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2009 Medicare Part D Plan (PDP Only) Formulary Browser

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Health Net Orange Option 1 (S5678-016-0)
Tier 1 (1535)
Tier 2 (1575)
Tier 3 (451)
Tier 4 (910)
Tier 5 (272)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
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Has Quantity Limits:
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A B C D E F G H I J K L 
M N O P Q R S T U V W X Y Z 0-9 
2009 Medicare Part D Plan Formulary Information
Health Net Orange Option 1 (S5678-016-0)
Benefit Details  
The Health Net Orange Option 1 (S5678-016-0)
Formulary Drugs Starting with the Letter A

in CMS PDP Region 5 which includes: DC DE MD
Drugs Starting with Letter A

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
A METHAPRED METHLYPREDNISOLONE SODIUM SUCCINATE FOR INJECTION 125 MG   4 Injectable 25%N/ANone
A-HYDROCORT 100MG VIAL   4 Injectable 25%N/ANone
A-METHAPRED 40MG UNIVIAL   4 Injectable 25%N/ANone
ABELCENT INJECTION SUSPENSION 5MG/ML   4 Injectable 25%N/ANone
ABILIFY 10MG TABLET   2 Preferred Brand $45.00$90.00Q:1
/1Days
ABILIFY 15MG TABLET   2 Preferred Brand $45.00$90.00Q:1
/1Days
ABILIFY 1MG/ML SOLUTION   2 Preferred Brand $45.00$90.00Q:30
/1Days
ABILIFY 20MG TABLET   2 Preferred Brand $45.00$90.00Q:1
/1Days
ABILIFY 2MG TABLET   2 Preferred Brand $45.00$90.00Q:2
/1Days
ABILIFY 30MG TABLET   2 Preferred Brand $45.00$90.00Q:1
/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ABILIFY 5MG TABLET (OTSUKA)   2 Preferred Brand $45.00$90.00Q:2
/1Days
ABILIFY DISCMELT 10MG TABLET   2 Preferred Brand $45.00$90.00P Q:2
/1Days
ABILIFY DISCMELT 15MG TABLET   2 Preferred Brand $45.00$90.00P Q:2
/1Days
ABILIFY INJ 9.75MG   4 Injectable 25%N/ANone
ABRAXANE 100MG VIAL   4 Injectable 25%N/ANone
ACARBOSE 100MG TABLET S   1 Preferred Generic $2.00$4.00None
ACARBOSE 25MG TABLET S   1 Preferred Generic $2.00$4.00None
ACARBOSE 50MG TABLET S   1 Preferred Generic $2.00$4.00None
ACCOLATE 10MG TABLET   2 Preferred Brand $45.00$90.00S Q:2
/1Days
ACCOLATE 20MG TABLET   2 Preferred Brand $45.00$90.00S Q:2
/1Days
ACCUNEB 0.63MG/3ML INH TUBEX   2 Preferred Brand $45.00$90.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACCUNEB 1.25MG/3ML INH TUBEX   2 Preferred Brand $45.00$90.00P
ACCUPRIL 10MG TABLET   2 Preferred Brand $45.00$90.00Q:2
/1Days
ACCUPRIL 20MG TABLET   2 Preferred Brand $45.00$90.00Q:2
/1Days
ACCUPRIL 40MG TABLET   2 Preferred Brand $45.00$90.00Q:2
/1Days
ACCUPRIL 5MG TABLET   2 Preferred Brand $45.00$90.00Q:2
/1Days
ACCURETIC 10-12.5MG TABLET   2 Preferred Brand $45.00$90.00Q:1
/1Days
ACCURETIC 20-12.5MG TABLET   2 Preferred Brand $45.00$90.00Q:1
/1Days
ACCURETIC 20-25MG TABLET   2 Preferred Brand $45.00$90.00Q:1
/1Days
ACCUTANE 10MG CAPSULE   3 Non-Preferred Brand $90.00$225.00None
ACCUTANE 20MG CAPSULE   3 Non-Preferred Brand $90.00$225.00None
ACCUTANE 40MG CAPSULE   3 Non-Preferred Brand $90.00$225.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACEBUTOLOL 200MG CAPSULE   1 Preferred Generic $2.00$4.00None
ACEBUTOLOL 400MG CAPSULE   1 Preferred Generic $2.00$4.00None
ACEON 2MG TABLET   3 Non-Preferred Brand $90.00$225.00Q:1
/1Days
ACEON 4MG TABLET   3 Non-Preferred Brand $90.00$225.00Q:1
/1Days
ACEON 8MG TABLET   3 Non-Preferred Brand $90.00$225.00Q:2
/1Days
ACETADOTE 200MG/ML VIAL   4 Injectable 25%N/ANone
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-15MG (1000 CT)   1 Preferred Generic $2.00$4.00None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-30MG (60 CT)   1 Preferred Generic $2.00$4.00None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-60MG (500 CT)   1 Preferred Generic $2.00$4.00None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET 300MG-60MG (500 CT)   1 Preferred Generic $2.00$4.00None
ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT)   1 Preferred Generic $2.00$4.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACETAMINOPHEN/COD SOLUTION   1 Preferred Generic $2.00$4.00None
ACETASOL HC SOLUTION 10ML 10 ML BOT   1 Preferred Generic $2.00$4.00None
ACETAZOLAMIDE 125MG TABLET   1 Preferred Generic $2.00$4.00None
ACETAZOLAMIDE 250MG TABLET (100 CT)   1 Preferred Generic $2.00$4.00None
ACETAZOLAMIDE EXTENDED RELEASE CAPSULES 500MG 100 BOT   1 Preferred Generic $2.00$4.00None
ACETAZOLAMIDE SOD 500MG VL   4 Injectable 25%N/ANone
ACETIC ACID 2% SOLUTION NON-ORAL   1 Preferred Generic $2.00$4.00None
ACETIC ACID-HYDROCORTISONE 2%-1% DROPS   1 Preferred Generic $2.00$4.00None
ACETYLCYSTEINE 10% VIAL   1 Preferred Generic $2.00$4.00P
ACETYLCYSTEINE 20% VIAL 3 X 30ML CRTN   1 Preferred Generic $2.00$4.00P
ACIPHEX 20MG TABLET EC   2 Preferred Brand $45.00$90.00Q:1
/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACTHIB VACCINE VIAL 10-24UNT/5ML   4 Injectable 25%N/ANone
