Drugs: Contract Drugs List Part 1 – drugs cdl p1a
Prescription Drugs (A through D)1
This section lists the codes and units for contract drugs. For additional help, refer to the Drugs: Contract Drugs List Introduction section of this manual.
‡ * ABACAVIR SULFATE
*Restricted to use as combination therapy in the treatment of Human Immunodeficiency Virus (HIV) infection. Also restricted to NDC labeler codes 00173 (GlaxoSmithKline) and 49702
(ViiV Healthcare) only.
Tablets300mgea
Liquid20mg/mlml
‡ * ABACAVIR SULFATE AND LAMIVUDINE
*Restricted to use as combination therapy in the treatment of Human Immunodeficiency Virus (HIV) infection. Also restricted to NDC labeler code 49702 (ViiV Healthcare) only.
Tablets600mg/300 mgea
‡ * ABACAVIR SULFATE/DOLUTEGRAVIR/LAMIVUDINE
*Restricted to use in the treatment of Human Immunodeficiency Virus (HIV) infection only. Also restricted to NDC labeler code 49702 (ViiV Healthcare) only.
Tablets600mg/50 mg/300 mgea
‡ * ABACAVIR SULFATE, LAMIVUDINE AND ZIDOVUDINE
*Restricted to use alone or as combination therapy in the treatment of Human Immunodeficiency Virus (HIV) infection. Also restricted to NDC labeler codes 00173 (GlaxoSmithKline) and 49702 (ViiV Healthcare) only.
Tablets300mg/150 mg/300 mgea
‡*ABEMACICLIB†
*Restricted to use in the treatment of cancer only. Also restricted to NDC labeler code00002 (Eli Lilly and Company) only.†
Tablets50mgea†
100mgea†
150mgea†
200mgea†
†Effective January 1, 2018
*Code I. See paragraph (2) of “General Provisions” in the Drugs: Contract Drugs List Introduction section of this manual regarding authorization and prescription documentation requirements.
+Frequency of billing requirement. See paragraph (3) of “General Provisions” in the Drugs: Contract Drugs List Introduction section regarding information and exceptions.
††Cost is based on this package size. See paragraph (4) of “General Provisions” in the Drugs: Contract Drugs List Introduction section for more information.
§Authorization not needed for continuing care. See paragraph (6) of “General Provisions” in the Drugs: Contract Drugs List Introduction section for more information.
‡Drug is exempt from the monthly drug claim line limit. See paragraph (7) of “General Provisions” in the Drugs: Contract Drugs List Introduction section for more information.
2 – Drugs: Contract Drugs List Part 1 – Pharmacy 910
Prescription Drugs (A through D)December 2017
drugs cdl p1a
1
ABI
‡ * ABIRATERONE ACETATE
*Restricted to use in the treatment of cancer only. Also restricted to NDC labeler code 57894 (Janssen Biotech, Inc.) only.
Tablets250mgea
Film-coated Tablets500mgea
‡*ACALABRUTINIB†
*Restricted to use in the treatment of cancer only. Also restricted to NDC labeler code 00310 (AstraZeneca LP) only.†
Capsule100mgea†
ACARBOSE
+Tabletsea
ACEBUTOLOL
+Capsules200mgea
400mgea
ACETAZOLAMIDE
+Tablets125mgea
250mgea
+Capsules, sustained release500mgea
ACETIC ACID
Irrigating solution0.25%250mlml
500mlml
1000mlml
2000mlml
ACETIC ACID WITH ALUMINUM ACETATE
Otic solution2%ml
ACETIC ACID WITH HYDROCORTISONE
Otic solution2 %-1%ml
†Effective November 1, 2017
*Code I. See paragraph (2) of “General Provisions” in the Drugs: Contract Drugs List Introduction section of this manual regarding prior authorization and prescription documentation requirements.
+Frequency of billing requirement. See paragraph (3) of “General Provisions” in the Drugs: Contract Drugs List Introduction section regarding information and exceptions.
