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CMS/Medicare high-risk medication list

The Centers for Medicare and Medicaid Services (CMS) has identified the drugs listed here as posing a higher risk to patients, especially to seniors. These drugs will no longer be included in the Priority Health Medicare formulary as of Jan. 1, 2012.

Download and print a copy of the CMS High-Risk Medication guide (114KB PDF)

Key:

  • Boldface = higher risk
  • ALL CAPS = brand name
  • lower case = generic
  • Initial caps = OTC
  • NA = not available
  • ST = step therapy required
  • B/D = Medicare Part B/Part D determination needed for prior authorization

Medication Risk Alternative & tier

Amphetamines

  • amphetamine & dextroamphetamine (ADDERALL/XR)
  • benzphetamine (DIDREX)
  • dexmethylphenidate (FOCALIN/XR)
  • dextroamphetamine (DEXADRINE, DEXTROSTAT)
  • diethylpropion (DURAD, TENUATE, TEPANIL)
  • methamphetamine (DESOXYN)
  • methylphenidate (RITALIN/LA, CONCERTA, DAYTRANA, METADATE CD)
  • phendimetrazine (BONTRIL)
  • phentermine (ADIPEX-P)
 CNS stimulation: agitation, insomnia; hypertension, myocardial ischemia; dependence; appetite suppression NA

Analgesics

  • ketorolac (TORADOL)
 Gastrointestinal bleeding risk increased in elderly Mild pain:
APAP, not covered
ibuprofen, T1
naproxen, T1
meloxicam, T1

Moderate/severe pain:
tramadol, T1
morphine sulfate (MS Contin), T1
hydrocodone/APAP (VICODIN, etc.), T1
oxycodone (OxyIR), T1
oxycodone/APAP (PERCOCET), T1
fentanyl patch (DURAGESIC), T1
OXYCONTIN, T2
AVINZA, T3 (ST)

Anti-anxiety

  • meprobamate (EQUINIL)
  • aspirin/meprobamate (EQUAGESIC)
 Dependence; sedation; depression; confusion; falls; fractures; respiratory depression (especially in COPD) Anxiety:
buspirone (BUSPAR), T1

Sleep:
zolpidem (AMBIEN), T1
zalepon (SONATA), T1
LUNESTA, T3 (ST)
ROZEREM, T3 (ST)

Anti-emetics

  • scopolamine (SCOPACE, TRANSDERM-SCOP)
  • trimethobenzamide (TIGAN)
 Anticholinergic side effects: worsened cognition & behavioral problems (especially in dementia); urinary retention OR incontinence; questionable efficacy ondansetron (ZOFRAN), T1 (B/D)
granisetron (KYTRIL)), T1 (B/D)
prochlorperazine (COMPAZINE)), T1 (B/D)
metoclopramide (REGLAN) *), T1 (B/D)

*Avoid using long-term and/or in Parkinson's disease

Antihistamines


APAP= acetaminophen
PSE= pseudoephedrine
  • APAP/dextromethorphan/ diphenhydramine
  • APAP/diphenhydramine/ phenylephrine
  • APAP/diphenhydramine/PSE
  • APAP & diphenhydramine
  • carbetapentane/ diphenhydramine/ phenylephrine
  • codeine/promethazine/phenylephrine
  • codeine & promethazine
  • cyproheptadine
  • dexchlorpheniramine
  • dexchlorpheniramine/ dextromethorphan/ PSE
  • dexchlorpheniramine/ guaifenesin/PSE
  • dexchlorpheniramine/ hydrocodone/ phenylephrine
  • dexchlorpheniramine/ methscopolamine/ PSE
  • dexchlorpheniramine & PSE
  • dextromethorphan & promethazine
  • diphenhydramine
  • diphenhydramine/ hydrocodone/ phenylephrine
  • diphenhydramine & phenylephrine
  • diphenhydramine & PSE
  • diphenhydramine & magnesium salicylate
  • hydroxyzine hydrochloride
  • hydroxyzine pamoate
  • phenylephrine & promethazine
  • promethazine

Note: Various brand name drugs apply

 Anticholinergic side effects: worsened cognition & behavioral problems (especially in dementia); urinary retention OR incontinence; confusion; enhanced sedation levocetirizine, T1
CLARINEX, T3 (ST)
Medication Risk Alternative & tier

Antipsychotics

  • thioridazine (MELLARIL)
 CNS side effects; seizure risk; extrapyramidal effects: tremor, slurred speech, muscular rigidity, dystonia (involuntary muscle contractions), bradykinesia (slowing of movement), akathisia (inability to sit/stand still) haloperidol (Haldol), T1

