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Pending Changes to the Formularies

From time to time, we add drugs to or remove them from the PriorityMedicareSM formularies. We also may change their tier, which determines how much you pay for them. We make these changes based on the scientific evidence we have of their value in helping people get well and stay healthy.

If You Are Taking a Drug That Is Being Removed
If we remove drugs from a formulary during the year, we will notify you of the change at least 60 days before the date that the change becomes effective. You may ask PriorityMedicare to make an exception to the formulary for you. We must make a decision within 72 hours of your request. Contact us to make these requests at our regular member Customer Service numbers.

Current and Pending Changes to the Formularies


KEY:
  • PA = Prior Authorization needed
  • QL = Quantity Limits
  • ST = Step Therapy required

Additions to the Formularies:
Drug Name Effective Date Tier Category
etoposide 4/1/2007 1 Antineoplastics
meloxicam 4/1/2007 1 Anti-inflammatories
prednicarbate 4/1/2007 1 Hormonal agents, stimulant/ replacement/ modifying (adrenal)
trimipramine
maleate		 4/1/2007 1 Antidepressants
amlodipine
besylate		 7/1/2007 1 Cardiovascular agents
amylase/
lipase/ protease		 7/1/2007 1 Enzyme replacements/ modifiers
benzoyl peroxide 7/1/2007 1 Antibacterials
brompheniramine
tannate		 7/1/2007 1 Respiratory tract agents
bupropion hcl xl 7/1/2007 1 Antidepressants
ceftriaxone 7/1/2007 1 Antibacterials
colestipol hcl 7/1/2007 1 Cardiovascular agents
combiflex 7/1/2007 1 Analgesics
estradiol transdermal
patch		 7/1/2007 1 Hormonal agents, stimulant/ replacement/ modifying (sex hormones/ modifiers)
hydrocortisone acetate w/urea 7/1/2007 1 Dermatological agents;
hormonal agents, stimulant/ replacement/ modifiying (adrenal); ophthalmic agents
hyoscyamine
sulfate		 7/1/2007 1 Genitourinary agents
jolessa 7/1/2007 1 Hormonal agents, stimulant/ replacement/ modifying (sex
hormones/ modifiers)
methscopolamine bromide 7/1/2007 1 Gastrointestinal agents
metronidazole vaginal 7/1/2007 1 Antiparasitics
metoprolol
succinate		 7/1/2007 1 Cardiovascular agents
naltrexone 7/1/2007 1 Antidotes, deterrents, and toxicologic agents
nitroglycerin transdermal 7/1/2007 1 Cardiovascular agents
ondansetron
(PA/QL)
 7/1/2007 1 Antiemetics
oxybutynin
chloride er		 7/1/2007 1 Genitourinary agents
permethrin 7/1/2007 1 Antiparasitics
pilocarpine hcl 7/1/2007 1 Antimyasthenic agents
potassium citrate 7/1/2007 1 Therapeutic nutrients/ minerals/ electrolytes
prolastin 7/1/2007 1 Respiratory tract agents
quasense 7/1/2007 1 Hormonal agents, stimulant/ replacement/ modifying (sex
hormones/ modifiers)
tranylcypromine sulfate 7/1/2007 1 Antidepressants


Changes to/Removals from the Formularies:


Drug Name Effective Date Tier Category Formulary Alternative Tier Removal Reason
chlorpheniramine/
pseudoephedrine		 7/1/2007 1 Respiratory tract agents loratadine-D 1 No longer covered by Medicare
QUINERVA 7/1/2007 1 Antiparasitics primaquine phosphate 1 Significant risk of serious side effects
quinine sulfate 7/1/2007 1 Antiparasitics primaquine phosphate 1 Significant risk of serious side effects
XOPENEX 7/1/2007 3 Respiratory tract agents N/A N/A Tier change
ZADITOR 7/1/2007 1 Ophthalmic agents ketotifen fumarate 1 No longer covered by Medicare
ACTICIN 9/1/2007 2 Antiparasitics permethrin 1 Generic now available
ANUSOL-HC 9/1/2007 2 Hormonal agents, stimulant/ replacement/ modifying (adrenal) hydrocortisone 1 Generic now available
ARALAST 9/1/2007 2 Respiratory tract agents prolastin 1 Generic now available
BROVEX 9/1/2007 2 Respiratory tract agents brompheniramine tannate 1 Generic now available
CLIMARA 9/1/2007 2 Hormonal agents, stimulant/ replacement/ modifying (sex hormones/ modifiers) estradiol transdermal patch 1 Generic now available
COLESTID 9/1/2007 2 Cardiovascular agents colestipol hcl 1 Generic now available
DERMATOP E Emollient Ointment 9/1/2007 2 Hormonal agents, stimulant/ replacement/ modifying (adrenal) prednicarbate 1 Generic now available
DOLOREX 9/1/2007 2 Analgesics anabar 1 Generic now available
DURABAC 9/1/2007 2 Analgesics combiflex 1 Generic now available
KAYEXALATE 9/1/2007 2 Antidotes, deterrents, and toxicologic agents sodium polystyrene sulfonate 1 Generic now available
KLARON 9/1/2007 3 Antibacterials sulfacetamide sodium 1 Generic now available
MOBIC 9/1/2007 3 Anti- inflammatories meloxicam 1 Generic now available
NORVASC 9/1/2007 2 Cardiovascular agents amlodipine besylate 1 Generic now available
PAMINE 9/1/2007 3 Gastrointestinal agents methscopolamine bromide 1 Generic now available
PARNATE 9/1/2007 2 Antidepressants tranylcypromine sulfate 1 Generic now available
RIFAMATE 9/1/2007 2 Antimyco- bacterials isoniazid 1 Generic now available
ROCEPHIN 9/1/2007 2 Antibacterials ceftriaxone 1 Generic now available
SURMONTIL 9/1/2007 2 Antidepressants trimipramine maleate 1 Generic now available
TRIAZ 9/1/2007 3 Antibacterials benzoyl peroxide 1 Generic now available
URO BLUE 9/1/2007 2 Genitourinary agents hyoscyamine sulfate 1 Generic now available
ZITHROMAX 9/1/2007 2 Antibacterials azithromycin 1 Generic now available
ZOFRAN 9/1/2007 2 Antiemetics ondansetron 1 Generic now available
AMIGESIC 10/1/2007 2 Analgesics salsalate 1 Generic now available
CARMOL 40 10/1/2007 Dermatological agents urea 1 Generic now available
CARMOL-HC 10/1/2007 2 Dermatological agents;
hormonal agents, stimulant/ replacement/ modifiying (adrenal); ophthalmic
agents		 hydrocortisone acetate w/urea 1 Generic now available
DEPADE 10/1/2007 2 Antidotes, deterrents, and toxicologic agents naltrexone hcl 1 Generic now available
DITROPAN XL 10/1/2007 2 Genitourinary agents oxybutynin chloride er 1 Generic now available
DURAGESIC 10/1/2007 1 Analgesics fentanyl 1 Generic now available
KETEK 10/1/2007 2 Antibacterials azithromycin 1 New black box warnings
METROGEL VAGINAL 10/1/2007 2 Antiparasitics metronidazole vaginal 1 Generic now available
MINITRAN 10/1/2007 2 Cardiovascular agents nitroglycerin transdermal 1 Generic now available
PANCREASE MT 10/1/2007 3 Enzyme replacements/ modifiers amylase/ lipase/ protease 1 Generic now available
TOPOSAR 10/1/2007 2 Antineoplastics etoposide 1 Generic now available
UROCIT K 10/1/2007 3 Therapeutic nutrients/ minerals/ electrolytes potassium citrate 1 Generic now available


Drugs Medicare Does Not Cover


No Medicare Part D plan covers these drugs:
  • Drugs for anorexia, weight loss, or weight gain (i.e., Xenical, Meridia, phentermine HCl, etc.).
  • Drugs that promote fertility (i.e., Clomid, Gonal-f, Ovidrel, Follistim, etc.).
  • Drugs for cosmetic purposes or hair growth (i.e., Propecia, Renova, Vaniqa, etc.).
  • Drugs for the symptomatic relief of cough and colds (i.e., Phenergan w/Codeine, Robitussin AC, Tanafed, Tessalon Perle, etc.).
  • Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations (i.e., Nephrocaps, Foltx, Cyanocobalamin, etc.).
  • Nonprescription drugs other than Prilosec OTC and loratadine products.
  • Barbiturates (i.e., Phenobarbital, Seconal Sodium, Butisol Sodium, etc.).
  • Benzodiazepines (i.e., clorazepate dipotassium, Ativan (lorazepam), Valium (diazepam), Xanax (alprazolam), Librium (chlordiazepoxide HCl), Serax (oxazepam), etc.).
  • Drugs for sexual dysfunction (i.e., Viagra, Cialis, Levitra, Muse, Caverject)--effective 1/1/07.
  • Non-FDA-Approved products
  • DESI drugs (see explanation of DESI drugs, below)
  • Bulk Chemicals in the following STCs:  U6I, U6Q, U6U, U6W, and U6X.  Bulk chemicals do not meet the definition of a Part D covered drug (FDA-approved, prescription medication with a compendial indication)--effective 7/1/2007. 