ACTICIN 5% CREAM   1 Preferred Generic $2.00$4.00Q:8
/1Days
ACTIGALL 300MG CAPSULE   2 Preferred Brand $45.00$90.00None
ACTIMMUNE SOLUTION FOR INJECTION 100MCG   5 Specialty 25%N/AP
ACTIVELLA 0.5-0.1MG TABLET 28 DLPK   3 Non-Preferred Brand $90.00$225.00None
ACTIVELLA 1-0.5MG TABLET 28 DLPK   3 Non-Preferred Brand $90.00$225.00None
ACTONEL 150MG TABLET   2 Preferred Brand $45.00$90.00None
ACTONEL 30MG TABLET   2 Preferred Brand $45.00$90.00Q:1
/1Days
ACTONEL 35MG TABLET   2 Preferred Brand $45.00$90.00Q:4
/28Days
ACTONEL 5MG TABLET   2 Preferred Brand $45.00$90.00Q:1
/1Days
ACTONEL 75MG TABLET   2 Preferred Brand $45.00$90.00Q:2
/28Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACTONEL WITH CALCIUM TABLET   2 Preferred Brand $45.00$90.00Q:1
/1Days
ACTOPLUS MET 15MG/500MG TABLET   2 Preferred Brand $45.00$90.00None
ACTOPLUS MET 15MG/850MG TABLET   2 Preferred Brand $45.00$90.00None
ACTOS 15MG TABLET   2 Preferred Brand $45.00$90.00None
ACTOS 30MG TABLET (500 CT)   2 Preferred Brand $45.00$90.00None
ACTOS 45MG TABLET   2 Preferred Brand $45.00$90.00None
ACULAR 0.5% EYE DROPS   2 Preferred Brand $45.00$90.00Q:10
/30Days
ACULAR LS 0.4% OPHTH SOL   2 Preferred Brand $45.00$90.00Q:10
/30Days
ACULAR PF 0.5% EYE DROPS   2 Preferred Brand $45.00$90.00Q:24
/30Days
ACYCLOVIR 200MG CAPSULE (1000 CT)   1 Preferred Generic $2.00$4.00None
ACYCLOVIR 200MG/5ML SUSP   1 Preferred Generic $2.00$4.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ACYCLOVIR 400MG TABLET (100 CT)   1 Preferred Generic $2.00$4.00None
ACYCLOVIR SOD 50MG/ML VIAL   4 Injectable 25%N/ANone
ACYCLOVIR SODIUM 1GM VIAL   4 Injectable 25%N/ANone
ACYCLOVIR SODIUM 500MG VIAL   4 Injectable 25%N/ANone
ACYCLOVIR TABLET USP 800MG (100 CT)   1 Preferred Generic $2.00$4.00None
ADACEL VIAL 2UNT/5UNT   4 Injectable 25%N/ANone
ADAGEN 250U/ML VIAL   5 Specialty 25%N/ANone
ADALAT CC 30MG TABLET   3 Non-Preferred Brand $90.00$225.00None
ADALAT CC 60MG TABLET   3 Non-Preferred Brand $90.00$225.00None
ADALAT CC 90MG TABLET   3 Non-Preferred Brand $90.00$225.00None
ADDERALL 10MG TABLET   2 Preferred Brand $45.00$90.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADDERALL 12.5MG TABLET   2 Preferred Brand $45.00$90.00None
ADDERALL 15MG TABLET   2 Preferred Brand $45.00$90.00None
ADDERALL 20MG TABLET   2 Preferred Brand $45.00$90.00None
ADDERALL 30MG TABLET   2 Preferred Brand $45.00$90.00None
ADDERALL 5MG TABLET   2 Preferred Brand $45.00$90.00None
ADDERALL 7.5MG TABLET   2 Preferred Brand $45.00$90.00None
ADRIAMYCIN 10MG VIAL   4 Injectable 25%N/ANone
ADRIAMYCIN 20MG VIAL   4 Injectable 25%N/ANone
ADRIAMYCIN 50MG VIAL   4 Injectable 25%N/ANone
ADVAIR DISKU MIS 100/50   2 Preferred Brand $45.00$90.00Q:60
/30Days
ADVAIR DISKU MIS 250/50   2 Preferred Brand $45.00$90.00Q:60
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ADVAIR DISKU MIS 500/50   2 Preferred Brand $45.00$90.00Q:60
/30Days
ADVAIR HFA 115/21MCG INHALER   2 Preferred Brand $45.00$90.00Q:12
/30Days
ADVAIR HFA 230/21MCG INHALER   2 Preferred Brand $45.00$90.00Q:12
/30Days
ADVAIR HFA 45/21MCG INHALER   2 Preferred Brand $45.00$90.00Q:12
/30Days
AFEDITAB CR 30MG TABLET SA   3 Non-Preferred Brand $90.00$225.00None
AFEDITAB CR 60MG TABLET SA   3 Non-Preferred Brand $90.00$225.00None
AGGRENOX 25-200MG CAPSULE   2 Preferred Brand $45.00$90.00None
AGRYLIN 0.5MG CAPSULE   2 Preferred Brand $45.00$90.00None
AK-CON 0.1% EYE DROPS   1 Preferred Generic $2.00$4.00None
AK-POLY-BAC EYE OINTMENT 500UNT/1000UNT   1 Preferred Generic $2.00$4.00None
AK-SPORE EYE OINTMENT 3.5 MG   1 Preferred Generic $2.00$4.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AKTOB 0.3% EYE DROPS   1 Preferred Generic $2.00$4.00None
ALA-CORT 1% CREAM   1 Preferred Generic $2.00$4.00None
ALA-CORT 1% LOTION   1 Preferred Generic $2.00$4.00None
ALBALON LIQUIFILM 0.1% DROP   2 Preferred Brand $45.00$90.00None
ALBENZA 200MG TABLET   3 Non-Preferred Brand $90.00$225.00None
ALBUTEROL SULFATE 0.63MG/3ML VIAL NEBULIZER   1 Preferred Generic $2.00$4.00None
ALBUTEROL SULFATE 1.25MG/3ML VIAL NEBULIZER   1 Preferred Generic $2.00$4.00P
ALBUTEROL SULFATE 2.5MG/3ML VIAL NEBULIZER   1 Preferred Generic $2.00$4.00P
ALBUTEROL SULFATE 4MG TABLET SR 12HR   1 Preferred Generic $2.00$4.00None
ALBUTEROL SULFATE 8MG TABLET SR 12HR   1 Preferred Generic $2.00$4.00None
ALBUTEROL SULFATE INHALATION SOLUTION 0.5% 20ML BOTDR   1 Preferred Generic $2.00$4.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALBUTEROL SULFATE SYRUP 2MG/5ML 16 FLO BOT   1 Preferred Generic $2.00$4.00None
ALBUTEROL SULFATE TABLET 2MG (500 CT)   1 Preferred Generic $2.00$4.00None
ALBUTEROL TABLET 4MG (500 CT)   1 Preferred Generic $2.00$4.00None
ALCLOMETASONE DIPROPIONATE 0.05% CREAM   3 Non-Preferred Brand $90.00$225.00Q:2
