400
Effective October 1, 2007 March 20, 2008
Page 13 of 61
2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 0 0 0
ELIGIBLE COVERED FOR DUAL
Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y
2 0 2 2 2 2 0 0
Y Y Y Y Y Y Y Y
0
Y
0 0 0 0 0 0 0 0 0 0 0
N N N N N N N N N N N
AMEND
DRUG NAME DUET STUARTNATAL EMBREX-600 GENERIC PRENATALS ICAR PRENATAL INATAL ADVANCE 90-1MG INATAL GT 90-1MG INATAL ULTRA 90-1MG MARNATAL-F PLUS 60-1MG MATERNA NATACAPS 106-1MG NATACHEW NATAFOLIC-OB NATAFORT NATALCARE PLUS NATALCARE THREE NATALVIT NATATAB NATATAB CFE NATELLE 27-1MG NATELLE PREFER NESTABS CBF NESTABS FA NESTABS RX NIFEREX PN FORTE NU-NATAL ADVANCED OBEGYN O-CAL PRENATAL POLY IRON PN 60-1MG POLY IRON PN FORTE 60-1MG PRECARE PRECARE CONCEIVE PREMESIS RX PRENAFIRST PRENATABS CBF PRENATABS FA PRENATABS OBN 29-1MG PRENATABS RX PRENATAL 19 PRENATAL AD PRENATAL FORMULA PRENATAL H PRENATAL MR 90 FE PRENATAL MTR PRENATAL PC 40 PRENATAL START PRENATAL-U
Effective October 1, 2007 March 20, 2008
Page 14 of 61
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
ELIGIBLE COVERED FOR DUAL
Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N
AMEND
DRUG NAME PRIMACARE 30-300-1MG RE DUALVIT OB STUART PRENATAL STUARTNATAL PLUS 3 TANDEM OB TRINATE ULTRA-NATAL ULTRANATAL CARE UNI-REX 600 VEROTIN-BY VEROTIN-GR VINATAL VINATAL FORTE VINATE ADVANCED VINATE AZ 27-1 VINATE AZ EXTRA VINATE M VINATE PRENATAL VINATE-90 ZENATE C6G-GERIATRIC VITAMIN PREPARATIONS (may be covered for dual eligible) GERIATRIC VITAMINS (COMPARE TO CENTRUM, GEVRABON, ZYMASYRUP) C6H-PEDIATRIC VITAMINS (may be covered for dual eligible) CHEWABLES AND LIQUID DROPS GENERICS CHEWABLES W/FLUORIDE AND LIQUID DROPS W/FLUORIDE CHEWABLES WITH IRON AND FLUORIDE GENERICS CHEWABLES WITH IRON AND LIQUID DROPS WITH IRON GENERICS INFUVITE LIQUID DROPS WITH IRON AND FLUORIDE GENERICS C6K-VITAMIN K PREPARATIONS (may be covered for dual eligible) MEPHYTON 5MG VITAMIN K 10MG/ML INJ C6L-VITAMIN B-12 PREPARATIONS (may be covered for dual eligible) CYANOCOBALAMIN INJ 1000MG/ML FOLCAPS 0.5-2.2-25MG FOLPLEX 2.2MG NUFOL 1-2.5-25MG C6M-FOLIC ACID PREPARATIONS (may be covered for dual eligible) DIALYVITE FOLIC ACID 1MG FOLIC ACID INJ 5MG/ML LEUCOVORIN CALCIUM PDR FOR INJ 50MG,100MG,200MG LEUCOVORIN CALCIUM TABS 5MG C6N-NIACIN PREPARATIONS (may be covered for dual eligible) NIACIN SR 125MG,250MG,500MG SLO-NIACIN 250,500,750MG
Effective October 1, 2007 March 20, 2008
Page 15 of 61
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
ELIGIBLE COVERED FOR DUAL
Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N N N N N N N N N N N N N N N N N N
0
Y
0 0 0 0 0 0
Y Y Y Y Y Y
0 0
Y Y
0 2 2 2
Y Y Y Y
0 0 2 0 0
Y Y Y Y Y
0 2
Y Y
AMEND
DRUG NAME C6T-VITAMIN B1 PREPARATIONS (may be covered for dual eligible) THIAMINE HCL INJ 100MG/ML C6Z-MULTIVITAMIN PREPARATIONS (may be covered for dual eligible) GENERIC EQUIVALENTS TO: ALLBEE C BEROCCA PLUS CENTRUM ONE-A-DAY & ONE-A-DAY W/IRON STRESSTAB 600 FORMULA, WITH IRON AND WITH ZINC THERAGRAN, THERAGRAN M & THERAGRAN H UNICAP, UNICAP W/IRON, UNICAP M CERNEVIT DAILY VITAMIN FORMULA DEXTROSE W/VITAMINS INFUVITE INFUVITE ADULT INJ RENAX THERAPEUTIC M THERAPEUTIC M 27-0,4MG VITAMIN B COMPLEX INJ VITAMINS FOR INFUSION C7A-HYPERURICEMIA TX - PURINE INHIBITORS ALLOPURINOL 100MG,300MG C7B-DECARBOXYLASE INHIBITORS (SEE ALSO H6A) CARBIDOPA/LEVODOPA 10/100,25/100,25/250 C7D-METABOLIC DEFICIENCY AGENTS CYSTADANE 1GM/1.7ML C7F-APPETITE STIMULANTS FOR ANOREXIA, CACHEXIA, WASTING SYNDROME MEGACE ES 625MG/5ML C8A-METALLIC POISON ANTIDOTES CHEMET 100MG DEFEROXAMINE MESYLATE 500MG,2GM DESFERAL INJ 500MG,2GM EXJADE 125MG, 250MG, 500MG GALZIN 25MG, 50MG SYPRINE 250MG D1D-DENTAL AIDS & PREPARATIONS CHLORHEXIDINE GLUCONATE SOLN TRIAMCINOLONE DENTAL PASTE D2A-FLUORIDE PREPARATIONS SODIUM FLUORIDE 2.2MG TABS (1MG FLUORIDE) SODIUM FLUORIDE DROPS 0.125MG/ML, 0.5MG/ML
Effective October 1, 2007 March 20, 2008
Page 16 of 61
0
ELIGIBLE COVERED FOR DUAL
Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
Y
0 0 0 0 0 0 0 0 2 0 2 2 2 2 0 0 0 2
Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y
0
N
0
N
2
N
2
N
2 0 2 2 2 2
N N N N N N
0 0
N N
0 0
N N
AMEND
Page 17 of 61 ELIGIBLE COVERED FOR DUAL
Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
DRUG NAME D4B-ANTACIDS (may be covered for dual eligible if available over the counter) GENERIC EQUIVALENTS OF: GAVISCON 358-95/15ML, 237.5-254, 20-80 0 Y MAALOX 400-400-30, 400-400-40, 200-225-25, 450-500-40, 200-225 0 Y MYLANTA 400-400-30, 200-200-20, 400-400-40 0 Y RIOPAN 540MG/5ML 0 Y ALU-CAPS 475MG 2 Y ALUMINUM HYDROXIDE 600MG/5ML, 320MG/5ML 0 Y ALU-TAB 600MG 2 Y CALCIUM CARBONATE 500MG/5ML 0 Y SODIUM BICARBONATE 5GR, 10GR 0 Y D4E-ANTIULCER PREPARATIONS CARAFATE 1GM/10ML 2 N CYTOTEC 100MCG, 200MCG 0 N SUCRALFATE 1GM 0 N D4F-ANTI-ULCER-H.PYLORI AGENTS HELIDAC 2 N PREVPAC 30/500/500 2 N PYLERA 125-125 2 N D4G-GASTRIC ENZYMES LACTRASE 250MG 2 N SUCRAID 8.5MU/ML 2 N D4I-ORAL MUCOSITIS/STOMATITIS ANTI-INFLAMMATORY AGENT APHTHASOL PASTE 5% 2 N D4K-GASTRIC ACID SECRETION REDUCERS NEXIUM 20MG, 40MG CAPS 0 N PREVACID 15MG,30MG 0 N PREVACID SOLUTAB 15MG, 30MG (AGES 0-6) * N D4N-ANTIFLATULENTS (may be covered for dual eligible if available over the counter) SIMETHICONE 80MG TABS 0 Y SIMETHICONE DROPS 40MG/0.6ML 0 Y D5P-INTESTINAL ADSORBENTS AND PROTECTIVES (may be covered for dual eligible if available over the counter) ACIDOPHILUS W/PECTIN LIQ 0 Y KAOLIN-PECTIN (ATTAPULGITE) SUSP 750MG/15ML 0 Y D6C-IRRITABLE BOWEL SYNDROME AGENT,5HT-3 ANTAGONIST-TYPE LOTRONEX 0.5MG, 1MG 2 N D6D-ANTIDIARRHEALS (may be covered for dual eligible if available over the counter) BISMUTH SUSPENSION 525MG/15ML 0 Y DIPHENOXYLATE/ATROPINE SULFATE TABS, LIQUID 0 N LOPERAMIDE HCL 2MG TABS, 1MG/5ML SOLN 0 N MOTOFEN TABS 2 N PAREGORIC 0 N D6F-DRUG TX-CHRONIC INFLAM. COLON DX,5-AMINOSALICYLATE ASACOL 400MG 2 N COLAZAL 750MG 2 N
Effective October 1, 2007 March 20, 2008
AMEND
Page 18 of 61 ELIGIBLE COVERED FOR DUAL
Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
DRUG NAME DIPENTUM 250MG 2 LIALDA 1.2G 2 PENTASA 250MG, 500MG 2 D6S-LAXATIVES & CATHARTICS (may be covered for dual eligible if available over the counter) AMITIZA 24MG 2 BISACODYL 10MG SUPPS, 5MG TABS 0 COLYTE 2 DOCUSATE CALCIUM 240MG 0 DOCUSATE SODIUM DROPS, LIQUID, SYRUP 150MG/15ML, 60MG/15ML 0 DOCUSATE SODIUM CAPS 100MG, 250MG 0 DOCUSATE SODIUM/CASANTHRANOL SYRUP, CAPS 300-100/5ML, 300-100 0 FIBER LAXATIVE TABS 500MG, 625MG 0 GLYCOLAX POWDER 2 GOLYTELY SOLUTION 2 LACTULOSE SYRUP 10GM/15ML 0 MILK OF MAGNESIA 400MG/5ML, 800MG/5ML 0 MIRALAX 2 NULYTELY SOLUTION 2 OCL 2 PEG-3350 0 POLYCARBOPHYL 625MG 0 POLYETHYLENE GLYCOL GRAN 0 PSYLLIUM PREPARATIONS/VEGETABLE LAXATIVES 0 SENNA CONCENTRATES 8.6MG 0 SENNA LIQUID 8.8MG/5ML 0 SENNA W/DOCUSATE 8.6MG-50MG 0 TRILYTE 2 D7A-BILE SALTS ACTIGALL 300MG 2 URSO 250MG 2 URSODIOL 300MG 0 D7L-BILE SALT SEQUESTRANTS CHOLESTYRAMINE LIGHT BULK 0 CHOLESTYRAMINE POWDER 378GM 0 COLESTID GRANULES, 1GM TABS 2 PREVALITE POWDER 0 QUESTRAN BULK POWDER 2 QUESTRAN LIGHT BULK POWDER 2 WELCHOL 625 MG 2 D8A-PANCREATIC ENZYMES AMYLASE/LIPASE/PROTEASE 33.2-10-38, 60-16-60 0 AMYLASE/LIPASE/PROTEASE 39/12/39, 59/18/59, 65/20/65 0 AMYLASE/LIPASE/PROTEASE 48-16-48 0 AMYLASE/LIPASE/PROTEASE 66.4-20-75 0 COTAZYM S 5000U 2 CREON 16.6-5-19, 33.2-10-38, 66.4-20-75 2
Effective October 1, 2007 March 20, 2008
N N N N Y N Y Y Y Y Y N N N Y N N N N Y N Y Y Y Y N N N N N N N N N N N N N N N N N
AMEND
DRUG NAME DYGASE 30-2.4-30 KUTRASE 30-2.4-30 KU-ZYME 15-1.2-15 KU-ZYME HP LAPASE 15-1.2-15 LIPRAM-PN20 56/20/44 PANCREASE MT-4, MT-10, MT-16, MT-20 PANCREATIC ENZYMES 20-4-25, 20-4.5-25, 30-8-30, 30-10-30 PANCRECARB MS-4 (25-4-25), MS-8 (40-8-45), MS-16 (52-16-52) ULTRASE 4000U, 25-5-20 ULTRASE MT-6, MT-12, MT-18, MT-20 VIOKASE 60-16-60 VIOKASE 8000U VIOKASE POWDER ZYMASE 5000U D9A-AMMONIA INHIBITOR BUPHENYL POWDER 500MG LACTULOSE 10GM/15ML LITHOSTAT 250MG F1A-ANDROGENIC AGENTS ANDRODERM 2.5MG/24H, 5MG/24H ANDROGEL 12.5MG, 25MG, 50MG DELATESTRYL 200MG/ML DEPOTESTOSTERONE INJ 200MG/ML FLUOXYMESTERONE 10MG METHITEST 10MG NANDROLONE DECANOATE INJ 100MG TESTIM 1% (50MG) TESTOSTERONE PROPIONATE INJ 100MG/ML G1A-ESTROGENIC AGENTS ACTIVELLA 1-0.5MG ALORA 0.025MG/24HR, 0.05MG/24HR, 0.075MG/24HR, 0.1MG/24HR CENESTIN 0.3MG, 0.45MG, 0.625MG, 0.9MG, 1.25MG CLIMARA 0.025MG/24 HR, 0.075MG/24 HR CLIMARA 0.0375MG/24HR, 0.06MG/24HR CLIMARA 3.9MG, 7.8MG CLIMARA PRO 45-15/24H COMBIPATCH 0.05-0.14/24 HR, 0.05-0.25/24 HR DELESTROGEN INJ 40MG/ML DEPOESTRADIOL INJ 5MG/ML ELESTRIN 0.06% GEL ENJUVIA TABLET 0.3MG, 0.45MG, 0.625MG, 0.9MG, 1.25MG ESTRADERM PATCH 0.05MG, 0.1MG ESTRADIOL 0.5MG, 1MG, 2MG ESTRADIOL CYPIONATE INJ 5MG/ML ESTRADIOL VALERATE INJ 40MG/ML
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Page 19 of 61
2 2 2 2 2 0 2 0 2 2 2 2 2 2 2
ELIGIBLE COVERED FOR DUAL
Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N N N N N N N N N N N N N
2 0 2
N N N
2 2 2 2 0 2 0 2 0
N N N N N N N N N
2 2 2 0 2 0 2 2 2 2 2 2 2 0 0 0
N N N N N N N N N N N N N N N N
AMEND
DRUG NAME ESTRASORB 2.5/G-1.74 ESTRATAB 0.625MG ESTROGEL 0.75/1.25G ESTROPIPATE 0.625MG, 0.75MG, 1.25MG, 2.5MG, 3MG FEMHRT 1-0.005MG, 2.5MCG-0.5 FEMPATCH 0.025MG/24HR FEMTRACE 0.45MG, 0.9MG, 1.8MG GYNODIOL 0.5MG, 1.5MG, 2MG MENEST 0.3MG, 0.625MG, 1.25MG, 2.5MG ORTHO-PREFEST 1-1-0.09MG PREMARIN 0.3MG, 0.45MG, 0.625MG, 0.9MG, 1.25MG, 2.5MG PREMPHASE 0.625/5 PREMPRO 0.3-1.5MG, 0.625/2.5, 0.625/5 PREMPRO LOW DOSE 0.45MG-1.5MG STILPHOSTROL INJ 50MG/ML VIVELLE 0.025MG/24 HR DOT, PATCH VIVELLE, DOT, PATCH 0.0375/24HR, 0.075/24HR, 0.05/24HR, 0.1/24HR G1D-ESTROGEN & PROGESTIN WITH ANTIMINERALOCORTICOID CB ANGELIQ 0.5 MG/1 MG TABLET G2A-PROGESTATIONAL AGENTS AYGESTIN 5MG DEPOPROVERA INJ 400MG/ML MEDROXYPROGESTERONE ACETATE 2.5MG, 5MG, 10MG NORETHINDRONE ACETATE 5MG PROGESTERONE INJ 50MG/ML PROMETRIUM 100MG, 200MG G3A-OXYTOCICS (family planning) METHERGINE 0.2MG G8A-CONTRACEPTIVES, ORAL (family planning) ALESSE 0.1-0.02 APRI 0.15-0.03 ARANELLE 7/9/5 AVIANE 0.1-0.002 BALZIVA 28 TABLET BREVICON 0.5-0.035MG CAMILA 0.35MG CESIA 7 DAYSX3 CRYSELLE 0.3-0.03MG CYCLESSA 7-7-7 DEMULEN 1/0.035MG, 1/0.050MG DESOGEN 0.15/0.3 ENPRESSE 6-5-10 ERRIN 0.35MG ESTROSTEP 5-7-9-7 ETHINYL ESTRADIOL/NORETHINDRONE 10/11 ETHINYL ESTRADIOL/NORETHINDRONE 35MCG/0.5MG
Effective October 1, 2007 March 20, 2008
Page 20 of 61
2 2 2 0 2 2 2 0 2 2 2 2 2 2 2 2 2
ELIGIBLE COVERED FOR DUAL
Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N N N N N N N N N N N N N N N
2
N
2 2 0 0 0 2
N N N N N N
0
N
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
N N N N N N N N N N N N N N N N N
AMEND
DRUG NAME ETHINYL ESTRADIOL/NORETHINDRONE 35MCG/1MG ETHYNODIOL DIACET/ETH ESTRA 1/0.035, 1/0.05 JENEST-28 JOLESSA 0.15 MG/0.03 MG TAB JOLIVETTE 0.35MG JUNEL 1-0.02MG, 1.5-0.03MG JUNEL FE 1.5-0.03MG, 1-0.02MG KARIVA 21-5 LEENA 7-9-5 LESSINA 0.1-0.02 LEVLEN 0.15/0.03 LEVLITE 0.1-0.02 LEVONORGESTROL/ETH ESTRADIOL 6-5-10 LEVORA 0.15/0.03 LO/OVRAL 0.3/0.03 LOESTRIN 1.5/0.03, 1/0.02 LOESTRIN 24 FE LOESTRIN FE 1.5/30, 1/20 LUTERA 0.1-0.02 MESTRANOL/NORETHINDRONE 50MCG/1MG MICROGESTIN 1.0-02MG, 1.5-0.03MG MICROGESTIN FE 1.5-0.035, 1.0-0.02 MICRONOR 0.35MG MIRCETTE 21-2-5 NECON 10/11 NECON 7 DAYS X 3 NORA-BE 0.35MG NORDETTE 0.15/0.03 NORGESTIMATE/ETHINYL ESTRADIOL 0.25/0.035 NORGESTREL/ETHINYL ESTRADIOL 0.3/0.03 NORTREL 7 DAYS X 3 NOTREL 0.5-0.035,1.0-0.035 OGESTREL 0.5-0.05MG ORTHO NOVUM 1/35, 1/50, 10/11, 7/7/7 ORTHO-CEPT 0.15/30 ORTHO-TRICYCLEN ORTHO-TRICYCLEN LO 7-7-7-LOW 1 OVCON 1/0.05, 0.4/0.035 OVRAL 0.5/0.05 OVRETTE PLAN B PORTIA 0.15-0.03 QUASENSE 0.15/0.03 MG RECLIPSEN SEASONALE SEASONIQUE
Effective October 1, 2007 March 20, 2008
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ELIGIBLE COVERED FOR DUAL
Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N
AMEND
DRUG NAME SOLIA 0.15-0.03 SPRINTEC 0.25-0.035MG SPRONYX TILIA FE 5-7-9-7 TRI-LEVLEN 6-5-10 TRINESSA 7DAYS X 3 TRI-NORINYL 7-9-5 TRIPHASIL 6-5-10 TRI-LEGEST FE 5-7-9-7 TRI-PREVIFEM 7 DAYS X 3 TRI-SPRINTEC 7 DAYS X 3 VELIVET 7 DAYS X 3 YASMIN 28 YAZ ZENCHENT 0.4-0.035 ZOVIA 1/0.05MG, 1/0.035MG G8F-CONTRACEPTIVE, TRANSDERMAL (family planning) ORTHO-EVRA 20-150/24HR G9A-CONTRACEPTIVES, INTRAVAGINAL (family planning) BECAUSE CONCEPTROL GEL, INSERTS DELFEN FOAM EMKO FOAM GYNOL II SEMICID G9B- CONTRACEPTIVES, INTRAVAGINAL, SYSTEMIC (family planning) NUVA RING 0.12-0.015 H0B-LOCAL ANESTHETICS LIDOCAINE GEL 2% LIDOCAINE INJ 1% LIDOCAINE VISCOUS 2% H0E-AGENTS TO TREAT MULTIPLE SCLEROSIS AVONEX 30MCG BETASERON 0.3MG COPAXONE 20MG REBIF 22MCG/0.5ML,44MCG/0.5ML, TITRATION PACK (8.8MCG AND 22MCG) H1A-ALZHEIMER'S THERAPY, NMDA RECEPTOR ANTAGONISTS NAMENDA 5MG, 10MG, 5-10MG, 10MG/5ML H2A-CNS STIMULANTS CYLERT 18.75MG, 75MG CYLERT 37.5MG CYLERT CHEWABLE 37.5MG PEMOLINE 37.5MG, 75MG H2D-BARBITURATES (may be covered for dual eligible) BUTISOL SODIUM ELIXIR 30MG/5ML BUTISOL SODIUM TABS 15MG, 30MG, 50MG, 100MG
Effective October 1, 2007 March 20, 2008
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Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N N N N N N N N N N N N N N
0
N
0 0 0 0 0 0
N N N N N N
0
N
0 0 0
N N N
2 2 2 2
N N N N
2
N
0 0 0 0
N N N N
2 2
Y Y
AMEND
DRUG NAME LUMINAL INJ 60MG/ML PHENOBARBITAL 1/4GR, 1/2GR, 1GR, 1-1/2GR PHENOBARBITAL ELIXIR 20MG/5ML PHENOBARBITAL INJ 30MG/ML, 60MG/ML, 65MG/ML, 130MG/ML SECONAL SODIUM 100MG H2E-NON-BARB SEDATIVE-HYPNOTIC (benzodiazepines may be covered for dual eligible) AQUACHLORAL SUPPS 324MG, 648MG ATIVAN INJ 2MG/ML, 4MG/ML CHLORAL HYDRATE SUPPS 500MG CHLORAL HYDRATE SYRUP 500MG/5ML ESTAZOLAM 1MG, 2MG FLURAZEPAM 15MG, 30MG LORAZEPAM INJ 2MG/ML, 4MG/ML LUNESTA 1MG, 2MG, 3MG MIDAZOLAM HCL SYRUP 2MG/ML TEMAZEPAM 15MG,30MG ZOLPIDEM 5MG, 10MG TRIAZOLAM 0.125MG,0.25MG H2F-ANTI-ANXIETY DRUGS (benzodiazepines may be covered for dual eligible) ALPRAZOLAM 0.25MG, 0.5MG, 1MG, 2MG BUSPIRONE 5MG, 7.5MG, 10MG, 15MG, 30MG CHLORDIAZEPOXIDE HCL 5MG, 10MG, 25MG CLORAZEPATE 3.75MG, 7.5MG, 15MG DIAZEPAM 2MG, 5MG, 10MG DIAZEPAM INJ 5MG/ML DIAZEPAM ORAL SOLN 5MG/ML, 5MG/5ML LORAZEPAM 0.5MG, 1MG, 2MG LORAZEPAM INTENSOL SOLN 2MG/ML MEPROBAMATE 200MG, 400MG OXAZEPAM 10MG, 15MG, 30MG H2G-ANTI-PSYCHOTICS PHENOTHIAZINES (SEE ALSO H6J) CHLORPROMAZINE 10MG, 25MG, 50MG, 100MG, 200MG CHLORPROMAZINE CONC SOLN 30MG/ML, 100MG/ML CHLORPROMAZINE INJ 25MG/ML FLUPHENAZINE DECANOATE INJ 25MG/ML FLUPHENAZINE HCL 1MG, 2.5MG, 5MG, 10MG FLUPHENAZINE INJ 2.5MG/ML FLUPHENAZINE SOLN 2.5MG/5ML, 5MG/ML PERPHENAZINE 2MG, 4MG, 8MG, 16MG THIORIDAZINE 10MG, 15MG, 25MG, 50MG, 100MG, 150MG, 200MG THIORIDAZINE 30MG/ML, 100MG/ML SOLN TRIFLUOPERAZINE HCL 1MG, 2MG, 5MG, 10MG H2H-MONOAMINEOXIDASE INHIBITORS (SEE ALSO H6A) EMSAM 6MG/24H, 9MG/24H, 12MG/24H SELEGILINE HCL 5MG
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Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
Y Y Y Y Y
2 2 0 0 0 0 0 2 0 0 0 0
N Y N N Y Y Y N Y Y N Y
0 0 0 0 0 0 0 0 0 0 0
Y N Y Y Y Y Y Y Y N Y
0 0 0 0 0 0 0 0 0 0 0
N N N N N N N N N N N
2 0
N N
AMEND
DRUG NAME H2J-ANTIDEPRESSANTS AMITRIPTYLINE HCL 10MG, 25MG, 50MG, 75MG, 100MG, 150MG AMOXAPINE 25MG, 50MG, 100MG, 150MG DESIPRAMINE 10MG, 25MG, 50MG, 75MG, 100MG, 150MG DESYREL DIVIDOSE 300MG DOXEPIN HCL 10MG, 25MG, 50MG, 75MG, 100MG, 150MG DOXEPIN HCL ORAL CONC 10MG/ML IMIPRAMINE HCL 10MG, 25MG, 50MG MAPROTILINE 25MG, 50MG, 75MG NORTRIPTYLINE 10MG, 25MG, 50MG, 75MG, 10MG/5ML ORAL PAMELOR SOLN 10MG/5ML TRAZODONE HCL 50MG, 100MG, 150MG H2K-ANTIDEPRESSANT COMBINATIONS AMITRIPTYLINE/CHLORDIAZEPOXIDE 12.5/5, 25/10 AMITRIPTYLINE/PERPHENAZINE 10/2, 10/4, 25/2, 25/4, 50/4 H2L-ANTIPSYCHOTIC, NON-PHENOTHIAZINE LOXAPINE SUCCINATE 5MG, 10MG, 25MG, 50MG THIOTHIXENE 1MG, 2MG, 5MG, 10MG, 5MG/ML ORAL CONC H2M-ANTI-MANIA DRUGS ESKALITH CR 450MG LITHIUM CARBONATE 150MG, 300MG, 600MG LITHIUM CARBONATE SR 300MG, 450MG LITHIUM CITRATE SYRUP 8MEQ/5ML LITHOBID 300MG H2R-ANTIPRURITICS (SYSTEMIC) CYPROHEPTADINE 4MG CYPROHEPTADINE SYRUP 2MG/5ML H2S-SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) CITALOPRAM 10MG/5ML CITALOPRAM HBR 10MG, 20MG, 40MG FLUOXETINE 10MG TABS FLUOXETINE 10MG, 20MG CAPS, 20MG/5ML FLUVOXAMINE MALEATE 25MG, 50MG, 100MG LEXAPRO 5MG, 20MG, 5MG/5ML PAROXETINE HCL 10MG, 20MG, 30MG, 40MG PAXIL CR 12.5MG, 25MG, 37.5MG PAXIL LIQUID 10MG/5ML PEXEVA 10MG, 20MG, 30MG, 40MG PROZAC WEEKLY 90MG SERTRALINE 25MG, 50MG, 100MG, 20MG/ML H2U-TRICYCLIC ANTIDEPRESSANTS & REL. NON-SEL. RU-INHIB CLOMIPRAMINE 25MG, 50MG, 75MG PROTRIPTYLINE 5MG SURMONTIL 25MG, 50MG, 100MG TOFRANIL PM 75MG, 100MG, 125MG, 150MG VIVACTIL 5MG, 10MG
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0 0 0 0 0 0 0 0 0 2 0
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Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N N N N N N N N N
0 0
N N
0 0
N N
2 0 0 0 2
N N N N N
0 0
N N
0 0 0 0 0 2 0 2 2 2 2 0
N N N N N N N N N N N N
0 0 2 2 2
N N N N N
AMEND
DRUG NAME H2V-TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY CONCERTA 18MG, 27MG, 36MG, 54MG (AGE 6 AND OVER) FOCALIN 2.5MG, 5MG, 10MG (AGE 6 AND OVER) FOCALIN XR 5MG, 10MG, 15MG, 20MG (AGE 6 AND OVER) METADATE CD 10MG, 20MG, 30MG, 40MG, 50MG, 60MG (AGE 5 AND OVER) METADATE ER 10MG (AGE 5 AND OVER) METHYLIN 5MG/5ML, 10MG/5ML (AGE 5 AND OVER) METHYLIN ER 10MG (AGE 5 AND OVER) METHYLPHENIDATE HCL 5MG, 10MG, 20MG (AGE 5 AND OVER) METHYLPHENIDATE SR 20MG (AGE 5 AND OVER) H3A-NARCOTIC ANALGESICS ACETAMINOPHEN/CODEINE 15-300, 30-300, 60-300 ACETAMINOPHEN/CODEINE ELIXIR 120-12MG/5ML ASPIRIN/CODEINE 30-325, 60-325 ASTROMORPH 4MG/ML B&O SUPRETTES 15-A,16-A BELLADONNA/OPIUM SUPPS 30-16.2MG CODEINE PHOSPHATE 1/2GR, 1GR CODEINE PHOSPHATE INJ 15MG/ML, 30MG/ML CODEINE SULFATE 1/4GR, 1/2GR, 1GR DEMEROL INJ 25MG/ML, 50MG/ML, 75MG/ML, 75MG/1.5ML, 100MG/ML DILAUDID 3MG SUPPS DILAUDID INJ 1MG/ML, 2MG/ML, 4MG/ML, 10MG/ML DILAUDID-5 1MG/ML ORAL DURAGESIC PATCH 12MCG DURAGESIC PATCH 25MCG, 50MCG, 75MCG, 100MCG HYDROCODONE/ACETA 10MG/325MG HYDROCODONE/ACETA 2.5-167/5ML HYDROCODONE/ACETA 5MG/500MG, 7.5MG/500MG, 7.5MG/750MG, 10MG/500MG HYDROMORPHONE HCL 2MG, 4MG, 8MG HYDROMORPHONE HCL ORAL LIQ 1MG/ML HYDROMORPHONE INJ 2MG/ML, 4MG/ML, 10MG/ML HYDROMORPHONE SUPPS 3MG KADIAN 20MG, 30MG, 50MG, 60MG, 80MG, 100MG, 200MG LEVO-DROMERAN INJ 2MG/ML MEPERIDINE 50MG, 100MG MEPERIDINE HCL INJ 10MG/ML, 25MG/ML, 50MG/ML, 75MG/ML, 100MG/ML MEPERIDINE SYRUP 50MG/5ML METHADONE 10MG/5ML METHADONE 5MG, 10MG, 40MG METHADONE SOLN 5MG/5ML, 10MG/ML CONC SOLN METHADOSE 10MG/ML MORPHINE SULFATE SOLN, ELIXIR 20MG/ML MORPHINE SULFATE 10MG, 15MG, 30MG MORPHINE SULFATE ER 15MG, 30MG, 60MG, 100MG, 200MG MORPHINE SULFATE INJ 8MG/ML, 10MG/ML, 15MG/ML, 25MG/ML, 50MG/ML
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Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N
AMEND
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CO-PAYMENT
DRUG CLASS
5101:3-9-12
DRUG NAME MORPHINE SULFATE INJ 0.5MG/ML, 1MG/ML, 2MG/ML, 4MG/ML, 5MG/ML 0 N MORPHINE SULFATE SOLN 10MG/5ML, 20MG/5ML 0 N MORPHINE SULFATE SUPPS 5MG, 10MG, 20MG, 30MG 0 N OXYCODONE ER 10MG, 20MG, 40MG, 80MG 0 N OXYCODONE HCL 5MG, 15MG, 30MG 0 N OXYCODONE HCL 5MG/5ML, 20MG/ML 0 N OXYCODONE HCL/ACETA 5-325, 5-500, 7.5-325, 7.5-500, 10-325, 10-650 0 N OXYCODONE HCL/OXY T/ASA 4.5/0.38/325 0 N ROXICET ORAL SOLN 5MG/325MG 2 N ROXICODONE 5MG/5ML 2 N SUBOXONE 2MG-0.5MG, 8MG-2MG 2 N SUBUTEX 2MG, 8MG 2 N H3B-ANALGESICS BUTORPHANOL INJ 2MG/ML 0 N BUTORPHANOL NS 10MG/ML 0 N STADOL INJ 2MG/ML 2 N TRAMADOL 50MG 0 N H3C-ANALGESICS, NON-NARCOTICS PROPOXYPENE NAPSYLATE/ACETA 100/650 0 N PROPOXYPHENE CPD 65 0 N PROPOXYPHENE HCL 65MG 0 N PROPOXYPHENE/ACETA 65/650 0 N H3D-ANALGESIC/ANTIPYRETICS, SALICYLATES (may be covered for dual eligible if available over the counter) ANABAR 200-300-20 2 N ASPIRIN 800MG 0 N ASPIRIN 975MG 0 N ASPIRIN EC 81MG, 325MG, 650MG 0 Y BE-FLEX PLUS 200-300-20 2 N CETAZONE-T 2 N CHOLINE MAGNESIUM TRISALICYLATE 500MG, 750MG, 1000MG 0 N CHOLINE MAGNESIUM TRISALICYLATE LIQUID 500MG/5ML 0 N ED-FLEX 200-300-20 2 N SALSALATE 500MG, 750MG 0 N ZORPRIN 800MG 2 N H3E-ANALGESIC, ANTIPYRETIC-NON-SAL (may be covered for dual eligible if available over the counter or contains barbiturate) ACETAMINOPHEN SUPPOSITORIES 120MG, 325MG, 650MG 0 Y ACETAMINOPHEN/BUTALBITAL 325MG/50MG, 650MG/50MG 0 Y BUTALBITAL/ACETAMINOPHEN/CAFFEINE 325/40/50 CAP, TAB 0 Y BUTALBITAL/ACETAMINOPHEN/CAFFEINE 500-40-50 TAB 0 Y DOLGIC LIQUID 325-40-50/5ML 2 Y DOLOGESIC 500-30MG 2 N PHRENILIN 2 Y PHRENILIN FORTE 2 Y
Effective October 1, 2007 March 20, 2008
AMEND
Page 27 of 61