††Cost is based on this package size. See paragraph (4) of “General Provisions” in the Drugs: Contract Drugs List Introduction section for more information.
§Prior authorization not needed for continuing care. See paragraph (6) of “General Provisions” in the Drugs: Contract Drugs List Introduction section for more information.
‡Drug is exempt from the monthly drug claim line limit. See paragraph (7) of “General Provisions” in the Drugs: Contract Drugs List Introduction section for more information.
2 – Drugs: Contract Drugs List Part 1 – Pharmacy 754
Prescription Drugs (A through D)June 2011
drugs cdl p1a
1
ACE
ACETOHEXAMIDE
+Tablets500mgea
Note:This product is no longer manufactured or available.
ACETYLCYSTEINE
Solution10%4mlml
10mlml
30mlml
20%4mlml
10mlml
30mlml
‡ * ACYCLOVIR
*Restricted to use in herpes genitalis, immunocompromised patients and herpes zoster (shingles).
Capsules200mgea
Tablets400mgea
800mgea
*ADEFOVIR DIPIVOXIL
*Restricted to use for the treatment of chronic Hepatitis B virus infection and dates of service from August 1, 2008, through August 31, 2011.
+Tablets10mgea
‡ * ADO-TRASTUZUMAB EMTANSINE
*Restricted to use in the treatment of cancer only. Also restricted to NDC labeler code 50242 (Genentech, Inc.) only.
Vial100mgea
160mgea
*Code I. See paragraph (2) of “General Provisions” in the Drugs: Contract Drugs List Introduction section of this manual regarding authorization and prescription documentation requirements.
+Frequency of billing requirement. See paragraph (3) of “General Provisions” in the Drugs: Contract Drugs List Introduction section regarding information and exceptions.
††Cost is based on this package size. See paragraph (4) of “General Provisions” in the Drugs: Contract Drugs List Introduction section for more information.
§Authorization not needed for continuing care. See paragraph (6) of “General Provisions” in the Drugs: Contract Drugs List Introduction section for more information.
‡Drug is exempt from the monthly drug claim line limit. See paragraph (7) of “General Provisions” in the Drugs: Contract Drugs List Introduction section for more information.
2 – Drugs: Contract Drugs List Part 1 – Pharmacy 910
Prescription Drugs (A through D)December 2017
drugs cdl p1a
1
AFA
‡ * AFATINIB
*Restricted to use in the treatment of cancer only. Also restricted to NDC labeler code 00597 (Boehringer Ingelheim Pharmaceuticals) only.
Tablets20mgea
30mgea
40mgea
* ALBUTEROL
*Restricted to dates of service from January 1, 1996, to January 31, 2007.
Inhaler with adapter17gmgm
Inhaler without adapter17gmgm
ALBUTEROL SULFATE
+Tablets or capsules2mgea
4mgea
+Long-acting tablets4mgea
8mgea
*Inhaler (without chlorofluorocarbons
as the propellant)6.7gmgm
*Restricted to NDC labeler code 00085 (Schering-Plough/MERCK & CO, Inc.) only.
*Inhaler (without chlorofluorocarbons
as the propellant)8.5gmgm
*Restricted to NDC labeler code 59310 (Teva Respiratory, LLC) only.
Solution for inhalation0.5%20ml
Solution for inhalation, premixed0.083%ml
1.25mg/3 mlml
0.63mg/3 mlml
Liquid2mg/5 mlml
Capsules for inhalationPackage containingea capsule
with inhalation device96 or 100 capsules and
one inhalation device
Capsules only, for inhalationea
*Code I. See paragraph (2) of “General Provisions” in the Drugs: Contract Drugs List Introduction section of this manual regarding authorization and prescription documentation requirements.
+Frequency of billing requirement. See paragraph (3) of “General Provisions” in the Drugs: Contract Drugs List Introduction section regarding information and exceptions.
††Cost is based on this package size. See paragraph (4) of “General Provisions” in the Drugs: Contract Drugs List Introduction section for more information.
§Authorization not needed for continuing care. See paragraph (6) of “General Provisions” in the Drugs: Contract Drugs List Introduction section for more information.
