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Satellite Health Plan (HMO-SNP)
Pormularyo para sa 2014
(Listahan ng Saklaw na Mga Gamot)
PAKIBASA: ANG DOKUMENTONG ITO AY NAGLALAMAN NG IMPORMASYON TUNGKOL
SA MGA GAMOT NA ISINASAMA NAMIN SA SAKLAW NG PLANONG ITO
Ang pormularyong ito ay isinapanahon noong 10/25/2014. Para sa mas bagong impormasyon o iba pang mga
tanong, pakitawagan ang Satellite Health Plan sa 1-888-978-6095 o, para sa mga gumagamit ng TTY,
1-800-735-2929, 8 a.m. – 8 p.m., 7 araw/linggo, o puntahan ang www.satellitehealthplan.com.
Kapag binabanggit ng listahan ng gamot na ito (pormularyo) ang mga salitang “kami,” “amin,” o “namin,”
ang tinutukoy nito ay ang Satellite Health Plan. Kapag binabanggit nito ang mga salitang “plano” o “aming
plano,” ang tinutukoy nito ay ang Satellite Health Plan.
Kasama sa dokumentong ito ang isang listahan ng mga gamot (pormularyo) para sa aming plano na siyang
pinakabago sa Nobyembre 1, 2014. Para sa naisapanahong pormularyo, makipag-ugnayan sana sa amin. Ang
impormasyon kung paano kami matatawagan, kasama ang petsa na huli naming binago ang pormularyo, ay
makikita sa harap at likod ng mga pabalat na pahina.
Dapat ay sumang-ayon kayong gamitin ang mga botika ng network upang magamit ninyo ang inyong
benepisyo sa de-resetang gamot. Ang mga benepisyo, pormularyo, network ng botika, hulog at/o mga
copayment/coinsurance ay maaaring magbago sa Enero 1, 2015.
Formulary ID: 14510.000, Version: 19
Petsang Epektibo: Nobyembre 01, 2014
Huli update: Oktubre 25, 2014
H5765_14_PBM_10_001_RV1_TA Accepted 08272013
Ano ang Pormularyo ng Satellite Health Plan?
Ang pormularyo ay isang listahan ng mga saklaw na gamot na pinili ng Satellite Health Plan matapos
konsultahin ang isang pangkat ng mga tagapagbigay ng pangangalagang pangkalusugan, na kumakatawan sa
mga de-resetang terapiya na pinaniniwalaang mahalagang bahagi ng de-kalidad na programa sa paggamot.
Sa karaniwan isasama ng Satellite Health Plan sa saklaw ang mga gamot na nakalista sa aming pormularyo
hangga’t ang gamot ay medikal na kinakailangan, ang reseta ay kukunin sa isang botika sa network ng
Satellite Health Plan, at susundin ang iba pang mga patakaran. Para sa karagdagang impormasyon kung
paano kukunin ang inyong mga de-resetang gamot, pakibasa ulit ang inyong Katibayan ng Coverage.
Maaari bang magbago ang Pormularyo (listahan ng gamot)?
Sa kalahatan, kung gumagamit kayo ng gamot na nasa aming pormularyo para sa 2014 na saklaw sa simula
ng taon, hindi namin ihihinto o babawasan ang coverage ng gamot sa 2014 na taon ng coverage maliban
kapag magkaroon ng bago, mas murang generic na gamot o kapag may inilabas na bagong hindi magandang
impormasyon tungkol sa kaligtasan o pagiging epektibo ng isang gamot. Ang iba pang mga uri ng pagbabago
sa pormularyo, tulad ng pagtatanggal ng isang gamot mula sa aming pormularyo, ay hindi makakaapekto sa
mga miyembro na kasalukuyang gumagamit sa gamot na iyon. Mananatili itong magagamit sa parehong
paghahati sa gastos para sa mga miyembrong gumagamit nito sa nalalabing panahon ng taon ng coverage.
Itinuturing naming mahalaga na mayroon kayong nagpapatuloy na access para sa nalalabing bahagi ng taon
ng coverage sa mga gamot sa pormularyo na magagamit noong pinili ninyo ang aming plano, maliban sa
mga kaso kung saan makakatipid kayo ng karagdagang pera o masisiguro namin ang inyong kaligtasan.
Kung magtatanggal kami ng mga gamot mula sa aming pormularyo, o magdaragdag ng nauunang
awtorisasyon, mga limitasyon sa dami at/o mga paghihigpit sa step therapy sa isang gamot o ilipat ang isang
gamot sa mas mataas na baitang ng paghahati sa gastos, dapat naming pasabihan ang mga apektadong
miyembro tungkol sa pagbabago sa loob ng hindi bababa sa 60 araw bago maging epektibo ang pagbabago, o
sa panahong muling hihingin ng miyembro ang gamot, kung kailan tatanggap ang miyembro ng 60-araw na
supply ng gamot. Kung ipapasya ng Pangasiwaan ng Pagkain at Gamot na hindi ligtas ang isang gamot sa
aming pormularyo o tatanggalin ng tagagawa ang gamot mula sa merkado, agad naming tatanggalin ang
gamot sa aming pormularyo at magbibigay abiso sa mga miyembrong gumagamit ng gamot na iyon. Ang
nakalakip na pormularyo ay pinakabago sa Nobyembre 1, 2014. Upang kumuha ng naisapanahong
impormasyon tungkol sa mga gamot na saklaw ng Satellite Health Plan, tumawag sana sa amin. Ang
impormasyon kung paano kami matatawagan ay nasa harap at likod ng mga pabalat na pahina. Kung
magkaroon ng pagbabago sa pormularyo na walang kinalaman sa maintenance sa kasalukuyang taon,
magpapadala agad ang Satellite Health Plan ng sulat sa koreo na nagbibigay-abiso sa mga benepisyaryo
tungkol sa pagbabago, at ilalagay rin ang mga abiso na ito tungkol sa pagbabago sa pormularyo sa bahaging
Pharmacy (Botika) ng website ng Satellite Health Plan: www.satellitehealthplan.com
Paano ko gagamitin ang Pormularyo?
May dalawang paraan upang hanapin ang inyong gamot sa pormularyo:
Kondisyong Medikal
Nagsisimula ang pormularyo sa pahina 13. Ang mga gamot sa pormularyong ito ay grinupo sa mga
kategorya depende sa uri ng mga kondisyong medikal na ginagamot ng mga ito. Halimbawa, ang mga
gamot na ginagamit na panggamot sa kondisyon sa puso ay nakalista sa ilalim ng kategorya na
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
2
Epektibo: Nobyembre 1, 20141
Cardiovascular Agents (Mga Gamot sa Puso at Mga Ugat). Kung alam ninyo kung saan ginagamit ang
inyong gamot, hanapin ang pangalan ng kategorya sa listahang nagsisimula sa 13. Pagkatapos ay hanapin
ang inyong gamot sa ilalim ng pangalan ng kategorya.
Listahan ayon sa Alpabeto
Kung hindi kayo sigurado kung saang kategorya maghahanap, dapat ninyong hanapin ang inyong gamot
sa Index na nagsisimula sa pahina I-1. Kapwa ang mga de-tatak at generic na gamot ay nakalista sa
Index. Tingnan ang Index at hanapin ang inyong gamot. Sa tabi ng inyong gamot, makikita ninyo ang
pahina kung saan ninyo matatagpuan ang impormasyon sa coverage. Pumunta sa pahinang nakalista sa
Index at hanapin ang pangalan ng inyong gamot sa unang hanay ng listahan.
Ano ang mga generic na gamot?
Saklaw ng Satellite Health Plan ang kapwa mga de-tatak at generic na gamot. Ang generic na gamot ay
inaprubahan ng FDA bilang mayroong parehong aktibong sangkap tulad ng de-tatak na gamot. Sa
karaniwan, ang mga generic na gamot ay mas mura kaysa sa mga de-tatak na gamot.
Mayroon bang anumang mga paghihigpit sa aking coverage?
Ang ilang saklaw na gamot ay maaaring may karagdagang kinakailangan o limit sa coverage. Ang mga
kinakailangan at limit na ito ay maaaring kinabibilangan ng:

Nauunang Awtorisasyon: Hinihingi ng Satellite Health Plan na kumuha kayo o ang inyong doktor
ng nauunang awtorisasyon para sa ilang gamot. Ibig sabihin nito na kailangan ninyong kumuha ng
pag-apruba mula sa Satellite Health Plan bago ninyo kunin ang inyong mga de-resetang gamot. Kung
hindi kayo kukuha ng pag-apruba, maaaring hindi isasama sa saklaw ng Satellite Health Plan ang
gamot.

Mga Limit sa Dami: Para sa ilang gamot, nililimitahan ng Satellite Health Plan ang dami ng gamot
na sasagutin ng Satellite Health Plan. Halimbawa, nagbibigay ang Satellite Health Plan ng 18 tableta
kada reseta para sa sumatriptan. Maaaring dagdag ito sa karaniwang isang-buwan o tatlong-buwang
supply.

Step Therapy: Sa ilang kaso, hinihingi ng Satellite Health Plan sa inyo na subukan muna ninyo ang
ilang gamot na panlunas sa inyong kondisyon bago namin isama sa saklaw ang isa pang gamot para
sa kondisyong iyon. Halimbawa, kung parehong ginagamot ng Gamot A at Gamot B ang inyong
kondisyong medikal, maaaring hindi isasama ng Satellite Health Plan sa saklaw ang Gamot B
maliban kung susubukan muna ninyo ang Gamot A. Kung hindi mabisa ang Gamot A para sa inyo,
tsaka pa lamang isasama ng Satellite Health Plan sa saklaw ang Gamot B.
Maaari ninyong tingnan ang pormularyo simula sa pahina 13 upang alamin kung ang inyong gamot ay may
mga karagdagang kinakailangan o limit. Maaari rin kayong makakuha ng karagdagang impormasyon tungkol
sa mga paghihigpit na ipinapataw sa mga partikular na saklaw na gamot sa pamamagitan ng pagpunta sa
aming Web site. Ang impormasyon kung paano kami matatawagan, kasama ang petsa na huli naming binago
ang pormularyo, ay makikita sa harap at likod ng mga pabalat na pahina.
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
3
Epektibo: Nobyembre 1, 20141
Maaari ninyong hingin na gumawa ang Satellite Health Plan ng exception sa mga paghihigpit o limit na ito o
para isama sa listahan ang iba pang katulad na mga gamot na maaaring panlunas sa kondisyon ng inyong
kalusugan. Tingnan ang bahaging, “Paaano ako hihingi ng exception sa pormularyo ng Satellite Health
Plan?” sa pahina 5 para sa impormasyon kung paano hihingi ng exception.
Ano ang mga gamot na nabibili nang walang reseta (OTC)?
Ang mga gamot na OTC ay mga gamot na hindi nangangailangan ng reseta na hindi karaniwang saklaw ng
Medicare Prescription Drug Plan. Sinasagot ng Satellite Health Plan ang ilang gamot na OTC.
MGA SAKLAW NA GAMOT NA NABIBILI NANG WALANG RESETA (OTC)
GAMOT
Uri ng Dosis
Generic na Pangalan
(Sangguniang Tatak)
cetirizine hydrochloride
(Zyrtec)
Nangunguyang Mga Tableta,
Solusyon, Mga Tableta
cetirizine hydrochloride/
pseudoephedrine hydrochloride
(Zyrtec-D)
12 Oras na Mga Tableta
loratadine
(Claritin)
loratadine/
pseudoephedrine sulfate
(Claritin-D)
ketotifen fumarate
(Zaditor)
Natutunaw sa Tubig na Mga Tableta,
Solusyon, Syrup, Mga Tableta
12 Oras na Mga Tableta
24 Oras na Mga Tableta
Drops, Solusyon
Ibibigay ng Satellite Health Plan ang mga gamot na OTC na ito nang wala kayong babayaran. Ang halagang
babayaran ng Satellite health Plan para sa mga gamot na OTC na ito ay hindi mabibilang tungo sa inyong
kabuuang halaga ng gamot sa Part D (iyan ay, ang halagang binabayaran ninyo ay hindi nabibilang para sa
coverage gap).
Paano kung wala sa Pormularyo ang aking gamot?
Kung hindi kasama sa pormularyong (listahan ng mga saklaw na gamot) ito ang inyong gamot, dapat muna
ninyong tawagan ang Mga Serbisyo sa Miyembro at tanungin kung saklaw ang inyong gamot.
Kung malalaman ninyo na hindi isinasama sa saklaw ng Satellite Health Plan ang gamot, mayroon kayong
dalawang pagpipilian:

Maaari ninyong hingin sa Mga Serbisyo sa Miyembro ang listahan ng mga katulad na gamot na
isinasama sa saklaw ng Satellite Health Plan. Kapag natanggap ninyo ang listahan, ipakita ito sa
inyong doktor at hingin sa kanyang magreseta ng katulad na gamot na saklaw ng Satellite Health
Plan.

Maaari ninyong hingin na gumawa ang Satellite Health Plan ng exception at isama sa saklaw ang
inyong gamot. Tingnan sa ibaba ang impormasyon kung paano hihingi ng exception.
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
4
Epektibo: Nobyembre 1, 20141
Paano ako hihingi ng exception sa Pormularyo ng Satellite Health Plan?
Maaari ninyong hingin na gumawa ang Satellite Health Plan ng exception sa aming mga patakaran sa
coverage. Mayroong ilang uri ng exception na maaari ninyong hingin sa amin.

Maaari ninyong hingin na isama namin sa saklaw ang isang gamot kahit pa wala ito sa aming
pormularyo. Kung maaprubahan, isasama sa saklaw ang gamot na ito sa nauna nang ipinasyang antas
ng paghahati sa gastos, at hindi na ninyo maaaring hingin sa amin na ibigay ang gamot sa mas
mababang antas ng paghahati sa gastos.

Maaari ninyong hingin na isama namin sa saklaw ang isang gamot sa pormularyo sa mas mababang
antas ng paghahati sa gastos kung ang gamot na ito ay wala sa baitang ng espesyalidad. Kung
maaprubahan mapapababa nito ang halagang dapat ninyong bayaran para sa gamot.

Maaari ninyong hingin na isantabi namin ang mga paghihigpit o limit sa coverage ng inyong gamot.
Halimbawa, para sa ilang gamot, nililimitahan ng Satellite Health Plan ang dami ng gamot na
sasagutin ng Satellite Health Plan. Kung ang inyong gamot ay nalilimitahan ang dami, maaari
ninyong hingin na isantabi namin ang limit at isama sa saklaw ang mas maraming kantidad.
Sa karaniwan, aaprubahan lamang ng Satellite Health Plan ang inyong kahilingan para sa exception kung ang
mga alternatibong gamot na kasama sa pormularyo ng plano, ang gamot na may mas mababang paghahati sa
gastos o karagdagang paghihigpit sa paggamit ay hindi magiging kasing-epektibo sa paggamot sa inyong
kondisyon at/o magdudulot sa inyo ng mga hindi mabuting epektong medikal.
Dapat kayong makipag-ugnayan sa amin upang hingin sa amin ang desisyon sa inisyal na coverage para sa
exception sa pormularyo, sa paghihigpit sa pagbabaitang o paggamit. Kapag hihingi kayo ng exception sa
pormularyo, pagbabaitang o paggamit, dapat kayong magsumite ng pahayag mula sa inyong
tagapagreseta o doktor na sumusuporta sa inyong kahilingan. Sa karaniwan, dapat naming gawin ang
aming desisyon sa loob ng 72 oras pagkatanggap sa pahayag ng inyong tagapagreseta na sumusuporta sa
kahilingan. Maaari kayong humingi ng pinabilis (mabilis) na exception kung naniniwala kayo o ang inyong
doktor na maaaring lubhang mapipinsala ang inyong kalusugan kung maghihintay kayo nang hanggang
72 oras para sa desisyon. Kung pagbibigyan ang inyong kahilingang pabilisin, dapat naming ibigay sa inyo
ang aming desisyon nang hindi lalampas sa 24 oras pagkatanggap namin sa pahayag ng inyong doktor o
tagapagreseta na sumusuporta sa kahilingan.
Ano ang gagawin ko bago ko kausapin ang aking doktor tungkol sa pagpapalit ng aking
mga gamot o paghingi ng exception?
Bilang bago o nagpapatuloy na miyembro ng aming plano maaaring gumagamit kayo ng mga gamot na wala
sa aming pormularyo. O, maaaring gumagamit kayo ng gamot na nasa aming pormularyo ngunit limitado
ang inyong kakayahang makuha ito. Halimbawa, maaaring kailangan ninyo ng nauunang awtorisasyon mula
sa amin bago ninyo makukuha ang inyong de-resetang gamot. Dapat ninyong kausapin ang inyong doktor
upang magdesisyon kung dapat kayong lumipat sa isang angkop na gamot na isinasama namin sa saklaw o
humingi ng exception sa pormularyo upang isama namin sa saklaw ang gamot na ginagamit ninyo. Habang
kausap ninyo ang inyong doktor upang ipasya ang tamang hakbang para sa inyo, maaari naming isama sa
saklaw ang inyong gamot sa ilang kaso sa unang 90 araw na miyembro kayo ng aming plano.
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
5
Epektibo: Nobyembre 1, 20141
Para sa bawat isa sa inyong mga gamot na wala sa aming pormularyo o kung limitado ang inyong
kakayahang makuha ang inyong mga gamot, isasama namin sa saklaw ang pansamantalang 30-araw na
supply (maliban kung mayroon kayong reseta para sa mas kaunting bilang ng mga araw) kapag pupunta kayo
sa isang botika ng network. Pagkatapos ng inyong unang 30-araw na supply, hindi na kami magbabayad para
sa ganitong mga gamot, kahit pa naging miyembro kayo ng plano nang mas mababa sa 90 araw.
Kung kayo ay residente sa isang pasilidad ng pangmatagalang pangangalaga, pahihintulutan namin kayong
muling kunin ang inyong de-resetang gamot hanggang bigyan namin kayo ng 91-araw na supply habang
lumilipat, sang-ayon sa pagdagdag sa ibinibigay, (maliban kung mayroon kayong reseta para sa mas
kaunting bilang ng mga araw). Isasama namin sa saklaw ang higit sa isang muling pagkuha ng mga ganitong
gamot para sa unang 90 araw na miyembro kayo ng aming plano. Kung kailangan ninyo ng gamot na wala sa
aming pormularyo o limitado ang inyong kakayahang makuha ang inyong mga gamot ngunit lampas na kayo
sa unang 90 araw ng pagiging miyembro ng aming plano, isasama namin sa saklaw ang 31-araw na
emergency supply ng gamot na iyon (maliban kung ang inyong reseta ay para sa mas kaunting bilang
ng mga araw) habang humihingi kayo ng exception sa pormularyo.
Ang mga medikasyon sa paglipat ay ibibigay sa mga miyembro na magpapalit ng paggamot dahil sa mga
pagbabago sa antas ng pangangalaga (hal., mga indibiduwal na papasok sa mga pasilidad ng pangmatagalang
pangangalaga mula sa mga ospital o lilipat sa ambulatory setting mula sa isang ospital).
Ang mga miyembro na may mga pagbabago sa antas ng pangangalaga ay maaaring makipag-ugnayan sa
amin (o hingin sa kanilang doktor o tagapagreseta na makipag-ugnayan sa amin) upang humingi ng mga
supply ng medikasyon sa paglipat habang lumilipat sila ng pangangalaga. Hindi magbibigay ang Satellite
Health Plan ng supply sa paglipat para sa anumang gamot na hindi naaprubahan sa Part D.
Para sa karagdagang impormasyon
Para sa mas detalyadong impormasyon tungkol sa inyong coverage sa de-resetang gamot sa Satellite Health
Plan, pakibasa muli ang inyong Katibayan ng Coverage at iba pang mga materyales ng plano.
Kung may mga tanong kayo tungkol sa Satellite Health Plan, makipag-ugnayan sana sa amin. Ang
impormasyon kung paano kami matatawagan, kasama ang petsa na huling isinapanahon namin ang
pormularyo, ay makikita sa harap at likod ng mga pabalat na pahina.
Kung mayroon kayong mga pangkalahatang katanungan tungkol sa coverage sa de-resetang gamot sa
Medicare, pakitawagan ang Medicare sa 1-800-MEDICARE (1-800-633-4227) 24 oras sa maghapon/
7 araw sa isang linggo. Ang mga gumagamit ng TTY ay dapat tumawag sa 1-877-486-2048. O pumunta
sa www.medicare.gov.
Pormularyo ng Satellite Health Plan
Ang pormularyong nagsisimula sa pahina 13 ay nagbibigay ng impormasyon sa coverage tungkol sa mga
gamot na isinasama sa saklaw ng Satellite Health Plan. Kung nahihirapan kayong hanapin ang inyong gamot
sa listahan, pumunta sa Index na nagsisimula sa pahina I-1.
Nakalista sa unang hanay ng tsart ang pangalan ng gamot. Ang mga de-tatak na gamot ay nakasulat sa
malalaking letra (hal., COUMADIN) at ang mga generic na gamot ay nakasulat sa maliliit na letrang pahilig
sa kanan (hal., warfarin).
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
6
Epektibo: Nobyembre 1, 20141
Sasabihin sa inyo ng impormasyon sa hanay ng mga Kinakailangan/Limit kung ang Satellite Health Plan ay
may anumang espesyal na mga kinakailangan para sa coverage ng inyong gamot.
Ang mga sumusunod na daglat ay makikita sa katawan ng dokumentong ito
MGA DAGLAT SA MGA TALA SA COVERAGE
DAGLAT
PA
PA BvD
PA NSO
QL
ST
LA
NM
PAGLALARAWAN
PALIWANAG
Mga Paghihigpit sa Pangangasiwa sa Paggamit
Kayo (o ang inyong doktor) ay kailangang kumuha ng nauunang
Paghihigpit sa
awtorisasyon mula sa Satellite Health Plan bago ninyo kunin ang
Nauunang
inyong reseta ng gamot na ito. Kung walang nauunang pag-apruba,
Awtorisasyon
maaaring hindi isama sa saklaw ng Satellite Health Plan ang gamot
na ito.
Ang gamot na ito ay maaaring kuwalipikadong mabayaran sa ilalim
Paghihigpit sa
ng Medicare Part B o Part D. Kayo (o ang inyong doktor) ay
Nauunang
kailangang kumuha ng nauunang awtorisasyon mula sa Satellite
Awtorisasyon para
Health Plan upang ipasya na ang gamot na ito ay saklaw sa ilalim
sa Pagpapasya sa
ng Medicare Part D bago ninyo kunin ang inyong reseta ng gamot
Part B vs Part D
na ito. Kung walang nauunang pag-apruba, maaaring hindi isama sa
saklaw ng Satellite Health Plan ang gamot na ito.
Paghihigpit sa
Kung kayo ay bagong miyembro, kayo (o ang inyong doktor) ay
Nauunang
kailangang kumuha ng nauunang awtorisasyon mula sa Satellite
Awtorisasyon para sa Health Plan bago ninyo kunin ang inyong reseta ng gamot na ito.
Mga Bagong
Kung walang nauunang pag-apruba, maaaring hindi isama sa
Kasisimula Lamang saklaw ng Satellite Health Plan ang gamot na ito.
Paghihigpit sa Limit Nililimitahan ng Satellite Health Plan ang dami ng gamot na ito na
ng Dami
saklaw kada reseta, o sa loob ng partikular na panahon.
Bago magbigay ang Satellite Health Plan ng coverage para sa
gamot na ito, dapat muna ninyong subukan ang iba pang (mga)
Paghihigpit sa
gamot upang lunasan ang inyong kondisyong medikal. Ang gamot
StepTherapy
na ito ay isasama lamang sa saklaw kung hindi epektibo sa inyo ang
ibang (mga) gamot.
Iba pang Mga Espesyal na Kinakailangan para sa Coverage
Ang de-resetang gamot na ito ay maaaring makuha lamang sa ilang
botika. Para sa karagdagang impormasyon konsultahin ang inyong
Gamot na Limitado
Direktoryo ng Botika o tumawag sa Mga Serbisyo sa Miyembro sa
ang Access
1-888-978-6095, 8 a.m. – 8 p.m., 7 araw/ linggo. Ang mga
gumagamit ng TTY/TDD ay dapat tumawag sa 1-800-735-2929.
Maaari kayong tumanggap ng mahigit sa 1-buwang supply ng
karamihan ng gamot sa inyong pormularyo sa pamamagitan ng
Gamot na Hindi Na- pag-oorder sa koreo sa mas mababang paghahati sa gastos. Ang
oorder sa Koreo
mga gamot na hindi makukuha sa pamamagitan ng benepisyong
pag-oorder sa koreo ay namarkahan ng “NM” sa hanay na Mga
Kinakailangan/Limit sa inyong pormularyo.
