Medicare Part D Wrap Around Formulary
IMPORTANT: The "Wrap Around" Formulary is for MSHO and Medicare D eligible PrimeWest Members to provide coverage for items excluded from traditional Medicare Part D plans. The primary classes of additional coverage applies to benzodiazepines, OTC items, cough and cold preparations, barbituates, and some adult vitamins. Items subject to change without warning and all final coverage determinations are to be done by Prime Therapeutics/MHP medical directors.
Barbiturate and barbiturate combinations
BUTALBITAL-ACETAMINOPHEN CAP
BUTALBITAL-ACETAMINOPHEN TAB
BUTALBITAL-ACETAMINOPHEN-CAFFEINE CAP
BUTALBITAL-ACETAMINOPHEN-CAFFEINE TAB
BUTALBITAL-ASPIRIN-CAFF W/ CODEINE CAP
BUTALBITAL-ASPIRIN-CAFFEINE CAP
BUTALBITAL-ASPIRIN-CAFFEINE TAB
PHENOBARBITAL ELIXIR
PHENOBARBITAL TAB
Benzodiazepine
ALPRAZOLAM CONC
ALPRAZOLAM TAB
CLONAZEPAM TAB
DIAZEPAM CONC
DIAZEPAM RECTAL GEL DELIVERY SYSTEM
DIAZEPAM SOLN
DIAZEPAM TAB
ESTAZOLAM TAB
LORAZEPAM CONC
LORAZEPAM TAB
LORAZEPAM INJECTABLE
TEMAZEPAM CAP
Cough & cold, agents for the symptomatic relief of
BENZONATATE CAP
CODEINE-GUAIFENESIN LIQUID
CODEINE-GUAIFENESIN SYRUP
CODEINE-GUAIFENESIN TAB
HYDROCODONE-GUAIFENESIN SYRUP
PSEUDOEPHEDRINE-CHLORPHEN W/ CODEINE LIQ
Vitamin and mineral products (Rx), except prenatal floride
PEDIATRIC MULTIPLE VITAMINS W/ FL-FE CHEW TAB
PEDIATRIC MULTIPLE VITAMINS W/ FL-FE DROPS
PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE CHEW TAB
PEDIATRIC MULTIPLE VITAMINS W/ FLUORIDE SOLN
PEDIATRIC VITAMINS ACD FLUORIDE & FE DROPS
PEDIATRIC VITAMINS ACD W/ FLUORIDE CHEW TAB
PEDIATRIC VITAMINS ACD W/ FLUORIDE SOLN
CALCITRIOL CAP
CALCITRIOL ORAL SOLN
CYANOCOBALAMIN INJ
ERGOCALCIFEROL CAP
FOLIC ACID TAB
PHYTONADIONE TAB