LIS MEDIKAMAN KI KOUVRI YO

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LIS MEDIKAMAN KI KOUVRI YO
LIS MEDIKAMAN
KI KOUVRI YO
Community Care Plus
FIDA-MMP 2015
1.877.ICS.2525
www.icsny.org
ICS_15412000_A2TC_G_EFF01012015_
08042014_174025_Comprehensive_R11 3 14_Approved
ICS Community Care Plus FIDA-MMP | 2015 Lis Medikaman
Garanti yo (Fòmilè)
Lis sa a se yon lis medikaman Patisipan yo kapab resevwa nan ICS Community Care
Plus FIDA-MMP.
 ICS Community Care Plus FIDA-MMP se yon plan swen kontwole ki gen kontra
avèk Medicare ak Depatman Sante Eta New York (New York State Department of
Health) (Medicaid) pou bay avantaj toulède pwogram yo pou Patisipan yo avèk
Demonstrasyon Fully Integrated Duals Advantage (FIDA).
 Avantaj yo, Lis Medikaman ki Garanti yo, ak rezo famasi ak pwofesyonèl swen sante
ka chanje tanzantan pandan tout ane a ak 1ye janvye chak ane.
 Ou kapab toujou tcheke dènye lis Medikaman Garanti ICS Community Care Plus
FIDA-MMP sou entènèt nan sitwèb www.icsny.org/care-plus oswa depi ou rele Sèvis
Patisipan Community Care Plus FIDA-MMP nan nimewo 1.887.ICS.2525.
 Ka gen limit ak restriksyon ki anvigè. Pou jwenn plis enfòmasyon, rele Sèvis
Patisipan Plan ICS Community Care Plus FIDA-MMP oswa li Tiliv Enfòmasyon
Patisipan ICS Community Care Plus FIDA-MMP.
 Pa gen kopeman pou okenn medikaman ki garanti.
 Ou kapab jwenn enfòmasyon sa yo gratis nan lòt fòma, tankou ekriti Bray oswa gwo
lèt. Rele nimewo 1.877.ICS.2525. Koutfil la gratis.
 Ou kapab jwenn tout enfòmasyon sa a gratis nan lòt lang. Rele ICS nan
1.877.ICS.2525 ak TTY 1.855.ICS.4TTY, ant 8 a.m. ak 8 p.m., lendi jiska vandredi.
Apèl la gratis.
 You can get this information for free in other languages. Call 1.877.ICS.2525 and
TTY 1.855.ICS.4TTY during the hours of 8 a.m. to 8 p.m., Monday through Friday.
The call is free.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
 Вы можете бесплатно получить всю эту информацию на других языках.
Звоните в ICS по телефону 1.877.ICS.2525 и телетайпу 1.855.ICS.4TTY с
понедельника по пятницу с 8:00 до 20:00. Звонок бесплатный.
 您可免费获得所有这些信息的其他语言版本。请在周一至周五上午 8 点至晚上 8 点致
电 ICS,电话号码为 1.877.ICS.2525,听障专线 (TTY) 为 1.855.ICS.4TTY。此为免
费电话。
 Puede obtener toda esta información en otros idiomas de manera gratuita. Llame a
ICS al 1.877.ICS.2525 y a la línea TTY 1.855.ICS.4TTY, entre las 8 a. m. y las 8 p.
m., de lunes a viernes. La llamada es gratuita.
 이 모든 정보는 타 언어로 무료로 제공됩니다. 월요일~금요일, 오전 8시~오후 8시
사이에 1.877.ICS.2525 및 TTY(청각 장애인용 전화) 1.855.ICS.4TTY로 ICS에
전화해 주십시오. 이 전화는 무료입니다.
 Le informazioni in questione sono disponibili gratuitamente anche in altre lingue.
Chiamare ICS ai numeri 1.877.ICS.2525 e TTY 1.855.ICS.4TTY tra le 8:00 e le
20.00 dal lunedì al venerdì. La chiamata è gratuita.
 Eta New York te kreye yon pwogram defandè sitwayen ki rele Independent
Consumer Advocacy Network (ICAN) pou bay Patisipan yo asistans konfidansyèl
gratis sou nenpòt sèvis Community Care Plus FIDA-MMP ofri. Ou ka kontakte ICAN
gratis nan 1-844-614-8800 oswa sou entènèt nan adrès icannys.org.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
Kesyon Moun Poze Souvan
Jwenn repons yo la a pou kesyon ou genyen sou Lis Medikaman Garanti sa yo. Ou
kapab li Kesyon Moun Poze Souvan pou aprann plis bagay, oswa pou chèche yon
kesyon ak repons.
1.
Ki medikaman sou preskripsyon ki sou Lis Medikaman Garanti
yo? (Nou rele Lis Medikaman Garanti yo “Lis Medikaman”
toukout.)
Medikaman ki sou Lis Medikaman Garanti yo ki kòmanse nan paj 15 se medikaman ICS
Community Care Plus FIDA-MMP garanti. Medikaman sa yo disponib nan famasi ki nan
rezo nou. Yon famasi nan rezo nou an si nou gen yon akò avèk yo pou travay avèk nou
epi pou ba ou sèvis. Nou rele famasi sa yo “famasi rezo a.”
 ICS Community Care Plus FIDA-MMP ap garanti tout medikaman ki sou Lis
Medikaman an si:
 doktè ou oswa lòt moun ki gen otorizasyon pou preskri medikaman di ou bezwen
yo pou refè oswa pou rete an sante,
 medikaman an nesesè pou rezon medikal pou pwoblèm sante ou, epi
 ou pran medikaman sou preskripsyon an nan yon famasi ki nan rezo ICS
Community Care Plus FIDA-MMP.
 ICS Community Care Plus FIDA-MMP ka gen lòt etap ou gen aksè nan sèten
medikaman (gade kesyon 5 ki anba la a). Nan kèk ka, ou ka gen pou fè yon bagay
anvan ou kapab jwenn yon medikaman, tankou eseye lòt medikaman yo anvan.
Ou kapab wè yon dènye lis medikaman nou garanti sou sitwèb nou nan
www.icsny.org/care-plus/pharmacy-benefits oswa rele Sèvis Patisipan nan nimewo
1.877.ICS.2525.
2.
Èske Lis Medikaman an ap janm chanje?
Wi. ICS Community Care Plus FIDA-MMP ka ajoute oswa retire medikaman sou Lis
Medikaman an pandan ane a. Anjeneral, Lis Medikaman an ap chanje sèlman si:
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
 gen yon nouvo medikaman ki efikas menm jan avèk yon medikaman ki sou Lis
Medikaman an kounye a, oswa
 nou aprann yon medikaman danjere.
Nou ka chanje règ nou yo tou konsènan medikaman yo. Pa egzanp, nou kapab:
 deside egzije oswa pa egzije apwobasyon davans pou yon medikaman
(Apwobasyon davans se pèmisyon ou jwenn nan ICS Community Care Plus FIDAMMP oswa nan Ekip Entè-Disiplinè (Interdisciplinary Team, IDT) ou anvan ou
kapab resevwa yon medikaman.)
 ajoute oswa chanje kantite nan yon medikaman ou kapab resevwa (sa rele “limit
sou kantite”)
 ajoute oswa chanje restriksyon pou terapi-pa-etap sou yon medikaman (Terapi-paetap vle di ou dwe eseye yon medikaman anvan n ap garanti yon lòt medikaman.)
(Pou jwenn plis enfòmasyon sou règ medikaman sa yo, gade paj 5.)
N ap fè ou konnen kilè nou retire yon medikaman w ap pran nan Lis Medikaman an. N
ap fè ou konnen tou kilè nou chanje règ nou yo pou garanti yon medikaman. Kesyon 3,
4 ak 7 ki anba la a gen plis enfòmasyon sou sa k ap pase lè Lis Medikaman an chanje.
 Ou kapab toujou tcheke dènye Lis Medikaman ICS Community Care Plus FIDAMMP sou entènèt nan sitwèb www.icsny.org/care-plus/drug-list.
 Ou kapab rele Sèvis Patisipan tou pou tcheke dènye Lis Medikaman an nan nimewo
1.877.ICS.2525.
3.
Kisa k ap pase lè yon medikaman ki pi bon mache fè pwogrè epi li
travay menm jan avèk yon medikaman ki sou Lis Medikaman an
kounye a?
Si yon medikaman ki pi bon mache vin disponib epi li travay menm jan avèk yon
medikaman ki sou Lis Medikaman an kounye a:

Famasyen ou ka ba ou medikaman ki pi bon mache a lòt fwa w ap pran
medikaman sou preskripsyon ou. Si oumenm ak pwofesyonèl swen sante ou
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
deside medikaman ki pi bon mache pa bon pou ou, pwofesyonèl swen sante ou
kapab di famasyen an pou li kontinye ba ou medikaman w ap pran kounye a.
4.

ICS Community Care Plus FIDA-MMP ka deside retire medikaman ki pi chè a
sou Lis Medikaman an. Si w ap pran yon medikaman nou retire nan Lis
Medikaman an paske yon medikaman ki pi bon mache ak efikas tou fè pwogrè, n
ap fè ou konnen sa omwen 60 jou anvan nou retire li sou Lis Medikaman an
oswa lè ou mande pou yon renouvèlman. Answit, ou kapab resevwa yon kantite
nan medikaman an pou 60 jou anvan nou fè chanjman an sou Lis Medikaman
an.

ICS Community Care Plus FIDA-MMP ap fè manm yo konnen chanjman sa yo
pa lapòs, epitou n ap mete enfòmasyon sou fason pou fè yon doleyans, yon
kontestasyon, oswa yon demann eksepsyon. ICS Community Care Plus FIDAMMP ap mete enfòmasyon sa a sou sitwèb nou tou. W ap kapab jwenn li sou
sitwèb www.icsny.org/care-plus, epi n ap fè manm yo konnen dènye fòmilè nou
an chak ane. Nou kapab bay enfòmasyon sa yo nan lòt kalite fòma.
Kisa k ap pase lè nou vin konnen yon medikaman danjere?
Si Ajans Etazini pou Kontwòl Manje ak Medikaman (Food and Drug Administration,
FDA) di yon medikaman w ap pran danjere, n ap retire li sou Lis Medikaman an touswit.
N ap voye yon lèt ba ou tou epitou n ap rele ou pou fè ou konnen nou te retire
medikaman ki danjere a sou Lis Medikaman an. N ap ba ou enstriksyon pou kontakte
doktè ki preskri ou medikaman an san pèdi tan, epitou n ap ba ou enstriksyon pou
ranplase medikaman sou sispann itilize a. Ou kapab kontakte manadjè swen sante ou
pou jwenn èd.
5.
Èske gen nenpòt restriksyon oswa limit sou garanti medikaman?
Oswa èske gen nenpòt aksyon ki obligatwa pou mwen fè pou
mwen kapab resevwa sèten medikaman?
Wi, kèk medikaman gen règ sou garanti yo oswa y gen limit sou kantite ou kapab
resevwa ladan yo. Nan kèk ka, ou dwe fè yon bagay anvan ou kapab resevwa
medikaman an. Pa egzanp:
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
 Anvan apwobasyon an (oswa anvan otorizasyon an): Pou kèk medikaman,
oumenm oswa doktè ou oswa lòt moun ki gen otorizasyon pou preskri medikaman
dwe jwenn apwobasyon ICS Community Care Plus FIDA-MMP oswa Ekip EntèDisiplinè (Interdisciplinary Team, IDT) ou anvan ou pran medikaman sou
preskripsyon ou. Si ou pa resevwa apwobasyon, ICS Community Care Plus FIDAMMP pa ka garanti medikaman an.
 Limit sou kantite: Pafwa ICS Community Care Plus FIDA-MMP limite kantite nan
yon medikaman ou kapab resevwa.
 Terapi-pa-etap: Pafwa ICS Community Care Plus FIDA-MMP egzije ou pou fè
terapi-pa-etap. Sa vle di w ap gen pou eseye medikaman yo nan yon sèten lòd
pou pwoblèm medikal ou. Ou ta ka gen pou eseye yon medikaman anvan n ap
garanti yon lòt medikaman. Si doktè ou panse premye medikaman an pa efikas
pou ou, lè sa a n ap garanti dezyèm nan.
Ou kapab chèche konnen si medikaman ou gen nenpòt kondisyon siplemantè oswa
limit. Pou fè sa, gade nan tablo ki kòmanse nan paj 15 lan. Ou kapab jwenn plis
enfòmasyon tou si ou ale sou sitwèb nou nan www.icsny.org/care-plus/pharmacybenefits. Nou mete dokiman sou entènèt ki eksplike otorizasyon davans nou ak
restriksyon pou terapi-pa-etap la. Ou ka mande nou pou voye yon kopi ba ou tou.
Ou kapab mande yon “eksepsyon” nan limit sa yo. Tanpri gade kesyon 11 pou jwenn
plis enfòmasyon sou eksepsyon yo.
 Si ou nan yon kay retrèt oswa nan yon sant medikal pou anpil tan epi ou bezwen
yon medikaman ki pa sou Lis Medikaman an, oswa si ou pa kapab jwenn
medikaman ou bezwen an fasil, nou kapab ede ou. N ap garanti yon kantite nan
medikaman ou bezwen annijans pou 31 jou (sof si ou gen yon preskripsyon pou
mwens jou), kit ou se yon nouvo Patisipan ICS Community Care Plus FIDA-MMP kit
ou pa yon nouvo Patisipan. Sa ap ba ou tan pou pale avèk doktè ou oswa avèk lòt
moun ki gen otorizasyon pou preskri medikaman. Li kapab ede ou deside si gen yon
medikaman sanblab sou Lis Medikaman ou kapab pran pito oswa si pou mande yon
eksepsyon. Tanpri gade kesyon 11 pou jwenn plis enfòmasyon sou eksepsyon yo.
6.
Kijan w ap konnen si medikaman ou vle a gen limit oswa si gen
aksyon ki nesesè pou fè pou resevwa medikaman an?
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
Lis Medikaman ki Garanti nan paj 15 la gen yon kolòn ki rele “Aksyon ki nesesè,
restriksyon, oswa limit sou itilizasyon.”
7.
Kisa k ap pase si nou chanje règ nou yo sou fason nou garanti
kèk medikaman? Pa egzanp, si nou ajoute otorizasyon davans
(apwobasyon), limit sou kantite ak/oswa restriksyon pou terapipa-etap sou yon medikaman.
N ap fè ou konnen si nou ajoute otorizasyon davans, limit sou kantite, ak/oswa
restriksyon pou terapi-pa-etap sou yon medikaman. N ap fè ou konnen omwen 60 jou
anvan nou ajoute restriksyon an oswa lè ou mande yon renouvèlman yon lòt fwa.
Answit, ou kapab resevwa yon kantite nan medikaman an pou 60 jou anvan nou fè
chanjman an sou Lis Medikaman an. Sa ba ou tan pou pale avèk doktè ou oswa avèk
lòt moun ki gen otorizasyon pou preskri medikaman sou sa pou fè apre.
8.
Kijan ou kapab jwenn yon medikaman sou Lis Medikaman an?
Gen de (2) fason pou jwenn yon medikaman:
 Ou kapab fè rechèch nan lòd lèt alfabè a (si ou konnen kijan pou eple medikaman
an), oswa
 Ou kapab fè rechèch dapre pwoblèm medikal la.
Pou chèche lòd lèt alfabè a, ale nan Endèks ki nan paj I-1. Answit chèche non
medikaman ou nan lis la.
Pou chèche selon pwoblèm medikal, jwenn “Lis medikaman yo selon pwoblèm
medikal la” nan paj 15. Answit jwenn pwoblèm medikal la. Pa egzanp, si ou gen yon
pwoblèm kè, ou ta dwe gade nan kategori sa a. Sa vle di kote w ap jwenn medikaman ki
trete pwoblèm kè.
9.
Kisa pou ou fè si medikaman ou vle pran an pa sou Lis
Medikaman an?
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
Si ou pa wè medikaman ou sou Lis Medikaman an, rele Sèvis Patisipan nan nimewo
1.855.ICS.2525 epi mande enfòmasyon sou sa. Si ou vin konnen ICS Community Care
Plus FIDA-MMP p ap garanti medikaman an, ou kapab fè youn nan bagay sa yo:
 Mande Sèvis Patisipan an yon lis medikaman tankou sa ou vle pran an. Answit,
montre lis la ba doktè ou oswa ba lòt moun ki gen otorizasyon pou preskri
medikaman. Li kapab preskri ou yon medikaman ki sou Lis Medikaman an ki
tankou sa ou vle pran an. Oswa
 Ou kapab mande plan an oswa Ekip Entè-Disiplinè (Interdisciplinary Teamm IDT)
ou pou fè yon eksepsyon pou garanti medikaman ou. Tanpri gade kesyon 11 pou
jwenn plis enfòmasyon sou eksepsyon yo.
10. Kisa pou ou fè si ou se yon nouvo Patisipan ICS Community Care
Plus FIDA-MMP epi ou pa kapab jwenn medikaman ou sou Lis
Medikaman an oswa ou gen yon pwoblèm pou jwenn medikaman
ou?
Nou kapab ede. Nou dwe garanti jiska 90 jou kantite medikaman pwovizwa, jan li
nesesè, pandan premye 90 jou ou se yon Patisipan ICS Community Care Plus FIDAMMP. Sa ap ba ou tan pou pale avèk doktè ou oswa avèk lòt moun ki gen otorizasyon
pou preskri medikaman. Li kapab ede ou deside si gen yon medikaman sanblab sou Lis
Medikaman ou kapab pran pito oswa si pou mande yon eksepsyon.
N ap garanti jiska 90 jou kantite pwovizwa medikaman ou si:
 w ap pran yon medikaman ki pa sou Lis Medikaman nou, oswa
 règ plan sante a pa kite ou resevwa kantite moun ki gen otorizasyon pou preskri
medikaman rekòmande pou ou, oswa

medikaman an egzije pou gen apwobasyon ICS Community Care Plus FIDAMMP oswa Ekip Entè-Disiplinè (Interdisciplinary Team, IDT) ou davans, oswa
 w ap pran yon medikaman ki se pati nan yon restriksyon terapi-pa-etap.
Si w ap viv nan yon kay retrèt oswa nan yon lòt sant medikal pou anpil tan, ou ka
renouvle medikaman sou preskripsyon pou jiska 98 jou. Ou ka renouvle medikaman an
anpil fwa pandan 98 jou. Sa bay tan pou moun ki gen otorizasyon pou preskri ou
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
medikaman an chanje medikaman ou yo an sa ki sou Lis Medikaman an oswa pou li
mande yon eksepsyon.
Si ou se yon patisipan regilye ki gen yon chanjman nan nivo swen ou ant yon
anviwònman tretman ak yon lòt, ou ka kalifye pou apeprè 90 jou kantite yon medikaman
ki pa sou Lis Medikaman an pou bay doktè ou oswa pwofesyonèl swen sante ki preskri
medikaman an tan pou chèche youn ki sou lis la oswa pou aplike pou yon eksepsyon.
Ou ka kalifye pou yon kantite medikaman tranzisyon nan nivo swen ou si ou:

antre nan yon sant sante alontèm (long-term care, LTC) nan yon lopital oswa nan
yon lòt anviwònman

kite yon sant medikal LTC epi retounen nan kominote a

jwen egzeyat nan yon lopital pou ale nan yon kay

fini kantite tan ou pase nan yon kay retrèt espesyalize ki garanti anba Pati A
Medicare (tankou frè pou peye famasi), epi retounen vin gen pwoteksyon an
anba Pati D

retounen ant kondisyon ospis ak avantaj nan Pati A ak B Medicare oswa

jwenn egzeyat nan yon lopital sikyatrik avèk rejim medikaman ki trè adapte apa
pou chak moun.
11. Èske ou kapab mande yon eksepsyon pou garanti medikaman ou?
Wi. Ou kapab mande ICS Community Care Plus FIDA-MMP oswa Ekip Entè-Disiplinè
(Interdisciplinary Team, IDT) ou pou fè yon eksepsyon pou garanti yon medikaman ki
pa sou Lis Medikaman an.
Ou kapab mande ICS Community Care Plus FIDA-MMP oswa IDT ou tou pou chanje
règ yo sou medikaman ou.
 Pa egzanp, ICS Community Care Plus FIDA-MMP ka limite kantite yon
medikaman n ap garanti. Si medikaman ou gen yon limit, ou kapab mande nou
oswa IDT pou chanje limit lan epi pou garanti plis.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
 Kèk lòt egzanp: Ou kapab mande nou oswa IDT ou pou diminye restriksyon pou
terapi-pa-etap oswa kondisyon pou jwenn apwobasyon davans.
12. Konbyen tan l ap pran pou jwenn yon eksepsyon?
Toudabò, CS Community Care Plus FIDA-MMP oswa Ekip Entè-Disiplinè
(Interdisciplinary Team, IDT) ou dwe resevwa yon deklarasyon moun ki gen otorizasyon
pou preskri medikaman an ki sipòte demann ou pou yon eksepsyon. Apre nou resevwa
deklarasyon an, w ap resevwa yon desizyon sou demann ou pou eksepsyon an nan
72 èdtan.
Si oumenm oswa moun ki gen otorizasyon pou preskri medikaman an panse sante ou
ka domaje si ou gen pou rete tann 72 èdtan pou yon desizyon, ou kapab mande yon
eksepsyon rapid. Sa a se yon desizyon ki pi rapid. Si moun ki gen otorizasyon pou
preskri medikaman an sipòte demann ou, w ap resevwa yon desizyon nan 24 èdtan
apre nou resevwa deklarasyon sipò moun ki gen otorizasyon pou preskri medikaman
an.
13. Kijan ou kapab mande yon eksepsyon?
Pou mande yon eksepsyon, rele Manadjè Swen Sante ou. Manadjè Swen Sante ou ap
travay avèk ou ak moun ki gen otorizasyon pou preskri medikaman an pou ede ou
mande yon eksepsyon.
14. Kisa medikaman jenerik yo?
Medikaman jenerik yo fèt avèk menm engredyan ak medikaman mak komèsyal yo.
Anjeneral, yo koute mwens lajan pase medikaman mak komèsyal yo, epitou anjeneral,
yo pa gen non tout moun konnen byen. Ajans Etazini pou Kontwòl Manje ak Medikaman
(Food and Drug Administration, FDA) apwouve medikaman jenerik yo.
ICS Community Care Plus FIDA-MMP pwoteje medikaman ki gen non komèsyal ak
medikaman jenerik.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
15. Kisa medikaman OTC ye?
OTC vle di “san preskripsyon”. ICS Community Care Plus FIDA-MMP garanti kèk
medikaman OTC lè se pwofesyonèl swen sante ou ki ekri preskripsyon pou yo.
Ou kapab li Lis Medikaman ICS Community Care Plus FIDA-MMP pou wè ki
medikaman OTC ki garanti.
16. Èske ICS Community Care Plus FIDA-MMP garanti pwodui ki pa
medikaman OTC?
ICS Community Care Plus FIDA-MMP garanti kèk pwodui ki pa medikaman OTC lè se
pwofesyonèl swen sante ou ki ba ou preskripsyon pou yo, pa egzanp, tanpon alkòl,
tanpon-a-gaz, ak sereng pou pran ensilin.
Ou kapab li Lis Medikaman ICS Community Care Plus FIDA-MMP pou wè ki pwodui pa
medikaman OTC ki garanti.
17. Kisa kopeman ou ye?
Nou p ap fè ou peye yon kopeman pou medikaman ki sou Lis Medikaman an.
18. Kisa nivo medikaman yo ye?
Nivo yo se gwoup medikaman. Chak medikaman ki sou Lis Medikaman plan an nan
youn nan 4 nivo yo. Ou pa gen frè pou peye pou medikaman ki nan nenpòt nivo.
 Nivo 1: Medicare garanti medikaman jenerik yo
 Nivo 2: Medicare garanti medikaman non komèsyal yo ak medikaman


espesyalite yo
Nivo 3: Medicaid garanti medikaman jenerik ak medikaman non komèsyal ki pa
nan Pati D
Nivo 4: Medicaid garanti Medikaman San Preskripsyon (OTC)
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
Lis Medikaman ki Garanti yo
Lis medikaman ki garanti ki kòmanse nan paj apre a yo ba ou enfòmasyon sou
medikaman ICS Community Care Plus FIDA-MMP garanti. Si ou gen pwoblèm pou
jwenn medikaman ou nan lis la, ale nan Endèks ki kòmanse nan paj I-1.
Premye kolòn tablo a bay lis non medikaman an. Medikaman mak komèsyal yo ekri an
majiskil (pa egzanp, AVONEX), epi medikaman jenerik yo endike an lèt italik miniskil
(pa egzanp, amoxicillin).
Enfòmasyon ki nan aksyon nesesè, restriksyon oswa limit sou kolòn itilizasyon an ap fè
ou konnen si ICS Community Care Plus FIDA-MMP gen nenpòt règ pou garanti
medikaman ou.
Abrevyasyon ak Senbòl
Ou ka jwenn abrevyasyon ki endike anba la yo nan kò dokiman sa a
ABREVYASYON
DESKRIPSYON
EKSPLIKASYON
Restriksyon pou Kontwòl Itilizasyon
PA
PA BvD
Restriksyon pou
Otorizasyon Davans
Oumenm (oswa doktè ou) gen obligasyon
pou jwenn otorizasyon davans nan ICS
Community Care Plus FIDA-MMP anvan
ou egzekite preskripsyon ou pou
medikaman sa a. San apwobasyon
davans lan, ICS Community Care Plus
FIDA-MMP ka pa garanti medikaman sa a.
Medikaman sa a ka kalifye pou peman
anba Pati B oswa Pati D Medicare.
Oumenm (oswa doktè ou) gen obligasyon
pou jwenn otorizasyon davans nan ICS
Restriksyon pou
Otorizasyon Davans Community Care Plus FIDA-MMP pou
pou Pati B parapò ak detèmine si medikaman sa a garanti anba
Detèminasyon Pati D Pati D Medicare anvan ou egzekite
preskripsyon ou pou medikaman sa a. San
apwobasyon davans lan, FIDA Care
Complete ka pa garanti medikaman sa a.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
ABREVYASYON
PA NSO
QL
ST
DESKRIPSYON
EKSPLIKASYON
Restriksyon pou
Otorizasyon Davans
pou Nouvo Patisipan
yo
Si ou se yon nouvo manm, oswa si ou pa t
pran medikaman sa a anvan, oumenm
(oswa doktè ou) gen obligasyon pou jwenn
otorizasyon davans nan ICS Community
Care Plus FIDA-MMP anvan ou egzekite
preskripsyon ou pou medikaman sa a. San
apwobasyon davans lan, FIDA Care
Complete ka pa garanti medikaman sa a.
ICS Community Care Plus FIDA-MMP
Restriksyon pou Limit limite kantite medikaman ki garanti pou
chak preskripsyon, oswa nan yon peryòd
nan Kantite
tan espesyal.
Restriksyon pou
Terapi-pa-Etap
Anvan ICS Community Care Plus FIDAMMP ap bay pwoteksyon pou medikaman
sa a, ou dwe eseye yon (kèk) lòt
medikaman pou trete pwoblèm medikal
ou. Nou ka garanti medikaman sa a
sèlman si lòt medikaman (yo) pa efikas
pou ou.
Lòt Abrevyasyon Pwoteksyon
*
Pa yon Medikaman
Pati D
LA
Medikaman ki gen
Aksè Limite
GC
Peryòd Sispansyon
Pwoteksyon
Medikaman sa a se yon medikaman ki pa
nan Pati D, epi se Medicaid ki garanti li.
Preskripsyon sa a ka disponib sèlman nan
sèten famasi. Pou jwenn plis enfòmasyon,
ale nan Anyè Famasi a oswa rele ICS
Community Care Plus FIDA-MMP nan
nimewo 1.877.ICS.2525, lendi jiska
vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale
sou sitwèb www.icsny.org/care-plus.
Nou bay pwoteksyon pou medikaman sou
preskripsyon sa a nan peryòd sispansyon
pwoteksyon an. Tanpri ale nan Prèv
Pwoteksyon ou pou jwenn plis
enfòmasyon sou pwoteksyon sa a.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
Nòt: Asterisk (*) ki toupre yon medikaman vle di medikaman an pa yon “medikaman
Pati D.” Medikaman sa yo gen diferan règ pou kontestasyon. Yon kontestasyon se yon
fason fòmèl pou mande yon revizyon epi pou fè chanjman nan yon desizyon sou
pwoteksyon si ou panse te gen yon erè. Pa egzanp, ICS Community Care Plus FIDAMMP oswa Ekip Entè-Disiplinè (Interdisciplinary Team, IDT) ou ta ka deside yon
medikaman ou vle pa garanti oswa pa garanti ankò anba Medicare oswa Medicaid. Si
oumenm oswa doktè ou oswa lòt moun ki gen otorizasyon pou preskri medikaman pa
dakò avèk desizyon an, ou kapab fè yon kontestasyon. Pou mande enstriksyon sou
fason pou fè yon kontestasyon, rele Sèvis Patisipan nan nimewo 1.877.ICS.2525 oswa
Independent Consumer Advocacy Network (ICAN) at 1-844-614-8800. Ou kapab li Tiliv
Enfòmasyon Patisipan tou pou aprann kijan pou konteste yon desizyon .
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
Tier level
What the
drug will
cost you
(Acetaminophen)
(Acetaminophen)
(Tylenol 8 Hour)
4
4
4
$0
$0
$0
(Acetaminophen)
4
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
(Tencon)
1
$0
(Esgic)
1
$0
(Fiorinal)
1
$0
(Butorphanol
Tartrate)
1
$0
2
4
4
4
4
4
4
$0
$0
$0
$0
$0
$0
$0
Name of Drug
Necessary Actions,
Restrictions, or
Limits on Use
Analgesics
Analgesics, Miscellaneous
acephen *
acetaminophen * oral
acetaminophen * oral
acetaminophen * rectal suppository
120 mg, 650 mg
acetaminophen-codeine oral
solution
acetaminophen-codeine oral tablet
300-15 mg, 300-30 mg
acetaminophen-codeine oral tablet
300-60 mg
buprenorphine hcl injection
(Acetaminophen
with Codeine)
(Tylenol-Codeine
No.3)
(Tylenol-Codeine
No.3)
(Buprenorphine
HCl)
butalb-acetaminophen-caffeine oral
(Esgic)
capsule 50-325-40 mg
(Fioricet with
butalbital-acetaminop-caf-cod
Codeine)
butalbital-acetaminophen
butalbital-acetaminophen-caff oral
tablet 50-325-40 mg
butalbital-aspirin-caffeine oral
capsule
butorphanol tartrate nasal
BUTRANS
children's mapap *
children's non-aspirin * oral
children's non-aspirin * oral
children's pain & fever relief * oral
children's pain reliever * oral
children's pain reliever * oral
(Acetaminophen)
(Acetaminophen)
(Acetaminophen)
(Infants' Tylenol)
(Acetaminophen)
(Acetaminophen)
QL (2700 per 30 days)
QL (360 per 30 days)
QL (180 per 30 days)
PA-HRM; QL (180 per
30 days)
PA-HRM; QL (180 per
30 days)
PA-HRM; QL (180 per
30 days)
PA-HRM; QL (180 per
30 days)
PA-HRM; QL (180 per
30 days)
QL (5 per 28 days)
QL (4 per 28 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
14
Tier level
What the
drug will
cost you
4
$0
1
$0
1
$0
2
$0
(Actiq)
1
$0
(Duragesic)
1
$0
(Duragesic)
1
$0
(Acetaminophen)
4
$0
(Hycet)
1
$0
Name of Drug
children's silapap *
codeine sulfate oral tablet
codeine-butalbital-asa-caffein oral
capsule 30-50-325-40 mg
DURAMORPH (PF)
fentanyl citrate
fentanyl transdermal patch 72 hour
100 mcg/hr
fentanyl transdermal patch 72 hour
12 mcg/hr, 25 mcg/hr, 37.5
mcg/hour, 50 mcg/hr, 62.5
mcg/hour, 75 mcg/hr, 87.5
mcg/hour
feverall * rectal suppository 120
mg, 325 mg, 650 mg
hydrocodone-acetaminophen oral
solution
hydrocodone-acetaminophen oral
tablet 10-300 mg, 5-300 mg, 7.5300 mg
hydrocodone-acetaminophen oral
tablet 10-325 mg, 2.5-325 mg, 5325 mg, 7.5-325 mg
hydrocodone-ibuprofen
hydromorphone (pf) injection
solution 10 mg/ml
hydromorphone (pf) injection
solution 4 mg/ml
hydromorphone injection solution
hydromorphone injection syringe 2
mg/ml
(Tylenol Sore
Throat)
(Codeine Sulfate)
(Fiorinal with
Codeine #3)
(Norco)
1
$0
(Norco)
1
$0
(Ibudone)
(Hydromorphone
HCl/PF)
1
$0
1
$0
(Dilaudid)
1
$0
1
$0
1
$0
(Hydromorphone
HCl)
(Hydromorphone
HCl)
Necessary Actions,
Restrictions, or
Limits on Use
QL (180 per 30 days)
PA-HRM; QL (180 per
30 days)
PA; QL (120 per 30
days)
PA; QL (20 per 30
days)
PA; QL (10 per 30
days)
QL (2700 per 30 days)
(includes Vicodin,
Vicodin ES and
Vicodin HP); QL (390
per 30 days)
QL (360 per 30 days)
QL (150 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
15
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
(Dilaudid)
1
$0
(Dilaudid)
1
$0
QL (1200 per 30 days)
QL (180 per 30 days)
(Dilaudid)
(Acetaminophen)
(Acetaminophen)
(Acetaminophen)
(Acetaminophen)
(Acetaminophen)
1
4
4
4
4
4
$0
$0
$0
$0
$0
$0
2
$0
1
$0
4
4
$0
$0
4
$0
4
4
4
4
4
$0
$0
$0
$0
$0
(Diskets)
1
$0
(Methadone HCl)
(Methadone HCl)
(Diskets)
(Msir)
(Morphine Sulfate)
1
1
1
1
1
$0
$0
$0
$0
$0
(Morphine Sulfate)
1
$0
(Morphine Sulfate)
(Morphine Sulfate)
(Morphine Sulfate)
1
1
1
$0
$0
$0
Name of Drug
hydromorphone oral liquid
hydromorphone oral tablet 2 mg, 4
mg
hydromorphone oral tablet 8 mg
infant acetaminophen *
infantaire *
infant's pain reliever *
jr. acetaminophen *
junior mapap *
LAZANDA
levorphanol tartrate
mapap (acetaminophen) * oral
mapap (acetaminophen) * oral
mapap (acetaminophen) * oral
liquid 500 mg/15 ml
mapap (acetaminophen) * oral
mapap (acetaminophen) * oral
mapap (acetaminophen) * oral
mapap arthritis pain *
mapap extra strength *
methadone hcl oral tablet,soluble
40 mg
methadone injection
methadone oral
methadone oral
morphine concentrate oral solution
morphine concentrate oral syringe
morphine injection solution 10
mg/ml, 15 mg/ml, 8 mg/ml
morphine injection syringe
morphine intramuscular
morphine intravenous
(Levorphanol
Tartrate)
(Acetaminophen)
(Acetaminophen)
(Tylenol Sore
Throat)
(Infants' Tylenol)
(Tylenol)
(Acetaminophen)
(Tylenol 8 Hour)
(Tylenol)
QL (240 per 30 days)
PA; QL (30 per 30
days)
QL (180 per 30 days)
QL (90 per 30 days)
QL (1800 per 30 days)
QL (360 per 30 days)
QL (200 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
16
Tier level
What the
drug will
cost you
(Morphine Sulfate)
1
$0
(Morphine Sulfate)
(Msir)
(Msir)
1
1
1
1
$0
$0
$0
$0
(MS Contin)
1
$0
(MS Contin)
1
$0
(Morphine Sulfate)
(Acetaminophen)
(Tylenol Sore
Throat)
(Acetaminophen)
(Acetaminophen)
1
4
$0
$0
4
$0
4
4
2
2
$0
$0
$0
$0
(Oxycodone
HCl/Acetaminophe
n)
1
$0
(Xolox)
1
$0
(Xolox)
1
$0
(Percodan)
(Oxycodone HCl)
(Oxycodone HCl)
(Percolone)
1
1
1
1
$0
$0
$0
$0
(Xolox)
1
$0
(Xolox)
1
$0
Name of Drug
morphine intravenous solution 25
mg/ml, 50 mg/ml
morphine intravenous
morphine oral solution 10 mg/5 ml
morphine oral solution 20 mg/5 ml
MORPHINE ORAL TABLET
morphine oral tablet extended
release 100 mg, 30 mg, 60 mg
morphine oral tablet extended
release 15 mg, 200 mg
morphine rectal
non-aspirin extra strength * oral
non-aspirin extra strength * oral
non-aspirin jr strength *
nortemp * oral
NUCYNTA
NUCYNTA ER
oxycodone hcl-acetaminophen oral
solution 5-325 mg/5 ml
oxycodone hcl-acetaminophen oral
tablet 10-325 mg, 2.5-325 mg, 5325 mg, 7.5-325 mg
oxycodone hcl-acetaminophen oral
tablet 5-500 mg
oxycodone hcl-aspirin
oxycodone oral concentrate
oxycodone oral solution
oxycodone oral tablet
oxycodone-acetaminophen oral
tablet 10-325 mg, 2.5-325 mg, 5325 mg, 7.5-325 mg
oxycodone-acetaminophen oral
tablet 10-650 mg
Necessary Actions,
Restrictions, or
Limits on Use
QL (700 per 30 days)
QL (300 per 30 days)
QL (180 per 30 days)
QL (120 per 30 days)
QL (180 per 30 days)
QL (181 per 30 days)
QL (60 per 30 days)
QL (1800 per 30 days)
QL (360 per 30 days)
QL (240 per 30 days)
QL (360 per 30 days)
QL (180 per 30 days)
QL (1300 per 30 days)
QL (180 per 30 days)
QL (360 per 30 days)
QL (180 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
17
Tier level
What the
drug will
cost you
(Xolox)
1
$0
(Percodan)
1
$0
2
$0
2
$0
(Opana)
1
$0
(Opana ER)
1
$0
(Opana ER)
1
$0
4
$0
4
$0
(Tylenol 8 Hour)
4
$0
(Acetaminophen)
(Acetaminophen)
(Tylenol)
(Tylenol)
(Acetaminophen)
(Tylenol Sore
Throat)
(Tylenol)
(Acetaminophen)
(Tylenol)
(Tylenol)
(Ultram)
(Ultracet)
4
4
4
4
4
$0
$0
$0
$0
$0
4
$0
4
4
4
4
1
1
$0
$0
$0
$0
$0
$0
Name of Drug
oxycodone-acetaminophen oral
tablet 7.5-500 mg
oxycodone-aspirin
OXYCONTIN ORAL
TABLET,ORAL
ONLY,EXT.REL.12 HR 10 MG,
15 MG, 20 MG, 30 MG, 40 MG, 60
MG
OXYCONTIN ORAL
TABLET,ORAL
ONLY,EXT.REL.12 HR 80 MG
oxymorphone oral tablet
oxymorphone oral tablet extended
release 12 hr 10 mg, 15 mg, 20 mg,
5 mg, 7.5 mg
oxymorphone oral tablet extended
release 12 hr 30 mg, 40 mg
pain relief adult *
pain relief * oral capsule
pain relief * oral tablet extended
release
pain reliever jr strength *
pain reliever * oral
pharbetol *
q-pap extra strength *
q-pap * oral drops
q-pap * oral liquid
q-pap * oral tablet
silapap *
tactinal *
tactinal extra strength *
tramadol oral tablet
tramadol-acetaminophen
Necessary Actions,
Restrictions, or
Limits on Use
QL (240 per 30 days)
QL (360 per 30 days)
QL (60 per 30 days)
QL (120 per 30 days)
(Tylenol Sore
Throat)
(Acetaminophen)
QL (180 per 30 days)
QL (60 per 30 days)
QL (120 per 30 days)
QL (240 per 30 days)
QL (240 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
18
Name of Drug
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
xylon 10
(Ibudone)
1
$0
QL (150 per 30 days)
Nonsteroidal Anti-Inflammatory Agents
advil * oral tablet
(Motrin Ib)
4
$0
advil * oral tablet,chewable
(Ibuprofen)
4
$0
aspirin * oral tablet
(Ecotrin)
4
$0
(Bayer Chewable
aspirin * oral tablet,chewable
4
$0
Aspirin)
aspirin * oral tablet,delayed release
(Ecotrin)
4
$0
(dr/ec) 325 mg, 500 mg, 81 mg
aspirin * rectal
(Aspirin)
4
$0
(Aspirin/Calcium
aspirin, buffered *
4
$0
Carbonate/Mag)
aspir-low *
(Ecotrin)
4
$0
(Aspirin/Calcium
bufferin * oral tablet 325 mg
4
$0
Carbonate/Mag)
CALDOLOR INTRAVENOUS
2
$0
RECON SOLN
celecoxib
(Celebrex)
1
$0
QL (60 per 30 days)
(Children'S
children's advil *
4
$0
Motrin)
(Choline Sal/Mag
choline,magnesium salicylate
1
$0
Salicylate)
COMFORT PAC-IBUPROFEN
1
$0
COMFORT PAC-MELOXICAM
1
$0
COMFORT PAC-NAPROXEN
1
$0
diclofenac potassium
(Cataflam)
1
$0
diclofenac sodium oral tablet
(Voltaren-XR)
1
$0
extended release 24 hr
diclofenac sodium oral
(Diclofenac
1
$0
tablet,delayed release (dr/ec)
Sodium)
diclofenac sodium topical gel
(Solaraze)
1
$0
diclofenac-misoprostol
(Arthrotec 50)
1
$0
diflunisal
(Diflunisal)
1
$0
e.c. prin *
(Ecotrin)
4
$0
etodolac
(Etodolac)
1
$0
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
19
Tier level
What the
drug will
cost you
1
$0
2
1
$0
$0
4
$0
4
4
$0
$0
(Ibuprofen)
1
$0
(Motrin Ib)
4
$0
(Ibuprofen)
1
$0
indomethacin oral capsule 25 mg
(Indomethacin)
1
$0
indomethacin oral capsule 50 mg
(Indomethacin)
1
$0
(Indomethacin)
1
$0
(Indocin I.V.)