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
7
Epektibo: Nobyembre 1, 20141
MGA DAGLAT NG LAKAS AT URI NG DOSIS
DAGLAT
adh. itinatapal
aer br act
aer pow
aer pow ba
aer refill
aer w/adap
Ampul
Blkbaginj
cap dr mp
cap ds pk
cap er 12h
cap er 24h
cap er deg
cap er pel
cap mphase
cap.sa 24h
cap.sr 12h
cap.sr 24h
cap24h pct
cap24h pel
cap sprink
cap sr pel
cap w/dev
kapsula dr
kapsula er
kapsula sa
cmb cappad
cmb ont fm
cmb ont lt
cmb tabpad
combo. Pkg
cpmp 12hr
cpmp 24hr
cpmp 30-70
cpmp 50-50
cream(g), cream(gm)
cream(ml)
cream/appl
cream, er (g)
cream pack
PAGLALARAWAN
itinatapal na may pandikit
aerosol, pinagagana ng hininga
aerosol, powder
aerosol powder, pinagagana ng hininga
aerosol refill
aerosol na may adapter
ampule
bulk bag na iniksyon
kapsula, hindi kaagad inilalabas ang aktibong sangkap may iba’t ibang yugto
kapsula, pakete ng dosis
kapsula, mas mabagal na inilalabas ang aktibong sangkap sa 12 oras
kapsula, mas mabagal na inilalabas ang aktibong sangap sa 24 na oras
kapsula, mas mabagal na inilalabas ang aktibong sangkap degradable
kapsula, mga bulitas mas mabagal naglalabas ng aktibong sangkap
kapsula, may iba’t ibang yugto
kapsula, inilalabas ang aktibong sangkap sa tukoy na dosis sa partikular na
oras sa 24 na oras
kapsula, dahan-dahang inilalabas ang aktibong sangkap sa 12 oras
kapsula, dahan-dahang inilalabas ang aktibong sangkap sa 24 na oras
kapsula, mga bulitas na kontrolado ang onset sa 24 na oras
kapsula, mga bulitas na dahan-dahang naglalabas ng aktibong sangkap sa
24 na oras
kapsula, sprinkle
kapsula, mga bulitas na dahan-dahang naglalabas ng aktibong sangkap
kapsula na may aparato
kapsula, hindi kaagad inilalabas ang aktibong sangkap
kapsula, mas mabagal na inilalabas ang aktibong sangkap
kapsula, inilalabas ang aktibong sangkap sa tukoy na dosis
kumbinasyon: kapsula, pad
kumbinasyon: ointment, foam
kumbinasyon: ointment, lotion
kumbinasyon: tableta, pad
kumbinasyong pakete
kapsula, iba't ibang yugto sa 12 oras
kapsula, iba't ibang yugto sa 24 na oras
kapsula, iba’t ibang yugto, 30%-70%
kapsula, iba’t ibang yugto, 50%-50%
cream (grams)
cream (milliliters)
cream may pampahid
cream, mas mabagal na inilalabas ang aktibong sangkap (grams)
cream, pakete
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
8
Epektibo: Nobyembre 1, 20141
DAGLAT
dehp fr bg
dis na karayom
disk w/dev
disp syrin
drops susp
drps hpvis
emul adhes
emul packt
emulsn(g)
foam/appl.
froz.piggy
g
gel/pf app
gel (gm)
gel (ml)
gel md pmp
gel w/appl
gel w/pump
gran pack
hfa aer ad
infus. btl
insuln pen
ip soln
irrig soln
iv soln.
jel
jelly/app
jel/pf app
kit cl&crm
kt crm le
kt lotn ce
kt oint le
lotion, er
lozenge hd
m.ht na itinatapal
ma buc tab
mcg
med. pad
med. swab
med. tape
mg
ml
muc er 12h
PAGLALARAWAN
di(2-ethylhexyl)phthalate libreng bag
maaaring itapon na karayom
disk na may aparato para sa paglanghap
maaaring itapon na herenggilya
drops, suspension
drops, hyperviscous
emulsyon na madikit
pakete ng emulsyon
emulsyon (grams)
foam na may panlagay
frozen piggyback
gram
gel na may kargado nang panlagay
gel (grams)
gel (milliliters)
gel sa naka-metrong pambomba ng dosis
gel na may pampahid
gel na may pambomba
pakete ng maliliit na butil
hfa aerosol adapter
bote ng infusion
insulin pen
intraperitoneal solution
panlinis na solution
solution na ini-iniksyon sa ugat
jelly
jelly na may pampahid
jelly na may kargado nang pampahid
kit: panlinis at cream
kit: cream, lotion emollient
kit: lotion, cream emollient
kit: ointment, lotion emollient
lotion, mas mabagal na inilalabas ang aktibong sangkap
lozenge handle
may-gamot na mainit na itinatapal
mucoadhesive buccal tablet
microgram
may-gamot na pad
may-gamot na swab
may-gamot na tape
milligram
milliliter
mucoadhesive system, mas mabagal na inilalabas ang aktibong sangkap sa
12 oras
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
9
Epektibo: Nobyembre 1, 20141
DAGLAT
ndl fr inj
nl fm susp
oint. (g), oint.(gm)
iniinom na conc
iniinom na susp
pasta (g)
itinatapal td24
itinatapal td72
itinatapal tdsw
itinatapal tdsw
pca syring
pca vial
pellet(ea)
pen ij kit
pen injctr
pggybk btl
plast. bag
pakete ng powd
sol md pmp
sol w/appl
sol/pf app
sol-gel
soln recon
soln(gram)
spray susp
spray/pambomba
stick(ea)
supp.rect
supp.vag
suppos.
sus er 24h
sus er rec
sus mc rec
suspdr pkt
susp recon
kit ng herenggilya
tab nangunguya
tab er 12h
tab er 24h
tab er prt
tab er seq
tab disper
tab ds pk
tab er 24
PAGLALARAWAN
karayom na pang-iniksyon
nail film suspension
ointment (grams)
iniinom na concentrate
iniinom na suspension
pasta (grams)
itinatapal, idinidikit sa balat 24 na oras
itinatapal, idinidikit sa balat 72 na oras
itinatapal, idinidikit sa balat tuwing dalawang linggo
itinatapal, idinidikit sa balat linggo-linggo
kontrolado-ng-pasyente na herenggilya ng gamot sa pananakit
kontrolado-ng-pasyente na vial ng gamot sa pananakit
bulitas (bawat isa)
pen injector kit
pen injector
piggyback bottle
plastik na bag
pakete ng powder
solution na may maraming dosis na pambomba
solution na may panlagay
solution na may kargado nang panlagay
solution, bumubuo-ng-gel
solution, reconstituted
solution (grams)
spray, suspension
spray na may pambomba
stick (bawat isa)
suppository, para sa tumbong
suppository, para sa puwerta
suppository
suspension, mas mabagal na inilalabas ang aktibong sangkap sa 24 na oras
suspension, mas mabagal na inilalabas ang aktibong sangkap reconstituted
suspension, microcapsule reconstituted
suspension, hindi kaagad inilalabas ang aktibong sangkap pakete
suspension, reconstituted
kit ng herenggilya
tableta, nangunguya
tableta, mas mabagal na inilalabas ang aktibong sangkap sa 12 oras
tableta, mas mabagal na inilalabas ang aktibong sangkap sa 24 oras
tableta, maliliit na piraso mas mabagal na inilalabas ang aktibong sangkap
tableta, mga sequel mas mabagal na inilalabas ang aktibong sangkap
tableta, naghihiwa-hiwalay
tableta, pakete ng dosis
tableta, mas mabagal na inilalabas ang aktibong sangkap sa 24 oras
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
10
Epektibo: Nobyembre 1, 20141
DAGLAT
tab mphase
tab part
tab rap dr
tab rapdis
tab subl
tab.sr 12h
tab.sr 24h
tabergr24hr
tableta dr
tableta, er
tableta eff
tableta sa
tableta sol
tb er dspk
tb mp dspk
tb rd dspk
tbdspk 3mo
tbmp 12hr
tbmp 24hr
u
vag ring
PAGLALARAWAN
tableta, iba’t ibang yugto
tableta, maliliit na piraso
tableta, mabilis na natutunaw hindi kaagad inilalabas ang aktibong sangkap
tableta, mabilis na natutunaw
tableta, sa ilalim ng dila
tableta, dahan-dahang inilalabas ang aktibong sangkap sa 12 oras
tableta, dahan-dahang inilalabas ang aktibong sangkap sa 24 na oras
tableta, paunti-unting mas mabagal na inilalabas ang aktibong sangkap sa
24 na oras
tableta, hindi kaagad inilalabas ang aktibong sangkap
tableta, mabagal na inilalabas ang aktibong sangkap
tableta, bumubula
tableta, inilalabas ang aktibong sangkap sa tukoy na dosis sa partikular na oras
tableta, natutunaw
tableta, pakete ng dosis na mabagal naglalabas ang aktibong sangkap
tableta, pakete ng dosis na may iba’t ibang yugto
tableta, pakete ng dosis na mabilis na natutunaw
tableta, pakete ng 3-buwang dosis
tableta, iba’t ibang yugto sa 12 oras
tableta, iba’t ibang yugto sa 24 na oras
yunit
vaginal ring
MGA HALAGA NG COPAYMENT/COINSURANCE
Uri ng Gamot
Botika sa Loob-ngnetwork
1-buwang supply
Botika sa Loob-ngnetwork
3-buwang supply
Botika sa Pagoorder sa Koreo
3-buwang supply
Botika ng
Pangmatagalang
Pangangalaga
1-buwang supply
Baitang 1
Baitang 2
Baitang 3
Baitang 4
Baitang 5
Pinipiling
Generic
Di-Pinipiling
Generic
Pinipiling
Tatak
Di-Pinipiling
Tatak
Baitang ng
Espesyalidad
$0
$10
$40
$65
25%
coinsurance
$0
$30
$120
$195
25%
coinsurance
$0
$25
$100
$162.50
Wala
$0
$10
$40
$65
25%
coinsurance
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
11
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
Baitang ng
Gamot
Mga Kinakailangan/Limit
Analgesics
Analgesics, Miscellaneous
acetaminophen with codeine
acetaminophen with codeine
2
2
QL: 180 in 30 days
QL: 360 in 30 days
tablet: 300mg-60mg
tablet: 300mg-15mg, 300mg30mg
buprenorphine hcl
2
(injectable)
butalb/acetaminophen/
2
PA, QL: 180 in 30 days tablet: 50-325-40, (High Risk
caffeine
Med for Ages 65 and Older)
butalb/acetaminophen/
2
PA, QL: 2700 in 30 days solution, (High Risk Med for
caffeine
Ages 65 and Older)
butalbit/acetamin/caff/
2
PA, QL: 180 in 30 days capsule: 50-300-30, (High Risk
codeine
Med for Ages 65 and Older)
butalbit/acetamin/caff/
2
PA, QL: 180 in 30 days capsule: 50-325-30, (High Risk
codeine
Med for Ages 65 and Older)
butalbital/acetaminophen
2
PA, QL: 180 in 30 days tablet: 50mg-325mg, (High
Risk Med for Ages 65 and
Older)
butorphanol tartrate
2
syringe, vial
butorphanol tartrate
2
QL: 5 in 28 days
spray
BUTRANS
3
QL: 4 in 28 days
patch tdwk: 5mcg/hr, 10mcg/hr,
15mcg/hr, 20mcg/hr
BUTRANS
3
QL: 4 in 28 days
patch tdwk: 7.5mcg/hr
codeine phos/acetaminophen
2
QL: 2500 in 30 days
codeine sulfate
2
QL: 180 in 30 days
tablet
codeine/butalbital/asa/
2
PA, QL: 180 in 30 days (High Risk Med for Ages 65 and
caffein
Older)
fentanyl citrate
5
NM, PA, QL: 120 in 30
days
fentanyl
2
PA
hydrocodone/acetaminophen
2
QL: 150 in 30 days
tablet: 7.5-750mg, 10-750mg
hydrocodone/acetaminophen
2
QL: 180 in 30 days
tablet: 7.5-650mg, 10-660mg,
10mg-650mg
hydrocodone/acetaminophen
2
QL: 2025 in 30 days
solution: 10-300/15
hydrocodone/acetaminophen
2
QL: 240 in 30 days
capsule, tablet: 2.5-500mg, 5mg500mg, 7.5-500mg, 10mg500mg
hydrocodone/acetaminophen
2
QL: 2700 in 30 days
solution: 7.5-325/15
hydrocodone/acetaminophen
2
QL: 2700 in 30 days
solution: 7.5-500/15, 10-325/15
hydrocodone/acetaminophen
2
QL: 360 in 30 days
tablet: 2.5-325mg, 5mg-325mg,
7.5-325mg, 10mg-325mg
hydrocodone/acetaminophen
2
QL: 390 in 30 days
tablet: 5mg-300mg, 7.5-300mg,
10mg-300mg
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Epektibo: Nobyembre 1, 20141
Formulary ID: 14510.000, Version: 19
12
Pangalan ng Gamot
Baitang ng
Gamot
hydrocodone/ibuprofen
hydromorphone hcl/pf
hydromorphone hcl/pf
hydromorphone hcl
hydromorphone hcl
hydromorphone hcl
hydromorphone hcl
ibuprofen/oxycodone hcl
LAZANDA
2
2
2
2
2
2
2
2
5
levorphanol tartrate
methadone hcl
methadone hcl
methadone hcl
methadone hcl
methadone hcl
morphine sulfate/0.9% nacl/
pf
morphine sulfate/pf
morphine sulfate
2
2
2
2
2
2
2
morphine sulfate
morphine sulfate
MORPHINE SULFATE
morphine sulfate
morphine sulfate
morphine sulfate
morphine sulfate
nalbuphine hcl
NUCYNTA ER
NUCYNTA
OFIRMEV
oxycodone hcl/
acetaminophen
oxycodone hcl/
acetaminophen
oxycodone hcl/
acetaminophen
oxycodone hcl/
acetaminophen
oxycodone hcl/aspirin
oxycodone hcl
2
2
2
2
2
2
2
2
3
3
4
2
Mga Kinakailangan/Limit
QL: 150 in 30 days
QL: 1200 in 30 days
QL: 180 in 30 days
QL: 240 in 30 days
QL: 28 in 30 days
NM, PA, QL: 30 in 30
days
QL: 180 in 30 days
QL: 1800 in 30 days
QL: 1800 in 30 days
QL: 360 in 30 days
QL: 90 in 30 days
2
2
QL: 120 in 30 days
QL: 180 in 30 days
QL: 180 in 30 days
QL: 200 in 30 days
QL: 300 in 30 days
QL: 700 in 30 days
ampul
vial
syringe
liquid
tablet: 2mg, 4mg
tablet: 8mg
vial
oral conc
solution
tablet
tablet sol
ampul, cartridge: 8mg/ml, 10mg/
ml, 15mg/ml; pen injctr,
supp.rect, syringe, vial, vial port
cartridge: 2mg/ml, 4mg/ml
tablet er: 30mg, 60mg, 100mg
tablet er: 15mg, 200mg
solution: 100mg/5ml
solution: 20mg/5ml
solution: 10mg/5ml
QL: 60 in 30 days
QL: 181 in 30 days
QL: 180 in 30 days
tablet: 10mg-650mg
2
QL: 1800 in 30 days
solution
2
QL: 240 in 30 days
2
QL: 360 in 30 days
capsule, tablet: 5mg-500mg, 7.5500mg
tablet: 2.5-325mg, 5mg-325mg,
7.5-325mg, 10mg-325mg
2
2
QL: 360 in 30 days
QL: 1300 in 30 days
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
13
solution
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
Baitang ng
Gamot
Mga Kinakailangan/Limit
oxycodone hcl
OXYCONTIN
OXYCONTIN
2
3
3
QL: 180 in 30 days
QL: 120 in 30 days
QL: 60 in 30 days
oxymorphone hcl
oxymorphone hcl
oxymorphone hcl
2
2
2
QL: 120 in 30 days
QL: 180 in 30 days
QL: 60 in 30 days
tramadol hcl/acetaminophen
2
tramadol hcl
2
XARTEMIS XR
3
Nonsteroidal Anti-inflammatory Agents
butalbital/aspirin/caffeine
2
QL: 240 in 30 days
QL: 240 in 30 days
QL: 360 in 30 days
PA, QL: 180 in 30 days
CALDOLOR
CELEBREX
choline sal/mag salicylate
diclofenac potassium
diclofenac sodium/
misoprostol
diclofenac sodium
diflunisal
etodolac
fenoprofen calcium
FLECTOR
flurbiprofen
ibuprofen
ibuprofen
indomethacin sodium
4
3
2
2
2
2
2
2
2
3
2
1
2
2
PA
indomethacin
2
PA, QL: 120 in 30 days
indomethacin
2
PA, QL: 240 in 30 days
indomethacin
2
PA, QL: 60 in 30 days
ketoprofen
ketorolac tromethamine
ketorolac tromethamine
ketorolac tromethamine
ketorolac tromethamine
mefenamic acid
meloxicam
2
2
2
2
2
2
1
capsule, oral conc, tablet
tab er 12h: 80mg
tab er 12h: 10mg, 15mg, 20mg,
30mg, 40mg, 60mg
tab er 12h: 30mg, 40mg
tablet
tab er 12h: 5mg, 7.5mg, 10mg,
15mg, 20mg
tablet
(High Risk Med for Ages 65 and
Older)
ST, QL: 60 in 30 days
gel (gram), tab er 24h, tablet dr
QL: 20 in 30 days
QL: 20 in 30 days
QL: 40 in 30 days
QL: 40 in 30 days
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
14
tablet
oral susp: 100mg/5ml
(High Risk Med for Ages 65 and
Older)
capsule: 50mg, (High Risk Med
for Ages 65 and Older)
capsule: 25mg, (High Risk Med
for Ages 65 and Older)
capsule er, (High Risk Med for
Ages 65 and Older)
cartridge: 30mg/ml
tablet, vial: 60mg/2ml
cartridge: 15mg/ml
vial: 15mg/ml
tablet
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
meloxicam
nabumetone
naproxen sodium
naproxen
naproxen
piroxicam
salsalate
sulindac
tolmetin sodium
VOLTAREN
Baitang ng
Gamot
Mga Kinakailangan/Limit
2
2
1
1
2
2
2
2
2
3
oral susp
tablet
oral susp, tablet dr
(Topical Gel)
Anesthetics
Local Anesthetics
cocaine hcl
lidocaine hcl/pf
2
2
lidocaine hcl
lidocaine hcl
2
2
lidocaine hcl
lidocaine/prilocaine
lidocaine
LIDODERM
2
2
2
2
PA BvD
PA BvD
PA BvD
PA BvD
ampul: 15mg/ml, 40mg/ml, (PA
for ESRD Only)
disp syrin, solution: 4%
jel (ml), jel/pf app, solution: 2%,
40mg/ml
vial, (PA for ESRD Only)
(PA for ESRD Only)
oint. (g), (PA for ESRD Only)
Anti-addiction/substance Abuse Treatment Agents
Anti-addiction/substance Abuse Treatment Agents
acamprosate calcium
2
buprenorphine hcl/naloxone
2
PA, QL: 90 in 30 days
hcl
buprenorphine hcl
2
PA, QL: 90 in 30 days
CAMPRAL
4
CHANTIX
3
QL: 168 in 84 days
CHANTIX
3
QL: 53 in 28 days
CHANTIX
3
QL: 56 in 28 days
disulfiram
2
naloxone hcl
2
naloxone hcl
2
naltrexone hcl
2
NICOTROL
4
QL: 2016 in 365 days
SUBOXONE
4
PA, QL: 60 in 30 days
SUBOXONE
4
PA, QL: 90 in 30 days
ZUBSOLV
3
tab ds pk
tablet: 0.5mg, 1mg
tab ds pk
tablet: 1mg
syringe: 0.4mg/ml; vial
syringe: 1mg/ml
film: 12mg-3mg
film: 2mg-0.5mg, 4mg-1mg,
8mg-2mg
PA, QL: 90 in 30 days
Antianxiety Agents
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
15
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
Baitang ng
Gamot
Mga Kinakailangan/Limit
Benzodiazepines
alprazolam
alprazolam
2
2
QL: 60 in 30 days
QL: 90 in 30 days
chlordiazepoxide hcl
clonazepam
clonazepam
2
2
2
QL: 120 in 30 days
QL: 300 in 30 days
QL: 90 in 30 days
clorazepate dipotassium
clorazepate dipotassium
DIASTAT ACUDIAL
diazepam
diazepam
diazepam
diazepam
estazolam
flurazepam hcl
lorazepam
lorazepam
lorazepam
midazolam hcl/pf
midazolam hcl
midazolam hcl
ONFI
2
2
4
2
2
2
2
2
2
2
2
2
2
2
2
4
QL: 120 in 30 days
QL: 60 in 30 days
ONFI
4
ONFI
4
temazepam
triazolam
2
2
QL: 120 in 30 days
QL: 1200 in 30 days
QL: 2 in 28 days
QL: 30 in 30 days
QL: 30 in 30 days
QL: 150 in 30 days
QL: 2 in 30 days
QL: 90 in 30 days
QL: 2 in 30 days
QL: 10 in 30 days
QL: 2 in 30 days
PA NSO, QL: 480 in 30
days
PA NSO, QL: 60 in 30
days
PA NSO, QL: 60 in 30
days
QL: 30 in 30 days
QL: 30 in 30 days
tab er 24h: 1mg, 2mg, 3mg
tab er 24h: 0.5mg; tab rapdis,
tablet
tab rapdis: 2mg; tablet: 2mg
tab rapdis: 0.125mg, 0.25mg,
0.5mg, 1mg; tablet: 0.5mg, 1mg
tablet: 15mg
tablet: 3.75mg, 7.5mg
kit
tablet
oral conc, solution
syringe
oral conc
syringe, vial
tablet
syrup
syringe
oral susp
tablet: 10mg, 20mg
tablet: 5mg
Antibacterials
Aminoglycosides
BETHKIS
gentamicin in nacl, iso-osm
gentamicin in nacl, iso-osm
5
2
2
gentamicin sulfate/pf
gentamicin sulfate
kanamycin sulfate
neomycin sulfate
streptomycin sulfate
2
2
2
2
2
NM, PA BvD
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
16
piggyback: 100mg/50ml
piggyback: 60mg/50ml, 70mg/
50ml, 80mg/100ml, 80mg/50ml,
90mg/100ml, 100mg/0.1l
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
Baitang ng
Gamot
TOBI PODHALER
tobramycin in 0.225% nacl
tobramycin sulfate
tobramycin/sodium chloride
tobramycin/sodium chloride
Antibacterials, Miscellaneous
bacitracin
chloramphenicol sod succ
clindamycin hcl
clindamycin palmitate hcl
clindamycin phosphate/d5w
clindamycin phosphate
colistin (colistimethate na)
CUBICIN
FUROXONE
methenamine hippurate
nitrofurantoin macrocrystal
5
5
2
2
2
nitrofurantoin
2
polymyxin b sulfate
SYNERCID
trimethoprim
vancomycin hcl/d5w
vancomycin hcl
2
5
2
2
2
vancomycin hcl
2
VANCOMYCIN HCL
vancomycin hcl
XIFAXAN
4
5
5
XIFAXAN
5
ZYVOX
Cephalosporins
CEDAX
5
2
2
2
2
2
2
2
5
3
2
2
Mga Kinakailangan/Limit
NM, QL: 224 in 28 days
NM, PA BvD
piggyback: 60mg/50ml
piggyback: 80mg/100ml
vial port
NM, PA BvD
(PA for ESRD Only)
PA, QL: 120 in 30 days
(High Risk Med. QL applies to
all members; PA required for 65
years and older with over 90
days cumulative use of
nitrofurantoin drugs)
PA, QL: 2400 in 30 days (High Risk Med. QL applies to
all members; PA required for 65
years and older with over 90
days cumulative use of
nitrofurantoin drugs)
NM
PA BvD
PA BvD
NM
NM, PA, QL: 9 in 30
days
NM, ST, QL: 60 in 30
days
NM
vial: 1g, 10g, (PA for ESRD
Only)
vial: 750mg, (PA for ESRD
Only)
capsule
tablet: 200mg
tablet: 550mg
4
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
17
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
Baitang ng
Gamot
Mga Kinakailangan/Limit
cefaclor
cefadroxil
cefazolin sodium/
dextrose,iso
cefazolin sodium/
dextrose,iso
cefazolin sodium
cefdinir
cefditoren pivoxil
cefditoren pivoxil
cefepime hcl
CEFEPIME
CEFEPIME-DEXTROSE
cefotaxime sodium
cefotetan disod/dextrose,iso
cefotetan disodium
cefoxitin sodium/dextrose,iso
cefoxitin sodium
cefpodoxime proxetil
cefprozil
ceftazidime pentahydrate
ceftazidime pentahydrate
ceftibuten dihydrate
ceftriaxone na/dextrose,iso
ceftriaxone sodium
cefuroxime axetil
cefuroxime sodium/
dextrose,iso
cefuroxime sodium
cephalexin
2
2
2
froz.piggy
2
piggyback
cephalexin
SUPRAX
TAZICEF IN DEXTROSE
tea tree oil
Macrolides
azithromycin
clarithromycin
DIFICID
ery e-succ/sulfisoxazole
ERY-TAB
ERYTHROCIN
LACTOBIONATE
1
4
4
1
2
2
2
2
2
4
4
2
2
2
2
2
2
2
2
2
2
2
2
2
2
tablet: 200mg
tablet: 400mg
vial
vial port
tablet
2
1
2
2
5
2
2
4
capsule: 250mg, 500mg; susp
recon, tablet
capsule: 750mg
susp recon, tab chew, tablet
NM, QL: 20 in 10 days
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
18
vial port: 1g
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
Baitang ng
Gamot
ERYTHROCIN
4
LACTOBIONATE
erythromycin base
2
erythromycin base
2
erythromycin ethylsuccinate
2
erythromycin ethylsuccinate
2
erythromycin stearate
2
KETEK
4
Miscellaneous B-lactam Antibiotics
aztreonam
2
CAYSTON
5
imipenem/cilastatin sodium
2
INVANZ
4
INVANZ
4
meropenem
2
Penicillins
amoxicillin trihydrate
1
amoxicillin/potassium clav
2
amoxicillin
1
Mga Kinakailangan/Limit
vial port: 500mg
capsule dr
tablet, tablet dr
susp recon
tablet
ST
LA, NM
vial
vial port
ampicillin sodium/sulbactam
na
ampicillin sodium/sulbactam
na
ampicillin sodium
ampicillin sodium
ampicillin trihydrate
BICILLIN C-R
BICILLIN L-A
dicloxacillin sodium
NAFCILL IN DEXTROSE
nafcillin sodium
nafcillin sodium
oxacillin sodium/dextrose,iso
oxacillin sodium
pen g pot/dextrose-water
pen g pot/dextrose-water
2
capsule, susp recon, tab chew,
tablet
vial
2
vial port
2
2
1
4
4
2
2
2
2
2
2
2
2
vial
vial port
penicillin g potassium/d5w
penicillin g potassium
penicillin g procaine
penicillin g procaine
penicillin v potassium
2
2
2
2
2
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
19
vial
vial port
froz.piggy: 1mm/50ml
froz.piggy: 2mm/50ml, 3mm/
50ml
syringe: 1.2mm/2ml
syringe: 600000/ml
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
Baitang ng
Gamot
Mga Kinakailangan/Limit
piperacillin sodium/
tazobactam
Quinolones
AVELOX ABC PACK
AVELOX IV
ciprofloxacin hcl
ciprofloxacin lactate/d5w
ciprofloxacin lactate
ciprofloxacin/ciprofloxa hcl
