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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.
*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)
 Valacyclovir HCl  Valtrex
 Anti-infective Agents  Nucleosides and Nucleotides
 GC
 5/1/2010
 Brand deletion. Generic addition to formulary.
 
 Amox Tr/Potassium Clavulanate  Augmentin XR
 Anti-infective Agents  Penicillins
 GC
 9/1/2010
 Brand deletion. Generic added to formulary.
 
 Piperacillin Na/Tazobactam Na Inj  Zosyn
 Anti-infective Agents  Penicillins
 GC
 9/1/2010
 Brand deletion. Generic added to formulary.
 
 Doxycycline Monohydrate Susp  Vibramycin
 Anti-infective Agents  Tetracyclines
 GC
 9/1/2010
 Brand deletion. Generic added to formulary.
 
 Amox Tr/Potassium Clavulanate  Augmentin Susp 250-62.5
 Anti-infective Agents  Penicillins
 GC
 9/1/2010
 Brand deletion. Generic added to formulary.
 
 Bicalutamide  Casodex
 Antineoplastic Agents  Antineoplastic Agents
 GC
 9/1/2010
 Brand deletion. Generic added to formulary.
 
 Melphalan HCl  Alkeran
 Antineoplastic Agents  Antineoplastic Agents
 GC
 9/1/2010
 Brand deletion. Generic added to formulary.
 
 Oxaliplatin  Eloxatin
 Antineoplastic Agents  Antineoplastic Agents
 GC PA
 9/1/2010
 Brand deletion. Generic added to formulary.
 
 Romidepsin  Istodax
 Antineoplastic Agents  Antineoplastic Agents
 
 5/1/2010
 Formulary addition.
 
 Clonidine HCl Transdermal  Catapres TTS
 Cardiovascular Drugs  Hypotensive Agents
 GC
 9/1/2010
 Brand deletion. Generic added to formulary.
 
 Carbamazepine extended release  Tegretol XR
 Central Nervous System Agents  Anticonvulsants
 GC
 9/1/2010
 Brand deletion. Generic added to formulary.
 
 Protriptyline HCl  Vivactil
 Central Nervous System Agents  Antidepressants
 GC
 9/1/2010
 Brand deletion. Generic added to formulary.
 
 Pramipexole Di-HCl  Mirapex
 Central Nervous System Agents  Antiparkinsonian Agents
 GC
 6/1/2010
 Brand deletion. Generic addition to formulary.
 
 Buprenorphine HCl  Subutex
 Central Nervous System Agents  Opiate Partial Agonists
 GC QL
 5/1/2010
 Brand deletion. Generic addition to formulary.
 
 Oxcarbazepine  Trileptal suspension
 Central Nervous System Agents  Anticonvulsants
 GC
 5/1/2010
 Brand deletion. Generic addition to formulary.
 
 Olanzapine Pamoate  Zyprexa Relprevv
 Central Nervous System Agents  Antipsychotics
 PA QL
 6/1/2010
 
 
 Apraclonidine HCl  Iopidine
 Eye, Ear, Nose and Throat (EENT) Preparations  EENT Drugs, Miscellaneous
 GC
 9/1/2010
 Brand deletion. Generic added to formulary.
 
 Ketorolac Tromethamine  Acular
 Eye, Ear, Nose and Throat (EENT) Preparations  EENT Nonsteroidal Anti-inflammatory Agents
 GC
 9/1/2010
 Brand deletion. Generic added to formulary.
 
 Ketorolac Tromethamine  Acular LS
 Eye, Ear, Nose and Throat (EENT) Preparations  EENT Nonsteroidal Anti-inflammatory Agents
 GC
 9/1/2010
 Brand deletion. Generic added to formulary.
 
 Lansoprazole  Prevacid
 Gastrointestinal Drugs  Antiulcer Agents and Acid Suppressants
 GC ST QL
 5/1/2010
 Brand deletion. Generic addition to formulary.
 
 Peg 3350/Na sulf, Bicarb, Cl/KCl  Golytely
 Gastrointestinal Drugs  Cathartics and Laxatives
 GC
 9/1/2010
 Brand deletion. Generic added to formulary.
 
 Ursodiol  Urso
 Gastrointestinal Drugs  Cholelitholytic Agents
 GC
 9/1/2010
 Brand deletion. Generic added to formulary.
 
 Budesonide Inh Soln  Pulmicort Respules
 Hormones and Synthetic Substitutes  Adrenals
 GC PA QL
 9/1/2010
 Brand deletion. Generic added to formulary.
 
 Levonorgestrel  Plan B
 Hormones and Synthetic Substitutes  Contraceptives
 GC
 9/1/2010
 Brand deletion. Generic added to formulary.
 
 Liothyronine Sodium  Cytomel
 Hormones and Synthetic Substitutes  Thyroid and Antithryroid Agents
 GC
 9/1/2010
 Brand deletion. Generic added to formulary.
 
 Mycophenolate Mofetil  CellCept
 Miscellaneous Therapeutic Agents  Miscellaneous Therapeutic Agents
 GC
 9/1/2010
 Brand deletion. Generic added to formulary.
 
 Tacrolimus Anhydrous  Prograf
 Miscellaneous Therapeutic Agents  Miscellaneous Therapeutic Agents
 GC GA
 9/1/2010
 Brand deletion. Generic added to formulary.
 
 Malathion  Ovide
 Skin and Mucous Membrane Agents  Scabicides and Pediculicides
 GC
 9/1/2010
 Brand deletion. Generic added to formulary.
 
 Imiquimod  Aldara
 Skin and Mucous Membrane Agents  Skin and Mucouse Membrane Agents, Miscellaneous
 GC
 9/1/2010
 Brand deletion. Generic added to formulary.