Department of Health & Human Services

Home , Micafungin

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard Baltimore, Maryland 21244-1850

CENTER FOR BENEFICIARY CHOICES

MEMORANDUM

Date: April 11, 2006

To: All Part D Sponsors

From: Cynthia Tudor, Acting Director, Medicare Drug Benefit Group

Subject: Contract Year 2007 Formulary Submissions

As a reminder, the 2007 Formulary submission period ends on Monday, April 17, 2006 at 5pm ET. We do not anticipate extending the submission deadline as this will jeopardize the initial formulary review period that must occur prior to the bid submission period. All Part D sponsors wishing to offer 2007 benefits are required to upload and validate a new formulary file by this deadline. We strongly encourage organizations to begin submitting formulary files to HPMS in order to test connectivity and formulary flat file structure. In order to create a 2007 formulary submission, please utilize the “Submit New Formulary” option in the CY2007 HPMS formulary module.

CMS has published a formulary reference NDC file that must be utilized when building 2007 formulary submissions. This file was last updated and distributed on March 27, 2006. The formulary reference NDC file is a tool for assisting with the 2007 formulary submission. It is not intended to serve as a Part D drug coverage list for 2006 or 2007. If you should encounter a drug that is missing from the formulary reference NDC file, please communicate the specifics of your findings to Kady Flannery at [email protected].

Since the last update to the formulary reference NDC file, we have identified Part D drugs that were inadvertently excluded from previous versions of the file. The proxy NDCs in Appendix A have been added and will be available for upload beginning today.

Appendix A

PROXY NDC BRAND NAME GENERIC NAME DOSAGE STRENGTH CODE FORM

68158014951 PLENAXIS ABARELIX SUSR 100 MG ACETAMINOPHEN AND 63481062770 PERCOCET OXYCODONE HYDROCHLORIDE TABS 325 MG;2.5 MG

58980015010 HYPERCARE ALUMINUM CHLORIDE SOLN 20 %

00096070960 XERAC AC ALUMINUM CHLORIDE SOLN 6.25 %

49938010704 PASER AMINOSALICYLIC ACID (4-ASA) PACK 4 GM

54162061305 GERI-HYDROLAC AMMONIUM LACTATE CREA 12 % AMYLASE (DIASTASE) AND LIPASE (AS PANCRELIPASE) AND 70000 UNIT;16800 58914011508 VIOKASE PROTEASE POWD UNIT;70000 UNIT ASCORBIC ACID AND BETA CAROTENE AND BIOTIN AND 100 MG;0 -;30 CALCIUM CARBONATE AND MCG;250 MG;10 12939035010 TERNAMAR CALCIUM PANTOTHENATE TABS MG ASCORBIC ACID AND BETA CAROTENE AND CALCIUM CARBONATE AND 250 MG;2700 CHOLECALCIFEROL AND UNIT;250 MG;400 11026261603 OBSTETRIX-100 CYANOCOBALAMIN TABS UNIT;12 MCG ASCORBIC ACID AND BETA CAROTENE AND CALCIUM CITRATE AND CUPRIC OXIDE AND 120 MG;0 -;200 00904539361 ULTRA TABS CYANOCOBALAMIN TABS MG;2 MG;12 MCG ASCORBIC ACID AND BIOTIN AND CALCIUM AND CALCIUM CARBONATE AND CARROT 60 MG;30 MCG;125 51674500106 NUTRACARE POWDER CHEW MG;125 MG;1 MG ASCORBIC ACID AND BIOTIN AND CALCIUM CARBONATE AND 120 MG;30 CALCIUM PANTOTHENATE AND MCG;200 MG;10 12939036010 TERNAMAR CHROMIC CHLORIDE TABS MG;25 MCG ASCORBIC ACID AND BIOTIN AND 500 MG;150 CALCIUM PANTOTHENATE AND MCG;25 MG;0.1 12830080001 M-VIT CHROMIUM AND CUPRIC OXIDE TABS MG;3 MG ASCORBIC ACID AND CALCIUM AND COPPER AND CYANOCOBALAMIN 100 MG;225 MG;10 55532031530 VITA-PREN AND DOCUSATE SODIUM TABS MG;12 MCG;50 MG ASCORBIC ACID AND CALCIUM AND COPPER AND CYANOCOBALAMIN 100 MG;200 MG;2 67112010100 TRICARE AND FERROUS FUMARATE TABS MG;12 MCG;27 MG ASCORBIC ACID AND CALCIUM CARBONATE AND MARNATAL-F CHOLECALCIFEROL AND CUPRIC 100 MG;250 MG;400 00682250001 PLUS DUO PACK OXIDE AND CYANOCOBALAMIN MISC UNIT;2 MG;12 MCG ASCORBIC ACID AND CALCIUM CARBONATE AND CHOLECALCIFEROL AND CUPRIC SULFATE ANHYDROUS AND 60 MG;600 MG;400 58177043738 CARENATE 600 CYANOCOBALAMIN MISC UNIT;2 MG;12 MCG