ciprofloxacin
FACTIVE
levofloxacin/d5w
levofloxacin
levofloxacin
moxifloxacin hcl
nalidixic acid
NOROXIN
ofloxacin
Sulfonamides
sulfadiazine
sulfamethoxazole/
trimethoprim
sulfamethoxazole/
trimethoprim
sulfasalazine
Tetracyclines
demeclocycline hcl
doxycycline hyclate
doxycycline hyclate
2
doxycycline monohydrate
doxycycline monohydrate
2
2
MINOCIN
minocycline hcl
tetracycline hcl
TYGACIL
5
2
2
5
NM
5
5
NM
NM, PA NSO, QL: 3 in
21 days
3
4
1
2
2
2
2
4
2
1
2
2
2
4
2
tablet
solution, vial
2
1
tablet
2
oral susp, vial
2
2
2
2
capsule dr, tablet: 100mg
capsule, tablet: 20mg; tablet dr,
vial
capsule: 150mg
capsule: 75mg, 100mg; susp
recon, tablet
vial
NM
Anticancer Agents
Anticancer Agents
ABRAXANE
ADCETRIS
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
20
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
Baitang ng
Gamot
AFINITOR DISPERZ
5
AFINITOR
5
ALIMTA
anastrozole
ARRANON
ARZERRA
5
2
5
5
AVASTIN
azacitidine
BELEODAQ
BEXXAR
bicalutamide
BICNU
bleomycin sulfate
BOSULIF
5
5
5
5
2
4
2
5
BOSULIF
5
BUSULFEX
CAPRELSA
5
5
CAPRELSA
5
carboplatin
CEENU
CEENU
cisplatin
cladribine
CLOLAR
COMETRIQ
2
3
3
2
2
5
5
cyclophosphamide
cyclophosphamide
CYCLOPHOSPHAMIDE
CYRAMZA
cytarabine/pf
cytarabine/pf
dacarbazine
dactinomycin
daunorubicin hcl
DAUNOXOME
2
2
4
5
2
2
2
2
2
4
Mga Kinakailangan/Limit
NM, PA NSO, QL: 112
in 28 days
NM, PA NSO, QL: 28 in
28 days
NM
NM
NM, PA NSO, QL: 80 in
30 days
NM, PA NSO
NM
NM, PA NSO
NM
PA BvD
NM, PA NSO, QL: 120
in 30 days
NM, PA NSO, QL: 30 in
30 days
NM
NM, PA NSO, QL: 30 in
30 days
NM, PA NSO, QL: 60 in
30 days
tablet: 100mg
tablet: 500mg
tablet: 300mg
tablet: 100mg
capsule: 100mg
capsule: 10mg, 40mg
PA BvD
NM
NM, PA NSO, QL: 112
in 28 days
PA BvD, ST
PA BvD
PA BvD, ST
NM, PA NSO
PA BvD
PA BvD
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
21
tablet
vial
vial: 1g, 100mg
vial: 500mg
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
Baitang ng
Gamot
Mga Kinakailangan/Limit
decitabine
DOCEFREZ
docetaxel
docetaxel
doxorubicin hcl pegliposomal
doxorubicin hcl
DROXIA
ELIGARD
ELIGARD
ELIGARD
ELIGARD
ELSPAR
EMCYT
epirubicin hcl
ERBITUX
ERIVEDGE
5
5
5
5
5
NM
NM
NM
NM
NM, PA BvD
2
3
4
4
4
5
3
3
2
5
5
PA BvD
vial: 10mg
QL: 1 in 112 days
QL: 1 in 28 days
QL: 1 in 84 days
NM, QL: 1 in 168 days
syringe: 30mg
syringe: 7.5mg
syringe: 22.5mg
syringe: 45mg
ERWINAZE
5
ETOPOPHOS
etoposide
exemestane
FARESTON
FASLODEX
FIRMAGON
floxuridine
fludarabine phosphate
fluorouracil
fluorouracil
flutamide
FOLOTYN
GAZYVA
gemcitabine hcl
GILOTRIF
4
2
2
5
5
4
2
5
2
2
2
5
5
5
5
GLEEVEC
5
GLEEVEC
5
HALAVEN
5
HERCEPTIN
5
vial: 20mg/2ml, 20mg/ml(1)
vial: fnl20mg/2
NM, PA NSO
NM, PA NSO, QL: 30 in
30 days
NM, PA NSO, QL: 60 in
30 days
NM
NM
PA BvD
NM
PA BvD
PA BvD
vial: 1g/20ml
vial: 500mg/10ml
NM
NM, PA NSO
NM
NM, PA NSO, QL: 30 in
30 days
NM, PA NSO, QL: 60 in tablet: 400mg
30 days
NM, PA NSO, QL: 90 in tablet: 100mg
30 days
NM, PA NSO, QL: 24 in
28 days
NM, PA NSO
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
22
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
Baitang ng
Gamot
HEXALEN
hydroxyurea
ICLUSIG
5
2
5
ICLUSIG
5
idarubicin hcl
ifosfamide/mesna
ifosfamide
IMBRUVICA
2
5
2
5
INLYTA
5
INLYTA
5
irinotecan hcl
ISTODAX
IXEMPRA
JAKAFI
5
5
5
5
JEVTANA
KADCYLA
5
5
KYPROLIS
5
letrozole
LEUKERAN
leuprolide acetate
lomustine
LUPRON DEPOT
LUPRON DEPOT
LUPRON DEPOT
LUPRON DEPOT-PED
LUPRON DEPOT-PED
LYSODREN
MARQIBO
2
4
2
2
5
5
5
5
5
3
5
MATULANE
MEGACE ES
megestrol acetate
MEKINIST
5
3
2
5
Mga Kinakailangan/Limit
NM
NM, PA NSO, QL: 30 in tablet: 45mg
30 days
NM, PA NSO, QL: 60 in tablet: 15mg
30 days
NM, PA BvD
kit: 1g-1g, 3g-1g
PA BvD
NM, PA NSO, QL: 120
in 30 days
NM, PA NSO, QL: 180 tablet: 1mg
in 30 days
NM, PA NSO, QL: 60 in tablet: 5mg
30 days
NM
NM, PA NSO
NM
NM, PA NSO, QL: 60 in
30 days
NM
NM, PA NSO, QL: 2 in
21 days
NM, PA NSO, QL: 6 in
21 days
QL: 2 in 28 days
NM, QL: 1 in 168 days
NM, QL: 1 in 28 days
NM, QL: 1 in 84 days
NM, QL: 1 in 112 days
NM, QL: 1 in 28 days
syringekit: 45mg
syringekit: 3.75mg
syringekit: 11.25mg, 22.5mg
syringekit: 30mg
kit, syringekit: 11.25mg
NM, PA NSO, QL: 4 in
28 days
NM
NM, PA NSO, QL: 30 in tablet: 2mg
30 days
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
23
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
Baitang ng
Gamot
MEKINIST
5
melphalan hcl
mercaptopurine
methotrexate sodium/pf
methotrexate sodium
methotrexate sodium
mitomycin
mitoxantrone hcl
MUSTARGEN
NEXAVAR
5
2
2
2
2
2
2
3
5
NILANDRON
ONCASPAR
ONTAK
oxaliplatin
paclitaxel
pentostatin
PERJETA
3
5
5
5
2
5
5
POMALYST
5
PROLEUKIN
PURIXAN
REVLIMID
5
5
5
RITUXAN
SOLTAMOX
SPRYCEL
5
4
5
STIVARGA
5
SUTENT
5
SYLVANT
SYLVANT
SYNRIBO
5
5
5
TABLOID
TAFINLAR
3
5
tamoxifen citrate
2
Mga Kinakailangan/Limit
NM, PA NSO, QL: 90 in tablet: 0.5mg
30 days
NM
PA BvD
PA BvD, ST
PA BvD
PA BvD
tablet
vial
NM, PA NSO, QL: 120
in 30 days
NM
NM
NM
NM
NM, PA NSO, QL: 14 in
21 days
NM, PA NSO, QL: 21 in
28 days
NM
NM
LA, NM, PA NSO, QL:
28 in 28 days
NM, PA NSO
NM, PA NSO, QL: 30 in
30 days
NM, PA NSO, QL: 84 in
28 days
NM, PA NSO, QL: 30 in
30 days
NM, PA NSO
vial: 100mg
NM, PA NSO
vial: 400mg
NM, PA NSO, QL: 28 in
28 days
NM, PA NSO, QL: 120
in 30 days
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
24
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
Baitang ng
Gamot
TARCEVA
5
TARGRETIN
5
TASIGNA
5
TEMODAR
teniposide
thiotepa
topotecan hcl
TORISEL
5
2
2
5
5
TREANDA
TRELSTAR
TRELSTAR
TRELSTAR
tretinoin
TREXALL
TRISENOX
TYKERB
VALSTAR
VECTIBIX
VELCADE
vinblastine sulfate
vincristine sulfate
vinorelbine tartrate
VOTRIENT
5
5
5
5
5
4
5
5
5
5
5
2
2
2
5
VUMON
XALKORI
4
5
XTANDI
5
YERVOY
ZALTRAP
ZANOSAR
ZELBORAF
5
5
3
5
ZOLADEX
ZOLADEX
ZOLINZA
ZYDELIG
4
4
5
5
Mga Kinakailangan/Limit
NM, PA NSO, QL: 30 in
30 days
NM, PA NSO, QL: 420
in 30 days
NM, PA NSO, QL: 112
in 28 days
NM, PA NSO
(vial only)
NM
NM, PA BvD, QL: 4 in
28 days
NM
NM, QL: 1 in 168 days
NM, QL: 1 in 28 days
NM, QL: 1 in 84 days
NM
PA BvD, ST
NM
NM
NM
NM, PA NSO
NM, PA NSO
PA BvD
PA BvD
vial
syringe: 3.75mg/2ml
syringe: 11.25/2ml
(capsule: 10mg)
NM, PA NSO, QL: 120
in 30 days
NM, PA NSO, QL: 60 in
30 days
NM, PA NSO, QL: 120
in 30 days
NM, PA NSO
NM, PA NSO
NM, PA NSO, QL: 240
in 30 days
QL: 1 in 28 days
implant: 3.6mg
QL: 1 in 84 days
implant: 10.8mg
NM
NM, PA NSO, QL: 60 in
30 days
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
25
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
Baitang ng
Gamot
ZYKADIA
5
ZYTIGA
5
Mga Kinakailangan/Limit
NM, PA NSO, QL: 140
in 28 days
NM, PA NSO, QL: 120
in 30 days
Anticholinergic Agents
Antimuscarinics/antispasmodics
ANORO ELLIPTA
atropine sulfate
atropine sulfate
propantheline bromide
3
2
2
2
QL: 60 in 30 days
syringe
vial
Anticonvulsants
Anticonvulsants
APTIOM
4
BANZEL
4
carbamazepine
2
CELONTIN
3
DILANTIN
3
divalproex sodium
2
ethosuximide
2
felbamate
2
fosphenytoin sodium
2
FYCOMPA
3
gabapentin
2
GABITRIL
3
GRALISE
4
ST, QL: 78 in 30 days
GRALISE
4
ST, QL: 90 in 30 days
LAMICTAL ODT (BLUE)
4
LAMICTAL ODT (GREEN)
4
LAMICTAL ODT
4
(ORANGE)
LAMICTAL ODT
4
LAMICTAL
4
lamotrigine
2
lamotrigine
2
levetiracetam in nacl (iso2
os)
levetiracetam
2
LUMINAL SODIUM
4
QL: 2 in 30 days
LYRICA
3
QL: 90 in 30 days
LYRICA
3
QL: 900 in 30 days
oxcarbazepine
2
OXTELLAR XR
4
PEGANONE
3
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
26
capsule: 30mg
tablet: 12mg, 16mg
tab er 24h: 300-600mg
tab er 24h: 300mg, 600mg
tb chw dsp: 2mg
tab ds pk
tab er 24, tablet, tb chw dsp
syringe
capsule
solution
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
Baitang ng
Gamot
phenobarbital sodium
phenobarbital
phenobarbital
phenobarbital
2
2
2
2
PHENYTEK
phenytoin sodium extended
phenytoin sodium
phenytoin sodium
phenytoin
POTIGA
POTIGA
primidone
QUDEXY XR
SABRIL
TEGRETOL XR
tiagabine hcl
topiramate
topiramate
TRILEPTAL
TROKENDI XR
valproic acid (as sodium
salt)
valproic acid
VIMPAT
VIMPAT
VIMPAT
zonisamide
3
2
2
2
2
4
4
2
4
5
3
2
2
2
4
4
2
2
4
4
4
2
Mga Kinakailangan/Limit
QL: 2 in 30 days
QL: 1500 in 30 days
QL: 200 in 30 days
QL: 90 in 30 days
vial: 65mg/ml, 130mg/ml
elixir: 20mg/5ml
tablet: 30mg
tablet: 15mg, 16.2mg, 32.4mg,
60mg, 64.8mg, 97.2mg, 100mg
ampul
syringe
QL: 270 in 30 days
QL: 90 in 30 days
tablet: 50mg
tablet: 200mg, 300mg, 400mg
NM
tab er 12h: 100mg
cap spr 24
cap sprink, tablet
oral susp
QL: 1200 in 30 days
QL: 200 in 5 days
QL: 60 in 30 days
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
27
solution
vial
tablet
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
Baitang ng
Gamot
Mga Kinakailangan/Limit
Antidementia Agents
Antidementia Agents
donepezil hcl
EXELON
EXELON
galantamine hbr
galantamine hbr
galantamine hbr
NAMENDA XR
NAMENDA XR
NAMENDA
NAMENDA
NAMENDA
rivastigmine tartrate
2
3
4
2
2
2
3
3
3
3
3
2
QL: 30 in 30 days
QL: 30 in 30 days
QL: 232 in 30 days
QL: 200 in 30 days
QL: 30 in 30 days
QL: 60 in 30 days
QL: 28 in 28 days
QL: 30 in 30 days
QL: 360 in 30 days
QL: 49 in 28 days
QL: 60 in 30 days
QL: 60 in 30 days
Antidepressants
amitriptyline hcl
2
PA NSO
(High Risk Med for Ages 65 and
Older)
amoxapine
BRINTELLIX
bupropion hcl
citalopram hydrobromide
citalopram hydrobromide
clomipramine hcl
2
4
2
1
2
2
QL: 30 in 30 days
tablet
solution
(High Risk Med for Ages 65 and
Older)
desipramine hcl
DESVENLAFAXINE ER
doxepin hcl
2
4
2
duloxetine hcl
duloxetine hcl
EMSAM
escitalopram oxalate
FETZIMA
fluoxetine hcl
fluoxetine hcl
fluvoxamine maleate
imipramine hcl
2
2
4
2
4
1
2
2
2
QL: 30 in 30 days
QL: 60 in 30 days
QL: 30 in 30 days
imipramine pamoate
2
PA NSO
patch td24
solution
solution
cap24h pel
tablet
cap24 dspk
cap spr 24
solution
tab ds pk
tablet
Antidepressants
PA NSO
QL: 30 in 30 days
PA NSO
(High Risk Med for Ages 65 and
Older)
capsule dr: 30mg
capsule dr: 20mg, 60mg
capsule
capsule dr, solution, tablet
PA NSO
KHEDEZLA
4
QL: 30 in 30 days
maprotiline hcl
2
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
28
(High Risk Med for Ages 65 and
Older)
(High Risk Med for Ages 65 and
Older)
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
Baitang ng
Gamot
MARPLAN
mirtazapine
nefazodone hcl
nortriptyline hcl
olanzapine/fluoxetine hcl
paroxetine hcl
PAXIL
perphenazine/amitriptyline
hcl
phenelzine sulfate
PRISTIQ ER
protriptyline hcl
sertraline hcl
sertraline hcl
SILENOR
tranylcypromine sulfate
trazodone hcl
trimipramine maleate
4
2
2
2
2
2
4
2
VENLAFAXINE HCL ER
VENLAFAXINE HCL ER
venlafaxine hcl
VIIBRYD
2
4
2
4
2
4
2
1
2
3
2
1
2
Mga Kinakailangan/Limit
PA NSO
oral susp
(High Risk Med for Ages 65 and
Older)
QL: 30 in 30 days
tablet
oral conc
QL: 30 in 30 days
PA NSO
(High Risk Med for Ages 65 and
Older)
tab er 24: 37.5mg, 75mg, 150mg
tab er 24: 225mg
QL: 30 in 30 days
Antidiabetic Agents
Antidiabetic Agents, Miscellaneous
acarbose
2
BYDUREON PEN
3
BYDUREON
3
BYETTA
4
BYETTA
4
CYCLOSET
4
GLYSET
4
INVOKAMET
3
INVOKAMET
3
QL: 90 in 30 days
ST, QL: 4 in 28 days
ST, QL: 4 in 28 days
ST, QL: 1.2 in 28 days
ST, QL: 2.4 in 28 days
QL: 180 in 30 days
QL: 90 in 30 days
ST, QL: 120 in 30 days
ST, QL: 60 in 30 days
INVOKANA
INVOKANA
JANUMET XR
ST, QL: 30 in 30 days
ST, QL: 60 in 30 days
QL: 30 in 30 days
3
3
3
JANUMET XR
3
QL: 60 in 30 days
JANUMET
3
QL: 60 in 30 days
JANUVIA
3
QL: 30 in 30 days
JENTADUETO
3
QL: 60 in 30 days
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
29
pen injctr: 5mcg/0.02
pen injctr: 10mcg/0.04
tablet: 50mg-500mg
tablet: 50-1000mg, 150-1000mg,
150-500mg
tablet: 300mg
tablet: 100mg
tbmp 24hr: 50mg-500mg, 1001000mg
tbmp 24hr: 50-1000mg
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
Baitang ng
Gamot
Mga Kinakailangan/Limit
JUVISYNC
KORLYM
3
5
metformin hcl
metformin hcl
metformin hcl
metformin hcl
metformin hcl
metformin hcl
nateglinide
PRANDIMET
repaglinide
SYMLIN
SYMLINPEN 120
SYMLINPEN 60
TANZEUM
TRADJENTA
VICTOZA 3-PAK
Insulins
HUMALOG MIX 50-50
HUMALOG MIX 50-50
HUMALOG MIX 75-25
HUMALOG MIX 75-25
HUMALOG
HUMALOG
HUMULIN 70-30
HUMULIN 70-30
HUMULIN N
HUMULIN N
HUMULIN R
LANTUS SOLOSTAR
LANTUS
LEVEMIR FLEXPEN
LEVEMIR
NOVOLIN 70-30
NOVOLIN 70-30
NOVOLIN N
NOVOLIN N
NOVOLIN R
NOVOLIN R
NOVOLOG FLEXPEN
NOVOLOG MIX 70-30
FLEXPEN
1
1
1
2
2
2
2
3
2
4
4
4
3
3
4
QL: 30 in 30 days
NM, PA, QL: 112 in 28
days
QL: 150 in 30 days
QL: 60 in 30 days
QL: 90 in 30 days
QL: 120 in 30 days
QL: 60 in 30 days
QL: 90 in 30 days
QL: 90 in 30 days
QL: 150 in 30 days
QL: 240 in 30 days
QL: 20 in 28 days
QL: 10.8 in 28 days
QL: 6 in 28 days
ST
QL: 30 in 30 days
PA, QL: 9 in 28 days
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
QL: 30 in 28 days
QL: 40 in 28 days
QL: 30 in 28 days
QL: 40 in 28 days
QL: 30 in 28 days
QL: 40 in 28 days
QL: 30 in 28 days
QL: 40 in 28 days
QL: 30 in 28 days
QL: 40 in 28 days
QL: 40 in 28 days
QL: 30 in 28 days
QL: 40 in 28 days
ST, QL: 30 in 28 days
ST, QL: 40 in 28 days
QL: 30 in 28 days
QL: 40 in 28 days
QL: 30 in 28 days
QL: 40 in 28 days
QL: 30 in 28 days
QL: 40 in 28 days
QL: 30 in 28 days
QL: 30 in 28 days
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
30
tablet: 500mg
tablet: 1000mg
tablet: 850mg
tab er 24h: 500mg
tab er 24
tab er 24h: 750mg
insuln pen
vial
insuln pen
vial
cartridge
vial
insuln pen
vial
insuln pen
vial
cartridge
vial
cartridge
vial
cartridge
vial
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
Baitang ng
Gamot
Mga Kinakailangan/Limit
NOVOLOG MIX 70-30
NOVOLOG
Sulfonylureas
glimepiride
glimepiride
glipizide/metformin hcl
glipizide/metformin hcl
glipizide
glipizide
glipizide
glipizide
glyburide,micronized
3
3
QL: 40 in 28 days
QL: 40 in 28 days
1
1
2
2
1
1
2
2
2
QL: 30 in 30 days
QL: 60 in 30 days
QL: 120 in 30 days
QL: 240 in 30 days
QL: 120 in 30 days
QL: 60 in 30 days
QL: 30 in 30 days
QL: 60 in 30 days
PA, QL: 30 in 30 days
glyburide,micronized
2
PA, QL: 60 in 30 days
glyburide/metformin hcl
2
PA, QL: 120 in 30 days
glyburide/metformin hcl
2
PA, QL: 240 in 30 days
glyburide
2
PA, QL: 120 in 30 days
glyburide
2
PA, QL: 30 in 30 days
tolazamide
tolazamide
tolbutamide
Thiazolidinediones
ACTOPLUS MET XR
AVANDAMET
AVANDARYL
AVANDIA
pioglitazone hcl/glimepiride
pioglitazone hcl/metformin
hcl
pioglitazone hcl
2
2
2
QL: 120 in 30 days
QL: 60 in 30 days
QL: 180 in 30 days
3
4
4
4
2
2
QL: 60 in 30 days
PA, QL: 60 in 30 days
PA, QL: 30 in 30 days
PA, QL: 30 in 30 days
QL: 30 in 30 days
QL: 90 in 30 days
2
QL: 30 in 30 days
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
31
tablet: 1mg, 2mg
tablet: 4mg
tablet: 2.5-500mg, 5mg-500mg
tablet: 2.5-250mg
tablet: 10mg
tablet: 5mg
tab er 24: 2.5mg, 5mg
tab er 24: 10mg
tablet: 1.5mg, 3mg, (High Risk
Med for Ages 65 and Older)
tablet: 6mg, (High Risk Med for
Ages 65 and Older)
tablet: 2.5-500mg, 5mg-500mg,
(High Risk Med for Ages 65 and
Older)
tablet: 1.25-250mg, (High Risk
Med for Ages 65 and Older)
tablet: 5mg, (High Risk Med for
Ages 65 and Older)
tablet: 1.25mg, 2.5mg, (High
Risk Med for Ages 65 and
Older)
tablet: 250mg
tablet: 500mg
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
Baitang ng
Gamot
Mga Kinakailangan/Limit
Antifungals
Antifungals
ABELCET
amphotericin b
CANCIDAS
ciclopirox olamine
ciclopirox
clotrimazole/betamethasone
dip
clotrimazole
econazole nitrate
ERAXIS (WATER
DILUENT)
EXELDERM
fluconazole in nacl,iso-osm
fluconazole
fluconazole
flucytosine
griseofulvin ultramicrosize
griseofulvin, microsize
itraconazole
ketoconazole
NOXAFIL
NOXAFIL
nystatin/triamcin
nystatin
SPORANOX
terbinafine hcl
voriconazole
voriconazole
5
2
5
2
2
2
2
2
5
4
2
1
2
5
2
2
2
2
5
5
2
2
4
2
2
5
NM, PA BvD
PA BvD
NM
NM
tablet
susp recon
NM
NM
NM
oral susp, tablet dr
vial
solution
NM
vial
susp recon, tablet
Antihistamines
Antihistamines
carbinoxamine maleate
carbinoxamine maleate
2
2
PA
PA
clemastine fumarate
clemastine fumarate
2
2
PA
PA
clemastine fumarate
2
PA
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
32
liquid: 4mg/5ml; tablet: 4mg
liquid: 4mg/5ml; tablet: 4mg,
(High Risk Med for Ages 65 and
Older)
syrup, tablet: 2.68mg
syrup, tablet: 2.68mg, (High
Risk Med for Ages 65 and
Older)
tablet: 1.34mg, (High Risk Med
for Ages 65 and Older)
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
Baitang ng
Gamot
cyproheptadine hcl
2
diphenhydramine hcl
diphenhydramine hcl
levocetirizine
dihydrochloride
p-epd tan/chlor-tan
promethazine hcl
2
2
2
tripelennamine hcl
2
2
2
Mga Kinakailangan/Limit
PA
(High Risk Med for Ages 65 and
Older)
syringe
vial
PA
(High Risk Med for Ages 65 and
Older)
Anti-infectives (Skin and Mucous Membrane)
Anti-infectives (Skin and Mucous Membrane)
AVC
3
clindamycin phosphate
2
metronidazole
2
miconazole nitrate
2
sod propion/inositol/aa14/
2
urea
terconazole
2
Antimigraine Agents
Antimigraine Agents
dihydroergotamine mesylate
dihydroergotamine mesylate
ERGOMAR
naratriptan hcl
rizatriptan benzoate
sumatriptan succinate
sumatriptan succinate
sumatriptan succinate
sumatriptan
zolmitriptan
2
2
3
2
2
2
2
2
2
2
QL: 30 in 28 days
QL: 4 in 28 days
QL: 40 in 28 days
QL: 18 in 28 days
QL: 18 in 28 days
QL: 18 in 28 days
QL: 4 in 28 days
QL: 4 in 28 days
QL: 12 in 28 days
QL: 12 in 28 days
ampul
spray/pump
tablet
cartridge: 4mg/0.5ml
cartridge: 6mg/0.5ml; vial
Antimycobacterials
Antimycobacterials
CAPASTAT SULFATE
dapsone
ethambutol hcl
isoniazid
isoniazid
PASER
PRIFTIN
rifabutin
rifampin
4
2
2
1
2
4
4
2
2
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
33
tablet
solution, vial
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
Baitang ng
Gamot
RIFATER
SEROMYCIN
SIRTURO
4
4
5
TRECATOR
4
Mga Kinakailangan/Limit
NM, PA, QL: 188 in 168
days
Antinausea Agents
Antinausea Agents
CESAMET
dimenhydrinate
dronabinol
EMEND
EMEND
EMEND
EMEND
granisetron hcl/pf
granisetron hcl
granisetron hcl
granisetron hcl
meclizine hcl
ondansetron hcl
ondansetron hcl
ondansetron
prochlorperazine edisylate
prochlorperazine maleate
prochlorperazine maleate
promethazine hcl
promethazine hcl
4
2
2
4
4
4
4
2
2
2
2
2
2
2
2
2
1
2
2
2
QL: 180 in 30 days
PA BvD, QL: 1 per fill
PA BvD, QL: 2 per fill
PA BvD, QL: 3 per fill
QL: 2 in 28 days
capsule: 40mg, 125mg
capsule: 80mg
cap ds pk
vial
PA BvD
PA BvD
vial
solution
tablet
PA BvD
PA BvD
PA
PA
vial
solution, tablet
tablet
supp.rect
supp.rect, tablet
supp.rect, tablet, (High Risk
Med for Ages 65 and Older)
Antiparasite Agents
Antiparasite Agents
ALBENZA
ALINIA
atovaquone/proguanil hcl
atovaquone
BILTRICIDE
COARTEM
DARAPRIM
HALFAN
hydroxychloroquine sulfate
mefloquine hcl
metronidazole/sodium
chloride
4
4
2
5
4
4
4
4
2
2
2
NM
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
34
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
metronidazole
NEBUPENT
paromomycin sulfate
PENTAM 300
pentamidine isethionate
PRIMAQUINE
quinine sulfate
STROMECTOL
tinidazole
Baitang ng
Gamot
2
4
2
4
2
4
2
3
2
Mga Kinakailangan/Limit
PA BvD
QL: 90 in 30 days
PA, QL: 42 in 30 days
Antiparkinsonian Agents
Antiparkinsonian Agents
amantadine hcl
APOKYN
AZILECT
benztropine mesylate
benztropine mesylate
2
5
3
1
1
benztropine mesylate
2
bromocriptine mesylate
cabergoline
carbidopa/levodopa/
entacapone
carbidopa/levodopa
carbidopa
entacapone
NEUPRO
pramipexole di-hcl
ropinirole hcl
selegiline hcl
trihexyphenidyl hcl
2
2
2
2
2
2
3
2
2
2
2
NM, QL: 60 in 30 days
PA
PA
PA
tablet
tablet, (High Risk Med for Ages
65 and Older)
vial, (High Risk Med for Ages
65 and Older)
ST, QL: 30 in 30 days
PA
(High Risk Med for Ages 65 and
Older)
ST, QL: 60 in 30 days
ST, QL: 90 in 30 days
NM, QL: 1 in 28 days
ST, QL: 161.2 in 28 days
ST, QL: 30 in 30 days
tab rapdis: 15mg
tab rapdis: 10mg
Antipsychotic Agents
Antipsychotic Agents
ABILIFY DISCMELT
ABILIFY DISCMELT
ABILIFY MAINTENA
ABILIFY
ABILIFY
3
3
5
3
3
vial
tablet: 5mg, 10mg, 15mg, 20mg,
30mg
tablet: 2mg
solution
ABILIFY
3
ST, QL: 60 in 30 days
ABILIFY
3
ST, QL: 900 in 30 days
ADASUVE
5
NM
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Epektibo: Nobyembre 1, 20141
Formulary ID: 14510.000, Version: 19
35
Pangalan ng Gamot
Baitang ng
Gamot
Mga Kinakailangan/Limit
chlorpromazine hcl
chlorpromazine hcl
clozapine
clozapine
clozapine
clozapine
FANAPT
FANAPT
FAZACLO
FAZACLO
fluphenazine decanoate
fluphenazine hcl
GEODON
haloperidol decanoate
haloperidol lactate
haloperidol
INVEGA SUSTENNA
INVEGA SUSTENNA
INVEGA SUSTENNA
INVEGA SUSTENNA
INVEGA SUSTENNA
INVEGA
INVEGA
LATUDA
2
2
2
2
2
2
4
4
4
4
2
2
4
2
2
2
3
3
5
5
5
4
4
4
QL: 135 in 30 days
QL: 270 in 30 days
QL: 90 in 30 days
ST, QL: 90 in 30 days
ST, QL: 60 in 30 days
ST, QL: 8 in 28 days
ST, QL: 120 in 30 days
ST, QL: 180 in 30 days
ampul, tablet
oral conc.
