2010 Medicare Part B And D Prior Approvals Band DPrior Approvals_Old_01062011 Old 01062011

User Manual: MedicarePartBandPartDPriorApprovals_Old_01062011

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GUILDNET GOLD HMO- POS SNP
2010 Medicare Part B and Part D Prior Approvals
This drug may be covered under Medicare Part B or D depending upon the circumstances.
Information may be needed to be submitted describing the use and setting of the drug to make
the determination.

MEDICATION NAME
ABELCET
ABRAXANE
ACCUNEB
ACETADOTE
ACETYLCYSTEINE
ACYCLOVIR SODIUM
ADAGEN
ADRIAMYCIN
ALBUTEROL SULFATE
ALBUTEROL SULFATE
ALCOHOL IN DEXTROSE
ALDURAZYME
ALIMTA
ALKERAN
ALLOPURINOL SODIUM
ALOPRIM
ALOXI
AMBISOME
A-METHAPRED
AMEVIVE
AMIKACIN SULFATE
AMIKIN
AMIKIN PEDIATRIC
AMINOPHYLLINE
AMINOSYN II 3.5% M-D5W
AMIODARONE HCL
AMMONIUM CHLORIDE
AMPHOTEC
AMPHOTERICIN B
AMPICILLIN SODIUM
AMPICILLIN-SULBACTAM
ANTIZOL
ANZEMET
ANZEMET
ARALAST

DOSAGE FORM
VIAL
VIAL
VIAL
VIAL
VIAL
VIAL
VIAL
VIAL
SOLUTION
VIAL
SOLUTION
VIAL
VIAL
VIAL
VIAL
VIAL
VIAL
VIAL
VIAL
VIAL
VIAL
VIAL
VIAL
VIAL
SOLUTION
AMPULE
VIAL
VIAL
VIAL
VIAL
VIAL
VIAL
TABLET
VIAL
VIAL

ROUTE
INTRAVENOUS
INTRAVENOUS
INHALATION
INTRAVENOUS
INHALATION
INTRAVENOUS
INTAMUSCULAR
INTRAVENOUS
INHALATION
INHALATION
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INJECTABLE
INTAMUSCULAR
INJECTABLE
INJECTABLE
INJECTABLE
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INJECTABLE
INJECTABLE
INJECTABLE
INTRAVENOUS
ORAL
INTRAVENOUS
INTRAVENOUS
1

GUILDNET GOLD HMO- POS SNP
2010 Medicare Part B and Part D Prior Approvals
This drug may be covered under Medicare Part B or D depending upon the circumstances.
Information may be needed to be submitted describing the use and setting of the drug to make
the determination.
MEDICATION NAME
ARCALYST
AREDIA
ARRANON
ASTRAMORPH-PF
ATROPINE SULFATE
AVASTIN
AVELOX IV
AZACTAM

DOSAGE FORM
VIAL
VIAL
VIAL
VIAL
SYRINGE
VIAL
SOLUTION
VIAL

ROUTE
SUBCUTANEOUS
INTRAVENOUS
INTRAVENOUS
INJECTABLE
INJECTABLE
INTRAVENOUS
INTRAVENOUS
INJECTABLE

AZACTAM-ISO-OSMOTIC
DEXTROSE
AZASAN
AZATHIOPRINE
AZATHIOPRINE SODIUM
AZITHROMYCIN
BACIIM
BENTYL
BENZTROPINE
BICNU
BLEOMYCIN SULFATE
BONIVA
BRETHINE
BUDESONIDE
BUMETANIDE
BUPRENORPHINE HCL
BUSULFEX
CALCIJEX
CALCITRIOL
CALCITRIOL
CAMPATH
CAMPTOSAR
CANCIDAS
CAPASTAT SULFATE
CARBOPLATIN
CARDENE I.V.
CARNITOR

SOLUTION
TABLET
TABLET
VIAL
VIAL
VIAL
AMPULE
VIAL
VIAL
VIAL
KIT
VIAL
SUSPENSION
VIAL
SYRINGE
VIAL
AMPULE
AMPULE
VIAL
VIAL
VIAL
VIAL
VIAL
VIAL
AMPULE
VIAL

INTRAVENOUS
ORAL
ORAL
INJECTABLE
INTRAVENOUS
INTAMUSCULAR
INTAMUSCULAR
INJECTABLE
INTRAVENOUS
INJECTABLE
INTRAVENOUS
SUBCUTANEOUS
INHALATION
INJECTABLE
INJECTABLE
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INJECTABLE
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
2

