Medicare tier 4 comprehensive - 2008

Tier Requirements/
Medicare Tier 4 Comprehensive - 2008

ANALGESICS
NSAIDs
diclofenac sodium delayed-rel Tier COX-2 Inhibitors
Gout
Narcotic Analgesics
Narcotic Analgesics, CII
morphine sulfate immediate release Tier Tier Requirements/
Non-narcotic Analgesics

ANESTHETICS
Local Anesthetics

ANTI-INFECTIVES
Antibacterials
CEFUROXIME SODIUM/DEXTROSE inj 750 mg Tier Requirements/
AUGMENTIN chewable tabs 125 mg, 250 mg doxycycline hyclate caps, tabs Tier Tier Requirements/
Antifungals
Antimalarials
Antiretroviral Agents
Tier Requirements/
Non-nucleoside Reverse Transcriptase Inhibitors Nucleoside Reverse Transcriptase Inhibitors Nucleotide Reverse Transcriptase Inhibitors Antitubercular Agents
Antivirals
Tier Requirements/
QL: Tamiflu caps (30 mg) - 20 caps per 180 days Tamiflu caps (45 mg, 75 mg) - 10 caps per 180 days Miscellaneous
sulfamethoxazole/trimethoprim Tier sulfamethoxazole/trimethoprim inj Tier Requirements/
QL: Alinia tabs - 6 tabs per 25 days Alinia susp - 60 mL per 25 days
ANTINEOPLASTIC AGENTS
Hormonal Antineoplastic Agents
Luteinizing Hormone-releasing Hormone (LHRH) Agonists Injectable Agents
Tier Requirements/
Tier Requirements/
Oral Agents
Tier Requirements/
Protective Agents

CARDIOVASCULAR
ACE Inhibitors
ACE Inhibitor/Calcium Channel Blocker Combinations
ACE Inhibitor/Diuretic Combinations
benazepril/hydrochlorothiazide Tier Tier Requirements/
Adrenolytics, Central
Aldosterone Receptor Antagonists
Alpha Blockers
Angiotensin II Receptor Antagonists/Combinations
Antiarrhythmics
quinidine gluconate ext-rel 324 mg Tier Requirements/
Antilipemics
Beta-blockers
Tier Requirements/
Beta-blocker/Diuretic Combinations
Calcium Channel Blockers
Calcium Channel Blocker/Antilipemic Combinations
Digitalis Glycosides
Direct Renin Inhibitors
Diuretics
spironolactone/hydrochlorothiazide Tier Requirements/
Endothelin Receptor Antagonists
Nitrates
isosorbide dinitrate ext-rel tabs Tier Miscellaneous

CENTRAL NERVOUS SYSTEM
Antianxiety
Anticonvulsants
Tier Requirements/
lamotrigine chewable dispersible tabs QL: gabapentin caps and tabs - 3600 mg/day per 25 days Neurontin oral soln - 1880 mg/day per 25 days Antidementia
Antidepressants
Tier Requirements/
Selective Serotonin Reuptake Inhibitors (SSRIs) Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)*
* Indicates the proposed mechanism of action, based on the American
Psychiatric Association Summary of Treatment Recommendations.
Antiparkinsonian Agents
Tier Requirements/
Antipsychotics
Attention Deficit Hyperactivity Disorder
Tier Requirements/
Hypnotics
Migraine
QL: Frova - 9 tabs per 25 days Imitrex inj - 5 inj per 25 days Imitrex kits - 2 kits per 25 days Imitrex spray 5 mg - 12 doses per 25 days Imitrex spray 20 mg - 6 doses per 25 days Maxalt/Maxalt-MLT - 12 tabs per 25 days Relpax - 12 tabs per 25 days Zomig/Zomig-ZMT tabs - 6 tabs per 25 days Mood Stabilizers
Tier Requirements/
Multiple Sclerosis Agents
Musculoskeletal Therapy Agents
Narcolepsy/Cataplexy
Psychotherapeutic-Miscellaneous
Miscellaneous
Tier Requirements/
ENDOCRINE AND METABOLIC
Androgens
Antidiabetics
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors Dipeptidyl Peptidase-4 (DPP-4) Inhibitor/Biguanide Combinations Tier Requirements/
Insulin Sensitizer/Biguanide Combinations Insulin Sensitizer/Sulfonylurea Combinations Bisphosphonates
Calcitonins
Calcium Receptor Antagonists
Chelating Agents
Tier Requirements/
Contraceptives
norethindrone acetate/EE/iron 1/20 levonorgestrel/EE 0.15/30 - Levora norethindrone acetate/EE/iron 1.5/30 norgestrel/EE 0.3/30 - Low-Ogestrel levonorgestrel/EE 0.15/30 - Quasense Tier ethynodiol diacetate/EE 1/35 - Zovia 1/35 Tier ethynodiol diacetate/EE 1/50 - Zovia 1/50 Tier Tier Requirements/
medroxyprogesterone acetate 150 mg/mL Tier Endometriosis
Enzyme Replacements
Estrogens
Tier Requirements/
Estrogen/Progestins
Glucocorticoids
methylprednisolone sodium succinate inj Glucose Elevating Agents
Human Growth Hormones
Tier Requirements/
Parathyroid Hormones
Phosphate Binder Agents
Progestins
Selective Estrogen Receptor Modulators
Thyroid Agents
Vasopressins
Miscellaneous
Tier Requirements/
GASTROINTESTINAL
Antidiarrheals
Antiemetics
trimethobenzamide caps 300 mg Tier Emend (Trifold Pack) - 2 packs per 25 days Marinol - 60 caps per 25 days ondansetron (4 mg, 8 mg) - 18 tabs per 25 days Ondansetron (24 mg) - 2 tabs per 25 days ondansetron (2 mg/mL) inj - 10 mL per 25 days ondansetron (32 mg/50 mL) inj - 50 mL per 25 days ondansetron oral soln - 100 mL per 25 days Ondansetron/NaCl (32 mg/50 mL) inj - 50 mL per 25 days Antispasmodics
Tier Requirements/
Cholelitholytics
H2-Receptor Antagonists
Inflammatory Bowel Disease
Irritable Bowel Syndrome
Laxatives
Pancreatic Enzymes
Tier Requirements/
Prostaglandins
Proton Pump Inhibitors
Proton Pump Inhibitor/Anti-infective Combinations
Saliva Stimulants
Steroids, Rectal
Miscellaneous