tablet: 200mg
tablet: 100mg
tablet: 25mg, 50mg
tab rapdis
tablet
tab ds pk
tab rapdis: 200mg
tab rapdis: 150mg
QL: 6 in 28 days
vial
QL: 0.25 in 28 days
QL: 0.5 in 28 days
NM, QL: 0.75 in 28 days
NM, QL: 1 in 28 days
NM, QL: 1.5 in 28 days
ST, QL: 30 in 30 days
ST, QL: 60 in 30 days
ST, QL: 30 in 30 days
syringe: 39mg/0.25
syringe: 78mg/0.5ml
syringe: 117mg/0.75
syringe: 156mg/ml
syringe: 234mg/1.5
tab er 24: 1.5mg, 3mg, 9mg
tab er 24: 6mg
tablet: 20mg, 40mg, 60mg,
120mg
tablet: 80mg
LATUDA
loxapine succinate
MOBAN
olanzapine
4
2
4
2
ST, QL: 60 in 30 days
olanzapine
ORAP
perphenazine
quetiapine fumarate
RISPERDAL CONSTA
risperidone
risperidone
risperidone
2
4
2
2
4
2
2
2
QL: 31 in 30 days
SAPHRIS
SEROQUEL XR
SEROQUEL XR
4
4
4
ST, QL: 60 in 30 days
ST, QL: 30 in 30 days
ST, QL: 60 in 30 days
QL: 30 in 30 days
QL: 90 in 30 days
QL: 4 in 28 days
QL: 120 in 30 days
QL: 480 in 30 days
QL: 60 in 30 days
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
36
tab rapdis: 5mg, 10mg, 15mg;
tablet, vial
tab rapdis: 20mg
tab rapdis: 3mg, 4mg
solution
tab rapdis: 0.25mg, 0.5mg, 1mg,
2mg; tablet
tab er 24h: 200mg
tab er 24h: 50mg, 150mg,
300mg, 400mg
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
Baitang ng
Gamot
Mga Kinakailangan/Limit
thioridazine hcl
2
PA NSO
thioridazine hcl
2
PA NSO
thiothixene
trifluoperazine hcl
VERSACLOZ
2
2
5
ziprasidone hcl
ZYPREXA RELPREVV
2
5
oral conc., (High Risk Med for
Ages 65 and Older)
tablet, (High Risk Med for Ages
65 and Older)
NM, ST, QL: 540 in 30
days
QL: 60 in 30 days
NM, QL: 2 in 28 days
Antivirals (systemic)
Antiretrovirals
abacavir sulfate
2
abacavir/lamivudine/
5
NM
zidovudine
APTIVUS
4
APTIVUS
5
NM
ATRIPLA
5
NM
COMPLERA
5
NM
CRIXIVAN
4
didanosine
2
EDURANT
5
NM
EMTRIVA
3
EPIVIR HBV
4
EPIVIR
4
EPZICOM
5
NM
FUZEON
5
NM
INTELENCE
3
INTELENCE
5
NM
INVIRASE
5
NM
ISENTRESS
3
ISENTRESS
5
NM
KALETRA
3
KALETRA
5
NM
lamivudine/zidovudine
5
NM
lamivudine
2
LEXIVA
3
LEXIVA
5
NM
nevirapine
2
NORVIR
4
PREZISTA
3
PREZISTA
4
PREZISTA
5
NM
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
37
solution
capsule
solution
solution
tablet: 25mg
tablet: 100mg, 200mg
powd pack, tab chew
tablet
tablet: 100mg-25mg
solution, tablet: 200mg-50mg
oral susp
tablet
tablet: 75mg, 150mg
oral susp
tablet: 400mg
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
Baitang ng
Gamot
Mga Kinakailangan/Limit
PREZISTA
RESCRIPTOR
RETROVIR
REYATAZ
REYATAZ
SELZENTRY
stavudine
STRIBILD
SUSTIVA
SUSTIVA
TIVICAY
TRIUMEQ
TRUVADA
VIDEX
VIRACEPT
VIRAMUNE XR
VIREAD
ZIAGEN
zidovudine
Antivirals, Miscellaneous
foscarnet sodium
RELENZA
rimantadine hcl
SYNAGIS
TAMIFLU
Hcv Protease Inhibitors
INCIVEK
5
4
3
3
5
5
2
5
4
4
5
5
5
3
4
3
5
4
2
NM
2
4
2
5
3
PA BvD
5
OLYSIO
5
VICTRELIS
5
NM, PA, QL: 168 in 28
days
NM, PA, QL: 28 in 28
days
NM, PA, QL: 336 in 28
days
Interferons
ALFERON N
INTRON A
5
4
NM
PA NSO
INTRON A
PEGASYS PROCLICK
PEGASYS
PEGINTRON REDIPEN
PEGINTRON
SYLATRON 4-PACK
4
5
5
5
5
5
PA NSO
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA NSO, QL: 1 in
28 days
NM
NM
tablet: 600mg, 800mg
vial
capsule: 100mg
capsule: 150mg, 200mg, 300mg
NM
capsule: 100mg
capsule: 50mg, 200mg; tablet
NM
NM
NM
tab er 24h: 100mg
NM
solution
NM
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
38
pen ij kit, vial: 18mmunit,
50mmunit
vial: 6mmunit/ml, 10mmunit
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
Baitang ng
Gamot
Mga Kinakailangan/Limit
Nucleosides And Nucleotides
acyclovir sodium
acyclovir
adefovir dipivoxil
BARACLUDE
BARACLUDE
cidofovir
entecavir
famciclovir
ganciclovir sodium
ribavirin
ribavirin
ribavirin
2
2
5
4
5
5
5
2
2
2
5
5
PA BvD
SOVALDI
5
TYZEKA
valacyclovir hcl
VALCYTE
VALCYTE
5
2
4
5
NM, PA, QL: 28 in 28
days
NM
NM
NM
NM
NM
solution
tablet
PA BvD
NM
NM
NM
capsule, tablet
tab ds pk: 200-400mg
tab ds pk: 400-400mg, 600400mg
soln recon
tablet
Blood Products/modifiers/volume Expanders
Anticoagulants
CEPROTIN
5
NM
ELIQUIS
3
enoxaparin sodium
2
QL: 13.6 in 30 days
syringe: 40mg/0.4ml
enoxaparin sodium
2
QL: 18 in 30 days
syringe: 30mg/0.3ml
enoxaparin sodium
2
QL: 20.4 in 30 days
syringe: 60mg/0.6ml
enoxaparin sodium
2
QL: 27.2 in 30 days
syringe: 80mg/0.8ml
enoxaparin sodium
2
QL: 36 in 30 days
vial
enoxaparin sodium
5
NM, QL: 27.2 in 30 days syringe: 120mg/.8ml
enoxaparin sodium
5
NM, QL: 34 in 30 days syringe: 150mg/ml
enoxaparin sodium
5
NM, QL: 36 in 30 days syringe: 100mg/ml
fondaparinux sodium
2
QL: 12 in 30 days
syringe: 5mg/0.4ml
fondaparinux sodium
2
QL: 15 in 30 days
syringe: 2.5mg/0.5
fondaparinux sodium
2
QL: 18 in 30 days
syringe: 7.5mg/0.6
fondaparinux sodium
2
QL: 24 in 30 days
syringe: 10mg/0.8ml
heparin sod,pork in 0.45%
2
nacl
heparin sodium,porcine/d5w
2
iv soln: 12500/250, 25000/500
heparin sodium,porcine/d5w
2
iv soln: 20k/500ml, 25000/250
heparin sodium,porcine/ns/
2
pf
heparin sodium,porcine/pf
2
vial port
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Epektibo: Nobyembre 1, 20141
Formulary ID: 14510.000, Version: 19
39
Pangalan ng Gamot
Baitang ng
Gamot
heparin sodium,porcine/pf
heparin sodium,porcine/pf
heparin sodium,porcine
IPRIVASK
2
2
2
5
PRADAXA
warfarin sodium
XARELTO
Blood Formation Modifiers
BERINERT
4
1
3
CINRYZE
5
EPOGEN
GRANIX
LEUKINE
LEUKINE
MOZOBIL
NEULASTA
NEUMEGA
NEUPOGEN
PROCRIT
3
5
5
5
5
5
5
5
3
PROCRIT
5
PROCRIT
5
PROMACTA
5
5
Hematologic Agents, Miscellaneous
aminocaproic acid
2
anagrelide hcl
2
protamine sulfate
2
tranexamic acid
2
tranexamic acid
2
Platelet-aggregation Inhibitors
AGGRENOX
4
BRILINTA
3
cilostazol
2
clopidogrel bisulfate
2
EFFIENT
3
pentoxifylline
2
Volume Expanders
Mga Kinakailangan/Limit
PA BvD
PA BvD
PA BvD
NM, PA, QL: 24 in 28
days
PA, QL: 60 in 30 days
syringe, (PA for ESRD Only)
vial, (PA for ESRD Only)
(PA for ESRD Only)
NM, PA, QL: 9 in 30
days
NM, PA, QL: 20 in 28
days
PA, QL: 12 in 28 days
NM
NM
vial: 250mcg
NM
vial: 500mcg/ml
NM, PA, QL: 9.6 per fill
NM
NM
NM
PA, QL: 12 in 28 days
vial: 2000/ml, 3000/ml, 4000/ml,
10000/ml
NM, PA, QL: 12 in 28
vial: 20000/ml
days
NM, PA, QL: 6 in 28
vial: 40000/ml
days
NM, PA, QL: 30 in 30
days
PA BvD
QL: 30 in 30 days
(PA for ESRD Only)
vial
tablet
QL: 60 in 30 days
QL: 60 in 30 days
QL: 30 in 30 days
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
40
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
ALBUKED-25
ALBUKED-5
ALBUMIN (HUMAN)
ALBUMINAR-25
ALBUMINAR-5
ALBURX
ALBUTEIN
BUMINATE
FLEXBUMIN
KEDBUMIN
PLASBUMIN-25
PLASBUMIN-5
STERILE DILUENT
Baitang ng
Gamot
Mga Kinakailangan/Limit
4
4
4
4
4
4
4
4
4
4
4
4
4
Caloric Agents
Caloric Agents
AMINO ACIDS
4
PA BvD
AMINOSYN II
4
PA BvD
AMINOSYN II
4
PA BvD
AMINOSYN II
4
PA BvD
AMINOSYN II
4
PA BvD
AMINOSYN II
4
PA BvD
AMINOSYN M
4
PA BvD
AMINOSYN with
4
PA BvD
ELECTROLYTES
AMINOSYN
4
PA BvD
AMINOSYN
4
PA BvD
AMINOSYN
4
PA BvD
AMINOSYN
4
PA BvD
AMINOSYN
4
PA BvD
AMINOSYN-HBC
4
PA BvD
AMINOSYN-PF
4
PA BvD
AMINOSYN-PF
4
PA BvD
AMINOSYN-RF
4
PA BvD
CLINIMIX E
4
PA BvD
CLINIMIX E
4
PA BvD
CLINIMIX E
4
PA BvD
CLINIMIX E
4
PA BvD
CLINIMIX E
4
PA BvD
CLINIMIX E
4
PA BvD
CLINIMIX E
4
PA BvD
CLINIMIX E
4
PA BvD
CLINIMIX E
4
PA BvD
CLINIMIX
4
PA BvD
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
41
iv soln: 10%
iv soln: 15%
iv soln: 7%
iv soln: 8.5%
iv soln: 8.5%
iv soln: 10%
iv soln: 3.5%
iv soln: 7%
iv soln: 8.5%
iv soln: 8.5%
iv soln: 10%
iv soln: 7%
iv soln: 2.75%
iv soln: 2.75%
iv soln: 4.25%
iv soln: 4.25%
iv soln: 4.25%
iv soln: 5%
iv soln: 5%
iv soln: 5%
iv soln: 5%
iv soln: 2.75%
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
CLINIMIX
CLINIMIX
CLINIMIX
CLINIMIX
CLINIMIX
CLINIMIX
CLINIMIX
CLINISOL
cysteine hcl
dextrose 10 % and 0.2 %
nacl
dextrose 10 % and 0.2 %
nacl
dextrose 10 % and 0.9 %
nacl
dextrose 10%-0.5 normal
saline
dextrose 10%-water
dextrose 2.5 % in water
dextrose 2.5% in half ringers
dextrose 2.5%-0.5normal
saline
dextrose 20%-water
dextrose 25 % in water
dextrose 40%-water
dextrose 5 % and 0.3 % nacl
dextrose 5 % and 0.9 % nacl
dextrose 5 % in water
dextrose 5 %-0.2 % nacl
dextrose 5 %-0.45 % nacl
dextrose 5% in ringers
dextrose 5%-lactated ringers
dextrose 50 % in water
dextrose 60 % in water
dextrose 70%-water
FREAMINE HBC
FREAMINE III
FREAMINE III
fructose 10%
HEPATAMINE
HEPATASOL
INTRALIPID
INTRALIPID
Baitang ng
Gamot
4
4
4
4
4
4
4
4
2
2
Mga Kinakailangan/Limit
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
iv soln: 4.25%
iv soln: 4.25%
iv soln: 4.25%
iv soln: 4.25%
iv soln: 5%
iv soln: 5%
iv soln: 5%
dehp fr bg
2
iv soln
2
2
2
2
2
2
PA BvD
PA BvD
2
2
2
2
2
2
2
2
2
2
2
2
2
4
4
4
2
4
4
4
4
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
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
42
iv soln: 10%
iv soln: 8.5%
emulsion: 10%
emulsion: 20%, 30%
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
KABIVEN
LIPOSYN II
LIPOSYN III
LIPOSYN III
NEPHRAMINE
NOVAMINE
PERIKABIVEN
PREMASOL
PREMASOL
PROCALAMINE
PROSOL
QUICK MIX with LYTES
TRAVAMULSION
TRAVASOL W/
DEXTROSE
TRAVASOL W/
ELECTROLYTES
TRAVASOL W/
ELECTROLYTES
TRAVASOL with
DEXTROSE
TRAVASOL with
DEXTROSE
TRAVASOL with
DEXTROSE
TRAVASOL with
ELECTROLYTES
TRAVASOL
TRAVASOL
TRAVASOL
TRAVASOL
TRAVERT IN NORMAL
SALINE
TRAVERT
TRAVERT
TROPHAMINE
TROPHAMINE
Baitang ng
Gamot
Mga Kinakailangan/Limit
4
4
4
4
4
4
4
4
4
4
4
4
4
4
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
4
PA BvD
iv soln.: 5.5%
4
PA BvD
iv soln.: 8.5%
4
PA BvD
iv soln: 8.5%
4
PA BvD
iv soln: 8.5%
4
PA BvD
iv soln: 8.5%
4
PA BvD
4
4
4
4
4
PA BvD
PA BvD
PA BvD
PA BvD
PA BvD
iv soln.
iv soln: 10%
iv soln: 5.5%
iv soln: 8.5%
4
4
4
4
PA BvD
PA BvD
PA BvD
PA BvD
iv soln: 10%
iv soln: 5%
iv soln: 10%
iv soln: 6%
2
1
2
QL: 4 in 28 days
patch tdwk: 0.1mg/24hr, 0.2mg/
24hr
emulsion: 10%, 20%
emulsion: 30%
iv soln: 10%
iv soln: 6%
Cardiovascular Agents
Alpha-adrenergic Agents
clonidine hcl/chlorthalidone
clonidine hcl
clonidine
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
43
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
clonidine
doxazosin mesylate
guanfacine hcl
Baitang ng
Gamot
2
2
2
Mga Kinakailangan/Limit
QL: 8 in 28 days
patch tdwk: 0.3mg/24hr
PA
(High Risk Med for Ages 65 and
Older)
midodrine hcl
2
phenylephrine hcl
2
prazosin hcl
2
Angiotensin Ii Receptor Antagonists
BENICAR HCT
3
BENICAR
3
candesartan cilexetil
2
candesartan/
2
hydrochlorothiazid
DIOVAN
2
EDARBI
4
EDARBYCLOR
4
eprosartan mesylate
2
irbesartan/
2
hydrochlorothiazide
irbesartan
2
losartan potassium
1
losartan/hydrochlorothiazide
2
telmisartan/
2
hydrochlorothiazid
telmisartan
2
TEVETEN HCT
4
TEVETEN
4
TRIBENZOR
3
valsartan/
2
hydrochlorothiazide
Angiotensin-converting Enzyme Inhibitors
benazepril hcl
1
benazepril/
2
hydrochlorothiazide
captopril/
2
hydrochlorothiazide
captopril
1
enalapril maleate
1
enalapril/
2
hydrochlorothiazide
enalaprilat dihydrate
2
fosinopril sodium
2
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
44
tablet: 400mg
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
Baitang ng
Gamot
fosinopril/
hydrochlorothiazide
lisinopril/
hydrochlorothiazide
lisinopril
moexipril hcl
moexipril/
hydrochlorothiazide
perindopril erbumine
quinapril hcl
quinapril/
hydrochlorothiazide
ramipril
trandolapril
Antiarrhythmic Agents
amiodarone hcl
amiodarone hcl
disopyramide phosphate
flecainide acetate
lidocaine hcl/d5w/pf
lidocaine hcl/pf
2
lidocaine hcl/pf
2
Mga Kinakailangan/Limit
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
ampul, tablet
syringe
PA BvD
mexiletine hcl
2
MULTAQ
3
procainamide hcl
2
procainamide hcl
2
PRONESTYL
4
propafenone hcl
2
quinidine gluconate
2
quinidine sulfate
2
TIKOSYN
3
XYLOCAINE
2
Beta-Adrenergic Blocking Agents
acebutolol hcl
2
atenolol/chlorthalidone
1
atenolol
1
betaxolol hcl
2
bisoprolol fumarate/hctz
2
bisoprolol fumarate
2
BYSTOLIC
3
carvedilol
1
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
45
iv soln: 2mg/ml, 8mg/ml
syringe, vial: 100mg/ml, 200mg/
ml
vial: 20mg/ml, (PA for ESRD
Only)
capsule, tablet sa
vial
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
Baitang ng
Gamot
COREG CR
3
DUTOPROL
3
esmolol hcl
2
labetalol hcl
2
metoprolol succinate
2
metoprolol tartrate
1
metoprolol tartrate
2
metoprolol/
2
hydrochlorothiazide
nadolol
2
pindolol
2
propranolol hcl
2
propranolol/
2
hydrochlorothiazid
sotalol hcl
2
SOTALOL HCL
4
timolol maleate
2
Calcium-Channel Blocking Agents
diltiazem hcl
1
diltiazem hcl
2
verapamil hcl
verapamil hcl
1
2
verapamil hcl
2
Mga Kinakailangan/Limit
PA BvD
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
46
tablet
vial
tablet
cap er 12h, cap er 24h, cap er
deg, capsule er, syringe, tab er
24h, vial port
tablet
ampul, cap24h pct, cap24h pel,
tablet er
syringe
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
digoxin
Baitang ng
Gamot
Cardiovascular Agents, Miscellaneous
2
Mga Kinakailangan/Limit
PA, QL: 30 in 30 days
digoxin
2
PA
DIGOXIN
3
PA, QL: 75 in 30 days
dobutamine hcl/d5w
dobutamine hcl
dopamine hcl/d5w
dopamine hcl/dextrose 5%water
dopamine hcl
ephedrine sulfate
epinephrine
epinephrine
EPIPEN 2-PAK
EPIPEN JR 2-PAK
ethanolamine oleate
FIRAZYR
hydralazine hcl
hydralazine/
hydrochlorothiazid
LANOXIN
2
2
2
2
PA BvD
PA BvD
PA BvD
PA BvD
2
2
2
2
3
3
2
5
2
2
PA BvD
4
PA, QL: 30 in 30 days
milrinone lactate/d5w
milrinone lactate
norepinephrine bitartrate
ORENITRAM ER
ORENITRAM ER
papaverine hcl
RANEXA
VECAMYL
Dihydropyridines
amlodipine besylate/
benazepril
amlodipine besylate
AZOR
CLEVIPREX
5
5
2
3
5
2
3
5
NM, PA BvD
NM, PA BvD
PA BvD
PA
NM, PA
PA
tablet, (High Risk Med for Ages
65 and Older and Dose is
Greater Than 125mcg Per Day)
ampul, (High Risk Med for
Ages 65 and Older)
(High Risk Med for Ages 65 and
Older and Dose is Greater Than
125mcg Per Day)
ampul
auto injct, syringe
NM
tablet: 62.5mcg, 187.5mcg,
(High Risk Med for Ages 65 and
Older and Dose is Greater Than
125mcg Per Day)
tablet er: 0.125mg
tablet er: 0.25mg, 1mg, 2.5mg
NM
2
1
3
4
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
47
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
EXFORGE HCT
EXFORGE
felodipine
isradipine
nicardipine hcl
nifedipine
nifedipine
Diuretics
amiloride hcl
amiloride/
hydrochlorothiazide
bumetanide
chlorothiazide sodium
chlorothiazide
chlorthalidone
DYRENIUM
furosemide
furosemide
furosemide
hydrochlorothiazide
indapamide
methyclothiazide
metolazone
torsemide
triamterene/
hydrochlorothiazid
Dyslipidemics
ADVICOR
ALTOPREV
amlodipine/atorvastatin
atorvastatin calcium
cholestyramine (with sugar)
cholestyramine/aspartame
colestipol hcl
CRESTOR
fenofibrate nanocrystallized
fenofibrate,micronized
fenofibrate
fenofibric acid (choline)
fenofibric acid
fluvastatin sodium
gemfibrozil
Baitang ng
Gamot
3
2
2
2
2
2
2
Mga Kinakailangan/Limit
tab er 24, tablet er: 30mg, 60mg
tablet er: 90mg
2
2
2
2
1
1
4
1
2
2
1
1
2
2
2
2
4
4
2
2
2
2
2
3
2
2
2
2
2
2
2
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
48
tablet
solution, syringe: 10mg/ml; vial
syringe: 10mg/ml
tablet
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
Baitang ng
Gamot
KYNAMRO
5
Mga Kinakailangan/Limit
NM, PA, QL: 4 in 28
days
lovastatin
1
niacin
2
omega-3 acid ethyl esters
2
pravastatin sodium
1
simvastatin
1
QL: 30 in 30 days
VASCEPA
3
VYTORIN
4
WELCHOL
3
ZETIA
4
Renin-Angiotensin-Aldosterone System Inhibitors
eplerenone
2
spironolact/
2
hydrochlorothiazid
spironolactone
2
Vasodilators
isosorbide dinitrate
1
isosorbide dinitrate
1
isosorbide dinitrate
2
isosorbide mononitrate
2
minoxidil
2
NITRO-BID
3
nitroglycerin/d5w
2
nitroglycerin
2
nitroglycerin
2
nitroglycerin
2
QL: 30 in 30 days
nitroglycerin
NITROSTAT
nylidrin hcl
PROGLYCEM
2
3
2
4
QL: 60 in 30 days
tab er 24h, tablet
tab subl: 2.5mg
tab subl: 5mg
tablet, tablet er
vial: 50mg/10ml
vial: 5mg/ml
patch td24: 0.1mg/hr, 0.2mg/hr,
0.6mg/hr
patch td24: 0.4mg/hr
Central Nervous System Agents
Central Nervous System Agents
AMPYRA
5
caffeine citrated
caffeine/sodium benzoate
clonidine hcl
dexmethylphenidate hcl
dextroamphetamine sulfate
dextroamphetamine sulfate
2
2
2
2
2
2
NM, PA, QL: 60 in 30
days
QL: 60 in 30 days
QL: 120 in 30 days
QL: 180 in 30 days
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
49
tablet
capsule er
tablet: 5mg, 10mg
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
Baitang ng
Gamot
Mga Kinakailangan/Limit
dextroamphetamine/
amphetamine
dextroamphetamine/
amphetamine
flumazenil
INTUNIV
lithium carbonate
lithium citrate
methylphenidate hcl
2
QL: 30 in 30 days
cap er 24h: 5mg, 10mg, 15mg
2
QL: 60 in 30 days
cap er 24h: 20mg, 25mg, 30mg;
tablet
methylphenidate hcl
2
QL: 60 in 30 days
methylphenidate hcl
methylphenidate hcl
methylphenidate hcl
NUEDEXTA
QUILLIVANT XR
riluzole
SAVELLA
STRATTERA
XENAZINE
2
2
2
3
3
2
3
3
5
QL: 90 in 30 days
QL: 90 in 30 days
QL: 900 in 30 days
QL: 60 in 30 days
QL: 360 in 30 days
4
PA
2
4
2
2
2
QL: 30 in 30 days
QL: 30 in 30 days
cpbp 30-70, cpbp 50-50: 20mg,
40mg; tab er 24: 18mg, 27mg,
54mg
cpbp 50-50: 30mg; tab er 24:
36mg
tablet er: 10mg
tablet, tablet er: 20mg
solution
QL: 60 in 30 days
NM, PA, QL: 112 in 28
days
Contraceptives
Contraceptives
ANGELIQ
desog-e.estradiol/e.estradiol
desogestrel-ethinyl estradiol
ethinyl estradiol/
drospirenone
ethynodiol d-ethinyl
estradiol
levonorgestrel
levonorgestrel-ethin
estradiol
levonorgestrel-ethin
estradiol
l-norgest-eth estr/ethin estra
l-norgest-eth estr/ethin estra
norelgestromin/
ethin.estradiol
noreth-ethinyl estradiol/iron
(High Risk Med for Ages 65 and
Older)
2
2
2
2
2
2
2
QL: 91 in 84 days
tablet: 0.1-0.02, 0.15-0.03, 6-510
tbdspk 3mo
2
2
2
QL: 91 in 84 days
QL: 91 in 84 days
tbdspk 3mo: 100-20(84)
tbdspk 3mo: 150-30(84)
2
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
50
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
Baitang ng
Gamot
norethindrone ac-eth
estradiol
norethindrone
norethindrone-e.estradioliron
norethindrone-ethinyl estrad
2
norethindrone-mestranol
norgestimate-ethinyl
estradiol
norgestrel-ethinyl estradiol
NUVARING
ORTHO EVRA
2
2
Mga Kinakailangan/Limit
2
2
2
2
3
4
tablet: 0.4-0.035, 0.5-0.035,
1mg-35mcg, 7-9-5, 7daysx3, 1011
QL: 1 in 28 days
QL: 3 in 28 days
Dental And Oral Agents
Dental And Oral Agents
cevimeline hcl
chlorhexidine gluconate
KEPIVANCE
pilocarpine hcl
triamcinolone acetonide
2
2
5
2
2
NM
Dermatological Agents
Dermatological Agents, Other
8-MOP
acitretin
acyclovir
adapalene
alcohol antiseptic pads
aluminum chloride
ammonium lactate
ANACAINE
calcipotriene/betamethasone
calcipotriene
calcitriol
CARAC
CONDYLOX
DENAVIR
FLUOROPLEX
fluorouracil
imiquimod
4
5
2
2
1
2
2
4
2
2
2
4
4
4
4
2
2
NM
gel (gram)
PA NSO, QL: 24 in 30
days
LEVULAN
4
mafenide acetate
2
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
51
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
Baitang ng
Gamot
methoxsalen, rapid
METVIXIA
OXSORALEN-ULTRA
PANRETIN
PICATO
PICATO
podofilox
podophyllum resin
potassium hydroxide
REGRANEX
SANTYL
silver nitrate applicator
UVADEX
VALCHLOR
VEREGEN
XERAC AC
ZOVIRAX
ZYCLARA
5
4
5
5
3
3
2
2
2
4
4
2
4
5
4
3
4
4
ZYCLARA
4
Mga Kinakailangan/Limit
NM
NM
NM
QL: 2 in 56 days
QL: 3 in 56 days
gel (ea): 0.05%
gel (ea): 0.015%
PA, QL: 30 in 30 days
NM
QL: 15 in 30 days
PA NSO, QL: 15 in 28
days
PA NSO, QL: 28 in 28
days
Dermatological Antibacterials
clindamycin phos/benzoyl
2
perox
clindamycin phosphate
2
erythromycin base/ethanol
2
erythromycin/benzoyl
2
peroxide
gentamicin sulfate
2
metronidazole
2
mupirocin calcium
2
mupirocin
2
neomy sulf/polymyxin b
2
sulfate
selenium sulfide
2
selenium sulfide
2
silver nitrate
2
silver sulfadiazine
2
sulfacetamide sodium
2
THERMAZENE
2
Dermatological Anti-inflammatory Agents
alclometasone dipropionate
2
APEXICON E
4
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
52
cream (g)
crm md pmp: 2.5%
crm md pmp: 3.75%
gel (gram): 1%-5%
shampoo
suspension
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
Baitang ng
Gamot
betamethasone dipropionate
betamethasone valerate
betamethasone/propylene
glyc
clobetasol propionate
clocortolone pivalate
CLODERM
CORDRAN
CORDRAN
desonide
desoximetasone
diflorasone diacetate
ELIDEL
fluocinonide
2
2
2
fluticasone propionate
halobetasol propionate
hydrocortisone acetate/aloe
v
hydrocortisone acetate/urea
hydrocortisone acetate
hydrocortisone butyrate
hydrocortisone valerate
hydrocortisone
2
2
2
hydrocortisone
LOCOID
mometasone furoate
prednicarbate
PROTOPIC
PROTOPIC
triamcinolone acetonide
2
4
2
2
4
4
2
triamcinolone acetonide
Dermatological Retinoids
adapalene
TARGRETIN
2
TAZORAC
tretinoin microspheres
tretinoin
Scabicides And Pediculicides
EURAX
4
2
2
2
2
4
4
4
2
2
2
3
2
Mga Kinakailangan/Limit
cream (g), lotion, oint. (g)
med. tape
PA
2
2
2
2
2
2
5
(PA for Ages < 2)
cream (g): 0.05%; gel (gram),
oint. (g), solution
cream (g), oint. (g)
cream (g), cream/appl, enema,
lotion, oint. (g)
cream(gm)
cream (g)
PA
PA
(0.03%; PA for Ages < 2)
(0.1%; PA for Ages < 15)
cream (g), lotion, oint. (g):
0.025%, 0.1%, 0.5%
cream, oint. (g): 0.05%
NM, PA NSO, QL: 60 in
28 days
PA
PA
4
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
53
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
Baitang ng
Gamot
malathion
permethrin
spinosad
Mga Kinakailangan/Limit
2
2
2
Devices
Devices
needles, insulin disposable
syring w-ndl,disp,insul,0.3ml
syring w-ndl,disp,insul,0.5ml
syring w-o ndl,disp,insul,
1ml
2
2
2
2
Enzyme Replacement/modifiers
Enzyme Replacement/modifiers
ADAGEN
ALDURAZYME
CEREZYME
CHENODAL
5
5
5
5
CIMZIA
5
CREON
ELAPRASE
ELELYSO
ELITEK
FABRAZYME
KRYSTEXXA
KUVAN
LINZESS
lipase/protease/amylase
LOTRONEX
LUMIZYME
MYOZYME
NAGLAZYME
ORFADIN
PANCREAZE
PERTZYE
PULMOZYME
VIMIZIM
VPRIV
ZAVESCA
ZENPEP
3
5
5
5
5
5
5
3
2
5
5
5
5
5
4
4
5
5
5
5
3
NM
NM
NM
NM, PA, QL: 210 in 30
days
NM, PA, QL: 3 in 28
days
NM
NM
NM
NM
NM
NM
QL: 30 in 30 days
NM
NM
NM
NM
NM
NM, PA BvD
NM, PA
NM
NM, QL: 90 in 30 days
Eye, Ear, Nose, Throat Agents
Eye, Ear, Nose, Throat Anti-infectives Agents
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
54
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
acetic acid/hydrocortisone
acetic acid
bacitracin/polymyxin b
sulfate
bacitracin
BLEPHAMIDE S.O.P.
BLEPHAMIDE
CILOXAN
CIPRO HC
CIPRODEX
ciprofloxacin hcl
ciprofloxacin hcl
COLY-MYCIN S
CORTISPORIN-TC
erythromycin base
gatifloxacin
gentamicin sulfate
levofloxacin
MOXEZA
NATACYN
neo/polymyx b sulf/dexameth
neomy sulf/bacitra/
polymyxin b
neomy sulf/bacitrac zn/poly/
hc
neomycin sulfate/dex na ph
neomycin/polymyxin b sulf/
hc
neomycin/polymyxn b/
gramicidin
ofloxacin
polymyxin b sulf/
trimethoprim
sulfacetamide sodium
sulfacetamide/prednisolone
sp
TOBRADEX
tobramycin sulfate
tobramycin/dexamethasone
trifluridine
VIGAMOX
ZIRGAN
ZYLET
Baitang ng
Gamot
Mga Kinakailangan/Limit
2
2
2
2
3
4
4
3
3
2
2
4
4
2
2
2
2
3
3
2
2
oint. (g)
droperette
drops
2
2
2
2
2
2
2
2
4
2
2
2
3
4
3
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
55
oint. (g)
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
Baitang ng
Gamot
Mga Kinakailangan/Limit
Eye, Ear, Nose, Throat Anti-inflammatory Agents
ALREX
3
BROMDAY
3
bromfenac sodium
2
dexamethasone sod
2
phosphate
diclofenac sodium
2
DUREZOL
3
fluorometholone
2
flurbiprofen sodium
2
ILEVRO
3
ketorolac tromethamine
2
LOTEMAX
3
NEVANAC
3
prednisolone acetate
2
prednisolone sod phosphate
2
PROLENSA
3
RESTASIS
3
PA, QL: 60 in 30 days
Eye, Ear, Nose, Throat Drugs, Miscellaneous
AKTEN
4
apraclonidine hcl
2
atropine sulfate
2
azelastine hcl
2
azelastine hcl
2
QL: 30 in 25 days
BEPREVE
4
ST
carteolol hcl
2
cromolyn sodium
2
CYCLOGYL
3
cyclopentolate hcl
2
CYSTARAN
5
NM
epinastine hcl
2
homatropine hbr
2
ISOPTO HOMATROPINE
3
LACRISERT
3
naphazoline hcl/antazoline
2
PATADAY
3
ST
PATANOL
3
ST
phenylephrine hcl
1
phenylephrine hcl
2
proparacaine hcl
2
proparacaine/fluorescein
2
sod
