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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