GENITOURINARY
Benign Prostatic Hyperplasia
Urinary Antispasmodics
Tier Requirements/
Vaginal Anti-infectives
Miscellaneous

HEMATOLOGIC
Anticoagulants
Hematopoietic Growth Factors
Platelet Aggregation Inhibitors
Platelet Synthesis Inhibitors
Tier Requirements/
Miscellaneous

IMMUNOLOGIC AGENTS
Disease-modifying Antirheumatic Drugs (DMARDs)
Immunoglobulins
Immunomodulators
Immunosuppressants
Tier Requirements/
Vaccines
PERTUSSIS, and HAEMOPHILUS B CONJUGATE VACCINE HAEMOPHILUS B CONJUGATE and HEPATITIS B Tier 2 MEASLES and RUBELLA VIRUS VACCINE (LIVE) Tier Requirements/
NUTRITIONAL/SUPPLEMENTS
Electrolytes
sodium polystyrene sulfonate Tier Vitamins
Miscellaneous

RESPIRATORY
Anaphylaxis Treatment Agents
Anticholinergics
QL: Atrovent HFA - 2 inhalers per 25 days Anticholinergic/Beta Agonist Combinations
QL: Combivent - 2 inhalers per 25 days ipratropium/albuterol Tier Requirements/
Antihistamines, Low/Nonsedating
Antihistamines, Sedating
Antihistamine/Decongestant Combinations
Beta Agonists
QL: albuterol ampules - 300 mL per 25 days albuterol inhaler - 2 inhalers per 25 days Foradil - 60 caps per 25 days Maxair - 1 inhaler per 25 days Proair HFA - 2 inhalers per 25 days Proventil HFA - 2 inhalers per 25 days Tier Requirements/
Cystic Fibrosis
Leukotriene Receptor Antagonists
Mast Cell Stabilizers
QL: cromolyn ampules - 240 mL per 25 days Nasal Steroids
QL: flunisolide spray - 2 inhalers per 25 days fluticasone spray - 1 inhaler per 25 days Nasacort AQ - 1 inhaler per 25 days Steroid/Beta Agonist Combinations
Steroid Inhalants
Pulmicort Flexhaler (90 mcg) - 4 inhalers per 25 days Pulmicort Flexhaler (180 mcg) - 2 inhalers per 25 days Pulmicort Respules - 60 Respules per 25 days Pulmicort Turbuhaler - 2 inhalers per 25 days Tier Requirements/
Xanthines
Miscellaneous
Dermatology
clindamycin gel, lotion, soln Tier Tier Requirements/
alclometasone crm, oint 0.05% Tier fluocinolone acetonide soln 0.01% Tier hydrocortisone crm, lotion, oint 2.5% Tier Requirements/
betamethasone valerate crm, lotion, oint 0.1% Tier fluocinolone acetonide crm, oint 0.025% fluticasone propionate crm 0.05%, oint 0.005% Tier 1 hydrocortisone butyrate crm, oint, soln 0.1% hydrocortisone valerate crm, oint 0.2% mometasone crm, lotion, oint 0.1% Tier triamcinolone acetonide crm, lotion, triamcinolone acetonide crm, lotion, oint 0.1% betamethasone dipropionate augmented crm, betamethasone dipropionate crm, lotion, desoximetasone crm, oint 0.25%, gel 0.05% fluocinonide crm, gel, oint, soln 0.05% triamcinolone acetonide crm, oint 0.5% Tier betamethasone dipropionate augmented gel, clobetasol propionate crm, foam, oint 0.05% halobetasol propionate crm, oint 0.05% Tier Requirements/
metronidazole crm, gel, lotion Tier Mouth/Throat/Dental Agents
Ophthalmic
Tier Requirements/
sulfacetamide oint, soln 10% Tier Anti-infective/Anti-inflammatory Combinations neomycin/polymyxin B/dexamethasone neomycin/polymyxin B/hydrocortisone sulfacetamide/prednisolone phosphate Tier Requirements/
Carbonic Anhydrase Inhibitor/Beta-blocker Combinations Sympathomimetic/Beta-blocker Combinations Otic
Anti-infective/Anti-inflammatory Combinations neomycin/polymyxin B/hydrocortisone Tier Tier Requirements/
fluocinolone acetonide crm, oint 0.025% . 43 fluocinonide crm, gel, oint, soln 0.05% . 43 hydrocortisone crm, lotion, oint 2.5% . 42 hydrocortisone valerate crm, oint 0.2%. 43 halobetasol propionate crm, oint 0.05%.43 levonorgestrel/EE 0.15/30 - Quasense . 28 methylprednisolone sodium succinate inj. 30 triamcinolone acetonide crm, oint 0.5% . 43

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