2012 Formulary Print document - Alameda Alliance for Health

Alliance CompleteCare (HMO SNP)
2012 Formulary
2012 年 藥 房 目 錄
Formulario de 2012
H7292-001 H7292_22f_Final5 File & Use 02.07.2012

Alliance CompleteCare (HMO SNP)
2012 Formulary
(List of Covered Drugs)
2012 年 保 賠 藥 品 清 單
Formulario 2012
(Lista de medicamentos cubiertos)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE
COVER IN THIS PLAN
請 閱 讀 : 本 文 件 包 含 有 關 本 項 計 劃 保 賠 的 藥 品 資 訊
SÍRVASE LEER LO SIGUIENTE: ESTE DOCUMENTO CONTIENE INFORMACIÓN SOBRE LOS
MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN
Note to existing members: This formulary has changed since last year. Please review this document to make
sure that it still contains the drugs you take.
Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits, formulary,
pharmacy network, and/or copayments/coinsurance may change on January 1, 2013.
Alliance CompleteCare is brought to you by Alameda Alliance for Health, a health plan with a Medicare
contract.
To receive this material in another language or format, please contact the Care Advisor Unit at 1-877-585-
7526, 8:00 a.m. to 8:00 p.m., seven days a week. (TTY/TDD users should call 1-800-735-2929.)
向 現 有 會 員 發 出 的 通 知 : 本 保 賠 藥 品 清 單 自 從 去 年 以 來 已 經 變 更 。 請 閱 讀 本 文 件 , 核 實 本 保 賠 藥 品 清
單 仍 然 包 括 您 使 用 的 藥 品 。
保 險 受 益 人 必 須 透 過 計 畫 服 務 網 絡 範 圍 內 藥 房 獲 得 其 處 方 藥 福 利 待 遇 。 福 利 待 遇 、 處 方 藥 一 覽 表 、
藥 房 服 務 網 絡 , 和 ( 或 ) 共 付 額 / 共 同 承 擔 之 保 險 費 可 能 會 於 2013 年 1 月 1 日 發 生 變 化 。
將 由 與 Medicare 簽 約 的 Alameda_Alliance_for_Health 健 康 保 險 計 畫 為 您 提 供 Alliance
CompleteCare 保 險 服 務 。
如 果 您 需 要 以 其 他 文 本 或 其 他 版 本 格 式 提 供 的 此 資 料 , 請 聯 絡 醫 療 保 健 顧 問 科 , 電 話 號 碼 是 1-877-
585-7526; 每 週 七 天 服 務 , 服 務 時 間 為 早 上 8 點 至 晚 上 8 點 。
(TTY/TDD 專 線 使 用 者 請 撥 1-800-735-2929。)
H7292-001 H7292_22f_ Final4 File & Use 02.07.2012 Effective: May 01, 2012
Formulary ID: 12140.000; Version: 10 Last Updated: April 25, 2012
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Nota a los clientes actuales: Este formulario cambió desde el año pasado. Sírvase revisar este documento
para asegurarse de que todavía contiene los medicamentos que usted toma.
Los beneficiarios deberán utilizar las farmacias de la red para tener acceso al beneficio de medicamentos
recetados. Es posible que el 1º de enero de 2013 se modifiquen los beneficios, el formulario, la red de
farmacia o los copagos o coaseguros.
Alliance CompleteCare se ofrece a través de Alameda Alliance for Health, un plan de salud que tiene un
contrato con Medicare.
Para recibir este material en otro idioma o formato, por favor contacte a la Unidad de Asesoramiento de
Atención al 1-877-585-7526, de 8:00 a.m. a 8:00 p.m., los siete días de la semana. (Los usuarios de
TTY/TDD deben llamar al 1-800-735-2929.)
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What is the Alliance CompleteCare Formulary?
A formulary is a list of covered drugs selected by Alliance CompleteCare in consultation with a team of
health care providers, which represents the prescription therapies believed to be a necessary part of a quality
treatment program. Alliance CompleteCare will generally cover the drugs listed in our formulary as long as
the drug is medically necessary, the prescription is filled at an Alliance CompleteCare network pharmacy,
and other plan rules are followed. For more information on how to fill your prescriptions, please review your
Evidence of Coverage.
Can the Formulary change?
Generally, if you are taking a drug on our 2012 formulary that was covered at the beginning of the year, we
will not discontinue or reduce coverage of the drug during the 2012 coverage year except when a new, less
expensive generic drug becomes available or when new adverse information about the safety or
effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our
formulary, will not affect members who are currently taking the drug. It will remain available at the same
cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that
you have continued access for the remainder of the coverage year to the formulary drugs that were available
when you chose our plan, except for cases in which you can save additional money or we can ensure your
safety.
If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy
restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the
change at least 60 days before the change becomes effective, or at the time the member requests a refill of
the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug
Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug
from the market, we will immediately remove the drug from our formulary and provide notice to members
who take the drug. The enclosed formulary is current as of May 1, 2012. To get updated information about
the drugs covered by Alliance CompleteCare, please visit our Web site at www.alliancecompletecare.org or
call Customer Service (Care Advisor Unit) at 1-877-585-7526, 8:00 a.m. - 8:00 p.m., 7 days a week.
TTY/TDD users should call 1-800-735-2929. In the event of mid-year non-maintenance formulary changes,
the Alliance CompleteCare formulary will be updated via errata sheets.
How do I use the Formulary?
There are two ways to find your drug within the formulary:
Medical Condition
The formulary begins on page 31. The drugs in this formulary are grouped into categories depending on
the type of medical conditions that they are used to treat. For example, drugs used to treat a heart
condition are listed under the category, “Cardiac Drugs.” If you know what your drug is used for, look
for the category name in the list that begins on page 31. Then look under the category name for your
drug.
Alphabetical Listing
If you are not sure what category to look under, you should look for your drug in the Index that begins on
page I-1. The Index provides an alphabetical list of all of the drugs included in this document. Both brand
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name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your
drug, you will see the page number where you can find coverage information. Turn to the page listed in
the Index and find the name of your drug in the first column of the list.
What are generic drugs?
Alliance CompleteCare covers both brand name drugs and generic drugs. A generic drug is approved by the
FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than
brand name drugs.
Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements and limits
may include:
• Prior Authorization: Alliance CompleteCare requires you or your physician to get prior
authorization for certain drugs. This means that you will need to get approval from Alliance
CompleteCare before you fill your prescriptions. If you don’t get approval, Alliance CompleteCare
may not cover the drug.
• Quantity Limits: For certain drugs, Alliance CompleteCare limits the amount of the drug that
Alliance CompleteCare will cover. For example, Alliance CompleteCare provides 9 tablets per
prescription for sumatriptan succinate. This may be in addition to a standard one month or three
month supply.
• Step Therapy: In some cases, Alliance CompleteCare requires you to first try certain drugs to treat
your medical condition before we will cover another drug for that condition. For example, if Drug A
and Drug B both treat your medical condition, Alliance CompleteCare may not cover Drug B unless
you try Drug A first. If Drug A does not work for you, Alliance CompleteCare will then cover Drug
B. You can find out if your drug has any additional requirements or limits by looking in the
formulary that begins on page 31. You can also get more information about the restrictions applied to
specific covered drugs by visiting our Web site at www.alliancecompletecare.org.
You can ask Alliance CompleteCare to make an exception to these restrictions or limits. See the section,
“How do I request an exception to Alliance CompleteCare’s formulary?” on page 5 for information about
how to request an exception.
What if my drug is not on the Formulary?
If your drug is not included in this formulary, you should first contact Customer Service (Care Advisor Unit)
and confirm that your drug is not covered. If you learn that Alliance CompleteCare does not cover your drug,
you have two options:
• You can ask Customer Service (Care Advisor Unit) for a list of similar drugs that are covered by
Alliance CompleteCare. When you receive the list, show it to your doctor and ask him or her to
prescribe a similar drug that is covered by Alliance CompleteCare.
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• You can ask Alliance CompleteCare to make an exception and cover your drug. See below for
information about how to request an exception.
How do I request an exception to the Alliance CompleteCare Formulary?
You can ask Alliance CompleteCare to make an exception to our coverage rules. There are several types of
exceptions that you can ask us to make.
• You can ask us to cover your drug even if it is not on our formulary.
• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs,
Alliance CompleteCare limits the amount of the drug that we will cover. If your drug has a quantity
limit, you can ask us to waive the limit and cover more.
• You can ask us to provide a higher level of coverage for your drug. If your drug is contained in our
second tier, you can ask us to cover it as the cost-sharing amount that applies to drugs in the first tier
instead. This would lower the amount you must pay for your drug. Please note, if we grant your
request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of
coverage for the drug.
Generally, Alliance CompleteCare will only approve your request for an exception if the alternative drugs
included on the plan’s formulary, the lower-tiered drug, or additional utilization restrictions would not be as
effective in treating your condition and/or would cause you to have adverse medical effects.
You should contact us to ask us for an initial coverage decision for a formulary, tiering, or utilization
restriction exception. When you are requesting a formulary, tiering, or utilization restriction exception
you should submit a statement from your physician supporting your request. Generally, we must make
our decision within 72 hours of getting your prescriber’s or prescribing physician’s supporting statement.
You can request an expedited (fast) exception if you or your doctor believes that your health could be
seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must
give you a decision no later than 24 hours after we get your prescriber’s or prescribing physician’s
supporting statement.
What do I do before I can talk to my doctor about changing my drugs or requesting an
exception?
As a new or continuing member in our plan, you may be taking drugs that are not on our formulary. Or, you
may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need
a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if
you should switch to an appropriate drug that we cover or request a formulary exception so that we will
cover the drug you take. While you talk to your doctor to determine the right course of action for you, we
may cover your drug in certain cases during the first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary, or if your ability to get your drugs is limited, we will
cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a
network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a
member of the plan less than 90 days.
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If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have
provided you with a 93-day transition supply, consistent with the dispensing increment (unless you have a
prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days
you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your
drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day
emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary
exception.
For more information
For more detailed information about your Alliance CompleteCare prescription drug coverage, please review
your Evidence of Coverage and other plan materials.
If you have questions about Alliance CompleteCare, please call Customer Service (Care Advisor Unit) at 1-
877-585-7526, 8:00 a.m. - 8:00 p.m., 7 days a week. TTY/TDD users should call 1-800-735-2929. Or visit
www.alliancecompletecare.com.
If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-
MEDICARE (1-800-633-4227) 24 hours a day, 7 days a week. TTY/TDD users should call 1-877-486-2048.
Or visit www.medicare.gov.
Alliance CompleteCare’s Formulary
The formulary starting on page 31 provides coverage information about some of the drugs covered by
Alliance CompleteCare. If you have trouble finding your drug in the list, turn to the Index that begins on
page I-1.
The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., ZITHROMAX) and
generic drugs are listed in lower-case italics (e.g., azithromycin).
The information in the Requirements/Limits column tells you if Alliance CompleteCare has any special
requirements for coverage of your drug.
• QL - means that there are Quantity Limits on the use of the drug. This means that Alliance
CompleteCare limits the amount of the drug that will be covered during a specified time period.
• PA - means that you need to get Prior Authorization, or approval, to use this drug.
• ST - means that there are Step Therapy requirements on the use of the drug. This means that you will
have to try certain other drugs to treat your medical condition before Alliance CompleteCare will
cover the drug.
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什 麼 是 Alliance CompleteCare 保 賠 藥 品 清 單 ?
保 賠 藥 品 清 單 是 Alliance CompleteCare 向 健 康 護 理 服 務 提 供 者 團 隊 洽 詢 後 選 擇 的 保
賠 藥 品 名 錄 , 該 名 錄 是 構 成 優 質 治 療 計 劃 必 要 成 份 的 處 方 藥 療 法 部 份 。 只 要 藥 品 具 有 醫 療 上 的 必 要
性 、 在 Alliance CompleteCare 網 路 內 藥 房 配 藥 、 並 且 符 合 其 他 計 劃
規 定 ,Alliance CompleteCare 通 常 為 保 賠 藥 品 清 單 中 所 列 的 藥 品 提 供 保 賠 。 如 需 瞭
解 如 何 配 藥 的 詳 情 , 請 查 閱 「 保 賠 證 明 」。
保 賠 藥 品 清 單 是 否 會 變 更 ?
通 常 , 如 果 您 在 服 用 年 初 享 受 保 賠 的 2012 年 保 賠 藥 品 清 單 中 的 藥 品 , 我 們 不 會 在
2012 年 保 賠 年 度 中 終 止 或 減 少 該 藥 品 的 保 賠 額 , 除 非 推 出 價 格 較 便 宜 的 、 新 的 非 專 利 藥 , 或 者 發 佈 有
關 藥 品 的 安 全 性 或 有 效 性 的 、 新 的 不 利 資 訊 。 其 他 類 型 的 保 賠 藥 品 清 單 變 化 ( 例 如 從 保 賠 藥 品 清 單 中 刪
除 某 種 藥 品 ) 不 會 對 目 前 正 在 服 用 此 種 藥 品 的 會 員 產 生 影 響 。 在 保 賠 年 度 剩 餘 時 間 內 , 將 以 相 同 的 費 用
分 享 方 法 向 服 用 該 藥 品 的 會 員 提 供 該 藥 品 。 我 們 認 為 , 除 了 能 夠 為 您 節 約 更 多 的 費 用 或 確 保 您 的 安 全
之 外 的 情 形 , 允 許 您 在 保 賠 年 度 的 剩 餘 時 間 繼 續 獲 得 在 您 選 擇 我 們 的 計 劃 時 向 您 提 供 的 保 賠 藥 品 清 單
中 的 藥 品 十 分 重 要 。
如 果 我 們 從 保 賠 藥 品 清 單 中 刪 除 某 種 藥 品 、 增 加 某 種 藥 品 事 先 授 權 的 要 求 、 作 出 數 量 限 制 及 / 或 分 級
療 法 限 制 , 或 提 高 一 種 藥 品 的 共 付 額 級 別 , 我 們 必 須 在 變 更 生 效 前 至 少 60 天 或 在 會 員 要 求 重 新 配 藥
時 向 受 變 化 影 響 的 會 員 發 出 通 知 , 會 員 可 在 重 新 配 藥 時 配 取 60 天 的 藥 量 。 如 果 美 國 食 品 與 藥 物 管 理
局 認 為 我 們 的 保 賠 藥 品 清 單 中 的 某 種 藥 品 不 安 全 , 或 者 藥 品 製 造 商 從 市 場 中 撤 除 某 種 藥 品 , 我 們 會
立 即 從 我 們 的 保 賠 藥 品 清 單 中 刪 除 該 藥 品 , 並 向 服 用 該 藥 品 的 會 員 發 出 通 知 。 隨 附 的 保 賠 藥 品 清 單
是 截 止 於 2012 年 1 月 的 最 新 清 單 。 如 需 瞭 解 Alliance CompleteCare 保 賠 藥 品 的 最 新 資 訊 , 請 查 閱 我 們
的 網 站 www.alliancecompletecare.org, 或 電 洽 客 戶 服 務 部 ( 護 理 諮 詢 部 ), 電 話 號 碼 1-877-585-
7526, 營 業 時 間 為 每 週 七 天 上 午 八 時 至 下 午 八 時 。TTY/TDD 使 用 者 請 電 洽 1-800-735-2929。
如 何 使 用 保 賠 藥 品 清 單 ?
可 採 用 兩 種 方 法 在 保 賠 藥 品 清 單 中 查 找 所 需 的 藥 品 :
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醫 療 症 狀
保 賠 藥 品 清 單 從 26 頁 開 始 。 清 單 中 的 藥 品 按 照 藥 品 治 療 的 醫 療 症 狀 類 型 分 類 。
例 如 , 用 於 治 療 心 臟 病 的 藥 品 列 在 「 心 臟 病 藥 」 類 別 。 如 果 您 瞭 解 藥 品 的 用 途 , 在 從 26 頁 開 始 的 名
錄 中 查 找 類 別 名 稱 。 然 後 在 該 類 別 中 查 找 所 需 的 藥 品 。
按 字 母 順 序 排 列 的 名 錄
如 果 您 不 確 定 應 當 查 找 哪 一 個 類 別 , 您 應 當 在 從 第 I-1 頁 開 始 的 索 引 中 查 找 所
需 的 藥 品 。 該 索 引 中 有 一 份 按 字 母 順 序 排 列 本 文 件 中 包 括 的 所 有 藥 品 的 名 錄 。 該 索 引 中 列 有 專 利
藥 及 非 專 利 藥 。 請 在 索 引 中 查 找 所 需 的 藥 品 。 藥 品 旁 註 有 頁 號 , 您 可 以 在 該 頁 查 找 保 賠 資 訊 。 請
在 索 引 中 所 列 的 頁 號 中 名 錄 的 第 一 欄 查 找 所 需 的 藥 品 名 稱 。
什 麼 是 非 專 利 藥 ?
Alliance CompleteCare 為 專 利 藥 及 非 專 利 藥 提 供 保 賠 。 非 專 利 藥 已 獲 得 美 國 食 品 與 藥 物 管 理 局 (FDA)
的 批 准 , 所 含 的 活 性 成 份 與 專 利 藥 中 所 含 的 活 性 成 份 相 同 。 非 專 利 藥 的 價 格 通 常 比 專 利 藥 的 價 格 便
宜 。
對 我 享 受 的 保 賠 是 否 有 任 何 限 制 ?
某 些 保 賠 藥 品 可 能 有 附 加 要 求 或 保 賠 限 制 。 此 類 要 求 及 限 制 可 能 包 括 :
• 事 先 授 權 :Alliance CompleteCare 要 求 您 或 您 的 醫 生 為 某 些 藥 品 獲 得 事 先 授 權 。 這 表 示 您 必 須 在
配 藥 之 前 獲 得 Alliance CompleteCare 的 批 准 。 如 果 您 未 獲 得 批 准 ,Alliance CompleteCare 可 能
不 會 為 該 藥 品 提 供 保 賠 。
• 數 量 限 制 : 對 於 某 些 藥 品 ,Alliance CompleteCare 會 限 制 藥 品 的 保 賠 數 量 。 例 如 ,Alliance Comp
leteCare 對 sumatriptan succinate 的 限 制 是 每 張 處 方 9 片 藥 。 這 可
能 是 標 準 的 一 個 月 或 三 個 月 藥 量 之 外 的 額 外 藥 量 。
• 分 級 療 法 : 在 某 些 情 況 下 ,Alliance CompleteCare 要 求 您 首 先 試 用 某 種 治 療 您 的 醫 療 症 狀 的 藥 品
, 然 後 才 為 治 療 該 症 狀 的 另 一 種 藥 品 提 供 保 賠 。 例 如 , 如 果 藥 品 A 與 藥 品 B 均 可 治 療 您 的 醫 療
症 狀 ,Alliance CompleteCare 可 能 只 有 在 您 首 先 試 用 藥 品 A 之 後 才 為 藥 品 B 提 供 保 賠 。 如 果 藥
品 A 對 您 無 效 ,Alliance CompleteCare 則 會 為 藥 品 B 提 供 保 賠 。
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您 可 以 查 閱 從 31 頁 開 始 的 保 賠 藥 品 清 單 , 瞭 解 所 需 的 藥 品 是 否 有 附 加 要 求 或 限
制 。 您 也 可 以 瀏 覽 我 們 的 網 站 www.alliancecompletecare.org, 瞭 解 對 保 險 範 圍 的 某 種 藥 品 的 限 制 詳 情
。
您 可 以 要 求 Alliance CompleteCare 作 為 此 類 限 制 的 例 外 情 況 處 理 。 請 查 閱 第 5 頁 中 的 「 如 何 要 求 作 為 A
lliance CompleteCare 保 賠 藥 品 清 單 的 例 外 情 況 處 理 ?」 一 節 , 瞭 解 如 何 提 出 例 外 情 況 申 請 的 資 訊 。
如 果 所 需 的 藥 品 未 列 入 保 賠 藥 品 清 單 , 怎 麼 辦 ?
如 果 您 需 要 的 藥 品 未 列 入 本 保 賠 藥 品 清 單 , 您 應 當 首 先 與 客 戶 服 務 部 ( 護 理 諮 詢 部 ) 聯 絡 , 核 實 您 的 藥
品 不 在 保 賠 範 圍 內 。 如 果 您 獲 悉 Alliance CompleteCare 不 為 您 的 藥 品 保 賠 , 您 有 兩 種 選 擇 :
• 您 可 以 向 客 戶 服 務 部 ( 護 理 諮 詢 部 ) 索 取 一 份 Alliance CompleteCare 提 供 保 賠 的 類 似 藥 品 名 錄 。
收 到 名 錄 後 , 將 名 錄 交 給 您 的 醫 生 , 請 您 的 醫 生 為 您 開 一 種 Alliance CompleteCare 提 供 保 賠 的
類 似 藥 品 。
• 您 可 以 要 求 Alliance CompleteCare 作 為 例 外 情 況 處 理 , 為 您 需 要 的 藥 品 提 供
保 賠 。 請 參 閱 以 下 有 關 如 何 提 出 例 外 情 況 申 請 的 資 訊 。
如 何 提 出 Alliance CompleteCare 保 賠 藥 品 清 單 例 外 情 況 申 請 ?
您 可 以 要 求 Alliance CompleteCare 作 為 保 賠 規 定 例 外 情 況 處 理 。 您 可 以 申 請 的 例 外
情 況 有 以 下 幾 種 類 型 。
• 即 使 您 的 藥 品 未 列 入 我 們 的 保 賠 藥 品 清 單 , 您 也 可 以 要 求 我 們 為 您 需 要 的 藥 品 提 供 保 賠 。
• 您 可 以 要 求 我 們 豁 免 對 您 需 要 的 藥 品 的 保 賠 限 制 。 例 如 , 對 於 某 些 藥 品 ,Alliance CompleteC
are 會 限 制 藥 品 的 保 賠 數 量 。 如 果 您 需 要 的 藥 品 有 數 量 限 制 , 您 可 以 要 求 我 們 豁 免 此 項 限 制 ,
為 更 多 的 藥 量 提 供 保 賠 。
• 您 可 要 求 我 們 提 供 較 高 的 藥 品 保 險 額 。 如 果 您 的 藥 品 屬 於 我 們 的 第 二 等 級 範 圍 , 您 可 要 求 我
們 將 其 納 入 第 一 等 級 藥 物 的 共 付 額 保 險 範 圍 。 這 會 降 低 您 必 須 支 付 的 藥 費 。 請 注 意 , 如 果 我
們 已 同 意 您 的 要 求 , 將 不 屬 於 保 賠 藥 品 清 單 的 藥 品 納 入 保 險 範 圍 , 您 不 能 要 求 我 們 為 這 種 藥
品 提 供 較 高 等 級 的 保 險 。
9

通 常 , 只 有 在 計 劃 保 賠 藥 品 清 單 、 費 用 級 別 較 低 的 藥 物 或 附 加 使 用 限 制 中 包 括 的 替 代 藥 品 在 治 療 您
的 症 狀 時 效 果 不 佳 及 / 或 可 能 導 致 不 利 療 效 時 ,Alliance CompleteCare 才 會 批 准 您 的 例 外 情 況 申 請 。
您 應 當 與 我 們 聯 絡 , 要 求 我 們 作 出 保 賠 藥 品 清 單 、 費 用 級 別 或 使 用 限 制 例 外 情 況 的 初 始 保 賠 決 定 。 在
提 出 保 賠 藥 品 清 單 、 費 用 級 別 或 使 用 限 制 例 外 情 況 申 請 時 , 請 提 交 一 份 您 的 醫 生 支 持 您 的 申 請 的 說 明
。 通 常 , 我 們 必 須 在 收 到 您 的 處 方 者 或 開 藥 醫 生 的 支 持 說 明 後 的 72 小 時 內 作 出 決 定 。 如 果 您 或 您 的 醫
生 認 為 等 候 72 小 時 作 出 決 定 會 對 您 的 健 康 狀 況 造 成 嚴 重 損 害 , 您 可 以 提 出 例 外 情 況 加 速 處 理 申 請 。 如
果 您 的 加 速 處 理 申 請 獲 得 批 准 , 我 們 必 須 在 收 到 您 的 處 方 者 或 開 藥 醫 生 的 支 持 說 明 後 的 24 小 時 內 作 出
決 定 。
在 向 我 的 醫 生 提 出 更 換 藥 品 或 例 外 情 況 申 請 之 前 , 我 應 當 做 什 麼 ?
作 為 本 項 計 劃 的 新 老 會 員 , 您 可 能 在 使 用 未 列 入 我 們 的 保 賠 藥 品 清 單 的 藥 品 。 或 者 可 能 在 使 用 列 入
我 們 的 保 賠 藥 品 清 單 、 但 您 的 獲 取 藥 品 的 能 力 受 到 限 制 的 藥 品 。 例 如 , 您 可 能 需 要 在 配 藥 之 前 獲 得 A
lliance CompleteCare 的 事 先 授 權 。 您 應 當 向 您 的 醫 生 洽 詢 , 決 定 您 是 否 應 當 轉 用 我 們 提 供 保 賠 的 適 當
藥 品 , 或 者 提 出 保 賠 藥 品 清 單 例 外 情 況 申 請 , 以 便 我 們 為 您 使 用 的 藥 品 提 供 保 賠 。 在 與 您 的 醫 生 討
論 採 取 何 種 對 您 適 當 的 措 施 時 , 我 們 可 能 在 您 成 為 本 計 劃 會 員 的 頭 90 天 內 在 某 些 情 況 下 為 您 的 藥 品
提 供 保 賠 。
對 於 每 一 種 未 列 入 我 們 的 保 賠 藥 品 清 單 或 者 您 獲 取 藥 品 的 能 力 受 到 限 制 的 藥 品 , 我 們 將 為 您 在 網 路
內 藥 房 領 取 的 臨 時 31 天 的 藥 量 提 供 保 賠 ( 除 非 您 的 處 方 藥 量 只 有 幾 天 )。 在 頭 31 天 的 藥 量 之 後 , 即 使 您
成 為 本 項 計 劃 的 會 員 時 間 尚 不 足 90 天 , 我 們 不 再 為 此 類 藥 品 付 款 。
如 果 您 住 在 長 期 護 理 設 施 內 , 我 們 將 為 31 天 臨 時 過 渡 藥 量 提 供 保 賠 ( 除 非 您 的 處 方 劑 量 只 有 幾 天 )。 我
們 將 在 您 參 加 本 計 劃 的 頭 90 天 內 為 此 類 藥 品 的 一 次 以 上 重 新 配 藥 提 供 保 賠 。 如 果 您 需 要 一 種 未 列 入
我 們 的 保 賠 藥 品 清 單 或 者 您 獲 取 藥 品 的 能 力 受 到 限 制 的 藥 品 , 但 是 您 參 加 本 計 劃 已 超 過 90 天 , 我 們
將 在 您 提 出 保 賠 藥 品 清 單 例 外 情 況 申 請 的 過 程 中 為 您 的 31 天 緊 急 藥 量 提 供 保 賠 ( 除 非 您 的 處 方 藥 量 只
有 幾 天 )。
瞭 解 詳 情
如 需 瞭 解 有 關 Alliance CompleteCare 處 方 藥 保 賠 的 進 一 步 詳 情 , 請 查 閱 「 保 賠 證 明 」
及 其 他 計 劃 資 料 。
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如 果 您 對 Alliance CompleteCare 有 任 何 疑 問 , 請 電 洽 我 們 的 客 戶 服 務 部 ( 護 理 諮 詢 部 ), 電 話 號 碼 1-877-
585-7526, 營 業 時 間 為 每 週 七 天 上 午 八 時 至 下 午 八 時 。TTY 使 用 者 請 電 洽 1-800-735-
2929, 或 請 查 閱 網 站 www.alliancecompletecare.com。
如 果 您 對 Medicare 處 方 藥 保 賠 有 一 般 性 問 題 , 請 每 週 七 天 、 每 天 二 十 四 小 時 電 洽
Medicare, 電 話 號 碼 1-800-MEDICARE (1-800-633-4227)。TTY 使 用 者 請 電 洽
1-877-486-2048, 或 請 查 閱 網 站 www.medicare.gov。
Alliance CompleteCare 保 賠 藥 品 清 單
從 31 頁 開 始 的 保 賠 藥 品 清 單 列 出 有 關 Alliance CompleteCare 保 賠 的 某 些 藥 品 的 保 賠
資 訊 。 如 果 您 未 在 該 清 單 中 找 到 所 需 的 藥 品 , 請 查 閱 從 I-1 頁 開 始 的 索 引 。
該 表 的 第 一 欄 列 出 藥 品 名 稱 。 專 利 藥 用 大 寫 字 母 列 出 ( 例 如 ,ZITHROMAX), 非 專 利 藥 用 小 寫 字 母 及
斜 體 列 出 ( 例 如 ,azithromycin)。
「 註 釋 」 欄 目 中 的 資 訊 列 出 Alliance CompleteCare 對 您 使 用 的 藥 品 保 賠 是 否 有 任 何 特 殊 的 要 求 。
• QL — 表 示 藥 品 的 使 用 有 「 數 量 限 制 」。 這 表 示 Alliance CompleteCare 會 限 制 在
指 定 階 段 內 藥 品 的 保 賠 數 量 。
• PA — 表 示 使 用 該 藥 品 需 要 獲 得 事 先 授 權 或 批 准 。
• ST — 表 示 藥 品 的 使 用 有 「 分 級 療 法 」 要 求 。 這 表 示 您 必 須 首 先 試 用 治
療 您 的 醫 療 症 狀 的 其 他 藥 品 ,Alliance CompleteCare 才 會 為 這 種 藥 品 提 供 保 賠 。
11

