2008 Medicare Assured SM Online Formulary

Download Printable Formulary (PDF) Request Medicare Assured SM Drug Exception Form View Recent Updates View Year to Date Updates
*NOTES
GC - Generic Covered PA - Prior Authorization
ST - Step Therapy QL - Quantity Limited
GA - Generic Available SP - Specialty Pharmacy
OTC - This drug does not count towards your total out of pocket expenditure and if you are receiving extra help to pay for your prescription, you will not receive any extra help to pay for it.

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Therapeutic CategoryTherapeutic ClassGeneric NameBrand NameNotes
Antihistamine DrugsFirst Generation AntihistaminesClemastine FumarateTavist GC
Antihistamine DrugsFirst Generation AntihistaminesCyproheptadine HClCyproheptadine HCl GC
Antihistamine DrugsFirst Generation AntihistaminesDexchlorpheniramine MaleateDexchlorpheniramine Maleate GC
Antihistamine DrugsFirst Generation AntihistaminesDiphenhydramine HClDiphenhydramine GC
Antihistamine DrugsFirst Generation AntihistaminesDiphenhydramine HCl InjBenadryl GC
Antihistamine DrugsFirst Generation AntihistaminesPromethazine HClPhenergan GC
Antihistamine DrugsFirst Generation AntihistaminesPromethazine HClPhenergan Suppository GC
Antihistamine DrugsSecond Generation AntihistaminesFexofenadineAllegra GC ST
Antihistamine DrugsSecond Generation AntihistaminesPseudoephedrine HCl/AcrivasSemprex-D
Antihistamine DrugsSecond Generation AntihistaminesLoratadineClaritin - OTC GC OTC
Anti-infective AgentsAdamantanesRimantadine HClFlumadine GC
Anti-infective AgentsAmebicidesParomomycin SulfateHumatin GC
Anti-infective AgentsAminoglycosidesGentamicin Sulfate InjGentamicin Sulfate GC
Anti-infective AgentsAminoglycosidesNeomycin SulfateNeomycin Sulfate GC
Anti-infective AgentsAminoglycosidesTobramycin Sulfate InjTobramycin Sulfate GC
Anti-infective AgentsAminoglycosidesTobramycin/0.25 Normal SalineTobi PA
Anti-infective AgentsAnthelminticsMebendazoleVermox GC
Anti-infective AgentsAnthelminticsPraziquantelBiltricide
Anti-infective AgentsAnthelminticsThiabendazoleMintezol
Anti-infective AgentsAntibacterials, MiscellaneousClindamycin HClCleocin HCl GC
Anti-infective AgentsAntibacterials, MiscellaneousClindamycin PalmitateCleocin Palmitate
Anti-infective AgentsAntibacterials, MiscellaneousClindamycin Phosphate InjCleocin Phosphate GC
Anti-infective AgentsAntibacterials, MiscellaneousColistimethate sodiumColistimethate sodium GC
Anti-infective AgentsAntibacterials, MiscellaneousDaptomycinCubicin
Anti-infective AgentsAntibacterials, MiscellaneousLinezolidZyvox PA QL
Anti-infective AgentsAntibacterials, MiscellaneousLinezolid InjZyvox PA
Anti-infective AgentsAntibacterials, MiscellaneousTetracyc HCl/Bis Ss/MetronidHelidac
Anti-infective AgentsAntibacterials, MiscellaneousVancomycin HClVancocin HCl
Anti-infective AgentsAntibacterials, MiscellaneousVancomycin HCl InjVancomycin HCL GC
Anti-infective AgentsAntifungalsAmphotericin BFungizone IV GC PA
Anti-infective AgentsAntifungalsFluconazoleDiflucan GC QL
Anti-infective AgentsAntifungalsFlucytosineAncobon
Anti-infective AgentsAntifungalsGriseofulvin UltramicrosizeGris-PEG
Anti-infective AgentsAntifungalsGriseofulvin, MicrosizeGrifulvin V GC
Anti-infective AgentsAntifungalsItraconazoleSporanox GC PA
Anti-infective AgentsAntifungalsKetoconazoleNizoral GC
Anti-infective AgentsAntifungalsNystatinMycostatin GC
Anti-infective AgentsAntifungalsTerbinafine HClLamisil GC QL
Anti-infective AgentsAntimalarialsAtovaquone/Proguanil HClMalarone
Anti-infective AgentsAntimalarialsChloroquine PhosphateAralen Phosphate GC
Anti-infective AgentsAntimalarialsHydroxychloroquine SulfatePlaquenil GC
Anti-infective AgentsAntimalarialsMefloquine HClLariam GC
Anti-infective AgentsAntimalarialsPrimaquine PhosphatePrimaquine