‡Drug is exempt from the monthly drug claim line limit. See paragraph (7) of “General Provisions” in the Drugs: Contract Drugs List Introduction section for more information.
2 – Drugs: Contract Drugs List Part 1 – Pharmacy 786
Prescription Drugs (A through D)October 2012
drugs cdl p1a
1
ALC
ALCAFTADINE
Ophthalmic Solution0.25%ml
ALCLOMETASONE DIPROPIONATE
Cream0.05%15gmgm
45gmgm
60gmgm
Ointment0.05%15gmgm
45gmgm
60gmgm
‡ *ALDESLEUKIN
*Restricted to use in the treatment of cancer only. Also restricted to NDC labeler code 65483 (Prometheus Laboratories, Inc.) only.
Powder for injection22million IU (1.3 mg)/vialea
‡*ALECTINIB
*Restricted to use in the treatment of cancer only. Also restricted to NDC labeler code 50242 (Genentech USA, Inc.) only.
Capsules 150mgea
* ALEMTUZUMAB
*Restricted to use in the treatment of cancer and to claims submitted with dates of service from
May 7, 2001, through February 28, 2010, only. Continuing care with a date of service on or after March 1, 2010 is available when the following conditions are met: 1) The beneficiary had a paid
fee-for-service claim for this drug on or before February 28, 2010; 2) A claim has been submitted and paid within the past 100 days; 3) The claim being submitted is within 100 days of the date of service of the last paid claim.
Injection30mg/1 ml vialml
*Code I. See paragraph (2) of “General Provisions” in the Drugs: Contract Drugs List Introduction section of this manual regarding authorization and prescription documentation requirements.
+Frequency of billing requirement. See paragraph (3) of “General Provisions” in the Drugs: Contract Drugs List Introduction section regarding information and exceptions.
††Cost is based on this package size. See paragraph (4) of “General Provisions” in the Drugs: Contract Drugs List Introduction section for more information.
§Authorization not needed for continuing care. See paragraph (6) of “General Provisions” in the Drugs: Contract Drugs List Introduction section for more information.
‡Drug is exempt from the monthly drug claim line limit. See paragraph (7) of “General Provisions” in the Drugs: Contract Drugs List Introduction section for more information.
2 – Drugs: Contract Drugs List Part 1 – Pharmacy 910
Prescription Drugs (A through D)December 2017
drugs cdl p1a
1
ALE
ALENDRONATE SODIUM
*Effervescent tablet70mgea
*Restricted to NDC labeler code 00178 (Mission Pharmacal Company) for the effervescent tablet onlyand to claims submitted with dates of service from July 1, 2013, throughJune 30, 2016.
*Oral solution70mg/75 mlml
*Restricted to claims submitted with dates of service from November 1, 2005, through
August 31, 2013, for the oral solution only.
+Tablets5mgea
10mgea
35mgea
40mgea
70mgea
* ALENDRONATE SODIUM/CHOLECALCIFEROL
*Restricted to NDC labeler code 00006 (Merck & Co., Inc.) only.
+Tablets70mg/2800 IUea
70mg/5600 IUea
ALFUZOSIN HCL
+Tablets, extended release10mgea
* ALISKIREN/VALSARTAN
*Restricted to claims submitted through July 20, 2012.
Tablets150mg/160 mgea
300mg/320 mgea
‡ * ALITRETINOIN
*Restricted to use in the topical treatment of cutaneous lesions in patients with AIDS-related Kaposi’s sarcoma.
Gel0.1%60gmgm
*Code I. See paragraph (2) of “General Provisions” in the Drugs: Contract Drugs List Introduction section of this manual regarding authorization and prescription documentation requirements.
+Frequency of billing requirement. See paragraph (3) of “General Provisions” in the Drugs: Contract Drugs List Introduction section regarding information and exceptions.
††Cost is based on this package size. See paragraph (4) of “General Provisions” in the Drugs: Contract Drugs List Introduction section for more information.