¿Qué es el Formulario de Alliance CompleteCare?
Un formulario es una lista de medicamentos cubiertos que selecciona Alliance CompleteCare en
colaboración con un equipo de proveedores de atención médica, el cual representa las terapias de
medicamentos recetados que se cree que son una parte necesaria de un programa de tratamiento de calidad.
Alliance CompleteCare generalmente cubrirá los medicamentos que figuran en nuestro formulario siempre
que el medicamento sea médicamente necesario, la receta médica se surta en una farmacia de la red de
Alliance CompleteCare y se sigan las demás reglas del plan. Para obtener más información sobre cómo surtir
sus recetas médicas, revise su Evidencia de Cobertura.
¿Se puede modificar el Formulario?
Por lo general, si está tomando un medicamento que figura en nuestro formulario 2012 que estaba cubierto al
principio del año, no descontinuaremos ni reduciremos la cobertura del medicamento durante la cobertura del
año 2012, excepto cuando esté disponible un nuevo medicamento genérico menos costoso o cuando se
divulgue nueva información adversa sobre la seguridad o eficacia del medicamento. Otros tipos de cambios en
el formulario, como retirar un medicamento de la lista, no afectarán a los miembros que estén tomando el
medicamento en ese momento, el cual permanecerá disponible al mismo costo compartido para los miembros
que lo tomen durante el resto del año de cobertura. Creemos que es importante que usted tenga acceso
continuo durante el resto del año de cobertura a los medicamentos del formulario que estaban disponibles
cuando eligió nuestro plan, excepto los casos en los que pueda ahorrar más dinero o cuando podamos
garantizar su seguridad.
Si retiramos medicamentos de nuestro formulario o agregamos el requisito de una autorización previa, límites
de cantidad y/o restricciones en la terapia de pasos de un medicamento, o bien colocamos un medicamento en
un nivel de costo compartido más alto, debemos notificar el cambio a los miembros afectados al menos 60
días antes de que dicha modificación entre en vigencia, o cuando el miembro solicite surtir nuevamente un
medicamento, lo que significa que el miembro recibirá un suministro del medicamento por 60 días. Si la
Administración de Alimentos y Medicamentos considera que un medicamento de nuestro formulario no es
seguro o el fabricante de dicho medicamento lo retira del mercado, retiraremos el medicamento de nuestro
formulario inmediatamente y notificaremos este cambio a los clientes que tomen dicho medicamento. El
formulario adjunto estará vigente a partir de enero de 2012. Para obtener información actualizada sobre los
medicamentos cubiertos por Alliance CompleteCare, visite nuestro sitio web en
www.alliancecompletecare.org o llame a Servicio al Miembro (Unidad de Asesores de Atención) al 1-877-
585-7526, de 8:00 a.m. a 8:00 p.m., los 7 días de la semana. Los usuarios del sistema TTY/TDD deben llamar
al 1-800-735-2929. En el caso de que se efectúen cambios en el formulario que no sean de mantenimiento en
la mitad del año, el formulario de Alliance CompleteCare se actualizará por medio de avisos de fe de erratas.
¿Cómo utilizo el Formulario?
Hay dos maneras de encontrar un medicamento dentro del formulario:
Afección médica
El formulario comienza en la página 31. Los medicamentos de este formulario están agrupados por
categorías según el tipo de afección médica para la que se utilicen. Por ejemplo, los medicamentos que se
utilicen para tratar una afección cardíaca figuran en la categoría “Cardiac Drugs” (Medicamentos para el
12

corazón). Si sabe para qué se utiliza el medicamento que toma, busque el nombre de la categoría en la
lista que comienza en la página 31. Luego, busque el nombre de la categoría de su medicamento.
Lista por orden alfabético
Si no está seguro de cuál es la categoría, debe buscar el medicamento en el índice que comienza en la
página I-1. El índice proporciona una lista en orden alfabético de todos los medicamentos incluidos en
este documento. En el índice figuran tanto los medicamentos de marca como los genéricos. Busque su
medicamento en el índice. Junto al medicamento, figura el número de la página en donde podrá encontrar
información sobre la cobertura. Vaya a la página indicada en el índice y busque el nombre de su
medicamento en la primera columna de la lista.
¿Qué son los medicamentos genéricos?
Alliance CompleteCare ofrece cobertura tanto para medicamentos de marca como para medicamentos
genéricos. Un medicamento genérico está aprobado por la Administración de Alimentos y Medicamentos
(Food and Drug Administration, FDA) como un producto que contiene los mismos ingredientes activos que
un medicamento de marca. Por lo general, los medicamentos genéricos tienen un costo menor que los
medicamentos de marca.
¿Existe alguna restricción en mi cobertura?
Algunos medicamentos cubiertos pueden tener límites o requisitos adicionales en la cobertura. Estos
requisitos y límites pueden incluir lo siguiente:
• Autorización Previa: Alliance CompleteCare exige que usted o su médico obtengan una
autorización previa para determinados medicamentos. Esto quiere decir que usted necesitará obtener
la aprobación de Alliance CompleteCare antes de surtir sus recetas médicas. Si no obtiene la
aprobación, es posible que Alliance CompleteCare no cubra el medicamento.
• Límites de Cantidad: Para ciertos medicamentos, Alliance CompleteCare establece un límite en la
cantidad del medicamento que cubrirá. Por ejemplo, Alliance CompleteCare ofrece 9 comprimidos
por receta médica de succinato de sumatriptán. Esto podría agregarse al suministro estándar de un
mes o tres meses.
• Terapia de Pasos: En algunos casos, Alliance CompleteCare exige que usted primero pruebe
determinados medicamentos para tratar su afección médica antes de cubrir otro medicamento para
dicha afección. Por ejemplo, si el medicamento A y el medicamento B sirven para tratar su afección
médica, es posible que Alliance CompleteCare no cubra el medicamento B a menos que primero
pruebe el medicamento A. Si el medicamento A no es efectivo, Alliance CompleteCare entonces
cubrirá el medicamento B.
Puede averiguar si su medicamento tiene límites o requisitos adicionales consultando el formulario que
comienza en la página 31. Además, puede obtener más información sobre las restricciones que se aplican a
determinados medicamentos cubiertos visitando nuestro sitio web en www.alliancecompletecare.org.
Puede pedirle a Alliance CompleteCare que haga una excepción de estas restricciones o límites. Consulte la
sección, “¿Cómo solicito una excepción del Formulario de Alliance CompleteCare?” en la página 5 para
obtener información sobre cómo solicitar una excepción.
13

¿Qué sucede si mi medicamento no figura en el Formulario?
Si su medicamento no está incluido en este formulario, primero debe comunicarse con el departamento de
Servicio al Miembro (Unidad de Asesores de Atención) y confirmar que su medicamento no está cubierto. Si
se entera de que Alliance CompleteCare no cubre su medicamento, usted tendrá dos opciones:
• Puede pedirle a Servicio al Miembro (Unidad de Asesores de Atención) una lista de medicamentos
similares que estén cubiertos por Alliance CompleteCare. Cuando reciba la lista, muéstresela a su
médico y pídale que le recete un medicamento similar que sí esté cubierto por Alliance
CompleteCare.
• Puede pedirle a Alliance CompleteCare que haga una excepción y cubra su medicamento. Lea a
continuación la información sobre cómo solicitar una excepción.
¿Cómo solicito una excepción del Formulario de Alliance CompleteCare?
Puede pedirle a Alliance CompleteCare que haga una excepción de nuestras reglas de cobertura. Existen
varios tipos de excepciones que puede pedir:
• Puede pedir que cubramos el medicamento incluso si no se encuentra en nuestro formulario.
• Puede pedir que no apliquemos los límites o las restricciones de cobertura a su medicamento. Por
ejemplo, para ciertos medicamentos, Alliance CompleteCare establece un límite en la cantidad del
medicamento que cubriremos. Si su medicamento tiene un límite de cantidad, puede pedir que no
apliquemos dicho límite y cubramos más.
• Puede pedir que le proporcionemos una cobertura de un nivel más alto para su medicamento. Si su
medicamento se encuentra en nuestro segundo nivel, puede pedir que cubramos dicho medicamento
por la cantidad del costo compartido que se aplica a los medicamentos del primer nivel. Esto
reducirá la cantidad que debe pagar por su medicamento. Tenga en cuenta que si aprobamos su
solicitud de cubrir un medicamento que no figura en nuestro formulario, es posible que no pueda
pedir que le proporcionemos una cobertura de un nivel más alto para dicho medicamento.
Por lo general, Alliance CompleteCare sólo aprobará su solicitud para una excepción cuando el medicamento
alternativo incluido en el formulario del plan, el medicamento que figure en un nivel más bajo o las
restricciones de utilización adicionales no sean eficaces para tratar su afección y/o causen efectos médicos
perjudiciales para su salud.
Debe comunicarse con nosotros para solicitar una decisión inicial de cobertura para una excepción del
formulario, del nivel o de una restricción de utilización. Cuando solicite una excepción de una restricción
de utilización, de un nivel o del formulario, debe presentar una declaración de su médico que apoye su
solicitud. Generalmente, debemos tomar una decisión en un plazo de 72 horas después de recibir la
declaración de apoyo del médico o personal médico con autoridad para recetar el medicamento. Puede
solicitar una excepción rápida si usted o su médico creen que su salud podría verse gravemente perjudicada
si espera 72 horas para recibir la decisión. Si se acepta su solicitud de excepción rápida, debemos
comunicarle una decisión antes de las 24 horas de haber recibido la declaración de apoyo del médico o
personal médico con autoridad para recetar el medicamento.
14

¿Qué debo hacer antes de hablar con mi médico para cambiar mis medicamentos o
solicitar una excepción?
Como miembro nuevo o continuo de nuestro plan, es posible que esté tomando medicamentos que no se
encuentren en nuestro formulario. O bien, puede estar tomando un medicamento que figura en nuestro
formulario, pero su posibilidad para obtenerlo es limitada. Por ejemplo, es posible que necesite una
autorización previa de nuestra parte antes de poder surtir su receta médica. Debe hablar con su médico para
decidir si debe cambiar a un medicamento adecuado que cubramos o solicitar una excepción del formulario
para que cubramos el medicamento que toma. Mientras habla con su médico para determinar las medidas
correctas que se deben tomar, es posible que cubramos el medicamento en ciertos casos durante los primeros
90 días después de que comience a ser miembro de nuestro plan.
Para cada medicamento que no esté en nuestro formulario, o si su posibilidad de obtener un medicamento es
limitada, cubriremos un suministro temporal de 30 días (a menos que tenga una receta médica escrita que
indique menos días) cuando vaya a una farmacia de la red. Después del primer suministro de 30 días, ya no
pagaremos estos medicamentos, incluso si ha sido miembro del plan durante un plazo menor de 90 días.
Si es residente de un centro de atención a largo plazo, cubriremos un suministro temporal de transición de 31
días (a menos que tenga una receta médica escrita por menos días). Cubriremos más de un surtido de estos
medicamentos durante los primeros 90 días desde que comience a ser miembro de nuestro plan. Si necesita
un medicamento que no está en nuestro formulario o si su posibilidad de obtener el medicamento es limitada
pero han pasado los primeros 90 días de membresía en nuestro plan, cubriremos un suministro de emergencia
de 31 días para ese medicamento (a menos que tenga una receta médica escrita por menos días) mientras
usted prepara la solicitud de excepción del formulario.
Para obtener más información
Para obtener información más detallada sobre la cobertura de medicamentos recetados de Alliance
CompleteCare, revise su Evidencia de Cobertura y los demás materiales del plan.
Si tiene alguna pregunta sobre Alliance CompleteCare, llame a Servicio al Miembro (Unidad de Asesores de
Atención) al 1-877-585-7526, de 8:00 a.m. a 8:00 p.m., los 7 días de la semana. Los usuarios del sistema
TTY/TDD deben llamar al 1-800-735-2929 o bien, visite el sitio www.alliancecompletecare.com.
Si tiene preguntas generales sobre la cobertura de medicamentos recetados de Medicare, llame a Medicare al
1-800-MEDICARE (1-800-633-4227), las 24 horas del día, los 7 días de la semana. Los usuarios del sistema
TTY/TDD deben llamar al 1-877-486-2048 o bien, visite el sitio www.medicare.gov.
Formulario de Alliance CompleteCare
El formulario que figura a continuación ofrece información sobre la cobertura de algunos de los
medicamentos cubiertos por Alliance CompleteCare. Si tiene problemas para encontrar un medicamento en
la lista, consulte el índice que comienza en la página I-1.
La primera columna de la tabla indica el nombre del medicamento. Los medicamentos de marca están
escritos en letra mayúscula (por ejemplo, ZITHROMAX) y los medicamentos genéricos figuran en letra
minúscula y en cursiva (por ejemplo, azithromycin).
15

La información de la columna “Notes” (Notas) le indica si Alliance CompleteCare tiene algún requisito
especial para la cobertura de su medicamento.
• QL: Significa que existen Límites de Cantidad (Quantity Limits) en el uso del medicamento. Esto
quiere decir que Alliance CompleteCare establece un límite en la cantidad del medicamento que
estará cubierto durante un período específico.
• PA: Significa que usted necesitará obtener una Autorización Previa (Prior Authorization) o
aprobación para utilizar este medicamento.
• ST: Indica que se aplican requisitos de Terapia de Pasos (Step Therapy) para el uso del
medicamento. Esto quiere decir que usted tendrá que probar otros medicamentos específicos para
tratar su afección médica antes de que Alliance CompleteCare cubra el medicamento.
16

The following abbreviations may be found within the body of this document:
COVERAGE NOTES ABBREVIATIONS
ABBREVIATION DESCRIPTION EXPLANATION
Utilization Management Restrictions
PA
QL
ST
Prior Authorization
Restriction
Quantity Limit Restriction
Step Therapy Restriction
Other Special Requirements for Coverage
HI
Home Infusion Drug
You (or your physician) are required to get
prior authorization from Alliance CompleteCare
before you fill your prescription for this drug.
Without prior approval, Alliance CompleteCare
may not cover this drug.
Alliance CompleteCare limits the amount of
this drug that is covered per prescription, or
within a specific time frame.
Before Alliance CompleteCare will provide
coverage for this drug, you must first try
another drug(s) to treat your medical condition.
This drug may only be covered if the other
drug(s) does not work for you.
This prescription drug may be covered under
our medical benefit. For more information, call
the Care Advisor Unit at 1-877-585-7526, 8:00
a.m. to 8:00 p.m., seven days a week.
(TTY/TDD users should call 1-800-735-2929.)
17

Strength and Dosage Form Abbreviations
ABBREVIATION
DESCRIPTION
adh. patch
adhesive patch
aer pow ba
aerosol powder, breath activated
aer refill
aerosol refill
aer w/adap
aerosol with adapter
ampul
ampule
blkbaginj
bulk bag injection
cap dr mp
capsule, delayed release, multiphasic
cap ds pk
capsule, dose pack
cap sprink
capsule, sprinkle
cap sr pel
capsule sustained release pellet
cap w/dev
capsule with device
cap.sa 24h
capsule, 24 hour sustained action
cap.sr 12h
capsule, sustained release 12 hour
cap.sr 24h
capsule, sustained release 24 hour
cap24h pel
capsule, 24 hour sustained release pellets
capsule cr
capsule, controlled release
capsule dr
capsule, delayed release
capsule sa
capsule, sustained action
combo. pkg
combination package
cpmp 12hr
capsule, multiphasic, 12 hour
cpmp 24hr
capsule, multiphasic, 24 hour
cpmp 30-70 capsule, multiphasic, 30%-70%
cpmp 50-50 capsule, multiphasic, 50%-50%
cream(gm)
cream (grams)
cream/appl
cream with applicator
crm sr(gm)
cream, sustained release (grams)
dehp fr bg
di(2-ethylhexyl)phthalate free bag
dis needle
needle, disposable
disk w/dev
disk with inhalation device
disp syrin
disposable syringe
drop recon
drops, reconstituted
drops susp
drops, suspension
emul packt
emulsion packet
foam/appl.
aerosol, foam with applicator
froz.piggy
frozen piggyback
g
gram
gel (gm)
gel (grams)
gel md pmp
gel in metered dose pump
gel (ml)
gel (milliliters)
gel w/appl
gel with applicator
gel/pf app
gel with prefilled applicator
18

ABBREVIATION
gran pack
hfa aer ad
infus. btl
insuln pen
irrig soln
iv soln.
jel
kt crm cs
kt oint cs
kt tpsp cc
lozenge hd
m.ht patch
mcg
med. pad
med. swab
med. tape
mg
ml
muc sr 12h
oint.(gm)
oral conc.
oral susp
paste (gm)
patch td24
patch td72
patch tdsw
patch tdwk
pca syring
pca vial
pe/2
pe/10
pen ij kit
pen injctr
pggybk btl
powd pack
sol/pf app
sol-gel
soln recon
spray susp
supp.rect
supp.vag
sus mc rec
sus sr rec
DESCRIPTION
granule pack
hfa aerosol adapter
infusion bottle
insulin pen
solution, irrigating
intravenous solution
jelly
kit, cream corticosteroid
kit, ointment corticosteroid
kit, topical suspension and complimentary cream
lozenge handle
medicated, heated patch
microgram
medicated pad
medicated swab
medicated tape
milligram
milliliter
mucoadhesive system, 12 hour sustained release
ointment (grams)
concentrate, oral
oral suspension
paste (grams)
patch, transdermal 24 hour
patch, transdermal 72 hour
patch, transdermal biweekly
patch, transdermal weekly
patient controlled analgesic syringe
patient controlled analgesic vial
phenytoin sodium equivalent units per 2 milliliter vial
phenytoin sodium equivalent units per 10 milliliter vial
pen injector kit
pen injector
piggyback intravenous bottle
powder pack
solution with pre-filled applicator
gel-forming solution
solution, reconstituted, oral
spray, suspension
suppository, rectal
suppository, vaginal
suspension, microcapsule reconstituted
suspension, sustained release, reconstituted
19

ABBREVIATION
DESCRIPTION
suspdr pkt
suspension, delayed release packet
susp recon
suspension, reconstituted
syringekit
syringe kit
tab chew
tablet, chewable
tab disper
tablet, dispersable
tab ds pk
tablet, dose pack
tab er2 24 tablet, extended release 24 hour (2)
tab mphase
tablet, multiphasic
tab osm 24
tablet, osmotic 24 hour
tab part
tablet, particles
tab prt sr
tablet, sustained release particles
tab rap dr
tablet, rapid disintegrating, delayed release
tab rapdis
tablet, rapid disintegrating
tab subl
tablet, sublingual
tab.sr 12h
tablet, sustained release, 12 hour
tab.sr 24h
tablet, sustained release, 24 hour
tablet dr
tablet, delayed release
tablet eff
tablet, effervescent
tablet sa
tablet, sustained action
tablet sol
tablet, soluble
tabsrgr24h
tablets regular 24 hour release
tbdspk 3mo
tablet, dose pack, 3 months
tbmp 12hr
tablet, multiphasic, 12 hour
tbmp 24hr
tablet, multiphasic, 24 hour
u
unit
vag ring
vaginal ring
20

以 下 略 語 可 能 會 出 現 在 此 文 件 中 :
承 保 項 目 註 釋 略 語
略 語 說 明 解 釋
藥 物 福 利 使 用 管 理 限 制
您 ( 或 您 的 醫 生 ) 必 須 在 您 領 取 本 處 方 藥 之 前 獲 得 Alli
PA
QL
ST
其 他 特 殊 的 承 保 術 語
HI
事 先 授 權 限 制
數 量 限 制
逐 步 漸 進 治 療 限
制
居 家 輸 液 藥 物
ance CompleteCare 的 事 先 授 權 。
未 經 事 先 授 權 ,Alliance
CompleteCare 可 能 不 會 為 本 藥 物 提 供 承 保 。
Alliance
CompleteCare 針 對 為 每 份 處 方 或 具 體 時 段 內 所 承 保 的 藥
量 設 有 限 制 。
在 Alliance
CompleteCare 為 本 藥 物 提 供 承 保 之 前 , 您 必 須 首 先 試
用 另 一 種 治 療 您 病 症 的 藥 物 。
可 能 僅 在 另 一 種 藥 物 對 您 無 療 效
的 情 況 下 , 才 會 承 保 此 藥 物 。
此 類 處 方 藥 可 由 本 醫 療 保 險 計 畫 承 保 。
若 需 詳 細 資 訊 ,
請 致 電 醫 療 保 健 顧 問 科 , 電 話 號 碼 是 1-877-585-7526,
每 週 七 天 服 務 , 服 務 時 間 為 早 上 8 點 至 晚 上 8 點 。
(TTY/TDD 專 線 使 用 者 請 撥 1-800-735-2929。)
21

藥 物 強 度 與 劑 量 之 略 語 清 單
略 語
adh. patch
aer pow ba
aer refill
aer w/adap
ampul
blkbaginj
cap dr mp
說 明
黏 性 藥 貼 片
氣 溶 膠 粉 , 呼 吸 啟 動 式
氣 溶 膠 補 充 劑
氣 溶 膠 , 帶 適 配 器
安 瓿
集 裝 袋 注 射 劑
膠 囊 , 緩 釋 劑 , 多 階 段 釋 出
cap ds pk
膠 囊 , 一 劑 量 封 裝 包
cap sprink
膠 囊 , 分 撒 型
cap sr pel
膠 囊 , 持 續 釋 出 顆 粒
cap w/dev
膠 囊 , 帶 裝 置
cap.sa 24h
膠 囊 ,24 小 時 持 續 藥 效
cap.sr 12h
膠 囊 ,12 小 時 持 續 釋 出
cap.sr 24h
膠 囊 ,24 小 時 持 續 釋 出
cap24h pel
膠 囊 ,24 小 時 持 續 釋 出 顆 粒
capsule cr
膠 囊 , 受 控 釋 出
capsule dr
膠 囊 , 緩 釋 劑
capsule sa
膠 囊 , 持 續 藥 效
combo. pkg
組 合 封 裝
cpmp 12hr
膠 囊 , 多 階 段 釋 出 ,12 小 時
cpmp 24hr
膠 囊 , 多 階 段 釋 出 ,24 小 時
cpmp 30-70 膠 囊 , 多 階 段 釋 出 ,30%-70%
cpmp 50-50 膠 囊 , 多 階 段 釋 出 ,50%-50%
cream(gm) 乳 膏 ( 公 克 )
cream/appl
乳 膏 , 帶 注 藥 器
crm sr(gm) 乳 膏 , 持 續 釋 出 ( 公 克 )
dehp fr bg
不 含 (2- 乙 基 已 基 ) 鄰 苯 二 甲 酸 酯 類 的 封 裝 袋
22

略 語
說 明
dis needle
針 頭 , 用 後 棄 置 型
disk w/dev
圓 盤 , 帶 吸 入 劑 裝 置
disp syrin
用 後 棄 置 型 注 射 器
drop recon
滴 劑 , 復 水 型
drops susp
滴 劑 , 懸 液 劑
emul packt
乳 劑 封 裝 包
foam/appl.
氣 溶 膠 , 泡 沫 型 , 帶 注 藥 器
froz.piggy
冷 凍 藥 劑 袋
g
公 克
gel (gm) 凝 膠 ( 公 克 )
gel md pmp
凝 膠 , 裝 在 定 量 藥 劑 泵 瓶 內
gel (ml) 凝 膠 ( 毫 升 )
gel w/appl
凝 膠 , 帶 注 藥 器
gel/pf app
凝 膠 , 帶 預 灌 藥 注 藥 器
gran pack
成 包 顆 粒
hfa aer ad
hfa 氣 溶 膠 適 配 器
infus. btl
輸 液 瓶
insuln pen
筆 形 胰 島 素 注 射 器
irrig soln
沖 洗 劑
iv soln.
靜 脈 注 射 劑
jel
凝 膠 劑
kt crm cs
套 裝 皮 質 激 素 乳 膏
kt oint cs
套 裝 皮 質 激 素 油 膏
kt tpsp cc
套 裝 外 用 懸 液 劑 及 免 費 贈 送 軟 膏
lozenge hd
m.ht patch
mcg
med. pad
med. swab
菱 形 握 柄
含 藥 熱 貼 片
微 克
含 藥 墊
含 藥 棉 籤
23

略 語
med. tape
mg
ml
muc sr 12h
說 明
含 藥 膠 貼 布
毫 克
毫 升
黏 膜 給 藥 系 統 ,12 小 時 持 續 釋 出
oint.(gm) 油 膏 ( 公 克 )
oral conc.
oral susp
濃 縮 劑 , 口 服 藥
口 服 懸 液 劑
paste (gm) 軟 膏 ( 公 克 )
patch td24
patch td72
patch tdsw
patch tdwk
pca syring
pca vial
pe/2
pe/10
pen ij kit
pen injctr
pggybk btl
powd pack
sol/pf app
sol-gel
soln recon
spray susp
supp.rect
supp.vag
sus mc rec
sus sr rec
suspdr pkt
藥 貼 片 , 經 皮 膚 吸 收 ,24 小 時 藥 效
藥 貼 片 , 經 皮 膚 吸 收 ,72 小 時 藥 效
藥 貼 片 , 經 皮 膚 吸 收 , 每 兩 週 一 次
藥 貼 片 , 經 皮 膚 吸 收 , 每 週 一 次
患 者 自 行 使 用 的 鎮 痛 藥 注 射 器
患 者 自 行 使 用 的 管 裝 鎮 痛 藥 注 射 劑
苯 妥 英 納 等 效 單 位 2 毫 升 針 劑
苯 妥 英 納 等 效 單 位 10 毫 升 針 劑
筆 形 注 射 器 用 具 包
筆 形 注 射 器
借 道 靜 脈 輸 液 吊 瓶
粉 劑 封 裝 包
藥 液 , 帶 預 灌 藥 注 藥 器
膠 體 藥 液
藥 液 , 復 水 型 , 口 服
噴 霧 劑 , 懸 液 劑
栓 劑 , 直 腸
栓 劑 , 陰 道
栓 劑 , 復 水 型 微 型 膠 囊
栓 劑 , 持 續 釋 出 , 復 水 型
栓 劑 , 緩 釋 劑 封 裝 包
24

略 語
說 明
susp recon
栓 劑 , 復 水 型
syringekit
注 射 器 用 具 包
tab chew
片 劑 , 口 嚼 片
tab disper
片 劑 , 水 散 片 劑
tab ds pk
片 劑 , 一 劑 量 封 裝
tab er2 24 片 劑 ,24 小 時 持 續 釋 出 (2)
tab mphase
片 劑 , 多 階 段 釋 出
tab osm 24
片 劑 ,24 小 時 滲 透 釋 出
tab part
片 劑 , 微 粒
tab prt sr
片 劑 , 持 續 釋 出 微 粒
tab rap dr
片 劑 , 速 溶 , 緩 釋 劑
tab rapdis
片 劑 , 速 溶
tab subl
片 劑 , 舌 下 含 服
tab.sr 12h
片 劑 ,12 小 時 持 續 釋 出
tab.sr 24h
片 劑 ,24 小 時 持 續 釋 出
tablet dr
片 劑 , 緩 釋 劑
tablet eff
片 劑 , 泡 腾 片
tablet sa
片 劑 , 持 續 藥 效
tablet sol
片 劑 , 水 溶 式
tabsrgr24h
片 劑 , 標 準 24 小 時 釋 出
tbdspk 3mo
片 劑 , 一 劑 量 封 裝 ,3 個 月 用 藥 量
tbmp 12hr
片 劑 , 多 階 段 釋 出 ,12 小 時
tbmp 24hr
片 劑 , 多 階 段 釋 出 ,24 小 時
u
單 位
vag ring
陰 道 避 孕 環
25

Las siguientes abreviaturas pueden aparecer en el cuerpo de este documento:
ABREVIATURAS DE LAS NOTAS DE COBERTURA
ABREVIATURA DESCRIPCIÓN EXPLICACIÓN
Restricciones de gestión de utilización
PA
QL
ST
Otros requisitos especiales de cobertura
HI
Requiere autorización
previa
Restricción de límite de
cantidad
Restricción de terapia de
pasos
Medicamentos de infusión
en el hogar
Usted (o su médico) tienen que obtener la
autorización previa de Alliance CompleteCare
antes de surtir la receta de este medicamento.
Sin la autorización previa, Alliance
CompleteCare podría no cubrir este
medicamento.
Alliance CompleteCare establece un límite en
la cantidad de este medicamento que está
cubierto por cada receta, o dentro de un lapso
de tiempo específico.
Antes de que Alliance CompleteCare provea
la cobertura de este medicamento, primero
debe probar otros medicamentos para tratar su
afección médica. Este medicamento podría
sólo estar cubierto si los demás medicamentos
no le surten efecto.
Este medicamento recetado puede estar
cubierto por nuestro beneficio médico. Para
obtener más información, llame a la Unidad
de Asesoramiento de Atención al 1-877-585-
7526, de 8:00 a.m. a 8:00 p.m., los siete días
de la semana. (Los usuarios de TTY/TDD
deben llamar al 1-800-735-2929.)
26

ABREVIATURAS DE CONCENTRACIÓN Y FORMA FARMACÉUTICA
ABREVIATURA
DESCRIPCIÓN
adh. patch
parche adhesivo
aer pow ba
polvo en aerosol activado con aliento
aer refill
reabastecimiento de aerosol
aer w/adap
aerosol con adaptador
ampul
ampolla
blkbaginj
inyección en bolsa a granel
cap dr mp
cápsula multifásica de liberación retardada
cap ds pk
cápsula en paquete de dosis
cap sprink
cápsula espolvoreable
cap sr pel
pildorita en cápsula de liberación prolongada
cap w/dev
cápsula con aparato
cap.sa 24h
cápsula de acción prolongada de 24 horas
cap.sr 12h
cápsula de liberación prolongada de 12 horas
cap.sr 24h
cápsula de liberación prolongada de 24 horas
cap24h pel
cápsula con pildoritas de liberación prolongada de 24 horas
capsule cr
cápsula de liberación controlada
capsule dr
cápsula de liberación retardada
capsule sa
cápsula de acción prolongada
combo. pkg
paquete combinado
cpmp 12hr
cápsula multifásica, 12 horas
cpmp 24hr
cápsula multifásica, 24 horas
cpmp 30-70 cápsula multifásica, 30%-70%
cpmp 50-50 cápsula multifásica, 50%-50%
cream(gm)
crema (gramos)
cream/appl
crema con aplicador
crm sr(gm)
crema de liberación prolongada (gramos)
dehp fr bg
bolsa sin di(2-etilhexil)ftalato
dis needle
aguja desechable
disk w/dev
disco con dispositivo para inhalación
disp syrin
jeringa desechable
drop recon
gotas reconstituidas
drops susp
suspensión en gotas
emul packt
paquete de emulsión
foam/appl.
espuma en aerosol con aplicador
froz.piggy
infusión intravenosa congelada
g
gramo
gel (gm)
gel (gramos)
gel md pmp
gel en bomba de dosis medida
gel (ml)
gel (mililitros)
gel w/appl
gel con aplicador
gel/pf app
gel con aplicador
gran pack
paquete de gránulos
27