(Infants' Motrin)
(Ketoprofen)
1
4
3
1
$0
$0
$0
$0
(Ketoprofen)
1
$0
(Toradol)
1
$0
(Toradol)
1
$0
1
$0
1
$0
Name of Drug
fenoprofen oral tablet
FLECTOR
flurbiprofen
ibuprofen * 100 mg/5 ml susp
children's (otc)
ibuprofen jr strength *
ibuprofen * oral
ibuprofen oral suspension 100 mg/5
ml
ibuprofen * oral tablet 100 mg, 200
mg
ibuprofen oral tablet 400 mg, 600
mg, 800 mg
indomethacin oral capsule,
extended release
indomethacin sodium
infant's ibuprofen *
INFANT'S MOTRIN *
ketoprofen oral capsule
ketoprofen oral capsule,ext rel.
pellets 24 hr 200 mg
ketorolac injection cartridge 15
mg/ml
ketorolac injection cartridge 30
mg/ml
ketorolac injection solution 15
mg/ml
ketorolac injection solution 30
mg/ml (1 ml)
(Fenoprofen
Calcium)
(Ansaid)
(Children'S
Motrin)
(Ibuprofen)
(Advil)
(Ketorolac
Tromethamine)
(Ketorolac
Tromethamine)
Necessary Actions,
Restrictions, or
Limits on Use
PA
PA-HRM; QL (240 per
30 days)
PA-HRM; QL (120 per
30 days)
PA-HRM; QL (60 per
30 days)
PA-HRM
QL (40 per 30 days)
QL (20 per 30 days)
QL (40 per 30 days)
QL (20 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
20
Tier level
What the
drug will
cost you
1
$0
1
$0
1
1
1
1
1
$0
$0
$0
$0
$0
(Ec-Naprosyn)
1
$0
(Anaprox)
1
$0
(Feldene)
(Salsalate)
(Bayer Chewable
Aspirin)
(Ecotrin)
(Sulindac)
(Tolmetin Sodium)
(Aspirin/Calcium
Carbonate/Mag)
1
1
$0
$0
4
$0
4
1
1
$0
$0
$0
4
$0
(Advil)
2
4
$0
$0
glydo
(Lidocaine HCl)
1
$0
lidocaine (pf) injection solution
(Xylocaine-MPF)
1
$0
lidocaine hcl injection solution
(Xylocaine)
1
$0
1
1
$0
$0
Name of Drug
ketorolac intramuscular solution
ketorolac oral
mefenamic acid
meloxicam
nabumetone
naproxen oral suspension
naproxen oral tablet
naproxen oral tablet,delayed
release (dr/ec)
naproxen sodium oral tablet 275
mg, 550 mg
piroxicam
salsalate
st joseph aspirin *
st. joseph aspirin *
sulindac oral
tolmetin
tri-buffered aspirin *
VOLTAREN TOPICAL
wal-profen * oral
(Ketorolac
Tromethamine)
(Ketorolac
Tromethamine)
(Ponstel)
(Mobic)
(Nabumetone)
(Naprosyn)
(Naprosyn)
Necessary Actions,
Restrictions, or
Limits on Use
QL (20 per 30 days)
QL (20 per 30 days)
Anesthetics
Local Anesthetics
lidocaine hcl laryngotracheal
(Xylocaine)
lidocaine hcl mucous membrane gel (Lidocaine HCl)
PA BvD; (PA for
ESRD Only)
PA BvD; (PA for
ESRD Only)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
21
Tier level
What the
drug will
cost you
(Lidocaine HCl)
1
$0
(Xylocaine)
1
$0
(Lidocaine HCl)
1
$0
(Lidoderm)
1
$0
lidocaine topical ointment
(Lidocaine)
1
$0
lidocaine-prilocaine topical
(EMLA)
1
$0
lidocaine-prilocaine topical kit
(Lidocaine/Prilocai
ne)
1
$0
2
$0
Anti-Addiction/Substance Abuse Treatment Agents
acamprosate
(Campral)
1
$0
buprenorphine hcl sublingual
1
$0
1
$0
1
2
$0
$0
2
$0
2
$0
2
$0
1
1
1
1
$0
$0
$0
$0
Name of Drug
lidocaine hcl mucous membrane
jelly in applicator
lidocaine hcl mucous membrane
solution
lidocaine hcl urethral
lidocaine topical adhesive
patch,medicated
LIDODERM
Necessary Actions,
Restrictions, or
Limits on Use
PA
PA BvD; (PA for
ESRD Only)
PA BvD; (PA for
ESRD Only)
PA BvD
PA
Anti-Addiction/Substance Abuse Treatment Agents
buprenorphine-naloxone
bupropion hcl sr 150 mg tablet f/c
CHANTIX
CHANTIX CONTINUING
MONTH BOX
CHANTIX CONTINUING
MONTH PAK
CHANTIX STARTING MONTH
BOX
disulfiram
naloxone
naltrexone hcl
naltrexone
(Subutex)
(Buprenorphine
HCl/Naloxone
HCl)
(Zyban)
(Antabuse)
(Naloxone HCl)
(Revia)
(Revia)
PA; QL (90 per 30
days)
PA; QL (90 per 30
days)
QL (168 per 84 days)
QL (56 per 28 days)
QL (56 per 28 days)
QL (53 per 28 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
22
Name of Drug
NICODERM CQ *
TRANSDERMAL PATCH 24
HOUR 14 MG/24 HR, 21 MG/24
HR
NICODERM CQ *
TRANSDERMAL PATCH 24
HOUR 7 MG/24 HR
nicorelief * buccal gum
nicorette * buccal gum 2 mg
nicotine (polacrilex) *
nicotine * transdermal patch 24
hour 14 mg/24 hr, 7 mg/24 hr
nicotine * transdermal patch 24
hour 21 mg/24 hr, 22 mg/24 hr
NICOTROL
ZUBSOLV SUBLINGUAL
TABLET 1.4-0.36 MG, 5.7-1.4 MG
ZUBSOLV SUBLINGUAL
TABLET 8.6-2.1 MG
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
QL (168 per 365 days)
4
$0
4
$0
(Nicorette)
(Nicorette)
(Nicorette)
4
4
4
$0
$0
$0
(Nicoderm Cq)
4
$0
(Nicoderm Cq)
4
$0
2
$0
2
$0
2
$0
(Xanax)
1
$0
(Xanax XR)
1
$0
(Xanax XR)
1
$0
(Alprazolam)
1
$0
(Chlordiazepoxide
HCl)
1
$0
(Klonopin)
1
$0
(Klonopin)
1
$0
QL (180 per 365 days)
QL (168 per 365 days)
PA; QL (90 per 30
days)
PA; QL (60 per 30
days)
Antianxiety Agents
Benzodiazepines
alprazolam oral tablet
alprazolam oral tablet extended
release 24 hr 0.5 mg
alprazolam oral tablet extended
release 24 hr 1 mg, 2 mg, 3 mg
alprazolam oral
tablet,disintegrating
chlordiazepoxide hcl
clonazepam oral tablet 0.5 mg, 1
mg
clonazepam oral tablet 2 mg
QL (90 per 30 days)
QL (90 per 30 days)
QL (60 per 30 days)
QL (90 per 30 days)
QL (120 per 30 days)
QL (90 per 30 days)
QL (300 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
23
Tier level
What the
drug will
cost you
(Clonazepam)
1
$0
(Clonazepam)
1
$0
(Tranxene T-Tab)
1
$0
(Tranxene T-Tab)
1
$0
2
$0
1
1
1
1
1
$0
$0
$0
$0
$0
Name of Drug
clonazepam oral
tablet,disintegrating 0.125 mg, 0.25
mg, 0.5 mg, 1 mg
clonazepam oral
tablet,disintegrating 2 mg
clorazepate dipotassium oral tablet
15 mg
clorazepate dipotassium oral tablet
3.75 mg, 7.5 mg
DIASTAT ACUDIAL RECTAL
KIT 12.5-15-17.5-20 MG
diazepam injection
diazepam intensol
diazepam oral solution
diazepam oral tablet
diazepam rectal
Necessary Actions,
Restrictions, or
Limits on Use
QL (90 per 30 days)
(Diazepam)
(Diazepam)
(Diazepam)
(Valium)
(Diastat Acudial)
estazolam oral tablet 1 mg
(Estazolam)
1
$0
estazolam oral tablet 2 mg
(Estazolam)
1
$0
QL (300 per 30 days)
QL (120 per 30 days)
QL (60 per 30 days)
QL (10 per 28 days)
QL (1200 per 30 days)
QL (1200 per 30 days)
QL (120 per 30 days)
PA-HRM; (High Risk
Med. QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use with
any nonbenzodiazepine
hypnotic drug); QL (60
per 30 days)
PA-HRM; (High Risk
Med. QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use with
any nonbenzodiazepine
hypnotic drug); QL (30
per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
24
Name of Drug
Tier level
What the
drug will
cost you
flurazepam oral capsule 15 mg
(Flurazepam HCl)
1
$0
flurazepam oral capsule 30 mg
(Flurazepam HCl)
1
$0
lorazepam injection solution
lorazepam injection syringe
lorazepam oral tablet
(Ativan)
(Ativan)
(Ativan)
(Midazolam
HCl/PF)
(Midazolam
HCl/PF)
(Midazolam HCl)
1
1
1
$0
$0
$0
1
$0
1
$0
1
$0
ONFI ORAL SUSPENSION
2
$0
ONFI ORAL TABLET 10 MG, 20
MG
2
$0
midazolam (pf) injection
midazolam (pf) injection syringe 2
mg/2 ml (1 mg/ml)
midazolam oral syrup 2 mg/ml
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM; (High Risk
Med. QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use with
any nonbenzodiazepine
hypnotic drug); QL (60
per 30 days)
PA-HRM; (High Risk
Med. QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use with
any nonbenzodiazepine
hypnotic drug); QL (30
per 30 days)
QL (2 per 30 days)
QL (2 per 30 days)
QL (90 per 30 days)
QL (2 per 30 days)
QL (2 per 30 days)
QL (10 per 30 days)
PA NSO; QL (480 per
30 days)
PA NSO; QL (60 per
30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
25
Name of Drug
Tier level
What the
drug will
cost you
temazepam oral capsule 15 mg,
22.5 mg, 30 mg
(Restoril)
1
$0
temazepam oral capsule 7.5 mg
(Restoril)
1
$0
triazolam oral tablet 0.125 mg
(Halcion)
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM; (High Risk
Med. QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use with
any nonbenzodiazepine
hypnotic drug); QL (30
per 30 days)
PA-HRM; (High Risk
Med. QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use with
any nonbenzodiazepine
hypnotic drug); QL
(120 per 30 days)
PA-HRM; (High Risk
Med. QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use with
any nonbenzodiazepine
hypnotic drug); QL
(120 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
26
Name of Drug
triazolam oral tablet 0.25 mg
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
1
$0
PA-HRM; (High Risk
Med. QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use with
any nonbenzodiazepine
hypnotic drug); QL (60
per 30 days)
2
$0
PA BvD
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
2
1
$0
$0
1
$0
1
$0
1
$0
1
$0
1
$0
Tier level
(Halcion)
Antibacterials
Aminoglycosides
BETHKIS
gentamicin in nacl (iso-osm)
intravenous piggyback
gentamicin injection solution
gentamicin sulfate (ped) (pf)
gentamicin sulfate (pf) intravenous
solution
neomycin
streptomycin intramuscular
(Gentamicin In
Nacl, Iso-Osm)
(Garamycin)
(Gentamicin
Sulfate/PF)
(Gentamicin
Sulfate/PF)
(Neomycin Sulfate)
(Streptomycin
Sulfate)
TOBI PODHALER INHALATION
tobramycin in 0.225 % nacl
(Tobi)
(Tobramycin/Sodiu
tobramycin in 0.9 % nacl
m Chloride)
tobramycin sulfate injection
(Nebcin)
solution
Antibacterials, Miscellaneous
bacitracin intramuscular
(Bacitracin)
(Chloramphenicol
chloramphenicol sod succinate
Sod Succ)
clindamycin hcl
(Cleocin HCl)
QL (224 per 28 days)
PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
27
Name of Drug
clindamycin in 5 % dextrose
clindamycin palmitate hcl
clindamycin phosphate injection
clindamycin phosphate intravenous
solution
colistin (colistimethate na)
CUBICIN
linezolid
methenamine hippurate
methenamine mandelate oral tablet
1 gram
(Cleocin Phosphate
In D5w)
(Cleocin Palmitate)
(Cleocin
Phosphate)
(Cleocin
Phosphate)
(Coly-Mycin M
Parenteral)
(Zyvox)
(Hiprex)
(Methenamine
Mandelate)
Tier level
What the
drug will
cost you
1
$0
1
$0
1
$0
1
$0
1
$0
2
1
1
$0
$0
$0
1
$0
nitrofurantoin macrocrystal oral
capsule
(Macrodantin)
1
$0
nitrofurantoin monohyd/m-cryst
(Macrobid)
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM; (High Risk
Med. QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use of
nitrofurantoin drugs);
QL (120 per 30 days)
PA-HRM; (High Risk
Med. QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use of
nitrofurantoin drugs);
QL (120 per 30 days)
SYNERCID
2
$0
trimethoprim
(Trimethoprim)
1
$0
vancomycin in d5w intravenous
(Vancomycin
1
$0
piggyback
HCl/D5W)
vancomycin intravenous recon soln
(Vancomycin HCl)
1
$0
1,000 mg, 10 gram, 750 mg
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
28
Tier level
What the
drug will
cost you
1
$0
1
$0
2
$0
2
$0
2
$0
(Cefaclor)
1
$0
(Cefaclor)
1
$0
(Cefadroxil)
1
$0
(Cefadroxil)
1
$0
(Cefadroxil)
1
$0
(Cefazolin Sodium)
1
$0
1
$0
1
$0
(Cefazolin Sodium)
1
$0
(Cefazolin Sodium)
(Cefdinir)
(Spectracef)
(Maxipime)
1
1
1
1
2
$0
$0
$0
$0
$0
2
$0
Name of Drug
vancomycin intravenous recon soln
500 mg
vancomycin oral capsule
XIFAXAN ORAL TABLET 200
MG
XIFAXAN ORAL TABLET 550
MG
ZYVOX ORAL
Cephalosporins
cefaclor oral capsule
cefaclor oral suspension for
reconstitution 125 mg/5 ml, 250
mg/5 ml, 375 mg/5 ml
cefadroxil oral capsule
cefadroxil oral suspension for
reconstitution 250 mg/5 ml, 500
mg/5 ml
cefadroxil oral tablet
cefazolin in dextrose (iso-os)
intravenous piggyback 1 gram/50
ml
cefazolin in dextrose (iso-os)
intravenous piggyback 2 gram/50
ml
cefazolin injection recon soln
cefazolin injection recon soln 100
gram, 300 g
cefazolin intravenous
cefdinir
cefditoren pivoxil
cefepime
CEFEPIME IN DEXTROSE 5 %
CEFEPIME IN DEXTROSE,ISOOSM INTRAVENOUS
PIGGYBACK
(Vancomycin
HCl/D5W)
(Vancocin HCl)
(Cefazolin
Sodium/Dextrose,
Iso)
(Ancef)
Necessary Actions,
Restrictions, or
Limits on Use
PA; QL (9 per 30 days)
ST; QL (60 per 30
days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
29
Tier level
What the
drug will
cost you
(Claforan)
(Mefoxin)
(Cefoxitin
Sodium/Dextrose,
Iso)
(Cefpodoxime
Proxetil)
(Cefprozil)
1
1
$0
$0
1
$0
1
$0
1
$0
(Ceftazidime)
1
$0
(Cedax)
(Ceftriaxone
Na/Dextrose, Iso)
(Rocephin)
(Ceftriaxone
Na/Dextrose, Iso)
(Ceftin)
1
$0
1
$0
1
$0
1
$0
1
$0
(Zinacef)
1
$0
(Zinacef)
(Cefuroxime
Sodium/Dextrose,
Iso)
(Keflex)
1
$0
1
$0
1
$0
(Cephalexin)
1
$0
(Cephalexin)
1
$0
2
$0
2
$0
2
$0
2
$0
1
$0
Name of Drug
cefotaxime
cefoxitin
cefoxitin in dextrose, iso-osm
intravenous piggyback 2 gram/50
ml
cefpodoxime
cefprozil
ceftazidime intravenous recon soln
1 gram, 2 gram
ceftibuten
ceftriaxone in dextrose,iso-os
ceftriaxone injection recon soln
ceftriaxone intravenous
cefuroxime axetil oral tablet
cefuroxime sodium injection recon
soln 1.5 gram, 750 mg
cefuroxime sodium intravenous
cefuroxime-dextrose (iso-osm)
cephalexin oral capsule
cephalexin oral suspension for
reconstitution
cephalexin oral tablet
MEFOXIN IN DEXTROSE (ISOOSM)
SUPRAX ORAL TABLET
SUPRAX ORAL
TABLET,CHEWABLE
TEFLARO
Macrolides
azithromycin
(Zithromax)
Necessary Actions,
Restrictions, or
Limits on Use
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
30
Tier level
What the
drug will
cost you
(Biaxin)
1
$0
(Biaxin)
1
$0
(Biaxin XL)
1
$0
2
2
$0
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
2
1
2
1
$0
$0
$0
$0
$0
1
$0
1
$0
1
$0
Name of Drug
clarithromycin oral suspension for
reconstitution
clarithromycin oral tablet
clarithromycin oral tablet extended
release 24 hr
DIFICID
ERYTHROCIN
erythromycin base oral
tablet,delayed release (dr/ec) 250
mg, 500 mg
ERYTHROMYCIN BASE ORAL
TABLET,DELAYED RELEASE
(DR/EC) 333 MG
erythromycin ethylsuccinate oral
suspension for reconstitution
erythromycin ethylsuccinate oral
tablet
erythromycin oral capsule,delayed
release(dr/ec)
(Erythromycin
Base)
(Eryped 200)
(Erythromycin
Ethylsuccinate)
(Erythromycin
Base)
(Erythromycin
erythromycin oral tablet
Base)
erythromycin stearate oral tablet
(Erythromycin
250 mg
Stearate)
Miscellaneous B-Lactam Antibiotics
aztreonam
(Azactam)
CAYSTON
imipenem-cilastatin
(Primaxin)
INVANZ
meropenem
(Merrem)
Penicillins
amoxicillin oral capsule
(Amoxicillin)
amoxicillin oral suspension for
(Amoxil)
reconstitution
amoxicillin oral tablet
(Amoxicillin)
Necessary Actions,
Restrictions, or
Limits on Use
QL (20 per 10 days)
LA
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
31
Tier level
What the
drug will
cost you
(Amoxicillin)
1
$0
(Augmentin)
1
$0
(Augmentin)
1
$0
(Augmentin XR)
1
$0
1
$0
1
$0
(Totacillin-N)
1
$0
(Totacillin-N)
1
$0
(Unasyn)
1
$0
(Unasyn)
1
2
2
$0
$0
$0
1
$0
2
$0
1
1
$0
$0
1
$0
1
1
$0
$0
1
$0
Name of Drug
amoxicillin oral tablet,chewable
125 mg, 250 mg
amoxicillin-pot clavulanate oral
suspension for reconstitution
amoxicillin-pot clavulanate oral
tablet
amoxicillin-pot clavulanate oral
tablet extended release 12 hr
amoxicillin-pot clavulanate oral
tablet,chewable
ampicillin
ampicillin sodium injection recon
soln
ampicillin sodium intravenous
recon soln
ampicillin-sulbactam injection
recon soln
ampicillin-sulbactam intravenous
BICILLIN C-R
BICILLIN L-A
dicloxacillin
nafcillin in dextrose iso-osm
nafcillin injection
nafcillin intravenous recon soln
oxacillin in dextrose(iso-osm)
oxacillin injection recon soln
oxacillin intravenous recon soln
penicillin g pot in dextrose
(Amoxicillin/Potas
sium Clav)
(Ampicillin
Trihydrate)
(Dicloxacillin
Sodium)
(Nafcillin In
Dextrose,Iso-Osm)
(Unipen)
(Nallpen)
(Oxacillin
Sodium/Dextrose,
Iso)
(Oxacillin Sodium)
(Oxacillin Sodium)
(Pen G
Pot/DextroseWater)
Necessary Actions,
Restrictions, or
Limits on Use
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
32
Tier level
What the
drug will
cost you
1
$0
1
$0
1
$0
(Zosyn)
1
$0
(Cipro)
(Cipro)
(Cipro I.V.)
1
1
1
$0
$0
$0
(Cipro I.V.)
1
$0
(Levaquin)
1
$0
(Levofloxacin)
(Levaquin)
(Avelox)
(Ofloxacin)
1
1
1
1
$0
$0
$0
$0
(Sulfadiazine)
(Sulfamethoxazole/
Trimethoprim)
(Sulfamethoxazole/
Trimethoprim)
1
$0
1
$0
1
$0
(Bactrim)
1
$0
(Azulfidine)
(Sulfamethoxazole/
Trimethoprim)
(Azulfidine)
(Azulfidine)
1
$0
1
$0
1
1
$0
$0
Name of Drug
penicillin g potassium injection
recon soln
penicillin g procaine
penicillin v potassium
piperacillin-tazobactam intravenous
recon soln
Quinolones
ciprofloxacin
ciprofloxacin hcl oral
ciprofloxacin in 5 % dextrose
ciprofloxacin lactate intravenous
solution 400 mg/40 ml
levofloxacin in d5w intravenous
piggyback
levofloxacin intravenous
levofloxacin oral
moxifloxacin
ofloxacin oral
Sulfonamides
sulfadiazine oral
sulfamethoxazole-trimethoprim
intravenous
sulfamethoxazole-trimethoprim oral
suspension
sulfamethoxazole-trimethoprim oral
tablet
sulfasalazine
sulfatrim
sulfazine
sulfazine ec
Tetracyclines
(Penicillin G
Potassium)
(Penicillin G
Procaine)
(Penicillin V
Potassium)
Necessary Actions,
Restrictions, or
Limits on Use
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
33
Tier level
What the
drug will
cost you
(Morgidox)
1
$0
(Doryx)
(Doxycycline
Hyclate)
1
$0
1
$0
(Adoxa)
1
$0
(Morgidox)
1
$0
(Adoxa)
1
$0
(Doryx)
1
$0
(Adoxa)
1
$0
(Vibramycin)
1
$0
(Adoxa)
1
$0
(Minocin)
(Minocycline HCl)
(Ala-Tet)
1
1
1
2
$0
$0
$0
$0
Anticancer Agents
ABRAXANE
2
$0
ADCETRIS
2
$0
AFINITOR DISPERZ
2
$0
2
$0
2
$0
Name of Drug
doxycycline hyclate oral capsule
100 mg
doxycycline hyclate 100 mg tab f/c
doxycycline hyclate intravenous
doxycycline hyclate oral capsule
100 mg
doxycycline hyclate oral capsule 50
mg
doxycycline hyclate oral tablet 100
mg
doxycycline hyclate oral tablet 20
mg
doxycycline monohydrate oral
capsule
doxycycline monohydrate oral
suspension for reconstitution
doxycycline monohydrate oral
tablet
minocycline oral capsule
minocycline oral tablet
tetracycline
TYGACIL
Necessary Actions,
Restrictions, or
Limits on Use
Anticancer Agents
AFINITOR ORAL TABLET 10
MG
AFINITOR ORAL TABLET 2.5
MG, 5 MG, 7.5 MG
PA NSO; QL (4 per 21
days)
PA NSO; QL (112 per
28 days)
PA NSO; QL (56 per
28 days)
PA NSO; QL (28 per
28 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
34
Name of Drug
ALIMTA INTRAVENOUS
RECON SOLN
anastrozole
ARRANON
ARZERRA
AVASTIN
azacitidine
BELEODAQ
bicalutamide
bleomycin
(Arimidex)
(Vidaza)
(Casodex)
(Bleomycin
Sulfate)
BLINCYTO
BOSULIF ORAL TABLET 100
MG
BOSULIF ORAL TABLET 500
MG
CAPRELSA ORAL TABLET 100
MG
CAPRELSA ORAL TABLET 300
MG
carboplatin intravenous solution
cisplatin
(Carboplatin)
(Cisplatin)
COMETRIQ
cyclophosphamide intravenous
recon soln
CYCLOPHOSPHAMIDE ORAL
CAPSULE
cyclophosphamide oral tablet
(Cyclophosphamid
e)
(Cyclophosphamid
e)
Tier level
What the
drug will
cost you
2
$0
1
2
2
2
1
2
1
$0
$0
$0
$0
$0
$0
$0
1
$0
2
$0
2
$0
2
$0
2
$0
2
$0
1
1
$0
$0
2
$0
1
$0
2
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA NSO
PA NSO
PA NSO
PA BvD
PA NSO; QL (140 per
365 days)
PA NSO; QL (120 per
30 days)
PA NSO; QL (30 per
30 days)
PA NSO; QL (60 per
30 days)
PA NSO; QL (30 per
30 days)
PA NSO; QL (112 per
28 days)
PA BvD
PA BvD; ST
PA BvD; ST
CYRAMZA
2
$0
PA NSO
cytarabine
(Cytarabine)
1
$0
PA BvD
cytarabine (pf) injection recon soln (Cytarabine/PF)
1
$0
PA BvD
cytarabine (pf) injection solution
(Cytarabine/PF)
1
$0
PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
35
Tier level
What the
drug will
cost you
(Dtic-Dome IV)
(Dactinomycin)
(Dacogen)
1
1
1
$0
$0
$0
(Doxorubicin HCl)
1
$0
(Doxil)
1
$0
(Doxil)
1
2
$0
$0
2
$0
2
$0
2
$0
2
$0
2
$0
1
$0
2
$0
ERIVEDGE
2
$0
ETOPOPHOS
etoposide intravenous
exemestane
FARESTON
2
1
1
2
$0
$0
$0
$0
2
$0
Name of Drug
dacarbazine intravenous recon soln
dactinomycin
decitabine
doxorubicin hcl intravenous recon
soln 10 mg
doxorubicin hcl peg-liposomal
intravenous suspension 2 mg/ml
doxorubicin, peg-liposomal
DROXIA
ELIGARD SUBCUTANEOUS
SYRINGE 22.5 MG
ELIGARD SUBCUTANEOUS
SYRINGE 30 MG
ELIGARD SUBCUTANEOUS
SYRINGE 45 MG
ELIGARD SUBCUTANEOUS
SYRINGE 7.5 MG
EMCYT
epirubicin intravenous solution 50
mg/25 ml
ERBITUX INTRAVENOUS
SOLUTION
(Ellence)
(Etoposide)
(Aromasin)
FARYDAK
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA BvD
PA BvD
QL (1 per 84 days)
QL (1 per 112 days)
QL (1 per 168 days)
QL (1 per 28 days)
PA NSO
PA NSO; QL (30 per
30 days)
PA NSO; QL (6 per 21
days)
FASLODEX
2
$0
FIRMAGON KIT W DILUENT
2
$0
SYRINGE
floxuridine
(FUDR)
1
$0
PA BvD
fludarabine
(Fludara)
1
$0
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
36
Tier level
What the
drug will
cost you
1
$0
1
$0
GAZYVA
2
$0
gemcitabine intravenous recon soln
(Gemzar)
1 gram
1
$0
GILOTRIF
2
$0
2
$0
2
$0
HALAVEN
2
$0
HERCEPTIN
HEXALEN
hydroxyurea
2
2
1
$0
$0
$0
IBRANCE
2
$0
ICLUSIG ORAL TABLET 15 MG
2
$0
ICLUSIG ORAL TABLET 45 MG
2
$0
1
1
$0
$0
1
$0
IMBRUVICA
2
$0
INLYTA ORAL TABLET 1 MG
2
$0
INLYTA ORAL TABLET 5 MG
2
$0
Name of Drug
fluorouracil intravenous solution
2.5 gram/50 ml, 5 gram/100 ml, 500 (Fluorouracil)
mg/10 ml
flutamide
(Flutamide)
PA BvD
GLEEVEC ORAL TABLET 100
MG
GLEEVEC ORAL TABLET 400
MG
ifosfamide intravenous recon soln
ifosfamide intravenous solution
ifosfamide-mesna
Necessary Actions,
Restrictions, or
Limits on Use
(Hydrea)
(Ifex)
(Ifex)
(Ifosfamide/Mesna
)
PA NSO; QL (40 per
28 days)
PA NSO; QL (30 per
30 days)
PA NSO; QL (90 per
30 days)
PA NSO; QL (60 per
30 days)
PA NSO; QL (24 per
28 days)
PA NSO
PA NSO; QL (21 per
28 days)
PA NSO; QL (60 per
30 days)
PA NSO; QL (30 per
30 days)
PA BvD
PA BvD
PA BvD
PA NSO; QL (120 per
30 days)
PA NSO; QL (180 per
30 days)
PA NSO; QL (60 per
30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
37
Tier level
What the
drug will
cost you
ISTODAX
IXEMPRA
2
2
$0
$0
JAKAFI
2
$0
JEVTANA
KADCYLA INTRAVENOUS
RECON SOLN
KEYTRUDA INTRAVENOUS
RECON SOLN
2
$0
2
$0
2
$0
KYPROLIS
2
$0
2
1
2
$0
$0
$0
1
$0
1
2
2
2
2
2
$0
$0
$0
$0
$0
$0
2
$0
LYNPARZA
2
$0
LYSODREN
2
$0
MARQIBO
2
$0
MATULANE
MEGACE ES
megestrol oral suspension
2
2
1
$0
$0
$0
Name of Drug
LENVIMA
letrozole
LEUKERAN
leuprolide
lomustine
LUPRON DEPOT
LUPRON DEPOT (3 MONTH)
LUPRON DEPOT (4 MONTH)
LUPRON DEPOT (6 MONTH)
LUPRON DEPOT-PED
LUPRON DEPOT-PED (3
MONTH) INTRAMUSCULAR
SYRINGE KIT
(Femara)
(Leuprolide
Acetate)
(Gleostine)
Necessary Actions,
Restrictions, or
Limits on Use
PA NSO
PA NSO; QL (60 per
30 days)
PA NSO
PA NSO
PA NSO; QL (6 per 28
days)
PA NSO
QL (1 per 28 days)
QL (1 per 84 days)
QL (1 per 84 days)
QL (1 per 168 days)
QL (1 per 28 days)
QL (1 per 84 days)
PA NSO; QL (480 per
30 days)
PA NSO; QL (4 per 28
days)
(Megace)
(Megestrol
megestrol oral tablet
1
$0
Acetate)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
38
Tier level
What the
drug will
cost you
MEKINIST ORAL TABLET 0.5
MG
2
$0
MEKINIST ORAL TABLET 2 MG
2
$0
1
1
$0
$0
1
$0
1
$0
1
$0
1
$0
1
1
2
$0
$0
$0
NEXAVAR
2
$0
NILANDRON
ONCASPAR
OPDIVO INTRAVENOUS
SOLUTION 40 MG/4 ML
oxaliplatin intravenous solution 100
(Eloxatin)
mg/20 ml
paclitaxel
(Paclitaxel)
PERJETA
2
2
$0
$0
2
$0
1
$0
1
2
$0
$0
POMALYST
2
$0
PROLEUKIN
PURIXAN
2
2
$0
$0
REVLIMID
2
$0
Name of Drug
melphalan hcl intravenous
mercaptopurine
methotrexate sodium (pf) injection
recon soln
methotrexate sodium (pf) injection
solution
methotrexate sodium injection
methotrexate sodium oral
mitomycin intravenous recon soln
mitoxantrone
MUSTARGEN
(Alkeran)
(Purinethol)
(Methotrexate
Sodium/PF)
(Methotrexate
Sodium)
(Methotrexate
Sodium)
(Methotrexate
Sodium)
(Mitomycin)
(Novantrone)
Necessary Actions,
Restrictions, or
Limits on Use
PA NSO; QL (90 per
30 days)
PA NSO; QL (30 per
30 days)
PA BvD
PA BvD
PA BvD
PA BvD; ST
PA BvD
PA NSO; QL (120 per
30 days)
PA NSO
PA NSO
PA NSO
PA NSO; QL (21 per
28 days)
PA NSO; LA; QL (21
per 28 days)
PA NSO
RITUXAN
2
$0
SOLTAMOX
2
$0
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
39
Tier level
What the
drug will
cost you
SPRYCEL ORAL TABLET 100
MG, 140 MG, 50 MG, 70 MG, 80
MG
2
$0
SPRYCEL ORAL TABLET 20 MG
2
$0
STIVARGA
2
$0
SUTENT
2
$0
SYLVANT
2
$0
SYNRIBO
2
$0
TABLOID
2
$0
TAFINLAR
2
$0
1
$0
2
$0
2
$0
TARGRETIN ORAL
2
$0
TARGRETIN TOPICAL
2
$0
TASIGNA
2
$0
TEMODAR INTRAVENOUS
toposar intravenous
topotecan intravenous
2
1
1
$0
$0
$0
TORISEL
2
$0
TREANDA INTRAVENOUS
RECON SOLN
2
$0
Name of Drug
(Tamoxifen
Citrate)
tamoxifen
TARCEVA ORAL TABLET 100
MG, 25 MG
TARCEVA ORAL TABLET 150
MG
(Etoposide)
(Hycamtin)
Necessary Actions,
Restrictions, or
Limits on Use
PA NSO; QL (30 per
30 days)
PA NSO; QL (60 per
30 days)
PA NSO; QL (84 per
28 days)
PA NSO; QL (30 per
30 days)
PA NSO
PA NSO; QL (28 per
28 days)
PA NSO; QL (120 per
30 days)
PA NSO; QL (60 per
30 days)
PA NSO; QL (90 per
30 days)
PA NSO; QL (420 per
30 days)
PA NSO; QL (60 per
28 days)
PA NSO; QL (112 per
28 days)
PA NSO; (vial only)
PA BvD; QL (4 per 28
days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
40
Name of Drug
TREANDA INTRAVENOUS
SOLUTION
TRELSTAR INTRAMUSCULAR
SUSPENSION FOR
RECONSTITUTION
TRELSTAR INTRAMUSCULAR
SYRINGE 11.25 MG/2 ML
TRELSTAR INTRAMUSCULAR
SYRINGE 22.5 MG/2 ML
TRELSTAR INTRAMUSCULAR
SYRINGE 3.75 MG/2 ML
tretinoin (chemotherapy)
TREXALL
TYKERB
VALSTAR
VECTIBIX INTRAVENOUS
SOLUTION
VELCADE
Tier level
What the
drug will
cost you
2
$0
QL (1 per 168 days)
2
$0
2
$0
2
$0
2
$0
1
2
2
2
$0
$0
$0
$0
2
$0
2
$0
1
$0
1
$0
1
$0
1
$0
VOTRIENT
2
$0
XALKORI
2
$0
XTANDI
2
$0
2
$0
2
$0
vinblastine intravenous
vincristine
vincristine sulfate intravenous
solution 1 mg/ml
vinorelbine intravenous solution
Necessary Actions,
Restrictions, or
Limits on Use
(Tretinoin)
(Vinblastine
Sulfate)
(Vincristine
Sulfate)
(Vincristine
Sulfate)
(Navelbine)
YERVOY INTRAVENOUS
SOLUTION
ZALTRAP INTRAVENOUS
SOLUTION
QL (1 per 84 days)
QL (1 per 168 days)
QL (1 per 28 days)
(capsule: 10mg)
PA BvD; ST
PA NSO
PA NSO
PA BvD
PA BvD
PA BvD
PA NSO; QL (120 per
30 days)
PA NSO; QL (60 per
30 days)
PA NSO; QL (120 per
30 days)
PA NSO
PA NSO
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
41
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
2
$0
ZYDELIG
2
$0
ZYKADIA
2
$0
ZYTIGA
2
$0
1
$0
1
$0
1
$0
2
2
$0
$0
(Carbatrol)
1
$0
(Tegretol)
1
$0
(Tegretol XR)
1
$0
(Carbamazepine)
1
$0
2
$0
2
$0
Name of Drug
ZELBORAF
ZOLADEX SUBCUTANEOUS
IMPLANT 10.8 MG
ZOLADEX SUBCUTANEOUS
IMPLANT 3.6 MG
ZOLINZA
Necessary Actions,
Restrictions, or
Limits on Use
PA NSO; QL (240 per
30 days)
QL (1 per 84 days)
QL (1 per 28 days)
PA NSO; QL (60 per
30 days)
PA NSO; QL (140 per
28 days)
PA NSO; QL (120 per
30 days)
Anticholinergic Agents
Antimuscarinics/Antispasmodics
atropine injection solution 0.4
(Atropine Sulfate)
mg/ml
atropine injection syringe 0.05
(Atropine Sulfate)
mg/ml, 0.1 mg/ml
(Propantheline
propantheline
Bromide)
Anticonvulsants
Anticonvulsants
APTIOM
BANZEL
carbamazepine oral capsule, er
multiphase 12 hr
carbamazepine oral suspension
carbamazepine oral tablet extended
release 12 hr
carbamazepine oral tablet,chewable
CELONTIN ORAL CAPSULE 300
MG
DILANTIN
ST
ST
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
42
Name of Drug
divalproex oral capsule, sprinkle
(Depakote
Sprinkle)
Tier level
What the
drug will
cost you
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
divalproex oral tablet extended
(Depakote ER)
1
$0
release 24 hr
divalproex oral tablet,delayed
(Depakote)
1
$0
release (dr/ec)
ethosuximide
(Zarontin)
1
$0
felbamate
(Felbatol)
1
$0
fosphenytoin
(Cerebyx)
1
$0
FYCOMPA
2
$0
ST
gabapentin oral capsule
(Neurontin)
1
$0
gabapentin oral solution
(Neurontin)
1
$0
gabapentin oral tablet 600 mg, 800
(Neurontin)
1
$0
mg
GABITRIL ORAL TABLET 12
2
$0
MG, 16 MG
LAMICTAL ORAL TABLET,
CHEWABLE DISPERSIBLE 2
2
$0
MG
lamotrigine oral tablet
(Lamictal)
1
$0
lamotrigine oral tablet extended
(Lamictal XR)
1
$0
release 24hr
lamotrigine oral tablet, chewable
(Lamictal)
1
$0
dispersible
lamotrigine oral tablets,dose pack
(Lamictal (Blue))
1
$0
25 mg (35)
levetiracetam intravenous
(Keppra)
1
$0
levetiracetam oral solution
(Keppra)
1
$0
levetiracetam oral tablet
(Keppra)
1
$0
levetiracetam oral tablet extended
(Keppra XR)
1
$0
release 24 hr
LUMINAL
2
$0
QL (2 per 30 days)
LYRICA ORAL CAPSULE
2
$0
QL (90 per 30 days)
LYRICA ORAL SOLUTION
2
$0
QL (900 per 30 days)
oxcarbazepine
(Trileptal)
1
$0
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
43
Tier level
What the
drug will
cost you
(Phenobarbital)
2
2
1
$0
$0
$0
(Phenobarbital)
1
$0
(Phenobarbital)
(Phenobarbital
Sodium)
1
$0
1
$0
(Dilantin-125)
1
$0
(Dilantin)
(Phenytoin
Sodium)
(Dilantin)
1
$0
1
$0
1
$0
2
$0
2
$0
(Gabitril)
(Topamax)
1
2
2
1
1
$0
$0
$0
$0
$0
(Qudexy XR)
1
$0
(Topamax)
1
$0
2
$0
(Depacon)
(Depakene)
2
1
1
$0
$0
$0
(Depakene)
1
$0
Name of Drug
OXTELLAR XR
PEGANONE
phenobarbital oral elixir
phenobarbital oral tablet 100 mg,
15 mg, 16.2 mg, 32.4 mg, 60 mg,
64.8 mg, 97.2 mg
phenobarbital oral tablet 30 mg
phenobarbital sodium injection
solution
phenytoin oral suspension 125 mg/5
ml
phenytoin oral
phenytoin sodium
phenytoin sodium extended
POTIGA ORAL TABLET 200 MG,
300 MG, 400 MG
POTIGA ORAL TABLET 50 MG
primidone
QUDEXY XR
SABRIL
tiagabine
topiramate oral capsule, sprinkle
topiramate oral capsule,sprinkle,er
24hr
topiramate oral tablet
TRILEPTAL ORAL
SUSPENSION
TROKENDI XR
valproate sodium
valproic acid
valproic acid (as sodium salt) oral
solution 250 mg/5 ml
(Mysoline)
Necessary Actions,
Restrictions, or
Limits on Use
ST
QL (1500 per 30 days)
QL (90 per 30 days)
QL (200 per 30 days)
QL (2 per 30 days)
ST; QL (90 per 30
days)
ST; QL (270 per 30
days)
ST
ST
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
44
Tier level
What the
drug will
cost you
VIMPAT INTRAVENOUS
2
$0
VIMPAT ORAL SOLUTION
2
$0
VIMPAT ORAL TABLET
2
$0
(Zonegran)
1
$0
(Aricept)
(Aricept Odt)
1
1
$0
$0
1
$0
(Razadyne ER)
1
$0
(Razadyne)
(Razadyne)
1
1
2
2
2
$0
$0
$0
$0
$0
2
$0
2
$0
1
$0
1
$0
1
2
1
$0
$0
$0
Name of Drug
zonisamide
Necessary Actions,
Restrictions, or
Limits on Use
ST; QL (200 per 5
days)
ST; QL (1200 per 30
days)
ST; QL (60 per 30
days)
Antidementia Agents
Antidementia Agents
donepezil oral tablet
donepezil oral tablet,disintegrating
EXELON TRANSDERMAL
PATCH 24 HOUR 4.6 MG/24 HR,
9.5 MG/24 HR
galantamine oral capsule,ext rel.