DRUG NAME H3F-ANTIMIGRAINE PREPARATIONS AMERGE 1MG, 2.5MG 2 AXERT 6.25MG, 12.5MG 2 CAFERGOT 1-100MG 2 CAFERGOT SUPPOSITORIES 2 CAFFEINE-ERGOTAMINE SUPPOSITORIES 0 ERGOTAMINE/CAFFEINE TABS 1-100MG 0 FROVA 2.5MG 2 IMITREX INJ 4MG/0.5ML, 6MG/0.5ML 2 IMITREX NASAL 5MG, 20MG 2 IMITREX TAB 25MG, 50MG, 100MG 2 MAXALT 5MG, 10MG 2 MAXALT MLT 5MG, 10MG 2 MIGRANAL NASAL 4MG/ML, 0.5MG/SPRAY 2 RELPAX 20MG, 40MG 2 H3T-NARCOTIC ANTAGONISTS NALTREXONE HCL 50MG 0 H4B-ANTICONVULSANTS (benzodiazepines and barbiturates may be covered for dual eligible) CARBAMAZEPINE 100MG, 200MG, 100MG/5ML 0 CARBATROL 100MG, 200MG, 300MG 2 CELONTIN 150MG, 300MG 2 CLONAZEPAM 0.5MG, 1MG, 2MG 0 DEPAKENE 250MG (BMN ONLY) 2 DEPAKENE SYRUP 250MG/5ML (BMN ONLY) 2 DEPAKOTE 125MG, 250MG, 500MG 2 DEPAKOTE ER 250MG, 500MG 2 DEPAKOTE SPRINKLE 125MG 2 DIASTAT 2.5MG, 5MG, 10MG, 20MG 2 DIASTAT ACUDIAL 10, 20 2 DILANTIN 30MG, 50MG CHEWABLE, 100MG 2 DILANTIN SUSP 125MG/5ML 2 ETHOSUXIMIDE SYRUP 250MG/5ML 0 EQUETRO 100MG, 200MG, 300MG 2 FELBATOL 400MG, 600MG 2 FELBATOL SUSP 600MG/5ML 2 GABAPENTIN 100MG, 300MG, 400MG, 600MG, 800MG 0 LAMICTAL 5MG 0 LAMICTAL 25MG, 100MG, 150MG, 200MG, 25-100 2 MEBARAL 32MG, 50MG, 100MG 2 MEPHOBARBITAL 32MG, 50MG, 100MG 0 MYSOLINE 250MG (BMN ONLY) 2 MYSOLINE 50MG 2 MYSOLINE SUSP 250MG/5ML 2 NEURONTIN 250MG/5ML 2 PEGANONE 250MG 2 PHENYTEK 200MG, 300MG 2
Effective October 1, 2007 March 20, 2008
ELIGIBLE COVERED FOR DUAL
Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N N N N N N N N N N N N N N N N Y N N N N N Y Y N N N N N N N N N Y Y N N N N N N
AMEND
DRUG NAME PHENYTOIN SODIUM 100MG, ER100MG PHENYTOIN SODIUM INJ 50MG/ML PHENYTOIN SUSP 125MG/5ML PRIMIDONE 250MG PRIMIDONE 50MG TEGRETOL 100MG, 200MG (BMN ONLY) TEGRETOL SUSP 100MG/5ML TEGRETOL XR 100MG, 200MG, 400MG TOPAMAX 15MG, 25MG, 50MG, 100MG, 200MG TRILEPTAL 150MG, 300MG, 600MG, 300MG/5ML VALPROIC ACID 250MG VALPROIC ACID SYRUP 250MG/5ML ZARONTIN 250MG ZARONTIN SYRUP 250MG/5ML H4C-ANTICONVULSANTS GABITRIL 2MG, 4MG, 12MG, 16MG KEPPRA 100MG/ML KEPPRA 250MG, 500MG, 750MG, 1000MG LYRICA 25MG, 50MG, 75MG, 100MG, 150MG, 200MG, 225MG, 300MG ZONISAMIDE 25MG, 50MG, 100MG H6A-ANTIPARKINSON DRUGS, OTHER (SEE ALSO C7B, H2H) AMANTADINE HCL 100MG AMANTADINE SYRUP 50MG/5ML APOKYN 10MG/ML AZILECT 0.5MG, 1MG BROMOCRIPTINE 2.5MG, 5MG CARBIDOPA/LEVODOPA 10/100, 25/100, 25/250 CARBIDOPA/LEVODOPA CR 25/100, 50/200 COMTAN 200MG LARODOPA 100MG, 250MG, 500MG MIRAPEX 0.125MG, 0.25MG, 0.5MG, 0.75MG, 1MG, 1.5MG NEUPRO PATCH 2MG/24HR, 4MG/24HR, 6MG/24HR PARLODEL 2.5MG, 5MG PERGOLIDE 0.05MG, 0.25MG, 1MG PERMAX 0.05MG, 0.25MG, 1MG REQUIP 0.25MG, 0.5MG, 1MG, 2MG, 3MG, 4MG, 5MG SELEGILINE HCL 5MG STALEVO 12.5/50/200, 25/100/200, 37.5/150/200, 50/200/200 TASMAR 100MG, 200MG ZELAPAR 1.25MG H6B-ANTIPARKINSONISM DRUGS,ANTICHOLINERGIC AKINETON 2MG BENZTROPINE 0.5MG, 1MG, 2MG COGENTIN INJ 1MG/ML KEMADRIN 5MG TRIHEXIPHENIDYL HCL 2MG, 5MG, 2MG/5ML
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Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N N N N N N N N N N N N
2 2 2 2 0
N N N N N
0 0 2 2 0 0 0 2 2 2 2 2 0 2 2 0 2 2 2
N N N N N N N N N N N N N N N N N N N
2 0 2 2 0
N N N N N
AMEND
DRUG NAME H6C-ANTITUSSIVE NON-NARC (may be covered for dual eligible) BENZONATATE 100MG DELSYM 30MG/5ML DEXTROMETHORPHAN HBR 15MG/5ML ELIXSURE COUGH 7.5MG/5ML (DM) ROBITUSSIN PEDIATRIC 7.5MG/5ML H6H-SKELETAL MUSCLE RELAXANTS BACLOFEN 10MG, 20MG CHLORZOXAZONE 250MG, 500MG CYCLOBENZAPRINE 5MG, 10MG METHOCARBAMOL 500MG, 750MG METHOCARBAMOL WITH ASPIRIN 400/325 NORFLEX 30MG/ML INJ ORPHENADRINE CITRATE 100MG ORPHENADRINE CITRATE INJ 30MG/ML ORPHENADRINE CPD 385/30/25 ORPHENADRINE CPD 770/60/50 ROBAXIN INJ 100MG/ML TIZANIDINE HCL 2MG, 4MG H6J-ANTIEMETIC/ANTIVERTIGO AGENTS (SEE ALSO H2G) ANTI-NAUSEA LIQUID CESAMET 1MG COLA SYRUP COMPAZINE INJ 5MG/ML DIMENHYDRINATE 50MG DIMENHYDRINATE 50MG/ML EMEND 40MG, 80MG, 125MG, 125-80 MARINOL 2.5MG, 5MG, 10MG MECLIZINE 12.5MG, 25MG CHEWABLE, 25MG NAUSETROL SOLN ONDANSETRON 4MG, 8MG, 24MG ONDANSETRON ODT 4MG, 8MG ONDANSETRON ORAL SOLUTION 4MG/5ML PROCHLORPERAZINE EDISYLATE INJ 5MG/ML PROCHLORPERAZINE MALEATE 5MG, 10MG PROCHLORPERAZINE MALEATE SUPP 25MG PROMETHAZINE SUPPS, 12.5MG, 25MG, 50MG SCOPACE 0.4MG TIGAN INJ 100MG/ML TORECAN 10MG, 5MG/ML INJ TRANSDERM SCOP PATCH 1.5MG/72HRS TRIMETHOBENZAMIDE HCL 300MG TRIMETHOBENZAMIDE INJ 100MG/ML
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Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
Y Y Y Y Y
0 0 0 0 0 2 0 0 0 0 2 0
N N N N N N N N N N N N
0 2 0 2 0 0 2 2 0 0 0 0 0 0 0 0 0 2 2 2 2 0 0
N N N N N N N N N N N N N N N N N N N N N N N
AMEND
DRUG NAME H7B-ALPHA-2 RECEPTOR ANTAGONIST ANTIDEPRESSANTS MIRTAZAPINE 7.5MG, 15MG, 30MG, 45MG, SOL-TABS MIRTAZAPINE RAPID DISSOLVE TABLET 15MG, 30MG, 45MG REMERON SOL-TABS 15MG, 30MG, 45MG H7C-SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS) CYMBALTA 20MG, 30MG, 60MG EFFEXOR 25MG, 37.5MG, 50MG, 75MG, 100MG EFFEXOR XR 37.5MG, 75MG, 150MG VENLAFAXINE HCL 25MG, 37.5MG, 50MG, 75MG, 100MG TABS H7D-NOREPINEPHRINE AND DOPAMINE REUPTAKE INHIB (NDRIS) BUPROPION HCL 75MG, 100MG BUPROPION SR 100MG, 150MG, 200MG WELLBUTRIN SR 100MG, 150MG, 200MG WELLBUTRIN XL 150MG, 300MG H7E-SEROTONIN-2 ANTAGONIST/REUPTAKE INHIBITORS (SARIS) NEFAZODONE HCL 50MG, 100MG, 150MG, 200MG, 250MG H7J-MAOIS - NON-SELECTIVE & IRREVERSIBLE NARDIL 15MG PARNATE 10MG H7O-ANTIPSYCHOTICS,DOPAMINE ANTAGONISTS,BUTYROPHENONES HALDOL INJ 5MG/ML HALOPERIDOL 0.5MG, 1MG, 2MG, 5MG, 20MG HALOPERIDOL DECANOATE 50MG/ML, 100MG/ML HALOPERIDOL LACTATE CONC LIQUID 2MG/ML H7R-ANTIPSYCH, DOPAMINE ANTAGONIST, DIPHENYLBUTYLPIPERIDINES ORAP 1MG, 2MG H7S-ANTIPSYCHOTICS, DOPAMINE ANTAGONIST, DIHYDROINDOLONES MOBAN 5MG, 10MG, 25MG, 50MG H7T-ANTIPSYCHOTICS, ATYPICAL,DOPAMINE,& SEROTONIN ANTAG CLOZAPINE 12.5MG, 25MG, 50MG, 100MG, 200MG CLOZARIL 25MG, 100MG (BMN ONLY) FAZACLO TABLET 12.5MG, 25MG, 100MG GEODON 20MG, 40MG, 60MG, 80MG RISPERDAL 0.25MG, 0.5MG, 1MG, 2MG, 3MG, 4MG RISPERDAL M 0.5MG, 1MG, 2MG, 3MG, 4MG RISPERDAL SOLN 1MG/ML SEROQUEL 25MG, 50MG, 100MG, 200MG, 300MG, 400MG SEROQUEL XR 200MG, 300MG, 400MG ZYPREXA 2.5MG, 5MG, 7.5MG, 10MG, 15MG, 20MG ZYPREXA ZYDIS 5MG, 10MG, 15MG, 20MG H7X-ANTIPSYCHOTICS, ATYP, D2 PARTIAL AGONIST/5HT MIXED ABILIFY 2MG, 5MG, 10MG, 15MG, 20MG, 30MG ABILIFY 5MG/5ML ABILIFY DISCMELT 10MG, 15MG ABILIFY INJ 9.75MG/1.3ML
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Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N
2 2 2 0
N N N N
0 0 2 2
N N N N
0
N
2 2
N N
0 0 0 0
N N N N
2
N
2
N
0 2 2 2 2 2 2 2 2 2 2
N N N N N N N N N N N
2 2 2 2
N N N N
AMEND
DRUG NAME H7Y-TX FOR ATTENTION DEFICIT-HYPERACT.(ADHD), NRI-TYPE STRATTERA 10MG, 18MG, 25MG, 40MG, 60MG, 80MG, 100MG (AGE 6 AND OLDER) H7Z-SSRI &ANTIPSYCH, ATYP, DOPAMINE & SEROTONIN ANTAG COMB SYMBYAX 3MG-25MG, 6MG-25MG, 6MG-50MG, 12MG-25MG, 12MG-50MG H8B-HYPNOTICS, MELATONIN MT1/MT2 RECEPTOR AGONISTS ROZEREM 8MG J1A-PARASYMPATHETIC AGENTS BETHANECHOL CHLORIDE 5MG, 10MG, 25MG, 50MG EVOXAC 30MG GUANIDINE HCL 125MG PILOCARPINE HCL 5MG SALAGEN 5MG J1B-CHOLINESTERASE INHIBITORS ARICEPT 5MG,10MG ARICEPT ODT 5MG, 10MG COGNEX 10MG, 20MG, 30MG, 40MG EXELON 1.5MG, 3MG, 4.5MG, 6MG, 2MG/ML EXELON PATCH 4.6MG/24HR, 9.5MG/24HR MESTINON 180MG MESTINON 60MG/5ML LIQUID MYTELASE 10MG PROSTIGMIN 15MG PYRIDOSTIGMINE BROMIDE 60MG RAZADYNE 4MG, 8MG, 12MG, 4MG/ML RAZADYNE ER 8MG, 16MG, 24MG J2A-BELLADONNA ALKALOIDS ATROPINE INJ 1MG/ML COLYTROL 0.031MG/ML COLYTROL LIQ, PED DROPS, TABS CYSTOSPAZ 0.15MG HYOSCYAMINE 0.125MG, 0.15MG HYOSCYAMINE 0.125MG/ML, 0.125MG/5ML HYOSCYAMINE 0.375MG HYOSCYAMINE SULFATE 0.25MG PAMINE 2.5MG PAMINE FORTE 5MG SAL-TROPINE 0.4MG SYMAX 0.125MG J2B-ANTICHOLINERGIC, QUATERNARY AMMONIUM CANTIL 25MG GLYCOPYRROLATE 1MG, 2MG PROPANTHELINE 15MG ROBINUL 1MG ROBINUL FORTE 2MG ROBINUL INJ 0.2MG/ML
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Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N
2
N
2
N
0 2 2 0 2
N N N N N
2 2 2 2 2 2 2 2 2 0 2 2
N N N N N N N N N N N N
0 2 2 2 0 0 0 0 2 2 2 2
N N N N N N N N N N N N
2 0 0 2 2 2
N N N N N N
AMEND
DRUG NAME J2D-ANTICHOLINERGIC ANTISPASMODICS BENTYL 10MG/5ML DICYCLOMINE HCL 10MG, 20MG DICYCLOMINE HCL INJ 10MG/ML OXYBUTYNIN CHLORIDE 5MG OXYBUTYNIN CHLORIDE 5MG/5ML J3A-SMOKING DETERRENT AGENTS (GANGLIONIC STIM, OTHERS) COMMIT 2MG, 4MG NICODERM CQ PATCH 7MG/24HR, 14MG/24HR, 21MG/24HR NICORETTE GUM 2MG, 4MG NICOTINE GUM 2MG, 4MG NICOTROL INHALER NICOTROL NASAL SPRAY ZYBAN 150MG J3C-SMOKING DETERRENT-NICOTINIC RECEPT.PARTIAL AGONIST CHANTIX 0.5MG, 1MG, MONTH PAK J5A-ADRENERGIC AGENTS, CATECHOLAMINES ADRENALIN CHLORIDE 1MG/ML EPINEPHRINE 0.1MG/ML EPINEPHRINE 1MG/ML ISOETHARINE HCL 1% J5B-ADRENERGICS, AROMATIC, NON-CATECHOLAMINE ADDERALL 5MG, 10MG, 20MG, 30MG ADDERALL 7.5MG, 12.5MG, 15MG ADDERALL XR 5MG, 10MG, 15MG, 20MG, 25MG, 30MG AMPHETAMINE SALT COMBO 5MG, 10MG, 20MG, 30MG VYVANSE 30MG, 50MG, 70MG J5D-BETA ADRENERGIC AGENTS ALBUTEROL 2MG, 4MG ACCUNEB (AGE 0 TO 12 ONLY) 0.21MG/ML, 0.42MG/ML ALBUTEROL 0.83MG/ML SOLN FOR INH ALBUTEROL 2MG/5ML SYRUP ALBUTEROL 5MG/ML SOLN FOR INH ALBUTEROL 90MCG INH, REF BRETHINE 1MG/ML INJ BRETHINE 2.5MG, 5MG COMBIVENT 103-18MCG MAXAIR AUTOHALER METAPROTERENOL 10MG, 20MG METAPROTERENOL 10MG/5ML SYRUP METAPROTERENOL SOLN FOR INH 0.4%, 0.6% PROAIR HFA (FORMERLY ALBUTEROL SULFATE HFA) TERBUTALINE SO4 2.5MG, 5MG VENTOLIN HFA
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CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N N N
2 0 2 0 2 2 2
N N N N N N N
2
N
2 0 0 0
N N N N
2 0 2 0 2
N N N N N
0 * 0 0 0 0 2 2 2 2 0 0 0 0 0 2
N N N N N N N N N N N N N N N N
AMEND
DRUG NAME VOSPIRE ER 4MG, 8MG XOPENEX 0.63MG/3ML, 1.25MG/3ML, 0.31MG/3ML XOPENEX HFA J5E-SYMPATHOMIMETIC AGENTS CHILDRENS NASAL DECONGESTANT 15MG/5ML (PSEUDO) EPHEDRINE SULFATE 25MG PHENYLEPHRINE HCL 10MG PSEUDOEPHEDRINE HCL 30MG, 60MG PSEUDOEPHEDRINE HCL 30MG/5ML J5F-ANAPHYLAXIS THERAPY AGENTS EPIPEN, EPIPEN JR 0.15MG J5H-ADRENERGIC VASOPRESSOR AGENTS MIDODRINE HCL 2.5MG, 5MG, 10MG PROAMATINE 2.5MG, 5MG, 10MG J7A-ALPHA/BETA-ADRENERGIC BLOCKING AGENTS CARVEDILOL TABLETS 3.125MG, 6.25MG, 12.5MG, 25MG COREG 3.125MG, 6.25MG, 12.5MG, 25MG COREG CR 10MG, 20MG, 40MG, 80MG LABETALOL 100MG, 200MG, 300MG J7C-BETA ADRENERGIC BLOCKERS ACEBUTOLOL 200MG, 400MG ATENOLOL 25MG, 50MG, 100MG BETAXOLOL HCL 10MG, 20MG BISOPROLOL FUM 5MG, 10MG INDERAL LA 60MG, 80MG, 120MG, 160MG METOPROLOL TARTRATE 25MG, 50MG, 100MG NADOLOL 20MG, 40MG, 80MG, 120MG, 160MG PINDOLOL 5MG, 10MG PROPRANOLOL 20MG/5ML, 40MG/5ML SOLN PROPRANOLOL HCL 10MG, 20MG, 40MG, 60MG, 80MG, 90MG PROPRANOLOL LA 60MG, 80MG, 120MG, 160MG SOTALOL 80MG, 120MG, 160MG, 240MG TIMOLOL MALEATE 5MG, 10MG, 20MG TOPROL XL 50MG, 100MG, 200MG TOPROL XL 25MG J9A-INTESTINAL MOTILITY STIMULANTS METOCLOPRAMIDE HCL 10MG METOCLOPRAMIDE HCL 5MG/5ML ORAL SOLN METOCLOPRAMIDE HCL 5MG/ML INJ L0B-TOPICAL/MUCOUS MEMBRANE/SUBCUTANEOUS ENZYME ACCUZYME 0.83MMU SPRAY ACCUZYME 0.83MMU/GM, OINT ACCUZYME SE SPRAY EMULSION ETHEZYME 0.83MMU/G, 1.1MMU/G GLADASE 0.83MMU/GM GLADASE-C
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CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N
0 0 0 0 0
N N N N N
2
N
0 2
N N
0 2 2 0
N N N N
0 0 0 0 2 0 0 0 2 0 0 0 0 2 0
N N N N N N N N N N N N N N N
0 0 0
N N N
2 2 2 2 2 2
N N N N N N
AMEND
DRUG NAME KOVIA OINT PANAFIL 10%, SPRAY 521700-10 PANAFIL SE SPRAY EMULSION PAPAIN-UREA-CHLOROPHYLLIN 1.1MMU/G PAP-UREA 830000 U/G PAPTASE FOAM 83000-10 SANTYL ZIOX 405 L1A-ANTIPSORIATIC AGENTS,SYSTEMIC SORIATANE 10MG, 25MG SORIATANE CK KIT 10MG, 25MG L2A-EMOLLIENTS AMLACTIN CREAM 12% AMMONIUM LACTATE 12% CREAM KERI SENSITIVE SKIN LOTION LAC-HYDRIN CREAM RESURFIX L3A-PROTECTIVES (may be covered for dual eligible if available over the counter) ALOE VESTA BAZA PROTECT CRITIC-AID CLEAR OINT DERMAMED OINT, SPRAY PELEVERUS REMEDY SKIN REPAIR CREAM 1.5% L3B - PROTECTIVES (may be covered for dual eligible if available over the counter) SENSI-CARE L3P-ANTIPRURITICS TOPICAL AMLACTIN AP 1% DIPHENHYDRAMINE 2% CREAM PRUDOXIN 5% ZONALON 5% L5A-KERATOLYTICS AMLACTIN LOTION 12% AMMONIUM LACTATE LOTION 12% BENZAC AC 2.5% BENZOYL PEROXIDE GEL 2.5%, 5%, 10% BENZOYL PEROXIDE LOTION 5%, 10% BENZOYL PEROXIDE WASH 2.5%, 5%, 10% BREVOXYL CLEANSING LOTION 4% BREVOXYL CREAMY WASH 4%, 8% BREVOXYL GEL 4%, 8% BREVOXYL-8 LOTION 8% CONDYLOX GEL 0.5% CONDYLOX TOP SOLN 0.5% DESQUAM-E 2.5% HYDRISALIC CREAM
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CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N N N N N N
2 2
N N
2 0 2 2 2
N N N N N
2 2 2 2 2 2
Y Y Y Y Y Y
2
Y
2 0 2 2
N N N N
2 0 2 0 0 0 2 2 2 2 2 0 2 2
N N N N N N N N N N N N N N
AMEND
DRUG NAME KEROL 42% REDI-CLOTHS LACTINOL 10% MECTALYTE TOPICAL SUSP 40% NEOBENZ MICRO CREAM 3.5%, 5.5%, 8.5% OSCION CLEANSER 3%, 6%, 9% SALAC 2% SALACTIC FILM 16.7% SAL-PLANT GEL 17% SALICYLIC ACID 6% SHAMPOO TRIAZ 3%, 6%, 9% GEL TRIAZ CLEANSING LOTION 3%, 6%, 10% UREA GEL 40% UREA LOTION 35%, 40% UREALAC 50% NAIL STICK VANAMIDE 40% ZACLIR 4%, 8% L5E-ANTISEBORRHEIC AGENTS CARMOL SCALP TREATMENT KIT 10-10% CARMOL SCALP TREATMENT LOTION 10% L5F-ANTIPSORIATICS ANTHRALIN 1% DOVONEX CREAM, OINT, SOLN 0.005% PSORIATEC 1% TAZORAC GEL 0.05%, 0.1%(AGES 0-23) L5G-ROSACEA AGENTS, TOPICAL FINACEA 15% METROGEL 0.75% METROGEL 1% METROLOTION 0.75% METRONIDAZOLE 0.75% TOPICAL GEL NORITATE 1% ROZEX 0.75% L5H-ACNE AGENTS, TOPICAL AZELEX 20% (AGES 0-23) BENZACLIN 1-5% DUAC 1-5% ZIANA GEL 1.2-0.025% (AGES 0-23) L6A-IRRITANTS/COUNTER-IRRITANTS CAPSAGEL 0.05% CAPSAICIN 0.025%, 0.05%, 0.075% CREAM, LOTION ZIKS OINT L9A-MISC TOPICAL AGENTS ATRAC-TAIN 10% CARA-KLENZ CARMOL 40 CREAM CARMOL 40% LOTION, GEL
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CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N N N N N N N N N N N N N N
2 2
N N
0 2 2 2
N N N N
2 0 2 2 0 2 2
N N N N N N N
2 2 2 2
N N N N
2 0 2
N N N
2 2 2 2
N N N N
AMEND
DRUG NAME RE UREA 40 SELENIUM SULFIDE 2.5% UREA CREAM, LOTION 40% WOUN'DRES L9B-VITAMIN A DERIVATIVES AVITA CREAM, GEL 0.025% (AGES 0-23) DIFFERIN CREAM, GEL, SOLN 0.1% (AGES 0-23) RENOVA EMOLLIENT 0.05% (AGES 0-23) RETIN A CREAM 0.025%, 0.05%, 0.1% (AGES 0-23) RETIN A GEL 0.01%, 0.025% (AGES 0-23) RETIN A MICRO 0.04%, 0.1% (AGES 0-23) M0D-PLASMA EXPANDERS DEXTRAN75/DEXTROSE 5% M0E-ANTIHEMOPHILIC FACTORS ADVATE 250, 500, 1000, 1500, 1800-2200 (+/-)U ADVATE H 1000 (+/-)U ADVATE L 250 (+/-)U ADVATE M 500 (+/-)U ADVATE SH 1500 (+/-)U ADVATE UH 2000 (+/-)U ALPHANATE 250-500, 1000-1500 (+/-)U ANTIHEMOPHILIC FACTOR BIOCLATE 1020 FEIBA VH IMMUNO 490U, 400-650U, 1750-3250U HELIXATE FS 250, 500, 1000 (+/-)U HEMOFIL-M 220-400, 401-800, 801-1700, 1701-2000 (+/-)U HEMOFIL-T 30 1000U HUMATE-P 250-600U, 500-1200U, 1000-2400U KOATE-DVI 250U, 500U, 1000U KOGENATE FS 250U, 500U, 1000U MONOCLATE-P 250U, 500U, 1000U NOVOSEVEN 1200MCG, 2400MCG, 4800MCG RECOMBINATE 310AHFU, 407AHFU, 600AHFU REFACTO 250U, 500U, 1000U, 2000U M0F-FACTOR IX PREPARATIONS ALPHANINE 375U, 800U BEBULIN VH IMMUNO 700U BENEFIX 250U, 500U, 1000U MONONINE 250U, 500U, 1000U PROFILNINE SD 500U, 1250U PROPLEX SX 300-1200U PROPLEX T 300-1200U M4B-IV FAT EMULSIONS FAT EMULSION 10%, 20% INTRALIPID 10%, 20%, 30% LIPOSYN II 10%, 20%
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CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N N
2 2 2 0 0 2
N N N N N N
2
N
2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2
N N N N N N N N N N N N N N N N N N N N
2 2 2 2 2 2 2
N N N N N N N
2 2 2
N N N
AMEND
DRUG NAME LIPOSYN III 10%, 20%, 30% TRAVAMULSION 10%, 20% M4E-LIPOTROPICS ADVICOR 20-500MG, 20-750MG, 20-1000MG, 40-1000 GEMFIBROZIL 600MG LOVASTATIN 10MG, 20MG, 40MG NIASPAN 500MG, 750MG, 1000MG PRAVASTATIN 10MG, 20MG, 40MG, 80MG SIMVASTATIN 5MG, 10MG, 20MG, 40MG, 80MG TRICOR 48MG, 54MG, 145MG, 160MG M4F-LIPOTROPICS CRESTOR 5MG, 10MG, 20MG, 40MG LESCOL 20MG, 40MG LESCOL XL 80MG LIPITOR 10MG, 20MG, 40MG, 80MG VYTORIN 10-10, 10-20, 10-40, 10-80MG ZETIA 10MG M4G-HYPERGLYCEMICS GLUCACON 1MG, EMERGENCY KIT 1MG GLUTOSE 40% PROGLYCEM 50MG/ML M4I-LIPOTROPICS-CALCIUM CHANNEL BLOCKER COMBINATION CADUET 2.5-10, 2.5-20, 2.5-40, 5-10, 5-20, 5-40, 5-80, 10-10, 10-40, 10-80 M9D-ANTIFIBRINOLYTIC AGENTS AMICAR 250MG/ML INJ AMICAR 250MG/ML SYRUP AMICAR 500MG, 1000MG CYKLOKAPRON 100MG/ML INJ M9K-HEPARIN AND RELATED PREPARATIONS ARIXTRA 2.5MG/0.5ML, 5MG/0.5ML, 7.5MG/0.6ML, 10MG/0.8ML FRAGMIN 2500U/0.2ML, 5000U/0.2ML FRAGMIN 7500U/0.3ML, 10000U/ML, 25000U/ML HEPARIN 10U/ML, 100U/ML, 1000U/ML HEPARIN 5000U/ML, 7500U/ML, 10000U/ML, 20000U/ML INNOHEP 20MU/ML LOVENOX 30MG, 40MG, 60MG, 80MG, 100MG, 120MG, 150MG INJ M9L-ANTICOAGULANTS, COUMARIN TYPE WARFARIN SODIUM 1, 2, 2.5, 3, 4, 5, 6, 7.5, 10 M9P-PLATELET AGGREGATE INHIB AGGRENOX 25-200MG CILOSTAZOL 50MG, 100MG PLAVIX 75MG TICLOPIDINE 250MG M9S-HEMORRHEOLOGIC AGENTS PENTOXIFYLLINE 400MG
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CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N
2 0 0 2 0 0 2
N N N N N N N
2 2 2 2 2 2
N N N N N N
2 2 2
N N N
2
N
2 0 2 2
N N N N
2 2 2 0 0 2 2
N N N N N N N
0
N
2 0 2 0
N N N N
0
N
AMEND
DRUG NAME N1C-LEUKOCYTE STIMULANTS LEUKINE 250MCG, 500MCG INJ NEULASTA 6MG/0.6ML NEUPOGEN 300MCG/ML INJ N1D-PLATELET REDUCING AGENTS ANAGRELIDE HCL 0.5MG, 1MG N1E-PLATELET PROLIFERATION STIMULANTS NEUMEGA 5MG INJ P1B-SOMATOSTATIC AGENTS SANDOSTATIN 0.05MG/ML, 0.1MG/ML, 0.2MG/ML SANDOSTATIN 0.5MG/ML, 1MG/ML P1C-LUTEINIZING HORMONES LUPRON DEPOT 3.75MG, 7.5MG P1E-ADRENOCORTICOTROPHIC HORM ACTHAR HP 80U P1F-PITUITARY SUPPRESSIVE AGENTS CABERGOLINE 0.5MG DANAZOL 50MG, 100MG, 200MG DANOCRINE 50MG, 100MG, 200MG DOSTINEX 0.5MG SYNAREL 2MG/ML NASAL SOLN P1G-ADRENAL STEROID INHIBITORS CYTADREN 250MG P2B-ANTIDIURETIC AND VASOPRESSOR HORMONES DDAVP 0.1MG, 0.2MG DDAVP 4MCG/ML INJ DDAVP NASAL 0.01%, SPRAY PUMP 10MCG/DOSE DESMOPRESSIN ACETATE INJ 4MCG/ML DESMOPRESSIN ACETATE NASAL 0.1MG/ML P3A-THYROID HORMONES ARMOUR THYROID 15MG, 30MG, 60MG, 100MG, 120MG, 180MG, 240MG, 300MG CYTOMEL 5MCG, 25MCG, 50MCG LEVOTHROID 0.0137 LEVOTHYROXINE SODIUM 0.025, 0.05, 0.075, 0.88, 0.1, 0.112, 0.125MG LEVOTHYROXINE SODIUM 0.137, 0.15, 0.175, 0.2, 0.3MG LEVOXYL 0.137 SYNTHROID 0.137MG THYROID 30MG, 60MG, 120MG, 180MG WESTHROID 120MG P3L-ANTITHYROIDS METHIMAZOLE 5MG, 10MG, 20MG PROPYLTHIOURACIL 50MG P4D - HYPERPARATHYROID VITAMIN D ANALOG HECTOROL 0.5MG, 2.5MG ZEMPLAR 1MCG, 2MCG, 4MCG
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CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N
0
N
2
N
0 0
N N
2
N
2
N
0 0 2 2 2
N N N N N
2
N
2 2 2 0 0
N N N N N
2 2 0 0 0 2 2 0 2
N N N N N N N N N
0 0
N N
2 2
N N
AMEND
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CO-PAYMENT
DRUG CLASS
5101:3-9-12
DRUG NAME P4L-BONE RESORPTION INHIBITORS ACTONEL 5MG, 30MG, 70MG 2 BONIVA 2.5MG, 150MG 2 DIDRONEL 200MG, 400MG, 50MG/ML 2 ETIDRONATE 200MG, 400MG 0 EVISTA 60MG 2 FOSAMAX 5MG, 10MG, 35MG, 40MG, 70MG, 70MG/75ML 2 MIACALCIN 200U/ML INJ, NASAL SOLN 200U/DOSE 2 P4N-BONE OSSIFICATION SUPPRESSION RESORPTION INHIBITOR & VITAMIN D COMBINATIONS FOSAMAX PLUS D 70MG-2800, 70MG-5600 2 P5A-GLUCOCORTICOIDS CORTEF 5MG, 10MG 2 CORTISONE ACETATE 25MG 0 DELTASONE 2.5MG 2 HYDROCORTISONE 10MG, 20MG 0 HYDROCORTISONE SODIUM SUCCINATE 100MG INJ 0 HYDROCORTONE 10MG 2 MEDROL 2MG, 16MG 2 MEDROL 8MG 0 METHYLPREDNISOLONE TABLET 4MG, 16MG, 32MG 0 METHYLPREDNISOLONE ACETATE INJ 40MG/ML, 80MG/ML 0 ORAPRED 15MG/5ML 2 ORAPRED ODT TAB 10MG, 15MG, 30MG 2 PEDIAPRED LIQUID 6.7MG/5ML 2 PREDNISOLONE 5MG 0 PREDNISOLONE ORAL SOLN 15MG/5ML, 5MG/5ML 0 PREDNISOLONE SOD PHOS 5MG/5ML, 15MG/5ML 0 PREDNISONE 1MG, 2.5MG, 5MG, 10MG, 20MG, 50MG 0 SOLU-CORTEF INJ 100MG 2 SOLU-MEDROL INJ 125MG 2 TRIAMCINOLONE ACETONIDE INJ 40MG/ML 0 P5B-GLUCOCORTICOIDS, SYSTEMIC CELESTONE 0.6MG/5ML SOLN 2 CELESTONE SOLUSPAN INJ 6MG/ML 2 DECADRON 0.5MG, 0.75MG 2 DEXAMETHASONE 0.5MG, 0.75MG, 1.5MG, 4MG, 6MG 0 DEXAMETHASONE 0.5MG/5ML 0 DEXAMETHASONE ACETATE INJ 8MG/ML 0 DEXAMETHASONE SODIUM PHOSPHATE INJ 4MG/ML 0 DEXPAK 1.5MG 2 ENTOCORT EC 3MG 2 PULMICORT 0.25MG/2ML, 0.5MG/2ML 2 QVAR INH 0.04MG, 0.08MG PER ACTUATION 2 TRIAMCINOLONE DIACETATE INJ 40MG/ML 0
Effective October 1, 2007 March 20, 2008
N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N
AMEND
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CO-PAYMENT
DRUG CLASS
5101:3-9-12
DRUG NAME P5C-GLUCOCORTICOIDS, TOPICAL AEROBID, AEROBID-M 2 ARISTOCORT 4MG 2 ASMANEX 2 AZMACORT INH 100MCG/ACTUATION 2 FLOVENT DISKUS 50MCG 2 FLOVENT HFA SPRAY 44MCG, 110MCG, 220MCG 2 KENALOG 40 INJ 40MG/ML 2 P5S-MINERALOCORTICOIDS FLORINEF ACETATE 0.1MG 2 FLUDROCORTISONE 0.1MG 0 Q2C-OPHTHALMIC ANTI-INFLAMMATORY IMMUNOMODULATOR-TYPE RESTASIS 0.05% 2 Q3A-RECTAL PREPS ANUSOL HC 2.5% CREAM 2 HYDROCORTISONE CREAM 2.5% 0 PROCTOCORT 1% 2 PROCTOCREAM HC 2.5% 2 PROCTOSOL HC 2.5% 2 PROCTOZONE HC 2.5% 2 Q3B-RECTAL/LOWER BOWEL PREP.,GLUCOCORTICOID (NON-HEMORRHOID) HYDROCORTISONE ENEMA 100MG 0 Q3D-HEMORRHOIDAL PREPS HEMORRHOIDAL CREAM, OINT, SUPP 0 Q3E - CHRONIC INFLAMMATORY COLON DX, 5-A-SALICYLAT,RECTAL TX CANASA 500MG, 1000MG 2 ROWASA ENEMA 4GM/60ML 2 Q3S-LAXATIVES, LOCAL/RECTAL (may be covered for dual eligible if available over the counter) DOCUSOL MINI ENEMA 2 ENEMEEZ MINI ENEMA 2 ENEMEEZ PLUS MINI ENEMA 2 Q4A-VAGINAL MISC AMINO ACID CERVICAL 0 Q4B-VAGINAL ANTISEPTICS ACID JELLY 0 Q4F-VAGINAL ANTIFUNGALS CLOTRIMAZOLE VAG CREAM, SUPPS 0 GYNAZOLE-1 2 MICONAZOLE NITRATE VAG CREAM 2% 0 MICONAZOLE VAG SUPPS 100MG, 200MG 0 MICONAZOLE VAGINAL COMBO PAK 200MG-2% CREAM 0 MONISTAT 1 COMBINATION PACK 2 MONISTAT 3 VAG SUPPS 2 MONISTAT COMBO PAK 100MG SUPP-2% CREAM 2 NYSTATIN 100000U VAG TABS 0 TERAZOL 3 VAG CREAM 0.8% 0