GUILDNET GOLD HMO- POS SNP
2010 Medicare Part B and Part D Prior Approvals
This drug may be covered under Medicare Part B or D depending upon the circumstances.
Information may be needed to be submitted describing the use and setting of the drug to make
the determination.
MEDICATION NAME
CEFAZOLIN SODIUM
CEFAZOLIN SODIUM
CEFEPIME HCL
CEFIZOX IN 5% DEXTROSE
CEFOTAXIME SODIUM
CEFOTETAN
CEFOXITIN
CEFOXITIN SODIUM
CEFTAZIDIME
CEFTRIAXONE
CEFTRIAXONE
CEFUROXIME
CEFUROXIME SODIUM
CELLCEPT
CELLCEPT
CELLCEPT
CEREBYX
CEREDASE
CEREZYME
CERUBIDINE

DOSAGE FORM
SOLUTION
VIAL
VIAL
SOLUTION
VIAL
VIAL
VIAL
SOLUTION
VIAL
SOLUTION
VIAL
SOLUTION
VIAL
CAPSULE
SUSPENSION
TABLET
VIAL
VIAL
VIAL
VIAL

ROUTE
INTRAVENOUS
INJECTABLE
INJECTABLE
INTRAVENOUS
INJECTABLE
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INJECTABLE
INTRAVENOUS
INJECTABLE
INTRAVENOUS
INJECTABLE
ORAL
ORAL
ORAL
INJECTABLE
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS

CHLORAMPHENICOL SOD
SUCCINATE
CHLOROTHIAZIDE SOD
CHORIONIC GONADOTROPIN
CIMETIDINE
CIMZIA
CIPRO I.V.
CIPROFLOXACIN
CISPLATIN
CLADRIBINE
CLAFORAN
CLAFORAN GALAXY
CLEOCIN PHOSPHATE
CLEOCIN PHOSPHATE IN D5W
CLINDAMYCIN PHOSPHATE

VIAL
VIAL
VIAL
VIAL
KIT
SOLUTION
VIAL
VIAL
VIAL
VIAL
SOLUTION
VIAL
SOLUTION
VIAL

INTRAVENOUS
INJECTABLE
INTAMUSCULAR
INJECTABLE
SUBCUTANEOUS
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INJECTABLE
INTRAVENOUS
INJECTABLE
INTRAVENOUS
INTRAVENOUS
3

GUILDNET GOLD HMO- POS SNP
2010 Medicare Part B and Part D Prior Approvals
This drug may be covered under Medicare Part B or D depending upon the circumstances.
Information may be needed to be submitted describing the use and setting of the drug to make
the determination.
MEDICATION NAME
CLOLAR
COLISTIMETHATE SODIUM
COLY-MYCIN M PARENTERAL
COSMEGEN
COUMADIN
CROMOLYN SODIUM
CUBICIN
CYCLOPHOSPHAMIDE
CYCLOPHOSPHAMIDE
CYCLOSPORINE
CYKLOKAPRON
CYSTADANE
CYTARABINE
CYTOVENE
CYTOXAN
D.H.E.45
DACARBAZINE
DACOGEN
DAUNORUBICIN HCL
DAUNOXOME
DDAVP
DELATESTRYL
DELESTROGEN
DEMADEX
DEMEROL
DEMEROL
DEPACON
DEPO-ESTRADIOL
DEPO-MEDROL
DEPO-PROVERA
DEPO-SUBQ PROVERA 104
DEPO-TESTOSTERONE
DESMOPRESSIN ACETATE

DOSAGE FORM
VIAL
VIAL
VIAL
VIAL
VIAL
AMPULE
VIAL
TABLET
VIAL
CAPSULE
AMPULE
POWDER
VIAL
VIAL
VIAL
AMPULE
VIAL
VIAL
VIAL
VIAL
AMPULE
VIAL
VIAL
AMPULE
SYRINGE
VIAL
VIAL
VIAL
VIAL
VIAL
SYRINGE
VIAL
VIAL

