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2012 Medicare Assured® HMO SNP 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 SNP. 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 SNP Drug List.
*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 = Brand
Last updated: 1/25/2012 (00010020 20)
 Levocetirizine Dihydrochloride  Xyzal
 Antihistamine Drugs  Second Generation Antihistamines
 GC
 2/1/2012
 Generic Added 2/1/12
 
 Levofloxacin  Levaquin
 Anti-infective Agents  Quinolones
 GC
 2/1/2012
 Generic Added 2/1/12
 
 Rivaroxaban  Xarelto
 Blood Formation, Coagulation and Thrombosis  Anticoagulants
 
 1/1/2012
 Formulary Addition
 
 Triamcinolone Acetonide  Nasacort AQ
 Eye, Ear, Nose and Throat (EENT) Preparations  Corticosteroids (EENT)
 GC
 2/1/2012
 Generic Added 2/1/12
 
 Alfuzosin HCl  Uroxatral
 Miscellaneous Therapeutic Agents  Miscellaneous Therapeutic Agents
 GC QL
 1/1/2012
 Generic Covered