OptumHealth NM Medicare Part D Prescription Drug List
2013 Preferred Medicare Part D Drug List (PDL)
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June 2013
OptumHealth NM Medicare Part D Prescription Drug List Preface ............................................................................................................................................... 3 Central Nervous System Agents................................................................................................. 5 Migraine and Headache ............................................................................................................. 5 Gastrointestinal Agents ................................................................................................................ 5 Ulcer Treatment and Prevention ............................................................................................. 5 Musculoskeletal Agents ................................................................................................................ 5 Analgesics .................................................................................................................................... 5 Nutritional Supplements ............................................................................................................... 5 Electrolyte Replacements ......................................................................................................... 5 Vitamins ......................................................................................................................................... 5 Respiratory Agents ......................................................................................................................... 5 Antihistamines ............................................................................................................................. 5 Antitussives, Expectorants, and Mucolytics ....................................................................... 5 Index ................................................................................................................................................... 6
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June 2013
OptumHealth NM Medicare Part D Prescription Drug List Preface 2012 OptumHealth New Mexico Preferred Drug List (PDL) The OptumHealth New Mexico Preferred Drug List (PDL) is listed by therapeutic class and organized alphabetically by the brand name. An alphabetical index by drug name is listed at the end. The PDL is subject to change without notification. Medicaid does not cover drug items for recipients eligible for Medicare part D when the drug item or class of drug meets the federal definition of a Medicare part D covered drug. Medicaid does not cover any copayment due from the recipient towards a claim paid by Medicare part D nor any Medicare part D covered drug or class of drug where the recipient has a gap in Medicare part D coverage due to a Medicare coverage limit. Items or drug classes specifically excluded by Medicare part D are covered, non-covered or limited to the same extent that Medicaid covers the excluded drug items for full benefit Medicaid recipients who are not dual eligibles. Generic Substitution OptumHealth New Mexico has a “generic substitution required” policy. Substitution of a product for a brand name drug is mandatory when a U.S. Food and Drug Administration (FDA) approved generic equivalent is available. A generic equivalent drug is made with the exact same active ingredients at the same dose as the brand name drug. You can expect the generic equivalent to work the same as the brand name drug. For your convenience, we have bolded the drug that is covered. Edits/Limitations Some medications come in multiple formulations. The formulary lists which formulation is covered and if there are any restrictions to the amount that may be dispensed. If the provider feels the consumer needs a formulation that is not covered or will need more than the maximum allowed dispensed, they may submit a Prior Authorization. Prior Authorization and Pharmacy Exceptions Pharmacy Prior Authorizations are requests for coverage of drugs that are on the established PDL but must be approved prior to filling a prescription. Pharmacy exceptions are requests for coverage of drugs that are not on the established PDL; use of drugs on the established PDL that exceed edits/limitations; and/or use of drugs prior to meeting step therapy requirements. The form may be obtained on our website at https://www.optumhealthnewmexico.com/provider/pharmacy.html or by calling 1-866-6607182, option 6. To request a prior authorization or pharmacy exception, providers may complete and fax a prior authorization request form to 1-877-296-5955. The initial decision for all completed Prior Authorizations will be processed within two business days. The decision will be faxed back to the provider at the fax number provided on the form.
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June 2013
OptumHealth NM Medicare Part D Prescription Drug List Contact Information The OptumHealth New Mexico Pharmacy Services help desk is open Monday – Friday 8 am to 5 pm; closed on holidays and weekends. An after hours pharmacy help desk is available for assistance with prescriptions on weekends, outside of normal hours, and on holidays through Prescription Solutions by OptumRx. Consumers can call 1-866-660-7185 for questions. Providers and pharmacies can call 1-866-660-7182, option 6 for questions/assistance. The OptumHealth New Mexico Pharmacy Services fax number is 1-877-296-5955.
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June 2013
OptumHealth NM Medicare Part D Prescription Drug List OptumHealth New Mexico Medicare Part D Prescription Drug List Central Nervous System Agents Brand Name
Generic Name
Edits/ Limitations
Migraine and Headache APAP/butalbital/caffeine ASA/butalbital/caffeine
Fioricet Fiorinal
Tablets are covered Capsules are covered
Gastrointestinal Agents Ulcer Treatment and Prevention omeprazole delayed release
Promethazine VC/Codeine Robitussin AC Tessalon Perles
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Syrup is covered Syrup is covered Capsules are covered
June 2013
OptumHealth NM Medicare Part D Prescription Drug List Index A acetaminophen OTC ..................................................................................................... 5 APAP/butalbital/caffeine ............................................................................................... 5 ASA/butalbital/caffeine ................................................................................................. 5 aspirin OTC .................................................................................................................... 5 B B-complex with C and folic acid .................................................................................. 5 benzonatate ................................................................................................................... 5 C Claritin OTC ................................................................................................................... 5 codeine/guaifensen ....................................................................................................... 5 F Fioricet ........................................................................................................................... 5 Fiorinal ........................................................................................................................... 5 folic acid......................................................................................................................... 5 H homatropine/hydrocodone ........................................................................................... 5 Hycodan ......................................................................................................................... 5 K K-Lor............................................................................................................................... 5 K-Lyte/CL ....................................................................................................................... 5 L loratadine ....................................................................................................................... 5 M Mephyton ....................................................................................................................... 5 N Nephrocaps ................................................................................................................... 5 Nephro-vite .................................................................................................................... 5 O omeprazole delayed release......................................................................................... 5 P Phenergan DM ............................................................................................................... 5 Phenergan W/Codeine .................................................................................................. 5 phenylephrine-promethazine w/codeine ..................................................................... 5 phytonadione ................................................................................................................. 5 potassium bicarbonate/chloride .................................................................................. 5 potassium chloride powder packet 20 MEQ ............................................................... 5 Prilosec OTC.................................................................................................................. 5 promethazine DM .......................................................................................................... 5 Promethazine VC/Codeine............................................................................................ 5 promethazine w/codeine............................................................................................... 5 R Robitussin AC ............................................................................................................... 5
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June 2013
OptumHealth NM Medicare Part D Prescription Drug List T Tessalon Perles ............................................................................................................. 5 Tylenol OTC ................................................................................................................... 5