2 PROXY NDC BRAND NAME GENERIC NAME DOSAGE STRENGTH CODE FORM ASCORBIC ACID AND CALCIUM CARBONATE AND CHOLECALCIFEROL AND CUPRIC SULFATE ANHYDROUS AND 60 MG;600 MG;400 51991014213 VINATAL 600 CYANOCOBALAMIN MISC UNIT;2 MG;12 MCG ASCORBIC ACID AND CALCIUM CARBONATE AND CHOLECALCIFEROL AND CYANOCOBALAMIN AND FERROUS 60 MG;125 MG;400 00642007812 VITAFOL-PN FUMARATE TABS UNIT;5 MCG;65 MG ASCORBIC ACID AND CALCIUM CARBONATE AND CHOLECALCIFEROL AND CYANOCOBALAMIN AND FOLIC 120 MG;200 MG;400 58177046326 NUTRISPIRE ACID TABS UNIT;8 MCG;1 MG ASCORBIC ACID AND CALCIUM CARBONATE AND CUPRIC OXIDE 80 MG;250 MG;2 POLY IRON PN AND CYANOCOBALAMIN AND MG;12 MCG;400 10267210101 FORTE ERGOCALCIFEROL TABS UNIT

39822020005 BACI-RX BACITRACIN POWD 0

49452080001 BACITRACIN BACITRACIN POWD 0

51927182300 BELLADONNA BELLADONNA TINC 0 BENZALKONIUM CHLORIDE AND CYSTEINE AND INOSITOL AND AMINO ACID METHIONINE AND SODIUM 0 -;0.35 %;0.83 60267023414 CERVICAL PROPIONATE CREA %;0.83 %;0.5 % BENZALKONIUM CHLORIDE AND CYSTEINE AND INOSITOL AND METHIONINE AND SODIUM 0 -;0.35 %;0.83 00396601030 AMINO-CERV PROPIONATE CREA %;0.83 %;0.5 % BIOTIN AND CALCIUM ASCORBATE ANHYDROUS AND CALCIUM CARBONATE AND 35 MCG;100 CHOLECALCIFEROL AND MG;400 MG;400 64011014628 PRIMACARE CHROMIUM MISC UNIT;45 MCG BISACODYL AND POLYETHYLENE GLYCOL AND POTASSIUM CHLORIDE AND SODIUM HALFLYTELY BICARBONATE AND SODIUM 5 MG;210 GM;0.74 52268050201 BOWEL PREP KIT CHLORIDE KIT GM;2.86 GM;5.6 GM