ABREVIATURA
hfa aer ad
infus. btl
insuln pen
irrig soln
iv soln.
jel
kt crm cs
kt oint cs
kt tpsp cc
lozenge hd
m.ht patch
mcg
med. pad
med. swab
med. tape
mg
ml
muc sr 12h
oint.(gm)
oral conc.
oral susp
paste (gm)
patch td24
patch td72
patch tdsw
patch tdwk
pca syring
pca vial
pe/2
pe/10
pen ij kit
pen injctr
pggybk btl
powd pack
sol/pf app
sol-gel
soln recon
spray susp
supp.rect
supp.vag
sus mc rec
sus sr rec
DESCRIPCIÓN
adaptador para aerosol de hidrofluoroalcanos
botella de infusión
pluma de insulina
solución para irrigación
solución intravenosa
jalea
estuche de crema con corticosteroides
estuche de ungüento con corticosteroides
estuche de suspensión tópica y crema de obsequio
comprimidos para chupar
parche caliente medicinal
microgramo
almohadilla medicinal
hisopo medicinal
cinta medicinal
miligramo
mililitro
sistema mucoadhesivo de liberación prolongada de 12 horas
ungüento (gramos)
concentrado oral
suspensión oral
pasta (gramos)
parche transdérmico, 24 horas
parche transdérmico, 72 horas
parche transdérmico quincenal
parche transdérmico semanal
jeringa con analgésico controlado por el paciente
ampolleta con analgésico controlado por el paciente
unidades equivalentes de fenitoína sódica por ampolleta de 2
mililitros
unidades equivalentes de fenitoína sódica por ampolleta de10
mililitros
estuche con pluma de inyección
pluma de inyección
botella de infusión intravenosa
paquete de polvo
solución con aplicador prellenado
solución en forma de gel
solución reconstituida oral
suspensión en pulverizador
supositorio rectal
supositorio vaginal
suspensión en microcápsula reconstituida
suspensión reconstituida de liberación prolongada
28

ABREVIATURA
DESCRIPCIÓN
suspdr pkt
paquete con suspensión de liberación retardada
susp recon
suspensión reconstituida
syringekit
estuche de jeringas
tab chew
tableta masticable
tab disper
tableta dispersable
tab ds pk
paquete de dosis en tabletas
tab er2 24 tableta de liberación extendida, 24 horas (2)
tab mphase
tableta multifásica
tab osm 24
tableta osmótica, 24 horas
tab part
partículas de tableta
tab prt sr
tableta con partículas de liberación prolongada
tab rap dr
tableta de desintegración rápida y liberación prolongada
tab rapdis
tableta de desintegración rápida
tab subl
tableta sublingual
tab.sr 12 horas
cápsula de liberación prolongada, 12 horas
tab.sr 24 horas
cápsula de liberación prolongada, 24 horas
tablet dr
tableta de liberación retardada
tablet eff
tableta efervescente
tablet sa
tableta de acción prolongada
tablet sol
tableta, soluble
tabsrgr24h
tabletas de liberación normal de 24 horas
tbdspk 3mo
paquete de dosis de tabletas, 3 meses
tbmp 12hr
tableta multifásica, 12 horas
tbmp 24hr
tableta multifásica, 24 horas
u
unidad
vag ring
anillo vaginal
29

For help or information,
please call the Care Advisor Unit
(Member Services):
如 需 獲 得 幫 助 或 瞭 解 資 訊 ,
請 電 洽 護 理 諮 詢 部
( 會 員 服 務 部 ):
Para obtener ayuda o información,
llame al departamento de Asesores de Atención
(Servicios al Cliente):
Toll-free numbers:
免 費 號 碼 :
Números gratuitos:
1-877-585-7526
(TTY 1-800-735-2929)
8 a.m. – 8 p.m., seven days a week
每 週 七 天 上 午 八 時 至 下 午 八 時
8 a.m. – 8 p.m., los siete días de la semana
Alameda Alliance for Health
1240 South Loop Road
Alameda, California 94502
www.alliancecompletecare.org
30

Drug Name
Acidifying and Alkalinizing Agents
Acidifying and Alkalinizing Agents
Drug
Tier
Requirements/Limits
ammonium chloride (Ammonium Chloride) 1
citric acid/sodium citrate (Bicitra) 1
K-PHOS M.F. 2
K-PHOS NO.2 2
phosphorus #1 (K-phos Neutral) 1
potassium citrate (Urocit-K) 1
potassium citrate/citric (Polycitra-k) 1
acid
sod/pot/k cit/sod cit/cit (Polycitra-lc) 1
acid
sodium bicarbonate (Sodium Bicarbonate) 1 disp syrin: 0.5meq/
ml; iv soln., vial
sodium bicarbonate (Sodium Bicarbonate) 1 disp syrin: 0.9meq/
ml, 1meq/ml
sodium lactate (Sodium Lactate) 1 vial
Adrenals
Adrenals
ADVAIR DISKUS 2 QL: 62 in
31 days
ADVAIR HFA 2 QL: 12 in
28 days
betamet acet/betamet na (Celestone) 1 PA
ph
budesonide (Entocort EC) 1 capdr & er
cortisone acetate (Cortisone Acetate) 1 PA
DEPO-MEDROL 2 PA vial: 20mg/ml
dexamethasone sod (Dexamethasone Sod Phosphate) 1 PA vial: 10mg/ml
phosphate
dexamethasone sod (Dexamethasone Sod Phosphate) 1 PA vial: 4mg/ml
phosphate
dexamethasone (Dexamethasone) 1 PA elixir, tablet
dexamethasone (Dexpak) 1 PA tab ds pk
DULERA 2 QL: 13 in
28 days
FLOVENT DISKUS 2 QL: 120
in 30
days
disk w/dev: 250mcg
31
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
FLOVENT DISKUS 2 QL: 60 in disk w/dev: 50mcg,
30 days 100mcg
FLOVENT HFA 2 QL: 12 in aer w/adap: 110mcg
28 days
FLOVENT HFA 2 QL: 21.2 aer w/adap: 44mcg
in 28
days
FLOVENT HFA 2 QL: 24 in aer w/adap: 220mcg
28 days
fludrocortisone acetate (Florinef Acetate) 1
hydrocortisone sod (Hydrocortisone Sod Succinate) 1 PA vial: 100mg
succinate
hydrocortisone (Cortef) 1 PA
methylprednisolone (Depo-medrol) 1 PA
acetate
methylprednisolone sod (Solu-medrol) 1 PA
succ
methylprednisolone (Medrol) 1 PA
prednisolone acetate (Prednisolone Acetate) 1 PA
prednisolone sod (Orapred) 1 PA
phosphate
prednisolone (Prednisolone) 1 PA
PREDNISONE
2 PA
INTENSOL
prednisone (Prednisone) 1 PA solution, tablet
prednisone (Prednisone) 1 PA tab ds pk
QVAR 2 QL: 17.4
in 25
days
SOLU-MEDROL 2 PA vial: 2g
SYMBICORT 2 QL: 11 in hfa aer ad: 80-
25 days 4.5mcg, 160-4.5mcg
triamcinolone acetonide (Kenalog-40) 1 PA
VERIPRED 20 1 PA
Adrenocortical Insufficiency
Adrenocortical Insufficiency
ACTHAR H.P. 2 PA, QL:
45 in 28
days
32
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Alpha-Adrenergic Blocking Agents
Alpha-Adrenergic Blocking Agents
Drug
Tier
Requirements/Limits
doxazosin mesylate (Cardura) 1
prazosin hcl (Minipress) 1
terazosin hcl (Hytrin) 1
Ammonia Detoxicants
Ammonia Detoxicants
BUPHENYL 2
CARBAGLU 2
lactulose (Lactulose) 1 solution
lactulose (Lactulose) 1 syrup
LITHOSTAT 2
Analgesics and Antipyretics
Analgesics And Antipyretics, Miscellaneous
acetaminophen/phenyltolx
cit
(Staflex) 1 tablet: 500mg-
30mg, 500mg-
50mg, 650mg-
50mg, 650mg-60mg
(Durabac Forte) 1
mg sal/acetaminophn/ptlox/caf
OFIRMEV 2
sal-amide/acetamin/p-tlox/ (Durabac) 1
caff
sal-amide/acetaminophn/ (Asp) 1
p-tlox
salicylamide/
(Salicylamide/acetaminophen) 1
acetaminophen
Nonsteroidal Anti-inflammatory Agents
aspirin (Easprin) 1
CALDOLOR 2
CELEBREX 2 ST, QL:
62 in 31
days
choline sal/mag salicylate (Choline Sal/mag Salicylate) 1
diclofenac potassium (Cataflam) 1
diclofenac sodium (Voltaren) 1
diflunisal (Diflunisal) 1
etodolac (Etodolac) 1
fenoprofen calcium (Fenoprofen Calcium) 1
flurbiprofen (Ansaid) 1
33
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
ibuprofen (Motrin) 1
INDOCIN 2 oral susp
indomethacin sodium (Indocin I.v.) 1
trihydrate
indomethacin (Indomethacin) 1
ketoprofen (Ketoprofen) 1
ketorolac tromethamine (Ketorolac Tromethamine) 1 QL: 40 in vial: 15mg/ml
31 days
ketorolac tromethamine (Toradol) 1 QL: 20 in cartridge: 30mg/ml
31 days
ketorolac tromethamine (Toradol) 1 QL: 20 in tablet, vial: 60mg/
31 days 2ml
ketorolac tromethamine (Toradol) 1 QL: 40 in cartridge: 15mg/ml
31 days
magnesium salicylate (Novasal) 1
meclofenamate sodium (Meclofenamate Sodium) 1
mefenamic acid (Ponstel) 1
meloxicam (Mobic) 1
methyl salicylate (Methyl Salicylate) 1
nabumetone (Relafen) 1
naproxen sodium (Anaprox) 1
naproxen (Naprosyn) 1
oxaprozin (Daypro) 1
phenylbutazone (Phenylbutazone) 1
piroxicam (Feldene) 1
salsalate (Salflex) 1
sulindac (Clinoril) 1
tolmetin sodium (Tolmetin Sodium) 1
VIMOVO 2 ST
VOLTAREN 2 ST gel (gram)
Opiate Agonists
acetaminophen with
codeine
(Tylenol-codeine No.3) 1 tablet: 300mg-
15mg, 300mg-
30mg, 300mg-60mg
acetaminophen with
codeine
(Tylenol-codeine No.3) 1 tablet: 650mg-
30mg, 650mg-60mg
ASTRAMORPH-PF 1
codeine phos/
(Codeine Phos/acetaminophen) 1
acetaminophen
codeine phosphate (Codeine Phosphate) 1
codeine sulf (Codeine Sulf) 1
34
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
codeine/butalbit/acetamin/ (Fioricet with Codeine) 1
caff
codeine/butalbital/asa/ (Fiorinal with Codeine #3) 1
caffein
dhcodeine bt/
(Dhcodeine Bt/acetaminophn/ 1 capsule
acetaminophn/caff caff)
dhcodeine bt/
(Panlor SS) 1 tablet
acetaminophn/caff
fentanyl citrate (Actiq) 2 PA, QL:
120 in 30
days
fentanyl (Duragesic) 1 PA, QL:
10 in 30
days
patch td72: 12mcg/
hr, 25mcg/hr,
50mcg/hr, 75mcg/hr
fentanyl (Duragesic) 1 PA, QL:
20 in 30
days
hydrocodone bit/
acetaminophen
patch td72: 100mcg/
hr
(Vicodin) 1 capsule, solution:
7.5-325/15, 7.5-500/
15; tablet
hydrocodone bit/
acetaminophen
(Zamicet) 1 solution: 10-300/15,
10-325/cup
hydrocodone/ibuprofen (Vicoprofen) 1
hydromorphone hcl (Dilaudid) 1 tablet
hydromorphone hcl (Dilaudid) 1 vial
hydromorphone hcl/pf (Dilaudid) 1 ampul: 10mg/ml
hydromorphone hcl/pf (Hydromorphone HCl/PF) 1 ampul: 4mg/ml;
disp syrin
ibuprofen/oxycodone hcl (Combunox) 1
KADIAN 2 ST, QL:
120 in 30
days
KADIAN 2 ST, QL:
60 in 30
days
cap er pel: 200mg
cap er pel: 10mg
levorphanol tartrate (Levo-dromoran) 1
methadone hcl (Methadose) 1 oral conc, solution,
tablet, vial
methadone hcl (Methadose) 1 tablet sol
morphine sulfate in 0.9 %
nacl
(Morphine Sulfate In 0.9 %
NaCl)
35
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10
1

