Download drugs to be excluded

February 23, 2006
Dear Prescription Advantage Member:
This letter is to inform you about changes to your Prescription Advantage coverage because of
the new Medicare prescription drug coverage that began on January 1, 2006. Since this drug
coverage will be available, Prescription Advantage will provide supplemental coverage for
prescription drug purchases of members who are eligible for Medicare.
For all members, with or without Medicare, Prescription Advantage will only cover classes of
drugs that Medicare has not excluded from coverage.
We have determined that you have taken one or more of the prescription drugs listed on the
second page of this letter, which Medicare has excluded from coverage.
As of March 31, 2006, Prescription Advantage will no longer cover these drugs. We recommend
that you speak to your doctor regarding this change in drug coverage as he or she can most
appropriately advise you of any viable alternatives or substitutions that are available to you.
Your doctor is the most qualified person to determine which prescription drugs are suitable for
you.
If you have any questions, please call Customer Service (toll free) at 1-800-AGE-INFO (1-800243-4636) or TTY for the deaf and hard of hearing at 1-877-610-0241.
Sincerely,
Prescription Advantage
Executive Office of Health and Human Services
Executive Office of Elder Affairs
Commonwealth of Massachusetts
Prescription Advantage
1-800-AGE-INFO (1-800-243-4636)
TTY: 1-877-610-0241
www.800ageinfo.com
3/9/2006 Page 2 of 3
Alkabel-sr tablet
Amibid dm tablet sa
Antispasmodic elixir
Apap/butalbital 325/50 tab
Ascomp w/codeine capsule
Avage 0.1% cream
B-complex vitamin plus
Fioricet tablet
Fiorinal capsule
Folbalin tablet
Folbee plus tablet
Folbic tablet
Folcaps tablet
Folgard rx 2.2 tablet
Belladonna/phenobarb elixir
Bellamine-s tablet
Bellatal er tablet
Benoquin 20% cream
Benzonatate 100 mg
Biotussin ac syrup
Botox 100 units vial
Brometane dx syrup
Bromplex hd liquid
Btrex tablet
Butalbital
Butisol sodium
Cefol filmtab
Cerefolin tablet
Certuss-d tablet
Cheratussin ac syrup
Chromagen
Clidinium/cdp capsule
Codal-dh syrup
Codituss dh syrup
Combgen tablet
Conison capsule
C-tanna 12 suspension
Cyanocobalamin
Dexfol tablet
Dialyvite 3,000 tablet
Diatx tablet
Diatx zn tablet
Donnatal
Drisdol
Eperbel-s tablets
Esgic
Fa-cyancoba-pyridoxine tab
Farbital capsule
Feogen capsule
Feogen forte softgel
Ferocon capsule
Ferrex 150 forte capsule
Ferrous sulfate 325 mg tab
Folic acid
Folitab 500 caplet
Folplex 2.2 tablet
Foltrin capsule
Foltx tablet
Fortabs tablet
Gani-tuss nr liquid
Gfn 1,000/dm 60 tab
Guaifenesin
Guaifenex dm tablet sa
Gual-co liquid
Guiatuss ac syrup
H-c tussive syrup
Hemax sr caplet
Histinex hc syrup
Humibid dm capsule
Hycodan syrup
Hydrocodone compound syrup
Hydrocodone/guaifenesin syr
Hydrocodone/homatropine tab
Hydromet syrup
Hydroquinone 3% solution
Iophen-c nr liquid
Librax capsule
Marten-tab 325/50 tablet
Mebaral
Meridia 10 mg capsule
Metanx tablet
Muco-fen dm tablet sa
Multi-ret folic 500 tablet
Mytussin ac syrup
Mytussin dac syrup
Nascobal nasal gel
Nephplex rx tablet
Nephrocaps capsule
Niaspan
Nicomide tablet
Niferex-150 forte capsule
Nufol tablet
Phenazopyridine plus
Phenobarbital
Phenylhistine dh liquid
Phrenilin tablet
Poly-iron 150 forte
Proferrin-forte tablet
Promethazine w/dm
Promethazine/codeine
syrup
Propecia 1 mg tablet
Protect plus nr softgel
Pyridium plus tablet
Renal caps softgel
Renaphro softgel
Renax caplet
Renova 0.02% cream
Repan tablet
Repliva 21/7 tablet
Robafen ac syrup
Solage topical solution
Strovite tablet
Su-tuss hd elixir
Tannate 12 s susp
Therobec plus tablet
Touro cc caplet sa
Touro dm tablet sa
Tretinoin 0.05% cream
Tri-luma cream
Trinsicon capsule
Tussi-12 tablet
Tussi-12d tablet
Tussionex pennkinetic susp
Tussi-organidin nr liquid
Uni-daily tablet
Urelief plus tablet
Vaniqa 13.9% cream
V-c forte capsule
Vi-q-tuss syrup
Vitacon forte capsule
Vitamin D capsule
Vitaplex tablet
Xenical 120 mg capsule
Executive Office of Health and Human Services
Executive Office of Elder Affairs
Commonwealth of Massachusetts
Prescription Advantage
1-800-AGE-INFO (1-800-243-4636)
TTY: 1-877-610-0241
www.800ageinfo.com
3/9/2006 Page 3 of 3