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2010 Medicare Assured^® HMO Online Formulary:
Recent Updates

A formulary (sometimes called a “Drug List”) is a list of Part D prescription drugs covered by Gateway Health Plan Medicare Assured^® HMO. The drugs on this list are selected by the Plan with the help of a team of doctors and pharmacists. The list must meet requirements set by Medicare. Medicare has approved the Medicare Assured^® HMO Drug List.

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*Notes
GC - Generic Covered	PA - Prior Authorization
ST - Step Therapy	QL - Quantity Limited
GA - Generic Available	SP - Specialty Pharmacy
Drug Tier 1 = Generic	Drug Tier 2 = Preferred Brand
Drug Tier 3 = Brand	Drug Tier 4 = Specialty
Last updated: 6/24/2010 (00010020 20)

Generic Name: Valacyclovir HCl	Brand Name: Valtrex
Therapeutic Category: Anti-infective Agents	Therapeutic Class: Nucleosides and Nucleotides
Notes: GC
Effective Date: 5/1/2010
Reason: Brand deletion. Generic addition to formulary.

Generic Name: Amox Tr/Potassium Clavulanate	Brand Name: Augmentin XR
Therapeutic Category: Anti-infective Agents	Therapeutic Class: Penicillins
Notes: GC
Effective Date: 9/1/2010
Reason: Brand deletion. Generic added to formulary.

Generic Name: Piperacillin Na/Tazobactam Na Inj	Brand Name: Zosyn
Therapeutic Category: Anti-infective Agents	Therapeutic Class: Penicillins
Notes: GC
Effective Date: 9/1/2010
Reason: Brand deletion. Generic added to formulary.

Generic Name: Doxycycline Monohydrate Susp	Brand Name: Vibramycin
Therapeutic Category: Anti-infective Agents	Therapeutic Class: Tetracyclines
Notes: GC
Effective Date: 9/1/2010
Reason: Brand deletion. Generic added to formulary.

Generic Name: Amox Tr/Potassium Clavulanate	Brand Name: Augmentin Susp 250-62.5
Therapeutic Category: Anti-infective Agents	Therapeutic Class: Penicillins
Notes: GC
Effective Date: 9/1/2010
Reason: Brand deletion. Generic added to formulary.

Generic Name: Bicalutamide	Brand Name: Casodex
Therapeutic Category: Antineoplastic Agents	Therapeutic Class: Antineoplastic Agents
Notes: GC
Effective Date: 9/1/2010
Reason: Brand deletion. Generic added to formulary.

Generic Name: Melphalan HCl	Brand Name: Alkeran
Therapeutic Category: Antineoplastic Agents	Therapeutic Class: Antineoplastic Agents
Notes: GC
Effective Date: 9/1/2010
Reason: Brand deletion. Generic added to formulary.

Generic Name: Oxaliplatin	Brand Name: Eloxatin
Therapeutic Category: Antineoplastic Agents	Therapeutic Class: Antineoplastic Agents
Notes: GC PA
Effective Date: 9/1/2010
Reason: Brand deletion. Generic added to formulary.

Generic Name: Romidepsin	Brand Name: Istodax
Therapeutic Category: Antineoplastic Agents	Therapeutic Class: Antineoplastic Agents
Notes:
Effective Date: 5/1/2010
Reason: Formulary addition.

Generic Name: Clonidine HCl Transdermal	Brand Name: Catapres TTS
Therapeutic Category: Cardiovascular Drugs	Therapeutic Class: Hypotensive Agents
Notes: GC
Effective Date: 9/1/2010
Reason: Brand deletion. Generic added to formulary.

Generic Name: Carbamazepine extended release	Brand Name: Tegretol XR
Therapeutic Category: Central Nervous System Agents	Therapeutic Class: Anticonvulsants
Notes: GC
Effective Date: 9/1/2010
Reason: Brand deletion. Generic added to formulary.

Generic Name: Protriptyline HCl	Brand Name: Vivactil
Therapeutic Category: Central Nervous System Agents	Therapeutic Class: Antidepressants
Notes: GC
Effective Date: 9/1/2010
Reason: Brand deletion. Generic added to formulary.

Generic Name: Pramipexole Di-HCl	Brand Name: Mirapex
Therapeutic Category: Central Nervous System Agents	Therapeutic Class: Antiparkinsonian Agents
Notes: GC
Effective Date: 6/1/2010
Reason: Brand deletion. Generic addition to formulary.

Generic Name: Buprenorphine HCl	Brand Name: Subutex
Therapeutic Category: Central Nervous System Agents	Therapeutic Class: Opiate Partial Agonists
Notes: GC QL
Effective Date: 5/1/2010
Reason: Brand deletion. Generic addition to formulary.