DESI Drugs

A DESI (drug efficacy study implementation) drug is one that the FDA has determined to be safe, but not effective.  The following DESI drugs are not covered by any Medicare Part D plans:

  • Alcortin gel
  • Amidrine capsule
  • Analpram HC 2.5% cream
  • APAP-Isomethep-Dichlphen cap
  • Belladonna/Phenobarb tablet
  • Bellaspas tablet
  • Clidinium/CDP capsule
  • Duradrin capsule
  • EEMT HS tablet
  • Epidrin capsule
  • Essian tablet
  • Estratest H.S. tablet
  • Estrogen-Methyltestost H.S. tab
  • HC Pramoxine 2.5% cream
  • HC Pramoxine 2.5% rectal cream
  • Hemorrhoidal HC 25mg supp
  • Hydrocortisone AC 25mg supp
  • Isometh/D-Chloralphenz/APAP
  • Isoxsuprine 10mg tablet
  • Migquin capsule
  • Migratine capsule
  • Migrin-A capsule
  • Pramosone 1% cream
  • Proctosert HC 30mg supp
  • Rectasol-HC 25mg supp
  • Syntest D.S. tablet
  • Tebamide 200mg supp
  • Trimethobenzamide 200mg supp

Updates to Medicare's Non-Covered Drug List In 2007:

Description Eff. Date Note
Analgesics, Narcotics/Dietary Supplement Combo
Example: Theracodophen
 12/20/2006 Non-FDA-Approved product
Antivenins
Example: Snake antivenin
 1/1/2006 Not available via pharmacy distribution
Antidiarrheal Microorg. Agents 1/1/2007 Non-FDA-Approved product
Grafco Silver Nitrate Applicator 1/1/2007 Not FDA-approved
Hypoglycemics, Biguanide Type_Dietary Supp. Comb.
Example: Appformin, Appformin-D
 1/18/2007 Medical food/drug combination package product; not FDA-approved (new STC)
Contraceptives, Implantable
Example: Implanon
 1/23/2007 Implanon removed from the proxy file
Hemmorhoidal HC Crm. 1/23/2007 DESI
Xenaderm Oint. 1/23/2007 DESI
Granulex Spray 1/23/2007 DESI
Proctofoam-HC 1/23/2007 DESI
Epifoam 1/23/2007 DESI
Analpram HC Lotion 1/23/2007 DESI
Analpram HC Cream 1/23/2007 DESI
Numobid Tablet SA 1/23/2007 Not FDA-approved
Bucalcide Spray 1/23/2007 Not FDA-approved
Ryna-12X Tablet 1/23/2007 Not FDA-approved
Ryna-12X Susp. 1/23/2007 Not FDA-approved
Mimyx Cream 1/23/2007 Not FDA-approved
Caphosol Solution 1/23/2007 Not FDA-approved
Bucalsep Spray 1/23/2007 Not FDA-approved
Bucalsep Solution 1/23/2007 Not FDA-approved
Guaif/Pseudoeph. 600/60 Tab SR 1/23/2007 Not FDA-approved
Guaif/Pseudpeph. 1200/120 Tab SR 1/23/2007 Not FDA-approved
Non-Narcotic Antituss-Decon-Expect with Zinc Comb.
Example: Zinx
 1/26/2007 Part D Cough/Cold Exclusion (new STC)
Non-Narcotic-Antitussive-Decongest with Zinc Comb.
Example: Zinx
 1/26/2007 Part D Cough/Cold Exclusion (new STC)
Aquoral Spray/Pump 2/1/2007 Not FDA-approved as a drug
Dietary Supplement, Miscellaneous (Cont. 2)
Example: Lister-V
 2/7/2007 Medical food; not FDA-approved.  All other products in class are OTC (new STC)
Digoxin 500mcg tablet 3/1/2007 Not FDA-approved
Dyphylline elixir 3/1/2007 Not FDA-approved
Guaifenesin/Dyphylline elixir 3/1/2007 Not FDA-approved
Guaifenesin/Dyphylline 400/200mg tablet 3/1/2007 Not FDA-approved
Guaifenesin/Dyphylline syrup 3/1/2007 Not FDA-approved
Guaifenesin/Dyphylline 300/200mg tablet 3/1/2007 Not FDA-approved
Guaifenesin/Dyphylline 100/200mg tablet 3/1/2007 Not FDA-approved
Guaifenesin/Dyphylline liquid 3/1/2007 Not FDA-approved
Guaifenesin/Dyphylline liquid 3/1/2007 Not FDA-approved
Guaifenesin/Dyphylline syrup 3/1/2007 Not FDA-approved
Guaifenesin/Dyphylline 200/200 tablet 3/1/2007 Not FDA-approved
Guaif/Phenyleph/Pseudoeph susp. 3/1/2007 DESI
Stannous Fluoride 0.4% gel 3/1/2007 Not FDA-approved
Diphenhydramine 50mg tablet 3/1/2007 Not FDA-approved
HC Acetate/Lidocaine/Aloe gel 3/1/2007 Not FDA-approved
HC Acetate/Lidocaine cream kit 3/1/2007 Not FDA-approved
HC Acetate/Lidocaine cream kit 3/1/2007 Not FDA-approved
HC Acetate/Lidocaine cream 3/1/2007 Not FDA-approved
HC Acetate/Lidocaine lotion 3/1/2007 Not FDA-approved
HC/Pramoxine/Chloroxylenol ear drops 3/1/2007 DESI
HC/Pramoxine/Chloroxylenol ear drops 3/1/2007 DESI
HC/Pramoxine/Chloroxylenol lotion 3/1/2007 DESI
HC/Pramoxine/Chloroxylenol ear drops 3/1/2007 DESI
Ibuprofen 100mg/5ml susp 3/1/2007 OTC
Diphenhydramine 12.5mg/5ml syrup 3/1/2007 OTC
Diphenhydramine 50mg tablet 3/1/2007 OTC
Analpram HC 1% Cream Singles 4/23/2007 DESI per 2/20/07 Medicaid Drug Rebate Program
Optase Gel 4/23/2007 DESI per 2/20/07 Medicaid Drug Rebate Program
Ergocaff PB Suppository 4/23/2007 DESI per 2/20/07 Medicaid Drug Rebate Program
Trepadone Capsule 4/23/2007 Not FDA-approved as a drug
Ammonium Lactate 12% cream 6/1/2007 No valid FDA application on file
Benzoyl Peroxide/Sulfur combination products 6/1/2007 No valid FDA application on file
Brompheniramine Maleate products 6/1/2007 No valid FDA application on file
Carbachol drops 6/1/2007 No valid FDA application on file
Chlor-Mal/Methscopolamine Nit 8-2.5mg tab.SR 12H 6/1/2007 No valid FDA application on file
Chlorpheniramine Maleate capsules 6/1/2007 No valid FDA application on file
Dexchlorpheniramine Maleate tablets 6/1/2007 No valid FDA application on file
Guaifen/Phenylephrine/APAP 30mg-250mg tab. SR 12H 6/1/2007 No valid FDA application on file
Guaifenesin/P-ephed HCl combination products 6/1/2007 No valid FDA application on file