/1Days
ALCLOMETASONE DIPROPIONATE 0.05% OINTMENT   3 Non-Preferred Brand $90.00$225.00Q:2
/1Days
ALCOHOL 5%/DEXTROSE 5%   4 Injectable 25%N/ANone
ALCOHOL ANTISEPTIC PADS   2 Preferred Brand $45.00$90.00Q:200
/30Days
ALDACTAZIDE 25/25 TABLET   2 Preferred Brand $45.00$90.00None
ALDACTAZIDE 50/50 TABLET   2 Preferred Brand $45.00$90.00None
ALDACTONE 100MG TABLET   2 Preferred Brand $45.00$90.00None
ALDACTONE 25MG TABLET   2 Preferred Brand $45.00$90.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALDACTONE 50MG TABLET   2 Preferred Brand $45.00$90.00None
ALDARA 5% CREAM   3 Non-Preferred Brand $90.00$225.00P
ALDURAZYME 2.9MG/5ML VIAL   5 Specialty 25%N/ANone
ALENDRONATE SODIUM 10MG TABLET   1 Preferred Generic $2.00$4.00Q:1
/1Days
ALENDRONATE SODIUM 40MG TABLET   1 Preferred Generic $2.00$4.00Q:1
/1Days
ALENDRONATE SODIUM 5MG TABLET   1 Preferred Generic $2.00$4.00Q:1
/1Days
ALENDRONATE SODIUM 70MG TABLET 4 BLPK   1 Preferred Generic $2.00$4.00Q:4
/28Days
ALENDRONATE SODIUM TABLET 35MG 20 CRTN   1 Preferred Generic $2.00$4.00Q:4
/28Days
ALFERON N INJ 5MU/ML   5 Specialty 25%N/ANone
ALIMTA 500MG VIAL   5 Specialty 25%N/ANone
ALIMTA INJECTION   5 Specialty 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALKERAN 50MG VIAL   4 Injectable 25%N/ANone
ALLEGRA 180MG TABLET   2 Preferred Brand $45.00$90.00Q:1
/1Days
ALLEGRA 30MG TABLET   2 Preferred Brand $45.00$90.00Q:2
/1Days
ALLEGRA 30MG/5ML SUSPENSION ORAL   2 Preferred Brand $45.00$90.00Q:20
/1Days
ALLEGRA 60MG TABLET   2 Preferred Brand $45.00$90.00Q:2
/1Days
ALLEGRA-D 12 HOUR TABLET 60-120MG (500 CT)   2 Preferred Brand $45.00$90.00Q:2
/1Days
ALLEGRA-D 24 HOUR TABLET   2 Preferred Brand $45.00$90.00Q:1
/1Days
ALLOPURINOL SODIUM 500MG VIAL   4 Injectable 25%N/ANone
ALLOPURINOL TABLET 300MG (1000 CT)   1 Preferred Generic $2.00$4.00None
ALLOPURINOL TABLET USP 100MG (1000 CT)   1 Preferred Generic $2.00$4.00None
ALOPRIM 500MG VIAL   4 Injectable 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALORA 0.025MG PATCH   3 Non-Preferred Brand $90.00$225.00Q:8
/28Days
ALORA 0.05MG PATCH   3 Non-Preferred Brand $90.00$225.00Q:8
/28Days
ALORA 0.075MG PATCH   3 Non-Preferred Brand $90.00$225.00Q:8
/28Days
ALORA 0.1MG PATCH   3 Non-Preferred Brand $90.00$225.00Q:8
/28Days
ALOXI 0.25MG/5ML VIAL   5 Specialty 25%N/AP
ALPHAGAN P 0.1% DROPS   2 Preferred Brand $45.00$90.00Q:15
/30Days
ALPHAGAN P 0.15% EYE DROPS   2 Preferred Brand $45.00$90.00Q:10
/30Days
ALREX 0.2% EYE DROPS   3 Non-Preferred Brand $90.00$225.00Q:15
/30Days
ALTABAX 1% OINTMENT   2 Preferred Brand $45.00$90.00S Q:15
/30Days
ALTACE 1.25MG CAPSULE   2 Preferred Brand $45.00$90.00Q:2
/1Days
ALTACE 10MG CAPSULE (100 CT)   2 Preferred Brand $45.00$90.00Q:2
/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ALTACE 2.5MG CAPSULE   2 Preferred Brand $45.00$90.00Q:2
/1Days
ALTACE 5MG CAPSULE   2 Preferred Brand $45.00$90.00Q:2
/1Days
ALUPENT 650MCG INHALER COMP   2 Preferred Brand $45.00$90.00None
AMANTADINE 100MG CAPSULE   1 Preferred Generic $2.00$4.00None
AMANTADINE 100MG TABLET   1 Preferred Generic $2.00$4.00None
AMARYL 1MG TABLET   2 Preferred Brand $45.00$90.00None
AMARYL 2MG TABLET   2 Preferred Brand $45.00$90.00None
AMARYL 4MG TABLET   2 Preferred Brand $45.00$90.00None
AMBIEN 10MG TABLET   2 Preferred Brand $45.00$90.00Q:1
/1Days
AMBIEN 5MG TABLET   2 Preferred Brand $45.00$90.00Q:1
/1Days
AMBIEN CR 12.5MG TABLET   2 Preferred Brand $45.00$90.00S Q:1
/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMBIEN CR 6.25MG TABLET   2 Preferred Brand $45.00$90.00S Q:1
/1Days
AMBISOME 50MG VIAL   4 Injectable 25%N/ANone
AMCINONIDE 0.1% CREAM   3 Non-Preferred Brand $90.00$225.00Q:1
/1Days
AMCINONIDE 0.1% LOTION   3 Non-Preferred Brand $90.00$225.00Q:60
/30Days
AMCINONIDE 0.1% OINTMENT 60GM TUBE   3 Non-Preferred Brand $90.00$225.00Q:1
/1Days
AMERGE 1MG TABLET   2 Preferred Brand $45.00$90.00Q:9
/30Days
AMERGE 2.5MG TABLET   2 Preferred Brand $45.00$90.00Q:9
/30Days
AMEVIVE ADMISTRATION PACK FOR INTRAMUSCULAR ADMINISTRATION KIT 15MG 1 X 4 PKGCOM   5 Specialty 25%N/AP
AMIFOSTINE FOR INJECTION 500MG/VIAL   4 Injectable 25%N/ANone
AMIKACIN 250MG/ML VIAL   4 Injectable 25%N/ANone
AMIKACIN 50MG/ML VIAL   4 Injectable 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMIKIN 250MG/ML VIAL   4 Injectable 25%N/ANone
AMIKIN POWDER FOR INJECTION   4 Injectable 25%N/ANone
AMILORIDE HCL 5MG TABLET   1 Preferred Generic $2.00$4.00None
AMILORIDE HCL W/HCTZ 5MG-50MG TABLET   1 Preferred Generic $2.00$4.00None
AMINESS 5.2% IV SOLUTION   4 Injectable 25%N/AP
AMINOPHYLLINE 100MG TABLET (100 CT)   1 Preferred Generic $2.00$4.00None
AMINOPHYLLINE 200MG TABLET (1000 CT)   1 Preferred Generic $2.00$4.00None
AMINOPHYLLINE INJECTION 250MG 10ML X 25 VIALSD   4 Injectable 25%N/ANone