Effective October 1, 2007 March 20, 2008
N N N N N N N N N N N N N N N N N N N N Y Y Y N N N N N N N N N N N N
Appendix A
DRUG NAME TERAZOL 3 VAG TABS TERAZOL 7 VAG CREAM 0.4% TICONAZOLE-1 6.5% Q4K-VAGINAL ESTROGENS (SEE ALSO G1A) ESTRING 7.5MCG/24HR ESTRACE VAG CREAM 0.01% FEMRING 0.05MG/24HR PREMARIN VAG CREAM 0.625MG/GM VAGIFEM 25MCG Q4S-VAGINAL SULFONAMIDES AVC 15% VAG CREAM Q4W-VAGINAL ANTIBIOTICS CLEOCIN VAG CREAM 2% CLEOCIN VAG TAB 100MG CLINDESSE 2% METROGEL VAG CREAM 0.75% Q5A-TOPICAL PREPS, MISC (may be covered for dual eligible if available over the counter) DERMAGRAN OINT, SPRAY NAIL SCRUB Q5B-TOPICAL ANTIBACTERIALS CAPITROL 2% FINEVIN 20% (AGES 0-23) NITROFURAZONE PHISOHEX 3% POVIDONE-IODINE OINT, SCRUB, SOLN Q5F-TOPICAL ANTIFUNGALS CLOTRIM/BETAMETH CRM CLOTRIMAZOLE CREAM 1%, AF CREAM CICLOPIROX 8% SOLUTION DERMA FUNGAL 2% FUNGOID TR KETOCONAZOLE 2% KETOCONAZOLE SHAMPOO 2% LOPROX CREAM, SUSP 0.77% LOPROX SHAMPOO 1%, GEL 0.77% MICONAZOLE NITRATE CREAM, POWDER 2% MPM ANTIFUNGAL CREAM 1% NAFTIN CREAM, GEL 1% NYSTATIN CREAM, OINT, PDR 100000U/GM NYSTATIN TRIAMCINOLONE CREAM, OINT OXISTAT CREAM, LOTION 1% PEDI-DRI 100MU/GM PENLAC 8% TOLNAFTATE CREAM, POWDER, SOLN 1% VUSION OINT
Effective October 1, 2007 March 20, 2008
2 0 0
ELIGIBLE COVERED FOR DUAL
AMEND
Page 41 of 61 CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N
2 2 2 2 2
N N N N N
2
N
0 2 2 0
N N N N
2 2
Y Y
2 2 0 2 0
N N N N N
0 0 0 0 2 0 0 0 2 0 2 2 0 0 2 2 2 0 2
N N N N N N N N N N N N N N N N N N N
AMEND
DRUG NAME Q5H-TOPICAL LOCAL ANESTHETICS ELA-MAX 4% ELA-MAX PLUS 4% EMLA CREAM 2.5%/2.5% EXACTACAIN SPRAY 2-14-2% L.M.X.4 4% L.M.X.4 PLUS 4% LIDA MANTLE 3% LIDA MANTLE HC 0.5-3% LIDOCAINE OINT 5% LIDOCAINE-HC 0.5-3% LIDOCAINE-PRILOCAINE 2.5-2.5% LIDOCAINE 3%, 4% CREAM LIDODERM 5% MPM REGENECARE Q5K-TOPICAL-IMMUNOSUPPRESSIVE AGENTS ELIDEL 1% PROTOPIC 0.03%, 0.1% Q5N-TOPICAL ANTINEOPLASTIC & PREMALIGNANT LESION AGENTS CARAC 0.5% EFUDEX CREAM 5%, SOLN 2%, 5% FLUOROPLEX CREAM 1% SOLARAZE 3% Q5P-TOPICAL ANTI-INFLAMMATORY STEROIDAL ACLOVATE CREAM, OINT 0.05% AMCINONIDE 0.1% LOTION, CREAM BETAMETHASONE DIPROPIONATE CRM, GEL, OINT, LOT 0.05% BETAMETHASONE DP AUGMENTED BETAMETHASONE VALERATE CREAM, OINT, LOT 0.1% CAPEX SHAMPOO 0.01% CARMOL HC 1% CLOBETASOL E CREAM 0.05% CLOBETASOL PROPIONATE OINT, CREAM, GEL, SCALP 0.05% CLOBEX 0.05% LIQ CLODERM 0.1% CORDRAN OINT 0.05% CORDRAN LOTION 0.05% CORDRAN TAPE 4MCG/SQC CYCLOCORT CREAM, OINT 0.1% CYCLOCORT LOT 0.1% DERMA-SMOOTHE/FS OIL 0.01% DERMATOP 0.1% CREAM, OINT DESONIDE CREAM, OINT, LOTION 0.05% DESOXIMETASONE CREAM, OINT 0.05%, 0.25% DESOXIMETASONE GEL 0.05% DIFLORASONE DIACETATE CREAM, OINT 0.05%
Effective October 1, 2007 March 20, 2008
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2 2 2 2 2 2 2 2 0 0 0 0 2 2
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Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N N N N N N N N N N N N
2 2
N N
2 2 2 2
N N N N
0 0 0 0 0 2 2 0 0 2 2 2 2 2 0 2 2 2 0 0 0 0
N N N N N N N N N N N N N N N N N N N N N N
AMEND
DRUG NAME DIPROLENE AF CREAM DIPROLENE LOTION 0.05% ELOCON CREAM, OINT, LOT 0.1% FLUOCINOLONE ACETONIDE CREAM, OINT 0.025% FLUOCINOLONE ACETONIDE CREAM, SOLN 0.01% FLUOCINONIDE CREAM, OINT, SOLN, GEL 0.05% FLUOCINONIDE E CREAM 0.05% FLUTICASONE PROPIONATE CRM 0.05% FLUTICASONE PROPIONATE OINT 0.005% HALOBETASOL PROPIONATE 0.05% CREAM HALOG CREAM, OINT, SOLN 0.1% HYDROCORTISONE ACETATE W/UREA 1% HYDROCORTISONE BUTYRATE CREAM, SOLN, OINT 0.1% HYDROCORTISONE CREAM, OINT, 0.5%, 1%, 2.5% HYDROCORTISONE LOT 1%, 2.5% HYDROCORTISONE VALERATE 0.2% CREAM KENALOG AEROSOL KERATOL HC 1% CREAM LOCOID CREAM, OINT, LOT, LIPOCREAM 0.1% LUXIQ 0.12% MAXIFLOR CREAM, OINT 0.05% MOMETASONE FUROATE OINT 0.1% NUTRACORT LOTION 2.5% OLUX OLUX-E PANDEL CREAM 1% PSORCON E CREAM, OINT 0.05% TEMOVATE EMOLLIENT CREAM 0.05% TEXACORT 1%, 2.5% TOPICORT OINT 0.25%, GEL 0.05% TRIAMCINOLONE CREAM, OINT 0.025%, 0.1%, 0.5% TRIAMCINOLONE LOT 0.025%, 0.1% ULTRAVATE CREAM, OINT 0.05% VANOS 0.1% Q5R-TOPICAL ANTIPARISITICS ELIMITE CREAM 5% EURAX CREAM, LOTION 10% LINDANE LOTION, SHAMPOO OVIDE 0.5% PERMETHRIN 1% LIQUID, 5% CREAM PYRINYL/LICE TREATMENT LIQUID Q5S-TOPICAL SULFONAMIDES AVAR 10%/5% CLENIA 10%/5% NICOSYN 10%/5% PLEXION 10/5%
Effective October 1, 2007 March 20, 2008
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0 2 0 0 0 0 0 0 0 0 2 0 0 0 0 0 2 2 2 2 2 0 2 2 2 2 2 2 2 2 0 0 0 2
ELIGIBLE COVERED FOR DUAL
Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N
2 2 0 2 0 0
N N N N N N
2 2 2 2
N N N N
AMEND
Page 44 of 61
DRUG NAME PRASCION 10-5% (W/W) 2 ROSADERM 10-5% 2 ROSANIL 10-5% 2 ROSULA 10%/5% 0 SILVER SULFADIAZINE 1% 0 SODIUM SULFACETAMIDE/SULFUR LOTION 10%/5% 0 SULFACET-R LOTION 2 SULFAMYLON 8.5% 2 SULFATOL, SULFATOL-M 10%/5% 2 ZETACET 10-5% 2 Q5V-TOPICAL ANTIVIRALS DENAVIR CREAM 1% 2 ZOVIRAX OINT 5% 2 Q5W-TOPICAL ANTIBIOTICS (may be covered for dual eligible if available over the counter) BACITRACIN TOPICAL 500U/GM 0 BACITRACIN/POLYMYXIN OINT 500U/GM/10MU/GM 0 0 2 BACTROBAN CREAM, OINT 2% 02 BENZAMYCIN GEL 30MG/50MG CENTANY 2% 0 CLEOCIN T GEL 0 CLINDAGEL 1% 2 CLINDAMYCIN TOP SOLN 1% 0 ERYTHROMYCIN GEL, SOLN, PADS 2% 0 ERYTHROMYCIN-BENZOYL PEROXIDE GEL 3%-5% 0 GENTAMICIN SULFATE CREAM, OINT 0.1% 0 MUPIROCIN OINT 2% 0 POLYSPORIN TOPICAL POWDER 2 TRIPLE ANTIBIOTIC OINT 0 Q5X-TOPICAL ANTIBIOTICS/ANTIINFLAMMATORY,STEROIDAL CORTISPORIN OINT 1% 2 Q6A-EYE PREPS MISC ALTACHLORE OINT, SOLN 5% 2 FML-S SUSP 10%/0.1% 2 MURO 128 SOLN, OINT 5% 2 SODIUM CHLORIDE SOLN, OINT 5% 0 Q6C-EYE VASOCONSTRICTORS RX NAPHAZOLINE SOLN 0.1% 0 NEO-SYNEPHRINE SOLN 2.5%, 10% 2 PHENYLEPHRINE SOLN 2.5%, 10% 0 Q6D-EYE VASOCONSTRICTORS OTC TETRAHYDROZOLINE/ZINC 0.5-0.25% 0 VASOCON A 0.05%/0.5% 2 Q6G-MIOTICS/OTHER INTRAOC. PRESSURE REDUCERS ALPHAGAN P SOLN 0.15% 2 AZOPT SOLN 1% 2 BETAXOLOL HCL 0.5% 0
Effective October 1, 2007 March 20, 2008
ELIGIBLE COVERED FOR DUAL
Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N N N N N N N N N N Y Y N N N N N N N N N N N Y N N N N N N N N N N N N N
AMEND
DRUG NAME BETIMOL SOLN 0.25%, 0.5% BRIMONIDINE TARTRATE 0.2% CARTEOLOL HCL 1% COMBIGAN 0.2-0.5% COSOPT PLUS 2-0.5% COSOPT SOLN 2%/0.5% EPINAL 1% ISOPTO CARBACHOL SOLN 1.5%, 3% ISOPTO CARPINE SOLN 8%, 10% LEVOBUNOLOL SOLN 0.25%, 0.5% METIPRANOLOL 0.3% PHOSPHOLINE IODIDE SOLN 0.125% PILOCARPINE SOLN 0.5%, 1%, 2%, 3%, 4%, 5%, 6% PILOPINE HS GEL 4% TIMOLOL MALEATE SOL 0.25%, 0.5% TIMOLOL MALEATE SOLN XE 0.25%, 0.5% TRAVATAN 0.004% TRAVATAN Z 0.004% TRUSOPT 2% XALATAN 0.005% Q6H-EYE LOCAL ANESTHETICS FLUORACAINE 0.5-0.25% PROPARICAINE HCL SOLN 0.5% TETRACAINE HCL SOLN 0.5% Q6I- EYE ANTIBIOTIC-CORTICOID COMBINATIONS CORTISPORIN SUSP NEOMYCIN/POLYMYXIN/HC SUSP POLYPRED SUSP PRED G SUSP, OINT TOBRADEX SUSP, OINT 0.3%/0.1% ZYLET EYE DROPS 0.3%-0.5% Q6J-MYDRIATICS AK-PENTOLATE SOLN 2% ATROPINE SULFATE SOLN, OINT 1% CYCLOGYL 0.5%, 1%, 2% CYCLOMYDRIL SOLN 0.2%/1% CYCLOPENTOLATE SOLN 1% DIPIVEFRIN SOLN 0.1% ISOPTO ATROPINE SOLN 1% ISOPTO HOMATROPINE SOLN 2%, 5% ISOPTO HYOSCINE SOLN 0.25% TROPICAMIDE SOLN 0.5%, 1% Q6P-EYE ANTIINFLAMMATORY AGENTS ACULAR LS 0.4% ACULAR SOLN 0.5% ALREX SOLN 0.2%
Effective October 1, 2007 March 20, 2008
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2 0 0 2 2 2 2 2 2 0 0 2 0 2 0 0 2 2 2 2
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Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N N N N N N N N N N N N N N N N N N
2 0 0
N N N
2 0 2 2 2 2
N N N N N N
0 0 2 2 0 0 2 2 2 0
N N N N N N N N N N
2 2 2
N N N
AMEND
Page 46 of 61
DRUG NAME DEXAMETHASONE SOD PHOSPHATE OINT 0.05%, SOLN 0.1% 0 ECONOPRED 0.125% 2 FLUOROMETHOLONE SOLN 0.1% 0 FLURBIPROFEN SODIUM 0.03% 0 FML FORTE SOLN 0.25% 2 FML SOP OINT 0.1% 2 HMS LIQUIFILM SOLN 1% 2 INFLAMASE MILD 0.125% 2 LOTEMAX SOLN 0.5% 2 MAXIDEX SOLN 0.1% 2 NEVANAC 0.1% 2 PRED MILD SOLN 0.12% 2 PREDNISOLONE ACETATE SOLN 1% 0 PREDNISOLONE SOD PHOSPHATE SOLN 0.125%, 1% 0 VEXOL SOLN 1% 2 VOLTAREN SOLN 0.1% 2 Q6R-EYE ANTIHISTAMINE ALAWAY 0.025% 2 OPTIVAR 0.05% 2 PATADAY 0.2% 2 PATANOL 0.1% 2 ZADITOR 0.025% 2 Q6S-EYE SULFONAMIDES BLEPHAMIDE OINT, SOLN 0.2% 2 PREDNISOLONE/SULFACETAMIDE SOLN 0.25%-10% 0 SULFACETAMIDE OINT 10% 0 SULFACETAMIDE SODIUM, SOLN 10%, 30% 0 Q6T-EYE LUBRICANTS/TEARS (may be covered for dual eligible if available over the counter) ARTIFICIAL TEARS 0.5%, 1.4%, 1.4%/0.6% 0 FRESHKOTE 2 GENTEAL MILD 2% 2 HYPOTEARS OINT, SOLN 2 LUBRICANTS, DRY EYES, REFRESH 0 TEARS NATURALE FORTE 2 TEARS NATURALE PM 0 Q6U-EYE MAST CELL STABILIZERS ALOCRIL 2% 2 ALOMIDE SOLN 0.1% 2 CROMOLYN SODIUM SOLN 4% 0 Q6V-EYE ANTIVIRALS TRIFLURIDINE SOLN 1% 0 VIROPTIC SOLN 1% 2 Q6W-EYE ANTIBIOTICS AKTETRA 2 AZASITE 1% EYE DROPS 2 BACITRACIN OINT 500U/GM 0
Effective October 1, 2007 March 20, 2008
ELIGIBLE COVERED FOR DUAL
Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N N N N N N N N N N N N N N N N N N N N N N N Y N Y Y Y Y Y N N N N N N N N
AMEND
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Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
DRUG NAME BACITRACIN/NEOMYCIN/POLYMYXIN/HC OINT 0 N BACITRACIN/POLYMYXIN OINT 0 N CILOXAN OINT 0.3% 2 N CIPROFLOXACIN 0.3% 0 N DEXAMETHASONE/NEOMYCIN/POLYMYXIN OINT, SOLN 0 N ERYTHROMYCIN OINT 5MG/GM 0 N GENTAMICIN SOLN 3MG/ML, OINT 3MG/GM 0 N IQUIX 1.5% 2 N NATACYN 5% 2 N NEOMYCIN/POLYMYXIN/BACITRACIN OINT 0 N NEOMYCIN/POLYMYXIN/GRAMICIDIN SOLN 0 N POLYMYXIN/TRIMETHOPRIM SOLN 0 N TOBRAMYCIN SOLN 0.3% 0 N TOBREX 0.3% OINT 2 N VIGAMOX 0.5% 2 N ZYMAR 0.3% SOLN 2 N Q6Y-EYE PREP, MISC (may be covered for dual eligible) ALTALUBE OPH OINT 0 Y Q7A-NOSE PREPARATIONS, MISCELLANEOUS (RX) IPRATROPIUM BR 21MCG, 42MCG NS 0 N Q7C-NASAL VASOCONSTRICTORS RX TYZINE 0.05%, 0.1% 2 N Q7D-NASAL VASOCONSTRICTORS OTC OXYMETAZOLINE HCL 0.05% 0 N PHENYLEPHRINE HCL 0.125%, 1% 0 N Q7E-NASAL ANTIHISTAMINE ASTELIN NASAL SPRAY 137MCG 2 N Q7H-NASAL MAST CELL STABILIZERS AGENTS (may be covered for dual eligible if available over the counter) CROMOLYN SODIUM 40MG/ML 0 Y NASALCROM 40MG/ML 2 Y Q7P-NASAL, ANTI-INFLAMMATORY STEROIDS FLONASE AQ 0.05% 0 N NASACORT AQ 2 N NASONEX 50MCG 2 N Q7W-NASAL ANTIBIOTICS BACTROBAN NASAL 2% 2 N Q7Y-NASAL OTC MISC (may be covered for dual eligible if available over the counter) SODIUM CHLORIDE (SALINE) NASAL SPRAY 0.65% 0 Y Q8B-EAR PREPS, MISC ANTI-INFECTIVE ACETIC ACID HC OTIC 2% 0 N ACETIC ACID OTIC 2% 0 N ACETIC ACID/ ALUMINUM ACETATE 0 N AERO OTIC HC 2 N Q8F-OTIC PREPARATIONS, ANTI-INFLAMMATORY-ANTIBIOTICS CIPRO HC OTIC 2 N
Effective October 1, 2007 March 20, 2008
AMEND
Page 48 of 61 ELIGIBLE COVERED FOR DUAL
Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
DRUG NAME CIPRODEX 0.3-0.1% 2 Q8H-EAR PREPS, LOCAL ANESTHETIC ANTIPYRINE/BENZOCAINE 0 OTICAINE 20% 2 OTIGESIC 0 OTOCAIN 20% 2 TYMPAGESIC 2 Q8R-EAR WAX REMOVAL PREPS (may be covered for dual eligible if available over the counter) CARBAMIDE PEROXIDE 6.5% 0 Q8W-EAR ANTIBIOTICS COLYMYCIN-S 2 CORTISPORIN-TC SUSP 2 FLOXIN OTIC 2 NEOMYCIN/POLYMYXIN/HC SUSP, SOLN 0 PEDIOTIC 2 Q9B-BPH/MICTURITION AGENTS AVODART 0.5MG 2 FINASTERIDE 5MG 0 FLOMAX 0.4MG 2 RIA-URINARY TRACT ANTISPASMODICS/ANTIINCONTINENCE AGENT DETROL LA 2MG, 4MG 2 FLAVOXATE 100MG 0 R1E-CARBONIC ANHYDRASE INHIBITORS ACETAZOLAMIDE 125MG, 250MG 0 DIAMOX SEQUELS 500MG 2 METHAZOLAMIDE 25MG, 50MG 0 R1F-THIAZIDE DIURETIC&REL CHLOROTHIAZIDE 250MG, 500MG 0 CHLORTHALIDONE 25MG, 50MG, 100MG 0 DIURIL 250MG/5ML 2 HYDROCHLOROTHIAZIDE 25MG, 50MG, 100MG 0 INDAPAMIDE 1.25MG, 2.5MG 0 METHYCLOTHIAZIDE 2.5MG, 5MG 0 METOLAZONE 2.5MG, 5MG, 10MG 0 SALURON 50MG 2 R1H-POTASSIUM SPARING DIURETICS (SEE ALSO P5T) AMILORIDE HCL 5MG 0 ALDACTONE 25MG, 50MG, 100MG 2 INSPRA 25MG, 50MG 2 SPIRONOLACTONE 25MG, 50MG, 100MG 0 R1I-TRACT ANTISPASMODIC, M(3) SELECTIVE ANTAG. ENABLEX 7.5MG, 15MG 2 VESICARE 5MG, 10MG 2 R1K-DIURETICS,MISCELLANEOUS ISMOTIC 45% 2
Effective October 1, 2007 March 20, 2008
N N N N N N Y N N N N N N N N N N N N N N N N N N N N N N N N N N N N
AMEND
DRUG NAME R1L-POTASSIUM SPARING DIURETICS IN COMBINATION AMILORIDE/HCTZ 5/50 SPIRONOLACTONE/HCTZ 25/25 TRIAMTERENE HCTZ 25/50, 25/37.5, 50/75 R1M-LOOP DIURETICS BUMETANIDE 0.5MG, 1MG, 2MG BUMETANIDE INJ 0.25MG/ML DEMADEX 5MG, 10MG, 20MG, 10MG/ML EDECRIN 25MG, 50MG FUROSEMIDE 10MG/ML INJ FUROSEMIDE 10MG/ML ORAL, 40MG/5ML ORAL FUROSEMIDE 20MG, 40MG, 80MG TORSEMIDE 5MG, 10MG, 20MG, 100MG R1R-URICOSURIC AGENTS PROBENECID 500MG SULFINPYRAZONE 100MG R1S-URINARY PH MODIFIERS BICITRA SOLN CITRIC ACID/SODIUM CITRATE 334-500MG CITROLITH CYTRA-2 SOLN CYTRA-3 SOLN CYTRA-K SOLN K-PHOS M.F., #2 K-PHOS NEUTRAL 250MG K-PHOS ORIGINAL PEDAMETH 15MG/ML PEDAMETH 200MG PHOSPHA 250 NEUTRAL 250 MG POLYCITRA LC SOLN POLYCITRA SYRUP POLYCITRA-K SOLN POTASSIUM CITRATE/CITRIC ACID RENACIDIN SOLN UROCIT-K 540MG, 750MG UROQID-ACID NO.2 VIS-PHOS N 250MG TABLET R4A-KIDNEY STONE AGENTS CALCIBIND CYSTAGON 50MG, 150MG THIOLA R5A-URINARY TRACT ANESTHETIC/ANALGESIC AGENTS AZO 95MG PHENAZOPYRIDINE 100MG, 200MG PHENAZOPYRIDINE PLUS 150-0.3-15 PYRIDIUM PLUS
Effective October 1, 2007 March 20, 2008
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0 0 0
ELIGIBLE COVERED FOR DUAL
Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N
0 0 0 2 0 0 0 0
N N N N N N N N
0 0
N N
2 0 2 0 0 0 2 2 2 2 2 2 2 2 2 0 0 2 2 2
N N N N N N N N N N N Y N N N N N N N N
2 2 2
N N N
2 0 0 2
N N N N
AMEND
DRUG NAME R5B-URINARY ANALGESICS ELMIRON 100MG S2A-COLCHICINES COLCHICINE 0.6MG PROBENECID W/ COLCHICINE 500MG/0.5MG S2B-NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ADVIL 40MG/ML, 100MG/5ML ADVIL 50MG, 100MG CELEBREX 50MG, 100MG, 200MG, 400MG (AGE 60+) DICLOFENAC POTASSIUM 50MG DICLOFENAC SODIUM 25MG, 50MG, 75MG, 100MG ELIXSURE IB 10MG/5ML ETODOLAC 200MG, 300MG, 400MG, 500MG ETODOLAC XL 400MG, 500MG, 600MG FENOPROFEN CALCIUM 600MG FLURBIPROFEN 50MG, 100MG IBUPROFEN 100MG, 200MG, 400MG, 600MG, 800MG IBUPROFEN 100MG/5ML SUSP, 40MG/ML DROPS INDOCIN SUSP 25MG/5ML INDOMETHACIN 25MG, 50MG KETOPROFEN 100MG, 200MG SR KETOPROFEN 25MG, 50MG, 75MG KETOROLAC TROMETHAMINE 10MG, INJ 15MG/ML, 30MG/ML MECLOFENAMATE SODIUM 50MG, 100MG MELOXICAM 7.5MG, 15MG MOTRIN 40MG/ML, 100MG/5ML MOTRIN 50MG, 100MG NABUMETONE 500MG, 750MG NAPROSYN 125MG/5ML NAPROXEN 250MG, 375MG, 500MG, 125MG/5ML NAPROXEN EC 375MG, 500MG NAPROXEN SODIUM 220MG, 275MG, 550MG ORUDIS KT 12.5MG PIROXICAM 10MG, 20MG SULINDAC 150MG, 200MG TORADOL INJ 15MG/ML S2C-GOLD SALTS RIDAURA 3MG S2D-ANTI-INFLAMMATORY AGENTS OXAPROZIN 600MG S2I-ANTI-INFLAMMATORY, PYRIMIDINE SYNTHESIS INHIBITOR LEFLUNOMIDE 10MG, 20MG S2K-ANTI-ARTHRITIC AND CHELATING AGENTS CUPRIMINE 250MG DEPEN 250MG
Effective October 1, 2007 March 20, 2008
Page 50 of 61
2
ELIGIBLE COVERED FOR DUAL
Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N
0 0
N N
0 2 2 0 0 0 0 0 0 0 0 0 2 0 0 0 0 0 0 0 2 0 2 0 0 0 2 0 0 2
N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N
2
N
0
N
0 2 2 2
N N N N
AMEND
DRUG NAME U6E-OINTMENT-CREAM BASES HYDROPHILIC PETROLATUM U6F-HYDROPHILIC CREAM/OINTMENT BASES HYDROPHILIC TRIAD U6N-VEHICLES ORA-BLEND SF ORA-SWEET ORA-SWEET SF U6W-BULK CHEMICALS CLORPACTIN WCS-90 HYDROUS EMULSIFIED BASE L-GLUTAMINE PDR ORA-PLUS ZINC SULFATE PDR V1A-ALKYLATING AGENTS ALKERAN 2MG, INJ 50MG CARBOPLATIN INJ 50MG, 150MG, 450MG CEENU 10MG, 40MG, 100MG, DOSEPAK CISPLATIN INJ 1MG/ML CYTOXAN 25MG, 50MG CYTOXAN LYOPHILIZED INJ 500MG, 1GM, 2GM DROXIA 200MG, 300MG, 400MG HYDROXYUREA 500MG IFEX-MESNEX 1GM/1GM, 1GM/3GM LEUKERAN 2MG MUSTARGEN INJ 10MG MYLERAN 2MG PARAPLATIN INJ 50MG, 150MG, 450MG TEMODAR 5MG, 20MG, 100MG, 140MG, 180MG, 250MG V1B-ANTIMETABOLITES CYTARABINE INJ 1GM, 2GM, 100MG, 500MG FLUOROURACIL INJ 50MG/ML GEMZAR INJ 200MG, 1GM MERCAPTOPURINE 50MG METHOTREXATE INJ 25MG/ML, TAB 2.5MG METHOTREXATE LPF INJ 25MG/ML PURINETHOL 50MG THIOGUANINE 40MG XELODA 150MG, 500MG V1C-VINCA ALKALOIDS NAVELBINE INJ 10MG/ML VINBLASTINE INJ 10MG VINORELBINE INJ 10MG/ML
Effective October 1, 2007 March 20, 2008
Page 51 of 61
2
ELIGIBLE COVERED FOR DUAL
Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N
2 2
N N
2 2 2
N N N
2 0 2 2 2
N N N N N
2 0 2 0 0 0 2 0 2 2 2 2 2 2
N N N N N N N N N N N N N N
0 0 2 0 0 0 2 2 2
N N N N N N N N N
2 0 0
N N N
AMEND
DRUG NAME V1D-ANTIBIOTIC ANTINEOPLASTICS BLENOXANE INJ 15U, 30U BLEOMYCIN SULFATE INJ 15U, 30U COSMEGEN INJ 0.5MG MITHRACIN 2500MCG V1E-STEROID ANTINEOPLASTICS EMCYT 140MG MEGESTROL ACETATE 20MG, 40MG, 40MG/ML TESLAC 50MG V1F-MISC ANTINEOPLASTICS ARIMIDEX 1MG ETOPOSIDE 20MG. LYSODREN 500MG MATULANE 50MG MITOXANTRONE 2MG/ML NOVANTRONE INJ 2MG/ML VEPESID 50MG CAP VESANOID 10MG CAP V1H-ANTINEOPLASTIC-BREAST CANCER AROMASIN 25MG FEMARA 2.5MG V1I-CHEMOTHERAPY RESCUE/ANTIDOTE AGENTS MESNEX 100MG/ML V1J-ANTIANDROGENIC AGENTS CASODEX 50MG EULEXIN 125MG FLUTAMIDE 125MG NILANDRON 150MG V1O-ANTINEOPLASTIC LHRH(GNRH) AGONIST,PITUITARY SUPPR. TRELSTAR DEPOT 3.75MG V1Q-ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS GLEEVEC 100MG, 400MG IRESSA 250MG NEXAVAR 200MG SUTENT 12.5MG, 25MG, 50MG TARCEVA 25MG, 100MG, 150MG TASIGNA 200MG TYKERB 250MG V1T-SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERM) FARESTON 60MG TAMOXIFEN CITRATE 10MG, 20MG W1A-PENICILLINS AMOX TR/POTASSIUM CLAV 200-28.5/5, 400-57/5, 600-42.9/5ML AMOX TR/POTASSIUM CLAV 500-125MG, 875-125MG AMOX TR/POTASSIUM CLAV CHEW TAB 200-28.5, 400-57 AMOXICILLIN 250MG, 500MG, 875MG, 125MG/5ML, 250MG/5ML
Effective October 1, 2007 March 20, 2008
Page 52 of 61
2 0 2 2
ELIGIBLE COVERED FOR DUAL
Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N N
2 0 2
N N N
2 0 2 2 0 2 0 2
N N N N N N N N
2 2
N N
2
N
2 2 0 2
N N N N
2
N
2 2 2 2 2 2 2
N N N N N N N
2 0
N N
0 0 0 0
N N N N
AMEND
DRUG NAME AMOXICILLIN 200MG/5ML, 400MG/5ML AMOXICILLIN CHEWABLE 125MG, 200MG, 250MG, 400MG AMOXICILLIN PED DROPS 50MG/ML AMOXIL 875MG AMPICILLIN 250MG, 500MG AMPICILLIN SUSP 125MG/5ML, 250MG/5ML AMPICILLIN VIAL 250MG, 500MG, 1GM, 2GM AMPICILLIN/SULBACTAM INJ 1.5GM, 3GM AUGMENTIN CHEWABLES 125/31.25, 250/62.5 AUGMENTIN CHEWABLES 200/28.5, 400/56 AUGMENTIN ES 600 SUSP AUGMENTIN SUSP 125-31.25/5ML AUGMENTIN SUSP 250-62.5/5ML AUGMENTIN TABS 250/125, 500/125, 875/125 AUGMENTIN XR 1000-62.5 BACTOCILL INJ 500MG, 1GM BICILLIN CR INJ 150/150, 600MU/ML, 1.2MMU/2ML BICILLIN L-A INJ 600, 1.2MMU/2ML, 2.4MMU/4ML DICLOXACILLIN 250MG, 500MG GEOCILLIN 382MG NAFCILLIN SODIUM INJ 500MG, 2GM PENICILLIN G POTASSIUM INJ 1MMU, 5MMU, 20MMU PENICILLIN G PROCAINE 600000U, 1200000U PENICILLIN VK 250MG, 500MG, 125MG/5ML, 250MG/5ML TICAR INJ 1GM, 3GM TIMENTIN INJ 3.1GM/100ML TOTACILLIN N INJ 2GM UNASYN INJ 1.5GM, 3GM ZOSYN 2.25G/50ML, 3.375G/50ML, 4.5G/100ML ZOSYN INJ 2/0.25, 3/0.375, 4/0.5, 36/4.5 W1C-TETRACYCLINES DOXYCYCLINE HYCLATE 50MG, 100MG MINOCYCLINE HCL 50MG, 100MG SUMYCIN 125MG/5ML TETRACYCLINE HCL 250MG, 500MG VIBRAMYCIN 25MG/5ML SUSP VIBRAMYCIN CALCIUM 50MG/5ML SYRUP W1D-MACROLIDES AZITHROMYCIN 250MG, 500MG, 600MG AZITHROMYCIN IV 500MG AZITHROMYCIN PACKETS 1GM AZITHROMYCIN SUSP 100MG/5ML, 200MG/5ML CLARITHROMYCIN 250MG, 500MG CLARITHROMYCIN ER 500MG CLARITHROMYCIN SUSP 125MG/5ML, 250MG/5ML ERYPED DROPS 40MG/ML
Effective October 1, 2007 March 20, 2008
Page 53 of 61
0 0 0 0 0 0 0 0 0 2 2 0 0 0 2 2 2 2 0 2 0 0 0 0 2 2 2 2 2 2
ELIGIBLE COVERED FOR DUAL
Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N
0 0 2 0 2 2
N N N N N N
0 0 0 0 0 0 0 2
N N N N N N N N
AMEND
DRUG NAME ERYTHROMYCIN 250MG ERYTHROMYCIN 333MG ERYTHROMYCIN 500MG ERYTHROMYCIN ESTOLATE 125MG/5ML, 250MG/5ML ERYTHROMYCIN ETHYLSUCCINATE 400MG, 200MG/5ML, 400MG/5ML ERYTHROMYCIN LACTOBIONATE INJ 500MG/1GM ERYTHROMYCIN STEARATE 250MG, 500MG ERYTHROMYCIN W/ SULFISOXAZOLE 200/600 SUSP ZMAX 2GM/60ML W1F-AMINOGLYCOSIDES AMIKACIN SULFATE INJ 50MG/ML, 250MG/ML GENTAMICIN INJ 10MG/ML, 40MG/ML NEO-FRADIN 125MG/5ML NEOMYCIN SULFATE 500MG TOBI 300MG/5ML TOBRAMYCIN SULFATE 10MG/ML, 40MG/ML W1G-ANTITUBERCULAR ANTIBIOTICS RIFADIN 150MG RIFAMPIN 300MG RIFATER 120/50/300 W1H-AMINOCYCLITOLS TROBICIN W/DILUENT 2GM W1J-VANCOMYCIN AND DERIVATIVES VANCOCIN 125MG, 250MG VANCOCIN INJ 1GM VANCOMYCIN 500MG, 1GM W1K-LINCOSAMIDES CLEOCIN 300MG CLEOCIN 75MG, 75MG/5ML CLEOCIN PHOSPHATE INJ 150MG/ML CLINDAMYCIN HCL 150MG, 300MG CLINDAMYCIN PHOSPHATE INJ 150MG/ML LINCOCIN INJ 300MG/ML W1N-POLYMYXIN AND DERIVATIVES COLISTIMETHATE NA 150MG COLY-MYCIN M INJ 150MG W1P-BETA LACTAMS AZACTAM INJ 500MG, 1GM, 2GM W1Q-QUINOLONES AVELOX 400MG CIPRO SUSP (AGES 0-12) CIPROFLOXACIN 250MG, 500MG, 750MG W1S-CARBAPENEMS (THIENAMYCINS) PRIMAXIN IM/IV 250MG, 500MG
Effective October 1, 2007 March 20, 2008
Page 54 of 61
0 0 0 0 0 0 0 0 2
ELIGIBLE COVERED FOR DUAL
Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N N N N N N N
0 0 2 0 2 0
N N N N N N
0 0 2
N N N
2
N
2 2 0
N N N
0 2 2 0 0 2
N N N N N N
0 2
N N
2
N
2 * 0
N N N
2
N
AMEND