§Authorization not needed for continuing care. See paragraph (6) of “General Provisions” in the Drugs: Contract Drugs List Introduction section for more information.
‡Drug is exempt from the monthly drug claim line limit. See paragraph (7) of “General Provisions” in the Drugs: Contract Drugs List Introduction section for more information.
2 – Drugs: Contract Drugs List Part 1 – Pharmacy 786
Prescription Drugs (A through D)October 2012
drugs cdl p1a
1
ALL
ALLOPURINOL
+Tablets100mgea
300mgea
*ALOGLIPTIN
*Restricted to NDC labeler code 64764 (Takeda Pharmaceuticals America, Inc.) only.
Tablets6.25mgea
12.5mgea
25mgea
*ALOGLIPTIN/METFORMIN HCL
*Restricted to NDC labeler code 64764 (Takeda Pharmaceuticals America, Inc.) only.
Tablets12.5mg/500 mgea
12.5mg/1000 mgea
*ALOGLIPTIN/PIOGLITAZONE
*Restricted to NDC labeler code 64764 (Takeda Pharmaceuticals America, Inc.)only.
Tablets12.5mg/15 mgea
12.5mg/30 mgea
12.5mg/45 mgea
25mg/15 mgea
25mg/30 mgea
25mg/45mgea
‡ * ALTRETAMINE
*Restricted to use in the treatment of cancer only.
Capsules50mgea
*AMANTADINE
*Use in beneficiaries less than 2 years of age requires treatment authorization approval.
+Capsules100mgea
Liquid50mg/5 mlml
*Code I. See paragraph (2) of “General Provisions” in the Drugs: Contract Drugs List Introduction section of this manual regarding authorization and prescription documentation requirements.
+Frequency of billing requirement. See paragraph (3) of “General Provisions” in the Drugs: Contract Drugs List Introduction section regarding information and exceptions.
††Cost is based on this package size. See paragraph (4) of “General Provisions” in the Drugs: Contract Drugs List Introduction section for more information.
§Authorization not needed for continuing care. See paragraph (6) of “General Provisions” in the Drugs: Contract Drugs List Introduction section for more information.
‡Drug is exempt from the monthly drug claim line limit. See paragraph (7) of “General Provisions” in the Drugs: Contract Drugs List Introduction section for more information.
2 – Drugs: Contract Drugs List Part 1 – Pharmacy 910
Prescription Drugs (A through D)December 2017
drugs cdl p1a
1
AMI
AMIKACIN SULFATE
Injection, vial50mg/mlml
250mg/mlml
AMINOPHYLLINE
Injection250mg10mlml
500mg20mlml
Suppository0.25gmea
0.5gmea
+Tablets100mgea
200mgea
Liquid105mg/5 mlml
AMIODARONE
Tablets200mgea
*AMITRIPTYLINE
*Use in beneficiaries less than 12 years of age requires treatment authorization approval.
Injection10mg/mlml
Tablets10mgea
25mg†† 1000s ea
50mgea
75mgea
100mgea
150mgea
AMITRIPTYLINE HCL/PERPHENAZINE
Tablets10mg/2 mgea
10mg/4 mgea
25mg/2 mg†† 500s ea
25mg/4 mgea
AMLODIPINE BESYLATE
+Tablets2.5mgea
5mgea
10mgea
*Code I. See paragraph (2) of “General Provisions” in the Drugs: Contract Drugs List Introduction section of this manual regarding authorization and prescription documentation requirements.
+Frequency of billing requirement. See paragraph (3) of “General Provisions” in the Drugs: Contract Drugs List Introduction section regarding information and exceptions.
††Cost is based on this package size. See paragraph (4) of “General Provisions” in the Drugs: Contract Drugs List Introduction section for more information.
§Authorization not needed for continuing care. See paragraph (6) of “General Provisions” in the Drugs: Contract Drugs List Introduction section for more information.
‡Drug is exempt from the monthly drug claim line limit. See paragraph (7) of “General Provisions” in the Drugs: Contract Drugs List Introduction section for more information.