AMINOSYN 10% IV SOLUTION   4 Injectable 25%N/AP
AMINOSYN 3.5% IV SOLUTION   4 Injectable 25%N/AP
AMINOSYN 5% IV SOLUTION   4 Injectable 25%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN 7% IV SOLUTION   4 Injectable 25%N/AP
AMINOSYN 7%-ELECTROLYTE SOL   4 Injectable 25%N/AP
AMINOSYN 8.5% IV SOLUTION   4 Injectable 25%N/AP
AMINOSYN II 10% IV SOLUTION   4 Injectable 25%N/AP
AMINOSYN II 15% IV SOLUTION   4 Injectable 25%N/AP
AMINOSYN II 3.5% IN D25W IV   4 Injectable 25%N/AP
AMINOSYN II 3.5% IN D5W IV   4 Injectable 25%N/AP
AMINOSYN II 3.5% M/D5W IV   4 Injectable 25%N/AP
AMINOSYN II 3.5% W/ELEC DEX   4 Injectable 25%N/AP
AMINOSYN II 4.25% IN D10W   4 Injectable 25%N/AP
AMINOSYN II 4.25% IN D20W   4 Injectable 25%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN II 4.25% M/D10W IV   4 Injectable 25%N/AP
AMINOSYN II 4.25% W/ELEC DW   4 Injectable 25%N/AP
AMINOSYN II 4.25%-D25W IV   4 Injectable 25%N/AP
AMINOSYN II 5% IN D25W IV   4 Injectable 25%N/AP
AMINOSYN II 7% IV SOLUTION   4 Injectable 25%N/AP
AMINOSYN II 8.5% ELECTROLYT   4 Injectable 25%N/AP
AMINOSYN II 8.5% IV SOLUTION   4 Injectable 25%N/AP
AMINOSYN M 3.5% IV SOLUTION   4 Injectable 25%N/AP
AMINOSYN PF INJECTION   4 Injectable 25%N/AP
AMINOSYN WITH ELECTROLYTES SULFITE FREE INJECTION 8.5%   4 Injectable 25%N/AP
AMINOSYN-HBC 7% IV SOLUTION   4 Injectable 25%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMINOSYN-HF 8% IV SOLUTION   4 Injectable 25%N/AP
AMINOSYN-PF 7% IV SOLUTION   4 Injectable 25%N/AP
AMIODARONE HCL 200MG TABLET (60 CT)   1 Preferred Generic $2.00$4.00None
AMIODARONE HCL 400MG TABLET   1 Preferred Generic $2.00$4.00None
AMIODARONE HCL INJECTION   4 Injectable 25%N/ANone
AMITIZA 24 MCG CAPSULES   2 Preferred Brand $45.00$90.00None
AMITIZA 8MCG CAPSULE   2 Preferred Brand $45.00$90.00None
AMITRIP/CDP 25-10 TABLET   1 Preferred Generic $2.00$4.00None
AMITRIP/PERPHEN 10-2 TABLET   1 Preferred Generic $2.00$4.00None
AMITRIP/PERPHEN 10-4 TABLET   1 Preferred Generic $2.00$4.00None
AMITRIP/PERPHEN 25-2 TABLET   1 Preferred Generic $2.00$4.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMITRIP/PERPHEN 25-4 TABLET   1 Preferred Generic $2.00$4.00None
AMITRIP/PERPHEN 50-4 TABLET   1 Preferred Generic $2.00$4.00None
AMITRIPTYLINE HCL 100MG TABLET   1 Preferred Generic $2.00$4.00None
AMITRIPTYLINE HCL 10MG TABLET   1 Preferred Generic $2.00$4.00None
AMITRIPTYLINE HCL 150MG TABLET (100 CT)   1 Preferred Generic $2.00$4.00None
AMITRIPTYLINE HCL 25MG TABLET USP (100 CT)   1 Preferred Generic $2.00$4.00None
AMITRIPTYLINE HCL 50MG TABLET   1 Preferred Generic $2.00$4.00None
AMITRIPTYLINE HCL 75MG TABLET USP (100 CT)   1 Preferred Generic $2.00$4.00None
AMLODIPINE BESYLATE 10MG TABLET (90 CT)   1 Preferred Generic $2.00$4.00Q:1
/1Days
AMLODIPINE BESYLATE 2.5MG TABLET (90 CT)   1 Preferred Generic $2.00$4.00Q:1
/1Days
AMLODIPINE BESYLATE 5MG TABLET (90 CT)   1 Preferred Generic $2.00$4.00Q:1
/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMMONIUM CHLORIDE 5 MEQ/ML   4 Injectable 25%N/ANone
AMMONIUM LACTATE 12% CREAM   1 Preferred Generic $2.00$4.00None
AMMONIUM LACTATE 12% LOTION   1 Preferred Generic $2.00$4.00None
AMMONIUM LACTATE 12% LOTION   1 Preferred Generic $2.00$4.00None
AMNESTEEM 10MG CAPSULE   3 Non-Preferred Brand $90.00$225.00None
AMNESTEEM 20MG CAPSULE   3 Non-Preferred Brand $90.00$225.00None
AMNESTEEM 40MG CAPSULE   3 Non-Preferred Brand $90.00$225.00None
AMOCLAN 200-28.5/5 SUSPENSION RECONSTITUTED ORAL   1 Preferred Generic $2.00$4.00None
AMOCLAN 400-57MG/5 SUSPENSION RECONSTITUTED ORAL   1 Preferred Generic $2.00$4.00None
AMOX TR-K CLV 200-28.5 CHEW   1 Preferred Generic $2.00$4.00None
AMOX TR-K CLV 200-28.5/5 SU   1 Preferred Generic $2.00$4.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOX TR-K CLV 400-57 CHW TABLET   1 Preferred Generic $2.00$4.00None
AMOX TR-K CLV 400-57/5 SUSP   1 Preferred Generic $2.00$4.00None
AMOX TR-K CLV 500-125MG TABLET   1 Preferred Generic $2.00$4.00None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5/5 SUSPENSION RECONSTITUTED ORAL   1 Preferred Generic $2.00$4.00None
AMOX TR-POTASSIUM CLAVULANATE 200-28.5MG TABLET CHEWABLE   1 Preferred Generic $2.00$4.00None
AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET   1 Preferred Generic $2.00$4.00None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG TABLET CHEWABLE   1 Preferred Generic $2.00$4.00None
AMOX TR-POTASSIUM CLAVULANATE 400-57MG/5 SUSPENSION RECONSTITUTED ORAL   1 Preferred Generic $2.00$4.00None
AMOX TR-POTASSIUM CLAVULANATE 500-125MG TABLET   1 Preferred Generic $2.00$4.00None
AMOXAPINE 100MG TABLET   2 Preferred Brand $45.00$90.00None
AMOXAPINE 150MG TABLET   2 Preferred Brand $45.00$90.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXAPINE 25MG TABLET   2 Preferred Brand $45.00$90.00None
