Medicare Part D Excluded Drug List - Blue Cross …

1 Medicare part D Excluded DRUGS LIST 2016_updated July 2016 Reason: LIST = multiple reasons it's Excluded ; "not covered under part D law"Reason: Not properly listed with FDA = CMS considers it best practice for part D sponsors to consider the proper listing of a drug product with the FDA as a prerequisite for making a part D drug coverage determination. The FDA is unable to provide regulatory status determinations through their regular processes if a drug product is not properly listed. Therefore, part D sponsors should begin the drug coverage determination process by confirming that a prescription drug product national drug code (NDC) is properly listed with the FDA.

2 Reason: DESI = Less Than Effective (LTE) drug for ALL indicationsLabel NameReason1ST BASE CREBulk Ingredient2-FUCCOSYLLA PAK LACTO-NMedical FoodABANEU-SL SUBV itamin/MineralABLAVAR INJ 244MG/MLDiagnostic AgentACACIA EXTRA SOL 1:20 Non-standardized allergenicACCUCAINE INJ 1%LISTACD FORMULA SOL ABlood ComponentACD-A SOLB lood ComponentACLARO PD EMU 4%CosmeticACREMONIUM SOL 20000 PNUNon-standardized allergenicACTCT FLEX 3 PAD 4"X4"Not properly listed with FDAACTHREL INJ 100 MCGD iagnostic AgentACTI ANTIMIC PAD 2"X2"Not properly listed with FDAACTI ANTIMIC PAD 4"X4"Not properly listed with FDAACTICOAT 7 PAD 2"X2"Not properly listed with FDAACTICOAT 7 PAD 4"X5"Not properly listed with FDAACTICOAT ABS PAD 4"X5"Not properly listed with FDAACTICOAT MOI PAD 2"X2"Surgical Supply/MedicalACTICOAT MOI PAD 4"X4"Surgical Supply/MedicalACTICOAT MOI PAD 4"X8"Surgical

3 Supply/MedicalACTICOAT SUR PAD 4"X10"Surgical Supply/MedicalACTICOAT SUR PAD 4"X8"Surgical Supply/MedicalACTICOAT SUR PAD "Surgical Supply/MedicalACTICOAT SUR PAD 4X4-3/4"Surgical Supply/MedicalACTIVASE INJ 50 MGLISTACTIVE INJEC INJ DLBulk IngredientACTIVE INJEC INJ M-1 Bulk IngredientACTIVE INJEC KIT BLM-1 Bulk IngredientACTIVE INJEC KIT BMBulk IngredientACTIVE INJEC KIT DBulk IngredientACTIVE INJEC KIT DLMBulk IngredientACTIVE INJEC KIT KET-LBulk IngredientACTIVE INJEC KIT KETMARCBulk IngredientACTIVE INJEC KIT KL-3 Bulk IngredientACTIVE INJEC KIT KMBulk IngredientACTIVE INJEC KIT LM-2 Bulk IngredientACTIVE INJEC KIT LM-DEP-1 Bulk IngredientACTIVE MEDIC KIT SPECIMEND iagnostic AgentACTIVE OB CAPV itamin/MineralACTIVE-PAC/ MIS GABA 300 LISTACTIVE-PREP CRE KIT IBulk IngredientACTIVE-PREP CRE KIT IIBulk IngredientACTIVE-PREP CRE KIT IIIBulk IngredientACTIVE-PREP CRE KIT IVBulk IngredientACTIVE-PREP CRE KIT VBulk IngredientMEDICARE part D Excluded DRUGS LIST 2016_updated July 2016 Reason: LIST = multiple reasons it's Excluded ; "not covered under part D law"Reason: Not properly listed with FDA = CMS considers it best practice for part D sponsors to consider the proper listing of a drug product with the FDA as a prerequisite for making a part D drug coverage determination.

4 The FDA is unable to provide regulatory status determinations through their regular processes if a drug product is not properly listed. Therefore, part D sponsors should begin the drug coverage determination process by confirming that a prescription drug product national drug code (NDC) is properly listed with the FDA. Reason: DESI = Less Than Effective (LTE) drug for ALL indicationsLabel NameACUICYN LIQNot properly listed with FDAACUNOL TAB 600 MGUnapproved DrugADAPTADERM CRENot properly listed with FDAADAZIN CREU napproved DrugADDYI TAB 100 MGSexual Dysfunction AgentADENOSCAN INJ 3MG/MLDiagnostic AgentADENOSINE INJ 3MG/MLDiagnostic AgentADIPEX-P CAP , Anti-obestiy AgentADIPEX-P TAB.

5 Anti-obestiy AgentADRENAL C TAB FORMULAV itamin/MineralADREVIEW INJD iagnostic AgentADV ALLERGY KIT COLLECTINot properly listed with FDAADVANCED MIS AM/PMVitamin/MineralADVANCED BAS CRE PLUSNot properly listed with FDAADVANCED DNA KIT COLLECTID iagnostic AgentADVATE INJ 1000 UNITB lood ComponentADVATE INJ 1500 UNITB lood ComponentADVATE INJ 2000 UNITB lood ComponentADVATE INJ 250 UNITB lood ComponentADVATE INJ 3000 UNITB lood ComponentADVATE INJ 4000 UNITB lood ComponentADVATE INJ 500 UNITB lood ComponentADYNOVATE INJ 1000 UNITB lood ComponentADYNOVATE INJ 2000 UNITB lood ComponentADYNOVATE INJ 250 UNITB lood ComponentADYNOVATE INJ 500 UNITB lood ComponentAERO OTIC HC SOLDESIAFLURIA INJ 2012-13 Influenza VaccineAFLURIA INJ 2013-14 Influenza VaccineAFLURIA INJ 2014-15 Influenza VaccineAFLURIA INJ 2015-16 Influenza VaccineAFLURIA INJ PF 12-13 Influenza VaccineAFLURIA INJ PF 13-14 Influenza VaccineAFLURIA INJ PF 14-15 Influenza VaccineAFLURIA INJ PF 15-16 Influenza VaccineAFSTYLA KIT 1000 UNITB lood ComponentAFSTYLA KIT 2000 UNITB lood ComponentAFSTYLA KIT 250 UNITB lood ComponentAFSTYLA KIT 3000 UNITB lood ComponentAFSTYLA KIT 500 UNITB lood ComponentAIF #2 DRUG CRE PREP