DRUG NAME W1W-CEPHALOSPORINS - 1ST GENERATION CEFADROXIL MONOHYDRATE 500MG CEFAZOLIN SODIUM INJ 500MG, 1GM, 10GM CEPHALEXIN 250MG, 500MG, 125MG/5ML, 250MG/5ML DURICEF 250MG/5ML, 500MG/5ML W1X-CEPHALOSPORINS - 2ND GENERATION CEFACLOR 250MG, 500MG CEFACLOR SUSP 125/5, 187/5, 250/5, 375/5ML CEFTIN SUSPENSION (AGE 0 THROUGH 12) CEFUROXIME 250MG, 500MG CEFUROXIME SODIUM INJ 750MG, 1.5GM ZINACEF INJ 750MG, 1.5GM W1Y-CEPHALOSPORINS - 3RD GENERATION CEDAX 400MG, 90MG/5ML SUSP CEFOTAXIME INJ 1GM CEFTRIAXONE 250MG, 500MG, 1GM, 2GM, 10GM CLAFORAN IM/IV 500MG, 1GM, 2GM FORTAZ INJ 500MG, 1GM, 2GM, 6GM OMNICEF 125MG/5ML, 250MG/5ML OMNICEF 300MG ROCEPHIN INJ 250MG, 500MG, 1GM, 2GM, 10GM TAZICEF INJ 1GM, 2GM, 6GM W1Z-CEPHALOSPORINS - 4TH GENERATION MAXIPIME INJ 500MG, 1GM, 2GM W2A-ABSORBABLE SULFONAMIDES AZULFIDINE ENTABS 500MG GANTRISIN SUSP 500MG/5ML SEPTRA IV 400/80 SULFADIAZINE 500MG SULFAMETHOXAZOLE/TRIMETHOPRIM INJ 400/80 SULFAMETHOXAZOLE/TRIMETHOPRIM SUSP 200&40/5 SULFAMETHOXAZOLE/TRIMETHOPRIM TAB 400/80, 800/160 SULFASALAZINE 500MG, EC500MG SULFISOXAZOLE 500MG W2E-ANTI-MYCOBACTERIUM AGENTS ETHAMBUTOL HCL 400MG ISONIAZID 100MG, 300MG, 50MG/5ML MYAMBUTOL 100MG, 400MG MYCOBUTIN 150MG PASER 4GM PYRAZINAMIDE 500MG TRECATOR-SC 250MG W2F-NITROFURAN DERIVATIVES FURADANTIN 25MG/5ML ORAL SUSP FUROXONE 100MG, 50MG/15ML LIQUID MACROBID 100MG
Effective October 1, 2007 March 20, 2008
Page 55 of 61
0 0 0 0
ELIGIBLE COVERED FOR DUAL
Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N N
0 0 * 0 0 2
N N N N N N
2 0 0 0 2 0 0 2 2
N N N N N N N N N
2
N
2 2 2 0 0 0 0 0 0
N N N N N N N N N
0 0 2 2 2 0 2
N N N N N N N
2 2 2
N N N
AMEND
DRUG NAME MACRODANTIN 25MG, 50MG, 100MG NITROFURANTOIN MONOHYDRATE MACRO 100MG W2G-CHEMOTHERAPEUTICS, ANTIBACTERIAL, MISC. HIPREX 1GM METHENAMINE HIPPURATE 1GM METHENAMINE MANDELATE 500MG, 1GM MONUROL 3GM PRIMSOL 50MG/5ML PROLOPRIM 100MG TRIMETHOPRIM 100MG UREX 1GM URINARY ANTISEPTIC VARIOUS URISED URITACT DS 81.6MG UTA 120-0.12MG UTIRA 81.6-0.12MG W3A-ANTIFUNGAL ANTIBIOTICS FULVICIN U/F 250MG GRIFULVIN V 500MG GRISEOFULVIN 125MG/5ML GRIS-PEG 125MG, 250MG NYSTATIN SUSP 100000U/ML, TAB 500,000U W3B-ANTIFUNGALS ANCOBON 250MG, 500MG KETOCONAZOLE 200MG MYCELEX 10MG TROCHE W3C-ANTIFUNGALS DIFLUCAN IN DEXTROSE 200MG/100ML, 400MG/200ML DIFLUCAN IN SALINE 200MG/100ML, 400MG/200ML DIFLUCAN SUSP 50/5, 200/5 FLUCONAZOLE 50MG, 100MG, 150MG, 200MG FLUCONAZOLE IN DEXTROSE 200MG/100ML, 400MG/200ML FLUCONAZOLE IN SALINE 200MG/100ML, 400MG/200ML LAMISIL 250MG TERBINAFINE HCL 250MG TABLET W4A-ANTIMALARIALS ARALEN PHOSPHATE 500MG CHLOROQUINE PHOSPHATE 250MG,500MG DARAPRIM 25MG FANSIDAR 500/25 HYDROXYCHLOROQUINE SULFATE 200MG MALARONE 62.5/25MG,250/100MG MEFLOQUINE 250MG PRIMAQUINE PHOSPHATE 26.3MG
Effective October 1, 2007 March 20, 2008
Page 56 of 61
0 0
ELIGIBLE COVERED FOR DUAL
Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N
2 0 0 2 2 2 0 2 0 2 2 2 2
N N N N N N N N N N N N N
2 2 0 2 0
N N N N N
2 0 0
N N N
2 2 0 0 0 0 2 0
N N N N N N N N
2 0 2 2 0 2 0 2
N N N N N N N N
AMEND
DRUG NAME QUALAQUIN 324MG QUININE SULFATE 260MG QUININE SULFATE 325MG W4C-AMEBACIDES HUMATIN 250MG PAROMOMYCIN 250 MG TINDAMAX 250MG, 500MG W4E-ANAEROBIC ANTIPROTOZOAL-ANTIBACTERIAL AGENTS FLAGYL ER 750MG METRONIDAZOLE 250MG, 500MG W4K-MISC ANTI-PROTOZOALS MEPRON 750MG/5ML NEBUPENT AEROSOL NEUTREXIN INJ 25MG PENTAMIDINE ISOETHIONATE 300MG INJ W4L-ANTHELMINTICS ALBENZA 200MG MEBENDAZOLE 100MG MINTEZOL 500MG, 500MG/5ML STROMECTOL 3MG W4M-ANTIPARASITICS ALINIA 100MG/5ML ALINIA 500MG W4O-MISC ANTI-INFECTIVES BILTRICIDE 600MG W4P-ANTI-LEPROTICS DAPSONE 25MG, 100MG W5A-ANTIVIRALS, GENERAL ACYCLOVIR 200MG, 400MG, 800MG, 200MG/5ML ACYCLOVIR SODIUM 500MG, 1000MG CYTOVENE 500MG CYTOVENE INJ 500MG/10ML FLUMADINE 50MG/5ML SYRUP FOSCARNET SODIUM 24MG/ML FOSCAVIR INJ 24MG/ML GANCICLOVIR 250MG, 500MG RELENZA 5MG RIMANTADINE 100MG TAMIFLU 12MG/ML TAMIFLU 30MG, 45MG, 75MG VALCYTE 450MG VALTREX 500MG, 1000MG W5C-ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITORS AGENERASE 15MG/ML AGENERASE 50MG, 150MG CRIXIVAN 100MG, 200MG, 333MG, 400MG
Effective October 1, 2007 March 20, 2008
Page 57 of 61
2 0 0
ELIGIBLE COVERED FOR DUAL
Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N
2 0 2
N N N
0 0
N N
2 2 2 0
N N N N
2 0 2 2
N N N N
2 2
N N
2
N
2
N
0 0 2 2 2 0 2 0 2 0 2 2 2 2
N N N N N N N N N N N N N N
2 2 2
N N N
AMEND
DRUG NAME INVIRASE 200MG, 500MG LEXIVA 700MG TABLET, 50MG/ML SUSPENSION NORVIR 100MG, 80MG/ML SOLN REYATAZ 100MG, 150MG, 200MG, 300MG VIRACEPT 250MG, 625MG, PED ORAL PDR 50MG/GM W5F-HEPATITIS B TREATMENT AGENTS BARACLUDE 0.05MG/ML BARACLUDE 0.5MG, 1MG EPIVIR HBV 100MG, 25MG/5ML HEPSERA 10MG TYZEKA 600MG W5G-HEPATITIS C TREATMENTS INFERGEN 9MCG/0.3ML, 15MCG/0.5ML PEGASYS 180MCG/ML PEGASYS SYRINGE 180MCG/ML PEG-INTRON 100MCG, 160MCG, 240MCG PEG-INTRON REDIPEN 120MCG/0.5, 150MCG/0.5 PEG-INTRON REDIPEN 50MCG/0.5, 80MCG/0.5 REBETOL 200MG REBETOL 40MG/ML W5I-ANTIVIRALS, HIV-SPECIFIC, NUCLEOTIDE ANALOG, RTI VIREAD 300MG W5J-ANTIVIRALS, HIV-SPECIFIC, NUCLEOSIDE ANALOG, RTI DIDANOSINE 200MG, 250MG, 400MG EMTRIVA 200MG EPIVIR 150MG, 300MG, 10MG/ML ORAL SOLN HIVID 0.375MG, 0.75MG RETROVIR 100MG, 10MG/ML SYRUP RETROVIR IV 10MG/ML VIDEX 25MG, 50MG, 100MG, 150MG, 200MG VIDEX EC 125MG, 200MG, 250MG, 400MG VIDEX PACKET 167MG, 250MG VIDEX PED SUSP 2GM/120MG, 4GM/240ML ZERIT 15MG, 20MG, 30MG, 40MG, 1MG/ML ORAL ZIAGEN 20MG/ML ZIAGEN 300MG ZIDOVUDINE 100MG, 300MG, 10MG/ML W5K-ANTIVIRALS, HIV-SPECIFIC, NON-NUCLEOSIDE, RTI RESCRIPTOR 100MG, 200MG SUSTIVA 50MG, 100MG, 200MG, 600MG VIRAMUNE 200MG, 50ML/5ML W5L-ANTIVIRALS, HIV-SPEC., NUCLEOSIDE ANALOG, RTI COMBO COMBIVIR 150MG/300MG EPZICOM 600-300MG TRIZIVIR 300-150MG
Effective October 1, 2007 March 20, 2008
Page 58 of 61
2 2 2 2 2
ELIGIBLE COVERED FOR DUAL
Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N N N
2 2 2 2 2
N N N N N
2 2 2 2 2 2 0 2
N N N N N N N N
2
N
0 2 2 2 2 2 2 2 2 2 2 2 2 0
N N N N N N N N N N N N N N
2 2 2
N N N
2 2 2
N N N
AMEND
DRUG NAME W5M-ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITOR COMBO KALETRA 25-100, 133.3-33.3, 500-200 KALETRA 400-100/5ML W5N-ANTIVIRALS, HIV-SPECIFIC, FUSION INHIBITORS FUZEON 90MG/ML W5O-ANTIVIRALS, HIV-SPEC, NUCLEOSIDE-NUCLEOTIDE ANALOG TRUVADA 200MG-300MG W5P-ANTIVIRALS, HIV-SPEC, NON-PEPTIDIC PROTEASE INHIB APTIVUS 250MG PREZISTA 300MG W5Q-ANTIRETROVIRAL COMB NUCLEOSIDE, NUCLEOTIDE, & NON-NUCLEOSIDE RTI ATRIPLA 600-200 W5T-ANTIVIRALS, HIV-SPECIFIC, CCR5 CO-RECEPTOR ANTAGONITSTS SELZENTRY TABLET 150MG, 300MG W5U-ANTIVIRALS, HIV-1 INTEGRASE STRAND TRANSFER INHIBITOR ISENTRESS 400MG W8F-IRRIGANTS ACETIC ACID SOLN 0.25% NEOSPORIN G.U. IRRIGANT SEA-CLENS SODIUM CHLORIDE SOLN 0.45%,0.9% SORBITOL SOLN 70% SORBITOL UROLOGIC IRRIGATION 3%,3.3% WATER FOR IRRIGATION, STERILE W8J-MISC ANTIBACTERIAL IRRIGANTS AMINOACETIC ACID IRRIGATION 1.5% GLYCINE W9A-KETOLIDES KETEK 300MG, 400MG Z2A-ANTIHISTAMINES (oral diphenhydramine may be available for dual eligible) A.R.M. 60-4MG CARBINOXAMINE DROPS, SYRUP 4MG/5ML CARBINOXAMINE/PSEUDO 4-60/5ML, 4/60, 8/120 CHLORPHENIRAMINE 4MG, 8MGTR, 12MGTR DEXCHLORPHENIRAMINE MALEATE 4MG, 6MG, 2MG/5ML DIPHENHYDRAMINE 25MG, 50MG, 12.5MG/5ML DIPHENHYDRAMINE INJ 10MG/ML, 50MG/ML MINTEX 30-2MG/5ML PROMETHAZINE 6.25MG/5ML, 12.5MG, 25MG, 50MG PSE 15/CPM 2 15-2MG CHEWABLE PSEUDO TAN/CHLORPHEN TAN 75-4.5/5ML SILDEC DROPS 15-1/ML SILDEC LIQ 45-4/5ML
Effective October 1, 2007 March 20, 2008
Page 59 of 61
2 2
ELIGIBLE COVERED FOR DUAL
Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N
2
N
2
N
2 2
N N
2
N
2
N
2
N
0 2 2 0 0 0 0
N N N N N N N
0 0
N N
2
N
2 0 0 0 0 0 0 2 0 0 0 0 0
N N N N N Y N N N N N N N
AMEND
DRUG NAME Z2D-HISTAMINE 2 INHIBITORS CIMETIDINE 200MG, 300MG, 400MG, 800MG, 300MG/5ML CIMETIDINE INJ 150MG/ML FAMOTIDINE 10MG FAMOTIDINE 20MG, 40MG, 10MG/ML INJ, 20MG/50ML INJ RANITIDINE 150MG, 300MG ZANTAC 150MG/10ML SYRUP, 15MG/ML ORAL SOLN (0-12 YRS) ZANTAC INJ 25MG/ML Z2E-IMMUNOSUPPRESSIVES AZASAN 75MG, 100MG AZATHIOPRINE 50MG CELLCEPT 200MG/ML CELLCEPT 250MG, 500MG CYCLOSPORINE 25MG, 50MG, 100MG, 100MG/ML GENGRAF 25MG, 100MG, 100MG/ML MYFORTIC 180MG, 360MG NEORAL 100MG/ML ORAL NEORAL 25MG, 100MG PROGRAF 0.5MG, 1MG, 5MG RAPAMUNE 1MG, 2MG RAPAMUNE 1MG/ML SANDIMMUNE 100MG/ML INJ SANDIMMUNE 25MG, 100MG Z2F-MAST CELL STABILIZERS CROMOLYN SODIUM 10MG/ML INH SOLN GASTROCOM 20MG/ML INTAL 800MCG INH 112 SPRAY, 200 SPRAY TILADE 1.75MG AEROSOL Z2G-IMMUNOMODULATORS INTRON A 6MMU, 10MMU, 18MMU, 50MMU INTRON A PEN DELIVERY SYSTEMS 3MMU, 5MMU, 10MMU Z2N-1ST GEN ANTIHISTAMINE & DECONGESTANT COMBINATIONS BROVEX ADT HISDEC 30-2/5 HISTEX 30MG-2MG/5ML HYDRO-TUSSIN CBX NALEX A 5-7.5-2.5MG/5ML PEDIOX 15-2MG PHENYLEPHRINE/BROMPHENIRAMINE 2.5-1MG/5 PHENYLEPHRINE/CHLORPHENIRAMINE 12.5-4MG/5ML, 3.5-1MG/ML RHINACON A 5-7.5-2.5MG/5ML SUPHEDRINE COLD & ALLERGY 60MG-4MG TRIAMINIC COLD & ALLERGY 15-1MG/5ML Z2O-2ND GEN ANTIHISTAMINE & DECONGESTANT COMBINATIONS ALAVERT 120-5MG ALLERGY AND CONGESTION RELIEF 240-10MG (PSE-LORAT)
Effective October 1, 2007 March 20, 2008
Page 60 of 61
0 0 0 0 0 * 2
ELIGIBLE COVERED FOR DUAL
Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N N N N N
2 0 2 2 0 2 2 2 2 2 2 2 2 2
N N N N N N N N N N N N N N
0 2 2 2
N N N N
2 2
N N
2 2 2 2 2 2 0 0 2 2 2
N N N N N N N N N N N
2 0
N N
AMEND
DRUG NAME ALLERGY RELIEF D 240-10MG LORATADINE D 240-10MG SEMPREX-D 60/8 Z2P-ANTIHISTAMINES - 1ST GENERATION BROMPHENIRAMINE 6MG BROVEX 12MG/5ML B-VEX 12MG/5ML CLEMASTINE 1.34MG, 2.68MG, 0.67MG/5ML HISTEX PD 12 2MG-6MG/5ML HYDROXYZINE HCL 10MG, 25MG, 50MG HYDROXYZINE HCL INJ 25MG/ML, 50MG/ML HYDROXYZINE HCL SYRUP 10MG/5ML HYDROXYZINE PAMOATE 25MG, 50MG, 100MG LODRANE 6MG (BROMPHENIRAMINE) LODRANE XR 8MG/5ML NOLAHIST 25MG PALGIC 4MG, 4MG/5ML PHENERGAN 25MG PROMETHAZINE HCL 12.5MG, 25MG, 50MG TAB PROMETHAZINE HCL INJ 25MG/ML, 50MG/ML PROMETHAZINE SYRUP 6.25MG/5ML TANACOF XR 8MG/5ML VAZOL 2MG/5ML VISTARIL 25MG/5ML ZYMINE 1.25MG/5ML Z2Q-ANTIHISTAMINES - 2ND GENERATION ALAVERT 10MG ALLERGY RELIEF 5MG/5ML (LORATADINE) LORATADINE 10MG ZYRTEC CHEW 5MG, 10MG (AGES 0-6) ZYRTEC SYRUP (AGES 0-6) Z4B-LEUKOTRIENE RECEPTOR ANTAGONISTS ACCOLATE 10MG, 20MG SINGULAIR 4MG, 5MG, 10MG SINGULAIR ORAL GRANULES 4MG
Effective October 1, 2007 March 20, 2008
Page 61 of 61
0 0 2
ELIGIBLE COVERED FOR DUAL
Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N
0 2 2 0 2 0 0 0 0 2 2 2 2 2 0 0 0 0 2 2 2
N N N N N N N N N N N N N N N N N N N N N
2 0 0 * *
N N N N N
2 2 2
N N N
Appendix A
DRUG NAME A1A-DIGITALIS GLYCOSIDES DIGOXIN 0.05MG/ML PED ELIXIR DIGOXIN 0.125MG, 0.25MG, 0.5MG DIGOXIN 0.25MG/ML INJ LANOXICAPS 0.1MG, 0.2MG LANOXIN 0.05MG/ML PED ELIXIR LANOXIN 0.125MG, 0.25MG LANOXIN 0.25MG/ML INJ A1B-XANTHINES AMINOPHYLLINE 100MG, 200MG TAB AMINOPHYLLINE 105MG/5ML LIQUID AMINOPHYLLINE 500MG/20ML INJ CAFCIT 20MG/ML CAFFEINE CITRATE 20MG/ML DILOR 200MG, 400MG DYPHYLLINE 100MG/15ML ELIXOPHYLLIN ELIXIR 80MG/15ML THEO-24 100MG, 200MG, 300MG, 400MG THEOPHYLLINE ANHYDROUS CAPS 100MG, 125MG, 200MG, 300MG THEOPHYLLINE LIQUID 80MG/15ML THEOPHYLLINE SR TAB 100MG, 200MG, 300MG, 450MG UNIPHYL 400MG, 600MG A1D-GENERAL BRONCHODILATOR AGENTS ATROVENT HFA ATROVENT INH, REF 18MCG IPRATROPIUM 0.2MG/ML KIE LIQUID SPIRIVA INHALER 18MCG A2A-ANTIARRHYTHMICS AMIODARONE 200MG CORDARONE IV 50MG/ML DISOPYRAMIDE CR 150MG DISOPYRAMIDE PHOSPHATE 100MG, 150MG ETHMOZINE 200MG, 250MG, 300MG FLECAINIDE ACETATE 50MG, 100MG, 150MG MEXILITENE HCL 150MG, 200MG, 250MG NORPACE CR 100MG, 150MG PACERONE 200MG PROCAINAMIDE HCL 250MG, 500MG PROCAINAMIDE HCL INJ 100MG/ML, 500MG/ML PROCAINAMIDE HCL SR 500MG PROCAINAMIDE HCL SR 750MG, 1000MG PROCANBID 500MG, 1000MG PRONESTYL 250MG, 500MG PROPAFENONE 150MG, 225MG QUINIDINE GLUCONATE 324MG
0 0 0 2 2 2 2
ELIGIBLE COVERED FOR DUAL
AMEND
Page 1 of 61 CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N N N N N
0 0 0 2 0 2 2 2 2 0 0 0 2
N N N N N N N N N N N N N
2 2 0 2 2
N N N N N
0 2 0 0 2 0 0 2 0 0 0 0 0 2 2 0 0
N N N N N N N N N N N N N N N N N
Effective October 1, 2007 March 20, 2008 APPENDIX p(31979) pa(40321) d(168211) ra(140269)
print date: 02/19/2008 10:36 AM
Appendix A
DRUG NAME QUINIDINE SULFATE 200MG, 300MG QUINIDINE SULFATE SR 300MG RYTHMOL 150MG, 225MG RYTHMOL 300MG RYTHMOL SR 225MG, 325MG, 425MG TAMBOCOR 50MG, 100MG, 150MG TIKOSYN 0.125MG, 0.25MG, 0.5MG A2C-ANTI-ANGINAL AND ANTI-ISCHEMIC AGENTS, NON-HEMODYNAMIC RANEXA 500MG A4A-HYPOTENSIVES, VASODILATORS DOXAZOSIN MESYLATE 1MG, 2MG, 4MG, 8MG HYDRALAZINE HCL 10MG, 25MG, 50MG, 100MG HYDRALAZINE INJ 20MG/ML HYDRALAZINE/HCTZ 25/25, 50/50, 100/50 HYDRALAZINE/HCTZ/RESERPINE 25-0.1-15 MINOXIDIL 2.5MG, 10MG PRAZOSIN HCL 1MG, 2MG, 5MG TERAZOSIN HCL 1MG, 2MG, 5MG, 10MG A4B-HYPOTENSIVES, SYMPATHOLYTIC CATAPRES-TTS 0.1MG, 0.2MG, 0.3MG CLONIDINE HCL 0.1MG, 0.2MG, 0.3MG CLORPRES 0.1/15, 0.2/15, 0.3/15 ENDURONYL FORTE 0.5/5 GUANABENZ 4MG, 8MG GUANFACINE 1MG, 2MG HYDROCHLOROTHIAZIDE/RESERPINE 50/0.125 ISMELIN 10MG, 25MG METHYLDOPA 250MG, 500MG METHYLDOPA/HCTZ 250/15, 250/25, 500/30 RESERPINE 0.1MG, 0.25MG SALUTENSIN 0.125MG/50MG SALUTENSIN-DEMI 0.125MG/25MG A4C-HYPOTENSIVES, GANGLIONIC BLOCKERS INVERSINE 2.5MG A4D-HYPOTENSIVES, ACE INHIBITORS BENAZEPRIL 5MG, 10MG, 20MG, 40MG BENAZEPRIL/HCTZ 5-6.25MG, 10-12.5MG, 20-12.5MG, 20-25MG CAPTOPRIL 12.5MG, 25MG, 50MG, 100MG CAPTOPRIL/HCTZ 25/15, 25/25, 50/15, 50/25 ENALAPRIL 2.5MG, 5MG, 10MG, 20MG ENALAPRIL/HCTZ 5/12.5, 10/25 LISINOPRIL 2.5MG, 5MG, 10MG, 20MG, 30MG, 40MG LISINOPRIL/HCTZ 10/12.5, 20/12.5, 20/25 A4F-HYPOTENSIVES, ANGIOTENSIN RECEPTOR ANTAGONIST AVALIDE 12.5-150, 12.5-300, 300-25 AVAPRO 75MG, 150MG, 300MG
Effective October 1, 2007 March 20, 2008
0 0 2 0 2 2 2
ELIGIBLE COVERED FOR DUAL
AMEND
Page 2 of 61 CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N N N N N
2
N
0 0 0 0 0 0 0 0
N N N N N N N N
2 0 2 2 0 0 0 2 0 0 0 2 2
N N N N N N N N N N N N N
2
N
0 0 0 0 0 0 0 0
N N N N N N N N
2 2
N N
Appendix A
ELIGIBLE COVERED FOR DUAL
AMEND
Page 3 of 61 CO-PAYMENT
DRUG CLASS
5101:3-9-12
DRUG NAME BENICAR 5MG, 20MG, 40MG 2 BENICAR HCT 20/12.5, 40/12.5, 40/25 2 COZAAR 25MG, 50MG, 100MG 2 DIOVAN 40MG, 80MG, 160MG, 320MG 2 DIOVAN HCT 80/12.5, 160/12.5, 160/25, 320/12.5, 320/25 2 HYZAAR 50/12.5, 100/12.5, 100/25 2 MICARDIS 20MG, 40MG, 80MG 2 MICARDIS HCT 40-12.5, 80-12.5, 80-25 2 A4H-ANGIOTENSIN RECEPTOR ANTAGONIST & CALCIUM CHANNEL BLOCKER COMBINATION EXFORGE TABLET 5MG-160MG, 10MG-160MG, 5MG-320MG, 10MG-320MG 2 A4K-ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATION LOTREL 10/2.5, 10/5, 10/20, 20/5, 40/5, 40/10 2 TARKA 2/180, 1/240, 2/240, 4/240 2 A4Y-HYPOTENSIVES,MISC ATENOLOL/CHLORTHALIDONE 25/50, 25/100 0 BISOPROLOL FUMARATE/HCTZ 6.25/2.5, 6.25/5, 6.25/10 0 DEMSER 250MG 2 PROPRANOL/HCTZ 25/40, 25/80 0 TIMOLIDE 10/25 2 A7B-CORONARY VASODILATORS DILATRATE SR 40MG 2 DIPYRIDAMOLE 25MG, 50MG, 75MG 0 IMDUR 120MG 0 ISOSORBIDE DINITRATE ORAL 5MG, 10MG, 20MG, 30MG 0 ISOSORBIDE DINITRATE SL 2.5MG, 5MG 0 ISOSORBIDE DINITRATE SR 40MG 0 ISOSORBIDE MONONITRATE 10MG, 20MG, 30MG, 60MG 0 MINITRAN 0.1MG/HR, 0.2MG/HR, 0.4MG/HR, 0.6MG/HR 2 NITROBID OINT 2% 2 NITRO-DUR 0.1MG/HR, 0.3MG/HR, 0.8MG/HR 2 NITRO-DUR II 0.1MG/HR, 0.2MG/HR, 0.3MG/HR 2 NITRO-DUR II 0.4MG/HR, 0.6MG/HR 2 NITROGLYCERIN ORAL 2.5MG, 6.5MG, 9MG 0 NITROGLYCERIN PATCHES 0.1MG/HR, 0.2MG/HR, 0.4MG/HR, 0.6MG/HR 0 NITROGLYCERIN SL 0.3, 0.4, 0.6 0 NITROLINGUAL SPRAY 0.4MG/DOSE 2 NITROQUICK 0.3MG, 0.4MG, 0.6MG 0 NITROSTAT 0.3MG, 0.4MG, 0.6MG 2 A7C-PERIPHERAL VASODILATORS ERGOT ALKALOIDS ORAL 1MG 0 PAPAVERINE HCL 150MG 0 A9A-CALCIUM CHANNEL BLOCKERS AMLODIPINE 2.5MG, 5MG, 10MG 0 DILTIAZEM 30MG, 60MG, 90MG, 120MG 0 DILTIAZEM CD 120MG, 180MG, 240MG, 300MG, 360MG 0 DILTIAZEM INJ 5MG/ML 0
Effective October 1, 2007 March 20, 2008
N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N
Appendix A
DRUG NAME DILTIAZEM SR 60MG, 90MG, 120MG DILTIAZEM XR 120MG, 180MG, 240MG, DYNACIRC 2.5MG, 5MG DYNACIRC CR 5MG, 10MG FELODIPINE ER 2.5MG, 5MG, 10MG NICARDIPINE HCL 20MG, 30MG NIPEDIPINE ER 30MG, 60MG, 90MG SULAR 10MG, 20MG, 30MG, 40MG TAZTIA XT 120MG, 180MG, 240MG, 300MG, 360MG VERAPAMIL HCL 40MG, 80MG, 120MG VERAPAMIL SR 120MG, 180MG, 240MG, 360MG B0A-GENERAL INHALATION AGENTS DEY-PAK 10% DEY-PAK 3% SODIUM CHLORIDE FOR INHALATION 0.9% B3A-MUCOLYTICS ACETYLCYSTEINE SOLN 10%, 20% PULMOZYME 2.5MG B3J-EXPECTORANTS (cough suppressants may be covered for dual eligible) BRONTEX LIQUID BRONTEX TABS DE-CHLOR G 100-10-2/5ML GDP-EX 200-300-10 GUAIFENESIN 200MG, 400MG, 600MG, 1200MG GUAIFENESIN CODEINE 300/10MG TABS, 150-5/10ML GUAIFENESIN CODEINE SYRUP 100-10/5 ML, 150-5/10ML GUAIFENESIN DM 600/30 TABS GUAIFENESIN DM SYRUP 100-10/5ML, 100-15/5ML, 200-10/5ML, 200-30/5ML GUAIFENESIN PE SYRUP 100-30/5ML GUAIFENESIN PE/HC SYRUP 50-7.5-2.5/5ML GUAIFENESIN SYRUP 100MG/5ML GUAIFENESIN/DM/PE 200-30-10/5ML GUAIFENESIN/PHENYLEPH/HCOD 100-10-2MG/5ML GUAIFENESIN/PSEUDOEPHEDRINE 100-30/5ML GUAIFENESIN/PSEUDOEPHEDRINE 250/120, 300/60 GUAIFENESIN/PSEUDOEPHEDRINE 50-15/5ML GUAIFENESIN/PSEUDOEPHEDRINE 600/120, 600/60 GUAIFENESIN/PSEUDOEPHEDRINE/CODEINE 100-30-10/5 GUAIFENESIN/PSEUDOEPHEDRINE/DEXTROMETHORPHANLIQ 100-10-30/5ML GUAIFENESIN/PSEUDOEPHEDRINE/DEXTROMETHORPHANTAB 600-60-30 GUAITUSS CF (GUAIFENESIN/DEXTROMETHORPHAN/PSE 100-10-30) HCA COUGH FORMULA 200-30/5ML HUMIBID LA 600-300 HYDROCODONE/GUAI/PSEUDO 5-200-60/5ML, 100-15-3/5ML HYDROCODONE/GUAIFENESIN SYRUP 5MG-100MG/5ML HYDRON EX 120-2.5MG/5ML
Effective October 1, 2007 March 20, 2008
0 0 0 2 0 0 0 2 0 0 0
ELIGIBLE COVERED FOR DUAL
AMEND
Page 4 of 61 CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N N N N N N N N N
2 0 0
N N N
0 2
N N
0 0 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 2 0 0 2
Y Y Y Y N Y Y Y Y N Y Y Y Y N N N N Y Y Y Y Y N Y Y Y
Appendix A
ELIGIBLE COVERED FOR DUAL
AMEND
Page 5 of 61 CO-PAYMENT
DRUG CLASS
5101:3-9-12
DRUG NAME HYDRO-TUSSIN XP 2 Y INTENSE COUGH RELIEVER SYRUP 2 Y MINTUSS G 100-10-2/5ML 2 Y MUCINEX TABLET 600MG, 1200MG 2 Y POT GUAIACO-HYDROCOD 120-2.5MG/5ML 0 Y PRO-CLEAR 350-3MG/5ML 2 Y PRO-COF 300MG-5MG/5ML 2 Y ROBITUSSIN DM 200-10MG/5ML 2 Y ROBITUSSIN DM INFANT DROPS 100-5/2.5ML 2 Y B3K-COUGH AND/OR COLD PREPARATIONS (cough suppressants may be covered for dual eligible) AMERITUSS AD 15-10-3/5ML 2 Y ATUSS HC 10-2.5-2MG/5ML 2 Y BROMAXEFED RF 45-4/5ML 0 N BROMODIPHENHYDRAMINE/CODEINE 12.5-10/5ML 0 Y BROMPLEX DM 30-60-4MG/5ML 2 Y CARBINOXAMINE/PSEUDO 4MG/60MG, 8MG/120MG 0 N CARBINOXAMINE/PSEUDO DROPS, SYRUP 15-1/1ML, 15-2/1ML, 60-4/5ML 0 N CARBINOXAMINE/PSEUDO/DM DROPS, SYRUP 4-15-1/1ML, 4-15-2/1ML 0 Y CHILDS ALLERGY 5-15-1MG/5ML 2 Y CHLORPHEN/P-EPH/HC 2-2-5/5 0 Y CHLORPHEN/P-EPH/PHENYLTOX 4/20/50 0 N CHLORPHEN/PSEUDO 4MG/60MG, 8MG/120MG 0 N CHLORPHEN/PSEUDO SYRUP 2MG-30MG/5ML, 1-15/5ML 0 N CHLORPHEN/PSEUDO/ACETA 4/60/650 0 N CLORFED 60-4MG 2 N COLDCOUGH HC 15-3-2/5ML 2 Y DEXBROMPHENIRAMINE/PSEUDO 6/120 0 N DEXTROMETHORPHAN/PSEUDOEPHEDRINE/CHRLORPHENIRAMINE5-15-1/5ML 0 Y DIHISTINE DH (PSEUDO/CPM/COD) 0 Y DM TAN/P-EPH TAN-CP TAN 25MG-75MG-4.5MG/5ML 0 Y DM/PE/CHLORPHEN 15-10-2MG/5ML, 15-6-2/5ML 0 Y DUOTAN PD 75-2.5MG/5ML 2 N HISTADE 120MG-12MG 2 N HYDROCODONE/HOMATRO 5/1.5 TAB, SYRUP 0 Y HYDROCODONE/PSEUDO LIQUID 5MG-60MG/5ML 0 Y HYDRON CP 10-5-2MG/5ML 2 Y NOVAHISTINE DH 2 Y PEDIA COUGH-COLD 5-15-1MG/5ML 2 Y PEDIACARE 7.5-15MG CHEW 2 Y PHENYLEPH/HCOD BT/CP 5-2.5-2/5ML, 10-5-2/5ML, 5-5-2/5ML, 10-2.5-2/5ML 0 Y PHENYLEPH/PYRIL/DM 5-8.33-10/5ML 0 Y PHENYLEPH/PYRIL/HCOD 7.5-15/5 0 Y PHENYLEPHRINE/PYRILAMINE TANNATE 5-30/5ML 0 N PROMETHAZINE CODEINE SYRUP 10-6.25/5ML 0 Y PROMETHAZINE VC CODEINE SYRUP 0 Y PROMETHAZINE VC SYRUP 0 N
Effective October 1, 2007 March 20, 2008
Appendix A
ELIGIBLE COVERED FOR DUAL
AMEND
Page 6 of 61 CO-PAYMENT
DRUG CLASS
5101:3-9-12
DRUG NAME PRO-RED 5-2-8.33/5ML 2 PSE-BROM 30-60-4/5ML 2 PSEUDO/BROM MAL 15-1/5ML,60-4/5ML 0 PSEUDO/BROM MAL DM 15-1-5/ML,60-4-15/5ML 0 PSEUDO/BROMPHEN/DM 45-4-15/5ML, 10-30-2/5ML, 30-60-4/5 0 PSEUDO/CARB MAL 15-2/ML 0 PSEUDO/HC/CTM 15-3-2/5ML 0 PSEUDOEPHEDRINE/CHLORPHENIRAMINE/CODEINE 30-10-2/5ML 0 RELACON HC 10-3.5-2.5MG/5ML 2 ROBITUSSIN 10MG-30MG-2MG/5ML 0 ROBITUSSIN PM 7.5MG-15MG-1MG/5ML 2 R-TANNIC-S 5-30MG/ML 0 RU-TUSS A 15-10-2MG/5ML 0 TRIACTING COLD & ALLERGY 0 TRIACTING COLD/COUGH 5-15-1/5ML 0 TRIACTING SORE THROAT 7.5-15-160MG/5ML 2 TRIAMINIC COUGH 5-15 MG/5ML 2 TRIAMINIC COUGH/SORE THROAT 7.5-15-160/5ML 2 TRIPROLIDINE/PSEUDO 2.5/60 TAB 0 TRIPROLIDINE/PSEUDO LIQUID 1.25-30/5ML 0 TRIPROLIDINE/PSEUDO/CODEINE SYRUP 0 TUSSIN PEDIATRIC COUGH-COLD 7.5-15MG/5ML 2 UNI-TUSS DM 15-5-2/5 2 B3P-NON-NARC ANTITUS-1ST GEN ANTIHIST-DECON-ANALGES CB (cough suppressants may be covered for dual eligible) DIMETAPP 5-15-160-1 2 TRIAMINIC COLD/COUGH/FEVER 2 B3Q-NARCOTIC ANTITUSS-1ST GEN. ANTIHISTAMINE-DECONGEST (cough suppressants may be covered for dual eligible) BROMPHENIRAMINE-HYDROCOD-PSE 30-2.5-3MG/5ML 0 BROVEX HC 2 HYDRO-TUSSIN HC 15-3-2/5ML 2 PHENYLEPHRINE-HYDROCODONE-CP 5-5-2MG/5ML 0 B3R-NON-NARC ANTITUSS-1ST GEN. ANTIHISTAMINE-DECONGEST (cough suppressants may be covered for dual eligible) CODIMAL DM SYRUP 2 DEXTROMETHORPHAN/PHENYLEPHRIN/BROMPHENIRAMINE5-2.5-1/5 0 DEXTROMETHORPHAN/PHENYLEPHRINE/CHLORPHENIRAMINE15-12.5-4, 3-3.51/ML, 15-10-2/5ML 0 DIMETAPP DM 2 PE-HIST DM 15-5-2MG/5ML 2 RESCON DM 10MG-30MG, 10-30-2/5 2 TANACOF-DM 25-75-2.5/5ML 2 TRIAMINIC COLD & COUGH 5-15-1MG/5ML 2 TRIAMINIC NIGHT TIME 2