Drug Name
Drug
Tier
Requirements/Limits
morphine sulfate (Kadian) 1 ST, QL:
60 in 30
days
cap er pel: 20mg,
30mg, 50mg, 60mg,
80mg
morphine sulfate (Kadian) 2 ST, QL: cap er pel: 100mg
60 in 30
days
morphine sulfate (Morphine Sulfate) 1 ampul, disp syrin,
pen injctr, supp.rect,
vial
morphine sulfate (MS Contin) 1 solution, tablet,
tablet er
morphine sulfate/0.9% (Morphine Sulfate/0.9% Nacl/ 1
nacl/pf
PF)
morphine sulfate/d5w (Morphine Sulfate/D5W) 1
morphine sulfate/pf (Morphine Sulfate/PF) 1 pca vial, vial:
0.5mg/ml, 1mg/ml
morphine sulfate/pf (Morphine Sulfate/PF) 1 vial: 25mg/ml
NUCYNTA ER 2 QL: 60 in
30 days
NUCYNTA 2 QL: 181
in 30
days
oxycodone hcl (Oxycodone HCl) 1 QL: 124 tab er 12h: 80mg
in 31
days
oxycodone hcl (Oxycodone HCl) 1 QL: 93 in tab er 12h: 10mg,
31 days 20mg, 40mg
oxycodone hcl (Roxicodone) 1 capsule, oral conc,
tablet: 5mg, 15mg,
30mg
oxycodone hcl (Roxicodone) 1 solution, tablet:
10mg, 20mg
oxycodone hcl/
(Percocet) 1
acetaminophen
oxycodone hcl/aspirin (Percodan) 1
oxycodone hcl/oxycodon (Oxycodone HCl/oxycodon Ter/ 1
ter/asa
asa)
OXYCONTIN 2 QL: 120
in 30
days
tab er 12h: 60mg,
80mg
36
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
OXYCONTIN 2 QL: 60 in tab er 12h: 10mg,
30 days 15mg, 20mg, 30mg,
40mg
oxymorphone hcl (Opana) 1
tramadol hcl (Ultram) 1 tab er 24h, tablet
tramadol hcl/
(Ultracet) 1
acetaminophen
Opiate Partial Agonists
BUPRENEX 2
buprenorphine hcl (Subutex) 1
butorphanol tartrate (Butorphanol Tartrate) 1 disp syrin
butorphanol tartrate (Butorphanol Tartrate) 1 QL: 5 in spray
28 days
nalbuphine hcl (Nubain) 1
SUBOXONE 2
Androgens
Androgens
ANADROL-50 2
ANDRODERM 2 QL: 30 in patch td24: 2mg/
30 days 24hr, 4mg/24hr
ANDRODERM 2 QL: 30 in patch td24: 5mg/
30 days 24hr
ANDRODERM 2 QL: 60 in patch td24: 2.5mg/
30 days 24hr
ANDROGEL 2 QL: 300
in 30
days
AXIRON 2 QL: 180
in 28
days
danazol (Danocrine) 1
fluoxymesterone (Fluoxymesterone) 1
oxandrolone (Oxandrin) 1
testosterone cypionate (Depo-testosterone) 1 PA
testosterone enanthate (Delatestryl) 1 PA, QL:
5 in 28
days
testosterone (Tesamone-100) 1 PA, QL:
40 in 28
days
37
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Anorexigenics, Respiratory, Cerebral Stimulants
Amphetamines
amphet asp/amphet/damphet
amphet asp/amphet/damphet
dextroamphetamine
sulfate
dextroamphetamine
sulfate
Drug
Tier
(Adderall XR) 1 PA, QL:
30 in 30
days
(Adderall) 1 PA, QL:
60 in 30
days
(Dexedrine) 1 PA, QL:
120 in 30
days
(Dextrostat) 1 PA, QL:
180 in 30
days
methamphetamine hcl (Desoxyn) 1 QL: 150
in 30
days
Anorexigenics, Respiratory, Cerebral Stimulants, Miscellaneous
caffeine citrated (Cafcit) 1
caffeine/sodium benzoate (Caffeine/sodium Benzoate) 1
CONCERTA 2 PA, QL:
31 in 31
days
dexmethylphenidate hcl (Focalin) 1 PA, QL:
60 in 30
days
methylphenidate hcl (Concerta) 1 PA, QL:
31 in 31
days
methylphenidate hcl (Methylin) 1 PA, QL:
900 in 30
days
methylphenidate hcl (Ritalin LA) 1 PA, QL:
30 in 30
days
methylphenidate hcl (Ritalin LA) 1 PA, QL:
60 in 30
days
methylphenidate hcl (Ritalin) 1 PA, QL:
90 in 30
days
Requirements/Limits
cap er 24h
tablet
capsule er
tablet
tab er 24
solution
cpmp 50-50: 20mg,
40mg
cpmp 50-50: 30mg
tablet, tablet er
38
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
PROVIGIL 2 PA, QL:
62 in 31
days
Anthelmintics
Anthelmintics
ALBENZA 2
BILTRICIDE 2
mebendazole (Mebendazole) 1
STROMECTOL 2
Antiallergic Agents
Antiallergic Agents
ALAMAST 2 ST
ASTEPRO 2 QL: 30 in
25 days
azelastine hcl (Astelin) 1 QL: 30 in spray/pump
25 days
azelastine hcl (Optivar) 1 drops
epinastine hcl (Elestat) 1
PATADAY 2 ST
PATANOL 2 ST
Antibacterials
Aminoglycosides
amikacin sulfate (Amikacin Sulfate) 1
gentamicin in nacl, isoosm
(Gentamicin In Nacl, Iso-osm) 1 piggyback: 100mg/
50ml
gentamicin in nacl, isoosm
(Gentamicin In Nacl, Iso-osm) 1 piggyback: 60mg/
100ml, 70mg/50ml,
80mg/100ml, 80mg/
50ml, 90mg/100ml,
100mg/0.1l, 120mg/
0.1l
gentamicin sulfate (Garamycin) 1
gentamicin sulfate/pf (Gentamicin Sulfate/PF) 1
kanamycin sulfate (Kanamycin Sulfate) 1 vial: 1g/3ml
kanamycin sulfate (Kanamycin Sulfate) 1 vial: 500mg/2ml
neomycin sulfate (Neomycin Sulfate) 1 solution
neomycin sulfate (Neomycin Sulfate) 1 tablet
streptomycin sulfate (Streptomycin Sulfate) 1
TOBI 2 PA
tobramycin sulfate (Nebcin) 1
39
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
(Tobramycin/sodium Chloride) 1
Requirements/Limits
tobramycin/sodium
chloride
Antibacterials, Miscellaneous
bacitracin (Bacitracin) 1
chloramphenicol na succ (Chloramphenicol Na Succ) 1
clindamycin hcl (Cleocin HCl) 1 capsule: 150mg,
300mg
clindamycin hcl (Cleocin HCl) 1 capsule: 75mg
clindamycin palmitate hcl (Cleocin Palmitate) 1
clindamycin phosphate (Cleocin Phosphate) 1
colistin (colistimethate na) (Coly-mycin M Parenteral) 1
CUBICIN 2 PA (PA for ESRD only)
polymyxin b sulfate (Polymyxin B Sulfate) 1
SYNERCID 2
VANCOCIN HCL 2
vancomycin hcl (Vancomycin HCl) 1 PA (PA for ESRD only)
vancomycin hcl/d5w (Vancomycin HCl/D5W) 1
VANCOMYCIN HCL 2
VIBATIV 2
XIFAXAN 2 PA, QL:
60 in 30
days
XIFAXAN 2 PA, QL:
9 in 30
days
tablet: 550mg
tablet: 200mg
ZYVOX 2
Cephalosporins
cefaclor (Ceclor) 1 capsule, tab er 12h
cefaclor (Ceclor) 1 susp recon
cefadroxil hydrate (Cefadroxil Hydrate) 1
cefazolin sodium (Ancef) 1
cefazolin sodium/ (Cefazolin Sodium/dextrose, Iso) 1
dextrose,iso
cefdinir (Omnicef) 1
cefditoren pivoxil (Spectracef) 1
cefepime hcl (Maxipime) 1
CEFEPIME 2
CEFEPIME-DEXTROSE 2
cefotaxime sodium (Claforan) 1
cefpodoxime proxetil (Vantin) 1
40
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
cefprozil (Cefzil) 1
ceftazidime pentahydrate (Fortaz) 1 vial port: 1g
ceftazidime pentahydrate (Fortaz) 1 vial, vial port: 2g
CEFTAZIDIME 1
ceftriaxone na/
(Ceftriaxone Na/dextrose, Iso) 1
dextrose,iso
ceftriaxone sodium (Rocephin) 1
CEFTRIAXONE 1
cefuroxime axetil (Ceftin) 1
cefuroxime sodium (Zinacef) 1
cefuroxime sodium/ (Cefuroxime Sodium/dextrose, 1
dextrose,iso
Iso)
cephalexin (Keflex) 1
FORTAZ IN ISO-
2
OSMOTIC DEXTROSE
SUPRAX 2 tablet
TAZICEF IN
2
DEXTROSE
Macrolides
azithromycin hydrogen (Azithromycin Hydrogen
1
citrate
Citrate)
azithromycin (Zithromax) 1 packet
azithromycin (Zithromax) 1 susp recon, tablet,
vial
clarithromycin (Biaxin) 1
DIFICID 2 QL: 20 in
10 days
ery e-succ/sulfisoxazole (Pediazole) 1
ERY-TAB 1
ERYTHROCIN
2 vial
LACTOBIONATE
ERYTHROCIN
2 vial port
LACTOBIONATE
erythromycin base (Eryc) 1 capsule dr
erythromycin base (Erythromycin Base) 1 tablet, tablet dr
erythromycin
ethylsuccinate
(Erythromycin Ethylsuccinate) 1 oral susp: 200mg/
5ml
erythromycin
(Erythromycin Ethylsuccinate) 1 tablet
ethylsuccinate
erythromycin stearate (Erythromycin Stearate) 1 tablet: 250mg
erythromycin stearate (Erythromycin Stearate) 1 tablet: 500mg
41
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
KETEK PAK 2 ST
KETEK 2 ST
ZMAX 2
Miscellaneous B-lactam Antibiotics
aztreonam (Azactam) 1
CAYSTON 2 LA
cefotetan disod/
(Cefotetan Disod/dextrose, Iso) 1
dextrose,iso
cefotetan disodium (Cefotetan Disodium) 1
cefoxitin sodium (Mefoxin) 1
cefoxitin sodium/ (Cefoxitin Sodium/dextrose, Iso) 1
dextrose,iso
DORIBAX 2
imipenem/cilastatin (Primaxin) 1
sodium
INVANZ 2 vial
INVANZ 2 vial port
meropenem (Merrem) 1
PRIMAXIN I.M. 2
PRIMAXIN 2
Penicillins
amoxicillin (Amoxil) 1 capsule, susp recon,
tab chew: 125mg,
200mg, 250mg;
tablet
amoxicillin (Amoxil) 1 tab chew: 400mg
amoxicillin/potassium clav (Augmentin) 1
ampicillin sodium (Totacillin-N) 1 vial port: 2g
ampicillin sodium (Totacillin-N) 1 vial, vial port: 1g
ampicillin sodium/ (Unasyn) 1 vial
sulbactam na
ampicillin sodium/ (Unasyn) 1 vial port
sulbactam na
ampicillin trihydrate (Ampicillin Trihydrate) 1
BICILLIN C-R 2
BICILLIN L-A 2
dicloxacillin sodium (Dicloxacillin Sodium) 1
nafcillin sodium (Unipen) 1 vial
nafcillin sodium (Unipen) 1 vial port
oxacillin sodium (Oxacillin Sodium) 1
42
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
oxacillin sodium/ (Oxacillin Sodium/dextrose, Iso) 1
dextrose,iso
pen g pot/dextrose-water (Pen G Pot/dextrose-water) 1 froz.piggy: 1mm/
50ml
pen g pot/dextrose-water (Pen G Pot/dextrose-water) 1 froz.piggy: 2mm/
50ml, 3mm/50ml
penicillin g potassium (Penicillin G Potassium) 1 vial: 20mmunit
penicillin g potassium (Penicillin G Potassium) 1 vial: 5mmunit
penicillin g potassium/d5w (Penicillin G Potassium/D5W) 1
penicillin g procaine (Penicillin G Procaine) 1 disp syrin: 1.2mm/
2ml
penicillin g procaine (Penicillin G Procaine) 1 disp syrin: 600000/
ml
PENICILLIN G SODIUM 1
penicillin v potassium (Veetids 500) 1
piperacillin sodium (Piperacillin Sodium) 1
piperacillin sodium/ (Zosyn) 1
tazobactam
ZOSYN 2 froz.piggy
Quinolones
AVELOX ABC PACK 2
AVELOX IV 2
AVELOX 2
ciprofloxacin hcl (Cipro) 1
ciprofloxacin lactate (Cipro I.V.) 1
ciprofloxacin lactate/d5w (Cipro I.V.) 1
ciprofloxacin/ciprofloxa (Cipro XR) 1
hcl
levofloxacin (Levaquin) 1
levofloxacin/dextrose 5%- (Levaquin) 1
water
nalidixic acid (Nalidixic Acid) 1
ofloxacin (Floxin) 1
Sulfonamides (Systemic)
sulfadiazine (Sulfadiazine) 1
sulfamethoxazole/ (Bactrim DS) 1
trimethoprim
sulfasalazine (Azulfidine) 1
Tetracyclines
demeclocycline hcl (Declomycin) 1
doxycycline hyclate (Morgidox) 1
43
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
doxycycline monohydrate (Adoxa) 1 capsule: 150mg
doxycycline monohydrate (Adoxa) 1 capsule: 75mg;
tablet
MINOCIN 2 vial
minocycline hcl (Dynacin) 1
tetracycline hcl (Ala-tet) 1 capsule
tetracycline hcl (Tetracycline HCl) 1 oral susp
TYGACIL 2
VIBRAMYCIN 2 syrup
Anticholinergic Agents
Antimuscarinics/Antispasmodics
atropine sulfate (Atropine Sulfate) 1 ampul, vial
atropine sulfate (Atropine Sulfate) 1 disp syrin
ATROVENT HFA 2 QL: 25.8
in 28
days
CANTIL 2
dicyclomine hcl (Bentyl) 1 capsule, syrup,
tablet
glycopyrrolate (Robinul) 1
isopropamide/
(Isopropamide/prochlorperazine) 1
prochlorperazine
methscopolamine bromide (Pamine) 1
SPIRIVA 2 QL: 30 in
30 days
Anticonvulsants
Anticonvulsants, Miscellaneous
BANZEL 2 ST
carbamazepine (Tegretol) 1
divalproex sodium (Depakote ER) 1
felbamate (Felbatol) 1
FELBATOL 2 oral susp
gabapentin (Neurontin) 1
GABITRIL 2
lamotrigine (Lamictal) 1 tablet, tb chw dsp
lamotrigine (Lamotrigine) 1 tab ds pk
levetiracetam in nacl (isoos)
(Levetiracetam In Nacl (iso-os)) 1
levetiracetam (Keppra) 1
44
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
LYRICA 2 QL: 93 in
31 days
magnesium chloride (Magnesium Chloride) 1
magnesium sulfate (Magnesium Sulfate) 1 disp syrin, infus. btl,
piggyback
magnesium sulfate (Magnesium Sulfate) 1 vial
magnesium sulfate/d5w (Magnesium Sulfate/D5W) 1 piggyback
magnesium sulfate/d5w (Magnesium Sulfate/D5W) 1 plast. bag
oxcarbazepine (Trileptal) 1
primidone (Mysoline) 1
SABRIL 2
TEGRETOL XR 2 tab er 12h: 100mg
topiramate (Topamax) 1
valproate sodium (Depakene) 1
valproic acid (Depakene) 1
VIMPAT 2 ST, QL: solution
1200 in
30 days
VIMPAT 2 ST, QL: vial
200 in 5
days
VIMPAT 2 ST, QL: tablet
60 in 30
days
zonisamide (Zonegran) 1
Hydantoins
DILANTIN 2 capsule: 30mg
DILANTIN 2 tab chew
fosphenytoin sodium (Cerebyx) 1
PEGANONE 2
PHENYTEK 2
phenytoin sodium (Dilantin) 1
extended
phenytoin sodium (Phenytoin Sodium) 1 disp syrin
phenytoin sodium (Phenytoin Sodium) 1 vial
phenytoin (Dilantin-125) 1
Succinimides
CELONTIN 2
ethosuximide (Zarontin) 1
Antidiabetic Agents
45
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Antidiabetic Agents, Miscellaneous
acarbose (Precose) 1 QL: 90 in
30 days
BYETTA 2 PA, QL:
1.2 in 28
days
BYETTA 2 PA, QL:
2.4 in 28
days
GLYSET 2 QL: 90 in
30 days
JANUMET XR 2 ST, QL:
30 in 30
days
JANUMET XR 2 ST, QL:
60 in 30
days
JANUMET 2 ST, QL:
60 in 30
days
JANUVIA 2 ST, QL:
30 in 30
days
JENTADUETO 2 ST, QL:
60 in 30
days
JUVISYNC 2 ST, QL:
30 in 30
days
KOMBIGLYZE XR 2 ST, QL:
30 in 30
days
metformin hcl (Glucophage) 1 QL: 120
in 30
days
metformin hcl (Glucophage) 1 QL: 60 in
30 days
metformin hcl (Glucophage) 1 QL: 90 in
30 days
metformin hcl (Metformin HCl) 1 QL: 60 in
30 days
Requirements/Limits
pen injctr: 5mcg/
0.02
pen injctr: 10mcg/
0.04
tbmp 24hr: 50mg-
500mg, 100-
1000mg
tbmp 24hr: 50-
1000mg
tab er 24h: 500mg;
tablet: 500mg
tablet: 1000mg
tab er 24h: 750mg;
tablet: 850mg
tab er 24
46
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
nateglinide (Starlix) 1 QL: 90 in
30 days
ONGLYZA 2 ST, QL:
30 in 30
days
PRANDIMET 2 ST, QL:
150 in 30
days
PRANDIN 2 ST, QL:
240 in 30
days
SYMLIN 2 PA, QL:
20 in 28
days
SYMLINPEN 120 2 PA, QL:
5.4 in 28
days
SYMLINPEN 60 2 PA, QL:
3 in 28
days
TRADJENTA 2 ST, QL:
30 in 30
days
VICTOZA 3-PAK 2 PA, QL:
9 in 28
days
Insulins
HUMALOG MIX 50-50 2 QL: 30 in insuln pen
28 days
HUMALOG MIX 50-50 2 QL: 40 in vial
28 days
HUMALOG MIX 75-25 2 QL: 30 in insuln pen
28 days
HUMALOG MIX 75-25 2 QL: 40 in vial
28 days
HUMALOG 2 QL: 30 in insuln pen
28 days
HUMALOG 2 QL: 40 in vial
28 days
HUMULIN 50-50 2 QL: 40 in
28 days
47
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
HUMULIN 70-30 2 QL: 30 in insuln pen
28 days
HUMULIN 70-30 2 QL: 40 in vial
28 days
HUMULIN N 2 QL: 30 in insuln pen
28 days
HUMULIN N 2 QL: 40 in vial
28 days
HUMULIN R 2 QL: 40 in
28 days
LANTUS SOLOSTAR 2 QL: 30 in
28 days
LANTUS 2 QL: 40 in
28 days
LEVEMIR 2 ST, QL: insuln pen
30 in 28
days
LEVEMIR 2 ST, QL: vial
40 in 28
days
NOVOLIN 70-30
INNOLET
2 QL: 30 in
28 days
NOVOLIN 70-30 2 QL: 40 in
28 days
NOVOLIN N INNOLET 2 QL: 30 in
28 days
NOVOLIN N 2 QL: 40 in
28 days
NOVOLIN R 2 QL: 30 in insuln pen
28 days
NOVOLIN R 2 QL: 40 in vial
28 days
NOVOLOG MIX 70-30 2 QL: 30 in insuln pen
28 days
NOVOLOG MIX 70-30 2 QL: 40 in vial
28 days
NOVOLOG 2 QL: 30 in insuln pen
28 days
NOVOLOG 2 QL: 40 in vial
28 days
Sulfonylureas
48
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
glimepiride (Amaryl) 1 QL: 30 in tablet: 1mg, 2mg
30 days
glimepiride (Amaryl) 1 QL: 60 in tablet: 4mg
30 days
glipizide (Glucotrol XL) 1 QL: 30 in tab er 24: 2.5mg,
30 days 5mg
glipizide (Glucotrol) 1 QL: 120 tablet: 10mg
in 30
days
glipizide (Glucotrol) 1 QL: 60 in tab er 24: 10mg;
30 days tablet: 5mg
glipizide/metformin hcl (Metaglip) 1 QL: 120
in 30
tablet: 2.5-500mg,
5mg-500mg
days
glipizide/metformin hcl (Metaglip) 1 QL: 60 in tablet: 2.5-250mg
30 days
glyburide (Micronase) 1 QL: 120 tablet: 5mg
in 30
days
glyburide (Micronase) 1 QL: 30 in tablet: 1.25mg,
30 days 2.5mg
glyburide,micronized (Glynase) 1 QL: 30 in tablet: 1.5mg, 3mg
30 days
glyburide,micronized (Glynase) 1 QL: 60 in tablet: 6mg
30 days
glyburide/metformin hcl (Glucovance) 1 QL: 120
in 30
days
glyburide/metformin hcl (Glucovance) 1 QL: 60 in
30 days
tolazamide (Tolazamide) 1 QL: 120
in 30
days
tolazamide (Tolazamide) 1 QL: 60 in
30 days
tolbutamide (Tolbutamide) 1 QL: 180
in 30
days
Thiazolidinediones
tablet: 2.5-500mg,
5mg-500mg
tablet: 1.25-250mg
tablet: 250mg
tablet: 500mg
49
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
ACTOPLUS MET XR 2 ST, QL:
60 in 30
days
ACTOPLUS MET 2 ST, QL:
90 in 30
days
ACTOS 2 ST, QL:
30 in 30
days
AVANDAMET 2 ST, QL:
60 in 30
days
AVANDARYL 2 ST, QL:
30 in 30
days
AVANDIA 2 ST, QL:
30 in 30
days
DUETACT 2 ST, QL:
30 in 30
days
Antidiarrhea Agents
Antidiarrhea Agents
diphenoxylate hcl/atropine (Lomotil) 1
loperamide hcl (Loperamide HCl) 1
paregoric (Paregoric) 1
Antiemetics
5-ht3 Receptor Antagonists
granisetron hcl (Kytril) 1 vial
granisetron hcl (Kytril) 1 PA solution, tablet
granisetron hcl/pf (Kytril) 1
ondansetron hcl (Zofran) 1 vial
ondansetron hcl (Zofran) 1 PA solution, tablet
ondansetron in 0.9 % (Ondansetron In 0.9 % Nacl/PF) 1
nacl/pf
ondansetron (Zofran Odt) 1 PA
Antiemetics, Miscellaneous
CESAMET 2
dronabinol (Marinol) 1
50
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
EMEND 2 PA, QL:
1 per fill
capsule: 40mg,
125mg
EMEND 2 PA, QL: capsule: 80mg
2 per fill
EMEND 2 PA, QL: cap ds pk
3 per fill
EMEND 2 QL: 2 in vial
28 days
Antihistamines (GI Drugs)
ANTIVERT 2 tablet: 50mg
dimenhydrinate (Dimenhydrinate) 1
meclizine hcl (Antivert) 1
prochlorperazine edisylate (Compazine) 1
prochlorperazine maleate (Compazine) 1
Antifungal (Systemic)
Antifungals, Miscellaneous
ABELCET 2 PA
AMBISOME 2 PA
AMPHOTEC 2 PA
amphotericin b (Amphotericin B) 1 PA
flucytosine (Ancobon) 2
griseofulvin,microsize (Grifulvin V) 1
GRIS-PEG 2
nystatin (Nystatin) 1 oral susp, tablet
nystatin (Nystatin) 1 powder
terbinafine hcl (Lamisil) 1
triacetin (Triacetin) 1
Azoles
fluconazole in nacl,isoosm
(Diflucan in Saline) 1
fluconazole (Diflucan) 1
itraconazole (Sporanox) 1
ketoconazole (Nizoral) 1
NOXAFIL 2
SPORANOX 2 solution
VFEND IV 2
VFEND 2 susp recon
voriconazole (Vfend) 2
Echinocandins
CANCIDAS 2
51
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
ERAXIS (WATER
2
DILUENT)
Antiglaucoma Agents
Antiglaucoma Agents
acetazolamide sodium (Acetazolamide Sodium) 1
acetazolamide (Acetazolamide) 1
ALPHAGAN P 2 drops: 0.1%
AZOPT 2
betaxolol hcl (Betaxolol HCl) 1
BETIMOL 2 ST
brimonidine tartrate (Alphagan P) 1
COMBIGAN 2
dorzolamide hcl (Trusopt) 1
dorzolamide hcl/timolol (Cosopt) 1
maleat
ISOPTO CARPINE 2 drops: 8%
ISTALOL 2
latanoprost (Xalatan) 1
levobunolol hcl (Betagan) 1
LUMIGAN 2 QL: 2.5
in 25
days
methazolamide (Neptazane) 1
metipranolol (Optipranolol) 1
PHOSPHOLINE IODIDE 2
pilocarpine hcl (Isopto Carpine) 1
PILOPINE HS 2
timolol maleate (Timoptic) 1
TRAVATAN Z 2 QL: 2.5
in 25
days
Anti-infectives (EENT)
Anti-infectives (EENT)
acetic acid (Vosol) 1
acetic acid/aluminum (Domeboro) 1
acetate
acetic acid/hydrocortisone (Vosol HC) 1
bacitracin (Bacitracin) 1
bacitracin/polymyxin b
sulfate
(Polycin-b) 1
52
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
BLEPHAMIDE S.O.P. 2
BLEPHAMIDE 2
chlorhexidine gluconate (Peridex) 1
CIPRO HC 2
CIPRODEX 2
ciprofloxacin hcl (Ciloxan) 1
COLY-MYCIN S 2
CORTISPORIN-TC 2
cresyl ace/ben alc/ (Cresyl Ace/ben Alc/butanol/ipa) 1
butanol/ipa
doxycycline hyclate (Periostat) 1
erythromycin base (Ilotycin) 1
gentamicin sulfate (Garamycin) 1
levofloxacin (Quixin) 1
MOXEZA 2
NATACYN 2
neo/polymyx b sulf/ (Maxitrol) 1
dexameth
neomy sulf/bacitra/ (Neo-polycin) 1
polymyxin b
neomy sulf/bacitrac zn/ (Triple Antibiotic HC) 1
poly/hc
neomycin sulfate/dex na (Neomycin Sulfate/dex Na Ph) 1
ph
neomycin/polymyxin b (Oticin HC) 1
sulf/hc
neomycin/polymyxn b/ (Neosporin) 1
gramicidin
ofloxacin (Ocuflox) 1
polymyxin b sulfate/tmp (Polytrim) 1
POLY-PRED 2
sulfacetamide sodium (Sulfac) 1 drops
sulfacetamide sodium (Sulfacetamide Sodium) 1 oint. (g)
sulfacetamide/
(Sulfacetamide/prednisolone Sp) 1
prednisolone sp
tobramycin sulf/ (Tobradex) 1
dexamethasone
tobramycin sulfate (Tobrex) 1
trifluridine (Viroptic) 1
VIGAMOX 2
ZYLET 2
53
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
ZYMAR 2
ZYMAXID 2
Anti-infectives (Skin and Mucous Membrane)
Antibacterials (Skin and Mucous Membrane)
clindamycin phos/benzoyl (Benzaclin) 1
perox
clindamycin phosphate (Cleocin T) 1
erythromycin base/ethanol (Emgel) 1
erythromycin/benzoyl (Benzamycin) 1
peroxide
gentamicin sulfate (Gentamicin Sulfate) 1
metronidazole (Metrocream) 1
mupirocin (Bactroban) 1
neomy sulf/polymyxin b (Neosporin G.U. Irrigant) 1
sulfate
Antifungals (Skin and Mucous Membrane)
ciclopirox olamine (Loprox) 1
ciclopirox (Penlac) 1
clotrimazole (Mycelex) 1
clotrimazole/
(Lotrisone) 1
betamethasone dip
econazole nitrate (Spectazole) 1
EXELDERM 2
GYNAZOLE-1 2
ketoconazole (Kuric) 1
LAMISIL 2
miconazole nitrate (Monistat 3) 1
NAFTIN 2 cream (g): 1%; gel
(gram)
NAFTIN 2 cream (g): 2%
nystatin (Mycostatin) 1 cream (g), oint. (g),
powder
nystatin (Nystatin) 1 tablet
nystatin/triamcin (Mycogen II) 1
sod propionate/inosi/aa14/ (Sod Propionate/inosi/aa14/urea) 1
urea
sodium thiosulfate/sal acid (Sodium Thiosulfate/sal Acid) 1
terconazole (Terazol 7) 1
Antivirals (Skin and Mucous Membrane)
DENAVIR 2
54
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
ZOVIRAX 2 QL: 10 cream (g)
per fill
ZOVIRAX 2 QL: 30 oint. (g)
per fill
Local Anti-infectives, Miscellaneous
acetic ac/ricinoleic/ (Acetic Ac/ricinoleic/oxyquinol) 1
oxyquinol
alcohol antiseptic pads (Alcohol Antiseptic Pads) 1
AVC 2
selenium sulfide (Selenium Sulfide) 1 suspension
selenium sulfide (Selseb) 1 shampoo
silver nitrate (Silver Nitrate) 1
silver sulfadiazine (Thermazene) 1 cream (g): 1%
sulfacetamide sodium (Klaron) 1
Scabicides and Pediculicides
EURAX 2
lindane (Lindane) 1
malathion (Ovide) 1
permethrin (Elimite) 1
Anti-infectives (systemic), Miscellaneous
Anti-infectives (systemic), Miscellaneous
FUROXONE 2
Anti-inflammatory Agents (EENT)
Anti-inflammatory Agents (EENT)
ALREX 2
BROMDAY 2
bromfenac sodium (Bromfenac Sodium) 1
dexamethasone sod (Ak-dex) 1
phosphate
diclofenac sodium (Voltaren) 1
DUREZOL 2
flunisolide (Nasarel) 1 QL: 25 in
25 days
fluocinolone acetonide oil (Dermotic) 1
fluorometholone (Fluorometholone) 1
flurbiprofen sodium (Ocufen) 1
fluticasone propionate (Flonase) 1 QL: 16 in
30 days
ketorolac tromethamine (Acular LS) 1
LOTEMAX 2
55
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
NASONEX 2 QL: 34 in
28 days
NEVANAC 2
prednisolone acetate (Pred Forte) 1
prednisolone sod (Prednisol) 1
phosphate
RESTASIS 2 PA, QL:
64 in 31
days
triamcinolone acetonide (Nasacort Aq) 1 QL: 16.5
in 30
days
Anti-inflammatory Agents (GI Drugs)
Anti-inflammatory Agents (GI Drugs)
APRISO 2
ASACOL HD 2
ASACOL 2
balsalazide disodium (Colazal) 1
DIPENTUM 2
mesalamine (Rowasa) 1
PENTASA 2
Anti-inflammatory Agents (Respiratory)
Anti-inflammatory Agents (Respiratory)
cromolyn sodium (Cromolyn Sodium) 1 drops, solution
cromolyn sodium (Intal) 1 PA ampul-neb
SINGULAIR 2
zafirlukast (Accolate) 1
ZYFLO CR 2
ZYFLO 2
Anti-inflammatory Agents (Skin and Mucous)
Anti-inflammatory Agents (Skin and Mucous)
alclometasone
(Aclovate) 1
dipropionate
amcinonide (Amcinonide) 1
APEXICON E 2
betamet diprop/prop gly (Diprolene AF) 1
betamethasone
(Betamethasone Dipropionate) 1 gel (gram)
dipropionate
betamethasone
dipropionate
(Del-beta) 1 cream (g), lotion,
oint. (g)
56
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
betamethasone valerate (Betamethasone Valerate) 1
clobetasol propionate (Temovate) 1
CLODERM 2
CORDRAN SP 2
CORDRAN 2 lotion, med. tape
CORDRAN 2 oint. (g)
CUTIVATE 2 lotion
desonide (Desowen) 1 cream (g), lotion,
oint. (g): 0.05%
desoximetasone (Topicort) 1
diflorasone diacetate (Psorcon) 1
fluocinolone acetonide (Synalar) 1 cream (g): 0.01%
fluocinolone acetonide (Synalar) 1 cream (g): 0.025%;
cream(gm), oint.
(g), solution
fluocinolone/shower cap (Derma-smoothe-fs) 1
fluocinonide (Lidex) 1
fluticasone propionate (Cutivate) 1
halobetasol propionate (Ultravate) 1
hydrocortisone acetate (Hydrocortisone Acetate) 1
hydrocortisone acetate/ (Nuzon) 1
aloe v
hydrocortisone acetate/ (Carmol HC) 1
urea
hydrocortisone butyrate (Locoid) 1
hydrocortisone valerate (Westcort) 1
hydrocortisone (Anusol-HC) 1
mometasone furoate (Elocon) 1
prednicarbate (Dermatop) 1
triamcinolone acetonide (Triamcinolone Acetonide) 1 cream
triamcinolone acetonide (Triamcinolone Acetonide) 1 cream (g), lotion,
oint. (g), paste (g)
Antilipemic Agents
Antilipemic Agents, Miscellaneous
LOVAZA 2
niacin (Niacin) 1 tablet: 500mg
NIASPAN 2
ZETIA 2
57
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Bile Acid Sequestrants
Drug
Tier
Requirements/Limits
cholestyramine (with (Questran) 1
sugar)
cholestyramine/aspartame (Questran Light) 1
colestipol hcl (Colestid) 1
WELCHOL 2
Fibric Acid Derivatives
fenofibrate (Lofibra) 1
fenofibrate,micronized (Lofibra) 1
fenofibric acid (Fibricor) 1
gemfibrozil (Lopid) 1
LIPOFEN 2
TRICOR 2
TRILIPIX 2
HMG-CoA Reductase Inhibitors
amlodipine/atorvastatin (Caduet) 1
CRESTOR 2
LIPITOR 1
lovastatin (Mevacor) 1
pravastatin sodium (Pravachol) 1
simvastatin (Zocor) 1
Antimigraine Agents
Selective Serotonin Agonists
MAXALT MLT 2 ST, QL:
18 in 28
days
MAXALT 2 ST, QL:
18 in 28
days
naratriptan hcl (Amerge) 1 QL: 9 in
28 days
RELPAX 2 ST, QL:
6 in 28
days
sumatriptan succinate (Imitrex) 1 QL: 4 in cartridge, vial
28 days
sumatriptan succinate (Imitrex) 1 QL: 9 in tablet
28 days
sumatriptan (Imitrex) 1 QL: 12 in spray: 20mg
28 days
58
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
sumatriptan (Imitrex) 1 QL: 18 in spray: 5mg
28 days
Antimycobacterials
Antimycobacterials
CAPASTAT SULFATE 2
cycloserine (Cycloserine) 2
dapsone (Dapsone) 1
ethambutol hcl (Myambutol) 1
isoniazid (Isoniazid) 1
MYCOBUTIN 2
PASER 2
PRIFTIN 2
pyrazinamide (Pyrazinamide) 1
rifampin (Rifadin) 1
rifampin/isoniazid (Rifamate) 1
RIFATER 2
SEROMYCIN 2
TRECATOR 2
Antineoplastic Agents
Antineoplastic Agents
ABRAXANE 2
ADCETRIS 2
AFINITOR 2 tablet: 2.5mg, 5mg,
10mg
AFINITOR 2 tablet: 7.5mg
ALIMTA 2
anastrozole (Arimidex) 1 PA
ARRANON 2
ARZERRA 2 PA, QL:
80 in 30
days
AVASTIN 2
BEXXAR 2
bicalutamide (Casodex) 1
BICNU 2
bleomycin sulfate (Blenoxane) 1 PA
BUSULFEX 2
CAMPATH 2
59
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
CAPRELSA 2 PA, QL: tablet: 300mg
30 in 30
days
CAPRELSA 2 PA, QL: tablet: 100mg
60 in 30
days
carboplatin (Paraplatin) 1
CEENU 2
cisplatin (Cisplatin) 1
cladribine (Leustatin) 1 PA
CLOLAR 2
cyclophosphamide (Cytoxan) 1 PA, ST tablet
cyclophosphamide (Cytoxan) 1 PA vial
cytarabine/pf (Cytarabine/PF) 1 PA
dacarbazine (Dtic-Dome IV) 1
DACOGEN 2
dactinomycin (Cosmegen) 1
daunorubicin hcl (Cerubidine) 1
DAUNOXOME 2
DOCEFREZ 2
docetaxel (Taxotere) 2 vial: 20mg/2ml,
20mg/ml(1)
docetaxel (Taxotere) 2 vial: fnl20mg/2
DOXIL 2 PA
doxorubicin hcl liposomal (Doxil) 1 PA
doxorubicin hcl (Adriamycin RDF) 1 PA vial: 10mg
DROXIA 2
ELIGARD 2 QL: 1 in disp syrin: 30mg
112 days
ELIGARD 2 QL: 1 in disp syrin: 45mg
168 days
ELIGARD 2 QL: 1 in disp syrin: 7.5mg
28 days
ELIGARD 2 QL: 1 in disp syrin: 22.5mg
ELSPAR 2
EMCYT 2
epirubicin hcl (Ellence) 1
ERBITUX 2
84 days
60
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
ERWINAZE 2 PA, QL:
60 in 30
days
ETOPOPHOS 2
etoposide (Etoposide) 1
exemestane (Aromasin) 1 PA
FARESTON 2
FASLODEX 2 disp syrin: 125mg/
2.5
FASLODEX 2 disp syrin: 250mg/
5ml
FIRMAGON 2
floxuridine (FUDR) 1 PA
fludarabine phosphate (Fludara) 2
fluorouracil (Fluorouracil) 1 PA
flutamide (Flutamide) 1
FOLOTYN 2
gemcitabine hcl (Gemzar) 2
GLEEVEC 2
HALAVEN 2 PA, QL:
6 in 28
days
HERCEPTIN 2 PA
HEXALEN 2
hydroxyurea (Hydrea) 1
idarubicin hcl (Idamycin Pfs) 1
ifosfamide (Ifex) 1 PA
ifosfamide/mesna (Ifex/mesnex) 1 PA
IRESSA 2 PA, QL:
30 in 30
days
irinotecan hcl (Camptosar) 2
ISTODAX 2 PA
IXEMPRA 2
JAKAFI 2 PA, QL:
60 in 30
days
JEVTANA 2
letrozole (Femara) 1 PA
LEUKERAN 2
61
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
leuprolide acetate (Lupron) 1 QL: 2 in
28 days
LUPRON DEPOT 2 ST, QL: syringekit: 30mg
1 in 112
days
LUPRON DEPOT 2 ST, QL: syringekit: 45mg
1 in 168
days
LUPRON DEPOT 2 ST, QL:
1 in 28
days
syringekit: 3.75mg,
7.5mg
LUPRON DEPOT 2 ST, QL:
1 in 84
days
LUPRON DEPOT-PED 2 ST, QL:
1 in 28
days
LYSODREN 2
MATULANE 2
MEGACE ES 2
megestrol acetate (Megace) 1
melphalan hcl (Alkeran) 2
mercaptopurine (Purinethol) 1
methotrexate sodium (Methotrexate Sodium) 1 PA, ST tablet
methotrexate sodium (Methotrexate Sodium) 1 PA vial
methotrexate sodium/pf (Methotrexate Sodium/PF) 1 PA
MITHRACIN 2
mitomycin (Mutamycin) 1 PA
mitoxantrone hcl (Novantrone) 1
MUSTARGEN 2
MYLOTARG 2
NEXAVAR 2
NILANDRON 2
ONCASPAR 2
ONTAK 2
oxaliplatin (Oxaliplatin) 2
paclitaxel (Taxol) 1
pentostatin (Nipent) 2
PHOTOFRIN 2
PROLEUKIN 2
RITUXAN 2 PA
syringekit:
11.25mg, 22.5mg
62
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
SPRYCEL 2
SUTENT 2
TABLOID 2
tamoxifen citrate (Nolvadex) 1
TARCEVA 2 PA, QL:
30 in 30
days
TARGRETIN 2
TASIGNA 2
TAXOTERE 2
thiotepa (Thiotepa) 1
topotecan hcl (Hycamtin) 2
TORISEL 2 PA
TREANDA 2
TRELSTAR 2 ST, QL: vial
1 in 168
days
TRELSTAR 2 ST, QL:
1 in 28
days
disp syrin: 3.75mg/
2ml
TRELSTAR 2 ST, QL:
1 in 84
days
tretinoin (Tretinoin) 2
TREXALL 2 PA, ST
TRISENOX 2
TYKERB 2
VALSTAR 2
VANDETANIB 2 PA, QL:
30 in 30
days
VANDETANIB 2 PA, QL:
60 in 30
days
VECTIBIX 2
VELCADE 2
VIDAZA 2
vinblastine sulfate (Vinblastine Sulfate) 1 PA
vincristine sulfate (Vincristine Sulfate) 1 PA
vinorelbine tartrate (Navelbine) 1
VOTRIENT 2
disp syrin: 11.25/
2ml
tablet: 300mg
tablet: 100mg
63
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
VUMON 2
XALKORI 2 PA, QL:
60 in 30
days
YERVOY 2 PA, QL:
30 in 21
days
ZANOSAR 2
ZELBORAF 2 PA, QL:
240 in 30
days
ZOLADEX 2 QL: 1 in implant: 3.6mg
28 days
ZOLADEX 2 QL: 1 in implant: 10.8mg
84 days
ZOLINZA 2
ZYTIGA 2 PA, QL:
120 in 30
days
Antiparkinsonian Agents
Antiparkinsonian Agents
amantadine hcl (Amantadine HCl) 1
APOKYN 2
AZILECT 2
benztropine mesylate (Benztropine Mesylate) 1
bromocriptine mesylate (Parlodel) 1
cabergoline (Cabergoline) 1
carbidopa/levodopa (Sinemet 25-100) 1
COMTAN 2
pramipexole di-hcl (Mirapex) 1
ropinirole hcl (Requip) 1
selegiline hcl (Eldepryl) 1
STALEVO 100 2
STALEVO 125 2
STALEVO 150 2
STALEVO 200 2
STALEVO 50 2
STALEVO 75 2
TASMAR 2
trihexyphenidyl hcl (Trihexyphenidyl HCl) 1
64
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
ZELAPAR 2
Antiprotozoal Agents
Antiprotozoal Agents
ALINIA 2
atovaquone/proguanil hcl (Malarone) 1 tablet: 250-100mg
atovaquone/proguanil hcl (Malarone) 1 tablet: 62.5-25mg
chloroquine phosphate (Aralen Phosphate) 1
COARTEM 2
DARAPRIM 2
HALFAN 2
hydroxychloroquine (Plaquenil) 1
sulfate
MALARONE 2 tablet: 62.5-25mg
mefloquine hcl (Lariam) 1
MEPRON 2
metronidazole (Flagyl) 1
metronidazole/sodium (Metro IV) 1
chloride
paromomycin sulfate (Humatin) 1
pentamidine isethionate (Pentam 300) 1
PRIMAQUINE 2
QUALAQUIN 2 PA, QL:
42 in 30
days
YODOXIN 2
Antipruritics and Local Anesthetics
Antipruritics and Local Anesthetics
AMERICAINE 2
ANACAINE 2
lidocaine hcl (Xylocaine) 1 PA (PA for ESRD only)
lidocaine/prilocaine (EMLA) 1 PA (PA for ESRD only)
LIDODERM 2
phenazopyridine hcl (Urodol) 1
Antiulcer Agents
Antiulcer Agents
cimetidine hcl (Cimetidine HCl) 1
cimetidine in 0.9 % nacl (Cimetidine In 0.9 % NaCl) 1
cimetidine (Tagamet) 1
DEXILANT 2 ST
65
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
famotidine in nacl,isoosm/pf
(Famotidine In Nacl,iso-osm/PF) 1
famotidine (Pepcid) 1
lansoprazole (Prevacid) 1 ST
misoprostol (Cytotec) 1
nizatidine (Axid) 1
omeprazole (Prilosec) 1 capsule dr: 10mg,
20mg, 40mg
omeprazole/sodium (Zegerid) 1
bicarbonate
pantoprazole sodium (Protonix) 1
PROTONIX IV 2
ranitidine hcl (Zantac) 1
sucralfate (Carafate) 1 tablet
sucralfate (Sucralfate) 1 oral susp
Antivirals (Systemic)
Antiretrovirals
APTIVUS 2 capsule
APTIVUS 2 solution
ATRIPLA 2
COMBIVIR 2
COMPLERA 2
CRIXIVAN 2
didanosine (Videx EC) 1
EDURANT 2
EMTRIVA 2
EPIVIR HBV 2
EPIVIR 2 solution
EPZICOM 2
FUZEON 2
INTELENCE 2
INVIRASE 2
ISENTRESS 2
KALETRA 2
lamivudine (Epivir) 1
lamivudine/zidovudine (Combivir) 2
LEXIVA 2
NORVIR 2
PREZISTA 2
RESCRIPTOR 2
66
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
RETROVIR 2 vial
REYATAZ 2
SELZENTRY 2
stavudine (Zerit) 1
SUSTIVA 2 capsule: 100mg
SUSTIVA 2 capsule: 50mg,
200mg; tablet
TRIZIVIR 2
TRUVADA 2
VIDEX 2
VIRACEPT 2
VIRAMUNE XR 2
VIRAMUNE 2
VIREAD 2
ZIAGEN 2
zidovudine (Retrovir) 1
Antivirals, Miscellaneous
foscarnet sodium (Foscavir) 1 PA
INCIVEK 2 PA, QL:
168 in 28
days
RELENZA 2
rimantadine hcl (Flumadine) 1
SYNAGIS 2
TAMIFLU 2 QL: 42 in capsule: 75mg
180 days
TAMIFLU 2 QL: 48 in capsule: 45mg
180 days
TAMIFLU 2 QL: 525
in 180
days
TAMIFLU 2 QL: 540
in 180
days
TAMIFLU 2 QL: 84 in
180 days
VICTRELIS 2 PA, QL:
336 in 28
days
Interferons
ALFERON N 2
susp recon: 12mg/
ml
susp recon: 6mg/ml
capsule: 30mg
67
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
INTRON A 2 PA pen ij kit, vial:
6mmunit/ml,
10mmunit
INTRON A 2 PA vial: 50mmunit
PEGASYS PROCLICK 2 PA
PEGASYS 2 PA
PEGINTRON REDIPEN 2 PA
PEGINTRON 2 PA kit: 50mcg/0.5
PEGINTRON 2 PA kit: 80mcg/0.5,
120mcg/0.5,
150mcg/0.5
SYLATRON 4-PACK 2 PA, QL:
1 in 28
days
Nucleosides and Nucleotides
acyclovir sodium (Acyclovir Sodium) 1 PA
acyclovir (Zovirax) 1
BARACLUDE 2
famciclovir (Famvir) 1
ganciclovir sodium (Cytovene) 1 PA
ganciclovir (Cytovene) 1 capsule: 250mg
ganciclovir (Cytovene) 2 capsule: 500mg
HEPSERA 2
REBETOL 2 solution
ribavirin (Rebetol) 1 capsule, tablet
ribavirin (Ribatab) 2 tab ds pk
TYZEKA 2
valacyclovir hcl (Valtrex) 1
VALCYTE 2 tablet
VALCYTE 2 PA soln recon
VISTIDE 2
Anxiolytics, Sedatives and Hypnotics
Anxiolytics, Sedatives and Hypnotics, Miscellaneous
buspirone hcl (Buspar) 1
chloral hydrate (Chloral Hydrate) 1
droperidol (Inapsine) 1
glutethimide (Glutethimide) 1
hydroxyzine hcl (Hydroxyzine HCl) 1
hydroxyzine pamoate (Vistaril) 1
LUNESTA 2
68
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
zaleplon (Sonata) 1
zolpidem tartrate (Ambien) 1
Astringents
Astringents
aluminum chloride (Drysol) 1
XERAC AC 2
Beta-Adrenergic Blocking Agents
Beta-Adrenergic Blocking Agents
acebutolol hcl (Sectral) 1
atenolol (Tenormin) 1
atenolol/chlorthalidone (Tenoretic 100) 1
betaxolol hcl (Kerlone) 1
bisoprolol fumarate (Zebeta) 1
bisoprolol fumarate/hctz (Ziac) 1
BYSTOLIC 2
carvedilol (Coreg) 1
COREG CR 2
DUTOPROL 2
esmolol hcl (Esmolol HCl) 1 PA
labetalol hcl (Trandate) 1
metoprolol succinate (Toprol XL) 1
metoprolol tartrate (Lopressor) 1
metoprolol/
(Lopressor HCT) 1
hydrochlorothiazide
nadolol (Corgard) 1
nadolol/
(Corzide) 1
bendroflumethiazide
pindolol (Pindolol) 1
propranolol hcl (Inderal) 1
propranolol/
(Inderide-40/25) 1
hydrochlorothiazid
sotalol hcl (Betapace) 1
SOTALOL HCL 2
timolol maleate (Timolol Maleate) 1
Blood Derivatives
Blood Derivatives
ALBUKED-25 2
ALBUKED-5 2
ALBUMARC 2
ALBUMIN (HUMAN) 2
69
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
ALBUMINAR-25 2
ALBUMINAR-5 2
ALBURX 2
ALBUTEIN 2
BUMINATE 2
FLEXBUMIN 2
PLASBUMIN-25 2
PLASBUMIN-5 2
STERILE DILUENT 2
Calcium-Channel Blocking Agents
Calcium-Channel Blocking Agents, Miscellaneous
CARDIZEM CD 2 cap er 24h: 360mg
diltiazem hcl (Cardizem CD) 1 various dosage and/
or strengths are
available
diltiazem hcl (Dilacor XR) 1 cap er deg: 240mg
verapamil hcl (Calan) 1 ampul, cap24h pct,
cap24h pel: 120mg,
180mg, 240mg;
tablet, tablet er
verapamil hcl (Verelan) 1 cap24h pel: 360mg;
disp syrin
Dihydropyridines
amlodipine besylate (Norvasc) 1
amlodipine besylate/ (Lotrel) 1
benazepril
AZOR 2 ST
CARDENE I.V. 2 piggyback
CLEVIPREX 2
EXFORGE HCT 2 ST
EXFORGE 2 ST
felodipine (Plendil) 1
isradipine (Dynacirc) 1
nicardipine hcl (Nicardipine HCl) 1
nifedipine (Procardia XL) 1
nimodipine (Nimotop) 1
nisoldipine (Sular) 1
70
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Caloric Agents
Caloric Agents
AMINOSYN II 3.5% M-
DEXTROSE 5%
AMINOSYN II 3.5%-
DEXTROSE 25%
AMINOSYN II 3.5%-
DEXTROSE 5%
AMINOSYN II 4.25% M-
DEXT 10%
AMINOSYN II 4.25%-
DEXTROSE 25%
AMINOSYN II 5% IN
25% DEXTROSE
AMINOSYN II IN
DEXTROSE
AMINOSYN II with
LYTES-CA-DW
AMINOSYN II with
Drug Name
Drug
Tier
2 PA
2 PA
2 PA
2 PA
2 PA
2 PA
2 PA
Requirements/Limits
2 PA iv soln: 3.5%
2 PA iv soln: 4.25%
LYTES-CA-DW
AMINOSYN II 2 PA iv soln: 10%
AMINOSYN II 2 PA iv soln: 15%
AMINOSYN II 2 PA iv soln: 7%
AMINOSYN II 2 PA iv soln: 8.5%
AMINOSYN M 2 PA
AMINOSYN with
2 PA
ELECTROLYTES
AMINOSYN 2 PA iv soln: 10%
AMINOSYN 2 PA iv soln: 3.5%
AMINOSYN 2 PA iv soln: 5%
AMINOSYN 2 PA iv soln: 7%
AMINOSYN 2 PA iv soln: 8.5%
AMINOSYN-HBC 2 PA
AMINOSYN-HF 2 PA
AMINOSYN-PF 2 PA iv soln: 10%
AMINOSYN-PF 2 PA iv soln: 7%
AMINOSYN-RF 2 PA
BRANCHAMIN 2 PA
CLINIMIX E 2 PA iv soln: 2.75%
CLINIMIX E 2 PA iv soln: 4.25%
71
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
CLINIMIX E 2 PA iv soln: 5%
CLINIMIX 2 PA iv soln: 2.75%
CLINIMIX 2 PA iv soln: 4.25%
CLINIMIX 2 PA iv soln: 5%
CLINISOL 2 PA
cysteine hcl (Cysteine HCl) 1 PA
dextrose 10 % and 0.225 (Dextrose 10 % and 0.225 % 1
% nacl
NaCl)
dextrose 10 % and 0.9 % (Dextrose 10 % and 0.9 % NaCl) 1
nacl
dextrose 10%-0.5 normal (Dextrose 10%-0.5 Normal 1
saline
Saline)
dextrose 10%-water (Dextrose 10%-water) 1 PA
dextrose 2.5%-0.5normal (Dextrose 2.5%-0.5 Normal 1
saline
Saline)
dextrose 2.5%-water (Dextrose 2.5%-water) 1 PA
dextrose 20%-water (Dextrose 20%-water) 1 PA
dextrose 25%-water (Dextrose 25%-water) 1 PA
dextrose 40%-water (Dextrose 40%-water) 1 PA
dextrose 5 % and 0.33 % (Dextrose 5 % and 0.33 % NaCl) 1
nacl
dextrose 5 % and 0.9 % (Dextrose 5 % and 0.9 % NaCl) 1
nacl
dextrose 5 %-0.225 % (Dextrose 5 %-0.225 % NaCl) 1
nacl
dextrose 5 %-0.45 % nacl (Dextrose 5 %-0.45 % NaCl) 1
dextrose 5%-water (Dextrose 5%-water) 1
dextrose 50%-water (Dextrose 50%-water) 1 PA
dextrose 60%-water (Dextrose 60%-water) 1 PA
dextrose 70%-water (Dextrose 70%-water) 1 PA
ethyl alcohol/d5w (Ethyl Alcohol/D5W) 1
FREAMINE HBC 2 PA
FREAMINE III with
2 PA
ELECTROLYTES
FREAMINE III 2 PA iv soln: 10%
FREAMINE III 2 PA iv soln: 8.5%
fructose 10% (Fructose 10%) 1 PA
HEPATAMINE 2 PA
HEPATASOL 2 PA
INTRALIPID 2 PA emulsion: 10%
72
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
INTRALIPID 2 PA emulsion: 20%,
30%
LIPOSYN II 2 PA
LIPOSYN III 2 PA
NEPHRAMINE 2 PA
NOVAMINE 2 PA
NUTRESTORE 2
PREMASOL 2 PA iv soln: 10%
PREMASOL 2 PA iv soln: 6%
PROCALAMINE 2 PA
PROSOL 2 PA
QUICK MIX with LYTES 2 PA
RENAMIN 2 PA
TRAVAMULSION 2 PA
TRAVASOL W/
2 PA iv soln.: 5.5%
ELECTROLYTES
TRAVASOL W/
2 PA iv soln.: 8.5%
ELECTROLYTES
TRAVASOL with
2 PA iv soln: 8.5%
DEXTROSE
TRAVASOL with
2 PA
ELECTROLYTES
TRAVASOL 2 PA iv soln: 10%
TRAVASOL 2 PA iv soln: 5.5%
TRAVASOL 2 PA iv soln: 8.5%
TRAVERT IN NORMAL
2 PA
SALINE
TRAVERT 2 PA iv soln: 10%
TRAVERT 2 PA iv soln: 5%
TROPHAMINE 2 PA iv soln: 10%
TROPHAMINE 2 PA iv soln: 6%
Cardiac Drugs
Antiarrhythmic Agents
amiodarone hcl (Amiodarone HCl) 1 disp syrin
amiodarone hcl (Cordarone) 1 ampul, tablet
disopyramide phosphate (Norpace) 1 capsule
disopyramide phosphate (Norpace) 1 capsule er
flecainide acetate (Tambocor) 1
lidocaine hcl (Lidocaine HCl) 1
73
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
lidocaine hcl/d5w/pf (Lidocaine HCl/d5w/PF) 1 iv soln: 2mg/ml,
8mg/ml
lidocaine hcl/d7.5w/pf (Lidocaine HCl/d7.5w/PF) 1
lidocaine hcl/pf (Lidocaine HCl) 1
LIDOCAINE HCL 1
mexiletine hcl (Mexitil) 1
MULTAQ 2
procainamide hcl (Procainamide HCl) 1 capsule, tablet er,
tablet sa
procainamide hcl (Procainamide HCl) 1 vial
PRONESTYL 2
propafenone hcl (Rythmol) 1
quinidine gluconate (Quinidine Gluconate) 1
quinidine sulfate (Quinidine Sulfate) 1
TIKOSYN 2
Cardiac Drugs, Miscellaneous
digoxin (Lanoxin) 1
DIGOXIN 2
inamrinone lactate (Inamrinone Lactate) 1 PA
LANOXIN PEDIATRIC 2
milrinone lactate (Milrinone Lactate) 2 PA
milrinone lactate/d5w (Primacor in 5% Dextrose) 2 PA
RANEXA 2 QL: 120 tab er 12h: 500mg
in 30
days
RANEXA 2 QL: 60 in tab er 12h: 1000mg
30 days
Cathartics and Laxatives
Cathartics and Laxatives
AMITIZA 2 QL: 60 in
30 days
peg 3350/na sulf,bicarb,cl/ (Colyte with Flavor Packets) 1
kcl
polyethylene glycol 3350 (Polyethylene Glycol 3350) 1 powd pack: 17g
sodium chloride/nahco3/ (Nulytely) 1
kcl/peg
Cell Stimulants and Proliferants
Cell Stimulants and Proliferants
KEPIVANCE 2
tretinoin (Retin-A) 1 PA
74
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
Central Nervous System Agents, Miscellaneous
Central Nervous System Agents, Miscellaneous
CAMPRAL 2 tab ds pk
CAMPRAL 2 tablet dr
flumazenil (Romazicon) 1
lithium carbonate (Eskalith) 1
lithium citrate (Lithium Citrate) 1
LODOSYN 2
NAMENDA 2 PA, QL:
360 in 30
days
NAMENDA 2 PA, QL:
49 in 28
days
NAMENDA 2 PA, QL:
62 in 31
days
RILUTEK 2
SAVELLA 2 QL: 60 in
30 days
STRATTERA 2
XENAZINE 2 PA, QL:
112 in 28
days
XYREM 2 LA
Contraceptives
Contraceptives
desogestrel-ethinyl
estradiol
(Desogen) 1
solution
tab ds pk
tablet
desog-et estra/ethin estra (Mircette) 1
ethinyl estradiol/ (Yaz) 1
drospirenone
ethynodiol d-ethinyl (Demulen 1-50-21) 1
estradiol
levonorgestrel (Plan B) 1
levonorgestrel-eth (Lybrel) 1 tablet
estradiol
levonorgestrel-eth
estradiol
(Seasonale) 1 QL: 91 in tbdspk 3mo
84 days
75
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
l-norgest-eth estr/ethin (Seasonique) 1 QL: 91 in tbdspk 3mo: 100-
estra
84 days 20(84), 150-30(84)
l-norgest-eth estr/ethin (Seasonique) 1 QL: 91 in tbdspk 3mo: 150-
estra
84 days 30(84)
noreth a-et estra/fe (Loestrin Fe) 1
fumarate
noreth-ethinyl estradiol/ (Femcon Fe) 1
iron
norethindrone a-e (Loestrin) 1
estradiol
norethindrone (Nor-Q-D) 1
norethindrone-ethinyl (Ortho-novum) 1
estrad
norethindrone-mestranol (Ortho-novum) 1
norgestimate-ethinyl (Ortho-cyclen) 1
estradiol
norgestrel-ethinyl (Lo-ovral-28) 1
estradiol
NUVARING 2 ST, QL:
1 in 28
days
ORTHO EVRA 2 ST, QL:
3 in 28
days
Devices
Devices
needles, insulin disposable (Needles, Insulin Disposable) 1
syring w-
(Syring W-ndl,disp,insul,0.3ml) 1
ndl,disp,insul,0.3ml
syring w-
(Syring W-ndl,disp,insul,0.5ml) 1
ndl,disp,insul,0.5ml
syringe & needle,insulin,1 (Syringe & Needle,insulin,1 Ml) 1
ml
Diuretics
Diuretics, Miscellaneous
chlorthalidone (Chlorthalidone) 1
indapamide (Lozol) 1
metolazone (Zaroxolyn) 1
SAMSCA 2 QL: 30 in tablet: 15mg
30 days
76
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
SAMSCA 2 QL: 60 in tablet: 30mg
30 days
Loop Diuretics
bumetanide (Bumex) 1
furosemide (Furosemide) 1 disp syrin
furosemide (Lasix) 1 solution, tablet, vial
torsemide (Demadex) 1
Potassium-sparing Diuretics
amiloride hcl (Midamor) 1
amiloride/
(Amiloride/hydrochlorothiazide) 1
hydrochlorothiazide
DYRENIUM 2
triamterene/
(Maxzide-25mg) 1
hydrochlorothiazid
Thiazide Diuretics
chlorothiazide (Chlorothiazide) 1
hydrochlorothiazide (Hydrochlorothiazide) 1
methyclothiazide (Methyclothiazide) 1
EENT Drugs, Miscellaneous
EENT Drugs, Miscellaneous
apraclonidine hcl (Iopidine) 1
carteolol hcl (Carteolol HCl) 1
ipratropium bromide (Atrovent) 1 QL: 15 in spray: 42mcg
10 days
ipratropium bromide (Atrovent) 1 QL: 30 in spray: 21mcg
28 days
LACRISERT 2
naphazoline hcl (Albalon) 1
naphazoline hcl/antazoline (Naphazoline HCl/antazoline) 1
phenylephrine hcl (Mydfrin) 1
TYZINE 2 drops
TYZINE 2 spray
Enzymes
Enzymes
ADAGEN 2
ALDURAZYME 2
CEREDASE 2
CEREZYME 2
ELAPRASE 2
ELITEK 2
77
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
FABRAZYME 2
KRYSTEXXA 2
LUMIZYME 2
MYOZYME 2
NAGLAZYME 2
PULMOZYME 2 PA
SUCRAID 2
VPRIV 2
XIAFLEX 2 PA, QL:
1 in 28
days
Estrogens and Antiestrogens
Estrogens and Antiestrogens
COMBIPATCH 2 QL: 8 in
28 days
ESTRACE 2 cream/appl
ESTRADERM 2 QL: 8 in
28 days
estradiol valerate (Delestrogen) 1
estradiol (Climara) 1 QL: 4 in patch tdwk
28 days
estradiol (Estrace) 1 tablet
estradiol/noreth ac (Activella) 1 tablet: 0.5-0.1mg
estradiol/noreth ac (Activella) 1 tablet: 1-0.5mg
ESTRASORB 2 QL:
97.44 in
28 days
estropipate (Ogen) 1
EVISTA 2
MENEST 2
norethind ac/ethinyl (Femhrt) 1 tablet: 1mg-5mcg
estradiol
PREMARIN 2
PREMPHASE 2
PREMPRO 2
VIVELLE-DOT 2 QL: 8 in
28 days
First Generation Antihistamines
First Generation Antihistamines
carbinoxamine maleate (Palgic) 1
78
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
chlorpheniramine maleate (Chlorpheniramine Maleate) 1
clemastine fumarate (Clemastine Fumarate) 1 syrup, tablet:
2.68mg
clemastine fumarate (Clemastine Fumarate) 1 tablet: 1.34mg
diphenhydramine hcl (Diphenhydramine HCl) 1 capsule: 25mg; disp
syrin
diphenhydramine hcl (Diphenhydramine HCl) 1 capsule: 50mg; vial
doxylamine succinate (Doxylamine Succinate) 1
p-epd tan/chlor-tan (P-epd Tan/chlor-tan) 1
phenyleph/acetaminop/ptlox/cp
(Phenyleph/acetaminop/p-tlox/ 1
cp)
phenylephrine/chlor-tan (Rynatan) 1
promethazine hcl (Promethazine HCl) 1
tripelennamine hcl (Tripelennamine HCl) 1
Genitourinary Smooth Muscle Relaxants
Genitourinary Smooth Muscle Relaxants
DETROL LA 2
DETROL 2
flavoxate hcl (Urispas) 1
oxybutynin chloride (Ditropan) 1
TOVIAZ 2
trospium chloride (Sanctura) 1
VESICARE 2
GI Drugs, Miscellaneous
GI Drugs, Miscellaneous
CHENODAL 2 PA, QL:
120 in 30
days
CIMZIA 2 PA, QL:
3 in 28
days
CREON 2 capsule dr: 3-9.5-
15k
CREON 2 capsule dr: 6k-19k-
30k, 12k-38k-60,
24-76-120k
lipase/protease/amylase (Zenpep) 1
LOTRONEX 2
metoclopramide hcl (Metoclopramide HCl) 1 disp syrin
metoclopramide hcl (Reglan) 1 solution, tablet, vial
79
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
RELISTOR 2 PA, QL: disp syrin
28 in 28
days
RELISTOR 2 PA, QL: kit
28 in 28
days
ursodiol (Actigall) 1
ZENPEP 2
Heavy Metal Antagonists
Heavy Metal Antagonists
BAL IN OIL 2
CA-DTPA 2
CALCIUM DISODIUM
2
VERSENATE
CHEMET 2
CUPRIMINE 2
deferoxamine mesylate (Desferal) 1 PA
DEPEN 2
edetate disodium (Edetate Disodium) 1
ENDRATE 2
EXJADE 2
FERRIPROX 2
GALZIN 2
na nitrite/na thiosul/amyl (Na Nitrite/na Thiosul/amyl Nit) 1
nit
sodium thiosulfate (Sodium Thiosulfate) 1
SYPRINE 2
ZN-DTPA 2
Hematologic Agents
Anticoagulants
CEPROTIN 2
citrate-phos-dex solution (Citrate-phos-dex Solution) 1
COUMADIN 2 vial
enoxaparin sodium (Lovenox) 1 QL: 13.6
in 30
days
disp syrin: 40mg/
0.4ml
enoxaparin sodium (Lovenox) 1 QL: 18 in
30 days
disp syrin: 30mg/
0.3ml
80
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
enoxaparin sodium (Lovenox) 1 QL: 20.4
in 30
disp syrin: 60mg/
0.6ml
days
enoxaparin sodium (Lovenox) 2 QL: 27.2
in 30
disp syrin: 80mg/
0.8ml, 120mg/.8ml
days
enoxaparin sodium (Lovenox) 2 QL: 34 in disp syrin: 150mg/
30 days ml
enoxaparin sodium (Lovenox) 2 QL: 36 in disp syrin: 100mg/
30 days
fondaparinux sodium (Arixtra) 1 QL: 11.2
in 28
days
fondaparinux sodium (Arixtra) 1 QL: 5.6
in 28
days
fondaparinux sodium (Arixtra) 1 QL: 7 in
28 days
fondaparinux sodium (Arixtra) 1 QL: 8.4
in 28
days
FRAGMIN 2 PA, QL:
10.2 in
30 days
FRAGMIN 2 PA, QL:
12 in 30
days
FRAGMIN 2 PA, QL:
12.24 in
30 days
FRAGMIN 2 PA, QL:
15.2 in
30 days
FRAGMIN 2 PA, QL:
17 in 30
days
FRAGMIN 2 PA, QL:
5.1 in 30
days
ml
disp syrin: 10mg/
0.8ml
disp syrin: 5mg/
0.4ml
disp syrin: 2.5mg/
0.5
disp syrin: 7.5mg/
0.6
disp syrin: 15000/
0.6
disp syrin: 2500/
0.2ml
disp syrin: 18000/
0.72
vial
disp syrin: 10000/ml
disp syrin: 7500/
0.3ml
81
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
FRAGMIN 2 PA, QL:
6 in 30
disp syrin: 5000/
0.2ml
days
FRAGMIN 2 PA, QL:
8.5 in 30
disp syrin: 12500/
0.5
days
heparin sodium,porcine (Hep-lock) 1 PA (PA for ESRD only)
heparin sodium,porcine/ (Heparin Sodium, porcine/D5W) 1
d5w
heparin sodium,porcine/ (Heparin Sodium, porcine/ns/PF) 1 iv soln: 1000/500ml
ns/pf
heparin sodium,porcine/ (Heparin Sodium, porcine/ns/PF) 1 iv soln: 2k/1000ml
ns/pf
heparin sodium,porcine/pf (Hep-lock) 1 vial port: 10000/5ml
heparin sodium,porcine/pf (Hep-lock) 1 vial port: 25k/10ml
heparin sodium,porcine/pf (Monoject Prefill Advanced) 1 PA disp syrin, (PA for
ESRD only)
heparin sodium,pork in 1/ (Heparin Sodium, pork in 1/2 1
2 ns
NS)
IPRIVASK 2 PA, QL:
24 in 28
days
LOVENOX 2 QL: 12 in vial
30 days
warfarin sodium (Coumadin) 1
Hematologic Agents, Miscellaneous
aminocaproic acid (Amicar) 1
anagrelide hcl (Agrylin) 1
CYKLOKAPRON 2
LYSTEDA 2 QL: 30 in
30 days
pentoxifylline (Trental) 1
protamine sulfate (Protamine Sulfate) 1 PA (PA for ESRD only)
tranexamic acid (Tranexamic Acid) 1
Platelet-aggregation Inhibitors
cilostazol (Pletal) 1
EFFIENT 2
PLAVIX 2
82
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Hematopoietic Agents
Hematopoietic Agents
ARANESP 2 PA, QL:
1.2 in 28
days
ARANESP 2 PA, QL:
1.6 in 28
days
ARANESP 2 PA, QL:
1.68 in
28 days
ARANESP 2 PA, QL:
2 in 28
days
ARANESP 2 PA, QL:
2.4 in 28
days
ARANESP 2 PA, QL:
4 in 28
days
EPOGEN 2 PA, QL:
12 in 28
days
EPOGEN 2 PA, QL:
6 in 28
days
LEUKINE 2
MOZOBIL 2 PA, QL:
9.6 per
fill
NEULASTA 2
NEUMEGA 2
NEUPOGEN 2
PROCRIT 2 PA, QL:
12 in 28
days
PROCRIT 2 PA, QL:
6 in 28
days
Requirements/Limits
disp syrin: 60mcg/
0.3, 150mcg/0.3
disp syrin: 40mcg/
0.4, 200mcg/0.4
disp syrin: 25mcg/
0.42
disp syrin: 100mcg/
0.5
disp syrin: 300mcg/
0.6
disp syrin: 500mcg/
ml; vial
vial: 2000/ml, 3000/
ml, 4000/ml, 10000/
ml, 20000/ml
vial: 40000/ml
vial: 2000/ml, 3000/
ml, 4000/ml, 10000/
ml, 20000/ml
vial: 40000/ml
83
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
PROMACTA 2 PA, QL:
30 in 30
days
Hypotensive Agents
Hypotensive Agents, Miscellaneous
clonidine hcl (Catapres) 1
clonidine hcl/
(Clonidine HCl/chlorthalidone) 1
chlorthalidone
clonidine (Catapres-TTS 3) 1 QL: 4 in
28 days
clonidine (Catapres-TTS 3) 1 QL: 8 in
patch tdwk: 0.1mg/
24hr, 0.2mg/24hr
patch tdwk: 0.3mg/
24hr
28 days
fenoldopam mesylate (Fenoldopam Mesylate) 1 PA
guanabenz acetate (Guanabenz Acetate) 1 tablet: 4mg
guanabenz acetate (Guanabenz Acetate) 1 tablet: 8mg
guanfacine hcl (Tenex) 1
hydralazine hcl (Apresoline) 1
hydralazine/
(Hydralazine/
1
hydrochlorothiazid hydrochlorothiazid)
hydralazine/reserpin/hctz (Hydralazine/reserpin/hctz) 1
minoxidil (Minoxidil) 1
PROGLYCEM 2
reserpine (Reserpine) 1
reserpine/
(Reserpine/hydrochlorothiazide) 1
hydrochlorothiazide
Ion-Removing Agents
Ion-Removing Agents
calcium acetate (Phoslo) 1
calcium carbonate/mag (Calcium Carbonate/mag Carb/ 1
carb/fa
fa)
PHOSLYRA 2
RENAGEL 2
RENVELA 2 powd pack: 2.4g;
tablet
sodium polystyrene (Sodium Polystyrene Sulfonate) 1
sulfonate
Irrigating Solutions
Irrigating Solutions
acetic acid (Acetic Acid) 1
84
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
IRRIGATING
2
SOLUTION G
LACTATED RINGERS 2
mannitol/sorbitol solution (Mannitol/sorbitol Solution) 1
ringers solution (Tis-u-sol) 1
sod chloride 0.45% irrig. (Sod Chloride 0.45% Irrig. Soln) 1
soln
sodium chloride irrig (Sodium Chloride Irrig Solution) 1
solution
sorbitol solution (Sorbitol Solution) 1
urologic solution-g (Urologic Solution-g) 1
water for irrigation,sterile (Water for Irrigation, Sterile) 1
Keratolytic Agents
Keratolytic Agents
benzoyl peroxide
microspheres
(Neobenz Micro) 1
benzoyl peroxide&skin (Brevoxyl-4) 1
cleansr5
benzoyl peroxide (Delos) 1
benzoyl peroxide/aloe (Benzoyl Peroxide/aloe Vera) 1
vera
benzoyl peroxide/ (Benzoyl Peroxide/
1
hydrocortison
hydrocortison)
benzoyl peroxide/skin (Benzoyl Peroxide/skin Clnsr7) 1
clnsr7
benzoyl peroxide/urea (Zoderm) 1
potassium hydroxide (Potassium Hydroxide) 1
salicylic acid (Salex) 1
Requirements/Limits
salicylic acid/ammon lact/ (Salkera) 1
aloe
salicylic acid/ceramide (Salex) 1
cmb #1
silver nitrate applicator (Silver Nitrate Applicator) 1 stick (ea): 75%-25%
urea (Uramaxin) 1
urea/lactic ac/zn (Kerol) 1
undecylenate
urea/lactic acid/salicyl
acid
(Kerol) 1
85
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Keratoplastic Agents
Keratoplastic Agents
CARMOL SCALP 2
DRITHO-SCALP 2
sulfacetamide sodium/urea (Rosula Ns) 1
Local Anesthetics
Local Anesthetics
aa/antipyrn/bcaine/
polico#1/al
(Auralgan) 1
Requirements/Limits
aa/antpy/bcaine/polico/al (Aa/antpy/bcaine/polico/al Acet) 1
acet
AKTEN 2
antipyrine/benzocaine/ (Otra Nr) 1
glycerin
benzocaine (Omedia Otic) 1
chloroprocaine hcl/pf (Nesacaine-MPF) 1
chloroxylenol/pramoxine (Oticin) 1
hcl
cocaine hcl (Cocaine HCl) 1
lidocaine hcl (Xylocaine) 1 jel (ml), jel/pf app,
solution
lidocaine hcl (Xylocaine) 1 PA vial: 10mg/ml, (PA
for ESRD only)
lidocaine hcl (Xylocaine) 1 PA vial: 20mg/ml, (PA
for ESRD only)
lidocaine hcl/pf (Xylocaine-MPF) 1 PA ampul, (PA for
ESRD only)
lidocaine hcl/pf (Xylocaine-MPF) 1 PA vial, (PA for ESRD
only)
mepivacaine hcl/pf (Mepivacaine HCl/PF) 1
NESACAINE 2 vial: 10mg/ml
phenylephrine/antipy/bcaine
(Otogesic) 1
proparacaine hcl (Ophthetic) 1
proparacaine/fluorescein (Proparacaine/fluorescein Sod) 1
sod
tetracaine hcl (Pontocaine) 1
tetracaine hcl/pf (Tetracaine HCl/PF) 1
86
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Miscellaneous Therapeutic Agents
Miscellaneous Therapeutic Agents
ACTEMRA
Drug
Tier
2
Requirements/Limits
PA, QL:
40 in 30
days
ACTIMMUNE 2
ACTONEL with
CALCIUM
2 ST, QL:
28 in 28
days
ACTONEL 2 ST, QL:
1 in 28
days
ACTONEL 2 ST, QL:
31 in 31
days
ACTONEL 2 ST, QL:
4 in 28
days
tablet: 150mg
tablet: 5mg, 30mg
tablet: 35mg
alendronate sodium (Fosamax) 1 tablet: 5mg, 10mg,
40mg
alendronate sodium (Fosamax) 1 QL: 4 in tablet: 35mg, 70mg
28 days
allopurinol sodium (Aloprim) 1
allopurinol (Zyloprim) 1
amifostine crystalline (Ethyol) 1
AMPYRA 2 PA, QL:
60 in 30
days
ANTABUSE 2
ARCALYST 2
ATGAM 2
AVODART 2
AVONEX
ADMINISTRATION
PACK
AVONEX 2
azathioprine sodium (Azathioprine Sodium) 1 PA
azathioprine (Imuran) 1 PA
BENLYSTA 2 PA, QL:
2 in 28
days
87
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10
2