tetracaine hcl/pf
2
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
56
drops
spray/pump
drops: 0.5%
drops: 2%
drops: 2.5%
drops: 10%
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
TYZINE
TYZINE
Baitang ng
Gamot
Mga Kinakailangan/Limit
4
4
drops: 0.05%
drops: 0.1%; spray
Gastrointestinal Agents
Antiulcer Agents And Acid Suppressants
CARAFATE
3
cimetidine hcl
2
cimetidine hcl
2
cimetidine in 0.9 % nacl
2
cimetidine
2
DEXILANT
3
ST
esomeprazole sodium
2
famotidine in nacl,iso-osm/pf
2
famotidine
1
famotidine
1
famotidine
2
famotidine
2
lansoprazole/amoxiciln/
clarith
lansoprazole
misoprostol
nizatidine
omeprazole
pantoprazole sodium
ranitidine hcl
ranitidine hcl
oral susp
solution
vial
(Rx Product Only)
tablet
tablet, (Rx Product Only)
oral susp, vial
oral susp, vial, (Rx Product
Only)
2
2
2
2
2
2
1
2
sucralfate
2
sucralfate
2
Gastrointestinal Agents, Other
AMITIZA
3
QL: 60 in 30 days
BUPHENYL
5
NM
CARBAGLU
5
NM
cromolyn sodium
5
NM
dicyclomine hcl
2
diphenoxylate hcl/atropine
2
FULYZAQ
4
QL: 60 in 30 days
glycopyrrolate
2
isopropamide/
2
prochlorperazine
lactulose
2
lactulose
2
loperamide hcl
2
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
57
(Rx Product Only)
tablet, (Rx Product Only)
capsule, syrup, vial, (Rx
Product Only)
oral susp
tablet
tablet
solution: 10; syrup
solution: 10g/15ml
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
methscopolamine bromide
metoclopramide hcl
metoclopramide hcl
metoclopramide hcl
NUTRESTORE
paregoric
RAVICTI
RELISTOR
RELISTOR
sodium phenylbutyrate
ursodiol
Laxatives
MOVIPREP
peg 3350/na sulf,bicarb,cl/
kcl
polyethylene glycol 3350
sodium chloride/nahco3/kcl/
peg
Phosphate Binders
calcium acetate
calcium carbonate/mag
carb/fa
FOSRENOL
PHOSLYRA
RENAGEL
RENVELA
sodium polystyrene sulfonate
sodium polystyrene sulfonate
Baitang ng
Gamot
2
1
2
2
4
2
5
4
4
5
2
Mga Kinakailangan/Limit
tablet
disp syrin
solution, vial
NM, PA
PA, QL: 28 in 28 days
PA, QL: 28 in 28 days
NM
syringe: 12mg/0.6ml
syringe: 8mg/0.4ml
3
2
2
2
2
2
4
4
3
3
2
2
enema
oral susp
Genitourinary Agents
Antispasmodics, Urinary
flavoxate hcl
GELNIQUE
GELNIQUE
oxybutynin chloride
oxybutynin chloride
OXYTROL
tolterodine tartrate
TOVIAZ
trospium chloride
VESICARE
2
4
4
1
2
4
2
3
2
3
QL: 30 in 30 days
QL: 92 in 30 days
gel packet
gel md pmp
tablet
tab er 24
QL: 8 in 28 days
Heavy Metal Antagonists
Heavy Metal Antagonists
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
58
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
Baitang ng
Gamot
deferoxamine mesylate
edetate disodium
EXJADE
EXJADE
FERRIPROX
GALZIN
na nitrite/na thiosul/amyl nit
sodium thiosulfate
SYPRINE
2
2
4
5
5
4
2
2
5
Mga Kinakailangan/Limit
PA BvD
NM
NM
tab disper: 125mg
tab disper: 250mg, 500mg
NM
Hormonal Agents, Stimulant/replacement/modifying
Androgens
ANADROL-50
ANDRODERM
ANDROGEL
ANDROGEL
ANDROGEL
AXIRON
danazol
fluoxymesterone
oxandrolone
testosterone cypionate
testosterone enanthate
Estrogens and Antiestrogens
COMBIPATCH
5
3
3
3
3
3
2
2
2
2
2
NM
PA, QL: 30 in 30 days
PA, QL: 150 in 30 days
PA, QL: 150 in 30 days
PA, QL: 300 in 30 days
PA, QL: 180 in 28 days
3
PA, QL: 8 in 28 days
DUAVEE
3
PA
ESTRACE
estradiol valerate
estradiol valerate
estradiol/norethindrone acet
estradiol/norethindrone acet
3
2
2
2
2
PA
PA
estradiol
2
PA, QL: 4 in 28 days
estradiol
2
PA
ESTRASORB
4
ESTRING
estropipate
4
2
PA, QL: 97.44 in 28
days
QL: 1 in 84 days
PA
FEMRING
4
QL: 1 in 84 days
gel md pmp
gel packet: 1.25g-1.62
gel packet: 50mg(1%)
PA
PA, QL: 5 in 28 days
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
59
(High Risk Med for Ages 65 and
Older)
(High Risk Med for Ages 65 and
Older)
cream/appl
vial: 10mg/ml
vial: 20mg/ml, 40mg/ml
(High Risk Med for Ages 65 and
Older)
patch tdwk, (High Risk Med for
Ages 65 and Older)
tablet, (High Risk Med for Ages
65 and Older)
(High Risk Med for Ages 65 and
Older)
(High Risk Med for Ages 65 and
Older)
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
Baitang ng
Gamot
Mga Kinakailangan/Limit
MENEST
4
PA
norethindrone ac-eth
estradiol
PREMARIN
PREMARIN
2
PA
3
3
PA
PREMPHASE
3
PA
PREMPRO
3
PA
raloxifene hcl
VAGIFEM
VIVELLE-DOT
2
3
3
QL: 18 in 28 days
PA, QL: 8 in 28 days
Glucocorticoids/mineralocorticoids
A-HYDROCORT
4
betamet acet/betamet na ph
2
cortisone acetate
2
dexamethasone acetate
2
dexamethasone sod
2
phosphate
dexamethasone
1
dexamethasone
2
fludrocortisone acetate
2
hydrocortisone sod succinate
2
hydrocortisone
2
methylprednisolone acetate
2
methylprednisolone sod succ
2
methylprednisolone sod succ
2
methylprednisolone
2
prednisolone acetate
2
prednisolone sod phosphate
2
prednisolone
2
PREDNISONE INTENSOL
4
prednisone
1
prednisone
2
prednisone
2
RAYOS
4
SOLU-CORTEF
4
SOLU-MEDROL
4
triamcinolone acetonide
2
UCERIS
5
(High Risk Med for Ages 65 and
Older)
(High Risk Med for Ages 65 and
Older)
cream/appl, vial
tablet, (High Risk Med for Ages
65 and Older)
(High Risk Med for Ages 65 and
Older)
(High Risk Med for Ages 65 and
Older)
(High Risk Med for Ages 65 and
Older)
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
PA BvD
PA BvD
NM, ST
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
60
tablet
elixir
vial: 40mg, 125mg
vial: 500mg, 1000mg
tablet
solution
tab ds pk
vial: 40mg/ml
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
Pituitary
DDAVP
desmopressin
(nonrefrigerated)
desmopressin acetate
desmopressin acetate
GENOTROPIN
GENOTROPIN
Baitang ng
Gamot
4
2
Mga Kinakailangan/Limit
ampul: 15mcg/ml
QL: 15 in 30 days
2
2
4
5
QL: 15 in 30 days
PA
NM, PA
HUMATROPE
INCRELEX
NORDITROPIN FLEXPRO
NORDITROPIN
NORDIFLEX
NORDITROPIN
NOVAREL
NUTROPIN AQ NUSPIN
NUTROPIN AQ
NUTROPIN
NUTROPIN
octreotide acetate
5
5
5
5
NM, PA
NM
NM, PA
NM, PA
5
4
5
5
5
5
2
NM, PA
octreotide acetate
OMNITROPE
OMNITROPE
SAIZEN
SAIZEN
SANDOSTATIN LAR
SEROSTIM
SOMATULINE DEPOT
SOMAVERT
SOMAVERT
STIMATE
SUPPRELIN LA
TEV-TROPIN
VANTAS
vasopressin
ZORBTIVE
Progestins
DEPO-PROVERA
medroxyprogesterone acet
medroxyprogesterone
acetate
5
4
5
5
5
5
5
5
5
5
4
5
4
5
2
5
NM
PA
NM, PA
NM, PA
NM, PA
NM
NM, PA
NM, QL: 1 in 28 days
NM
NM
4
2
2
QL: 10 in 28 days
NM, PA
NM, PA
NM, PA
NM, PA
tablet, vial
solution
syringe: 0.2mg/0.25
various dosage and/or strengths
are available
vial: 10mg
vial: 5mg
ampul, vial: 100mcg/ml,
200mcg/ml
vial: 1000mcg/ml
cartridge: 10mg/1.5ml
cartridge: 5mg/1.5ml; vial
cartridge, vial: 5mg
vial: 8.8mg
vial: 10mg, 15mg, 20mg
vial: 25mg, 30mg
NM, QL: 1 in 360 days
PA
NM, QL: 1 in 360 days
NM, PA
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
61
vial: 400mg/ml
tablet
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
Baitang ng
Gamot
medroxyprogesterone
2
acetate
medroxyprogesterone
2
acetate
norethindrone acetate
2
progesterone,micronized
2
progesterone
2
Thyroid and Antithyroid Agents
levothyroxine sodium
1
levothyroxine sodium
2
levothyroxine sodium
2
liothyronine sodium
2
methimazole
2
methimazole
2
propylthiouracil
2
Mga Kinakailangan/Limit
QL: 1 in 84 days
syringe
QL: 1 in 84 days
vial
tablet
vial: 100mcg
vial: 200mcg, 500mcg
tablet: 20mg
tablet: 5mg, 10mg
Immunological Agents
Immunological Agents
ARCALYST
ASTAGRAF XL
AUBAGIO
5
4
5
azathioprine sodium
azathioprine
CARIMUNE NF
NANOFILTERED
CELLCEPT
CELLCEPT
cyclosporine, modified
cyclosporine
ENBREL
2
2
5
ENBREL
5
ENBREL
5
FLEBOGAMMA DIF
FLEBOGAMMA
GAMASTAN S-D
GAMMAGARD LIQUID
GAMMAPLEX
GAMUNEX-C
HUMIRA
5
5
3
5
5
5
5
4
5
2
2
5
NM
PA BvD
NM, PA, QL: 28 in 28
days
PA BvD
PA BvD
NM, PA BvD
PA BvD
NM, PA BvD
PA BvD
PA BvD
NM, PA, QL: 7.84 in 28
days
NM, PA, QL: 8 in 28
days
NM, PA, QL: 8.16 in 28
days
NM, PA BvD
NM, PA BvD
NM, PA BvD
NM, PA BvD
NM, PA BvD
NM, PA, QL: 4 in 28
days
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
62
vial
susp recon
pen injctr
vial
syringe
kit, pen ij kit: 40mg/0.8ml
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
Baitang ng
Gamot
HUMIRA
5
HYPERRAB S-D
HYPERRHO S-D
ILARIS
4
4
5
IMOGAM RABIES-HT
KINERET
4
5
leflunomide
MICRHOGAM ULTRAFILTERED PLUS
mycophenolate mofetil
mycophenolate sodium
NULOJIX
OCTAGAM
ORENCIA
2
4
ORENCIA
5
PRIVIGEN
PROGRAF
RAPAMUNE
RAPAMUNE
RHOGAM ULTRAFILTERED PLUS
RHOPHYLAC
RIDAURA
sirolimus
tacrolimus
TYSABRI
5
4
3
5
4
WINRHO SDF
ZORTRESS
4
4
ZORTRESS
5
Vaccines
ACTHIB
ADACEL TDAP
ADACEL TDAP
BCG VACCINE (TICE
STRAIN)
3
3
3
3
2
2
5
5
5
4
5
2
2
5
Mga Kinakailangan/Limit
NM, PA, QL: 6 in 28
days
pen ij kit: 40mg/0.8ml, (Starter
Kit)
NM, PA, QL: 2 in 28
days
NM, PA, QL: 18.76 in
28 days
PA BvD
PA BvD
NM, PA BvD
NM, PA BvD
NM, PA, QL: 4 in 28
days
NM, PA, QL: 4 in 28
days
NM, PA BvD
PA BvD
PA BvD
NM, PA BvD
syringe
vial
ampul
solution
tablet: 1mg, 2mg
NM
PA BvD
PA BvD
LA, NM, PA, QL: 15 in
28 days
PA BvD, QL: 120 in 30
days
NM, PA BvD, QL: 120
in 30 days
tablet: 0.25mg
tablet: 0.5mg, 0.75mg
syringe
vial
PA BvD
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
63
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
BOOSTRIX TDAP
CERVARIX
COMVAX
DAPTACEL DTAP
DIPHTHERIA-TETANUS
TOXOIDS-PED
ENGERIX-B ADULT
ENGERIX-B PEDIATRICADOLESCENT
GARDASIL
HAVRIX
HAVRIX
IMOVAX RABIES
VACCINE
INFANRIX DTAP
INFANRIX PF
IPOL
IXIARO
JE-VAX
KINRIX
MENACTRA
MENHIBRIX
MENOMUNE-A-C-Y-W135
MENVEO A-C-Y-W-135DIP
M-M-R II VACCINE
PEDIARIX
PEDVAXHIB
PENTACEL ACTHIB
COMPONENT
PENTACEL DTAP-IPV
COMPONENT
PENTACEL
PROQUAD
RABAVERT
RECOMBIVAX HB
ROTARIX
ROTATEQ
TE ANATOXAL BERNA
TENIVAC
TETANUS DIPHTHERIA
TOXOIDS
Baitang ng
Gamot
Mga Kinakailangan/Limit
3
4
3
3
3
3
3
4
3
3
3
PA BvD
PA BvD
syringe: 1440/ml
syringe: 720/0.5ml; vial
PA BvD
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
4
3
3
3
3
3
3
3
PA BvD
PA BvD
PA BvD
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
64
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
Baitang ng
Gamot
TETANUS TOXOID
ADSORBED
THERACYS
TWINRIX
TWINRIX
TYPHIM VI
VAQTA
VARIVAX VACCINE
YF-VAX
ZOSTAVAX
Mga Kinakailangan/Limit
3
PA BvD
3
3
3
3
3
3
3
3
PA BvD
syringe
vial
Inflammatory Bowel Disease Agents
Inflammatory Bowel Disease Agents
APRISO
3
ASACOL HD
4
balsalazide disodium
2
budesonide
5
DIPENTUM
4
ST
NM
ST
Irrigating Solutions
Irrigating Solutions
acetic acid
GLYCINE
LACTATED RINGERS
mannitol/sorbitol solution
ringers solution
sodium chloride irrig
solution
sorbitol solution
urologic solution-g
water for irrigation,sterile
2
2
3
2
2
2
2
3
2
Metabolic Bone Disease Agents
Metabolic Bone Disease Agents
ACTONEL
ACTONEL
ACTONEL
alendronate sodium
alendronate sodium
alendronate sodium
ATELVIA
calcitonin,salmon,synthetic
calcitriol
doxercalciferol
etidronate disodium
3
3
3
1
1
2
4
2
2
2
2
QL: 1 in 28 days
QL: 30 in 30 days
QL: 4 in 28 days
QL: 4 in 28 days
QL: 300 in 28 days
QL: 4 in 28 days
QL: 3.7 in 28 days
PA BvD
PA BvD
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
65
tablet: 150mg
tablet: 5mg, 30mg
tablet: 35mg
tablet: 5mg, 10mg, 40mg
tablet: 35mg, 70mg
solution
(PA for ESRD Only)
(PA for ESRD Only)
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
Baitang ng
Gamot
FORTEO
FORTICAL
ibandronate sodium
4
4
2
ibandronate sodium
MIACALCIN
pamidronate disodium
paricalcitol
PROLIA
risedronate sodium
XGEVA
2
3
2
2
4
2
5
ZEMPLAR
zoledronic acid/
mannitol&water
zoledronic acid/
mannitol&water
zoledronic acid
ZOMETA
3
2
Mga Kinakailangan/Limit
QL: 3 in 28 days
QL: 3.7 in 28 days
PA BvD, QL: 3 in 84
days
QL: 1 in 28 days
PA BvD
PA BvD
PA BvD
PA, QL: 1 in 180 days
QL: 1 in 28 days
NM, PA, QL: 1.7 in 28
days
PA BvD
vial, (PA for ESRD Only)
tablet
vial, (PA for ESRD Only)
(PA for ESRD Only)
(PA for ESRD Only)
vial, (PA for ESRD Only)
piggyback
2
QL: 100 in 300 days
infus. btl
2
5
NM
infus. btl
NM, PA, QL: 3.6 in 28
days
NM, PA, QL: 40 in 30
days
NM
syringe
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
ACTEMRA
5
ACTEMRA
5
ACTIMMUNE
allopurinol sodium
allopurinol
amifostine crystalline
ammonium chloride
AVODART
AVONEX
ADMINISTRATION PACK
AVONEX
BENLYSTA
5
2
1
2
2
3
5
BETASERON
bethanechol chloride
BOTOX
BOTOX
buspirone hcl
citrate phosphate dextros
soln
5
2
4
4
2
2
5
5
vial
NM, ST
NM, ST
NM, PA, QL: 2 in 28
days
NM, ST
QL: 1 in 90 days
QL: 4 in 90 days
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
66
vial: 200unit
vial: 100unit
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
Baitang ng
Gamot
Mga Kinakailangan/Limit
colchicine/probenecid
COLCRYS
COPAXONE
CYSTADANE
dexrazoxane
droperidol
DUODOTE
DYSPORT
ELMIRON
EXTAVIA
finasteride
fomepizole
FUSILEV
gauze bandage
GILENYA
2
3
5
5
2
2
3
4
4
5
2
5
5
1
5
GLUCAGEN
GLUCAGON
EMERGENCY KIT
glutethimide
guanidine hcl
H.P. ACTHAR
3
3
hydroxyzine hcl
2
NM, PA, QL: 35 in 28
days
PA
hydroxyzine pamoate
2
PA
JALYN
KALBITOR
leucovorin calcium
levocarnitine (with sugar)
levocarnitine
LITHOSTAT
mesna
MESNEX
MESTINON
methylene blue
methylergonovine maleate
methylergonovine maleate
MYOBLOC
MYTELASE
neostigmine methylsulfate
3
5
2
2
2
3
2
5
4
2
2
2
4
4
2
QL: 30 in 30 days
NM
2
2
5
NM
NM
NM, ST
NM
NM
NM, PA, QL: 28 in 28
days
(High Risk Med for Ages 65 and
Older)
(High Risk Med for Ages 65 and
Older)
PA BvD
PA BvD
(PA for ESRD Only)
(PA for ESRD Only)
NM
tablet
syrup, tablet er
ampul
tablet
QL: 1 in 90 days
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
67
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
Baitang ng
Gamot
NPLATE
5
OTEZLA
5
physostigmine salicylate
PRALIDOXIME
CHLORIDE
probenecid
PROCYSBI
PROSTIGMIN
PROTOPAM CHLORIDE
pyridostigmine bromide
REBIF REBIDOSE
REBIF
REGONOL
REMICADE
SENSIPAR
SENSIPAR
SIGNIFOR
SIMPONI ARIA
2
4
SIMPONI
5
SIMPONI
5
SIMULECT
sodium morrhuate
sodium tetradecyl sulfate
SOLIRIS
STELARA
5
2
2
5
5
STELARA
5
STELARA
5
SYNAREL
TECFIDERA
5
5
TECFIDERA
5
THALOMID
5
ULORIC
3
2
5
4
4
2
5
5
4
5
3
5
5
5
Mga Kinakailangan/Limit
NM, PA, QL: 8 in 28
days
NM, PA, QL: 60 in 30
days
NM
NM
NM
NM, PA
NM
NM, QL: 60 in 30 days
NM, PA, QL: 24 in 28
days
NM, PA, QL: 0.5 in 28
days
NM, PA, QL: 3 in 28
days
NM, PA BvD
NM
NM, PA, QL: 10 in 360
days
NM, PA, QL: 10 in 360
days
NM, PA, QL: 5 in 360
days
NM
NM, PA, QL: 14 in 30
days
NM, PA, QL: 60 in 30
days
NM, PA NSO, QL: 60 in
30 days
ST, QL: 30 in 30 days
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
68
tablet: 30mg
tablet: 60mg, 90mg
pen injctr
syringe
syringe: 45mg/0.5ml
vial
syringe: 90mg/ml
capsule dr: 120mg
capsule dr: 120-240mg, 240mg
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
VORAXAZE
XELJANZ
Baitang ng
Gamot
5
5
Mga Kinakailangan/Limit
NM
NM, PA, QL: 60 in 30
days
Ophthalmic Agents
Antiglaucoma Agents
acetazolamide sodium
acetazolamide
ALPHAGAN P
AZOPT
betaxolol hcl
BETIMOL
BETOPTIC S
brimonidine tartrate
COMBIGAN
dorzolamide hcl/timolol
maleat
dorzolamide hcl
ISOPTO CARPINE
ISTALOL
latanoprost
levobunolol hcl
levobunolol hcl
LUMIGAN
methazolamide
metipranolol
PHOSPHOLINE IODIDE
pilocarpine hcl
PILOPINE HS
SIMBRINZA
timolol maleate
TRAVATAN Z
travoprost (benzalkonium)
ZIOPTAN
2
2
3
3
2
4
4
2
3
2
2
3
4
2
2
2
3
2
2
4
2
4
3
2
3
2
4
drops: 0.1%
(drops: 0.15%, 0.20%)
drops: 8%
drops: 0.25%
drops: 0.5%
QL: 2.5 in 25 days
QL: 2.5 in 25 days
QL: 2.5 in 25 days
QL: 30 in 30 days
Replacement Preparations
Replacement Preparations
0.9 % sodium chloride
2
calcium chloride
2
calcium gluconate
2
PA BvD
citric acid/sodium citrate
2
dex 2.5%-half str
2
lact.ringers
DEXTROSE W/
4
ELECTROLYTE A
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
69
(PA for ESRD Only)
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
DEXTROSE W/
ELECTROLYTE B
electrolyte-48 solution/d5w
electrolyte-48/fructose 10%
electrolyte-48/fructose 5%
electrolyte-75 solution/d5w
electrolyte-75/fructose 5%
HYPERLYTE CR
HYPERLYTE R
IONOSOL B with
DEXTROSE 5%
IONOSOL MBDEXTROSE 5%
IONOSOL T-DEXTROSE
5%
ISOLYTE E
ISOLYTE H W/
DEXTROSE
ISOLYTE M W/
DEXTROSE
ISOLYTE P with
DEXTROSE
ISOLYTE R W/
DEXTROSE
ISOLYTE S with
DEXTROSE
ISOLYTE S
K-PHOS NO.2
magnesium chloride
magnesium sulfate in water
magnesium sulfate/d5w
magnesium sulfate
magnesium sulfate
NORMOSOL-M and
DEXTROSE
NORMOSOL-R PH 7.4
NUTRILYTE II
NUTRILYTE
phosphorus #1
PLASMA-LYTE 148
PLASMA-LYTE 56 IN
DEXTROSE
PLASMA-LYTE A PH 7.4
Baitang ng
Gamot
Mga Kinakailangan/Limit
4
2
2
2
2
2
4
4
4
4
4
4
4
4
4
2
4
4
3
2
2
2
2
2
4
infus. btl
syringe, vial
4
4
4
2
4
4
4
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
70
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
Baitang ng
Gamot
PLASMA-LYTE M IN
DEXTROSE
pot chloride/pot bicarb/cit
ac
potassium acetate
potassium bicarbonate/cit ac
potassium chlorid/d100.2%nacl
potassium chloride in
0.9%nacl
potassium chloride in d5w
potassium chloride in d5w
potassium chloride in lr-d5
potassium chloride/d50.2%nacl
potassium chloride/d50.2%nacl
potassium chloride/d50.25ns
potassium chloride/d50.3%nacl
potassium chloride/d50.45nacl
potassium chloride/d50.9%nacl
potassium chloride-0.45%
nacl
potassium chloride
4
potassium chloride
potassium citrate/citric acid
potassium gluconate
potassium phos,m-basic-dbasic
ringers solution
SHOHL'S MODIFIED
sod/pot/k cit/sod cit/cit acid
sodium acetate
sodium bicarbonate
sodium chloride 0.45 %
sodium chloride 3%
sodium chloride 5%
sodium chloride
2
2
2
2
Mga Kinakailangan/Limit
2
2
2
2
2
2
2
2
2
2
iv soln: 10meq/l, 30meq/l
iv soln: 20meq/l, 40meq/l
iv soln: 10meq/l, 30meq/l,
40meq/l
iv soln: 20meq/l
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
71
capsule er, piggyback, syringe,
tab er prt, tablet er
liquid, packet, tablet sa
vial: 2.5meq/ml
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
sodium chloride
SODIUM LACTATE
sodium lactate
sodium phos,m-basic-d-basic
TPN ELECTROLYTES
TRAVERTELECTROLYTE NO.1
TRAVERTELECTROLYTE NO.2
TRAVERTELECTROLYTE NO.2
TRAVERTELECTROLYTE NO.3
TRAVERTELECTROLYTE NO.4
Baitang ng
Gamot
Mga Kinakailangan/Limit
2
2
2
2
4
4
vial: 4meq/ml
4
iv soln: 10%
4
iv soln: 5%
4
4
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
72
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
Baitang ng
Gamot
Mga Kinakailangan/Limit
Respiratory Tract Agents
Anti-inflammatories, Inhaled Corticosteroids
ADVAIR DISKUS
3
QL: 60 in 30 days
ADVAIR HFA
3
QL: 12 in 28 days
BREO ELLIPTA
3
QL: 60 in 30 days
DULERA
3
QL: 13 in 28 days
FLOVENT DISKUS
3
QL: 120 in 30 days
FLOVENT DISKUS
3
QL: 60 in 30 days
FLOVENT HFA
3
QL: 12 in 28 days
FLOVENT HFA
3
QL: 21.2 in 28 days
FLOVENT HFA
3
QL: 24 in 28 days
flunisolide
2
QL: 50 in 25 days
flunisolide
2
QL: 50 in 25 days
fluticasone propionate
2
QL: 16 in 30 days
NASONEX
3
QL: 34 in 28 days
QNASL
3
QL: 8.7 in 28 days
QVAR
3
QL: 17.4 in 25 days
SYMBICORT
4
ST, QL: 11 in 25 days
triamcinolone acetonide
2
QL: 16.5 in 30 days
Antileukotrienes
montelukast sodium
2
zafirlukast
2
Bronchodilators
albuterol sulfate
2
albuterol sulfate
2
PA BvD
aminophylline
2
aminophylline
2
ATROVENT HFA
3
QL: 25.8 in 28 days
COMBIVENT RESPIMAT
3
QL: 8 in 30 days
COMBIVENT
3
QL: 29.4 in 30 days
FORADIL
3
QL: 62 in 30 days
ipratropium bromide
2
QL: 15 in 10 days
ipratropium bromide
2
QL: 30 in 28 days
MAXAIR AUTOHALER
4
QL: 14 in 30 days
metaproterenol sulfate
2
PROAIR HFA
3
QL: 17 in 25 days
SEREVENT DISKUS
3
QL: 60 in 30 days
SPIRIVA
3
QL: 30 in 30 days
terbutaline sulfate
2
theophylline anhydrous
2
theophylline/d5w
2
VENTOLIN HFA
3
QL: 36 in 25 days
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
73
blst w/dev: 250mcg
blst w/dev: 50mcg, 100mcg
aer w/adap: 110mcg
aer w/adap: 44mcg
aer w/adap: 220mcg
spray: 25mcg
spray: 29mcg
syrup, tab er 12h, tablet
solution, vial-neb: 0.63mg/3ml,
1.25mg/3ml
liquid
vial
spray: 42mcg
spray: 21mcg
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
Baitang ng
Gamot
Respiratory Tract Agents, Other
acetylcysteine
2
ARALAST NP
5
cromolyn sodium
2
DALIRESP
3
KALYDECO
5
Mga Kinakailangan/Limit
XOLAIR
5
ZEMAIRA
5
PA BvD
NM
PA BvD
QL: 30 in 30 days
NM, PA, QL: 60 in 30
days
NM, PA, QL: 6 in 28
days
NM
Skeletal Muscle Relaxants
baclofen
carisoprodol
2
2
PA, QL: 120 in 30 days
carisoprodol
2
PA, QL: 120 in 30 days
chlorzoxazone/
acetaminophen
chlorzoxazone
2
PA
2
PA
cyclobenzaprine hcl
2
PA
dantrolene sodium
dantrolene sodium
metaxalone
2
2
2
PA
methocarbamol
2
PA
tizanidine hcl
2
Skeletal Muscle Relaxants
tablet: 250mg, (High Risk Med
for Ages 65 and Older)
tablet: 350mg, (High Risk Med
for Ages 65 and Older)
(High Risk Med for Ages 65 and
Older)
(High Risk Med for Ages 65 and
Older)
(High Risk Med for Ages 65 and
Older)
capsule
vial
(High Risk Med for Ages 65 and
Older)
(High Risk Med for Ages 65 and
Older)
Sleep Disorder Agents
Sleep Disorder Agents
BUTISOL SODIUM
BUTISOL SODIUM
BUTISOL SODIUM
modafinil
ROZEREM
XYREM
4
4
4
2
3
5
QL: 120 in 30 days
QL: 473 in 30 days
QL: 60 in 30 days
PA, QL: 60 in 30 days
tablet: 30mg
elixir: 30mg/5ml
tablet: 50mg
LA, NM
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
74
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
Baitang ng
Gamot
Mga Kinakailangan/Limit
zaleplon
2
PA, QL: 60 in 30 days
zolpidem tartrate
2
PA, QL: 30 in 30 days
(High Risk Med. QL applies to
all members; PA required for 65
years and older with over 90
days cumulative use with any
non-benzodiazepine hypnotic
drug)
(High Risk Med. QL applies to
all members; PA required for 65
years and older with over 90
days cumulative use with any
non-benzodiazepine hypnotic
drug)
Sympatholytic Adrenergic Blocking Agents
Alpha-Adrenergic Blocking Agents
alfuzosin hcl
2
phentolamine mesylate
2
tamsulosin hcl
2
terazosin hcl
1
PA
Vasodilating Agents
Vasodilating Agents
ADCIRCA
5
ADEMPAS
5
alprostadil
epoprostenol sodium
(glycine)
epoprostenol sodium
(glycine)
ISOVEX
LETAIRIS
OPSUMIT
5
REMODULIN
REVATIO
5
5
sildenafil citrate
TRACLEER
2
5
TYVASO
VENTAVIS
5
5
2
2
NM, PA, QL: 60 in 30
days
NM, PA, QL: 90 in 30
days
PA
PA BvD
vial: 0.5mg
5
NM, PA BvD
vial: 1.5mg
4
5
NM, PA, QL: 30 in 30
days
NM, PA, QL: 30 in 30
days
NM, PA BvD
NM, PA, QL: 37.5 in 1
day
PA, QL: 90 in 30 days
LA, NM, PA, QL: 60 in
30 days
NM, PA BvD
NM, PA BvD
vial
Vitamins and Minerals
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
75
Epektibo: Nobyembre 1, 20141
Pangalan ng Gamot
Vitamins and Minerals
LOZI-FLUR
pedi m.vit no.17 with
fluoride
pedi mvi no.12/sodium
fluoride
pnv with ca,no.72/iron/fa
Baitang ng
Gamot
Mga Kinakailangan/Limit
2
2
2
3
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
76
(All Rx Prenatal Vitamins
Covered)
Epektibo: Nobyembre 1, 20141
77
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
Epektibo: Nobyembre 1, 2014
INDISE
0.9 % sodium chloride .......... 69
8-MOP................................... 51
abacavir sulfate ..................... 37
abacavir/lamivudine/zidovudine
........................................... 37
ABELCET............................. 32
ABILIFY ............................... 35
ABILIFY DISCMELT .......... 35
ABILIFY MAINTENA ........ 35
ABRAXANE ........................ 20
acamprosate calcium ............ 15
acarbose ................................ 29
acebutolol hcl ........................ 45
acetaminophen with codeine . 12
acetazolamide ....................... 69
acetazolamide sodium ........... 69
acetic acid ....................... 55, 65
acetic acid/hydrocortisone .... 55
acetylcysteine ........................ 74
acitretin ................................. 51
ACTEMRA ........................... 66
ACTHIB ................................ 63
ACTIMMUNE ...................... 66
ACTONEL ............................ 65
ACTOPLUS MET XR .......... 31
acyclovir .......................... 39, 51
acyclovir sodium ................... 39
ADACEL TDAP ................... 63
ADAGEN .............................. 54
adapalene ........................ 51, 53
ADASUVE ........................... 35
ADCETRIS ........................... 20
ADCIRCA............................. 75
adefovir dipivoxil .................. 39
ADEMPAS ........................... 75