2 – Drugs: Contract Drugs List Part 1 – Pharmacy 786
Prescription Drugs (A through D)October 2012
drugs cdl p1a
1
AML
* AMLODIPINE BESYLATE/ATORVASTATIN CALCIUM
*Restricted to NDC labeler code 00069 (Pfizer Inc.) and to claims with dates of service from December 1, 2007, through October 31, 2016only. Continuing care with a date of service on or after November 1, 2016, is available when the following conditions are met: 1) The beneficiary had a paid fee-for-service claim for this drug on or before October 31, 2016; 2) A claim has been submitted and paid within the past 100 days; and 3) The claim being submitted is within 100 days of the date of service of the last paid claim.†
+Tablets2.5mg – 10 mgea
2.5mg – 20 mgea
2.5mg – 40 mgea
5mg – 10 mgea
5mg – 20 mgea
5mg – 40 mgea
5mg – 80 mgea
10mg – 10 mgea
10mg – 20 mgea
10mg – 40 mgea
10mg – 80 mgea
AMLODIPINE BESYLATE/BENAZEPRIL HYDROCHLORIDE
+Capsules2.5mg – 10 mgea
5mg – 10 mgea
5mg – 20 mgea
10mg – 20 mgea
5mg – 40 mgea
10mg – 40 mgea
* AMLODIPINE/TELMISARTAN
*Restricted to NDC labeler code 00597 (Boehringer Ingelheim Pharmaceuticals, Inc.) and to claims with dates of service from June 1, 2010, through May 31, 2013, only.
Tablets5mg/40 mgea
5mg/80 mgea
10mg/40 mgea
10mg/80 mgea
†Effective November 1, 2016
*Code I. See paragraph (2) of “General Provisions” in the Drugs: Contract Drugs List Introduction section of this manual regarding authorization and prescription documentation requirements.
+Frequency of billing requirement. See paragraph (3) of “General Provisions” in the Drugs: Contract Drugs List Introduction section regarding information and exceptions.
††Cost is based on this package size. See paragraph (4) of “General Provisions” in the Drugs: Contract Drugs List Introduction section for more information.
§Authorization not needed for continuing care. See paragraph (6) of “General Provisions” in the Drugs: Contract Drugs List Introduction section for more information.
‡Drug is exempt from the monthly drug claim line limit. See paragraph (7) of “General Provisions” in the Drugs: Contract Drugs List Introduction section for more information.
2 – Drugs: Contract Drugs List Part 1 – Pharmacy 882
Prescription Drugs (A through D)October 2016
drugs cdl p1a
1
AML (continued)
* AMLODIPINE/VALSARTAN
*Restricted to NDC labeler code 00078 (Novartis Pharmaceuticals Corporation) only.
Tablets5mg/160 mgea
10mg/160 mgea
5mg/320 mgea
10mg/320 mgea
*AMLODIPINE/VALSARTAN/HYDROCHLOROTHIAZIDE
*Restricted to NDC labeler code 00078 (Novartis Pharmaceuticals Corporation) only.
Tablets5 mg/160 mg/12.5mgea
10 mg/160 mg/12.5mgea
5 mg/160 mg/25mgea
10 mg/160 mg/25mgea
10 mg/320 mg/25mgea
* AMOXICILLIN/CLAVULANATE POTASSIUM
*Tablets, chewable125mgea
200mgea
250mgea
400mgea
*Restricted to a maximum dispensing quantity of thirty (30) tablets and a maximum of two (2) dispensings in any 30-day period.
*Tablets, oral250mgea
500mgea
*Restricted a maximum dispensing quantity of thirty (30) tablets and a maximum of two (2) dispensings in any 30-day period for the 250 mg and 500 mg oral tablets only.
*Tablets, oral875mgea
*Restricted to a maximum dispensing quantity of twenty (20) tablets and a maximum of two (2) dispensings in any 30-day period for the 875 mg oral tablets only.
