Medicaid-Covered, Part D-Excluded Drug List
Last updated 3/1/09
IMPORTANT: This list is sometimes called a "wrap around" formulary. It is for Part D-eligible PrimeWest Health members only. Your Medical Assistance prescription benefit covers certain items, which are excluded from traditional Medicare Part D coverage. The main classes of added coverage are benzodiazepines, over-the-counter items, cough and cold preparations, barbiturates, and some vitamins. Covered items are subject to change without warning. You may request coverage for drugs not listed in these therapeutic classes by using the formulary exception process. All final coverage determinations are made by PrimeWest Health.
Barbiturate and barbiturate combinations *GPI #
butalbital-acetaminophen capsule N/A
butalbital-acetaminophen tablet N/A
butalbital-acetaminophen-caffeine capsule N/A
butalbital-acetaminophen-caffeine tablet N/A
butalbital-aspirin-caffeine w/ codeine capsule N/A
butalbital-aspirin-caffeine capsule N/A
butalbital-aspirin-caffeine tablet N/A
phenobarbital elixir N/A
phenobarbital tablet N/A
Benzodiazepine
alprazolam concentrated oral solution N/A
alprazolam tablet N/A
clonazepam tablet N/A
diazepam concentrated oral solution N/A
diazepam rectal gel delivery system N/A
diazepam solution N/A
diazepam tablet N/A
estazolam tablet N/A
lorazepam concentrated oral solution N/A
lorazepam tablets N/A
lorazepam injectable N/A
temazepam capsules N/A
Cardiovascular
nitroglycerin er capsules 321000300007**
NITROQUICK SUBLINGUAL TABLETS 321000300002**
potassium chloride powders and liquids 797000300009** 797000300030**
Cough & cold
benzonatate capsule N/A
codeine-guaifenesin liquid N/A
codeine-guaifenesin syrup N/A
codeine-guaifenesin tablet N/A
hydrocodone-guaifenesin syrup N/A
pseudoephedrine-chlorpheniramine w/ codeine liquid N/A
Dental
PREVIDENT RINSE, CREAM, PASTE 8840202000****
sodium flouride gel 884020200040**
Endocrine
ARMOUR THYROID 28100050000305
Gastro-Intestinal
hyoscyamine tablets 49101030100310
Hematology
aminocaproic acid tablets 500mg 84100010000305
Ophthalmic
atropine (ophthalmic) 86350010102010
pilocarpine 865010301020**
Otic
antipyrine/benzocaine otic drops 87992002202010
Pain
oxycodone 20mg/ml oral concentrate 65100075101321
codeine sulfate tablets 6510002020****
morphine suppositories 651000551052**
morphine sulfate injectable, 2mg/ml 65100055102005
morphine sulfate injectable, 4mg/ml 65100055102010
morphine sulfate injectable, 10mg/ml 65100055102030
belladonna &opium suppositories (pain/gi) 49109902155210
Renal
k-phos 561010022003**
k-phos neutral 561010022003**
Topical
aluminum chloride 20% 90970010002010
CARMOL 40 GEL & LOTION 90660080004040
Vitamin and mineral products (Rx)
phytonadione tablets N/A
*GPI #s are unique numbers used by PrimeWest Health staff to identify specific drugs.
| H2416/H2926 DHS Approval: 05/15/2009 CMS Approval: 06/12/2009 | Last Updated: 06/16/2009 |