ROUTE
INTRAVENOUS
INJECTABLE
INJECTABLE
INTRAVENOUS
INTRAVENOUS
INHALATION
INTRAVENOUS
ORAL
INTRAVENOUS
ORAL
INTRAVENOUS
ORAL
INJECTABLE
INTRAVENOUS
INTRAVENOUS
INJECTABLE
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INJECTABLE
INTAMUSCULAR
INTAMUSCULAR
INTRAVENOUS
INJECTABLE
INJECTABLE
INTRAVENOUS
INTAMUSCULAR
INJECTABLE
INTAMUSCULAR
SUBCUTANEOUS
INTAMUSCULAR
INJECTABLE

DEXAMETHASONE SODIUM
PHOSPHATE

VIAL

INJECTABLE
4

GUILDNET GOLD HMO- POS SNP
2010 Medicare Part B and Part D Prior Approvals
This drug may be covered under Medicare Part B or D depending upon the circumstances.
Information may be needed to be submitted describing the use and setting of the drug to make
the determination.
MEDICATION NAME
DEXRAZOXANE
DEXTROSE 10%-1/4NS
DEXTROSE 10%-1/4NS-KCL
DEXTROSE 5%-1/2NS-KCL
DEXTROSE 5%-1/3NS-KCL
DEXTROSE 5%-1/4NS-KCL

DOSAGE FORM
VIAL
SOLUTION
SOLUTION
SOLUTION
SOLUTION
SOLUTION

ROUTE
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS

DEXTROSE 5%-ELECTROLYTE
#48
DEXTROSE 5%-LR
DEXTROSE 5%-NS-KCL

SOLUTION
SOLUTION
SOLUTION

INTRAVENOUS
INTRAVENOUS
INTRAVENOUS

DEXTROSE 5%-POTASSIUM
CHLORIDE
DEXTROSE IN WATER

SOLUTION
SOLUTION

INTRAVENOUS
INTRAVENOUS

DEXTROSE WITH SODIUM
CHLORIDE
DICYCLOMINE HCL
DIFLUCAN IN SALINE

SOLUTION
VIAL
BOTTLE

INTRAVENOUS
INTAMUSCULAR
INTRAVENOUS

DIHYDROERGOTAMINE
MESYLATE
DILAUDID
DILAUDID-HP
DILTIAZEM HCL
DIPHENHYDRAMINE HCL
DIURIL SODIUM
DORIBAX
DOXIL
DOXORUBICIN HCL
DOXYCYCLINE HYCLATE
DUONEB
DURAMORPH
ELAPRASE
ELIGARD
ELITEK
ELLENCE
ELOXATIN
ELSPAR

AMPULE
VIAL
VIAL
VIAL
VIAL
VIAL
VIAL
VIAL
VIAL
VIAL
AMPULE
AMPULE
VIAL
SYRINGE
VIAL
VIAL
VIAL
VIAL

INJECTABLE
INJECTABLE
INJECTABLE
INTRAVENOUS
INJECTABLE
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INHALATION
INJECTABLE
INTRAVENOUS
SUBCUTANEOUS
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INJECTABLE
5

GUILDNET GOLD HMO- POS SNP
2010 Medicare Part B and Part D Prior Approvals
This drug may be covered under Medicare Part B or D depending upon the circumstances.
Information may be needed to be submitted describing the use and setting of the drug to make
the determination.
MEDICATION NAME
EMEND
ENGERIX-B
ENGERIX-B
EPINEPHRINE
EPIRUBICIN HCL
ERAXIS
ERBITUX
ERYTHROCIN LACTOBIONATE
ETHYOL
ETOPOPHOS
ETOPOSIDE
FABRAZYME
FAMOTIDINE
FAMOTIDINE
FASLODEX
FENTANYL CITRATE
FIRMAGON
FLUCONAZOLE IN DEXTROSE
FLUDARA
FLUDARABINE PHOSPHATE
FLUOROURACIL
FOMEPIZOLE
FORTAZ

DOSAGE FORM
CAPSULE
SYRINGE
VIAL
SYRINGE
VIAL
VIAL
VIAL
VIAL
VIAL
VIAL
VIAL
VIAL
SOLUTION
VIAL
SYRINGE
SYRINGE
VIAL
SOLUTION
VIAL
VIAL
VIAL
VIAL
VIAL

ROUTE
ORAL
INTAMUSCULAR
INTAMUSCULAR
INJECTABLE
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INTAMUSCULAR
INJECTABLE
SUBCUTANEOUS
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INJECTABLE

FORTAZ IN ISO-OSMOTIC
DEXTROSE
FOSCARNET SODIUM
FOSCAVIR
FOSPHENYTOIN SODIUM
FUROSEMIDE
FUSILEV
GEMZAR
GENTAMICIN SULFATE IN NS
GEODON
GLYCOPYRROLATE
GRANISETRON HCL

