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2010 Medicare Assured^® HMO Formulary:
Year to Date 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: Diphenhydramine HCl	Brand Name: Diphenhydramine
Therapeutic Category: Antihistamine Drugs	Therapeutic Class: First Generation Antihistamines
Notes: GC
Effective Date: 1/1/2010
Reason: Formulary deletion

Generic Name: Promethazine HCl	Brand Name: Phenergan
Therapeutic Category: Antihistamine Drugs	Therapeutic Class: First Generation Antihistamines
Notes: GC
Effective Date: 1/1/2010
Reason: Formulary deletion

Generic Name: Promethazine HCl	Brand Name: Phenergan Suppository
Therapeutic Category: Antihistamine Drugs	Therapeutic Class: First Generation Antihistamines
Notes: GC
Effective Date: 1/1/2010
Reason: Formulary deletion

Generic Name: Fexofenadine	Brand Name: Allegra
Therapeutic Category: Antihistamine Drugs	Therapeutic Class: Second Generation Antihistamines
Notes: GC
Effective Date: 1/1/2010
Reason: Step therapy removed

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: Amikacin	Brand Name: Amikin
Therapeutic Category: Anti-infective Agents	Therapeutic Class: Aminoglycosides
Notes: GC
Effective Date: 1/1/2010
Reason: Formulary addition

Generic Name: Cefixime	Brand Name: Suprax
Therapeutic Category: Anti-infective Agents	Therapeutic Class: Cephalosporins
Notes:
Effective Date: 1/1/2010
Reason: Formulary addition

Generic Name: Cefixime	Brand Name: Suprax Suspension
Therapeutic Category: Anti-infective Agents	Therapeutic Class: Cephalosporins
Notes:
Effective Date: 1/1/2010
Reason: Formulary addition

Generic Name: Capreomycin sulfate	Brand Name: Capastat Sulfate
Therapeutic Category: Anti-infective Agents	Therapeutic Class: Antituberculosis Agents
Notes:
Effective Date: 1/1/2010
Reason: Formulary addition

Generic Name: Aminosalicylic Acid	Brand Name: Paser
Therapeutic Category: Anti-infective Agents	Therapeutic Class: Antituberculosis Agents
Notes:
Effective Date: 1/1/2010
Reason: Formulary addition

Generic Name: Ethionamide	Brand Name: Trecator
Therapeutic Category: Anti-infective Agents	Therapeutic Class: Antituberculosis Agents
Notes:
Effective Date: 1/1/2010
Reason:

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: Everolimus	Brand Name: Afinitor
Therapeutic Category: Antineoplastic Agents	Therapeutic Class: Antineoplastic Agents
Notes: PA QL
Effective Date: 1/1/2010
Reason:

Generic Name: Pazopanib HCl	Brand Name: Votrient
Therapeutic Category: Antineoplastic Agents	Therapeutic Class: Antineoplastic Agents
Notes: QL
Effective Date: 3/1/2010
Reason: Formulary addition

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: Dicyclomine HCl	Brand Name: Bentyl
Therapeutic Category: Autonomic Drugs	Therapeutic Class: Antimuscarinics/Antispasmodics
Notes: GC
Effective Date: 1/1/2010
Reason: Formulary deletion

Generic Name: Metaproterenol Sulfate	Brand Name: Alupent
Therapeutic Category: Autonomic Drugs	Therapeutic Class: Beta-adrenergic Agonists
Notes: QL
Effective Date: 1/1/2010
Reason: Formulary deletion

Generic Name: Metaproterenol Sulfate Inh Soln	Brand Name: Metaproterenol Sulfate
Therapeutic Category: Autonomic Drugs	Therapeutic Class: Beta-adrenergic Agonists
Notes: GC PA QL
Effective Date: 1/1/2010
Reason:

Generic Name: Pirbuterol Acetate	Brand Name: Maxair Autohaler
Therapeutic Category: Autonomic Drugs	Therapeutic Class: Beta-adrenergic Agonists
Notes: QL
Effective Date: 1/1/2010
Reason: Formulary deletions

Generic Name: Carisoprodol	Brand Name: Soma
Therapeutic Category: Autonomic Drugs	Therapeutic Class: Skeletal Muscle Relaxants
Notes: GC
Effective Date: 1/1/2010
Reason: Formulary deletion

Generic Name: Cyclobenzaprine HCl	Brand Name: Flexeril
Therapeutic Category: Autonomic Drugs	Therapeutic Class: Skeletal Muscle Relaxants
Notes: GC
Effective Date: 1/1/2010
Reason: Formulary deletion

Generic Name: Galantamine HBr	Brand Name: Razadyne
Therapeutic Category: Autonomic Drugs	Therapeutic Class: Parasympathomimetic (Cholinergic) Agents
Notes: GC PA QL
Effective Date: 3/1/2010
Reason: Formulary addition