AMOXAPINE 50MG TABLET   2 Preferred Brand $45.00$90.00None
AMOXICIILIN CLAVULNATE POTASSIUM FOR ORAL SUSPENSION   1 Preferred Generic $2.00$4.00None
AMOXICILLIN 125MG TABLET CHEW   1 Preferred Generic $2.00$4.00None
AMOXICILLIN 200MG TABLET CHEW   1 Preferred Generic $2.00$4.00None
AMOXICILLIN 250MG CAPSULE   1 Preferred Generic $2.00$4.00None
AMOXICILLIN 400MG TABLET CHEW   1 Preferred Generic $2.00$4.00None
AMOXICILLIN 500MG CAPSULE   1 Preferred Generic $2.00$4.00None
AMOXICILLIN 500MG TABLET (100 CT)   1 Preferred Generic $2.00$4.00None
AMOXICILLIN 875MG TABLET   1 Preferred Generic $2.00$4.00None
AMOXICILLIN CLAVULANATE POTASSIUM FOR SUSPENSION 600-42.9MG 125ML BOT   1 Preferred Generic $2.00$4.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMOXICILLIN CLAVULANATE POTASSIUM TABLET 875-125MG 1 BLPK   1 Preferred Generic $2.00$4.00None
AMOXICILLIN FOR ORAL SUSPENSION 125MG/5ML 100ML BOT   1 Preferred Generic $2.00$4.00None
AMOXICILLIN FOR ORAL SUSPENSION 200MG/5ML 100ML BOTGL   1 Preferred Generic $2.00$4.00None
AMOXICILLIN FOR ORAL SUSPENSION 250MG/5ML 100ML BOT   1 Preferred Generic $2.00$4.00None
AMOXICILLIN FOR ORAL SUSPENSION 400MG/5ML 50ML BOTGL   1 Preferred Generic $2.00$4.00None
AMOXICILLIN TABLET USP CHEWABLE 250MG (250 CT)   1 Preferred Generic $2.00$4.00None
AMOXIL 250MG/5ML SUSPENSION   1 Preferred Generic $2.00$4.00None
AMOXIL 400MG/5ML SUSPENSION   2 Preferred Brand $45.00$90.00None
AMOXIL 500MG CAPSULE   1 Preferred Generic $2.00$4.00None
AMOXIL 50MG/ML PED DROPS   2 Preferred Brand $45.00$90.00None
AMPHET ASP/ AMPHET/ D-AMPHET 10MG TABLET   1 Preferred Generic $2.00$4.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMPHET ASP/ AMPHET/ D-AMPHET 5MG TABLET   1 Preferred Generic $2.00$4.00None
AMPHETAMINE SALT COMBO 12.5MG TABLET   1 Preferred Generic $2.00$4.00None
AMPHETAMINE SALT COMBO 15MG TABLET   1 Preferred Generic $2.00$4.00None
AMPHETAMINE SALT COMBO 30MG TABLET   1 Preferred Generic $2.00$4.00None
AMPHETAMINE SALT COMBO 7.5MG TABLET   1 Preferred Generic $2.00$4.00None
AMPHETAMINE SALTS 20MG TABLET   1 Preferred Generic $2.00$4.00None
AMPHETAMINE SALTS 30MG TABLET   1 Preferred Generic $2.00$4.00None
AMPHOTEC 100MG VIAL   4 Injectable 25%N/ANone
AMPHOTEC INJ 50MG   4 Injectable 25%N/ANone
AMPHOTERICIN B FOR INJECTION 50 MG   4 Injectable 25%N/ANone
AMPICILLIN AND SULBACTAM FOR INJECTION 1-0.5 10 VIAL VIAL   4 Injectable 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMPICILLIN AND SULBACTAM FOR INJECTION 10-5 1 VIAL   4 Injectable 25%N/ANone
AMPICILLIN AND SULBACTAM FOR INJECTION 2-1 10 VIAL   4 Injectable 25%N/ANone
AMPICILLIN FOR INJECTION   4 Injectable 25%N/ANone
AMPICILLIN FOR INJECTION 1GM VIAL   4 Injectable 25%N/ANone
AMPICILLIN FOR INJECTION 2GM/ML 10 VIAL   4 Injectable 25%N/ANone
AMPICILLIN FOR INJECTION 500MG VIAL   4 Injectable 25%N/ANone
AMPICILLIN FOR INJECTION POWDER   4 Injectable 25%N/ANone
AMPICILLIN FOR INJECTION USP 125MG/ML 1 VIAL   4 Injectable 25%N/ANone
AMPICILLIN FOR ORAL SUSPENSION 125MG 100ML BOT   1 Preferred Generic $2.00$4.00None
AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT   1 Preferred Generic $2.00$4.00None
AMPICILLIN POWDER FOR INJECTION 1 GM/ML   4 Injectable 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AMPICILLIN SODIUM STERILE 2 GM/VIAL   4 Injectable 25%N/ANone
AMPICILLIN TR 250MG CAPSULE   1 Preferred Generic $2.00$4.00None
AMPICILLIN TR 500MG CAPSULE   1 Preferred Generic $2.00$4.00None
ANADROL-50 50MG TABLET (100 CT)   5 Specialty 25%N/ANone
ANAFRANIL 25MG CAPSULE   2 Preferred Brand $45.00$90.00None
ANAFRANIL 50MG CAPSULE   2 Preferred Brand $45.00$90.00None
ANAFRANIL 75MG CAPSULE   2 Preferred Brand $45.00$90.00None
ANAGRELIDE HCL 0.5MG CAPSULE   1 Preferred Generic $2.00$4.00None
ANAGRELIDE HCL 1MG CAPSULE   1 Preferred Generic $2.00$4.00None
ANAPROX 275MG TABLET   2 Preferred Brand $45.00$90.00None
ANAPROX DS 550MG TABLET   2 Preferred Brand $45.00$90.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ANCOBON 250MG CAPSULE   3 Non-Preferred Brand $90.00$225.00None
ANCOBON 500MG CAPSULE   3 Non-Preferred Brand $90.00$225.00None
ANDRODERM 2.5MG/24HR PATCH   2 Preferred Brand $45.00$90.00Q:2
/1Days
ANDRODERM 5MG/24HR PATCH   2 Preferred Brand $45.00$90.00Q:1
/1Days
ANDROGEL 1%(25MG) GEL PACKET   2 Preferred Brand $45.00$90.00Q:10
/1Days
ANDROGEL 1.25G (1%) GEL IN METERED-DOSE PUMP   2 Preferred Brand $45.00$90.00Q:10
/1Days
ANDROGEL 1%(50MG) GEL PACKET   2 Preferred Brand $45.00$90.00Q:10
/1Days
ANDROID 10MG CAPSULE   2 Preferred Brand $45.00$90.00None
ANTABUSE 250MG TABLET   2 Preferred Brand $45.00$90.00None
ANTABUSE 500MG TABLET   2 Preferred Brand $45.00$90.00None
ANTARA 130MG CAPSULE   2 Preferred Brand $45.00$90.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ANTARA 43MG CAPSULE   2 Preferred Brand $45.00$90.00None