pellets 24 hr
galantamine oral solution
galantamine oral tablet
NAMENDA ORAL SOLUTION
NAMENDA ORAL TABLET
NAMENDA TITRATION PAK
NAMENDA XR ORAL
CAP,SPRINKLE,ER 24HR DOSE
PACK
NAMENDA XR ORAL
CAPSULE,SPRINKLE,ER 24HR
rivastigmine tartrate
(Exelon)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (200 per 30 days)
QL (60 per 30 days)
QL (360 per 30 days)
QL (60 per 30 days)
QL (49 per 28 days)
QL (28 per 28 days)
QL (30 per 30 days)
QL (60 per 30 days)
Antidepressants
Antidepressants
amitriptyline
amoxapine
BRINTELLIX
bupropion hcl oral tablet
(Amitriptyline
HCl)
(Amoxapine)
(Wellbutrin)
PA NSO-HRM
ST
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
45
Tier level
What the
drug will
cost you
(Wellbutrin SR)
1
$0
(Wellbutrin XL)
1
$0
1
$0
1
1
1
1
$0
$0
$0
$0
(Cymbalta)
1
$0
(Cymbalta)
1
$0
(Prozac)
2
1
2
1
$0
$0
$0
$0
(Prozac Weekly)
1
$0
(Fluoxetine HCl)
(Fluoxetine HCl)
1
1
$0
$0
1
$0
1
$0
1
$0
1
1
$0
$0
2
$0
Name of Drug
bupropion hcl oral tablet extended
release , 150 mg
bupropion hcl oral tablet extended
release 24 hr
citalopram oral solution
citalopram oral tablet
clomipramine
desipramine oral
doxepin oral
duloxetine oral capsule,delayed
release(dr/ec) 20 mg, 60 mg
duloxetine oral capsule,delayed
release(dr/ec) 30 mg
EMSAM
escitalopram oxalate
FETZIMA
fluoxetine oral capsule
fluoxetine oral capsule,delayed
release(dr/ec)
fluoxetine oral solution
fluoxetine oral tablet 10 mg, 20 mg
FLUOXETINE ORAL TABLET 60
MG
fluvoxamine oral capsule,extended
release 24hr
fluvoxamine oral tablet
imipramine hcl
imipramine pamoate
(Citalopram
Hydrobromide)
(Celexa)
(Anafranil)
(Norpramin)
(Doxepin HCl)
(Lexapro)
(Luvox CR)
(Fluvoxamine
Maleate)
(Tofranil)
(Tofranil-Pm)
KHEDEZLA
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 30 days)
PA NSO-HRM
PA NSO-HRM
QL (60 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
ST
PA NSO-HRM
PA NSO-HRM
ST; QL (30 per 30
days)
maprotiline
(Maprotiline HCl)
1
$0
MARPLAN
2
$0
mirtazapine
(Remeron)
1
$0
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
46
Tier level
What the
drug will
cost you
(Nefazodone HCl)
(Pamelor)
(Nortriptyline HCl)
(Symbyax)
(Paxil)
1
1
1
1
1
$0
$0
$0
$0
$0
(Paxil CR)
1
$0
2
$0
1
$0
1
$0
2
$0
ST; QL (30 per 30
days)
$0
$0
$0
$0
$0
$0
QL (30 per 30 days)
PA NSO-HRM
(Parnate)
(Trazodone HCl)
1
1
2
2
1
1
(Effexor XR)
1
$0
(Venlafaxine HCl)
1
$0
(Venlafaxine HCl)
1
$0
2
$0
1
2
$0
$0
2
$0
Name of Drug
nefazodone
nortriptyline oral capsule
nortriptyline oral solution
olanzapine-fluoxetine
paroxetine hcl oral tablet
paroxetine hcl oral tablet extended
release 24 hr
PAXIL ORAL SUSPENSION
perphenazine-amitriptyline
phenelzine
(Perphenazine/Ami
triptyline HCl)
(Nardil)
PRISTIQ
protriptyline
sertraline
SILENOR
SURMONTIL
tranylcypromine
trazodone
venlafaxine oral capsule,extended
release 24hr
venlafaxine oral tablet
venlafaxine oral tablet extended
release 24hr 150 mg, 37.5 mg, 75
mg
VIIBRYD
(Vivactil)
(Zoloft)
Necessary Actions,
Restrictions, or
Limits on Use
PA NSO-HRM
Antidiabetic Agents
Antidiabetic Agents, Miscellaneous
acarbose
(Precose)
BYDUREON
BYETTA SUBCUTANEOUS PEN
INJECTOR 10 MCG/DOSE(250
MCG/ML) 2.4 ML
QL (90 per 30 days)
QL (4 per 28 days)
QL (2.4 per 28 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
47
Name of Drug
BYETTA SUBCUTANEOUS PEN
INJECTOR 5 MCG/DOSE (250
MCG/ML) 1.2 ML
CYCLOSET
GLYXAMBI
INVOKAMET ORAL TABLET
150-1,000 MG, 150-500 MG, 501,000 MG
INVOKAMET ORAL TABLET
50-500 MG
INVOKANA ORAL TABLET 100
MG
INVOKANA ORAL TABLET 300
MG
JANUMET
JANUMET XR ORAL TABLET,
ER MULTIPHASE 24 HR 1001,000 MG, 50-500 MG
JANUMET XR ORAL TABLET,
ER MULTIPHASE 24 HR 501,000 MG
JANUVIA
Tier level
What the
drug will
cost you
2
$0
2
2
$0
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
QL (1.2 per 28 days)
QL (180 per 30 days)
QL (30 per 30 days)
ST; QL (60 per 30
days)
ST; QL (120 per 30
days)
ST; QL (60 per 30
days)
ST; QL (30 per 30
days)
QL (60 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
2
$0
2
$0
JARDIANCE
2
$0
JENTADUETO
2
$0
KORLYM
2
$0
(Glucophage)
(Glucophage)
(Glucophage)
1
1
1
$0
$0
$0
(Glucophage XR)
1
$0
(Glucophage XR)
1
$0
metformin oral tablet 1,000 mg
metformin oral tablet 500 mg
metformin oral tablet 850 mg
metformin oral tablet extended
release 24 hr 500 mg
metformin oral tablet extended
release 24 hr 750 mg
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 30 days)
ST; QL (30 per 30
days)
QL (60 per 30 days)
PA; QL (112 per 28
days)
QL (60 per 30 days)
QL (120 per 30 days)
QL (90 per 30 days)
QL (120 per 30 days)
QL (90 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
48
Tier level
What the
drug will
cost you
(Fortamet)
1
$0
(Starlix)
(Actos)
(Duetact)
(Actoplus Met)
1
1
1
1
2
1
$0
$0
$0
$0
$0
$0
SYMLINPEN 120
2
$0
SYMLINPEN 60
TRADJENTA
TRULICITY
VICTOZA
Insulins
HUMALOG KWIKPEN
HUMALOG MIX 50-50
HUMALOG MIX 50-50
KWIKPEN
HUMALOG MIX 75-25
HUMALOG MIX 75-25
KWIKPEN
HUMALOG SUBCUTANEOUS
HUMULIN 70/30
HUMULIN 70/30 KWIKPEN
HUMULIN 70/30 PEN
HUMULIN N
HUMULIN N KWIKPEN
HUMULIN N PEN
HUMULIN R
HUMULIN R U-500
"CONCENTRATED"
LANTUS
LANTUS SOLOSTAR
2
2
2
2
$0
$0
$0
$0
2
2
$0
$0
2
$0
2
$0
2
$0
2
2
2
2
2
2
2
2
$0
$0
$0
$0
$0
$0
$0
$0
2
$0
2
2
$0
$0
Name of Drug
metformin oral tablet extended
release 24hr
nateglinide
pioglitazone
pioglitazone-glimepiride
pioglitazone-metformin
PRANDIMET
repaglinide
(Prandin)
Necessary Actions,
Restrictions, or
Limits on Use
QL (60 per 30 days)
QL (90 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (90 per 30 days)
QL (150 per 30 days)
QL (240 per 30 days)
PA; QL (10.8 per 28
days)
PA; QL (6 per 28 days)
QL (30 per 30 days)
QL (4 per 28 days)
PA; QL (9 per 28 days)
QL (30 per 28 days)
QL (40 per 28 days)
QL (30 per 28 days)
QL (40 per 28 days)
QL (30 per 28 days)
QL (40 per 28 days)
QL (40 per 28 days)
QL (30 per 28 days)
QL (30 per 28 days)
QL (40 per 28 days)
QL (30 per 28 days)
QL (30 per 28 days)
QL (40 per 28 days)
QL (40 per 28 days)
QL (40 per 28 days)
QL (30 per 28 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
49
Tier level
What the
drug will
cost you
2
2
2
2
2
2
2
2
$0
$0
$0
$0
$0
$0
$0
$0
QL (40 per 28 days)
QL (40 per 28 days)
QL (40 per 28 days)
QL (40 per 28 days)
QL (30 per 28 days)
QL (40 per 28 days)
QL (30 per 28 days)
QL (7.5 per 28 days)
(Amaryl)
(Amaryl)
(Glucotrol)
(Glucotrol)
1
1
1
1
$0
$0
$0
$0
(Glucotrol XL)
1
$0
QL (30 per 30 days)
QL (60 per 30 days)
QL (120 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
(Glucotrol XL)
1
$0
1
$0
1
$0
Name of Drug
NOVOLIN 70/30
NOVOLIN N
NOVOLIN R
NOVOLOG
NOVOLOG FLEXPEN
NOVOLOG MIX 70-30
NOVOLOG MIX 70-30 FLEXPEN
TOUJEO SOLOSTAR
Sulfonylureas
glimepiride oral tablet 1 mg, 2 mg
glimepiride oral tablet 4 mg
glipizide oral tablet 10 mg
glipizide oral tablet 5 mg
glipizide oral tablet extended
release 24hr 10 mg
glipizide oral tablet extended
release 24hr 2.5 mg, 5 mg
glipizide-metformin oral tablet 2.5250 mg
glipizide-metformin oral tablet 2.5500 mg, 5-500 mg
glyburide micronized oral tablet 1.5
mg
glyburide micronized oral tablet 3
mg
glyburide micronized oral tablet 6
mg
(Glipizide/Metform
in HCl)
(Glipizide/Metform
in HCl)
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 30 days)
QL (60 per 30 days)
QL (120 per 30 days)
PA-HRM; QL (400 per
30 days)
PA-HRM; QL (180 per
(Glynase)
1
$0
30 days)
PA-HRM; QL (120 per
(Glynase)
1
$0
30 days)
PA-HRM; QL (280 per
glyburide oral tablet 1.25 mg
(Glyburide)
1
$0
30 days)
PA-HRM; QL (240 per
glyburide oral tablet 2.5 mg
(Glyburide)
1
$0
30 days)
PA-HRM; QL (120 per
glyburide oral tablet 5 mg
(Glyburide)
1
$0
30 days)
glyburide-metformin oral tablet
PA-HRM; QL (240 per
(Glucovance)
1
$0
1.25-250 mg
30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
(Glynase)
1
$0
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
50
Tier level
What the
drug will
cost you
(Glucovance)
1
$0
(Tolazamide)
(Tolazamide)
(Tolbutamide)
1
1
1
$0
$0
$0
(Miconazole
Nitrate)
4
$0
2
4
$0
$0
4
$0
2
1
4
4
4
4
4
2
1
1
1
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
1
$0
1
4
4
4
1
1
1
$0
$0
$0
$0
$0
$0
$0
Name of Drug
glyburide-metformin oral tablet 2.5500 mg, 5-500 mg
tolazamide oral tablet 250 mg
tolazamide oral tablet 500 mg
tolbutamide
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM; QL (120 per
30 days)
QL (120 per 30 days)
QL (60 per 30 days)
QL (180 per 30 days)
Antifungals
Antifungals
3 day vaginal *
ABELCET
af *
aloe vesta * topical ointment 2 %
AMBISOME
amphotericin b
antifungal (tolnaftate) * topical
antifungal (tolnaftate) * topical
antifungal * topical solution
athlete's foot (clotrimazole) *
baza antifungal *
CANCIDAS
ciclopirox topical cream
ciclopirox topical gel
ciclopirox topical shampoo
ciclopirox topical solution
ciclopirox topical suspension
ciclopirox-ure-camph-menth-euc
clotrimazole * 1% cream (otc)
clotrimazole * 1% solution (otc)
clotrimazole 3 day *
clotrimazole mucous membrane
clotrimazole topical cream 1 %
clotrimazole topical solution 1 %
(Tinactin)
(Miconazole
Nitrate)
(Amphotericin B)
(Tolnaftate)
(Tolnaftate)
(Undecylenic Acid)
(Lotrimin AF)
(Nuzole)
(Ciclodan)
(Loprox)
(Loprox)
(Penlac)
(Ciclopirox
Olamine)
(Ciclodan)
(Lotrimin AF)
(Clotrimazole)
(Gyne-Lotrimin)
(Clotrimazole)
(Clotrimazole)
(Lotrimin)
PA BvD
PA BvD
PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
51
Tier level
What the
drug will
cost you
(Gyne-Lotrimin)
(Clotrimazole)
(Gyne-Lotrimin)
4
4
4
$0
$0
$0
(Lotrisone)
1
$0
1
$0
4
$0
4
$0
4
1
4
1
$0
$0
$0
$0
1
$0
1
$0
1
4
4
4
1
4
1
1
1
1
4
4
4
4
4
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
Name of Drug
clotrimazole * vaginal cream
clotrimazole * vaginal tablet
clotrimazole-3 *
clotrimazole-betamethasone topical
cream
clotrimazole-betamethasone topical
lotion
critic-aid clear af *
dermafungal *
desenex * topical cream
econazole topical
elon dual defense *
fluconazole
fluconazole in dextrose(iso-o)
intravenous piggyback
fluconazole in nacl (iso-osm)
intravenous piggyback
flucytosine
fungi cure *
FUNGI-NAIL * TOPICAL
fungoid-d *
griseofulvin microsize oral tablet
inzo antifungal *
itraconazole
ketoconazole oral
ketoconazole topical cream
ketoconazole topical shampoo
LAMISIL (AEROSOL) *
lamisil af *
LAMISIL AT * TOPICAL
LOTRIMIN ULTRA *
micatin *
(Clotrimazole/Beta
methasone Dip)
(Miconazole
Nitrate)
(Miconazole
Nitrate)
(Lotrimin AF)
(Econazole Nitrate)
(Undecylenic Acid)
(Diflucan)
(Fluconazole In
Nacl,Iso-Osm)
(Fluconazole In
Nacl,Iso-Osm)
(Ancobon)
(Clotrimazole)
(Tinactin)
(Grifulvin V)
(Nuzole)
(Sporanox)
(Ketoconazole)
(Ketoconazole)
(Nizoral)
(Tolnaftate)
(Nuzole)
Necessary Actions,
Restrictions, or
Limits on Use
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
52
Name of Drug
miconazole 7 * vaginal suppository
miconazole nitrate * topical cream
miconazole nitrate * vaginal
miconazole nitrate * vaginal
(Miconazole
Nitrate)
(Nuzole)
(Miconazole
Nitrate)
(Miconazole
Nitrate)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
miconazole nitrate * vaginal kit 200
(Monistat 3)
4
$0
mg- 2 % (9 gram)
miconazole nitrate vaginal
(Monistat 3)
1
$0
suppository 200 mg
MONISTAT 3 * VAGINAL
COMB PACK,PREFILL APPL &
4
$0
CREAM
MONISTAT 3 * VAGINAL KIT
4
$0
(Miconazole
monistat 7 * vaginal
4
$0
Nitrate)
myco nail a *
(Undecylenic Acid)
4
$0
NOXAFIL ORAL
2
$0
nystatin
(Nystatin)
1
$0
NYSTATIN (BULK) POWDER 1
1
$0
BILLION UNIT
nystatin oral
(Nystatin)
1
$0
nystatin oral
(Nystatin)
1
$0
nystatin topical
(Nystatin)
1
$0
(Nystatin/Triamcin
nystatin-triamcinolone
1
$0
)
podactin *
(Tolnaftate)
4
$0
terbinafine hcl oral
(Lamisil)
1
$0
terbinafine hcl * topical
(Desenex)
4
$0
tolnaftate * topical
(Tinactin)
4
$0
tolnaftate * topical
(Tolnaftate)
4
$0
(Miconazole
triple paste af *
4
$0
Nitrate)
voriconazole intravenous
(Vfend IV)
1
$0
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
53
Name of Drug
voriconazole oral
(Vfend)
Tier level
What the
drug will
cost you
1
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
4
4
4
$0
$0
$0
$0
$0
4
$0
4
$0
4
4
$0
$0
4
$0
4
$0
4
4
4
4
4
4
4
$0
$0
$0
$0
$0
$0
$0
Necessary Actions,
Restrictions, or
Limits on Use
Antihistamines
Antihistamines
alavert d-12 allergy-sinus *
aller-chlor * oral syrup
aller-chlor * oral tablet
allerclear d-12hr *
allerclear d-24hr *
allergy (chlorpheniramine) *
allergy relief (cetirizine) * oral
allergy relief (loratadine) * oral
allerhist-1 *
aller-tec d *
ambi 60pse-4cpm *
aprodine *
banophen allergy *
banophen * oral capsule 25 mg
banophen * oral
benadryl allergy * oral tablet
cetirizine * oral solution
cetirizine * oral tablet
cetirizine * oral tablet,chewable
cetirizine-pseudoephedrine *
child triaminic cold & allergy *
child wal-tap cold-allergy *
children's aller-tec *
(Claritin-D 12
Hour)
(Chlorpheniramine
Maleate)
(Chlor-Trimeton)
(Claritin-D 12
Hour)
(Claritin-D 24
Hour)
(Chlor-Trimeton)
(Zyrtec)
(Claritin)
(Tavist-1)
(Zyrtec-D)
(Pseudoephed/Chlo
rpheniramine)
(Pseudoephedrine/
Triprolidine)
(Zzzquil)
(Benadryl)
(Diphenhydramine
HCl)
(Diphenhydramine
HCl)
(Cetirizine HCl)
(Zyrtec)
(Zyrtec)
(Zyrtec-D)
(Dimetapp)
(Dimetapp)
(Cetirizine HCl)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
54
Name of Drug
children's cetirizine * oral
(Zyrtec)
tablet,chewable 5 mg
CHILDREN'S CLARITIN * ORAL
children's wal-dryl allergy * oral
(Zzzquil)
children's wal-zyr * oral
(Zyrtec)
CHILDREN'S ZYRTEC
ALLERGY *
CLARITIN *
CLARITIN LIQUI-GEL *
CLARITIN REDITABS *
CLARITIN-D 12 HOUR *
CLARITIN-D 24 HOUR *
(Clemastine
clemastine oral syrup
Fumarate)
clemastine * oral tablet 1.34 mg
(Tavist-1)
(Clemastine
clemastine oral tablet 2.68 mg
Fumarate)
(Triaminic Cold
cold & cough * oral liquid
and Cough)
(Diphenhydramine
compoz *
HCl)
(Cyproheptadine
cyproheptadine
HCl)
dailyhist-1 *
(Tavist-1)
dayhist allergy *
(Tavist-1)
dimaphen (pe) *
(Dimetapp)
(Triaminic Cold
dimetapp cold-congestion *
and Cough)
diphenhist * oral capsule
(Benadryl)
diphenhist * oral
(Zzzquil)
(Diphenhydramine
diphenhist * oral tablet 25 mg
HCl)
diphenhydramine hcl injection
(Diphenhydramine
solution 50 mg/ml
HCl)
Tier level
What the
drug will
cost you
4
$0
4
4
4
$0
$0
$0
4
$0
4
4
4
4
4
$0
$0
$0
$0
$0
1
$0
4
$0
1
$0
4
$0
4
$0
1
$0
4
4
4
$0
$0
$0
4
$0
4
4
$0
$0
4
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM
PA-HRM
PA-HRM
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
55
Name of Drug
diphenhydramine hcl injection
syringe
diphenhydramine hcl * oral capsule
diphenhydramine hcl * oral tablet
50 mg
ed chlorped jr *
levocetirizine
loradamed *
loratadine * oral
loratadine * oral
loratadine-d * oral tablet extended
release 12 hr
loratadine-d * oral tablet extended
release 24 hr
phenylephrine-chlorpheniramine *
oral tablet 4-10 mg
promethazine oral syrup
q-dryl * oral liquid
q-tapp *
siladryl sa *
simply sleep *
sinus & allergy (pseudoephed) *
sleep aid (diphenhydramine) * oral
sleep-tabs *
sudogest cold & allergy *
(Diphenhydramine
HCl)
(Benadryl)
(Diphenhydramine
HCl)
(Chlorpheniramine
Maleate)
(Xyzal)
(Claritin)
(Claritin)
(Claritin)
(Claritin-D 12
Hour)
(Claritin-D 24
Hour)
(Phenylephrine/Chl
orpheniramine)
(Promethazine
HCl)
(Zzzquil)
(Pseudoephedrine/
Brompheniramin)
(Zzzquil)
(Diphenhydramine
HCl)
(Pseudoephed/Chlo
rpheniramine)
(Zzzquil)
(Diphenhydramine
HCl)
(Pseudoephed/Chlo
rpheniramine)
TRIAMINIC COLD & COUGH
NT (PE) *
Tier level
What the
drug will
cost you
1
$0
4
$0
4
$0
4
$0
1
4
4
4
$0
$0
$0
$0
4
$0
4
$0
4
$0
1
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
56
Name of Drug
ultra sleep (doxylamine succ) *
unisom sleepgels *
wal-act d cold & allergy *
wal-dryl allergy * oral
wal-dryl allergy * oral
wal-finate *
wal-finate-d *
wal-itin *
wal-itin d *
wal-itin d 12 hour *
wal-phed * oral tablet 4-60 mg
wal-phed pe sinus & allergy *
wal-sleep z * oral capsule
wal-sleep z * oral liquid
wal-sleep z * oral
tablet,disintegrating
wal-som * oral capsule
wal-tap *
wal-zyr (cetirizine) * oral
wal-zyr (cetirizine) * oral
wal-zyr d *
z-sleep *
ZYRTEC * ORAL CAPSULE
ZYRTEC * ORAL TABLET
ZYRTEC * ORAL
TABLET,DISINTEGRATING
(Doxylamine
Succinate)
(Benadryl)
(Pseudoephedrine/
Triprolidine)
(Benadryl)
(Diphenhydramine
HCl)
(Chlor-Trimeton)
(Pseudoephed/Chlo
rpheniramine)
(Claritin)
(Claritin-D 24
Hour)
(Claritin-D 12
Hour)
(Pseudoephed/Chlo
rpheniramine)
(Phenylephrine/Chl
orpheniramine)
(Benadryl)
(Zzzquil)
(Unisom
Sleepmelts)
(Benadryl)
(Dimetapp)
(Cetirizine HCl)
(Zyrtec)
(Zyrtec-D)
(Zzzquil)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
$0
$0
4
$0
4
4
4
4
4
4
4
4
$0
$0
$0
$0
$0
$0
$0
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
57
Tier level
What the
drug will
cost you
4
2
1
1
1
1
$0
$0
$0
$0
$0
$0
(Amerge)
(Maxalt)
1
1
2
1
1
$0
$0
$0
$0
$0
(Maxalt Mlt)
1
$0
(Imitrex)
(Imitrex)
1
1
$0
$0
(Imitrex)
1
$0
(Imitrex)
1
$0
(Imitrex)
1
$0
(Zomig)
1
$0
(Zomig Zmt)
1
$0
(Dapsone)
(Myambutol)
2
1
1
$0
$0
$0
Name of Drug
Necessary Actions,
Restrictions, or
Limits on Use
Anti-Infectives (Skin And Mucous Membrane)
Anti-Infectives (Skin And Mucous Membrane)
ABREVA *
AVC VAGINAL
clindamycin phosphate vaginal
(Cleocin)
metronidazole vaginal
(Metrogel-Vaginal)
terconazole vaginal cream
(Terazol 7)
terconazole vaginal suppository
(Terconazole)
Antimigraine Agents
Antimigraine Agents
dihydroergotamine injection
dihydroergotamine nasal
ERGOMAR
naratriptan
rizatriptan oral tablet
rizatriptan oral
tablet,disintegrating
sumatriptan nasal spray
sumatriptan oral tablet
sumatriptan succinate subcutaneous
cartridge 6 mg/0.5 ml
sumatriptan succinate subcutaneous
pen injector
sumatriptan succinate subcutaneous
solution
zolmitriptan oral tablet
zolmitriptan oral
tablet,disintegrating
(D.H.E.45)
(Migranal)
QL (30 per 28 days)
QL (4 per 28 days)
QL (40 per 28 days)
QL (18 per 28 days)
QL (18 per 28 days)
QL (18 per 28 days)
QL (12 per 28 days)
QL (18 per 28 days)
QL (4 per 28 days)
QL (4 per 28 days)
QL (4 per 28 days)
QL (12 per 28 days)
QL (12 per 28 days)
Antimycobacterials
Antimycobacterials
CAPASTAT
dapsone
ethambutol
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
58
Tier level
What the
drug will
cost you
1
2
2
1
1
1
1
2
$0
$0
$0
$0
$0
$0
$0
$0
SIRTURO
2
$0
TRECATOR
2
$0
4
1
4
4
1
$0
$0
$0
$0
$0
2
$0
2
$0
2
$0
2
$0
(Granisetron
HCl/PF)
1
$0
(Kytril)
1
$0
(Granisetron HCl)
1
$0
(Meclizine HCl)
4
$0
(Meclizine HCl)
4
$0
Name of Drug
isoniazid oral
PASER
PRIFTIN
pyrazinamide
rifabutin
rifampin
rifampin
RIFATER
(Isoniazid)
(Pyrazinamide)
(Mycobutin)
(Rifadin)
(Rifadin)
Necessary Actions,
Restrictions, or
Limits on Use
PA; QL (188 per 168
days)
Antinausea Agents
Antinausea Agents
ambizine *
dimenhydrinate injection solution
dramamine * oral tablet
driminate *
dronabinol
EMEND INTRAVENOUS RECON
SOLN
EMEND ORAL CAPSULE 125
MG, 40 MG
(Meclizine HCl)
(Dimenhydrinate)
(Dimenhydrinate)
(Dimenhydrinate)
(Marinol)
EMEND ORAL CAPSULE 80 MG
EMEND ORAL CAPSULE,DOSE
PACK
granisetron (pf) intravenous
solution
granisetron hcl intravenous solution
1 mg/ml (1 ml)
granisetron hcl oral
meclizine * 12.5 mg caplet caplet
(otc)
meclizine * 25 mg tablet (otc)
QL (2 per 28 days)
PA BvD; QL (1 per 1
day)
PA BvD; QL (2 per 1
day)
PA BvD; QL (3 per 1
day)
PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
59
Tier level
What the
drug will
cost you
(Antivert)
1
$0
(Dimenhydrinate)
(Zofran Odt)
(Ondansetron
HCl/PF)
(Zofran)
4
1
$0
$0
1
$0
1
$0
(Compazine)
1
$0
(Compazine)
(Compazine)
(Phenergan)
(Promethazine
HCl)
(Phenergan)
1
1
1
$0
$0
$0
1
$0
1
2
4
4
$0
$0
$0
$0
2
2
1
1
2
1
2
2
1
1
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
1
$0
1
$0
Name of Drug
meclizine oral tablet 12.5 mg, 25
mg
motion sickness *
ondansetron
ondansetron hcl (pf) injection
ondansetron hcl oral
prochlorperazine edisylate injection
solution
prochlorperazine maleate
prochlorperazine maleate oral
promethazine hcl
promethazine oral tablet
promethazine rectal
TRANSDERM-SCOP
travel sickness (meclizine) *
wal-dram *
(Bonine)
(Dimenhydrinate)
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA BvD
PA-HRM
PA-HRM
PA-HRM
QL (10 per 30 days)
Antiparasite Agents
Antiparasite Agents
ALBENZA
ALINIA
atovaquone
atovaquone-proguanil
BILTRICIDE
chloroquine phosphate oral
COARTEM
DARAPRIM
hydroxychloroquine oral
ivermectin oral
mefloquine
metronidazole in nacl (iso-os)
metronidazole oral
(Mepron)
(Malarone)
(Aralen Phosphate)
(Plaquenil)
(Stromectol)
(Mefloquine HCl)
(Metronidazole/So
dium Chloride)
(Flagyl)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
60
Tier level
What the
drug will
cost you
2
$0
1
$0
2
2
1
$0
$0
$0
1
2
2
$0
$0
$0
1
$0
1
1
1
1
$0
$0
$0
$0
(Sinemet CR)
1
$0
(Stalevo 50)
(Comtan)
1
1
$0
$0
2
$0
(Mirapex)
(Requip)
1
1
$0
$0
(Requip XL)
1
$0
(Eldepryl)
(Selegiline HCl)
(Trihexyphenidyl
HCl)
1
1
$0
$0
1
$0
Name of Drug
NEBUPENT
paromomycin
PENTAM
PRIMAQUINE
quinine sulfate
(Paromomycin
Sulfate)
(Qualaquin)
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
QL (90 per 30 days)
PA; QL (42 per 7 days)
Antiparkinsonian Agents
Antiparkinsonian Agents
amantadine hcl oral
APOKYN
AZILECT
benztropine oral
bromocriptine
cabergoline
carbidopa
carbidopa-levodopa oral tablet
carbidopa-levodopa oral tablet
extended release
carbidopa-levodopa-entacapone
entacapone
(Amantadine HCl)
(Benztropine
Mesylate)
(Parlodel)
(Cabergoline)
(Lodosyn)
(Sinemet CR)
NEUPRO
pramipexole oral tablet
ropinirole oral tablet
ropinirole oral tablet extended
release 24 hr
selegiline hcl oral capsule
selegiline hcl oral tablet
trihexyphenidyl
QL (60 per 30 days)
PA-HRM
ST; QL (30 per 30
days)
PA-HRM
Antipsychotic Agents
Antipsychotic Agents
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
61
Name of Drug
ABILIFY DISCMELT ORAL
TABLET,DISINTEGRATING 10
MG
ABILIFY DISCMELT ORAL
TABLET,DISINTEGRATING 15
MG
ABILIFY INTRAMUSCULAR
ABILIFY MAINTENA
ABILIFY ORAL SOLUTION
ABILIFY ORAL TABLET 10 MG,
15 MG, 20 MG, 30 MG, 5 MG
ABILIFY ORAL TABLET 2 MG
aripiprazole oral tablet 10 mg, 15
(Abilify)
mg, 20 mg, 30 mg, 5 mg
aripiprazole oral tablet 2 mg
(Abilify)
(Chlorpromazine
chlorpromazine
HCl)
clozapine oral tablet 100 mg
(Clozaril)
clozapine oral tablet 200 mg
(Clozaril)
clozapine oral tablet 25 mg, 50 mg (Clozaril)
clozapine oral tablet,disintegrating
(Fazaclo)
100 mg, 12.5 mg, 25 mg
clozapine oral tablet,disintegrating
(Fazaclo)
150 mg
clozapine oral tablet,disintegrating
(Fazaclo)
200 mg
FANAPT ORAL TABLET
FANAPT ORAL TABLETS,DOSE
PACK
FAZACLO ORAL
TABLET,DISINTEGRATING 150
MG
Tier level
What the
drug will
cost you
2
$0
2
$0
2
2
2
$0
$0
$0
2
$0
2
$0
1
$0
1
$0
1
$0
1
1
1
$0
$0
$0
1
$0
1
$0
1
$0
2
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
QL (90 per 30 days)
QL (60 per 30 days)
2
$0
QL (161.2 per 28 days)
QL (1 per 28 days)
QL (900 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
QL (270 per 30 days)
QL (135 per 30 days)
QL (90 per 30 days)
ST; QL (90 per 30
days)
ST; QL (180 per 30
days)
ST; QL (120 per 30
days)
ST; QL (60 per 30
days)
ST; QL (8 per 28 days)
ST; QL (180 per 30
days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
62
Name of Drug
FAZACLO ORAL
TABLET,DISINTEGRATING 200
MG
fluphenazine decanoate
fluphenazine hcl
GEODON INTRAMUSCULAR
haloperidol
haloperidol decanoate
intramuscular solution 100 mg/ml
haloperidol decanoate
intramuscular solution 50 mg/ml
haloperidol lactate
(Fluphenazine
Decanoate)
(Fluphenazine
HCl)
(Haloperidol)
(Haloperidol
Decanoate)
(Haldol Decanoate
50)
(Haloperidol
Lactate)
Tier level
What the
drug will
cost you
2
$0
1
$0
1
$0
2
1
$0
$0
1
$0
1
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
ST; QL (120 per 30
days)
QL (6 per 28 days)
INVEGA ORAL TABLET
ST; QL (30 per 30
EXTENDED RELEASE 24HR 1.5
2
$0
days)
MG, 3 MG, 9 MG
INVEGA ORAL TABLET
ST; QL (60 per 30
EXTENDED RELEASE 24HR 6
2
$0
days)
MG
INVEGA SUSTENNA
QL (0.75 per 28 days)
INTRAMUSCULAR SYRINGE
2
$0
117 MG/0.75 ML
INVEGA SUSTENNA
QL (1 per 28 days)
INTRAMUSCULAR SYRINGE
2
$0
156 MG/ML
INVEGA SUSTENNA
QL (1.5 per 28 days)
INTRAMUSCULAR SYRINGE
2
$0
234 MG/1.5 ML
INVEGA SUSTENNA
QL (0.25 per 28 days)
INTRAMUSCULAR SYRINGE 39
2
$0
MG/0.25 ML
INVEGA SUSTENNA
QL (0.5 per 28 days)
INTRAMUSCULAR SYRINGE 78
2
$0
MG/0.5 ML
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
63
Tier level
What the
drug will
cost you
LATUDA ORAL TABLET 120
MG, 20 MG, 40 MG, 60 MG
2
$0
LATUDA ORAL TABLET 80 MG
2
$0
(Loxitane)
(Zyprexa)
(Zyprexa)
1
1
1
$0
$0
$0
(Zyprexa Zydis)
1
$0
(Zyprexa Zydis)
1
$0
(Risperdal)
(Risperdal)
2
1
1
2
1
1
$0
$0
$0
$0
$0
$0
(Risperdal M-Tab)
1
$0
(Risperdal M-Tab)
1
$0
2
$0
2
$0
ST; QL (60 per 30
days)
ST; QL (60 per 30
days)
2
$0
ST; QL (30 per 30
days)
1
1
$0
$0
1
$0
Name of Drug
loxapine succinate
olanzapine intramuscular
olanzapine oral tablet
olanzapine oral
tablet,disintegrating 10 mg, 15 mg,
5 mg
olanzapine oral
tablet,disintegrating 20 mg
ORAP
perphenazine
quetiapine
RISPERDAL CONSTA
risperidone oral solution
risperidone oral tablet
risperidone oral
tablet,disintegrating 0.25 mg, 0.5
mg, 1 mg, 2 mg
risperidone oral
tablet,disintegrating 3 mg, 4 mg
(Perphenazine)
(Seroquel)
SAPHRIS (BLACK CHERRY)
SEROQUEL XR ORAL TABLET
EXTENDED RELEASE 24 HR
150 MG, 300 MG, 400 MG, 50 MG
SEROQUEL XR ORAL TABLET
EXTENDED RELEASE 24 HR
200 MG
thioridazine
(Thioridazine HCl)
thiothixene
(Navane)
(Trifluoperazine
trifluoperazine
HCl)
Necessary Actions,
Restrictions, or
Limits on Use
ST; QL (30 per 30
days)
ST; QL (60 per 30
days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (30 per 30 days)
QL (31 per 30 days)
QL (90 per 30 days)
QL (4 per 28 days)
QL (480 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
QL (120 per 30 days)
PA NSO-HRM
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
64
Name of Drug
VERSACLOZ
ziprasidone hcl
ZYPREXA RELPREVV
INTRAMUSCULAR
SUSPENSION FOR
RECONSTITUTION 210 MG, 405
MG
(Geodon)
Tier level
What the
drug will
cost you
2
$0
1
$0
2
$0
1
1
2
2
2
$0
$0
$0
$0
$0
2
$0
1
2
2
2
2
2
2
2
2
2
2
1
1
2
1
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
Necessary Actions,
Restrictions, or
Limits on Use
ST; QL (540 per 30
days)
QL (60 per 30 days)
QL (2 per 28 days)
Antivirals (Systemic)
Antiretrovirals
abacavir
abacavir-lamivudine-zidovudine
APTIVUS
ATRIPLA
COMPLERA
CRIXIVAN ORAL CAPSULE 200
MG, 400 MG
didanosine
EDURANT
EMTRIVA
EPIVIR HBV ORAL SOLUTION
EPZICOM
EVOTAZ
FUZEON SUBCUTANEOUS
INTELENCE
INVIRASE
ISENTRESS
KALETRA
lamivudine
lamivudine-zidovudine
LEXIVA
nevirapine oral suspension
nevirapine oral tablet
(Ziagen)
(Trizivir)
(Videx EC)
(Epivir)
(Combivir)
(Viramune)
(Viramune)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
65
Name of Drug
nevirapine oral tablet extended
release 24 hr
NORVIR
PREZCOBIX
PREZISTA
RESCRIPTOR
RETROVIR INTRAVENOUS
REYATAZ ORAL CAPSULE 150
MG, 200 MG, 300 MG
REYATAZ ORAL POWDER IN
PACKET
SELZENTRY
stavudine
STRIBILD
SUSTIVA
TIVICAY
TRIUMEQ
TRUVADA
VIDEX 2 GRAM PEDIATRIC
VIDEX 4 GRAM PEDIATRIC
VIRACEPT ORAL TABLET
VIRAMUNE XR ORAL TABLET
EXTENDED RELEASE 24 HR
100 MG
VIREAD
VITEKTA
ZIAGEN ORAL SOLUTION
zidovudine oral capsule
zidovudine oral syrup
zidovudine oral tablet
Antivirals, Miscellaneous
foscarnet
RELENZA DISKHALER
rimantadine
(Viramune XR)
(Zerit)
(Retrovir)
(Retrovir)
(Zidovudine)
(Foscavir)
(Flumadine)
Tier level
What the
drug will
cost you
1
$0
2
2
2
2
2
$0
$0
$0
$0
$0
2
$0
2
$0
2
1
2
2
2
2
2
2
2
2
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
2
$0
2
2
2
1
1
1
$0
$0
$0
$0
$0
$0
1
2
1
$0
$0
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
66
Tier level
What the
drug will
cost you
SYNAGIS
TAMIFLU ORAL CAPSULE 30
MG
TAMIFLU ORAL CAPSULE 45
MG
TAMIFLU ORAL CAPSULE 75
MG
TAMIFLU ORAL SUSPENSION
FOR RECONSTITUTION
Hcv Antivirals
2
$0
2
$0
2
$0
2
$0
2
$0
HARVONI
2
$0
OLYSIO
2
$0
SOVALDI
2
$0
VIEKIRA PAK
2
$0
2
2
$0
$0
2
$0
2
2
$0
$0
2
$0
2
$0
1
$0
1
$0
Name of Drug
Interferons
INTRON A INJECTION
PEGASYS
PEGASYS PROCLICK
SUBCUTANEOUS PEN
INJECTOR
PEGINTRON
PEGINTRON REDIPEN
SYLATRON
SYLATRON 4-PACK
SUBCUTANEOUS KIT 200 MCG,
300 MCG
Nucleosides And Nucleotides
acyclovir oral capsule
(Zovirax)
acyclovir oral suspension 200 mg/5
(Zovirax)
ml
Necessary Actions,
Restrictions, or
Limits on Use
QL (84 per 180 days)
QL (48 per 180 days)
QL (42 per 180 days)
QL (540 per 180 days)
PA; QL (30 per 30
days)
PA; QL (28 per 28
days)
PA; QL (28 per 28
days)
PA; QL (112 per 28
days)
PA NSO
PA
PA
PA
PA
PA NSO; QL (4 per 28
days)
PA NSO; QL (4 per 28
days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
67
Tier level
What the
drug will
cost you
(Zovirax)
(Acyclovir
Sodium)
(Acyclovir
Sodium)
(Hepsera)
(Baraclude)
(Famvir)
(Cytovene)
(Rebetol)
1
$0
1
$0
1
$0
1
1
1
1
1
$0
$0
$0
$0
$0
(Copegus)
1
$0
(Valtrex)
(Valcyte)
2
1
1
2
$0
$0
$0
$0
(Lovenox)
2
2
1
$0
$0
$0
(Lovenox)
1
$0
(Lovenox)
1
$0
(Lovenox)
1
$0
(Lovenox)
1
$0
(Lovenox)
1
$0
(Lovenox)
1
$0
Name of Drug
acyclovir oral tablet
acyclovir sodium intravenous recon
soln
acyclovir sodium intravenous
solution
adefovir
entecavir
famciclovir
ganciclovir sodium
ribavirin oral capsule 200 mg
ribavirin oral tablet 200 mg, 400
mg, 600 mg
TYZEKA
valacyclovir
valganciclovir
VIRAZOLE
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA BvD
PA BvD
PA BvD
Blood Products/Modifiers/Volume Expanders
Anticoagulants
CEPROTIN (BLUE BAR)
ELIQUIS
enoxaparin subcutaneous solution
enoxaparin subcutaneous syringe
100 mg/ml
enoxaparin subcutaneous syringe
120 mg/0.8 ml, 80 mg/0.8 ml
enoxaparin subcutaneous syringe
150 mg/ml
enoxaparin subcutaneous syringe
30 mg/0.3 ml
enoxaparin subcutaneous syringe
40 mg/0.4 ml
enoxaparin subcutaneous syringe
60 mg/0.6 ml
QL (36 per 30 days)
QL (36 per 30 days)
QL (27.2 per 30 days)
QL (34 per 30 days)
QL (18 per 30 days)
QL (13.6 per 30 days)
QL (20.4 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
68
Tier level
What the
drug will
cost you
(Arixtra)
1
$0
(Arixtra)
1
$0
(Arixtra)
1
$0
(Arixtra)
1
$0
(Heparin Sodium
in 5% Dextrose)
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
Name of Drug
fondaparinux subcutaneous syringe
10 mg/0.8 ml
fondaparinux subcutaneous syringe
2.5 mg/0.5 ml
fondaparinux subcutaneous syringe
5 mg/0.4 ml
fondaparinux subcutaneous syringe
7.5 mg/0.6 ml
heparin (porcine) in 5 % dex
intravenous parenteral solution
12,500 unit/250 ml, 20,000 unit/500
ml (40 unit/ml)
HEPARIN (PORCINE) IN 5 %
DEX INTRAVENOUS
PARENTERAL SOLUTION
25,000 UNIT/250 ML(100
UNIT/ML), 25,000 UNIT/500 ML
(50 UNIT/ML)
heparin (porcine) in nacl (pf)
intravenous parenteral solution
1,000 unit/500 ml
heparin (porcine) injection
heparin, porcine (pf) injection
heparin, porcine (pf) intravenous
syringe 100 unit/ml
HEPARIN-0.45% NACL 25,000
UNITS/250 ML (100 UNITS/ML)
BAG LATEX-FREE, OUTER
HEPARIN-0.45% NACL 25,000
UNITS/500 ML (50 UNITS/ML)
BAG LATEX-FREE, OUTER
heparin-d5w 25,000 units/250 ml
(100 units/ml) bag excel container
(Heparin
Sodium,Porcine/Ns
/PF)
(Heparin
Sodium,Porcine)
(Monoject Prefill
Advanced)
(Monoject Prefill
Advanced)
(Heparin Sodium
in 5% Dextrose)
Necessary Actions,
Restrictions, or
Limits on Use
QL (24 per 30 days)
QL (15 per 30 days)
QL (12 per 30 days)
QL (18 per 30 days)
PA BvD; (PA for
ESRD Only)
PA BvD; (PA for
ESRD Only)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
69
Tier level
What the
drug will
cost you
1
$0
IPRIVASK
2
$0
jantoven
(Coumadin)
PRADAXA
warfarin
(Coumadin)
XARELTO
Blood Formation Modifiers
EPOGEN INJECTION SOLUTION
10,000 UNIT/ML, 2,000 UNIT/ML,
20,000 UNIT/2 ML, 20,000
UNIT/ML, 3,000 UNIT/ML, 4,000
UNIT/ML
GRANIX
LEUKINE INJECTION RECON
SOLN
1
2
1
2
$0
$0
$0
$0
Name of Drug
heparin-d5w 25,000 units/500 ml
(50 units/ml) bag excel container
(Heparin Sodium
in 5% Dextrose)
Necessary Actions,
Restrictions, or
Limits on Use
PA; QL (24 per 28
days)
QL (60 per 30 days)
PA; QL (12 per 28
days)
2
$0
2
$0
2
$0
MIRCERA
2
$0
MOZOBIL
NEULASTA SUBCUTANEOUS
SYRINGE
NEUMEGA
NEUPOGEN
PROCRIT INJECTION
SOLUTION 10,000 UNIT/ML,
2,000 UNIT/ML, 20,000 UNIT/2
ML, 20,000 UNIT/ML, 3,000
UNIT/ML, 4,000 UNIT/ML
PROCRIT INJECTION
SOLUTION 40,000 UNIT/ML
2
$0
2
$0
2
2
$0
$0
PA; QL (0.6 per 28
days)
PA; QL (12 per 28
days)
2
$0
2
$0
PROMACTA
2
$0
Hematologic Agents, Miscellaneous
aminocaproic acid oral
(Amicar)
1
$0
PA; QL (6 per 28 days)
PA; QL (30 per 30
days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
70
Name of Drug
Tier level
What the
drug will
cost you
anagrelide
(Agrylin)
1
$0
protamine
(Protamine Sulfate)
1
$0
tranexamic acid intravenous
(Tranexamic Acid)
tranexamic acid oral
(Lysteda)
Platelet-Aggregation Inhibitors
AGGRENOX
BRILINTA
cilostazol
(Pletal)
clopidogrel
(Plavix)
EFFIENT
pentoxifylline
(Pentoxifylline)
Volume Expanders
ALBUKED-25
ALBUKED-5
ALBUMIN, HUMAN 25 %
ALBUMIN, HUMAN 5 %
ALBUMINAR 25 %
ALBUMINAR 5 %
ALBURX (HUMAN) 5 %
ALBUTEIN 25 %
ALBUTEIN 5 %
BUMINATE 25 %
BUMINATE 5 %
FLEXBUMIN 25 %
FLEXBUMIN 5 %
KEDBUMIN
PLASBUMIN 25 %
PLASBUMIN 5 %
1
1
$0
$0
2
2
1
1
2
1
$0
$0
$0
$0
$0
$0
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD; (PA for
ESRD Only)
QL (30 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
Caloric Agents
Caloric Agents
AMINO ACIDS 15 %
2
$0
PA BvD
AMINOSYN 10 %
2
$0
PA BvD
AMINOSYN 3.5 %
2
$0
PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
71
Name of Drug
AMINOSYN 7 %
AMINOSYN 7 % WITH
ELECTROLYTES
AMINOSYN 8.5 %
AMINOSYN 8.5 %ELECTROLYTES
AMINOSYN II 10 %
AMINOSYN II 15 %
AMINOSYN II 7 %
AMINOSYN II 8.5 %
AMINOSYN II 8.5 %ELECTROLYTES
AMINOSYN M 3.5 %
AMINOSYN-HBC 7%
AMINOSYN-PF 10 %
AMINOSYN-PF 7 % (SULFITEFREE)
AMINOSYN-RF 5.2 %
CLINIMIX 5%/D15W SULFITE
FREE
CLINIMIX 5%/D25W SULFITEFREE
CLINIMIX 2.75%/D5W SULFIT
FREE
CLINIMIX 4.25%/D10W SULF
FREE
CLINIMIX 4.25%/D5W SULFIT
FREE
CLINIMIX 4.25%-D20W SULFFREE
CLINIMIX 4.25%-D25W SULFFREE
CLINIMIX 5%-D20W(SULFITEFREE)
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
2
$0
2
2
2
2
$0
$0
$0
$0
2
$0
2
2
2
$0
$0
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
72
Name of Drug
CLINIMIX E 2.75%/D10W SUL
FREE
CLINIMIX E 2.75%/D5W SULF
FREE
CLINIMIX E 4.25%/D10W SUL
FREE
CLINIMIX E 4.25%/D25W SUL
FREE
CLINIMIX E 4.25%/D5W SULF
FREE
CLINIMIX E 5%/D15W SULFIT
FREE
CLINIMIX E 5%/D20W SULFIT
FREE
CLINIMIX E 5%/D25W SULFIT
FREE
CLINISOL SF 15 %
cysteine (l-cysteine) intravenous
solution
(Cysteine HCl)
(Dextrose 10 %
and 0.45 % NaCl)
(Dextrose 2.5 %
d2.5 %-0.45 % sodium chloride
and 0.45 % NaCl)
(Dextrose 5 % and
d5 % and 0.9 % sodium chloride
0.9 % NaCl)
(Dextrose 5 %-0.45
d5 %-0.45 % sodium chloride
% NaCl)
dex4 glucose * oral tablet,chewable (Dextrose)
(Dextrose 10 %
dextrose 10 % and 0.2 % nacl
and 0.2 % NaCl)
dextrose 10 % in water (d10w)
(Dextrose 10 % in
intravenous
Water)
(Dextrose 2.5 % in
dextrose 2.5 % in water(d2.5w)
Water)
d10 % & 0.45 % sodium chloride
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
2
$0
1
$0
1
$0
1
$0
1
$0
1
$0
4
$0
1
$0
1
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
73
Name of Drug
dextrose 20 % in water (d20w)
dextrose 25 % in water (d25w)
dextrose 40 % in water (d40w)
dextrose 5 % in ringers
dextrose 5 % in water (d5w)
intravenous
dextrose 5 %-lactated ringers
dextrose 5%-0.2 % sod chloride
dextrose 5%-0.3 % sod.chloride
dextrose 50 % in water (d50w)
dextrose 70 % in water (d70w)
dextrose with sodium chloride
(Dextrose 20 % in
Water)
(Dextrose 25 % in
Water)
(Dextrose 40 % in
Water)
(Dextrose 5% In
Ringers)
(Dextrose 5 % in
Water)
(Dextrose 5%Lactated Ringers)
(Dextrose 5 %-0.2
% NaCl)
(Dextrose 5 % and
0.3 % NaCl)
(Dextrose 50 % in
Water)
(Dextrose 70 % in
Water)
(Dextrose 5 %-0.2
% NaCl)
FREAMINE HBC 6.9 %
FREAMINE III 10 %
gluco burst *
glucose gel *
glucose * oral tablet,chewable
glutose 15 *
HEPATAMINE 8%
HEPATASOL 8 %
(Dextrose)
(Dextrose)
(Dextrose)
(Dextrose)
insta-glucose *
(Dextrose/Dextrin/
Maltose)
INTRALIPID INTRAVENOUS
EMULSION 20 %, 30 %
KABIVEN
Tier level
What the
drug will
cost you
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
2
2
4
4
4
4
2
2
$0
$0
$0
$0
$0
$0
$0
$0
4
$0
2
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
74
Tier level
What the
drug will
cost you
2
2
2
2
2
$0
$0
$0
$0
$0
1
$0
2
2
2
2
2
2
2
$0
$0
$0
$0
$0
$0
$0
(Catapres)
(Clonidine
HCl/Chlorthalidon
e)
1
$0
1
$0
(Catapres-Tts 1)
1
$0
(Catapres-Tts 1)
1
$0
(Cardura)
(Tenex)
(Midodrine HCl)
1
1
1
$0
$0
$0
(Medi-Phenyl)
4
$0
2
$0
1
1
4
$0
$0
$0
Name of Drug
LIPOSYN II
LIPOSYN III
NEPHRAMINE 5.4 %
NUTRILIPID
PERIKABIVEN
potassium chloride in lr-d5
intravenous parenteral solution
PREMASOL 10 %
PREMASOL 6 %
PROCALAMINE 3%
PROSOL 20 %
TRAVASOL 10 %
TROPHAMINE 10 %
TROPHAMINE 6%
(Potassium
Chloride In Lr-D5)
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
Cardiovascular Agents
Alpha-Adrenergic Agents
clonidine hcl oral tablet
clonidine hcl-chlorthalidone
clonidine transdermal patch weekly
0.1 mg/24 hr, 0.2 mg/24 hr
clonidine transdermal patch weekly
0.3 mg/24 hr
doxazosin
guanfacine oral tablet
midodrine
nasal decongestant (pe) * oral
tablet 10 mg
NORTHERA
phenylephrine hcl injection
prazosin oral
sudogest pe *
(Vazculep)
(Minipress)
(Medi-Phenyl)
QL (4 per 28 days)
QL (8 per 28 days)
PA-HRM
PA; QL (180 per 30
days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
75
Name of Drug
Tier level
What the
drug will
cost you
wal-phed pe *
(Medi-Phenyl)
Angiotensin Ii Receptor Antagonists
BENICAR
BENICAR HCT
candesartan
(Atacand)
candesartan-hydrochlorothiazid
(Atacand HCT)
irbesartan
(Avapro)
irbesartan-hydrochlorothiazide
(Avalide)
losartan
(Cozaar)
losartan-hydrochlorothiazide
(Hyzaar)
telmisartan
(Micardis)
telmisartan-hydrochlorothiazid
(Micardis HCT)
TRIBENZOR
valsartan
(Diovan)
valsartan-hydrochlorothiazide
(Diovan HCT)
Angiotensin-Converting Enzyme Inhibitors
benazepril
(Lotensin)
benazepril-hydrochlorothiazide
(Lotensin HCT)
captopril
(Captopril)
(Captopril/Hydroch
captopril-hydrochlorothiazide
lorothiazide)
enalapril maleate
(Vasotec)
(Enalaprilat
enalaprilat intravenous injectable
Dihydrate)
enalapril-hydrochlorothiazide
(Vaseretic)
(Fosinopril
fosinopril
Sodium)
(Fosinopril/Hydroc
fosinopril-hydrochlorothiazide
hlorothiazide)
lisinopril
(Zestril)
lisinopril-hydrochlorothiazide
(Zestoretic)
moexipril
(Univasc)
moexipril-hydrochlorothiazide
(Uniretic)
perindopril erbumine
(Aceon)
4
$0
2
2
1
1
1
1
1
1
1
1
2
1
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
1
1
1
$0
$0
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
1
1
1
1
$0
$0
$0
$0
$0
Necessary Actions,
Restrictions, or
Limits on Use
ST
ST
ST
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
76
Tier level
What the
drug will
cost you
(Accupril)
(Accuretic)
(Altace)
(Mavik)
1
1
1
1
$0
$0
$0
$0
(Cordarone)
1
$0
(Cordarone)
1
$0
(Norpace)
1
$0
1
$0
1
$0
1
$0
1
2
$0
$0
(Procainamide
HCl)
1
$0
(Rythmol SR)
1
$0
(Rythmol)
(Quinidine
Gluconate)
(Quinidine Sulfate)
1
$0
1
$0
Name of Drug
quinapril
quinapril-hydrochlorothiazide
ramipril
trandolapril
Antiarrhythmic Agents
amiodarone hcl oral tablet 100 mg,
200 mg, 400 mg
amiodarone oral
disopyramide phosphate oral
capsule
flecainide
lidocaine (pf) intravenous syringe
50 mg/5 ml (1 %)
lidocaine in 5 % dextrose (pf)
intravenous parenteral solution 8
mg/ml (0.8 %)
mexiletine
MULTAQ
procainamide injection
propafenone oral capsule,extended
release 12 hr
propafenone oral tablet
quinidine gluconate oral
(Flecainide
Acetate)
(Lidocaine
HCl/PF)
(Lidocaine
HCl/D5w/PF)
(Mexiletine HCl)
Necessary Actions,
Restrictions, or
Limits on Use
quinidine sulfate
1
$0
TIKOSYN
2
$0
Beta-Adrenergic Blocking Agents
acebutolol oral
(Sectral)
1
$0
atenolol
(Tenormin)
1
$0
atenolol-chlorthalidone
(Tenoretic 50)
1
$0
betaxolol oral
(Kerlone)
1
$0
bisoprolol fumarate
(Zebeta)
1
$0
bisoprolol-hydrochlorothiazide
(Ziac)
1
$0
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
77
Tier level
What the
drug will
cost you
2
1
1
1
1
1
1
$0
$0
$0
$0
$0
$0
$0
1
$0
1
1
1
1
$0
$0
$0
$0
(Inderal LA)
1
$0
(Propranolol HCl)
(Propranolol HCl)
(Propranolol/Hydro
chlorothiazid)
1
1
$0
$0
1
$0
1
$0
1
1
$0
$0
1
1
$0
$0
1
$0
1
$0
1
$0
1
$0
Name of Drug
BYSTOLIC
carvedilol
esmolol intravenous
labetalol intravenous solution
labetalol oral
metoprolol succinate
metoprolol ta-hydrochlorothiaz
metoprolol tartrate intravenous
metoprolol tartrate oral
nadolol
pindolol
propranolol intravenous
propranolol oral capsule,extended
release 24 hr
propranolol oral solution
propranolol oral tablet
propranolol-hydrochlorothiazid
(Coreg)
(Esmolol HCl)
(Trandate)
(Trandate)
(Toprol XL)
(Lopressor HCT)
(Metoprolol
Tartrate)
(Lopressor)
(Corgard)
(Pindolol)
(Propranolol HCl)
sotalol hcl oral tablet 120 mg, 160
(Betapace)
mg, 240 mg, 80 mg
sotalol oral
(Betapace)
timolol maleate oral
(Timolol Maleate)
Calcium-Channel Blocking Agents
cartia xt
(Cardizem CD)
diltiazem hcl intravenous
(Cardizem CD)
diltiazem hcl oral capsule, extended
(Cardizem CD)
release 180 mg, 360 mg, 420 mg
diltiazem hcl oral capsule,extended
(Cardizem CD)
release 12 hr
diltiazem hcl oral capsule,extended
(Cardizem CD)
release 24hr
diltiazem hcl oral tablet
(Cardizem CD)
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
78
Name of Drug
diltiazem hcl oral tablet extended
(Cardizem LA)
release 24 hr
dilt-xr
(Cardizem CD)
matzim la
(Cardizem CD)
taztia xt
(Cardizem CD)
verapamil intravenous syringe
(Verapamil HCl)
verapamil oral capsule, 24 hr er
(Verelan Pm)
pellet ct
verapamil oral capsule,ext rel.