Drug Name
Drug
Tier
Requirements/Limits
BERINERT 2
BETASERON 2 ST
BONIVA 2 PA, ST,
QL: 1 in
disp syrin, (PA for
ESRD only)
84 days
BONIVA 2 ST, QL: tablet: 150mg
1 in 28
days
BONIVA 2 ST, QL: tablet: 2.5mg
31 in 31
days
BOTOX 2 PA, QL: vial: 200unit
1 in 90
days
BOTOX 2 PA, QL: vial: 100unit
3 in 90
days
CELLCEPT 2 PA susp recon
CELLCEPT 2 PA vial
CINRYZE 2 PA, QL:
20 in 28
days
colchicine/probenecid (Colchicine/probenecid) 1
COLCRYS 2
COPAXONE 2
cyclosporine (Sandimmune) 1 PA capsule, vial
cyclosporine (Sandimmune) 1 PA solution
cyclosporine, modified (Neoral) 1 PA
CYSTADANE 2
CYSTAGON 2
dexrazoxane (Totect) 1
disulfiram (Antabuse) 1
DUODOTE 2
DYSPORT 2 PA, QL:
2 in 90
days
ELMIRON 2
ENBREL 2 PA, QL:
7.84 in
28 days
pen injctr
88
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
ENBREL 2 PA, QL: kit
8 in 28
days
ENBREL 2 PA, QL: disp syrin
8.16 in
28 days
ergoloid mesylates (Ergoloid Mesylates) 1 tab subl
ergoloid mesylates (Ergoloid Mesylates) 1 tablet
etidronate disodium (Didronel) 1
EXTAVIA 2 ST
finasteride (Proscar) 1
FIRAZYR 2
FLUOR-A-DAY 2 drops
FLUOR-A-DAY 2 tab chew
FLUORITAB 2
FLURA-DROPS 2
fomepizole (Antizol) 2
FOSAMAX 2 QL: 300 solution
in 28
days
FUSILEV 2
gauze bandage (Gauze Bandage) 1
GILENYA 2 PA, QL:
28 in 28
days
GLUCAGEN 2
GLUCAGON
2
EMERGENCY KIT
gold sodium thiomalate (Myochrysine) 1
HUMIRA 2 PA, QL:
4 in 28
days
HUMIRA 2 PA, QL:
6 in 28
days
ibandronate sodium (Boniva) 1 QL: 1 in
28 days
ILARIS 2
KALBITOR 2
kit, pen ij kit: 40mg/
0.8ml
pen ij kit: 40mg/
0.8ml
89
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
KINERET 2 PA, QL:
18.76 in
28 days
KUVAN 2
leflunomide (Arava) 1
leucovorin calcium (Leucovorin Calcium) 1
levocarnitine (with sugar) (Carnitor) 1 PA (PA for ESRD only)
levocarnitine (Carnitor) 1 PA (PA for ESRD only)
mesna (Mesnex) 1
MESNEX 2 tablet
methylene blue (Methylene Blue) 1
methylergonovine maleate (Methergine) 1 tablet
methylergonovine maleate (Methylergonovine Maleate) 1 vial
mycophenolate mofetil (Cellcept) 1 PA
MYFORTIC 2 PA
MYOBLOC 2 PA, QL:
1 in 90
days
NPLATE 2 PA, QL:
8 in 28
days
NULOJIX 2 PA
octreotide acetate (Sandostatin) 1 vial: 50mcg/ml,
100mcg/ml,
200mcg/ml
octreotide acetate (Sandostatin) 2 ampul, vial:
1000mcg/ml
ORENCIA 2 PA, QL: disp syrin
4 in 28
days
ORENCIA 2 PA, QL: vial
4 in 28
days
ORFADIN 2
ORTHOCLONE OKT-3 2 PA
pamidronate disodium (Aredia) 1 PA (PA for ESRD only)
PRALIDOXIME
2
CHLORIDE
probenecid (Probenecid) 1
PROGRAF 2 PA ampul
90
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
PROLIA 2 PA, QL:
1 in 180
days
PROTOPAM CHLORIDE 2
RAPAMUNE 2 PA
REBIF 2
RECLAST 2 QL: 100
in 300
days
REMICADE 2 PA, QL:
35 in 150
days
REVLIMID 2 LA, QL:
30 in 30
days
RIDAURA 2
SANDOSTATIN LAR 2
SENSIPAR 2
SIMPONI 2 PA, QL:
0.5 in 28
days
SIMULECT 2 PA
sodium fluoride (Sodium Fluoride) 2 drops, tab chew
SOLIRIS 2
SOMATULINE DEPOT 2 QL: 1 in
28 days
STELARA 2 PA, QL:
10 in 360
days
STELARA 2 PA, QL:
10 in 360
days
STELARA 2 PA, QL:
5 in 360
days
SUPPRELIN LA 2 QL: 1 in
360 days
SUPPRELIN 2
SYNAREL 2
tacrolimus (Prograf) 1 PA
disp syrin: 45mg/
0.5ml
vial
disp syrin: 90mg/ml
91
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
THALOMID 2 QL: 60 in
30 days
THIOLA 2
THYMOGLOBULIN 2
TYSABRI 2 LA, PA,
QL: 15 in
28 days
ULORIC 2 ST, QL:
31 in 31
days
VANTAS 2 QL: 1 in
360 days
XGEVA 2 PA, QL:
1.7 in 28
days
ZAVESCA 2
ZOMETA 2 infus. btl
ZOMETA 2 vial
ZORTRESS 2 PA, QL:
60 in 30
days
Myasthenia Gravis
Myasthenia Gravis
ENLON-PLUS 2
Mydriatics
Mydriatics
atropine sulfate (Isopto Atropine) 1
CYCLOGYL 2 drops: 0.5%, 2%
cyclopentolate hcl (Cyclogyl) 1
homatropine hbr (Isopto Homatropine) 1
ISOPTO
2 drops: 2%
HOMATROPINE
PROPINE 2
tropicamide (Mydriacyl) 1
Opiate Antagonists
Opiate Antagonists
naloxone hcl (Naloxone HCl) 1 disp syrin
naloxone hcl (Naloxone HCl) 1 vial
naltrexone hcl (Revia) 1
92
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Parasympathomimetics (Cholinergic Agents)
Parasympathomimetics (Cholinergic Agents)
Drug
Tier
Requirements/Limits
ARICEPT 2 PA, QL: tablet: 23mg
31 in 31
days
bethanechol chloride (Urecholine) 1
CHANTIX 2 PA, QL: tablet
168 in 84
days
CHANTIX 2 PA, QL: tab ds pk
53 in 28
days
donepezil hcl (Aricept) 1 QL: 31 in
31 days
EVOXAC 2
EXELON 2 PA, QL: patch td24
30 in 30
days
EXELON 2 QL: 240 solution
in 31
days
galantamine hbr (Razadyne ER) 1 QL: 30 in cap24h pel
30 days
galantamine hbr (Razadyne) 1 QL: 200 solution
in 30
days
galantamine hbr (Razadyne) 1 QL: 60 in tablet
30 days
guanidine hcl (Guanidine HCl) 1
MESTINON 2 syrup, tablet er
MYTELASE 2
neostigmine methylsulfate (Neostigmine Methylsulfate) 1
NICOTROL 2 QL: 2016
in 365
days
physostigmine salicylate (Physostigmine Salicylate) 1
pilocarpine hcl (Salagen) 1
PROSTIGMIN 2
pyridostigmine bromide (Mestinon) 1
REGONOL 2
93
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
rivastigmine tartrate (Exelon) 1 QL: 62 in
31 days
Parathyroid
Parathyroid
calcitonin,salmon,syntheti
c
(Miacalcin) 1 QL: 3.7
in 28
days
Requirements/Limits
FORTEO 2 PA, QL:
3 in 28
days
FORTICAL 2 QL: 3.7
in 28
days
MIACALCIN 2 PA vial, (PA for ESRD
only)
Pituitary
Pituitary
DDAVP 2 ampul: 15mcg/ml
desmopressin acetate (DDAVP) 1 tablet, vial
desmopressin acetate (Minirin) 1 QL: 15 in
30 days
GENOTROPIN 2 PA, QL:
28 in 28
days
GENOTROPIN 2 PA, QL:
5 in 28
days
HUMATROPE 2 PA, QL:
18 in 28
days
HUMATROPE 2 PA, QL:
25 in 28
days
HUMATROPE 2 PA, QL:
5 in 28
days
HUMATROPE 2 PA, QL:
9 in 28
days
solution, spray/
pump
disp syrin
cartridge
cartridge: 6mg
vial
cartridge: 24mg
cartridge: 12mg
94
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