64011000108 GYNAZOLE-1 BUTOCONAZOLE NITRATE CREA 2 %

00015564420 STADOL BUTORPHANOL TARTRATE SOLN 2 MG/ML CALCIUM AND CALCIUM ASCORBATE ANHYDROUS AND CHOLECALCIFEROL AND FOLIC 150 MG;25 MG;170 64011014219 PRIMACARE ONE ACID AND IRON CARBONYL CAPS UNIT;1 MG;27 MG CALCIUM CARBONATE AND CYANOCOBALAMIN AND FOLIC ACID AND NIACINAMIDE AND 125 MG;3 MCG;1 00131220909 NIFEREX PN POLYSACCHARIDE IRON COMPLEX TABS MG;10 MG;60 MG

3 PROXY NDC BRAND NAME GENERIC NAME DOSAGE STRENGTH CODE FORM CALCIUM CARBONATE AND CYANOCOBALAMIN AND FOLIC ACID AND NIACINAMIDE AND 125 MG;3 MCG;1 10267210201 POLY IRON PN POLYSACCHARIDE IRON COMPLEX TABS MG;10 MG;60 MG

00006382210 CANCIDAS CASPOFUNGIN ACETATE SOLR 50 MG

00006382310 CANCIDAS CASPOFUNGIN ACETATE SOLR 70 MG CASTOR OIL (RICINE OIL) AND 788 MG/GM;87 PERUVIAN BALSAM AND TRYPSIN, MG/GM;90 00064390060 XENADERM CRYSTALLIZED OINT UNIT/GM

00003011350 VELOSEF CEPHRADINE CAPS 250 MG CEVIMELINE HYDROCHLORIDE 63395020113 EVOXAC HEMIHYDRATE CAPS 30 MG CHLOROXYLENOL (P-CHLOR-M- XYLENOL) AND HYDROCORTISONE 1 MG/ML;10 66440376701 AERO OTIC HC AND PRAMOXINE HYDROCHLORIDE SOLN MG/ML;10 MG/ML CHLOROXYLENOL (P-CHLOR-M- XYLENOL) AND HYDROCORTISONE 1 MG/ML;10 60258045110 CYOTIC AND PRAMOXINE HYDROCHLORIDE SOLN MG/ML;10 MG/ML CHLOROXYLENOL (P-CHLOR-M- XYLENOL) AND HYDROCORTISONE 1 MG/ML;10 12539062310 EXOTIC-HC AND PRAMOXINE HYDROCHLORIDE SOLN MG/ML;10 MG/ML CHLOROXYLENOL (P-CHLOR-M- XYLENOL) AND HYDROCORTISONE 1 MG/ML;10 65615043010 GENEXOTIC-HC AND PRAMOXINE HYDROCHLORIDE SOLN MG/ML;10 MG/ML CHLOROXYLENOL (P-CHLOR-M- XYLENOL) AND HYDROCORTISONE 1 MG/ML;10 65615043110 GENEZOTO-HC AND PRAMOXINE HYDROCHLORIDE SOLN MG/ML;10 MG/ML CHLOROXYLENOL (P-CHLOR-M- XYLENOL) AND HYDROCORTISONE 1 MG/ML;10 49326040015 OTICIN HC AND PRAMOXINE HYDROCHLORIDE SOLN MG/ML;10 MG/ML

00245003623 PREVALITE CHOLESTYRAMINE POWD 4 GM/DOSE CYTRA K CITRIC ACID AND POTASSIUM 60258000501 CRYSTALS CITRATE PACK 1002 MG;3300 MG POLYCITRA-K CITRIC ACID AND POTASSIUM 17314932001 CRYSTALS CITRATE PACK 1002 MG;3300 MG DEXTROSE (ANHYDROUS) AND MAGNESIUM MAGNESIUM SULFATE, 00074672709 SULFATE IN D5W HEPTAHYDRATE SOLN 5 %;10 MG/ML