Effective October 1, 2007 March 20, 2008
Y Y N Y Y N Y Y Y Y Y N Y N Y Y Y Y N N Y Y Y
Y Y
Y Y Y Y
Y Y Y Y Y Y Y Y Y
Appendix A
ELIGIBLE COVERED FOR DUAL
AMEND
Page 7 of 61 CO-PAYMENT
DRUG CLASS
5101:3-9-12
DRUG NAME B3T-NON-NARCOTIC ANTITUSSIVE AND EXPECTORANT COMB (cough suppressants may be covered for dual eligible) GUAIFENESIN/DEXTROMETHORPHAN 100-5MG/5, 400-20MG TAB 0 Y HCA COUGH FORMULA (WALSH) 300-20/5ML 2 Y B4A-NON-NARCOTIC ANTITUSSIVE-ANALGESIC COMBINATIONS (cough suppressants may be covered for dual eligible) DEXTROMETHORPHAN/ACETAMINOPHEN 30-1000/30, 7.5-160/5 0 Y B4D-NARCOTIC ANTITUSSIVE-1ST GENERATION ANTIHISTAMINE COTAB AX 4-20MG 2 Y B4E-NON-NARC ANTITUSSIVE-1ST GEN ANTIHISTAMINE COMB (cough suppressants may be covered for dual eligible) DEXTROMETHORPHAN/CHLORPHENIRAMINE 7.5-1MG/5ML 0 Y PROMETHAZINE DM SYRUP 15-6.25/5 0 Y ROBITUSSIN COUGH-COLD LIQUID 7.5MG-1MG/5ML 0 Y B4K-NARCOTIC ANTITUSSIVE-DECONGESTANT COMBINATIONS (cough suppressants may be covered for dual eligible) HISTUSSIN D 60-5MG/5ML 2 Y PANCOF HC 15-3/5ML 2 Y B4M-NON-NARCOTIC ANTITUSSIVE-DECONGESTANT-ANALGESIC CB (cough suppressants may be covered for dual eligible) D-METHORPHAN/PE/ACETAMINOPHEN 5-325MG/15 0 Y B4P-NON-NARC ANTITUSS-DECONGESTANT-ANALGESIC-EXPECT CB (cough suppressants may be covered for dual eligible) HCA COUGH AND COLD RELIEVER (WALSH) 10-5-325/5ML 2 Y B4Q-NARCOTIC ANTITUSS-DECONGESTANT-EXPECTORANT COMB (cough suppressants may be covered for dual eligible) DONATUSSIN DC SYR 2 Y B4R-NON-NARCOTIC ANTITUSS-DECONGESTANT-EXPECTORANT CMB (cough suppressants may be covered for dual eligible) GUAIFENISEN/DEXTROMETHORPHAN/PHENYLEPHRINE 100-10-5/5ML 0 Y TUSNEL PEDIATRIC LIQUID 50-5-15/5ML 2 Y B4S-NARCOTIC ANTITUSSIVE-EXPECTORANT COMBINATION (cough suppressants may be covered for dual eligible) EXECOF-XP 90-3/5ML 2 Y GUAIFENESIN W/CODEINE SYRUP 100-10MG/5 0 Y M-CLEAR 400-5/5ML 2 Y PANCOF XP 90-3/5ML 2 Y B4W-DECONGESTANT-EXPECTORANT COMBINATIONS MARDROPS-EX 50-15/1ML 2 N RESCON GG 100-5/5ML 2 N RESPAIRE SR 200/60 2 N ROBITUSSIN PE 2 N TRIACTING CHEST CONGESTION 0 N TRIAMINIC CHEST CONGESTION 50-15MG/5ML 2 N
Effective October 1, 2007 March 20, 2008
Appendix A
DRUG NAME C0B-WATER STERILE WATER FOR INHALATION STERILE WATER FOR INJECTION C0C-DRUGS USED TO TREAT ACIDOSIS LACTATED RINGERS SOLN C0D-ANTI-ALCOHOLIC PREPARATIONS ANTABUSE 250MG, 500MG CAMPRAL 333MG C0K-BICARBONATE PRODUCING/CONTAINING AGENTS SODIUM ACETATE 2MEQ/ML, 4MEQ/ML SODIUM LACTATE 5MEQ/ML C1A-ELECTROLYTE DEPLETERS FOSRENOL 250MG, 500MG, 750MG, 1000MG KAYEXALATE POWDER KIONEX PDR MAGNEBIND 450/200, 300/300, 200/400 PHOSLO 667MG RENAGEL 400MG, 800MG SODIUM POLYSTYRENE SULFONATE 15GM/60ML C1B-SODIUM/SALINE PREPARATIONS SODIUM CHLORIDE SOLUTION 0.45%, 0.9%, 5%, 2.5 MEQ/ML, 4MEQ/ML C1D POTASSIUM REPLACEMENT DEXTROSE 10% - 1/4NS-KCL DEXTROSE 5% - 1/4NS-KCL DEXTROSE 5% - 1/2NS-KCL DEXTROSE 5% - KCL DEXTROSE 5% - LACT RING-KCL EFFER-K TABLETS 10MEQ, 20MEQ KAON 20MEQ/15ML KAON-CL 10MEQ KLOR-CON 10, 10MEQ KLOR-CON 25 EFFERVESCENT KLOR-CON 25, 25MEQ KLOTRIX 10MEQ K-TAB 10MEQ MICRO-K EXTENCAPS 8MEQ POTASSIUM CHLORIDE 10 MEQ, 20MEQ POTASSIUM CHLORIDE 8MEQ, 10MEQ POTASSIUM CHLORIDE EFF PKTS 25MEQ POTASSIUM CHLORIDE INJ 20MEQ, 40MEQ POTASSIUM CHLORIDE ORAL LIQ 10%, 20% POTASSIUM CHLORIDE PACKETS 20MEQ POTASSIUM GLUCONATE ELIXIR 4.68GM/15ML TRAVERT 10%-1/2NS KCL 40MEQ
Effective October 1, 2007 March 20, 2008
0 0
ELIGIBLE COVERED FOR DUAL
AMEND
Page 8 of 61 CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N
0
N
2 2
N N
0 0
N N
2 2 0 2 2 2 0
N N N N N N N
0
N
0 1 2 0 0 2 2 2 2 0 2 2 2 2 0 0 0 0 0 0 0 2
N N N N N N N N N N N N N N N N N N N N N N
Appendix A
DRUG NAME C1F-CALCIUM REPLACEMENT (may be covered for dual eligible) CALCI-MIX 1.25GM CALCIUM CARBONATE 1.25 GM CALCIUM CARBONATE 10GR CALCIUM CITRATE 950MG, 1040MG CALCIUM GLUBIONATE 1.8GM/5ML CALCIUM GLUCONATE 10% CALCIUM GLUCONATE 10GR CALCIUM LACTATE 10GR CITRACAL 950MG NEPHRO CALCI 1500MG OYSTER SHELL CALC W/D 250MG/125U, 500MG/125U, 500MG/200U OYSTER SHELL CALCIUM 500MG C1H-MAGNESIUM SALTS REPLACEMENT (may be covered for dual eligible) MAG DELAY 64MG MAGNESIUM GLUCONATE 500MG MAGNESIUM OXIDE 400MG MAGNESIUM SULFATE 4MEQ/ML MAGNESIUM SULFATE/DEX 1%, 2% MAGONATE 1GM/5ML ORAL MAGTAB SR 84MG SLOW MAG 64MG URO-MAG 140MG C1P-PHOSPHATE REPLACEMENT (may be covered for dual eligible) NEUTRA-PHOS NEUTRA-PHOS-K PHOS-NAK POTASSIUM PHOS 3MM/ML SODIUM PHOS 3MM/ML C1W-ELECTROLYTE MAINTENANCE DEXTROSE 10% - ELECTROLYE #48 DEXTROSE 5% - ELECTROLYE #48, #75 FRUCTOSE 10% ELECTROLYTE #48 FRUCTOSE 5% ELECTROLYTE #48, #75 M.T.E. M.T.E. -4, -5, -6, -7 MULTITRACE-4, -5 P.T.E. -4, -5 PEDTRACE-4 PLASMA-LYTE TRAVERT - ELECTROLYTES #1, #2, #3, #4 C1Z-ELECTROLYTE REPLACEMENT NORMOSOL-M AND DEXTROSE 5% ORAL ELECTROLYTES PARENTERAL ELECTROLYTES
Effective October 1, 2007 March 20, 2008
2 0 0 0 0 0 0 0 2 2 0 0
ELIGIBLE COVERED FOR DUAL
AMEND
Page 9 of 61 CO-PAYMENT
DRUG CLASS
5101:3-9-12
Y Y Y Y Y Y Y Y Y Y Y Y
0 0 0 0 2 2 2 2 2
Y Y Y Y Y Y Y Y Y
2 2 2 0 0
Y Y Y Y Y
2 2 2 2 2 2 2 2 2 2 2
N N N N N N N N N N N
2 0 2
N Y N
AMEND
DRUG NAME PARENTERAL ELECTROLYTES W/DEXTROSE PEDIAPOP C3B-IRON REPLACEMENT (may be covered for dual eligible) B-COMPLEX PLUS IRON CHROMAGEN FA 70-150-1 CHROMAGEN FORTE 151-60-1 CORVITE 150 CORVITE FREE DEXFERRUM 50MG/ML FEFUM/C/B12/IF/FA 0.5MG FEOGEN FORTE 460/60MG FERROGELS FORTE 460/60MG FERROUS FUM/C/B-12 FERROUS FUM/C/B-12/FA FERROUS FUMARATE 325MG FERROUS GLUCONATE EC 5GR, 240MG FERROUS SULFATE 5GR FERROUS SULFATE DROPS, ELIXIR 75MG/0.6ML, 220MG/5ML FERROUS/FA/B&C HEMATOGEN HEMATOGEN FA 200-250MG HEMATOGEN FORTE 460-60MG INFED INJ 100MG/2ML MYKIDZ IRON 10 SUSPENSION 15MG/1.5ML NEPHRON FA NIFEREX 100MG/5ML ELIXIR NIFEREX 150 FORTE POLYSACCARIDE 150 FORTE POLYSACCARIDE FORTE ELIXIR POLYSACCARIDE IRON 150MG RE DUALVIT F 106-1MG RE DUALVIT PLUS 106-1MG REOCYTE PLUS 106-1MG STRESS FORMULA + IRON C3C-ZINC REPLACEMENT (may be covered for dual eligible) ZINC SULFATE 220MG C3H-IODINE CONTAINING AGENTS (may be covered for dual eligible) POTASSIUM IODIDE 1GM/ML C3M-MISC MINERAL REPLACEMENT (may be covered for dual eligible) MOLYPEN 25MCG/ML C4F-ANTIHYPERGLY, (DPP-4) INHIBITOR & BIGUANIDE COMB. JANUMET 50-500, 50-1000 C4G-INSULINS LANTUS 100U/ML NOVOLIN 70/30 100U/ML, 150U/1.5ML, 70-30U/ML NOVOLIN N
Effective October 1, 2007 March 20, 2008
Page 10 of 61
2 0
ELIGIBLE COVERED FOR DUAL
Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N Y
0 2 2 2 2 2 0 0 0 0 0 0 0 0 0 0 0 0 0 2 0 2 2 2 0 0 0 2 2 2 0
Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y
2
Y
0
Y
2
Y
2
N
2 2 2
N N N
AMEND
DRUG NAME NOVOLIN R NOVOLOG 100U/ML NOVOLOG MIX 70/30 C4H-ANTIHYPERGLYCEMIC, AMYLIN ANALOG-TYPE SYMLIN 0.6MG/ML C4I-ANTIHYPERGLYCEMIC, INCRETIN MIMETIC(GLP-1 RECEPTOR AGONIST) BYETTA 5MCG/0.02, 10MCG/0.04 C4J-ANTIHYPERGLYCEMIC, DPP-4 INHIBITORS JANUVIA 25MG, 50MG, 100MG C4K-HYPOGLYCEMICS, INSULIN-RELEASE STIMULANT TYPE ACETOHEXAMIDE 250MG,500MG CHLORPROPAMIDE 100MG, 250MG GLIMEPIRIDE 1MG, 2MG, 4MG GLIPIZIDE 5MG,10MG GLIPIZIDE ER 2.5MG,5MG,10MG GLYBURIDE 1.25MG,2.5MG,5MG GLYBURIDE MICRONIZED 1.5MG,3MG,6MG STARLIX 60MG,120MG TOLAZAMIDE 100MG,250MG,500MG TOLBUTAMIDE 500MG TOLINASE 100MG C4L-HYPOGLYCEMICS, BIGUANIDE TYPE (NON-SULFONYLUREAS) METFORMIN 500MG, 850MG, 1000MG METFORMIN HCL ER 500MG, 750MG C4M-HYPOGLYCEM, ALPHA-GLUCOSIDASE INHIB TYPE (N-S) GLYSET 25MG,50MG,100MG PRECOSE 25MG,50MG,100MG C4N-HYPOGLYCEMICS, INSULIN-RESPONSE ENHANCER (N-S) ACTOPLUS MET 15-500, 15-850 ACTOS 15MG, 30MG, 45MG AVANDIA 2MG,4MG,8MG C4R-HYPOGLYCEMICS, INSULIN-RESPONSE & INSULIN RELEASE COMBINATION AVANDARYL 4-1, 4-2, 4-4, 8-2, 8-4 DUETACT 30-2, 30-4 C4S-HYPOGLY, INSULIN-REL STIM. & BIGUANIDE (N-S) COMB. GLYBURIDE-METFORMIN 1.25-250, 2.5-500, 5-500 C4T-HYPOGLY, INSUL-RESP. ENHANCER & BIGUANIDE COMB. AVANDAMET 1-500, 2-500, 4-500, 2-1000, 4-1000 C5A-CARBOHYDRATES TRAVERT IN NORMAL SALINE C5B-PROTEIN REPLACEMENT NOVAMINE 15% PREMASOL 6%, 10% PROSOL 20% INJECTION
Effective October 1, 2007 March 20, 2008
Page 11 of 61
2 2 2
ELIGIBLE COVERED FOR DUAL
Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N
2
N
2
N
2
N
0 0 0 0 0 0 0 2 0 0 2
N N N N N N N N N N N
0 0
N N
2 2
N N
2 2 2
N N N
2 2
N N
0
N
2
N
2
N
2 2 2
N N N
AMEND
DRUG NAME C5F-DIETARY SUPPLEMENTS, MISC (may be covered for dual eligible) CO ENZYME Q10 LIQ10 50MG/5ML Q-GEL MEGA 100MG C5H-VITAMINS INJ (may be covered for dual eligible) M.V.I. PED, 12 C5J-IV SOLNS DEXTROSE/WATER DEXTROSE 5% W/POTASSIUM CHLORIDE 10MEQ/L, 20MEQ/L, 30MEQ/L, 40MEQ/L DEXTROSE/WATER 5%, 10%, 50%, 70% C5K-IV SOLNS DEXTROSE/SALINE/KCL DEXTROSE 5%/0.25%NS/KCL 10MEQ/L, 20MEQ/L, 30MEQ/L, 40MEQ/L DEXTROSE 5%/0.33%NS/KCL 10MEQ/L, 20MEQ/L, 30MEQ/L, 40MEQ/L DEXTROSE 5%/0.45%NS/KCL 10MEQ/L, 20MEQ/L, 30MEQ/L, 40MEQ/L DEXTROSE/NACL 2%/0.45%, 5%/0.2%, 5%/0.33%, 5%/0.45%, 5%/0.9% DEXTROSE/NS/KCL 10MEQ/L, 20MEQ/L,30MEQ/L,40MEQ/L C5M-IV SOLNS DEXTROSE/LACT RINGERS DEXTROSE 5%/LACTATED RINGERS C5N-PROTEIN REPLACEMENT AMINESS 5.2% AMINOSYN 5%, 5.2%, 7%, 8.5%, 10% AMINOSYN II 4.25%, 5%, 7%, 8.5%, 10% AMINOSYN-HBC 7% AMINOSYN-HF 8% AMINOSYN-PF 7%, 10% CLINIMIX 2.75%,4.25%,5% CLINIMIX-E 2.75/5, 2.75/10, 4.25/5, 4.25/10, 4.25/25, 5/15, 5/20, 5/25 CLINISOL 15% FREAMINE III 8.5%, 10% FREAMINE HBC 6.9% HEPATAMINE 8% HEPATASOL 8% PROCALAMINE 3% QUICK MIX W/LYTES 2.75%, 4.25% RENAMIN 6.5% TRAVASOL 5.5%, 8.5%, 10% TRAVASOL/DEXTROSE 5.5%, 8.5% TRAVASOL/ELECTROLYTES 5.5%, 8.5% TROPHAMINE 6%, 10% C5O-SOLNS MISCELLANEOUS DILUENT ELLIOTTS B C6B-VITAMIN B PREPARATIONS (may be covered for dual eligible) ALLANTEX CEREFOLIN 1-5-50-5MG CEREFOLIN NAC DEXFOL 5MG
Effective October 1, 2007 March 20, 2008
Page 12 of 61
0 0 0
ELIGIBLE COVERED FOR DUAL
Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
Y Y Y
2
Y
0 0
N N
0 0 0 0 0
N N N N N
0
N
2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2
N N N N N N N N N N N N N N N N N N N N
2 2
N N
2 2 2 2
Y Y Y Y
AMEND
DRUG NAME DIALYVITE 3000 DIATX DIATX ZN 5-1.5-25MG FOLAMIN 2-2.5-25MG FOLBALIN 1-2.5-25MG FOLBALIN PLUS 2-2.5-25 FOLBEE 1-2.5-25MG FOLBEE PLUS FOLBIC 2-2.5-25MG FOLEVE TABLET FOLGARD RX 0.5-2.2-25, 1-2.2-25 FOLNATE TABLET FOLNATE PLUS TABLET FOLTX 2-2.5-25 METANX 2-2.8-25MG NEPHPLEX RX NEPHROCAPS NEPHRONEX 1MG NEPHRO-VITE RX RENAL CAPS 1MG RENAPHRO 1MG RENA-VITE RENA-VITE RX C6D-VITAMIN D PREPARATIONS (may be covered for dual eligible) CALCIFEROL LIQ 8,000U/ML CALCITRIOL 0.25MCG, 0.5MCG DHT 0.125MG, 0.2MG, 0.4MG DHT INTENSOL 0.2MG/ML DRISDOL 8000 IU/ML ROCALTROL 0.25MCG, 0.5MCG ROCALTROL 1MCG/ML VITAMIN D 50,000U C6E-VITAMIN E PREPARATIONS (may be covered for dual eligible) AQUAVIT-E 50U/ML C6F-PRENATAL VITAMINS (family planning) ANEMAGEN OB CARENATE 600 CENOGEN OB CENOGEN ULTRA CHROMAGEN OB CITRACAL PRENATAL RX 27-1-50MG CITRANATAL RX 27-1-50 CO-NATAL FA DUET DUET DHA STUARTNATAL DUET DHA EC STUARTNATAL 29-1-400
Effective October 1, 2007 March 20, 2008
Page 13 of 61
2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 0 0 0
ELIGIBLE COVERED FOR DUAL
Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y
2 0 2 2 2 2 0 0
Y Y Y Y Y Y Y Y
0
Y
0 0 0 0 0 0 0 0 0 0 0
N N N N N N N N N N N
AMEND
DRUG NAME DUET STUARTNATAL EMBREX-600 GENERIC PRENATALS ICAR PRENATAL INATAL ADVANCE 90-1MG INATAL GT 90-1MG INATAL ULTRA 90-1MG MARNATAL-F PLUS 60-1MG MATERNA NATACAPS 106-1MG NATACHEW NATAFOLIC-OB NATAFORT NATALCARE PLUS NATALCARE THREE NATALVIT NATATAB NATATAB CFE NATELLE 27-1MG NATELLE PREFER NESTABS CBF NESTABS FA NESTABS RX NIFEREX PN FORTE NU-NATAL ADVANCED OBEGYN O-CAL PRENATAL POLY IRON PN 60-1MG POLY IRON PN FORTE 60-1MG PRECARE PRECARE CONCEIVE PREMESIS RX PRENAFIRST PRENATABS CBF PRENATABS FA PRENATABS OBN 29-1MG PRENATABS RX PRENATAL 19 PRENATAL AD PRENATAL FORMULA PRENATAL H PRENATAL MR 90 FE PRENATAL MTR PRENATAL PC 40 PRENATAL START PRENATAL-U
Effective October 1, 2007 March 20, 2008
Page 14 of 61
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
ELIGIBLE COVERED FOR DUAL
Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N
AMEND
DRUG NAME PRIMACARE 30-300-1MG RE DUALVIT OB STUART PRENATAL STUARTNATAL PLUS 3 TANDEM OB TRINATE ULTRA-NATAL ULTRANATAL CARE UNI-REX 600 VEROTIN-BY VEROTIN-GR VINATAL VINATAL FORTE VINATE ADVANCED VINATE AZ 27-1 VINATE AZ EXTRA VINATE M VINATE PRENATAL VINATE-90 ZENATE C6G-GERIATRIC VITAMIN PREPARATIONS (may be covered for dual eligible) GERIATRIC VITAMINS (COMPARE TO CENTRUM, GEVRABON, ZYMASYRUP) C6H-PEDIATRIC VITAMINS (may be covered for dual eligible) CHEWABLES AND LIQUID DROPS GENERICS CHEWABLES W/FLUORIDE AND LIQUID DROPS W/FLUORIDE CHEWABLES WITH IRON AND FLUORIDE GENERICS CHEWABLES WITH IRON AND LIQUID DROPS WITH IRON GENERICS INFUVITE LIQUID DROPS WITH IRON AND FLUORIDE GENERICS C6K-VITAMIN K PREPARATIONS (may be covered for dual eligible) MEPHYTON 5MG VITAMIN K 10MG/ML INJ C6L-VITAMIN B-12 PREPARATIONS (may be covered for dual eligible) CYANOCOBALAMIN INJ 1000MG/ML FOLCAPS 0.5-2.2-25MG FOLPLEX 2.2MG NUFOL 1-2.5-25MG C6M-FOLIC ACID PREPARATIONS (may be covered for dual eligible) DIALYVITE FOLIC ACID 1MG FOLIC ACID INJ 5MG/ML LEUCOVORIN CALCIUM PDR FOR INJ 50MG,100MG,200MG LEUCOVORIN CALCIUM TABS 5MG C6N-NIACIN PREPARATIONS (may be covered for dual eligible) NIACIN SR 125MG,250MG,500MG SLO-NIACIN 250,500,750MG
Effective October 1, 2007 March 20, 2008
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0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
ELIGIBLE COVERED FOR DUAL
Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N N N N N N N N N N N N N N N N N N
0
Y
0 0 0 0 0 0
Y Y Y Y Y Y
0 0
Y Y
0 2 2 2
Y Y Y Y
0 0 2 0 0
Y Y Y Y Y
0 2
Y Y
AMEND
DRUG NAME C6T-VITAMIN B1 PREPARATIONS (may be covered for dual eligible) THIAMINE HCL INJ 100MG/ML C6Z-MULTIVITAMIN PREPARATIONS (may be covered for dual eligible) GENERIC EQUIVALENTS TO: ALLBEE C BEROCCA PLUS CENTRUM ONE-A-DAY & ONE-A-DAY W/IRON STRESSTAB 600 FORMULA, WITH IRON AND WITH ZINC THERAGRAN, THERAGRAN M & THERAGRAN H UNICAP, UNICAP W/IRON, UNICAP M CERNEVIT DAILY VITAMIN FORMULA DEXTROSE W/VITAMINS INFUVITE INFUVITE ADULT INJ RENAX THERAPEUTIC M THERAPEUTIC M 27-0,4MG VITAMIN B COMPLEX INJ VITAMINS FOR INFUSION C7A-HYPERURICEMIA TX - PURINE INHIBITORS ALLOPURINOL 100MG,300MG C7B-DECARBOXYLASE INHIBITORS (SEE ALSO H6A) CARBIDOPA/LEVODOPA 10/100,25/100,25/250 C7D-METABOLIC DEFICIENCY AGENTS CYSTADANE 1GM/1.7ML C7F-APPETITE STIMULANTS FOR ANOREXIA, CACHEXIA, WASTING SYNDROME MEGACE ES 625MG/5ML C8A-METALLIC POISON ANTIDOTES CHEMET 100MG DEFEROXAMINE MESYLATE 500MG,2GM DESFERAL INJ 500MG,2GM EXJADE 125MG, 250MG, 500MG GALZIN 25MG, 50MG SYPRINE 250MG D1D-DENTAL AIDS & PREPARATIONS CHLORHEXIDINE GLUCONATE SOLN TRIAMCINOLONE DENTAL PASTE D2A-FLUORIDE PREPARATIONS SODIUM FLUORIDE 2.2MG TABS (1MG FLUORIDE) SODIUM FLUORIDE DROPS 0.125MG/ML, 0.5MG/ML
Effective October 1, 2007 March 20, 2008
Page 16 of 61
0
ELIGIBLE COVERED FOR DUAL
Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
Y
0 0 0 0 0 0 0 0 2 0 2 2 2 2 0 0 0 2
Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y
0
N
0
N
2
N
2
N
2 0 2 2 2 2
N N N N N N
0 0
N N
0 0
N N
AMEND
Page 17 of 61 ELIGIBLE COVERED FOR DUAL
Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
DRUG NAME D4B-ANTACIDS (may be covered for dual eligible if available over the counter) GENERIC EQUIVALENTS OF: GAVISCON 358-95/15ML, 237.5-254, 20-80 0 Y MAALOX 400-400-30, 400-400-40, 200-225-25, 450-500-40, 200-225 0 Y MYLANTA 400-400-30, 200-200-20, 400-400-40 0 Y RIOPAN 540MG/5ML 0 Y ALU-CAPS 475MG 2 Y ALUMINUM HYDROXIDE 600MG/5ML, 320MG/5ML 0 Y ALU-TAB 600MG 2 Y CALCIUM CARBONATE 500MG/5ML 0 Y SODIUM BICARBONATE 5GR, 10GR 0 Y D4E-ANTIULCER PREPARATIONS CARAFATE 1GM/10ML 2 N CYTOTEC 100MCG, 200MCG 0 N SUCRALFATE 1GM 0 N D4F-ANTI-ULCER-H.PYLORI AGENTS HELIDAC 2 N PREVPAC 30/500/500 2 N PYLERA 125-125 2 N D4G-GASTRIC ENZYMES LACTRASE 250MG 2 N SUCRAID 8.5MU/ML 2 N D4I-ORAL MUCOSITIS/STOMATITIS ANTI-INFLAMMATORY AGENT APHTHASOL PASTE 5% 2 N D4K-GASTRIC ACID SECRETION REDUCERS NEXIUM 20MG, 40MG CAPS 0 N PREVACID 15MG,30MG 0 N PREVACID SOLUTAB 15MG, 30MG (AGES 0-6) * N D4N-ANTIFLATULENTS (may be covered for dual eligible if available over the counter) SIMETHICONE 80MG TABS 0 Y SIMETHICONE DROPS 40MG/0.6ML 0 Y D5P-INTESTINAL ADSORBENTS AND PROTECTIVES (may be covered for dual eligible if available over the counter) ACIDOPHILUS W/PECTIN LIQ 0 Y KAOLIN-PECTIN (ATTAPULGITE) SUSP 750MG/15ML 0 Y D6C-IRRITABLE BOWEL SYNDROME AGENT,5HT-3 ANTAGONIST-TYPE LOTRONEX 0.5MG, 1MG 2 N D6D-ANTIDIARRHEALS (may be covered for dual eligible if available over the counter) BISMUTH SUSPENSION 525MG/15ML 0 Y DIPHENOXYLATE/ATROPINE SULFATE TABS, LIQUID 0 N LOPERAMIDE HCL 2MG TABS, 1MG/5ML SOLN 0 N MOTOFEN TABS 2 N PAREGORIC 0 N D6F-DRUG TX-CHRONIC INFLAM. COLON DX,5-AMINOSALICYLATE ASACOL 400MG 2 N COLAZAL 750MG 2 N
Effective October 1, 2007 March 20, 2008
AMEND
Page 18 of 61 ELIGIBLE COVERED FOR DUAL
Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
DRUG NAME DIPENTUM 250MG 2 LIALDA 1.2G 2 PENTASA 250MG, 500MG 2 D6S-LAXATIVES & CATHARTICS (may be covered for dual eligible if available over the counter) AMITIZA 24MG 2 BISACODYL 10MG SUPPS, 5MG TABS 0 COLYTE 2 DOCUSATE CALCIUM 240MG 0 DOCUSATE SODIUM DROPS, LIQUID, SYRUP 150MG/15ML, 60MG/15ML 0 DOCUSATE SODIUM CAPS 100MG, 250MG 0 DOCUSATE SODIUM/CASANTHRANOL SYRUP, CAPS 300-100/5ML, 300-100 0 FIBER LAXATIVE TABS 500MG, 625MG 0 GLYCOLAX POWDER 2 GOLYTELY SOLUTION 2 LACTULOSE SYRUP 10GM/15ML 0 MILK OF MAGNESIA 400MG/5ML, 800MG/5ML 0 MIRALAX 2 NULYTELY SOLUTION 2 OCL 2 PEG-3350 0 POLYCARBOPHYL 625MG 0 POLYETHYLENE GLYCOL GRAN 0 PSYLLIUM PREPARATIONS/VEGETABLE LAXATIVES 0 SENNA CONCENTRATES 8.6MG 0 SENNA LIQUID 8.8MG/5ML 0 SENNA W/DOCUSATE 8.6MG-50MG 0 TRILYTE 2 D7A-BILE SALTS ACTIGALL 300MG 2 URSO 250MG 2 URSODIOL 300MG 0 D7L-BILE SALT SEQUESTRANTS CHOLESTYRAMINE LIGHT BULK 0 CHOLESTYRAMINE POWDER 378GM 0 COLESTID GRANULES, 1GM TABS 2 PREVALITE POWDER 0 QUESTRAN BULK POWDER 2 QUESTRAN LIGHT BULK POWDER 2 WELCHOL 625 MG 2 D8A-PANCREATIC ENZYMES AMYLASE/LIPASE/PROTEASE 33.2-10-38, 60-16-60 0 AMYLASE/LIPASE/PROTEASE 39/12/39, 59/18/59, 65/20/65 0 AMYLASE/LIPASE/PROTEASE 48-16-48 0 AMYLASE/LIPASE/PROTEASE 66.4-20-75 0 COTAZYM S 5000U 2 CREON 16.6-5-19, 33.2-10-38, 66.4-20-75 2
Effective October 1, 2007 March 20, 2008
N N N N Y N Y Y Y Y Y N N N Y N N N N Y N Y Y Y Y N N N N N N N N N N N N N N N N N
AMEND
DRUG NAME DYGASE 30-2.4-30 KUTRASE 30-2.4-30 KU-ZYME 15-1.2-15 KU-ZYME HP LAPASE 15-1.2-15 LIPRAM-PN20 56/20/44 PANCREASE MT-4, MT-10, MT-16, MT-20 PANCREATIC ENZYMES 20-4-25, 20-4.5-25, 30-8-30, 30-10-30 PANCRECARB MS-4 (25-4-25), MS-8 (40-8-45), MS-16 (52-16-52) ULTRASE 4000U, 25-5-20 ULTRASE MT-6, MT-12, MT-18, MT-20 VIOKASE 60-16-60 VIOKASE 8000U VIOKASE POWDER ZYMASE 5000U D9A-AMMONIA INHIBITOR BUPHENYL POWDER 500MG LACTULOSE 10GM/15ML LITHOSTAT 250MG F1A-ANDROGENIC AGENTS ANDRODERM 2.5MG/24H, 5MG/24H ANDROGEL 12.5MG, 25MG, 50MG DELATESTRYL 200MG/ML DEPOTESTOSTERONE INJ 200MG/ML FLUOXYMESTERONE 10MG METHITEST 10MG NANDROLONE DECANOATE INJ 100MG TESTIM 1% (50MG) TESTOSTERONE PROPIONATE INJ 100MG/ML G1A-ESTROGENIC AGENTS ACTIVELLA 1-0.5MG ALORA 0.025MG/24HR, 0.05MG/24HR, 0.075MG/24HR, 0.1MG/24HR CENESTIN 0.3MG, 0.45MG, 0.625MG, 0.9MG, 1.25MG CLIMARA 0.025MG/24 HR, 0.075MG/24 HR CLIMARA 0.0375MG/24HR, 0.06MG/24HR CLIMARA 3.9MG, 7.8MG CLIMARA PRO 45-15/24H COMBIPATCH 0.05-0.14/24 HR, 0.05-0.25/24 HR DELESTROGEN INJ 40MG/ML DEPOESTRADIOL INJ 5MG/ML ELESTRIN 0.06% GEL ENJUVIA TABLET 0.3MG, 0.45MG, 0.625MG, 0.9MG, 1.25MG ESTRADERM PATCH 0.05MG, 0.1MG ESTRADIOL 0.5MG, 1MG, 2MG ESTRADIOL CYPIONATE INJ 5MG/ML ESTRADIOL VALERATE INJ 40MG/ML
Effective October 1, 2007 March 20, 2008
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2 2 2 2 2 0 2 0 2 2 2 2 2 2 2
ELIGIBLE COVERED FOR DUAL
Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N N N N N N N N N N N N N
2 0 2
N N N
2 2 2 2 0 2 0 2 0
N N N N N N N N N
2 2 2 0 2 0 2 2 2 2 2 2 2 0 0 0
N N N N N N N N N N N N N N N N
AMEND
DRUG NAME ESTRASORB 2.5/G-1.74 ESTRATAB 0.625MG ESTROGEL 0.75/1.25G ESTROPIPATE 0.625MG, 0.75MG, 1.25MG, 2.5MG, 3MG FEMHRT 1-0.005MG, 2.5MCG-0.5 FEMPATCH 0.025MG/24HR FEMTRACE 0.45MG, 0.9MG, 1.8MG GYNODIOL 0.5MG, 1.5MG, 2MG MENEST 0.3MG, 0.625MG, 1.25MG, 2.5MG ORTHO-PREFEST 1-1-0.09MG PREMARIN 0.3MG, 0.45MG, 0.625MG, 0.9MG, 1.25MG, 2.5MG PREMPHASE 0.625/5 PREMPRO 0.3-1.5MG, 0.625/2.5, 0.625/5 PREMPRO LOW DOSE 0.45MG-1.5MG STILPHOSTROL INJ 50MG/ML VIVELLE 0.025MG/24 HR DOT, PATCH VIVELLE, DOT, PATCH 0.0375/24HR, 0.075/24HR, 0.05/24HR, 0.1/24HR G1D-ESTROGEN & PROGESTIN WITH ANTIMINERALOCORTICOID CB ANGELIQ 0.5 MG/1 MG TABLET G2A-PROGESTATIONAL AGENTS AYGESTIN 5MG DEPOPROVERA INJ 400MG/ML MEDROXYPROGESTERONE ACETATE 2.5MG, 5MG, 10MG NORETHINDRONE ACETATE 5MG PROGESTERONE INJ 50MG/ML PROMETRIUM 100MG, 200MG G3A-OXYTOCICS (family planning) METHERGINE 0.2MG G8A-CONTRACEPTIVES, ORAL (family planning) ALESSE 0.1-0.02 APRI 0.15-0.03 ARANELLE 7/9/5 AVIANE 0.1-0.002 BALZIVA 28 TABLET BREVICON 0.5-0.035MG CAMILA 0.35MG CESIA 7 DAYSX3 CRYSELLE 0.3-0.03MG CYCLESSA 7-7-7 DEMULEN 1/0.035MG, 1/0.050MG DESOGEN 0.15/0.3 ENPRESSE 6-5-10 ERRIN 0.35MG ESTROSTEP 5-7-9-7 ETHINYL ESTRADIOL/NORETHINDRONE 10/11 ETHINYL ESTRADIOL/NORETHINDRONE 35MCG/0.5MG