NORDITROPIN
NORDIFLEX
NORDITROPIN
NORDIFLEX
NORDITROPIN
NORDIFLEX
NORDITROPIN
NORDIFLEX
Drug Name
Drug
Tier
Requirements/Limits
2 PA, QL: pen injctr: 15mg/
13 in 28 1.5ml
days
2 PA, QL: pen injctr: 30mg/
15 in 28 3ml
days
2 PA, QL:
20 in 28
days
2 PA, QL:
39 in 28
days
NORDITROPIN 2 PA, QL:
17 in 28
days
NORDITROPIN 2 PA, QL:
33 in 28
days
NOVAREL 2
NUTROPIN AQ NUSPIN 2 PA, QL:
20 in 28
days
NUTROPIN AQ NUSPIN 2 PA, QL:
34 in 28
days
NUTROPIN AQ 2 PA, QL:
10 in 28
days
NUTROPIN AQ 2 PA, QL:
20 in 28
days
NUTROPIN 2 PA, QL:
10 in 28
days
OMNITROPE 2 PA, QL:
13.5 in
28 days
OMNITROPE 2 PA, QL:
22.5 in
28 days
pen injctr: 10mg/
1.5ml
pen injctr: 5mg/
1.5ml
vial: 8mg
vial: 4mg
cartridge: 10mg/2ml
cartridge: 5mg/2ml
cartridge: 20mg/2ml
cartridge: 10mg/2ml
cartridge: 10mg/
1.5ml
cartridge: 5mg/
1.5ml
95
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
OMNITROPE 2 PA, QL: vial
8 in 28
days
SAIZEN 2 PA, QL: cartridge
3 in 28
days
SAIZEN 2 PA, QL: vial: 8.8mg
3 in 28
days
SAIZEN 2 PA, QL: vial: 5mg
4 in 28
days
SEROSTIM 2 PA, QL:
28 in 28
days
TEV-TROPIN 2 PA, QL:
17 in 28
days
vasopressin (Pitressin) 1
ZORBTIVE 2 PA, QL:
28 in 28
days
Progestins
Progestins
DEPO-PROVERA 2 QL: 10 in vial: 400mg/ml
28 days
DEPO-SUBQ PROVERA
104
2 QL: 1 in
84 days
medroxyprogesterone acet (Depo-provera) 1 QL: 1 in disp syrin
84 days
medroxyprogesterone acet (Depo-provera) 1 QL: 1 in vial
84 days
medroxyprogesterone acet (Provera) 1 tablet
norethindrone acetate (Aygestin) 1
progesterone (Progesterone In Oil) 1
progesterone,micronized (Prometrium) 1
PROMETRIUM 2
Psychotherapeutic Agents
Antidepressants
amitriptyline hcl (Amitriptyline HCl) 1
96
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
amoxapine (Amoxapine) 1
bupropion hcl (Wellbutrin SR) 1
citalopram hydrobromide (Celexa) 1
clomipramine hcl (Anafranil) 1
CYMBALTA 2 QL: 30 in capsule dr: 30mg
30 days
CYMBALTA 2 QL: 60 in capsule dr: 20mg,
30 days 60mg
desipramine hcl (Norpramin) 1
doxepin hcl (Doxepin HCl) 1
EMSAM 2 QL: 30 in
30 days
escitalopram oxalate (Lexapro) 1 QL: 31 in tablet
31 days
escitalopram oxalate (Lexapro) 1 QL: 720 solution
in 31
days
fluoxetine hcl (Prozac) 1 capsule, capsule dr,
solution, tablet:
10mg, 20mg
fluoxetine hcl (Rapiflux) 1 tablet: 60mg
fluvoxamine maleate (Fluvoxamine Maleate) 1
imipramine hcl (Tofranil) 1
imipramine pamoate (Tofranil-PM) 1
LEXAPRO 2 ST, QL: tablet
31 in 31
days
LEXAPRO 2 ST, QL: solution
720 in 31
days
LUVOX CR 2 ST, QL: cap er 24h: 150mg
62 in 31
days
LUVOX CR 2 ST, QL: cap er 24h: 100mg
93 in 31
days
maprotiline hcl (Maprotiline HCl) 1
MARPLAN 2
mirtazapine (Remeron) 1
nefazodone hcl (Serzone) 1
nortriptyline hcl (Pamelor) 1
97
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
paroxetine hcl (Paxil) 1
perphenazine/
(Perphenazine/amitriptyline 1
amitriptyline hcl HCl)
phenelzine sulfate (Nardil) 1
PRISTIQ ER 2 ST, QL:
31 in 31
days
protriptyline hcl (Vivactil) 1
sertraline hcl (Zoloft) 1
SURMONTIL 2 capsule: 100mg
tranylcypromine sulfate (Parnate) 1
trazodone hcl (Desyrel) 1
trimipramine maleate (Surmontil) 1
VENLAFAXINE HCL
1
ER
venlafaxine hcl (Effexor XR) 1
VIIBRYD 2 PA, QL:
30 in 30
days
Antipsychotic Agents
ABILIFY DISCMELT 2 QL: 62 in tab rapdis: 15mg
31 days
ABILIFY DISCMELT 2 QL: 93 in tab rapdis: 10mg
31 days
ABILIFY 2 QL: vial
161.2 in
28 days
ABILIFY 2 QL: 31 in tablet
31 days
ABILIFY 2 QL: 930 solution
in 31
days
chlorpromazine hcl (Chlorpromazine HCl) 1 ampul, tablet
chlorpromazine hcl (Chlorpromazine HCl) 1 oral conc.
clozapine (Clozaril) 1 QL: 140 tablet: 200mg
in 31
days
clozapine (Clozaril) 1 QL: 279
in 31
days
tablet: 100mg
98
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
clozapine (Clozaril) 1 QL: 93 in tablet: 25mg, 50mg
31 days
FANAPT 2 ST, QL: tablet
60 in 30
days
FANAPT 2 ST, QL: tab ds pk
8 in 28
days
FAZACLO 2 ST, QL: tab rapdis: 200mg
124 in 31
days
FAZACLO 2 ST, QL: tab rapdis: 150mg
186 in 31
days
FAZACLO 2 ST, QL:
93 in 31
tab rapdis: 12.5mg,
25mg, 100mg
days
fluphenazine decanoate (Fluphenazine Decanoate) 1
fluphenazine hcl (Fluphenazine HCl) 1
GEODON 2 QL: 6 in vial
28 days
GEODON 2 QL: 62 in capsule
31 days
HALDOL DECANOATE
2
100
HALDOL DECANOATE
2
50
HALDOL 2
haloperidol decanoate (Haloperidol Decanoate) 1
haloperidol lactate (Haloperidol Lactate) 1
haloperidol (Haloperidol) 1
INVEGA SUSTENNA 2 QL: 0.25
in 28
days
INVEGA SUSTENNA 2 QL: 0.5
in 28
days
INVEGA SUSTENNA 2 QL: 0.75
in 28
days
disp syrin: 39mg/
0.25
disp syrin: 78mg/
0.5ml
disp syrin: 117mg/
0.75
99
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
INVEGA SUSTENNA 2 QL: 1 in
28 days
disp syrin: 156mg/
ml
INVEGA SUSTENNA 2 QL: 1.5
in 28
days
disp syrin: 234mg/
1.5
INVEGA 2 ST, QL:
31 in 31
days
INVEGA 2 ST, QL:
62 in 31
days
LATUDA 2 ST, QL:
30 in 30
days
LATUDA 2 ST, QL:
30 in 30
days
tab er 24: 1.5mg,
3mg, 9mg
tab er 24: 6mg
tablet: 20mg
tablet: 40mg, 80mg
loxapine succinate (Loxitane) 1
MOBAN 2
NAVANE 2 capsule: 20mg
olanzapine (Zyprexa Zydis) 1 QL: 31 in
31 days
ORAP 2
perphenazine (Perphenazine) 1
RISPERDAL CONSTA 2 QL: 4 in
28 days
risperidone (Risperdal M-tab) 1 QL: 124
in 31
days
risperidone (Risperdal) 1 QL: 496
in 31
days
risperidone (Risperdal) 1 QL: 62 in
31 days
SAPHRIS 2 ST, QL:
60 in 30
days
SEROQUEL XR 2 QL: 31 in
31 days
tab rapdis: 3mg,
4mg
solution
tab rapdis: 0.25mg,
0.5mg, 1mg, 2mg;
tablet
tab er 24h: 200mg
100
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug
Drug Name
Requirements/Limits
Tier
SEROQUEL XR 2 QL: 62 in tab er 24h: 50mg,
31 days 150mg, 300mg,
400mg
SEROQUEL 2 QL: 93 in
31 days
thioridazine hcl (Thioridazine HCl) 1 oral conc.
thioridazine hcl (Thioridazine HCl) 1 tablet
thiothixene (Navane) 1
trifluoperazine hcl (Trifluoperazine HCl) 1
ziprasidone hcl (Geodon) 1 QL: 62 in
31 days
ZYPREXA RELPREVV 2 QL: 2 in
28 days
ZYPREXA 2 QL: 31 in
31 days
Renin-Angiotensin-Aldosterone System Inhibitors
Angiotensin II Receptor Antagonists
BENICAR HCT 2 ST
BENICAR 2 ST
DIOVAN HCT 2 ST
DIOVAN 2 ST
eprosartan mesylate (Teveten) 1
losartan potassium (Cozaar) 1
losartan/
(Hyzaar) 1
hydrochlorothiazide
TRIBENZOR 2 ST
Angiotensin-Converting Enzyme Inhibitors
benazepril hcl (Lotensin) 1
benazepril/
(Lotensin HCT) 1
hydrochlorothiazide
captopril (Capoten) 1
captopril/
(Capozide) 1
hydrochlorothiazide
enalapril maleate (Vasotec) 1
enalapril/
(Vaseretic) 1
hydrochlorothiazide
enalaprilat dihydrate (Enalaprilat Dihydrate) 1
fosinopril sodium (Monopril) 1
fosinopril/
hydrochlorothiazide
(Monopril HCT) 1
vial
101
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
lisinopril (Zestril) 1
lisinopril/
(Prinzide) 1
hydrochlorothiazide
moexipril hcl (Univasc) 1
moexipril/
(Uniretic) 1
hydrochlorothiazide
perindopril erbumine (Aceon) 1
quinapril hcl (Accupril) 1
quinapril/
(Accuretic) 1
hydrochlorothiazide
ramipril (Altace) 1
trandolapril (Mavik) 1
trandolapril/verapamil hcl (Trandolapril/verapamil HCl) 1
Renin-Angiotensin-Aldosterone System Inhibitors
eplerenone (Inspra) 1
spironolact/
(Aldactazide) 1
hydrochlorothiazid
spironolactone (Aldactone) 1
Replacement Preparations
Replacement Preparations
0.9 % sodium chloride (0.9 % Sodium Chloride) 1
calcium chloride (Calcium Chloride) 1
calcium gluconate (Calcium Gluconate) 1 PA (PA for ESRD only)
dex 2.5%-half str (Dex 2.5%-half Str Lact.ringers) 1
lact.ringers
dextrose 2.5% in half (Dextrose 2.5% In Half Ringers) 1
ringers
dextrose 5% in ringers (Dextrose 5% In Ringers) 1
dextrose 5%-lactated (Dextrose 5%-Lactated Ringers) 1
ringers
DEXTROSE W/
2
ELECTROLYTE A
DEXTROSE W/
2
ELECTROLYTE B
electrolyte-48 solution/ (Electrolyte-48 Solution/d10w) 1
d10w
electrolyte-48 solution/ (Electrolyte-48 Solution/D5W) 1
d5w
electrolyte-48/fructose
10%
(Electrolyte-48/fructose 10%) 1
102
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
electrolyte-48/fructose 5% (Electrolyte-48/fructose 5%) 1
electrolyte-75 solution/ (Electrolyte-75 Solution/D5W) 1
d5w
electrolyte-75/fructose 5% (Electrolyte-75/fructose 5%) 1
electrolyte-r solution/d5w (Normosol-r and Dextrose) 1
HYPERLYTE CR 2
HYPERLYTE R 2
IONOSOL B with
2
DEXTROSE 5%
IONOSOL MB-
2
DEXTROSE 5%
IONOSOL T-DEXTROSE
2
5%
ISOLYTE E 2
ISOLYTE H W/
2
DEXTROSE
ISOLYTE M W/
2
DEXTROSE
ISOLYTE P with
2
DEXTROSE
ISOLYTE S with
2
DEXTROSE
ISOLYTE S 2
LACTATED RINGERS 2
NORMOSOL-M and
2
DEXTROSE
NORMOSOL-R PH 7.4 2
NUTRILYTE II 2
NUTRILYTE 2
PLASMA-LYTE 148 2
PLASMA-LYTE 56 IN
2
DEXTROSE
PLASMA-LYTE A PH
2
7.4
PLASMA-LYTE M IN
2
DEXTROSE
pot chloride/pot bicarb/cit (K-lyte-cl) 1
ac
potassium acetate (Potassium Acetate) 1
potassium bicarbonate/cit (K-lyte) 1
ac
Requirements/Limits
103
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

potassium chlorid/d10-
0.2%nacl
potassium chlorid/d5-
0.225nacl
Drug Name
(Potassium Chlorid/d10-
0.2%NaCl)
(Potassium Chlorid/d5-
0.225NaCl)
Drug
Tier
1
Requirements/Limits
1 iv soln: 10meq/l,
20meq/l, 40meq/l,
10meq/l, 20meq/l,
40meq/l
1 iv soln: 30meq/l
potassium chlorid/d5-
0.225nacl
(Potassium Chlorid/d5-
0.225NaCl)
potassium chloride in (Potassium Chloride In
1
0.9%nacl
0.9%NaCl)
potassium chloride (Kaon-cl) 1 liquid, packet
potassium chloride (K-dur) 1 capsule er,
piggyback, tab er
prt, tablet er, tablet
sa, vial
potassium chloride/d5- (Potassium Chloride/D5-0.25 1 30meq/l
0.25ns
NS)
potassium chloride/d5- (Potassium Chloride/d5-
1
0.33nacl
0.33NaCl)
potassium chloride/d5- (Potassium Chloride/d5-
1
0.45nacl
0.45NaCl)
potassium chloride/d5- (Potassium Chloride/d5-
1
0.9%nacl
0.9%NaCl)
potassium chloride/d5lr (Potassium Chloride/D5 LR) 1
potassium chloride/d5w (Potassium Chloride/D5W) 1
potassium chloride-0.45% (Potassium Chloride-0.45% 1
nacl
NaCl)
potassium gluconate (Potassium Gluconate) 1
potassium phos,m-basic-dbasibasic)
(Potassium Phos,m-basic-d-
1
ringers solution (Ringers Solution) 1
sodium acetate (Sodium Acetate) 1
sodium chloride 0.45 % (Sodium Chloride 0.45 %) 1
sodium chloride 3% (Sodium Chloride 3%) 1
sodium chloride 5% (Sodium Chloride 5%) 1
sodium chloride (Sodium Chloride) 1 vial: 2.5meq/ml
sodium chloride (Sodium Chloride) 1 vial: 4meq/ml
sodium phos,m-basic-dbasic
(Sodium Phos,m-basic-d-basic) 1
TPN ELECTROLYTES 2
104
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
TRAVERT-
2
ELECTROLYTE NO.1
TRAVERT-
2 iv soln: 10%
ELECTROLYTE NO.2
TRAVERT-
2 iv soln: 5%
ELECTROLYTE NO.2
TRAVERT-
2
ELECTROLYTE NO.3
TRAVERT-
2
ELECTROLYTE NO.4
Respiratory Tract Agents, Miscellaneous
Respiratory Tract Agents, Miscellaneous
acetylcysteine (Acetylcysteine) 1
aminophylline (Aminophylline) 1 liquid
aminophylline (Aminophylline) 1 tablet, vial
ARALAST NP 2
DALIRESP 2 ST, QL:
30 in 30
days
guaifen/theop anhyd/pephed
(Guaifen/theop Anhyd/p-ephed) 1
PROLASTIN C 2
PROLASTIN 2
theophylline anhydrous (Theochron) 1 elixir, tab er 12h:
100mg, 200mg,
300mg, 450mg;
tablet er
theophylline anhydrous (Theochron) 1 solution, tab er 12h:
200mg
theophylline/dextrose 5%- (Theophylline/dextrose 5%- 1
water
water)
XOLAIR 2 PA, QL:
6 in 28
days
ZEMAIRA 2
Sclerosing Agents
Sclerosing Agents
ethanolamine oleate (Ethanolamine Oleate) 1
sodium morrhuate (Sodium Morrhuate) 1
sodium tetradecyl sulfate (Sodium Tetradecyl Sulfate) 1
105
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
talc (Talc) 1
Second Generation Antihistamines
Second Generation Antihistamines
fexofenadine hcl (Allegra) 1
levocetirizine
(Xyzal) 1
dihydrochloride
Serums
Serums
ANASCORP 2
ANTIVENIN
2
LATRODECTUS
MACTANS
ANTIVENIN
2
MICRURUS FULVIUS
CARIMUNE NF
2 PA
NANOFILTERED
CROFAB 2
CYTOGAM 2
DIGIBIND 2
DIGIFAB 2
FLEBOGAMMA DIF 2 PA
FLEBOGAMMA 2 PA
GAMASTAN S-D 2 PA
GAMMAGARD S-D 2 PA
GAMMAPLEX 2 PA
GAMUNEX 2 PA
HIZENTRA 2 PA
HYPERRAB S-D 2
HYPERRHO S-D 2
IMOGAM RABIES-HT 2
MICRHOGAM PLUS 2
OCTAGAM 2 PA
PRIVIGEN 2 PA
RHOGAM PLUS 2
RHOPHYLAC 2
VIVAGLOBIN 2 PA
WINRHO SDF 2
Skeletal Muscle Relaxants
Skeletal Muscle Relaxants
baclofen (Baclofen) 1
106
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
carisoprodol (Soma) 1 QL: 120 tablet: 250mg
in 30
days
carisoprodol (Soma) 1 QL: 120 tablet: 350mg
in 30
days
chlorzoxazone (Parafon Forte DSC) 1
chlorzoxazone/
(Chlorzoxazone/acetaminophen) 1
acetaminophen
cyclobenzaprine hcl (Flexeril) 1 cap er 24h, tablet:
5mg, 10mg
dantrolene sodium (Dantrium) 1 capsule
dantrolene sodium (Dantrium) 1 vial
metaxalone (Skelaxin) 1
methocarbamol (Robaxin-750) 1
tizanidine hcl (Zanaflex) 1
Skin and Mucous Membrane Agents, Miscellaneous
Skin and Mucous Membrane Agents, Miscellaneous
8-MOP 2
adapalene (Differin) 1
AMEVIVE 2 PA, QL:
4 in 28
days
ammonium lactate (Lac-hydrin) 1
calcipotriene (Dovonex) 1
calcitriol (Vectical) 1
CARAC 2
CONDYLOX 2 gel (gram)
DOVONEX 2 cream
ELIDEL 2 PA
FLUOROPLEX 2
fluorouracil (Efudex) 1
imiquimod (Aldara) 1 PA, QL:
24 in 30
days
isotretinoin (Accutane) 1
LEVULAN 2
METVIXIA 2
OXSORALEN-ULTRA 2
PANRETIN 2
107
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
podofilox (Condylox) 1
podophyllum resin (Pododerm) 1
PROTOPIC 2 PA
REGRANEX 2 PA, QL:
30 in 30
days
SANTYL 2
TARGRETIN 2
TAZORAC 2
UVADEX 2
VECTICAL 2
ZYCLARA 2 PA, QL:
28 in 28
days
Somatotropin Agonists and Antagonists
Somatotropin Agonists and Antagonists
INCRELEX 2
SOMAVERT 2
Sympatholytic Adrenergic Blocking Agents
Alpha-Adrenergic Blocking Agents
alfuzosin hcl (Uroxatral) 1
DIBENZYLINE 2
dihydroergotamine (D.H.E. 45) 1
mesylate
ERGOMAR 2
ergotamine tartrate/ (Ergotamine Tartrate/caffeine) 1
caffeine
phentolamine mesylate (Phentolamine Mesylate) 1 PA
tamsulosin hcl (Flomax) 1
Sympathomimetic (Adrenergic) Agents
Sympathomimetic (Adrenergic) Agents
albuterol sulfate (Accuneb) 1 PA solution, vial-neb:
0.63mg/3ml,
1.25mg/3ml, 2.5mg/
3ml
albuterol sulfate (Proventil) 1 syrup, tab er 12h,
tablet
albuterol (Albuterol) 1
108
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
COMBIVENT 2 QL: 29.4
in 30
days
dobutamine hcl (Dobutamine HCl) 1 PA
dobutamine hcl/d5w (Dobutamine HCl/D5W) 1 PA
dopamine hcl (Dopamine HCl) 1 PA
dopamine hcl/dextrose (Dopamine HCl/dextrose 5%- 1 PA
5%-water
water)
ephedrine sulfate (Ephedrine Sulfate) 1
epinephrine (Adrenaclick) 1 QL: 2 in pen injctr
30 days
epinephrine (Epinephrine) 1 disp syrin
epinephrine/pf (Epinephrine/PF) 1
EPIPEN JR 2 QL: 2 in
30 days
EPIPEN 2 QL: 2 in
30 days
FORADIL 2 QL: 62 in
31 days
isoproterenol hcl (Isoproterenol HCl) 1
metaproterenol sulfate (Metaproterenol Sulfate) 1 syrup, tablet
midodrine hcl (Proamatine) 1
norepinephrine bit/0.9 % (Norepinephrine Bit/0.9 % 1 PA
nacl
NaCl)
norepinephrine bitartrate (Norepinephrine Bitartrate) 1 PA
phenylephrine hcl (Phenylephrine HCl) 1
phenylephrine tannate (Phenylephrine Tannate) 1
PROAIR HFA 2 QL: 17 in
25 days
SEREVENT DISKUS 2 QL: 62 in
31 days
terbutaline sulfate (Brethine) 1
Thyroid and Antithyroid Agents
Thyroid and Antithyroid Agents
ARMOUR THYROID 2
levothyroxine sodium (Levothyroxine Sodium) 1 vial
levothyroxine sodium (Synthroid) 1 tablet
liothyronine sodium (Cytomel) 1
methimazole (Tapazole) 1 tablet: 20mg
methimazole (Tapazole) 1 tablet: 5mg, 10mg
109
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
propylthiouracil (Propylthiouracil) 1
thyroid (Thyroid) 1
Toxoids
Toxoids
ADACEL 2 disp syrin
ADACEL 2 vial
BOOSTRIX 2
DAPTACEL 2
DIPHTHERIA-
2
TETANUS TOXOID
INFANRIX 2 vial: 25-58-10
TE ANATOXAL BERNA 2 PA
TENIVAC 2
TETANUS DIPHTHERIA
1
TOXOIDS
TETANUS TOXOID
2 PA
ADSORBED
TETANUS-DIPHTERIA-
2
DECAVAC
TRIHIBIT 2
TRIPEDIA 2
Urinary Anti-infectives
Urinary Anti-infectives
methen mand/naphos m-b (Methen Mand/naphos M-b M- 1
m-h
h)
methenamine hippurate (Hiprex) 1
methenamine mandelate (Mandelamine) 1
MONUROL 2
nitrofurantoin
(Macrobid) 1
macrocrystal
PRIMSOL 2
trimethoprim (Trimethoprim) 1
Vaccines
Vaccines
ACTHIB 2
ATTENUVAX
2 PA
VACCINE with
DILUENT
BCG VACCINE (TICE
STRAIN)
2 PA
110
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
BIOTHRAX 2
CERVARIX 2
COMVAX 2
ENGERIX-B 2 PA disp syrin: 10mcg/
0.5
ENGERIX-B 2 PA disp syrin: 20mcg/
ml; vial
GARDASIL 2 disp syrin
GARDASIL 2 vial
HAVRIX 2 PA disp syrin
HAVRIX 2 PA vial
HIBERIX 2
IMOVAX RABIES
2 PA
VACCINE
IPOL 2
IXIARO 2
JE-VAX 2
KINRIX 2
MENACTRA 2 disp syrin
MENACTRA 2 vial
MENOMUNE-A-C-Y-W-
2
135
MENVEO A-C-Y-W-135-
2
DIP
MERUVAX II VACCINE
2
W-DILUENT
M-M-R II VACCINE 2
MUMPSVAX VACCINE
2
W-DILUENT
PEDIARIX 2
PEDVAXHIB 2
PENTACEL 2
PROQUAD 2
RABAVERT 2 PA
RECOMBIVAX HB 2 PA disp syrin
RECOMBIVAX HB 2 PA vial
ROTARIX 2
ROTATEQ 2
THERACYS 2 PA
TWINRIX 2 disp syrin
111
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
TWINRIX 2 vial
TYPHIM VI 2
VAQTA 2 PA disp syrin
VAQTA 2 PA vial
VARIVAX VACCINE 2
VIVOTIF BERNA 2
YF-VAX 2
ZOSTAVAX 2
Vasodilating Agents
Vasodilating Agents
ADCIRCA 2 PA, QL:
60 in 30
days
AGGRENOX 2 QL: 60 in
30 days
alprostadil (Prostin Vr Pediatric) 1 PA
amyl nitrite (Amyl Nitrite) 1
epoprostenol sodium (Flolan) 1 PA vial: 0.5mg
(glycine)
epoprostenol sodium (Flolan) 2 PA vial: 1.5mg
(glycine)
isosorbide dinitrate (Isordil) 1
isosorbide mononitrate (Imdur) 1
ISOVEX 2
LETAIRIS 2 PA, QL:
30 in 30
days
NITRO-BID 2
nitroglycerin (Nitro-dur) 1 QL: 30 in patch td24: 0.1mg/
30 days hr, 0.2mg/hr, 0.6mg/
hr
patch td24: 0.4mg/
hr
nitroglycerin (Nitro-dur) 1 QL: 60 in
30 days
nitroglycerin (Nitroglycerin) 1 vial
nitroglycerin (Nitrolingual) 1 spray
nitroglycerin/d5w (Nitroglycerin/D5W) 1
NITROSTAT 2
nylidrin hcl (Nylidrin HCl) 1 tablet: 12mg
papaverine hcl (Papaverine HCl) 1 PA
REMODULIN 2 PA
112
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