ADVAIR DISKUS................ 73
ADVAIR HFA ...................... 73
ADVICOR ............................ 48
AFINITOR ............................ 21
AFINITOR DISPERZ ........... 21
AGGRENOX ........................ 40
A-HYDROCORT ................. 60
AKTEN ................................. 56
ALBENZA ............................ 34
ALBUKED-25 ...................... 41
ALBUKED-5 ........................ 41
ALBUMIN HUMAN ............ 41
ALBUMINAR-25 ................. 41
ALBUMINAR-5 ................... 41
ALBURX .............................. 41
ALBUTEIN........................... 41
albuterol sulfate .................... 73
alclometasone dipropionate .. 52
alcohol antiseptic pads ......... 51
ALDURAZYME................... 54
alendronate sodium............... 65
ALFERON N ........................ 38
alfuzosin hcl .......................... 75
ALIMTA ............................... 21
ALINIA ................................. 34
allopurinol............................. 66
allopurinol sodium ................ 66
ALPHAGAN P ..................... 69
alprazolam ............................ 16
alprostadil ............................. 75
ALREX ................................. 56
ALTOPREV .......................... 48
aluminum chloride ................ 51
amantadine hcl ...................... 35
amifostine crystalline ............ 66
amiloride hcl ......................... 48
amiloride/hydrochlorothiazide
........................................... 48
AMINO ACIDS .................... 41
aminocaproic acid ................ 40
aminophylline........................ 73
AMINOSYN ......................... 41
AMINOSYN II ..................... 41
AMINOSYN M .................... 41
AMINOSYN with
ELECTROLYTES ............ 41
AMINOSYN-HBC ............... 41
AMINOSYN-PF ................... 41
AMINOSYN-RF ................... 41
amiodarone hcl ..................... 45
AMITIZA .............................. 57
I-1
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
amitriptyline hcl .................... 28
amlodipine besylate .............. 47
amlodipine besylate/benazepril
........................................... 47
amlodipine/atorvastatin ........ 48
ammonium chloride .............. 66
ammonium lactate ................. 51
amoxapine ............................. 28
amoxicillin............................. 19
amoxicillin trihydrate............ 19
amoxicillin/potassium clav.... 19
amphotericin b ...................... 32
ampicillin sodium .................. 19
ampicillin sodium/sulbactam na
........................................... 19
ampicillin trihydrate ............. 19
AMPYRA ............................. 49
ANACAINE .......................... 51
ANADROL-50 ...................... 59
anagrelide hcl ....................... 40
anastrozole ............................ 21
ANDRODERM ..................... 59
ANDROGEL......................... 59
ANGELIQ ............................. 50
ANORO ELLIPTA ............... 26
APEXICON E ....................... 52
APOKYN .............................. 35
apraclonidine hcl .................. 56
APRISO ................................ 65
APTIOM ............................... 26
APTIVUS .............................. 37
ARALAST NP ...................... 74
ARCALYST ......................... 62
ARRANON ........................... 21
ARZERRA ............................ 21
ASACOL HD ........................ 65
ASTAGRAF XL ................... 62
ATELVIA ............................. 65
atenolol ................................. 45
atenolol/chlorthalidone ......... 45
atorvastatin calcium.............. 48
atovaquone ............................ 34
atovaquone/proguanil hcl ..... 34
Epektibo: Nobyembre 1, 2014
ATRIPLA .............................. 37
atropine sulfate ............... 26, 56
ATROVENT HFA ................ 73
AUBAGIO ............................ 62
AVANDAMET ..................... 31
AVANDARYL ..................... 31
AVANDIA ............................ 31
AVASTIN ............................. 21
AVC ...................................... 33
AVELOX ABC PACK ......... 20
AVELOX IV ......................... 20
AVODART ........................... 66
AVONEX .............................. 66
AVONEX
ADMINISTRATION PACK
........................................... 66
AXIRON ............................... 59
azacitidine ............................. 21
azathioprine .......................... 62
azathioprine sodium .............. 62
azelastine hcl ......................... 56
AZILECT .............................. 35
azithromycin .......................... 18
AZOPT .................................. 69
AZOR .................................... 47
aztreonam .............................. 19
bacitracin ........................ 17, 55
bacitracin/polymyxin b sulfate
........................................... 55
baclofen ................................. 74
balsalazide disodium............. 65
BANZEL ............................... 26
BARACLUDE ...................... 39
BCG VACCINE TICE
STRAIN ............................ 63
BELEODAQ ......................... 21
benazepril hcl ........................ 44
benazepril/hydrochlorothiazide
........................................... 44
BENICAR ............................. 44
BENICAR HCT .................... 44
BENLYSTA .......................... 66
benztropine mesylate ............. 35
BEPREVE ............................. 56
BERINERT ........................... 40
betamet acet/betamet na ph .. 60
betamethasone dipropionate . 53
betamethasone valerate ........ 53
betamethasone/propylene glyc
........................................... 53
BETASERON ....................... 66
betaxolol hcl .................... 45, 69
bethanechol chloride ............. 66
BETHKIS .............................. 16
BETIMOL ............................. 69
BETOPTIC S ........................ 69
BEXXAR .............................. 21
bicalutamide.......................... 21
BICILLIN C-R ...................... 19
BICILLIN L-A ...................... 19
BICNU .................................. 21
BILTRICIDE ........................ 34
bisoprolol fumarate............... 45
bisoprolol fumarate/hctz ....... 45
bleomycin sulfate .................. 21
BLEPHAMIDE ..................... 55
BLEPHAMIDE S.O.P. ......... 55
BOOSTRIX TDAP ............... 64
BOSULIF .............................. 21
BOTOX ................................. 66
BREO ELLIPTA ................... 73
BRILINTA ............................ 40
brimonidine tartrate .............. 69
BRINTELLIX ....................... 28
BROMDAY .......................... 56
bromfenac sodium ................. 56
bromocriptine mesylate ......... 35
budesonide ............................ 65
bumetanide ............................ 48
BUMINATE ......................... 41
BUPHENYL ......................... 57
buprenorphine hcl ........... 12, 15
buprenorphine hcl/naloxone hcl
........................................... 15
bupropion hcl ........................ 28
buspirone hcl ......................... 66
BUSULFEX .......................... 21
I-2
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
butalb/acetaminophen/caffeine
........................................... 12
butalbit/acetamin/caff/codeine
........................................... 12
butalbital/acetaminophen ..... 12
butalbital/aspirin/caffeine ..... 14
BUTISOL SODIUM ............. 74
butorphanol tartrate.............. 12
BUTRANS ............................ 12
BYDUREON ........................ 29
BYDUREON PEN ................ 29
BYETTA ............................... 29
BYSTOLIC ........................... 45
cabergoline ........................... 35
caffeine citrated .................... 49
caffeine/sodium benzoate ...... 49
calcipotriene ......................... 51
calcipotriene/betamethasone 51
calcitonin,salmon,synthetic ... 65
calcitriol .......................... 51, 65
calcium acetate ..................... 58
calcium carbonate/mag carb/fa
........................................... 58
calcium chloride.................... 69
calcium gluconate ................. 69
CALDOLOR ......................... 14
CAMPRAL ........................... 15
CANCIDAS .......................... 32
candesartan cilexetil ............. 44
candesartan/hydrochlorothiazid
........................................... 44
CAPASTAT SULFATE ....... 33
CAPRELSA .......................... 21
captopril ................................ 44
captopril/hydrochlorothiazide
........................................... 44
CARAC ................................. 51
CARAFATE ......................... 57
CARBAGLU......................... 57
carbamazepine ...................... 26
carbidopa .............................. 35
carbidopa/levodopa .............. 35
carbidopa/levodopa/entacapone
........................................... 35
Epektibo: Nobyembre 1, 2014
carbinoxamine maleate ......... 32
carboplatin ............................ 21
CARIMUNE NF
NANOFILTERED ............ 62
carisoprodol .......................... 74
carteolol hcl .......................... 56
carvedilol .............................. 45
CAYSTON ............................ 19
CEDAX ................................. 17
CEENU ................................. 21
cefaclor ................................. 18
cefadroxil .............................. 18
cefazolin sodium.................... 18
cefazolin sodium/dextrose,iso 18
cefdinir .................................. 18
cefditoren pivoxil .................. 18
CEFEPIME ........................... 18
cefepime hcl .......................... 18
CEFEPIME-DEXTROSE ..... 18
cefotaxime sodium ................. 18
cefotetan disod/dextrose,iso .. 18
cefotetan disodium ................ 18
cefoxitin sodium .................... 18
cefoxitin sodium/dextrose,iso 18
cefpodoxime proxetil ............. 18
cefprozil................................. 18
ceftazidime pentahydrate ...... 18
ceftibuten dihydrate .............. 18
ceftriaxone na/dextrose,iso ... 18
ceftriaxone sodium ................ 18
cefuroxime axetil ................... 18
cefuroxime sodium ................ 18
cefuroxime sodium/dextrose,iso
........................................... 18
CELEBREX .......................... 14
CELLCEPT ........................... 62
CELONTIN........................... 26
cephalexin ............................. 18
CEPROTIN ........................... 39
CEREZYME ......................... 54
CERVARIX .......................... 64
CESAMET ............................ 34
cevimeline hcl........................ 51
CHANTIX............................. 15
CHENODAL......................... 54
chloramphenicol sod succ ..... 17
chlordiazepoxide hcl ............. 16
chlorhexidine gluconate ........ 51
chlorothiazide ....................... 48
chlorothiazide sodium ........... 48
chlorpromazine hcl ............... 36
chlorthalidone ....................... 48
chlorzoxazone ....................... 74
chlorzoxazone/acetaminophen
........................................... 74
cholestyramine (with sugar) . 48
cholestyramine/aspartame .... 48
choline sal/mag salicylate ..... 14
ciclopirox .............................. 32
ciclopirox olamine ................ 32
cidofovir ................................ 39
cilostazol ............................... 40
CILOXAN............................. 55
cimetidine .............................. 57
cimetidine hcl ........................ 57
cimetidine in 0.9 % nacl........ 57
CIMZIA ................................ 54
CINRYZE ............................. 40
CIPRO HC ............................ 55
CIPRODEX........................... 55
ciprofloxacin ......................... 20
ciprofloxacin hcl ............. 20, 55
ciprofloxacin lactate ............. 20
ciprofloxacin lactate/d5w...... 20
ciprofloxacin/ciprofloxa hcl .. 20
cisplatin ................................. 21
citalopram hydrobromide ..... 28
citrate phosphate dextros soln
........................................... 66
citric acid/sodium citrate ...... 69
cladribine .............................. 21
clarithromycin ....................... 18
clemastine fumarate .............. 32
CLEVIPREX......................... 47
clindamycin hcl ..................... 17
clindamycin palmitate hcl ..... 17
clindamycin phos/benzoyl perox
........................................... 52
I-3
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
clindamycin phosphate... 17, 33,
52
clindamycin phosphate/d5w .. 17
CLINIMIX ...................... 41, 42
CLINIMIX E ......................... 41
CLINISOL ............................ 42
clobetasol propionate............ 53
clocortolone pivalate ............ 53
CLODERM ........................... 53
CLOLAR............................... 21
clomipramine hcl .................. 28
clonazepam ........................... 16
clonidine.......................... 43, 44
clonidine hcl .................... 43, 49
clonidine hcl/chlorthalidone . 43
clopidogrel bisulfate ............. 40
clorazepate dipotassium........ 16
clotrimazole........................... 32
clotrimazole/betamethasone dip
........................................... 32
clozapine ............................... 36
COARTEM ........................... 34
cocaine hcl ............................ 15
codeine phos/acetaminophen 12
codeine sulfate ...................... 12
codeine/butalbital/asa/caffein12
colchicine/probenecid ........... 67
COLCRYS ............................ 67
colestipol hcl ......................... 48
colistin (colistimethate na) .... 17
COLY-MYCIN S .................. 55
COMBIGAN ......................... 69
COMBIPATCH .................... 59
COMBIVENT ....................... 73
COMBIVENT RESPIMAT .. 73
COMETRIQ .......................... 21
COMPLERA ......................... 37
COMVAX ............................. 64
CONDYLOX ........................ 51
COPAXONE ......................... 67
CORDRAN ........................... 53
COREG CR........................... 46
cortisone acetate ................... 60
CORTISPORIN-TC .............. 55
Epektibo: Nobyembre 1, 2014
CREON ................................. 54
CRESTOR............................. 48
CRIXIVAN ........................... 37
cromolyn sodium ....... 56, 57, 74
CUBICIN .............................. 17
cyclobenzaprine hcl .............. 74
CYCLOGYL ......................... 56
cyclopentolate hcl ................. 56
cyclophosphamide ................. 21
CYCLOPHOSPHAMIDE..... 21
CYCLOSET .......................... 29
cyclosporine .......................... 62
cyclosporine, modified .......... 62
cyproheptadine hcl ................ 33
CYRAMZA........................... 21
CYSTADANE ...................... 67
CYSTARAN ......................... 56
cysteine hcl ............................ 42
cytarabine/pf ......................... 21
dacarbazine ........................... 21
dactinomycin ......................... 21
DALIRESP ........................... 74
danazol .................................. 59
dantrolene sodium................. 74
dapsone ................................. 33
DAPTACEL DTAP .............. 64
DARAPRIM ......................... 34
daunorubicin hcl ................... 21
DAUNOXOME .................... 21
DDAVP ................................. 61
decitabine .............................. 22
deferoxamine mesylate .......... 59
demeclocycline hcl ................ 20
DENAVIR............................. 51
DEPO-PROVERA ................ 61
desipramine hcl ..................... 28
desmopressin (nonrefrigerated)
........................................... 61
desmopressin acetate ............ 61
desog-e.estradiol/e.estradiol . 50
desogestrel-ethinyl estradiol . 50
desonide ................................ 53
desoximetasone ..................... 53
DESVENLAFAXINE ER..... 28
dex 2.5%-half str lact.ringers 69
dexamethasone ...................... 60
dexamethasone acetate ......... 60
dexamethasone sod phosphate
..................................... 56, 60
DEXILANT .......................... 57
dexmethylphenidate hcl ......... 49
dexrazoxane .......................... 67
dextroamphetamine sulfate ... 49
dextroamphetamine/
amphetamine ..................... 50
dextrose 10 % and 0.2 % nacl
........................................... 42
dextrose 10 % and 0.9 % nacl
........................................... 42
dextrose 10%-0.5 normal saline
........................................... 42
dextrose 10%-water .............. 42
dextrose 2.5 % in water ........ 42
dextrose 2.5% in half ringers 42
dextrose 2.5%-0.5normal saline
........................................... 42
dextrose 20%-water .............. 42
dextrose 25 % in water ......... 42
dextrose 40%-water .............. 42
dextrose 5 % and 0.3 % nacl 42
dextrose 5 % and 0.9 % nacl 42
dextrose 5 % in water ........... 42
dextrose 5 %-0.2 % nacl ....... 42
dextrose 5 %-0.45 % nacl ..... 42
dextrose 5% in ringers .......... 42
dextrose 5%-lactated ringers 42
dextrose 50 % in water ......... 42
dextrose 60 % in water ......... 42
dextrose 70%-water .............. 42
DEXTROSE W/
ELECTROLYTE A .......... 69
DEXTROSE W/
ELECTROLYTE B ........... 70
DIASTAT ACUDIAL .......... 16
diazepam ............................... 16
diclofenac potassium ............. 14
diclofenac sodium ........... 14, 56
I-4
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
diclofenac sodium/misoprostol
........................................... 14
dicloxacillin sodium .............. 19
dicyclomine hcl ..................... 57
didanosine ............................. 37
DIFICID ................................ 18
diflorasone diacetate ............. 53
diflunisal ............................... 14
digoxin................................... 47
DIGOXIN ............................. 47
dihydroergotamine mesylate . 33
DILANTIN ........................... 26
diltiazem hcl .......................... 46
dimenhydrinate ..................... 34
DIOVAN ............................... 44
DIPENTUM .......................... 65
diphenhydramine hcl ............. 33
diphenoxylate hcl/atropine.... 57
DIPHTHERIA-TETANUS
TOXOIDS-PED ................ 64
disopyramide phosphate ....... 45
disulfiram .............................. 15
divalproex sodium ................. 26
dobutamine hcl ...................... 47
dobutamine hcl/d5w .............. 47
DOCEFREZ .......................... 22
docetaxel ............................... 22
donepezil hcl ......................... 28
dopamine hcl ......................... 47
dopamine hcl/d5w ................. 47
dopamine hcl/dextrose 5%water ................................. 47
dorzolamide hcl ..................... 69
dorzolamide hcl/timolol maleat
........................................... 69
doxazosin mesylate................ 44
doxepin hcl ............................ 28
doxercalciferol ...................... 65
doxorubicin hcl ..................... 22
doxorubicin hcl peg-liposomal
........................................... 22
doxycycline hyclate ............... 20
doxycycline monohydrate...... 20
dronabinol ............................. 34
Epektibo: Nobyembre 1, 2014
droperidol ............................. 67
DROXIA ............................... 22
DUAVEE .............................. 59
DULERA .............................. 73
duloxetine hcl ........................ 28
DUODOTE ........................... 67
DUREZOL ............................ 56
DUTOPROL ......................... 46
DYRENIUM ......................... 48
DYSPORT ............................ 67
econazole nitrate ................... 32
EDARBI................................ 44
EDARBYCLOR ................... 44
edetate disodium ................... 59
EDURANT ........................... 37
EFFIENT............................... 40
ELAPRASE .......................... 54
electrolyte-48 solution/d5w ... 70
electrolyte-48/fructose 10% .. 70
electrolyte-48/fructose 5% .... 70
electrolyte-75 solution/d5w ... 70
electrolyte-75/fructose 5% .... 70
ELELYSO ............................. 54
ELIDEL................................. 53
ELIGARD ............................. 22
ELIQUIS ............................... 39
ELITEK................................. 54
ELMIRON ............................ 67
ELSPAR ................................ 22
EMCYT................................. 22
EMEND ................................ 34
EMSAM ................................ 28
EMTRIVA ............................ 37
enalapril maleate .................. 44
enalapril/hydrochlorothiazide
........................................... 44
enalaprilat dihydrate ............ 44
ENBREL ............................... 62
ENGERIX-B ADULT .......... 64
ENGERIX-B PEDIATRICADOLESCENT ................ 64
enoxaparin sodium ................ 39
entacapone ............................ 35
entecavir ................................ 39
ephedrine sulfate ................... 47
epinastine hcl ........................ 56
epinephrine ........................... 47
EPIPEN 2-PAK ..................... 47
EPIPEN JR 2-PAK ............... 47
epirubicin hcl ........................ 22
EPIVIR .................................. 37
EPIVIR HBV ........................ 37
eplerenone ............................. 49
EPOGEN ............................... 40
epoprostenol sodium (glycine)
........................................... 75
eprosartan mesylate .............. 44
EPZICOM ............................. 37
ERAXIS WATER DILUENT32
ERBITUX ............................. 22
ERGOMAR........................... 33
ERIVEDGE........................... 22
ERWINAZE .......................... 22
ery e-succ/sulfisoxazole ........ 18
ERY-TAB ............................. 18
ERYTHROCIN
LACTOBIONATE ...... 18, 19
erythromycin base ........... 19, 55
erythromycin base/ethanol .... 52
erythromycin ethylsuccinate . 19
erythromycin stearate ........... 19
erythromycin/benzoyl peroxide
........................................... 52
escitalopram oxalate ............. 28
esmolol hcl ............................ 46
esomeprazole sodium ............ 57
estazolam............................... 16
ESTRACE ............................. 59
estradiol ................................ 59
estradiol valerate .................. 59
estradiol/norethindrone acet . 59
ESTRASORB ....................... 59
ESTRING .............................. 59
estropipate............................. 59
ethambutol hcl ....................... 33
ethanolamine oleate .............. 47
ethinyl estradiol/drospirenone
........................................... 50
I-5
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
ethosuximide ......................... 26
ethynodiol d-ethinyl estradiol 50
etidronate disodium .............. 65
etodolac ................................. 14
ETOPOPHOS ....................... 22
etoposide ............................... 22
EURAX ................................. 53
EXELDERM ......................... 32
EXELON............................... 28
exemestane ............................ 22
EXFORGE ............................ 48
EXFORGE HCT ................... 48
EXJADE ............................... 59
EXTAVIA ............................. 67
FABRAZYME ...................... 54
FACTIVE .............................. 20
famciclovir ............................ 39
famotidine ............................. 57
famotidine in nacl,iso-osm/pf 57
FANAPT ............................... 36
FARESTON .......................... 22
FASLODEX .......................... 22
FAZACLO ............................ 36
felbamate ............................... 26