The following atypical antipsychotics are associated w/ increased mortality when used to treat behavioral issues in elderly w/ dementia:
risperidone (RISPERDAL), T1
ABILIFY, T1
FANAPT, T2
GEODON, T3 (ST)
INVEGA, T3 (ST)
SEROQUEL, T2
ZYPREXA, T2

Barbiturates

  • butabarbital (BUTISOL)
  • mephobarbital (MEBARAL)
  • pentobarbital (NEMBUTAL)
  • phenobarbital (LUMINAL)
  • secobarbital (SECONAl)
 Higher risk of side effects: falls; fractures; confusion; cognitive impairment; dependence Sleep:
zolpidem (AMBIEN), T1
zalepon (SONATA), T1
LUNESTA, T3 (ST)
ROZEREM, T3 (ST)

Belladona alkaloids


CPM=chlorpheniramine

PE=phenylephrine
  • atropine
  • atropine/ CPM/ hyoscyamine/ PE/ scopolamine (STA-D)
  • atropine/ hyoscyamine/ phenobarbital/ scopolamine (BELLADONNA ALKALOIDS, DONNATAL, ANTISPASMODIC ELIXIR)
  • atropine & difenoxin (MOTOFEN)
  • atropine & diphenoxylate (LOMOTIL, LONOX, LOGEN, LOMANATE)
  • atropine & edrophonium (ENLON)
  • belladonna
  • belladonna/ ergotamine/ phenobarbital (BELLAMINE)
  • butabarbital/ hyoscyamine/ phenazopyridine (BELLAMINE)
    (PHENAZOPYRIDEINE PLUS, PHENAZOFORTE PLUS)
  • digestive-enzymes/ hyoscyamine/ phenyltoloxamine (DIGEX NF)
  • hyoscyamine (HYOMAX, LEVSIN,LEVSINEX, NULEV, SYMAX)
  • hyoscyamine/ methenam/ m-blue/ phenyl salicyl (URISED, USEPT)
 Anticholinergic AEs: worsened cognition & behavioral problems (especially in dementia); urine retention; agitation & delirium Constipation:
psyllium fiber (Metamucil), Not covered
polyethylene glycol (Miralax), Not covered
docusate, not covered

Diarrhea:
loperamide (Imodium), T1
Aluminum hydroxide, Not covered

Benzodiazepines (long-acting)

  • amitriptyline & chlordiazepoxide (LIMBITROL DS) 
  • chlordiazepoxide (LIBRIUM)
  • chlordiazepoxide & clidinium (LIBRAX)
  • diazepam (VALIUM)
  • flurazepam (DALMANE)
 Dependence; depression; prolonged sedation; confusion; falls; fractures; respiratory depression (especially in COPD); accumulation of drug Anxiety:
buspirone (BUSPAR), T1

Sleep:
zolpidem (AMBIEN), T1
zalepon (SONATA), T1
LUNESTA, T3 (ST)
ROZEREM, T3 (ST)

Calcium channel blockers

  • nifedipine (short-acting immediate release only) (ADALAT CC, PROCARDIA)
 Hypotension; constipation nifedipine ER (PROCARDIA XL), T1

Gastrointestinal anti-spasmodics

  • dicyclomine (BENTYL)
  • propantheline (PROBANTHINE)
 Anticholinergic side effects: worsened cognition & behavioral problems (especially in dementia); urinary retention OR incontinence; questionable efficacy Constipation:
psyllium fiber (Metamucil), Not covered
polyethylene glycol (Miralax), Not covered
docusate, Not covered

Diarrhea:
loperamide (Imodium), T1
aluminum hydroxide, Not covered
Medication Risk Alternative & tier

Narcotics


ASA=aspirin
APAP= acetaminophen
  • ASA/caffeine/propoxyphene (DARVON COMPOUND)
  • APAP & pentazocine (TALACEN)
  • APAP & propoxyphene (DARVOCET)
  • belladonna & opium (B&O SUPPRETTES) 
  • meperidine (DEMEROL)
  • meperidine & promethazine (MEPROZINE)
  • naloxone & pentazocine
    (TALWIN NX)
  • pentazocine (TALWIN)
  • propoxyphene hydrochloride (DARVON)
  • propoxyphene napsylate (DARVON)
 Enhanced CNS effects: confusion, hallucinations; falls; fractures; seizure risk Mild pain:
APAP, Not covered
ibuprofen, T1
naproxen, T1
meloxicam, T1

Moderate/severe pain:
tramadol, T1
morphine sulfate (MS Contin), T1
hydrocodone/APAP (VICODIN, etc.), T1
oxycodone (OXY IR), T1
oxycodone/APAP (PERCOSET), T1
fentanyl patch (DURAGESIC), T1
OXYCONTIN, T2
AVINZA, T3 (ST)