Drug Name
Drug
Tier
Requirements/Limits
REVATIO 2 PA, QL: vial
37.5 in 1
day
REVATIO 2 PA, QL: tablet
90 in 30
days
TRACLEER 2 LA, PA,
QL: 60 in
30 days
Vitamins and Minerals
Vitamins and Minerals
calcitriol (Rocaltrol) 1 PA (PA for ESRD only)
CYANOKIT 2
FLUOR-A-DAY 2
fluoride/iron/vit a,c&d (Fluoride/iron/vit A,c&d) 2
FLURA 2
GESTICARE DHA 2
HECTOROL 2 PA (PA for ESRD only)
iron,carbonyl/vit c/vit b12/ (Iron,carbonyl/vit C/vit B12/fa) 2
fa
LOZI-FLUR 2
multivitamins with (Multivitamins with Fluoride) 2 drops
fluoride
multivitamins with (Multivitamins with Fluoride) 2 tab chew
fluoride
ped mv a,c,d3 #21 w- (Ped Mv A,c,d3 #21 W-fluoride) 2
fluoride
pedi mvi no.12/sodium (Mvc-fluoride) 2
fluoride
pnv with ca,no.72/iron/fa (Pnv with Ca,no.72/iron/fa) 2
sodium fluoride (Luride) 2
113
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

INDEX
0.9 % sodium chloride .....102 ADCIRCA........................112 amiloride/
8-MOP..............................107 ADVAIR DISKUS.............31 hydrochlorothiazide....... 77
aa/antipyrn/bcaine/polico#1/ ADVAIR HFA ...................31 aminocaproic acid ............. 82
al ....................................86 AFINITOR .........................59 aminophylline .................. 105
aa/antpy/bcaine/polico/al AGGRENOX ...................112 AMINOSYN...................... 71
acet.................................86 AKTEN ..............................86 AMINOSYN II.................. 71
ABELCET..........................51 ALAMAST.........................39 AMINOSYN II 3.5% M-
ABILIFY............................98 ALBENZA .........................39 DEXTROSE 5%............ 71
ABILIFY DISCMELT.......98 ALBUKED-25 ...................69 AMINOSYN II 3.5%-
ABRAXANE ..................... 59 ALBUKED-5 .....................69 DEXTROSE 25%.......... 71
acarbose.............................46 ALBUMARC .....................69 AMINOSYN II 3.5%-
acebutolol hcl.....................69 ALBUMIN HUMAN .........69 DEXTROSE 5%............ 71
acetaminophen with codeine ALBUMINAR-25 ..............70 AMINOSYN II 4.25% M-
........................................34 ALBUMINAR-5 ................70 DEXT 10% .................... 71
acetaminophen/phenyltolx cit ALBURX ...........................70 AMINOSYN II 4.25%-
........................................33 ALBUTEIN........................70 DEXTROSE 25%.......... 71
acetazolamide ....................52 albuterol ...........................108 AMINOSYN II 5% IN 25%
acetazolamide sodium........52 albuterol sulfate................108 DEXTROSE .................. 71
acetic ac/ricinoleic/oxyquinol
........................................55
alclometasone dipropionate
........................................56
AMINOSYN II IN
DEXTROSE .................. 71
acetic acid ....................52, 84 alcohol antiseptic pads.......55 AMINOSYN II with LYTESacetic
acid/aluminum acetate ALDURAZYME................77 CA-DW.......................... 71
........................................52 alendronate sodium............87 AMINOSYN M ................. 71
acetic acid/hydrocortisone.52 ALFERON N......................67 AMINOSYN with
acetylcysteine ...................105 alfuzosin hcl......................108 ELECTROLYTES......... 71
ACTEMRA........................87 ALIMTA ............................59 AMINOSYN-HBC ............ 71
ACTHAR H.P....................32 ALINIA ..............................65 AMINOSYN-HF ............... 71
ACTHIB...........................110 allopurinol..........................87 AMINOSYN-PF................ 71
ACTIMMUNE...................87 allopurinol sodium .............87 AMINOSYN-RF ............... 71
ACTONEL.........................87 ALPHAGAN P...................52 amiodarone hcl.................. 73
ACTONEL with CALCIUM alprostadil ........................112 AMITIZA .......................... 74
........................................87 ALREX...............................55 amitriptyline hcl................. 96
ACTOPLUS MET .............50 aluminum chloride..............69 amlodipine besylate ........... 70
ACTOPLUS MET XR.......50 amantadine hcl ...................64 amlodipine besylate/
ACTOS ..............................50 AMBISOME ......................51 benazepril ...................... 70
acyclovir.............................68 amcinonide .........................56 amlodipine/atorvastatin..... 58
acyclovir sodium ................68 AMERICAINE...................65 ammonium chloride ........... 31
ADACEL .........................110 AMEVIVE .......................107 ammonium lactate............ 107
ADAGEN...........................77 amifostine crystalline .........87 amoxapine.......................... 97
adapalene.........................107 amikacin sulfate..................39 amoxicillin ......................... 42
ADCETRIS........................59 amiloride hcl ......................77 amoxicillin/potassium clav 42
I-1
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

amphet asp/amphet/d-amphet atenolol/chlorthalidone ......69 benazepril/
........................................38 ATGAM .............................87 hydrochlorothiazide..... 101
AMPHOTEC......................51 atovaquone/proguanil hcl ..65 BENICAR........................ 101
amphotericin b ...................51 ATRIPLA...........................66 BENICAR HCT............... 101
ampicillin sodium...............42 atropine sulfate.............44, 92 BENLYSTA ...................... 87
ampicillin sodium/sulbactam ATROVENT HFA .............44 benzocaine ......................... 86
na....................................42 ATTENUVAX VACCINE benzoyl peroxide................ 85
ampicillin trihydrate ..........42 with DILUENT ............110 benzoyl peroxide
AMPYRA ..........................87 AVANDAMET ..................50 microspheres.................. 85
amyl nitrite.......................112 AVANDARYL...................50 benzoyl peroxide&skin
ANACAINE.......................65 AVANDIA .........................50 cleansr5 ......................... 85
ANADROL-50................... 37 AVASTIN ..........................59 benzoyl peroxide/aloe vera 85
anagrelide hcl ....................82 AVC ...................................55 benzoyl peroxide/
ANASCORP ....................106 AVELOX ...........................43 hydrocortison................. 85
anastrozole.........................59 AVELOX ABC PACK.......43 benzoyl peroxide/skin clnsr7
ANDRODERM..................37 AVELOX IV ......................43 ....................................... 85
ANDROGEL......................37 AVODART ........................87 benzoyl peroxide/urea........ 85
ANTABUSE ......................87 AVONEX...........................87 benztropine mesylate ......... 64
antipyrine/benzocaine/
glycerin ..........................86
ANTIVENIN
AVONEX
ADMINISTRATION
PACK .............................87
BERINERT........................ 88
betamet acet/betamet na ph31
betamet diprop/prop gly .... 56
LATRODECTUS
MACTANS..................106
ANTIVENIN MICRURUS
AXIRON ............................37
azathioprine........................87
azathioprine sodium ...........87
betamethasone dipropionate
....................................... 56
betamethasone valerate ..... 57
FULVIUS.....................106 azelastine hcl......................39 BETASERON.................... 88
ANTIVERT........................51 AZILECT ...........................64 betaxolol hcl ................ 52, 69
APEXICON E....................56 azithromycin.......................41 bethanechol chloride ......... 93
APOKYN...........................64 azithromycin hydrogen citrate BETIMOL ......................... 52
apraclonidine hcl ...............77 ........................................41 BEXXAR........................... 59
APRISO .............................56 AZOPT...............................52 bicalutamide ...................... 59
APTIVUS...........................66 AZOR.................................70 BICILLIN C-R .................. 42
ARALAST NP.................105 aztreonam...........................42 BICILLIN L-A .................. 42
ARANESP .........................83 bacitracin .....................40, 52 BICNU............................... 59
ARCALYST ......................87 bacitracin/polymyxin b sulfate BILTRICIDE..................... 39
ARICEPT...........................93 ........................................52 BIOTHRAX..................... 111
ARMOUR THYROID.....109 baclofen ............................106 bisoprolol fumarate ........... 69
ARRANON........................59 BAL IN OIL.......................80 bisoprolol fumarate/hctz.... 69
ARZERRA.........................59 balsalazide disodium..........56 bleomycin sulfate ............... 59
ASACOL............................56 BANZEL ............................44 BLEPHAMIDE ................. 53
ASACOL HD.....................56 BARACLUDE ...................68 BLEPHAMIDE S.O.P. ...... 53
aspirin ................................33 BCG VACCINE TICE
BONIVA............................ 88
ASTEPRO..........................39 STRAIN .......................110 BOOSTRIX ..................... 110
ASTRAMORPH-PF ..........34 benazepril hcl ...................101 BOTOX ............................. 88
atenolol ..............................69 BRANCHAMIN................ 71
I-2
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

imonidine tartrate...........52 carbinoxamine maleate ......78 CEREDASE....................... 77
BROMDAY .......................55 carboplatin .........................60 CEREZYME...................... 77
bromfenac sodium..............55 CARDENE I.V...................70 CERVARIX..................... 111
bromocriptine mesylate......64 CARDIZEM CD ................70 CESAMET......................... 50
budesonide .........................31 CARIMUNE NF
CHANTIX ......................... 93
bumetanide.........................77 NANOFILTERED .......106 CHEMET........................... 80
BUMINATE ......................70 carisoprodol .....................107 CHENODAL ..................... 79
BUPHENYL ......................33 CARMOL SCALP .............86 chloral hydrate .................. 68
BUPRENEX ...................... 37 carteolol hcl........................77 chloramphenicol na succ... 40
buprenorphine hcl..............37 carvedilol............................69 chlorhexidine gluconate .... 53
bupropion hcl.....................97 CAYSTON.........................42 chloroprocaine hcl/pf ........ 86
buspirone hcl......................68 CEENU...............................60 chloroquine phosphate ...... 65
BUSULFEX....................... 59 cefaclor...............................40 chlorothiazide .................... 77
butorphanol tartrate...........37 cefadroxil hydrate ..............40 chloroxylenol/pramoxine hcl
BYETTA............................46 cefazolin sodium.................40 ....................................... 86
BYSTOLIC........................69 cefazolin sodium/dextrose,iso chlorpheniramine maleate. 79
cabergoline ........................64 ........................................40 chlorpromazine hcl............ 98
CA-DTPA ..........................80 cefdinir ...............................40 chlorthalidone.................... 76
caffeine citrated .................38 cefditoren pivoxil................40 chlorzoxazone .................. 107
caffeine/sodium benzoate...38 CEFEPIME.........................40 chlorzoxazone/acetaminophen
calcipotriene ....................107 cefepime hcl........................40 ..................................... 107
calcitonin,salmon,synthetic 94 CEFEPIME-DEXTROSE ..40 cholestyramine (with sugar)
calcitriol...................107, 113 cefotaxime sodium..............40 ....................................... 58
calcium acetate ..................84 cefotetan disod/dextrose,iso42 cholestyramine/aspartame. 58
calcium carbonate/mag carb/ cefotetan disodium..............42 choline sal/mag salicylate . 33
fa ....................................84 cefoxitin sodium..................42 ciclopirox........................... 54
calcium chloride...............102 cefoxitin sodium/dextrose,iso ciclopirox olamine ............. 54
CALCIUM DISODIUM
........................................42 cilostazol............................ 82
VERSENATE ................80 cefpodoxime proxetil ..........40 cimetidine........................... 65
calcium gluconate ............102 cefprozil..............................41 cimetidine hcl..................... 65
CALDOLOR......................33 CEFTAZIDIME .................41 cimetidine in 0.9 % nacl .... 65
CAMPATH........................59 ceftazidime pentahydrate....41 CIMZIA............................. 79
CAMPRAL ........................75 CEFTRIAXONE ................41 CINRYZE.......................... 88
CANCIDAS .......................51 ceftriaxone na/dextrose,iso.41 CIPRO HC......................... 53
CANTIL.............................44 ceftriaxone sodium .............41 CIPRODEX ....................... 53
CAPASTAT SULFATE ....59 cefuroxime axetil ................41 ciprofloxacin hcl.......... 43, 53
CAPRELSA .......................60 cefuroxime sodium..............41 ciprofloxacin lactate.......... 43
captopril...........................101 cefuroxime sodium/
ciprofloxacin lactate/d5w .. 43
captopril/hydrochlorothiazide dextrose,iso.....................41 ciprofloxacin/ciprofloxa hcl
......................................101 CELEBREX .......................33 ....................................... 43
CARAC............................107 CELLCEPT ........................88 cisplatin ............................. 60
CARBAGLU......................33 CELONTIN........................45 citalopram hydrobromide.. 97
carbamazepine ...................44 cephalexin...........................41 citrate-phos-dex solution ... 80
carbidopa/levodopa ...........64 CEPROTIN ........................80 citric acid/sodium citrate... 31
I-3
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

cladribine ...........................60 COMTAN...........................64 DARAPRIM ...................... 65
clarithromycin....................41 COMVAX ........................111 daunorubicin hcl................ 60
clemastine fumarate...........79 CONCERTA ......................38 DAUNOXOME................. 60
CLEVIPREX......................70 CONDYLOX ...................107 DDAVP ............................. 94
clindamycin hcl ..................40 COPAXONE ......................88 deferoxamine mesylate ...... 80
clindamycin palmitate hcl..40 CORDRAN ........................57 demeclocycline hcl............. 43
clindamycin phos/benzoyl CORDRAN SP...................57 DENAVIR ......................... 54
perox ..............................54 COREG CR........................69 DEPEN .............................. 80
clindamycin phosphate.40, 54 cortisone acetate ................31 DEPO-MEDROL............... 31
CLINIMIX ......................... 72 CORTISPORIN-TC ...........53 DEPO-PROVERA............. 96
CLINIMIX E................71, 72 COUMADIN......................80 DEPO-SUBQ PROVERA
CLINISOL .........................72 CREON ..............................79 104 ................................. 96
clobetasol propionate.........57 CRESTOR..........................58 desipramine hcl.................. 97
CLODERM........................57 cresyl ace/ben alc/butanol/ipa desmopressin acetate......... 94
CLOLAR............................60
clomipramine hcl ...............97
........................................53
CRIXIVAN ........................66
desogestrel-ethinyl estradiol
....................................... 75
clonidine.............................84 CROFAB..........................106 desog-et estra/ethin estra... 75
clonidine hcl.......................84 cromolyn sodium ................56 desonide............................. 57
clonidine hcl/chlorthalidone CUBICIN ...........................40 desoximetasone.................. 57
........................................84 CUPRIMINE......................80 DETROL ........................... 79
clotrimazole........................54 CUTIVATE........................57 DETROL LA ..................... 79
clotrimazole/betamethasone
dip ..................................54
CYANOKIT.....................113
cyclobenzaprine hcl..........107
dex 2.5%-half str lact.ringers
..................................... 102
clozapine ......................98, 99 CYCLOGYL ......................92 dexamethasone................... 31
COARTEM........................65 cyclopentolate hcl...............92 dexamethasone sod phosphate
cocaine hcl .........................86 cyclophosphamide ..............60 ................................. 31, 55
codeine phos/acetaminophen cycloserine..........................59 DEXILANT....................... 65
........................................34 cyclosporine .......................88 dexmethylphenidate hcl ..... 38
codeine phosphate..............34 cyclosporine, modified .......88 dexrazoxane....................... 88
codeine sulf ........................34 CYKLOKAPRON..............82 dextroamphetamine sulfate 38
codeine/butalbit/acetamin/
caff..................................35
CYMBALTA .....................97
CYSTADANE....................88
dextrose 10 % and 0.225 %
nacl ................................ 72
codeine/butalbital/asa/caffein
........................................35
CYSTAGON ......................88
cysteine hcl .........................72
dextrose 10 % and 0.9 % nacl
....................................... 72
colchicine/probenecid........88 cytarabine/pf.......................60 dextrose 10%-0.5 normal
COLCRYS .........................88 CYTOGAM......................106 saline.............................. 72
colestipol hcl ......................58 dacarbazine ........................60 dextrose 10%-water........... 72
colistin (colistimethate na).40 DACOGEN ........................60 dextrose 2.5% in half ringers
COLY-MYCIN S...............53 dactinomycin ......................60 ..................................... 102
COMBIGAN......................52 DALIRESP.......................105 dextrose 2.5%-0.5normal
COMBIPATCH .................78 danazol ...............................37 saline.............................. 72
COMBIVENT..................109 dantrolene sodium............107 dextrose 2.5%-water.......... 72
COMBIVIR........................66 dapsone...............................59 dextrose 20%-water........... 72
COMPLERA...................... 66 DAPTACEL.....................110 dextrose 25%-water........... 72
I-4
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

dextrose 40%-water ...........72 DIPHTHERIA-TETANUS electrolyte-48 solution/d5w
dextrose 5 % and 0.33 % nacl TOXOID.......................110 ..................................... 102
........................................72 disopyramide phosphate.....73 electrolyte-48/fructose 10%
dextrose 5 % and 0.9 % nacl disulfiram ...........................88 ..................................... 102
........................................72 divalproex sodium ..............44 electrolyte-48/fructose 5%103
dextrose 5 %-0.225 % nacl 72 dobutamine hcl .................109 electrolyte-75 solution/d5w
dextrose 5 %-0.45 % nacl ..72 dobutamine hcl/d5w .........109 ..................................... 103
dextrose 5% in ringers.....102 DOCEFREZ .......................60 electrolyte-75/fructose 5%103
dextrose 5%-lactated ringers docetaxel.............................60 electrolyte-r solution/d5w 103
......................................102 donepezil hcl.......................93 ELIDEL ........................... 107
dextrose 5%-water .............72 dopamine hcl ....................109 ELIGARD.......................... 60
dextrose 50%-water ...........72 dopamine hcl/dextrose 5%- ELITEK ............................. 77
dextrose 60%-water ...........72 water.............................109 ELMIRON......................... 88
dextrose 70%-water ...........72 DORIBAX..........................42 ELSPAR ............................ 60
DEXTROSE W/
dorzolamide hcl..................52 EMCYT ............................. 60
ELECTROLYTE A .....102 dorzolamide hcl/timolol
EMEND............................. 51
DEXTROSE W/
maleat.............................52 EMSAM............................. 97
ELECTROLYTE B......102 DOVONEX ......................107 EMTRIVA......................... 66
dhcodeine bt/acetaminophn/ doxazosin mesylate.............33 enalapril maleate............. 101
caff..................................35 doxepin hcl .........................97 enalapril/hydrochlorothiazide
DIBENZYLINE...............108 DOXIL ...............................60 ..................................... 101
diclofenac potassium..........33 doxorubicin hcl...................60 enalaprilat dihydrate ....... 101
diclofenac sodium ........33, 55 doxorubicin hcl liposomal..60 ENBREL...................... 88, 89
dicloxacillin sodium...........42 doxycycline hyclate ......43, 53 ENDRATE......................... 80
dicyclomine hcl ..................44 doxycycline monohydrate...44 ENGERIX-B.................... 111
didanosine..........................66 doxylamine succinate .........79 ENLON-PLUS .................. 92
DIFICID.............................41 DRITHO-SCALP...............86 enoxaparin sodium ...... 80, 81
diflorasone diacetate..........57 dronabinol ..........................50 ephedrine sulfate.............. 109
diflunisal ............................33 droperidol...........................68 epinastine hcl..................... 39
DIGIBIND .......................106 DROXIA ............................60 epinephrine ...................... 109
DIGIFAB .........................106 DUETACT .........................50 epinephrine/pf.................. 109
digoxin................................74 DULERA............................31 EPIPEN............................ 109
DIGOXIN ..........................74 DUODOTE.........................88 EPIPEN JR ...................... 109
dihydroergotamine mesylate DUREZOL .........................55 epirubicin hcl..................... 60
......................................108 DUTOPROL.......................69 EPIVIR .............................. 66
DILANTIN ........................45 DYRENIUM ......................77 EPIVIR HBV..................... 66
diltiazem hcl.......................70 DYSPORT..........................88 eplerenone ....................... 102
dimenhydrinate ..................51 econazole nitrate ................54 EPOGEN ........................... 83
DIOVAN..........................101 edetate disodium.................80 epoprostenol sodium (glycine)
DIOVAN HCT.................101 EDURANT.........................66 ..................................... 112
DIPENTUM.......................56 EFFIENT............................82 eprosartan mesylate......... 101
diphenhydramine hcl..........79 ELAPRASE........................77 EPZICOM.......................... 66
diphenoxylate hcl/atropine.50 electrolyte-48 solution/d10w
......................................102
ERAXIS WATER DILUENT
....................................... 52
I-5
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

ERBITUX ..........................60 EXFORGE .........................70 fluocinolone acetonide oil . 55
ergoloid mesylates .............89 EXFORGE HCT ................70 fluocinolone/shower cap.... 57
ERGOMAR......................108 EXJADE.............................80 fluocinonide ....................... 57
ergotamine tartrate/caffeine EXTAVIA ..........................89 FLUOR-A-DAY........ 89, 113
......................................108 FABRAZYME ...................78 fluoride/iron/vit a,c&d..... 113
ERWINAZE.......................61 famciclovir..........................68 FLUORITAB..................... 89
ery e-succ/sulfisoxazole .....41 famotidine...........................66 fluorometholone................. 55
ERY-TAB ..........................41 famotidine in nacl,iso-osm/pf FLUOROPLEX ............... 107
ERYTHROCIN
........................................66 fluorouracil................ 61, 107
LACTOBIONATE.........41 FANAPT ............................99 fluoxetine hcl...................... 97
erythromycin base........41, 53 FARESTON .......................61 fluoxymesterone................. 37
erythromycin base/ethanol.54 FASLODEX.......................61 fluphenazine decanoate ..... 99
erythromycin ethylsuccinate FAZACLO .........................99 fluphenazine hcl................. 99
........................................41 felbamate ............................44 FLURA ............................ 113
erythromycin stearate ........41 FELBATOL .......................44 FLURA-DROPS................ 89
erythromycin/benzoyl
felodipine............................70 flurbiprofen........................ 33
peroxide..........................54 fenofibrate ..........................58 flurbiprofen sodium ........... 55
escitalopram oxalate..........97 fenofibrate,micronized........58 flutamide ............................ 61
esmolol hcl .........................69 fenofibric acid ....................58 fluticasone propionate . 55, 57
ESTRACE..........................78 fenoldopam mesylate..........84 fluvoxamine maleate.......... 97
ESTRADERM ...................78 fenoprofen calcium.............33 FOLOTYN......................... 61
estradiol .............................78 fentanyl...............................35 fomepizole.......................... 89
estradiol valerate ...............78 fentanyl citrate....................35 fondaparinux sodium ......... 81
estradiol/noreth ac.............78 FERRIPROX......................80 FORADIL........................ 109
ESTRASORB ....................78 fexofenadine hcl................106 FORTAZ IN ISO-OSMOTIC
estropipate..........................78 finasteride...........................89 DEXTROSE .................. 41
ethambutol hcl....................59 FIRAZYR...........................89 FORTEO............................ 94
ethanolamine oleate.........105 FIRMAGON.......................61 FORTICAL........................ 94
ethinyl estradiol/drospirenone flavoxate hcl .......................79 FOSAMAX........................ 89
........................................75 FLEBOGAMMA .............106 foscarnet sodium................ 67
ethosuximide ......................45 FLEBOGAMMA DIF......106 fosinopril sodium ............. 101
ethyl alcohol/d5w...............72 flecainide acetate................73 fosinopril/
ethynodiol d-ethinyl estradiol FLEXBUMIN.....................70 hydrochlorothiazide..... 101
........................................75 FLOVENT DISKUS ....31, 32 fosphenytoin sodium .......... 45
etidronate disodium ...........89 FLOVENT HFA.................32 FRAGMIN................... 81, 82
etodolac..............................33 floxuridine ..........................61 FREAMINE HBC.............. 72
ETOPOPHOS ....................61 fluconazole .........................51 FREAMINE III.................. 72
etoposide ............................61 fluconazole in nacl,iso-osm 51 FREAMINE III with
EURAX..............................55 flucytosine...........................51 ELECTROLYTES......... 72
EVISTA .............................78 fludarabine phosphate........61 fructose 10%...................... 72
EVOXAC...........................93 fludrocortisone acetate.......32 furosemide ......................... 77
EXELDERM......................54 flumazenil ...........................75 FUROXONE ..................... 55
EXELON............................93 flunisolide...........................55 FUSILEV........................... 89
exemestane .........................61 fluocinolone acetonide .......57 FUZEON ........................... 66
I-6
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

gabapentin..........................44 GYNAZOLE-1...................54 hydrocodone bit/
GABITRIL.........................44 HALAVEN.........................61 acetaminophen............... 35
galantamine hbr.................93 HALDOL ...........................99 hydrocodone/ibuprofen...... 35
GALZIN.............................80 HALDOL DECANOATE hydrocortisone............. 32, 57
GAMASTAN S-D ...........106 100..................................99 hydrocortisone acetate ...... 57
GAMMAGARD S-D.......106 HALDOL DECANOATE 50 hydrocortisone acetate/aloe v
GAMMAPLEX................106 ........................................99 ....................................... 57
GAMUNEX .....................106 HALFAN............................65 hydrocortisone acetate/urea
ganciclovir .........................68 halobetasol propionate.......57 ....................................... 57
ganciclovir sodium.............68 haloperidol .........................99 hydrocortisone butyrate..... 57
GARDASIL .....................111 haloperidol decanoate........99 hydrocortisone sod succinate
gauze bandage ...................89 haloperidol lactate .............99 ....................................... 32
gemcitabine hcl ..................61 HAVRIX ..........................111 hydrocortisone valerate..... 57
gemfibrozil .........................58 HECTOROL.....................113 hydromorphone hcl............ 35
GENOTROPIN..................94 heparin sodium,porcine......82 hydromorphone hcl/pf........ 35
gentamicin in nacl, iso-osm39 heparin sodium,porcine/d5w hydroxychloroquine sulfate 65
gentamicin sulfate ..39, 53, 54 ........................................82 hydroxyurea....................... 61
gentamicin sulfate/pf..........39 heparin sodium,porcine/ns/pf hydroxyzine hcl.................. 68
GEODON...........................99 ........................................82 hydroxyzine pamoate ......... 68
GESTICARE DHA..........113 heparin sodium,porcine/pf .82 HYPERLYTE CR............ 103
GILENYA..........................89 heparin sodium,pork in 1/2 ns HYPERLYTE R .............. 103
GLEEVEC .........................61 ........................................82 HYPERRAB S-D ............ 106
glimepiride .........................49 HEPATAMINE..................72 HYPERRHO S-D ............ 106
glipizide..............................49 HEPATASOL.....................72 ibandronate sodium ........... 89
glipizide/metformin hcl ......49 HEPSERA ..........................68 ibuprofen............................ 34
GLUCAGEN......................89 HERCEPTIN......................61 ibuprofen/oxycodone hcl.... 35
GLUCAGON EMERGENCY HEXALEN.........................61 idarubicin hcl..................... 61
KIT.................................89 HIBERIX..........................111 ifosfamide........................... 61
glutethimide........................68 HIZENTRA......................106 ifosfamide/mesna ............... 61
glyburide ............................49 homatropine hbr.................92 ILARIS .............................. 89
glyburide,micronized .........49 HUMALOG .......................47 imipenem/cilastatin sodium42
glyburide/metformin hcl.....49 HUMALOG MIX 50-50 ....47 imipramine hcl................... 97
glycopyrrolate....................44 HUMALOG MIX 75-25 ....47 imipramine pamoate.......... 97
GLYSET ............................ 46 HUMATROPE...................94 imiquimod ........................ 107
gold sodium thiomalate......89 HUMIRA............................89 IMOGAM RABIES-HT .. 106
granisetron hcl...................50 HUMULIN 50-50...............47 IMOVAX RABIES
granisetron hcl/pf...............50 HUMULIN 70-30...............48 VACCINE ................... 111
griseofulvin,microsize ........51 HUMULIN N .....................48 inamrinone lactate............. 74
GRIS-PEG..........................51 HUMULIN R .....................48 INCIVEK........................... 67
guaifen/theop anhyd/p-ephed hydralazine hcl ...................84 INCRELEX ..................... 108
......................................105 hydralazine/
indapamide ........................ 76
guanabenz acetate..............84 hydrochlorothiazid .........84 INDOCIN .......................... 34
guanfacine hcl....................84 hydralazine/reserpin/hctz...84 indomethacin ..................... 34
guanidine hcl......................93 hydrochlorothiazide ...........77
I-7
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

indomethacin sodium
isosorbide mononitrate.....112 lansoprazole ...................... 66
trihydrate........................34 isotretinoin .......................107 LANTUS ........................... 48
INFANRIX ......................110 ISOVEX ...........................112 LANTUS SOLOSTAR...... 48
INTELENCE......................66 isradipine............................70 latanoprost......................... 52
INTRALIPID ...............72, 73 ISTALOL ...........................52 LATUDA......................... 100
INTRON A.........................68 ISTODAX ..........................61 leflunomide ........................ 90
INVANZ ............................42 itraconazole........................51 LETAIRIS ....................... 112
INVEGA ..........................100 IXEMPRA..........................61 letrozole ............................. 61
INVEGA SUSTENNA .....99, IXIARO............................111 leucovorin calcium ............ 90
100
JAKAFI ..............................61 LEUKERAN...................... 61
INVIRASE.........................66 JANUMET .........................46 LEUKINE.......................... 83
IONOSOL B with
JANUMET XR...................46 leuprolide acetate .............. 62
DEXTROSE 5% ..........103 JANUVIA...........................46 LEVEMIR ......................... 48
IONOSOL MB-DEXTROSE JENTADUETO ..................46 levetiracetam ..................... 44
5% ................................103 JE-VAX............................111 levetiracetam in nacl (iso-os)
IONOSOL T-DEXTROSE
5% ................................103
JEVTANA..........................61
JUVISYNC.........................46
....................................... 44
levobunolol hcl .................. 52
IPOL.................................111 KADIAN ............................35 levocarnitine ...................... 90
ipratropium bromide..........77 KALBITOR........................89 levocarnitine (with sugar) . 90
IPRIVASK .........................82 KALETRA .........................66 levocetirizine dihydrochloride
IRESSA..............................61 kanamycin sulfate...............39 ..................................... 106
irinotecan hcl .....................61 KEPIVANCE .....................74 levofloxacin.................. 43, 53
iron,carbonyl/vit c/vit b12/fa
......................................113
IRRIGATING SOLUTION G
KETEK...............................42
KETEK PAK......................42
ketoconazole.................51, 54
levofloxacin/dextrose 5%-
water .............................. 43
levonorgestrel .................... 75
........................................85 ketoprofen...........................34 levonorgestrel-eth estradiol75
ISENTRESS.......................66 ketorolac tromethamine34, 55 levorphanol tartrate........... 35
ISOLYTE E .....................103 KINERET...........................90 levothyroxine sodium....... 109
ISOLYTE H W/DEXTROSE KINRIX............................111 LEVULAN ...................... 107
......................................103 KOMBIGLYZE XR...........46 LEXAPRO......................... 97
ISOLYTE M W/DEXTROSE K-PHOS M.F......................31 LEXIVA ............................ 66
......................................103 K-PHOS NO.2....................31 lidocaine hcl .......... 65, 73, 86
ISOLYTE P with
KRYSTEXXA....................78 LIDOCAINE HCL ............ 74
DEXTROSE................. 103 KUVAN .............................90 lidocaine hcl/d5w/pf .......... 74
ISOLYTE S......................103 labetalol hcl........................69 lidocaine hcl/d7.5w/pf ....... 74
ISOLYTE S with
LACRISERT ......................77 lidocaine hcl/pf ............ 74, 86
DEXTROSE................. 103 LACTATED RINGERS....85, lidocaine/prilocaine........... 65
isoniazid .............................59 103
LIDODERM ...................... 65
isopropamide/
lactulose .............................33 lindane ............................... 55
prochlorperazine............44 LAMISIL............................54 liothyronine sodium ......... 109
isoproterenol hcl ..............109 lamivudine ..........................66 lipase/protease/amylase..... 79
ISOPTO CARPINE ...........52 lamivudine/zidovudine........66 LIPITOR............................ 58
ISOPTO HOMATROPINE92 lamotrigine .........................44 LIPOFEN........................... 58
isosorbide dinitrate .......... 112 LANOXIN PEDIATRIC....74 LIPOSYN II....................... 73
I-8
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