SOLUTION
BOTTLE
CONCENTRATE
VIAL
VIAL
VIAL
VIAL
SOLUTION
VIAL
VIAL
TABLET

INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INJECTABLE
INJECTABLE
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INTAMUSCULAR
INJECTABLE
ORAL
6

GUILDNET GOLD HMO- POS SNP
2010 Medicare Part B and Part D Prior Approvals
This drug may be covered under Medicare Part B or D depending upon the circumstances.
Information may be needed to be submitted describing the use and setting of the drug to make
the determination.
MEDICATION NAME
GRANISETRON HCL
HECTOROL
HEPARIN SODIUM
HEPARIN SODIUM IN 0.9% NACL

DOSAGE FORM
VIAL
AMPULE
VIAL
SOLUTION

ROUTE
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS

HEPARIN SODIUM IN 5%
DEXTROSE
HEPARIN-1/2NS 25,000 UNIT/250
HEPARIN-1/2NS 25,000 UNIT/500
HEPARIN-NS 2,000 UNIT/1,000 ML
HYCAMTIN
HYDRALAZINE HCL
HYDROMORPHONE HCL
HYDROXYZINE HCL
IDAMYCIN PFS
IDARUBICIN HCL
IFEX
IFOSFAMIDE
IFOSFAMIDE-MESNA
IMURAN
INCRELEX
INFUMORPH
INNOHEP
INVANZ
INVEGA
IPRATROPIUM BROMIDE
IPRATROPIUM-ALBUTEROL
IRINOTECAN HCL
IXEMPRA
KANAMYCIN SULFATE
KYTRIL
KYTRIL
LABETALOL HCL
LACTATED RINGERS
LANOXIN
LANOXIN PEDIATRIC

SOLUTION
SOLUTION
SOLUTION
SOLUTION
VIAL
VIAL
AMPULE
VIAL
VIAL
VIAL
VIAL
VIAL
KIT
TABLET
VIAL
AMPULE
VIAL
VIAL
SYRINGE
SOLUTION
AMPULE
VIAL
VIAL
VIAL
TABLET
VIAL
VIAL
SOLUTION
AMPULE
AMPULE

INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INJECTABLE
INJECTABLE
INTAMUSCULAR
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
ORAL
SUBCUTANEOUS
INJECTABLE
SUBCUTANEOUS
INJECTABLE
INTAMUSCULAR
INHALATION
INHALATION
INTRAVENOUS
INTRAVENOUS
INJECTABLE
ORAL
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INJECTABLE
INJECTABLE
7

GUILDNET GOLD HMO- POS SNP
2010 Medicare Part B and Part D Prior Approvals
This drug may be covered under Medicare Part B or D depending upon the circumstances.
Information may be needed to be submitted describing the use and setting of the drug to make
the determination.
MEDICATION NAME
LEUCOVORIN CALCIUM
LEUCOVORIN CALCIUM
LEUPROLIDE ACETATE
LEUSTATIN
LEVALBUTEROL
LEVAQUIN
LEVAQUIN
LEVETIRACETAM
LEVOCARNITINE
LEVO-DROMORAN
LIDOCAINE HCL
LINCOCIN
LOPRESSOR
LUPRON
LUPRON DEPOT
LUPRON DEPOT
LUPRON DEPOT-PED
MAGNESIUM SULFATE
MAGNESIUM SULFATE
MAXIPIME

DOSAGE FORM
TABLET
VIAL
KIT
VIAL
SOLUTION
SOLUTION
VIAL
VIAL
VIAL
AMPULE
VIAL
VIAL
AMPULE
KIT
KIT
SYRINGE
KIT
SOLUTION
SYRINGE
VIAL

ROUTE
ORAL
INJECTABLE
SUBCUTANEOUS
INTRAVENOUS
INHALATION
INTRAVENOUS
INTRAVENOUS
INJECTABLE
INTRAVENOUS
INJECTABLE
INJECTABLE
INJECTABLE
INTRAVENOUS
SUBCUTANEOUS
INTAMUSCULAR
INTAMUSCULAR
INTAMUSCULAR
INTRAVENOUS
INJECTABLE
INTRAVENOUS