Anti-infective AgentsAntimalarialsPyrimethamineDaraprim
Anti-infective AgentsAntimalarialsPyrimethamine/SulfadoxineFansidar
Anti-infective AgentsAntimycobacterials, MiscellaneousDapsoneDapsone
Anti-infective AgentsAntiprotozoals, MiscellaneousAtovaquoneMepron
Anti-infective AgentsAntiprotozoals, MiscellaneousMetronidazoleFlagyl GC
Anti-infective AgentsAntiprotozoals, MiscellaneousPentamidine IsethionateNebupent
Anti-infective AgentsAntiretroviralsAbacavir SulfateZiagen
Anti-infective AgentsAntiretroviralsAbacavir Sulfate/LamivudineEpzicom
Anti-infective AgentsAntiretroviralsAbacavir/Lamivudine/ZidovudineTrizivir
Anti-infective AgentsAntiretroviralsAmprenavir/Vitamin EAgenerase
Anti-infective AgentsAntiretroviralsAmprenavir/Vitamin E/Prop GlyAgenerase Oral Soln
Anti-infective AgentsAntiretroviralsAtazanavir SulfateReyataz
Anti-infective AgentsAntiretroviralsDarunavir ethanolatePrezista
Anti-infective AgentsAntiretroviralsDelavirdine MesylateRescriptor
Anti-infective AgentsAntiretroviralsDidan/Calcium Carb/MagnesiumVidex
Anti-infective AgentsAntiretroviralsDidanosineVidex EC GC
Anti-infective AgentsAntiretroviralsEfavirenzSustiva
Anti-infective AgentsAntiretroviralsEfavirenz/Emtricitab/TenofovirAtripla
Anti-infective AgentsAntiretroviralsEmtricitabine Emtriva
Anti-infective AgentsAntiretroviralsEmtricitabine/TenofovirTruvada
Anti-infective AgentsAntiretroviralsEnfurvitideFuzeon PA QL
Anti-infective AgentsAntiretroviralsFosamprenavir CalciumLexiva
Anti-infective AgentsAntiretroviralsIndinavir SulfateCrixivan
Anti-infective AgentsAntiretroviralsLamivudineEpivir
Anti-infective AgentsAntiretroviralsLamivudineEpivir HBV
Anti-infective AgentsAntiretroviralsLamivudine/ZidovudineCombivir
Anti-infective AgentsAntiretroviralsNelfinavir MesylateViracept
Anti-infective AgentsAntiretroviralsNevirapineViramune
Anti-infective AgentsAntiretroviralsRitonavirNorvir
Anti-infective AgentsAntiretroviralsRitonavir/LopinavirKaletra
Anti-infective AgentsAntiretroviralsSaquinavir MesylateInvirase
Anti-infective AgentsAntiretroviralsStavudineZerit
Anti-infective AgentsAntiretroviralsTenofovir Disoproxil FumarateViread
Anti-infective AgentsAntiretroviralsTipranavirAptivus
Anti-infective AgentsAntiretroviralsZidovudineRetrovir GC
Anti-infective AgentsAntiretroviralsZidovudineRetrovir IV
Anti-infective AgentsAntituberculosis AgentsCycloserineSeromycin
Anti-infective AgentsAntituberculosis AgentsEthambutol HClMyambutol GC
Anti-infective AgentsAntituberculosis AgentsIsoniazidIsoniazid GC
Anti-infective AgentsAntituberculosis AgentsPyrazinamidePyrazinamide GC
Anti-infective AgentsAntituberculosis AgentsRifabutinMycobutin
Anti-infective AgentsAntituberculosis AgentsRifampinRifadin GC
Anti-infective AgentsAntituberculosis AgentsRifapentinePriftin
Anti-infective AgentsCephalosporinsCefaclorCeclor GC
Anti-infective AgentsCephalosporinsCefadroxil HydrateDuricef GC
Anti-infective AgentsCephalosporinsCefazolin Sodium InjCefazolin GC
Anti-infective AgentsCephalosporinsCefdinirOmnicef GC
Anti-infective AgentsCephalosporinsCefepime HClMaxipime
Anti-infective AgentsCephalosporinsCeftazidime Pentahydrate InjFortaz
Anti-infective AgentsCephalosporinsCeftazidime Pentahydrate InjTazicef
Anti-infective AgentsCephalosporinsCeftriaxone Sodium InjRocephin GC
Anti-infective AgentsCephalosporinsCefuroxime AxetilCeftin GC
Anti-infective AgentsCephalosporinsCefuroxime Sodium InjZinacef GC
Anti-infective AgentsCephalosporinsCephalexin MonohydrateKeflex GC
Anti-infective AgentsInterferonsInterferon Alfa-2A, Recomb.Roferon-A PA
Anti-infective AgentsInterferonsInterferon Alfa-2B, Recomb.Intron A (vials; 5, 10 mmu pens) PA
Anti-infective AgentsInterferonsInterferon Alfacon-1Infergen PA
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