(Verelan)
pellets 24 hr
verapamil oral tablet
(Calan)
verapamil oral tablet extended
(Calan SR)
release
Cardiovascular Agents, Miscellaneous
ADRENALIN 1 MG/ML VIAL
SUV
adrenalin injection solution 1
(Epinephrine)
mg/ml (1:1,000) (1ml)
DEMSER
Tier level
What the
drug will
cost you
1
$0
1
1
1
1
$0
$0
$0
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
2
$0
digitek oral tablet 125 mcg
(Lanoxin)
1
$0
digitek oral tablet 250 mcg
(Lanoxin)
1
$0
digoxin injection
(Digoxin)
1
$0
2
$0
DIGOXIN ORAL SOLUTION
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM; (High Risk
Med for Ages 65 and
Older and Dose is
Greater Than 125mcg
Per Day); QL (30 per
30 days)
PA-HRM; QL (30 per
30 days)
PA-HRM
PA-HRM; QL (300 per
30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
79
Name of Drug
Tier level
digoxin oral tablet
(Lanoxin)
dobutamine in d5w intravenous
parenteral solution
dobutamine intravenous solution
dopamine in 5 % dextrose
intravenous solution
dopamine intravenous solution
ephedrine sulfate injection solution
epinephrine 1 mg/ml ampul latexfree
epinephrine injection auto-injector
epinephrine injection syringe 0.1
mg/ml (1:10,000)
EPIPEN 2-PAK
EPIPEN JR 2-PAK
(Dobutamine
HCl/D5W)
(Dobutamine HCl)
(Dopamine
HCl/D5W)
(Dopamine HCl)
(Ephedrine Sulfate)
1
$0
1
$0
1
$0
1
$0
1
1
$0
$0
(Epinephrine)
1
$0
(Adrenaclick)
1
$0
(Epinephrine)
1
$0
2
2
$0
$0
1
$0
2
1
$0
$0
(Ethanolamine
Oleate)
ethamolin
FIRAZYR
hydralazine
(Hydralazine HCl)
LANOXIN ORAL TABLET 187.5
MCG, 62.5 MCG
milrinone
milrinone in 5 % dextrose
intravenous piggyback 40 mg/200
ml (200 mcg/ml)
What the
drug will
cost you
2
$0
(Milrinone Lactate)
1
$0
(Milrinone
Lactate/D5W)
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM; (High Risk
Med for Ages 65 and
Older and Dose is
Greater Than 125mcg
Per Day); QL (30 per
30 days)
PA BvD
PA BvD
PA BvD
PA BvD
PA-HRM; (High Risk
Med for Ages 65 and
Older and Dose is
Greater Than 125mcg
Per Day); QL (30 per
30 days)
PA BvD
PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
80
Name of Drug
norepinephrine bitartrate
papaverine injection solution
papaverine oral
RANEXA
Dihydropyridines
amlodipine
amlodipine-benazepril
AZOR
CLEVIPREX INTRAVENOUS
EMULSION
EXFORGE
EXFORGE HCT
felodipine
isradipine
nicardipine oral
nifedipine oral tablet extended
release 24hr 30 mg
nifedipine oral tablet extended
release 24hr 60 mg, 90 mg
nifedipine oral tablet extended
release 30 mg, 60 mg
Diuretics
amiloride oral
amiloride-hydrochlorothiazide
(Levophed
Bitartrate)
(Papaverine HCl)
(Papaverine HCl)
(Norvasc)
(Lotrel)
Tier level
What the
drug will
cost you
1
$0
1
1
2
$0
$0
$0
1
1
2
$0
$0
$0
2
$0
(Felodipine)
(Isradipine)
(Nicardipine HCl)
1
1
1
1
1
$0
$0
$0
(Adalat CC)
1
$0
(Procardia XL)
1
$0
(Adalat CC)
1
$0
(Midamor)
(Amiloride/Hydroc
hlorothiazide)
(Bumetanide)
(Chlorothiazide)
(Sodium Diuril)
1
$0
1
$0
1
1
1
$0
$0
$0
1
$0
2
1
1
$0
$0
$0
bumetanide
chlorothiazide
chlorothiazide sodium
chlorthalidone oral tablet 25 mg, 50
(Chlorthalidone)
mg
DYRENIUM
furosemide injection
(Furosemide)
furosemide oral solution
(Furosemide)
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA
PA
ST
ST
ST
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
81
Tier level
What the
drug will
cost you
(Lasix)
(Microzide)
(Hydrochlorothiazi
de)
(Indapamide)
(Methyclothiazide)
(Zaroxolyn)
(Demadex)
1
1
$0
$0
1
$0
1
1
1
1
$0
$0
$0
$0
(Dyazide)
1
$0
(Maxzide)
1
$0
(Caduet)
(Lipitor)
(Questran)
(Cholestyramine/A
spartame)
1
1
1
$0
$0
$0
1
$0
(Questran)
1
$0
(Colestid)
1
2
$0
$0
(Slo-Niacin)
4
$0
(Antara)
(Tricor)
(Lofibra)
(Fibricor)
(Trilipix)
(Lopid)
(Inositol/Choline/V
it B Comp)
(Mevacor)
1
1
1
1
1
1
$0
$0
$0
$0
$0
$0
4
$0
1
$0
Name of Drug
furosemide oral tablet
hydrochlorothiazide oral capsule
hydrochlorothiazide oral tablet
indapamide
methyclothiazide
metolazone
torsemide oral
triamterene-hydrochlorothiazid oral
capsule
triamterene-hydrochlorothiazid oral
tablet
Dyslipidemics
amlodipine-atorvastatin
atorvastatin
cholestyramine (with sugar) oral
cholestyramine-aspartame oral
powder 4 gram
cholestyramine-aspartame oral
powder in packet 4 gram
colestipol
CRESTOR
endur-acin * oral tablet extended
release 500 mg
fenofibrate micronized
fenofibrate nanocrystallized
fenofibrate oral tablet
fenofibric acid
fenofibric acid (choline)
gemfibrozil oral
lipogen *
lovastatin
Necessary Actions,
Restrictions, or
Limits on Use
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
82
Name of Drug
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
niacin * oral capsule, extended
(Niacin)
4
$0
release 500 mg
niacin * oral tablet 100 mg, 50 mg,
(Slo-Niacin)
4
$0
500 mg
niacin oral tablet extended release
(Niaspan)
1
$0
24 hr
niacin * oral tablet extended
(Slo-Niacin)
4
$0
release 500 mg
omega-3 acid ethyl esters
(Lovaza)
1
$0
pravastatin
(Pravachol)
1
$0
simvastatin
(Zocor)
1
$0
QL (30 per 30 days)
VASCEPA
2
$0
WELCHOL
2
$0
ZETIA
2
$0
Renin-Angiotensin-Aldosterone System Inhibitors
eplerenone
(Inspra)
1
$0
spironolactone
(Aldactone)
1
$0
spironolacton-hydrochlorothiaz
(Aldactazide)
1
$0
Vasodilators
isosorbide dinitrate oral
(Isochron)
1
$0
(Isosorbide
isosorbide dinitrate sublingual
1
$0
Dinitrate)
(Isosorbide
isosorbide mononitrate oral tablet
1
$0
Mononitrate)
isosorbide mononitrate oral tablet
(Imdur)
1
$0
extended release 24 hr
minitran transdermal patch 24 hour
QL (30 per 30 days)
(Nitro-Dur)
1
$0
0.1 mg/hr, 0.2 mg/hr, 0.6 mg/hr
minitran transdermal patch 24 hour
QL (60 per 30 days)
(Nitro-Dur)
1
$0
0.4 mg/hr
minoxidil oral
(Minoxidil)
1
$0
NITRO-BID
2
$0
nitroglycerin in 5 % dextrose
(Nitroglycerin/D5
1
$0
intravenous solution
W)
nitroglycerin intravenous
(Nitroglycerin)
1
$0
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
83
Tier level
What the
drug will
cost you
(Nitro-Dur)
1
$0
(Nitro-Dur)
1
$0
2
2
$0
$0
Central Nervous System Agents
amphetamine salt combo
(Adderall)
1
$0
AMPYRA
2
$0
1
1
$0
$0
1
$0
Name of Drug
nitroglycerin transdermal patch 24
hour 0.1 mg/hr, 0.2 mg/hr, 0.6
mg/hr
nitroglycerin transdermal patch 24
hour 0.4 mg/hr
NITROSTAT
PROGLYCEM
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 30 days)
QL (60 per 30 days)
Central Nervous System Agents
caffeine citrated intravenous
caffeine citrated oral
caffeine-sodium benzoate
(Cafcit)
(Cafcit)
(Caffeine/Sodium
Benzoate)
QL (60 per 30 days)
PA; QL (60 per 30
days)
clonidine hcl oral tablet extended
(Kapvay)
1
$0
release 12 hr
dexmethylphenidate oral tablet
(Focalin)
1
$0
QL (60 per 30 days)
dextroamphetamine oral capsule,
QL (120 per 30 days)
(Dexedrine)
1
$0
extended release
dextroamphetamine oral tablet
(Dexedrine)
1
$0
QL (180 per 30 days)
dextroamphetamine-amphetamine
QL (30 per 30 days)
oral capsule,extended release 24hr (Adderall XR)
1
$0
10 mg, 15 mg, 5 mg
dextroamphetamine-amphetamine
QL (60 per 30 days)
oral capsule,extended release 24hr (Adderall XR)
1
$0
20 mg, 25 mg, 30 mg
flumazenil
(Romazicon)
1
$0
guanfacine oral tablet extended
(Intuniv)
1
$0
release 24 hr
lithium carbonate oral capsule
(Eskalith)
1
$0
lithium carbonate oral tablet
(Lithobid)
1
$0
lithium carbonate oral tablet
(Lithobid)
1
$0
extended release
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
84
Tier level
What the
drug will
cost you
(Lithium Citrate)
1
$0
(Metadate Cd)
1
$0
(Metadate Cd)
1
$0
(Metadate Cd)
1
$0
(Metadate Cd)
1
$0
(Ritalin LA)
1
$0
(Methylin)
(Ritalin)
1
1
$0
$0
(Ritalin-SR)
1
$0
(Concerta)
1
$0
(Concerta)
1
$0
(Rilutek)
2
2
1
2
2
$0
$0
$0
$0
$0
2
$0
1
1
1
$0
$0
$0
Name of Drug
lithium citrate oral solution
methylphenidate oral capsule, er
biphasic 30-70 10 mg, 20 mg, 50
mg, 60 mg
methylphenidate oral capsule, er
biphasic 30-70 30 mg
methylphenidate oral capsule,er
biphasic 50-50 20 mg
methylphenidate oral capsule,er
biphasic 50-50 30 mg
methylphenidate oral capsule,er
biphasic 50-50 40 mg
methylphenidate oral solution
methylphenidate oral tablet
methylphenidate oral tablet
extended release
methylphenidate oral tablet
extended release 24hr 18 mg, 27
mg, 54 mg
methylphenidate oral tablet
extended release 24hr 36 mg
NUEDEXTA
QUILLIVANT XR
riluzole
SAVELLA
STRATTERA
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
QL (60 per 30 days)
QL (30 per 30 days)
QL (900 per 30 days)
QL (90 per 30 days)
QL (90 per 30 days)
QL (30 per 30 days)
XENAZINE
QL (60 per 30 days)
QL (60 per 30 days)
QL (60 per 30 days)
PA; QL (112 per 28
days)
Contraceptives
Contraceptives
ashlyna
deblitane
desog-e.estradiol/e.estradiol
(Seasonique)
(Nor-Q-D)
(Mircette)
QL (91 per 84 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
85
Tier level
What the
drug will
cost you
(Desogen)
1
$0
(Yaz)
1
2
1
$0
$0
$0
1
$0
1
1
1
1
4
$0
$0
$0
$0
$0
1
$0
Name of Drug
desogestrel-ethinyl estradiol oral
tablet 0.1/.125/.15-25 mg-mcg,
0.15-0.03 mg
drospirenone-ethinyl estradiol
ELLA
ethinyl estradiol/drospirenone
ethynodiol d-ethinyl estradiol
gildess 24 fe
l norgest&e estradiol-e estrad
levonorgestrel 1.5 mg tablet (rx)
levonorgestrel oral tablet 0.75 mg
levonorgestrel * oral tablet 1.5 mg
levonorgestrel-ethin estradiol oral
tablet 0.1-20 mg-mcg, 0.15-0.03
mg, 50-30 (6)/75-40 (5)/125-30(10)
levonorgestrel-ethin estradiol oral
tablets,dose pack,3 month 0.15-30
mg-mcg
levonorgestrel-ethinyl estrad oral
tablet
levonorgestrel-ethinyl estrad oral
tablets,dose pack,3 month
l-norgest-eth estr/ethin estra
next choice one dose 1.5 mg tb (rx)
1.5 mg
norelgestromin/ethin.estradiol
noreth-ethinyl estradiol/iron
norethindrone
norethindrone (contraceptive)
norethindrone ac-eth estradiol oral
tablet 1-20 mg-mcg, 1.5-30 mg-mcg
(Yaz)
(Ethynodiol DEthinyl Estradiol)
(Loestrin Fe)
(Seasonique)
(Plan B One-Step)
(Plan B One-Step)
(Plan B One-Step)
(Amethyst)
Necessary Actions,
Restrictions, or
Limits on Use
QL (91 per 84 days)
QL (6 per 365 days)
QL (6 per 365 days)
QL (91 per 84 days)
(LevonorgestrelEthin Estradiol)
1
$0
(Amethyst)
1
$0
1
$0
1
$0
(Plan B One-Step)
1
$0
(Ortho Evra)
(Femcon Fe)
(Nor-Q-D)
(Nor-Q-D)
1
1
1
1
$0
$0
$0
$0
(Loestrin)
1
$0
(LevonorgestrelEthin Estradiol)
(Seasonique)
QL (91 per 84 days)
QL (91 per 84 days)
QL (6 per 365 days)
QL (3 per 28 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
86
Tier level
What the
drug will
cost you
(Loestrin Fe)
1
$0
(Modicon)
1
$0
(Norinyl 1+50)
(Ortho-Cyclen)
(Norgestrel-Ethinyl
Estradiol)
1
1
$0
$0
1
$0
2
4
3
1
$0
$0
$0
$0
4
4
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Name of Drug
norethindrone-e.estradiol-iron oral
tablet 1 mg-20 mcg (21)/75 mg (7),
1 mg-20 mcg (24)/75 mg (4), 120(5)/1-30(7) /1mg-35mcg (9), 1.5
mg-30 mcg (21)/75 mg (7)
norethindrone-ethinyl estrad oral
tablet 0.4-35 mg-mcg, 0.5-35 mgmcg, 0.5-35/1-35 mg-mcg/mg-mcg,
0.5/0.75/1 mg- 35 mcg, 0.5/1/0.5-35
mg-mcg, 1-35 mg-mcg
norethindrone-mestranol
norgestimate-ethinyl estradiol
norgestrel-ethinyl estradiol
NUVARING
opcicon one-step *
PLAN B ONE-STEP *
tarina fe
(Plan B One-Step)
(Loestrin Fe)
Necessary Actions,
Restrictions, or
Limits on Use
ST; QL (1 per 28 days)
QL (6 per 365 days)
QL (6 per 365 days)
Cough And Cold Products
Cough And Cold Products
30pse-150gfn-15dm *
(Trispec Pse)
adt robitussin peak cld dm max *
(G-Zyncof)
(Pseudoephedrine
adult nasal decongestant *
HCl)
(Dextromethorphan
adult robitussin lingering cld *
Hbr)
adult robitussin peak cold dm *
(G-Zyncof)
(Robitussin
adult wal-tussin *
Mucus-Chest
Congest)
adult wal-tussin dm max *
(G-Zyncof)
(Guaifenesin/Dextr
alka-seltzer plus mucus-conges *
omethorphan)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
87
Name of Drug
(DMethorphan/Pe/Ac
etaminophen)
(Dm/Phenyleph/Ch
ambi 10peh-4cpm-20dm *
lorpheniramine)
ambi 20dm-4cpm *
(Coricidin Hbp)
(Guaifenesin/Dm/P
ambi 40pse-400gfn-20dm *
seudoephedrine)
(D-Methorphan
ambi 60pse-4cpm-20dm *
Hb/P-Ephed
HCl/Cp)
benzonatate *
(Zonatuss)
(D-Methorphan
bio-dtuss dmx *
Hb/P-Epd
HCl/Bpm)
(Guaifenesin/Dm/P
bionel *
seudoephedrine)
bionel pediatric *
(Trispec Pse)
biospec dmx *
(G-Zyncof)
(D-Methorphan
bromphenex dm *
Hb/P-Epd
HCl/Bpm)
(D-Methorphan
brompheniramine-pseudoeph-dm *
Hb/P-Epd
oral liquid
HCl/Bpm)
(D-Methorphan
brompheniramine-pseudoeph-dm *
Hb/P-Epd
oral syrup
HCl/Bpm)
(Brompheniram/Ph
brompheniram-phenylephrine-dm *
enylephrine/Dm)
broncotron-s *
(G-Zyncof)
cardec dm (phenyleph-chlorphn) * (Accuhist Pdx)
cheratussin ac *
(M-Clear Wc)
cheratussin dac *
(Tusnel C)
chest congestion relief + dm *
(Allfen Dm)
alka-seltzer plus sinus-cough *
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
3
$0
4
$0
4
$0
4
4
$0
$0
4
$0
4
$0
4
$0
3
$0
4
4
4
4
4
$0
$0
$0
$0
$0
Necessary Actions,
Restrictions, or
Limits on Use
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
88
Name of Drug
chest congestion relief d *
chest congestion relief pe *
child cough & sore throat *
child mucinex chest congestion *
child mucus relief cough *
child plus cough & runny nose *
child triaminic cough-congest *
child wal-tussin cough relief *
children's chest congestion *
(Guaifenesin/Pseud
oephedrne HCl)
(Maxiphen)
(D-Methorphan
Hb/Acetaminophen
)
(Robitussin
Mucus-Chest
Congest)
(G-Zyncof)
(Dextromethorphn/
Acetaminoph/Cp)
(Guaifenesin/Dextr
omethorphan)
(Dextromethorphan
Hbr)
(Robitussin
Mucus-Chest
Congest)
CHILDREN'S DIMETAPP COLD
&FLU *
children's flu relief *
children's mucinex cough *
children's silfedrine *
children's sudafed *
children's sudafed pe cough *
chlophedianol-guaifenesin *
chlorpheniramine-phenyleph-dm *
codituss dm *
(Childrens Tylenol
Plus Cold)
(G-Zyncof)
(Pseudoephedrine
HCl)
(Pseudoephedrine
HCl)
(Dextromethorphan
/Phenylephrine)
(Vanacof G)
(Dm/Phenyleph/Ch
lorpheniramine)
(Pyrilamine/Pe/De
xtromethorphan)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
89
Name of Drug
(Comtrex Cold and
Cough)
(Dm
cold multi-symptom day/night *
Hb/Pe/Acetaminop
hen/Chlorph)
(Dm/Pe/Acetamino
cold multi-symptom nighttime *
phen/Doxylamine)
(Dm
cold relief m/s day/night *
Hb/Pe/Acetaminop
hen/Chlorph)
(Dcold-flu relief * oral liquid 12.5-30Methorphan/Aceta
1,000 mg/30 ml
min/Doxylamn)
(Vicks Dayquilcold-flu relief, day/night *
Nyquil)
(Guaifenesin/Pseud
congestac *
oephedrne HCl)
(Guaifenesin/Dextr
coricidin hbp * oral capsule
omethorphan)
cough & cold * oral
(Coricidin Hbp)
cough & runny nose * oral liquid 1- (Vicks Children'S
5 mg/5 ml
Nyquil)
coughtab *
(Allfen)
(Guaifenesin/Dextr
creo-terpin (dm-guaifenesin) *
omethorphan)
DALLERGY DM *
daytime cold & cough *
(Triaminic)
(Ddaytime cold-flu *
Methorphan/Pe/Ac
etaminophen)
(Dextromethorphan
day-time cough *
Hbr)
daytime mucus relief dm *
(G-Zyncof)
(Vicks Dayquildaytime-nighttime *
Nyquil)
cold multi-symptom *
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
$0
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
90
Name of Drug
daytime-nighttime cold-flu *
daytime-nighttime cough *
decongestant cough *
delsym cough+chest congest dm *
despec-dm (pseudoeph-dm-guaif) *
oral tablet 30-10-200 mg
dexchlorphen-pse-chlophedianol *
dextromethorphan polistirex *
diabetic siltussin das-na *
diabetic tussin dm *
diabetic tussin ex * oral
dimaphen dm *
d-methorphan hb-p-epd hcl-bpm *
oral syrup 2-30-10 mg/5 ml
dm-phenyleph-chlorpheniramine *
oral drops 1-2-3 mg/ml
dm-phenyleph-chlorpheniramine *
oral liquid 2-5-15 mg/5 ml, 4-10-15
mg/5 ml
double-tussin dm *
ed bron gp *
entre-cough *
exefen dmx *
(Dm/Pe/Acetamino
phen/Doxylamine)
(Dextromethorphan
Hb/Doxylamine)
(Trispec Pse)
(G-Zyncof)
(Guaifenesin/Dm/P
seudoephedrine)
(DChlorphenira/Pse/C
hlophedian)
(Delsym)
(Robitussin
Mucus-Chest
Congest)
(G-Zyncof)
(Robitussin
Mucus-Chest
Congest)
(Brompheniram/Ph
enylephrine/Dm)
(D-Methorphan
Hb/P-Epd
HCl/Bpm)
(Dm/Phenyleph/Ch
lorpheniramine)
(Dm/Phenyleph/Ch
lorpheniramine)
(G-Zyncof)
(Despec)
(Trispec Pse)
(Guaifenesin/Dm/P
seudoephedrine)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
4
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
3
$0
4
$0
4
$0
4
4
4
$0
$0
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
91
Name of Drug
expectorant max strength *
expectorant * oral
flu formula daytime-nighttime *
flu severe cold-congestion *
flu-severe cold-cough * oral
powder in packet 10-20-650 mg
guaiatussin ac *
guaifenesin dac *
guaifenesin * oral tablet 200 mg
guaifenesin * oral tablet extended
release 12hr
head congestion day-night *
hydrocodone bit-homatrop me-br *
oral syrup 5-1.5 mg/5 ml
hydrocodone-chlorpheniramine *
hydrocodone-homatropine * oral
syrup 5-1.5 mg/5 ml
hydrocodone-homatropine * oral
tablet
infants' non-aspirin cold *
intense cough reliever * oral liquid
kidkare cough/cold *
liquibid d-r *
(Dextromethorphan
/Pseudoephed)
(Robitussin
Mucus-Chest
Congest)
(Dm/Pe/Acetamino
ph/Diphenhydram)
(Theraflu)
(DMethorphan/Pe/Ac
etaminophen)
(M-Clear Wc)
(Tusnel C)
(Allfen)
(Mucinex)
(Dm
Hb/Pe/Acetaminop
hen/Chlorph)
(Hydrocodone
Bit/Homatrop MeBr)
(Tussionex)
(Hydrocodone
Bit/Homatrop MeBr)
(Tussigon)
(Dm/Pseudoephed/
Acetaminophen)
(G-Zyncof)
(D-Methorphan
Hb/P-Ephed
HCl/Cp)
(Maxiphen)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
4
$0
$0
$0
4
$0
4
$0
3
$0
3
$0
3
$0
3
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
92
Name of Drug
lohist peb dm *
lortuss ex * oral syrup
mar-cof bp *
mar-cof cg *
maximum strength flu *
medi-brom *
mesehist dm *
mucinex fast-max dm max *
mucus dm *
mucus dm max *
mucus relief * oral tablet 400 mg
multi-symptom cold night time *
multi-symptom cold-cough *
nasal & sinus decongestant *
neo-tuss *
NEXAFED *
night time cold-flu * oral
night time cold-flu relief * oral
liquid
night time * oral capsule
nighttime cold-flu *
(Ala-Hist Dm)
(Tusnel C)
(Bromphenira/Pseu
doephed/Codein)
(M-Clear Wc)
(Coricidin Hbp)
(D-Methorphan
Hb/P-Epd
HCl/Bpm)
(D-Methorphan
Hb/P-Ephed
HCl/Cp)
(G-Zyncof)
(Mucinex Dm)
(Mucinex Dm)
(Allfen)
(Theraflu)
(Dm
Hb/Pseudoephed/A
cetamin/Cp)
(Sudafed 12-Hour)
(G-Zyncof)
(Dm/PEphed/Acetaminop
h/Doxylam)
(Dm/PEphed/Acetaminop
h/Doxylam)
(Dm/PEphed/Acetaminop
h/Doxylam)
(DMethorphan/Aceta
min/Doxylamn)
Tier level
What the
drug will
cost you
4
4
$0
$0
3
$0
3
4
$0
$0
4
$0
4
$0
4
4
4
4
4
$0
$0
$0
$0
$0
4
$0
4
4
4
$0
$0
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
93
Name of Drug
nighttime cough *
nite time cold-flu * oral
nite time-d cold-flu relief *
nohist-dm *
non-aspirin cold *
non-aspirin flu * oral tablet 30-15500 mg
pecgen dmx *
pedia relief *
pedia relief infant *
pediacare multi-symptom cold *
phenylhistine dh *
poly-tussin *
(Dextromethorphan
Hb/Doxylamine)
(DMethorphan/Aceta
min/Doxylamn)
(Dm/PEphed/Acetaminop
h/Doxylam)
(Dm/Phenyleph/Ch
lorpheniramine)
(Dm
Hb/Pseudoephed/A
cetamin/Cp)
(Dm/Pseudoephed/
Acetaminophen)
(G-Zyncof)
(D-Methorphan
Hb/P-Ephed
HCl/Cp)
(Dextromethorphan
/Pseudoephed)
(Dextromethorphan
/Phenylephrine)
(P-Ephed
HCl/Cod/Chlorphe
nir)
(Chlorcyclizine/Co
deine)
POLY-TUSSIN DM *
promethazine-codeine *
promethazine-dm *
promethazine-phenyleph-codeine *
(Promethazine
HCl/Codeine)
(D-Methorphan
Hb/Prometh HCl)
(Promethazine/Phe
nyleph/Codeine)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
3
$0
3
$0
3
$0
Necessary Actions,
Restrictions, or
Limits on Use
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
94
Name of Drug
pseudoephedrine hcl * oral
pseudoephedrine hcl * oral
q-tapp dm *
q-tussin *
q-tussin dm *
refenesen *
refenesen pe *
relcof c *
REZIRA *
robafen *
robafen cough *
robafen dm *
robitussin cough & cold cf *
robitussin cough-chest-cong dm *
robitussin dm max *
ROBITUSSIN LONG-ACTING *
robitussin pediatric *
rydex *
safe tussin dm *
scot-tussin dm *
(Pseudoephedrine
HCl)
(Sudafed 12-Hour)
(D-Methorphan
Hb/P-Epd
HCl/Bpm)
(Robitussin
Mucus-Chest
Congest)
(Guaifenesin/Dextr
omethorphan)
(Allfen)
(Maxiphen)
(M-Clear Wc)
(Robitussin
Mucus-Chest
Congest)
(Dextromethorphan
Hbr)
(Guaifenesin/Dextr
omethorphan)
(Giltuss)
(Guaifenesin/Dextr
omethorphan)
(G-Zyncof)
(Dextromethorphan
Hbr)
(Bromphenira/Pseu
doephed/Codein)
(G-Zyncof)
(Vicks Children'S
Nyquil)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
3
3
$0
$0
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
$0
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
95
Name of Drug
scot-tussin expectorant *
siltussin dm das *
siltussin sa *
sudogest *
suphedrin * oral
suphedrine pe day-night *
suphedrine severe cold max str *
(Robitussin
Mucus-Chest
Congest)
(G-Zyncof)
(Robitussin
Mucus-Chest
Congest)
(Sudafed 12-Hour)
(Pseudoephedrine
HCl)
(Diphenhydram/Pe/
Dm/Acetamin/Gg)
(Dm/Pseudoephed/
Acetaminophen)
THERAFLU NIGHTTIME
SEVERE COLD *
THERAFLU SEVERE COLDCOUGH *
triacting m-sym cold/cough *
triaminic cold & cough (pe) *
triaminic cough-nasal congesti *
(D-Methorphan
Hb/P-Ephed
HCl/Cp)
(Dextromethorphan
/Phenylephrine)
(Robitussin
Pediatric)
TRIAMINIC COUGH-SORE
THROAT *
tri-dex pe *
trigofen dm *
trymine cg *
tusnel diabetic *
TUSNEL PEDIATRIC * ORAL
LIQUID
tussin cf cough-cold *
(Dm/Phenyleph/Ch
lorpheniramine)
(Accuhist Pdx)
(M-Clear Wc)
(G-Zyncof)
(Giltuss)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
4
$0
$0
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
96
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
(G-Zyncof)
4
$0
(G-Zyncof)
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
$0
$0
4
$0
4
$0
4
$0
4
$0
4
3
4
$0
$0
$0
Name of Drug
tussin cf * oral
tussin cold-congestion *
tussin cough (dm only) * oral
tussin dm cough & chest * oral
liquid 10-200 mg/5 ml
tussin dm max * oral liquid 10-100
mg/5 ml
tussin dm * oral syrup 15-100 mg/5
ml
tussin maximum strength cough *
tussin pe * oral liquid
valu-tapp dm *
vicks dayquil cough *
vicks nature fusion cough *
virdec dm *
wal-phed * oral tablet 30 mg
wal-phed pe day-night *
wal-tussin cough *
wal-tussin cough & cold cf *
wal-tussin dm *
zephrex-d *
ZONATUSS *
zyncof *
(Guaifenesin/Dm/P
seudoephedrine)
(Guaifenesin/Dm/P
seudoephedrine)
(Dextromethorphan
Hbr)
(Guaifenesin/Dextr
omethorphan)
(Dextromethorphan
Hbr)
(Despec)
(D-Methorphan
Hb/P-Epd
HCl/Bpm)
(Dextromethorphan
Hbr)
(Dextromethorphan
Hbr)
(Accuhist Pdx)
(Sudafed 12-Hour)
(Diphenhydram/Pe/
Dm/Acetamin/Gg)
(Dextromethorphan
Hbr)
(Giltuss)
(Guaifenesin/Dextr
omethorphan)
(Sudafed 12-Hour)
(G-Zyncof)
Necessary Actions,
Restrictions, or
Limits on Use
Dental And Oral Agents
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
97
Tier level
What the
drug will
cost you
(Evoxac)
1
$0
(Peridex)
1
$0
4
$0
1
3
$0
$0
1
$0
(Soriatane)
(Benzoyl Peroxide)
2
1
4
$0
$0
$0
(Benzoyl Peroxide)
4
$0
(Benzoyl Peroxide)
(Zovirax)
4
1
1
1
1
1
$0
$0
$0
$0
$0
$0
4
$0
4
$0
4
$0
1
$0
1
$0
2
$0
Name of Drug
Dental And Oral Agents
cevimeline
chlorhexidine gluconate mucous
membrane
PHOS-FLUR * DENTAL
SOLUTION
pilocarpine hcl oral
PREVIDENT 5000 SENSITIVE *
triamcinolone acetonide dental
paste 0.1 %
(Salagen)
(Triamcinolone
Acetonide)
Necessary Actions,
Restrictions, or
Limits on Use
Dermatological Agents
Dermatological Agents, Other
8-MOP
acitretin
acne medication * topical gel 10 %
acne medication * topical lotion 10
%
acne-clear *
acyclovir topical
ALCOHOL PADS
ALCOHOL PREP PADS
ALCOH-WIPE
aluminum chloride
amlactin * topical lotion
(Drysol)
(Lac-Hydrin
Twelve)
(Ammonium
Lactate)
(Lac-Hydrin
Twelve)
ammonium lactate * 12% cream
fragrance free (otc)
ammonium lactate * 12% lotion
(otc)
ammonium lactate topical cream 12
(Lac-Hydrin)
%
ammonium lactate topical lotion 12
(Lac-Hydrin)
%
ANACAINE
QL (30 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
98
Tier level
What the
drug will
cost you
(Benzoyl Peroxide)
4
$0
(Benzac Ac)
(Benzoyl Peroxide)
3
4
$0
$0
(Benzoyl Peroxide)
4
$0
(Calcipotriene)
(Dovonex)
(Calcipotriene)
(Vectical)
4
1
1
1
1
$0
$0
$0
$0
$0
4
$0
2
2
2
1
1
$0
$0
$0
$0
$0
4
$0
(Aldara)
1
$0
(Isotretinoin)
1
$0
4
4
1
1
2
4
2
2
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
Name of Drug
benzoyl peroxide * 10% gel
aqueous (otc)
benzoyl peroxide * topical gel 10 %
benzoyl peroxide * topical gel 5 %
benzoyl peroxide * topical lotion 5
%
BETADINE SPRAY *
calcipotriene
calcipotriene topical cream
calcipotriene topical solution
calcitriol topical
CASTELLANI PAINT MODIFIED
*
CONDYLOX TOPICAL GEL
COSENTYX PEN (2 PENS)
FLUOROPLEX
fluorouracil topical cream
fluorouracil topical solution
geri-hydrolac * topical
imiquimod
isotretinoin oral capsule 10 mg, 20
mg, 30 mg, 40 mg
LACTINOL HX *
lobana bath *
mafenide acetate
methoxsalen rapid
PANRETIN
persa-gel *
PICATO TOPICAL GEL 0.015 %
PICATO TOPICAL GEL 0.05 %
podofilox
(Carac)
(Fluorouracil)
(Lac-Hydrin
Twelve)
(Mineral Oil)
(Mafenide Acetate)
(Oxsoralen-Ultra)
(Benzoyl Peroxide)
(Condylox)
Necessary Actions,
Restrictions, or
Limits on Use
PA
PA NSO; QL (24 per
30 days)
QL (3 per 56 days)
QL (2 per 56 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
99
Name of Drug
podophyllum resin
potassium hydroxide
(Podophyllum
Resin)
(Potassium
Hydroxide)
SANTYL
silver nitrate applicators
skin treatment *
(Silver Nitrate
Applicator)
(Lac-Hydrin
Twelve)
VALCHLOR
zinc oxide * topical ointment
(Boudreauxs)
ZOVIRAX TOPICAL CREAM
Dermatological Antibacterials
bacitracin * topical
(Bacitracin)
bacitraycin plus * topical ointment
(Bacitracin)
500 unit/gram
clindamycin phosphate topical gel
(Cleocin T)
clindamycin phosphate topical
(Cleocin T)
lotion
clindamycin phosphate topical
(Cleocin T)
solution
clindamycin phosphate topical swab (Cleocin T)
(Erythromycin
erythromycin base-ethanol
Base/Ethanol)
erythromycin with ethanol topical
(Emgel)
gel
erythromycin with ethanol topical
(Erythromycin
solution
Base/Ethanol)
erythromycin with ethanol topical
(Erythromycin
swab
Base/Ethanol)
(Gentamicin
gentamicin topical
Sulfate)
metronidazole topical cream 0.75 % (Metrocream)
metronidazole topical
(Nydamax)
metronidazole topical
(Metrolotion)
Tier level
What the
drug will
cost you
1
$0
1
$0
2
$0
1
$0
4
$0
2
4
2
$0
$0
$0
4
$0
4
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
1
1
$0
$0
$0
Necessary Actions,
Restrictions, or
Limits on Use
QL (15 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
100
Name of Drug
mupirocin
mupirocin calcium
neomycin-polymyxin b gu
(Centany)
(Bactroban)
(Neosporin G.U.