MEDROXYPROGESTERONE
ACETATE
MELPHALAN HCL
MEPERIDINE HCL
MEPERIDINE HCL
MEROPENEM
MESNA
MESNEX
METHADONE HCL
METHOTREXATE
METHOTREXATE
METHYLDOPATE HCL

VIAL
VIAL
SYRINGE
VIAL
VIAL
VIAL
VIAL
VIAL
TABLET
VIAL
VIAL

INTAMUSCULAR
INTRAVENOUS
INJECTABLE
INJECTABLE
INJECTABLE
INTRAVENOUS
INTRAVENOUS
INJECTABLE
ORAL
INJECTABLE
INTRAVENOUS

METHYLPREDNISOLONE
ACETATE

VIAL

INJECTABLE

METHYLPREDNISOLONE SOD
SUCC

VIAL

INJECTABLE
8

GUILDNET GOLD HMO- POS SNP
2010 Medicare Part B and Part D Prior Approvals
This drug may be covered under Medicare Part B or D depending upon the circumstances.
Information may be needed to be submitted describing the use and setting of the drug to make
the determination.
MEDICATION NAME
METOCLOPRAMIDE HCL
METOPROLOL TARTRATE
MIACALCIN
MITOMYCIN
MITOXANTRONE HCL
MORPHINE SULFATE
MOZOBIL
MUSTARGEN
MYCAMINE
MYCOPHENOLATE MOFETIL
MYFORTIC
MYLOTARG
MYOZYME
NAFCILLIN
NAFCILLIN SODIUM
NAGLAZYME
NALBUPHINE HCL

DOSAGE FORM
VIAL
VIAL
VIAL
VIAL
VIAL
VIAL
VIAL
VIAL
VIAL
TABLET
TABLET
VIAL
VIAL
SOLUTION
VIAL
VIAL
VIAL

ROUTE
INJECTABLE
INTRAVENOUS
INJECTABLE
INTRAVENOUS
INTRAVENOUS
INJECTABLE
INJECTABLE
INJECTABLE
INTRAVENOUS
ORAL
ORAL
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INJECTABLE
INTRAVENOUS
INJECTABLE

NALLPEN-ISO-OSMOTIC
DEXTROSE
NALOXONE HCL
NAVELBINE
NEUMEGA
NEUTREXIN
NICARDIPINE HCL
NIPENT
NITROGLYCERIN
NORFLEX
NOVANTRONE
NOVAREL
ONCASPAR
ONDANSETRON HCL
ONDANSETRON HCL
ONDANSETRON HCL
ONDANSETRON ODT
ONTAK

SOLUTION
SYRINGE
VIAL
VIAL
VIAL
VIAL
VIAL
VIAL
AMPULE
VIAL
VIAL
VIAL
SOLUTION
TABLET
VIAL
TABLET
VIAL

INTRAVENOUS
INJECTABLE
INTRAVENOUS
SUBCUTANEOUS
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INJECTABLE
INTRAVENOUS
INTAMUSCULAR
INJECTABLE
ORAL
ORAL
INJECTABLE
ORAL
INTRAVENOUS
9

GUILDNET GOLD HMO- POS SNP
2010 Medicare Part B and Part D Prior Approvals
This drug may be covered under Medicare Part B or D depending upon the circumstances.
Information may be needed to be submitted describing the use and setting of the drug to make
the determination.
MEDICATION NAME
ONXOL
ORENCIA
ORPHENADRINE CITRATE
ORTHOCLONE OKT-3
OXACILLIN
OXACILLIN SODIUM
OXALIPLATIN
PACLITAXEL
PAMIDRONATE DISODIUM
PENICILLIN G POTASSIUM
PENICILLIN G PROCAINE
PENICILLIN G SODIUM

DOSAGE FORM
VIAL
VIAL
VIAL
AMPULE
SOLUTION
VIAL
VIAL
VIAL
VIAL
VIAL
SYRINGE
VIAL

ROUTE
INTRAVENOUS
INTRAVENOUS
INJECTABLE
INTRAVENOUS
INTRAVENOUS
INJECTABLE
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INJECTABLE
INTAMUSCULAR
INJECTABLE

PENICILLIN GK-ISO-OSM
DEXTROSE
PENTAM 300
PENTOSTATIN
PEPCID
PERFOROMIST
PHENERGAN
PHENYTOIN SODIUM
PHOTOFRIN
PHYSIOLYTE
PHYSIOSOL
PIPERACILLIN
PIPERACILLIN-TAZOBACTAM
PLATINOL-AQ