LIPOSYN III......................73 meclofenamate sodium .......34 methylprednisolone............ 32
lisinopril...........................102 medroxyprogesterone acet .96 methylprednisolone acetate32
lisinopril/hydrochlorothiazide mefenamic acid...................34 methylprednisolone sod succ
......................................102 mefloquine hcl ....................65 ....................................... 32
lithium carbonate...............75 MEGACE ES .....................62 metipranolol ...................... 52
lithium citrate.....................75 megestrol acetate................62 metoclopramide hcl ........... 79
LITHOSTAT......................33 meloxicam...........................34 metolazone......................... 76
l-norgest-eth estr/ethin estra melphalan hcl .....................62 metoprolol succinate.......... 69
........................................76 MENACTRA ...................111 metoprolol tartrate ............ 69
LODOSYN ........................75 MENEST............................78 metoprolol/
loperamide hcl ...................50 MENOMUNE-A-C-Y-W-135 hydrochlorothiazide....... 69
losartan potassium...........101 ......................................111 metronidazole .............. 54, 65
losartan/hydrochlorothiazide
......................................101
LOTEMAX........................ 55
MENVEO A-C-Y-W-135-
DIP ...............................111
mepivacaine hcl/pf..............86
metronidazole/sodium
chloride.......................... 65
METVIXIA ..................... 107
LOTRONEX......................79 MEPRON ...........................65 mexiletine hcl..................... 74
lovastatin............................58 mercaptopurine ..................62 mg sal/acetaminophn/p-tlox/
LOVAZA ...........................57 meropenem .........................42 caf .................................. 33
LOVENOX ........................82 MERUVAX II VACCINE MIACALCIN..................... 94
loxapine succinate............100 W-DILUENT ...............111 miconazole nitrate ............. 54
LOZI-FLUR.....................113 mesalamine.........................56 MICRHOGAM PLUS ..... 106
LUMIGAN.........................52 mesna..................................90 midodrine hcl................... 109
LUMIZYME......................78 MESNEX ...........................90 milrinone lactate................ 74
LUNESTA .........................68 MESTINON .......................93 milrinone lactate/d5w........ 74
LUPRON DEPOT..............62 metaproterenol sulfate......109 MINOCIN.......................... 44
LUPRON DEPOT-PED.....62 metaxalone .......................107 minocycline hcl.................. 44
LUVOX CR .......................97 metformin hcl......................46 minoxidil ............................ 84
LYRICA.............................45 methadone hcl ....................35 mirtazapine ........................ 97
LYSODREN ...................... 62 methamphetamine hcl.........38 misoprostol ........................ 66
LYSTEDA .........................82 methazolamide....................52 MITHRACIN..................... 62
magnesium chloride...........45 methen mand/naphos m-b m-h mitomycin........................... 62
magnesium salicylate.........34 ......................................110 mitoxantrone hcl................ 62
magnesium sulfate..............45 methenamine hippurate....110 M-M-R II VACCINE ...... 111
magnesium sulfate/d5w......45 methenamine mandelate...110 MOBAN .......................... 100
MALARONE..................... 65 methimazole......................109 moexipril hcl.................... 102
malathion ...........................55 methocarbamol.................107 moexipril/
mannitol/sorbitol solution..85 methotrexate sodium ..........62 hydrochlorothiazide..... 102
maprotiline hcl...................97 methotrexate sodium/pf ......62 mometasone furoate........... 57
MARPLAN........................97 methscopolamine bromide..44 MONUROL..................... 110
MATULANE ..................... 62 methyclothiazide.................77 morphine sulfate ................ 36
MAXALT ..........................58 methyl salicylate.................34 morphine sulfate in 0.9 %
MAXALT MLT.................58 methylene blue....................90 nacl ................................ 35
mebendazole.......................39 methylergonovine maleate..90 morphine sulfate/0.9% nacl/pf
meclizine hcl.......................51 methylphenidate hcl............38 ....................................... 36
I-9
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

morphine sulfate/d5w.........36 neo/polymyx b sulf/dexameth noreth a-et estra/fe fumarate
morphine sulfate/pf ............36 ........................................53 ....................................... 76
MOXEZA ..........................53
MOZOBIL .........................83
MULTAQ ..........................74
multivitamins with fluoride
......................................113
neomy sulf/bacitra/polymyxin
b......................................53
neomy sulf/bacitrac zn/poly/
hc ....................................53
neomy sulf/polymyxin b
noreth-ethinyl estradiol/iron
....................................... 76
norethind ac/ethinyl estradiol
....................................... 78
norethindrone .................... 76
MUMPSVAX VACCINE W- sulfate .............................54 norethindrone acetate........ 96
DILUENT ....................111 neomycin sulfate.................39 norethindrone a-e estradiol76
mupirocin ...........................54 neomycin sulfate/dex na ph 53 norethindrone-ethinyl estrad
MUSTARGEN...................62 neomycin/polymyxin b sulf/hc ....................................... 76
MYCOBUTIN ...................59 ........................................53 norethindrone-mestranol... 76
mycophenolate mofetil .......90 neomycin/polymyxn b/
norgestimate-ethinyl estradiol
MYFORTIC.......................90 gramicidin ......................53 ....................................... 76
MYLOTARG..................... 62 neostigmine methylsulfate ..93 norgestrel-ethinyl estradiol 76
MYOBLOC........................90 NEPHRAMINE..................73 NORMOSOL-M and
MYOZYME.......................78 NESACAINE .....................86 DEXTROSE ................ 103
MYTELASE ......................93 NEULASTA.......................83 NORMOSOL-R PH 7.4... 103
na nitrite/na thiosul/amyl nit NEUMEGA........................83 nortriptyline hcl ................. 97
........................................80 NEUPOGEN ......................83 NORVIR............................ 66
nabumetone........................34 NEVANAC ........................56 NOVAMINE ..................... 73
nadolol ...............................69 NEXAVAR ........................62 NOVAREL ........................ 95
nadolol/bendroflumethiazide niacin..................................57 NOVOLIN 70-30............... 48
........................................69 NIASPAN...........................57 NOVOLIN 70-30 INNOLET
nafcillin sodium..................42 nicardipine hcl....................70 ....................................... 48
NAFTIN.............................54 NICOTROL........................93 NOVOLIN N ..................... 48
NAGLAZYME ..................78 nifedipine............................70 NOVOLIN N INNOLET... 48
nalbuphine hcl....................37 NILANDRON ....................62 NOVOLIN R ..................... 48
nalidixic acid......................43 nimodipine..........................70 NOVOLOG ....................... 48
naloxone hcl.......................92 nisoldipine ..........................70 NOVOLOG MIX 70-30 .... 48
naltrexone hcl.....................92 NITRO-BID .....................112 NOXAFIL.......................... 51
NAMENDA .......................75 nitrofurantoin macrocrystal NPLATE............................ 90
naphazoline hcl ..................77 ......................................110 NUCYNTA........................ 36
naphazoline hcl/antazoline 77 nitroglycerin.....................112 NUCYNTA ER ................. 36
naproxen ............................34 nitroglycerin/d5w .............112 NULOJIX .......................... 90
naproxen sodium................34 NITROSTAT....................112 NUTRESTORE ................. 73
naratriptan hcl ...................58 nizatidine ............................66 NUTRILYTE................... 103
NASONEX ........................56 NORDITROPIN.................95 NUTRILYTE II ............... 103
NATACYN........................53 NORDITROPIN
NUTROPIN....................... 95
nateglinide..........................47 NORDIFLEX .................95 NUTROPIN AQ ................ 95
NAVANE.........................100 norepinephrine bit/0.9 % nacl NUTROPIN AQ NUSPIN. 95
needles, insulin disposable.76 ......................................109 NUVARING...................... 76
nefazodone hcl ...................97 norepinephrine bitartrate.109 nylidrin hcl....................... 112
nystatin......................... 51, 54
I-10
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

nystatin/triamcin ................54 paregoric ............................50 phenylephrine/antipy/b-caine
OCTAGAM .....................106 paromomycin sulfate ..........65 ....................................... 86
octreotide acetate...............90 paroxetine hcl.....................98 phenylephrine/chlor-tan .... 79
OFIRMEV..........................33 PASER ...............................59 PHENYTEK ...................... 45
ofloxacin.......................43, 53 PATADAY.........................39 phenytoin ........................... 45
olanzapine........................100 PATANOL .........................39 phenytoin sodium............... 45
omeprazole.........................66 ped mv a,c,d3 #21 w-fluoride phenytoin sodium extended 45
omeprazole/sodium
......................................113 PHOSLYRA ...................... 84
bicarbonate ....................66
OMNITROPE ..............95, 96
pedi mvi no.12/sodium
fluoride .........................113
PHOSPHOLINE IODIDE . 52
phosphorus #1.................... 31
ONCASPAR ...................... 62 PEDIARIX .......................111 PHOTOFRIN..................... 62
ondansetron........................50 PEDVAXHIB...................111 physostigmine salicylate.... 93
ondansetron hcl..................50 peg 3350/na sulf,bicarb,cl/kcl pilocarpine hcl............. 52, 93
ondansetron in 0.9 % nacl/pf ........................................74 PILOPINE HS ................... 52
........................................50 PEGANONE ......................45 pindolol.............................. 69
ONGLYZA ........................47 PEGASYS ..........................68 piperacillin sodium............ 43
ONTAK..............................62 PEGASYS PROCLICK .....68 piperacillin sodium/
ORAP...............................100 PEGINTRON .....................68 tazobactam..................... 43
ORENCIA..........................90 PEGINTRON REDIPEN ...68 piroxicam........................... 34
ORFADIN..........................90 pen g pot/dextrose-water....43 PLASBUMIN-25............... 70
ORTHO EVRA..................76 penicillin g potassium.........43 PLASBUMIN-5................. 70
ORTHOCLONE OKT-3....90 penicillin g potassium/d5w.43 PLASMA-LYTE 148 ...... 103
oxacillin sodium.................42 penicillin g procaine...........43 PLASMA-LYTE 56 IN
oxacillin sodium/dextrose,iso PENICILLIN G SODIUM .43 DEXTROSE ................ 103
........................................43 penicillin v potassium.........43 PLASMA-LYTE A PH 7.4
oxaliplatin ..........................62 PENTACEL .....................111 ..................................... 103
oxandrolone .......................37 pentamidine isethionate......65 PLASMA-LYTE M IN
oxaprozin............................34 PENTASA..........................56 DEXTROSE ................ 103
oxcarbazepine ....................45 pentostatin ..........................62 PLAVIX............................. 82
OXSORALEN-ULTRA...107 pentoxifylline ......................82 pnv with ca,no.72/iron/fa. 113
oxybutynin chloride............79 p-epd tan/chlor-tan.............79 podofilox .......................... 108
oxycodone hcl.....................36 perindopril erbumine........102 podophyllum resin ........... 108
oxycodone hcl/acetaminophen permethrin ..........................55 polyethylene glycol 3350 ... 74
........................................36 perphenazine ....................100 polymyxin b sulfate ............ 40
oxycodone hcl/aspirin ........36 perphenazine/amitriptyline polymyxin b sulfate/tmp..... 53
oxycodone hcl/oxycodon ter/ hcl...................................98 POLY-PRED ..................... 53
asa..................................36 phenazopyridine hcl ...........65 pot chloride/pot bicarb/cit ac
OXYCONTIN..............36, 37 phenelzine sulfate ...............98 ..................................... 103
oxymorphone hcl................37 phentolamine mesylate .....108 potassium acetate ............ 103
paclitaxel............................62 phenylbutazone...................34 potassium bicarbonate/cit ac
pamidronate disodium .......90 phenyleph/acetaminop/p-tlox/ ..................................... 103
PANRETIN......................107 cp ....................................79 potassium chlorid/d10-
pantoprazole sodium..........66 phenylephrine hcl .......77, 109 0.2%nacl...................... 104
papaverine hcl..................112 phenylephrine tannate......109
I-11
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

potassium chlorid/d5-
PRIFTIN.............................59 PROVIGIL......................... 39
0.225nacl......................104 PRIMAQUINE...................65 PULMOZYME.................. 78
potassium chloride...........104 PRIMAXIN ........................42 pyrazinamide ..................... 59
potassium chloride in
PRIMAXIN I.M. ................42 pyridostigmine bromide..... 93
0.9%nacl ......................104 primidone ...........................45 QUALAQUIN ................... 65
potassium chloride/d5-0.25ns PRIMSOL.........................110 QUICK MIX with LYTES 73
......................................104 PRISTIQ ER.......................98 quinapril hcl .................... 102
potassium chloride/d5-
0.33nacl........................104
potassium chloride/d5-
PRIVIGEN .......................106
PROAIR HFA ..................109
probenecid..........................90
quinapril/hydrochlorothiazide
..................................... 102
quinidine gluconate ........... 74
0.45nacl........................104 procainamide hcl................74 quinidine sulfate ................ 74
potassium chloride/d5-
PROCALAMINE...............73 QVAR................................ 32
0.9%nacl ......................104 prochlorperazine edisylate.51 RABAVERT.................... 111
potassium chloride/d5lr ...104 prochlorperazine maleate ..51 ramipril............................ 102
potassium chloride/d5w ...104 PROCRIT...........................83 RANEXA........................... 74
potassium chloride-0.45% progesterone.......................96 ranitidine hcl...................... 66
nacl...............................104 progesterone,micronized....96 RAPAMUNE..................... 91
potassium citrate................31 PROGLYCEM ...................84 REBETOL ......................... 68
potassium citrate/citric acid PROGRAF .........................90 REBIF................................ 91
........................................31 PROLASTIN....................105 RECLAST ......................... 91
potassium gluconate.........104 PROLASTIN C ................105 RECOMBIVAX HB........ 111
potassium hydroxide ..........85 PROLEUKIN .....................62 REGONOL ........................ 93
potassium phos,m-basic-dbasic
PROLIA .............................91 REGRANEX ................... 108
.............................104 PROMACTA......................84 RELENZA......................... 67
PRALIDOXIME
promethazine hcl ................79 RELISTOR ........................ 80
CHLORIDE ...................90 PROMETRIUM .................96 RELPAX............................ 58
pramipexole di-hcl .............64 PRONESTYL.....................74 REMICADE ...................... 91
PRANDIMET ....................47 propafenone hcl..................74 REMODULIN ................. 112
PRANDIN..........................47 proparacaine hcl ................86 RENAGEL......................... 84
pravastatin sodium.............58 proparacaine/fluorescein sod RENAMIN......................... 73
prazosin hcl........................33 ........................................86 RENVELA......................... 84
prednicarbate.....................57 PROPINE ...........................92 RESCRIPTOR................... 66
prednisolone.......................32 propranolol hcl...................69 reserpine ............................ 84
prednisolone acetate ....32, 56 propranolol/
reserpine/hydrochlorothiazide
prednisolone sod phosphate hydrochlorothiazid .........69 ....................................... 84
..................................32, 56 propylthiouracil................110 RESTASIS......................... 56
prednisone..........................32 PROQUAD.......................111 RETROVIR ....................... 67
PREDNISONE INTENSOL PROSOL.............................73 REVATIO........................ 113
........................................32 PROSTIGMIN ...................93 REVLIMID........................ 91
PREMARIN.......................78 protamine sulfate................82 REYATAZ......................... 67
PREMASOL ...................... 73 PROTONIX IV ..................66 RHOGAM PLUS............. 106
PREMPHASE....................78 PROTOPAM CHLORIDE.91 RHOPHYLAC................. 106
PREMPRO.........................78 PROTOPIC.......................108 ribavirin............................. 68
PREZISTA.........................66 protriptyline hcl..................98 RIDAURA......................... 91
I-12
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

ifampin..............................59 silver sulfadiazine...............55 STALEVO 125.................. 64
rifampin/isoniazid ..............59 SIMPONI ...........................91 STALEVO 150.................. 64
RIFATER...........................59 SIMULECT........................91 STALEVO 200.................. 64
RILUTEK ..........................75 simvastatin..........................58 STALEVO 50.................... 64
rimantadine hcl ..................67 SINGULAIR ......................56 STALEVO 75.................... 64
ringers solution ..........85, 104 sod chloride 0.45% irrig. soln stavudine............................ 67
RISPERDAL CONSTA...100 ........................................85 STELARA ......................... 91
risperidone .......................100 sod propionate/inosi/aa14/ STERILE DILUENT......... 70
RITUXAN..........................62 urea.................................54 STRATTERA .................... 75
rivastigmine tartrate ..........94 sod/pot/k cit/sod cit/cit acid31 streptomycin sulfate........... 39
ropinirole hcl .....................64 sodium acetate..................104 STROMECTOL ................ 39
ROTARIX........................111 sodium bicarbonate............31 SUBOXONE ..................... 37
ROTATEQ.......................111 sodium chloride................104 SUCRAID.......................... 78
SABRIL .............................45 sodium chloride 0.45 %....104 sucralfate ........................... 66
SAIZEN .............................96 sodium chloride 3%..........104 sulfacetamide sodium .. 53, 55
sal-amide/acetamin/p-tlox/ sodium chloride 5%..........104 sulfacetamide sodium/urea 86
caff..................................33 sodium chloride irrig solution sulfacetamide/prednisolone
sal-amide/acetaminophn/ptlox..................................33
........................................85 sp.................................... 53
sodium chloride/nahco3/kcl/ sulfadiazine........................ 43
salicylamide/acetaminophen peg ..................................74 sulfamethoxazole/
........................................33 sodium fluoride...........91, 113 trimethoprim .................. 43
salicylic acid ......................85 sodium lactate ....................31 sulfasalazine ...................... 43
salicylic acid/ammon lact/ sodium morrhuate ............105 sulindac.............................. 34
aloe.................................85 sodium phos,m-basic-d-basic sumatriptan.................. 58, 59
salicylic acid/ceramide cmb
......................................104 sumatriptan succinate........ 58
#1....................................85 sodium polystyrene sulfonate SUPPRELIN...................... 91
salsalate .............................34 ........................................84 SUPPRELIN LA................ 91
SAMSCA ..................... 76, 77 sodium tetradecyl sulfate..105 SUPRAX ........................... 41
SANDOSTATIN LAR....... 91 sodium thiosulfate ..............80 SURMONTIL.................... 98
SANTYL..........................108 sodium thiosulfate/sal acid.54 SUSTIVA .......................... 67
SAPHRIS .........................100 SOLIRIS.............................91 SUTENT............................ 63
SAVELLA .........................75 SOLU-MEDROL ...............32 SYLATRON 4-PACK....... 68
selegiline hcl ......................64 SOMATULINE DEPOT....91 SYMBICORT.................... 32
selenium sulfide..................55 SOMAVERT....................108 SYMLIN............................ 47
SELZENTRY.....................67 sorbitol solution..................85 SYMLINPEN 120 ............. 47
SENSIPAR.........................91 sotalol hcl ...........................69 SYMLINPEN 60 ............... 47
SEREVENT DISKUS......109 SOTALOL HCL.................69 SYNAGIS.......................... 67
SEROMYCIN.................... 59 SPIRIVA ............................44 SYNAREL......................... 91
SEROQUEL.....................101 spironolact/
SYNERCID ....................... 40
SEROQUEL XR ......100, 101 hydrochlorothiazid .......102 SYPRINE........................... 80
SEROSTIM........................96 spironolactone..................102 syring w-ndl,disp,insul,0.3ml
sertraline hcl ......................98 SPORANOX ......................51 ....................................... 76
silver nitrate.......................55 SPRYCEL ..........................63 syring w-ndl,disp,insul,0.5ml
silver nitrate applicator .....85 STALEVO 100...................64 ....................................... 76
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Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

syringe & needle,insulin,1 ml THYMOGLOBULIN.........92 TRAVERT-ELECTROLYTE
........................................76 thyroid ..............................110 NO.2 ............................ 105
TABLOID..........................63 TIKOSYN ..........................74 TRAVERT-ELECTROLYTE
tacrolimus ..........................91 timolol maleate.............52, 69 NO.3 ............................ 105
talc....................................106 tizanidine hcl ....................107 TRAVERT-ELECTROLYTE
TAMIFLU..........................67 TOBI...................................39 NO.4 ............................ 105
tamoxifen citrate ................63 tobramycin sulf/
trazodone hcl ..................... 98
tamsulosin hcl ..................108 dexamethasone ...............53 TREANDA ........................ 63
TARCEVA.........................63 tobramycin sulfate........39, 53 TRECATOR ...................... 59
TARGRETIN.............63, 108 tobramycin/sodium chloride TRELSTAR....................... 63
TASIGNA..........................63 ........................................40 tretinoin ....................... 63, 74
TASMAR...........................64 tolazamide ..........................49 TREXALL......................... 63
TAXOTERE ......................63 tolbutamide.........................49 triacetin.............................. 51
TAZICEF IN DEXTROSE 41 tolmetin sodium ..................34 triamcinolone acetonide ... 32,
TAZORAC.......................108 topiramate ..........................45 56, 57
TE ANATOXAL BERNA110 topotecan hcl ......................63 triamterene/
TEGRETOL XR ................45 TORISEL ...........................63 hydrochlorothiazid ........ 77
TENIVAC........................110 torsemide ............................77 TRIBENZOR................... 101
terazosin hcl.......................33 TOVIAZ.............................79 TRICOR............................. 58
terbinafine hcl ....................51 TPN ELECTROLYTES...104 trifluoperazine hcl............ 101
terbutaline sulfate ............109 TRACLEER .....................113 trifluridine.......................... 53
terconazole.........................54 TRADJENTA.....................47 trihexyphenidyl hcl ............ 64
testosterone ........................37 tramadol hcl .......................37 TRIHIBIT ........................ 110
testosterone cypionate........37 tramadol hcl/acetaminophen TRILIPIX........................... 58
testosterone enanthate .......37 ........................................37 trimethoprim .................... 110
TETANUS DIPHTHERIA trandolapril ......................102 trimipramine maleate ........ 98
TOXOIDS....................110 trandolapril/verapamil hcl TRIPEDIA....................... 110
TETANUS TOXOID
......................................102 tripelennamine hcl ............. 79
ADSORBED................110 tranexamic acid..................82 TRISENOX ....................... 63
TETANUS-DIPHTERIA- tranylcypromine sulfate......98 TRIZIVIR .......................... 67
DECAVAC ..................110 TRAVAMULSION............73 TROPHAMINE................. 73
tetracaine hcl .....................86 TRAVASOL.......................73 tropicamide........................ 92
tetracaine hcl/pf .................86 TRAVASOL W/
trospium chloride............... 79
tetracycline hcl...................44 ELECTROLYTES .........73 TRUVADA........................ 67
TEV-TROPIN.................... 96 TRAVASOL with
TWINRIX................ 111, 112
THALOMID ......................92 DEXTROSE...................73 TYGACIL.......................... 44
theophylline anhydrous....105 TRAVASOL with
TYKERB ........................... 63
theophylline/dextrose 5%-
ELECTROLYTES .........73 TYPHIM VI..................... 112
water ............................105 TRAVATAN Z ..................52 TYSABRI .......................... 92
THERACYS ....................111 TRAVERT .........................73 TYZEKA ........................... 68
THIOLA.............................92 TRAVERT IN NORMAL TYZINE............................. 77
thioridazine hcl ................101 SALINE..........................73 ULORIC ............................ 92
thiotepa ..............................63
thiothixene........................101
TRAVERT-ELECTROLYTE
NO.1 .............................105
urea.................................... 85
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Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10

urea/lactic ac/zn
undecylenate ..................85
urea/lactic acid/salicyl acid85
urologic solution-g.............85
ursodiol ..............................80
UVADEX.........................108
valacyclovir hcl..................68
VALCYTE.........................68
valproate sodium................45
valproic acid ......................45
VALSTAR .........................63
VANCOCIN HCL ............. 40
vancomycin hcl...................40
VANCOMYCIN HCL.......40
vancomycin hcl/d5w...........40
VANDETANIB .................63
VANTAS ...........................92
VAQTA............................112
VARIVAX VACCINE .... 112
vasopressin.........................96
VECTIBIX.........................63
VECTICAL......................108
VELCADE.........................63
venlafaxine hcl ...................98
VENLAFAXINE HCL ER 98
verapamil hcl .....................70
VERIPRED 20...................32
VESICARE........................79
VFEND ..............................51
VFEND IV.........................51
VIBATIV ...........................40
VIBRAMYCIN..................44
VICTOZA 3-PAK..............47
VICTRELIS .......................67
VIDAZA ............................63
VIDEX ...............................67
VIGAMOX.........................53
VIIBRYD ...........................98
VIMOVO ...........................34
VIMPAT.............................45
vinblastine sulfate...............63
vincristine sulfate ...............63
vinorelbine tartrate ............63
VIRACEPT ........................67
VIRAMUNE ......................67
VIRAMUNE XR................67
VIREAD.............................67
VISTIDE ............................68
VIVAGLOBIN.................106
VIVELLE-DOT .................78
VIVOTIF BERNA ...........112
VOLTAREN ......................34
voriconazole .......................51
VOTRIENT........................63
VPRIV................................78
VUMON.............................64
warfarin sodium .................82
water for irrigation,sterile..85
WELCHOL ........................58
WINRHO SDF .................106
XALKORI..........................64
XENAZINE........................75
XERAC AC........................69
XGEVA..............................92
XIAFLEX...........................78
XIFAXAN..........................40
XOLAIR...........................105
XYREM .............................75
YERVOY ...........................64
YF-VAX...........................112
YODOXIN......................... 65
zafirlukast .......................... 56
zaleplon.............................. 69
ZANOSAR ........................ 64
ZAVESCA......................... 92
ZELAPAR ......................... 65
ZELBORAF....................... 64
ZEMAIRA....................... 105
ZENPEP............................. 80
ZETIA................................ 57
ZIAGEN ............................ 67
zidovudine.......................... 67
ziprasidone hcl................. 101
ZMAX ............................... 42
ZN-DTPA .......................... 80
ZOLADEX ........................ 64
ZOLINZA.......................... 64
zolpidem tartrate ............... 69
ZOMETA........................... 92
zonisamide ......................... 45
ZORBTIVE ....................... 96
ZORTRESS ....................... 92
ZOSTAVAX.................... 112
ZOSYN.............................. 43
ZOVIRAX ......................... 55
ZYCLARA ...................... 108
ZYFLO .............................. 56
ZYFLO CR........................ 56
ZYLET............................... 53
ZYMAR............................. 54
ZYMAXID ........................ 54
ZYPREXA....................... 101
ZYPREXA RELPREVV . 101
ZYTIGA ............................ 64
ZYVOX ............................. 40
I-15
Alliance CompleteCare 2012 Part D Formulary Effective: May 01, 2012
Formulary ID: 12140.000, Version: 10