Irrigant)
(Selenium Sulfide)
(Silver Nitrate)
selenium sulfide
silver nitrate topical
silver sulfadiazine topical cream 1
(Silvadene)
%
sulfacetamide sodium (acne)
(Klaron)
Dermatological Anti-Inflammatory Agents
alclometasone topical cream
(Aclovate)
(Alclometasone
alclometasone topical ointment
Dipropionate)
aquanil hc *
(Cortizone-10)
beta-hc *
(Cortizone-10)
betamethasone dipropionate topical
(Diprosone)
cream
betamethasone dipropionate topical (Betamethasone
lotion
Dipropionate)
betamethasone dipropionate topical (Betamethasone
ointment
Dipropionate)
betamethasone valerate topical
(Betamethasone
cream
Valerate)
betamethasone valerate topical
(Luxiq)
foam
betamethasone valerate topical
(Betamethasone
lotion
Valerate)
betamethasone valerate topical
(Betamethasone
ointment
Valerate)
betamethasone, augmented topical
(Diprolene AF)
cream
betamethasone, augmented topical (Betamethasone
gel
Dipropionate)
betamethasone, augmented topical
(Diprolene)
lotion
Tier level
What the
drug will
cost you
1
1
$0
$0
1
$0
1
1
$0
$0
1
$0
1
$0
1
$0
1
$0
4
4
$0
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
101
Name of Drug
betamethasone, augmented topical
ointment
clobetasol propionate topical
solution 0.05 %
clobetasol topical cream
clobetasol topical foam
clobetasol topical gel
clobetasol topical lotion
clobetasol topical ointment
clobetasol topical shampoo
clobetasol topical solution
clobetasol-emollient topical
clocortolone pivalate
CORDRAN TOPICAL
OINTMENT
cortizone-10 * topical cream
CORTIZONE-10 * TOPICAL
LOTION
cortizone-10 * topical ointment
dermarest eczema (hydrocort) *
desonide topical cream
desonide topical ointment
desoximetasone
ELIDEL
fluocinonide topical cream 0.05 %
fluocinonide topical gel
fluocinonide topical ointment
fluocinonide topical solution
fluocinonide-emollient base
fluticasone topical cream
fluticasone topical ointment
halobetasol propionate
(Diprolene)
(Clobetasol
Propionate)
(Temovate)
(Olux)
(Temovate)
(Clobex)
(Temovate)
(Clobex)
(Clobetasol
Propionate)
(Temovate)
(Cloderm)
(Hydrocortisone)
(Hydrocortisone)
(Cortizone-10)
(Desowen)
(Tridesilon)
(Topicort)
(Vanos)
(Fluocinonide)
(Fluocinonide)
(Fluocinonide)
(Vanos)
(Cutivate)
(Fluticasone
Propionate)
(Ultravate)
Tier level
What the
drug will
cost you
1
$0
1
$0
1
1
1
1
1
1
$0
$0
$0
$0
$0
$0
1
$0
1
1
$0
$0
2
$0
4
$0
4
$0
4
4
1
1
1
2
1
1
1
1
1
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
1
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA; (PA for Ages
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
102
Tier level
What the
drug will
cost you
(Cortizone-10)
4
$0
(Hydrocortisone)
4
$0
(Cortizone-10)
3
$0
(Hydrocortisone)
4
$0
(Nuzon)
1
$0
4
$0
1
$0
1
1
1
1
1
$0
$0
$0
$0
$0
(Hydrocortisone)
4
$0
(Anusol-HC)
1
$0
(Rederm)
3
$0
(Rederm)
1
$0
(Hydrocortisone)
4
$0
(Hydrocortisone)
1
$0
(Hydrocortisone
Valerate)
1
$0
(Westcort)
1
$0
(Elocon)
(Hydrocortisone)
(Dermatop)
1
4
1
$0
$0
$0
Name of Drug
hydro skin * topical
hydrocortisone * 1% cream
maximum strength (otc)
hydrocortisone * 1% lotion (otc)
hydrocortisone * 1% ointment
carton (otc)
hydrocortisone acet-aloe vera
topical gel
hydrocortisone acetate * topical
cream 1 %
hydrocortisone acetate-urea
hydrocortisone butyrate
hydrocortisone butyr-emollient
hydrocortisone rectal cream 1 %
hydrocortisone rectal cream 2.5 %
hydrocortisone rectal enema
hydrocortisone * topical cream 0.5
%
hydrocortisone topical cream 1 %,
2.5 %
hydrocortisone * topical lotion 1 %
hydrocortisone topical lotion 2 %,
2.5 %
hydrocortisone * topical ointment
0.5 %
hydrocortisone topical ointment 1
%, 2.5 %
hydrocortisone valerate topical
cream
hydrocortisone valerate topical
ointment
mometasone
neosporin anti-itch *
prednicarbate
(Hydrocortisone
Acetate)
(Hydrocortisone
Acetate/Urea)
(Locoid)
(Locoid)
(Anusol-HC)
(Hydrocortisone)
(Cortenema)
Necessary Actions,
Restrictions, or
Limits on Use
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
103
Tier level
What the
drug will
cost you
(Hydrocortisone)
(Hydrocortisone)
(Protopic)
(Triamcinolone
Acetonide)
4
4
1
$0
$0
$0
1
$0
(Kenalog)
1
$0
(Triderm)
1
$0
(Triamcinolone
Acetonide)
1
$0
1
1
2
1
1
$0
$0
$0
$0
$0
4
$0
4
$0
4
1
1
4
$0
$0
$0
$0
1
$0
1
$0
Name of Drug
preparation h hydrocortisone *
recort plus *
tacrolimus topical
triamcinolone acetonide topical
cream
triamcinolone acetonide topical
lotion
triamcinolone acetonide topical
ointment 0.025 %, 0.05 %, 0.1 %,
0.5 %
triderm topical cream
Dermatological Retinoids
adapalene topical cream
(Differin)
adapalene topical gel 0.1 %
(Differin)
TAZORAC TOPICAL CREAM
tretinoin microspheres
(Retin-A Micro)
tretinoin topical
(Retin-A)
Scabicides And Pediculicides
lice cream rinse *
(Nix)
(Piperonyl
lice killing *
Butoxide/Pyrethrin
s)
lice treatment * topical liquid 1 %
(Nix)
malathion
(Ovide)
permethrin topical cream
(Elimite)
permethrin * topical liquid
(Nix)
Necessary Actions,
Restrictions, or
Limits on Use
PA
PA
Devices
Devices
ASSURE ID INSULIN SAFETY
SYRINGE
BD INSULIN PEN NEEDLE UF
SHORT
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
104
Name of Drug
BD INSULIN SYRINGE ULTRAFINE SYRINGE 0.3 ML 31 X
5/16", 1 ML 31 X 5/16", 1/2 ML 31
X 5/16"
INSULIN PEN NEEDLE NEEDLE
INSULIN SYRINGE
NEEDLELESS
INSULIN SYRINGE SYRINGE
INSULIN SYRINGE-NEEDLE U100 SYRINGE
SURE COMFORT INS. SYR. U100
Tier level
What the
drug will
cost you
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
4
$0
2
2
$0
$0
2
$0
2
$0
2
$0
2
2
$0
$0
2
$0
2
$0
2
2
2
1
$0
$0
$0
$0
Necessary Actions,
Restrictions, or
Limits on Use
Disinfectants (For Non-Dermatologic Use)
Disinfectants (For Non-Dermatologic Use)
iodine *
(Iodine)
Enzyme Replacement/Modifiers
Enzyme Replacement/Modifiers
ADAGEN
ALDURAZYME
CEREZYME INTRAVENOUS
RECON SOLN 400 UNIT
CIMZIA
CIMZIA POWDER FOR
RECONST
CREON
ELAPRASE
ELITEK INTRAVENOUS RECON
SOLN
FABRAZYME INTRAVENOUS
RECON SOLN
KRYSTEXXA
KUVAN
LINZESS
lipase-protease-amylase
(Zenpep)
PA
PA
QL (30 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
105
Name of Drug
LOTRONEX
LUMIZYME
MYOZYME
NAGLAZYME
ORFADIN
PULMOZYME
VIMIZIM
VPRIV
ZAVESCA
ZENPEP
Tier level
What the
drug will
cost you
2
2
2
2
2
2
2
2
2
2
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
2
4
1
4
1
4
$0
$0
$0
$0
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
1
1
4
$0
$0
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA
QL (90 per 30 days)
Eye, Ear, Nose, Throat Agents
Eye, Ear, Nose, Throat Agents, Miscellaneous
AKTEN (PF)
alaway *
(Zaditor)
altacaine
(Tetcaine)
altamist *
(Little Remedies)
apraclonidine
(Iopidine)
artificial tears (petro/min) *
(Genteal Pm)
(Dextran
artificial tears (pf) * ophthalmic
70/Hypromellose/P
dropperette 0.1-0.3 %
F)
artificial tears * ophthalmic drops
(Tears Naturale)
0.1-0.3 %
artificial tears * ophthalmic drops (Polyvinyl
0.5-0.6 %
Alcohol/Povidone)
artificial tears * ophthalmic
(Petrolat,Wht/Min
ointment
Oil/Sod Chl)
(Glycerin/Propylen
artificial tears(glycerin-peg) *
e Glycol)
(Genteal Mild To
artificial tears(hypromellose) *
Moderate)
atropine ophthalmic drops
(Isopto Atropine)
atropine ophthalmic ointment
(Atropine Sulfate)
ayr saline * nasal aerosol,spray
(Little Remedies)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
106
Tier level
What the
drug will
cost you
4
1
1
$0
$0
$0
4
$0
1
$0
1
$0
2
$0
1
2
4
$0
$0
$0
4
$0
1
$0
4
$0
4
$0
4
4
4
$0
$0
$0
(Isopto
Homatropine)
1
$0
(Atrovent)
1
$0
(Atrovent)
1
$0
4
$0
4
2
$0
$0
Name of Drug
ayr saline * nasal drops
azelastine nasal
azelastine ophthalmic
bion tears (pf) *
carteolol
cromolyn ophthalmic
CYCLOGYL OPHTHALMIC
DROPS 0.5 %
cyclopentolate
CYSTARAN
deep sea nasal *
dristan long lasting *
epinastine
eq gentle *
(Sodium Chloride)
(Astepro)
(Optivar)
(Dextran
70/Hypromellose/P
F)
(Carteolol HCl)
(Cromolyn
Sodium)
(Cyclogyl)
(Little Remedies)
(Oxymetazoline
HCl)
(Elestat)
(Genteal Mild To
Moderate)
GENTEAL MILD TO
MODERATE *
GENTEAL GEL *
GENTEAL MILD *
GENTEAL SEVERE *
homatropine hbr
ipratropium bromide nasal
spray,non-aerosol 0.03 %
ipratropium bromide nasal
spray,non-aerosol 0.06 %
isopto tears *
ketotifen fumarate *
LACRISERT
(Genteal Mild To
Moderate)
(Zaditor)
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 25 days)
QL (30 per 28 days)
QL (15 per 10 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
107
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
(Refresh Tears)
4
$0
(Refresh Optive)
(Genteal Pm)
(Sodium Chloride)
(Naphazoline HCl)
(Afrin)
(Genteal Mild To
Moderate)
(Dextran
70/Hypromellose/P
F)
(Genteal Mild To
Moderate)
(Oxymetazoline
HCl)
(Petrolat,Wht/Min
Oil/Sod Chl)
(Little Remedies)
(Patanase)
4
4
4
1
4
$0
$0
$0
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
1
$0
$0
Name of Drug
liquitears *
lubricant dry eye relief *
lubricant eye (cmc-glycer)(pf) *
lubricant eye (cmc-glycerin) *
lubricant eye (pg-peg 400)(pf) *
lubricant eye (polyv alcohol) *
lubricant eye (propyl glycol) *
lubricant eye drops * ophthalmic
dropperette
lubricant eye drops * ophthalmic
drops
lubricating drops *
lubrifresh pm *
muro 128 *
naphazoline
nasal decongestant (oxymetazl) *
natural balance *
natural tears (pf) *
nature's tears *
neo-synephrine 12 h spr (oxym) *
nighttime relief eye *
ocean nasal *
olopatadine
(Polyvinyl
Alcohol)
(Carboxymethylcel
lulose Sodium)
(Carboxymethylcel
l/Glycerin/PF)
(Refresh Optive)
(Propylene
Glycol/Peg
400/PF)
(Polyvinyl
Alcohol)
(Propylene Glycol)
(Carboxymethylcel
lulose Sodium)
Necessary Actions,
Restrictions, or
Limits on Use
QL (30.5 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
108
Tier level
What the
drug will
cost you
(Mydfrin)
(Proparacaine HCl)
2
2
1
1
$0
$0
$0
$0
(Proparacaine HCl)
1
$0
1
$0
4
$0
4
4
4
4
$0
$0
$0
$0
4
$0
4
4
4
4
4
$0
$0
$0
$0
$0
4
$0
4
$0
4
1
$0
$0
4
$0
4
$0
4
4
4
$0
$0
$0
Name of Drug
PATADAY
PATANOL
phenylephrine hcl ophthalmic
proparacaine
proparacaine hcl ophthalmic drops
0.5 %
proparacaine-fluorescein sod
pure & gentle eye *
(Proparacaine/Fluo
rescein Sod)
(Genteal Mild To
Moderate)
REFRESH CLASSIC (PF) *
REFRESH LACRI-LUBE *
REFRESH LIQUIGEL *
REFRESH OPTIVE *
retaine cmc *
saline mist *
sea soft nasal mist *
sochlor * ophthalmic
sodium chloride * ophthalmic
STERILE LUBRICANT *
tears again * ophthalmic drops
tears again * ophthalmic ointment
TEARS NATURALE II *
tetracaine hcl
ultra fresh pm *
vicks qlearquil(oxymetazoline) *
vicks sinex 12-hour *
wal-zyr (ketotifen) *
zyrtec itchy eye drops (keto) *
(Carboxymethylcel
lulose Sodium)
(Little Remedies)
(Little Remedies)
(Sodium Chloride)
(Sodium Chloride)
(Polyvinyl
Alcohol)
(Lanolin/Min
Oil/Petrolat, Wht)
(Tetcaine)
(Lanolin/Min
Oil/Petrolat, Wht)
(Oxymetazoline
HCl)
(Afrin)
(Zaditor)
(Zaditor)
Necessary Actions,
Restrictions, or
Limits on Use
ST
ST
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
109
Name of Drug
Eye, Ear, Nose, Throat Anti-Infectives Agents
acetic acid otic
(Vosol)
bacitracin ophthalmic
(Bacitracin)
(Bacitracin/Polymy
bacitracin-polymyxin b ophthalmic
xin B Sulfate)
CIPRODEX
ciprofloxacin hcl ophthalmic
(Ciloxan)
ciprofloxacin hcl otic
(Cetraxal)
COLY-MYCIN S
erythromycin ophthalmic
(Ilotycin)
gatifloxacin
(Zymaxid)
gentamicin ophthalmic
(Garamycin)
gentamicin sulfate ophthalmic
(Garamycin)
ointment 0.3 % (3 mg/gram)
levofloxacin ophthalmic
(Quixin)
MOXEZA
NATACYN
(Neomy
neomy sulf-bacitrac zn-poly-hc
Sulf/Bacitrac
Zn/Poly/HC)
(Neomy
neomycin-bacitracin-poly-hc
Sulf/Bacitrac
Zn/Poly/HC)
(Neomy
neomycin-bacitracin-polymyxin
Sulf/Bacitra/Polym
yxin B)
neomycin-polymyxin b-dexameth
(Maxitrol)
neomycin-polymyxin-gramicidin
(Neosporin)
neomycin-polymyxin-hc
(Oticin HC)
ofloxacin ophthalmic
(Ocuflox)
ofloxacin otic
(Ocuflox)
polymyxin b sulf-trimethoprim
(Polytrim)
REFRESH OPTIVE ADVANCED
*
Tier level
What the
drug will
cost you
1
1
$0
$0
1
$0
2
1
1
2
1
1
1
$0
$0
$0
$0
$0
$0
$0
1
$0
1
2
2
$0
$0
$0
1
$0
1
$0
1
$0
1
1
1
1
1
1
$0
$0
$0
$0
$0
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
110
Name of Drug
sulfacetamide sodium
sulfacetamide sodium ophthalmic
drops 10 %
sulfacetamide-prednisolone
Tier level
What the
drug will
cost you
1
$0
1
$0
1
$0
2
1
1
2
2
$0
$0
$0
$0
$0
2
$0
1
$0
1
$0
1
$0
2
1
1
1
2
1
2
2
2
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
1
$0
2
2
$0
$0
(Sulfacetamide
Sodium)
(Sulfacetamide
Sodium)
(Sulfacetamide/Pre
dnisolone Sp)
TOBRADEX ST
tobramycin
(Tobrex)
trifluridine
(Viroptic)
VIGAMOX
ZYLET
Eye, Ear, Nose, Throat Anti-Inflammatory Agents
ALREX
(Bromfenac
bromfenac
Sodium)
dexamethasone sodium phosphate
(Dexasol)
ophthalmic
(Diclofenac
diclofenac sodium ophthalmic
Sodium)
DUREZOL
fluorometholone
(FML)
flurbiprofen sodium
(Ocufen)
fluticasone nasal
(Flonase)
ILEVRO
ketorolac ophthalmic
(Acular)
LOTEMAX
NASONEX
NEVANAC
prednisolone acetate
(Omnipred)
prednisolone sodium phosphate
(Prednisolone Sod
ophthalmic
Phosphate)
PROLENSA
RESTASIS
Necessary Actions,
Restrictions, or
Limits on Use
QL (16 per 30 days)
QL (34 per 28 days)
QL (60 per 30 days)
Gastrointestinal Agents
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
111
Name of Drug
Antiflatulents
anti-gas maximum strength *
(Gas-X)
bicarsim forte *
(Simethicone)
gas free extra strength *
(Gas-X)
gas relief 80 *
(Gas-X)
gas relief extra strength * oral
(Gas-X)
gas relief * oral
(Gas-X)
gas-x ultra-strength *
(Gas-X)
mi-acid gas relief *
(Gas-X)
mylanta gas *
(Gas-X)
mytab gas *
(Gas-X)
mytab gas maximum strength *
(Gas-X)
simethicone * oral capsule 180 mg (Gas-X)
simethicone * oral
(Infants' Mylicon)
Antiulcer Agents And Acid Suppressants
acid reducer (famotidine) *
(Pepcid Ac)
acid reducer (ranitidine) * oral
(Zantac)
tablet 150 mg
acid relief (cimetidine) *
(Tagamet Hb)
amoxicil-clarithromy-lansopraz
(Prevpac)
CARAFATE ORAL SUSPENSION
cimetidine hcl oral
(Cimetidine HCl)
cimetidine oral tablet 200 mg, 300
(Tagamet)
mg, 400 mg, 800 mg
cvs cimetidine * 200 mg tablet (otc) (Tagamet Hb)
esomeprazole sodium
(Nexium I.V.)
famotidine (pf)
(Famotidine/PF)
(Famotidine In
famotidine (pf)-nacl (iso-os)
Nacl,Iso-Osm/PF)
famotidine oral tablet 20 mg, 40 mg (Pepcid)
lansoprazole * dr 15 mg capsule
(Prevacid 24hr)
2x14 day course (otc)
lansoprazole oral capsule,delayed
(Prevacid)
release(dr/ec) 15 mg, 30 mg
Tier level
What the
drug will
cost you
4
4
4
4
4
4
4
4
4
4
4
4
4
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
4
$0
4
$0
4
1
2
1
$0
$0
$0
$0
1
$0
4
1
1
$0
$0
$0
1
$0
1
$0
4
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
(Rx Product Only)
(Rx Product Only)
(Rx Product Only)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
112
Tier level
What the
drug will
cost you
(Cytotec)
(Omeprazole
Magnesium)
1
$0
4
$0
(Prilosec)
1
$0
(Omeprazole)
4
$0
(Zegerid)
3
$0
1
$0
1
4
$0
$0
4
$0
4
$0
1
1
$0
$0
1
$0
4
1
1
4
4
$0
$0
$0
$0
$0
4
4
4
$0
$0
$0
4
$0
2
$0
Name of Drug
misoprostol
omeprazole magnesium *
omeprazole oral capsule,delayed
release(dr/ec)
omeprazole * oral tablet,delayed
release (dr/ec)
omeprazole-sodium bicarbonate
oral capsule 20-1.1 mg-gram
pantoprazole intravenous
(Pantoprazole
Sodium)
(Protonix)
pantoprazole oral
PRILOSEC OTC *
pub famotidine * 20 mg tablet max
(Pepcid Ac)
strength (otc)
ra omepraz-bicarb 20-1,100 cap
(Zegerid Otc)
3x14 day course (otc)
ranitidine hcl injection
(Zantac)
ranitidine hcl oral syrup
(Ranitidine HCl)
ranitidine hcl oral tablet 150 mg,
(Zantac)
300 mg
ranitidine hcl * oral tablet 75 mg
(Zantac)
sucralfate oral suspension
(Sucralfate)
sucralfate oral tablet
(Carafate)
wal-zan 75 *
(Zantac)
zantac 75 *
(Zantac)
Gastrointestinal Agents, Other
acid gone antacid *
(Gaviscon)
almacone * oral suspension
(Mylanta)
almacone-2 *
(Mylanta)
aluminum hydroxide gel * oral
(Alternagel)
suspension 320 mg/5 ml
AMITIZA
Necessary Actions,
Restrictions, or
Limits on Use
(Rx Product Only)
(Rx Product Only)
(Rx Product Only)
(Rx Product Only)
QL (60 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
113
Tier level
What the
drug will
cost you
(Calcium
Carbonate/Simethi
cone)
4
$0
(Tums)
4
$0
(Mylanta)
4
$0
(Pepto-Bismol)
4
$0
(Loperamide HCl)
4
$0
(Imodium A-D)
4
$0
(Pepto-Bismol)
4
$0
(Pepto-Bismol)
(Tums)
4
2
4
$0
$0
$0
(Tums)
4
$0
(Tums)
4
$0
4
$0
4
4
4
2
4
1
4
1
1
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
Name of Drug
antacid anti-gas * oral
antacid * oral tablet,chewable 200
mg calcium (500 mg)
antacid plus anti-gas * oral
suspension
anti-diarrheal *
anti-diarrheal (loperamide) * oral
capsule
anti-diarrheal (loperamide) * oral
bismatrol * oral suspension 262
mg/15 ml
bismatrol * oral tablet,chewable
BUPHENYL ORAL TABLET
calci-chew *
calcium antacid * oral
tablet,chewable
calcium carbonate * oral
tablet,chewable 500 mg calcium
(1,250 mg)
CALCIUM CARBONATEVITAMIN D3 * ORAL
TABLET,CHEWABLE 500-100
MG-UNIT
cal-gest antacid *
children's pepto *
children's soothe *
CHOLBAM
comfort gel extra strength *
cromolyn oral
diamode *
dicyclomine oral capsule
dicyclomine oral solution
dicyclomine oral tablet
(Tums)
(Tums)
(Tums)
(Mylanta)
(Gastrocrom)
(Imodium A-D)
(Bentyl)
(Dicyclomine HCl)
(Bentyl)
Necessary Actions,
Restrictions, or
Limits on Use
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
114
Tier level
What the
drug will
cost you
1
$0
1
4
4
$0
$0
$0
(Mylanta)
4
$0
(Almacone)
4
$0
(Robinul)
(Robinul)
(Loperamide HCl)
1
1
4
4
4
1
1
4
4
4
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
(Uromag)
4
$0
(Magox 400)
4
$0
(Mylanta)
(Pamine)
(Reglan)
(Metoclopramide
HCl)
(Reglan)
(Mylanta)
(Calcium
Carb/Magnesium
Hydrox)
(Mylanta)
4
1
1
$0
$0
$0
1
$0
1
4
$0
$0
4
$0
4
$0
Name of Drug
diphenoxylate-atropine oral liquid
diphenoxylate-atropine oral tablet
flanax antacid *
foaming antacid *
gelusil antacid & anti-gas * oral
suspension
gelusil antacid & anti-gas * oral
tablet,chewable
glycopyrrolate
glycopyrrolate
imodium a-d * oral liquid
IMODIUM A-D * ORAL TABLET
kaopectate (bismuth subsalicy) *
lactulose
loperamide oral
loperamide * oral
maalox advanced * oral suspension
MAGNEBIND 300 *
magnesium oxide * oral capsule
500 mg
magnesium oxide * oral tablet 250
mg, 400 mg, 500 mg
masanti double strength *
methscopolamine oral
metoclopramide hcl injection
metoclopramide hcl oral
metoclopramide hcl oral
mi-acid * oral suspension
mi-acid * oral tablet,chewable
mintox *
(Diphenoxylate
HCl/Atropine)
(Lomotil)
(Mylanta)
(Gaviscon)
(Pepto-Bismol)
(Lactulose)
(Loperamide HCl)
(Loperamide HCl)
(Mylanta)
Necessary Actions,
Restrictions, or
Limits on Use
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
115
Tier level
What the
drug will
cost you
4
4
2
2
4
4
$0
$0
$0
$0
$0
$0
RELISTOR SUBCUTANEOUS
2
$0
RELISTOR SUBCUTANEOUS
2
$0
(Mylanta)
(Mylanta)
(Sodium
Bicarbonate)
(Bismuth
Subsalicylate)
(Pepto-Bismol)
(Bismuth
Subsalicylate)
(Tums)
(Actigall)
(Urso)
4
4
$0
$0
4
$0
4
$0
4
$0
4
$0
4
1
1
$0
$0
$0
(Dulcolax)
(Dulcolax)
(Dulcolax)
(Dulcolax)
(Dulcolax)
(Miralax)
(Sof-Lax)
(Sof-Lax)
(Docusate Sodium)
(Surfak)
(Docusate Sodium)
4
4
4
4
4
4
4
4
4
4
4
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
Name of Drug
mintox maximum strength *
mintox plus *
MOVANTIK
NUTRESTORE
pep-t-med *
phillips *
ri-gel ii *
ri-mox *
sodium bicarbonate * oral tablet
650 mg
soothe (bismuth subsalicylate) *
oral
soothe regular strength *
stomach relief * oral
ultra strength antacid *
ursodiol oral capsule
ursodiol oral tablet
Laxatives
alophen *
bisac-evac *
bisacodyl * oral
bisacodyl * rectal
biscolax *
clearlax * oral
colace * oral capsule 100 mg
doc-q-lace * oral
docu *
docusate calcium *
docusate sodium * oral
(Mylanta)
(Almacone)
(Pepto-Bismol)
(Magox 400)
Necessary Actions,
Restrictions, or
Limits on Use
QL (30 per 30 days)
PA; QL (28 per 28
days)
PA; QL (28 per 28
days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
116
Tier level
What the
drug will
cost you
(Docusate Sodium)
(Sof-Lax)
(Docusate Sodium)
(Sof-Lax)
(Enema)
4
4
4
4
4
$0
$0
$0
$0
$0
(Enema)
4
$0
(Docusate Sodium)
4
$0
(Docusol Plus)
4
$0
4
$0
4
4
4
$0
$0
$0
4
$0
(Citrucel)
4
$0
(Citrucel)
(Fibercon)
(Miralax)
(Miralax)
(Miralax)
(Psyllium Seed)
(Metamucil)
(Fibercon)
4
4
4
4
3
4
4
4
4
$0
$0
$0
$0
$0
$0
$0
$0
$0
(Psyllium Husk)
4
$0
(Miralax)
(Milk Of
Magnesia)
4
$0
4
$0
Name of Drug
docusol *
dok * oral capsule
dok * oral tablet
dulcolax stool softener (dss) *
enema disposable *
enema * rectal enema * 19-7
gram/118 ml
enemeez * rectal enema 283 mg/5
ml
enemeez * rectal enema 283-20
mg/5 ml
equalactin *
fiber (calcium polycarbophil) *
fiber laxative * oral tablet
fiber smooth *
fiber therapy (psyllium/sugar) *
fiber therapy * oral powder 2
gram/19 gram
fiber therapy * oral tablet
fiber-lax *
FLEET BISACODYL *
gentlelax *
glycolax * oral powder
healthylax *
hydrocil instant *
konsyl (sugar) * oral
konsyl fiber *
konsyl sugar-free * oral powder in
packet
laxative peg 3350 *
milk of magnesia *
(Calcium
Polycarbophil)
(Fibercon)
(Citrucel)
(Psyllium Seed)
(Psyllium Seed
(With Sugar))
Necessary Actions,
Restrictions, or
Limits on Use
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
117
Name of Drug
mineral oil laxative *
MOVIPREP
natural fiber laxative therapy *
oral saline laxative * oral
peg 3350-electrolytes
PEG 3350-GRX
peg 3350-na sulf,bicarb,cl-kcl
peg3350 *
peg-electrolyte soln
peri-colace *
phillips liqui-gels *
phosphate laxative * oral
polyethylene glycol 3350 oral
powder
polyethylene glycol 3350 * oral
powder in packet
promolaxin *
purelax *
(Mineral Oil)
(Psyllium Seed
(With Sugar))
(Na Phos,M-B/Na
Phos,Di-Ba)
(Golytely)
(Golytely)
(Miralax)
(Nulytely with
Flavor Packs)
(Sennosides/Docus
ate Sodium)
(Sof-Lax)
(Na Phos,M-B/Na
Phos,Di-Ba)
(Polyethylene
Glycol 3350)
(Miralax)
Tier level
What the
drug will
cost you
4
2
$0
$0
4
$0
4
$0
1
1
1
4
$0
$0
$0
$0
1
$0
4
$0
4
$0
4
$0
1
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
(Docusate Sodium)
4
$0
(Miralax)
4
$0
(Psyllium Seed
reguloid * oral powder
4
$0
(With Sugar))
senexon * oral syrup
(Sennosides)
4
$0
senexon * oral tablet
(Senokot)
4
$0
senna lax *
(Senokot)
4
$0
senna * oral capsule
(Sennosides)
4
$0
senna * oral syrup 8.8 mg/5 ml
(Sennosides)
4
$0
senna * oral tablet
(Senokot)
4
$0
(Sennosides/Docus
senna with docusate sodium *
4
$0
ate Sodium)
(Sennosides/Docus
senokot-s *
4
$0
ate Sodium)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
118
Tier level
What the
drug will
cost you
(Docusate Sodium)
(Colace)
(Miralax)
(Nulytely with
Flavor Packs)
(Dulcolax)
4
4
4
$0
$0
$0
1
$0
4
$0
(Phoslo)
(Calcium Acetate)
(Calcium
Carbonate/Mag
Carb/Fa)
(Calcium Acetate)
1
1
$0
$0
1
$0
4
2
2
2
$0
$0
$0
$0
1
$0
1
$0
1
$0
1
$0
Name of Drug
silace * oral liquid
silace * oral syrup
smoothlax * oral
sodium chloride-nahco3-kcl-peg
oral recon soln 420 gram
the magic bullet *
Phosphate Binders
calcium acetate oral capsule
calcium acetate oral tablet
calcium carbonate-mag carb-fa
calphron *
PHOSLYRA
RENAGEL
RENVELA
sodium polystyrene sulfonate oral
powder
sodium polystyrene sulfonate oral
suspension 15 gram/60 ml
sodium polystyrene sulfonate rectal
enema 30 gram/120 ml
(Sodium
Polystyrene
Sulfonate)
(Sodium
Polystyrene
Sulfonate)
(Sodium
Polystyrene
Sulfonate)
Necessary Actions,
Restrictions, or
Limits on Use
Genitourinary Agents
Antispasmodics, Urinary
oxybutynin chloride oral tablet
(Oxybutynin
Chloride)
oxybutynin chloride oral tablet
(Ditropan XL)
1
$0
extended release 24hr
tolterodine oral capsule,extended
(Detrol LA)
1
$0
release 24hr
tolterodine oral tablet
(Detrol)
1
$0
TOVIAZ
2
$0
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
119
Name of Drug
trospium oral capsule,extended
(Sanctura XR)
release 24hr
trospium oral tablet
(Sanctura)
Genitourinary Agents, Miscellaneous
alfuzosin
(Uroxatral)
tamsulosin
(Flomax)
terazosin
(Terazosin HCl)
Tier level
What the
drug will
cost you
1
$0
1
$0
1
1
1
$0
$0
$0
1
2
2
2
$0
$0
$0
$0
1
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
Heavy Metal Antagonists
Heavy Metal Antagonists
deferoxamine injection recon soln
(Desferal)
DEPEN TITRATABS
EXJADE
FERRIPROX
sodium thiosulfate intravenous
(Sodium
solution 1 gram/10 ml (100 mg/ml),
Thiosulfate)
12.5 gram/50 ml (250 mg/ml)
SYPRINE
PA BvD
Hormonal Agents, Stimulant/Replacement/Modifying
Androgens
ANDRODERM
2
$0
PA; QL (30 per 30
days)
PA; QL (300 per 30
days)
ANDROGEL TRANSDERMAL
GEL IN METERED-DOSE PUMP
2
$0
1.25 GRAM/ ACTUATION (1 %)
ANDROGEL TRANSDERMAL
PA; QL (150 per 30
GEL IN METERED-DOSE PUMP
2
$0
days)
20.25 MG/1.25 GRAM (1.62 %)
ANDROGEL TRANSDERMAL
PA; QL (300 per 30
GEL IN PACKET 1 % (25
days)
2
$0
MG/2.5GRAM), 1 % (50 MG/5
GRAM)
ANDROGEL TRANSDERMAL
PA; QL (150 per 30
GEL IN PACKET 1.62 % (20.25
days)
2
$0
MG/1.25 GRAM), 1.62 % (40.5
MG/2.5 GRAM)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
120
Tier level
What the
drug will
cost you
1
1
1
$0
$0
$0
1
$0
testosterone enanthate
testosterone transdermal gel in
(Androgel)
packet 1 % (25 mg/2.5gram)
Estrogens And Antiestrogens
1
$0
1
$0
COMBIPATCH
2
$0
DUAVEE
ESTRACE VAGINAL
estradiol oral
estradiol transdermal patch
semiweekly
(Estrace)
2
2
1
$0
$0
$0
(Vivelle-Dot)
1
$0
estradiol transdermal patch weekly
(Climara)
1
$0
estradiol valerate
estradiol/norethindrone acet
estradiol-norethindrone acet
(Delestrogen)
(Activella)
(Activella)
1
1
1
$0
$0
$0
2
$0
(Ogen)
1
2
2
$0
$0
$0
(Femhrt)
1
$0
(Evista)
2
2
2
2
2
1
$0
$0
$0
$0
$0
$0
Name of Drug
danazol oral
fluoxymesterone
oxandrolone
testosterone cypionate
(Danazol)
(Fluoxymesterone)
(Oxandrin)
(DepoTestosterone)
(Delatestryl)
ESTRASORB
estropipate
FEMRING
MENEST
norethindrone ac-eth estradiol oral
tablet 1-5 mg-mcg
PREMARIN INJECTION
PREMARIN ORAL
PREMARIN VAGINAL
PREMPHASE
PREMPRO
raloxifene
Necessary Actions,
Restrictions, or
Limits on Use
PA
PA; QL (5 per 28 days)
PA; QL (150 per 30
days)
PA-HRM; QL (8 per 28
days)
PA-HRM
PA-HRM
PA-HRM; QL (8 per 28
days)
PA-HRM; QL (4 per 28
days)
PA-HRM
PA-HRM
PA-HRM; QL (97.44
per 28 days)
PA-HRM
QL (1 per 84 days)
PA-HRM
PA-HRM
PA-HRM
PA-HRM
PA-HRM
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
121
Name of Drug
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
VAGIFEM
2
$0
QL (18 per 28 days)
Glucocorticoids/Mineralocorticoids
betamethasone acet,sod phos
(Celestone)
1
$0
PA BvD
cortisone
(Cortisone Acetate)
1
$0
PA BvD
dexamethasone oral
(Dexamethasone)
1
$0
PA BvD
dexamethasone oral
(Dexamethasone)
1
$0
PA BvD
dexamethasone sodium phosphate
(Dexamethasone
PA BvD
1
$0
injection
Sod Phosphate)
(Fludrocortisone
fludrocortisone
1
$0
Acetate)
hydrocortisone oral
(Cortef)
1
$0
PA BvD
(Hydrocortisone
PA BvD
hydrocortisone sod succinate
1
$0
Sod Succinate)
methylprednisolone
(Medrol)
1
$0
PA BvD
methylprednisolone acetate
(Depo-Medrol)
1
$0
PA BvD
methylprednisolone sodium succ
PA BvD
(A-Methapred)
1
$0
injection recon soln 125 mg, 40 mg
methylprednisolone sodium succ
PA BvD
(A-Methapred)
1
$0
intravenous
prednisolone sodium phosphate
PA BvD
(Orapred)
1
$0
oral solution
prednisone
(Prednisone)
1
$0
PA BvD
SOLU-CORTEF (PF) INJECTION
PA BvD
2
$0
RECON SOLN 100 MG/2 ML
(Triamcinolone
triamcinolone acetonide injection
1
$0
Acetonide)
Pituitary
(Desmopressin
desmopressin injection
1
$0
Acetate)
desmopressin nasal
(DDAVP)
1
$0
QL (15 per 30 days)
(Desmopressin
QL (15 per 30 days)
desmopressin nasal
1
$0
Acetate)
desmopressin oral
(DDAVP)
1
$0
GENOTROPIN
2
$0
PA
GENOTROPIN MINIQUICK
2
$0
PA
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
122
Name of Drug
HUMATROPE
INCRELEX
NORDITROPIN FLEXPRO
SUBCUTANEOUS PEN
INJECTOR 10 MG/1.5 ML (6.7
MG/ML), 15 MG/1.5 ML (10
MG/ML), 5 MG/1.5 ML (3.3
MG/ML)
NORDITROPIN NORDIFLEX
NUTROPIN AQ NUSPIN
NUTROPIN AQ
SUBCUTANEOUS
NUTROPIN SUBCUTANEOUS
RECON SOLN 10 MG
octreotide acetate injection solution
1,000 mcg/ml, 100 mcg/ml, 200
(Sandostatin)
mcg/ml, 500 mcg/ml
octreotide acetate injection solution (Octreotide
50 mcg/ml
Acetate)
(Octreotide
octreotide acetate injection syringe
Acetate)
OMNITROPE
PREGNYL
SAIZEN
SAIZEN CLICK.EASY
SANDOSTATIN LAR DEPOT
INTRAMUSCULAR KIT
SEROSTIM SUBCUTANEOUS
RECON SOLN 4 MG, 5 MG, 6
MG
SOMATULINE DEPOT
SOMAVERT
SUPPRELIN LA
TEV-TROPIN
vasopressin
(Pitressin)
Tier level
What the
drug will
cost you
2
2
$0
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA
PA
2
$0
2
2
$0
$0
2
$0
2
$0
1
$0
1
$0
1
$0
2
2
2
2
$0
$0
$0
$0
2
$0
2
$0
2
2
2
2
1
$0
$0
$0
$0
$0
PA
PA
PA
PA
PA
PA
PA
PA
QL (1 per 28 days)
QL (1 per 360 days)
PA
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
123
Tier level
What the
drug will
cost you
2
$0
1
$0
1
$0
1
1
1
1
$0
$0
$0
$0
1
$0
1
1
$0
$0
1
$0
1
$0
Immunological Agents
ARCALYST
ASTAGRAF XL
2
2
$0
$0
AUBAGIO
2
$0
1
$0
1
$0
Name of Drug
Progestins
DEPO-PROVERA
INTRAMUSCULAR SOLUTION
medroxyprogesterone
(Depo-Provera)
intramuscular suspension
medroxyprogesterone
(Medroxyprogester
intramuscular syringe
one Acetate)
medroxyprogesterone oral
(Provera)
norethindrone acetate
(Aygestin)
progesterone
(Progesterone)
progesterone micronized
(Prometrium)
Thyroid And Antithyroid Agents
(Levothyroxine
levothyroxine intravenous
Sodium)
levothyroxine oral
(Levoxyl)
liothyronine oral
(Cytomel)
methimazole oral tablet 10 mg, 5
(Tapazole)
mg
propylthiouracil
(Propylthiouracil)
Necessary Actions,
Restrictions, or
Limits on Use
QL (10 per 28 days)
QL (1 per 84 days)
QL (1 per 84 days)
Immunological Agents
azathioprine
azathioprine sodium
CARIMUNE NF
NANOFILTERED
INTRAVENOUS RECON SOLN
CELLCEPT INTRAVENOUS
cyclosporine intravenous
cyclosporine modified
(Imuran)
(Azathioprine
Sodium)
PA BvD
PA; QL (28 per 28
days)
PA BvD
PA BvD
PA BvD
(Sandimmune)
(Neoral)
2
$0
2
1
1
$0
$0
$0
PA BvD
PA BvD
PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
124
Name of Drug
cyclosporine oral capsule
cyclosporine, modified
ENBREL
ENBREL SURECLICK
FLEBOGAMMA DIF
GAMASTAN S/D
GAMMAGARD LIQUID
GAMMAPLEX
GAMUNEX-C INJECTION
SOLUTION
HUMIRA
HUMIRA CROHN'S DIS START
PCK
HUMIRA PEN
HYPERRAB S/D (PF)
HYQVIA
ILARIS (PF)
IMOGAM RABIES-HT (PF)
(Sandimmune)
(Neoral)
KINERET
leflunomide
mycophenolate mofetil
mycophenolate sodium
NULOJIX
OCTAGAM
ORENCIA
ORENCIA (WITH MALTOSE)
PRIVIGEN
PROGRAF INTRAVENOUS
RAPAMUNE ORAL SOLUTION
RAPAMUNE ORAL TABLET 1
MG, 2 MG
RIDAURA
sirolimus
(Arava)
(Cellcept)
(Myfortic)
(Rapamune)
Tier level
What the
drug will
cost you
1
1
2
2
2
2
2
2
$0
$0
$0
$0
$0
$0
$0
$0
2
$0
2
$0
2
$0
2
2
2
2
2
$0
$0
$0
$0
$0
2
$0
1
1
1
2
2
2
2
2
2
2
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
2
$0
2
1
$0
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA BvD
PA
PA
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA
PA
PA
PA BvD
PA
PA; QL (18.76 per 28
days)
PA BvD
PA BvD
PA BvD
PA BvD
PA; QL (4 per 28 days)
PA
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
125
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
1
$0
TYSABRI
2
$0
ZORTRESS
2
$0
PA BvD
PA; LA; QL (15 per 28
days)
PA BvD; QL (120 per
30 days)
Name of Drug
tacrolimus oral
(Hecoria)
Vaccines
ACTHIB (PF)
2
$0
ADACEL(TDAP
2
$0
ADOLESN/ADULT)(PF)
BCG VACCINE, LIVE (PF)
2
$0
PA BvD
BEXSERO (PF)
2
$0
BOOSTRIX TDAP
2
$0
CERVARIX VACCINE (PF)
2
$0
COMVAX (PF)
2
$0
DAPTACEL (DTAP PEDIATRIC)
2
$0
(PF)
ENGERIX-B (PF)
2
$0
PA BvD
ENGERIX-B PEDIATRIC (PF)
2
$0
PA BvD
GARDASIL (PF)
2
$0
GARDASIL 9 (PF)
2
$0
HAVRIX (PF)
INTRAMUSCULAR
2
$0
SUSPENSION
HAVRIX (PF)
2
$0
INTRAMUSCULAR SYRINGE
IMOVAX RABIES VACCINE
PA BvD
2
$0
(PF)
INFANRIX (DTAP) (PF)
2
$0
INTRAMUSCULAR
IPOL
2
$0
IXIARO (PF)
2
$0
KINRIX (PF)
2
$0
MENACTRA (PF)
2
$0
INTRAMUSCULAR SOLUTION
MENHIBRIX (PF)
2
$0
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
126
Name of Drug
MENOMUNE - A/C/Y/W-135 (PF)
MENVEO A-C-Y-W-135-DIP (PF)
MENVEO MENA COMPONENT
(PF)
MENVEO MENCYW-135
COMPNT (PF)
M-M-R II (PF)
PEDIARIX (PF)
PEDVAX HIB (PF)
PENTACEL (PF)
PENTACEL ACTHIB
COMPONENT (PF)
PENTACEL DTAP-IPV COMPNT
(PF)
PROQUAD (PF)
QUADRACEL (PF)
RABAVERT (PF)
RECOMBIVAX HB (PF)
ROTARIX
ROTATEQ VACCINE
TENIVAC (PF)
INTRAMUSCULAR
TETANUS TOXOID,ADSORBED
(PF)
TETANUS,DIPHTHERIA TOX
PED(PF)
TETANUS-DIPHTHERIA
TOXOIDS-TD
TICE BCG
TRUMENBA
TWINRIX (PF)
TYPHIM VI INTRAMUSCULAR
VAQTA (PF)
VARIVAX (PF)
Tier level
What the
drug will
cost you
2
2
$0
$0
2
$0
2
$0
2
2
2
2
$0
$0
$0
$0
2
$0
2
$0
2
2
2
2
2
2
$0
$0
$0
$0
$0
$0
2
$0
2
$0
2
$0
2
$0
2
2
2
2
2
2
$0
$0
$0
$0
$0
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
PA BvD
PA BvD
PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
127
Name of Drug
YF-VAX (PF)
ZOSTAVAX (PF)
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
2
2
$0
$0
QL (1 per 365 days)
2
2
1
1
2
2
$0
$0
$0
$0
$0
$0
ST
1
1
$0
$0
2
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
Inflammatory Bowel Disease Agents
Inflammatory Bowel Disease Agents
APRISO
ASACOL HD
balsalazide
(Colazal)
budesonide oral
(Entocort EC)
DELZICOL
DIPENTUM
Irrigating Solutions
Irrigating Solutions
acetic acid irrigation
GLYCINE IRRIGATION
LACTATED RINGERS
IRRIGATION
ringers irrigation
sodium chloride irrigation
sorbitol irrigation
sorbitol-mannitol
water for irrigation, sterile
(Acetic Acid)
(Tis-U-Sol)
(Sodium Chloride
Irrig Solution)
(Sorbitol Solution)
(Mannitol/Sorbitol
Solution)
(Water For
Irrigation,Sterile)
Metabolic Bone Disease Agents
Metabolic Bone Disease Agents
(Alendronate
alendronate oral solution
Sodium)
alendronate oral tablet 10 mg, 40
(Fosamax)
mg, 5 mg
alendronate oral tablet 35 mg, 70
(Fosamax)
mg
calcitonin (salmon)
(Miacalcin)
QL (300 per 28 days)
QL (4 per 28 days)
QL (3.7 per 28 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
128
Name of Drug
Tier level
What the
drug will
cost you
calcitriol intravenous solution 1
mcg/ml
(Calcitriol)
1
$0
calcitriol oral
(Rocaltrol)
1
$0
doxercalciferol intravenous
(Doxercalciferol)
1
$0
doxercalciferol oral
(Hectorol)
1
$0
etidronate disodium
(Etidronate
Disodium)
1
$0
FORTEO
2
$0
FORTICAL
2
$0
ibandronate intravenous solution
(Ibandronate
Sodium)
1
$0
ibandronate oral
(Boniva)
1
$0
MIACALCIN INJECTION
2
$0
NATPARA
2
$0
(Zemplar)
1
$0
(Actonel)
2
1
$0
$0
XGEVA
2
$0
ZEMPLAR INTRAVENOUS
2
$0
(Zometa)
(Zoledronic
Acid/Mannitol and
Water)
1
$0
1
$0
(Reclast)
1
$0
paricalcitol oral
PROLIA
risedronate oral tablet 150 mg
zoledronic acid intravenous
zoledronic acid-mannitol-water
intravenous piggyback
zoledronic acid-mannitol-water
intravenous solution
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD; (PA for
ESRD Only)
PA BvD; (PA for
ESRD Only)
PA BvD; (PA for
ESRD Only)
PA BvD; (PA for
ESRD Only)
PA; QL (2.4 per 28
days)
QL (3.7 per 28 days)
PA BvD; (PA for
ESRD Only); QL (3 per
84 days)
QL (1 per 28 days)
PA BvD; (PA for
ESRD Only)
PA; QL (2 per 28 days)
PA BvD; (PA for
ESRD Only)
QL (1 per 180 days)
QL (1 per 28 days)
PA; QL (1.7 per 28
days)
PA BvD; (PA for
ESRD Only)
QL (100 per 300 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
129
Tier level
What the
drug will
cost you
2
$0
2
$0
ACTEMRA SUBCUTANEOUS
2
$0
ACTIMMUNE
allopurinol
amifostine crystalline
2
1
1
$0
$0
$0
1
$0
2
2
2
2
$0
$0
$0
$0
2
$0
2
1
$0
$0
2
$0
2
$0
1
2
1
$0
$0
$0
1
$0
2
$0
2
$0
Name of Drug
ZOMETA INTRAVENOUS
SOLUTION 4 MG/100 ML
Necessary Actions,
Restrictions, or
Limits on Use
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
ACTEMRA INTRAVENOUS
SOLUTION
anticoag citrate phos dextrose
AVODART
AVONEX (WITH ALBUMIN)
AVONEX INTRAMUSCULAR
AVONEX INTRAMUSCULAR
BENLYSTA INTRAVENOUS
RECON SOLN
BETASERON SUBCUTANEOUS
bethanechol chloride
BOTOX INJECTION RECON
SOLN 100 UNIT
BOTOX INJECTION RECON
SOLN 200 UNIT
buspirone
CERDELGA
colchicine oral tablet
colchicine-probenecid
(Zyloprim)
(Ethyol)
(Citrate Phosphate
Dextros Soln)
(Urecholine)
(Vanspar)
(Colcrys)
(Colchicine/Proben
ecid)
COLCRYS
COPAXONE SUBCUTANEOUS
SYRINGE
PA; QL (40 per 30
days)
PA; QL (3.6 per 28
days)
ST
ST
ST
PA
ST
PA; QL (4 per 90 days)
PA; QL (1 per 90 days)
PA
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
130
Tier level
What the
drug will
cost you
1
$0
(Acetic Acid)
(Droperidol)
2
4
1
2
$0
$0
$0
$0
(Ergoloid
Mesylates)
1
$0
(Acetic Acid)
(Acetic Acid)
(Proscar)
(Fomepizole)
2
4
4
1
1
2
$0
$0
$0
$0
$0
$0
GILENYA
2
$0
GLUCAGEN HYPOKIT
GLUCAGON EMERGENCY KIT
(HUMAN)
guanidine
hydroxyzine hcl intramuscular
hydroxyzine hcl oral syrup 10 mg/5
ml
hydroxyzine hcl oral tablet
hydroxyzine pamoate
JALYN
2
$0
2
$0
(Guanidine HCl)
(Hydroxyzine HCl)
1
1
$0
$0
(Hydroxyzine HCl)
1
$0
(Hydroxyzine HCl)
(Vistaril)
1
1
2
$0
$0
$0
2
$0
1
$0
1
$0
1
$0
Name of Drug
CURITY GAUZE TOPICAL
BANDAGE 2 X 2 "
CYSTADANE
douche vinegar & water extra *
droperidol injection solution
ELMIRON
ergoloid
EXTAVIA SUBCUTANEOUS
extra cleansing douche *
feminine care douche *
finasteride oral tablet 5 mg
fomepizole
FUSILEV
LEMTRADA
leucovorin calcium injection recon
soln 100 mg, 200 mg, 350 mg
leucovorin calcium oral
levocarnitine (with sugar)
(Leucovorin
Calcium)
(Leucovorin
Calcium)
(Levocarnitine
(With Sugar))
Necessary Actions,
Restrictions, or
Limits on Use
ST
PA; QL (28 per 28
days)
PA-HRM
PA-HRM
PA-HRM
PA-HRM
QL (30 per 30 days)
PA; QL (9.6 per 365
days)
PA BvD; (PA for
ESRD Only)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
131
Tier level
What the
drug will
cost you
1
$0
1
$0
1
2
2
2
4
4
$0
$0
$0
$0
$0
$0
1