SOLUTION
VIAL
VIAL
VIAL
VIAL
VIAL
AMPULE
VIAL
SOLUTION
SOLUTION
VIAL
VIAL
VIAL

INTRAVENOUS
INJECTABLE
INTRAVENOUS
INTRAVENOUS
INHALATION
INJECTABLE
INTRAVENOUS
INTRAVENOUS
IRRIGATION
IRRIGATION
INTRAVENOUS
INJECTABLE
INTRAVENOUS

POTASSIUM CHL-NORMAL
SALINE
POTASSIUM CHLORIDE
POTASSIUM CHLORIDE
POTASSIUM CHLORIDE IN D5LR
POTASSIUM CHLORIDE-NACL
PREGNYL
PREMARIN
PRIMAXIN

SOLUTION
SOLUTION
VIAL
SOLUTION
SOLUTION
VIAL
VIAL
VIAL

INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INTAMUSCULAR
INJECTABLE
INTRAVENOUS
10

GUILDNET GOLD HMO- POS SNP
2010 Medicare Part B and Part D Prior Approvals
This drug may be covered under Medicare Part B or D depending upon the circumstances.
Information may be needed to be submitted describing the use and setting of the drug to make
the determination.
MEDICATION NAME
PRIMAXIN I.M.
PROCAINAMIDE HCL
PROGRAF
PROGRAF
PROLASTIN
PROMETHAZINE HCL
PROMETHAZINE HCL
PROPRANOLOL HCL
PULMICORT
PULMOZYME
RANITIDINE HCL
RAPAMUNE
RAPAMUNE
RECOMBIVAX HB
REGLAN
REGONOL
REMODULIN
RIFADIN
RIFAMPIN
ROBAXIN
ROBINUL
ROCEPHIN

DOSAGE FORM
VIAL
VIAL
AMPULE
CAPSULE
VIAL
SYRINGE
VIAL
VIAL
AMPULE
SOLUTION
VIAL
SOLUTION
TABLET
VIAL
VIAL
AMPULE
VIAL
VIAL
VIAL
VIAL
VIAL
VIAL

ROUTE
INTAMUSCULAR
INJECTABLE
INTRAVENOUS
ORAL
INTRAVENOUS
INJECTABLE
INJECTABLE
INTRAVENOUS
INHALATION
INHALATION
INJECTABLE
ORAL
ORAL
INTAMUSCULAR
INJECTABLE
INJECTABLE
INJECTABLE
INTRAVENOUS
INTRAVENOUS
INJECTABLE
INJECTABLE
INJECTABLE

ROCEPHIN/ISO-OSMOTIC
DEXTROSE
SANCUSO
SIMULECT
SODIUM BICARBONATE
SODIUM CHLORIDE
SODIUM CHLORIDE
SODIUM EDECRIN
SODIUM LACTATE
SODIUM LACTATE
SOLU-CORTEF
SOLU-MEDROL
SOMATULINE

SOLUTION
PATCH
VIAL
SYRINGE
SOLUTION
VIAL
VIAL
SOLUTION
VIAL
VIAL
VIAL
SYRINGE

INTRAVENOUS
TRANSDERMAL
INTRAVENOUS
INJECTABLE
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INJECTABLE
INJECTABLE
SUBCUTANEOUS
11

GUILDNET GOLD HMO- POS SNP
2010 Medicare Part B and Part D Prior Approvals
This drug may be covered under Medicare Part B or D depending upon the circumstances.
Information may be needed to be submitted describing the use and setting of the drug to make
the determination.
MEDICATION NAME
SOMATULINE DEPOT
SOMAVERT
SOTALOL
STADOL
STELARA
STELARA
STREPTOMYCIN SULFATE
SUCRAID

DOSAGE FORM
SYRINGE
VIAL
VIAL
VIAL
SYRINGE
VIAL
VIAL
SOLUTION

ROUTE
SUBCUTANEOUS
SUBCUTANEOUS
INJECTABLE
INJECTABLE
SUBCUTANEOUS
SUBCUTANEOUS
INTAMUSCULAR
ORAL

SULFAMETHOXAZOLETRIMETHOPRIM
SUMATRIPTAN
SUMAVEL DOSEPRO
SYNERCID
TACROLIMUS
TALWIN
TAXOTERE
TAZICEF
TERBUTALINE SULFATE
TESTOSTERONE CYPIONATE
TESTOSTERONE ENANTHATE
THIOTEPA
TIGAN
TIMENTIN
TIS-U-SOL
TOPOSAR
TORISEL
TORSEMIDE
TREANDA
TRELSTAR DEPOT
TRELSTAR LA
TRIMETHOBENZAMIDE HCL
TRISENOX
TYGACIL
TYSABRI
UNASYN