ANTIVERT 12.5MG TABLET   2 Preferred Brand $45.00$90.00None
ANTIVERT 25MG TABLET   2 Preferred Brand $45.00$90.00None
ANTIZOL INJECTION 1GM 4 X 1.5ML VIAL CRTN   4 Injectable 25%N/ANone
ANUSOL-HC 2.5% CREAM   2 Preferred Brand $45.00$90.00None
ANZEMET 20MG/ML VIAL   4 Injectable 25%N/AP
APHTHASOL 5% PASTE   3 Non-Preferred Brand $90.00$225.00None
APOKYN FOR INJECTION 30MG 5 CTG   5 Specialty 25%N/AP
APRI 0.15-0.03 TABLET   1 Preferred Generic $2.00$4.00Q:1
/1Days
APTIVUS 250MG CAPSULE   5 Specialty 25%N/ANone
ARALAST 1000MG VIAL   5 Specialty 25%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARALAST 500MG VIAL   5 Specialty 25%N/AP
ARANELLE 7-9-5 TABLET   1 Preferred Generic $2.00$4.00Q:1
/1Days
ARANESP 100MCG/ML VIAL   4 Injectable 25%N/AP
ARANESP 200MCG/0.4ML SYRINGE   4 Injectable 25%N/AP
ARANESP 200MCG/ML VIAL   4 Injectable 25%N/AP
ARANESP 25MCG/ML VIAL   4 Injectable 25%N/AP
ARANESP 300MCG/ML VIAL   4 Injectable 25%N/AP
ARANESP 500MCG/1ML SYRINGE   4 Injectable 25%N/AP
ARANESP 60MCG/ML VIAL   4 Injectable 25%N/AP
ARANESP PREFILLED SYRINGE SINGLE USE 150MCG 4 SYR   4 Injectable 25%N/AP
ARANESP PREFILLED SYRINGE SINGLE USE 25MCG/0.42ML SYR   4 Injectable 25%N/AP
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARANESP PREFILLED SYRINGE SINGLE USE 40MCG 4 X 40MCG SYR   4 Injectable 25%N/AP
ARANESP SINGLE USE PREFILLED AUTOINJECTOR SOLUTION 100MCG/.5ML   4 Injectable 25%N/AP
ARANESP SINGLE USE PREFILLED SURECLICK AUTOINJECTOR SOLUTION 500MCG/ML   4 Injectable 25%N/AP
ARANESP SINGLE USE PREFILLED SURECLIK AUTOINJECTOR 60MCG/.3ML   4 Injectable 25%N/AP
ARANESP SINGLE USE VIAL 150MCG 4 X 150MCG/ 0.75ML VIALSD   4 Injectable 25%N/AP
ARANESP SINGLE USE VIAL 40MCG 4 X 40MCG/ 1ML VIALSD   4 Injectable 25%N/AP
ARAVA 10MG TABLET   2 Preferred Brand $45.00$90.00P Q:1
/1Days
ARAVA 20MG TABLET   2 Preferred Brand $45.00$90.00P Q:1
/1Days
ARCALYST INJECTION 220MG/VIAL   5 Specialty 25%N/AP
AREDIA 30MG VIAL   4 Injectable 25%N/ANone
AREDIA 90MG VIAL   4 Injectable 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ARICEPT 10MG TABLET   2 Preferred Brand $45.00$90.00Q:1
/1Days
ARICEPT 5MG TABLET   2 Preferred Brand $45.00$90.00Q:1
/1Days
ARICEPT ODT 10MG TABLET   2 Preferred Brand $45.00$90.00Q:1
/1Days
ARICEPT ODT 5MG TABLET   2 Preferred Brand $45.00$90.00Q:1
/1Days
ARIMIDEX 1MG TABLET   2 Preferred Brand $45.00$90.00None
ARIXTRA 10MG SYRINGE   4 Injectable 25%N/AQ:8
/10Days
ARIXTRA 2.5MG SYRINGE   4 Injectable 25%N/AQ:5
/10Days
ARIXTRA 5MG SYRINGE   4 Injectable 25%N/AQ:4
/10Days
ARIXTRA 7.5MG SYRINGE   4 Injectable 25%N/AQ:6
/10Days
AROMASIN 25MG TABLET   2 Preferred Brand $45.00$90.00None
ARRANON 250MG VIAL   5 Specialty 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ASACOL 400MG TABLET EC   2 Preferred Brand $45.00$90.00None
ASCOMP W/CODEINE 30-50-325 CAPSULE   3 Non-Preferred Brand $90.00$225.00None
ASMANEX 220MCG(14) AEROSOL POWDER BREATH ACTIVATED   2 Preferred Brand $45.00$90.00None
ASMANEX TWISTHALER 220MCG #120   2 Preferred Brand $45.00$90.00Q:1
/1Days
ASMANEX TWISTHALER 220MCG #30   2 Preferred Brand $45.00$90.00None
ASMANEX TWISTHALER 220MCG #60   2 Preferred Brand $45.00$90.00None
ASTELIN 137MCG AEROSOL SPRAY W/PUMP   2 Preferred Brand $45.00$90.00Q:60
/30Days
ASTEPRO NASAL SPRAY 137 MCG/SPRY   2 Preferred Brand $45.00$90.00Q:60
/30Days
ASTRAMORPH-PF 0.5MG/ML VIAL   4 Injectable 25%N/ANone
ASTRAMORPH-PF 1MG/ML VIAL   4 Injectable 25%N/ANone
ATACAND 16MG TABLET   3 Non-Preferred Brand $90.00$225.00S Q:1
/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATACAND 32MG TABLET   3 Non-Preferred Brand $90.00$225.00S Q:1
/1Days
ATACAND 4MG TABLET   3 Non-Preferred Brand $90.00$225.00S Q:1
/1Days
ATACAND 8MG TABLET   3 Non-Preferred Brand $90.00$225.00S Q:1
/1Days
ATAMET   1 Preferred Generic $2.00$4.00None
ATENOLOL 25MG TABLET (100 CT)   1 Preferred Generic $2.00$4.00None
ATENOLOL TABLET 100MG (100 CT)   1 Preferred Generic $2.00$4.00None
ATENOLOL TABLET USP 50MG (100 CT)   1 Preferred Generic $2.00$4.00None
ATENOLOL/CHLORTHALIDONE TABLET 100-25MG (100 CT)   1 Preferred Generic $2.00$4.00None
ATENOLOL/CHLORTHALIDONE TABLET 50-25MG (100 CT)   1 Preferred Generic $2.00$4.00None
ATGAM 50MG/ML AMPUL   4 Injectable 25%N/AP
ATRIPLA TABLET 600MG/200MG   5 Specialty 25%N/ANone
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
ATROPINE 0.05MG/ML SYRINGE   4 Injectable 25%N/ANone
ATROPINE 0.1MG/ML SYRINGE   4 Injectable 25%N/ANone
ATROVENT NASAL SPRAY 0.03%   2 Preferred Brand $45.00$90.00Q:60
/30Days
ATROVENT NASAL SPRAY 0.06%   2 Preferred Brand $45.00$90.00Q:30
/30Days
ATTENUVAX VACCINE W/DILUENT 1 DOSE/0.5ML   4 Injectable 25%N/ANone
AUGMENTIN 125 SUSPENSION   2 Preferred Brand $45.00$90.00None