felodipine............................... 48
FEMRING............................. 59
fenofibrate ............................. 48
fenofibrate nanocrystallized.. 48
fenofibrate,micronized .......... 48
fenofibric acid ....................... 48
fenofibric acid (choline) ........ 48
fenoprofen calcium................ 14
fentanyl .................................. 12
fentanyl citrate ...................... 12
FERRIPROX......................... 59
FETZIMA ............................. 28
finasteride ............................. 67
FIRAZYR ............................. 47
FIRMAGON ......................... 22
flavoxate hcl .......................... 58
FLEBOGAMMA .................. 62
FLEBOGAMMA DIF ........... 62
flecainide acetate .................. 45
FLECTOR ............................. 14
Epektibo: Nobyembre 1, 2014
FLEXBUMIN ....................... 41
FLOVENT DISKUS ............. 73
FLOVENT HFA ................... 73
floxuridine ............................. 22
fluconazole ............................ 32
fluconazole in nacl,iso-osm... 32
flucytosine ............................. 32
fludarabine phosphate .......... 22
fludrocortisone acetate ......... 60
flumazenil .............................. 50
flunisolide.............................. 73
fluocinonide........................... 53
fluorometholone .................... 56
FLUOROPLEX..................... 51
fluorouracil ..................... 22, 51
fluoxetine hcl ......................... 28
fluoxymesterone .................... 59
fluphenazine decanoate ......... 36
fluphenazine hcl .................... 36
flurazepam hcl ....................... 16
flurbiprofen ........................... 14
flurbiprofen sodium............... 56
flutamide ............................... 22
fluticasone propionate .... 53, 73
fluvastatin sodium ................. 48
fluvoxamine maleate ............. 28
FOLOTYN ............................ 22
fomepizole ............................. 67
fondaparinux sodium ............ 39
FORADIL ............................. 73
FORTEO ............................... 66
FORTICAL ........................... 66
foscarnet sodium ................... 38
fosinopril sodium .................. 44
fosinopril/hydrochlorothiazide
........................................... 45
fosphenytoin sodium.............. 26
FOSRENOL .......................... 58
FREAMINE HBC ................. 42
FREAMINE III ..................... 42
fructose 10% ......................... 42
FULYZAQ ............................ 57
furosemide ............................. 48
FUROXONE ......................... 17
FUSILEV .............................. 67
FUZEON ............................... 37
FYCOMPA ........................... 26
gabapentin............................. 26
GABITRIL ............................ 26
galantamine hbr .................... 28
GALZIN ................................ 59
GAMASTAN S-D ................ 62
GAMMAGARD LIQUID ..... 62
GAMMAPLEX ..................... 62
GAMUNEX-C ...................... 62
ganciclovir sodium ................ 39
GARDASIL .......................... 64
gatifloxacin ........................... 55
gauze bandage ...................... 67
GAZYVA .............................. 22
GELNIQUE .......................... 58
gemcitabine hcl ..................... 22
gemfibrozil ............................ 48
GENOTROPIN ..................... 61
gentamicin in nacl, iso-osm .. 16
gentamicin sulfate ..... 16, 52, 55
gentamicin sulfate/pf ............. 16
GEODON .............................. 36
GILENYA ............................. 67
GILOTRIF ............................ 22
GLEEVEC ............................ 22
glimepiride ............................ 31
glipizide ................................. 31
glipizide/metformin hcl ......... 31
GLUCAGEN......................... 67
GLUCAGON EMERGENCY
KIT .................................... 67
glutethimide........................... 67
glyburide ............................... 31
glyburide,micronized ............ 31
glyburide/metformin hcl ........ 31
GLYCINE ............................. 65
glycopyrrolate ....................... 57
GLYSET ............................... 29
GRALISE .............................. 26
granisetron hcl ...................... 34
granisetron hcl/pf .................. 34
GRANIX ............................... 40
I-6
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
griseofulvin ultramicrosize ... 32
griseofulvin, microsize .......... 32
guanfacine hcl ....................... 44
guanidine hcl ......................... 67
H.P. ACTHAR ...................... 67
HALAVEN ........................... 22
HALFAN .............................. 34
halobetasol propionate ......... 53
haloperidol ............................ 36
haloperidol decanoate .......... 36
haloperidol lactate ................ 36
HAVRIX ............................... 64
heparin sod,pork in 0.45% nacl
........................................... 39
heparin sodium,porcine ........ 40
heparin sodium,porcine/d5w. 39
heparin sodium,porcine/ns/pf 39
heparin sodium,porcine/pf ... 39,
40
HEPATAMINE..................... 42
HEPATASOL ....................... 42
HERCEPTIN......................... 22
HEXALEN ............................ 23
homatropine hbr.................... 56
HUMALOG .......................... 30
HUMALOG MIX 50-50 ....... 30
HUMALOG MIX 75-25 ....... 30
HUMATROPE ...................... 61
HUMIRA ........................ 62, 63
HUMULIN 70-30 ................. 30
HUMULIN N ........................ 30
HUMULIN R ........................ 30
hydralazine hcl ...................... 47
hydralazine/hydrochlorothiazid
........................................... 47
hydrochlorothiazide .............. 48
hydrocodone/acetaminophen 12
hydrocodone/ibuprofen ......... 13
hydrocortisone ................ 53, 60
hydrocortisone acetate .......... 53
hydrocortisone acetate/aloe v 53
hydrocortisone acetate/urea . 53
hydrocortisone butyrate ........ 53
hydrocortisone sod succinate 60
Epektibo: Nobyembre 1, 2014
hydrocortisone valerate ........ 53
hydromorphone hcl ............... 13
hydromorphone hcl/pf ........... 13
hydroxychloroquine sulfate ... 34
hydroxyurea .......................... 23
hydroxyzine hcl ..................... 67
hydroxyzine pamoate ............ 67
HYPERLYTE CR ................. 70
HYPERLYTE R.................... 70
HYPERRAB S-D .................. 63
HYPERRHO S-D.................. 63
ibandronate sodium .............. 66
ibuprofen ............................... 14
ibuprofen/oxycodone hcl ....... 13
ICLUSIG ............................... 23
idarubicin hcl ........................ 23
ifosfamide .............................. 23
ifosfamide/mesna................... 23
ILARIS .................................. 63
ILEVRO ................................ 56
IMBRUVICA ........................ 23
imipenem/cilastatin sodium .. 19
imipramine hcl ...................... 28
imipramine pamoate ............. 28
imiquimod ............................. 51
IMOGAM RABIES-HT........ 63
IMOVAX RABIES VACCINE
........................................... 64
INCIVEK .............................. 38
INCRELEX ........................... 61
indapamide............................ 48
indomethacin ......................... 14
indomethacin sodium ............ 14
INFANRIX DTAP ................ 64
INFANRIX PF ...................... 64
INLYTA ................................ 23
INTELENCE......................... 37
INTRALIPID ........................ 42
INTRON A............................ 38
INTUNIV .............................. 50
INVANZ ............................... 19
INVEGA ............................... 36
INVEGA SUSTENNA ......... 36
INVIRASE ............................ 37
INVOKAMET ...................... 29
INVOKANA ......................... 29
IONOSOL B with DEXTROSE
5% ..................................... 70
IONOSOL MB-DEXTROSE
5% ..................................... 70
IONOSOL T-DEXTROSE 5%
........................................... 70
IPOL ...................................... 64
ipratropium bromide ............. 73
IPRIVASK ............................ 40
irbesartan .............................. 44
irbesartan/hydrochlorothiazide
........................................... 44
irinotecan hcl ........................ 23
ISENTRESS .......................... 37
ISOLYTE E .......................... 70
ISOLYTE H W/DEXTROSE 70
ISOLYTE M W/DEXTROSE70
ISOLYTE P with DEXTROSE
........................................... 70
ISOLYTE R W/DEXTROSE 70
ISOLYTE S ........................... 70
ISOLYTE S with DEXTROSE
........................................... 70
isoniazid ................................ 33
isopropamide/prochlorperazine
........................................... 57
ISOPTO CARPINE .............. 69
ISOPTO HOMATROPINE .. 56
isosorbide dinitrate ............... 49
isosorbide mononitrate ......... 49
ISOVEX ................................ 75
isradipine .............................. 48
ISTALOL .............................. 69
ISTODAX ............................. 23
itraconazole........................... 32
IXEMPRA............................. 23
IXIARO................................. 64
JAKAFI ................................. 23
JALYN .................................. 67
JANUMET ............................ 29
JANUMET XR ..................... 29
JANUVIA ............................. 29
I-7
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
JENTADUETO ..................... 29
JE-VAX................................. 64
JEVTANA............................. 23
JUVISYNC ........................... 30
KABIVEN............................. 43
KADCYLA ........................... 23
KALBITOR .......................... 67
KALETRA ............................ 37
KALYDECO......................... 74
kanamycin sulfate.................. 16
KEDBUMIN ......................... 41
KEPIVANCE ........................ 51
KETEK ................................. 19
ketoconazole .......................... 32
ketoprofen ............................. 14
ketorolac tromethamine .. 14, 56
KHEDEZLA ......................... 28
KINERET ............................. 63
KINRIX................................. 64
KORLYM ............................. 30
K-PHOS NO.2 ...................... 70
KRYSTEXXA ...................... 54
KUVAN ................................ 54
KYNAMRO .......................... 49
KYPROLIS ........................... 23
labetalol hcl .......................... 46
LACRISERT ......................... 56
LACTATED RINGERS ....... 65
lactulose ................................ 57
LAMICTAL .......................... 26
LAMICTAL ODT ................. 26
LAMICTAL ODT BLUE ..... 26
LAMICTAL ODT GREEN .. 26
LAMICTAL ODT ORANGE 26
lamivudine ............................. 37
lamivudine/zidovudine .......... 37
lamotrigine ............................ 26
LANOXIN ............................ 47
lansoprazole .......................... 57
lansoprazole/amoxiciln/clarith
........................................... 57
LANTUS ............................... 30
LANTUS SOLOSTAR ......... 30
latanoprost ............................ 69
Epektibo: Nobyembre 1, 2014
LATUDA .............................. 36
LAZANDA ........................... 13
leflunomide............................ 63
LETAIRIS ............................. 75
letrozole................................. 23
leucovorin calcium ................ 67
LEUKERAN ......................... 23
LEUKINE ............................. 40
leuprolide acetate.................. 23
LEVEMIR ............................. 30
LEVEMIR FLEXPEN .......... 30
levetiracetam ......................... 26
levetiracetam in nacl (iso-os) 26
levobunolol hcl ...................... 69
levocarnitine ......................... 67
levocarnitine (with sugar) ..... 67
levocetirizine dihydrochloride
........................................... 33
levofloxacin ..................... 20, 55
levofloxacin/d5w ................... 20
levonorgestrel ....................... 50
levonorgestrel-ethin estradiol 50
levorphanol tartrate .............. 13
levothyroxine sodium ............ 62
LEVULAN ............................ 51
LEXIVA ................................ 37
lidocaine ................................ 15
lidocaine hcl .......................... 15
lidocaine hcl/d5w/pf .............. 45
lidocaine hcl/pf................ 15, 45
lidocaine/prilocaine .............. 15
LIDODERM ......................... 15
LINZESS............................... 54
liothyronine sodium .............. 62
lipase/protease/amylase ........ 54
LIPOSYN II .......................... 43
LIPOSYN III ......................... 43
lisinopril ................................ 45
lisinopril/hydrochlorothiazide
........................................... 45
lithium carbonate .................. 50
lithium citrate ........................ 50
LITHOSTAT......................... 67
l-norgest-eth estr/ethin estra . 50
LOCOID ............................... 53
lomustine ............................... 23
loperamide hcl ...................... 57
lorazepam.............................. 16
losartan potassium ................ 44
losartan/hydrochlorothiazide 44
LOTEMAX ........................... 56
LOTRONEX ......................... 54
lovastatin ............................... 49
loxapine succinate ................. 36
LOZI-FLUR .......................... 76
LUMIGAN ............................ 69
LUMINAL SODIUM ........... 26
LUMIZYME ......................... 54
LUPRON DEPOT ................. 23
LUPRON DEPOT-PED ........ 23
LYRICA ................................ 26
LYSODREN ......................... 23
mafenide acetate ................... 51
magnesium chloride .............. 70
magnesium sulfate................. 70
magnesium sulfate in water .. 70
magnesium sulfate/d5w ......... 70
malathion .............................. 54
mannitol/sorbitol solution ..... 65
maprotiline hcl ...................... 28
MARPLAN ........................... 29
MARQIBO ............................ 23
MATULANE ........................ 23
MAXAIR AUTOHALER ..... 73
meclizine hcl.......................... 34
medroxyprogesterone acet .... 61
medroxyprogesterone acetate
..................................... 61, 62
mefenamic acid ..................... 14
mefloquine hcl ....................... 34
MEGACE ES ........................ 23
megestrol acetate .................. 23
MEKINIST ..................... 23, 24
meloxicam ....................... 14, 15
melphalan hcl ........................ 24
MENACTRA ........................ 64
MENEST............................... 60
MENHIBRIX ........................ 64
I-8
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
MENOMUNE-A-C-Y-W-135
........................................... 64
MENVEO A-C-Y-W-135-DIP
........................................... 64
mercaptopurine ..................... 24
meropenem ............................ 19
mesna .................................... 67
MESNEX .............................. 67
MESTINON .......................... 67
metaproterenol sulfate .......... 73
metaxalone ............................ 74
metformin hcl ........................ 30
methadone hcl ....................... 13
methazolamide ...................... 69
methenamine hippurate ......... 17
methimazole .......................... 62
methocarbamol ..................... 74
methotrexate sodium ............. 24
methotrexate sodium/pf ......... 24
methoxsalen, rapid ................ 52
methscopolamine bromide .... 58
methyclothiazide ................... 48
methylene blue ...................... 67
methylergonovine maleate .... 67
methylphenidate hcl .............. 50
methylprednisolone ............... 60
methylprednisolone acetate .. 60
methylprednisolone sod succ 60
metipranolol .......................... 69
metoclopramide hcl ............... 58
metolazone ............................ 48
metoprolol succinate ............. 46
metoprolol tartrate ................ 46
metoprolol/hydrochlorothiazide
........................................... 46
metronidazole ............ 33, 35, 52
metronidazole/sodium chloride
........................................... 34
METVIXIA ........................... 52
mexiletine hcl ........................ 45
MIACALCIN ........................ 66
miconazole nitrate ................. 33
MICRHOGAM ULTRAFILTERED PLUS ............. 63
Epektibo: Nobyembre 1, 2014
midazolam hcl ....................... 16
midazolam hcl/pf ................... 16
midodrine hcl ........................ 44
milrinone lactate ................... 47
milrinone lactate/d5w ........... 47
MINOCIN ............................. 20
minocycline hcl ..................... 20
minoxidil ............................... 49
mirtazapine ........................... 29
misoprostol............................ 57
mitomycin .............................. 24
mitoxantrone hcl ................... 24
M-M-R II VACCINE ............ 64
MOBAN ................................ 36
modafinil ............................... 74
moexipril hcl ......................... 45
moexipril/hydrochlorothiazide
........................................... 45
mometasone furoate .............. 53
montelukast sodium ............... 73
morphine sulfate.................... 13
MORPHINE SULFATE ....... 13
morphine sulfate/0.9% nacl/pf
........................................... 13
morphine sulfate/pf ............... 13
MOVIPREP .......................... 58
MOXEZA ............................. 55
moxifloxacin hcl .................... 20
MOZOBIL ............................ 40
MULTAQ ............................. 45
mupirocin .............................. 52
mupirocin calcium ................ 52
MUSTARGEN...................... 24
mycophenolate mofetil .......... 63
mycophenolate sodium .......... 63
MYOBLOC........................... 67
MYOZYME .......................... 54
MYTELASE ......................... 67
na nitrite/na thiosul/amyl nit. 59
nabumetone ........................... 15
nadolol .................................. 46
NAFCILL IN DEXTROSE... 19
nafcillin sodium..................... 19
NAGLAZYME ..................... 54
nalbuphine hcl ....................... 13
nalidixic acid ......................... 20
naloxone hcl .......................... 15
naltrexone hcl........................ 15
NAMENDA .......................... 28
NAMENDA XR.................... 28
naphazoline hcl/antazoline ... 56
naproxen ............................... 15
naproxen sodium ................... 15
naratriptan hcl ...................... 33
NASONEX ........................... 73
NATACYN ........................... 55
nateglinide............................. 30
NEBUPENT .......................... 35
needles, insulin disposable.... 54
nefazodone hcl ...................... 29
neo/polymyx b sulf/dexameth 55
neomy sulf/bacitra/polymyxin b
........................................... 55
neomy sulf/bacitrac zn/poly/hc
........................................... 55
neomy sulf/polymyxin b sulfate
........................................... 52
neomycin sulfate.................... 16
neomycin sulfate/dex na ph ... 55
neomycin/polymyxin b sulf/hc 55
neomycin/polymyxn b/
gramicidin ......................... 55
neostigmine methylsulfate ..... 67
NEPHRAMINE .................... 43
NEULASTA ......................... 40
NEUMEGA........................... 40
NEUPOGEN ......................... 40
NEUPRO............................... 35
NEVANAC ........................... 56
nevirapine ............................. 37
NEXAVAR ........................... 24
niacin..................................... 49
nicardipine hcl ...................... 48
NICOTROL .......................... 15
nifedipine............................... 48
NILANDRON ....................... 24
NITRO-BID .......................... 49
nitrofurantoin ........................ 17
I-9
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
nitrofurantoin macrocrystal .. 17
nitroglycerin .......................... 49
nitroglycerin/d5w .................. 49
NITROSTAT ........................ 49
nizatidine ............................... 57
NORDITROPIN ................... 61
NORDITROPIN FLEXPRO . 61
NORDITROPIN NORDIFLEX
........................................... 61
norelgestromin/ethin.estradiol
........................................... 50
norepinephrine bitartrate...... 47
noreth-ethinyl estradiol/iron . 50
norethindrone ........................ 51
norethindrone acetate ........... 62
norethindrone ac-eth estradiol
..................................... 51, 60
norethindrone-e.estradiol-iron
........................................... 51
norethindrone-ethinyl estrad 51
norethindrone-mestranol ...... 51
norgestimate-ethinyl estradiol
........................................... 51
norgestrel-ethinyl estradiol ... 51
NORMOSOL-M and
DEXTROSE ...................... 70
NORMOSOL-R PH 7.4 ........ 70
NOROXIN ............................ 20
nortriptyline hcl .................... 29
NORVIR ............................... 37
NOVAMINE ......................... 43
NOVAREL ........................... 61
NOVOLIN 70-30 .................. 30
NOVOLIN N ........................ 30
NOVOLIN R ......................... 30
NOVOLOG ........................... 31
NOVOLOG FLEXPEN ........ 30
NOVOLOG MIX 70-30 ........ 31
NOVOLOG MIX 70-30
FLEXPEN ......................... 30
NOXAFIL ............................. 32
NPLATE ............................... 68
NUCYNTA ........................... 13
NUCYNTA ER ..................... 13
Epektibo: Nobyembre 1, 2014
NUEDEXTA ......................... 50
NULOJIX .............................. 63
NUTRESTORE..................... 58
NUTRILYTE ........................ 70
NUTRILYTE II .................... 70
NUTROPIN .......................... 61
NUTROPIN AQ.................... 61
NUTROPIN AQ NUSPIN .... 61
NUVARING ......................... 51
nylidrin hcl ............................ 49
nystatin .................................. 32
nystatin/triamcin ................... 32
OCTAGAM .......................... 63
octreotide acetate .................. 61
OFIRMEV............................. 13
ofloxacin .......................... 20, 55
olanzapine ............................. 36
olanzapine/fluoxetine hcl ...... 29
OLYSIO ................................ 38
omega-3 acid ethyl esters...... 49
omeprazole ............................ 57
OMNITROPE ....................... 61
ONCASPAR ......................... 24
ondansetron........................... 34
ondansetron hcl ..................... 34
ONFI ..................................... 16
ONTAK................................. 24
OPSUMIT ............................. 75
ORAP .................................... 36
ORENCIA ............................. 63
ORENITRAM ER ................. 47
ORFADIN ............................. 54
ORTHO EVRA ..................... 51
OTEZLA ............................... 68
oxacillin sodium .................... 19
oxacillin sodium/dextrose,iso 19
oxaliplatin ............................. 24
oxandrolone .......................... 59
oxcarbazepine ....................... 26
OXSORALEN-ULTRA ........ 52
OXTELLAR XR ................... 26
oxybutynin chloride ............... 58
oxycodone hcl.................. 13, 14
oxycodone hcl/acetaminophen
........................................... 13
oxycodone hcl/aspirin ........... 13
OXYCONTIN ....................... 14
oxymorphone hcl ................... 14
OXYTROL ........................... 58
paclitaxel ............................... 24
pamidronate disodium .......... 66