VIAL
SYRINGE
SYRINGE
VIAL
CAPSULE
VIAL
VIAL
VIAL
VIAL
VIAL
VIAL
VIAL
VIAL
VIAL
SOLUTION
VIAL
VIAL
VIAL
VIAL
VIAL
VIAL
SYRINGE
AMPULE
VIAL
VIAL
VIAL

INTRAVENOUS
SUBCUTANEOUS
SUBCUTANEOUS
INTRAVENOUS
ORAL
INJECTABLE
INTRAVENOUS
INTRAVENOUS
SUBCUTANEOUS
INTAMUSCULAR
INTAMUSCULAR
INJECTABLE
INTAMUSCULAR
INTRAVENOUS
IRRIGATION
INTRAVENOUS
INTRAVENOUS
INJECTABLE
INTRAVENOUS
INTAMUSCULAR
INTAMUSCULAR
INTAMUSCULAR
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INJECTABLE
12

GUILDNET GOLD HMO- POS SNP
2010 Medicare Part B and Part D Prior Approvals
This drug may be covered under Medicare Part B or D depending upon the circumstances.
Information may be needed to be submitted describing the use and setting of the drug to make
the determination.
MEDICATION NAME
UVADEX

DOSAGE FORM
VIAL

ROUTE
INJECTABLE

VANCOMYCIN HCL
VANCOMYCIN HCL
VECTIBIX
VELCADE
VERAPAMIL HCL
VFEND IV
VIBATIV
VIDAZA
VIMPAT
VINBLASTINE SULFATE
VINCRISTINE SULFATE
VINORELBINE TARTRATE
VIRAZOLE
VISTIDE
VIVITROL
VPRIV
XOPENEX
XYLOCAINE
ZANOSAR
ZANTAC
ZEMAIRA
ZEMPLAR
ZENAPAX
ZINACEF
ZINACEF IN ISO-OSMOTIC WATER

SOLUTION
VIAL
VIAL
VIAL
AMPULE
VIAL
VIAL
VIAL
VIAL
VIAL
VIAL
VIAL
VIAL
VIAL
SUSPENSION
VIAL
VIAL
VIAL
VIAL
VIAL
VIAL
VIAL
VIAL
VIAL
SOLUTION

INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INJECTABLE
SUBCUTANEOUS
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INHALATION
INTRAVENOUS
INTAMUSCULAR
INJECTABLE
INHALATION
INJECTABLE
INTRAVENOUS
INJECTABLE
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
INTRAVENOUS

ZINACEF ISO-OSMOTIC
DEXTROSE
ZINECARD
ZITHROMAX
ZOFRAN
ZOFRAN
ZOFRAN
ZOFRAN ODT
ZOMETA

SOLUTION
VIAL
VIAL
SOLUTION
TABLET
VIAL
TABLET
VIAL

INTRAVENOUS
INTRAVENOUS
INTRAVENOUS
ORAL
ORAL
INTRAVENOUS
ORAL
INTRAVENOUS
13

GUILDNET GOLD HMO- POS SNP
2010 Medicare Part B and Part D Prior Approvals
This drug may be covered under Medicare Part B or D depending upon the circumstances.
Information may be needed to be submitted describing the use and setting of the drug to make
the determination.
MEDICATION NAME
ZORTRESS
ZOSYN
ZOSYN
ZUPLENZ
ZYPREXA

DOSAGE FORM
TABLET
SOLUTION
VIAL
SOLUBLE FILM
VIAL

ROUTE
ORAL
INTRAVENOUS
INTRAVENOUS
ORAL
INTAMUSCULAR

14



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File Type Extension             : pdf
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Page Count                      : 14
Language                        : en-US
Tagged PDF                      : Yes
Title                           : 2010 Medicare Part B and Part D Prior Approvals
Author                          : mlieu
Creator                         : Microsoft® Office Word 2007
Create Date                     : 2010:11:02 16:33:32
Modify Date                     : 2010:11:02 16:33:32
Producer                        : Microsoft® Office Word 2007
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