$0
OTEZLA
2
$0
OTEZLA STARTER
2
$0
2
$0
2
$0
1
2
1
2
2
2
2
2
$0
$0
$0
$0
$0
$0
$0
$0
2
$0
2
$0
2
$0
Name of Drug
levocarnitine oral
levoleucovorin calcium
mesna
MESNEX ORAL
MESTINON ORAL SYRUP
MESTINON TIMESPAN
MINERAL OIL *
mineral oil light *
morrhuate sodium
PLEGRIDY SUBCUTANEOUS
PEN INJECTOR
PLEGRIDY SUBCUTANEOUS
SYRINGE 125 MCG/0.5 ML
probenecid
PROCYSBI
pyridostigmine bromide
REBIF (WITH ALBUMIN)
REBIF REBIDOSE
REBIF TITRATION PACK
REMICADE
SENSIPAR
(Carnitor)
(Levoleucovorin
Calcium)
(Mesnex)
(Mineral Oil)
(Sodium
Morrhuate)
(Probenecid)
(Mestinon)
SIMPONI ARIA
SIMPONI SUBCUTANEOUS PEN
INJECTOR 100 MG/ML
SIMPONI SUBCUTANEOUS PEN
INJECTOR 50 MG/0.5 ML
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD; (PA for
ESRD Only)
PA; QL (60 per 30
days)
PA; QL (60 per 30
days)
ST
ST
PA
PA; QL (12 per 28
days)
PA; QL (3 per 28 days)
PA; QL (0.5 per 28
days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
132
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
2
$0
1
$0
(Acetic Acid)
4
$0
(Acetic Acid)
4
4
2
$0
$0
$0
2
$0
Name of Drug
SIMPONI SUBCUTANEOUS
SYRINGE 100 MG/ML
SIMPONI SUBCUTANEOUS
SYRINGE 50 MG/0.5 ML
SOLIRIS
STELARA SUBCUTANEOUS
SYRINGE
STERILE PADS TOPICAL
BANDAGE 2 X 2 "
summer's eve disposable douche *
vaginal solution
summers eve extra cleansing *
SUSPENDOL-S *
SYNAREL
TECFIDERA ORAL
CAPSULE,DELAYED
RELEASE(DR/EC) 120 MG
TECFIDERA ORAL
CAPSULE,DELAYED
RELEASE(DR/EC) 120 MG (14)240 MG (46), 240 MG
2
$0
THALOMID
2
$0
TYBOST
2
$0
ULORIC
2
$0
XELJANZ
2
$0
(Diamox Sequels)
1
$0
(Acetazolamide)
(Acetazolamide
Sodium)
1
$0
1
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA; QL (3 per 28 days)
PA; QL (0.5 per 28
days)
PA
PA; QL (14 per 30
days)
PA; QL (60 per 30
days)
PA NSO; QL (60 per
30 days)
QL (30 per 30 days)
ST; QL (30 per 30
days)
PA; QL (60 per 30
days)
Ophthalmic Agents
Antiglaucoma Agents
acetazolamide oral capsule,
extended release
acetazolamide oral tablet
acetazolamide sodium
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
133
Tier level
What the
drug will
cost you
2
$0
2
1
1
1
2
1
1
1
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
2
$0
(Neptazane)
(Metipranolol)
1
1
2
$0
$0
$0
(Isopto Carpine)
1
$0
(Timolol Maleate)
2
1
$0
$0
(Timoptic-Xe)
1
$0
2
$0
1
$0
4
$0
4
$0
4
$0
Name of Drug
ALPHAGAN P OPHTHALMIC
DROPS 0.1 %
AZOPT
betaxolol ophthalmic
bimatoprost
brimonidine
COMBIGAN
dorzolamide
dorzolamide-timolol
latanoprost
levobunolol
LUMIGAN OPHTHALMIC
DROPS 0.01 %
methazolamide oral
metipranolol
PHOSPHOLINE IODIDE
pilocarpine hcl ophthalmic drops 1
%, 2 %, 4 %
SIMBRINZA
timolol maleate ophthalmic drops
timolol maleate ophthalmic gel
forming solution
TRAVATAN Z
travoprost (benzalkonium)
(Betaxolol HCl)
(Bimatoprost)
(Alphagan P)
(Trusopt)
(Cosopt)
(Xalatan)
(Betagan)
(Travoprost
(Benzalkonium))
Necessary Actions,
Restrictions, or
Limits on Use
(drops: 0.15%, 0.20%)
QL (2.5 per 25 days)
QL (2.5 per 25 days)
QL (2.5 per 25 days)
Replacement Preparations
Replacement Preparations
(Ca/D3/Mag
ca-d3-mag ox-zinc-cop-mang-bor *
Ox/Zinc/Cop/Mang
oral tablet,chewable
/Bor)
(Calcium
calcionate *
Glubionate)
calcitrate *
(Calcium Citrate)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
134
Tier level
What the
drug will
cost you
4
$0
4
$0
(Os-Cal 500+D3)
4
$0
(Os-Cal 500+D3)
(Caltrate 600)
(Calcium
Carbonate/Vitamin
D3)
(Os-Cal 500+D3)
(Calcium
Carbonate/Vitamin
D3)
(Calcium
Carbonate)
4
4
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
1
$0
4
$0
1
$0
Name of Drug
calcitrate-vitamin d *
calcium 500 + d (d3) *
calcium 500 + d * oral tablet 500
mg(1,250mg) -400 unit
calcium 500 with d *
calcium 600 *
calcium 600 + d(3) * oral capsule
calcium 600 + d(3) * oral tablet
calcium 600 with vitamin d3 * oral
calcium carbonate * oral
(Citracal-Vitamin
D)
(Os-Cal 500+D3)
calcium carbonate * oral tablet 260
(Caltrate 600)
mg calcium (648 mg)
(Calcium
calcium carbonate-vitamin d2 *
Carbonate/Vitamin
D2)
calcium carbonate-vitamin d3 *
(Calcium
oral capsule 600 mg(1,500mg) -100
Carbonate/Vitamin
unit, 600 mg(1,500mg) -400 unit,
D3)
600 mg(1,500mg) -500 unit
calcium carbonate-vitamin d3 *
(Os-Cal 500+D3)
oral tablet
calcium carbonate-vitamin d3 *
oral tablet,chewable 500
(Os-Cal 500+D)
mg(1,250mg) -400 unit
calcium chloride intravenous
(Calcium Chloride)
calcium citrate-vitamin d3 * oral
(Citracal-Vitamin
tablet 315-250 mg-unit
D)
(Calcium
calcium gluconate intravenous
Gluconate)
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD; (PA for
ESRD Only)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
135
Tier level
What the
drug will
cost you
(Calcium
Gluconate)
4
$0
(Calcium Lactate)
4
$0
(Os-Cal 500+D3)
4
4
$0
$0
4
$0
4
$0
4
$0
1
$0
4
$0
4
$0
1
$0
4
4
2
2
2
2
2
2
2
4
1
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
1
$0
1
$0
Name of Drug
calcium gluconate * oral tablet 45
mg (500 mg)
calcium lactate * oral tablet 84 mg
(648 mg), 85 mg (650 mg)
calcium+d * oral tablet
CALTRATE 600 + D *
CALTRATE-600 + D VIT D3
(800) *
CENTRUM PRO NUTRIENTS *
citracal + d maximum *
citric acid-sodium citrate
citrus calcium * oral tablet
coral calcium * oral tablet
electrolyte-48 in d5w
enfalyte *
hi-cal plus vit d *
HYPERLYTE CR
IONOSOL-B IN D5W
IONOSOL-MB IN D5W
ISOLYTE M IN 5 % DEXTROSE
ISOLYTE-H IN 5 % DEXTROSE
ISOLYTE-P IN 5 % DEXTROSE
ISOLYTE-S
KELP (IODINE) *
KLOR-CON
klor-con 10
(Citracal-Vitamin
D)
(Citric
Acid/Sodium
Citrate)
(Citracal-Vitamin
D)
(Caltrate 600)
(Electrolyte-48
Solution/D5W)
(Pedialyte)
(Os-Cal 500+D3)
(Potassium
Chloride)
KLOR-CON 8
Necessary Actions,
Restrictions, or
Limits on Use
(Potassium
1
$0
Chloride)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
klor-con m10
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
136
Tier level
What the
drug will
cost you
1
$0
1
$0
1
$0
4
$0
4
$0
4
$0
4
$0
4
$0
1
$0
4
4
$0
$0
(Magnesium
Sulfate/D5W)
1
$0
(Magnesium
Sulfate in Water)
1
$0
1
$0
4
$0
2
$0
2
2
2
2
$0
$0
$0
$0
Name of Drug
klor-con m15
klor-con m20
(Potassium
Chloride)
(Potassium
Chloride)
KLOR-CON/EF
liquid calcium with vitamin d *
mag 64 *
mag-delay *
mag-g *
magnesium (oxide/aa chelate) *
magnesium chloride injection
magnesium gluconate * oral tablet
magnesium * oral tablet 250 mg
magnesium sulfate in d5w
intravenous piggyback 1 gram/100
ml
magnesium sulfate in water
intravenous piggyback 4 gram/100
ml (4 %), 4 gram/50 ml (8 %)
magnesium sulfate injection
natural calcium *
NORMOSOL-M IN 5 %
DEXTROSE
NORMOSOL-R
NORMOSOL-R PH 7.4
NUTRILYTE
NUTRILYTE II
(Calcium
Carbonate/Vitamin
D3)
(Magnesium
Chloride)
(Magnesium
Chloride)
(Magonate)
(Magnesium
Oxide/Mag Aa
Chelate)
(Magnesium
Chloride)
(Magonate)
(Magnesium)
(Magnesium
Sulfate)
(Caltrate 600)
Necessary Actions,
Restrictions, or
Limits on Use
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
137
Tier level
What the
drug will
cost you
4
4
4
4
4
4
4
4
4
4
1
2
2
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
2
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
(Potassium
Chloride In D5w)
1
$0
potassium chloride intravenous
(Potassium
Chloride)
1
$0
potassium chloride oral capsule,
extended release
(Micro-K)
1
$0
Name of Drug
oralyte *
oysco 500/d * oral tablet
oysco d *
oysco-500 *
oyster shell calcium 500 *
oyster shell calcium-vit d3 *
oystercal-d *
pediatric electrolyte * oral solution
pediatric freezer pops *
PHOS-NAK *
phosphorus #1
PLASMA-LYTE 148
PLASMA-LYTE A
PLASMA-LYTE-56 IN 5 %
DEXTROSE
potassium acetate intravenous
potassium bicarb and chloride
potassium bicarb-citric acid
potassium bicarbonate-cit ac oral
tablet, effervescent 25 meq
potassium chlorid-d5-0.45%nacl
potassium chloride in 0.9%nacl
intravenous parenteral solution 20
meq/l, 40 meq/l
potassium chloride in 5 % dex
intravenous parenteral solution 20
meq/l, 30 meq/l, 40 meq/l
(Pedialyte)
(Os-Cal 500+D3)
(Os-Cal 500+D3)
(Caltrate 600)
(Caltrate 600)
(Os-Cal 500+D3)
(Os-Cal 500+D3)
(Pedialyte)
(Pedialyte)
(K-Phos Neutral)
(Potassium
Acetate)
(Pot Chloride/Pot
Bicarb/Cit Ac)
(Klor-Con-Ef)
(Klor-Con-Ef)
(Potassium
Chloride/D50.45nacl)
(Potassium
Chloride In
0.9%NaCl)
Necessary Actions,
Restrictions, or
Limits on Use
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
138
Tier level
What the
drug will
cost you
(Kaochlor)
(Klor-Con)
1
1
$0
$0
(Klor-Con 8)
1
$0
(Klor-Con 8)
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
1
$0
$0
1
$0
1
$0
1
$0
Name of Drug
potassium chloride oral liquid
potassium chloride oral packet
potassium chloride oral tablet
extended release
potassium chloride oral tablet,er
particles/crystals 10 meq
potassium chloride oral tablet,er
particles/crystals 20 meq
(Potassium
Chloride)
(Potassium
potassium chloride-0.45 % nacl
Chloride-0.45%
NaCl)
(Potassium
potassium chloride-d5-0.2%nacl
Chloride/D50.2%NaCl)
potassium chloride-d5-0.3%nacl
(Potassium
intravenous parenteral solution 20 Chloride/D5meq/l
0.3%NaCl)
(Potassium
potassium chloride-d5-0.9%nacl
Chloride/D50.9%NaCl)
potassium citrate-citric acid oral
(Potassium
packet
Citrate/Citric Acid)
potassium citrate-citric acid oral
(Potassium
solution 1,100-334 mg/5 ml
Citrate/Citric Acid)
(Potassium
potassium phosphate dibasic
Phos,M-Basic-DBasic)
ringers intravenous
(Ringers Solution)
sodium acetate intravenous
(Sodium Acetate)
(Sodium
sodium bicarbonate intravenous
Bicarbonate)
(Sodium Chloride
sodium chloride 0.45 % intravenous
0.45 %)
sodium chloride 0.9 % injection
(0.9 % Sodium
solution
Chloride)
Necessary Actions,
Restrictions, or
Limits on Use
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
139
Name of Drug
sodium chloride 0.9 % intravenous
sodium chloride 3 %
sodium chloride 5 %
sodium chloride intravenous
sodium citrate-citric acid
sodium lactate intravenous
sodium phosphate
sod-pot-k cit-sod cit-cit acid
(0.9 % Sodium
Chloride)
(Sodium Chloride
3 %)
(Sodium Chloride
5 %)
(Sodium Chloride)
(Citric
Acid/Sodium
Citrate)
(Sodium Lactate)
(Sodium Phos,MBasic-D-Basic)
(Sod/Pot/K Cit/Sod
Cit/Cit Acid)
TPN ELECTROLYTES
TPN ELECTROLYTES II
Tier level
What the
drug will
cost you
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
1
$0
2
2
$0
$0
2
2
2
2
$0
$0
$0
$0
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
Respiratory Tract Agents
Anti-Inflammatories, Inhaled Corticosteroids
ADVAIR DISKUS
ADVAIR HFA
BREO ELLIPTA
DULERA
FLOVENT DISKUS
INHALATION BLISTER WITH
DEVICE 100 MCG/ACTUATION,
50 MCG/ACTUATION
FLOVENT DISKUS
INHALATION BLISTER WITH
DEVICE 250 MCG/ACTUATION
FLOVENT HFA INHALATION
HFA AEROSOL INHALER 110
MCG/ACTUATION
QL (60 per 30 days)
QL (12 per 28 days)
QL (60 per 30 days)
QL (13 per 28 days)
QL (60 per 30 days)
QL (120 per 30 days)
2
$0
2
$0
QL (12 per 28 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
140
Tier level
What the
drug will
cost you
2
$0
2
$0
2
$0
(Singulair)
(Accolate)
1
1
$0
$0
(Albuterol Sulfate)
1
$0
(Albuterol Sulfate)
(Albuterol Sulfate)
1
1
$0
$0
(Vospire ER)
1
$0
2
2
2
$0
$0
$0
1
$0
2
2
2
2
$0
$0
$0
$0
1
$0
1
$0
1
$0
Name of Drug
FLOVENT HFA INHALATION
HFA AEROSOL INHALER 220
MCG/ACTUATION
FLOVENT HFA INHALATION
HFA AEROSOL INHALER 44
MCG/ACTUATION
QVAR
Antileukotrienes
montelukast
zafirlukast
Bronchodilators
albuterol sulfate inhalation solution
for nebulization
albuterol sulfate oral syrup
albuterol sulfate oral tablet
albuterol sulfate oral tablet
extended release 12 hr
ANORO ELLIPTA
ATROVENT HFA
COMBIVENT RESPIMAT
metaproterenol oral
QL (24 per 28 days)
QL (21.2 per 28 days)
(Metaproterenol
Sulfate)
PROAIR HFA
SEREVENT DISKUS
SPIRIVA RESPIMAT
SPIRIVA WITH HANDIHALER
terbutaline oral
terbutaline subcutaneous
Necessary Actions,
Restrictions, or
Limits on Use
(Terbutaline
Sulfate)
(Terbutaline
Sulfate)
theophylline anhydrous oral tablet
(Theophylline
extended release 12 hr 100 mg, 200
Anhydrous)
mg, 300 mg
QL (17.4 per 25 days)
PA BvD
QL (60 per 30 days)
QL (25.8 per 28 days)
QL (8 per 30 days)
QL (17 per 25 days)
QL (60 per 30 days)
QL (4 per 30 days)
QL (30 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
141
Tier level
What the
drug will
cost you
1
$0
1
$0
1
$0
1
$0
2
$0
QL (1 per 28 days)
1
1
2
$0
$0
$0
PA BvD
PA BvD
1
$0
4
2
$0
$0
ESBRIET
2
$0
KALYDECO
2
$0
OFEV
2
$0
3
$0
2
2
$0
$0
1
$0
Name of Drug
theophylline in dextrose 5 %
intravenous parenteral solution 200
(Theophylline/D5
mg/100 ml, 200 mg/50 ml, 400
W)
mg/250 ml, 400 mg/500 ml, 800
mg/250 ml
(Theophylline
theophylline oral
Anhydrous)
(Theophylline
theophylline oral
Anhydrous)
(Theophylline
theophylline oral
Anhydrous)
TUDORZA PRESSAIR
Respiratory Tract Agents, Other
acetylcysteine
(Acetadote)
acetylcysteine solution
(Acetadote)
ARALAST NP
(Cromolyn
cromolyn inhalation
Sodium)
cromolyn * nasal
(Nasalcrom)
DALIRESP
sodium chloride * inhalation
solution for nebulization 0.9 %
XOLAIR
ZEMAIRA
(Pulmosal)
Necessary Actions,
Restrictions, or
Limits on Use
PA BvD
QL (30 per 30 days)
PA; QL (270 per 30
days)
PA; QL (60 per 30
days)
PA; QL (60 per 30
days)
PA; QL (6 per 28 days)
Skeletal Muscle Relaxants
Skeletal Muscle Relaxants
baclofen
(Baclofen)
PA-HRM; QL (120 per
30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
carisoprodol
(Soma)
1
$0
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
142
Tier level
What the
drug will
cost you
1
$0
1
$0
1
$0
(Fexmid)
1
$0
(Dantrium)
(Dantrium)
(Skelaxin)
(Robaxin)
(Zanaflex)
1
1
1
1
1
$0
$0
$0
$0
$0
2
2
2
$0
$0
$0
1
$0
Name of Drug
chlorzoxazone
COMFORT PACCYCLOBENZAPRINE
COMFORT PAC-TIZANIDINE
cyclobenzaprine oral tablet 10 mg,
5 mg
dantrolene
dantrolene sodium
metaxalone
methocarbamol oral
tizanidine
(Parafon Forte
DSC)
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM
PA-HRM
PA-HRM
PA-HRM
PA-HRM
Sleep Disorder Agents
Sleep Disorder Agents
NUVIGIL
ROZEREM
XYREM
zaleplon
(Sonata)
PA
LA
PA-HRM; (High Risk
Med. QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use with
any nonbenzodiazepine
hypnotic drug); QL (60
per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
143
Name of Drug
Tier level
What the
drug will
cost you
zolpidem oral tablet
(Ambien)
1
$0
zolpidem oral tablet,ext release
multiphase
(Ambien CR)
1
$0
1
$0
ADCIRCA
2
$0
ADEMPAS
2
$0
1
$0
LETAIRIS
2
$0
OPSUMIT
2
$0
Necessary Actions,
Restrictions, or
Limits on Use
PA-HRM; (High Risk
Med. QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use with
any nonbenzodiazepine
hypnotic drug); QL (30
per 30 days)
PA-HRM; (High Risk
Med. QL applies to all
members; PA required
for 65 years and older
with over 90 days
cumulative use with
any nonbenzodiazepine
hypnotic drug); QL (30
per 30 days)
Sympatholytic Adrenergic Blocking Agents
Alpha-Adrenergic Blocking Agents
(Phentolamine
phentolamine injection
Mesylate)
PA
Vasodilating Agents
Vasodilating Agents
epoprostenol (glycine)
(Flolan)
PA; QL (60 per 30
days)
PA; QL (90 per 30
days)
PA BvD
PA; QL (30 per 30
days)
PA; QL (30 per 30
days)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
144
Tier level
What the
drug will
cost you
Necessary Actions,
Restrictions, or
Limits on Use
ORENITRAM
REMODULIN
2
2
$0
$0
REVATIO INTRAVENOUS
2
$0
1
$0
TRACLEER
2
$0
TYVASO
TYVASO REFILL KIT
TYVASO STARTER KIT
VENTAVIS
2
2
2
2
$0
$0
$0
$0
PA
PA BvD
PA; QL (37.5 per 1
day)
PA; QL (90 per 30
days)
PA; LA; QL (60 per 30
days)
PA BvD
PA BvD
PA BvD
PA BvD
4
$0
4
$0
4
$0
4
$0
4
$0
Name of Drug
sildenafil oral tablet 20 mg
(Revatio)
Vitamins And Minerals
Vitamins And Minerals
a thru z advanced formula *
a thru z high potency * oral tablet
a thru z select 50+ formula *
a thru z select * oral tablet
a thru z select * oral tablet 300600-300 mcg, 500-300-250 mcg
(Multivitamin/Iron/
Folic Acid)
(Multivitamin WMinerals/Lutein)
(Biocel)
(Multivitamin WMinerals/Lutein)
(Biocel)
(Multivits W4
$0
Fe,Other Min/Lut)
abc plus *
(Biocel)
4
$0
(One-A-Day
adult one daily gummies *
4
$0
Vitacraves)
adults 50+ daily formula *
(Biocel)
4
$0
(Multivitamin/Iron/
adults' daily formula *
4
$0
Folic Acid)
(Vit A,C, and
airshield * oral tablet, effervescent
E/Dietary Supp
4
$0
5,000-1000-30 unit-mg-unit
No.12)
animal chews *
(Multivitamin)
4
$0
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
a thru z select women's *
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
145
Name of Drug
animal shape vitamins *
animal shapes plus iron *
antioxidant *
antioxidant formula *
antioxidant vitamins * oral tablet
antioxidant vitamins * oral tablet
1,000 unit-200 mg-60 unit-2 mg
apatate forte *
(Multivitamin)
(Multivitamins
with Iron)
(Beta-Carotene(A)
W-C and E/Min)
(Beta-Carotene(A)
W-C and E/Min)
(Multivitamin with
Minerals)
(Ocuvite with
Lutein)
(Multivitamin with
Minerals)
ascorbic acid * oral tablet extended
(Ascorbic Acid)
release 1,500 mg
ascorbic acid * oral
(Ascorbic Acid)
(Vitamin B
b complete *
Complex)
(Vitamin B
b complex 1 *
Complex)
(Vitamin B
b complex-vitamin b12 *
Complex)
b complex-vitamin c-folic acid *
(Dialyvite 800)
(Vitamin B
b-100 complex * oral tablet
Complex)
b-12 dots *
(B-12)
(Vitamin B
b-50 complex * oral tablet
Complex)
(Vitamin B
bal b-100 *
Complex)
(Vitamin B
bal b-50 *
Complex)
(Vitamin B
balance b-100 *
Complex)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
146
Name of Drug
balance b-50 *
balanced b-100 * oral
balanced b-100 * oral tablet 100
mg
balanced b-150 *
balanced b-50 * oral tablet
b-complex * oral tablet
b-complex with vitamin c * oral
capsule
b-complex with vitamin c * oral
tablet
bee-zee *
biosupp *
biotin * oral tablet 300 mcg
biovol *
c complex *
calcidol *
centamin *
central vite with lutein *
central-vite for seniors *
central-vite * oral tablet 18-400
mg-mcg
central-vite select * oral tablet
(Vitamin B
Complex)
(Vitamin B
Complex)
(Vit B Complex
100 Cmb
#3/Herbs)
(Vitamin B
Complex)
(Vitamin B
Complex)
(Vitamin B
Complex)
(B Complex with
Vitamin C)
(Vita-Bee with C)
(Multivitamin with
Minerals)
(Multivitamin with
Minerals)
(Biotin)
(Multivitamin with
Minerals)
(Ascorbic Acid)
(Drisdol)
(Multivits WMin/Ferrous Gluc)
(Biocel)
(Multivitamin
W/Iron, Minerals)
(Multivitamin/Iron/
Folic Acid)
(Multivitamin WMinerals/Lutein)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
147
Tier level
What the
drug will
cost you
(Biocel)
(Multivits WMin/Ferrous Gluc)
(Multivitamin
W/Iron, Minerals)
(Multivitamin/Iron/
Folic Acid)
(Multivits WMin/Ferrous Gluc)
(Biocel)
(Multivitamin/Iron/
Folic Acid)
(Biocel)
(Multivits WFe,Other Min/Lut)
(Multivitamin WMinerals/Lutein)
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
(Biocel)
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Name of Drug
central-vite senior *
centram-care *
centravites 50 plus *
centrum complete *
centrum * oral liquid
centrum silver * oral tablet
centrum ultra women's *
century adults 50+ *
century advanced formula *
century mature * oral tablet
century mature * oral tablet 0.4300-250 mg-mcg-mcg, 500-300-250
mcg
century * oral tablet 18-400 mgmcg
century ultimate women's * oral
tablet 18-400 mg-mcg
(Multivitamin/Iron/
Folic Acid)
(Multivitamin/Iron/
Folic Acid)
(Multivits Wcerovite *
Min/Ferrous Gluc)
(Multivitamin/Iron/
cerovite advanced formula *
Folic Acid)
(Multivitamin
cerovite jr *
W/Iron, Minerals)
(Multivitamin Wcerovite senior *
Minerals/Lutein)
certavite senior-antioxidant *
(Biocel)
certavite-antioxid (iron gluc) * oral (Multivits Wliquid 9 mg iron/15 ml
Min/Ferrous Gluc)
Necessary Actions,
Restrictions, or
Limits on Use
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
148
Name of Drug
certavite-antioxidant *
chewable multi vitamin *
chewable-vite *
chewable-vite with iron *
child complete multivitamin *
child vitamin with minerals *
(Multivitamin/Iron/
Folic Acid)
(Multivitamin)
(Multivitamin)
(Multivitamins
with Iron)
(Pedi Mv
No.58/Ferrous
Fumarate)
(Multivitamin
W/Iron, Minerals)
(Multivitamin)
children's chewable *
children's chewable complete * oral
(Multivitamin)
tablet,chewable
children's chewable vitamin *
(Multivitamin)
(Multivitamin
children's chewable w/minerals *
W/Iron, Minerals)
(Pedi Mv
children's complete vitamin *
No.67/Ferrous
Fumarate)
children's multivit w/extra c *
(Multivitamin)
(Multivitamins
children's vitamin with iron *
with Iron)
childs chew vite *
(Multivitamin)
(Multivitamins
child's chewable vitamins/iron *
with Iron)
(Multivitamins
child's vitamin with iron *
with Iron)
child's vitamin with vitamin c *
(Multivitamin)
(Multivitamins
childs/iron *
with Iron)
(Multivitamin
compete *
W/Iron, Minerals)
complete 50+ *
(Biocel)
complete multi 50+ *
(Biocel)
Tier level
What the
drug will
cost you
4
$0
4
4
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
$0
$0
Necessary Actions,
Restrictions, or
Limits on Use
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
149
Tier level
What the
drug will
cost you
(Multivits,Th WFe,Other Min)
4
$0
(Biocel)
4
$0
4
$0
4
$0
4
$0
3
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
4
$0
$0
$0
Name of Drug
complete multivitamin * oral tablet
complete multivitamin * oral tablet
0.4-300-250 mg-mcg-mcg
complete multivitamin-mineral *
oral tablet
complete senior * oral tablet
complete senior * oral tablet 0.4300-250 mg-mcg-mcg
cyanocobalamin (vitamin b-12) *
injection
cyanocobalamin (vitamin b-12) *
oral drops 1,000 mcg/ml
cyanocobalamin (vitamin b-12) *
oral tablet 1,000 mcg, 100 mcg, 250
mcg, 500 mcg
daily gummies *
daily multiple * oral tablet
daily multiple * oral tablet 18-400
mg-mcg
daily multi-vitamin *
daily multivitamin with iron *
daily multivitamin-minerals *
daily multi-vitamins/iron *
daily teen multi-vitamin *
daily value *
daily vitamin *
daily vitamin formula *
(Multivitamin/Iron/
Folic Acid)
(Multivitamin
W/Iron, Minerals)
(Biocel)
(Cyanocobalamin
(Vitamin B-12))
(Cyanocobalamin
(Vitamin B-12))
(B-12)
(One-A-Day
Vitacraves)
(Multivitamin)
(Multivitamin/Iron/
Folic Acid)
(Multivitamin)
(Multivitamin/Iron/
Folic Acid)
(Multivitamin with
Minerals)
(Multivitamins
with Iron)
(Multivitamin/Iron/
Folic Acid)
(Multivitamin)
(Multivitamin)
(Multivitamin)
Necessary Actions,
Restrictions, or
Limits on Use
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
150
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
4
4
$0
$0
$0
4
$0
4
$0
4
$0
4
$0
(Drisdol)
3
$0
(Drisdol)
4
$0
4
$0
4
$0
4
4
$0
$0
3
$0
3
$0
4
$0
Name of Drug
daily vitamin formula + iron *
daily vitamin formula-minerals *
daily vitamin with iron *
daily vites/iron *
daily-vite *
dino-life *
dino-life with extra c *
dino-life with iron-zinc *
(Multivitamin/Iron/
Folic Acid)
(Multivitamin with
Minerals)
(Multivitamins
with Iron)
(Multivitamins
with Iron)
(Multivitamin)
(Multivitamin)
(Multivitamin)
(Multivitamin
W/Iron, Minerals)
ECEE PLUS *
eldertonic *
ellis tonic *
ergocalciferol (vitamin d2) * oral
capsule
ergocalciferol (vitamin d2) * oral
drops
essentia *
essential balance with lutein *
essential daily *
essential one daily *
fe fumarate-doss-fa-bcomp and c *
fe fumarate-vit c-b12-if-fa * oral
capsule 110-0.5 mg
ferate * oral tablet
(B1,B2,B3,B6,B12
/Dexpan/Zn/Mang)
(Multivitamin with
Minerals)
(Multivitamin/Iron/
Folic Acid)
(Multivits WFe,Other Min/Lut)
(Tab A Vite)
(Multivitamin)
(Fe
Fumarate/Doss/Fa/
Bcomp and C)
(Fe Fumarate/Vit
C/B12-If/Fa)
(Fergon)
Necessary Actions,
Restrictions, or
Limits on Use
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
151
Tier level
What the
drug will
cost you
3
$0
4
4
$0
$0
4
$0
4
$0
(Ferrous Fumarate)
4
$0
(Fergon)
(Fer-In-Sol)
(Ferrous Sulfate)
(Ferrous Sulfate)
4
4
4
4
$0
$0
$0
$0
(Ferrous Sulfate)
4
$0
(Ferrous Sulfate)
4
$0
(Multivitamin
W/Iron, Minerals)
4
$0
(Multivitamin)
4
$0
(Pedi Mv
No.79/Ferrous
Fumarate)
4
$0
(Multivitamin)
4
$0
(Folic Acid)
3
4
$0
$0
(Folic Acid)
4
$0
4
$0
4
4
4
$0
$0
$0
Name of Drug
ferotrinsic *
ferretts * oral tablet
ferrex 150 *
ferrex 150 plus *
ferrocite *
ferrous fumarate * oral tablet 324
mg (106 mg iron)
ferrous gluconate * oral tablet
ferrous sulfate * oral
ferrous sulfate * oral
ferrous sulfate * oral
ferrous sulfate * oral tablet 325 mg
(65 mg iron)
ferrous sulfate * oral tablet,delayed
release (dr/ec) 324 mg (65 mg iron)
flintstones complete (iron) * oral
tablet,chewable
flintstones multivitamin * oral
tablet,chewable
flintstones with iron *
flintstones/extra c * oral
tablet,chewable
folic acid * 1 mg tablet (rx)
FOLIC ACID * ORAL CAPSULE
folic acid * oral tablet 1 mg, 400
mcg, 800 mcg
fosfree *
fruity chews *
geravim *
geriaton *
(Fe Fumarate/Vit
C/B12-If/Fa)
(Ferrous Fumarate)
(Pic 200)
(Iron Aspgly and
Ps Cmplx/C/Sucac)
(Ferrous Fumarate)
(Calcium/Multivita
mins W-Iron)
(Multivitamin)
(Pediavit)
(Pediavit)
Necessary Actions,
Restrictions, or
Limits on Use
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
152
Name of Drug
germ defense *
gummi bear multivitamin *
gummy swirls *
hair vitamins *
hair,skin & nails * oral tablet
hair,skin & nails * oral tablet 1 mg
iron-66.7 mcg-1,000 mcg
healthy eyes *
hemocyte *
hi-b complex *
high potency multivit-multimin *
honey bears *
honey bears with iron-zinc *
icaps plus *
iferex 150 *
iron high potency *
i-vite *
kid's vitamins + extra c *
kids vitamins + iron *
kid's vitamins + iron *
kid's vitamins * oral
tablet,chewable
(Vit A,C, and
E/Dietary Supp
No.12)
(Multivitamin)
(Multivitamin)
(Multivitamins
with Iron)
(Multivitamin with
Minerals)
(Mv,Ca,Min/Iron
Gluc/Fa/Biotin)
(Ocuvite with
Lutein)
(Ferrous Fumarate)
(Vitamin B
Complex)
(Multivitamin WMinerals/Lutein)
(Multivitamin)
(Multivitamin
W/Iron, Minerals)
(Multivitamin with
Minerals)
(Pic 200)
(Fergon)
(Ocuvite with
Lutein)
(Multivitamin)
(Ped Multivit
#17/Iron Fumarate)
(Multivitamins
with Iron)
(Multivitamin)
Tier level
What the
drug will
cost you
4
$0
4
4
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
153
Name of Drug
life-pack women's *
LIQUI-E *
little animals *
little animals/iron *
lysiplex plus * oral liquid
MACUVITE *
MACUVITE EYE CARE *
maximum daily multivitamin *
mega multiple/chelated mineral *
mega multivitamin with mineral *
oral tablet
men's multi-vitamin *
men's one daily * oral tablet
(Multivitamin
W/Iron, Minerals)
(Multivitamin)
(Multivitamins
with Iron)
(Pediavit)
(Tab A Vite)
(Multivitamin with
Minerals)
(Multivitamin with
Minerals)
(Multivitamin)
(Multivitamin with
Minerals)
MEPHYTON *
milltrium senior *
multi complete with iron *
multi-day with iron *
multi-delyn *
multi-delyn with iron *
multilex *
multilex-t&m *
multiple vitamin-minerals *
multiple vitamins *
(Multivitamin WMinerals/Lutein)
(Multivitamin/Iron/
Folic Acid)
(Multivitamin/Iron/
Folic Acid)
(Multivitamin)
(Multivitamin/Ferr
ous Gluconate)
(Multivitamin
W/Iron, Minerals)
(Multivits,Th WFe,Other Min)
(Multivitamin with
Minerals)
(Multivitamin)
Tier level
What the
drug will
cost you
4
$0
4
4
$0
$0
4
$0
4
4
4
4
$0
$0
$0
$0
4
$0
4
$0
4
$0
4
$0
3
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
154
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
3
$0
4
$0
4
$0
4
$0
4
$0
3
$0
4
$0
4
$0
4
4
$0
$0
(Niacinamide)
4
$0
(Pic 200)
4
$0
Name of Drug
multiple vitamins with iron *
multivital platinum * oral tablet
multivital platinum * oral tablet
500-300-250 mcg
multi-vitamin hp/minerals *
multivitamin * oral tablet
multivitamin with iron *
multivitamin with minerals * oral
liquid
multivitamin with minerals * oral
tablet
multivitamins with min no.7-fa *
oral capsule 1 mg
multi-vite *
multi-vite 50 & over *
my favorite multiple *
my-vitalife *
(Multivitamins
with Iron)
(Multivitamin WMinerals/Lutein)
(Biocel)
(Multivitamins,The
r W-Minerals)
(Multivitamin)
(Multivitamins
with Iron)
(Multivits WMin/Ferrous Gluc)
(Multivitamin with
Minerals)
(Multivitamins
with Min No.7/Fa)
(Multivitamin/Iron/
Folic Acid)
(Multivitamin WMinerals/Lutein)
(Multivitamin)
(Multivitamin with
Minerals)
NASCOBAL *
natural b-100 *
natural b-100 complex *
nephro-vite *
niacinamide * oral tablet 500 mg
niacinamide * oral tablet extended
release
nu-iron *
(Vitamin B
Complex)
(Vit B Complex
100 Cmb
#2/Herbs)
(Dialyvite 800)
(Niacinamide)
Necessary Actions,
Restrictions, or
Limits on Use
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
155
Name of Drug
ocutabs *
once daily *
oncovite *
one daily 50 plus *
one daily complete * oral tablet
one daily energy * oral tablet
one daily essential * oral tablet
one daily maximum (with ca) *
one daily men's 50+ * oral tablet
one daily multi-vit w-mineral *
one daily multivitamin * oral tablet
one daily multivitamin * oral tablet
400 mcg
(Beta-Carotene(A)
W-C and E/Min)
(Multivitamin)
(Multivitamins,The
rapeutic)
(Multivitamin with
Minerals)
(Multivitamin with
Minerals)
(Multivitamin with
Minerals)
(Multivitamin)
(Tab A Vite)
(Multivitamin with
Minerals)
(Multivitamins
with Iron)
(Multivitamin)
(Quintabs)
(Multivitamin/Iron/
Folic Acid)
one daily * oral tablet
(Multivitamin)
(Multivitamins
one daily plus iron * oral tablet
with Iron)
one daily plus iron * oral tablet 18- (Multivitamin/Iron/
400 mg-mcg
Folic Acid)
(Multivitamin with
one daily plus minerals *
Minerals)
(Multivitamins
one daily with iron *
with Iron)
one-a-day essential *
(Multivitamin)
(Multivitamin with
one-a-day maximum formula *
Minerals)
one daily multivitamin-iron *
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
4
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
156
Name of Drug
one-a-day teen advantage * oral
tablet 18-400 mg-mcg
one-a-day teen advantage * oral
tablet 9 mg iron-400 mcg
(Multivitamin/Iron/
Folic Acid)
(Multivits,Ca,Mine
rals/Iron/Fa)
(Ocuvite with
opti-vitamins *
Lutein)
pedi m.vit no.17 with fluoride oral
(Pedi Mvi No.82
drops 0.25 mg/ml
with Fluoride)
pediatric multivitamin *
(Multivitamin)
pharmacist favorite multi-vit *
(Multivitamin)
phytonadione * oral tablet 100 mcg (Phytonadione)
poly-iron *
(Pic 200)
(Pediatric Multivit
poly-vita *
Comb No.20)
(Ped Multivit
poly-vita (iron) *
#46/Iron Sulfate)
(Pediatric Multivit
poly-vitamin *
Comb No.20)
poly-vitamin with iron * oral drops (Ped Multivit
1,500 unit-400 unit-10 mg/ml
#46/Iron Sulfate)
(Multivitamin
polyvitamin/iron *
W/Iron, Minerals)
poly-vitamins *
(Multivitamin)
prenatal formula * oral tablet 28(Classic Prenatal)
0.8 mg
prenatal * oral tablet 28-0.8 mg
(Classic Prenatal)
(Prenatal
prenatal vit#96-ferrous fum-fa *
Vit#96/Ferrous
Fum/Fa)
prenatal vitamin with minerals *
(Classic Prenatal)
prenatal vitamins oral tablet 27 mg (Pnv with
iron- 1 mg
Ca,No.72/Iron/Fa)
(Pnv119/Iron
prenatal vitamins with iron
Fumarate/Fa/Dss)
prenatal vit-iron fumarate-fa *
(Classic Prenatal)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
1
$0
4
4
4
4
$0
$0
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
2
$0
2
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
(All Rx Prenatal
Vitamins Covered)
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
157
Tier level
What the
drug will
cost you
4
$0
3
$0
4
$0
4
$0
4
$0
4
$0
1
$0
(Sodium Fluoride)
3
$0
(Biocel)
(Multivitamin/Iron/
Folic Acid)
(Pediavit)
(Multivitamins
with Iron)
(Multivitamin
W/Iron, Minerals)
(Multivitamin WMinerals/Lutein)
(Multivitamin/Iron/
Folic Acid)
(Multivits,Stress
Formula/Zinc)
(Multivits,Stress
Formula/Zinc)
(Vitamin B
Complex)
(Multivits,Stress
Formula)
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Name of Drug
prosight *
pyridoxine * injection
ra central-vite select * tab p/f
scooby-doo one a day *
sentry * oral tablet 18-400 mg-mcg
sentry senior *
sodium fluoride oral tablet
sodium fluoride * oral
tablet,chewable 0.25 mg fluorid
(0.55 mg)
spectravite adult 50+ * oral tablet
spectravite advanced formula * oral
tablet
spectravite * oral liquid
spectravite * oral tablet,chewable
spectravite senior * oral tablet
spectravite senior w-lycopene *
spectravite ultra women *
stress 500 plus zinc *
stress b with zinc *
stress b-biotin *
stress formula *
(A/C/E/Zinc/Sod
Selenate/Copper)
(Pyridoxine HCl)
(Multivitamin
W/Iron, Minerals)
(Multivitamin
W/Iron, Minerals)
(Multivitamin/Iron/
Folic Acid)
(Biocel)
(Pedi Mvi No.82
with Fluoride)
Necessary Actions,
Restrictions, or
Limits on Use
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
158
Name of Drug
stress formula plus iron *
stress formula with iron *
stress formula with zinc *
stuart prenatal *
sunvite *
super b complex-vitamin c *
super b/c *
super b-50 complex *
super b-50 complex plus *
super multiple * oral tablet
super multivitamin *
super quints b-50 *
super thera vite m *
superior 35 *
superplex-t *
support *
support-500 *
tab-a-vite *
tab-a-vite/iron *
(Iron/Multivits,Stre
ss Formula)
(Vit B
Comp/C/Fa/Iron/Vi
t E)
(Multivits,Stress
Formula/Zinc)
(Classic Prenatal)
(Mv-Min/Iron
Fum/Fa/Lyco/Lutn/
K)
(Vita-Bee with C)
(B Complex with
Vitamin C)
(Vitamin B
Complex)
(Vitamin B
Complex)
(Multivitamin
W/Iron, Minerals)
(Multivitamin)
(Vitamin B
Complex)
(Multivitamins,The
r W-Minerals)
(Multivitamin
W/Iron, Minerals)
(Vita-Bee with C)
(Multivitamin with
Minerals)
(B Complex with
Vitamin C)
(Multivitamin)
(Multivitamins
with Iron)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
3
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
159
Name of Drug
(Multivitamin with
Minerals)
(Multivits,Ca,Mine
thera m plus (ferrous fumarat) *
rals/Iron/Fa)
(Multivitamins,The
thera vitamin *
rapeutic)
(Multivit,Ther
theradex m *
Iron,Ca,Fa and
Min)
(Multivits,Th Wthera-m * oral tablet
Fe,Other Min)
(Multivit,Ther
thera-m * oral tablet 27-0.4 mg
Iron,Ca,Fa and
Min)
thera-m * oral tablet 9 mg iron-400 (Multivits,Ca,Mine
mcg
rals/Iron/Fa)
(Multivitamin with
theramill forte * oral capsule
Minerals)
(Multivitamins,The
therapeutic liquid *
rapeutic)
therapeutic m + beta-carotene *
(Tab A Vite)
(Multivitamins
therapeutic vitamins/minerals *
with Min No.7/Fa)
therapeutic-m * oral tablet 9 mg
(Multivits,Ca,Mine
iron-400 mcg
rals/Iron/Fa)
(Multivit,Ther
therapeutic-m vitamin/minerals *
Iron,Ca,Fa and
oral tablet 27-0.4 mg
Min)
(Multivitamins,The
thera-tabs *
rapeutic)
(Multivitamin
theratrum complete 50 plus *
W/Iron, Minerals)
(Multivitamin Wtheratrum complete 50 plus/lut *
Minerals/Lutein)
tab-a-vite-minerals *
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
3
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
160
Name of Drug
therems *
therems-h *
therems-m *
thiamine hcl * injection
thiamine hcl * oral tablet 500 mg
total b/c *
totalday multiple *
tri-vi-sol *
tri-vita *
tri-vitamin *
ultra b-100 complex * oral tablet
unicomplex-m *
vision *
vision formula *
vision formula (with lutein) *
vision plus lutein *
vit b cmplx 3-fa-vit c-biotin * oral
tablet 1-60-300 mg-mg-mcg
(Multivitamins,The
rapeutic)
(Multivits,Th WFe,Other Min)
(Multivits,Th WFe,Other Min)
(Thiamine HCl)
(Thiamine HCl)
(Vita-Bee with C)
(Multivitamin with
Minerals)
(Vit A
Palmitate/Vit C/Vit
D3)
(Pedi Multivits
A,C, and D3
No.21)
(Pedi Multivits
A,C, and D3
No.21)
(Vitamin B
Complex)
(Multivitamin
W/Iron, Minerals)
(Beta-Carotene(A)
W-C and E/Min)
(Beta-Carotene(A)
W-C and E/Min)
(Ocuvite with
Lutein)
(Multivitamin WMinerals/Lutein)
(Vit B Cmplx
3/Fa/Vit C/Biotin)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
3
4
4
$0
$0
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
3
$0
Necessary Actions,
Restrictions, or
Limits on Use
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
161
Tier level
What the
drug will
cost you
3
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
(Pyridoxine HCl)
4
$0
(Ascorbic Acid)
4
$0
(Ascorbic Acid)
4
$0
(Ascorbic Acid)
4
$0
(Ascorbic Acid)
4
$0
(Ascorbic Acid)
4
$0
4
$0
4
$0
4
$0
Name of Drug
vit b cmplx no3-fa-c-biot-zinc *
vitabee/c *
vitalets * oral tablet,chewable
vitamin a * oral capsule 10,000
unit, 25,000 unit
vitamin b complex *
vitamin b complex with c *
vitamin b-1 * oral tablet
vitamin b-100 complex *
vitamin b12-folic acid * oral
vitamin b-6 * oral tablet 100 mg, 25
mg, 250 mg, 50 mg
vitamin c * oral capsule, extended
release
vitamin c * oral syrup
vitamin c * oral tablet 1,000 mg,
250 mg, 500 mg
vitamin c * oral tablet extended
release
vitamin c * oral tablet,chewable
250 mg, 500 mg
vitamins & minerals *
vitamins b complex * oral capsule
vitamins b complex * oral tablet
(Vit B Cmplx
No3/Fa/C/Biot/Zin
c)
(Vita-Bee with C)
(Multivitamins
with Iron)
(Vitamin A)
(Vitamin B
Complex)
(B Complex with
Vitamin C)
(Thiamine HCl)
(Vitamin B
Complex)
(Cyanocobalamin/
Folic Acid)
(Multivitamins,The
r W-Minerals)
(Vitamin B
Complex)
(Vitamin B
Complex)
Necessary Actions,
Restrictions, or
Limits on Use
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
162
Name of Drug
vitamins b complex * oral tablet
500 mg-400 mcg- 18 mg iron
vitamins for hair * oral tablet
vitrum senior * oral tablet
(Vit B
Comp/C/Fa/Iron/Vi
t E)
(Multivitamin)
(Multivitamin WMinerals/Lutein)
vitrum senior * oral tablet 500-300(Biocel)
250 mcg
women's daily multivitamin *
(Tab A Vite)
(Multivitamin/Iron/
yelets *
Folic Acid)
zoo chews *
(Multivitamin)
Tier level
What the
drug will
cost you
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
4
$0
Necessary Actions,
Restrictions, or
Limits on Use
You can find information on what the symbols and abbreviations in this table mean by going to the
introduction pages of this document.