AUGMENTIN 200MG/5ML SUSP   2 Preferred Brand $45.00$90.00None
AUGMENTIN 250 SUSPENSION   2 Preferred Brand $45.00$90.00None
AUGMENTIN 250 TABLET   2 Preferred Brand $45.00$90.00None
AUGMENTIN 250 TABLET CHEW   2 Preferred Brand $45.00$90.00None
AUGMENTIN 400MG/5ML SUSP   2 Preferred Brand $45.00$90.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AUGMENTIN 500MG TABLET   2 Preferred Brand $45.00$90.00None
AUGMENTIN 875MG TABLET   2 Preferred Brand $45.00$90.00None
AUGMENTIN ES-600 SUSPENSION   2 Preferred Brand $45.00$90.00None
AUGMENTIN XR 1000-62.5 TABLET   2 Preferred Brand $45.00$90.00None
AVANDAMET 2MG/1000MG TABLET   2 Preferred Brand $45.00$90.00None
AVANDAMET 2MG/500MG TABLET   2 Preferred Brand $45.00$90.00None
AVANDAMET 4MG/500MG TABLET   2 Preferred Brand $45.00$90.00None
AVANDAMET TABLET 4-1000MG   2 Preferred Brand $45.00$90.00None
AVANDARYL 4MG/1MG TABLET   2 Preferred Brand $45.00$90.00None
AVANDARYL 4MG/2MG TABLET   2 Preferred Brand $45.00$90.00None
AVANDARYL 4MG/4MG TABLET   2 Preferred Brand $45.00$90.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVANDARYL 8MG-2MG TABLET   2 Preferred Brand $45.00$90.00None
AVANDARYL 8MG-4MG TABLET   2 Preferred Brand $45.00$90.00None
AVANDIA 2MG TABLET   2 Preferred Brand $45.00$90.00None
AVANDIA 4MG TABLET (90 CT)   2 Preferred Brand $45.00$90.00None
AVANDIA 8MG TABLET (90 CT)   2 Preferred Brand $45.00$90.00None
AVAPRO 150MG TABLET   3 Non-Preferred Brand $90.00$225.00S Q:1
/1Days
AVAPRO 300MG TABLET   3 Non-Preferred Brand $90.00$225.00S Q:1
/1Days
AVAPRO 75MG TABLET (30 CT)   3 Non-Preferred Brand $90.00$225.00S Q:1
/1Days
AVASTIN 100MG/4ML VIAL   5 Specialty 25%N/AP
AVASTIN 400MG/16ML VIAL   5 Specialty 25%N/AP
AVELOX 400MG TABLET   2 Preferred Brand $45.00$90.00Q:1
/1Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVELOX ABC PACK 400MG TABLET   2 Preferred Brand $45.00$90.00Q:1
/1Days
AVELOX IV 400MG/250ML   4 Injectable 25%N/ANone
AVIANE 0.1-0.02 TABLET   1 Preferred Generic $2.00$4.00Q:1
/1Days
AVINZA 120MG CAPSULE MULTIPHASIC RELEASE 24 HR   2 Preferred Brand $45.00$90.00Q:13
/1Days
AVINZA 30MG CAPSULE MULTIPHASIC RELEASE 24 HR   2 Preferred Brand $45.00$90.00Q:1
/1Days
AVINZA 60MG CAPSULE MULTIPHASIC RELEASE 24 HR   2 Preferred Brand $45.00$90.00Q:1
/1Days
AVINZA 90MG CAPSULE MULTIPHASIC RELEASE 24 HR   2 Preferred Brand $45.00$90.00Q:17
/1Days
AVINZA CAPSULES EXTENDED RELEASE 45MG 100 BOTPL   2 Preferred Brand $45.00$90.00Q:1
/1Days
AVINZA CAPSULES EXTENDED RELEASE 75MG 100 BOTPL   2 Preferred Brand $45.00$90.00Q:1
/1Days
AVITA 0.025% CREAM   1 Preferred Generic $2.00$4.00Q:20
/30Days
AVODART 0.5MG SOFTGEL   2 Preferred Brand $45.00$90.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AVONEX ADMIN PACK 30MCG SYR   5 Specialty 25%N/AP
AVONEX ADMIN PACK 30MCG VL   5 Specialty 25%N/AP
AYGESTIN 5MG TABLET   2 Preferred Brand $45.00$90.00None
AZACTAM 1GM VIAL   4 Injectable 25%N/ANone
AZACTAM 2GM VIAL   4 Injectable 25%N/ANone
AZACTAM INJECTION 1GM 50ML BAG   4 Injectable 25%N/ANone
AZACTAM/ISO-OSMOT 2GM/50ML   4 Injectable 25%N/ANone
AZASAN 100MG TABLET   2 Preferred Brand $45.00$90.00P
AZASAN 75MG TABLET   2 Preferred Brand $45.00$90.00P
AZASITE 1% DROPS   3 Non-Preferred Brand $90.00$225.00Q:2
/30Days
AZATHIOPRINE 50MG TABLET   1 Preferred Generic $2.00$4.00P
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZATHIOPRINE SOD 100MG VIAL   4 Injectable 25%N/AP
AZILECT 0.5MG TABLET   2 Preferred Brand $45.00$90.00None
AZILECT 1MG TABLET   2 Preferred Brand $45.00$90.00None
AZITHROMYCIN 100MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Preferred Generic $2.00$4.00Q:15
/5Days
AZITHROMYCIN 1G PACKET   1 Preferred Generic $2.00$4.00Q:2
/5Days
AZITHROMYCIN 200MG/5ML SUSPENSION RECONSTITUTED ORAL   1 Preferred Generic $2.00$4.00Q:30
/5Days
AZITHROMYCIN 250MG TABLET (30 CT)   1 Preferred Generic $2.00$4.00Q:6
/5Days
AZITHROMYCIN 500MG TABLET (30 CT)   1 Preferred Generic $2.00$4.00Q:3
/3Days
AZITHROMYCIN FOR INJECTION 500MG 10 VIALSD   4 Injectable 25%N/ANone
AZITHROMYCIN TABLET 600MG (30 CT)   1 Preferred Generic $2.00$4.00Q:8
/28Days
AZMACORT AER 75MCG   2 Preferred Brand $45.00$90.00Q:40
/30Days
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
AZOPT SUSPENSION OPHTHALMIC 1% 15ML BOT   2 Preferred Brand $45.00$90.00Q:10
/30Days
AZOR 10MG-20MG TABLET   2 Preferred Brand $45.00$90.00Q:1
/1Days
AZOR 10MG-40MG TABLET (30 CT)   2 Preferred Brand $45.00$90.00Q:1
/1Days
AZOR 5MG-20MG TABLET (30 CT)   2 Preferred Brand $45.00$90.00Q:1
/1Days
AZOR 5MG-40MG TABLET   2 Preferred Brand $45.00$90.00Q:1
/1Days
AZULFIDINE 500MG TABLET   2 Preferred Brand $45.00$90.00None
AZULFIDINE EN TABLET S 500MG TABLET 6 X (300 CT)PL   2 Preferred Brand $45.00$90.00None

Chart Legend:

Below are a few notes to help you understand the above 2009 Medicare Part D Health Net Orange Option 1 Plan Formulary.