Effective October 1, 2007 March 20, 2008
Page 20 of 61
2 2 2 0 2 2 2 0 2 2 2 2 2 2 2 2 2
ELIGIBLE COVERED FOR DUAL
Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N N N N N N N N N N N N N N N
2
N
2 2 0 0 0 2
N N N N N N
0
N
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
N N N N N N N N N N N N N N N N N
AMEND
DRUG NAME ETHINYL ESTRADIOL/NORETHINDRONE 35MCG/1MG ETHYNODIOL DIACET/ETH ESTRA 1/0.035, 1/0.05 JENEST-28 JOLESSA 0.15 MG/0.03 MG TAB JOLIVETTE 0.35MG JUNEL 1-0.02MG, 1.5-0.03MG JUNEL FE 1.5-0.03MG, 1-0.02MG KARIVA 21-5 LEENA 7-9-5 LESSINA 0.1-0.02 LEVLEN 0.15/0.03 LEVLITE 0.1-0.02 LEVONORGESTROL/ETH ESTRADIOL 6-5-10 LEVORA 0.15/0.03 LO/OVRAL 0.3/0.03 LOESTRIN 1.5/0.03, 1/0.02 LOESTRIN 24 FE LOESTRIN FE 1.5/30, 1/20 LUTERA 0.1-0.02 MESTRANOL/NORETHINDRONE 50MCG/1MG MICROGESTIN 1.0-02MG, 1.5-0.03MG MICROGESTIN FE 1.5-0.035, 1.0-0.02 MICRONOR 0.35MG MIRCETTE 21-2-5 NECON 10/11 NECON 7 DAYS X 3 NORA-BE 0.35MG NORDETTE 0.15/0.03 NORGESTIMATE/ETHINYL ESTRADIOL 0.25/0.035 NORGESTREL/ETHINYL ESTRADIOL 0.3/0.03 NORTREL 7 DAYS X 3 NOTREL 0.5-0.035,1.0-0.035 OGESTREL 0.5-0.05MG ORTHO NOVUM 1/35, 1/50, 10/11, 7/7/7 ORTHO-CEPT 0.15/30 ORTHO-TRICYCLEN ORTHO-TRICYCLEN LO 7-7-7-LOW 1 OVCON 1/0.05, 0.4/0.035 OVRAL 0.5/0.05 OVRETTE PLAN B PORTIA 0.15-0.03 QUASENSE 0.15/0.03 MG RECLIPSEN SEASONALE SEASONIQUE
Effective October 1, 2007 March 20, 2008
Page 21 of 61
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
ELIGIBLE COVERED FOR DUAL
Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N
AMEND
DRUG NAME SOLIA 0.15-0.03 SPRINTEC 0.25-0.035MG SPRONYX TILIA FE 5-7-9-7 TRI-LEVLEN 6-5-10 TRINESSA 7DAYS X 3 TRI-NORINYL 7-9-5 TRIPHASIL 6-5-10 TRI-LEGEST FE 5-7-9-7 TRI-PREVIFEM 7 DAYS X 3 TRI-SPRINTEC 7 DAYS X 3 VELIVET 7 DAYS X 3 YASMIN 28 YAZ ZENCHENT 0.4-0.035 ZOVIA 1/0.05MG, 1/0.035MG G8F-CONTRACEPTIVE, TRANSDERMAL (family planning) ORTHO-EVRA 20-150/24HR G9A-CONTRACEPTIVES, INTRAVAGINAL (family planning) BECAUSE CONCEPTROL GEL, INSERTS DELFEN FOAM EMKO FOAM GYNOL II SEMICID G9B- CONTRACEPTIVES, INTRAVAGINAL, SYSTEMIC (family planning) NUVA RING 0.12-0.015 H0B-LOCAL ANESTHETICS LIDOCAINE GEL 2% LIDOCAINE INJ 1% LIDOCAINE VISCOUS 2% H0E-AGENTS TO TREAT MULTIPLE SCLEROSIS AVONEX 30MCG BETASERON 0.3MG COPAXONE 20MG REBIF 22MCG/0.5ML,44MCG/0.5ML, TITRATION PACK (8.8MCG AND 22MCG) H1A-ALZHEIMER'S THERAPY, NMDA RECEPTOR ANTAGONISTS NAMENDA 5MG, 10MG, 5-10MG, 10MG/5ML H2A-CNS STIMULANTS CYLERT 18.75MG, 75MG CYLERT 37.5MG CYLERT CHEWABLE 37.5MG PEMOLINE 37.5MG, 75MG H2D-BARBITURATES (may be covered for dual eligible) BUTISOL SODIUM ELIXIR 30MG/5ML BUTISOL SODIUM TABS 15MG, 30MG, 50MG, 100MG
Effective October 1, 2007 March 20, 2008
Page 22 of 61
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
ELIGIBLE COVERED FOR DUAL
Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N N N N N N N N N N N N N N
0
N
0 0 0 0 0 0
N N N N N N
0
N
0 0 0
N N N
2 2 2 2
N N N N
2
N
0 0 0 0
N N N N
2 2
Y Y
AMEND
DRUG NAME LUMINAL INJ 60MG/ML PHENOBARBITAL 1/4GR, 1/2GR, 1GR, 1-1/2GR PHENOBARBITAL ELIXIR 20MG/5ML PHENOBARBITAL INJ 30MG/ML, 60MG/ML, 65MG/ML, 130MG/ML SECONAL SODIUM 100MG H2E-NON-BARB SEDATIVE-HYPNOTIC (benzodiazepines may be covered for dual eligible) AQUACHLORAL SUPPS 324MG, 648MG ATIVAN INJ 2MG/ML, 4MG/ML CHLORAL HYDRATE SUPPS 500MG CHLORAL HYDRATE SYRUP 500MG/5ML ESTAZOLAM 1MG, 2MG FLURAZEPAM 15MG, 30MG LORAZEPAM INJ 2MG/ML, 4MG/ML LUNESTA 1MG, 2MG, 3MG MIDAZOLAM HCL SYRUP 2MG/ML TEMAZEPAM 15MG,30MG ZOLPIDEM 5MG, 10MG TRIAZOLAM 0.125MG,0.25MG H2F-ANTI-ANXIETY DRUGS (benzodiazepines may be covered for dual eligible) ALPRAZOLAM 0.25MG, 0.5MG, 1MG, 2MG BUSPIRONE 5MG, 7.5MG, 10MG, 15MG, 30MG CHLORDIAZEPOXIDE HCL 5MG, 10MG, 25MG CLORAZEPATE 3.75MG, 7.5MG, 15MG DIAZEPAM 2MG, 5MG, 10MG DIAZEPAM INJ 5MG/ML DIAZEPAM ORAL SOLN 5MG/ML, 5MG/5ML LORAZEPAM 0.5MG, 1MG, 2MG LORAZEPAM INTENSOL SOLN 2MG/ML MEPROBAMATE 200MG, 400MG OXAZEPAM 10MG, 15MG, 30MG H2G-ANTI-PSYCHOTICS PHENOTHIAZINES (SEE ALSO H6J) CHLORPROMAZINE 10MG, 25MG, 50MG, 100MG, 200MG CHLORPROMAZINE CONC SOLN 30MG/ML, 100MG/ML CHLORPROMAZINE INJ 25MG/ML FLUPHENAZINE DECANOATE INJ 25MG/ML FLUPHENAZINE HCL 1MG, 2.5MG, 5MG, 10MG FLUPHENAZINE INJ 2.5MG/ML FLUPHENAZINE SOLN 2.5MG/5ML, 5MG/ML PERPHENAZINE 2MG, 4MG, 8MG, 16MG THIORIDAZINE 10MG, 15MG, 25MG, 50MG, 100MG, 150MG, 200MG THIORIDAZINE 30MG/ML, 100MG/ML SOLN TRIFLUOPERAZINE HCL 1MG, 2MG, 5MG, 10MG H2H-MONOAMINEOXIDASE INHIBITORS (SEE ALSO H6A) EMSAM 6MG/24H, 9MG/24H, 12MG/24H SELEGILINE HCL 5MG
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CO-PAYMENT
DRUG CLASS
5101:3-9-12
Y Y Y Y Y
2 2 0 0 0 0 0 2 0 0 0 0
N Y N N Y Y Y N Y Y N Y
0 0 0 0 0 0 0 0 0 0 0
Y N Y Y Y Y Y Y Y N Y
0 0 0 0 0 0 0 0 0 0 0
N N N N N N N N N N N
2 0
N N
AMEND
DRUG NAME H2J-ANTIDEPRESSANTS AMITRIPTYLINE HCL 10MG, 25MG, 50MG, 75MG, 100MG, 150MG AMOXAPINE 25MG, 50MG, 100MG, 150MG DESIPRAMINE 10MG, 25MG, 50MG, 75MG, 100MG, 150MG DESYREL DIVIDOSE 300MG DOXEPIN HCL 10MG, 25MG, 50MG, 75MG, 100MG, 150MG DOXEPIN HCL ORAL CONC 10MG/ML IMIPRAMINE HCL 10MG, 25MG, 50MG MAPROTILINE 25MG, 50MG, 75MG NORTRIPTYLINE 10MG, 25MG, 50MG, 75MG, 10MG/5ML ORAL PAMELOR SOLN 10MG/5ML TRAZODONE HCL 50MG, 100MG, 150MG H2K-ANTIDEPRESSANT COMBINATIONS AMITRIPTYLINE/CHLORDIAZEPOXIDE 12.5/5, 25/10 AMITRIPTYLINE/PERPHENAZINE 10/2, 10/4, 25/2, 25/4, 50/4 H2L-ANTIPSYCHOTIC, NON-PHENOTHIAZINE LOXAPINE SUCCINATE 5MG, 10MG, 25MG, 50MG THIOTHIXENE 1MG, 2MG, 5MG, 10MG, 5MG/ML ORAL CONC H2M-ANTI-MANIA DRUGS ESKALITH CR 450MG LITHIUM CARBONATE 150MG, 300MG, 600MG LITHIUM CARBONATE SR 300MG, 450MG LITHIUM CITRATE SYRUP 8MEQ/5ML LITHOBID 300MG H2R-ANTIPRURITICS (SYSTEMIC) CYPROHEPTADINE 4MG CYPROHEPTADINE SYRUP 2MG/5ML H2S-SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) CITALOPRAM 10MG/5ML CITALOPRAM HBR 10MG, 20MG, 40MG FLUOXETINE 10MG TABS FLUOXETINE 10MG, 20MG CAPS, 20MG/5ML FLUVOXAMINE MALEATE 25MG, 50MG, 100MG LEXAPRO 5MG, 20MG, 5MG/5ML PAROXETINE HCL 10MG, 20MG, 30MG, 40MG PAXIL CR 12.5MG, 25MG, 37.5MG PAXIL LIQUID 10MG/5ML PEXEVA 10MG, 20MG, 30MG, 40MG PROZAC WEEKLY 90MG SERTRALINE 25MG, 50MG, 100MG, 20MG/ML H2U-TRICYCLIC ANTIDEPRESSANTS & REL. NON-SEL. RU-INHIB CLOMIPRAMINE 25MG, 50MG, 75MG PROTRIPTYLINE 5MG SURMONTIL 25MG, 50MG, 100MG TOFRANIL PM 75MG, 100MG, 125MG, 150MG VIVACTIL 5MG, 10MG
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CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N N N N N N N N N
0 0
N N
0 0
N N
2 0 0 0 2
N N N N N
0 0
N N
0 0 0 0 0 2 0 2 2 2 2 0
N N N N N N N N N N N N
0 0 2 2 2
N N N N N
AMEND
DRUG NAME H2V-TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY CONCERTA 18MG, 27MG, 36MG, 54MG (AGE 6 AND OVER) FOCALIN 2.5MG, 5MG, 10MG (AGE 6 AND OVER) FOCALIN XR 5MG, 10MG, 15MG, 20MG (AGE 6 AND OVER) METADATE CD 10MG, 20MG, 30MG, 40MG, 50MG, 60MG (AGE 5 AND OVER) METADATE ER 10MG (AGE 5 AND OVER) METHYLIN 5MG/5ML, 10MG/5ML (AGE 5 AND OVER) METHYLIN ER 10MG (AGE 5 AND OVER) METHYLPHENIDATE HCL 5MG, 10MG, 20MG (AGE 5 AND OVER) METHYLPHENIDATE SR 20MG (AGE 5 AND OVER) H3A-NARCOTIC ANALGESICS ACETAMINOPHEN/CODEINE 15-300, 30-300, 60-300 ACETAMINOPHEN/CODEINE ELIXIR 120-12MG/5ML ASPIRIN/CODEINE 30-325, 60-325 ASTROMORPH 4MG/ML B&O SUPRETTES 15-A,16-A BELLADONNA/OPIUM SUPPS 30-16.2MG CODEINE PHOSPHATE 1/2GR, 1GR CODEINE PHOSPHATE INJ 15MG/ML, 30MG/ML CODEINE SULFATE 1/4GR, 1/2GR, 1GR DEMEROL INJ 25MG/ML, 50MG/ML, 75MG/ML, 75MG/1.5ML, 100MG/ML DILAUDID 3MG SUPPS DILAUDID INJ 1MG/ML, 2MG/ML, 4MG/ML, 10MG/ML DILAUDID-5 1MG/ML ORAL DURAGESIC PATCH 12MCG DURAGESIC PATCH 25MCG, 50MCG, 75MCG, 100MCG HYDROCODONE/ACETA 10MG/325MG HYDROCODONE/ACETA 2.5-167/5ML HYDROCODONE/ACETA 5MG/500MG, 7.5MG/500MG, 7.5MG/750MG, 10MG/500MG HYDROMORPHONE HCL 2MG, 4MG, 8MG HYDROMORPHONE HCL ORAL LIQ 1MG/ML HYDROMORPHONE INJ 2MG/ML, 4MG/ML, 10MG/ML HYDROMORPHONE SUPPS 3MG KADIAN 20MG, 30MG, 50MG, 60MG, 80MG, 100MG, 200MG LEVO-DROMERAN INJ 2MG/ML MEPERIDINE 50MG, 100MG MEPERIDINE HCL INJ 10MG/ML, 25MG/ML, 50MG/ML, 75MG/ML, 100MG/ML MEPERIDINE SYRUP 50MG/5ML METHADONE 10MG/5ML METHADONE 5MG, 10MG, 40MG METHADONE SOLN 5MG/5ML, 10MG/ML CONC SOLN METHADOSE 10MG/ML MORPHINE SULFATE SOLN, ELIXIR 20MG/ML MORPHINE SULFATE 10MG, 15MG, 30MG MORPHINE SULFATE ER 15MG, 30MG, 60MG, 100MG, 200MG MORPHINE SULFATE INJ 8MG/ML, 10MG/ML, 15MG/ML, 25MG/ML, 50MG/ML
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Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N
AMEND
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DRUG NAME MORPHINE SULFATE INJ 0.5MG/ML, 1MG/ML, 2MG/ML, 4MG/ML, 5MG/ML 0 N MORPHINE SULFATE SOLN 10MG/5ML, 20MG/5ML 0 N MORPHINE SULFATE SUPPS 5MG, 10MG, 20MG, 30MG 0 N OXYCODONE ER 10MG, 20MG, 40MG, 80MG 0 N OXYCODONE HCL 5MG, 15MG, 30MG 0 N OXYCODONE HCL 5MG/5ML, 20MG/ML 0 N OXYCODONE HCL/ACETA 5-325, 5-500, 7.5-325, 7.5-500, 10-325, 10-650 0 N OXYCODONE HCL/OXY T/ASA 4.5/0.38/325 0 N ROXICET ORAL SOLN 5MG/325MG 2 N ROXICODONE 5MG/5ML 2 N SUBOXONE 2MG-0.5MG, 8MG-2MG 2 N SUBUTEX 2MG, 8MG 2 N H3B-ANALGESICS BUTORPHANOL INJ 2MG/ML 0 N BUTORPHANOL NS 10MG/ML 0 N STADOL INJ 2MG/ML 2 N TRAMADOL 50MG 0 N H3C-ANALGESICS, NON-NARCOTICS PROPOXYPENE NAPSYLATE/ACETA 100/650 0 N PROPOXYPHENE CPD 65 0 N PROPOXYPHENE HCL 65MG 0 N PROPOXYPHENE/ACETA 65/650 0 N H3D-ANALGESIC/ANTIPYRETICS, SALICYLATES (may be covered for dual eligible if available over the counter) ANABAR 200-300-20 2 N ASPIRIN 800MG 0 N ASPIRIN 975MG 0 N ASPIRIN EC 81MG, 325MG, 650MG 0 Y BE-FLEX PLUS 200-300-20 2 N CETAZONE-T 2 N CHOLINE MAGNESIUM TRISALICYLATE 500MG, 750MG, 1000MG 0 N CHOLINE MAGNESIUM TRISALICYLATE LIQUID 500MG/5ML 0 N ED-FLEX 200-300-20 2 N SALSALATE 500MG, 750MG 0 N ZORPRIN 800MG 2 N H3E-ANALGESIC, ANTIPYRETIC-NON-SAL (may be covered for dual eligible if available over the counter or contains barbiturate) ACETAMINOPHEN SUPPOSITORIES 120MG, 325MG, 650MG 0 Y ACETAMINOPHEN/BUTALBITAL 325MG/50MG, 650MG/50MG 0 Y BUTALBITAL/ACETAMINOPHEN/CAFFEINE 325/40/50 CAP, TAB 0 Y BUTALBITAL/ACETAMINOPHEN/CAFFEINE 500-40-50 TAB 0 Y DOLGIC LIQUID 325-40-50/5ML 2 Y DOLOGESIC 500-30MG 2 N PHRENILIN 2 Y PHRENILIN FORTE 2 Y
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AMEND
Page 27 of 61
DRUG NAME H3F-ANTIMIGRAINE PREPARATIONS AMERGE 1MG, 2.5MG 2 AXERT 6.25MG, 12.5MG 2 CAFERGOT 1-100MG 2 CAFERGOT SUPPOSITORIES 2 CAFFEINE-ERGOTAMINE SUPPOSITORIES 0 ERGOTAMINE/CAFFEINE TABS 1-100MG 0 FROVA 2.5MG 2 IMITREX INJ 4MG/0.5ML, 6MG/0.5ML 2 IMITREX NASAL 5MG, 20MG 2 IMITREX TAB 25MG, 50MG, 100MG 2 MAXALT 5MG, 10MG 2 MAXALT MLT 5MG, 10MG 2 MIGRANAL NASAL 4MG/ML, 0.5MG/SPRAY 2 RELPAX 20MG, 40MG 2 H3T-NARCOTIC ANTAGONISTS NALTREXONE HCL 50MG 0 H4B-ANTICONVULSANTS (benzodiazepines and barbiturates may be covered for dual eligible) CARBAMAZEPINE 100MG, 200MG, 100MG/5ML 0 CARBATROL 100MG, 200MG, 300MG 2 CELONTIN 150MG, 300MG 2 CLONAZEPAM 0.5MG, 1MG, 2MG 0 DEPAKENE 250MG (BMN ONLY) 2 DEPAKENE SYRUP 250MG/5ML (BMN ONLY) 2 DEPAKOTE 125MG, 250MG, 500MG 2 DEPAKOTE ER 250MG, 500MG 2 DEPAKOTE SPRINKLE 125MG 2 DIASTAT 2.5MG, 5MG, 10MG, 20MG 2 DIASTAT ACUDIAL 10, 20 2 DILANTIN 30MG, 50MG CHEWABLE, 100MG 2 DILANTIN SUSP 125MG/5ML 2 ETHOSUXIMIDE SYRUP 250MG/5ML 0 EQUETRO 100MG, 200MG, 300MG 2 FELBATOL 400MG, 600MG 2 FELBATOL SUSP 600MG/5ML 2 GABAPENTIN 100MG, 300MG, 400MG, 600MG, 800MG 0 LAMICTAL 5MG 0 LAMICTAL 25MG, 100MG, 150MG, 200MG, 25-100 2 MEBARAL 32MG, 50MG, 100MG 2 MEPHOBARBITAL 32MG, 50MG, 100MG 0 MYSOLINE 250MG (BMN ONLY) 2 MYSOLINE 50MG 2 MYSOLINE SUSP 250MG/5ML 2 NEURONTIN 250MG/5ML 2 PEGANONE 250MG 2 PHENYTEK 200MG, 300MG 2
Effective October 1, 2007 March 20, 2008
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Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N N N N N N N N N N N N N N N N Y N N N N N Y Y N N N N N N N N N Y Y N N N N N N
AMEND
DRUG NAME PHENYTOIN SODIUM 100MG, ER100MG PHENYTOIN SODIUM INJ 50MG/ML PHENYTOIN SUSP 125MG/5ML PRIMIDONE 250MG PRIMIDONE 50MG TEGRETOL 100MG, 200MG (BMN ONLY) TEGRETOL SUSP 100MG/5ML TEGRETOL XR 100MG, 200MG, 400MG TOPAMAX 15MG, 25MG, 50MG, 100MG, 200MG TRILEPTAL 150MG, 300MG, 600MG, 300MG/5ML VALPROIC ACID 250MG VALPROIC ACID SYRUP 250MG/5ML ZARONTIN 250MG ZARONTIN SYRUP 250MG/5ML H4C-ANTICONVULSANTS GABITRIL 2MG, 4MG, 12MG, 16MG KEPPRA 100MG/ML KEPPRA 250MG, 500MG, 750MG, 1000MG LYRICA 25MG, 50MG, 75MG, 100MG, 150MG, 200MG, 225MG, 300MG ZONISAMIDE 25MG, 50MG, 100MG H6A-ANTIPARKINSON DRUGS, OTHER (SEE ALSO C7B, H2H) AMANTADINE HCL 100MG AMANTADINE SYRUP 50MG/5ML APOKYN 10MG/ML AZILECT 0.5MG, 1MG BROMOCRIPTINE 2.5MG, 5MG CARBIDOPA/LEVODOPA 10/100, 25/100, 25/250 CARBIDOPA/LEVODOPA CR 25/100, 50/200 COMTAN 200MG LARODOPA 100MG, 250MG, 500MG MIRAPEX 0.125MG, 0.25MG, 0.5MG, 0.75MG, 1MG, 1.5MG NEUPRO PATCH 2MG/24HR, 4MG/24HR, 6MG/24HR PARLODEL 2.5MG, 5MG PERGOLIDE 0.05MG, 0.25MG, 1MG PERMAX 0.05MG, 0.25MG, 1MG REQUIP 0.25MG, 0.5MG, 1MG, 2MG, 3MG, 4MG, 5MG SELEGILINE HCL 5MG STALEVO 12.5/50/200, 25/100/200, 37.5/150/200, 50/200/200 TASMAR 100MG, 200MG ZELAPAR 1.25MG H6B-ANTIPARKINSONISM DRUGS,ANTICHOLINERGIC AKINETON 2MG BENZTROPINE 0.5MG, 1MG, 2MG COGENTIN INJ 1MG/ML KEMADRIN 5MG TRIHEXIPHENIDYL HCL 2MG, 5MG, 2MG/5ML
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CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N N N N N N N N N N N N
2 2 2 2 0
N N N N N
0 0 2 2 0 0 0 2 2 2 2 2 0 2 2 0 2 2 2
N N N N N N N N N N N N N N N N N N N
2 0 2 2 0
N N N N N
AMEND
DRUG NAME H6C-ANTITUSSIVE NON-NARC (may be covered for dual eligible) BENZONATATE 100MG DELSYM 30MG/5ML DEXTROMETHORPHAN HBR 15MG/5ML ELIXSURE COUGH 7.5MG/5ML (DM) ROBITUSSIN PEDIATRIC 7.5MG/5ML H6H-SKELETAL MUSCLE RELAXANTS BACLOFEN 10MG, 20MG CHLORZOXAZONE 250MG, 500MG CYCLOBENZAPRINE 5MG, 10MG METHOCARBAMOL 500MG, 750MG METHOCARBAMOL WITH ASPIRIN 400/325 NORFLEX 30MG/ML INJ ORPHENADRINE CITRATE 100MG ORPHENADRINE CITRATE INJ 30MG/ML ORPHENADRINE CPD 385/30/25 ORPHENADRINE CPD 770/60/50 ROBAXIN INJ 100MG/ML TIZANIDINE HCL 2MG, 4MG H6J-ANTIEMETIC/ANTIVERTIGO AGENTS (SEE ALSO H2G) ANTI-NAUSEA LIQUID CESAMET 1MG COLA SYRUP COMPAZINE INJ 5MG/ML DIMENHYDRINATE 50MG DIMENHYDRINATE 50MG/ML EMEND 40MG, 80MG, 125MG, 125-80 MARINOL 2.5MG, 5MG, 10MG MECLIZINE 12.5MG, 25MG CHEWABLE, 25MG NAUSETROL SOLN ONDANSETRON 4MG, 8MG, 24MG ONDANSETRON ODT 4MG, 8MG ONDANSETRON ORAL SOLUTION 4MG/5ML PROCHLORPERAZINE EDISYLATE INJ 5MG/ML PROCHLORPERAZINE MALEATE 5MG, 10MG PROCHLORPERAZINE MALEATE SUPP 25MG PROMETHAZINE SUPPS, 12.5MG, 25MG, 50MG SCOPACE 0.4MG TIGAN INJ 100MG/ML TORECAN 10MG, 5MG/ML INJ TRANSDERM SCOP PATCH 1.5MG/72HRS TRIMETHOBENZAMIDE HCL 300MG TRIMETHOBENZAMIDE INJ 100MG/ML
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CO-PAYMENT
DRUG CLASS
5101:3-9-12
Y Y Y Y Y
0 0 0 0 0 2 0 0 0 0 2 0
N N N N N N N N N N N N
0 2 0 2 0 0 2 2 0 0 0 0 0 0 0 0 0 2 2 2 2 0 0
N N N N N N N N N N N N N N N N N N N N N N N
AMEND
DRUG NAME H7B-ALPHA-2 RECEPTOR ANTAGONIST ANTIDEPRESSANTS MIRTAZAPINE 7.5MG, 15MG, 30MG, 45MG, SOL-TABS MIRTAZAPINE RAPID DISSOLVE TABLET 15MG, 30MG, 45MG REMERON SOL-TABS 15MG, 30MG, 45MG H7C-SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS) CYMBALTA 20MG, 30MG, 60MG EFFEXOR 25MG, 37.5MG, 50MG, 75MG, 100MG EFFEXOR XR 37.5MG, 75MG, 150MG VENLAFAXINE HCL 25MG, 37.5MG, 50MG, 75MG, 100MG TABS H7D-NOREPINEPHRINE AND DOPAMINE REUPTAKE INHIB (NDRIS) BUPROPION HCL 75MG, 100MG BUPROPION SR 100MG, 150MG, 200MG WELLBUTRIN SR 100MG, 150MG, 200MG WELLBUTRIN XL 150MG, 300MG H7E-SEROTONIN-2 ANTAGONIST/REUPTAKE INHIBITORS (SARIS) NEFAZODONE HCL 50MG, 100MG, 150MG, 200MG, 250MG H7J-MAOIS - NON-SELECTIVE & IRREVERSIBLE NARDIL 15MG PARNATE 10MG H7O-ANTIPSYCHOTICS,DOPAMINE ANTAGONISTS,BUTYROPHENONES HALDOL INJ 5MG/ML HALOPERIDOL 0.5MG, 1MG, 2MG, 5MG, 20MG HALOPERIDOL DECANOATE 50MG/ML, 100MG/ML HALOPERIDOL LACTATE CONC LIQUID 2MG/ML H7R-ANTIPSYCH, DOPAMINE ANTAGONIST, DIPHENYLBUTYLPIPERIDINES ORAP 1MG, 2MG H7S-ANTIPSYCHOTICS, DOPAMINE ANTAGONIST, DIHYDROINDOLONES MOBAN 5MG, 10MG, 25MG, 50MG H7T-ANTIPSYCHOTICS, ATYPICAL,DOPAMINE,& SEROTONIN ANTAG CLOZAPINE 12.5MG, 25MG, 50MG, 100MG, 200MG CLOZARIL 25MG, 100MG (BMN ONLY) FAZACLO TABLET 12.5MG, 25MG, 100MG GEODON 20MG, 40MG, 60MG, 80MG RISPERDAL 0.25MG, 0.5MG, 1MG, 2MG, 3MG, 4MG RISPERDAL M 0.5MG, 1MG, 2MG, 3MG, 4MG RISPERDAL SOLN 1MG/ML SEROQUEL 25MG, 50MG, 100MG, 200MG, 300MG, 400MG SEROQUEL XR 200MG, 300MG, 400MG ZYPREXA 2.5MG, 5MG, 7.5MG, 10MG, 15MG, 20MG ZYPREXA ZYDIS 5MG, 10MG, 15MG, 20MG H7X-ANTIPSYCHOTICS, ATYP, D2 PARTIAL AGONIST/5HT MIXED ABILIFY 2MG, 5MG, 10MG, 15MG, 20MG, 30MG ABILIFY 5MG/5ML ABILIFY DISCMELT 10MG, 15MG ABILIFY INJ 9.75MG/1.3ML
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Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N
2 2 2 0
N N N N
0 0 2 2
N N N N
0
N
2 2
N N
0 0 0 0
N N N N
2
N
2
N
0 2 2 2 2 2 2 2 2 2 2
N N N N N N N N N N N
2 2 2 2
N N N N
AMEND
DRUG NAME H7Y-TX FOR ATTENTION DEFICIT-HYPERACT.(ADHD), NRI-TYPE STRATTERA 10MG, 18MG, 25MG, 40MG, 60MG, 80MG, 100MG (AGE 6 AND OLDER) H7Z-SSRI &ANTIPSYCH, ATYP, DOPAMINE & SEROTONIN ANTAG COMB SYMBYAX 3MG-25MG, 6MG-25MG, 6MG-50MG, 12MG-25MG, 12MG-50MG H8B-HYPNOTICS, MELATONIN MT1/MT2 RECEPTOR AGONISTS ROZEREM 8MG J1A-PARASYMPATHETIC AGENTS BETHANECHOL CHLORIDE 5MG, 10MG, 25MG, 50MG EVOXAC 30MG GUANIDINE HCL 125MG PILOCARPINE HCL 5MG SALAGEN 5MG J1B-CHOLINESTERASE INHIBITORS ARICEPT 5MG,10MG ARICEPT ODT 5MG, 10MG COGNEX 10MG, 20MG, 30MG, 40MG EXELON 1.5MG, 3MG, 4.5MG, 6MG, 2MG/ML EXELON PATCH 4.6MG/24HR, 9.5MG/24HR MESTINON 180MG MESTINON 60MG/5ML LIQUID MYTELASE 10MG PROSTIGMIN 15MG PYRIDOSTIGMINE BROMIDE 60MG RAZADYNE 4MG, 8MG, 12MG, 4MG/ML RAZADYNE ER 8MG, 16MG, 24MG J2A-BELLADONNA ALKALOIDS ATROPINE INJ 1MG/ML COLYTROL 0.031MG/ML COLYTROL LIQ, PED DROPS, TABS CYSTOSPAZ 0.15MG HYOSCYAMINE 0.125MG, 0.15MG HYOSCYAMINE 0.125MG/ML, 0.125MG/5ML HYOSCYAMINE 0.375MG HYOSCYAMINE SULFATE 0.25MG PAMINE 2.5MG PAMINE FORTE 5MG SAL-TROPINE 0.4MG SYMAX 0.125MG J2B-ANTICHOLINERGIC, QUATERNARY AMMONIUM CANTIL 25MG GLYCOPYRROLATE 1MG, 2MG PROPANTHELINE 15MG ROBINUL 1MG ROBINUL FORTE 2MG ROBINUL INJ 0.2MG/ML
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CO-PAYMENT
DRUG CLASS
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N
2
N
2
N
0 2 2 0 2
N N N N N
2 2 2 2 2 2 2 2 2 0 2 2
N N N N N N N N N N N N
0 2 2 2 0 0 0 0 2 2 2 2
N N N N N N N N N N N N
2 0 0 2 2 2
N N N N N N
AMEND
DRUG NAME J2D-ANTICHOLINERGIC ANTISPASMODICS BENTYL 10MG/5ML DICYCLOMINE HCL 10MG, 20MG DICYCLOMINE HCL INJ 10MG/ML OXYBUTYNIN CHLORIDE 5MG OXYBUTYNIN CHLORIDE 5MG/5ML J3A-SMOKING DETERRENT AGENTS (GANGLIONIC STIM, OTHERS) COMMIT 2MG, 4MG NICODERM CQ PATCH 7MG/24HR, 14MG/24HR, 21MG/24HR NICORETTE GUM 2MG, 4MG NICOTINE GUM 2MG, 4MG NICOTROL INHALER NICOTROL NASAL SPRAY ZYBAN 150MG J3C-SMOKING DETERRENT-NICOTINIC RECEPT.PARTIAL AGONIST CHANTIX 0.5MG, 1MG, MONTH PAK J5A-ADRENERGIC AGENTS, CATECHOLAMINES ADRENALIN CHLORIDE 1MG/ML EPINEPHRINE 0.1MG/ML EPINEPHRINE 1MG/ML ISOETHARINE HCL 1% J5B-ADRENERGICS, AROMATIC, NON-CATECHOLAMINE ADDERALL 5MG, 10MG, 20MG, 30MG ADDERALL 7.5MG, 12.5MG, 15MG ADDERALL XR 5MG, 10MG, 15MG, 20MG, 25MG, 30MG AMPHETAMINE SALT COMBO 5MG, 10MG, 20MG, 30MG VYVANSE 30MG, 50MG, 70MG J5D-BETA ADRENERGIC AGENTS ALBUTEROL 2MG, 4MG ACCUNEB (AGE 0 TO 12 ONLY) 0.21MG/ML, 0.42MG/ML ALBUTEROL 0.83MG/ML SOLN FOR INH ALBUTEROL 2MG/5ML SYRUP ALBUTEROL 5MG/ML SOLN FOR INH ALBUTEROL 90MCG INH, REF BRETHINE 1MG/ML INJ BRETHINE 2.5MG, 5MG COMBIVENT 103-18MCG MAXAIR AUTOHALER METAPROTERENOL 10MG, 20MG METAPROTERENOL 10MG/5ML SYRUP METAPROTERENOL SOLN FOR INH 0.4%, 0.6% PROAIR HFA (FORMERLY ALBUTEROL SULFATE HFA) TERBUTALINE SO4 2.5MG, 5MG VENTOLIN HFA
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CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N N N
2 0 2 0 2 2 2
N N N N N N N
2
N
2 0 0 0
N N N N
2 0 2 0 2
N N N N N
0 * 0 0 0 0 2 2 2 2 0 0 0 0 0 2
N N N N N N N N N N N N N N N N
AMEND
DRUG NAME VOSPIRE ER 4MG, 8MG XOPENEX 0.63MG/3ML, 1.25MG/3ML, 0.31MG/3ML XOPENEX HFA J5E-SYMPATHOMIMETIC AGENTS CHILDRENS NASAL DECONGESTANT 15MG/5ML (PSEUDO) EPHEDRINE SULFATE 25MG PHENYLEPHRINE HCL 10MG PSEUDOEPHEDRINE HCL 30MG, 60MG PSEUDOEPHEDRINE HCL 30MG/5ML J5F-ANAPHYLAXIS THERAPY AGENTS EPIPEN, EPIPEN JR 0.15MG J5H-ADRENERGIC VASOPRESSOR AGENTS MIDODRINE HCL 2.5MG, 5MG, 10MG PROAMATINE 2.5MG, 5MG, 10MG J7A-ALPHA/BETA-ADRENERGIC BLOCKING AGENTS CARVEDILOL TABLETS 3.125MG, 6.25MG, 12.5MG, 25MG COREG 3.125MG, 6.25MG, 12.5MG, 25MG COREG CR 10MG, 20MG, 40MG, 80MG LABETALOL 100MG, 200MG, 300MG J7C-BETA ADRENERGIC BLOCKERS ACEBUTOLOL 200MG, 400MG ATENOLOL 25MG, 50MG, 100MG BETAXOLOL HCL 10MG, 20MG BISOPROLOL FUM 5MG, 10MG INDERAL LA 60MG, 80MG, 120MG, 160MG METOPROLOL TARTRATE 25MG, 50MG, 100MG NADOLOL 20MG, 40MG, 80MG, 120MG, 160MG PINDOLOL 5MG, 10MG PROPRANOLOL 20MG/5ML, 40MG/5ML SOLN PROPRANOLOL HCL 10MG, 20MG, 40MG, 60MG, 80MG, 90MG PROPRANOLOL LA 60MG, 80MG, 120MG, 160MG SOTALOL 80MG, 120MG, 160MG, 240MG TIMOLOL MALEATE 5MG, 10MG, 20MG TOPROL XL 50MG, 100MG, 200MG TOPROL XL 25MG J9A-INTESTINAL MOTILITY STIMULANTS METOCLOPRAMIDE HCL 10MG METOCLOPRAMIDE HCL 5MG/5ML ORAL SOLN METOCLOPRAMIDE HCL 5MG/ML INJ L0B-TOPICAL/MUCOUS MEMBRANE/SUBCUTANEOUS ENZYME ACCUZYME 0.83MMU SPRAY ACCUZYME 0.83MMU/GM, OINT ACCUZYME SE SPRAY EMULSION ETHEZYME 0.83MMU/G, 1.1MMU/G GLADASE 0.83MMU/GM GLADASE-C