Si ou gen kesyon, tanpri rele ICS Community Care Plus FIDA-MMP nan nimewo
1.877.ICS.2525, TTY 1.855.ICS.4TTY, lendi jiska vandredi, ant 8 a.m. ak 8 p.m. Koutfil la
gratis. Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
163
INDEX
3
3 day vaginal .......................... 50
30pse-150gfn-15dm ............... 85
8
8-MOP.................................... 95
A
a thru z advanced formula .... 141
a thru z high potency ............ 141
a thru z select ....................... 141
a thru z select 50+ formula... 141
a thru z select women's ........ 141
abacavir .................................. 63
abacavir-lamivudine-zidovudine
............................................ 63
abc plus ................................ 141
ABELCET.............................. 50
ABILIFY .......................... 60, 61
ABILIFY DISCMELT ........... 60
ABILIFY MAINTENA ......... 60
ABRAXANE ......................... 34
ABREVA ............................... 56
acamprosate............................ 22
acarbose.................................. 46
acebutolol ............................... 76
acephen .................................. 14
acetaminophen ....................... 14
acetaminophen-codeine.......... 14
acetazolamide ....................... 130
acetazolamide sodium .......... 130
acetic acid..................... 107, 125
acetylcysteine ....................... 138
acid gone antacid.......... 110, 111
acid reducer (famotidine) ..... 109
acid reducer (ranitidine) ....... 109
acid relief (cimetidine) ......... 109
acitretin .................................. 95
acne medication ............... 95, 96
acne-clear ............................... 96
ACTEMRA .................. 126, 127
ACTHIB (PF) ....................... 123
ACTIMMUNE ..................... 127
acyclovir ........................... 66, 96
acyclovir sodium .................... 66
ADACEL(TDAP
ADOLESN/ADULT)(PF) 123
ADAGEN ............................. 102
adapalene .............................. 101
ADCETRIS ............................ 34
ADCIRCA .................... 140, 141
adefovir .................................. 66
ADEMPAS........................... 141
adrenalin ................................. 77
ADRENALIN ........................ 77
adt robitussin peak cld dm max
............................................ 85
adult nasal decongestant......... 85
adult one daily gummies ...... 142
adult robitussin lingering cld.. 85
adult robitussin peak cold dm 85
adult wal-tussin ...................... 85
adult wal-tussin dm max ........ 85
adults 50+ daily formula ...... 142
adults' daily formula ............. 142
ADVAIR DISKUS ............... 137
ADVAIR HFA ..................... 137
advil ........................................ 18
af 50
AFINITOR ............................. 34
AFINITOR DISPERZ ............ 34
AGGRENOX ......................... 69
airshield ................................ 142
AKTEN (PF) ........................ 103
alavert d-12 allergy-sinus . 52, 53
alaway .................................. 103
ALBENZA ............................. 59
ALBUKED-25 ....................... 69
ALBUKED-5 ......................... 69
ALBUMIN, HUMAN 25 % ... 69
ALBUMIN, HUMAN 5 % ..... 69
ALBUMINAR 25 % .............. 69
ALBUMINAR 5 % ................ 69
ALBURX (HUMAN) 5 % ..... 69
ALBUTEIN 25 % .................. 69
ALBUTEIN 5 % .................... 69
albuterol sulfate .................... 137
alclometasone ......................... 98
ALCOHOL PADS ................. 96
ALCOHOL PREP PADS ....... 96
ALCOH-WIPE ....................... 96
ALDURAZYME .................. 102
alendronate ........................... 125
alfuzosin ............................... 117
ALIMTA ................................ 34
ALINIA .................................. 59
alka-seltzer plus mucus-conges
............................................ 85
alka-seltzer plus sinus-cough . 85
aller-chlor ............................... 53
allerclear d-12hr ..................... 53
allerclear d-24hr ..................... 53
allergy (chlorpheniramine) ..... 53
allergy relief (cetirizine) ......... 53
allergy relief (loratadine)........ 53
allerhist-1................................ 53
aller-tec d ................................ 53
allopurinol ............................ 127
almacone .............................. 111
almacone-2 ........................... 111
aloe vesta ................................ 50
alophen ................................. 113
ALPHAGAN P..................... 130
I-1
Fòmilè ICS Community Care Plus 2015 FIDA-MMP
ID Fòmilè a: 15412.000, Vèsyon: 12
Anvigè apati: 1 Jiyè 2015
alprazolam .............................. 23
ALREX ................................ 108
altacaine ............................... 103
altamist ................................. 103
aluminum chloride ................. 96
aluminum hydroxide gel ...... 111
amantadine hcl ....................... 59
ambi 10peh-4cpm-20dm ........ 85
ambi 20dm-4cpm ................... 85
ambi 40pse-400gfn-20dm ...... 85
ambi 60pse-4cpm ................... 53
ambi 60pse-4cpm-20dm......... 85
AMBISOME .......................... 50
ambizine ................................. 58
amifostine crystalline ........... 127
amiloride ................................ 79
amiloride-hydrochlorothiazide79
AMINO ACIDS 15 % ............ 70
aminocaproic acid .................. 69
AMINOSYN 10 % ................. 70
AMINOSYN 3.5 % ................ 70
AMINOSYN 7 % ................... 70
AMINOSYN 7 % WITH
ELECTROLYTES ............. 70
AMINOSYN 8.5 % ................ 70
AMINOSYN 8.5 %ELECTROLYTES ............. 70
AMINOSYN II 10 % ............. 70
AMINOSYN II 15 % ............. 70
AMINOSYN II 7 % ............... 70
AMINOSYN II 8.5 % ............ 70
AMINOSYN II 8.5 %ELECTROLYTES ............. 70
AMINOSYN M 3.5 % ........... 70
AMINOSYN-HBC 7% .......... 70
AMINOSYN-PF 10 % ........... 70
AMINOSYN-PF 7 %
(SULFITE-FREE) .............. 70
AMINOSYN-RF 5.2 % ......... 70
amiodarone ............................. 75
amiodarone hcl ....................... 75
AMITIZA ............................. 111
amitriptyline ..................... 44, 45
amlactin .................................. 96
amlodipine.............................. 79
amlodipine-atorvastatin .......... 80
amlodipine-benazepril ............ 79
ammonium lactate .................. 96
amoxapine .............................. 45
amoxicil-clarithromy-lansopraz
.......................................... 109
amoxicillin ............................. 31
amoxicillin-pot clavulanate .... 31
amphetamine salt combo ........ 82
amphotericin b........................ 50
ampicillin ............................... 31
ampicillin sodium................... 31
ampicillin-sulbactam .............. 32
AMPYRA............................... 82
ANACAINE ........................... 96
anagrelide ............................... 69
anastrozole ............................. 34
ANDRODERM .................... 117
ANDROGEL ................ 117, 118
animal chews ........................ 142
animal shape vitamins .......... 142
animal shapes plus iron ........ 142
ANORO ELLIPTA .............. 137
antacid .................................. 111
antacid anti-gas .................... 111
antacid plus anti-gas ............. 111
anticoag citrate phos dextrose
.......................................... 127
anti-diarrheal ........................ 111
anti-diarrheal (loperamide) .. 111
antifungal ............................... 50
antifungal (tolnaftate) ............. 50
anti-gas maximum strength .. 109
antioxidant............................ 142
antioxidant formula .............. 142
antioxidant vitamins ............. 142
apatate forte .......................... 142
APOKYN ............................... 60
apraclonidine ........................ 103
APRISO........................ 124, 125
aprodine .................................. 53
APTIOM ................................ 41
APTIVUS ............................... 63
aquanil hc ............................... 98
ARALAST NP ..................... 138
ARCALYST ......................... 121
aripiprazole ............................. 61
ARRANON ............................ 34
artificial tears ........................ 104
artificial tears (petro/min) .... 103
artificial tears (pf) ................. 104
artificial tears(glycerin-peg) . 104
artificial tears(hypromellose) 104
ARZERRA ............................. 34
ASACOL HD ....................... 125
ascorbic acid ......................... 142
ashlyna.................................... 83
aspirin ..................................... 19
aspirin, buffered ..................... 19
aspir-low ................................. 19
ASSURE ID INSULIN
SAFETY ........................... 102
ASTAGRAF XL .................. 121
atenolol ................................... 76
atenolol-chlorthalidone .......... 76
athlete's foot (clotrimazole) .... 50
atorvastatin ............................. 80
atovaquone ............................. 59
atovaquone-proguanil ............. 59
ATRIPLA ............................... 63
atropine ........................... 41, 104
ATROVENT HFA ............... 138
AUBAGIO ........................... 121
AVASTIN .............................. 34
AVC VAGINAL .................... 56
AVODART .......................... 127
AVONEX ............................. 127
AVONEX (WITH ALBUMIN)
.......................................... 127
ayr saline .............................. 104
azacitidine .............................. 34
I-2
Fòmilè ICS Community Care Plus 2015 FIDA-MMP
ID Fòmilè a: 15412.000, Vèsyon: 12
Anvigè apati: 1 Jiyè 2015
azathioprine .......................... 121
azathioprine sodium ............. 121
azelastine .............................. 104
AZILECT ............................... 60
azithromycin .......................... 30
AZOPT ................................. 130
AZOR ..................................... 79
aztreonam ............................... 31
B
b complete ............................ 142
b complex 1 .......................... 142
b complex-vitamin b12 ........ 142
b complex-vitamin c-folic acid
.......................................... 142
b-100 complex ..................... 142
b-12 dots............................... 142
b-50 complex ....................... 143
bacitracin .................. 27, 97, 107
bacitracin-polymyxin b ........ 107
bacitraycin plus ...................... 97
baclofen ................................ 139
bal b-100 .............................. 143
bal b-50 ................................ 143
balance b-100 ....................... 143
balance b-50 ......................... 143
balanced b-100 ..................... 143
balanced b-150 ..................... 143
balanced b-50 ....................... 143
balsalazide ............................ 125
banophen ................................ 53
banophen allergy .................... 53
BANZEL ................................ 41
baza antifungal ....................... 50
BCG VACCINE, LIVE (PF) 123
b-complex ............................ 143
b-complex with vitamin c .... 143
BD INSULIN PEN NEEDLE
UF SHORT ...................... 102
BD INSULIN SYRINGE
ULTRA-FINE .................. 102
bee-zee ................................. 143
BELEODAQ .......................... 34
benadryl allergy...................... 53
benazepril ............................... 74
benazepril-hydrochlorothiazide
............................................ 74
BENICAR .............................. 74
BENICAR HCT ..................... 74
BENLYSTA ......................... 127
benzonatate............................. 85
benzoyl peroxide .................... 96
benztropine ............................. 60
BETADINE SPRAY .............. 96
beta-hc .................................... 98
betamethasone acet,sod phos 119
betamethasone dipropionate .. 98,
99
betamethasone valerate .......... 99
betamethasone, augmented .... 99
BETASERON ...................... 127
betaxolol ......................... 76, 130
bethanechol chloride ............ 127
BETHKIS ............................... 26
BEXSERO (PF) ................... 123
bicalutamide ........................... 34
bicarsim forte ....................... 109
BICILLIN C-R ....................... 32
BICILLIN L-A ....................... 32
BILTRICIDE ......................... 59
bimatoprost........................... 130
bio-dtuss dmx ......................... 86
bion tears (pf) ....................... 104
bionel ...................................... 86
bionel pediatric ....................... 86
biospec dmx ........................... 86
biosupp ................................. 143
biotin .................................... 143
biovol ................................... 143
bisac-evac ............................. 113
bisacodyl .............................. 113
biscolax ................................ 113
bismatrol............................... 111
bisoprolol fumarate ................ 76
bisoprolol-hydrochlorothiazide
............................................ 76
bleomycin ............................... 34
BLINCYTO............................ 34
BOOSTRIX TDAP .............. 123
BOSULIF ............................... 34
BOTOX ................................ 127
BREO ELLIPTA .................. 137
BRILINTA ............................. 69
brimonidine .......................... 130
BRINTELLIX ........................ 45
bromfenac ............................. 108
bromocriptine ......................... 60
bromphenex dm ...................... 86
brompheniramine-pseudoephdm ....................................... 86
brompheniram-phenylephrinedm ....................................... 86
broncotron-s ........................... 86
budesonide............................ 125
bufferin ................................... 19
bumetanide ............................. 79
BUMINATE 25 % ................. 70
BUMINATE 5 % ................... 70
BUPHENYL ........................ 111
buprenorphine hcl............. 14, 22
buprenorphine-naloxone ........ 22
bupropion hcl ................... 22, 45
buspirone .............................. 127
butalb-acetaminophen-caffeine
............................................ 14
butalbital-acetaminop-caf-cod 14
butalbital-acetaminophen ....... 14
butalbital-acetaminophen-caff 14
butalbital-aspirin-caffeine ...... 14
butorphanol tartrate ................ 14
BUTRANS ............................. 14
BYDUREON.......................... 46
BYETTA ................................ 47
BYSTOLIC ............................ 76
C
c complex ............................. 143
I-3
Fòmilè ICS Community Care Plus 2015 FIDA-MMP
ID Fòmilè a: 15412.000, Vèsyon: 12
Anvigè apati: 1 Jiyè 2015
cabergoline ............................. 60
ca-d3-mag ox-zinc-cop-mangbor .................................... 131
caffeine citrated ...................... 82
caffeine-sodium benzoate ...... 82
calci-chew ............................ 111
calcidol ................................. 143
calcionate ............................. 131
calcipotriene ........................... 96
calcitonin (salmon)............... 125
calcitrate ............................... 131
calcitrate-vitamin d .............. 131
calcitriol ......................... 96, 125
calcium 500 + d.................... 131
calcium 500 + d (d3) ............ 131
calcium 500 with d ............... 131
calcium 600 .......................... 131
calcium 600 + d(3) ............... 131
calcium 600 with vitamin d3 131
calcium acetate ..................... 116
calcium antacid .................... 111
calcium carbonate ........ 111, 132
calcium carbonate-mag carb-fa
.......................................... 116
calcium carbonate-vitamin d2
.......................................... 132
calcium carbonate-vitamin d3
.......................................... 132
CALCIUM CARBONATEVITAMIN D3 .................. 111
calcium chloride ................... 132
calcium citrate-vitamin d3 ... 132
calcium gluconate ................ 132
calcium lactate ..................... 132
calcium+d............................. 132
CALDOLOR .......................... 19
cal-gest antacid..................... 111
calphron................................ 116
CALTRATE 600 + D .......... 132
CALTRATE-600 + D VIT D3
(800) ................................. 132
CANCIDAS ........................... 50
candesartan ............................. 74
candesartan-hydrochlorothiazid
............................................ 74
CAPASTAT ........................... 57
CAPRELSA ..................... 34, 35
captopril ................................. 74
captopril-hydrochlorothiazide 74
CARAFATE......................... 109
carbamazepine ........................ 42
carbidopa ................................ 60
carbidopa-levodopa ................ 60
carbidopa-levodopa-entacapone
............................................ 60
carboplatin .............................. 35
cardec dm (phenyleph-chlorphn)
............................................ 86
CARIMUNE NF
NANOFILTERED ........... 121
carisoprodol .......................... 139
carteolol ................................ 104
cartia xt ................................... 76
carvedilol ................................ 76
CASTELLANI PAINT
MODIFIED ........................ 96
CAYSTON ............................. 31
cefaclor ................................... 28
cefadroxil ......................... 28, 29
cefazolin ................................. 29
cefazolin in dextrose (iso-os) . 29
cefdinir ................................... 29
cefditoren pivoxil ................... 29
cefepime ................................. 29
CEFEPIME IN DEXTROSE 5
% ........................................ 29
CEFEPIME IN
DEXTROSE,ISO-OSM ..... 29
cefotaxime .............................. 29
cefoxitin ................................. 29
cefoxitin in dextrose, iso-osm 29
cefpodoxime ........................... 29
cefprozil ................................. 29
ceftazidime ............................. 29
ceftibuten ................................ 29
ceftriaxone ........................ 29, 30
ceftriaxone in dextrose,iso-os. 29
cefuroxime axetil .................... 30
cefuroxime sodium ................. 30
cefuroxime-dextrose (iso-osm)
............................................ 30
celecoxib ................................ 19
CELLCEPT INTRAVENOUS
.......................................... 121
CELONTIN ............................ 42
centamin ............................... 143
central vite with lutein .......... 144
central-vite............................ 144
central-vite for seniors.......... 144
central-vite select ......... 144, 153
central-vite senior ................. 144
centram-care ......................... 144
centravites 50 plus ................ 144
centrum ................................. 144
centrum complete ................. 144
CENTRUM PRO NUTRIENTS
.......................................... 132
centrum silver ....................... 144
centrum ultra women's ......... 144
century .................................. 144
century adults 50+ ................ 144
century advanced formula .... 144
century mature ...................... 144
century ultimate women's..... 144
cephalexin .............................. 30
CEPROTIN (BLUE BAR) .... 66,
67
CERDELGA ........................ 127
CEREZYME ........................ 103
cerovite ................................. 144
cerovite advanced formula ... 144
cerovite jr ............................. 145
cerovite senior ...................... 145
certavite senior-antioxidant .. 145
certavite-antioxid (iron gluc) 145
certavite-antioxidant ............. 145
I-4
Fòmilè ICS Community Care Plus 2015 FIDA-MMP
ID Fòmilè a: 15412.000, Vèsyon: 12
Anvigè apati: 1 Jiyè 2015
CERVARIX VACCINE (PF)
.......................................... 123
cetirizine ................................. 53
cetirizine-pseudoephedrine .... 53
cevimeline .............................. 95
CHANTIX.............................. 22
CHANTIX CONTINUING
MONTH BOX ................... 22
CHANTIX CONTINUING
MONTH PAK .................... 22
CHANTIX STARTING
MONTH BOX ................... 22
cheratussin ac ......................... 86
cheratussin dac ....................... 86
chest congestion relief + dm .. 86
chest congestion relief d......... 86
chest congestion relief pe ....... 86
chewable multi vitamin ........ 145
chewable-vite ....................... 145
chewable-vite with iron........ 145
child complete multivitamin 145
child cough & sore throat ....... 86
child mucinex chest congestion
............................................ 86
child mucus relief cough ........ 86
child plus cough & runny nose
............................................ 86
child triaminic cold & allergy 53
child triaminic cough-congest 87
child vitamin with minerals . 145
child wal-tap cold-allergy ...... 53
child wal-tussin cough relief .. 87
children's advil ....................... 19
children's aller-tec .................. 53
children's cetirizine ................ 53
children's chest congestion..... 87
children's chewable .............. 145
children's chewable complete
.......................................... 145
children's chewable vitamin . 145
children's chewable w/minerals
.......................................... 145
CHILDREN'S CLARITIN ..... 53
children's complete vitamin . 145
CHILDREN'S DIMETAPP
COLD &FLU ..................... 87
children's flu relief ................. 87
children's mapap ..................... 14
children's mucinex cough ....... 87
children's multivit w/extra c . 145
children's non-aspirin ............. 14
children's pain & fever relief.. 14
children's pain reliever ........... 14
children's pepto .................... 111
children's silapap .................... 15
children's silfedrine ................ 87
children's soothe ................... 111
children's sudafed ................... 87
children's sudafed pe cough ... 87
children's vitamin with iron . 145
children's wal-dryl allergy...... 54
children's wal-zyr ................... 54
CHILDREN'S ZYRTEC
ALLERGY ......................... 54
childs chew vite .................... 145
child's chewable vitamins/iron
.......................................... 145
child's vitamin with iron....... 145
child's vitamin with vitamin c
.......................................... 145
childs/iron............................. 146
chlophedianol-guaifenesin ..... 87
chloramphenicol sod succinate
............................................ 27
chlordiazepoxide hcl .............. 23
chlorhexidine gluconate ......... 95
chloroquine phosphate ........... 59
chlorothiazide ......................... 79
chlorothiazide sodium ............ 79
chlorpheniramine-phenyleph-dm
............................................ 87
chlorpromazine....................... 61
chlorthalidone......................... 79
chlorzoxazone ...................... 139
CHOLBAM .......................... 111
cholestyramine (with sugar) ... 80
cholestyramine-aspartame ...... 80
choline,magnesium salicylate 19
ciclopirox................................ 50
ciclopirox-ure-camph-menth-euc
............................................ 50
cilostazol ................................ 69
cimetidine ............................. 109
cimetidine hcl ....................... 109
CIMZIA................................ 103
CIMZIA POWDER FOR
RECONST........................ 103
CIPRODEX .......................... 107
ciprofloxacin .......................... 32
ciprofloxacin hcl............. 32, 107
ciprofloxacin in 5 % dextrose 32
ciprofloxacin lactate ............... 32
cisplatin .................................. 35
citalopram ............................... 45
citracal + d maximum........... 132
citric acid-sodium citrate ...... 132
citrus calcium ....................... 133
clarithromycin ........................ 30
CLARITIN ............................. 54
CLARITIN LIQUI-GEL ........ 54
CLARITIN REDITABS......... 54
CLARITIN-D 12 HOUR........ 54
CLARITIN-D 24 HOUR........ 54
clearlax ................................. 113
clemastine ............................... 54
CLEVIPREX .......................... 79
clindamycin hcl ...................... 27
clindamycin in 5 % dextrose .. 27
clindamycin palmitate hcl ...... 27
clindamycin phosphate .... 27, 56,
97, 98
CLINIMIX 5%/D15W
SULFITE FREE ................. 70
CLINIMIX 5%/D25W
SULFITE-FREE ................. 70
I-5
Fòmilè ICS Community Care Plus 2015 FIDA-MMP
ID Fòmilè a: 15412.000, Vèsyon: 12
Anvigè apati: 1 Jiyè 2015
CLINIMIX 2.75%/D5W
SULFIT FREE ................... 71
CLINIMIX 4.25%/D10W SULF
FREE .................................. 71
CLINIMIX 4.25%/D5W
SULFIT FREE ................... 71
CLINIMIX 4.25%-D20W
SULF-FREE ....................... 71
CLINIMIX 4.25%-D25W
SULF-FREE ....................... 71
CLINIMIX 5%D20W(SULFITE-FREE) ... 71
CLINIMIX E 2.75%/D10W
SUL FREE ......................... 71
CLINIMIX E 2.75%/D5W
SULF FREE ....................... 71
CLINIMIX E 4.25%/D10W
SUL FREE ......................... 71
CLINIMIX E 4.25%/D25W
SUL FREE ......................... 71
CLINIMIX E 4.25%/D5W
SULF FREE ....................... 71
CLINIMIX E 5%/D15W
SULFIT FREE ................... 71
CLINIMIX E 5%/D20W
SULFIT FREE ................... 71
CLINIMIX E 5%/D25W
SULFIT FREE ................... 71
CLINISOL SF 15 %............... 71
clobetasol ............................... 99
clobetasol propionate ............. 99
clobetasol-emollient ............... 99
clocortolone pivalate .............. 99
clomipramine ......................... 45
clonazepam ............................ 23
clonidine ................................. 73
clonidine hcl ..................... 73, 82
clonidine hcl-chlorthalidone .. 73
clopidogrel ............................. 69
clorazepate dipotassium ......... 23
clotrimazole...................... 50, 51
clotrimazole 3 day .................. 50
clotrimazole-3 ........................ 51
clotrimazole-betamethasone... 51
clozapine ................................ 61
COARTEM ............................ 59
codeine sulfate........................ 15
codeine-butalbital-asa-caffein 15
codituss dm ............................ 87
colace ................................... 113
colchicine ............................. 127
colchicine-probenecid .......... 127
COLCRYS ........................... 127
cold & cough .......................... 54
cold multi-symptom ............... 87
cold multi-symptom day/night87
cold multi-symptom nighttime
............................................ 87
cold relief m/s day/night ........ 87
cold-flu relief.......................... 87
cold-flu relief, day/night ........ 88
colestipol ................................ 80
colistin (colistimethate na) ..... 27
COLY-MYCIN S ................. 107
COMBIGAN ........................ 130
COMBIPATCH ................... 118
COMBIVENT RESPIMAT . 138
COMETRIQ ........................... 35
comfort gel extra strength .... 111
COMFORT PACCYCLOBENZAPRINE ... 139
COMFORT PAC-IBUPROFEN
............................................ 19
COMFORT PACMELOXICAM ................... 19
COMFORT PAC-NAPROXEN
............................................ 19
COMFORT PAC-TIZANIDINE
.......................................... 139
compete ................................ 146
COMPLERA .......................... 64
complete 50+ ........................ 146
complete multi 50+ .............. 146
complete multivitamin ......... 146
complete multivitamin-mineral
.......................................... 146
complete senior .................... 146
compoz ................................... 54
COMVAX (PF) .................... 123
CONDYLOX ......................... 96
congestac ................................ 88
COPAXONE ........................ 127
coral calcium ........................ 133
CORDRAN ............................ 99
coricidin hbp........................... 88
cortisone ............................... 119
cortizone-10.................... 99, 100
CORTIZONE-10 .................. 100
COSENTYX PEN (2 PENS) . 96
cough & cold .......................... 88
cough & runny nose ............... 88
coughtab ................................. 88
CREON ................................ 103
creo-terpin (dm-guaifenesin) .. 88
CRESTOR .............................. 80
critic-aid clear af .................... 51
CRIXIVAN ............................ 64
cromolyn .............. 104, 112, 138
CUBICIN ............................... 27
CURITY GAUZE ................ 127
cyanocobalamin (vitamin b-12)
.......................................... 146
cyclobenzaprine.................... 139
CYCLOGYL ........................ 104
cyclopentolate ...................... 104
cyclophosphamide .................. 35
CYCLOPHOSPHAMIDE ...... 35
CYCLOSET ........................... 47
cyclosporine ......................... 121
cyclosporine modified .......... 121
cyclosporine, modified ......... 122
cyproheptadine ....................... 54
CYRAMZA ............................ 35
CYSTADANE...................... 127
CYSTARAN ........................ 104
cysteine (l-cysteine) ............... 71
I-6
Fòmilè ICS Community Care Plus 2015 FIDA-MMP
ID Fòmilè a: 15412.000, Vèsyon: 12
Anvigè apati: 1 Jiyè 2015
cytarabine ............................... 35
cytarabine (pf) ........................ 35
D
d10 % & 0.45 % sodium
chloride .............................. 71
d2.5 %-0.45 % sodium chloride
............................................ 71
d5 % and 0.9 % sodium chloride
............................................ 72
d5 %-0.45 % sodium chloride 72
dacarbazine ............................ 35
dactinomycin .......................... 35
daily gummies ...................... 146
daily multiple ....................... 146
daily multi-vitamin............... 146
daily multivitamin with iron 146
daily multivitamin-minerals . 146
daily multi-vitamins/iron ..... 146
daily teen multi-vitamin ....... 147
daily value ............................ 147
daily vitamin ........................ 147
daily vitamin formula ........... 147
daily vitamin formula + iron 147
daily vitamin formula-minerals
.......................................... 147
daily vitamin with iron ......... 147
daily vites/iron ..................... 147
dailyhist-1 .............................. 54
daily-vite .............................. 147
DALIRESP .......................... 138
DALLERGY DM................... 88
danazol ................................. 118
dantrolene ............................. 139
dantrolene sodium ................ 139
dapsone .................................. 57
DAPTACEL (DTAP
PEDIATRIC) (PF) ........... 123
DARAPRIM .......................... 59
dayhist allergy ........................ 54
daytime cold & cough ............ 88
daytime cold-flu ..................... 88
day-time cough....................... 88
daytime mucus relief dm ........ 88
daytime-nighttime .................. 88
daytime-nighttime cold-flu .... 88
daytime-nighttime cough ....... 88
deblitane ................................. 83
decitabine ............................... 35
decongestant cough ................ 88
deep sea nasal ....................... 104
deferoxamine ........................ 117
delsym cough+chest congest dm
............................................ 88
DELZICOL .......................... 125
DEMSER ............................... 77
DEPEN TITRATABS .......... 117
DEPO-PROVERA ............... 121
dermafungal ........................... 51
dermarest eczema (hydrocort)
.......................................... 100
desenex ................................... 51
desipramine ............................ 45
desmopressin ........................ 119
desog-e.estradiol/e.estradiol ... 83
desogestrel-ethinyl estradiol .. 83
desonide ............................... 100
desoximetasone .................... 100
despec-dm (pseudoeph-dmguaif) .................................. 88
dex4 glucose ........................... 72
dexamethasone ..................... 119
dexamethasone sodium
phosphate ................. 108, 119
dexchlorphen-pse-chlophedianol
............................................ 88
dexmethylphenidate ............... 82
dextroamphetamine ................ 82
dextroamphetamineamphetamine ...................... 82
dextromethorphan polistirex .. 88
dextrose 10 % and 0.2 % nacl 72
dextrose 10 % in water (d10w)
............................................ 72
dextrose 2.5 % in water(d2.5w)
............................................ 72
dextrose 20 % in water (d20w)
............................................ 72
dextrose 25 % in water (d25w)
............................................ 72
dextrose 40 % in water (d40w)
............................................ 72
dextrose 5 % in ringers ........... 72
dextrose 5 % in water (d5w) .. 72
dextrose 5 %-lactated ringers . 72
dextrose 5%-0.2 % sod chloride
............................................ 72
dextrose 5%-0.3 % sod.chloride
............................................ 72
dextrose 50 % in water (d50w)
............................................ 72
dextrose 70 % in water (d70w)
............................................ 72
dextrose with sodium chloride 72
diabetic siltussin das-na.......... 89
diabetic tussin dm ................... 89
diabetic tussin ex .................... 89
diamode ................................ 112
DIASTAT ACUDIAL ............ 23
diazepam .......................... 23, 24
diazepam intensol ................... 24
diclofenac potassium .............. 19
diclofenac sodium .......... 19, 108
diclofenac-misoprostol ........... 19
dicloxacillin ............................ 32
dicyclomine .......................... 112
didanosine .............................. 64
DIFICID ................................. 30
diflunisal ................................. 19
digitek ..................................... 77
digoxin.............................. 77, 78
DIGOXIN ............................... 78
dihydroergotamine ................. 57
DILANTIN ............................. 42
diltiazem hcl ..................... 76, 77
dilt-xr ...................................... 77
I-7
Fòmilè ICS Community Care Plus 2015 FIDA-MMP
ID Fòmilè a: 15412.000, Vèsyon: 12
Anvigè apati: 1 Jiyè 2015
dimaphen (pe) ........................ 54
dimaphen dm .......................... 89
dimenhydrinate ...................... 58
dimetapp cold-congestion ...... 54
dino-life ................................ 147
dino-life with extra c ............ 147
dino-life with iron-zinc ........ 147
DIPENTUM ......................... 125
diphenhist ............................... 54
diphenhydramine hcl .............. 54
diphenoxylate-atropine ........ 112
disopyramide phosphate......... 75
disulfiram ............................... 22
divalproex .............................. 42
d-methorphan hb-p-epd hcl-bpm
............................................ 89
dm-phenyleph-chlorpheniramine
............................................ 89
dobutamine............................. 78
dobutamine in d5w................. 78
doc-q-lace ............................. 113
docu ...................................... 114
docusate calcium .................. 114
docusate sodium ................... 114
docusol ................................. 114
dok........................................ 114
donepezil ................................ 44
dopamine ................................ 78
dopamine in 5 % dextrose ...... 78
dorzolamide.......................... 130
dorzolamide-timolol............. 130
double-tussin dm .................... 89
douche vinegar & water extra
.......................................... 127
doxazosin ............................... 73
doxepin................................... 45
doxercalciferol ..................... 126
doxorubicin hcl ...................... 35
doxorubicin hcl peg-liposomal
............................................ 35
doxorubicin, peg-liposomal ... 35
doxycycline hyclate ............... 33
doxycycline monohydrate ...... 33
dramamine .............................. 58
driminate ................................ 58
dristan long lasting ............... 104
dronabinol .............................. 58
droperidol ............................. 127
drospirenone-ethinyl estradiol 83
DROXIA ................................ 35
DUAVEE ............................. 118
dulcolax stool softener (dss) 114
DULERA ............................. 137
duloxetine ............................... 45
DURAMORPH (PF) .............. 15
DUREZOL ........................... 108
DYRENIUM .......................... 79
E
e.c. prin ................................... 19
ECEE PLUS ......................... 147
econazole ................................ 51
ed bron gp............................... 89
ed chlorped jr ......................... 55
EDURANT............................. 64
EFFIENT ................................ 69
ELAPRASE ......................... 103
eldertonic .............................. 147
electrolyte-48 in d5w ........... 133
ELIDEL ................................ 100
ELIGARD .............................. 35
ELIQUIS ................................ 67
ELITEK ................................ 103
ELLA ..................................... 83
ellis tonic .............................. 147
ELMIRON ........................... 127
elon dual defense .................... 51
EMCYT.................................. 35
EMEND ................................. 58
EMSAM ................................. 45
EMTRIVA ............................. 64
enalapril maleate .................... 74
enalaprilat ............................... 74
enalapril-hydrochlorothiazide 74
ENBREL .............................. 122
ENBREL SURECLICK ....... 122
endur-acin ............................... 80
enema ................................... 114
enema disposable ................. 114
enemeez ................................ 114
enfalyte ................................. 133
ENGERIX-B (PF) ................ 123
ENGERIX-B PEDIATRIC (PF)
.......................................... 123
enoxaparin .............................. 67
entacapone .............................. 60
entecavir ................................. 66
entre-cough ............................. 89
ephedrine sulfate .................... 78
epinastine.............................. 104
epinephrine ............................. 78
EPIPEN 2-PAK ...................... 78
EPIPEN JR 2-PAK................. 78
epirubicin................................ 35
EPIVIR HBV ......................... 64
eplerenone .............................. 81
EPOGEN ................................ 68
epoprostenol (glycine) .......... 141
EPZICOM .............................. 64
eq gentle ............................... 104
equalactin ............................. 114
ERBITUX .............................. 36
ergocalciferol (vitamin d2) ... 147
ergoloid ................................ 127
ERGOMAR ............................ 57
ERIVEDGE ............................ 36
ERYTHROCIN ...................... 30
erythromycin .................. 31, 107
erythromycin base .................. 30
ERYTHROMYCIN BASE .... 30
erythromycin base-ethanol ..... 98
erythromycin ethylsuccinate . 30,
31
erythromycin stearate ............. 31
erythromycin with ethanol ..... 98
ESBRIET.............................. 139
escitalopram oxalate ............... 45
I-8
Fòmilè ICS Community Care Plus 2015 FIDA-MMP
ID Fòmilè a: 15412.000, Vèsyon: 12
Anvigè apati: 1 Jiyè 2015
esmolol ................................... 76
esomeprazole sodium ........... 110
essentia ................................. 147
essential balance with lutein 147
essential daily ....................... 147
essential one daily ................ 147
estazolam................................ 24
ESTRACE ............................ 118
estradiol ................................ 118
estradiol valerate .................. 118
estradiol/norethindrone acet . 118
estradiol-norethindrone acet. 118
ESTRASORB ...................... 118
estropipate ............................ 118
ethambutol.............................. 57
ethamolin................................ 78
ethinyl estradiol/drospirenone 83
ethosuximide .......................... 42
ethynodiol d-ethinyl estradiol 84
etidronate disodium .............. 126
etodolac .................................. 19
ETOPOPHOS ........................ 36
etoposide ................................ 36
EVOTAZ................................ 64
exefen dmx ............................. 89
EXELON................................ 44
exemestane ............................. 36
EXFORGE ............................. 79
EXFORGE HCT .................... 79
EXJADE .............................. 117
expectorant ............................. 89
expectorant max strength ....... 89
EXTAVIA ............................ 128
extra cleansing douche ......... 128
F
FABRAZYME ..................... 103
famciclovir ............................. 66
famotidine ............................ 110
famotidine (pf) ..................... 110
famotidine (pf)-nacl (iso-os) 110
FANAPT ................................ 61
FARESTON ........................... 36
FARYDAK ............................ 36
FASLODEX ........................... 36
FAZACLO ............................. 61
fe fumarate-doss-fa-bcomp and
c ........................................ 147
fe fumarate-vit c-b12-if-fa ... 148
felbamate ................................ 42
felodipine ............................... 79
feminine care douche ........... 128
FEMRING ............................ 118
fenofibrate .............................. 80
fenofibrate micronized ........... 80
fenofibrate nanocrystallized ... 80
fenofibric acid ........................ 80
fenofibric acid (choline) ......... 80
fenoprofen .............................. 19
fentanyl................................... 15
fentanyl citrate........................ 15
ferate..................................... 148
ferotrinsic ............................. 148
ferretts .................................. 148
ferrex 150 ............................. 148
ferrex 150 plus ..................... 148
FERRIPROX ........................ 117
ferrocite ................................ 148
ferrous fumarate ................... 148
ferrous gluconate .................. 148
ferrous sulfate ....................... 148
FETZIMA .............................. 45
feverall ................................... 15
fiber (calcium polycarbophil)
.......................................... 114
fiber laxative ........................ 114
fiber smooth ......................... 114
fiber therapy ......................... 114
fiber therapy (psyllium/sugar)
.......................................... 114
fiber-lax ................................ 114
finasteride ............................. 128
FIRAZYR............................... 78
FIRMAGON KIT W DILUENT
SYRINGE .......................... 36
flanax antacid ....................... 112
FLEBOGAMMA DIF .......... 122
flecainide ................................ 75
FLECTOR .............................. 19
FLEET BISACODYL .......... 114
FLEXBUMIN 25 % ............... 70
FLEXBUMIN 5 % ................. 70
flintstones complete (iron) ... 148
flintstones multivitamin ....... 148
flintstones with iron.............. 148
flintstones/extra c ................. 148
FLOVENT DISKUS ............ 137
FLOVENT HFA................... 137
floxuridine .............................. 36
flu formula daytime-nighttime89
flu severe cold-congestion...... 89
fluconazole ............................. 51
fluconazole in dextrose(iso-o) 51
fluconazole in nacl (iso-osm) . 51
flucytosine .............................. 51
fludarabine.............................. 36
fludrocortisone ..................... 119
flumazenil ............................... 82
fluocinonide.......................... 100
fluocinonide-emollient base . 100
fluorometholone ................... 108
FLUOROPLEX ...................... 96
fluorouracil ....................... 36, 97
fluoxetine................................ 45
FLUOXETINE ....................... 45
fluoxymesterone ................... 118
fluphenazine decanoate .......... 61
fluphenazine hcl ..................... 61
flurazepam ........................ 24, 25
flurbiprofen ............................ 19
flurbiprofen sodium .............. 108
flu-severe cold-cough ............. 89
flutamide ................................ 36
fluticasone .................... 100, 108
fluvoxamine............................ 45
foaming antacid .................... 112
folic acid ............................... 148
I-9
Fòmilè ICS Community Care Plus 2015 FIDA-MMP
ID Fòmilè a: 15412.000, Vèsyon: 12
Anvigè apati: 1 Jiyè 2015
FOLIC ACID ....................... 148
fomepizole............................ 128
fondaparinux .......................... 67
FORTEO .............................. 126
FORTICAL .......................... 126
foscarnet ................................. 65
fosfree .................................. 148
fosinopril ................................ 75
fosinopril-hydrochlorothiazide
............................................ 75
fosphenytoin ........................... 42
FREAMINE HBC 6.9 %........ 72
FREAMINE III 10 % ............. 72
fruity chews .......................... 148
fungi cure ............................... 51
FUNGI-NAIL ........................ 51
fungoid-d ................................ 51
furosemide.............................. 79
FUSILEV ............................. 128
FUZEON ................................ 64
FYCOMPA ............................ 42
G
gabapentin .............................. 42
GABITRIL ............................. 42
galantamine ............................ 44
GAMASTAN S/D ................ 122
GAMMAGARD LIQUID .... 122
GAMMAPLEX .................... 122
GAMUNEX-C ..................... 122
ganciclovir sodium ................. 66
GARDASIL (PF) ................. 123
GARDASIL 9 (PF) .............. 123
gas free extra strength .......... 109
gas relief ............................... 109
gas relief 80 .......................... 109
gas relief extra strength ........ 109
gas-x ultra-strength .............. 109
gatifloxacin .......................... 107
GAZYVA ............................... 36
gelusil antacid & anti-gas..... 112
gemcitabine ............................ 36
gemfibrozil ............................. 80
GENOTROPIN .................... 119
GENOTROPIN MINIQUICK
.......................................... 120
gentamicin ................ 26, 98, 107
gentamicin in nacl (iso-osm) .. 26
gentamicin sulfate ................ 107
gentamicin sulfate (ped) (pf) .. 27
gentamicin sulfate (pf) ........... 27
GENTEAL MILD TO
MODERATE ................... 105
GENTEAL GEL .................. 105
GENTEAL MILD ................ 105
GENTEAL SEVERE ........... 105
gentlelax ............................... 114
GEODON ............................... 61
geravim................................. 149
geriaton................................. 149
geri-hydrolac .......................... 97
germ defense ........................ 149
gildess 24 fe ........................... 84
GILENYA ............................ 128
GILOTRIF ............................. 36
GLEEVEC ............................. 36
glimepiride ............................. 49
glipizide .................................. 49
glipizide-metformin ............... 49
GLUCAGEN HYPOKIT ..... 128
GLUCAGON EMERGENCY
KIT (HUMAN) ................ 128
gluco burst .............................. 72
glucose ................................... 73
glucose gel.............................. 73
glutose 15 ............................... 73
glyburide ................................ 49
glyburide micronized ............. 49
glyburide-metformin ........ 49, 50
GLYCINE ............................ 125
glycolax ................................ 114
glycopyrrolate ...................... 112
glydo....................................... 21
GLYXAMBI .......................... 47
granisetron (pf) ....................... 58
granisetron hcl ........................ 58
GRANIX ................................ 68
griseofulvin microsize ............ 51
guaiatussin ac ......................... 89
guaifenesin ....................... 89, 90
guaifenesin dac ....................... 89
guanfacine ........................ 74, 82
guanidine .............................. 128
gummi bear multivitamin ..... 149
gummy swirls ....................... 149
H
hair vitamins ......................... 149
hair,skin & nails ................... 149
HALAVEN ............................ 36
halobetasol propionate ......... 100
haloperidol.............................. 61
haloperidol decanoate............. 61
haloperidol lactate .................. 62
HARVONI ............................. 65
HAVRIX (PF) ...................... 123
head congestion day-night...... 90
healthy eyes .......................... 149
healthylax ............................. 114
hemocyte .............................. 149
heparin (porcine) .................... 68
heparin (porcine) in 5 % dex . 67,
68
HEPARIN (PORCINE) IN 5 %
DEX.................................... 67
heparin (porcine) in nacl (pf) . 67
HEPARIN(PORCINE) IN
0.45% NACL...................... 68
heparin, porcine (pf) ............... 68
HEPATAMINE 8% ............... 73
HEPATASOL 8 % ................. 73
HERCEPTIN .......................... 36
HEXALEN ............................. 36
hi-b complex......................... 149
hi-cal plus vit d ..................... 133
high potency multivit-multimin
.......................................... 149
homatropine hbr ................... 105
I-10
Fòmilè ICS Community Care Plus 2015 FIDA-MMP
ID Fòmilè a: 15412.000, Vèsyon: 12
Anvigè apati: 1 Jiyè 2015
honey bears .......................... 149
honey bears with iron-zinc ... 149
HUMALOG ........................... 48
HUMALOG KWIKPEN ........ 48
HUMALOG MIX 50-50 ........ 48
HUMALOG MIX 50-50
KWIKPEN ......................... 48
HUMALOG MIX 75-25 ........ 48
HUMALOG MIX 75-25
KWIKPEN ......................... 48
HUMATROPE ..................... 120
HUMIRA ............................. 122
HUMIRA CROHN'S DIS
START PCK .................... 122
HUMIRA PEN ..................... 122
HUMULIN 70/30................... 48
HUMULIN 70/30 KWIKPEN 48
HUMULIN 70/30 PEN .......... 48
HUMULIN N ......................... 48
HUMULIN N KWIKPEN ..... 48
HUMULIN N PEN ................ 48
HUMULIN R ......................... 48
HUMULIN R U-500 .............. 48
hydralazine ............................. 78
hydro skin............................. 100
hydrochlorothiazide ............... 80
hydrocil instant..................... 114
hydrocodone bit-homatrop mebr ........................................ 90
hydrocodone-acetaminophen . 15
hydrocodone-chlorpheniramine
............................................ 90
hydrocodone-homatropine ..... 90
hydrocodone-ibuprofen .......... 15
hydrocortisone...... 100, 101, 119
hydrocortisone acet-aloe vera
.......................................... 100
hydrocortisone acetate ......... 100
hydrocortisone acetate-urea . 100
hydrocortisone butyrate ....... 100
hydrocortisone butyr-emollient
.......................................... 100
hydrocortisone sod succinate 119
hydrocortisone valerate ........ 101
hydromorphone ................ 15, 16
hydromorphone (pf) ............... 15
hydroxychloroquine ............... 59
hydroxyurea ........................... 36
hydroxyzine hcl .................... 128
hydroxyzine pamoate ........... 128
HYPERLYTE CR ................ 133
HYPERRAB S/D (PF) ......... 122
HYQVIA .............................. 122
I
ibandronate ........................... 126
IBRANCE .............................. 36
ibuprofen ................................ 20
ibuprofen jr strength ............... 20
icaps plus .............................. 149
ICLUSIG ................................ 37
iferex 150 ............................. 149
ifosfamide............................... 37
ifosfamide-mesna ................... 37
ILARIS (PF) ......................... 122
ILEVRO ............................... 108
IMBRUVICA ......................... 37
imipenem-cilastatin ................ 31
imipramine hcl ....................... 45
imipramine pamoate ............... 45
imiquimod .............................. 97
imodium a-d ......................... 112
IMODIUM A-D ................... 112
IMOGAM RABIES-HT (PF)
.......................................... 122
IMOVAX RABIES VACCINE
(PF)................................... 123
INCRELEX .......................... 120
indapamide ............................. 80
indomethacin .......................... 20
indomethacin sodium ............. 20
INFANRIX (DTAP) (PF) .... 123
infant acetaminophen ............. 16
infantaire ................................ 16
infant's ibuprofen ................... 20
INFANT'S MOTRIN ............. 20
infants' non-aspirin cold ......... 90
infant's pain reliever ............... 16
INLYTA ................................. 37
insta-glucose ........................... 73
INSULIN PEN NEEDLE ..... 102
INSULIN SYRINGE ........... 102
INSULIN SYRINGE
NEEDLELESS ................. 102
INSULIN SYRINGE-NEEDLE
U-100................................ 102
INTELENCE .......................... 64
intense cough reliever ............ 90
INTRALIPID ......................... 73
INTRON A ............................. 66
INVANZ ................................ 31
INVEGA ................................ 62
INVEGA SUSTENNA........... 62
INVIRASE ............................. 64
INVOKAMET........................ 47
INVOKANA .......................... 47
inzo antifungal ........................ 51
iodine .................................... 102
IONOSOL-B IN D5W ......... 133
IONOSOL-MB IN D5W ...... 133
IPOL ..................................... 123
ipratropium bromide............. 105
IPRIVASK ............................. 68
irbesartan ................................ 74
irbesartan-hydrochlorothiazide
............................................ 74
iron high potency.................. 149
ISENTRESS ........................... 64
ISOLYTE M IN 5 %
DEXTROSE ..................... 133
ISOLYTE-H IN 5 %
DEXTROSE ..................... 133
ISOLYTE-P IN 5 %
DEXTROSE ..................... 133
ISOLYTE-S.......................... 133
isoniazid ................................. 57
isopto tears ........................... 105
I-11
Fòmilè ICS Community Care Plus 2015 FIDA-MMP
ID Fòmilè a: 15412.000, Vèsyon: 12
Anvigè apati: 1 Jiyè 2015
isosorbide dinitrate ................. 81
isosorbide mononitrate ........... 81
isotretinoin ............................. 97
isradipine ................................ 79
ISTODAX .............................. 37
itraconazole ............................ 51
ivermectin .............................. 59
i-vite ..................................... 149
IXEMPRA.............................. 37
IXIARO (PF) ....................... 123
J
JAKAFI .................................. 37
JALYN ................................. 128
jantoven .................................. 68
JANUMET ............................. 47
JANUMET XR ...................... 47
JANUVIA .............................. 47
JARDIANCE ......................... 47
JENTADUETO ...................... 47
JEVTANA.............................. 37
jr. acetaminophen ................... 16
junior mapap .......................... 16
K
KABIVEN.............................. 73
KADCYLA ............................ 37
KALETRA ............................. 64
KALYDECO........................ 139
kaopectate (bismuth subsalicy)
.......................................... 112
KEDBUMIN .......................... 70
KELP (IODINE) .................. 133
ketoconazole .......................... 51
ketoprofen .............................. 20
ketorolac ......................... 20, 109
ketotifen fumarate ................ 105
KEYTRUDA.......................... 37
KHEDEZLA .......................... 46
kidkare cough/cold ................. 90
kid's vitamins ....................... 149
kid's vitamins + extra c ........ 149
kids vitamins + iron ............. 149
kid's vitamins + iron ............. 149
KINERET............................. 122
KINRIX (PF)........................ 123