PANCREAZE ....................... 54
PANRETIN ........................... 52
pantoprazole sodium ............. 57
papaverine hcl ....................... 47
paregoric ............................... 58
paricalcitol ............................ 66
paromomycin sulfate ............. 35
paroxetine hcl........................ 29
PASER .................................. 33
PATADAY ........................... 56
PATANOL ............................ 56
PAXIL ................................... 29
pedi m.vit no.17 with fluoride 76
pedi mvi no.12/sodium fluoride
........................................... 76
PEDIARIX ............................ 64
PEDVAXHIB ....................... 64
peg 3350/na sulf,bicarb,cl/kcl58
PEGANONE ......................... 26
PEGASYS ............................. 38
PEGASYS PROCLICK ........ 38
PEGINTRON ........................ 38
PEGINTRON REDIPEN ...... 38
pen g pot/dextrose-water....... 19
penicillin g potassium ........... 19
penicillin g potassium/d5w ... 19
penicillin g procaine ............. 19
penicillin v potassium ........... 19
PENTACEL .......................... 64
PENTACEL ACTHIB
COMPONENT .................. 64
PENTACEL DTAP-IPV
COMPONENT .................. 64
PENTAM 300 ....................... 35
pentamidine isethionate ........ 35
pentostatin ............................. 24
I-10
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
pentoxifylline ......................... 40
p-epd tan/chlor-tan ............... 33
PERIKABIVEN .................... 43
perindopril erbumine ............ 45
PERJETA .............................. 24
permethrin ............................. 54
perphenazine ......................... 36
perphenazine/amitriptyline hcl
........................................... 29
PERTZYE ............................. 54
phenelzine sulfate .................. 29
phenobarbital ........................ 27
phenobarbital sodium ........... 27
phentolamine mesylate .......... 75
phenylephrine hcl ............ 44, 56
PHENYTEK ......................... 27
phenytoin ............................... 27
phenytoin sodium .................. 27
phenytoin sodium extended ... 27
PHOSLYRA ......................... 58
PHOSPHOLINE IODIDE .... 69
phosphorus #1 ....................... 70
physostigmine salicylate ....... 68
PICATO ................................ 52
pilocarpine hcl ................ 51, 69
PILOPINE HS ....................... 69
pindolol ................................. 46
pioglitazone hcl ..................... 31
pioglitazone hcl/glimepiride . 31
pioglitazone hcl/metformin hcl
........................................... 31
piperacillin sodium/tazobactam
........................................... 20
piroxicam .............................. 15
PLASBUMIN-25 .................. 41
PLASBUMIN-5 .................... 41
PLASMA-LYTE 148 ............ 70
PLASMA-LYTE 56 IN
DEXTROSE ...................... 70
PLASMA-LYTE A PH 7.4 ... 70
PLASMA-LYTE M IN
DEXTROSE ...................... 71
pnv with ca,no.72/iron/fa ...... 76
podofilox ............................... 52
Epektibo: Nobyembre 1, 2014
podophyllum resin ................. 52
polyethylene glycol 3350....... 58
polymyxin b sulf/trimethoprim
........................................... 55
polymyxin b sulfate ............... 17
POMALYST ......................... 24
pot chloride/pot bicarb/cit ac 71
potassium acetate .................. 71
potassium bicarbonate/cit ac 71
potassium chlorid/d100.2%nacl ........................... 71
potassium chloride ................ 71
potassium chloride in 0.9%nacl
........................................... 71
potassium chloride in d5w .... 71
potassium chloride in lr-d5 ... 71
potassium chloride/d50.2%nacl ........................... 71
potassium chloride/d5-0.25ns 71
potassium chloride/d50.3%nacl ........................... 71
potassium chloride/d5-0.45nacl
........................................... 71
potassium chloride/d50.9%nacl ........................... 71
potassium chloride-0.45% nacl
........................................... 71
potassium citrate/citric acid . 71
potassium gluconate.............. 71
potassium hydroxide ............. 52
potassium phos,m-basic-d-basic
........................................... 71
POTIGA ................................ 27
PRADAXA ........................... 40
PRALIDOXIME CHLORIDE
........................................... 68
pramipexole di-hcl ................ 35
PRANDIMET ....................... 30
pravastatin sodium ................ 49
prazosin hcl ........................... 44
prednicarbate ........................ 53
prednisolone .......................... 60
prednisolone acetate ....... 56, 60
prednisolone sod phosphate . 56,
60
prednisone ............................. 60
PREDNISONE INTENSOL . 60
PREMARIN .......................... 60
PREMASOL ......................... 43
PREMPHASE ....................... 60
PREMPRO ............................ 60
PREZISTA ...................... 37, 38
PRIFTIN ............................... 33
PRIMAQUINE ..................... 35
primidone .............................. 27
PRISTIQ ER ......................... 29
PRIVIGEN ............................ 63
PROAIR HFA ....................... 73
probenecid............................. 68
procainamide hcl .................. 45
PROCALAMINE .................. 43
prochlorperazine edisylate.... 34
prochlorperazine maleate ..... 34
PROCRIT .............................. 40
PROCYSBI ........................... 68
progesterone ......................... 62
progesterone,micronized ....... 62
PROGLYCEM ...................... 49
PROGRAF ............................ 63
PROLENSA .......................... 56
PROLEUKIN ........................ 24
PROLIA ................................ 66
PROMACTA ........................ 40
promethazine hcl ............. 33, 34
PRONESTYL ....................... 45
propafenone hcl .................... 45
propantheline bromide .......... 26
proparacaine hcl ................... 56
proparacaine/fluorescein sod 56
propranolol hcl ..................... 46
propranolol/hydrochlorothiazid
........................................... 46
propylthiouracil .................... 62
PROQUAD ........................... 64
PROSOL ............................... 43
PROSTIGMIN ...................... 68
protamine sulfate .................. 40
I-11
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
PROTOPAM CHLORIDE.... 68
PROTOPIC ........................... 53
protriptyline hcl .................... 29
PULMOZYME ..................... 54
PURIXAN ............................. 24
pyridostigmine bromide ........ 68
QNASL ................................. 73
QUDEXY XR ....................... 27
quetiapine fumarate .............. 36
QUICK MIX with LYTES.... 43
QUILLIVANT XR................ 50
quinapril hcl .......................... 45
quinapril/hydrochlorothiazide
........................................... 45
quinidine gluconate ............... 45
quinidine sulfate .................... 45
quinine sulfate ....................... 35
QVAR ................................... 73
RABAVERT ......................... 64
raloxifene hcl ........................ 60
ramipril ................................. 45
RANEXA .............................. 47
ranitidine hcl ......................... 57
RAPAMUNE ........................ 63
RAVICTI .............................. 58
RAYOS ................................. 60
REBIF ................................... 68
REBIF REBIDOSE ............... 68
RECOMBIVAX HB ............. 64
REGONOL ........................... 68
REGRANEX ......................... 52
RELENZA ............................ 38
RELISTOR ........................... 58
REMICADE .......................... 68
REMODULIN....................... 75
RENAGEL ............................ 58
RENVELA ............................ 58
repaglinide ............................ 30
RESCRIPTOR ...................... 38
RESTASIS ............................ 56
RETROVIR........................... 38
REVATIO ............................. 75
REVLIMID ........................... 24
REYATAZ ............................ 38
Epektibo: Nobyembre 1, 2014
RHOGAM ULTRAFILTERED PLUS ............. 63
RHOPHYLAC ...................... 63
ribavirin ................................ 39
RIDAURA ............................ 63
rifabutin................................. 33
rifampin ................................. 33
RIFATER .............................. 34
riluzole .................................. 50
rimantadine hcl ..................... 38
ringers solution ............... 65, 71
risedronate sodium................ 66
RISPERDAL CONSTA ........ 36
risperidone ............................ 36
RITUXAN............................. 24
rivastigmine tartrate ............. 28
rizatriptan benzoate .............. 33
ropinirole hcl ........................ 35
ROTARIX ............................. 64
ROTATEQ ............................ 64
ROZEREM ........................... 74
SABRIL ................................ 27
SAIZEN ................................ 61
salsalate ................................ 15
SANDOSTATIN LAR.......... 61
SANTYL ............................... 52
SAPHRIS .............................. 36
SAVELLA ............................ 50
selegiline hcl ......................... 35
selenium sulfide ..................... 52
SELZENTRY ........................ 38
SENSIPAR ............................ 68
SEREVENT DISKUS ........... 73
SEROMYCIN ....................... 34
SEROQUEL XR ................... 36
SEROSTIM ........................... 61
sertraline hcl ......................... 29
SHOHL'S MODIFIED .......... 71
SIGNIFOR ............................ 68
sildenafil citrate .................... 75
SILENOR .............................. 29
silver nitrate .......................... 52
silver nitrate applicator ........ 52
silver sulfadiazine ................. 52
SIMBRINZA......................... 69
SIMPONI .............................. 68
SIMPONI ARIA ................... 68
SIMULECT........................... 68
simvastatin ............................ 49
sirolimus................................ 63
SIRTURO ............................. 34
sod propion/inositol/aa14/urea
........................................... 33
sod/pot/k cit/sod cit/cit acid .. 71
sodium acetate ...................... 71
sodium bicarbonate............... 71
sodium chloride............... 71, 72
sodium chloride 0.45 % ........ 71
sodium chloride 3% .............. 71
sodium chloride 5% .............. 71
sodium chloride irrig solution
........................................... 65
sodium chloride/nahco3/kcl/peg
........................................... 58
sodium lactate ....................... 72
SODIUM LACTATE............ 72
sodium morrhuate ................. 68
sodium phenylbutyrate .......... 58
sodium phos,m-basic-d-basic 72
sodium polystyrene sulfonate 58
sodium tetradecyl sulfate ...... 68
sodium thiosulfate ................. 59
SOLIRIS ............................... 68
SOLTAMOX ........................ 24
SOLU-CORTEF ................... 60
SOLU-MEDROL .................. 60
SOMATULINE DEPOT ....... 61
SOMAVERT......................... 61
sorbitol solution .................... 65
sotalol hcl .............................. 46
SOTALOL HCL ................... 46
SOVALDI ............................. 39
spinosad ................................ 54
SPIRIVA ............................... 73
spironolact/hydrochlorothiazid
........................................... 49
spironolactone....................... 49
SPORANOX ......................... 32
I-12
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
SPRYCEL ............................. 24
stavudine ............................... 38
STELARA............................. 68
STERILE DILUENT ............ 41
STIMATE ............................. 61
STIVARGA .......................... 24
STRATTERA ....................... 50
streptomycin sulfate .............. 16
STRIBILD............................. 38
STROMECTOL .................... 35
SUBOXONE ......................... 15
sucralfate............................... 57
sulfacetamide sodium ...... 52, 55
sulfacetamide/prednisolone sp
........................................... 55
sulfadiazine ........................... 20
sulfamethoxazole/trimethoprim
........................................... 20
sulfasalazine.......................... 20
sulindac ................................. 15
sumatriptan ........................... 33
sumatriptan succinate ........... 33
SUPPRELIN LA ................... 61
SUPRAX ............................... 18
SUSTIVA .............................. 38
SUTENT ............................... 24
SYLATRON 4-PACK .......... 38
SYLVANT ............................ 24
SYMBICORT ....................... 73
SYMLIN ............................... 30
SYMLINPEN 120 ................. 30
SYMLINPEN 60 ................... 30
SYNAGIS ............................. 38
SYNAREL ............................ 68
SYNERCID........................... 17
SYNRIBO ............................. 24
SYPRINE .............................. 59
syring w-ndl,disp,insul,0.3ml 54
syring w-ndl,disp,insul,0.5ml 54
syring w-o ndl,disp,insul, 1ml 54
TABLOID ............................. 24
tacrolimus ............................. 63
TAFINLAR ........................... 24
TAMIFLU ............................. 38
Epektibo: Nobyembre 1, 2014
tamoxifen citrate ................... 24
tamsulosin hcl ....................... 75
TANZEUM ........................... 30
TARCEVA ............................ 25
TARGRETIN .................. 25, 53
TASIGNA ............................. 25
TAZICEF IN DEXTROSE ... 18
TAZORAC ............................ 53
TE ANATOXAL BERNA .... 64
tea tree oil ............................. 18
TECFIDERA......................... 68
TEGRETOL XR ................... 27
telmisartan ............................ 44
telmisartan/hydrochlorothiazid
........................................... 44
temazepam............................. 16
TEMODAR ........................... 25
teniposide .............................. 25
TENIVAC ............................. 64
terazosin hcl .......................... 75
terbinafine hcl ....................... 32
terbutaline sulfate ................. 73
terconazole ............................ 33
testosterone cypionate ........... 59
testosterone enanthate .......... 59
TETANUS DIPHTHERIA
TOXOIDS ......................... 64
TETANUS TOXOID
ADSORBED ..................... 65
tetracaine hcl/pf .................... 56
tetracycline hcl ...................... 20
TEVETEN............................. 44
TEVETEN HCT.................... 44
TEV-TROPIN ....................... 61
THALOMID ......................... 68
theophylline anhydrous ......... 73
theophylline/d5w ................... 73
THERACYS ......................... 65
THERMAZENE ................... 52
thioridazine hcl ..................... 37
thiotepa ................................. 25
thiothixene ............................. 37
tiagabine hcl.......................... 27
TIKOSYN ............................. 45
timolol maleate................ 46, 69
tinidazole ............................... 35
TIVICAY .............................. 38
tizanidine hcl ......................... 74
TOBI PODHALER ............... 17
TOBRADEX ......................... 55
tobramycin in 0.225% nacl ... 17
tobramycin sulfate........... 17, 55
tobramycin/dexamethasone... 55
tobramycin/sodium chloride . 17
tolazamide ............................. 31
tolbutamide ........................... 31
tolmetin sodium ..................... 15
tolterodine tartrate ................ 58
topiramate ............................. 27
topotecan hcl ......................... 25
TORISEL .............................. 25
torsemide ............................... 48
TOVIAZ ................................ 58
TPN ELECTROLYTES........ 72
TRACLEER .......................... 75
TRADJENTA ....................... 30
tramadol hcl .......................... 14
tramadol hcl/acetaminophen 14
trandolapril ........................... 45
tranexamic acid ..................... 40
tranylcypromine sulfate ........ 29
TRAVAMULSION............... 43
TRAVASOL ......................... 43
TRAVASOL W/DEXTROSE
........................................... 43
TRAVASOL W/
ELECTROLYTES ............ 43
TRAVASOL with DEXTROSE
........................................... 43
TRAVASOL with
ELECTROLYTES ............ 43
TRAVATAN Z ..................... 69
TRAVERT ............................ 43
TRAVERT IN NORMAL
SALINE ............................ 43
TRAVERT-ELECTROLYTE
NO.1 .................................. 72
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Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
TRAVERT-ELECTROLYTE
NO.2 .................................. 72
TRAVERT-ELECTROLYTE
NO.3 .................................. 72
TRAVERT-ELECTROLYTE
NO.4 .................................. 72
travoprost (benzalkonium) .... 69
trazodone hcl ......................... 29
TREANDA ........................... 25
TRECATOR ......................... 34
TRELSTAR .......................... 25
tretinoin ........................... 25, 53
tretinoin microspheres .......... 53
TREXALL ............................ 25
triamcinolone acetonide. 51, 53,
60, 73
triamterene/hydrochlorothiazid
........................................... 48
triazolam ............................... 16
TRIBENZOR ........................ 44
trifluoperazine hcl ................. 37
trifluridine ............................. 55
trihexyphenidyl hcl ................ 35
TRILEPTAL ......................... 27
trimethoprim ......................... 17
trimipramine maleate ............ 29
tripelennamine hcl ................ 33
TRISENOX ........................... 25
TRIUMEQ ............................ 38
TROKENDI XR.................... 27
TROPHAMINE .................... 43
trospium chloride .................. 58
TRUVADA ........................... 38
TWINRIX ............................. 65
TYGACIL ............................. 20
TYKERB............................... 25
TYPHIM VI .......................... 65
TYSABRI ............................. 63
TYVASO .............................. 75
TYZEKA............................... 39
TYZINE ................................ 57
UCERIS ................................ 60
ULORIC ................................ 68
urologic solution-g ................ 65
Epektibo: Nobyembre 1, 2014
ursodiol ................................. 58
UVADEX .............................. 52
VAGIFEM ............................ 60
valacyclovir hcl ..................... 39
VALCHLOR ......................... 52
VALCYTE ............................ 39
valproic acid ......................... 27
valproic acid (as sodium salt)27
valsartan/hydrochlorothiazide
........................................... 44
VALSTAR ............................ 25
vancomycin hcl...................... 17
VANCOMYCIN HCL .......... 17
vancomycin hcl/d5w .............. 17
VANTAS .............................. 61
VAQTA................................. 65
VARIVAX VACCINE ......... 65
VASCEPA ............................ 49
vasopressin ............................ 61
VECAMYL ........................... 47
VECTIBIX ............................ 25
VELCADE ............................ 25
venlafaxine hcl ...................... 29
VENLAFAXINE HCL ER ... 29
VENTAVIS........................... 75
VENTOLIN HFA ................. 73
verapamil hcl ........................ 46
VEREGEN ............................ 52
VERSACLOZ ....................... 37
VESICARE ........................... 58
VICTOZA 3-PAK ................. 30
VICTRELIS .......................... 38
VIDEX .................................. 38
VIGAMOX ........................... 55
VIIBRYD .............................. 29
VIMIZIM .............................. 54
VIMPAT ............................... 27
vinblastine sulfate ................. 25
vincristine sulfate .................. 25
vinorelbine tartrate ............... 25
VIRACEPT ........................... 38
VIRAMUNE XR .................. 38
VIREAD ............................... 38
VIVELLE-DOT .................... 60
VOLTAREN ......................... 15
VORAXAZE......................... 69
voriconazole .......................... 32
VOTRIENT........................... 25
VPRIV................................... 54
VUMON ............................... 25
VYTORIN............................. 49
warfarin sodium .................... 40
water for irrigation,sterile .... 65
WELCHOL ........................... 49
WINRHO SDF ...................... 63
XALKORI............................. 25
XARELTO ............................ 40
XARTEMIS XR.................... 14
XELJANZ ............................. 69
XENAZINE .......................... 50
XERAC AC .......................... 52
XGEVA................................. 66
XIFAXAN............................. 17
XOLAIR ............................... 74
XTANDI ............................... 25
XYLOCAINE ....................... 45
XYREM ................................ 74
YERVOY .............................. 25
YF-VAX ............................... 65
zafirlukast.............................. 73
I-14
Satellite Health Plan (HMO SNP) 2014 Part D Formulary
Formulary ID: 14510.000, Version: 19
zaleplon ................................. 75
ZALTRAP............................. 25
ZANOSAR ............................ 25
ZAVESCA ............................ 54
ZELBORAF .......................... 25
ZEMAIRA ............................ 74
ZEMPLAR ............................ 66
ZENPEP ................................ 54
ZETIA ................................... 49
ZIAGEN ................................ 38
zidovudine ............................. 38
ZIOPTAN ............................. 69
ziprasidone hcl ...................... 37
ZIRGAN ............................... 55
ZOLADEX ............................ 25
zoledronic acid ...................... 66
zoledronic acid/
mannitol&water ................ 66
ZOLINZA ............................. 25
zolmitriptan ........................... 33
zolpidem tartrate ................... 75
ZOMETA .............................. 66
zonisamide............................. 27
ZORBTIVE ........................... 61
ZORTRESS........................... 63
ZOSTAVAX ......................... 65
ZOVIRAX............................. 52
ZUBSOLV ............................ 15
ZYCLARA ............................ 52
ZYDELIG ............................. 25
ZYKADIA ............................ 26
ZYLET .................................. 55
ZYPREXA RELPREVV ...... 37
ZYTIGA ................................ 26
ZYVOX................................. 17
Epektibo: Nobyembre 1, 2014
Ang pormularyong ito ay naisapanahon noong 10/25/2014. Para sa mas bagong impormasyon o iba pang
mga tanong, pakitawagan ang Satellite Health Plan sa 1-888-978-6095 o, para sa mga gumagamit ng TTY, 1800-735-2929, 8 a.m. – 8 p.m., 7 araw/linggo, o puntahan ang www.satellitehealthplan.com.
Ang Satellite Health Plan (HMO SNP) ay isang HMO Special Needs Plan na may kontrata sa Medicare. Ang
ibinigay na impormasyon tungkol sa benepisyo ay maikling buod, hindi kumpletong paglalarawan sa mga
benepisyo. Para sa karagdagang impormasyon tawagan ang Satellite Health Plan. Maaaring maipataw ang
mga limit, copayment, at paghihigpit. Ang mga benepisyo, at pormularyo ay maaaring magbago sa Enero 1
ng bawat taon.
H5765_14_PBM_10_001_RV1_TA Accepted 08272013