Generic Name: Oxcarbazepine	Brand Name: Trileptal suspension
Therapeutic Category: Central Nervous System Agents	Therapeutic Class: Anticonvulsants
Notes: GC
Effective Date: 5/1/2010
Reason: Brand deletion. Generic addition to formulary.

Generic Name: Olanzapine Pamoate	Brand Name: Zyprexa Relprevv
Therapeutic Category: Central Nervous System Agents	Therapeutic Class: Antipsychotics
Notes: PA QL
Effective Date: 6/1/2010
Reason:

Generic Name: Apraclonidine HCl	Brand Name: Iopidine
Therapeutic Category: Eye, Ear, Nose and Throat (EENT) Preparations	Therapeutic Class: EENT Drugs, Miscellaneous
Notes: GC
Effective Date: 9/1/2010
Reason: Brand deletion. Generic added to formulary.

Generic Name: Ketorolac Tromethamine	Brand Name: Acular
Therapeutic Category: Eye, Ear, Nose and Throat (EENT) Preparations	Therapeutic Class: EENT Nonsteroidal Anti-inflammatory Agents
Notes: GC
Effective Date: 9/1/2010
Reason: Brand deletion. Generic added to formulary.

Generic Name: Ketorolac Tromethamine	Brand Name: Acular LS
Therapeutic Category: Eye, Ear, Nose and Throat (EENT) Preparations	Therapeutic Class: EENT Nonsteroidal Anti-inflammatory Agents
Notes: GC
Effective Date: 9/1/2010
Reason: Brand deletion. Generic added to formulary.

Generic Name: Lansoprazole	Brand Name: Prevacid
Therapeutic Category: Gastrointestinal Drugs	Therapeutic Class: Antiulcer Agents and Acid Suppressants
Notes: GC ST QL
Effective Date: 5/1/2010
Reason: Brand deletion. Generic addition to formulary.

Generic Name: Peg 3350/Na sulf, Bicarb, Cl/KCl	Brand Name: Golytely
Therapeutic Category: Gastrointestinal Drugs	Therapeutic Class: Cathartics and Laxatives
Notes: GC
Effective Date: 9/1/2010
Reason: Brand deletion. Generic added to formulary.

Generic Name: Ursodiol	Brand Name: Urso
Therapeutic Category: Gastrointestinal Drugs	Therapeutic Class: Cholelitholytic Agents
Notes: GC
Effective Date: 9/1/2010
Reason: Brand deletion. Generic added to formulary.

Generic Name: Budesonide Inh Soln	Brand Name: Pulmicort Respules
Therapeutic Category: Hormones and Synthetic Substitutes	Therapeutic Class: Adrenals
Notes: GC PA QL
Effective Date: 9/1/2010
Reason: Brand deletion. Generic added to formulary.

Generic Name: Levonorgestrel	Brand Name: Plan B
Therapeutic Category: Hormones and Synthetic Substitutes	Therapeutic Class: Contraceptives
Notes: GC
Effective Date: 9/1/2010
Reason: Brand deletion. Generic added to formulary.

Generic Name: Liothyronine Sodium	Brand Name: Cytomel
Therapeutic Category: Hormones and Synthetic Substitutes	Therapeutic Class: Thyroid and Antithryroid Agents
Notes: GC
Effective Date: 9/1/2010
Reason: Brand deletion. Generic added to formulary.

Generic Name: Mycophenolate Mofetil	Brand Name: CellCept
Therapeutic Category: Miscellaneous Therapeutic Agents	Therapeutic Class: Miscellaneous Therapeutic Agents
Notes: GC
Effective Date: 9/1/2010
Reason: Brand deletion. Generic added to formulary.

Generic Name: Tacrolimus Anhydrous	Brand Name: Prograf
Therapeutic Category: Miscellaneous Therapeutic Agents	Therapeutic Class: Miscellaneous Therapeutic Agents
Notes: GC GA
Effective Date: 9/1/2010
Reason: Brand deletion. Generic added to formulary.

Generic Name: Malathion	Brand Name: Ovide
Therapeutic Category: Skin and Mucous Membrane Agents	Therapeutic Class: Scabicides and Pediculicides
Notes: GC
Effective Date: 9/1/2010
Reason: Brand deletion. Generic added to formulary.

Generic Name: Imiquimod	Brand Name: Aldara
Therapeutic Category: Skin and Mucous Membrane Agents	Therapeutic Class: Skin and Mucouse Membrane Agents, Miscellaneous
Notes: GC
Effective Date: 9/1/2010
Reason: Brand deletion. Generic added to formulary.