KLOR-CON ......................... 133
klor-con 10 ........................... 133
KLOR-CON 8 ...................... 133
klor-con m10 ........................ 133
klor-con m15 ........................ 133
klor-con m20 ........................ 133
KLOR-CON/EF ................... 133
konsyl (sugar) ....................... 114
konsyl fiber .......................... 114
konsyl sugar-free .................. 114
KORLYM .............................. 47
KRYSTEXXA ..................... 103
KUVAN ............................... 103
KYPROLIS ............................ 37
L
l norgest&e estradiol-e estrad 84
labetalol .................................. 76
LACRISERT ........................ 105
LACTATED RINGERS ...... 125
LACTINOL HX ..................... 97
lactulose ............................... 112
LAMICTAL ........................... 42
LAMISIL (AEROSOL) ......... 51
lamisil af................................. 51
LAMISIL AT ......................... 51
lamivudine.............................. 64
lamivudine-zidovudine........... 64
lamotrigine ............................. 42
LANOXIN ............................. 78
lansoprazole ......................... 110
LANTUS ................................ 48
LANTUS SOLOSTAR .......... 49
latanoprost ............................ 130
LATUDA ............................... 62
laxative peg 3350 ................. 114
LAZANDA ............................ 16
leflunomide .......................... 122
LEMTRADA ....................... 128
LENVIMA ............................. 37
LETAIRIS ............................ 141
letrozole .................................. 37
leucovorin calcium ............... 128
LEUKERAN .......................... 37
LEUKINE .............................. 68
leuprolide................................ 37
levetiracetam .................... 42, 43
levobunolol ........................... 130
levocarnitine ......................... 128
levocarnitine (with sugar) .... 128
levocetirizine .......................... 55
levofloxacin .............. 32, 33, 107
levofloxacin in d5w ................ 32
levoleucovorin calcium ........ 128
levonorgestrel ......................... 84
levonorgestrel-ethin estradiol . 84
levonorgestrel-ethinyl estrad .. 84
levorphanol tartrate ................ 16
levothyroxine........................ 121
LEXIVA ................................. 64
lice cream rinse .................... 102
lice killing............................. 102
lice treatment ........................ 102
lidocaine ........................... 21, 22
lidocaine (pf) .................... 21, 75
lidocaine hcl ........................... 21
lidocaine in 5 % dextrose (pf) 75
lidocaine-prilocaine ................ 22
LIDODERM ........................... 22
life-pack women's ................ 150
linezolid .................................. 27
LINZESS .............................. 103
liothyronine .......................... 121
lipase-protease-amylase ....... 103
lipogen .................................... 80
LIPOSYN II ........................... 73
LIPOSYN III .......................... 73
liquibid d-r.............................. 90
liquid calcium with vitamin d
.......................................... 133
LIQUI-E ............................... 150
liquitears ............................... 105
lisinopril ................................. 75
I-12
Fòmilè ICS Community Care Plus 2015 FIDA-MMP
ID Fòmilè a: 15412.000, Vèsyon: 12
Anvigè apati: 1 Jiyè 2015
lisinopril-hydrochlorothiazide 75
lithium carbonate ................... 82
lithium citrate ......................... 82
little animals ......................... 150
little animals/iron ................. 150
l-norgest-eth estr/ethin estra ... 84
lobana bath ............................. 97
lohist peb dm .......................... 90
lomustine ................................ 37
loperamide............................ 112
loradamed ............................... 55
loratadine................................ 55
loratadine-d ............................ 55
lorazepam oral solution .......... 25
lortuss ex ................................ 90
losartan ................................... 74
losartan-hydrochlorothiazide . 74
LOTEMAX .......................... 109
LOTRIMIN ULTRA .............. 51
LOTRONEX ........................ 103
lovastatin ................................ 80
loxapine succinate .................. 62
lubricant dry eye relief ......... 105
lubricant eye (cmc-glycer)(pf)
.......................................... 105
lubricant eye (cmc-glycerin) 105
lubricant eye (pg-peg 400)(pf)
.......................................... 105
lubricant eye (polyv alcohol) 105
lubricant eye (propyl glycol) 105
lubricant eye drops ............... 105
lubricating drops .................. 105
lubrifresh pm ........................ 105
LUMIGAN ........................... 131
LUMINAL ............................. 43
LUMIZYME ........................ 103
LUPRON DEPOT .................. 37
LUPRON DEPOT (3 MONTH)
............................................ 37
LUPRON DEPOT (4 MONTH)
............................................ 37
LUPRON DEPOT (6 MONTH)
............................................ 37
LUPRON DEPOT-PED ......... 37
LUPRON DEPOT-PED (3
MONTH) ............................ 38
LYNPARZA .......................... 38
LYRICA ................................. 43
lysiplex plus ......................... 150
LYSODREN .......................... 38
M
maalox advanced .................. 112
MACUVITE......................... 150
MACUVITE EYE CARE .... 150
mafenide acetate ..................... 97
mag 64 .................................. 133
mag-delay ............................. 133
mag-g ................................... 133
MAGNEBIND 300 .............. 112
magnesium ........................... 134
magnesium (oxide/aa chelate)
.......................................... 134
magnesium chloride ............. 134
magnesium gluconate ........... 134
magnesium oxide ................. 112
magnesium sulfate................ 134
magnesium sulfate in d5w.... 134
magnesium sulfate in water.. 134
malathion .............................. 102
mapap (acetaminophen) ......... 16
mapap arthritis pain ................ 16
mapap extra strength .............. 16
maprotiline ............................. 46
mar-cof bp .............................. 90
mar-cof cg .............................. 90
MARPLAN ............................ 46
MARQIBO ............................. 38
masanti double strength ....... 112
MATULANE ......................... 38
matzim la ................................ 77
maximum daily multivitamin
.......................................... 150
maximum strength flu ............ 90
meclizine ................................ 58
medi-brom .............................. 90
medroxyprogesterone ........... 121
mefenamic acid ...................... 20
mefloquine.............................. 59
MEFOXIN IN DEXTROSE
(ISO-OSM) ......................... 30
mega multiple/chelated mineral
.......................................... 150
mega multivitamin with mineral
.......................................... 150
MEGACE ES ......................... 38
megestrol ................................ 38
MEKINIST ............................. 38
meloxicam .............................. 20
melphalan hcl intravenous...... 38
MENACTRA (PF) ............... 123
MENEST .............................. 118
MENHIBRIX (PF) ............... 123
MENOMUNE - A/C/Y/W-135
(PF) ................................... 123
men's multi-vitamin.............. 150
men's one daily ..................... 150
MENVEO A-C-Y-W-135-DIP
(PF) ................................... 123
MENVEO MENA
COMPONENT (PF) ......... 124
MENVEO MENCYW-135
COMPNT (PF) ................. 124
MEPHYTON........................ 150
mercaptopurine ....................... 38
meropenem ............................. 31
mesehist dm ............................ 90
mesna.................................... 128
MESNEX ............................. 128
MESTINON ......................... 128
MESTINON TIMESPAN .... 128
metaproterenol...................... 138
metaxalone ........................... 139
metformin ......................... 47, 48
methadone .............................. 16
methadone hcl ........................ 16
I-13
Fòmilè ICS Community Care Plus 2015 FIDA-MMP
ID Fòmilè a: 15412.000, Vèsyon: 12
Anvigè apati: 1 Jiyè 2015
methazolamide ..................... 131
methenamine hippurate .......... 27
methenamine mandelate......... 27
methimazole ......................... 121
methocarbamol ..................... 139
methotrexate sodium .............. 38
methotrexate sodium (pf) ....... 38
methoxsalen rapid .................. 97
methscopolamine ................. 112
methyclothiazide .................... 80
methylphenidate ............... 82, 83
methylprednisolone .............. 119
methylprednisolone acetate .. 119
methylprednisolone sodium succ
.......................................... 119
metipranolol ......................... 131
metoclopramide hcl .............. 112
metolazone ............................. 80
metoprolol succinate .............. 76
metoprolol ta-hydrochlorothiaz
............................................ 76
metoprolol tartrate .................. 76
metronidazole ............. 56, 59, 98
metronidazole in nacl (iso-os) 59
mexiletine............................... 75
MIACALCIN ....................... 126
mi-acid ......................... 112, 113
mi-acid gas relief.................. 109
micatin.................................... 51
miconazole 7 .......................... 51
miconazole nitrate .................. 52
midazolam .............................. 25
midazolam (pf) ....................... 25
midodrine ............................... 74
milk of magnesia .................. 115
milltrium senior.................... 150
milrinone ................................ 78
milrinone in 5 % dextrose ...... 78
MINERAL OIL .................... 128
mineral oil laxative .............. 115
mineral oil light .................... 129
minitran .................................. 81
minocycline ............................ 34
minoxidil ................................ 81
mintox .................................. 113
mintox maximum strength ... 113
mintox plus........................... 113
MIRCERA ............................. 68
mirtazapine ............................. 46
misoprostol ........................... 110
mitomycin .............................. 38
mitoxantrone .......................... 38
M-M-R II (PF) ..................... 124
moexipril ................................ 75
moexipril-hydrochlorothiazide
............................................ 75
mometasone ......................... 101
MONISTAT 3 ........................ 52
monistat 7 ............................... 52
montelukast .......................... 137
morphine .......................... 16, 17
MORPHINE ........................... 17
morphine concentrate ............. 16
morrhuate sodium ................ 129
motion sickness ...................... 58
MOVANTIK ........................ 113
MOVIPREP ......................... 115
MOXEZA............................. 107
moxifloxacin .......................... 33
MOZOBIL ............................. 68
mucinex fast-max dm max ..... 90
mucus dm ............................... 90
mucus dm max ....................... 90
mucus relief ............................ 91
MULTAQ............................... 75
multi complete with iron ...... 150
multi-day with iron............... 150
multi-delyn ........................... 150
multi-delyn with iron ........... 150
multilex ................................ 150
multilex-t&m ........................ 150
multiple vitamin-minerals .... 150
multiple vitamins.................. 150
multiple vitamins with iron .. 150
multi-symptom cold night time
............................................ 91
multi-symptom cold-cough .... 91
multivital platinum ............... 151
multivitamin ......................... 151
multi-vitamin hp/minerals .... 151
multivitamin with iron.......... 151
multivitamin with minerals .. 151
multivitamins with min no.7-fa
.......................................... 151
multi-vite .............................. 151
multi-vite 50 & over ............. 151
mupirocin ............................... 98
mupirocin calcium .................. 98
muro 128 .............................. 105
MUSTARGEN ....................... 38
my favorite multiple ............. 151
myco nail a ............................. 52
mycophenolate mofetil ......... 122
mycophenolate sodium......... 122
mylanta gas........................... 109
MYOZYME ......................... 103
mytab gas ............................. 109
mytab gas maximum strength
.......................................... 109
my-vitalife ............................ 151
N
nabumetone ............................ 21
nadolol .................................... 76
nafcillin .................................. 32
nafcillin in dextrose iso-osm .. 32
NAGLAZYME .................... 103
naloxone ................................. 22
naltrexone ............................... 22
naltrexone hcl ......................... 22
NAMENDA ........................... 44
NAMENDA TITRATION PAK
............................................ 44
NAMENDA XR ..................... 44
naphazoline .......................... 105
naproxen ................................. 21
naproxen sodium .................... 21
I-14
Fòmilè ICS Community Care Plus 2015 FIDA-MMP
ID Fòmilè a: 15412.000, Vèsyon: 12
Anvigè apati: 1 Jiyè 2015
naratriptan .............................. 57
nasal & sinus decongestant .... 91
nasal decongestant (oxymetazl)
.......................................... 106
nasal decongestant (pe) .......... 74
NASCOBAL ........................ 151
NASONEX .......................... 109
NATACYN .......................... 107
nateglinide .............................. 48
NATPARA ........................... 126
natural b-100 ........................ 151
natural b-100 complex ......... 151
natural balance ..................... 106
natural calcium ..................... 134
natural fiber laxative therapy 115
natural tears (pf) ................... 106
nature's tears ......................... 106
NEBUPENT ........................... 59
nefazodone ............................. 46
neomy sulf-bacitrac zn-poly-hc
.......................................... 107
neomycin ................................ 27
neomycin-bacitracin-poly-hc 107
neomycin-bacitracin-polymyxin
.......................................... 108
neomycin-polymyxin b gu ..... 98
neomycin-polymyxin bdexameth .......................... 108
neomycin-polymyxingramicidin ........................ 108
neomycin-polymyxin-hc ...... 108
neosporin anti-itch ............... 101
neo-synephrine 12 h spr (oxym)
.......................................... 106
neo-tuss .................................. 91
NEPHRAMINE 5.4 % ........... 73
nephro-vite ........................... 151
NEULASTA .......................... 68
NEUMEGA............................ 69
NEUPOGEN .......................... 69
NEUPRO................................ 60
NEVANAC .......................... 109
nevirapine ............................... 64
NEXAFED ............................. 91
NEXAVAR ............................ 38
niacin ................................ 80, 81
niacinamide .......................... 151
nicardipine .............................. 79
NICODERM CQ .................... 22
nicorelief ................................ 22
nicorette .................................. 22
nicotine ................................... 23
nicotine (polacrilex) ............... 23
NICOTROL ........................... 23
nifedipine ............................... 79
night time ............................... 91
night time cold-flu .................. 91
night time cold-flu relief ........ 91
nighttime cold-flu ................... 91
nighttime cough...................... 91
nighttime relief eye .............. 106
NILANDRON ........................ 38
nite time cold-flu .................... 91
nite time-d cold-flu relief ....... 91
NITRO-BID ........................... 81
nitrofurantoin macrocrystal .... 28
nitrofurantoin monohyd/m-cryst
............................................ 28
nitroglycerin ..................... 81, 82
nitroglycerin in 5 % dextrose . 81
NITROSTAT ......................... 82
nohist-dm ............................... 91
non-aspirin cold...................... 91
non-aspirin extra strength....... 17
non-aspirin flu ........................ 91
non-aspirin jr strength ............ 17
NORDITROPIN FLEXPRO 120
NORDITROPIN NORDIFLEX
.......................................... 120
norelgestromin/ethin.estradiol 84
norepinephrine bitartrate ........ 79
noreth-ethinyl estradiol/iron ... 84
norethindrone ......................... 84
norethindrone (contraceptive) 84
norethindrone acetate ........... 121
norethindrone ac-eth estradiol
.................................... 84, 118
norethindrone-e.estradiol-iron 84
norethindrone-ethinyl estrad .. 84
norethindrone-mestranol ........ 85
norgestimate-ethinyl estradiol 85
norgestrel-ethinyl estradiol..... 85
NORMOSOL-M IN 5 %
DEXTROSE ..................... 134
NORMOSOL-R ................... 134
NORMOSOL-R PH 7.4 ....... 134
nortemp .................................. 17
NORTHERA .......................... 74
nortriptyline ............................ 46
NORVIR ................................ 64
NOVOLIN 70/30 ................... 49
NOVOLIN N .......................... 49
NOVOLIN R .......................... 49
NOVOLOG ............................ 49
NOVOLOG FLEXPEN ......... 49
NOVOLOG MIX 70-30 ......... 49
NOVOLOG MIX 70-30
FLEXPEN .......................... 49
NOXAFIL .............................. 52
NUCYNTA ............................ 17
NUCYNTA ER ...................... 17
NUEDEXTA .......................... 83
nu-iron .................................. 151
NULOJIX ............................. 122
NUTRESTORE .................... 113
NUTRILIPID ......................... 73
NUTRILYTE ....................... 134
NUTRILYTE II .................... 134
NUTROPIN.......................... 120
NUTROPIN AQ ................... 120
NUTROPIN AQ NUSPIN ... 120
NUVARING .......................... 85
NUVIGIL ............................. 139
nystatin ................................... 52
NYSTATIN (BULK) ............. 52
nystatin-triamcinolone............ 52
I-15
Fòmilè ICS Community Care Plus 2015 FIDA-MMP
ID Fòmilè a: 15412.000, Vèsyon: 12
Anvigè apati: 1 Jiyè 2015
O
ocean nasal ........................... 106
OCTAGAM ......................... 122
octreotide acetate ................. 120
ocutabs ................................. 151
OFEV ................................... 139
ofloxacin ........................ 33, 108
olanzapine .............................. 62
olanzapine-fluoxetine............. 46
olopatadine ........................... 106
OLYSIO ................................. 65
omega-3 acid ethyl esters ....... 81
omeprazole ........................... 110
omeprazole magnesium ....... 110
omeprazole-sodium bicarbonate
.......................................... 110
OMNITROPE ...................... 120
ONCASPAR .......................... 38
once daily ............................. 151
oncovite ................................ 152
ondansetron ............................ 58
ondansetron hcl ...................... 58
ondansetron hcl (pf) ............... 58
one daily ............................... 152
one daily 50 plus .................. 152
one daily complete ............... 152
one daily energy ................... 152
one daily essential ................ 152
one daily maximum (with ca)
.......................................... 152
one daily men's 50+ ............. 152
one daily multi-vit w-mineral
.......................................... 152
one daily multivitamin ......... 152
one daily multivitamin-iron . 152
one daily plus iron ................ 152
one daily plus minerals ........ 152
one daily with iron ............... 152
one-a-day essential ............... 152
one-a-day maximum formula152
one-a-day teen advantage ..... 152
ONFI ...................................... 25
opcicon one-step .................... 85
OPDIVO................................. 38
OPSUMIT ............................ 141
opti-vitamins ........................ 153
oral saline laxative ............... 115
oralyte................................... 134
ORAP ..................................... 62
ORENCIA ............................ 122
ORENCIA (WITH MALTOSE)
.......................................... 122
ORENITRAM ...................... 141
ORFADIN ............................ 103
OTEZLA .............................. 129
OTEZLA STARTER ........... 129
oxacillin.................................. 32
oxacillin in dextrose(iso-osm) 32
oxaliplatin............................... 39
oxandrolone.......................... 118
oxcarbazepine......................... 43
OXTELLAR XR .................... 43
oxybutynin chloride ............. 116
oxycodone .............................. 17
oxycodone hcl-acetaminophen
............................................ 17
oxycodone hcl-aspirin ............ 17
oxycodone-acetaminophen..... 17
oxycodone-aspirin .................. 17
OXYCONTIN ........................ 18
oxymorphone ......................... 18
oysco 500/d .......................... 134
oysco d ................................. 134
oysco-500 ............................. 134
oyster shell calcium 500 ....... 134
oyster shell calcium-vit d3 ... 134
oystercal-d ............................ 134
P
paclitaxel ................................ 39
pain relief ............................... 18
pain relief adult ...................... 18
pain reliever............................ 18
pain reliever jr strength .......... 18
PANRETIN ............................ 97
pantoprazole ......................... 110
papaverine .............................. 79
paricalcitol ............................ 126
paromomycin.......................... 59
paroxetine hcl ......................... 46
PASER ................................... 57
PATADAY ........................... 106
PATANOL ........................... 106
PAXIL .................................... 46
pecgen dmx ............................ 91
pedi m.vit no.17 with fluoride
.......................................... 153
pedia relief .............................. 92
pedia relief infant ................... 92
pediacare multi-symptom cold92
PEDIARIX (PF) ................... 124
pediatric electrolyte .............. 134
pediatric freezer pops ........... 134
pediatric multivitamin .......... 153
PEDVAX HIB (PF).............. 124
peg 3350-electrolytes ........... 115
PEG 3350-GRX ................... 115
peg 3350-na sulf,bicarb,cl-kcl
.......................................... 115
peg3350 ................................ 115
PEGANONE .......................... 43
PEGASYS .............................. 66
PEGASYS PROCLICK ......... 66
peg-electrolyte soln .............. 115
PEGINTRON ......................... 66
PEGINTRON REDIPEN ....... 66
penicillin g pot in dextrose ..... 32
penicillin g potassium ............ 32
penicillin g procaine ............... 32
penicillin v potassium ............ 32
PENTACEL (PF) ................. 124
PENTACEL ACTHIB
COMPONENT (PF) ......... 124
PENTACEL DTAP-IPV
COMPNT (PF) ................. 124
PENTAM ............................... 59
pentoxifylline ......................... 69
I-16
Fòmilè ICS Community Care Plus 2015 FIDA-MMP
ID Fòmilè a: 15412.000, Vèsyon: 12
Anvigè apati: 1 Jiyè 2015
pep-t-med ............................. 113
peri-colace ............................ 115
PERIKABIVEN ..................... 73
perindopril erbumine .............. 75
PERJETA ............................... 39
permethrin ............................ 102
perphenazine .......................... 63
perphenazine-amitriptyline .... 46
persa-gel ................................. 97
pharbetol ................................ 18
pharmacist favorite multi-vit 153
phenelzine .............................. 46
phenobarbital.......................... 43
phenobarbital sodium ............. 43
phentolamine ........................ 140
phenylephrine hcl ........... 74, 106
phenylephrine-chlorpheniramine
............................................ 55
phenylhistine dh ..................... 92
phenytoin................................ 43
phenytoin sodium ................... 43
phenytoin sodium extended ... 43
phillips.................................. 113
phillips liqui-gels ................. 115
PHOS-FLUR .......................... 95
PHOSLYRA ........................ 116
PHOS-NAK ......................... 134
phosphate laxative................ 115
PHOSPHOLINE IODIDE ... 131
phosphorus #1 ...................... 134
phytonadione ........................ 153
PICATO ................................. 97
pilocarpine hcl ................ 95, 131
pindolol .................................. 76
pioglitazone ............................ 48
pioglitazone-glimepiride ........ 48
pioglitazone-metformin.......... 48
piperacillin-tazobactam .......... 32
piroxicam ............................... 21
PLAN B ONE-STEP.............. 85
PLASBUMIN 25 % ............... 70
PLASBUMIN 5 % ................. 70
PLASMA-LYTE 148 ........... 134
PLASMA-LYTE A .............. 134
PLASMA-LYTE-56 IN 5 %
DEXTROSE ..................... 135
PLEGRIDY .......................... 129
podactin .................................. 52
podofilox ................................ 97
podophyllum resin.................. 97
polyethylene glycol 3350 ..... 115
poly-iron ............................... 153
polymyxin b sulf-trimethoprim
.......................................... 108
poly-tussin .............................. 92
POLY-TUSSIN DM .............. 92
poly-vita ............................... 153
poly-vita (iron) ..................... 153
poly-vitamin ......................... 153
poly-vitamin with iron ......... 153
polyvitamin/iron ................... 153
poly-vitamins ....................... 153
POMALYST .......................... 39
potassium acetate ................. 135
potassium bicarb and chloride
.......................................... 135
potassium bicarb-citric acid . 135
potassium bicarbonate-cit ac 135
potassium chlorid-d5-0.45%nacl
.......................................... 135
potassium chloride ............... 135
potassium chloride in 0.9%nacl
.......................................... 135
potassium chloride in 5 % dex
.......................................... 135
potassium chloride in lr-d5 .... 73
potassium chloride-0.45 % nacl
.......................................... 135
potassium chloride-d5-0.2%nacl
.......................................... 135
potassium chloride-d5-0.3%nacl
.......................................... 136
potassium chloride-d5-0.9%nacl
.......................................... 136
potassium citrate-citric acid . 136
potassium hydroxide .............. 97
potassium phosphate dibasic 136
POTIGA ................................. 43
PRADAXA ............................ 68
pramipexole ............................ 60
PRANDIMET ........................ 48
pravastatin .............................. 81
prazosin .................................. 74
prednicarbate ........................ 101
prednisolone acetate ............. 109
prednisolone sodium phosphate
.................................. 109, 119
prednisone ............................ 119
PREGNYL ........................... 120
PREMARIN ......................... 118
PREMASOL 10 % ................. 73
PREMASOL 6 % ................... 73
PREMPHASE ...................... 118
PREMPRO ........................... 119
prenatal ................................. 153
prenatal formula ................... 153
prenatal vit#96-ferrous fum-fa
.......................................... 153
prenatal vitamin with minerals
.......................................... 153
prenatal vitamins .................. 153
prenatal vit-iron fumarate-fa 153
preparation h hydrocortisone 101
PREVIDENT 5000 SENSITIVE
............................................ 95
PREZCOBIX.......................... 64
PREZISTA ............................. 64
PRIFTIN ................................. 57
PRILOSEC OTC .................. 110
PRIMAQUINE ....................... 59
primidone ............................... 43
PRISTIQ ................................. 46
PRIVIGEN ........................... 122
PROAIR HFA ...................... 138
probenecid ............................ 129
procainamide .......................... 75
I-17
Fòmilè ICS Community Care Plus 2015 FIDA-MMP
ID Fòmilè a: 15412.000, Vèsyon: 12
Anvigè apati: 1 Jiyè 2015
PROCALAMINE 3% ............ 73
prochlorperazine edisylate ..... 58
prochlorperazine maleate ....... 59
PROCRIT ............................... 69
PROCYSBI .......................... 129
progesterone ......................... 121
progesterone micronized ...... 121
PROGLYCEM ....................... 82
PROGRAF ........................... 122
PROLENSA ......................... 109
PROLEUKIN ......................... 39
PROLIA ............................... 126
PROMACTA ......................... 69
promethazine .................... 55, 59
promethazine hcl .................... 59
promethazine-codeine ............ 92
promethazine-dm ................... 92
promethazine-phenylephcodeine ............................... 92
promolaxin ........................... 115
propafenone............................ 75
propantheline.......................... 41
proparacaine ......................... 106
proparacaine hcl ................... 106
proparacaine-fluorescein sod 106
propranolol ............................. 76
propranolol-hydrochlorothiazid
............................................ 76
propylthiouracil .................... 121
PROQUAD (PF) .................. 124
prosight ................................ 153
PROSOL 20 % ....................... 73
protamine ............................... 69
protriptyline............................ 46
pseudoephedrine hcl............... 92
PULMOZYME .................... 103
pure & gentle eye ................. 106
purelax.................................. 115
PURIXAN .............................. 39
pyrazinamide .......................... 57
pyridostigmine bromide ....... 129
pyridoxine ............................ 153
Q
q-dryl ...................................... 55
q-pap....................................... 18
q-pap extra strength ................ 18
q-tapp ..................................... 55
q-tapp dm ............................... 92
q-tussin ................................... 92
q-tussin dm ............................. 92
QUADRACEL (PF) ............. 124
QUDEXY XR ........................ 43
quetiapine ............................... 63
QUILLIVANT XR ................. 83
quinapril ................................. 75
quinapril-hydrochlorothiazide 75
quinidine gluconate ................ 75
quinidine sulfate ..................... 75
quinine sulfate ........................ 59
QVAR .................................. 137
R
RABAVERT (PF) ................ 124
raloxifene ............................. 119
ramipril ................................... 75
RANEXA ............................... 79
ranitidine hcl ........................ 110
RAPAMUNE ....................... 122
REBIF (WITH ALBUMIN). 129
REBIF REBIDOSE .............. 129
REBIF TITRATION PACK 129
RECOMBIVAX HB (PF) .... 124
recort plus ............................. 101
refenesen ................................ 92
refenesen pe............................ 92
REFRESH CLASSIC (PF)... 106
REFRESH LACRI-LUBE ... 106
REFRESH LIQUIGEL ........ 106
REFRESH OPTIVE ............. 106
REFRESH OPTIVE
ADVANCED ................... 108
reguloid ................................ 115
relcof c.................................... 92
RELENZA DISKHALER ...... 65
RELISTOR........................... 113
REMICADE ......................... 129
REMODULIN ...................... 141
RENAGEL ........................... 116
RENVELA ........................... 116
repaglinide .............................. 48
RESCRIPTOR........................ 64
RESTASIS ........................... 109
retaine cmc ........................... 106
RETROVIR ............................ 64
REVATIO ............................ 141
REVLIMID ............................ 39
REYATAZ ............................. 64
REZIRA ................................. 92
ribavirin .................................. 66
RIDAURA............................ 122
rifabutin .................................. 57
rifampin .................................. 57
RIFATER ............................... 57
ri-gel ii .................................. 113
riluzole.................................... 83
rimantadine ............................. 65
ri-mox ................................... 113
ringers ........................... 125, 136
risedronate ............................ 126
RISPERDAL CONSTA ......... 63
risperidone .............................. 63
RITUXAN .............................. 39
rivastigmine tartrate ............... 44
rizatriptan ............................... 57
robafen.................................... 93
robafen cough ......................... 93
robafen dm ............................. 93
robitussin cough & cold cf ..... 93
robitussin cough-chest-cong dm
............................................ 93
robitussin dm max .................. 93
ROBITUSSIN LONG-ACTING
............................................ 93
robitussin pediatric ................. 93
ropinirole ................................ 60
ROTARIX ............................ 124
ROTATEQ VACCINE ........ 124
I-18
Fòmilè ICS Community Care Plus 2015 FIDA-MMP
ID Fòmilè a: 15412.000, Vèsyon: 12
Anvigè apati: 1 Jiyè 2015
ROZEREM .......................... 139
rydex ...................................... 93
S
SABRIL ................................. 43
safe tussin dm ......................... 93
SAIZEN ............................... 120
SAIZEN CLICK.EASY ....... 120
saline mist ............................ 106
salsalate .................................. 21
SANDOSTATIN LAR DEPOT
.......................................... 120
SANTYL ................................ 97
SAPHRIS (BLACK CHERRY)
............................................ 63
SAVELLA ............................. 83
scooby-doo one a day........... 154
scot-tussin dm ........................ 93
scot-tussin expectorant ........... 93
sea soft nasal mist ................ 106
selegiline hcl .......................... 60
selenium sulfide ..................... 98
SELZENTRY ......................... 64
senexon ................................ 115
senna .................................... 115
senna lax............................... 115
senna with docusate sodium. 115
senokot-s .............................. 116
SENSIPAR ........................... 129
sentry .................................... 154
sentry senior ......................... 154
SEREVENT DISKUS .......... 138
SEROQUEL XR .................... 63
SEROSTIM .......................... 120
sertraline ................................. 46
silace .................................... 116
siladryl sa ............................... 55
silapap .................................... 18
sildenafil oral tablet 20 mg .. 141
SILENOR ............................... 46
siltussin dm das ...................... 93
siltussin sa .............................. 93
silver nitrate ........................... 98
silver nitrate applicators ......... 97
silver sulfadiazine .................. 98
SIMBRINZA ........................ 131
simethicone .......................... 109
simply sleep............................ 55
SIMPONI ............................. 129
SIMPONI ARIA .................. 129
simvastatin ............................. 81
sinus & allergy (pseudoephed)
............................................ 55
sirolimus ............................... 122
SIRTURO............................... 58
skin treatment ......................... 97
sleep aid (diphenhydramine) .. 55
sleep-tabs ................................ 55
smoothlax ............................. 116
sochlor .................................. 106
sodium acetate ...................... 136
sodium bicarbonate ...... 113, 136
sodium chloride ... 106, 125, 136,
139
sodium chloride 0.45 % ....... 136
sodium chloride 0.9 % ......... 136
sodium chloride 3 % ............ 136
sodium chloride 5 % ............ 136
sodium chloride-nahco3-kcl-peg
.......................................... 116
sodium citrate-citric acid ...... 136
sodium fluoride .................... 154
sodium lactate ...................... 136
sodium phosphate ................. 136
sodium polystyrene sulfonate
.......................................... 116
sodium thiosulfate ................ 117
sod-pot-k cit-sod cit-cit acid 136
SOLIRIS............................... 129
SOLTAMOX ......................... 39
SOLU-CORTEF (PF) .......... 119
SOMATULINE DEPOT ...... 120
SOMAVERT ........................ 120
soothe (bismuth subsalicylate)
.......................................... 113
soothe regular strength ......... 113
sorbitol.................................. 125
sorbitol-mannitol .................. 125
sotalol ..................................... 76
sotalol hcl ............................... 76
SOVALDI .............................. 65
spectravite ............................ 154
spectravite adult 50+ ............ 154
spectravite advanced formula
.......................................... 154
spectravite senior .................. 154
spectravite senior w-lycopene
.......................................... 154
spectravite ultra women ....... 154
SPIRIVA RESPIMAT ......... 138
SPIRIVA WITH
HANDIHALER................ 138
spironolactone ........................ 81
spironolacton-hydrochlorothiaz
............................................ 81
SPRYCEL .............................. 39
st joseph aspirin ...................... 21
st. joseph aspirin ..................... 21
stavudine ................................ 64
STELARA ............................ 129
STERILE LUBRICANT ...... 106
STERILE PADS................... 129
STIVARGA............................ 39
stomach relief ....................... 113
STRATTERA ......................... 83
streptomycin ........................... 27
stress 500 plus zinc............... 154
stress b with zinc .................. 154
stress b-biotin ....................... 154
stress formula ....................... 154
stress formula plus iron ........ 154
stress formula with iron ........ 154
stress formula with zinc ....... 155
STRIBILD .............................. 64
stuart prenatal ....................... 155
sucralfate .............................. 110
sudogest .................................. 93
I-19
Fòmilè ICS Community Care Plus 2015 FIDA-MMP
ID Fòmilè a: 15412.000, Vèsyon: 12
Anvigè apati: 1 Jiyè 2015
sudogest cold & allergy ......... 55
sudogest pe ............................. 74
sulfacetamide sodium........... 108
sulfacetamide sodium (acne).. 98
sulfacetamide-prednisolone . 108
sulfadiazine ............................ 33
sulfamethoxazole-trimethoprim
............................................ 33
sulfasalazine ........................... 33
sulfatrim ................................. 33
sulfazine ................................. 33
sulfazine ec............................. 33
sulindac .................................. 21
sumatriptan nasal spray .......... 57
sumatriptan succinate ............. 57
summer's eve disposable douche
.......................................... 129
summers eve extra cleansing 130
sunvite .................................. 155
super b complex-vitamin c ... 155
super b/c ............................... 155
super b-50 complex .............. 155
super b-50 complex plus ...... 155
super multiple....................... 155
super multivitamin ............... 155
super quints b-50 .................. 155
super thera vite m ................. 155
superior 35 ........................... 155
superplex-t............................ 155
suphedrin ................................ 93
suphedrine pe day-night ......... 93
suphedrine severe cold max str
............................................ 93
support.................................. 155
support-500 .......................... 155
SUPPRELIN LA .................. 120
SUPRAX ................................ 30
SURE COMFORT INS. SYR.
U-100 ............................... 102
SURMONTIL ........................ 46
SUSPENDOL-S ................... 130
SUSTIVA ............................... 64
SUTENT ................................ 39
SYLATRON .......................... 66
SYLATRON 4-PACK ........... 66
SYLVANT ............................. 39
SYMLINPEN 120 .................. 48
SYMLINPEN 60 .................... 48
SYNAGIS .............................. 65
SYNAREL ........................... 130
SYNERCID ............................ 28
SYNRIBO .............................. 39
SYPRINE ............................. 117
T
tab-a-vite .............................. 155
tab-a-vite/iron ....................... 155
tab-a-vite-minerals ............... 155
TABLOID .............................. 39
tacrolimus ..................... 101, 122
tactinal .................................... 18
tactinal extra strength ............. 18
TAFINLAR ............................ 39
TAMIFLU .............................. 65
tamoxifen ............................... 39
tamsulosin ............................ 117
TARCEVA ............................. 39
TARGRETIN ................... 39, 40
tarina fe .................................. 85
TASIGNA .............................. 40
TAZORAC ........................... 101
taztia xt ................................... 77
tears again ............................ 107
TEARS NATURALE II ....... 107
TECFIDERA ........................ 130
TEFLARO .............................. 30
telmisartan .............................. 74
telmisartan-hydrochlorothiazid
............................................ 74
temazepam ....................... 25, 26
TEMODAR ............................ 40
TENIVAC (PF) .................... 124
terazosin ............................... 117
terbinafine hcl ........................ 52
terbutaline............................. 138
terconazole ....................... 56, 57
testosterone ........................... 118
testosterone cypionate .......... 118
testosterone enanthate .......... 118
TETANUS
TOXOID,ADSORBED (PF)
.......................................... 124
TETANUS,DIPHTHERIA TOX
PED(PF) ........................... 124
TETANUS-DIPHTHERIA
TOXOIDS-TD.................. 124
tetracaine hcl ........................ 107
tetracycline ............................. 34
TEV-TROPIN ...................... 120
THALOMID ........................ 130
the magic bullet .................... 116
theophylline .......................... 138
theophylline anhydrous ........ 138
theophylline in dextrose 5 % 138
thera m plus (ferrous fumarat)
.......................................... 155
thera vitamin......................... 155
theradex m ............................ 156
THERAFLU NIGHTTIME
SEVERE COLD ................. 93
THERAFLU SEVERE COLDCOUGH.............................. 94
thera-m ................................. 156
theramill forte ....................... 156
therapeutic liquid .................. 156
therapeutic m + beta-carotene
.......................................... 156
therapeutic vitamins/minerals
.......................................... 156
therapeutic-m........................ 156
therapeutic-m vitamin/minerals
.......................................... 156
thera-tabs .............................. 156
theratrum complete 50 plus .. 156
theratrum complete 50 plus/lut
.......................................... 156
therems ................................. 156
I-20
Fòmilè ICS Community Care Plus 2015 FIDA-MMP
ID Fòmilè a: 15412.000, Vèsyon: 12
Anvigè apati: 1 Jiyè 2015
therems-h.............................. 156
therems-m ............................ 156
thiamine hcl .......................... 156
thioridazine ............................ 63
thiothixene.............................. 63
tiagabine ................................. 43
TICE BCG ........................... 124
TIKOSYN .............................. 76
timolol maleate............... 76, 131
TIVICAY ............................... 64
tizanidine .............................. 139
TOBI PODHALER ................ 27
TOBRADEX ST .................. 108
tobramycin ........................... 108
tobramycin in 0.225 % nacl ... 27
tobramycin in 0.9 % nacl ....... 27
tobramycin sulfate .................. 27
tolazamide .............................. 50
tolbutamide ............................ 50
tolmetin .................................. 21
tolnaftate ................................ 52
tolterodine ............................ 116
topiramate .............................. 43
toposar intravenous ................ 40
topotecan ................................ 40
TORISEL ............................... 40
torsemide ................................ 80
total b/c................................. 157
totalday multiple .................. 157
TOUJEO SOLOSTAR ........... 49
TOVIAZ ............................... 117
TPN ELECTROLYTES....... 137
TPN ELECTROLYTES II ... 137
TRACLEER ......................... 141
TRADJENTA ........................ 48
tramadol ................................. 18
tramadol-acetaminophen ........ 18
trandolapril ............................. 75
tranexamic acid ...................... 69
TRANSDERM-SCOP............ 59
tranylcypromine ..................... 46
TRAVASOL 10 % ................. 73
TRAVATAN Z .................... 131
travel sickness (meclizine) ..... 59
travoprost (benzalkonium) ... 131
trazodone ................................ 46
TREANDA............................. 40
TRECATOR........................... 58
TRELSTAR ........................... 40
tretinoin ................................ 101
tretinoin (chemotherapy) ........ 40
tretinoin microspheres .......... 101
TREXALL ............................. 40
triacting m-sym cold/cough ... 94
triamcinolone acetonide 95, 101,
119
triaminic cold & cough (pe) ... 94
TRIAMINIC COLD & COUGH
NT (PE) .............................. 55
triaminic cough-nasal congesti
............................................ 94
TRIAMINIC COUGH-SORE
THROAT ........................... 94
triamterene-hydrochlorothiazid
............................................ 80
triazolam................................. 26
TRIBENZOR ......................... 74
tri-buffered aspirin ................. 21
triderm .................................. 101
tri-dex pe ................................ 94
trifluoperazine ........................ 63
trifluridine ............................ 108
trigofen dm ............................. 94
trihexyphenidyl ...................... 60
TRILEPTAL .......................... 44
trimethoprim........................... 28
triple paste af .......................... 52
TRIUMEQ ............................. 65
tri-vi-sol ................................ 157
tri-vita ................................... 157
tri-vitamin............................. 157
TROKENDI XR ..................... 44
TROPHAMINE 10 % ............ 73
TROPHAMINE 6% ............... 73
trospium................................ 117
TRULICITY ........................... 48
TRUMENBA ....................... 124
TRUVADA ............................ 65
trymine cg............................... 94
TUDORZA PRESSAIR ....... 138
tusnel diabetic......................... 94
TUSNEL PEDIATRIC........... 94
tussin cf .................................. 94
tussin cf cough-cold ............... 94
tussin cold-congestion ............ 94
tussin cough (dm only) ........... 94
tussin dm ................................ 94
tussin dm cough & chest ........ 94
tussin dm max ........................ 94
tussin maximum strength cough
............................................ 94
tussin pe .................................. 94
TWINRIX (PF) .................... 124
TYBOST .............................. 130
TYGACIL .............................. 34
TYKERB ................................ 40
TYPHIM VI ......................... 124
TYSABRI ............................. 123
TYVASO.............................. 141
TYVASO REFILL KIT ....... 141
TYVASO STARTER KIT ... 141
TYZEKA ................................ 66
U
ULORIC ............................... 130
ultra b-100 complex ............. 157
ultra fresh pm ....................... 107
ultra sleep (doxylamine succ). 55
ultra strength antacid ............ 113
unicomplex-m ...................... 157
unisom sleepgels .................... 55
ursodiol ................................. 113
V
VAGIFEM............................ 119
valacyclovir ............................ 66
VALCHLOR .......................... 97
valganciclovir ......................... 66
I-21
Fòmilè ICS Community Care Plus 2015 FIDA-MMP
ID Fòmilè a: 15412.000, Vèsyon: 12
Anvigè apati: 1 Jiyè 2015
valproate sodium .................... 44
valproic acid ........................... 44
valproic acid (as sodium salt) 44
valsartan ................................. 74
valsartan-hydrochlorothiazide 74
VALSTAR ............................. 40
valu-tapp dm .......................... 95
vancomycin ............................ 28
vancomycin in d5w ................ 28
VAQTA (PF) ....................... 124
VARIVAX (PF) ................... 124
VASCEPA ............................. 81
vasopressin ........................... 120
VECTIBIX ............................. 40
VELCADE ............................. 40
venlafaxine ............................. 46
VENTAVIS.......................... 141
verapamil................................ 77
VERSACLOZ ........................ 63
vicks dayquil cough ............... 95
vicks nature fusion cough ...... 95
vicks qlearquil(oxymetazoline)
.......................................... 107
vicks sinex 12-hour .............. 107
VICTOZA .............................. 48
VIDEX 2 GRAM PEDIATRIC
............................................ 65
VIDEX 4 GRAM PEDIATRIC
............................................ 65
VIEKIRA PAK ...................... 65
VIGAMOX .......................... 108
VIIBRYD ............................... 46
VIMIZIM ............................. 103
VIMPAT ................................ 44
vinblastine .............................. 40
vincristine ............................... 40
vincristine sulfate ................... 40
vinorelbine ............................. 40
VIRACEPT ............................ 65
VIRAMUNE XR ................... 65
VIRAZOLE............................ 66
virdec dm ............................... 95
VIREAD................................. 65
vision .................................... 157
vision formula ...................... 157
vision formula (with lutein) . 157
vision plus lutein .................. 157
vit b cmplx 3-fa-vit c-biotin . 157
vit b cmplx no3-fa-c-biot-zinc
.......................................... 157
vitabee/c ............................... 157
vitalets .................................. 157
vitamin a............................... 157
vitamin b complex ................ 157
vitamin b complex with c ..... 158
vitamin b-1 ........................... 158
vitamin b-100 complex ........ 158
vitamin b12-folic acid .......... 158
vitamin b-6 ........................... 158
vitamin c............................... 158
vitamins & minerals ............. 158
vitamins b complex .............. 158
vitamins for hair ................... 158
VITEKTA .............................. 65
vitrum senior ........................ 158
VOLTAREN .......................... 21
voriconazole ........................... 52
VOTRIENT ............................ 41
VPRIV .................................. 103
W
wal-act d cold & allergy ......... 55
wal-dram ................................ 59
wal-dryl allergy ................ 55, 56
wal-finate ............................... 56
wal-finate-d ............................ 56
wal-itin ................................... 56
wal-itin d ................................ 56
wal-itin d 12 hour ................... 56
wal-phed ........................... 56, 95
wal-phed pe ............................ 74
wal-phed pe day-night ............ 95
wal-phed pe sinus & allergy... 56
wal-profen .............................. 21
wal-sleep z.............................. 56
wal-som .................................. 56
wal-tap .................................... 56
wal-tussin cough..................... 95
wal-tussin cough & cold cf .... 95
wal-tussin dm ......................... 95
wal-zan 75 ............................ 110
wal-zyr (cetirizine) ................. 56
wal-zyr (ketotifen) ................ 107
wal-zyr d................................. 56
warfarin .................................. 68
water for irrigation, sterile.... 125
WELCHOL ............................ 81
women's daily multivitamin . 158
X
XALKORI .............................. 41
XARELTO ............................. 68
XELJANZ ............................ 130
XENAZINE............................ 83
XGEVA ................................ 126
XIFAXAN .............................. 28
XOLAIR ............................... 139
XTANDI ................................ 41
xylon 10 .................................. 18
XYREM ............................... 139
Y
yelets .................................... 158
YERVOY ............................... 41
YF-VAX (PF)....................... 124
Z
zafirlukast ............................. 137
zaleplon ................................ 140
ZALTRAP .............................. 41
zantac 75............................... 110
ZAVESCA ........................... 103
ZELBORAF ........................... 41
ZEMAIRA............................ 139
ZEMPLAR ........................... 126
ZENPEP ............................... 103
zephrex-d ................................ 95
ZETIA .................................... 81
ZIAGEN ................................. 65
zidovudine .............................. 65
I-22
Fòmilè ICS Community Care Plus 2015 FIDA-MMP
ID Fòmilè a: 15412.000, Vèsyon: 12
Anvigè apati: 1 Jiyè 2015
zinc oxide ............................... 97
ziprasidone hcl ....................... 63
ZOLADEX ............................. 41
zoledronic acid ..................... 126
zoledronic acid-mannitol-water
.......................................... 126
ZOLINZA .............................. 41
zolmitriptan ............................ 57
zolpidem............................... 140
ZOMETA ............................. 126
ZONATUSS ........................... 95
zonisamide ............................. 44
zoo chews ............................. 158
ZORTRESS .......................... 123
ZOSTAVAX (PF) ................ 124
ZOVIRAX .............................. 97
z-sleep .................................... 56
ZUBSOLV ............................. 23
ZYDELIG .............................. 41
ZYKADIA.............................. 41
ZYLET ................................. 108
zyncof ..................................... 95
ZYPREXA RELPREVV ........ 63
ZYRTEC ................................ 56
zyrtec itchy eye drops (keto) 107
ZYTIGA ................................. 41
ZYVOX .................................. 28
I-23
Fòmilè ICS Community Care Plus 2015 FIDA-MMP
ID Fòmilè a: 15412.000, Vèsyon: 12
Anvigè apati: 1 Jiyè 2015
Nou te fè dènye chanjman nan fòmilè sa a nan dat 1 jen 2015. Si ou gen kesyon, tanpri
rele ICS Community Care Plus FIDA-MMP nan nimewo 1.877.ICS.2525, lendi jiska
vandredi, ant 8 a.m. ak 8 p.m. Koutfil la gratis.
Pou jwenn plis enfòmasyon, ale sou sitwèb www.icsny.org/care-plus.
1.877.ICS.2525
www.icsny.org
Biwo Administratif
Independence Care System
257 Park Ave. South
2nd Floor
New York, NY 10010
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400 East Fordham Road
10th floor
Bronx, New York 10458
25 Elm Place
5th Floor
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