*Tablets, oral1gmea
*Restricted to a maximum dispensing quantity of forty (40) tablets and a maximum of two (2) dispensings in any 30-day period for the 1 gm oral tablets only.
*Code I. See paragraph (2) of “General Provisions” in the Drugs: Contract Drugs List Introduction section of this manual regarding authorization and prescription documentation requirements.
+Frequency of billing requirement. See paragraph (3) of “General Provisions” in the Drugs: Contract Drugs List Introduction section regarding information and exceptions.
††Cost is based on this package size. See paragraph (4) of “General Provisions” in the Drugs: Contract Drugs List Introduction section for more information.
§Authorization not needed for continuing care. See paragraph (6) of “General Provisions” in the Drugs: Contract Drugs List Introduction section for more information.
‡Drug is exempt from the monthly drug claim line limit. See paragraph (7) of “General Provisions” in the Drugs: Contract Drugs List Introduction section for more information.
2 – Drugs: Contract Drugs List Part 1 – Pharmacy 786
Prescription Drugs (A through D)October 2012
drugs cdl p1a
1
AMO
* AMOXICILLIN/CLAVULANATE POTASSIUM (continued)
*Solution or suspension125mg/5mlml
200mg/5mlml
250mg/5mlml
400mg/5mlml
600mg/5mlml
*Restricted to a maximum of two (2) dispensings in any 30-day period.
AMOXICILLIN TRIHYDRATE
Solution or suspension125mg/5ml80mlml
100mlml
150mlml
250mg/5ml80mlml
100mlml
150mlml
200mlml
Pediatric drops50mg/ml15mlml
30mlml
Capsules250mgea
500mgea
Chewable tablets250mgea
*Code I. See paragraph (2) of “General Provisions” in the Drugs: Contract Drugs List Introduction section of this manual regarding authorization and prescription documentation requirements.
+Frequency of billing requirement. See paragraph (3) of “General Provisions” in the Drugs: Contract Drugs List Introduction section regarding information and exceptions.
††Cost is based on this package size. See paragraph (4) of “General Provisions” in the Drugs: Contract Drugs List Introduction section for more information.
§Authorization not needed for continuing care. See paragraph (6) of “General Provisions” in the Drugs: Contract Drugs List Introduction section for more information.
‡Drug is exempt from the monthly drug claim line limit. See paragraph (7) of “General Provisions” in the Drugs: Contract Drugs List Introduction section for more information.
2 – Drugs: Contract Drugs List Part 1 – Pharmacy 878
Prescription Drugs (A through D)August 2016
drugs cdl p1a
1
AMP
* AMPHETAMINE, MIXED SALTS (AMPHETAMINE SULFATE, AMPHETAMINE ASPARTATE MONOHYDRATE, DEXTROAMPHETAMINE SULFATE AND DEXTROAMPHETAMINE SACCHARATE) †
*Use in beneficiaries less than 6 years of age or greater than 16 years of age requires treatment authorization approval. Restricted to use in Attention Deficit Disorder in individuals from 6 through 17 years of age only.†
Tablets5mgea
7.5mgea
10mgea
12.5mgea
15mgea
20mgea
30mgea
*Capsules, extended release5mgea
10mgea
15mgea
20mgea
25mgea
30mgea
*Restricted to NDC labeler code 54092 (Shire US, Inc.) for extended release capsules only.only and dates of service from October 1, 2006, through July 31, 2011. Continuing care with a date of service on or after August 1, 2011, is available when the following conditions are met: 1) The beneficiary had a paid fee-for-service claim for this drug on or before July 31, 2011; 2) A claim has been submitted and paid within the past 100 days; and 3) The claim being submitted is within 100 days of the date of service of the last paid claim, for the extended release capsules only.†
AMPHOTERICIN B
Creamgm
Ointmentgm
Lotionml
‡Injectionea
Note:Cream, Ointment, and Lotion products are no longer manufactured or available.
†Effective May 1, 2017
*Code I. See paragraph (2) of “General Provisions” in the Drugs: Contract Drugs List Introduction section of this manual regarding authorization and prescription documentation requirements.