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CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N
0 0 0 0 0
N N N N N
2
N
0 2
N N
0 2 2 0
N N N N
0 0 0 0 2 0 0 0 2 0 0 0 0 2 0
N N N N N N N N N N N N N N N
0 0 0
N N N
2 2 2 2 2 2
N N N N N N
AMEND
DRUG NAME KOVIA OINT PANAFIL 10%, SPRAY 521700-10 PANAFIL SE SPRAY EMULSION PAPAIN-UREA-CHLOROPHYLLIN 1.1MMU/G PAP-UREA 830000 U/G PAPTASE FOAM 83000-10 SANTYL ZIOX 405 L1A-ANTIPSORIATIC AGENTS,SYSTEMIC SORIATANE 10MG, 25MG SORIATANE CK KIT 10MG, 25MG L2A-EMOLLIENTS AMLACTIN CREAM 12% AMMONIUM LACTATE 12% CREAM KERI SENSITIVE SKIN LOTION LAC-HYDRIN CREAM RESURFIX L3A-PROTECTIVES (may be covered for dual eligible if available over the counter) ALOE VESTA BAZA PROTECT CRITIC-AID CLEAR OINT DERMAMED OINT, SPRAY PELEVERUS REMEDY SKIN REPAIR CREAM 1.5% L3B - PROTECTIVES (may be covered for dual eligible if available over the counter) SENSI-CARE L3P-ANTIPRURITICS TOPICAL AMLACTIN AP 1% DIPHENHYDRAMINE 2% CREAM PRUDOXIN 5% ZONALON 5% L5A-KERATOLYTICS AMLACTIN LOTION 12% AMMONIUM LACTATE LOTION 12% BENZAC AC 2.5% BENZOYL PEROXIDE GEL 2.5%, 5%, 10% BENZOYL PEROXIDE LOTION 5%, 10% BENZOYL PEROXIDE WASH 2.5%, 5%, 10% BREVOXYL CLEANSING LOTION 4% BREVOXYL CREAMY WASH 4%, 8% BREVOXYL GEL 4%, 8% BREVOXYL-8 LOTION 8% CONDYLOX GEL 0.5% CONDYLOX TOP SOLN 0.5% DESQUAM-E 2.5% HYDRISALIC CREAM
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CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N N N N N N
2 2
N N
2 0 2 2 2
N N N N N
2 2 2 2 2 2
Y Y Y Y Y Y
2
Y
2 0 2 2
N N N N
2 0 2 0 0 0 2 2 2 2 2 0 2 2
N N N N N N N N N N N N N N
AMEND
DRUG NAME KEROL 42% REDI-CLOTHS LACTINOL 10% MECTALYTE TOPICAL SUSP 40% NEOBENZ MICRO CREAM 3.5%, 5.5%, 8.5% OSCION CLEANSER 3%, 6%, 9% SALAC 2% SALACTIC FILM 16.7% SAL-PLANT GEL 17% SALICYLIC ACID 6% SHAMPOO TRIAZ 3%, 6%, 9% GEL TRIAZ CLEANSING LOTION 3%, 6%, 10% UREA GEL 40% UREA LOTION 35%, 40% UREALAC 50% NAIL STICK VANAMIDE 40% ZACLIR 4%, 8% L5E-ANTISEBORRHEIC AGENTS CARMOL SCALP TREATMENT KIT 10-10% CARMOL SCALP TREATMENT LOTION 10% L5F-ANTIPSORIATICS ANTHRALIN 1% DOVONEX CREAM, OINT, SOLN 0.005% PSORIATEC 1% TAZORAC GEL 0.05%, 0.1%(AGES 0-23) L5G-ROSACEA AGENTS, TOPICAL FINACEA 15% METROGEL 0.75% METROGEL 1% METROLOTION 0.75% METRONIDAZOLE 0.75% TOPICAL GEL NORITATE 1% ROZEX 0.75% L5H-ACNE AGENTS, TOPICAL AZELEX 20% (AGES 0-23) BENZACLIN 1-5% DUAC 1-5% ZIANA GEL 1.2-0.025% (AGES 0-23) L6A-IRRITANTS/COUNTER-IRRITANTS CAPSAGEL 0.05% CAPSAICIN 0.025%, 0.05%, 0.075% CREAM, LOTION ZIKS OINT L9A-MISC TOPICAL AGENTS ATRAC-TAIN 10% CARA-KLENZ CARMOL 40 CREAM CARMOL 40% LOTION, GEL
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CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N N N N N N N N N N N N N N
2 2
N N
0 2 2 2
N N N N
2 0 2 2 0 2 2
N N N N N N N
2 2 2 2
N N N N
2 0 2
N N N
2 2 2 2
N N N N
AMEND
DRUG NAME RE UREA 40 SELENIUM SULFIDE 2.5% UREA CREAM, LOTION 40% WOUN'DRES L9B-VITAMIN A DERIVATIVES AVITA CREAM, GEL 0.025% (AGES 0-23) DIFFERIN CREAM, GEL, SOLN 0.1% (AGES 0-23) RENOVA EMOLLIENT 0.05% (AGES 0-23) RETIN A CREAM 0.025%, 0.05%, 0.1% (AGES 0-23) RETIN A GEL 0.01%, 0.025% (AGES 0-23) RETIN A MICRO 0.04%, 0.1% (AGES 0-23) M0D-PLASMA EXPANDERS DEXTRAN75/DEXTROSE 5% M0E-ANTIHEMOPHILIC FACTORS ADVATE 250, 500, 1000, 1500, 1800-2200 (+/-)U ADVATE H 1000 (+/-)U ADVATE L 250 (+/-)U ADVATE M 500 (+/-)U ADVATE SH 1500 (+/-)U ADVATE UH 2000 (+/-)U ALPHANATE 250-500, 1000-1500 (+/-)U ANTIHEMOPHILIC FACTOR BIOCLATE 1020 FEIBA VH IMMUNO 490U, 400-650U, 1750-3250U HELIXATE FS 250, 500, 1000 (+/-)U HEMOFIL-M 220-400, 401-800, 801-1700, 1701-2000 (+/-)U HEMOFIL-T 30 1000U HUMATE-P 250-600U, 500-1200U, 1000-2400U KOATE-DVI 250U, 500U, 1000U KOGENATE FS 250U, 500U, 1000U MONOCLATE-P 250U, 500U, 1000U NOVOSEVEN 1200MCG, 2400MCG, 4800MCG RECOMBINATE 310AHFU, 407AHFU, 600AHFU REFACTO 250U, 500U, 1000U, 2000U M0F-FACTOR IX PREPARATIONS ALPHANINE 375U, 800U BEBULIN VH IMMUNO 700U BENEFIX 250U, 500U, 1000U MONONINE 250U, 500U, 1000U PROFILNINE SD 500U, 1250U PROPLEX SX 300-1200U PROPLEX T 300-1200U M4B-IV FAT EMULSIONS FAT EMULSION 10%, 20% INTRALIPID 10%, 20%, 30% LIPOSYN II 10%, 20%
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Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N N
2 2 2 0 0 2
N N N N N N
2
N
2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2
N N N N N N N N N N N N N N N N N N N N
2 2 2 2 2 2 2
N N N N N N N
2 2 2
N N N
AMEND
DRUG NAME LIPOSYN III 10%, 20%, 30% TRAVAMULSION 10%, 20% M4E-LIPOTROPICS ADVICOR 20-500MG, 20-750MG, 20-1000MG, 40-1000 GEMFIBROZIL 600MG LOVASTATIN 10MG, 20MG, 40MG NIASPAN 500MG, 750MG, 1000MG PRAVASTATIN 10MG, 20MG, 40MG, 80MG SIMVASTATIN 5MG, 10MG, 20MG, 40MG, 80MG TRICOR 48MG, 54MG, 145MG, 160MG M4F-LIPOTROPICS CRESTOR 5MG, 10MG, 20MG, 40MG LESCOL 20MG, 40MG LESCOL XL 80MG LIPITOR 10MG, 20MG, 40MG, 80MG VYTORIN 10-10, 10-20, 10-40, 10-80MG ZETIA 10MG M4G-HYPERGLYCEMICS GLUCACON 1MG, EMERGENCY KIT 1MG GLUTOSE 40% PROGLYCEM 50MG/ML M4I-LIPOTROPICS-CALCIUM CHANNEL BLOCKER COMBINATION CADUET 2.5-10, 2.5-20, 2.5-40, 5-10, 5-20, 5-40, 5-80, 10-10, 10-40, 10-80 M9D-ANTIFIBRINOLYTIC AGENTS AMICAR 250MG/ML INJ AMICAR 250MG/ML SYRUP AMICAR 500MG, 1000MG CYKLOKAPRON 100MG/ML INJ M9K-HEPARIN AND RELATED PREPARATIONS ARIXTRA 2.5MG/0.5ML, 5MG/0.5ML, 7.5MG/0.6ML, 10MG/0.8ML FRAGMIN 2500U/0.2ML, 5000U/0.2ML FRAGMIN 7500U/0.3ML, 10000U/ML, 25000U/ML HEPARIN 10U/ML, 100U/ML, 1000U/ML HEPARIN 5000U/ML, 7500U/ML, 10000U/ML, 20000U/ML INNOHEP 20MU/ML LOVENOX 30MG, 40MG, 60MG, 80MG, 100MG, 120MG, 150MG INJ M9L-ANTICOAGULANTS, COUMARIN TYPE WARFARIN SODIUM 1, 2, 2.5, 3, 4, 5, 6, 7.5, 10 M9P-PLATELET AGGREGATE INHIB AGGRENOX 25-200MG CILOSTAZOL 50MG, 100MG PLAVIX 75MG TICLOPIDINE 250MG M9S-HEMORRHEOLOGIC AGENTS PENTOXIFYLLINE 400MG
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CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N
2 0 0 2 0 0 2
N N N N N N N
2 2 2 2 2 2
N N N N N N
2 2 2
N N N
2
N
2 0 2 2
N N N N
2 2 2 0 0 2 2
N N N N N N N
0
N
2 0 2 0
N N N N
0
N
AMEND
DRUG NAME N1C-LEUKOCYTE STIMULANTS LEUKINE 250MCG, 500MCG INJ NEULASTA 6MG/0.6ML NEUPOGEN 300MCG/ML INJ N1D-PLATELET REDUCING AGENTS ANAGRELIDE HCL 0.5MG, 1MG N1E-PLATELET PROLIFERATION STIMULANTS NEUMEGA 5MG INJ P1B-SOMATOSTATIC AGENTS SANDOSTATIN 0.05MG/ML, 0.1MG/ML, 0.2MG/ML SANDOSTATIN 0.5MG/ML, 1MG/ML P1C-LUTEINIZING HORMONES LUPRON DEPOT 3.75MG, 7.5MG P1E-ADRENOCORTICOTROPHIC HORM ACTHAR HP 80U P1F-PITUITARY SUPPRESSIVE AGENTS CABERGOLINE 0.5MG DANAZOL 50MG, 100MG, 200MG DANOCRINE 50MG, 100MG, 200MG DOSTINEX 0.5MG SYNAREL 2MG/ML NASAL SOLN P1G-ADRENAL STEROID INHIBITORS CYTADREN 250MG P2B-ANTIDIURETIC AND VASOPRESSOR HORMONES DDAVP 0.1MG, 0.2MG DDAVP 4MCG/ML INJ DDAVP NASAL 0.01%, SPRAY PUMP 10MCG/DOSE DESMOPRESSIN ACETATE INJ 4MCG/ML DESMOPRESSIN ACETATE NASAL 0.1MG/ML P3A-THYROID HORMONES ARMOUR THYROID 15MG, 30MG, 60MG, 100MG, 120MG, 180MG, 240MG, 300MG CYTOMEL 5MCG, 25MCG, 50MCG LEVOTHROID 0.0137 LEVOTHYROXINE SODIUM 0.025, 0.05, 0.075, 0.88, 0.1, 0.112, 0.125MG LEVOTHYROXINE SODIUM 0.137, 0.15, 0.175, 0.2, 0.3MG LEVOXYL 0.137 SYNTHROID 0.137MG THYROID 30MG, 60MG, 120MG, 180MG WESTHROID 120MG P3L-ANTITHYROIDS METHIMAZOLE 5MG, 10MG, 20MG PROPYLTHIOURACIL 50MG P4D - HYPERPARATHYROID VITAMIN D ANALOG HECTOROL 0.5MG, 2.5MG ZEMPLAR 1MCG, 2MCG, 4MCG
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Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N
0
N
2
N
0 0
N N
2
N
2
N
0 0 2 2 2
N N N N N
2
N
2 2 2 0 0
N N N N N
2 2 0 0 0 2 2 0 2
N N N N N N N N N
0 0
N N
2 2
N N
AMEND
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CO-PAYMENT
DRUG CLASS
5101:3-9-12
DRUG NAME P4L-BONE RESORPTION INHIBITORS ACTONEL 5MG, 30MG, 70MG 2 BONIVA 2.5MG, 150MG 2 DIDRONEL 200MG, 400MG, 50MG/ML 2 ETIDRONATE 200MG, 400MG 0 EVISTA 60MG 2 FOSAMAX 5MG, 10MG, 35MG, 40MG, 70MG, 70MG/75ML 2 MIACALCIN 200U/ML INJ, NASAL SOLN 200U/DOSE 2 P4N-BONE OSSIFICATION SUPPRESSION RESORPTION INHIBITOR & VITAMIN D COMBINATIONS FOSAMAX PLUS D 70MG-2800, 70MG-5600 2 P5A-GLUCOCORTICOIDS CORTEF 5MG, 10MG 2 CORTISONE ACETATE 25MG 0 DELTASONE 2.5MG 2 HYDROCORTISONE 10MG, 20MG 0 HYDROCORTISONE SODIUM SUCCINATE 100MG INJ 0 HYDROCORTONE 10MG 2 MEDROL 2MG, 16MG 2 MEDROL 8MG 0 METHYLPREDNISOLONE TABLET 4MG, 16MG, 32MG 0 METHYLPREDNISOLONE ACETATE INJ 40MG/ML, 80MG/ML 0 ORAPRED 15MG/5ML 2 ORAPRED ODT TAB 10MG, 15MG, 30MG 2 PEDIAPRED LIQUID 6.7MG/5ML 2 PREDNISOLONE 5MG 0 PREDNISOLONE ORAL SOLN 15MG/5ML, 5MG/5ML 0 PREDNISOLONE SOD PHOS 5MG/5ML, 15MG/5ML 0 PREDNISONE 1MG, 2.5MG, 5MG, 10MG, 20MG, 50MG 0 SOLU-CORTEF INJ 100MG 2 SOLU-MEDROL INJ 125MG 2 TRIAMCINOLONE ACETONIDE INJ 40MG/ML 0 P5B-GLUCOCORTICOIDS, SYSTEMIC CELESTONE 0.6MG/5ML SOLN 2 CELESTONE SOLUSPAN INJ 6MG/ML 2 DECADRON 0.5MG, 0.75MG 2 DEXAMETHASONE 0.5MG, 0.75MG, 1.5MG, 4MG, 6MG 0 DEXAMETHASONE 0.5MG/5ML 0 DEXAMETHASONE ACETATE INJ 8MG/ML 0 DEXAMETHASONE SODIUM PHOSPHATE INJ 4MG/ML 0 DEXPAK 1.5MG 2 ENTOCORT EC 3MG 2 PULMICORT 0.25MG/2ML, 0.5MG/2ML 2 QVAR INH 0.04MG, 0.08MG PER ACTUATION 2 TRIAMCINOLONE DIACETATE INJ 40MG/ML 0
Effective October 1, 2007 March 20, 2008
N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N
AMEND
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CO-PAYMENT
DRUG CLASS
5101:3-9-12
DRUG NAME P5C-GLUCOCORTICOIDS, TOPICAL AEROBID, AEROBID-M 2 ARISTOCORT 4MG 2 ASMANEX 2 AZMACORT INH 100MCG/ACTUATION 2 FLOVENT DISKUS 50MCG 2 FLOVENT HFA SPRAY 44MCG, 110MCG, 220MCG 2 KENALOG 40 INJ 40MG/ML 2 P5S-MINERALOCORTICOIDS FLORINEF ACETATE 0.1MG 2 FLUDROCORTISONE 0.1MG 0 Q2C-OPHTHALMIC ANTI-INFLAMMATORY IMMUNOMODULATOR-TYPE RESTASIS 0.05% 2 Q3A-RECTAL PREPS ANUSOL HC 2.5% CREAM 2 HYDROCORTISONE CREAM 2.5% 0 PROCTOCORT 1% 2 PROCTOCREAM HC 2.5% 2 PROCTOSOL HC 2.5% 2 PROCTOZONE HC 2.5% 2 Q3B-RECTAL/LOWER BOWEL PREP.,GLUCOCORTICOID (NON-HEMORRHOID) HYDROCORTISONE ENEMA 100MG 0 Q3D-HEMORRHOIDAL PREPS HEMORRHOIDAL CREAM, OINT, SUPP 0 Q3E - CHRONIC INFLAMMATORY COLON DX, 5-A-SALICYLAT,RECTAL TX CANASA 500MG, 1000MG 2 ROWASA ENEMA 4GM/60ML 2 Q3S-LAXATIVES, LOCAL/RECTAL (may be covered for dual eligible if available over the counter) DOCUSOL MINI ENEMA 2 ENEMEEZ MINI ENEMA 2 ENEMEEZ PLUS MINI ENEMA 2 Q4A-VAGINAL MISC AMINO ACID CERVICAL 0 Q4B-VAGINAL ANTISEPTICS ACID JELLY 0 Q4F-VAGINAL ANTIFUNGALS CLOTRIMAZOLE VAG CREAM, SUPPS 0 GYNAZOLE-1 2 MICONAZOLE NITRATE VAG CREAM 2% 0 MICONAZOLE VAG SUPPS 100MG, 200MG 0 MICONAZOLE VAGINAL COMBO PAK 200MG-2% CREAM 0 MONISTAT 1 COMBINATION PACK 2 MONISTAT 3 VAG SUPPS 2 MONISTAT COMBO PAK 100MG SUPP-2% CREAM 2 NYSTATIN 100000U VAG TABS 0 TERAZOL 3 VAG CREAM 0.8% 0
Effective October 1, 2007 March 20, 2008
N N N N N N N N N N N N N N N N N N N N Y Y Y N N N N N N N N N N N N
Appendix A
DRUG NAME TERAZOL 3 VAG TABS TERAZOL 7 VAG CREAM 0.4% TICONAZOLE-1 6.5% Q4K-VAGINAL ESTROGENS (SEE ALSO G1A) ESTRING 7.5MCG/24HR ESTRACE VAG CREAM 0.01% FEMRING 0.05MG/24HR PREMARIN VAG CREAM 0.625MG/GM VAGIFEM 25MCG Q4S-VAGINAL SULFONAMIDES AVC 15% VAG CREAM Q4W-VAGINAL ANTIBIOTICS CLEOCIN VAG CREAM 2% CLEOCIN VAG TAB 100MG CLINDESSE 2% METROGEL VAG CREAM 0.75% Q5A-TOPICAL PREPS, MISC (may be covered for dual eligible if available over the counter) DERMAGRAN OINT, SPRAY NAIL SCRUB Q5B-TOPICAL ANTIBACTERIALS CAPITROL 2% FINEVIN 20% (AGES 0-23) NITROFURAZONE PHISOHEX 3% POVIDONE-IODINE OINT, SCRUB, SOLN Q5F-TOPICAL ANTIFUNGALS CLOTRIM/BETAMETH CRM CLOTRIMAZOLE CREAM 1%, AF CREAM CICLOPIROX 8% SOLUTION DERMA FUNGAL 2% FUNGOID TR KETOCONAZOLE 2% KETOCONAZOLE SHAMPOO 2% LOPROX CREAM, SUSP 0.77% LOPROX SHAMPOO 1%, GEL 0.77% MICONAZOLE NITRATE CREAM, POWDER 2% MPM ANTIFUNGAL CREAM 1% NAFTIN CREAM, GEL 1% NYSTATIN CREAM, OINT, PDR 100000U/GM NYSTATIN TRIAMCINOLONE CREAM, OINT OXISTAT CREAM, LOTION 1% PEDI-DRI 100MU/GM PENLAC 8% TOLNAFTATE CREAM, POWDER, SOLN 1% VUSION OINT
Effective October 1, 2007 March 20, 2008
2 0 0
ELIGIBLE COVERED FOR DUAL
AMEND
Page 41 of 61 CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N
2 2 2 2 2
N N N N N
2
N
0 2 2 0
N N N N
2 2
Y Y
2 2 0 2 0
N N N N N
0 0 0 0 2 0 0 0 2 0 2 2 0 0 2 2 2 0 2
N N N N N N N N N N N N N N N N N N N
AMEND
DRUG NAME Q5H-TOPICAL LOCAL ANESTHETICS ELA-MAX 4% ELA-MAX PLUS 4% EMLA CREAM 2.5%/2.5% EXACTACAIN SPRAY 2-14-2% L.M.X.4 4% L.M.X.4 PLUS 4% LIDA MANTLE 3% LIDA MANTLE HC 0.5-3% LIDOCAINE OINT 5% LIDOCAINE-HC 0.5-3% LIDOCAINE-PRILOCAINE 2.5-2.5% LIDOCAINE 3%, 4% CREAM LIDODERM 5% MPM REGENECARE Q5K-TOPICAL-IMMUNOSUPPRESSIVE AGENTS ELIDEL 1% PROTOPIC 0.03%, 0.1% Q5N-TOPICAL ANTINEOPLASTIC & PREMALIGNANT LESION AGENTS CARAC 0.5% EFUDEX CREAM 5%, SOLN 2%, 5% FLUOROPLEX CREAM 1% SOLARAZE 3% Q5P-TOPICAL ANTI-INFLAMMATORY STEROIDAL ACLOVATE CREAM, OINT 0.05% AMCINONIDE 0.1% LOTION, CREAM BETAMETHASONE DIPROPIONATE CRM, GEL, OINT, LOT 0.05% BETAMETHASONE DP AUGMENTED BETAMETHASONE VALERATE CREAM, OINT, LOT 0.1% CAPEX SHAMPOO 0.01% CARMOL HC 1% CLOBETASOL E CREAM 0.05% CLOBETASOL PROPIONATE OINT, CREAM, GEL, SCALP 0.05% CLOBEX 0.05% LIQ CLODERM 0.1% CORDRAN OINT 0.05% CORDRAN LOTION 0.05% CORDRAN TAPE 4MCG/SQC CYCLOCORT CREAM, OINT 0.1% CYCLOCORT LOT 0.1% DERMA-SMOOTHE/FS OIL 0.01% DERMATOP 0.1% CREAM, OINT DESONIDE CREAM, OINT, LOTION 0.05% DESOXIMETASONE CREAM, OINT 0.05%, 0.25% DESOXIMETASONE GEL 0.05% DIFLORASONE DIACETATE CREAM, OINT 0.05%
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CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N N N N N N N N N N N N
2 2
N N
2 2 2 2
N N N N
0 0 0 0 0 2 2 0 0 2 2 2 2 2 0 2 2 2 0 0 0 0
N N N N N N N N N N N N N N N N N N N N N N
AMEND
DRUG NAME DIPROLENE AF CREAM DIPROLENE LOTION 0.05% ELOCON CREAM, OINT, LOT 0.1% FLUOCINOLONE ACETONIDE CREAM, OINT 0.025% FLUOCINOLONE ACETONIDE CREAM, SOLN 0.01% FLUOCINONIDE CREAM, OINT, SOLN, GEL 0.05% FLUOCINONIDE E CREAM 0.05% FLUTICASONE PROPIONATE CRM 0.05% FLUTICASONE PROPIONATE OINT 0.005% HALOBETASOL PROPIONATE 0.05% CREAM HALOG CREAM, OINT, SOLN 0.1% HYDROCORTISONE ACETATE W/UREA 1% HYDROCORTISONE BUTYRATE CREAM, SOLN, OINT 0.1% HYDROCORTISONE CREAM, OINT, 0.5%, 1%, 2.5% HYDROCORTISONE LOT 1%, 2.5% HYDROCORTISONE VALERATE 0.2% CREAM KENALOG AEROSOL KERATOL HC 1% CREAM LOCOID CREAM, OINT, LOT, LIPOCREAM 0.1% LUXIQ 0.12% MAXIFLOR CREAM, OINT 0.05% MOMETASONE FUROATE OINT 0.1% NUTRACORT LOTION 2.5% OLUX OLUX-E PANDEL CREAM 1% PSORCON E CREAM, OINT 0.05% TEMOVATE EMOLLIENT CREAM 0.05% TEXACORT 1%, 2.5% TOPICORT OINT 0.25%, GEL 0.05% TRIAMCINOLONE CREAM, OINT 0.025%, 0.1%, 0.5% TRIAMCINOLONE LOT 0.025%, 0.1% ULTRAVATE CREAM, OINT 0.05% VANOS 0.1% Q5R-TOPICAL ANTIPARISITICS ELIMITE CREAM 5% EURAX CREAM, LOTION 10% LINDANE LOTION, SHAMPOO OVIDE 0.5% PERMETHRIN 1% LIQUID, 5% CREAM PYRINYL/LICE TREATMENT LIQUID Q5S-TOPICAL SULFONAMIDES AVAR 10%/5% CLENIA 10%/5% NICOSYN 10%/5% PLEXION 10/5%
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Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N
2 2 0 2 0 0
N N N N N N
2 2 2 2
N N N N
AMEND
Page 44 of 61
DRUG NAME PRASCION 10-5% (W/W) 2 ROSADERM 10-5% 2 ROSANIL 10-5% 2 ROSULA 10%/5% 0 SILVER SULFADIAZINE 1% 0 SODIUM SULFACETAMIDE/SULFUR LOTION 10%/5% 0 SULFACET-R LOTION 2 SULFAMYLON 8.5% 2 SULFATOL, SULFATOL-M 10%/5% 2 ZETACET 10-5% 2 Q5V-TOPICAL ANTIVIRALS DENAVIR CREAM 1% 2 ZOVIRAX OINT 5% 2 Q5W-TOPICAL ANTIBIOTICS (may be covered for dual eligible if available over the counter) BACITRACIN TOPICAL 500U/GM 0 BACITRACIN/POLYMYXIN OINT 500U/GM/10MU/GM 0 0 2 BACTROBAN CREAM, OINT 2% 02 BENZAMYCIN GEL 30MG/50MG CENTANY 2% 0 CLEOCIN T GEL 0 CLINDAGEL 1% 2 CLINDAMYCIN TOP SOLN 1% 0 ERYTHROMYCIN GEL, SOLN, PADS 2% 0 ERYTHROMYCIN-BENZOYL PEROXIDE GEL 3%-5% 0 GENTAMICIN SULFATE CREAM, OINT 0.1% 0 MUPIROCIN OINT 2% 0 POLYSPORIN TOPICAL POWDER 2 TRIPLE ANTIBIOTIC OINT 0 Q5X-TOPICAL ANTIBIOTICS/ANTIINFLAMMATORY,STEROIDAL CORTISPORIN OINT 1% 2 Q6A-EYE PREPS MISC ALTACHLORE OINT, SOLN 5% 2 FML-S SUSP 10%/0.1% 2 MURO 128 SOLN, OINT 5% 2 SODIUM CHLORIDE SOLN, OINT 5% 0 Q6C-EYE VASOCONSTRICTORS RX NAPHAZOLINE SOLN 0.1% 0 NEO-SYNEPHRINE SOLN 2.5%, 10% 2 PHENYLEPHRINE SOLN 2.5%, 10% 0 Q6D-EYE VASOCONSTRICTORS OTC TETRAHYDROZOLINE/ZINC 0.5-0.25% 0 VASOCON A 0.05%/0.5% 2 Q6G-MIOTICS/OTHER INTRAOC. PRESSURE REDUCERS ALPHAGAN P SOLN 0.15% 2 AZOPT SOLN 1% 2 BETAXOLOL HCL 0.5% 0
Effective October 1, 2007 March 20, 2008
ELIGIBLE COVERED FOR DUAL
Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N N N N N N N N N N Y Y N N N N N N N N N N N Y N N N N N N N N N N N N N
AMEND
DRUG NAME BETIMOL SOLN 0.25%, 0.5% BRIMONIDINE TARTRATE 0.2% CARTEOLOL HCL 1% COMBIGAN 0.2-0.5% COSOPT PLUS 2-0.5% COSOPT SOLN 2%/0.5% EPINAL 1% ISOPTO CARBACHOL SOLN 1.5%, 3% ISOPTO CARPINE SOLN 8%, 10% LEVOBUNOLOL SOLN 0.25%, 0.5% METIPRANOLOL 0.3% PHOSPHOLINE IODIDE SOLN 0.125% PILOCARPINE SOLN 0.5%, 1%, 2%, 3%, 4%, 5%, 6% PILOPINE HS GEL 4% TIMOLOL MALEATE SOL 0.25%, 0.5% TIMOLOL MALEATE SOLN XE 0.25%, 0.5% TRAVATAN 0.004% TRAVATAN Z 0.004% TRUSOPT 2% XALATAN 0.005% Q6H-EYE LOCAL ANESTHETICS FLUORACAINE 0.5-0.25% PROPARICAINE HCL SOLN 0.5% TETRACAINE HCL SOLN 0.5% Q6I- EYE ANTIBIOTIC-CORTICOID COMBINATIONS CORTISPORIN SUSP NEOMYCIN/POLYMYXIN/HC SUSP POLYPRED SUSP PRED G SUSP, OINT TOBRADEX SUSP, OINT 0.3%/0.1% ZYLET EYE DROPS 0.3%-0.5% Q6J-MYDRIATICS AK-PENTOLATE SOLN 2% ATROPINE SULFATE SOLN, OINT 1% CYCLOGYL 0.5%, 1%, 2% CYCLOMYDRIL SOLN 0.2%/1% CYCLOPENTOLATE SOLN 1% DIPIVEFRIN SOLN 0.1% ISOPTO ATROPINE SOLN 1% ISOPTO HOMATROPINE SOLN 2%, 5% ISOPTO HYOSCINE SOLN 0.25% TROPICAMIDE SOLN 0.5%, 1% Q6P-EYE ANTIINFLAMMATORY AGENTS ACULAR LS 0.4% ACULAR SOLN 0.5% ALREX SOLN 0.2%
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2 0 0 2 2 2 2 2 2 0 0 2 0 2 0 0 2 2 2 2
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Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N N N N N N N N N N N N N N N N N N
2 0 0
N N N
2 0 2 2 2 2
N N N N N N
0 0 2 2 0 0 2 2 2 0
N N N N N N N N N N
2 2 2
N N N
AMEND
Page 46 of 61
DRUG NAME DEXAMETHASONE SOD PHOSPHATE OINT 0.05%, SOLN 0.1% 0 ECONOPRED 0.125% 2 FLUOROMETHOLONE SOLN 0.1% 0 FLURBIPROFEN SODIUM 0.03% 0 FML FORTE SOLN 0.25% 2 FML SOP OINT 0.1% 2 HMS LIQUIFILM SOLN 1% 2 INFLAMASE MILD 0.125% 2 LOTEMAX SOLN 0.5% 2 MAXIDEX SOLN 0.1% 2 NEVANAC 0.1% 2 PRED MILD SOLN 0.12% 2 PREDNISOLONE ACETATE SOLN 1% 0 PREDNISOLONE SOD PHOSPHATE SOLN 0.125%, 1% 0 VEXOL SOLN 1% 2 VOLTAREN SOLN 0.1% 2 Q6R-EYE ANTIHISTAMINE ALAWAY 0.025% 2 OPTIVAR 0.05% 2 PATADAY 0.2% 2 PATANOL 0.1% 2 ZADITOR 0.025% 2 Q6S-EYE SULFONAMIDES BLEPHAMIDE OINT, SOLN 0.2% 2 PREDNISOLONE/SULFACETAMIDE SOLN 0.25%-10% 0 SULFACETAMIDE OINT 10% 0 SULFACETAMIDE SODIUM, SOLN 10%, 30% 0 Q6T-EYE LUBRICANTS/TEARS (may be covered for dual eligible if available over the counter) ARTIFICIAL TEARS 0.5%, 1.4%, 1.4%/0.6% 0 FRESHKOTE 2 GENTEAL MILD 2% 2 HYPOTEARS OINT, SOLN 2 LUBRICANTS, DRY EYES, REFRESH 0 TEARS NATURALE FORTE 2 TEARS NATURALE PM 0 Q6U-EYE MAST CELL STABILIZERS ALOCRIL 2% 2 ALOMIDE SOLN 0.1% 2 CROMOLYN SODIUM SOLN 4% 0 Q6V-EYE ANTIVIRALS TRIFLURIDINE SOLN 1% 0 VIROPTIC SOLN 1% 2 Q6W-EYE ANTIBIOTICS AKTETRA 2 AZASITE 1% EYE DROPS 2 BACITRACIN OINT 500U/GM 0
Effective October 1, 2007 March 20, 2008
ELIGIBLE COVERED FOR DUAL
Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N N N N N N N N N N N N N N N N N N N N N N N Y N Y Y Y Y Y N N N N N N N N
AMEND
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Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
DRUG NAME BACITRACIN/NEOMYCIN/POLYMYXIN/HC OINT 0 N BACITRACIN/POLYMYXIN OINT 0 N CILOXAN OINT 0.3% 2 N CIPROFLOXACIN 0.3% 0 N DEXAMETHASONE/NEOMYCIN/POLYMYXIN OINT, SOLN 0 N ERYTHROMYCIN OINT 5MG/GM 0 N GENTAMICIN SOLN 3MG/ML, OINT 3MG/GM 0 N IQUIX 1.5% 2 N NATACYN 5% 2 N NEOMYCIN/POLYMYXIN/BACITRACIN OINT 0 N NEOMYCIN/POLYMYXIN/GRAMICIDIN SOLN 0 N POLYMYXIN/TRIMETHOPRIM SOLN 0 N TOBRAMYCIN SOLN 0.3% 0 N TOBREX 0.3% OINT 2 N VIGAMOX 0.5% 2 N ZYMAR 0.3% SOLN 2 N Q6Y-EYE PREP, MISC (may be covered for dual eligible) ALTALUBE OPH OINT 0 Y Q7A-NOSE PREPARATIONS, MISCELLANEOUS (RX) IPRATROPIUM BR 21MCG, 42MCG NS 0 N Q7C-NASAL VASOCONSTRICTORS RX TYZINE 0.05%, 0.1% 2 N Q7D-NASAL VASOCONSTRICTORS OTC OXYMETAZOLINE HCL 0.05% 0 N PHENYLEPHRINE HCL 0.125%, 1% 0 N Q7E-NASAL ANTIHISTAMINE ASTELIN NASAL SPRAY 137MCG 2 N Q7H-NASAL MAST CELL STABILIZERS AGENTS (may be covered for dual eligible if available over the counter) CROMOLYN SODIUM 40MG/ML 0 Y NASALCROM 40MG/ML 2 Y Q7P-NASAL, ANTI-INFLAMMATORY STEROIDS FLONASE AQ 0.05% 0 N NASACORT AQ 2 N NASONEX 50MCG 2 N Q7W-NASAL ANTIBIOTICS BACTROBAN NASAL 2% 2 N Q7Y-NASAL OTC MISC (may be covered for dual eligible if available over the counter) SODIUM CHLORIDE (SALINE) NASAL SPRAY 0.65% 0 Y Q8B-EAR PREPS, MISC ANTI-INFECTIVE ACETIC ACID HC OTIC 2% 0 N ACETIC ACID OTIC 2% 0 N ACETIC ACID/ ALUMINUM ACETATE 0 N AERO OTIC HC 2 N Q8F-OTIC PREPARATIONS, ANTI-INFLAMMATORY-ANTIBIOTICS CIPRO HC OTIC 2 N