Oral estrogens

  • conjugated estrogen (PREMARIN)
  • conjugated estrogen & medroxyprogesterone (PREMPRO, PREMPHASE)
  • esterified estrogen (MENEST)
  • esterified estrogen & methyltestosterone (COVARYX, ESTRATEST)
  • estropipate (OGEN, ORTHO-EST)
 Increased risk of breast &/or endometrial cancer; NOT cardioprotective

estradiol tablets, T1

Hot flashes (non-drug therapy should be emphasized):
venlafaxine (EFFEXOR), T1
paroxetine (PAXIL), T1
fluoxetine (PROZAC), T1
sertraline (ZOLOFT), T1
gabapentin, T1

Bone density:
calcium, Not covered
vitamin D, Not covered
alendronate (FOSAMAX), T1
ACTONEL, T2
BONIVA, T3
EVISTA, T2

Transdermal estrogen:
estradiol patch, T1
ALORA patch, T2
ESTRASORB, T2
CLIMARA PRO patch, T2
VELLE-DOT, T2
MENOSTAR patch, T2
DIVIGEL topical gel, T2
ELESTRIN topical gel, T2
EVAMIST topical spray, T2

Oral hypoglycemics

  • chlorpropamide (DIABINESE, INSULASE)
 Prolonged hypoglycemia; risk of SIADH glimepiride (AMARYL), T1
glipizide (GLUCOTROL), T1

NOTE: Avoid glyburide (MICRONASE, GLUCOTROL XL) because of increased hypoglycemia risk
Medication Risk Alternative & tier

Skeletal muscle relaxants


ASA=aspirin
  • ASA/ caffeine/ orphenadrine
  • ASA/ carisoprodol/ codeine
  • ASA & carisoprodol
  • ASA & methocarbamol
  • carisoprodol (SOMA) 
  • chlorzoxazone (PARAFON FORTE)
  • cyclobenzaprine (FLEXERIL, AMRIX, FEXMID)
  • metaxalone (SKELAXIN)
  • methocarbamol (ROBAXIN)
  • orphenadrine (NORFLEX)
 Anticholinergic side effects: worsened cognition & behavioral problems (especially in dementia); urinary retention OR incontinence; confusion sedation; weakness; questionable efficacy (at lower doses) baclofen (LIORESAL), T1
tizanidine (ZANAFLAX), T1

Vasodilators

  • dipyridamole (short-acting only) (PERSANTINE)
  • ergot mesyloid (ERGOMAR)
  • isoxsuprine (VASODILAN)
 Orthostatic hypotension; ineffective for stroke prevention; unproven &/or questionable efficacy Stroke prevention:
aspirin, Not covered
PLAVIX, T2
AGGRENOX, T2

Alzheimer's/dementia:
galantamine, T1
rivastigmine, T1
ARICEPT, T2
EXELON, T2
Medication Risk Alternative & tier

OTHER

(androgen, anabolic steroid; thyroid drug; urinary anti-infectives)
  • methyltestosterone (ANDROID, TESTRED)
  • nitrofurantoin (FURADANTIN)
  • nitrofurantoin macrocrystals (MACRODANTIN)
  • nitrofurantoin macrocrystals-monohydrate (MACROBID)
  • thyroid desiccated
    (ARMOUR THYROID)
 Methyltestosterone = cardiac side effects & prostatic enlargement in men

Nitrofurantoin = nephrotoxicity (kidney)

Thyroid desiccated = cardiac AEs		 NA

Urinary tract infections:
ciprofloxacin, T1
trimethoprim-sulfamethoxazole (BACTRIM DS), T1

Thyroid:
levothyroxine (SYNTHROID), T1
levoxyl, T1

References

  1. Fick DM, Cooper JW, Wade WE, Waller JL, Maclean JR, Beers MH. Updating the beers criteria for potentially inappropriate medication use in older adults. Arch Intern Med. 2003; 163(22): 2716-24.
  2. Simon SR, Chan A, Soumerai SB, Wagner AK, Andrade SE, Feldstein AC, et al. Potentially inappropriate medication use by elderly persons in U.S. health maintenance organizations, 2000-2001. J Am Geriatr Soc. 2005; 53(2): 227-32.
  3. Chang CM, Liu PY, Yang YK, Yang YC, Wu C, Lu F. Use of the beers criteria to predict adverse drug reactions among first-visit elderly outpatients. Pharmacotherapy. 2005; 25(6): 831-38.
  4. Potentially harmful drugs in the elderly: beers list and more. Pharmacist’s Letter/Prescriber’s Letter 2007; 23(9):230907.
Last modified: 4/18/2012
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