Guaifenesin/Phenylephrine HCl combination products 6/1/2007 No valid FDA application on file
Guaifenesin/Theophylline combination products 6/1/2007 No valid FDA application on file
HC Acetate/Lidocaine HCl 0.5-3% Cream/Appl 6/1/2007 No valid FDA application on file
Hydrocortisone 10% gel 6/1/2007 No valid FDA application on file
Hyoscyamine Sulfate 0.375mg 6/1/2007 No valid FDA application on file
Lactic Acid 10% lotion and cream 6/1/2007 No valid FDA application on file
Lidocaine HCl 2% jel 6/1/2007 No valid FDA application on file
Lidocaine HCl 20mg/ml solution 6/1/2007 No valid FDA application on file
Lidocaine HCl 3% cream 6/1/2007 No valid FDA application on file
Lidocaine HCl 3% lotion 6/1/2007 No valid FDA application on file
Na Sulfacetamide/Avobenzone/Sulfur 10%-5% cream 6/1/2007 No valid FDA application on file
P-Ephed HCl/Acetaminophen/D-Cp 45-650-2mg tablet 6/1/2007 No valid FDA application on file
P-Ephed HCl/Brompheniramine combination prodcuts 6/1/2007 No valid FDA application on file
P-Ephed HCl/Chlor-Mal/Scop combination products 6/1/2007 No valid FDA application on file
P-Ephed HCl/Dexchlorphen 60mg-4mg Tab.SR 12H 6/1/2007 No valid FDA application on file
P-Ephed HCl/Dexchlorphen/Scop 45-3.5-1mg Tab.SR 12H 6/1/2007 No valid FDA application on file
P-Ephed HCl/Methscopolamine 120-2.5mg Tab.SR 12H 6/1/2007 No valid FDA application on file
P-Ephed HCl/Triprolidine HCl 45-1.25/5 liquid 6/1/2007 No valid FDA application on file
P-Ephed Sul/D-Bromp mal 120-6mg Tab.SR 12H 6/1/2007 No valid FDA application on file
Phenazopy HCl/Hyoscy/Butabarb 150-0.3-15 Tablet 6/1/2007 No valid FDA application on file
Phenylephrine HCl/Chlor-Mal combination products 6/1/2007 No valid FDA application on file
Phenylephrine HCl/APAP/{ryil/Cp 5-300-2mg Tablet 6/1/2007 No valid FDA application on file
Phenylephrine/Brompheniramine combination products 6/1/2007 No valid FDA application on file
Phenylephrine/Chlor-Mal/Scop combination products 6/1/2007 No valid FDA application on file
Phenylephrine/Phenyltolox/Cp 20-50-4mg Cap.SR 12H 6/1/2007 No valid FDA application on file
Phenylephrine/P-Tlox Ci/Cp combination products 6/1/2007 No valid FDA application on file
Phenylephrine/Pyril Mal/Cp combination products 6/1/2007 No valid FDA application on file
Pnv/Fe,Carbo/Doss/FaLm-Folate 90-50-1mg Tablet 6/1/2007 No valid FDA application on file
Prental Vit/Fe Fumarate/Fa 27-0.8mg Tablet 6/1/2007 No valid FDA application on file
Prental Vit/Fe Fumarate/Fa 29mg-1mg Tab Chew 6/1/2007 No valid FDA application on file
Prenatal Vits W-Ca,Fe,Fa (<1mg) Tablet 6/1/2007 No valid FDA application on file
Progesterone 100mg Supp.Vag 6/1/2007 Compounding Kit; no valid FDA application on file
Progesterone 200mg Supp.Vag 6/1/2007 Compounding Kit; no valid FDA application on file
Progesterone 50mg Supp.Vag 6/1/2007 Compounding Kit; no valid FDA application on file
Progesterone,Micronized 10% Cream 6/1/2007 Compounding Kit; no valid FDA application on file
Progesterone,Micronized 5% Cream 6/1/2007 Compounding Kit; no valid FDA application on file
Pseudoephed Pl/Chlorphen Polac 30mg-4mg Tab Chew 6/1/2007 No valid FDA application on file
Pseudoephed Pl/Chlorphen Polis 30-6mg/5ml Sus. 12H SR 6/1/2007 No valid FDA application on file
Pseudoephedrine HCl/Chlor-Mal combination products 6/1/2007 No valid FDA application on file
Pyril Mal/Phenlytolox/Phenir 4-4-4mg/5ml Liquid 61/2007 No valid FDA application on file
Sulfacetamide Sodium 10% drops, cream, foam, gel, liquid, ointment 6/1/2007 No valid FDA application on file
Sulfacetamide Sodium/Sulfur 10%-5% cleanser, gel, med. pad, lotion, cream, suspension 6/1/2007 No valid FDA application on file
Sulfuric Acid/Sulf Phenol 30%-50% Solution 6/1/2007 No valid FDA application on file
Testosterone Propionate 2% cream, ointment 6/1/2007 Compounding Kit; no valid FDA application on file
Tetracaine/Benzocaine/Butamben 2-14-2% Spray 6/1/2007 No valid FDA application on file
Triprolidine HCl 1.25mg/5ml Syrup 6/1/2007 No valid FDA application on file



H2320_4000_4006_59 F&U (01/07) S5857_4000_4006_59 F&U (01/07)
Last modified 11/01/07