Effective October 1, 2007 March 20, 2008
AMEND
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Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
DRUG NAME CIPRODEX 0.3-0.1% 2 Q8H-EAR PREPS, LOCAL ANESTHETIC ANTIPYRINE/BENZOCAINE 0 OTICAINE 20% 2 OTIGESIC 0 OTOCAIN 20% 2 TYMPAGESIC 2 Q8R-EAR WAX REMOVAL PREPS (may be covered for dual eligible if available over the counter) CARBAMIDE PEROXIDE 6.5% 0 Q8W-EAR ANTIBIOTICS COLYMYCIN-S 2 CORTISPORIN-TC SUSP 2 FLOXIN OTIC 2 NEOMYCIN/POLYMYXIN/HC SUSP, SOLN 0 PEDIOTIC 2 Q9B-BPH/MICTURITION AGENTS AVODART 0.5MG 2 FINASTERIDE 5MG 0 FLOMAX 0.4MG 2 RIA-URINARY TRACT ANTISPASMODICS/ANTIINCONTINENCE AGENT DETROL LA 2MG, 4MG 2 FLAVOXATE 100MG 0 R1E-CARBONIC ANHYDRASE INHIBITORS ACETAZOLAMIDE 125MG, 250MG 0 DIAMOX SEQUELS 500MG 2 METHAZOLAMIDE 25MG, 50MG 0 R1F-THIAZIDE DIURETIC&REL CHLOROTHIAZIDE 250MG, 500MG 0 CHLORTHALIDONE 25MG, 50MG, 100MG 0 DIURIL 250MG/5ML 2 HYDROCHLOROTHIAZIDE 25MG, 50MG, 100MG 0 INDAPAMIDE 1.25MG, 2.5MG 0 METHYCLOTHIAZIDE 2.5MG, 5MG 0 METOLAZONE 2.5MG, 5MG, 10MG 0 SALURON 50MG 2 R1H-POTASSIUM SPARING DIURETICS (SEE ALSO P5T) AMILORIDE HCL 5MG 0 ALDACTONE 25MG, 50MG, 100MG 2 INSPRA 25MG, 50MG 2 SPIRONOLACTONE 25MG, 50MG, 100MG 0 R1I-TRACT ANTISPASMODIC, M(3) SELECTIVE ANTAG. ENABLEX 7.5MG, 15MG 2 VESICARE 5MG, 10MG 2 R1K-DIURETICS,MISCELLANEOUS ISMOTIC 45% 2
Effective October 1, 2007 March 20, 2008
N N N N N N Y N N N N N N N N N N N N N N N N N N N N N N N N N N N N
AMEND
DRUG NAME R1L-POTASSIUM SPARING DIURETICS IN COMBINATION AMILORIDE/HCTZ 5/50 SPIRONOLACTONE/HCTZ 25/25 TRIAMTERENE HCTZ 25/50, 25/37.5, 50/75 R1M-LOOP DIURETICS BUMETANIDE 0.5MG, 1MG, 2MG BUMETANIDE INJ 0.25MG/ML DEMADEX 5MG, 10MG, 20MG, 10MG/ML EDECRIN 25MG, 50MG FUROSEMIDE 10MG/ML INJ FUROSEMIDE 10MG/ML ORAL, 40MG/5ML ORAL FUROSEMIDE 20MG, 40MG, 80MG TORSEMIDE 5MG, 10MG, 20MG, 100MG R1R-URICOSURIC AGENTS PROBENECID 500MG SULFINPYRAZONE 100MG R1S-URINARY PH MODIFIERS BICITRA SOLN CITRIC ACID/SODIUM CITRATE 334-500MG CITROLITH CYTRA-2 SOLN CYTRA-3 SOLN CYTRA-K SOLN K-PHOS M.F., #2 K-PHOS NEUTRAL 250MG K-PHOS ORIGINAL PEDAMETH 15MG/ML PEDAMETH 200MG PHOSPHA 250 NEUTRAL 250 MG POLYCITRA LC SOLN POLYCITRA SYRUP POLYCITRA-K SOLN POTASSIUM CITRATE/CITRIC ACID RENACIDIN SOLN UROCIT-K 540MG, 750MG UROQID-ACID NO.2 VIS-PHOS N 250MG TABLET R4A-KIDNEY STONE AGENTS CALCIBIND CYSTAGON 50MG, 150MG THIOLA R5A-URINARY TRACT ANESTHETIC/ANALGESIC AGENTS AZO 95MG PHENAZOPYRIDINE 100MG, 200MG PHENAZOPYRIDINE PLUS 150-0.3-15 PYRIDIUM PLUS
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0 0 0
ELIGIBLE COVERED FOR DUAL
Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N
0 0 0 2 0 0 0 0
N N N N N N N N
0 0
N N
2 0 2 0 0 0 2 2 2 2 2 2 2 2 2 0 0 2 2 2
N N N N N N N N N N N Y N N N N N N N N
2 2 2
N N N
2 0 0 2
N N N N
AMEND
DRUG NAME R5B-URINARY ANALGESICS ELMIRON 100MG S2A-COLCHICINES COLCHICINE 0.6MG PROBENECID W/ COLCHICINE 500MG/0.5MG S2B-NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ADVIL 40MG/ML, 100MG/5ML ADVIL 50MG, 100MG CELEBREX 50MG, 100MG, 200MG, 400MG (AGE 60+) DICLOFENAC POTASSIUM 50MG DICLOFENAC SODIUM 25MG, 50MG, 75MG, 100MG ELIXSURE IB 10MG/5ML ETODOLAC 200MG, 300MG, 400MG, 500MG ETODOLAC XL 400MG, 500MG, 600MG FENOPROFEN CALCIUM 600MG FLURBIPROFEN 50MG, 100MG IBUPROFEN 100MG, 200MG, 400MG, 600MG, 800MG IBUPROFEN 100MG/5ML SUSP, 40MG/ML DROPS INDOCIN SUSP 25MG/5ML INDOMETHACIN 25MG, 50MG KETOPROFEN 100MG, 200MG SR KETOPROFEN 25MG, 50MG, 75MG KETOROLAC TROMETHAMINE 10MG, INJ 15MG/ML, 30MG/ML MECLOFENAMATE SODIUM 50MG, 100MG MELOXICAM 7.5MG, 15MG MOTRIN 40MG/ML, 100MG/5ML MOTRIN 50MG, 100MG NABUMETONE 500MG, 750MG NAPROSYN 125MG/5ML NAPROXEN 250MG, 375MG, 500MG, 125MG/5ML NAPROXEN EC 375MG, 500MG NAPROXEN SODIUM 220MG, 275MG, 550MG ORUDIS KT 12.5MG PIROXICAM 10MG, 20MG SULINDAC 150MG, 200MG TORADOL INJ 15MG/ML S2C-GOLD SALTS RIDAURA 3MG S2D-ANTI-INFLAMMATORY AGENTS OXAPROZIN 600MG S2I-ANTI-INFLAMMATORY, PYRIMIDINE SYNTHESIS INHIBITOR LEFLUNOMIDE 10MG, 20MG S2K-ANTI-ARTHRITIC AND CHELATING AGENTS CUPRIMINE 250MG DEPEN 250MG
Effective October 1, 2007 March 20, 2008
Page 50 of 61
2
ELIGIBLE COVERED FOR DUAL
Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N
0 0
N N
0 2 2 0 0 0 0 0 0 0 0 0 2 0 0 0 0 0 0 0 2 0 2 0 0 0 2 0 0 2
N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N
2
N
0
N
0 2 2 2
N N N N
AMEND
DRUG NAME U6E-OINTMENT-CREAM BASES HYDROPHILIC PETROLATUM U6F-HYDROPHILIC CREAM/OINTMENT BASES HYDROPHILIC TRIAD U6N-VEHICLES ORA-BLEND SF ORA-SWEET ORA-SWEET SF U6W-BULK CHEMICALS CLORPACTIN WCS-90 HYDROUS EMULSIFIED BASE L-GLUTAMINE PDR ORA-PLUS ZINC SULFATE PDR V1A-ALKYLATING AGENTS ALKERAN 2MG, INJ 50MG CARBOPLATIN INJ 50MG, 150MG, 450MG CEENU 10MG, 40MG, 100MG, DOSEPAK CISPLATIN INJ 1MG/ML CYTOXAN 25MG, 50MG CYTOXAN LYOPHILIZED INJ 500MG, 1GM, 2GM DROXIA 200MG, 300MG, 400MG HYDROXYUREA 500MG IFEX-MESNEX 1GM/1GM, 1GM/3GM LEUKERAN 2MG MUSTARGEN INJ 10MG MYLERAN 2MG PARAPLATIN INJ 50MG, 150MG, 450MG TEMODAR 5MG, 20MG, 100MG, 140MG, 180MG, 250MG V1B-ANTIMETABOLITES CYTARABINE INJ 1GM, 2GM, 100MG, 500MG FLUOROURACIL INJ 50MG/ML GEMZAR INJ 200MG, 1GM MERCAPTOPURINE 50MG METHOTREXATE INJ 25MG/ML, TAB 2.5MG METHOTREXATE LPF INJ 25MG/ML PURINETHOL 50MG THIOGUANINE 40MG XELODA 150MG, 500MG V1C-VINCA ALKALOIDS NAVELBINE INJ 10MG/ML VINBLASTINE INJ 10MG VINORELBINE INJ 10MG/ML
Effective October 1, 2007 March 20, 2008
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2
ELIGIBLE COVERED FOR DUAL
Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N
2 2
N N
2 2 2
N N N
2 0 2 2 2
N N N N N
2 0 2 0 0 0 2 0 2 2 2 2 2 2
N N N N N N N N N N N N N N
0 0 2 0 0 0 2 2 2
N N N N N N N N N
2 0 0
N N N
AMEND
DRUG NAME V1D-ANTIBIOTIC ANTINEOPLASTICS BLENOXANE INJ 15U, 30U BLEOMYCIN SULFATE INJ 15U, 30U COSMEGEN INJ 0.5MG MITHRACIN 2500MCG V1E-STEROID ANTINEOPLASTICS EMCYT 140MG MEGESTROL ACETATE 20MG, 40MG, 40MG/ML TESLAC 50MG V1F-MISC ANTINEOPLASTICS ARIMIDEX 1MG ETOPOSIDE 20MG. LYSODREN 500MG MATULANE 50MG MITOXANTRONE 2MG/ML NOVANTRONE INJ 2MG/ML VEPESID 50MG CAP VESANOID 10MG CAP V1H-ANTINEOPLASTIC-BREAST CANCER AROMASIN 25MG FEMARA 2.5MG V1I-CHEMOTHERAPY RESCUE/ANTIDOTE AGENTS MESNEX 100MG/ML V1J-ANTIANDROGENIC AGENTS CASODEX 50MG EULEXIN 125MG FLUTAMIDE 125MG NILANDRON 150MG V1O-ANTINEOPLASTIC LHRH(GNRH) AGONIST,PITUITARY SUPPR. TRELSTAR DEPOT 3.75MG V1Q-ANTINEOPLASTIC SYSTEMIC ENZYME INHIBITORS GLEEVEC 100MG, 400MG IRESSA 250MG NEXAVAR 200MG SUTENT 12.5MG, 25MG, 50MG TARCEVA 25MG, 100MG, 150MG TASIGNA 200MG TYKERB 250MG V1T-SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERM) FARESTON 60MG TAMOXIFEN CITRATE 10MG, 20MG W1A-PENICILLINS AMOX TR/POTASSIUM CLAV 200-28.5/5, 400-57/5, 600-42.9/5ML AMOX TR/POTASSIUM CLAV 500-125MG, 875-125MG AMOX TR/POTASSIUM CLAV CHEW TAB 200-28.5, 400-57 AMOXICILLIN 250MG, 500MG, 875MG, 125MG/5ML, 250MG/5ML
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2 0 2 2
ELIGIBLE COVERED FOR DUAL
Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N N
2 0 2
N N N
2 0 2 2 0 2 0 2
N N N N N N N N
2 2
N N
2
N
2 2 0 2
N N N N
2
N
2 2 2 2 2 2 2
N N N N N N N
2 0
N N
0 0 0 0
N N N N
AMEND
DRUG NAME AMOXICILLIN 200MG/5ML, 400MG/5ML AMOXICILLIN CHEWABLE 125MG, 200MG, 250MG, 400MG AMOXICILLIN PED DROPS 50MG/ML AMOXIL 875MG AMPICILLIN 250MG, 500MG AMPICILLIN SUSP 125MG/5ML, 250MG/5ML AMPICILLIN VIAL 250MG, 500MG, 1GM, 2GM AMPICILLIN/SULBACTAM INJ 1.5GM, 3GM AUGMENTIN CHEWABLES 125/31.25, 250/62.5 AUGMENTIN CHEWABLES 200/28.5, 400/56 AUGMENTIN ES 600 SUSP AUGMENTIN SUSP 125-31.25/5ML AUGMENTIN SUSP 250-62.5/5ML AUGMENTIN TABS 250/125, 500/125, 875/125 AUGMENTIN XR 1000-62.5 BACTOCILL INJ 500MG, 1GM BICILLIN CR INJ 150/150, 600MU/ML, 1.2MMU/2ML BICILLIN L-A INJ 600, 1.2MMU/2ML, 2.4MMU/4ML DICLOXACILLIN 250MG, 500MG GEOCILLIN 382MG NAFCILLIN SODIUM INJ 500MG, 2GM PENICILLIN G POTASSIUM INJ 1MMU, 5MMU, 20MMU PENICILLIN G PROCAINE 600000U, 1200000U PENICILLIN VK 250MG, 500MG, 125MG/5ML, 250MG/5ML TICAR INJ 1GM, 3GM TIMENTIN INJ 3.1GM/100ML TOTACILLIN N INJ 2GM UNASYN INJ 1.5GM, 3GM ZOSYN 2.25G/50ML, 3.375G/50ML, 4.5G/100ML ZOSYN INJ 2/0.25, 3/0.375, 4/0.5, 36/4.5 W1C-TETRACYCLINES DOXYCYCLINE HYCLATE 50MG, 100MG MINOCYCLINE HCL 50MG, 100MG SUMYCIN 125MG/5ML TETRACYCLINE HCL 250MG, 500MG VIBRAMYCIN 25MG/5ML SUSP VIBRAMYCIN CALCIUM 50MG/5ML SYRUP W1D-MACROLIDES AZITHROMYCIN 250MG, 500MG, 600MG AZITHROMYCIN IV 500MG AZITHROMYCIN PACKETS 1GM AZITHROMYCIN SUSP 100MG/5ML, 200MG/5ML CLARITHROMYCIN 250MG, 500MG CLARITHROMYCIN ER 500MG CLARITHROMYCIN SUSP 125MG/5ML, 250MG/5ML ERYPED DROPS 40MG/ML
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0 0 0 0 0 0 0 0 0 2 2 0 0 0 2 2 2 2 0 2 0 0 0 0 2 2 2 2 2 2
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Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N
0 0 2 0 2 2
N N N N N N
0 0 0 0 0 0 0 2
N N N N N N N N
AMEND
DRUG NAME ERYTHROMYCIN 250MG ERYTHROMYCIN 333MG ERYTHROMYCIN 500MG ERYTHROMYCIN ESTOLATE 125MG/5ML, 250MG/5ML ERYTHROMYCIN ETHYLSUCCINATE 400MG, 200MG/5ML, 400MG/5ML ERYTHROMYCIN LACTOBIONATE INJ 500MG/1GM ERYTHROMYCIN STEARATE 250MG, 500MG ERYTHROMYCIN W/ SULFISOXAZOLE 200/600 SUSP ZMAX 2GM/60ML W1F-AMINOGLYCOSIDES AMIKACIN SULFATE INJ 50MG/ML, 250MG/ML GENTAMICIN INJ 10MG/ML, 40MG/ML NEO-FRADIN 125MG/5ML NEOMYCIN SULFATE 500MG TOBI 300MG/5ML TOBRAMYCIN SULFATE 10MG/ML, 40MG/ML W1G-ANTITUBERCULAR ANTIBIOTICS RIFADIN 150MG RIFAMPIN 300MG RIFATER 120/50/300 W1H-AMINOCYCLITOLS TROBICIN W/DILUENT 2GM W1J-VANCOMYCIN AND DERIVATIVES VANCOCIN 125MG, 250MG VANCOCIN INJ 1GM VANCOMYCIN 500MG, 1GM W1K-LINCOSAMIDES CLEOCIN 300MG CLEOCIN 75MG, 75MG/5ML CLEOCIN PHOSPHATE INJ 150MG/ML CLINDAMYCIN HCL 150MG, 300MG CLINDAMYCIN PHOSPHATE INJ 150MG/ML LINCOCIN INJ 300MG/ML W1N-POLYMYXIN AND DERIVATIVES COLISTIMETHATE NA 150MG COLY-MYCIN M INJ 150MG W1P-BETA LACTAMS AZACTAM INJ 500MG, 1GM, 2GM W1Q-QUINOLONES AVELOX 400MG CIPRO SUSP (AGES 0-12) CIPROFLOXACIN 250MG, 500MG, 750MG W1S-CARBAPENEMS (THIENAMYCINS) PRIMAXIN IM/IV 250MG, 500MG
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0 0 0 0 0 0 0 0 2
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Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N N N N N N N
0 0 2 0 2 0
N N N N N N
0 0 2
N N N
2
N
2 2 0
N N N
0 2 2 0 0 2
N N N N N N
0 2
N N
2
N
2 * 0
N N N
2
N
AMEND
DRUG NAME W1W-CEPHALOSPORINS - 1ST GENERATION CEFADROXIL MONOHYDRATE 500MG CEFAZOLIN SODIUM INJ 500MG, 1GM, 10GM CEPHALEXIN 250MG, 500MG, 125MG/5ML, 250MG/5ML DURICEF 250MG/5ML, 500MG/5ML W1X-CEPHALOSPORINS - 2ND GENERATION CEFACLOR 250MG, 500MG CEFACLOR SUSP 125/5, 187/5, 250/5, 375/5ML CEFTIN SUSPENSION (AGE 0 THROUGH 12) CEFUROXIME 250MG, 500MG CEFUROXIME SODIUM INJ 750MG, 1.5GM ZINACEF INJ 750MG, 1.5GM W1Y-CEPHALOSPORINS - 3RD GENERATION CEDAX 400MG, 90MG/5ML SUSP CEFOTAXIME INJ 1GM CEFTRIAXONE 250MG, 500MG, 1GM, 2GM, 10GM CLAFORAN IM/IV 500MG, 1GM, 2GM FORTAZ INJ 500MG, 1GM, 2GM, 6GM OMNICEF 125MG/5ML, 250MG/5ML OMNICEF 300MG ROCEPHIN INJ 250MG, 500MG, 1GM, 2GM, 10GM TAZICEF INJ 1GM, 2GM, 6GM W1Z-CEPHALOSPORINS - 4TH GENERATION MAXIPIME INJ 500MG, 1GM, 2GM W2A-ABSORBABLE SULFONAMIDES AZULFIDINE ENTABS 500MG GANTRISIN SUSP 500MG/5ML SEPTRA IV 400/80 SULFADIAZINE 500MG SULFAMETHOXAZOLE/TRIMETHOPRIM INJ 400/80 SULFAMETHOXAZOLE/TRIMETHOPRIM SUSP 200&40/5 SULFAMETHOXAZOLE/TRIMETHOPRIM TAB 400/80, 800/160 SULFASALAZINE 500MG, EC500MG SULFISOXAZOLE 500MG W2E-ANTI-MYCOBACTERIUM AGENTS ETHAMBUTOL HCL 400MG ISONIAZID 100MG, 300MG, 50MG/5ML MYAMBUTOL 100MG, 400MG MYCOBUTIN 150MG PASER 4GM PYRAZINAMIDE 500MG TRECATOR-SC 250MG W2F-NITROFURAN DERIVATIVES FURADANTIN 25MG/5ML ORAL SUSP FUROXONE 100MG, 50MG/15ML LIQUID MACROBID 100MG
Effective October 1, 2007 March 20, 2008
Page 55 of 61
0 0 0 0
ELIGIBLE COVERED FOR DUAL
Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N N
0 0 * 0 0 2
N N N N N N
2 0 0 0 2 0 0 2 2
N N N N N N N N N
2
N
2 2 2 0 0 0 0 0 0
N N N N N N N N N
0 0 2 2 2 0 2
N N N N N N N
2 2 2
N N N
AMEND
DRUG NAME MACRODANTIN 25MG, 50MG, 100MG NITROFURANTOIN MONOHYDRATE MACRO 100MG W2G-CHEMOTHERAPEUTICS, ANTIBACTERIAL, MISC. HIPREX 1GM METHENAMINE HIPPURATE 1GM METHENAMINE MANDELATE 500MG, 1GM MONUROL 3GM PRIMSOL 50MG/5ML PROLOPRIM 100MG TRIMETHOPRIM 100MG UREX 1GM URINARY ANTISEPTIC VARIOUS URISED URITACT DS 81.6MG UTA 120-0.12MG UTIRA 81.6-0.12MG W3A-ANTIFUNGAL ANTIBIOTICS FULVICIN U/F 250MG GRIFULVIN V 500MG GRISEOFULVIN 125MG/5ML GRIS-PEG 125MG, 250MG NYSTATIN SUSP 100000U/ML, TAB 500,000U W3B-ANTIFUNGALS ANCOBON 250MG, 500MG KETOCONAZOLE 200MG MYCELEX 10MG TROCHE W3C-ANTIFUNGALS DIFLUCAN IN DEXTROSE 200MG/100ML, 400MG/200ML DIFLUCAN IN SALINE 200MG/100ML, 400MG/200ML DIFLUCAN SUSP 50/5, 200/5 FLUCONAZOLE 50MG, 100MG, 150MG, 200MG FLUCONAZOLE IN DEXTROSE 200MG/100ML, 400MG/200ML FLUCONAZOLE IN SALINE 200MG/100ML, 400MG/200ML LAMISIL 250MG TERBINAFINE HCL 250MG TABLET W4A-ANTIMALARIALS ARALEN PHOSPHATE 500MG CHLOROQUINE PHOSPHATE 250MG,500MG DARAPRIM 25MG FANSIDAR 500/25 HYDROXYCHLOROQUINE SULFATE 200MG MALARONE 62.5/25MG,250/100MG MEFLOQUINE 250MG PRIMAQUINE PHOSPHATE 26.3MG
Effective October 1, 2007 March 20, 2008
Page 56 of 61
0 0
ELIGIBLE COVERED FOR DUAL
Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N
2 0 0 2 2 2 0 2 0 2 2 2 2
N N N N N N N N N N N N N
2 2 0 2 0
N N N N N
2 0 0
N N N
2 2 0 0 0 0 2 0
N N N N N N N N
2 0 2 2 0 2 0 2
N N N N N N N N
AMEND
DRUG NAME QUALAQUIN 324MG QUININE SULFATE 260MG QUININE SULFATE 325MG W4C-AMEBACIDES HUMATIN 250MG PAROMOMYCIN 250 MG TINDAMAX 250MG, 500MG W4E-ANAEROBIC ANTIPROTOZOAL-ANTIBACTERIAL AGENTS FLAGYL ER 750MG METRONIDAZOLE 250MG, 500MG W4K-MISC ANTI-PROTOZOALS MEPRON 750MG/5ML NEBUPENT AEROSOL NEUTREXIN INJ 25MG PENTAMIDINE ISOETHIONATE 300MG INJ W4L-ANTHELMINTICS ALBENZA 200MG MEBENDAZOLE 100MG MINTEZOL 500MG, 500MG/5ML STROMECTOL 3MG W4M-ANTIPARASITICS ALINIA 100MG/5ML ALINIA 500MG W4O-MISC ANTI-INFECTIVES BILTRICIDE 600MG W4P-ANTI-LEPROTICS DAPSONE 25MG, 100MG W5A-ANTIVIRALS, GENERAL ACYCLOVIR 200MG, 400MG, 800MG, 200MG/5ML ACYCLOVIR SODIUM 500MG, 1000MG CYTOVENE 500MG CYTOVENE INJ 500MG/10ML FLUMADINE 50MG/5ML SYRUP FOSCARNET SODIUM 24MG/ML FOSCAVIR INJ 24MG/ML GANCICLOVIR 250MG, 500MG RELENZA 5MG RIMANTADINE 100MG TAMIFLU 12MG/ML TAMIFLU 30MG, 45MG, 75MG VALCYTE 450MG VALTREX 500MG, 1000MG W5C-ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITORS AGENERASE 15MG/ML AGENERASE 50MG, 150MG CRIXIVAN 100MG, 200MG, 333MG, 400MG
Effective October 1, 2007 March 20, 2008
Page 57 of 61
2 0 0
ELIGIBLE COVERED FOR DUAL
Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N
2 0 2
N N N
0 0
N N
2 2 2 0
N N N N
2 0 2 2
N N N N
2 2
N N
2
N
2
N
0 0 2 2 2 0 2 0 2 0 2 2 2 2
N N N N N N N N N N N N N N
2 2 2
N N N
AMEND
DRUG NAME INVIRASE 200MG, 500MG LEXIVA 700MG TABLET, 50MG/ML SUSPENSION NORVIR 100MG, 80MG/ML SOLN REYATAZ 100MG, 150MG, 200MG, 300MG VIRACEPT 250MG, 625MG, PED ORAL PDR 50MG/GM W5F-HEPATITIS B TREATMENT AGENTS BARACLUDE 0.05MG/ML BARACLUDE 0.5MG, 1MG EPIVIR HBV 100MG, 25MG/5ML HEPSERA 10MG TYZEKA 600MG W5G-HEPATITIS C TREATMENTS INFERGEN 9MCG/0.3ML, 15MCG/0.5ML PEGASYS 180MCG/ML PEGASYS SYRINGE 180MCG/ML PEG-INTRON 100MCG, 160MCG, 240MCG PEG-INTRON REDIPEN 120MCG/0.5, 150MCG/0.5 PEG-INTRON REDIPEN 50MCG/0.5, 80MCG/0.5 REBETOL 200MG REBETOL 40MG/ML W5I-ANTIVIRALS, HIV-SPECIFIC, NUCLEOTIDE ANALOG, RTI VIREAD 300MG W5J-ANTIVIRALS, HIV-SPECIFIC, NUCLEOSIDE ANALOG, RTI DIDANOSINE 200MG, 250MG, 400MG EMTRIVA 200MG EPIVIR 150MG, 300MG, 10MG/ML ORAL SOLN HIVID 0.375MG, 0.75MG RETROVIR 100MG, 10MG/ML SYRUP RETROVIR IV 10MG/ML VIDEX 25MG, 50MG, 100MG, 150MG, 200MG VIDEX EC 125MG, 200MG, 250MG, 400MG VIDEX PACKET 167MG, 250MG VIDEX PED SUSP 2GM/120MG, 4GM/240ML ZERIT 15MG, 20MG, 30MG, 40MG, 1MG/ML ORAL ZIAGEN 20MG/ML ZIAGEN 300MG ZIDOVUDINE 100MG, 300MG, 10MG/ML W5K-ANTIVIRALS, HIV-SPECIFIC, NON-NUCLEOSIDE, RTI RESCRIPTOR 100MG, 200MG SUSTIVA 50MG, 100MG, 200MG, 600MG VIRAMUNE 200MG, 50ML/5ML W5L-ANTIVIRALS, HIV-SPEC., NUCLEOSIDE ANALOG, RTI COMBO COMBIVIR 150MG/300MG EPZICOM 600-300MG TRIZIVIR 300-150MG
Effective October 1, 2007 March 20, 2008
Page 58 of 61
2 2 2 2 2
ELIGIBLE COVERED FOR DUAL
Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N N N
2 2 2 2 2
N N N N N
2 2 2 2 2 2 0 2
N N N N N N N N
2
N
0 2 2 2 2 2 2 2 2 2 2 2 2 0
N N N N N N N N N N N N N N
2 2 2
N N N
2 2 2
N N N
AMEND
DRUG NAME W5M-ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITOR COMBO KALETRA 25-100, 133.3-33.3, 500-200 KALETRA 400-100/5ML W5N-ANTIVIRALS, HIV-SPECIFIC, FUSION INHIBITORS FUZEON 90MG/ML W5O-ANTIVIRALS, HIV-SPEC, NUCLEOSIDE-NUCLEOTIDE ANALOG TRUVADA 200MG-300MG W5P-ANTIVIRALS, HIV-SPEC, NON-PEPTIDIC PROTEASE INHIB APTIVUS 250MG PREZISTA 300MG W5Q-ANTIRETROVIRAL COMB NUCLEOSIDE, NUCLEOTIDE, & NON-NUCLEOSIDE RTI ATRIPLA 600-200 W5T-ANTIVIRALS, HIV-SPECIFIC, CCR5 CO-RECEPTOR ANTAGONITSTS SELZENTRY TABLET 150MG, 300MG W5U-ANTIVIRALS, HIV-1 INTEGRASE STRAND TRANSFER INHIBITOR ISENTRESS 400MG W8F-IRRIGANTS ACETIC ACID SOLN 0.25% NEOSPORIN G.U. IRRIGANT SEA-CLENS SODIUM CHLORIDE SOLN 0.45%,0.9% SORBITOL SOLN 70% SORBITOL UROLOGIC IRRIGATION 3%,3.3% WATER FOR IRRIGATION, STERILE W8J-MISC ANTIBACTERIAL IRRIGANTS AMINOACETIC ACID IRRIGATION 1.5% GLYCINE W9A-KETOLIDES KETEK 300MG, 400MG Z2A-ANTIHISTAMINES (oral diphenhydramine may be available for dual eligible) A.R.M. 60-4MG CARBINOXAMINE DROPS, SYRUP 4MG/5ML CARBINOXAMINE/PSEUDO 4-60/5ML, 4/60, 8/120 CHLORPHENIRAMINE 4MG, 8MGTR, 12MGTR DEXCHLORPHENIRAMINE MALEATE 4MG, 6MG, 2MG/5ML DIPHENHYDRAMINE 25MG, 50MG, 12.5MG/5ML DIPHENHYDRAMINE INJ 10MG/ML, 50MG/ML MINTEX 30-2MG/5ML PROMETHAZINE 6.25MG/5ML, 12.5MG, 25MG, 50MG PSE 15/CPM 2 15-2MG CHEWABLE PSEUDO TAN/CHLORPHEN TAN 75-4.5/5ML SILDEC DROPS 15-1/ML SILDEC LIQ 45-4/5ML
Effective October 1, 2007 March 20, 2008
Page 59 of 61
2 2
ELIGIBLE COVERED FOR DUAL
Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N
2
N
2
N
2 2
N N
2
N
2
N
2
N
0 2 2 0 0 0 0
N N N N N N N
0 0
N N
2
N
2 0 0 0 0 0 0 2 0 0 0 0 0
N N N N N Y N N N N N N N
AMEND
DRUG NAME Z2D-HISTAMINE 2 INHIBITORS CIMETIDINE 200MG, 300MG, 400MG, 800MG, 300MG/5ML CIMETIDINE INJ 150MG/ML FAMOTIDINE 10MG FAMOTIDINE 20MG, 40MG, 10MG/ML INJ, 20MG/50ML INJ RANITIDINE 150MG, 300MG ZANTAC 150MG/10ML SYRUP, 15MG/ML ORAL SOLN (0-12 YRS) ZANTAC INJ 25MG/ML Z2E-IMMUNOSUPPRESSIVES AZASAN 75MG, 100MG AZATHIOPRINE 50MG CELLCEPT 200MG/ML CELLCEPT 250MG, 500MG CYCLOSPORINE 25MG, 50MG, 100MG, 100MG/ML GENGRAF 25MG, 100MG, 100MG/ML MYFORTIC 180MG, 360MG NEORAL 100MG/ML ORAL NEORAL 25MG, 100MG PROGRAF 0.5MG, 1MG, 5MG RAPAMUNE 1MG, 2MG RAPAMUNE 1MG/ML SANDIMMUNE 100MG/ML INJ SANDIMMUNE 25MG, 100MG Z2F-MAST CELL STABILIZERS CROMOLYN SODIUM 10MG/ML INH SOLN GASTROCOM 20MG/ML INTAL 800MCG INH 112 SPRAY, 200 SPRAY TILADE 1.75MG AEROSOL Z2G-IMMUNOMODULATORS INTRON A 6MMU, 10MMU, 18MMU, 50MMU INTRON A PEN DELIVERY SYSTEMS 3MMU, 5MMU, 10MMU Z2N-1ST GEN ANTIHISTAMINE & DECONGESTANT COMBINATIONS BROVEX ADT HISDEC 30-2/5 HISTEX 30MG-2MG/5ML HYDRO-TUSSIN CBX NALEX A 5-7.5-2.5MG/5ML PEDIOX 15-2MG PHENYLEPHRINE/BROMPHENIRAMINE 2.5-1MG/5 PHENYLEPHRINE/CHLORPHENIRAMINE 12.5-4MG/5ML, 3.5-1MG/ML RHINACON A 5-7.5-2.5MG/5ML SUPHEDRINE COLD & ALLERGY 60MG-4MG TRIAMINIC COLD & ALLERGY 15-1MG/5ML Z2O-2ND GEN ANTIHISTAMINE & DECONGESTANT COMBINATIONS ALAVERT 120-5MG ALLERGY AND CONGESTION RELIEF 240-10MG (PSE-LORAT)
Effective October 1, 2007 March 20, 2008
Page 60 of 61
0 0 0 0 0 * 2
ELIGIBLE COVERED FOR DUAL
Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N N N N N
2 0 2 2 0 2 2 2 2 2 2 2 2 2
N N N N N N N N N N N N N N
0 2 2 2
N N N N
2 2
N N
2 2 2 2 2 2 0 0 2 2 2
N N N N N N N N N N N
2 0
N N
AMEND
DRUG NAME ALLERGY RELIEF D 240-10MG LORATADINE D 240-10MG SEMPREX-D 60/8 Z2P-ANTIHISTAMINES - 1ST GENERATION BROMPHENIRAMINE 6MG BROVEX 12MG/5ML B-VEX 12MG/5ML CLEMASTINE 1.34MG, 2.68MG, 0.67MG/5ML HISTEX PD 12 2MG-6MG/5ML HYDROXYZINE HCL 10MG, 25MG, 50MG HYDROXYZINE HCL INJ 25MG/ML, 50MG/ML HYDROXYZINE HCL SYRUP 10MG/5ML HYDROXYZINE PAMOATE 25MG, 50MG, 100MG LODRANE 6MG (BROMPHENIRAMINE) LODRANE XR 8MG/5ML NOLAHIST 25MG PALGIC 4MG, 4MG/5ML PHENERGAN 25MG PROMETHAZINE HCL 12.5MG, 25MG, 50MG TAB PROMETHAZINE HCL INJ 25MG/ML, 50MG/ML PROMETHAZINE SYRUP 6.25MG/5ML TANACOF XR 8MG/5ML VAZOL 2MG/5ML VISTARIL 25MG/5ML ZYMINE 1.25MG/5ML Z2Q-ANTIHISTAMINES - 2ND GENERATION ALAVERT 10MG ALLERGY RELIEF 5MG/5ML (LORATADINE) LORATADINE 10MG ZYRTEC CHEW 5MG, 10MG (AGES 0-6) ZYRTEC SYRUP (AGES 0-6) Z4B-LEUKOTRIENE RECEPTOR ANTAGONISTS ACCOLATE 10MG, 20MG SINGULAIR 4MG, 5MG, 10MG SINGULAIR ORAL GRANULES 4MG
Effective October 1, 2007 March 20, 2008
Page 61 of 61
0 0 2
ELIGIBLE COVERED FOR DUAL
Appendix A
CO-PAYMENT
DRUG CLASS
5101:3-9-12
N N N
0 2 2 0 2 0 0 0 0 2 2 2 2 2 0 0 0 0 2 2 2
N N N N N N N N N N N N N N N N N N N N N
2 0 0 * *
N N N N N
2 2 2
N N N
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