00575620030 PROGLYCEM DIAZOXIDE SUSP 50 MG/ML

00574011501 FLAVOXATE HCL FLAVOXATE HYDROCHLORIDE TABS 100 MG

00071400810 CEREBYX FOSPHENYTOIN SODIUM SOLN 50 MG PE/ML HYDROCORTISONE SODIUM 00009090020 SOLU-CORTEF SUCCINATE SOLR 100 MG HYDROCORTISONE SODIUM 00009092003 SOLU-CORTEF SUCCINATE SOLR 1000 MG HYDROCORTISONE SODIUM 00009090916 SOLU-CORTEF SUCCINATE SOLR 250 MG

4 PROXY NDC BRAND NAME GENERIC NAME DOSAGE STRENGTH CODE FORM

10148010100 VENTAVIS ILOPROST SOLN 10 MCG/ML LAMICTAL STARTER/NOT 00173059402 TAKI LAMOTRIGINE KIT 0 LAMICTAL STARTER/TAKING 00173059401 C LAMOTRIGINE KIT 0

54482014508 CARNITOR LEVOCARNITINE SOLN 1 GM/10ML

54482014701 CARNITOR LEVOCARNITINE SOLN 200 MG/ML

64980050312 LEVOCARNITINE LEVOCARNITINE SOLN 1 GM/10ML

00703040402 LEVOCARNITINE LEVOCARNITINE SOLN 200 MG/ML LIDOMAR 12939078010 VISCOUS LIDOCAINE HYDROCHLORIDE SOLN 2 %

00115703701 METHITEST METHYLTESTOSTERONE TABS 10 MG

00469325010 MYCAMINE MICAFUNGIN SODIUM SOLR 50 MG MONISTAT 7 00062542202 COMBINATION PA MICONAZOLE NITRATE KIT 0 M-ZOLE 3 COMBO 49614059194 PACK MICONAZOLE NITRATE KIT 0

19810030097 VAGISTAT-3 MICONAZOLE NITRATE KIT 0

63010001190 VIRACEPT NELFINAVIR MESYLATE POWD 50 MG/GM BACTERIOSTATIC 63323024930 WATER PARA PARABENS AND WATER, STERILE SOLN 0

00472080216 PAREGORIC PAREGORIC TINC 2 MG/5ML PHENOXYBENZAMINE 65197000101 DIBENZYLINE HYDROCHLORIDE CAPS 10 MG

54799053105 NEOFRIN PHENYLEPHRINE HYDROCHLORIDE SOLN 10 %

54799053015 NEOFRIN PHENYLEPHRINE HYDROCHLORIDE SOLN 2.5 % PHENYLEPHRINE 68552069403 HCL PHENYLEPHRINE HYDROCHLORIDE SOLN 10 % PHENYLEPHRINE 66758001603 HCL PHENYLEPHRINE HYDROCHLORIDE SOLN 10 MG/ML PHENYLEPHRINE 61314034202 HCL PHENYLEPHRINE HYDROCHLORIDE SOLN 2.5 %

62175044231 GLYCOLAX POLYETHYLENE GLYCOL POWD 0

52268080003 MIRALAX POLYETHYLENE GLYCOL POWD 0

5 PROXY NDC BRAND NAME GENERIC NAME DOSAGE STRENGTH CODE FORM

POLYETHYLENE 00904575527 GLYCOL 3350 POLYETHYLENE GLYCOL POWD 0 QUINIDINE 00002140701 GLUCONATE QUINIDINE GLUCONATE SOLN 80 MG/ML SELENIUM 45802004064 SULFIDE SELENIUM SULFIDE LOTN 2.5 %

00062165003 ERTACZO SERTACONAZOLE NITRATE CREA 2 %

00409660902 NEUT SODIUM BICARBONATE SOLN 4 %

62592018864 BUPHENYL SODIUM PHENYLBUTYRATE POWD 0 SODIUM POLYSTYRENE SODIUM POLYSTYRENE 46287001216 SULFON SULFONATE POWD 0

48878402003 JUST FOR KIDS STANNOUS FLUORIDE GEL 0.4 % ANDROGEL 00051848888 PUMP TESTOSTERONE GEL 1 %