6 KITNot properly listed with FDAAIF #3 DRUG CRE PREP KITNot properly listed with FDAAIRAVITE TABV itamin/MineralAK-FLUOR INJ 10% OPDiagnostic AgentAK-FLUOR INJ 25% OPDiagnostic AgentReasonLabel NameReasonMEDICARE part D Excluded DRUGS LIST 2016_updated July 2016 Reason: LIST = multiple reasons it's Excluded ; "not covered under part D law"Reason: Not properly listed with FDA = CMS considers it best practice for part D sponsors to consider the proper listing of a drug product with the FDA as a prerequisite for making a part D drug coverage determination. The FDA is unable to provide regulatory status determinations through their regular processes if a drug product is not properly listed.

7 Therefore, part D sponsors should begin the drug coverage determination process by confirming that a prescription drug product national drug code (NDC) is properly listed with the FDA. Reason: DESI = Less Than Effective (LTE) drug for ALL indicationsALA-QUIN CRE CREU napproved DrugALBAFORT INJV itamin/MineralALBATUSSIN CAPDESIALBATUSSIN LIQ NNDESIALBUKED 25 INJ 25%Blood ComponentALBUKED 5 INJ 5%Blood ComponentALBUMIN HUM INJ 25%Blood ComponentALBUMIN HUM INJ 5%Blood ComponentALBUMIN-ZLB INJB lood ComponentALBUMIN-ZLB SOL 25%Blood ComponentALBUMINAR-25 INJ 25%Blood ComponentALBUMINAR-5 INJ 5%Blood ComponentALBURX INJ 5%Blood ComponentALBUTEIN INJ 25%Blood ComponentALBUTEIN INJ 5%Blood ComponentALCOHOL INJ 98%Unapproved DrugALCOHOL BASE GELNot properly listed with FDAALCOHOL GEL GELNot properly listed with FDAALCORTIN A

8 GELDESIALCORTIN A GEL 1-2-1%DESIALDER EXTRAC SOL 1:20 Non-standardized allergenicALEVICYN GELNot properly listed with FDAALEVICYN SOL DERMALNot properly listed with FDAALEVICYN SG LIQ ANTIPRURNot properly listed with FDAALKERAN TAB 2 MGOral drug for cancer; infusion available under part BALLEVYN AG PAD 2"X2"Not properly listed with FDAALLEVYN AG PAD 2"X2"Surgical Supply/MedicalALLEVYN AG PAD 3"X3"Not properly listed with FDAALLEVYN AG PAD 4"X4"Not properly listed with FDAALLEVYN AG PAD 4"X4"Surgical Supply/MedicalALLEVYN AG PAD 5"X5"Not properly listed with FDAALLEVYN AG PAD 6"X6"Not properly listed with FDAALLEVYN AG PAD 6"X6"Surgical Supply/MedicalALLEVYN AG PAD 6-3/4"Not properly listed with FDAALLEVYN AG PAD 7"X7"Not properly listed with FDAALLEVYN AG PAD 8"X8 Surgical Supply/MedicalALLEVYN AG PAD 8"X8"Not properly listed with FDAALLEVYN AG PAD 9"X9"SACNot properly listed with

9 FDAALLEVYN GENT PAD 4"X4 Not properly listed with FDAALLEVYN GENT PAD 8"X8"Not properly listed with FDAALLO-PAX CRE 5-5%Unapproved DrugALODOX KIT 20 MGUnapproved DrugALOQUIN GEL OINNot properly listed with FDAL abel NameReasonMEDICARE part D Excluded DRUGS LIST 2016_updated July 2016 Reason: LIST = multiple reasons it's Excluded ; "not covered under part D law"Reason: Not properly listed with FDA = CMS considers it best practice for part D sponsors to consider the proper listing of a drug product with the FDA as a prerequisite for making a part D drug coverage determination. The FDA is unable to provide regulatory status determinations through their regular processes if a drug product is not properly listed.

10 Therefore, part D sponsors should begin the drug coverage determination process by confirming that a prescription drug product national drug code (NDC) is properly listed with the FDA. Reason: DESI = Less Than Effective (LTE) drug for ALL indicationsALPHANATE INJ VWF/HUMB lood ComponentALPHANATE INJ VWF/HUMB lood ComponentALPHANATE INJ VWF/HUMB lood ComponentALPHANATE INJ VWF/HUMB lood ComponentALPHANATE INJ VWF/HUMB lood ComponentALPHANINE SD INJ 1000 UNITB lood ComponentALPHANINE SD INJ 1500 UNITB lood ComponentALPHANINE SD INJ 500 UNITB lood ComponentALPHAQUIN HP CRE 4%CosmeticALPROLIX INJ 1000 UNITB lood ComponentALPROLIX INJ 2000 UNITB lood ComponentALPROLIX INJ 250 UNITB lood ComponentALPROLIX INJ 3000 UNITB lood ComponentALPROLIX INJ 500 UNITB lood ComponentALPROSTADIL INJ 500 MCGE rectile DysfunctionALTACAINE SOL OPUnapproved