  • Plan Name: This is the official Medicare Part D prescription drug plan name from the Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different Plan ID in each state (or CMS Region).

  • Monthly Premium: This is the amount you must pay each month for this prescription drug plan. This monthly premium must be paid even if you are in the initial deductible phase or the coverage gap (donut hole) phase.

  • Deductible: If your Part D plan has an initial deductible, you are 100% responsible for your drug costs until your expenses exceed this value and you begin your Initial Coverage Phase. Many Medicare Part D plans use the standard $295 deductible as provided by CMS in their Standard plan design. Some Part D plan providers offer an initial deductible lower than the Standard deductible. Many prescription drug plans do not have a deductible (also called first dollar coverage or a $0 deductible), however the monthly premium for a plan with a $0 deductible may be slightly higher.

  • Qualifies for LIS: The Extra Help or Low Income Subsidy (LIS) Program.
    • Yes - This plan qualifies for the $0 Premium for those persons with a full LIS or Extra Help benefit. Persons on the LIS program who select a qualifying plan will also pay a $0 deductible, pay lower cost-sharing payments and have coverage through the Coverage Gap or Doughnut Hole.

    • No - This plan does not qualify for the $0 Premium for persons with the full LIS benefit.

  • Plan ID: This is the Medicare Part D prescription drug plan's unique ID.
  • Drug Tier Information - Drug Tiers are the logical grouping of prescription drugs on a Part D plan formulary. These fields represent the Tier (or drug list group) - for this particular medication - on this particular plan’s Formulary or Drug List.
    • Tier Number - This is the actual numerical tier level from the formulary. Most Part D plans have four (4) tiers 1=Preferred Generics, 2=Preferred Brands, 3=Non-preferred Brands and Generics, 4=Specialty Drugs.
    • Drug Description - This is the Medicare Part D plan’s description of this particular drug tier.
  • Cost Sharing - Copay / Coinsurance - These figures apply to the initial coverage phase of your plan. This is the phase after the initial deductible has been met and before you reach the Coverage Gap (Donut Hole). Plans often cover drugs in "tiers". Tiers are specific to the list of drugs covered by the plan. Plans may have several tiers, and the copay for a drug depends on the drug’s tier. The drug Tier is shown to the left of this column. These cost sharing figures DO NOT necessarily apply to the Coverage Gap. The plan may have a separate copay/coinsurance for the same drug while in the Coverage Gap. There are two figures shown under this "Cost Sharing" category:
    • Preferred Network Pharmacy - (Preferred Pharm) - This is the cost-share amount you would pay during the initial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $2700) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2013 Humana Walmart-Preferred Rx Plan the cost-sharing is much higher at a network pharmacy over a "Preferred" network pharmacy. "Preferred" network pharmacies for this plan include only Walmart, Sam’s Club and RightSource.
    • Mail Order - This is the cost-share amount you would pay during the initial coverage phase for a 90-Day supply if you purchased your medication through your plan’s preferred mail order partner(s).
  • Drug Utilization Management or Coverage Rules - (Drug Usage Mgmt) - This shows the plan requires drug utilization management controls for this particular medication.
    • None - This drug does not fall under any drug utilization management controls.
    • P - Prior Authorization -This drug is subject to prior authorization.
    • S - Step Therapy -This drug is subject to step therapy.
    • Q - Quantity Limits -This drug is subject to quantity limits. The actual quantity limit is shown as Q:Amount/Days. For Example: Q:6/28Days means the quantity limit is a quantity of 6 pills per 28 days. Q:90/365Days would mean that the plan limits this drug to 90 pills for the entire year.




(Chart Source: Centers for Medicare and Medicaid files: CMS Data October 2009 )

Please note: The above plan information comes from CMS. We make every attempt to keep our information up-to-date with plan/premium changes. However, the Medicare Part D plan data changes over time and we cannot guarantee the accuracy of this information. You should always verify cost and coverage information with your Part D plan provider.







Tips & Disclaimers
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDP-Compare.com and MA-Compare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.