Generic Name: Plerixafor	Brand Name: Mozobil
Therapeutic Category: Blood Formation, Coagulation and Thrombosis	Therapeutic Class: Hemorrheologic Agents
Notes: PA QL
Effective Date: 4/1/2010
Reason: Formulary addition

Generic Name: Procainamide HCl	Brand Name: Procanbid
Therapeutic Category: Cardiovascular Drugs	Therapeutic Class: Antiarrhythmic Agents
Notes:
Effective Date: 1/1/2010
Reason: Formulary deletion

Generic Name: Procainamide HCl	Brand Name: Pronestyl
Therapeutic Category: Cardiovascular Drugs	Therapeutic Class: Antiarrhythmic Agents
Notes:
Effective Date: 1/1/2010
Reason: Formulary deletion

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: Amlodipine / Olmesartan	Brand Name: Azor
Therapeutic Category: Cardiovascular Drugs	Therapeutic Class: Dihydropyridines
Notes: ST QL
Effective Date: 1/1/2010
Reason: Formulary addition

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: Aripiprazole	Brand Name: Abilify (2, 5mg)
Therapeutic Category: Central Nervous System Agents	Therapeutic Class: Antipsychotics
Notes: QL
Effective Date: 1/1/2010
Reason: Step therapy removed per CMS

Generic Name: Olanzapine	Brand Name: Zyprexa (2.5, 5mg)
Therapeutic Category: Central Nervous System Agents	Therapeutic Class: Antipsychotics
Notes: QL
Effective Date: 1/1/2010
Reason: Step therapy removed per CMS

Generic Name: Quetiapine Fumarate	Brand Name: Seroquel (25, 50, 100mg)
Therapeutic Category: Central Nervous System Agents	Therapeutic Class: Antipsychotics
Notes: QL
Effective Date: 1/1/2010
Reason: Step therapy removed per CMS

Generic Name: Risperidone	Brand Name: Risperdal (0.25, 0.5, 1mg)
Therapeutic Category: Central Nervous System Agents	Therapeutic Class: Antipsychotics
Notes: GC QL
Effective Date: 1/1/2010
Reason: Step therapy removed per CMS

Generic Name: Ziprasidone HCl	Brand Name: Geodon (20mg)
Therapeutic Category: Central Nervous System Agents	Therapeutic Class: Antipsychotics
Notes: QL
Effective Date: 1/1/2010
Reason: Step therapy removed per CMS

Generic Name: Hydroxyzine HCl	Brand Name: Atarax
Therapeutic Category: Central Nervous System Agents	Therapeutic Class: Anxiolytics, Sedatives & Hypnotics, Miscellaneous
Notes: GC
Effective Date: 1/1/2010
Reason: Formulary deletion

Generic Name: Hydroxyzine HCl Inj	Brand Name: Hydroxyzine HCl
Therapeutic Category: Central Nervous System Agents	Therapeutic Class: Anxiolytics, Sedatives & Hypnotics, Miscellaneous
Notes: GC
Effective Date: 1/1/2010
Reason: Formulary deletion

Generic Name: Hydroxyzine Pamoate	Brand Name: Vistaril
Therapeutic Category: Central Nervous System Agents	Therapeutic Class: Anxiolytics, Sedatives & Hypnotics, Miscellaneous
Notes: GC
Effective Date: 1/1/2010
Reason: Formulary deletion

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: Propoxyphene HCl	Brand Name: Darvon
Therapeutic Category: Central Nervous System Agents	Therapeutic Class: Opiate Agonists
Notes: GC
Effective Date: 1/1/2010
Reason: Formulary deletion

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: Lacosamide	Brand Name: Vimpat
Therapeutic Category: Central Nervous System Agents	Therapeutic Class: Anticonvulsants
Notes:
Effective Date: 1/1/2010
Reason: Formulary addition

Generic Name: Aripiprazole	Brand Name: Abilify Inj
Therapeutic Category: Central Nervous System Agents	Therapeutic Class: Antipsychotics
Notes:
Effective Date: 1/1/2010
Reason: Formulary addition

Generic Name: Aripiprazole	Brand Name: Abilify (10, 15, 20, 30mg)
Therapeutic Category: Central Nervous System Agents	Therapeutic Class: Antipsychotics
Notes: QL
Effective Date: 1/1/2010
Reason:

Generic Name: Quetiapine Fumarate	Brand Name: Seroquel (200, 300, 400mg)
Therapeutic Category: Central Nervous System Agents	Therapeutic Class: Antipsychotics
Notes: QL
Effective Date: 1/1/2010
Reason:

Generic Name: Olanzapine	Brand Name: Zyprexa (10, 15, 20mg)
Therapeutic Category: Central Nervous System Agents	Therapeutic Class: Antipsychotics
Notes: QL
Effective Date: 1/1/2010
Reason:

Generic Name: Risperidone	Brand Name: Risperdal (2, 3, 4mg)
Therapeutic Category: Central Nervous System Agents	Therapeutic Class: Antipsychotics
Notes: GC QL
Effective Date: 1/1/2010
Reason:

Generic Name: Vigabatrin	Brand Name: Sabril
Therapeutic Category: Central Nervous System Agents	Therapeutic Class: Anticonvulsants
Notes: PA
Effective Date: 1/1/2010
Reason:

Generic Name: Asenapine	Brand Name: Saphris
Therapeutic Category: Central Nervous System Agents	Therapeutic Class: Antipsychotics
Notes: PA
Effective Date: 1/1/2010
Reason:

Generic Name: Fluoxetine HCl	Brand Name: Prozac (tablets)
Therapeutic Category: Central Nervous System Agents	Therapeutic Class: Antidepressants
Notes: GC QL
Effective Date: 1/1/2010
Reason:

Generic Name: Diclofenac sodium	Brand Name: Voltaren Gel
Therapeutic Category: Central Nervous System Agents	Therapeutic Class: Nonsteroidal Anti-inflammatory Agents
Notes: PA QL
Effective Date: 3/1/2010
Reason: Formulary addition

Generic Name: Iloperidone	Brand Name: Fanapt
Therapeutic Category: Central Nervous System Agents	Therapeutic Class: Antipsychotics
Notes: QL
Effective Date: 3/1/2010
Reason: Formulary addition

Generic Name: Paliperidone palmitate	Brand Name: Invega Sustenna (117mg, 156mg, 234mg)
Therapeutic Category: Central Nervous System Agents	Therapeutic Class: Antipsychotics
Notes: PA QL
Effective Date: 3/1/2010
Reason: Formulary addition

Generic Name: Paliperidone palmitate	Brand Name: Invega Sustenna (39mg, 78mg)
Therapeutic Category: Central Nervous System Agents	Therapeutic Class: Antipsychotics
Notes: PA QL
Effective Date: 3/1/2010
Reason: Formulary addition

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: Sevelamer HCl	Brand Name: Renagel
Therapeutic Category: Electrolytic, Caloric, and Water Balance	Therapeutic Class: Ion-Removing Agents
Notes:
Effective Date: 1/1/2010
Reason: Formulary deletion

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: Azelastine HCl	Brand Name: Astepro
Therapeutic Category: Eye, Ear, Nose and Throat (EENT) Preparations	Therapeutic Class: Antiallergic Agents
Notes:
Effective Date: 1/1/2010
Reason:

Generic Name: Travoprost	Brand Name: Travatan Z
Therapeutic Category: Eye, Ear, Nose and Throat (EENT) Preparations	Therapeutic Class: Antiglaucoma Agents
Notes:
Effective Date: 1/1/2010
Reason:

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: Pantoprazole Sodium	Brand Name: Protonix
Therapeutic Category: Gastrointestinal Drugs	Therapeutic Class: Antiulcer Agents and Acid Suppressants
Notes: GC ST QL
Effective Date: 1/1/2010
Reason: Formulary deletion

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: Omeprazole	Brand Name: Prilosec
Therapeutic Category: Gastrointestinal Drugs	Therapeutic Class: Antiulcer Agents and Acid Suppressants
Notes: GC QL
Effective Date: 1/1/2010
Reason: Formulary addition

Generic Name: Methylnaltrexone Br	Brand Name: Relistor
Therapeutic Category: Gastrointestinal Drugs	Therapeutic Class: GI Drugs, Miscellaneous
Notes: PA
Effective Date: 1/1/2010
Reason: Formulary addition

Generic Name: Ondansetron HCl	Brand Name: Zofran Inj
Therapeutic Category: Gastrointestinal Drugs	Therapeutic Class: Antiemetics
Notes: GC QL
Effective Date: 1/1/2010
Reason: Formulary addition

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: Estradiol	Brand Name: Gynodiol (1.5mg)
Therapeutic Category: Hormones and Synthetic Substitutes	Therapeutic Class: Estrogens and Antiestrogens
Notes:
Effective Date: 1/1/2010
Reason:

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: Tetanus, reduced diphtheria, acellular pertussis	Brand Name: Boostrix
Therapeutic Category: Serums, Toxoids, and Vaccines	Therapeutic Class: Toxoids
Notes:
Effective Date: 1/1/2010
Reason: Formulary addition

Generic Name: Tetanus, diphtheria, acellular pertussis	Brand Name: Adacel
Therapeutic Category: Serums, Toxoids, and Vaccines	Therapeutic Class: Toxoids
Notes:
Effective Date: 1/1/2010
Reason: Formulary addition

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.